HospitalInspections.org

Based on review of medical record #1, Unusual Occurrence Reports, policy and procedures and interview, it was determined the facility failed to collect and analyze data to ensure patient safety. The failed practice had the potential to affect all patients admitted to the facility. Findings follow:
1) Review of the nursing notes and physician progress notes in medical record #1 revealed the patient suffered a fall on July 13, 2009.
2) Review of the Unusual Occurrence Reports for July and August 2009 revealed there was no evidence an Unusual Occurrence Report had been completed for the patient's fall on July 13, 2009.
3) There was no evidence a report had been completed to initiate an investigation of the patient's fall on July 13, 2009. Policy and Procedure #1.24 stated a report should be completed for patient and visitor falls.
4) Interview with the Chief Quality Officer at 1315 on 01/05/10 revealed he was not aware of an Unusual Occurrence Report involving this patient or of this patient's fall.
5) Interview with the Chief Nursing Officer at 1300 on 01/05/10 revealed she was not aware of an Unusual Occurrence Report involving this patient or of this patient's fall.