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Based on staff interview and medical record review, the facility failed to ensure that Neuro Interventional Radiology services developed and implemented an effective Quality Assessment and Performance Improvement (QAPI) plan.

As a result, the quality of patient care service(s) was not monitored.


Findings:

See Tags A 283 & A 309)

Based on staff interview and medical record review, the facility failed to ensure that data for Neuro-Interventional Radiology Services was collected for Quality Assurance Performance Improvement (QAPI) program in order to assess and evaluate and/or track and trend the information regarding the quality of patient care and to identify areas for improvement.


Findings:

On 03/03/16, the latest quarterly QAPI reports for Neuro Surgical Interventions were requested several times, but were not provided by the facility.

On 03/03/2016, at 11:40, an interview was conducted with Staff B (Interventional Neuro Radiology) and Staff H (Interventional Neuro Radiology). During the interview Staff B stated that Quality Assurance and Performance Improvement studies are conducted and reviewed quarterly.
The facility failed to provide evidence of its QAPI activities and that the activities focused on areas that are high risk (severity), high volume (incidence or prevalence), or problem prone.




On 03/02/2016-03/07/2016, the facility failed to provide the required information for the Hospital/CAH Data Base Worksheet.
As per Staff A (VP Medical Affairs), Neuro Intervention is a relatively new service that is being provided by the facility, but there was no evidence of QAPI monitoring for this service. No QAPI quarterly reports were provided by the Neuro Interventional Radiology Department.

These findings were confirmed with the facility's Staff H (Director, Patient Safety).

Based on interview and document review, there is no evidence that the facility has an ongoing formal Quality Assurance and Performance Improvement (QAPI) program aimed at improvement of quality of care and services.

Findings:

On 03/02/2016, at 12:07, an interview was conducted with Staff A regarding QAPI program. During the interview, the Staff A (Vice President of Medical Affairs) stated that the administration is working on a contract with a consulting firm to provide external QAPI peer review services.
On 03/04/2016, at 15:00, an interview was conducted with Staff R (AVP Business Development and Service Lines) who stated that the consulting firm is a part of the facility's QAPI program, but does not have a contract with the firm. Staff R stated that it is a work in progress that has been ongoing for a year.

There was no evidence that the facility has a formal QAPI program and clearly designated staff responsible for the QAPI program. There was no evidence of written policies and procedures; and allocation of budgeting resources dedicated to QAPI program.

Based on an interview and medical record review, the facility failed to ensure that drugs are administered in accordance with Federal and State laws which is a deviation from the accepted standards of practice and carries risks and potential harm to patient's health and well being.

Findings:
Review of the medical record for Patient #1 revealed that the nurse withheld an anticoagulant medication for the patient against a physician's order. Two physicians consulted and made a decision to continue with administration of an anticoagulant medication, but the nurse withheld it.
On 03/03/2016, at 11:13, during an interview with a Respiratory Care Unit Registered Nurse, she stated that it is acceptable to hold a medication with an MD order using her "nursing judgement."
During discussions with Staff #J, the Director of Quality, on 3/3/16 at 2:30PM, who witnessed the interview with the nurse and who stated that holding medications with physician orders is against the policy, it was verified that the nurse acted against facility policy.
This event was not investigated by the facility or reported.