HospitalInspections.org

Based on document review & interview the facility failed to ensure that medical records (MR) be promptly & accurately written for 1 of 10 MRs reviewed (Pt #1).

Findings include;

1. Review of facility documentation dated 05-15-17 indicated that Pt #1 had jumped from the Sky Farm. Pt #1 was lying face down in a mulch bed. Pt #1 was transported to the facility Emergency Department (ED) & was later pronounced deceased in the ED.

2. On 05-18-17 at 0925 hours staff #40 & 41 confirmed that staff #42 was with Pt #1 on the Sky Farm on the 7th floor when the patient had jumped off the roof. Staff #42 tried grabbing the patient & was almost pulled over the the roof ledge as well.

3. Review of Pt #1's MR indicated the patient was admitted on 05-11-17 after sustaining a self inflicted stab wound to the right lateral neck. Pt #1's MR indicated that on 05-11-17 at 1256 hours the following physician order was written; Patient will need 1:1 sitter for suicide precautions. Review of the Nursing Documentation for Pt #1's MR indicated that on 05-15-17 at 0915 hours the patient was in assigned room talking with staff. Pt #1's MR lacked nursing/sitter documentation on 05-15-17 of the Pt #1 leaving the unit with a sitter to go to the Sky Farm & the events describing what happened while on the Sky Farm. Review of the Physician's Discharge Summary Note Date of Service 05-15-17 at 1004 hours indicated the following; Plan for patient to be discharged to inpatient psych today but patient was brought to ED as code 77 after falling 7 stories.

4. On 05-18-17 at 1540 hours staff #44 confirmed that Pt #1's MR lacked documentation from nursing for the events that occured on 05-15-17 on the Sky Farm with Pt #1.