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| SANDHILLS REGIONAL MEDICAL CENTER | 1000 WEST HAMLET AVENUE HAMLET, NC 28345 | July 16, 2015 |
| VIOLATION: PROGRAM SCOPE, PROGRAM DATA | Tag No: A0273 | |
| Based on the Organization-wide Quality Assessment and Performance Improvement Program, the 2015 Performance Indicator Log Review, Hand Washing Monitor Monthly Totals, and staff interviews, the facility failed to collect performance assessment data in the frequency identified for 1 of 4 indicators reviewed (Hand Hygiene). The findings include: Review of the Organization-wide Quality Assessment and Performance Improvement Program 2015, revised 05/2015, revealed "...The Department Leaders are accountable....for the quality and safety of care/services and performance of their staff and departments. Department Directors and Managers of those departments and services that impact patient care are responsible for the systematic monitoring and analysis of the quality and safety of care provided in their departments. Directors will:....Monitor and analyze the processes in their areas that affect patient care, safety, outcomes and satisfaction....Collect data identified and assigned by leadership... ." Review of 2015 Performance Indicators revealed an indicator, "% (percent) Compliance Handwashing Policy (via observation)." Review revealed a goal of 95% and space for monthly data collection. Review of Hand Washing Monitor Monthly Totals form revealed a document with the names of departments expected to report handwashing compliance. Review revealed handwritten results of compliant observations and total observations by department, along with calculated percent compliance. A form was presented for each month January - June 2015. Review of the forms revealed two departments (Radiology, Endoscopy) did not submit any reports for the six month time period. Further review revealed other areas with missing data, two of them (Wound Clinic, Gynecology Office) had not submitted data for 4 of 6 months. Interview with Infection Control Nurse (ICN) # 1, on 07/15/2015, revealed Department Managers are to observe and record 20 handwashing observations per month and send in the results monthly. Interview revealed ICN # 1 sends e-mail reminders to submit the data. Interview confirmed there was data missing that had not been submitted. Interview with Administrative Staff # 1, on 07/16/2015, confirmed there were gaps in submitting data. NC 633 |
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