HospitalInspections.org

Based on review of documentation and interviews, the facility failed to ensure that all patient medical record entries were complete, as evidenced by the failure to document the agency to which a report was made and the name of the person taking report, a dog bite for one (patient #3) of two patients reviewed for animal bites.

Findings were:

The facility policy entitled "Reportable Conditions and/or Crimes-Identifying and Managing", last revised 11/21/2023, reflected in part, " ...Animal Bites/Exposure: 1. Animal bites (possible rabies exposures) are reportable to the appropriate Animal Control officer in the county where the incident occurred. Reporting is mandatory ...Documentation: 1. Document all conversations with patients, the agency to which a report is made, including name/badge number of person taking report, the name/badge number of any persons who are present at the hospital to investigate the incident and/or to receive potential evidence ...3. Thorough, complete, narrative documentation is essential ..."

Review of the medical record for Patient #3 revealed in part, "...patient presented to the Ascension Seton Williamson ED 7/20/24 at 15:51 with multiple animal bites to her abdomen and right hand by unprovoked dog while delivering doordash order..."

During an interview on the afternoon of 9/4/24, Molly Hundley-Levine, ED Manager stated, "When a patient presents to the Emergency Department with an animal bite, the expectation is that we will call the county animal control that the dog bite happened in.
And it will be documented in the patient's record. It was not documented in patient #3's record."