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Tag No.: A0398
A. Based on medical record review, policy review and staff interview it was determined nursing failed to follow their assessment policy in one (1) of eleven (11) records reviewed (patient #1). This failure has the potential to negatively impact all patients receiving care in the facility.
Findings include:
A review of the medical record for patient #1 revealed the patient was transferred from another hospital for suicidal attempt by ingesting five (5) Tylenol, swallowed a small drill bit and unknown amount of stool softeners on 07/04/23 at 3:57 a.m. A review of a "History and Physical" note by Psychiatrist #1 revealed their past history includes oppositional defiant disorder, unspecified mood disorder and Attention Deficient Hyperactivity Disorder (ADHD). The patient has superficial cuts on both forearms.
A review of the medical record for patient #1 revealed an admission assessment but failed to document a skin assessment. A review of all shift assessments from 07/04/23 at 3:57 a.m. [time of admission] through 07/07/23 at 6:54 p.m. [time of discharge] the only assessment of the skin was completed on 07/05/23 at 2:29 p.m. Review of a "free text nursing" note and an assessment flow sheet at 3:53 p.m. revealed a superficial cut on the inside of the left and right thigh from self-harm. On 07/06/23 at 8:32 a.m., a superficial cut was noted to the inner thigh from self-harm. On 07/06/23 at 3:56 p.m., a superficial cut was noted to the inner thigh from self-harm. On 07/07/23 at 8:33 a.m., a superficial cut was noted to the inner thigh from self-harm.
A review of the policy, titled "Assessment of Patients", last reviewed 11/21/23, states in part: "Nursing: Initial Assessment- A Registered Nurse [RN] assess the patient's need for nursing care in all settings in which nursing care is provided. This assessment includes completion of the admission assessment and the initial physical assessment, both of which are to be completed within 24 [twenty-four] hours of admission ... Shift Assessment-The initial shift assessment (full head-to-toe/complete assessment) by the Registered Nurse must be completed near the start of the shift and followed by completed documentation in the electronic health record (EHR). Definitions: Assessment: Full head-to-toes/complete assessment. Shift: The scheduled/assigned shift, may be 4 [four], 8 [eight], or 12 [twelve] hours."
An interview was conducted with the AVPBM on 07/18/23 at 8:00 a.m. and they concurred the patient was missing the above noted nursing assessments of the skin.
An interview was conducted with the Interim Director of the Inpatient unit on 07/18/23 at 11:00 a.m. and they concurred the above noted nursing assessments were not documented in the medical records.
B. Based on medical record review, policy review and staff interview it was determined nursing failed to follow their patient safety event policy in one (1) of eleven (11) records reviewed (patient #1). This failure has the potential to negatively impact all patients receiving care in the facility.
Findings include:
A review of the medical record for patient #1 revealed the patient was transferred from another hospital for suicidal attempt by ingesting five (5) Tylenol, swallowed a small drill bit and unknown amount of stool softeners on 07/04/23 at 3:57 a.m. A "History and Physical" note by Psychiatrist #1 revealed their past history includes oppositional defiant disorder, unspecified mood disorder and Attention Deficient hyperactivity Disorder (ADHD). The patient has superficial cuts on both forearms.
Review of a document, titled "Orders", revealed an order on 07/05/23 at 2:06 p.m. to discontinue two (2) on one (1) (2:1) safety checks and complete constant visual on patient when outside of their room. All safety checks were completed as ordered.
Review of a document, titled "Free text nursing note", on 07/05/23 at 2:29 p.m. revealed the patient was in their room and RN #1 went into the room to complete a safety check. The patient handed the RN a blunt screw that they had removed from under their desk. An assessment was completed, and the patient had a superficial cut on the inside of the left and right thigh. Physician #1 was notified and no new orders were given. RN #1 placed the patient on 2:1 safety checks and staff was immediately placed with the patient. All safety checks were completed as ordered.
A review of patient safety events from March 2023 through present revealed no safety event was filed for patient #1.
A review of the policy, titled "Sentinel and Patient Safety Event Policy", last reviewed 12/22/23, states in pertinent part: "The following patient safety events such as, adverse events, no-harm events, close calls, hazardous conditions and unsafe conditions that involve patients, staff and visitors shall be entered into the Event Management System (EMS) ... The individual who discovers the patient safety event or the individual most directly involved must complete a safety report and submit the report in EMS that will be shared with their location manager within 24 hours ..."
An interview was conducted on 07/17/23 at 11:15 a.m. with RN #1. When asked if they remembered patient #1, and if so, were they present when they injured themselves with a screw, and if it occurred more than once, they stated in part, "Yes, I actually was team lead/supervisor that day and I went to do a check on them because they were in their room. When I walked in, they opened their hand and told me they got the screw from under the desk. I checked the skin, and they had a superficial cut that was not bleeding on both of their thighs. I contacted the doctor, and no orders were given. I placed the patient on 2:1 for their safety. The screw was a blunt screw." When asked if they filed a safety report, they stated in part, "No, I told the unit to do it and it didn't get done. That is on me though. I should've circled back around to make sure it was done."
An interview was conducted with the AVPBM on 07/17/23 at 12:00 p.m. and they concurred no safety report was filed.