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Based on review of documentation and interviews, the facility failed to ensure that all patient medical record entries were complete, as evidenced by the failure to document Animal Control had been notified of an animal bite for one of one patient reviewed (Patient #18) for animal bites.

Findings were:

Review of the facility policy and procedure titled "Animal or Human Bite Treatment and Reporting" last revised 4/6/2022 reflected in part: " ...A. Animal Bites 1. Clean and treat wounds. 2. All instances of animal bites, scratches with claws or teeth, by a domestic or wild animal, including animals owned by the patient or family member, will be reported to animal control authorities in the county in which the incident occurred. 3. The report to the animal control authorities will be documented in the electronic health record in the appropriate location ..."

Review of the medical record for Patient #18 revealed in part, "...Service date: 03/07/24 1839...HPI: 8-year-old, previously healthy, immunized female presents to the ED with her parents for evaluation after being bitten by her pet rabbit just PTA (prior to arrival). Patient had her face close to her rabbit when it suddenly bit her just above her top lip. Parents and patient report a very small amount of bleeding that stopped pretty quickly. They cleaned the wound and put some ointment on top. No additional injuries. No other complaints...."

During an interview on the afternoon of 3/26/24, Jennifer Williams, ED Director stated, "When a patient comes in with an animal bite, Animal Control must be contacted. Most of the time, the Nurse calls Animal Control and the patient verifies the information about the animal on the phone with the Nurse present. The Nurse should then document that Animal Control was contacted and the patient verified the information."

The above findings were verified with Staff members #2 and #7 on the afternoon of 3/26/24.