F0684

D

Failure to Timely Assess and Escalate Care for Persistent Upper Extremity Pain and Swelling

Tampa, Florida Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely and adequately address a resident’s ongoing left upper extremity pain and swelling despite multiple reports and observable changes in condition. The resident was admitted with dementia, severe cognitive impairment (BIMS score of 6), muscle weakness, and chronic kidney disease. On 1/7/2026, nursing documented that the resident was yelling that her hand hurt, and an ARNP was notified, who ordered an X‑ray of the hand/wrist and PRN Tylenol. The X‑ray on 1/7/2026 showed no fracture, anatomic alignment, and no soft tissue swelling. The resident’s RR was informed that the X‑ray was clear. A change in condition report was completed that same day for hand pain, but no further documented nursing assessment of the left upper extremity followed after this initial workup.

On 1/9/2026, a PTA performing a quarterly therapy screen noted that the resident complained of left wrist pain and resisted giving her hand when positioned on her side. The PTA reported these concerns to the unit nurse and documented them on a communication form, but the medical record contained no subsequent nursing assessment by an LPN in response to this report. Pain Management evaluated the resident starting 1/17/2026 for left wrist pain and swelling and ordered routine Tylenol and a topical gel. The Pain Management provider later stated he did not perform range of motion because the resident was in too much pain when her wrist was moved and that he relied on nursing to report further pain, which they did not. The ARNP saw the resident again on 2/3/2026 for a routine visit and acknowledged being aware of prior pain and discomfort in the left hand and wrist, but her progress note contained no documented range of motion or focused assessment of the left hand, wrist, or shoulder; she later stated she did not know why she failed to document her assessment.

During this period, the resident’s RR observed progressive changes. After being told the initial X‑ray was clear, he visited about a week later and noticed swelling of the arm and an abnormal hanging position of the hand. When he lightly touched the arm above the wrist, the resident screamed in pain. He reported this to nursing and made multiple phone calls requesting to speak with the DON about the plan of care but did not receive a return call. Eventually, he went to the facility, located the DON, and showed her the resident’s arm; when the DON and physician touched the arm, the resident again screamed in pain. The RR insisted on hospital transfer, while the DON initially suggested trying other in‑house measures. A nursing note dated 2/10/2026 documented that the RR requested emergency room evaluation for left hand/wrist edema and pain and a provider change. The Medical Director examined the resident that day, noting left arm swelling and pain present for over four weeks, the resident’s refusal to allow range of motion, and the inability to fully examine the axilla. He agreed with the RR to send the resident to the emergency room for immediate imaging. At the hospital, the resident was found to have a left shoulder dislocation that could not be reduced, and the hospital physician documented that the shoulder appeared to have been dislocated for a long time. The facility’s change‑in‑condition policy required prompt notification and documentation of changes in condition, but the facility was unable to provide an assessment change‑in‑condition policy beyond the general notification policy, and the record lacked timely, thorough nursing assessments in response to repeated reports of pain and swelling.

Additional staff interviews corroborated that the resident repeatedly voiced pain without corresponding documented follow‑up assessments. A CNA recalled hearing the resident yelling in pain while passing meal trays and reported this to the nurse, after which she only heard that an X‑ray had been done. An LPN stated that about a month before the hospital transfer, a CNA reported the resident’s hand pain; she observed some swelling, notified the ARNP, and obtained the initial X‑ray and PRN Tylenol, but she did not describe any further systematic reassessment after the negative X‑ray. The DON stated that her expectation was that when another discipline reported a change in condition, the nurse should notify the physician and family and complete a change‑in‑condition note, with follow‑up documentation that the physician and family were made aware. She also stated that 2/10/2026 was the first time she personally assessed the resident and observed that the resident was in pain and unable to move her arm. The combination of repeated complaints of pain, observed swelling and abnormal arm positioning, lack of documented follow‑up assessments after therapy and Pain Management reports, and delayed escalation to hospital evaluation led to the discovery of a longstanding left shoulder dislocation.

The facility’s own documentation and staff statements show that, despite multiple indicators of a persistent and worsening problem with the resident’s left upper extremity, there was no timely, comprehensive reassessment or escalation of diagnostic evaluation beyond the initial negative hand/wrist X‑ray and symptomatic treatment with Tylenol and topical gel. The ARNP’s lack of documented assessment of the left upper extremity during the 2/3/2026 visit, the absence of nursing assessments following therapy’s 1/9/2026 report of continued wrist pain, and the failure of the DON to respond to multiple calls from the RR about the resident’s condition all contributed to the delay in identifying the true source of the resident’s pain. Ultimately, the resident’s RR’s insistence on hospital transfer prompted the emergency room evaluation that revealed the left shoulder dislocation, which the hospital physician believed had been present for at least a month.