Proposed Plan of Correction: Acceptable Response
The facility proposes the following PoC.
Directions:
- Ask yourself why the facility’s response is acceptable.
- Hover over Acceptable Response Explanation for information on why the response is acceptable.
The facility will ensure that the documentation of investigation reports reflects that all injuries of unknown origin are thoroughly investigated, as evidenced by:
| Required PoC Criterion | Facility's Response |
|---|---|
| Criterion 1: How the corrective action will be accomplished for those identified individuals found to have been affected by the deficient practice. | The incomplete investigations for non-serious injuries of unknown cause have been reopened. There was not a system in place to ensure thorough investigations. Persons responsible: the facility director and director of quality services management (QSM). |
| Criterion 2: How the facility will identify other individuals having the potential to be affected by the deficient practice and how the facility will act to protect individuals in similar situations. | All individuals at the facility have the potential for harm due to this deficient practice. |
| Criterion 3: What measures will be put into place or system changes made to ensure that the deficient practice will not recur. | The Preliminary Investigation Report for Injuries of Unknown Origin will be revised to ensure a more complete investigation and will be used when investigating non-serious injuries and injuries of unknown origin. Unit directors (UDs), assistant unit directors (AUDs), management supervisors, campus coordinators, and the nurse manager for the facility will be in-serviced of the revision. Persons Responsible: facility director and director of medical services. |
| Criterion 4: How the corrective actions will be monitored to ensure the deficient practice is being corrected and will not recur and who will be responsible for monitoring. | The facility director will conduct a monthly meeting with UDs/AUDs to critique investigations regarding completeness. If an injury report with a non-serious injury of unknown cause has not been investigated within 2 working days, the safety officer will notify the appropriate UD for action. Quality assurance staff will randomly monitor investigations for completeness. Any problems will be referred to the facility director for corrective action. Persons Responsible: facility director and director of QSM. |
| Criterion 5: When corrective action will be completed. Must be at least one day past the date of exit. | The corrective action will be completed within one month of the day of exit. |