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Based on medical record review, interview and policy review there is no evidence to indicate Patient #1 was assessed or that the physician was notified following an occurrence in which Patient #27 had jumped into Patient #1's bed.

Findings include:

Review of policy, Event Notification, last reviewed 11/14/14 revealed an "Event" is any unusual occurrence involving patient or visitor that is not consistent with regular hospital routine regardless of whether there is an apparent injury or other damage. All employees are responsible for completing and submitting event notification reports. Upon recognition that an event or near miss has occurred, an event notification will be initiated. The event should be documented in the medical record as a separate entry from the event notification to the best of the ability of the staff member who is reporting it. Information should include: date, time, specific injury (if any) actions taken, and notification of MD.

Phone interview with Staff (F), Registered Nurse on 06/19/19 revealed she was the assigned nurse for Patient #1 and his roommate (Patient #27) on 03/09/19. She indicated that Patient #1 reported that Patient #27 had jumped into Patient #1's bed. Patient #1 stated that he put Patient #27 back into his own bed. Staff (F) reported this incident to Staff (G), Manager of Hospital Operations and Patient #27 was moved to another room. Staff (F) indicated she did not notify the physician or document the event in either of the patients medical records or facility event log, nor does she recall if she performed a patient assessment.

Interview on 06/20/19 at 05:45 AM with Staff (G), Manager of Hospital Operations, revealed that on 03/09/19 Staff (F) had called to report the encounter between Patient #1 and #27. Staff (G) instructed Staff (F) to complete an incident report and separate the patients.

Review of Patient #1 medical record between 03/07/19 and 03/14/19 revealed no nursing or physician notes relating to the event involving Patient #27 on 03/9/19.

Review of facility event reports between 03/07/19 and 03/14/19 revealed no evidence an event report was initiated following this event.

Interview on 06/21/19 with Staff (A), VP Quality/Chief Nursing Officer verified the above findings.