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56 FRANKLIN STEET

WATERBURY, CT 06706

MEDICAL SCREENING EXAM

Tag No.: A2406

Based on review of the hospital corrective action plan (CAP), review of hospital education, review of hospital rounding tools and interviews, the hospital failed to ensure that the CAP to prevent recurrence for deficient practice was followed as submitted. The finding includes:

Review of the hospital CAP dated 5/4/22 identified the completion date of 5/2/22 for the reinforcement of the hourly rounding tool in the emergency department and the performance of one days audit per week to monitor compliance.

Review of ED rounding tools on 5//12/22 noted hourly rounding for the dates of 5/9, 5/10. 5/11, and 5/12/2022. The hourly rounding tool could not be provided for 5/2/22 through 5/8/22. In addition, the hourly rounding tool for 5/9/22 through 5/12/22 indicated the 7:00 AM to 7:00 PM was the only shift to utilize the tool. Auditing for the use of the tool could not be provided.

Interview with the ED Nursing Director on 5/12/22 at 11:12 AM noted hourly rounding was not initiated until Monday (5/9/22). He further identified training for the use of the tool was provided verbally during huddles and by off- shift clinical coordinators. Interview with the Director of Quality on 5/12/22 at 11:14 AM noted formal training regarding the rounding tool and its requirements will be sent to all ED nursing staff today and will include an attestation requirement.

The hospital was found to be noncompliant with the CAP as submitted.


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