The July incident at Lake Mills Care Center revealed a facility without policies on pain assessment after falls or clear guidelines for when staff should contact physicians about resident injuries.
Resident #1 fell around 3 a.m. while trying to reach the bathroom. Staff A, who was walking behind the resident, watched her slip and fall backward against the door before sliding to the floor about two feet down. The resident landed on her left side with her legs facing the bathroom.
Staff A assessed the resident's range of motion immediately after the fall. The resident complained of leg pain and could point to where it hurt, but couldn't rate the severity initially. Staff A noted the resident could lift and rotate her legs with no obvious shortening visible.
The resident's condition deteriorated rapidly once staff moved her back to bed. She described the pain as "the worst pain ever" and Staff A documented it as a 10 on the pain scale. Instead of calling a doctor, Staff A gave the resident Tylenol around 5:15 a.m.
The facility had no policy requiring physician notification for every fall. Staff A said the decision to call doctors was left to "nursing discretion."
By 5:30 a.m., the resident had fallen asleep after receiving the pain medication. But she continued using her call light frequently, repeatedly asking for more medication to manage the pain.
The severity of the resident's condition became undeniable at 6:45 a.m. when Staff E, an LPN starting her medication rounds, heard screaming from the resident's room.
"Help me! Help me! I'm in so much pain," the resident yelled.
Staff E found the resident with red eyes and facial grimacing. The resident's left leg was positioned abnormally, abducted outward, and she wouldn't allow staff to move it. Staff E later admitted she forgot to document this crucial detail about the leg positioning.
Staff F, a nursing assistant, had checked on the resident at 6 a.m. and found her sleeping peacefully. When Staff F returned 45 minutes later to ask about breakfast, the resident immediately began screaming about pain.
"Staff F reported she could tell it in her eyes she was in pain," according to the inspection report.
Staff E called the resident's son, who visited frequently, and told him his mother needed hospital evaluation because of severe pain and staff's inability to move her safely. The facility sent the resident by ambulance to the emergency department.
Multiple staff members noted this level of pain was unprecedented for the resident. Staff E said the woman had "mild aches and pains but never acted like how she was with the severe pain." Staff A similarly observed that while the resident had general aches and pains, "the pain had not been localized" like this before.
The Director of Nursing admitted during the inspection that the facility provided no education to staff about pain assessment, pain management, or physician notification protocols related to falls. She said she was unaware of the severe pain the resident experienced during the overnight hours.
The facility's fall policy, last revised in February 2024, contained no guidance for staff on managing pain after falls, treating pain symptoms, or determining when physician notification was required for pain-related concerns.
Staff A's decision-making process revealed the gaps in training and protocols. She gave Tylenol based on her own judgment, monitored the resident's sleep, and noted the frequent call light usage and medication requests without escalating concerns to a physician or supervisor.
The three-and-a-half-hour delay between the resident rating her pain as "worst pain ever" and receiving proper medical evaluation illustrated the consequences of inadequate fall response procedures.
Staff E's observation about the resident's leg positioning suggests the injury may have been more serious than initially assessed. The resident's inability to allow movement of the affected leg, combined with the abnormal positioning, indicated potential fracture or significant soft tissue damage that Tylenol couldn't address.
The facility's approach left a resident in severe pain for hours while staff provided only over-the-counter medication for what appeared to be a significant injury requiring emergency department evaluation and imaging.
The inspection found the facility failed to ensure residents received proper assessment and treatment for pain following falls, putting residents at risk for delayed diagnosis and treatment of serious injuries.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lake Mills Care Center from 2025-10-16 including all violations, facility responses, and corrective action plans.