HospitalInspections.org

Based upon observations and interviews, the hospital failed to ensure the physical environment of the offsite Intensive Out-Patient (IOP) building was maintained to ensure the well being of all the patients. This was evidenced by the failure to implement a maintenance plan to ensure the interior walls were free of mold when flood waters reached approximately 9 inches inside of the IOP building. Findings:

On 09/06/16 at 10:00 a.m., observation of the IOP facility with S1Administrator revealed the walls in the LPC office and in the group room had a water line on the sheet rock wall, approximately 9 inches from the floor. Observations of the extended office area, which was connected to the main building by a breezeway, also revealed a water line on the sheet rock walls. Observation of the chart room in this area revealed multiple client charts on a shelf that had been previously wet. At that time, interview with S1Administrator revealed that the charts had been stored on the floor during the flood in March 2016 and had been soaked with water. She further confirmed that the water had risen to the line seen on the sheet rock walls, approximately 9 inches from the floor.

Further interview with S1Administrator revealed that after the flooding, several de-humidifiers were brought into the building to dry up the moisture. She stated that mold was never observed at the facility, so nothing further was done at that time. When S1Administrator was asked if the Louisiana Department of Health, Health Standards Section was notified the IOP had to close for 5 days due to the flooding, she respond "no" and added she was not aware this needed to be done.

On 09/06/16 at 10:20 a.m., interview with S1Administrator revealed that upon S6LPC resigning from employment at the facility on 08/17/16, the employee stated that she had been exposed to mold at the IOP. S1Administrator stated at that time, she ordered a mold testing kit and placed 3 different tests throughout the IOP. She further revealed that she received those results back one week ago, but she was unsure how to interpret the results. S1Administrator stated that she then contacted another mold testing/removal company, but they have not yet performed any testing at the IOP.

Based upon record review and interviews, the hospital failed to ensure the infection control officer developed measures for the identification, investigation, reporting and prevention of infections. This was evidenced by the failure of the infection control officer, S2RN/DON (Registered Nurse/Director of Nursing) to developed infection control activities for the Intensive Out-Patient Programs. Findings:

Review of the Infection Control Plan, Reference #10000, Effective 07/2010 and revised 10/2013 revealed "Responsibility And Scope Of Service: The DON for the hospital has overall responsibility for the hospital's performance assessment and improvement plan and follow-up for the quality of care/service provided to all customers of the hospital...Members of the departments from inpatient and outpatient programs will participate in the measuring, assessing and improving important patient care and organizational functions."

Review of the infection control log revealed there failed to be documented evidence the outpatient programs participated in the infection control program. Interview with S2RN/DON on 09/06/16 at 1:30 p.m.. revealed when asked if infection control activities were implemented for the Intensive Out-Patient programs, she replied "no". Interview with S1Administrator on 09/07/16 at 11:00 a.m. revealed when asked about infection control activities with the IOP's she responded she was not aware the out-patient programs needed to be included in the hospital's Infection Control Program.