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Based on record review, policy review, and interview, it was determined, the facility failed to identify and implement facility wide corrective action to minimize the risk of reoccurrence for one adverse event involving Patient #1.

The findings included:

Review of the facility adverse events revealed one entry related to Patient #1 dated 12/22/21.
Clinical record and administrative document reviews conducted on 01/18/22 and 01/19/22 disclosed Patient #1 experienced delay in care while in the intensive care setting.

The facility completed an investigation and a root cause analysis identifying issues with the new monitoring system in the intensive care setting as a primary factor leading to the event and implemented corrective action.

The corrective action implemented by the facility failed to address the process failure as a systemic problem, at a hospital wide level. The scope of the corrective plan did not address future implementation of new products or equipment, specifically addressing needs of staff competency prior to live implementation and failed to ensure that quality administrative officials are responsible and accountable for ensuring clear expectations for safety prior to new products or equipment implementation.

Interview with The Administrator Director of Clinical Quality Improvement (ADCQI), The Director of Patient Safety (DPS) and The Infection Prevention Manager conducted on 01/19/21 at approximately 10:58 AM revealed the ADCQI participated in the root cause analysis of the incident involving Patient #1 and stated the quality and patient safety team did not participate in the training for the new monitoring system in the intensive care setting. The director of the intensive care unit, the plant operations manager and the intensive care nurses participated in the training provided by the vendor representative. The ADCQI was asked to clarify the facility process and policies and procedures when purchasing and installing new products or services, the timeline for installation of the monitors and the content of the training,

Subsequent interview with The ADCQI on 01/19/22 at approximately 1:15 PM revealed the facility does not have a policy addressing the acquisition or implementation of new products. The process is the materials and plant operations discuss the process daily during the safety huddles. The safety huddles include all the leaders and so far the process has been successful.

On 01/21/22, The Director of Patient Safety provided policy titled "Medical Equipment User Training" last reviewed on 08/19. The policy documents Purpose: To assure that medical equipment operators have the competency skills to operate medical devices safely. New equipment progress reports will be given by the responsible leader monthly to Quality Improvement Patient Safety Committee (QIPSC) and Environment of Care (EOC). These committees will ensure that progress is being made and barriers or issues are resolved timely."

Based on the review, the corrective action implemented by the facility would not prevent a similar incident from occurring in another setting, unit, department in the facility. The scope of the corrective action was limited to the intensive care setting and did not address educational needs and competencies for future equipment or product upgrades.

Quality Improvement Plan dated 11/2021 documents "Quality Improvement, Patient Safety Committee (QIPSC)".
The QIPSC oversees and coordinates all quality improvement and patient safety activities within the organization. This committee is responsible for evaluating, prioritizing and supporting performance improvement opportunities."