New patients barred at Knoxville nursing home after woman with broken knees left in agony for 9 days

State officials have halted admissions at one of the biggest nursing homes in Knoxville after it was discovered that a bedridden dementia patient fractured both her knees in a fall but did not see a doctor and was left in agony for nine days.

 The patient fractured her knees while falling out of bed in front of a nurse assistant, then complained of "intense pain," state records show. However, it took the nursing home five days to perform an x-ray, then another four days to have her be seen by a doctor.

The doctor then sent her for knee surgery at a hospital, where she died a month later.

As a result of this incident, Westmoreland Health and Rehabilitation Center has been ordered to stop accepting new patients, according to a news release from the Tennessee Department of Health. The nursing home, which is on Lyons View Pike, must also pay $30,000 in penalties. The state has appointed a special monitor to oversee operations at the nursing home.

Westmoreland, previously known as Brakebill Nursing Home, opened in 1977. It is licensed for 222 beds and is the second-largest nursing home in Knoxville.

At Westmoreland, no new patients

The injured patient incident, which occurred in November, was revealed during a state investigation of the facility earlier this month. Investigation documents released to the USA TODAY NETWORK - Tennessee on Monday describe the incident.

According to those documents, the patient, who is not identified, fell out of bed and landed on her knees while a nursing assistant was changing her sheets on Nov. 11. The patient then reported a new source of pain but was not assessed by a doctor or a nurse.

Medical records, reviewed during the investigation, show that the patient “complained of pain in her legs and knees daily,” and was “noted to have bruising and swelling of the knees,” but nursing home staff responded only by giving her pain medication, the documents state. At one point, another nursing assistant reported that the patient had "screamed" in pain and appeared to be desperate for help — saying "oh please, please please" — the documents state.

"The (certified nursing assistant) further stated she asked staff everyday if anything had been done for the resident, such as an x-ray, and was told no," the documents state.

Five days after the fall, the patient finally received an x-ray, revealing fractures in both knees. Four days later, the patient was seen by an orthopedic physician, who admitted her at a hospital “due to the severity of the knee fractures,” the documents state.

At the hospital, the woman’s knees were repaired to alleviate her pain but it was clear she would not recover. She died about a month later on Dec. 18.

According to the state news release, Westmoreland was found to be below state standards for nursing home administration, performance improvement, nursing services, radiology services and resident rights. Tennessee Health Commissioner John Dreyzehner can suspend admissions at a nursing home if conditions are deemed likely to be “detrimental to the health, safety or welfare of the residents.”

Westmoreland did not immediately respond to a request for comment on Monday.

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New patients barred at Knoxville nursing home after woman with broken knees left in agony for 9 days