HospitalInspections.org

Based on record review and interview the facility failed to measure, analyze, and track ...adverse patient events ...for 15 of 15 patients (Patient #1,# 2, #3, #4, #5, #6, #7, #8, #10, #11, #12, #13, #14, #15) in that the facility failed to complete an incident report as stated by facility policy.

Findings:

Record review of #1's medical record reflected a Progress Note from 09/25/2023 at 10:30 AM by Personnel 10, " ...when assisting patient to sit up and move to EOB (end of bed), OT noted white pill in patient's bed. OT retrieved and brought to charge nurse and nursing manager." After reviewing the Incident report log from for 9/25/2023 indicated no incident report was completed on patient #1.
Record review of patients #1 medical record reflected a nursing note from 09/26/2023, " ...Patient lethargic, disoriented, BP 77/46 to right leg, patient transferred to bed, supine. 77/44 right lower leg, pulse ox 82/88. O2 increased to 4l per nasal cannula...EMS notified for need of transfer ..."EMS leaving facility with patient on stretcher. All personal belongings remained in room. Staff suspected patient taking additional narcotic on own from personal supply."

Record review of the facilities Memorandum of Transfer (MOT) log indicated Patient #1,#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 were transferred requiring a higher level of care.

Record review of The Incident Report Log dated 08/01/2023 to 01/17/2024 reflected no incident report was completed on Patient's #1,# 2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 who required a higher level of care and were transferred to another facility.

Facility Policy and Procedure titled "Incident Report", #PI-01, created 03/22/2021, revised 09/09/2022 ...An incident is defined as" ...any happening which is not consistent with the routine operation of the hospital or the routine care of a particular patient ..."A hospital Incident Report is completed at time of incident. This form is completed immediately, in its entirety and given to the departmental supervisor.1 ...Report any break in routine whether there is a risk of injury or a potential for injury. 2. Any unusual incident should be reported."

During an interview on 01/17/2024, Personnel #1 and #2 confirmed the above findings. Personnel #1 and #2 confirmed the facility incident reports are not accurate and are not being completed with each event. Personnel #1 and #2 confirmed an incident report must be completed on all patients who transferred out of the facility.