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Based on record review and interview, the hospital failed to ensure that medical records were promptly completed. This deficient practice was evidenced by having discharge summaries not completed by the physician within 30 days of discharge for 1 (Patient #7) of 7 records reviewed out of a total sample of 30 records reviewed.
Findings:

Review of Patient #7's medical record on 03/20/2023 revealed an admit date of 01/24/2023 and a discharge date of 01/26/2023. Further review failed to reveal a discharge summary for Patient #7.

In an interview on 03/21/2023 at 9:20 a.m., S6HIM reviewed Patient #7's medical record and confirmed it did not contain a discharge summary.

Based on observation, interview, and record review, the hospital failed to ensure the infection control officer developed a system for controlling infections and communicable diseases of patients. This deficient practice was evidenced by: 1) failing to ensure the glucose meter was disinfected after patient use for 1 (#2) of 1 patient observed for capillary blood glucose sampling; 2) failing to maintain a sanitary environment by not containing construction dust during hospital construction, and 3) failing to maintain a sanitary environment in patient care areas.


Findings:

1) Failing to ensure the glucose meter was disinfected after patient use.

On 03/21/23 at 11:05 a.m. an observation was conducted of S3RN performing a capillary blood glucose on Patient #2. S3RN performed the test and returned the glucose meter back into the holder in the medication room in the nursing station without disinfecting the meter.

Interview on 03/21/23 at 11:15 a.m. with S3RN confirmed that she was finished using the glucose meter and began to prepare the s/s insulin for administering to the patient.

Interview on 03/21/23 at 12:40 p.m. with S2CNO revealed that the glucometer should be disinfected after each use with "Purple Top" Sani-wipes.

2) Failing to maintain a sanitary environment by not containing construction dust during hospital construction.

Review of document titled Infection Control Risk Assessment Matrix of Precautions for Construction & Renovation revealed Class III. 1. Remove or isolate HVAC system in area where work is being done to prevent contamination of duct system. 2. Complete All critical barriers i.e. to seal area from non-work area ...

Observation on 03/21/23 at 8:45 a.m. upon entering hospital, surveyor noticed on the floor white footprints in hallway corridor leading to bathroom by front lobby. Door observed open to room undergoing current construction for new pharmacy location with no barrier noted and no mats on floor to reduce or contain construction dust.

Interview on 03/21/23 at 8:50 a.m. with S2CNO stated that the hospital had ordered sticky mats for the floor for construction but had not come in as of yet. She stated construction began on 03/13/23 and was projected to continue for 4-6 months.

3) On 03/20/23 at 11:20 a.m., a tour of the hospital revealed the max care room had a soiled washcloth on the bathroom sink, a used patient gown in the chair by the bedside, trash in the trash can, debris on the floor and a piece of plastic wrap on the bed.

An interview at this time with S5COO confirmed there had not been a patient in the room in a long time and the room should have been cleaned and ready for new admission within 24 hours after the last patient was discharged.

On 3/20/23 at 11:30 a.m., room a had a bedside toilet that was not covered or labeled as clean in a room designated as clean. S2CNO acknowledged it would be considered dirty since it was not covered with a plastic bag.



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Based on record review and interview, the surgical services failed to assure the achievement and maintenance of high standards of medical practice and patient care as evidenced by not ensuring that the "Timeout Procedure" was conducted prior to the administration of anesthesia for for 2 (#6, #9) of 5 surgery patients reviewed.

Findings:

Review of the hospital's policy for Operative Site Verification revealed, in part: Upon transfer to the O.R. suite, a "Time Out" period should be observed...should be verified with the patient and surgeon verbally one more time prior to anesthesia administration.

Patient #6
Review of the surgical record for Patient #6 with S4RN, Surgical Director, revealed the patient had a laparoscopic cholecystectomy on 03/20/2023.
Review of the Anesthesia Record for Patient #6, completed by S7Anesthesiologist, revealed the initial induction of the anesthesia agents/drugs was recorded as 11:00a.m. There was no documented time noted on the anesthesia record for the "surgical timeout."
Review of the "Timeout" documented in the Nurse Notes revealed it occurred at 11:32a.m, which was 32 minutes after the anesthesia induction was recorded.

Patient #9
Review of the surgical record for Patient #9 with S4RN, Surgical Director, revealed the patient had an excision of a neuroma on 03/20/2023.
Review of the Anesthesia Record for Patient #9, completed by S7Anesthesiologist, revealed the initial induction of the anesthesia agents/drugs was recorded as 8:20a.m. There was no documented time noted on the anesthesia record for the "surgical timeout."
Review of the "Timeout" documented in the Nurse Notes revealed it occurred at 8:52a.m, which was 32 minutes after the anesthesia induction was recorded.

On 03/21/2023 at 2:15p.m., record review and interview with S4RN, Surgical Director, confirmed that the documentation on the Anesthesia Records did not confirm that the "Timeout" procedure was conducted prior to the induction of the anesthesia.

Based on record review and interview, the anesthesiologist failed to execute a properly informed consent for anesthesia for 5 (#6, #9, #10, #11, #12) of 5 surgery patients reviewed.

Findings:

Review of the Patient Consent to Anesthesia Procedures form revealed: I ...You have the right as a patient to be informed about your condition and the recommended anesthetic procedures to be performed upon you; II ...Based upon the information available to us at this time, your anesthetic plan may necessitate the following marked procedures below ...Further review revealed seven listed anesthesia procedures with checkboxes to be marked as optional anesthesia procedures.

Review of the surgical record for Patient #6 with S4RN, Surgical Director, revealed he had a laparoscopic cholecystectomy on 03/20/23. Review of the anesthesia consent form for Patient #6 revealed none of the seven anesthesia procedures was checked, and there was no documented evidence that the patient was informed about which type(s) of anesthesia would be administered.

Review of the surgical record for Patient #9 with S4RN, Surgical Director, revealed he had an excision of a neuroma on 03/20/23. Review of the anesthesia consent form for Patient #9 revealed none of the seven anesthesia procedures was checked, and there was no documented evidence that the patient was informed about which type(s) of anesthesia would be administered.

Review of the surgical records for Patients #10, #11 and #12 with S4RN, Surgical Director, revealed they had colonoscopies on 03/20/23. Review of the anesthesia consent form for Patients #10, #11 and #12 revealed none of the seven anesthesia procedures was checked, and there was no documented evidence that the patient was informed about which type(s) of anesthesia would be administered.

On 03/21/23 at 2:15p.m., record review and interview with S4RN, Surgical Director, confirmed that the Anesthesia Consents for Patients #6, #9, #10, #11 and #12 did not provide documented evidence that they were informed of the type of anesthesia that was planned to be administered.

Based on record review and interview, the hospital failed to ensure that an intraoperative anesthesia record was completed for each patient who received anesthesia as evidenced by failure of the anesthesiologist to identify all drugs and agents used in the administration of anesthesia for 5 (#6, #9, #10, #11, #12) of 5 surgery patients reviewed.

Findings:

Patient #6
Review of the surgical record for Patient #6 with S4RN, Surgical Director, revealed he had a laparoscopic cholecystectomy on 03/20/2023.
Review of the Anesthesia Record for Patient #6, completed by S7Anesthesiologist, revealed a section labeled Agents & Drugs with several options available: Box 1 - Sevo/Des; Box 2 - Fentanyl/Demerol; Box 3- Propofol/Amidate; and, Box 4 - Zemuron/Nimbax. The name of the selected agent/drug administered in each box was not documented - only the dosage was noted.

Patient #9
Review of the surgical record for Patient #9 with S4RN, Surgical Director, revealed he had an excision of a neuroma on 03/20/2023.
Review of the Anesthesia Record for Patient #9, completed by S7Anesthesiologist, revealed a section labeled Agents & Drugs with several options available: Box 1 - Sevo/Des; Box 2 - Fentanyl/Demerol; Box 3- Propofol/Amidate; and, Box 4 - Zemuron/Nimbax. The name of the selected agent/drug administered in each box was not documented - only the dosage was noted.

Review of the surgical records for Patients #10, #11 and #12 with S4RN, Surgical Director, revealed that they had colonoscopies on 03/20/2023.
Review of the Anesthesia Records for Patients #10, #11 and #12, completed by S7Anesthesiologist, revealed a section labeled Agents & Drugs with several options available: Box 1 - Sevo/Des; Box 2 - Fentanyl/Demerol; Box 3- Propofol/Amidate; and, Box 4 - Zemuron/Nimbax. The name of the selected agent/drug administered in each box was not documented - only the dosage was noted.

On 03/21/2023 at 2:15p.m., record review and interview with S4RN, Surgical Director, confirmed that the names of anesthesia agents and/or drugs administered to Patients #6, #9, #10, #11 and #12 were not documented on the Anesthesia Records.

Based on record review and interview, the hospital failed to ensure its Emergency Preparedness Plan that was reviewed and updated at least every 2 years.
Findings:

Review of the hospital's Governing Body Minutes failed to reveal the Emergency Preparedness Plan was reviewed and updated at least every 2 years.

In an interview on 03/22/2023 at 11:20 a.m., S5COO acknowledged there was no documented evidence that the Emergency Preparedness plan had been reviewed and updated in the past 2 years.

Based on review of the facility's emergency preparedness plan and interview, the facility failed to provide a letter of confirmation or certified receipt which indicated that their Emergency Preparedness Plan had been submitted to the local parish Office of Homeland Security and Emergency Preparedness (OHSEP) within the past 2 years.
Findings:

Review of facility's Emergency Preparedness Plan binder failed to reveal verification that the plan had been submitted to the local parish Office of Homeland Security and Emergency Preparedness (OHSEP) within the last 2 years.

During an interview on 03/22/2023 at 11:20 a.m. S5COO acknowledged they had not submitted the facility's Emergency Preparedness Plan to the local parish OHSEP.