GREENSBORO, NC - A January 2025 inspection at Blumenthal Nursing & Rehabilitation Center uncovered serious deficiencies in medical care coordination and pain management that left a resident with a fractured femur waiting five days for necessary surgery, during which time she remained in the facility with inadequate pain control.
Breakdown in Medical Communication Delays Emergency Treatment
On November 17, 2024, staff discovered a resident sitting on the floor beside her bed following an unwitnessed fall. The initial assessment documented no injuries and no pain complaints. However, when the resident's family member arrived approximately 45 minutes later, the resident reported pain in her left hip. At that point, the on-call provider ordered a STAT (immediate) x-ray at 3:04 PM and pain medication.
The x-ray was not completed until the following day, November 18, at 9:23 AM. Results confirmed an acute nondisplaced transverse intertrochanteric femur fracture - a serious break in the thigh bone near the hip joint. Despite the severity of this injury, the resident remained at the facility rather than being transferred to a hospital for immediate orthopedic evaluation.
The nurse practitioner who reviewed the x-ray results made the decision to manage the fracture in-house, ordering scheduled opioid pain medication and scheduling an orthopedic consultation for November 26 - eight days after the fracture was confirmed. The facility's medical director was not informed of the fracture diagnosis and was not consulted about this treatment plan.
The lack of coordination between medical providers created a critical gap in care. The medical director did not become aware of the fracture until November 22, when he examined the resident during routine rounds. Upon discovering the injury, he immediately ordered the resident sent to the emergency department if an orthopedic appointment could not be secured that same day. The resident was seen by an orthopedic specialist on November 22 and sent directly to the hospital, where surgery was performed on November 23.
Medical Consequences of Delayed Orthopedic Care
Femur fractures, particularly in the intertrochanteric region where the upper thigh bone connects to the hip, require prompt surgical intervention. The standard of care for such fractures calls for evaluation by an orthopedic specialist and surgical repair within 24-48 hours of injury. This timeframe is not arbitrary - delays in treatment significantly increase the risk of serious complications.
When a long bone like the femur is fractured, immobility becomes dangerous. Patients unable to move or bear weight face increased risks of deep vein thrombosis, where blood clots form in the deep veins of the legs. These clots can break loose and travel to the lungs, causing potentially fatal pulmonary embolisms. Extended bed rest also increases pneumonia risk, as patients cannot take deep breaths or clear their lungs effectively. Pressure ulcers develop more rapidly in immobilized patients, particularly those with compromised circulation around fracture sites.
The orthopedic surgeon who ultimately performed the resident's surgery confirmed these risks in interviews with inspectors. While noting that the ultimate healing outcome would not differ with delayed surgery, he emphasized that complication risks increase substantially when treatment is postponed beyond the 24-48 hour window. Research studies demonstrate approximately 30% perioperative mortality rates for hip fractures treated beyond 48 hours, compared to significantly lower rates when surgery occurs promptly.
In this case, the delay in treatment appeared to contribute to complications. During hospitalization, the resident experienced an aspiration event - when food, liquids, or stomach contents enter the lungs instead of the esophagus. This resulted in acute hypoxic respiratory failure, a condition where insufficient oxygen reaches the bloodstream. Intravenous antibiotics were initiated on November 24, and the resident required additional oral antibiotics for three days after returning to the facility on November 26.
Inadequate Pain Assessment and Management
Beyond the delayed surgical intervention, inspectors identified significant failures in pain management throughout the five-day period between fracture diagnosis and hospital transfer. Despite physician orders requiring pain assessments using a 0-10 scale or non-verbal scoring tool every shift, nurses failed to conduct or document proper pain evaluations from November 19-22.
Femur fractures are intensely painful injuries. While a patient lying completely still may experience tolerable discomfort, any movement - rolling in bed, transferring to a chair, or repositioning for personal care - causes significant pain. This resident was non-verbal due to severe cognitive impairment, making systematic pain assessment using non-verbal indicators critically important.
Documentation revealed inconsistent and inadequate pain monitoring. On November 18, the resident reported pain levels of 7 and 4 out of 10, indicating substantial discomfort. However, from November 19-22, medication administration records showed only checkmarks indicating pain assessments were "completed" without any numerical values, pain locations, or non-verbal assessment scores recorded.
Multiple nurse aides reported observing signs of pain during this period. One aide working the overnight shift November 20-21 stated the resident said "ow" during incontinence care when her left hip was touched. Another aide working November 21-22 observed the resident refusing care, unwilling to get out of bed, and grabbing the aide's arm as if to say "stop" when the aide attempted to turn her in bed. These observations were not communicated to nursing staff or medical providers.
The night nurse supervisor acknowledged during interviews that she did not actually assess the resident for pain on November 18, 19, or 20. Instead, she copied information from previous shifts' documentation "just so that some kind of documentation was completed." This practice created false medical records suggesting the resident had been evaluated when no such assessments occurred.
Systemic Failures in Provider Coordination
The inspection revealed confusion about roles and responsibilities between the facility's medical director and nurse practitioner. When questioned, the nurse practitioner stated he was not trained to communicate with the medical director on specific topics and would only consult him if he had questions about treatment. He indicated he made the decision to keep the resident in the facility after consultations with the unit supervisor and director of nursing - neither of whom are physicians.
The medical director stated he expected the nurse practitioner to communicate when unsure about something or when questions arose, which happened regularly. However, he also indicated the nurse practitioner was an experienced independent practitioner who made similar decisions daily and did not need to consult about situations he felt comfortable managing.
This lack of clarity about when collaboration was required created dangerous gaps. The medical director reviewed x-ray and laboratory results by checking a physical communication book where nurses placed printouts. When he cleared electronic results from the computer system on November 18 without placing the original orders, he did not review the x-ray report showing the fracture. No system existed to ensure critical diagnostic results reached the appropriate physician in a timely manner.
Additional Issues Identified
Inspectors documented the facility's failure to immediately report the allegation of neglect to the state agency. The administrator was notified of the neglect allegation on January 3, 2025, but did not submit the required report until January 6 - three days later. During interviews, the administrator stated he assumed reporting was unnecessary because all parties, including the state agency, were already aware of the situation.
The inspection also revealed inaccurate medical record documentation. Multiple nurses copied information from previous shifts' documentation without conducting actual patient assessments, creating false records that suggested evaluations had occurred when they had not. These fabricated entries compromised the medical record's integrity and masked the resident's deteriorating condition.
Federal inspectors issued an immediate jeopardy citation - the most serious category of deficiency - indicating the facility's practices put residents at risk of serious injury, harm, impairment, or death. The immediate jeopardy was removed on January 5, 2025, after the facility implemented corrective measures including comprehensive staff education on abuse and neglect recognition, physician notification protocols, pain assessment requirements, and provider collaboration standards.
The facility conducted extensive remediation, including reviewing all residents who had fallen in the previous 30 days, auditing pain management across all residents, and establishing new protocols requiring the medical director, nurse practitioners, and covering providers to collaborate three times weekly regarding any resident with a fracture or significant change in condition. All facility staff, including contract and agency personnel, received mandatory training on recognizing when residents require immediate medical treatment and proper procedures for reporting delays in physician orders or diagnostic testing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Blumenthal Nursing & Rehabilitation Center from 2025-01-09 including all violations, facility responses, and corrective action plans.
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