HospitalInspections.org

Based on document review and interview, it could not be determined that care was provided in a safe setting due to facility failure to follow their policy ensuring an incident report, related to a patient to patient altercation, was completed in one (1) instance and investigated. (Patient # 9 & Patient # 10)

Findings include:

1. Review of the hospital policy titled, "Incident Reports", PolicyStat ID: 8824000, indicated an incident was defined as any event which would not be consistent with the routine operation of the hospital and that adversely affected or threatened to affect the well being of the patients. The hospital staff should complete and submit an incident report as soon as possible. This policy was last revised on 01/2020.

2. Daily Nursing Narrative note dated 02/10/2022 for patient # 9 indicated the patient was in his/her room after being hit by his/her roommate.

3. Medical Progress note dated 02/10/2022 by the Nurse Practitioner (NP) indicated patient # 10 was seen privately in his/her room. "As I came in" the patient's room he/she was in the middle of a verbal and physical altercation with his/her roommate.

4. The Incident Log for the month of 02/2022 lacked any documentation an incident report had been completed related to the altercation or that an investigation was conducted..

5. In interview on 03/02/2022 at approximately 12:30 pm by administrative staff member A # 2 (Regional Director of Compliance), confirmed patient # 9 and patient # 10 were roommates and an incident report was not completed.