HospitalInspections.org

Based on interview and record review, the facility failed to ensure their QA program was hospital-wide specifically including the emergency department. Findings include:

During a second on-site EMTALA revisit survey staff member A, CEO reported she had no documentation available to reflect a QA process had been initiated to collect data, measure results, form appropriate corrective action if necessary and monitor effectiveness. Staff member D, QI coordinator, reported the facility PI meetings did not include a QA process of surveillance for the emergency department violations. For details refer to C-336, C-341, and C-342.

Based on interview and record review, the facility failed to address ongoing monitoring and data collection, data analysis, identification of corrective action, implementation of corrective action, evaluation of corrective actions and measures to improve QA on an ongoing basis facility wide, specifically, to address the emergency department violations. Findings include:

During an interview on 6/9/15 at 8:45 a.m., staff member C, medical records, stated emergency department charts were randomly picked for review. Staff member C reported there was no time frame that she was aware of for the physicians to return their audit reviews. During this interview, staff member A, CEO, stated there was no audit information for QA, and she was not sure when the next QA meeting would be.

During an interview on 6/9/15 at 9:15 a.m., with staff member A and staff member C, staff member C stated she had no findings from audits to report to the PI committee. Staff member C stated the audits from the EMTALA survey POC, dated 5/13/15, were just sent out this week to be reviewed, and there would be no information to report to PI for the next scheduled meeting on 6/20/15. Staff member A stated there was no QA information for the emergency department.

In an interview on 6/9/15 at 9:34 a.m., staff member D, RN, QI coordinator, stated PI meetings are scheduled every other month with the next one due in June. Staff member D stated QA was not addressed regarding the emergency department by the facility.

Review of the facility PI report dated 4/27/15 reflected a lack of information related to QA monitoring for emergency department violations.

Review of the facility document titled QA/PI team tracking tool did not reflect a project to address the emergency department violations.

Review of the facility document, with no title, submitted by staff member A, reflected a spreadsheet with a type of chart review. Staff member A stated she did not know what happened with the results, as the previous DON, who is no longer employed there, did not share that information with anyone to include QA/PI.

The facility did not submit any further documentation to show audits were completed or a QA process was ongoing to address emergency department violations prior to the survey exit.

Based on record review and interview, the facility failed to complete audits for emergency department cited violations, and did not share collected data with QA/PI to ensure corrective action was taken as appropriate. Findings include:

During an interview on 6/9/15 at 8:45 a.m., staff member C, medical records, stated emergency department charts were randomly picked for review. Staff member C reported there was no time frame that she was aware of for the physicians to return their audit reviews. During this interview, staff member A, CEO, stated there was no audit information for QA, and she was not sure when the next QA meeting would be.

During an interview on 6/9/15 at 9:15 a.m., with staff member A and staff member C, staff member C stated she had no findings from audits to report to the PI committee. Staff member C stated the audits from the EMTALA survey POC, dated 5/13/15, were just sent out this week to be reviewed, and there would be no information to report to PI for the next scheduled meeting on 6/20/15. Staff member A stated there was no QA information for the emergency department.

In an interview on 6/9/15 at 9:34 a.m., staff member D, RN, QI coordinator, stated PI meetings are scheduled every other month with the next one due in June. Staff member D stated QA was not addressed regarding the emergency department by the facility.

Review of the facility PI report dated 4/27/15 reflected a lack of information related to QA monitoring for emergency department violations.

Review of the facility document titled QA/PI team tracking tool did not reflect a project to address the emergency department violations.

Review of the facility document, with no title, submitted by staff member A, reflected a spreadsheet with a type of chart review. Staff member A stated she did not know what happened with the results, as the previous DON, who is no longer employed there, did not share that information with anyone to include QA/PI.

The facility did not submit any further documentation to show audits were completed or a QA process was ongoing to address emergency department violations prior to the survey exit.

Based on interview and record review, the facility failed to address emergency department cited violations due to a lack of a quality assurance process. Findings include:

During an interview on 6/9/15 at 8:45 a.m., staff member C, medical records, stated emergency department charts were randomly picked for review. Staff member C reported there was no time frame that she was aware of for the physicians to return their audit reviews. During this interview, staff member A, CEO, stated there was no audit information for QA, and she was not sure when the next QA meeting would be.

During an interview on 6/9/15 at 9:15 a.m., with staff member A and staff member C, staff member C stated she had no findings from audits to report to the PI committee. Staff member C stated the audits from the EMTALA survey POC, dated 5/13/15, were just sent out this week to be reviewed, and there would be no information to report to PI for the next scheduled meeting on 6/20/15. Staff member A stated there was no QA information for the emergency department.

In an interview on 6/9/15 at 9:34 a.m., staff member D, RN, QI coordinator, stated PI meetings are scheduled every other month with the next one due in June. Staff member D stated QA was not addressed regarding the emergency department by the facility.

Review of the facility PI report dated 4/27/15 reflected a lack of information related to QA monitoring for emergency department violations.

Review of the facility document titled QA/PI team tracking tool did not reflect a project to address the emergency department violations.

Review of the facility document, with no title, submitted by staff member A, reflected a spreadsheet with a type of chart review. Staff member A stated she did not know what happened with the results, as the previous DON, who is no longer employed there, did not share that information with anyone to include QA/PI.

The facility did not submit any further documentation to show audits were completed or a QA process was ongoing to address emergency department violations prior to the survey exit.