HospitalInspections.org

Based on record review and interview, the governing body failed to ensure that an ongoing, hospital-wide program for quality improvement was maintained by failing to collect, analyze and evaluate data from all hospital departments.
Findings:

On 03/05/21 at 1:00 p.m., review of the hospital's QAPI program and interview with S1ICP/QA revealed that no QA committee meetings had been held since 03/11/20. Review of the individual departmental QA data collection reports revealed the most current collection and analysis of QAPI data from each department was completed as follows:
03/2021 - Medical Records; Laboratory; Respiratory; Grievances; Clinics; Infection Control
12/2020 - Dietary
09/2020 - Nursing; Emergency
08/2020 - Ambulance
01/2020 - Pharmacy; Radiology; Housekeeping; Case Management; Maintenance
Further interview with S1ICP/QA confirmed the data should be collected, analyzed and evaluated from all departments monthly and reviewed monthly by the QA committee.

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 3 (Patient #2, 11, 12) of 13 records reviewed for completeness in a total sample of 20.
Findings:

Review of the Medical Staff Bylaws revealed that a History and Physical should be completed on each patient within 24 hours following admission.

Review of the electronic medical record with S4DON for Patient #11 revealed an admit date of 04/12/21. Further review of the record revealed no documented history and physical. On 05/05/21 at 11:00 a.m., S4DON confirmed that she was unable to locate a history and physical for Patient #11.

Review of the electronic medical record with S4DON for Patient #12 revealed an admit date of 04/19/21. Further review of the record revealed no documented history and physical. On 05/05/21 at 11:15 a.m., S4DON confirmed that she was unable to locate a history and physical for Patient #12.

Review of the electronic medical record with S2RN-IT for Patient #2 revealed an admit date of 04/26/21 and a discharge date of 04/29/21. Review of the history and physical revealed it was dictated and signed on 05/03/21, 7 days after admission and 4 days after discharge. On 05/04/21 at 10:45 a.m., an interview with S2RN-IT confirmed that the above history and physical was not completed within 24 hours following admission.


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Based on record review and interview, the hospital failed to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed (review 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, 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.

On 05/03/21 at 2:30 p.m., interview with S3Pharmacist revealed that the hospital's pharmacy hours are Monday-Friday from 8 a.m.-4:30 p.m. and a couple of hours on weekends. When asked the procedure for performing first dose reviews for any new medications (non-emergent) ordered after pharmacy hours, S3Pharmacist stated that a contracted pharmacy (Pharmacy A) performs first dose reviews for the hospital. When asked how Pharmacy A was doing with first dose reviews, S3Pharmacist stated that they do miss some, because she reviews all new medication orders when she returns every morning and catches them. S3Pharmacist further stated that staff has the ability to override medications in the Pyxis (automated medication dispensing device) in order to obtain the initial dose of medication for the patient. At this time, the surveyor requested the override report for the Pyxis.

Review of the override report provided by S3Pharmacist revealed it had multiple overrides for medications. When asked if the pharmacy investigates the overrides to determine the reason, she stated no. Review of the override report with S3Pharmacist revealed Patient #6 had the medication, Protonix 40mg IV pulled (override) from the Pyxis on 05/02/21 at 3:44 p.m.. Further review of the patient's medical record with S3Pharmacist revealed the Protonix was administered at 3:48 p.m. and was verified by a pharmacist at 4:06 p.m. by Pharmacy A. When asked if this happens often, she stated yes. When asked why the nurses are administering medication prior to a first dose review by a pharmacist, S3Pharmacist stated they do not like to wait for the time it takes.

Review of the electronic medical record for Patient #7 with S4DON revealed that the patient had a new physician order dated 04/22/21 for Rocephin 1 gram IV every day for 7 days. Review of the MAR revealed the first dose of Rocephin was administered on 04/22/21 at 1:45 p.m. Further review of the record revealed the medication was not verified by a pharmacist (first dose review) until 04/22/21 at 2:10 p.m., after the medication was administered.

Further review of the medical record for Patient #7 revealed a new physician order dated 04/24/21 for Solumedrol 40mg IV every 12 hours and an order for Coreg 3.125mg twice daily. Review of the MAR revealed the patient received the first dose of Solumedrol on 04/24/21 at 9:30 a.m. and Coreg on 04/24/21 at 9:30 a.m. Further review of the record with S4DON revealed that the medications were not verified by a pharmacist (first dose review) until 04/24/21 at 10:57 a.m. Interview with S4DON on 05/05/21 at 10:10 a.m. confirmed that the above medications were not reviewed by a pharmacist prior to the first doses being administered.

On 05/05/21 at 10:40 a.m., interview with S3Pharmacist revealed that she was unable to locate a policy and procedure for first dose reviews. When asked if the issue with first dose reviews and overrides was being looked at through QA, she stated no.

Based on observation and interview, the hospital failed to ensure that outdated, mislabeled or otherwise unusable drugs and biologicals were not available for patient use as evidenced by having expired and/or unusable medications and biologicals available for patient use.
Findings:

On 05/03/21 at 10:30a.m., observation of the crash cart on the nursing unit with S3Pharmacist revealed the following:
1 vial of Solu-medrol 1 gram expired 03/2021;
1 500 ml bag of Lidocaine in 5% Dextrose solution expired 03/2021;
2 500ml bags of 10% Dextrose solution expired 04/2021;
8 packages of K-Y jelly expired 08/2020
Interview at that time with S3Pharmacist confirmed the above medications and biologicals were currently available for patient use and should have been removed from the crash cart.

On 05/03/21 at 10:50 a.m., observation of the nurses supply room revealed an opened 250ml bottle of normal saline with no documented date that it was opened. Review of the label revealed it should be discarded within 60 days of opening. Interview at that time with S1ICP/QA confirmed that the bottle of saline should have been labeled with the date of first use, and she was unable to confirm what the open date was.

On 05/03/21 at 11:10 a.m., observation through the glass window in the Pyxis (automated medication dispensing machine) revealed a bottle of Promethazine syrup with an expiration date of April 2021. At that time, interview with S6RN confirmed the Promethazine was expired.

On 05/05/21 at 1:15 p.m., another observation of the Pyxis was conducted and the Promethazine syrup was still in the Pyxis, with an expiration date of April 2021.

On 05/05/21 at 1:30 p.m., interview with S3Pharmacist revealed that she runs a monthly report of all expiration dates of medications in the Pyxis on the nursing hall and the Pyxis in the emergency department. At that time, the surveyor asked S3Pharmacist to view the report. Review of the report with S3Pharmacist revealed that there were 35 medications that had expired in April 2021 and 2 medications that had expired in March 2021. S3Pharmacist confirmed that these medications were expired and available to be used for the patients.



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Based on observation and interview, the facility failed to ensure that equipment was maintained to ensure an acceptable level of safety by failing to have annual inspections conducted on 2 of the computers on wheels used by the nursing staff.
Findings:

On 05/03/21 at 10:40 a.m., observation of the computer on wheels #1 revealed an inspection sticker dated 10/31/18. Observation on 05/04/21 at 11:00 a.m. of computer on wheels #3 revealed no evidence of an inspection.

An interview at that time with S1ICP/QA confirmed that the equipment should be inspected annually and confirmed there was no evidence of annual inspections conducted on computers #1 and #3.

Based on record review, observation and interview, the hospital failed to employ methods for preventing and controlling the transmission of infections within the hospital as evidenced by 1) failing to ensure that 1 (S6RN) of 2 nurses observed performed proper hand hygiene before and after patient care; 2) failing to ensure a sanitary environment; and 3) failing to implement infection control measures related to hospital personnel for 2 (S5CNA, S8CNA) of 7 direct care staff personnel files reviewed.
Findings:

1) Failing to ensure that 1 (S6RN) of 2 nurses observed performed proper hand hygiene before and after patient care

Review of the hospital policy and procedure titled, Hand Hygiene, revealed in part that hand hygiene should be performed before each patient encounter and after coming in contact with a patient. Further review revealed that after washing hands with soap and water, the faucets should be turned off with the used paper towel.

On 05/04/21 at 12:30 p.m., observation revealed S6RN revealed she entered a patient's room to administer IV medication. Further observations revealed S6RN washed her hands at the patient's sink and turned off the faucets with her clean bare hands, and did not use a paper towel to turn off the faucets.

On 05/04/21 at 2:00 p.m., observation revealed S6RN unplugged the electronic blood pressure machine and the computer on wheels and entered Patient #8's room to hang one unit of blood. Upon entering the room, S6RN donned gloves and began to hang the blood. S6RN was not observed to perform any hand hygiene prior to donning the gloves. At 2:35 p.m., S6RN discarded her gloves in the patient's trash and exited the room. S6RN was not observed to perform any hand hygiene after removing the gloves and exiting the patient's room. Further observations revealed after leaving the patient's room, S6RN plugged back in both machines on the hallway, entered the nurses station and began to chart at the desk. No hand hygiene was performed.

On 05/05/21 at 1:45 p.m., interview with S1ICP/QA revealed that staff should perform hand hygiene prior to and after patient contact. When asked if there was any documentation that hand hygiene had been observed and monitored, she stated no.

2) Failing to ensure a sanitary environment

On 05/03/21 at 10:30 a.m., tour of the nursing unit and patient rooms with S1ICP/QA revealed the following:

- Room c had sticky`peeling black tape covering the nurse call buttons on the side rails.
- Room f had sticky`peeling black tape covering the nurse call buttons on the side rails. The chair in the room had tears in the vinyl and the call bell had a black substance on the cord.
- Room g had two rolls of used tape on top of the glove box and an old lottery ticket was on top of the paper towel holder. Brown splatters were on the wall near call bell box.
- Room h had dirt and debris in the drawer of the bed side table.
- Room i had tears in the vinyl of the bedside chair. Old tape and tape residue was on the wall biohazard box. Brown debris was on the siderails and was easily wiped off by the surveyor.
- A stretcher was observed at the end of nursing unit hallway. The stretcher had multiple tears and worn areas in the mattress.

Interview with S1ICP/QA on 05/03/21 at 11:00 a.m., confirmed the above rooms had been cleaned and were supposed to be ready for new patients. S1ICP/QA further confirmed that the rooms were in need of further cleaning.

On 05/03/21 at 10:30 a.m., observation on room b revealed an opened package of EKG dots, a 5ml syringe of saline and a red bag of patient's clothing in the closet were left remaining in a room designated as clean. On 05/03/21 at 10:33 a.m., S7CNA acknowledged the findings in the room designated as cleaned and stated all items were to be removed prior to the room being cleaned.

On 05/03/21 at 10:45a.m., observation of the hallway bathroom used for patients in rooms e and f revealed the floor was sticky and the wax was wearing away. Further observation revealed dirt, dust and grime was noted underneath the old wax on the color and along the baseboards and corners of the room. A dried, brown substance was noted in the sink. An interview with S1ICP/QA at this time confirmed the bathroom is used by patients.

On 05/03/21 at 11:00 a.m., observation of room a revealed grime and debris in the whirlpool tub which was designated as clean. On 05/03/21 at 11:02 a.m., S1ICP/QA acknowledged the findings and stated the whirlpool should have been clean.

On 05/05/21 at 10:45 a.m., observation revealed room d had rips/tears to the patient's procedure chair. On 05/05/21 at 10:46 a.m., S1ICP/QA acknowledged the findings and confirmed the chair could not be properly sanitized.


3) Failing to implement infection control measures related to hospital personnel

Review of the personnel files revealed no evidence that S5CNA and S8CNA had been screened for their current tuberculosis or flu vaccination status.

On 05/05/21 at 1:15 p.m., an interview with S1ICP/QA confirmed that the above staff had not been screened for the tuberculosis or flu vaccination status upon hire and there was no documentation of their current status.


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