Failure to Provide Timely Assessment and Pain Management After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of Alzheimer's disease experienced a fall resulting in a fractured hip. Following the fall, the resident exhibited clear signs of severe pain, inability to bear weight, and abnormal alignment of the right leg. Despite these symptoms, the facility did not promptly initiate emergency medical treatment or appropriate mobility interventions for a potential hip fracture. The resident was placed in a recliner rather than being immobilized, and the care plan was not updated to reflect the new risk factors or interventions needed for pain and immobility. Pain assessments and management were inadequate. Only one pain assessment was documented from the time of the fall until 6 PM, with a pain rating of 10/10, and only one additional assessment was recorded overnight, with a pain rating of 8/10. The only pain medication administered was acetaminophen, which was documented as non-effective for the resident's severe pain. No other pain relief measures were provided, and the resident continued to experience excruciating pain until transfer to the hospital the following morning. The facility also failed to ensure timely diagnostic evaluation, as the x-ray ordered after the fall was not completed before the resident's transfer to the hospital. Upon arrival at the emergency department, the resident was found to have a comminuted, displaced, and angulated hip fracture, and surgery was scheduled. The emergency room physician noted the lack of immediate transfer to the hospital despite the resident's severe pain and significant injury. Documentation inconsistencies were also noted regarding whether the fall was witnessed and the care provided post-fall.