The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

INDIANA UNIVERSITY HEALTH 1701 N SENATE BLVD INDIANAPOLIS, IN 46202 July 13, 2016
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on document review and interview, the facility failed to ensure all entries in the medical record are complete in accordance with facility policy and procedure for 1 of 10 (1) patient medical records reviewed.

Findings:

1. Policy #ADM 1.51, Patient Incident and Significant Event Management, revised/reapproved 12/15, indicated a significant event should be documented in patient's medical record including the objective data surrounding a significant event and an incident report completed in the web-based incident reporting system in as timely a manner as possible after a significant event occurs.

2. Review of Security Reports indicated two significant events occurred on 6/15/16 at 1747 and 1933 hours related to patient 1.

3. Review of administrative documents on 7/13/16 at approximately 1420 hours indicated an incident report was completed for the significant event that occurred on 6/15/16 at approximately 1747 hours, but an incident report was lacking for the significant event that occurred on 6/15/16 at approximately 1933 hours. The incident report completed on 6/15/16 for the significant event that occurred on 6/15/16 at approximately 1747 hours, indicated patient 1 had spit on staff 5 (R.N.) and F2 staff A (BHRA) multiple times while placing left hand back into soft wrist restraint. Prior to this, staff 5 witnessed F2 staff A on live-feed camera at the nurse's station come out of the patient's bathroom waving his hands in an aggressive manner towards patient 1. Staff 6 (Unit Secretary) was alerted to witness on the camera what was being observed. F2 staff A stomped on patient 1's left leg while in bed. Security was immediately alerted and PO1 (Police Officer F1), PO2 (Police Officer F1) and PO3 (Police Officer F1) responded and F2 staff A was taken into custody. IMPD, F2 administrative staff, Risk Management staff and senior leadership were notified.
Another significant event occurred on 6/15/16 at approximately 1933 hours and an incident report was lacking for the significant event, but there was a security report that indicated PO5 (Police Officer F1) and PO6 (Police Officer F1) responded. Staff 7 (R.N.) and staff 8 (Charge Nurse) stated they witnessed on live-fee camera from the nurse's station F2 staff B (BHRA) cover patient 1's face with a blanket and slammed patient's head into the pillow 3 to 4 times. Patient was assessed by nursing and had no injuries.

4. Review of patient 1's medical record on 7/13/16 at approximately 1430 hours indicated lack of a significant event note for both significant events that occurred on 6/15/16.

5. Staff 4 (Clinical Nurse Specialist of Quality) was interviewed on 7/13/16 at approximately 1523 and 1611 hours and confirmed patient 1 was involved in two separate incidents on 6/15/16 at approximately 1747 and 1933 hours that also involved F2 staff A (Behavioral Health Recovery Attendant [BHRA]) and F2 staff B (BHRA) from F2. These incidents were significant events and according to policy titled, Patient Incident and Significant Event Management, documentation in the patient's medical record should include objective data surrounding the event in the form of a significant event note. This documentation for these two significant events was lacking in the patient's medical record.

6. Staff 2 (Accreditation and Regulatory Compliance Specialist) was interviewed on 7/13/16 at approximately 1530 hours and confirmed there was an incident report for the significant event occurring at approximately 1747 hours, but not one for the significant event occurring at 1933 hours as required by facility policy and procedure.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on document review and interview, the facility failed to ensure patients have the right to be free from all forms of abuse or harassment for 1 of 10 (1) patient medical records reviewed.

Findings:

1. Review of Security Reports indicated two significant events occurred on 6/15/16 at 1747 and 1933 hours related to patient 1.

2. Review of administrative documents on 7/13/16 at approximately 1420 hours indicated an incident report was completed for the significant event that occurred on 6/15/16 at approximately 1747 hours that indicated patient 1 had spit on staff 5 (R.N.) and F2 staff A (BHRA) multiple times while placing left hand back into soft wrist restraint. Prior to this, staff 5 witnessed F2 staff A on live-feed camera at the nurse's station come out of the patient's bathroom waving his hands in an aggressive manner towards patient 1. Staff 6 (Unit Secretary) was alerted to witness on the camera what was being observed. F2 staff A stomped on patient 1's left leg while in bed.
Another significant event occurred on 6/15/16 at approximately 1933 hours and the security report indicated PO5 (Police Officer F1) and PO6 (Police Officer F1) responded. Staff 7 (R.N.) and staff 8 (Charge Nurse) stated they witnessed on live-fee camera from the nurse's station F2 staff B (BHRA) cover patient 1's face with a blanket and slammed patient's head into the pillow 3 to 4 times. Patient was assessed by nursing and had no injuries.

3. Review of patient 1's medical record on 7/13/16 at approximately 1430 hours indicated lack of a significant event note for both significant events that occurred on 6/15/16.

4. Staff 4 (Clinical Nurse Specialist of Quality) was interviewed on 7/13/16 at approximately 1523 and 1611 hours and confirmed patient 1 was involved in two separate incidents on 6/15/16 at approximately 1747 and 1933 hours that also involved F2 staff A (Behavioral Health Recovery Attendant [BHRA]) and F2 staff B (BHRA) from F2. These incidents were significant events and according to policy titled, Patient Incident and Significant Event Management, documentation in the patient's medical record should include objective data surrounding the event in the form of a significant event note. This documentation for these two significant events was lacking in the patient's medical record.

5. A policy was requested related to abuse and neglect of inpatients, but staff 1 (Accreditation Regulatory Specialist) stated the facility did not have this type of policy.