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Based on interview and record review, the facility failed to provide treatment for 1 (#2) patient with a femoral neck fracture.

Record review of an ambulance report dated 4/16/21, in patient #2's medical record, showed, ..."center staff report they gave her everything for pain they could and she was still in pain ... chief complaint of left side pain."

Record review of patient #2's Emergency Department Report, signed by staff member N, showed, "Pt fell last week. She sat on the edge of a swivel chair, then slid to the floor. X rays were done and no fractures seen. The aides at the [facility name] have been helping her get up. She feels like she may have twisted her back during that process. No further injuries. Pain is in left lower ribs and upper left abdomen., but without tenderness."

Record review of patient #2's Radiology Report, dated 04/16/21 showed, "After secondary review the left femoral neck is fractured, impacted with mild proximal migration. No dislocation. The addendum was called to the referring provider at 22:25 on 4/16/2021."

Record review of patient #2's ED discharge instructions, dated 04/16/21 at 10:29 p.m., and signed by staff member N showed, "Bacterial UTI, rib pain on left side ...Take your antibiotic twice a day for 5 days. Drink plenty of fluids ...Chew each bite of food at least 20 times, before swallowing. Follow up with gastroenterologist about the food bolus that was seen today (your food is not emptying into your stomach properly). Return if worse or new symptoms develop."

Record review of an ambulance report dated 4/22/21, in patient #2's medical record showed, ... pt is still in pain and at this point they are unable to control the pain, ... transported to [facility] ...

The medical record showed patient #2 was admitted to the hospital on 4/22/21 for intractable pain of the left hip, and treatment of failure to thrive due to that pain.

Review of a Physical Therapy note dated 4/23/21, in patient #2's medical record showed, ... Upon review of films, x-ray L hip 4/10/21 was negative but there is a CT from 4/16/21 that initially did not reference the hip, but an addendum later showed L hip fracture: "After secondary review of the left femoral neck is fractured, impacted with mild proximal migration. No dislocation."... reported to Dr. [physician name]..., consulting with ortho...

During an interview on 10/13/21 at 11:10 a.m., staff member C stated staff member N was no longer on the ED schedule.

Staff member N did not address the femoral neck fracture documented in patient #2's medical record prior to her discharge back to the assisted living on 4/16/21. Staff member N did not order any further tests or medications for patient #2's femoral neck fracture. Patient #2 returned to the facility and was admitted on 4/22/21, placed on comfort measures on 4/25/21, and passed away at the hospital on 4/26/21.

Based on record review, the facility failed to re-evaluate and update the discharge process for the patient's condition, for 1 (#2) of 10 patients sampled.

Record review of an ambulance report dated 4/16/21, in patient #2's medical record, showed, ..."center staff report they gave her everything for pain they could and she was still in pain ... chief complaint of left side pain."

Record review of patient #2's Emergency Department Report, signed by staff member N, showed, "Pt fell last week. She sat on the edge of a swivel chair, then slid to the floor. X rays were done and no fractures seen. The aides at the [facility name] have been helping her get up. She feels like she may have twisted her back during that process. No further injuries. Pain is in left lower ribs and upper left abdomen., but without tenderness."

Record review of patient #2's Radiology Report, dated 04/16/21 showed, "After secondary review the left femoral neck is fractured, impacted with mild proximal migration. No dislocation. The addendum was called to the referring provider at 22:25 on 4/16/2021."

Record review of patient #2's ED discharge instructions, dated 04/16/21, signed by staff member N showed, "Bacterial UTI, rib pain on left side ...Take your antibiotic twice a day for 5 days. Drink plenty of fluids ...Chew each bite of food at least 20 times, before swallowing. Follow up with gastroenterologist about the food bolus that was seen today (your food is not emptying into your stomach properly). Return if worse or new symptoms develop."

The medical record did not reflect updated discharge instructions and plan for treatment of patient #2's femoral neck fracture. Patient #2's discharge instructions were in regards to her UTI, antibiotic, and swallowing problems.