F0697

G

Failure to Provide Ordered Pain Management After Fall With Back Hematoma and Compression Fracture

Iron River, Michigan Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide physician-ordered pain treatment and pain medication for a resident following a fall, resulting in prolonged, inadequately relieved pain and a decline in urinary continence. The resident, who had chronic pain syndrome, cancer, COPD, and anxiety disorder, was cognitively intact and had a history of frequent pain that interfered with sleep, rehabilitation, and daily activities. On the date of the fall, the resident reported that her legs gave out and her back struck the bed frame, causing unbearable pain and a large, tender hematoma on the lower back. The incident report documented a large hematoma/abrasion with missing skin and bleeding, and the resident rated her pain as 6/10 at that time. A physician progress note from that day documented a very tender large hematoma and contusion to the lower back, with instructions that ice could be used for two days followed by heat, and that oxycodone might need to be increased if pain was uncontrolled.

In the days following the fall, the resident reported excruciating pain to a family member and stated that her pain medication did not relieve the pain. She reported staying in bed for days, being afraid to get up due to pain, and becoming incontinent in bed because she did not get up to use the bathroom. A CNA confirmed that after the fall the resident complained of pain, was concerned about the appearance of the hematoma, did not get out of bed due to pain, and was incontinent for a couple of days. Nursing pain assessments documented that the resident had frequent pain over multiple five-day periods, with pain frequently making it hard to sleep, limiting participation in rehabilitation, and limiting day-to-day activities. Pain intensity was documented as very severe/horrible shortly after the fall and later as 5, with notes linking the pain to the hematoma from the fall.

Despite these findings, there were multiple failures to implement and consistently provide ordered pain-related interventions. The DON and RN staff acknowledged that non-pharmacological interventions such as cold or hot/warm compresses, which the physician and DON described as standard of care for a hematoma, were not initiated until about a week after the fall, and skin evaluations on 1/7 and 1/14 documented the back bruise/hematoma with "no interventions." When warm compresses were finally ordered on 1/14 to be applied three times daily, the MAR showed multiple missed administrations with no documented rationale. The resident’s scheduled oxycodone regimen for chronic pain and later for trochanter pain was also not administered at several scheduled times on multiple days, again without documentation of why doses were omitted. The DON acknowledged a delay in treatment, uncertainty about whether the physician was notified of increased pain, and that the resident’s increased pain was not communicated to the physician, while the physician stated that staff did not inform him of increased pain and that he was unaware of it until a follow-up visit. An x-ray ordered on 1/14 and completed on 1/16 revealed a compression fracture of the L1 vertebra associated with post-fall pain. The facility’s pain management policy required recognition, evaluation, and management of pain, use of non-pharmacological interventions such as cold compresses, and practitioner notification when pain was not controlled, but the documented actions and omissions showed that these standards were not followed for this resident.

The cumulative effect of these failures—delayed initiation of non-pharmacological interventions, inconsistent provision of ordered warm compresses, missed doses of scheduled oxycodone without explanation, and lack of timely communication to the physician about increased pain—resulted in the resident experiencing prolonged pain that was not adequately relieved by medications and a decline in urinary continence, as the resident remained in bed and was incontinent due to fear of worsening pain when getting up.