Failure to Evaluate and Communicate Change in Condition and Pain Management
Penalty
Summary
Facility staff failed to ensure a complete evaluation and timely physician notification regarding a resident's change in condition and pain management needs. The resident, who had a history of falls and was admitted with hip, pelvis, and knee pain, continued to experience significant pain and functional limitations after admission. Despite ongoing reports of pain from both the resident and therapy staff, and documentation of pain interfering with therapy progress, nursing staff did not adequately monitor or communicate the onset, duration, and severity of the resident's pain to the physician. On multiple occasions, the resident reported moderate to severe pain in the right hip and knee, which was not effectively managed with Tylenol. Therapy notes indicated that pain was constant and limited the resident's ability to participate in functional activities. Although Tramadol was indicated for pain management, there was no evidence that nursing staff obtained a physician's order or discussed the need for this medication with the physician. Additionally, there was no documentation that Tramadol was administered on the relevant dates. Interviews with staff confirmed that the physician was not notified of the significant change in the resident's medical condition, and pain management was not appropriately addressed. The lack of monitoring and communication contributed to the resident being sent to the hospital, where a deformed fracture of the right femur was diagnosed. The facility's failure to follow its policy for evaluating and reporting changes in condition resulted in inadequate pain management and delayed treatment for the resident.