HospitalInspections.org

Based on the fact documented in the emergency room report for patient #1848759 on 09/30/2010 and the eyewitness statement contained in the complaint the allegation is substantiated and the hospital failed to maintain a safe setting allowing the adolescent patient to take an unattended scalpel and inflict 2 lacerations to her left forearm.

Based on the review of 5 clinical records including the patient record (1848759) it was determined that 3 of 5 clinical records did not always have entries that were dated and timed as required as evidenced by but not limited to the following:

? Record #1848759 did not have the time identified for the order for restraints it also lacked the date and time of the signature for medication history form.
? Record #92457 did not have the date or time on the procedure sedation record, no time on a physician order and lacked the date and time of the signature for medication history form.
? Record #154247 lacked the date and time of the signature for medication history form.