HospitalInspections.org

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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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