HospitalInspections.org

Based on review of medical records (MR), review of facility documents, and interviews with staff (EMP) it was determined that the facility staff failed to report and investigate a serious reportable safety event as per facility policy.

Findings:
Review of facility document "Safety and/or Sentinel Event and/or Serious Reportable Event Reporting and Management" last revised September 8, 2025, reads in part: "... This policy provides a supportive structure with a goal of preventing patient safety events.... Policy. BSMH empowers all associates to report safety events, incidents or unsafe conditions that are inconsistent with routine operations and quality medical care. Events determined to be safety and/or sentinel events and/or National Quality Forum (NQF) Serious Reportable Events (SREs), near miss events and unsafe conditions are investigated within the BSMH Patient Safety Evaluation System (PSES) to identify real and potential risk points and implement process changes to improve patient safety.... V. Policy Details. Event, incident, hazard, or condition occurs, which resulted in an actual potential patient harm or no patient harm (near miss) or identification of an unsafe condition that does not involve a patient.... B. Event escalation: The Event Escalation Protocol ensures leadership involvement and facilitates rapid diffusion of information across facilities and throughout the ministry. The Protocol provides a guide to decision making of when and to whom to escalate serious events. 1. Sentinel, SRE, and harm events that reach the patient require staff to follow the escalation protocol. 2. The reporter of an event which results in serious harm, poses imminent risk of serious harm or is a sentinel event or SRE initiates the escalation policy.... D. Event reporting: All entities within the organization ... are responsible for reporting patient safety occurrences and potential occurrences. 1. Associates who identify or observe a safety event document the circumstances and facts in the event reporting system.... 2. Clinically pertinent information is documented in the medical record....

Review of the internal medicine progress note dated August 12, 2025, at 5:15 PM revealed documentation that MR4 had a left posterior shoulder dislocation and fracture. The progress note revealed that the injury likely occurred during a seizure and was not present on admission to the hospital.

Review of the orthopedics progress note dated August 13, 2025, at 9:32 AM revealed that there was no fracture of the left proximal humerus on MR4's x-ray from August 7, 2025, and there was no documentation of a fall in the patient's medical record.

Interview on September 22, 2025, at 3:22 PM, EMP2 indicated that there was no "SafeCare" event report submitted for MR4's left humerus fracture diagnosed on August 12, 2025, that was not present on the x-ray completed on August 7, 2025, when the patient came to the hospital. EMP2 indicated that the patient safety team was notified of the hospital acquired fracture at the end of August 2025 via a report that is run based on the electronic medical record system's review of records for key words, such as "fall with fracture". EMP2 indicated that MR4's hospital acquired left humerus fracture would be reviewed at the next patient safety committee meeting to determine if the event met criteria for a root cause analysis.

Interview on September 24, 2025, at 12:39 PM, EMP10 indicated that if there is a patient injury that occurs while the patient is in the hospital and the injury was not present upon admission to the hospital, then it should be escalated as per the event notification process.

Interview on September 24, 2025, at 12:41 PM, EMP28 indicated that MR4's left humerus fracture should have been reported in the facility's event reporting system, and "thankfully" the electronic medical record system report identified it.

Interview on September 24, 2025, at 2:18 PM, EMP30 indicated that MR4's left humerus fracture should be reported in the facility's event reporting system.

Based on review of medical records (MR) and interviews with staff (EMP), it was determined that medical staff failed to ensure an order for seizure precautions was documented in the patient's medical record for one (1) of one (1) patient's medical record reviewed, MR4.

Findings:

Review of facility document "Medical Staff Rules & Regulations" approved by the Board on January 23, 2025, reads in part: "... 3.5 Patient Orders ... Orders must be documented in the patient's medical record...."

Review of facility document "Lippencott Procedures - Seizure Management" last revised November 18, 2024, reads in part: "... Patients at risk for seizures need precautionary measures to help prevent injury if a seizure occurs. Equipment ... Padding for side rails .... If the patient is at risk for seizures, pad the patient's side rails ... Documentation. Documentation associated with seizure precautions includes: reason seizure precautions are required, all precautions taken ... interventions you performed ...

Review of the internal medicine significant event addendum for MR4 dated August 10, 2025, at 2:20 AM revealed documentation that the patient had an episode of "generalized shaking" and was on Keppra (medication used to treat certain types of seizures in people with epilepsy, including partial onset seizures, myoclonic seizures, and tonic-clonic seizures) for seizure like symptoms and "seizure precautions".

Review of the medical record for MR4 with EMP10 revealed no documentation of an order for seizure precautions and no nursing documentation that seizure precautions were implemented during the patient's admission.

Interview on September 24, 2025, at 11:11 AM, EMP17 did no recall EMP4 having padded bed rails as a seizure precaution during the shifts EMP17 cared for MR4.

Interview on September 24, 2025, at 11:54 AM, EMP10 confirmed that there was no order for seizure precautions in MR4's medical record but there was a note by internal medicine that documented "seizure precautions". EMP10 indicated that there was no nursing documentation that seizure precautions were implemented during MR4's admission at the facility.

Interview on September 24, 2025, at 2:00 PM, EMP30 indicated that a patient diagnosed with seizures and witnessed seizures must have seizure precautions ordered as it is the standard of care. Seizure precautions would include padded side rails, bed alarms, frequent checks, and no restraints for tonic-clonic seizures. EMP30 indicated that MR4 should have had an order for seizure precautions.