HospitalInspections.org

Based on medical record review, document review, and interview, in 1 (one) of 6 (six) patient incidents reviewed, the facility did not utilize its Quality Assessment and Performance Improvement program (QAPI) to assess and evaluate a corrective action related to a patient incident.

This failure places all patients at risk of adverse outcomes.

Findings include:

Review of the medical record for patient # 1 revealed that the patient was admitted to the hospital on 12/18/2022 for a stroke with left sided weakness. On 01/01/2023, the patient sustained a burn from hot soup.

Per interview with Staff A (Patient Representative) on 04/19/2023 at 2:09PM, the patient's sister complained on 01/09/2023, at 1:00PM, that the patient had spilled something hot on the patient's left leg.

The facility Policy and Procedure titled "Grievance Resolution policy", last reviewed 08/25/2022 instructs staff that "The Risk Management staff will enter Patient Grievances into the Patient Grievance Log ...", and "The Patient Relations Department shall investigate verbal complaints with support from local nursing leadership ..."

Review of hospital complaint and grievance log for 01/2023 through 02/2023 revealed no documented evidence of the patient's complaint.

The facility Policy and Procedure titled "Protocol for Rounding with Purpose on In-Patient Units", last reviewed 08/05/2021, instructs staff to "Assess the area and patient for safety concerns."

Per interview with Staff C (Nursing Supervisor) on 04/19/2023, at 10:41AM, the "Protocol for Rounding with Purpose" requires staff to round for patient safety concerns; for example, patients that need assistance while eating their meals.

The medical record lacked documented evidence that the post-stroke patient was assessed for the need for assistance with feeding.

The facility policy & procedure titled "Patient Occurrence and Reporting" last reviewed 11/17/2022, states "All incidents affecting patients ... are appropriately reported to Risk Management, for facilitating the investigation and implementing and monitoring the plan of corrective action ... with the assistance of the Department of Quality Management."

Review of hospital incident and accident log for 01/2023 through 02/2023 revealed no documentation that the patient burn incident was recorded in the log or reported to risk management.

Per the facility organization quality improvement plan dated 2022 -2023, the "department of risk and quality management are required to discuss quality issues including but not limited to patient safety".

Review of the facility QAPI minutes from 01/2023 to 2/2023 showed no documented evidence that the patient's burn injury was reviewed through the QAPI process.

Per interview on 04/20/2023 at 11:59 AM, Staff D, Director of Quality Management acknowledged these findings.

The facility QAPI improvement plan lacks specific instructions to include the review of patient complaints, grievance, or incidents.

Based on document review, medical record review, and interview, in 1 (one) of 6 (six) patient incidents reviewed, nursing staff did not ensure that a patient incident was reported to the supervisor in accordance with facility policy.

This failure may impact the quality of patient care.

Findings include:

Review of the medical record for patient # 1 revealed that the patient was admitted to the hospital on 12/18/2022 for a stroke. On 01/01/2023, the patient spilled hot soup on themselves causing a burn.

Per wound management consult request on 01/01/2023 at 1:49PM, staff F (RN) observed a blister when turning the patient that day.

The Facility policy and procedure, (P&P) titled "Patient Occurrence and Reporting", last reviewed 11/17/2022, instructs any staff member who becomes aware of an occurrence by observation, participation or report is required to notify the appropriate supervisory personnel, e.g., Nurse Manager, Supervisor, or Chair.

The policy also states that the staff member will initiate a report in Risk Module and will ensure the event is documented in the involved patient's medical record as well.

The medical record lacked documented evidence of the report of the incident in the Risk Module or to the nursing supervisor.

Per interview with staff F (RN) on 04/20/2023, at 1:52 PM, the nurse did not notify the supervisor and did not initiate a report in the Risk Module.