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Based on record review and interview the hospital failed to ensure the Quality Assurance Performance Improvement (QAPI) program measured, analyzed, and tracked quality indicators and other aspects of performance that assessed processes of care, hospital service and operations by failing to include Respiratory Services and Physical Therapy Services in their QAPI program.

Findings:

Review of the Hospital QAPI data binders for 2013 and 2014 revealed no quality indicators for the Respiratory Services Department or the Physical Therapy Department of the hospital.

In an interview on 2/12/14 at 12:19 p.m. with S1DON, she said she was over the QAPI program at the hospital. S1DON verified no quality indicators for Respiratory services or Physical Therapy were included in QAPI program but should have been.

Based on interview and record review, the hospital failed to ensure actions taken to improve performance were modified when they were unsuccessful. This deficient practice is evidenced by failing to update interventions since 4/15/13 for the identified problems of medication errors, medical records being monitored for completion within 30 days of a patient's discharge, and Post Anesthesia Care Unit (PACU) evaluations not being completed within 48 hours.
Findings:
Review of the Quality Assurance (QA) binder revealed the most recent 4 QA meetings were held on 1/20/14, 11/4/13, 7/29/13, and 4/15/13.

Review of the QA binder for 2013 and 2014 revealed problems had been identified as early as 4/15/13 with medication errors, medical records being monitored for completion within 30 days of a patient's discharge, and Post Anesthesia Care Unit (PACU) evaluations not being completed within 48 hours. These problems were listed on PDCA (Plan Do Check Act) forms which identified the problem areas, the plans to correct the problems, the actions to achieve the goals and the outcomes of the actions taken. Further review revealed the same problems with the same plans, actions and changes were on the PDCA forms with the 7/29/13, 11/4/13, and 1/20/14 meeting minutes.

In an interview on 2/12/14 at 12:19 with S1DON, she said she was over the QA program at the hospital. S1DON said the QA meetings were held quarterly. S1DON said PDCA forms were generated each quarter and identified problem areas, the plans of how the performance was going to be improved, and the results of the actions taken. S1DON verified the objectives, plans, acts to hold the gains, issues and do the change sections from the quarterly PDCA reports were essentially reprinted for each meeting and there were no changes to the plan to correct problems for medication errors, medical records being monitored for completion within 30 days of a patient's discharge, and Post Anesthesia Care Unit (PACU) evaluations not being completed within 48 hours. S1DON said data was being collected on problem areas, but plans to correct problems and the actions taken were not being updated. S1DON also verified the 3 problem areas mentioned above were still problem areas at the hospital.

30364


Based on interview and record review, the hospital failed to ensure the nursing staff developed and kept current a comprehensive nursing care plan for 5 (#4, #8 #13, #17, #18) of 20 (#1- #20) patients sampled.

Findings:

Review of the hospital policy entitled Patient Care, Planning of, last reviewed on 3/09, last revised 11/09, revealed the following, in part:
Purpose:
To ensure patient care coordination among health care professionals.
Policy:
1. Clinical care givers work collaboratively to assess patient needs and to develop an individualized plan of care which is implemented, evaluated, and revised throughout the patient's hospital stay.
5. The interdisciplinary plan of care is a working document and is used by all caregivers to document the identification and resolution of patient problems. It accompanies the patient throughout the patient's hospitalization and is used to guide the delivery of appropriate patient care to the patient and to facilitate the exchange of information between professionals.
6. The Interdisciplinary plan of care is reviewed at least every 24 hours by the Registered nurse and updated as disciplines needed basis on patient reassessment policy.


Patient #4

Review of Patient #4's medical record revealed an admission date of 2/11/14 and diagnoses including the following, in part: numbness and tingling in the left leg, anxiety, bulging disc (lumbar) and pain ( back and neck). Further review revealed Patient #4 was admitted for a Transforaminal Lumbar Interbody Fusion (TLIF) back surgery.

Further review of Patient #4's medical record revealed the patient received as needed medication for treatment of anxiety.

Review of Patient #4's current plan of care revealed anxiety was not identified as a problem on the patient's care plan.


Patient #8

Review of Patient #8's medical record revealed an admission date of 2/11/14 and Diagnoses including the following, in part: Diabetes, Hypertension, Hypercholesterolemia and Sleep disorder. Further review revealed Patient #8 was admitted for an Anterior Cervical Discectomy and Fusion (ACDF).

Review of Patient #8's current plan of care revealed Diabetes, Hypertension, Hypercholesterolemia and Sleep disorder were not identified as problems on the patient's care plan.


Patient #13
Review of the medical record for Patient #13 revealed she had been admitted to the hospital for surgery on 11/7/13. Further review of the History and Physical for Patient #13 dated 10/30/13 revealed the patient had a history of Addison's disease (chronic adrenal insufficiency).

Review of the nurse's notes for Patient #13 dated 11/9/13 at 3:40 a.m. revealed the following entry: Patient in Addison crisis, uncontrollably shaking and crying. Solucortef 100mg (milligrams) given IV (intravenous) per patient's husband from his personal emergency stock which he keeps for these emergencies.

Review of the care plans for Patient #13 revealed no care plan had been initiated for her Addison's Disease.

In an interview on 2/12/14 at 2:26 p.m. with S1DON, she verified Patient #13 should have had her Addison's Disease included on her care plans but did not.


Patient #17

Review of Patient #17's medical record revealed an admission date of 8/26/13 and Diagnoses including the following, in part: Chronic back pain, Hypertension, Osteoarthritis, Sleep Apnea, Bladder Infection (current, on antibiotics) and Anemia. Further review revealed Patient #17 was admitted for a Posterior Lumbar Interbody Fusion (PLIF).

Review of Patient #17's current plan of care revealed Hypertension, Osteoarthritis, Sleep Apnea, Bladder Infection (current, on antibiotics) and Anemia were not identified as problems on the patient's care plan.

In an interview on 2/12/14 at 3:30 p.m., with S1DON, she said patient care plans should include all medical diagnoses and not just diagnoses related to surgical services. She also agreed the plan of care should be reviewed every 24 hours and updated as set forth in the hospital's policy.


Patient #18
Review of the medical record for Patient #18 revealed she was a 64 year old female who was admitted to the hospital for surgery on 12/17/13. Review of the physician progress notes revealed the patient was diagnosed with Pneumonia on 12/19/13.

Review of the care plan for Patient #18 revealed no documented evidence the care plan was updated with the patient's new diagnosis of Pneumonia. Further review of the patient's record revealed the patient received a blood transfusion on 12/20/13. There was no documented evidence the patient's care plan was updated with the need for a blood transfusion.

In an interview on 02/12/14 at 2:40 p.m., S1DON verified the care plan for Patient #18 was not updated after the patient developed pneumonia and received blood transfusions.










30984

Based on record reviews, and interviews, the hospital failed to:
1) ensure that patients' discharge medical records dating back to 2012 were stored in a manner to protect them from water damage in the event that the sprinkler system was activated as evidenced by 2800 paper medical records being stored on open shelving in a sprinklered room.
2) ensure the hospital policy and medical staff bylaws were followed for physicians with delinquent medical records.
Findings:

1) Record protection from water damage:

Review of the hospital policy titled, "Health Information Management General Standards", revised 02/09, and presented as current by S1DON (Director of Nursing), revealed in part the following: ....The hospital will comply with state laws on storage, maintenance access and confidentiality of closed records.... There was no documented evidence of any provisions for how medical records would be protected from water damage in the event the sprinkler system was activated.

On 02/10/14 at 12:40 p.m. an observation of the medical records department was made with S3Medical Records Director. Open metal shelving was observed to have 3 full rows of shelving filled with paper discharged medical records. One third of another row was filled with medical records. One open cabinet was noted with 5 shelves of paper medical records. S3Medical Records Director stated the medical records department was sprinklered. S3Medical Records Director stated there were 2800 patient records currently stored in the department and they were patient records from 2012. S3Medical Records Director verified the 2800 patient records would not be protected from water damage in the event the sprinkler system was activated.

2) Delinquent Medical Records:

Review of the hospital policy titled, "Requirements of Record Content", revised date of 03/13 and presented as current policy by S1DON, revealed in part the following:
Purpose: To define the requirements for record content of complete medical records/electronic health record....
Policy: The medical staff shall be responsible for the prompt completeness, legibility, and accuracy of the medical record/electronic health record for each patient treated.
The medical record/electronic health record shall be completed by medical staff within 30 days of the patient's discharge date and the record shall be considered delinquent thereafter.
If not completed in 30 days, a letter will be issued. The Medical Executive Committee will be notified.
Physicians will be notified of delinquencies and deficiencies so as to make timely arrangements to completed the medical record/electronic health record....

Review of the Medical Staff Rules & Regulations, revised date of 12/20/10, presented as current by S1DON, revealed in part the following:
Article IX Medical Records....Section 9. Delinquent Medical Records
(a.) Failure to complete medical records thirty (30) days after discharge shall require a written notification from the Medical Records Department advising the medical staff appointee.
(b.) If the medical staff appointee has failed to complete the delinquent medical record(s) within forty-five (45) days after the discharge, the appointee will receive a second written notice from the Medical Records Department, at the time that Medical Executive Committee will be advised of the situation.
(c.) Failure to complete the medical record(s) within sixty (60) days from the date of the first notification by the Medical Records Department shall constitute automatic relinquishment of all clinical privileges and voluntary resignation from the medical staff....

In an interview on 02/10/14 at 12:40 p.m., S3Medical Records Director and S11Medical Records staff provided a list of physicians with incomplete and delinquent records. Review of the list revealed the following:
S13Physician - 5 records over 30 days incomplete (delinquent) and 1 record 82 days incomplete (52 days delinquent).
S14Physician - 1 record 90 days incomplete (60 days delinquent).
S15Physician - 1 record 52 days incomplete (22 days delinquent).
S16Physician - 3 records over 30 days incomplete (delinquent).
S13Physician - 1 record 136 days incomplete (106 days delinquent), and 1 record 73 days incomplete (43 days delinquent).

On 02/10/14 at 12:55 p.m. S1DON and S3Medical Records Director were interviewed. S3Medical Records Director stated the physician was sent a letter when the record was 30 days incomplete. She stated the electronic health record provided a daily prompt that a signature was needed when the physician logged on. S3Medical Records Director verified the physician was to be suspended of privileges when the medical records were not completed 60 days after the first letter was sent. S1DON stated no physicians had been suspended. She stated the CEO (S5ADM) sends an email to the physician and that usually gets it done. After reviewing the above list of incomplete/delinquent medical records, S1DON verified 3 of the physicians had records that were over 60 days incomplete. S1DON stated the hospital changed to electronic letter notification to the physician in September 2013 and she would have to check with IT (Information Technology) to see if the electronic letters were sent to the physicians.

In an interview on 02/10/14 at 2:50 p.m., S1DON stated IT confirmed the incomplete record letters did not go to the physicians via the software system. S1DON stated the medical records department stopped sending letters to the physicians in September 2013 and thought the letters were being sent electronically. S1DON stated the records that were incomplete over 60 and 90 days were not being reported to her and only the number of incomplete records for one month was reported and tracked. S1DON verified there was a system problem with physician notification of incomplete records.

Based on observation, interview and record review, the hospital failed to ensure all drugs and biologicals were kept in a secure area to prevent unmonitored access by unauthorized individuals. This deficient practice is evidenced by having a portable box containing 50 anesthesia emergency medications in an unlocked cabinet in an unsecure area on the inpatient unit at the hospital.

Findings:

Review of the hospital Policy and procedure titled Pharmacy: General, PCS: 04-01, Revised 8/10, stated in part:
All medications, including biological and Controlled Substances, will be stored in a secure area to prevent diversion, and locked when necessary, in accordance with law and regulations.

An observation on 2/10/14 at 10:15 a.m. of an area behind the nursing station on the inpatient unit revealed an unlocked and unsupervised area with an unlocked cabinet containing emergency anesthesia medications in a portable plastic box.

Review of the Anesthesia Tray Charge Sheet provided by S4PharmacyDirector revealed the Anesthesia Emergency Anesthesia Tray contained 50 vials, ampules, syringes or tubes of medications.

In an interview on 2/10/14 at 10:18 a.m. with S1DON, she verified the anesthesia medications were not being kept in a locked cabinet. S1DON said the medications should have been kept in a locked cabinet or within the crash cart.

In an interview on 2/10/14 at 12:45 p.m. with S4PharmacyDirector, he said the anesthesia emergency medication box on the second floor should have been either in a locked room or a locked cabinet.

Based on 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 failing to ensure the functionality of a call button located on the handrails of the beds on the inpatient unit. Findings:

Observations were made on the inpatient unit of the hospital on 2/10/14 between 10:00 a.m. and 10:45 a.m. with S1DON (Director of Nursing). A call button for the nurse was noted to be on both side rails of the bed in room 220. S1DON stated all the hospital's 23 beds have a nurse call button in the side rail and none of them are functional. S1DON stated the nurse call button on the cord was functional and stated, "staff consistently orient patients" to the call system. S1DON stated she had tried to cover the nurse call button in the side rails with tape, but that did not work. S1DON confirmed the unit's patients were post-operative patients that could be sedated or confused at times.

Based on observation, interviews and record review, the hospital failed to ensure the infection control officer implemented measures to prevent and control infections by maintaining a sanitary hospital environment. This is evidenced by:
1) failing to separate the storage of clean and dirty equipment/supplies;
2) failing to ensure clean storage rooms were dusted as per hospital policy.
3) failing to ensure frozen chicken was prepared under sanitary conditions by thawing raw, unpackaged chicken parts in a sink with the chicken contacting the bare surface of the sink.

Findings:
1) Failing to separate the storage of clean and dirty equipment/supplies.

An observation on 12/10/14 at 10:25 a.m. of the inpatient unit revealed 2 portable fans with dirty blades being stored in the clean utility room.

In an observation on 2/10/14 at 10: 30 a.m. of the inpatient unit clean utility room, a PCA (patient controlled analgesia) pump was noted to have a sticky substance on the handle.

In an interview on 12/10/14 at 10:27 a.m. with S1DON, she stated the dirty fans should not have been stored in the clean utility room.

In an interview on 2/10/14 at 10:35 a.m. with S1DON, she confirmed the PCA pump was dirty and should not have been stored in the clean utility room..


2) Failing to ensure clean storage rooms were dusted as per hospital policy.

Review of the Policy: Clean Utility Room Cleaning, Reviewed 11/07, revealed in part:
Procedure: The following procedure will be followed when cleaning the clean utility room:
High dust, Damp dust shelves with hospital approved germicidal solution.

In an observation on 2/10/14 at 10:25 a.m. of the inpatient unit clean storage room, a television set on a cart was observed having a layer of dust on the top and back of the television and a layer of dust on a shelf on the cart.

In an observation 2/10/14 at 10:30 a.m. of the inpatient unit clean storage room, an observation was made of a dusty Intravenous ( IV) pump. Dust was noted on the top of the pump.

In an observation on 2/10/14 at 11:00 a.m. of the supply storage area in the peri-operative unit, bins containing supplies were noted to have dust accumulated in them. Dust was also noted to be clinging, in a clump, to the supply packages.

In an interview on 2/10/14 at 10:29 a.m. with S1DON, she stated the television set and the cart should have not been covered in dust.

In an interview on 2/10/14 at 10:35 a.m. with S1DON, she said the IV pump not should not have been dusty.

In an interview on 2/12/14 at 2:50 p.m. with S1DON, she said it was everybody's responsibility to ensure the clean supply rooms remained clean.


3) failing to ensure frozen chicken was prepared under sanitary conditions by thawing the chicken in a sink with the chicken contacting the bare surface of the sink.

Review of the hospital policy entitled Service of Food, effective date: 7/12, last reviewed: blank, last revised: blank, revealed the following, in part:
Purpose:
To establish standards and procedures for serving foods.
Policy:
Foods are served in an attractive manner according to nutrition principles and food safety procedures to ensure quality, accuracy, and timeliness.

In an observation on 2/11/14 at 12:39 p.m. frozen chicken parts were noted thawing in the hospital kitchen sink. The raw, unpackaged chicken parts were noted to be laying on the bare surface of the sink with water running over them.

In an interview on 2/11/14 at 12:40 p.m. with S7DM, he said he did not know thawing raw, unpackaged chicken parts contacting the bare sink surface was a problem.

S1DON was present at the time of the observation and she confirmed the raw, unpackaged chicken should have not have been contacting the bare sink surface.




30984

Based on interview and record review the hospital failed to ensure patient safety from potential fire risk when using alcohol based skin preparations by failing to document visualization of the surgical site for dryness and drying time interval for surgical site for 6 (#4, #5,#8, #9,#17, #19) of 6 (4, #5,#8, #9,#17, #19) patients reviewed for documentation of drying of skin preparation solutions.
Review of the Operation Room policy, entitled Skin Preparation, last reviewed 10/06, revised: 10/07, revealed the following, in part:
Policy:
Skin preparation is performed according to physician preference by qualified personnel.
4. The procedural site and surrounding area is prepared with an antimicrobial agent of physician choice.
6. Alcohol based skin preps should have a drying time of 3 minutes.

Patient #4
Review of Patient #4's electronic medical record (EMR) revealed an admission date of 2/11/14 and diagnoses including the following, in part: numbness and tingling in the left leg, anxiety, bulging disc (lumbar) and pain ( back and neck). Further review revealed Patient #4 was admitted for a Transforaminal Lumbar Interbody Fusion (TLIF) back surgery.

Review of Patient #4's Surgical Case Record Preparation Screen, dated 2/11/14, revealed the following:
Skin prep: Duraprep
Drying Time (minutes): blank
Site visibly dry: blank
Area prepped: back

Patient #5
Review of Patient #5's electronic medical record (EMR) revealed an admission date of 2/11/14 and diagnoses including the following, in part: Displacement of lumbar intervertebral disc without myelopathy and pain. Further review revealed Patient #5 was admitted for a Lumbar Laminectomy (Lum Lam ) with disc back surgery.

Review of Patient #5's Surgical Case Record Preparation Screen , dated 2/11/14, revealed the following:
Skin prep: Alcohol, Chlorhexidine, Betadine Solution, Chloraprep
Drying Time (minutes): blank
Site visibly dry: blank
Area prepped: Scapula to sacrum

Patient #8
Review of Patient #8's electronic medical record (EMR) revealed an admission date of 2/11/14 and diagnoses including the following, in part: Diabetes, Hypertension, Hypercholesterolemia and sleep disorder. Further review revealed Patient #8 was admitted for an Anterior Cervical Discectomy and Fusion (ACDF).

Review of Patient #8's Surgical Case Record Preparation Screen, dated 2/11/14, revealed the following:
Skin prep: Duraprep
Area prepped: neck, chin, and chest
No place for documentation of Drying Time (minutes) or visualization of the site as visibly dry noted in this section of Patient #8's Surgical Case Record.


Patient #9
Review of Patient #9's electronic medical record (EMR) revealed an admission date of 2/10/14 and diagnoses including the following, in part: C-1 (cervical) fracture, L (lumbar) 3 and 5 right transverse fracture. Further review revealed Patient #9 was admitted for a Posterior Cervical Fusion (PCF)/Hip Graft.

Review of Patient #9's Surgical Case Record Preparation Screen, dated 2/10/14, revealed the following:
Skin prep: Alcohol, Betadine Solution, Chloraprep, Chlorhexidine
Drying Time (minutes): blank
Site visibly dry: blank
Area prepped: posterior neck, left posterior hip

Patient #17
Review of Patient #17's electronic medical record (EMR) revealed an admission date of 8/26/13 and diagnoses including the following, in part: Chronic back pain, Hypertension, Osteoarthritis, Sleep Apnea, and bladder infection (current, on antibiotics) . Further review revealed Patient #17 was admitted for a Posterior Lumbar Interbody Fusion (PLIF).

Review of Patient #17's Surgical Case Record Preparation Screen, dated 8/26/13, revealed the following:
Skin prep: Alcohol, Duraprep
Drying Time (minutes): blank
Site visibly dry: blank
Area prepped: Back

Patient #19
Review of Patient #19's electronic medical record (EMR) revealed an admission date of 12/17/13 and diagnoses including the following, in part: Cervical Spondylosis, Numbness (neck, left foot). Further review revealed Patient #19 was admitted for a Posterior Cervical Fusion (PCF).

Review of Patient #19's Surgical Case Record Preparation Screen, dated 12/17/13, revealed the following:
Skin prep: Alcohol, Betadine Solution, Chlorhexidine, Duraprep
Drying Time (minutes): blank
Site visibly dry: blank
Area prepped: Posterior head, neck and shoulders

In an interview on 2/11/14 at 8:30 a.m., with S2PerioperativeDirector, she was asked if the hospital used alcohol based surgical site preparations (preps). She said Duraprep and Chlorprep were used for surgical site preparation. S2PerioperativeDirector was asked if the drying time of the site and visualization of the site for dryness was documented in the surgical record and she said no, it is not documented.
In an interview on 2/11/14 at 4:00 p.m., with S1DON, she acknowledged the drying time of the prepped surgical site and visualization of the surgical site for dryness were not documented in the surgical record.

Based on record review and interview the hospital failed to ensure all patients administered anesthesia received a post-anesthesia evaluation within 48 hours after surgery which included assessment of respiratory function, cardiovascular function, mental status, temperature, pain, presence of nausea and vomiting and post-op hydration according to the current standards of anesthesia care for 14 of 14 patients reviewed for post anesthesia evaluations (#2, #3, #4, #5, #6, #7, #8, #9, #11, #12, #13, #15, #17, #19) out of a total of 20 sampled medical records (#1-20). Findings:

Review of the Medical Staff Rules & Regulations revised date of 12/20/10, and presented by S1DON as current, revealed in part the following: Article V Surgical Care....Section 3 Anesthesia Rules and Records....(e.) The findings of a pre-anesthesia assessment by an anesthesiologist shall be recorded within twenty-four (24) hours of surgery. Post-anesthesia follow-up findings shall be recorded by an anesthesiologist or nurse anesthetist within forty-eight (48) hours after surgery. (f.) The recording of post-anesthetic visits shall include at least one note describing the presence or absence of anesthesia-related complications....

Review of the hospital policy titled "Documentation of Anesthesia Care" revised date 03/09 and presented as current by S1DON revealed in part the following: ....6. Post-anesthesia documentation shall include the following:....F. On all patients anesthesia will reassess patient, 0-48 hours post procedure and provide documentation of stability.

Review of the Anesthesia Record used by the anesthesiologist or his/her designee revealed a section titled "Postoperative Evaluation" which included a space for the date, time, and signature. Further review revealed a check box next to the following: No Anesthesia complication and Anesthesia Complications/Comments with 4 lines following.

Review of the Anesthesia Record of Patients #2, #3, #6, #7, #11, #12, #13, and #19 revealed the "Postoperative Evaluation" was left blank and there was no other documented assessment of respiratory function, cardiovascular function, mental status, temperature, pain, presence of nausea and vomiting, or post-op hydration.

Review of the Anesthesia Record of Patients #4, #5, #8, #9, #15, #17 revealed a check was made in the box next to the statement indicating "No Anesthesia Complications". Further review of the above medical records revealed no documented evidence an assessment of respiratory function, cardiovascular function, mental status, temperature, pain, presence of nausea and vomiting and post-op hydration was performed.

In an interview on 02/11/14 at 3:45 p.m., S1DON (Director of Nursing) reviewed the above sampled medical records for the post anesthesia evaluation and verified the post anesthesia evaluation was either blank or incomplete. S1DON stated she did not know where else the post anesthesia would be documented. S1DON stated the physicians had requested reminders be provided for completion of the evaluation, but she stated the physicians/CRNAs (Certified Registered Nurse Anesthetist) were responsible and she was not doing the reminders.

In an interview on 02/11/14 at 4:25 p.m., S2Perioperative Director verified the post anesthesia evaluations were not done and stated they struggled with the physicians doing the post anesthesia evaluation. S2Perioperative Director stated anesthesia was "in and out" and it was difficult to get them to see the patient and document the record.

In an interview on 02/12/14 at 8:20 a.m., S6Director of Anesthesiology stated they try to do the post anesthesia evaluation before the patient leaves the recovery room. S6Director of Anesthesiology verified the only place the anesthesiologist/CRNA document the post anesthesia evaluation was on the Anesthesia Record and the evaluation consisted of a check for no complications or a check for complications/comments. S6Director of Anesthesiology indicated changes would be made to meet the requirements.

Based on record review, staff interview, and review of Louisiana Physical Therapy Practice Act, the hospital failed to ensure that physical therapy (PT) services were provided only under the orders of a licensed practitioner by failing to obtain physician's orders for therapy services provided after the initial evaluation by the therapist for 2 of 2 sampled patients reviewed for physical therapy (#12, #18) out of a total sample of 20. Findings:

Review of the hospital policy titled, "Referral and Initiation of Services", effective date 10/09 and presented as current policy by S1DON (Director of Nursing) revealed in part the following: Physical, Occupational, and Speech Therapy will be provided under the supervision of licensed professionals in accordance with a physician order...A licensed professional clinician may provide direct patient services only after receiving an order from any of the following licensed health care practitioners: Medical Doctor, Doctor of Osteopathy, Dentist.

Review of the hospital policy titled, "Patient Evaluation", effective date 10/09 and presented as current policy by S1DON revealed in part the following: ....After completion of the evaluation, a Plan of Care is established for approval by the attending or consulting physician as evidenced by his/her signature.


Patient #12
Review of the patient's medical record revealed the patient was a 72 year old female admitted to the hospital for surgery on 11/06/13. Review of the physician's orders revealed an order dated/timed 11/06/13 at 4:02 p.m. for physical therapy to evaluate and treat in a.m. Further review of the physician orders revealed an order for "Continue Physical Therapy Routine" dated 11/07/13 at 6:44 a.m. There was no documented evidence of an order for the specific frequency of physical therapy or the treatment modalities.

Review of the physical therapy evaluation dated 11/07/13 revealed the physical therapist planned to continue physical therapy twice a day Monday through Friday and daily on Saturday and Sunday. Modalities documented on the evaluation included bed mobility, transfer and gait training. Review of the PT notes revealed physical therapy was provided twice a day on 11/08/13 and once on 11/09/13.


Patient #18
Review of the patient's medical record revealed the patient was a 64 year old female admitted to the hospital for surgery on 12/17/13. Review of the physician's orders revealed an order dated/timed 12/17/13 at 4:13 p.m. for physical therapy to evaluate and treat in a.m. Further review of the physician orders revealed an order for "Continue Physical Therapy Routine" dated 12/18/13 at 7:24 a.m. There was no documented evidence of an order for the specific frequency of physical therapy or the treatment modalities.

Review of the physical therapy evaluation dated 12/18/13 revealed the physical therapist planned to continue physical therapy twice a day Monday through Friday and daily on Saturday and Sunday. Modalities documented on the evaluation included bed mobility, transfer and gait training. Review of the PT notes revealed physical therapy was provided twice a day on 12/19/13, 12/20/13, and once on 12/21/13.

In an interview on 02/12/14 at 2:40 p.m., S1DON verified there were no specific orders for PT services after the evaluation except for "Continue PT". S1DON confirmed the orders did not include specific frequency of visits or treatment modalities.


Review of the Louisiana Revised Statutes, 37:2401-37:2424 Chapter 29. Louisiana Physical Therapy Practice Act revealed in part the following:
?2418. Authority to practice as a physical therapist or physical therapist assistant
A. A physical therapist or physical therapist assistant licensed in Louisiana is authorized to practice physical therapy as defined in this Chapter. A physical therapist is responsible for managing all aspects of the physical therapy care of each patient. B. Without prescription or referral, a physical therapist may perform an initial evaluation or consultation of a screening nature to determine the need for physical therapy and may perform physical therapy or other services provided in Subsection C of this Section. However, implementation of physical therapy treatment shall otherwise be based on the prescription or referral of a person licensed to practice medicine, surgery, dentistry, podiatry, or chiropractic....