Failure to Provide Timely Pain Management After Resident Fall
Penalty
Summary
A resident with multiple medical conditions, including chronic obstructive pulmonary disease, schizoaffective disorder, muscle weakness, and moderate protein-calorie malnutrition, experienced an unwitnessed fall in their room. Following the fall, the resident was found on the floor, complained of right inguinal and thigh pain, and was unable to perform normal functions. Despite these complaints and visible signs of pain, no pain medication was administered for several hours after the incident. The resident's care records indicated a physician order for acetaminophen to be given as needed for mild pain, and the facility's pain management policy required prompt assessment and management of pain, especially in cognitively impaired residents. However, the LPN on duty did not provide any pain medication after the fall or during her shift, even after being notified multiple times by a CNA about the resident's continued pain. The resident's family also reported that the resident expressed pain during their visit, and the MAR confirmed that no pain medication was given on the day of the fall. Imaging was eventually ordered and performed, revealing a displaced fracture of the right femoral neck. The physician was not notified of a pain assessment or the resident's inability to bear weight, and there was a delay in both imaging and pain management. The DON later confirmed that pain should have been assessed and medication administered when the resident verbalized pain, but documentation showed that pain relief was not provided until the following day.