HospitalInspections.org

Based on document review and interview, nursing services failed to complete an incident report related to physical and aggressive behaviors against staff and other patients in 1 out of 10 patient MRs (Medical Records) reviewed (patient #1); nursing services failed to document presence of bowel sounds on the Daily Nursing Assessment Form for entire hospitalization in 1 out of 10 patient MRs reviewed (patient #1); and nursing services failed to ensure patient received daily shower and/or grooming for 1 of 10 patient MRs reviewed (patient #1).

Findings include:

1. Facility policy titled, "Incident Reports," PolicyStat ID: 13033981, last approved 01/2023, indicated under Purpose: An incident is defined as: any event which is not consistent with the routine operation of the hospital and that adversely affects or threatens to affect the well-being of the patients, employees, medical staff, visitors, consultants, or property of, regardless of whether an actual injury is involved or not. Any hospital staff member who witnesses, discovers or has direct involvement in and/or knowledge of an event must complete an incident report, or give a detailed report to the person completing the incident report.

2. Facility policy titled, "Bowel Management," PolicyStatID: 12197203, last approved 08/2022, indicated under Assessment: Nursing Admission Database Form: Once every shift, the nurse will document presence of bowel sounds on the Daily Nursing Assessment form, in the narrative section.

3. Facility policy titled, "Patient Personal Care," PolicyStatID: 12197137, last approved 08/2022, indicated under General Care: All patients shall be encouraged or assisted in grooming daily or more often as needed.

4. Review of patient #1's MR indicated the following:
a. The patient was admitted on 07/03/24 and discharged on 07/08/24.
b. On 07/05/24 at 2100 hours nurse note indicated patient #1 was aggressive towards other patients, hitting other patients, and when redirected patient #1 was physically and verbally aggressive with staff.
c. MR lacked documentation of presence of bowel sounds on the Daily Nursing Assessment Form for entire hospitalization.
d. MR lacked documentation of shower, grooming and incontinent care on the Patient Observation Rounds Form and Daily Nursing Assessment Form for 4 of 6 days (07/03/24, 07/04/24, 07/05/24, and 07/06/24).

5. Review of incident reports from 2/1/2024 through 7/30/2024 indicated no incident report were completed by staff for patient #1 on 07/05/24 for physical aggression towards other patients and staff.

6. Interview with A5, (BHA, Behavioral Health Assistant) on 08/19/24 at approximately 4:25 p.m., indicated they assisted with patient #1 was verbally and physically aggressive and resistant with care.

7. Interview with A2 (DON, Director of Nursing) on 08/19/24 at approximately 12:30 p.m., indicated that staff reported patient #1 was resistive with care, refused care, wandered in and out of other patients' rooms, was verbally aggressive to staff and other patients, and at times would attempt to hit others. A2 confirmed charting for incontinence is completed by nursing with their daily charting. A2 confirmed there was no incident reports completed for patient #1's aggressive and physical behaviors.