HospitalInspections.org

Based on document review and staff interview, the facility failed to ensure a safe setting was provided for 1 of 5 patients (patient #3).

Findings:

1. Review of patient #3 (15 year old) medical record indicated the following:
(A) He/she was admitted on 5/23/13.
(B) Nurses notes dated 5/27/13 at 1500 indicated the patient complained of a nosebleed after an altercation in the gym with a peer.
(C) The medical record lacked documentation that the parent or physician was made aware of the altercation and nosebleed.

2. There was no incident report or other documentation for the altercation involving patient #3 on 5/27/13. Therefore, it could not be determined that measures were in place to assure a safe setting and to assure prevention of future occurances.

3. Facility policy titled "Emergency Medical Care and First Aid" last reviewed/revised 4/13 states on page 1 under policy: "..............Notification of pertinent persons, (parent, guardian, POA) will be completed in the event of an injury and/or emergency medical care." Page 2 states under Epistaxis/Nose Bleeds: "The attending physician or the physician on-call shall be notified......" Page 5 states under notification "The unit nurse will notify family, guardian, or power of attorney of an injury and/or emergency medical care."

4. Staff member #A2 indicated the following in interview beginning at 1:10 p.m. on 7/30/13:
(A) He/she verified that there was no physician or family notification of the altercation resulting in a nosebleed on patient #3.

5. Staff member #A1 indicated the following in interview beginning at 1:30 p.m. on 7/30/13:
(A) There was no incident report completed for the incident with patient #3 on 5/27/13, therefore no evidence of investigation etc.

Based on document review and staff interview, the facility failed to ensure a patient was free from abuse of a peer for 1 of 5 patients (patient #3) and failed to include the right to be free from abuse from patients and others in facility policy.

Findings:

1. Review of patient #3 (15 year old) medical record indicated the following:
(A) He/she was admitted on 5/23/13.
(B) Nurses notes dated 5/27/13 at 1500 indicated the patient complained of a nosebleed after an altercation in the gym with a peer.

2. Facility policy titled "Patient Rights" last reviewed/revised 1/18/13 states on page 2: "K. The right to be free from physical and/or emotional abuse by any member of the staff and the right to immediate access to reporting procedures." The policy did not indicate the patient has the right to be free from abuse from others besides staff.

Based on document review and staff interview, the facility failed to ensure that the nursing staff notified parents and/or the physician of incidents per policy for 3 of 5 patients (patients #1, 3, and 5) and failed to document the need for specialized follow-up care on discharge paperwork for 1 of 5 patients (patient #1).

Findings:

1. Review of patient #1 (16 year old) medical record indicated the following:
(A) He/she was admitted on 5/21/13.
(B) The patient became angry during a family session with a parent on 5/24/13 and punched a wall. The father was aware the patient punched the wall, however the medical record lacked documentation that the parent was made aware that the patient had an x-ray later on 5/24/13 that revealed a "Salter-Harris fracture of proximal phalanx of ring finger" and the recommendation was an orthopedic consult for further evaluation and management.
(C) The attending physician wrote an order on 5/25/13 to follow up with "ortho appointment" after discharge for the fracture.
(D) The patient was discharged on 5/28/13 and the discharge paperwork lacked documentation concerning the fracture and that the patient was to follow up with an orthopedic consult for the fracture.

2. Review of patient #3 (15 year old) medical record indicated the following:
(A) He/she was admitted on 5/23/13.
(B) Nurses notes dated 5/27/13 at 1500 indicated the patient complained of a nosebleed after an altercation in the gym with a peer.
(C) The medical record lacked documentation that the parent or physician was made aware of the altercation and nosebleed.

3. Review of patient #5 (13 year old) medical record indicated the following:
(A) He/she was admitted on 5/14/13.
(B) Nurses notes indicated that on 5/24/13 at 2040, the patient became upset and punched the wall.
(C) The record indicated the hand was x-rayed on 5/24/13, however the parent was not made aware of the incident or the x-ray.

4. Staff member #A2 indicated the following in interview beginning at 1:10 p.m. on 7/30/13:
(A) He/she verified that the parent of patient #1 was not made aware of his/her fractured hand and the need for orthopedic follow-up was not part of the discharge paperwork.
(B) He/she verified that there was no physician or family notification of the altercation resulting in a nosebleed on patient #3.
(C) He/she verified that there was no family notification of patient #5 hitting the wall requiring an x-ray of the hand.

5. Facility policy titled "Emergency Medical Care and First Aid" last reviewed/revised 4/13 states on page 1 under policy: "..............Notification of pertinent persons, (parent, guardian, POA) will be completed in the event of an injury and/or emergency medical care." Page 2 states under Epistaxis/Nose Bleeds: "The attending physician or the physician on-call shall be notified......" Page 5 states under notification "The unit nurse will notify family, guardian, or power of attorney of an injury and/or emergency medical care."