Failure to Assess and Manage Pain After Resident Fall With Fracture
Penalty
Summary
Facility staff failed to thoroughly assess and manage pain for a resident following a fall that resulted in a fracture. After the resident was rolled out of bed during care, documentation showed that the physician was notified and an order for an x-ray and Tylenol for pain was obtained. Nursing notes indicated that Tylenol was administered and that the resident was to be monitored for effective pain management. However, the Medication Administration Record (MAR) did not show any documentation of Tylenol being given, and there were no follow-up pain assessments recorded after the initial administration. Pain levels were documented as 8 out of 10 before and after the incident, but there were no pain assessments between the early afternoon and the time the resident was transferred to the emergency room, where stronger pain medication was administered. Interviews with staff confirmed the lack of documentation regarding pain medication administration and pain assessments. The Assistant Director of Nursing (ADON) was unable to confirm that pain assessments were conducted or that the resident was medicated for pain from the time of the fall until hospital transfer. The resident reported receiving Tylenol but stated it did not relieve the pain and that significant pain persisted until after hospital treatment. The deficiency centers on the facility's failure to provide safe and appropriate pain management, including thorough assessment and documentation, for a resident who required such services after sustaining a fracture.