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Based on interview and record review, the facility failed to ensure that an RN supervised and evaluated the care of one (1) of five sampled discharged patients (Patient ID# 7).

Nursing staff failed to inform the physician of bruising and pain to patient ' s left hip following a fall, resulting in a delay in obtaining an x-ray and identification of a hip fracture.

Findings include:

TX# 00185875

Record review on 11-15-13 of the clinical record of Patient ID # 7 revealed she was an 87 year old female with a history of Chronic Obstructive Pulmonary Disease (COPD) exacerbation and pneumonia. Patient ID # 7 had been admitted to a skilled nursing facility a few weeks prior; easily fatigued and experienced shortness of breath.

Record review of nursing notes, dated 08-23-13 (time 2045) read: " ...pt reported found in bathroom by staff member and assisted to commode, Noted lacerations to left eye brow, area cleaned with normal saline, pressure dressing applied. House doctor notified. Responsible party ( ) and ( ) notified. House supervisor notified. Patient alert, awake, denies any pain. Patient received three stiches by House doctor. "

Record review of facility incident report, dated 08-23-13 revealed a staff member witnessed Patient ID # 7 attempting to sit on the toilet, lost her balance, and fell on her left side. The report contained documentation the house physician assessed Patient ID #7; CT scan of the head was negative.

Interview on 11-15-13 at 10:50 a.m. with Chief Operations Officer/Rehabilitation Director ID # 3, she stated that she was responsible for oversight of the Fall Prevention program. She reported that part of her duties included conducting a post fall assessment on all patients who sustained falls.

Rehabilitation Director ID # 3 went on to say she visited Patient ID # 7 the day after the fall on 08-24-13. At this time, Patient ID # 7 complained of pain to her left hip and bruising was noted to the left hip. Rehab Director ID # 3 stated she suggested to the nurse to obtain an order for an x-ray of the left hip.

Interview with Licensed Vocational Nurse (LVN) ID # 12 at 11:40 a.m. reported she remembered the patient well. LVN # 12 reviewed her nurse ' s notes dated 08-24-13 and noted Patient ID # 7 did not complain of pain during the morning nursing assessment. LVN ID # 12 recalled the Rehab. Director and herself visiting the patient later in the day; but she did not recall calling the physician to report the pain and bruising. LVN ID # 12 was unable to locate documentation in the nurses notes that the physician was informed of Patient ID #7 ' s pain and bruising to the left hip.

Interview on 11-15-13 at 1: 25 p.m. with Director of Nurses (DON) ID # 2 she stated LVN # 12 have informed the physician of Patient ID # 7 ' s pain and bruising. She also should have documented a nursing assessment of the findings at the time.

Interview on 11-15-13 at 3:35 with Physician ID # 14, he stated he was providing medical care for Patient ID # 7 on the week-end she sustained the fall. He acknowledged that had he been informed of the patient ' s pain and bruising to the left hip, he would have ordered an x-ray as a precautionary measure.

Record review of facility policy titled " Standardized Approach to Hand Off Communications, " dated 07-09-13, read: " ...Provider Notification, when it becomes necessary to notify the physician provider of patient status change, critical lab results, and any other situation regarding the patient; details of the notification shall include the provider name/role, date, time, situation, how it was communicated, read back and the physician ' s response. "

Record review of facility policy titled " Assessment: Medical Nursing Flow Sheet, " dated 07-09-13, read: " ...5. Variances from previously reported information should be identified and followed up with a narrative note. "

Based on interview and record review, the facility failed to ensure that one of five (5) sampled discharged patients (Patient ID # 7) records contained a Discharge Summary.

Findings include:

TX # 00185875

Record review on 11-13-13 of complaint intake # TX # 00185875 revealed multiple concerns regarding quality of care and discharge rights.

Record review on 11-15-13 of the clinical record of Patient ID # 7 revealed she was an 87 year old female admitted to the facility on 08-12-13 with a history of Chronic Obstructive Pulmonary Disease (COPD) exacerbation and pneumonia. Patient ID # 7 had been admitted to a skilled nursing facility a few weeks prior; easily fatigued and experienced shortness of breath. Patient ID # 7 was transferred to another hospital on 08-27-13.

Further review of Patient ID # 7 ' s medical records failed to reveal a physician ' s Discharge Summary.

Interview on 11-15-13 at 1:50 p.m. with Director of Health Information Management (HIM) ID # 13; she stated there was no Discharge Summary completed for Patient ID # 7. She acknowledged the Discharge Summary should be completed within 30 days of the patient ' s discharge.

Review of facility " Medical Staff Rules & Regulations, " dated 10-06-12, read: " ... Discharge Summary with outcome of the hospitalization, disposition of case and provision of care shall include ...primary and secondary diagnosis, infections and other complications ...reasons for hospitalization, follow up plan ... f. Final diagnosis and completion of medical records within 30 days ... "