HospitalInspections.org

Based on review of the current Patient Rights policy and procedure (2/2010) and interview with the DON, the hospital failed to provide to the patient and/or patient's representative the internal grievance process, including whom to contact to file a grievance, and the phone number and address for lodging a grievance with the State agency. Findings:

Review of the patient admission packet revealed a form listing Patient Rights. Further review revealed information indicating that patients had "The right to be informed in writing about the hospital's policies and procedures for initiation, review and resolution of patient complaints, including the address and telephone number of where complaints may be filed with the department". There failed to be a contact name, a telephone number, or an address for filing a grievance.

Interview on 1/20/11 at 1:30 PM with S7 DON confirmed the Patient Rights form, provided to patients on admission, failed to indicate who to contact to file a grievance or a phone number and address for lodging a grievance with the State agency. S7 confirmed the patient would have to request that information in order to file a complaint/grievance.

Based on review of personnel files and interview with staff, the hospital failed to ensure policies and procedures of the hospital are adhered to by not providing orientation or annual evaluations for 2 of 2 contract nurses (S3, S4) who assisted the cardiologist with invasive cardiac procedures. Findings:

Review of personnel files maintained by the hospital for S3 Contract RN and S4 Contract RN revealed each file contained licensure verification for the RNs and results of their TB skin tests. These files failed to contain documented evidence of an application for employment, general hospital orientation, job description, or a performance evaluation. The files also indicated S2 and S3 had worked in their present part-time position since 6/09.

Interview on 1/20/11 at 2:30 PM with S5 Human Resource Director revealed she was unsure when S3 and S4 actually came to work at the hospital, but confirmed the RNs began working in surgery with the cardiologist without going through orientation training. Additionally, S5 confirmed at that time an annual evaluation had not been done for S3 and S4 since their hire date.

Based on observation, review of medical staff meeting minutes from 1/01/2010 to 1/01/2011 and interview with surgical staff, the hospital failed to obtain Medical Staff approval to change the endoscopic high level disinfectant solution. The hospital failed to provide documented evidence of staff training on the use of the new high level disinfectant. Findings:

On 1/18/11 at 9:00 AM, observation in the processing room for endoscopes, revealed there was no odor of Cidex. Interview with S10 RN surgery charge nurse revealed surgical services no longer used Cidex for disinfecting endoscopes. S10 stated that back in March 2010 the gastroenterologist suggested using ReCert XL since it had no toxic fumes and did not leave the scopes sticky like Cidex solution. S10 also stated the immersion time was less and increased turnaround time. Review of the literature on the ReCert XL label revealed the immersion time was a minimum of 8 minutes and the solution was to be discarded after 21 days. Observation at that time revealed there was a timer for the endoscope processing staff to set to ensure proper immersion time. There were no endoscopes scheduled during the survey.

Review of the activation record log revealed the ReCert XL solution was activated 4/9/10 and discarded 5/20/10: available for disinfection for 41 days; solution was activated 8/3/10 and discarded 8/26/10: available for disinfection for 24 days; solution activated 12/10/10 and discarded 01/03/11: available for disinfection for 24 days.

Interview with S10 RN surgery charge nurse on 1/20/11 at 9:45 AM revealed the decision was made to change the solution on the suggestion of the gastroenterologist and it was not approved for use by the Medical Staff. Review of medical staff meting minutes from 1/01/2010 to 1/01/2011 failed to reveal documentation that ReCert XL was approved for use in the hospital. During the interview S10 stated the surgery staff received training from the ReCert XL sales representative, but there was no documented evidence of attendance.

Based on review of 5 of 11 sampled personnel files maintained by the hospital and interviews, the hospital failed to ensure individuals found guilty of abuse, neglect or mistreatment of patients are not employed. This was evidenced by the failure of the hospital to obtain a thorough pre-employment criminal background check on all new employees to identify potential hiring risks for safety and security reasons. Findings:

Review of personnel files for 3 RNs (S8, S3 and S4) 1 LPN (S7) and 1 radiology tech (S9) revealed they had worked at the hospital since 2009. Review of the criminal background checks for the 4 staff revealed they were only done in the parish each staff member resided in, and the information only pertained to charges in that parish. In an interview on 1/20/2011 at 2:30 PM S5 Human Resources Director confirmed she was directed by S11 Administrator to only request pre-employment criminal background checks from the parish where the individuals resided. This was confirmed by S11 during the exit conference on 1/20/2011 at 3:30 PM.

I. Based on record review and interview the hospital failed to ensure the activity program for swing bed patients was directed by a qualified professional. This was evidenced by the failure of the hospital to provide documentation that S1 Discharge Planning Coordinator was qualified to direct the activity program. Findings:

Review of the 1/18/2011 daily census revealed there were 4 patients in swing bed. Review of the medical records failed to reveal activity assessments for 3 of the 4 patients and the patients had been in swing bed longer than 3 days. In an interview on 1/18/2011 at 11:45 AM S2 RN Charge Nurse reported the swing bed activity program was provided by S1 Discharge Planning Coordinator.

Review of the personnel file maintained by the hospital for S1 Discharge Planning Coordinator failed to reveal documentation that S1 was licensed or registered to provide therapeutic activities for swing bed patients. Additionally, the file did not contain a job description for the activity coordinator for swing bed patients. On 1/18/2011 at 2:25 PM an interview with S1 revealed she completed an activity program "years ago but I lost my certificate and cannot find it".


II. Based on record review and interview the hospital failed to ensure 6 of 8 sampled patients occupying swing bed (#4, #5, #7, #9, #10 and #18) were provided a comprehensive assessment of their interests in order to design an ongoing program of activities to meet the needs of each patient . Findings:

Review of the open medical records for patients #7, #9 and #10 and the closed medical records for patients #4, #5, #and #18 failed to reveal a comprehensive assessment of each patient's interest to assist in providing an ongoing program of activities while the patients were in swing bed. S1 Discharge Planning Coordinator stated in an interview on 1/18/2011 at 2:25 PM that "most patients just want to watch TV" and confirmed she does not provide a variety of projects to peak the interest of swing bed patients.