Failure to Provide Timely Pain Management After Resident Fall
Penalty
Summary
A resident with diagnoses including dementia, peripheral vascular disease, and osteoarthritis, who was identified as being at risk for falls and experiencing both acute and chronic pain, suffered a fall resulting in severe pain and a subsequent fracture. Following the fall, the resident was found on the floor, assessed, and neuro checks were initiated. Although the resident was noted to be in visible pain, with swelling and deformity of the right leg, there was a significant delay in obtaining an x-ray and providing effective pain management. The resident repeatedly exhibited signs of distress, including grimacing, holding the affected leg, and verbalizing pain, but only received PRN Tylenol after several hours, which was initially declined. Morphine was not administered until much later, and the x-ray confirming a comminuted and displaced femur fracture was not completed until 14 hours post-fall. Throughout this period, documentation shows that responsible parties, including the DON and Nursing Home Administrator, were informed of the resident's ongoing severe pain, but no additional assessments, treatments, or emergency interventions were initiated until after the x-ray was completed. The DON did not assess the resident or follow up on the x-ray order despite being aware of the situation. Interviews confirmed that no appropriate action was taken to address the resident's severe pain for 14 hours, resulting in prolonged unmanaged pain and actual harm.