F0684

G

Failure to Assess Post-Fall Injuries and Provide Translation, Resulting in Delayed Fracture Treatment

Lincolnshire, Illinois Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary care, services, and effective translation for a resident after a fall that resulted in hip and arm fractures. The resident had dementia, prior fractures, osteoarthritis, and spinal stenosis, required substantial/maximal assistance for most ADLs, and used a wheelchair. Her MDS documented Mandarin as her preferred language and that she wanted an interpreter to communicate with health care staff, and also showed she had no range of motion limitations prior to the events. Despite this, multiple staff and responding paramedics reported that the facility did not use translation services and instead relied on speaking English and interpreting the resident’s moans and groans, with staff and paramedics unsuccessfully attempting to use phone-based translation on their own.

On one date, the resident fell from bed while attempting a self-transfer, landing on her left side and bumping a dresser, with a small bruise to the left forehead documented and no pain or functional change reported at that time. The NP note for that fall described no change in mental status, pain, or ADL function post-event. Over the following weekend, the resident’s daughter and primary nurse reported that the resident was walking, using both arms, and not exhibiting pain. However, the roommate later reported hearing a loud fall on a subsequent night, describing the resident crawling to her side of the room, wedging herself by the door, and moaning and yelling in apparent pain. The roommate stated she activated the call light, staff had difficulty entering due to the resident’s position, and the resident was taken out in a chair and later returned to bed, with the roommate noting that the resident was in pain when moved. The roommate, who was cognitively intact per her MDS, also reported that staff did not use translator services and that she sometimes used Google Translate herself and had learned from the daughter that certain commonly used words meant “pain” and “bathroom.”

The night LPN later stated she found the resident on the floor around 12:30 a.m. during rounds, assessed her, and documented no pain or abnormal findings, gave acetaminophen “just in case,” and moved her to a wheelchair near the nurses’ station before she was later returned to bed. This fall note, however, was not entered until more than two days later and after the survey began, and the NP indicated she would not have seen a fall note in the chart at the time she was consulted. The day RN reported being told only that the resident was in pain and pointing to her hip, not that a fall had occurred, and obtained stat X‑ray orders for the left hip and forearm. CNAs reported that on the morning after the undocumented fall the resident remained in bed, ate in her room, and repeatedly said “Iyo” during care, a word they did not understand; the daughter later explained that “Iyo” meant “ouch” or pain. When EMS arrived for transfer after X‑rays showed fractures, paramedics found the resident in bed, noted bruising to the left side of her face and guarding of the left arm, and documented that staff reported a hip and left forearm fracture from a fall five days prior and that the resident only spoke Chinese. Paramedics reported that facility nurses told them they had no translator and that they communicated with the resident in English and interpreted her needs from sounds. Hospital evaluation confirmed a left hip fracture and displaced left elbow fracture, with the orthopedic note stating that staff reported the resident had started moaning the prior night and that X‑rays at the facility showed the fractures. The facility’s own policies required effective communication and language assistance services, as well as thorough assessment, documentation, and post‑fall procedures after any fall or change in condition, but the record and interviews showed gaps in timely fall documentation, incomplete communication of the fall and pain to the NP and oncoming staff, and lack of effective translation services, resulting in the resident experiencing pain and a delay in treatment.