F0684

G

Failure to Assess and Respond to Post-Fall Pain and Delay in Diagnostic Imaging

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to recognize and appropriately assess the seriousness of an unwitnessed fall and associated pain, and to complete and document comprehensive nursing assessments to determine the need for transfer to a higher level of care. The resident involved had a history of traumatic subdural hemorrhage, fractured ribs, type II diabetes, muscle weakness, unsteadiness, and a prior fall with fracture before admission, and was cognitively intact and required supervision with toilet transfers and toileting hygiene. During a night shift, the resident activated the call light for assistance to the bathroom, but no one responded, and the resident attempted to get up independently, lost balance, and fell. A nursing assistant later found the resident on the floor; the resident was unsure if she was injured. The NA notified the nurse, and together they assisted the resident from the floor into a wheelchair and then into bed. During this transfer, the resident winced and said, “Oh my leg,” but the nurse did not complete a full assessment, relying instead on an impression that range of motion appeared intact. No post-fall assessment or documentation of the fall or the resident’s condition was entered in the nursing progress notes for that shift.

On the following day shift, the oncoming nurse received verbal report that the resident had an unwitnessed fall but did not complete an assessment, stating her day was too busy. She visually checked on the resident at some point and believed the resident appeared comfortable, but did not document an assessment. Vital signs later recorded in the electronic record showed the resident reporting pain levels of 8/10 in the morning and higher levels later in the day, with acetaminophen administered but no documented comprehensive assessment of the fall-related condition. A nursing assistant on the day shift, who had not been informed of the fall, reported that while changing the resident’s brief the resident repeatedly said “ouch” and stated she had fallen during the night. This NA relayed the information to a medication aide, who also had not been told of the fall, and then to the Unit Manager. The medication aide, upon seeing the resident, observed that the resident appeared to be in agony and reported a pain level of 10/10. Therapy staff who saw the resident that morning and midday documented extreme right hip pain, tenderness to palpation, and significant pain with passive range of motion, and reported these concerns to nursing and management.

The Unit Manager assessed the resident after being informed of the fall and pain complaints and documented that the resident reported attempting to walk to the bathroom without assistance, slipping and falling, and being helped off the floor and back to bed by two female staff. The Unit Manager’s note indicated the resident complained of right hip pain, was unable to bear weight on the right lower extremity, and had limited range of motion with increased pain on movement. However, the progress note did not include a pain scale rating, vital signs, or descriptive details such as redness, swelling, bruising, or external rotation of the leg. The Unit Manager obtained a verbal order for a stat right hip x-ray and post-fall monitoring, but instead of entering the order into the computerized system required by the mobile imaging provider, she phoned the order directly to the provider, who later reported they did not accept verbal orders and required electronic entry. The mobile imaging provider’s records showed receipt of the electronic order later that morning, with dispatch occurring thereafter. The delay in proper ordering contributed to a delay in imaging and subsequent transfer. When the x-ray was finally obtained, therapy staff visually noted what appeared to be a fracture, and the physician then ordered transfer to the emergency department for evaluation and treatment. Hospital imaging confirmed a comminuted, displaced, and impacted right hip fracture, and the resident was admitted and then transferred to another hospital for surgical repair. Throughout the period from the fall discovery until transfer, there were no comprehensive, timely nursing assessments documented that correlated the resident’s persistent high pain levels and functional limitations with the need for urgent evaluation at a higher level of care.

The Director of Nursing later stated that Nurse #1 did not report the fall to the physician or to the oncoming shift and was not in the resident’s room long enough to have completed a post-fall assessment. The DON also stated that Nurse #2, a new nurse, failed to document the resident’s condition on the day shift, and that she found no documentation of a completed assessment. The Nurse Practitioner reported that she was notified by the Unit Manager that the resident had fallen and gave an order for a right hip x-ray due to reported pain, and further stated that if she had been informed of the severity of the resident’s pain, she might have given different treatment orders. The facility submitted a plan of correction for past non-compliance, but this plan was later determined to be incomplete and lacking necessary information.