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Based on record review and interview the facility failed to provide written notice of the hospital's determination after investigation of a grievance. This deficiency is evidenced by the lack of a letter of resolution in one (R5) of five (R1, R2, R3, R4, R5) grievances reviewed.
Findings:

Review of the hospital policy titled, "Patient Complaint-Grievance Resolution," approved 03/28/2011, revealed in part, "If a verbal patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires an investigation, and/ or requires further action for resolution, then the complaint is a grievance for the purpose of these requirements."

Review of the grievance log revealed a submission dated 08/18/2021 marked as both a complaint and a grievance. The grievance was received by phone and required an investigation. An investigation was performed and the patient was called after the investigation. The record did not indicate that a written notification was sent.

In interview on 12/01/2021 at 10:05 a.m., S1CEO verified that written notice was not sent.

Based on observation and interview the facility failed to maintain a safe and ligature free environment on the psychiatric unit. This deficiency is evidenced by the presence of ligature risk points at the base of the toilet and the toilet seat in 9 (a, f, g, h, I, j, k, l, and m) of 9 (a, f, g, h, I, j, k, l, and m) rooms viewed on the psychiatric unit.
Findings:

Direct observation during the initial tour of the facility on 11/29/2021 revealed exposure behind the base of the toilet and regular toilet seats which are risk areas for ligatures.

The finding of ligature risks was repeatedly confirmed by S1CEO during the tour of the psychiatric unit on 11/29/2021 between 11:52 and 12:15 p.m.

Based on record review and interview, the hospital's governing body failed to ensure the Quality Assessment and Performance Improvement program (QAPI) reflected the complexity of the hospital's organization and involved all hospital departments and services. This deficiency is evidenced by the failure of the governing body to include occupational therapy, physical therapy, discharge planning, contract linens, contract waste disposal and outpatient services in the Quality Assessment and Performance Improvement Program (QAPI).
Findings:

Review of the Allen Parish Hospital Policy titled, "Quality: Annual Continous Performance Improvement Plan," revised 10/13/2021, revealed in part, "Each department or service will identify the patient care services they provide and the clinical services they perform...Each department will identify their important areas to include, clinical activities that involve high volume patients that carry a high degree of risk to patients, or that tend to produce problems for staff or patients will be deemed most important for purpose of monitoring and evaluation."

Record review on 11/29/2021 navigated by S3Q/IC revealed no measured QAPI metrics for occupational therapy, physical therapy, discharge planning, contract linens, contract waste disposal and outpatient services.

In interview on 11/29/2021 between 3:00 p.m. and 3:11 p.m. S3Q/IC verified physical therapy, occupational therapy, outpatient services, and discharge planning were not included in the QAPI program.

In interview on 12/01/2021 at 10:03 a.m., S1CEO verified that the contracted linen service and the contracted waste management service were not included in the QAPI program.

Based on record review and interviews, the hospital failed to ensure all drugs and biologicals were administered as ordered by the physician and according to acceptable standards of practice for patient records reviewed for 2 (#1, #12) of 5 medical records reviewed for insulin sliding scale protocol from a total sample of 30 patient records.

Findings:

Review of the hospital's policy titled "Safe Use of Insulin in Adults" revealed in part, check the blood glucose level and record the result prior to administering the insulin.

Patient #1
Review of Patient #1's medical record revealed an order for Insulin Regular 100u/ml per sliding scale protocol. According to the physician's order, the times to check the blood glucose were 7:15 a.m., 11:15 a.m., 5:15 p.m., and 8:00 p.m. per day. Further review revealed no documentation of a blood glucose had been checked or an explanation as to why it had not been done on 11/05/2021 at 7:15 a.m., 11/15/2021 at 7:15 a.m., and 11/17/2021 at 5:15 p.m.

In an interview on 11/30/2021 at 10:07 a.m. S3Q/IC confirmed the above stated blood glucose checks were not done, no insulin was given, and no reason for not checking the blood glucose was documented by the nurse.

Patient #12
Review of Patient #12's medical record revealed an order for Insulin Regular 100u/ml per sliding scale protocol. According to the physician's order, the times to check the blood glucose were 7:15 a.m., 11:15 a.m., 5:15 p.m., and 8:00 p.m. per day. Further review revealed no documentation of a blood glucose had been checked or an explanation as to why it had not been done on 09/26/2021 at 7:15 a.m. and 09/27/2021 at 7:15 a.m.

In an interview on 12/01/2021 at 8:15 a.m. S3Q/IC confirmed the above stated blood glucose checks were not done, no insulin was given, and no reason for not checking the blood glucose was documented by the nurse.

Based on record review and interview, the hospital failed to ensure medication administration errors were documented in the patients' medical records and reported to the attending physician for 2 of 2 (#1, #2) sampled patients reviewed with known medication errors out of a total sample of 30. Findings:

Review of the hospital policy titled, Medication Management-Medication Errors, revealed in part, the nurse caring for the patient at the time of the discovery of the medication error shall report the error to the practitioner ordering the medication...The following should be documented in the patient's medical record: a. medication, dose, strength, form ordered b. medication, dose, strength, form given c. date, time & method of prescriber notification d. any subsequent monitoring, test, or orders given by the prescriber.

Review of the medication error reporting form dated 10/17/2021 for Patient #1 revealed Pravastatin 40 mg-Take 2 tablets by mouth every evening at bedtime was ordered by the physician. According to the medication error form only 1 tablet was administered to the patient.

Review of the medication error reporting form dated 11/04/21 for Patient #2 revealed Oxycodone/APAP 10/325 mg by mouth every 6 hours as needed was ordered by the physician. Hydrocodone/APAP 10/325 mg was administered instead according to the medication error report form.

An interview was conducted with S13Dir of Informatics on 11/30/2021 at 1:49 p.m. She stated with review of the EMR of Patient #1 and #2, there was no documentation of the medication error in the patients' EMR or of the physician being notified of the medication error.

Based on observation and interview the facility failed to maintain the physical environment in such a manner that the safety and well-being of the patient were assured. This deficiency is evidenced by 1) A large area of black substance on the shower tile in one (f) of nine (a, f, g, h, I, j, k, l, and m) bathrooms viewed on the psychiatric unit. 2) Presence of cracked and peeling floor tile in one (n) of two (n and o) main group rooms.
Findings:

1) A large area of black substance on the shower tile in one (f) of nine (a, f, g, h, I, j, k, l, and m) bathrooms viewed on the psychiatric unit.

Direct observation on 11/29/2021 during the initial tour of the facility revealed the shower in Room f had a black powdery substance extending from the showerhead to approximately 1 foot above the base of the shower.

In interview during the tour on 11/29/2021 at 12:00 p.m, S1CEO verified that the shower needed to be cleaned.

2) Presence of cracked and peeling floor tile in one (n) of two (n,m) main group rooms.

Direct observation on 11/29/2021 during the initial tour of the facility revealed cracked, chipped and stained tile in Room n which could not be properly cleaned. The room is used for quiet activities and also for the distribution of food trays.

In interview during the tour on 11/29/2021 at 12:16 p.m., S1CEO verified the damaged tile could not be properly cleaned.

Based on record review, observation, and interview the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by:

1. failing to ensure the crash cart was checked each shift for availability and function of equipment, supplies, and drugs, as evidenced by pre-documenting the PM shift check on the daily log;

2. failing to ensure expired supplies were not available for patient use;

3. failing to record temperatures of the medication refrigerator for 2 shifts in the month of November;

4. failing to ensure the AED was checked daily as evidenced by no documentation of the AED being checked on 11/28/2021.

Findings:
1. failing to ensure the crash cart was checked each shift for availability and function of equipment, supplies, and drugs, as evidenced by pre-documenting the PM shift check on the daily log.

Review of the hospital's policy titled "Medication Use- Maintenance of Emergency Drug Containers" revealed in part, nurses and ancillary staff shall inspect emergency drug containers at least once per shift to ensure that the cart is locked and ready for use.

Review of the emergency drug container daily check log that was provided by the hospital on 11/29/2021 at 11:32 a.m. revealed the PM shift for 11/29/2021 was already checked and signed by nursing staff.

In an interview on 11/29/2021 at 12:24 p.m. S1CEO verified the emergency drug container daily check log was already filled out for the PM shift on 11/29/2021 and should not have been pre-documented by the nursing staff.

2. failing to ensure expired supplies were not available for patient use.

Review of the hospital's policy titled "Rotation of Expiration Date/Inventory Supplies" revealed in part, all expiration dated inventory supplies must be issued first in first out method.

In an observation of the hospital on 11/29/2021 at 11:00 a.m. - 12:20 p.m. revealed the following supplies were expired:
Supplies located in the Emergency Department
8 of 8 female urinary specimen kits with an expiration date of 10/01/2021.
3 of 3 irrigation tray with piston syringe with an expiration date of 11/01/2021.
4 of 4 disposable skin stapler kits with an expiration date of 11/13/2020.
1 of 1 ChloraPrep one-step with tint with an expiration date of 4/2021.
1 of 1 6F intubation stilette with expiration date of 05/04/2021.
3 of 3 pediatric lumbar puncture trays with the expiration date of 02/28/2021.

Supplies located in the Medical Unit
5 of 5 female urinary specimen kits with an expiration date of 10/01/2021.
3 of 3 irrigation tray with piston syringe with an expiration date of 11/01/2021.

During the observation on 11/29/2021 at 11:00 a.m. - 12:20 p.m. S1CEO verified the above stated supplies were expired.

3. failing to record temperatures of the medication refrigerator for 2 shifts in the month of November.

Review of the hospital's policy titled "Refrigeration and Freezing" revealed in part, pharmacy with assistance from the nursing staff shall be responsible for recording temperatures on medication units in the main facility.

Review of the medication refrigerator temperature log in the behavioral health unit revealed the log had not been completed for the PM shift on 11/28/2021 and the AM shift on 11/29/2021.

In an interview on 11/29/2021 at 11:58 a.m. S4BHDON verified the medication refrigerator temperature log had not been completed for the PM shift on 11/28/2021 and the AM shift on 11/29/2021. In an interview on 12/01/2021 at 8:55 a.m. S4BHDON confirmed the temperature of the medication refrigerator is checked twice (AM & PM) per day.

4. failing to ensure the AED was checked daily as evidenced by no documentation of the AED being checked on 11/28/2021.

Review of the AED log in the behavioral health unit revealed in part, AED is to be checked nightly. Further reviewed revealed there was no documentation of the AED being checked on 11/28/2021.

In an interview on 11/29/2021 at 12:02 p.m. S4BHDON verified there was no documentation of the AED being checked on 11/28/2021.

Based on record review and interview, the facility failed to ensure patients admitted to the Swing Beds were notified of all their rights prior to admission for 2 of 2 patients (#4, #5) admitted to a Swing Bed out of a total sample of 30 patients.
Findings:

Review of the patient rights presented to the Swing bed patients on admission revealed the right to choose to or refuse to perform services for the facility and the right to send and receive mail was not included in the patient rights.

An interview was conducted with S1CEO on 12/01/2021 at 10:30 a.m. S1CEO confirmed the right to choose or refuse to perform services for the facility and the right to send and receive mail was not included in the patient rights for the Swing bed patients.

Based on interview, the hospital failed to notify the Swing bed residents or residents' representatives of a transfer or discharge in writing for 2 out of 2 (#4 and #5) swing bed patients reviewed out of a sample of 30.
Findings:

An interview was conducted with S1CEO on 12/01/2021 at 10:30 a.m. She reported the hospital does not notify the swing bed residents or their representatives of their pending transfers or discharges in writing.