Delayed Hospital Transfer and Inadequate Pain Management Following Fracture
Penalty
Summary
A resident with Alzheimer's Disease and dementia, residing on a locked memory care unit, experienced a fall and subsequently complained of right thigh pain. An initial x-ray of the right hip was negative for fracture, and the resident was prescribed oxycodone for pain as needed. Over the following days, the resident continued to report significant pain, with documented pain scores ranging from 4 to 8, and received several doses of pain medication. Despite ongoing pain and difficulty ambulating, a second x-ray was not ordered until the next day, which revealed an acute right femur fracture late in the evening. After the positive fracture diagnosis, there was no documentation that the physician was notified promptly, nor was there evidence of further pain assessment or administration of pain medication throughout the night. The provider was not made aware of the x-ray results until the following morning, at which point the resident was assessed and orders were given for hospital transfer. This resulted in a delay of approximately 9.5 hours from the time the fracture was confirmed to the time the resident was sent to the hospital. There was also no documentation of when EMS was called or when the resident was actually transferred. During this period, the resident did not receive additional pain management or documented assessments for pain or discomfort. Upon hospital admission, the resident required surgical intervention for the fracture and was administered IV morphine for pain control. The facility failed to provide timely transfer to the hospital following confirmation of the femur fracture and did not adequately monitor or manage the resident's pain prior to transfer.