HospitalInspections.org

Based on document review and interview, nursing services failed to complete an incident report for a patient exposing him/herself and assaulting a staff member in 1 of 10 medical records reviewed. (P1)

Findings Include:

1. Facility policy titled, INCIDENT REPORTS, policy number NU.28, last reviewed 6/2021, indicated 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 WHAT SHOULD BE REPORTED: Any event that falls outside of the "norm" of expected event or any situation where there has been harm or potential for harm to a patient, family member, visitor, contractor, or employee requires the completion of an H1 Incident Report. Examples include but are not limited to: Falls, Medication errors / variances, Needle Sticks, Restraint, Assault-patient on staff, Assault-patient on patient, Suicide, Suicide attempt / self-harm attempt / self-inflicted injury, Elopement, Property damage, Allegation of abuse or neglect, Discharge against placing agency recommendation, Inappropriate sexual behavior, Physical illness, Deaths, Any physical injury.

2. MR (medical record) documentation for P1 indicated on 3/25/24, P1 walked up to another patient in the milieu and exposed himself/herself, staff intervened, P1 became physically aggressive towards staff punching the staff member in the chest and head.

3. In an interview on 4/16/24 at approximately 2:52 pm with A1 (Chief Executive Officer) confirmed an incident report was not filed for P1 in relation to him/her exposing him/herself and/or assault of a staff member on 3/25/24 and should have been.