HospitalInspections.org

Based on observation and interview, the facility failed to investigate unexplained bruising to a patient. This affected one (Patient #11) of 13 sampled patients. The census was 141.

Findings include:

Record review revealed Patient #11 was admitted on 11/05/18 as a transfer from another area facility for further evaluation of abdominal pain, nausea and vomiting, jaundice and elevated liver enzymes. The patient was discharged on 11/13/18.

A physician's activity order dated 11/05/18 that stated the patient was to be up as tolerated.


A review of the facility's complaint log revealed a family member of Patient #11 had called to complain that on 11/08/18, the patient had been dropped on to the side rail of a stretcher during a transfer. Review of the complaint revealed the nurse who was present at each transfer on to a stretcher on 11/08/18 was interviewed and denied the patient had been dropped.

Review of nursing notes dated 11/08/18 at 10:00 A.M., document the patient's skin was warm, dry, moist and without discoloration. At 3:30 P.M., the patient went to an endoscopic suite to have an endoscopic sphincterotomy cytology stent placed. The patient arrived back to the unit from the procedure on 11/08/18 at 8:00 P.M.

A nursing assessment dated 11/08/18 at 8:30 P.M. that stated the patient had bruises, but did not document where the bruises were located on the body or the size of the bruising.

A nursing assessment dated 11/09/18 at 8:34 A.M. documented the patient still had bruises, but again did not document the location or size of the bruising, or if it was the same bruising noted the day prior.

A nursing assessment dated 11/10/18 at 8:30 A.M. again documented bruising, but no location, size or if it was the same bruising as noted the two days prior.

During interview on 12/26/18 at 4:30 P.M., Staff D stated she had documented the patient had bruises, but could not remember anything about them.

During interview on 12/26/18 at 4:37 P.M., Staff E stated she also had documented the patient had bruises, but could not remember anything about them as well.

During interview on 12/27/18 at 8:55 AM, Staff B stated the transporter present during the transfer did not witness the patient being dropped and stated he "would have filled out an incident report if they had."

The nursing notes and care plan revealed during the patient's stay from 11/05/18 through 11/3/18, nursing had the patient on bed rest with an assist of two people to ambulate. The medical record contained no documentation the patient had been injured. No further investigation or documentation regarding the unexplained bruising was provided.

Based on interview, observation, and record review, the facility failed to assess whether a foam belt used on every patient hospitalized in the rehabilitation unit was a restraint and failed to monitor the use of such belts. This affected two (Patients #8 and #9) of five patients reviewed for restraint use. The rehabilitation unit was ten.

Findings include:

1. Record review for Patient #8 revealed a history and physical dated 12/18/18 that stated the patient was admitted for a stroke and right upper extremity weakness.

On 12/26/18 at 11:35 A.M., Patient #8 was observed up in his chair with a foam Velcro belt across his umbilicus.

A review of the patient's nursing assessments and care plans contained no documentation as to why the patient needed a Velcro belt, why the Velcro belt was the most appropriate nursing intervention and whether the patient could remove the belt.

The medical record review did not document when the belt had been first applied, how long the patient had been wearing the belt or how the belt was applied.

During interview on 12/26/18 at 11:56 A.M., Staff G explained staff would need to free text their use of the belt in the nursing documentation, whereas before they did not.

2. Record review for Patient #9 revealed the patient was admitted with diagnoses of Parkinson's disease, chronic obstructive pulmonary disease, hypertension, and left knee replacement.

On 12/26/18 at 11:35 A.M. Patient #9 was observed up in a chair with with a foam Velcro belt across her umbilicus.

A review of the patient's nursing assessments and care plans contained no documentation as to why the patient needed a Velcro belt, why the Velcro belt was the most appropriate nursing intervention and whether the patient could remove the belt.

During interview on 12/27/18 at 12:55 P.M., Staff C stated the belt was routinely applied for trunk stability. Staff C was unable to provide documentation in the medical record indicating Patient #9 needed trunk stability or the reason for the use of the belt. Staff C stated the belt was routinely used on all patients.

During interview on 12/27/18 at 9:27 A.M., Staff A stated the use of the Velcro belt is "not currently documented in the system."

A review of the belt's application instructions revealed five steps needed to be taken to apply the belt, including positioning the patient on the belt as far back in the seat as possible and checking for proper fit by sliding an open hand between the belt and the patient. The instructions stated to ensure the patient "cannot slide down, or fall off the chair seat or mattress and become suspended or entrapped" and "there is a risk of chest compression or suffocation if the patient's body weight is suspended off the mattress or chair seat."