F0697

G

Failure to Provide Effective Pain Management After Unwitnessed Fall and Hip Fracture

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide effective pain management to a cognitively intact resident who experienced an unwitnessed fall and subsequently reported severe right hip pain. The resident had a history of traumatic subdural hemorrhage, fractured ribs, diabetes, muscle weakness, and unsteadiness on her feet, and had a PRN order for acetaminophen 500 mg, two tablets every six hours as needed for pain. During the night/early morning, the resident activated her call light for assistance to the bathroom, but no one responded, and she attempted to ambulate independently, lost her balance, and fell. A nursing assistant later found her on the floor around 5:30 AM; the resident reported she had tried to go to the bathroom and fell and 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 to bed. The nurse recalled the resident wincing and saying, "Oh my leg," when being lifted but did not complete a pain assessment, did not document the fall, and did not administer any pain medication at that time.

On the following day shift, another NA reported that when she was changing the resident before breakfast, the resident repeatedly said "ouch" with repositioning, stated she had fallen during the night, and complained of right leg pain. This NA reported the fall and pain complaint to the Unit Manager, who said she would check on the resident. A medication aide, upon being informed of the reported fall, entered the room between 8:00 and 9:00 AM and observed that the resident’s appearance had significantly changed from the prior day, with an expression consistent with severe discomfort and a self-reported pain level of 10/10. Around the same time, the Unit Manager assessed the resident, who was alert, oriented, very emotional, and complaining of right leg pain, with limited range of motion and increased pain on movement; the resident was unable to bear weight on the right lower extremity. The Unit Manager instructed that acetaminophen be given and obtained an order for a right hip x-ray, but the nursing progress note documenting this assessment did not include a numerical pain scale.

Vital sign documentation at 8:58 AM showed the resident reporting pain at 8/10, outside her documented acceptable pain range of 0–4/10, and acetaminophen was administered at 8:59 AM. However, the nurse did not reassess the resident’s pain until 12:20 PM, when the resident reported pain at 5/10, still above the acceptable range, and no additional interventions were documented. A therapy note between 8:50 and 9:10 AM recorded the resident stating she was in extreme right hip pain rated 10/10, and a physical therapist evaluating the resident between 11:01 AM and 12:10 PM documented right hip pain rated 7/10, significant pain with passive range of motion, and tenderness to palpation; the therapist reported these concerns to nursing. Despite these repeated high pain scores and reports, there was no documented escalation of pain management beyond PRN acetaminophen, no documented timely reassessment after administration consistent with facility expectations, and no additional non-pharmacologic interventions such as positioning or ice documented.

Later that day, further vital sign entries showed the resident continuing to report pain levels of 5/10 and then 10/10, with acetaminophen again administered at 2:13 PM and a final documented pain score of 10/10 at 3:00 PM without listed interventions. The resident reported to multiple staff and to her responsible party that she had told several people throughout the day that she was in a lot of pain and that she was not offered anything beyond acetaminophen or other measures for pain relief. Emergency medical services were called, and upon arrival they documented right hip pain with tenderness to touch. At the hospital, imaging revealed a comminuted, displaced, and impacted right hip fracture. Interviews with the DON and Nurse Practitioner confirmed that the initial fall was not reported or documented by the night nurse, that the day nurse was new and failed to adequately document the resident’s condition and pain, and that the provider was not fully informed of the severity of the resident’s pain, which affected the treatment orders given. These actions and omissions resulted in the facility’s failure to provide safe, appropriate, and effective pain management for a resident with acute severe pain following a fall and hip fracture.