HospitalInspections.org

Based on a review of medical records (MR) and facility documentation and staff interview (EMP), it was determined the facility failed to document an unusual incident in the medical record for one of 30 medical records reviewed (MR1).
Findings include:
Review of facility policy "Basic Clinical Documentation" last revised November 2016 revealed "...B. What to Document In The Medical Record. The medical record should provide a detailed account of the patient's stay from the time they enter the facility until discharge. The record should be clear and concise. Three main categories will make the record clear and concise if used correctly ...3. Patient outcomes ...f. Patient mishaps, incidents or injuries sustained while in the hospital and any follow-up care provided. ..."
1) Review of facility incident report dated May 6, 2017, at 11:30 AM revealed "...Patient (MR1) pulled IV (intravenous) out, Nurse at this time reports entering room IV intact on patient's stomach, patient said "I pulled this out."
2) During an interview on July 11, 2017, at approximately 11:13 EMP2 was asked if there was documentation in MR1's medical record of the unusual incident regarding MR1 pulling out their IV. EMP2 stated, "I did not see it