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A. Based on document review, record review and staff interview it was determined the facility failed to ensure the nursing staff followed the electronic event reporting policy, pertaining to the appropriate measures for reporting events, for one (1) out of five (5) records reviewed in which an event occurred (patient #1). Failure to report an event has the potential for patients not to receive proper treatment.

Findings include:

1. Review of the hospital policy entitled, "Electronic Event Reporting", effective 11/17/13 and last reviewed on 1/13/14, states, in part: "Actual event is defined as an event occurred that reached the patient or individual (e.g.,visitor fall, student injury, etc.)...The foundation of a Risk Management program is based upon the ability to promptly obtain important facts and the details of the circumstances surrounding an event within a reasonable time frame of when the event occurred. To this end, an Event Report-is to be completed for every occurrence which meets the following definition: any happening not consistent with the routine care or operation of the facility, or the desired routine care of the patient and/or operation of the facility, which places our patients and visitors at increase risk for harm and the Company at an increased risk for liability."

2. Review of the hospital document entitled, "List of Event Reports Year to Date", for the month of December 2015, revealed no electronic event report for patient #1 on 12/16/15.

3. Review of the medical record for patient #1 revealed no electronic event report for an event reported to the facility on 12/16/15.

4. The above findings were reviewed and discussed with the Director of Risk and Quality on 1/13/16 at 11:35 a.m. and she concurred with the findings. She also stated: "It is our expectation, especially if a picture is taken, that an event report should have been completed."



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B. Based on document review, record review and staff interview it was determined the facility failed to ensure nursing staff documented a patient injury in the patient's medical record, per policy, for one (1) of four (4) patients with documented injuries sustained during their hospitalization (Patient #2). Failure to communicate a patient injury can lead to inconsistent and/or inappropriate patient care, with possible negative outcomes.

Findings include:

1. Facility policy entitled, "Patient Safety Protocol/Plan", last revised 12/11, last reviewed 11/15, states, in part: "Upon identification of a medical/health care error or a potential safety issue, the patient care provider will immediately: ...Preserve any information related to the error...Preservation of information includes documenting the facts regarding the error on an occurrence report, and the clinical event in the medical record as appropriate."

2. Facility document entitled, "List of Event Reports Year to Date", was reviewed on 1/12/16 and revealed an entry dated 12/29/15 indicating a "Skin/Tissue" event for Patient #2.

3. Review of the document entitled, "Skin/Tissue Event #94674", dated 12/29/15, revealed the author as Licensed Practical Nurse #1, and the entries, "Event type: Laceration", and, "While (Physician #1) was doing rounds she found a laceration to the right eye/eyebrow, believed to be from bracelets. (Physician #1) ordered it to be pictured to just monitor it."

4. Review of Patient #2's medical record on 1/12/16 revealed a photograph taken of a laceration to the patient's right eye taken 12/29/15. No further documentation by nursing staff was found in the medical record related to the events surrounding the laceration.

5. An interview was conducted with the Director of Risk and Quality on 1/13/16 at 8:35 a.m. at which time Patient #2's medical record was reviewed. The Director confirmed no nursing note was found related to the patient's injury on 12/29/16 and stated her expectation was for such a note to be present in the medical record related to the event, staff response, communication with other staff members, contact with family members, and any resulting new orders.