HospitalInspections.org

Based on document review, policy review, medical record review and interview, the hospital failed to ensure the safety of all patients and ensure the staff provided care using the techniques they were trained to use when dealing with patients exhibiting behaviors resulted in 1 of 1 (Patient #1) patient sustaining a 12 centimeters (cm) skin tear/laceration that required surgical repair.

The findings included:

1. Patient #1 was an inpatient at the hospital. On 11/24/19, Registered Nurse (RN) #1 was attempting to give medications to Patient #1 became agitated, flailing her arms and resisting staff. After RN #1 spoke with Patient #1, the patient agreed to take the medications if RN #1 would put the medication in a syringe and let her take the medication by herself. RN #1 gave the syringe with medication in it to the patient, and the patient swung at the nurse. RN #1 grabbed Patient #1's arm. The patient jerked her arm from RN #1's grab, tearing the patient's skin. Patient #1 suffered a 12 cm skin tear/laceration which required surgical intervention.

Based on document review, policy review, medical record review, and interview, the hospital failed to ensure the safety of all patients and ensure the staff provided care using the techniques they were trained to use when dealing with patients exhibiting behaviors resulted in 1 of 1 (Patient #1) patients sustaining a 12 centimeters (cm) skin tear/laceration that required surgical repair.

The findings included:

1. Review of the hospital's crisis intervention training manual titled, "Techniques for Effective Aggression Management (TEAM) showed, "...Verbal De-escalation Techniques Verbal techniques play a key role when trying to de-escalate a situation...The goal of verbal de-escalation is to help keep patients and staff safe...Respect their personal space by keeping our distance. Try to maintain at least 2 arm's lengths, or 6 feet of distance...Stress and Anxiety are forms of a person's natural response to events in which they have little control...Some things that we can do to help reduce the impacts of stress and anxiety...Avoid physically touching them...The High Tension stage is the point where the person becomes physically aggressive and assaultive...their cognitive processes deteriorate...When confrontation turns physical, use the techniques below to stay safe and successfully resolve the situation. Use clear words when communicating with the person...Protect yourself from injury. Move away, get out to the room or area...Defense From Hand Strike The Key is to focus on their upper-arm. 1. Meet the strike with both forearms inside of the aggressor's upper-arm. Pass through by rolling your forearms downward. Disengage..."

2. Review of Registered Nurse (RN) #1's personnel file showed she had successfully completed the hospital's crisis intervention training titled, "Techniques for Effective Aggression Management (TEAM)" on 2/28/19.

3. Review of the hospital's policy titled, "Patient Rights and Responsibilities" dated 11/17/14 showed, "...Purpose: To provide a mechanism to ensure that all patients are treated equally with dignity and respect...Patients have the right to be treated in a dignified and respectful manner and to receive reasonable responses to reasonable requests for services...Refuse care, treatment or services in accordance with law and regulation... An environment that is safe..."

4. Review of the hospital's policy titled, "Event Reporting Policy" dated 9/11/19 showed, "...Definitions: A patient safety event is an event, incident, or condition that resulted or could have resulted in harm to a patient. Patient safety events also include adverse events, no-harm events, close calls (near misses), and hazardous conditions...Preventable events: "Never Events" are the subset of patient events that are caused by error...Deviation From Generally Accepted Performance Standards (GAPS) are determined by comparing actual performance to expected performance...Serious Safety Event (SSE): An event whereby a deviation from GAPS that reaches the patient and results in moderate to severe harm or death..."

5. Review of the hospital's "Event Log for Regulators" dated 11/14/19 at 10:45 PM, showed Patient #1 sustained an "Acquired Skin Tear/Abrasion unrelated to Fall or Procedure."

6. Medical record review showed Patient #1 was a 90 year old female with an admission date of 11/12/19 with diagnoses that included Syncope, Pneumonia, Congestive Heart Failure, Anemia and Type 2 Diabetes Mellitus. Review of the Assessment Forms dated 11/13/19 through 11/14/19 showed the patient's skin turgor (elasticity of the skin) was described as "thin" but was intact.

Review of a nursing note written by RN #1 dated 11/14/19 at 10:45 PM showed Patient #1 had been confused and combative throughout the day, had pulled her intravenous catheter (IV) access out and refused to have it replaced. The nurse documented, at 9:00 PM, "I attempted to give the patient her night time medications, patient refused to take them...I attempted to educate the patient on the importance of taking her medications and offered to give them in either juice or apple sauce. Patient continued to become more aggressive and told me that I 'needed to get out of her house or she will beat me.' After 15 minutes of attempting to reassure the patient that we were in the hospital and that we were only here to help her get better I decided to give the patient time to calm and settle. Around 2200 [10:00 PM] I attempted for a second time to reeducate the patient on the importance of taking her medications and [named Certified Nursing Assistant (CNA) #1] attempted to check if patient was wet, the patient again became agitated and started to get physically aggressive with staff...After time [the amount of time was not specified] myself and the tech had calmed the patient and she agreed to take the medications if they were mixed into her tea in a syringe. I complied with the patient request and ground the medications put them into the tea and into the syringe. The patient again refused to take the medications and stated she 'would be willing to take them if she could give them to herself.' I then informed the patient that I would comply with this request as long as the patient would agree not to become combative with staff. The patient agreed and was handed the syringe. The patient immediately attempted to punch the tech with her right hand, the hand with the syringe in it. I grabbed her right hand and the tech grabbed her left hand, then the patient violently ripped her hand from mine, resulting in a large skin tear. Immediately, [named Physician #1] was contacted by the charge nurse, [named RN #2], he was informed of the situation and his presence was requested at the bedside. At the same time a second Intensive Care Unit (ICU) nurse was on the floor [named RN #3] assisted me with controlling the bleeding and the patient also became verbally aggressive with her as well saying things such as, 'if you had not been in my home assaulting me this never would have happened...Provider [Physician #1] dressed the wound and assumed care of the wound at that time...Shift report was given to [named RN #2] around 0000 [12:00 AM], as my presence was requested back in ICU, who contacted family and informed them that the patient would have surgery to repair the tear around 0530 [5:30 AM]..."

Review of a nursing note written by CNA #1 dated 11/14/19 at 10:45 PM showed, "...the patient was hitting the nurses while they were putting mitts on her because she was being very combative and taking everything off. The nurse [named RN #1] tried giving the patient her meds with whole pills but she then threw them across the room. Then the nurse put the meds in a syringe with some tea to give the patient but she wouldn't open her mouth to take the meds. So then the nurse was going to start an IV on the patient so she could get her meds, when the patient then said she would take the meds if she could hold the syringe herself and take the meds with her own hands. The nurse then told the patient only if she promised not to throw the meds across the room. The nurse took the patients mit [mitten] off her hand and gave her the syringe to take the medicine herself when she then tried to hit the tech/CNA [named CNA #1] and she stepped back and grabbed her left hand and the nurse [named RN #1] grabbed the patients right hand with the syringe, and she took the syringe from the patients hand and tossed it on the table, then the patient decided she was going to jerk her hand away from the nurse and when she did it resulted in a skin tear on the patients hand. The patient stated if we would just stay out of her house and quit meddling this wouldn't have happened..."

Review of a progress note written by Physician #1 dated 11/15/19 at 12:31 AM showed, "called by nurse for avulsion injury R [right] hand. Pt [patient] combative earlier and was hitting nurse. nurse held her hand to try to put mitts but pt pulled...resulting in avulsion/large dorsal [top] R hand from skin between 4th and 5th digit [finger] all the way to wrist w [with] fascia [a band or sheet of connective tissue, primarily collagen, beneath the skin that attaches, stabilizes, encloses and separates muscles and other internal organs] exposed...I irrigated and covered w dressing and kerlix [rolled gauze]. [named Physician #2] to take to OR [operating room] for repair..."

Review of a nursing note written by RN #2 dated 11/15/19 at 1:30 AM, showed "...Family notified due to pt injury to Rt [right] hand..."

Review of a consultation report written by Physician #2 dated 11/15/19 at 5:50 AM, showed, "...90-year-old female who was being combative and was being placed into restraints by a nurse...Right hand with large thick skin tear from the third webspace dorsally between the fourth and fifth digits dorsally to the wrist. Intact tendon function retinaculum [a region in which tendon groups from different muscles pass under one connective tissue band] exposed. Neuro-vascularly intact...Plan is for irrigation and primary closure with dressing right hand laceration dorsally.

Review of the Operative Report dated 11/15/19 at 6:56 PM, showed, "...Right hand skin laceration irrigation debridement and primary repair...carefully irrigated the skin tear on the dorsum of the hand this measured to be about 12 cm. We carefully repaired the skin... taking great care to gently approximate the skin edges as this skin quality was very poor and very fragile..."

7. During an interview on 12/10/19 at 6:30 PM, RN #1 was asked to describe the incident involving Patient #1. She stated that Patient #1 had been confused and combative with staff during her shift, refusing her medications, and had pulled her IV out on the previous shift. RN #1 attempted to administer her night time medications but the patient refused. After attempting to re-educate the patient on the importance of taking her medications, the patient became agitated and actually threw her pills across the room, so she decided to leave the room and give the patient some time to calm down. RN #1 stated, she returned to the room around 10:00 along with CNA #1, who went to render incontinence care. The patient agreed to take her medications if they were mixed with tea in a syringe. RN #1 complied with her request; however when she attempted to administer the medications, Patient #1 insisted on holding the syringe herself. RN #1 asked the patient to promise not to strike at the nursing staff. RN #1 then stated, "I gave her the syringe and she immediately tried to punch the tech [CNA #1]. I reached and got her hand and she pulled it down and towards her body making a twisting motion towards her belly resulting in a skin tear..." RN #1 was asked if she notified the family about the incident. She stated, "No, [named RN #2] did because I was pulled back to ICU to admit a patient." RN #1 was asked if she had been trained on how to handle aggressive patients. She stated, "Yes, TEAM training. It's an avoidance thing. We should try to avoid it [touching the patient], and try talking them down..."

During an interview on 12/10/19 at 6:47 PM, CNA #1 was asked to describe the incident involving Patient #1. She stated the patient was being very combative when the nurse (RN #1) was trying to get her to take her medications in a syringe, and told her she would have to start another IV if she wouldn't take it. The patient told her she could take it if she could hold it herself. CNA #1 then stated, "[named RN #1] handed it [syringe containing the medications] to the patient and she started to swing at us. [named RN #1] took her hand and the patient tried to jerk it away and that's when it happened [skin tear]...We discussed among ourselves that maybe we should have tried to back away more..." CNA #1 was asked if she thought RN #1 intentionally tried to harm the patient. She stated, "I personally don't think so, but since she said she wasn't going to take it [the medications] she should have left her alone..."

During an interview on 12/10/19, the unit Nurse Manager reported he was informed of the incident when he reported to work the following morning (11/15/19). He stated staff informed him they were trying to give her medications and she wouldn't take them. They informed him the patient agreed to take them in tea if she could hold the syringe herself, but when the nurse gave her the syringe, she started swinging at them. The nurse grabbed her hand, and the injury happened when the patient jerked away from her. She ended up with a skin tear. The unit Nurse Manager then stated, "I started asking how did this happen and how could it have been prevented and what changes we needed to make in the future. I real-time coached them that night if someone was that way [combative] to stand back far enough away to keep from having to put hands on them in the future...I plan to send them back to de-escalation training, TEAM training here..."

During an interview on 12/10/19 at 6:37 PM, RN #2 was asked to describe what she could recall regarding the incident involving Patient #1. She reported she did not witness the incident as she was out of the room. She called Physician #1 and requested he come assess the patient, which he did and he consulted a surgeon. RN #2 then stated, "The main thing I did was dress the hand, talk with the family, and get her ready for the procedure [surgical repair of the skin tear]. She had real fragile skin..."

During a telephone interview on 12/11/19 at 8:32 AM, Physician #1 was asked what he could recall about Patient #1's hand injury. He stated, "I was on call that night and went and saw her...she had a pretty good injury, open wound. I irrigated and cleaned it, and put in an urgent consult for an orthopedic surgeon to come repair her. That was the extent of my involvement...This injury was certainly more than a skin tear. She had no muscle buffering the injury on her hand...The only thing left is exposure of the tendons...Even if her skin wasn't so thin, the same damage could have occurred. It [the injury] was more of a laceration than a tear...Looking at the wound, it was hard to know how it occurred. I just went by what she [RN #1] told me. It was bizarre. Clearly, her skin was very fragile and a little pressure could certainly have caused it."

During an interview on 12/11/19 at 8:10 AM, the Director of Critical Care Services was asked if RN #1 should have grabbed Patient #1's hand. She stated, "...In my opinion, it was a reflex grab. It would depend on how close the people were. Of course hind site is 20/20. Having looked at the whole story, her skin was friable..."