HospitalInspections.org

Based on the review of documents, medical record and staff interview it was determined the hospital failed to recognize a complaint had been made to the hospital and failed to ensure the complainant's concerns were reviewed and resolved in accordance with hospital policy in order to determine how a patient's injury occurred. This situation occurred in one (1) of one (1) patient's reviewed which suffered an injury while being restrained (patient #1). This failure has the potential to allow patients to acquire unexplained injuries/abrasions during the restraint process without appropriate care including: assessment, treatment and investigation of the matter. Findings include:

1. During interview with the Nursing Supervisor on 7/19/11 in the afternoon, she indicated the West Virginia Department of Health and Human Resources (WVDHHR) Guardian of the patient had come to the hospital and had spoken with her regarding the patient being restrained with a subsequent abrasion noticed on the patient's face. She said she thought the WVDHHR Guardian was making a complaint and directed the Guardian to speak with the Quality/Risk Manager regarding her concerns.

2. During interview with the Director of Quality/Risk Manager on 7/19/11 in the p.m., she indicated the patients WVDHHR Guardian had come to her office and requested a copy of the incident report regarding the patient's take-down/restraint incident. She said she offered the guardian the opportunity to review the medical record but did not give them the incident report. She said the guardian was upset and left. She stated she did not consider this a grievance, did not initiate the grievance process and therefore there was no investigation conducted into how the injury occurred.

3. Review of the medical record for patient #1 revealed the risk manager documented in part, the following related to this meeting at 1230 on 6/24/11: "information requested, wanted details about pt injuries (abrasions) during restraint..."

4. A review of the hospital's "Complaint Process" last dated 10/18/10 indicated in part: "It is the policy .... to provide patients, their families, and staff with a vehicle for communicating concerns or complaints regarding services and patient care ... and such complaints (of possible abuse) shall be addressed within 48 hours."

5. These findings were reviewed with the Quality/Risk Manager on 7/20/11 in the p.m. and she agreed with the findings.

Based on medical record review, document review and staff interviews, it was determined the hospital failed to capture one (1) of one (1) adverse patient events for a patient discharged to the wrong setting. Also, it was determined the hospital failed to follow its "Incident Reporting Policy" in sixty three (63) of eighty four (84) incident reports. This has the potential to adversely affect the tracking and analyzing of adverse patient events.
Findings include:

1. The hospital's "Incident Reporting Policy" (revised 7/1/11) states (in part):

"In the event that any employee, or other person providing services on an on-going basis at Highland Hospital, shall observe or be made aware of an event representing an actual or potential threat to any person or property at the hospital, that person shall complete an incident report according to the procedures set forth below.

2. The employee observing the event shall fill out the incident report form in ink. The form may be completed by anyone having knowledge of event if the person directly involved is not able to complete the report. The report is to be completed as soon as possible after the event."

2. Review of the medical record revealed Patient #1 was in the custody of the West Virginia Department of Health and Human Resources (WVDHHR). When he was discharged from the hospital on 6/29/11 he was discharged home with his Grandmother, not discharged to the WVDHHR as he legally should have been..

3. The Unit Manager of the Adolescent Unit (AU) and the Case Manager of the AU were interviewed in the afternoon of 7/19/11. Both said they were aware the day after (6/30/11) patient #1's discharge that he had been inappropriately discharged to his Grandmother and not to the WVDHHR. However, neither filled out an incident report as per policy.

4. The Quality Assurance Director/Risk Manager was interviewed in the morning of 7/20/11. She agreed patient #1 had been inappropriately discharged and this should have generated an incident report.

5. The hospital's "Incident Reporting Policy" further states (in part): "The incident reports are sent to the Department Head for review, referral or further action as necessary. The Department Head will do any additional collection and investigation of facts and record the findings on the Outcome Section or Report Follow-up Form or as additions thereto."

6. Review of incident reports for May, June and July 2011 revealed: In May, twenty three (23) of thirty five (35) incident reports revealed no indication the Department Head had reviewed the incidents. In June, thirty one (31) of forty (40) incident reports revealed no indication the Department Head had reviewed the incidents. In July, nine (9) of nine (9) incident reports revealed no indication the Department Head had reviewed the incidents.

7. During the interview with the Quality Assurance Director/Risk Manager in the morning of 7/20/11, she agreed these incident reports showed no indication the Department Head had reviewed them. She stated "The hospital needs to start over from square one with our incident reporting policy and we need to inservice all staff relative to the importance of incident reporting and subsequent followup."

Based on review of the medical record, hospital policy and staff interview it was determined the registered nurse (RN) failed to evaluate and document an injury for one (1) of one (1) patients reviewed who was injured during a restraint episode (Patient #1). This failure creates the potential for the care and condition of all patients who are restrained to be adversely impacted. Findings include:

1. The State Agency received a complaint regarding patient #1. An allegation was made regarding a scrape on the right cheek and above the right eye which was alleged to have occurred during a restraint episode on 6/22/11.

2. Review of nursing documentation revealed the patient was admitted at 1850 on 6/21/11 and no injuries to the face were noted by the RN.

3. Review of the medical record revealed the patient was restrained two (2) times on 6/22/11. The first restraint occurred from 1400 to 1535. The second restraint occurred from 1740 to 1850. The RN assessments related to these restraint episodes, completed at 1400 and 1745 revealed no documentation of an injury.

4. At 1859 on 6/23/11 the physician conducted a physical exam of the patient. An abrasion on the right side of face and abrasion on right side of forehead were noted. Bacitracin ointment was ordered to treat the abrasions at that time.

5. Interview with Behavioral Health Technician (BHT) #2 was conducted in the afternoon of 7/20/11. She stated the patient was in restraint when she came on duty at 1500 on 6/22/11. She stated she monitored the patient until he was released from restraint and did not not notice an injury at that time. She acknowledged she did see an abrasion later.

6. Interview with BHT #1 was conducted in the afternoon of 7/20/11. She stated she came on duty at 1500 on 6/22/11. She noted the patient was in his room when she came on duty and she did not see him until after the second episode of restraint. She stated she saw an abrasion on the side of the patient's head at that time.

7. An interview was conducted with the Licensed Practical Nurse (LPN), who was present for the first restraint on 6/22/11, in the afternoon of 7/19/11. He stated he did not see an injury to the patient. This LPN was off duty at approximately 1500 on 6/22/11. The LPN stated he returned to work on 6/24/11. He noted the order for Bacitracin ointment and saw the abrasions on the face of patient #1. He stated he asked the RN about the injury and the RN indicated it occurred during restraint.

8. The RN who worked sixteen (16) hours on 6/22/11 was on vacation and unavailable for interview.

9. The policy "Seclusion and Restraint," (revised 4/11) was provided for review. It states in part under Documentation: "Physical assessment of patient for any evidence of injury and written documentation."

10. The record lacked documentation of an assessment of this injury by the RN. During the course of the survey this record was discussed and reviewed with the LPN, Nursing Supervisor and Risk Manager who agreed with these findings.