Failure to Provide Timely Pain Management After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including muscle weakness, cognitive communication deficit, anxiety, depression, and schizoaffective disorder, sustained a fall and subsequently experienced severe pain. The resident, who had a low BIMS score indicating significant cognitive impairment and dependence on staff for mobility and toileting, was found on the floor after an unwitnessed fall. Upon assessment, the resident complained of left hip pain rated as 10 out of 10, with visible distress and limited range of motion. Orders were obtained for a STAT x-ray, bedrest, and ice application, and the resident was to be treated for pain as needed. Despite clear signs of severe pain, interventions to manage the resident's pain were not implemented in a timely manner. Ice was not applied until the day shift, several hours after the fall, and as-needed acetaminophen was not administered until more than eight hours later, when the resident continued to report significant pain. Nursing staff interviews revealed that the resident was assisted back to bed without pain assessment or medication, and pain management interventions were delayed. Documentation showed that pain was not reassessed prior to the end of the shift, and the effectiveness of interventions was not evaluated as required by facility policy. Imaging later confirmed the resident had sustained an acute left femoral intertrochanteric fracture, and the resident was transferred to the hospital for surgical intervention. Facility policy required prompt development and implementation of pain management interventions and documentation of their effectiveness, but these steps were not followed after the resident's fall and complaints of severe pain.