Failure to Provide Timely and Effective Pain Management After Resident Fall
Penalty
Summary
A resident with a history of stroke and right-sided hemiplegia experienced a fall during an assisted transfer, resulting in acute pain and later confirmed fractures of the tibia and fibula. The resident, whose preferred language was Spanish and required an interpreter, reported severe pain immediately after the fall, rating it as 9 out of 10. Despite these reports, there was ineffective communication among staff, and a medical provider was not notified of the fall or the resident's pain until two days later. During this period, staff failed to use an interpreter to accurately assess the resident's pain level or the effectiveness of any interventions. Documentation and interviews revealed that the resident repeatedly expressed pain through both verbal and non-verbal cues, such as grimacing, crying, and grabbing her knee. Staff members, including nurse aides and nurses, were made aware of the resident's pain and the fall, but there was a lack of timely action to address her needs. Pain assessments were documented as zero on the medication administration record, despite clear evidence of pain, and the resident did not receive any pain medication until ibuprofen was ordered and administered two days after the incident. This initial pain management was ineffective, and there was no evidence that a provider was contacted for additional or alternative pain control until the nurse practitioner was notified of the x-ray results. The resident did not have a care plan in place for pain, and staff did not consistently use interpreters to communicate with her, resulting in inadequate assessment and delayed treatment. The nurse practitioner, upon finally being notified and using an interpreter, assessed the resident and ordered opioid pain medication, which was effective. The deficiency was identified through record review, interviews, and direct observation, showing a failure to provide safe and appropriate pain management for a resident with acute pain following a fall.