Oak Hill Center: Fracture Patient Left in Pain - PA

Resident 1 began experiencing severe right hip pain on August 27, 2025. At 2:08 AM, nursing notes documented the resident "yelling and moaning in pain" and receiving 5 milligrams of oxycodone. The pattern continued throughout the day.

At 6:58 AM, staff noted the resident was "calling out, can't state her pain level" and administered another dose of oxycodone. By 12:35 PM, the resident was "moaning and unable to walk" and received a third dose of the pain medication.

The physician ordered additional X-rays at 4:06 PM due to the resident's "ongoing pain and difficulty ambulating." Staff gave another dose of oxycodone at 4:12 PM when the resident continued moaning in pain. At 7:11 PM, nursing notes showed the resident still reported a pain level of 4.

Then documentation stopped.

The X-ray results came back at 11:26 PM showing an "acute fracture of the right sub capital femur." But no one documented notifying the physician. No nursing notes recorded any pain assessments through the night. No additional pain medication was given after the 4:12 PM dose.

The resident spent the entire night with an untreated broken hip.

According to a timeline provided by the Director of Nursing, the physician wasn't notified until approximately 8:30 AM the next morning — 9.5 hours after the fracture was confirmed. The doctor immediately assessed the resident and ordered hospital transfer, which occurred around 9:00 AM.

Hospital records revealed the resident required surgical intervention and received intravenous morphine for pain management until surgery. The resident underwent right hemiarthroplasty — partial hip replacement surgery — and was later readmitted to Oak Hill with no post-operative complications.

During interviews with federal inspectors, the Director of Nursing acknowledged that X-ray results typically get faxed to the facility, and unusual findings usually prompt a phone call to ensure timely receipt. She couldn't confirm whether such a call was received about this fracture.

"The DON revealed she would have expected it to be documented on Resident 1's clinical record when the physician was notified of the positive fracture," inspectors wrote.

The facility's clinical records contained no documentation of when emergency medical services were called or when the resident was transferred to the hospital. Most significantly, there were no progress notes showing staff assessed the resident for pain or discomfort during the evening and overnight shifts while the fracture went untreated.

The Nursing Home Administrator told inspectors on September 11 that he "would have expected staff to monitor Resident 1 for pain and documenting if any pain assessments were completed prior to the Resident being transferred to the hospital."

The violation represents a failure in multiple areas of care. Staff failed to ensure timely physician notification of critical test results. They failed to monitor and assess a resident in obvious distress. They failed to provide adequate pain management for someone with a confirmed fracture.

The Director of Nursing explained that X-ray results "usually get faxed to the facility, unless it is an unusual finding then they will usually call to confirm it was received by the facility timely." An acute femur fracture would qualify as unusual, yet the facility couldn't confirm receiving such a call.

Federal inspectors found the facility violated quality of care standards by failing to provide timely hospital transfer following confirmation of the fracture. The violation also cited inadequate pain monitoring and failure to provide appropriate as-needed pain medication before transfer.

The inspection classified this as causing "actual harm" to the resident, who endured nearly 10 hours of untreated pain from a broken hip that ultimately required surgical repair. The resident's night of suffering could have been prevented with proper notification protocols and basic pain assessment practices.

While the resident eventually received appropriate surgical treatment and returned to the facility without complications, the gap in care represents a fundamental breakdown in communication and clinical oversight that left a vulnerable person in unnecessary agony.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Oak Hill Center For Rehabilitation and Nursing from 2025-09-11 including all violations, facility responses, and corrective action plans.

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