HospitalInspections.org

Based on policy and procedure review, document review and staff interview, it was determined the hospital failed to:

a. clearly define the difference between a complaint and a grievance in the hospital's policy and procedure;

b. inform the patient of the internal complaint and grievance process, including whom to contact to file a complaint or grievance;

c. notify patients of the right to file a grievance with the Oklahoma State Department of Health regardless of whether he/she first used the hospital's complaint or grievance process.

Findings:

1. A hospital policy, titled, "1557 Grievance" did not correctly define complaints versus grievances, according to CMS regulations.

2. The admission packet did not identify who in the hospital to contact to file a complaint. The patient's rights section of admission packet had no information on the hospital's internal complaint/grievance process to include written responses to grievances and time frames for responses. The admission packet did not instruct patients on how to file a complaint or grievance after hours and on weekends.

3. The admission packet did not inform patients they could contact the Oklahoma State Department of Health.

During staff interviews, 3 (Staff A, E, and F) of 3 staff were unable to distinguish the difference between a complaint and a grievance or the process for either.

On 11/16/20 at 1:20 p.m., When asked to explain the difference between a complaint and a grievance, Staff A stated "all complaints and grievances are the same."
On 11/17/20 at 10:00 a.m., When asked to explain the difference between a complaint and a grievance, Staff E stated, "I guess I thought they were the same thing."
On 11/17/20 at 10:15 a.m., When asked to explain the difference between a complaint and a grievance, Staff F stated, "I'm not sure I knew they were different but I would inform my supervisor either way."

Based on record review and interview, the hospital failed to develop a hospital-wide quality program that measured, analyzed, and tracked patient quality indicator data to improve health outcomes.

This failed practice had the potential to affect the safety and health of all patients receiving care due to the hospital's failure to identify risks and quality improvement opportunities, and implement action plans to improve patient outcomes. (A-273)

Based on record review and interview, the hospital failed to ensure the QAPI committee identified opportunities for improvement, action plans, and tracked the improvements specific to the hospital to determine the sustainability of efforts.

This failed practice had the likelihood to affect patient safety and health outcomes for all patients admitted to the hospital and reduce the hospital's ability for improvement in quality indicators and implement best practice standards. (A-283)

Based on record review and interview, the hospital failed to conduct annual PIPs designed to improve the safety and quality of care.

This failed practice had the likelihood to affect the safety and health of all patients receiving care at the hospital due to the hospital's failure to identify annual PIPs, perform continued assessments, and analyze performance towards goal to determine effectiveness and sustainability. (A-297)

Based on record review and interview, the Governing Body and Medical Staff failed to provide oversight over the QAPI Program and ensure QAPI activities:

1) had established quality indicators that were measured at a designated frequency, analyzed, and evaluated for effectiveness;
2) were determined, designed, and prioritized annually;
3) were defined with clear, specific safety expectations and included the establishment of goals or benchmarks in order to measure sustained improvement at a desired level.
4) had a documented reasons for being conducted, were designed for safety and quality, and measurable progress was achieved.

These failed practices had the potential for the Governing Body, who has full responsibility for hospital operations, to miss key safety and quality improvement opportunities, and to misinterpret what the data being gathered represented. (A-308)

Based on record review and interview, the hospital failed to develop a hospital-wide quality program that measured, analyzed, and tracked patient quality indicator data to improve health outcomes.

This failed practice had the potential to affect the safety and health of all patients receiving care due to the hospital's failure to identify risks and quality improvement opportunities, and implement action plans to improve patient outcomes.

Findings:

The surveyor requested QAPI documentation for the past twelve months and was provided documents titled "Choctaw Memorial Hospiatl Q.I. Comittee Meeting" from 01/14/19 - 09/09/19 and one for 2020 dated 10/19/20. The documents do not contain information from patient satisfaction surveys, record reviews, adverse medication reactions or medication errors, and incident/grievance/complaint reports, etc.

The minutes recorded information with minimal data and no analysis to assist the Governing Body with the decision-making information necessary to provide quality hospital services. There were no quality measurements, no evaluations or identifications of trends or root causes of topics listed.

No identification of departmental and service line (including contract services) indicators and/or projects, no establishment of goals and action plans, no directive in the method of gathering data were included. Data was not analyzed and no action plans developed to move issues towards sustained improvement.

The minutes reflected only the data reported and vague discussions. There was no evidence the surveillance activities were chosen and prioritized. There was no evidence the Governing Body provided direction for quality data overview including detection, data collection and analysis, monitoring, and evaluation of preventive interventions. There were no benchmarks or comprehensive quality improvement plan for noncompliance of activity.

On 11/17/ at 2:39 pm, Staff A and by telephone Staff B stated there was no other QAPI information and no approval of the Plan by the Governing Body; they were not aware of the required elements for a QAPI program.

Based on record review and interview, the hospital failed to ensure the QAPI committee identified opportunities for improvement, action plans, and tracked the improvements specific to the hospital to determine the sustainability of efforts.

This failed practice had the likelihood to affect patient safety and health outcomes for all patients admitted to the hospital and reduce the hospital's ability for improvement in quality indicators and implement best practice standards.


Findings:

QAPI documentation that was provided was dated from 01/14/19 - 09/09/19 and one for 2020 dated 10/19/20. The documents showed no documentation of identified opportunities for improvement, action plans and discussion specific to the hospital to determine the sustainability and effectiveness of the facility's QAPI activities.

Review of hospital documents titled "Governing Body" meeting minutes dated: October 30, 2019; December 11, 2019; January 29, 2020; February 26, 2020; March 25, 2020; April 3, 2020; April 29, 2020; May 27, 2020; June 24, 2020; July 29, 2020; August 26, 2020; September 30, 2020; and October 28, 2020 did not show documentation of identified opportunities for improvement, action plans and discussion specific to the hospital to determine the sustainability and effectiveness of the facility's QAPI activities.

On 11/17/ at 2:39 pm, Staff A and by telephone Staff B stated there was no other documented QAPI information and no Governing Body identified actions for improvement.

Based on record review and interview, the hospital failed to conduct annual PIPs designed to improve the safety and quality of care.

This failed practice had the likelihood to affect the safety and health of all patients receiving care at the hospital due to the hospital's failure to identify annual PIPs, perform continued assessments, and analyze performance towards goal to determine effectiveness and sustainability.

Findings:

A review of QAPI records showed no documented PIPs for 2019 and up to 11/17/20.

On 11/17/ at 2:39 pm, Staff A and by telephone Staff B stated there were no documented PIPs.

Based on record review and interview, the Governing Body and Medical Staff failed to provide oversight over the QAPI Program and ensure QAPI activities:

1) had established quality indicators that were measured at a designated frequency, analyzed, and evaluated for effectiveness;
2) were determined, designed, and prioritized annually;
3) were defined with clear, specific safety expectations and included the establishment of goals or benchmarks in order to measure sustained improvement at a desired level.
4) had a documented reasons for being conducted, were designed for safety and quality, and measurable progress was achieved.

These failed practices had the potential for the Governing Body, who has full responsibility for hospital operations, to miss key safety and quality improvement opportunities, and to misinterpret what the data being gathered represented.

Findings:

A review of QAPI dated 01/14/19 - 09/09/19 and one for 2020 dated 10/19/20 showed routine data collected by departments with no initiation of PIP and no specific and measurable program.

On 11/17/ at 2:39 pm, Staff A and by telephone Staff B stated there was no other documented QAPI information and no Governing Body identified actions for improvement.

Based on record review and interview, the hospital failed to ensure reassessment of pain medication administration for two (Patient #3, and #7) of ten patients

This failed practice has the likelihood to result in no assessment of a patient's clinical condition and delayed intervention.

Review of a facility policy titled "Pain Assessment, Reassessment, and Management" read in part, "re-assess pain after each pain management intervention."

Patient #3

Review of the electronic medication record (EMR) showed acetaminophen-hydrocodone was administered for pain on 09/04/20 at 11:56 AM and pain reassessment not completed per facility policy.

On 11/17/20 at 1:00 PM, Staff G reviewed the EMR for Patient #8 and stated the pain reassessment was not completed per facility policy.

Patient #7

Review of the EMR showed acetaminophen-hydrocodone was administered for pain on 08/03/20 at 4:37 AM and pain reassessment not completed per facility policy.

On 11/17/20 at 1:20 PM, Staff G reviewed the EMR for Patient #9 and stated the pain reassessment was not completed per facility policy.

Based on record review and interview, the hospital failed to ensure the practitioner completed the history and physical for two (Patient #7 and #9) of 10 patients.

This failed practice has the likelihood to place patients at risk of receiving care that is non-therapeutic and not having their individualized patient history information communicated.

Findings:

Patient #7

Review of patient electronic medical record (EMR) "History and Physical" showed Patient #7 was admitted on 10/06/20 and the practitioner signed the document on 10/08/20 (2 days after admission).

On 11/17/20 at 1:43 PM, Staff G stated that this H&P was not signed within the appropriate time frame.

Patient #9

Review of patient electronic medical record (EMR) "History and Physical" showed Patient #9 was admitted on 10/12/20 and the practitioner signed the document on 10/23/20 (11 days after admission).

On 11/17/20 at 1:55 PM, Staff G stated that this H&P was not signed within 24 hours.


.