HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the care plan reflected the primary diagnosis for one (Pt. 1) of five patients reviewed.

Findings:

Pt #1
A review of the medical records showed the patient was seen at the ED due to an abscess to R lateral leg. The patient was admitted to the hospital 05/19/25 with a diagnosis of sepsis related to an abscess to the R lateral leg. The abscess to R lateral leg measured 8.5 x 9.5 x unknown (L x W x D) area 80.75 cm2. The care plan did not reflect a wound or issues with skin integrity or wound care.
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On 05/22/25 Staff C at 10:42 am stated the care plan should reflect the wound.

Based on record review and interview, the facility failed to ensure a grievance with investigation was completed for one (Pt 2) of five patients reviewed.

Findings:

Pt 2
A review of the record showed the patient alleged that they had been abused. The allegation did not result in a grievance with an investigation conducted or completed.

On 05/22/25 at 2:14 pm Staff F stated:
1) They would have started an investigation of the allegation regardless of the patient's mental status;
2) The Quality Risk Manager should have completed the investigation;
3) They would have investigated the allegation by conducting a chart review, visiting with providers and witnesses;
4) There was no investigation documented.