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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.12 Governing Body, was out of compliance.

A-0043: There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body.

Based on observations, interviews, and document review, the governing body failed to ensure patient care services were provided in a safe manner and in accordance with professional standards of practice. Specifically, the governing body failed to provide oversight in the following areas: patient rights and nursing services.

Findings include:

Facility policy:

The Staffing Guideline policy, originated on 4/24/14, read, the staffing coordinator will work collaboratively with nurse in charge prior to shift start and clinical manager/assistant nurse manager (ANM) to ensure unit/department is staffed to specific unit staffing plan. Under usual patient type and patient acuity, a -1/+1 to staffing plan is within acceptable staffing guidelines. The charge nurse should use the staffing plan for guidance and adjust based on clinical judgment of acuity. The policy was approved by the vice president of enterprise nursing excellence and the enterprise clinical policy coordinator on 1/23/23; however, there was no evidence showing the policy was approved by the facility's nurse staffing committee.

References:

The facility's Scope of Services read, Governance and Leadership: Leadership will be responsible for providing a framework for planning health care services provided by the organization based on the hospital's mission statement and for developing and implementing an effective planning process that allows for defining timely and clear goals. The planning process includes a collaborative assessment of our customers and community health needs, defining a strategic plan, developing operational plans, establishing and operating budgets, and monitoring compliance. Establishing resource allocation and policies, and ongoing evaluation of the implementation and success of the plans.

Leadership is responsible for establishing standards of care that all patients can expect, and which can be monitored through the hospital performance improvement and patient safety plan. The performance improvement and patient safety plan is approved by hospital leadership and the Board of Trustees and is designed to be able to prioritize areas for improvement and to adjust and re-prioritize in response to unexpected events. Additional responsibilities include: ensuring staffing and resources are available to appropriately meet the needs of the patients served and delivering care in a safe manner.

The Board of Trustees has the responsibility for activities related to performance improvement, patient care and safety, credentialing of the medical staff, financial oversight, and all other activities related to the delivery of safe and effective care.

The Chief Executive Officer (CEO) is responsible for operating the hospital according to the authority provided by the Board of Trustees (The Board). The CEO is responsible and accountable for the planning, organization, direction, coordination, and evaluation of the delivery of services at the facility.

According to the Standards for Hospitals and Health Facilities Chapter 4 - General Hospitals 6 CCR 1011-1 Chapter 4, Part 14.7 Nurse Staffing Plans, (A) Master Nurse Staffing Plan, (1) The nurse staffing committee shall annually develop and oversee a master nurse staffing plan for the hospital that: (c) Includes minimum staffing requirements for each inpatient unit and emergency department that are aligned with nationally recognized standards and guidelines; (e) Includes guidance and a process for reducing nurse-to-patient assignments to align with the demand based on patient acuity; (f) Is voted on and recommended by at least sixty (60) percent of the nurse staffing committee.

The staffing plans, which were identified by staff as the facility's staffing grids, were provided by the facility. The staffing plans listed the name of each unit at the facility, specified the variable patient census range for each unit and the specified number of registered nurses (RN) and certified nursing assistants (CNA) expected to be staffed and present on each unit according to the current patient census. The staffing plans specified the nurse-to-patient ratios according to the patient census and amount of nurses required. The staffing plans read, the unit charge nurse would make adjustments as needed based on clinical judgment of acuity.

1. The Governing Body failed to ensure patients were provided care in a safe environment.

A. A review of medical records from Facility A (separately licensed facility certified under Facility B) revealed a lack of monitoring of patients and notifying providers of changes in condition, resulting in an adverse patient outcome. (Cross-reference A-0286) For example:

i. Medical record review revealed, on 12/14/23 at 11:42 a.m., Patient #2 was admitted to 6W (medical-surgical unit) with a diagnosis of sepsis (life-threatening response to an infection) and acute hypoxic respiratory failure (inadequate oxygen to the body). At 12:51 p.m., Patient #2's provider placed an order which read, keep oxygen saturation (o2 sat) above 90 percent (%), and notify the provider if the patient experienced a change in oxygen flow rate of 4 liters per minute (lpm) or more in 6 hours, required high flow mask to maintain o2 sat level, and or the patient's o2 sat was less than 90% on 6 lpm.

According to the history and physical (H&P) notes entered by Physician #1 at 1:45 p.m., Physician #1 documented Patient #2 did not normally require oxygen supplementation, however, upon admission Patient #2 required 4 liters (L) of supplemental oxygen to be delivered by nasal cannula to maintain an o2 sat of 91%.

i. A review of the Full Disclosure (the cardiac and pulse oximetry record) for Patient #2 revealed on 12/14/23 at 11:32 p.m. Patient #2's o2 sat level was 64%. Five minutes later at 11:37 p.m., Patient #2's o2 sat level was 38% and at 11:49 p.m. Patient #2's o2 sat was 39%. There was no evidence RN #2 was notified Patient #2's o2 sat had dropped below 90% between 11:37 p.m. to 11:49 p.m. Further review of the Full Disclosure revealed RN #2 was not notified Patient #2's pulse ox probe was off and no o2 sat readings were recorded for one hour and 31 minutes, from 12:00 a.m. to 1:31 a.m.

Upon review of the discharge summary note signed by Provider #1 on 12/15/23 at 7:50 a.m., a code blue (a code used to indicate a patient requiring resuscitation) was initiated for Patient #2 on 12/15/23 at approximately 1:35 a.m. According to the discharge summary note, the code blue was initiated after RN #2 had received a call from telemetry, entered Patient #2's room, and identified Patient #2 was unresponsive, pulseless, and not breathing. Provider #1 documented life-saving interventions had been attempted however Patient #2 remained pulseless during the entire course of the code blue. The discharge summary note revealed Patient #2's time of death was 1:54 a.m. on 12/15/23.

There was no evidence of telemetry tech communications in Patient #2's medical record from 12/14/23 at 10:18 p.m. through 12/15/23 at 1:30 a.m. and there was no evidence the telemetry tech had attempted to notify RN #2 or had escalated communication to the Charge RN regarding Patient #2's o2 sat being below 90% and or Patient #2's pulse ox probe had been off.

This was in contrast to the Cardiac and Pulse Oximetry Monitoring Appendix A and the High-Risk Clinical Alarm Safety policy (see above) which stated telemetry techs would notify the primary RN or the inpatient unit Charge RN when the patient's pulse ox levels were less than or equal to 80% and when pulse ox probes were off or not reading. In addition, alarm systems were intended to alert healthcare providers of potential problems and if not properly addressed and managed, could compromise the patient's safety.

B. Observations and document review revealed similar failures of a lack of continuous monitoring as identified in the review of Patient #2's medical record.

i. On 12/28/23 between 5:50 a.m. and 6:52 a.m., observations were conducted in the telemetry monitoring room. Observations revealed Patient #5's o2 sat was not monitored as required per provider orders. During the observation, telemetry staff called the primary RN for Patient #5 at 6:10 a.m. and 6:18 a.m. and informed the primary RN that Patient #5's o2 sat was not visible on the telemetry monitor screen and was not being monitored. At 6:21 a.m. Patient #5's o2 sat level returned on the telemetry monitor screen.

a. Review of Patient #5's Full Disclosure revealed on 12/28/23 from 5:51 a.m. to 6:21 a.m. (30 minutes), Patient #5's o2 sat level was not detected and monitored. The Telemetry Tech had not identified Patient #5's o2 sat level was not visible on the monitor for 19 minutes before calling the patient's nurse.

C. Interviews revealed staff were aware of the continuing concerns regarding the monitoring of patients, however, additional measures had not been implemented to mitigate the concern.

i. On 12/28/23 at 6:30 a.m., an interview was conducted with Telemetry Tech #5. Telemetry Tech #5 stated Telemetry techs were required to perform multiple activities while also continuously monitoring patients. Telemetry Tech #5 stated lapses in continuous monitoring could occur when telemetry techs were required to continuously monitor up to 60 patients. Telemetry tech #5 stated irregular heart rhythms, disconnection of the pulse ox cord, declining o2 sats, and even death could occur when telemetry techs were unable to continuously monitor patients. Telemetry Tech #5 stated on 12/27/23 they had monitored 54 patients at the same time. Telemetry Tech #5 also stated the number of patients monitored by the tech increased when they monitored their stations and another telemetry station during breaks and meals.

ii. On 1/11/24 at 1:46 p.m., an interview was conducted with chief medical officer (CMO) #35. CMO #35 stated they were responsible for overseeing quality at both Facility A and B as well as oversight of the medical staff and care provided. CMO #35 further explained they had only been at the facility for a few weeks so could not speak to how the facility had been operating prior to his arrival. CMO #35 stated they would take any concerns to the Board to ensure they were aware of the concerns and what was being done to correct the concern.

iii. On 1/11/24 at 1:04 p.m., an interview was conducted with chief executive officer (CEO) #30. CEO #30 stated they oversaw the operations at Facility A. CEO #30 stated the Board had responsibility for the quality of care provided at the facility. CEO #30 explained the Board was made aware of concerns at the facility and ensured staff had the resources they needed to provide care to patients.

This was in contrast to a review of staffing schedules for Facility A which revealed the facility was consistently understaffed according to their nurse staffing plan.

iv. On 1/11/24 at 11:42 a.m., an interview was conducted with CEO #31. CEO #31 stated they oversaw the operations at Facility B. CEO #31 explained if there was a safety concern, the CMO would notify them. They further explained the quality committee would also provide a report to the Board on serious safety events.

Interviews were in contrast to the review of Board meeting for Facility A and Facility B on 11/2/23 which revealed the Board was aware of the lack of continuous monitoring concern when initially identified, however, there was no evidence of the Board's action while the concerns continued to occur.

2. The Governing Body failed to ensure nursing services were provided according to facility policies and procedures and failed to ensure there was an adequate amount of nursing staff to provide safe patient care.

A. A review of medical records and corresponding staff assignment sheets for Facility A revealed inadequate staffing based on the facility's staffing plan.

i. On 12/14/23 at 11:42 a.m., Patient #2 was admitted to 6W (medical-surgical unit) with a diagnosis of sepsis (life-threatening response to an infection) and acute hypoxic respiratory failure (inadequate oxygen to the body). At 12:51 p.m., Patient #2's provider placed an order which read, keep oxygen saturation (o2 sat) above 90 percent (%), and notify the provider if the patient experienced a change in oxygen flow rate of 4 liters per minute (lpm) or more in 6 hours, required high flow mask to maintain o2 sat level, and or the patient's o2 sat was less than 90% on 6 lpm. A review of the Full Disclosure (the cardiac and pulse oximetry record) for Patient #2 revealed on 12/14/23 at 11:32 p.m. Patient #2's o2 sat level was 64%. Five minutes later at 11:37 p.m., Patient #2's o2 sat level was 38% and at 11:49 p.m. Patient #2's o2 sat was 39%. There was no evidence RN #2 was notified Patient #2's o2 sat had dropped below 90% between 11:37 p.m. to 11:49 p.m. Further review of the Full Disclosure revealed RN #2 was not notified Patient #2's pulse ox probe was off and no o2 sat readings were recorded for one hour and 31 minutes, from 12:00 a.m. to 1:31 a.m.

Upon review of the discharge summary note signed by Provider #1 on 12/15/23 at 7:50 a.m., a code blue (a code used to indicate a patient requiring resuscitation) was initiated for Patient #2 on 12/15/23 at approximately 1:35 a.m. According to the discharge summary note, the code blue was initiated after RN #2 had received a call from telemetry, entered Patient #2's room, and identified Patient #2 was unresponsive, pulseless, and not breathing. Provider #1 documented life-saving interventions had been attempted however Patient #2 remained pulseless during the entire course of the code blue. The discharge summary note revealed Patient #2's time of death was 1:54 a.m. on 12/15/23.

a. A review of 6W (medical-surgical unit) staffing assignments revealed, on 12/14/23, the 6W staffing did not meet the 6W staffing plan. The Plan read the ratio of nurse to patients based on the census at that time was to be 1 nurse for 4 patients. Further review revealed Registered nurse (RN) #2 who provided care to Patient #2, was assigned five patients at this time.

ii. A review of four additional medical records and corresponding staff assignment sheets revealed similar findings for patients on 6W and other units throughout the facility (Patient #1, #9, #10, and #12).

B. Interviews with staff from Facility A revealed the leadership and the governing board had not implemented actions to ensure the approved staffing plan was met in order to provide safe patient care.

i. On 1/8/24 at 1:43 p.m., an interview was conducted with staffing committee RN #12. RN #12 stated -1/+1 referred to the ability to adjust nursing staff based on acuity. RN #12 stated when the units had high acuity, nurses could ask for extra personnel. RN #12 also stated when acuity changed during the shift, units did not receive extra nurses.

ii. On 1/8/24 at 4:28 p.m., an interview was conducted with house supervisor (Supervisor) #9. Supervisor #9 stated they were not aware of the -1/+1 to staffing plan referenced in the Staffing Guideline policy. Supervisor #9 stated the staffing guidelines were created by staff in finance and were based on productivity. Supervisor #9 also stated the RN ratios were never met if the charge nurse did not take patients. Supervisor #9 stated it was expected for nurses on 6W to have six patients each and it was never a four-patient ratio on the night shift.

Additionally, Supervisor #9 stated patients did not receive the attention and care they required when nurses had five or six patients each. Supervisor #9 stated nurses did not have time to fully assess their patients or to review the patients' records which could result in changes being missed.

iii. On 1/11/24 at 10:06 a.m., an interview was conducted with vice president of nursing operations (VP) #11. VP #11 stated the allotted number of nursing staff hours for each shift was determined by finance staff and depended on the patient demographic for the unit. VP #11 stated the unit staffing plans were based on the facility's budget. VP #11 also stated the auditing process for the staffing plan effectiveness was based on how many times the units had enough nurses based on the units' staffing plans and how often the units utilized the -1/+1 addition or subtraction referenced in the Staffing Guideline policy.

iv. On 1/11/24 at 1:04 p.m., an interview was conducted with CEO #30. CEO #30 stated they oversaw the operations at Facility A. CEO #30 explained the Board was made aware of concerns at the facility and ensured staff had the resources they needed to provide care to patients. CEO #30 stated they looked at daily staffing reports to see the amount of staff that worked in comparison to the amount of patients that were on each unit.

C. A review of staff assignment sheets for Facility B revealed inadequate staffing based on the facility's staffing plan.

i. A review of the Critical Care Unit's (CCU)staff assignment sheets revealed numerous instances where CCU RNs were routinely assigned three patients. For example:

a. On 11/19/23 seven nurses were assigned three patients each.

b. On 11/26/23 twelve nurses were assigned three patients each.

c. Additional shifts reviewed throughout the months of December and January revealed similar findings of nurses being assigned three patients each.

These examples were in contrast to the CCU FY23 Staffing Plan which read, CCU nurses should be assigned to provide nursing care for one to two patients.

ii. A review of the Renal/Diabetic Unit (5W) staff assignment sheets revealed RNs were assigned to care for patients on the 5W unit in addition to patients on other units who needed to receive continuous ambulatory peritoneal dialysis (CAPD).

D. Interviews with staff from Facility B revealed the leadership and the governing board had not implemented actions to ensure the approved staffing plan was met in order to provide safe patient care.

i. On 1/11/24 at 11:42 a.m., an interview was conducted with CEO #31. CEO #31 stated they oversaw the operations at Facility B. CEO #31 stated the facility tried to avoid ICU nurses having more than two patients assigned to care for, however, this could not always be avoided.

Interviews with leadership and review of staff assignment sheets were in contrast to the Standards for Hospitals and Health Facilities Chapter 4 - General Hospitals 6 CCR 1011-1 Chapter 4, Part 14.7 Nurse Staffing Plans, (A) Master Nurse Staffing Plan, which read, the plan included guidance and a process for reducing nurse-to-patient assignments to align with the demand based on patient acuity.

The facility failed to provide evidence the master staffing plan considered individual patient acuity as in accordance with Code of Colorado Regulations (CCR) 1011-1 Chapter Four regulations.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.21 QAPI was out of compliance.

A-0286: PATIENT SAFETY (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities. The hospital's governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. Based on interviews and document reviews, the facility failed to ensure adverse patient safety events were reported, investigated, and analyzed to identify contributing factors and implement preventive actions to prevent recurrence.

A-0315: (e)(4) PROVIDING ADEQUATE RESOURCES
[The hospital's governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following:] (4) That adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital's performance and reducing risk to patients. Based on interviews and document review, the facility failed to ensure adequate resources were allocated to operate a quality assurance and performance improvement (QAPI) program which analyzed underlying causes of adverse patient events and developed performance improvement plans to reduce risk to patients.

Based on interviews and document reviews, the facility failed to ensure adverse patient safety events were reported, investigated, and analyzed to identify contributing factors and implement preventive actions to prevent recurrence. (Cross-reference A-0043)

Findings include:

Facility policy:

The Adverse Clinical Event Reporting, Analysis, Disclosure and Non-Payment policy requires a rapid response team for event investigations, initiated within 72 hours of event awareness and completed within 45 days.
Reference:

The Clinical Quality Assurance, Patient Safety, and Process Improvement Plan FY2024 (QAPI) mandates oversight responsibilities for ensuring quality care.

1. The facility failed to adhere to patient safety protocols, policy and practice, and ensure leadership's oversight, to prevent further occurrences of patient safety events.

A. Review of reporting and investigating adverse events revealed:

i. Patient #13 Incident (9/27/23): Patient #13 was admitted at 2:17 a.m. for alcohol withdrawal. Provider #16 ordered continuous telemetry monitoring at 3:54 a.m. for 48 hours. RN #17 noted the absence of available telemetry boxes. At 11:28 a.m., the patient was found unresponsive and pulseless, leading to a code blue at 12:10 p.m. and subsequent death. The RCA, conducted on 11/30/23, failed to address the non-notification of Provider #16 regarding the unavailability of telemetry monitoring.

ii. Patient #9 Incident (9/30/23): Admitted at 1:00 p.m. with pneumonia and other complications. Provider orders specified notification for specific oxygen saturation levels. Records from 10/5/23 showed Patient #9's oxygen saturation dropped below the required threshold with no provider notification. Patient #9's condition worsened, resulting in death on 10/6/23. No safety event report was filed.

iii. Patient #1 Incident (11/28/23): Admitted at 1:59 p.m. with congestive heart failure. On 11/29/23, telemetry indicated ventricular tachycardia. The nurse failed to notify the provider of this critical change, leading to the patient's cardiac arrest and subsequent death.

iv. Patient #6 Incident (11/29/23): Admitted at 6:19 p.m. with general weakness and encephalopathy. An IV morphine order was placed, to be administered only if oral medication was not an option. RN #21 administered IV morphine without verifying the patient's ability to take oral medication. The patient's condition deteriorated, leading to cardiac arrest and death.

B. Leadership interviews revealed a lack of compliance with facility policy and preventative action implementation:

i. Interview with Interim Quality Director (1/10/24): The director admitted to not being involved in the review or investigation of adverse patient safety events since their appointment in September 2023. This lack of oversight contributed to the continued pattern of non-compliance.

ii. Interview with Patient Safety Program Manager (1/10/24): The manager confirmed the absence of event reporting for Patients #1 and #9. They acknowledged that no interventions were implemented following the investigation into Patient #6's event. They expressed concern that more thorough investigations could have prevented subsequent incidents, such as that of Patient #2 on 12/14/23. (Cross-reference A-0043)

Based on interviews and document review, the facility failed to ensure adequate resources were allocated to operate a quality assurance and performance improvement (QAPI) program which analyzed underlying causes of adverse patient events and developed performance improvement plans to reduce risk to patients. (Cross-reference A-0043 and A-0286).

Findings include:

Facility references:

The facility's Community Board Bylaws read, the Board holds the facility's CEO and leadership accountable for quality safety and patient experience scores. Additionally, the Board is to be aware of risks and hold leadership accountable for taking all reasonable steps to avoid patient harm. The Board will review the facility's quality indicators and safety metrics and develop a plan to promote and report quality of patient care.

The Clinical Quality Assurance, Patient Safety and Process Improvement Plan read, the services Community Board maintains the following QAPI oversight responsibilities: assuring adequate resources to support the plan; approving key indicators for measuring clinical quality, patient experience and patient safety; and reviewing and making recommendations on any other matter pertaining to the quality of care and patient safety.

The facility's Scope of Services read, Governance and Leadership: Leadership will be responsible for providing a framework for planning health care services provided by the organization based on the hospital's mission statement and for developing and implementing an effective planning process that allows for defining timely and clear goals. The planning process includes a collaborative assessment of our customers and community health needs, defining a strategic plan, developing operational plans, establishing and operating budgets, and monitoring compliance. Establishing resource allocation and policies, and ongoing evaluation of the implementation and success of the plans.

Leadership is responsible for establishing standards of care that all patients can expect, and which can be monitored through the hospital performance improvement and patient safety plan. The performance improvement and patient safety plan is approved by hospital leadership and the Board of Trustees and is designed to be able to prioritize areas for improvement and to adjust and re-prioritize in response to unexpected events. Additional responsibilities include: ensuring staffing and resources are available to appropriately meet the needs of the patients served and delivering care in a safe manner.

The Board of Trustees has the responsibility for activities related to performance improvement, patient care, and safety, credentialing of the medical staff, financial oversight, and all other activities related to the delivery of safe and effective care.

The chief executive officer (CEO) is responsible for operating the hospital according to the authority provided by the board of trustees (The Board). The CEO is responsible and accountable for the planning, organization, direction, coordination, and evaluation of the delivery of services at the facility.

1. The facility's governing body failed to ensure the QAPI program had adequate resources to conduct its duties.

a. Patient incidents/safety events were reviewed (Cross-reference A-0286). There was insufficient evidence to show that incidents/safety events were investigated to determine contributing factors and to prevent recurrent incidents/safety events. For example:

i. Medical record review revealed on 9/27/23 at 2:17 a.m., Patient #13 was directly admitted to inpatient unit 6W (medical-surgical unit) for alcohol withdrawal. Patient #13's medical record revealed at 11:28 a.m., approximately seven hours and three minutes after Patient #13 had been admitted to the facility, the patient was unresponsive and pulseless. The Discharge Summary signed by Provider #16 on 10/1/23 at 7:51 a.m. revealed a code blue (a code used to indicate a patient requiring resuscitation) was initiated on 9/27/23 at 12:10 p.m., and the patient subsequently died.

On 11/30/23, over two months after the patient's event occurred, the facility completed a root cause analysis (RCA) in response to Patient #13's adverse safety event. However, the RCA revealed no evidence the facility addressed the lack of provider notification for changes in patient condition and provider orders not being followed as written.

b. During a survey conducted from 12/26/23 to 1/11/24, continued non-compliance of patients not being continuously monitored and providers not being notified of changes in condition resulting in negative patient outcomes were identified between the date of Patient #13's adverse event on 9/27/23 and when the RCA was completed on 11/30/23. (Cross-reference A-0043 and A-0263)

c. Interviews with staff revealed there were not adequate resources and staff to complete incident investigations, analyze underlying causes, and develop corrective action plans or performance improvement activities.

i. On 1/10/24 at 8:36 a.m., an interview was conducted with Patient Safety Program Manager (Manager) #22. Manager #22 stated another patient safety manager assisted in training her on how to investigate patient safety events. Manager #22 explained the facility did not have a succinct process to track and trend incident reports. They further explained a tracking sheet had been developed but was not implemented at the time of the interview. Manager #22 stated they felt they did not have adequate resources to investigate events and implement preventative measures. Manager #22 stated staff who investigated incident reports were not able to meet the expectations of the facility to investigate all patient events. Manager #22 explained the patient safety program requested additional resources from leadership to assist with investigating patient events, however, they were only provided additional education on the investigation process. Manager #22 stated there was a potential for a patient event to continue happening if uninvestigated, causing a potential risk of harm to patients.

This was in contrast to the Clinical Quality Assurance, Patient Safety and Process Improvement Plan which read, the Board was responsible for assuring adequate resources to support the plan and reviewing and making recommendations on any other matter pertaining to the quality of care and patient safety.