HospitalInspections.org

Based on documents review, and interview, the facility failed to utilize its Quality Assessment and Performance Improvement (QAPI) program to ensure that data collected are analyzed, trended and corrective action plans implemented for identified problems.

Findings include:

Review of occurrence and incidence reports for 2019 showed that incident reports generated from all departments were compiled monthly in a folder. These incidents included, but were not limited to elopements, medication errors, and wrong name identification labels.

In February 2019, there were 6 medication incidents.
In December 2019, there were 4 medication incidents.

There was no documented evidence that incidents/occurrences for 2019 were analyzed and trended to identify problems concerning patient care and clinical performance.

Review of the facility policy and procedure titled: "Patient Occurrence Reporting and Disclosure" dated 12/19/19 pages 1 to 13 states in paragraph B page 2: "The department Chairpersons and Directors of Nursing (or their designees) are responsible for ensuring that all incidents affecting patients occurring on their service or which occur under the auspices of their services are appropriately reported to Risk Management for facilitating the investigation and implementing and monitoring the plan of corrective action, where necessary, with the assistance of the department of Quality Management".

There was no documented evidence of corrective action plan to address incidents that were reported in 2019.

During interview with facility Risk Management team on 1/29/2020 at 2:30 PM, Staff C, (Medical Director in charge of Quality Assurance) stated that the facility is only collecting and analyzing data on falls and is aware of other "themed" areas of occurrences and is in the process of implementing a computer system that could process incidents and occurrence reports to yield data for determining performance improvement and ensuring patient safety.