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Based on review of documentation and interview, it was determined that the facility failed to always document procedures and incidents in the patient medical record.

Findings were:

On 10/14/13, Patient # 1 was evaluated in the Emergency Room of Ward Memorial Hospital. An IV was initiated in the patient's right forearm without an MD order or mention in the nursing progress notes. The patient was discharged later in the day with the heplock still intact. This was not mentioned in the nursing progress notes. An Occurrence Report was not initiated nor was the incident reported to the Safety Committee.

In interviews with Staff Member # 9 (ER Room RN) and the Director of Nurses on 2/12/14, the lack of documentation in the above incident was confirmed.

Based on review of documentation and interview, it was determined that the facility failed to always report and track adverse events in the facility.

Findings were:

Ward Memorial Hospital Safety Program stated its purpose: "The purpose of Ward Memorial Hospital's Safety Program is to improve healthcare safety and reduce risk to patients, visitors, contract staff and employees through an environment that encourages:
? Recognition and reporting of risks to patient safety and medical/health errors
? Review of reported risks to identify underlying causes and system changes needed to reduce the likelihood of recurrence
? The initiation of actions to reduce these risks
? The internal reporting of what has been found and actions taken
? A focus on processes and systems
? Minimization of individual blame or retribution for involvement in a medical/health care error
? Prospective analysis of selected health care services before an adverse event occurs to identify system redesign that will reduce the likelihood of error
? Organizational learning about medical/health care errors
? Support of the sharing of that knowledge to effect behavioral changes in itself and other healthcare organizations

The scope of Ward Memorial Hospital's Safety Program includes an ongoing assessment, using internal and external knowledge and experience, to prevent error occurrence, maintain and improve healthcare safety. Safety occurrence information from aggregated data reports and individual incident occurrence reports will be reviewed by the Safety Officer, the Risk Manager, and the Safety Committee to prioritize organizational safety activity efforts. The aggregate resource information comes from, but not limited to the following:
? Occurrence Reports
? Medication Errors
? Adverse Drug Reactions
? Transfusion Reactions
? Sentinel Events
? Near Misses

The scope of the hospital wide Safety Program encompasses the patient population, visitors, volunteers, contract staff, physicians and employees. The program addresses maintenance and improvement in healthcare safety issues in every department throughout the facility. It is the responsibility of Administration, Department Directors/Managers and Supervisors to ensure full compliance with this program. There will be emphasis on important functions of:
? Patient Rights
? Assessment of Patients
? Care of Patients
? Patient/Family Education
? Continuum of Care
? Leadership
? Improving Organizational Performance
? Management of Information
? Management of Human Resources
? Management of Environment of Care
? Surveillance, Prevention and Control of Infection."

On 10/14/13, Patient # 1 was evaluated in the Emergency Room of Ward Memorial Hospital. During the time in the ER, Patient # 1 experienced a fall without injury. An IV was initiated in the patient ' s right forearm without an MD order or mention in the nursing progress notes. The patient was discharged later in the day with the heplock still intact. This was not mentioned in the nursing progress notes. An Occurrence Report regarding the patient fall and the removal of the heplock was not initiated nor was the incident reported to the Safety Committee.

In interviews with Staff Member # 9 (ER Room RN) and the Director of Nurses on 2/12/14, the lack of reporting adverse occurrences per hospital policy in the above incident was acknowledged.