HospitalInspections.org

Based on document review and staff interview it was determined the Director of Quality Assurance failed to ensure the hospital maintained an effective, ongoing, hospital-wide, data-driven quality program. This failure has the potential for all safety issues to become a systemic problem that can cause harm to all patients (See Tag A 273).

Based on document review and staff interview it was determined the Quality Assurance/ Performance Improvement (QA/PI) Coordinator failed to ensure the QA/PI program met monthly to track, trend and analyze any quality indicators. This failure led to no tracking, trending, or analyzing of staff to patient abuse to ensure patients remain free from abuse.

A review of the document titled "Quality Assurance Performance Improvement (QAPI) and Patient Safety Plan" last revised 06/30/20, states in part: "This plan establishes a collaborative, planned systematic and organization-wide approach to measure, assess, and approve the quality of care and patient outcomes while continuing to identify and reduce safety risk to patients, visitors, students, and staff ... Quality Council ... Council meets monthly: Quality Council meeting is prior to the monthly QAPI committee to review departmental PI data and to review specific areas identified for improvement."

A review of QA/PI from 08/2021 through 7/25/22 revealed there were no QA/PI meetings conducted in August, September and December 2021 and January, February, March, April, May or June 2022. Meetings did occur in October and November 2021. Neither meeting discussed staff to patient abuse. An Agenda for a meeting scheduled on 7/26/22 does not mention staff to patient abuse as a topic for discussion or analysis.

A review of the job description for the Director of the Quality Assurance/Performance Staff Development revealed: "Interprets and implements quality assurance standards in hospital to ensure staffing effectiveness through staff training and development and quality of care to patients by performing the following duties ... Reviews quality assurance standards, studies existing hospital policies and procedures, and interviews hospital personnel and patients to evaluate effectiveness of quality improvement initiatives."

An interview was conducted on 07/26/22 at 9:30 a.m. with the QA/PI Coordinator. When asked when the last QA/PI meeting occurred, and why they had not been conducting meetings and how were they monitoring staff to patient abuse, they stated, "The last meeting was in November [2021]. We have had many people out on sick leave in our department. We monitor staff abuse to patients through APS [Adult Protective Services]." When asked how they were analyzing the occurrences and making changes in procedures if they were not meeting to discuss the information, they stated, "That's a good question." When asked how frequently QA/PI meetings should occur, they stated, "Monthly." It should be noted a request was made for the number of APS referrals for staff abuse at the time of the survey and the information was not received prior to exit.

An interview was conducted on 07/26/22 at 10:47 p.m. with the Chief Executive Officer. When asked how frequently QA/PI meetings should occur and if they were aware of when the last meeting occurred, they stated in part, "The meetings should be quarterly and at any critical junction, and the last meeting was in November [2021]. I attend all of the meetings. QA has taken information to the medical staff meetings and the governing body meetings." When asked how does the QA/PI have time for medical staff meetings and Board meetings but not for their own meetings to solve problems and fix the systemic problem, they stated in part, "You are right" and concurred with the finding.