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Based on record review and interview, the governing body failed to ensure a process was in place for the appraisal of emergencies, initial treatment, and referral when appropriate. Findings:

Review of the policy titled, Code Blue Policy for the Medical Surgical Unit (revised 06/22/17), revealed the Medical Surgical personnel must be capable of determining that a patient has had a cardiac arrest and initiating CPR. A physician is responsible for determining the proper treatment of a patient resuscitation. Orders given will be completed by a Registered Nurse. Employees will assist as directed, remaining until released by the Physician or Director of the unit.

In an interview on 08/23/17 at 2:00 p.m., S1CNO/Administrator indicated that medical staff members are not always on-site after surgeries are finished each day to respond to emergencies and/or code events. S1CNO/Administrator indicated if there is a code during the evening and/or night hours, hospital personnel will call the physician at the walk-in clinic next door to provide assistance.

Based on record review and interview, the hospital failed to measure, analyze, and track quality indicators and other aspects of performace that assess processes of care within the hospital. This was evidenced by the hospital's failure to evaluate quality indicators for all patient care services including, but not limited to Dietary Services and Respiratory Services. Findings:

Review of the hospital's Quality Assurance Performance Improvement Program revealed no documentation to indicate quality indicators were evaluated for Dietary Services and Respiratory Services.

Interview on 08/23/17 at 3:00 p.m. with S3RN revealed when asked if dietary services were reviewed through the Quality Assurance Program, she replied "no".

Based on observation and interview, the provider failed to properly store medical records in a secure location protected from fire and water damage by storing unscanned medical records on an open countertop directly beneath a sprinkler head.
Findings:

On 08/22/17 at 9:30a.m., observation of the Medical Records department revealed nine stacks of paper records with approximately 15 records per stack were sitting on an open countertop directly underneath a sprinkler head.

On 08/22/17 at 9:30a.m., an interview with S9RHIA confirmed that these were older records that had not yet been scanned for storage into the electronic system. She further confirmed that this has been the storage location for these records for some time, and that they would not be protected from water damage should the sprinkler system be activated.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable standards of practice, consistent with state law. This deficient practice was evidenced by failing to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist, before the first dose was dispensed, for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications.
Findings:

Review of the Louisiana Administrative Code, Professional and Occupational Standards,
Title 46: LIII, Pharmacist, Chapter 15, Hospital Pharmacy, §1511. Revealed in part:
Prescription Drug Orders
A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial
dose of medication, except in cases of emergency.

On 08/21/17 at 2:30 p.m., interview with S10Pharmacist revealed that the hospital pharmacy is open Monday-Friday 6:00 a.m.-6:00 p.m and the hours vary on weekends. S10Pharmacist stated that if a new medication is ordered after pharmacy hours, the nurses obtain the medication from the "night cabinet" and administer it to the patient. She stated that a first dose review is not conducted prior to the first dose of medication being administered to the patients after pharmacy hours. She stated that it would be reviewed the next morning.

At that time, further interview with S10Pharmacist revealed that there was no policy and procedure developed to address the requirement of the pharmacist to review all medication orders (except in emergency situations), before the first dose was dispensed, for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications.

Based on interview and record review, the hospital failed to ensure the dietary manager, who served as director of the food and dietetic services, supervised the daily management of the dietary services.
Findings:

On 08/21/17 at 10:00 a.m., interview with S1CNO/Administrator revealed that S2RN served as the dietary manager for the hospital. She further revealed that S2RN was also the charge nurse on the inpatient floor.

On 08/23/17 at 3:30 p.m., interview with S2RN confirmed that she was the director of food and dietetic services at the hospital. She further confirmed that she was also the charge nurse. When asked the duties she performed for the dietary service, S2RN replied she ensures the meal temperatures were taken and documented in the dietary book. When asked if she monitored any of the meals to ensure the correct diet was provided she replied "no".

Review of the personnel file for S2RN revealed that she had no job description for a director of food and dietetic services and no indication of training relative to the supervision of food and dietary services within a hospital.

Based on observation, record review and interview, the hospital failed to ensure individual patient nutritional needs were met in accordance with recognized dietary practices. This was evidenced by failing to approve patient menus prior to them being served to the patients and failing to ensure that the patients received therapeutic diets as ordered by the physician for 1 of 1 inpatient record reviewed (#1).
Findings:

On 08/21/17 at 10:00 a.m., tour of the hospital revealed it did not have a food preparation area for patient meals.

On 08/22/17 at 9:30 a.m., interview with S7RN revealed that she was the registered nurse on the inpatient floor. When asked how meals were obtained for the patients, she stated that they were obtained from the local college or from a local restaurant. She further stated that the nurses called the establishment prior to meal times to let them know how many patient meals are needed. She stated that the hospital courier would pick up the meals and bring to them back to the hospital for the patients. When asked who determined which establishment to get the meals from, she stated that if the college is closed (for holidays, etc.), then the hospital would use the restaurant. Further interview with S7RN revealed that if a patient is on a therapeutic diet, the staff would remove items from the meal tray that the patient should not eat. When asked if the registered dietician was involved in this process, she stated no. She stated that the only time the dietician was contacted was if a patient had orders for intravenous nutrition. She further stated that the dietician comes to the hospital monthly, but she was not sure exactly what she did during her visits.

On 08/21/17 at 10:00 a.m., interview with S1CNO/Administrator revealed that S2RN served as the dietary manager for the hospital. She further revealed that S2RN was also the charge nurse on the inpatient floor.

On 08/23/17 at 8:15 a.m., interview with S1CNO/Administrator indicated that using off-site vendors has been the hospitals practice since March 2015. When asked if the patient menus were approved prior to them being served to the patients, she stated "no".

On 08/23/17 at 3:30 p.m., interview with S2RN confirmed that she was the director of food and dietetic services at the hospital. She further confirmed that she was also the charge nurse. When asked the duties she performed for the dietary service, S2RN replied she ensures the meal temperatures were taken and documented in the dietary book. When asked if she monitored any of the meals to ensure the correct diet was provided she replied "no".

On 08/23/17 at 3:00 p.m., the surveyor reviewed patient #1's medical record with S5RN. The record revealed upon admission, the physician had ordered a cardiac diet for the patient (07/11/17). When asked how the staff ensured that the patient received a cardiac diet, she stated that the patient is only served baked foods. She further stated that if something is on the patient's tray that he should not be eating, it would be removed from the tray. At that time, S5RN obtained a binder that contained all meals that were served to the patients, as well as meal temperatures. Review of this binder with S5RN revealed on 08/23/17, patient #1's breakfast was eggs, biscuit, bacon and grits. For lunch, the patient received a grilled cheese. Further review of the dietary binder revealed on 08/21/17, the patient received a hamburger, fries and vanilla cake. At that time, interview with S5RN confirmed the patient was not being served a cardiac diet.

Based on record review and interview, the hospital failed to ensure a registered dietician approved a current therapeutic diet manual that included therapuetic diets and meals to be served to patients. Findings:

On 08/21/17 at 10:00 a.m., tour of the hospital revealed it did not have a food preparation area for patient meals.

On 08/22/17 at 9:30 a.m., interview with S7RN revealed that she was the registered nurse on the inpatient floor. When asked how meals were obtained for the patients, she stated that they were obtained from the local college or from a local restaurant. She further stated that the nurses called the establishment prior to meal times to let them know how many patient meals are needed. She stated that the hospital courier would pick up the meals and bring to them back to the hospital for the patients. When asked who determined which establishment to get the meals from, she stated that if the college is closed (for holidays, etc.), then the hospital would use the restaurant. Further interview with S7RN revealed that if a patient is on a therapeutic diet, the staff would remove items from the meal tray that the patient should not eat. When asked if the registered dietician was involved in this process, she stated no. She stated that the only time the dietician was contacted was if a patient had orders for intravenous nutrition. She further stated that the dietician comes to the hospital monthly, but she was not sure exactly what she did during her visits.

On 08/23/17 at 8:15 a.m., interview with S1CNO/Administrator indicated that using off-site vendors has been the hospitals practice since March 2015. When asked if the patient menus were approved prior to them being served to the patients, she stated "no".

Based on record review and interview, the hospital failed to have adequate numbers of qualified staff available to meet and respond to the respiratory needs of the patients. This was evidenced by: 1) the failure to have on-going competency evaluations of the nursing staff conducted by a qualified individual, and 2) the failure to have a process in place to ensure for the effective appraisal and care of emergencies 24 hours per day for inpatients admitted to the hospital.
Findings:

1) Review of the policy titled, Authority and Approval for Respiratory Therapy Services (revised 06/11), revealed respiratory care services shall be delivered in accordance with medical staff directives....There shall be a physician director of the respiratory service who coordinates with the Chief Nursing Officer to supervise and administer the services properly. There shall be adequate numbers of qualified personnel who meet the qualifications to provide respiratory care services to meet the needs of the patients.

Review of the policy titled, Scope of Services: Respiratory Services (effective 06/11), revealed staffing and qualifications included: Registered Nurses and Licensed Nursing staff proficient by competency assessment to perform designated services. Services include: hand-held nebulizer treatments, aerosol treatments (including delivery of pharmacological agents), percussion and cough, pulse oximetry, bedside incentive spirometer instruction, electrocardiography, delivery of oxygen, arterial blood gas procurement and analysis and education related to respiratory services to patients and family members.

On 08/23/17 at 10:00 a.m., an interview with S5RN confirmed that there is no Respiratory Department in the hospital and there are no respiratory therapists on staff. She stated that nurses provide all respiratory services as delineated in the above policy. She further stated that the registered nurses perform arterial punctures for arterial blood gas (ABG) tests. She revealed that the respiratory services are provided under the medical direction of the staff pulmonologist.

Review of the Competency Evaluation Tools for Arterial Puncture/Arterial Blood Draw for Arterial Blood Gas (ABG) presented by S1CNO/Administrator revealed that the last dated competency evaluations were performed on 09/21/11 by the contracted Certified Respiratory Therapist.

On 08/23/17 at 1:30 p.m., an interview with S1CNO/Administrator revealed that the hospital used to have a contract with a Certified Respiratory Therapist who provided the initial competency evaluations, annual in-servicing and annual competency evaluations of the nursing staff. She stated that the therapist canceled the contract a few years ago and they have not replaced him. She stated that the nurses check each other off for competency evaluations.

2) On 08/23/17 at 9:30 a.m., an interview with S7RN revealed that several patients undergoing surgery with anesthesia are admitted to the nursing floor overnight for observation and treatment.

Review of the policy titled, Code Blue Policy for the Medical Surgical Unit (revised 06/22/17), revealed the Medical Surgical personnel must be capable of determining that a patient has had a cardiac arrest and initiating CPR. A physician is responsible for determining the proper treatment of a patient resuscitation. Orders given will be completed by a Registered Nurse. Employees will assist as directed, remaining until released by the Physician or Director of the unit.

On 08/23/17 at 2:00 p.m., an interview with S1CNO/Administrator confirmed that there are no respiratory therapists or medical staff on duty after surgeries are finished each day to supervise respiratory services or respond to code events or respiratory emergencies. She stated that if there is a code during the evening and/or night hours, they call the physician at the walk-in clinic next door to provide assistance.