Failure to Recognize, Assess, and Manage Pain Following Resident Fall
Penalty
Summary
A deficiency occurred when a resident who had recently been admitted to the facility experienced a fall during toileting and was subsequently moved by nurse aides and an occupational therapy assistant without a nurse first assessing the resident for pain or injuries. The nurse aides did not immediately report the resident's pain to the nurse after the fall. When the nurse was eventually notified of the resident's leg pain, a proper pain assessment was not completed at that time. Instead, the nurse administered acetaminophen and only later performed a head-to-toe assessment after being approached by the resident's family member, who reported the fall and pain. The resident involved had significant medical conditions, including metabolic encephalopathy, type 2 diabetes, cirrhosis of the liver, and sepsis due to E. coli. The resident was admitted to the facility for only a few hours before the incident occurred. There was no comprehensive care plan available for the resident, and the initial assessment documentation was incomplete, particularly regarding the resident's mobility and safety needs. Staff interviews revealed that the hospital did not communicate the need for lift assistance, and the admitting nurse did not complete the required documentation to inform other staff of the resident's assistance needs, which may have contributed to the fall and subsequent handling of the resident. Witness statements and interviews with staff indicated that the resident complained of pain during and after being moved, but the information was not promptly or adequately communicated to the nurse. The nurse did not perform an immediate assessment upon learning of the pain and only took action after the family intervened. The resident was later transported to the hospital, where a femoral fracture was diagnosed. The facility's failure to recognize, assess, and manage the resident's pain in accordance with professional standards and the lack of proper communication and documentation led to the identified deficiency.