HospitalInspections.org

Based on document review and interview, the facility failed to document an incident report in one (1) instance (P1).

Findings include:
1. Review of the policy titled Incident Reports, Policy No.: NU.28, indicated the following;
Procedure: An Incident report should be completed immediately when an incident occurs. Staff will complete an Incident Report regarding events occurring within the organization that are out of scope of expected events. All sections of the report that pertain to the event should be completed and the incident report form should be filled out.

What should be reported
Any event that falls outside the "norm" of expected event or any situation where there has been harm or potential harm to a patient, family member, visitor, contractor or employee requires the completion of an Assurance Health System Incident Report. Examples include but are not limited to:
Falls
This policy/procedure last reviewed/revised on 12/20/2020.

2. Review of the following report number 294 that was sent to Indiana State Department of Health Survey Report System. This document indicated that P1 had an incident that resulted in a fracture of the left orbital, left wrist and the left foot. An investigation was completed by A3 (Chief Executive Officer). Camera footage from 05/29/2023 at 1905 hours confirmed that P1 had a fall while trying to ambulate on his/her own. P1 lost balance and fell to the ground P1 attempted to break the fall with his/her left arm.

3. In interview dated 07/03/2023 at approximately 3:40 pm with A1 (Director of Nurses), confirmed there were no incident report completed for the fall that occurred on 05/29/2023.

Based on document review and interview, the facility failed to ensure nursing staff followed policy/procedure for neurological assessment being completed on 1 (P1) of 10 medical records (MR) reviewed.

Findings include:

1. Review of the policy titled "Assessment-Neurological", Policy: NU.3, last reviewed 06/2021, indicates the registered nurse assigned to the patient will provide neurological assessments and reassessments when a neuro deficit is suspected or the assessments are ordered by a physician or post fall events and the patient has hit his/her head.

2. Review of the following report number 294 that was sent to Indiana State Department of Health Survey Report System. This document indicated that P1 had an incident that resulted in a fracture of the left orbital, left wrist and the left foot. An investigation was completed by A3 (Chief Executive Officer). Camera footage from 05/29/2023 at 1905 hours confirmed that P1 had a fall while trying to ambulate on his/her own. P1 lost balance and fell to the ground P1 attempted to break the fall with his/her left arm.

Review of P1's MR lacked documentation that a neurological assessment was initiated after the injury was found.

3. On 07/03/2023 at 1500 hours, staff A1 (Director of Nursing) was interviewed and confirmed the above MR's provided for review were complete patient records as presented. Staff A1 confirmed nursing staff should have followed policy/procedure for Assessment-Neurological.