HospitalInspections.org

Based on findings from facility document review and interview, quality assurance performance improvement (QAPI) data collected related to emergency department (ED) services at the hospital was not analyzed. Therefore, plans of action were not developed and implemented.

Findings include:

- - Per review of facility document titled "Emergency Department Statistics - 2014," left without being seen (LWBS) was one of the indicators being monitored. LWBS goal was <2%.

The following months showed the data noted:

August 3.8% patients LWBS
September 4.0 patients LWBS
October 2.9% patients LWBS
November 2.6 % patients LWBS
December 2.6 % patients LWBS

- - Per review of meeting minutes titled "Department of Emergency Medicine," dated 10/23/14, under a section titled Quality Management the minutes indicate LWBS rate was 4% and that this number has increased every month since the beginning of the year.

Another indicator for which data collection was described in 2014 was the percentage of unplanned returns to the ED within 72 hours.

The following months showed the percentages noted for unplanned returns to the ED within 72 hours:

August - 3.8%
September - 3.2%
October - 3.4%
November - 3.2 %
December - 3.7%

- - Per review of meeting minutes titled "Department of Emergency Medicine," dated 9/18/14, under section a titled Quality Management the minutes indicated there were 132 unplanned returns to the ED within 72 hours to date in 2014, and this was a significant increase.

- - During interview with the Director of Regulatory Affairs on 1/21/15 at 3:30 pm, he/she acknowledged that the data collected above was not analyzed and action plans to address these issues were not put into place.