Indiana University Health Bloomington Hospital

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50584 Based on document review and interview, nursing services failed to maintain documentation of daily weights per physician order in 5 of 10 MRs (Medical Records) reviewed. (P2, P4, P6, P7, P8) Findings include: 1. Facility policy titled Assessment and Reassessment of Adult Inpatients, no policy number, Publication Date: 9/24/2024, under I. Purpose: This policy outlines organizational standards for nursing admission assessments and reassessments for adult inpatients. II. Scope: The policy applies to Registered Nurses (RN), who are responsible for assessing, planning, and directing patient care. Licensed Practical Nurses (LPN), patient care interns, patient care residents, certified patient care assistants (PCA) and other nursing support staff are responsible for delegated levels of care and associated documentation at F1. This policy applies to nursing assessment and reassessment from the initiation of inpatient status to discharge. VI. Procedures: 2. Reassessments will be conducted throughout hospitalization in accordance with the patient’s needs and unit-level expectations. Reassessments will include information on the patient’s response to treatment/interventions, significant change in condition, and progress towards goals and discharge. 6. RNs are accountable for the patient assessment and documentation process. 2. Review of P2 MR (Medical Record) indicated: a. P2 was admitted to F1 (acute care hospital) on 11/6/26 with diagnosis of gastrointestinal bleeding. b. On 11/7/26 physician order indicated to weigh P2 every 24 hours. c. MR lacked documentation of a daily weight on 11/7/25 and 11/8/25. 3. Review of P4 MR indicated: a. P4 was admitted to F1 on 12/31/25 with diagnosis of chest pain. b. On 1/6/26 physicians’ order indicated to weigh P4 daily. c. P4 MR lacked documentation of a daily weight on 1/6/26, 1/7/26, 1/8/26, 1/9/26, 1/10/26, 1/11/26, 1/12/26, 1/13/26, 1/14/26, 1/15/26, 1/17/26, 1/18/26, 1/19/26, 1/20/26, 1/26/26, 1/27/26, and 1/28/26 per physician order. 4. Review of P6 MR indicated: a. P6 was admitted to F1 on 2/4/26 with diagnosis of Heart Failure and Atrial Fibrillation. b. On 2/5/26 physician order indicated to weigh P6 daily. c. P6 MR lacked documentation of a daily weight on 2/10/26, 2/11/26, 2/12/26, 2/13/26, 2/14/26, 2/15/26, 2/16/26, 2/17/26, 2/18/26, 2/19/26, 2/20/26, and 2/21/26 per physician order. 5. Review of P7 MR for admission 3/12/26 through 4/3/26 indicated: a. On 3/12/26 P7 was admitted to F1 with decompensated heart failure, post CABG, dilated cardiomyopathy, and Acute Kidney Injury. c. On 3/12/26 physician order placed to weigh P7 daily. r. MR lacked documentation of a daily weight on 3/24/26 per physician order. 6. Review of P8 MR indicated: a. P8 was admitted to F1 on 4/10/26 with diagnosis of Dyspnea and Heart Failure. b. On 4/11/26 physician order indicated weigh P8 daily. c. P8 MR lacked documentation of a daily weight on 4/14/26 per physician order. 7. In interview on 5/20/26 at 1115 hours with A8 (Clinical Quality Coordinator), he/she confirmed that P2 MR lacked documentation of a daily weight on 11/7/25 and 11/8/25 per physician order, P4 MR lacked documentation of a daily weight on 1/6/26, 1/7/26, 1/8/26, 1/9/26, 1/10/26, 1/11/26, 1/12/26, 1/13/26, 1/14/26, 1/15/26, 1/17/26, 1/18/26, 1/19/26, 1/20/26, 1/26/26, 1/27/26, and 1/28/26 per physician order, P6 MR lacked documentation of a daily weight on 2/10/26, 2/11/26, 2/12/26, 2/13/26, 2/14/26, 2/15/26, 2/16/26, 2/17/26, 2/18/26, 2/19/26, 2/20/26, and 2/21/26 per physician order, P7 MR lacked documentation of a daily weight on 3/24/26 per physicians order, and P8 MR lacked documentation of a daily weight on 4/14/26 per physician order.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 50584 Based on document review and interview, nursing services failed to document education to staff following a patient incident in 1 of 5 incidents reviewed. (P7) Findings include: 1. Facility policy titled Patient Incident and Significant Event Management, no policy number, Publication Date: 05/19/25, under Purpose: To provide a framework for identification, reporting, and management of patient safety incidents and significant events at F1. V. Policy Statements: In accordance with principle of high reliability, F1 fosters an environment in which patients, their families, team members and health care providers can identify, manage and learn from actual and potential risks to patient safety. 2. Review of P7 MR indicated: a. On 3/23/26 preoperative nursing note indicated P7 arrived from the 4E unit with checklist done, report not called, no armband on, consent forms lacking proper dates/times. 3. Review of facility Incident Reports from 11/19/26 through 5/19/26 indicated the following incident involving P7: a. Incident report dated 3/26/2026 indicated P7 arrived at pre-operative area with a completed pre-operative checklist, however no report was called, P7 arrived at the unit without a wrist band on, and the surgical and blood consents were not properly completed. The witness did not write the year on either form or the time correctly, so those had to be re-done pre-operatively. Follow-up indicated A13 (Manager Cardiovascular ICU [Intensive Care Unit]), spoke to A17 regarding the incident, and A17 reported that a technician was the only one who arrived on the floor to get P7, and primarily RN’s do a bedside shift report. A17 attempted to ask about delivering a report to the technician and he/she indicated he/she would have a nurse call to get the report. The consents were not completed fully due to P7 and the family having questions and wanting to speak with the physician prior to completing consents. P7’s arm band was possibly cut off due to swelling. b. Incident report lacked documentation of re-education provided to A17 on the inpatient to operating room process and checklist to be accurately completed prior to a patient’s transfer to the OR (operating room). 4. In interview on 5/20/26 at 0955 hours with A12 (Director Critical Care Services), he/she confirmed that the incident report on 3/23/26 involving P7 lacked documentation of the re-education of A17 on the patient to operating room process and checklist to be accurately completed prior to a patient’s transfer to the OR.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 50584 Based on document review and interview, facility failed to adhere to the procedure for examining patients in a private consultation room in the ED (Emergency Department) to ensure patients rights to privacy. Findings include: 1. Facility document titled Patient Rights and Responsibilities indicated under Privacy: personal and informational: You are entitled to privacy in treatment and in caring for your personal needs. This includes the right to be interviewed and examined in a surrounding designed to assure reasonable privacy. You have a right to an environment which preserves your dignity and contributes to a positive self-image. 2. In interview on 12/16/25 at approximately 1037 hours with A13 (Emergency Department Manager), he/she indicated the ED uses the Lever document when they have increased capacity and are boarding six or more patients in the ED. The ED has fast track rooms where patients are placed in recliners together with a small divider between them. If the physician is ready to examine the patient, the procedure is for the patient to be moved to a private consultation room. Patients are not to be examined in front of other patients. 3. In interview on 12/16/25 at approximately 1320 hours with N2 (RN [Registered Nurse]), he/she indicated he/she has seen physicians come into the fast-track rooms several times and examine patients with other patients present. The patients are supposed to be moved to a private consultation room for examination, discussion of condition and treatment. N2 confirmed that patient privacy does not always happen. 4. In interview on 12/16/25 at approximately 1330 hours with N1 (RN), he/she indicated the best practice is for the patient to be moved from the fast-track area to a private consultation room for an examination by the physician. N1 has seen physicians examine patients in the fast-track chairs, it is not ideal. 5. In interview on 12/16/25 at approximately 1345 hours with MD1 (D.O. [Doctor of Osteopathic Medicine] Acute Care Service Line Executive), he/she indicated due to increased ED capacity that he/she had examined a patient in a fast track chair and tried to pull the divider for privacy and talk lower, it is not ideal, but it does happen. The procedure is to take the patient to a private consultation room for examination, about 10% of the time it does not happen, and patients are examined near other patients.”

“PATIENT RIGHTS: TIMELY REFERRAL OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee.] The grievance process must include a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization. At a minimum: This Standard is not met as evidenced by: 50584 Based on document review and interview facility failed to document follow-up, investigation and outcome of a complaint/grievance in 1 (one) instance (P2). Findings include: 1. Facility policy titled Patient/Parent Rights and Responsibilities, Complaints and Grievances, no policy number, Publication Date: 07/05/2023, under IV. Definitions, Patient Grievance: 1. Any patient complaint that cannot be resolved promptly on the spot, by patient care team members after escalating through immediate supervisor, their delegate, or clinical leadership. VI. Procedures, B. Patient Complaint Process, 3. Unresolved complaints may become grievances, and the following procedures may apply if resolution is not achieved. C. Patient Grievance Process, 3. The Patient Relations Consultant will notify the patient that their grievance is being reviewed and confirm the grievance steps. Efforts will be made to resolve grievances within seven business days. 4. The Patient Relations Consultant will contact the appropriate physician, nursing team members, or ancillary department to participate in resolving the grievance. Resolving the grievance may include additional conversations between the patient and clinical leaders or physicians. 5. The Patient Relations Consultant will communicate the results of the investigation and any needed action to the patient. 6. The patient will receive a written response regarding the resolution of the patient grievance. 2. Review of facility Complaint/Grievance log from 12/1/24 through 5/5/25 indicated the following complaint related to allegations involving P2: a. Encounter Type: Response, Theme: In the moment, Assigned to A20 (Patient Liaison), Resolved: No, Received a Diagnote from Unit Coordinator from 5 East Unit. Family of P2 requested to speak to a patient advocate about the care for P2. A20 spoke with A18 (Nurse Manager 5 East Unit) regarding any issues expressed by P2’s family. A18 indicated call light issues were brought up and he/she pulled call light reports and the average time to answer call lights was about 11 minutes. Family had issues with responsiveness, cleanliness and overall communication regarding P2’s care. A20 rounded on P2 and spoke with FM1 (P2 family member). P2 was getting ready to eat and was unable to cut a very burnt piece of chicken and a new lunch tray was ordered. FM1 expressed several complaints. Call lights, timely pain medication, care team response to requests made by family were perceived as rude. The family requested for P2 to have a bath prior to discharge. P2 was assisted with a shower prior to discharge. Due to response to call lights family had brought in supplies for the patient. FM1 also indicated Respiratory Therapy had not consistently checked on P2 and did not get P2’s CPAP (Continuous Positive Airway Pressure) on until 0100 hours and P2 uses CPAP routinely for sleep. FM1 was pleased that A20 was able to sit and listen. No follow up, no formal grievance entered, or investigation documentation noted on allegations A20 received regarding P2. 3. In phone interview on 5/6/25 at approximately 1611 hours with A20, he/she confirmed there should have been additional documentation regarding complaints made by P2’s family. A20 confirmed he/she should have entered a grievance that would have been sent out to each department involved in the complaint to further investigate allegations made to follow-up with staff members.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50584 Based on document review and interview, staff failed to provide a daily bath for 6 of 10 patient medical records reviewed. (P2, P4, P6, P8, P9 and P10) Findings include: 1. Facility document titled Education Express Patient Care: Daily Hygiene and Urinary Diversion Devices, September 2024, Guidelines for Patient Care: Nursing Teams Must: Provide and document that bathing was provided or refused every 24 hours regardless of patient condition. 2. Review of P2 MR indicated patient admitted to the facility on 3/20/25 through 3/25/25. a. MR lacked documentation of patient bath or refusal on 3/21/25 and 3/23/25. 3. Review of P4 MR indicated patient admitted to the facility on 1/21/25 through 2/3/25. a. MR lacked documentation of patient bath or refusal on 1/29/25. 4. Review of P6 MR indicated patient admitted to the facility on 3/25/25 through 3/31/25. a. MR lacked documentation of patient bath or refusal on 3/26/25. 5. Review of P8 MR indicated patient admitted to the facility on 4/17/25 through 4/21/25. a. MR lacked documentation of patient bath or refusal on 4/19/25 and 4/20/25. 6. Review of P9 MR indicated patient admitted to the facility on 2/28/25 through 3/7/25. a. MR lacked documentation of patient bath or refusal on 3/1/25, 3/2/25, 3/3/25 and 3/4/25. 7. Review of P10 MR indicated patient admitted to the facility on 1/16/25 through 1/30/25. a. MR lacked documentation of patient bath or refusal on 1/17/25, 1/24/25 and 1/27/25. 8. In interview on 5/5/25 at approximately 1610 hours with A11 (Quality), he/she confirmed P2, P4, P6, P8, P9 and P10 MRs lacked documentation of patient bath or refusal of bath.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 50584 Based on document review and interview Nursing Services failed to administer ordered medication in accordance with physician orders, failed to maintain PCA (Patient-Controlled Analgesia) pump keys in a secure place, and failed to maintain documentation of PCA Intake and Output for 1 of 10 patient MRs (Medical Records) reviewed. (P4) The cumulative effects of these systemic problems resulted in the facility’s inability to provide nursing care in a safe manner”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 50584 Based on document review and interview Nursing Services failed to document event follow-up and re-education to staff involved in a medication error for 1 of 10 MRs (Medical Records) reviewed. (P4) 1. Facility policy titled Adverse Event Management and Error Reporting, no policy number, Publication Date: 09/26/2022, Page 4, Under VI. Procedures, d. The Apparent Analysis or Root Cause will entail: iii. The conduction of a meeting of the persons involved and any identified experts to review the findings and approve the identified root cause(s). iv. Determination of a risk reducation strategy and action plan that includes the measurement of the effectiveness of process and system improvements to reduce risk. Such action plan will include responsibility and a time frame for the identified actions. e. Any new or modified processes identified as actions by the team shall: ii. Meet the needs of the individuals served, staff and others. vi. Incorporate the results of performance improvement activities. 2. Incident Abstract Report Riskonnect form dated 11/7/24 at approximately 0400 hours indicated P4 had a Hydromorphone PCA (Patient Controlled Analgesia) that had been set up on day shift by N1 (RN [Registered Nurse] Labor & Delivery) and witnessed by N2 (RN Postpartum). The night shift nurse, N3 (RN Labor and Delivery), had not had a patient with a PCA before and was unaware that he/she needed to verify settings at shift change. At around 0115 hours, N3 had N4 (RN Postpartum) accompany her to P4’s room because the PCA was alarming that the maximum dose had been reached and he/she was unsure how to clear the alarm. N4 showed N3 how to check shift totals and at that time they realized that the PCA showed only two dose attempts with no doses delivered, so it could not have been maxed out. When N3 and N4 verified the settings, they saw that the PCA had been programmed with a continuous dose of 1mg (milligram) per hour, but a continuous dose had not been ordered. The other program details were correct. The one-hour lockout dose was 1 mg, so that is why the PCA alarmed when P4 attempted to administer a dose. N4 noticed that the PCA key had also been left inserted into the PCA. N3 and N4 reprogrammed the PCA with the correct details and removed the key. It was also noted the PCA had not been charted in Cerner (computer charting system) in the Intake & Output Flowsheet. Incident report lacked documentation of follow up/education with N1 and N2 regarding medication error, key left in PCA and charting on the Cerner Intake and Output Flowsheet. 3. Email dated 12/19/24 at 1101 hours from A15 (Manager of Clinical Operations NICU [Neonatal Intensive Care Unit] and Pediatrics) indicated a debriefing took place on 11/7/24 at approximately 0930 hours regarding medication error involving P4. Debriefing lacked documentation of a sign in sheet including but not limited to staff involved in the medication error. 4. Email dated 12/19/24 at 1301 hours from A19 (Clinical Advisor) indicated on 11/7/24 N2 was very upset by medication error and a PCA pump was set up and reviewed with N2. Other nurses gathered around the PCA but A19 was unsure of the staff that reviewed the PCA pump during this time. 5. In interview on 12/19/24 at approximately 1400 hours with A17 (Manager of Clinical Operations Postpartum), he/she indicated A14 (Risk Manager) did a huddle with a debriefing regarding PCA medication error with N2 and other nurses on the Postpartum Unit on 11/7/24. A17 confirmed there was not a sign in sheet regarding what education was given and who attended. 6. In interview on 12/19/24 at approximately 1430 hours with A18 (Director of Perinatal and Pediatrics), he/she confirmed there was no follow-up and/or re-education documented with N1 regarding PCA medication error.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50584 Based on document review and interview Nursing Services failed to administer ordered medication in accordance to physician orders, failed to maintain PCA (Patient-Controlled Analgesia) pump keys in a secure place, and failed to maintain documentation of PCA Intake and Output for 1 of 10 patient MRs (Medical Records) reviewed. (P4) Findings include: 1. Facility policy titled Patient Controlled Analgesia, no policy number, Publication Date: 10/24/2023, under I. Purpose, To provide for safe and effective pain management using a patient-controlled analgesia (PCA) infusion pump for delivery of intravenous (IV) analgesics. Page 2, Under V. Policy Statements, K. Nursing Considerations: 9. PCA keys are controlled substance keys and will be monitored and kept in the possession of the responsible nurse at all times. PCA keys must be kept in a secure place except when being used to establish or change PCA settings or change PCA medication syringe. Page 5, Under VI. Procedures, O. Documentation 3. At a minimum, total PCA dose received is charted with every shift. 2. Facility policy titled Medication Administration and Management, no policy number, Publication date: 09/17/2024, Under I. Purpose, To ensure that medications are administered in a safe and effective manner, and in a manner that complies with all hospital, Joint Commission, state and federal regulations. 3. Review of P4 MR indicated: a. On 11/6/2024 at 0736 hours a PCA order was entered by provider with following settings: PCA Dose mg (milligrams) = 0.2, Lock-out interval min (minutes) = 10, Max limit in one hour (mg) = 0.5. b. On 11/6/24 at 1349 hours N1 (RN [Registered Nurse]) and N2 (RN) set up initial Hydromorphone PCA (Patient-Controlled Analgesia Pumps) settings. c. MR lacked documentation of PCA Intake and Output on Nursing Flowsheet on 11/6/24. d. Provider order entered for PCA to discontinued on 11/7/2024 at 0944 hours. 4. Incident Abstract Report Riskonnect form dated 11/7/24 at approximately 0400 hours indicated P4 had a Hydromorphone PCA that had been set up on day shift by N1 (RN [Registered Nurse] Labor & Delivery) and witnessed by N2 (RN Postpartum). The night shift nurse, N3 (RN Labor and Delivery), had not had a patient with a PCA before and was unaware that he/she needed to verify settings at shift change. At around 0115 hours, N3 had N4 (RN Postpartum) accompany her to P4’s room because the PCA was alarming that the maximum dose had been reached and he/she was unsure how to clear the alarm. N4 showed N3 how to check shift totals and at that time they realized that the PCA showed only two dose attempts with no doses delivered, so it could not have been maxed out. When N3 and N4 verified the settings, they saw that the PCA had been programmed with a continuous dose of 1mg (milligram) per hour, but a continuous dose had not been ordered. The other program details were correct. The one-hour lockout dose was 1 mg, so that is why the PCA alarmed when P4 attempted to administer a dose. N4 noticed that the PCA key had also been left inserted into the PCA. N3 and N4 reprogrammed the PCA with the correct details and removed the key. It was also noted the PCA had not been charted in Cerner (computer charting system) in the Intake & Output Flowsheet. Incident report lacked documentation of follow up/education with N1 and N2 regarding medication error, key left in PCA and charting on the Cerner Intake and Output Flowsheet. 5. In interview on 12/19/24 at approximately 1410 hours with A16 (Manager of Clinical Operations, Labor and Delivery), he/she indicated N1 (RN [Registered Nurse]) that was pulled to Postpartum floor approached A16 on 11/6/24 in tears regarding his/her assignment on Postpartum Unit and was overwhelmed, N1 had not had a PCA pump prior to this assignment and required assistance from N2 to set the pump up. A16 confirmed the PCA pump was set up incorrectly with continuous dose instead of intermittent dose as ordered per provider, PCA key was left in the pump and not secured, and MR lacked documentation of PCA Intake and Output on Nursing flowsheets.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 50584 Based on document review and interview, Nursing Services failed to complete an incident report per facility policy for 1 patient event/incident that occurred. (P3) Findings include: 1. Facility policy titled Adverse Event Management and Error Reporting, no policy number, Publication date 09/26/2022, under I. Purpose, To provide a framework for identifying, reporting, and managing adverse events that occurred at F1 (Acute Care Hospital) including team members injured during a physical assault. Under V. Policy Statements: All employees are responsible for reporting any unexpected outcome, incident, or other situation that is likely to lead to undesirable effects or that varies from established policies and procedures or practices. Under VI. Procedures, a. Any patient safety incident or near miss/good catch should be documented in the web-based incident reporting system. Under E. Patient Disclosure of Sentinel and Adverse Events, 7. When appropriate the Clinical Risk Manager will refer incident reports to the Patient Relations Consultant for documentation of the interactions and follow up. 2. Review of P3 MR indicated a lack of documentation of an event/incident that occurred on 10/9/24 at discharge. 3. Review of Incident reports from 6/1/24 through 12/19/24 indicated no incidents related to P3. 4. Incident Abstract reports dated 11/21/24 indicated on page 3 that on 12/3/24 FM1 requested he/she would like F2 leadership to also follow up on the incident involving P3 on 10/9/24. Page 11 indicated on 12/4/24 the F2 crew reported that P3 had full strength and range of motion after the incident and the incident was not documented. Page 16 indicated on 11/21/24, A14 (Risk Consultant) would interview everyone that was involved or may have witnessed the situation, even the nurse that was referenced. Report lacked interview with N2. 5. In interview on 12/16/24 at approximately 1315 hours with N2 (Registered Nurse), he/she confirmed the incident involving P3 did happen. N2 indicated he/she witnessed P3’s foot getting caught in the stretcher and P3 cried out in pain. N2 was unsure of which foot. P3 was then placed on the stretcher, EMT’s looked at foot and P3 was transported to SNF. N2 confirmed there was not an incident report filled out regarding the event. N2 did not assess the foot. 6. In interview on 12/16/24 at approximately 1415 with A1 (ACNO [Assistant Chief Nursing Officer]), he/she confirmed an incident report should have been filled out regarding P3’s ankle injury by staff caring for P3 at the time of discharge.”