HospitalInspections.org

*** At the time of the re-visit, this deficiency had not been corrected.***

Based on document review and interviews with hospital staff, the hospital does not ensure the hospital has an effective quality assessment and performance improvement (QAPI) program that includes all analyzes the data and implements corrective action to ensure the quality and appropriateness of all patient care was furnished. The quality assurance meeting minutes for 2014 and 2015 provided for review did not have an analysis of any data that was collected and no evidence of the implementation of any corrective action taken. This was confirmed by the administrative staff on the afternoon of 02/03/15.

*** At the time of the re-visit, this deficiency had not been corrected.***

Based on document review and interviews with hospital staff, the hospital does not ensure that the quality assessment and performance improvement (QAPI) program evaluates the hospital's patient care services to ensure patient health and safety.

Findings:

1. The quality assurance meeting minutes for 2014 and 2015 were reviewed.

2. Medication errors reported to QAPI were not analyzed and trended to evaluate and formulate an action plan to decrease medication errors. This finding was reviewed and confirmed by the administrative staff on the afternoon of 02/03/15.

*** At the time of the re-visit, this deficiency had not been corrected.***


Based on document review and interviews with hospital staff, the hospital does not ensure that appropriate remedial action is taken to address deficiencies identified through the quality assessment and performance improvement (QAPI) program. Review of QAPI meeting minutes for 2014 and 2015 did not show medication errors and nosocomial infections identified were analyzed and an remedial action plan implemented to correct the identified deficiencies. This was verified by administrative staff on the afternoon of 02/03/15.