Failure to Timely Assess, Manage Pain, and Obtain Evaluation After Resident Fall With Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up care, assessment, and pain management after a resident sustained a fall and subsequently was found to have a right hip fracture. The resident had significant cognitive deficits, stroke with right-sided weakness, COPD, and TIA, and was dependent on staff for toileting and bathing. The care plan identified the resident as at risk for falls with walking and balance problems and specified that the resident should not be left alone in the wheelchair or bathroom and should have the call light within reach, but the fall that occurred on 02/10/26 and the resident’s pain were not added to the care plan. After the fall, documentation showed the resident was found on the floor near the bed after attempting to get into bed and was transferred back to bed with a mechanical lift. Following the fall, there was no documented post-fall assessment on the day of the incident, and subsequent nursing notes did not include complete assessments of gait, grasp, or upper and lower extremity movement. CNA and therapy staff reported the resident was grunting, groaning, grimacing, and turning red with movement, and that the leg appeared swollen, but these observations were not reflected in the nursing documentation. Pain assessments recorded on the MAR for several days after the fall consistently showed a pain score of 0 on all shifts, and no acetaminophen or other pain medication was administered, despite family reports of pain and therapy staff concerns. The facility’s policies required assessment and treatment of injuries after a fall, notification of the practitioner for accidents or new pain, and support of residents’ right to optimal pain assessment and management, including recognition of non-verbal expressions of pain. When the resident’s family reported pain in the right leg/hip area, an order was obtained for a mobile x-ray of the right hip. The mobile x-ray service was unable to perform the x-ray as initially scheduled and delayed it until the following day, yet the resident was not sent to the hospital that night despite ongoing pain complaints. Nursing notes during this period still lacked complete assessments of lower extremity movement. The x-ray ultimately showed an acute right hip fracture, and the resident was then sent to the hospital by ambulance. Interviews with staff revealed that therapy had notified an LPN about the resident’s pain and that multiple CNAs had reported pain complaints after the fall, but nursing staff did not treat the pain or promptly arrange hospital evaluation when mobile x-ray was unavailable, resulting in several days without appropriate pain management or timely diagnostic follow-up.
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