Monday, July 30, 2018
Admissions Barred at Knoxville Nursing Home
By Walter F. Roche Jr.
New admissions to a Knoxville nursing home have been barred after state inspectors found that a patient there suffered fractures to both knees from an avoidable accident but didn't even get to see a physician for over a week.
Tennessee Health Commissioner John Dreyzehner ordered the admissions freeze and imposed $30,000 in fines on the Westmoreland Health and Rehabilitation Center, a 222 bed facility.
In a 55-page report state surveyors said the woman suffered the fractures on Nov. 11 of last year when a certified nursing assistant attempted to change the patient's sheets without the assistance of a second staffer, as had been ordered.
The patient slid off the bed and landed on her knees crying out in pain, according to the report.
"The fractures were extremely painful," the report states.
After reviewing nursing home records and interviewing staffers, the state inspectors found that despite the patient's repeated complaints of severe pain, X-Rays were not taken until five days after the fall and it was another four days before she was seen by an orthopedic specialist.
The unnamed woman was then hospitalized and treated for the fractures. She died on Dec. 18.
The state surveyors learned that the delay was apparently the result of a note posted at the nurses' station telling staffers they were not to contact the physician or his nurse practitioner "until contact has been made with the on-call nursing manager."
One staffer told the inspectors that the note disappeared after nursing home officials learned they were being sued.
The home's physician told the state surveyors he only learned of the bilateral fractures from their call. He told them he should have been notified about a fracture.
The report states that the physician and the home's director of nursing also never assessed the patient.
Under Dreyzehner's order the home was fined $5,000 each for six violations including failure to notify the physician of a significant change in a patient's condition and "placing a resident in an environment that was detrimental to their health, safety and welfare."