F0697

G

Failure to Promptly Assess and Adequately Manage Severe Pain After Arm Fracture

Olney, Illinois Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to promptly assess and adequately manage severe pain for a resident who sustained an acute left humerus fracture. The resident was a recent admission with multiple serious diagnoses, including COPD, Type 2 diabetes, CHF, small cell B lymphoma, hypertension, prostate cancer, and lymphoma. On the afternoon of admission, two CNAs repositioned the resident in a recliner by placing their arms under the resident’s armpits and lifting without a gait belt. During this maneuver, three loud pops were heard from the resident’s left arm, and the resident immediately stated that the arm was broken. A family member present confirmed hearing a loud crack and reported that the resident said, “You broke my arm.” The CNA promptly reported the incident to the RN on duty (V5), who stated she would assess the resident after completing a medication pass but then forgot, did not assess the resident, and did not report the incident to the oncoming nurse.

Later that evening, the oncoming RN (V6) was informed by the CNA that there had been a popping noise from the resident’s arm during repositioning and that the resident was in pain. V6 assessed the resident and noted that the left arm was not bruised or swollen and was not painful if immobile, but there was significant pain with movement and decreased range of motion. V6 contacted the on-call physician (V9), who ordered a portable x-ray, and administered two Tylenol tablets around 7:00 p.m. per an existing PRN order. The family member reported that as the evening progressed, the resident was in “horrible pain,” moaning and screaming out when repositioned, and that Tylenol was not given until sometime around 9:00 p.m. The family member also stated that when she requested stronger pain medication, V6 responded that obtaining a narcotic order at that time of day was “a whole big thing.” The x-ray later confirmed an acute, likely pathological, fracture of the proximal shaft of the left humerus.

Overnight, the night-shift RN (V7) recalled that the resident was guarding the arm and did not want it moved, but did not recall performing a pain scale or the specific severity of the pain, and was unsure if Tylenol was administered during her shift. The MAR documented that Tylenol was given at 9:29 p.m. and again at 6:35 a.m., with no numeric pain ratings recorded and only qualitative notes that it was effective or slightly effective. The facility’s records also showed a standing order for pain assessment every shift, with pain documented as zero on the evening and night shifts, despite reports of significant pain with movement and family observations of severe pain. On the following morning, the day-shift RN (V8) assessed the resident and documented a pain level of 10/10. Tylenol was administered around 6:30 a.m. with little effect, and V8 contacted the primary care physician (V10), who ordered hydrocodone-acetaminophen PRN. Due to limitations in e-prescribing and pharmacy access, the narcotic was not administered until after 10:30 a.m., during which time the resident continued to experience severe pain. Staff interviews indicated that nurses perceived obtaining narcotic pain medications, especially at night and for new residents, as difficult, and this contributed to delays in escalating pain management beyond Tylenol.

The facility’s own Pain Prevention and Treatment Policy required that each resident be assessed for pain using an appropriate pain rating scale upon admission and at least quarterly, and that after completion of the assessment, residents receive interventions to reduce or alleviate pain, including pharmacological interventions with a physician’s order. The resident’s MDS pain assessment documented that in the last five days the resident rarely or not at all experienced pain, and that the worst pain over the last five days was rated as 4, which did not reflect the documented 10/10 pain level and severe pain behaviors described after the fracture. The MAR lacked numeric pain ratings associated with PRN pain medication administration and showed a pain score of zero on shifts when the resident was reported to have significant pain with movement. These actions and inactions—including failure to promptly assess the injury when first reported, failure to consistently and accurately assess and document pain using a numeric scale, and delays in obtaining and administering stronger pain medication—resulted in the resident experiencing severe pain for approximately four hours after sustaining the fractured left humerus.