HospitalInspections.org

Based on review of medical records (MR), review of facility documents and interview with staff (EMP), it was determined that the facility failed to report and investigate injuries of unknown origin to rule out abuse for two of five medical records reviewed (MR1 and MR2).

Findings include:

1. Review of facility document "Abuse Reporting, Patient," dated May 2014, revealed " ... Investigation ... Reports of Abuse or Neglect which occur while the patient is hospitalized will be thoroughly investigated by the Risk Manager or other staff as assigned by the Chief Executive Officer. ... Interviews related to the investigation will be completed by the Risk Manager, Human Resources Manager or the Patient Advocate, as assigned by the Chief Executive Officer ... The investigation will be fully documented, including objective details of each interview. ... The investigation files will be maintained as Risk Management files by the Risk Manager. ... "

Review of MR1 psychiatrist progress note, dictated on July 6, 2015, at 10:58 AM, revealed " ... Interval History: ... My concern today is that [MR1] was found to have a large bump on [MR1] head, which is swollen, as well as bruises on [MR1] extremities. [MR1] has no idea how this happened. [MR1] does not know whether [MR1] had a fall. This is all because that [MR1] is quite demented. ... "

Review of MR2 physician assistant progress note, dictated on July 15, 2015, revealed " ... Interval History: ... Skin: Positive contusion on [MR2] right elbow with no tenderness to palpation and normal range of motion of the elbow. Also positive contusion of the left buttock with minimal tenderness to palpation. ... Assessment and Plan: ... 6. Contusions of unknown origin. ...We will monitor the bruises for resolution. ... "

Interview on August 31, 2015, at 11:00AM, with EMP6 confirmed that the injuries of unknown origin contained in MR1 and MR2 were not investigated to rule out abuse.

2. Review of facility document "Abuse Reporting, Patient," dated May 2014, revealed " ... Definitions: ... injuries of unknown sources mean injuries for which there is no known explanation for their cause or origin. ... Duty to Report: 1. All licensed health care facilities shall immediately report abuse, neglect or misappropriation of property to the adult protective services division. 2. All licensed health care facilities shall report ... injuries of unknown sources to the division within a twenty four (24) hour period. ... "

Review of MR1 psychiatrist progress note, dictated on July 6, 2015, at 10:58 AM revealed " ... Interval History: ... My concern today is that [MR1] was found to have a large bump on [MR1] head, which is swollen, as well as bruises on [MR1] extremities. [MR1] has no idea how this happened. [MR1] does not know whether [MR1] had a fall. This is all because that [MR1] is quite demented. ... "

Review of MR2 physician assistant progress note, dictated on July 15, 2015, revealed " ... Interval History: ... Skin: Positive contusion on [MR2] right elbow with no tenderness to palpation and normal range of motion of the elbow. Also positive contusion of the left buttock with minimal tenderness to palpation. ... Assessment and Plan: ... 6. Contusions of unknown origin. ...We will monitor the bruises for resolution. ... "

Interview on August 31, 2015, at 11:00AM, with EMP6 confirmed that MR1 and MR2 were identified with injuries of unknown origin and that the facility failed to report to the adult protective services division in accordance with facility policy.

Based on review of medical records (MR), review of facility documents and interview with staff (EMP), it was determined that the facility failed to develop and implement a nursing plan of care for anticoagulant therapy and risks associated with its use for one of five records reviewed (MR1).

Findings Include:

Review of facility document "Assessment / Reassessment," dated July 2015, revealed " Policy ... All patients admitted to the hospital will receive a thorough assessment and evaluation. Results of assessments are reviewed and integrated by the multidisciplinary team to prioritize identified problems within the Interdisciplinary Treatment Plan. ... "

Review of MR1 "Medical Progress Note," dated June 28, 2015, revealed " ... Assessment and Plan: ... 4. Anemia. Maintained on FeSO4 325 t.i.d. We will decrease that to once a day. ... 5. [MR1] is maintained on Coumadin. That is for history of pulmonary embolism. ..."

Review of MR1 psychiatrist progress note, dictated on July 6, 2015, at 10:58 AM, revealed " ... My concern today is that [MR1] was found to have a large bump on her head, which is swollen, as well as bruises on [MR1] extremities. [MR1] has no idea how this happened. [MR1] does not know whether [MR1] had a fall. This is all because that [MR1] is quite demented. As she is taking Warfarin, ... "

Review of MR1 laboratory study, dated June 29, 2015, revealed that the patient had a INR (International Normalized Ratio- measurement of blood clotting tendency of a person's blood- how thick or think the blood is) and a PT (Prothrombin Time- how long it will take for a person's blood to clot) test. The laboratory results revealed that the patient's INR was 1.62 (Reference Range .90 - 1.10) and Prothrombin Time was 19.10 (Reference Range 11.40 - 14.20 Seconds).

Review of MR1 laboratory study, dated July 2, 2015, revealed that the patient's INR was 3.20 (Reference Range .90 - 1.10) and Prothrombin Time was 32.50 (Reference Range 11.40 - 14.20 Seconds).

Review of MR1 laboratory study, dated July 6, 2015 that the patient's INR was 5.55 (Reference Range .90 - 1.10) and Prothrombin Time was 51.70 (Reference Range 11.40 - 14.20 Seconds).

Review of MR1 revealed no documented evidence that a plan of care was developed and implemented for anticoagulant therapy and risks associated with its use (bruising/bleeding, monitoring/notification of critical lab values, etc.).

Interview on August 31, 2015, at 1:10PM, with EMP5 confirmed that a nursing plan of care had not been developed.

Based on review of medical records (MR), review of facility documents and interviews with staff(EMP), it was determined the facility failed to maintain clear, complete and accurate documentation related to skin intergrity and evaluations of critical laboratory values for one of five medical record reviewed (MR1).

Findings Include:

Review of facility document "Assessment / Reassessment," dated July 2015, revealed " Policy ... All patients admitted to the hospital will receive a thorough assessment and evaluation. Results of assessments are reviewed and integrated by the multidisciplinary team to prioritize identified problems within the Interdisciplinary Treatment Plan. ... Reassessments ... Reassessments are completed by the RN on each shift on the 24 hour Nursing Reassessment form . In addition, each is reassessed as necessary based on the patient's plan for care or change in their condition ... "

Review of facility document "Critical Lab and Test Results," dated August 2015, revealed "... Definitions: Critical Test Results: A Test result that is beyond the normal variation whose values reflect an emergent situation including laboratory and imaging services provided through contractual agreement. ... Critical Test Notification: ... The contracted lab will notify the registered nurse via telephone of all critical lab results immediately upon receiving the results. ... Results of all lab tests will also print automatically at the Nurse's Station from the Lab. ... The RN will document the following information in the patient's medical record.
Date and time of the call.
Identification of person giving the information.
Documentation of critical lab value.
Verifying that the information was read back and verified.
Time and the date that the physician was notified of the critical value.
Orders from the physician as a result of the critical lab value. ..."

Review of MR1 revealed that the patient was admitted on June 26, 2015.

Review of MR1 laboratory study, dated June 29, 2015, revealed that the patient had a INR (International Normalized Ratio- measurement of blood clotting tendency of a person's blood- how thick or think the blood is) and a PT (Prothrombin Time- how long it will take for a person's blood to clot) test. The laboratory results revealed that the patient's INR was 1.62 (Reference Range .90 - 1.10) and Prothrombin Time was 19.10 (Reference Range 11.40 - 14.20 Seconds).

Review of MR1 laboratory study, dated July 2, 2015, revealed that the patient's INR was 3.20 (Reference Range .90 - 1.10) and Prothrombin Time was 32.50 (Reference Range 11.40 - 14.20 Seconds).

Review of MR1 laboratory study, dated July 6, 2015 that the patient's INR was 5.55 (Reference Range .90 - 1.10) and Prothrombin Time was 51.70 (Reference Range 11.40 - 14.20 Seconds).

Further review of MR1 revealed no evidence that nursing documented these critical labaratory values in the patient's medical record, nor was there documented evidence of the date, time or if the physician was notified of these critical values.

Interview on August 31, 2015, at 1:00PM, with EMP5 confirmed that there was no evidence that nursing documented these critical labaratory values in the patient's medical record, nor was there documented evidence of the date, time or if the physician was notified of these critical values.
Review of MR1 psychiatrist progress note, dictated on July 6, 2015, revealed " ... My concern today is that [MR1] was found to have a large bump on [MR1] head, which is swollen, as well as bruises on [MR1] extremities. ... "

Review of MR1 physician assistant progress note, dated on July 8, 2015, revealed " ... Examination: ... Skin: Two contusion on [MR1] forehead ... 2-3 small contusions on each forearm ... "

Review of MR1 physician assistant progress note, dated July 9, 2015, revealed " ... [MR1] has a large bruise on [MR1] forehead with contusions ... "

Review of MR1 "Nursing Reassessment," dated July 7, 2015, revealed " ... Medical Assessment: ... Skin: ... Normal ... "

Review of MR1 "Nursing Reassessment," dated July 8, 2015, revealed " ... Medical Assessment: ... Skin: ... Normal ... "

Review of MR1 "Nursing Reassessment," dated July 9, 2015, revealed " ... Medical Assessment: ... Skin: ... Pink / Normal ... "

Review of MR1 "Nursing Reassessment," dated July 10, 2015, revealed " ... Medical Assessment: ... Skin: ... Pink / Normal ... "

Interview on on August 31, 2015, at 1:15 PM with EMP5, confirmed that the medical record did not contain accurate information related to the patient's change in skin intergrity.

Based on review of medical records (MR), review of facility documentation and interviews with staff (EMP), it was determined that the facility failed to provide necessary medical information for follow-up care for one of five medical records reviewed (MR1).

Findings include:

Review of facility policy "Discharge/Aftercare Plan," dated May 2014, revealed "Policy ... The physician and therapist, with the support of nursing, coordinate the discharge arrangements with the patient and family. Certain dispositions/discharge needs may be considered for the patient, including a return to the home, placement in an Assisted Living or Skilled Nursing Facility, partial hospitalization, outpatient therapy, community programs and support groups, transportation, medical follow-up, and aftercare programs.
The facility ensures that appropriate patient care and clinical information is exchanged when patients are referred, transferred, or discharged to include: reason for transfer, referral or discharge, patient's physical and psychosocial status, summary of care provided and progress toward goals, and community resources and referrals provided to the patient. ... "

Review of MR1 revealed that the patient was discharged to a long term care facility on July 10, 2015. Further review of MR1 revealed no documented evidence that the facility provided necessary medical information, related to the patient sustaining injuries of unknown origin and critically high laboratory values, to the long term care facility.

Interview on August 31, 2015, at 10:45 AM, with EMP1 confirmed that the facility transferred the patient back to long term care facility but failed to provide information, related to injuries of unknown origin and critical laboratory values, to the receiving facility.