F0684

D

Failure to Report Resident’s Pain During Transfer Prior to Discharge

Charlotte, North Carolina Survey Completed on 01-28-2026

Penalty

Fine: $26,685

Summary

A resident with chronic pain, morbid obesity, muscle weakness, gait and mobility abnormalities, and bilateral lower extremity range of motion impairment was admitted and used a manual wheelchair and walker for mobility. The admission MDS indicated the resident was cognitively intact, had no reported pain in the five days prior to the assessment, and no prior falls. A physician order was in place for Tramadol 50 mg every 12 hours as needed, and pain assessments were documented twice daily. In July, the resident’s last documented pain score was 7/10 on day shift on 7/28, and the last documented Tramadol administration was on the morning of 7/30; no pain medication was documented on 7/31, the day of discharge. The PT reported that the resident could not complete the initial PT assessment on admission due to pain and fatigue, that therapy was limited to bed mobility and stretching because the resident could not tolerate getting out of bed due to pain, and that the resident began complaining of increased left hip pain on 7/23, which was reported to the Medical Director, who asked PT to continue to monitor.

On the day of discharge, the nurse documented a pain score of 0 and noted in a progress note that the resident was discharged to another SNF with all belongings via a transport company, with report given that there were no concerns or issues at the time of discharge. However, NA #8 later reported that while she and another NA were transferring the resident from bed to a manual wheelchair using a mechanical lift, the resident yelled out that her left leg was hurting as she was being raised in the lift. NA #8 stated that she and the other NA quickly lowered the resident into the wheelchair to ease the pain, and that the resident stopped complaining of pain once seated. NA #8 acknowledged that she did not inform the nurse or anyone else of the resident’s complaint of pain during the transfer, explaining that the resident often complained of pain with positioning but did not usually yell or scream, and that she focused on expediting the transfer rather than notifying the nurse.

After the transfer to the wheelchair, the transportation driver took the resident to the van; the NAs did not escort them. The transportation company’s Operations Manager reported that video review showed the driver rolling the resident into the van on a hydraulic lift, locking the wheelchair in place, and never removing the resident from the wheelchair, with no observed fall or impact and no pain complaints reported to the driver. Subsequently, the receiving SNF reported that the resident complained of pain on arrival, and an x-ray obtained at the hospital revealed an acute impacted fracture through the left femoral neck. The Medical Director stated that he had not issued new orders earlier because staff had not reported a fall, impact, or significant change, and later opined that the fracture could have occurred prior to admission, during transfer, or at the new SNF. The deficiency centers on NA #8’s failure to report the resident’s acute complaint of left leg pain during the lift transfer to the nurse, resulting in no nursing assessment being completed prior to discharge and no pain or condition concerns being communicated to the receiving facility.