Failure to Notify Providers and Manage Worsening Pain After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to effectively manage and treat a cognitively impaired resident’s pain following a fall from a wheelchair. On 2/1/26, the resident fell backwards onto the floor while seated in a wheelchair during care, landing directly on his back. A nurse practitioner was notified by phone of the fall and ordered Tramadol 50 mg every four hours as needed for pain, in addition to the resident’s scheduled Tramadol three times daily. Progress notes for that day documented the fall and the new pain medication order but did not show that the resident was seen or assessed in person by a physician or nurse practitioner on 2/1/26. On 2/2/26, progress notes documented that the resident began complaining of increased back pain with movement, yelling when the head of bed was elevated or lowered or when staff assisted with repositioning. Nursing staff interviews confirmed that the resident stayed in bed, yelled with movement due to back pain, and refused cares because movement worsened his pain. Despite these observations of worsening pain and refusal of care, there was no documentation that the physician or nurse practitioner was notified on 2/2/26, and no evidence that the resident was seen or assessed by a provider that day. The nurse practitioner later stated she had been in the facility seeing other residents on that date but was not informed of the resident’s worsening pain. By 2/3/26, progress notes showed the resident continued to have back pain from the fall, was yelling out when staff attempted to provide care, and refused a shower, stating he hurt too badly. Nursing staff notified a nurse practitioner that morning regarding the resident’s condition and that he was yelling out in pain even when not being touched. The resident’s POA was also notified and requested that he be sent to the hospital. The resident was transferred by ambulance, and a hospital CT scan on 2/3/26 revealed an acute, unstable fracture of the eighth thoracic vertebra consistent with a hyperextension injury from the fall. The facility’s own pain management policy required reassessment and revision of the pain management regimen and plan of care when pain was not adequately controlled, but the record showed no timely provider notification or adjustment of treatment in response to the resident’s worsening pain on 2/1/26 and 2/2/26.
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