HospitalInspections.org

Based on document review and interview, the facility failed to ensure care in a safe setting in one instance for 2 patients (Patient 3 and Patient 8).

Findings include:

1. The hospital policy titled, "Patient Rights and Responsibilities", PolicyStat ID 10359862, stated patients had the right to receive care in a safe setting. This policy was last revised in 09/2021.

2. The hospital policy titled, "Patient Abuse and Neglect", PolicyStat ID 11795580, stated abuse was an act that results in pain including, but not limited to, rough handling, hitting, slapping, pinching, pushing, shoving, kicking...This policy was last revised in 01/2020.

3. Incident Report (IR) log was reviewed for the months of October 2022 through December 2022. One IR was documented for Patient 3 and Patient 8 and indicated on 12/1/2022 at 6:00 a.m., patient-to-patient verbal and physical (hitting/punching) aggression occurred between these patients. One patient [Patient 8] struck the other [Patient 3] because he/she was wandering around in his/her room. No injuries documented.

4. Medical record review for:
a. Patient 3, History and Physical dated 11/26/2022, indicated no acute trauma, no skin rash or excoriation, no wounds or bruises noted. Psychology Progress Note dated 12/1/2022, indicated patient with restless behaviors like pacing and using fingers to continuously and repetitively touch objects...becomes agitated and may hit, kick, bite, scream or grab. Weekly Skin Assessment dated 12/2/2022, indicated purple bruises under right eye, right shoulder/forearm, left upper arm bruise, scratch to nose and upper left back, and right hip bruise.
b. Patient 8, History and Physical dated 11/26/2022, indicated no acute trauma, no skin rash or excoriation, no wounds or bruises. Discharge Summary dated 12/3/2022, indicated no skin rash or excoriation, no wounds or bruises.

5. Staff P3 (Director of Quality/Interim Director of Nursing) was interviewed on 12/16/2022 at approximately 1:46 p.m., and stated: Patient 3 was confused and physically/verbally aggressive. Liked to kick and punch items, staff, etc.

Based on document review and interview, a registered nurse failed to supervise and evaluate nursing care by not fully completing an Incident Report (IR) in one instance for 2 patients (Patient 3 and Patient 8).

Findings include:

1. The facility policy titled, "Incident Reports", PolicyStat ID 12386386, indicated Incident Reports shall include documentation of actions taken...The Provider On-Call and Administrator On-Call are to be notified as soon as possible after any incident. In addition, the Director of Quality/Risk Management and Director of Nursing or designee are to be notified of any potential for injury/unsafe conditions.

2. IR log was reviewed for the months of October 2022 through December 2022. One IR was documented for Patient 3 and Patient 8 and indicated on 12/1/2022 at 6:00 a.m., patient-to-patient verbal and physical (hitting/punching) aggression occurred between these patients. One patient [Patient 8] struck the other [Patient 3] because he/she was wandering around in his/her room. No injuries documented. The IR form had a section titled Parties Involved/Notified/Witnesses and this section was blank lacking documentation of parties involved; notification of spouse, the Provider On-Call, Administrator On-Call, Director of Quality/Risk Management or Director of Nursing or designee; and witnesses.

3. Staff P3 (Director of Quality/Interim Director of Nursing) was interviewed on 12/16/2022 at approximately 1:46 p.m., and stated: Unable to find documentation that spouse of Patient 3 and/or Patient 8 was notified of incident that occurred on 12/1/2022 at 6 a.m. and should have been. Also, the parties involved, Provider On-Call, Administrator On-Call, Director of Quality/Risk Management or Director of Nursing or designee and witnesses were not documented on the IR form in the area labeled notification. IR's are not documented in patient medical records.