HospitalInspections.org

Based on document review and interview, the hospital failed to ensure medical record (MR) documentation was completed per hospital policies and procedures (P&P) for 1 of 3 MR's with incidents reviewed (P#4).

Findings:

1. Review of the policy and procedure (P&P) titled Report of Incident/Injury, indicated Accidents or incidents involving any patient shall be reported as soon as possible. The P&P also indicated Every injury, incident, minor or major, shall be written in the patient's chart in descriptive terms, including the nature of injury, incident, location, severity and action taken. The P&P was effective 11/14/13.

2. Review of facility documentation indicated allegations of physical abuse had occurred on 08-30-15 with Pt#4.

3. Review of patient P#4's MR lacked documentation of the reported incident to have occurred 8/30/15.

4. On 9/30/15 at 3:15pm, A2, Performance Improvement Director, indicated documentation of any incident is to be included in the MR and further indicated P#4's MR lacked documentation of an incident on 8/30/15.

5. On 9/30/15 at 1:25 pm, A5, Director of Nursing, indicated he/she had report that on 8/30/15, on unit F, at approximately 20:00 hrs, patient P#4, who is a 1:1 staffing patient, was being toileted and became aggressive in the restroom. A5 indicated, on the date of the incident, there were 3 to 4 staff assisting at the time. A5 indicated that when the patient was being returned to the reclining broda chair, a staff member (E#3), was witnessed by other staff to have punched P#4 in the thigh, kneed patient legs, and pushed the patients shoulders back against the chair.