Failure to Document Patient's Fractured Hand

The Centers for Medicare and Medicaid Services (CMS) cited Austin Lakes Hospital for failing to uphold a patient’s right to care in a safe setting. The cited deficiency relates to an incident in which hospital staff failed to document that a patient had sustained a right hand fracture during his hospital stay. Even though the patient received an X-Ray per physician orders, the patient’s clinical nursing notes did not mention the X-Ray, or any assessment of the patient related to the fracture. CMS issued an additional citation against the facility for medical record deficiencies related to the incident. Not only were nursing assessments regarding the fracture missing, but there was no incident report describing how the injury occurred. As a result, the facility submitted a plan of correction to address its cited deficiencies and practices.