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Based on observation, interview and record review, the hospital failed to assure an adverse patient event resulting in an allegation of abuse was reported in accordance with State Law and failed to conduct a timely and thorough investigation of the patient event for 1 applicable patient. (Patient #1) Findings include:

1. Per review on 1/11/10, Patient #1, who was ventilator dependent and immobile with contractures of the arms, was admitted to the hospital MICU (Medical Intensive Care Unit) on 12/21/09 after an episode of hypoxia (insufficient oxygenation). On 12/26/09 a humeral neck fracture of the right upper arm was identified by X-ray during a routine daily portable chest x-ray for Patient #1. During the morning of 12/27/09 MICU staff, including nurses and physicians, were made aware of the fracture of unknown etiology. A orthopedic consult was conducted on 12/27/09 concluding this fracture may have been due to the patient's significant upper arm contractures and years of limited mobility resulting in osteopenia (when bone mineral density is lower then normal). Per interview on the afternoon of 1/12/10 the Manager for Social Services/Case Management confirmed an investigation was initiated on 12/29/09 regarding the fracture of unknown etiology. A subsequent management team meeting occurred on 12/30/09 which included Risk Management, Case Management/Social Services, Quality Council and Nursing to review information obtained regarding the identification of an injury of unknown origin. However, although the injury experienced by Patient #1 was significant and warranted a report to Adult Protective Services (APS) within 48 hours, a report was not made until 1/5/10, 9 days after hospital staff became aware of the injury. This was confirmed on the afternoon of 1/12/10 with staff from the Department of Case Management and Social Services, who are responsible for assisting in the filing of a report to APS.

Per review from 1/11/10 through 1/13/10, reports completed by Nursing, the Department of Case Management/Social Services and Quality Council staff revealed internal investigations were not timely or thorough and were inaccurate or incomplete. The departments failed to interview all staff/caregivers who were identified to have provided care between 7 AM on 12/24/09 through 6:00 AM on 12/25/09 (the time span identified by Radiology after interpretation of previous films when the fracture occurred). The report stated consultation with the manager of Respiratory Therapy noted "...none of his staff had any direct physical contact with this patient on that date...". However, respiratory therapists had provided care with routine suctioning of Patient #1 throughout the 23 hour period in question (7 AM on 12/24 and 6 AM on 12/25/09). Radiology technicians were also not interviewed. Per interview on 1/12/10 at 7:40 AM a radiology technician confirmed he/she was assisted by 2 other radiology technicians to perform a portable chest X-Rays on 12/25/09 at 6:00 AM on Patient #1 which involves repositioning of the patient. Assistant Nurse Managers of the MICU were delegated the responsibility to interview staff which included nurses and licensed nursing assistants (LNAs) who had provided care to Patient #1 during the specific time period. However, per interview on 1/12/09 at 12:05 PM an Assistant Nurse Manager confirmed only a review of documentation by nursing staff was conducted without individual interviews for 2 of 6 nurses on the list. Investigational information that was obtained by nursing was found to be incomplete and inaccurate.

The report stated that "all caregivers" were included in the investigation of the incident. Per interview on 1/13/10 at 1:10 PM the two Assistant Nurse Managers for the MICU concurred they were unfamiliar with how to conduct an investigation. They stated that they had not interviewed all nursing staff who had provided care to the patient during the period when the fracture was determined to have occurred.

Per interview on 1/13/10 at 11:00 AM the Director of Regulatory Readiness/Quality Council confirmed the investigation was incomplete and that staff delegated investigations of alleged abuse required more detailed instruction and direction to assure all relative evidence was identified and reviewed during the hospital's internal investigation.

Based on interviews and record review, the hospital's Quality Assessment and Performance Improvement program failed to conduct an effective analysis of an adverse patient event by it's failure to assure all pertinent information was obtained and considered. Findings include:

Per interview on 1/13/10 at 11:00 AM the Director of Regulatory Readiness of the Quality Council confirmed the internal investigation of an injury of unknown origin was incomplete and staff delegated to conduct investigations of an allegation of abuse required more detail instruction and direction to assure all relative evidence was identified and reviewed during the hospital's internal investigation.

Refer to Tag A145

Based on staff interview and record review, nursing staff failed to consistently evaluate and provide care in accordance with a patient's needs for 1 applicable patient in the sample. (Patient#1) Findings include:

Per record review and confirmed by Registered Nurse (RN) interview on 1/12/10 at 3:35 PM, Patient #1 had the blood pressure cuff (Dynamap) on the right arm when the RN came on duty for the evening shift 12/27/09. The RN stated that she learned during report prior to the start of the shift that the patient was suspected to have sustained a right arm fracture and had orders for an orthopedic consult. The RN verified that the Dynamap should not have been placed on the injured arm and moved it to the left lower extremity.

Per staff interview and record review, nursing staff failed to develop a care plan to address the identified needs for 1 applicable patient in the sample. (Patient #1) Findings include:

Per record review on the afternoon of 1/11/10, the nursing care plan for Patient #1 did not address the patient's severe contractures of the upper extremities and did not describe the specific communication abilities of the patient. This was confirmed during interview and care plan review with the RN Assistant Nurse Manager for the Medical Intensive Care Unit (MICU) the same day.