Mercy Regional Medical Center

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 47962 Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.21 Quality Assessment and Performance Improvement Program, was out of compliance. A-0283 The hospital must use the data collected to (ii) Identify opportunities for improvement and changes that will lead to improvement. (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. Based on interviews and document review, the facility failed to ensure the quality assurance and performance improvement (QAPI) program identified opportunities for improvement in high-risk problem-prone areas, specifically the family birth center (FBC), and implemented performance improvement (PI) activities for improving health outcomes and patient safety. Specifically, the facility failed to ensure QAPI was aware of, and had measures in place to track and trend infections occurring during or after admission to the FBC. This failure impacted four of five medical records reviewed for patients readmitted to the facility after receiving care in the FBC. (Patients #2, #3, #7, and #8) A-0286 The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will identify and reduce medical errors. (2) The hospital must measure, analyze, and track adverse patient events.(2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. Based on interviews and document review, the facility failed to ensure the quality assurance and process improvement (QAPI) program analyzed an adverse patient event to identify causative factors and implement preventive actions to protect patient safety.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 47962 Based on interviews and document review, the facility failed to ensure the quality assurance and performance improvement (QAPI) program identified opportunities for improvement in high-risk problem-prone areas, specifically the family birth center (FBC), and implemented performance improvement (PI) activities for improving health outcomes and patient safety. Specifically, the facility failed to ensure QAPI was aware of, and had measures in place to track and trend infections occurring during or after admission to the FBC. This failure impacted four of five medical records reviewed for patients readmitted to the facility after receiving care in the FBC. (Patients #2, #3, #7, and #8) (Cross-reference A-0144 and A-0286) Findings include: Facility policies: According to the Clinical Quality Assurance, Patient Safety, and Process Improvement (QAPI) Plan 2025, the purpose is to provide continual prioritized improvement in the delivery of safe, quality care for all services, which includes the delivery of effective health outcomes through person-centered processes. QAPI maintains an integrated, organization-wide PI program to maintain high-quality patient care and safety and improve clinical outcomes. The department collects, aggregates, and analyzes data, including understanding current performance and the identification of opportunities for improvement, facilitates the patient safety event review process, including robust investigation of individual cases and analysis and reporting of safety event trends, and the development, implementation, sustainment, and reporting of action plans. The Quality and Patient Safety Committee (QPSC) oversees and ensures the operational quality and patient safety activities. The committee’s responsibilities include assuring compliance with federal and state quality standards and assuring effective and accountable systems are in place to monitor and improve clinical quality and effectiveness. The Quality Director has oversight responsibilities including the collection and analysis of data, the ongoing evaluation of service delivery and processes of care, the development and implementation of action plans for improvement activities, and provides oversight, guidance, and leadership to the quality team. The overall goals of the quality department are to develop and sustain a culture of patient safety, assure the highest quality of care for all patients, proactively reduce or eliminate risk of harm for patients, identify and analyze high-risk, high-volume, or problem-prone processes for improvement, build participation in identifying quality and safety gaps as well as in working as teams to reduce those gaps, produce clinical excellence through evidence-based practice, provide an optimal, reliable level of care through the reduction and elimination of unnecessary and correctable risks and hazards, and decrease clinical care variation to improve clinical outcomes. According to the Infection Prevention and Control Plan 2025, the program and its surveillance activities are designed to reduce the risk of acquisition and transmission of infections. Facility leadership ensures infection prevention and control activities are reviewed on an ongoing basis and integrated into patient safety initiatives. The Infection Prevention and Control Committee (IPCC) has the authority to institute any appropriate control measures and to recommend corrective action to protect patients from communicable diseases. The IPCC assesses infection risks and prioritizes goals, develops strategies to minimize, reduce, or eliminate identified risks, determines how risk reduction strategies will be evaluated, and reviews and revises the program to improve outcomes. Action items are sent to the Quality & Patient Safety Committee. The infection prevention program managers are responsible for supervising and coordinating the daily management of the infection prevention and control program (IPCP). They collect, review, and analyze surveillance data, collaborate with others to identify, report, and investigate infections and communicable diseases, perform ongoing risk assessments, assist with process improvement initiatives, oversee and investigate risk management issues or patient safety concerns, institute appropriate corrective actions, and identify infection risks based on surveillance and other infection control data. The goals for the program are to identify and minimize or eliminate the risk of acquiring or transmitting infections through the process of surveillance, ongoing risk assessment, and participation in patient safety and quality improvement projects. The infection preventionists will perform the surveillance activities using continuous systematic collection, analysis, interpretation, and dissemination of the data. The surveillance activities will be evaluated annually. The facility reviews the data from the surveillance to prioritize any identified risks for acquiring and transmitting infections and update its goals and associated plan of action. 1. The facility failed to ensure the QAPI program identified opportunities for improvement in high-risk problem-prone areas, specifically the FBC, and implemented PI activities for improving health outcomes and patient safety. A. Document Review i. A review of Patient #3’s medical record revealed Patient #3 was admitted to the FBC on 4/30/25 for a scheduled cesarean section (C-section). During Patient #3’s stay, they developed a smelly yellow discharge, which was not evaluated or treated by the patient’s care team. Patient #3 was readmitted with sepsis (a serious condition in which the body responds improperly to an infection) on 5/12/25, eight days after leaving the hospital. Patient #3 expired on 5/13/25,10 days after reporting the yellow discharge to staff. (Cross-reference A-0144) ii. A review of Patient #8’s medical record revealed Patient #8 was admitted to the FBC on 7/11/25 for a C-section. They were discharged home on 7/13/25 and readmitted on 7/20/25, seven days after discharge, with sepsis and an incisional abscess. iii. A review of Patient #7’s medical record revealed Patient #7 was admitted to the FBC on 5/21/25 for a C-section. They were discharged home on 5/22/25 and readmitted to the emergency department (ED) on 6/1/25, 10 days after discharge, with surgical site dehiscence (surgical wound re-opening) and cellulitis (bacterial infection of the skin and the tissues beneath the skin). iv. A review of Patient #2’s medical record revealed Patient #2 was admitted to the FBC on 5/20/25 for labor and delivery. They were discharged home on 5/22/25 and readmitted to the ED on 5/26/25, four days after discharge, with increased pain and foul-smelling discharge in the area of their surgically repaired tears. On 10/1/25 at 10:48 a.m., and on 11/19/25 at 12:26 p.m., interviews were conducted with infection preventionist (IP) #8. IP #8 stated perinatal specialist (Specialist) #11 tracked readmission data in the FBC, they did not have access to this information, and they were thus unaware of all OB patients readmitted to the facility. IP #8 stated they could not speak to whether the four OB patients’ medical records reviewed, who experienced an infection leading to a readmission to the inpatient unit or the ED, fell within expected infection rates. This review of medical records and interview with IP #8 was in contrast to the Infection Prevention and Control Plan which read, IPs collaborated to identify, report, and investigate infections, performed ongoing risk assessments, oversaw and investigated patient safety concerns, instituted appropriate corrective actions, and identified infection risks based on infection control data. This was also in contrast to the QAPI Plan which read, QAPI assured effective systems were in place to monitor and improve clinical quality and effectiveness. QAPI developed and sustained a culture of patient safety, assured the highest quality of care, and identified and analyzed high-risk and problem-prone processes for improvement. v. A live review of grievances on 9/30/25 at 2:11 p.m. with IP #8, who was also the former patient safety program manager, and patient safety advocate (Advocate) #10 revealed a grievance, relating in part to a concern about Patient #7’s infection. vi. A live review of occurrences (patient safety events) on 9/30/25 at 3:01 p.m. with IP #8 revealed an occurrence, in part related to infections, linked to Patient #8’s stay, and no occurrences related to infections for Patients #2, #3, or #7. The review of grievances and occurrences revealed, while the facility’s quality review had identified Patient #7 and #8 as having infections, they had not identified these concerns for Patient #3 or #2. This review of grievances and occurrences was in contrast to the Infection Prevention and Control Plan which read, IPs collaborated to identify, report, and investigate infections, performed ongoing risk assessments, oversaw and investigated patient safety concerns, instituted appropriate corrective actions, and identified infection risks based on infection control data. This was also in contrast to the QAPI Plan which read, QAPI assured effective systems were in place to monitor and improve clinical quality and effectiveness. QAPI developed and sustained a culture of patient safety, assured the highest quality of care, and identified and analyzed high-risk and problem-prone processes for improvement. B. Interviews i. On 9/30/25 at 4:38 p.m., an interview was conducted with the FBC nurse manager (Manager) #5. Manager #5 stated of the patients whose records were reviewed (Patients #2, #3, #7, and #8), none of those infections were on the surgical site infection (SSI) dashboard and would have been difficult for the facility to track. This was in contrast to the QAPI Plan which read, QAPI assured effective systems were in place to monitor and improve clinical quality and effectiveness. QAPI developed and sustained a culture of patient safety, assured the highest quality of care, and identified and analyzed high-risk and problem-prone processes for improvement. ii. On 11/18/25 at 1:19 p.m., an interview was conducted with Specialist #11. Specialist #11 stated their role focused on quality improvement initiatives determined by the corporate leadership team to improve safety for FBC patients. They stated they had access to and reviewed the readmission log for the FBC, however, they were not involved in infection prevention, nor were they involved in infection surveillance. This statement, along with IP #8’s statement that they did not have access to the readmission data for FBC patients, was in contrast to the Infection Prevention and Control Plan which read, IPs collaborated to identify, report, and investigate infections. The facility reviewed the surveillance data to prioritize any identified risks for acquiring and transmitting infections and updated its associated plan of action. This was also in contrast to the QAPI Plan which read, QAPI assured effective systems were in place to monitor and improve clinical quality and effectiveness. QAPI developed and sustained a culture of patient safety, assured the highest quality of care, and identified and analyzed high-risk and problem-prone processes for improvement. iii. On 10/1/25 at 10:48 a.m., and on 11/19/25 at 12:26 p.m., interviews were conducted with IP #8. IP #8 stated patient safety events were important to understanding trends in care and what the facility needed to do to create positive change and improve patient care. This was in contrast to the lack of occurrences related to infections for Patients #2, #3, or #7. IP #8 stated they had recently started as the infection preventionist. They stated their role required centralized surveillance, reviewing lab results, patient medical records, daily huddles, the SSI dashboard, reviewing patient readmissions, and rounding frequently in areas such as the operating room and sterile processing department. IP #8 stated appropriate infection control practices decreased the risk of hospital-acquired infections. IP #8 stated SSIs were infections that occurred after a surgical procedure in the operating room (OR) with signs and symptoms including infection, heat, drainage, purulent (pus-containing), dehiscence, and unhealed wounds. They stated the SSI dashboard identified patients who were readmitted or had imaging or labs performed, which came back positive for microorganisms (small organisms such as bacteria or viruses which can cause disease). IP #8 stated infections which did not occur after a surgery in the OR were not considered SSIs and thus were not captured in the information they collected and reviewed. IP #8 stated FBC patients with sepsis, infected obstetrical (OB) sutures, and/or other infections after their admissions, and which caused the patients to return to the ED, would not be routinely reviewed as part of their infection control surveillance. They stated patients who presented to the facility’s OB providers (a contracted medical group) outside of the facility would not have their visits or concerns documented in the electronic medical record (EMR), and thus there would not be a way to track and trend those concerns. IP #8 stated non-OB patients who went to their primary care providers (PCP), with the potential for that provider to be in-system, would have their concerns tracked in the EMR. IP #8 stated this inability to track return visits to the OB providers created a barrier to bettering patient care. This was in contrast to the Infection Prevention and Control Plan which read, IPs collaborated to identify, report, and investigate infections, performed ongoing risk assessments, oversaw and investigated patient safety concerns, instituted appropriate corrective actions, and identified infection risks based on infection control data. IP #8 stated they did not have access to FBC readmissions and thus were not aware of OB patients readmitted to the facility. They stated Specialist #11, who did have access to the readmission report, did not have any infection prevention responsibilities. IP #8 stated they were not aware of infection control practices in the FBC. This was in contrast to the QAPI Plan which read, QAPI assured effective systems were in place to monitor and improve clinical quality and effectiveness. QAPI developed and sustained a culture of patient safety, assured the highest quality of care, and identified and analyzed high-risk and problem-prone processes for improvement. This was also in contrast to the Infection Prevention and Control Plan which read, IPs collaborated to identify, report, and investigate infections, performed ongoing risk assessments, oversaw and investigated patient safety concerns, instituted appropriate corrective actions, and identified infection risks based on infection control data. IP #8 stated the facility routinely acted on and elevated concerns with patient care in order to identify opportunities for improvement, which was in contrast to QAPI’s lack of identification of the FBC as being a problem-prone, high-risk area. They stated it was important to reduce infection in order to help reduce recovery time, reduce the use of antibiotics, reduce the likelihood of readmission, and prevent complications so as not to worsen the condition in which patients presented to the facility. This statement was in contrast to the medical records for Patients #2, #3, #7, and #8, who had infections after admission in the FBC, which led to subsequent readmissions and in one case, a patient death (Patient #3). iv. On 10/1/25 at 12:42 p.m., and on 11/19/25 at 2:31 p.m., interviews were conducted with the quality director (Director) #9. Director #9 stated they provided oversight to IP #8 as the infection preventionist and in their former patient safety role. They stated IP #8 relayed all infection prevention concerns and findings to the quality team. Director #9 stated they collaborated with Specialist #11 on quality in the FBC. They stated they had access to the same information, however, Specialist #11 pulled the reports and reviewed the data. This was in contrast to the interview with Specialist #11, who stated they did not have infection prevention responsibilities and did not review the FBC infection data, other than reports of general FBC readmissions. This was in contrast to the QAPI Plan which read, the quality director had QAPI oversight responsibilities including the collection and analysis of data, the ongoing evaluation of service delivery and processes of care, development and implementation of action plans for improvement activities, and provided oversight to the quality team. Director #9 stated PI projects were driven by serious safety events, rounding on units, trends in occurrence reports, and feedback from frontline staff. They stated infections in the FBC were not being tracked or trended by QAPI at this time. Director #9 stated Patient #3 was septic after having a retained placenta (pieces of the placenta were left inside the uterus after delivery) and this infection was not due to the surgery itself. They stated they tracked infections when an OR patient returned to the OR and had not identified trends. This statement was in contrast to a review of the occurrences, which failed to reveal the identification of PI opportunities in the FBC after four patients had infections requiring readmissions (Patients #2, #3, #7, and #8) and one patient death (Patient #3). This interview was in contrast to the QAPI Plan which read, QAPI assured effective systems were in place to monitor and improve clinical quality and effectiveness. QAPI developed and sustained a culture of patient safety, assured the highest quality of care, and identified and analyzed high-risk and problem-prone processes for improvement. The quality director and patient safety officer had QAPI oversight responsibilities including the collection and analysis of data, the ongoing evaluation of service delivery and processes of care, the development and implementation of action plans for improvement activities, and provided oversight to the quality team. v. On 11/19/25 at 2:31 p.m., an interview was conducted with chief nursing officer (CNO) #7. CNO #7 stated QAPI’s focus allowed for improved patient safety as the work was collaborative, multi-disciplinary, and across levels of staff. CNO #7 stated each department’s QAPI work allowed for improved patient safety. They stated it was important for teams to discuss safety events and current concerns to ensure quality patient care. This was in contrast to the interviews with IP #8 and Director #9, which failed to reveal the FBC staff, IP, or quality team had identified opportunities for improvement after four FBC patients were readmitted with infections and one patient died. CNO #7 stated they had not been concerned with infection rates in the FBC, as infections had never been brought to their attention. They stated they had not seen any infection control concerns in the department. This statement was in contrast to the QAPI Plan which read, QAPI assured effective systems were in place to monitor and improve clinical quality and effectiveness. QAPI developed and sustained a culture of patient safety, assured the highest quality of care, and identified and analyzed high-risk and problem-prone processes for improvement. This was also in contrast to the Infection Prevention and Control Plan, which read, the goals for the program were to identify and minimize the risk of acquiring or transmitting infections through surveillance, ongoing risk assessment, and participation in patient safety and quality improvement projects. The facility reviewed the surveillance data to prioritize any identified risks for acquiring and transmitting infections and updated its associated plan of action.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 47962 Based on interviews and document review, the facility failed to ensure the quality assurance and process improvement (QAPI) program analyzed an adverse patient event to identify causative factors and implement preventive actions to protect patient safety. (Cross-reference A-0144 and A-0283) Findings include: Facility policies: According to the Clinical Quality Assurance, Patient Safety, and Process Improvement (QAPI) Plan 2025, the purpose is to provide continual prioritized improvement in the delivery of safe, quality care for all services, which includes the delivery of effective health outcomes through person-centered processes. The Quality and Patient Safety Committee (QPSC) facilitates and oversees the quality and patient safety activities and ensures effective and accountable systems are in place to monitor and improve clinical quality and effectiveness. QAPI maintains an integrated, organization-wide performance improvement (PI) program to maintain high-quality patient care and safety and improve clinical outcomes. The department collects, aggregates, and analyzes data, including understanding current performance and the identification of opportunities for improvement, facilitates the patient safety event review process, including robust investigation of individual cases and analysis and reporting of safety event trends, and the development and implementation of action plans. The quality director has oversight responsibilities including the collection and analysis of data, the ongoing evaluation of service delivery and processes of care, development and implementation of action plans for improvement activities, and provides oversight, guidance, and leadership to the quality team. The overall goals of the quality department are to develop and sustain a culture of patient safety, assure the highest quality of care for all patients, proactively reduce or eliminate risk of harm for patients, identify and analyze high-risk, high-volume, or problem-prone processes for improvement, and provide an optimal, reliable level of care through the reduction and elimination of unnecessary and correctable risks and hazards. According to the Infection Prevention and Control Plan 2025, the program and its surveillance activities are designed to reduce the risk of acquisition and transmission of infections. Facility leadership ensures that infection prevention and control activities are reviewed on an ongoing basis and integrated into patient safety initiatives. The infection prevention program managers are responsible for supervising and coordinating the daily management of the infection prevention and control program. They collect, review, and analyze surveillance data, collaborate with others to identify, report, and investigate infections and communicable diseases, perform ongoing risk assessments, assist with process improvement initiatives, oversee and investigate risk management issues or patient safety concerns, institute appropriate corrective actions, and identify infection risks based on surveillance and other infection control data. The goals and objectives for the program are to identify and minimize or eliminate the risk of acquiring or transmitting infections through the process of surveillance, ongoing risk assessment, and participation in patient safety and quality improvement projects. The infection preventionists will perform the surveillance activities using continuous systematic collection, analysis, interpretation, and dissemination of the data. 1. The facility failed to ensure the QAPI program analyzed an adverse patient event to identify causative factors and implement preventive actions to protect patient safety. A. Document Review i. A review of Patient #3’s medical record revealed Patient #3 was admitted to the family birth center (FBC) on 4/30/25 for a scheduled cesarean section (C-section). During Patient #3’s stay, they developed a smelly yellow discharge, which was not evaluated or treated by the patient’s care team. Patient #3 was readmitted with sepsis (a serious condition in which the body responds improperly to an infection) on 5/12/25, eight days after leaving the hospital. Patient #3 expired on 5/13/25, 10 days after reporting the yellow discharge to staff. (Cross-reference A-0144) ii. A review of facility occurrences (patient safety events) on 9/30/25 at 3:01 p.m. with the infection preventionist (IP) #8, who was also the former patient safety program manager, revealed two occurrences linked to Patient #3’s stay. The first occurrence was related to a concern for missing revenue due to a missed consult when the patient was readmitted with sepsis. The second occurrence was a review of the patient’s code blue (the facility’s emergent and life-saving interventions in response to a patient’s cardiac (heart) or respiratory event). During the review, IP #8 stated the first occurrence was rated a near miss, and appropriate care had been provided. They stated the second occurrence had identified an opportunity for better staff positioning during code blues for bariatric (someone being treated for obesity) patients. IP #8 stated the facility had not performed a root cause analysis (RCA) for Patient #3’s care, as they had focused on their precipitous demise and code blue. IP #8 stated the quality review of Patient #3’s care had focused on their readmission, and the quality team had not identified concerns with Patient #3’s care during their first admission from 4/30/25 to 5/4/25. This review of Patient #3’s occurrences from 4/30/25 to 5/13/25 and interview with IP #8 failed to reveal the facility had reviewed both of Patient #3’s admissions to identify causative factors and PI opportunities, although the patient had reported a symptom consistent with an infection after a surgical procedure and was later readmitted with sepsis before expiring. This was in contrast to the QAPI Plan which read, QAPI assured effective systems were in place to monitor and improve clinical quality and effectiveness. QAPI maintained high-quality patient care and safety, improved clinical outcomes, and understood current performance and the identification of opportunities for improvement. QAPI facilitated the patient safety event review process, including robust investigation of individual cases and analysis, developed and sustained a culture of patient safety, and assured the highest quality of care for all patients B. Interviews i. On 10/1/25 at 10:48 a.m., and on 11/19/25 at 12:26 p.m., interviews were conducted with IP #8. IP #8 stated in their former role they and quality director (Director) #9 reviewed all occurrences, which they defined as safety events. They stated it was important to identify all occurrences as this allowed the facility to understand any gaps in their processes and implement corrective actions. IP #8 stated without safety events being reported as occurrences, the facility would not be aware of individual events, trends in care, and what and where to create positive change. IP #8 stated by investigating and reporting back on each occurrence, the quality team contributed to the protection of patient safety and a safer environment for all. IP #8 stated the facility’s robust reporting system allowed the quality team to identify errors. They stated after compiling the information, they were able to identify the extent of the concern and the person or persons responsible for addressing the concern. IP #8 stated if quality concerns were not addressed, there were missed opportunities to improve patient care. IP #8 stated if a patient returned to the facility with an infection, an occurrence was to be filed, which was in contrast to a review of Patient #3’s record, a review of the occurrences, and their statement on 9/30/25 that no such occurrence was created. Furthermore, these interviews revealed IP #8 had not been aware of gaps in Patient #3’s care relating to the identification and treatment of an infection during their first admission. This lack of identification and investigation of the initial infection, as well as the lack of occurrence reporting once the patient returned with sepsis, was in contrast to the QAPI Plan, which read, QAPI maintained high-quality patient care and safety, improved clinical outcomes, and the identification of opportunities for improvement, including a robust investigation of individual cases. QAPI assured the highest quality of care for all patients. This was also in contrast to the Infection Prevention and Control Plan which read, the IPs identified, reported, and investigated infections and oversaw and investigated patient safety concerns. IP #8 stated it was important to reduce patient infections to keep patients healthy and to reduce the likelihood of readmission or subsequent complications. ii. On 10/1/25 at 12:42 p.m., and on 11/19/25 at 2:31 p.m., interviews were conducted with Director #9. Director #9 stated they provided oversight to IP #8 as the infection preventionist and as the former patient safety program manager. Director #9 stated their review of Patient #3’s care from 4/30/25 to 5/13/25 met their expectations. They stated the provider had evaluated the patient during their initial admission and followed up on the patient’s concern, which was in contrast to a review of Patient #3’s medical record. Director #9 stated quality was driven by serious safety events, which was in contrast to a review of the occurrences, which failed to reveal an occurrence for Patient #3’s readmission for sepsis and subsequent death to investigate and identify causative factors and opportunities for improvement in their first admission. This was also in contrast to the QAPI Plan which read, QAPI maintained high-quality patient care and safety, improved clinical outcomes, and the identification of opportunities for improvement. QAPI assured the highest quality of care for all patients. The quality director had oversight responsibilities, including the ongoing evaluation of service delivery and processes of care, and provided oversight to the quality team. iii. On 11/19/25 at 2:31 p.m., an interview was conducted with chief nursing officer (CNO) #7. CNO #7 stated QAPI’s focus allowed for improved patient safety as the work was collaborative, multi-disciplinary, and clinical and leadership staff. CNO #7 stated Patient #3 had psychosocial challenges and difficulty advocating for their own health care. They stated for Patient #3’s care to be different, Patient #3 would have had to participate in their own care. This statement was in contrast to a review of the medical record which revealed Patient #3 had informed nursing staff of their medical concern and this concern was not addressed. This statement was also in contrast to the QAPI Plan which read, QAPI maintained high-quality patient care and safety, improved clinical outcomes, and the identification of opportunities for improvement. QAPI assured the highest quality of care for all patients.”