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Based on observation, interview, and record review, the facility failed to provide an incident report of injury for (1) out of (20) patients admitted to Parkland Health and Hospital System. (Patient #3)

The findings included:

A review a facility documentation on 10/02/2021 at 3:56 PM, the nurse noted in a wound assessment revealedthe doctor, "notified patient's wife at bedside reported patient has blisters from reaching for hot Noodles[sic]; advised to apply water-based lubricant." Patient is paralized on his left side and was unable to feel pain and needed assistance with activities of daily living (ADL).

The facility failed to follow their policy and procedure to identify and investigate reports of injury. Review of facility policy, SYS.PI.003 titled, "Management of Adverse Events via the Cause Analysis (CA) Process page 2" states, in part: "A formalized team response that stabilizes the patient, discloses the event to the patient and family and provides support for the family with the involvement of Patient Safety & Clinical Risk Management, as well as the workforce involved in the event was not completed."

Interview with RN via phone on 01/04/2023 at 1:30 PM. RN was the first nurse to complete a wound assessment on 10/2/2021 at 3:56 PM.
Surveyor: Did you observe the soup spill?
RN: No, I was not in the room.
Surveyor: Who reported the soup spill?
RN: It was the wife or the sitter.
Surveyor: Who called the PCP for notification?
RN: I did.
Surveyor: Did you write a progress note?
RN: I can't remember
Surveyor: What is a sitters responsibility?
RN: Patient safety.
Surveyor: Did you fill out an incident report?
RN: "I don't believe I did."
Surveyor: When do you have to fill out an incident report?
RN: "If something happens to a patient. I should have filled one out."

Interview with Patient Care Advocate (PCA) on 01/04/2023 at approximately 2:00 PM. The PCA was assigned as a sitter on 10/02/2021 to patient #3.
Surveyor: What is your responsibility as a sitter?
PCA: I'm not a sitter I'm a PCA.
Surveyor: What is your responsibility as a PCA?
PCA: Vital signs and patient care.
Surveyor: Did you hear the patient's ex-wife ask for the burns to be reported to someone?
PCA: No, she was not in the room at the time.
Surveyor: Who provided the soup?
PCA: The family did.

A summary of an email sent from the PCA to her supervisor, revealed the following: PCA had been relieved by another staff so she could warm up noodle soup for the patient. She put the soup on the microwave for three minutes. She brought the soup to the patient and told him he would have to wait to eat the soup, it was still hot. Patient grabbed the soup and it spilled on his body. PCA removed the cup and immediately took his blanket and gown off and provided ADL's for the patient.

Interview with Staff #2, with Director of Regulatory Accreditation Affairs on 01/04/2023 at approximately 2:50 PM
Surveyor: have you been able to locate an incident report?
Director of Regulatory Accreditation Affairs: No, I have not.

No incident report could be found for patient #3.