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Based on record review and interview the facility failed to provide Quality Assurance, Performance Improvement program that measures, analyzes and tracks adverse patient events to include their causes and implemented preventative actions and mechanisms that include feedback and learning throughout the facility. This failed practice can lead to ongoing occurrence of practices leading to adverse events and can cause patient harm.

The findings are:

A. Record review of Adverse Events for the past three months (January-March 2022) X 3 dates for 01/10, 01/21, and 01/25 of 2022. In the three events from the January dates, the call system was not working and staff was unable to efficiently call a code. 2 patients survived and were transferred to the ICU and the 3rd patient died after family requested CPR be discontinued. The events were not reported to Quality or Risk Committee and were listed as No Harm by a staff member who has since been terminated.

B. Record review of facility policy titled "Quality Assurance and Performance Improvement (QAPI)" created 03/2022, Last Approved 03/2022. Document states the" quality committee will meet monthly or no less than quarterly" and under Section E. (Facility Name) QAPI plan will be presented to the Quality Committee, Medical Executive Committee and Board of Directors Annually and an evaluation of yearly activities will be conducted, including the targeted process or program outcomes, the performance indicators(measures), findings, data, assessment and initiatives taken in response to findings. A summary of this data and related discussion, will be documented in a standard format and consists of: #5 Monthly Evaluations/Monitoring Activities/Reports, (letter c.) incident reports, (letter e. ) sentinel events, and (letter f.) \clinical monthly operating reports." . In the 12 months provided there is no mention of the failing call light system and there is very limited information regarding complaints/grievances/adverse events.

C. On 04/04/22 at 3:00 pm during interview with S(Staff) 2 (Director of Quality) who confirmed, "This facility had an issue with adverse events being recorded, reported and closed appropriately. The facility identified the issue and the staff responsible has been terminated. The 3 adverse events reviewed never made it to QAPI or Governing Body meetings."

Based on record review and interview the facility failed to report adverse events to the facility's governing body and QAPI (Quality Assurance Performance Improvement) program in order to set clear expectations for patient safety. This failed practice can lead to ongoing occurrence of practices leading to adverse events and can cause patient harm.

The findings are:

A. Record review of Adverse Events for the past three months (January-March 2022) X 3 dated 01/10, 01/21, and 01/25 of 2022 . In the 3 events from January, the call system was not working and staff was unable to efficiently call a code. 2 patients survived and were transferred to the ICU and the 3rd patient died after family requested CPR be discontinued. The events were not reported to Quality, Governing Body or Risk Committee and were listed as No Harm by a staff member who has since been terminated.

B. Record review of facility "Board Meeting Minutes" for 03/04/21 - 11/17/21, included only "Adverse Events" listed and did not expand on any discussion of any items.

C. Record review of facility policy titled "Quality Assurance and Performance Improvement (QAPI)" created 03/2022, Last Approved 03/2022. Document states the" quality committee will meet monthly or no less than quarterly" and under Section E. (Facility Name) QAPI plan will be presented to the Quality Committee, Medical Executive Committee and Board of Directors Annually and an evaluation of yearly activities will be conducted, including the targeted process or program outcomes, the performance indicators(measures), findings, data, assessment and initiatives taken in response to findings. A summary of this data and related discussion, will be documented in a standard format and consists of: #5 Monthly Evaluations/Monitoring Activities/Reports, (letter c.) incident reports, (letter e. ) sentinel events, and (letter f.) \clinical monthly operating reports." . In the 12 months provided there is no mention of the failing call light system and there is very limited information regarding complaints/grievances/adverse events.

D. On 04/04/22 at 3:00 pm during interview with S(Staff) 2 (Director of Quality) who confirmed, "This facility had an issue with adverse events being recorded, reported and closed appropriately. The facility identified the issue and the staff responsible has been terminated. The 3 adverse events reviewed never made it to QAPI or Governing Body meetings."

Based on record review and interview the facility failed to document a policy and procedure for preventing and controlling transmission of Covid-19 (a contagious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)) for all facility staff. This failed practice can cause transmission of Covid-19 in the facility.

The findings are:

A. Record review of Facility Policy titled, "Employee Covid-19 Vaccination" last revised 03/22. This policy does not address the need for exempt staff to get weekly testing and states staff will provide additional documentation as required but does not specify what additional documentation (testing). Staff S4 (Infection Control Director) brought in an email and a form that was sent out to employees that addresses the need for weekly testing for staff with exempt status on 02/18/22 that was not reflected on the policy revision on 03/22.

B. On 04/04/22 at 3:55 pm during interview with S4, (Infection Control Director), who confirmed, "When the Covid-19 policy was updated in March of 2022 the information on the email dated 01/06/22 and the Weekly Covid-19 Testing Requirement for Unvaccinated (Facility Name) Employees dated 02/18/22 that addresses the need for weekly testing, was not included in the policy, it may have been overlooked."