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Based on document review, staff interview, and policy and procedure review, the facility failed to maintain and demonstrate an effective, ongoing, hospital-wide data driven Quality Assessment and Performance Improvement (QAPI) program involving all hospital departments and services focusing on indicators related to improved health outcomes.

Findings Include:

Review of the facility's Quality Assurance documentation revealed no documented evidence of any indicators being tracked throughout the last 12 month period, data collection used to identify opportunities for improvement and changes or measurable progress achieved on Performance Improvement projects; no documented evidence of their discharge planning being reviewed on an on-going basis; and no documented evidence of a facility quality projects being conducted, the reason why or any measure progress.


During an interview on 10/25/17 at 2:00 p.m. the Clinical Operations Director confirmed the facility has had no performance improvement projects.

During an interview on 10/26/17 at 10:00 a.m. the Administrator confirmed the Quality Assurance did not include discharge planning.

During an interview on 10/26/17 at 12:30 p.m. the Director of Medical Records stated, "We have been identifying problems but have not been tracking or measuring the outcomes. I don't know if we have conducted an annual evaluation."

Review of the facility's Quality Assurance policy (not dated) revealed: "Purpose/Objective: The medical surgical unit participates in a hospital wide Quality Assurance (PI) program design to monitor, evaluate and improve the quality, appropriateness and outcomes of clinical services by planning, designing, measuring, assessing, improving new or revised processes of patient care and service ...Goals of Quality Assurance: The primary goals of the Medical Unit Quality Assurance plan are to continually and systematically plan, design, measure, assess and improve performance of priority focus areas, improve health care outcomes and reduce and prevent medical/health care errors ...Provide for a program that assures the department designs processed well, with special emphasis on design of new services or revisions in established services, and systematically measures, assesses and improves it performance to achieve optimal patient health outcomes in a collaborative, cross-departmental interdisciplinary approach ... the status of identified problems is tracked to assure improvement or problem resolution. Quality Assurance Measures: Performance measures with related Quality Assurance outcomes will be established as a means to systematically monitor the identified processed for review in an ongoing manner and to provide operational linkages between the risk management functions related to the clinical aspects of patient care and safety and the Quality Assurance functions ...".

Based on staff interview, policy and procedure review, Infection Control Committee Meeting minutes review, and Infection Control Manual review, the facility failed to ensure it provided an active program for the prevention, control, and investigation of infections and communicable diseases.

Findings Include:

During an interview on 10/24/17 at 11:30 a.m. the Director of Housekeeping revealed that she was the only person who used the Steam Generator. When asked where the chemical indicator logs were kept she stated, "I don't keep any logs anymore." When asked how the instruments were being cleaned before going into the Steam Generator the Director of Housekeeping stated, "I wash them with Dial soap and a little bit of bleach, then place the instruments into these bags and into the Steam Generator. I keep them in the Steam Generator for about an hour." At 12:30 p.m. when asked about the use of chemical indicator strips, the Director of Housekeeping stated, "I use to use them, send them off and keep it documented in a log, but no one ever asked to see the logs so I quit doing it."

Review of the facility's "Equipment Decontamination" policy, last reviewed May of 2011, revealed: "Policy: (facility name) is dedicated to minimizing the risk of nosocomial infection that may occur if shared patient equipment is inadvertently used before being cleaned. Purpose: To establish guidelines for recognition and standards for treatment/disinfection of shared equipment, and storage of clean or unclean equipment ...Sterilization is the complete elimination or destruction of all forms of microbial life. Either a physical or a chemical process such as steam under pressure, dry heat, ETO gas, and liquid chemicals accomplishes it ...A. Critical Items. 1. Objects that enter sterile tissue or the vascular system are defined by the CDC as critical items. They carry a high risk of infection if they become contaminated with any microorganism. Thus it is critical that any such item is sterile in order to prevent disease transmission. 2. These items should either be purchased as sterile or sterilized by approved/accepted methods. 3. Examples include, but are not limited to the following: surgical instruments, cardiac and urinary catheters, vascular devices, and implants. 4. Sterility is verified by intact wrappers, chemical package indicators, and records of sterility equipment monitoring ...".

Based on review of the facility's Organ and Tissue Donation agreement, Tissue Donation Report review, and staff interview, the facility failed to ensure the specific organ, tissue, and eye procurement requirements are met.

Findings Include:

Review of the facility's contract "Organ and Tissue Donation Agreement" dated 02/19/14 revealed: "Timely Notification for Organ Donation a timely referral is one that is made as soon as possible (ideally within one (1) hour) and allows MORA to evaluate and determine eligibility for organ donation potential for any severely brain-injured or brain dead patient prior to the withdrawal of the ventilator and/or care."

Review of the facility's "Tissue Donation Report" revealed the months of January and May 2017 had negative reporting ... Review revealed January and May had one (1) death that was not reported within the one (1) hour timeframe.

During an interview on 10/25/17 at 1:30 p.m. Director of Medical Records confirmed the deaths in January and May were called to MORA over an hour late."

Based on medical record review, staff interview, and policy review, the facility failed to ensure that each patient or representative was informed of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible for 27 of 27 patient's records reviewed. Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, and #27.

Findings Include:

Record review for Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, and #27 revealed no documented evidence that the patient or patient's representative was informed of the patient's rights prior to treatment or before discontinuing patient care.

An interview with the Information System Coordinator, Registered Nurse (RN) on 10/26/17 at 10:45 a.m. revealed he reviewed the medical records and confirmed there was not an area in the medical record for the patient or representative to sign they have received their rights. He did state the rights are posted in all patient areas. The Administrator confirmed this at this time.

Review of the facility's policy, "Patient Rights and Responsibilities", no approval or revised date revealed: "...Become informed of his or her rights as a patient in advance of, when possible or when discontinuing, the provision of care."


Review of the facility's "Advance Directives" policy without an effective or revision date revealed, "Procedure-An inquiry will be made by the Admitting Department during the admissions process of the patient ...A request of the patient/significant other to provide a copy of the advance directive for medical record entry will be make by the nursing staff during the admission process. As part of the admission process the patient/significant other will be provided with an information packet outlining the individual's rights to make decisions concerning medical care ...".

Based on medical record review, staff interview, and policy review, the facility failed to ensure the patient's or patient's representative was informed of the patient's rights prior to treatment or documentation. 27 of 27 medical records: Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, and #27

Findings Include:

Cross Refer to A117 for the facility's failure to ensure the patient's or patient's representative was informed of the patient's rights prior to treatment or documentation they was informed of advance directive upon admit.

Based on document review, staff interview, and policy and procedure review, the facility failed to have a Quality Assessment and Performance Improvement (QAPI) program that includes, but is not limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes or measure, analyze, and track quality indicators and other aspects of care, hospital service and operations.

Findings Include:

Cross Refer to A263/462.21 for the facility's failure to maintain and demonstrate an effective, ongoing, hospital-wide data driven Quality Assessment and Performance Improvement (QAPI) program involving all hospital departments and services focusing on indicators related to improved health outcomes.

Based on document review, staff interview, and policy and procedure review, the facility failed to set priorities for its performance improvement activities that focus on high-risk, high volume, or problem-prone areas.

Findings Include:

Cross Refer to A263/462.21 for the facility's failure to set priorities for its performance improvement activities that focus on high-risk, high volume, or problem-prone areas.

Based on document review, staff interview, and policy and procedure review, the facility failed to have performance improvement activities that track medical errors and adverse patient events, analyze their causes and implement preventive actions and mechanisms that include feedback and learning throughout the hospital.

Findings Include:

Cross Refer to A263/462.21 for the facility's failure to have performance improvement activities that track medical errors and adverse patient events, analyze their causes and implement preventive actions and mechanisms that include feedback and learning throughout the hospital.

Based on document review, staff interview, and policy and procedure review, the facility failed to document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.

Findings Include:

Cross Refer to A263/462.21 for the facility's failure to document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure verbal orders were dated, timed, and authenticated promptly by the ordering practitioner for eight (8) of 27 patients reviewed, Patient #1, #3, #4, #5, #6. #8, #9 and #10.

Findings Include:

Record review revealed Patient #1, #3, #4, #5, #6. #8, #9 and #10 had unsigned verbal orders in their chart.

During an interview on 10/25/17 at 1:00 p.m. the Director of Medical Records confirmed verbal orders were not signed within 48 hours by the medical doctor.

Review of the facility's Verbal and Written Orders policy (not dated) revealed: "Procedure: Verbal/Telephone Orders ... the prescribing practitioner must sign the writing record of the verbal/telephone order within 48 hours of giving the order."

Based on review of the facility's Infection Control Committee Meeting minutes, Infection Control Manual, and staff interview, the facility failed to ensure that a system was developed for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.

Findings Include:

Review of the facility's Infection Control Committee Meeting minutes and Infection Control Manual revealed no documented evidence of current, ongoing review and analysis of data collected pertaining to hospital acquired infections or ongoing monitoring.

During an interview on 10/25/17 at 12:45 p.m. the Infection Control Officer stated he had documented reports of the urine, blood and respiratory cultures and results that the lab processed every month, but did not have documented evidence of any investigation, tracking or follow-up of the data.

Based on observation, patient interview, staff interview, and policy and procedure review, the facility failed to have an ongoing program of activities based on patient assessment of interest and needs, and psychosocial well-being of each patient for two (2) of two (2) patients, Patient #21 and #22.

Findings Include:

On 10/23/17 at 1:45 p.m. observations made on the Acute Floor, where the Swing Bed patients reside, revealed there was no activity area.

Record review revealed Patient #21 and #22 had no activity assessment, no activity care plan, no activity progress note, and no documentation of provision of activities.

An interview with Patient #21 on 10/24/17 at 11:00 a.m. revealed no activities had been provided for him during his hospitalization. He stated that the nurses come in and turn his TV on when he asks them to.

An interview with the Activities Coordinator on 10/25/17 at 1:15 p.m. revealed that she was new to this position and did not have an activity calendar for the patients. She also confirmed that she did not have an activity assessment, an activity care plan, and no provision of activities that are documented.

Review of the facility's "Swing Bed Program" policy, no effective or revised date, revealed, "An activity director will be assigned by the administrator to be responsible for the patient activities program. The activity director is responsible for planning, structuring and coordinating activities for patients that are beneficial in overcoming specific identified problems. Specific patient interests, past hobbies/leisure time activities ...are identified on individual patient activity history/assessment ...The activity assessment will be used to develop an activity plan that incorporates the identified patient needs, interests ...The activity weekly progress note should include the patient's participation in activities, progress towards the patient's goals ...".