HospitalInspections.org

Based on review of one (1) out of one (1) medical record (#1), staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure implementation of its "Nursing Documentation" policy by ensuring a nurses note is entered in the patients medical record when an unusual incident occurs.

Findings include:

Reference: Facility policy titled "Nursing Documentation" states, "...Procedure: ...Nursing notes using charting by exception should include but not be limited to the following: any accident or other unusual incident occurs. Include a physical assessment of the patient, notification of physician and notification of the parent/guardian. ..."

1. On 5/12/2021 at 10:15 AM, Staff #1 and Staff #2 stated that on 6/9/20, Patient #1 told the Personal Care Assistant (PCA) Supervisor that he/she was slapped in the face by his/her PCA.

a. Medical Record #1 was reviewed and lacked a nursing note on 6/9/20, documenting the alleged incident, the physical assessment of the patient, and notification of the physician.

(i) On 5/13/21 at 10:00 AM, Staff #2 confirmed the nurse sent an email to the social worker documenting the incident however, a nursing note should have been entered in the medical record on the "Interdisciplinary Notes" indicating the allegation, the assessment of the patient and physician notification.

2. The above finding was confirmed by Staff #1 and Staff #2 at the time of the finding.