HospitalInspections.org

Based on review of documents and staff interview, it was determined the facility failed to ensure the program data requirements were met. This can potentially affect all patient's in that the failure to collect and evaluate data results in the inability to monitor and institute safe practices.

Findings include:

1. Review of the Quality Assurance/Performance Improvement (QA/PI) meeting minutes revealed data is not being collected in a uniform manner.

2. During an interview with the QA/PI Director on 7/9/12 at 1400 hours, she stated there are no documented methods instructing staff on how to collect data, when to collect data and where this data goes.

Based on review of documents and staff interview, it was determined the facility failed to ensure the entire facility was participating in the collection of information/data relative to a performance improvement program. This can potentially affect all patient's in that the failure to collect and evaluate data results in the inability to monitor and institute safe practices.

Findings include:

1. Review of the Quality Assurance/Performance Improvement (QA/PI) meeting minutes revealed data is not being collected in a uniform manner. There is no evidence to indicate that all departments are participating in the collection of data under the hospitals performance improvement program.

2. During an interview with the QA/PI Director on 7/9/12 at 1400 hours, she stated there are no documented methods instructing staff on how to collect data, when to collect data and where this data goes.

Based on review of documents and staff interview, it was determined the facility failed to ensure there was documentation of all quality improvement projects being conducted. This has the potential to negatively affect patient care by staff being uninformed of data collection impacting safe patient care.

Findings include:

1. Review of the Quality Assurance/Performance Improvement (QA/PI) manual revealed there was no documentation of all projects being conducted.

2. Review of the Governing Body meeting minutes since 2010 revealed there was no information presented to the Governing Body in reference to which quality improvement projects were going to be conducted for approval.

3. Interview with the Director of QA/PI on 7/10/12 at 1530 hours revealed there has never been a formal document presented to the Governing Body indicating what quality improvement projects were being conducted.

Based on review of documents and staff interview, it was determined the facility failed to ensure the Governing Body was made aware of the Quality Assurance/Performance Improvement (QA/PI) projects being conducted in the facility. This has the potential to negatively affect patient care in that the governing body cannot be accountable for ensuring the safety of all patients.

Findings include:

1. Review of the Governing Body meeting minutes revealed there has not been a formal plan presented to the governing body since 2010.

2. Review of the QA/PI manual revealed there was no documentation indicating the governing body had been made aware of the QA/PI plan.

3. An interview conducted on 7/10/12 at 1530 hours with the Director of QA/PI revealed a formal plan for QA/PI has not been presented to the governing body.

Based on review of documents and staff interview, it was determined the facility failed to ensure the Governing Body was made aware of the Quality Assurance/Performance Improvement (QA/PI) projects being conducted in the facility. This has the potential to negatively affect patient care in that the governing body cannot be accountable for ensuring the safety of all patients.

Findings include:

1. Review of the Governing Body meeting minutes revealed there has not been a formal plan presented to the governing body since 2010, nor has this plan been defined or implemented.

2. Review of the QA/PI manual revealed there was no documentation indicating the governing body had been made aware of the QA/PI plan.

3. An interview conducted on 7/10/12 at 1530 hours with the Director of QA/PI revealed a formal plan for QA/PI has not been presented to the governing body.

Based on review of documents and staff interview, it was determined the facility failed to ensure the Governing Body was made aware of the Quality Assurance/Performance Improvement projects (QA/PI) being conducted in the facility. The QA/PI program did not define nor was implemented and maintained to include patient safety. This has the potential to negatively affect patient care in that the governing body cannot be accountable for ensuring the safety of all patients.

Findings include:

1. Review of the Governing Body meeting minutes revealed there has not been a formal plan presented to the governing body since 2010, nor has there been a defined plan implemented and maintained.

2. Review of the QA/PI manual revealed there was no documentation indicating the governing body had been made aware of the QA/PI plan.

3. An interview conducted on 7/10/12 at 1530 hours with the Director of QA/PI revealed a formal plan for QA/PI has not been presented to the governing body.

Based on review of documents and staff interview, it was determined the facility failed to ensure the Governing Body was made aware of the Quality Assurance/Performance Improvement (QA/PI) projects being conducted in the facility, nor the plan evaluation. This has the potential to negatively affect patient care in that the governing body cannot be accountable for ensuring the safety of all patients.

Findings include:

1. Review of the Governing Body meeting minutes revealed there has not been a formal plan presented to the governing body since 2010, nor has this plan been evaluated.

2. Review of the QA/PI manual revealed there was no documentation indicating the governing body had been made aware of the QA/PI plan.

3. An interview conducted on 7/10/12 at 1530 hours with the Director of QA/PI revealed a formal plan for QA/PI has not been presented to the governing body.

Based on review of documents and staff interview, it was determined the facility failed to ensure the Governing Body was made aware of the Quality Assurance/Performance Improvement (QA/PI) projects being conducted in the facility, nor the number of projects being conducted. This has the potential to negatively affect patient care in that the governing body cannot be accountable for ensuring the safety of all patients.

Findings include:

1. Review of the Governing Body meeting minutes revealed there has not been a formal plan presented to the governing body since 2010. There is no evidence to indicate the governing body was made aware the performance improvement projects conducted within the hospital.

2. Review of the QA/PI manual revealed there was no documentation indicating the governing body had been made aware of the QA/PI plan.

3. An interview conducted on 7/10/12 at 1530 hours with the Director of QA/PI revealed a formal plan for QA/PI has not been presented to the governing body.