MOORESVILLE, NC - A nursing home resident with a fractured hip was denied immediate medical care for nearly 24 hours after staff improperly moved him following a fall, according to a recent state inspection of Accordius Health At Mooresville.
Critical Assessment Failures Following Resident Fall
On May 27, 2024, at 10:40 PM, multiple staff members at Accordius Health At Mooresville responded to a room after hearing another resident call out that a patient had fallen. The staff found Resident #40 face down on the floor and made several critical errors in their response that violated established medical protocols.
Instead of conducting a thorough assessment before moving the resident, nursing staff immediately rolled the patient over and lifted him back into bed by his arms while a nursing aide held his left leg. This improper transfer occurred without first checking for potential injuries, particularly fractures that could be worsened by movement.
Medical protocols require that fall victims remain immobilized until a comprehensive assessment can determine whether movement is safe. Moving a patient with a potential hip fracture can cause severe complications, including damage to blood vessels, nerves, and surrounding tissue. The femur is one of the strongest bones in the human body, and fractures typically occur from significant trauma, making immediate medical evaluation essential.
Delayed Recognition and Cancelled Emergency Response
Only after moving the resident did Nurse #3 perform an assessment and obtain vital signs. During this evaluation, she observed that the resident's left leg was internally rotated and shorter than the right leg - classic signs of a hip fracture that should have prompted immediate emergency medical intervention.
Recognizing the severity of the situation, Nurse #3 initially summoned Emergency Medical Services. However, after consulting with the Director of Nursing and reviewing the resident's advance directive, she was instructed to cancel the EMS call. The directive indicated "Do Not Hospitalize" unless comfort needs could not be met at the facility.
This decision violated medical standards that require immediate evaluation of suspected fractures regardless of advance directive status. Pain management and proper medical assessment for a hip fracture cannot typically be provided in a nursing home setting and require hospital-level care.
Medical Consequences of Treatment Delays
Hip fractures, particularly in elderly residents, constitute medical emergencies requiring prompt surgical intervention. The delay in proper medical care exposed Resident #40 to unnecessary pain and potential complications including blood clots, pneumonia, and tissue death around the fracture site.
Internal rotation and leg shortening are definitive signs of a displaced femoral fracture. These fractures disrupt blood supply to the femoral head and can lead to avascular necrosis if not promptly addressed. Additionally, untreated hip fractures cause severe pain that cannot be adequately managed without proper medical intervention and positioning.
The facility's decision to delay treatment for nearly 24 hours also increased the resident's surgical risk. Research consistently shows that hip fracture patients who receive surgery within 24 hours have better outcomes and lower mortality rates compared to those who experience delays.
Confirmation and Belated Transfer
An X-ray performed on May 28, 2024 - nearly 24 hours after the fall - confirmed what the physical assessment had already indicated: Resident #40 had sustained an acute fracture of the proximal left femur. Only then was the resident transferred to a hospital for proper evaluation and pain management.
The inspection revealed that advance directives should not prevent appropriate medical evaluation and comfort care measures. Even residents with "Do Not Hospitalize" preferences are entitled to proper assessment and pain management, which often requires hospital-level resources for conditions like hip fractures.
Industry Standards and Proper Protocol
Standard nursing home protocols require comprehensive assessments before moving fall victims, including neurological checks, pain assessment, and evaluation for obvious deformities or injuries. When a hip fracture is suspected, residents should remain immobilized and receive immediate emergency medical evaluation.
The Centers for Medicare & Medicaid Services requires nursing homes to ensure residents receive necessary medical care without delay. Facilities must have policies for emergency situations that prioritize resident safety and proper medical assessment over administrative considerations.
Additional Issues Identified
The inspection classified this violation as "immediate jeopardy to resident health or safety," the most serious level of deficiency. The improper response affected one of three residents reviewed for change of condition protocols, suggesting potential systemic issues with emergency response procedures at the facility.
The state's investigation determined that the facility's actions violated federal regulations requiring comprehensive assessments and appropriate medical intervention following significant changes in a resident's condition.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Accordius Health At Mooresville from 2024-06-13 including all violations, facility responses, and corrective action plans.
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