Resident #1 fell at Foremost at Sharon LLC in August and broke their left clavicle. An X-ray confirmed the midshaft fracture, and the hospital emergency department sent the resident back with clear discharge orders: wear a simple sling, check the skin around it daily, loosen it if fingers became numb or turned cold and blue, and put no weight on the left arm until seeing an orthopedic doctor.
The nursing home never followed any of these instructions.
Federal inspectors found no physician's orders related to the hospital's discharge summary. No treatment records showed the resident's left arm was placed in a sling. No nursing notes documented monitoring of the arm or maintaining non-weight bearing status.
For nearly two weeks, from August 23 through September 2, nursing staff wrote progress notes with no mention of a sling, arm monitoring, or weight restrictions. The resident went without the prescribed treatment until an orthopedic consultation on September 3 finally cleared them to bear weight on the left arm.
Nurse #1, who cared for the resident multiple times during their stay, told inspectors she was completely unaware of the hospital orders. She couldn't recall the resident ever wearing a sling.
"She was unaware that Resident #1 returned from the Hospital ED with orders for a sling, non-weight bearing of the left arm and to monitor his/her left arm," inspectors wrote after interviewing the nurse on December 30 and again by phone on January 12.
The nurse knew what proper care should look like. When asked about fractured arm protocols, she explained that nursing staff should monitor for circulation, sensation, and motion of the extremity and document it in the medical record.
She just didn't know her patient needed that care.
The Director of Nursing acknowledged the breakdown during her interview with inspectors. She confirmed that the resident had fallen, fractured their left clavicle, and returned from the emergency department with a sling.
"It was her expectation that staff implement the orders from the Hospital ED Discharge Summary and that nursing documents in the medical record the use of a sling and monitoring of the left arm," the inspection report stated.
That expectation wasn't met.
Hospital discharge instructions exist for critical medical reasons. The emergency department specifically warned about circulation problems that could develop if the sling became too tight. They emphasized the importance of daily skin checks and immediate adjustments if the patient's fingers showed signs of compromised blood flow.
Without the sling, the fractured clavicle received no stabilization. Without monitoring, potential complications could have gone undetected. Without weight-bearing restrictions, the resident risked further injury to the healing bone.
The gap between hospital discharge and nursing home implementation lasted from August 22, when the resident returned from the emergency room, until September 3, when the orthopedic doctor finally evaluated the patient. During those twelve days, medical orders sat unfollowed while the resident went without prescribed treatment.
Federal inspectors cited the facility for failing to ensure residents receive proper treatment and services. The violation fell under regulations requiring nursing homes to provide care and services according to each resident's comprehensive assessment and plan of care.
The inspection found that communication between the hospital and nursing home broke down completely. Discharge orders never translated into facility physician orders. Treatment records never reflected the prescribed interventions. Nursing staff remained unaware of basic care requirements for a common orthopedic injury.
For Resident #1, the two-week gap meant healing without proper support, monitoring, or protection. The fractured clavicle eventually healed enough for normal weight-bearing, but only after the resident endured nearly two weeks without the medical care prescribed by emergency room physicians.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Foremost At Sharon LLC from 2025-12-30 including all violations, facility responses, and corrective action plans.