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Based on review of medical records, quality assurance/quality improvement data, and staff interviews, it was determined that the nursing staff failed to provide a safe setting for the care of 1 of 3 (#1) patients whose records were reviewed.

Findings were:

Review of the medical record for patient #1 revealed that the patient was admitted to the facility on an involuntary status (1013) due to the patient's increased confusion and level of agitation. The patient had been diagnosed with dementia (irreversible deterioration of functioning level) several years ago and the symptoms had recently become worse. The patient, according to the family, was unable to care for him/her self. The patient was also experiencing auditory and visual hallucinations (hearing and seeing things that were not real). Review of the history and physical examination, done at the time of admission, revealed that the patient had some bruising to the upper extremities. The nursing assessment, also done at the time of admission, revealed only some redness to the buttocks area with no mention of bruising to extremities. A review of the nursing progress notes, written on day five (5) through day nine (9), and the day of discharge, revealed that the patient received pain medication for mouth pain. The notes referred to the pain as having been caused by discomfort to the gums in some notes, as an ulcer to the gums in other notes, and as an ulcer beneath the patient's dentures in one progress note. The medical record lacked evidence of the mouth problems having been assessed by nursing or reported for further follow-up with the medical physician. A nursing flow sheet on day six (6) indicated that the patient had bruising to the right and left eye area. The medical record lacked any evidence of how the bruising had occurred or an assessment of the bruising or the patient. There was no further documentation regarding the bruising to the eye area in either the nursing or physician progress notes. The medical record lacked documented evidence of having reported or providing an explanation to the family members regarding patient #1's bruising.

An interview at 1:40 p.m. on 04/20/2010 was conducted with the nurse (employee #1) who was involved in the care of patient #1 and had documented the bruising to the right and left eye area, and the Director of Nursing (DON). The nurse expressed being familiar with the patient and he/she reported that the patient complained of pain in his/her gums and was given pain medication but was unable to remember the nature of the soreness. When questioned about the patient's bruises to the eye area, the nurse reported that he/she believed the patient had fallen. The nurse was not on duty when the patient fell, but remembered it being reported to him/her. Upon review of the medical record during the interview, the nurse was unable to find any evidence of a fall or documentation of an injury. The nurse reported that he/she believed that the patients's mouth had been assessed by the medical physician but was unable to find documented evidence to support that this had occurred. Additionally, the DON confirmed that the medical record lacked documented evidence of an explanation and/or an assessment of the bruising to the patient's eye area or an adequate assessment or follow-up of the patient's mouth problem.

An interview at 12:30 p.m. on 04/20/2010 with the DON, revealed that the DON also believed that the patient had sustained a fall. However, according to the DON, there was no documented evidence of an incident report having been submitted for patient #1 at any time during the hospitalization indicating that the patient had fallen and/or sustained injuries to the face. The DON confirmed that it was unclear as to how the patient had received the bruising to the eye area.

Based on review of medical records, quality assurance/quality improvement data, and staff interviews, it was determined that nursing staff failed to adequately assess the patient care needs for 1 of 3 (#1) patients whose records were reviewed.

Findings were:

Review of the medical record for patient #1 revealed that the patient was admitted to the facility on an involuntary status (1013) due to the patient's increased confusion and level of agitation. The patient had been diagnosed with dementia (irreversible deterioration of functioning level) several years ago and the symptoms had recently become worse. The patient, according to the family, was unable to care for his/her self. The patient was also experiencing auditory and visual hallucinations (hearing and seeing things that were not real). Review of the history and physical examination, done at the time of admission, revealed that the patient had some bruising to the upper extremities. The nursing assessment, also done at the time of admission, revealed only some redness to the buttocks area with no mention of bruising to the extremities. A review of nursing progress notes, written on day five (5) through day nine (9), and the day of discharge, revealed that the patient received pain medication for mouth pain. The notes referred to the pain as having been caused by discomfort to the gums in some notes, as an ulcer to the gums in other notes, and as an ulcer beneath the patient's dentures in one progress note. The medical record lacked documented evidence of the mouth problems having been assessed by nursing or reported for further follow-up with the medical physician. A nursing flow sheet on day six (6) indicated that the patient had bruising to the right and left eye area. The medical record lacked any evidence of how the bruising had occurred or an assessment of the bruising or the patient. There was no further documentation regarding the bruising to the eye area in either the nursing or physician progress notes. The medical record lacked documented evidence of having reported or providing explanations to family members regarding patient 1's bruising.

An interview at 1:40 p.m. on 04/20/2010, was conducted with the nurse (employee #1), who was involved in the care of the patient and had documented the bruising to the right and left eye area, and the director of nursing (DON). The nurse expressed being familiar with the patient. The nurse reported that the patient complained of pain in his/her gums and was given pain medication but was unable to remember the nature of the soreness. When questioned about the patient's bruises to the eye area, the nurse reported that he/she believed the patient had fallen. The nurse was not on duty when the patient fell, but remembered it being reported to him/her. Upon review of patient #1's medical record during the interview, the nurse was unable to find any evidence of a fall or documentation of an injury. The nurse also reported that he/she believed that the patients's mouth had been assessed by the medical physician but was unable to find evidence to support that this had happened. Additionally, the DON confirmed that the medical record lacked documented evidence of an explanation and/or an assessment of the bruising to the patient's eye area or an adequate assessment or follow- up of the patient's mouth problems.

An interview at 12:30 p.m. on 04/20/2010 with the DON, revealed that the DON also believed that the patient had sustained a fall. However, according to the DON, there was no documented evidence of an incident report having been submitted for patient #1 at any time during the hospitalization indicating that the patient had fallen and/or sustained injuries to the face. The DON confirmed that it was unclear as to how the patient had received the bruising to the eye area.