| 11361 |
MONTCLAIR NURSING AND REHABILITATION CENTER |
285054 |
2525 SOUTH 135TH AVENUE |
OMAHA |
NE |
68144 |
2012-02-29 |
520 |
H |
1 |
1 |
IWZ611 |
LICENSURE REFERENCE NUMBER 175 NAC 12-006.07C Based on record review and interview; the facility's Risk Management/Quality Improvement Program (RM/QIP) failed to identify ongoing issues relevant to F157, F221, F225, F281, F309, F311, F315, F323, F325, F329, F332, F333, F431, F469, F490, F505 and F520 and implement effective plans of action to correct the deficient practice. The RM/QIP Committee failed to assure repeated deficiencies at F157, F253, F280, F315, F323 and F329 were corrected and the correction maintained. The sample size of the survey consisted of 26 sampled and 2 non-sampled residents. The facility staff identified a census pf 157. Findings are: Record review of the facility policy and procedure for the RM/QIP revised on 03/2011 revealed the following: -The RM/QIP is directed by the Administrator. The program is focused on minimizing risk and improving resident/patient care by implementing a process for root cause analysis ad the utilization of the Quality Improvement teams. -Procedure: -#6. Prepare a written agenda for each meeting to include the discussion of incidents, issues and concerns. -#7. Develop a action plan to improve the identified process or system. Action plan is to include goals, outcome indicators and a monitoring plan. -#8. Complete written minutes of the meeting to document items discussed and the proposed action item. -#9. Implement action plan. -#10. Collect, study and analyze the outcome data. -#11. Continue to monitor the completion and effectiveness of the action plan. Modify the action plan (if) results are not acceptable. -#12. Report results to RM/QIP committee. An interview on 2/23/2012 at 7:35 AM was conducted with Nursing Assistant (NA) C . During the interview, NA C stated (gender) was not aware of the RM/QIP committee or how the RM/QIP functioned. NA-C was not aware of what the QI (Quality Improvement) process was, did not know how to access the committee, and was not able to verbalize any specific plans of action the RM/QIP was working on. An interview on 2/23/2012 at 7:40 AM was conducted with NA-D. During the interview, NA-D reported (Gender) was not aware of the QI committee or how it functioned. NA-D was not aware what the QI process was, did not know how to access the committee, and was not able to verbalize any specific program or action plans the RM/QIP was working on. An interview on 2/23/2012 at 7:55 AM was conducted with NA-E. During the interview NA E stated (gender) was not aware of the RM/QIP or how the RM/QIP committee functioned. NA-E was not aware what the RM/QIP process was, did not know how to access the committee, and was not able to verbalize any specific plans of action described by the RM/QIP committee. In an interview on 2/23/2012 at 8:00AM, NA-F stated NA-F was not aware of the RM/QIP committee or how it functions. NA F was not able to verbalize any specific plans of action described by the QI committee. An interview with the Director of Nursing (DON) was conducted on 2/23/2012 at 9:30 AM. During the interview, the DON stated the facility RM/QIP committee was working on " routine things". When asked if the facility had identified any issues, other than routine items, The DON stated "no". When asked if any action plans were in place prior to the survey, the DON stated "no, just the routine things". An interview was conducted with the facility Administrator on 2/23/2012 at 9:45 AM. During the interview, the facility Administration was able to identify the RM/QIP process, how often the committee meets and what action plans were. When asked if the RM/QIP action plan would include, identifying the issue, implementing a plan and re-evaluation the intervention and monitoring, the Administrator stated "yes". When asked to describe an action plan the RM/QIP was currently working on, the Administrator identified resident falls was an action plan. The Administration was asked for evidence of the action plan. A follow up interview was conducted with the Administrator on 3/23/2012 at 10:25 AM. During the interview, the Administrator reported the information was not available as identified in the RM/QIP i.e. Develop an action plan, identify goals, outcome indicator, have a monitoring plan and re-evaluate your action plan as needed. The Administrator stated "we don't have it". |
2015-06-01 |