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Based on policy and procedure review, medical record review and staff interview, the nursing services director failed to direct, monitor, and evaluate the nursing care furnished by not assuring the implementation of the facility's policy and procedure related to minor injury for 1 of 5 (N1) closed patient medical records reviewed.

Findings:

1. Policy No. 6.22 titled, "Minor Injury Policy and Procedure" was reviewed on 6/9/10 at 1:00 PM and indicated: "Purpose: To provide appropriate medical care for clients who become ill or acquire an injury while hospitalized at ICC (In-Patient Care Center). Who May Perform: Licensed medical staff and/or Nurse Practitioner. Action: 1. If a client complains of pain and /or symptoms of illness or injury, the Registered Nurse taking care of the client will assess the client accordingly; 2. The nurse will then notify the attending physician or physician on-call if immediate medical attention is required; 3. For minor illness and injury, the nurse will document the pt's name and nature of illness and/or injury on the medical physician's clipboard; 4. The nurse will document her assessment findings in the client's chart and pass on all pertinent information to the next shift in report; 5. The client will be seen within 24 hours by the Licensed Medical Staff on- call for that particular day. Their findings will be documented in the client's chart and any necessary orders will be written."

2. Review of closed patient medical records on 6/9/10 at indicated Patient N1, per Psych Tech Progress Note dictated 3/1/10 at 5:12 PM, "As writer was making a round for Anger Management group at 1300 PM, client was observed to be in room, on bed and crying while holding the crimped end of a toothpaste tube to his/her wrist and scratching self with it...Writer asked to look at wrist and he/she refused to show it...Writer encouraged him/her to make a better choice and he/she complied. Writer provided support to him/her and encouraged him/her to come to group. He/She attended Anger Management group and participated actively."

3. Lack of documentation in the client's chart of assessment post minor injury by the Registered Nurse and lack of documentation of this information being passed on to the next shift in report; lack of notification of the attending physician; lack of documentation by the Registered Nurse of the patient's name and nature of illness and/ or injury on the medical physician's clipboard; lack of documentation that the client was seen within 24 hours by the Licensed Medical Staff on-call for that particular day with their findings documented in the client's chart and any necessary orders.

4. Personnel P1 was interviewed on 6/9/10 at 12:12 PM and confirmed the client did attempt to harm self per Psych Tech Progress Note and although the Psych Tech discussed the incident with the client and provided support to him/her, facility policy and procedure was not followed related to assessment, notification of physician, and documentation. Psych Techs are not licensed medical staff.

Based on policy and procedure review, medical record review and staff interview, the nursing services director failed to direct, monitor, and evaluate the nursing care furnished by not assuring the implementation of the facility's policy and procedure related to minor injury for 1 of 5 (N1) closed patient medical records reviewed.

Findings:

1. Policy No. 6.22 titled, "Minor Injury Policy and Procedure" was reviewed on 6/9/10 at 1:00 PM and indicated: "Purpose: To provide appropriate medical care for clients who become ill or acquire an injury while hospitalized at ICC (In-Patient Care Center). Who May Perform: Licensed medical staff and/or Nurse Practitioner. Action: 1. If a client complains of pain and /or symptoms of illness or injury, the Registered Nurse taking care of the client will assess the client accordingly; 2. The nurse will then notify the attending physician or physician on-call if immediate medical attention is required; 3. For minor illness and injury, the nurse will document the pt ' s name and nature of illness and/ or injury on the medical physician ' s clipboard; 4. The nurse will document her assessment findings in the client's chart and pass on all pertinent information to the next shift in report; 5. The client will be seen within 24 hours by the Licensed Medical Staff on- call for that particular day. Their findings will be documented in the client's chart and any necessary orders will be written."

2. Review of closed patient medical records on 6/9/10 at indicated Patient N1, per Psych Tech Progress Note dictated 3/1/10 at 5:12 PM, "As writer was making a round for Anger Management group at 1300 PM, client was observed to be in room, on bed and crying while holding the crimped end of a toothpaste tube to his/her wrist and scratching self with it...Writer asked to look at wrist and he/she refused to show it...Writer encouraged him/her to make a better choice and he/she complied. Writer provided support to him/her and encouraged him/her to come to group. He/She attended Anger Management group and participated actively."

3. Lack of documentation in the client's chart of assessment post minor injury by the Registered Nurse and lack of documentation of this information being passed on to the next shift in report; lack of notification of the attending physician; lack of documentation by the Registered Nurse of the patient's name and nature of illness and/ or injury on the medical physician's clipboard; lack of documentation that the client was seen within 24 hours by the Licensed Medical Staff on-call for that particular day with their findings documented in the client's chart and any necessary orders.

4. Personnel P1 was interviewed on 6/9/10 at 12:12 PM and confirmed the client did attempt to harm self per Psych Tech Progress Note and although the Psych Tech discussed the incident with the client and provided support to him/her, facility policy and procedure was not followed related to assessment, notification of physician, and documentation. Psych Techs are not licensed medical staff.