HospitalInspections.org

Based on interview and record review the facility failed to promptly investigate and analyze an adverse patient event which occurred on 1/21/2020 in which a patient reported to staff he had been "raped" by the sitter. Interviews with hospital personnel were conducted onsite on 4/6/2021. Medical record review of the index patient was completed offsite between 4/6/2021 and 4/13/2021. Survey staff reviewed the hospital policy entitled "Event Reporting and Investigation" effective 8/12/2019 on 5/6/2021.
Findings:
-The Director of Quality and Patient Safety was interviewed during the 4/6/2021 onsite by DOH Survey staff and stated this event was not in their Occurrence Reporting System, Patient Experience tracking, Security log or presented to their Grievance Committee for follow-up. The Director said there was no incident report documenting this event.
-The facility policy "Event Reporting and Investigation" requires staff to complete an incident report in the Hospital's electronic database.

The NYSDOH investigation determined that nursing staff failed to file an incident report of this event with the hospital patient safety officer. This resulted in a missed opportunity for review and analysis by the hospital wide QAPI program of an important patient safety event.