Failure to Adequately Assess, Monitor, and Communicate After Unwitnessed Fall With Pain Complaint
Penalty
Summary
The deficiency involves the facility’s failure to properly assess, acknowledge, monitor, and communicate about pain, and to implement appropriate interventions following an unwitnessed fall with a resulting femur fracture for one resident. The resident had dementia and was documented on the MDS as rarely or never understood, with long- and short-term memory problems. On the evening of 4/2/25, an LPN found the resident on the floor in their room, with the upper body leaning halfway on a chair. The resident could not give an accurate statement but complained of left leg pain. The LPN’s assessment documented no visible injury, no swelling, redness, or signs of trauma, and noted that the resident was offered pain medication but refused it three times before being assisted to bed. The LPN later stated in interview that the resident complained of leg pain, was able to take a couple of steps to the bed, and that the LPN did not return to check on the resident after the initial assessment because the resident did not require pain medication and the LPN needed to complete a medication pass. The LPN reported calling and leaving a message for the physician and calling the family, but did not inform the physician that the resident was complaining of pain, explaining that the resident always complained of leg pain from arthritis. There was no progress note identified from the 3 p.m. to 11 p.m. or 11 p.m. to 7 a.m. shifts documenting the fall beyond the late entry note, and the care plan later reflected that the resident was sent to the hospital for evaluation of left hip pain after the unwitnessed fall. Review of the neurological flow sheet from the time of the fall through the following morning showed multiple incomplete entries. The resident’s level of consciousness was not completed for several time points overnight, with only a notation of sleep, and movement entries were missing or marked as refused, including a blank entry at 3:00 a.m. The initials section was left blank for multiple time slots on the evening and overnight shifts. The DON stated that after an injury the nurse should monitor a resident according to the neurological flow sheet and complete pain monitoring for 48 hours, that no blanks should be present on the neurological flow sheet, and that the LPN should have spoken directly to the provider and explained that the resident was in pain rather than just leaving a message. Facility policies required immediate practitioner notification by phone when a fall results in significant injury or condition change, observation and documentation of delayed complications for approximately 48 hours, and documentation of pain and related signs and symptoms, as well as prompt initiation and documentation of accident/incident investigations and care plan review when desired outcomes are not met.
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