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Based on review of facility documentation, policy, procedure and clinical records and staff interviews it was determined the risk manager failed to investigate and analyze the cause of specific types of adverse incidents for three (#1, #3, #7) of five sampled records. This practice does not allow for tracking and trending of specific adverse incidents to promote patient safety and improved care.

Findings include:

1. Patient #1 was admitted on 11/5/11 from the Emergency Department (ED). Review of the ED record did not show a history of seizures. Review of the physician History and Physical revealed no history of seizures. The patient was admitted to the Progressive Care Unit (PCU) on 11/5/11 at 9:40 p.m. Review of Licensed Practical Nurse (LPN) documentation dated 11/6/11 at 1:08 a.m. revealed the patient complained of limited range of motion with pain to both arms. The documentation noted the patient had a seizure yesterday that was unwitnessed.

There was no documentation of where the unwitnessed seizure had occurred, the patient being placed on seizure precautions or the physician being notified of the allegation of an unwitnessed seizure or bilateral decreased range of motion to the arms.

Interview on 12/22/11 at approximately 2:30 p.m. with Registered Nurse (RN) on Neuroscience Unit revealed when a patient is admitted to the unit with a history of seizures, they are placed on seizure precautions, which would include padded side rails.

On 11/7/11 at 4:10 a.m. a rapid response was called. Review of the Rapid Response Team documentation indicated the patient was found unresponsive. Review of the neurology consult dated 11/7/11 at 8:05 a.m. revealed the impression was a probable seizure.

Nursing documentation revealed the pain in both arms was reported to the Advanced Registered Nurse Practitioner (ARNP) on 11/9/11 at 9:05 a.m. An orthopedic consult was completed on 11/10/11 at 11:03 a.m. It was discovered the patient had bilateral fractures of right and left shoulders. The consult indicated the fractures were presumed to be caused by the unwitnessed seizure on 11/7/11.

Interview on 12/22/11 at approximately 2:00 p.m. with the PCU Nurse Manager and the Risk Manager confirmed there was no documentation in the medical record related to the unwitnessed seizure while the patient was in PCU or seizure precautions being implemented after the patient had stated she had an unwitnessed seizure the day prior. The interviews revealed no further investigation was completed since the physician indicated the fractures were presumed to be from an unwitnessed seizure. The review by the facility did not show evidence of the investigation as to why the information from 1/6/11 was not reported to the physician, the lack of documentation of the unwitnessed seizure by the nursing staff or other possibilities for the bilateral shoulder fractures.

2. Patient #7 was admitted on 10/12/11. The physician's History and Physical dated 10/12/11 revealed a history of recurrent falls. She was placed with a 1:1 sitter in the Neuroscience Unit.

Interview with the Risk Manager on 12/22/11 at 11:30 a.m. revealed on 10/13/11, exact time unknown, the patient was in the Neuroscience Unit with a 1:1 sitter. The patient was swinging her arms at staff. The sitter grabbed the patient's arms. The Nursing Supervisor went into the patient's room and talked with the patient. The patient stated "she broke my arm" and pointed to the sitter.

A physician's order dated 10/13/11, no time, ordered an x-ray of the left forearm and wrist. The x-ray was completed on 10/14/11 at 10:28 a.m. The result showed a fracture of the distal ulna.

Interview on 12/22/11 at approximately 11:30 a.m. with Risk Manager revealed security responded to a code gray in the patient's room on 10/14/11 at 12:10 p.m. (the day after the alleged wrist fracture being caused by the sitter and the physician's order for the x-ray).The patient was combative and uncooperative. The interview revealed she threw herself to the floor. She was kicking and swinging her arms.

Review of the medical record revealed physician's order for a right shoulder and elbow x-ray dated 10/13/11 at 6:45 p.m. and was completed at 10:55 p.m.. Radiology report dated 10/14/11 at 10:48 a.m. revealed no fractures.

A phone interview was conducted on 12/22/11 with the attending physician at approximately 9:30 a.m. She stated "I documented in the progress note patient was walking in hallway and threw herself to floor. I do not remember who informed me of this event." She also stated " It happened in the evening, so I was not in hospital". The physician indicated she believed the wrist fracture occurred when the patient fell in the hallway.

Review of the Discharge Summary dictated on 10/16/11 noted the patient sustained a wrist fracture after falling in the hallway.

The interview with the Risk Manager on 12/22/11 at approximately 11:30 a.m. revealed there was no investigation concerning the contradicting information between the physician and medical record documentation on how and when the fracture occurred .

3. Patient #3's triage record revealed the patient presented via ambulance from a Skilled Nursing Facility (SNF) on 11/12/11 at 3:26 p.m. with a chief complaint of a right leg Deep Vein Thrombosis (DVT). The documentation noted the patient was oriented to person only with a history of dementia. Review of ED nursing initial assessment documentation at 3:28 p.m. revealed the patient was oriented to person only and with a history of dementia. The documentation showed the skin was within normal parameters. ED nursing notes at 7:30 p.m. indicated the patient was found on the floor. There were no reports of injuries.

Review of the medical surgical unit nursing documentation noted the patient arrived from the ED on 11/12/11 at 10:52 p.m. Review of the initial assessment dated 11/12/11 at 11:12 p.m. revealed the skin assessment was Within Normal Parameters (WNP) and the patient did not have a urinary catheter. Nursing documentation dated 11/13/11 at 6:10 a.m. noted a bath was given. Documentation at 6:24 a.m. showed the adult brief was changed and peri care provided. Shift evaluation dated 11/13/11 at 8:01 a.m. revealed the skin was not WNP. The documentation noted redness on the coccyx. Nursing shift evaluation dated 11/13/11 at 9:22 p.m. noted the skin was not WNP. The area noted was described as redness on the coccyx. The wound bed was red and the surrounding tissue was pink. The patient used adult brief for toileting. Nursing documentation dated 11/14/11 at 6:16 a.m. noted a complete bath was given. Shift evaluation dated 11/14/11 at 8:00 a.m. revealed the skin was not WNP. The documentation noted redness on the coccyx. Nursing documentation showed the patient was discharged on 11/14/11 at 2:39 p.m. to the SNF.

Hand written on the computer form dated 11/13/11 was a late entry dated 11/18/11 at 12:10 p.m. by a registered nurse that stated at 2:00 p.m. the nurse went into change the adult brief and noted a small pencil width two inch bruise in the peri anal area. No other skin discoloration noted after assessing the vaginal and upper thigh area. Hand written on the computer form dated 11/12/11 was a late entry dated 11/17/11 at 3:55 p.m. by a different registered nurse that noted a hematoma located in the rear peri area and both legs. The area was not opened, the wound bed was purple and the surrounding tissue was pink.

Review of the physician ' s History and Physical revealed no evidence of bruising. Physician progress notes dated 11/13-11/14/11 revealed no evidence of the peri area bruising .

Review of the discharge summary dictated 12/6/11 revealed no mention of the bruising in the peri area.

Interview with the wound care nurse on 12/22/11 at approximately 10:50 a.m. and review of the wound care referral form dated 11/13/11 at 11:31 p.m. revealed a request for the skin care person to visit. There was no reason documented for the wound care referral. Wound care nurse referral form dated 11/14/11 at 10:57 a.m. noted a request for the wound care nurse to visit for a red bottom and bruising on the peri area. The interview revealed she received the referral via computer at approximately 11:00 a.m. while making her wound care rounds. She stated when she actually viewed the referral the patient had already been discharged. The patient was never seen by a wound care nurse.

Review of the transfer out form dated 11/12/11 from the SNF revealed no evidence of bruising or a urinary catheter prior to transfer from the SNF to the ED

Interview with a Licensed Practical Nurse (LPN) on 3 East on 12/22/11 at approximately 10:15 a.m. revealed given a scenario of bruising in the peri area the LPN would document the findings, take pictures, and notify the resource nurse, unit charge nurse, and physician.

Interview with the 3 East unit manager on 12/22/11 at approximately 10:25 noted pictures would be taken of bruising in the peri area. She did not recall if pictures were taken of the patient. The interview revealed the findings must be documented when found. The interview revealed the facility thought the bruises were related to the fall in the ED.

Interview with one of the nurses who wrote the late entry on 12/22/11 at approximately 9:00 a.m. revealed she just forgot to document the findings of the bruises in the peri area.

Review of facility documentation dated 11/17/11 at 2:27 p.m. revealed a patient complaint was received from a family member on 11/15/11. The family member stated the SNF informed her that the patient had bruising in the outer vaginal area and inner thigh. The documentation noted the patient had fallen in the ED on 11/12/11. There was no documentation of the bruising in the nursing assessments. The documentation noted when asked all staff remembered the bruising.

Interview with the Vice President (VP) of Quality and Risk and the Assistant Chief Nursing Officer on 12/21/11 at approximately 4:00 p.m. revealed on 11/15/11 a call was received from the family member. She told her the SNF informed her that the patient had bruising in the groin area. The Sheriff department requested information from the facility on 11/15/11. The interview revealed the Unit Director had done a chart review. Late entries were made. The interview revealed the abuse registry was called by the hospital on 11/18/11. The risk manager delayed in calling the abuse registry until the investigation was done. The interview noted the SNF facility thought the bruising was due to a urinary catheter from the hospital. There was no documentation of bruising in the record or of a urinary catheter being used.

The interview revealed there was no documentation of how the patient was when she was found on the floor in the ED. The interview with the VP of Quality and Risk confirmed there were discrepancies between the two late entries' documentation by the registered nurses, the physician was not notified of the bruising nor were pictures taken of the bruising.

Review of policy and procedure "Victims of Domestic Violence/Abuse/Neglect" #NPE-06 dated 6/10 indicated under Checklist-Recognition of Abuse under the heading of sexual abuse signs included bruises in the perineal area.

The clinical record, facility documentation and interviews revealed the bruises were noted on 11/13/11 by at least two registered nurses. The patient had been assessed on each shift evaluation, had baths and adult brief changes, and was seen by the physician service from 11/12/11 to 11/14/11 with no documentation of bruises in the peri area. The late entry had conflicting descriptions that were written three and four days after discharge. The patient was discharged before the wound care nurse could perform her assessment of the findings on 11/14/11. A call was received from a family member on 11/15/11 that the receiving SNF informed her bruises were found near the vaginal area, facility documentation was not written until 11/17/11. The abuse registry was not notified until 11/17/11. There was no evidence of an investigation or results of the chart review that was conducted or the rationale in the delay of investugating or reporting to rule out potential abuse.


There was no evidence of the facility analyzing adverse patient events and other aspects of performance that assess processes of care for three of three patients reviewed with an adverse event.

Based on clinical record review, facility documentation, policy and procedure reviews and staff interviews it was determined the nursing staff failed to assess, plan, intervene, and evaluate nursing care and inform the physician of changes in a patient's condition for 3 (#1, #3, #7) of 10 sampled patients who sustained an injury in the facility. The facility administrative personnel failed to ensure adequate number of licensed nurses and other nursing personnel were available to deliver safe and complete nursing care. These practices did not ensure patient goals were met, that safe nursing care was provided, and therefore, did not lead to the prevention of injury for three patients.


The nursing staff on 3 East, the Progressive Care Unit, the Neuroscience Unit, and the Emergency Department (ED) failed to ensure the nursing process was implemented and the physician was notified of changes in the patient's condition:
1. Patient #3 had a history of dementia and crawling out of bed as indicated on the ambulance run sheet. There were no fall precaution implemented in the ED. The patient sustained a fall in the ED. There was no assessment by the registered nurse after the fall. Refer to A0395.
2. Patient #3's nursing documentation revealed a redness on the coccyx from admission to discharge. Facility documentation revealed reports of bruising in the vaginal and thigh area from the receiving facility. Three and four days after the facility received the report of bruising, contradicting late entries were documented concerning the bruises by two registered nurses. The physician was not notified of the bruises in the perineal area. The lack of the skin assessment may have prevented a thorough investigation for abuse. Refer to A0395.
3. Patient #1 indicated on 11/6/11 she had an unwitnessed seizure the day before. There was no evidence of th physician being notified or seizure precautions being implemented. The patient sustained two fractures of the upper arms during a second unwitnessed presumed seizure on 11/7/11. The lack of implementation of seizure precautions may have prevented injury during an unwitnessed seizure. Refer to A0395.
4. Patient #7 sustained a wrist fracture. The patient alleged it was due to the sitter holding her wrist. There was no assessment by the registered nurse of the patient's wrist after the allegation of the injury. Refer to A0395.
5. Confidential interviews revealed an inadequate number of registered nurses and other nursing personnel to meet the needs of the patient for assessments and meeting the individual needs related to their diagnosis. Refer to A0392.

Due to the lack of assessments, planing, intervening, implementation of preventive measures for fall and seizures, and not notification of the physician for changes in patients' condition and insufficient staff to meet the needs of patients, the Condition of Participation for Nursing Services was found to be out of compliance.

Based on medical record review, falls tracking and trending, and review of team meeting minutes of falls and staff interview it was determined the facility failed to ensure that patient needs are met by ongoing assessments of the needs and that nursing staff is adequately provided to meet those needs. There must be sufficient numbers, licensed nursing staff and other nursing personnel to respond to the appropriate nursing needs and care of the patient population of each department or nursing unit.

Findings include:

1. Confidential interview revealed the Neuroscience Unit (NSU) had a very high patient acuity. The nurse to patient ratio was usually 1:5 or 1:6. One Certified Nursing Assistant (CNA) can be responsible for 30 patients and is unable to assist nurses when needed. Most of the patients on the NSU are stroke, altered mental status, and dementia patients. These types of patients require maximum assistance for ambulation and care. The confidential interview revealed because of the high acuity and staffing issues there are safety concerns. It was stated the Emergency Department (ED) did not want to have ED holds. The ED sends admissions to the NSU even if their diagnosis is not neuro related.
The confidential interview revealed that Licensed Practical Nurses (LPNs) do their own assessments and are not usually reassessed by the Registered Nurse (RN). The RN may sign after the LPN, but does not actually reassess the patient. The confidential interview noted falls have been on the increase believed to be related to staffing.

2. Patient #3 did not have an assessment performed after a fall in the ED on 11/12/11. The ambulance run sheet indicated the patient had a history of crawling out of bed. The nursing staff did not implement fall precautions. The patient did not have accurate and complete skin assessments from admission on 11/13/11 to discharge on 11/14/11. The physician was not notified of bruising in the perineal ara.

3. Patient #7 sustained a wrist fracture while at the facility on 10/13/11. There was no nursing assessment of the wrist injury after the patient reported the injury.

4. Patient #1 indicated on 11/6/11 she had an unwitnessed seizure the day before. There was no evidence of the physician being notified or seizure precautions being implemented. The patient sustained two fractures of the upper arms during a second unwitnessed presumed seizure on 11/7/11.

5. Review of falls tracking and trending revealed that falls that occurred in 9/11 were 2.69 (falls/1000 Patient Days and Observation days). In 10/11 it was 3.59 and on 11/11 it was 3.55. Review of fall team meeting minutes dated 12/12/11 revealed the NSU falls were consistently above the rest of the facility. It noted 80% to 90% of the neuro patients are on fall precautions.

Based on clinical record review and staff interview it was determined that the Registered Nurse failed to supervise and evaluate nursing care related to assessment and prevention of injury for 3 ( #1, #3, #7) of 10 sampled patients. This practice does not ensure patient goals are met and may prolong hospital stays.

Findings include:

1. Patient #1 was admitted on 11/5/11 from the Emergency Department (ED). Review of the ED record did not show a history of seizures. Review of the physician History and Physical revealed no history of seizures. The patient was admitted for a hypertensive crisis. The patient was admitted to the Progressive Care Unit 11/5/11 at 9:40 p.m. and placed on telemetry. The initial nursing assessment did show evidence of a prior history of seizures. Review of Licensed Practical Nurse (LPN)
documentation dated 11/6/11 at 1:08 a.m. revealed the patient complained of limited range of motion with pain to both arms. The documentation noted the patient had a seizure yesterday that was unwitnessed.

There was no documentation of the patient being placed on seizure precautions or the physician being notified of the allegation of an unwitnessed seizure or bilateral decreased range of motion to the arms.

Interview with the Director of Telemetry on 12/22/11 at approximately 3:30 p.m. revealed she had talked with the LPN who had completed the admission assessment. The LPN indicated the patient had told him she had a seizure at home.

Interview on 12/22/11 at approximately 2:30 p.m. with Registered Nurse (RN) on Neuroscience Unit revealed when a patient is admitted to the unit with a history of seizures, they are placed on seizure precautions,which would include padded side rails.

There was no evidence of seizure precaution being implemented for the patient after a reported unwitnessed.

On 11/7/11 at 4:10 a.m. a rapid response was called to the patient's room. There was no nursing documentation from the Progressive Care Unit (PCU) nurse indicating why a rapid response was called or the patient's condition. Review of the Rapid Response Team documentation indicated the patient was found unresponsive and a stroke alert was called. Intensive Care Unit (ICU) nursing documentation dated 11/7/11 at 8:00 a.m. indicated patient had no pain. Review of the neurology consult dated 11/7/11 at 8:05 a.m. revealed the impression was a probable seizure.

Review of daily shift evaluation nursing assessments from 11/6/11 to 11/8/11 revealed musculoskeletal assessments that showed no problems with range of motion (ROM) and no pain reported.

There were no evidence of nursing documentation found until 11/9/11 at 7:30 a.m. that indicated the patient was having difficulty moving her arms and unable to raise her shoulders. Nursing reported the pain to the Advanced Registered Nurse Practitioner (ARNP) on 11/9/11 at 9:05 a.m. An orthopedic consult was completed 11/10/11 at 11:03 a.m. It was discovered the patient had bilateral fractures of right and left shoulders. The consult indicated the fractures were presumed to be caused by the unwitnessed seizure on 11/7/11.

Interview on 12/22/11 at approximately 2:00 p.m. with the PCU Nurse Manager and the Risk Manager agreed there was no documentation in the medical record related to the unwitnessed seizure while the patient was in PCU or seizure precautions being implemented after the patient had stated she had an unwitnessed seizure the day prior.

2. Patient #7 was admitted on 10/12/11. The physician's History and Physical dated 10/12/11 revealed a history of recurrent falls. A fall assessment was completed by nursing on admission. There was no evidence of a care plan for falls being developed or implemented.

A physician's order dated 10/13/11, no time, ordered an x-ray of the left forearm and wrist due to the patient complaining of pain. The x-ray was completed on 10/14/11 at 10:28 a.m. The result showed a fracture of the distal ulna.

Interview with the Risk Manager on 12/22/11 at 11:30 a.m. revealed on 10/13/11, exact time unknown, the patient was in the Neuroscience Unit with a 1:1 sitter. The patient was swinging her arms at staff. The sitter grabbed the patient's arms. The Nursing Supervisor came into room and talked with patient. The patient stated "she broke my arm" and pointed to sitter.

Ortho consult report dated 10/14/11 revealed forearm fracture. A long arm cast was applied.

There was no evidence of a nursing assessment being completed after the allegation from the patient about her wrist being broken.

3. Patient #3's triage record revealed the patient presented via ambulance form a Skilled Nursing Facility (SNF) on 11/12/11 at 3:26 p.m. with a chief complaint of a right leg Deep Vein Thrombosis (DVT). The documentation noted the patient was oriented to person only and a history of dementia. Review of the ambulance run sheet dated 11/12/11 noted the SNF stated the patient was constantly crawling out of bed. The patient was taken to room 7.

Review of ED nursing initial assessment documentation at 3:28 p.m. revealed the patient was oriented to person only and with a history of dementia. Documentation at 7:13 p.m. revealed report was given to the medical surgical unit. ED nursing notes at 7:30 p.m. indicated the patient was found on the floor.

There was no evidence of fall precautions being implemented in the ED since the patient had a history of crawling out of bed as indicated on the ambulance run sheet. There was no assessment of how the patient was found on the floor. There was no documentation of the time the patient left the ED after the fall.

Interview with the ED Charge Nurse and ED Manager on 12/21/11 at approximately 1:20 p.m. revealed patients at risk for falls are placed in visual view from the nurses' station. The ED also utilize sitters, security, or use diversion activity. Interview with the Charge Nurse and Manager did not reveal any concerns the patient was a fall risk after they reviewed the record. They did not note the ambulance run sheet information.

Observation during tour of the ED on 12/21/11 at approximately 1:35 p.m. noted room 7 was not in visual view from the nurses' station.

Review of policy and procedure " Fall Reduction Program " NTX-59 dated 3/10 indicated all employees will assist in identifying patients exhibiting unsafe behavior.


Review of the medical surgical unit nursing care plan for 11/12-14/11 revealed no evidence of a plan of care for a patient who sustained a fall after crawling out of bed in the ED and a history of crawling out of bed in a SNF.


4. Patient #3's ED nursing initial assessment documentation at 3:28 p.m. revealed the patient was oriented to person only with a history of dementia. The documentation showed the skin was within normal parameters. The documentation noted the patient received Heparin and Lovenox while in the ED. The documentation noted the patient had sustained a fall while in the ED.

Review of the medical surgical unit nursing documentation noted the patient arrived on 11/12/11 at 10:52 p.m. Review of the initial assessment dated 11/12/11 at 11:12 p.m. revealed the skin assessment was Within Normal Parameters (WNP) and the patient did not have a urinary catheter. Nursing documentation dated 11/13/11 at 6:10 a.m. noted a bath was given. Documentation at 6:24 a.m. showed the diaper was changed and peri care provided. Shift evaluation dated 11/13/11 at 8:01 a.m. revealed the skin was not WNP. The documentation noted redness on the coccyx. Nursing shift evaluation dated 11/13/11 at 9:22 p.m. noted the skin was not WNP. The area noted was described as redness on the coccyx. The wound bed was red and the surrounding tissue was pink. The patient used adult brief for toileting. Nursing documentation dated 11/14/11 at 6:16 a.m. noted a complete bath was given. Shift evaluation dated 11/14/11 at 8:00 a.m. revealed the skin was not WNP. The documentation noted redness on the coccyx. Nursing documentation showed the patient was discharged on 11/14/11 at 2:39 p.m. to a SNF.

Hand written on the computer form dated 11/13/11 was a late entry dated 11/18/11 at 12:10 p.m. by a registered nurse that stated at 2:00 p.m. the nurse went into change the adult brief and noted a small pencil width two inch bruise in the peri anal area. No other skin discoloration noted after assessing the vaginal and upper thigh area. Hand written on the computer form dated 11/13/11 was a late entry dated 11/17/11 at 3:55 p.m. by a different registered nurse that noted a hematoma located on the rear peri area and both legs. The area was not opened, the wound bed was purple and the surrounding tissue was pink.

Review of the physician's History and Physical revealed no evidence of bruising or the coccyx being red. Physician progress notes dated 11/13-11/14/11 revealed no evidence of the peri area bruising or the coccyx being red.

Review of the discharge summary dictated 12/6/11 revealed no mention of the bruising in the peri area or the coccyx being red.

Review of the transfer out form dated 11/12/11 from the SNF revealed no evidence of bruising or a urinary catheter when transferred from the SNF to the ED.

Interview with the wound care nurse on 12/22/11 at approximately 10:50 a.m. and review of the wound care referral form dated 11/13/11 at 11:31 p.m. revealed a request for the skin care person to visit. Wound care nurse referral form dated 11/14/11 at 10:57 a.m. noted for the wound care person to visit for a red bottom and bruising on the peri area. The interview revealed she received the referral via computer at approximately 11:00 a.m. She was making her wound care rounds. She stated when she actually viewed the referral the patient had already been discharged. The patient was never seen by wound care.

Interview with a Licensed Practical Nurse (LPN) on 3 East on 12/22/11 at approximately 10:15 a.m. revealed given a scenario of bruising in the peri area the LPN would document the findings, take pictures, and notify the resource nurse, unit charge nurse, and physician.

Interview with the 3 East unit manager on 12/22/11 at approximately 10:25 noted pictures would be taken of bruising in the peri area. She did not recall if pictures were taken of the patient. The interview revealed the findings must be documented when found.

Interview with one of the nurses who wrote the late entry on 12/22/11 at approximately 9:00 a.m. revealed she just forgot to document the findings.

Review of facility documentation dated 11/17/11 at 2:27 p.m. revealed a patient complaint was received from a family member on 11/15/11. The family member stated the SNF informed her that the patient had bruising in the outer vaginal area and inner thigh. The documentation noted when asked all staff remembered the bruising.

Interview with the Vice President (VP) of Quality and Risk and the Assistant Chief Nursing Officer on 12/21/11 at approximately 4:00 p.m. revealed the Unit Director had done a chart review. Late entries were made. The interview revealed there was no documentation of how the patient was when she was found on the floor in the ED. The interview with the Vice President (VP) of Quality and Risk confirmed there were discrepancies between the two late entries' and the original documentation in the record. She confirmed there was no documentation that the physician was notified of the bruising or that pictures were taken of the bruising.