Brunswick Health & Rehab: Fractured Hip Undetected - NC

Resident #61 complained of hip pain on July 18, 2025, prompting staff to order mobile X-rays. But the facility's Unit Manager assigned to her care that afternoon never entered the resident's room or assessed her pain level, federal inspectors found during an April 2026 review.

"She was not scheduled for any medication during the time she was assigned to her, so she did not go into Resident #61's room and did not assess the resident," Unit Manager #1 told inspectors. The manager worked the 11:00 AM to 3:00 PM shift on July 18 as the facility's wound care nurse.

The X-ray results, completed at 11:31 PM that same day, revealed an acute left femoral neck fracture with displacement. Nobody discovered the results until the next morning.

Nurse #5 found the X-ray report on the fax machine when he arrived early for his July 19 shift. The fracture had gone undetected for nearly 15 hours while the resident remained in her room with a broken hip.

"When he came on for his shift, he found the x-ray results for Resident #61 dated 7/18/25 on the fax machine," according to the inspection report. Only then did staff contact the on-call provider and receive orders to transfer the resident to the hospital.

The resident received acetaminophen at 10:36 AM on July 19, documented as effective. But nursing records contained no numerical pain monitoring with the medication administration, despite federal requirements for pain assessment.

Unit Manager #1 told inspectors she assumed the dementia patient couldn't rate her pain or request medication due to cognitive impairment. "She did not think that Resident #61 was able to rate her pain on a 0 to 10 scale or request pain medication due to her dementia with impaired cognition."

That assumption contradicted the facility's own Director of Nursing, who told inspectors during the April review that residents with cognitive impairment still required thorough pain assessment.

"Her expectation was for the nursing staff to monitor residents for pain, assess the resident, and report increased pain or any changes in condition to the physician for further evaluation," the DON stated. She emphasized that Resident #61 "should have been assessed for pain using non-verbal indicators and provided with pain medication as needed."

The resident was transferred to the emergency department at 12:45 PM on July 19 for evaluation. Hospital records show she immediately told emergency staff about her hip pain upon arrival.

Emergency physicians prescribed hydromorphone, a potent narcotic for moderate to severe pain, along with a muscle relaxant. The resident received intravenous hydromorphone the following morning before undergoing left hip replacement surgery.

The hospital discharge summary indicated Resident #61 underwent a left hip hemiarthroplasty on July 20 without complications and returned to the nursing facility in stable condition.

Nurse #5 couldn't recall during his inspector interview whether the resident had indicated pain levels or requested medication, or even whether he administered the acetaminophen after discovering the fracture results. His uncertainty highlighted the facility's inadequate pain monitoring protocols.

The nursing progress notes from July 18 made no reference to pain levels or assessment of the resident's left lower extremity, despite her verbalized complaints. Staff documented the resident's hip pain but failed to follow through with proper evaluation.

Federal inspectors determined the facility failed to ensure adequate pain management for residents unable to express their needs clearly. The violation affected few residents but caused actual harm, according to the Centers for Medicare and Medicaid Services classification.

The case illustrates broader problems with pain assessment in nursing home residents with dementia. Research shows that cognitive impairment doesn't eliminate the ability to experience or communicate pain, but requires different assessment approaches.

Unit Manager #1's decision to skip room visits for residents without scheduled medications violated basic nursing standards. Pain assessment should occur regardless of medication schedules, particularly when residents have verbalized discomfort.

The 15-hour delay in discovering critical X-ray results also revealed communication breakdowns in the facility's medical information systems. Urgent diagnostic results require immediate review and action, not discovery during shift changes.

Resident #61's case demonstrates how assumptions about dementia patients' communication abilities can lead to inadequate care. The resident clearly expressed pain to staff and later communicated effectively with emergency department personnel about her symptoms.

The facility's failure extended beyond individual staff decisions to systemic problems with pain management protocols. Proper procedures would have ensured regular pain assessment regardless of cognitive status and immediate review of diagnostic results.

Hospital records confirmed the severity of the missed diagnosis. The displaced femoral neck fracture required surgical intervention that could have been initiated hours earlier with proper assessment and communication.

The Director of Nursing's acknowledgment that staff should have used non-verbal pain indicators highlighted the facility's awareness of appropriate protocols, making the failure more concerning to federal regulators.

Resident #61's experience with delayed fracture diagnosis and inadequate pain management represents the human cost of assuming dementia patients cannot communicate their medical needs effectively.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Brunswick Health & Rehab Center from 2026-04-09 including all violations, facility responses, and corrective action plans.

Additional Resources

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