HospitalInspections.org

Based on document review and interviews, it was determined the hospital's Quality Assessment Performance and Improvement (QAPI) program did not include a system that measured, tracked, and analyzed all quality indicators that is likely to have an impact on the safety and health of patients.

This failure may result in missed opportunities to prevent adverse outcomes and improve the quality of care to patients.

Findings include:

The Hospital's QAPI Plan for 2020-2021 does not provide any directive for the program to collect, track and trend data for adverse events, patient incidents, and occurrences.

The QAPI minutes from 5/25/21 to 3/22/22 showed no evidence that data was collected on patient incidents and occurrences and that they were tracked, trended, and analyzed. The QAPI meeting minutes did not include any information or discussions regarding patient incidents and adverse occurrences.

During an interview on 5/2/22 at 11:10 AM, Staff B, Manager of Quality and Patient Safety, the staff stated that the QAPI Plan for 2022 was being developed and had not been completed. She acknowledged that the QAPI minutes had no discussions or analysis of data regarding adverse occurrences and patient incidents.

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Based on document review and interviews, the facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) Program that identified and addressed high risk and problem prone areas.
Specifically the hospital failed to (1) ensure that all security incidents are documented and investigated; (2) Quantify the number of alleged incidents related to patients' complaints of improper conduct and abuse by security officers; (3) Develop a plan to reduce the number of these incidents.

This failure may result in missed opportunities to prevent adverse outcomes and improve the quality of care to patients.

Findings include:

1. Review of the QAPI program minutes from 5/2021 to 3/2022 showed no documented evidence that the hospital reviewed, tracked, trended and or analyzed Security Department incidents.

2. Review of the security incident report logs from 5/2021 to 3/2022 showed that not all incident/occurrences are documented.

In January 2022, it was alleged that three (3) security officers in the Emergency Department physically assaulted a patient who sustained injuries that included a fractured nose and laceration to the mouth which required 15 sutures to his oral mucosa.

During an interview on 5/2/2022, Staff A, Security Manager confirmed the findings and stated that the three (3) security officers that were involved refused to 5/2021 write a report. The Security Manager acknowledged that he was responsible for entering all incidents into the computer. He acknowledged that this incident was not entered into the computer.

3. The QAPI minutes for 5/2021 to 3/2022 had no review or discussion of these incidents and there were no corrective actions proposed and implemented.

(i) In January 2022, the father of a teenage patient alleged that his daughter was sexually harassed verbally by a Security Officer in the Emergency Department.

(ii) In November 2021, an occurrence report described a "physical exchange" between two (2) security Officers and a patient. Unknown if incident resulted in harm to the patient.

(iii) In August 2021, a patient sustained a nosebleed during an altercation with security officers.

During an interview on 5/2/22 at 11:10 AM, Staff B, Manager of Quality and Patient Safety confirmed the findings.