Failure to Provide Timely Pain Assessment and Management
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of falls reported pain in their right hip to a home health aide. The aide notified an LPN, who did not immediately assess the resident or escalate the concern to a registered nurse, instructing the aide to wait for the incoming shift. As a result, the resident was not assessed or provided pain management in a timely manner, with a delay of approximately 40 minutes before Tylenol was administered by the next shift's LPN. The resident, who required substantial assistance for mobility and had a care plan in place for pain management, was later found to have significant swelling and pain in the right leg. Upon assessment by a registered nurse, the resident was unable to move or bear weight on the right leg, and swelling was observed. The resident was subsequently transferred to the hospital, where an acute traumatic comminuted right femoral intertrochanteric fracture was diagnosed. Facility records and interviews confirmed that the LPN did not implement any interventions upon first being notified of the resident's pain and did not report the concern to the incoming nurse or supervisor. The facility's pain management policy required prompt assessment and management of pain, which was not followed in this instance. The delay in assessment and pain management was attributed to staff inaction and failure to follow established protocols.