BATON ROUGE, LA - The Guest House Care Center faces immediate jeopardy citations after inspection officials found that staff failed to notify medical providers for over two days when a cognitively impaired resident experienced severe leg pain and mobility changes that were later determined to be from an acute femur fracture.
Critical Delay in Medical Notification
The most serious violation involved a resident who went from walking independently to being unable to bear weight on his left leg, yet nursing staff failed to contact medical providers until 48 hours after the symptoms began. On July 13, 2024, at 5:24 a.m., the resident complained of pain extending from his groin down to his thigh. By 7:32 a.m., nursing notes documented that his left knee was swollen, he could not bear weight, and rated his pain as 6 out of 10.
Despite these clear signs of a significant change in condition, no physician was contacted until July 15 at 8:00 a.m. - more than two full days later. The delayed notification occurred even though multiple staff members observed the resident's dramatic decline, including his need for a wheelchair and complete inability to walk.
When medical providers finally examined the resident, X-rays revealed an acute left proximal femur fracture - a serious hip fracture that required emergency surgery. The resident underwent a left hip hemiarthroplasty (hip replacement surgery) on July 16, 2024.
Staff Acknowledged Serious Change in Condition
Multiple nursing staff interviewed during the inspection confirmed they recognized the resident's condition had changed dramatically. A certified nursing assistant who worked July 14 stated that before that date, the resident "was ambulatory without assistance or pain and continent," but observed him in a wheelchair at the beginning of her shift and noted he "was unable to walk" and "rubbed his left leg and verbalized pain."
Another CNA working July 12-14 described how the resident went from ambulating "as usual without assistance or pain" to being "in bed complaining of leg pain, and unable to stand or bear weight" by the morning of July 13. She noted the resident "grimaced when he moved" and appeared "restless and couldn't keep still."
The licensed practical nurse (LPN) working July 13-14 admitted she recognized this represented "a significant change in condition" but failed to notify medical providers. When asked why, she stated it was "the end of her shift, and she had already stayed over an extra hour."
Medical Standards Require Immediate Provider Notification
Nursing home regulations mandate that physicians be contacted immediately when residents experience significant changes in condition. In this case, multiple clinical indicators should have triggered immediate medical evaluation: sudden inability to bear weight, new onset severe pain, loss of mobility function, and changes in continence status.
The facility's Director of Nursing confirmed during interviews that "any significant change in a resident's condition should be reported immediately to the medical provider" and that weekend or after-hours changes require contacting the on-call provider immediately.
The nurse practitioner who eventually examined the resident confirmed that had she been notified on July 13 when staff first discovered the changes, she would have ordered X-rays immediately. She noted that the delay caused the resident to experience prolonged pain and declining range of motion and mobility.
Consequences of Delayed Treatment
Femur fractures in elderly residents require immediate medical attention, as delays can lead to complications including increased pain, muscle contractures, blood clots, and pneumonia from immobility. Hip fractures are particularly serious in nursing home residents, as they significantly increase mortality risk and often result in permanent mobility loss.
In this case, the resident went from being completely independent in walking to requiring a wheelchair permanently. The delay also meant the resident experienced unnecessary pain for over 48 hours while the fracture remained undiagnosed and untreated.
Video footage reviewed by facility administrators confirmed the timeline: the resident was seen walking independently in the hallway at 7:30 p.m. on July 12, but was next observed being transferred by wheelchair to the day room at 6:53 a.m. on July 13 - indicating the injury likely occurred overnight between July 12-13.
Quality Improvement Measures Implemented
Following the citation, the facility implemented a quality improvement project that included staff interviews, camera footage review, and comprehensive training programs. The facility provided in-service training to all nursing staff on both fall prevention and identifying and reporting changes in resident conditions.
The facility established ongoing monitoring protocols, including twice-weekly reviews of nursing documentation by the Director of Nursing and daily reviews of nursing notes by the administrative team. Weekly rounds on cognitively impaired residents were implemented to monitor for changes in transfer and ambulation status.
Officials noted the facility achieved substantial compliance by July 23, 2024, after implementing these corrective measures and demonstrating consistent proper notification procedures.
The case highlights the critical importance of immediate medical evaluation when nursing home residents experience sudden changes in mobility, pain levels, or functional status - particularly for cognitively impaired residents who may be unable to clearly communicate their symptoms.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Care Center The from 2024-07-31 including all violations, facility responses, and corrective action plans.
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