HospitalInspections.org

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Based policy record review, interview, and policy review the facility failed to meet the Condition of Participation of Quality Assessment and Performance Improvement (QAPI) program in that the hospital failed to develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven QAPI program. This failed practice had the potential to affect all 53 inpatients and any future patients admitted to the facility.

Findings include:

1. The facility failed to utilize their QAPI activities to collect and analyze data from their Plan of Correction (PoC) for a complaint survey conducted 6/29/21 - 7/1/21. Specifically, the facility failed to follow their PoC to bring forth audit data for the correction of Patient Rights citations to the monthly QAPI meetings for ongoing compliance monitoring and sustainability. (Refer to A273)

2. The facility failed to: 1) take action to fully implement their Plan of Correction (PoC) for a complaint survey conducted 6/29/21 - 7/1/21 and 2) utilize their Quality Assessment and Performance Improvement (QAPI) activities to collect and analyze data from their PoC to ensure the PoC's progress, completion, and sustainability. Specifically, the facility failed to: 1) complete their PoC actions aimed at performance improvement and 2) bring forth audit data collected to the monthly QAPI meetings for ongoing compliance monitoring and sustainability. (Refer to A283)

3. The facility failed to measure progress towards quality improvement project goals, or measure outcomes of projects currently being addressed for 3 quality improvement projects, out of 3 sampled quality improvement projects. This failed practice had the potential to inhibit the project's success and/or sustainability which could affect the overall improvement of patient safety and overall wellbeing for all 53 inpatients and any future patients admitted to the facility. (Refer to A297)


4. The facility's Governing Body (GB) failed to ensure that the hospital-wide Quality Assessment and Performance Improvement (QAPI) efforts addressed priorities for improved quality of care and patient safety and that all improvement actions were evaluated. Specifically, the GB did not collect and analyze data from the facility's Plan of Correction (PoC) for a complaint survey conducted 6/29/21 - 7/1/21. (Refer to A309)

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Based on document review and interview, the facility failed to utilize their Quality Assessment and Performance Improvement (QAPI) activities to collect and analyze data from their Plan of Correction (PoC) for a complaint survey conducted 6/29/21 - 7/1/21. Specifically, the facility failed to follow their PoC to bring forth audit data for the correction of Patient Rights citations to the monthly QAPI meetings for ongoing compliance monitoring and sustainability. This failed practice had the potential to effect sustainable correction of direct patient care practices concerning Patient Rights for all patient residing in the facility (based on a census of 53). Findings:

Review of the facility's PoC, with a completion date of 8/1/21, revealed:

-A115 Patient Rights (CFR(s): 482.13): Plan of Correction: " ...The hospital has implemented regular and on going audits to include the monitoring of medication administration, safe patient care environment, and abuse and neglect reporting. The results of these audits are reporting in bi-weekly nursing leadership meetings, weekly CEO [Chief Executive Officer] meetings, and monthly QAPI meetings ..."

- A131 Patient Rights: Informed Consent (CFR(s): 482.13(b)(2)): Plan of Correction: " ...Monitoring and QAPI: [Facility] nursing leadership will implement weekly observation rounds of medication administration ...Results from the observed medication administration will be presented during twice monthly Nursing Leadership meeting as well as monthly QAPI meeting ...3. Audit results from the Nurse Manager Mediation Administration rounds will be presented to the monthly QAPI committee meeting as part of the monthly compliance reporting. The QAPI committee will report results of all Patient Rights audits and rounds are to be aggregated and reported in the monthly QAPI committee meeting as part of ongoing compliance monitoring. This will continue to be monitored until 6 consecutive months of 100% compliance is achieved. Individual responsible: Director of Nursing."

- A144 Patient Rights: Care in Safe Setting (CFR(s): 482.13(c)(2)): Plan of Correction: " ...Monitoring and QAPI: Leadership rounds are conducted weekly to ensure the patient environment of care continues to support the patient's right to receive care in a safe setting. Rounds will include review of patient private rooms, bathrooms, and common spaces to ensure no ligature risks are reintroduced to patient care areas ...Results from leadership rounds will be reported to the bi-monthly hospital leadership meeting. Maintenance will report on the status of the toilet tissue holder replacement at the monthly EOC [Environment of Care] and QAPI meetings. Maintenance to report to EOC and QAPI at all scheduled meetings the removal of the doors and the status of the replacement doors ...Results of all Patient Rights audits and round are to be aggregated and reported in the monthly QAPI committee meeting as part of ongoing compliance monitoring. This will continue to be monitored until 6 consecutive months of 100% compliance is achieved. Individuals responsible: Interim Building Maintenance Supervisor and Director of Clinical Services."

- A145 Patient Rights: Free From Abuse/Harassment (CFR9S): 482.13(c)(3)): Plan of Correction: " ... Monitoring and QAPI: The Interim Risk Manager will meet weekly with the CEO to review trends of events and will escalate to the CEO or designee immediately any allegations of abuse. All allegations of abuse and neglect will be recorded in a UOR [Unusual Occurrence Report] per hospital policy. UOR data related to abuse and neglect is reviewed and reported during bi-monthly leadership meeting and hospital monthly QAPI meetings. Individual responsible: Interim Risk Manager and CEO."

QAPI Meetings

Review of the facility's QAPI meeting minutes, dated 8/11/21, revealed: " ...Medication Management ...[Medication] rounds are completed and results will be presented at the Medication Management and QAPI meetings ..." Further review revealed no audit data from the medication rounds regarding patient rights were documented within the meeting minutes. Additional review of the meeting minutes revealed no documentation of the weekly leadership rounds of the patient environment of care for ligature risks, maintenance reports of toilet tissue holder or door replacement statuses, or UOR data related to abuse and neglect.

Review of the facility's QAPI meeting minutes, dated 9/8/21, revealed: "EOC ...Toilet paper holders/style now in review for ligature safety ...Nursing ... Nursing is auditing medication management, with 10 observations per unit per week. Data will be presented by the end of this week for the CMS [Centers for Medicare and Medicaid Services] cap tracker ...Patient Advocacy ...Grievances per 1000 patient days trends upward mostly from the [adolescent] and [acute adult] units. Most of the complaints are against staff and the treatment team ..." Further review revealed no audit data from the medication rounds regarding patient rights were documented within the meeting minutes. Additional review of the meeting minutes revealed no documentation of the weekly leadership rounds of the patient environment of care for ligature risks, maintenance reports of toilet tissue holder or door replacement statuses, or UOR data related to abuse and neglect.

Review of the facility's QAPI meeting minutes, dated 10/13/21, revealed: "QAPI Dashboard ...Nursing, medication management, EOC, and [Infection Control] completed rounds and audits this month. The QAPI dashboard records whether or not each department is improving or not ...Patient Advocacy ...[acute adult unit] had the most grievances about staff and a few on treatment. One of the favorables is 'treated with dignity and respect' ..." Further review revealed no audit data from the medication rounds regarding patient rights were documented within the meeting minutes. Additional review of the meeting minutes revealed no documentation of the weekly leadership rounds of the patient environment of care for ligature risks, maintenance reports of toilet tissue holder or door replacement statuses, or UOR data related to abuse and neglect.

Review of the facility's QAPI dashboard (a quantifiable and measurable table of patient safety data to include Utilization, Suicide Assessment, Discharge Planning, Infection Control, Clinical Care, Rehab Therapy, Grievance/Family Support, EOC and Safety, and Medication Management), dated from January 2021 (first quarter) to September 2021 (third quarter), revealed no audit data from the medication rounds regarding patient rights were documented on the dashboard. Additional review of the dashboard revealed no documentation of the weekly leadership rounds of the patient environment of care for ligature risks, maintenance reports of toilet tissue holder or door replacement statuses, or UOR data related to abuse and neglect.

During an interview on 11/4/21 at 1:39pm, the Director of Nursing (DON) stated there was no documentation in the QAPI meeting minutes for 8/11/21, 9/8/21, or 10/13/21 concerning the audit data from the medication rounds regarding patient rights, weekly leadership rounds of the patient environment of care for ligature risks, maintenance reports of toilet tissue holder or door replacement statuses, or UOR data related to abuse and neglect.

During an interview on 11/4/21 at 3:46 pm, Interim Quality Director #2 stated he/she could not recollect the last time UORs were discussed in QAPI meetings.

During an interview on 11/5/21 at 12:00 pm, Interim Quality Director #2 stated data presented on the QAPI dashboard, and in the QAPI meetings, was based primarily on the areas identified within the dashboard sections. He/she further stated due to staffing shortages, there had not been key staff members in key roles to focus on the PoC.

The Interim Quality Director #2 further stated that data was measured and analyzed within QAPI when data was collected and complied in a report, then someone would relay that report in QAPI. He/she stated there was currently a gap between this data collection and how to determine if improvements were made. He/she also stated he/she could not recall if QAPI had ever provided feedback or guidance to make improvements.

During an interview on 11/5/21 at 12:58 pm, the DON stated that the PoC was developed with all administrative leadership input. She stated that there were weekly meetings scheduled to monitor the PoC's status and the data was also presented at the bi-monthly leadership meetings. The DON stated there was no documentation that could be presented to show this. The DON further agreed there was no place to document the PoC's status on the QAPI dashboard and the DON stated the PoC actions and audit data was not presented to QAPI.

During an interview on 11/5/21 at 1:04pm, the DON stated that gaps and oversights were identified within QAPI when the previous Director of Quality put in his/her notice. She recalled there was a meeting to look at the QAPI gaps, but could not recall the date. The DON further stated there was no documentation about that meeting and that no performance improvement plan was made concerning the QAPI gaps. The DON stated that at this time, QAPI oversight is missing.

The DON further stated that she was unaware that the PoC was not completed. She stated this was not reported to oversight and it didn't cross her radar that there were pieces of the PoC that were missing.

During an interview on 11/5/21 at 2:24pm, the CEO stated he was unaware the PoC was not completed. The CEO further stated that he could not recollect if the PoC was presented in QAPI. In regards to the QAPI committee, the CEO stated QAPI had not measured improvements that he could recall. The CEO further stated there was no documentation to present that QAPI collected, measured, or analyzed the PoC actions or audits. He agreed there was room for improvement in this area.

Review of the facility's policy "Quality Assurance and Performance Improvement (QAPI) Program," dated 1/15/21, revealed "The goal of the program is to provide a framework and motivation for improvement of health outcomes ...by implementation of an organization-wide process of assessment, measurement, and improvement. The purpose of the Performance Improvement Plan is to: ... Determine priorities for improving systems ...sustaining improved performance of organization-wide systems and processes through a planned systematic approach ...to provide the framework for planning, directing, coordinating, and improving patient care ...To maintain a mechanism by which the Governing Board remain knowledgeable about the quality of services being delivered ..." Further review revealed "Goal: API has developed a Performance Improvement Plan committed to the continuous designing, monitoring performance, analyzing data, and improving and sustaining organizational performance. The hospital mission supports an environment where performance improvement efforts are an integral component of daily functioning."

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Based on document review and interview, the facility failed to: 1) take action to fully implement their Plan of Correction (PoC) for a complaint survey conducted 6/29/21 - 7/1/21 and 2) utilize their Quality Assessment and Performance Improvement (QAPI) activities to collect and analyze data from their PoC to ensure the PoC's progress, completion, and sustainability. Specifically, the facility failed to: 1) complete their PoC actions aimed at performance improvement and 2) bring forth audit data collected to the monthly QAPI meetings for ongoing compliance monitoring and sustainability. This failed practice had the potential to effect sustainable correction of direct patient care practices concerning Patient Rights for all patient residing in the facility (based on a census of 53). Findings:

Facility PoC

Review of the facility's PoC, with a completion date of 8/1/21, revealed:

-A115 Patient Rights (CFR(s): 482.13): Plan of Correction: " ...The hospital has implemented regular and on going audits to include the monitoring of medication administration, safe patient care environment, and abuse and neglect reporting. The results of these audits are reporting in bi-weekly nursing leadership meetings, weekly CEO meetings, and monthly QAPI meetings ..."

- A131 Patient Rights: Informed Consent (CFR(s): 482.13(b)(2)): Plan of Correction:

"[Facility] has reviewed policies and procedures and conducted retraining for hospital employees in order to ensure that all patients has the right to make informed decisions regarding their care. This right includes the patient's ability to be involved in care planning and treatment as well as the ability to request or refuse treatment."

"The hospital policy titled "Patient Rights" effective 3/14/2019 has been reviewed and amended to include the language that the patient has the right to receive care in a safe setting ...All employees will receive retaining on the additional policy language by August 1st."

"Training has been initiated for all nurses, nursing staff, clinical services staff, social work staff, rehabilitation staff, and nursing leadership on Patient Rights policy, Informed Consent, Abuse and Neglect. Training to be completed by August 1, 2021."

"Staff who have not completed the training by August 1st will be removed from patient care until training can be completed ..."

- A144 Patient Rights: Care in Safe Setting (CFR(s): 482.13(c)(2)): Plan of Correction:

"[Facility] has reviewed the hospital ligature risk assessment, related policies and mitigation plans. The hospital ensures the patients have the right to receive care in a safe setting."

"The hospital policy titled "Patient Rights" effective 3/14/2019 has been reviewed and amended to include the language that the patient has the right to receive care in a safe setting ...All employees will receive retaining on the additional policy language by August 1st."

"Monitoring and QAPI: Leadership rounds are conducted weekly to ensure the patient environment of care continues to support the patient's right to receive care in a safe setting. Rounds will include review of patient private rooms, bathrooms, and common spaces to ensure no ligature risks are reintroduced to patient care areas ..."

- A145 Patient Rights: Free from Abuse/Harassment (CFR9S): 482.13(c)(3)): Plan of Correction:

[Facility] has completed policy review and revision, and 100% employee training to ensure that all patients have the right to be free from all forms of abuse and harassment ..."

" ...The following steps were taken to ensure compliance with this standard. A retraining for all staff on hospital policy regarding abuse and neglect was initiated on July 20th and with a targeted completed date of August 1st. Training to be completed by August 1, 2021. Staff who have not completed the training by August 1st will be removed from patient care until the training can be completed...The hospital policy "Unusual Occurrence Reporting" [UOR] was reviewed and approved by leadership and presented to the multidisciplinary policy committee on July 27, 2021. A retraining for all staff on the UOR policy was initiated on July 20th and projected to be finished by August 1st.

Nurse Leadership Meetings

Review of the facility's "Nurse Leadership Meeting" minutes, dated 8/24/21, revealed: "Audits: Reminder that the mediation administration audits need to continue along with the weekly nursing leadership rounds ..." Further review revealed no audit data from the medication rounds regarding patient rights were documented within the meeting minutes. Additional review of the meeting minutes revealed no documentation about weekly leadership rounds of the patient environment of care for ligature risks.

Review of the facility's "Nurse Leadership Meeting" minutes, dated 10/14/21, revealed no audit data from the medication rounds regarding patient rights were documented within the meeting minutes. Additional review of the meeting minutes revealed no documentation about weekly leadership rounds of the patient environment of care for ligature risks.

Review of the facility's "Nurse Leadership Meeting" minutes, dated 10/26/21, revealed: "Regulatory Compliance. We are approaching the time frame for CMS [Centers for Medicare and Medicaid Services] to return for a reevaluation of our progress from the last survey. This coming week, please survey your units for cleanliness, hand hygiene, PPE adherence, treatment team updates, code cart checks things like that ..." Further review revealed no audit data from the medication rounds regarding patient rights were documented within the meeting minutes. Additional review of the meeting minutes revealed no documentation about weekly leadership rounds of the patient environment of care for ligature risks.

Review of the facility's "Nurse Leadership Meeting" minutes, dated 11/3/21, revealed: "Regulatory Compliance: Managers will be completing unit rounds on the environment of care in preparation for the joint commission survey and everyday regulatory compliance. Review of the tool was completed. Managers will trial the tool and review next week with the team. Further review revealed no audit data from the medication rounds regarding patient rights were documented within the meeting minutes. Additional review of the meeting minutes revealed no documentation about weekly leadership rounds of the patient environment of care for ligature risks.

Review of the facility's tool that was mentioned in the Nurse Leadership Meeting on 11/3/21, titled "[Facility], Safety & EOC REVIEW CHECKLIST", revealed 10 areas of focus for the Manger rounds: Safety & Security, Hazardous Material, Emergency Management, Fire & Safety, Utility systems, Medical Equipment, Infection Prevention, EVS/Laundry, Facilities, and Employee Knowledge. Further review of the Safety & EOC Review Checklist tool revealed no assessment section to ensure no ligature risks are reintroduced to the patient environment of care.

Record review of the facility's PoC audits, from 7/1/21 to present, revealed no data was provided to show weekly leadership rounds of the patient environment of care, to include review of patient private rooms, bathrooms, and common spaces to ensure no ligature risks are not reintroduced.

During an interview on 11/4/21 at 2:19 pm, the Director of Nursing (DON) stated that the weekly leadership rounds identified on the PoC of the patient environment of care for safe setting, specifically to audit for the reintroduction of ligature risks, was never conducted.

The DON further stated the new "[Facility}'s Safety & EOC Review Checklist" did not have a section to assess for the reintroduction of ligature risks within the patient environment of care.

The DON state that the Nurse Managers conducted daily "safety huddles" on each unit and an environment of care walk-through was completed each day to assess for safety issues.

Review of the facility's daily "Flash Report Morning Huddle Agenda" reports provided; 8 reports from August 2021, 7 reports from September 2021, 3 reports from October 2021, and 2 reports from November 2021, revealed no documentation showing an audit was conducted for the possible reintroduction of ligature risks in the patient environment of care.

Staff Reeducation

During the entrance conference on 11/4/21, the Survey Team requested the staff retraining data for all policies updated based on the PoC, to include Patient Rights, Abuse and Neglect, and UOR. A review of all direct patient care staff's training dates, to include Nurse Managers, Nurses, Psychiatric Nurses Assistants (PNAs), Social Workers, and Psychology, revealed a deficiency to meet the August 1, 2021 deadline of the PoC:

-Patient Rights: Out of 175 direct patient care employees, 113 of them were never retrained after 7/1/21 on the Patient Rights policy revision to include the language that the patient has the right to receive care in a safe setting. At the time of this survey, these employees were still deficient to be retrained on the revised Patient Rights policy. Of the employees that were retrained, 5 employees did not meet the 8/1/21 deadline.

-Abuse and Neglect: Out of 175 direct patient care employees, 13 of them were never retrained after 7/1/21 on the Abuse and Neglect policy. At the time of this survey, these employees were still deficient to be retrained on the Abuse and Neglect policy. Of the employees that were retrained, 5 employees did not meet the 8/1/21 deadline.

-UOR: Out of 175 direct patient care employees, 100 of them were never retrained after 7/1/21 on the UOR policy. At the time of this survey, these employees were still deficient to be retrained on the UOR policy. Of the employees that were retrained, 10 employees did not meet the 8/1/21 deadline.

During an interview on 11/4/21 at 2:23 pm, Interim Quality Director #2 stated that when the training was assigned for reeducation, their training software called "NetLearning" it did not assign retraining to employees who had completed the training earlier in the year. Employees who completed Patient Rights, Abuse and Neglect, and/or UOR training after January 1, 2021, but before July 1, 2021, did not complete the reeducation. She further stated this was not caught on the multitude of audits completed from the start of the PoC to now, as what was being audited was a red, yellow, green colorization of completed trainings, rather than the date the training was completed. Up until the time of this survey, Interim Quality Director #2 had assumed the retraining was completed and this action of the PoC was also completed.

During an interview on 11/4/21 at 2:33 pm, Interim Quality Director #2 stated that there is no facility policy to pull employees off the floor for incomplete education requirements. To her recollection, he/she stated employees who did not meet the 8/1/21 deadline for retraining were not pulled from the floor as the PoC had indicated.

QAPI

Review of the hospital's PoC, with a completion date of 8/1/21, revealed:

-A115 Patient Rights (CFR(s): 482.13): Plan of Correction: ...The hospital has implemented regular and on going audits to include the monitoring of medication administration, safe patient care environment, and abuse and neglect reporting. The results of these audits are reporting in bi-weekly nursing leadership meetings, weekly CEO meetings, and monthly QAPI meetings ..."

- A131 Patient Rights: Informed Consent (CFR(s): 482.13(b)(2)): Plan of Correction: " ...Monitoring and QAPI: [Facility] nursing leadership will implement weekly observation rounds of medication administration ...Results from the observed medication administration will be presented during twice monthly Nursing Leadership meeting as well as monthly QAPI meeting ...3. Audit results from the Nurse Manager Mediation Administration rounds will be presented to the monthly QAPI committee meeting as part of the monthly compliance reporting. The QAPI committee will report results of all Patient Rights audits and rounds are to be aggregated and reported in the monthly QAPI committee meeting as part of ongoing compliance monitoring. This will continue to be monitored until 6 consecutive months of 100% compliance is achieved. Individual responsible: Director of Nursing."

- A144 Patient Rights: Care in Safe Setting (CFR(s): 482.13(c)(2)): Plan of Correction: " ...Monitoring and QAPI: Leadership rounds are conducted weekly to ensure the patient environment of care continues to support the patient's right to receive care in a safe setting. Rounds will include review of patient private rooms, bathrooms, and common spaces to ensure no ligature risks are reintroduced to patient care areas ...Results from leadership rounds will be reported to the bi-monthly hospital leadership meeting. Maintenance will report on the status of the toilet tissue holder replacement at the monthly EOC [Environment of Care] and QAPI meetings. Maintenance to report to EOC and QAPI at all scheduled meetings the removal of the doors and the status of the replacement doors ...Results of all Patient Rights audits and round are to be aggregated and reported in the monthly QAPI committee meeting as part of ongoing compliance monitoring. This will continue to be monitored until 6 consecutive months of 100% compliance is achieved. Individuals responsible: Interim Building Maintenance Supervisor and Director of Clinical Services."

- A145 Patient Rights: Free From Abuse/Harassment (CFR9S): 482.13(c)(3)): Plan of Correction: " ... Monitoring and QAPI: The Interim Risk Manager will meet weekly with the CEO [Chief Executive Officer] to review trends of events and will escalate to the CEO or designee immediately any allegations of abuse. All allegations of abuse and neglect will be recorded in a UOR [Unusual Occurrence Report] per hospital policy. UOR data related to abuse and neglect is reviewed and reported during bi-monthly leadership meeting and hospital monthly QAPI meetings. Individual responsible: Interim Risk Manager and CEO."

QAPI Meetings

Review of the facility's QAPI meeting minutes, dated 8/11/21, revealed: " ...Medication Management ...[Medication] rounds are completed and results will be presented at the Medication Management and QAPI meetings ..." Further review revealed no audit data from the medication rounds regarding patient rights were documented within the meeting minutes. Additional review of the meeting minutes revealed no documentation of the weekly leadership rounds of the patient environment of care for ligature risks, maintenance reports of toilet tissue holder or door replacement statuses, or UOR data related to abuse and neglect.

Review of the facility's QAPI meeting minutes, dated 9/8/21, revealed: "EOC ...Toilet paper holders/style now in review for ligature safety ...Nursing ... Nursing is auditing medication management, with 10 observations per unit per week. Data will be presented by the end of this week for the CMS cap tracker ...Patient Advocacy ...Grievances per 1000 patient days trends upward mostly from the [adolescent] and [acute adult] units. Most of the complaints are against staff and the treatment team ..." Further review revealed no audit data from the medication rounds regarding patient rights were documented within the meeting minutes. Additional review of the meeting minutes revealed no documentation of the weekly leadership rounds of the patient environment of care for ligature risks, maintenance reports of toilet tissue holder or door replacement statuses, or UOR data related to abuse and neglect.

Review of the facility's QAPI meeting minutes, dated 10/13/21, revealed: "QAPI Dashboard ...Nursing, medication management, EOC, and [Infection Control] completed rounds and audits this month. The QAPI dashboard records whether or not each department is improving or not ...Patient Advocacy ...[acute adult unit] had the most grievances about staff and a few on treatment. One of the favorables is 'treated with dignity and respect' ... Further review revealed no audit data from the medication rounds regarding patient rights were documented within the meeting minutes. Additional review of the meeting minutes revealed no documentation of the weekly leadership rounds of the patient environment of care for ligature risks, maintenance reports of toilet tissue holder or door replacement statuses, or UOR data related to abuse and neglect.

Review of the facility's QAPI dashboard (a quantifiable and measurable table of patient safety data to include Utilization, Suicide Assessment, Discharge Planning, Infection Control, Clinical Care, Rehab Therapy, Grievance/Family Support, EOC and Safety, and Medication Management), dated from January 2021 (first quarter) to September 2021 (third quarter), revealed no audit data from the medication rounds regarding patient rights were documented on the dashboard. Additional review of the dashboard revealed no documentation of the weekly leadership rounds of the patient environment of care for ligature risks, maintenance reports of toilet tissue holder or door replacement statuses, or UOR data related to abuse and neglect.

During an interview on 11/4/21 at 1:39pm, the Director of Nursing (DON) stated there was no documentation in the QAPI meeting minutes for 8/11/21, 9/8/21, or 10/13/21 concerning the audit data from the medication rounds regarding patient rights, weekly leadership rounds of the patient environment of care for ligature risks, maintenance reports of toilet tissue holder or door replacement statuses, or UOR data related to abuse and neglect.

During an interview on 11/4/21 at 3:46 pm, Interim Quality Director #2 stated he/she could not recollect the last time UORs were discussed in QAPI meetings.

During an interview on 11/5/21 at 12:00 pm, Interim Quality Director #2 stated data presented on the QAPI dashboard, and in the QAPI meetings, was based primarily on the areas identified within the dashboard sections. He/she further stated due to staffing shortages, there had not been key staff members in key roles to focus on the PoC.

Interim Quality Director #2 further stated that data was measured and analyzed within QAPI when data was collected and complied in a report, then someone would relay that report in QAPI. He/she stated there is currently a gap between this data collection and how to determine if improvements were made. He/she also stated he/she could recall if QAPI had ever provided feedback or guidance to make improvements.

During an interview on 11/5/21 at 12:58 pm, the DON stated that the PoC was developed with all administrative leadership input. She stated that there were weekly meetings scheduled to monitor the PoC's status and the data was also presented at the bi-monthly leadership meetings. The DON stated there was no documentation that could be presented to show this. The DON further agreed there was no place to document the PoC's status on the QAPI dashboard and the DON stated the PoC actions and audit data was not presented to QAPI.

During an interview on 11/5/21 at 1:04pm, the DON stated that gaps and oversights were identified within QAPI when the previous Director of Quality put in his/her notice. She recalled there was a meeting to look at the QAPI gaps but could not recall the date. The DON further stated there was no documentation about that meeting and that no performance improvement plan was made concerning the QAPI gaps. The DON stated that at this time, QAPI oversight is missing.

The DON further stated that she was unaware that the PoC was not completed. She stated this was not reported to oversight and it didn't cross her radar that there were pieces of the PoC that were missing.

During an interview on 11/5/21 at 2:24pm, the CEO stated he was unaware the PoC was not completed. The CEO further stated that he could not recollect if the PoC was presented in QAPI. In regards to the QAPI committee, the CEO stated QAPI had not measured improvements that he could recall. The CEO further stated there was no documentation to present that QAPI collected, measured, or analyzed the PoC actions or audits. He agreed there was room for improvement in this area.

Review of the facility's policy "Quality Assurance and Performance Improvement (QAPI) Program," dated 1/15/21, revealed "The goal of the program is to provide a framework and motivation for improvement of health outcomes ...by implementation of an organization-wide process of assessment, measurement, and improvement. The purpose of the Performance Improvement Plan is to: ... Determine priorities for improving systems ...sustaining improved performance of organization-wide systems and processes through a planned systematic approach ...to provide the framework for planning, directing, coordinating, and improving patient care ...To maintain a mechanism by which the Governing Board remain knowledgeable about the quality of services being delivered ..." Further review revealed "Goal: API has developed a Performance Improvement Plan committed to the continuous designing, monitoring performance, analyzing data, and improving and sustaining organizational performance. The hospital mission supports an environment where performance improvement efforts are an integral component of daily functioning."

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Based on interview, facility quality improvement projects review, and policy review the facility failed to measure progress towards quality improvement project goals, or measure outcomes of projects currently being addressed for 3 quality improvement projects, out of 3 sampled quality improvement projects. This failed practice had the potential to inhibit the project's success and/or sustainability which could affect the overall improvement of patient safety and overall wellbeing for all 53 inpatients and any future patients admitted to the facility. Findings:

During an interview on 11/4/21 at 3:36 pm, the Interim Quality Director #2 stated the goal for the facility's quality improvement program was staff education, and the QAPI committee would "drive" what was needed on the patient care units. The Interim Quality Director #2 stated the format for quality improvement projects was to plan, do, study and act. The Interim Quality Director #2 further stated the facility identified the problem and provided education to the staff.

During a follow up interview on 11/5/21 at 11:58 am, when asked about quality improvement project goals, the Interim Quality Director #2 stated the facility was performing the work, but the work was not getting captured in the charting. When asked to provide the performance improvement projects the facility was working on for the past year, three projects were received.

Review on 11/5/21 at 12:30 pm of the facility provided document "Nursing communication improvement project," dated 2/2021, revealed under "Success (what went well?) All nursing department leaders provided the DON [Director of Nursing] and ADON [Assistant Director of Nursing] positive feedback on the benefit of the daily call to improve communication and planning for admission. We have seen improved patient outcomes." Further review revealed no documentation of the measurable progress achieved on this project.

Review on 11/5/21 at 12:30 pm of the facility provided document "PDSA [plan do study act] cycle- Hygiene PDSA Cycle: Personal and Oral Hygiene Completion," not dated, revealed " ...60-day Review ...The data supports implementing a hygiene intervention at the unit level to address prompting, initiation of providing supplies, and education on the importance of participation in personal hygiene. There have been multiple barriers to implementing a unit level intervention. The biggest current barriers are consistent staff training, communication, availability of supplies, and consistent means of documentation. Multiple meetings have occurred between occupational therapy (OT), psychiatric nursing assistants (PNAs), and floor nurses to address concerns with the barriers listed." Further review revealed no documentation of measurable progress achieved on this project.

Review on 11/5/21 at 12:40 pm of the facility provided document "Changes for Contraband process PDSA 3/9/21," revealed "At discharge: After LIP [Licensed Independent Practitioner] approval, Unit supervisor/PNA IV will either: attempt to make arrangements to have items released to responsible third party; Send items via mail to forwarding address; If no arrangements can be made property will be held for 90 days [and] disposed of by unit supervisor/PNA IV and document on contraband form by a minimum of two licensed staff ..." Further review revealed no documentation of measurable progress achieved on this project.

During an interview on 11/5/21 at 11:58 am, when asked how the facility documented how improvements were being made, the Interim Quality Director #2 stated the facility had been in "survival mode" and there was a gap in that part of the process. The CW further stated each department was working on a quality improvement project, and the facility had developed a framework over the last 2 months because the work was not getting done. The Interim Quality Director #2 further stated staff did not have working knowledge of the quality improvement process.

During an interview on 11/5/21 at 12:48 pm, when asked how gaps in quality measures were reviewed, the DON stated she was accustomed to outcome related data, and when she was provided the data, she noted errors. The DON further stated staff had a foundational lack of understanding on what was supposed to be done. The DON further stated that she did not know if a plan was created to address those gaps and the facility was in the process of hiring someone to fix this. The DON stated the facility was struggling with the infrastructure to deal with this issue.

During an interview on 11/5/21 at 2:24 pm, when asked how the facility measured quality progress, the CEO stated the facility had not done that. The CEO stated the facility had not been documenting the progress and there was room for improvement in that area.

Review on 11/5/21 at 2:00 pm of the facility's policy "Quality Assurance and Performance Improvement Plan for API," dated 1/15/21, revealed "Performance Improvement Teams: ...Responsibility: ...The teams will identify performance measure appropriate for monitoring performance of the process being studied, including, but not limited to: measures identifying events they were intended to measure. Measures with defined data elements and allowable values. Measures with detectable changes in performance over time. Measures allowing comparison over time."Based on interview, facility quality improvement projects review, and policy review the facility failed to measure progress towards quality improvement project goals, or measure outcomes of projects currently being addressed for 3 quality improvement projects, out of 3 sampled quality improvement projects. This failed practice had the potential to inhibit the project's success and/or sustainability which could affect the overall improvement of patient safety and overall wellbeing for all 53 inpatients and any future patients admitted to the facility. Findings:

During an interview on 11/4/21 at 3:36 pm, the Interim Quality Director #2 stated the goal for the facility's quality improvement program was staff education, and the QAPI committee would "drive" what was needed on the patient care units. The Interim Quality Director #2 stated the format for quality improvement projects was to plan, do, study and act. The Interim Quality Director #2 further stated the facility identified the problem and provided education to the staff.

During a follow up interview on 11/5/21 at 11:58 am, when asked about quality improvement project goals, the Interim Quality Director #2 stated the facility was performing the work, but the work was not getting captured in the charting. When asked to provide the performance improvement projects the facility was working on for the past year, three projects were received.

Review on 11/5/21 at 12:30 pm of the facility provided document "Nursing communication improvement project," dated 2/2021, revealed under "Success (what went well?) All nursing department leaders provided the DON [Director of Nursing] and ADON [Assistant Director of Nursing] positive feedback on the benefit of the daily call to improve communication and planning for admission. We have seen improved patient outcomes." Further review revealed no documentation of the measurable progress achieved on this project.

Review on 11/5/21 at 12:30 pm of the facility provided document "PDSA [plan do study act] cycle- Hygiene PDSA Cycle: Personal and Oral Hygiene Completion," not dated, revealed " ...60-day Review ...The data supports implementing a hygiene intervention at the unit level to address prompting, initiation of providing supplies, and education on the importance of participation in personal hygiene. There have been multiple barriers to implementing a unit level intervention. The biggest current barriers are consistent staff training, communication, availability of supplies, and consistent means of documentation. Multiple meetings have occurred between occupational therapy (OT), psychiatric nursing assistants (PNAs), and floor nurses to address concerns with the barriers listed." Further review revealed no documentation of measurable progress achieved on this project.

Review on 11/5/21 at 12:40 pm of the facility provided document "Changes for Contraband process PDSA 3/9/21," revealed "At discharge: After LIP [Licensed Independent Practitioner] approval, Unit supervisor/PNA IV will either: attempt to make arrangements to have items released to responsible third party; Send items via mail to forwarding address; If no arrangements can be made property will be held for 90 days [and] disposed of by unit supervisor/PNA IV and document on contraband form by a minimum of two licensed staff ..." Further review revealed no documentation of measurable progress achieved on this project.

During an interview on 11/5/21 at 11:58 am, when asked how the facility documented how improvements were being made, the Interim Quality Director #2 stated the facility had been in "survival mode" and there was a gap in that part of the process. The CW further stated each department was working on a quality improvement project, and the facility had developed a framework over the last 2 months because the work was not getting done. The Interim Quality Director #2 further stated staff did not have working knowledge of the quality improvement process.

During an interview on 11/5/21 at 12:48 pm, when asked how gaps in quality measures were reviewed, the DON stated she was accustomed to outcome related data, and when she was provided the data, she noted errors. The DON further stated staff had a foundational lack of understanding on what was supposed to be done. The DON further stated that she did not know if a plan was created to address those gaps and the facility was in the process of hiring someone to fix this. The DON stated the facility was struggling with the infrastructure to deal with this issue.

During an interview on 11/5/21 at 2:24 pm, when asked how the facility measured quality progress, the CEO stated the facility had not done that. The CEO stated the facility had not been documenting the progress and there was room for improvement in that area.

Review on 11/5/21 at 2:00 pm of the facility's policy "Quality Assurance and Performance Improvement Plan for API," dated 1/15/21, revealed "Performance Improvement Teams: ...Responsibility: ...The teams will identify performance measure appropriate for monitoring performance of the process being studied, including, but not limited to: measures identifying events they were intended to measure. Measures with defined data elements and allowable values. Measures with detectable changes in performance over time. Measures allowing comparison over time."

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Based on record review and interview the facility's Governing Body (GB) failed to ensure that the hospital-wide Quality Assessment and Performance Improvement (QAPI) efforts addressed priorities for improved quality of care and patient safety and that all improvement actions were evaluated. Specifically, the GB did not collect and analyze data from the facility's Plan of Correction (PoC) for a complaint survey conducted 6/29/21 - 7/1/21. This failed practice had the potential to effect sustainable correction of direct patient care practices concerning Patient Rights for all patient residing in the facility (based on a census of 53). Findings:

Review of the facility's GB meeting minutes, dated 7/15/21, revealed: " ...QAPI Report ...f. Survey: 1. [Facility] hosted an unannounced CMS [Centers for Medicare and Medicaid Services] survey. 2. There were with five (5) separate complaints. CMS was present for three (3) days; participated in tours of the units and interviewed several staff pertaining to allegations of patient abuse and neglect. 3. [Facility] has not yet received the final report. We anticipate that two (2) of the five (5) complaints will be substantiated. We are reviewing policies and procedures to ensure that practices align with our policies and Joint Commission standards. Upon receipt of the report, we will have ten (10) days to respond with a corrective action plan ..."

Review of the facility's GB meeting minutes, dated 8/19/2021, revealed: " ...v. QAPI Report: ...j. CMS survey a. Concern about ligature risk. Determined toilet paper roll dispenser is a significant risk so all have to be updated." Further review revealed no documentation of PoC actions status, audit results, retraining status, or QAPI involvement of PoC implementation.

Review of the facility's GB meeting minutes, dated 9/16/21, revealed: " ...CMS Survey Response Update. [Interim Quality Director #1] reported on the work that it was doing for its follow up to the Centers for Medicare and Medicaid Services (CMS) survey response as part of its plan of correction with CMS. Unusual Occurrence Report, Consults outside [Facility], Abuse and Neglect and Patient Rights were discussed as part of the plans of correction with CMS ...QAPI Report. [Interim Quality Director #1] presented the QAPI Report dashboard. The QAPI report included utilization, suicide assessment, discharge planning, infection control, clinical care, rehab therapy, grievance and family support, environment of care and safety, and medication management information. [Facility] reported twenty-six hand observations, but those could be higher. [Facility] will have latest information in the next QAPI report." Further review revealed that other than the documentation of policy review and/or revision, there was no documentation of PoC actions status, audit results, retraining status, or QAPI involvement of PoC implementation.

Review of the facility's GB meeting minutes, dated 10/21/21, revealed: " ...QAPI Report. [Interim Quality Director #1] reported [Facility] will be revamping its QAPI report/dashboard that is given to the Governing Body and that the Governing Body can anticipate changes to this report coming soon." Further review revealed no documentation of PoC actions status, audit results, retraining status, or QAPI involvement of PoC implementation.

During an interview on 11/5/21 at 12:58 pm, the Director of Nursing (DON) stated that the only QAPI information that was presented to the GB was the QAPI dashboard information. She further stated that no information concerning the PoC was presented to the GB.

During an interview on 11/5/21 at 1:04pm, the DON stated that gaps and oversights were identified within QAPI when the previous Director of Quality put in his/her notice. She recalled there was a meeting to look at the QAPI gaps but could not recall the date. The DON further stated there was no documentation about that meeting and that no performance improvement plan was made concerning the QAPI gaps.

The DON further stated that she was unaware that the PoC was not completed. She stated this was not reported to oversight and it didn't cross her radar that there were pieces of the PoC that were missing.

During an interview on 11/5/21 at 1:23 pm, The Interim Quality Director #2 stated that the QAPI dashboard was the only data, other than the policy review and/or revision, that was presented to the GB on 8/19/21 and 9/16/21. She further stated no QAPI information was presented to the GB in October as this was when the Interim Quality Director #1 identified the whole QAPI program needed to be "revamped."

During an interview on 11/5/21 at 2:24pm, the CEO stated he was unaware the PoC was not completed. The CEO further stated that he could not recollect if the PoC was presented in QAPI. In regards to the QAPI committee, the CEO stated QAPI had not measured improvements that he could recall. The CEO further stated there was no documentation to present that QAPI collected, measured, or analyzed the PoC actions or audits. He agreed there was room for improvement in this area.

Review of the facility's Governing Body Bylaws, dated 10/15/2020, revealed:

- ARTICLE II GOVERNING BODY OF THE HOSPITAL: SECTION 1. LEGAL AUTHORITY AND ORGANIZATIONAL STRUCTURE ...B. The Commissioner delegates the responsibilities of operations of the Hospital to the Governing Body ...C. The [Facility] exists within DHSS [Department of Health and Social Services] as a specifically budgeted Division and is headed by a Chief Executive Officer ("CEO") ...The CEO is delegated the following responsibilities and authority by the Governing Body: ...c. Drafting a Strategic Plan that addresses identified problems ...The Strategic Plan will be a detailed, written document of guidance concerning ...outcome measures, quality assurance, safety, and operation of the [facility].g. The authority to assure the appropriate and available resources are used to support systems for the quality assessment and improvement functions and risk management functions related to patient care and safety; ...i. Will be responsible for meeting all applicable laws and regulations pertaining to the Hospital and acting promptly upon reports and reviews of regulatory, inspecting, and accrediting agencies ...

- SECTION 3. DUTIES AND RESPONSIBILITIES ...C. Members of the [facility] Governing Body accept fiduciary responsibility for the Hospital and its operations, policies, governance, and the obligation to continuously strive to provide safe and high-quality care ...D. The [facility] Governing Body shall is empowered to determine and maintain the objectives, purposes, and values of the Hospital and to approve the scope of services and to ensure the highest quality of inpatient psychiatric services to patients of the Hospital ...M. The Governing Body ensures that a process is in place for monitoring and evaluating quality of patient care through an organized performance improvement plan and for the provision of consistent level of care in the Hospital ...N. The Governing Body ensures that a process is in place to obtain the necessary information to fulfill its duties and responsibilities ...Q. The Governing Body ensures that an effective safety management program is in place and receives regular reports on its performance.

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