HospitalInspections.org

Based on record review and interview, the hospital failed to report an allegation of potential abuse/neglect to LDH-HSS (Louisiana Department of Health - Health Standards Section) or a local law enforcement agency within 24 hours of receipt of the allegation for 1 (#2) of 1 sampled patient reviewed for abuse/neglect.

Findings:

Review of the State law R.S. 40:2009.20 revealed "Any person who is engaged in the practice of medicine, social service, facility administration, psychological services or any RN, LPN, nurses' aide, personal care attendant, respite worker, physician's assistant, physical therapist, or any other healthcare giver having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within 24 hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect."

Review of the hospital policy titled," Assessment and Reporting of Abuse, Neglect, Exploitation, and/or Extortion of Youth and Adults", Policy Number: AS-18, revealed in part: Policy: In order to protect children, adults, and the elderly from harm by evaluating all allegations, observations, and suspected cases of neglect, exploitation, and abuse external to the organization and that which could occur while the patient is receiving care, treatment, and services; provide appropriate advocacy, care; and report abuse, this organization supports and maintains compliance with assessment/reporting standards set by these organizations: * Area police/sheriff's departments. * Department of Health and Hospitals.
Self-Reporting: A facility must self-report internal allegations of abuse/neglect to maintain compliance with: *CMS Regulation 482.13(c)/LA R.S. 40:2009.20. * LA R.S. 40:2009.20. Calls for reporting of knowledge of potential abuse incidents within 24 hours to either law enforcement or DHH (now LDH).

A request was made, upon survey team entry, for the hospital's self-reports of allegations of abuse/neglect submitted to LDH-HSS for the time period of 1/1/19-2/21/19. S1Adm indicated there had been no self-reports made to LDH-HSS in the time period requested.

Review of the hospital's incident reports for 1/1/19 - 1/21/19 revealed a report indicating on 2/16/19 at 11:30 p.m. Patient #2 had been found sitting in the bed with hematomas on her forehead, right forearm, and right elbow. The patient was sent to an area hospital for evaluation.

Review of Patient #2's medical record from SNF "A" revealed the following entry from S6MD: Assessment/Plan: Elder abuse, initial encounter: Director of Nursing (SNF "A") has, on my behalf, made a report to the state for potential elder abuse. The pattern of ecchymosis and the lack of history and accountability are concerning for abuse right now.

In an interview on 2/25/19 at 12:50 p.m. with S1Adm, he was asked if there had been any inquiries questioning the nature of Patient #2's injuries due to the extent of the injuries. S1Adm indicated he had a conversation with the administrator of SNF "A" (where Patient #2 currently resides) about Patient #2's injuries on the night the patient had returned to the SNF. S1Adm indicated he had assured him the staff at the psychiatric hospital "did not abuse their patients." When asked if he had self-reported the allegation of abuse to LDH-HSS, S1Adm reported he had not self-reported because they saw it as a fall and not as a neglect or abuse issue.

Based on record reviews, interviews, and observations, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by failure to ensure the condition of patients' skin was accurately assessed for 4 (#1, #2, #3, #4) of 4 (#1- #4) sampled patients reviewed for altered skin integrity from a total patient sample of 5 (#1 - #5).

Findings:

Patient #1
Review of Patient #1's admission History and Physical skin assessment revealed the following:
Skin warm and dry with wounds to left elbow measured 1 cm X 0.5 cm with scab; Three wounds to the right leg that measured 2 cm X 2 cm, 1 cm X 1 cm, and ½ cm X 0.5 cm. Hyper pigmented areas to bilateral lower extremities with hematoma surrounding wound to right lower leg and surrounding erythema/edema.

Review of Patient #1's Admit Nursing Assessment dated 2/11/19 at 8:40 p.m. revealed his integumentary system was documented as "clammy" only.

Review of Patient #1's daily nurses' shift notes dated 2/12/19 through 2/20/19 revealed the skin assessments were documented by checking a preprinted box labeled "bruises." The description "other" was also selected with nothing written as an explanation or "cellulitus" written. There were no measurements or descriptions of locations of the wounds.

Review of Patient #1's Skin assessments revealed one documented on 2/11/19, one not dated, and one dated 2/16/19. The skin assessment from 2/11/19 indicated Patient #1 had a wound to his upper back and right lower leg. The skin assessment documented on 2/16/19 indicated he had a red mark on his back and right lower leg cellulitis. The skin assessment that was not dated indicated he had wounds to the back of his left arm, back of right arm, red spot on the back, and red discolored skin with edema to lower legs. Photographs of Patient #1's wounds taken on 2/12/19 (day after admission) showed a skin tear to his right nipple, bruising to his right lower leg and a skin tear and scab to his left elbow.

In an interview on 2/21/19 at 12:50 p.m. with S4RN, she verified Patient #1's wound descriptions did not match the pictures that were taken on admission.


Patient #2
Review of Patient #2's medical record revealed and admission date of 2/1/19, from a SNF, for behaviors of cursing, yelling, threatening staff, and stating she was going to kill herself. Further review revealed the patient was on Plavix (an anticoagulant).

Review of Patient #2's initial skin assessment and wound documentation, dated 2/1/19 at 8:35 p.m., revealed the following findings on the body shaped skin audit: Dark bruises documented on right arm and multiple small bruises indicated on bilateral lower extremities on thighs (fronts), knees, and shins. Further review revealed the color and shape of the bruises was not described on the assessment nor was there an indication of whether the bruises were raised or flat.

Review of Patient #2's daily nurses' shift notes dated 2/2/19 - 2/5/19 (both day and night shifts) revealed no documentation of the bruising noted on the admit skin assessment performed on 2/1/19.

Further review of the daily nurses' shift notes revealed the following skin assessment notations:
2/6/19 (day and night shift): Bruises;
2/7/19 and 2/8/19: No bruising documented;
2/10/19 - 2/12/19 (day shift): Bruising/skin tears;
2/13/19: No documentation of bruising/skin tears;
2/14 /19: (day shift): Profuse bruising;
2/17/19: (day shift): Bruising;
2/17/19: (night shift): No bruising was documented.
2/18/19: Hematoma and skin tears.
2/19/19: Bruises with no mention of the patient's hematomas.

Further review of the above referenced daily nurses' shift notes and skin assessments/body audits revealed no description of the bruised areas such as size, color, number of bruises, and whether the bruised area was flat or raised (except for the entry on 2/18/19 indicating the patient had a hematoma).

Patient #3
Review of Patient #3's medical record revealed an admission date of 2/8/19 with an admission diagnosis of dementia with behavioral disturbances.

On 2/21/19 at 9:15 a.m., an observation was made of Patient #3. She was observed to have bluish/green areas of bruising on her hands and wrists bilaterally where the exposed portions of her arms could be visualized.

Review of Patient #3's Skin Assessement and Wound Care Documentation Assessments revealed the following body diagram notes:

2/9/19 9:15 a.m.: Circled areas on right forearm, backs of right arm, back of left arm, circles on pinkie and 4th finger on left hand and circle on right hand with a note indicating several small bruises on right forearm.

2/16/19 9:30 a.m.: Wavy lines drawn on left and right forearms and left and right backs of arms with a notation indicating multiple bruises and a few skin tears on bilateral arms.

Review of the daily nurses' shift notes dated 2/22/19 - 2/25/19 (day and night shift) revealed boxes indicating Bruises or Integumentary assessment were checked.

Further review of the above referenced weekly skin assessments/body audits revealed no description of the bruised areas such as size, color, number of bruises, and whether the bruised area was flat or raised.

Patient #4
Review of Patient #4's medical record revealed an admission date of 2/12/19 with an admission diagnosis of Delusional Disorders.

Review of Patient #4's Skin Assessement and Wound Care Documentation Assessments revealed the following body diagram notes:

2/16/19 5:00 p.m.: Circled area on the back of the left arm and a circle on the back of the left hand, a circled area on the back of the right hand with a note indicating bruises where the circled areas were located.

Review of the daily nurses' shift notes dated 2/13/19 - 2/21/19 (day and night shift) revealed boxes indicating Bruises and/or Integumentary assessment were checked.

Further review of the above referenced daily nurses' shift notes and skin assessments/body audits revealed no description of the bruised areas such as size, color, number of bruises, and whether the bruised areas were flat or raised.

On 2/25/19 at 11:10 a.m. S5RN was observed performing a skin assessment on Patient #4. The following findings were observed:
Left upper arm yellowish green 2 cm old bruise; left forearm- 2 cm old yellow bruise; right antecubital 4 cm old purplish-green bruise, upper right leg purplish pinpoint bruises; and right ankle/foot- 8cm x 1 cm arc shaped purplish- blue bruised area.

The above referenced findings from 11:10 a.m. on 2/25/19 were compared to the skin assessment performed at 5:30 a.m. on 2/25/19 and the following differences in the assessment findings were noted:
No documented findings regarding the second 2 cm yellow old bruise documented as being on the left forearm;
No documented purplish pinpoint bruises on right upper leg; and
No bruising documented on right ankle/foot.

In an interview on 2/21/19 at 12:58 p.m. with S2DON, she reported skin assessments were performed on admit, weekly, as needed, with falls, and at discharge. S2DON agreed bruises should have been described indicating size, color, number of bruises, and whether the bruised area was flat or raised. S2DON acknowledged skin assessments were not consistent.

In an interview on 2/25/19 at 8:29 a.m. with S3RN, she reported skin assessments were done on admit, weekly, after a fall, and on discharge. S3RN indicated skin assessments for daily nurses' shift notes usually were just checked boxes indicating bruises with no further description of the bruises or integumentary assessment.