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Based on interview and patient records and policy and procedure review, it was determined that the hospital failed to design, implement, monitor and evaluate a mechanism for practitioners and staff to report adverse patient events and/or unusual occurrences and to establish and maintain a safe environment for patients and staff members.

Findings:

On 06/30/2014, during a complaint investigation, the hospital quality management team was given a list of 5 patients selected for medical record review. The surveyors also requested; "Grievance logs/records and any internal investigations involving patients selected for the review sample." The hospital quality management team reviewed the hospital's complaint and grievance tracking system and determined that, of the five patients selected, none of the patients had a complaint or grievance associated with their care at the facility. During their review of the selected patient records, prior to providing them to the surveyors, they noted that one patient's primary care physician had written a note in EPIC that indicated suspected elder abuse. The Quality Manager stated "We did not know about any of this until we reviewed the five patient records that you listed, so we do not have anything started on this yet."


On 06/30/2014, during review of policy and procedure titled: Providence Health & Services General Operating Policy No. 255.00, last reviewed October 2011, Subject: Unusual Occurrence Reporting this policy stipulated the following: Under IV. Procedure: "A. When an unusual occurrence is discovered, the individual involved in the event and/or the individual discovering the event will complete an Unusual Occurrence Report as soon as possible so that the details will not be forgotten. It is expected that anytime an event of serious consequences occurs, the person who becomes aware of the event will notify their supervisor/manager immediately to provide assistance and take actions, if appropriate. The supervisor/manager should contact Quality Management as soon as possible. Action will be taken as appropriate to reduce any immediate danger to patients, visitors, or staff."

On 07/01/2014 at 1000, during the exit conference with the quality management team and the senior rehab manager present, the note discovered in EPIC written by the patient's PCP was discussed. This form of notification was available, in the chart for anyone with access to patient charts to discover, including the accused. In addition, this notification did not alert management that an issue had been discovered and did not initiate an investigation in order to protect patients and/or the employee.