HospitalInspections.org

Based on medical record review, review of outside facility medical records, and interview, the facility failed to ensure a patient received care in a safe setting by not assessing and addressing an injury of unknown origin for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Medical record review for Patient #1 revealed an admission date of 11/16/2021 with diagnoses which included Altered Mental Status, Acute Metabolic Encephalopathy, Acute Urinary Tract Infection (UTI), Atrial Fibrillation with Rapid Ventricular Response, Chronic Diastolic Congestive Heart Failure, and Dementia.

Physician #1 initiated a medical screening exam on 11/16/2021 at 7:05 PM. Physician #1 documented that Patient #1 had a history of dementia but "reportedly can communicate...who presents with being found to quote just moan quote today [sic]..." Physician #1 documented on the physical exam, "...Head: atraumatic, normocephalic...Skin: warm and dry..." There was no documentation of bruising or hematoma by Physician #1.

After presentation to the Emergency Department (ED), Nurse #1 assessed Patient #1 on 11/16/2021 at 8:07 PM and documented that Patient #1's skin was warm and dry with skin color within expectations for ethnicity. There was no documentation of bruising or hematoma by Nurse #1.

Patient #1 was admitted to the medical/surgical unit of the hospital and was transferred from the ED to the floor on 11/17/2021 at 1:27 AM.

Physician #2 documented a physical exam in the history and physical on 11/16/2021 at 11:45 AM, "...Head/Eyes: atraumatic...normocephalic...Skin: dry, intact..." There was no documentation of bruising or hematoma by Physician #2.

Nurse #2 documented an admission assessment on 11/17/2021 at 1:42 AM that Patient #1's skin was warm and dry with skin color within expectations for ethnicity and no skin alteration. There was no documentation of bruising or hematoma by Nurse #2.

Nurse #3 documented an assessment for Patient #1 on 11/17/2021 at 8:00 AM, "...SKIN ALTERATION...Present/Exists...Bruise Anterior Head/neck...Tissue type-worst: Purple/maroon/deep red...Bruise Generalized...Tissue type-worst: Purple/maroon/deep red..."

Physician #3 documented in a progress note on 11/17/2021 at 1:00 PM, "...this morning the pt [patient] says that she is feeling okay, no problems..." Physician #3 documented on the physical exam, "...Head/Eyes: atraumatic...normocephalic...Skin: dry, intact..." There was no documentation of bruising or hematoma by Physician #3.

Nurse #4 documented an assessment for Patient #1 on 11/17/2021 at 8:05 PM, "...SKIN ALTERATION...Present/Exists ...Bruise Anterior Head/neck ...Tissue type-worst: Purple/maroon/deep red...Bruise Generalized...Tissue type-worst: Purple/maroon/deep red..."

Nurse #5 documented an assessment for Patient #1 on 11/18/2021 at 7:47 AM, "...SKIN ALTERATION...Present/Exists...Bruise Anterior Head/neck...Tissue type-worst: Purple/maroon/deep red...Bruise Generalized...Tissue type-worst: Purple/maroon/deep red..."

Physician #4 documented in a progress note on 11/18/2021 at 8: 40 AM that Patient #1 was feeling well with no complaints. Physician #4 documented on the physical exam, "...Head/Eyes: atraumatic...normocephalic...Skin: dry, intact..." There was no documentation of bruising or hematoma by Physician #4.

Nurse Practitioner #1 documented in a progress note on 11/18/2021 at 10:36 AM that Patient #1 was currently lying in bed in no acute distress and denies any complaints. Nurse Practitioner #1 documented on the physical exam, "...Head/Eyes: atraumatic...Skin: dry..." There was no documentation of bruising or hematoma by Nurse Practitioner #1.

Physician #5 documented an addendum at 1:42 PM to Nurse Practitioner #1's progress note on 11/18/2021, "[Patient #1] has large diffuse ecchymosis and scalp hematoma (CT [computerized tomography] head OK) thus no longer a candidate for A/C [anticoagulant]."

Physician #4 documented the discharge summary on 11/18/2021 at 11:46 AM including a problem list, hospital course, and physical exam. There was no documentation of bruising or hematoma by Physician #4 in the discharge summary.

2. Review of the medical record from Memory Care Facility #1 revealed a progress note dated 11/16/2021 at 6:49 PM, "...Went in to administer evening meds [medications] and found resident lying on her bed. [Patient #1] was lethargic and nonverbal except for moaning with movement. Eyes closed, skin warm and dry...Contacted [Family Member #1], instructed to send to [Hospital #1] for eval. [evaluation]..." There was no documentation of bruising or hematoma at Memory Care Facility #1 prior to admission to Hospital #1.

A progress note dated 11/18/2021 at 7:35 PM revealed, "Alert charting for recent admission to hospital for UTI and subsequently fell causing left facial hematomas. [Patient #1] is at this time total care and difficult to feed or medicate due to confusion and weakness. [Family Member #2] brought medications and...was unaware of fall in hospital..." There was no documentation at Hospital #1 that Patient #1 had fallen.

3. During an interview on 5/10/2022 at 12:30 PM, the Patient Safety Director stated she spoke with Family Member #1 about concerns for Patient #1's care. The Patient Safety Director stated Family Member #1 questioned when and how Patient #1 sustained the bruising and hematoma to her head and neck area. The Patient Safety Director stated she reviewed the medical record and did not find documentation about any bruising or hematomas.

During a phone interview on 5/10/2022 at 1:15 PM, Family Member #1 stated she spoke with the Patient Safety Director and wanted to send photographs of Patient #1 which showed the bruising and hematoma, but the Patient Safety Director was not interested in seeing them. Family Member #1 stated the Patient Safety Director told her that maybe Patient #1 came to the hospital that way with the bruises and hematoma already in existence. Family Member #1 stated that was not true and that Patient #1 sustained the bruising and hematoma during hospitalization.

During an interview on 5/11/2022 at 9:15 AM, the Director of Nursing (DON) for Memory Care Facility #1 stated she had not seen Patient #1 on the day the patient was sent to the hospital (11/16/2021) but had seen her a couple days before that. The DON stated Patient #1 did not have any significant bruising on her arms and did not have any on her head and neck when she last saw Patient #1. The DON stated she and the staff were shocked at Patient #1's appearance when she arrived at the facility from the hospital on 11/18/2021. The DON stated Patient #1 had significant bruising to the left side of her head and neck area.

During an interview on 5/11/2022 at 10:16 AM, the Nurse Manager for the Medical/Surgical Unit stated nursing staff should notify the hospital physician if they discover bruising on a patient. The Nurse Manager stated Nurse #3 documented bruising to Patient #1's head and neck area and generalized bruising that had not been documented on previous assessments. The Nurse Manager stated that no staff entered an event into the computer system to explain how Patient #1 sustained the bruising and hematoma.

During a phone interview on 5/11/2022 at 10:24 AM, Physician #4 stated she did not see any documentation in her notes about Patient #1 having any bruising or hematoma. Physician #4 stated she did not remember Patient #1 having any bruises or hematomas.