HospitalInspections.org

Based on review of incident reports, staff interview, and policy review, the facility failed to track adverse patient events. This could affect all patients receiving services from the facility. The facility census was 172.

Findings include:

Review of the Policy and Procedure for Patient Safety/Risk Management Plan (Approval date 09/08/21) revealed the mission of the Patient Safety/Risk Management Program incorporates Southern Ohio Medical Center's mission to make a difference, by supporting a safe environment for patients, visitors, employees, providers, and volunteers. It was designed to enhance the culture of safety where the focus on risk identification, reduction, prevention, and evaluation of hazards that will in turn reduce the likelihood of errors while minimizing financial loss to the organization. The Patient Safety Process includes incident reporting which is described as an event not consistent with the desired operation of the facility or the care of patients. Data is aggregated, reviewed, and analyzed by the Risk Manager to identify trends regarding accidents or occurrences.

Review of a facility internal investigation completed on 08/25/21 revealed an employee was terminated for drug diversion.

Staff I confirmed in an interview on 10/04/21 at 1:14 PM although an investigation was completed an incident report was not documented as per policy.