HospitalInspections.org

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Based on medical record review, document review, and interview, in one (1) of twelve (12) medical records reviewed, the facility failed to ensure that the incident of a patient who was identified to have sustained a fracture during hospitalization was investigated and the patient protected from further injury.

Findings:

See Tag 0144.

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Based on medical record review, document review, and interview, in one (1) of twelve (12) medical records reviewed, the facility failed to ensure that the incident of a patient who was identified to have sustained a fracture during hospitalization was investigated and the patient protected from further injury.

Findings:

A review of the medical record for Patient #1 identified that the patient was admitted on 08/20/2024 with diagnoses of Pneumonia and Urinary Tract Infection.

On 09/02/2024 at 2:14 PM, the patient had an abdominal computerized tomography (C.T.) scan [computerized x-ray imaging procedure] to rule out "Aortic Aneurism or Dissection" (a tear in a main artery). The scan revealed no evidence of abdominal aortic aneurism or dissection but a new finding of an "Angular Impacted Fracture of the Right Neck of Femur" (a fracture within the capsule of the hip joint) compared to the C.T. scan on 08/21/2024.

On 09/03/2024 at 10:25 AM, an Orthopedic Consultant (Staff L) documented, "Right femoral neck fracture incidentally found on C.T. abdomen and pelvis. New since previous C.T. on August 21st. Traumatic event unknown." The patient has bilateral lower extremity contracture and is not alert and oriented to place, persons, and time. There is no plan for operative intervention, but orthopedic services will continue to follow the patient's clinical progression and reevaluate for surgery.

During an interview on 10/25/2024 at 12:33 PM with Staff C (Unit Nurse Manager, 11E), they stated the patient had contractions and required frequent repositioning in bed. Staff C reported that the patient had no fall incident and that they did not know the cause of the fracture. Staff C confirmed the facility did not investigate the incident.

On 10/29/2024 at 12:01 PM, during an interview with Staff H (Registered Nurse, 11E), they stated the patient had a history of osteomyelitis and deep pressure sores; they were bedbound and needed frequent repositioning. Staff H acknowledged that the patient sustained a fracture, but the fracture was not investigated because it was not a reportable incident.

A review of the facility's policy titled "Reporting of Adverse Events (Incident Reporting)" reviewed and reissued 01/2024) stated, "Adverse Event" means untoward incidents, therapeutic misadventures, iatrogenic injuries, or other adverse occurrences directly associated with care or services provided during the course of a patient's hospitalization, during outpatient care or while a person is a visitor at the facility (e.g. IV infiltrate, allergic drug reaction, burns, fall with injury, unexpected death, air embolism, unexpected postoperative complication, etc.)... The Patient Safety Risk Management Department shall review, investigate, and monitor all reported incidents and untoward occurrences, as appropriate and necessary."

There was no documentation of an investigation of the patient's fracture, and no measures were implemented to protect the patient from further injury.

During an interview on 10/29/2024 at 2:39 PM, Staff J (Senior Director of Patient Safety and Risk Management) acknowledged the findings and stated that the patient's fracture, although of unknown origin, should have been reported as an incident, investigated to determine the cause of the fracture, and, if problems are identified, implement corrective actions.

On 10/29/24, at 4:00 PM, during an interview with Staff L, they reported that they could not determine how the patient sustained the fracture. Staff L stated that the patient was bedbound, and the decision was not to perform a surgical repair.

These findings were brought to the attention of Staff J (Chief Regulatory Officer) during the exit conference on 10/29/2024 at approximately 5:00 PM.