Failure to Provide Effective Pain Management After Resident Fall
Penalty
Summary
A resident with a history of cervical spine fusion, functional quadriplegia, inflammatory spondylopathy, chronic pain syndrome, and cervical spinal stenosis experienced a fall when staff tilted the resident's wheelchair backward to transport him, resulting in the resident striking his head and neck on the concrete ground. Following the incident, the resident reported increased and persistent pain in the neck and back, radiating to the arms, with pain levels escalating from a pre-fall 8/10 to 9/10 post-fall. Despite these complaints, nursing staff did not conduct a thorough pain assessment or effectively manage the resident's pain in accordance with professional standards and the facility's pain management policy. The resident's medical records and interviews revealed that pain medication, including oxycodone-acetaminophen, was administered as needed, but the resident consistently reported that the medication was ineffective in controlling his pain. Documentation showed repeated high pain scores (averaging 8/10) over several weeks, and staff notes indicated the resident verbalized the ineffectiveness of the prescribed pain regimen. However, there was no evidence that staff reassessed the pain management plan, notified the physician of the ongoing uncontrolled pain, or revised the care plan as required by facility policy. Additionally, the facility failed to follow up on incomplete cervical spine x-ray results, which were necessary to rule out injury after the fall. The lack of follow-up on diagnostic results and the absence of a systematic approach to pain assessment and management led to the resident experiencing avoidable, uncontrolled pain. Staff interviews confirmed that the expected process of assessment, documentation, and physician notification was not followed, resulting in unmanaged pain for the resident after the fall.