HospitalInspections.org

Based on record review and interview the facility failed to provide a Quality Assurance, Performance Improvement program that analyzes, tracks, and trends medical errors, patient safety and adverse events. This failed practice can lead to ongoing occurrences of safety issues and adverse events that can potentially cause harm to all patients.

Findings are:

A. Record review of facility policy "Event Reporting Policy - Riskonnect" last revised 03/2021 states under "Purpose: C. To track and trend processes at risk that impact patient safety by using the Riskonnect Reporting System. D. To track and trend all levels of harm. E. To analyze trends to prevent harm, improve patient safety, healthcare quality and healthcare outcomes. Policy: 6. Risk Manager or Chief Quality Officer/Quality Director will utilize data and reports to support patient safety and risk prevention measures ad performance improvement opportunities."

B. Record review of facility policy "Organization-wide Quality Assessment and Performance Improvement Program 2022", states under "Quality Improvement Council: 7. Analyze and identify trends or patterns that might suggest an improvement opportunity. Quality and Patient Safety Integration: The Quality and Risk Management programs seek to reduce the frequency and severity of adverse events, thus minimizing loss and contributing to Quality Improvement through risk identification, evaluation, control and education."

C. Record review of facility Quality Improvement Council meeting minutes dated June 21, 22 2022, July 19, 22 2022, and August 16, 22 2022 shows no complaints or adverse events tracked, analyzed, or discussed in meeting.

D. Interview with Staff (S3), (Director of Quality) on 09/27/2022, when asked why complaints, grievances and adverse events weren't discussed in Quality meetings, S3 answered "I think for a while because it is a confidential system, for a while nobody can know what is going on."