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Based on record reviews and interviews, the hospital failed to ensure the hospital's grievance process was implemented according to its policies and procedures as evidenced by having no documented evidence of having conducted an investigation for 2 of 3 grievances reviewed from a total of 6 grievances received from patients or their representative in 2013 (R2, R3). Findings:

Review of the hospital policy titled "Grievances", effective 07/10/12 and contained in the PACES Geriatric Psychiatric Unit policy manual presented by S3DON of the Psychiatric Unit as the current policies, revealed that a complaint must be in writing and contain the name and address of the person filing the complaint. All grievances, whether verbal or written, shall be documented on a grievance form and logged on the grievance log.

Review of the hospital policy titled "Patient Grievance Process", revised 12/16/13 and presented by S1Administrator as the hospital's current policy for handling patient grievances, revealed that the Grievance Coordinator will conduct an investigation of the grievance by reviewing the patient's medical record to obtain information regarding the patient's clinical condition. The Coordinator will interview the patient and/or patient's representative for additional information as needed and will also query other members of the healthcare team who have been involved in the care of the patient. Further review revealed that grievances against physicians would be forwarded to the Medical Staff Executive Committee for Peer Review.

Review of the "Statement Of Concern/Grievance Report" presented by S6Comptroller for the grievance submitted on 09/18/13 by Patient R2's mother revealed that Patient R2's mother reported that the physician was "rude and showed no concern" and "indicated she was the reason for the child's condition." Review of the investigation revealed that S7Medical Director was informed of the grievance on 09/17/13 (day before the grievance was documented), and S6Comptroller met with S1Administrator, S28RN, and S7Medical Director on 09/18/13. Further review revealed that S7Medical Director would speak with S29Physician when he (S29Physician) returns on 09/23/13. Further review of the resolution revealed that S7Medical Director stated he spoke with S29Physician concerning his behavior (no documented evidence of the date of the meeting). There was no documented evidence of the interviews held with S1Administrator, S28RN, and S7Medical Director on 09/18/13. There was no documented evidence of documentation by S7Medical Director regarding the interview he had with S29Physician.

Review of the "Statement Of Concern/Grievance Report" presented by S6Comptroller for the grievance submitted on 10/05/13 by Patient R3's son revealed Patient R3's son complained that S30Physician "got in his face and caused him feel threatened and made fun of his family" and that S30Physician is rude. Review of the investigation revealed that S6Comptroller spoke with S7Medical Director who will speak with S30Physician concerning this situation. There was no documented evidence of a documented resolution, that the grievance was submitted for peer review, interviews with members of the healthcare team who were involved in the care of Patient R3, and the interview conducted by S7Medical Director with S30Physician.

In an interview on 02/05/14 at 9:00 a.m., S1Administrator indicated the policy that stated that the complaint must be in writing was a policy of the PACES Geriatric Psychiatric Unit. She presented the revised hospital policy for handling grievances during the interview. S1Administrator confirmed that the grievance policy was not consistent between the PACES Geriatric Psychiatric Unit, which is a unit of the hospital, and the hospital.

In an interview on 02/05/14 at 10:15 a.m., S6Comptroller indicated that she was responsible for handling grievances received by the hospital. She further indicated that when a grievance is received about a physician, it is sent for peer review. She further indicated that she should have checked "yes" for sending the grievance for peer review for Patient R3, because S7Medical Director was given the grievance to review, and he is Chief of Staff. S6Comptroller confirmed that the grievances for Patients R2 and R3 did not have documentation of any investigation that was conducted.

Based on record reviews and interviews, the hospital failed to ensure the response letter sent to the complainant following the completion of the grievance process included the name of the hospital contact person, the results of the grievance process, and the date the grievance investigation was completed for 3 of 3 grievances reviewed from a total of 6 grievances received from patients or their representative in 2013 (R1, R2, R3).
Findings:

Review of the hospital policy titled "Grievances", effective 07/10/12 and contained in the PACES Geriatric Psychiatric Unit policy manual presented by S3DON of the Psychiatric Unit as the current policies, revealed that a complaint must be in writing and contain the name and address of the person filing the complaint. All grievances, whether verbal or written, shall be documented on a grievance form and logged on the grievance log.

Review of the hospital policy titled "Patient Grievance Process", revised 12/16/13 and presented by S1Administrator as the hospital's current policy for handling patient grievances, revealed that the Grievance Coordinator will conduct an investigation of the grievance by reviewing the patient's medical record to obtain information regarding the patient's clinical condition. The Coordinator will interview the patient and/or patient's representative for additional information as needed and will also query other members of the healthcare team who have been involved in the care of the patient. Further review revealed that grievances against physicians would be forwarded to the Medical Staff Executive Committee for Peer Review.

Review of the "Statement Of Concern/Grievance Report" presented by S6Comptroller for the grievance submitted on 09/18/13 by Patient R2's mother revealed that Patient R2's mother reported that the physician was "rude and showed no concern" and "indicated she was the reason for the child's condition." Review of the investigation revealed that S7Medical Director was informed of the grievance on 09/17/13 (day before the grievance was documented), and S6Comptroller met with S1Administrator, S28RN, and S7Medical Director on 09/18/13. Further review revealed that S7Medical Director would speak with S29Physician when he (S29Physician) returns on 09/23/13. Further review of the resolution revealed that S7Medical Director stated he spoke with S29Physician concerning his behavior (no documented evidence of the date of the meeting). There was no documented evidence of the interviews held with S1Administrator, S28RN, and S7Medical Director on 09/18/13. There was no documented evidence of documentation by S7Medical Director regarding the interview he had with S29Physician.

Review of the "Statement Of Concern/Grievance Report" presented by S6Comptroller for the grievance submitted on 10/05/13 by Patient R3's son revealed Patient R3's son complained that S30Physician "got in his face and caused him feel threatened and made fun of his family" and that S30Physician is rude. Review of the investigation revealed that S6Comptroller spoke with S7Medical Director who will speak with S30Physician concerning this situation. There was no documented evidence of a documented resolution, that the grievance was submitted for peer review, interviews with members of the healthcare team who were involved in the care of Patient R3, and the interview conducted by S7Medical Director with S30Physician.

In an interview on 02/05/14 at 9:00 a.m., S1Administrator indicated the policy that stated that the complaint must be in writing was a policy of the PACES Geriatric Psychiatric Unit. She presented the revised hospital policy for handling grievances during the interview. S1Administrator confirmed that the grievance policy was not consistent between the PACES Geriatric Psychiatric Unit, which is a unit of the hospital, and the hospital.

In an interview on 02/05/14 at 10:15 a.m., S6Comptroller indicated that she was responsible for handling grievances received by the hospital. She further indicated that when a grievance is received about a physician, it is sent for peer review. She further indicated that she should have checked "yes" for sending the grievance for peer review for Patient R3, because S7Medical Director was given the grievance to review, and he is Chief of Staff. S6Comptroller confirmed that the grievances for Patients R2 and R3 did not have documentation of any investigation that was conducted.

Based on observations and interview, the hospital failed to ensure that patients in the PACES Geriatric Psychiatric Unit received care in a safe setting by having: electric beds with attached electrical cords that could be used for strangulation; drawer handles on bedside tables in patient rooms, shower heads in the shower room and Room "c" protruding from the wall approximately 3 inches, standard round door knobs on patient rooms and bathroom doors in patient rooms, plastic curtain rods in the shower room that do not release when pulled, sink faucet and handles in the shower room and in the bathrooms of patient rooms, and handrails in the shower of Room "c" and in the halls with an opening between the rail and the wall that provided an opportunity for wrapping items around these items that could be used for hanging oneself; hand-held shower heads attached to an approximate 5 inch long flexible plastic cord in the shower room and Room "c" that provided a means of strangulation; patient beds that allowed the surface that held the mattress to be lifted and propped up without holding it that provided a means of injuring oneself if a part of the body became trapped under the surface; a plastic liner in the soiled linen hamper in the shower room; a box of rubber gloves mounted on the wall in the patients' shower room; multiple plastic garbage bags on the top of the cabinet in the patients' shower room; and non-tamper-resistant screws used throughout the unit and accessible to patients.
Findings:

Observations on the PACES Geriatric Psychiatric Unit on 02/03/14 from 2:00 p.m. through 2:35 p.m. with S3Director of Nursing (DON) of the Psychiatric Unit present revealed the following safety hazards for psychiatric patients:
Electric beds in Rooms "a", "b", and "d" with attached electric cords that could be used for strangulation;
drawer handles on bedside tables in patient rooms that provided an opportunity for wrapping items around that handle that could be used for hanging oneself;
Shower heads in the shower room and Room "c" that protruded from the wall approximately 3 inches that provided an opportunity for wrapping items around the connection that could be used for hanging oneself;
Standard round door knobs on patient rooms and bathroom doors in patient rooms that provided an opportunity for wrapping items around the knobs that could be used for hanging oneself;
Plastic curtain rods in the shower room with attached curtains (that were not a quick-release type) that did not release when pulled that provided an opportunity for hanging oneself;
Hand-held shower heads attached to an approximate 5 inch long flexible plastic cord in the shower room and Room "c" that could be used as a means of strangulation;
Sink faucet and handles in the shower room and in the bathrooms of patient rooms that provided an opportunity for wrapping items around the faucet and handles that could be used for hanging oneself;
Handrails in the shower of Room "c" and in the halls with an opening between the rail and the wall that provided an opportunity for wrapping items around handrails that could be used for hanging oneself;
Patient beds in Rooms "e", "f", "g", "h" and "i" that allowed the surface that held the mattress to be lifted and propped up without holding it that provided a means of injuring oneself if a part of the body became trapped under the surface;
A plastic liner in the soiled linen hamper in the shower room that provided a means of strangulation;
A box of rubber gloves mounted on the wall in the patients' shower room that provided a means of strangulation if tied together and a means of suffocation if used to cover one's nose and mouth;
Multiple plastic garbage bags on the top of the cabinet in the patients' shower room that could be used for suffocation; and
Non-tamper-resistant screws used throughout the unit and accessible to patients.

In an interview on 02/03/14 at 2:50 p.m., S3DON of the Psychiatric Unit confirmed the above observations presented a safety risk for all patients admitted to the PACES Geriatric Psychiatric Unit. She indicated that she had been employed at the hospital since May 2013, and the unit had electric beds at that time.

Based on record review and interviews, the hospital failed to ensure the hospital had annual inspections performed by the Office of State Fire Marshal and Office of Public Health as required by the hospital licensing regulations.
Findings:

S1Administrator could not produce documented evidence of a current inspection of the hospital conducted within 1 year of the survey by the Office of State Fire Marshal and Office of Public Health. Review of the Office of State Fire Marshal inspection presented by S1Administrator revealed it was last done on 03/19/12. Review of the Office of Public Health inspection dated 01/28/13 presented by S1Administrator revealed it was the inspection of the hospital's rural health clinic and not that of the hospital.

In an interview on 02/05/14 at 2:45 p.m., S1Administrator indicated the hospital did not have documentation of a current inspection by the Office of State Fire Marshal and by the Office of Public Health. She indicated the Office of State Fire Marshal inspection of the PACES Geriatric Psychiatric Unit was performed on 03/13/13.

Based on record review and interviews the CAH (critical access hospital) failed to meet the requirements of the Condition of Participation for Emergency Services.

The CAH failed to ensure the emergency care provided by the Emergency Department (ED) met the needs of its inpatients and outpatients as evidenced by:
1) Failing to ensure policies, procedures, and protocols were developed and implemented for the pediatric population that were specific for the medical care and the emergency care of the pediatric patient. The Emergency Department provided care to 1,204 pediatric patients ranging in age from birth to 8 years old from 01/01/13 - 01/31/14 (13 months).
2) Failing to ensure all emergency room registered nurses were trained in pediatric advanced life support (PALS) as set forth in the Louisiana State Hospital Licensing Regulations for provision of Emergency Services Section 9327E.1. Personnel for 2 (S2DON, S23RN) of 3 ( S2DON, S18RN, S23RN) emergency room registered nurses' personnel records reviewed.
3) Failing to ensure all nurses providing care to the patients in the Emergency Department on Propofol were competent in monitoring a patient on Propofol for 2 (S18RN, S23RN) of 3 (S2DON, S18RN, S23RN) emergency room nurses' personnel records reviewed.
Findings:

Review of the hospital's Emergency Department Policy and Procedure manual, last reviewed/revised 6/24/09, revealed the following, in part:
Goals and Objectives:
Section 2: Purpose:
To ensure that all staff members, working within the department, receive adequate special training and possess the necessary skills for satisfactory performance of their duties.
To guide emergency patient care by written policies and procedures.

1) Failing to ensure policies, procedures, and protocols were developed and implemented for the pediatric population that were specific for the medical care and the emergency care of the pediatric patient:
Review of documentation provided by the hospital's Health Information Management department revealed the hospital's ED had provided care to 1,204 pediatric patients ranging in age from birth to 8 years old from 01/01/13 - 01/31/14 (13 months).

Review of the hospital's Emergency Department Policy and Procedure manual revealed no documented evidence of policies, procedures, or protocols regarding care of the pediatric patient in the ED.

In an interview on 02/04/14 at 1:35 p.m. with S2DON, he was asked if the (ED) treated pediatric patients and he replied, "Yes". S2DON was asked if the ED had any specific training related to pediatric patients and/or protocols, policies, and procedures specific to the treatment and management of care of pediatric patients and he replied, "I don't think so".

In an interview on 02/05/14 at 9:45 a.m. with S7MedicalDirector, he was asked if the hospital ( including the ED) had any policies, procedures, and/or protocols specific to treatment and management of care of the pediatric patients and he replied "No, we do not have policies, procedures and protocols specific to pediatric patients. They are treated as regular patients, no different from adults".

In an interview on 02/05/14 at 12:54 p.m. with S23RN, she said she had been employed at the hospital since 09/25/13. She was asked if she had any pediatric experience and she replied, "No". S23RN was asked if the ED had policies/procedures and/or protocols specific to care and management of pediatric patients and she replied "No, it does not have pediatric-specific policies, procedures or protocols".

2) Failing to ensure all emergency room nurses were trained in pediatric advanced life support as set forth in the Louisiana State Hospital Licensing Regulations for provision of Emergency Services Section 9327E.1. Personnel:

Review of the Louisiana State Hospital Licensing Regulations for provision of Emergency Services Section 9327E.1. Personnel revealed, in part, the following: There shall be a registered nurse and other nursing service personnel qualified in emergency care to meet written emergency procedures and needs anticipated by the hospital. All registered nurses working in Emergency Services shall be trained in pediatric advanced life support.

Review of the personnel record for S2DON revealed he was a registered nurse who was the Director of Nurses, but also worked in the emergency room if he was needed. Further review of his personnel record revealed he had no competencies documented for emergency care of the pediatric patient and was not PALS certified.

Review of the personnel record for S23RN revealed she was a registered nurse assigned to work in the emergency room department. Further review of her personnel record revealed she had no competencies documented for emergency care of the pediatric patient and was not PALS certified.

In an interview on 02/04/14 at 1:15 pm with S2DON, he was asked if the nurses had skills competencies (initial and annual) for emergency care of the pediatric patient, and he replied he had just recently taken the job of DON. He explained he had no staff competencies in the nursing staff's personnel records from the former DON (whom he had replaced).

In an interview on 02/04/14 at 1:35 p.m. with S2DON, he was asked if the emergency room treated pediatric patients, and he replied "Yes". S2DON was asked if the hospital had any specific training related to pediatric patients, and he replied "I don't think so".

In an interview on 02/04/14 at 3:14 p.m. with S2DON, he said, to his knowledge, the nurses did not have training in emergency care of the pediatric patient. He further stated, to his knowledge, the nurses did not have PALS training either.

In an interview on 02/05/14 at 12:54 p.m. with S23RN, she said she had been employed at the hospital since 09/25/13. She was asked if she had any pediatric experience and she replied "No, I worked labor and delivery at another hospital prior to coming to this hospital". She was asked if she had been trained in Pediatric Advanced Life Support (PALS) or pediatric trauma, and she replied "No". S23RN said her orientation had consisted of shadowing people she was working with. She explained her orientation had not included any class time or formal training. She also explained her skills/competencies had not been checked off, and she had received no training specific to pediatrics. She also said the hospital had no policies/procedures/protocols specific to care of pediatric patients.

3) Failing to ensure all nurses providing care to the patients in the Emergency Department on Propofol were competent in monitoring a patient on Propofol:
Review in part of the Louisiana State Board of Nursing Declaratory Statement on the role and scope of practice of the Registered Nurse in the administration of medication and monitoring of the patients during the levels of procedural sedation (minimal, moderate, deep, and anesthesia) as defined herein in revealed, "...It is within the scope of practice for a registered nurse to administer non-anesthetic medication and to monitor patients in minimal, moderate, and deep sedation levels as defined by JCAHO (Joint Commission of Accreditation of Healthcare Organizations) provided the registered nurse is specifically trained and with demonstrated knowledge, skills and abilities in accordance with the following provisions in various settings to include inpatient and outpatient environments...
A. The registered nurse {non-CRNA (Certified Registered Nurse Anesthetist)} shall have documented education and competency to include:
Knowledge of sedative drugs and reversal agents, their dosing and physiologic effects...
Demonstrate the acquired knowledge of anatomy, physiology, pharmacology, and basic cardiac arrhythmia recognition; recognize complication of undesired outcomes related to sedation/analgesia; demonstrate appropriate interventions in compliance with standards of practice, emergency protocols, or guidelines.
Demonstrate the knowledge of age specific considerations in regard to assessment parameters, potential complication and appropriate interventions according to hospital protocol or guidelines...
Application of the principles of accurate documentation in providing a comprehensive description of patient responses and outcomes.
B. Competencies will be measured initially during orientation and on an annual basis...
This statement is not intended to prohibit registered nurses from administering Propofol(Diprivan) to intubated, ventilated patients in a critical care setting..."

Review of medical record for Patient #18 revealed the patient was seen in the Emergency Room on 11/10/13 with diagnoses that included the following: Altered Mental Status, Acute Coronary Syndrome, Cerebral Vascular Infarction. Further review of the medical record revealed the patient was administered Propofol by S23RN. Review of the Medication, IV (intravenous) fluid, and Blood administration orders revealed Patient #18 was on a Propofol drip (20 micrograms in 100 milliliters D5W (5% dextrose in water), which was infusing at 51 mls/hr (milliliters/hour) at 13:27 (1:27 p.m.) . Response to treatment was noted as unchanged. The Propofol concentration was changed to 40 micrograms in 100 milliliters D5W, and the rate was increased to 102 mls/hr at 13:28 (1:28 p.m.). Additional order instructions were noted: titrate to adequate sedation with SBP (systolic blood pressure) greater than 160 or DBP ( diastolic blood pressure) greater than 80. Response to treatment was noted as improved.

Review of medical record for Patient #19 revealed the patient was seen in the Emergency Room on 12/02/13 for a Grand Mal Seizure. Further review of the medical record revealed the patient was administered Propofol by S18RN. Review of the Nursing Notes revealed Patient #19 was on a Propofol drip, which was increased from 19 mls/hr (milliliters/hour) to 30 mls/hr at 03:55 (3:55 a.m.). At 04:10 (4:10 a.m.) the Propofol was infusing to titration.

Review of the personnel record for S23RN revealed she was a registered nurse assigned to work in the emergency room department. Further review of her personnel record revealed she had no competencies documented for monitoring a patient on Propofol.

Review of the personnel record for S18RN revealed she was a registered nurse assigned to work the emergency room department and the inpatient floor. Further review of her personnel record revealed she had no competencies documented for monitoring a patient on Propofol.

In an interview on 02/04/14 at 1:15 pm with S2DON, he was asked if the nurses had skills competencies (initial and annual) and he replied he had just recently taken the job of DON, and he explained he had no staff competencies in personnel records from the former DON (whom he had replaced).

In an interview on 02/04/14 at 1:37 p.m. with S2DON, he said Propofol was administered by RN's under the direct supervision of the MD. He was asked if the nurses administering the Propofol had any competencies for administering Propofol and he replied "I am not aware of any competencies for registered nurses (RNs) administering Propofol".

In an interview on 02/05/14 at 9:45 a.m. with S7Medical Director, he was asked if Propofol was administered in the ED. He said he had been employed at the hospital for 10 years and had not personally administered Propofol. He was told Propofol had been administered in the ED 8 times from February 2013 to December 2013. He explained Propofol would have been administered as a third line drug for status epilepticus and for rapid sequence intubation in the ED.

In an interview on 02/05/14 at 12:54 p.m. with S23RN, she said she had been employed at the hospital since 09/25/13. She was asked if she had administered Propofol, and she replied "Yes" . She explained she had started Propofol drips (mixed by pharmacy) on patients in the ED with a doctor present . She said she had not administered Propofol intravenous (IV) push. She was asked if she had been trained in using sedation scales to measure level of sedation, and she replied she had not received training in the use of sedation scales to evaluate level of sedation. She explained the Propofol doses were increased in a stepwise fashion based on the patient's vital sign response. She was asked who mixed the Propofol drips if pharmacy was not in house, and she replied the nurses would mix the Propofol based upon the instructional inserts in the procedure boxes (prepared by pharmacy). She said these boxes were available in a locked cabinet in the ED. S23RN stated her skills/competency for mixing and administering Propofol had not been checked off/evaluated by supervisory staff.

A phone interview was conducted with S9Physician on 02/05/14 at 2 p.m. He reported he was an emergency physician who worked in the Emergency Department at the hospital. He went on to report he did use Propofol in the emergency room for rapid intubation and on occasion used Propofol as a drip. He further reported he titrated the Propofol based on the patient's vital signs, specifically the patient's blood pressure.

In an interview on 02/05/14 at 2:30 p.m. with S5Pharmacy Director, she explained pharmacy mixed the Propofol drips when the pharmacist is in house. She further explained medical/nursing staff would mix the Propofol if it was needed after hours using the Propofol procedure box. She said pharmacy stocked procedure boxes that contained Propofol (1- 200 milligram vial), a 100 milliliter bag of 5% (per cent) Dextrose IV (intravenous) solution, a Propofol package insert, and an instructional sheet for mixing Propofol based upon weight in the ED drug cabinet.







30984

Based on record reviews and interviews, the hospital failed to ensure the governing body assumed the full legal responsibility for determining, implementing, and monitoring policies governing the hospital's total operation and ensuring that the hospital's policies were administered so as to provide quality health care in a safe environment. The governing body failed to ensure the Medical Staff By-Laws were implemented relative to the credentialing and privileging of physicians. The Hospital failed to ensure all required information required for reappointment was available for review by the Medical Executive Review Committee and the Governing Board before the physician was reappointed for 1 of 6 physician credentialing files reviewed from a total of 31 active and contracted physicians (excluding pathology and radiology) (S8). The hospital failed to ensure specific privileges were requested and approved rather than core privileges as required by the Medical Staff By-Laws for 4 of 6 physician credentialing files reviewed from a total of 31 active and contracted physicians (excluding pathology and radiology) (S7, S8, S9, S10).
Findings:

Review of the Medical Staff By-Laws, presented by S1Administrator as the current By-Laws, revealed the Medical Executive Committee (MEC) shall examine the evidence of the character, professional competence, qualifications, and ethical standing of the applicant, and shall determine through information contained in references given by the applicant that he has established and meets all the necessary qualifications for membership and the clinical privileges requested by him. At reappointment the Medical Executive Committee shall review all pertinent information available scheduled for periodic reappraisal every 2 years for the purpose of making recommendations for reappointment to the Medical Staff and for granting of clinical privileges. The MEC shall transmit its recommendations to the Board of Commissioners. Each application for appointment and reappointment must contain a request for the specific clinical privileges desired by the applicant.

S7Medical Director
Review of S7Medical Director's credentialing file revealed his reappointment was for the period of 06/24/13 to 06/23/15. Review of his privileges revealed he requested and was approved for core privileges for Internal Medicine, wound care, and Emergency Medicine. There was no documented evidence that the specific privileges were requested as required by the Medical Staff By-Laws.

S8Psychiatrist
Review of S8Psychiatrist's credentialing file revealed his reappointment was the period of 06/24/13 to 06/23/15. Further review revealed affiliations references were received on 07/03/13 and 08/05/13 after he had been approved by the governing body. Further review revealed his peer references were received on 07/02/13, 07/23/13, and 07/24/13 after he had been approved by the governing body. Review of his request for privileges revealed the privileges requested and approved were core privileges for psychiatry rather than specific privileges as required by the Medical Staff By-Laws.

S9Physician
Review of S9Physician's credentialing file revealed his reappointment was the period of 08/26/13 to 08/25/15. Review of his clinical privileges requested and approved revealed core privileges in Emergency Medicine were requested rather than specific privileges as required by the Medical Staff By-Laws.

S10Radiologist
Review of S10Radiologists's credentialing file revealed his reappointment was the period of 01/28/13 to 01/27/15. Review of his clinical privileges requested and approved revealed core privileges in Radiology were requested rather than specific privileges as required by the Medical Staff By-Laws.

In an interview on 02/05/14 at 3:25 p.m., S15Executive Assistant indicated she was responsible for the credentialing process at the hospital. When asked what type of training she had received relative to credentialing, she answered "not a lot". She indicated that at reappointment 2 peer references and affiliations were required. She further indicated that she doesn't always get the references back before the credentialing file goes to the MEC and the governing body. She confirmed that she sends the credentialing files for approval by the MEC and the governing body before she has all the required items. She further indicated that the hospital used core privileges rather than specific privileges as required by the Medical Staff By-Laws. S15Executive Assistant confirmed that the references for S8Psychiatrist were received after he had been approved by the MEC and the governing body.

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of the Provision of Services as evidenced by:

1) Failing to ensure the staffing and assignments of nurses were made in accordance to the needs of the patient and the competence of the staff as evidenced by failure to ensure skill competencies were evaluated on the nursing staff of the hospital to ensure nursing staff assignments were made appropriately for 3 (S18RN, S23RN, S24LPN) of 4 (S2DON, S18RN, S23RN and S24LPN) nurses' personnel records reviewed for competencies in nursing skills. The hospital employed 16 RNs (registered nurse) and 16 LPNs (licensed practical nurse) (see findings in tag C0295);

2) Failing to ensure that nursing services provided to the inpatient psychiatric patients by non-CAH (critical access hospital) nursing staff met the needs of the patients as evidenced by having the orientation, training, supervision, and evaluation of the clinical activities of each non-CAH nursing staff performed by a non-CAH-employed Registered Nurse (RN) (see findings in tag C0294);

3) Failing to ensure the storage, handling, dispensing, and administering of drugs and biologicals were implemented according to accepted professional principles, hospital policy, and the Louisiana State Board of Pharmacy as evidenced by: a) Failure to ensure its policies and procedures and hospital practice for dispensing and administering medications and biologicals followed the requirements of the Louisiana State Board of Pharmacy regarding the pharmacist's review of medication orders prior to the first dose being administered except in emergencies. The hospital policies and practice allowed medications to be administered prior to the pharmacist's review when the pharmacy was closed or the pharmacist was not available and b) Failure to ensure drugs and biologicals were secure and not accessible to patients and visitors. The hospital's computer on wheels (COW) medication cart was unlocked and unattended in the patient care unit hallway that was accessible to the public, and the COW medication carts were not in a locked room when not in use. Drugs and biologicals were stored in an unlocked room located in a high traffic area that was accessible to patients and visitors (see findings in tag C0276);

4) Failing to implement measures to ensure the provision of a safe environment consistent with nationally recognized infection control precautions as evidenced by: a) Having an unsealed, unsecured, used sharps container (containing needles) on the counter in the unattended and unlocked Wound Care/Endoscopy Recovery Room; b) Storing clean suction supplies (26 suction canisters, 4 suction canister lids, and an open bag of loose suction canister elbow connectors) in the soiled utility room; c) Failure to repair water damage on the sheetrock as evidenced by having a black substance on the damaged sheetrock in the bathrooms of Rooms "i" and "k"; d) Storing a plastic bin containing bags of 0.9% (per cent) Sodium Chloride, 4 boxes of sterile water used for irrigation, leg splints (8), and walking boots (3) on the floor in the emergency supply room; e) Storing patient care supplies, equipment, and dirty equipment in the same area; f) Having the clean supply room with equipment on the floor and accumulated dust on stored equipment; and g) Having a clean linen cart with linen open to air stored with a soiled linen cart in Room "l" (see findings in tag C0278);
5) Failing to ensure the registered nurse (RN) supervised and evaluated the nursing care for each patient. The RN failed to assess each patient to determine that the patient met the criteria for delegation according to the LSBN's (Louisiana State Board of Nursing) administrative rules for 2 of 9 inpatient records (#6, #13) reviewed and 3 of 5 random patient records (R4, R5, R14) reviewed for RN assessments from a total of 25 sampled patients and 14 random patients. Patient #6 was an inpatient at the time of the survey (see findings in tag C0296);
6) Failing to ensure lab services were provided to meet the diagnosis and treatment needs of each patient. The hospital failed to have lab tests performed as ordered by the physician, have physician orders for tests performed, and followed up on lab results in a timely manner for 3 of 14 patient records reviewed for lab services provided from a total of 25 sampled patients (#3, #4, #7). Patient #3 was an inpatient at the time of the survey (see findings in tag C0282); and

7) Failing to ensure the nutritional needs of inpatients were met according to recognized dietary practices and the orders of the physician as evidenced by: a) Failure to ensure nutritional assessments were performed by the registered dietitian (RD) as ordered by the physician and within 72 hours of the order according to hospital policy for 4 of 6 psychiatric inpatients' medical records reviewed for nutritional assessments from a total of 25 sampled patients (#3, #4, #7, #10). Patient #3 was an inpatient at the time of the survey and b) Failure to ensure the dietary manager assured the dishwasher's water temperature was maintained according to the manufacturer's guidelines for 76 wash cycles out of 286 wash cycles performed from 11/01/13 through 02/04/14 (see findings in tag C279).

Based on record reviews and interviews, the hospital failed to ensure the storage, handling, dispensing, and administering of drugs and biologicals were implemented according to accepted professional principles, hospital policy, and the Louisiana State Board of Pharmacy.
1) the hospital failed to ensure its policies and procedures and hospital practice for dispensing and administering medications and biologicals followed the requirements of the Louisiana State Board of Pharmacy regarding the pharmacist's review of medication orders prior to the first dose being administered except in emergencies. The hospital policies and practice allowed medications to be administered prior to the pharmacist's review when the pharmacy was closed or the pharmacist was not available and
2) the hospital failed to ensure drugs and biologicals were secure and not accessible to patients and visitors. The hospital's computer on wheels (COW) medication cart was unlocked and unattended in the patient care unit hallway that was accessible to the public, and the COW medication carts were not in a locked room when not in use. Drugs and biologicals were stored in an unlocked room located in a high traffic area that was accessible to patients and visitors.
Findings:

1) Ensure its policies and procedures and hospital practice for dispensing and administering medications and biologicals followed the requirements of the Louisiana State Board of Pharmacy regarding the pharmacist's review of medication orders prior to the first dose being administered except in emergencies:
Review of the "Louisiana Administrative Code Title 46 - Professional and Occupational Standards Part LIII: Pharmacists Chapter 15. Hospital Pharmacy" revealed that the pharmacist shall review the practitioner's medical order prior to dispensing the initial dose of medication, except in cases of emergency.

Review of the hospital policy titled "Medication Management - Preparation & (and) Dispensing", presented as a current policy by S5Pharmacy Director, revealed that a pharmacist shall review the prescriber's original order or a direct copy of it before the initial dose is dispensed or removed from floor stock or from an automated dispensing cabinet unless a licensed independent practitioner with appropriate clinical privileges controls the ordering, preparation, and administration of the medication or in an urgent situation. If the order is written when the pharmacy is closed or the pharmacist is unavailable, a healthcare professional, determined to be qualified by the organization, reviews the medication order in the pharmacist's absence. If the need arises to administer a medication prior to pharmacist review of the order, two licensed individuals with the authority to administer medications, such as two RNs (registered nurses), should verify the order and the medication prior to administration.

Review of Patient #5's medical record revealed he was admitted on 02/04/14 with diagnoses of COPD (congestive obstructive pulmonary disease) Exacerbation, Congestive heart Failure, and Pneumonia. Review of his MARs (medication administration record) revealed he was administered Lasix 40 mg (milligrams) IV (intravenously) on 02/04/14 at 8:34 a.m. by S2DON (director of nursing. Further review revealed S25LPN (licensed practical nurse) administered Potassium Chloride (K-Dur) 20 meq (milliequivalent) and Norco 7.5/325 (325 mg Acetaminophen and 7.5 mg Hydrocodone Bitartrate) orally and applied a Nicoderm Patch 21 mg on 02/04/14 at 8:53 a.m.

In an interview on 02/04/14 at 12:15 p.m., S25LPN (licensed practical nurse) the above medications were administered as documented. She further indicated that S7Medical Director reconciled Patient #5's home meds at 9:13 a.m. She further indicated that after the physician reviews the medications, a screen will appear on the computer for the nurse to verify the medications. She indicated that the screen message is how the nurses know that they are able to give the medications. She further indicated that the pharmacist releases the medications after the reconciliation is completed by the physician. S25LPN confirmed that she administered Patient #5's medications prior to the pharmacist reviewing the medication order.

In an interview on 02/04/14 at 12:20 p.m., S2DON (director of nursing) confirmed that he administered Lasix for Patient #5 prior to the pharmacist reviewing the medication order.

In an interview on 02/04/14 at 9:45 a.m., S4Pharmacist indicated that she reviewed Patient #5's medications at 9:34 a.m. on 02/04/14. She further indicated that the nurse had administered the medications prior to her review of the ordered medications. S4Pharmacist indicated that after hours and on weekends, the computer system is set up for a message to go to the nurse after the physician verifies the medications. She confirmed that medications are not reviewed prior to administration on weekends and after 3:00 p.m. on weekdays.

In an interview on 02/04/14 at 2:40 p.m., S5Pharmacy Director confirmed that the pharmacy board required medication orders to be reviewed by the pharmacist prior to the first dose being administered except in emergencies.

2) Ensure drugs and biologicals were secure and not accessible to patients and visitors:
Review of the hospital policy titled "Medication Management - Preparation & Dispensing", presented as a current policy by S5Pharmacy Director, revealed patient medications shall be stored in individual containers in the patient care area in cubicles or drawers. further review revealed no documented evidence that the policy addressed the security to be maintained with medications.

On 02/03/14 at 12:10 p.m., an observation was made of COW #1. It was noted to be unlocked and unattended in the patient care unit hallway that was accessible to the public. COW #1 had six drawers and all 6 of the drawers were unlocked and accessible. COW #1 Drawer "a" contained a 5 milliliter bottle of Nystatin oral solution and COW #1 Drawer "b" contained a Spiriva inhaler.

In an interview on 02/03/14 at 12:15 p.m. with S2DON (director of nursing), he verified COW #1 should have been locked when not in use.

On 02/04/14 at 1:40 p.m. an observation was made of COW #1 and COW#2 (which have individual patient medication drawers) plugged into the wall of the patient care unit hallway that is accessible to the public. They were unattended at the time of the observation.

On 02/05/14 at 3:00 p.m. an observation was made of COW#1 and COW#2 (which have individual patient medication drawers) plugged into the wall of the patient care unit hallway that is accessible to the public. They were unattended at the time of the observation.

In an interview on 02/04/14 at 1:45 p.m., with S2DON, he was asked if the COWs were stored in the hall when not in use and he replied, "Yes" . He was asked if the COWs were ever stored in a locked, secured room and he replied, "No".

Observation in the Endoscopy Recovery area of the hospital on 02/05/14 at 10:00 a.m. revealed an unlocked red cart located in an unlocked area. The cart was noted to contain the following:
Drawer #1: Proshield skin protector (1), Elta cream moisturizer (3), Silver Nitrate stick (19), Idosorb iodine gel (1), Silver gel ( hydrogel dressing & wound filler) (1), Lidocaine ointment 5% (per cent) (3), Vaolex ointment (2), Hypergel (1), Elta silver gel wound gel (4), Vashe dermal cleansing solution (1); Drawer#2: Lidocaine 2 % plain 50 ml (milliliters) (1) that had expired 02/01/04, Lidocaine 4% topical (1) 40 ml, Vancomycin 500 mg (milligrams) powdered for random Patient R13, Imipenm/Cilastatin- 20/120 powered for random Patient R13, Iodoflex iodine pad (1) box, Xylocaine 2 % Plain (1) 20 ml, Xylocaine 2 % Plain (1) 50 ml, Normal saline flushes (14).

In an interview on 02/05/14 at 10:00 a.m., S13LPN indicated that the room door was closed at all times but unlocked, and the area was in an unsecured area of the hospital accessible by patients for outpatient laboratory and X-ray services.

In an interview on 02/05/14 at 10:45 a.m., S2DON confirmed that the room was not locked, not monitored, and was accessible to patient and visitors.


30984




31206

Based on observations and interviews, the hospital failed to implement measures to ensure the provision of a safe environment consistent with nationally recognized infection control precautions as evidenced by:
1) Having an unsealed, unsecured, used sharps container (containing needles) on the counter in the unattended and unlocked Wound Care/Endoscopy Recovery Room;
2) Storing clean suction supplies (26 suction canisters, 4 suction canister lids, and an open bag of loose suction canister elbow connectors) in the soiled utility room;
3) Failing to repair water damage on the sheetrock as evidenced by having a black substance on the damaged sheetrock in the bathrooms of Rooms "i" and "k";
4) Storing a plastic bin containing bags of 0.9% (per cent) Sodium Chloride, 4 boxes of sterile water used for irrigation, leg splints (8), and walking boots (3) on the floor in the emergency supply room;
5) Storing patient care supplies, equipment, and dirty equipment in the same area;
6) Having the clean supply room with equipment on the floor and accumulated dust on stored equipment; and
7) Having a clean linen cart with linen open to air stored with a soiled linen cart in Room "l".
Findings:
1) Having an unsealed, unsecured, used sharps container (containing needles) on the counter in the unattended and unlocked Wound Care/Endoscopy Recovery Room: On 02/03/14 at 11:40 a.m. an observation was made of an unsealed, unsecured container for used sharps on the counter in the Wound Care/Endoscopy Recovery Room. The sharps container was noted to contain needles. The room was unattended and unlocked at the time of the observation.
In an interview on 02/03/14 at 11:45 a.m. with S1Administrator, she said the Wound Care/Endoscopy Recovery Room was unattended by staff at times, and the room was not locked when there were no patients present in the room. She confirmed there was an unsealed, unsecured container for used sharps on the counter in the room. She also confirmed the room was unattended and unlocked at the time of the observation.

2) Storing clean suction supplies (26 suction canisters, 4 suction canister lids, and an open bag of loose suction canister elbow connectors) in the soiled utility room: On 02/03/14 at 11:55 a.m., an observation was made in the soiled utility room. There were clean suction canisters (26), suction canister lids (4) , and an open bag of loose suction tubing elbow connectors on shelves in the soiled utility room.
In an interview on 020/3/14 at 11:57 a.m. with S1Administrator, she confirmed the clean suction canisters, canister lids, and elbow connectors should have been stored in a clean storage area and not in the soiled utility room.
On 02/03/14 at 12:00 noon in an interview with S2DON (director of nursing), he said the suction canisters/lids/elbow connectors were clean and could have been used. He confirmed they should not have been stored in the soiled utility room.

3) Failing to repair water damage on the sheetrock as evidenced by having a black substance on the damaged sheetrock in the bathrooms of Rooms "i" and "k": An observation was made on 02/03/14 at 12:00 p.m. during the initial tour of the bathroom in patient Room "k" having water damage on the sheet rock and a black substance on the water-damaged sheet rock.

Another observation was made on 02/03/14 at 12:15 p.m. during the initial tour of the bathroom in patient Room "i" having a black substance on the sheet rock of the bathroom. S1Administrator was present during these observations.

4) Storing 4 boxes of sterile water used for irrigation, a plastic bin containing bags of 0.9% Sodium Chloride, leg splints (8), and walking boots (3) on the floor in the emergency supply room:
An observation in the emergency supply room with S1Administrator present on 02/03/14 at 11:35 a.m. revealed 4 boxes of sterile water used for irrigation on the floor and a plastic bin on the floor filled with 1000 ml (milliliter) bags of 0.9% Sodium Chloride.

An observation was made on 02/03/14 at 11:45 a.m. with S1Administrator present in the emergency supply room of 8 leg splints stored on the floor under the supply shelf with 3 walking boots stored next to them on the floor.

5) Storing patient care supplies, equipment, and dirty equipment in the same area: Observation in the Emergency Room Storage area for the the hospital on 02/03/14 at 11:30 a.m. revealed clean and dirty patient supplies and equipment were being stored in the same area. Dirty surgical instruments used in the Emergency Room were cleaned, sterilized, and packaged all in the same area.
In an interview on 02/05/14 at 1:00 p.m., S17Infection Control RN indicated that during the Infection Control/Safety Validation Walk on 08/06/13 and 11/07/13, it was identified that the clean and dirty supplies and equipment were stored in the same area. According to S17Infection Control RN, S1Administrator was aware of the issue as it had been an ongoing issue since May 2012.

In an interview on 02/05/14 at 4:00 p.m., S1Administrator confirmed that the clean and dirty patient care equipment and supplies were stored in one area behind the Emergency Room and that the hospital had a problem with storage space.

6) Having the clean supply room with equipment on the floor and accumulated dust on stored equipment: Observation of the clean supply room on 02/03/14 at 12:10 p.m. revealed a piece of exercise equipment with wheelchair footrests on it that had an accumulation of dust. There were 2 boxes on the floor that contained portable door isolation boxes (used to attach to a patient's room door to hold isolation supplies). There was portable whirlpool in the room that a\had an accumulation of dust on the surface. A fan was in operation in the room and had dirty dried substances on the surface and particles of dust attached and flying in the wind produced by the fan. A portable rolling Gomco (suction machine) had an accumulation of dust. Communication equipment in the room (digital television receiver) had a large amount of dust accumulated on the surface that could be wiped off. These observations were confirmed by S2DON.
7) Having a clean linen cart with linen open to air stored with a soiled linen cart in Room "l": Observation in Room "l" on 02/03/14 at 12:20 p.m. revealed a clean linen cart that contained clean linen used for patient care that had the protective covering folded on the top of the cart leaving the linen exposed. In front of the clean linen cart was a soiled linen cart with used linen in it and covered by a sheet draped over the top of the cart.
In an interview on 02/03/14 at 12:20 p.m., S2DON indicated the soiled linen cart should not be in Room "l". He further indicated that Room "l" is under renovation, and the clean linen cart should have been removed before the renovation began.


26351




25065









31206

Based on record reviews and interviews, the hospital failed to ensure the nutrutional needs of inpatients were met according to recognized dietary practices and the orders of the physician as evidenced by:
1) Failing to ensure nutritional assessments were performed by the registered dietitian (RD) as ordered by the physician and within 72 hours of the order according to hospital policy for 4 of 6 psychiatric inpatients' medical records reviewed for nutritional assessments from a total of 25 sampled patients (#3, #4, #7, #10). Patient #3 was an inpatient at the time of the survey and
2) failing to ensure the dietary manager assured the dishwasher's water temperature was maintained according to the manufacturer's guidelines for 76 wash cycles out of 286 wash cycles performed from 11/01/13 through 02/04/14.
Findings:

1) Failed to ensure nutritional assessments were performed by the RD as ordered by the physician and within 72 hours of the order according to hospital policy:
Review of the hospital policy titled "Nutritional Screening and Assessment Policy", originally approved 01/27/14 and presented as the current policy by S32Contracted RD, revealed that once a patient's nutritional needs triggers 3 points or more on the initial nutrition screening performed by nursing the intervention is filed into CPSI (hospital's computer system) for a dietary consult. A screening/consult notification is automatically forwarded to the dietary manager via CPSI in a mail attachment. The dietary manager and dietary staff will check this electronic mail daily. At the time a dietary consult is received by the dietary staff, they will contact the RD to notify of the assessment screening needed. The assessment by the RD will be performed within 48 hours of the initial nutritional screening for patients on the medical/surgical floor and within 72 hours for patients on the geriatric inpatient psychiatric unit.

Patient #3
Review of Patient #3's medical record revealed she was a 97 year old female admitted on 01/27/14 at 4:00 p.m. with a diagnosis of Dementia.

Review of Patient #3's physician admit orders dated 01/27/14 at 8:30 p.m. revealed an order for a nutrition consult. Review of her entire medical record revealed no documented evidence that a nutrition consult had been performed as of the date of the chart review on 02/04/14, 8 days after Patient #3's admission and the order for a nutrition consult.

Patient #4
Review of Patient #4's medical record revealed he was a 55 year old male admitted on 11/21/13 with a diagnosis of Depression and was discharged on 11/25/13. Review of his physician admit orders dated 11/21/13 at 9:15 a.m. revealed an order for a nutrition consult.

Review of Patient #4's medical record revealed she had a "Diet History Form - Paces" and a "Nutrition Screen" completed by S20Dietary Manager on 12/10/13 at 5:25 p.m., 15 days after Patient #4 had been discharged. Further review of the "Nutrition Screen" completed by S20Dietary Manager revealed the result of the screen was a total of 3 points with a note that patients with a score of 3 or above are to be referred to the RD for a nutrition assessment. There was no documented evidence in Patient #4's medical record that a nutrition assessment had been performed by a RD.

Patient #7
Review of Patient #7's medical record revealed he was 79 year old male admitted on 01/02/14 at 6:15 p.m. with a diagnosis of Altered Mental Status and discharged on 01/20/14. Review of his physician admit orders dated 01/02/14 at 6:15 p.m. revealed an order for a nutrition consult.

Review of Patient #7's entire medical record revealed no documented evidence that a nutrition assessment was performed by the RD during Patient #7's 18 day hospital stay.

Patient #10
review of Patient #10's medical record revealed she was a 58 year old female admitted on 01/23/14 with a diagnosis of Confusion and discharged on 01/29/14.

Review of Patient #10's physician admit orders dated 01/23/14 at 6:30 p.m. revealed an order for a nutrition consult. Review of her entire medical record revealed no documented evidence that a nutrition assessment was performed by the RD during Patient #10's 6 day hospital stay.

In an interview on 02/04/14 at 2:50 p.m., S3Director of Nursing (DON) of the PACES Geriatric Psychiatric Unit confirmed Patients #3, #4, #7, and #10 did not have a nutrition assessment performed by the RD as ordered by the physician. She indicated that hey had been having problems with communication, and the RD was being notified of the need for a consult. She further indicated the nurse performs a nutritional screening assessment at admit, but if the consult is ordered by the physician, the patient should receive the nutrition assessment regardless of the nutrition screening score.

In an interview on 02/05/14 at 10:15 a.m., S32Contracted RD indicated the hospital policy originally allowed her 7 days to complete the nutritional assessment, but the hospital recently changed. She indicated that she has 48 hours from the the time the assessment is ordered to complete the assessment for hospital inpatients and 72 hours for patients on the PACES Geriatric Psychiatric Unit. When asked why a difference is made between the two units, she answered that it was due to the turn-around time for hospital stays, explaining that hospital inpatients' stays are usually of short duration, and there inpatient psychiatric patients generally stay longer in the hospital. S32Contracted RD indicated if a nutritional assessment wasn't done, it was because she wasn't notified of the consult.

2) The dietary manager failed to ensure the dishwasher's water temperature was maintained according to the manufacturer's guidelines for 76 wash cycles out of 286 wash cycles performed from 11/01/13 through 02/04/14:
Review of the Hospital Policy "Ecolab Dishwasher" presented as current (02/25/13) reads in part: The Ecolab Dishwasher shall be supplied with water at a temperature not less than 120 degrees Fahrenheit.
Observations in the dietary area of the hospital on 02/04/14 at 9:30 a.m. revealed S31Cook rechecking the dishwasher temperature.
Review of the Dishwasher temperature log revealed a notation which indicated that the dishwasher temperatures are required to be at or above 120 degrees Fahrenheit. If temperatures do not meet the requirements, the supervisor is to be notified immediately. Continued review of the dishwasher logs from the period of November 2013 to the day of the survey revealed the following: November 2013 - 45 times below 120 degrees out of 90 washes; December 2013 - 10 times below 120 degrees out of 93 washes; January 2014 - 17 times below 120 degrees out or 93 washes; February 2014 - 4 times below 120 degrees out of 10 washes.
In an interview on 02/04/14 at 9:30 a.m., S31Cook indicated that the dishwasher temperature did not always reach 120 degrees, and when that happens the temperature is rechecked. S20 DM (dietary manager) indicated that the dishwasher temperature is noted to be below 120 degrees. When S20DM was asked what is done when the dishwasher temperature is below 120 degrees, she stated that the temperature is rechecked. According to S20DM the dishwasher had been repaired a couple of months ago (unable to recall time). S20DM indicated that S1Administrator was aware of the issue with the dishwasher.
In an interview on 02/05/14 at 1:00 p.m., S17Infection Control RN revealed that the dishwasher temperature had been identified by the Infection Control/Safety Validation on 10/03/13 that the dishwasher temperature readings were below the recommended level twice. According to S17Infection Control RN, the dishwasher temperature readings were acceptable during the Infection Control/Safety Validation on 01/02/14.
In an interview on 02/05/14 at 3:30 p.m., S16Environment of Care Director indicated that the heater on the dishwasher was in need of repair in order to maintain the temperature at the manufacturer's recommendation.
In an interview on 02/05/14 at 4:00 p.m., S1Administrator indicated that she was aware of the fluctuation of the dishwasher temperature, and that S16Environment of Care Director was responsible for the repairs.


31206

Based on record reviews and interview, the hospital failed to ensure that patient care policies and procedures were reviewed at least annually by the group of hospital professional personnel. The Emergency Services Policy and Procedure Manual had not been reviewed since 06/24/09. Findings:
Review of the hospital Emergency Services Policy and Procedure Manual revealed the last date of review/approval of the manual by the Chief of Staff, Chief Executive Officer, Board of Directors, and the Emergency Department Manager was 06/24/09.
In an interview on 02/05/14 at 1:30 p.m., with S2DON, he said he was in the process of reviewing and writing policies. He said he had not reviewed and revised/written all of the policies yet.

Based on record reviews and interviews, the hospital failed to ensure lab services were provided to meet the diagnosis and treatment needs of each patient. The hospital failed to have lab tests performed as ordered by the physician, have physician orders for tests performed, and followed up on lab results in a timely manner for 3 of 14 patient records reviewed for lab services provided from a total of 25 sampled patients (#3, #4, #7). Patient #3 was an inpatient at the time of the survey.
Findings:

Patient #3
Review of Patient #3's medical record revealed she was a 97 year old female admitted on 01/27/14 at 4:00 p.m. with a diagnosis of Dementia.

Review of Patient #3's "Physician Admit Orders & (and) Problem List" dated 01/27/14 at 8:30 p.m. revealed orders for a Urinalysis, Vitamin B12 and Folate levels.

Review of Patient #3's lab results revealed results of a urine culture ordered and collected on 01/27/14 and reported on 01/29/14. There was no documented evidence of results of a urinalysis, and there was no documented evidence of an order for a urine culture. Further review revealed blood was drawn to test Vitamin B12 and Folate levels on 01/28/14 and reported on 01/31/14, 3 days after the blood was drawn. Further review revealed a Magnesium level was drawn on 02/03/14 and reported on 02/03/14. There was no documented evidence of a physician's order to draw a Magnesium level for Patient #3.

Patient #4
Review of Patient #4's medical record revealed he was a 55 year old male admitted on 11/21/13 with a diagnosis of Depression.

Review of Patient #4's lab results revealed a Basic Metabolic Panel (BMP) was collected and reported on 11/25/13. There was no documented evidence of a physician's order to draw blood for a BMP on 11/25/13.

Patient #7
Review of Patient #7's medical record revealed he was 79 year old male admitted on 01/02/14 at 6:15 p.m. with a diagnosis of Altered Mental Status.

Review of Patient #7's physician admit orders dated 01/02/14 at 6:15 p.m. revealed an order to draw a Protime and INR (international normalized ratio) and Magnesium.

Review of Patient #7's lab results revealed blood was drawn on 01/06/14 for a Protime and INR and Magnesium, 4 days after the order was received. There was no documented evidence of the reason for the delay in drawing blood. Further review of the lab results revealed blood was drawn on 01/13/14 for a Protime and INR, Magnesium, and BMP and on 01/15/14 for a Protime and INR. There was no documented evidence of a physician's order for the lab tests done on 01/13/14 and 01/15/14.

In an interview on 02/03/14 at 3:50 p.m., S19Medical Technologist indicated lab tests that are sent to the contracted lab should be reported within 24 hours and couldn't explain why Patient #3's Vitamin B12 and Folate levels were reported 3 days after the blood was drawn.

In an interview on 02/04/14 at 2:50 p.m., S3Director of Nursing (DON) of the PACES Geriatric Psychiatric Unit confirmed that a Urinalysis was ordered and not a Urine Culture for Patient #3. She also confirmed that there was no Urinalysis result on the chart. S3DON of the PACES Geriatric Psychiatric Unit indicated that lab results should be available on the chart within 24 hours, and this was part of the chart check done by the nurse on the night shift to ensure that all labs ordered had results of the patient's record. She could not explain why Patient #3's results had not been identified as a delay in obtaining lab results. She confirmed there was no physician order for the Magnesium that was drawn on 02/03/14. S3DON of the PACES Geriatric Psychiatric Unit confirmed the findings for Patient #4. She indicated that the nurse was supposed to enter the physician's order in the computer and must not be entering it correctly. She further indicated that the lab gets the request for the lab test even though the nurse may not have entered the verbal or telephone order. She indicated that she was not aware that this was a problem. She further indicated that the inpatient psychiatric unit did not have a quality indicator related to lab testing that would have helped her to identify this problem. S3DON of the PACES Geriatric Psychiatric Unit confirmed there was no physician order for labs drawn for Patient #7 on 01/13/14 and 01/15/14.

Based on record reviews and interviews, the hospital failed to ensure that nursing services provided to the inpatient psychiatric patients by non-CAH (critical access hospital) nursing staff met the needs of the patients as evidenced by having the orientation, training, supervision, and evaluation of the clinical activities of each non-CAH nursing staff performed by a non-CAH-employed Registered Nurse (RN).
Findings:

Review of the personnel files of S3Director of Nursing (DON) of the PACES Geriatric Psychiatric Unit, S12LCSW (licensed clinical social worker), and S13RN revealed their orientation, training, and evaluations were completed by a RN employed by Company A, the company contracted by the hospital for inpatient psychiatric services, rather than a hospital-employed RN. The personnel files were not housed at the hospital. They were maintained at Company A's facility.

In an interview on 02/04/14 at 2:50 p.m., S3DON of the PACES Geriatric Psychiatric Unit indicated all staff of the PACES Geriatric Psychiatric Unit were employed by Company A. She further indicated that she was supervised and evaluated by the Regional Manager of Company A and was not supervised or evaluated by anyone at Bunkie General Hospital.

In an interview on 02/05/14 at 9:00 a.m., S1Administrator indicated that the hospital pays Company A to manage the inpatient psychiatric unit, and they (Company A) hire the staff. She further indicated Company A has their own personnel records. S1Administrator indicated S3DON of the PACES Geriatric Psychiatric Unit supervises the PACES Geriatric Psychiatric Unit staff, and she's supervised by Company A. She confirmed that S3DON of the PACES Geriatric Psychiatric Unit was not evaluated by S2DON (of the hospital), and S3DON's of the PACES Geriatric Psychiatric Unit competency evaluation and performance evaluations were not done by a hospital-employed RN.

26351


Based on record reviews and interviews, the hospital failed to ensure the staffing and assignments of nurses were made in accordance to the needs of the patient and the competence of the staff as evidenced by failure to ensure skill competencies were evaluated on the nursing staff of the hospital to ensure nursing staff assignments were made appropriately for 3 (S18RN, S23RN, S24LPN) of 4 (S2DON, S18RN, S23RN and S24LPN) nurses' personnel records reviewed for competencies in nursing skills. The hospital employed 16 RNs (registered nurse) and 16 LPNs (licensed practical nurse).
Findings:

Review of the personnel record for S17RN revealed she was a registered nurse. Further review of her personnel record revealed she had no competencies documented of her nursing skills.

Review of the personnel record for S23RN revealed she was a registered nurse assigned to work in the the emergency room department. Further review of her personnel record revealed she had no competencies documented of her nursing skills.

Review of the personnel record for S24LPN revealed she was a licensed practical nurse assigned to work in the emergency room department. Further review of her personnel record revealed she had no competencies documented of her nursing skills.

In an interview on 02/04/14 at 1:15 pm with S2DON, he was asked if the nurses had skill competencies (initial and annual) and he replied he had just recently taken the job of DON and he explained he had no staff competencies in personnel records from the former DON (whom he had replaced). He explained in January 2014 and February 2014 he had begun the process of performing staff evaluations/competencies to attempt to get staff up to date.







30984

Based on record reviews and interview, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care for each patient. The RN failed to assess each patient to determine that the patient met the criteria for delegation according to the LSBN's (Louisiana State Board of Nursing) administrative rules for 2 of 9 inpatient records (#6, #13) reviewed and 3 of 5 random patient records (R4, R5, R14) reviewed for RN assessments from a total of 25 sampled patients and 14 random patients. Patient #6 was an inpatient at the time of the survey.
Findings:

Review of the Louisiana State Board of Nursing's "Administrative Rules Defining RN Practice LAC46:XLVII" revealed, in part, "3703. Definition of Terms Applying to Nursing Practice ... Delegating Nursing Interventions - ... The registered nurse retains the accountability for the total nursing care of the individual. ... The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. The assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required..." Further review revealed that any situation where tasks are delegated should meet the following criteria: 1) the person has been adequately trained for the task; 2) the person has demonstrated that the task has been learned; 3) the person can perform the task safely in the given nursing situation; 4) the patient's status is safe for the person to carry out the task; 5) appropriate supervision is available during the task implementation; 6) the task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all. The registered nurse may delegate to licensed practical nurses the major part of the nursing care needed by individuals in stable nursing situations, that is, when the following three conditions prevail at the same time in a given situation: 1) nursing care ordered and directed by R.N./M.D. (medical doctor) requires abilities based on a relatively fixed and limited body of scientific fact and can be performed by following a defined nursing procedure with minimal alteration, and responses of the individual to the nursing care are predictable; 2) change in the patient's clinical conditions is predictable; and 3) medical and nursing orders are not subject to continuous change or complex modification.
Patient #6
Review of Patient #6's "Patient Progress Notes" revealed her nursing care was provided on the night shift of 01/29/14 (7:00 p.m. to 7:00 a.m.) by an LPN, and her nursing care on the day shift on 01/30/14 (7:00 a.m. to 7:00 p.m.) was provided by an LPN. There was no documented evidence that Patient #6 was assessed by the RN to determine if she met the criteria for her care to be delegated to the LPN according to the LSBN's administrative rules.

Patient #13
Review of Patient #13's "Patient Progress Notes" revealed her nursing care was provided on the night shift of 01/20/14 by an LPN, and her nursing care on the day shift on 01/21/14 was provided by an LPN. Further review revealed her nursing care was provided on the night shift of 01/23/14 by an LPN, and her nursing care on the day shift on 01/24/14 was provided by an LPN. There was no documented evidence that Patient #13 was assessed by the RN to determine if she met the criteria for her care to be delegated to the LPN according to the LSBN's administrative rules on 01/21/14 and 01/24/14.

Patient R4
Review of Patient R4's "Patient Progress Notes" revealed her nursing care was provided on the night shift of 01/25/14 by an LPN, her nursing care on the day shift on 01/26/14 was provided by an LPN, and her nursing care on the night shift of 01/26/14 was provided by an LPN. There was no documented evidence that Patient R4 was assessed by the RN to determine that she met the criteria for her care to be delegated to the LPN according to the LSBN's administrative rules on 01/25/14 and 01/26/14.

Patient R5
Review of Patient R5's "Patient Progress Notes" revealed her nursing care was provided on the night shift of 01/19/14 by an LPN, and her nursing care on the day shift of 01/20/14 was provided by an LPN. There was no documented evidence that Patient R5 was assessed by the RN to determine that she met the criteria for her care to be delegated to the LPN according to the LSBN's administrative rules.

Patient R14
Review of Patient R14's Patient Progress Notes" revealed her nursing care was provided on the day and night shifts of 01/26/14 by an LPN. There was no documented evidence that Patient R14 was assessed by the RN to determine that she met the criteria for her care to be delegated to the LPN according to the LSBN's administrative rules.

In an interview on 02/05/14 at 2:00 p.m., S2DON (director of nursing) indicated that sometimes the RN on the inpatient unit was shared with the Emergency Department. He confirmed that when this occurred on 01/20/14, 01/21/14, 01/26/14, and 01/30/14 the patients on the inpatient unit were not assessed by the RN to determine that they met the criteria for their care to be delegated to the LPN according to the LSBN's administrative rules.

Based on record reviews and interviews, the hospital failed to develop and keep a current nursing plan of care for each inpatient for 5 (#1, #6, #15, #16, #25) of 16 patients' records reviewed for care plans from a total sample of 25 patients.
Findings:

Review of the hospital policy entitled Care Planning, last review/revision date: blank, revealed the following, in part:
Policy:
Care, treatment and services are planned to ensure that they are appropriate to the patients' needs. Therefore, it is the policy of the hospital to provide an individualized, interdisciplinary plan of care for al patients that is appropriate to the patients' needs, strengths, limitations and goals. Care planning will be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals for the patient that are reasonable and measurable. The plan of care will be documented through the use of computerized care planning.
Procedure:
Within eight (8) hours of admission all patients shall have a computerized plan of care generated by the registered nurse or the licensed practical/vocational nurse under the direct supervision of the registered nurse.
The plan of care shall be individualized, based on the diagnosis, patient assessment and personal goals of the patient and his/her family.

Review of the electronic medical record (EMR) for Patient # 1 revealed an admission date of 11/08/13, a discharge date of 11/11/13, and diagnoses which included the following: Anemia, Hyperlipidemia, and Colostomy Status. Further review of Patient #1's EMR revealed she had received received blood transfusions for treatment of anemia during her hospital stay. Additional review of the patient's EMR revealed Patient #1 had no Plan of Care in her medical record.

Review of the electronic medical record for Patient #6 revealed she had been admitted to the hospital on 01/28/14 with the diagnoses of Leukocytosis, Cellulitis of lower extremities and Renal Insufficiency and discharged on 02/04/14. Further review revealed that Patient #6 had no Plan of Care in her medical record.

Review of the electronic medical record for Patient #15 revealed she had been admitted to the hospital on on 12/30/13 with the diagnoses of Viral Pneumonia and Acute Bronchitis and was discharged on 01/15/14. Further review revealed Patient #15 had no Plan of Care in her medical record.

Review of the electronic medical record for Patient #16 revealed an admission date of 12/03/13, a discharge date of 12/09/13, and diagnoses which included the following: Acute or Chronic Pancreatitis, Hypokalemia, Hepatitis B, Hypertension, Diabetes Mellitus, Peptic Ulcer Disease, Hyperlipidemia, Arthritis, and Hypomagnesemia. Further review of the patient's EMR revealed Patient #16 had no Plan of Care in his medical record.

Review of the electronic medical record for Patient #25 revealed he had been admitted to the hospital on 01/16/14 with the diagnosis of Cellulitis of the left leg and discharged on 01/19/14. Further review revealed Patient #25 had no Plan of Care.

In an interview on 02/04/14 at 1:25 p.m,. S2DON (director of nursing) confirmed that Patient #6, Patient #15 and Patient #25 had no Plan of Care.

An interview was conducted with S2DON on 02/04/14 at 2:45 p.m. He reported care plans on the patients are not typically done due to the nurses not knowing how to use the care plan section of the electronic medical record. He further stated he was aware of the problem and planned to address the problem.


30984





31206

Based on interview and policy review the hospital failed to ensure a designated member of the hospital staff was responsible for maintaining all patient records by failing to include monitoring of PACES Geriatric Psychiatric Unit records in the hospital information management system.
Findings:

Review of the hospital HIM (Health Information Management) Department policy entitled Objectives and Plan, last reviewed:January 2013; approved: January 2013, revealed the following, in part:

Health Information Management Objectives and Plan:
The plan will identify processes to obtain, manage, and use information to enhance and improve individual and organization performance in patient care, patient management and patient health information.
Vision:
The vision of Health Information Management is to maintain and provide inpatient health information in a consistent and concise manner to the person/persons throughout the organization in order to improve communications and quality of patient care and organizational functions while maintaining confidentiality of the information contained in the patient record.

Review of the HIM policy entitled Policies and Regulations, last reviewed 1/2013, revised and approved January 2013, revealed the following, in part:

Responsibilities of the Department:
Responsibilities of the Medical Record Department are to organize, centralize, and preserve the medical records compiled during the treatment of patients so they can be used a permanent reference in the event of future illness, as an aid in clinical and statistical research, and/or as an administrative tool for planning and evaluating hospital patient, hospital, staff and physicians.
The hospital Health Information Management will adhere to the State of Louisiana Licensing Standards Subchapter H revised as of January 1, 2004.

1. Primary Functions:
a. Organize and maintain complete and legible medical records and other medical data for all patients to meet the requirements of the hospital, state, federal, and accrediting agencies.

2. General Policies:
a. The hospital will maintain an adequate medical record for each individual who is evaluated or treated as an inpatient, outpatient, or emergency room patient.

In an interview on 02/05/14 at 1:45 p.m. with S11RHIA (registered health information administrator), he said he does not monitor the PACES Geriatric Psychiatric records. He explained those records were monitored for deficiencies by a Licensed Practical Nurse from PACES. He said the records were monitored separately because the PACES Geriatric Psychiatric Unit was a separate unit. He acknowledged that ultimately he was responsible for all patient records.

Based on observation and interview the hospital failed to ensure confidentiality of patient information and protection of patients' medical records from loss and destruction as evidenced by:
1) Failing to maintain the confidentiality of patients' information from unauthorized use relative to the laboratory results for 5 (R6, R7, R8, R9, R10) of 7 random patients and relative to the registration ledger for 2 (R11, R12) of 7 random patients from a total sample of 25 patients and 14 random patients. Confidential patient information was located in a drawer in the endoscopy room that was unsecured and was a high traffic area that was accessible to the public; and
2) Storing PACES Geriatric Psychiatric Unit's patients' records in a building that was not sprinklered to protect them from fire damage.
Findings:

1) Confidentiality of patient information:
Observation in the Endoscopy Recovery area of the hospital (not a secured area of the hospital) on 02/05/14 at 10:00 a.m. revealed a stand-alone sink with one drawer and two pull out panels that had confidential patient information in the drawer. The confidential patient information included laboratory results for random patients R6, R7, R8, R9 and R10 and the social security number, address, and telephone number of R11 and R#12.

In an interview on 02/05/14 at 10:00 a.m., S26LPN (licensed practical nurse) confirmed that the above was patient information and should have been in a locked area.

In an interview on 02/05/14 at 10:45 a.m., S2DON (director of nursing) indicated that the patient information was for wound care patients. S2DON indicated there was a designated locked file cabinet for storage of the wound care patients' records.

2) Protection of Records from loss and destruction:
Review of the hospital HIM (Health Information Management) department policy entitled Policies and Regulations, last reviewed: 1/2013; revised and approved: 1/2013, revealed the following, in part:
A. Responsibilities of the Department
2. General Policies:
h. The hospital will be responsible for safeguarding both the medical record and its contents against loss, defacement, tampering, and unauthorized use.

In an interview on 02/05/14 at 1:45 p.m., with S11RHIA (registered health information administrator), he said PACES Geriatric Psychiatric Unit's records were stored outside, in a storage shed, behind the Geriatric Psychiatric wing. S11RHIA also said the records were stored on open shelves. S11RHIA confirmed the shed was not sprinklered. He stated the shed housed records from 2009 to present (2014).

On 02/05/14 at 4:00 p.m. an observation was made of the storage area for PACES Geriatric Psychiatric Unit patient records (accompanied by S11RHIA). The records were stored in a metal shed, located outside, behind the Geriatric Psychiatric wing. The building had a particle board ceiling and walls. It was not sprinklered. The medical record folders were stored on open shelves and in cardboard boxes. The shed contained records from 2009-2014 (approximately 1066 records: 400 records on open shelves, 37 cardboard boxes with 15-20 records in each box). These records were for both inpatient and outpatient psychiatric patients.


31206

Based on interview the hospital failed to ensure that a representative sample of both active and closed clinical records were reviewed as part of the annual evaluation. The hospital failed to include active records as well as active and closed records from the PACES Geriatric Psychiatric Unit in its review.
Findings:

In an interview on 02/05/14 at 2:20 p.m., S11RHIA (registered health information administrator) indicated that he only audited closed records for the annual evaluation and was not reviewing active records. He further indicated that he doesn't include medical records of the PACES Geriatric Psychiatric Unit in his review. S11RHIA indicated that he can't be certain that he actually is reviewing at least 10% (per cent) of active and closed records for this review.

Based on record review and interview the hospital failed to provide an ongoing program of activities for 3 out of 3 swing bed patients (Patient #13, #14, and #17) hospitalized in the last year.
Findings:

Patient #13
Patient #13 was admitted on 01/21/14 to the hospital into a swing bed for weakness and increase number of falls at home.

Patient #14
Patient #14 was admitted on 09/23/13 to the hospital to a swing bed for Gastritis Hemorrhagic.

Patient #17
Patient #17 was admitted on 09/26/13 to the hospital to a swing bed for swelling and redness of his right leg.

Review of the medical records for Patients #13, #14 and #17 revealed no documentation or evidence of any ongoing program of activities during their hospitalization.

An interview was conducted with S2DON (director of nursing) on 02/04/14 at 2 p.m. He reported there was not an activity director and no ongoing activities were provided to the patients except when physical therapy was ordered for the patient. Physical therapy would get the patient out of bed and the nurses would also.

An interview was conducted with S1Administrator on 02/04/14 at 3:25 p.m. She reported the hospital had a contract with S12LCSW (licensed clinical social worker) to provide ongoing activities and social services to the swing bed patients. She was not sure if S12LCSW was notified of Patient #13's, #14's, and #17's admission to the hospital.

An interview was conducted with S12LCSW on 02/04/14 at 4 p.m. She reported she was the contracted Activities Director and Social Worker for the swing bed patients at the hospital. She went on to report she was not consulted and did not work with Patients #13, #14, and #17 while they were swing bed patients in the hospital.

Based on record review and interview the hospital failed to provide medically-related social services to obtain the patients' highest practicable physical, mental, and psychosocial well-being for 3 out of 3 swing bed patients (Patient #13, #14, and #17) hospitalized in the last year.
Findings:

Patient #13
Patient #13 was admitted on 01/21/14 to the hospital into a swing bed for weakness and increase number of falls at home.

Patient #14
Patient #14 was admitted on 09/23/13 to the hospital to a swing bed for Gastritis Hemorrhagic.

Patient #17
Patient #17 was admitted on 09/26/13 to the hospital to a swing bed for swelling and redness of his right leg.

Review of the medical records for Patients #13, #14 and #17 revealed no documentation or evidence of a social worker consulted or working with the patients during their hospitalization.

An interview was conducted with S2DON (director of nursing) on 02/04/14 at 2 p.m. He reported there was not a social worker employed by the hospital.

An interview was conducted with S1Administrator on 02/04/14 at 3:25 p.m. She reported the hospital had a contract with S12LCSW (licensed clinical social worker) to provide ongoing activities and social services to the swing bed patients. She was not sure if S12LCSW was notified of Patient #13's, #14's, and #17's admission to the hospital.

An interview was conducted with S12LCSW on 02/04/14 at 4 p.m. She reported she was the contracted Activities Director and Social Worker for the swing bed patients at the hospital. She went on to report she was not consulted and did not work with Patients #13, #14, and #17 while they were swing bed patients in the hospital.

Based on record reviews and interviews, the hospital failed to ensure that each inpatient received a psychiatric evaluation that was completed within 60 hours of admission as evidenced by having psychiatric evaluations performed more than 60 hours after admission 3 of 6 patients' records reviewed for completion of the psychiatric evaluation within 60 hours of admission from a total of 25 sampled patients (#3, #7, #8). Patient #3 was a current inpatient on the PACES Geriatric Psychiatric Unit of the hospital.
Findings:

Review of the hospital policy titled "Assessments of Patients", contained in the policy manual presented by S3Director of Nursing (DON) of the PACES Geriatric Psychiatric Unit and revised on 07/10/12, revealed that psychiatric evaluations were to be performed by a psychiatrist or nurse practitioner within 60 hours of admission.

Review of the hospital policy titled "Psychiatric Evaluation", contained in the policy manual presented by S3DON of the PACES Geriatric Psychiatric Unit and revised on 07/10/12, revealed that the psychiatric evaluation was to include the following information: identifying data; chief complaint in the patient's own words; present illness including reason for admission, onset, precipitation factors, history of inpatient and outpatient treatment, family history, educational, occupational/vocational history, social history; medical/surgical history; current physical disorders; medications; mental status including orientation, thought process, content, hallucinations, delusions, mood, attitude, intellect, memory, appearance, behavior; diagnosis including Axis I, Axis II, Axis III, Axis IV, Axis V; patient's assets; plan; and estimated length of stay.

Patient #3
Review of Patient #3's medical record revealed she was a 97 year old female admitted on 01/27/14 at 4:00 p.m. with a diagnosis of Dementia. Review of her "Psychiatric Evaluation" revealed it was performed by S8Psychiatrist on 01/30/14 at 11:00 a.m., 67 hours after admission rather than within 60 hours of admission as required by hospital policy and federal certification regulations.

Patient #7
Review of Patient #7's medical record revealed he was 79 year old male admitted on 01/02/14 at 6:15 p.m. with a diagnosis of Altered Mental Status. Review of his "Psychiatric Evaluation" revealed it was performed by S8Psychiatrist on 01/06/14 at 1:20 p.m., 81 hours after admission rather than within 60 hours of admission as required by hospital policy and federal certification regulations.

Patient #8
Review of Patient #8's medical record revealed she was an 83 year old female admitted on 01/19/14 at 5:30 p.m. with a diagnosis of Major Depression. Review of her "Psychiatric Evaluation Update" revealed it was to be used when there is a completed evaluation within 30 days. Further review revealed S8Psychiatrist performed the evaluation and documented the update on 01/20/14 at 11:00 a.m. There was no documented evidence of a completed psychiatric evaluation that contained precipitation factors of present illness, history of inpatient and outpatient treatment, education, occupational/vocational history, medical/surgical history, current physical disorders, medications, memory, appearance, Axis III diagnosis, and patient's assets.

In an interview on 02/04/14 at 2:50 p.m., S3DON of the PACES Geriatric Psychiatric Unit confirmed the psychiatric evaluations for Patients #3 and #7 were completed more than 60 hours after admission. She indicated that she should have obtained the psychiatric evaluation that S8Psychiatrist performed for Patient #8 at another hospital for the chart. When asked if a psychiatric evaluation could be transferred from one hospital to another, S3DON of the PACES Geriatric Psychiatric Unit answered "no."

In an interview on 02/05/14 at 9:45 a.m., S7Medical Director indicated that having psychiatric evaluations completed within 60 hours of admission have been an ongoing problem. He further indicated that S8Psychiatrist makes rounds 3 to 4 times a week and if a patients is admitted late on Friday, the evaluation could be completed more than 60 hours admission. S7Medical Director indicated he doesn't "deal with the psychiatric aspect ... dealing more with the medical side. When asked if he was over all the medical staff at the hospital, S7Medical Director answered "yes."

In a telephone interview on 02/05/14 at 1:40 p.m., S8Psychiatrist indicated the delay in completing psychiatric evaluations was probably when it snowed, and he couldn't get to the hospital. When told the dates on the evaluations for Patients #3, #7, and #8, he indicated that all of them were not during the time of weather issues. When informed that an update was documented for Patient #8, S8Psychiatrist asked if he had done the original evaluation. He asked if he was supposed to complete a psychiatric evaluation for a patient seen in his outpatient center when he/she was admitted to the hospital. He indicated that he didn't know that he couldn't use a psychiatric evaluation that was done at another hospital within 30 days of admission.

Based on interview the hospital failed to provide or have available psychological services to meet the needs of the inpatients by having no employed or contracted psychologist available to provide psychological services if needed.
Findings:

In an interview on 02/05/14 at 9:00 a.m., S1Administrator indicated the hospital did not have a psychologist employed or contracted by the hospital to provide psychological services for the PACES Geriatric Psychiatric Unit.