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Based on interview, record review and policy review the governing body failed to ensure that all departments and services were included in the facility-wide Quality Assurance and Performance Improvement (QAPI) Program for two departments (Social Services and Activity Therapy) of 15 departments reviewed. The facility also failed to ensure that the data collected for one department (Geriatric Psychiatric Unit, unit for treating psychiatric illnesses of the elderly) was trended for identifiable problems. These failures had the potential to affect all patients' health and quality of services provided. The facility census was 15.

Findings included:

1. Record review of the facility policy titled, "Quality Assessment and Performance Improvement-Patient (QAPI) Safety Plan," dated 05/2015, showed directive for facility staff that each department will be required to participate in QAPI. The QAPI committee will act as an advisory body to coordinate and monitor the quality and appropriateness of all direct patient and ancillary services provided by the facility.

2. Record review and subsequent interview on 04/27/16 at 10:45 AM, showed no involvement by Social Services and Activity Therapy of Performance Improvement Goals, data collection, or evaluation. Staff A, Quality Risk Manager confirmed that neither department had any QAPI.

During an interview on 04/26/16 at 3:08 PM, Staff BB, Social Worker, stated that she was unaware of who evaluated the quality and appropriateness of the care for Social Services.

During an interview on 04/27/16 at 1:40 PM, Staff N, Director, Geriatric Psychiatric Unit, stated that once a month she completed one medical record review which included all services within the record, but did not trend any data collected.

During an interview on 04/27/16 at 2:17 PM, Staff B, Chief Nursing Officer and Chief Operating Officer, stated that the facility needed to involve all services in the QAPI program.

















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Based on interview, record review and policy review, the facility failed to ensure nursing staff acknowledged and notified the physician of abnormal lab results for one patient (#4) of six records reviewed on the Geriatric Psychiatric Unit (Geri Psych, unit for treating psychiatric illnesses of the elderly). This failure had the potential to affect all patients admitted to the Geri Psych Unit in the delay of appropriate treatment. The facility census was 15.

Findings included:

1. Record review of the facility's policy titled, "Hand-Off Communication," revised 04/2015, showed:
- Purpose was to provide accurate valuable patient care, treatment and service information from one healthcare provider to another.
- Could be conducted per telephone/fax.
- Communication should include shift report and unit to unit communication regarding labs, either, pending or pertinent, abnormal findings/results.
- SBAR (Situation, Background, Assessment,Recommendation) communication between members of the health care team about a patient's condition that will ensure efficient and accurate communication.

2. Record review on 04/25/16 of Patient #4's medical record showed a faxed lab result for a urine culture (a test to find and identify germs, usually bacteria, that may be the cause of an infection in the urinary tract) dated 04/23/16 indicated a final report of a positive growth of Methicillin Resistant Staphylococcus Aureus, (MRSA, an infection caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections).

During an interview on 04/25/16 at 4:15 PM, Staff F, Registered Nurse, (RN), stated that he worked on the Geri Psych unit on 04/23/16 and cared for Patient #4. He did not remember seeing any lab results for the patient on that date.

During an interview on 04/25/16 at 4:00 PM, Staff E, RN, Case Management stated that the process for lab results was for the lab to fax the results to the in-patient unit and to the hospitalist (a dedicated in-patient physician who works exclusively in a hospital). The unit nursing staff were to review the lab results and either call the physician or send an SBAR communication to the physician. The SBAR's were a standardized form completed by the nurse and sent to the physician and kept in a notebook on the nursing unit. Staff E verified there was no SBAR in the notebook for Patient #4 regarding her abnormal lab results.

During an interview on 04/27/16 at 10:50 AM, Staff B, Chief Nursing Officer, (CNO), stated that there was a problem with the way lab results were communicated to nursing staff and the physicians. She stated that they cannot rely on fax machines alone and there was no way of ensuring the staff that received the results from the fax machine ever reviewed it and/or made sure the physician was aware of the result.

During an interview on 04/27/16 at 1:40 PM, Staff DD, Lab Director, Infection Control Officer, stated that she was aware that there was a problem with the current process. She stated that there needs to be way to ensure that the results were actually reviewed and that the hospitalist received and reviewed the results that were faxed to them.