Discrete problems may be more difficult to identify. Even though they may occur within a system, they could affect only a small part of the entire system.

For example, the problem may:

• Reflect an isolated incident;
• Affect a small number of individuals or staff;
• Be present at one time or a limited number of times; or
• Be present in various locations.

When there are few problems within a system, the violation/deficiency may be related to a discrete problem, rather than a systemic problem. The facility must examine all problems carefully to determine whether there is a system failure before assuming the problem is discrete.

Even relatively isolated problems could stem from a systemic problem. For example:

• DCS A abused Individual 1. It would be discrete if the facility's systems were in place. It would be systemic, however, even if it's just one DCS and the abuse happened just once, if the failure was due to the facility's lack of screening. Other individuals might not have been impacted but have the potential to be because it's a system flaw.

At first glance, a complex situation could appear to be either a systemic or discrete failure. In such a case, the facility must examine the situation critically to determine the ultimate basis of the failure.

Once the facility fully assesses the cause of the failure and determines its type, it must take steps to correct the failure and the circumstance of its existence.