HospitalInspections.org

Based on document review and interview, in 1 of 1 hospital "Quality Management Reviews," the hospital did not adequately identify areas for process improvement and did not develop, implement, or evaluate a plan for improvement. This could negatively effect health outcomes, patient safety and quality of care.

Findings include:

-- Review of the hospital's policy and procedure (P&P) titled "Review of Events/Unusual Occurrences/Patient Care Issues," last revised 5/15/2018, indicated to review the adequacy of systems/processes and identify system/process improvements.

-- Review of the hospital's "Quality Management Review," dated 10/21/2019, identified an area with opportunity for improvement, i.e., to increase documentation of vital signs around doses of hydromorphone. However, there was no documentation of how this was going to be done, e.g., staff education/ re-education, revision of P&Ps. Also, the review did not identify the need for additional provider training regarding dosage and frequency of hydromorphone.

During interview of Staff A, the Director of Quality Management, on 7/8/2020 at 11:00 am, he/she acknowledged this finding.