HospitalInspections.org

Based on interview and record review the facility failed to fully analyze and implement important corrective actions related to an adverse event that involved two (2) patients (#1 and #5) of 10 patients.

Findings include:

Patient (ID# 5), was observed on 5/24/2018 at 1100 to have discoloration of left eye.

Record review on 5/24/2018 of nursing notes on 5/20/2018 at 0620 reported patient (ID # 5) with a contusion of left eye. An incident report was initiated on 5/20/2018.

Record review on 5/24/2018 of patient (ID #5) of entire medical record did not reveal that a post-fall packet (documents completed after a suspected fall) was initiated.

Record review on 5/24/2018 of patient's (ID #5) medical record (physicians progress note) dated 5/20/2018 at 1023 by provider (ID #60), documented a diagnosis of dementia and confusion regarding the fall, but labeled the incident as an unwitnessed fall.

Interview on 5/24/2018 at 1100 with patient (ID#5) about the discoloration of left eye, revealed the patient did not know how the incident occurred. She stated "I do not know how it happened, I did not fall".

Interview on 5/25/2018 at 1330 with staff (ID #53) stated "there was no packet (post fall assessment) done because the patient stated she didn't fall".

Record review on 5/25/2018 of the patient post-fall packet front sheet stated:
"To be completed with every fall."
"The incident report along with the RN assessment should be completed."

Patient #1

Record review on 5/25/2018 of progress note dated 8/21/2017 at 2: 00 p.m. by staff (ID #72), she documented that she spoke with patients (ID #1) daughter who stated her father was having surgery today for a fracture to the left arm.

Record review on 5/25/2018 of nurses notes dated 8/21/2017 Patient (ID #1), family reported the patient would be having surgery for a broken arm after being transferred to the emergency department on 8/17/2017 for a swollen left hand.

Record review on 5/25/2018 of the incident log for August 2017 stated patient (ID # 1) on 8/15/2017 at 1730 hit a staff member, with no injury or transfer and wife was called. No other documentation noted regarding the incident.

Record review on 5/25/2018 of current facility policy "Patient Incident & Occurrence Reporting" dated 1/11/2016 stated:
"A patient incident or occurrence is anything that is out of the expected norm for the patient."

Record review on 5/25/2018 of current facility policy "Sentinel Events" dated 1/11/2016 stated:
"All sentinel events-significant unanticipated events-take precedence and will be immediately and thoroughly investigated to determine the root cause of the event, and corrective action will be implemented to reduce the risk of the event recurring."

"Definitions: Serious injuries specifically included the loss of limb or function."