HospitalInspections.org

Based on interview, document review, and policy review the Critical Access Hospital (CAH) failed to develop a Quality Assessment and Performance Improvement Plan (QAPI) that monitors program data and activities. The CAH's failure to monitor program data and activities has the potential to not meet quality standards and to not identify and correct underlying causes of systemic problems to prevent serious injury, infection, or death.

Findings Include:

Review of the CAH's document titled, "The Medical Staff of Rush County Memorial Hospital Meeting Minutes," dated 06/29/21, showed that the QAPI program was not addressed in the meeting.

Review of the CAH's document titled, "QI/IP/RM Nurse Job Description," dated 08/01/19, showed that the Quality Improvement nurse's essential functions include ..."Plan, organize and direct department quality, risk and infections operations and activities" ..."plan and implement quality risk management programs to meet the needs of the hospital" ..."Evaluates programs and effective changes as needed to improve quality programs and assure compliance with requirements, hospital standards policies and procedures, job descriptions and standards" ... "maintain close liaison with other hospital departments to assure coordination, standardization and continuity of quality improvement programs. Providing risk identification and control through analysis of incident patterns."

Review of the CAH's document titled, "Director of Nursing Job Description," dated 09/01/19, showed that the Director of Nursing (DON) essential functions include ... "With administration, direct development and implementation of quality and utilization standards across the continuum of care to ensure coordinated plans."

Review of the CAH's undated policy titled, "Quality Improvement Program plan," showed that the policy was not signed, approved by the Board of Directors, and undated. Policy showed that "Department managers will actively participate in the Quality Improvement Program and will review their monthly initiates at the monthly quality meeting." ... "Each department manager is responsible for collecting and analyzing data, developing and implementing changes, and monitoring data." ... "Each department will be responsible for implementing their own Quality Improvement activities and keeping track of their activities." ... "The Quality Improvement Program Plan is reviewed annually."

During an interview on 07/28/21 at 9:45 AM, Staff C, Quality Improvement/Infection Preventionist/Risk Management (QI/IP/RM), Registered Nurse (RN) stated that her job responsibilities include infection control, education, risk management, and quality improvement. Staff C stated that she started this position in January of 2021. She stated that she does not know when the QAPI plan was updated, but she was aware that the copy she provided the surveyors was not signed or dated. She stated that she has no experience with QAPI, and she has not received any direction or training from administration. She stated that she has only attended one meeting of the Medical Staff and she was not given direction on what she is required to be reporting at the meetings. Staff C stated that at the one meeting she attended, she reported on hospital falls, and infections.

Based on observation, document review, and interview, it was determined that the Critical Access Hospital (CAH) did not have an individual that is qualified by education, training, experience or certification as the infection preventionist/infection control professional responsible for the infection prevention and control program including COVID-19 pandemic infection control based on recommendations from the Centers for Disease Control and Prevention (CDC). This deficient practice places all patients, visitors, and staff at this facility as risk for contracting or spreading HAIs, COVID-19, or other communicable diseases that could lead to possible infections and/or death.


Findings Include:


Review of policy titled, "Infection Prevention Plan," dated 04/2018 showed, " ...Infection Prevention Registered Nurse will receive regular training and on-going education, and will maintain a yearly membership to APIC (Association for Professionals in Infection Control and Epidemiology) ..."


Review of a facility document titled, "Rush County Memorial Hospital QI/IP/RM (Quality Improvement/Infection Preventionist/Risk Management) Nurse," dated 08/01/2019, stated " ...Qualifications: Registered Nurse, licensed to practice nursing in Kansas, minimum 2 years professional nursing experience, Acceptably demonstrated leadership and management experience ... Essential functions: Plan, organize and direct department quality, risk and infections operations and activities ... Provides information to hospital committees and department managers to formulate changes in the policies, procedures and/or processes which could reduce the spread of infection. Interacts with physicians, nurses, department managers, supervisors, and occupational health and other professional/non-professional staff members to provide resource information, resolve infection control problems, and identify new opportunities to improve serve and reduce costs ... Select, train, orient personnel and staff in programs in assigned areas with appropriate personnel and maintain quality, profession growth and development ... Be aware of standards precautions for infection control and implement the infection control guidelines in his day to day activities. ..."


Review of Staff C's personnel file failed to provide documentation that Staff C was qualified by education, training, experience, or certification to be the infection preventionist/infection control professional responsible for the infection prevention and control program.

During an interview on 07/28/2021 at 9:45 AM, Staff C stated she has no knowledge of how staff were educated on infection control related to COVID-19 prior to accepting the IP position in January 2021. She stated in January 2021 new hires were required to sign the facility COVID-19 Employee Guidelines policy but stated education/training was only done verbally and she denied hands on training or completion of a skills checklist to determine competency of staff related to COVID-19 screening. When asked who is responsible for training staff on COVID-19 screening, Staff C replied, "Probably me." Staff C reported that she had no previous experience working as an Infection Preventionist. She reported "I feel like I received no direction from administration" and "nobody told me what was needed." She reported she received no training or education for the role of QI/IP/RM position. Staff C stated that COVID-19 screening is required for all staff and visitors and is to include temperature and screening questions. She reported that screening documentation is no longer required for visitors and the hospital stopped documenting visitor screening in May or June when they received information in a webinar that it was no longer required. She was unable to provide the name of the webinar or who presented the information.

During an interview on 07/28/2021 at 1:230 PM, Staff B, DON (Director of Nursing) stated that the hospital's membership with APIC expired in September 2020.

Based on interview, and policy review the Critical Access Hospital (CAH) failed to ensure the Infection Control Nurse fulfilled the responsibilities of communication and collaboration with the CAH's QAPI program on infection prevention and control issues. The failure of the Infection Control Nurse to fulfill expected responsibilities has the potential for substandard quality of care.


Findings Include:


Review of the CAH's undated policy titled, "Quality Improvement Program plan," showed that the policy was not signed, approved by the Board of Directors, and undated. Policy showed that "Department managers will actively participate in the Quality Improvement Program and will review their monthly initiatives at the monthly quality meeting." ... "Each department manager is responsible for collecting and analyzing data, developing and implementing changes, and monitoring data." ... "Each department will be responsible for implementing their own Quality Improvement activities and keeping track of their activities." ... "The Quality Improvement Program Plan is reviewed annually."

During an interview on 07/28/21 at 9:45 AM, Staff C, Quality Improvement/Infection Preventionist/Risk Management (QI/IP/RM), Registered Nurse (RN) stated that her job responsibilities include infection control, education, risk management, and quality improvement. Staff C stated that she started this position in January of 2021. Stated that she does not know when the QAPI plan was updated, but she was aware that the copy she provided the surveyors was not signed or dated. She stated that she has no experience with QAPI, and she has not received any direction or training from administration. She stated that she has only attended one meeting of the Medical Staff and she was not given direction on what she is required to be reporting at the meetings. Staff C stated that at the one meeting she attended, she reported on hospital falls, and infections.

Based on document review, policy review, and interview, it was determined that the Critical Access Hospital (CAH) did not ensure the leadership responsibilities of the Infection Preventionist were fulfilled in providing competency-based training and education to all CAH personnel and staff on the practical application of infection prevention and control guidelines. This deficient practice places all patients, visitors, and staff at this facility at risk for contracting and spreading COVID-19, HAIs, or other communicable diseases that may lead to infection and/or death.


Findings Include:


Review of the facility policy titled, "Employee Education," revised 05/2016 showed that employees will receive education upon hire, annually, and as deemed necessary by Administration. The facility failed to provide written or electronic documentation of competency-based training for CAH personnel and staff.


Review of the facilities documents for employee receipt and acknowledgment of the facility policy titled, "COVID-19 Employee Guidelines," regarding masking expectations per the Plan of Correction (POC), failed to show documentation for the following departments and individuals: Director of Nursing, Chief Executive Officer, Infection Control RN, Human Resources, Finance, Information Technology, Maintenance, Laundry Services, Housekeeping, Acute Care Unit staff, Radiology, Laboratory, and Medical Records. The facility failed to provide any competency-based training or education related to COVID-19 infection control.


During an interview on 07/28/2021 at 9:45 AM, Staff C stated she has no knowledge of how staff were educated on infection control related to COVID-19 prior to accepting the IP position in January 2021. She stated in January 2021 new hires were required to sign the facility COVID-19 Employee Guidelines policy but stated education/training was only done verbally and denied hands on competency-based training or completion of a skills checklist to determine competency of staff related to COVID-19 screening. When asked who is responsible for training staff on COVID-19 screening, Staff C replied, "Probably me."