HospitalInspections.org

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Based on document review and interview, the facility failed to conduct investigations of occurrences to identify circumstances surrounding the incidents.

This failure places all patients at risk for repeat incidents to occur.

Findings:

Review of the facility's "Patient Occurrence Reporting Form" revealed that on 06/25/18, Patient #6 was "discharged, waiting for cab in waiting room and became agitated. Patient [#6] punched the Purell cannister, garbage pail and wall".

The report documents that the patient was brought to the Behavioral Health Emergency Department Area, was evaluated for injuries, and medicated for agitation.

There is no documented evidence of an investigation into the cause or events leading up to the patient occurrence.

Review of the facility's "Patient Occurrence Reporting Form" revealed that on 06/14/18, Patient #5 was entering the Secured Behavioral Health Emergency Department Area, but "escaped through the door, then exited the second door as it was closing, then escaped through the [emergency department] exit door". The report documents that the patient was secured and returned to Behavioral Health.

The report documents that staff were "educated on the importance of maintaining safety". However, there is no documented evidence of an investigation into the cause of the events leading up to the patient occurrence.

Per interview with Staff S (Assistant Executive Director of Quality Assurance) on 08/02/18 at 1:45PM, the staff member confirmed that there was no additional investigation documentation on the reviewed occurrence reports.

The facility's Policy and Procedure titled "Occurrence Reporting" last dated 11/2014, lacked instruction on investigating reported occurrences.