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GREEN OAKS HOSPITAL 7808 CLODUS FIELDS DRIVE DALLAS, TX Jan. 30, 2015
VIOLATION: NURSING SERVICES Tag No: A0385
Based on records review and interviews, it was determined that the hospital nursing staff failed to assess one of one patient (Patient #1) according to his ongoing needs.


Patient #1 was admitted to the hospital's Psychiatric Emergency Services (PES) on 01/16/15. On 01/19/15 at 07:32 Patient #1 was punched in the face by another patient and fell on the floor, bleeding from the mouth. The patient was dazed and needed assistance from staff twice to prevent a fall. Nursing staff did not notify the physician that the patient was unable to eat a regular breakfast and required a basin and towel for continuous bleeding from his mouth until shortly before lunch. There was no evidence of reassessment of Patient #1's neurological status after the initial assessment.


A day after the incident, Patient #1 requested discharge against medical advice and sought treatment at a medical hospital. Oral and Maxillofacial Surgery was consulted, Morphine pain management was provided, and Patient #1 underwent surgery to repair his twice broken jaw and teeth.


Cross refer to A -395
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on records review and interviews, nursing staff failed to supervise and evaluate the care for one of one patient (Patient # 1) who was struck in the face by another patient on 01/19/15 at 07:32 in that:


1) Nursing did not report to the physician that Patient #1 was unable to eat a regular breakfast and required a basin and a towel for continuous bleeding from his mouth,


2) There was no evidence that nursing staff reassessed Patient #1 for neurological changes after an initial assessment at the time of incident,


3) An ice pack was not applied until approximately 23.5 hours after the incident, and


4) A clinical consult and x-ray examination were not ordered until 25 hours after the initial incident.


The patient left the psychiatric hospital against medical advice to seek treatment at a medical hospital, received intravenous Morphine pain treatment and underwent surgery for a twice broken jaw and tooth repair.



Findings included:


1) Patient #1's Psychiatric Evaluation dated 01/16/15, at 13:34, noted that the patient was admitted to the hospital's Psychiatric Emergency Services (PES) for diagnoses including Psychosis and Cannabis Abuse.


Employee #10 stated during an interview on 01/23/15. at 16:45, that Patient #1 was bleeding after he was punched in the face. A "puddle of bright red blood" in front of Patient #1 was noted and required housekeeping services. Patient #1 was unable to eat regular breakfast foods and Employee #10 brought him yogurt and jello.


Employee #7 stated during an interview on 01/23/15, at 18:00, he observed the incident and thought Patient #1's "jaw was broken from the intensity and sound of the punch...blood came out like after a tooth is being pulled."
Employee #7 provided the patient with a towel and a basin which had blood in it until "shortly before lunch."


2) Emergency patient record dated 01/19/15, at 07:40, by Employee #13 noted "... assisted to restroom after spitting up bright red blood...was assisted to the floor x 2 [twice]...MD...instructed to take vital signs and observe Pt [Patient #1] closely for any neurological changes."


Emergency patient record dated 01/19/15, at 07:40, by Employee #10 reflected Patient #1 was "hit in the mouth/jaw by another pt [patient]. Began bleeding, bleeding able to be controlled...VS [vital signs] taken and stable. Neuro checks WDP [within defined parameter]...no further orders received...will continue to monitor."


There was no evidence of further evaluation of Patient #1's neurological status.


Employee Physician #6 stated on 01/23/15 at 15:40 that she went into the bathroom with Patient #1 after the incident. Two nurses cleaned the patient up. The physician "tried to get him [Patient #1] to open his mouth but he was in shock." The physician told the nurses to asses the patient "later" and notify the physician of any problems. The physician "did not hear back from the nurses." The physician saw Patient #1 later "eating a roll and jelly" and concluded that "nothing was wrong with his jaw."


3) Physician orders dated 01/20/15, at 06:55, noted an order for ice pack to Patient #1's swollen jaw. This was approximately 23.5 hours after the incident was witnessed by nursing staff.


Emergency patient record dated 01/20/15, at 09:11, by Employee #14 noted "...ice pack application to shoulder and jaw in the morning."


On 01/23/15 at 16:45 Employee #10 (RN) said that she had offered an ice pack to Patient #1 after the incident, but he refused. There was no documentation of this in the medical record.


4) On 01/20/15 at 08:27 a clinical consult was ordered because the patient had been "punched" in the mouth.


On 01/20/15, at 08:30, an x-ray examination was ordered to rule out a fracture and Ibuprofen 800 mg (milligram) was ordered three times daily for "mild" pain.


Employee Physician #6 stated on 01/23/15, at 15:40, that on 01/20/15, Patient #1's jaw was swollen and x-rays were ordered.


Physician Psych Disposition dated 01/20/15, at 06:43, noted that Patient #1 "...wants to go home...it appears pt's [Patient #1's] speech is affected by getting hit in the face yesterday..." Patient #1 left against medical advice on 01/20/15 at 12:12.


Medical Hospital A's Patient Admission Registration dated 01/21/15, at 10:32, noted that Patient #1 was admitted to Emergency Services. Computer tomography scan dated 01/21/15, at 11:39, noted "...two fractures are identified within the mandible [jaw bone]...fracture through the angle of the left mandible extending through the tooth socket of the posterior molar...contralateral fracture is demonstrated through the body of the right mandible, also through a tooth socket." Patient #1 was transferred via EMS provider to Medical Hospital B for treatment of Mandible Fracture and Blunt Trauma.


Medical Hospital B Emergency Department (ED) Provider Notes dated 01/21/15, at 16:44, noted a chief complaint of Facial Injury after being "punched in the face while at Green Oaks Hospital..."


Medical Hospital B Oral and Maxillofacial Surgery Consult Note dated 01/21/15, at 22:33, noted Patient #1...will likely have operative surgery tomorrow."


Medical Hospital B Medication Administration dated 01/21/15, at 18:08, noted Morphine was ordered at 4 mg (milligram) doses to be administered intravenously for pain. Patient #1 received Morphine seven times during his 25 hour stay at Medical Hospital B.


Medical Hospital B Procedure Summary dated 01/22/15, at 13:53, noted Patient #1 underwent an approximately four hour procedure to repair the broken jaw.


Employee #4 at "Green Oaks Hospital" stated on 01/23/15, at 15:30, that hospital administration had been unaware that Patient #1's jaw was broken until the morning of 01/23/15 when it received notification of the patient status by outpatient clinic staff.