HospitalInspections.org

Based on policy review, record review, interview, and photography review, the facility failed to ensure care was provided in a safe setting related to an injury of unknown origin for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Review of the facility's "PATIENT'S RIGHTS" policy revealed, "...It shall be the policy that all hospital staff...performing patient care activities shall observe these patients' rights...The patient has the right to...timely attention to his or her needs...Patients have the right to receive care in a safe setting..."

2. Medical record review revealed Patient #1 was admitted to the hospital on 6/2/18 with diagnoses of Dementia with Behaviors, Benign Prostatic Hyperplasia, and Hypertension. Review of the Admission Nursing Assessment dated 6/2/18 revealed Patient #1's skin was intact with no skin ulcers, rashes, wounds, lesions, or bruises.

Review of a Shift Note dated 6/19/18 revealed, "...Late entry: upon DC [discharge] noted scrape on Lt. [left] leg [symbol for with] scab, 1 + [plus] edema noted. assured wife we kept leg elevated when up but at times he wasn't compliant..."

There was no other documentation in the medical record related to the injury to Patient #1's left leg.

3. Review of a photograph submitted with the complaint revealed a scabbed area on Patient #1's left shin, approximately 3.5 inches up from his ankle, measuring approximately 1.5 inches long and 0.5 inches across.

4. In an interview on 7/2/18 at 1:23 PM, in the conference room, Registered Nurse (RN) #1 verified that she observed the scab on Patient #1's left leg at the time of discharge on 6/18/18. RN #1 also verified that she did not document the injury until 6/19/18. When asked to describe the injury, RN #1 revealed, "...the scab was really small...a dot really..."

In an interview on 7/2/18 at 1:35 PM, in the conference room, the Nurse Manager verified that RN #1 should have documented the injury to Patient #1, as well as the injury's size, location, and any other assessment information, when she first observed it on 6/18/18.

Based on policy review, record review, observation, interview, and photography review, the facility failed to ensure all patient's needs were met for 1 of 1 (Patient #1) sampled patients and 2 of 14 (Patient #6 and 7) random patients related to nail care and ensure assessments were completed related to injuries for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Review of the facility's "PATIENT'S RIGHTS" policy revealed, "...It shall be the policy that all hospital staff...performing patient care activities shall observe these patients' rights...The patient has the right to...timely attention to his or her needs..."

2. Review of the facility's "PERSONAL HYGIENE" policy revealed, "...All patients...will be supported and educated in ADL's [activities of daily living] focusing on personal hygiene and grooming...all patients shall be encouraged or assisted in grooming daily or more often as needed...nail care will be provided as needed..."

3. Medical record review revealed Patient #1 was admitted to the hospital on 6/2/18 with diagnoses of Dementia with Behaviors, Benign Prostatic Hyperplasia, and Hypertension.

Review of the Admission Nursing Assessment for Patient #1 dated 6/2/18 revealed his skin was intact with no skin ulcers, rashes, wounds, lesions, or bruises.

Review of a Shift Note dated 6/19/18 revealed, "...Late entry: upon DC [discharge] noted scrape on Lt. [left] leg [symbol for with] scab, 1 + [plus] edema noted. assured wife we kept leg elevated when up but at times he wasn't compliant..."

There was no other documentation in the medical record related to the injury to Patient #1's left leg.

4. Review of a photograph submitted with the complaint revealed a scabbed area on Patient #1's left shin, approximately 3.5 inches up from his ankle, measuring approximately 1.5 inches long and 0.5 inches across. The photograph submitted with the complaint also revealed long and jagged nails on Patient #1's left middle, ring, and little fingers.

5. Observations in the dayroom on 7/2/18 beginning at 10:03 AM, revealed Patient #6 had long painted fingernails and several nails had jagged edges. Further observations revealed Patient #7 had long nails and several nails had jagged edges.

6. In an interview on 7/2/18 at 10:10 AM, Psychiatric Care Technician #1 verified that Patient #6 and 7 would cooperate with nail care.

In an interview on 7/2/18 at 1:23 PM, in the conference room, Registered Nurse (RN) #1 verified that she observed the scab on Patient #1's left leg at the time of discharge on 6/18/18. RN #1 also verified that she did not document the injury until 6/19/18. When asked to describe the injury, RN #1 revealed, "...the scab was really small...a dot really..."

In an interview on 7/2/18 at 1:35 PM, in the conference room, the Nurse Manager verified that RN #1 should have documented the injury to Patient #1, as well as the injury's size, location, and any other assessment information, when she first observed it on 6/18/18.