HospitalInspections.org

Based on record review and interview, the facility failed to include in the QAPI (Quality Assurance Performance Improvenment) program the adverse patient event for 1 of 5 patients (Patient #1's 9/04/16 Fall with major injury) in the 2016 Quality metrics and minutes.

Findings included

The Fall Event Log reflected falls for Patient #1 on 9/04/16 with final outcome of "Laceration requiring sutures" and on 9/06/16 final outcome of "No injury."

The facility's event report defined, "Severity Definitions: No injury: no evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the patient; no change in the patient's behavior is noted after the fall...Injury except major: skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains; or any fall-related injury that causes pain...Major injury: bone fracture, joint dislocation, closed head injury with altered consciousness, or subdural hematoma."

The Quality Assurance documentation for 2016 reflected the track and trend of the falls rate and the falls with major injury on the facility's Quality Metrics Report 2016 and did not reflect a Fall with major Injury for Patient #1.

During an interview on 8/22/17 at 4:45 PM, Personnel #1 brought an email from the liaison in September 2016 that detailed the follow up of Patient #1 at the acute hospital he was sent to with a hip fracture from the documented fall. Personnel #1 was informed that the hospital was aware of Patient #1's major injury. Personnel #1 stated, "Yes." Personnel #1 was informed the 2016 Quality Metrics for falls with major injury was reported without Patient #1's major injury. Personnel #1 stated, "Yes."