Failure to Provide Timely and Appropriate Pain Management and Documentation
Penalty
Summary
A resident with a history of cerebrovascular accident with hemiplegia and dementia, whose primary language is Creole, reported pain in the left arm. Initial assessment by nursing staff resulted in the administration of Acetaminophen, which provided only temporary relief. Over the following days, the resident exhibited increasing swelling and pain in the left upper arm, which was observed by both nursing staff and a certified nursing assistant. Despite these ongoing symptoms, there was a lack of consistent documentation and follow-up regarding the resident's pain and swelling. A physician was notified and gave a verbal order for a STAT x-ray and Acetaminophen 1000 mg. However, the order was not entered into the electronic medical record, and there was no documented evidence that the medication was administered or that the x-ray was performed. Communication breakdowns occurred between shifts, with staff failing to relay critical information about the resident's condition and physician orders. The resident's pain management care plan was not updated to reflect the new symptoms or interventions, and the resident was not placed on the 24-hour report as required by facility policy. The resident's condition deteriorated, with increased swelling, warmth in the affected area, and altered mental status. Eventually, the resident was transferred to the hospital, where a left proximal humerus fracture was diagnosed. Interviews with staff revealed confusion and lack of clarity regarding the handling of physician orders, documentation, and follow-up care. There was no evidence of abuse, neglect, or staff misconduct related to the fracture, but the facility failed to provide safe, appropriate pain management and did not follow its own policies for assessment, documentation, and communication.