HospitalInspections.org

Based on observation, record review and interview, the hospital failed to meet the requirements for the Condition of Participation for Patient Rights as evidenced by:

1) Failing to ensure the safety of patients placed on a Physician Emergency Certificate (PEC) after being assessed/evaluated to be a danger to self and/or a danger to others and/or gravely disabled. The hospital allowed 2 PEC'd patients (Patient #21, #22) to elope from the hospital's Emergency Department (ED) on 01/25/17 and failed to implement corrective action to ensure patients that were PEC'd in the ED received care in a safe setting. This deficient practice had the potential to affect all PEC'd patients in the ED. (See Findings at A-0144)

An Immediate Jeopardy situation was identified on 02/01/17 at 4:15 p.m. due to the hospital failing to implement corrective action to ensure patients that were PEC'd in the ED received care in a safe setting.

S1CNO and S18CEO presented a written corrective action plan for lifting the immediacy of the Immediate Jeopardy situation on 02/01/17 at 5:55 p.m. The written plan was reviewed by the survey team which indicated the following actions had been taken: Effective immediately, the hospital will provide one on one observation of patients under a PEC or CEC order in the Emergency Department. A staff member will be assigned by the ED Charge Nurse and will be dedicated to monitor the patient at all times. Confirmation of appropriate training through the MOAB training module will be verified prior to the assignment. Effective 1725 on 02/01/17, all staff members will receive training specific to one on one observation of PEC and CEC patients and the requirements to go hands on using the current MOAB curriculum if necessary to prevent the patient from leaving the ED. The CNO or designee will be notified of all PEC and CEC patients. The CNO or designee will do visual rounds and a process review within 24 hours of notification which will be integrated into the ED QI process. In the event that a patient under a PEC or CEC order elopes from the ED, the ED charge nurse will immediately notify the local police department and Louisiana Department of Health to notify them of the incident.

Based on interviews and review of the corrective action plan, the Corrective Action Plan was accepted on 02/01/17 at 5:55 p.m. The Immediacy of the Immediate Jeopardy situation was lifted though there was not enough evidence to determine sustainability of Compliance for the Condition of Patient Rights to be cleared. Noncompliance remains at the Condition Level.

Based on record review and interview, the hospital failed to ensure that the grievance process was implemented as evidenced by failing to thoroughly investigate grievances for 4 of 4 patient grievances reviewed (Patient #21, 22, 23, 24)
Findings:

Review of the hospital policy titled, Procedure for Acting on Patient Complaints/Grievances (Policy number 09.13.01) revealed in part that the following actions will be performed on all patient complaints: Investigation of the problem area immediately, comments submitted by the employee involved in the patient complaint and any action taken, collection of all pertinent data pertaining to the patient complaint. All investigative documentation to a complaint should be written on a "Complaint Analysis Record to Quality Improvement Committee" form. Documentation should include any action taken. In the event the complaint is of a serious nature, the Administrator will be notified.

Patient #21 and #22
Review of the "Patient Complaint" form dated 01/26/17 and completed by S6RN/Director of Quality revealed that the mother of Patients #21 and #22 complained that that her children had left the ED on 01/25/17 after being PEC'd and ran home over two miles. The mother further complained that the ED staff did not notify her that the children had eloped.

Further review of the "Patient Complaint" form revealed under the area titled "Findings": Nurses stated that security had been in and out of the ED but did not stay with the patients. Nurses stated that the CNO had told them that we did not have the staff to continuously monitor PEC'd patients in the ED. Under the area on the form titled "What could be done to prevent reoccurrence of similar situation", the area was left blank.

On 02/01/17 at 10:10 a.m., interview with S6RN/Director of Quality revealed that there were no written statements obtained from the staff involved in the incident. She further stated that there was no further documented investigation regarding the incident. Further interview with S6RN/Director of Quality revealed that the hospital has put no system in place to ensure that PEC'd patients in the ED were properly supervised after becoming aware of the situation involving Patients #21 and #22.

Patient #23
Review of the "Patient Complaint" form dated 01/23/17 and completed by S6RN/Director of Quality revealed that the son of the patient called and complained that the patient was seen in the ED on 01/18/17 after falling in the bathtub and hitting her head. The patient's son stated that the patient was discharged home from the ED and died later that night.

Further review of the "Patient Complaint" form revealed the area titled "Findings" stated: CT shows no evidence of stroke. Patient was instructed to return to ED if other symptoms occurred. ER care was appropriate. A copy of the patient's ED record was stapled to the form.

On 02/01/17 at 10:40 a.m., interview with S6RN/Director of Quality revealed that she talked to the ED nurse who took care of the patient that day, but there was no documented evidence of this. She stated that she reviewed the patient's record and determined that the care was appropriate. She further confirmed that there was no further investigation regarding the above patient complaint.

Patient #24
Review of the "Patient Complaint" form dated 01/17/17 and completed by S6RN/Director of Quality revealed the mother of the patient called and complained that the patient needed a blood transfusion and did not get it and was discharged home with a low hemoglobin and hematocrit. The patient was later readmitted and received blood and fluids related to dehydration.

Further review of the "Patient Complaint" form revealed that S6RN/Director of Quality documented that she has "already addressed this with the patient and her husband. The patient's mother was in the room when I talked with patient and her husband."

On 02/01/17 at 11:00 a.m., interview with S6RN/Director of Quality revealed that another one of the patient's family members had complained of poor care in the past and when she talked to the patient then, the patient stated her care was good, so she did not investigate this complaint.

Further interview with S6RN/Director of Quality on 02/01/17 at 11:40 a.m. confirmed that thorough investigations were not completed for the above patient complaints. She further stated that she was new to this position and was doing the best that she could.

Based on observation, record review and interview, the hospital

1) failed to ensure that patients received care in a safe setting by not ensuring the safety of patients placed on a Physicians Emergency Certificate (PEC) after the patients were assessed/evaluated to be a danger to self and/or danger to others and/or gravely disabled. This was evidenced by allowing 2 PEC'd patients (Patient #21, #22) to elope from the hospital's Emergency Department (ED) on 01/25/17 and failing to implement corrective action to ensure patients that were PEC'd in the ED received care in a safe setting.; and

2) failed to ensure the safety and security of newborns. This deficient practice was evidenced by failure of the hospital to initiate measures to reduce the risk of infant abduction when the infants were in the mother's hospital room, in the unsecured/unlocked Obstetrical Unit, after delivery.
Findings:
1) Failed to ensure the safety of patients placed on a Physicians Emergency Certificate (PEC) after the patients were assessed/evaluated to be a danger to self and/or danger to others and/or gravely disabled.
Observations on 01/30/17 at 12:45 p.m. of the Emergency Department revealed a room across from the nursing station. Interview with S13RN, during the observations, revealed this room was designated as a holding room for psychiatric patients who were awaiting transfer to a psychiatric facility for admission. According to S13RN, personnel would be assigned to observe the psychiatric patient and either be within arms length of the patient or stationed immediately outside the ED room.

Review of the hospital policy titled Psychiatric Patients in the Emergency Department, Policy number 16.08.00 with a policy start date of 11/2016, revealed it included the following elements. After the PEC is signed by the physician, the patient should be placed in a room while awaiting transfer that has been made safe. Observation documentation should occur every 15 minutes to include the patient's location, activity and behavior. Observation monitoring of psychiatric patients can be delegated from the patient's nurse to appropriate unlicensed staff and the patient's nurse retains accountability and supervision.

Patient #21
Review of the record revealed the patient was a 16 year old female who presented to the ED with her mother on 01/25/17 at 11:19 a.m. with complaints of hearing voices in her head that "tells me to hurt others". Review of the nurses note dated 01/25/17 at 12:08 p.m. revealed the patient had suicidal thinking present with past attempts at suicide.

Further review of the record revealed S17ED Physician examined the patient on 01/25/17 at 12:38 p.m. and signed a PEC dated 01/25/17 and timed 2:50 p.m. Review of the PEC revealed the patient was having auditory hallucinations and was a danger to herself.

Review of the nurses notes dated 01/25/17 at 3:00 p.m. revealed the patient "ran out of the ER EMS doors" and that the sheriff was notified. The notes further revealed that the patient was returned to the ED by the local police at 7:15 p.m. (over 4 hours later).

Review of the patient's "ER Observation Flowsheet" dated 01/25/17 revealed documentation by S9RN that observations were made of the patient every 15 minutes from 12:30 p.m. until 6:30 p.m. The documentation of behaviors during the above times revealed the patient was either quiet, lying or sitting, standing still, or walking/pacing. Further review of the "ER Observation Flowsheet" dated 01/25/17 revealed that S9RN documented from 6:30 p.m. thru 7:00 p.m., "patient left". The documentation of every 15 minute observations picked back up at 7:15 p.m. on 01/25/17 by the oncoming nurse.

Further review of the record revealed that after multiple attempts to transfer the patient to a psychiatric hospital, the coroner evaluated the patient on 01/27/17 at 2:40 p.m. and released the patient from the PEC to to be discharged home with her mother.


Patient #22
Review of the record revealed the patient was a 15 year old male who presented to the ED with his mother on 01/25/17 at 11:22 a.m. with a presenting complaint of "I black out and hurt myself". Review of the nurses note dated 01/25/17 at 12:04 p.m. revealed the patient had suicidal thinking present with past attempts at suicide.

Further review of the record revealed S17ED Physician examined the patient on 01/25/17 at 12:15 p.m. and signed a PEC on 01/25/17 at 2:30 p.m. Review of the PEC revealed the patient was violent and a danger to himself.

Review of the nurses notes dated 01/25/17 at 6:38 p.m. revealed that S9RN called the sheriffs office to notify them that the patient left the ED. The notes further stated that the city police was also called at that time. The notes further revealed that the patient was returned to the ED by the police at 7:15 p.m. on 01/25/17.

Review of the patient's "ER Observation Flowsheet" dated 01/25/17 revealed documentation by S9RN that observations were made of the patient every 15 minutes from 12:15 p.m. until 6:30 p.m. The documentation of behaviors during the above times revealed the patient was either quiet, lying or sitting, standing still, or walking/pacing. Further review of the "ER Observation Flowsheet" dated 01/25/17 revealed that S9RN documented from 6:30 p.m. thru 7:00 p.m., "patient left". The documentation of every 15 minute observations picked back up at 7:15 p.m. on 01/25/17 by the oncoming nurse.

Further review of the record revealed that the patient was transferred from the ED to a psychiatric hospital on 01/26/17 at 5:15 p.m.

On 02/01/17 at 2:00 p.m., an interview was conducted with S9RN. He stated that he was the nurse for patients #21 and #22 on 01/25/17. He stated that after the physician signed the PEC, the patients were placed in a room together in the ED that was used for PEC'd patients. He further stated that there was no staff assigned to constantly monitor the patients and he was also assigned other patients to care for in the ED at that time. S9RN stated that he was working on a pediatric patient who was in respiratory distress when he was notified by either another patient or another staff member (he could not remember) that both patients had ran out of the ED door. S9RN reviewed the records for Patients #21 and #22 and confirmed that he had documented that Patient #21 eloped at 3:00 p.m. on 01/25/17 and returned at 7:15 p.m. He confirmed that there was no documentation of Patient #22 eloping at the same time. He further confirmed that he had documented observations of the patients during the time that they were gone. S9RN stated that when he returned back to work the next morning, on 01/26/17, the patients remained in the same room without constant supervision.

Further interview with S9RN on 02/01/17 at 2:00 p.m. revealed that the ED staff was told by administration that due to budgetary constraints, sitters and/or security guards were not to be utilized by the ED staff to supervise the PEC'd patients. He further stated that he was unaware that he could physically place his hands on PEC'd patients in order to keep them in the ED.

On 02/01/17 at 10:10 a.m., interview with S6RN/Director of Quality revealed that the mother of Patients #21 and #22 had called her on 01/26/17 with a complaint that her children had left the ED on 01/25/17 after being PEC'd and ran home over two miles. The mother further complained that the ED staff did not notify her that the children had eloped.

Review of the "Patient Complaint" form dated 01/26/17 and completed by S6RN/Director of Quality revealed under the area titled "Findings": Nurses stated that security had been in and out of the ED but did not stay with the patients. Nurses stated that the CNO had told them that we did not have the staff to continuously monitor PEC'd patients in the ED. Under the area on the form titled "What could be done to prevent reoccurrence of similar situation", the area was left blank.

Further interview with S6RN/Director of Quality revealed that the hospital has put no system in place to ensure that PEC'd patients in the ED were properly supervised after becoming aware of the situation involving Patients #21 and #22.

Interview with S1CNO on 02/01/17 at 2:00 p.m. confirmed that if a psychiatric patient was in the ED under a PEC, nursing staff could not "touch" the psychiatric patient and prevent the patient from leaving the hospital.


2) Failed to ensure the safety and security of newborns by failure to initiate measures to reduce the risk of infant abduction when the infants were in the mother's hospital room, in the unsecured/unlocked Obstetrical Unit, after delivery.

An observation was made of the hospital ' s Obstetrical Unit on 1/30/17 at 2:00 p.m. The unit was not locked and no type of secured entry mechanism (such as keycard or keypad) was noted at the entry to the unit. The post-partum mothers were housed on the Obstetrical Unit after delivery. Infants were brought out in cribs from the nursery, to their mothers ' rooms, after delivery.
In an interview on 1/30/17 at 2:00 p.m., during the observation, S1CNO confirmed the post-partum mothers were housed on the Obstetrical Unit after delivery. She reported the infants were brought out to their mothers ' rooms in cribs. S1CNO confirmed the unit was an open unit. S1CNO also confirmed there was no infant security system, currently in place, to reduce the risk of infant abductions when the newborns were in the room with their mothers on the Obstetrical Unit. S1CNO agreed an infant could be removed from the mother's room on the Obstetrical Unit if the mother was asleep and the nurses were busy.

Based on record review and interview, the hospital failed to ensure any incidents of abuse, neglect, and/or harassment were reported and analyzed, and the hospital was in compliance with applicable local, State, and Federal Laws and Regulations. This deficient practice was evidenced by the hospitals failure to investigate an incident involving the lack of supervision of 2 patients (#21, #22) who were PEC'd in the Emergency Department resulting in them eloping from the hospital and failing to report the allegation of neglect to the Louisiana Department of Health within 24 hours.
Findings:

Review of La R.S. 40:2009.20 revealed the following:
A. As used in this Section, the following terms shall mean:
(2) "Neglect" is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer's well-being.
B.(1) Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, licensed practical nurse, nurse's aide, personal care attendant, respite worker, physician's assistant, physical therapist, or any other direct caregiver having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department....

Patient #21
Review of the record revealed the patient was a 16 year old female who presented to the ED with her mother on 01/25/17 at 11:19 a.m. with complaints of hearing voices in her head that "tells me to hurt others". Review of the nurses note dated 01/25/17 at 12:08 p.m. revealed the patient had suicidal thinking present with past attempts at suicide.

Further review of the record revealed S17ED Physician examined the patient on 01/25/17 at 12:38 p.m. and signed a PEC dated 01/25/17 and timed 2:50 p.m. Review of the PEC revealed the patient was having auditory hallucinations and was a danger to herself.

Review of the nurses notes dated 01/25/17 at 3:00 p.m. revealed the patient "ran out of the ER EMS doors" and that the sheriff was notified. The notes further revealed that the patient was returned to the ED by the local police at 7:15 p.m. (over 4 hours later).

Patient #22
Review of the record revealed the patient was a 15 year old male who presented to the ED with his mother on 01/25/17 at 11:22 a.m. with a presenting complaint of "I black out and hurt myself". Review of the nurses note dated 01/25/17 at 12:04 p.m. revealed the patient had suicidal thinking present with past attempts at suicide.

Further review of the record revealed S17ED Physician examined the patient on 01/25/17 at 12:15 p.m. and signed a PEC on 01/25/17 at 2:30 p.m. Review of the PEC revealed the patient was violent and a danger to himself.

Review of the nurses notes dated 01/25/17 at 6:38 p.m. revealed that S9RN called the sheriffs office to notify them that the patient left the ED. The notes further stated that the city police was also called at that time. The notes further revealed that the patient was returned to the ED by the police at 7:15 p.m. on 01/25/17.

On 02/01/17 at 10:10 a.m., interview with S6RN/Director of Quality revealed that the mother of Patients #21 and #22 had called her on 01/26/17 with a complaint that her children had left the ED on 01/25/17 after being PEC'd and ran home over two miles. The mother further complained that the ED staff did not notify her that the children had eloped.

Review of the "Patient Complaint" form dated 01/26/17 and completed by S6RN/Director of Quality revealed under the area titled "Findings": Nurses stated that security had been in and out of the ED but did not stay with the patients. Nurses stated that the CNO had told them that we did not have the staff to continuously monitor PEC'd patients in the ED. Under the area on the form titled "What could be done to prevent reoccurrence of similar situation", the area was left blank.

Further interview with S6RN/Director of Quality revealed that the hospital has put no system in place to ensure that PEC'd patients in the ED were properly supervised after becoming aware of the situation involving Patients #21 and #22. She further confirmed that the incident was not reported to the Louisiana Department of Health, because she was not aware that it was to be reported.

Based on record review and interview, the hospital failed to ensure the hospital's Quality Program identified opportunities for improvement and change that would lead to improvement in patient safety and quality of care. This deficient practice was evidenced by the hospital's failure to identify and develop corrective actions related to:

1) safety and supervision of Physicians Emergency Certificate (PEC) patient's in the ED to prevent patient elopement for 2 (#21,#22) of 2 patients reviewed for elopement out of a total patient sample of 35 patients.;

2) safety and security of newborns to reduce the risk of infant abduction when the infants were in the mother's hospital room,after delivery, in the unsecured/unlocked Obstetrical Unit.; and

3) failure of the hospital to assign a designated staff member whose sole responsibility was to monitor telemetry patients on continuous cardiac monitoring for 1 (#20) of 1 total patients observed on ordered continuous cardiac (Telemetry) monitoring out of a total patient sample of 35.

Findings:

1) Safety and supervision of Physicians Emergency Certificate (PEC) patient's in the ED to prevent patient elopement.

Review of the hospital's complaints and grievances revealed a complaint, dated 01/26/17, from a mother indicating that her two children (Patients #21 and #22) had left the ED on 01/25/17 after being PEC'd and ran home over two miles. The mother also indicated in the complaint that the ED staff had not notified her that the children had eloped from the hospital. Further review of the complaint intake revealed in part: Findings: Nurses stated that security had been in and out of the ED but did not stay with the patients. Nurses stated that the CNO had told them that we did not have the staff to continuously monitor PEC'd patients in the ED. The portion of the complaint form titled "What could be done to prevent re-occurrence of similar situation" was left blank.

In an interview on 02/01/17 at 10:10 a.m., with S6RN/Director of Quality she reported that the mother of Patients #21 and #22 had called her on 01/26/17 with a complaint that her children had left the ED on 01/25/17 after being PEC'd. The mother also indicated no one had notified her of the elopement. She reported the children ran home over two miles. S6RN/Director of Quality revealed that the hospital had put no system in place to ensure that PEC'd patients in the ED were properly supervised after becoming aware of the situation involving Patients #21 and #22.

In an interview on 02/01/17 at 12:30 p.m. with S6RN/Director of Quality, she confirmed the above referenced issue with supervision of PEC patients in the ED/patient elopement had not been identified as a problem to be addressed through the hospital's quality program.

2) Safety and security of newborns to reduce the risk of infant abduction when the infants were in the mothers' hospital room, after delivery, in the unsecured/unlocked Obstetrical Unit, .

An observation was made of the hospital's Obstetrical Unit on 1/30/17 at 2:00 p.m. The unit was not locked and no type of secured entry mechanism (such as keycard or keypad) was noted at the entry to the unit. The post-partum mothers were housed on the Obstetrical Unit after delivery. Infants were brought out in cribs from the nursery, to their mothers' rooms, after delivery.

In an interview on 1/30/17 at 2:00 p.m., during the observation, S1CNO confirmed the post-partum mothers were housed on the Obstetrical Unit after delivery. She reported the infants were brought out to their mothers ' rooms in cribs. S1CNO confirmed the unit was an open unit. S1CNO also confirmed there was no infant security system, currently in place, to reduce the risk of infant abductions when the newborns were in the room with their mothers on the Obstetrical Unit. S1CNO agreed an infant could be removed from the mother's room on the Obstetrical Unit if the mother was asleep and the nurses were busy.

In an interview on 02/01/17 at 12:35 p.m. with S6RN/Director of Quality, she confirmed the above referenced issue with the hospital's Obstetrical Unit being an unsecured and unlocked unit leaving infants at increased risk for abduction from the mothers' rooms had not been identified as a performance improvement issue to be addressed through the hospital's quality program.

3) failure of the hospital to assign a designated staff member whose sole responsibility was to monitor telemetry patients on continuous cardiac monitoring.

On 1/30/17 from 1:55 p.m. - 2:05 p.m. an observation was made of the hospital's Intensive Care Unit. A large, double screened monitor was noted on the desk in the nurses' station. S4RN indicated, during the observation, that there were 8 ICU beds and 4 Telemetry capable beds that could be monitored on the double screened monitor at one time. No staff member was noted to be continuously observing the telemetry monitor during the observation.

Review of the medical record for Patient #20 revealed the patient was on ordered continuous cardiac monitoring at the time of the observation referenced above. S2RN confirmed Patient #20 had been placed on telemetry on 1/30/17 at 12:03 p.m. Patient #20 was the only patient currently on ordered Telemetry at the time of the observation.

In an interview on 1/30/17 at 1:50 p.m. with S4RN, she confirmed the ICU nurses were responsible for monitoring all patients on ordered telemetry as well as responsible for the care and monitoring of their own assigned ICU patients. S4RN indicated there were 4 rooms with Telemetry monitoring capabilities. S4RN also confirmed there was no one designated staff member with the sole responsibility of continuously monitoring the telemetry patients.

In an interview on 02/01/17 at 12:38 p.m. with S6RN/Director of Quality, she confirmed the above referenced issue with failure to designate one staff member with the sole responsibility of continuously monitoring the telemetry patients had not been identified as a performance improvement issue to be addressed through the hospital's quality program.

Based on record review, observation and staff interview, the Hospital failed to ensure a registered nurse (RN) assigned the nursing care of each patient to other nursing personnel according to the needs of the patient and the qualifications and competence of the available staff. This deficient practice was evidenced by 1) failure to ensure competency evaluations for Propofol infusion administration were documented for 3 (S3RN, S4RN, S14RN) of 3 ICU RN personnel allowed to administer Propofol in the ICU setting; and 2) failure to assign a designated staff member whose sole responsibility was to monitor telemetry patients on continuous cardiac monitoring for 1 (#20) of 1 total patients observed on ordered continuous cardiac (Telemetry) monitoring.
Findings:
1) Failure to ensure competency evaluations for Propofol infusion administration were documented.
Review of the Louisiana State Board of Nursing, "Declaratory Statement on the Role and Scope of Practice of the Registered Nurse in the Administration of Medication and Monitoring of Patients During the Levels of Procedural Sedation (Minimal, Moderate, Deep, and Anesthesia) as Defined Herein" revealed in part the following: Position Statement, March 17, 2004.....The Registered nurse (non-CRNA) (Certified Registered Nurse Anesthetist) shall have documented education and competency to include: A. Knowledge of sedative drugs and reversal agents, their dosing and physiologic effects. Advanced Cardiac Life Support....Skill in establishing an open airway, head-tilt, chin lift, use of bag-valve-mask device, oral and nasal airways, and emergency procedures. This includes rescuing a patient that may progress beyond deep sedation. Demonstration of the acquired knowledge of anatomy, physiology, pharmacology, and basic cardiac arrhythmia recognition; recognize complications of undesired outcomes related to sedation/analgesia; demonstrated appropriate interventions in compliance with standards of practice, emergency protocols, or guidelines....
B. Competencies will be measured initially during orientation and on an annual basis....
S3RN
In an interview on 1/30/17 at 1:54 p.m. with S3RN (ICU), she confirmed she had administered Propofol to patients in the ICU.

Review of S3RN's personnel record revealed no documented evidence of competency evaluations for Propofol infusion administration.

S4RN
In an interview on 1/30/17 at 1:55 p.m. with S4RN (ICU), she confirmed she had administered Propofol to patients in the ICU.

Review of S4RN's personnel record revealed no documented evidence of competency evaluations for Propofol infusion administration.

S14RN (ICU)
Review of Patient #5's medical record revealed S14RN had administered Propofol to the patient.

Review of S14RN's personnel record revealed no documented evidence of competency evaluations for Propofol infusion administration.

In an interview on 2/1/17 at 4:00 p.m. with S1CNO, she indicated competency evaluations for Propofol infusion administration should have been found in nursing personnel records. S1CNO further indicated if the personnel records of the above referenced staff did not contain competency evaluations then the staff did not have documented competency evaluations for Propofol administration.

2) Failure to assign a designated staff member whose sole responsibility was to monitor telemetry patients on continuous cardiac monitoring.

Review of the Hospital policy titled, " Monitoring System " , policy number ICU 13.15.02, revealed in part: Purpose: To allow constant observance of heart rhythm; To give a tracing of a patient's heart pattern for medical records or examining the strip for learning purposes; To be able to observe sudden changes in the patient's heart pattern which may be life threatening and be able to act appropriately.
Designated personnel: ICU trained personnel.

On 1/30/17 from 1:55 p.m. - 2:05 p.m. an observation was made of the hospital's Intensive Care Unit. A large, double screened monitor was noted on the desk in the nurses' station. S4RN indicated, during the observation, that there were 8 ICU beds and 4 Telemetry capable beds that could be monitored on the double screened monitor at one time. She further indicated one of the Telemetry capable beds was located in the ICU and the other three were located in the hallway outside of the ICU. No staff member was noted to be continuously observing the telemetry monitor during the observation.
Review of the medical record for Patient #20 revealed the patient was on ordered continuous cardiac monitoring at the time of the observation referenced above. S2RN confirmed Patient #20 had been placed on telemetry on 1/30/17 at 12:03 p.m. Patient #20 was the only patient currently on ordered Telemetry at the time of the observation.
In an interview on 1/30/17 at 1:50 p.m. with S4RN, she confirmed the ICU nurses were responsible for monitoring all patients on ordered telemetry as well as responsible for the care and monitoring of their own assigned ICU patients. S4RN indicated there were 4 rooms with Telemetry monitoring capabilities. S4RN also confirmed there was no one designated staff member with the sole responsibility of continuously monitoring the telemetry patients.

Based on policy review and interview, the Hospital failed to ensure all prescriber's orders were reviewed for appropriateness by a pharmacist before the first dose of ordered medications were dispensed.
Findings:
Review of the Louisiana Administrative Code, Title 46 Professional and Occupational Standards, Part LIII Pharmacist, Chapter 15 Hospital Pharmacy, Section: 1511: Prescription Drug Orders, Item A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial dose of medication, except in cases of emergency.
Review of the hospital's policy titled, "Documentation of Clinical Interventions", revealed in part: Policy: 1. New Medication Orders: As they receive each new medication order, the pharmacist reviews it against the patient's medication profile for appropriate dose; potential drug/drug or food/drug interactions; formulary status of the prescribed therapy; appropriateness of the therapy for the patient's age and clinical condition; and other pertinent clinical data.
In an interview on 1/31/17 at 2:00 p.m. with S2RN, she confirmed the hospital did not have a 24 hour pharmacy. She indicated when an initial dose of a new medication (that was not an emergent medication) was ordered for a patient after pharmacy hours, the staff pulled the new medication from the automated medication dispense system and administered it without prior review by the pharmacist. She indicated the new medication was reviewed by the pharmacist the next day, after the initial dose had already been administered to the patient.
In an interview on 1/31/17 at 4:00 p.m. with S7Pharmacist, she indicated the pharmacy hours were Monday - Friday 7:30 a.m. - 5:30 p.m. with a pharmacist on call after hours. S7Pharmacist also confirmed first dose review was not performed on medications ordered after hours. She reported the new medication orders were reviewed the next morning.
In an interview on 2/1/17 at 3:00 p.m. with S16Pharmacist, he confirmed the hospital did not have a 24 hour pharmacy. He also confirmed the pharmacists were not presently conducting first dose review prior to patients receiving the initial doses of the medication that were ordered after hours. He acknowledged first dose review should have been performed prior to patients receiving the initial dose of a new medication if the ordered medication was not an emergent medication.

Based on record review and interview, the Hospital failed to ensure identified medication errors were documented in the patient's electronic medical record for 2 (# 7, #9 ) of 2 hospital identified medication errors reviewed.
Findings:
Patient #7
Review of the hospital ' s medication variance reports revealed on 9/12/16 at 9:00 a.m. Patient #7 had received an infusion of a premixed bag of Clindamycin 900mg (milligrams)/50ml (milliliters) that had been mislabeled by the pharmacist as Levofloxacin 750 mg. The patient's order was for Levofloxacin 750 mg. The error was discovered on the day shift of 9/13/16 when the bag was removed to hang a new bag.

Review of Patient #7 ' s medical record revealed no documented evidence that the above mentioned medication error had been documented in the patient's medical record.

Patient #9
Review of the hospital's medication variance reports revealed on 5/3/16 at 2:57 p.m. Patient #9 had received Stadol 1 mg and Phenergan 25 mg administered IV (Intravenously) instead of IM (intramuscularly) as ordered per physician order. The patient became over sedated with altered mental status. The patient had required treatment with Narcan 4 mg IVP (intravenous push) for narcotic reversal. The patient was admitted to Telemetry for observation and discharged less than 24 hours later.

Review of Patient #9 ' s medical record revealed no documented evidence that the above mentioned medication error had been documented in the patient's medical record.
In an interview on 1/31/17 at 1:52 p.m. with S1CNO, she confirmed the medication errors referenced above (Patients #7 and #9) had not been documented in the patient's medical record.

Based on observation and interview, the Hospital failed to ensure hospital equipment was maintained in such a manner to assure the safety and well being of patients. This deficient practice was evidenced by the hospital having patient beds with a nurse call feature on the handrails that was non-functional available for patient use for a total of 35 inpatient beds (26 beds located on the 2nd floor [medical unit] and 9 beds located in the Intensive Care Unit).

Findings:

Observations made on 1/30/17 between 1:45 p.m. and 2:15 p.m., accompanied by S1CNO, revealed patient beds that had a non-functional nurse call feature (a red cross-shaped symbol located on the side rail of the beds) were available for patient use. During the observation a corded nurse call light was also observed to be attached to the wall in the inpatient rooms. S1CNO indicated the corded nurse call light was the functional nurse call system to be utilized by patients when calling a nurse for assistance.

In an interview on 1/31/17 at 2:30 p.m. with S2RN, she indicated 35 inpatient beds total (26 beds located on the 2nd floor of the hospital and 9 located in the ICU) had the non-functional nurse call buttons located on the side-rail. She indicated the nurse call buttons on the side rail of the bed could be functional, but the patient rooms where they were located only had one receptacle available for plugging in the equipment. She said either the corded call system or the bed side-rail nurse call system could be utilized separately, but both systems could not be utilized at the same time. S2RN indicated patients were oriented to use the corded nurse call system. She agreed having a non-functional nurse call feature on the side rail could cause confusion for a patient when attempting to call a nurse for assistance.

Based on record review and interview, the hospital failed to document the discharge planning evaluation in the patient's medical record in a timely manner for 4 (Patient #25, #26, #27, #29) of 6 (Patient #8, #25, #26, #27, #28, #29) patients reviewed for discharge planning needs.
Findings:

Review of the hospital's policy and procedure for Discharge Planning Assessment (BE03.01.01) revealed: Discharge planning begins on admission with the patient and family and will be documented in the EHR (electronic health record). The discharge plan will be updated as the patient's needs change.
Further review of the policy revealed: Evaluation by CRM (Clinical Resource Manager) of the patient and their daily progress should give the case manager information on the patient's functional ability. The patient should be interviewed by CRM using the discharge assessment tool in the EHR. Evaluation should be ongoing.

Patient #25:
Review of the medical record for patient #25 revealed she was admitted to the hospital 01/25/17 and discharged to a nursing home on 01/31/17 for therapy. There was no documented evidence of a discharge assessment or discharge plan on the medical record.

Patient #26:
Review of the medical record for patient #26 revealed she was admitted 01/29/17 and remained in the hospital as of 02/01/17. There was no documented evidence of a discharge assessment or discharge plan in the medical record.

Patient #27:
Review of the medical record for patient #27 revealed he was admitted 01/20/17. The discharge assessment was not documented until 10 days later on 01/30/17, with a progress note dated the same day indicating a plan for discharge to home with home health and intravenous antibiotics.

Patient #29:
Review of the medical record for patient #29 revealed she was admitted 12/01/16 from a nursing home and discharged back to the nursing home on 12/07/16. The discharge assessment was not documented until 12/05/17.

On 2/01/17 at 10:00 a.m. an interview with S10RN/Case Manager confirmed that she did not document her assessments in the EHR at the time she interviewed the patients and family for the initial assessment. She further confirmed that there was nothing documented on paper to show her assessment data and discharge planning activities or daily progress of the patient. She stated she just has the information "in her head" and sums it up in the EHR whenever she can get to it.

Based on observation, record review and interview, the Hospital failed to ensure individualized Swing Bed Activity Care Plans were developed and Swing Bed Activity Progress Notes were documented as set forth in the Hospital's Swing Bed policies/procedures for 2 (#6,#8) of 2 swing bed patients reviewed out of a total patient sample of 35.

Findings:

Review of the Hospital's Swing Bed Handbook (procedures) revealed in part: Activity Care Plan: After completion of the Initial Activity Assessment, the Activity Care Plan is completed by the Certified Recreational Activities Director. The form is used to indicate the patient's problems, goals, and interventions. Multiple selections in each category can be made ...The next selection is the evaluation. An evaluation of the patient's progress is conducted at least once a week or as needed.
Progress Note: A progress note is completed each time staff comes in contact with the Swing Bed patient when the interaction is related to activity. The progress note can include any of the following: type of activity, type of participation, frequency of participation, reaction to the activity, level of participation, interaction, behavior, family involvement, independent pursuits, and progress toward care goals. Either the Certified Recreational Activities Director or Activities Assistant can complete this form.
Daily Participation Record: This form is used to indicate actual activities the patient participates in.

Patient #6
Review of Patient #6's medical record revealed the patient was admitted to Swing Bed status on 12/13/16 and discharged home on 12/16/16.

Review of Patient #6's Swing Bed Initial Activity Assessment, dated 12/15/16, revealed the patient was assessed as somewhat active, with good hearing, and good visual ability. Further review revealed the patient was oriented to person, place, time, and situation. Additional review revealed the patient was able to understand others and had adequate short-term memory and good long-term memory.

Review of Patient #6's Swing Bed Plan of Care revealed no documented evidence of establishment of an individualized activities plan with types and frequencies of activities, goals and interventions to meet the patient's activity needs.

Additional review of Patient #6's medical record, assisted by S10RN/CaseManager, revealed no documented evidence of Patient Activity Progress Notes (A progress note was to be completed each time staff comes in contact with the Swing Bed patient when the interaction is related to activity).

Patient #8
Review of Patient #8's medical record revealed the patient was admitted to swing bed status on 01/05/17 and discharged to Hospice on 01/13/17.

Review of Patient #8's Swing Bed Initial Activity Assessment, dated 01/06/17, revealed the patient was assessed as moderately active, with good hearing and good visual ability. Further review revealed the patient was also assessed as being oriented to person, place, time and situation. Additional review revealed the patient was able to understand others and had good short-term and long-term memory with no listed barriers to participating in activities.

Review of Patient #8's Swing Bed Plan of Care revealed no documented evidence of establishment of an individualized activities plan with types and frequencies of activities, goals and interventions to meet the patient's activity needs.

Additional review of Patient #8's medical record, assisted by S10RN/CaseManager, revealed no documented evidence of Patient Activity Progress Notes (A progress note was to be completed each time staff comes in contact with the Swing Bed patient when the interaction is related to activity per the Hospital's Swing Bed policies/procedures).

In an interview on 02/01/17 at 3:00 p.m. with S10RN/CaseManager, she confirmed there were no scheduled Swing Bed patient group activities. S10RN/CaseManager indicated all Swing Bed patient activities were individual. S10RN/CaseManager reported she only performed an Initial Swing Bed Activities Assessment. She confirmed she does not formulate an individualized Swing Bed Activity Care Plan. S10RN/CaseManager indicated the nursing staff created the Swing Bed Activity Care Plan. She said the aides conducted the Swing Bed patient activities and they would have been the staff members who would have written Swing Bed Patient Activity Progress Notes.

In an interview on 02/01/17 at 3:10 p.m. with S10RN/CaseManager, she confirmed (after speaking with one of the nurse aides who conducted patient activities) the aides who were performing Swing Bed patient activities were not documenting patient participation/evaluating patient response on Swing Bed Activity Progress Notes as she had thought. She confirmed the above referenced Swing Bed patients (#6, #8) did not have Swing Bed Activity Progress Notes. She confirmed Swing Bed Activity Progress notes should have been written. She agreed the Swing Bed Activity care plans referenced above did not have types and frequencies of activities with goals and interventions.