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Based on the hospital's "Performance Improvement Plan" review, Performance Improvement (PI) activities data review, and staff interview, the hospital's leadership staff failed to track adverse patient events as identified by the hospital in order to implement preventive actions and mechanisms for staff feedback and learning in the hospital.

Findings included:

Review on 01/31/2018 of the hospital's "Performance Improvement Plan" (Year 2017), revealed "I. Introduction: The Program for Performance Improvement (PI) of (Hospital Name) involves a planned systemic, organization-wide approach to process, design and performance measurement, analysis and improvement. II. Purpose: 3. Collecting data to monitor the stability of existing processes, identify opportunities for improvement, identify changes that will lead to improvement and sustain improvement." Further review of the "Performance Improvement Plan" revealed no specific documentation for measuring, analyze, and tracking of adverse patient events.

Review on 01/31/2018 of the hospitals listed "Adverse Events" from the period of "July 2017 through January 2018" revealed as follows:

~07/2017 = 1 patient adverse events,
~08/2017 = 4 patient adverse events,
~09/2017 = 5 patient adverse events,
~10/2017 = 6 patient adverse events,
~11/2017 = 0 patient adverse events,
~12/2017 = 3 patient adverse events, and
~01/2018 = 2 patient adverse events.

Review on 01/31/2018 of the hospital's "Quality Council Meeting" minutes revealed the hospital held meetings monthly on 07/20/2017, 08/17/2017, 09/21/2017, 10/19/2017, 11/16/2017, and 12/14/2017. Review of the minutes revealed there was no documentation that the hospital's QAPI program had performance improvement activities that tracked adverse patient events, analyze their causes, and implemented preventive actions and mechanisms that would initiate feedback and learning throughout the hospital.

Interview on 01/31/2018 at 1017 with the hospital's Risk Manager/PI Director revealed that the hospital does investigate adverse events but that review in the QAPI program probably would not be seen in review. The interview revealed that the topic of adverse events is not brought up in the QAPI meetings for tracking or trending. Interview again on 02/01/2018 with the Risk Manager/PI Director revealed that adverse events are created by staff who turn the paper documents into their supervisor before submission to the Risk Manager for review and entry into a computer database. If the adverse event is determined to be a risk to patients or potential harm that could lead to death, severe reaction, or lead to ER (Emergency Department) visit, then it is considered an adverse event. The interview also revealed that sexual allegations or identified sexual encounters would be counted as adverse events. The interview confirmed the QAPI adverse event tracking findings.

NC00135181