Failure to Assess and Manage Severe Pain for Resident with Fracture
Penalty
Summary
A deficiency occurred when a resident with a fractured tibia and fibula experienced severe breakthrough pain that was not adequately assessed or managed by facility staff. Despite physician orders for as-needed Norco and Tylenol, and a care plan specifying the need for prompt pain management and monitoring, the resident went without any pain medication or documented non-pharmacological interventions for over 48 hours. During this period, the resident was observed multiple times displaying clear signs of pain, such as moaning, tearfulness, and fist-clenching, both during general observation and while receiving direct care. Medical record review showed the resident had multiple comorbidities, including heart failure, renal insufficiency, diabetes, depression, and COPD, and was cognitively intact but dependent on staff for most activities of daily living. The resident's pain was documented as frequent and severe, with a pain score of 7 out of 10 and a goal of 1. However, there was no documentation of pain assessment, administration of pain medication, or use of non-pharmacological interventions during the period in question. Staff interviews confirmed that the resident's pain was reported to nursing staff, but no action was taken to address or escalate the issue, and the nurse practitioner was not notified of the resident's pain as required. Facility policy required staff to assess and manage pain promptly, including identifying residents at risk, using standardized pain assessment tools, and anticipating pain during care activities. Despite these requirements, the resident's pain was not addressed, and there was no evidence of staff following the pain protocol or care plan interventions. This failure resulted in the resident experiencing actual harm due to unmanaged pain.