HospitalInspections.org

Based on review of document, photograph's and interview, in 1 (one) of 10 (ten) medical records reviewed, the facility did not ensure that the policy for complaint investigation was followed.


Findings include:

Review of Patient A's medical record (MR) identified: A 55 year old female with comorbidities of Hypertension, End Stage Renal Disease (ESRD) on Hemodialysis and Mental Retardation. The patient was brought to the Emergency Department (ED) on 8/3/15 from New York Renal Dialysis Center for chief complaints of fever and hypotension and was admitted to the Intensive Care Unit (ICU) for septic shock management related to suspected perma-catheter infection. She was placed on behavior management which included a one-to-one observation for safety and elopement, with patient's verbal desire to go home.
There was no documentation of the skin impairment as documented in the photograph taken on 09/08/15, in the patient's medical record.

Observation of a photograph of the patient, dated 09/08/15 at 5:22 AM, presented to the surveyor on 9/24/15 at 3:30 PM, showed 2 images: top image showing the patient's face; image on the bottom showed a black and blue pen in a plastic bag.
The image of patient's face showed: Two (2) open skin tear above left temporal area, irregular in shape with jagged edges; area of discoloration at the left side of the forehead, above the skin tear, bruising under the left outer corner of the eye with redness and swelling, protrusion of the frontal area of the forehead characteristic of an area of swelling.


During entrance conference on 9/22/15 at 10 AM, a request for facility's complaint and incident logs for February 2015 to August 2015, was made by the surveyor. Initial review of the complaint and incident logs revealed no entry for this patient.

The facility policy and procedure titled, "Patient Complaints and Grievances," last revised 1/2014, included instructions for the staff to: refer complaint to Patient Relations, at receipt of complaint Patient Relations would log in complaint into a master log, and the referring Director of Service will investigate and submit a report of findings and corrective actions to Patient Relations if needed.

During interview of Staff #3 (Director Critical Care Unit), on 9/24/15 at approximately 11:30 AM, staff confirmed that the patient had an incident around August 2015, however, she could not remember the exact date and time. Staff #3 stated "We spoke with the family for three hours, I can't remember the date and time. The family was upset and complained that they were not notified of what happened." Staff #3 was unable to provide documentation regarding her meeting/encounter with the family and any response to the family regarding the incident.

During interview of Staff #6 (Assistant Regulatory Coordinator/Quality Assurance-Performance Improvement), and Staff #7 (Associate Director of Risk Management/QAPI), on 9/22/15 and 9/24/15, both staff stated that they were unaware of any complaint or incident for this patient.

Based on review of photographs, document review, and interview, in 1 (one) of 10 (ten) medical records reviewed, (1) the facility failed to ensure this patient with mental disability, behavior problem, and medical co-morbidities was provided care in a safe environment; and (2) the facility failure to ensure implementation of policies for hiring of supplemental staff to ensure quality of care and patient safety; and (3) the facility failed to assure that incidents were reported and analyzed to identify potential unsafe situations.

This failure put all patients at risk.


Findings include:

1) Observation of a photograph of the patient, dated 09/08/15 at 5:22 AM, presented to the surveyor on 9/24/15 at 3:30 PM, showed 2 images: top image showing the patient ' s face; image on the bottom showed a black and blue pen in a plastic bag. The image of patient's face showed:
Two (2) open skin tear above left temporal area, irregular in shape with jagged edges; area of discoloration at the left side of the forehead, above the skin tear, bruising under the left outer corner of the eye with redness and swelling, protrusion of the frontal area of the forehead characteristic of an area of swelling.


Review of Patient A's medical record (MR) identified: A 55 year old female with comorbidities of Hypertension, End Stage Renal Disease (ESRD) on Hemodialysis and Mental Retardation. The patient was brought to the Emergency Department (ED) on 8/3/15 from New York Renal Dialysis Center for chief complaints of fever and hypotension and was admitted to the Intensive Care Unit (ICU) for septic shock management related to suspected perma-catheter infection. She was placed on behavior management which included a one-to-one observation for safety and elopement, with patient's verbal desire to go home.
There was no documentation of the skin impairment as documented in the photograph taken on 09/08/15, in the patient's medical record.

During interview on 9/24/15 at approximately 3:30 PM, Staff #3 (Director Critical Care Unit) stated, "I was called for this patient early morning of Saturday going into Sunday, I cannot remember the exact date. I was made aware that the patient had a scratch on the temporal area with Staff #1 Certified Nurse Aide (CNA)/Patient Care Technician (PCT) trying to prevent patient from getting up. The patient hurt herself with the pen on her hand. The patient always had the pen for drawing. The patient claimed that Staff #1 injured her.

During interview with Staff #15 (RN assigned to the patient on 8/9/15, 8 PM to 8:30 AM), on 9/24/15 at 12:05 PM, RN stated, " .....The CNA was doing the one to one coverage, she was cleaning up the patient with the curtain drawn. I was 5 to 6 feet away with the computer, I remember I heard the CNA saying ' Stay in bed, stay in bed.' I immediately left the computer and went to the bedside. The patient was sitting on the side of the bed with feet dangling. I came to assist the patient. The patient had some kind of a punctured wound above left eye and I asked the CNA why the patient was bleeding. The CNA stated that the patient bit her when trying to get up from bed. I noticed the patient still had the pen in her hand. I proceeded to stop the bleeding. I called the charge nurse, nurse manager, and the doctor .... I can't remember the doctor, the doctor responded immediately. All of us assess the patient, cleaned the wound, and applied the dressing. The bleeding was not heavy, just stayed in the wound and did not run down her face. The event happened at 6:15 AM.

Staff #15 was asked by Surveyor what should be expected in his documentation in the medical record and he indicated, "What I wrote was sufficient. I filled out the Incident Report. I feel the Incident Report was in detail."

There was no documented evidence that Staff #15 documented the incident of 8/9/15 at 6:15 AM in the medical record. This was not consistent with the facility's "Incident Reporting Policy," which stated: "The nurse assigned to the patient must document the event objectively in the medical records, briefly describing the event, the patient's condition, and notification of the physician. "


Review of the clinical progress notes for 8/9/15 through the patient's discharge on 8/20/15, revealed no documented evidence, on all shifts, of a skin/wound assessment and treatment for the patient's left forehead skin impairment sustained on 8/9/15 at 6:15 AM. A Nursing Endorsement dated 8/9/15 at 8:35 AM written by Staff #5 documented, "...Skin warm, dry with abrasion to the left upper corner of eye..."

Staff #5 (RN who took care of the patient on 8/9/15 from 8:30 AM-8:00PM), during interview on 9/25/15 at 2:12 PM, acknowledged the patient's skin impairment. Staff #5 stated: " The patient had a scratch, it was not straight, and it was a scratch. A topical ointment or cream was placed by shift before." Staff also stated she could not remember any physician's order for wound care and any treatment for it. MR review identified no written physician order for treatment.

The facility policy titled, "Care of Pressure Ulcer, Skin Tear Assessment, Wound Care Protocol and Prevention of Pressure Ulcers," last revised 3/14, stated appropriate skin assessment and intervention is documented each shift and upon admission, transfer and discharge in the EMR (Electronic Medical Record). The policy also instructed the treatment protocol for Skin Tear and other skin impairments.

There was no documented evidence in the medical record that a physician immediately examined the patient, and the findings documented in the progress note to include a treatment plan and notification to the patient's family where appropriate.

This was not consistent with the facility's "Incident Reporting Policy," which stated: "A physician should immediately examine the patient and document the findings in a progress note that includes the physician's findings, treatment plan and notification to the patient, and/or the patient's family where appropriate. "



2) Review of the personnel files of CNA #1 (CNA who took care of the patient on 8/9/15 at 6:15 AM), identified Staff #1 as an agency staff.

During interview of Staff #8, on 9/24/15 at 4:00 PM and on 9/29/15 at 4:40 PM, she validated that the file is from the agency who is responsible to make sure the necessary documentation are submitted to the nurse recruiter.
The facility staff were unable to provide documented evidence that CNA #1 completed Bronx-Lebanon Hospital requirements for hiring; including background check, orientation and training, and proficiency evaluation. There was no documentation of an on-going training including but not limited to Patient's Rights.

Similar finding was identified for CNA #2 who also provided care for the patient.


Review of the facility policy titled, "Supplemental Staff Procedure Inpatient, (Procedure for all Per Diem/Agency and Float Pool Staff)," reviewed on 9/29/15, identified the policy had no evidence of approval by the Governing Body, no designated staff/department who performs the final clearance and determination in the hiring of agency/per diem staff including the CNAs, and no mechanism for training and proficiency evaluations.



3) The facility did not ensure that the Occurrence Reporting Form was appropriately completed and a comprehensive investigation of the incident was done by the clinical staff.


Patient A's "Occurrence Reporting Form" dated 8/9/15 at 6:30 AM, was received on 9/24/15 at 3:30 PM. Documentation review identified incomplete information regarding the following:

Section for Skin: "Break/Tear/ Scratch, Burn, Pressure Ulcer" has boxes unchecked/empty:

Section for "Physician/Physician Assistant/Nurse Practitioner Findings" with boxes to check for Laceration/Pain had boxes unchecked/empty;

Section for "Describe Occurrence Briefly" had entries which are not legible.