Failure to Provide Timely Assessment and Care for Pain and Injury
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards, the person-centered care plan, and resident preferences for two of seven sampled residents. In the first case, a resident with a history of cerebrovascular accident, hemiplegia, and dementia complained of left arm pain over multiple days. Despite these complaints, there was no documented evidence that a pain assessment was conducted, pain medication was administered, or that a physician was notified in a timely manner. Orders for a STAT x-ray and acetaminophen were reportedly given verbally but were not entered into the electronic medical record, nor was there evidence that these orders were communicated to the appropriate staff or carried out. The resident's condition worsened, with increased swelling and altered mental status, leading to a hospital transfer where a left proximal humerus fracture was diagnosed. Documentation gaps and communication failures among nursing staff and between nursing and medical staff contributed to the lack of timely intervention and treatment for the resident's pain and swelling. In the second case, another resident with severe cognitive impairment and multiple comorbidities complained of left leg and hip pain. The initial response involved administration of Tylenol, but there was no comprehensive assessment or timely notification of a physician on the day the pain was first reported. Subsequent documentation showed that swelling and limited range of motion were observed, and a STAT x-ray was ordered only after further assessment the following day. However, the x-ray was not performed in the facility, and the resident was eventually transferred to the hospital, where a displaced comminuted intertrochanteric fracture of the left proximal femur was diagnosed. There was no evidence that a thorough physical assessment was documented at the time of the initial complaint, nor that the physician was notified promptly. Delays in diagnostic testing and incomplete documentation contributed to the deficiency. Both cases demonstrate failures in following facility policies regarding pain assessment, change in condition, and timely execution of physician orders for diagnostic services. There were repeated lapses in communication, documentation, and follow-through on physician orders, resulting in residents not receiving appropriate and timely care for their complaints of pain and changes in condition. These deficiencies led to actual harm for at least one resident, as evidenced by the delayed diagnosis and treatment of a fracture.