The resident had been receiving an abduction pillow and nutritional supplement before her August hospital transfer. When she returned three days later, the hospital's discharge summary made no mention of either intervention. Staff simply entered what the hospital sent back.
The abduction pillow and nutritional supplement were never reinstated.
Federal inspectors found the facility had no policy for reviewing previously established interventions when residents return from hospitals. The lapse affected a woman with malignant cervix cancer, protein-calorie malnutrition, vitamin D deficiency, and bilateral femoral neck fractures who cannot walk or transfer herself.
The resident scored one on a cognitive assessment, indicating severe impairment. She had lived at the facility since November 2019.
"The facility only re-enters what the hospital sends back after clarification with the provider," the Assistant Director of Nursing told inspectors on November 6. "They did not seek clarification about pre-hospital interventions of the abduction pillow or nutritional supplement."
The Director of Nursing confirmed during her interview that the provider was not contacted to clarify the missing orders. "They should have," she said.
When inspectors reached the facility's nurse practitioner by phone, she verified that neither she nor the on-call practitioner had been contacted about whether the interventions should continue. They should have been, she said.
The administrator acknowledged the facility lacked any policy regarding transcription of readmission orders or review of previously established interventions to determine if they should continue.
For a resident who cannot ambulate and depends on others for transfers, an abduction pillow helps maintain proper hip positioning and prevents dislocation. The intervention is particularly critical for someone with bilateral femoral neck fractures.
The nutritional supplement addresses the resident's documented protein-calorie malnutrition, a condition that can worsen quickly in cancer patients and elderly residents with cognitive impairment who may forget to eat or have difficulty feeding themselves.
Hospital discharge summaries frequently omit interventions that were working before admission. The gap creates a critical moment when nursing homes must actively verify which treatments should continue rather than simply transcribing whatever appears on discharge paperwork.
The breakdown occurred during a routine process that happens thousands of times daily across American nursing homes. A resident goes to the hospital for treatment, returns with new orders that may or may not include everything they were receiving before, and staff must decide what to resume.
At Great Oaks, that decision defaulted to doing nothing.
The facility's approach meant interventions could disappear simply because a hospital failed to mention them in discharge documentation. No one checked whether the abduction pillow was still medically necessary for someone with bilateral hip fractures. No one verified whether nutritional supplements should continue for someone with documented malnutrition.
The resident's complex medical history made the oversight particularly concerning. Cancer patients often require consistent nutritional support to maintain strength during treatment. Proper positioning devices become essential for residents who cannot move independently and have suffered fractures.
Federal inspectors reviewed hospital readmissions for three residents. They found the communication breakdown affected one of the three, but the facility's lack of policy suggested the problem could occur repeatedly.
The inspection occurred after someone filed a complaint about the facility. Inspectors classified the violation as causing minimal harm or potential for actual harm to few residents.
The nurse practitioner's confirmation that she should have been contacted highlighted how easily preventable the lapse was. A single phone call could have clarified whether both interventions should resume. Instead, the resident went without them indefinitely.
Great Oaks operates on Chase Street in this small town south of Memphis. The facility serves residents with complex medical needs who require rehabilitation services and long-term care.
The woman affected by the policy failure remains dependent on staff for all transfers and mobility. Her cognitive impairment means she cannot advocate for herself or request the interventions that were helping her before the hospital stay.
Her abduction pillow and nutritional supplement remained discontinued as of the November inspection, more than two months after her return from the hospital.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Great Oaks Rehabilitation and Healthcare Center from 2025-11-06 including all violations, facility responses, and corrective action plans.
Additional Resources
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