HospitalInspections.org

Based on clinical record review, document review and staff interviews it was determined nursing staff failed to provide care in a safe setting for patients #2 and 3 by failing to follow facility policy and procedures. This failure was identified in two (2) out of ten (10) record reviews. This failure to provide care in a safe setting has the potential for all patients to be at risk for abuse and injury.

Findings include:

A review of facility policy, "Incident Reporting," revised 03/2020, states in part: "Any facility staff member who witnesses, discovers or had direct knowledge of an incident should complete an Incident Report as soon as practical after the incident is witnessed or discovered and/or before the end of the shift/work day."

A review of the event log from 05/2021 through 06/2021 revealed no event was recorded for patients #2 and 3 on 06/05/21 through 06/06/21.

An interview was conducted on 06/23/21 at approximately 10:18 a.m. with Behavioral Health Technician (BHT) #2. When asked what happened with patients #2 and 3, she stated in part, "I found out about the event on 06/06/21 after shift report." When asked if someone reported it, she stated in part, "I don't know if an event report was completed. It must be filled out in twenty-four (24) hours of the event."

An interview was conducted on 06/23/21 at approximately 11:12 a.m. with Registered Nurse (RN) #1. When asked about what happened with patients #2 and 3 on 06/05/21, she stated in part, "I was told patient #2 gave oral sex to patient #3. It was after I left. I didn't see anything while I was there. It was RN #3, I received it in report the next day. I assume they did an incident report. ...."

An interview was conducted on 06/23/21 at approximately 12:15 p.m. with RN #2. When asked what happened with patients #2 and 3, she stated in part, "I do remember the incident. ... I learned about the incident on Monday. ... It was reported to me in shift change from night shift."

An interview was conducted on 06/23/21 at approximately 12:24 p.m. with the Interim Chief Nursing Officer. When asked if she received a report from the nursing staff about the event from the weekend, she concurred she did not receive any report of the event until notification by patient #2's grandfather.

Based on clinical record review, document review and interviews it was revealed the facility failed to ensure nursing staff follow hospital policy and procedures. This failure was identified in two (2) out of ten (10) patients (patient #2 and 3). This failure has the potential for all patients to be a risk for injury.

Findings include:

A review of facility policy, "Incident Reporting," revised 03/2020, states in part: "Any facility staff member who witnesses, discovers or had direct knowledge of an incident should complete an Incident Report as soon as practical after the incident is witnessed or discovered and/or before the end of the shift/work day."

A review of the event log from 05/2021 through 06/2021 revealed no event was recorded for patients #2 and 3 on 06/05/21 through 06/06/21.

An interview was conducted on 06/23/21 at approximately 10:18 a.m. with Behavioral Health Technician (BHT) #2. When asked what happened with patients #2 and 3, she stated in part, "I found out about the event on 06/06/21 after shift report." When asked if someone reported it, she stated in part, "I don't know if an event report was completed. It must be filled out in twenty-four (24) hours of the event."

An interview was conducted on 06/23/21 at approximately 11:12 a.m. with Registered Nurse (RN) #1. When asked about what happened with patients #2 and 3 on 06/05/21, she stated in part, "I was told patient #2 gave oral sex to patient #3. It was after I left. I didn't see anything while I was there. It was RN #3, I received it in report the next day. I assume they did an incident report. ...."

An interview was conducted on 06/23/21 at approximately 12:15 p.m. with RN #2. When asked what happened with patients #2 and 3, she stated in part, "I do remember the incident. ... I learned about the incident on Monday. ... It was reported to me in shift change from night shift."

An interview was conducted on 06/23/21 at approximately 12:24 p.m. with the Interim Chief Nursing Officer. When asked if she received a report from the nursing staff about the event from the weekend, she concurred she did not receive any report of the event until notification by patient #2's grandfather.