HospitalInspections.org

Based on observation, record review, and interview, the hospital failed to ensure the Administrator (ADM) and the Director of Nursing Services (DON) ensured the quality assessment and performance improvement (QAPI) program and training programs addressed problems identified in a complaint survey on 10/9/14, and successful corrective action plans were implemented in the affected problem areas. This was evidenced by no documentation of identified deficiencies being monitored for correction or maintenance of correction actions.
Findings:

In an interview 11/19/14 at 11:35 a.m. with SF1ADM, SF2DON, SF3LPN, and SF11InfectionControl, SF3LPN reported that she was responsible for monitoring and collecting quality assurance data related to deficient practices identified in a complaint survey dated 10/9/14. SF3LPN reported that monthly "walk through's", defined as walking tours by department heads and administration had not been implemented yet. SF3LPN further reported that no monitoring for correct and compliance was being done. SF3LPN reported none of the deficiencies identified during the survey of 10/9/14 had been added to the QA indicators. SF1ADM and SF2DON, present for the interview, did not add any comments related to "walk through's" not being performed or identified deficiencies not incorporated into the QA program.