HospitalInspections.org

Based on policy review and medical record reviews, the facility failed to protect and promote each patient's rights to receive care in a safe setting by failing to document/conduct an investigation for injuries of unknown origin (A0144). The cumulative effects of these systemic practices resulted in the facility's inability to ensure patients receive care in a safe setting. This had the potential to affect the facility's 54 patients.

Based on medical record reviews and policy review, the facility failed to document/conduct an investigation for injuries of unknown origin for one patient (Patient #4) of 10 medical records reviewed. This had the potential to affect all of the facility's 54 patients.

Findings include:

The facility's Patient Right policy (# RR-01, Created 01/19/18) stated:
Each patient has the right to receive care in a safe and clean setting.

The facility's Incident and Risk Management policy ( LD #2, Effective 07/09/20) stated:
Purpose:
To require review and analysis of all incidents to assure identification and implementation of corrective measures designed to prevent recurrence and manage risk.
POLICY:
Any incident out of the normal operations of the program shall be reported to the Supervisor. The Supervisor shall determine the level of incident and reporting necessary based upon regulatory guidelines and organizational internal reporting.
DEFINITIONS:
"Incident" means an event that poses a danger to the health and safety of patients or staff and
visitors of the provider and is not consistent with routine care of persons served or routine
operations of the provider.
PROCEDURE:
Any staff member who is aware of any incident out of the normal activities of the
program/environment, shall report the incident utilizing a paper incident reporting form to the
Supervisor. The Supervisor shall review the incident, investigate all circumstances related to the incident, interview any individuals related to the incident, collect statements from any witnesses to any incident, and analyze the information collected.
o An incident report shall be submitted in written form to the Supervisor within twenty-four hours of discovery, unless on the weekend. The Supervisor will determine level of reporting necessary as next steps as needed.
o Any reportable incidents will be reviewed and analyzed monthly to determine required performance improvement initiatives.
o The Supervisor will maintain an ongoing log of its reportable incidents for departmental review.

The medical record of Patient #4 contained a Nursing Progress Notes on 10/07/20 for the 7:00 AM - 7:00 PM shift. The note stated Patient #4 had several bruises on his left shoulder, elbow, knee and swollen lip but could not tell staff how he got them.

A Progress Note by Staff C on 10/07/20 stated:
SKIN: Warm and dry. There are some bruised areas noted to left shoulder, left elbow, left hip and left knee.

A Progress Notes Form from 10/07/20 at 3:30 PM stated:
Addendum
- Bruises on left elbow

A Nursing Transfer Transition Form from 10/07/20 at 4:30 PM reported the reason for transfer was altered mental status, blood pressure of 80/60 and confusion. Skin abnormalities were indicated as bruising to the left side of the face and arms.

The facility's incident report logs were reviewed. The logs did not contain an investigation or report of Patient #4's bruises

The medical record of Patient #4 from Facility B was reviewed. A Critical Care Consult note on 10/08/20 at 4:57 AM stated:
Patient #4 presented to the facility for altered mental status and bruising. The patient also woke up with bruising to the left side of his body that the staff were unsure how he got.
Physical Exam:
· Skin: Ecchymoses of varying all over the body. Ecchymosis to the left lower leg, thigh, hip and the right lateral thigh.
· Head: Ecchymosis to the left mandible. Normocephalic
Patient #4 was diagnosed with a closed left hip fracture, present on admission, on 10/07/20 at Facility B. A CT of the head showed a tiny 4 mm left frontal, parietal, and temporal subdural collection, likely chronic subdural hematoma.
An Emergency Department Provider Note on 10/07/20 at 4:19 PM stated:
74-year-old male with past medical history Alzheimer's dementia, diabetes type 1. Presented to the emergency department due to concerns for worsening mentation. Patient was noted to be extremely confused, lethargic. On presentation patient was noted to also have left-sided bruising of the hip, upper extremity and knee. Patient could not tolerate movement of his lower extremity. Patient is unable to answer any questions.
A Discharge Summary from Facility B stated:
Hospital Course:
**fall *sustained a fracture of his left femur and was also found to be in DKA. He was a resident at Facility A when this occurred. He has dementia, that has gotten worse.
Patient #4 was transferred to a Hospice facility on 10/08/20.