-
pso.ahrq.gov/sites/default/files/wysiwyg/oig-list-long-term-care-hospitals-2019.pdf
January 01, 2019 - changes in mental status
• Cascade with oversedation while on multiple opioid medications leading to a fall … thromboembolisms, deep vein thrombosis, or pulmonary embolisms
• Acute pulmonary embolus with inadequate prevention … patient resulting in desaturation, hypoxemia, replacement of the tube, and aspiration
pneumonia
Fall … with injury
• Fall with recurrent right hip fracture associated with inadequate monitoring
Page 5 … with injury
• Fall with laceration forehead
• Fall with soft tissue hematoma over left maxillary sinus
-
pso.ahrq.gov/sites/default/files/wysiwyg/working-with-pso-webinar-value-hospitals.pdf
January 01, 2020 - Acuity, Size,
IRF/IRU
Quarterly conference
calls/Safe Tables
• General webinar
and Infection
Prevention … Writing an Infection Control Plan for Joint Commission Survey
• Durability of Outcomes/Readmission Prevention
-
pso.ahrq.gov/sites/default/files/wysiwyg/adverse-events-rehab-hospitals.pdf
July 01, 2016 - event
• Skin tear with fungal infection that developed under brace
• Skin excoriation on buttocks
Fall … associated with patient care
• Fall from bed with minor injuries (elbow, knees, and small skin tear