HospitalInspections.org

Based on interview, record review, and observation the facility failed to promote safety, and detect hazardous events and circumstances when (1) one out of (7) seven patients medical records reviewed, after Patient #1 reporting an incident while in the facility, the facility did not complete an incident report for the incident. This failure places patients at risk of injury due to the the facility's lack of tracking and analyzing all incidents.

Findings include:

An observation made on the morning of 4/16/24, in the inpatient conference room, revealed Patient #1 sitting in a chair wearing a long-sleeved light gray sweater; there were several small smears of bright red lines on the right sleeve and upper neck. Patient #1 had a dark red, approximately ½ cm (centimeter) wound to her left lower lip.

During an interview, on the morning of 4/16/24, in the inpatient conference room, when asked about the stained sweatshirt and sore on the lip, Patient #1 stated in part, "My roommate (Patient #4) threw water on me, then held my face between her thighs, she started slapping my face with her thighs. She (Patient #4) said she did it to her previous roommate. She (Patient #4) tried to choke me and cut my lip; staff came in when I yelled; I was moved to another unit."

During an interview, on 4/16/24 at 10:00 am in the facility conference room, when informed of an incident on 4/8/24, between Patient #1 and Patient #4 and asked to see the incident report. Staff #1, CNO stated, I can't find an incident report for 4/8/24. There should be an incident report."

Review of the facility provided policy Incident Reporting (Reviewed, 01/2020) reflected, "POLICY:
It is the policy of Cross Creek Hospital to utilize the Risk Management Program techniques to promote safety, pro-actively focus on loss prevention, and detect hazardous events and circumstances. It must provide a systematic, multi-disciplinary approach to managing and reporting incidents of injury, damages, and loss.

2.0 PURPOSE:
The Incident Report is a risk management tool that raises awareness of potential exposures to perils that may/did cause harm. It enables the facility to manage risk, increase safety, and improve the quality of health care provided in the facility through risk control intervention and monitoring the effectiveness of the interventions and corrective action plan.

An "incident" is an unanticipated event which was not consistent with the standard of care and/or operation of the facility and may have occurred due to a violation of policy and procedure. It results in, or nearly causes, a negative impact on a patient(s) receiving care at the facility, or visitor(s) at the facility. Any harm caused can be temporary, long-term, or permanent and range in severity from no obvious or significant injury up to death. The Incident Report will help the various facility committees and administration in identifying potential areas of risk and implementing measures to improve the overall quality of care throughout the facility.

3.0 PROCEDURE:
Any facility staff member who witnesses, discovers, or has direct knowledge of an incident must complete an Incident Report before the end of the shift/workday.
3.1. Supervisor will review the Incident Report for legibility, completion, signature and date. Supervisor will notify Risk Manager of a serious incident as well as take the lead in investigating non-serious incidents.
3.2. The Incident Report will be routed to the facility Risk Manager within 24 hours of incident.
3.3. If the incident involves a patient, staff must chart relevant information in the patient's medical record. When documenting incidents in the medical records, staff will chart precisely what happened without making reference to an "error" or that an Incident Report was completed ..."

Based on record review and interview the facility failed to accurately document (1) one out of (7) seven medical records reviewed for having an incident while in the facility. The nursing staff did not document Patient #1's facial injury. This failure placed a patient with injuries at risk of not being assessed, treated, and monitored for adequate healing.

Findings include:

Review of the facility provided policy, Documentation Protocol (reviewed 01/2023) reflected, "POLICY: Cross Creek Hospital records, reports, charts, and documents are to be accurate, truthful and complete. Staff is to document accurately our services provided, patient interactions, and all financial records and transactions. Every staff who creates or reviews documentation in a medical record or responds to or implements orders or directives contained in a medical record, ensures the medical record complies with this Protocol. This duty to ensure accuracy of medical records applies to the entire medical record, not just documentation a staff individually creates, reviews or acts upon.

PURPOSE: To assure accurate and timely documentation; to provide a means of communication between healthcare providers; to provide a legal record to protect the patient, the facility and health care team; and, to provide information in the medical record for performance improvement.

PROCEDURE:
1. All patient medical record entries are to be:
o legible,
o complete,
o timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, and
consistent with facility policies and procedures ..."

Review of Patient #1's Nurse's Note, dated 4/13/24 at 11:30 pm, reflected in part, "Lidocaine patch used for back pain. Patient was attacked by roommate." The skin assessment did not indicate the bleeding lower lip.

During an interview, on the morning of 4/17/24 in an administrative conference room, Staff #1, CNO (Chief Nursing Officer) was informed of Patient #1 reporting the event to the surveyor and the surveyor's observations of her bloody shirt and busted lip. When asked where the nurse would document the event in the patient records. Staff #1, CNO stated, "He didn't write the busted lip, he would have written it here. (indicating the nursing narrative.)