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Based on record review and interview, the facility failed to document on 1 of 3 patient (Patient #1) adverse occurrences in a total of 10 patients medical records reviewed.

Findings include:

Review of Patient #1's medical record was conducted on 1/24/2019 at 11:27 AM accompanied by Supervisor D who confirmed the following findings: On 1/22/2019 at 11:58 PM Registered Nurse L documented in a progress note that Doctor F was notified of superficial rub marks that Patient #1 had self-inflicted to the tops of both hands and that there was no bleeding.

Per phone interview with Registered Nurse L on 1/24/2019 at 1:30 PM regarding Patient #1's injuries, Nurse L stated L did not know when (during the PM shift of 1/22/2019), Patient #1's self-inflicted scratches occurred on the backs of #1's hands, but it was, "Earlier in the shift," than when Doctor F was notified (1/24/2019 at 11:27 AM). When asked how Nurse L knew about the scratches, Nurse L stated, "The patient told me. [Patient #1] was either in the hallway or by the med [medication] room when [Patient #1] told me. There was no bleeding, they were superficial, redness and raw looking, bandaids were applied."

Review of the adverse occurrence log, on 1/24/2019 at 1:40 PM revealed no documentation of Patient #1's incident of attempting to cut self with fingernails.

Interview on 1/24/2019 at 1:45 PM, Risk Manager B stated, "The staff did not complete an adverse occurrence report for [patient #1], the staff should have completed the form."