HospitalInspections.org

Based on document review, record review, video review and staff interview it was determined the facility failed to ensure all investigations related to patient safety were completed in a timely manner in one (1) of one (1) investigations reviewed for patient safety (patient #2). Failure to ensure all investigations are completed in a timely manner to ensure analysis of the incident and implementation of corrective action has the potential to negatively impact all patients who receive care at the facility.

Findings include:

1. Review of the facility policy entitled "Sentinel Events-Investigation and Reporting", last revised 6/2017, revealed it stated, in part: "Serious injury is defined as any significant impairment of the physical condition of the member...this includes but is not limited to:...bone fractures...Within [seventy-two] (72) hours of the potential sentinel event, the Executive Team shall initiate an analysis of all available information to determine...[the cause of the incident]."

2. A review of the medical record for patient #2 revealed the nursing documentation on 6/16/18 stated the patient had a fractured hip and was transferred to a local hospital. An interview was conducted on 6/26/18 at about 3:10 p.m. with the Registered Nurse who was present during the altercation between patient #1 and 2. The altercation was discussed. She stated she cared for patient #2 after the altercation, ordered X-rays and received results that patient #2 had a hip fracture. She notified the family and transferred the patient to the hospital for treatment of the fractured hip.

3. The facility video for the self-reported incident involving the above noted patients was reviewed.

4. The facility investigation for the altercation on 6/16/18 between patient #1 and 2 was reviewed. There was no analysis or concluding recommendation completed for the altercation. The investigation was not complete.

5. The Risk Manager was interviewed on 6/26/18 at about 9:15 a.m. The above patient altercation incident and investigation was discussed. She stated the facility investigation had not been completed to date. She concurred the facility had failed to follow it's own policy to complete this type of investigation within seventy-two (72) hours or three (3) days since the altercation had happened ten (10) days previously.