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Based on record review and interview, the CAH (Critical Access Hospital) failed to ensure the pharmacy's policies regarding first dose review were written and implemented based on accepted professional principles. This deficient practice was evidenced by failing to ensure all prescriber's orders were reviewed for appropriateness by a pharmacist before the first dose of ordered medications were dispensed.
Findings:
Review of the Louisiana Administrative Code, Title 46 Professional and Occupational Standards, Part LIII Pharmacist, Chapter 15 Hospital Pharmacy, Section: 1511: Prescription Drug Orders, Item A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial dose of medication, except in cases of emergency.

Review of CAH's policy titled, "Order Processing: Pharmacy, Policy Number: 14-11, revealed in part:
Reviews of original or direct copy of order by a Pharmacist: A pharmacist shall review the prescriber's order, or a direct copy thereof, before the initial dose is dispensed (with the exception of emergency orders when time does not permit). If the order is written when the pharmacy is "closed " or the pharmacist is otherwise unavailable, it should be reviewed by a pharmacist as soon thereafter as possible, preferably within 24 hours.

In an interview on 11/23/16 at 11:14 a.m. with S5Pharmacist, she indicated the hospital's pharmacy hours were 8:00 a.m.-4:00 p.m. Monday-Friday. She said weekend pharmacy coverage was available both in-house and by phone. S5Pharmacist reported the weekend pharmacy staff did not have set hours for in-house availability. S5Pharmacist indicated she reviewed first dose orders that were written when she was in-house. She said orders written during pharmacy off-hours were reviewed within 24 hours of being written because that was hospital policy. S5Pharmacist indicated medication orders written after hours on the weekend were reviewed on Monday morning. S5Pharmacist confirmed not all medication orders were reviewed prior to initial dose administration.

In an interview on 11/29/16 at 11:10 a.m. with S8RN, he confirmed medications prescribed to treat both emergent and non-emergent medical conditions were administered in the Emergency Department. S8RN indicated none of the medications administered in the Emergency Department were ever reviewed by the pharmacist prior to administration of initial doses of new medications.

In an interview on 11/29/16 at 12:00 p.m. with S1Administrator, he confirmed the hospital did not have 24 hour pharmacist coverage to perform first dose review prior to administration of initial doses of new medications. S1Administrator agreed the hospital needed 24 hour pharmacist coverage. S1Administrator also agreed that not all medications administered in the Emergency Department were emergent. S1Administrator indicated medications prescribed in the Emergency Department that were not emergent should be reviewed by the pharmacist prior to the first dose being administered.

Based on record review and interview, the CAH failed to ensure diagnostic radiological services were maintained and made available to meet the needs of the patients. This deficient practice was evidenced by failure of the CAH to be able to provide radiological services to inpatients and patients in the hospital's emergency department when the hospital's x-ray capabilities were unavailable due to wireless network malfunction. This deficient practice had the potential to affect 1 current inpatient on the Acute/Swing bed Unit (#R6) and 8 current inpatients (#R7-#R14) in the Distinct Part Psychiatric Unit.

Findings:

Review of the documentation of the hospital's divert times revealed the hospital had been on divert due to x-ray capabilities being unavailable on the following days:
4/29/16: X-ray down-on x-ray divert; Time down: 4 hours and 4 minutes;
5/2/16: X-ray down/WiFi (wireless Internet) down- on divert; Time down: 44 minutes;
4/29/16: X-ray down-on x-ray divert; Time down: 4 hours;
5/2/16: X-ray down-on x-ray divert; Time down: 44 minutes;
5/12/16: Internet down-on divert; Time down: 2 hours and 13 minutes;
7/25/16: No x-ray capability, placed on x-ray divert- no start time, off of divert at 3:30 p.m.
8/8/16: X-ray down- on x-ray divert; Time down: approximately 7 hours (6:45 a.m.- 2:00 p.m.). Further review revealed no documented evidence of wireless/x-ray divert after 8/8/16.

Review of the hospital's contracted services revealed no documented evidence of a contract with a mobile x-ray service.

In an interview on 11/28/16 at 1:26 p.m. with S9Radiology, she indicated at times the hospital's radiological service capabilities were unavailable due to malfunction of the hospital's wireless network. S9Radiology went on to explain that the hospital utilized a CR (computer reader) that was linked to an IP (Internet Protocol) address. S9Radiology further explained that anytime the Internet was down the Radiology Department could not run images. S9Radiology confirmed this inability to run films impacted the inpatient units (Acute/Swing and Psychiatric Distinct Part Unit) and patients that were being treated in the Emergency Department when the system was down. S9Radiology indicated the hospital did not have a backup system in place such as a contract with a mobile x-ray company to provide x-ray services to the inpatient units (Acute/Swing and Psychiatric Distinct Part Unit) and patients receiving treatment in the Emergency Department when the system was down.

In an interview on 11/29/16 at 11:21 a.m. with S1Administrator, he confirmed the hospital's inability to run films when the system was down impacted the inpatient units (Acute/Swing and Psychiatric Distinct Part Unit) and patients that were receiving treatment in the Emergency Department. He confirmed the hospital did not have a back up system in place to provide x-ray capabilities when the hospital's system was down. S1Administrator agreed a back-up system needed to be in place to provide radiological services for the patients on the inpatient units (Acute/Swing and Psychiatric Distinct Part Unit) and patients receiving treatment in the Emergency Department when the hospital's radiological services were unavailable due to malfunction of the wireless network.

Based on observation and interview, the CAH failed to ensure patient medical records were protected against loss or destruction. This deficient practice was evidenced by failure of the hospital to protect approximately 10,000 patient medical records that had not been scanned, copied or backed up from potential loss, damage and destruction from water if the sprinkler system was activated.

Findings:

An observation was made of the hospital's medical records storage area on 11/23/16 at 11:15 a.m. The medical records were noted to be stored on 10 open shelving units. The shelving units were approximately 5 1/2 to 6 feet tall, each with 6-7 double sided shelves. Paper patient medical records were stored in manila folders on the shelves. The room contained sprinklers and the open shelving units were fully exposed to potential spray from the sprinklers if the sprinkler system was activated.

On 11/23/16 at 11:20 a.m. S6HIM indicated, during the observation of the hospital's medical record storage area, that the above referenced patient medical records dated back 10 years. She approximated the shelves contained 10,000 patient medical records that had not been scanned, copied or backed up in any way. S6HIM confirmed the records had nothing in place to protect them from potential water damage if the sprinkler system was activated.

Based on record review and interview, the CAH failed to meet the needs of Swing Bed patients as evidenced by failure to provide specialized Occupational Rehabilitative Therapy Services, either directly or through contractual agreement. This deficient practice has the potential to affect all Swing Bed patients receiving care at the CAH.

Findings:

Review of the hospital's list of contracted services, provided as current by S2DON, revealed no documented evidence of a contract for Occupational Therapy Services.

In an interview on 11/23/16 at 12:30 p.m. with S7PT (Physical Therapist), he indicated Physical Therapy and Speech Therapy Services were available for the CAH's Swing Bed patients. S7PT confirmed the hospital did not provide specialized Occupational Therapy Services for Swing Bed patients.

In an interview on 11/29/16 at 11:21 a.m. with S1Administrator, he confirmed the hospital did not have Occupational Therapy Services available for Swing Bed patients. S1Administrator indicated the hospital had previously had to transfer a stroke patient to another hospital due to the need for specialized Occupational Therapy Services. S1Administrator agreed Occupational Therapy Services should be provided if they are required for Swing Bed patients.