HospitalInspections.org

Based on interview and record review, the facility failed to ensure supervision of nursing services. Specifically the facility failed to identify, appropriately assess, document, and/or communicate injury concerns and assessments to a medical provider, resulting in the delay of care for 2 of 2 patients with orthopedic fractures. These failures place all patients at risk for potential, pain, suffering, and further injury. Refer to A-395.


.

Based on record review and interview, the facility failed to ensure a physical assessment was completed, communication of physical injury concerns were documented, and referral for medical assessment was completed, when injury or concern of injury had been reported to nursing staff and interventions had been implemented. Failure to provide a physical assessment and communicate injury concerns to licensed independent practitioners resulted in a delay of medical treatment for 2 of 2 patient records reviewed for fractures. Findings:

Patient #1

Record review on 9/24-26/14 revealed Patient #1 was admitted to the hospital on 8/18/14 with a diagnosis of ADHD (Attention Deficit Hyperactivity Disorder).


9/13/14

Record review of the "Daily Nursing Assessment/Progress" note, dated 9/13/14, revealed "...2100 [9:00 pm] in attempt to create distance between violent patient and staff open hand techniques were used to avoid assault and pt [patient] and staff member tripped over bed frame..., pt [patient] hitting L [left] side of face receiving a 1 mm cut under eye and some swelling. Ice provided pt [patient] refused any other interventions."

No further nursing assessment or documentation specific to the injury was noted by a nurse or medical provider.

Record review of the "ADOL Intervention/Progress", dated 9/13/14, used by the MHS (Mental Health Specialist) to document daily activities revealed, "...cut to the left side of his face. His eye was swollen, 2300 [11:00 pm]."


9/14/14

Record review of the "ADOL Intervention/Progress", dated 9/14/14, used by the MHS (Mental Health Specialist) to document daily activities revealed the patient had breakfast between 8:30 am-9:00 am then attended Community/Target Goal group between 9:30 am-10:00 am. No documentation of left eye swelling, bruising, or pain.

Record review of the "Physician's Orders", dated 9/14/14 at 10:30 am, revealed an order for "In system consult re [regarding] black eye." This was a verbal order request from the RN on duty this date. No nursing documentation of an assessment of eye injury.

Record review of the "Request for In-System Consult", dated 9/14/14 at 10:30 am, completed by the Physician Assistant at 11:45 am, revealed "Lt [eye] swollen & red unable to open upper lid surrounding hematoma..., Lt eye can't assess due to edema..., refer to ANMC (Alaska Native Medical Center) ED (Emergency Department) to eval (evaluate) Lt eye contusion".

Record review of the "Daily Nursing Assessment/Progress" note, dated 9/14/14 at 3:00 pm, after the patient had been at the ANMC ED since 12:59 pm, revealed "Pt's eye more swollen/bruised than evening previous..." Nursing notes from the previous evening did not reflect a nursing assessment of the injury.

The patient was admitted to the Emergency Department at ANMC at 12:59 pm on 9/14/14. The radiology report revealed a left orbital fracture and the patient was admitted to inpatient at ANMC.

Review of the facility policy " PC112, Seclusion, and Physical Restraint " revised 8/14, revealed " ...Face to face evaluation by the physician, or trained RN/PA: Within 1 hour of the initiation of restraint ..... " The medical record revealed no documentation of a licensed independent practitioner assessment until 8/13/14 at 10:30 am.


Record review of the facility ' s internal investigation dated 8/13/14, revealed the patients attending psychiatrist had been notified, and stated he was told by the RN that a [medical] consult was not needed. In addition, this report stated the patient had been given Tylenol but there is no documentation of Tylenol given on 8/13/14.



Patient #2

Record review on 9/24-26/14 revealed Patient #2 was admitted to the hospital on 8/12/14, diagnoses of ADHD and IED (Intermittent Explosive Disorder).

Record review of the "Daily Nursing Assessment/Progress Note", dated 8/29/14, revealed "Medical Concerns: Injury" the response was checked "No" for the day shift (7:00 am-3:30 pm).

Further review of the evening shift (3:00 pm-11:30 pm) documentation revealed "Injury: No".

Record review of the "Progress Record", dated 8/29/14 at 3:30 pm, revealed, "Addendum to day shift note: Pt escalating as evidenced by yelling, screaming, flailing on the floor... pt [patient] stated that RN hurt pt's L arm [with] the door... no swelling, bruising, or sign of injury was present. Ice was applied to arm for comfort measure ..., No consult was initiated as RN assessed no injury by end of shift."A comprehensive assessment to include the location and level of pain was not completed.


8/30/14

Record review of "Daily Nursing Assessment/Progress Note", dated 8/30/14, revealed "Medical Concerns: Injury". The response was checked "No" for both the day shift and evening shift.

Record review of the "Progress Record", dated 9/5/14 (5 days after the injury), revealed "Late entry for 8/30/14 Addendum: ...While sitting in the quiet room Pt had c/o [complaint] left arm hurting, 0 (no) apparent injury, 0 bruising, able to use hand and move fingers w/o [without] difficulty. Mom visited...notified of the c/o and informed me that it happened Thursday/Friday [8/28-29/14]. Pt had no further c/o verbalized after the initial c/o." A comprehensive assessment to include the location and level of pain was not completed.

Record review of the "Restraint/Seclusion Order/Record", dated 9/5/14 (5 days after the injury was first noticed) at 5:00 pm, revealed, "Late Entry for 8/30/14 ...Pt did have c/o pain/discomfort to L arm prior to this outburst - there was no obvious evidence of injury, 0 bruising - 0 edema - hands pink in color. Pt able to use and have normal Range of Motion of hands and fingers. "A comprehensive assessment to include the location and level of pain was not completed.


8/31/14

Record review of the "Daily Nursing Assessment", dated 8/31/14, revealed "Medical Concerns: Injury" response was checked "No" for both the day shift and evening shift.

Record review of the "Progress Record", dated 9/5/14, revealed "Late entry for 8/31/14 Pt [patient] in Quiet Room w [with] c/o L [left] arm hurting..., moist heat applied to L arm w/verbalization that his arm was feeling better..., Heat was applied once for approximately 15 minutes." A comprehensive assessment to include the location and level of pain was not completed.


9/1/14

Record review of the "Child/PT Intervention /Progress Sheet", dated 9/1/14, revealed "Recreational Therapy..., comments:... 'hurt arm' wanted ice..., Behavior:... obsessed with hurt arm all day..." The form was signed by Mental Health Specialist.

Record review of the "Daily Nursing Assessment", dated 9/1/14, revealed "9/1/14 @ 1520 [3:20 pm] RN PT continued to report L wrist/forearm pain today, pt stating injury occurred on Friday (8/29) RN applied ice which was helpful, initiated a consult to have L arm assessed by in house consult. When contacting mom she expressed interest in having arm x-rayed today. Throughout the day, pt has been escalative, assaultive, non-compliant, openly defiant ...Pt refused to go [to in-system consult] stating "I'll get it looked at tomorrow."

Further review revealed that 5 ? hours after the noted request for an in-house consult, at "... 2055 [8:55 pm] Pt was seen by PA [Physician Assistant]. PA ordered out of system consult for L arm, ice PRN and ace wrap to arm. "A comprehensive assessment to include the location and level of pain was not completed by the RN.

Record review revealed, multiple late entries however, these late entries were not available to staff at the time they accepted the responsibility of care for the patient which placed the continuity of care for the patient at risk. There was no documentation found during record review that identified the patient's reported injury on 8/29/14 was ever conveyed from staff to staff.

In addition, the in-house consult was not ordered until 9/1/14 when the LN present during the reported injury on 8/29/14 returned to work. The Patient was seen by the PA, 81 hours and 25 minutes after the injury was first reported to nursing staff.

The out of system consult from a medical provider was completed on 9/2/14, per mother's request, and an x-ray confirmed a fracture.


9/2/14

Record review of the "Discharge Summary", dated 9/2/1, revealed "On day 4 of the injury an in-system consult was placed and the in-house medical staff evaluated the patient... [on 9/2/14], an x-ray was completed. The arm was identified as having been fractured."

During an interview on 9/24/14 at 2:25 pm, RN #1 stated if a patient sustained an injury, the RN would contact the family member, physician, and supervisor before the end of the RN's shift. The RN further stated, if the injury was severe, then the Physician would be contacted immediately to request an in-system consult and an out of system consult if needed.

During an interview on 9/26/14 the Director of Nursing stated the injuries reported for Patient #s 1 and 2 should have been assessed, documented, and communicated between staff responsible for the care of the patients as well as reported to the physician and family.
The DON further stated an assessment should always be done for any injury sustained by a patient and confirmed no nursing assessment of the injury had been documented on either Patients #s 1 or 2.