HospitalInspections.org

Based on record review and interview, the hospital failed to ensure each physician/practitioner providing services in the hospital, including radiologists performing telemedicine (radiology) services, was credentialed and privileged, by the Governing Body for 2 of 2 (S5MD, S6MD) radiologists' credentialing files reviewed for credentialing and privileging.
Findings:

Review of Patient #R9's chest x-ray, performed on 01/30/2020, revealed S5MD with Company "C" interpreted the x-ray.

Review of Patient #R10's right hand x-ray, performed on 02/15/2020, revealed S6MD with Company "C" interpreted the x-ray.

Review of the Governing Body minutes for 2018, 2019 and 2020 failed to revealed S5MD and S6MD telemedicine radiologists were approved for credentialing and privileged by the Governing Body of the hospital.

An interview was conducted with S1Adm on 02/27/2020 at 11:30 a.m. She reported she was not familiar with S5MD and S6MD. She also reported the telemedicine radiologists had not been credentialed with the hospital.

Based on observation and interview, the hospital failed to ensure patients at risk for harm to self or others were provided care in a safe setting. This deficient practice was evidenced by failure to ensure the patients' physical environment was free of safety risks and did not afford opportunities for self -injury/harm to others. Findings:

An observation on 02/24/2020 at 9:25 a.m. of the patient shower room, located adjacent to Room 119, revealed a ceiling tile that was not clamped, separated slightly from the metal ceiling crosspiece, located above the upper right hand corner of the shower stall. S3SafetyOfficer confirmed, during the observation, that the tile was not clamped and verified it should have been secured with a clamp.

An observation was conducted on 02/24/2020 at 10:00 a.m. of Room 120: The footboard of the bed was noted to have 2 long screws protruding outward, approximately 1 inch, from the center of the footboard.

An interview was conducted with S3Safety Officer on 02/24/2020 at 10:00 a.m. He confirmed the finding and stated the bed alarm must have been removed from the bed and the screws were not removed.

An observation on 02/24/2020 at 10:10 a.m. of Room 119, Closet B, revealed a pair of drawstring waist athletic pants with the drawstring still in the pants. The patient room door was open and was accessible to patients. S2DON confirmed the finding and acknowleged the drawstring was a contraband item and should not have been accessible to patients.

An observation was conducted on 02/24/2020 at 10:15 a.m. of an elbow hinge door closure at the top of a door which was located between a patient room and the small day room.

An interview was conducted with S3SafetyOfficer on 02/24/2020 at 10:15 a.m. He confirmed the area was difficult to view from the nursing station and may present as a ligature risk to patients.


An observation was conducted on 02/24/2020 at 10:20 a.m. of the hallway of the hospital. The hand rails in the hallways were anchored to the wall with screws that were not tamper proof. Areas in the hallway were difficult to view from the nurses' station. S3SafetyOfficer confirmed the screws were not tamper proof and that all hand rails in the hallway had the same type of screws.





30984

Based on record review, observation, and interview, the hospital failed to ensure the hospital-wide QAPI program set priorities aimed at performance improvement activities that focused on high risk, high volume, or problem prone areas that affected health outcomes, patient safety, and quality of care. This deficient practice was evidenced by failure of the hospital's QAPI program to identify the reason for numerous overrides being conducted by the nurses on the automated drug delivery system (medication errors), the failure to accurately assess dietary concerns in the patients, and failure to perform accurate skin assessment.

Findings:

Review of the Quality Assurance and Performance Improvement Measures revealed in part, the hospital administrator is designated as the Quality Assurance and Performance Improvement (QAPI) Coordinator. As such, the Administrator is responsible for ensuring that reporting is timely, opportunities for improvement are identified, and action plans are implemented and monitored.

Review of the QAPI plan for 2019 and 2020 did not include the identification of the reason for the numerous over rides being conducted by the nurses on the automated drug delivery system (medication errors), the failure to accurately assess dietary concerns in the patients, and failure to perform accurate skin assessment.

An interview was conducted with S1Adm on 02/27/2020 at 3:00 p.m. She reported she was unaware of the numerous over rides on the automated drug delivery system and the issue will need to be investigated. She also stated she was unaware that dietary risk assessment and skin assessments were not being accurately completed. She further stated this was not identified by the hospital's QAPI program.

Based on observations, record review, and interviews, the hospital failed to ensure the registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by:

1) failure of the RN to perform and document accurate physical assessments of a patient's lower extremity edema (left lower leg) during the patient's hospitalization for 1 (#3) of 2 ( #3, #7) patients reviewed for skin assessments/skin issues from a total patient sample of 8 (#1- #8); and
2) failure of the RN to perform an accurate suicide risk assessment for 1 (#1) out of 5 (#1, #3, #4, #5,#6) reviewed for an accurate suicide risk assessment from a total patient sample of 8 (#1-#8).

Findings:
1. Failure to perform accurate physical assessment
On 02/24/2020 at 10:24 a.m. Patient #3 was observed seated on the sofa in the commons/group area. Patient #3's left leg was observed to be edematous and it was twice the size of his left leg. He had multiple purplish-red circular spots located on the lateral side of his left knee.

S2DON verified the patient observed was Patient #3 and observed his leg with the surveyor. S2DON asked the patient if his left leg was "more swollen than usual" and he responded "No."

Review of Patient #3's electronic medical record revealed an admission date of 02/13/2020 who was PEC'd due to suicidal ideations, poor insight, and being dangerous to self.

Review of Patient #3's History and Physical, completed on admission, revealed the following entry: Mild edema to lower extremities- Left leg greater than right leg.

Further review of Patient #3 entire electronic medical record, assisted by S4RN, Clinical Educator, revealed the patient's edema to his lower extremities was not referenced on the patient's initial nursing assessment and no skin issues were identified. Additional review revealed nursing staff failed to include an assessment of the patient's edema to his lower extremities in the nursing assessment documentation from the time of his admission on 02/13/2020 to the time of the record review on 02/26/2020.

In an interview on 02/26/2020 at 11:13 a.m. with S4RN, navigator, she confirmed assessment of Patient #3's left leg edema, observed by the surveyor on 02/24/2020, that was documented in the patient's admission history and physical, had not been documented in narrative nursing notes nor was it addressed in patient skin assessments/assessments of extremities. S4RN confirmed the condition of the patient's leg should have been assessed and monitored by nursing staff and should have been documented in the patient's electronic medical record.


2) Failure to perform an accurate self harm/suicide risk assessment

Review of the hospital's instruction's for completion of the Risk Assessment revealed in part, you must include your soucrce of information for completing this assessment. You may check all that apply. You should take into consideration sources of information other than the patient's report of suicidal/homicidal intent. For example, if the patient has been admitted via PEC due to suicidal or homicidal thoughts/behavior, but responds "no" to these questions, the assessment answer should accurately reflect the recent behavior that took place, rather than solely the patient's statement. You must consider the patient's history when completing this assessment.

Patient #1
Review of Patient #1's EMR, navigated by S2DON, and PEC dated 02/15/2020 revealed in part, behavior issues- self inflicting- danger to self, yelling out, attempting to cause injury to self by tipping self over in his wheelchair. Patient was listed as dangerous to self, gravely disabled and unable to seek voluntary admission.

Review of the Harm to Self/Suicide Risk Assessment, dated 02/16/2020 at 2:15 a.m., revealed the source of the information was the patient and the following answers to the assessment performed by the nurse, in part:
History of attempt to harm self? no
If yes how recent? 18 month or NA (not applicable)
Any thoughts/feeling of harming self? No
How often does the patient experience these thoughts/feelings? Rarely/Never
With further review of the Harm to Self/Suicide Risk Assessment revealed the patient's score for harm to self/suicide risk assessment was a "0", indicating the patient was low risk for self-harm/suicide risk. The patient was admitted per the treatment plan for self inflicting danger to self.

An interview was conducted with S2DON on 02/26/2020 at 9:40 a.m. S2DON confirmed the Self Harm/Suicide risk assessment did not take into account the patient's self-injurious behavior prior to his admission to the hospital.

Based on record review and interview, the hospital failed to ensure the nursing staff developed, and kept current, a nursing care plan for each patient. This deficient practice was evidenced by failure of the nursing staff to address all of the patients' medical and psychiatric conditions as identified problems on the patients' plan of care for 3 (#3, #4, #5) of 3 (#3-#5) sampled patient records reviewed for care plans from a total patient sample of 8 (#1-#8) .

Findings:

Patient #3
On 02/24/2020 at 10:24 a.m. Patient #3 was observed seated on the sofa in the commons/group area. Patient #3's left leg was observed to be edematous and it was twice the size of his left leg. He had multiple purplish-red circular spots located on the lateral side of his left knee.

Review of Patient #3's History and Physical, completed on admission, revealed the following entry: Mild edema to lower extremities - Left leg greater than right leg.

Further review of Patient #3 electronic medical record, assisted by S4RN, Clinical Educator, revealed the patient's edema to his lower extremities was not referenced on the patient's plan of care at the time of the record review on 02/26/2020 at 11:13 a.m. S4RN verified the patient's lower extremity edema had not been addressed on the plan of care and confirmed it should have been identified as a problem on the care plan.

Patient #4
Review of Patient #4's electronic medical record revealed the patient had a comorbid diagnosis of Fibromyalgia documented on admission.

Review of Patient #4 care plan, assisted by S4RN, Clinical Educator, revealed the patient's potential for pain related to a diagnosis of Fibromyalgia was not referenced on the patient's plan of care at the time of the record review on 02/26/2020 at 10:54 a.m. S4RN verified the patient's potential for pain associated with Fibromyalgia had not been addressed on the plan of care and confirmed it should have been identified as a problem on the care plan.


Patient #5
Review of Patient #5's electronic medical record revealed the patient had co-morbid diagnoses of chronic neck and back pain, Osteoarthritis, and Renal Insufficiency documented on admission.

Review of Patient #5 care plan, assisted by S4RN, Clinical Educator, revealed the patient's risk for pain associated with chronic neck/back pain and Osteoarthritis and Renal Insufficiency requiring a special diet (renal) was not referenced on the patient's plan of care at the time of the record review on 02/26/2020 at 11:23 a.m. S4RN verified the patient's chronic neck/back pain, Osteoarthritis, and Renal Insufficiency requiring a special diet (renal) had not been addressed on the plan of care and confirmed the above referenced diagnoses should have been identified as a problems on the care plan.

Based on record review and interview, the RN failed to ensure the nursing care of each patient was assigned to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the available nursing care staff as evidenced by failure to have documented evidence of a competency evaluation in performing vital signs for 2 (S11MHT, S12MHT) of 3 (S10MHT, S11MHT, S12MHT) MHTs' personnel files reviewed for competency evaluations.
Findings:

Review of the Hospital's policy on Staff Orientation and Ongoing Training revealed in part, competency demonstrations (which may include written and practical tests) are completed at least annually. Performance is documented by the Department Manager or designee. Results are maintained in employee files.

Review of the personnel files for S11MHT and S12MHT revealed no competencies for performing vital signs.

An interview was conducted with S2DON on 02/26/2020 at 10:00 a.m. She reported the MHTs perform the vital signs and if there is an abnormal reading the MHT notifies the nurse.

An interview was conducted with S13HIM on 2/27/2020 at 2:30 p.m. She confirmed S11MHT and S12 MHT did not have competencies for performing the patients' vital signs.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable standards of practice, consistent with state law. This deficient practice was evidenced by failing to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications for 2 (#7, R7) of 3 (#7, R7, R8) patient records reviewed for First Dose Review.

Findings:

Review of the Louisiana Administrative Code, Professional and Occupational Standards,
Title 46: LIII, Pharmacist, Chapter 15, Hospital Pharmacy, §1511. Revealed in part:
Prescription Drug Orders: A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial dose of medication, except in cases of emergency.

On 02/27/2020 at 11:35 a.m. a review of the hospital policy Pharmaceutical Services, Review of First Dose revealed in part:
Policy:
In accordance with State and Federal regulations and laws, and standards of practice, and to ensure patient safety, Beacon Behavioral Hospital ensures that a pharmacist reviews all orders for medication not documented as having been previously administered to the patient. Such review is conducted 24 hours a day and is never omitted unless an urgent or emergent situation exists in which a delay of administration of the medication is likely to result in harm to the patient.

Patient #7

A review of the Medication Errors for the February 14, 2020 revealed a request from Company "B" stating, "We have no orders for the following profile overrides performed in the Med-Dispense." Further review of the Profile overrides revealed Company "B" stated they did not receive an order from the hospital for Patient #7's Clonazepam (Klonopin) 1mg nor Pregabalin, (Lyrica) 75mg that was removed from the Med-Dispense on 02/13/2020 by S2DON.

On 02/27/2020 at 11:30 a.m. a review of Patient #7's medical record revealed an order for Klonopin Tablet 1mg BID and Lyrica Capsule 100mg BID ordered on 02/13/2020 at 4:13 p.m. with the Completion Action noted as "print".

A review of Patient #7's Medication Administration Record revealed Klonopin 1 mg tablet and Lyrica Oral Capsule 100 mg capsule were administered on 02/13/2020 at 10:48 p.m. by S2DON.

In an interview on 02/27/2020 at 11:15 a.m. S2DON verified because the patient order Completion Action was to "print", pharmacy had not received nor reviewed the medications noted above prior to administration of the first dose.

Patient R7

A review of the Medication Errors for the February 14, 2020 revealed a request from Company "B" stating, "We have no orders for the following profile overrides performed in the Med-Dispense." Further review of the Profile overrides revealed Company "B" stated they did not receive an order from the hospital for Patient R7's Alprazolam 0.25 mg (Xanax) that was removed from the Med-Dispense on 02/13/2020 at 8:36 p.m. by S2DON.

On 02/27/2020 at 11:30 a.m. a review of Patient R7's medical record revealed an order for Xanax 0.25 mg TID ordered on 02/13/2020 at 6:28 p.m. with the Completion Action noted as "print".

A review of Patient R7's Medication Administration Record revealed Xanax Tablet 0.25 mg 1 tablet administered on 02/13/2020 at 10:51 p.m. by S2DON.

In an interview on 02/27/2020 at 11:15 a.m. S2DON verified because the patient order Completion Action was to "print", pharmacy had not received nor reviewed the medications noted above prior to administration of the first dose.

Based on observation and interview, the hospital failed to ensure that outdated, mislabeled or otherwise unusable drugs and biologicals were not available for patient use as evidenced by:
1) Failing to date opened medications;
2) Failing to ensure medications for patients either discharged or discontinued medications was not utilized for other patients.

Findings:

1) Failing to date opened medications.

On 02/24/2020 at 10:25 a.m. an observation of a cart in the nurses' station contained the following open undated medications:
a) 2 tubes Diclofenac Sodium Topical Gel 1%, 100g;
b) 1 tube Nystatin Triamcinolone Acetonide 30g;
c) 1 tube Nystatin Cream 30g;
d) 1 tube Triamcinolone Acetonide Cream 15 grams.

In an interview on 02/24/2020 at 10:25 a.m. S2DON verified the open undated medications. She also confirmed they were being utilized by the staff for patient use.

2) Failing to ensure medications for patients either discharged or discontinued medications were not utilized for other patients.

On 02/24/2020 at 10:30 a.m. an observation of the Medication Cart revealed the following medication blister packs with the patient names scratched out and labeled as stock.
a) Methocarbam 500 mg tab., 7 tabs;
b) Amitiza 8mcg cap., 4 caps.;
c) Doxazosin 1mg tab., 3 tabs.;
d) Chlorpromazine 100 mg tab.;
e) Memantine HC 21 mg ER Cap., 3 Cap;
f) Methocarbam 750 mg tab., 8 tabs.;
g) Cyproheptadine 4 mg tab., 21 tabs.;
h) Amantadine 100 mg cap., 5 caps.;
i) Irbesartan 150 mg tab., 4 tabs.;
j) Glipizide 5 mg tab., 2 tabs.;
k) Sodium Bicarb 650 mg tab., 2 tabs.;
l) AZO Standard Max ST tab., 9 tabs.

In an interview on 02/24/2020 at 10:35 a.m. S8DietMgr confirmed the above medications were for patients who were discharged or the medication was discontinued. She further confirmed staff were using the medications as stock medications for current patients. She also verified that the medical staff and pharmacy had not approved the process.

In an interview on 02/26/2020 at 5:30 p.m. S9Pharm verified that he was not aware the staff were using discontinued medications and medications from discharged patients as stock medications for current patients. He further acknowledged this is not an approved process.

Based on record review and interview, the hospital failed to ensure individual patient nutritional needs were met in accordance with recognized dietary practices. The deficient practice was evidenced by failure of the hospital to ensure a patient whose medical condition could be adversely affected by their nutritional intake (Patient # 6 - Renal Disease with increased serum potassium requiring hospitalization ) and a patient presenting signs/symptoms of compromised nutritional status/increased calorie needs (Patient #1 - Huntington's Chorea diagnosis with BMI = 19.42) had been referred to the dietician for assessment due to being at risk for compromised nutritional status for 2 ( #1, #6 ) of 2 patients reviewed for special dietary needs/dietary consults from a total patient sample of 8 (#1 - #8).

Findings:

Review of the hospital policy titled,"Nutritional Consult", revised 03/21/2018, revealed in part: Beacon Behavioral Hospital ensures that a comprehensive nutritional consult is completed by a registered dietician and a plan of carefor nutritional needs is developed and implemented for any inpatient determined to by the treating prescriber to be at nutritional risk.
Procedure: 1. The need for a nutritional consult with a registered dietician may initially be triggered by any of the following: a. Screening conducted as part of the nursing admission assessment, b. Notations regarding intake in the nurses' progress notes and/or daily flowsheet, c. Diagnostic test results, d. History and Physical Assessment, and e. Other indications or reports. 2. As soon as practicable, the nurse will notify the treating provider that there is a trigger for further nutritional evaluation, if the precipitating information is not part of the results routinely and/or frequently monitored by the prescriber.

Review of the hospital policy titled, "Food and Dietetic Services", revised 03/21/2018, revealed the following, in part:
Beacon Behavioral Hospital meets the nutritional needs of its inpatients through the use of contracted Dietary Service vendors that have been approved to provide services to licensed healthcare facilities.
Procedure: 1. As part of the nursing admission assessment the patient will be screened for indications that further evaluation by the registered dietician is needed.
5. If indicated the prescriber may order a nutritional consult by the registered dietician upon admission or at any point during treatment.
6. The nurse transcribes and notes all orders issued. Any orders pertaining to dietary services will be sent to the vendor, registered dietician, and/or dietary manager, as appropriate.
10. A nurse will notify the treating transcriber of any findings significant to the patient's nutrition/hydration status as soon as possible.
Note: Determination of nutrition and hydration provided is based solely on the patients' identified needs and medical requirements.

Patient #1
Review of Patient #1's medical record, navigated by S2DON, revealed an admission date of 2/16/2020 due to having behavior issues. Patient #1 also had co-morbid diagnosis of Huntington Disease, Abnormal Weight Loss and Dysphagia Unspecific.

Review of Patient #1's Nursing Assessment on 02/16/2020 revealed the patient was 5'7" in height and with a weight of 124 pounds. His BMI was 19.42. Further review of the Nursing Assessment revealed the diet was listed as regular with consistency listed as mechanical soft, chewing difficulty, and difficulty swallowing. Follow up was documented as stable no further action required. The check box to order a dietary consult was not initiated.

Review of Patient#1's History and Physical on 02/16/2020 performed by S21APRN revealed an assessment and plan of the following: Dysphagia-Choking precautions, mechanical soft diet and nectar thickened liquids, underweight (BMI 19.4) Ensure one can BID and MVI one po daily. Well-balanced diet, Hypoalbuminemia-well-balanced diet.

An interview was conducted with S2DON on 02/26/2020 at 10:30 a.m. She confirmed a dietary consult was not initiated for Patient #1.

Patient #6
Review of Patient #6's medical record revealed an admission date of 02/12/2020 due to having Dementia with progressive hallucinations, disorientation, and agitation. Patient #6 also had a co-morbid diagnosis of renal insufficiency on admission.

Further revealed Patient #6 had been transferred out of the hospital twice for care at an acute care hospital (on 02/17/2020 and on 02/25/2020) due to having an increased serum potassium level.

Review of Patient #6's History and Physical, dated 02/12/2020, revealed the patient had the following co-morbid conditions: Renal insufficiency and anemia.

Review of Patient #6's labs revealed the following:
02/14/2020: Serum Potassium: 5.8 mmol/L - High (normal range 3.5 mmol/L - 5.1 mmol/L); BUN: 48 mg/dL - High (normal range: 5mg/dL -25 mg/dL), and Creatinine: 2.10 mg/dL - High ( normal range: 0.57 mg/dL- 1.25 mg/dL);

02/16/2020 : Serum Potassium: 5.6 mmol/L- High, BUN: 54 mg/dL- High, and Creatinine: 2.64 mg/dL- High; and

02/17/2020: Serum Potassium: 6.2 mmol/L - High, BUN: 63 mg/dL- High, and Creatinine: 3.12 mg/dL- High

Review of the hospitals' inpatient diet lists revealed Patient #6 had not been on a renal diet during her hospitalization.

In an interview on 02/26/2020 at 9:00 a.m. with S4RN, electronic medical record navigator, she indicated Patient #6 had been sent out out to an acute level of care due to having had an elevated serum Potassium of 6.3 mmol/L that had not responded to treatment with Kayexelate (medication used to bind with serum Potassium in order to bring Potassium levels down). She confirmed the patient had not had a dietary consult ordered with the hospital's registered dietician related to her renal disease and issues with increased Potassium.

In an interview on 02/27/2020 at 12:00 p.m. with S8DietMgr, she indicated patients' nutritional status was assessed on the initial nursing assessment when patients were admitted. She reported potential dietary issues that may require a dietary consult with the dietician would be identified at that time and would trigger the need for a consult with the dietician. She indicated the dietician would make recommendations based on their assessment and the physician/nurse practitioner would usually order whatever the dietician had recommended.

In an interview on 02/27/2020 at 1:07 p.m. with S7RD, she confirmed she was the hospital's current dietician and indicated she performed nutritional assessments on the hospital's patients when she received notification of a consult from the hospital staff. She corfirmed she had not performed a nutritional assessment on Patient #6 and confirmed Patient #6 should have been assessed due to her ongoing issues with elevated serum Potassium and her diagnosis of end stage renal disease.

In an interview on 02/27/2020 at 2:30 p.m. with S2DON, she indicated the reason Patient #6 had been transferred out for treatment at an acute care hospital on 02/25/2020 was due to having had an elevated serum Potassium again (Patient #6 had returned on 02/22/2020 from a previous hospitalization for treatment for increased serum Potassium). S2DON reported the patient had end stage renal disease and it was to be expected that she would have elevated serum Potassium levels.

In an interview on 02/27/2020 at 3:00 p.m. with S1Adm, she indicated she had not realized nutritional assessments were not being performed correctly and patients in need of consults with the dietician were not being triggered.

Based on record review and interview, the hospital failed to ensure a system for controlling infections and communicable diseases of patients and personnel were established. This deficient practice was evidenced by the hospital's:
1) failure to ensure expired lab specimen tubes were not readily available for patient use;
2) failure to ensure medication, laboratory, and patient nourishment refrigerator temperature checks were documented;
3) failure to ensure glucometer quality control checks were documented daily;
4) failure to ensure staff are appropriately trained on cleaning the glucometer;
5) failure to ensure patient laundry was cleaned and processed as per CDC standards;
6) failure to cover the clean linen while stored and while in transport to the patient unit;
7) failure to maintain the Formica in the nurses' station.

Findings:

1) Failure to ensure expired lab specimen tubes were not readily available for patient use.

On 02/24/2020 at 9:55 a.m. a tour of the Lab/Exam Room revealed:
a) 46 Grey top lab tubes expired on 09/30/2019;
b) 40 Blue top lab tubes expired on 05/10/2019;
c) 16 Blue top lab tubes expired on 01/14/2020.
d) Lab Specimen refrigerator missing documented temperatures on January 9, 10, 11, 13, 14, 20, 29, 30 of 2020 and February 3, 4, 11, 25-28 of 2020

In an interview on 02/24/2020 at 10:20 a.m. S2DON confirmed the expired lab tubes.


2) Failure to ensure medication, laboratory, and patient nourishment refrigerator temperature checks were documented.

A review of hospital policy titled Infection Control, Infection Prevention and Control Program revealed in part:
On an ongoing basis:
A temperature log will be maintained for each refrigerator. Documentation on the log will be daily in inpatient settings and on days of operation in outpatient settings. A staff member will record the temperature reading and, if it is outside the acceptable range (as dictated by LAC 51), will immediately notify a supervisor.


On 02/24/2020 at 10:45 a.m. an observation of the patient nourishment room revealed refrigerator and freezer temperatures had not been logged on the following days: 02/01/2020, 02/03/2020, 02/04/2020, 02/11/2020, 02/14/2020, and 02/17/2020. S2DON confirmed the lapses in recording of the refrgierator/freezer temperatures at the time of the observation.


On 02/24/ 2020 at 10:55 a.m. an observation of the medication refrigerator temperature log revealed no documented temperature on January 6, 9, 10, 11-14, 20, 27, 29 and 30 of 2020 and February 3, 4, 11, 14, 20-22, 25-28 of 2020.

On 02/24/2020 at 11:00 a.m. an observation of the laboratory refrigerator temperature log revealed no documented temperature on February 3, 4, 11, 14, 25-28 of 2020.

In an interview on 02/24/2020 at 10:20 a.m. S2DON confirmed the missing lab specimen refrigerator temperatures.

In an interview on 02/22/2020 at 11:05 a.m. S8DietMgr verified the missing medication refrigerator temperatures and confirmed the temperature is to be documented daily on the night shift.


3) Failure to ensure glucometer quality control checks were documented daily.

A review of the hospital policy: Nursing Service, Capillary Blood Glucose Monitoring revealed in part:
Procedure: 1. Quality control assessment with control solutions shall be completed at least daily on Capillary Blood Glucose Meters. Control shall be conducted by a nurse.

On 02/24/2020 at 10:56 an observation of the Glucometer quality control checks failed to reveal documented check on December 26, 27, 2020.

In an interview on 02/24/2020 at 10:56 a.m. S8DietMgr verified the missing documented quality checks and confirmed the checks are to be done and documented daily.

4) Failure to ensure staff are appropriately trained on cleaning the glucometer.

Review of documentation found at FDA.gov relative to disinfection of capillary blood glucose monitoring systems revealed the following information, in part: 2. Validated cleaning and disinfection procedures: a. The disinfection solvent used should be effective against HIV, Hepatitis B virus, and Hepatitis C virus. Outbreak episodes have been largely due to transmission of Hepatitis B and C viruses. However, of the two, Hepatitis B virus is the most difficult to kill. Please note that 70% ethanol solutions are not effective against viral blood-borne pathogens.


On 02/27/2020 at 9:40 a.m. a review of the hospital policy titled Nursing Service, Capillary Blood Glucose Monitoring failed to reveal a procedure for cleaning the multiuse glucometer.

In an interview on 02/24/2020 at 10:56 a.m. S8DietMgr stated she cleans the glucometer with alcohol between patients.

5) Failure to ensure patient laundry was cleaned and processed as per CDC standards.

Review of the CDC Guidelines for Environmental Infection Control in Health-Care Facilities (2003) revealed the following, in part:
A laundry facility is usually partitioned into two separate areas - a "dirty" area for receiving and handling the soiled laundry and a "clean" area for processing the washed items. To minimize the potential for decontaminating cleaned laundry with aerosolized contaminated lint, areas receiving contaminated textiles should be at negative air pressure relative to the clean areas. Laundry areas should have handwashing facilities readily available to workers. Laundry workers should wear appropriate personal protective equipment (e.g., gloves and protective garments) while sorting soiled fabrics and textiles.

On 02/27/2020 at 7:30 a.m. an observation of the laundry room revealed the washer and dryer in the same room. Further observation revealed open shelves with folded laundry on the shelves in the laundry room. The observation failed to reveal a readily available hand washing facility in or near the laundry room.

In an interview on 02/27/2020 at 8:15 a.m. S3Safety Officer stated, dirty laundry is brought into the room in paper bags washed and dried then folded on the table in the same room. He further acknowledged the clothes on the open shelves are clean and used for patients who may need clothes. He confirmed dirty and clean linen are handled and stored in the same room.

In an interview on 02/27/2020 at S17MHT stated staff has to use the handwashing facility either in the patient unit or the staff bathroom. He confirmed there is no readily available handwashing facility in or near the patient laundry room.

In an interview on 02/27/2020 at 11:30 a.m. S3Safety Officer confirmed the laundry room is not negative pressure and there is no readily available handwashing facility.

In an interview on 02/27/2020 at 11:45 a.m. S18FireMarshal confirmed the laundry room is not a negative pressure room.

6) Failure to cover the clean linen while stored and while in transport to the patient unit.

On 02/27/2020 at 7:35 a.m. an observation of the clean linen room revealed folded clean linen stored uncovered on open shelves and a rolling cart with linen covered with an open mesh material.

In an interview on 02/27/2020 at 7:35 a.m. S2DON stated the linen is only covered when it is transported onto the unit from the clean linen room. She also stated the linen on the rolling cart was clean and the cart is used to transport the linen on to the unit.

On 02/27/2020 at 8:32 a.m. an observation of S19Housekeeping revealed her transporting clean linen from the linen closet on an open cart uncovered to the patient unit.

In an interview on 02/27/2020 at 8:32 a.m. S3Safety Officer confirmed the uncovered linen and stated the linen should be covered during transport.

7) Failure to maintain the Formica in the nurses' station.

On 02/27/2020 at 9:45 a.m. a tour of the nurses' station revealed missing Formica on the counter top in numerous places with exposed wood, which cannot be appropriately cleaned.

On 02/27/2020 at 9:45 a.m. in an interview S20LPN verified the missing Formica, exposed wood and the inability to appropriately clean the wood.




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