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Based on interview and review of facility's policy and Governing Board (GB) minutes, it was determined the facility failed to ensure the GB approved the Performance Improvement Program (PIP) selected indicators and the frequency of data collection for those indicators.

The findings include:

Review of facility's policy entitled, "Performance Improvement Program," Section E (24), effective date 8/25/14, revealed the GB's accountability for quality was discharged through its performance of four (4) major responsibilities, one (1) of which was requiring that objective measures be used to gauge the quality of care and services being provided. The policy further revealed there were two (2) tiers of indicators. One (1) tier was system priority, and the second tier was dashboard indicators which were quality control measures that were monitored at the unit level and only reported to the Patient Safety and Quality Committee (PISC) if the results were unfavorable. The policy further revealed a PIP objective was the development of an organizational dashboard of key process indicators.

Review of facility GB minutes from November 2014 through May 2015 revealed there were no specific indicators listed with the associated frequency of their data collection approved by the GB for 2015.

Interview with the Director of Quality, on 06/18/15 at 4:30 PM, revealed she agreed the 2015 performance indicators being measured and tracked had not been explicitly spelled out and approved by the GB as reflected in their minutes. She further revealed the facility had never listed each indicator with the required frequency of measurement for GB approval but would do so in the future.

Based on interview and review of facility's policy and Governing Board (GB) minutes, it was determined the facility failed to ensure the GB approved the Performance Improvement Program (PIP) number of distinct projects chosen to improve quality for 2015.

The findings include:

Review of facility's policy entitled, "Performance Improvement Program," Section E (24), effective date 08/25/14, revealed the GB delegated to the Patient Safety and Quality Committee (PISC) the central authority for managing the PIP. One of the responsibilities of the PISC was to prioritize performance improvement (PI) projects and charter PI teams.

Review of facility GB minutes from November 2014 through May 2015 revealed there was no listing of PI projects, neither chartering them nor prioritizing them, for GB approval.

Interview with the Director of Quality, on 06/18/15 at 4:30 PM, revealed she agreed the 2015 PI projects had not been explicitly spelled out with chartering and prioritization of them and approved by the GB as reflected in their minutes. She further revealed the facility had never listed each PI project and related information for GB approval but would do so in the future.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection as evidenced by an observation of staff not following contact and droplet isolation precautions when in a contaminated area.

The findings include:

Review of the facility's policy titled, "Infection Control," dated 4/22/14, revealed the facility's infection control policies and practices were intended to minimize the risk or prevent the spread of communicable infectious disease among patients, team members and visitors. Further review of the policy revealed contact and droplet isolation required personal protective equipment (PPE) such as gloves, gown and mask be donned before entering a patient's room. The policy further stated contact isolation was required when an infectious agent could be transmitted by directly touching the patient, or indirectly by touching items in the patient's environment; droplet isolation was required when infectious pathogens could spread when a patient coughed or sneezed, releasing respiratory droplets over short distances.

Observation, on 06/17/15 at 2:10 PM , of care for Patient #6 who was under contact and droplet isolation precautions revealed the Respiratory Therapist failed to use PPE when giving a respiratory treatment to him/her. Further observation revealed Patient #6 had a PPE rack and contact and respiratory isolation signs on his/her door indicating he/she was in isolation.

Record review revealed Patient #6 was admitted to the facility on 06/11/15 with diagnoses which included Sepsis, Clostridium Difficile (C-Diff), Methicillin Resistant-Staphylococcus Aureus (MRSA) in sputum and Pneumonia. The record further revealed he/she was placed in contact and droplet isolation.

Interview, on 06/17/15 at 2:10 PM, with Registered Respiratory Therapist (RRT) #1 revealed he was aware of the contact and droplet precautions for Patient #6 but did not put on PPE during a treatment for him/her, although he should have. RRT #1 further revealed he did not follow the facility's policy, and he should have.

Interview, on 06/17/15 at 2:20 PM, with Patient Care Manager (PCM) #1, revealed RRT #1 should have followed the isolation precautions on Patient #6's door and should not have been in the patient's room without wearing required PPE. PCM #1 further revealed when a patient was in isolation for an infectious illness, PPE equipment was set up outside of the patient's room with an isolation precaution sign placed on the door of the patient's room indicating which isolation precaution was to be used.

Interview, on 06/18/15 at 1:12 PM, with the Infection Control Nurse (ICN) revealed all staff were trained on infection control and were expected to follow the facility's infection control policy. The ICN further revealed RRT #1 should have put on PPE before entering Patient #6's room.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to have an effective discharge planning process in place for one (1) of five (5) patients reviewed for discharge planning compliance, Patient #2.

The findings include:

Review of the facility's policy, "Discharge Planning Process, Section I(40)", effective 06/08/12, revealed within twenty-four (24) hours of admission the nursing service would complete an initial admission assessment and identify those patients who may be high-risk and require a discharge planning evaluation. It further revealed identified patients would be referred to the Social Worker (SW) for completion of the evaluation, and the SW would complete a discharge planning evaluation within forty-eight (48) hours of receiving a consult.

Review of Patient #2's clinical record revealed he/she was admitted to the Intensive Care Unit (ICU) from the Emergency Room (ER) on Saturday, 04/04/15, with diagnoses which included Status-Post Cerebral Vascular Accident (CVA). Patient #2 was a readmission within thirty (30) days. Nursing notes revealed a referral was made to Social Services for follow-up that same day. Hospital records for Patient #2 do not reflect the Social Worker (SW) having seen or talked with Patient #2 regarding discharge plans throughout his/her hospitalization. Patient #2 was discharged on 04/08/15.

Interview with SW #1, on 06/17/15 at 11:05 AM, revealed his/her primary duty as a SW was discharge planning which involved trying to facilitate the discharge and meeting the patient's needs at discharge. SW #1 further revealed there were three (3) ways to trigger a consult: 1) physicians or nurses put in a request for a consult in the computer; 2) nursing assessments identify the need for a consult; or 3) patients request a consult. SW #1 further revealed he/she would make arrangements for durable medical equipment and contact the home health agency chosen by the patient from a list given to him/her according to the demographics of where the patient lived. For Skilled Nursing facility needs, the same process was followed. SW #1 revealed all patients over the age of seventy-five (75), those with certain diagnoses, or re-admits less than thirty (30) days were automatically consulted. SW #1 also revealed on weekends there was a SW on call in the ED, and he/she would go to the computer every working day to look for consults that had been initiated. SW #1 then revealed the consult for Patient #2 should have been received on 04/06/15, and he/she should have seen the patient. SW #1 then stated he/she had no idea why the consult was missed, but if there had been immediate needs for SW services for Patient #2, nursing would not have discharged the patient without SW seeing the patient and addressing those needs. SW #1 revealed he/she could not recall another case where a consult had been missed, as in the case of Patient #2.

Interview with Physician #2, on 06/17/15 at 11:25 AM, revealed discharge planning was looked at from the first day of the patient's admission with physicians communicating with the discharge planners, trying to project patient discharge planning needs. Physician #2 also revealed there were hoops that had to be jumped through to get equipment, etc., but the process was usually smooth. Physician #2 stated he/she looked at readmits and post-acute follow-ups to try and improve the discharge planning process. He/she further revealed the facility was working on a clinic for closer followup for outpatients with certain complicated diagnoses such as Congestive Heart Failure which were prone to have frequent ER visits or readmissions. Physician #2 revealed the team approach had and would help in managing patients with complex health problems.

Interview with Physician #2, on 06/17/15 at 11:30 AM, revealed SW's and case managers round with physicians to address discharge needs with the goal being to provide the patient/family with the care and/or equipment needed at home.

Interview with the Director of Quality, on 06/18/15 at 2:35 PM, revealed the SW should have met with Patient #2 on 04/06/15 to discuss his/her discharge plans. The Director of Quality revealed that a closer look at the process would be done to prevent missed SW consults.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to evaluate, on a timely basis, the needs of one (1) of five (5) patients reviewed for discharge planning compliance, Patient #2.

The findings include:

Review of the facility's policy, "Discharge Planning Process, Section I(40)," effective 06/08/2012, revealed within twenty-four (24) hours of admission nursing service would complete an initial admission assessment and identify those patients who may be high-risk and require a discharge planning evaluation. It further revealed identified patients would be referred to the Social Worker (SW) for completion of the evaluation, and the SW would complete a discharge planning evaluation within forty-eight (48) hours of receiving a consult.

Review of Patient #2's clinical record revealed he/she was admitted to the Intensive Care Unit (ICU) from the Emergency Room (ER) on Saturday, 04/04/15, with diagnoses which included Status-Post Cerebral Vascular Accident (CVA). Patient #2 was a readmission within thirty (30) days. Nursing notes revealed a referral was made to Social Services for follow-up that same day. Hospital records for Patient #2 do not reflect the SW having seen or talked with Patient #2 regarding discharge plans throughout his/her hospitalization. Patient #2 was discharged on 04/08/15.

Interview with Social Worker (SW) #1, on 06/17/15 at 11:05 AM, revealed his/her primary duty as a SW was discharge planning which involved trying to facilitate the discharge and meeting the patient's needs at discharge. SW #1 further revealed there were three (3) ways to trigger a consult: 1) physicians or nurses would put in a request for a consult in the computer; 2) nursing assessments would identify the need for a consult; or 3) patients would request a consult. SW #1 further revealed he/she would make arrangements for durable medical equipment and contact the home health agency chosen by the patient from a list given to him/her according to the demographics of where the patient lived. For Skilled Nursing facility needs, the same process was followed. SW #1 revealed all patients over the age of seventy-five (75), those with certain diagnoses, or re-admits less than thirty (30) days automatically received a consult. SW #1 also revealed on weekends there was a SW on call in the ER, and he/she would go to the computer every working day to look for consults that had been initiated. SW #1 then revealed the consult for Patient #2 should have been received on 04/06/15, and he/she should have seen the patient. SW #1 then stated he/she had no idea why the consult was missed, but if there had been immediate needs for SW services for Patient #2, nursing would not have discharged the patient without the SW seeing the patient and addressing those needs. SW #1 revealed he/she could not recall another case where a consult had been missed, as in the case of Patient #2. SW #1 stated he/she tried to see all readmissions of thirty (30) days or less.

Interview with the Director of Quality, on 06/18/15 at 2:35 PM, revealed SW #1 should have met with Patient #2 on 04/06/15 to discuss his/her discharge plans. The Director of Quality revealed that a closer look at the process would be done to prevent missed SW consults.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure the results of the discharge evaluation were discussed with the patient or individual acting on his or her behalf before the patient was discharged from the facility for one (1) of five (5) patients reviewed for discharge planning compliance, Patient #2.

The findings include:

Review of the facility's policy, "Discharge Planning Process, Section I(40)," effective 06/08/2012, revealed within twenty-four (24) hours of admission nursing service would complete an initial admission assessment and identify those patients who may be high-risk and require a discharge planning evaluation. It further revealed identified patients would be referred to the Social Worker (SW) for completion of the evaluation, and the SW would complete a discharge planning evaluation within forty-eight (48) hours of receiving a consult. This evaluation would include, but would not be limited to, education and review with patient and/or representative of anticipated discharge planning needs and resources anticipated to be necessary to adequately meet those needs.

Review of Patient #2's clinical record revealed he/she was admitted to the Intensive Care Unit (ICU) from the Emergency Room (ER) on Saturday, 04/04/15, with diagnoses which included Status-Post Cerebral Vascular Accident (CVA). Patient #2 was a readmission within thirty (30) days. Nursing notes revealed a referral was made to Social Services for follow-up that same day. Hospital records for Patient #2 do not reflect the SW having seen or talked with Patient #2 regarding discharge plans throughout his/her hospitalization. Patient #2 was discharged on 04/08/15.

Interview with Social Worker (SW) #1, on 06/17/15 at 11:05 AM, revealed his/her primary duty as a SW was discharge planning which involved trying to facilitate the discharge and meeting the patient's needs at discharge. SW #1 further revealed there were three (3) ways to trigger a consult: 1) physicians or nurses would put in a request for a consult in the computer; 2) nursing assessments would identify the need for a consult; or 3) patients would request a consult. SW #1 further revealed he/she would make arrangements for durable medical equipment and contact the home health agency chosen by the patient from a list given to him/her according to the demographics of where the patient lived. For Skilled Nursing facility needs, the same process was followed. SW #1 revealed all patients over the age of seventy-five (75), those with certain diagnoses, or re-admits less than thirty (30) days automatically received a consult. SW #1 also revealed on weekends there was a SW on call in the ER; and SW #1 also revealed he/she would go to the computer every working day to look for consults that had been initiated. SW #1 then revealed the consult for Patient #2 should have been received on 04/06/15, and he/she should have seen the patient. SW #1 then stated he/she had no idea why the consult was missed, but if there had been immediate needs for SW services for Patient #2, nursing would not have discharged the patient without the SW seeing the patient and addressing those needs. SW #1 revealed he/she could not recall another case where a consult had been missed, as in the case of Patient #2. SW #1 stated he/she tried to see all readmissions of thirty (30) days or less.

Interview with the Director of Quality, on 06/18/15 at 2:35 PM, revealed SW #1 should have met with Patient #2 on 04/06/15 to discuss his/her discharge plans. The Director of Quality revealed that a closer look at the process would be done to prevent missed SW consults.