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Based on record review and interview, the hospital failed to ensure the Quality Assurance/Performance Improvement (QAPI) program measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of hospital services and operations. This deficient practice was evidenced by failing to ensure incident reporting and assessments were correctly detailed in the final investigation of its self-reporting process.

Review of the hospital's policy RISK.0210 titled, "Risk Management Incident Reporting Policy" revealed in part:
Purpose: The Incident Report is a Risk Management tool that raises awareness of actual or potential exposures to harm.
Procedure: An incident is an unanticipated event which results in, or nearly causes, a negative impact on patient care or visitor safety.
4.4 If the incident involves a patient, staff must chart relevant factual information in the patient's medical record.
5.6 Comply with state regulations regarding adverse events.

Review of the hospital's incident reports revealed Patient #2 was in an altercation and suffered a swollen right eye, laceration to the chin and swelling to the face. Patient sent to ER per orders.

Review of Patient #2's medical record revealed a telephone order 07/28/24 18:59 Transfer patient to ER for evaluation after an altercation.

Review of the hospital's LDH Self-Report 07/28/2024 6:30 p.m. revealed in part:
5. Patient #1 went into Patient #2's room and hit him, unprovoked. MHT's were present and immediately separated the patients.
H. The patients were immediately separated and assessed for injuries. No injuries noted.

Interview 08/19/2024 at 4:17 p.m., S2Performance Improvement acknowledged there was no current tracking mechanism to ensure self-reporting was accurately reflected in correlation with incident reporting.

Based on record review and interview, the hospital failed to have a registered nurse supervise and evaluate the nursing care for each patient. This deficient practice was evidenced by failure to assess and document Patient #2's condition prior to and following treatment at another hospital's Emergency Department.
Findings:

Review of the hospital's policy RISK.0210 titled, "Risk Management Incident Reporting Policy" revealed in part:
4.4 If the incident involves a patient, staff must chart relevant factual information in the patient's medical record.

Review of Patient #2's medical record revealed a telephone order 07/28/24 6:59 p.m. Transfer patient to ER for evaluation after an altercation.

Review of Patient #2's medical record revealed in part: 07/28/24 Patient came back from hospital at 10:00 p.m. Further review failed to reveal the RN's documentation of the injuries requiring the patient to be transferred to another hospital for evaluation in their ER; or the assessment following Patient #2's return from the ER.

Interview 08/19/2024 at 3:00 p.m., S1CNO acknowledged there was no documented assessments in Patient #2's medical record detailing the injuries prior to being transferred to the ER, and no documentation of an assessment following Patient #2's return.