HospitalInspections.org

Based on document review and interview, the facility failed to perform performance improvement activities which monitor and report adverse patient events.

Findings include:

1. Review of Quality Assurance Committee meeting minutes on 7-13-10 indicated lack of evidence that adverse patient events were included in the facility Quality Assurance and Performance Improvement (QAPI) activities.
2. Interview with #S1 on 7-15-10 at 0830 hours confirmed that adverse patient events are not included in the facility's QAPI activities. Additional documents were requested; none were provided prior to exit.

Based on document review and interview, the facility failed to conduct performance improvement projects.

Findings include:

1. Review of Quality Assurance Committee meeting minutes on 7-13-10 indicated lack of evidence that the facility had conducted any performance improvement projects.
2. Interview with #S1 on 7-15-10 at 0830 hours indicated the facility had not conducted any performance improvement projects. Additional documents were requested; none were provided prior to exit.

Based on document review and interview, the facility failed to establish an effective Utilization Review Committee.

Findings include:

1. Review of facility documents on 7-15-10 indicates the Utilization Review Committee composition is limited to one physician, #S9.
2. Review of Utilization Review Committee minutes on 7-15-10 indicated #S9 was absent from 5 of the 7 meetings held over the past 12 months.
3. Interview with #S1 on 7-15-10 at 0900 hours confirmed #S9 is the only physician on the Utilization Review Committee and #S9 was absent from 5 of the 7 meetings held over the past 12 months. Additional documents were requested; none were provided prior to exit.

Based on observation and interview, the facility failed to ensure an acceptable level of safety in the water testing area by not providing an eye wash station where caustic agents were used.

Findings include:

1. While touring the facility of 7-14-10 at 1020 hours in the presence of #S5, #S7 and #S2, it was observed that there was no eye wash available in the area where water testing is conducted and caustic agents are used.
2. Interview with #S7 on 7-14-10 at 1020 indicated the nearest eye wash was not within easy access to the area where water testing is conducted.

27548

Based on document review and interview, the infection control officer failed to develop a system to identify, report, investigate, and control infections and communicable diseases for 11 of 11 personnel reviewed.

Findings include:

1. Review of personnel files on 7-14-10 indicated the following:
a.) #S10 did not have documented immunity to varicella
b.) #S11 did not have documented immunity to rubella, rubeola, or varicella
c.) #S12 did not have documented immunity to rubella, rubeola, or varicella
d.) #S13 did not have documented immunity to varicella
e.) #S14 did not have documented immunity to rubella, rubeola, or varicella
f.) #S15 did not have documented immunity to rubella, rubeola, or varicella
g.) #S16 did not have documented immunity to rubella, rubeola, or varicella
h.) #S5 did not have documented immunity to varicella
i.) #S17 did not have documented immunity to rubella, rubeola, or varicella
j.) #S8 did not have documented immunity to rubella, rubeola, or varicella
k.) #S18 did not have documented immunity to rubella, rubeola, or varicella
2. Review of employee health records at 3:26 PM on 7/13/10, indicated:
a. Personnel P1, P2, P3, and P4, Registered Nurses (R.N.) providing direct patient care lacked documentation of Rubella, Rubeola, and Varicella immunity or vaccination.
3. Interview with #S8 on 7-14-10 at 1500 hours confirmed the above findings and confirmed that the facility did not have a system in place to identify, report, investigate or control infections and communicable diseases related to facility personnel. Additional documents were requested; none were provided prior to exit.

Based on document review and interview, the facility failed to provide Quality Assurance and Performance Improvement (QAPI) data to the Governing Board for 7 of 7 meetings over the past 12 months.

Findings include:

1. Review of the facility Quality Improvement Plan on 7-13-10 indicated the Board of Directors will ensure that Madison Center fulfills and demonstrates fidelity to its mission, and provides guidance and support to executive leadership in the maintenance of quality of care and patient safety.
2. Review of Governing Board meeting minutes on 7-14-10 indicated lack of evidence that QAPI data was provided or discussed at the governing board meetings for 7 of 7 meetings over the past 12 months.
3. Interview with #S1 on 7-15-10 at 0830 hours confirmed that QAPI data was not provided to the Governing Board at the past 7 of 7 meetings for review. Additional documents were requested; none were provided prior to exit.

Based on document review and interview, the facility failed to ensure 8 direct services and 6 contract services were included in the Quality Assurance and Performance Improvement (QAPI) program.

Findings include:

1. Review of facility documents on 7-14-10 indicated lack of evidence that the direct services of alcohol/drug services, ICU, maintenance, security, psychiatry, pediatrics, housekeeping, and discharge planning were included in the facility QAPI program.
2. Review of facility documents on 7-14-10 indicated lack of evidence that the contract services on bioengineering, lab, radiology ambulance service, biohazardous waste and laundry/linen were included in the facility QAPI program.
3. Interview with #S1 on 7-15-10 at 0830 hours confirmed the above services are not included in the facility QAPI program. Additional documents were requested; none were provided prior to exit.