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SPRING GROVE HOSPITAL CENTER WADE AVENUE CATONSVILLE, MD Aug. 21, 2014
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on a survey inclusive of policy and procedure, interview of staff and the review of 12 patient records, it is revealed that 1) 1:1 staff monitoring patient #1 failed to inform the on duty RN of self-injurious and destructive behaviors on the morning of 8/1/2014; 2) the hospital transported patient #1 with a suspected hip fracture to the hospital by wheelchair and van, 3) the hospital failed to identify that the subsequent diagnosis of a left hip fracture while being monitored 1:1 could be indicative of abuse or serious accident and 4) the hospital failed to conduct an investigation into the events leading to the patient being found with a fractured hip.


Hospital policy and procedure for abuse reporting states in part, " Any employee who has reason to believe that a patient has been abused while an inpatient at (the hospital), shall immediately report alleged abuse to: 1) the head nurse on the patient ' s home ward or if the head nurse is unavailable; 2)the Charge nurse on the patient ' s home ward; and the 3) The Superintendent or his/her designee ...; and 4) Hospital Police ...


Patient #1 is a late middle-aged female who was transferred in mid-April 2014 to the psychiatric hospital on the basis of two physician certificates from a referring psychiatric hospital. Patient #1 has been in the custody of the Social Services since the age of 25, and has a guardian of person. Patient #1 has a history of psychosis, dementia, self-injurious and aggressive behaviors towards others. Patient #1 ' s behaviors include kicking, biting, and other types of unpredictable attacks. Though patient #1 has self-injurious behaviors, no history of head injury or fractures was known at the time of admission. Patient #1 also has a gait disturbance and had recently fractured metatarsals in her right foot. Patient #1 had a 24 hour a day 1:1 staff monitor and uses a wheelchair.
On the night of 7/31 into the morning of 8/1/2014, patient #1 is reported by the 11 PM to 7 am Charge RN to have had difficulty going to bed. Per the Charge RN, patient #1 had been sitting in her wheelchair with a 1:1 staff monitoring. According to the RN, patient #1 was placing objects on her bed such as cookies, newspaper and puzzle pieces, and warned the 1:1 staff and RN not to touch or move them. The RN also stated that it was a " turn-over night " when all the orders are updated and transcribed on the new month ' s medication administration record forms, and indicated that due to this activity it was a " Very busy night. "
One to one (1:1) documentation reveals that from 11:30 PM on 7/31, and largely through 5:45 am of 8/1, patient #1 had " verbal outbursts/yelling/screaming, " and the 1:1 " Provided specific direction/supervision.
An RN note of 6:45 AM documented " Patient was unable to sleep " .... " This morning patient was aggressive towards 1:1, " though the note did not characterize the aggression. The RN also documented a blood sugar check at 6 AM for patient #1 who is diabetic and giving insulin coverage for a blood sugar of 355. When interviewed by the surveyor, the RN stated that when she last saw the patient around 6 am, the patient was not in any pain.
The 1:1 flow notes documenting every-15-minutes from 6 am through 6:30 AM reveal behavioral codes for " Self-injurious behavior, " and " Acting destructive towards the environment. " The intervention from the 1:1 is again documented as " provided specific direction/supervision. " Interview with the Charge nurse reveals that the 1:1 did not call for her during this period of self-injurious and destructive behaviors, nor were these behaviors reported to her during the shift.
No other documentation is found until a somatic physician note of 8:30 am. The somatic MD documented, " Patient was checked as she was crying with pain in the left hip. __ deformed swollen L hip & upper thigh with lateral rotation of leg. Patient had severe pain when the leg is moved or the upper thigh is touched. " 1. Fracture of femur .....2. Patient head to ER for evaluation and treatment ... "
No other nursing note appears in the record regarding patient #1 ' s hip until 2:50 PM which states in part, " Upon getting patient ready this AM for x-ray appointment it was observed that patients left leg was significantly more swollen from hip to ankle and that patient was in obvious discomfort. Patient moaning and saying " ouch " with even the lightest movement. Dr. __ and PA came to see patient and ordered her to be sent to (hospital) for evaluation and treatment.

Patient #1 is noted to have been transported to the acute hospital by hospital van instead of ambulance. The standard of care for appropriate body alignment and reduction of pain for persons suspected of having a hip fracture would dictate an ambulance transfer. An ambulance transfer would place the patient in a supine position, and avoid flexion at the hip (the site of the possible fracture). Clearly, per the physician note, a hip fracture was suspected, yet an ambulance was not called for appropriate transport. Consequently, every bump in the road taken by the transport van would have increased patient #1 ' s pain dramatically, and based on the RN report that patient #1 had moaning with even the lightest movement.

The 1:1 staff who documented self-harming and destructive behaviors between 6 am and 6:30 AM accompanied patient #1 to the hospital. A hospital physician note states in part, "Pt is accompanied by a care provider who gave (sic) represented the pt. (sic) requires 1:1 supervision 24/7 because of her comorbidities including dementia. Reportedly, the pt indicated to the staff at (the hospital) that her hip was hurting while she was getting changed this a.m. There is no report of recent trauma, falls, or assault. Staff could offer no reason for the pt ' s current condition. " Based on this note, the 1:1 staff did not inform the physician of patient #1 ' s self-injurious and destructive behaviors that she documented earlier that morning. Patient was admitted and diagnosed with a left intertrochanteric fracture. On 8/3, patient #1 had surgery and received a left intramedullary hip screw fixation.

Upon investigation some 20 days after the injury, it was found that when the hospital received a diagnosis of a hip fracture for a patient #1 who was on 1:1 monitoring, there was no suspicion that the injury could have originated from physical abuse. While patient #1 was self and other-harming at times, this did not automatically explain her severe injury. However, no investigation was launched, no statements were gathered, and the hospital police responsible for conducting abuse investigations were not informed. While the administration stated they would be conducting an internal investigation, no information had been gathered by the time of survey in order to determine a cause of the injury to patient #1.
In summary:

1) 1:1 Staff failed to inform the RN of patient #1 behaviors which would cause her harm, and failed to inform the acute hospital of the specific behaviors she had noted prior to her injury.
2) Staff inappropriately transported patient #1 in a van after it was identified that she likely had a hip fracture, undoubtedly causing her pain and continued flexion at the site of a probable fracture.
3) Staff failed to identify possible abuse of patient #1 who incurred a fracture while on 1:1 without any explanation.
4) Staff failed to launch an investigation into the injury.

Based on this information, the hospital failed to treat patient #1 in a safe setting.