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Based on review of the Performance Improvement (PI) Plan for 2011, PI meeting minutes, and interviews, it was determined the Hospital failed to require the Quality Assurance Performance Improvement plan evaluate patients' diagnoses, treatment, care, and outcomes for quality and appropriateness.

Findings include:

The PI Plan revealed: "Principle: Recognizing that most problems/opportunities for improvement come from process weaknesses, and that solutions must come from the collaboration of interdisciplinary groups, Benson Hospital provides for the systematic assessment and improvement of performance by identifying important functions, assessing performance, identifying areas for improvement, setting priorities for improvement , systematically improving performance and maintaining stability of these processes."

The PI Plan revealed:

"1.1 The Governing Board shall have the authority and responsibility for the assurance of a flexible, comprehensive and integrated performance improvement (P.I.) program.
1. 2 The Governing Board delegates authority and accountability for the operation of the program to the CEO (Chief Executive Officer) and the Medical Staff.
1.3 The CEO holds administrative authority and responsibility for the process. The CEO assures that adequate resources are allocated to the P.I. process by...
1.4 The Director of Professional and Support Services coordinates and manages the performance improvement activities of the hospital. The Director schedules, plans, and coordinates monthly performance improvement committee meetings; acts as a performance improvement resource to the Governing Board, medical staff, CEO, and hospital departments; collects, formats, and presents data to the medical staff as required in section 8.2; and reports on the hospital's performance improvement activities to the Governing Board on at least a quarterly basis...
1.6 Performance Improvement activities will be a collaborative effort involving the hospital leadership including the Governing Board Representative, CEO, Department Managers, Medical Staff Representative, Director of Nursing, and Director of Professional and Support Services.
1.7 Department managers will continuously monitor the key functions (section 3.0) within their departments via the data sources listed in 6.0 By the use of thresholds for evaluation as defined in section 5.0 they will determine when an assessment is to be initiated using the methodology shown in section 7.0."

The Plan included: "4.0 Indicators: 4.1 The focus of indicator identification is to continuously improve quality through an organized, systematic approach that includes the participation of all appropriate personnel in addressing systems of care. Indicators are quantitative measures of key functions or aspects of care. These measures can be related to the process or outcome of care. 4.2. There are two types of indicators; clinical and non clinical: 4.2.1 Significant event...4.2.2 Rate-based - measures a patient care event that requires further assessment only if the rate of events shows a significant trend over time, exceeds predetermined thresholds, or evidences significant differences when compared to rates in peer institutions."

The PI Plan revealed: "7.0 Methodology: To assure effective performance improvement activities quality indicators will be reviewed annually. This will align the entire organization through a common set of well understood objectives...."

The 2011 Quality Indicator Worksheet revealed: Emergency Services: "Chart accuracy audits: Documents and discharge instructions will be legible and complete for both ER and Inpatient. Patient satisfaction surveys...Imaging: Imaging results will be in HMS system within 72 hours of study. Imaging results will be available to ordering physician & PCP (Primary Care Physician) within 48 hours of study. Patient satisfaction surveys...Nursing: Compliance with meaningful use and using the CHP (Complete Health Profile) on every inpatient. Patient satisfaction surveys...Utilization review: Number of inpatient admissions lost due to unavailability of rehab on the weekends. All patients admitted to SNF (skilled nursing) will have documented in their record the dates of previous qualifying acute stay."

The Imaging Supervisor stated, during interview conducted on 11/03/11 at 11:00 A.M., that he did not know if overreads were being conducted to assure the quality of imaging reads. Subsequent to the interview, the Supervisor contacted the contracted radiology service to inquire if overreads were being conducted. The Supervisor subsequently advised surveyor that a percentage of overreads were being sent by the contracted radiology service to a different radiology group for overreads. When asked specifically if he knew if Benson Hospital imaging results were included in the contracted service overreads, the Supervisor stated that he did not know.

The quality indicators for Imaging did not include an analysis of the quality of the imaging reads.

The PI plan and meeting minutes had no documentation of the steps for monitoring and evaluating the care, treatments and treatment outcomes to include: what data to collect, analysis of the data, identifying corrective actions, implementation of the corrective actions, evaluation of the actions, and measures to improve on a continual basis.

The Director of Nursing verified in an interview conducted on 11/04/2011, the nursing department conducts monthly chart audits not included in PI meeting minutes.

No documentation was presented that data was collected to follow up adverse events that occurred in the past year, i.e.; on the number and causes of falls, the use of restraints in the ED, the number of extravasation's of contrast dye in the x-ray department.

The Director of Professional and Support Services acknowledged during an interview conducted on 11/03/2011, the meeting minutes did not reflect the analysis of data collected by the departments.

Based on review of the Critical Access Hospital's (CAH) Quality Assurance and Performance Improvement data and committee minutes, Governing Board minutes, and interviews, it was determined that the CAH failed to require an evaluation of all patient care services and other services affecting patient health and safety.

Findings include:

Interviews conducted with multiple department managers revealed quality data by departments went to the Performance Improvement (PI) Committee. The minutes of the meetings did not include an evaluation of all patient care services and other services affecting patient health and safety. There was no documentation that included analyzing data, identifying problems or issues, or plans for implementing remedial actions.

The Director of Professional and Support Services acknowledged that no evaluation of patient care services and other services affecting patient health and safety had been documented in the meeting minutes.

The Governing Board minutes for the past year did not contain documentation of an evaluation of patient care services.

Based on record review, facility documentation, policy and procedures and interviews, it was determined the facility failed to maintain an ongoing activity program for 4 (Residents #5, 12, 14, and 19) of 4 residents reviewed in the swing bed program.

Findings include:

The hospital's policy "Nurses Swing Bed Program Patient/Resident Activities" included:

1.1 The Activities Coordinator shall be responsible for the maintenance of an activities program, in consultation with a contracted Occupational Therapist...
2.4 The consultant will participate in the development of an interdisciplinary care plan, which includes identified limitations and precautions...
3.2 The Activity Coordinator will record interventions and resident response to activities on the patient's electronic health record."

There was no evidence of a monthly activity calendar. A review of records for residents #5, 12, 14, and 19, had no documentation of activity attendance and the responses to the activity interventions. There was also no evidence of consultation with the Occupational Therapist.

Resident #12 was admitted to a swing bed 8/22/11, with the diagnoses of status post bilateral knee replacements, generalized weakness and decreased functional mobility. The admitting orders included: "Activity: Fall risk: up for all meals with assist...CPM (Continuous Passive Motion) at 130 (degrees) each knee 2 hours 3 times a day...." The resident's electronic record of Activity Daily Assessment from 8/22/11 through discharge on 8/25/11, revealed: "What is the physical ability of the patient? Exercise, Movement, Active."

Resident #19 was admitted 11/2/11, with the diagnoses of status post left ankle fusion, wound care due to cellulitis in post surgical wound, and intravenous antibiotic therapy. The resident had limited mobility. The initial Activity Assessment dated 11/3/11 did not have any response to the question "What is the mobility of the patient?"

The Activity Coordinator was interviewed 11/2/11. She stated she provides activities for all the residents but did not have a monthly calendar of activities. She acknowledged a calendar was originally kept but in the last few years she just provides activities depending on what the patient requests, such as videos or books. Her reporting supervisor was the Director of Nurses (DON).

The DON was interviewed 11/3/11, regarding care plans not addressing activities for each resident and the lack of consultation with the Occupational Therapist (OT). She stated the daily activity assessment was considered part of the care plan. She did acknowledge there were no goals or interventions and responses to the activities on the care plan. She presented a written statement that the Activity Coordinator was to utilize the OT as a consultant. The DON stated she believed the activity coordinator did talk to the OT, but there was no evidence of documentation of this communication.