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.

EVANSVILLE STATE HOSPITAL 3400 LINCOLN AVENUE EVANSVILLE, IN Oct. 2, 2015
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on document review and interview, the hospital failed to ensure medical record (MR) documentation was completed per hospital policies and procedures (P&P) for 1 of 3 MR's with incidents reviewed (P#4).

Findings:

1. Review of the policy and procedure (P&P) titled Report of Incident/Injury, indicated Accidents or incidents involving any patient shall be reported as soon as possible. The P&P also indicated Every injury, incident, minor or major, shall be written in the patient's chart in descriptive terms, including the nature of injury, incident, location, severity and action taken. The P&P was effective 11/14/13.

2. Review of facility documentation indicated allegations of physical abuse had occurred on 08-30-15 with Pt#4.

3. Review of patient P#4's MR lacked documentation of the reported incident to have occurred 8/30/15.

4. On 9/30/15 at 3:15pm, A2, Performance Improvement Director, indicated documentation of any incident is to be included in the MR and further indicated P#4's MR lacked documentation of an incident on 8/30/15.

5. On 9/30/15 at 1:25 pm, A5, Director of Nursing, indicated he/she had report that on 8/30/15, on unit F, at approximately 20:00 hrs, patient P#4, who is a 1:1 staffing patient, was being toileted and became aggressive in the restroom. A5 indicated, on the date of the incident, there were 3 to 4 staff assisting at the time. A5 indicated that when the patient was being returned to the reclining broda chair, a staff member (E#3), was witnessed by other staff to have punched P#4 in the thigh, kneed patient legs, and pushed the patients shoulders back against the chair.