HospitalInspections.org

Based on document review and interview, the facility failed to keep patient safe from harm and provide neurological assessment in 1 out of 10 medical records reviewed (P3).

Findings include:

1. Policy and Procedure titled Patient Rights, approved 1/31/22, states on number 14 "Patients have the right to receive humane care and be free from mental, physical, sexual and verbal abuse, neglect and exploitation.".

2. Review of patient (P3) medical record included a nursing assessment on 8/30/22 that had documentation P3 was assessed for head injury at 11:00 A.M. and 4:00 P.M., then at 6:00 P.M. discharge instructions given to parent including physician instructions for any neurological changes to go to emergency room. The medical record lacked documentation of complete neurological assessments for a head injury and interventions to prevent future harm.

3. Interview on 9/22/22 at approximately 1:45 P.M. with A3 (Director of Risk Management) indicated P3 was involved in 2 altercations while an inpatient at facility and facility would not provide incident reports for review where the neurological assessment was documented.