HospitalInspections.org

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Based on record review and interviews, the facility failed to provide a complete discharge plan in 1 (#1) out of 5 sampled patients was included in the medical record and discussed with the patient or the patient's representative. health care services in accordance with written policies. This failed practice placed the patient at risk for lack of valuable discharge information and follow-up care needs

Findings:

Record review of the Emergency Department Physician Note, dated 7/11/25 at 11:43 AM, revealed Patient #1 was found on the ground by his/her bed by Assisted Living Facility (ALF) staff for an unknown amount of time. Patient #1 was brought to the facility via ambulance. The patient reported he/she was trying to get medication out of the cabinet and was unsure how long he/she was on the floor. Patient #1 was initially screaming in pain on arrival at the facility. He/She further stated that the pain was the worst in his/her arm and his/her hip. The note further stated there was a suspected low impact fall from bed to floor. Hip was inspected with no signs of fracture on x-ray.

Record review of the diagnostic radiology review, dated 7/11/25 at 11:20 AM, revealed Radiologist #1 documented the impressions of the x-ray was " ...demineralization [bone weakening] with possible nondisplaced fracture [fracture that has not moved out of place] of the left femoral neck [top of long leg bone entering the hip joint]". Radiologist also documented: "Consider MRI [magnetic resonance imaging] to further evaluate. Considering the demineralization, an insufficiency fracture [stress fracture that occurs when a bone weakened by various medical conditions breaks under normal pressure] could be present." Further review of the Radiologist findings revealed "The bones are normally aligned. Bones are quite demineralized. There is a transverse lucency [horizontal line] across the femoral neck on the left which could represent a collar of degenerative osteophytosis [bone growth that occurs as a response to joint damage] but cannot exclude nondisplaced fracture. Considering the demineralization, possible insufficiency fracture. Consider further evaluation with MRI."

During an interview on 8/19/25 at 12:59 PM, Caregiver #1 stated the facility completed an assessment and an x-ray of Patient #1's hip and leg. Caregiver #1 was told there was no fracture, and the provider discharged the patient with instructions to push him/her to walk. Caregiver #1 further stated that as time progressed post-discharge, Patient #1's pain was unable to be managed, and he/she eventually refused to walk. The patient returned to the facility on 7/28/25 where a CT (computed tomography) scan was conducted and revealed a fracture to the left femoral head. Caregiver #1 further stated no information was provided regarding the radiologist findings of possible fracture and the need for an MRI scan to investigate further.

Record review of the Emergency Department Discharge Information, date 7/11/25, revealed "Test Preformed ...Radiology ...[x-ray] Hip 2-3 Views Left ..." No additional information was provided on the emergency room physician's interpretation of the x-ray, nor inclusion of the radiologist impression and findings.

Interview on 8/28/25 at 2:00 PM, License Nurse #1 stated Patient #1's discharge information did not contain information regarding the outcome of the x-ray evaluation. The License Nurse further stated that additional information regarding the x-ray should have been in the discharge information provided to the patient or patient representative.