HospitalInspections.org

Based on record review and interview, the hospital failed to ensure that the RN supervised and evaluated the nursing care of each patient as evidenced by failing to ensure that a patient on a Dopamine drip was receiving the correct dosage as ordered by the physician.
Findings:

Review of the hospital's Policy and Procedure - Subject: Titration Policy revealed, in part, the following:
Orders for medications that require titration must include the desired state the prescriber desires for the patient (i.e. titrated medication to achieve blood pressure of ____ /____). Useful dosage adjustment parameters must be known before titrating medication.

Review of patient #31's physician orders dated 3/12/18 at 1:30 p.m. revealed an order for Dopamine 10 micrograms per kilogram per minute (mcg/kg/mn).

During an interview on 3/13/18 at 10:10 a.m., S12ICU stated patient #31's Dopamine was currently infusing at 5 mcg/kg/min and she titrates the medication according to the patient's blood pressure. S12ICU acknowledged the order did not include titration parameters and titrating a medication without the parameters was against the hospital's policy.

Based on record review and staff interviews, the registered nurse failed to develop a nursing care plan for each patient. The deficient practice was evidenced by the registered nurse failing to include care plan interventions for 8 patients (#20, 21, 22, 23, 24, 28, 29, 30) of 8 patients (#20, 21, 22, 23, 24, 28, 29, 30) charts reviewed for nursing care plans out of 31 total charts reviewed.

Findings:

Review of hospital's Policy and Procedures Departments: Nursing - Wide "Utilization Standards Based Documentation" revealed, in part, the following:
A. Generating Plan of Care: An initial Plan of Care is generated ... This plan of care is individualized ...
E. Implementation of the Plan of Care: Necessary to achieve desired outcomes. All interventions ...can be viewed and accessed ... Staff documents interventions that directly address the ... identified problems.

Review of patient #20's nursing care plan failed to reveal care plan interventions.

During an interview on 3/14/18 at 10:30 a.m., S8CaseMgr acknowledged patient #20's nursing care plan did not include interventions.
S14RN confirmed S8CaseMgr's findings at this time and acknowledged the nursing care plan did not include interventions and interventions should be in the care plan.

Review of patient #21's nursing care plan failed to reveal care plan interventions.

During an interview on 3/14/18 at 10:35 a.m., S8CaseMgr acknowledged patient #21's nursing care plan did not include interventions.

Review of patient #22's nursing care plan failed to reveal care plan interventions.

During an interview on 3/14/18 at 10:40 a.m., S8CaseMgr acknowledged patient #22's nursing care plan did not include interventions.

Review of patient #23's nursing care plan failed to reveal care plan interventions.

During an interview on 3/14/18 at 10:45 a.m., S8CaseMgr acknowledged patient #23's nursing care plan did not include interventions.

Review of patient #24's nursing care plan failed to reveal care plan interventions.

During an interview on 3/14/18 at 10:50 a.m., S8CaseMgr acknowledged patient #24's nursing care plan did not include interventions.

Review of patient #28's nursing care plan failed to reveal care plan interventions.

During an interview on 3/14/18 at 1:45 p.m., S8CaseMgr acknowledged patient #28's nursing care plan did not include interventions.

Review of patient #29's nursing care plan failed to reveal care plan interventions.

During an interview on 3/14/18 at 1:50 p.m., S8CaseMgr acknowledged patient #29's nursing care plan did not include interventions.

Review of patient #30's nursing care plan failed to reveal care plan interventions.

During an interview on 3/14/18 at 1:55 p.m., S8CaseMgr acknowledged patient #30's nursing care plan did not include interventions.

Based on record review and interview the hospital failed to ensure the clinical records system were maintained in accordance with written policies and procedures and failed to ensure patient medical records were protected against loss or destruction. The deficient practice was evidenced by the hospital failing to follow it's Policys and Bylaws for delinquent medical records and by failure to protect its 2008-2009 patient medical records that had not been scanned, copied or backed up to prevent potential destruction/damage from water.

Findings:

A. Review of hospital's Medical Staff Rules and Regulations revealed, in part, the following:

Article 3: Medical Records 3.22 All medical records must be completed within thirty (30) days from the date of the patient's discharge. Those medical records not completed within thirty (30) days of discharge shall be considered delinquent. 3.23 ...A letter will be sent to the responsible physician notifying him of his delinquent status.

Article 6: Corrective Actions 6.6.5 ...When a Medical Staff member ... has failed to complete a medical record and the record becomes delinquent, following notification, his/her clinical privileges shall be automatically suspended. The suspension shall continue until ...delinquent records are completed.

Review of the hospital's Deficiency Report by Physician/*Employee dated 3/13/18 revealed the following medical record deficiencies:

S16MD: 31-60 days deficient: 0; 61-90 days deficient: 2; Total deficient records: 2

S17MD: 31-60 days deficient: 1; 61-90 days deficient: 0; Total deficient records: 1

S18MD: 31-60 days deficient: 0: 61-90 days deficient: 1; Total deficient records: 1

During an interview on 3/13/1 at 11:15 a.m., S9MedRec Health Information Manager stated she had not sent any delinquent record notifications to physicians with delinquent medical records.

During an interview on 3/14/18 at 12:57 p.m., S15ERSPV stated she is the person who would draft the letter of delinquent medical records notifying the physicians with delinquent charts and it would be signed by the administrator and mailed to the physicians. She continued to state that she has not written any delinquent medical record letters.

During an interview on 3/14/18 at 1:00 p.m., S1ADM stated he had not sent delinquent medical record letters to the physicians with delinquent records and there were no suspensions of privileges enacted for the physicians with delinquent records. S1ADM acknowledged he did not follow the Medical Staff Bylaws and Medical Staff Policy/Procedures.

B. Observation on 3/12/18 at 2:00 p.m. revealed two storage buildings labeled with a number 2 and a number 3, which contained the entire patient medical records dating from 2008 to 2009 that had not been scanned, copied or backed up for prevention of potential destruction/damage from water.

During an interview on 3/12/18 at 2:10 p.m., S9Health Information Manager stated the outbuildings containing the medical records does not protect the records from potential destruction/damage from water if there was a leak or the fire suppression sprinklers were activated.

Based on record review and interview, the hospital failed to ensure a medical history and physical examination (H&P) was completed and document for each patient by no more than 30 days before or 24 hours after admission or registration for 6 (#17, 21, 23, 28, 29, 30) of 12 (#16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30) patient's medical records reviewed for H&Ps out of a total of 31 medical records reviewed.
Findings:


A review of the hospital's Medical Staff Rules and Regulations revealed, in part, the following: Article 3. Medical Records 3.2 - A complete history and physical shall be completed no more than 30 days before or 24 hours after admission by a physician or other qualified individual who has been granted these privileges by the medical staff, and placed in the patient's medical recorded within 24 hours after admission.

Patient #17
Review of patient #17's medical record revealed an admit date of 12/9/17 with the diagnoses of anemia, renal failure and a soft tissue infection. S19MD completed patient #17's H&P on 12/11/17.
During an interview on 3/14/18 at 1:30 p.m., S9MedRec acknowledged S19MD failed to follow hospital policy by failing to complete an H&P in patient #17's chart within 24 hours of admission or within 30 days prior.

Patient # 21
Review of patient #21's medical record revealed an admit date of 3/8/18 with the diagnoses of vomiting and abnormal blood glucose. Patient #21 did not have an H&P in their chart.
During an interview on 3/14/18 at 10:35 a.m., S8CaseMgr acknowledged that patient #21 did not have an H&P completed within 24 hours of admission or 30 days prior.

Patient #23
Review of patient #23's medical record revealed an admit date of 3/8/18 with the diagnoses of urinary tract infection and sepsis. Patient #23 did not have an H&P in their chart.
During an interview on 3/14/18 at 10:40 a.m., S8CaseMgr acknowledged that patient #23 did not have an H&P completed within 24 hours of admission or 30 days prior.

Patient #28
Review of patient #28's medical record revealed an admit date of 3/1/18 with the diagnoses of hypertension and chronic kidney disease. S19MD completed patient #28's H&P on 3/5/18.
During an interview on 3/14/18 at 1:45 p.m., S8CaseMgr acknowledged S19MD failed to follow hospital policy by failing to complete an H&P in patient #28's chart within 24 hours of admission or within 30 days prior.

Patient # 29
Review of patient #29's medical record revealed an admit date of 3/9/18 with the diagnoses of urinary tract infection and altered mental status. Patient #29 did not have an H&P in their chart.
During an interview on 3/14/18 at 1:50 p.m., S8CaseMgr acknowledged that patient #29 did not have an H&P completed within 24 hours of admission or 30 days prior.

Patient #30
Review of patient 30's medical record revealed an admit date of 3/10/18 with a diagnosis of pneumonia. S19MD completed patient #30's H&P on 3/13/18.
During an interview on 3/14/18 at 1:55 p.m., S8CaseMgr acknowledged S19MD failed to follow hospital policy by failing to complete an H&P in patient #30's chart within 24 hours of admission or within 30 days prior.

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

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

Review of the hospital policy titled, Medication Orders, revealed in part that a pharmacist shall review the prescriber's original order, or a direct copy thereof, before the initial dose is dispensed (with the exception of emergency orders when time does not permit). If the order is written when the pharmacy is closed, or the pharmacist is otherwise unavailable, it should be reviewed by a pharmacist upon opening.

On 03/13/18 at 10:00 a.m., interview with S3Pharmacist revealed that the hospital pharmacy is open Monday-Friday 7:30 a.m.-4:30 p.m. and the hours vary on weekends. S3Pharmacist stated that he has computerized access to hospital records at home and at 10:00 p.m. every night during the week, he checks his computer at home to see if there are any new medication orders that need a first dose review. He further stated that if any new medications are ordered after 10:00 p.m., a first dose review is not conducted. He stated that the nurses obtain the new medication from the medication dispensing machine at the hospital and administer the medication to the patient. S3Pharmacist further stated that a first dose review is not always conducted prior to the first dose of medication being administered to the patients after pharmacy hours. He stated the medication orders would be reviewed the next morning.

Based on observation and interview, the hospital failed to develop a system for identifying and controlling infections of patients as evidenced by failing to maintain a safe and sanitary hospital environment.
Findings:

1. On 03/13/18 at 2:00 p.m., observation of one of the radiology exam rooms revealed a spray bottle of Virex TB on the counter. At that time, interview with S6Radiology Supervisor revealed that the staff cleans the exam tables with Virex TB after each patient use. When asked the procedure for using the Virex TB, she stated that she sprays it on the table and waits a few seconds before wiping it off with a towel.

On 03/14/18 at 11:30 a.m., review of the manufacturers recommendations for Virex TB with S15ER Supervisor revealed the following: For use as a cleaner/disinfectant: Spray evenly on surface. Be sure to wet all surfaces thoroughly. Let product remain on surface for 3 minutes. For Hepatitis A, let product remain wet for 10 minutes. Wipe with clean cloth, sponge or paper towel. Interview with S15ER Supervisor at this time confirmed that the staff in radiology were not cleaning/disinfecting the exam tables per manufacturers recommendations.

2. On 03/14/18 at 10:30 a.m., observation of the laboratory revealed an area at the front that was used for blood collection for outpatients of the hospital. Further observations of this area revealed a large sharps container that was sitting on the floor unsecured that was overflowing with syringes and needles. At that time, interview with S5Phlebotomist confirmed that sharps were overflowing past the "Fill Line" and should have been changed out.

3. On 03/14/18 at 11:00 a.m., observation of the kitchen with S4Dietary Manager revealed the ceiling vents over the food steam table were coated with a build up of dust and grime. Further observations revealed the sprinkler heads in the ceiling throughout the kitchen were coated with a build up of dust and grime. Interview with S4Dietary Manager at this time confirmed the ceiling vents and sprinkler heads were over patient food and were in need of cleaning.

4. On 03/12/18 at 2:30 p.m., observation of the surgical suite with S7Surgery Director revealed the following:
a) in the procedure room: 2 endoscopes stored inside an unvented cabinet with the tips touching the bottom surface of the cabinet, and 2 endoscopes hanging on the wall, open to air;
b) in operating room 2: 1 large oxygen tank covered with rust; 2 small oxygen tanks with rusted surfaces;
c) in operating room 1: a rusty antique anesthesia cart with an uncovered lamb's wool cloth sitting on the shelf; uncovered tubings attached to the anesthesia cart and the wall air/suction; an oxygen tank with rusted surfaces.

Review of the Perioperative Standards and Recommended Practices by AORN 2013 Edition, Cleaning and Processing Flexible Endoscopes Recommendation IX.a, page 478, states: Flexible endoscopes should be stored in a closed cabinet with venting that allows air circulation around the flexible endoscopes,...adequate height to allow flexible endoscopes to hang without touching the bottom of the cabinet.

An interview with S7Surgery Director at that time confirmed the hospital follows AORN guidelines. She further confirmed that the rusted surfaces on the equipment could not be disinfected and the tubings should not be attached and left uncovered on the equipment.

5. Observation on 3/12/18 at 11: 40 a.m. accompanied by S2CNO of the medical-surgical ward revealed the following:

Room #139 had one dirty infusion pump and two bottles of multi-use patient body-wash containers that were in a room designated as clean.
Room #143 had two bottles of multi-use patient body-wash containers that were in a room designated as clean.
Room #147 had one bottle of multi-use patient body-wash container that were in a room designated as clean.
Room #156 had one dirty infusion pump in patient room that were in a room designated as clean.

At this time, an interview with S13SHK confirmed the multi use bottles of body-wash are left in the showers and not removed during the room cleaning.

Continued observation revealed a storage area with clean and dirty equipment stored together along with clean towels in a cart.

During an interview at 3/12/18 at 12:10 p.m. S2CNO acknowledged the multi-use body-wash left remaining in the rooms and the clean and dirty equipment stored together was an infection control issue.

Observation on 3/13/18 at 9:30 a.m. revealed a crash cart in the medical-surgical nurse's station that had a defibrillator covered in dust. The top of the crash cart and upper edges of the cart's drawers were also covered in dust.

During an interview on 3/13/18 at 9:35 a.m., S2CNO acknowledged the dirty crash cart was an infection control issue.

6. Observation of the Rehabilitation building on 3/12/18 at 2:30 p.m. revealed the following:

Exam room #1 had an exam table in the room with two (one 20cm, one 8cm) tear to the covering of the top surface.
Exam room #2 had an exam/traction table with one 5 cm tear to the covering of the top surface.
Exam room # 3 had three (one 1cm and two 5cm) tears to the covering of the top surface.
Exam #4 had a 1.5cm tear to the covering of the top surface of the exam table.
The Plinth Table in the gym had three 2cm tears to the top surface.

During an interview on 3/12/18 at 2:45 p.m., S10PT acknowledged that the tears in the exam room's patient exam/assessment tables prevented the tables from being properly sanitized and were an infection control issue.



20310

Based on interview, the hospital failed to provide an ongoing program of activities for residents residing in their swing beds as evidenced by the hospital not having a qualified activity director.

Findings:

During an interview on 3/14/18 at 2:30 p.m., S21HR stated the hospital does not have an activity directory or anyone qualified as an activity director.