BREVARD, NC – THE OAKS-BREVARD

Based on record review, staff, Physician Assistant (PA) and Physician interviews, the facility failed to identify the urgent need for medical attention or notify the physician when an acute change was first identified for 1 of 3 residents reviewed for accidents (Resident #1). Resident #1 was admitted to the hospital on 05/27/21 and diagnosed with an impacted (occurs when the broken ends of the bone are jammed together by the force of the injury), angulated (where the normal axis of the bone has been altered causing the distal portion of the bone to point off in the opposite direction) and comminuted (the bone has broken into three or more pieces and in most cases, the number of bone fragments corresponds with the amount of force needed to break the bone) right femoral diaphyseal (bone break that occurs along the shaft of the long bone) periprosthetic (broken bone that occurs around the implants of a total hip replacement) fracture that required immediate surgical repair. Resident #1 was also diagnosed with bilateral [CONDITION(S)] (DVT; blood clots that form in veins deep inside the body) and subsequently passed away on 06/02/21.

During a telephone interview on 06/08/21 at 4:53 PM, the Medical Director (MD) stated Resident #1 was a very frail, elderly lady with advanced dementia and poor nutritional status. The MD could not state what could have caused her to sustain a femur fracture and explained any clinical condition could potentially cause mottling and lack of pedal pulse.

During a telephone interview on 06/11/21 at 2:11 PM, the hospital Radiologist (physician specializing in Radiology) stated the x-ray results for Resident #1 confirmed she had an angulated, impacted and comminuted right femoral diaphyseal periprosthetic fracture. The Radiologist explained there would had to have been a good amount of impact to cause this type of fracture and typically, this type of fracture was caused by a traumatic event such as a fall out of bed or knocking the leg into a wall forcefully. The Radiologist added although Resident #1 was osteopenic at baseline, she did not have an insufficiency fracture (type of stress fracture which is the result of normal stresses on abnormal bone); therefore, it was highly unlikely the fracture occurred due to turning or repositioning Resident #1 in bed during care.