HospitalInspections.org

Based on facility policy review, clinical record review and staff interview, the facility failed to ensure nursing notes, reports of treatment and other information necessary to monitor the patient's condition were documented.

Findings included:

Facility policy titled "Healthcare Peer Review (HPR)" stated in part, "Policy: A. To improve patient care, ensure safe healthcare facility practices through concurrent identification of ... evaluation or patient care, and intervention to reduce occurrences.
...Definitions:
A. Occurrence (Incident Type)" that which is not consistent with the routine care of a patient and/or the desired operations of the facility. The results of this event require or could have required (near miss) ... unexpected intensity of care, or causes or had the potential to cause an unexpected physical or mental impairment ...
Procedure:
A. Any facility employee or staff member who discovers, is directly involved in or is responding to an event/occurrence is to complete or direct the completion of a Healthcare Peer Review ...
C. Completing the HPR:
...c. The HPR is not part of the patient's chart.
d. The event is documented in the medical record by the person most closely associated with the event and includes:
*A concise statement of the facts of the event, statements are non-judgmental and objective.
*Clinical condition of patient (as a result of immediate examination by physician if indicated).
*Names, times of notification of physician, supervisory personnel, family members as necessary ..."

An incident occurred on 5/25/18 in which a patient attacked another patient. Review of the medical records for those patients, patients # 5 and #6, revealed no documentation of the facts of the event, clinical condition of the patient or names and times of notification of physician or supervisory personnel.

An incident occurred on 5/5/18 in which a patient attacked another patient, patient #9 and #10. Review of the medical record for patient #9 revealed observation rounds dated 5/5/18 that stated in part:
"5:30 am: behavior: Sleeping; location: patient room ...
5:45 am: behavior: agitated; location: patient room ...
6:00 am: behavior: agitated; location: patient room ...
6:15 am: behavior: cooperative; location: Day Rm ..."

Nursing note dated 5/5/18 at 11:45 am stated in part, "Police officers in the building talks to patient regards previous night incident, house supervisor aware, no further instruction received ..."

No further documentation of the incident was found.

Review of the medical record for patient #10 revealed observation rounds dated 5/5/18 stated the following:
"5:30 am: behavior: out of control, defiant, agitated; location: patient room ...
5:45 am: behavior: out of control, defiant, agitated; location: patient room ...
6:00 am: behavior: cooperative, agitated; location: patient room ...
6:15 am: behavior: cooperative, agitated; location: patient room ..."

There was no further documentation of the incident throughout the medical record. No physician or nurse addressed the incident.

In an interview with staff #2 when discussed the lack of documentation regarding the incidents in the medical records, staff #2 stated, "It should be charted."