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Based on interview and document review the facility failed to ensure the patient's, or the patient's representative, were informed of the patient's health status and involved in the plan and treatment for 1 of 10 patients reviewed for patient rights, when staff discovered patient #1 (P1) had a right arm fracture. Facility staff failed to inform P1's parents of her new right arm fracture and failed to involve them in the plan, and treatment, of P1's right arm fracture.

Findings include:

P1's medical record was reviewed and indicated P1 was admitted on 04/23/18. Her diagnoses included neuroaxonal dystrophy, upper GI bleed, vitamin D deficiency, anemia, malnutrition, and severe osteopenia/osteoporosis.

A radiology report dated 04/24/18, at 2:59 a.m. indicated the patient sustained an acute supracondylar fracture. The x-ray showed a transverse fracture through the supracondylar region with some impaction of fracture fragments. The radiocapitellar joint remained normally aligned, and there was no elbow dislocation. There was configurational deformity of the humeral head consistent with a remote fracture. The patient's bones appeared thin and osteopenic.

A nurse's note dated 04/24/18, at 7:48 a.m. indicated right upper arm/elbow swelling noted at 12:00 a.m., staff notified the intensivist. Staff assessed P1's arm, and obtained an x-ray. The x-ray indicated a fracture and staff consulted orthopedics. Staff applied a molded splint (casted) to the patient's right arm.

An orthopedic consult noted date 04/25/18 at 1:26 p.m. indicated a fracture of the distal humerus. P1 had generalized osteopenia and the fracture was consistent with an acute fragility fracture occurring sometime within the last 2 weeks per the orthopedist. Wrist and hand bones are also extremely osteopenic to the point that the carpals are hard to visualize. The patient's growth plates were fused, and, per the radiologists report, there was a deformity of the right head of the humerus suggesting another remote fracture.

During an interview on 08/02/187 at 1:12 p.m. registered nurse (RN)-A stated she was charge nurse when P1 was admitted to PICU. P1 arrived at the facility on stretcher with several stuffed animals around her body to prop her body up. She knew P1 from previous admissions and P1 's limbs were hypertonic ( the muscles had an increased tension, and were abnormally rigid which hampered proper movement) RN-A stated that P1's right arm was less stiff than usual. RN-A stated she did not see redness or swelling in P1's right arm. She gave P1 a bed bath with RN-B and RN-A stated the nurses were very gentle when they move P1.

During an interview on 08/02/18 at 1:35 p.m., (RN)-B stated that she cared for P1 the night P1 was admitted to the PICU. P1 arrived on the unit sometime between 5:00 p.m. and 5:30 p.m. She bathed P1 with the assistance of RN-A. RN-B stated she stood on P1's left side and RN-A stood on P1's right side. Both nurses took off P1's shirt by sliding it down over P1's hips and feet. P1's limbs did not move normally. P1's parents were not at the facility and RN-B called P1's parents and let them know P1 arrived at the hospital. P1's parents were driving to the facility. P1's left arm was stiff. RN-B stated she did not see redness or swelling on P1's right arm, and P1 did not exhibit non-verbal signs of pain. RN-B stated she and RN-A were extremely gentle when they moved P1 because her bones were fragile.

During an interview on 08/03/18, at 8:12 a.m. medical doctor (MD)-C stated she admitted P1 on 04/23/18. She stated P1 she has training in critical care pediatrics and ethics. P1 was neurologically impaired since birth required trach/vent to breath. P1 was non-ambulatory, non-verbal, and had an implanted feeding tube for nutrition. P1's history included severe osteoporosis from being bed ridden her entire life. P1's arms were abnormal due to her condition and MD-C stated she did not see redness or swelling in P1's right arm. Swelling happens over hours to days unclear to know when fracture occurred. P1 was at risk for fractures due to being positioned only on her back for 17 years and had not has her menses which builds bone strength. MD-C stated P1's family can tell when P1 is uncomfortable but staff did not observe non-verbal signs of pain. P1 had no vital signs changes, no grimaces, and appeared comfortable from admit through the night when staff discovered P1 fractures. P1 was at risk for fractures her whole life her bones appeared old hollow more abnormal than normal bone. X-rays grossly abnormal Essentially body eating up bones. P1's family was upset and frustrated that the doctor on call on nights on 04/24/18, did not wake them up to inform them of P1's right arm fracture when they were just sleeping down the hall from the PICU.

During an interview on 08/03/18, at 9:06 a.m., and 1:47 p.m., (RN)-D stated she cared for P1 the first night she was admitted at 11:00 p.m. She got report that P1 had several attempts to start an IV and draw blood. She spoke with P1's parents and they went to sleep in the sleep room down the hall between 11:00 p.m. and 11:30 p.m. At approximately midnight, RN-D noticed P1 had minimal to moderate right upper arm swelling and slight redness. She could not recall how large of an area was swollen and red. RN-D notified the charge nurse and the physician on call. The physician assessed P1's arm and ordered an x-ray. The x-ray showed a fracture and a nurse from the emergency department came to the PICU and placed a splint at approximately 6:00 a.m. The splint consisted of cast material on the bottom of P1's arm and an ace wrap. RN-D stated she did not think to notify the family, and she did not know if the on-call doctor notified the family. She did not see the family that morning.

During an interview on 08/03/18 at 9:49 a.m. RN-E stated she cared for P1 from 7:00 p.m. to 11:00 p.m. on the night she was admitted. P1's parents arrived sometime between 9:00 p.m. and 10:00 p.m. RN-E stated she did not see redness or swelling in P1's right arm. P1 did not exhibit non-verbal signs of pain.

During an interview on 08/03/18, at 10:05 a.m., (RN)-F stated she worked in Sedation Procedural Services and staff called her to the PICU to place an intravenous (IV) line in P1 the night P1 was admitted. She used an ultrasound machine to place the IV. RN-F stated she assessed P1's arms and legs for possible IV sites. She moved P1's arms and legs gently. She made several attempts to place the IV. She did not recall how many attempts she made to place the IV or where she placed the IV. P1 had an existing IV in the left arm. P1 did not exhibit signs of pain when RN-F attempted to place an IV. RN-F stated P1's left arm was stiff and P1's right arm was easier to move. P1 did not move and RN-F did not require assistance from other staff to place the IV. RN-F stated she did not notice swelling or redness in P1's right arm but P1 was had generalized puffiness.

During an interview on 08/13/18, P1's family member (FM)-G that she and her husband were sleeping in the hospital the first night P1 was admitted to the PICU. The sleep room was right down the hall from the PICU. Her husband woke early on 04/24/18, between 7:30 a.m. and 8:00 a.m., and walked down the hall to PICU to see P1 and saw P1's right arm casted. He returned to the sleep room and told FM-G that P1 had a fractured arm. FM-G stated that none of the medical staff called, or knocked on the door, during the night to inform the family of P1's broken arm. FM-G stated she told staff to call them if anything happened during the night. FM-G stated P1's bones were thin and staff should have called her when they noticed swelling. FM-G stated P1 could not speak and should not have been alone with a broken arm.