HospitalInspections.org

Based on record review and interview, the facility failed to ensure that for one of one patients (Patient #1) enrolled in the facility outpatient program, nursing documentation of a nursing assessemnt was available after the patient had been locked in the facility van for an indeterminate time period.

Findings included:

Review of Facilty Incident, dated 07/15/2022, revealed but was not limited to the following:
"Patient was picked up at designated pick-up point to be taken to outpatient program. Patient fell asleep in the back of the transportation van. Staff dropped off passengers, drove back to the in-patient hospital and parked the van. Approximately 10 minutes later the patient was found knocking on the doors of the in-patient hospital, telling staff she kicked the window of the van to get out of the vehicle. Patient has a superficial scratch to the left leg, no other noted/reported injuries. Patient was returned to outpatient and completed the programing day."

Interview on 09/19/2022 at 12:49 PM with Mental Health Worker #A revealed that she transported Patient #1 back to the outpatient program after Patient #1 kicked out the window of the van. She further stated that the facility outpatient nurse assessed Patient #1 after she returned her to the facility outpatient program. She confirmed that Patient #1 had some "minor" stratches on her legs and bandages were placed on Patient #1's legs by the facility outpatient nurse.

Record review of Patient #1's Medical Record documenting her facility outpatient admission did not reveal a nursing assessment completed on 07/15/2022 by the facility outpatient nurse.

Interview on 09/19/2022 at 1:57 PM with facility outpatient Program Director confirmed that the facility outpatient nurse put bandages on Patient #1 and should have documented her assessment and treatment per facility policy and procedures.