HospitalInspections.org

Based on document review and interview it was determined that for 1 of 2 (Pt #1) clinical records reviewed for resolution of a grievance, the Hospital failed to ensure that the patient (Pt #1) received written notice of it's decision that contains the name of the hospital, contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

Findings include:

1. The Hospital's policy titled, "Patient Complaints and Grievances" (revised 7/19) was reviewed on 11/19/19 at approximately 10:10 AM, and included, " ...4. The Grievance Committee will respond to the complainant in writing within seven (7) days ...5. In its resolution of the Grievance, the ...committee will provide the patient with a written notice of the Hospital's decision that includes the name of the hospital contact person, the steps taken on behalf of the patient to investigate ...the results of the grievance process, and the date of completion ...6. All documentation of investigations, resolutions and patient communication will be maintained by the ...committee ..."

2. The clinical record for Pt #1 was reviewed on 11/19/19. Pt # 1 presented to the Emergency Department (ED) on 10/16/19 at 2:53 PM and was admitted to the Psychiatric unit at 9:40 PM.

-The ED History and Physical Note dated 10/16/19 at 2:45 PM, was reviewed and included, "Chief Complaint: Psychiatric Evaluation; Review of Systems - Musculoskeletal: no symptoms reported; Skin: no symptoms reported-normal to inspection, normal color, warm/dry; Progress: Patient (Pt #1) is medically cleared for Psych (Psychiatric Unit) ..."

-The Nursing Admission Assessment dated 10/16/19 at 9:40 PM, was reviewed and included, "Reason for Admission: Aggressive Behavior, Verbally and Physically. Patient NH (Nursing Home) Petitioned ...Pain due to Neuropathic (nerve pain) Pain in legs ...Musculo-skeletal: No deformities, pain or stiffness noted on Initial Nursing Assessment ..."

-The History and Physical Note dated 10/17/19 at 9:44 PM, was reviewed and included, "56-year-old, with long history of psychiatric problems, bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder (persistent feeling of sadness) was brought to the emergency room ...for aggressive behavior ...Complaints of pain in the right hand. According to patient, someone slammed the door on his right hand this morning. Patient (Pt #1) just had x-rays taken and pending results ...PLAN: Referral to Orthopedic Service for right hand proximal phalanx fracture ..."

3. Interviews were conducted with the Chief Nursing Officer (E #1). On 11/19/19 at 1:20 PM, 2:58 PM and on 11/201/9 at approximately 9:30 AM. E #1 stated, "Myself and the House Supervisor were notified by Pt #1's Nurse on 10/17/19 at approximately 6:00 PM that the patient (Pt #1) was reporting an incident that occurred that morning around 8 AM... I will be honest with you, I did not send a follow up letter or resolution letter to the patient (Pt #1), but I did discuss my findings with the patient over the phone..."

Based on document review and interview, it was determined that for 1 of 1, (Pt #1) clinical record reviewed with a patient with complaint of finger pain, Hospital failed to ensure the patient was provided care in a safe setting, to prevent injury.

Findings include:

1. The Hospital's policy titled, "Patient Rights and Responsibilities (revised 3/19) included, " ...7. Receive considerate and respectful care in a safe setting ..."

2. The clinical record for Pt #1 was reviewed on 11/19/19. Pt # 1 presented to the Emergency Department (ED) on 10/16/19 at 2:53 PM with chief complaint of Psychiatric Evaluation and was admitted to the Psychiatric Unit at 9:40 PM.

-The ED History and Physical Note dated 10/16/19 at 2:45 PM, was reviewed and included, "Chief Complaint: Psychiatric Evaluation; Review of Systems - Musculoskeletal: no symptoms reported; Skin: no symptoms reported-normal to inspection, normal color, warm/dry; Progress: Patient (Pt #1) is medically cleared for Psych (Psychiatric Unit) ..."

-The Nursing Admission Assessment dated 10/16/19 at 9:40 PM, was reviewed and included, "Reason for Admission: Aggressive Behavior, Verbally and Physically. Patient NH (Nursing Home) Petitioned ...Pain due to Neuropathic (nerve pain) Pain in legs ...Musculo-skeletal: No deformities, pain, or stiffness pain noted on Initial Nursing Assessment ..."

-The History and Physical Note dated 10/17/19 at 9:44 PM, (three hours after Pt #1 complained of pain) was reviewed and included, "56-year-old, with long history of psychiatric problems, bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder (persistent feeling of sadness) was brought to the emergency room ...for aggressive behavior ...Complaints of pain in the right hand. According to patient, someone slammed the door on his right hand this morning (10/17/19). Patient (Pt #1) just had x-rays taken and pending results..."

-A Radiology Report dated 10/17/19 at 7:12 PM, was reviewed and included, "X-Ray of Right Hand: INDICATION: Pain and Swelling ...IMPRESSION: Mildly displaced fracture of the proximal phalanx of the right fifth digit ..."

3. Interviews were conducted with the Chief Nursing Officer On (CNO-E #1) 11/19/19 at 1:20 PM, 2:58 PM and 11/201/9 at approximately 9:30 AM. E #1 stated, "Myself and the House Supervisor were notified by the patient's (Pt #1) Nurse on 10/17/19 at approximately 6:00 PM, that the patient was reporting an incident that occurred that morning around 8:00 AM...The patient (Pt #1) should not have gottten a fractured finger while being hospitalized, he came here with a chief complaint of aggressive behavior, there was no documentation that shows the patient (Pt #1) had a fractured finger when admitted..."

4. On 11/20/19 at approximately 10:55 AM, an interview was conducted with a Registered Nurse (RN-E #5). E #5 stated, "I was the assigned nurse for this patient (Pt #1) but I was not present during the incident. I did not become aware of this incident until later that night. The patient (Pt #1) complained of pain and asked for pain medication, I asked the patient (Pt #1) where the pain was...The patient (Pt #1) stated that, Frank (no staff or patient by this name on the unit) slammed the door on patient's (Pt #1's) hand...The patient (Pt #1) was taken down to x ray after the doctor evaluated the patient (Pt #1) and the x-ray showed a fracture..."