HospitalInspections.org

Based on interviews and record review the facility failed to ensure Licensed Registered Nurses are following the facility's procedure for completing incident reports within the facility when there is a physical confrontation between patients for 1 (P [patient] 2) of 10 (P1-P10) patients reviewed for incident reporting. This deficient practice of Licensed Registered Nurses not completing the in-house facility incident reports led to a patient presenting to an outside hospital (facility #2) with injuries of unknown origin that could have been identified if a related incident report was completed by the Licensed Registered Nurse.

A. Record review of the facility's nursing procedure for incident reporting within the facility, titled Behavioral Health Risk Management dated 2020, under the section "When to complete an incident report" stated "physical confrontation between two patients".

B. Record review of P2's medical record from facility #1 revealed that P2 was admitted on 02/06/24. Under the skin assessment on admission stated, "no findings." A nursing note made on 02/06/24 at 10: 30 PM revealed P2 was in a physical confrontation with another patient. "Pt [patient] is hyper-active and does not follow instructions. He is getting into fights and arguments with other patients. . . he bit one of the patient's finger [sic]." A document titled "Patient Observation Rounds" in the patients' medical record revealed the patient was sent to an outside hospital (Facility #2) on 02/09/24 at 9:00 PM.

C. Record review of facility #1's incident log revealed that there was no incident report filed regarding the P2's physical confrontation.

D. Record review of the P2's medical record from Facility #2, a hospital Emergency Room, under "Exam" on 2/10/24 at 6:44 AM, revealed that P2 presented with "ecchymosis [bruising] to bilateral orbits [both eyes], to torso [upper body trunk], back, hip and buttocks and lower extremities [sic]."

E. During an interview with Staff (S)3, Registered Nurse, on 02/27/24 at 3:45 PM. S3 confirmed that an incident report should be completed and submitted by the registered nurse if there is any physical altercation between patients. When asked if one still needs to be done if there is no harm, S3 stated "any altercation that is physical requires an incident report."

F. During an interview with S1, CNO (Chief Nursing Officer) on 02/29/24 at 11:15 AM, S1 confirmed that there should have been an incident report completed and submitted on the physical altercation involving P2.