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TEXAS REHABILITATION HOSPITAL OF ARLINGTON
PATIENT SAFETY
Tag No.: A0286
Based on interview and record review, the hospital failed to ensure an incident report was completed for 1 of 1 patient (Patient #1) who obtained a bruise on the right side of the head while using the toilet on 07/05/22. This failure to complete an incident report missed out learning opportunities in an adverse event.
Findings included:
Patient #1 was admitted to the hospital on 06/30/22 for acute metabolic encephalopathy secondary to subacute cerebrovascular accident. The patient would receive therapeutic intervention, physical, occupational therapy for at least 3 hours a day, 5 days a week.
On 07/05/22 at 10:00 AM Personnel #6 reported to a staff RN that Patient #1 "bumped her head during assistance in the bathroom."
On 07/05/22 between 10:00 AM and 10:45 AM, an occupational therapist noted "Patient reported she had a knot on her head due to her hitting her head while standing using the restroom."
On 07/05/22, Patient #1 was transferred to Hospital B due to abnormal oxygen saturation despite on 13 liters oxygen via non-rebreather mask. One of the diagnostic tests for Patient #1 was a CT scan of the head and brain. The findings were "mild soft tissue in the right temple/zygomatic region. Bruising temporal scalp. No fracture..."
During an interview on 07/28/22 at 11:25 AM, Personnel #4 stated there was no incident report completed on Patient #1's incident about "bumped her head during assistance in the bathroom."
During an interview on 08/03/22 at 10:50 AM via phone call, Personnel #5 was asked if she saw a bruise in Patient #1's head when she visited her in Hospital B on 07/05/22. Personnel #5 replied "she saw a noticeable bruise on the patient's right side of the head."
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on interview and record review, the hospital's registered nurse (RN) did not supervise and evaluate the nursing care for 1 of 1 patient (Patient #1) who hit her right side of the head while using the toilet on 07/05/22. The RN did not assess Patient #1 immediately or promptly.
Findings included:
Patient #1 was admitted to the hospital on 06/30/22 for acute metabolic encephalopathy secondary to subacute cerebrovascular accident. The patient would receive therapeutic intervention, physical, occupational therapy for at least 3 hours a day, 5 days a week.
On 07/05/22 at 10:00 AM Personnel #6 reported to a staff RN that Patient #1 "bumped her head during assistance in the bathroom." There was no documentation that Patient #1 was immediately or promptly assessed by a RN.
On 07/05/22 between 10:00 AM and 10:45 AM, an occupational therapist noted "Patient reported she had a knot on her head due to her hitting her head while standing using the restroom."
During an interview on 08/03/22 at 10:50 AM via phone call, Personnel #5 was asked if she saw a bruise in Patient #1's head when she visited her in Hospital B on 07/05/22. Personnel #5 replied "she saw a noticeable bruise on the patient's right side of the head."