QAPI Program Utilization_Manual

ADVERSE EVENT REPORTS (OBQI SOURCE REPORT) ( potential or actual problem areas are targeted for correction or improvement ) Year: ____________ Quarter: ___ Report completed by: __________________________________________ Total patients served in the quarter: _________ Signature: _________________________________________ Potential or Actual Problem (OASIS-C Source ) Total Patients % of total Correction, improvement, action plan (Determine Effectiveness of the Improvement Plan) Increase in number of pressure ulcers (M1306) Unhealed Pressure Ulcer at Stage II or Higher (M1308) Current Number of Unhealed Pressure Ulcers at Each Stage Discharged to the Community Needing Toileting Assistance (M2102) Types and Sources of Assistance (M1840) Toilet Transferring (M1845) Toileting Hygiene (M2420) Discharge Disposition Emergent Care for Wound Infections, Deteriorating Wound Status (M2300) Emergent Care (M2310) Reason for Emergent Care Emergent Care for Injury Caused by Fall (M2300) Emergent Care (M2310) Reason for Emergent Care Emergent Care for Improper Medication Administration, Medication Side Effects (M2300) Emergent Care (M2310) Reason for Emergent Care Emergent Care for Hypo/Hyperglycemia (M2300) Emergent Care (M2310) Reason for Emergent Care Page 1 63