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MELROSEWAKEFIELD HEALTHCARE
INTEGRATION OF OUTPATIENT SERVICES
Tag No.: A1077
Based on interview and records reviewed the Outpatient Department failed to follow Hospital policy for documentation of an adverse event for one (Patient #1) of eleven patients sampled.
The Hospital policy titled Sentinel Events and Serious Reportable Events, dated 7/1/18, indicated that clinicians caring for a patient who is the subject of an adverse event should document a complete and factual description of the event as well as the objective details of the event.
The Surveyor reviewed Patient #1's record at 10:00 A.M. on 9/5/19. Anesthesiologist #2 documented in Patient #1's medical record that Psychiatrist #1 had spoken with Patient #1's family about the "situation" but no additional facts of the event were described as required by hospital policy.