HospitalInspections.org

Based on medical record review, staff interview, and policy review, the facility failed to ensure that Patient #1 received care in a safe setting. An injury of unknown origin was not reported and not investigated.


Findings include:


On 5/30/17 the State Agency received a complaint from Patient #1's family which stated: "My mother (Patient #1) was a patient in (facility) to get sleep medication regulated. Her sleeplessness was directly related to her lack of sleep. When she entered (the facility) she was alert, feeding herself, and maneuvering her wheelchair. After leaving (the facility) she cannot feed herself, barely speaks, and cannot sit up in her wheelchair. We feel this is a direct result of her being given 100 mg (milligram) of Seroquel that was not prescribed by (her doctor). That night she fell resulting in a huge knot on her forehead and bruising of the left side of her face and she could hardly open the left eye. No staff member can tell us how, when, where this fall occurred. She is unable to lift herself up, so someone knew. No one contacted me, my brother or 2 sisters about the fall. After this she could hardly hold her head up, could not feed herself, and barely spoke. She was also left in her bed of urine. We complained to the CEO and Administrator one week later to inquire about their investigation of our concerns. (The CEO) told me that "our lawyers should talk to their lawyers". We have since removed our Mother to a private home. This incompetent and negligent place should be investigated and shut down. Please do not allow another loved one to be abused..."


An unannounced visit was made to the facility on 6/1/17. The nature of the visit was discussed with the Administrator at 2:35 p.m.


Review of a 5/15/17 Complaint and Grievance Form filed by the family revealed: "...Complaintant's Concern or Issue: Family is concerned on how pt received the injury to forehead. Also concerned about medications that pt is currently taking... Staff Findings and Resolution of Complaint: Notification process was not followed and family/administration was not notified.... Actions Taken: Reviewed/Revised P&P... Provided in-service to staff. Completed on 5/23 - 5/24... Posted Memo to staff. Posted Post-fall instructions.. Circulated information for review. Posted incident reporting process..."


Record review revealed that Patient #1, a 77-year-old female, was admitted to the facility's Geri-Psychiatric Unit on 5/06/17. The Psychiatric Evaluation dated 5/8/17 stated: "Justification for 24-hour Care Criteria: pt (patient) gravely disabled, unable to care for self, confused, depressed, delusional, hallucinations and other factors resulting in severe loss of functioning. History of Present Illness: 77 year old female with h/o (history of) dementia was admitted for increase confusion/agitation and aggression. pt reportedly getting increasingly agitated and irritable with staff in recent days. reports hearing voices and seeing things which are not there. crying with no reason. calling out loud help, help. during interview pt appeared to be very confused and delusional. tells me she is in a motel... visiting with her husband to get away from family. pt could not provide any reliable information during interview. denies feeling depressed. no evident mania or psychosis... Previous Psychiatric History: Dx (diagnosis) dementia... currently lives at nh (nursing home)... Prognosis: guarded.. Preliminary Treatment Plan A. Assessment/Problem List: depression, agitation/aggression, delusional/psychosis..."


Review of Nurse's Notes revealed:
"5/11/17 19:45 (7:45 p.m.) ... perform neuro (neurological) checks due to unwitnessed injury to head..."
"5/12/17 19:15 (7:15 a.m.) ...hematoma to forehead above right eye...unwitnessed incident.. alert awake oriented to self.."
"5/14/17 00.00 ..family member called upset, requesting pt to be discharged..feel she is not being cared for due to fall resulting in hematoma to right forehead on 5/11/17..."


Review of a 5/15/17 09:20 (9:20 a.m.) Social Services note revealed: "Narrative Note: This social worker and administrator... met with pt's three daughters per their request. Daughters expressed unhappiness "with her medical and mental state". Daughters stated they would like to have the pt transferred to another facility. (Daughter #1) stated the pt had a fall and the family was not notified... stated when she visited the pt on Saturday, the pt was in bed and she noticed "a knot on her forehead and she was not able to wake up and talk."... was informed a CT (Computerized Tomography) was done which was negative... wants to know what happened to the patient between Thursday (5/11/17) after 5:00 p.m. and Friday (5/12/17). Daughters stated they feel the pt's condition has deteriorated since she has been at this facility..."


Review of Physician Notes revealed:
"5/10/17 16:00 (4:00 p.m.) Patient remains very confused, but less agitated, sleeping better with Trazadone - met with daughter in treatment team who is a nurse practitioner, agrees with trying current regimen and possibly switiching to Seroquel if ineffective.." Seroquel 100 mg at bed time was ordered by the physician on 5/10/17 at 6:32 p.m. and was given at 9:00 p.m. The Seroquel was discontinued on 5/11/17 at 5:17 p.m.
"05/13/2017 at 14:13 (2:13 p.m.) Progress: pt remains very confused and drowsy this am. reportly had a fall. CT head negative. sleeping better..."
"05/19/17 ...contusion on forehead and periorbital hematoma from previous incident healing well. CT results: No acute findings. Nonspecific soft tissue scalp prominence in the right frontal area with no underlying skull abnormality. Cortical atrophy with ventricular dilatation - No other significant findings compared to the previous exam..."


On 6/2/17 at 2:35 p.m. an interview with the facility's Social Worker revealed that she saw Patient #1 throughout her stay at the facility. She stated that the only change she saw in the patient was that she got weaker.


On 6/2/17 at 3:00 p.m. the Activity Director stated that Patient #1 required assistance with activities, but was able to participate. She did not notice any increase in physicial limitations.


Review of Patient #1's medical record from the nursing home she was in prior to the geri-psych admission revealed that on 5/3/17 she had a fall and sustained a hematoma above the occipital bone. She experience another fall on 5/4/17 with no injuries.


Review of the facility's "Patient Incident & Occurrence Reporting" policy revealed:
"Policy: Facility staff will report all patient occurrences through the use of the facility's incident reporting form... A patient incident or occurrence is anything that is out of the expected norm for the patient (ex: elopement, fall, altercation, psychiatric emergency).
Purpose: To document any potential or adverse occurrence within the facility or on the facility grounds/property/vehicle, with the facts available at the time, recorded by persons involved, either in the incident or in discovery of the incident.
Procedure: All Staff: If one has witnessed an incident or is informed that an incident has occurred, completes the incident reporting process; Completes the appropriate form; Provides incident details as reported or witnessed by those involved; When reporting the incident, the information should be clear, concise and factual; Routes form to QAPI (Quality Assurance Performance Improvement) Director or in some cases immediate supervisor for investigation; The Administrator will be notified of any Sentinel Event or unanticipated outcome; Notify patient's family and physician..."


On 6/5/17 at 2:48 p.m. these findings were reviewed with the Administrator. No other information was submitted for review.


The complaint that Patient #1 received an injury of unknown origin which was not reported or investigated was substantiated.