HospitalInspections.org

Based on interviews and record reviews the hospital failed to ensure 1 of 10 patients (Patient #1) was evaluated and/or assessed for injuries after a restraint/seclusion and/or prior to transfer to Hospital B on 01/31/15. Upon arrival to Hospital B a picture taken of Patient #1 verified bruising to the forehead.

Findings included:

Patient #1's 01/30/15 timed at 0200 Physical Assessment reflected, "No documentation which indicated Patient #1 had any skin conditions such as bruises, abrasions..."

Patient #1's PEC (Psychiatric Emergency Center) note dated 01/31/15 timed at 1130 reflected, "Patient threw an object at an elderly patient...staff member attempted to redirect, the patient pushed him...during team escort, patient pulled free and struck a staff member twice in the face and scratched his hand...patient placed in seclusion...at 1145 upon entering the seclusion room for emergency medication administration, patient hit and kicked staff and officers...received medication...at 1353 patient begins striking door with fist...put mattress over the window to block view...patient can be observed sitting in the corner of seclusion room..."

Patient #1's PEC note dated 01/31/15 timed at 1645 reflected, "Patient is transported to Hospital B with Sheriff 's deputies with belongings and instructions..." No patient assessment was found prior to transfer to Hospital B.

Hospital B's medical record for Patient #1 dated 01/31/15 revealed the following:

Patient #1's Client Face Sheet reflected, "01/31/15 admit date and admit time 1703...hospital patient photo timed at 1703 revealed bruising to Patient #1's forehead..."

Hospital B's Skin and Body Assessment for Patient #1 dated 01/31/15 at 1845 reflected, "Bruises to forehead...red areas to right and left inner forearms...and one bruise to the top of the left hand..."

On 09/17/15 at 0935 Personnel #7 was interviewed by telephone. Personnel #7 stated he remembered Patient #1. He stated the patient was extremely aggressive he punched him in the face and he hurt his back. Personnel #7 was asked if Patient #1 sustained any injuries. Personnel #7 stated he saw some marks on Patient #1's forehead. Personnel #7 stated Patient #1 hit his head on the wall. Personnel #7 stated he was not assigned to monitor Patient #1.

On 09/17/15 at 1500 Personnel #6 was interviewed. Personnel #6 stated she did not see any injuries or redness to Patient #1's face. Personnel #6 was asked if Patient #1 was assessed before he was transferred to Hospital B. Personnel #6 stated assessments are done upon arrival to the hospital not when discharged. Personnel #6 was shown Patient #1's picture from Hospital B which showed bruising to Patient #1's forehead upon arrival from Hospital A. Personnel #6 did not say anything.

On 09/17/15 at approximately 1600 Personnel #1 was interviewed. Personnel #1 was asked if the hospital had any documentation which indicated Patient #1 was assessed prior to transfer to Hospital B and/or any documentation regarding any injury to his face. The surveyor did refer to the pictures she obtained from Hospital B which revealed bruising to Patient #1's forehead upon transfer from Hospital A. Personnel #1 verified no documentation could be found.

The Hospital Policy and Procedure entitled, "PC 101 Nursing Documentation on Assessment and Reassessment" with an effective date of 02/03/15: reflected, "Assessment and plan of care is as appropriate for the patient's needs...any change in the patient's condition...patient is reassessed by an RN (Registered Nurse)..."