HospitalInspections.org

Based on record review, policy review and interview, the facility failed to provide physical assessment and failed to notify the physician after an alleged abuse incident for one patient (#26) of one case reviewed. The current census was 48.
Findings included:
1. Review of the facility policy, " Abuse of Patient, Elder, Child by staff identification-Response and Reporting " , Policy # PC 02-014 (Revised -1/2007) stated, in part the following information: " #4. Notify the patient ' s attending physician. " And " #11. Nursing will be responsible for appropriate documentation on the admission assessment and the nursing progress notes ... " and
" #12. Physical examination will be conducted promptly with sensitivity and the patient ' s right to privacy is protected at all times. "
2. Review of facility notes showed a report filed for the date of 9/26/10, which stated an alleged incident of a staff person (Staff EEE), a Certified Nursing Aide, using rough technique to reposition Patient #26.
3. Record review for Patient #26, admitted 9/17/2010 to 10/22/2010, showed the patient did not have a physical exam on the date of the alleged incident and the physician was not called with the information.
4. During an interview on 12/1/10 at 1:30 PM, the Director of Clinical Services, Staff LL confirmed the above information and stated that the physician had not been called and a physical exam for assessment of possible injury had not been done.