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Based on record review and interview, the hospital failed to ensure personnel met applicable standards required by State regulations for hospital personnel. This deficient practice is evidenced by failure to ensure that unlicensed staff had no criminal convictions that would bar employment as per Louisiana Revised Statute 40:1203.3 for 1 (S7PCT) of 2 unlicensed staff whose personnel files were reviewed.
Findings:

Review of the Louisiana Revised Statute Title 40-Public Health and Safety, RS 40:1203.3 revealed that it listed criminal convictions that bar an employer from hiring a non-licensed person. The criminal convictions listed include RS 40:967- Prohibited acts-Schedule II penalties.

Review of the personnel file for S7PCT (unlicensed staff) revealed a hire date of 01/24/22. Review of S7PCT's background check report revealed a conviction dated 2013 for possession of a controlled dangerous substance -Schedule II (RS 40:967). Further review of the background report revealed that S7PCT was on parole until 2024.

On 02/07/23 at 1:20 p.m., interview with S2ADM revealed that she was aware of S7PCT's background check and had approved the hiring of S7PCT. Further interview with S2ADM revealed that she was unaware of the Louisiana Revised Statute regarding the hiring unlicensed personnel with non-waiveable convictions.

Based on record review and interview, the hospital failed to ensure that a medical history and physical examination was completed and documented for each patient no more than 30 days before or 24 hours after admission or registration for 2 (Patient #8, #13) of 23 records reviewed for completeness in a total sample of 30.
Findings:

Review of the facility's Health Information Management policy revealed in part: 4. History and Physical - The attending physician must sign the history and physical. This must be completed within 24 hours after admission. All reports must be dated and signed.

Review of the electronic medical record with S1DON for Patient #8 revealed an admit date of 01/27/23. Further review of the record revealed history and physical completed 01/30/23.

On 02/08/23 at 9:00 a.m., S1DON confirmed the history and physical for Patient #8 was not completed within 24 hours after admission.

Review of the electronic medical record with S1DON for Patient #13 revealed an admit date of 01/26/23. Further review of the record revealed history and physical completed 01/30/23.

On 02/08/23 at 9:45 a.m., S1DON confirmed the history and physical for Patient #13 was not completed within 24 hours after admission.

Based on record review and interview, the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient as evidenced by failing to interpret telemetry stips for 4 of 4 patients reviewed who were on continuous telemetry monitoring in a total sample of 30 (Patient #20, 24, 25, 26)
Findings:

Review of the policy titled Telemetry Monitoring revealed in part that nurses are to ensure the initiation of cardiac monitoring upon a patients admission, perform ongoing assessment and monitoring and document care.

Patient #20
Review of the patient's electronic medical record with S1DON revealed an admit date of 07/20/22 with admission orders for telemetry monitoring. Review of the record revealed no telemery strips were included. Review of the daily nursing assessments revealed "See telemetry strip documentation". There were no interpretations of heart rhythm or any telemetry strips documented in the medical record.

Patient #24
Review of the patient's electronic medical record with S1DON revealed an admit date of 01/09/23 with admission orders for telemetry monitoring. Review of the record revealed no telemetry strips were included. Review of the daily nursing assessments revealed "Telemetry in use". There were no interpretations of heart rhythm or any telemetry strips documented in the medical record.

Patient #25
Review of the patient's electronic medical record with S1DON revealed an admit date of 01/13/23 with admission orders for telemetry monitoring. Review of the record revealed no telemetry strips were included. Review of the daily nursing assessments revealed "Telemetry in use". There were no interpretations of heart rhythm or any telemetry strips documented in the medical record.

Patient #26
Review of the patient's electronic medical record with S1DON revealed an admit date of 01/10/23 with admission orders for telemetry monitoring. Review of admission EKG dated 01/10/23 revealed the patient was in atrial fibrillation. Review of the record revealed no telemetry strips were included. Review of the daily nursing assessments revealed "Telemetry in use". There were no interpretations of heart rhythm or any telemetry strips documented in the medical record.

On 02/08/23 at 9:45 a.m., S1DON confirmed that printed telemetry stips are not placed in the medical records of patients who are on continuous telemetry monitoring. S1DON further confirmed that nurses do not interpret telemetry stips or place the telemetry strips in the medical records.

Based on observation and interview, the hospital failed to ensure that medical records were properly filed and maintained to ensure the protrection of the records from water damage in the event that the fire protections sprinklers were activated.
Findings:

On 02/07/23 at 10:15 a.m., observation of the medical records storage room revealed several rolling cabinets with open shelving that contained medical records located directly below the sprinkler heads.

An interview at this time with S5Med Records revealed that all medical records for the last seven years are stored electronically. She confirmed that the medical records stored on the open shelving units were 7 to 10 years old and records on two of the shelving units had not been scanned into the electronic system. She further confirmed that they would be damaged or destroyed if the sprinkler system was activated.

Based on record review and interview, the hospital failed to follow its policy to ensure that medical records were complete within 30 days after patient discharge by failing to have practitioners complete the discharge summary within 30 days after patient discharge.
Findings:

Review of the hospital's Medical Staff Bylaws revealed, in part, the following:
7.2-1: All practitioners must complete their medical records (including all appropriate entries, with orders and dictations read and signed) within (30) days after the patient has been discharged.
7.2-5: Completion of all medical records shall be accomplished within 30 days of the patient's discharge in compliance with State law. Failure to complete charts within 30 days could result in suspension of Medical Staff privileges.

Review of the Delinquent Dictation list with S5Med Records revealed S6NP had 15 delinquent discharge summaries greater than 30 days after discharge, with the oldest discharge date of 11/07/22.

On 02/07/23 at 10:30 a.m., an interview with S5Med Records revealed that she sends a list of delinquent records to the practitioner weekly, and provides the same list to the S2ADM. She confirmed there is no further action taken on her part to ensure that the delinquencies are corrected.

On 02/07/23 at 10:45am, an interview with S2ADM confirmed there is no policy in place and are no other corrective actions taken to ensure that medical records are completed within 30 days of discharge beyond the weekly list provided to the practitioner by medical records.

Based on record review and interview, the hospital failed to ensure that drug administration errors were immediately reported to the attending physician and documented in the medical record for 3 of 4 patient medication errors reviewed (Patient #2, 3, 4).
Findings:

Review of the facility's Policy MM-6.20-20 titled, "Medication Management/Medication Misadventures" revealed in part: Definition of a Medication Error - An adverse drug reaction (ADR) is defined as any response to a medication which is detrimental, unintended and unexpected. Adverse drug reactions or suspected ADRs shall be reported in a timely manner to the practitioner who ordered the medication. ADRs / suspected ADRs and follow-up action(s) shall be properly recorded in the patient's medical record. ADR Severity Levels - I. The problem was corrected before it reached the patient. II. The reaction resulted in no harm to the patient. III. The reaction resulted in a need for increased monitoring of the patient; there was no change in vital signs and no harm to the patient... IV; V; VI; VII.

Patient 2
Review of the Medication Error Report for Patient #2 dated 07/26/22 at 9:24 p.m. revealed in part: Patient ordered Zanaflex 4 mg (milligram); Dose 1 mg by mouth twice daily; Dose ¼ tablet. Nurse administered 4 mg tablet. Wrong dose administration. Prescriber notified. Level II-the variance resulted in no harm to the patient.

Review of Patient #2's medical record with S1DON failed to reveal the medication error was documented in the medical record.

Patient 3
Review of the Medication Error Report for Patient #3 dated 07/15/22 at 8:48 p.m. revealed in part: Patient has order for Klonopine 0.5 mg at hours of sleep. Patient was administered 0.25 mg dose. Wrong dose administered. Unit supervisor notified. Level II-the variance resulted in no harm to the patient.

Review of Patient #3's medical record with S1DON failed to reveal the medication error was reported to the physician and failed to reveal the medication error was documented in the medical record.

Patient 4
Review of the Medication Error Report for Patient #4 dated 08/15/23 at 2:44 p.m. revealed in part: Patient was prescribed intravenous Ceftriaxone daily but was given Levofloxacin. Wrong medication administered. Prescriber notified. Level II-the variance resulted in no harm to the patient.

Review of Patient #4's medical record with S1DON failed to reveal the medication error was documented in the medical record.

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 nurse call button located on the handrails of all inpatient beds.
Findings:

On 02/06/23 at 10:30 a.m., observation of occupied inpatient room (a) and unoccupied inpatient rooms (b, c) revealed the patient beds had non-functional nurse call buttons on the side rails of the beds. The nurse call button on the beds were pressed by the surveyor during the observations and no alert of any type was generated when it was pressed.

On 02/08/23 at 1:30 p.m., S1ADM confirmed that the nurse call buttons on all of the inpatient beds were non-functional but they should have plastic coverings on them. S1ADM further stated that she was not aware that the plastic covering was missing on some of the non-functional call bell buttons.

Based on observation, record review and interview, the hospital failed to follow its policies and procedures for preventing the transmission of infections by having a breach in the practice of venipuncture procedures in the laboratory.
Findings:

Review of the Laboratory policy for Venipuncture Procedures (reviewed by governing body on 12/22/21) revealed staff should remove gloves and wash hands immediately following procedures, and check the area to be sure that all used equipment has been removed and discard appropriately.

On 02/06/23 at 9:50 a.m., observation in the lab revealed that S3Phlebotomist was performing a venipuncture procedure on an outpatient. After the blood draw was completed, the patient left the lab. The patient's chair was not sanitized, and the used tourniquet was left on the arm of the chair. S3Phlebotomist called a second patient into the lab. After completing the blood draw, the patient left the lab. The patient chair was not sanitized, and the used tourniquet was still lying on the arm of the chair. A third patient came in and sat down in the chair. When the blood draw was completed, S3Phlebotomist removed her gloves and handled some items on the supply table before performing hand hygiene. Observations of the side of the lab chair revealed a dried substance, which was easily cleaned by S3Phlebotomist with a sanitizing wipe.

An interview at this time with S3Phlebotomist confirmed that according to the laboratory policy and procedure, she should remove her gloves and perform hand hygiene immediately after performing the blood draw, disinfect the chair between each patient and discard all used supplies.

Based on observation and interview, the hospital failed to ensure the infection prevention and control program included maintaining a clean and sanitary environment to avoid sources and transmission of infection. This deficient practice was evidenced by failing to ensure patient use equipment in the rehabilitation department was properly cleaned and sanitized.
Findings:

Observations of the therapy gym on 02/07/23 at 12:55 p.m. revealed a box fan with a large amount of grime and debris on the fan blades and grated blade cover. Observation of the hydrocollator monthly log from November 2022 through February 2023 failed to reveal the hydrocollator had been cleaned monthly.

In an interview on 02/07/23 at 1:05 p.m., S8OTA acknowledged the grime and debris on the box fan and confirmed the monthly cleaning of the hydrocollator was not documented.