BATON ROUGE, LA - A certified nursing assistant at Capital Oaks Nursing & Rehabilitation Center witnessed a resident fall and hit a wheelchair but failed to report the incident to nursing supervisors, ultimately delaying medical care for a resident who had sustained a displaced femur fracture, according to a state inspection report released in February.
Unreported Fall Results in Delayed Fracture Treatment
The inspection revealed that on January 2, 2025, a certified nursing assistant (CNA) was transferring a 77-year-old resident with severe cognitive impairment when the resident began to struggle during the transfer. According to the CNA's testimony to inspectors, she had to lower the resident to the ground, and "as he was being lowered he hit his left side on the wheelchair."
The resident was placed back in his wheelchair with assistance from another CNA. Despite the fall and impact with the wheelchair, the incident was not reported to nursing staff or supervisors. The resident showed no immediate visible injuries and did not complain of pain at the time, according to staff interviews.
However, later that same day at 1:15 p.m., when the resident was being transferred to bed, he complained of pain. The CNA reported the pain complaint to a licensed practical nurse but failed to mention the earlier fall incident. This critical omission delayed proper medical evaluation and treatment.
The resident's condition continued to deteriorate over the following day. On January 3, staff observed that the resident could no longer stand on his leg and was expressing pain complaints. Only then did nursing staff conduct a proper assessment, order X-rays, and discover the serious injury.
Severity of the Fracture and Medical Consequences
Medical imaging revealed the resident had sustained a displaced comminuted intertrochanteric femur fracture with surrounding soft tissue swelling. This type of fracture involves the breaking of bone into multiple pieces near the hip joint, representing one of the most serious types of hip fractures that can occur in elderly patients.
The fracture required immediate surgical intervention. The resident was transferred to a local hospital where orthopedic surgeons performed emergency surgery on January 4, 2025, to repair the fractured femur using surgical hardware.
Intertrochanteric femur fractures are particularly dangerous for elderly residents because they can lead to significant complications including blood loss, infection, and prolonged immobility. The delayed diagnosis and treatment in this case increased the resident's risk of complications and potentially worsened the long-term prognosis.
For elderly patients with cognitive impairment, early recognition and treatment of fractures is crucial because these residents may not be able to clearly communicate their pain or understand what has happened to them. The resident in this case had a Brief Interview of Mental Status score of 3, indicating severe cognitive impairment, and was oriented only to person, not time or place.
Communication Failures Among Staff
The inspection revealed a troubling pattern of communication failures among facility staff. Multiple certified nursing assistants witnessed concerning changes in the resident's condition but failed to connect these observations with the earlier fall incident.
One CNA reported that during a transfer around lunchtime on January 2, "Resident #1 cried out in pain when his left leg was moved." Another CNA noted that the resident, who previously could stand and pivot during transfers, was no longer able to stand on his own and required extensive assistance to get into his wheelchair.
A third CNA observed that on January 3, the resident "could not stand on his leg and he had complained of pain," noting this was unusual since the resident did not normally express pain complaints.
Despite these multiple warning signs, no staff member made the connection to the earlier fall incident because it had never been properly reported through the facility's incident reporting system.
Regulatory Violations and Standards of Care
The facility's own policies required that residents not be moved after a fall until a licensed nurse had assessed their condition, including checking for "deformed, discolored or painful body parts" and taking vital signs. The policy also mandated notifying the physician for further orders.
None of these protocols were followed because the fall was never reported to licensed nursing staff. This represents a fundamental breakdown in the facility's safety systems designed to protect vulnerable residents.
State investigators determined that the CNA's failure to report the fall constituted neglect under federal nursing home regulations. The facility's Director of Nursing confirmed to inspectors that "if a resident had fallen to the floor, expressed pain, and no report of fall was made she would consider this neglect."
The administrator echoed this assessment, stating that "a CNA withholding information about a resident's fall that would delay necessary care would be classified as neglect."
Medical Assessment Protocols for Cognitive Impairment
The case highlights the special challenges involved in caring for residents with severe cognitive impairment. These residents may not be able to communicate pain effectively or remember traumatic events that occurred even minutes earlier.
According to nursing staff interviews, proper pain assessment for cognitively impaired residents should include verbal questioning, physical manipulation of affected areas while observing for grimacing, and gathering detailed information from staff who reported concerns.
The licensed practical nurse who eventually assessed the resident noted that due to his cognitive impairment, "he was only capable of reporting pain he currently felt, not pain from an earlier time." This makes immediate reporting of incidents crucial, as delayed recognition can mean the difference between timely treatment and serious complications.
As one registered nurse explained to inspectors, "a reasonable person with a fracture" would be expected to "express pain with movement or manipulation," making proper assessment techniques essential for non-verbal or cognitively impaired residents.
Additional Issues Identified
The inspection also found that the facility failed to report the alleged neglect incident to proper authorities within the required two-hour timeframe after allegations were made to the state agency, representing an additional regulatory violation.
Corrective Actions Implemented
Following the inspection, Capital Oaks implemented multiple corrective measures including mandatory staff training on pain assessment, change of condition reporting, proper transfer techniques, and abuse and neglect policies. The facility also instituted enhanced monitoring procedures including daily huddles with nursing staff, random transfer monitoring, and questionnaires to verify staff understanding of reporting requirements.
The facility has asserted that as of February 7, 2025, the likelihood for serious harm to residents no longer exists due to these implemented corrective measures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Capital Oaks Nursing & Rehabilitation Center LLC from 2025-02-07 including all violations, facility responses, and corrective action plans.
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