Failure to Promptly Address and Report Acute Pain Following Resident Fall
Penalty
Summary
The facility failed to promptly identify, intervene, and notify the provider regarding an acute change in a resident's uncontrolled pain following a witnessed fall. After the fall, the resident, who had a history of severe cognitive impairment and other medical conditions, reported significant pain in her leg but was able to move her legs during the initial assessment. Despite the resident expressing that the pain was the worst she had ever experienced and repeatedly using her call light to request help, the nurse on duty only administered Tylenol and faxed the physician, rather than sending the resident for immediate evaluation. Throughout the early morning hours, the resident continued to express severe pain, activating her call light seven times within a 25-minute period. Staff interviews revealed that aides and nurses were aware of the resident's ongoing distress, but the nurse decided not to escalate care or notify the physician directly, citing facility practice and the presence of a different provider. The nurse relied on her discretion and did not recognize the severity of the pain as a significant change from the resident's baseline, despite documentation of a pain score of 10 and staff observations of the resident's distress. It was not until the next shift, when another nurse observed the resident yelling in pain and noted physical signs such as facial grimacing and an abducted leg, that the decision was made to send the resident to the hospital. Hospital records later confirmed a serious injury, specifically a comminuted left acetabular fracture with protrusion of the femoral head. The facility's fall policy lacked clear guidance on pain assessment and physician notification following falls, and the Director of Nursing confirmed that staff had not received education on these procedures.