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Based on review of hospital policy and procedures, medical record review, shift report and interviews it was determined the facility staff failed to complete an incident report after a patient fell at the facility. This affected Medical Record (MR) # 1 at the Decatur West campus and had the potential to affect all patients served by the hospital.

Findings include:


Policy: P.SAF.004
Title: Adverse Events, Unanticipated Outcome
Effective date: August 2010.

Purpose: To ensure that the hospital and all its components have processes to identify, analyze and respond to adverse events.

Definitions:
1. Adverse event: Undesirable and unintended event occurring in association with medical care from the view point of the patient.

Procedures:

1. Adverse event resulting in patient harm or Sentinel Event:
" a. Provide emergency treatment if necessary.
b. Reassess the patient (RN[ Registered Nurse]) and document in the medical record.
c. Notify the patient's attending physician...
d. Observe patient for changes in condition and effectiveness of treatment....
h. Complete a quality assurance report and forward to department director...

4. The Quality Management Department will analyze reports of hospital acquired conditions; identify trends and report through quality monitoring committees."


1. MR # 1 was admitted to the facility 9/11/13 with diagnoses of Psychosis, Suicidal/Homicidal Ideations, Diabetes Mellitus and Chronic Obstructive Pulmonary Disease.

The Nursing Note dated 9/12/13 at 01:26 AM documented, " At 0050 patient (pt) was found lying in bedroom floor...Pt had just been checked on about 5 minutes prior and was lying in bed with feet hanging off and snoring... repositioned pt in bed. Abrasion found on left elbow with active bleeding, red spot on back of pt's head and 3 small red spots on lower back... BP (Blood Pressure) 133/85 O2 sat 96% (Oxygen saturation) Respirations 18, HR (heart rate) 84, temperature 96.9 and FSBS (Fingerstick blood sugar) 54. Pt given juice and peanut butter crackers. Dr... notified and new orders received to send to Parkway ED (Emergency Department) for evaluation..."

The surveyor asked for an incident report / quality assurance report and the facility was not able to locate a report regarding the fall.

Employee Identifier # 2, Nurse Manager provided a Shift Report for 9/11/13, as she was the Shift Supervisor that night. EI # 2 stated she was certain she would have completed the report but was unable to locate it.
The shift report documented under Events/Problems the fall experienced by MR # 1.

In an interview 6/11/14 at 9:00 AM with Employee Identifier # 1, The Chief Nursing Officer verified that no report had been located

Based on review of medical records and interview it was determined the facility staff failed to:

1. Have an order for wound care provided

2. Obtain wound care orders to provide wound care

3. Assess wounds/lesions for signs/symptoms of infection or deterioration

4. Assess a patient post head injury from a fall.

This affected Medical Record # 1 and # 2 at Decatur Morgan West, 2 of 3 medical records reviewed and had the potential to affect all patients served by this facility.

Findings include:

1. MR # 1 was admitted to the facility 9/11/13 with diagnoses of Psychosis, Suicidal/Homicidal Ideations, Diabetes Mellitus and Chronic Obstructive Pulmonary Disease.


The Nursing Note dated 9/12/13 at 01:26 AM documented, " At 0050 patient (pt) was found lying in bedroom floor...Pt had just been checked on about 5 minutes prior and was lying in bed with feet hanging off and snoring... repositioned pt in bed. Abrasion found on left elbow with active bleeding, red spot on back of pt's head and 3 small red spots on lower back... BP (Blood Pressure) 133/85 O2 sat 96% (Oxygen saturation) Respirations 18, HR (heart rate) 84, temperature 96.9 and FSBS (Fingerstick blood sugar) 54. Pt given juice and peanut butter crackers. Dr... notified and new orders received to send to Parkway ED (Emergency Department) for evaluation..."

The Nursing Note dated 9/12/13 at 2:11 AM documented, " ... RN from Parkway ED called report on pt. Stated there was a tiny hematoma on head, antibiotic ointment applied to abrasion on elbow and last FSBS at 0153 (1:53 AM) was 172."

The Nursing Note dated 9/12/13 at 3:09 AM documented, " Patient returned back to unit at 0235 (2:35 AM), FSBS 168. Pt escorted to bathroom and back to bed,"

There was no documentation of an assessment being completed related to the hematoma on his head or the abrasion on the elbow or the appearance of any type dressing to the elbow.

The CRNP (Certified Registered Nurse Practitioner) documented 9/12/13 at 11:00 AM in the Progress Notes, " Pt ambulating with slow gait using walker; c/o (complained of) back and elbow pain...pt instructed to ring bell and/or call for assistance before getting out of bed; skin tear on Left elbow oozing will order cleanse with saline, pat dry, cover with opsite or similar..."

The CRNP failed to write an order for the wound care in the medical record.

The Nursing Note dated 9/13/13 at 2:48 PM documented, " Applied a dressing to patients left elbow. Cleaned with NS (Normal Saline), applied triple antibiotic ointment, covered with gauze and secured with tape at 1330 (1:30 PM).

There was no order for the wound care the nurse provided and no wound assessment documented.

The nurses failed to document any assessment of the patient's head or hematoma from the fall from 9/12/13 through discharge 9/16/13.

In an interview 6/16/14 at 9:38 AM with Employee Identifier (EI) # 2, the Nurse Manager confirmed the nurses fail to document any further dressing changes or assessments of the wound on the left elbow from the occurrence 9/12/14 until the discharge of the patient 9/16/13.

2. MR # 2 was admitted to Decatur Morgan West 12/31/13 with diagnoses of Bipolar Disorder, mixed with Psychosis and Hypothyroid.

The CRNP documented in the History and Physical completed 1/1/14, " Plan... Will also have Bactroban twice daily x 5 days for the lesion on her hand."

The nurses notes failed to include any documentation of a wound/ lesion or any assessment of an area on the patients hand.

The medication administration record confirmed the patient did receive Bactroban topical twice a day for 5 days.


In an interview 6/16/14 at 9:38 AM with EI # 2, the Nurse Manager confirmed the nurses fail to document or assess the wound/ lesion on the patients hand from the admission 12/31/13 through 1/9/14 discharge.