The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

JEWISH HOSPITAL & ST MARY'S HEALTHCARE 200 ABRAHAM FLEXNER WAY LOUISVILLE, KY 40202 Oct. 31, 2011
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, record review and review of the facility's abuse policy it was determined the facility failed to ensure injury of unknown origin was investigated to ensure all patients were free from all forms of abuse, for one (1) patient of the three (3) sampled patients and two (2) expanded sampled patients. Patient #1 had multiple incidents of injuries of unknown origin. However, the facility did not always investigate each incident of unknown injury to ensure abuse had not occurred.

The findings include:

Review of the facility's child abuse policy (revised 07/20/10) revealed the listed signs of abuse: multiple or patterned injuries and injuries in various stages of healing may indicate abuse, neglect, exploitation, or dependence.

Interview with the Director of Quality Risk Management, on 10/28/11 at 4:45 PM, revealed the facility used an IRIS (incident report) system to investigate any injury. If the injury is unknown, an investigation should be conducted to try and determine the cause of the injury. If abuse is suspected, the facility would investigate further and report to the appropriate state agency.

Observation of Patient #1, on 10/27/11 at 3:45 PM, revealed no bruising on exposed skin. The patient's face had a small red scratch-like mark on the forehead. The patient was involved in an activity on the unit.

Review of Patient #1's clinical record revealed the facility admitted the patient on 03/31/11 related to out of control behaviors, MR (mental retardation), Hydro[DIAGNOSES REDACTED], CP ([DIAGNOSES REDACTED]) and history of Fetal Alcohol Syndrome. Review of the most current treatment plan revealed the patient exhibited behaviors of physical aggression toward others. The goal was to decrease the physical aggression and improve self control.

Review of the wound documentation revealed the patient had injuries of unknown origin 04/04/11 (bruise on the right arm), 05/17/11 (large raised area on the left side of the head), 05/24/11 (bruising to right and left lower legs), 06/24/11 (bruise to left arm), 07/30/11 (bruising to Lt. shoulder), 08/11/11 ( abrasions to left and right elbows, and left wrist), 09/06/11 (scratch on top of the head), and 10/13/11 (bump on the head).

Review of event notes revealed the injury of 10/13/11 was determined to be unknown and an IRIS report was completed. Review of the report on 10/28/11 revealed the facility determined the injury to be of unknown origin. The facility interviewed the patient; however, the patient did not know how it occurred. Further review of the record revealed no further action was taken.

Continued review of the record revealed on 07/28/11, the facility placed Patient #1 in time out related to aggressive behaviors toward others. The staff placed the patient into a hook carry where the two staff hook their arms under the patient's arms and physically carried the patient to the time out area. This was two days prior to the 07/30/11 bruise discovery.

Review of the incident report dated 05/24/11 revealed the patient had "multiple bruises to the left shin. "Unknown origin of injury", brown, purple, blue in color. In addition, blue/green bruises were noted on the right shin. No evidence of further investigation was found.

Interview with 3 East Unit Manager, on 10/28/11 at 2:30 PM, revealed the patient gets hurt a lot related to behaviors and possible physical holds from staff. She stated the patient's behaviors had decreased since admission. She stated staff monitored the injuries and had not thought any of the unknown injuries were caused from abuse. "Children get hurt at times."

Continued interview with the Director of Quality Risk Management, on 10/28/11, revealed she tried to track and trend injuries of unknown origin; however, the Director revealed staff did not always complete the IRIS reports on unknown injuries and the focus had been on treatment of the injury instead of finding the cause.

Interview with the Vice President & CNO (Chief Nursing Officer), on 10/28/11 at 5:30 PM, revealed the facility received a substantial amount of incidents regarding minor injuries and due to the sheer volume, the facility had not been able to investigate all the injuries of unknown origin. He continued to state, some of the injuries could have been self injurious and some could have been caused by "holds." He had not looked at injury of unknown origin as being possible abuse, rather monitored the injury for medical reasons and need for further treatment. He stated they could not always determine the cause of the injury but indicated the facility should be attempting to find the cause.