HospitalInspections.org

Based on document review and interview, the nursing director failed to ensure the staff documented the completion and results of a patient complaint investigation for 1 of 5 patient medical records reviewed (patient #1).

Findings include:

1. Review of patient #1 medical record indicated the following:
(A) The patient was admitted to the offsite psychiatric facility on 8/19/11 with an AXIS I of Bipolar, Manic and an AXIS II of Narcissistic personality.
(B) M.D. #1 progress notes dated 9/7/11 at 1249 indicated the patient reported that another patient crawled into his/her room and made sexual actions toward him/her. The physician did write "may be delusional but needs investigated." The record lacked documentation that the patient's complaint was investigated as requested by the physician.

2. Staff member #2 indicated in interview beginning at 12:10 p.m. on 11/19/12 that he/she had no written documentation of the investigation of patient #1 complaints.

3. Staff member #3 indicated in interview beginning at 12:20 p.m. on 11/19/12 that the allegations made by patient #1 could not be substantiated. An incident report was not completed because it was determined that the patient's allegation were not substantiated and part of his/her delusions. There is no documentation of the investigation or results of the investigation.