The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

GEORGIA REGIONAL HOSPITAL ATLANTA 3073 PANTHERSVILLE ROAD DECATUR, GA Sept. 1, 2015
VIOLATION: GOVERNING BODY Tag No: A0043
Based on review of medical records, facility advertising, employee files, observation, and staff interview, the Governing Body failed to provide for the protection of patients' under their rights.

Cross refer to COP A-0115 as it relates to failure of the governing body to provide for the protection of patients under their rights.

Cross refer to COP A-0263 as it relates to failure of the governing body to ensure that unexpected patient incidents and/or complaints were documented, investigated, monitored and tracked to ensure quality and safety of patient care.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of medical records, facility advertising, employee files, observation, and interview the facility failed to provide for the protection of patients under their rights.

Cross Refer: A-0118 as it relates to failure of the facility to provide timely action or resolution of a complaint in one (1) of ten (10) patients whose records were reviewed.

Cross refer to A-O142 as it relates to failure of the facility to provide for the safety of the patients on Unit 5 (the men's unit).

Cross Refer to A-0144 as it relates to failure of the facility to ensure that care was provided in a safe environment.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on medical record review, policy review, public website review and interviews, the facility failed to provide timely action or resolution of a complaint in one (1) of ten (10) patients whose records were reviewed. This increased the risk of potential harm to at least one patient- patient #5.

Findings include:

Nursing notes dated 7/24/15, signed by a Registered Nurse (RN # 10), documented that he / she took a phone call from unspecified law enforcement at 5:50 a.m. Law enforcement stated that they had received several calls from a patient (identified as patient #5) reporting that an employee (identified as employee #5) had been in the patient's room making sexual advances towards him/her. No further mention of the incident was found in the chart. Unexpected event report on 8/31/15 at 10:30 a.m. was filled out at by Acting Nurse Executive.

A review of the unexpected event reports for the months of July and August 2015 failed to identify documentation of the above incident or of the allegations mentioned in the nursing notes dated 7/24/15.

During the entrance interview at 9:15 a.m. in the small conference room with the facility's Clinical Medical Director (Clinical MD Director- employee #8), Acting Nursing Executive (employee #26) and Quality Assessment and Performance Improvement (QAPI) staff (employee #27), surveyors were informed that because of construction occuring on Unit 5, the male and female patients were combined together on Unit 4 from 8:00 am to 5:00 pm, then the male patients went back to Unit 5 for evening care and to sleep.

During an interview at 2:20 pm on 9/1/15, the Nurse Manager (employee #12) reported that during a Treatment Team Conference on 8/13/15, the Treatment Team Facilitator pulled out a note dated 7/24/15 which documented that law enforcement had called the Central Unit nurses station at 5:50 am, and reported that a patient (identified as patient #5) had called 911 to report that an employee came in to his/her room making sexual advances. He/she stated that he/she had informed the accused employee (Health Service Technician- employee #5) of the allegations, but that no documentation was completed. Employee #5 was moved to the other side of the unit; however, because of construction in the unit, the employee still had access to the patient because both sexes were combined during certain times of the day.

The staffing schedule for the two weeks prior to 8/28/15 was reviewed and revealed that although employee #5 had been moved to the unit adjacent to the patient's unit, employee #5 continued to have access to the patient when the units were combined. The staffing schedule documented that employee #5 worked the 3:00 pm to 11:00 pm and was on duty with direct access to the patient from 3:00 pm to 5:00 pm on 8/18/15, 8/19/15, 8/20/15, 8/24/15, 8/26/15, and 8/28/15.

Policy # 0, last reviewed 7/23/15 and entitled Patients' Rights, 24-103 directed that the patient has the right to be free of mental, physical, sexual or verbal abuse and free of neglect or exploitation. An exhibit attached to this policy entitled, Rules and Regulations Chapter 290-4-6.03 from the Department of Health Services/ Mental Health/ Developmental Disabilities, and Addictive Diseases, documented that the facility acknowledged that the patient has a right to be free of any abuse.

Policy 369, last reviewed 9/17/14 and entitled Incident Management in Adult Mental Health and Forensic Units, 03-515 proclaims in part that: .."failure by an employee to report an incident of suspected abuse, neglect, or exploitation or to cooperate in an investigation of an incident or failure to intervene, when reasonably possible, to prevent abuse, neglect or exploitation shall be grounds for personnel action up to and including termination of employment. Further directions are that incidents are reported to external agencies as appropriate and required by law..."

Review of the facility's public website revealed that patients' rights included:
a. Getting the care they need;
b. Prompt and confidential service;
c. Treated with respect & dignity;
d. Protecting their health & safety;
e. Knowing the benefits & risks of treatment;
f. Participating in planning their own treatment;
g. Being free of restraints or seclusion, except as a last resort for safety;
h. Being free of physical, sexual, or verbal abuse; and
i. Being free of neglect or exploration.

During an interview on 08/31/15 at 11:02 p.m. in the employee dining area of building 4, a registered nurse (RN- employee #1) related that when an accusation of sexual misconduct is made, security is notified along with the patient's physician(s). A report was to be started by the employee to whom the incident was first reported. The manager on duty was notified depending on when the accusation was made/received. When notified, the patient's medical doctor would make the decision about coming in to see the patient, and if sexual assault was suspected, decided whether the patient would be sent to a medical hospital for examination- forensic exams were not performed in this facility. The RN further related that his/her supervisor had recently said that a male staff had touched a patient inappropriately, and identified patient #5 on the list of requested employee files. The accused employee was eventually identified, via the incident report, as employee #5, and that employee #5 was switched to work on another unit, but later resigned.

During an interview in the Conference Room in Building 4 at 4:05 pm on 8/31/15, patient #5 revealed that he/she had been here about 8 months, and reported that he/she was unaware of the reason for admission. The patient acknowledged receipt of a booklet with patient rights. Patient reported that a staff member (identified employee #5) came into his/her room and hit him/her in the head. The patient also reported the following: [Employee #5] grabbed his/her arm and shook him/her, leaving "a big red mark on my arm". Reported [employee #5] works on the other side now (unit 5). He/she comes to work in a uniform sometimes, like a police. Patient #5 reported that a strong African American male/female (employee #5) put their privates close to mine- I did not like that at all. He/she reported [employee #5] to the registered nurse (employee #10), but he/she did nothing. Reports he/she tries to stay away from [employee #5]. While watching TV, [employee #5] brushed his/her pelvic area up against his/her side. Patient #5 reports [employee #5] is usually here at dinner time. [Employee #5] touches and massages all the nurse's shoulders. [Employee #5] slipped up behind me and grabbed my shoulders; says "I didn't like it." Patient #5 denied being sexually abused or raped here and reported, "If anyone touched me inappropriately, I would call 911 and tell the staff", but also related that "they will not help me, nothing was done when I reported [employee #5]".

Telephone interview at 11:00 a.m. on 9/1/15 with the Acting Nursing Executive Director confirmed that there was no other incident report initiated from 7/24/15 until he/she had initiated such a report with the help of the department manager on 8/31/15 at 10:30 a.m.

During an interview at 2:20 pm on 9/1/15, the Nurse Manager (employee #12) reported that during a Treatment Team Conference on 8/13/15, the Treatment Team Facilitator pulled out a note dated 7/24/15 which documented that law enforcement had called the Central Unit nurses station at 5:50 am, and reported that a patient (identified as patient #5) had called 911 to report that an employee came in to his/her room making sexual advances. The Nurse Manager reported that the staff member (identified as employee #10) had taken the call from the police department but that no internal report was initiated. The Nurse Manager further reported that he/she had not had time to complete a report for the quality assurance report to be started. He/she stated that he/she had informed the accused employee (Health Service Technician- employee #5) of the allegations, but no documentation was completed. The employee was moved to the other side of the unit; however, because of construction in the unit, the employee still had access to the patient because both sexes were combined during certain times of the day. The employee recently resigned- confirmed through review of the employee's resignation letter which documented that the employee's last date to work would be 8/30/15.

Review of employee records revealed documentation that both the accused employee (#5) and the employee taking the phone call from law enforcement on 7/27/15 (RN #10) had undergone Annual Incident Management training on 8/19/14 and 2/17/15 respectively. This training included the initiation of quality assessment reports.

During an interview on 9/1/15 at 2:45 pm in the Conference Room in building 4 with employees #13, #14, #15, #16, #17 and #18 collectively, the employees each denied seeing a naked patient using the telephone.

In the exit interview in the large conference room in the administration building at 4:40 p.m. The CEO admitted that they follow the policy for reporting such incidents even to the point of reporting the incident to the State. He / She admitted , however, that in this case, policy was not followed as the quality assessment report was not started as per policy.
VIOLATION: PATIENT RIGHTS: PRIVACY AND SAFETY Tag No: A0142
Based on observation, interview, and review of patient's rights on the facility website, the facility failed to provide for the safety of the patients on Unit 5 (the men's unit).

Findings include:

On 9/31/15 at 10:00 a.m. it was noted that there was paint puckering from the 'popcorn' ceiling in the day room on Unit 5. By standing in a chair a patient could have easily peeled off the paint and ingested it.

While the patients were not located there from 8:00 a.m. - 5:00 p.m., all males were relocated there after construction was over for the day, and remained there until 8:00 a.m. the next weekday.

Upon entering the unit, the Chief Medical Officer for this unit (interview #8) stated that the work had been in progress since June 2014. The Acting Nursing Executive (employee #26) stated that they only had so much money and were having to do with what they have.

The floor nurse on Unit 4 came over to Unit 5 to demonstrate the use of the emergency suction on the emergency cart. He/she could not turn on the suction for the first 15 seconds.

Review of the facility's public website revealed that patients' rights included:
a. Getting the care they need;
b. Prompt and confidential service;
c. Treated with respect & dignity;
d. Protecting their health & safety;
e. Knowing the benefits & risks of treatment;
f. Participating in planning their own treatment;
g. Being free of restraints or seclusion, except as a last resort for safety;
h. Being free of physical, sexual, or verbal abuse; and
i. Being free of neglect or exploration.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on review of facility quality reports, medical records, staff and patient interviews, facility tour and facility policy and website information, it was determined that the facility failed to ensure that care was provided in a safe environment.

Findings were:

During an interview in the Conference Room in Building 4 at 4:05 pm on 8/31/15, patient #5 revealed that he/she had been there about 8 months, and reported that he/she was unaware of the reason for admission. The patient acknowledged receipt of a booklet with patient rights. The patient reported that a staff member (identified employee #5) came into his/her room and hit him/her in the head. The patient also reported the following: [Employee #5] grabbed his/her arm and shook him/her, leaving "a big red mark on my arm". Reported [employee #5] works on the other side now (unit 5). He/she comes to work in a uniform sometimes, like a police. Patient #5 reported that a strong African American male/female (employee #5) put their privates close to mine- I did not like that at all. He/she reported [employee #5] to the registered nurse (employee #10), but he/she did nothing. Reports he/she tries to stay away from [employee #5]. While watching TV, [employee #5] brushed his/her pelvic area up against his/her side. Patient #5 reports [employee #5] is usually here at dinner time. [Employee #5] touches and massages all the nurse's shoulders. [Employee #5] slipped up behind me and grabbed my shoulders; says "I didn't like it." Patient #5 denied being sexually abused or raped here and reported, "If anyone touched me inappropriately, I would call 911 and tell the staff", but also related that "they will not help me, nothing was done when I reported [employee #5]".

Nursing notes dated 7/24/15, signed by a Registered Nurse (RN # 10), documented that he / she took a phone call from unspecified law enforcement at 5:50 a.m. Law enforcement stated that they had received several calls from a patient (identified as patient #5) reporting that an employee (identified as employee #5) had been in the patient's room making sexual advances towards him/her. No further mention of the incident was found in the chart.

During an interview at 2:20 pm on 9/1/15, the Nurse Manager (employee #12) reported that during a Treatment Team Conference on 8/13/15, the Treatment Team Facilitator pulled out a note dated 7/24/15 which documented that law enforcement had called the Central Unit nurses station at 5:50 am, and reported that a patient (identified as patient #5) had called 911 to report that an employee came in to his/her room making sexual advances. The Nurse Manager reported that the staff member (identified as employee #10) had taken the call from the police department but that no internal report was initiated. The Nurse Manager further reported that he/she had not had time to complete a report for the quality assurance report to be started. He/she stated that he/she had informed the accused employee (Health Service Technician- employee #5) of the allegations, but no documentation was completed. The employee was moved to the other side of the unit; however, because of construction in the unit, the employee still had access to the patient because both sexes were combined during certain times of the day. The employee recently resigned- confirmed through review of the employee's resignation letter which documented that the employee's last date to work would be 8/30/15.

During the entrance interview at 9:15 a.m. in the small conference room with the facility's Clinical Medical Director (Clinical MD Director- employee #8), Acting Nursing Executive (employee #26) and Quality Assessment and Performance Improvement (QAPI) staff (employee #27), surveyors were informed that because of construction occuring on Unit 5, the male and female patients were combined together on Unit 4 from 8:00 am to 5:00 pm, then the male patients went back to Unit 5 for evening care and to sleep.

The staffing schedule for the two weeks prior to 8/28/15 was reviewed and revealed that although employee #5 had been moved to the unit adjacent to the patient's unit, employee #5 continued to have access to the patient when the units were combined. The staffing schedule documented that employee #5 worked the 3:00 pm to 11:00 pm and was on duty with direct access to the patient from 3:00 pm to 5:00 pm on 8/18/15, 8/19/15, 8/20/15, 8/24/15, 8/26/15, and 8/28/15.

During an interview on 08/31/15 at 11:02 p.m. in the employee dining area of building 4, a registered nurse (RN- employee #1) related that when an accusation of sexual misconduct is made, security is notified along with the patient's physician(s). A report was to be started by the employee to whom the incident was first reported. The manager on duty was notified depending on when the accusation was made/received. When notified, the patient's medical doctor would make the decision about coming in to see the patient, and if sexual assault was suspected, decided whether the patient would be sent to a medical hospital for examination- forensic exams were not performed in this facility. The RN further related that his/her supervisor had recently said that a male staff had touched a patient inappropriately, and identified patient #5 on the list of requested employee files. The accused employee was eventually identified, via the incident report, as employee #5, and that employee #5 was switched to work on another unit, but later resigned.

A review of the unexpected event reports for the months of July and August 2015 failed to identify documentation of the above incident or of the allegations mentioned in the nursing notes dated 7/24/15.

Policy # 0, last reviewed 7/23/15 and entitled Patients' Rights, 24-103 directed that the patient has the right to be free of mental, physical, sexual or verbal abuse and free of neglect or exploitation. An exhibit attached to this policy entitled, Rules and Regulations Chapter 290-4-6.03 from the Department of Health Services/ Mental Health/ Developmental Disabilities, and Addictive Diseases, documented that the facility acknowledged that the patient has a right to be free of any abuse.

Policy 369, last reviewed 9/17/14 and entitled Incident Management in Adult Mental Health and Forensic Units, 03-515 proclaims in part that: .."failure by an employee to report an incident of suspected abuse, neglect, or exploitation or to cooperate in an investigation of an incident or failure to intervene, when reasonably possible, to prevent abuse, neglect or exploitation shall be grounds for personnel action up to and including termination of employment. Further directions are that incidents are reported to external agencies as appropriate and required by law..."

Review of the facility's public website revealed that patients' rights included:
a. Getting the care they need;
b. Prompt and confidential service;
c. Treated with respect & dignity;
d. Protecting their health & safety;
e. Knowing the benefits & risks of treatment;
f. Participating in planning their own treatment;
g. Being free of restraints or seclusion, except as a last resort for safety;
h. Being free of physical, sexual, or verbal abuse; and
i. Being free of neglect or exploration.

Telephone interview at 11:00 a.m. on 9/1/15 with the Acting Nursing Executive Director confirmed that there was no other incident report initiated from 7/24/15 until he/she had initiated such a report with the help of the department manager on 8/31/15 at 10:30 a.m.

Review of employee records revealed documentation that both the accused employee (#5) and the employee taking the phone call from law enforcement on 7/27/15 (RN #10) had undergone Annual Incident Management training on 8/19/14 and 2/17/15 respectively. This training included the initiation of quality assessment reports.

In the exit interview in the large conference room in the administration building at 4:40 p.m. The CEO admitted that they follow the policy for reporting such incidents even to the point of reporting the incident to the State. He / She admitted , however, that in this case, policy was not followed as the quality assessment report was not started as per policy.
VIOLATION: QAPI Tag No: A0263
Based on medical record review, policy review, public website review and interviews, the facility failed to ensure that unexpected patient incidents and/or complaints were documented, investigated, monitored and tracked to ensure quality and safety of patient care.

Findings were:

Cross Refer: A-0273 as it relates to failure of the facility to ensure that unexpected patient incidents and/or complaints were documented and investigated for one (1) of ten (10) patients whose records were reviewed.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on medical record review, policy review, public website review and staff interviews, the facility failed to ensure that unexpected patient incidents and/or complaints were documented and investigated for one (1) of ten (10) patients whose records were reviewed. This resulted in possible harm to at least patient #5.

Findings include:

Nursing notes dated 7/24/15, signed by a Registered Nurse (RN # 10), documented that he / she took a phone call from unspecified law enforcement at 5:50 a.m. Law enforcement stated that they had received several calls from a patient (identified as patient #5) reporting that an employee (identified as employee #5) had been in the patient's room making sexual advances towards him/her. No further mention of the incident was found in the chart.

During an interview at 2:20 pm on 9/1/15, the Nurse Manager (employee #12) reported that during a Treatment Team Conference on 8/13/15, the Treatment Team Facilitator pulled out a note dated 7/24/15 which documented that law enforcement had called the Central Unit nurses station at 5:50 am, and reported that a patient (identified as patient #5) had called 911 to report that an employee came in to his/her room making sexual advances. The Nurse Manager reported that the staff member (identified as employee #10) had taken the call from the police department but that no internal report was initiated. The Nurse Manager further reported that he/she had not had time to complete a report for the quality assurance report to be started. He/she stated that he/she had informed the accused employee (Health Service Technician- employee #5) of the allegations, but no documentation was completed. The employee was moved to the other side of the unit; however, because of construction in the unit, the employee still had access to the patient because both sexes were combined during certain times of the day. This was confirmed through review of the staffing schedule which documented that employee #5 worked the 3:00 pm to 11:00 pm and was on duty with direct access to the patient from 3:00 pm to 5:00 pm on 8/18/15, 8/19/15, 8/20/15, 8/24/15, 8/26/15, and 8/28/15.

During the Entrance Conference on 8/31/15 at 9:15 am, the Clinical MD Director (employee #8) confirmed that he/she had been aware of the reported incident and had requested that an incident report be filled out. Additional information related to any action taken to investigate the incident, including examination and interview of the patient, review of video tapes, interview of staff, and any action taken to protect the patients from further occurrence was not provided.

During an interview at 11:30 am on 8/31/15 the Clinical Director (psychiatrist- employee #9) related that staff had reported an accusation of verbal-sexual conversation and that staff were requested to fill out an incident report. The Clinical Director reported that the Medical Director was not informed of the incident, and that no physical examination was performed on the patient.

Quality Council Minutes for 2015 were reviewed and revealed that each mentioned the Quality Assessment (QA) data of unexpected events and the investigation of that data. While specific events were not mentioned by name, they were discussed in general. The raw reports of the QA data for untoward events for the last two months, July and August 2015 were also reviewed and this particular incident concerning patient #5 and employee #5 was not mentioned.

Policy # 0 reviewed 7/23/15 and entitled Patients' Rights, 24-103 directs that the patient has the right to be free of mental, physical, sexual or verbal abuse and free of neglect or exploitation. In an exhibit attached to this policy entitled Rules and Regulations Chapter 290-4-6.03 from the Department of Health Services/ Mental Health/ Developmental Disabilities, and Addictive Diseases the facility acknowledged the patient has a right to be free of any abuse.

During an interview on 08/31/15 at 11:02 p.m. in the employee dining area of building 4, a registered nurse (RN- employee #1) related that when an accusation of sexual misconduct is made, security is notified along with the patient's physician(s). A report was to be started by the employee to whom the incident was first reported. The manager on duty was notified depending on when the accusation was made/received. When notified, the patient's medical doctor would make the decision about coming in to see the patient, and if sexual assault was suspected, decided whether the patient would be sent to a medical hospital for examination- forensic exams were not performed in this facility. The RN further related that his/her supervisor had recently said that a male staff had touched a patient inappropriately, and identified patient #5 on the list of requested employee files. The accused employee was eventually identified, via the incident report, as employee #5, and that employee #5 was switched to work on another unit, but later resigned.

Policy # 0 reviewed 7/23/15 and entitled Patients' Rights, 24-103 directs that the patient has the right to be free of mental, physical, sexual or verbal abuse and free of neglect or exploitation. In an exhibit attached to this policy entitled Rules and Regulations Chapter 290-4-6.03 from the Department of Health Services/ Mental Health/ Developmental Disabilities, and Addictive Diseases the facility acknowledged the patient has a right to be free of any abuse.

During an interview in the Conference Room in Building 4 at 4:05 pm on 8/31/15, patient #5 revealed that he/she had been here about 8 months, and reported that he/she was unaware of the reason for admission. The patient acknowledged receipt of a booklet with patient rights. Patient reported that a staff member (identified employee #5) came into his/her room and hit him/her in the head. The patient also reported the following: [Employee #5] grabbed his/her arm and shook him/her, leaving "a big red mark on my arm". Reports [employee #5] works on the other side now (unit 5). He/she comes to work in a uniform sometimes, like a police. Patient #5 reported that a strong African American male/female (employee #5) put their privates close to mine- I did not like that at all. He/she reported [employee #5] to the registered nurse (employee #10), but he/she did nothing. Reports he/she tries to stay away from [employee #5]. While watching TV, [employee #5] brushed his/her pelvic area up against his/her side. Patient #5 reports [employee #5] is usually here at dinner time. [Employee #5] touches and massages all the nurse's shoulders. [Employee #5] slipped up behind me and grabbed my shoulders; says "I didn't like it." Patient #5 denied being sexually abused or raped here and reported, "If anyone touched me inappropriately, I would call 911 and tell the staff", but also related that "they will not help me, nothing was done when I reported [employee #5].

The staffing schedule for the two weeks prior to 8/28/15 was reviewed and revealed that although employee #5 had been moved to the unit adjacent to the patient's unit, employee #5 continued to have access to the patient when the units were combined. The staffing schedule documented that employee #5 worked the 3:00 pm to 11:00 pm and was on duty with direct access to the patient from 3:00 pm to 5:00 pm on 8/18/15, 8/19/15, 8/20/15, 8/24/15, 8/26/15, and 8/28/15.

Review of employee records revealed documentation that both the accused employee (#5) and the employee taking the phone call from law enforcement on 7/27/15 (RN #10) had undergone Annual Incident Management training on 8/19/14 and 2/17/15 respectively. This training included the initiation of quality assessment reports. Additionally, the surveyor was provided a copy of employee #5's resignation letter which documented that the employee's last date to work would be 8/30/15.

Policy 369 reviewed 9/17/14 entitled Incident Management in Adult mental Health and Forensic Units, 03-515 proclaims in part that:.. "failure by an employee to report an incident of suspected abuse, neglect, or exploitation or to cooperate in an investigation of an incident or failure to intervene, when reasonably possible, to prevent abuse, neglect or exploitation shall be grounds for personnel action up to and including termination of employment. Further directions are that incidents are reported to external agencies as appropriate and required by law...

Quality Council Minutes for 2015 were reviewed and revealed that each mentioned the Quality Assessment (QA) data of unexpected events and the investigation of that data. While specific events were not mentioned by name, they were discussed in general. The raw reports of the QA data for untoward events for the last two months, July and August 2015 were also reviewed and this particular incident concerning patient #5 and employee #5 was not mentioned.

During an interview on 9/1/15 at 11:00 am, the Acting Nurse Executive confirmed that the unusual occurrence/incident report related to the event(s) reported on 7/24/15 was not begun until 8/31/15 at 10:30 am, after the surveyors' arrival.

In the exit interview in the large conference room in the administration building at 4:40 p.m. The CEO admitted that they follow the policy for reporting such incidents even to the point of reporting the incident to the State. He / She admitted , however, that in this case, policy was not followed as the quality assessment report was not started as per policy.