HospitalInspections.org

Based on interview and record review, the facility failed to ensure quality data that was collected was kept to show how they were analyzing and developing their performance improvements from February 2025-April 2025.

This deficient practice had the likelihood to cause harm to all patients.

Findings include:


Review of the facility's Quality dashboard revealed performance improvements listed with numbers and percentages listed for February -March 2025.

During an interview on 04/14/2025 after 1:31 p.m.,Staff #2 (Chief nursing officer) revealed there were medical record and surgery audits being performed by staff. A request was made to see the data she had obtained so far, and Staff #2 (Chief nursing officer) said they had just started auditing about 2 weeks ago. When asked when staff were supposed to provide the information to her from the audits, she did not give a definitive answer. Staff #2 (Chief nursing officer) said the 1st quarter ended 03/31/2025. Staff #2 (Chief nursing officer) said their next department meeting was 04/22/2025 and that she would have staff provide the information quarterly.



Review of the facility's undated policy named "Quality Management Plan Chapter/Department Quality Improvement Policy Number Q101" revealed some of the following:

"...V. FRAMEWORK FOR QUALITY MANAGEMENT...
..C. Data Collection
collection of data helps the organization evaluate outcomes or determine the performance of functions or processes. When the data collection is systemic and used to:
a) establish a performance baseline;
b) describe process performance or stability;
c) describe the dimensions of performance relevant to functions, processes and outcomes;
d) identify areas for more focused data collection; and
e) sustain improvement..."