HospitalInspections.org

Based on review of medical records and staff interview, the Governing Body failed to ensure the members of the medical staff were held accountable to the Governing Body for the quality of care provided to the patients as evidenced by medical staff members not assessing and pronouncing death for 1 (#1) of 1 deceased patient medical records reviewed. Findings:

Review of the hospital policy titled, Death Summations; Required Autopsies, revealed the following: Procedure: Respondents to Code Blue - Attending Physician: Examines patient and verifies death. There was no documented evidence of any other policy regarding the pronouncement of patient death in the hospital.

Review of the Medical Staff Rules & Regulations revised 08/12/10 revealed no documented evidence of any provisions related to the pronouncement of patient death in the hospital.

Patient #1
Review of the medical record for Patient #1 revealed the patient was a 45 year old male admitted to the hospital on 11/01/14 with diagnoses of Major Depression without psychosis with Suicidal Ideations, and Alcohol Dependence.

Review of the Multidisciplinary Progress Notes dated 11/06/14 revealed at 10:01 a.m., the patient was found unresponsive leaning on the bathroom wall. The notes revealed CPR (Cardio pulmonary resuscitation) was initiated, a "code blue" and 9-1-1- were called. At 10:10 a.m., an ambulance service arrived and care was relinquished to the ambulance personnel. The notes revealed the following: At 10:48 a.m., Ambulance stopped CPR. S1DON and S22NP (Nurse Practitioner) arrived on site and S22NP pronounced patient dead at 10:52 a.m.

Review of the Progress Notes documented on 11/06/14 at 11:30 a.m. by S22NP revealed in part the following: ....Upon arrival - patient remained non-responsive, no respirations, no pulse; EMS (Emergency Medical Service) present - pronounced time of death 10:52 a.m.

In an interview on 03/02/15 at 2:30 p.m., S2RN, Nurse Manager verified she was present for the patient's code. She stated S22NP pronounced the patient dead. She reviewed the record and verified the Multi Disciplinary Notes revealed S22NP pronounced the patient. S1DON (Also present for the interview) stated the coroner was in the hospital at the time. Stated they called him because they had not had a death before and were not sure what to do. S2RN, Nurse Manager stated the ambulance personnel came and took over the code. She stated they communicated with their physician over the phone and they stopped the code. Both S1DON and S2RN stated S22NP came in and pronounced the patient.

In an interview on 03/02/15 at 3:15 p.m. S1DON stated she had spoken to S22NP and she told her the EMS doctor called the code. S1DON stated S22NP told her the EMS physician called the code and pronounced the patient.

In an interview on 03/03/15 at 9:15 a.m., S1DON reviewed the hospital policies and verified the hospital did not have a policy for for the pronouncement of death.

In an interview on 03/03/15 at 12:05 p.m. S22NP stated she was rounding on patients when the code for Patient #1 was called. She stated she did not pronounce the patient and stated she did not know who pronounced the patient. After reviewing her note, she confirmed EMS had stopped the code and pronounced the patient.

Based on record review and interview, the hospital failed to ensure a patient's representative with a grievance received a written notice of the name of the contact person at the hospital, the steps taken on behalf of the patient to investigate the grievance, the result of the grievance process and the date of completion for 1 (#R9) of 2 patients' grievances reviewed.

Findings:

Review of the Hospital policy titled Grievance Procedures Patient and Family, Revised: 11/17/11, revealed in part:
13. You will be notified in writing of the findings of the investigation within 10 days of your written and/or verbal complaint, the actions taken to resolve the issue, and the name of the person to contact if you are not satisfied with the resolution to the complaint. If you are discharged before the investigation is complete, the hospital will mail its findings to the address in your medical record, to your attention.

Review of the grievance binder revealed a document titled Complaint and Resolution Form. The complaint involved Patient #R9's husband complaining of a staff member being disrespecting his wife on 12/28/14 and staff not controlling other patients' behavior and their comments to his wife. He also complained on 12/27/14 of staff not informing him of his wife's progress on 12/26/14. The Resolution/Corrective Action on the document dated 12/29/14 was listed as: I will speak with the charge nurse about what happened over the weekend. I explained to him our full time staff was off on Friday due to the holidays and that is why he did not get any information regarding his wife's progress. Further review revealed no investigation was documented. A call was documented as having been placed to Patient #R9's husband by S2RN, but no letter was documented as having been sent to the complainant.

In an interview on 3/3/15 at 10:00 a.m. with S1DON, she verified the above mentioned complaint was not resolved at the time of the complaint and also required an investigation which made it a grievance. She also verified the hospital did not mail a letter to the complainant as per hospital policy.

Based on record review, observation and interview, the hospital failed to ensure 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. Findings:

Review of the policy for Room Checks, Policy EOC-20 revealed in part, Nursing staff members will check patient rooms in the inpatient facility on a daily basis between 7 a.m. and noon to check patient housekeeping/hygiene habits and to check for any potentially dangerous articles and contraband. Room checks include searching drawers, looking under mattresses, etc. Poor housekeeping/hygiene habits will be dealt with therapeutically. Potentially dangerous articles/contrabands will be removed from the rooms. All life safety hazards will be brought to the attention of the Director of Nursing and the Administrator...
RN (Registered Nurse) -Brings to the attention of the treatment team any repeated violation of good housekeeping/hygiene standards and/or possession of potentially dangerous articles/contraband so problem can be addressed and treatment modified as necessary.

An observation was conducted on 03/02/15 at 10:50 a.m. of outdoor area used by the patients. A wooden plank fence was noted to enclose the outdoor patient area. A loose plank was observed in the fence located along the right side of the area and behind a storage shed. A nail was observed to be protruding from the loose plank. 2 moveable chairs were observed positioned next to the fence providing a step for escape over the wooden fence. At 11:40 a.m., S9RN confirmed the above observations in the patients' outdoor area.

An observation was conducted on 3/2/15 at 11 a.m. of the shower room. The shower room had 3 shower stalls with each shower stall having a shower head attached to approximately a 6 foot long shower hose (hand held shower head). Two of the showers had a grab bar attached to the wall with a greater than 2 inch opening between the bar and the wall. The knobs on the showers had a handle that presented a ligature risk also. In the ceiling of the shower room was a 3 tiered metal vent, which also was a ligature risk. S9RN confirmed the observations.

In an observation on 03/02/15 at 11:03 a.m. with S9RN, the doors to the patients' rooms and the bathroom doors were observed to have door hinges set apart widely enough to allow for potential ligature. The door handles on patient room doors and bathroom doors were positioned in a downward fashion to potentially facilitate ligature over the door frame. The screws for the hinges and the door handles were not tamper resistant. S9RN confirmed the above observations as potential ligature points.

An observation was conducted on 3/02/15 at 11:05 of a chest of drawers in every patients' rooms. The drawers in the chest could easily be removed. Also in Room 21 there were 3 wooden drawers that were broken and had visible splinters. In Room 16 a drawer was observed to have a portion of the face of the drawer broken away with large exposed splintering of bare wood. In all the patient bathrooms the toilet plumbing was visible and the sinks had goose-neck faucets. All the patients' beds had springs that were removable. In room 24-A and B the window in the room could be raised approximately 2 feet. The observation was confirmed by S9RN.

In an observation on 3/02/15 at 11:10 a.m. of the hallway where the patients' rooms were located, revealed an unlocked electrical panel. S9RN verified the panel should have been locked.

In an observation on 03/02/15 at 11:12 a.m., with S9RN in Room 20 B bed revealed the wooden cabinet for storage of patient's clothing contained a rod for hanging clothes. S9RN stated the rod should not be there and confirmed the rod could be a ligature point for hanging/strangulation. Further observation in Room 16 revealed a wooden cabinet with a rod for hanging clothes. S9RN confirmed the rod was present in the cabinet and could be used as a ligature point. S9RN stated all the rods should have been removed.

In an observation with S9RN on 3/2/15 at 11:12 a.m., the lids on the toilet tanks were not secured in the restroom near the seclusion room and patient rooms D-17, 22, and 24.

In an observation with S9RN on 3/2/15 at 11:15 a.m., a large fire extinguisher was discovered in an unlocked window case in the hallway. Patients' rooms were next to the unlocked fire extinguisher.

An observation was conducted with S9RN on 3/02/15 at 11:20 a.m. of 3 doors off of the hallway by the nurse's station for bathrooms and shower room that had exposed door closers at the top of the door. The doors also had 4 sets of open ended pinned hinges on each door. The handle on the outside of the door was a solid metal lip pull that represented a ligature and safety risk. The screws for the hinges, door closers, and handles were not tamper resistant. S9RN confirmed the observations of the door closers, hinges, handles, and screws.


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17091

Based on record review and interview, the hospital failed to ensure the use of restraints was documented in the patients' plan of care or treatment plan for 2 (#R1, #12) of 4 (#R1, #R2, #R3, #12) patients' medical records reviewed for restraints.

Findings:

Review of the hospital policy titled Restraint/Seclusion Process, created 10/21/14, revealed in part:
6) RN (Registered Nurse) shall make modifications to the patient's Behavior Modification Treatment Plan within 1 hour of implementation when R/S (restraint/seclusion) (including chemical restraints) are used to modify a patient's dangerous and/or destructive behavior.

Patient #R1
Review of a document titled Physician's Order Sheet for Seclusion/Restraints revealed Patient #R1 was administered Benadryl 50 mg (milligrams), Ativan 2 mg and Haldol 10 mg on 5/06/14 at 8:35 a.m. as a chemical restraint to protect him and others. Further review of the medical record revealed no modification had been made to Patient #R1's treatment plan.

In an interview on 3/04/15 at 9:00 a.m. with S2RN, she verified the treatment plan for Patient #R1 had not been modified to reflect the chemical restraints used on Patient #R1 on 5/06/14.


Patient #12
Review of the medical record for Patient #12 revealed the patient was admitted to the hospital on 12/02/14 with a diagnosis of Bipolar Disorder. Review of a document titled Physician's Order Sheet for Seclusion/Restraints revealed a therapeutic hold was ordered on 12/04/14 at 10:20 a.m. Review of the Restraint/Seclusion Flow Sheet revealed the therapeutic hold was implemented from 10:20 a.m. to 10:35 a.m.
Review of the record revealed no documented evidence the patient's treatment plan had been updated with the use of the restraint.

In an interview on 3/03/15 at 3:15 p.m., S2RN reviewed the medical record for Patient #12 and confirmed the treatment plan for Patient #12 had not been modified to reflect the restraint used on Patient #12 on 12/04/14.

Based on review of QAPI (Quality Assessment Performance Improvement) records and staff interview, the hospital failed to ensure quality indicators relative to the completion of medical records were included in the hospital's QAPI program.
Findings:
Review of the Hospital's Policy titled "Quality Assurance/Performance Improvement Plan" presented by S3Administrative Assistant as being current (12/24/14) revealed in part: The Performance Improvement Committee establishes, maintains, supports and documents evidence of an ongoing hospital-wide Performance Improvement programs for all departments .... D. Health Information (Medial Records) Management. The Performance Improvement Committee meets at least monthly to review and analyze data collected form monitoring and evaluation activities. Any negative patterns or trends and/or opportunities to improve performance will be discussed and shall result in conclusions by the committee.
Review of the QAPI data (Performance Improvement Committee Meeting (01/14- 01/15)) provided by S3Administrative Assistant, revealed no documented evidence of data collection from May of 2014 to January of 2015 for deficient & delinquent charts. The documentation revealed data had been "deferred " (no data collected). In addition, there was no documented evidence of the specific method and frequency of data collection for medical records.
In an interview on 03/04/15 at 1:30 p.m., S1DON & S3Administrative Assistant indicated the performance indicators for medical records were incomplete. S3Administrative Assistant indicated when data is not available at the time of the meeting, the information is considered to be "deferred." S1DON & S3Administrative Assistant provided no explanation for the "deferred" data from May of 2014 through January of 2015.

26351

Based on observation, record review and interview, the hospital failed to ensure the QAPI program established clear expectations of patient safety as evidenced by

1) failing to ensure the effective implementation of an infection control surveillance program relative to the hospital environment of care and failing to develop corrective actions relative to infection control breeches in regards to an unsanitary environment of care and;

2) failing to analyze a sentinel event and implement preventive actions for 1 of 1 (#1) sentinel event in the hospital.

Findings:

1) Failing to ensure the effective implementation of an infection control surveillance program relative to the hospital environment of care and failing to develop corrective actions relative to infection control breeches in regards to an unsanitary environment of care:
Review of the Hospital's Policy titled, "Quality Assurance/Performance Improvement Plan" presented by S3Administrative Assistant as being current (12/24/14) read in part: "The Performance Improvement Committee establishes, materials, supports and documents, evidence of an ongoing hospital-wide Performance Improvement program for all departments .....B. Infection Surveillance/Prevention/Control. Monitors and tracks organization-wide identified problems, corrective actions, improvements and outcomes ... Tracks ...patient and staff infections, over/under utilization, safety issues identified."

Review of the Infection Surveillance, Prevention and Control: Observation Tour of Facilities conducted by S23RN, Infection Control Nurse Consultant, dated 1/23/15, revealed no issues with the overall sanitation and cleanliness of the hospital.

Review of the policy for Room Checks, Policy EOC-20 revealed in part, Nursing staff members will check patient rooms in the inpatient facility on a daily basis between 7 a.m. and noon to check patient housekeeping/hygiene habits and to check for any potentially dangerous articles and contraband. Room checks include searching drawers, looking under mattresses, etc. Poor housekeeping/hygiene habits will be dealt with therapeutically. Potentially dangerous articles/contrabands will be removed from the rooms. All life safety hazards will be brought to the attention of the Director of Nursing and the Administrator.

An observation was conducted in the shower room of the hospital on 3/02/15 at 11 a.m. The shower room had 3 shower stalls. Three (3) out of the three (3) shower stalls had a black substance located on the tiles of the shower stalls. The black substance had a mold like appearance was located on 1/4 of the walls, starting at the bottom of the shower stalls. Other areas of the walls in the shower room, not located in the shower stalls, also had a black substance on them. The black substance was easily removed with a bleach solution. S9RN confirmed the findings at the time of the observation and indicated that the black substance appeared to be mold.

An observation was conducted of the soiled utility room on 3/02/15 at 10:45 a.m. On the floor of the soiled utility room was a box of opened unused rolls of paper towels (approximately 10 rolls). The observation was confirmed by S9RN at the time of the observation.

An interview was conducted with S4Housekeeper on 3/03/15 at 9:45 a.m. She reported she worked for Nursing Home A and came to the hospital once a day to clean the hospital's bathrooms and floors. She reported the mold in the shower room has been a problem.

An interview was conducted with S2RN on 3/03/15 at 1 p.m. S2RN reported she was in charge of the Infection Control Program. S2RN further reported S23 Infection Control Nurse Consultant comes to the hospital once a month to do environmental rounds. In addition, S2RN reported, the last time S23 Infection Control Nurse Consultant toured the hospital was on 1/23/15. S2RN reported the S23 didn't mention the unsanitary conditions of the hospital to her or the presence of the mold.

2) Failing to analyze a sentinel event and implement preventive actions for 1 of 1 (#1) sentinel event in the hospital.
Review of the hospital policy titled Adverse-Sentinel Events, Policy number LD-11, provided by S1DON (Director of Nursing) revealed in part the following: All sentinel events - significant unanticipated events - take precedence over all day to day administrative activities and will be immediately and thoroughly investigated to determine root cause of the event....Swift corrective actions will be implemented to reduce the risk of the event recurring. Additionally, the effectiveness of the corrective actions shall be monitored. Sentinel events at the hospital include, but are not limited to the following: any client death....
Review of the hospital policy titled, Death Summations; Required Autopsies, revealed the following: Procedure: Respondents to Code Blue - Attending Physician: Completes Special Case Review at time of death....
Patient #1
Review of the medical record for Patient #1 revealed the patient was a 45 year old male admitted to the hospital on 11/01/14 with diagnoses of Major Depression without psychosis with Suicidal Ideations, and Alcohol Dependence.

Review of the Multidisciplinary Progress Notes dated 11/06/14 revealed at 10:01 a.m., the patient was found unresponsive leaning on the bathroom wall. The notes revealed CPR (Cardio pulmonary resuscitation) was initiated, a "code blue" and 9-1-1- were called. At 10:10 a.m., an ambulance service arrived and care was relinquished to the ambulance personnel. The notes revealed the following: At 10:48 a.m., Ambulance stopped CPR. S1DON and S22NP (Nurse Practitioner) arrived on site and S22NP pronounced patient dead at 10:52 a.m.

In an interview on 03/03/15 at 9:15 a.m., S1DON was asked to provide the " Special Case Review " related to Patient #1's death as indicated in the Death Summations policy. S1DON provided the hospital's Adverse-Sentinel events policy and stated the death of Patient #1 was the only patient death and sentinel event the hospital had ever had. The sentinel event analysis or root cause analysis was requested for review. At 11:24 a.m. Sentinel event analysis was requested again.

In an interview on 03/03/15 at 2:41 p.m. S2RN confirmed there was no sentinel event/Root Cause Analysis done regarding the death of Patient #1 and there was no Special Case Review" documented by the physician. S2RN stated the only review that was done was the "Debriefing" that was the typed form attached to the incident report. S2RN and stated it was a typed timeline of the code procedure.

In an interview on 03/04/15 at 1:00 S1DON stated they did a review of the events that led to the patient's death, but she confirmed it was not documented. She stated they determined from the review of the code procedure that a clear leader was needed during a code. She stated they did an inservice regarding the code procedure for the staff. Review of the Code Blue inservice provided revealed all staff were not included. S1DON stated the inservice was only for the staff that were present during the code and it did not include all staff in the hospital. S1DON confirmed there was no RCA done for the patient's death.


31206

Based on record review and interview, the Governing Body failed to ensure that the hospital's QAPI (Quality Assessment Performance Improvement) program reflected the hospital's organization and services as evidenced by not having all hospital departments and services, including those services furnished under contract, involved in the QAPI Program. The governing body failed to ensure the QAPI program included monitoring of Respiratory, Dietary and Housekeeping Services.
Findings:
Review of the Hospital's Policy title "Quality Assurance/Performance Improvement Plan" presented by S2RN (Registered Nurse) as being current (12/24/14) revealed in part: "Overview: Performance Improvement is a continuous process. Its aim is to reflect the complexity of the Hospital's organization and involves all hospital departments and services including those services furnished under contract or agreement ... The Performance Improvement Program provides for an ongoing structured system for monitoring and evaluating of important aspects of patient care. The effectiveness and efficiency of the Performance Improvement program is evaluated on an annual basis."
Review of the QAPI records revealed no documented evidence that the contracted services of Respiratory, Dietary and Housekeeping Services were included in the Hospital's QAPI Program.
In an interview on 03/04/15 at 12:25 p.m. S1DON (Director of Nursing) confirmed the hospital did not include quality indicators for contracted services provided to the hospital for Respiratory, Dietary and Housekeeping.

Based on record review and interview, the hospital failed to ensure the current (2015) Performance Improvement Project had been approved by the hospital's medical staff and Governing Body.
Findings:
Review of the hospital 's Quality Assurance/Performance Improvement Plan, revised date of 12/24/14 read in part: "Two performance improvement projects have been identified for this year. Falls, the number one safety related incident in 2014, and Policy and Procedure Revisions/Forms. "
Review of the hospital QAPI (Quality Assessment Performance Improvement) records revealed there was no documented evidence that the hospital's current year (2015) project (work in progress) (Utilization Review) had not been approved by the hospital's Medical Staff and/or Governing Body.
In an interview on 03/04/15 at 1:15 p.m., S3Administrative Assistant confirmed the Performance Improvement Project had not been approved by the Medical Staff and/or the Governing Body.

Based on record review and staff interview, the hospital failed to ensure drugs and biologicals were administered in accordance with physician orders and hospital policy for 5 (#1, #2, #7, #9, #12) of 5 sampled patients reviewed for medications administration, and 4 (R4, R6, R7, R8) of 5 (R4, R5, R6, R7, R8) random patients reviewed for medication administration.

Findings:

Review of the hospital policy titled, Medication Variance Corrective Action revealed in part the following: Types of medication variances include, but are not limited to, the following:
Wrong patient - The administration of medication to a patient other that the patient for whom ordered.
Wrong dose - Any dose, either more than or less than the exact amount ordered.
Wrong Medication - The administration of any medication not ordered for that patient at the time of administration.
Wrong Time - Any medication administered either 60 minutes before or after the order time.
Wrong Route - Any medication administered by a route other than the ordered.
Omission of Medication - Dose of medication not administered when it was ordered.
Procedure: When a medication variance level 1 or above occurs, the person who made the error, or if not available, the person who discovered the variance will:
Assess patient, including vital signs and symptoms of reaction. Notify the patient's physician and DON or Charge RN.
Document the occurrence in chart without reference to "error" or "mistake."
Report all levels of medication incidents via incident reports.

Review of the hospital policy titled Administration of Drugs revealed in part:
When a medication is not given for any reason, chart this in the Nurses Notes and circle the space on the medication sheet with the reason for omission documented on the back of the MAR.

Patient #1
Review of the medical record for Patient #1 revealed the patient was a 45 year old male admitted to the hospital on 11/01/14 with diagnoses of Major Depression without psychosis with Suicidal Ideations, and Alcohol Dependence.

Review of the Multidisciplinary Progress Notes dated 11/06/14 revealed at 10:01 a.m., the patient was found unresponsive leaning on the bathroom wall. The notes revealed CPR (Cardio pulmonary resuscitation) was initiated, a "code blue" and 9-1-1- were called. At 10:10 a.m., an ambulance service arrived and care was relinquished to the ambulance personnel. The notes revealed the following: At 10:30 a.m., Ambulance personnel requested assistance form S2RN....S2RN pushed 50 mg. epinephrine and half of bicarb. CPR was ongoing....

Further review of the record revealed no documented evidence of any physician's orders for the epinephrine or the bicarb.

In an interview on 03/02/15 at 3:30 p.m., S2RN, Nurse Manager verified she administered intravenous epinephrine and sodium bicarb during the code. When asked who she received orders from to administer the medications, she stated the paramedic asked for her assistance and handed her the medications to push. She stated she did not know who gave the orders to the paramedic. She stated the paramedic started an intra-osseous line and she pushed the meds as instructed by paramedic through that line. She was asked if she was ACLS (Advanced Cardiac Life Support) certified, she stated no.

Patient #2
Review of the medical record for Patient #2 revealed he had been admitted to the hospital on 2/27/15 with the admission diagnosis of Schizophrenia.

Review of the medical record for Patient #2 revealed a medication order dated 2/28/15 for Vitamin C 500 mg (milligrams) p.o. (by mouth) q (every) day, Vitamin B12 500 mcg (microgram) q day, and Glipizide ER 5 mg po q day. The order was signed off by the nursing staff at 9:00 a.m. on 2/28/15.

Review of the MAR for Patient #2 revealed the Vitamin C 500mg, Vitamin B12 500mcg, and Glipizide ER 5mg were circled on 2/28/15 with a note written on the side, " unavailable. " Further review revealed the medications were not administered until 2/29/15 with no explanation in the medical record of why the medications were not given, that the pharmacy was notified or that the physician was notified.

In an interview on 3/4/15 at 10:25 a.m. with S1DON, she verified there should have been documentation in Patient #2 ' s medical record as to why the above mentioned medications were not given. She also said the pharmacy comes to the hospital twice a day so the medications should have been available.

Patient #7
Review of the medical record for Patient #7 revealed the patient was a 57 year old female admitted to the hospital on 02/26/15 with a diagnosis of Major Depressive Episode with Suicidal Ideations.Review of the physician's orders revealed an order dated/timed 03/02/15 at 8:30 a.m. for Toprol XL 25 mg. X 1 PO QHS (1 tablet by mouth at bedtime).
Review of the Medication Administration Record (MAR) revealed the Toprol XL 25 mg. was not administered on 03/02/15 as ordered. Further review of the MAR revealed the Toprol XL was administered on 03/03/15 at 8:00 a.m. by S11LPN (Licensed Practical Nurse). There was no documented evidence that the physician was notified of medication error.

In an interview on 03/04/15 at 10:15 a.m., S11LPN confirmed she administered the medication on 03/03/15 at 8:00 a.m. S11LPN stated she administered the medication at 8:00 a.m. because she saw the medication was not given at 8:00 p.m. on 03/02/15. S11LPN stated she did not know why it was not given on 03/02/15 at 8:00 p.m. S11LPN confirmed the medication had been ordered at 8:30 a.m. and should have been available to administer by 8:00 p.m. When asked if she had identified the missed dose on 03/02/15 as a medication error, she stated no, because of the issues they had with faxing orders to the Pharmacy. S11LPN confirmed she did not notify the patient's physician of the missed dose on 03/32/15 and confirmed she had not received a physician's order to administer the medication at 8:00 a.m. instead of 8:00 p.m. as it was ordered.


Patient #9
Review of the medical record for Patient #9 revealed the patient was 65 year old male admitted to the hospital on 02/18/15 with a diagnoses of Chronic Paranoid Schizophrenia.
Review of the physician's orders dated/timed 03/02/15 at 10:00 a.m. revealed an for Loxitane (Anti-psychotic) 50 mg. PO BID (Twice a day).
Review of the MAR revealed Loxitane was not administered on 03/02/15 at 8:00 p.m. as scheduled, nor was the Loxitane administered on 03/03/15 at 8:00 a.m.

In an interview on 03/04/15 at 9:35 a.m., S11LPN stated she worked the day shift on 03/03/15 and the medication was not available. She stated they had trouble with the faxed orders going through to pharmacy and she had to call pharmacy and re-fax the orders. She stated by the time she got the medication if was too late to administer the Loxitane at 8:00 a.m. She stated she notified S12Medical Director (patient's psychiatrist) that the medication was not available. She stated she did not know if the night nurse took any action on 03/02/15 regarding the 8:00 p.m. dose. S11LPN confirmed there was no documented evidence that the 8:00 p.m. Loxitane dose was administered on 03/02/15. She confirmed there was no documented evidence that the physician was notified of the missed 8:00 p.m. dose on 03/02/15.


Patient #12
Review of the medical record for Patient #12 revealed the patient was a 46 year old female admitted to the hospital on 12/02/14 with a diagnosis of Bipolar Disorder.
Review of the physician's orders dated/timed 12/03/14 at 6:30 p.m. revealed Cipro (antibiotic) 500 mg. PO BID X 5 days was ordered.
Review of the MAR revealed the Cipro was scheduled to be administered at 8:00 a.m. and 8:00 p.m. There was no documented evidence the Cipro was administered at 8:00 p.m. on 12/03/14.

Review of the emergency drug box inventory list revealed Cipro was included in the emergency drug box.

In an interview on 03/03/15 at 3:15 p.m., S2RN, Unit Manager reviewed the medical record and confirmed the Cipro was not administered as ordered on 12/03/14 and the omission had not been identified as a medication variance.



Patient #R4
Review of the patient's record revealed the patient was a 53 year old male admitted to the hospital on 03/03/15 with a diagnosis of Chronic Paranoid Schizophrenia.
Review of the physician's admit orders dated/timed 03/03/15 at 10:45 a.m. revealed an order for Valsartan (Medication for high blood pressure) 160 mg. PO BID (Twice a day).
Review of the MAR revealed the Valsartan was scheduled for 8:00 a.m. and 8:00 p.m. Review of the MAR revealed the Valsartan was not administered until 03/04/15 at 8:00 a.m.

In an interview on 03/04/15 at 9:55 a.m., S13RN reviewed the patient's record and confirmed the Valsartan was ordered on admission at 10:45 a.m. and the medication should have been available for administration for 8:00 p.m. on 03/03/15.

In an interview on 03/04/15 at 10:00 a.m., S11LPN stated she had faxed the orders to the pharmacy when the patient was admitted and thought the medication would have been available at 8:00 p.m. S11LPN stated the Prozac and the Valsartan were not available this morning. She stated she called the pharmacy and they sent the medications, so she was able to administer them this morning. S11LPN stated she did not know what the night nurse did about the medication not being available. S11LPN confirmed there was no documentation the physician was notified of the missed dose on 03/03/15 at 8:00 p.m. S11LPN confirmed the 24 hours chart check done by the night shift did not identify the missed dose of Valsartan as a medication error.


Patient #R6
Review of the incident report dated 12/31/14 revealed a medication variance was identified on 12/31/14. The variance identified was Zyprexa 15 mg. administered twice a day on 12/29/14 and 12/30/14, when the physician's order was for Zyprexa 15 mg. Q HS (At bedtime only). The report revealed S12Medical Director and patient's psychiatrist was notified on 12/31/4 at 10:00 a.m.

Review of the patient's record revealed the patient was a 70 year old male admitted to the hospital on 12/29/14 with a diagnosis of Schizoaffective Disorder.
Review of the physician's admission orders dated/timed 12/29/14 at 6:00 p.m. revealed Zyprexa 15 mg. PO Q HS was ordered.
Review of the MAR revealed the Zyprexa was transcribed as 15 mg. PO BID (Twice a day). The MAR revealed the patient received the medication at 8:00 a.m. and 8:00 p.m. on 12/30/14. There was no documented evidence in the patient's record that a medication variance occurred or that the patient's physician was notified.

In an interview on 03/05/15 at 11:15 a.m., S2RN, Unit Manager reviewed the patient ' s record and verified the medication error was not documented in the medical record and there was no documented evidence in the medical record that the physician was notified.

Patient #R7
Review of the incident report dated 01/02/15 revealed a medication variance was identified on 12/31/14. The variance identified was Mobic (Anti-inflammatory medication) 7.5 mg. was ordered, but was not put on the MAR or administered on 12/30/14. The report revealed S22NP was notified on 01/02/15 at 9:00 a.m.

Review of the patient's record revealed the patient was a 43 year old male admitted to the hospital on 12/30/14 with a diagnosis of Schizoaffective Disorder.
Review of the physician's admission orders dated/timed 12/30/14 at 12:00 p.m. revealed Mobic 7.5 mg. PO BID was ordered.
Review of the MAR revealed documentation that the Mobic was administered on 12/30/14 at 8:00 a.m. and 8:00 p.m.
There was no documented evidence in the patient's record that a medication variance occurred or that the patient's physician was notified.

In an interview on 03/04/15 at 11:20 a.m., S2RN, Unit Manager reviewed the medical record and the incident report. She stated she documented the incident report and reviewed the medical record after the LPN had reported the Mobic was not administered on 12/30/14. S2RN stated the LPN discovered when she came on duty on 12/31/14 (day shift) that the Mobic was not documented as administered on 12/30/14. S2RN stated the Mobic was not documented as given when she initially reviewed the record on 01/02/15 and stated she counseled the nurses who had not administered the medication and did an inservice for the staff. After reviewing the MAR now, she verified the MAR now revealed documentation of the nurse's initials indicating the medication was administered on 12/30/14. She stated what probably happened is that medical records flagged the chart for the nurses to sign the MAR when she noted the time and initials were not there. S2RN stated she was certain the MAR was blank for the Mobic administration on 12/30/14 when she did the incident report. She stated the nurses should not have gone back after the fact and documented the medication was given. After reviewing the nurse ' s documentation she verified there was no documentation in the record of the medication error and the physician was not notified until 1/2/15 at 0900.

Patient #R8
Review of the incident report dated 01/12/15 revealed a medication variance was identified on 12/31/14. The variance identified was Gabapentin was administered 4 times a day instead of 3 times a day as ordered. The report revealed the nurse practitioner was notified on 01/12/15 at 9:00 a.m.

Review of the patient's record revealed the patient was a 43 year old male admitted to the hospital on 12/25/14.
Review of the physician's admission orders dated/timed 12/25/14 at 7:30 p.m. revealed Gabapentin (medication for neuropathic pain) 300 mg. PO TID (Three times a day) was ordered.
Review of the MAR revealed documentation that the Gabapentin was administered 4 times a day on 12/26/14, 12/27/14, 12/28/14, 12/29/14 and 12/30/14. Further review of the MAR revealed the Gabapentin was changed on the MAR on 12/31/14 and the medication was administered at 8:00 a.m. Review of the record revealed the patient was discharged on 12/31/14.
There was no documented evidence in the patient's record that a medication variance occurred or that the patient's physician was notified.

In an interview on 03/03/15 at 3:41 p.m., S2RN, Unit Manager reviewed the patient's medical record and verified the Gabapentin was administered 4 times a day for 5 days before the error was identified on 12/31/14. S2RN confirmed the Gabapentin was ordered 3 times a day on admission. S2RN confirmed the LPN corrected the frequency on the MAR on 12/31/14 and there was no documented evidence the physician was notified and there was no documentation of the medication error in the medical record.


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Based on record review and interview, the hospital failed to have a process in place to ensure patients' medical records were completed within 30 days of discharge.
Findings:
Review of the hospital policy titled Authentication Process of Medical Records, Document Number HIM-10, revised 11/01/2011 revealed in part: To assure that all medical records are completed within 30 days post-discharge and that medical records are accurate for clients assessed, cared for, treated or served.

Review of Rules and Regulations, revised 8/12/2010 revealed in part:
10. Delinquent Medical Records. A Medical Record is determined to be delinquent 30 days after a patient's discharge if all components of the medical record are not completed, dated, timed, and authenticated by the attending physician. Written notifications are delivered to any physician by US mail if medical records are not completed by the 15th day following a patient's discharge. If the physician fails to respond within 20 days after a patient is discharged, a second written notification will be sent to the physician via US mail. If the record is not completed by the 40th day of a patient's discharge date, then the physician will be referred to the professional Peer Review Committee/Medical Director for further corrective action ...

Record review for Patient #12 revealed a discharge date of 12/04/2014 with the Psychiatric Evaluation not dated and authenticated. The record revealed the Discharge Summary did not include the Hospital Course ("Garbled" was hand written in this section) and was not signed/dated/timed by the practitioner. Review of the record also revealed verbal orders dated 12/04/14 that were not signed/dated/timed.

An interview on 3/4/2015 at 8:45 a.m. with S8Medical Records Coordinator confirmed the hospital had delinquent records. S8Medical Records Coordinator could not give surveyor a numbered amount of how many records were delinquent beyond 30 days, 60 days, and/or 90 days. S8Medical Records Coordinator indicated the hospital had over 200 delinquent medical records.

A telephone interview on 3/4/2015 at 10:00 a.m. with S24RHI (Registered Health Information) consultant revealed that she was aware of the delinquent medical records but could not give a definite number. S24RHI reported that she was aware the delinquent medical records dated back to early 2014. S24RHI indicated that the hospital included the delinquent records in their Quality Assurance but stated she did know how they were monitoring because there were no exact numbers available.

30364


Based on record review and interview, the hospital failed to ensure all entries in the patients' medical records were dated and timed by the person responsible for providing or evaluating the service provided for 5 (#1, #2, #7, #9, #12) of 12 (#1 - #12) patients sampled.

Findings:

Review of the hospital's Rules and Regulations of the Medical Staff revealed in part:
All Clinical entries and summaries shall be accurately dated, timed and authenticated.

Patient #1
Review of the Psychiatric Evaluation for Patient #1 revealed it had been written by S12Medical Director on 11/03/14 but the document was not timed.
In an interview on 03/02/15 at 2:30 p.m., S2RN reviewed the medical record for Patient #1 and confirmed there was no time documented by the physician when he authenticated the Psychiatric Evaluation.


Patient #2
Review of the Psychiatric Evaluation for Patient #2 revealed it had been written by S12Medical Director but the date of 2/29 did not include a year and the document was not timed.

Patient #7
Review of the Medical Progress note for Patient #7 revealed it had been dated on 3/2/15 by the practitioner but had not been timed.

In an interview on 3/4/15 at 10:00 a.m. with S1DON, she verified all entries in the medical record should have been dated and timed.


Patient #9
Review of the Psychiatric Evaluation for Patient #9, dated 02/20/15, revealed it had been written by the nurse practitioner and signed by both the nurse practitioner and S12Medical Director, but there was no documented evidence of the date and time the evaluation was authenticated by either practitioner. Review of the physician's admission orders revealed the S12Medical Director had signed the verbal orders, but did not date or time his signature.

In an interview on 03/03/15 at 10:20 a.m. S13RN reviewed the medical record for Patient #9 and confirmed the psychiatric evaluation was not dated or timed by either practitioner that signed it. S13RN confirmed the verbal admission orders were not dated or timed by the physician when he signed them.


Patient #12
Review of the Psychiatric Evaluation for Patient #12, dated 12/03/14, revealed it was not signed by the practitioner. Review of the physician's orders revealed a verbal order for restraints dated 12/04/14 that was not signed. Further review of the physician's orders revealed verbal orders dated 12/04/14 to transfer the patient to another facility that was not signed. Review of the Discharge Summary revealed no documented evidence that the physician had signed the document (2 months after patient's discharge).

In an interview on 3/03/15 at 3:15 p.m., S2RN reviewed the medical record for Patient #12 and confirmed the physician had not signed the verbal orders, psychiatric evaluation, or the discharge summary.

30364


Based on record review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with acceptable standards of practice. 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.

Findings:

Review of the hospital policy titled Medication Administration, MA-01A, revealed in part:
Transcription of Orders: Pharmacist- Provides medication ordered and dispenses according to order. If pharmacist is not at the hospital, and the medication needs to be given prior to the anticipated return of the pharmacist to the pharmacy, stock medications are to be used if available from the locked cabinet.

Patient #1
Review of the medical record for Patient #1 revealed the patient was a 45 year old male admitted to the hospital on 11/01/14 with diagnoses of Major Depression without psychosis with Suicidal Ideations, and Alcohol Dependence. The record revealed the patient expired at the hospital on 11/06/14.

Review of the physician's orders dated/time 11/04/14 at 10:00 p.m., revealed verbal order for Levaquin 750 mg. PO (by mouth) Now and Levaquin 250 mg. PO in AM 1X dose. Review of the Medication Administration Record (MAR) revealed the Levaquin was administered to the patient at 10:00 p.m. on 11/04/15.

In an interview at 2:41 p.m. on 03/03/15, S2RN Unit Manager reviewed MAR and the physician orders. She confirmed Levaquin 750 mg. was ordered on 11/4/14 at 10:00 p.m. to be administered "Now" and this was a new medication for the patient. S2RN confirmed the nurse administered the medication at 10:00 p.m.. She stated medication was probably taken from emergency drug box. S2RN confirmed that a first dose review of the patient's medications by the pharmacist was not done before the Levaquin was administered to the patient.

In an interview on 3/3/15 at 2:10 p.m. with S15Pharmacist, he said he was the Director of Pharmacy for the hospital. He said when a medication was ordered at the hospital, the order was faxed to the offsite pharmacy. S15Pharmacist also said the pharmacy hours of operation were 7:30 a.m. until 6:00 p.m. on Monday through Friday and 7:30 a.m. until 12:00 p.m. on the weekends. He said if a medication was a first dose medication ordered after pharmacy working hours, the staff would call the pharmacist only if the medication was unavailable in the stock medications. He said stock medications at the hospital included most of the commonly used psychiatric medications and other commonly used medications. S15Pharmacist said a new order from the staff at night would be on the fax machine when the pharmacist arrived at the pharmacy in the morning and would have been reviewed after the first dose had already been given.

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Radiology Services as evidenced by:

1) Failing to ensure there was a radiologist on medical staff who supervised the radiology services of the hospital (see findings in tag A-0546);

2) Failing to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital by Company A (see findings in tag A-0536).

Based on record reviews and staff interview, the hospital failed to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital by Company A. Findings:

Review of the policy and procedure manual of the hospital. provided by S1DON, revealed no evidence of any policies developed or implemented related to proper safety precautions against radiation hazards for the safety of the staff and patients during radiological procedures.

An interview was conducted with S3Administrative Assistant on 3/3/15 at 9:15 a.m. She reported the hospital had no policies and procedures related to proper safety precautions for the patients and the staff against radiation hazards during radiological procedures.

Based on record review and staff interview, the hospital failed to ensure there was a radiologist who supervised the radiology services of the hospital.

Findings:

Review of the credentialing record for S6Radiology/MD revealed he was reappointed to the medical staff in January of 2015. There was no documented evidence S6Radiology/MD was identified as the Director of Radiology or the Supervising Radiologist.

Review of the contracts provided by S1DON (Director of Nursing) revealed the hospital had a contract with Company A to provide radiology services.

Review of the credentialing record for S6Radiology/MD revealed the physician was privileged and credentialed as a radiologist. There was no documented evidence that S6Radiology/MD was appointed as the Director of Radiology for the hospital.

In an interview on 3/03/15 at 8:45 a.m., S1DON verified the hospital did not have a Director of Radiology services.

Based on interview and record review, the hospital failed to ensure the Director of Dietary Services failed to ensure the effective implementation of policies and procedures relative to the safe handling and/or serving of food. This was evidenced by the hospital's failure to implement a monitoring system to ensure that foods are served at safe temperatures. Findings:
Interview on 3/3/2015 at 10:50 a.m. with S2RN confirmed that she was the appointed Director of Dietary Services for the hospital. She further stated that she had not been to any specialized training for the hospital Dietary Services.
Review of the personnel record on 3/4/2015 at 11:20 a.m. revealed that the S2RN had been employed at the hospital for approximately 3 years. S2RN did not have a job description for the Director of Dietary Services in her file.
Interview on 3/3/2015 at 11:35 a.m. with S2RN revealed the meal trays were brought to the hospital on a meal service cart from the nursing home next door that contracted the hospital ' s meals. S2RN verbalized the food temperatures were checked 3 times a week and recorded in the Food Log Book by the MHT.
Interview on 3/3/2015 at 11:40 a.m. with S10MHT revealed that food temperatures were checked on Tuesdays, Thursdays, and Fridays. She further stated that the temperatures were documented in the Food Log Book.
Review of the Food Log Book on 3/3/2015 at 11:45 a.m. revealed documented food temperatures obtained for test trays on the following days:
(1/1) breakfast
(1/9) lunch
(1/30) lunch
(2/6) lunch
(2/13) breakfast
(2/20) breakfast
(2/27) lunch
Review of the hospital policy titled Food Temperature Log, Document Number IC-54, revised 11/04/2011 revealed in part: Food temperatures are to be randomly checked and recorded on Food Temperature Logs two times weekly.
Interview on 3/3/2015 at 11:50 a.m. with S2RN verified that she was unaware that the food temperatures were not being performed.

There was no documentation to indicate the hospital had implemented a monitoring system to ensure foods are served at safe temperatures as there was no consistent temperature monitoring at various meal times throughout the week.

Based on record review and interviews, the hospital failed to have two or more practitioners on the Utilization Committee to carry out the Utilization Review (UR) functions. Findings:

Review of the hospital's "Case Management/Utilization Review Plan" plan provided by S1DON as the current Utilization Review Plan revealed Utilization Review was defined as an audit of the appropriateness and quality of care provided to hospitalized patients, with an eye on cost control. Review of the plan revealed no provision for the composition of a Utilization Review Committee, but revealed the following: The Functions of Utilization Management/Case Management is incorporated into the Performance Improvement Committee for the day to day operations of the case management/utilization department. This includes preparing and maintaining reports and records requested by Medical Staff Committees, Administration and Regulatory Agencies. Further review of the plan revealed the Case Manager was responsible for the day to day operation of the Case Management/Utilization program that included performing reviews and preparing and maintaining reports and records. The Case Manager was responsible for referring any cases requiring medical review to the physician advisor for review and final determination. The plan revealed the physician advisor was a member of the active or consulting medical staff and was selected by the administrator. "The physician advisor serves as a member of the medical staff committees as advised by the administrator, as well as the physician representative regarding UR on the PIC (Performance Improvement Committee).

In an interview on 03/03/15 at 12:50 p.m. S19LPN, S20RN Admissions Coordinator, S1DON, S3Administrative Assistant requested to be included to explain the hospital's Utilization Review process. When asked who was on the UR committee, S1DON stated S12Medical Director, S3Administrative Assistant, S19LPN, S20RN, Admissions Coordinator, and S18Psychiatrist. S3Administrative Assistant stated S18Psychiatrist only reviewed patient records that were outliers and had a hospital stay over 28 days. They all verified the following process for UR: UR is done by S19LPN and S20RN and their findings are reported to PI Committee (S12Medical Director informed at this time). The only time S18Psychiatrist was involved was when a patient is here 28 days and she was asked to review record at that time. S1DON confirmed S12Medical Director developed and executed the patients' treatment plan. S1DON confirmed the hospital did not have 2 physicians involved in the UR process that were not involved in the patients' treatment plan.

Review of the credentialing record for S18Psychiatrist revealed a current contract to provide services of third party physician advisor/reviewer of all patient outlier stay reviews (patients with a length of stay greater than 28 days).

Based on record review and interviews, the hospital failed to develop and implement policies and procedures relevant to construction, renovation, maintenance, demolition, and repair, including the requirement for an infection control risk assessment to define the scope of the project and need for barrier measures before a project gets underway.

Findings:

Review of the hospital policy and procedure manual revealed no evidence of policies and procedures developed or implemented relevant to construction, renovation, maintenance, demolition and repair, including the requirement for an infection control risk assessment (ICRA) to define the scope of the project and need for barrier measures before a project gets underway.

An interview was conducted with S1DON on 3/03/15 at 12:00 p.m. She reported the hospital had not developed a policy relevant to infection control issues when any type of maintenance or repairs are occurring in the hospital.

Based on observations, record review and interviews the hospital failed to develop and implement an effective system in controlling infections and communicable diseases of patient and personnel as evidenced by:

1. failing to provide an sanitary environment for patients and personnel; and

2. failing to ensure proper handwashing techniques are being performed by personnel; and

3. failing to have an active handwashing surveillance program implemented in the facility.

Findings:

1. Sanitary Environment:

An observation was conducted in the shower room of the hospital on 3/02/15 at 11 a.m. The shower room had 3 shower stalls. Three (3) out of the three (3)shower stalls had a black substance located on the tiles of the shower stalls, located on 1/4 of the walls, starting at the bottom of the shower stalls. Other areas of the walls in the shower room, not located in the shower stalls, also had a black substance on them. An interview was conducted with S9RN at the time of the observation. S9RN verified the abundance of the black substance in the shower room and need to have the shower room cleaned immediately.

An interview was conducted with S4Housekeeper on 3/03/15 at 9:45 a.m. She reported she worked for Nursing Home A and came to the hospital once a day to clean the hospital's bathrooms and floors. She reported the mold in the shower room has been a problem.

An observation was conducted of the soiled utility room on 3/02/15 at 10:45 a.m. On the floor of the soiled utility room was a box of opened unused rolls of paper towels (approximately 10 rolls). The observation was confirmed by S9RN at the time of the observation.

An observation was conducted on 3/02/15 at 11:10 a.m. of the seclusion room. A plastic cup was on the floor with a thick, brown substance at the bottom of the cup. S9RN verified the seclusion room had been cleaned and the dirty cup should have not been on the floor.

An observation was made of the restroom near the seclusion room. A large amount of hair was observed in the sink around the drain. S9RN verified the sink had not been cleaned.

Observations of the patient rooms revealed dust, debris and hair on the window sills and air conditioners. S9RN verified the window sills and air conditioners were not clean.

2. Proper Handwashing:
An observation was conducted on 3/04/15 at 9:20 a.m. in the hospital of S10MHT (Mental Health Technician) making patients' beds. S10MHT went into room 20, 22, and 24 straightening the sheets and pillows of the patients' beds, currently being utilized by the patients, without washing her hands or using hand sanitizer in between making the individual patients' beds.

An interview was conducted with S10MHT on 3/04/15 at 9:25 a.m. She reported she had forgotten to wash her hands in between making the individual patients' beds.

3. Handwashing Surveillance:
Review of the facility's current Infection Control Plan revealed no evidence of handwashing surveillance being conducted in the facility.

An interview was conducted with S2RN on 3/03/15 at 1 p.m. She reported one of her job duties was being in charge of the infection control program of the hospital. She reported handwashing surveillance was not being conducted and was not included in their quality improvement monitoring program.


30364

Based on interviews and record reviews, the hospital failed to ensure that policies were developed that incorporated the OPO (Organ Procurement Organization) and the hospital's definition of Clinical Triggers and Imminent Death in order to identify potential donors as agreed upon by the hospital's OPO contract and in accordance with the Louisiana Uniform Anatomical Gift Act. The hospital failed to ensure the OPO organization was notified of a patient's death for 1 of 1 (#1) patient deaths reviewed.

Findings:
A review of the hospital policy titled, "Organ Donation", Policy number LD-15, revised dated of 11/01/11 provided by S1DON as the most current, revealed in part the following:
To ensure that every death that occurs at the Hospital is reported to the OPO and that every death is evaluated for potential organ and/or tissue donation....Charge Nurse on the unit: In the event a patient dies while at the Hospital, the OPO in notified within 1 hour of his/her death pronouncement. Notification must be made within 4 hours of cardiac arrest....For the purpose of monitoring the Organ/Tissue donation protocol a copy of the completed OPO forms and the patient death certificate will be sent by the Nursing Department to the Quality Improvement Coordinator for the purpose of maintaining quality control.
There was no other verbiage noted in the policy defining "Clinical Triggers or Imminent Death."


A review of the hospital's OPO signed contract dated 01/21/10 and provided by S1DON, as the current contract, revealed in part: Through the agreement, the parties seek to assure that families are afforded the opportunity to donate organs and tissues, in compliance with the Louisiana Uniform Anatomical Gift Act and CMS. "Clinical Triggers" is defined as any patient who is intubated and connected to a functioning ventilator, and has intact cardiac circulation, and meets a Glasgow Coma Scale of 5 or less, or other objective evaluation method, that indicates that a patient has a significant neurological deficit. Imminent Death is defined as a Donor Hospital patient who: meets the criteria for medically established "Clinical Triggers" for organ donor evaluation, or is being evaluated for a diagnosis of brain death as demonstrated by a neurological examination consistent with the diagnosis of brain death; or is under the orders of a physician to have cardiopulmonary sustaining therapies discontinued, pursuant to a decision made by an appropriate patient family decision maker. Timely referral is defined as a telephone call to the OPO by appropriate donor hospital staff within one hour of when a Donor Hospital identifies a patient that meets the Donor Hospital's definition of "Clinical Triggers: for organ donation.

Patient #1
Review of the medical record for Patient #1 revealed the patient was a 45 year old male admitted to the hospital on 11/01/14 with diagnoses of Major Depression Disorder without psychosis with Suicidal Ideations, and Alcohol Dependence. Review of the record revealed the patient was found unresponsive in the bathroom on 11/06/14. The record revealed resuscitation was attempted, but the patient expired at the hospital on 11/06/14 at 10:52 a.m. Review of the record revealed no documented evidence that the OPO was notified of the patient's death.

In an interview on 03/02/15 at 2:30 p.m., S2RN, Unit Manager reviewed the patient's record and confirmed there was no documented evidence that the OPO was notified of the patient's death. S2RN stated she participated in the patient's code (resuscitation) and remembered they talked about notification of the OPO, but it was not done.

In an interview on 03/03/15 at 9:15 a.m., S1DON reviewed the Organ Donation policy revealed the policy did not include provisions for clinical triggers or imminent death. S1DON confirmed the OPO was not notified of patient ' s death. She confirmed organ procurement was not included in QAPI and stated this was the only death that had occurred in the hospital.

Based on record review and interview, the hospital failed to have a Director of Respiratory Services to supervise and administer the services in the hospital. Findings:

Review of the hospital's credentialing files revealed a physician was not appointed as the hospital's Director of Respiratory Services.

An interview was conducted with S1DON on 3/02/15 at 2:20 p.m. She reported the nurses administer respiratory medications and treatments to the patients when the physician orders the medication and/or treatment. She further stated the hospital has not appointed a physician as Director of Respiratory Services.

Based on record review and interview, the facility failed to ensure patients' psychiatric evaluations contained an inventory of the patients' assets for 11 (#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12) of 12 (#1 - #12) sampled patients.

Findings:

Review of the hospital's Rules and Regulations of the Medical Staff revealed in part:
3. A comprehensive Psychiatric Evaluation shall be completed within 60 hours of admission and shall include the following: Patient strengths and liabilities.

Patient #2
Review of the medical record for Patient #2 revealed he was admitted to the hospital on 2/27/15 with the diagnosis of Schizophrenia. Further review revealed Patient #2's psychiatric evaluation dated 2/29 (no year written) did not contain an inventory of his assets.


Patient #3
Review of the medical record for Patient #3 revealed he was admitted to the hospital on 2/24/15 with the diagnosis of Depression. Further review revealed Patient #3's psychiatric evaluation dated 2/25/15 did not contain an inventory of his assets.


Patient #4
Review of the medical record for Patient #4 revealed he was admitted to the hospital on 02/20/15 with the diagnosis of SAD (Schizoaffective Disorder)/Acute Exacerbation. Further review revealed Patient #4's psychiatric evaluation dated 02/20/15 did not contain an inventory of his assets.

Patient #5
Review of patient #5's Psychiatric Evaluation dated 2/20/15 revealed there were no assets for the patient's strengths and weaknesses documented.

Patient #6
Review of patient #6's Psychiatric Evaluation dated 2/18/15 revealed there were no assets for the patient's strengths and weaknesses documented.

Patient #7
Review of the medical record for Patient #7 revealed she was admitted to the hospital on 2/26/15 with the diagnosis of Major Depressive Episode with Suicidal Ideations. Further review revealed Patient #7's psychiatric evaluation dated 2/27/15 did not contain an inventory of her assets.

In an interview on 3/04/15 at 10:54 a.m., S12Medical Director verified the preprinted psychiatric evaluation forms he used at the hospital did not have a question relative to patients' assets so he was not listing the assets for the patients.

Patient #8
Review of patient #8's Psychiatric Evaluation dated 2/26/15 revealed there were no assets for the patient's strengths and weaknesses documented.

Patient #9
Review of the medical record for Patient #9 revealed the patient was a 65 year old male admitted to the hospital on 02/18/15 with a diagnosis of Chronic Paranoid Schizophrenia.
Review of the Psychiatric Evaluation dated 02/20/15 revealed no documented evidence that the patient's assets and disabilities were assessed.

Patient #10
Review of patient #10's Psychiatric Evaluation dated 1/14/15 revealed there were no assets for the patient's strengths and weaknesses documented.

Patient #11
Review of patient #11's Psychiatric Evaluation dated 2/01/15 revealed there were no assets for the patient's strengths and weaknesses documented.

Interview on 3/02/15 at 2:10 p.m. with S2RN confirmed there were no documentation of the patient's assets for strengths and weaknesses addressed on the Psychiatric Evaluation form. The form had been revised and she was unaware that patient strengths and weaknesses had been deleted from the form.

Patient #12
Review of the medical record for Patient #12 revealed the patient was a 46 year old female admitted to the hospital on 12/02/14 with a diagnosis of Bipolar Disorder.
Review of the Psychiatric Evaluation dated 12/03/14 revealed no documented evidence that the patient's assets and disabilities were assessed.

In an interview on 03/03/15 at 3:15 p.m., S2RN, Unit Manager reviewed the medical record for Patient #9 and Patient #12 and confirmed the psychiatric evaluation did not include an assessment of the patient's assets and disabilities.


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