Failure to Assess and Monitor After Falls Resulting in Delay of Treatment and Increased Pain
Penalty
Summary
A resident with a history of dementia, difficulty walking, schizophrenia, and diabetes experienced two falls within a short period, one of which was unwitnessed. Following the unwitnessed fall, required neurological assessments and pain evaluations were not performed as per facility protocol. The incident report for the first fall was incomplete, with critical assessment fields left blank, and neurovital sign monitoring was not initiated immediately. The nurse responsible did not communicate the details of the falls, including the unwitnessed nature of one, to the oncoming nurse, resulting in a lack of timely monitoring and assessment. Throughout the night and into the following day, there were no documented neurological or pain assessments for the resident, despite observable signs of distress and confusion. The resident was later found to have a swollen, painful, and displaced left leg, with a pain level of 8/10, only after a nurse aide alerted the day shift nurse. The resident's pain was not addressed with medication until the following day, and the neurological assessment was only started at that time. The nurse practitioner, upon assessment, observed significant changes in the resident's condition and arranged for immediate transfer to the hospital, where a left hip fracture was diagnosed. Documentation in the medical record and medication administration record was inconsistent and incomplete, with unclear codes and missing entries regarding pain management. The facility failed to provide its neurological assessment and pain management policies when requested. The lack of thorough assessment, monitoring, and documentation after the falls led to a delay in treatment, increased physical distress, and worsening pain for the resident.