HospitalInspections.org

Based on interview and documentation review the Hospital failed to ensure that an incident report was completed for the Patient's bruise.

Findings included:

Review of the Hospital's Policy/Procedure titled Incident Reports indicated that bruising that occurred following blood draws and needlesticks should be documented in the progress notes or skin assessment.

The Complainant was interviewed on 2/3/10 at 2:40 P.M. and the Complainant's Letter , dated 2/1/10, was reviewed. The Complainant said and the Letter indicated that on 1/13/10 the Patient was handled roughly resulting in bruising on the left arm.

The Progress Notes, dated 1/13/10, indicated that a bruise was noted on the Patient's left mid-arm near the elbow.

Review of the Hospital's investigation of the Complaint indicated that the Patient was unable to identify the caregiver who may have caused the bruise.

The investigation did not identify that the bruise was the result a blood draw or needlestick and the Progress Note did not identify the source of the bruise.

Review of the Hospital's Incident Report Log, dated 8/1/109 to 2/9/10, indicated that there was no indication an incident report had been completed.