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.
|CROSS CREEK HOSPITAL||8402 CROSS PARK DRIVE AUSTIN, TX 78754||Aug. 30, 2016|
|VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING||Tag No: A0144|
|Based on review of documentation, staff interviews, and review of hospital policies the facility failed to ensure that patient received care in a safe setting. The facility staff failed to complete incident reports following the discovery of the patient's injuries.
Facility document entitled "Incident Reporting," states in part, "Policy: The Risk Management Program techniques must pro-actively focus on loss prevention, safety promotions, and detection of hazardous events and circumstances. It must provide a systematic, multi-disciplinary approach to managing and reporting incidents of injury, damages, and loss. Purpose: The Responsibility for completing an Incident Report rests with any facility staff member who witnesses, discovers, or has direct knowledge of an incident. An incident is an unanticipated happening which was not consistent with the routine care and/or operation of the facility and may have occurred due to a violation of policy and procedure. Procedure: Any facility staff member who witnesses, discovers, or has direct knowledge of an incident must complete an Incident Report as soon as practical after the incident is witnessed or discovered, before the end of the shift/work day.
Review of patient's medical record and facility policies on 08/30/16 revealed that the on 3/21/16 at 0045 nursing staff documented that the patient had a bruise in left zygomatic facial area that seems no more than 3 days old. No incident report was available.
On 3/20/16 at 1845 nursing progress note states in part, "throughout this shift pt. has been crawling on the floor in hall, leaning up against door frame of room. Pt. was checked by this nurse several times, assisted & redirected for safety. Pt has small bruises in various stages of healing." No incident report was available.
The above findings were confirmed by the Director of PI/Risk Management in the afternoon of 08/30/2016 in the facility's conference room.