Failure to Address and Treat Resident Pain After Shower Chair Injury
Penalty
Summary
A deficiency occurred when a resident with hemiplegia, hemiparesis, and dysphagia, who only spoke Hmong, experienced an accident while in a shower chair. The resident slipped and became stuck in the chair, resulting in a cut and visible injury to the right thigh. Multiple staff, including CNAs and nurses, witnessed the incident and observed the resident expressing pain both verbally and through facial grimacing. Family members also confirmed that the resident complained of pain following the incident. Despite clear evidence of injury and pain, there was a complete lack of documentation or follow-up in the resident's medical record. No accident or injury was recorded in the electronic medical record, and there were no notes from social workers, no physician consultation, no psychosocial follow-up, and no updates to the care plan. The Medication Administration Record showed no administration of new pain medication after the incident, and pain scores were recorded as zero each day, despite staff and family reports of pain. Interviews with staff revealed that the incident was known to the Director of Nursing and other nursing staff, but no one documented the event or addressed the resident's pain. The facility's pain management policy required recognition and evaluation of pain, especially after significant changes in condition, but these steps were omitted. The resident suffered without any pain relief or appropriate clinical response following the injury.