Injury to patient. New nurse questions.

[amandamichigan]

I am a new RN (California) working at a skilled nursing/long term facility. So far things have been mostly fine but this is the situation from last night:

I worked PM shift. When a dementia resident was being assisted to bed, the CNA found a *tiny* skin tear on left knee, called me in to see it. The resident had been walking around, fine that evening - no indication of anything wrong, no complaints. No bruises, nothing. I did everything I was supposed to for this. One thing to note however - the tear was not fresh, looks as though it had happened during the morning shift and either ignored or missed by the CNA before our shift.

The next morning the resident was noted to be holding one arm, and ended up having a fracture.

They called me in, and I reported again what happened. I explained that it was not fresh and that there had not been complaining or showing any signs of injury other than the tear.

They said they are opening an investigation and that State will be notified. My charge nurse just seemed really mad at me specifically (even asked if I had not reported a fall - absolutely not!). I had no indication that something was wrong. Being new, I am wondering what the ramifications and process are for this. Am I potentially going to be in big trouble here? I feel like I did everything that I was supposed to, but now wondering if I could have done more...

[amoLucia]

When you say you did everything, did you (1) initiate an incident report and (2), notify the nsg supervisor (or other higher-upper) to start an investigation and (3), how thorough was your physical assessment to include upper torso injury, not just the knees & legs???

When nursing home pts sustain fractures, they're considered "sentinel events" and they do get reported to the State for further investigation. There must be evidence of in-house investigation that will be reviewed. Your pt sustained a skin tear "of unknown origin" that should have been followed with an incident report and subsequent investigation.

Regardless of how small or innocuous an injury might appear, it requires 'the full monty', replete with all the documentation and notifications of MD, family and nsg home admin. Even if there was NO (nada, nothing) evidence of anything , as in UNWITNESSED, you still proceed as if there were a problem. The investigation's documentation will explain the pt's dementia, contributing diagnoses and medications, poor history details, staff observations of pt activities, interviews of other residents as able, etc.

Even if the pt or anyone else (like a roommate) only SAYS the word "FALL" (or "bruise") you act upon it. Even if their memory is so faulty that the fall was 10 years ago, you report it and let the higher-uppers investigate it.

It sounds like your pt had an UNWITNESSED fall and got up on her own power and didn't (or couldn't) tell anyone and no one on staff knew. Maybe she was helped by another pt or a good Samaritan visitor who never told staff. They freq don't think much about it either as fracture pain and immobility freq can take a day or more to become evident. Pt probably put her arms out to break her fall causing her fracture. But it is the investigation by the proper admin staff that will determine cause & effect.

The clue was that skin tear/abrasion that should have been actively acted upon. That would have started the ball rolling. For this occurrence (as you describe it) will need a very, very thorough investigation. It sounds like your nsg admin got caught unawares, and that is NOT GOOD.

Not to scare you, but you might want to contact your malpractice insurance carrier and ask their advice. And they may advise you to refrain from talking about this on all social media.

[Cosmo&Wanda]

What does doing "everything you were supposed to do" entail? If you followed your facility's protocol precisely then you have a firm leg to stand on. If you documented carefully then you can be confident that you can be confident if you are interviewed by the state. Especially if you notified the supervisor upon observing the skin tear.

I've been interviewed by the state (NY) before in response to reportable incidents, and I've seen this sort of thing happen with other nurses as well. Have confidence that that you made a nursing assessment and reported accordingly. If you allow the supervisor to make you nervous and start questioning yourself then you are going to appear guilty and uncertain. If you stand by your initial statement with confidence then you are likely ok.

It sounds like you care about the resident and are taking your job seriously. Perhaps the fracture was there at the time you assessed her, but if she wasn't complaining of pain and didn't have apparent signs of injury then how would you know?

[Cosmo&Wanda]

One more thing, you might want to write out a statement to make sure your thoughts are straight. Email it to yourself so you don't lose it and you have a time stamp. If you can, keep a copy of the progress note you wrote on that day as well. The investigation will likely take some time and you will start to forget the exact sequence of events. If you are interviewed you will want to be able to reiterate the occurrence in the same way you reported it initially.