Resident 1 was found on the floor at 3:50 p.m. on October 4, complaining of pain he rated 10 out of 10 on the standard pain scale. The resident, who had been admitted with neuropathy and chronic obstructive pulmonary disease, received an X-ray the following day.
The October 5 X-ray revealed "deformity of the right femoral neck area consistent with subcapital fracture," a break in the thigh bone below the head of the femur. The radiologist recommended confirmation with CT or MRI examination.
Progress notes from that same day at 7:14 p.m. stated: "Results sent to MD and placed in box for review." No documentation exists showing the doctor replied on October 5.
The resident wasn't transferred to the hospital until October 6 at 12:44 p.m., more than 48 hours after his fall.
A certified nursing assistant who cared for the resident on Monday, October 6, said during an October 20 interview that staff had informed her the resident "fell on Saturday and was in a lot of pain."
During a December 24 interview, the director of nursing confirmed the timeline. She acknowledged the resident had fallen on October 4 at 3:50 p.m., X-ray results were received October 5, and the resident was sent to the hospital two days after his fall.
"The time it took to send Resident 1 to the hospital after his fall was not ok," the director of nursing told inspectors.
The facility's own policy requires staff to "promptly notify the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition." The policy specifically states nurses must notify the attending physician or physician on call "when there has been an accident or incident involving the resident and the need to transfer the resident to a hospital/treatment center."
Federal inspectors determined the delay had "the potential to delay care compromising the resident's health, safety, and overall well-being."
The violation occurred despite clear documentation of the resident's severe pain and objective evidence from imaging studies. Hip fractures in elderly residents typically require immediate medical attention, as delays can lead to complications including infection, blood clots, and prolonged disability.
The inspection, conducted as part of a complaint investigation, found the facility failed to meet professional standards of quality for medical care. Inspectors reviewed three residents' records and identified this failure in one case.
The resident's medical history included conditions that could complicate recovery from a hip fracture. Neuropathy affects nerve function and can cause numbness or weakness, while chronic obstructive pulmonary disease creates breathing difficulties that can complicate surgery and recovery.
No documentation shows what happened during the critical period between when X-ray results arrived on October 5 evening and when the resident was finally transferred to the hospital the following afternoon. The gap represents nearly 17 hours when the resident remained at the facility with a confirmed hip fracture.
The facility's policy language appears straightforward, requiring prompt notification of physicians about resident incidents requiring hospital transfer. Yet the implementation failed when the resident needed it most.
State inspectors classified the violation as causing "minimal harm or potential for actual harm," though the two-day delay with a fractured hip suggests the potential for significant complications.
The director of nursing's admission that the response time "was not ok" indicates facility leadership recognized the failure to follow established protocols for emergency medical situations.
Hip fractures represent one of the most serious injuries that can occur in nursing homes, particularly for elderly residents with multiple chronic conditions. The standard of care typically requires immediate evaluation and rapid transfer to acute care facilities equipped for orthopedic surgery.
For Resident 1, the weekend became a prolonged ordeal of maximum pain while X-ray results sat in a box awaiting physician review that never came.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cypress Ridge Care Center from 2025-12-23 including all violations, facility responses, and corrective action plans.