Failure to Provide Timely Pain Assessment and Intervention After Fall
Penalty
Summary
A deficiency occurred when a resident admitted for respite care with hospice services experienced a fall resulting in displaced fractures of the left tibia and fibula. Despite the fall, there was no evidence of a pain assessment at admission or after the incident. The resident was found on the floor by an LPN, who documented no apparent injuries and did not complete a pain assessment or notify hospice of the fall. Throughout the night following the fall, the resident exhibited significant distress, including screaming, crying, and aggression, yet there was no documentation of pain assessments, offers or refusals of pain medication, or notification to hospice regarding the resident's deteriorating condition. The resident's pain escalated, and it was not until a hospice visit the following day that swelling, bruising, and inability to bear weight on the left knee were observed. The hospice nurse notified the facility, and an x-ray was ordered, which later confirmed the fractures. The medication administration record showed no pain medication was offered, refused, or administered until nearly 24 hours after the fall, despite the resident's ongoing and escalating pain. Interviews with staff confirmed a lack of pain assessment, inadequate documentation, and failure to notify hospice in a timely manner. Facility policy required pain assessment at admission and during changes in condition, but this was not followed. The resident was eventually transferred to the hospital after the fractures were identified, but there was no documentation of the transfer, pain assessment at discharge, or communication of x-ray results to hospice. The failure to provide timely and adequate pain assessment and intervention following the fall resulted in actual harm to the resident.