HospitalInspections.org

Based on document review and interview the Hospital did not utilized its Quality Assessment and Performance Improvement Program (QAPI) to identify opportunities for improvement and implement a comprehensive action plan to ensure patient safety.

This failure may increase the the risk of an adverse patient outcome.


Findings include:
The Hospital "Quality and Patient Safety Plan," last reviewed February 2019 states that the facility would review activities of all patient services to enhance and improve the quality and safety of patient care, to identify actual and potential problems concerning patient care and clinical performance..........

Review of The Outpatient Risk Events, from 8/21/18 to 8/21/19, revealed a total of 245 events.
These Risk Event (incidents) included, but not limited to:
23 Adverse Drug Reaction.
26 Diagnosis/Treatment.
17 Falls.
15 IV Vascular Access Device.
35 Medication/Fluid.

The QAPI Reports showed no evidence that these events were trended and analyzed, and plans were developed to address identified problems.


During interview on 8/23/19 at 10:20AM, Staff A, Vice President of Operations and Staff B, Quality Management Director, confirmed the findings and stated that the events are discussed, but were not documented.

Based on medical record review, document review and interview, in four (4) of 17 medical records reviewed, the facility failed to ensure patient assessment at the Outpatient Cancer Infusion Center included:
a) patient vital signs during and after infusion were monitored and documented.
b) patient education during each treatment was provided in accordance with its policy to ensure quality care and patient safety. (Patient #1, #2, #3, and #4)

This failure may place patients at potential risk for harm.


Findings include:

Review of the facility's policy and procedure on "Assessment of Patients in the Cancer Center," revised 10/2018, documented:

-The clinical nurse will assess each patient presenting for treatment in the cancer center prior to, during, and after treatment for risk factors, symptoms and toxicities related to treatment.

-In the Infusion Center: The patient will be assessed at each treatment including but not limited to vital signs, weight and possible side effects of treatment received.

-All assessments will be documented in the EMR (Electronic Medical Record) including Patient Education and Medication review.

Review of the medical record for Patient #1 identified: a 69- year old female who was on antineoplastic chemotherapy for malignant neoplasm of the right breast, axilla and upper lymph nodes. The record indicated the patient received infusion chemotherapy since March 2019 for two antineoplastic medications of Pertuzumab
(drug used for the treatment of metastatic breast cancer) and Trastuzumab (used to treat metastatic (spread) breast cancer). On 10/31/19, 11/28/19, and 12/19/19 documentation revealed the patient had her chemotherapy infusions as prescribed.

There was no documented evidence that the patient's vital signs were obtained during and after treatment, and the patient was provided with medication education review as directed by its protocol.

Similar findings of patient assessments with no documented vital signs during and after treatment, and patient not provided with medication education review were noted for Patients # 2, # 3, and # 4.

On 8/26/19 at 2:30 PM, Staff H, Registered Nurse Infusion Center, stated the patient's vital signs are obtained prior to treatment, and the nurse documents by exception when there is a patient reaction noted. Staff H also stated it is the expectation and based on the facility's protocol, the patient is provided with medication education and education is documented in the medical record.

The facility did not ensure patient assessment at the outpatient infusion center was conducted in accordance with its policy.

On 8/26/19 at 2:30 PM, the findings were brought to the attention of Staff G, Clinical Nurse Manager, and Staff B, Director of Quality Assurance and Performance Improvement, who acknowledged the findings.