HospitalInspections.org

Based on record review and interview, the facility did not provide a safe care setting to 1 of 1 patient (Patient #1) who sustained eye and nose bruising and/or swelling after trying to free himself from restraints on 7/14/14. There was no documentation of physician notification and no incident report was completed.

Findings included:

Patient #1 was admitted the evening of 7/12/14. At approximately 6:05 AM, Personnel #4 started an initial nursing assessment for admission. At 6:30 PM, Personnel #4 noted in the nurse's notes "Change of condition ...Agitated patient ...When patient arrived on unit, the patient was agitated, hitting and kicking at staff and EMS personnel (emergency medical service). While attempting to put the left wrist restraint...the patient tried to free his arm and while doing so hit himself on the nose and left eye. There was some slight bruising of the nose and eye." There was no documentation that a physician was notified after the incident. An incident report was not completed. There was no documentation nursing interventions were provided.

In an interview on 10/23/14 between 10:30 AM to 12:00 PM, Personnel #2 and #3 were informed of the above findings. Personnel #2 and #3 confirmed the findings after reviewing Patient #1's medical record.

"H-PC 04-009 PRO Assessment /Re-Assessment-Interdisciplinary Patient" dated 2/2014 required "...d. The admitting RN will screen each patient...to identify those patients requiring further specialized interventions, and/or possible referral to and assessment by other appropriate disciplines..."

"Event Reporting System" dated 8/2014 required "...the facility require that all patient and visitor events be reported using the facility's Reporting System."

Based on record review and interview, the registered nurse (RN) did not supervise and evaluate the nursing care for each patient in that 1 of 1 patient (Patient #1) sustained eye and nose bruising and/or swelling after trying to free himself from restraints on 7/14/14. A physician was not notified. There was no documentation that nursing interventions were performed.

Findings included:

Patient #1 was admitted the evening of 7/12/14. At approximately 6:05 AM, Personnel #4 started an initial nursing assessment for admission. At 6:30 PM, Personnel #4 noted in the nurse's notes "Change of condition ...Agitated patient ...When patient arrived on unit, the patient was agitated, hitting and kicking at staff and EMS personnel (emergency medical service). While attempting to put the left wrist restraint...the patient tried to free his arm and while doing so hit himself on the nose and left eye." There was no documentation that a physician was notified. Nursing interventions were not performed.

In an interview on 10/23/14 between 10:30 AM to 12:00 PM, Personnel #2 and #3 were informed of the above findings. Personnel #2 and #3 confirmed the findings and stated they could not find documentation that a physician was notified and nursing interventions provided.

"H-PC 04-009 PRO Assessment /Re-Assessment-Interdisciplinary Patient" dated 2/2014 required "...3. Nursing Department...d. The admitting RN will screen each patient...to identify those patients requiring further specialized interventions, and/or possible referral to and assessment by other appropriate disciplines..."

Based on record review and interview, the facility failed to ensure that the nursing care plan for 1 of 1 patient (Patient #1) was kept current during his hospitalization.

Findings included:

Patient #1 was admitted the evening of 7/12/14. At approximately 6:05 AM, Personnel #4 started an initial nursing assessment for admission. At 6:30 PM, Personnel #4 noted in the nurse's notes "Change of condition ...Agitated patient ...When patient arrived on unit, the patient was agitated, hitting and kicking at staff and EMS personnel (emergency medical service). While attempting to put the left wrist restraint...the patient tried to free his arm and while doing so hit himself on the nose and left eye. There was some slight bruising of the nose and eye." This finding was not included in Patient #1's plan of care.

In an interview on 10/23/14 between 10:30 AM to 12:00 PM, Personnel #2 and #3 were informed of the above findings. Personnel #2 and #3 confirmed the findings and stated they could not find a nursing plan of care addressing Patient #1's bruising and swelling of his eye and nose.

"H-PC 04-009 PRO Assessment /Re-Assessment-Interdisciplinary Patient" dated 2/2014 required "...3. Nursing Department...c...A patient Plan of Care developed and recorded...h. All nursing assessment(s)/ reassessment(s) are recorded in the patient's medical record..."