HospitalInspections.org

Based on observation, interview, and policy review, the provider failed to ensure equipment and supplies were properly monitored or maintained for the provision of emergency care for:
*Multiple supplies in one of one Broselow/Hinkle cart in emergency room 1.
*Documentation of monitoring/testing for one of one defibrillator in emergency room 1.
*One of one ventilator in emergency room 2.
*Availability of one of one defibrillator and crash cart for emergency use in emergency room 1 and the surgery room.
Findings include:

1. Observation of the Broselow/Hinkle PES (pediatric emergency system) color-coded cart located in emergency room 1 revealed the following outdated supplies:
*One bone marrow needle expired 4/2011.
*One intraosseous needle expired 4/2011.
*Two tracheostomy tubes expired 8/2011.
*Two nasogastric tubes with expiration dates of 6/2010 and 9/2010.
*Four esophageal tubes with expiration dates of 12/2010, 2/2011, 5/2011, and 10/2011.
*Two duodenal tubes with expiration dates of 7/2010 and 9/2010.
*Two suction catheters with expiration dates of 12/2010 and 1/2011.
*Three guaze sponges with expiration dates of 8/2011.
*One intravenous catheter expired 1/2012.
*Three oxygen tube/delivery modules, one with an expiration date of 6/2011, and two with expiration dates of 8/2011.

Interview on 2/28/12 at 10:00 a.m. with registered nurse (RN) F revealed the Broselow/Hinkle cart was a "work in progress." She stated she was aware multiple items needed to have been reordered, but that had not been done.

Interview on 2/29/12 at 1:00 p.m. with the director of patient care services revealed she was not aware there were so many items in the Broselow/Hinkle cart that were outdated. She stated the provider maintained a list of supplies needed for that cart, but it had not been restocked and updated.

2. Interview on 2/28/12 at 10:00 a.m. with RN F revealed nursing staff were to have run monitoring strips on the defibrillator each shift. She stated no log was maintained to ensure that had been done. She stated those strips were thrown away after the monitoring had been completed.

Interview on 2/29/12 at 11:40 a.m. with the director of patient care services revealed a log for checking monitoring strips on the emergency room defibrillator should have been maintained. She stated the provider had a tool to be used for monitoring those strips. She confirmed she did not have a record of that tool being completed since June 2011. She stated the provider did not have a policy regarding monitoring of the defibrillator.



27457

3. Observation on 2/28/12 at 12:40 p.m. of the Crossvent-3+ Ventilator in emergency room two revealed:
*The test lung was attached to the ventilator circuit. The test lung was cracked and had multiple tears in it making it unusable (photo 4).
*The biomedical inspection sticker on the back of the ventilator read it had last been nspected in September 2010.

Interview on 2/28/12 at 12:45 p.m. with licensed practical nurse (LPN) I revealed:
*She confirmed the test lung was damaged.
*She had never tested the ventilator before.

Interview and manufacturer's manual review on 2/28/12 at 1:00 p.m. with the director of patient care services, RN F, and LPN I revealed:
*They all confirmed the test lung was damaged.
*The ventilator was the only one in the facility and would have been used in the emergency room and the procedure room in the case of an emergency in either area.
*They believed they had ordered a new test lung but were unable to provide this surveyor an invoice indicating a new test lung had been ordered.
*No testing, calibration, or performance checks had been completed for the ventilator since they had gotten it. They thought they had received the ventilator two years ago.
*They all confirmed after reviewing the manufacturer's manual with this surveyor that proper testing, calibration, and performance checks had not been completed for the ventilator.
*They all confirmed logs for the testing, calibration, and performance checks for the ventilator should have been created.
*The director of patient care services agreed the ventilator was a life saving/sustaining piece of equipment and should have been properly monitored and maintained to ensure its function in the advent of an emergency.

4. Interview and observation on 2/28/12 at 11:00 a.m. with the director of patient care services in the procedure room/operating room revealed:
*She administered conscious sedation to the patients who had gastrointestinal procedures.
*The only procedures performed at the facility were endoscopic gastrointestinal procedures. Those procedures were performed one day a month. On most of the procedure days, five to nine procedures were performed taking up most of the day.
*The procedure room had no emergency supplies or equipment in it at that time (i.e. defibrillator, medications, and emergency oxygen supplies). When she was asked where the emergency supplies were she stated she took the emergency rooms entire emergency cart including the defibrillator into the procedure room on procedure day.
*The provider had only one defibrillator.
*She agreed on procedure days the emergency room was left without proper, readily available, emergency supplies and equipment in it for multiple hours. Those supplies were in the procedure room and unavailable to emergency room staff.

Based on observation, interview, and policy review, the provider failed to:
*Maintain one of one ventilator in a safe operating condition and with a current biomedical inspection.
*Follow expiration dates on thirteen randomly observed cans of quick care waterless antimicrobial foaming hand rub.
*Implement a cleaning policy and procedure for the hydrocollator in physical therapy.
*Store seven cases of examination (exam) gloves and one case of surgical masks off the floor in one of one clean linen room.
*Ensure all electrical medical equipment passed a biomedical inspection prior to being placed in operation.
Findings include:

1. Observation, interview, and manufacturer's manual review on 2/28/12 from 11:40 a.m. through 1:00 p.m. revealed the provider was not properly maintaining its emergency ventilator. Refer to C204, finding 3.

Interview on 2/28/12 at 1:45 p.m. with the biomedical technician responsible for testing the provider's equipment revealed:
*He had no record of the ventilator on his list of equipment and had no record of the last biomedical inspection for the ventilator.
*The sticker that was on the equipment would indicate the last time the ventilator had been through a biomedical inspection.

2. Random observation on 2/28/12 starting at 8:30 a.m. revealed a total of thirteen cans of expired quick care waterless antimicrobial foaming hand rub located at the following locations:
*In the clinic at exam room 1, between exam rooms 2 and 3, the nurses station, and by procedure room 7. All cans had an expiration date of December 2011.
*In the hospital at rooms 120, 121, and 123 the cans had a November 2011 expiration date.
*In the hospital at rooms 115, 125, emergency room 2, the dirty utility, the laboratory draw room, and the computed tomography room the cans had a December 2011 expiration date.

Interview on 2/29/12 at 9:30 a.m. with the head of environmental services revealed:
*Housekeeping staff were supposed to track the expiration dates on the cans while performing the daily cleaning of the hospital.
*The cans were supposed to be removed from service when the expiration date was reached.

3. Observation and interview on 2/28/12 at 1:30 p.m. with physical therapist D in physical therapy revealed:
*The provider had a hydrocollator.
*Physical therapist D had been at the facility for about one year. She had not cleaned the hydrocollator since she had started. She did not know when it was last cleaned. There was no schedule or policy and procedure for the cleaning of the hydrocollator.
*She did not have the operator's manual for the hydrocollator. She was not aware the manufacturer's recommendation for the cleaning of the hydrocollator was a minimum of every two weeks.

4. Observation on 2/28/12 at 2:30 p.m. in the clean linen room with the director of environmental services revealed:
*Seven cases of exam gloves and one case of surgical masks were stored on the floor in the clean linen room (photos 1, 2, and 3).
*Those items were the emergency disaster preparedness supplies. He agreed the supplies should not have been stored on the floor.

5. Random observation on 2/28/12 revealed one Welch Allyn spot vital signs monitor and one Nihon Kohden bedside monitor did not have a biomedical inspection sticker.

Interview on 2/28/12 at 1:45 p.m. with the biomedical technician responsible for testing the provider's equipment revealed:
*He was not aware the provider had either piece of equipment.
*If the equipment was not inspected before being placed in service it would not have a biomedical inspection sticker.

Interview on 2/28/12 at 1:47 p.m. with the head of environmental services revealed:
*The provider's policy was to have all new equipment inspected by the biomedical technician before being placed into service.
*Lately some of the new equipment had not passed through the maintenance department. The nursing department would order the new equipment, assemble it, and put it into service without it being inspected.

Review of the provider's undated biomedical policy revealed:
*"All electrical and electronic testing will be done at intervals not to exceed six months on patient care equipment.
*Special care areas such as Surgery, ICU, Cardiopulmonary Services, Nursery, OB, and Emergency Department will be tested semi-annually.
*All new equipment is tested, evaluated and put on a p.m. card prior to use."






25107

Based on observation, policy review, and interview, the provider failed to ensure:
*Medications in five of eight areas where medications were stored (pharmacy, nurses station medication room, outpatient clinic, emergency room, and ultrasound room) were not used after their expiration dates or assigned beyond use dates had been reached. Findings include:

1. Observation on 2/28/12 at 9:30 a.m. of the nurses station medication room revealed one multiple-dose vial of lidocaine 1 percent (%) injection not marked with an opening date.

2. Observation on 2/28/12 at 9:45 a.m. of the pharmacy revealed:
*Seven pre-mixed bags of Zosyn 3.375 gram with an expiration date of 1/3/12.
*Ten Vials of atracurium 50 milligram (mg)/milliliter (ml) injection with an expiration date of January 2012.
*Five bottles of 100 ciprofloxacin 500 mg tablets with an expiration date of October 2011.

3. Observation on 2/29/12 at 9:30 a.m. of the outpatient clinic revealed one multiple-dose vial of lidocaine with epinephrine injection marked with an opening date of 1/3/12.

4. Observation on 2/29/12 at 10:00 a.m. of the emergency room crash cart revealed one bag of heparin drip solution with an expiration date of 2/1/12.

5. Review of the provider's policy and procedure for multiple/single-use vials reviewed in January 2010 revealed:
*Previously entered multiple-dose vials should have been discarded when a month had gone by since the first entry.
*Multiple-dose vials that were not dated on first entry should have been discarded when discovered.

6. Interview on 2/29/12 at 10:00 a.m. with pharmacist G revealed the provider's procedure was for all multiple-dose vials of medication to be removed from use thirty days after opening. He was not sure if the personnel in the outpatient clinic were aware of the policy.

7. Review of the USP General Chapter <797> Pharmaceutical Compounding - Sterile Preparations, effective 6/1/08, revealed the beyond-use date for an opened or entered (e.g., needle-punctured) multiple-dose container with antimicrobial preservatives was twenty-eight days, unless otherwise specified by the manufacturer.




23059

8. Observation on 2/28/12 at 9:55 a.m. in emergency room (ER) one revealed one 50 ml vial of lidocaine hydrochloride 1%/epinephrine 1:100,000 units had expired on 2/1/12.

Interview with registered nurse F at that time revealed supplies in the ER were checked when the nurses had time. She stated there was no regular schedule for when supplies should have been checked.



27457

9. Observation on 2/28/12 at 10:34 a.m. of the cabinet above the sink in the ultrasound room revealed an opened 30 ml vial of sodium chloride with the expiration date 12/1/10. The vial had not been labeled with the date it had been opened.

Interview on 2/28/12 at 10:50 a.m. with the pharmacist revealed he agreed the above vial:
*Had not been properly labeled after it had been opened.
*Should have been removed from circulation as it was expired.

3. Interview on 2/28/12 at 10:35 a.m. with the head of central supply and sterilization revealed:
*Each load processed in the sterilizer had a biological indicator processed with it.
*The biological indicator was taken to the laboratory to incubate. Once it had been incubated the laboratory technician would read and record the results. The results were only reported to the head of central supply and sterilization if the biological showed a failed result.

Interview and record review on 2/28/12 at 10:50 a.m. with laboratory technician H revealed:
*The biological indicator was incubated and read at twenty-four and forty-eight hours.
*The results were recorded on a pad of paper. No control was documented with the results.
*No control biological indicator was incubated with the sterilized biological indicator to verify the biological indicators were working correctly.
*Technician H was not aware a control should have been run to verify the biological indicators were working correctly.

Interview on 2/28/12 at 11:00 a.m. with the head of central supply and sterilization revealed:
*She had no formal training in sterilizer operation. All of her training was on the job.
*She had never been taught to run a control biological indicator.
*She agreed without running a control biological indicator she could not verify the biological indicator was working correctly.
*She did not have the instructions for the biological indicator the provider was using. She did not have the operator's manual for the sterilizer.

Review of the provider's undated quality control in sterilization by means of an autoclave policy revealed the policy did not address the use of a control biological indicator.

4. Observation and interview on 2/29/12 at 8:45 a.m. with the head of central supply and sterilization revealed:
*A warming cabinet was kept in the decontamination room (photo 7). The warming cabinet was used to store two bags of fluids and some blankets.
*The fluids were used mostly in the patients' rooms. The blankets were used in the patients' rooms and in the operating room.
*The decontamination room was used for cleaning of contaminated medical equipment such as endoscopes.
*The blankets and fluids would be considered clean, and the decontamination room would be considered dirty.
*The warming cabinet had been in the decontamination room since 2006 which was before she had started working in the sterilization department. She had never thought about the warming cabinet being stored in the decontamination room since it had always been there. She agreed clean supplies should not have been stored in a dirty room.

Interview on 2/29/12 at 9:10 a.m. with the director of patient care services revealed she agreed the blanket warmer should not have been stored in the decontamination room.


23059

Based on observation, interview, and policy review, the provider failed to ensure effective infection control practices were implemented and maintained for the:
*Education and training of the infection prevention and control (IPC) nurse.
*Monitoring of staff practices related to infection prevention and control.
*Monitoring of controls for sterilization equipment.
*Storage of clean supplies away from potentially contaminated equipment in the decontamination room.
*Blood draw process for one of one phlebotomist (H) observed.
*Monitoring of supplies in the operating room.
Findings include:

1. Phone interview on 2/29/12 at 1:10 p.m. with the IPC nurse revealed she had received no formalized training in infection prevention and control. She stated she had attended "a couple of in-services" at Avera McKennan Hospital and would contact the IPC nurse there if she had questions. She stated she worked part-time for this provider and was also employed at another facility. She stated she would complete IPC duties as time allowed while working as a staff nurse on the floor.

2. Phone interview at the above time with the IPC nurse revealed she had not monitored staff practices related to infection prevention and control. She stated she had asked staff members to monitor each other but had not received any reports regarding that monitoring. Information provided to this surveyor by fax on 3/5/12 revealed hand hygiene observations had last been conducted "8/16." There was no year documented on the forms to indicate when the observation had been completed.



27457

5. Observation on 2/28/12 at 8:43 a.m. of patient 1 having blood drawn revealed:
*Laboratory (lab) technician H came into her room and set down her tray full of laboratory supplies on the patient's bed. She then proceeded to set her protime machine and other lab supplies on the patient's bedside tray that had the patient's meal on it. After drawing the patient's blood she placed an alcohol swab on the patient's bedside tray. She then squirted blood from the blood draw syringe into that swab saturating it with blood, exposing the bedside tray to that blood. The blood left in that syringe was used by her to inoculate the test strip in the protime machine. That bedside tray was never disinfected after it had been exposed to blood.
*After completion of the blood draw lab technician H proceed to place the uncleaned protime machine into her lab tray full of clean supplies with the bloody test strip still in it.
*As lab technician H left the patient's room blood dripped from the protime machine test strip she had left in the machine onto the hallway floor. She proceeded to set her lab tray on the hallway floor and then used a single alcohol pad to clean the floor. After completing that clean-up she proceeded to take that uncleaned cross-contaminated lab tray and protime machine back to the lab.

Interview on 2/29/12 at 9:04 a.m. with the lab director revealed she agreed:
*The lab tray noted above should not have been on the patient's bed or on the hallway floor as that cross-contaminated the tray.
*Proper phlebotomy (blood drawing) technique was not used when using the protime machine.
*Proper disinfection of the bedside table, the protime machine, and the hallway floor had not occurred during the above observation.
*The lab tray and the protime machine should have been cleaned/disinfected prior to leaving the patient's room.
*The above phlebotomy observation had not met the provider's infection control or phlebotomy policies.

6. Observation and interview on 2/28/12 at 11:00 a.m. in the procedure/operating room with the patient services director revealed:
*The following supplies had expired:-Two needle injectors used in gastrointestinal procedures had expired on 4/4/91.
-Thirty Hand-trol cautery units had expired in January 2012.
*Three plastic bags of miscellaneous unlabeled gastrointestinal wires and forceps were in the bottom of the cabinet with clean supplies.
*She agreed all expired supplies should have been removed from circulation.
*The miscellaneous gastrointestinal wires and forceps found above were old and were no longer used. She was unable to tell this surveyor if that equipment had been disinfected prior to storage. She agreed that equipment should have been removed to ensure cleanliness and safety standards were met.
*She confirmed the above findings were infection control breaches and had not met the provider's policies related to expired supplies.

Based on interview and manual review, the provider failed to ensure policies were reviewed annually for ten of ten policy manuals (radiology, emergency, infection control, swing bed, physical therapy, operating room, sterilization, medical record, laboratory, and nursing services) reviewed. Findings include:

1. Review of policy and procedure manuals revealed:
*The radiology department manual was last reviewed in 2001.
*The emergency department manual was last reviewed in 2005.
*The infection control manual, the swing bed manual, the physical therapy manual, the operating room manual, the sterilization department manual, the medical record department manual, and laboratory manual were last reviewed in 2008.
*The nursing services department manual was last reviewed in 2010.

Interview on 2/29/12 at 9:15 a.m. with the radiology department director stated her department's policy and procedure manual had not been reviewed for some time. She was not sure when the manual had last been reviewed.




18560

Interview on 2/29/12 at 9:15 a.m. with the administrator revealed:
*He was not aware policies from multiple departments had not been updated annually.
*He was not aware of the requirement for annually updating policies for all service lines.




27457

Based on observation, interview, and manufacturer's manual review, the provider failed to ensure nursing staff were trained and oriented on how to use, find, and recognize emergency equipment in two of two emergency rooms. Findings include:

1. Interview and manufacturer's manual review on 2/28/12 at 1:00 p.m. with the director of patient care services, registered nurse (RN) F, and licensed practical nurse (LPN) I regarding the set-up and use of the ventilator revealed:
*Nursing staff were responsible for all respiratory care duties as no respiratory therapists were employed by the provider.
*The provider had the ventilator available for use for over two years.
*The ventilator would have been used in the emergency room as well as the procedure/operating room in the case of an emergency.
*None of them were able to demonstrate how to set-up or use the ventilator.
*They had not completed any recent training or competency testing related to the set-up and use of the ventilator.
*None of them had reviewed the manufacturer's manual on how to properly use, monitor, and inspect the ventilator. Refer to C204, finding 3 and C222, finding 1.
*RN F and LPN I had received some training on the ventilator, however they could not remember when.
*They were not aware of any policies or procedures developed for the set-up and use of the ventilator.
*They were not aware if any of the physicians or mid-level providers had training on the set-up and use of the ventilator.
*Director of patient care services had not received training on the ventilator. She would have been responsible for the use and set-up of the ventilator in the procedure/operating room, as she was the only nurse in the room for all procedures.
*They all agreed nursing staff were not properly trained on the set-up, use, and monitoring of the ventilator.

2. Interview and observation on 2/28/12 at 1:10 p.m. with RN F and LPN I regarding the location of the provider's tracheostomy set revealed:
*Both nurses were responsible for the emergency room that day.
*When this surveyor requested to see the provider's tracheostomy set one nurse showed this surveyor a chest tube tray and the other showed this surveyor a chest tube. After ten minutes of looking through the supplies in the emergency room neither nurse was able to find the tracheostomy set. They both concluded they did not have one.
*They had not received training related to emergency tracheostomy set-up.

Interview and observation on 2/28/12 at 1:25 p.m. with the director of patient care services revealed:
*She was able to immediately locate and identify the tracheostomy set located in the same cupboard RN F and LPN I had been looking in.
*She agreed nurses who were staffing the emergency room should have been able to immediately locate, identify, and set-up the tracheostomy set.
*She agreed nursing staff needed to have regular training and practice on the completion of emergency procedures not normally performed to maintain competence and patient safety.

Based on interview and policy review, the provider failed to have electronic medical record policies and procedures that described the use of the electronic medical record and protection of the electronic medical record. Findings include:

1. Interview on 2/28/12 at 8:30 a.m. with registered nurse F revealed the provider used an electronic medical record for all nursing documentation and a paper medical record for all other entries.

Review of the provider's medical records policy and procedure manual revealed no policies had been developed to address the provider's use of the electronic medical record.

Interview on 2/29/12 at 8:35 a.m. with the medical records director revealed:
*She confirmed medical records did not have a policy for the use and protection of electronic medical records.
*She believed the director of patient care services would have been responsible for the policies related to the electronic medical record as only nurses used the electronic medical record.
*She was not aware who was responsible for the monitoring and the protection of the electronic nursing data.

Interview on 2/29/12 at 9:30 a.m. with the director of patient care services revealed:
*She had no responsibility for development of electronic medical policies.
*She was not aware who was responsible for the monitoring and the protection of the electronic nursing data.
*She confirmed policies should have been in place for the use and protection of the electronic medical record.

Interview on 2/29/12 at 1:35 p.m. with the medical records director revealed:
*She had contacted the corporate office and found out policies should have been developed and implemented for electronic medical record use and protection prior to the time it was first used.
*She agreed medical records staff and administration should have developed policies for the use and protection of electronic medical records.

Based on observation, interview, and policy review, the provider failed to ensure safeguards were in place against unauthorized use of patient medical information in two of two radiology film storage areas across the hall from the physical therapy area. Findings include:

1. Observation on 2/28/12 at 10:07 a.m. of the cabinets in the hallway across from the physical therapy area revealed:
*Two cabinets holding hundreds of radiology films with patient information on them were unsecured.
*The hallway was open to the public and had outpatient traffic in it.
*The hallway was not monitored by hospital staff.

Interview on 2/28/12 at 10:15 a.m. with radiology technologist J revealed:
*Those records were never secured.
*She was unsure where to find the key to lock-up the radiology films.
*She considered radiology films part of a patient's medical record.
*She agreed the radiology films should have been secured.

Interview on 2/28/12 at 10:30 a.m. with the director of medical records revealed she:
*Was not aware radiology staff were leaving radiology films unsecured.
*Agreed radiology films were part of the patient's medical record and should have been secured from unauthorized use.

Review of the provider's September 2008 record protection policy revealed it was the responsibility of hospital staff to ensure the protection of patient information from unauthorized use.

Based on interview, record review, and policy review, the provider failed to maintain an effective quality assurance program to ensure:
*Ongoing monitoring and data collection for all services provided.
*Problems were identified, evaluated, and programs put in place for future prevention.
*Corrective actions were identified, implemented, and evaluated.
*Measures were implemented to improve quality on a continuous basis.
Findings include:

1. Review of the provider's quality assurance meeting minutes binder revealed minutes were last recorded for a 9/20/11 meeting. Review of the minutes revealed the members had discussed customer service. No other areas of provider service were noted as having been discussed at the meeting. It was noted in the minutes that new quality assurance plans were needed for all areas for 2012.

2. Review of the provider's department level annual quality assurance plan revealed each service area was required to maintain an individual plan. Review of those plans revealed each plan contained:
*Department reviewed.
*Dates of review.
*Facility priority focus area.
*Name of quality area studied.
*Numerator and denominator for measuring quality.
*Goal or benchmark for the project.
*Key players to be involved.
*Ways to identify patients or data resources.
*Opened or closed record review.
*Method of data collection.
*Sample size.
*Frequency of data collection.
*Data collectors.
*Where the data would be reported.

Review of each of the department area's annual quality plan revealed:
*Of eighteen department areas reviewed only two had identified a new quality improvement plan for 2012.
*Of fifty studies undertaken by the above department areas only twelve areas had been revised or updated since 2009. Most studies remained the same since 10/1/07.
*A scorecard for outcomes on the above study areas had not been maintained since 9/30/10.

3. Review of the provider's quality performance improvement plan last updated for fiscal year 10/1/09 through 9/30/10 revealed:
*The provider's board of directors, medical staff, and administration were to ensure there was a quality improvement program designed to objectively and systematically monitor, evaluate, and improve the services offered by the provider.
*The quality improvement program would ensure the delivery of safe, efficient, and cost-effective services to patients, families, and customers.
*Quality improvement would be accomplished by assessing patient care and other support processes in a systematic, ongoing manner in order to identify improvement opportunities and act on them in a timely manner.
*The administrator was responsible for the overall operation of the quality improvement program.
*The quality team was to have been made up of representatives of all departments including the medical staff. The quality team's responsibilities included:
-Education to organizational staff on quality improvement.
-Assurance of an active, ongoing, effective process.
-Establishment and support of priorities for quality improvement efforts.
-Making recommendations for formalized quality improvement teams.
-Assurance that each department was participating in quality improvement efforts.
-Evaluation of all quality improvement efforts for effectiveness.
-Monitoring routine reports that evaluate quality and outcomes, and facilitate change as necessary.
-Monitoring quality performance to ensure improvements were sustained.
-Reporting quality monitoring through dashboards.
*The quality team was to have reported its findings to the medical staff and board of directors.
*All activities were to have been tracked on a dashboard reporting format.

Review of the provider's quality improvement plan revealed it had last been reviewed by the governing board on 2/24/09.

Review of the provider's dashboard scorecard revealed it had last been updated 9/30/10.

Interview on 2/29/12 at 10:20 a.m. with the administrator revealed the quality improvement team discussed customer service related to their departmental areas. He stated:
*Those areas were studied "until we are done with them."
*The team did not have a format or process in place for determining when an area of study had been completed.
*He thought data had been maintained on all areas, and he would check to find that documentation.
*The quality team met on a quarterly basis.
*He had written a 12/19/11 quality assurance committee meeting on his calendar. He stated he was sure the committee had met on that day but confirmed no minutes had been written from that meeting.
*He could not confirm a quality assurance meeting had been held since 9/20/11.
*He confirmed quality program indicators had not been shared with the governing board.

Continued interview on 2/29/12 at 3:00 p.m. with the administrator revealed he could not find updated data on quality improvement activities. He confirmed the last dashboard scorecard on those quality improvement processes had been completed on 9/30/10.