HospitalInspections.org

Based on record review and staff interview it has been determined that the hospital failed to investigate, report, and protect a patient relative to an injury of unknown origin for 1 of 2 sample patients (ID #13).

Findings are as follows:

Record review revealed patient ID #13 has a current care plan dated 7/7/2015 which indicates the resident has a traumatic brain injury, is non-communicative most of the time. S/he has left hemiplegia (paralysis) with minimal right upper extremity movement and both of the upper arms have contractures of the wrists and fingers. The patient requires total care from staff and is dependent for positioning.

Review of the nurse's note dated 7/20/2015 revealed the patient has a bruise under her/his right arm/armpit. Staff documented that the bruise on the right arm "is oblong in shape, approximately 2 inches long, purple in color...unknown origin".

When interviewed on 8/17/2015 at 2:45 PM, the Acting Administrator of Risk Management and the Nurse Manager (Staff A) were unable to produce evidence that the above injury of unknown origin had been reported and investigated.

Refer to A392

21980

Based upon observation, record review and staff interview, it has been determined that the hospital failed to ensure a registered nurse (RN) is available for every inpatient unit in the Adolf Meyer building, Adult Psychiatric Services.

Findings are as follows:

On 8/19/2015 at approximately 8:10 AM, unit 10 (located on the first floor) was observed without an RN present. At approximately 8:25 AM, the surveyor called the Nurse Manager of the building to the unit and asked as to the whereabouts of the unit RN. She stated that the unit RN (Staff B) was covering the patient's breakfast in the dining room located on the 3rd floor. She further indicated that when a nurse covers the dining room, the RN working the adjacent unit covers for both units.

The surveyor, in the presence of the Nurse Manager, walked onto the adjacent unit, # 7, and failed to locate the RN. The Nurse Manager then stated that the RN working unit 7 was also covering unit 8, which is located on the second floor. At 8:35 AM, the unit 10 nurse (Staff B) arrived on the unit after observing breakfast.

On 8/19/2015 at approximately 8:20 AM, Staff C was observed on unit 8. He stated that he is covering 2 units today and it happens occasionally that RN's must cover 2 units. When questioned further, he stated that the unit were on different floors.

Review of the staffing schedule for the past week revealed that on 8/15/2015 during the day shift, Staff C was assigned as the RN to cover 2 units and Staff D was assigned as the RN to cover 2 units.

When interviewed on 8/19/2015 at 10:45 AM, the Administrator and the Nurse Manager acknowledged that there are times when an RN covers 2 units.

Based on record review and staff interview, it has been determined that the hospital failed to provide evidence of reassessment of the patient's nursing care needs, response to nursing interventions, and revision of the plan of care for 2 of 2 relevant sample patients (ID #4 & 13) relative to injury of unknown origin.

Findings are as follows:

1. Record review revealed patient ID #4 was admitted to the hospital on 4/5/1999. The patient has diagnoses which include multiple sclerosis, quadriplegia with bilateral upper extremity contractures and lower extremity flaccidity (weakness/reduced muscle tone) and obesity.

Review of a care plan updated on 7/1/2015 and interview with unit nurses (staff F and G) revealed that the patient requires total care for all activities of daily living, including assistance with repositioning. The patient is incontinent of bowel and bladder and is transferred via mechanical lift to a wheelchair.

On 2/4/2013 the patient complained of leg pain and an x-ray of a left forearm and left hip were obtained. The x-ray results revealed a new diagnosis of osteopenia (a bone condition characterized by bone loss) in the left forearm and left hip.

Further record review revealed no evidence that the patient was reassessed or that nursing interventions and revision to the care plan had been done for this patient when the above new diagnosis of osteopenia was identified.

A 7/30/2015 nurse's note indicates the patient complained of pain to her/his left leg. The patient's left knee was noted to be slightly edematous but no redness or bruising noted and the left leg was warm to touch. A nursing assistant reported the patient's leg is not "so floppy as usual."

A review of the hospital incident report dated 7/31/2015 revealed that on 7/30/2015 the patient was sent out to the hospital for further evaluation for left leg pain, to rule out for deep vein thrombosis/cellulitis. The patient was admitted to the hospital with a left femur fracture and an old tibial plateau fracture.
A review of the hospital history and physical dated 7/31/2015 indicates an assessment and plan which identifies the fractures as suspicious given the patient is bed bound with no known history of fall or trauma.

During an interview on 8/12/2015 at 9:00 AM, Nursing Assistant (Staff E) who has been providing care to the patient indicated that, prior to the hip fracture, she had provided care (AM care, including repositioning) to the patient without assistance from other staff.

Interview with the unit nurse (Staff F) on 8/13/2015 at 10:00 AM revealed the patient needs total assistance for care and repositioning. The nurse further indicated that the patient is approximately 190 pounds and personal care is to be provided using 2 staff.

Additional unit nurses were interviewed, Staff G on 8/13/2015 at 9:55 AM, and Staff H at 1:15 PM indicated that two nursing assistants are required to provide care and repositioning.

When interviewed on 8/14/2015 at 2:00 PM, the Acting Nurse Manager (Staff I) was unable to produce evidence that the patient was reassessed following a new diagnosis of osteopenia or the care plan had been reviewed and/or revised to reflex this change.

2. Record review of the hospital incident report dated 7/18/2015 revealed patient ID #13 had two scratches of unknown etiology on the left hip and the scratches were already scabbed with no bleeding noted.

A review of the conclusion dated 7/21/2015 indicates "upon investigation and statement taken, no one knows how the scratches happened. Staff stated it could happened during care or during positioning."

Record review revealed a current care plan updated 7/7/2015 which indicates the patient has a traumatic brain injury and the patient is non-communicative most of the time. S/he has left hemiplegia (paralysis) with minimal right upper arm movement and both of the upper arms have contractures to the wrists and fingers. The patient requires total care from staff and is dependent for positioning.

A nurse's note dated 7/18/2015 indicates the patient's left hip area was "noted to be reddened with two scratches-are scabbed".

Further record review revealed that on 7/20/2015 a bruise was noted under the right arm/armpit. Staff documented that the bruise on the right arm "is oblong in shape, approximately 2 inches long, purple in color...unknown origin".

There is no evidence that this patient was reassessed after the injuries were discovered, or that nursing interventions and revision to the care plan had been done.

During an interview on 8/17/2015 at 2:45 PM, the Nurse Manager (Staff A) was unable to produce evidence that the above patient was reassessed or that nursing interventions and revision to the care plan had been done.

Based on record review and staff interview it has been determined that the hospital has failed to ensure that nursing personnel have appropriate education and training/competency relative to mechanical lift for 7 of 15 sample nursing assistants {NA(s)} and relative to body mechanics for 12 of 15 sample NA(s).

Findings are as follows:

Review of the hospital's policy and procedure entitled "Staff Education/Program" indicates:

A. Core Curriculum: ...to prepare the employee to function with increasing safety and effectiveness in his/her assigned role within the hospital setting...

Core I: Orientation...

Core II: Annual and Bi-Annual Training...

Bi-Yearly Training

4. Body Mechanics

Core III : Competency Training and Assessment
The following programs are currently conducted for nursing staff...

CNA (nursing assistant) Competencies/Frequency

Annual

1. Invacare/Hoyer (mechanical lift)-CNA only...

Bi-yearly

3. Body Mechanics


Review of NA(s)' personnel files relative to "skill competency validation" for mechanical lift revealed no evidence that the training or skill competency were done yearly for 7 of 15 sample NA(s) (Staff E, K, L, M, N, O, and P).

Further review of the above personnel files revealed no evidence of training nor skill competency for body mechanics were done every two years for 12 of 15 sample NA(s) (Staff E, M, N, O, P, Q, R, S, T, U, V, and W).

During an interview with the Clinical Training Instructor (Staff J) on 8/18/2015 at 8:55 AM, she indicated that NA(s) are required to have training and skill competency relative to mechanical lifts yearly. These NA(s) are also required to have training and skill competency relative body mechanics every two years. She was unable to provide evidence that the above NA(s) received training and skill competency according to the hospital policy and procedure.