HospitalInspections.org

Based on record review and interview, it was determined that the facility failed to follow their policies and procedures related to Incident Reports and Root Cause Analysis.

Findings were:

Review of Patient #10's medical record revealed the following:
- Patient #10 was admitted to the facility on 12/19/12.
- A nurses note dated 12/26/12 at 11:00 AM stated the following: "Pt complained of pain on her right rib cage 'stated that she was transferred/handled yesterday roughly by a male therapist' during her therapy yesterday. Dr. ---- called and notified about this and gave new order. Order written and carried out. Supervisor and manager made aware "
- An "Imaging Services Report" dated 12/26/12 stated the following: "Findings: There is a right posterior eighth rib fracture."

The following policies were reviewed on 2/13/13:
- Facility policy entitled "Incident Report" stated the following in part: "The purpose of this policy is to establish consistent guidelines to report and document certain events involving patients, visitors, volunteers, ect. at HealthSouth hospitals ...The foundation of a Risk Management program is based upon the ability to promptly obtain important facts and details of the circumstances surrounding an event within a reasonable time frame of when the event occurred. To this end, an Incident Report (attached) is to be completed for every occurrence which meets the following definition: any happening not consistent with the routine care or operation of the facility, or the desired routine care of the patient and/or operation of the facility, which places the Company at an increased risk for liability."
- Facility policy entitled "Root Cause Analysis" stated the following in part: "The purpose of this policy is to ensure proper management, trending, analysis of actual or potential Sentinel Events via performance of a thorough and credible Root Cause Analysis (RCA). RCA is the process of identifying the basic or contributing causal factors that underlie variations in performance, focusing primarily on systems and processes, not individual performance ...A Sentinel Event is defined as an unexpected occurrence involving death or serious physical or psychological injury. The terms 'sentinel event' and 'error' are not synonymous; not all sentinel events occur because of an error, and not all errors result in sentinel events."

In an interview with the Director of Quality and Risk Management on 2/13/12 he confirmed the above findings and stated that neither an incident report nor a root cause analysis had been initiated for this event.