HospitalInspections.org

Based on document review and interview, Nursing Services failed to complete an incident report per facility policy for 1 patient event/incident that occurred. (P3)

Findings include:

1. Facility policy titled Adverse Event Management and Error Reporting, no policy number, Publication date 09/26/2022, under I. Purpose, To provide a framework for identifying, reporting, and managing adverse events that occurred at F1 (Acute Care Hospital) including team members injured during a physical assault. Under V. Policy Statements: All employees are responsible for reporting any unexpected outcome, incident, or other situation that is likely to lead to undesirable effects or that varies from established policies and procedures or practices. Under VI. Procedures, a. Any patient safety incident or near miss/good catch should be documented in the web-based incident reporting system. Under E. Patient Disclosure of Sentinel and Adverse Events, 7. When appropriate the Clinical Risk Manager will refer incident reports to the Patient Relations Consultant for documentation of the interactions and follow up.

2. Review of P3 MR indicated a lack of documentation of an event/incident that occurred on 10/9/24 at discharge.

3. Review of Incident reports from 6/1/24 through 12/19/24 indicated no incidents related to P3.

4. Incident Abstract reports dated 11/21/24 indicated on page 3 that on 12/3/24 FM1 requested he/she would like F2 leadership to also follow up on the incident involving P3 on 10/9/24. Page 11 indicated on 12/4/24 the F2 crew reported that P3 had full strength and range of motion after the incident and the incident was not documented. Page 16 indicated on 11/21/24, A14 (Risk Consultant) would interview everyone that was involved or may have witnessed the situation, even the nurse that was referenced. Report lacked interview with N2.

5. In interview on 12/16/24 at approximately 1315 hours with N2 (Registered Nurse), he/she confirmed the incident involving P3 did happen. N2 indicated he/she witnessed P3's foot getting caught in the stretcher and P3 cried out in pain. N2 was unsure of which foot. P3 was then placed on the stretcher, EMT's looked at foot and P3 was transported to SNF. N2 confirmed there was not an incident report filled out regarding the event. N2 did not assess the foot.

6. In interview on 12/16/24 at approximately 1415 with A1 (ACNO [Assistant Chief Nursing Officer]), he/she confirmed an incident report should have been filled out regarding P3's ankle injury by staff caring for P3 at the time of discharge.