Patient Injures Eye, Facility Cited for Failing to Provide Safe Environment

The Centers for Medicare and Medicaid Services (CMS) cited SummitRidge for patient rights and nursing care deficiencies following a complaint investigation survey. The cited deficiencies relate to the facility’s failure in providing a safe care setting and adequate care assessments for an involuntarily admitted patient with dementia, agitation, and hallucinations.The patient’s medical records revealed that during the patient’s hospital stay, he/she received pain medication for mouth soreness (due to a possible mouth ulcer). However, there was no indication that the mouth issues were assessed by nursing staff or reported for further follow-up with a physician.

The patient was also found to have bruising around his/her eyes during day 6 of the hospitalization, but there was no evidence of how the injury occurred, if a follow-up assessment was conducted, or whether the patient’s family was notified. The DON (Director of Nursing) revealed in an interview that he/she believed the patient had sustained a fall, but there was no documented evidence of an incident report being submitted so it was “unclear as to how the patient had received the bruising to the eye area.”

As a result, SummitRidge had to submit a plan of correction to address its cited deficiencies, which included revising its deficient nursing assessment, family involvement in treatment, and medical consultation policies.