HospitalInspections.org

Based on review of the Quality and Performance Improvement Plan, Quality Meeting minutes and staff interview (EMP), it was determined the facility failed to ensure documentation of a rationale for each performance indicator selected.

Findings include:

Review of the Quality and Performance Improvement Plan dated reviewed June 2015 revealed "... II Purpose The purpose of the Quality Improvement Program is to ensure the organization's commitment to providing safe, competent quality care. The plan provides a framework for identifying opportunities for process design and improvement, measuring and assessing quality of care in a systematic, continuous manner and sustaining improvement over time. ... C. Clinical Quality Improvement Committee ... Responsibilities include: ... Ensures that hospital quality improvement activities are consistent with the requirements and recommendations of various accrediting and licensing agencies including but not limited to TJC [the Joint Commission], CMS [Centers for Medicare and Medicaid Services], Pennsylvania Patient Safety Authority and the Pennsylvania Department of Health as well as the Hospital's priorities or strategic direction. ... "

Review of the Quality Meeting minutes from January 2015 to April 2016 revealed improvement projects were conducted. There was no rationale documented for the quality improvement activities identified and conducted.

Interview with EMP3 on April 26, 2016, confirmed the quality improvement projects were monitored and there was no rationale for selection of the projects.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure the Board selected the number of distinct improvement projects for the year and specified the frequency of the data collection.

Findings include:

Review of the facility's "Quality [and] Performance Improvement Plan," dated last reviewed June 2015 revealed "... VIII. Authority The Board of Directors of Moses Taylor Hospital has the ultimate authority and responsibility to assure one level of quality patient care. In executing this resposibility, the Board is committed to the development, support and reappraisal of a Quality Performance Improvement Program which includes effective mechanisms for designing, measuring, assessing and improving all aspects of patient care as well as appropriate response to the findings of the process. ..."

Review of the Board meeting minutes from January 2015 to April 2016 revealed no documentation that the quality indicators for the year were selected and the frequency of data collection was determined.

Interview with OTH1 on April 26, 2016, at approximately 11:00 AM confirmed there was no documentation in the Board Meeting Minutes that the quality projects for the year were selected and approved by the Board. OTH1 confirmed there was no documentation the Board determined the frequency of the data collection.

Based on review of facility documents, a tour of the second floor and the Emergency Department, and staff interview (EMP), it was determined the facility failed to ensure the nursing unit on the second floor and the Emergency Department (ED) were maintained in a clean and sanitary manner.

Findings include:

A policy for environmental services was requested. No policy was provided.

A tour of the second floor on April 27, 2016, at approximately 1400 revealed the following: The floor was observed with heavy black scuff areas, especially at the doorways where each patient room met the main corridor. In the patient lounge, there was a heavy accumulation of dust on the floor. When the patient lounge furniture was moved, there was debris observed, for example, old ring tabs from soda cans, pens, crayons and an accumulation of crumbs on the floor. There was a small table in the center of the patient lounge. The surface of the table was soiled with dark dirty patches noted. The medication room floor was observed with debris on the floor, including medicine cups, elastic bands and glue debris that remained as a result of the labels being stuck to the floor. There were noticeable white drips on the medication cabinets. The nourishment room contained a refrigerator where soda was stored. The bottom shelf was noted to have a black discoloration. The soiled utility room contained a linen hamper. There was no bag in the linen hamper. This linen hamper was stored directly over the clinical service sink (hopper). The janitor's closet revealed metal lockers with a large accumulation of rust noted on the bottom. The floor sink in the janitor's closet had a heavy accumulation of black material noted. In the second floor storage room, there was an unidentified green dried substance noted on the floor. There was dust and debris on the floor. There was a floor buffer stored in this area and a soiled patient bed pad was thrown over the front of the buffer. The shower in patient room 203 had two muddy foot prints on the shower floor and a hard pink substance in the shower that could not be identified. The anteroom between rooms 221-222 revealed the caulking was missing around the sink. The metal rings around the faucets were loose and lifting. There was an accumulation of a white substance on the faucets.

Tour of the Emergency Department (ED) was initiated on April 26, 2016, at 0830. The ED waiting room bathroom revealed the door was closed. When the door was opened, a strong smell of urine was noted. The room was noted to be very warm. The floor was muddy, and toilet paper was thrown all over the floor.

Tour of the Emergency Department on April 27, 2016, at approximately 1045 revealed the floors were grey and discolored near the transitional areas of patient care and the hallways. In the clean utility room, the drywall on the corner had an open area approximately 4" x 5". Wall damage was also noted to this area. There were multiple open linear areas approximately 1/4" wide x 12" long on the surface of the wall.

The bathroom area for exam rooms seven, eight, and nine revealed grey and discolored flooring and dark brown areas on the commode.

Interview with EMP12 on April 27, 2016, at approximately 1300 confirmed there were nine open positions in housekeeping. EMP12 was unable to confirm the last time the hospital floors were stripped of wax and cleaned.