HospitalInspections.org

Based on document review and interview. it was determined that for 1 of 6 (Pt. #1) clinical records reviewed, the Hospital failed to ensure the patient did not sustain injuries.

Findings include:

1. The clinical record for Pt. #1 was reviewed on 5/2/14. Pt. #1 was a 91 year old female admitted on 4/25/14 with diagnoses of dementia with behavioral disturbances, psychotic disorder and mood disorder. A psychiatric evaluation dated 4/26/14 indicated Pt. #1 was transferred from a nursing home due to aggressive behavior, screaming, spitting, biting, yelling and difficult to redirect. The nursing admission assessment included: Skin integrity-dry/itchy; Musculoskeletal,motor activity -uncoordinated, restless/agitated; Gait-shuffling /unsteady. The fall risk assessment (Morse score system: low risk at 0-24; moderate risk at 25-44 and high risk at 45 or more) indicated Pt. #1 was at a high risk for falls with a total score of 75. The body inspection on the admission assessment identified a scab and dry skin areas on the right side of the face and several areas of redness and dry skin on the lower arms and hand. The clinical record indicated Pt. #1 was placed on special precautions with documentation of observations every 15 minutes from admission to transfer on 4/30/14.

A Nursing note dated 4/30/14 from 8:30 AM to 12:10 PM indicated the following: " Pt. assessed this am and found to have new bruise to upper lip & lower lip 3.8 x 1.5 cm -1x1 cm from unknown cause, no injury was reported, Dr. ...notified & lab orders. Son notified...Pt pain free at this time. " The attending physician's note on 4/30/14 indicated the following: " notified by staff that patient had been noted with bruising to the upper lip this morning and complained about being punched in the face. Pt is currently agitated after recent dressing/diaper change & is unable to elaborate much on the events ... Impression: marked bruising of upper lip ...bil u. ext (bilateral upper extremities) bruises-lighter compared to previous exam..."

2. The Director of Risk/Patient Advocacy/Patient Safety (E #9) and Director of Operations for Geriatric Services (E #10) were interviewed on 5/2/14 and 5/6/14. E #9 and #10 stated that an investigation began on 4/30/14 when the injury to Pt. #1's lip was noted and reported. E #9 and 10 have conducted interviews of all night and day shift staff on duty 4/29/14-4/30/14 and are reviewing Pt. #1's record. E #9 and 10 acknowledged that Pt. #1 sustained a bruised upper and lower lip but have not determined the cause of the injury. E #9 and 10 stated that no patient care issues have been identified contributing to the patient's injury, thus no corrective actions have been planned and implemented.