Failure to Monitor and Manage Post-Fall Pain
Penalty
Summary
The facility failed to monitor and manage post-fall pain for a resident who sustained a left hip fracture. After the resident, who had severe dementia and other comorbidities, fell in the early morning hours, the nurse on duty assessed her and noted complaints of back and side pain but did not document any pain assessment or administer pain medication. There was no documentation of pain intensity or descriptors, and the resident's care plan did not address pain management either before or after the fall. The nurse also failed to notify the physician of the resident's pain complaints at that time. The following shift, an LPN was alerted by CNAs that the resident was in severe pain and refused to get out of bed, which was unusual for her. The LPN immediately contacted the physician, arranged for the resident to be sent to the hospital, and later learned the resident had a left hip fracture. Review of medication administration records showed no pain medication was given post-fall, despite orders for as-needed analgesics. The facility's pain management policy required regular pain assessments and physician notification for pain indicators, but these procedures were not followed.