HospitalInspections.org

Based on policy/procedure review, document review, and staff interviews, it was determined the facility failed to develop and implement a corrective action plan to minimize reoccurrence of adverse incidents to ensure patient's receive care in a safe environment.

Findings include:

A review of the policy entitled, Sentinel Events, #BC-RSK-119, revised 01/2020, showed that upon identification of a sentinel event or possible sentinel event, an analysis is conducted to understand the causes of the event, and, when appropriate to make changes in systems and processes to reduce the probability of future events. A sentinel event is a patient safety event, not primarily to the natural course of the illness or underlying condition to include death.

A review of the three sentinel event deaths related to medication error and falls revealed the facility had failed to demonstrate changes in systems and processes to reduce probability of future events.

A review of facility reports from 01/2019 to 10/2020 failed to show a decrease or improvement in the numbers of patient incidents related to falls and medication errors.

On 10/08/20 at 11:00 AM, an interview with the facility Risk Manager (RM) confirmed the above findings.