F0689

G

Failure to Assess and Communicate Right Leg Pain Leading to Unwitnessed Femur Fracture

Bryan, Texas Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and assessment to prevent an accident and to identify and respond appropriately to a change in condition related to a resident’s right leg pain, which was later associated with a right femur fracture. The resident was an elderly female with dementia, a history of left femur fracture with surgical repair and left artificial hip joint, and other diagnoses including hypotension, iron deficiency, and pain. Her MDS showed severely impaired cognition (BIMS score of 01) and extensive physical assistance needs for bed mobility, transfers, and toileting, with full dependence for toilet transfer and incontinence care. Her care plan addressed pain related to a hip fracture with surgical repair, with interventions focused on administering ordered pain medication and observing for worsening pain symptoms to report to the physician.

On one morning, a CNA observed the resident moaning and grimacing in pain when her right leg was moved during incontinence care and reported this to an LVN. The LVN assessed the resident and noted no visible abnormalities, deformities, swelling, or redness in the lower extremities, but confirmed that the resident moaned when the right leg was grasped during perineal care. The LVN administered PRN acetaminophen for pain but did not document the incident in the EHR, did not notify the NP, and was unsure if the information was communicated to the oncoming nurse at shift change. As a result, there was no documented follow-up assessment or monitoring of the right leg pain, and subsequent nurses and CNAs working the following shifts reported they were not aware of the prior pain episode and did not perform focused assessments of the right leg.

Over the next several days, staff who provided care on various shifts reported no observed swelling, redness, or pain in the resident’s lower extremities during incontinence care, and there was no documentation in the EHR of ongoing pain assessment specific to the right leg. On a later date in the afternoon, a CNA observed the resident shivering and in apparent pain during lunch and reported this to an RN, who noted signs of pain in the right leg but no swelling or deformity, administered PRN acetaminophen, and reported the situation to the oncoming nurse. Later that same day, another CNA observed the resident moaning and grimacing in severe pain with significant swelling of the right leg from thigh to knee and reported this to the oncoming LVN, who assessed marked edema, warmth, and pain with palpation and movement, administered acetaminophen, and obtained an order to transfer the resident to the emergency department. Hospital records documented a distal right femur fracture from an unwitnessed ground-level fall at the facility, with radiology showing a dynamic hip screw in place and a midshaft comminuted impacted angulated spiral fracture below the implant. The NP and DON later stated they had not been informed of the initial right leg pain episode, and the DON acknowledged there was no evidence of continued assessment or communication regarding the resident’s right leg pain between the initial complaint and the later discovery of swelling and fracture.

The facility’s abuse prevention and prohibition policy defined injuries of unknown origin and required a licensed nurse to examine the resident and notify the physician of any injuries noted when the source of injury was not observed or could not be explained by the resident. In this case, the hospital record identified the fracture as resulting from an unwitnessed ground-level fall at the facility, and staff interviews and record review showed no documented fall episodes for the resident in the month in question and no clear explanation from staff for how the injury occurred. The RP reported being informed by the hospital that the swelling might have been present for several hours before discovery and believed the fracture might have occurred during repositioning or care, while facility staff were unable to provide a definitive explanation. The lack of documentation, incomplete communication between shifts, absence of timely notification to the NP, and failure to conduct and document focused, ongoing assessments of the resident’s right leg pain and condition contributed to the deficiency in ensuring adequate supervision and accident prevention for this resident.