The resident reported a pain level of 8 out of 10 throughout the ordeal. Staff documented giving Tylenol for pain relief, but the medication never appeared on official administration records.
The incident occurred on June 6 when nursing staff attempted to place a Hoyer lift pad under Resident 7. According to a nurse's note written at 1:01 PM, the patient "turned too far over rolling out of bed" during the procedure.
Within minutes, the resident's pain level spiked to 8 on a 10-point scale. Staff documented the same pain level again at 1:08 PM, noting the physician had been contacted and orders obtained for an x-ray and Tylenol.
Then the documentation stopped.
For the next seven hours and 47 minutes, no pain assessments were recorded. The resident remained at the facility with what would later be confirmed as a right knee distal fracture, waiting for x-ray results and eventual hospital transport.
A nursing note claimed staff administered "extra strength Tylenol for pain" with "some relief." But when federal inspectors examined the resident's Medication Administration Record, they found no evidence any pain medication had been given.
The Assistant Director of Nursing confirmed during an October interview that the medication records showed no Tylenol administration. When asked if she had personally witnessed the resident receiving the medication, she said no.
The ADON had signed the nursing note documenting the Tylenol administration, but told inspectors she had only "locked the note" in the system. When pressed to confirm through medical records that pain assessments were conducted and medication given between the fall and hospital transport, she admitted she could not.
X-ray results confirming the fracture came back at 10:09 PM. The physician ordered immediate transport to the emergency room for evaluation. By then, the resident had endured nearly nine hours with a broken knee.
The resident finally received 2 mg of IV morphine after arriving at the hospital emergency room at 8:45 PM.
During an interview with federal inspectors four months later, the resident recalled the aftermath of the fall with painful clarity. They thought they had received Tylenol but weren't certain of the amount. What they remembered clearly was that whatever they might have gotten "did not help the pain" and that they remained in agony "until after he/she went to the hospital."
The incident came to light through two separate complaints filed against the facility, alleging the resident had been "screaming in pain periodically" during a phone call and had "laid with a broken leg for more than 6 hours" before hospital transfer.
Federal inspectors noted that pain assessment is considered a fundamental nursing responsibility, with pain now recognized as "the fifth vital sign" in healthcare. Proper pain assessment requires documenting the words patients use to describe their discomfort, intensity levels, location, duration, and factors that worsen or improve the sensation.
The nursing note describing the incident wasn't even written until June 9, three days after the fall occurred. The ADON who authored the delayed documentation had not been present during the actual events.
The facility's failure extended beyond inadequate pain management to basic record-keeping. Staff documented administering medication that left no trace in official records, created pain management plans without follow-up assessments, and delayed critical documentation for days.
The resident's experience illustrates a cascade of care failures: inadequate supervision during routine care that led to a preventable fall, insufficient pain assessment after a traumatic injury, phantom medication administration, and delayed recognition of a serious fracture requiring immediate medical attention.
Federal inspectors determined the facility failed to provide safe, appropriate pain management for residents requiring such services. The violation received a rating of "minimal harm or potential for actual harm," though the resident's hours of documented agony suggest the impact was far from minimal.
The Director of Nursing and Nursing Home Administrator were informed of the inspection findings on October 8, 2025.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lochearn Nursing Home, LLC from 2025-10-08 including all violations, facility responses, and corrective action plans.