HospitalInspections.org

Based on medical record review and interview, the facility failed to ensure care was provided in a safe setting and all injuries were assessed and documented by the medical staff for 1 of 4 (Patient #1) sampled patients.

The findings included:

1. Medical record review for Patient #1 revealed the patient presented to the Emergency Department (ED) on 9/9/19 at 8:30 PM by ambulance after a fall at a grocery store.

The Admission physical examination revealed no injuries to the face, nose or eyes.

A CT scan of the Head performed on 9/9/19 at 10:22 PM revealed bones and joints were unremarkable showing no acute fractures and soft tissues were unremarkable.

On 9/10/19 at 1:15 AM, Patient #1 became combative with staff and required 4 point restraints until 5:00 AM.

The Nursing Flow record dated 9/10/19 at 7:15 AM revealed, " ...Bruising Location ...Right eye ...Appearance ...Purple/Black, Firm ...Distribution ...Generalized ..."

The facility was unable to provide documentation Patient #1's eye injury was assessed and treated.

2. In an interview in the conference room on 9/18/19 at 12:30 PM, a member of the Quality Management Team verified there was no documentation by the ED physician of Patient #1's eye injury in the medical record.

In a telephone interview on 9/23/19 at 1:44 PM, ED Physician #1 verified he observed the eye injury on Patient #1 after the restraint episode and failed to document the physical assessment in the medical record.