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QA Action Plan - Sample 2 Project Team:

Area of Concern:

Date:

Corrective Action (Specific)

/ Persons Responsible for Implementing Correction /

Target

Completion
Date /

Comments/Review

How other residents at risk for related non-compliance will be identified & what corrective actions will be taken

/ Persons Responsible for Implementing Correction /

Target

Completion
Date /

Comments/Review

System Changes to maintain compliance

/ Persons Responsible for Implementing Correction /

Target

Completion
Date /

Comments/Review

Monitoring for effectiveness of New Systems & Compliance

/ Persons Responsible for Implementing Correction /

Target

Completion
Date /

Comments/Review


QA Action Plan – Sample 2 Project Team: SDC, Unit Managers, QA Coordinator Area of Concern: F-272 Assessment -- Medical Records do not consistently reflect physical assessment and follow-up following a fall.

Date: 12/14/09

Corrective Action (Specific)

/ Persons Responsible for Implementing Correction /

Target

Completion
Date /

Comments/Review

Responsible nurses were re-educated and counseled. / SDC / 12/14/09 / Done 12/14/09

How other residents at risk for related non-compliance will be identified & what corrective actions will be taken

/ Persons Responsible for Implementing Correction /

Target

Completion
Date /

Comments/Review

The medical records of all current residents with falls in the past 2 weeks will be reviewed for documentation of physical assessment and follow-up following a fall. / SDC or designee / 12/27/09 / Completed – 12/26/09

System Changes to maintain compliance

/ Persons Responsible for Implementing Correction /

Target

Completion
Date /

Comments/Review

1. Licensed Nursing Staff will be inserviced on proper assessment, documentation and follow-up following falls.
2. Nursing Staff will be inserviced on the facility Neuro-Check Policy and Procedure.
3. The Unit Manager or designee will review the medical record documentation following all falls for appropriate assessment and follow-up documentation. Any nurse identified as not performing an appropriate assessment and/or follow-up will be re-educated and/or counseled. / SDC or designee
SDC or designee
Unit Manager or designee / 12/21/09
12/21/09
12/15/09 /

Completed – 12/19/09

Completed – 12/19/09
Started and on-going

Monitoring for effectiveness of New Systems & Compliance

/ Persons Responsible for Implementing Correction /

Target

Completion
Date /

Comments/Review

1. QA Coordinator or designee will randomly select 10% of residents with falls and conduct a QA audit regarding appropriate physical assessment and follow-up documentation monthly x 3 months
2. DON and Administrator will review the audit reports and report monthly findings to the QAA Committee.
3. QAA Committee will monitor reports monthly for patterns and trends and recommend adjustments accordingly.
4. Recommendations will be reviewed quarterly by the Medical Director, QAA Committee, DON, and Administrator. / QA Coordinator
Or designee
DON or designee
DON or designee
DON or designee / 1/24/10
1/31/10
1/31/10
1/31/10 / 2/10/10-- 10% only equaled 2 residents with adequate results but sample will be increased to 50% per month to provide a more accurate picture of action plan success
3/8/10 – Total records reviewed = 12. 100% compliance from Units 1 and 3; Unit 2 had 90% compliance and staff has been re-educated. Will continue with 50% review.