Failure to Assess and Document Change in Condition Resulting in Delayed Pain Treatment
Penalty
Summary
A deficiency occurred when staff failed to promptly assess and document a change in condition for a fully dependent, non-ambulatory resident with multiple comorbidities, including dementia, schizoaffective disorder, and heart failure. The resident exhibited increased pain and abnormal behaviors, such as intense rocking, grimacing, and vocalizations, which were observed by several CNAs and reported to nursing staff. Despite these observations, nursing staff attributed the behaviors to the resident's baseline diagnoses and did not conduct or document a thorough assessment or follow-up, even when the resident's leg was noted to be externally rotated and he displayed pain upon touch. Multiple staff members, including CNAs and nurses, reported noticing the resident's increased discomfort and abnormal leg positioning over several days. These changes were communicated during shift reports and to the responsible nurse, but no progress notes or assessments were completed to address the resident's change in condition. Pain assessments documented a score of zero on the day the leg abnormality was discovered, and pain medication was administered only twice in the days preceding the event. The resident's family member ultimately insisted on hospital transfer, where imaging revealed acute, complete bilateral femoral neck fractures. The facility's investigation did not identify abuse or neglect but concluded that the injuries were likely subacute and possibly pathological in nature. However, the lack of timely assessment, documentation, and communication with the medical director regarding the resident's increased pain and change in condition resulted in a delay in treatment and recognition of the fractures. The facility did not have a specific pain management policy, and staff failed to follow the existing policy for change in resident condition, which required physician and family notification for significant changes.