HospitalInspections.org

Based on review of 2 of 10 (Patient #1 and Patient #2) patient records, the Hospital failed to ensure that Hospital staff properly reported patient related incidents.

Findings include:

The Hospital policy titled Prevention, reporting and investigation of suspected abuse, mistreatment, neglect, harassment or exploitation of patients required the completion of an incident report for actual or suspected incident(s) of abuse, neglect or mistreatment.

The Hospital policy titled Patient Incident Reporting System required the completion of an incident report for all potential and actual events, incidents and accidents involving patients. The report should be completed as soon as possible following the event so that continuous improvements are made for the safety of patients.

Patient #1 (Alleged abuse)

The Hospital's incident report log dated 12/1/12 through 2/28/13 did not identify the incident related to Patient #1's examination by a Sexual Assault Examiner Nurse for an alleged sexual assault on 2/16/13.

Surveyor #2 interviewed the Risk Manager 8:15 A.M. on 3/18/13. The Risk Manager said that an incident report was not completed related to Patient #1's examination by a Sexual Assault Examiner Nurse for an alleged sexual assault.

Patient #2 (Wrong level spinal surgery)

Surveyors #2 and #3 interviewed the Physician Assistant (P.A.) at 3:07 P.M. on 3/21/13. The P.A. said that she evaluated Patient #2's 1/30/13 post-operative spinal x-ray and identified an x-ray discrepancy. The P.A. said that she reported the x-ray discrepancy to the covering neurosurgeon. The P.A. said that the covering neurosurgeon agreed the surgery was performed at an unintended level in the spine. The P.A. said that the covering neurosurgeon reported to her that it was not their place to disclose the wrong level spinal surgery to the patient. The P.A. said that she did not report the wrong level spinal surgery to the Hospital Risk Manager.

Surveyor #2 interviewed the Hospital Risk Manager at 8:00 A.M. on 3/19/13. The Hospital Risk Manager said the wrong level spinal surgery was reported to the Hospital on 2/26/13.

The incident report regarding Patient #2's wrong level spinal surgery indicated that the report was completed on 2/26/13 (5 days later). The P.A. and attending neurosurgeon's partner identified the wrong level spinal surgery on 2/21/13.

Based on review of 1 of 10 (Patient #2) medical records, the Hospital's Internal Investigation did not identify the delay in reporting of Patient #2's wrong level spinal surgery and therefore did not identify the opportunity for improvement.

Findings include:

The Hospital's Internal Investigation regarding Patient #2's wrong level spinal surgery did not identify the importance of timely reporting.

The Risk Manager was interviewed at 8:00 A.M. on 3/19/13. The Risk Manager said that the staff covering for the Attending Neurosurgeon did not report the wrong level spinal surgery when they identified the surgical error. The Risk Manger said that the staff covering for the Attending Neurosurgeon waited until the Attending Neurosurgeon returned to the office on 2/26/13.

Based on interviews and record reviews, the facility failed to ensure that the nursing staff performed and documented skin assessments, for 1 of 10 (Patient #1) patient records reviewed.

Findings include:

Patient #1's Emergency Department evaluation, dated 2/13/13 at 1:35 P.M., indicated ischial tuberosity/perineal bruising.

Patient #1's Admission Nursing Assessment, dated 2/13/13 at 9:45 P.M., did not include an assessment of Patient #1's perineal bruising that was identified by the Emergency Department evaluation.

The Department of Nursing policy titled Assessment/Reassessment indicated that re-assessments should be completed with each change in caregiver.

The nursing assessments documented by four change of caregivers (three nurses) in Patient #1's record, from 2/14/13 at 2:27 A.M. through 2/15/13 at 9:11 P.M., did not indicate Patient #1's perineal bruising was re-assessed as required by Hospital policy.

Surveyors #2 and #3 interviewed RN #6 at 8:40 A.M. on 4/3/13. RN #6 said that she did not receive report that Patient #1 had perineal bruising. RN #6 said that she was not certain if she assessed Patient #1's perineal area.

Surveyor #2 interviewed RN #7 at 1:16 P.M. on 4/3/13. RN #7 said that she did not receive report that Patient #1 had perineal bruising. RN #5 said that she assessed Patient #1's perineal area while cleaning Patient #1's perineum. RN #7 said that she did not see any perineal bruising.

Based on interviews and record reviews, the facility failed to ensure the nursing staff included a complete skin assessment in 1 of 10 (Patient #1) patient records reviewed.

Findings include:

Patient #1's Nursing Care Plan, dated 2/14/13 at 2:46 A.M., did not identify Patient #1's perineal bruising as a problem in his/her Nursing Care Plan.

The Nursing Note, dated 2/13/13 at 1:13 P.M. and the Medical Screening Examination dated 2/13/13 at 1:16 indicated Patient #1's ischial tuberosity/perineal bruising.

Because, Patient #1's ischial tuberosity/perineal bruising was not identified as a problem and included in the Nursing Care Plan, the nursing staff did not continue to evaluate Patient #1's ischial tuberosity/perineal bruising, with each change in caregivers (R.N.s), for more than 2 days.