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Based on medical record review, internal investigation report, staff interviews, and policies and procedures it was determined that the facility failed to ensure that the patient's next of kin or guardian was notified of unexpected events when it was determined that one patient (P) (P#1) of three patients reviewed sustained an injury to his head during transport. Family of P#1 was not notified of the injury.


Findings include:


A review of the facility's policy titled "Patient Rights and Responsibilities," last revised 05/2019 revealed II. Purpose. The purpose of this policy is to a. ensure care, treatment, and services are provided in a way that respects and fosters the patient's rights as outlined in this policy. III. Procedure. 9. Receive care in a safe environment free of neglect, exploitation, verbal, mental, physical or sexual abuse. GHS reports cases of neglect and abuse to law enforcement and other protective services at any of the offices listed below.

A review of the facility's policy titled "Patient Safety Observation," last revised 2/2022 revealed it is the policy to provide monitoring, observation and supervision to all patients who meet the appropriate risk criteria. Implementation of this policy is a nursing decision based upon clinical data, potential for patient safety concerns, and unique patient care needs. The type of monitoring that will be provided to the patients is dependent upon the condition of the patient as assessed by the Registered Nurse (RN) or physician providing care.

A review of the facility's policy titled "Informing Patients and/or Families of Unanticipated/Unexpected Outcome of Care," last revised 1/2019 revealed Policy Statement. It is the goal to have open, honest communication with patients and that all patients feel involved in their care and treatment. This communication may take the form of informed consent, communication of an unanticipated event, and talks with physician and staff. Patients or the appropriate guardian or representative will be provided relevant information about all outcomes of care. The Health System requires that patients and when appropriate, his/her legal guardian, healthcare representative or family are informed about the outcomes of care, including unanticipated/unexpected outcomes. It is the responsibility of the providing Licensed Independent Practitioner, or his/her designee to clearly explain the outcome of any treatment or procedures to the patient, and when appropriate his/her legal guardian, healthcare representative and/or family, in layman terms, wherever those outcomes differ significantly from the anticipated outcome. This policy will also be adhered to by all (facility) staff for all outcomes which includes: unanticipated/unexpected events.

A review of P#1 medical record revealed that P#1 was admitted to the facility on 10/5/2024 with a diagnosis of fall with dislocation of shoulder.

Review of nursing note dated 10/12/2024 at 1:01 a.m. revealed upon transferring pt from on bed to another, draw sheet was used to assist pt to the top of the bed, however, pt's head was struck on the backboard of the bed. A skin tear with small amount of blood was noted to the top of the pt's head. Pt did not complain of any pain or discomfort and neuro assessment was still intact. Upon my departure, pt was resting in bed with no complaints and side rails activated. Care transferred.

Review of nursing note dated 10/12/24 at 1:02 a.m. revealed patient on arrival to the unit, transferring patient from ICU bed to the unit bed, patient head hit to the head of the bed and started bleeding, 4x4 guess [sic] dressing was placed on it with pressure to stop the bleed, team trauma 1 called and notified, said they would be there to assess patient, A&Ox3, admission assessment and it's takes two performed by two nurses, on the skin assessment patient had generalized bruises, skin tear to the sacrum, vitals taken, all safety measures in place, will continue with plan of care.

Review of physician note dated 10/12/24 at 4:08 a.m. revealed assessed the pt at bedside after nurse informed me that during transfer, the patient's head hit the bed and started bleeding. He has 2 skin tears on the superior aspect of his scalp approx. 1 and 2 cm. Both wounds are hemostatic. Please change dressings as needed.

Review of physician progress note dated 10/12/24 at 7:09 a.m. revealed patient hit head during a transfer overnight, CT Head negative, patient resting in bed, tolerating a diet. Discussed discharge plans with the patients daughter who is requesting the patient to discharge home health. Will plan for physical therapy to evaluate the patient working towards going home.

Review of Nurse Practitioner progress note dated 10/15/24 at 5:25 p.m. revealed patient resting in bed; alert and oriented x3; denies pain just reports he is "uncomfortable"; new skin tear to left elbow from yesterday. Dressing changed, photo of wound in chart. Scalp dressing changed. Photo of wound in chart. Son and daughter-in-law at bedside and updated.

A review of the facility's incident log dated July 2024 through October 2024 revealed an incident #272246 was reported on 10/12/2024 regarding P#1 and Skin/Tissue harm. Continued review revealed that staff assisted the transfer of P#1 into the bed upon arrival to unit 5A. "The pt then needed further assistance to the head of the bed. A 5A Nurse and Tech were at the top of the bed, one on each side, and the 7KIS tech and I were assisting at the end of the bed with the pt's feet. The pt was assisted to the top of the bed via draw sheet, however, he was pulled up too far and hit his head on the backboard of the bed. A skin tear with small amount of blood was noted to the top of the pt's head. Pt did not complain of any pain or discomfort and neuro assessment was still intact. The primary RN was notified, pressure was held to top of head with gauze and Provider was notified and to come see pt at bedside. Upon my departure pt was resting in bed with no complaints and side rails activated."

An interview was conducted with Nurse Practitioner (NP) GG on 10/23/2024 at 10:30 a.m. in the Risk Management conference room. NP GG stated that she did recall caring for P#1 on Unit 5A for two days during his admission. She continued to explain that the skin tear injury to P#1's scalp occurred the day before she began caring for him however, when she saw P#1 for the first time she notice the skin tear on his scalp and changed the dressing. NP GG stated that the nursing staff will not generally call family regarding skin tears because with some vulnerable patients it happens all too often. NP GG continued to explain that when she saw P#1 for the second time he did have a new skin tear on his left elbow area that was not present on the previous day. She continued to explain that there was no documentation in his medical record as to how the skin tear on his left elbow happened. NP GG continued to explain that she did have one conversation with P#1's daughter about discharge planning and answered her questions and concerns, however, did not advise her of the injury to his scalp or left elbow. She continued to explain that she had a separate conversation with P#1's son who was at bedside during the second visit and he was upset about the skin tear on P#1's elbow because it was unexplained as to how it happened.

A telephone interview was conducted with Registered Nurse (RN) HH on 10/23/24 at 11:30 a.m. RN HH stated that he did recall P#1 during his admission on Unit 5A. He continued to explain that he did recall when P#1 received the skin tear on his scalp. RN HH stated that when P#1 was with transport transferring from one unit to Unit 5A he and the Tech were transferring P#1 from the transport bed to the bed in his room and during the transfer process we accidentally hit his head at the top of the headboard which caused the skin tear. RN HH continued to explain that he immediately contacted the unit manager and the Nurse Practitioner. He stated that he was advised to treat the wound and place a 4x4 gauze on his head and change gauze as needed. RN HH stated that he does not know how P#1 received the skin tear on his elbow. RN HH confirmed that he did not make contact with P#1's responsible party regarding the incident. He continued to say that P#1 has not sat for extended amounts of time in feces or urine. He continued to say that P#1 received bed baths during his admission to Unit 5A.

A telephone interview was conducted with RN II on 10/24/24 at 9:30 a.m. RN II stated that she did recall P#1 during his admission to the facility. She continued to explain that she cared for P#1 for approximately two days when to transferred from another unit to Unit 5A. RN II stated that she was present when P#1 was transferring from the previous unit's hospital bed to a bed on Unit 5A and during the transfer she was assisting another nurse and two other technicians when the transfer was a little rough, although unintentional, P#1's head hit the headboard of the bed to which he was transferring. She continued to explain that as a result of the hit to his head he sustained a skin tear to his scalp that began to bleed. RN II stated that she immediately advised the head nurse, RN HH, who walked in after P#1 sustained the hit to his head, about what had happened and then she immediately cleaned the wound and applied the 4x4 gauze to the injury. RN II stated that RN HH stated that he would report the injury to the NP. RN II stated that she advised RN HH that she would enter the incident report in the system. She stated that she could not confirm any information regarding the skin tear on P#1's elbow without reviewing his chart because he came to the facility with several injuries due to his fall. RN II confirmed that she did not contact P#1's family regarding the incident to his scalp.