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Based on interview and medical record review, the hospital failed to weigh Patient Identifier (PI) # 2, on admission and weekly, as ordered by the physician. As a result, there is no record of the patient's weight as it relates to his overall health, medications and diagnoses of Congestive Heart Failure and Hypertension. This affected one of ten sampled patients on the Geriatric Psychiatric Unit.

Findings Include:

PI # 2 was admitted to the hospital on 1/21/11 with diagnoses to include Dementia, Vascular Type with Delusions/Behavior Disturbance, Status Post Motor Vehicle Accident, Congestive Heart Failure and Hypertension.

PI # 2's Physician Orders, dated 1/21/11, indicate PI # 2 was to be weighed on admission and weekly.

A review of PI # 2's medical record reveals no documented weight on admission or during the entire hospitalization.

During an interview on 3/10/11 at 1:40 PM, the Geriatric Psychiatric Nurse Manager/Employee Identifier (EI) # 1, confirmed there are no weights documented in PI # 2's medical record.

This citation is written as a result of the investigation of Complaint Number AL00023971.

Based on observation, interview and review of incident reports, the hospital failed to ensure the jagged, metal edges of the handles on two geri-chairs, used by geriatric patients, were covered to protect the skin integrity of the patients on the Geriatric Psychiatric Unit (GPU). This affected Patient Identifier (PI ) # 1, who sustained a one inch cut on his arm on 2/12/11 and has the potential to affect all GPU patients who utilize a geri-chair.

Findings Include:

PI # 1 was admitted to the hospital's Geriatric Psychiatric Unit (GPU) on 1/21/11 with Axis I diagnoses to include: Dementia, Multifactorial Etiology, Alzheimer's versus Secondary to Medical Condition with Delusions and Behavioral Disturbance, Delirium secondary to Medical Condition, resolving; Benzodiazapine Dependency and Depressive Disorder not otherwise specified by history. Axis II Diagnoses Include: Congestive Heart Failure, Hypertension, Chronic Obstructive Pulmonary Disease, Oxygen Dependent, Multiple Falls and Macular Degeneration.

A review of incident reports reveal PI # 1 received five skin tears during his hospitalization (1/21/11 through 2/24/11). The incident report dated 2/12/11, documents PI # 1 sustained a one inch cut on his arm from a "metal" chair when he attempted to ambulate without assistance.

On 3/9/11 at 9:45 AM, eights patients were observed in the day room. Five of the eight patients were sitting in geri-chairs.

During observation of the same day room on
3/9/11 at 11:20 AM two geri-chairs (currently
unoccupied) were seen with exposed metal
handles that were not covered. The edges of
the handles were rusted and jagged.

During an interview on 3/9/11 at 12:00 PM, the GPU Nurse Manager Employee Identifier (EI ) # 1, verified the condition (lack of protective covering) on the geri-chairs. According to the Manager, she had previously covered the exposed chair handles with foam, but the covering failed to stay secured to the handles.

This citation is written as a result of the investigation of Complaint Number AL00023955.