BATON ROUGE, LA - Federal inspectors found that Capital Oaks Nursing & Rehabilitation Center LLC failed to properly assess and treat a cognitively impaired resident who suffered a displaced femur fracture, leaving him without pain medication for over 31 hours despite multiple reports of discomfort from staff members.
Delayed Medical Response After Undisclosed Fall
The investigation revealed that on January 2, 2025, at approximately 5:00 a.m., a certified nursing assistant was transferring an 85-year-old resident with Alzheimer's disease when she lost control during the transfer. The aide reported having to "lower the resident to the ground" after he began struggling, with the resident's left side striking a wheelchair during the incident. Despite facility policy requiring immediate nursing assessment after any fall, the aide failed to notify nursing staff or supervisors about the incident.
The resident, who had severe cognitive impairment with a Brief Interview of Mental Status (BIMS) score of 3, was unable to effectively communicate his pain due to his advanced dementia and expressive aphasia. Multiple staff members reported that throughout January 2nd, the resident displayed clear signs of distress. At 1:00 p.m., another aide noticed the resident crying out in pain when his left leg was moved during a transfer from bed to wheelchair. At 2:00 p.m., a different aide documented that the resident complained "my leg" when asked what was wrong and was unable to stand on his own - a significant change from his normal ability to stand and pivot during transfers.
Despite these multiple pain reports from certified nursing assistants throughout the day, nursing staff conducted only minimal assessments. When notified at 1:00 p.m. about the resident's pain complaint, the licensed practical nurse asked the resident if he was in pain but performed no physical assessment, range of motion testing, or other evaluation as required by facility protocol.
Critical Assessment Failures and Protocol Violations
The facility's own policies explicitly stated that after any fall, staff must not move the resident until a licensed nurse has evaluated their condition. The assessment should include checking vital signs, examining for deformed, discolored or painful body parts, and completing a thorough head-to-toe assessment including range of motion testing. None of these required steps were followed after the January 2nd incident.
It wasn't until January 3rd at approximately 7:00 a.m. - more than 26 hours after the initial fall - that nurses finally conducted a proper assessment. When they moved the resident's left leg, he grimaced in pain, prompting them to order an x-ray. The CT scan revealed a displaced comminuted intertrochanteric femur fracture with surrounding soft tissue swelling and fracture planes extending through the greater and lesser tuberosities.
The resident was transferred to the hospital that afternoon with a pain score of 4 and required morphine for pain management. He underwent surgical repair of the left femur fracture on January 4th.
Understanding the Medical Implications
A femur fracture is one of the most painful orthopedic injuries a person can experience. The femur, or thighbone, is the longest and strongest bone in the human body. When fractured, especially in a comminuted pattern where the bone breaks into multiple pieces, the injury causes severe pain due to nerve endings in the bone and surrounding tissues being damaged. The displaced nature of this fracture meant bone fragments had shifted from their normal position, potentially damaging surrounding blood vessels, nerves, and soft tissues.
For elderly residents, particularly those with osteoporosis as this resident had, untreated femur fractures carry serious risks. Prolonged immobilization from an untreated fracture increases the risk of pneumonia, blood clots, pressure sores, and urinary tract infections. The 31-hour delay in diagnosis and treatment subjected this vulnerable resident to unnecessary pain and increased these medical risks.
Standard medical protocol requires immediate evaluation following any fall in elderly patients, especially those with cognitive impairment who cannot reliably report symptoms. Pain assessment in dementia patients requires careful observation of non-verbal cues including facial expressions, body positioning, changes in behavior or activity level, and vocalizations during movement or care activities.
Additional Issues Identified
The investigation uncovered several other concerning practices at the facility. Staff interviews revealed confusion about proper pain assessment techniques for cognitively impaired residents. The nurse practitioner stated she was not notified about the fall on January 2nd and "should have been," noting she would have ordered an x-ray immediately if informed. The facility's communication breakdown meant critical information about the resident's condition never reached the appropriate medical decision-makers.
The facility has since implemented corrective measures including retraining all staff on immediate reporting of observed pain or condition changes, proper pain assessment techniques for cognitively impaired residents, and daily administrative huddles to review incidents and pain observations.
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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