HospitalInspections.org

Based on review of incident/event documentation for 5 of 14 patients who received hospital services (Patients 19, 24, 29, 31 and 37), review of staff training documents, review of the hospital's plan of correction for the survey conducted on 08/08/2019, and review of other documents, it was determined that the hospital failed to ensure patient's rights to be free from all forms of abuse, including neglect, as all components of an effective abuse prevention program were not carried out.
* Incident/event investigations and follow up actions were not timely, thorough and complete including cases of potential abuse or neglect for patients who experienced seclusion, self harm behaviors, falls with injuries, and skin conditions.

The CMS Interpretive Guidelines reflect that components necessary for effective abuse protection include, but are not limited to:
o Prevent.
o Identify. The hospital creates and maintains a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect.
o Investigate. The hospital ensures, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect or mistreatment.
o Report/Respond. The hospital must assure that any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law.

The CMS Interpretive Guidelines reflect that abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. Neglect, for the purpose of this requirement, is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.

Findings include:

1. The hospital's Plan of Correction submitted in response to the survey conducted on 08/08/2019 reflected "An Incident Report Summary template will be developed which will ensure thorough and timely investigations are conducted for events including those with potential or actual harm related to patient behaviors, elopement, medication errors, skin care, and ostomy/incontinence management....Department manager will document in the incident report the corrective actions, follow-up with staff and any policies/process improvements with dates completed...Department manager will document on the incident report whether staff performance met or did not meet the relevant standards of practice in the Follow-up section of the incident report...Department manager will document that the patient was assessed for any injuries as a result of the patient safety incident, the presence or absence of injuries, and treatment provided if injuries were found."
* "ED and Inpatient department managers will receive education on the expectation to complete thorough and timely investigations of events...They will also receive education on the use of the Incident Report Summary template which will include action items to ensure the events do not recur."

2. The following documents were provided in response to a request for the staff training/education identified in the hospital's plan of correction in finding 1 above:

2. a. An untitled staff education document dated 04/20/2020 was reviewed. The document had a yellow sticky note affixed to it with "education on timely investigation" hand written on it. The document reflected:
* "An ICARE Report Investigation & Documentation Template has been developed to ensure thorough & timely investigations are conducted for events including those with potential or actual harm related to...Patient behaviors (including allegations of abuse, issues re (sic) restraints/seclusion, self-harm, etc.)...Elopement/attempted elopement...Medication errors...Skin care, and...Ostomy/incontinence management."
* "The elements of the Template will include that the department manager/designee will document within the investigation of the ICARE...Whether staff performance met or did not meet the relevant standards of practice...Whether staff escalated the incident through their chain of command in a timely manner...Any countermeasures (e.g., staff education, coaching), follow-up with staff, and/or any policy/process improvements with dates completed, and...That the patient was assessed for any injuries as a result of the patient safety incident, the presence or absence of injuries, and treatment provided if injuries were found."
* "ED and Inpatient Department Manager Education...We are expected to complete thorough and timely investigations, including those events with potential or actual patient harm related to...Patient behaviors (including allegations of abuse, issues re (sic) restraint/seclusion, self-harm, etc.)...Skin care..."
* "Manager/designee will document within the 'Follow-Up Actions' section of the ICARE the following elements...Staff performance...Did staff adhere to the expected standard of care (SOC), policy, etc?...If yes, document this (and provide detail)...Document whether staff was provided re-education, coaching, and/or countermeasures including date(s) completed..."
* "Did staff escalate the incident through their chain of command?...in a timely manner?...If yes, document this (and provide detail)...If no, document this, and document countermeasures...follow-up with staff, and/or any policy/process improvements with dates completed."
* "Patient assessment...Document...Findings related to any injuries/harm sustained, and...Actions taken, countermeasures, and/or treatment, etc."
* "Review/initiate ICARE investigation within 24 business hours of receiving ICARE notification and document Example: ICARE investigation begun 1145 4/19/20."
* "Take actions immediately to mitigate risk to patient and document any actions taken including whether provider was notified."
* "Complete initial investigation within 72 hours of receipt of ICARE notification...Determine what further information or facts are needed...Determine and document factors that contributed to cause...Determine and document whether harm occurred, including subsequent patient assessments...Update level of severity of harm based on actual impact to patient and required treatment (if any)."
* "Finalize investigation and close ICARE within two weeks of receiving ICARE notification."

2. b. A staff training document titled "EMC ED Update," dated 04/21/2020 was reviewed and reflected:
* "Write iCares for reasons such as safety concerns, patient staff injury, patient or visitor fall, property damage, violence in the workplace, etc. This list is not all inclusive. Staff should write an iCare whenever there is a deviation from the standard of care or when there is an unexpected patient outcome. They must do this whether there was a measurable consequence as a result of that deviation or not."
* "Leaders review iCares in a reasonable amount of time. The time between submission and the initial leader review may vary based on when the iCare was submitted. For example, an iCare written on a Tuesday may be addressed the same day or sometime in the next 24 hours, whereas an iCare written on the Friday evening of a long weekend would have a slower turnaround time, up to 72 hours. The leader investigates and aims to close the iCare with a mitigation plan in place within 2 weeks. This process may take longer or shorter, depending on the complexity of the issues addressed in the iCare. Some problems will not have a mitigation plan in place at the end of two weeks, and some less severe issues are documented for trending purposes only."
* "Serious safety concerns or significant deviations from the standard of care will be escalated by ED staff by using the chain of command...A non-urgent matter is something that can wait until the leadership is back on campus."
* "For urgent issues, notify the Administrative Nursing Supervisor...They can be told in person or by phone since they are on-site 24/7. If unsure of the urgency of the issue, notify the manager and ANS..."

2. c. An undated staff training document titled "Reporting in a Culture of Safety," was reviewed and reflected:
* "...We have an incident reporting system (ICARE), so employees can communicate these errors or safety concerns."
* "What to Report...Anytime something you expect to happen does not, or when something you did not expect to happen does or nearly does (Good Catch)...Event may or may not reach the patient, but it should still be reported...Some examples...Falls...Patient or Visitor..Medication Events...Equipment Failures...Pressure Injuries...Alleged Abuse...Threats or Acts of Violence...Elopements...Employee Incidents...There are many more examples. If in doubt, submit. It is better to submit than to not."
* "Managing an Incident...First, attend to the patient/family's immediate clinical and emotional needs...If you need immediate help or the event requires action right away, do not wait. It is important to communicate these types of incidents to your manager, as the incident report may not be seen right away...If the patient is seriously injured and you know, or suspect, it is related to a medical error, contact Legacy Risk Management during business hours...or the Nursing Supervisor if after hours...Submit an incident report as soon as possible, before the end of shift, while the facts are still fresh in your mind."
* "What Happens to an Incident Report?..When an incident report is submitted, an e-mail alert is sent out to certain individuals for timely notification and investigation..."
* "Expectations of Incident Reporting...Employee Expectations...Report errors, near misses or safety concerns...Report required incident reporting (Falls, Pressure injuries, etc.)...Manager/Leader Expectations...Follow-up with reporting employee to close the feedback loop...Share what was learned...Collaborate with staff on improving systems that reduce the possibility of error..."

The staff training documents in findings 2. a., 2. b., and 2. c. lacked a clear process that ensured all situations that endangered a patient, such as neglect or abuse, were reviewed immediately and an investigation and other actions initiated as appropriate, given the seriousness of the allegations and the potential for harm to the patient.

3. The documents titled "Phase 1 Investigation Guidelines Reports of Inappropriate Behavior, Misconduct, Excessive Force or Abuse" dated "May 2020," and "Report of Inappropriate Behavior, Excessive Force or Abuse-Investigation Guidelines Phase 2" dated "May 2020" were provided and reviewed. The documents were clipped together and had a yellow sticky note affixed to them that reflected "Risk management abuse/neglect guidelines for abuse investigation." The documents lacked a clear process that ensured all situations that endangered a patient, such as neglect or abuse, were reviewed immediately and an investigation and other actions initiated as appropriate, given the seriousness of the allegations and the potential for harm to the patient. For example, the documents primarily addressed situations involving allegations of patient abuse by a staff member as follows:
* The top section of "Phase 1 Investigation Guidelines Reports of Inappropriate Behavior, Misconduct, Excessive Force or Abuse" reflected "Q: What should I do if a patient or family member approaches me to report another Legacy staff person or physician has engaged in inappropriate behaviors? A: All Legacy staff have a role in ensuring patient safety. The following will help you know how to respond...Complaints and concerns take many forms. Common things to listen for and report include...'That staff person makes me feel uncomfortable' or 'I think he (or) she is creepy...'My care giver...[did something weird/odd/inappropriate]'...You approach a treatment area and find a door locked or blocked that should be open or accessible...You enter a room and see staff behaving unprofessionally (making inappropriate comments, inappropriate touching pt., etc.)...The patient appears fearful or worried around a certain staff member...A patient or family member tells you a staff member behaved inappropriately or touched, looked at or spoke in a way they didn't like."
* "Immediate Action Steps...Ask for specifics such as, 'Help me understand - what specific actions or words do you mean when you say the nurse 'was abusive' or 'was creepy?' We can't make decisions based on labels...Do not share any details of the complaint with the specific staff member who is accused..."

4. Review of incident/event documentation reflected that on 07/02/2020 at 0800 on Unit 15 MACU, Patient 19 was "...sitting on edge of bed post-showering independently with no remarkable events. Pt became confused and had forgotten to wash the soap out of [his/her] hair, causing [him/her] to become increasingly agitated. Pt was speaking nonsensical terms and then became unable to find appropriate words...Pt was moving [his/her] mouth but couldn't make noise or form words. Pt then stood up appearing to motion towards the bathroom and fell headfirst (sic), striking [his/her] forehead on the edge of the open bathroom door. No obstacles present, and the Pt did not seem to lose [his/her] footing, more so that [he/she] became faint and lightheaded, resulting in the fall. Pt had refused non-slip footwear prior to this event x3. Small hematoma forming immediately after injury, Pt amendable to non-slip socks now...Sitter in place? Yes."

The "Follow-up Actions" dated 07/02/2020 at 1436 reflected the incident was reviewed by the AM, the "Follow-up Notes" section was blank, and the "Attachments" section reflected "No Attachment."
* The "Follow-up Actions" dated 07/02/2020 at 1625 reflected the incident was reviewed by the Director, the "Follow-up Notes" section was blank, and the "Attachments" section reflected "No Attachment."
* The "Follow-up Actions" dated 07/03/2020 at 0751 reflected the incident was reviewed by the Manager, the "Follow-up Notes" section was blank, and the "Attachments" section reflected "No Attachment."
* The "Follow-up Actions" dated 07/06/2020 at 0836, 4 days after the incident, reviewed by "[name and no title]" reflected only "Morse Fall Score needs to be updated," and the "Attachments" section reflected "No Attachment."
* The "Follow-up Actions" dated 07/07/2020 at 1411, 5 days after the incident, reviewed by "[name and no title]" reflected only "what are the pre- and post-fall scores for the pt? If pt high risk per screening and/or has behaviors contributing to fall risk, this would be an anticipated fall" and the "Attachments" section reflected "No Attachment."
* The "Follow-up Actions" dated 07/08/2020 at 1402, 6 days after the incident documented by the AM reflected:
- "changed file type to anticipated physiological fall."
- "7/3/reporter CNA, discussed w/ RN 7/3 huddle paper"
- "updated ICARE information based on findings"
- "contributing factors: confusion/agitation...hx of verbal and physical w/ staff/refusal of nonskid footwear/ possible medication changes and new epilepsy dx"
- "patient condition post fall: stable, bruise to forehead"
- "care plan opened: yes"
- "post fall huddle done: yes"
- "fall risk assessment documented pre- and post- event: yes..."
- "progress note written: yes..."
- "provider notified: yes..."
- "family guardian notified: no"
- "mitigation: able to change socks to red nonskid socks, SBA with activity w/ sitter"
- "7/8 follow up with RN: yellowing of bruise on forehead no complaints of pain." The "Attachments" section reflected "No Attachment."

* The "Follow-up Actions" dated 07/08/2020 at 1454 documented by the AM reflected:
- "Staff performance...met the expected/relevant standards...fall precautions in place exception pt with no chair/bed alarm d/t 1:1 observation...Staff escalated incident through chain of command...Staff was provided education, coaching..."
- "Mitigation done within moments for patient and care team: SBA for all activities, pt able to wear non-skid socks...Patient sustained harm or injuries as described: Bruising to forehead..." This was the final documentation of follow up actions.

* The documentation reflected the "File" was closed but did not include the date it was closed.

The investigation and follow up actions were unclear and were not timely or thorough. Examples included:
* The documentation reflected the patient was on "1:1 observation" and had a "sitter." The investigation did not identify the reason the patient had a sitter or the sitter's responsibilities at the time of the fall and if those responsibilities were or were not carried out.
* It was unclear how the patient who was on 1:1 observation with a sitter was permitted to shower independently and not wash soap out of [his/her] hair.
* The investigation did not include where the sitter was and if the sitter who was providing 1:1 observation attempted to intervene when the patient's agitation increased and the patient motioned towards the bathroom prior to the fall.
* The documentation reflected the patient appeared to become faint and lightheaded prior to the fall. However, there was no further investigation related to the "possible medication changes" and "new epilepsy dx" and if those may have contributed to the fall.
* There was no investigation that reflected if abuse or neglect was ruled out.
* The documentation reflected the AM and Director reviewed the incident on 07/02/2020; and the Manager reviewed the incident on 07/03/2020, but there was no documentation that reflected the investigation was initiated and documented within 24 business hours as reflected in the staff training document in finding 2. a. above including as described in the example that reflected, "ICARE investigation begun 1145 4/19/20." There was no documentation that reflected an initial investigation was completed within 72 hours of receipt of the incident notification that included a determination of whether further information or facts were needed as reflected in the training document in finding 2. a. above. Although the documentation reflected the file was closed, due to the lack of a thorough investigation, it was unclear if or when the investigation was completed.

There was no further investigation or follow up actions.

5. Review of incident/event documentation reflected that on 07/25/2020 at 1810, in the ED Patient 24 was "...placed in seclusion and was found to have a toothbrush [he/she] had filed down to a sharp point on the door." The "Other Specific Event Type" reflected "pt making a weapon." The "Equipment Details" reflected "Equipment/Device(s)...Not Specified." The "Parties Involved/Notified/Witnesses" section reflected "Not Specified." The "Attachments" section reflected "No Attachment."
* The "Follow-up Actions" dated 07/27/2020 at 0527 reflected the incident was reviewed by "[name and no title]," the "Follow-up Notes" section was blank, and the "Attachments" section reflected "No Attachment."
* The "Follow-up Actions" dated 07/27/2020 at 0836 reflected the incident was reviewed by the Director, the "Follow-up Notes" section was blank, and the "Attachments" section reflected "No Attachment."
* The "Follow-up Actions" dated 07/27/2020 at 0845 reflected the incident was reviewed by the Manager, the "Follow-up Notes" section was blank, and the "Attachments" section reflected "No Attachment."
* The "Follow-up Actions" dated 07/27/2020 at 1229 reflected the incident was reviewed by "[name and no title]," the "Follow-up Notes" section was blank, and the "Attachments" section reflected "No Attachment."
* The "Follow-up Actions" dated 07/27/2020 at 1526 documented by the Manager reflected "The patient was given a toothbrush and brushed [his/her] teeth. [He/she] then quickly escalated and was placed in seclusion. [He/she] proceeded to block the door and camera with the bed and mattress. Sand bed was then removed from the room and the toothbrush was found and confiscated. The end of the toothbrush was formed into a sharp point by rubbing against the door. This is a blind spot in the room in addition to the camera being blocked by the mattress." The "Attachments" section reflected "No Attachment."
* The "Follow-up Actions" dated 07/28/2020 at 0819 reflected the incident was reviewed by "[name and no title]," the "Follow-up Notes" section was blank, and the "Attachments" section reflected "No Attachment."
* The "Follow-up Actions" dated 07/29/2020 at 0914 documented by the Manager reflected only "We are trying to source finger toothbrushes," and the "Attachments" section reflected "No Attachment."
* The "Follow-up Actions" dated 08/05/2020 at 0847 documented by the Manager reflected only "Entering a request for this product in Lumere," and the "Attachments" section reflected "No Attachment." This was the final documentation of follow up actions.

* The documentation reflected the "File" was closed but did not include the date it was closed.

* An email from the ACC dated 09/24/2020 at 1558 regarding the incident was reviewed. The email included an attached document. The attached document was an email addressed to "EMC All Ed Staff" from a CN on 07/25/2020 at 1913 and reflected "This is a notice to all staff to be diligent about toothbrushes given to patients there (sic) was an incident today where a patient was caught with a toothbrush shank. The pt was observed sharpening it on one of our doors. Had the nurse or tech been busy and not seen this, it could have resulted in a serious injury as this patient was very violent. We are currently searching for alternative options that will eliminate this threat."

* A "Daily Safety and Readiness" document received in an email from the ACC dated 09/24/2020 at 1558 regarding the incident reflected:
- "Date issue occurred...07/25/2020...Location/Service...ED"
- "RED: Problem Statement...Pt was placed in seclusion and was found to have a toothbrush [he/she] had filed down to a sharp point on the door..."
- "Has this risk been contained?...Yes Process Countermeasure"
- "What help is needed? What are the next steps?...Describe the specific action item need to close this out..." followed by "process review"
- "How does this problem involve or impact other parts of Legacy...brief note how issue could effect other facilities or system" followed by a blank space.
- "Move to RTPS?...Yes"

The investigation and follow up actions were unclear and were not thorough. Examples included:
* The investigation did not include if the patient who was "very violent" was or was not evaluated and determined appropriate to be given a toothbrush.
* The investigation did not include how the patient was permitted to take a toothbrush into a seclusion room.
* The documentation reflected the patient was observed sharpening a toothbrush on a door. The investigation did not include what part of the door the toothbrush was sharpened on, details about how the patient was able to sharpen the toothbrush on the door, and how long this activity occurred before staff intervened.
* The documentation reflected there was a blind spot in the room in addition to the camera being blocked by the mattress. There was no investigation related to how long the patient was in a "blind spot" and the camera blocked by the mattress, if the "blind spot" had been identified prior to this incident, and if interventions were or should have been in place to address the blind spot for this patient and other patients.
* There was no documentation that reflected the provider was notified of the incident in accordance with the staff training document in finding 2. a. above.
* There was no investigation related to if the patient was injured, and treatment provided if injuries were found in accordance with the hospital's plan of correction and staff training document in findings 1 and 2. a. above.
* There was no investigation of whether relevant P&Ps and "standards of practice" related to, but not limited to, monitoring patients experiencing violent behaviors and use of seclusion were adhered to in accordance with the hospital's plan of correction and staff training document in findings 1 and 2. a. above.
* There was no further documentation that reflected what the "process review" and "RTPS" in the "Daily Safety and Readiness" document entailed and the outcome of those.
* There was no further follow up related to the "alternative options that will eliminate this threat" and "We are trying to source finger toothbrushes."
* There was no investigation that reflected if abuse or neglect was ruled out.

There was no further investigation or follow up actions to ensure similar events did not recur.

6. Review of incident/event documentation reflected that on 08/07/2020 at 2315 in the ED, Patient 29 was in "...seclusion in behavioral health for agitation and threatening behavior to staff. pt standing at room door and self inflicted wound to eyebrow by banging [his/her] head on the door. minor wound care post injury." The "Severity level (Reported)" reflected "...Harm - Temporary - Minor Treatment." The "Restraint Event Details" reflected "Restraint Start Time 22:15" and the "Restraint End Time" was blank.
* The "Follow-up Actions" dated 08/10/2020 at 0823 reflected the incident was reviewed by the Manager, the "Follow-up Notes" were blank, and the "Attachments" section reflected "No Attachment."
* The "Follow-up Actions" dated 08/11/2020 at 1439 reflected the incident was reviewed by the Manager, the "Follow-up Notes" reflected "Restraints applied appropriately when patient escalated and attempted self harm by banging head against the door." The "Attachments" section reflected "No Attachment." This was the final documentation of follow up actions.

* The documentation reflected the "File" was closed but did not include the date it was closed.

The investigation and follow up actions were unclear and were not timely or thorough. For example:
* It was unclear how long the patient was "banging [his/her] head on the door" before staff intervened.
* There was no further investigation of the type of injury the patient experienced or treatment provided. The documentation reflected only "self inflicted wound to eyebrow," "minor wound care," and "minor treatment."
* There was no investigation related to when the patient was last observed prior to the incident.
* There was no investigation of whether the provider was notified of the incident in accordance with the staff training document in findings 2. a. above.
* There was no investigation related to whether relevant P&Ps and "standards of practice" related to, but not limited to, management of patient behaviors and use of restraints and seclusion were adhered to in accordance with the hospital's plan of correction and staff training document in findings 1 and 2. a. above.
* There was no documentation that reflected the investigation was initiated and documented within 24 business hours as reflected in the staff training document in finding 2. a. above including as described in the example that reflected, "ICARE investigation begun 1145 4/19/20." There was no documentation that reflected an initial investigation was completed within 72 hours of receipt of the incident notification that included a determination of whether further information or facts were needed as reflected in the training document in finding 2. a. above. Although the documentation reflected the file was closed, due to the lack of a thorough investigation, it was unclear if or when the investigation was completed.
* There was no investigation that reflected if abuse or neglect was ruled out.

There was no further investigation or follow up actions to ensure similar events did not recur.

7. Review of incident/event documentation for Patient 31 reflected that the patient's "Admission Date" was 08/07/2020, and on 08/10/2020 at 1000 in the ICVR Unit, the patient experienced "Two partial thickness wounds present on admission to ICVR: coccyx and R buttock. Barrier cream applied. Patient states has been using at home and is aware of wounds, currently home on hospice. Patient independently repositions self on side in bed for pressure relief." The "Skin/Tissue Details" reflected "Ulcer Type Pressure Ulcer." The incident/event was categorized as "Near Miss/Good Catch."
* The "Follow-up Actions" dated 08/10/2020 at 1408 documented by "[name and no title]" reflected only "In ICVR - question if will be admitted for wound consult for staging?"
* The "Follow-up Actions" dated 08/12/2020 at 0910 documented by the Manager reflected only "Pt discharged same day."
* The "Follow-up Notes" dated 08/12/2020 at 1044 documented by "[name and no title]" reflected only "Stage changed to unknown as not seen by WOS RN."

* The documentation reflected the "File" was closed but did not include the date it was closed.

The investigation was unclear and was not timely or thorough. Examples included:
* The investigation was unclear related to when and how it was identified that the patient had "wounds present on admission." It was unclear if the patient should have been seen by WOS RN prior to discharge or "admitted for wound consult for staging" or other actions to address the patient's wounds.
* It was unclear what the "Near Miss/Good Catch" pertained to and if follow up actions were needed to address the "Near Miss/Good Catch."
* There was no documentation that reflected if the provider was notified in accordance with the staff training document in finding 2. a. above.
* There was no investigation of whether relevant P&Ps and "standards of practice" related to management of skin conditions were adhered to in accordance with the hospital's plan of correction and staff training document in findings 1 and 2. a. above.
* There was no documentation that reflected an initial investigation was completed within 72 hours of receipt of the incident notification that included a determination of whether further information or facts were needed as reflected in the training document in finding 2. a. above. Although the documentation reflected the file was closed, due to the lack of a thorough investigation, it was unclear if or when the investigation was completed.

There was no further investigation or follow up actions.

8. Review of incident/event documentation regarding Patient 37 reflected that on 08/18/2020 at 1717 in the Hemodialysis Unit "...Warm water (37C degrees) detected in RO machine approximately 2 minutes into Hemodialysis treatment. Water had been noted at 24C degrees upon pre-treatment checks approximately 15 minutes earlier. HD machine was put into bypass...while HD RN assessed the water temperature problem...numerous attempts to obtain cold water from the two blended water sources in the room. The shower was the original water source and was 36-37C at the coldest handle setting. The sink was not able to be accessed as no adaptor size was found. The universal adaptor would not work on the sink per the sinks (sic) fixture size, position and shape. There was no guarantee the sink would have been a suitable source, even if accessed, as it is also a blended and not a dedicated water source...[physician] notified and plans to dialyze pt. tomorrow...This situation has been communicated to [physician], the HD RN manager, the MACU Charge RN and the pt..." The incident/event was categorized as "Near Miss/Good Catch."
* The "Follow-up Actions" dated 08/19/2020 at 0752 reflected the incident was reviewed by the AM," the "Follow-up Notes" section was blank, and the "Attachments" section reflected "No Attachment."
* The "Follow-up Actions" dated 08/19/2020 at 0754 documented by the Manager reflected only "changed primary to dialysis added facilities as secondary." The "Attachments" section reflected "No Attachment."
* The "Follow-up Actions" dated 08/19/2020 at 1150 reflected the incident was reviewed by the Director, the "Follow-up Notes" section was blank, and the "Attachments" section reflected "No Attachment."
* The "Follow-up Actions" dated 08/20/2020 at 0912 reflected the incident was reviewed by the Manager, the "Follow-up Notes" section was blank, and the "Attachments" section reflected "No Attachment."
* The "Follow-up Actions" dated 08/24/2020 at 0710 reflected the incident was reviewed by "[name and no title]," the "Follow-up Notes" section was blank, and the "Attachments" section reflected "No Attachment."
* The "Follow-up Notes" dated 09/08/2020 at 0756, 21 days after the incident documented by the Manager reflected only "Water meeting with