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TRUSTPOINT HOSPITAL
PATIENT SAFETY
Tag No.: A0286
Based on policy review, medical record review, and interviews, the facility failed to report, investigate, and track an adverse event for one patient (#6) of 13 patients reviewed for adverse events.
The findings included:
Review of facility policy "Occurrence Reporting" effective date 8/1/12 revealed "...Occurrence reports serve to analyze the frequency and causes of general and specific types of events. This data is used to identify opportunities for improvement...An occurrence/incident is any unusual or unexpected, recognized, suspected, or potential event or condition that is not consistent with the routine safe delivery of patient care...Such unusual or unexpected events may include...Accidents and/or injuries occurring on hospital premises...The Occurrence Form is to be filled out completely and submitted to the Department Director/Manager within twenty-four (24) hours..."
Medical record review revealed Patient #6 was admitted to the facility on 10/7/19 with diagnosis including Early Alzheimer's Dementia, Coronary Artery Disease, and Arteriosclerotic Heart Disease.
Medical record review of a Nursing Shift Assessment dated 10/17/19 at 2:15 PM revealed "...Pt [patient] has small cut over R [right] eye with 1 steri strip in place, from another patient striking him..." Continued review at 4:05 PM revealed "...spoke with patient's wife about altercation between him [Patient #6] and another patient. Another patient became aggressive with [Patient #6] and he [Patient #6] got hit in the face..."
Review of the facility's Occurrence Reports for October 2019 and November 2019 revealed no documentation an occurrence report was completed for the altercation with injuries involving Patient #6.
Interview with the Quality Director on 12/3/19 at 2:00 PM, in the Administration Conference Room, confirmed no Occurrence Report was completed for Patient #6's injuries on 10/17/19. Continued interview confirmed an Occurrence Report must be completed for altercations between patients and for any patient injuries.