HospitalInspections.org

Based on interview, documentation in 1 of 1 medical record reviewed of a patient (Patient #2) with a hip fracture, and review of policies and procedures, it was determined the hospital failed to ensure the patient's right to safe care. Although the hospital identified the patient had a hip fracture, it failed to implement its own policies and procedures to address the fracture.

Findings include:

1. Review of a policy titled "Patient Screening, Assessment and Reassessment," dated 01/2013 reflected the following internal requirements: "The patient receives care based on initial and ongoing assessments...Each patient is reassessed by the various patient care services and departments at regularly specified times related to the patient's needs and the use of interdisciplinary collaboration. Examples of collaboration include communication in the health care record, interdisciplinary committees, patient care protocols, clinical paths, care planning rounds, patient care conferences, and direct verbal communication between team members."

The policy reflected that medical staff reassessments be conducted as follows: "...Reassessment of needs as patient's condition warrants. Pertinent progress notes sufficient to permit continuity of care and transferability shall be recorded at the time of observation. The condition of the patient will determine the frequency with which they are made.

The policy reflected that registered nurse reassessments be conducted as follows: "...Reassessment of needs occurs as patient's condition warrants...Needs reassessed when warranted by patient's condition with a maximum duration of 8 hours between observations."

2. Review of a policy titled, "Interdisciplinary Plan of Care," dated 12/2011 reflected the following internal requirements: "...The Registered Nurse will review the care plan every shift. Problems, interventions and goals will be revised as needed to meet patient care needs." Documentation requirements included the following: "...The care plan should be modified through the addition of new problems, goals or interventions, or resolution of problems and goals according to the patient's response to care."

3. Review of the medical record reflected Patient #2 was admitted to the hospital on 12/11/2012 at 1258 for management of a urinary tract infection, fever and altered mental status. The patient was bedridden and had a history of end stage multiple sclerosis, quadriplegia, and lower extremity contractures. The record reflected the patient was very difficult to understand, and did not normally communicate much.

A computed tomography (CT) urogram (an examination of the urinary system) was performed on 12/18/2012 at 0931. The results of the examination dated 12/18/2012 at 1030 reflected the patient had a right hip fracture.

Nurse flowsheets for 12/11/2012 through 12/24/2012 reflected the patient was bedrest, had contractures to both lower extremities and required assistance with care related activities such as bed mobility and hygiene. For example, on 12/19/2012 at 1200, the patient was dependent for mobility, and his/her activity was documented as "Poorly tolerated." On 12/24/2012 at 0700, the patient was bedrest, needed 2 persons for assistance with mobility, and was repositioned with a pillow support. None of the documentation addressed the patient's right hip fracture or how the patient's mobility status may be affected by the fracture, in order to ensure safe care was provided.

The record further reflected the patient experienced pain but was unable to communicate his/her pain level well. For example, on 12/17/2012 at 1637 the patient's pain rating was documented as "...[Patient] does not answer when asked but moans w/ turns." On 12/21/2012 at 1313 the patient would not rate his/her pain, but was medicated for pain. None of the documentation addressed the patient's right hip fracture or how the patient's pain level may be affected by the fracture.

The patient was discharged to an adult foster care home (AFH) on 12/24/2012 at 1424 (six days after the right hip fracture was identified on 12/18/2012). None of the documentation reflected that the patient's right hip fracture was communicated to the AFH in order to ensure safe care was provided after discharge.

A physician discharge summary dated 12/24/2012 at 0949 reflected it lacked documentation addressing the patient's right hip fracture, including any post discharge plans or follow up care related to the fracture.

The record lacked documentation of interdisciplinary collaboration and an assessment of the patient's needs related to the fracture in accordance with hospital policy. The record further lacked a documented modification to the plan of care addressing the patient's right hip fracture, including any goals, interventions or responses to care in accordance with hospital policy.

Nurse progress notes dated 12/24/2012 at 1726 (approximately 3 hours after the patient was discharged) reflected that a caregiver from the patient's AFH contacted the hospital and reported that the patient's right leg was pronated (rotated with the inner surface facing down or back) with crepitus (a crackling sound under the skin) in the hip. Hospital staff encouraged the caregiver to to bring the patient to the ED for further evaluation.

Physician ED notes dated 12/29/2012 at 1234 (five days after the patient was discharged) reflected the patient returned to the hospital. Physician ED notes dated 12/29/2012 at 1630 (eleven days after the right hip fracture was identified on 12/18/2012) again reflected that the patient had a right hip fracture. Review of a 12/29/2012 transfer form reflected the patient was transferred to another hospital for continued care of the fracture.

4. An interview was conducted on 05/03/2013 at 1430 with Interviewee B, a nurse who was assigned to care for Patient #2 on 12/24/2012. Interviewee B stated he/she medicated the patient for pain on 12/24/2012 because the patient was "scowling." He/she thought the patient may be in pain from being in bed for two weeks and from being assisted with repositioning. Interviewee B stated he/she was unaware that the patient had a right hip fracture and stated, "[His/her] leg certainly did not seem broken to me."

5. An interview was conducted on 06/06/2013 at 1530 with Interviewee F. He/she stated the 12/18/2012 CT urogram results which identified Patient #2's hip fracture would normally have been reviewed and addressed by nursing staff and physicians involved in the patient's care. However, he/she stated the hip fracture identified on the CT urogram "got missed." Therefore, the patient's hip fracture was not addressed as expected. He/she acknowledged that the medical record for Patient #2 lacked a documented plan of care, a discharge summary, or any communication with the AFH (prior to discharge 12/24/2012) addressing the patient's hip fracture.

6. An interview was conducted on 06/06/2013 at 1550 with Interviewee E. He/she acknowledged the medical record for Patient #2 lacked any assessments or physician progress notes (prior to discharge 12/24/2012) addressing the patient's needs related to the hip fracture. Interviewee E indicated that the impact on the patient was significant, and stated "It was probably very painful."