HospitalInspections.org

Based on record review and interview, the hospital failed to follow the Medical Staff Rules and Regulations for suspension of physicians for failure to complete medical records delinquent past 31 days after notification by certified mail. This was evidenced by the hospital's allowing a physician to admit a patient (#19) after he was notified of suspension from the hospital for 1 of 3 physicians (S31) put on suspension. Findings:

Review of the Physician Suspension List dated 12/13/11 for incomplete medical records over 31 days revealed the names of the following physicians MD S 33- suspension date 09/16/11; MD S 32- suspension date 11/28/11; and MD S 31- suspension date 11/28/11.

Review of the letter notifying MD S31 of his suspension from the hospital was dated 11/07/11 and sent certified mail #7009 0080 0002 1044 1477. Further review revealed MD S31 received the letter on 11/08/11.

Review of the hospital admissions dated 09/16/11 through 12/14/11 revealed MD S31 admitted Patient #19 to the hospital (by direct admit from his private practice office) on 12/13/11 while still on suspension from the hospital.

In a face to face interview on 12/14/11 at 3:00pm S2 Director of Quality Management verified MD S31 admitted Patient #19 directly from his office. S2 indicated this admission slipped through the admit department and the House Supervisor. Further S2 indicated Administration should have been notified of the admit when the patient arrived to the hospital.

Review of the Medical Staff Rules and Regulations adopted 09/2711 and submitted as the ones currently in use revealed..... "Medical Records: 22. For delinquent medical records (defined as any record not complete within 30 days of discharge) requiring dictation or information completion or signatures, suspension will occur when a chart is 31 days past the date of discharge. Notification will be sent to the practitioner that she/he is one suspension".

Review of the Medical Staff By-Laws dated 08/30/10 and submitted as the ones currently in use revealed.... "F. Temporary Suspension: 1. Failure to complete medical records for a patient's discharge in accordance with the Rules and Regulations following a warning of delinquency shall be grounds for temporary suspension of clinical privileges, effective until medical records are completed".

Based on record review and interview, the hospital failed to ensure the plan of care for a patient in restraints was implemented as outlined in hospital policy for 2 of 2 Emergency Department Patients in restraints out of a total sample of 25 (Patients #3, #6). Findings:

Review of the hospital policy titled, "Restraint Policy: Management and Philosophy of Patient Rights, # PC-080" presented by the hospital as current revealed in part, "Observation/Monitoring of the patient in Restraint or Seclusion. . . The patient in restraint or seclusion must be offered frequent opportunities for fluids and nourishment, toileting and elimination, range of motion and exercise of limbs. . . ."

Review of Patient #3's medical record revealed the patient presented to the Emergency Department on 12/11/2011 under an Order for Protective Custody from jail for urinating and defecating on the floor, playing in the toilet, and talking to herself. Further review revealed Patient #3 became violent and was placed in 4 point leather restraints, as ordered by the patient's physician, on 12/12/2011 at 2300 (11:00 p.m.). Review of Patient #3's entire medical record revealed no documented evidence that the patient's restraints had ever been removed with range of motion exercises performed or that the patient's position had been changed from 12/12/2011 at 2300 through 12/13/2011 at 0945 a.m. (10 hours and 45 minutes).

Patient #3 remained in 4 point leather restraints at the time of surveyor observation on 12/13/2011 at 10:25 a.m.

Review of Patient #6's medical record revealed the patient presented to the Emergency Department on 11/06/2011 with combative behavior. Further review revealed Patient #6 was placed in 4 point leather restraints at 1656 (4:56 p.m.) and remained in restraints until 2200 (10:00 p.m./ 5 hours and 4 minutes). Review of Patient #6's entire medical record revealed no documented evidence that the patient's restraints had ever been removed with range of motion exercise performed or that the patient's position had been changed.

During a face to face interview on 12/14/2011 at 8:15 a.m., Director of Emergency Department S6 indicated the Emergency Department nursing documentation for monitoring patients in physical restraints had not been complete (Patient #3 and Patient #6). S6 further indicated it was unclear if the patients had been offered fluid, toileted, provided range of motion exercise, or had their position changed. S6 indicated nursing staff should follow the hospital's restraint policy for providing care to patients in restraints.

Based on record review and interview, the hospital failed to ensure there was a policy developed and implemented regarding newly hired employees radiation exposure evaluation for 3 of 3 employees hired within the last year (S25, S26, S27). Findings:

Review of newly hired radiology employees personnel files (Radiology Techs S25, S26, and Nuclear Med Tech S27) revealed no documented evidence of evaluation of previous radiation exposure.

Review of a document presented by the hospital titled, "Environmental Regulatory Code, November 2010, Title 33, Part XV, $14. Determination of Prior Occupational Dose" revealed in part, "For each individual who is likely to receive, in a year, a occupational dose requiring monitoring in accordance with LAC 33:XV.431, the licensee or registrant shall determine the occupational radiation dose received during the current year and attempt to obtain the records of lifetime cumulative occupational radiation dose."

During a face to face interview on 12/14/2011 at 2:20 p.m., Director of Patient Imaging S24 indicated the hospital had no policy regarding evaluation of newly hired employees' previous radiation exposure. S24 further indicated she had researched the issue, in response to the survey, and had discovered Environmental Regulatory Code required the hospital to obtain prior radiation exposure reports on newly hired employees. S24 indicated she had not previously been aware of the environmental regulation and had failed to obtain exposure reports on newly hired employees.

Based on observation and interview, the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of quality as evidenced by failing to ensure the functionality of a call button labeled Nurse Call located on the handrails of the beds on the Pediatric and Post-Partum Unit. Findings:

Observations were made on the Pediatric and Post-Partum Unit on 12/13/11 between 9:30 a.m. and 10:30 a.m. A button labeled Nurse Call was noted to be on the handrail of the bed in Patient Room #2117. The button was noted to be non- functional as it failed to activate any type of nurse call system.

The Post-Partum Unit Charge Nurse (S3) was interviewed at the time of this observation. S3 confirmed that the button labeled Nurse Call was not functioning when pressed. S3 indicated the Patient Rooms on the Pediatric and Post-Partum Unit were not equipped with electrical receptacles that were compatible with the cords attached to the beds in these rooms. S3 indicated the cords that activate the call system on the handrails of the bed could not be plugged in to any of the receptacles in the patient rooms. When asked if this was the case for all beds on Pediatric and Post-Partum Unit, S3 replied yes.

Based on observation and interview, the hospital failed to ensure the implementation of all policies/procedures relating to infection control. This was evidenced by the failure to ensure that biohazardous waste was discarded and stored in accordance with the hospital's approved policy/procedure titled "Infectious Waste Removal and Transportation". Findings:

Observations were made on the rehabilitation unit on 12/14/11 between 10:00 a.m. and 10:30 a.m. S9, a staff member on the Disinfection Team, was observed coming out of a patient room with a red bag containing biohazardous waste in one hand and a clear bag containing trash in the other hand. S9 was observed entering the soiled utility room and placing both the red bag and the clear bag in the same grey plastic container. This plastic grey container was not labeled biohazardous waste. S9 (Disinfection Team) was interviewed at the time of this observation. S9 reported that she has been working at the hospital for approximately 6 months and has always placed the biohazardous waste and trash in the same grey container. S9 indicated that the soiled utility room was too small for a red biohazard container so all waste is placed in the grey container. Within fifteen minutes of S9 placing the red bag and clear bag in the same grey plastic container, S11 (Disinfection Team) was observed wheeling a large red biohazardous waste container to the soiled utility room. S11 was observed taking the red bag out of the grey plastic container and placing it in the large red biohazardous container that he had just wheeled to the room. S11 was interviewed at the time of this observation. S11 confirmed that he removed the red biohazardous waste bags from the grey plastic container and placed them in the large red biohazardous waste container. When asked what would be done with the clear bags that were still in the grey plastic container, S11 reported the clear bags would be placed in the dumpster with all the other trash.

The hospital approved policy/procedure titled "Infectious Waste Removal and Transportation" was reviewed. The policy/procedure documents "Red infectious waste bags shall be removed from the waste generating area to a centralized collection point in the soiled utility room and placed in rigid container labeled "Infectious Waste", that is provided for temporary storage. Containers must be covered with a rigid lid at all times".