Failure to Assess, Document, and Manage Resident Pain Following Fall
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident who required such services. The resident, who had multiple diagnoses including acidosis, major depressive disorder, muscle weakness, and cognitive communication deficits, was identified as being at risk for pain and had care plan interventions in place for pain monitoring and management. Despite these interventions, after an unwitnessed fall, the resident began to complain of pain, specifically in the left hip and leg, as reported by both the resident and their family member. Staff, including a unit manager and a certified nursing assistant, were made aware of the resident's pain, and the care plan called for monitoring, reporting, and intervention for pain. However, the medical record review revealed that no orders for pain medication or non-pharmaceutical pain relief methods were obtained or administered after the resident's pain was reported. There was no documentation of pain assessment, physician notification, or follow-up to obtain pain management orders. Interviews with staff confirmed that the responsibility to notify the physician and obtain pain medication orders was not fulfilled, and the electronic medical record showed no evidence of pain medication administration. The resident continued to experience significant pain throughout the day, as documented by physical therapy and nursing notes, and was eventually sent to the emergency department for evaluation. The facility's own pain assessment and management policy required appropriate assessment, documentation, physician notification, and intervention for pain, but these steps were not followed. The director of nursing acknowledged that the required assessments, notifications, and documentation were not completed, and that the facility's policies and procedures were not adhered to in this case. This resulted in a failure to provide appropriate pain management for the resident as required by professional standards and facility policy.