HospitalInspections.org

Based on document review and staff interview it was determined the facility failed to ensure completion of an annual review of all facility policies and procedures. This failure has the potential to prevent access, by all staff members, to uniform, current and accurate policies and procedures, with possible negative impact on all patients in the facility.

Findings include:

1. Administrative policy entitled, "Management of Policies and Procedures", last reviewed 12/2014, was reviewed on 3/25/15. It states, in part: "All policies and procedures of the hospital shall be reviewed and revised as necessary at least annually".

2. The facility's 'Master Policy and Procedure Manual' was reviewed on 3/25/15. All Pharmacy policies reviewed revealed a most current review date of 5/2012. All Radiology and Nursing/Medical policies reviewed revealed a most current review date of 11/2011.

3. An interview was conducted with the Director of Quality on 3/25/15 at 9:30 a.m. She concurred with the above findings and stated the annual review of policies had not been completed for all departments of the hospital.

Based on document review and staff interview it was determined the nursing staff failed to correctly document an incident involving two (2) patients, which was potentially harmful to both patients (patients #1 and 2). Failure to correctly report events of actual or potential threats to patients can lead to a failure to identify safety problems, and places all patients at risk.

Findings include:


1. Facility policy entitled, "Incident Reporting", last revised 12/14, states, in part: "In the event that any employee, or other person providing services on an on-going basis at Highland Hospital, shall observe or be made aware of an event representing an actual or potential threat to any person or property at the hospital, that person shall complete an incident report according to the procedures set forth below."

2. Patient #1's medical record was reviewed on 3/23/15 and revealed an entry by Registered Nurse (RN) #1 entitled, "Patient Progress Note/Nursing", dated 2/1/15 at 11:38 a.m., stating, in part: "(Patient #2) alleges that this pt. has been running in and out of her room today and has been touching her breasts. This was told to a BHT (Behavioral Health Technician) and myself. (Patient #1) said he has went in her room and talked but nothing else happened. This was reported by (Patient #2) after she was found in (Patient #1's) room laying down in his bed. (Patient #1) was getting up as she was laying down. See nurses' note for (Patient #2) for this date and timed at 10:55 pm and 11:30 pm... Dr..Nursing Supervisor, DHHR intake have all been made aware. Will continue to monitor."

3. Patient #2's medical record was reviewed on 3/23/15 and revealed an entry by RN #1 entitled, "Patient Progress Note/Nursing/Special Entry, dated 2/1/15 at 10:55 p.m., stating, in part: "Pt. was found laying down in another male pt's bed in his room and was fully dressed and BHT walked in room as male pt is getting up and walking into the hall...Both patients deny physical contact...(Patient #2) moved to time-out room and bedding is set up in there to sleep. Dr...Nursing Supervisor, and DHHR have all been made aware. Will continue to monitor."

4. The document entitled, "Supervisor's Report", dated 2/1/15, was reviewed on 3/23/15. It revealed the entry: "Children's Unit: (Patient #2) found laying on (Patient #1)'s bed, (Patient #1) says when she walked in he walked out no physical contact made. (Patient #2) to room change."

5. An interview was conducted with the Program Manager of the Children's Unit on 3/24/15 at 8:30 a.m. She stated the incident occurred on a weekend shift and she learned about it on Monday morning via her voice mail, the supervisor's report and in report. She stated she viewed available video footage of the incident and stated it corroborated the report of staff that Patient #2 had been found in Patient #1's bed during a routine bed/safety check of the unit, performed every fifteen (15) minutes, per policy. She stated her expectation was for an Incident Report to be completed and sent to Quality for investigation.

6. An interview was conducted with the Director of Quality and Risk Management on 3/23/15 at 1:30 p.m. She stated her expectation in this event was for an Incident Report to be generated and sent to her office, with an investigation to follow, per facility policy. She stated no such documentation could be located.