Failure to Provide Timely Pain Management After Resident Fall
Penalty
Summary
A resident with a history of dementia, muscle weakness, anxiety, and major depressive disorder experienced a fall in the dining room during the night. The resident was found on the floor, complaining of severe pain (rated 8 out of 10) in the right thigh, and exhibited limited range of motion due to pain. Despite having an active order for acetaminophen as needed for pain, the clinical record and Medication Administration Record (MAR) showed no documentation that pain medication was administered during the hour the resident waited to be transferred to the hospital. Both the charge nurse (LPN) and the Nursing Supervisor (RN) were present, observed the resident's pain, and acknowledged in interviews that the resident was in significant distress, but neither provided pain relief prior to transfer. Hospital imaging later confirmed the resident had sustained multiple minimally displaced pelvic fractures. Interviews with facility staff, including the APRN and Assistant Director of Nursing, confirmed that pain management should have been provided according to facility policy, which directs staff to evaluate and medicate for new or acute pain. The failure to administer pain medication was not in accordance with the facility's pain management policy and resulted in the resident remaining in severe pain for an extended period.