F0580

D

Failure to Notify Provider and Representative of Resident Fall and Subsequent Pain

Clemmons, North Carolina Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to immediately notify the nurse practitioner (NP) and the resident representative of a resident’s fall and to clearly communicate the occurrence of that fall when later reporting new pain symptoms. The resident, who had non-Alzheimer’s dementia, adult failure to thrive, a history of falling, and hypertension, was found on the floor in front of her wheelchair on 1/28/26. Nurse #7, who had just started her shift, assessed the resident for pain and injury, checked range of motion, and documented that the resident denied pain and had no apparent injury. Nurse #7 did not notify the provider, the family, or the DON of the fall on that date and believed the fall was witnessed by the Scheduler. The DON later stated that the incident was entered in the electronic medical record as an “injury” rather than a “fall,” which prevented the system from triggering the facility’s fall risk and post-fall evaluations.

On 1/30/26, the resident began complaining of right knee pain, rated 4/10, and was given acetaminophen. A health status note by Nurse #11 documented that the NP was notified of the resident’s knee pain and slight swelling, and an x-ray was ordered. The resident’s family, who visited that day, was also notified of the complaint of right knee pain, but neither the NP nor the family was informed that the resident had been found on the floor two days earlier. The NP later confirmed she was never officially notified of the 1/28/26 fall and ordered the x-ray based solely on the reported pain. The NP stated she typically would be called when a resident fell and that she did not learn of the fall until 2/11/26, after CT results were available and the facility began an internal investigation.

In the days following the onset of pain, the resident continued to report pain of varying intensity, including right lower extremity thigh/knee pain, and received acetaminophen, tramadol, and hydrocodone-acetaminophen. An x-ray could not be completed on one date due to snow, and the family initially requested waiting to send the resident out, later agreeing to further evaluation when the pain migrated to the hip. An x-ray of the knee was eventually done and was reported as fine, with a recommendation for CT if pain persisted. A CT scan performed on 2/9/26 revealed multiple serious fractures of the right hip and pelvis and flattening of the superior lateral right femoral head. The resident representative stated she was not notified of the 1/28/26 fall and only became aware of it in February when discussing CT results with the NP. The Medical Director also reported not being informed of the fall until 2/11/26, learning of it through record review. Hospital records documented that the resident was admitted with a displaced transverse-posterior fracture of the right acetabulum and severe pain with functional decline after experiencing a fall at the nursing facility.