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Based on document review and interview, the facility failed to protect and ensure the physical safety for three (3) of ten (10) patients. (Patient # 2, Patient # 4 & Patient # 10)

Findings include:

1. The facility policy titled, "Patient Rights and Responsibilities", PolicyStat ID 10359862, indicated every person who entered the hospital for care had the right to receive care in a safe setting, free from physical abuse or harassment. This policy was last revised in 09/2021.

2. The facility policy titled, "Patient Abuse and Neglect", PolicyStat ID 11795580, indicated all patients have the right to be free from abuse. The definition of physical abuse was an act that had resulted, or had the potential to result in death, pain, and/or impairment of any bodily function. An example would be pushing/shoving. This policy was last revised in 01/2020.

3. Review of the MR for patient # 2 indicated the following:
a. The 65 y/o (year/old) patient was admitted on 04/18/2022 with a diagnoses of bipolar affective disorder and dementia.
b. The Daily Nursing Narrative dated 04/29/2022 at 7:40 am, indicated the patient was walking in the milieu and another patient noted to come behind the patient and just pushed him/her down. The patient was unable to move the leg without pain. Orders received to send patient out to H # 3's (Acute Care Hospital) Emergency Room (ER) to eval & tx (evaluation and treatment).
c. The Daily Nursing Narrative lacked the time the patient had been sent out to the ER.

4. Review of the MR for patient # 4 indicated the following:
a. The 79 y/o patient was admitted on 06/08/2022 with a diagnoses of vascular dementia.
b. The Daily Nursing Narrative dated 06/18/2022 at 4:25 pm, indicated the patient was pushed down in milieu by another patient. The patient complained of pain to right thigh area. Mobile x-ray was ordered which resulted possible right hip fracture. Patient was sent out to H # 3's ER at 2:45 am.

5. Review of the MR for patient # 10 indicated the following:
a. The 80 y/o patient was admitted on 02/16/2022 with a diagnoses of dementia with behavioral disturbances, major depressive disorder and anxiety disorder.
b. The Daily Nursing Narrative dated 02/27/2022 at 5:45 am, indicated the patient was witnessed being pushed to the ground by another patient. The patient was observed falling from a standing position to his/her left side. Patient noted to hit head. Aggressor immediately left the scene. Patient was groaning in pain and a moderate amount of blood was noted. Patient stated that there was pain to head. Orders to send patient out were obtained and patient departed to H # 3's ER at 6:08 am.


6. In interview dated 07/11/2022 at approximately 1:30 pm with administrative staff member A # 1 (Registered Nurse-RN/Director of Quality), confirmed that per policy the incidents were considered patient to patient abuse.

Based on document review and interview, the facility failed to electronically document an incident report in one (1) instance (patient # 2) and failed to analyze and track adverse patient events in three (3) instances. (Patient # 2, Patient # 4 & Patient # 10).

Findings include:

1. The facility policy titled, "Incident Reports", PolicyStat ID 8824000, indicated an incident report should be completed in the system by the end of the shift in which the incident occurred but no later than twenty-four (24) hours from the time of the event occurred.

2. The facility policy titled, "Sentinel Events", PolicyStat ID 11462967, indicated a patient safety event resulting in harm due to a fall shall conduct a root cause analysis for identifying the causal and contributory factors for systemic improvement. This policy was last revised in 03/2022.

3. Review of the facilities incident report list indicated patient # 2 lacked an incident report from a fall which occurred in 04/2022.

4. Review of the following patient's medical records (MR's) indicated each patient was noted to have bodily injury after their fall.
a. Patient # 2 was unable to move his/her leg without pain after being pushed down by another patient on 04/29/2022.
b. Patient # 4 was pushed down in milieu by another patient on 06/18/2022. The patient complained of pain to right thigh area. Mobile x-ray was ordered which resulted possible right hip fracture.
c. Patient # 10 indicated the patient was witnessed being pushed to the ground by another patient on 02/27/2022. Patient noted to hit his/her head. Patient was groaning in pain and a moderate amount of blood was noted. Patient stated that he/she had pain to their head.

5. In interview dated 07/12/2022 at approximately 3:40 pm with administrative staff member A # 2 (Chief Executive Officer-CEO), confirmed there was no incident report completed for the incident from 04/2022 and no root cause analysis were conducted on the above patients.