HospitalInspections.org

Based on review of facility documentation and staff interview (EMP), it was determined that the facility failed to ensure the corrective action was taken as indicated by the analysis for one of one serious event.

Findings include:


Review of facility policy and procedure "Initial Incident/Event Reporting" dated December 1, 2014, revealed "P. Serious Event: As defined by Mcare: An event occurrence or situation involving the clinical care of a patient in a medical facility that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health care services to the patient."

Review of facility policy and procedure "Patient Safety Policy" reviewed February 8, 2013, revealed, "Patient Safety Officer will be responsible for the following: ..... Data related to actual events and incident will be aggregated and analyzed across the organization to identify patterns and trends. This data will be analyzed and acted upon by the Patient Safety Council."

Review of facility "UPMC Mercy Quality Improvement Plan" reviewed November 12, 2012, revealed. ... All activities are planned in a collaborative and interdisciplinary manner. Do the improvement process. Collect and analyze data. Implement the change strategies. Do small changes. Study the result. Understand the source of errors. Review the re-measurement data. Were the results of the change better, worse or a lateral change: Act to hold the gain and continue to improve the process. Follow up with documentation and report the team involved."

1. Review of facility documentation "Adverse Event Analysis Tool" dated January 27, 2015, revealed an investigation of a serious event that indicated, "Action Plan ... Risk Reduction Strategies ...educate staff ...measures of effectiveness ... chart audits .... date implemented May, 2015."

2. A request was made for documentation of the Action Plan, education to physician and non-physician staff members, and chart audits. However, the facility was unable to provide the requested documents.

On July 10, 2015, at approximately 12:45 PM, EMP1 confirmed the above findings and revealed, "We have done chart audits but I cannot show you the specifics of that incident."