HospitalInspections.org

Based on interview and record review, the facility failed to maintain a data-based analysis and patient-centered QAPI program. Findings include:

During an interview on 3/30/23 at 10:00 a.m., staff member C stated she facilitated the QAPI program and each department decided on their own performance improvement projects. Staff member B stated the facility had no patient concerns. He stated the patients had some falls, but not many. When asked about data analysis for patients leaving the Emergency department without being seen, and where the facility could affect the outcome, staff member C stated there was no pattern and it would be useless. The examples given by staff member C for patient-centered outcomes included ensuring the patients received the correct medications, fixing a hot water leak, cardiac markers were not delayed in the lab, and a more user friendly activity calendar. Staff member B stated falls, infection control, and patient concerns data had not been discussed at the QAPI meeting.

Record review the QAPI meeting minutes dated 3/23/23, did not include data elements or analysis to improve patient care outcomes.

Based on interview and record review, the facility failed to develop comprehensive and person-centered care plans for the 8 patients (#s 2, 3, 4, 5, 11, 12, 14, and 15) of 8 sampled patients in the swing beds. Findings include:

During an interview on 3/28/23 at 1:40 p.m., staff member B stated the care plans were in a binder at the nursing station.

Review of the care plan binder showed the 'plans' had not been reviewed or updated. The 'care plans' did not include initiation dates.

During an interview on 3/29/23 at 2:43 p.m., staff member D stated the binder was not patient care plans, but had been made to introduce the facility staff to the newly admitted patients from the long term care facility, which had closed. She stated she conducted the care plan meetings, but did not know what nursing did to create a care plan.

During an interview on 3/29/23 at 3:00 p.m., staff member H stated she was not sure where or how the care plans were used. Staff member J stated she had heard the term 'care plan' but did not know what it was.

Review of the patients' Electronic Health Record residing in the swing beds, did not include care plans.