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HICKORY TRAIL HOSPITAL
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on record review and interview, the hospital failed to complete an incident report for 1 of 1 Patient (Patient #1), after a bruise was identified on Patient #1's right thigh.
Findings Included:
The Nursing Progress note dated 08/10/15 reflected Patient #1 informed Personnel #3 that Patient #1 had a injury to the right thigh on 08/09/15.
The skin assessement dated 08/10/15 reflected Patient #1 had a bruise to her right thigh.
During an interview on 10/30/15 at 2:00 PM, Personnel #1 stated that the hospital did not complete an incident report concerning patient #1 and the discovery of the bruise.
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on record review and interview, a Registered Nurse (RN) failed to re-assess 1 of 1 Patient (Patient #1) who did not receive a nursing re-assessment from Personnel #11 after being informed by Hospital Personnel #3 that Patient #1 sustained a bruise to her right thigh.
Findings Included:
The Nursing Progress note dated 08/10/15 reflected Patient #1 informed Personnel #3 that Patient #1 had an injury to the right thigh on 08/09/15. There was no documentation of a nursing re-assessment on 08/09/15.
During an interview on 10/28/15 at 1:45 PM Personnel #11 indicated, "I assumed the bruise was assessed since it happened the day prior."
During an interview on 10/29/15 at 12:30 PM personnel #12 stated, the foster mother requested a re-assessment of Patient #1 on 08/10/15 at time of discharge. Personnel #12 completed the re-assessment prior to discharge on 08/10/15. The skin assessment reflected Patient #1 had a bruise on her thigh.