Failure to Assess Pain After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with right knee osteoarthritis, hypertension, and ataxia was not assessed for pain following a fall. The resident, who had cognitive impairment and required substantial assistance with daily activities, was found on the floor by a CNA after a loud noise was heard. The CNA, noting the resident was nonverbal but nodded to indicate she was okay, did not notify the Charge Nurse of the fall due to nervousness and the presence of a recertification survey. Instead, the CNA returned the resident to bed and monitored for pain or discomfort without further assessment. A review of the resident's records indicated that, during a change of condition assessment, the resident exhibited facial grimacing and right leg pain when moved, but was unable to verbalize pain. The facility's policy required that all incidents or accidents be reported to the Charge Nurse and documented immediately, with the Charge Nurse responsible for the completeness and accuracy of the report. However, this protocol was not followed, resulting in a delay in pain assessment and intervention for the resident.