HospitalInspections.org

30984

Based on observations and interviews, the hospital failed to ensure that patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for acute care geriatric psychiatric patients.

Findings:

On 8/22/16 from 10:00 a.m. - 10:35 a.m. the following observations were made in patient rooms:
a.Room numbers 101-106: beds with metal frames, springs and three hand-cranks at the foot of each of the beds- potential ligature points and potential means for self harm. Patient rooms 101,102 and 104-106 had 2 patient beds. Room 103 had only one patient bed.

In an interview on 8/22/16 at 10:23 a.m. with S2DON, she confirmed all of the findings referenced above. She indicated the hospital had planned to replace all of the beds with platform beds.

b.Room numbers 101-108: 9 screws (not tamper resistant) were noted in the double windows/window frames in all of the patient rooms.

In an interview on 8/22/16 at 10:25 a.m. with S2DON, she confirmed the screws in the double windows/window frames in all of the patient rooms were not tamper resistant screws.

30984

Based on record review and interview, the hospital failed to ensure the use of restraints were in accordance with a written modification to the patient's treatment plan for 2 of 2 (#4, #5) sampled patients with restraints out of a total sample of 5 (#1-#5).
Findings:

Review of the hospital's policy titled, Seclusion and Restraints, Policy Number CS-26, revealed in part the following: Therapeutic Holding is holding a patient in a manner that restricts the patient's movement against the patient's will. Therapeutic holding is considered a restraint. The policy revealed part of the documentation of restraints/seclusion included the treatment plan was to be evaluated and changed if necessary. Review of the policy revealed no time frame for written modification of the treatment plan.

Patient #4
Review of the medical record for Patient #4 revealed the patient was a 91 year old admitted from a skilled nursing facility to the hospital on 08/10/16 with a diagnosis of Delusional Disorders.
Review of the physician's orders revealed the following Seclusion/Restraint orders for Therapeutic hold (time limit 1 minute) dated 8/20/16 at 10:14 p.m. The seclusion/restraint orders had been obtained due to the patient had acute agitation, was physically aggressive, was trying to hit staff and others, and was trying to run people over with wheelchair. The record revealed the patient's behaviors had not been mitigated by therapeutic interventions.
Review of the Treatment Plan of Care for Patient #4 revealed the Therapeutic hold ordered/initiated on 8/20/16 at 10:14 p.m. had not been documented/initiated as a written modification to the patient's treatment plan.

In an interview on 08/23/16 at 12:37 p.m. S2DON reviewed the medical record for Patient #4 and confirmed a therapeutic hold was done on 8/20/16. S2DON confirmed the patient's treatment plan was not updated with the use of the restraint of therapeutic hold and stated it should have been.

Patient #5
Review of Patient #5's medical record revealed an admission date of 8/2/16 with an admission diagnosis of Dementia.
Review of Patient #5's physician's orders revealed the following Seclusion/Restraint orders for Therapeutic holds (time limit less than 3 minutes) dated 8/02/16 at 11:10 p.m., on 8/3/16 at 12:30 a.m., and 8/09/16 at 10:28 a.m. The seclusion/restraint orders had been obtained due to the patient's aggressive/violent behavior that had not been mitigated by therapeutic interventions.
Review of the Treatment Plan of Care for Patient #5 revealed the Therapeutic holds (defined as a restraint per hospital policy) ordered/initiated on 8/02/16 at 11:10 p.m., 8/03/16 at 12:30 a.m., and 8/09/16 at 10:28 a.m. had not been documented/initiated as a written modification to the patient treatment plan.
In an interview on 8/23/16 at 12:49 p.m. with S2DON, she confirmed therapeutic holds were considered restraints. S2DON indicated the therapeutic holds referenced above should have been included as a written modification to the patient's treatment plan.

Based on observation, record review and staff interview, the Hospital failed to ensure the Registered Nurse (RN) supervised and evaluated the nursing care for each patient as evidenced by:
1) Failure to complete a patient incident and occurrence report as directed per hospital policy for 1 (#1) of 2 (#1, #5) patients reviewed for incident reporting out of a total sample of 5 (#1-#5) patient records reviewed;
2) Failure to perform descriptive, detailed skin assessments for 5 of 5 (#1-#5) sampled patient records, and;
3) Failure to document blood pressure and pulse prior to administering medications for 3 (#1, #4, #5) of 4 (#1, #2, #4, #5) sampled patients reviewed for monitoring of medications out of a total sample of 5.


30984

1) Failure to complete a patient incident and occurrence report as directed per hospital policy:
Review of the hospital policy titled, Patient Incident and Occurrence Reporting Policy Number: EOC-13, revealed in part: Purpose : To document any potential or adverse occurrence within the facility or on the facility grounds/property/vehicle, with facts available at the time, recorded by persons involved, either in the incident or discovery of the incident. Policy: Facility staff will report all patient occurrences through the use of the facility's incident reporting form. A patient incident or occurrence is anything that is out of the expected norm for the patient (example: elopement, fall, medication error, altercation, psychiatric emergency).

Patient #1
Review of Patient #1's medical record revealed an admission date of 7/28/16 with an admission diagnosis of major depressive disorder recurrent with severe psychosis.
Further review revealed the patient had become physically aggressive toward staff on 7/31/16 at 9:15 p.m. The patient punched the MHT with closed fists, and kicked the MHT. During the altercation the patient sustained an approximately 2 cm cut to the left middle finger with a scant amount of bleeding.
Review of the incident report log, presented by S2DON, revealed no documented evidence that an incident report had been initiated for the incident that occurred on 7/31/16 at 9:15 p.m.
In interview on 8/23/16 at 12:35 p.m. with S2DON, she indicated the incident on 7/31/16 in which the patient sustained an injury (lacerated finger) should have generated an incident report. S2DON confirmed there was no documented evidence of an incident report being generated for the incident that occurred on 7/31/16.


2) Failure to perform descriptive, detailed skin assessments:
Review of the Hospital's policy titled, Skin/Wound Care Protocol, Policy Number NS-39, revealed in part the following: A weekly skin assessment is completed by the nurse on all patients.
Review of the Hospital's policy titled, Anticoagulation Therapy, Policy Number MM-13 revealed in part the following: The facility will assess patients for possible complications related to anticoagulation therapy....Bleeding Precautions: Daily assessment by nursing for sings of increased bleeding such as bruises, tarry stool, pinpoint red spots on skin, blood in urine, etc.

Patient #1
Review of Patient #1's medical record revealed an admission date of 7/28/16 with an admission diagnosis of major depressive disorder recurrent with severe psychosis.
Review of Patient #1's medical record revealed the patient was receiving 325 mg of ASA (Aspirin) daily as anticoagulant therapy for treatment of Atrial Fibrillation.
Further review revealed the patient had sustained the following injuries during altercations/while exhibiting aggressive behaviors: 7/29/16: Bilateral upper arm bruising and scratches; 7/31/16: 2 cm laceration to left middle finger; 8/01/16: swollen right hand/finger requiring medical evaluation and x-ray; 8/05/16: 1 scabbed areas less than 1 cm on right forearm and 2 scabbed areas less than 1 cm on the left forearm with scant blood. Additional review revealed no documented evidence of a full body, head to toe skin assessment after the patient was injured. The bruising sustained by the patient was not described with detail to include color or size as directed per hospital in-service information.

Patient #2
Review of Patient #2's medical record revealed an admission date of 8/16/16 with an admission diagnosis of major depressive disorder recurrent.
Review of Patient #2's medical record revealed the patient was receiving 325 mg of ASA daily as anticoagulant therapy for treatment of Atrial Fibrillation.
On 8/22/16 at 10:00 a.m. an observation was made of Patient #2. Multiple scratch-like purplish-red abrasions were observed on the both of the patient's shins.
Further review of Patient #2's medical record revealed the multiple deep red scratches observed on the patient's bilateral lower legs (on his shins) were not documented in descriptive terms indicating color, size and specific location.
In an interview on 8/22/16 at 4:21 with S3LPN, she indicated Patient #2 scratches his legs. S3LPN confirmed the skin scratches on Patient #2's legs should have been documented on a skin assessment in descriptive terms indicating color, size and specific location.

Patient #3
Review of the medical record for Patient #3 revealed the patient was a 97 year old admitted from a skilled nursing facility to the hospital on 07/21/16 with a diagnosis of Dementia with Behavioral Disturbances. Review of the Psychiatric Evaluation dated 07/22/16 revealed the patient had increasing aggression and agitation and the patient was involved in an altercation with another resident at the skilled nursing facility. Review of the admission orders dated 07/21/16 revealed "Bleeding Precautions" was ordered due to the patient was taking Xarelto, an anticoagulant medication (blood thinner).
Review of the Initial Nursing Assessment dated/timed 07/21/16 at 11:45 p.m. documented by S5RN revealed a diagram of the front and back of the body that had the back of the arms circled from the mid upper arm to the finger tips. Hand written above the circled area was, "Small scars and red discoloration to BUE." The front diagram also revealed "Small red areas r/t shoes" with an X marked on both feet below the great toe. An area was circled from the mid upper leg to the toes and hand written beside the circled area was, "Dark Discoloration to BLE." There was no documentation in the initial nursing assessment of a description of the discolored areas to include the size, color and specific location.

Review of the Skin and Braden Reassessment Documentation dated/timed 07/23/16 at 9:30 a.m. documented by S4RN revealed the diagram of the back of the body had areas circled from the mid-upper arm to the fingertips. Hand written above the circled areas was, "Multiple discolorations bruises." The diagram of the front of the body revealed a "Scratch" was indicated on the right lower extremity, "discolored" area was marked on the left leg below the knee, and "Reddened spots top of foot and medial aspect of bilateral great toes" was hand written in. There was no documentation in the skin assessment of a description of the discolored areas, and there was no documentation of any measurements of the areas.
Review of the Skin and Braden Reassessment Documentation dated/timed 07/26/16 at 6:00 a.m. documented by S6RN revealed the Skin Assessment section was documented as D/C Skin Assessment. Review of the diagram of the back of the body revealed it was left blank with no findings marked. Review of the front of the diagram revealed a line drawn on the right chest with "Scar" hand written over the line. The diagram also revealed multiple circular areas drawn over both forearms below the elbows with "Bilateral UE Bruising" documented beside the arms. Also hand written beside the diagram was the following, "Redness to scrotum, discoloration to BLE/feet, 2+ pitting edema to bilateral feet, discolored, thick toenails." There was no documentation in the skin assessment of a description of the discolored areas, and there was no documentation of any measurements of the areas.

Further review of the patient's record revealed the Daily Nurse Note was documented for each 12 hour shift. Review of the Daily Nurse Notes for Patient #3 from 07/21/16 to 07/26/16 revealed Bleeding Precautions was checked on some notes, but not all. Review of the notes revealed "Bruises" was checked on some notes, but not all. Review of all the Daily Nurse Notes revealed no documented evidence of the size, color or location of the "Bruises" checked by the RN.

In an interview on 08/22/16 at 3:48 p.m. with S4RN she stated the nurses do a head to toe assessment on admission and every Saturday. S4RN confirmed they do not document where the bruise is located or a description of the bruise. After reviewing the 07/23/16 skin assessment for Patient #3, S4RN stated when she circled the forearms the whole area had discoloration. She stated they were probably purplish bluish, and stated if it was a different color she would have documented that. Confirmed on this date the patient had multiple bruises on the front and back of his forearms.

In a telephone interview on 08/23/16 at 8:13 a.m., S6RN confirmed she had done the discharge skin assessment for Patient #3. S6RN stated the patient had bruises on his arms, "A lot of red bruising from his hands to mid upper arms." S6RN confirmed the skin assessment did not include measurements or specific descriptions of the bruising and discolored areas.

In an interview on 08/23/16 at 1:00 p.m. S2DON confirmed she had reviewed the skin assessments for Patient #3 and stated the documentation did not reflect the appearance of the patient's skin. She stated she knew what the patient's skin looked like on admission and at discharge and the record did not accurately reflect that. S2DON confirmed the areas of discoloration should have been documented in descriptive terms indicating color, size and specific location. After reviewing the Daily Nurse Notes for Patient #3, S2DON confirmed the Bleeding Precautions and Bruises were checked on some of the notes but not all. S2DON confirmed there was no documentation of the size, color, or location of the bruises checked by the RN.


Patient #4
During an observation of the unit on 08/22/16 at 9:55 a.m., Patient #4 was observed sitting in a wheelchair in the group room. The patient was observed to have multiple bluish colored bruises on her right forearm.
Review of the medical record for Patient #4 revealed the patient was a 91 year old admitted from a skilled nursing facility to the hospital on 08/10/16 at 3:30 p.m. with a diagnosis of Delusional Disorders. Review of the physician orders dated 08/12/16 revealed Bleeding Precautions was ordered due to the patient had Leukopenia and Thrombocytopenia (Low White Blood Cell Count and Low Platelet Count).
Review of the Initial Nursing Assessment dated/timed 08/10/16 (Wednesday) at 6:30 p.m. revealed a diagram of the front and back of the body that indicated there were no skin issues to either of the patient's upper extremities. Review of the Skin and Braden Reassessment Documentation revealed no documented evidence of a Skin Assessment on 08/13/16 (Saturday). Review of the only Skin and Braden Reassessment Documentation on the record revealed on 08/20/16 (Saturday, 10 days after admission) at 9:26 a.m. the patient had, "Large purple discoloration" to the front and back of the right forearm. Further review of the record revealed no documented evidence of when the bruises were initially identified or how the patient sustained the bruising.
Review of the Daily Nurse Notes for Patient #4 from 08/12/16 to 08/22/16 revealed Bleeding Precautions was checked on some notes, but not all. Review of the Daily Nurse Notes revealed "Bruises" was checked on some notes, but not all. Review of all the Daily Nurse Notes revealed no documented evidence of the size, color or location of the "Bruises" checked by the RN.

Review of the incident reports for August, 2016 revealed no documented evidence of an incident report for Patient #4.

In an interview on 08/22/16 at 3:48 p.m., S4RN stated the nurses do a skin assessment, head to toe of all the patients on admit and every Saturday. She stated even if patient comes in on a Friday they are to be assessed the next day (Saturday). S4RN stated the assessment is documented on the Skin and Braden Reassessment form. S4RN confirmed they do not document where the bruise is located or a description of the bruise. S4RN stated if new bruises are noted on weekly assessments the nurse would do follow up to determine how it came about.

In an interview on 08/23/16 at 12:37 p.m., S2DON reviewed the medical record for Patient #4 and confirmed a skin assessment should have been done on 08/13/16. She stated skin assessments are done on admit, every Saturday regardless of when the patient was admitted, and again at discharge. S2DON confirmed there was no documented evidence of how the patient sustained the bruises to the right forearm and confirmed the admission assessment indicated there were no bruises to the forearm. S2DON confirmed the nurses did not consistently document the patient was on Bleeding Precautions. S2DON confirmed although "Bruises" was checked on some of the Daily Nurse Notes, there was no documentation of the color, size, or location of the bruises. S2DON confirmed there was no incident report documented for Patient #4.


Patient #5
Review of Patient #5's medical record revealed an admission date of 8/02/16 with an admission diagnosis of Dementia.
Review of Patient #5's medical record revealed the patient was receiving 81 mg of ASA (Aspirin) daily as anticoagulant therapy for treatment of Atrial Fibrillation.
Further review revealed Patient #5 had sustained the following injuries during altercations/while exhibiting aggressive behaviors: 8/02/16: Skin tear times 1, 0.25 cm by 0.25 cm noted with flap in place and scattered red bruising to bilateral upper extremities; and 8/16/16: bleeding from scratch on top of nose and from 2 small scratches to left elbow.
Review of Patient #5's medical record revealed the bruising sustained by the patient during the above referenced altercations was not documented in descriptive terms indicating size and specific location (such as shins, calves, below the knee). Further review revealed the nursing staff failed to perform a full head to toe skin assessment after the patient sustained injuries on 8/02/16 and 8/16/16.
In an interview on 8/23/16 at 12:49 p.m. with S2DON, she indicated baseline bruising evaluations should have been assessed and described in descriptive terms specifying color, size and location. She also indicated the progression and/or healing of bruises should have been documented every shift. S2DON indicated findings of bleeding/bruising should have been documented in descriptive terms in the patients' medical records. She further indicated policy may not necessarily direct nursing staff to perform a full skin assessment after an incident with injury, but her expectation is that good nursing judgment would guide the nursing staff to perform and document a full skin assessment post incident with injury.


3) Failure to document blood pressure and pulse prior to administering medications:
Patient #1
Review of Patient #1's medical record revealed the patient had a co-morbid diagnosis of Hypertension.
Review of Patient #1's medication administration record revealed the patient was receiving the following medications for Hypertension management:
Norvasc 5 mg by mouth daily at 9:00 a.m.;
Lisinopril 40 mg by mouth daily at 9:00 a.m.;
Coreg 12.5 mg by mouth twice a day at 9:00 a.m. and 9:00 p.m.

Additional review of the patient's medication administration record and nursing notes revealed no documented evidence the patient's blood pressure had been assessed and documented prior to administration of the medication. Further review of the patient's medication administration record revealed an order for blood pressure checks every shift, but no specific times were documented to indicate when the patient's blood pressure had actually been taken.


Patient #4
Review of the medical record for Patient #4 revealed the patient was a 91 year old admitted from a skilled nursing facility to the hospital on 08/10/16 at 3:30 p.m. with a diagnosis of Delusional Disorders. The patient's medical diagnoses included Hypertension, Diabetes Mellitus, Type II, and Atrial Fibrillation.

Review of Patient #4's medication administration record revealed the patient was receiving the following medications for Hypertension management:
Norvasc 5 mg by mouth daily at 9:00 a.m. (Included on the MAR was, "Patient's blood pressure should be noted before administering").
Lisinopril 20 mg by mouth daily at 9:00 a.m. (Included on the MAR was, "Patient's blood pressure should be noted before administering").
Atenolol 25 mg by mouth daily at 9:00 a.m. (Included on the MAR was, "Record Apical Pulse on MAR, next to time given. Hold if less than or equal to 60 and notify MD.")

Additional review of the patient's medication administration record and nursing notes revealed no documented evidence the patient's blood pressure and pulse had been assessed and documented prior to administration of the medication. Further review of the patient's medication administration record revealed an order for blood pressure checks every shift, but no specific times were documented to indicate when the patient's blood pressure had actually been taken.

In an interview on 08/23/16 at 12:37 p.m. S2DON reviewed the medical record for Patient #4 and confirmed the patient's blood pressure and pulse were not documented as directed on the MAR. S2DON indicated it was her expectation that vital signs should be documented prior to medication administration because that is good nursing practice. She indicated nursing staff pulled the patients' routine vital sign flow sheets prior to medication administration for review, but that was not to substitute for nursing staff obtaining vital signs prior to medication administration. S2DON agreed changes in patient vital signs could have occurred since the routine vital signs had been assessed because those vital signs could have been taken 2-3 hours before the medication was scheduled for administration.


Patient #5
Review of Patient #5's medical record revealed the patient had a co-morbid diagnosis of Hypertension.
Review of Patient #5's medication administration record revealed the patient was receiving the following medication for Hypertension management:
Lopressor (beta blocker) 50 mg by mouth twice a day at 9:00 a.m. and 9:00 p.m. Further review revealed a directive to record apical pulse on medication administration record next to time given; Hold if less than or equal to 60. Additional review revealed no documented evidence that the patient's apical pulse had been taken prior to administration of the medication.

Further review of the patient's medication administration record and nursing notes revealed no documented evidence the patient's apical pulse had been assessed and documented prior to administration of the medication.
In an interview on 8/23/16 at 12:49 p.m. with S2DON, she indicated it was her expectation that vital signs should be documented prior to medication administration because that is good nursing practice. She indicated nursing staff pulled the patients' routine vital sign flow sheets prior to medication administration for review, but that was not to substitute for nursing staff obtaining vital signs prior to medication administration. S2DON agreed changes in patient vital signs could have occurred since the routine vital signs had been assessed because those vital signs could have been taken 2-3 hours before the medication was scheduled for administration.

30984

Based on interview, record review and observation, the hospital failed to ensure the nursing staff developed and kept current a comprehensive treatment plan for 5 (#1-#5 ) of 5 (#1-#5 ) patient records reviewed for comprehensive treatment plans.
Findings:

Review of the Hospital's Policy titled, Treatment Planning; Integrated/Multidisciplinary, Policy Number CS-02 revealed in part the following: The Treatment Plan shall be initiated as a component of the admissions process with continual development and formulation by the attending physician and multi-disciplinary treatment team, with the patient's involvement, throughout the course of treatment....Revises and develops nursing and medical components of the treatment plan based on additional findings from patient assessments, problems, needs, strengths and limitations, and physician's orders. Revises plan based on changes in condition and physician's orders received. All physician orders will be added to the Treatment Plan.


Patient #1
Review of Patient #1's medical record revealed an admission date of 7/28/16 with an admission diagnosis of major depressive disorder recurrent with severe psychosis.

Review of Patient #1's medical record revealed the patient was receiving 325 mg of ASA (Aspirin) daily as anticoagulant therapy for treatment of Atrial Fibrillation.

Further review revealed the patient had sustained the following injuries during altercations/while exhibiting aggressive behaviors:
7/31/16: 2 cm laceration to left middle finger;
8/01/16: swollen right hand/finger requiring medical evaluation and x-ray;
8/05/16: 1 scabbed areas less than 1 cm on right forearm and 2 scabbed areas less than 1 cm on the left forearm with scant blood.

Review of Patient #1's current treatment plan revealed Anticoagulant therapy was not initiated as a problem on the patient's treatment plan. Further review revealed the injuries sustained by the patient on 7/31/16, 8/01/16 and 8/05/16 were not documented/addressed on the patient's treatment plan.


Patient #2
Review of Patient #2's medical record revealed an admission date of 8/16/16 with an admission diagnosis of major depressive disorder recurrent.

Review of Patient #2's medical record revealed the patient was receiving 325 mg of ASA (Aspirin) daily as anticoagulant therapy for treatment of Atrial Fibrillation.

On 8/22/16 at 10:00 a.m. an observation was made of Patient #2. Multiple scratch-like purplish-red abrasions were observed on the both of the patient's shins.

Review of Patient #2's current treatment plan revealed Anticoagulant therapy was not initiated as a problem on the patient's treatment plan. Further review revealed the multiple deep red scratches observed on the patient's bilateral lower legs (on his shins) were not documented/addressed on the patient's treatment plan under the identified problem of potential for Impaired Skin Integrity.

In an interview on 8/22/16 at 4:21 p.m. with S3LPN, she indicated Patient #2 scratches his legs. S3LPN confirmed the skin scratches on Patient #2's legs should have been documented on the patient's plan of care.


Patient #3
Review of the medical record for Patient #3 revealed the patient was a 97 year old admitted from a skilled nursing facility to the hospital on 07/21/16 with a diagnosis of Dementia with Behavioral Disturbances.

Review of the Initial Nursing Assessment dated/timed 07/21/16 at 11:45 p.m. revealed the back of the arms circled from the mid upper arm to the finger tips had small scars and red discoloration to both upper extremities. The front diagram also revealed "Small red areas r/t shoes" with an X marked on both feet below the great toe. An area was circled from the mid upper leg to the toes and hand written beside the circled area was, "Dark Discoloration to BLE."
Review of the Skin and Braden Reassessment Documentation dated/timed 07/23/16 at 9:30 a.m. revealed the diagram of the back of the body had areas circled from the mid-upper arm to the fingertips. Hand written above the circled areas was, "Multiple discolorations bruises." The diagram of the front of the body revealed a "Scratch" was indicated on the right lower extremity, "discolored" area was marked on the left leg below the knee, and "Reddened spots top of foot and medial aspect of bilateral great toes" was hand written in.


Review of the record revealed the patient received Xarelto 15 mg. daily at bedtime (Anticoagulant). Review of the Multi-disciplinary Integrated Treatment Plan revealed the Potential for Impaired Coagulation related to Xarelto Therapy had been initiated on admission. Interventions for this identified problem included Assess for bleeding/bruising every shift for duration of treatment. Further review of the treatment plan revealed no documented evidence of any patient bruising on admission. There was no documented evidence the treatment plan was updated with the bruising/discoloration identified on the skin assessments.


Patient #4
Review of the medical record for Patient #4 revealed the patient was a 91 year old admitted from a skilled nursing facility to the hospital on 08/10/16 at 3:30 p.m. with a diagnosis of Delusional Disorders. Review of the physician orders dated 08/12/16 revealed Bleeding Precautions was ordered due to the patient had Leukopenia and Thrombocytopenia (Low White Blood Cell Count and Low Platelet Count).

On 8/22/16 at 9:55 a.m. an observation was made of Patient #4. Patient #4 was observed sitting in a wheelchair in the group room. The patient was observed to have multiple bluish colored bruises on her right forearm.

Review of Patient #4's current treatment plan revealed Anticoagulant therapy was not initiated as a problem on the patient's treatment plan. Further review revealed the multiple bruises observed on the patient's right forearm were not documented/addressed on the patient's treatment plan.


Patient #5
Review of Patient #5's medical record revealed an admission date of 8/02/16 with an admission diagnosis of Dementia.

Review of Patient #5's medical record revealed the patient was receiving 81 mg of ASA (Aspirin) daily as anticoagulant therapy for treatment of Atrial Fibrillation.

Further review revealed Patient #5 had sustained the following injuries during altercations/while exhibiting aggressive behaviors:
8/2/16: Skin tear times 1, 0.25 cm by 0.25 cm noted with flap in place and scattered red bruising to bilateral upper extremities, and;
8/16/16: bleeding from scratch on top of nose and from 2 small scratches to left elbow.

Review of Patient #5's current treatment plan revealed the bruising sustained by the patient during the above referenced altercations was not documented under the identified problem of Potential for Impaired Coagulation. Further review revealed the injuries sustained by the patient on 8/02/16 and 8/16/16 were not documented/addressed on the patient's treatment plan.

In an interview on 8/23/16 at 12:49 p.m. with S2DON, she indicated baseline bruising evaluations should have been included on patient treatment plans. She agreed impaired skin integrity should have included all skin issues including scratches, skin tears and any breaks in skin integrity. S2DON indicated findings of bleeding/bruising should have been documented on the patients' treatment plans. She further indicated patients receiving treatment with anticoagulants should have Potential for Impaired Coagulation identified as a problem on their treatment plans and any bruising should be documented under that problem.