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.
|UNITED HEALTH SERVICES HOSPITALS, INC||10-42 MITCHELL AVENUE BINGHAMTON, NY 13903||July 10, 2020|
|VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES||Tag No: A0283|
|Based on document review and interview, in 1 of 1 hospital "Quality Management Reviews," the hospital did not adequately identify areas for process improvement and did not develop, implement, or evaluate a plan for improvement. This could negatively effect health outcomes, patient safety and quality of care.
-- Review of the hospital's policy and procedure (P&P) titled "Review of Events/Unusual Occurrences/Patient Care Issues," last revised 5/15/2018, indicated to review the adequacy of systems/processes and identify system/process improvements.
-- Review of the hospital's "Quality Management Review," dated 10/21/2019, identified an area with opportunity for improvement, i.e., to increase documentation of vital signs around doses of hydromorphone. However, there was no documentation of how this was going to be done, e.g., staff education/ re-education, revision of P&Ps. Also, the review did not identify the need for additional provider training regarding dosage and frequency of hydromorphone.
During interview of Staff A, the Director of Quality Management, on 7/8/2020 at 11:00 am, he/she acknowledged this finding.