HospitalInspections.org

Based on observation and interview the hospital failed to ensure adequate space was provided for the storage of equipment; the cleaning, processing, and sterilizing of instruments or the storage of pharmaceuticals as evidenced by: 1) IV pumps and poles stored in the area used to clean and sterilize instruments and wheelchairs, IV pumps and poles, and a stretcher stored in the chapel; 2) Bio-med, Respiratory, Decontamination and storage utilizing one small approximately 10 X 12 foot room; 3) a hallway utilized for storage of the ice cart and patient supplies used by the CNAs (Certified Nursing Assistants); and 4) the Nursing Medication room used to store Pharmacy stock medications. Findings:

1) IV pumps and poles stored in the area used to clean and sterilize instruments and wheelchairs, IV pumps and poles, and a stretcher stored in the chapel
Observation on 07/12/11 at 10:15am of the space designated as "Central Supply/Decontamination" revealed four clean and one dirty IV Pump and pole stored in the decontamination room with the sink used for washing and preparing instruments and the autoclave machine used for sterilizing instruments.

Observation on 07/12/11 at 10:20am of the chapel revealed one stretcher, one wheelchair one fan, and numerous IV poles and pumps stored in the room.

In a face to face interview on 07/12/11 at 10:20am RN S2 Director of Nursing (DON) indicated ever since the hospital had undergone some re-modeling, storage of equipment had become a problem. S2 indicated equipment is being stored where space is available, even in the chapel which has become less frequently used.

2) Bio-med, Respiratory, Decontamination and storage utilizing one small approximately 10 X 12 foot room
Observation on 07/12/11 at 10:15am of the space designated as "Central Supply/Decontamination" revealed a room approximately 10 feet X 12 feet which was utilized by the following disciplines: Bio-Med for the repair of broken IV (Intravenous) pumps; storage area for clean IV four pumps; Respiratory Therapy for the performance of blood gases; and Central Decontamination to clean and sterile instruments.

In a face to face interview on 07/12/11 at 10:25am S4, Central Supply Director indicated the only thing that should be in the room would be either the autoclave to sterilize the instruments or the dirty instruments which needed to be cleaned. Further S4 indicated IV pumps, Bio-med and Respiratory should not be sharing space where dirty instruments are being cleaned or sterilized.

Observation on 07/12/11 at 11:00am of the space designated as the Nursing Medication Room revealed four

3) a hallway utilized for storage of the ice cart and patient supplies used by the CNAs (Certified Nursing Assistants)
Observation on 07/12/11 at 10:45am of the hallway located on the patient care wing revealed a small hallway to the right with doors that led to a bathroom (utilized by the on-call physicians and linen closet. The hallway contains a linen cart, a cart with an ice chest, desk which the CNAs use to perform paperwork and a file cabinet.

In a face to face interview on 07/12/11 at 10:50am RN S2 DON indicated there was no space to put the supplies that the patients needed and the hallway was the place least used.

4) the Nursing Medication room used to store Pharmacy stock medications
Observation on 07/12/11 at 10:15am of the Nursing Medication room revealed two upper walls to shelving which contained labeled boxes of stock medication. Further the lower drawers of a cart stored in the room contained vials of stock medication and pull drawers below the shelving units contained four drawers stocked with pre-packed IV (Intravenous) stock medications.

Observation on 07/12/11 at 11:30am of the space designated as the pharmacy revealed a small area with built-in shelving around most of the perimeter of the room. Further, there were metal shelves in the center room for additional storage which contained stock medication.

In a face to face interview on 07/12/11 at 2:10pm S3 Pharmacist indicated the space was too small to accommodate the needs of the pharmacy and many of the drugs which would be normally stored in the pharmacy are being kept in the medication room on the nursing unit.

In a face to face interview on 07/14/11 at 1:30pm S1 Administrator indicated renovations had taken place at the hospital before he came back as administrator. Further he indicated that the hospital actually lost square footage after the renovations took place; therefore storage was combined.

Based on observation and interview the hospital failed to ensure housekeeping implemented a program in order to provide clean premises as evidenced by: 1) Room B designated by a sign as "Ready for Patient Use" with visible dust hanging from the vent in the bathroom, thick dust build-up on the vents of the air-conditioning unit; thick black build-up around the baseboards, and visible dust which form a ball when touched on the conduit covering electrical lines in the room, and clothing belonging to the previously discharged patient hanging in the closet; 2) the uncovered air conditioning vent in Room K with a thick layer of dust and a white pedestal fan with dust coating the covering of the blades of the fan being utilized by a patient with respiratory problems; 3) four vents in the ceiling with a layer of dust caked on the metal vents, dust hanging from the upper position of the walls in the kitchen, and a cake blacked substance on the sides and bottom of the pots; 4) visible dust build-up on shelves where stock medication stored for patient use, visible stains and sticky residue on the floors, thick black buildup on the floor around the baseboards in the Pharmacy; 5) cleaning and sterilizing instruments in a room with chipping and flaking paint on the walls and ceiling, visible dust buildup on cabinets over the sink area used to clean instruments, heavy dirt build-up around baseboards and visible stains on the floors; and 6) Rips/tears were noted on the covering of the stretcher pad in the ED trauma room. Findings:

1) Room B designated by a sign as "Ready for Patient Use"
Observation on 07/12/11 at 10:15am of Room B designated by a sign as posted on the closed door as "Ready for Patient Use" revealed the following: visible dust hanging from the vent in the bathroom, thick dust build-up on the vents of the air-conditioning unit; thick black build-up around the baseboards, and visible dust which form a ball when touched on the conduit covering electrical lines in the room, and clothing belonging to the previously discharged patient hanging in the closet.

In a face to face interview on 07/12/11 at 10:20am Housekeeper S23 indicated the room was ready for occupancy and was shown the vents in the bathroom, the air-conditioning vent, the conduit line, and the clothes in the closet. S23 had no comment.

In a face to face interview on 07/12/11 at 10:21am RN S2 Director of Nursing (DON) indicated the room was not ready for occupancy of another patient and removed the sign.


2) the uncovered air conditioning vent in Room K with a thick layer of dust and a white pedestal fan with dust coating the covering of the blades of the fan
Patient #2 was admitted on 07/11/11 with the diagnoses of COPD (Chronic Obstruction Pulmonary Disease) Exacerbation. A tour of her room, room K, on 07/12/11 at 3:15 p.m. revealed a dirty wall air conditioner unit. The front cover of the air conditioner was removed and leaning against the wall. The vents on the air conditioner unit were caked with dust. A white pedestal fan was located in one corner of the room with dust coating the covering of the fan.

An interview was conducted with RN S2 DON on 07/12/11 at 3:20 p.m. She confirmed the air conditioner unit vents were dirty along with the pedestal fan in the corner of room K.


3) four vents in the ceiling with a layer of dust caked on the metal vents, dust hanging from the upper position of the walls in the kitchen, and a cake blacked substance on the sides and bottom of the pots
Observation of the kitchen on 07/13/11 at 9 a.m. with S8 Dietary Manager revealed three large pots with numerous layers of caked on black substance on the bottom and sides of the pots. S8 stated she needed to order new pots on 07/13/11 at 9:15 a.m.

Further observations made revealed the wall between the dishwashing area and the cooking area, a set of white metal cabinets were observed above and below a silver metal countertop. There were numerous areas of rusted areas on the metal cabinet above and below the countertop. S8 stated the cabinets needed to be painted and the countertop under the cabinets was used as a pass through for transportation of the clean dishes from the dishwashing station to the cooking area.

Also observed on the kitchen tour were 4 large vents in the ceiling with a layer of dust caked on the metal vents. Observed on the upper position of the walls in the kitchen was hanging dust. S8 confirmed the vents and the walls needed to be cleaned.

Review of the Dietary Sanitation Procedures in part revealed, " The following guideline will be followed by all Dietary employees as to secure a sanitary environment in the Dietary Department. A. Food Equipment and Utensils: 1. All equipment and utensils shall be so designed and of such material and workmanship as to be smooth, easily cleanable and durable, and shall be in good repair; .... "

Review of the policy for Infection Control/Dietary revealed in part ... " Subject: Hoods, Vents, Exhaust Fans, Air Conditioning Filters and Drip Pans, Cleaning of. Policy: It is the policy of the St. Helena Parish Hospital that all Dietary personnel will adhere to the following guidelines ...2. Housekeeping cleans and maintains the hoods every month; vents and exhaust fans every 3 months ... "

Review of the Infection Control/Dietary Policy for Wall Cleaning revealed the following in part " ... Policy: It is the policy of the St. Helena Parish Hospital that all Dietary personnel will adhere to the following guidelines. Purpose: To provide sanitary cleaning guidelines. Procedure: Daily or as Required 1. Wash stained walls with hot soapy water and cleaner with clean disposable wipe. 2. Rinse with hot water and clean disposable wipes. 3. Dry with clean disposable wipe. Every 6 months 1. Use power spray to soak walls with soap. 2. Power rinse walls without soap. Quarterly Housekeeping will clean walls and ceilings in kitchen, cafeteria and all other areas in the Dietary Department.


4) visible dust build-up on shelves where stock medication stored for patient use, visible stains and sticky residue on the floors, thick black buildup on the floor around the baseboards in the Pharmacy;

Observation on 07/12/11 at 11:00am of the Pharmacy revealed the following: visible dust on the shelves where medication is stored for patient use. Further review revealed the floors with visible stains and sticky residue and a black build-up around the baseboards.

In a face to face interview on 07/12/11 at 2:00pm Pharmacist S3 indicated the shelves are not dusted by housekeeping and he was not aware the last time the floors were mopped.

5) cleaning and sterilizing instruments in a room with chipping and flaking paint on the walls and ceiling, visible dirt buildup on cabinets over the sink area used to clean instruments, heavy dirt build-up around baseboards and visible stains on the floors

Observation on 07/12/11 at 10:20am of the room designated as the room used to clean and sterilize instruments revealed sections of the ceiling and the walls with bubbling, pealing and flaking paint, visible dirt buildup on cabinets over the sink area used to clean instruments, heavy dirt build-up around baseboards and visible stains on the floors.

In a face to face interview on 07/12/11 at 10:30am S4, Director of Central Supply indicated she had not witnessed Housekeeping mopping or dusting the sterilizing room, only emptying the trash and cleaning the countertop.

In a face to face interview on 07/12/11 at 10:35am RN S2, Director of Nursing (DON) indicated infection control rounds are made on a quarterly basis. Further S2 indicated she was not aware how dirty this area was.

6) Rips/tears were noted on the covering of the stretcher pad in the ED trauma room
Observations were made in the Emergency Department on 7/13/11 between 9:00 a.m. and 9:30 a.m. These observations revealed the following:
Rips/tears were noted on the covering of the stretcher pad in the ED trauma room. Exposed foam cushioning was noted under the rips/tears resulting in the inability to ensure disinfection as the surface area was not smooth and wipable.

In an interview at the time of the observation, the above findings were confirmed by the Respiratory Director (S17).

Based on record review and interview the hospital failed to ensure Medical Staff Bylaws were enforced regarding Delinquent Medical Records for 3 of 3 physicians with medical records listed as "30 - 60" days delinquent (Physician S18, S19, S20). Findings:

Review of the hospital's "Medical Staff Bylaws, Rules, and Regulations" presented by the hospital as current revealed in part, "Practitioners shall be notified of their delinquent charts on a regular basis by the Administrator of his designee. A chart becomes delinquent if it is not complete within twenty days after the patient's discharge from the hospital. Notification shall be in the form of a letter from the Medical Records Administrator and shall include a list of all delinquent chart numbers. A copy of this letter shall be sent to the Chief of Staff, Chief Executive Officer and Chairman of the Medical Records Committee. If the charts are not completed within seven days after the mailing of this notification, and if the Chief of the Practitioner's Service does not intercede on his behalf within the seven days, all of the Practitioner's clinical privileges shall be suspended, together with participation in all Staff activities. . ."

Review of a list of Delinquent Medical Records provided by HIM (Health Information Management) Director S6 on 7/14/2011 at 9:40 a.m. revealed the following:
Physician S18 was listed as having 5 medical records with delinquencies from 30 - 60 days.
Physician S19 was listed as having 1 delinquent medical record from 30 - 60 days.
Physician S20 was listed as having 1 delinquent medical record from 30 - 60 days.

During a face to face interview on 7/14/2011 at 10:00 a.m., HIM Director S6 indicated it was her (S6) job to provide physicians with a letter at day 20 indicating they had delinquent medical records. S6 indicated she (S6) had failed to provide letters to Physician's S18, S19, or S20 regarding delinquent medical records. S6 indicated the physicians were Emergency Medicine Physicians and worked through a contract for the hospital. S6 indicated the practice being conducted at the hospital was to send a fax' d copy of the medical record to the contracted agency and wait for the agency to contact the physician and have the medical record completed and sent back to the hospital. S6 indicated the policy/ bylaws regarding delinquent medical records; to include suspension of physicians, had not been followed. S6 indicated there had been no change in the Medical Staff Bylaws allowing for a change in practice with Emergency Department Physicians.

During a telephone interview on 7/14/2011 at 1300 (1:00 p.m.), Medical Director S9 indicated he had been unaware that the bylaws for delinquent medical records had not been followed in regards to Emergency Physicians who had delinquent medical records. S9 further indicated he (S9) would have to review the medical staff bylaws to determine if the current bylaws needed to be enforced or if the bylaws needed to be updated.

Based on observation and interview the hospital failed to ensure all expired and/or unlabeled drugs were not available for patient use as evidenced by: 1) expired IV (Intravenous) fluids in the Emergency Department; 2) unlabeled vials of medications in the refrigerator in the Nursing Medication Room; 3) expired medication in the Isolation Cart; and 4) expired medication in the Nursing Medication Room. Findings

1) expired IV (Intravenous) fluids in the Emergency Department
Observations were made in the Emergency Department on 7/13/11 between 9:00 a.m. and 9:30 a.m. These observations revealed the following:
Four (4) one hundred (100) milliliter bags of 0.9% Sodium Chloride with an expiration date of 3/01/11 were noted in one of the cabinets in the ED trauma room.

In an interview at the time of the observation, the above findings were confirmed by the Respiratory Director (S17).

2) unlabeled vials of medications in the refrigerator in the Nursing Medication Room
Observation on 07/12/11 at 1:15pm of the refrigerator located in the Nursing Medication Room revealed the following: one vial of Novolog 70/30 with no documented evidence of the date it was punctured and one vial of Acetylcysteine 20% with no documented evidence of the date it was punctured.

In a face to face interview on 07/12/11 at 1:15pm RN S2 DON indicated the nurse opening the vial is responsible for labeling the medication. In addition, S2 indicated the drugs in the refrigerator should be checked by both the nursing staff and the pharmacy.


3) expired medication in the Isolation Cart
Observation on 07/12/11 at 10:40am of the Isolation cart located in the 100 hallway used for patient care revealed the following:
1- 100mL bag of Sterile Water expiration date of January 2010
1 - 500mL bag of Sodium Chloride 0.9% expiration date of January 2009
Triadim Solution expiration date 12/09.

The expiration dates were verified by RN S2 DON and RN S5 Swing Bed Coordinator on 07/12/11 at 10:45am.


4) expired medication in the Nursing Medication Room
Observation on 07/12/11 at 1:15am of the Nursing Medication Room revealed the following:
Invanz- Intravenous 1 gram- 4 with an expiration date of 06/11.
Hydralazine 20 mg/ 1 ml- 4 with the expiration date of 4/11 and 4 with the expiration date of 6/11.
Chorpromazine 25 mg/ 1 ml vial- 6 vials with the expiration date of 06/11.

The following multidose vials were open and without a date or time when the vial was open:
Xylocaine 1% 10mg/mg and Labetalol 100 mg/20 ml.

An interview was conducted with RN S5 Swing Bed Coordinator. She stated multidose vials are suppose to be dated and initialed when opened. She stated the Xylocaine and the Labetalol vials were open, but not dated or initialed when they were opened.

Based on record review and interview the hospital failed to develop a list of all services furnished under agreement including the scope and nature of the services provided. Findings:

The hospital could not submit a list of services provided by agreement.

In a face to face interview on 07/13/11 at 3:00pm S1 Administrator verified the hospital had not developed a list of services provided by agreements.

Based on record review and interview the hospital failed to ensure a patient received medications as ordered by the physician for 1 of 19 sampled patients (#18). Findings:

Review of Patient #18's medical record revealed the patient was admitted to the hospital on 5/31/2011 with diagnoses that included Cerebrovascular Accident, Right sided Hemiplegia, Aphasia, Decubitus Ulcer, Diabetes Mellitus, and Hypertension.
Review of Patient #18's physician's orders dated 5/31/2011 with no documented time revealed in part, "Hemodialysis q (every) M, W, F (Monday, Wednesday, Friday) - will pick up at 10:15 (a.m.)., Allopurinal 100 mg pp qd (milligrams per peg every day), Amiodarone 200 mg (milligrams) pp bid (two times per day), Norvasc 5 mg pp qd, Aggrenox 200/25 mg pp bid, Hydralazine 100 mg pp tid (three times per day), Effexor XR 225 mg pp qd, Prevacid 30 mg pp qd, Sensipar 60 mg pp bid. Review of Patient #18's entire medical record revealed no documented evidence indicating the patient's physician ordered the 9:00 a.m. dose of medication to be held
Review of Patient #18's Medication Administration Record revealed medications ordered by the physician had been held on the following dates/times with documentation indicating the reason the medications were held as 'dialysis'.
6/24/2011 at 9:00 a.m. the following medications were held: Sensipar 30 milligrams, Venlafaxine 37.5 milligrams, Aggrenox 200/25, Allopurinol 100 milligrams, Amiodarone 200 milligrams, Amlodipine 5 milligrams, Hydralazine 25 milligrams, Metoclopramide 10 milligrams, Sensipar 30 milligrams, Venlafaxine 37.5 milligrams, Aggrenox 200/25, Allopurinol 100 milligrams, Amlodipine 5 milligrams, Hydralazine 25 milligrams, Metoclopramide 10 milligrams.
6/29/2011 at 9:00 a.m. the following medications were held: Sensipar 30 milligrams, Venlafaxine 37.5 milligrams, Aggrenox 200/25, Allopurinol 100 milligrams, Amiodarone 200 milligrams, Amlodipine 5 milligrams, Hydralazine 25 milligrams, Metoclopramide 10 milligrams, Sensipar 30 milligrams, Venlafaxine 37.5 milligrams
7/01/2011 at 9:00 a.m. the following medications were held: Protonix 30 cc, Amlodipine 5 milligrams, Hydralazine 25 milligrams, Metoclopramide 10 milligrams, Sensipar 30 milligrams, Venlafazine 37.5 milligrams, Dialvite with Zinc, Aggrenox 200/25, Allopurinol 100 milligrams, Amiodarone 200 milligrams
7/06/2011 at 9:00 a.m. the following medications were held: Metoclopramide 10 milligrams, Proteinex 15 Grams, Sensipar 30 milligrams, Venlafaxine 37.5 milligrams, Dialvite with Zinc, Allopurinol 100 milligrams, Amiodarone 200 milligrams, Amlodipine 5 milligrams, Hydralazine 25 milligrams.

During a face to face interview on 7/13/2011 at 1550 (3:50 p.m.), Registered Nurse S21 and Licensed Practical Nurse S22 indicated Patient #18's medication had been held in the mornings of dialysis due to the fact that the medications would dialyze out. S21 and S22 indicated Patient #18 would typically be picked up for dialysis around 10:30 a.m. or 11:00 a.m. and would not return to the hospital until around 4:30 - 5:00 p.m. S21 and S22 confirmed there was no documented evidence of an order to hold Patient #18's morning medications prior to dialysis. S21 and S22 further confirmed there had been no phone calls made to the patient's physician to clarify what should be done regarding administration of medications on the mornings of dialysis. The Director of Nursing S2 was informed on 7/13/2011 at 1600 (4:00 p.m.) that Patient #18's medications were being withheld on the mornings of dialysis. Director of Nursing S2 indicated she would have to look into the matter and would get back with the surveyor at a later time.

During a face to face interview on 7/14/2011 at 10:00 a.m., Director of Nursing S2 indicated she had spoken with Patient #18's physician and the physician indicated he expected Patient #18 to receive her medications every morning before dialysis. S2 indicated Patient #18's medications should never have been held without an order from the patient's physician.

Based on observation, record review, and interview the hospital failed to ensure a policy was developed and implemented to ensure medical records were protected from water damage in the event the sprinkler were to be activated for 3 of 3 locations where medical record were being stored (Main Campus Medical Records Room, Off Site Building in two locations: Equipment storage room on Main Floor and the Medical Records loft on second floor. Findings:

Review of the hospital policy titled, "Security of Medical Records" presented by the hospital as their current policy revealed in part, "All records are stored in areas that are protected from fire in the same manner that all departments are protected in accordance with safety regulations and no smoking regulations." Further review of the entire policy revealed no documented evidence of how the hospital would protect medical record from water destruction in the event that the hospital's sprinkler system were to be activated.

Observations on 7/11/2011 from 9:40 a.m. through 10:00 a.m. revealed Medical Records to be stored in three locations: Main Campus Medical Records Room, Off Site Building in two locations/ Equipment Storage Room on Main Floor and the Medical Records Loft on second floor. All locations were protected by a Sprinkler System. Observations of the Main Campus Medical Records Storage Room revealed Medical Records to be stored on open metal shelves with no protection from water were the Sprinkler System to be triggered. Observations of the Off Site Building where Medical Records were also being stored revealed 225 boxes of Medical Records estimated by HIM (Health Information Management) Director S6 as containing approximately 10 - 15 Medical Records per box to be stored on the floor of the second floor loft. Further observations revealed 8 boxes of death records and 1 box of Medical Records to be located on a crate in the Main Floor of the Off Site Building where equipment storage was located.

During a face to face interview on 7/11/2011 at 10:00 a.m., HIM Director S6 confirmed there was no protection from water were the sprinkler system to be triggered for Medical Records stored in all three locations (Main Campus Medical Records Room, Off Site Storage Building on First Floor Equipment Room, and Second Floor Loft Storage). S6 further indicated the first floor of the Off Site Storage Building was designated for Equipment Storage and there should never have been any Medical Records stored in that location. S6 confirmed the hospital's Policy for Safeguarding Medical Records failed to address how the records were to be protected from water damage.

Based on record review and interview the hospital failed to follow its policy and procedure for ensure an annual evaluation of its Quality Assurance/Performance Improvement Program was performed. Findings:

Review of Policy # 5001 Subject: Organizational Performance Improvement Plan, last reviewed 01/05/11 and submitted as the one currently in use, revealed .... ""The Quality Management Committee will aggregate annual review findings and provide an overall evaluation of the effectiveness of the performance improvement program..."

In a face to face interview on 07/14/11 at 11:30am LPN S14, QA Coordinator verified no evaluation was performed for the QA/PI program.

Based on record review and interview the hospital failed to develop and implement a system for the evaluation of nosocomial infections and the prescribed medication therapy. Findings:

Review of the Quality Management Meeting Minutes for the last three quarters dated 03/11, 12/10, and 09/11 revealed no documented evidence nosocomial infections were discussed.

Review of the data submitted to the QA/PI Committee the last three quarters dated 03/11, 12/10, and 09/11 revealed no documented evidence nosocomial infections and medications were monitored by the Infection Control Officer.

In a face to face interview on 07/14/11 at 11:30am LPN S14 the QA Coordinator indicated she only reports the information that is sent form the Infection Control Officer.

In a face to face interview on 07/14/11 at 8:40am LPN S12, the Infection Control Officer (ICO) indicated she had only recently been hired as the ICO and was following the list of duties provided to her by the previous ICO. Further S12 verified nosocomial infections and the effectiveness of the antibiotic treatments were not being monitored.

Based on record review and interview the hospital failed to ensure corrective actions taken for identified problems were evaluated. Findings:

Review of the Quality Management Committee Meeting Minutes for the last three quarters dated 03/11, 12/11, 09/11 and the statistics submitted by each reporting department revealed no documented evidence data had been trended, actions taken, or the outcomes of the those actions evaluated.

In a face to face interview on 07/14/11 at 11:30am LPN S14 the Quality Assurance Coordinator indicated due to the downsizing of the staff, she (S14) had only recently been given the responsibilities and duties of this job position. Further S14 indicated she was provided a list of duties by the previous QA Coordinator which she was following. S14 indicated she had no previous experience in quality management/performance improvement.

Based on record review and interview the hospital failed to ensure corrective actions taken for identified problems were evaluated. Findings:

Review of the Quality Management Committee Meeting Minutes for the last three quarters dated 03/11, 12/11, 09/11 and the statistics submitted by each reporting department revealed no documented evidence data had been trended, actions taken, or the outcomes of the those actions evaluated.

In a face to face interview on 07/14/11 at 11:30am LPN S14 the Quality Assurance Coordinator indicated due to the downsizing of the staff, she (S14) had only recently been given the responsibilities and duties of this job position. Further S14 indicated she was provided a list of duties by the previous QA Coordinator which she was following. S14 indicated she had no previous experience in quality management/performance improvement.

Based on record review and interview the hospital failed to ensure corrective actions taken for identified problems were evaluated. Findings:

Review of the Quality Management Committee Meeting Minutes for the last three quarters dated 03/11, 12/11, 09/11 and the statistics submitted by each reporting department revealed no documented evidence data had been trended, actions taken, or the outcomes of the those actions evaluated.

In a face to face interview on 07/14/11 at 11:30am LPN S14 the Quality Assurance Coordinator indicated due to the downsizing of the staff, she (S14) had only recently been given the responsibilities and duties of this job position. Further S14 indicated she was provided a list of duties by the previous QA Coordinator which she was following. S14 indicated she had no previous experience in quality management/performance improvement.