F0580

G

Failure to Report Fall and Notify Provider/Family Resulting in Delayed Hip Fracture Diagnosis

Lexington, North Carolina Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately notify the responsible party and physician after a cognitively intact resident experienced a fall with significant pain, resulting in delayed diagnostics and treatment for a fractured hip. The resident had been admitted with traumatic subdural hemorrhage, fractured ribs, type II diabetes, muscle weakness, and unsteadiness on her feet, and had a history of a fall with fracture prior to admission. On the night in question, the resident activated her call light to request assistance to the bathroom, but no one responded, so she attempted to ambulate independently, lost her balance, and fell. She reported that two female staff later found her, picked her up from the floor, placed her in a wheelchair, assisted her to the bathroom, and then back to bed, without performing an examination. The resident stated her right leg hurt after the fall and rated her pain as 10/10.

Nurse #1, who was on duty from the evening through the morning shift, stated she was informed by NA #1 around 5:30 AM that the resident had fallen. Nurse #1 and NA #1 assisted the resident off the floor into a wheelchair, asked what happened, but Nurse #1 did not complete an assessment. Nurse #1 observed the resident wince and say “Oh my leg” when being helped up but believed the resident was not hurt because she appeared to have full range of motion. Nurse #1 had the NA take the resident to the bathroom and then back to bed, and later looked in on the resident, who “looked fine,” and then left the room. Nurse #1 did not notify the physician, NP, or responsible party of the fall or the resident’s pain and did not document the fall in the medical record or report it to the oncoming nurse. The DON later confirmed that Nurse #1 failed to report the fall and that there was no corresponding documentation despite a time notation of 5:45 on the 24-hour report.

On the following day shift, NA #2 discovered before breakfast that the resident was in pain, saying “ouch” during care and reporting she had fallen during the night. NA #2 relayed this to the Medication Aide, who had not been informed of any fall. The Medication Aide then observed the resident and noted she appeared different than the previous day, with a look of agony and self-reported pain of 10/10. The Unit Manager, who had just arrived, was informed and went to assess the resident, finding her alert, oriented, emotional, and complaining of right leg pain, with inability to bear weight on the right leg, limited range of motion, and increased pain with movement. Vital sign entries throughout the late morning and afternoon documented persistent elevated pain scores (8/10 and then 5/10 and 10/10) with limited or no listed interventions. The Unit Manager learned that neither the Medication Aide nor Nurse #2 had received any report of a fall from the night shift. After reviewing camera footage showing Nurse #1 and NA #1 entering the resident’s room at 5:45 AM, the Unit Manager confronted Nurse #1, who then admitted the fall had occurred and that she had “messed up” by not reporting it. The physician and responsible party were not notified until later that afternoon, after the Unit Manager’s assessment and subsequent orders for imaging, at which point a right hip fracture was identified and the resident was sent to the hospital for evaluation and treatment.