HospitalInspections.org

Based on interview and record review, the hospital failed to protect and promote each patients rights.

Findings include:

The hospital failed to ensure all patients received care in a safe setting. (Refer to tag A-0144)

Based on interview and record review, it was determined the hospital did not provide care in a safe setting. Specifically, the hospital refused to provide evidence of appropriate follow-up to incidents and accidents, therefore compliance could not be determined.

Findings include:

On 9/5/23 during entrance conference, surveyors requested an incident/accident log for review. A generalized log was provided that had a column for general event type, a column for specific event type (which was a number), and a column for specific site of occurrence. There was no actual incidents or accidents on the log, or a way to choose a sample pertaining to the type of survey being conducted. Reviewing a sample of the hospital's incident and accident reports is important so the surveyors can see how the hospital responds to incidents/accidents and if their follow-up was carried out appropriately and according to regulations, and per the hospital policies and procedures.

Throughout the survey from 9/5/23 through 9/11/23, surveyors requested to review the hospitals follow-up on 3-5 incidents to verify compliance. The hospital refused to provide documented evidence of appropriate responses to incidents and/or accidents, citing patient safety work product (PSWP) was confidential. Survey staff requested the information be provided in a different format so the hospital could keep PSWP confidential. At the time of this writing, no information was received to determine compliance with the hospital's follow-up and response to incidences and accidents as required. Although PSWP can be confidential, the hospital still needs to demonstrate compliance in another fashion, which they had not.