HospitalInspections.org

Based on document review and interview, the facility failed to ensure an electronic incident report was completed in one (1) instance and failed to ensure Critical Incident Reports were submitted in two (2) instances.

Findings include:

1. The facility policy titled, "Incident Reports", PolicyStat ID 13033981, indicated an incident report should be completed in the system by the end of the shift in which the incident occurred but no later than twenty-four (24) hours from the time of the event occurred. This policy was last revised in 01/2023.

2. The hospital failed to follow their policy titled, "Critical Incident Reporting to Department of Mental Health & Addiction (DMHA)", PolicyStat ID 13034275, by not completing a patient safety event/root cause analysis for patient # 2 who had been sent out to the ER post fall on 04/28/2023 and again on 04/29/2023 fall with injury. This policy was last revised in 01/2023.

3. Review of the facilities incident report list indicated patient # 2 lacked an incident report from a fall which occurred on 04/28/2023.

4. Review of the following medical records (MR) for patient # 2 indicated the following:
a. Patient # 2 was admitted on 04/28/2023 at approximately 2:40 pm.
b. Daily Nursing Assessment dated 04/28/2023 at 8:50 pm indicated the patient was sent to the ER (Emergency Room) for evaluation after a fall. Patient reported headache and shoulder pain. No obvious signs of injury noted. Patient returned at approximately 4:00 am on 04/29/2023.
c. Provider Orders dated 04/28/2023 at 8:33 pm, indicated to send the patient to the ER for evaluation.
d. Daily Nursing Assessment dated 04/29/2023 at 4:50 pm indicated the patient was found lying in prone position on floor in room. Bleeding noted. Laceration to right eyebrow, skin tear to right wrist and patient complained of pain with redness to right anterior rib cage area. Provider notified and 911 called. Responsible party notified of fall and transfer.
e. Provider Orders dated 04/29/2023 at 4:51 pm, indicated to send the patient to the ER.

5. In interview dated 05/19/2023 at approximately 9:30 am with administrative staff member A # 3 (Director of Quality), confirmed there was no incident report completed for the incident which occurred on 04/28/2023. At 12:45 pm A # 3 confirmed that he/she had not completed and/or submitted a CIR (Critical Incident Report) to DMHA for the fall/transport event from 04/28/2023 and/or 04/29/2023.