HospitalInspections.org

Based on document review and interview, the facility failed to ensure the safety of the patient and keep them free from abuse in 1 of 10 (patient 6) medical records reviewed; see tag 0145.

The cumulative effect of this systemic problem resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review and interview, facility failed to protect 1 of 10 (patient 6) from abuse.

Findings Include:

1. Review of policy titled: Patient Rights and Responsibilities (PolicyStat ID: 13517670) last approved 04/2023, indicated patient's are entitled to humane care and protection from harm.

2. Review of medical record indicated Daily Nursing Narrative dated 01/05/24, nurse found patient 6 in bed with edema and small amount of blood present below right eye and orbit swollen shut. Incident Report completed and Registered Nurse notified.

3. Interview on 01/29/24 with P56 (Behavioral Health Aide) at 4:15 pm, confirmed found patient 6 in bed with bruising on both cheeks,, black eye and bruised neck.

4. Interview on 01/29/24 with P50 (Chief Executive Officer) at confirmed above scenario and that an Incident Report was completed, but there was no investigation.

Based on document review and interview, nursing failed to follow policies regarding skin care in 1 of 10 (patient 6) medical records reviewed.

Findings Include:

1. Review of policy titled: Skin Assessment (PolicyStat ID: 12385990) last approved 09/2022, indicated a weekly skin assessment to be completed and documented in the medical record.

2. Review of patient 6's medical record lacked documentation of weekly skin assessments (admitted 01/02/24 and discharged 01/18/24).

3. Interview on 01/29/24 with P50 (Chief Executive Officer) at 4:50 pm confirmed lack of documentation of weekly skin assessments.