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Based on record review and interview, the hospital's governing body failed to ensure the QAPI program reflected the complexity of the hospital's services as evidenced by failing to include all hospital services in the QAPI program. This deficient practice was evident by failing to include the hospital services of Discharge Planning and Respiratory Services in the hospital's QAPI program.

Findings:

Review of the hospital policy titled, Improving Organizational Performance Plan, I.E.5.06, revealed the scope of the Performance Improvement Program included measurement and assessment activities which address patients served by the Medical Staff, Nursing, and ancillary services and hospital wide functions. Both clinical and non-clinical departments are included.

Review of the document titled, "The NeuroMedical Center Rehabilitation Hospital 1st Quarter 2021 QAPI/ MEC Committee Agenda/ Minutes," dated 06/08/2021, provided by S1CEO as the updated version of quality indicators and performance measures monitored for 2021, revealed the following services were not included in the QAPI program and no data was collected for Respiratory Services and Discharge Planning Services.

In interview on 07/08/2021 at 10:00 a.m., S1CEO reviewed the QAPI meeting minutes and confirmed Discharge Planning Services and Respiratory Services were not included in the QAPI program for 2021.

Based on record review and interview, the hospital failed to ensure the receiver of patient verbal orders documented that the orders had been read back and verified for 2 (#7, 8) of 5 sampled patient records reviewed for verbal orders and failed to ensure the ordering practitioner signed telephone/ verbal orders within 48 hours per hospital policy for 1 (#25) of 5 records reviewed for signature by the ordering practitioner.

Findings:

A review of the hospital policy titled Authentication last reviewed 02/2021 reads in part:
C. Telephone Orders
Telephone/ verbal orders are to be signed, dated and timed within 48 hours.
All Telephone Orders and receiving critical test results should be verified and "read- back and verified" by the person receiving the order or test results.

A review of Patient #7's medical record revealed an order dated 07/07/2021 at 8:00 a.m. Record daily weights in Progress Notes daily for I.M. to Review- Dr. S9MD/ S8RN. Further review failed to reveal the order was clarified by S8RN.

A review of Patient #8's medical record revealed an order dated 07/06/2021 at 4:58 p.m. Recommend continuation of puree diet with mildly thick liquids. Ensure consistency ok. Free water protocol following strict oral care between meals only. Meds crushed in puree. 1:1 SPV. Close adherence to all swallowing precautions with oral care following all meals. T.O. S13MD / S12Speech. Further review failed to reveal a clarification of the telephone order.

A review of an order dated 07/05/ 2021 for Recommend MBSS to reassess swallowing function. TO. S13MD/ S12Speech. Further review failed to reveal the time the order was written as well clarification of the order.

A review of an order dated 06/30/2021 at 9:30 a.m. for Neurology consult; S11MD increased lethargy S13MD/ S8RN. Further review failed to reveal clarification of the order.

a review of an order dated 07/01/2021 UA with culture today. Urgency. CBC & Chem 7 in a.m. T.O. S10MD/ S8RN. Further review failed to reveal a clarification for the order.

In an interview on 07/07/2021 at 11:35 a.m. S8RN verified the telephone/ verbal orders failed to contain clarification of the orders.


On 07/08/2021 at 10:30 a.m. a review of Patient #25's medical record revealed multiple telephone orders dated 06/27/2021 at 5:30 p.m. given by S14MD. Further review failed to reveal the telephone orders were signed by S14MD within 48 hours.

In an interview on 07/08/2021 at 10:40 a.m. S7Him verified the physicians are to sign all verbal/ telephone orders within 48 hours of the order being given and the above orders were not yet signed.

Based on record review and interview, the hospital failed to ensure a person qualified by education and experience and competency in infection control practices was designated as the control officer as evidenced by failure to have documented evidence of education and prior experience for S3ADON who was designated as the infection control officer.

Findings:

Review of S3ADON's personnel record revealed no documented evidence of prior experience or infection control education as the designated infection control officer in a hospital.

An interview was conducted with S3ADON on 07/08/2021 at 10:30 a.m. She confirmed that she had no formal training, education, and/or experience for the Infection Control Officer of the hospital.