TAYLORSVILLE, NC - A recent federal inspection at Valley Nursing Center revealed critical breakdowns in medical care that led to a resident developing life-threatening blood clots in both legs, requiring emergency hospitalization and intensive treatment.
Communication Breakdown Led to Dangerous Blood Clot Development
The most serious violation occurred when the facility's nurse practitioner failed to collaborate with the medical director after a resident's family requested blood-thinning medication for their loved one. The resident, who had been admitted with multiple pelvic and spine fractures from a fall, was not receiving anticoagulation therapy despite being at high risk for blood clots due to her limited mobility and recent fractures.
On December 11, 2024, the resident's responsible party expressed concerns to facility staff that their family member was not receiving blood thinning medication, despite having received such treatment at the hospital prior to admission. The nurse practitioner initially ordered aspirin but quickly discontinued it after discovering the resident had an allergy to the medication and a history of gastrointestinal bleeding.
Rather than directly consulting with the medical director about alternative anticoagulation options, the nurse practitioner instructed nursing staff to contact the physician. This delegation of responsibility created a dangerous gap in medical communication. The medical director later confirmed he was never contacted about the resident's anticoagulation needs and stated that if he had been informed, he would have evaluated whether blood thinning medication was appropriate.
Deep vein thrombosis represents one of the most serious complications for immobilized patients. When blood clots form in deep veins, particularly in the legs, they can break loose and travel to the lungs, causing a pulmonary embolism that can be fatal. Patients with fractures who have limited mobility face significantly elevated risks for clot formation, making prompt medical evaluation and appropriate prevention measures critical.
Failure to Recognize Critical Warning Signs
Over the following weeks, the resident developed increasingly concerning symptoms that should have triggered immediate medical intervention. On December 18, the resident began experiencing swelling and discoloration in her left leg, which was initially diagnosed as a rash and treated with topical cream.
The resident's family member reported that by Christmas Day, December 25, the swelling had become so severe that the resident's leg brace no longer fit properly. Multiple nursing staff members documented observing significant swelling, redness, and warmth in the resident's left leg during the final days of her stay at the facility.
On December 27, when the nurse practitioner finally evaluated the resident for leg pain and swelling, she documented several critical findings: significant edema, increased pain, and a positive Homan's sign - a clinical indicator strongly suggestive of deep vein thrombosis. A Homan's sign occurs when pointing the toes toward the head causes pain behind the knee, indicating possible blood clot formation.
Medical protocols require immediate diagnostic testing when patients present with these classic signs of deep vein thrombosis. The combination of swelling, pain, warmth, and a positive Homan's sign in an immobilized patient with recent fractures should prompt urgent evaluation, typically including ultrasound imaging within hours rather than days.
Dangerous Delay in Emergency Care
Despite recognizing signs consistent with blood clots, the facility ordered an in-house venous doppler study that could not be performed until the following Monday - a three-day delay. The nurse practitioner was aware of this scheduling limitation but did not consider immediate hospital transfer for urgent evaluation.
Throughout December 27 and into December 28, the resident's condition continued to deteriorate. Nursing staff documented progressive swelling from hip to toes, increasing pain, and visible redness. The resident called her family early on December 28, reporting that her leg pain and swelling had worsened overnight and requesting to go to the hospital.
When Emergency Medical Services arrived at the facility, they documented the resident's blood pressure at 182/74 (elevated from normal 120/80) and severe pain rated 8 out of 10. EMS personnel administered intravenous morphine for pain control during transport - indicating the severity of the resident's distress.
Hospital Diagnosis Confirmed Worst Fears
Upon arrival at the emergency department, immediate diagnostic testing revealed extensive deep vein thrombosis in both of the resident's legs. The hospital promptly initiated anticoagulation therapy with heparin, a medication used to prevent clot expansion and break up existing clots. The resident required hospital admission and remained hospitalized for an extended period.
The development of bilateral deep vein thrombosis in both legs represents a particularly serious medical emergency. The extensive nature of the clots indicates they had been developing over time, consistent with the weeks of progressive symptoms documented at the nursing home. The immediate need for intravenous anticoagulation and hospitalization underscores the life-threatening nature of the condition.
Inadequate Pain Management Compounded Problems
Throughout this period, the facility also failed to adequately address the resident's escalating pain levels. Documentation shows the resident reported severe pain levels of 8-9 out of 10 on multiple occasions, particularly on December 27 when she exhibited clear signs of blood clots.
Despite having standing orders for both scheduled and as-needed pain medications, nursing records indicate the resident did not receive appropriate pain relief during her final days at the facility. On December 27, when the resident documented severe pain of 8 out of 10, no as-needed pain medication was administered. Similarly, on December 28, the resident missed her scheduled morning pain medication despite expressing significant discomfort.
Effective pain management serves multiple medical purposes beyond comfort. Uncontrolled pain can elevate blood pressure, increase stress hormones, and potentially worsen inflammatory responses. For patients with developing blood clots, adequate pain control is essential for both comfort and medical stability.
Additional Issues Identified
Federal inspectors also cited the facility for failing to report the allegation of neglect to state authorities as required by law. Despite being notified of immediate jeopardy related to the resident's care, facility administrators did not file mandatory reports with the state survey agency. Multiple facility staff members, including the Director of Nursing and Assistant Administrator, confirmed that no report had been filed following the neglect determination.
The facility's collaborative practice agreement between the nurse practitioner and medical director clearly outlined requirements for communication and consultation, particularly when medical management fell outside the nurse practitioner's scope of practice or when uncertainty existed regarding patient care. The failure to follow these established protocols contributed directly to the resident's adverse outcome.
State inspectors classified these violations as immediate jeopardy to resident health and safety, the most serious level of citation issued during nursing home inspections. The facility was required to implement comprehensive corrective measures, including staff education on recognizing blood clot symptoms, establishing daily monitoring systems for residents with pain or swelling, and strengthening communication protocols between medical providers.
The case highlights critical gaps in nursing home medical care that can have life-threatening consequences for vulnerable residents who depend on facility staff for comprehensive health monitoring and timely medical intervention.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Valley Nursing Center from 2025-01-13 including all violations, facility responses, and corrective action plans.
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