Resident #305 first showed signs of trouble on April 30, 2024, when a nurse noticed bluish discoloration on the patient's right lower leg. The affected area felt cold and clammy, though pulses were still detectable. The resident complained of generalized pain from a contracted right leg.
The physician immediately ordered a bilateral leg arterial ultrasound to check for blood clots.
By May 1, the resident's condition had worsened. Weekly skin checks documented the bluish discoloration spreading and the leg becoming increasingly painful. Staff noted the physician had been contacted the previous day and the ultrasound ordered.
Three days later, the resident was confused and crying out in pain. Nursing notes described the right lower extremity as cool to touch from mid-calf to toes, tender when touched, and purplish in color down to the toe pads.
The resident's pain escalated to 10 out of 10 by May 4. A monthly nursing summary documented increased pain in both lower extremities, cold and clammy skin, and worsening bluish discoloration. The summary noted the resident "likely had some circulatory problem" but revealed a critical problem: "there was no in house ultrasound available."
Staff continued documenting the resident's deteriorating condition. On May 6, nursing notes recorded that the resident "continued to cry out in pain when the resident's right lower extremity was touched or moved during care."
That same day, nurses called the facility's contracted diagnostics company to check on ultrasound availability. The company confirmed they still did not have an ultrasound technician. Despite the resident's blue discoloration and painful leg, the Unit Manager simply advised nurses to "call the Physician if the resident's leg got worse."
A behavior note from May 6 documented the resident "kept yelling and screaming."
Finally, on May 7 — a full week after the initial symptoms appeared — the facility sent the resident to the hospital via emergency transport. The transfer summary noted the ultrasound "could not be completed in the facility" and the physician had ordered hospitalization only after being notified of this limitation.
During the entire seven-day ordeal, staff failed to monitor basic vital signs that could have indicated the severity of the resident's condition. Clinical records showed no documentation of pedal pulse assessments after April 30, despite the suspected blood clot.
The facility's Unit Manager later admitted the delay was inappropriate. During a June 11 interview with inspectors, the Unit Manager acknowledged "the facility should have sent the resident to the hospital earlier and there was a delay in the care provided to the resident."
The Unit Manager confirmed that pedal pulses "should have been monitored at least daily for a suspected DVT" but admitted the only documented pulse check occurred on April 30.
The Director of Nursing was even more direct about the facility's failures. She told inspectors the resident "should have been sent to the hospital for any changes in condition if the facility could not manage the issue."
She specified that proper assessment would have included checking for pain and circulation to both lower extremities, including pulse monitoring. Most critically, she stated the resident "should have been sent to the hospital when the skin checks on 05/01/2024, documented the resident had cold and clammy skin with bluish discoloration."
The Director of Nursing also revealed another communication breakdown: she found no documentation that the physician had been notified about the unavailable ultrasound technician or the facility's inability to complete the ordered test.
The attending physician confirmed this communication gap during inspector interviews. The physician said the facility "had not informed the Physician the resident was declining while awaiting an ultrasound."
The physician explained that pulse assessments were expected "when a resident had a suspected DVT, and an ordered ultrasound was delayed." Most significantly, the physician stated that if properly notified of the resident's clinical decline and ultrasound unavailability, "the Physician would have ordered for the resident to be sent to the hospital with no delay."
The facility's own policies contradicted the care provided. A Licensed Nurses Standard of Care policy required nurses to perform evaluations of cardiovascular conditions and provide assessments affecting required services. Another policy on resident examination specifically mandated assessing peripheral pulses and notifying physicians of abnormalities.
Medical literature supports the urgency that should have been applied. Mayo Clinic documentation cited by inspectors identifies leg swelling, leg pain, and skin color changes as possible symptoms of deep vein thrombosis.
The case represents a cascade of care failures: inadequate monitoring of a resident with suspected blood clots, failure to communicate critical information to the attending physician, and administrative decisions that prioritized waiting for an unavailable service over patient safety.
Resident #305 was admitted with multiple conditions including pulmonary embolism, peripheral vascular disease, and cognitive deficits. The resident's existing circulation problems should have heightened staff vigilance when new symptoms appeared.
Instead, the resident endured seven days of escalating pain while facility staff waited for a diagnostic service they knew was unavailable, ultimately requiring emergency transport for care that could have been provided days earlier.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alta Skilled Nursing and Rehabilitation Center from 2024-06-13 including all violations, facility responses, and corrective action plans.
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