Failure to Timely Administer PRN Pain Medication After Resident Fall
Penalty
Summary
A deficiency occurred when a resident who experienced a fall and reported significant pain did not receive timely administration of PRN pain medication. After the fall, the resident was found unable to move his left leg and expressed considerable pain, especially with movement. Although nursing staff assessed the resident and notified the physician, there was a failure to ensure that pain medication was administered and documented in a timely manner. The resident's pain persisted for 44 hours before he was ultimately hospitalized and diagnosed with a left hip fracture requiring surgery. The resident involved had multiple complex medical conditions, including ataxia, epilepsy, abnormal gait, schizoaffective disorder, hypertension, diabetes with neuropathy, and heart failure. Following the fall, staff interviews and record reviews revealed lapses in pain assessment, documentation, and follow-up. Nursing staff did not consistently reassess the resident's pain or verify the effectiveness of any pain interventions. There was also confusion regarding the x-ray order, with delays in obtaining diagnostic imaging and a lack of follow-up with the diagnostic company. Documentation in the resident's medical record and Medication Administration Record (MAR) did not show evidence of pain medication being administered between the time of the incident and the resident's transfer to the hospital. Despite the facility's pain management policy requiring prompt assessment and intervention for pain, these procedures were not followed, resulting in the resident experiencing unaddressed pain for an extended period prior to hospitalization.