HospitalInspections.org

Based on review of hospital policies and procedures, hospital reports, medical record reviews, and staff interviews, the hospital's staff failed to follow hospital policy for reporting and investigating a patient injury in 2 of 2 patient records reviewed. (#1 and # 13)

The findings included:

Review on 09/30/2021 of the hospital policy titled, "Incident Reporting" approved date 07/24/2019 revealed "The (Hospital Name) Incident Reporting Program provides an effective method for reporting, investigation, follow-up, analysis, and trending of incidents involving patients and visitors ... An incident is an event that is inconsistent with a (Hospital Name) policy or procedure, or that is not part of the routine care of the patient. Such incidents may or may not result in actual injury ...1. Patient and visitor incidents should be reported on the web-based, on-line occurrence reporting system (Safety Zone Portal) by the person(s) who witnesses or discovers the incident immediately (sic) and the Department Director notified. After hours, the Administrative Coordinator or designee (AC) may be contacted in place of the Department Director ..."

1.Review on 09/28/2021 of the closed medical record for Patient #1 revealed an 89-year-old female admitted on 08/08/2021 at 2223 for "acute onset of dizziness." Review of the History and Physical note dated 08/08/2021 at 2223 revealed Patient #1's past medical history included "dementia, TIA (transient ischemic attack -brief stroke like symptoms that resolve without treatment), SSS (sick sinus syndrome - inability of a heart's natural pacemaker to adjust heart rate to supply oxygenated blood which is adequate for bodily needs) s/p PPM (status post permanent cardiac pacemaker)," and "HTN (hypertension - high blood pressure)." Review of the Nursing Assessment flowsheet dated 08/09/2021 at 2320 revealed "Integumentary [skin] (WDL) [within desired limits]; WDL". Review of the Nursing Assessment flowsheet dated 08/12/2021 at 0800 revealed "Integumentary ... WDL ... Skin Integrity: Intact ..." Review of the Nursing Assessment flowsheet dated 08/12/2021 at 2020 revealed "Integumentary .... X (exceptions) ... Skin Integrity: Ecchymosis (bruised); Ecchymosis Location: Arm, Lip; Ecchymosis Location Orientation: Bilateral; Ecchymosis Intervention: Cleansed ..." Review of the Discharge Summary dated 08/14/2021 at 1157 Patient #1 was discharged to a skilled nursing facility. Review of a Progress note dated 08/14/2021 at 1408 revealed " ... received call ... Daughter reports pt (patient) was noted to have bruised lip upon her admission to (Named SNF) ..." Review of the medical record revealed there no note or assessment that indicated a change in Patient #1's skin or lip that they had been assessed and treated.

Interview on 09/28/2021 at 1403 with Administrator #5 revealed there were no incident reports for Patient #1. Interview revealed "upon first seeing some bruising," Patient #1's family should have been notified and an incident report filled out.

Telephone interview on 09/28/2021 at 1542 with NT (Nurse Technician) #4 revealed she remembered Patient #1. Interview revealed NT #4 cared for Patient #1 two days in a row. Interview revealed "first day worked with her (Patient #1), her lip was fine." Interview revealed the second day NT #4 worked with Patient #1, she had "dried blood on her lip and tooth on the left side was missing." Interview revealed NT #4 asked the night shift NT about the lip and the tooth. NT #4 stated the night shift NT "did not know about it." Interview revealed NT #4 "just left it alone" and "did not bother" Patient #1 about it. Interview revealed NT #4 did not remember bruising on Patient #1's arms.

Telephone interview on 09/29/2021 at 1408 with Medical Doctor (MD) #1 revealed he was not notified that Patient #1 had blood on gown and around mouth. Interview revealed MD #1 saw and assessed Patient #1 daily.

Telephone interview on 09/29/2021 at 1550 with Registered Nurse (RN) #2 revealed she remembered Patient #1. Interview revealed RN #2 remembered Patient #1 had "bruising" but no open wounds. Interview revealed the bruising was "generalized and (a) lip wound". Interview revealed RN #2 cared for Patient #1 two consecutive days. Interview revealed on the second day, the certified nursing assistant (CNA) reported Patient #1 had blood on her gown and around her mouth to RN #2. Interview revealed RN #2 "went into Patient #1's room and did an assessment of her mouth." Interview revealed blood was coming from Patient #1's mouth and lip. Interview revealed RN #2 did not document her assessment nor did she write a nursing note. Interview revealed RN #2 was unsure if the blood was from a problem with a tooth. RN #2 stated that if a fall had been witnessed or an injury been witnessed, RN #2 would have filled out an incident report. Interview revealed not witnessing the injury, RN #2 would not fill out an incident report.

Telephone interview on 09/30/2021 at 1041 with Nurse Technician (NT) #3 revealed she remembered Patient #1. Interview revealed Patient #1 had dried blood on her mouth and on her gown when NT #3 went in the room. Interview revealed NT #3 notified the nurse, but the "nurse did not go in the room to assess the patient." Interview revealed the nurse told NT #3 to "get a washcloth and clean it up." Interview revealed NT #3 had "no idea when (someone was) supposed to fill out or who is supposed to fill out an incident report."

2. Review on 09/30/2021 of an internal incident report revealed Patient # 13's head hit the headboard of the bed while Patient #13 was being repositioned in the bed by staff. The report had the investigation documented as completed.

Review on 09/30/2021 of the closed medical record for Patient # 13 revealed a 75-year-old female admitted on 08/01/20201 at 2147 with a diagnosis of "Intracerebral hemorrhage nontraumatic cortical and subcortical on the left hemisphere." Review of the History and Physical note dated 08/01/2021 at 2147 revealed Patient #13 had a past medical history of hypertension, hyperlipidemia, anxiety, chronic low back pain, and degenerative disc disease. Review of the Physical Medicine and Rehabilitation Admission History and Physical note dated 08/04/2021 at 1540 revealed " ... Overal (sic) bed mobility: Needs Assistance ..." Review of Discharge Summary note dated 08/25/2021 at 1726 revealed " ... At admission, patient required total assist with basic ADL (activities of daily living) tasks and with mobility ... She has had improvement in activity tolerance, balance, postural control as well as ability to compensate for deficits ... Discharge disposition: ... Skilled Nursing Facility ...." Review of the medical record revealed no assessment or evaluation of Patient #13 after her head was hit on the head board while moving the patient up in the bed.

Interview on 09/30/2021 at 1428 with Assistant Director (AD) #6 revealed she investigated the complaint. Interview revealed AD #6 spoke with Patient #13 and the staff that was on duty caring for the patient on 08/24/2021. Interview revealed AD #6 did not talk with the staff that was caring for Patient #13 on the date the alleged incident happened. Interview revealed AD #6 confirmed she should have spoken with the staff caring for Patient #13 on the alleged date.

Based on policy review, medical record review and staff interviews, the hospital staff failed to assess a patient injury for 1 of 2 sampled patients with unreported injuries. (#1)

The findings include:

Review on 09/28/2021 of the hospital policy titled, "Nursing Process and Physical Assessment Standards" with an effective date of 06/11/2021 revealed, " ... Nursing process standards are defined according to the level of care required to meet the patient's needs ...Assessment of additional physical parameters, as well as greater assessment frequency, should be performed as appropriate based on the patient's clinical condition, presence of abnormal findings, suspected problems, and/or as ordered by the physician ..."

Review on 09/28/2021 of the closed medical record for Patient #1 revealed an 89-year-old female admitted on 08/08/2021 at 2223 for "acute onset of dizziness." Review of the History and Physical note dated 08/08/2021 at 2223 revealed Patient #1's past medical history included "dementia, TIA (transient ischemic attack -brief stroke like symptoms that resolve without treatment), SSS (sick sinus syndrome - inability of a heart's natural pacemaker to adjust heart rate to supply oxygenated blood which is adequate for bodily needs) s/p PPM (status post permanent cardiac pacemaker)," and "HTN (hypertension - high blood pressure)." Review of the Nursing Assessment flowsheet dated 08/09/2021 at 2320 revealed "Integumentary [skin] (WDL) [within desired limits]; WDL". Review of the Nursing Assessment flowsheet dated 08/12/2021 at 0800 revealed "Integumentary ... WDL ... Skin Integrity: Intact ..." Review of the Nursing Assessment flowsheet dated 08/12/2021 at 2020 revealed "Integumentary .... X (exceptions) ... Skin Integrity: Ecchymosis (bruised); Ecchymosis Location: Arm, Lip; Ecchymosis Location Orientation: Bilateral; Ecchymosis Intervention: Cleansed ..." Review of the Discharge Summary dated 08/14/2021 at 1157 Patient #1 was discharged to a skilled nursing facility. Review of a Progress note dated 08/14/2021 at 1408 revealed " ... received call ... Daughter reports pt (patient) was noted to have bruised lip upon her admission to (Named SNF) ..." Review of the medical record revealed there no note or assessment that indicated a change in Patient #1's skin or lip that they had been assessed and treated.

Telephone interview on 09/28/2021 at 1542 with NT (Nurse Technician) #4 revealed she remembered Patient #1. Interview revealed NT #4 cared for Patient #1 two days in a row. Interview revealed "first day worked with her (Patient #1), her lip was fine." Interview revealed the second day NT #4 worked with Patient #1, she had "dried blood on her lip and tooth on the left side was missing." Interview revealed NT #4 asked the night shift NT about the lip and the tooth. NT #4 stated the night shift NT "did not know about it." Interview revealed NT #4 "just left it alone" and "did not bother" Patient #1 about it. Interview revealed NT #4 did not remember bruising on Patient #1's arms.

Telephone interview on 09/29/2021 at 1408 with Medical Doctor (MD) #1 revealed he was not notified that Patient #1 had blood on gown and around mouth. Interview revealed MD #1 saw and assessed Patient #1 daily.

Telephone interview on 09/29/2021 at 1550 with Registered Nurse (RN) #2 revealed she remembered Patient #1. Interview revealed RN #2 remembered Patient #1 had "bruising" but no open wounds. Interview revealed the bruising was "generalized and lip wound". Interview revealed RN #2 cared for Patient #1 two consecutive days. Interview revealed on the second day, the certified nursing assistant (CNA) reported Patient #1 had blood on her gown and around her mouth to RN #2. Interview revealed RN #2 "went into Patient #1's room and did an assessment of her mouth." Interview revealed blood was coming from Patient #1's mouth and lip. Interview revealed RN #2 did not document her assessment nor did she write a nursing note. Interview revealed RN #2 was unsure if the blood was from a problem with a tooth. RN #2 stated that if a fall had been witnessed or an injury been witnessed, RN #2 would have filled out an incident report. Interview revealed not witnessing the injury, RN #2 would not fill out an incident report.

Telephone interview on 09/30/2021 at 1041 with Nurse Technician (NT) #3 revealed she remembered Patient #1. Interview revealed Patient #1 had dried blood on her mouth and on her gown when NT #3 went in the room. Interview revealed NT #3 notified the nurse, but the "nurse did not go in the room to assess the patient." Interview revealed the nurse told NT #3 to "get a washcloth and clean it up."

NC00180751; NC00181587