HospitalInspections.org

Based on record review and interview the facility failed to ensure that there is an effective, ongoing, hospital wide, data driven quality assessment and performance improvement program(QAPI) to evaluate the provision of care. This deficient practice created an environment with the potential to cause harm to all patients receiving care at this facility..

Findings:

Review of meeting minutes from "Committee as a Whole" dated February 2010, April 2010, and May 2010 revealed no documentation that data collected by Pharmacy Department, Radiology Department, and Respiratory Therapy Department using tools created by QAPI Program were ever addressed or discussed. No documentation of Nursing Services or Surgical Department data collection was found There was no documentation of any QAPI Program meeting minutes for 8 of 12 months in 2010.

Interview with current Director of Nurses confirmed she had been unable to find any documentation pertaining to QAPI Program from previous administration during late 2009 thru July 2010. Documentation of data collection was found for Respiratory, Pharmacy, and Radiology departments for 2010, but information was never analyzed, tracked, trended, or addressed for performance improvement. No other QAPI activities were documented by previous administration.
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