HospitalInspections.org

Based on document review and staff interview it was determined the Critical Access Hospital (CAH) failed to follow the policy for identifying and reporting risks for one (1) of one (1) issues reviewed which was identified by both internal and external processes. The CAH failed to complete a Risk Report and document analysis and follow-up per policy. This failure creates the potential for an adverse impact on the quality of care for all patients.

Findings include:

1. On 11/24/14 at 12 p.m. the Director of Clinical Services stated an occurrence (risk) report was completed regarding the circumstances of a transfer of patient #1. The Performance Improvement Director stated, at that time, that she was not aware of this occurrence.

2. On 11/24/14 at 1:20 p.m. the Vice President of Medical Affairs stated he was in the process of investigating an occurrence regarding the transfer of patient #1 which he received on 10/31/14. He stated he had not completed documentation of the follow-up as the investigation was not completed. He also stated the investigation was being completed following the policy/process for Risk Reporting.

3. On 11/25/14 at 9:30 a.m. the Chief Executive Officer (CEO) stated an occurrence (risk) report was completed regarding the circumstances of a transfer of patient #1. He also stated the hospital was contacted by an outside source with questions regarding the transfer of patient #1. He stated this issue was passed to the VP of Medical Affairs as an occurrence had already been completed and the circumstances were being investigated.

4. On 11/25/14 a request was made for the occurrence (risk) report. At 10:10 a.m. the Director of Clinical Services confirmed there was no occurrence report completed. She stated she was made aware of the 10/24/14 occurrence by the both the Extended Care Nurse Manager and Emergency Department Nurse Manager and she passed it along to the CEO.

5. The Policy "Risk Reporting, " revised 10/13, was provided for review. It states in part: "All Valley Health System personnel are expected to complete a Risk Report in order to notify the Risk Management Department of any occurrence, adverse event, medical error or near miss in a timely manner...In general, whoever notes the occurrence, adverse event, medical error or near miss should complete and submit the Risk Report...Authorized individuals should document analysis and follow-up of Risk Reports within 5 days of the receipt ...since timely notification is necessary for accurate summary/trend reports.