Lisner Louise Dickson Hurthome: Doctor Review Gaps - DC
The resident suffered what X-rays revealed as an "acute comminuted displaced intertrochanteric fracture involving the right femur with associated soft tissue swelling." Nobody knew how it happened.
Federal inspectors found the facility violated reporting requirements during a November complaint investigation, documenting how administrators knew about the serious injury on August 5th but didn't file the required incident report until August 8th.
The resident, identified in records as Resident #5, had been admitted with a history of repeated falls, difficulty walking, and seizures. Her August assessment showed severe cognitive impairment with a mental status score of 06 and required substantial help with basic activities like bathing, dressing, and using the toilet.
On August 5th at 7:10 AM, she complained to nursing staff about right hip pain. "I can't get OOB, my rt hip hurts," she told them, using medical shorthand for "out of bed."
The nurse who assessed her found the right hip visibly larger than the left and warm to touch. Staff gave her two tablets of Tylenol as ordered for pain. It provided no relief.
Twenty-three minutes later, at 7:33 AM, staff sent an electronic message to the primary care provider describing "new or worsening edema and uncontrolled pain." The doctor responded by ordering an X-ray of the right hip.
The radiology results came back that evening at 9:54 PM, more than 14 hours after the resident first complained of pain. The single-view X-ray of her right hip and pelvis revealed the extent of her injury.
The fracture was not just broken. It was comminuted, meaning shattered into multiple pieces. It was displaced, meaning the bone fragments had moved out of normal position. And it involved the intertrochanteric region, the area where the thighbone connects to the hip.
A physician immediately ordered her transfer to the hospital emergency department for evaluation of the acute fracture and associated soft tissue swelling.
At 6:31 AM the next morning, August 6th, facility staff called the hospital emergency room. The ER nurse confirmed what everyone already knew: the resident had a femur fracture and was being admitted.
The facility's incident report, finally submitted to the state agency on August 8th at 11:11 AM, documented the timeline. "On 8/5/2025 at approximately 7am resident c/o right hip pain and could not get out of bed," it read. "Hip site appeared swollen and warm to touch. X-ray was ordered and PRN pain medications were given."
The report noted the X-ray results showing the acute fracture with soft tissue swelling. Then came a crucial admission: "There has been no evidence or report of a fall."
This made it an injury of unknown origin. Federal regulations require nursing homes to report such incidents to state agencies within 24 hours. The facility missed that deadline by two full days.
When inspectors interviewed the Director of Nursing on September 23rd, she acknowledged the reporting failure. Her explanation was straightforward: computer problems.
"I was having IT issues and couldn't send off the report," Employee #2 told inspectors. "It was typed up and I had to wait until someone was able to help me to send it off."
The director's account suggested the report was ready to go but couldn't be transmitted due to technical difficulties. The inspection report doesn't indicate how long these IT issues persisted or what specific problems prevented submission.
For a resident with severe cognitive impairment, the three-day delay meant state investigators couldn't immediately begin examining how she sustained such a serious injury. The fracture was described as acute, meaning it happened recently, but without a witnessed fall or other obvious cause, determining what occurred became more difficult with each passing day.
The facility had coded the resident as having no falls since her prior assessment. Her medical history included repeated falls and difficulty walking, making an unwitnessed fall a possibility. But staff found no evidence of any fall.
The resident required substantial assistance for basic activities and used both a walker and wheelchair for mobility. Someone with her level of cognitive impairment and physical limitations would be particularly vulnerable to injury and unable to provide reliable information about what happened.
The warm, swollen hip that nursing staff observed suggests the injury was fresh when discovered. The severity of the fracture, with multiple bone fragments displaced from normal position, would have caused significant pain and made weight-bearing impossible.
Federal inspectors classified this as a violation causing minimal harm or potential for actual harm, affecting few residents. But the regulatory framework treats reporting delays seriously because they can compromise investigations into potential abuse or neglect.
The inspection report references District of Columbia regulations requiring timely incident reporting, indicating this wasn't just a federal violation but also a breach of local nursing home rules.
Lisner Louise Dickson Hurthome operates in Northwest Washington on Western Avenue. The facility's handling of this incident raises questions about its emergency protocols and backup systems for critical reporting requirements.
The resident's case illustrates how quickly serious injuries can develop in nursing home settings and how reporting delays can complicate efforts to understand what happened. Her complaint of hip pain at 7:10 AM led to hospitalization within 24 hours, but the state agency didn't learn about it for three days.
The Director of Nursing's explanation that the report was "typed up" but couldn't be sent suggests awareness of the reporting requirement. However, federal regulations don't provide exceptions for technical difficulties when it comes to the 24-hour reporting deadline for injuries of unknown origin.
The resident's severe cognitive impairment meant she couldn't advocate for herself or provide detailed information about her injury. In such cases, prompt reporting becomes even more critical for protecting vulnerable residents and ensuring proper investigation of suspicious incidents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lisner Louise Dickson Hurthome from 2025-11-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
LISNER LOUISE DICKSON HURTHOME in WASHINGTON, DC was cited for violations during a health inspection on November 13, 2025.
The resident, identified in records as Resident #5, had been admitted with a history of repeated falls, difficulty walking, and seizures.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.