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Based on interview and record review the hospital failed to ensure RN (registered nurse) (RN Personnel #22) supervised and evaluated the nursing care provided by 3 of 4 psychiatric technicians (Personnel #14, #15 and #17) for 1 of 20 patients (Patient #17). (Patient #17) was non-weight bearing and was transferred from the wheelchair to the bed by Personnel #14, #15 and #17. (Patient #17) sustained a fractured right ankle as a result of an unsafe transfer.

Findings Included:

(Patient # 17's) ED (emergency department) provider note dated 06/13/14 timed at 1715 reflected, "71 year old has a pacemaker sent from the nursing home for psychiatric evaluation ...caregiver at nursing home ...patient stated "would like to end it" and wants to go home ...denies HI (homicidal ideation)...SI (suicidal ideation)...physical exam...cataract left eye, bandaged pacemaker to left chest wall...musculoskeletal...no edema or tenderness to fistula to right side...waiting for psychiatric evaluation..."

The 06/13/14 ED note (Social Work) timed at 1827 reflected, "Patient reports being a resident of...nursing home...reported being left in the hoyer lift for extended periods of time daily... "

The 06/14/14 psychiatry nursing note timed at 0101 reflected, "Assumed care of the patient, patient was transferred from main ED by wheelchair for psychiatric evaluation...patient stated she was wrongly accused of trying to hang herself with a cord on her call light."

The 06/14/14 psychiatry nursing note timed at 0453 reflected, "Patient laying down screaming...complaining of pain to right ankle..."

The 06/14/14 provider note MD note (psychiatry) timed at 0544 reflected, "X-ray of right foot shows multiple fractures....spoke with Dr...to transfer to main ED..."

The 06/14/14 psychiatry nursing note timed at 0659 reflected, "At...MHT (mental health technician) came to nursing station stating patient complained about having generalized pain ...assessed patient in room three where she was laying down...complained about pain to right ankle..."

The nursing psychiatry note dated 06/14/14 timed at 0816 reflected, "Patient reports she was dropped...right ankle with obvious deformity...reddish discoloration to outer edges of ankle, unable or unwilling to wiggle toes, unable to palpate pulses to dorsalis pedis as patient screams when you touch her..."

The emergency medicine (ED) provider note dated 06/14/14 timed at 0853 reflected, " 71 year old female reports to ED c/o (complains of) ankle injury onset last night...reports she was in psych being interviewed and when they finished they wanted to move her to a chair but she says she told them she could not bear any weight in her legs...so when they tried to move her she fell and hurt her ankle... "

On 08/14/14 at 1550 RN Personnel #8 was interviewed. RN Personnel #8 stated she was the ED nurse for (Patient #17) when (Patient #17) had returned to the main ED from the psychiatric ED. RN Personnel #8 stated she read all the notes on (Patient #17) when (Patient #17) initially arrived in the main ED. RN Personnel #8 stated (Patient #17) did not have a fractured ankle and had not complained of ankle pain. RN Personnel #8 stated (Patient #17) told her the staff dropped her. RN Personnel #8 stated she had received in report (Patient #17) was non-weight bearing and could not walk.

On 08/14/14 at 2325 RN Personnel #6 was interviewed by telephone. RN Personnel #6 stated he was not present during (Patient #17's) transfer to the chair/bed. RN Personnel #6 stated RN Personnel #22 was present during (Patient #17's) transfer. RN Personnel #6 stated RN Personnel #22 informed him she saw the technician's transfer (Patient #17) and reported the patient had to be lowered to the floor. RN Personnel #6 was asked why the details of the transfer were not documented. RN Personnel #6 did not offer an explanation.

On 08/14/14 at 2348 Personnel #17 was interviewed by telephone. Personnel #17 stated Personnel #14 and himself (Personnel #17) transferred (Patient #17) from the wheelchair to the chair/bed. Personnel #17 stated both he (Personnel #17) and (Personnel #14) picked (Patient #17) up under each arm. Personnel #17 stated (Patient #17) could not stand at all and the weight of the patient caused her to be lowered to her knees. Personnel #17 stated all of (Patient #17's) weight placed pressure to (Patient #17's) right leg, foot and ankle. Personnel #17 stated Personnel #15 pulled (Patient #17's) lower legs out from under her and then she was placed on the bed. Personnel #17 stated the nurse (RN Personnel #22) watched the transfer and said nothing about the way (Patient #17) was being transferred. Personnel #17 stated the nursing staff did not inform the technicians that (Patient #17) was dependent for transfers and could not stand. Personnel #17 stated if he had known he would not have attempted to transfer (Patient #17). Personnel #17 stated he had some experience with transfers but not to the degree of assistance that (Patient #17) required.

The policy and procedure entitled, "Patient's Rights and Responsibilites" with a revision date of 08/13 reflected, "Receive considerate and respectful care in a safe setting..."