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Based on observation, record review, review of professional literature, water temperature readings, and staff interview, the Critical Access Hospital (CAH) failed to ensure the environment remained as free of accident hazards as possible in regard to safe water temperatures and storage of hazardous chemicals in 1 of 1 nursing unit. Failing to monitor water temperatures placed patients at risk for burns caused from scalding, and placed 1 of 1 patient identified with confusion and wandering behaviors (Patient #8) at risk of having accidents when hazardous chemicals were accessible.

Findings include:

Guidelines for Construction and Equipment of Hospital and Medical Facilities, 1992-93 edition, Chapter 8, Section 8.12, Table 8, Hot Water Use, states "...Temperature (Fahrenheit) [F], Resident Care Areas, 110 (max.) [maximum]..."

- A tour of the plant environment occurred on the morning of 06/15/11 with a supervisory plant manager (#2) and a supervisory nursing staff member (#3). The supervisory plant manager (#2), when asked, stated water temperatures are maintained around 125 degrees F. The supervisory plant manager (#2) stated the nursing unit maintained two different water heater units, one for each of the two corridors of the nursing unit. The manager identified the two corridors as the "old" and the "new" corridor.

Random water temperature readings, on 06/15/11 at 10:55 a.m., taken in one room, of each corridor, revealed the following:
* Room #11 ("old" wing) = 121.1 degrees F.
* Room #22 ("new" wing) = 122 degrees F.
* Tub Room across from room #22 = 113.3 degrees F.

The supervisory plant manager (#2) identified not maintaining a log to monitor water temperatures; and identified lacking a policy on water temperatures in the patient areas. The plant manager identified utilizing an equalizer to maintain the water temperature on the only tub for patient use to keep that water temperature from going no higher than 115 degrees F.

- Observation of the Equipment Storage Room/Utility room located at the south entrance to the nursing unit identified an unlocked room with the following chemicals stored in a bag hung from a garbage container:
* Antibacterial foaming bath and surface cleaner spray bottle, with a label of "Caution: Keep Out of Reach of Children"
* Crew Super Blue, with a warning of "causes skin and eye irritation"

Observation showed one and two gallon chemical containers stored on the upper shelves within this same room. Each of these containers had labels stating "Keep Out of Reach of Children":
* Pure Bright Disinfectant Bleach
* Liquid Kler-ro soap
* Innovative Cleaning Solutions Chemco Inc. Cool Breezo TB RTU detergent and disinfectant deodorizer, cleaner, disinfectant, tuberculocidal, virucide
* Clorox bleach
* Oxivir sanitizer
* Spectrum HBV Hospital virucidal disinfectant

During the environmental tour on the morning of 06/15/11, the supervisory plant manager (#2), present during the observation, identified awareness of the CAH having wandering patients. The supervisory plant manager, (#2) and a supervisory nursing staff member (#3), agreed unlocked chemicals could pose a hazard for wandering patients within the facility and agreed the hazardous chemicals should not be accessible to the patients. The staff members (#2 and #3) identified having no policy regarding locking of chemicals.

Observation of the CAH's nursing unit on all three days of survey identified the utilization of a watch mate system, or wander guard system, utilized specifically for wandering patients, to prevent them from exiting the building.

Observation on all three days of survey identified a wandering patient (Patient #8), and random observations showed the patient propelled herself in her wheelchair within the facility, and at times attempted to stand, at which times staff would redirect her.

Record review occurred on the afternoon of June 15, 2011. The record identified Patient #8 resided within the facility since June 1, 2011. Record review identified the patient with a diagnosis of dementia and a behavior of wandering in her wheelchair. The medical record identified the patient confused, difficult to reorient, ambulated with the assist of one and a wheelchair, and spent minimal time in her room. Observation and record review identified the presence of alarms on her wheelchair, bed and a wanderguard alarm bracelet.

The CAH failed to maintain an environment free of accident hazards, including hot water temperatures, and hazardous chemicals, to protect patients with memory loss, confusion, and /or wandering behaviors.

Based on observation, policy and procedure review, review of professional literature, record review, and staff interview, the Critical Access Hospital (CAH) failed to follow professional standards of care relating to infection control practices for 2 of 3 active patients (Patient #1 and Patient #28) observed receiving toileting and peri-cares, and failed to ensure the sanitation of medications by storing patient supplies (ice packs) with medications in 1 of 1 refrigerator in the medication room. Failure to follow infection control practices may allow transmission of organisms/bacteria from patients to staff, to other patients, or to visitors. Failure to ensure the sanitation of medications has the potential for patients to receive contaminated medications.

Findings include:

The Centers for Disease Control Morbidity and Mortality Weekly Report "Guideline for Hand Hygiene in Health-Care Settings, Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC [Hospital Infection Control Practices Advisory Committee]/SHEA [Society for Healthcare Epidemiology of America]/APIC [Association for Professionals in Infection Control and Epidemiology]/IDSA [Infectious Diseases Society of America] Hand Hygiene Task Force", dated 10/25/02, stated, ". . . Part II. Recommendations . . . 1. Indications for handwashing and hand antisepsis: . . . C. Decontaminate hands before having direct contact with patients . . . F. Decontaminate hands after contact with a patient's intact skin . . . I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient . . . J. Decontaminate hands after removing gloves . . ."

Review of the policy "Hospital Wide Infection Control Patient Care Policies" occurred on 06/15/11. This policy, revised 1998, stated, ". . . Hand washing before and after contact with any patient is the most important measure that can be taken to prevent the spread of infection. I. Purpose: A. To protect yourself and others from harmful microorganisms. B. To prevent transmission of infection from one patient to another via the healthcare worker. C. To remove transient bacteria on hands contaminated after handling patients, objects, and surfaces. II. Policy: Hand washing will occur at the following times . . . B. When hands become soiled C. Before and after contact with any patient . . . H. Immediately or as soon as possible following contact with blood or body fluids . . . I. Immediately or as soon as possible after removal of gloves . . ."

- Observation on 06/13/11 at 1:10 p.m. showed two nursing staff members (#5 and #8) entered Patient #1's room, donned gloves, and assisted the patient to the commode with the EZ Stand (a mechanical device used by staff to transfer patients). After Patient #1 finished on the commode, the two nursing staff members (#5 and #8) assisted the patient to stand, one nursing staff member (#5) cleansed Patient #1's buttocks of stool and removed the glove on the hand used to cleanse the patient. The two staff members (#5 and #8) applied a clean brief and pulled Patient #1's pants up, then assisted the patient to bed. The staff member (#5) removed the remaining glove and immediately donned a new pair of gloves, emptied the urine and stool contents from the commode into the toilet, rinsed and cleaned the commode, discarded the gloves in the garbage, left the patient's room, and walked down the hall in search of supplies. Observation showed the nursing staff member (#5) failed to perform hand hygiene or hand washing after cleansing Patient #1 and the commode of stool, after removing a soiled glove, and before leaving Patient #1's room, prior to moving onto another task or patient.

Observation on 06/14/11 at 10:25 a.m. showed two nursing staff members (#5 and #6) entered Patient #28's room, donned gloves, and assisted the patient to stand with the EZ Stand. The staff members (#5 and #6) pulled Patient #28's pants down, removed a soiled brief, and one staff member (#5) cleansed the patient's peri area of urine and removed the glove on the hand used to cleanse the patient. The two nursing staff members (#5 and #8) applied a clean brief, pulled Patient #28's pants up, assisted the patient to the wheelchair, and removed their gloves. A nursing staff member (#6) grabbed the garbage, left Patient #28's room, entered the soiled utility room, placed the garbage in a large garbage can, and returned to the patient's room while the other nursing staff member (#5) combed Patient #28's hair. Both nursing staff members (#5 and #6) left the room with the patient; one staff member (#6) pushing a tube feeding pump, and the other staff member (#5) pushing the patient in a wheelchair. Observation showed the two nursing staff members (#5 and #6) pushed Patient #28 down the hall to the activity room, then both went on to perform other tasks. The nursing staff member (#5) failed to perform hand hygiene or hand washing after cleansing Patient #28 of urine. Both nursing staff members (#5 and #6) failed to perform hand hygiene or handwashing after removing gloves and before leaving Patient #28's room, prior to moving onto another task or patient.

During an interview on 06/14/11 at 10:50 a.m., a nursing staff member (#6) stated staff usually washed their hands in the patient room after assisting the patients to other areas of the CAH. The staff member (#6) stated nursing staff should use hand sanitizer after providing cares to a patient, which is placed in dispensers outside many patient rooms. The nursing staff member (#6) agreed staff should wash their hands after the removal of gloves and in the patient's room immediately after providing cares to a patient.

During an interview on 06/14/11 at 4:00 p.m., an administrative nurse (#1) stated nursing staff must wash their hands or use hand sanitizer before and immediately after patient care, when staff remove gloves, and especially when gloves are soiled. The nurse (#1) stated staff must always perform hand washing or hand hygiene as staff leave the patients room, prior to moving onto another patient or task.

- Observation of the medication room occurred on 06/15/11 at 10:55 a.m. with a nursing staff member (#4), and showed a small refrigerator which contained multiple open vials of various medications, including insulin and vaccines. An open freezer compartment, located within the refrigerator, contained three frozen ice packs, which the nursing staff member (#4) confirmed patients used.

During an interview on 06/15/11 at 10:55 a.m., a nursing staff member (#4) stated staff placed the frozen ice packs on patients for knee or back pain. The staff member (#4) stated staff disinfected the ice packs with a pre-moistened sanitary cloth after they come in contact with patients, then placed the ice packs back in the freezer in the medication fridge.

During an interview on 06/15/11 at 1:40 p.m., an administrative nurse (#1) stated the frozen ice packs should not be stored with patient medications.

Based on observation, review of professional literature, record review, and staff interview, the Critical Access Hospital (CAH) failed to assess each patient individually prior to utilizing side rails, failed to consider side rails as restraints, and failed to provide education to the patient and the responsible party regarding the hazards of side rail use for 4 of 4 active swing bed patients (Patient #1, #3, #4, and #29) observed with two elevated side rails, and 1 of 1 active swing bed patient (Patient #2) records reviewed. Failure to assess and evaluate the use of side rails and educate patients and responsible parties regarding the hazards of using side rails placed Patients #1, #2, #3, #4, and #29 at risk of injury, physical and psychological harm, and restricted their movement.

Findings include:

The Food and Drug Administration (FDA) Center for Devices and Radiological Health publication titled, "Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment," issued on 03/10/06, stated, ". . . FDA has received reports in which . . . patients have become entrapped in hospital beds while undergoing care and treatment in health care facilities. The term 'entrapment' describes an event in which a patient is caught, trapped or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in death and serious injuries . . . The current International Electrotechnical Commission (IEC) standard recognizes that the bed frame, deck, and rails are the major elements involved in entrapment . . ."

Safety Alert: Entrapment Hazards with Hospital Bed Side Rails, August 23, 1995, and Joint Commission on Accreditation of Healthcare Organization: Sentinel Event Alert, Issue 27, September 6, 2002, identified bed rail-related entrapment deaths and injuries can occur in the elderly population, who are often at risk due to limited mobility, psychoactive or sedative medications, confusion, sedation, restlessness, lack of muscle control, size and physical deformities. Death by asphyxiation or injuries to the resident's extremities can occur when the resident becomes caught between the mattress and the bed rail; the headboard and the bed rail; or getting his or her head/extremity stuck in the bed rail. Both split and full rails have the potential to cause fall-related injuries as well as entrapment. Additionally fall-related injuries or injuries to extremities can occur when confused/disoriented residents climb over the top of side rails or get an arm or leg entrapped.

Clinical Guidance For the Assessment and Implementation of Bed Rails In Hospitals, Long Term Care Facilities, and Home Care Settings, Hospital Bed Safety Workgroup, Food and Drug Administration, April 2003, stated, "Guiding Principles . . . 2. Decisions to use or to discontinue the use of a bed rail should be made in the context of an individualized patient assessment using an interdisciplinary team with input from the patient and family or the patient's legal guardian. . . . Policy Considerations: 1. Regardless of the purpose for which bed rails are being used or considered, a decision to utilize or remove those in current use should occur within the framework of an individual patient assessment. . . . 3. Use of bed rails should be based on patients' assessed medical needs and should be documented clearly and approved by the interdisciplinary team. Bed rail effectiveness should be reviewed on a regular basis. The patient's chart should include a risk-benefit assessment that identifies why other care interventions are not appropriate or not effective if they were previously attempted and determined not to be the treatment of choice for the patient. . . . 7. Creating a safe bed environment does not necessarily preclude the use of bed rails. However, a decision to use them should be based on a comprehensive assessment and identification of the patient's needs, which include comparing the potential for injury or death associated with use or non-use of bed rails to the benefits for an individual patient. In creating a safe bed environment, the following general principles should be applied: Avoid the automatic use of bed rails of any size or shape. . . . Re-assess the patient's needs and re-evaluate the equipment if an episode of entrapment or near-entrapment occurs, with or without serious injury. This should be done immediately because fatal 'repeat' events can occur within minutes of the first episode. Process/Procedure Considerations . . . 1. Individualized Patient Assessment: Any decision regarding bed rail use or removal from use should be made within the framework of an individual patient assessment. . . . Risk Intervention: Assessment of risk should be part of the individual patient's assessment, and steps to address the risk should be incorporated into the patient's care plan. . . . Bed Rails as Restraints: When bed rails have the effect of keeping a patient from voluntarily getting out of bed, they fall under the definition of a physical restraint. If they are not necessary to treat medical symptoms, and less restrictive interventions have not been attempted and determined to be ineffective, bed rails used as restraints should be avoided. . . . Bed Rail Safety Guidelines: If it is determined that bed rails are required and that other environmental or treatment considerations may not meet the individual patient's assessed needs, or have been tried and were unsuccessful in meeting the patient's assessed needs, then close attention must be given to the design of the rails and the relationship between rails and other parts of the bed.

- Observation of the beds utilized on the nursing unit occurred on 06/13/11. The beds utilized by the current swing bed patients differed in style or make, but the majority of beds utilized included an attached single rail to each side of the bed. The single rail is capable of acting as either a grab bar when positioned in the "up" position, or capable of being moved into the "down" position, placing the rail across the middle third of the bed. The rail in the "down" position would limit the normal exiting pattern from a bed, and would inhibit a patient from exiting the middle of the bed without staff assistance to remove the rail. When two rails are used in the "down" position, the rails would be considered a restraint.

Observation of Patient #1, #3, #4, and #29 on June 13-14, 2011, while the patients rested in bed, identified a single rail attached to each side of the bed in the "down" position. When asked why the rails were in the "down" position on the above patient's beds, a nursing staff member (#6) stated staff placed all rails in the "down" position while patient's were in bed.

- Review of Patient #1's active record occurred on 06/13/11 and identified the CAH admitted the patient to swing bed on 08/30/10 for assistance with activities of daily living and physical therapy. Patient #1's medical history included a stroke, rheumatoid arthritis, and right and left total knee replacements. Review of Patient #1's admission nursing assessment, dated 08/30/10 at 2:35 p.m., indicated the patient's mental status as alert, cooperative, and forgetful, ambulation status as unable and wheelchair bound, bowel and bladder status as incontinent and needing assistance to the commode. Review of a form in Patient #1's record indicated the patient preferred the upper bed rails "up" for security, bed controls, and mobility.

Patient #1's Nurses Notes stated the following:
*10/17/10 at 8:05 a.m.: ". . . Implementing plan of pt. [patient] not receiving remote control for chair in effort to prevent recurrence of fall."
*10/19/10 at 6:00 a.m.: "Pt awake off and on during the night, thought it was morning . . ."
*11/18/10 at 3:00 a.m.: "Awake et [and] wants to get up for the day. . . . Pt very unsettled, could hear her 'puttering' [with] bedside table . . ."
*11/21/10 at 3:00 a.m.: ". . . called every 20-30 minutes wanting to get dressed for the day . . ."
*12/07/10 at 5:45 a.m.: ". . . Awake x [times] 1 during the noc [night], wanting to get up @ [at] 0200 for the day."
*12/21/10 at 5:30 a.m.: ". . . small bruise to [left] shin . . ."
*02/05/11 at 5:30 a.m.: "Slight ecchymosis noted [left] leg knee to ankle . . . [question] w/c [wheelchair] bruise."
*03/01/11 at 6:00 a.m.: ". . . healing bruises on lower legs . . ."
*03/03/11 at 5:30 a.m.: "Pt has new quarter size bruise on [left] front lower leg . . ."
*04/02/11 at 7:55 p.m.: "Pt yelling 'help' upon entry to room, pt had slid her bottom to the edge of her wheelchair . . ."
*05/12/11 at 6:00 a.m.: "Pt has lesion on [left] arm, open, bandaid applied . . ."
*05/12/11 at 8:30 p.m.: "Patient was very agitated this evening. Patient was crying . . ."
*05/19/11 at 7:45 p.m.: "Pt has dark purple ecchymotic area on [left] posterior forearm little larger area than a golfball."
*05/23/11 at 10:00 a.m.: ". . . Pt. noted to be slightly confused t/o [throughout] morning, unable to orientate. Emotional @ times. . . ."
*06/02/11 at 5:30 a.m.: ". . . 1 cm [centimeter] bruise noted near [left] elbow . . ."

The CAH staff failed to recognize Patient #1's forgetfulness/confusion as a risk factor for injury while utilizing side rails, and failed to consider the bruises on Patient #1's legs and arms as a result of injury from side rail use. Patient #1's medical record lacked an individualized assessment of risk and safety for use of side rails, lacked documentation of monitoring of the side rails, and lacked evidence of patient or responsible party education regarding the hazards of side rail use. The CAH staff failed to consider the side rails as a potential restraint and entrapment hazard.

- Review of Patient #2's active record occurred 06/13/11 and identified the CAH admitted the patient to swing bed on 01/07/11 with hip pain and rehabilitation after sustaining a fall at home prior to admission. Patient #2's medical history included macular degeneration. Review of Patient #2's admission nursing assessment, dated 01/07/11 at 4:00 p.m., indicated the patient's mental status as forgetful and disoriented, ambulation status as needing assistance and using a walker, bowel and bladder status as incontinent and needing assistance to the bathroom. Review of Patient #2's admission provider orders indicated fall precautions.

Patient #2's Nurses Notes stated the following:
*01/12/11 at 1:55 p.m.: ". . . is unable to understand how to use call light . . . Pt legally blind . . . Pt pleasantly confused. Oriented to person, place. Disoriented to time & situation. . . ."
01/18/11 at 6:00 a.m.: "Awake more often (x 5) during the noc. Sitting on end of bed, very confused - wants to take care of cables etc - only bedside stand near her. . . ."
*01/21/11 at 6:15 a.m.: "Pt up several times during the night incontinent of urine requires assistance to [change] brief. Pt gets up from toilet and requires prompting to pull up pad just starts walking back to bed holding up pad between her knees [with] hand."
*01/25/11 at 1:45 a.m.: "Pt has been awake sitting on edge of bed since 12:45 a.m. Unable to stand up shirt on and unable to get pants on, prompted that it was 0100 in the morning. Pt says she wants to go back to bed but moves blankets back [and] forth and stares into space."
*1/25/11 at 3:00 a.m.: "Pt awake unable to stand from bed required assist up from bed, pt knew to change pad but unable to find new pad unable to figure out how to open pad and put it on. Unable to stand up from toilet [without] assist. Pt states she is worn out from trying to stand up. . . ."
*01/28/11 at 8:00 a.m.: ". . . pt. confused most of the time."
*01/31/11 at 8:00 p.m.: ". . . Patient has bed alarm at night. Wander guard bracelet applied today."
*02/07/11 at 8:20 p.m.: ". . . pleasantly confused . . ."

The CAH staff failed to recognize Patient #2's disorientation/confusion as a risk factor for injury while utilizing side rails. Patient #2's medical record lacked an individualized assessment of risk and safety for use of side rails, lacked documentation of monitoring of the side rails, and lacked evidence of patient or responsible party education regarding the hazards of side rail use. The CAH staff failed to consider the side rails as a potential restraint and entrapment hazard.

- Review of Patient #3's active record occurred 06/13/11 and identified the CAH admitted the patient to swing bed on 04/30/10 with deconditioning and physical therapy. Patient #3's medical history included osteoarthritis and chronic low back pain. Review of Patient #3's admission nursing assessment, dated 04/30/10 at 5:35 p.m., indicated the patient's mental status as alert, forgetful, and disoriented, ambulation status as needing assistance and a walker, and bowel and bladder status as incontinent and needing assistance to the bathroom. Review of a form in Patient #3's record, dated 04/30/10, indicated the patient preferred the upper bed rails to be up, but lacked the reason for this. A fall risk assessment, completed on 04/30/10, indicated Patient #3 at high risk for falls.

The CAH staff failed to recognize Patient #3's high fall risk as a potential for injury while utilizing side rails. Patient #3's medical record lacked an individualized assessment of risk and safety for use of side rails, lacked documentation of monitoring of the side rails, and lacked evidence of patient or responsible party education regarding the hazards of side rail use. The CAH staff failed to consider the side rails as a potential restraint and entrapment hazard.

- Review of Patient #4's active record occurred 06/14/11 and identified the CAH admitted the patient to swing bed on 09/29/08 for strengthening and physical therapy following a surgical repair of left hip fracture. Patient #4's medical history included restless leg syndrome, and right and left hip replacements. Review of Patient #4's admission nursing assessment, dated 09/29/08, indicated the patient's mental status as alert and cooperative, ambulation status as needing assistance and walker/wheelchair, bowel and bladder status continent and needing assistance to the bathroom and commode. Review of a form in Patient #4's record indicated the patient preferred the upper bed rails to be up for security, bed controls, and mobility.

Patient #4's Nurse Notes stated the following:
*01/21/11 at 9:30 a.m.: ". . . Bruise to [right] FA [forearm] . . ."
*04/01/11 at 8:00 a.m.: ". . . Skin intact [except] red abrasion to [left] shin . . ."
*06/13/11 at 7:30 p.m.: ". . . ecchymotic areas to [left] lower leg . . ."

The CAH staff failed to consider the bruises on Patient #4's arm and leg as a result of injury from side rail use. Patient #4's medical record lacked an individualized assessment of risk and safety for use of side rails, lacked documentation of monitoring of the side rails, and lacked evidence of patient or responsible party education regarding the hazards of side rail use. The CAH staff failed to consider the side rails as a potential restraint and entrapment hazard.

During an interview on 06/14/11 at 11:25 a.m., a nursing staff member (#4) stated nursing staff elevate the side rails for patient safety, positioning/mobility, access to call light, and per patient/family request. The staff member (#4) stated nursing staff does not perform or document an assessment for risk factors or safety for utilization of side rails, or provide education to the patient or their representative on the risks of side rail usage. The nursing staff member (#4) stated the nursing staff failed to recognize the two elevated side rails as a restraint.

During an interview on 06/14/11 at 4:00 p.m., an administrative nurse (#1) stated the CAH recently purchased the beds on the nursing floor which included the side rails that could be used in the "up" or "down" position. The nurse (#1) stated staff placed the two side rails in the "down" position while patients were in bed for patient safety and positioning. The administrative nurse (#1) confirmed the CAH considered side rails a restraint in certain situations, which would then require a physician's order, but stated the CAH failed to consider these side rails as a restraint, risk for safety, and a potential hazard for entrapment. The nurse (#1) stated nursing staff does not perform an assessment of risk factors or safety for utilization of side rails, nor do they educate the patient or their family members on the risks of side rail usage.

Based on policy review, Quality Assurance (QA) record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the quality assurance program evaluated all patient care services affecting CAH patient health and safety, including cardiac rehabilitation, discharge planning and safety for 12 of 12 months reviewed (July 2010-June 2011). Failure to participate in quality assurance activities places patients at risk of not receiving appropriate care and services and failing to implement corrective action if necessary.

Findings include:

Review of the CAH's "QUALITY ASSURANCE PLAN" occurred on the afternoon of 06/14/11. The policy, dated 03/28/01, stated,
". . .GOAL:
To establish, implement, support, maintain, monitor, and document evidence that review and evaluation of the quality and appropriateness of patient care methods are constantly in progress, facility wide, within all clinical departments and services of our institution. . . .
SCOPE:
The Quality Assurance Plan shall be hospital wide, apply to all departments, services and practitioners whose activities within the hospital have direct influence on the quality of care. . . .
The following services/departments will participate in quality assurance activities. All department heads shall submit quarterly reports. . . .
b. Discharge Planning . . .
n. Cardiac Rehab . . .
q. Safety . . .

IMPLEMENTATION:
The findings of the Quality Assurance activities throughout the hospital shall be reported to the Quality Assurance Committee on a quarterly basis (as determined by the QA scheduled distributed to all departments). . . ."

Review of the Quality Assurance Quarterly Reporting Schedule occurred on the afternoon of 06/14/11. The schedule lacked reporting for cardiac rehab, discharge planning and safety on a quarterly basis.

Review of the Quality Assurance conducted and reported to the Quality Assurance committee on a quarterly basis by all departments occurred on the afternoon of 06/14/11. The following departments failed to report within the last 12 months: cardiac rehab, discharge planning and safety.

During interview, on 06/15/11 at 1:45 p.m., a management staff member (#1) stated cardiac rehab, discharge planning and safety do not report quality assurance activities to the Quality Assurance committee on a quarterly basis as required according to the QA plan.