HospitalInspections.org

Based on document review and interview, it could not be determined that the facility followed Event Reporting policy by completing incident report in 2 of 2 Event Reports requested.

Findings Include:

1. Review of policy titled: Event Reporting (ERS) Policy (PolicyStat ID: 8265018) indicated on page 1 and page 3 the following:
II. Definitions:
Adverse Event/Event: A happening or occurrence that is not part of the routine care of a particular patient or the routine operation of the healthcare entity (American Society for Healthcare Risk Management (ASHRM)).
IV. Documentation:
B. Guidance Regarding Disclosure/Release of Incident:
1. Indiana State Department of Health, CMS, or other agencies are not allowed to receive or view ERS events as they are considered PSWP (Patient Safety Work Product). If they are demanding to see an event the only thing that can be legally provided is the "Legal Copy" located in ERS.
This policy/procedure was last reviewed on 07/2020.

2. Review of Incident Report Log from 12/01/20 to 04/15/21 had incident for Patient 2 on 04/15/21 regarding admission/transfer/discharge plan and inadequate communication. Patient 6 had incident logged on 02/22/21 regarding treatment, therapies and dialysis complication. Unable to verify content or outcome of incident.

3. Interview on 04/20/21 at approximately 10:30 am and 2:50 pm requested incident reports from P51 (Manager Quality). P51 indicated the facility would not provide incident reports for review. The facility did not provide documentation to determine compliance.