HospitalInspections.org

Based on review of Quality Assessment Performance Improvement (QAPI) minutes, staff interviews, and QAPI policy review, the Chief Executive Officer (CEO) and the Director of Nursing (DON) failed to ensure the hospital-wide QAPI program addressed problems identified by the infection control program. The failure to include patients' infections, antibiotic treatment, surveillance data, and develop action plans created the potential for missed opportunities for all three in-patients to improve care and services.

Findings Include:

Review of the QAPI "program minutes" from April 2018 through October 2018 lacked documentation the Infection Control Preventionist (ICP) attended the meetings. Further review failed to reflect infection control statistics, patients treated with antibiotics for infections and surveillance data was reported to the QAPI committee.

During an interview on 11/13/18 at 2:30 PM, the ICP stated, "I started this position in March 2018. I do not attend the QAPI meetings because no one ever told me I should attend. The ICP confirmed that although she has a program for tracking and monitoring patient infections, antibiotic treatment and the patient outcome, the data is not presented at meetings of the QAPI committee.

An interview of the DON on 11/14/18 at 10:00 AM, she stated, "The ICP has not attended the QAPI meetings for some time." The DON confirmed infection statistics, antibiotic use and surveillance information obtained by the ICP have not been incorporated into the hospital QAPI program and action plans developed based on the information. The DON indicated the previous ICP did attend the QAPI meetings, but the current ICP just never was included in the QAPI committee.

Interview with the CEO on 11/14/18 at 10:10 AM confirmed he did not assure infection control program problems and statistical data identified by the ICP were included in the hospital QAPI program.

Review of the hospital "Quality Plan" dated 09/15/15 showed, The Responsibility of the Administrator to the Quality Committee...Supervise or provide support services for all quality assessment techniques, including criteria development, data retrieval and display, and data analysis...assist departments in investigating problems and determining follow up action.