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Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure all untoward or adverse occurrences were documented and patients were assessed for injury for four of ten medical records reviewed (MR2, MR3, MR4 and MR5).

Findings include:
The facility was requested to provide their policy/procedure for incident reporting on November 10, 2016. The policy provided and reviewed was " Wilkes-Barre General Hospital Event Reporting Policy, " Effective June 2005, last approved by the Medical Staff on March 9, 2015, and revealed " Purpose: A. To Establish a standardized mechanism by which to report events internally and to the CHS PSO, LLC [Community Health System Patient Safety Officer] involving patients and/or visitors events of harm. B. To track and trend processes at risk that impact patient safety by using a Patient Safety Evaluation System, Events Reporting System ( " ERS " ). C. To track and trend all severity levels of harm. D. To analyze trends to prevent harm, improve patient safety, healthcare quality and healthcare outcomes. E. To function as an organization wide policy for Event Report: Applies to Skilled Nursing Facility (SNF), Home Care, Hospice, Psychiatric, hospital owned clinics, ambulatory facilities and employed practitioners. ... Additional Reportable Events: A. Physical injury of patients, visitors, medical staff, or students. ... O. Any untoward or adverse occurrence.

Review on November 10, 2016, of MR2 revealed the patient was admitted to the facility on September 23, 2016. The nursing shift progress note revealed the patient was engaged in a physical altercation with a peer on October 1, 2016, at 4:05 PM which included slapping and slamming the peer onto the floor.

Interview on November 10, 2016 at approximately 1:00 PM with EMP2 confirmed there was no incident report completed. EMP2 confirmed the facility was unable to identify the peer involved in the physical altercation and if they were assessed for injuries.

Review on November 10, 2016, of MR3 revealed the patient was admitted to the facility on October 7, 2016. The nursing shift progress note revealed the patient struck a peer in the chest on October 11, 2016, at 3:50 PM, and the patient kicked a peer on October 11, 2016 at 11:32 PM.

Interview on November 10, 2016, at approximately 1:00 PM with EMP2 confirmed there were no incident reports completed. EMP2 confirmed the facility was unable to identify the peers involved in the altercations and if they were assessed for injuries.

Review on November 10, 2016, of MR4 revealed the patient was admitted to the facility on October 13, 2016. The nursing shift progress note revealed the patient attempted to stab self with a pen and then proceeded to place a pillowcase over their head on October 13, 2016 at 3:00 PM. There was no documentation in MR4 to confirm if the patient sustained an injury.

Interview on November 10, 2016 at approximately 1:00 PM with EMP2 confirmed there was no incident report completed. EMP2 confirmed the facility was unable to confirm if the patient sustained an injury.

Review on November 10, 2016, of MR5 revealed the patient was admitted to the facility on September 15, 2016. The nursing shift progress note revealed the patient struck a peer in the stomach on October 10, 2016 at 10:14 PM.

Interview on November 10, 2016 at approximately 1:00 PM with EMP2 confirmed there was no incident report completed. EMP2 confirmed the facility was unable to identify the peer involved in the altercation and if they were assessed for injuries.

Interview with EMP4, EMP5 and EMP6 on November 10, 2016, revealed when there was an occurrence/altercation between two patients, the facility documented the altercation in the patient ' s medical record if there was an injury. EMP4, EMP5 and EMP6 confirmed no incident reports were completed, and there was no documentation or tracking of an altercation if there were no injuries. EMP4, EMP5 and EMP6 revealed if a peer was injured the facility documented the assessment in that patient's medical record.