HospitalInspections.org

Based on record review, document review, and staff interview it was determined the facility failed to ensure a patient's right to participate in her own plan of care in one (1) of ten (10) records reviewed (patient #1). This failure has the potential to negatively impact the care of all patients at the facility.

Findings include:

1. Review of the medical record for patient #1 revealed documentation of a photograph of the patient's lower arms, dated 3/7/17, which stated 'bruising from venipuncture'.

2. In an interview with Laboratory Assistant #1 on 3/14/17 at about 10:20 a.m. she stated she performed a venipuncture on patient #1 on 3/7/17 between 6:30 a.m. and 7:30 a.m. She could not recall the exact time. She stated she was aware patient #1 was confused and had intermittently fought with staff who were trying to provide her medical care. When she told the patient she was going to do the venipuncture the patient told her no and started swinging her arm trying to hit the lab assistant. She asked the nursing assistant who was providing one (1) on one (1) care to hold the patient's left arm while she completed the venipuncture. She stated she completed the venipuncture and did not note any bruise or skin tear on the patient's right arm where the procedure was performed.

3. In an interview with the nursing assistant (who was serving as a paid 'sitter') on 3/15/17 at about 8:45 a.m. she concurred with the above accounting of the venipuncture in question except she recalled that she noticed a skin tear on patient #1's right arm. She stated she is a new nursing assistant just out of high school and the patient's behavior shook her up. She told Registered Nurse # 2 she observed a skin tear and the nurse called the doctor and the family and took care of it.