HospitalInspections.org

Based on document review and interview, it was determined that the facility staff failed to follow policy and procedure resulting in injury to one (1) of one (1) patient (Patient # 2).

The findings include:

On November 30, 2020 at 12:40 p.m., a review of the Clinical Record for Patient # 2 revealed Patient # 2 was Re-admitted to the facility on July 27, 2020 after an acute care in-patient stay. Patient # 2 was admitted to the acute facility with a diagnosis of septic shock secondary to an indwelling foley UTI (Urinary Tract Infection).

The History and Physical (H&P) dated July 27, 2020 reads in part "[Patient # 2] was sent to [Name of Acute Care Facility] because of a malfunctioning suprapubic catheter, a possible abscess. There, [Patient # 2] was admitted with septic shock secondary to an indwelling foley UTI. Covid-19 was ruled out. [Patient # 2] was seen by Urology. A new suprapubic was exchanged over wire."

Interdisciplinary notes review revealed the following:
On July 31, 2020 at 3:14 a.m., (Registered Nurse RN) Patient sleeping calm.
at 11:05 a.m., (Respiratory Therapist RT) Patient presents with no signs of distress with stable vitals and respiratory status notes.
at 2:33 p.m., (License Practical Nurse LPN) Patient resting in bed.
at 4:36 p.m., (RT) Patient tol (tolerated) current vent setting with no signs of distress.
at 7:53 p.m., Patient is comfortable with stable vital signs.
at 8:06 p.m., (LPN) received patient awake, nonresponsive verbally. no problems noted. dressings intact to left buttock and sacrum as well as one an abrasion on left elbow. no apparent distress noted.

On August 1, 2020 at 4:13 a.m. (LPN) Patient slept all night. no problems notes. dressings intact to left buttock and sacrum as well as one to an abrasion on left elbow. no apparent distress noted at this time.
At 6:30 a.m., (LPN) called to patient's room by CNA (certified nursing assistant) who stated patient was having some decrepit sound in elbow when it was moved. noted hearing the same when patient's arm moved in my presence. charge nurse came and examine patient arm. stated it wasn't an unusual thing for patient to have this and we left the room. patient was in no distress. [Patient # 2] did not grimace. no further problems were noted.
At 6:45 a.m., (LPN) in patient room with CNA to assist in repositioning. CNA gently lifted patients right arm and crepitus could be heard. Team leader and charge nurse came to room due to crepitus sound in right elbow. No facial grimaces or elevated heart rate noted. no abnormal movement noted by team leader or charge nurse.
At 6:45 a.m., (RN) The team leader of this patient and I were called to the room by the CNA. The CNA and another nurse from team one was changing the patient's gown. The CNA had a hold of the patient's right elbow correctly and was gently pushing on elbow saying "Can you hear this", it sounded like crepitus. I said very well could have been due too does not move any of joints. Gas will trap in the joint causing crepitus. That is why we do ROM (range of motion). The elbow was in proper alignment as well as the right shoulder.
At 7:45 a.m., (RN) During last round patient was laying on side with yellow wedge under lower back and bottom. Patient was calm and in no pain.
At 8:48 a.m., (RN) Received patient in bed on back side with yellow foam wedge positioned on right upper extremity. no acute distress.
At 9:15 a.m., (RN) CNA in room and was informed by TL/CN to be on the look out for patch on patient's back and upon turning patient it was noticed that the tip of patient's suprapubic catheter was coming out of patient's urethra with balloon intact. Nursing Supervisor called to room. At 9:24 a.m., (RN) on call [Physician's Name] made aware and ordered to send patient out to [Name of Acute Care Facility] ED. CNA also pointed out that patient's right shoulder appeared to have "dropped". Wound care (WC) nurse was called that patient's being sent out to ED. WC nurse came up to the room and pointed out that right shoulder also looked like it had "dropped" as compared to yesterday.
At 9:25 a.m., (LPN) Called to patient room by CN and CNA to assess patient. Upon walking into the room, noticed patients arm was hanging at an odd position. CNA said CN was notified as soon as noticed it was not in place. This nurse touched patients arm and noticed the patient grimaced in pain from it being moved. Walked out the room to notify CN and asked if there could be x-ray done since [patient] was going out to ED. Patients arm was not the same as it was the previous day when wound care was performed, as stated to the CN.
At 11:35 a.m., (RN) ambulance arrived on unit. report given.
At 4:40 p.m., (RN) Received report from [Acute Care Facility], patient is returning with a report of fractured right humerus with shoulder immobilizer, to follow up with ortho and that ultrasound of suprapubic catheter showed suprapubic was intact and draining yellow urine.

On November 30, 2020 at 1:00 p.m., an interview with Staff Members # 1 and # 2 revealed "Staff turned and reposition patient with one person."

On November 30, 2020 at 1:15 p.m., a review of the facility's policy provided by Staff Member # 1 titled "Turning, Positioning, Lifting Immobile Patient" reads in part "Dependent and immobile patient must be assisted by at least 2 staff members to turn, position, lift or transfer using assistive and mechanical devices."