HospitalInspections.org

Based on plan review, data review, meeting minutes review, and staff interview, the governing body failed to specify the frequency and detail of quality assessment and performance improvement (QAPI) data collection for 1 of 1 year reviewed (September 2014 - July 2015). Failure of the governing body to specify the frequency and detail of the hospital's QAPI data collection limits the governing body's ability to ensure the hospital has an effective program for quality improvement and patient safety.

Findings include:

Review of the hospital's current QAPI plan titled "North Dakota State Hospital Performance Improvement Plan" occurred on 08/25/15 at 12:35 p.m. This plan, dated 6/2013, stated,
". . . Organization, Authority and Responsibility
Governing Body: The Governing Body has the oversight responsibility for the quality, effectiveness, availability and accessibility of services provided. The Board authorizes and requires the Superintendent and medical Director to establish and maintain an effective Quality Management System. . . ." The plan lacked a requirement for the governing body to specify the frequency and detail of QAPI data collection.

Review of the hospital's QAPI data and meeting minutes occurred on 08/25/15. The QAPI data and meeting minutes from September 2014 through July 2015 lacked evidence the governing body had specified the frequency and detail of the hospital's QAPI data collection.

Review of the governing body's meeting minutes occurred on 08/25/15. The minutes from March 2014 through June 2015 lacked evidence the governing body had specified the frequency and detail of the hospital's QAPI data collection.

Upon request, the hospital failed to provide evidence the governing body specified the frequency and detail of QAPI data collection.

During an interview on 08/26/15 at approximately 8:50 a.m., an administrative staff member (#5) confirmed the governing body had not specified the frequency and detail of the hospital's QAPI data collection.

Based on plan review, bylaws review, and staff interview, the governing body failed to approve the hospital's quality assessment and performance improvement (QAPI) plan for 1 of 1 QAPI plan reviewed (dated 6/2013). Failure of the governing body to approve the hospital's QAPI plan limits the governing body's ability to ensure the hospital has an effective program for quality improvement and patient safety.

Findings include:

Review of the hospital's current QAPI plan titled "North Dakota State Hospital Performance Improvement Plan" occurred on 08/25/15 at 12:35 p.m. This plan, dated 6/2013, stated,
". . . Organization, Authority and Responsibility
Governing Body: The Governing Body has the oversight responsibility for the quality, effectiveness, availability and accessibility of services provided. The Board authorizes and requires the Superintendent and medical Director to establish and maintain an effective Quality Management System. . . ." The plan lacked evidence of the governing body's approval.

Review of the "North Dakota State Hospital Bylaws of the Governing Body" occurred on 08/25/15. These bylaws, approved 03/08/13, stated, ". . . II. Duties and responsibilities of the governing body. . . . 2. . . . f. Approving a program to assess and improve the quality of care provided, and appropriately addressing identified problems or opportunities to improve care, which include the medical staff, clinical staff, and staff of all departments and services . . ."

Upon request, the hospital failed to provide evidence the governing body approved the current QAPI plan, dated 6/2013.

During an interview on 08/26/15 at approximately 8:50 a.m., an administrative staff member (#5) confirmed the governing body had not approved the current QAPI plan.

Based on observation, review of a professional standard, and staff interview, the Hospital failed to ensure staff followed professional standards of practice regarding infection control during observations of care on 1 of 2 days of survey (August 25, 2015). Failure to ensure staff followed infection control practices may result in the spread of infection within the Hospital.

Findings include:

BLOOD GLUCOSE MONITORS:

Review of the Centers for Disease Control and Prevention document "Infection Prevention during Blood Glucose Monitoring and Insulin Administration" occurred on 08/26/15. The document, dated 03/17/11, stated, "Hand Hygiene . . . Wear gloves during blood glucose monitoring and during any other procedure that involves potential exposure to blood or body fluids. . . Change gloves that have touched potentially blood-contaminated objects or fingerstick wounds before touching clean surfaces. . . . Perform hand hygiene immediately after removal of gloves and before touching other medical supplies intended for use on other persons. . . ."

- Observation on 08/25/15 at 10:30 a.m. showed a licensed nurse (#2) exited the treatment room wearing gloves and carrying a container of supplies. The nurse went to Patient #1's bedside and used a lancet to obtain a blood sample from the patient's finger for blood glucose testing. Following the testing, the nurse (#2) put the blood glucose monitor in a plastic bag and placed it in the container. Without removing her gloves or performing hand hygiene, the nurse took the container to the nurses' station, cleansed the glucose monitor with a Sani-Wipe, and placed it back in the container. Still wearing the same gloves, the nurse carried the container down the hall, used a key to open the door to the treatment room, and placed the container on the counter. The nurse (#2) then removed her gloves and washed her hands.

During an interview on 08/26/15 at 8:45 a.m. an administrative nurse (#1) confirmed the nurse (#2) should have removed her gloves and performed hand hygiene before leaving Patient #1's room.

SOILED LAUNDRY:

- Observation on 08/25/15 at 1:35 p.m. showed two Certified Nursing Assistants (CNAs) (#3 and #4) assisted Patient #2 with toileting in a central bathroom. During cares, the CNAs changed Patient #2's soiled clothes. As the CNA (#3) transported Patient #2 down the hall, the other CNA (#4) picked up Patient #2's soiled clothes, and without placing them in a container, carried the clothes in her arms to the adjacent laundry room, and placed them in the washing machine.

- Observation on 08/25/15 at 4:50 p.m. showed an unidentified staff member exited a patient's room carrying several pieces of clothing in his arms and took them to the laundry room.

During an interview on 08/26/15 at 8:45 a.m. an administrative nurse (#1) stated each patient has their own laundry basket and staff should place the patient's soiled clothing in the basket for transporting to the laundry room.