Failure to Assess and Manage Pain Following Resident Fall
Penalty
Summary
A deficiency occurred when a resident who was at risk for falls and dependent on staff for all transfers was not properly assessed for injury and pain following a fall. The resident, who had a history of muscle weakness, abnormal gait, and prior knee replacements, was found to have sustained a hip and femur fracture. Despite having physician orders for as-needed pain medications, the resident did not receive any pain relief between the dates surrounding the incident, and pain assessments documented minimal or no pain, even though family members and staff observed signs of pain and physical abnormalities in the resident's leg. Family members reported that the resident appeared to be in pain and had visible leg deformities, prompting them to request further evaluation. Staff interviews revealed that pain and injury were reported to a nurse, but there was no evidence that the nurse conducted a thorough assessment, notified the physician or family, or administered pain medication. Documentation in the resident's medical record did not reflect the pain complaints or the fall, and pain assessments were inconsistent with the observations of pain by family and staff. When the resident was eventually sent to the hospital, x-rays confirmed fractures in the left femur and right hip. Hospital records indicated that the resident and her family had reported pain for several days prior to transfer, but the facility's records did not document these complaints or provide appropriate pain management. The facility's fall policy required consistent identification, evaluation, and treatment of residents who fall, which was not followed in this case.