HospitalInspections.org

Based on record review and interview, the hospital failed to ensure policy was followed for one (Patient #2) of three patients reviewed.

Findings:

Patient #2

Review of hospital and medical records showed the patient threw themself off the bed and did not show documentation of the occurrence by nursing. Specifically:

1. A nursing assessment titled "Assessments and Treatments Aggressive Behavior" dated 06/18/25 at 8:30 AM read in part, "Patient attempted to roll [themself] over bedrails."

2. An ED Physician Note dated 06/18/25 at 9:26 PM read in part, "At approximately 07:30 AM patient..threw [themself] off the bed, began banging [their] head against the ground and then against the wall. At this time, the decision was made to intubate the patient."

3. An internal hospital document dated 06/19/25 read in part, "Occurrence Date 6/18/2025. Occurrence Time 8:10 [AM] ...[Patient] was given more IM meds and was able to relax ...Patient came out of [their] resting state and flung [themself] over the side rails, to the floor."

Review of policy titled "Admission Placement Criteria For All Patient Care Areas" published date 04/07/25 read in part, "ED Minimum Shift Required Documentation for Nurses ...Narrative Nursing Note +PRN +With patient deviations (e.g., Status decline/marked change)."

On 12/10/25 at 11:12 AM, Staff B stated the nurse should have documented the patient flung themself over the bedrails.