HospitalInspections.org

Based on numerous tours throughout the hospital, observation, interviews with staff, and record review, it was determined that the governing body failed to implement and enforce policies and procedures of the facility; nor did the governing body(GB) ensure that the hospital's Quality Assessment Performance Improvement (QAPI) program assessed the services furnished directly by hospital staff, identify quality and performance problems, or implement appropriate corrective or improvement activities.
On 9/19/2013 staff # 6 presented a new computer platform to implement performance improvement projects to include all departments and to be accessible to all staff. As of 9/19/2013 there were nursing performance improvement activities present and ongoing. However, there was no other departments identified to improve or make changes based on committee, performance improvement teams, or action team recommendations.
Interview with staff #6 on 9/29/2013 confirmed that nursing and social work report data to Quality and have been participating in developing the computer platform. Staff #6 revealed that the QAPI process has not been implemented at this time, the plan has not been presented to the Medical Executive Committee (MEC), nor to the Governing Body. Staff # 1 and staff #13 both confirmed that the QAPI process was being developed but had not been completely implemented at this time. The QAPI process has not been approved by the MEC or GB.

Based on document review and interviews the Governing Body(GB) failed to monitor specific facility performance improvements (PI) to monitor the quality of care provided, and ensuring clear expectations for patient and staff safety.
On 9/19/2013 staff # 6 presented a new computer platform to implement performance improvement projects to include all departments and to be accessible to all staff. As of 9/19/2013 there were nursing performance improvement activities present and ongoing. However, there were no other departments identified to improve or make changes based on committee, performance improvement teams, or action team recommendations.
No evidence was provided of the facility's QAPI program recommending quality indicators or the Governing Body's involvement in approving quality indicators for the ECT procedure area or anesthesia service.
Interview with staff #6, and #13 on 9/19/2013 confirmed that Staff #10 was reporting data and performance improvent by #10 for Anesthesia. Staff#10 reported that she was not aware she needed to report the PI for Anesthesia. Staff #6, #16 and #10 confirmed the QAPI process has not been implemented at this time, the plan has not been presented to the Governing Body(GB).

Based on review of Quality Assessment and Performance Improvement (QAPI) information, and interviews, the facility failed to have approved performance improvement projects designed to address facility specific issues to improve the quality of patient care.
Interview with staff #6 on 9/19/2013 confirmed that nursing and social work report data to Quality and have been participating in developing the computer platform. Staff #6 revealed that the QAPI process has not been implemented at this time, the plan has not been presented to the Governing Body. Staff # 1 and staff #13 both confirmed that the QAPI process was being developed but had not been completely implemented at this time.

Based on document review and interviews, the Governing Body (GB) failed to involve all departments of the facility in the Quality Assessment Performance Improvement(QAPI) process.
Review of the QAPI data on 6/13/2013 revealed that the Laboratory, Anesthesia, Respiratory, and Laundry/Housekeeping departments were not being monitored in the QAPI process .On 9/19/2013 staff # 6 presented a new computer platform to implement performance improvement projects to include all departments and to be accessible to all staff. As of 9/19/2013 there were nursing performance improvement activities present and ongoing. However, there were no other departments identified to improve or make changes based on committee, performance improvement teams, or action team recommendations.
Interview with staff #6 on 9/29/2013 confirmed that nursing and social work report data to Quality and have been participating in developing the computer platform. Staff #6 revealed that the QAPI process has not been implemented at this time, the plan has not been presented to the Medical Executive Committee (MEC), or to the Governing Body. Staff # 1 and staff #13 both confirmed that the QAPI process was being developed but had not been completely implemented at this time. The QAPI process has not been approved by the MEC or GB.

Review of the Quality Assessment Performance Improvement (QAPI) program materials on 6/11/2013 revealed that the information gathered was data driven only. On 9/19/2013 staff # 6 presented a new computer platform to implement performance improvement projects to include all departments and to be accessible to all staff. As of 9/19/2013 there were nursing performance improvement activities present and ongoing. However, there were no other departments identified to improve or make changes based on committee, performance improvement teams, or action team recommendations.
Interview with staff #6 on 9/29/2013 confirmed that nursing and social work report data to Quality and have been participating in developing the computer platform. Staff #6 revealed that the QAPI process has not been implemented at this time, the plan has not been presented to the Medical Executive Committee (MEC), or to the Governing Body. Staff # 1 and staff #13 both confirmed that the QAPI process was being developed but had not been completely implemented at this time. The QAPI process has not been approved by the MEC or GB.

Based on interviews and record reviews, the facility failed to have an organized Respiratory Service to meet the needs of patient who require respiratory care. The facility failed to ensure the medical staff identified and approved the scope of diagnostic and/or therapeutic respiratory services provided by the facility.
An interview was conducted with Staff #13 on 9/19/2013. Staff #13 reported that a policy had been written for the respiratory services but he was unaware that oxygen administration, hand held nebulizers, inhalers, pulse oximeter monitoring, and suction as ordered by the physician needed to be included in the policy since nursing had those policies. Staff # 13 and Staff #6 confirmed that the respiratory department and the respiratory policy had not been approved by the governing body.

Based on interviews, the facility failed to have an organized Respiratory Department or a Director of Respiratory Services.
An Interview with staff #13 on 9/19/2013 confirmed that Staff #17 had verbally agreed to be the Director of Respiratory Services. Staff #13 reported that it was discussed in the Medical Executive Meeting but did not make it in the official minutes. Staff #13 confirmed that Staff #17 did not have any written agreement in his credentialing file. Staff #13 confirmed that the Director of Respiratory Services has not been approved through the Governing Board.

Based on interviews and record reviews, the facility failed to have an organized Respiratory Services or a Director of Respiratory Services.
Review of the facility's continuing education on 9/19/2013 revealed that the nursing staff had received appropriate training and staff education in respiratory services. Staff #13 confirmed that the facility has not approved the Respiratory Department, policy/procedure, or Respiratory Director in the Governing Body.

Based on Interviews the facility failed to have a scope of diagnostic and/or therapeutic respiratory services offered by the hospital defined in writing, and approved by the Governing Board.
An interview with staff #13 was conducted on 9/19/2013. Staff #13 confirmed that the Governing Board has not approved the Respiratory Department, policy/procedure, or Respiratory Director.

Based on Interviews the facility failed to have a scope of diagnostic and/or therapeutic Respiratory Services offered by the hospital defined in writing, and approved by the Governing Board.
An interview with staff #13 was conducted on 9/19/2013. Staff #13 confirmed that the Governing Board has not approved the Respiratory Department, policy/procedure, or a Respiratory Director.