HospitalInspections.org

Based on medical record and document review, policy review and staff interview it was determined the facility failed to implement the policy and procedure related to Abuse Recognition and Reporting to ensure patient were free from abuse for one (#6) of ten records review.

Findings include :

Review of the policy "Abuse Recognition and Reporting" Policy #PE-15 Effective date 1/1/96 noted on page 3 of 10 Paragraph IV, A. Reporting responsibility: According to Florida Statute 39.201, any person including, but not limited to, any physician, osteopath, medical examiner, nurse, social worker, mental health professional and other hospital personnel engaged in admission, examination, care or treatment of persons, who knows or has reasonable cause to suspect that a child, disable adult, or elder adult is abused or neglected, immediately reports such knowledge or suspicion to the Florida Abuse Hotline ( 1-800-96- ABUSE) or to Local Law Enforcement Agency. On Page 5 of 10 paragraph VI #2 stated "When there is an unexplained injury or complaint of injury inflicted on a patient .... Immediate steps to protect the patient must be taken".

Patient #6's medical record indicated the patient was an infant. Review of documentation dated 7/27/15 noted the day shift nurse documented the night nurse reported that during the night the patient was irritable, having tremors in the right leg and decreased movement in left leg. The left leg measured 19 centimeters (cm) at widest point and right leg was 17 cm at widest point. Review of the X-ray dated 7/27/15 showed a transverse oblique fracture of the femur. Social services and risk management were notified on 7/27/15. There was no evidence the facility reported the incident to the Abuse Registry Hotline until 7/29/15, approximately two days later.

An interview with the Risk Manager on 9/4/15 at approximately 2:00 p.m. confirmed the abuse registry was not notified immediately.