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Based on record review and interview, the hospital failed to ensure each patient was informed of all their rights prior to furnishing or discontinuing patient care as evidenced by failing to have all of the required patient rights in accordance with the certification regulations on the patient rights policy and the "Patient Rights" signed by the patient upon admit.
Findings:

Review of the hospital policy titled "Patient Rights" revealed the following patient rights were not addressed:
1. Be informed of the names and functions of all physicians and other health care professionals who are providing direct care to the patient;
2. Be included in experimental research only when he or she gives informed, written consent to such participation;
3. Be informed if the hospital has authorized other health care and/or educational institutions to participate in the patient's treatment;
4. Be informed by the attending physician and other providers of health care services about any continuing health care requirements after his/her discharge from the hospital;
5. Be free from restraints of any form that are not medically necessary;
6. To examine and receive an explanation of the patient's hospital bill regardless of source of payment, and may receive upon request, information relating to financial assistance available through the hospital.

Review of the "Patient Rights" form, provided by S1DON, and given to the patient or family member upon admission revealed the above rights were not addressed.

On 12/10/19 at 9:00 a.m., S1DON reviewed the "Patient Rights" given to all patients upon admission and confirmed that patient were not informed of all required rights, including the above listed rights.

Based on record review and interview, the hospital failed to ensure its QAPI program included quality indicators to be measured, analyzed, and tracked to assess processes of care and hospital service and operations as evidenced by failure to have quality indicators developed for the contracted services providing services to the hospital.
Findings:

Review of the QAPI meeting minutes for July, August, and September dated October 15, 2019 revealed no documented evidence that the contracted services for the hospital were included in the data presented.

Interview on 12/11/19 at 10:10 a.m. with S2ADON confirmed contracted services was not included in the hospitals QAPI and there were no quality indicators to measure, analyze, and track the services provided.

Based on record review and interview, the hospital failed to ensure the Medical Staff conducted appraisals of its members every year as required by the Medical Staff Bylaws for 1 of 6 physicians reviewed for credentialing (S11MD).
Findings:

Review of the hospital's Medical Staff bylaws revealed that reappointments to the Medical Staff shall be for a period of one year.

Review of the credentialing file for S11MD revealed the last reappointment was dated 05/03/17. Review of the Medical Executive Committee minutes and Governing Body meeting minutes revealed no documented evidence that the Medical Staff conducted an appraisal of S11MD since 2017.

On 12/11/19 at 10:20 a.m., interview with S6HIM revealed that she was responsible for all paperwork related to credentialing physicians. At that time, she reviewed the S11MD's credentialing file, Medical Executive Committe meeting minutes and Governing Body meeting minutes and confirmed that S11MD had not been recredentialed since 2017. S6HIM further confirmed that S11MD was a current physician at the hospital.

Based on record review and interview, the hospital failed to ensure that the credentialing process requirements were followed for initial and reappointments to the medical staff by failing to ensure that the candidate completed and the medical staff reviewed a request for clinical privileges for 6 of 6 physicians whose credentialing files were reviewed (S6MD, S7MD, S8MD, S9MD, S10MD, S11MD).
Findings:

Review of the Medical Staff Bylaws, Section 6-Clinical Privileges, revealed that each application for appointment to the Medical Staff must contain a request for the specific clinical privileges desired by the applicant. The Bylaws further stated that a member providing clinical services at this hospital shall be entitled to exercise only these clinical privileges specifically granted.

S6MD
Review of the credentialing file revealed S6MD was reappointed to the Medical Staff on 01/08/19. There was no documented evidence that S6MD had requested any specific clinical privileges to be approved. Further review of the credentialing file revealed no documented evidence that S6MD had ever requested any specific clinical privileges since being initially appointed to the Medical Staff in 2016.

S7MD
Review of the credentialing file revealed S7MD was initially appointed to the Medical Staff on 09/11/18. There was no documented evidence that S7MD had requested any specific clinical privileges to be approved.

S8MD
Review of the credentialing file revealed S8MD was initially appointed to the Medical Staff in 1995 with specific clinical privileges requested and approved. Further review of the file revealed the most current reappointment was dated 01/08/19, but there was no request for specific clinical privileges to be approved. There was no evidence in the file that any clinical privileges had been requested since 1995.

S9MD
Review of the credentialing file revealed S9MD was reappointed to the Medical Staff on 09/11/18. There was no documented evidence that S9MD had requested any specific clinical privileges to be approved. Further review of the credentialing file revealed no documented evidence that S9MD had ever requested any specific clinical privileges.

S10MD
Review of the credentialing file revealed S10MD was initially appointed to the Medical Staff on 08/21/19. There was no documented evidence that S10MD had requested any specific clinical privileges to be approved.

S11MD
Review of the credentialing file revealed S11MD was reappointed to the Medical Staff on 05/03/17. There was no documented evidence that S11MD had requested any specific clinical privileges to be approved at that reappointment. Further review of the credentialing file revealed no documented evidence that S11MD had requested any specific clinical privileges since 2000, when he was initally appointed to the Medical Staff.

On 12/11/19 at 10:20 a.m., interview with S5HIM revealed that she is responsible for the credentialing files. At that time, she reviewed the above credentialing files and confirmed that S6MD, S7MD, S9MD and S10MD were current physicians at the hospital but had never requested any specific clincial privileges to be approved. S5HIM further confirmed that the Medical Staff Bylaws stated that a request for specific clinical privileges should be submitted with each application, but that had not been occurring.

On 12/11/19 at 12:00 p.m., interview with S3Administrator revealed that the hospital began using new credentialing applications a few years ago and requested clinical privileges was not required on the new applications. S3Administrator further confirmed that the physicians should be requesting clinical privileges at each appointment and reapppointment.

Based on record review and interview the registered nurse failed to supervise and evaluate the nursing care of each patient as evidenced by:
1. Failing to perform neurological checks every 4 hours as per the physician's order;
2. Failing to perform wound assessments upon admit for 1 of 1 patients admitted with wounds (Patient #18) and failing to perform a complete wound assessment for 1(Patient #1) of 2 (Patient #1, #18) reviewed for wound assessments and
3. Failing to perform a pain assessment prior to administering a PRN pain medication for 1 (Patient #18) of 3 (Patient #16, #18, #19) patients reviewed for pain medication.
Findings:

1. Failing to perform neurological checks every 4 hours as per the physician's order

Review of Patient#4 EMR navigated by S1DON revealed the patient was admitted on 12/01/19 for Altered Mental Status and left leg weakness. Review of Patient#4's admission orders reveal an order for neuro checks q 2 h x 4 then q 4 h.

Review of the nursing notes revealed the patient did not have documented neuro checks from 12/02/19 at 5:00 p.m. until 12/03/19 at 9:41 a.m. No neuro checks were documented for 12/02/19 9:00 p.m., 12/03/19 at 1:00 a.m., and 12/03/19 at 5:00 a.m. neuro checks. The above findings were confirmed by S1DON.

An interview was conducted with S1DON on 12/11/19 at 2:00 p.m. She confirmed the neuro checks were not done as ordered by the physician and there was not an order to discontinue neuro checks.

2. Failing to perform wound assessments upon admit for 1 of 1 (Patient #18) patients admitted with wounds and failing to perform a complete wound assessment for 1 (Patient #1) of 2 (Patient #1, #18) reviewed for wound assessments.

Review of the hospital's policy for wound care revealed in part, "It will be the standard policy of West Carroll Hospital to take photos of wounds, lesions, decubitus or any skin breaks or abnormal areas. These photo will be taken on admit (or when area noted), weekly on Sundays, and on discharge. The photos will then be downloaded with the measurements done at that time. All wounds requiring a dressing or treatment will be assessed and documented by a licensed nurse each time the dressing or treatment is done."

Patient #1
Review of Patient #1's EMR navigated by S1DON revealed the patient had an admission date of 12/07/19 at 4:45 p.m. with a diagnosis of UTI and Pneumonia and an order on 12/08/19 for clean left heel with NS, paint with Betadine q day.

Review of the wound assessment dated 12/08/19 at 3:30 p.m. revealed the wound was a pressure wound on left heel, brown, closed and no edema. The wound assessment did not include the size of the pressure wound.

An interview was conducted with S1DON 12/10/19 at 10:00 a.m. She reported the nurse takes pictures of the wound with a measuring tape in the picture when conducting wound assessments. S1DON further stated she will download the pictures of the patients' wounds to the EMR. When the surveyor questioned how does other nurses determine if the wound is getting larger or smaller, she stated they would have to look at the camera.

Patient #18
Review of the patient's electronic medical record with S1DON revealed the patient had an admission date of 12/02/19 at 7:34 p.m. with a diagnosis of L3 compression fracture with an order to consult wound care for the site.

Review of the admit nursing assessment revealed no wound assessment was performed. Further review of the record revealed the wound was not assessed until 12/03/19 at 11:45 a.m.

On 12/10/19 at 3:25 p.m., interview with S1DON confirmed that the patient's wound was not assessed until the day after admission. S1DON further stated that the wound should have been assessed upon admit.

3. Failing to perform a pain assessment prior to administering a PRN pain medication for 1 (Patient #18) of 3 (Patient #16, #18, #19) patients reviewed for pain medication

Review of the medical record for Patient #18 revealed a physician order for Toradol 30mg intramuscular PRN for pain. Further review of the record revealed the patient received Toradol 30mg PRN on 12/08/19 at 6:30 p.m. and on 12/10/19 at 9:12 a.m.

Review of the electronic medical record with S1DON revealed no documented evidence of a pain assessment prior to administering Toradol or after administering the Toradol on the above dates. Interview at that time with S1DON confirmed a pain assessment should have been documented prior to and after administering the PRN medication.

Based on record review, observations, and interviews, the hospital failed to ensure the nursing care of each patient was assigned to personnel in accordance with the patient's needs and specialized qualification and competencies of the available nursing care staff as evidenced by failure to have documented evidence of competencies and training for RNs assigned to work in the Emergency Department for 6 (S17RN, S21RN, S23RN, S24RN, S25RN, and S26RN) of 6 personnel records reviewed for ED staff.
Findings:

Review of the personnel records for S17RN, S21RN, S23RN, S24RN, S25RN, and S26RN revealed they worked in the Emergency Department. Further review revealed no documentation of Trauma training, Pediatric Advanced Life Support, and/or competencies in Emergency care.

Interview on 12/10/19 at 2:30 p.m. with S4IT/Payroll confirmed the personnel records were complete and included all of the employee's current information.

Interview on 12/11/19 at 12:30 p.m. with S3Administrator revealed that the hospital did not require nursing staff to have trauma and pediatric training to work in the ED.




17450

Based on record review and interview, the hospital failed to administer medication as ordered by the physician and by acceptable standards of practice as evidenced by failing to notify the patient's physician for holding a dose of sliding scale insulin for 1 out of 1(Patient #1) patients reviewed for sliding scale insulin.
Findings:

Review of the Hospital's policy on Insulin Sliding Scale revealed in part, "When an order is received for insulin per sliding scale the following scale will be used. FSBS 1-200= no coverage, 201-250= 4 units, 251-300= 6 units, 301-350= 8 Units, 351-400= 10 units, > 400 call MD."

Review of Patient #1's medical record revealed an admission order dated 12/07/19 for Accucheck ac/hs with Humalog sliding scale. Review of the glucose reading on 12/09/19 at 8:00 p.m. revealed a 241 blood glucose reading. Review of the Medication Administration Record revealed the insulin was not given per sliding scale due to the patient was not eating. With further review of the medical record, there was no documentation the nurse notified the MD of holding the sliding scale insulin dose.

An interview was conducted with S1DON on 12/10/19 at 1:00 p.m. She confirmed this was a medication error and the nurse should have notified the physician prior to holding the sliding scale insulin.

Based on record reviews and interview, the hospital failed to ensure all patient medical records were promptly completed as evidenced by failing to have completed medical records 30 days after discharge.
Findings:

Review of the Hospital's Bylaws for the Medical Staff revealed in part, "All chart entries and discharge summaries shall be completed within 15 days of discharge. A temporary suspension in the form of withdrawal of a practitioner's admitting privileges, effective until medical records are completed, shall be imposed automatically for failure to complete medical records with the specified time-frame."

Review of the current medical record deficiency record provided by S5HIM revealed the following;

S9MD has 27 discharge summaries not completed and 5 history and physicals not completed.
S8MD has 9 discharge summaries not completed.
S28MD has 1 discharge summary not completed and 1 history and physical not completed.
S29MD has 1 discharge summary not completed and 5 History and physical not completed.
S7MD has 1 history and physical not completed.
S28MD has 22 signature deficiencies over 90 days delinquent.
S30MD has 3 signature deficiencies over 60 days and 2 over 90 days.
S29MD has 4 signature deficiencies over 30 days, 7 signature deficiencies over 60 days, and 3 signatures over 90 days.


An interview was conducted with S5HIM on 12/11/19 at 10:30 a.m. S5HIM reported Medical Records has not kept up with the number of charts that are incomplete in a while until the surveyor requested the number of deliquent medical records. S5HIM was unable to give the surveyor the date of the last time Medical Records have kept up with the numbers of medical records that are incomplete. S5HIM further reported she had been with medical records for the last 6 years and in the last 6 years, none of the medical staff have been place on suspension due to incomplete medical records.

Based on record review and interview, the hospital failed to ensure each patient had a medical H&P examination completed and documented no more than 30 days before or 24 hours after admission as evidenced by having H&Ps performed more than 24 hours after admission for 3 (Patient #1, #15, #16 ) of 5 (#1, #2, #3, #15, #16) patient records reviewed for H&Ps from a sample of 30 patients.
Findings:

Review of the Medical Staff Rules and Regulations revealed a history and physical shall be completed within 24 hours of admission.

Patient #1
Review of the medical record revealed the patient was admitted on 12/07/19. On 12/10/19 at 1:00 p.m.the surveyor reviewed the patient's EMR with S1DON. At that time S1DON confirmed she was unable to locate a History and Physical for the patient.

Patient #15
Review of the medical record revealed the patient was admitted on 12/08/19. On 12/10/19 at 3:00 p.m., the surveyor reviewed the patient's electronic medical record with S1DON. At that time S1DON confirmed she was unable to locate an H & P for the patient.

Patient #16
Review of the medical record revealed the patient was admitted on 12/05/19. On 12/10/19 at 3:00 p.m., the surveyor reviewed the patient's electronic medical record with S1DON. At that time S1DON confirmed she was unable to locate an H & P for the patient.

An interview was conducted with S5HIM on 12/10/19 at 2:00 p.m. She reported the History and Physicals should be completed 24 hours after the patient is admitted to the hospital.


17450

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 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 for 5 (#2, #9, #10, #11, and #14) of 9 records reviewed for first dose review.
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 pharmacy policy titled "After-Hours Pharmacy Verification", dated 01/2017 revealed in part: 1. All orders will be verified before first dose is given, unless it is an emergency. 2. Pharmacist will be notified when orders are approved and ready for pharmacist verification. 3. This process will only be implemented while pharmacy is closed. 4. Pharmacist will only be held responsible for verifying the medication, dose, and frequency are appropriate for the patient. 5. Only medications that need to be given while pharmacy is closed will be verified by the pharmacist.

Interview on 12/10/19 at 9:45 a.m. with S15Pharmacist revealed that she performed first dose reviews on all medications. She further stated that she had access to the system after hours and on the weekends to review all new medication orders.

Patient #2
Review of the medical record for Patient #2 revealed the patient was admitted on 10/26/19 with a diagnosis of Pneumonia, Hypoxemia, and Dehydration. Medication orders revealed Zofran 4 mg IVP and Xopenex inhalation treatments every 6 hours. Further review revealed no documentation of a first dose review by the Pharmacist before the medications were administered to the patient.

Patient #9
Review of the medical record for Patient #9 revealed the patient was admitted on 12/09/19 with a diagnosis of SOB. Medications ordered were Lasix 20 mg IVP and Solumedrol 125 mg IVP. Further review revealed no documentation of first dose reviews by the Pharmacist before the medications were administered to the patient.

Patient #10
Review of the medical record for Patient #10 revealed the patient was admitted on 12/04/19 with a diagnosis of Fall, Back pain. Medications ordered were Toradol 30 mg IVP and Kaylyte 50 mg PO. Further review revealed no documentation of first dose reviews by the Pharmacist before the medications were administered to the patient.

Patient #11
Review of the medical record for Patient #11 revealed the patient was admitted on 11/25/19 with a diagnosis of S/P ABD/Surgery, Pain. Medications ordered were Zofran 8mg IVP, Toradol 30mg IVP, Phenergan 12.5 mg PRN, Morphine 2 mg Q6 hours PRN. Further review revealed no documentation of first dose reviews by the Pharmacist before the medications were administered to the patient.

Patient #14
Review of the medical record for patient #14 revealed the patient was admitted on 10/26/19 with a diagnosis of Acute Bronchitis, Dehydration, and Abdominal Pain. Medications orders for Zithromax 200 mg day, Miralax 8.5 gm daily, and Albuterol Inhalation treatments q 6 hours prn. Further review revealed no documentation of first dose review by the Pharmacist before the medications were administered to the patient.

Interview on 12/10/19 at 10:10 a.m. with S2ADON confirmed that all new medications should be reviewed by the pharmacist prior to nursing staff administering the first dose.

Based on observation and interview, the hospital failed to ensure that outdated, mislabeled or otherwise unusable drugs and biologicals were not available for patient use as evidenced by having expired medications on 1 of 2 crash carts at the hospital.
Findings:

On 12/09/19 at 2:00 p.m., observation of crash cart on the inpatient unit with S1DON revealed the following expired medications:
- (7) Lidocaine 100mg/5ml vials, expiration date 11/2019
- (2) Sodium Bicarb 4.2% vials, expiration date 12/01/19
- (2) Sodium Bicarb 8.4% vials, expiration date 11/2019
- (2) Verapamil 5mg/2ml vials, expiration date 11/1/19

Interview with S1DON at that time confirmed that the above medications were expired and available for patient use.

Based on observation and interview, the hospital failed to ensure equipment was maintained to ensure an acceptable level of safety as evidenced by having non-functioning nurse call bells located on the side rails of 30 of 30 patient beds.
Findings:

On 12/09/19 at 1:00 p.m., observation of non-occupied patient rooms a, b, c, d, and e revealed a nurse call button on the bed's side rails which did not function when activation was attempted.

Interview with S1DON on 12/09/19 at 1:10 p.m. revealed that there were 30 patient beds in the hospital that had the visible non-functioning call button feature on the side rails. She further stated that the patients were explained the corded call bell system, but did not explain the push call system on the side rails did not work.

Based on record review and interview, the hospital failed to ensure a person qualified by education and experience and competency in infection control practices was designated as the infection control officer as evidenced by failure to have documented evidence of education and prior experience for S1DON who was designated as the infection control officer.
Findings:

Review of S1DON's personnel record revealed no documented evidence of prior experience or infection control education as the designated infection control officer in a hospital.

An interview was conducted with S1DON on 12/11/19 at 10:00 a.m. She reported she had completed online training in infection control, but was unable to locate her documentation of the training. She also reported her hard drive on her computer crashed and she was unable to obtain her documentation of her education from her computer either.

Based on record review and interview, the hospital failed to ensure a system for controlling infections and communicable diseases of patients and personnel was established. This deficient practice was evidenced by:

1. Failure to perform active surveillance to monitor compliance with hand hygiene practices by staff as evidenced by failure to provide documentation that active surveillance of hand hygiene practice had been performed and was maintained;
2. Failure of laundry staff to wear appropriate PPE when laundering contaminated patients' linens and
3. Failure to maintain a sanitary environment.
Findings:

1. Failing to perform active surveillance to monitor compliance with hand hygiene

Review of the hospital's Infection Control Program revealed no evidence of a hand hygiene surveillance program for hand hygiene and the use of PPEs.

An interview was conducted with S1DON on 12/10/19 at 11:00 a.m. She reported she was the Infection Control Officer and she had not implemented a surveillance program for hand hygiene and the use of PPEs.

2. Laundry staff not wearing appropriate PPE when laundering contaminated patient linens

Review of the Laundry and Bedding Soiled policy revealed in part, " Handling 1. All used laundry is handled as potentially contaminated until it is properly bagged and labeled for appropriate processing."

An interview was conducted with S12Landry and S13Landry on 12/09/19 at 2:00 p.m. They reported the only PPE used when handling potentially contaminated laundry are gloves, mask, eye protection. They reported they did not wear gowns when handling potentially contaminiated laundry. They further reported there were no gowns available to the laundry workers in the laundry room.

3. Failure to maintain a sanitary environment

On 12/09/19 at 12:55 p.m., observation of Room a with S1DON revealed it had a sticker on the door, indicating the room was clean. Observation of the left side rail on the bed revealed multiple smears and splatters of a dried red substance. At that time, S1DON confirmed the substance looked like dried blood and that the room was not adequately cleaned and disinfected.

On 12/11/19 at 11:30 a.m., observation of the exam room in the Emergency Department where endocopy procedures were performed revealed the endoscopes were stored in an unlocked wooden cabinet. Observation of the scopes revealed that 3 of the 6 scopes had tips that were touching the bottom floor of the cabinet. The bottom floor of the cabinet had multiple spills, debris and stains on it. The insides of the cabinet doors had a sticky substance on them. Further observations of the scopes revealed that 3 of the scopes had foreign debris on the handles.


17450

Based on record review and interview, the hospital failed to have a process to evaluate the patients' needs on discharge from the hospital for 4 out of 4 patients (Patient #26, #28, #29, #30) reviewed for discharge planning out of a sample of 30 patients.
Findings:

Review of the hospital's Discharge Planning policy revealed in part," On initial admission to the facility information will will be collected including but not limited to the patient prior living arrangements, history, dietary needs, psychosocial status and possible needs including prior home health."

Review of Patient #26's EMR,navigated by S1DON, revealed Patient #26 was a 56 year-old female admitted on 11/10/19 for a Fracture of her distal Fibula and Pneumonia. Review of her EMR revealed no documentation of discharge planning during the hospital admission other than the physician discharge orders.

Review of Patient #28's EMR revealed Patient #28 was a 74 year-old male admitted on 11/25/19 with the complaint of Chest Pain. Review of the EMR revealed no documentation of discharge planning during the hospital admission other than the physician discharge orders.

Review of Patient #29's EMR revealed the patient was a 16 year-old female admitted on 11/24/19 with the Cellulitis to right hand secondary to a cat bite. Review of the EMR revealed no documentation of discharge planning during the hospital admission other than the physician discharge orders.

Review of Patient #30's EMR revealed the patient was an 82 year-old female admitted on 10/22/19 with an infected wound to her right lower extremity. Review of the EMR revealed no documentation of discharge planning during the hospital admission other than the physician discharge orders.

An interview was conducted with S3Administrator on 12/11/19 at 10:00 a.m. S3Administrator reported before the hospital went to EMR, the hospital had a paper form where the nurses would document the needs of the patients on discharge. She further stated the hospital will have to have one developed for their EMR system.