HospitalInspections.org

Based on record review and interviews, for one (Patient #1) of ten patients sampled, the hospital failed to ensure that the hospital's performance improvement items in response to Patient #1's unexpected death event were implemented.

Findings include:

Review of the hospital's Root Cause Analysis (RCA conducted on 01/25/2022) on 09/01/2022 regarding Patient #1's unexpected death event identified corrective action to be implemented. The corrective action included a process for scheduling routine lab work for patients with extended length of stays in the hospital.

During an interview with the Director of Quality and Patient Safety on 09/01/2022 at 10:10 A.M., she said that a corrective action item identified was to initiate a process for scheduling routine lab work for patients with extended length of stays in the hospital. The Director acknowledged that this corrective action item was never implemented.