HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #2) self-harm events reviewed for reporting and follow up, the hospital failed to ensure a self-harm event was reported, as required.

Findings include:

1. The hospital's policy titled, "Safety Event and Medical Device Reporting" (updated 02/07/22) was reviewed and required, " ... 4. A Safety Event is completed for events involving patients ... and included, r. Self-harm events ... III. Procedure 1. Complete safety event at time of event ... "

2. The hospital's Safety Event (self-inflicted injury) log (05/2024 - 11/06/2024) was reviewed. The log did not include an event for (Pt.#2).

3. The clinical record for Pt.#2 was reviewed. Pt.#2 presented to the Emergency Department (ED) as a walk-in on 07/04/24 at 9:31 AM and was discharged to home on 07/06/24 at 12:34 PM. The clinical record included the following:

-Nursing Note (E#8), dated 07/06/24 at 12:30 PM, "(Pt.#2) refused care from RN (Registered Nurse), (Pt.#2) notified of DC (discharge) plan by psychiatry. (Pt.#2) observed attempting to hurt self with pitcher top, also observed picking on scabs to bleed, used bed sheet to strangle self. MD notified ... (Pt.#2) stated feeling agitated, PRN (as needed) meds (medication) administered, DC (discharge) papers given to (Pt.#2). DC to self at this time ... security assisting pt out."

4. An interview was conducted with a Registered Nurse (E#8) on 11/07/24 at 10:35 AM. E#8 stated that E#8 did not file a safety event report for the self-harming event by (Pt.#2).

5. An interview was conducted with the Emergency Department Director (E#15) on 11/07/24 at 12:10 PM. E#15 stated that incidents involving patients inflicting self-harm should be reported as a safety event.