HospitalInspections.org

Based on interview and record review the facility failed to fully analyze an adverse event in a timely manner.
The facility failed to ensure that a variance report was completed per policy guidelines following the discovery of an injury to Patient # 6 ' s leg.
Findings include:
TX # 00198669
Review of complaint intake TX # 00198669 revealed Patient ID # 6 was admitted to facility on 04-02-14 " for poor circulation of the right leg and gangrene of the second toe in her right foot. " According to the complaint intake documentation, Patient ID #6 left the room to have an angiogram on 04-04-14. Upon the Patient ' s return to the room, a family member discovered blood on the bed sheet and a " gash " on Patient # 6 ' s right leg, just above the ankle. There had been no mention of the injury provided to the family; the " gash was just covered by tape. "
Review of Patient ID # 6 ' s clinical record revealed she was a 96 year old female admitted to the facility on 04-02-14 for poor circulation and non-healing gangrenous right toes.
Record review on 07-23-14 of facility " Risk Occurrence Report, " dated 04-08-14 (0754) completed by RN # 62 read: " Patient and daughter stated that patient had a skin tear to rt. Lower extremity when she went down for angiogram. Daughter stated that her mother ' s skin was intact before leaving the floor and came back with skin tear ... "
Interview on 07-23-14 at 1:10 PM with RN # 63 she stated she was the nurse assigned to the angiogram case on 04-04-14 with Patient ID # 6. She said she remembered the patient was moved from the stretcher to the x-ray table with a " slider board. " There were staff at the patient ' s head and feet; Patient ID # 6 ' s legs were picked up during the transfer.
RN # 63 said after the transfer, she saw blood on the sheet and noticed the laceration to Patient ID # 6 ' s right lower leg. She said " I had no idea how it got there. It looked as if it had just happened; it was bleeding. " She went on to say she cleaned the wound with normal saline and covered it with a tegaderm dressing. The angiogram was done and report was given to the recovery room (RR) nurse. RN # 63 said she informed the RR room nurse of the wound to the patient ' s leg.
RN # 63 said she did not complete a variance report; stated " I should have. "Review of RN # 63 ' s nursing note on 04-04-14 read: " right lower extremity laceration; covered with tegaderm. "
Interview on 07-23-14 at 12:30 p.m. with facility Risk Manager ID # 52 she stated that when the facility met with the patient ' s daughter she seemed most upset that no staff informed her about the injury. Risk Manager ID # 52 acknowledged the variance report was completed 4 days after the injury was discovered and it should have been completed the same day.
Interview on 07-23-14 at 12:45 p.m. with facility Director of Risk Management ID # 56 she stated the expectation was that staff complete variance reports immediately or at least by the end of the shift the occurrence happened. She acknowledged that had a variance report been completed timely for Patient ID # 6 ' s injury, the communication process with the family would have begun sooner.
Review of facility policy titled: " Variance Reporting Patient and Non-Patient," revised date 12/11, read:
" Definition of ' event ' , variance, ' occurrence ' : any happening out of the ordinary that results in a potential for or actual injury to a patient visitor ...any event that is not consistent with or reasonably expected as a consequence of medical care and treatment. ...Policy " adverse events ...unexpected events ...will be promptly reported inline in the Meditech System even if the event seems insignificant at the time ...Event reports should be completed during the shift the event occurs or is discovered to have occurred...the individual most directly involved or who discovers the event is responsible for entering the event into the system ... "