HospitalInspections.org

Based on review of the minutes of the Department Head Meetings, the Medical Staff Meetings and Board of Trustee Meetings, review of the Departmental Quality Assurance (QA) Grid for 2012, and interview with staff, the hospital failed to ensure that it had an ongoing program of Quality Assurance/ Performance Improvement (QA/PI) that had measured, analyzed, and tracked quality indicators, including adverse patient events.


Findings include:


Review of the Minutes of the Department Head Meetings, Medical Staff Meetings and the Board of Trustee Meetings revealed that the hospital had done performance improvement studies, but there was no documented evidence available for review to verify that the facility had measured, analyzed and tracked quality indicators from each department as designated on the Departmental QA Grid for 2012.


Interview with the Administrator and the Coordinator for the QA/PI Program on October 10, 2012 at 1:30 p.m. revealed that while the facility had the indicators in place on the Departmental QA Grid for 2012, there had not been any monitoring of these indicators by the Departments of the Hospital.

Based on observation, the hospital failed to follow procedures for the proper routine storage and prompt disposal of bioharzdous trash.


Findings include:


On 10/09/2012, at approximately 11:00 a.m., observation revealed that biohazardous waste was being stored in an area surrounded by chain link fencing on the hospital grounds. The area had a covering on top but it was open on all sides. This failed to protect the bioharzdous waste from animals, rodents, rain and wind.