HospitalInspections.org

Based on observation, review of facility documentation and staff interview, the facility failed to provide a sanitary environment which avoided sources and transmission of infection for all patients, staff and visitors.

Findings were:

A tour of the hospital on the afternoon of 12/13/22 with the chief nursing officer and administrative assistant revealed the following:

In the nursing station medication room:
* Opened multidose vials of three (3) medications as follows:
-- Humalog U-100 opened on 11/8/22
-- Lantus 100 units/mL with no date when opened
-- Humulin R 100U/mL 3 opened 10/1/22
* A ceiling tile with a line of perforations across it. The perforations appeared to be slightly crumbly. Non-intact ceiling tiles can allow debris and other contaminants into the area.

In the patient nourishment area:
* Laminate had separated from the permeable strand-board behind it. The laminate was cracked and sticking off the cabinets in spots. The strand-board behind the laminate could not be adequately cleaned.

In the patient supply room:
* approximately 8 external shipping containers were housed on shelves above other clean patient supplies ready for patient use. External shipping containers can contain numerous contaminants, as well as house pests.


The two staff on the tour acknowledged surveyor findings during the tour. The administrative assistant stated, "We'll be getting the guys over here to work on this today."


Facility policy #Pharm-1007 entitled, "Labeling Standards," included the following:
"...* The beyond-use date (BUD) for an opened or entered (i.e., needle-punctured) multiple dose contained with antimicrobial preservatives shall be 28 days, unless otherwise specified by the manufacturer.
* The healthcare provider shall write the expiration date on the vial when it is opened.
* This revised expiration date replaces the manufacturer's original expiration date unless the original expiration date occurs earlier than the 28-day date..."

Based on a review of facility documentation and staff interview, the facility failed to ensure all hospital departments were actively involved in the comprehensive QAPI program.

Findings were:

Facility policy entitled "Quality Assurance and Performance Improvement Program and Patient Safety Plan," last approved 10/23/2018, included the following:
" ...As patient care is a coordinated and collaborative effort, the approach to improving performance involves multiple disciplines in establishing the plans, processes and mechanisms that comprise the performance improvement activities at MCHD (McCamey County Healthcare District) ...

II. GOALS ...
E. Emphasize a collaborative, collegial approach to both organization-wide departmental and interdepartmental performance improvement activities;
F. Use team methods and performance improvement tools to identify and analyze key customers, indicators, and processes ...

IV. QUALITY ASSUMPTIONS ...
D. Each department in the organization will be involved in the task of continuous quality improvement ...

XIV. REPORTING
A. Results of monitoring activities will be reported at regularly scheduled meetings of the QAPI committee ...

XXIII. QUALITY ASSURANCE PERFORMANCE IMPROVEMENT (QAPI)
A. In order for the QAPI Committee to address clinical, operational, and leadership processes, every department director and/or designee that participates in QAPI is responsible for the following:
1. Reviewing and modifying strategic goals, clinical indicators and PI focus as necessary specific to their department and any inter-departmental process improvements;
2. Fulfilling/achieving said performance outcomes/goals ...
5. Providing regular reports to the QAPI Committee ...

XXIX. Methodology: ...
A. All departments within the organization (patient care and non-patient care departments) shall be responsible to report patient safety occurrences and potential occurrences to their Director or designee who shall aggregate occurrence information and present a report to the interdisciplinary Quality Assurance Performance Improvement Committee on a quarterly basis ..."


A review of the facility QAPI committee meeting minutes for 2022 revealed multiple entries in which either very little or no indicator information was available for the various hospital departments. For example, the QAPI 3rd Quarter 2022 Minutes (no date) included the following:

" ...Old Business
B. Infection Prevention and Control
a. Continue monitoring COVID cases
b. Visitors are still required to wear a mask while in the facility ...
E. Radiology
Director not present at QAPI meeting ...

New Business ...
D. Laboratory
a. Director not present at QAPI meeting
E. Radiology
a. Director not present at QAPI meeting
F. Housekeeping/Laundry
a. Director not present at QAPI meeting ..."

In an interview with the hospital Director of Quality on 12/13/22 at 11:05 a.m. in the hospital conference room, she stated, "None of those directors were at that meeting." When asked why, she shrugged and said, "I don't know." When asked if the directors who weren't present at the meeting had submitted their reporting data to her for discussion there, she said they had not.

Based on a review of facility documentation and staff interview, the facility failed to ensure the hospital QAPI program and content of the QAPI committee meetings used and reflected objective measures to evaluate its current quality of patient care and safety, implemented and assessed interventions based on the results of such evaluation, and monitored outcomes.

Findings were:

Facility policy entitled "Quality Assurance and Performance Improvement Program and Patient Safety Plan," last approved 10/23/2018, included the following:
" ...As patient care is a coordinated and collaborative effort, the approach to improving performance involves multiple disciplines in establishing the plans, processes and mechanisms that comprise the performance improvement activities at MCHD (McCamey County Healthcare District) ...

II. GOALS ...
E. Emphasize a collaborative, collegial approach to both organization-wide departmental and interdepartmental performance improvement activities;
F. Use team methods and performance improvement tools to identify and analyze key customers, indicators, and processes ...
I. Utilize objective, consistent criteria for intensive review of indicators that do not meet established benchmarks ...

VII. QUALITY DEFINITION ...
A. Quality means doing the right things correctly and making continuous improvements ...
B. The collection, aggregation and analysis of relevant data relevant data leading to the identification and implementation of strategies to improve existing processes and outcomes ...

XIV. REPORTING
A. Results of monitoring activities will be reported at regularly scheduled meetings of the QAPI committee ...

XXIII. QUALITY ASSURANCE PERFORMANCE IMPROVEMENT (QAPI)
A. In order for the QAPI Committee to address clinical, operational, and leadership processes, every department director and/or designee that participates in QAPI is responsible for the following:
1. Reviewing and modifying strategic goals, clinical indicators and PI focus as necessary specific to their department and any inter-departmental process improvements;
2. Fulfilling/achieving said performance outcomes/goals ...

XXIX. Methodology: ...
A. All departments within the organization (patient care and non-patient care departments) shall be responsible to report patient safety occurrences and potential occurrences to their Director or designee who shall aggregate occurrence information and present a report to the interdisciplinary Quality Assurance Performance Improvement Committee on a quarterly basis ..."


A review of the facility QAPI committee meeting minutes for 2022 revealed meeting content primarily of a staff meeting-like nature, as well as multiple entries in which little or no departmental indicator reporting was included. For example, the minutes included the following:

QAPI 1st Quarter 2022 Minutes (no date):
" ...Old Business
a) Hospital ED
i) Census for inpatient and swing beds has increased.
ii) Currently seeking 1 FT RN ...
b) Infection Prevention and Control
i) Hospital quarantine policy
ii) Visitor policy for ED and the hospital.
iii) Discussed ancillary staff not wearing proper PPE during patient care ...
III. New Business
a) Hospital/ED
i) Census has increased slightly for ED ...
ii) 3 FT nurses needed ...
b) Infection Prevention and Control
i) Visitor policy for ED and the hospital
ii) Staff is 100% vaccinated facility wide ...
g) Safety/Maintenance ...
ii) 2 more keypads are needed for the hospital ..."

QAPI 3rd Quarter 2022 Minutes (no date):
" ...Old Business
B. Infection Prevention and Control
a. Continue monitoring COVID cases
b. Visitors are still required to wear a mask while in the facility ...
E. Radiology
Director not present at QAPI meeting ...

New Business ...
D. Laboratory
a. Director not present at QAPI meeting
E. Radiology
a. Director not present at QAPI meeting
F. Housekeeping/Laundry
a. Director not present at QAPI meeting ..."

In an interview with the Director of Quality on 12/13/22 at 11:05 a.m. in the hospital conference room, she said she had been in her position since February 2021, and reported she had recently attended a learning session with a quality consultant. She stated, "I feel like I know a little more about what I'm doing with quality now, but there's still a learning curve. It's been a learning curve." When asked if she understood that meeting content seemed staff meeting-like, she nodded. When asked if the directors who weren't present at the meeting(s) had submitted their reporting data to her for discussion there, she said they had not.