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Based on record review and interview, the facility failed to document a Quality Assessment and Performance Improvement review of the data for May, June, and July 2017.

Findings included

There were no minutes to reflect Quality Assessment and Performance Improvement (QAPI) review of the data for May, June, and July 2017.

During an interview on 9/21/17 ending at 3:35 PM, Ms. Pedron stated, "There was a quality meeting on July 2017 which reviewed April Data, but there has not been another meeting. Ms. Pedron was asked if QA had met on May, June and July data. Ms. Pedron stated, "No."

Based on record review and interview, the facility failed to ensure the discharge summary for 1 of 9 patients (Patient #4) depicted the outcome of hospitalization and disposition of care.

Findings included

Patient #4's 4/28/16 Nurse Patient Care Assessment and notes reflected, "Dysnea/ SOB on exertion...labored...Obeys Commands...10:00 AM Dr. Notified about patient's condition and abnormal labs. N/O (new order) received to send patient to ER (emergency room) for eval (evaluation)...Family notified...KCL (Potassium) level 7.4...11:15 AM patient transferred to (Hospital name/initials) ICU..."

Patient #1's Discharge Summary for the 4/28/16 discharge reflected, "Admission 4/13/16...pleasant 64-year-old...progress in a satisfactory manner...discharged with medications...follow-up with (Physician's name) in 1 week...(Same physician's name)...5/29/16..."

During a telephone interview on 9/26/17 ending at 10:37 AM, Personnel #2 was notified the discharge summary for Patient #4 did not depict the outcome of hospitalization and disposition of care accurately. Personnel #2 stated, "I see the same thing you see."