cms_PR: 27
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 27 | RYDER MEMORIAL HOSPITAL INC | 405018 | 355 AVE FONT MARTELO | HUMACAO | PR | 792 | 2017-05-04 | 520 | F | 0 | 1 | ZOYB11 | Based on a recertification extended survey performed from 5/2 to 5/4/17, from 8:00 am thru 5:00 pm, accompanied by the Infection Control Preventionist (employee # 7) it was determined that the facility failed to ensure that the QAPI Committee members have develop a plan of corrective actions as part of the QAPI surveillance program. Findings include: 1. During review of the QAPI quarterly reports from October- November- (MONTH) (YEAR) and (MONTH) (YEAR) (data from (MONTH) thru (MONTH) (YEAR)), performed on 5/4/17 at 10:30 am accompanied by the Infection Control Preventionist (employee #7), it was found that the indicators that have been identified do not mention a plan of corrective actions (P[NAME]) that will ensure compliance according to facility's P&P's and other professional regulations. a. On the quarterly reports from (MONTH) (YEAR) and (MONTH) (YEAR) the indicators develop for adequacy on the application of Influenza vaccine, the obtained percentage for compliance was 89% (October), 75% (November) and 31% (December) . The threshold for compliance is between 95 to 100 %. The P[NAME] for (MONTH) results was Notified to the physician. The P[NAME] for (MONTH) results was left in blank space and for (MONTH) results was reorientation (to staff) related to patient's vaccine documentation form. These P[NAME]'s do not mention a time frame where these ongoing activities will be performed and does not mention which other required activities are needed to reach the established goals. The same indicator was develop on the (MONTH) (YEAR) quarterly report and the reached percentage of compliance was 90%. The P[NAME] established activity was: Is still being evaluated. However, no evidence of a P[NAME] previous activities review has been performed due to lack of information. There is no mechanism that allows the coordinator to compare quality previous activities with the new activities that are needed to ensure compliance. 2. Other indicators that have been develop on the (MONTH) (YEAR) quarterly report and have been identified again in the (MONTH) (YEAR) quarterly report, are: adequacy on the protocol documentation of falls prevention whose percentage of compliance dropped from 100% (December2016) to 80% (March (YEAR)). However, the activity established on the P[NAME] is to continue reorientation (to staff). No other activities were develop to ensure compliance. 3. On the (MONTH) (YEAR) quarterly report, it was identified the indicator for adequacy on the clinical record documentation. The reached percentage was 84%. The P[NAME] established activities were: to continue with all staff reorientation related to clinical record documentation. It does not mention which areas of the documentation on the clinical record has to be improved, which members of the staff has to improve their documentation and no timeframe period has been established to perform the surveillance activity. 4. During review of the QAPI reports performed on 5/4/17 at 10:30 am, the indicators established are related to the Nursing Services. No evidence was found of the participation on tracking and monitoring activities for the QAPI program from other programs that offer services or direct care, such as: Therapy Rehabilitation Program, Social Services, Physician Services, Dietitian services, etc. | 2020-09-01 |