HospitalInspections.org
Bringing transparency to federal inspections
OSWEGO HOSPITAL
PATIENT SAFETY
Tag No.: A0286
Based on document review and interview, in 1 of 4 adverse events reviewed the facility's Quality Assurance Performance Improvement (QAPI) Program lacked adequate follow through of corrective actions identified during its investigation. This could lead to other similar adverse events.
Findings include:
-- Per review of adverse events in hospital's QAPI Program, in one event a patient (Patient #1) had a untoward outcome. The standard of care for medical care was met with room for improvement. The facility identified corrective improvement actions. One of the actions included updated policies and procedures (P&P) and education to staff and providers regarding the updated P&P. Review of documentation did not reveal that providers were educated about the updated P&P.
-- During interview of Staff A, Chief Nursing Officer, Senior Vice President of Clinical Operations on 10/25/2023 at 12:15 pm, he/she/they acknowledged the above findings.