Failure to Assess, Document, and Notify Provider of New Onset Pain
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with severe cognitive impairment and multiple comorbidities, including generalized osteoarthritis, dementia, and a history of right lower femur fracture. The resident, who was dependent on staff for most activities of daily living, experienced new onset pain that was not properly assessed, documented, or communicated to the provider in a timely manner. On the evening when the resident first exhibited significant pain, the nurse administered acetaminophen but did not perform or document a thorough pain assessment, nor did she notify the provider of the new onset pain. The following day, another nurse was alerted to the resident's pain, conducted an assessment, and identified pain in the right leg with movement, which was not typical for the resident. The nurse changed the resident's transfer method to accommodate the pain and attempted to notify the provider, but did not ensure that the provider received the notification before the end of her shift. The provider was not made aware of the situation until the next day, when an X-ray was ordered, ultimately revealing a right lower femur fracture. Throughout this period, there was a lack of documentation regarding the initial pain episode and insufficient communication with the provider about the resident's change in condition. The facility's policy required notification of significant changes in a resident's condition, but this was not followed. The delay in assessment, documentation, and provider notification contributed to a delay in identifying the cause of the resident's pain and in initiating appropriate interventions.