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Based on interview, medical record, and policy review, the nurse failed to ensure one of six patients (Patient (P) 1) plan of care was implemented and followed. Staff not following patient's individualized care plans has the potential to negatively affect in-patient care and safety for all 16 patients receiving care in the facility.


Findings Include:


Review of facility policy titled, "RN [Registered Nurse] Duties Policy and Procedure," last revised 01/21, showed the Registered Nurses (RN's) are to "Follow Patients Care of Plan" (sic).


Review of P1's medical record face sheet showed an admission date of 03/02/21 at 3:24 PM. Review of the "History and Physical" revealed P1 was admitted for burns to right hand and probable dementia. Review of P1's Care Plan (CP) revealed a bed or chair alarm for patient safety, related to dementia and wandering.


Review of an incident report involving P1s elopement on 03/05/21 revealed a review of video footage: At 09:29:00 AM, P1 is seen exiting building. At 09:29:08 AM, P1 steps off curb into parking space area. At 09:28:36 AM, P1 was seen exiting his/her room walked towards the nurses' station. At 09:29:11 AM, P1 steps onto asphalt of street and takes 4 steps into street as she leaves camera view. Only one of her shoes can still be seen. At 09:29:12 AM, a hospital staff is seen running out the door and P1 stops in her tracks and turns around.


During an interview on 11/29/21 at 9:30 AM, RN5 stated he/she was on duty on 03/05/21. RN 5 confirmed P1s CP required P1 to have a chair alarm on when sitting. RN5 stated he/she was aware P1 did not have the chair alarm before P1 eloped on 03/05/21, and stated, he/she did not always put the chair alarm on because P1 liked to walk.


During an interview on 11/29/21 at 1:05 PM, the Risk Manager/Quality Improvement Director (QID) 2 stated he/she had returned to P1's room at 9:28:30 AM and then went to nursing station to let Certified Nurse Aide (CNA) 6 and RN5 know P1 did not have the chair alarm on but was told "it was ok because P1 liked to walk around and stayed on the unit."


During an interview on 11/29/21 at 9:10 AM, the Business Office Manager (BOM) 4 stated he/she saw P1 on 03/05/21 walking towards the front office door but did not hear a chair alarm.


During an interview on 11/29/21 at 1:05 PM, the Director of Nursing (DON) and Hospital Co-Chief Executive Officer (CEO) confirmed nursing staff should have been following the CP for P1, and the chair alarm should have been placed when P1 went back to his/her room.

Based on interview, review of the Critical Access Hospital's (CAH) Quality Assessment and Performance Improvement (QAPI) program, review of data collection for falls, and review of the Quality Improvement Director (QID) Risk Manager (RM) job description, the hospital failed to implement an effective QAPI program that conducted periodic review of its total program and evaluated patient falls data.

The cumulative effects of the CAH's lack of trending, analysis of significant adverse patient events, and implementation of remedial action impacts the safety and well-being of all current and future hospital inpatients.


Findings Include:


The CAH failed to ensure the Quality Assessment and Performance Improvement (QAPI) program addressed measures to improve outcomes of significant patient adverse events based on the number of patients falls over a 15-month period of time. (See C-1311)


The CAH leadership and governance failed to assume ultimate responsiblility for the QAPI program and ensure the program activities focused on measures to improve health outcomes based on falls data collected for 15 months. (See C-1313)


The CAH failed to ensure the Quality Assessment Performance Improvement (QAPI) program tracked, trended, and analyzed patient falls in order to implement corrective action. (See C-1319).

Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure the Quality Assessment and Performance Improvement (QAPI) program addressed measures to improve outcomes of significant patient adverse events based on the number of patient falls over a 15-month period of time. The failure of the QAPI program to address measures to improve patient outcomes affects the health and safety of all patients being treated in the hospital, including the current 16 inpatients.


Findings Include:


Review of the "Quality Assurance Performance Improvement (QAPI) Plan" located in the QAPI binder showed the QAPI Plan was initiated on 10/31/19 and was last reviewed and approved by the QAPI committee was 11/15/19. Under the tab titled "QAPI Activity" the last assessment was 09/26/19.


Review of "Falls" data collected from the two inpatient hospital units between 08/01/20 - 11/30/21 (15 months) showed the hospital had 50 falls. 42 of the 50 falls occurred on the Intermediate Swing Bed (ISB) Unit.


Review of an undated job description titled, "Quality Improvement Director and Risk Management Coordinator," showed "The position is responsible for the design, development, and monitoring of quality activities. The director will direct and implement initiatives and functions including planning, coordinating corporate quality assurance programs ensuring continuous quality products; provide improvement consulting services and employ knowledge of performance improvement strategies, principles, methodology, techniques and date analysis. Develop, implement, and oversee quality improvement to ensure delivery of the highest quality patient care, optimal patient flow, provider productivity and continuity of care. Develop a conceptual framework for quality measurement and improvement activities across clinical sites."


During an interview on 11/29/21 at 1:05 PM, when asked about what the Quality Improvement Director (QID) Risk Manager (RM) responsibility to the QAPI program included, QID/RM stated, "to report out at the executive committee meetings." The QID/RM stated that nurses collect the data and turn it in, and nurses implemented changes after each patient specific incident. When asked for falls trends, monitoring, or any improvement projects, or measures, QID/RM stated there was no documentation of fall trends, measures, goals, or improvement projects related to falls.


During an interview on 11/30/21 at 12:50 PM, while reviewing available falls information, the QID/RM confirmed he/she did not look for trends. The QID/RM stated he/she was not aware that data was supposed to be reviewed. QID/RM stated, he/she has not had any training to conduct QA analysis and stated the former QI manager was supposed to train him/her, but abruptly left employment, and because QI/RM "wears several hats" as Radiology Technician, Director of Risk Management and QI, he/she does not have time to seek training or get all his/her work done. The QID/RM confirmed falls data has been collected as far back as 2016 but had no QA improvement projects for falls based on the falls data collected over the past 15 months to focus on measures to improved health or desired outcomes.

Based on interview, review of the Quality Assurance Performance Improvement (QAPI) program, and review of the Quality Improvement Director (QID) Risk Management (RM) Coordinator job description, the Critical Access Hospital's (CAH) leadership and governance failed to assume ultimate responsiblility for the QAPI program and ensure the program activities focused on measures to improve health outcomes based on falls data collected for 15 months. This has the potential to affect the current 16 inpatients at the facility.


Findings Include:


Review of the "Quality Assurance Performance Improvement Plan" located in the QAPI binder under the tab titled, "QAPI Plan," revealed the QAPI Plan was initiated on 10/31/19 and was last reviewed and approved by the QAPI committee was 11/15/19. The QAPI Plan showed that "The Board of Directors, Administrator, and QAPI Coordinator are responsible, and accountable for developing, leading, and closely monitoring the QAPI program."

Review of an undated hospital job description titled, "Quality Improvement Director and Risk Management Coordinator" showed "The position is responsible for the design, development, and monitoring of quality activities."

On 11/30/21 review of falls data, showed from 08/01/20 - 11/30/21 (15 months) the hospital had 50 falls. The average daily census was 16.


During an interview on 11/30/21 at 12:50 PM, when asked about the Quality Improvement Director (QID)/Risk Manager (RM) Coordinator responsibility to the QAPI program, the QID/RM stated, "to report out at the executive committee meetings." When asked, the QID/RM stated, the hospital does not take meeting minutes at executive meetings. The QID/RM confirmed there were not meeting minutes to verify what QAPI information is provided or evaluated by the executive meetings. QID/RM stated there are no program activities for the fall data collect over the past 15 months to focused on measures to improved health or desired outcomes.

Based on interview and document review, the Critical Access Hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) program tracked, trended, and analyzed patient falls in order to implement corrective action. The failure to have a QAPI program analyze trending of significant patient adverse events affects the health and safety of all patients being treated in the hospital including the current 16 inpatients.


Findings Include:


Review of an undated hospital job description titled, "Quality Improvement Director and Risk Management Coordinator" showed "The position is responsible for the design, development, and monitoring of quality activities. The director will direct and implement initiatives and functions including planning, coordinating corporate quality assurance programs ensuring continuous quality products; provide improvement consulting services and employ knowledge of performance improvement strategies, principles, methodology, techniques and date analysis."

A review of a printed list of patients falls for the inpatient units in the hospital from 08/01/20 - 11/30/21 (15 months) showed the hospital had a total of 50 falls which included the following information aggregated upon review:

1. 42 of the 50 falls occurred on the ISB Unit.
2. 13 of 50 the falls happened on a Sunday.
3. 28 of 50 falls listed patients as confused.
4. 37 of 50 falls were not witnessed

Included on the line list of patients falls for this time period were categories that contained missing falls data information including:

1. Under header for "Status", 21 of 50 patients listed in an empty line with no identified patient status.

2. Under header "Primary Drug Type" 39 of 50 incidence failed to identify the medication type.

3. Under header "Environment" 18 of 50 incidence did not identify the environment that patient was found in at the time of the fall.

During an interview on 11/30/21 at 12:50 PM, Quality Improvement Director (QID)/Risk Manager (RM) while reviewing falls data (above) with surveyor confirmed there were trends, related to the falls, specifically the 42 of 50 falls which occurred on the Intermediate Swing Bed (ISB) unit. QID/RM confirmed he/she could not trend data that was not identified in the data collection program "status", "primary drug type" and "environment". The QID/RM stated, he/she has not had any training to conduct quality assessment analysis. The QID/RM stated the former QID manager was supposed to train him/her, but abruptly left employment, and because QID/RM "wears several hats" as Radiology Technician, Director of Risk Management and QID, he/she does not have time to seek training or get all his/her work done. The QID/RM confirmed falls data has been collected as far back as 2016 but had no QAPI improvement projects for falls based on the falls data collected over the past 15-months. The QID/RM stated the falls program they use to gather falls data titled "Quality Data" does not allow for changing data collected within the program and confirmed there are missing pieces of the information from the current data collected on falls. The QID/RM confirmed 50 falls in a 15-month period was a significant number of falls for the hospital, when the average daily census is 16.