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Based on interview, record review, and observation, the hospital failed to ensure the storage, handling, dispensing, and administering of drugs and biologicals were implemented according to accepted professional principles, hospital policy, and the Louisiana State Board of Pharmacy. This deficient practice was evidenced by:
1) the hospital failed to ensure its policies and procedures and hospital practice for dispensing and administering medications and biologicals followed the requirements of the Louisiana State Board of Pharmacy regarding the pharmacist's review of medication orders prior to the first dose being administered except in emergencies. The hospital policies and practice allowed medications to be administered prior to the pharmacist's review when the pharmacy was closed or the pharmacist was not available.

2) The hospital failed to ensure drugs and biologicals were secure and not accessible to patients and visitors. The hospital's COW medication cart was unlocked and unattended in the patient care unit hallway that was accessible to the public.

Findings:

1) Ensure its policies and procedures and hospital practice for dispensing and administering medications and biologicals followed the requirements of the Louisiana State Board of Pharmacy regarding the pharmacist's review of medication orders prior to the first dose being administered except in emergencies. Review of the "Louisiana Administrative Code Title 46 - Professional and Occupational Standards Part LIII: Pharmacists Chapter 15. Hospital Pharmacy" revealed that 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 policy presented as a current policy by S3Pharmacy Director titled "Pharmacist Order Verification", Document Number 6351, revised 03/07/12, revealed in part: The Pharmacist will review each medication order before administration. A direct copy of the order is scanned into the Healthland system or Faxed to the Pharmacy Department staff immediately after it is written. The Pharmacist reviews the order and if normal pharmacy hours will enter the order onto the patient's profile. When the onsite pharmacy is not open 24 hours per day, seven (7) days a week, the first dose(s) may be given for emergency purposes. A Pharmacist shall conduct a retrospective review of all medication orders within 24 hours.

In an interview on 02/23/16 at 3:05 p.m. with S3Pharmacy Director, she revealed that she is on-call every other weekend and has access to the hospital record system and has the ability to verify first dose reviews on all new medication orders. S3Pharmacy Director further stated that on the weekends that she is not on-call, there is a relief Pharmacist that works, but after hours she has no access to the system for first dose review of medications. S3Pharmacy Director stated that she had reviewed the hospitals Policy and Procedures for Pharmacy but did not realize the policy for first dose review did not meet the requirements of the Louisiana State Board of Pharmacy.

In an interview on 02/24/16 at 10:40 a.m., S1DON stated that she was aware there were no first dose reviews performed after hours on the weekends that S3Pharmacy Director did not work. S1DON stated that the pharmacist reviewed the medication orders the next day.


2) The hospital failed to ensure drugs and biologicals were secured and not accessible to patients and visitors. The hospital's computer on wheels (COW) medication cart was unlocked and unattended in the patient care unit hallway that was accessible to the public.
Findings:

Review of the Hospital's Policy and Procedure titled "Medication Cart (COW)", presented by S1DON as being current (05/14) read in part: To prevent tampering with medications, the cart is locked at all times except when in direct care.
Observation on 02/23/15 from 9:55 a.m. to 10:07 a.m. revealed a COW located outside of Patient #4's room. The COW was noted to be unlocked and unattended. The following was observed to be in the COW: 10 ml saline flush syringes (11), IV catheters (8), insulin syringes (7), lancets (22), alcohol wipes (not counted), 2x2 gauze and tape. S5RN was observed to be in the patient's room administering insulin, then exited the room and returned to the nurses' station, leaving the cart unlocked and unsecured.
Observation on 02/23/16 from 11:03 a.m. to 11:18 a.m. revealed a COW located outside of R #1's room. The COW was observed to be unlocked and unattended. The COW was noted to contain the following: 10 ml. saline flush syringes (9), IV catheters (6), 9 Saline flush (10 ml), lancets (19), alcohol wipes, 2x2 gauze, and tape.
In an interview on 02/23/16 at 12:00 p.m., S4ICN indicated that the COWs are to be locked and secured at all times.
In an interview on 02/23/16 at 12:00 p.m., S5RN confirmed that she left the COW unlocked and unattended during both above observations.
In an interview on 02/24/16 at 2:00 p.m., S1DON confirmed that all COWs are to be locked and secured at all times.


31206

Based on observation, record review and interview, the hospital failed to ensure the infection control officer implemented measures to prevent and control infections and communicable diseases as evidence by failure to maintain patient care equipment in a clean and sanitary manner to avoid sources and transmission of infections and communicable diseases.
Findings:

Review of the Hospital's Policy and Procedure titled "Cleaning Patient Equipment and Medical Devices" presented by S1DON as being current (02/01/16) read in part: The cleanliness of any healthcare environment is important for infection prevention and control and patient well-being. _____(name of Hospital) is dedicated to minimizing the risk of nosocomial infection by establishing guidelines for the cleaning and disinfection of equipment. 2.11 If it is unclear whether patient care equipment has been cleaned, it must be cleaned before patient use.

An observation was made on 02/23/16 at 3:55 p.m. of the Hospital's Medical/Surgical Unit and the following was noted:
- Crash cart with visible dust on top of the cart.
- Defibrillator and cardiac pacer ( located on top of the crash cart) visible dust was noted.
- Blanket warmer was noted to have a large amount of visible dust on top of the unit.
- Bladder scanner (covered with transparent plastic bag) was noted to have visible dust on
scanner monitor screen, handle and base.
- Accu-vein (3 units covered individually with transparent plastic bags) was noted to have
visible dust on the handle and base.
- CPT machine (covered with transparent plastic bag) was noted to have visible dust on top
and on the base.
- EKG machine (covered with transparent plastic bag) was noted to have visible dust on the
top portion and lower base of the unit.
- CPAP machine (covered with transparent plastic bag) was noted to have visible dust on
the top portion of the machine and the base.
- COW was noted to have visible dust on screen, key board and base.
- CNA & Physician's COW- visible dust noted on screen, key board and base.
- Portable Air Purifier had visible dust noted in the air vents.
All of the above observations were confirmed by S1DON.

In an interview on 02/23/16 at 4:00 p.m., S1DON confirmed that all of the patient care equipment that have plastic covering (bags) was clean and available for patient use by the medical staff. She confirmed that patient care equipment located in the hallway was not maintained in a clean and sanitary manner as to avoid the transmission of infectious disease. S1DON indicated that all of the patient care equipment would have to be re-cleaned before used by the medical staff for treatment and/or patient care.

Based on record review and interview, the hospital failed to ensure the QAPI (Quality Assessment Performance Improvement) program included an effective system to analyze, monitor, and track new construction within the hospital.
Findings:

Review of the Hospital's Policies and Procedures Manual presented by S1DON as current, revealed no policy and procedure relevant to hospital construction, renovation, and the inclusion of the requirement for an ICRA to be performed prior to the beginning of any renovation and construction projects.

Review of the QAPI program Quality Monitoring and Evaluation Indicators revealed no documented evidence of monitoring of the new construction.

In an interview on 02/24/16 at 2:30 p.m., S6QA indicated the construction and renovation had not been included in the Hospital's QAPI program. She indicated that the construction workers meet weekly to discuss dead lines and progress.