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Based on review of the hospital's policies, review of quarterly Quality Assessment Performance Improvement (QAPI) committee meeting minutes for 2015, review of (QAPI) data, contract reviews and administrative staff interviews, the Governing Body failed to have a process in place to ensure services provided under contract were evaluated and performed in a safe and effective manner.

The findings include:

Review of the hospital's policies on 08/13/2015 revealed "Quality Assessment Performance Improvement Plan" reviewed/revised April 2013. The policy stated "The scope of the QAPI program requires an ongoing program that demonstrates measurable improvement in quality indicators that give evidence for improvement in health outcomes and identifies and reduces medical errors. [Name of hospital] will measure, analyze and track quality indicators including, but not limited to, medical errors, adverse patient events, hospital procedures, services and operations. The QAPI program shall reflect the complexity of [name of hospital] organization and services, and its involvement in all hospital departments and services, including those services furnished under contract or arrangement."

Review of the hospital's contracted services log revealed the contracted services included Medical Staff, Cardiac Monitoring, Pharmacy after hours, Diagnostic Imaging and Radiology, Laboratory, Dietary/Nutrition, Chaplain, Surgical Services, Code Blue Team and Endoscopy/Bronchoscopy services. Review of the hospital's quarterly QAPI meeting minutes and data tracking revealed no evidence of evaluation or monitoring of the listed contracted services.

Interview with the the Director of Quality and Compliance on 08/11/2015 at 1100 revealed there was no QAPI data available for the contracted services except the dialysis service. The interview revealed the dialysis contract included the company would provide quality measures on an annual basis. The interview revealed the other contracts did not include quality improvement data.

Interview with the Chief Executive Officer on 08/13/2015 at 1515 revealed the contracted services would be due for review and renewal on 10/01/2015. The interview revealed the new contract would include quality measures to ensure services were evaluated and performed in a safe and effective manner.

Based on review of the hospital's Fiscal Year 2015 Quality Assessment Performance Improvement (QAPI) Plan Goals, policy review and administrative staff interviews, the hospital failed to ensure departmental performance improvement projects were measured, analyzed and quality indicators tracked for 2 of 8 nursing/rehabilitaion performance improvement projects (HAPU [hospital acquired pressure ulcer] Prevention and Accurate Weight Measurement).

Findings include:

Review of the hospital's policies on 08/13/2015 revealed "Quality Assessment Performance Improvement Plan" reviewed/revised April 2013. The policy stated "The scope of the QAPI program requires an ongoing program that demonstrates measurable improvement in quality indicators that give evidence for improvement in health outcomes and identifies and reduces medical errors. [Name of hospital] will measure, analyze and track quality indicators including, but not limited to, medical errors, adverse patient events, hospital procedures, services and operations. The QAPI program shall reflect the complexity of [name of hospital] organization and services, and its involvement in all hospital departments and services . . . "

1. Review of the Fiscal Year 2015 QAPI Plan Goals revealed "HAPU Prevention - Adequate Nutrition for high risk patients defined by Registered Dietician." There was no evidence this departmental performance improvement project had been measured, analyzed and the quality indicator was tracked.

Interview with the the Director of Quality and Compliance on 08/11/2015 at 1100 revealed the hospital's fiscal year is October 1 through September 30. The interview revealed the registered dietician had been employed with the hospital for "about 8 months." The interview confirmed there was no QAPI data available for "HAPU Prevention - Adequate Nutrition for high risk patients defined by Registered Dietician."

2. Review of the Fiscal Year 2015 QAPI Plan Goals revealed "Accurate weight measurement - Use tracking to identify discrepancies and develop action plan." There was no evidence this departmental performance improvement project had been measured, analyzed and the quality indicator was tracked.

Interview with the the Director of Quality and Compliance on 08/11/2015 at 1100 revealed the hospital's fiscal year is October 1 through September 30. The interview revealed weights were measured daily, weekly or three times per week. The interview revealed there had been discrepancies in weight measurements related to different users with the scales and inconsistent weights on bed for bed weights. The interview confirmed there was no QAPI data available for "Accurate weight measurement - Use tracking to identify discrepancies and develop action plan."

Based on review of hospital policy, review of the hospital's Adverse Events/Close Calls log, review of quarterly Quality Assessment Performance Improvement (QAPI) committee meeting minutes for 2015, review of (QAPI) data, and administrative staff interviews, the hospital failed to ensure data was collected and analyzed to determine the effectiveness of corrective actions to prevent aspiration during a bronchoscopy.

Findings include:

Policy review on 08/13/2015 revealed "Assisting with Bronchoscopy" reviewed/revised January 2014. Review of the policy revealed "4. Confirm NPO [nothing by mouth] status for routine bronchoscopy, may not be valid in an emergent situation: a. Usually 6 to 8 hours for a patient that is independently eating or receiving enteral nutrition with feeding tube in stomach b. Can be less time if enteral feeding via feeding tube is located lower in the small intestine or at the discretion of the LIP [licensed independent practioner].

Review of the Adverse Events/Close Calls log revealed an Adverse Event with a corrective action implemented. The action plan included 1. Revise Bronchoscopy policy to include the patient's NPO status. 2. Make assistance with Bronchoscopy procedure an advanced competency for registered nurses. 3. Provide education on Bronchoscopy set-up.

Review of quarterly Quality Assessment Performance Improvement (QAPI) committee meeting minutes for 2015 and review of (QAPI) data revealed no evidence data was collected and analyzed to determine the effectiveness of corrective actions to prevent aspiration during a bronchoscopy.

Interview on 08/13/2015 at 0830 with the Quality/Compliance and Risk Management Director revealed there was no QAPI data collected and analyzed to determine the effectiveness of corrective actions to prevent aspiration during a bronchoscopy.

Based on review of the hospital's policies, review of quarterly Quality Assessment Performance Improvement (QAPI) committee meeting minutes for 2015, review of (QAPI) data, contract reviews and administrative staff interviews, the Governing Body failed ensure the QAPI Plan for 2015 included services provided under contract (Medical Staff, Cardiac Monitoring, Pharmacy after hours, Diagnostic Imaging and Radiology, Laboratory, Dietary/Nutrition, Chaplain, Surgical Services, Code Blue Team and Endoscopy/Bronchoscopy services).

The findings include:

Review of the hospital's policies on 08/13/2015 revealed "Quality Assessment Performance Improvement Plan" reviewed/revised April 2013. The policy stated "The scope of the QAPI program requires an ongoing program that demonstrates measurable improvement in quality indicators that give evidence for improvement in health outcomes and identifies and reduces medical errors. [Name of hospital] will measure, analyze and track quality indicators including, but not limited to, medical errors, adverse patient events, hospital procedures, services and operations. The QAPI program shall reflect the complexity of [name of hospital] organization and services, and its involvement in all hospital departments and services, including those services furnished under contract or arrangement."

Interview on 08/11/2015 at 1100 with the Quality/Compliance and Risk Management Director revealed there was no QAPI data available for the services provided under contract except the dialysis service.

Interview with the Chief Executive Officer on 08/13/2015 at 1515 revealed the contracted services would be due for review and renewal on 10/01/2015. The interview revealed the new services provided contracts would include quality measures to ensure services were evaluated and performed in a safe and effective manner.

Based on review of hospital policy, observation, and staff interviews, the hospital staff failed to ensure telemetry monitors were cleaned and disinfected following patient use in 10 of 11 monitors.

Findings include:

Hospital policy review on 08/13/2015 revealed the Infection Control (IC) policy "General Infection Control Issues" last revised April 2013, provided by administrative staff, revealed:
"Reusable Instruments/Equipment: see (Cleaning/Disinfection/Sterilization): a. Cleaning must be done to remove foreign material (dirt, body fluids) from objects prior to disinfecting or sterilization process as foreign material prohibits the disinfecting or sterilization... d. Non-disposable equipment that is brought into a patient's room shall be disinfected when removed from the room."

Observation during unit tour of the reusable equipment room on 8/11/15 at 1125 revealed 11 telemetry monitors housed on a shelf on the wall. Observation revealed 10 of the monitors had a thick layer of a brown substance in crevasses of the monitors. Observation revealed four sunken indentions similar to a sunken nail or screw on the back of the monitors. Observation revealed a thick layer of brown substance within the indentions. Observation revealed same in crevasses along the top of the monitors where electrode plug is inserted. Observation revealed same in sunken area and within crevasses on the front of the monitors as well.

Interview with the director of rehabilitation on 8/11/15 at 1130 revealed the expectation is that each monitor should be cleaned and disinfected after patient use, prior to being returned to the the reusable equipment room. Interview revealed the monitors "haven't been cleaned" according to hospital policy. Interveiw revealed given the patient population and potential of cross contamination, the findings were not acceptable.

Interview with the director of nursing on 8/11/15 at 1200 revealed the cleanliness of the telemetry monitors was the expectation. Interview revealed all reusable equipment should be "cleaned after each patient use".