Failure to Adequately Manage Ankle Fracture Pain and Notify Physician
Penalty
Summary
The deficiency involves the facility’s failure to provide pain management in accordance with professional standards of practice for a resident who sustained an ankle injury. The resident had diagnoses including chronic atrial fibrillation and diabetes and was documented as alert and able to make her needs known. After returning from a leave of absence, the resident’s right foot went under her wheelchair while being pushed by a transport company, and she was heard calling out. Initial documentation on the same day showed no redness or swelling, but the resident reported pain with a pain level of 5 and received 650 mg of acetaminophen twice that afternoon and evening. Later that evening, a health status note documented that the resident complained of right ankle pain, with swelling and redness observed; the ankle was wrapped with an ace bandage and ice was applied, and pain medication was administered. In the early morning hours, another note described continued complaints of right ankle pain, slight warmth, swelling, and sensitivity, and an x-ray of the right ankle was ordered. The MAR showed additional administration of 650 mg of acetaminophen for a pain level of 4. A subsequent note stated that the resident continued to experience right ankle pain and that pain medications were administered with little effect. Despite these ongoing complaints and limited response to PRN acetaminophen, there was no documentation that the physician was notified of the resident’s persistent pain or that additional or alternative pain medications were requested. An x-ray completed later that morning revealed a right bimalleolar ankle fracture. Subsequent notes documented that the resident remained in bed, voiced discomfort to the right lower extremity during repositioning, and received routine pain medication, again without evidence that the physician was notified regarding her pain. There was no physician note or assessment in the facility record addressing the resident’s pain. Hospital emergency department records showed that upon transfer, the resident reported immediate pain to the right ankle since the wheelchair incident, was noted to have significant ankle pain on musculoskeletal exam, and required IV morphine and IV fentanyl, as well as hospitalization for IV pain medications due to insufficient pain control. The facility’s failure to notify the physician and adjust pain management despite documented ongoing pain and ineffective PRN medication resulted in uncontrolled pain and hospitalization for pain management.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.