HospitalInspections.org

Based on document review and staff interviews it was revealed the Nursing Supervisor failed to provide patient care in a safe setting by failing to identify and triage high risk incident reports, notify the administrator and follow policy and procedures for incident reporting. This failure was found in three (3) out of thirty (30) medical records (patient #9, #10 and #11) reviewed. This failure has the potential to place all patients at risk for care in an unsafe setting.

Findings include:

1. A review of the medical record for patient #9 revealed the "Nursing Shift Note" written on 10/14/19 at 8:51 p.m. states in part: "It was reported by Behavioral Health Technician (BHT) that it was believed patient was trying to choke himself with a blanket." Physician #1's "Progress Note" written on 10/15/19 at 2:41 p.m. states in part: "BHT reported that he may have tried to choke himself with a blanket." A review of the completed Incident Report dated 10/14/19 revealed the incident was circled in the category, "All Others: Minor Injury to Patient." The category "High Risk: Suicide Attempt" was not circled.

2. A review of the medical record for patient #10 revealed the "Nursing Shift Note" written on 10/20/19 at 2:30 p.m. states in part: " ... patient was observed scratching her left inner forearm. Patient with open superficial scratch approximately five (5) inches long to left inner forearm. Patient took medication and then went to the bathroom carrying a shirt ... Staff went to bathroom, knocked on door and did not receive a response. Staff unlocked bathroom door and patient observed to have shower curtain wrapped around her neck. Shower curtain was removed from patient's neck by staff, despite patient's resistance." Physician #1's "Progress Note" written on 10/21/19 at 2:18 p.m. states in part: "Patient said that she tried to hurt herself this weekend because she was hearing voices who told her to hurt herself." A review of the completed Incident Report dated 10/20/19 revealed the incident was circled in the category "All Others: Minor Injury to Patient." The category "High Risk: Suicide Attempt" was not circled.

3. A review of the medical record for patient #11 revealed the "Nursing Shift Note" written on 05/25/19 at 11:05 a.m. states in part: "Patient reported that last night she and her roommate wrapped hospital socks around their necks." Physician #1's "Progress Note" written on 05/25/19 at 12:15 p.m. states in part: "Patient attempted suicide by tying a sock around her neck yesterday night. ... Patient reports she can not fully commit to safety." A review of the completed Incident Report dated 05/25/19 revealed the incident was circled in the category "All Others: Minor Injury to Patient." The category "High Risk: Suicide Attempt" was not circled.

4. A review of policy "Incident Reporting," revised date 07/11/19, states in part: "The triage of incidents will happen within the shift. There will be three (3) types of Incident Reports. 1- High Risk - These reports will be brought to the Nurse Supervisor's office immediately. The administrator on call will be called ... if not within regular weekday. The incident form is scanned and sent to the Incident report High Risk box-email for follow up. ... High Risk items will naturally have more follow up than a simple event with no injury."

5. An interview on 10/22/19 at approximately 11:00 a.m. was conducted with the Director of Quality & Risk Management. She stated in part: "High risk event includes suicide attempt. Usually these are texted out on the weekend as soon as they occur." She concurred the incidents were miscategorized and the supervisor should have notified administration on call.