F0580

G

Failure to Notify Orthopedic Surgeon of Persistent Post‑Operative Pain and Abnormal Limb Findings

Westfield, Indiana Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify an orthopedic surgeon when a post‑operative resident’s pain regimen was changed, when her condition did not improve, and when she had ongoing complaints of significant pain and abnormal right leg findings. The resident had a recent right hip hemiarthroplasty and a history of right hemiplegia and right foot drop. Upon admission for rehabilitation, she was ordered hydrocodone‑acetaminophen 10/325 mg every four hours as needed for severe pain, which was changed the next day to a scheduled every‑four‑hours dose. There is no documentation that the orthopedic surgeon was notified of this change from PRN to routine dosing. Early therapy notes documented high pain levels (8–9/10) in the right lower extremity, and the nurse practitioner present at one assessment planned to review the pain regimen. Family members reported that from admission onward the resident cried out in severe pain (“Ouch, Ouch, Ouch”) whenever she was moved, did not want her right leg touched, and that her right knee appeared deformed and the right leg shorter than the left.

Throughout the resident’s stay, therapy documentation showed slow progress, persistent pain, and functional limitations. Multiple PT and OT notes described the need for maximum assistance with sit‑to‑stand, transfers, and gait training, with the resident often unable to ambulate or bear weight effectively on the right leg. On one date, therapy staff measured a one‑inch discrepancy between the resident’s leg lengths, but there is no documentation that the orthopedic surgeon was contacted about this finding. Subsequent notes recorded increased pain in the right lower extremity with standing, limited active range of motion, and the resident’s report that her right lower leg felt numb; the unit manager was informed of the numbness, but there is no documentation that the orthopedic surgeon was notified. An OT note later indicated the resident was in constant pain and discomfort in the right hip area, and nursing was made aware, yet there is still no record of communication with the orthopedic surgeon prior to the already scheduled follow‑up visit.

Family members repeatedly voiced concerns to nursing and therapy staff about the resident’s severe pain, shortened right leg, and abnormal positioning of the right knee and foot. One family member, who worked in an orthopedic office, reported that the resident could not bear weight on the right leg and that therapists were attempting to have her walk despite her crying out in pain. Video recordings from a therapy session showed the resident not bearing weight on the right leg, standing only on the left leg with the right knee flexed and foot off the floor, and a therapist physically lifting and advancing the right leg while the resident vocalized pain. At the follow‑up orthopedic appointment, imaging demonstrated a dislocated right hip, and the orthopedic nurse practitioner later stated there should be no limb length discrepancy after hip surgery and that the observed shortened, rotated limb and family description of a “mangled” knee were hallmark signs of dislocation. The facility’s own policy required notifying the attending or on‑call physician when there was a significant change in condition or a need to significantly alter treatment, yet the record contains no evidence that the orthopedic surgeon was contacted about the change in pain medication frequency, the leg length discrepancy, the numbness, or the persistent severe pain and abnormal limb positioning before the scheduled follow‑up visit.