HospitalInspections.org

Based on closed medical record review and staff interviews, the facility failed to analyze adverse patient events to ensure clear expectations for safety for 2 of 2 events reviewed. (Patients #8 and #5).

The findings include:

Review of named facility organizational policy "Event Reporting Policy" revealed "...Procedure...6. Review/Follow-up: a)...all reports are reviewed by an initial investigator who will determine the severity and need for follow-up..."

Closed medical record of Patient #8 revealed a 32 year old male admitted on 04/22/2016 for auditory and visual hallucinations (hearing and seeing objects that do not exist).

Review of event report for patient #8 revealed that on 4/24/16 at 2210, the patient "...escalating psychosis in the hallway, went to room and punched mirror in room..." Review further revealed the unit manager reviewed the event report on 4/25/16 and stated in the Patient Related Follow-Up by Department Director/Supervisor "no problem".

Review failed to reveal documentation of interviews conducted with two named staff on the event report.

Closed medical record review of Patient #5 revealed a 52 year old female admitted on 03/19/2016 after walking in known busy Interstate Highway. Past medical history revealed a daily use of alcohol with bipolar disorder with psychotic features (psychiatric condition causing periods of depressed and elevated moods).

Review of event report for patient #5 revealed that on 3/20/16 approximately 1930 - 1950, the patient "...in seclusion room/quiet room since noon with door open. At approximately 1930 - 1950 seclusion room door was found shut with sheet over the top inside of door so you could not see through seclusion door window..." Review further revealed the unit manager reviewed the event report on 3/21/16 and stated in the 'Patient Related Follow-Up by Department Director/Supervisor' section, "pt (patient) had been agitating other pts (patients), was allowed to rest in room after meds, sheet removed and door opened."

Review failed to reveal documentation of interviews conducted with two named staff on the event report.

Interview with RM #1 on 6/2/16 at 0935 revealed "...events are reviewed by Risk Management daily Monday - Friday, and then entered into the risk management software program..."

Interview with CNO on 6/2/16 at 0935 revealed "...our expectation is that all persons involved who are listed on the event report would be interviewed about the event by the unit manager..." Further interview revealed there was a breakdown in the system and the policy was not followed with conducting investigation of the events.