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Based on interviews and record reviews, Hospital #1 failed to identify a fracture of the left hip of Patient #16 after a fall suffered in her assisted living home. This failure resulted in pain for the patient and her return via ambulance to Hospital #2 where the correct diagnosis and treatment were rendered. The findings are:

A. On 06/16/16 at 2:30 pm during interview, Physician #1 was asked if he was the physician who saw Patient #1 on 04/23/16 in the facility's Emergency Department (ED). Physician #1 responded, "I was the physician that saw [Patient #1]... I reviewed the patient's chart and clearly there was incomplete documentation. I believe I should have done a better assessment and charting. I did not assess the fractured hip."

B. On 06/16/16 at 9:25 am during interview, RN #1 from the ED was asked to review some of Patient #16's ED visit notes."Do you remember this lady in the ED back in April, April 23?" She replied, "I do. She had Alzheimer's and did not speak clearly, a kind of word soup." When asked if she remembered performing a passive range of motion on all extremities on [Patient #16], RN #1 stated, "No." RN #1 was then asked if a passive range of motion would help assess a fracture in a poor historian and communicator like [Patient #16]. She replied that it would.

C. On 06/16/16 at 10:23 pm during interview Quality Staffer #2 stated,"The event went to Risk [Management] to ED [Emergency Department] QA [quality assurance] which was peer reviewed on 04/25/16."

D. Record review of the Hospital #2's Patient #16 on 04/24/16 indicated the following: "History of Present Illness ... obtained from husband [name], review of records, and [ALF #1] staff. Patient is currently unable to provide any information due to somnolence." "79 yo [year old] highly functional [ALF #1 resident] (dementia unit) with hx [history] advanced Alzheimer's dementia, seasonal allergies, hard of hearing, unspecified chronic B LE [bilateral left extremity] edema, Fuch's corneal endothelial dystrophy." "[Patient #16 was see at [Hospital #1] yesterday and diagnosed with a L humeral neck/head fracture after she fell at her ALF. Per husband [name] patient is 'a social butterfly' and spends most of her day at ALF walking to different resident rooms and talking to them. She was about to sit down to talk to one of her friends and 'just toppled over onto her left side when she was about to sit in chair - she missed the chair.' CT of head negative. She was discharged back home with an arm sling. Then last night, patient started complaining of left hip pain and was unable to stand. She was brought back into the ED and pelvic/L hip xrays [left hip x-rays] revealed a L femoral neck fracture."

E. Record review of the Admission History and Physical for Patient #16, dated 04/28/16 at 11:32 pm on the patient's return to [Hospital #1] from the skilled nursing facility, revealed the following: "The patient was just in the hospital with a left hip and left humerus fracture that were repaired, and was recovering from that. She became poorly responsive in the AM today, actually not awakening well after sleeping during the night. The day before, yesterday, she was alert, confused as is her baseline with severe Alzheimer's disease but able to sit up and was awake. Today, she did not awaken. She had a low grade temperature elevation of 100 to 100.4, without an infection being apparent. A discussion with the family indicated they were in favor of the patient going ahead with the planned transfer to SNF [skilled nursing facility] unit. There, the staff felt the patient was too obtunded for care at their facility and asked that she be brought back here to the hospital. During the day, the patient has still not awakened. She has minimal responsiveness to sternal rub, and if I try to open her eyes to check pupils, she will clench eyelids tight, but that is all that she will respond. She is non verbal, and does not protect her airway well, having oral secretions that she will try to clear with a weak cough. The cause of this worsening of mental status today is not clear. There has been low grade temperature elevation without leukocytosis [increase in the number of white blood cells, indicating infection] and there is no sign of uti [urinary tract infection] or pneumonia. There is no apparent abdominal tenderness. She has had blood cultures, but no antibiotics have been started in the absence of any apparent source of infection."

F. Record review of the 05/02/16 progress note at [Hospital #2] indicated the following:
"Discharge Diagnoses: 1. Encephalopathy [problem in the brain], probably secondary to brain stem cerebrovascular accident [bleed or clot in the brain]. 2. Recent hip fracture and recent humerus fracture [upper arm]. 3. Advanced Alzheimer's disease."
"Disposition: The patient has been discharged to Hospice."
"Hospital Course and Treatment Rendered: [Patient #16] is a 79 year old who was discharged from [Hospital #1] on April 26, 2016 after a hip fracture, and a left humerus fracture; got admitted on the same day for encephalopathy. I got history from the patient's husband and daughter. According to them, the patient was encephalopathy on the day of the discharge, and the nursing home people had to send her back to hospital. During this hospitalization, she had an MRI of her brain and neck that did not show any obvious CVA [cerebrovascular accident]. From day 1, the patient has been nonverbal, sometimes she was opening her eyes spontaneously and sometimes had garbled speech. Family was given further options of evaluation of her encephalopathy through neurology consultation or doing a lumbar puncture to make sure she did not have meningitis, but family refused to proceed with further evaluation as they want to keep her comfort. At her baseline, her dementia Alzheimer dementia is advanced and she was not communicating appropriately. She was not recognizing people all the time. Her mental status gradually worsened during this hospitalization, possible brainstem stroke was considered as the etiology of her progressive worsening of her mental status. Per family request, hospice was consulted and patient was discharged to the hospice unit."

G. Record review of the 04/23/16 ED documentation at Hospital #1 indicated no passive range of motion assessment of Patient #16 by either nurse or physician. Nor were any x-rays performed by Hospital #1 of the hip and/or upper leg bone.

H. Record review of the ambulance report dated 04/23/16 for Patient #16 indicated the following: "Secondary Impressions: Shoulder pain left, hip pain left, knee pain left."

I. Record review of the [Parent Corporate Name] Healthcare Service of Albuquerque Medical Staff Bylaws indicated the following under Part I, Medical Staff Members Responsibilities: "Each staff member must provide for appropriate, timely, and continuous care of his/her patients at the level of quality and efficiency generally recognized as appropriate by medical professionals."