Failure to Assess and Investigate Resident’s Right Arm Pain and Shoulder Fracture
Penalty
Summary
The deficiency involves the facility’s failure to assess and investigate a resident’s right arm pain and a subsequent right shoulder fracture. The resident had a history of hemiplegia and hemiparesis affecting the right dominant side, severe cognitive impairment, and dependence on staff for ADLs. A CNA reported that during ADL care and dressing, the resident consistently reacted to movement of the right arm with moaning and saying “ouch,” and stated that charge nurses had been informed of this pain, though she could not recall specific dates or names. Another CNA stated that such complaints of right arm pain could indicate a possible fracture that staff were unaware of and needed to be assessed, addressed, and investigated. A family member observed that the resident had pain in the right arm when it was touched or moved and posted a note above the bed instructing staff to be mindful when caring for and repositioning the right arm because of the pain. An LVN acknowledged seeing this posted note, briefly touching the arm to check for swelling or redness, but did not further assess range of motion or pain with movement, did not contact the family member about the note, did not complete a change of condition assessment, and did not notify the physician. The DON later stated that the posted sign referred to the resident’s contracted right arm and that nurses were required to address concerns about the resident’s right arm pain, with charge nurses responsible for completing change of condition documentation and RNs to assess and notify the physician as needed. The resident was transferred to an acute hospital for hypotension and elevated pulse, and a chest x-ray performed there revealed a subacute displaced fracture of the surgical neck of the right humerus. The family member reported returning to the facility two days later to ask how the fracture occurred and was told by the DOR and DON that the facility was unaware of it and had no reports of falls or injuries. The DON stated that when she became aware of the fracture, she conducted only a verbal investigation with nurses and could not provide evidence of a written investigation, despite facility policy requiring prompt initiation and documentation of incident investigations and completion of an incident report within 24 hours. These actions and inactions resulted in the resident’s right arm pain not being timely assessed, the physician not being notified, and interventions to manage and treat the pain not being provided.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.