HospitalInspections.org

Based on review of medical records, review of facility documents, review of facility policy and procedures, and staff interview it was determined the facility failed to ensure staff identified, reported and investigated potential patient abuse for one (#1) of four patients sampled.

Findings included:

Review of the facility policy and procedure, "Adverse Events" revised 2/27/20 revealed the purpose included: (A) To provide guidelines for communicating, investigating and acting upon adverse events and serious adverse events and near misses; (B) To have a positive impact in improving patient care, treatment and services and preventing adverse events; and (E) To develop a reporting mechanism for any significant event affecting patient outcome.

The policy stated a system was in place for monitoring and reporting information related to adverse events that endanger the health and safety of clients and/or employees. An adverse event included but was not limited to: unusual occurrences; and other types of accidents or injuries. The policy stated all adverse events will be investigated and a determination made if the event meets the criteria of a serious adverse event. If the event does not meet the serious adverse event criteria, the appropriate follow-up action will occur. The policy stated all employee or contracted services shall immediately report an adverse event to the Administrator/Director.

Review of the medical record for Patient #1 revealed the patient was evaluated in the facility's ED (Emergency Department) on 3/5/2020 after a fall at home. The patient was admitted for observation due to recurrent falls, history of Parkinson's, and for CT scan of the head, consultation with Neurology, and consultation with Physical Therapy. Review of the nursing admission assessment revealed no evidence of any wounds, bruising or integumentary concerns.

Review of the nursing daily shift assessment, dated 3/6/2020 at 8:26 PM, revealed the patient's skin temperature, color, and appearance was assessed. Documentation revealed the patient's skin was warm, appropriate for race, and intact. The nurse documented the patient had a sitter at bedside. Review of the nursing assessment of the patient's skin, dated 3/7/2020 at 4:49 AM, revealed the patient had bruising under his right eye. There was no documentation to explain how the bruising under the right eye could have been sustained.

Review of the Patient Observer Monitoring Checklist form, which is used by patient sitters to document observations of the patient every 15 minutes, revealed there was no documentation by the assigned patient sitter on 3/6/2020 from 7:30 PM to 7:00 AM on 3/7/2020. A nursing note, dated 3/7/2020 at 1:39 AM, stated the patient was confused, trying to get out of bed, he was not responding to redirection, and the patient hit the sitter.

Nursing note, dated 3/7/2020 at 8:15 AM, stated the patient was walking with assistance from his wife and was in stable condition. The nurse assessed the patient's skin with bruising but did not indicate the location, and did not describe the color or size of the bruising. At 1:20 PM on 3/7/2020 the nurse documented the patient's right eye color was blue and the patient stated on the previous shift he was hit in the eye and someone stood on his foot. The patient's left toes also looked blue. The Charge nurse was notified of the findings.

Review of the nursing daily shift assessment, dated 3/8/2020 at 8:52 AM, revealed the patient had bruising to his skin. The nurse did not indicate the location, and did not describe the color or size of the bruising. On 3/8/2020 at 9:35 PM the night shift nurse assessed the patient's skin as warm, appropriate for race and no documentation of bruising. Review of the nursing daily shift assessment, dated 3/9/2020 at 2:00 PM, revealed the patient had bruising under his right eye. The nurse did not describe the color or size of the bruising. On 3/9/2020 at 7:30 PM the night shift nurse assessed the patient's skin as warm, appropriate for race and bruising. The nurse did not describe the location, color or size of the bruising.

Review of the nursing daily shift assessment, dated 3/10/2020 at 7:50 AM, revealed the patient had bruising under his right eye. The nurse documented under wound assessment that there was a bruise to the right eye, "see previous charting, picture in chart."

Review of the record revealed three photographs. Photograph #1 revealed bruising to the patient's right thigh. The picture did not have a date, time, or size of the bruise. Photograph #2 revealed bruising to the patient's left foot. The picture did not have a date, time, or size of the bruise. Photograph #3 revealed bruising to the patient's right eye. The picture did not have a date, time, or size of the bruise.

Review of the facility's adverse incident log revealed no adverse incident reports were submitted by any staff with direct knowledge of the incident of the patient hitting the sitter as reported to the nurse on 3/7/2020 at 1:39 AM. No adverse incident reports were submitted by staff who first identified and photographed the unexplained bruising to the patient's right eye, left foot, and right thigh.

An interview was conducted with the Risk Manager (RM) on 7/15/2020 at 2:45 PM. The RM confirmed she filed an adverse event report on 3/10/2020 under the category of staff complaint. She stated a call was received from the patient's spouse who provided concerns about the bruising the patient received and allegations that the patient's sitter mistreated him and caused the injuries. The RM confirmed law enforcement was contacted and interviewed the patient. Law enforcement did not file charges. The RM stated DCF (Department of Children & Families) investigated and had no findings. The RM stated she investigated the concerns and had no findings. There was no evidence any other staff members providing care to the patient on the evening shift of 3/6/2020 through the early morning hours on 3/7/2020 were interviewed. There was no evidence of an action plan to confirm staff understood the responsibility to identify and report adverse events.