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Based on policy review, document review and interview, the facility failed to ensure all data reported the Quality Assessment Performance Improvement (QAPI) committee was accurate for 1 of 2 units (Med Surg Unit-MSU) reviewed for the restraint usage indicator.

The findings included:

1. Review of the "Quality Management & Regulatory Compliance Plan" policy revealed, "...Scope and complexity...Reliable/valid data on the organization's processes and outcomes..."

2. Review of the restraint data revealed the March 2015 restraint hour usage for MSU was reported to be 182 hours for 2 patients on the unit during the month of March 2015. Data review revealed the restraint hour usage for the 2 patients was actually only 158 hours.

3. Interview with the unit director on 7/20/15 at 2:00 PM in the conference room revealed the unit director verified the data had been miscalculated.

Based on policy review, document review, record review and interview, the facility failed to ensure all performance improvement projects included in the hospital's Quality Assessment Performance Improvement (QAPI) reflected an appropriate scope for improvement and measurable progress for 1 of 5 (Code Blue) quality indicator areas reviewed.

The findings included:

1. Review of the "Quality Management & Regulatory Compliance Plan" procedure revealed, "...I. Goal Statement Concerning Services to be provided...To contribute to [name of hospital] mission to provide excellence in health care by providing support to...Ongoing efforts to maintain quality data measures needed to support...Coordinating hospital-wide QI activities including the medical staff...Compilation and analysis of quality data measures from all departments...Orientation and education related to QI...Communication of activities through upward and downward pathways...
VI. Appropriateness, Clinical Necessity and Timeliness of Support Services... Clinical necessity, appropriateness and timeliness are addressed in current quality measures...VIII. Availability of necessary staff...All staff work Monday through Friday and other shifts as needed...IX. Methods that Will be Used to Assess and Meet the Needs of Customers...Our QI evaluation process and random surveys to our customers..."

Review of the "Cardiopulmonary Resuscitation" policy revealed, "...It is the policy to initiate cardiopulmonary resuscitation (CPR) in order to attempt to restore and maintain life in the event of cardiac and/or respiratory arrest..."

2. Review of the 2/24/15 "Quality Improvement Council Meeting Minutes" revealed, "...Under Resuscitation..." the minutes revealed the CNO reported the crash cart contents were being revised, specifically medications on the crash carts. Once this is complete the CNO reported code drills would be conducted to help familiarize staff with the location of contents and strengthen competency during code situations.

The Action Plan for the Resuscitation indicator revealed the CNO would conduct research to determine if there is a national code survival rate that can be used as a benchmark and will add Rapid Response Team (RRT) data to resuscitation review criteria. "...[Name of Quality Director] will check with [Corporate Educator] director to see if they have an appropriate goal for a facility our size and complexity..."

There was no documentation of measurable goals developed for the progress of the Resuscitation/Code Blue indicator.

3. Review of the 4/8/15 "Code Blue Committee" meeting minutes revealed the team discussed opportunities for improvement in the response/management of Code Blues related to Resuscitation. "...All agreed that Crash Cart revision, review and practice are an immediate educational opportunity...physician staff have also recognized the need to provide additional education..." related to the process.

The Code Blue committee determined the need to implement the following Action Items:
Revise the current Code Blue Form.
Create a separate medication sheet.
Revise the policy with revision of role definitions and train staff.
Provide a mock cart with a new standardized format for item placement, prior to the Mock Codes.
Provide Mock Codes in every department on each shift, host 2 unannounced Mock Codes by the end of April, Committee will need to conduct one more meeting before the Mock Codes.

There was no documentation of measurable goals developed for the progress of the Resuscitation/Code Blue indicator. There was no documentation the Mock Codes were performed per plan.

4. Review of the 4/22/15 "Quality Improvement Council Meeting Minutes" revealed, "...Resuscitation data is pending.." The meeting minutes revealed the facility would "continue to measure with no target goal..." The CNO stated she plans to revisit the Resuscitation indicators soon."

5. Review of the 4/27/15 "Nursing Service Notes" revealed the Process [at least for now]...decided that [the name of the Educator] would determine the dates/times for the mock codes...Schedule: Based on upcoming issues and projects...to post pone the first Mock Code to a later time...to select a date in the future and confirm feasibility..."

There was no documentation of measurable goals developed for the progress of the Resuscitation/Code Blue indicator. There was no documentation the Mock codes were performed per plan.

6. Review of the 6/24/15 "Quality Improvement Council Minutes" revealed, "...discussed the recent Code Blue Team meeting." The minutes revealed the Code Blue forms had been revised, a separate medication form had been completed and current PI data was reviewed. The meeting minutes revealed, Time to CPR, first med, intubation and defibrillation will be added to the dashboard.

There was no documentation of measurable goals developed for the progress of the Resuscitation/Code Blue indicator. There was no documentation the Mock codes were performed per plan.

7. Review of documents revealed one (1) Mock Code was conducted on 6/25/15 at 2:00 PM on the Med Surg unit. There was no documentation of any other Mock Codes being conducted.

8. Record review revealed there were six (6) Code Blues performed in June 2015 and current in July 2015.

9. Interview with the Quality Director on 7/21/15 at 8:30 AM in the conference room revealed the Quality Director stated the Code Blue indicator was initiated to improve the Code Blue process, to ensure all carts are consistent and staff educated.

During a telephone interview with the Chief Nursing (CNO) officer on 7/21/15 at 8:45 AM revealed the CNO verified there had only been 1 Mock Code conducted.

Interview with the Quality Director on 7/22/15 at 8:30 AM in the conference room revealed the Quality Director was asked to provide evidence the Code Blue indicator process was progressing and being monitored. The Quality Director provided copies of the Code Blues that had been performed in June 2015 and July 2015 to date. The Quality Director stated the copies of the codes are sent to the CNO. The Quality Director stated there was no summary of the progress or monitoring, this would be done in the next Quality meeting in August.

Based on policy review, record review and interview, the facility failed to ensure the infection control program had a system to ensure personnel had annual TB skin tests for 2 of 8 (Staff #2 and 3) personnel files reviewed.

The findings included:

1. Review of the facility's "Infection Control" policy revealed, "... Tuberculosis is a highly communicable disease... In order to minimize the risk of TB transmission an effective program consisting of early identification... is key to preventing the spread of tuberculosis infection... Certain subgroups or individuals have a higher risk for TB either because they are more likely than other persons in the general population to have been exposed to and infected with M. tuberculosis... Health-care workers who provide service to people in high-risk groups... HCW [Health-care workers] TST [tuberculin skin tests] annually..."

2. Review of Staff #2's personnel file revealed a hire date of 4/19/11. Review of TB skin test revealed no result for 2013.

Review of Staff #3's personnel file revealed a hire date of 6/3/02. Review of TB skin test revealed no results for 2013.

3. During an interview with the Director of Human Resources on 7/21/15 at 1:20 PM, in the conference room, she stated the facility was without an employee health nurse for a few months and when she came, tried to catch everyone up as much as they can but "we just missed those."

Based on policy review, medical record review and interview, the facility failed to ensure staff followed discharge planning policies for 1 of 5 (Patient #3) sampled patients reviewed for discharge planning.

The findings included:

1. Review of the facility policy "Discharge Planning High Risk Screening Procedure..." revealed, "...The Case Manager will screen all patients, within one working day of admission...utilizing the High-Risk Screening Tool...The screening uses a scoring methodology to determine high risk needs. The scale for scoring the high risk screen is: Low Risk: total score less than or equal to 5 Moderate Risk: total score between 6-10 High Risk: total score between 11-19...If the patient has a total score that indicates the patient has moderate to high risk discharge planning needs, the discharge planning evaluation will be completed in a timeframe no greater than one business day after identification of need by the Case Manager..."

2. Medical record review for Patient #3 revealed an admission dated 5/24/15 and with the discharge screening tool completed on 5/25/15. The patient scored total of 6 (Moderate Risk) on the screening. There was no further evaluation by the Case Manager, as indicated in the facility policy.

3. During an interview with the Interim Case Management Director in the facility conference room on 7/20/15 at 1:25 PM, she verified that according to written policy, the assigned Case Manager should have completed the assessment for Patient #3.

Based on review of facility documents and interview, the facility failed to ensure the re-assessment of its' discharge planning process and failed to follow up on identified concerns for readmissions with in 30 days.

The findings included:

1. Review of Readmission Reduction Committee Meeting minutes documented the Quality Director and former Case Management Director held a meeting to discuss the 4th Quarter Readmission Report. There was no documentation of the other staff that attended the meeting. The minutes documented, "...The major readmission diagnosis were cardiac and Respiratory diagnosis...After much discussion it was determined that we should focus on decreasing readmissions in this area...We were tasked to develop our process to decrease our readmission rates for AMI [Acute Myocardial Infarction], Heart Failure. Our focus will be on Patient hospitalizations and readmissions within 30 days. Our efforts will measure our progress and develop reports for our follow up committee meetings...Chart audits will be performed monthly on all readmissions within 30 days to determine trends in the diagnosis....[name of Case Management Director] will run a list of Readmissions weekly and review for trends and opportunities. The Readmissions Committee will meet monthly to review results of the chart reviews. Our next meeting will be Thursday Jan 29th at 2:00 PM..."

Review of the "2015 Utilization Management Performance Indicators" revealed hospital readmissions in less than 30 days were: January 2015- 84, February 2015- 61, March 2015- 67. The facility did not have any numbers documented for readmissions for April May and June 2015.

2. During an interview with the Interim Case Management Director on 7/22/15 at 8:30 AM, she verified that the April , May and June 2015 30 day readmission numbers were not entered into the 2015 Utilization Management Performance Indicators . She stated she could not speak to why the numbers were not entered because she was not responsible for the Interim position until around 6/10/15.


During an interview with the Quality Director on 7/22/15 at 9:00 AM in the facility conference room, the Director stated the evaluation of the discharge planning process was measured by patient satisfaction surveys and tracking hospital re-admissions within 30 days. When asked if there had been a Readmission Committee meeting since 1/8/15, the Quality Director verified there was no additional documentation regarding follow up from the 1/8/15 meeting. She stated the Case Management Director retired suddenly in June and the Interim Director had been appointed recently.

The facility failed to track and trend 30 day readmissions for April May and June 2015, in accordance with the facility procedure for discharge planning evaluation The facility failed to follow up on the plan developed in the 1/9/15 meeting to address hospital readmissions within 30 days, one of the facility identified indicators to measure the success of the discharge planning process.