HospitalInspections.org

Based on review of documents and interviews, it was determined that the for 2 of 2 (Pt. #1 & 2) records reviewed of patients involved in altercations and/or sustaining bruises after admission, the Hospital failed to ensure the patients were free from harm and abuse, and all injuries and incidences were reported and thoroughly investigated.

The cumulative effects of these systemic practices resulted in the Hospital's inability to ensure patient safety. As a result the Condition of Participation for Patient Rights was not met.

Findings include:

1. The Hospital failed to ensure patients were free from harm or abuse. (See deficiency cited at A145 A)

2. The Hospital failed to complete an occurrence report to ensure a thorough and complete investigation of the patient incidents. (See deficiency cited at A145 B)

A. Based on document review and interview, it was determined that for 1 of 1 (Pt. #1) clinical record reviewed of a patient with bruises sustained after admission, the Hospital failed to ensure the patient was free from harm or abuse.

Findings include:

1. The clinical record of Pt. #1 was reviewed on 1/29/13. Pt. #1 was a 50 year old female admitted on 10/16/12 with a Diagnosis of Schizoaffective Disorder. The admitting assessment on 10/24/12, indicated that Pt. #1's skin was WNL (within normal limits), and no wounds, ulcers, or bruises were identified on admission. Nursing documentation during the hospitalization included frequent outburst, tantrums, and verbal and physical altercations with other patients.

Two (2) photographs dated 10/24/12, included in the clinical record, showed bruises to Pt. #1 's left upper arm. The record lacked any documentation of the origin or the cause of the bruises, an examination by a physician, and report or investigation of the cause for the bruises.

2. Hospital policy titled, "Patient Rights and Responsibilities," (revised 7/11) required, "...Specific Rights. The right to expect reasonable safety with respect to medical facility practices and the environment...."

3. The "Exercise of Patient Rights," document required, "The patient's Rights document includes at a minimum, that the patient has: F. The right to receive care in a safe setting. G. The right to be free from all forms of abuse or harassment...."

4. E#2 (RN) who took care of Pt. #1 on 10/24/12 was interviewed on 1/30/13 at 1:15 PM. E #2 stated that Pt. #1 came to the nursing desk and showed bruises on her arms, stating,
"look at my arms." E #2 stated he thought that the bruises were from getting PRN injections, and that the bruises looked old because of the blue/green/yellow coloring. E #2 stated he took the pictures of the bruises to the arm but did not document or report the bruises, and there was no examination of the bruises by a physician.

5. The Nurse Manager of 5 South Behavioral Unit (E #4) was interviewed on 1/30/13 at 1:00 PM. E #4 stated she did not recall any incident relative to Pt. #1, that would cause the bruises. E #4 stated she did not receive any report and was not aware of Pt. #1's bruises, photographed by E #2 on 10/24/12.

6. The above findings were discussed with the Director of Behavioral Health and the Assistant Administrator during an interview on 1/30/13 at approximately 1:30 PM.


B. Based on review of documents and interview, it was determined that for 2 of 2 (Pt. #1 & 2) records reviewed of patients involved in an altercation, and/or sustained bruises after admission, the Hospital failed to complete an occurrence report and thorough investigation of the incidents.

Findings include:

1. The Facility policy titled, "Incident Report Protocol" (reviewed 6/11) was reviewed on 1/30/13 at approximately 9:00 AM. The policy required, "An incident report will be initiated when an incident or near miss is reportable. Policy: all departments are responsible for reporting every incident or near miss that occurs within the area of responsibility. Purpose: To provide a record of the incident or near miss and documentation of the facts. To provide basis for further investigation and to determine and evaluate: deviations form standards of care, policies, procedure. Corrective measures needed to prevent reoccurrence. Procedure: A. Completely fill out the Incident Report and Incident Report Follow-up, B. Immediately report...to your supervisor, C. Notify house physician to examine patient involved in the assessment for injury and /or suspected injury. D. Notify attending physician and document the notification...."

2. The clinical record of Pt. #1 was reviewed on 1/29/13. Pt. #1 was a 50 year old female admitted on 10/16/12, with a Diagnosis of Schizoaffective Disorder. The Nursing note dated 10/20/12 at 3:30 PM, indicated that, "Patient was walking in the hallway had verbal altercation with another female Pt. and she screamed so loud that staff went running to intervene, the other female pt. attempted to choke her, ...code grey was called ...pt was checked for any injury, none noted, ...ER medical doctor notified and he came to check the pt.... "The Physician's note dated 10/20/12 at 5:00 PM, included the following: " ...at about 3:30 today was attacked by another patient who tried to strangle the patient. Placed hand around the neck, shoved her back to the wall, pt protected her neck now denies any pain in the neck, ...any pain in the upper back, no other complaints...."

The clinical record contained 2 photographs of bruises to the right upper arm dated 10/24/12. However the record lacked documentation of the origin of the bruise, an examination of the bruise by a physician, an investigation of the bruises, and documentation that it was reported to a supervisor.

3. The clinical record of Pt. #2 was reviewed on 1/30/13. Pt. #2 was a 39 year old female admitted on 10/15/12 with a diagnosis of Schizoaffective Disorder. Nursing documentation on 10/20/12 indicated that Pt. #2 was loud, aggressive and was observed choking another patient, (Pt. #1). Pt #2 was redirected to her room, de-escalated and was maintained on every 15 minute precautions monitoring. There was no documentation of a physical assessment of Pt. #2.

4. The incident reports for 10/1/12-1/29/13 were reviewed on 1/30/13. There were no incident reports of the altercation between Pt. #1 and Pt.#2 that occurred on 10/20/12, or for the bruises reported by Pt. #1 and photographed on 10/24/12.

5. The Hospital Assistant Administrator and the 5 South Nurse Manager were interviewed on 1/30/13 at approximately 1 :30 PM. The Administrator and the Manager stated that there were no incident reports generated for the patient to patient altercation on 10/20/12 involving Pt. #1 and 2. The Manager and the Administrator also indicated that they did not receive any report of the bruises identified on 10/24/12, and therefore no investigation was conducted on how Pt. #1 sustained bruising on her left forearm. Consequently, there has been no corrective actions developed or implemented.

6. The above findings were discussed with the Assistant Administrator and the Director of Behavioral Health interviewed on 1/30/13 at 3:00 PM who stated that there should have been incident reports on all of the above incidents and that the bruise should have been reported, examined and investigated.