F0684

G

Delayed Hospital Evaluation and Imaging After Resident’s Reported Leg Injury and Persistent Severe Pain

Arvin, California Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to promptly send a resident for hospital evaluation and treatment after the resident reported a left leg injury and requested an X-ray. The resident had intact cognition with a BIMS score of 15, used a wheelchair, and required assistance with ADLs. On the day of the incident, the resident returned from a family outing around 5 p.m., with nursing documentation initially indicating normal vital signs and no pain or discomfort. Approximately three hours later, an SBAR documented that the resident reported left leg pain, stated her leg had twisted while in a wheelchair with family, and that mild swelling of the left knee was noted. The nurse administered PRN pain medication, recorded normal vital signs, and notified the physician and responsible party. The physician ordered a lidocaine patch and Norco PRN for pain, but there was no documented physician order to send the resident to the hospital at that time.

Over the following days, the resident continued to experience significant pain that was repeatedly documented but not acted upon with timely diagnostic evaluation. The MAR showed ongoing high pain scores, including levels of 7 and 8, documented daily from the day after the injury through several subsequent days, with PRN hydrocodone-acetaminophen administered. A nurse’s note several days later again documented the resident’s complaint of left knee pain. Despite these persistent high pain scores and ongoing complaints, there was no documentation that the resident was sent promptly for imaging or hospital evaluation. The facility’s pain care plan and standing order to monitor and record pain every shift were in place, but the underlying cause of the pain was not promptly investigated.

When imaging was finally obtained several days after the initial injury, a radiology report of the left knee showed an acute nondisplaced distal femur fracture. An SBAR then documented that the X-ray results were communicated to the physician and responsible party, and the resident was sent to the hospital. The hospital H&P recorded that the resident arrived by EMS with left knee pain for six days, with imaging confirming a new nondisplaced distal femur fracture that had occurred six days earlier, and orthopedic surgical repair was planned. Interviews revealed that the RN had texted the physician on the night of the injury, including photos of the swollen knee and a statement that the resident was requesting an X-ray. The physician responded with a thumbs up emoji and pain medication orders, later stating that the thumbs up signified approval for an X-ray and an expectation that the resident would be sent to the ER that night or the next morning. The DON acknowledged miscommunication between the RN and physician, stated that emojis were not a professional communication method and could cause confusion, noted the resident’s Spanish-only language as a possible contributor to misunderstanding about how the injury occurred, and confirmed there was no facility policy on proper nurse-physician communication. Facility policies on quality of care, pain assessment and management, and change in condition required accommodation of needs, addressing underlying causes of pain, and physician notification and transfer when needed, but the resident was not promptly transferred for evaluation of the leg injury.

The deficiency is further supported by the resident’s own account of the events. In interview, the resident, who was alert and oriented, stated that she broke her left leg in the facility when she twisted her leg while going to the bathroom in her wheelchair and felt her left knee pop. She reported sharp, constant, moderate-intensity pain in her left knee daily from the time of injury until she was taken to the hospital six days later. She questioned why it took so long for her to be sent to the hospital and stated she believed she should have been taken the same day she injured her leg. These statements, combined with the documented persistent high pain scores, the delayed imaging and diagnosis of an acute femur fracture, and the lack of timely transfer despite physician contact and clear reports of pain and swelling, form the basis of the cited deficiency for failure to provide appropriate treatment and care according to orders, resident preferences, and goals.