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On the days of the Complaint Investigation based on record and interview, the hospital failed to ensure that mechanisms/methods were in place to ensure that hospital investigations into patient injuries of unknown origin were conducted in a thorough manner for 1 of 2 patient injuries of unknown origin (Patient #1) in that one person on duty who saw the patient after the injury was not interviewed during the hospital's investigation process.


The findings are:


On 3/10/11 at 1030, a review of Patient #1's chart showed Patient #1 was admitted through the hospital's emergency department on 1/7/11 with a chief complaint of abdominal pain and alcohol withdrawal. Review of a physician progress note dated 1/10/11 at 1043 revealed the patient had a platelet count of 77,000, was very confused, and at risk for delirium tremens. The physician progress note dated 1/11/11 at 0823 revealed the patient's mentation was improving, and the patient's platelet count was "84,000, probably alcohol induced". On 1/12/11 at 0815, the physician progress note revealed, "The patient is still intermittently confused and found to have ecchymosis on the left eye which is new. apparently no history of any fall and very possible that he fell and got up by himself to the bed. ....Will get a CT (Computerized Axial Tomography) scan of the head with bone window. ....".

On 1/12/11 at 0551 for an activity that occurred at 0540, the registered nurse recorded, " ...... FNP (Family Nurse Practitioner) on floor and asked to see .......(Patient #1) regarding his bruising to left eye." The registered nurse recorded on 1/12/11 at 0523 for an activity that occurred at 0100, "continuing to rest quietly". Registered Nurse #1 recorded an undated hand written late entry for 1/12/11 at 0500 which read, "Pt. (patient) sitting on side of bed with bruising to left eye and pants wet. When asked what happened, he said, " I fell 3 times; one last month and two yesterday. No bruising present during previous assessments. confused and unsteady on his feet.". "O540 .... FNP notified and in to assess. He told her the same thing regarding falls. Injury was not witnessed by staff."

Registered Nurse #1 completed an incident report related to the patient's incident at 0718 on 1/12/11. The patient's incident report showed Registered Nurse #1 recorded "bruise/bruising" with no location specified.

Review of the Risk Manager's report of the incident showed the Risk Manager had not interviewed the Family Nurse Practitioner about the incident. There was no documentation in the patient's record by the Family Nurse Practitioner regarding the incident or the Family Nurse Practitioner's assessment of the patient after the incident.

On 3/11/11 at 1000, the Risk Manager confirmed the Family Nurse Practitioner who saw the patient after the injury was discovered had not been interviewed about the incident.

On 3/14/11 at 0810, the Family Nurse Practitioner was interviewed via the telephone. The family Nurse Practitioner reported that she was on duty on 1/12/11 when she received notification from a registered nurse on the sixth floor that a patient had bruising on his eye. The Family Nurse Practitioner reported that she had gone to the unit at 0545 to visit the patient who was lying in the bed with the head of the bed elevated. The side rails were up. The Family Nurse Practitioner stated that she saw some bruising around the patient's eye, not much, and there was no hematoma. The Family Nurse Practitioner stated that she asked the patient what happened, and the patient told her that he didn't know what happened. The Family Nurse Practitioner verified that she had not documented the visit in the patient's chart, had not been interviewed about the incident by the hospital's Risk Manager, and had not completed a witness statement about the incident."

Hospital Policy and Procedure: A8, Effective 3/97 and last revised 11/10/11, titled, Abuse and/or Neglect, reads, "Procedure: 3. all findings from examinations and treatment are documented in the patient's medical record."

On the days of the Complaint Investigation based on patient record review, interview, and facility policy and procedures, the hospital failed to ensure that the physician order to discontinue restraints was followed for 1 of 5 patient records reviewed for restraints. (Patient #1)


The findings are:


Review of Patient #1's chart showed a hand written physician order dated 1/15/11 at 08:15 A.M. that reads, "Discontinue restraints". Review of Patient #1's Restraint Flow sheet dated 1/15/11 at 1000 revealed Patient #1 was still on soft wrist restraints and a vest/Posey. There was no documentation that the patient's restraints had been removed since the the physician's order dated 1/15/11 at 08:15. A section on the patient's restraint flow sheet showed the last restraint order was written on 1/14/11 at 2300. Review of the documentation recorded on the patient's restraint flow sheet dated 1/15/11 at 1200 showed the patient was on soft wrist restraints and a Posey/vest restraint, and the restraints had not been removed as requested in the physician order dated 1/15/11 at 08:15 A.M., and the last restraint order was dated 1/14/11 at 2300. Based on documentation on the patient's restraint flow sheet, nursing did not remove the patient's restraints until 1/15/11 at 1500.