HospitalInspections.org

Based on interview and record reviews, the hospital's Quality Assurance Program failed to assure that 1 applicable event report regarding patient care services was evaluated effectively and that corrective actions were taken. Findings include:

Per interviews conducted with hospital staff on 11/8/10 and 11/9/10 and review of facility documentation related to a patient complaint, the Quality Assurance Program failed to assure that all necessary corrective actions were implemented after a patient event. Patient #1 experienced a fall on 8/21/10 at 4:50 PM after being left unattended by nursing staff in the bathroom. During interview on 1/9/10 at 12:30 PM, the Nurse Manager confirmed that the incident report was incompletely filled out and failed to note that the care plan was not implemented by the Licensed Nursing Assistant (LNA) providing assistance to the patient. The physician had written an order at 12:20 PM on 8/21/10 that stated "fall risk, get OOB (out of bed) with supervision only". The LNA left the patient unattended in the bathroom contrary to the physician's order and the nursing care plan. In addition, not all potential witnesses or on duty nursing staff and family members were interviewed to determine all of the facts related to the fall. During interview on 11/9/10 at 2 PM, the Director of Quality Assurance (QA) confirmed that he/she had not noted the incomplete event report. The lack of documentation of all corrective actions taken related to the event was also confirmed at that time with the Vice President of Hospital Services, the QA Director and the Medical Surgical Nurse Manager.

Based on interviews and record review, the hospital failed to assure that the Quality Assurance Program completed necessary documentation for accurate analysis of a patient event. Findings include:

Per interview on 11/9/10 at 12:30 PM, the Nurse Manager of the Medical Surgical Unit verified that he/she had incompletely documented an event report dated 8/21/10 regarding a patient fall. The patient experienced a fall after being left unattended in the bathroom by the Licensed Nursing Assistant (LNA) on 8/21/10. The care plan stated to supervise the patient while OOB (out of bed) and the failure to do this was not documented on the report. Additionally, the re-education provided to the LNA was not included on the report although the Nurse Manager verified that this was done. Incomplete review of an adverse patient event could lead to inaccurate analysis of trends for Quality purposes.