F0684

G

Failure to Assess and Manage Pain After Unwitnessed Fall With Fracture

Hanover, Pennsylvania Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely assessment, monitoring, and pain management following an unwitnessed fall with injury. Facility policies required that any fall, including unwitnessed falls and those with possible head injury, receive a licensed nurse evaluation, documented neurological checks, vital signs, pain assessment, and appropriate notifications to the physician and responsible party. The resident involved had diagnoses including osteoarthritis, legal blindness, and a comminuted distal right radius fracture, was cognitively intact with a BIMS score of 14, and required one-person assist for ambulation to the toilet. The care plan identified the resident as high risk for falls due to vision impairment and chronic pain with muscle weakness, with interventions such as prompt response to call lights and therapy evaluations.

On the evening in question, the resident experienced an unwitnessed fall at approximately 9:45 PM and was found on the floor next to the bed. A nurse aide reported that the resident stated she had tried to get to the bathroom herself and complained of right wrist pain, with a visible bump on the wrist and a scrape on the upper back. The aide further documented that the resident was unable to use the right wrist to hold the bathroom rail, later complained of head pain, and had a bump with a cut on the right side of the head that was bleeding, as well as another bump on the wrist. The aide reported these findings to the RN on duty. Despite these complaints and visible injuries, there was no documented assessment by the licensed nurse on that shift of the resident’s wrist, head, back, pain level, or vital signs, and no neurological evaluation flow record or progress note was completed for the fall on the 3–11 shift.

Statements indicated that the RN on duty did not initiate a new neurological assessment, did not reassess the resident after being informed of pain and injuries, and did not notify the RN Supervisor, physician, or responsible persons about the fall and change in condition. The RN reported being overwhelmed with workload and stated that the resident was already on neuro checks from a previous fall, and therefore new neuro checks were not started. The Medication Administration Record showed that ordered PRN acetaminophen for pain scores of 4–10 was not administered on the day of the fall. Later, during the night, the resident complained of severe wrist pain, described as excruciating, and a subsequent evaluation identified visible deformity and bruising of the wrist. The physician was then notified and ordered transfer to the hospital, where imaging confirmed a comminuted distal right radius fracture. The facility’s failure to timely reassess after the fall, to perform and document required neurological and pain assessments, to manage pain, and to notify appropriate clinical and responsible parties resulted in fracture-related pain and delayed corrective treatment for the resident.