HospitalInspections.org

Based on document review and interview, the facility failed to ensure a patient incident of injury/abuse was reported to the DMHA (Division of Mental Health & Addiction); per policy; for 1 of 11 MRs (Medical Records) reviewed (Patient # 7).

Findings include:

1. The policy titled: "Patient Rights and Responsibilities", PolicyStat ID: 10359862, indicated on page 5, to notify government agency(ies) for injury/abuse. Last revised 9/2021.

2. The Facility corporate document, titled: "DMHA: Critical Incident Reports", sent to facility CEO (Chief Executive Officer) A # 1, via email, on 11/18/2022; indicated under "Incident"; "Patient Abuse", "patient to patient"; timeframe for reporting "10 days".

3. Review of closed MR for Patient # 7, reflected the following:
A. The patient was injured on 12/4/2022, at 2:05 pm; on unit 300, by another patient (Patient # 11). Patient # 7 had facial injury(ies) and was choked. Patient was assessed and sent out via EMS (Emergency Medical Services) to AH # 40 (Acute Care Hospital) for further evaluation and treatment.
B. Patient was returned to APH # 60 (Acute Psychiatric Hospital) after evaluation and treatment at AH # 40. Patient was reassigned to the 100 unit.

4. Review of incident report for above; that involved Patient # 7 and Patient # 11, reflected a fight in the nurses station; efforts by staff to separate patients and additional staff responded to assist. Since magnitude of the injury(ies) were unknown; patient with visible injury; 911 was initiated to send patient out for further evaluation. Police also arrived for extra security purposes. Notifications were made; included Medical staff, CEO, Social worker, and Patient # 7's Guardian. Document lacked attachments by administrative staff, related to a required notification to DMHA, in required timeframe.

5. In interview on 1/5/2023 at approximately 11:27 am, with A # 1 (CEO), the following was confirmed:
A. DMHA was not notified of the patient assault/injury.
B. Should have been reported to DMHA within 10 days; was not done.

6. In interview on 1/5/2023 at approximately 4:20 pm, with A # 2 (Corporate Quality/Compliance); via cell phone (A # 1's cell phone/on speaker), the following was confirmed:
A. Injuries with send outs are to be reported in 10 days to DMHA.
B. Incident should have been reported.