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Based on interview, record review and review of facility policy, it was determined the facility failed to ensure a registered nurse (RN) evaluated the care for one (1) of ten (10) sampled patients (Patient #1). Review of the nurse's notes dated 01/29/202, 01/30/2021, 01/31/2021, 02/01/2021, revealed Patient #1 had a bruised/swollen left thumb. However, there was no evidence the nurse notified Patient #1's physician of the change in the patient's condition until 02/02/2021.

The findings include:

Review of the facility's policy titled,"Reassessment of Psychiatric Patient", dated February 2016, revealed, any changes in the patient's diagnosis or condition, required changes in the plan of care reflecting the change in diagnosis or condition.

Review of the nursing notes for Patient #1 dated 01/29/2021 at 8:00 AM, revealed Registered Nurse (RN) #1 documented Patient #1 had a swollen left thumb with bruising noted. Continued review of the nurses notes revealed documentation the patient's thumb was bruised/swollen on 01/29/2021, 01/30/2021, 01/31/2021, 02/01/2021. However, there was no evidence in the medical record that the physician was notified of the patient's swollen and bruised left thumb until 02/02/2021.

Interview conducted with RN #1 on 02/24/2021 at 11:54 AM, revealed she had not notified Patient #1's physician on 01/29/2021, of the patient's swollen/bruised thumb but should have. The RN stated she thought the physician had been aware and had a busy day with another patient. The RN stated when she returned back to work on 02/02/2021, she realized the physician was not aware of the patient's bruised/swollen thumb. The RN stated she notified the physician on 02/02/2021,and had obtained orders for an X-ray of the left thumb. The RN stated she had received training by the facility on notification of the physician which included notifying the physician for changes in patient's condition.

Review of the X-ray reports dated 02/02/2021 at 9:31 AM, revealed the Patient #1 had a transverse fracture through the old physis of the occipital base of the occipital phalanx of the left thumb (fractured left thumb).

Continued review of Patient #1's medical record revealed the patient had left against medical advice on 02/03/2021 at 6:42 PM.

Interview conducted with RN #2 on 02/24/2021 at 11:49 AM, RN #3 on 02/24/2021 at 12:30 PM, and RN #4 on 02/24/2021 at 12:47 PM, revealed they had provided care for Patient #1 after the bruise and swelling was discovered to the patient's left thumb. The nurses revealed they had thought the physician had been notified by RN #1 because any change in a patient's condition was required to have physician notification. The nurses stated they would have notified the physician if they had been aware the physician had not been notified.

Interview with the Unit Manager on 02/24/2021 at 2:20 PM, revealed Patient #1's physician should have been notified immediately upon identifying the patient's swollen and bruised left thumb. Per the Unit Manager, staff did not identify the lapse between the identification of the patient's thumb and the time the physician was notified.

Interview conducted with the Chief Executive Officer (CEO) on 02/24/21 at 3:00 PM, revealed they had not identified the time lapse between the identification of Patient #1's left thumb being swollen/bruised and when the physician was notified. The CEO stated the physician should have been notified immediately.