HospitalInspections.org

Based on medical record (MR) review, document review and interview, the facility failed to identify, report and investigate a patient incident/occurrence as per facility policy.

This failure placed all patients at increased risk of harm.

Findings:

Review of the Patient #1's MR identified that this 48-year old patient was discharged from the facility's Emergency Department (ED) on 08/31/2021 at 3:50PM in stable condition.

Post discharge, Patient #1 was waiting for a taxi by the Emergency Room walk-in entrance. At 4:51PM, a Rapid Response Code was activated for Patient #1 by the Security Officer.

The Security Log dated 8/31/2021 identified no entry was logged for this occurrence.

During interview of Staff D (Security Manager) and Staff E (Senior Director of Security Health System) on 1/12/2022 at 01:34PM, Staff E stated, "We did not do a report because it was a clinical condition .... When it is a street call, it goes into a log."

During interview of Staff D on 01/12/2022 at 01:40PM, Staff D confirmed that this occurrence was not entered into the Security Log and that an Occurrence Report was not filed.

The facility policy and procedure (P&P) titled, "Occurrence Reporting to Patients, Visitors, Associates, Volunteers, Contract Employees, Students, and Instructors," last revised 08/2021, stated "For adverse or potentially serious safety events, the staff member who witnessed or became aware of the occurrence must notify their immediate supervisor and complete a paper Occurrence Report Form ....In a non-patient area - e.g. hallway, lobby, stairwells, sidewalk, parking area, etc., the Security Department must be notified immediately. The Security Officer will complete the Security Occurrence Report in accordance with SECURITY INCIDENT REPORTING POLICY 2-10, at the scene of the occurrence and forward it to Risk Management within 24 hours."

The facility P&P titled, "Security Occurrence Reporting," last revised 06/2020, stated "It is the policy of Montefiore Medical Center to collect information about and to investigate occurrences/incidents that effect the safety and security of all persons and property. All Security Occurrence Reports MUST be submitted to the Supervisor (or designee) on the date and tour that report was taken. Security reports must then be entered into the 'OmniGo' Security Occurrence Report System within 24 hours of occurrence."

On 1/12/2022, these findings were confirmed with Staff D (Security Manager), Staff A (ED Assistant Director of Nursing/RN), Staff H (ED Director/MD), and Staff K (Quality and Regulatory Affairs/MSW).