HospitalInspections.org

Based on interview and record review, the facility failed to maintain a complete clinical record for one of five patient records reviewed (Patient 1). Specifically, the facility failed to document the medical decision to not acquire a CT scan (computerized tomography) that was recommended after an x-ray had been acquired for Patient 1.

Findings Include:

Review of the "Patient Face Sheet" provided by Staff A, the Program Director, showed Patient 1 was admitted to the Life Care Unit on 11/16/18 at 9:15 PM.

Review of the 11/19/18 "Individual Patient Note," provided by Staff A on 01/03/19 at 12:22 PM, showed Patient 1 was sent for an x-ray of her right upper shoulder per the provider's request.

Review of the "Clinic Results," provided by Staff A on 01/03/19 at 11:58 AM, showed, a fracture of the proximal shaft of the humerus and a CT scan of the shoulder is recommended for further evaluation of this fracture.

During an interview on 01/03/19 at 3:20 PM, Staff B, the Chief Operating Officer, said that there was no specific documentation from the physician's assistant explaining why a CT scan had not been performed.

During an interview on 01/03/19 at 8:12 AM, Staff C, the Chief Compliance Officer, said that the Physician's Assistant had consulted with an orthopedic surgeon who said, because of the kidney failure, Patient 1 was not a good candidate for surgery and that a CT scan would not provide valuable information. Staff C said the Physician's Assistant thought she had documented this interaction with the orthopedic surgeon but had not. She said the Physician's Assistant was writing a late entry for the medical record.

Review of Patient 1's "Physician Notes Report," provided by Staff B on 01/04/19 at 9:08 AM, showed a late entry note was made by the Physician's Assistant on 01/04/19 for 11/19/18. The note discussed a consultation with the on-call provider at (name of orthopedic group.) The note showed, "We discussed patient's x-ray findings and PMH [past medical history] that she wouldn't be a surgical candidate. When discussing the option for a CT scan, it was decided that with her not being a surgical candidate at this time, that the CT scan would provide more information, but that it wouldn't change the current plan of care. She would have to be sedated for the scan with her current level of cooperation. They recommended placing the arm in a sling."

Based on interview and record review, the facility failed to conduct a thorough incident investigation for one of four patients reviewed for incident investigations (Patient 1). Specifically, Patient 1 sustained a fracture to her right proximal humerus bone, and the investigation of this injury was partial and incomplete. Failure to thoroughly investigate incidents places patients at risk for health care falling below the standard of care.

Findings include:

Review of Patient 1's "Clinic Results," provided by Staff A, the Program Director, on 01/03/19 at 11:58 AM, showed "a fracture of the proximal shaft of the humerus."

Review of Patient 1's incident investigation report narrative, dated 11/21/18, conducted by Staff D, the Nurse Manager, and provided on 01/04/19 at 2:30 PM, showed which staff were working on 11/19/18 when Patient 1 began to complain of pain in her right shoulder. The narrative showed interviews with the staff did not identify a probable cause for the injury.

During an interview on 01/03/19 at 2:30 PM, Staff D and Staff B, the Chief Operating Officer, said Staff D started the narrative portion of the incident investigation, but the incident had not been triggered in the electronic record, so the investigation did not continue.

Review of the undated facility policy titled, "Medical Center ," provided by Staff A on 01/04/19 at 1:45 PM, showed "Reporting shall be completed on ECH Exchange. Incidents shall be reported directly to - Risk Manager, Chief of Medical Staff, or Chief Executive Officer.

Review of the facility policy titled, "Fall Prevention, Three Level Precaution," last updated February 2018, provided by Staff D showed, "Complete Incident report for facility, and for Quality Health Care, as well as Investigation Form.