HospitalInspections.org

Based on clinical record review, document review and interviews it was revealed the facility failed to ensure Registered Nurse (RN) #1 follow hospital policy and procedures. This failure was identified in one (1) out of ten (10) patients (patient #1). This failure has the potential for all patients to be at risk for injury.

Findings include:

1. A review of the clinical record for patient #1 revealed an immediate patient assessment was not documented after the abuse of patient #1 which occurred approximately at 10:50 p.m.

2. A review of facility policy, "Reporting and Investigating Verbal, Physical, and Sexual Abuse of Patients, and Neglect," effective date 10/11/19, states in part: "The RN or Nurse Clinical Coordinator will immediately assess the victim(s) for signs of injury and document the physical and psychological findings in the medical record."

3. A telephone interview was conducted on 06/09/21 at approximately 8:56 a.m. with RN #1. When asked if she assessed the patient after the event and documented it, she stated in part, "Yes, I did the assessment when I gave him the medication. We don't really document those."

4. An interview was conducted on 06/09/21 at approximately 9:15 a.m. with the Chief Executive Officer. When notified there was not a documented assessment which occurred immediately following the event in patient #1's clinical record following facility policy, he concurred.