HospitalInspections.org

Based on interviews, review of documentation in 1 of 1 medical records where a patient sustained a skin tear (Patient 1), and review of policies and procedures, it was determined the hospital failed to implement it's policies and procedures related to investigation of patient injuries.

Findings include:

1. Review of the medical record for Patient 1, a 92 year-old with fever and SOB, reflected he/she was admitted to the ED of PHCG on 01/16/2017 at 0235. Documentation in the ED provider notes on 01/16/2017 at 0341 reflected the following: "Unfortunately patient suffered skin tears and bruising to the left arm while in radiology." An ED nursing skin assessment was documented on 01/16/2017 at 0320 with a notation "new hematoma to L forearm noticed on return from X-ray. There was no other nursing documentation in the record regarding the incident until 01/16/2017 at 1501 by an inpatient RN. Another inpatient nursing note dated 01/17/2017 at 1630 reflected the following: "[Family] states [the skin tear] happened down in x-ray as [staff] had to restrain [the patient] as they would not allow the caregiver and/or the [family] in the room to help comfort [the patient] and hold [the patient's] hands...[the family] states the tear occurred when the BP cuff was removed..."

2. Review of the policy titled, "Patient Complaint and Grievance Policy," dated last reviewed "03-28-20" [sic] reflected the following: "...this policy is to establish a system policy to promptly and fairly address inpatient, outpatient, and clinic patient complaints and grievances regarding patient care...Grievance: A complaint received by any means after the episode of care is complete from a patient, patient's family member or other patient representative regarding the quality of the patient's care...Patient: ...the patient and/or the patient's legal personal representative."

* Review of the procedure titled, "Patient Complaint and Grievance Procedure." dated "03-28-20" [sic] reflected the following: "Grievances are expressions of dissatisfaction or complaints that cannot be resolved to the patient's satisfaction during the episode or [sic] care or complaints received by any means after the episode of care is complete...all grievances...are documented in the electronic incident reporting (EIR) system."

3. During an interview with the Imaging Manager on 04/13/2017 at 0900, he/she stated no knowledge of a patient sustaining a skin tear while in imaging. Further, he/she confirmed there was no incident report and if imaging staff had been aware of an injury the technician's responsibility was to follow the policy that directs them to file an incident report and report the injury to the nurse manager and physician.

4. Review of a policy titled "Serious Safety Events Policy," last reviewed "02-17-17" reflected the following: "It is the policy of PeaceHealth to improve patient safety through identification and review of serious safety events, and close calls. Root Cause Analyses are conducted in a standardized approach to assure thorough and credible serious safety events (SSE) reviews and corrective actions."

* During an interview with Risk Manager on 04/12/2017 beginning at 0900 he/she reported there were no incident reports or investigations related to this incident or regarding this patient.