HospitalInspections.org

25065

Based on observations and interviews, the hospital failed to ensure each patient received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for patients admitted for acute inpatient psychiatric services. This deficient practice was evidenced by failure to ensure the patients' environment was free of ligature risks and safety hazards (after being cited for this violation on the 07/30/15 and 04/06/16 surveys).
Findings:

Observation on 05/20/16 at 11:05 a.m. revealed Rooms Ff, Fg, Fh, Fi, Fj, Fk, Fl, Fm, and Fn had protruding shower heads, round faucet knobs on the tubs, and door hinges on the room entrance door and the bathroom door with wide spaces between each hinge that presented a potential ligature risk. Further observation revealed Rooms Ff, Fh, and Fi had peeling sheetrock and/or puttied, unpainted walls in the bathroom. Room Ff had a brown substance on the front of the toilet rim. Room Fi had an uneven threshhold from the room to the bathroom with chipped mortar present.

Observation on 05/20/16 at 11:20 a.m. revealed the wall hand rail outside Room Fq had the edge with tape covering the edge which presented an infection control issue for disinfection. Further observation revealed Room Ft had patched walls with putty to the left side of the toilet and the right side of the sink that was not painted. The toilet plumbing was exposed and presented a potential ligature risk. The shower stall had a protruding faucet handle, and the entrance door and the door into the seclusion room had door hinges spaced widely apart enough to present a potential ligature risk.

In an interview on 05/20/16 at 11:20 a.m., S2DON confirmed the above observations. She indicated having tape on any object (referring to the hand rail outside Room Fq) "always is" an infection control issue.

Observation on 05/20/16 at 11:45 a.m. revealed Room Fu 's bathroom wall had peeling paint with putty that had not been painted, and the toilet was stained with brown scratches. The tub had a protruding shower head and round knobs that presented a potential ligature risk. The toilet seat was loose. The door hinges of the entrance door and into the seclusion room were spaced widely apart enough to present a ligature risk. The walls in the seclusion room had 3 areas that had been puttied and not painted. These observation were confirmed by S2DON who present during the observations.

Observation on 05/20/16 at 11:50 a.m. revealed Room Fs' bathroom had puttied, unpainted walls. Further observation revealed Rooms Fa, Fb, Fc, Fd, and Fe had the bathrooms blocked with plastic from floor to ceiling with ongoing construction in progress. The rooms were not in use. These observations were confirmed by S2DON who was present during the observation.


26351




30984

30984

Based on record reviews and interviews, the hospital failed to ensure an effective system was in place to ensure that each physician/practitioner providing services in the hospital was credentialed in accordance with the Medical Staff By-laws for 2 (SF4NP,SF5MD) of 7 current credentialed medical staff files reviewed from a total of 15 credentialed physicians.

Findings:

Review of the Medical Staff Bylaws provided by SF3DHIM as current revealed, in part, the following:
Article III. Medical Staff Membership:
Appointment to and subsequent membership on the Medical Staff shall confer on the Member only such clinical responsibilities, prerogatives, and other rights as have been granted by the Board in accordance with these Bylaws.
Article V. Allied Health Professionals:
Each AHP shall meet the same responsibilities as required for Physician Medical Staff Members....
Article VI. Procedure for Appointment:
Each Application for appointment to the Staff shall be in writing, submitted on the prescribed form, and signed by the applicant. The Medical Staff, through its Services, committees, and officers, shall investigate, verify, and consider each Application for appointment or reappointment to any staff status....The Medical Staff shall consider each Application for appointment, reappointment, and Responsibilities, and each request for modification of Medical Staff category using the standards set forth in these Bylaws and Rules. The Board shall be ultimately responsible for granting membership and Responsibilities.
The Application shall be submitted to the Health Information Management office, which shall initially process the Application and then submit it to the Credentials function of the MEC, or its designee, to have all information verified.
Specific Information Required: 3 Peer References, Continuing medical education for the past two years, professional liability insurance.
Section 11-The Reappointment Process:
A. Application: Within a reasonable period of time prior to the expiration of the Member's two-year appointment (but not less than one hundred twenty (120) days), the Administrator/CEO or his designated representative, such as the HIM office, shall provide each Member with an approved Application for Reappointment form which must be completed and returned within thirty (30) days to the Administrator/CEO for review on behalf of the Credentials function of the MEC. Information to be available for review shall include at least the following: Evidence of continuing licensure, training, education, and experience....Evidence of professional liability coverage....

Review of the hospital's Governing Body meeting minutes revealed no documented evidence of re-appointment of SF4NP and SF5MD by the Governing Body.

SF4NP
Review of the credentialing file for SF4NP revealed no documented evidence of reappointment to the medical staff by the Governing Body.

SF5MD
Review of the credentialing file for SF5MD revealed no documented evidence of reappointment to the medical staff by the Governing Body.
In an interview on 05/23/16 at 2:40 p.m. with SF3DHIM, she indicated SF4NP's and SF5MD's re-appointment had not been approved by the hospital's Governing Body as of 05/23/16. SF3DHIM indicated SF1ADM wanted to have one ADHOC (committee formed with the purpose of addressing a specific issue) meeting in order to take care of all appointments/re-apppointments to the medical staff by 05/31/16. She indicated the re-appointments for SF4NP and SF5MD would be approved/completed at that meeting.

25065




30984

Based on record reviews and interviews, the hospital failed to ensure a RN supervised and evaluated the nursing care of each patient as evidenced by:

1) Failing to ensure antihypertensive medication was administered and the blood pressure reassessed one hour after administration in accordance with physician orders for 1 (#F2) of 9 patient records reviewed for blood pressure checks with antihypertensive medication administration from a total sample of 9 patients.
2) Failing to ensure patients' vital signs were assessed 3 times a day as ordered per physician's order for 4 (#F2, #F5, #F7, #F8) of 9 patients' records reviewed for assessment of vital signs from a total sample of 9 patients.
3) Failing to ensure each patient incident, such as a fall, was documented in the patient's medical record and an assessment is performed and documented by the RN for 2 (#F4, #F5) of 2 patient records reviewed for falls from a total sample of 9 patients.


Findings:

1) Failing to ensure antihypertensive medication was administered and the blood pressure reassessed one hour after administration in accordance with physician orders:
Review of Patient #F2's physician orders revealed an order on 05/04/16 at 1:45 p.m. to check his blood pressure TID (three times a day) with Hypertension Protocol. Further review revealed an order on 05/04/16 at 1:45 p.m. for "Doctor's/LIP's Acute Hypertensive Crisis PRN Orders) that included the following: Clonidine 0.1 mg (milligrams) by mouth every 8 hours PRN blood pressure result of systolic > (greater than) 160 or diastolic > 100; Clonidine 0.2 mg by mouth every 8 hours PRN blood pressure result of systolic > 190 or diastolic > 115; medical consult for increased blood pressure; reassess blood pressure in one hour (if results above parameters Medical Doctor on call must be notified for additional interventions (necessary if patient requires a PRN dose of Clonidine).

Review of Patient #F2's "Graphic Sheet / I&O (intake and output) Sheet" revealed his blood pressure on 05/05/16 at 8:00 p.m. was 194/93.

Review of Patient #F2's "PRN and 1st Dose Medication Administration" record revealed no documented evidence he received Clonidine 0.2 mg by mouth on 05/05/16 at 8:00 p.m. for a blood pressure result of 194/93. Further review revealed on 05/05/16 at 9:08 p.m. his blood pressure was documented as 176/102, and Clonidine 0.1 mg by mouth was administered. There was no documented evidence Patient #F2's blood pressure was reassessed one hour after Clonidine was administered as ordered.

In an interview on 05/23/16 at 3:05 p.m., SF2DON confirmed Patient #F2 did not receive Clonidine 0.2 mg on 05/05/16 at 8:00 p.m., and his blood pressure was not reassessed one hour after he had received Clonidine 0.1 mg at 9:08 p.m.

2) Failing to ensure patients' vital signs were assessed 3 times a day as ordered per physician's order:
Patient #F2
Review of Patient #F2's physician orders revealed an order on 05/04/16 at 1:45 p.m. to check his blood pressure TID (three times a day) with Hypertension Protocol.

Review of Patient #F2's "Graphic Sheet / I&O (intake and output) Sheet" revealed his blood pressure was assessed only twice a day on 05/06/16 and 05/07/16 rather than three times a day as ordered.

In an interview on 05/23/16 at 3:05 p.m., S2DON confirmed Patient #F2's blood pressure was not assessed three times a day as ordered on 05/06/16 and 05/07/16.

Patient #F5
Review of Patient #F5's Medical Consult documented on 05/13/16 at 3:10 p.m. revealed an order to assess vital signs TID.

Review of Patient #F5's "Graphic Sheet / I&O Sheet" revealed no documented evidence her vital signs were assessed the night of 05/13/16 and three times a day on 05/14/16 (pulse and respiration assessed twice this day), 05/15/16, and 05/16/16.

In an interview on 05/23/16 at 3:05 p.m., SF2DON confirmed Patient #F5's vital signs were not assessed as ordered by the physician.

Patient #F7
Review of Patient #F7's medical record revealed an admission date of 05/13/16 with admission diagnoses of Schizophrenia and Polysubstance Abuse. .

Review of Patient #F7's medical record revealed a physician's order, dated 05/14/16, to obtain vital signs TID. Further review revealed no documented evidence of orders to decrease the frequency of the ordered vital signs.

Review of Patient #F7's vital sign graphic record revealed the following entries:
05/15/16, 05/16/16 and 05/17/16: vital signs documented twice, at 8:00 a.m. and 8:00 p.m.;
05/18/16, 05/19/16, 05/20/16 and 05/21/16: vital signs documented once at 8:00 a.m.

In an interview on 05/23/16 at 3:46 p.m. with SF2DON, she confirmed Patient #F7 had physician's orders for vital signs TID. SF2DON also confirmed Patient #F7's vital signs had not been performed as ordered TID. She indicated the patient's vital signs would have been documented on the vital sign graphics record if they had been obtained as ordered.

Patient #F8
Review of Patient #F8's physician orders revealed an order on 05/13/16 at 2:00 p.m. to assess his vital signs TID.

Review of Patient #F8's "Graphic Sheet / I&O Sheet" revealed his vital signs were assessed twice a day on 05/14/16 rather than three times a day as ordered.

In an interview on 05/23/16 at 3:05 p.m., SF2DON confirmed Patient #F8's vital signs were not assessed TID on 05/14/16.

3) Failing to ensure each patient incident, such as a fall, was documented in the patient's medical record and an assessment is performed and documented by the RN:
Patient #F4
Review of an incident documented on 05/14/16 at 9:30 p.m. revealed Patient #F4 had complained at 8:35 p.m. of pain to the left side related to a fall.

Review of Patient #F4's medical record revealed an entry on on 05/14/16 at 9:45 p.m. that Patient #F4 was complaining of left sided pain related to a previous fall earlier in the day.

Review of Patient #F4's "Multidisciplinary Notes" documented on 05/15/16 at 12:35 a.m. revealed Patient #F4 returned from the emergency room after being "pushed out of the wheelchair." Review of the nursing notes revealed no documented evidence of documentation of the fall and an assessment after the fall by the RN.

In an interview on 05/23/16 at 3:05 p.m., SF2DON confirmed Patient #F4's nursing notes had no documentation related to the fall and an assessment by the RN.

Patient #F5
Review of an incident report documented on 05/17/16 at 4:25 p.m. revealed Patient #F5 had reported falling in her room after standing up out of bed at 4:00 p.m. on 05/17/16.

Review of Patient #F5's nursing notes revealed no documented evidence of documentation of the fall and an assessment after the fall by the RN.

In an interview on 05/23/16 at 3:05 p.m., SF2DON confirmed Patient #F5's medical record had no documentation related to the fall and an assessment after the fall by a RN.

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 develop a policy to ensure that 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.

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.

Review of the hospital policy titled "After-Hour Medication Stock With Or Without Pharmacy Review", presented as the current policy by SF2DON, revealed that it is the policy of this facility that safe dispensing of medications will be in accordance with accepted standards of practice and includes, but is not limited to, the following: reviewing all medication orders (except in emergency situations) for appropriateness by a pharmacist before the first dose is dispensed. Further review of the procedure revealed that the hospital allows for an exception to pharmacist review of the medication order for certain situations when time does not permit pharmacist review. This often occurs in "first doses" or "emergency situation." In such cases, an exception is allowed because significant patient harm could result in the delay involved for a pharmacist review, and the potential harm would outweigh the benefits of a pharmacist review. If a first dose is ordered, the medication can be administered without pharmacist approval.

In an interview on 05/23/16 at 3:05 p.m., SF2DON indicated on 05/20/16, the pharmacist's hours changed to 8:00 a.m. to 9:00 p.m. Monday through Friday and 9:00 a.m. to 3:00 p.m. on weekends. She further indicated patients usually are admitted within this span of time. When asked what would happen if a patient was admitted outside the hours of the pharmacist's hours, SF2DON indicated emergency medications would be administered, but first dose medications would be administered the next morning after the pharmacist reviewed the medications.

In an interview on 05/23/16 at 4:50 p.m., SF1ADM indicated the wording of the policy presented as the current policy did not include the process that was discussed with DHH. He confirmed the policy as written is incorrect, because it allows for first dose medications to be administered without a pharmacist's review.












25065

30984

Based on record reviews and interviews, the hospital failed to ensure radiological services were under the direction of a Radiologist as evidenced by failure of the Governing Body to appoint a member of the medical staff, specialized in radiology, as Medical Director of the hospital's Radiological Services.
Findings:
Review of the hospital's Governing Body meeting minutes revealed no documented evidence of appointment of SF7MD as Medical Director of the hospital's Radiological Services.
In an interview on 05/20/16 at 1:05 p.m., SF1ADM indicated appointment of the radiologist as the Medical Director of Radiological Services was not going to be completed until 05/31/16.
In an interview on 5/23/16 at 2:40 p.m. with SF3DHIM, she indicated SF7MD had not been appointed/approved by the Medical Executive Committee as Director of Radiology as of 05/23/16. SF3DHIM indicated she had been waiting on a professional reference for SF7MD. SF3DHIM indicated she had received the professional reference as of 05/23/16. She said SF1ADM said he wanted to have one ADHOC (committee formed with the purpose of addressing a specific issue) meeting in order to take care of all appointments/re-appointments by 05/31/16. She indicated SF7MD would be appointed as Medical Director of the hospital's Radiological Services at that meeting.

26351




17091





25065

Based on record reviews, observations, and interviews, the hospital failed to ensure the infection control officer developed a system for controlling infections and communicable diseases of patients and personnel. This deficient practice is evidenced by:

1) Failing to ensure hospital policy for infection control was followed during blood glucose monitoring. This deficient practice was evidenced by SF8LPN failing to perform hand hygiene in accordance with hospital policy for one observation of the performance of an Accucheck for Patient #RF1 on 05/23/16 at 11:15 a.m.

2) Failing to ensure a sanitary environment was maintained to avoid sources and transmission of infections and communicable diseases as evidenced by having dirty and clean items stored together in Room Fo and having opened, unlabeled milk and water stored in the refrigerator in Room Fr.

Findings:

1) Failing to ensure hospital policy for infection control was followed during blood glucose monitoring:
Review of the hospital policy titled "Hand Hygiene", presented as a current policy by SF2DON, revealed that it is the policy of the facility that all employees, practitioners, and contract services are expected to wash their hands as follows: when arriving at the work area; before contact with each patient, his environment, and anything that comes in contact with the patient; after contact with each patient, his environment, and anything that comes in contact with the patient; when hands are visibly dirty or contaminated; before eating and after using the restroom; before leaving the hospital. Wear gloves for contact with blood or other potentially infectious materials, mucous membranes, or non-intact skin is anticipated. Remove gloves and perform hand hygiene after patient contact.

Observation on 05/23/16 at 11:15 a.m. revealed SF8LPN performing an Accucheck on Patient #RF1. Further observation revealed SF8LPN used hand sanitizer prior to beginning the procedure. He then donned gloves and performed the Accucheck. While wearing the same gloves contaminated during the Accucheck procedure, SF8LPN retrieved Insulin from the refrigerator, got an alcohol wipe and a syringe from the medication cart drawer, drew up the Insulin, and administered the Insulin to Patient #RF1's right arm. SF8LPN removed his gloves and redonned gloves to clean the glucometer without performing hand hygiene after removing his gloves and before redonning gloves.

In an interview on 05/23/16 at 11:27 a.m., SF8LPN confirmed the above breaches in infection control.

2) Failing to ensure a sanitary environment was maintained to avoid sources and transmission of infections and communicable diseases as evidenced by having dirty and clean items stored together in Room Fo and having opened, unlabeled milk and water stored in the refrigerator in Room Fr:
Observation on 05/20/16 at 10:20 a.m. in Room Fo revealed a copier machine, a blood pressure monitor, a plastic garbage bag with clothing in it situated on the floor, a refrigerator for patient food items, and a bin on the table with bags of chips and fruit in it.

In an interview on 05/20/16 at 10:20 a.m. with SF2DON present, SF9MHTS indicated when they get clothing donated by the public, they get the clothing washed, and the good clothing is placed in bins to be used for patients who need clothing. He confirmed the bag of clothing on the floor in Room Fo had not been washed yet, since it was received the previous night. SF2DON confirmed clean items used for patients should not be stored with dirty items, and food items should not be stored with patient and staff equipment.

Observation in Room Fr on 05/20/16 at 11:50 a.m. revealed the patient's refrigerator had an opened, unlabeled half-pint carton of milk and a 16.9 fluid ounce bottle of water in the refrigerator.

In an interview during the above observation on 05/20/16 at 11:50 a.m., SF2DON confirmed the opened, unlabeled items should not be stored in the refrigerator.

Based on record reviews and interviews, the hospital failed to ensure each patient received a psychiatric evaluation that included an inventory of the patient's assets in a descriptive manner and not an interpretive fashion for 3 (#F1, #F7, #F8) of 9 patient records reviewed for strengths/assets in the psychiatric evaluation from a total of 9 sampled patient medical records.

Findings:

Review of the hospital policy titled "Psychiatric Evaluations", presented as a current policy by SF2DON, revealed that the psychiatrist determines influences, assets, and strengths in a descriptive fashion that may impact the course of treatment.

Patient #F1
Review of Patient #F1's Psychiatric Evaluation documented on 05/14/16 at 8:25 a.m. revealed his assets were documented as "has goals, verbal, cooperative." There was no documented evidence that his assets were stated in a descriptive, not interpretive, fashion.

In an interview on 05/23/16 at 3:05 p.m., SF2DON confirmed Patient #F1's assets were not stated in a descriptive fashion in his psychiatric evaluation.

Patient #F7
Review of Patient #F7's medical record revealed an admission date of 5/13/16 with admission diagnoses including Schizophrenia and polysubstance abuse.
Review of Patient #F7's Psychiatric evaluation, dated 05/14/16 at 12:15 p.m., revealed the patient's assets were listed as follows: verbal, intelligent, and cooperative. The patient's assets were listed in subjective, not descriptive terms.
In an interview on 05/23/16 at 3:46 p.m. with SF2DON, she reviewed Patient #F7's Psychiatric Evaluation. SF2DON agreed Patient #F7's assets could have been documented in a more descriptive manner than just being listed as verbal, intelligent and cooperative.

Patient #F8
Review of Patient #F8's Psychiatric Evaluation documented on 05/13/16 at 3:30 p.m. revealed his assets were "I don't know. I just enjoy life." There was no documented evidence that his assets were stated in a descriptive, not interpretive, fashion.

In an interview on 05/23/16 at 3:05 p.m., SF2DON confirmed Patient #F8's assets were not stated in a descriptive fashion in his psychiatric evaluation. She indicated she asked the psychiatrist how they document a patient's assets, and she was told that he/she asks the patient what is a strong asset of theirs.







25065



26351



30984

30984


Based on record reviews and interviews, the hospital failed to ensure the nursing staff developed and kept current an individualized and comprehensive treatment plan for 4 (#F1, #F3, #F4, #F5) of 9 patient records reviewed for a current, individualized, updated, comprehensive treatment plan from a total of 9 sampled patients.

Findings:

Review of the hospital policy titled "Treatment Planning", presented as a current policy by SF2DON, revealed that the treatment plan is patient-specific, individualized, and includes defined problems and needs, measurable goals and objectives based on assessed needs, strengths and limits/weaknesses, frequency of care, treatment, and services, facilitating factors and barriers, and transition criteria to lower levels of care. The nurse revises and develops nursing and medical components of the treatment plan based on additional findings from patient assessments, problems, needs, strengths, limitations/weaknesses, and physician/LIP orders and/or diagnosis. The nurse revises the plan based on changes in the patient's condition.

Patient #F1
Review of an incident reports documented on 05/18/16 revealed that on 05/18/16 at 2:31 p.m. Patient #F1 had scratched his name into the flesh of his left forearm with his fingernail, and he was placed in a physical hold to administer Ativan for increased agitation. Further review revealed his level of observation was increased from every 15 minutes to line of sight while awake.

Review of Patient #F1's treatment plan revealed no documented evidence that his plan was revised when his level of observation was increased.

In an interview on 05/23/16 at 3:05 p.m., SF2DON confirmed Patient #F1's treatment plan was not revised when his level of observation was increased.

Patient #F3
Review of Patient #F3's medical record revealed an admission date of 05/6/16 with an admission diagnosis of Bipolar Disorder.
Review of the hospital's incident reports revealed an incident report, dated 05/14/16 at 11:10 a.m. regarding Patient #F3 smuggling in contraband items i.e. chewing tobacco into the hospital since his admission on 05/6/16. Further reivew revealed the patient had been "cheeking" the tobacco. Additional review revealed the patient had the tobacco hidden in his folded clothing (discovered after room search). Actions taken/recommendations initiated as a result of the incident included instruction to staff to perform room searches (inclusive of searching the patient's clothing and shoes) for hidden contraband items.
Review of Patient #F3's Master Treatment Plan revealed smuggling of contraband items i.e. chewing tobacco was not addressed in the patient's treatment plan after he was identified as having been smuggling in tobacco since his admission (05/6/16) and "cheeking" tobacco.

In an interview on 05/23/16 at 3:53 p.m. with SF2DON, she confirmed Patient #F3's Multidisciplinary Treatment Plan should have been updated after the staff had identified that the patient had been smuggling contraband (chewing tobacco) into the hospital since his admission on 05/6/16. She also indicated the "cheeking" of the tobacco should have also been addressed in the patient's treatment plan.

Patient #F4
Review of an incident documented on 05/14/16 at 9:30 p.m. revealed Patient #F4 had complained at 8:35 p.m. of pain to the left side related to a fall.

Review of Patient #F4's treatment plan for "seizures/falls" developed on 05/04/16 revealed the plan was not revised after the fall that required an emergency department evaluation.

In an interview on 05/23/16 at 3:05 p.m., SF2DON confirmed Patient #F4's treatment plan was not revised after she experienced a fall.

Patient #F5
Review of an incident report documented on 05/17/16 at 4:25 p.m. revealed Patient #F5 had reported falling in her room after standing up out of bed at 4:00 p.m. on 05/17/16.

Review of Patient #F5's treatment plan developed on 05/12/16 for falls revealed no documented evidence that the plan was revised after she experienced a fall on 05/17/16.

In an interview on 05/23/16 at 3:05 p.m., SF2DON confirmed Patient #F5's treatment plan was not revised after she experienced a fall on 05/17/16.