HospitalInspections.org

Based on medical record review, resident and staff interview, observation, and policy and procedure review, the facility failed to ensure injuries of unknown origin were reported and investigated as required for 2 of 2 sample residents (#3, #5) with injuries of unknown origin. The findings were:

1. Review of the medical record showed resident #5 was admitted to the Swing Bed unit on 7/1/18. Review of the 6/2/19 care plan showed the resident required assistance for activities of daily living (ADLs) including the use of mechanical lifts as needed or 3-person physical assistance for transfers. The resident was also non-compliant at times with medications and treatments. Observation on 9/17/19 at 11:39 AM showed the resident had large red and yellowish bruises to the tops of both hands and wrists, and on the right wrist there was a scabbed skin tear. Interview with the resident at that time revealed s/he was unable to explain how the bruising occurred. Additionally, review of the 5/20/19 at 11:10 PM nurse's note showed the resident had 2 bruises of "unknown origin". The bruises were described as "purple in color one to the top of [his/her] thumb, the other is on [his/her] forearm just below the elbow." The following concerns were identified:
a. Review of the incident log failed to show there was any incident recorded for the 5/20/19 injury of unknown origin. There was an event reporting form dated 5/20/19 that showed the resident had bruising to the thumb and wrist. The note showed certified nurse aides (CNAs) were interviewed and the resident had been "combative with cares for the last several days", and the bruises were from the resident "trying to strike staff." There were no further details on the form.
b. Review of the 9/5/19 timed at 8:30 AM late entry note showed the resident "suffered a skin tear to the right medial aspect of the wrist. Aide reporting stated that she was unaware of what happened she just looked down and saw [the resident] bleeding." Review of the 9/5/19 at 9 PM nurse's note showed there was "significant bruising on the tops of both wrists. This could be the result of person or persons assisting resident to a sitting position by pulling on wrists and arms will continue to monitor."
c. Interview with the director of nursing (DON) on 9/18/19 at 11:27 AM revealed there was not a report made regarding the 5/20/19 identified injuries, and an investigation was not completed with details of interviews or additional information. She further stated the resident's current bruising and scabbed skin tear were thought to be the result of staff handling the resident with transfers and care. However, there was not a report or investigation related to these injuries.

2. Review of the 8/27/19 care plan showed resident #3 resided on the Swing Bed unit and required assistance for transfers, and use of a mechanical lift. Review of the 9/13/19 skin monitoring form showed there was a new bruise identified on the resident's right forearm. There were no measurements or description of the bruise. Observation with the DON on 9/18/19 at 12:49 PM showed the bruise was located on the right forearm and was red and purple in color. The DON estimated the size of the bruise to be 2.5 inches by 1 inch with smaller areas trailing down the arm. The following concerns were identified:
a. Review of the medical record showed there were no nurse's notes related to the bruise.
b. Observation on 9/17/19 at 3:04 PM showed the resident was transferred using a Hoyer mechanical lift. CNA #1 used the lift to transfer the resident from the bed to reclining wheelchair with no additional staff present to provide assistance.
c. Interview with the lead CNA on 9/18/19 at 11:15 AM revealed the annual competency skills were coming due in October. She verified the expectation and training related to lift transfers for the Hoyer lifts was to use two staff members to ensure safety for the resident. She stated the resident's bruise may be a result of positioning and transfers, and this had been identified as an area for additional training during a meeting on 9/5/19.
d. Interview with the DON on 9/18/19 at 12:49 PM revealed the nurse should have made a note related to the bruise and possibly complete an event report form depending on the injury and information. She confirmed there was no note or event report form completed for this bruise.

3. Review of the 2/6/19 approved policy and procedure for Patient Abuse and Neglect showed mistreatment including injuries of unknown source was not addressed. Further the policy and procedure failed to include the required timeframe for reporting allegations to the State Survey Agency and Adult Protective Services.