HospitalInspections.org

Based on observation, interview, and record review, the Critical Access Hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.

Findings include:

Please refer to Life Safety Code inspection tags: K11, K17, K18, K29, K52, K77, K147.

Based on interview and document review the Critical Access Hospital (CAH) failed to have an effective quality assurance/performance improvement (QAPI) program which evaluated on a continuous basis the quality of all patient care services, including the areas of radiology, housekeeping, and laundry. This had the potential to affect all present and future CAH patients.

Findings include:

The CAH provided copies of their quality assurance/performance improvement protocols, expectations and goals related to improvements for patient care, and these documents were reviewed.

During follow up review with representatives from various departments within the CAH, it was determined that although data was generally being collected, not all departments were conducting QAPI in a manner so as to improve systems for patient care.

During interview with the radiology director on 3/24/15, at 2:30 p.m. it was learned the radiology department had been monitoring the same goals for the past year even though they had met their goals for radiation safety, technologist training, and image quality. Although a goal for labeling images was not met, there had been no modifications to the goal.

During interview with the housekeeping director on 3/25/15, at 11:00 a.m. revealed the housekeeping goals were related to cleaning of vents, fans and ceilings for the past year. Although the department was keeping records of when cleaning was done and that they had met consistently achieved 95% or greater success, there had been no modification to the department's goals for quality.

During interview with the laundry director on 3/25/15, at 11:15 a.m. confirmed the laundry department had only initiated goals for washing machine temperatures to be appropriate for the past year. There had been no modifications to the CAHs goals for the laundry department in order to improve quality for patients.

The QAPI program director was interviewed on 3/25/15, at 11:45 a.m. and confirmed this information.