HospitalInspections.org

Based on document review and interview, the facility failed to trend medical adverse events and document interdisciplinary interventions, resulting in the potential for ongoing and unrecognized poor outcomes. Findings include:

Review of the facility incident/accident report log, on 9/1/15 at approximately 0800, dated April through June 2015, revealed that the reports were listed in chronological order without grouping of incidents (e.g. falls, medication errors, etc) or severity levels. Interview with the Quality Manager #C (QM), on 9/1/15 at approximately 0830, revealed that the QM was aware of this, stating "We need better review or more detailed (review) through Collaborative Practice and better follow-up." Further interview with the QM, on 9/1/15 at approximately 1630, revealed that the facility could do general data sorts and presented raw numbers of instances, but patient outcome and severity rankings were missing and/or incomplete. Further review of the incident/accident report log revealed that the facility had multiple medication errors (lacked severity ranking), including a midazolam medication error with incomplete reporting (no specifics or actions documented) and a metformin administration error (hold metformin after radiology procedure). The QM was queried if a pharmacy representative was involved in medication error review at Collaborative Practice and she stated, "No."

Review of the Pharmacy and Therapeutics Committee quarterly meetings for the past year, on 9/2/15 at approximately 0800, revealed that medication errors were not evaluated/documented at those meetings. Interview with the Pharmacy Director #P, on 9/2/15 at approximately 0930, revealed that he did not trend medication errors by pharmacy or nursing either. It was not clear in the interview if a pharmacist would be involved in medication error evaluation or action plans for performance improvement.

Based on interview and document review, the facility failed to ensure the Infection Control Program was under the direction of a qualified professional who had training in infection prevention resulting in the potential for unsatisfactory patient outcomes. Findings include:

On 8/31/15 at approximately 1400 during review of the personnel files, it was discovered that the facility failed to provide evidence of specialized infection control training for the Infection Control Officer (ICO).

On 09/01/15 at 0820 an interview was conducted with the facility ICO (L) who confirmed that she had not participated in any webinars, conferences or educational courses specifically for infection control program training, but the ICO stated that she did read the publication entitled, "Infection Control Today." Staff L was unable to provide documentation to support any infection control training that she received.