HospitalInspections.org

Based on medical record (MR) review, document review and interview, in one (1) of 14 medical records (MR) reviewed, it was determined that the facility failed to report and investigate an incident related to a patient who sustained injuries after being restrained and perform an assessment or analysis to identify potential issues to prevent future occurrences.


Findings include:

The document titled "2024 Quality and Patient Safety Plan" states, "The QPS Program oversees activities of all hospital and patient services to enhance the quality and safety of patient care, to identify actual and potential problems concerning patient care and clinical performance and develop and implement strategies to prevent harm. The program measures, analyzes, and tracks quality indicators, including adverse events and other aspects of performance that assess processes of care, hospital services, and operations."

The policy titled "Adverse Event Reporting," last revised 8/2022 states:

"1. Events to report ... staff should report events that occur on hospital premises which are not consistent with routine operations or care of patients. The events may involve actual harm or no harm ...
A. Types of events to report are: 1) Events that cause harm, 2) Events that occur but do not cause harm ...
B. Events are categorized in the system within general event types such as: ... medication ... patient fall event ... safety/security ...

3. Event report submission ... Complete appropriate notifications (e.g., Supervisor, Provider, Attending) and enter the event into the Adverse Event Reporting System as soon as possible after the event has occurred."

Review of the MR of Patient #1 identified: a 49-year-old patient who presented to the emergency department (ED) on 2/21/24 at 2:58 PM for a manic episode. At 3:12 PM, the patient was triaged by ED Registered Nurse (RN) and was placed in the room at 3:22 PM. At 3:45 PM, the ED Attending evaluation documentation included: patient presented manic with anxiety and pressured speech and was requesting a psychiatric admission. The patient's past medical history was significant for Bipolar Disorder, Post-Traumatic Stress Disorder (PTSD), and two (2) previous suicidal attempts. The ED Attending placed an order for a psychiatric consultation and medication at 3:45 PM. The patient was administered Ativan (medication to treat anxiety) 2 milligrams intravenously at 3:59 PM.

At 7:57 PM, Staff I, Psychiatric Attending, documented in the Tele consult Note that during her evaluation, the patient attempted to leave, security was called, and further assessment was terminated due to escalating behaviors.

At 8:00 PM, ED Staff RN documented, the patient became agitated, needed to be put into four-point restraints and medicated. Restraints were removed on 2/22/24 at 6:29 AM.

At 8:55 PM, ED Attending, documented an updated ED Provider Note, that the patient had abrasions under his left eye and above the left ear, so he ordered a CT scan of the head.
CT scan of the head was performed on 2/22/24 at 6:50 AM, which showed no abnormal findings.

Review of the facility Keepsafe (Adverse Event Reporting System) from 10/2023 to 05/2024, revealed there was no entry related to an incident with Patient #1.


During an interview conducted on 5/16/24 at 2:02 PM, Staff F, Security Officer, stated that security was called to the patient's room due to the patient being verbally aggressive with staff. Upon arrival, the patient was making verbal threats to harm staff. An attempt to verbally deescalate the patient was made, but the patient eventually attempted to rush at security in attempt to escape. Security officers needed to restrain the patient and hold his limbs so that the RNs could safely place the four-point restraints.

During an interview conducted on 5/16/24 at 3:15 PM with Staff N, Assistant Director of Quality and Safety, confirmed that there was no incident report filed or investigation done regarding the patient's injuries.

During an interview conducted on 5/17/24 at 10:00 AM, Staff E, ED Attending, stated that he was informed that the patient was becoming increasingly agitated and verbally threatening towards staff, so he went to the bedside to reassess the patient and attempted to verbally deescalate the patient. Staff E determined the patient would require medication for his agitation and in the process of staff preparing the medication, the patient attempted to rush at security officers and had to be restrained. Staff E stated, in fear of the RNs getting injured, administered the medications while the patient was being restrained by security officers and the four-point restraints were being applied. After the patient had been put into four-point restraints, Staff E, noticed a superficial abrasion under the patient's left eye and above the left ear, so he ordered a CT scan of the head. Staff E stated that no treatment was necessary for the abrasions and that the patient had no physical complaints at that time.

When asked by the surveyor if he filed an incident report, Staff E, ED Attending stated that he did not but verbalized understanding that the injuries should have been reported.

Based on medical record review, document review and interview, in one (1) of 14 medical records (MR) reviewed, it was the determined the facility failed to provide a prescription for care of a patient's unstageable pressure ulcer when the patient was discharged from the hospital. (Patient #2)

Findings include:

The policy titled "Discharge Planning and the Continuum of Care," last revised 5/2023 states, "patients will have their post-acute care needs assessed and as applicable, will be provided with a discharge plan to support their continued recovery and well-being after leaving the in-patient care setting. Identification and implementation of the discharge plan is the responsibility of the interdisciplinary team."

Review of the MR for Patient #2 identified a 79-year-old patient who was admitted to the facility on 6/28/23 at 1:35 PM for Aspiration Pneumonitis. The patient's previous medical history was significant for Coronary Atherosclerotic Disease, Cognitive Impairment, Advanced Frontal Lobe Dementia, Hypertension, Hyperlipidemia, Hyperthyroidism, Thyroid Nodule, and Coronary Artery Bypass Graft.

The admitting diagnoses were Acute Hypoxic Respiratory Failure secondary to Aspiration, Aspiration Pneumonitis and Dysphagia/Choking. On 6/29/23 at 10:20 AM, the wound care nurse documented the patient's wound assessment; patient had an "unstageable pressure injury to the sacrum/sacrococcygeal area with an open area which measured 6 x 6 x 0.3 cm, bilateral calcanei with deep tissue pressure injuries each with maroon non-blanchable hue over boggy area, measures 1 x 1 cm. No fluctuance, induration or exudate present."

Daily nursing assessment and wound care was documented twice daily from 6/28/23 until discharge on 7/3/23.
The wound care nurse documented the patient's discharge instructions on 7/3/23 included instructions for wound care with the application of collagenase (Santyl) ointment daily to wound. (Medication used for removing damaged or burned skin to allow for wound healing...)

There was no documentation in the medical record that the interdisciplinary team provided a prescription to the patient/family for the collagenase ointment when the patient was discharged home on 7/3/23.

Documentation in the medical record revealed the prescription was sent to the pharmacy on 7/5/23, two (2) days after the patient was discharged from the facility.

During interview on 5/16/24 at 11:00 AM, Staff B, Manager Wound and Ostomy Care stated, in this case the patient was discharged with instructions for application of two (2) ointments for wound debridement of the sacrum.

During interview on 5/17/24 at 10:45AM, Staff A, physician, stated he did not recall the patient having a wound. He states he remembers receiving a call for the Santyl ointment a couple days after patient #2 was discharged from the hospital and he ordered the prescription for the wound care treatment on 7/5/23.

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