F0684

D

Failure to Notify MD of Abnormal X‑ray and Inadequate Pain Management After Fall

Anaheim, California Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide required skilled nursing services to a cognitively impaired resident who lacked capacity to understand and make decisions. The resident was admitted in June and had an H&P documenting lack of decision-making capacity. On a later date, the physician ordered bilateral hip and pelvis x‑rays. The radiology report showed fractures of the left superior and inferior pubic rami with indeterminate age. Facility policy on Laboratory and Radiology Documentation required licensed nurses to promptly call the physician with abnormal radiology results. Nursing documentation showed the x‑ray result was faxed to the primary physician, but there was no evidence the physician was called about the abnormal finding. RN 1 confirmed the record lacked documentation of a call, and RN 2 stated he only faxed the report and did not notify the physician because the fracture age was indeterminate. The DON stated the expectation was immediate reporting of abnormal radiology results to prevent delay in treatment.

The facility also failed to follow its Pain Management Protocol after the resident experienced an unwitnessed fall. On the date of the fall, documentation on the SBAR Communication Form and Progress Notes showed the resident was found on the floor, crying, pointing to the left hip, and reporting pain at 5/10. The subsequent radiology report confirmed fractures of the left superior and inferior pubic rami. Existing physician orders included PRN acetaminophen 325 mg, two tablets every six hours as needed for mild pain (1–3), and a later order for a Lidoderm 5% patch to the left hip for seven days. LVN 3, who found the resident on the floor, stated the resident was crying and complaining of hip pain but did not recall whether acetaminophen was administered after the fall. RN 1 also stated he did not know if LVN 3 gave acetaminophen at that time.

Medication administration records for January showed acetaminophen was repeatedly given for pain scores that exceeded the ordered “mild pain” range, including pain levels of 4–8, and the Lidoderm patch was applied daily for seven days. Nursing progress notes and the medical record did not show that the physician was notified when the resident’s pain exceeded the mild range on multiple documented occasions. The record also lacked a pain documentation flow sheet required by the facility’s Pain Management Protocol to record each PRN dose, the resident’s response, and any non‑pharmacological interventions. RN 1 verified that pain scores of 4 and above were not reported to the physician until a later physician visit and confirmed the absence of required pain flow sheet documentation and monitoring details in the MAR.