Failure to Provide Timely and Effective Pain Management Post-Fall
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents following a fall, resulting in ongoing uncontrolled pain and psychosocial harm. One resident, who was severely contracted and dependent on staff for all activities of daily living, sustained a femur fracture after falling from bed during care. Despite clear care plan instructions requiring two-person assistance for bed mobility and transfers, only one staff member was present at the time of the fall. The staff member involved was not adequately trained on the resident's care needs and did not request assistance, citing that other staff were busy. After the fall, the resident was assisted back to bed without a thorough assessment or documentation of vital signs and skin checks, and the family was not promptly notified of the incident. Following the fall, the resident experienced persistent and severe pain that was not effectively managed. There were delays in both the assessment and notification of the physician regarding the resident's pain, and an ordered X-ray was not completed in a timely manner. The resident was eventually transferred to the hospital, where a hip fracture was diagnosed, but she was deemed a poor surgical candidate due to her contractures and comorbidities. Upon return to the facility, there were further delays in administering prescribed pain medication due to prescription issues, and documentation of pain management was inconsistent. Staff interviews confirmed that the resident continued to experience significant pain, especially during care, and that pain assessments and care plan updates were lacking. The facility's documentation and communication failures extended to the care planning process, as the resident's pain care plan was not updated to reflect her increased pain and new interventions were not promptly implemented. Staff were not consistently aware of or following the most current care plan interventions, and there was a lack of coordination between therapy and nursing regarding pain management strategies. The cumulative effect of these failures resulted in ongoing physical pain and psychosocial distress for the resident, and the situation was determined to constitute Immediate Jeopardy.