Here is an example of a violation. How would you determine whether this is a system failure or a discrete failure?

The agency received a violation for Tag Z410, Coordination of Services, related to the requirement to document coordination of care between all service providers involved in the care of a client, including physicians.

The requirement was not met as evidence by:

Based on interview and record review, the agency failed to document that coordination of care occurred between the physician and agency staff in that the agency nurse did not notify the physician of a client's change in condition for 1 of 3 sampled records reviewed (#1).

The relevant evidence follows on the next page.