Failure to Provide Timely Assessment and Appropriate Pain Management After Resident Fall
Penalty
Summary
A resident with severe cognitive impairment and multiple comorbidities, including dementia, parkinsonism, osteoporosis, and a history of traumatic brain injury, experienced a fall in the facility. Staff failed to promptly assess the resident for a change in condition after the fall, despite the resident expressing pain in her left arm and hip. Instead of conducting an immediate assessment as required by facility policy, staff lifted the resident from the floor and placed her in a chair while she complained of pain. No vital signs or neurological assessments were performed at the time, and the physician was not notified immediately of the incident or the resident's complaints of pain. Following the fall, the resident continued to express moderate to severe pain, was unable to bear weight, and refused food. Staff administered acetaminophen, which was only ordered for mild pain, despite the resident reporting moderate pain levels. The medication was ineffective, and the resident's pain persisted for several hours. Documentation shows that the resident did not eat lunch or dinner due to her pain, and her pain was not adequately reassessed or managed according to the facility's pain management policy. The physician was not notified of the resident's ongoing pain and change in condition until several hours after the incident, and only after the pain had escalated to severe levels. Interviews with staff and witnesses confirmed that the resident was in visible distress, repeatedly vocalized her pain, and was unable to participate in normal activities. The lack of timely assessment, inadequate pain management, and delayed physician notification resulted in the resident experiencing prolonged pain and discomfort. The facility's own policies regarding post-fall assessment, pain management, and change in condition notification were not followed, directly contributing to the deficiency identified in the report.