HospitalInspections.org

Based on staff interview, medical record review, and review of facility documentation, it was determined that the facility failed to ensure that an incident report is complete in one (1) out of one (1) medical record reviewed in accordance with facility policy and the security service agreement.

Findings include:

Reference: Facility policy titled: "Incident and Occurrences" states: "...Incident - a patient related event that has caused or had the potential to cause injury..... Procedure: A) The person that has identified the incident shall report the incident to the Charge Nurse. B) The person reporting the incident will complete the top of the form describing the incident and sign it with their legal signature, title and current date..... H) The physician and Power of Attorney/Guardian/Responsible Party will be notified of incident/occurrence by the Charge Nurse.... M) Occurrence reports include, but are not limited to: ...7) Any other incident which had potential for serious consequences to patients, staff or facility... ."

1. A review of the medical record of Patient #1 was conducted. A "Nursing Note" by Staff #5, a nurse, on 5/25/2021 at 9:02 PM stated: "[The patient] was standing in the hallway near the med [medication] room, the nurse was walking by, while looking at another patient and brushed up on his/her right side, at which time, [The patient] turned around and put zip ties up to the nurses (sic) face, the security guard grabbed [The patient] from behind to prevent him/her from going after the nurse....."

2. An interview with Staff #7 and Staff #8 on 7/25/2021 at 11:01 AM, identified that zip ties are used to help keep pants up of patients who cannot have a belt. Staff #7 and Staff #8 also stated that zip ties would be considered a potential weapon and therefore, contraband. Staff #7 and Staff #8 stated the zip ties are kept in a locked drawer behind the nurse's station. Both Staff #7 and Staff #8 were uncertain how a patient would have obtained the zip ties.

3. Upon request to Staff #1, the facility was unable to find evidence of a facility incident report form. An interview on 7/25/2021 at 11:23 AM, Staff #1, a director of nursing, confirmed that the episode of the patient using zip ties in a threatening manner towards staff should have been escalated to an incident report and internal investigation.

4. The "Security Professional Service Agreement" was reviewed in the presence of Staff #1 at 1:00 PM. The service agreement identified that "...Any unusual incidents detected or reported will be reported to Client via the designated Client contact. An incident report will be filled out and a copy will be forward to Client....." Upon request to Staff #1, the facility was unable to provide evidence of an incident report generated by the security company as per the service agreement.