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Based on interview, record review, and policy review it was determined the facility failed to provide quality care and services for one (1) of ten (10) sampled patients (Patient #1) when the patient was identified to have a fractured arm while under continuous nursing care/supervision.

The findings include:

Review of the facility's policy titled "Nursing Care Service" revealed the facility had a system in place to ensure patients were assessed upon admission and daily for clinical status change, including skin assessments and potential for falls.

Medical record review revealed Patient #1 was placed on a ventilator soon after admission on 07/26/16. Patient #1 required total care from facility staff including turns/repositioning. Nursing notes dated 10/19/16 at approximately 4:00 PM revealed Patient #1 was found lying in bed with a swollen left arm/hand. The physician was notified of the patient's change in condition and according to the nursing note the swelling was thought to be related to cellulitis from a Peripherally Inserted Central Catheter (PICC) line. The PICC line site was transferred to the right arm and a Doppler study was conducted to assess the blood flow of the left arm which revealed no evidence of a blood clot. Further review of the medical record revealed Patient #1's left arm did not improve and on 10/26/16 the patient was transferred to a higher level of care.

A copy of the medical record was obtained from the receiving hospital where Patient #1 was transferred on 10/26/16. Review of the radiologist report dated 10/26/16 revealed Patient #1's left arm was fractured. Review of the consulting orthopedic physician report dated 10/26/16 revealed the fracture indicated that Patient #1's arm was probably externally rotated while the shoulder was fairly fixed and this created the fracture.

An interview was conducted on 11/03/16 at 1:00 PM with the on-call radiologist who stated it was his professional opinion that Patient #1's fracture was an "Acute Fracture" which could have occurred two (2) hours or two (2) weeks prior to the Computed Tomography (CT) Scan. The on-call radiologist stated the "tense hematoma" was located around the fracture site and most likely went with the fracture.

An interview was conducted on 11/01/16 at 10:00 AM with the Director of Nursing (DON) and Risk Manager. The DON and Risk Manager both stated there was no facility investigation conducted because the facility was not aware Patient #1 had a fractured arm. According to the DON and Risk Manager, no report of any incident/accident had been made regarding Patient #1. The DON and Risk Manager gave no explanation of how Patient #1's arm fracture occurred.

Interviews with staff (Certified Nursing Assistants #1, #2, #3, #4, #5, and #6, Licensed Practical Nurse #1, and Registered Nurses #1, #2, #3, and #4) that provided total care for Patient #1 revealed no knowledge of Patient #1's injury. Staff interviews gave no explanation of how Patient #1's arm fracture occurred.

An interview was conducted on 11/01/16 at 3:50 PM with Registered Nurse (RN) #4 who provided care for Patient #1 on 10/19/16 when the patient's arm was observed to be red and swollen. RN #4 stated the Primary Care Provider (PCP) was notified and the Emergency Department (ED) physician (ED Physician #1) came to assess Patient #1's arm. According to RN #4, the physician suspected problems with blood flow and ordered a Doppler test which was conducted but did not show any problems with blood flow.

Interview with the Nurse Manager on 11/03/16 at 3:08 PM revealed the Nurse Manager was contacted by the floor nurse (RN #4) on 10/21/16 when the nurse had concerns about the condition of Patient #1's arm. The Nurse Manager stated the PCP was aware and ED Physician #2 was asked to come and assess the patient's arm. According to the Nurse Manager, the Emergency Room was busy and ED Physician #2 did not come to assess Patient #1.

A telephone interview was conducted with ED Physician #2 on 11/03/16 at 3:00 PM. ED Physician #2 stated it was the PCP who decided who needed to assess the patient. ED Physician #2 stated he discussed Patient #1's arm with the Nurse Manager. ED Physician #2 stated it was not common practice for the ED Physicians to respond to Nursing. ED Physician #2 stated he was not asked by the PCP to see the patient so he did not assess the patient. "That's just the way things are done around here."

Based on interview, record review, and policy review it was determined the facility failed to update/revise care plans for two (2) of ten (10) sampled patients (Patients #1 and #10) selected for review. Patient #1 (a ventilator patient) was transferred to a higher level of care on 10/26/16 for a possible "tense hematoma" of the left arm which had developed while under continuous nursing care and was later determined to be a fracture. Patient #10 was transferred to a higher level of care on 10/03/16 for care of a nasojejunal (NJ) drain which had migrated through the patient's abdominal wall. There was no evidence the care plans for Patient #1 and Patient #10 had been updated/revised to include the patients' change of condition.

The findings include:

Review of the facility policy titled "Standards in Clinical Nursing Practice" revealed the facility had a system in place to ensure the nurse developed a plan of care that prescribes interventions to attain expected outcomes. Further review of the policy revealed ongoing assessment data was used to revise diagnoses, outcomes, and the plan of care, as needed. According to the policy, the patient's responses to the interventions were to be documented.

1. Medical record review revealed Patient #1 was placed on a ventilator soon after admission on 07/26/16. Patient #1 required total care from facility staff including turns/repositioning. Nursing notes dated 10/19/16 at approximately 4:00 PM revealed Patient #1 was found lying in bed with a swollen left arm/hand. Review of Patient #1's nursing care plan revealed the care plan was initiated and implemented upon admission on 07/26/16 to include care for respiratory failure; however, there was no evidence the care plan had been updated/revised regarding Patient #1's change in condition.

2. Medical record review revealed the facility admitted Patient #10 on 08/11/16 with a diagnosis that included respiratory failure. Patient #10 was on a ventilator and required total nursing care. During the hospitalization, Patient #10's NJ drain migrated through the abdominal wall. Patient #10 was transferred on 10/03/16 to a higher level of care. There was no evidence Patient #10's care plan had been updated/revised regarding the patient's change in condition.

Interview with the Nurse Manager on 11/03/16 at 3:00 PM revealed Nursing was responsible for updating and revising care plans. The Nurse Manager gave no explanation why the care plans for Patient #1 and Patient #10 had not been updated/revised regarding their change of condition.

Interviews with staff (Registered Nurses #2, #3, and #4) responsible for updating the patient care plans gave no explanation why Patient #1 and Patient #10's care plans had not been updated to include the patients' change of conditions.