HospitalInspections.org

Repeat Deficiency:

A. Based on a review of Hospital policy, clinical record review, a review of Hospital incidences and analyses, and staff interview, it was determined for 1 of 3 (Pt. #47) clinical records reviewed for patients incidences, the Hospital failed to ensure an Incident Report was completed and submitted for review.

Findings include:

1. Hospital policy #ADM I-1 entitled, "Incident Reporting," reviewed on 6/23/10 at approximately 11:30 A.M., requires, "An Incident Report must be completed anytime a patient, employee or visitor is injured or encounters an unusual occurrence - regardless of severity...Submit... The Risk Manager will review all Incident Reports... "

2. The clinical record for Pt. #47 reviewed on 6/23/10 at approximately 3:00 P.M., included that this was a 32-year-old female admitted 5/24/10 with complaints of suicidal attempt/overdose and depression. The record also included a progress note dated 5/24/10 at 7:24 P.M. that Pt. #47 was experiencing auditory hallucinations commanding her to"end her life." A "Resident Note" dated 5/25/10 at 2:40 P.M. included that the Resident responded to a Code Blue and Pt. #47 was "found with a bedsheet around her neck in an attempted suicide attempt". The note included that Pt. #47 was laying in bed- nonverbal but responds to painful stimuli. Vital signs: oxygen saturation=99, blood pressure=99/68, respirations=20, heart rate=94. The Resident physician's plan included to transfer Pt. #47 to 2 East Medical Psych Unit, 1:1 sitter, suicide precautions, soft neck collar.

3. The Hospital's Incident Reports and incident analyses reviewed for May-June 23,2010, on 6/23/10 at approximately 11:00 A.M., failed to include an Incident Report for the above incident (5/25/10) with Pt. #47.

4. In an interview with the Vice President of Quality and Compliance (VPQC), on 6/23/10 at approximately 11:30 A.M., the VPQC stated that no further incidents and analyses were available for May-June 23, 2010.


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