HospitalInspections.org

Review of facility documentation and staff interview(EMP) revealed the Quality Improvement Organization failed to incorporate quality indicator data to assess processes of care, hospital service and operations and the frequency and detail of the data collection was not specified by the hospitals governing body.

Findings included:

Review of facility documentation "Performance Improvement Plan" revised February 2009, revealed "The hospital Governing Body ensures that the program reflects the complexity of the hospital's organization and services; involves all hospital departments and services ... A. Structure and Organization ... 2. The Governing Body is responsible for the quality of patient care. Authority is delegated to the hospital Quality Committee to implement and evaluate the Performance Improvement Program. .. C. Data Collection ... 2. Frequency of data collection and the detail of data measures vary based on the process being monitored ... 4. Data is aggregated at the frequency appropriate to the activity or process being studied ... G. Ancillary Services Review ... 3. Each department submits reports of their selected monitoring activities to the Quality Committee."

1. Review of facility documentation "Performance Improvement Committee" dated May 14, 2015, revealed no documentation of indicators for the departments of Medical Staff, Nursing, Infection Control, Radiology, Environment of Care, Contracts, Case Management, Physical Therapy, Occupational Therapy, Pharmacy, Respiratory, Dietary, Security, or Infection Control.

2. Review of facility documentation "Performance Improvement Committee" dated August 24, 2015, revealed no documentation of indicators for the departments of Medical Staff, Radiology, Contracts, Case Management, Physical Therapy, Occupational Therapy, Pharmacy, Respiratory, Dietary, Security, or Infection Control.

3. Review of facility documentation "Performance Improvement Committee" dated November 23, 2015, revealed no documentation of indicators for the departments of Medical Staff, Radiology, Environment of Care, Contracts, Case Management, Physical Therapy, Occupational Therapy, Pharmacy, Respiratory, Dietary, and Security, or infection Control.

4. Further review of facility documentation revealed "Quality Council" dated March 4, 2016, revealed no documentation of indicators for the departments of Medical Staff, Radiology, Environment of Care, Contracts, Case Management, Physical Therapy, Occupational Therapy, Pharmacy, Respiratory, Dietary, Security, or Infection Control.


Interview with EMP3 on October 14, 2016, at approximately 9:25 AM when asked what was the frequency and detail of the data collection specified by the hospial's governing body revealed "I don't know where it says that. Quality Council is suppose to meet quarterly, the last council meeting was November 2015, we are a little in arrears. We only review select indicators. Further interview at approximately 10:20 AM revealed "Indicators are looked at in different committee's they are not all brought to Quality Council unless there is an issue."

Based on review of medical records (MR), facility documentation, and employee interview (EMP), it was determined the facility failed to prepare medications in accordance with hospital policies for three of three medical records reviewed (MR14, MR18, and MR20).

Findings include:

Review of facility policy "Medication Safety: High Alert Medications" last revised Sept 2014, revealed, "Purpose: Prevent patient injury from medication errors by establishing additional safeguards for high alert medications. ... Procedure ... B. Preparation of high-risk medications outside of the pharmacy department shall require two licensed nurses to verify physician order, patient identification and dose(s) prepared. Auxiliary labeling is applied to the medication to alert nursing staff to additional safety precautions."

1. Review of MR14 medication list on October 13, 2016, revealed an order for insulin with auxiliary labeling requiring documentation from the nurse preparing the insulin dose and the nurse verifying the insulin dose. Further review of MR14 revealed no documentation of a nurse verifying the insulin dose on October10, 2016 at 0800, 1000, and 1600, on October 11, 2016 at 0000, and October 12, 2016 at 0000.

2. Review of MR18 medication list on October 13, 2016, revealed an order for insulin with auxiliary labeling requiring documentation from the nurse preparing the insulin dose and the nurse verifying the insulin dose. Further review of MR18 revealed no documentation of a nurse verifying the insulin dose on August 26, 2016 at 0000, on August 27, 2016 at 0000 and 0800, August 28, 2016 at 0000, and August 29, 2016 at 1600.

3. Review of MR20 medication list on October 14, 2016, revealed an order for insulin with auxiliary labeling requiring documentation from the nurse preparing the insulin dose and the nurse verifying the insulin dose. Further review of MR20 revealed no documentation of a nurse verifying the insulin dose on June 28, 2016 at 0000, and 1600, on June 29, 2016 at 0800, on July 2, 2016 at 0000, on July 6, 2016 at 0000, and on July 7, 2016 at 1200.

4. Interview with EMP9 on October 14, 2016 confirmed the above and stated, "We will have to work on that."