HospitalInspections.org

Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to comply with their patient safety plan for disclosure of serious events to patient/significant other for three of 10 medical records reviewed (MR1, MR19 and MR20).
Review of facility Patient Safety Plan, August 2015, revealed, " ... E. Identification, reporting and disclosure of Healthcare-Associated Infections (HAI) ... 3. Disclosure of HAI a. HAI will be considered serious events under Mcare. B. Letters of disclosure will be sent to the patient/significant other within 7 days of confirmation of the infection."

1. Review of MR1 revealed a health-care associated lung infection date of October 14, 2016. Review of facility documents revealed no letter of disclosure was sent to the patient or significant other.

2. Further review of MR1 revealed a health-care associated bloodstream infection date of October 9, 2016. Review of facility documents revealed no disclosure was sent to the patient or significant other.

3. Review of MR19 revealed a health-care associated lung infection date of October 17, 2016. Review of facility documents revealed no disclosure was sent to the patient or significant other.

4. Review of MR20 revealed a health-care associated bloodstream infection date of October 13, 2016. Review of facility documents revealed no disclosure was sent to the patient or significant other.

5. Interview with EMP1, on January 5, 2016 at approximately 11:00 am, confirmed the above findings and revealed, "We didn't send the letters, it was a clerical error."