Failure to Complete Comprehensive Post-Fall and Pain Assessments
Penalty
Summary
A deficiency occurred when staff failed to provide care and treatment in accordance with professional standards of practice for a resident who experienced multiple falls and subsequent complaints of pain. Despite facility policy and professional guidelines requiring comprehensive head-to-toe, skin, respiratory, and pain assessments after each fall, documentation revealed that these assessments were not consistently completed. Specifically, after several falls, there was no documentation of head-to-toe skin assessments, and when the resident later complained of rib and hip pain, comprehensive pain and respiratory assessments were not performed or documented as required. The resident involved had a history of atrial fibrillation, congestive heart failure, hypotension, and syncope, and was cognitively intact according to the admission assessment. The resident experienced multiple falls, after which staff documented vital signs, musculoskeletal, and neurological assessments, but repeatedly omitted thorough skin and focused respiratory assessments. When the resident reported symptoms such as rib pain, shortness of breath, and increased pain intensity, staff did not complete or document comprehensive pain assessments that included quality, functional impairment, onset, and duration, nor did they perform focused respiratory assessments as indicated by the resident's complaints. Interviews with nursing staff and the DON confirmed that facility expectations and professional standards required these assessments and documentation, but acknowledged that they were not completed in this case. The resident was eventually transferred to the hospital, where imaging revealed multiple healing rib fractures, a left hip fracture, and other complications, indicating that injuries may have gone unrecognized due to the lack of comprehensive assessments following the falls and pain complaints.