Failure to Provide Timely Pain Management After Resident Fall
Penalty
Summary
A resident experienced a fall while ambulating with a walker, resulting in new onset pain that was documented as achy and later as sharp pain in the right hip. Despite repeated complaints of pain and a significant change in cognitive status, no pain medication or treatment was administered from the time of the fall until the resident was sent to the emergency room two days later. Nursing notes and medication administration records confirm that the resident's pain ratings increased from zero to four out of ten following the fall, but no interventions were initiated. The resident's physician was not notified of the increased pain and confusion until two days after the fall, at which point diagnostic imaging and hospital transfer were ordered. Staff interviews revealed that the resident was alert and able to communicate pain after the fall, but continued to experience worsening pain, increased confusion, and new incontinence over the weekend. The resident was found to have a displaced fracture of the right femoral neck and was admitted to the hospital for pain management and further evaluation. The resident's cognitive status declined significantly during this period, as documented by a drop in the Brief Interview for Mental Status (BIMS) score from 12 to 1.