Failure to Assess, Notify, and Manage Pain and Change in Condition
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for two residents, resulting in significant harm. In the first case, a resident with severe cognitive impairment and a diagnosis of dementia experienced sudden, severe pain with redness and swelling in the left knee. Despite multiple staff members observing and reporting the resident's pain and changes in condition over several days, there was no immediate physician notification, no comprehensive pain or physical assessment, and inadequate pain management. The resident continued to experience severe pain for five days before being hospitalized with a left femur fracture requiring surgical repair. Documentation was lacking for pain assessments, nursing assessments, and rationale for obtaining diagnostic imaging, and the resident's pain was not consistently managed or monitored as per facility policy. In the second case, a cognitively intact resident with a history of left femur fracture, hip replacement, diabetes, heart failure, and Alzheimer's disease suffered an unwitnessed fall. The initial assessment documented no complaints of pain or injury, but no neurological checks or post-fall assessments were performed for an extended period. Over the following days, the resident exhibited increasing pain, required more frequent pain medication, and demonstrated significant changes in mobility and function, including inability to bear weight and flaccid extremities. Multiple staff members observed and reported these changes, but there was a failure to recognize the change in condition and notify the physician in a timely manner. The resident was eventually sent to the hospital, where a subdural hematoma with midline shift and a dislocated hip were diagnosed, necessitating neurosurgical and orthopedic intervention. Both cases demonstrate failures to follow the facility's policies on notification of changes, pain management, and assessment following significant changes in condition or falls. Staff did not consistently assess, document, or communicate critical changes, resulting in delayed recognition and treatment of serious medical conditions. These deficiencies were confirmed through interviews, record reviews, and direct observations by surveyors.
Removal Plan
- The facility Nursing Staff was in serviced by Director of Nursing and Regional Nurse Consultant regarding pain management, evaluation and treatment, physician notifications, documentation and follow-up. All nursing staff who have not attended the in-service will be in-serviced prior to their start of next scheduled shift. Nursing staff not in-serviced will not be able to return to work until in-service has been completed.
- All residents were assessed for pain by Assistant Director of Nursing. All residents have a pain scale documented on their Medication Administration Record to be completed every shift. A nonverbal pain scale was added for residents who are not cognitively intact.
- Director of Nursing implemented daily clinical rounds with the nursing staff to ensure all acute/chronic pain is addressed, appropriate assessments are completed, and notification of the physician has been completed appropriately. Reports will be reviewed/addressed during morning clinical meeting each day. Daily morning Clinical sheets were reviewed and Director of Nursing has been completing daily.
- Director of Nursing and Assistant Director of Nursing in-serviced Nursing Staff regarding physician notification of changes by phone with follow up by fax and text message. Random review of progress notes confirm physicians have been notified by phone with condition changes.
- Each nurses station contained a list of hot rack charting for nurses to review daily. Director of Nursing is updating hot rack sheets daily with changes. Facility Nurses will use hot rack charting with their report sheet for shift to shift nursing report to assist with communication and follow up. The report sheets will be reviewed by Director of Nursing and discussed in morning QA (Quality Assurance) meetings.
- Director of Nursing provided a print out of the daily dashboard electronic clinical record. Director of Nursing is reviewing the Point Click Care Dashboard, 24-hour report, pain management, and physician notification of change, daily for four weeks, to ensure effective measures are implemented for quality resident care.
- Director of Nursing provided a pain management weekly audit sheet. This audit documents five residents are being reviewed weekly for pain management.
- The facility Pain, Change in condition, and notification of changes in-service documents Director of Nursing reviewed policies and procedures with all nursing staff. Director of Nursing will discuss pain management policy and procedure and notification of changes at monthly nursing meeting.
- Director of Nursing and Administrator held an interdisciplinary meeting to discuss changes in conditions of residents. Administrator provided quality assurance meeting notes.