HospitalInspections.org

Based on policy and procedure review, patient medical record review, and staff interview, the facility failed to ensure that staff obtained a consent for admission and treatment for 1 of 3 patients who died at the facility in October, 2012 (pt. # 3).

Findings:
1. at 10:00 AM on 10/19/12, review of the policy and procedure from the "Manual: Health Information Mgmt." with a last revision date of 1/27/12, indicated:
a. on page 7 under "Informed Consent", it reads: "All records must contain a properly executed and completed informed consent form for all procedures and treatments..."

2. at 11:00 AM on 10/18/12, review of the 3 facility death records indicated:
a. pt. #3:
A. was admitted on 10/5/12 at 6:30 PM and died at 10:04 AM on 10/8/12
B. was lacking a consent form related to admission and treatment at the facility

3. at 9:35 AM on 10/19/12, interview with staff member #54, the health information/medical records manager, indicated:
a. patient #3 was admitted at 6:30 PM on 10/5/12 (Friday) and died at 10:04 AM on Monday, 10/8/12
b. there was no multi page admission consent form present in the medical record for pt. #3
c. the "primary" nurse was responsible for assuring that the responsible family member(s) or guardian signed the admission forms on Friday evening of 10/5/12, or in their absence to get verbal phone consent
d. nursing staff check the charts every 24 hours and another nurse should have caught the fact that the admitting nurse failed to get a consent for admission at some time during the weekend
e. contact information was present in the medical record for nursing staff to be able to attempt to reach significant others for consent to admit and treat
f. there is no documentation, over that weekend by nursing staff, that attempts were made to call family for consent to admit
g. this staff member had done chart audits and found that the consent was missing, the follow up would be to alert the director of nursing for re education of staff--there was no documentation that any follow up had occurred to keep this absence of a consent form from occurring in the future

Based on review of the RN (registered nurse) job description, personnel file review, and staff interview, the facility failed to ensure that 2 of 4 RNs hired after June 1, 2012 were competent in ACLS (advanced cardiac life support), as required in the job description (staff members P6 and P8).

Findings:
1. at 1:00 PM on 10/18/12 and 11:45 AM on 10/19/12 , review of the RN job description indicated:
a. on page 2, under "Minimum Qualifications/Requirements", it reads: "Must possess specific educational and experience requirements such as: ...ACLS and BLS (basic life support) Certification"

2. at 12:50 PM on 10/18/12, review of personnel files indicated:
a. staff member P6 was hired 8/28/12 and lacked any documentation of ACLS certification
b. staff member P8 was hired 8/15/12 and lacked any documentation of ACLS certification

3. interview with staff member #54, human resources manager, indicated:
a. both RNs (P6 and P8) are scheduled to take the ACLS certification classes in November
b. the previous clinical coordinator allowed 90 days after the date of hire to become ACLS certified, even though this is not noted in the job description
c. the current language of the RN job descriptions does require ACLS at the time of hire

Based on policy and procedure review, patient medical record review, and staff interview, the nursing staff failed to care for and evaluate the nursing care for patients in: failing to follow physician's orders related to pt weights on admission and daily for 4 of 7 patients (pts. #1, 5, 6, and 7); failing to follow facility policy related to daily Braden Scale scoring for 6 of 7 patients (pts. #1, 2, 3, 5, 6, and 7); and failing to document patient repositioning every two hours for patients who scored as being at risk for skin breakdown for 4 of 7 patients (pts. #1, 2, 3, and 6).

Findings:
1. at 1:15 PM on 10/18/12, review of the policy and procedure "Skin & Wound Assessment Policy & Procedure" with no policy number and a revision date of June, 2011, indicated:
a. under "II. Policy Statements", it reads: "...3. At risk patients will be identified by use of Braden Scale on admission, every 24 hours, and upon transfer.."
b. under "III. Procedures", it reads: "...Prevention Protocol...3. Turn and reposition per the patient's needs and/or requests. Recommendation of turning every 2 hours...."

2. at 1:15 PM on 10/18/12, review of the "Braden Scale Policy", with no policy number and a last revision date of June 2011, indicated:
a. under "I. Policy Statements", it reads: "1. The Braden scale will be performed daily on all patients in [facility] by nursing personnel/wound nurse...4. Any patient at risk shall have preventative measure in line such as:...repositioning every 2 (two) hours,..."

3. at 3:30 PM on 10/17/12, review of the policy and procedure "Primary Nursing Care", policy number NSG.A.0018, with a last revision date of December, 2011, indicated:
a. under section "VI. Procedures" it reads: "...B. The PCN (primary care nurse) will process and perform all orders concerning or impacting his or her assigned patients...2. The PCN will ensure the accurate entry and performance of all non-medication related orders in concert with the appropriate secretarial, departmental, and/or ancillary staff...."

4. review of patient medical records through out the survey process of 10/17/12 to 10/19/12 indicated:
a. patient weights were ordered on admission and daily for all 7 patients with lack of weights being documented for 4 patients as follows:
A. pt. #1 lacked documentation of a weight on: 9/24/12, 9/26/12, 9/27/12, 9/31/12, 10/2/12, and 10/5/12
B. pt. #5 lacked the documentation for a weight on: 9/26/12 (day of admission), 9/27/12, 9/31/12, 10/2/12, 10/3/12, 10/4/12, 10/6/12, 10/8/12, 10/10/12, and 10/11/12--on 10/12/12 and 10/17/12, nursing staff documented the "bed not working" and "scale not weighing" on the chart, but did not follow up to get a weight for the patient or note that the problem was addressed by the nursing supervisor
C. pt. #6 lacked documentation of a weight on admission (9/17/12) and on 9/18/12
D. pt. #7 lacked the documentation of a weight being checked on 8/29/12, 8/30/12 and 9/3/12

b. patients lacked the documentation of a daily Braden Scale scoring as follows:
A. pt. #1 lacked documentation on the Braden Scale scoring form for: 9/24/12, 9/25/12, 9/27/12, and 9/28/12
B. pt. #2 lacked documentation on the Braden Scale scoring form for: 9/31/12, 10/2/12, 10/4/12, 10/5/12, 10/6/12 and 10/7/12
C. pt. #3 lacked documentation on the Braden Scale scoring form for: 10/7/12 and 10/8/12
D. pt. #6 lacked documentation on the Braden Scale scoring form for: 9/18/12, 9/22/12 and 9/23/12
E. pt. #7 lacked documentation on the Braden Scale scoring form for: 8/25/12, 8/26/12, 9/1/12, 9/2/12, 9/3/12, and 9/4/12

c. patients lacked documentation of every two hour repositioning on the "Patient Care Flowsheet" for patients care planned for skin precautions as follows:
A. pt. #1 lacked every two hour documentation of repositioning on: 9/30/12, 10/1/12, 10/5/12, 10/6/12, and 10/8/12
B. pt. #2 lacked every two hour documentation of repositioning on: 9/26/12, 9/27/12, 9/28/12, 9/30/12, 10/1/12, 10/2/12, 10/5/12, 10/6/12, and 10/7/12
C. pt. #3 lacked every two hour documentation of repositioning on: 10/5/12, 10/6/12, and 10/7/12
D. pt. #6 lacked every two hour documentation of repositioning on: 9/19/12, 9/20/12, and 9/22/12

5. interview with staff member #53, health information/medical record manager, at 11:10 AM on 10/19/12 indicated:
a. nursing staff lacked documentation of admission and daily weights, per physician orders for patients as listed in 4. above
b. nursing staff failed to document the Braden Scale daily, as per facility policy and procedure, for the patients as listed in 4. above
c. nursing staff failed to document every two hour repositioning as required when skin precautions are put into place, per facility policy, for patients as listed in 4. above

Based on policy and procedure review, patient medical record review, and staff interview, the nursing director failed to ensure the implementation of the policy related to nursing care plans for 5 of 7 patient records reviewed (pts. #1, #2, #3, #5 and #6).

Findings:
1. at 3:30 PM on 10/17/12, review of the policy and procedure "Nursing Care Plan", policy # NSG.A.0006, with a last revision date of December, 2011, indicated:
a. under section "V. Policy Statements", it reads: "A. It will be the policy at [facility] to establish a set of goals with measurable interventions for each patient upon admission that will be re-evaluated daily by their assigned Primary Care Nurse."

2. Review of patient medical records through out the survey process of 10/17/12 to 10/19/12, indicated:
a. pt. #1 was admitted on 9/21/12 and did not have
A. a care plan initiated until 9/25/12
B. a daily check of the nursing care plan documented on 9/31/12
b. pt. #2 was admitted on 9/26/12, died on 10/8/12, and lacked daily re-evaluation of the nursing care plane on 9/28/12, 9/31/12, and 10/4/12
c. pt. #3 was admitted on 10/5/12 and had "skin precautions" checked as being implemented on the last page (no number) of the "Patient Care Flowsheet " for each day of admission (10/5/12 to 10/8/12), but lacked any addition of skin precaution documentation on the nursing care plan
d. pt. #5 was admitted on 9/26/12 and had "fall precautions" checked as being implemented on the last page (no number) of the "Patient Care Flowsheet ", but lacked any addition for fall precautions documentation on the nursing care plan (as of 10/18/12 for this inpatient)
e. pt. #6 lacked documentation of daily checks of the nursing care plan for 9/21/12 and 9/22/12

3. at 9:35 AM and 11:10 AM on 10/19/12, interview with staff member #53, health information/medical record manager, indicated:
a. documentation related to the nursing care plans was lacking as stated in #2. above

Based on review of the agency RN (registered nurse) and LPN (licensed practical nurse) job descriptions, personnel file review, and staff interview, the facility failed to ensure that 2 of 4 RNs or LPNs who worked at the facility after June 1, 2012 were competent in ACLS (advanced cardiac life support), as required in the job descriptions (staff members P1 and P3).

Findings:
1. at 1:00 PM on 10/18/12 and 11:45 AM on 10/19/12, review of the RN and LPN job descriptions indicated:
a. on page 2, under "Minimum Qualifications/Requirements", it reads: "Must possess specific educational and experience requirements such as: ...ACLS and BLS (basic life support) Certification"

2. at 1:15 PM on 10/18/12, review of personnel files indicated:
a. staff member (RN) P1 first worked on 6/8/12 and lacked any documentation of ACLS certification
b. staff member (LPN) P3 first worked 9/20/12 and lacked any documentation of ACLS certification

3. at 10:30 AM on 10/19/12, interview with staff member #54, human resources manager, indicated:
a. the previous clinical coordinator allowed 90 days after the date of hire to become ACLS certified, even though this is not noted in the job description
b. the current language of the RN job descriptions does require ACLS at the time of hire
c. it was unknown that agency nursing staff must have ACLS certification the same as facility nursing staff
d. per phone calls to the agencies supplying nursing staff, ACLS certification is not a requirement for some of the contracted agencies

Based on review of medical staff rules and regulations, policy and procedure review, patient medical record review, and staff interview, the facility failed to ensure that authentication of physician orders, and other documentation, was made per the rules and regulations of the medical staff and medical records policies for 2 of 7 patients (pts. #1 and #5).

Findings:
1. at 11:45 AM on 10/19/12, review of the Medical Staff Rules and Regulations (approved June 1, 2012 per verbal response of staff #50, the Chief Executive Officer), indicated:
a. on page 70 under section "B. Medical Records", it reads: "8. All clinical entries in the medical record shall be accurately dated, timed, and authenticated..."

2. at 11:10 AM on 10/19/12, review of the policy and procedure "Long Term Acute Care Hospital Health Information Practice and Documentation Guidelines", with a "Manual: Health Information Mgmt." name (no policy number) and revision date of 1/27/12, indicated:
a. on page 2 in the section "Defining Who May Document in the Medical Record.", it reads: "Anyone documenting in the medical record should be credentialed and/or have the authority and right to document as defined by hospital policy..."
b. on page 2 in section "Date, Time, Timeliness and Authentication of Entries.", it reads: "Each entry must include a complete date (i.e. month, date, year), have a time associated with it....The authentication by the author should included at least the first initial, last name and title/credential."

3. review of patient medical records through out the survey process of 10/17/12 to 10/19/12 indicated:
a. pt. #1 had:
A. pre printed admission orders authenticated by the practitioner that lacked documentation of the practitioner's credentials
B. written physician orders authenticated on 9/22/12 that lacked documentation of the practitioner's credentials
C. "Daily Progress Notes" for 9/22/12 and 9/23/12 that were authenticated without the practitioner's credentials

b. pt. #5 had:
A. pre printed admission orders authenticated by the practitioner with only the physician's initials
B. had admission orders that lacked documentation of the practitioner's credentials

4. interview with staff member #53, manager of health information services, indicated:
a. the physicians are not always writing their credentials when authenticating progress notes or orders
b. most of the physicians authenticate with initials only and not their first initial and last name
c. without credentials when practitioners authenticate documentation, it cannot be determined that these are credentialed physician staff members

Based on policy and procedure review, observation, and interview, the dietitian failed to ensure the proper management, per facility policy, of supplemental nutritional products in regards to expired product in the pantry refrigerator.

Findings:
1. at 11:45 AM on 10/19/12, review of the policy and procedure "Disposal of Defective or Expired Nutritional Supplements", Policy #: 24.01.03, with an approval date of 6/2012, indicated:
a. under section "IV. Definitions", it reads: "A. Nutritional supplements include medical nutritionals for consumption by mouth and tube feedings (enteral nutrition)."
b. under section "V. Policy Statements", it reads: "The dietitian checks the stock of supplements once each week for ordering supplies and to check for expiration dates."
c. under section "VI. Procedures", it reads: "...C. If the dietitian finds some supplements that are defective or expired the dietitian removes the products and informs central supply."

2. at 3:25 PM on 10/18/12, while on tour of the nursing unit in the company of staff member #52, it was observed in the refrigerator that 3 cans of Nepro Nutritional Supplement (8 oz cans) had expired April 1, 2012 and 2 cans expired July 1, 2012.

3. at 11:30 AM on 10/19/12, interview with staff member #55, the facility RD (registered dietician), indicated:
a. this staff member is responsible for rotating nutritional supplement products to assure that expired products are removed from service
b. checking of expiration dates on nutritional supplements occurs when it is time to "order new supplies" for stocking the pantry
c. this staff member "missed" the 5 cans of expired product in their monitoring of nutritional supplements

Based on document review and interview, the facility failed to have a written policy and procedure for the proper routine storage and disposal of trash.

Findings:

1. Review of the facility's policies and procedures indicated there was not a written one for proper routine storage and disposal of trash.

2. In interview, on 10-18-12 at 2:145 pm, employee #A1 verified there was a not written policy and procedures for the proper routine storage and disposal of trash. No other documentation was provided prior to exit.

Based on observation and interview, the facility failed to identify and replace expired supplies for two pieces of equipment (Zoll Model M Series monitor/defibrillator and Abbott i-Stat blood analyzer ).

Findings:

1. During a tour of the facility on 10-18-12 at 1515 hours, the following condition was observed on top of the emergency code cart: 2 packages of multi-purpose defibrillator electrodes with an expiration date of 7-28-12 for the Zoll Model M Series monitor/defibrillator.

2. During a tour of the facility on 10-18-12 at 1520 hours, the following condition was observed in the supply storage room: 2 packages of multi-purpose defibrillator electrodes with an expiration date of 9-04-12 for the Zoll Model M Series monitor/defibrillator.

3. During an interview on 10-18-12 at 1520 hours, staff A1 confirmed that the electrodes had expired and confirmed that the hospital was responsible for ensuring the availability of the multi-purpose electrodes if needed.

4. During a tour of the facility on 10-18-12 at 1630 hours, the following condition was observed in a laboratory room refrigerator: (2) 25 count packages (containing 19 and 21 cartridges respectively) for arterial blood gas testing with an expiration date of 10-14-12 for an Abbott i-Stat blood analyzer to be operated by hospital employees.

5. During an interview on 10-18-12 at 1635 hours, staff A1 confirmed that the cartridges were expired and confirmed that the hospital was responsible for ensuring the availability of blood analyzer cartridges for use by staff.

Based on policy and procedure review, infection control plan review, Aplisol (tuberculin-PPD-purified protein derivative) package insert review, employee and agency personnel file review and staff interview, the infection control officer failed to assure the facility had a policy addressing the determination and/or follow-up of employees and/or contracted personnel for tuberculosis testing of and for immune status for rubella, rubeola, varicella and hepatitis B, failed to create a policy related to required reporting of communicable diseases to the State agency, failed to identify and follow up on immune status for 9 of 12 nursing staff files reviewed (P1, P3, and P5 through P11) and for 5 of 8 other facility and contracted agency staff (A1, A3, A4, A6 and A8) and failed to assure TB Mantoux test was read within the required time frame of 48-72 hours for P9 and P10.

Findings:
1. at 1:15 PM on 10/19/12, review of the policy and procedure "Employee Health", from the "Manual" -- "HR" with "New Employee Orientation", noted at the bottom of the page (no policy number) and with a last revision date of 4/17/12, indicated:
a. under section "V. Policy Statements", it reads: "A. New hires will have a TB (tuberculosis) test, health screen, drug test and titers drawn before they can work on the floor..."

2. at 10:05 AM on 10/19/12, review of the "Infection Control Plan" with policy number "NSG.IC.0010" and a last revision date of July 2012, indicated:
a. under section "V. Policy Statements", it reads: "...D. The IC (infection control) Program of [facility] delegates the responsibilities involved in the surveillance, prevention, and reduction of infections as follows:...3. The CS (clinical supervisor) is responsible for: 1. Facilitating the continued implementation of policies and procedures related to IC, 2. Updating policies and procedures related to IC as needed,..."
b. under section "V. Policy Statements", it reads: "...D. The IC Program of [facility] delegates the responsibilities involved in the surveillance, prevention, and reduction of infections as follows:...3. The CS (clinical supervisor) is responsible for:...5. Reporting to governmental agencies; and ..."
c under section "VI. Procedures", it reads: "...D. The IC Committee, in conjunction with the CS, will establish and evaluate employee health policies, develop all IC-related policies and/or protocols, and respond to questions regarding IC-related techniques or policies..."

3. at 11:45 AM on 10/19/12, review of the package insert for the product used for employee TB/mantoux tests was reviewed and indicated:
a. "Readings of Mantoux reactions should be made by a trained health professional during the period from 48 to 72 hours after the injection..."

4. review of facility and agency personnel files at 12:50 PM on 10/18/12 indicated:
a. agency RN (registered nurse) P1 lacked information regarding the immunity status, (history of immunization, physician documentation of having had the disease, or titer), for Rubella, Rubeola and Varicella
b. agency LPN (licensed practical nurse), P3 had an "equivocal" Rubeola titer result indicating the immune level was unknown or negative
c. staff RNs and LPNs P5, P6, P7, P9, P10 and P11 lacked documentation of Rubella, Rubeola, Varicella status and Hepatitis B information
d. staff RN P8 lacked documentation of Rubella, Rubeola, Varicella status
e. RN P9 had documentation that the 6/19/12 TB test was given at 9:10 AM and two times noted for "time read", with one time at 10:48 AM and the other at 10:25 AM on 6/22/12--both are beyond 72 hours, as required/recommended by the Aplisol manufacturer
f. PCT (patient care tech) P10 had no time given or time read noted for the TB test given on 7/14/12 and read on 7/19/12, but was noted as being read greater than 72 hours after the injection, as required/recommended by the Aplisol manufacturer

5. Personnel files for active facility and contracted agency staff (staff A1, A3, A4, A6 and A8) reviewed lacked documentation regarding immune status for rubella, rubeola, varicella and hepatitis B.

6. interview with staff member #54, the human resources manager, at 9:55 AM on 10/19/12 indicated:
a. even though the "Employee Health" policy is not specific for which immunization titers were required, facility practice was to obtain documentation related to Rubella, Rubeola, Varicella, and
Hepatitis B
b. a policy from "LTAC (long term acute care) of Greenwood" (Greenwood, Mississippi) was presented to represent the owner's stance related to Hepatitis B and Flu programs
c. the TB tests for staff members P9 and P10 were beyond the 72 hours recommended by the Aplisol package insert
d. there was no documentation for Rubella, Rubeola, Varicella and Hepatitis B for the staff members as noted in 4. above
e. per a phone call with contracted agencies, they do not require communicable disease status for Rubella, Rubeola, or Varicella
f. per a phone call with the contracted agency, agency staff member P3 had no follow up done after the equivocal Rubeola titer was indicated (no booster offered or given)

7. During an interview on 10-19-12 at 1135 hours, staff A5 confirmed that the staff files (staff A1, A3, A4, A6 and A8) lacked documentation of immunity to the infectious diseases.

8. at 10:05 AM on 10/19/12, interview with staff member #52, the Director of Nursing and Co-Chair of the Infection Control Committee, indicated:
a. the policy provided related to "Reporting of Communicable Diseases", as required by 410 IAC 1-2,3-47, was from another facility (host hospital) and lacked documentation of approval/acceptance of this policy by the facility infection control committee







29550

Based on review of the IOPO (Indiana Organ Procurement Organization) contract, review of the "patient log" of facility deaths, patient medical record review, and staff interview, the facility failed to ensure that the organ procurement agency was contacted in a timely manner once imminent death was determined for 3 of 3 patients whose death records were reviewed (pts. #1, 2, and 3).

Findings:
1. at 1:15 PM on 10/19/12, review of the IOPO contract with the facility (only odd pages provided to surveyor), indicated:
a. the contract was signed by facility administration on 5/11/10
b. on page 3, in section "i)", it reads: ""Imminent Death" shall mean the time when an individual's death is reasonably expected utilizing the criteria enumerated for Clinical Indicators."
c. on page 3, in section "l)", it reads: ""Timely Referral" shall mean a telephone call by Hospital notifying IOPO of an Imminent Death, in sufficient time to give IOPO an adequate opportunity to begin assessment of a Potential Donor prior to the withdrawal of, or discussion with family or guardian regarding, any life-sustaining therapies...and as soon as it is anticipated a patient will meet the criteria for Imminent Death."

2. at 3:30 PM on 10/17/12, the log of patient deaths, on the form titled "Indiana Organ Procurement Organization Patient Log", for October was reviewed and indicated:
a. pt. #1 died on 10/8/12 and IOPO was contacted at 3:00 PM
b. pt. #2 died on 10/8/12 and IOPO was contacted at 3:00 PM
c. pt. #3 died on 10/8/12 and IOPO was contacted at 11:00 AM

3. through out the survey process of 10/17/12 to 10/19/12, review of patient medical records, of those who were deceased in October 2012, indicated:
a. pt. #1:
A. lacked any documentation by nursing staff that IOPO was contacted either prior to the patient's death or after
B. had documentation in the medical record that "DNR (do not resuscitate)/comfort measures" were implemented at 11:00 AM on 10/8/12
C. was noted with death occurring at 2:32 PM

b. pt. #2:
A. had comfort measures indicated at 11:50 AM on 10/8/12
B. was noted with death occurring at 2:21 PM on 10/8/12
C. had nursing documentation that IOPO was called at 4:00 PM

c. pt. #3:
A. had nursing documentation at 8:00 AM that the patient was "not arousable"
B. had documentation of the patient's death at 10:04 AM
C. lacked nursing notation of any contact with IOPO

4. interview with staff member #53, health information manager, at 12:00 PM on 10/18/12, indicated:
a. the previous clinical coordinator was contacting IOPO after the death of patients and not the "primary care nurse" for the patients
b. patients #1, 2, and 3 had documentation in their medical records that indicated death was imminent for two or more hours prior to the actual time of death for these patients
c per the facility contract with IOPO regarding timely notification, the organ procurement agency should have been contacted prior to patient deaths for patients #1, 2 and 3

Based on document review and interview, the quality assessment/performance improvement (QAPI) program failed to include 1 directly-provided service (laboratory service) and 4 contracted services (alcohol/drug, psychology, medical record and maintenance).

Findings:

1. Review of the facility's quality assessment/performance improvement (QAPI) program indicated the directly-provided laboratory service was not included in the program.

2. Review of the facility's quality assessment/performance improvement (QAPI) program indicated the contracted services of alcohol/drug, psychology, medical record and maintenance were not included in the program.

3. In interview, on 10-18-12 at 1:00 pm, employee #A1 verified the above and no further documentation was provided prior to exit.

Based on document review and interview, the facility failed to measure, analyze and track quality indicators for 1 directly-provided service and 4 contracted services as part of its quality assessment/performance improvement (QAPI) program.

Findings:

1. Review of the facility's quality assessment/performance improvement (QAPI) program indicated the directly provided laboratory service and contracted services of alcohol/drug, psychology, medical record and maintenance were not included in the program. Therefore, the facility failed to measure, analyze and track quality indicators for these services.

2. In interview, on 10-18-12 at 1:00 pm, employee #A1 verified the above and no further documentation was provided prior to exit.

Based on document review and interview, the facility failed to measure the success and track performance to ensure that improvements were sustained in 1 quality improvement project.

Findings:

1. Review of a quality improvement project to reduce medication errors, initiated on
April 3, 2012, indicated there was identification of the problem and patient care was significantly compromised by the failure of this process. The goal was indicated to be no reported occurrences of this sort.

2. Further review of the project indicated there was no subsequent measurement of the success and the tracking of the performance of staff to show a reduction in medication errors.

3. In interview, on 10-18-12 at 3:00 pm, employee #A1 verified there was no subsequent measurement of the success and the tracking of the performance of staff to show a reduction in medication errors. No further documentation was provided prior to exit.