HospitalInspections.org

Based on record review and interview the facility failed to ensure that updates were completed to 2 of 3 patient's (#14, #23) Plans of Care (POC) after they experienced falls while on the Behavioral Health Unit. The facility also failed to ensure that 3 of 3 patient's (#14, #22, #23) "Occurrence Reports (OR)" that were reviewed by the Quality Improvement Department were complete and contained documentation of the Quality review findings/data. Findings include:

On 06/09/2014 at 1600 during review of an OR for patient #14 revealed that on 05/15/2014 (time of occurrence not documented on the OR) the patient experienced a fall that resulted in a minor injury. During review of the medical record on 06/09/2014 at 1620, revealed that there was no update to the patient's POC after the fall occurred.

On 06/09/2014 at 1645, review of an OR for patient #23 revealed that the patient had experienced a fall on 05/15/2014 at 0800. Patient #23 sustained a minor laceration to her forehead. OR reads, " Dermabond was applied & dressing done." At 1700, review of the medical record for patient #23 revealed that there was no update to the patient's POC after the fall occurred.

On 06/10/2014 at 0830 during an interview with staff E (Co-Manager of Behavioral Health Unit), she was unable to locate any further documentation regarding updates to the POC for patients #14 or #23 after they experienced falls. When queried about the lack of updates staff E stated, "Both of the care plans should have been updated after the patients fell. It is a work in progress to get everyone on board with what they are supposed to be doing."

On 06/09/2014 during review of ORs at 1600, 1645 and 1700, it was also noted that the reports were either not filled out completely or lacked data in the areas titled,
"Reporting" and "Quality Management Review." The OR for patient #14 lacked documentation of date and time of notifying the Director of Quality of the incident. The OR also lacked documentation of when the occurrence occurred in the section titled "Situation."

Review of the OR for patient #22 in the section titled "Quality Management Review" revealed a lack of data and contained only a date, time and staffs initials.
The OR for patient #23 in the section titled, "Reporting" lacks documentation of date and time of reporting the incident to the Chief Executive Officer (CEO). Review of the section titled, "Quality Management Review" contained only data regarding, "patient transferred to medical floor."

On 06/10/2014 at 0930 during an interview with staff A (Director of Quality Management) when queried as to what her role is in reviewing the ORs she stated,
"I make sure that the Director of Nursing and/or the House Supervisor has reviewed it, that appropriate action was taken and if it happened on the Behavioral Health Unit that the Recipient Rights Officer gets a copy of it." Staff A was then queried as to how putting just her initials or re-iterating that the patient was transferred shows evidence that she completed a Quality Management Review. Staff A replied, "I see what you are saying, it does not tell you the steps that I have taken to review the occurrence. I can start putting that on there and review the ORs for completeness." When queried as to how the Director of Nursing and/or the Behavioral Health Co-Managers are supposed to know that they need to improve on them (OR) if you don't review the report for completeness, document your findings and then bring the data to the Quality meeting. Staff A replied, "I see your point."

Noted on the top of the document titled "Occurrence Report" it states the following:
"Staff Must:
1. Complete all of Page 1 of the Occurrence Report before end of shift in which occurrence was identified.
2. Notify Supervisor or designee of occurrence. Document date and time of notification below.
3. Supervisor or designee to notify the CEO, CNO (Chief Nursing Officer), and/or Quality Management as required in Occurrence Reporting policy, ADM-0-1.
4. Fax a copy to Director of Quality.
5. Give to Supervisor, or House Director if Supervisor is not available, before end of shift in which occurrence was identified."






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