HospitalInspections.org

Based on observation, interview and record review, the facility failed to maintain and demonstrate evidence of its quality assessment and performance improvement (QAPI) program for review by the Centers for Medicare and Medicaid Services (CMS).

The facility failed to ensure documentation by Quality of new systems which were implemented to correct deficient practices cited on 05/10/2019.

The facility failed to ensure documentation by Quality of the Governing body and Medical Executive committee's approval of new systems which were implemented for deficient practices cited on 5/10/2019.

This deficient practice had the likelihood to cause harm to all patients.

Findings include:




Review of the Centers for Medicare and Medicaid Services form 2567with an exit date of 05/10/2019 revealed the facility was cited for areas involving patient grievances, patient safety, nurse staffing, problems with patients receiving baths, linen changes, range of motion, turning and repositioning and Foley catheter care. There were problems found with medications not being administered as ordered by the physician, timely, and reassessments performed after medication administration. There were also problems found with intravenous sites, tubing and fluids. The facility provided a Plan of Correction with a completion date of 06/30/2019.



Review of Medical Executive Committee Meeting Minutes dated 05/14/2019 revealed the following:

"CMS Survey
The hospital had a CMS survey on 05/6/-5/7/19 on 2 complaints. We will receive a report and complete a POC and inform the QIC of the findings. The committee agrees with the information as presented and will forward to MEC and BOT for Information."

Review of The Board of Trustees Meeting Minutes dated 05/20/2019 revealed the following:

"CMS visited on two patient complaints (report not final yet)
-Patient Rights - activities of daily living
-Quality of Care- assessment timely, interventions implemented
-Nursing Services- meds given correctly, IV documentation"


Review of Quality Improvement Council Committee Minutes dated 06/13/2019 and Medical Executive Committee Meeting Minutes dated 06/18/2019 revealed no mention of the new systems that were implemented to correct the deficient practices.


Review of The Board of Trustees Meeting Minutes dated 06/24/2019 revealed the following:

"CMS visited on two patient complaints (report not final yet)
-Patient Rights - activities of daily living
-Quality of Care- assessment timely, interventions implemented
-Nursing Services- meds given correctly, IV documentation
*Requested additional information regarding step down staffing and medication administration of the potassium protocol."

There was no documentation of the new systems that were being implemented to correct the deficient practices.

During observation and interviews on 07/01/2019 after 11:00 a.m., there was evidence of new systems that had been implemented to correct deficient practices that were cited on 05/10/2019.

Review of facility records revealed training, chart audit tools and changes in a policy that addressed the deficient practices that were cited on 05/10/2019.


During an interview on 07/01/2019 after 5:00 p.m., Staff #2 and #3 (Quality) confirmed there was no documentation of the new systems in the Meeting minutes. Staff #3 (Quality) said there was not enough data to report. Staff #3 said the survey was mentioned in the last Governing body meeting in June 2019. Staff #3 said the information would be reported in the July meetings to Quality and the Medical executive committee (after the plan of correction date of 06/30/2019)