HospitalInspections.org

Based on facility medical record review and staff interviews the facility failed to ensure patient received care in a safe setting.
The findings include:
Medical record reviewed on February 21, 2012 of patient #1 revealed nurse assessment on January 13, 2012 at 0700 it was noted patient having some redness to his left face area. Upon assessment, redness with some swelling noted to left side of face; some crusting and redness noted to conjunctiva area of left eye. Physician evaluation on January 13, 2012 at 12:40 pm revealed There is significant swelling in the mild subtle erythema in that area and mild crossing of the conjunctiva and erythema of the conjunctiva in that eye. Plan: I suspect the patient has a periorbital soft tissue infection, but it is possible the patient also had trauma causing this findings on the physical examination. Physician progress note on January 14, 2012 at 10:05 pm problem list includes facial trauma, aggressive disorder, hypertension and mental retardation.
During interview with staff #1 on February 21, 2012 at 09:30 am, staff #1 stated that the internal investigation was inconclusive and were unable to identify how patient sustained facial trauma.