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Based on record review, policy review, and staff interview, it was determined the facility failed to ensure the nursing staff took appropriate action to meet the needs of one (#3) of ten sampled patients.

Findings include:

The Progress Note - Nurse dated 11/6/14 at 12:33 p.m. and signed by the Licensed Practical Nurse (LPN) included documentation indicating the daughter of Patient #3 had informed the Registered Nurse (RN #A) assigned to the care of the patient on 11/5/14 that the patient's left foot had been injured while the patient was being transferred in a mechanical lift on 11/5/14. The note included documentation indicating the daughter had contacted the nephrologist requesting her mother's foot be x-rayed.

A detailed review of the record failed to reveal documentation by RN #A of the daughter's concern regarding her mother's left foot being injured while in the facility. The record contained no documentation of the assessment of Patient #3's foot in response to the daughter's concern. The record did not contain any evidence RN #A reported the possible injury to the attending physician, or to the nurse's chain of command.

The Progress Note-Physician dated 11/6/14 at 8:45 a.m. and signed by the attending physician did not contain any reference to a possible injury of the patient's left foot. There was no evidence the attending physician examined the foot.

The Physician Orders dated 11/6/14 at 12:54 p.m. included documentation of a telephone order to obtain an x-ray of Patient #3's left foot. The x-ray report dated 11/6/14 and signed by the radiologist at 3:55 p.m. reported impacted displaced fractures of the second, third, and fourth metatarsals.

Nursing Documentation, SOP 1:0054, revised 2/2009, was reviewed on 11/24/14. Section B. 2 indicated changes in the patient's condition, nursing interventions, actions and the patient's response to treatment will be documented on the nursing progress note.

An interview was conducted with RN #A on 11/24/14 at approximately 3:00 p.m. She indicated Patient #3's daughter had informed her on 11/5/14 between 9:30 a.m. and 10:30 a.m. that the patient was complaining of pain in her left foot from an injury she sustained while being transferred in a mechanical lift. RN #A stated in response to the daughter's concern she examined Patient #3's left leg and foot. She stated Patient #3 denied having pain in the foot at the time she examined the patient. She confirmed the finding she did not document the daughter's concern regarding a possible injury, nor her examination of the foot.

An interview was conducted with the Director of Quality and Risk Management and the Chief Nursing Officer on 11/24/14 at approximately 5:30 p.m. They confirmed the finding the RN failed to document in accordance with facility policy. They confirmed the finding the nurse failed to communicate the possible injury to the physician or to her chain of command.