HospitalInspections.org

Based on document review and interview, the Registered Nurse failed to follow the P&P (Policy & Procedure) related to Incident Reports; to include nurse notes for incident that occurred; in the patients MR (Medical Record), for 1 of 10 MR's reviewed (Patient # 2).

Findings include:

1. Review of established hospital policy titled: "Incident Reports", indicated on page 2, under Incident Reports shall include documentation of the following elements, 4th point "Copy of nurse's notes", and under C. "hard copies of supporting documents". Last revised 9/2022.

2. Review of Patient # 2 MR, indicated the following:
a. Patient admitted to APH # 40 (Acute Psychiatric Hospital) on 9/6/2022.
b. Nurse note on 9/16/2022 pm, reflected patient with noted pain and decreased ROM (range of motion) to left shoulder. NP (Nurse Practitioner) gave order for X-ray.
c. Discharge summary by MD (Doctor Of Medicine) # 30 (Psychiatrist), reflected patient sent out on 9/17/2022, due to X-ray results showing left humerus fracture.
d. MR lacked nursing note documentation related to patient trip/fall on 9/12/2022.

3. Review of incident report dated 9/12/2022, for patient # 2, reflected patient had tripped and fallen during redirection by staff.

4. In interview on 10/20/2022 at approximately 12:30 pm, with A # 6 (Director of Social Services), and A # 1 (Director Of Quality) at approximately 12:18 pm, the following was indicated:
A. Patient incident for trip/fall; no complaints of pain until days later.
B. X-ray completed, positive for fracture; patient sent out on 9/17/2022.
C. Should be/will be in patient's MR.
D. Medical record complete.