HospitalInspections.org

Based on observation, record review, and interviews, the hospital failed to ensure replacement solutions available for use in the emergency department were not expired.
Findings:
Review of the hospital policy titled "Unit Guidelines", policy number IP2020", revised 03/25/13, and presented by S1Administrator as a current policy, revealed contaminated and out-dated medicine would be discarded according to the date of expiration or when contaminated.
A tour of the Emergency Department was made on 04/23/13 at 10:00 a.m. with S2DON (Director of Nursing). The following items were found available for patient use:
1000ml (milliliters) Lactated Ringers expired 01/13.
1000ml 10% (per cent) Dextrose expired 10/12.
1000ml 5% Dextrose and 0.225% Sodium Chloride (2 bags) expired 01/04/13.
1000 ml Lactated Ringers 5% Dextrose (3 bags) expired 01/03/13.
In an interview on 04/23/13 at 10:05 a.m. with S2DON, she verified the above mentioned intravenous (IV) fluids were expired. S2DON stated the IV fluids should not have been available for patient use.
In an interview on 04/23/13 at 1:20 p.m. with S3Pharmacist, he stated he was responsible for ensuring IV fluids were not expired in the medication room of the emergency department. S3Pharmacist said the individual rooms in the emergency department were stocked from the medication room by the emergency department staff. S3Pharmacist also said the emergency department staff should have checked the expiration dates on the IV fluids before transferring them to the rooms.
In a face-to-face interview on 04/23/13 at 3:35 p.m., S2DON indicated the hospital did not have a policy for checking for expired medications.

Based on observation, record review, and interview, the hospital failed to ensure the safety of patients by having a restroom with a locking door and safety hazards present for use by an unobserved psychiatric patient assessed as being a danger to herself for 1 (#1) of 1 patient's record reviewed who was on a Physician Emergency Certificate from a total of 3 (#1, #13, #23) emergency department patients' records reviewed from a sample of 23 patients.
Findings:
An observation was made on 04/23/13 at 11:00 a.m. of the Emergency Department with S2DON (Director of Nursing). The restroom used by emergency room patients was located in the waiting room and was observed to have a door which locked from the inside. Further observation revealed the bathroom had a glass mirror, plastic trash can liners, and fluorescent light bulbs which were easily accessible by patients.
Review of the medical record for Patient #1 revealed she was a 15 year old female admitted to the emergency department on 04/22/13 at 12:13 p.m. with the chief complaint of being intoxicated at school. Further review revealed she admitted to smoking "mojo" (synthetic cannaboid) and taking narcotics (oxycodone).
Review of the PEC (Physician Emergency Certificate) for Patient #1 dated/timed 04/22/13 at 2:30 p.m. revealed she was listed as being "dangerous to self".
In an interview on 04/23/13 at 11:05 a.m. with S2DON, she stated if a patient had a PEC, they were observed every 15 minutes by a staff member. She also stated if the psychiatric patient had to use the restroom, they used the restroom in the waiting room outside of the emergency department. She stated unless they were diagnosed as suicidal, the nurse or technician would stand outside the door while the patient was in the restroom. S2DON said when the patients were in the restroom, they were not in direct site of the staff.
In an interview on 04/25/13 at 8:53 a.m. with S2DON, she verified Patient #1 was a psychiatric patient who was listed on her PEC as being dangerous to self. S2DON also verified when Patient #1 was being held in the emergency department (ED), Patient #1 was allowed to use the restroom in the waiting room by herself, while staff was outside of the closed door. S2DON verified the restroom had a locking door that only maintenance had the key to unlock from the outside. S2DON also verified maintenance was not in the hospital at night. S2DON said the restroom had fluorescent bulbs that could be broken, did not have a safety mirror, and had a plastic liner in the trash can which patients could use for suffocation. S2DON stated the restroom was unsafe for a psychiatric patient that was assessed as being dangerous to themselves. She stated the physician in the ED did not order the specific observation levels of the various psychiatric patients, and the hospital had no policies and procedures about the different observation levels for psychiatric patients and what was required of staff during observation of psychiatric patients. S2DON also verified the hospital had no policy for monitoring the safety of a suicidal patient.

Based on record review and interview, the hospital failed to ensure that calibration checks of the pulmonary function machine were performed daily to assure that it was maintained in a safe operating condition as evidenced by no documented evidence of pulmonary function testing on 18 days from 03/16/13 to 04/23/13. Findings:

Review of the "Pulmonary Function Test" results from 03/16/13 to 04/23/13 revealed no documented evidence that testing was performed on 03/23/13, 03/24/13, 03/27/13, 03/29/13, 03/30/13, 03/31/13, 04/05/13, 04/06/13, 04/07/13, 04/11/13, 04/13/13, 04/14/13, 04/15/13, 04/16/13, 04/17/13, 04/19/13, 04/20/13, and 04/21/13.

In a face-to-face interview on 04/23/13 at 10:45 a.m., S6Respiratory Supervisor confirmed the pulmonary function testing equipment was to be calibrated daily, and it was not done on the above dates. S6Respiratory Supervisor indicated she had not addressed the non-compliance with her staff yet.

Based on observations, record reviews, and interviews, the hospital failed to ensure:
1) refrigerator/freezer temperatures in the lab were checked daily according to hospital policy as evidenced by no documented evidence of refrigerator/freezer temperatures on 03/01/13 and 03/29/13 and no documented evidence of hourly temperature checks on the blood bank refrigerator that was implemented on 01/29/13 when the chart recorder malfunctioned;
2) the daily temperature log for room temperature, relative humidity, and barometric pressure of the respiratory department was documented as required by the "Respiratory Daily Temperature Log" as evidenced by the space for documentation of the room temperature, relative humidity, and barometric pressure on 04/07/13 and 04/11/13 being blank; and
3) the refrigerator's acceptable temperature range in the morgue was listed as being safe for storage of deceased bodies as evidenced by the "Refrigerator Temperature Log" listing the safe temperature for foods and medicines rather than a deceased body.
Findings:

1) Refrigerator/freezer temperatures in the lab were checked daily according to hospital policy:
Review of the hospital policy titled "Unit Guidelines", policy number IP2020, revised 03/25/13, and presented by S1Administrator as a current policy, revealed refrigerators were to have the temperature recorded daily by staff as assigned.

Review of the "Daily Temperature Log" for refrigerator #1, freezer #1, refrigerator #3, refrigerator #4, refrigerator #5, blood bank refrigerator, blood bank digital, blood bank chart, ultra low freezer, room temperature, and percent humidity in the lab for January 2013 revealed a hand-written note stating "recorder nonfunctional - new one due by 2/4 (February 4th) - hourly temps (temperatures) taken by techs" as of 01/29/13. Review of the "Daily Temperature Log" for February 2013 revealed a hand-written note stating "Hourly charts cannot be located as of 3/20/13. Hourly temp reading on BB (blood bank) fridge was implemented 1/29/13 due to chart recorder malfunctioning." There was no documented evidence of hourly temperature checks from 01/29/13 to 02/04/13 presented during this survey. Review of the "Daily Temperature Log" for March 2013 revealed no documented evidence that all temperatures were documented on 03/01/13 and freezer #1 and refrigerator #3 temperatures on 03/29/13.

In a face-to-face interview on 04/23/13 at 10:12 a.m., S5Medical Lab Tech confirmed refrigerator/freezer temperatures, room temperature and humidity were not documented daily as required by hospital policy. She confirmed she could not produce the hourly temperature checks from 01/29/13 to 02/04/13.

2) The daily temperature log for room temperature, relative humidity, and barometric pressure of the respiratory department was documented as required by the "Respiratory Daily Temperature Log":
Review of the "Respiratory Daily Temperature Log" presented as a required log to maintain by S6Respiratory Supervisor revealed 5 columns titled date, room temperature, relative humidity, barometric pressure, and tech initials. Review of the log for April 2013 revealed no documented evidence of the room temperature, relative humidity, and barometric pressure on 04/07/13 and 04/11/13.

In a face-to-face interview on 04/23/13 at 10:45 a.m., S6Respiratory Supervisor confirmed the temperatures were not documented as stated above.

3) The refrigerator's acceptable temperature range in the morgue was listed as being safe for storage of deceased bodies:
Observation of the refrigerator in the morgue on 04/23/13 at 10:05 a.m. with S3Pharmacist present revealed the "Refrigerator Temperature Log" for April 2013 included four columns titled danger zone, safe for foods/medicines, too cold, and initials. There was no documented evidence of the temperature range at which deceased bodies were to be maintained.

In a face-to-face interview on 04/23/13 at 10:05 a.m., S3Pharmacist indicated no food or medication was stored in the morgue refrigerator. He confirmed there was no documented evidence of the temperature at which the refrigerator should be maintained. S3Pharmacist indicated he did not know what the acceptable temperature range was for the storage of deceased bodies.

In a face-to-face interview on 04/23/13 at 10:10 a.m., S4Housekeeper indicated that she checked the refrigerator temperatures in the morgue on the days she worked. She further indicated the temperature should be between 30 to 35 degrees Fahrenheit. When shown the temperature log, S4Housekeeper indicated she was "off" with the temperature and then indicated the log said medicines. She indicated she didn't know the correct temperature range at which the morgue refrigerator should be maintained.

In a face-to-face interview on 04/23/13 at 3:00 p.m., S1Administrator indicated the hospital did not have a policy related to the temperature at which the refrigerator in the morgue should be maintained.

Based on interview and record review, the hospital failed to ensure the contract for an emergency water supply was current.
Findings:
Review of the contract with Company A for emergency water in the event of a local or national declared emergency or natural disaster revealed it had been agreed upon by the hospital on 08/19/11. Further review revealed the contract said in part:
(5) This agreement shall remain in effect for one (1) year from the Effective Date. A new Emergency Water Agreement, if needed, must be entered into by Customer each calendar year. Duration: One (1) year from the date of acceptance.
In an interview on 04/25/13 at 10:05 a.m. with S9DietaryManager, she stated she was over emergency preparedness at the hospital. She verified the contract for water with Company A had expired on 08/19/12. She also verified she did not have a current contract with a water supply company to supply water in an emergency situation when there was loss of water supply to the hospital.

Based on record reviews and interviews, the governing body failed to ensure policies governing the total operation of the hospital were implemented so as to provide quality health care in a safe environment as evidenced by:
1) Failing to ensure the safety of patients by having a restroom with a locking door and safety hazards present for use by an unobserved psychiatric patient assessed as being a danger to herself for 1 (#1) of 1 patient's record reviewed who was on a Physician Emergency Certificate from a total of 3 (#1, #13, #23) emergency department patients' records reviewed from a sample of 23 patients (see findings in tag C0221);
2) Failing to ensure the contract for an emergency water supply was current (see findings in tag C0229);
3) Failing to ensure a radiologist was credentialed and approved by the Governing Body to supervise radiology services (see findings in tag C0283);
4) Failing to ensure the 61 contracts or service agreements related to patient care were evaluated to assure that services provided enabled the hospital to comply with all applicable conditions of participation and standards for the contracted services (see findings in tag C0293);
5) Failing to ensure each patient having a procedure had a properly executed informed consent as evidenced by failing to disclose reasonable therapeutic alternatives and risks associated with such alternatives as required by Louisiana Revised Statute 40:1299.40 for 6 of 6 patients' records reviewed who had a procedure at the hospital from a sample of 23 patients (#2, #3, #7, #8, #9, #10) (see findings in tag C0304);
6) Failing to ensure patients' medical records were protected from loss and destruction as evidenced by having patients' medical records stored on open shelves in the medical record room with no protection from potential water damage in the event the sprinkler system was activated (see findings in tag C0308); and
7) Failing to ensure the yearly program evaluation identified hospital practices and policies that were not implemented as evidenced by failure to have a radiologist credentialed and privileged by the medical staff to interpret radiological tests and failing to ensure the registered dietitian performed nutritional assessments in person when an assessment was triggered or ordered (see findings in tag C0335).

Based on observations, record reviews, and interviews, the hospital failed to ensure that outdated drugs and medication-related devices were not available for use as evidenced by having expired medications and syringes available for use in the inpatient unit's medication room, the respiratory department, the special procedure room, and the stress testing room. Findings:

Review of the hospital policy titled "Unit Guidelines", policy number IP2020", revised 03/25/13, and presented by S1Administrator as a current policy, revealed contaminated and out-dated medicine would be discarded according to the date of expiration or when contaminated.

Observation of the cabinet in the respiratory department on 04/23/13 at 10:45 a.m. with S6Respiratory Supervisor present revealed an opened 16 fluid ounce (fl. oz.) bottle of Hydrogen Peroxide 3% (per cent) that had expired 11/05.

Observation of the inpatient medication room on 04/23/13 at 11:30 a.m. with S3Pharmacist present revealed that the following expired medications and syringes that were available for use:
one 500 ml (milliliters) Sterile Water for Irrigation - expired 10/01/12;
10 packs of 0.17 ounce Petrolatum Jelly Skin Protectant - expired 01/13;
one 4 fl.oz. Tincture of Benzoin Prep Spray - expired 02/10;
2 BD 20 ml syringes with luer-lok tip - expired 03/11;
1 BD 20 ml syringe with luer-lok tip - expired 08/11.

Observation of the special procedure room where flexible sigmoidoscopies were performed on 04/23/13 at 11:55 a.m., with S3Pharmacist present, revealed an opened 16 fl. oz. bottle of 70% Isopropyl Rubbing Alcohol that had expired 02/13.

Observation of the treadmill room where stress tests were performed on 04/23/13 at 12:00 p.m., with S3Pharmacist present, revealed a 4 fl. oz. bottle of Povidone-Iodine Solution that had expired 10/08.

In a face-to-face interview on 04/23/13 at 3:35 p.m., S2DON (Director of Nursing) indicated the hospital did not have a policy for checking for expired medications.

Based on observations, record reviews, and interviews, the hospital failed to implement measures to ensure the provision of a safe environment consistent with nationally recognized infection control precautions and hospital policy as evidenced by:
1) Having patient care supplies stored in a cabinet in the respiratory department that also contained bleach and disinfectant cleaners;
2) Having an opening in the wall in the radiology department where the film processor had been and was recently removed that had dirty, rusty pipes that were cut and leaking water onto the floor with pooled water containing debris from the floor which appeared as a dark brown paste collecting around a drain in the floor; and
3) Failing to implement corrective action to address identified non-compliance with hand hygiene practices by the staff.
Findings:

1) Having patient care supplies stored in a cabinet in the respiratory department that also contained bleach and disinfectant cleaners:
Review of the hospital policy titled "Unit Guidelines", policy number IP2020, revised 03/25/13, and presented as a current policy by S1Administrator, revealed clean and soiled equipment shall not be stored in the same area. Further review revealed patient care supplies shall be stored in a designated area in such a way as to prevent accidental contamination or compromise of the integrity of the packaging.

Observation in the respiratory department on 04/23/13 at 10:45 a.m. revealed a cabinet with a percussor (used for percussion after a patient had a breathing treatment), gloves, and surgical masks. Further observation revealed the following items were stored in the same cabinet with clean patient supplies:
6 containers of Super Sani-Cloth Germicidal Disposable Wipes;
96 fluid ounces Clorox Germicidal Bleach;
2 containers of Virex TB (tuberculosis) disinfectant cleaner;
1 container Fresh Scent dry spray micro-mist air freshener;
19 ounce container of Renown creamy lemon furniture polish;
2 containers of 32 fluid ounces Better Valu Lemon Dish Detergent;
1 opened gallon of Lasso-Bleach; 1 container of 18 ounces Foam Furniture Polish.

In a face-to-face interview on 04/23/13 at 10:45 a.m. at the time of the above observations, S6Respiratory Supervisor indicated the cleaning supplies should not be stored with clean patient supplies.

2) Having an opening in the wall in the radiology department where the film processor had been and was recently removed that had dirty, rusty pipes that were cut and leaking water onto the floor with pooled water containing debris from the floor which appeared as a dark brown paste collecting around a drain in the floor: Review of the hospital policy titled "Unit Guidelines", policy number IP2020, revised 03/25/13, and presented as a current policy by S1Administrator, revealed clean and soiled equipment shall not be stored in the same area.
Observation on 04/23/13 at 11:15 a.m. revealed an area in the Radiology Department where the wall had an opening where the film processor had been and was recently removed. This opening in the wall was between the Radiology Department and the room considered the "processing room." Also observed around the opening were dirty, rusty pipes that were cut and leaking water onto the floor. Further observation revealed water pooling on the floor with debris from the floor which appeared as a dark brown paste collecting around a drain in the floor. Observation of the processing room on 04/23/13 at 11:20 a.m. revealed a floor drain basin that was dirty. There were also dirty, rusty pipes leading from the open area of the wall into the processing room.
In a face-to-face interview on 04/23/13 at 11:30 a.m., S12Radiology Supervisor/QA (quality assurance) confirmed that the area in the Radiology Department where the film processor had previously been was dirty, and the cut pipes were leaking water onto the floor creating an unsanitary environment. She confirmed that the Radiology Department was considered a clean area and that the processing room was considered a dirty area. She further confirmed that the opening in the wall between a clean area and a dirty area posed an infection control risk, and that the portable x-ray machine used for patients was being stored in an area considered dirty.
3) Failing to implement corrective action to address identified non-compliance with hand hygiene practices by the staff:
Review of "Infection Prevention Minutes" presented by S7RN (registered nurse) Infection Control Nurse revealed in 01/24/12 (dated 01/24/12 but should read 01/24/13) the overall compliance with hand hygiene was 60% (per cent), with physicians and nurses having 82% compliance and lab and x-ray staff having 11% compliance. The follow-up included "to continue as ongoing observation and reporting".

Review of the "Infection Prevention Surveillance Plan 2013" revealed the indicator for hand hygiene included the actions to reduce risk was to have wall mounted units (of sanitizer hand gel) in all patient rooms and traffic areas, to send reports to team leaders on direct observations, and to report quarterly in minutes.

Review of the minutes of 04/18/13 revealed the January compliance was 79%, the February compliance was 60%, and the March compliance was 56%. Further review revealed the action included the following: results were sent to team leaders on 04/04/13 for staff to review; need to involve other disciplines in the monitoring process to get a better representation in all areas. Further review revealed the follow-up included "downward trend noted" and continue as ongoing observation and reporting.

There was no documented evidence presented during the survey of any staff education provided to address the identified non-compliance with hand hygiene practices.

In a face-to-face interview on 04/25/13 at 8:35 a.m., S7RN Infection Control Nurse indicated the hand hygiene compliance had dropped, and she wanted to get more disciplines involved in order to get a broader data base. She confirmed that she had not conducted any staff education related to hand hygiene practices as of the time of the survey. She indicated that she had started tracking and trending observations in November 2012.


31048

Based on record reviews and interviews, the hospital failed to ensure nutritional assessments were performed by the registered dietitian (RD) when the nutritional screening tool used by the registered nurse (RN) or dietary manager indicated a RD assessment was indicated for 3 of 13 patients' records reviewed for nutritional assessments by the RD from a sample of 23 patients (#11, #16, #19). Findings:

Review of the hospital policy titled "Nutritional Screening, Assessment, Reassessments, and Medical Nutritional Therapy Education", policy number 8, revised 03/07, and presented by S9Dietary Manager as a current policy, revealed any patient identified with one or more of the screening tool criteria shall be referred to the Certified Dietary Manager or the Registered Dietitian, depending on the patient's level of nutritional risk. There was no documented evidence of the manner that would be used to evaluate nutritional risk. Further review revealed the Registered Dietitian or designee shall perform the nutritional assessment within 24 to 48 hours of receipt of the nutritional screening form, and the dietitian's assessments and recommendations shall be entered in the nutritional notes section of the patient's medical record.

Review of S10RD's "Independent Contractor Agreement" revealed it was effective 01/01/08. Further review revealed S10RD's responsibilities included the provision of a nutritional assessment for patients within 48 hours of receipt of the nutritional screening.

Patient #11
Review of Patient #11's medical record revealed he was a 68 year old male admitted on 03/15/13 with diagnoses of Gastroenteritis and Dehydration.

Review of Patient #11's "Nursing Admission Assessment" performed on 03/15/13 at 11:30 a.m. revealed his nutritional assessment included the diet ordered was clear liquids and advance as tolerated, he had a decreased appetite, and he had nausea/vomiting and diarrhea. Further review revealed the box next to "Refer to RD for further intervention/assessment if one or more abnormalities identified, or if pt (patient) on modified diet" was checked.

Review of S8Dietary Manager's nutritional assessment performed on 03/15/13 revealed no documented evidence of his weight but his ideal body weight was documented. Further review revealed he was on a clear liquid diet that was to be advanced as tolerated, his glucose level was high at 175, his sodium level was high at 130, his BUN (blood urea nitrogen) was high at 46, and his creatinine was high at 3.0. Further review revealed S8Dietary Manager assessed his intake orally as good (greater than 75 per cent).

Review of Patient #11's medical record revealed no documented evidence that S11RD assessed her nutritional status.

In a face-to-face interview on 04/25/13 at 10:20 a.m., S8Dietary Manager indicated she assessed a patient's symptoms of nausea, vomiting, and diarrhea based on the patient's report of these symptoms. She confirmed her assessment did not have his weight documented, but she must have seen it in the chart, because she had completed the ideal body weight. She confirmed Patient #11 did not have a nutritional assessment performed by S10RD, because she didn't see the nurse's request for the referral.

Patient #16
Review of Patient #16's medical record revealed she was an 80 year old female admitted on 03/24/13 with diagnoses of Cellulitis of the Right Lower Extremity, Chronic Edema, and Skin Tear With Weepy Lesion to the Left Lower Extremity.

Review of Patient #16's "Nursing Admit Assessment" performed on 03/24/13 at 11:15 p.m. revealed she was assessed as needing nutritional education by the RD.

Review of Patient #16's "Nutrition Assessment" revealed a fax date and time of 03/25/13 at 11:45 a.m. and 03/25/13 at 6:54 p.m. Further review revealed S9Dietary Manager performed her assessment on 03/24/13 with no documented evidence of the time the assessment was performed. Further review revealed S10RD performed her assessment on 03/15/13 with no documented evidence of the time the assessment was performed.

In a face-to-face interview on 04/25/13 at 10:20 a.m., S9Dietary Manager indicated there was no documented time that her and S10RD performed their assessments. She confirmed that Patient #16's nutritional assessment documented by S10RD was done by S9Dietary Manager faxing S10RD the nutritional assessment done by S9Dietary Manager, and S10RD faxing her assessment back to S9Dietary Manager. S9Dietary Manager indicated S10RD saw the patient in person when requested by the physician or if she (S10RD) saw a need for an onsite visit. S9Dietary Manager indicated "more often than not S10RD doesn't see the patient."

Patient #19
Review of Patient #19's medical record revealed she was a 63 year old female admitted on 01/03/13 with diagnoses of Dehydration with Hypernatremia and Urinary Tract Infection.

Review of Patient #19's "Nursing Admit Assessment" performed on 01/03/13 at 9:15 a.m. revealed the box next to "Refer to RD for further intervention/assessment if one or more abnormalities identified, or if pt (patient) on modified diet" was checked.

Review of Patient #19's "Nutrition Assessment" performed on 01/03/13 by S9Dietary Manager (with no documented evidence of the time the assessment was done) revealed it was checked as moderate risk and "fax to RD". There was no documented evidence of a nutritional assessment performed by S10RD.

In a face-to-face interview on 04/25/13 at 10:20 a.m., S9Dietary Manager confirmed she did not date or time her signature on the "Nutrition Assessment". She also confirmed her documentation revealed that she faxed it to S10RD, but she did not fax it. She confirmed there was nutritional assessment performed by S10RD for Patient #19.

In a telephone interview on 04/25/13 at 11:05 a.m., S10RD indicated S9Dietary Manager gathers information for the nutritional assessment, and there's a nutritional screen done by the RN at admit. She further indicated S9Dietary Manager sends her the nutritional assessments scored by S9Dietary Manager as moderate to high risk. S10RD indicated she reviewed the information and called S9Dietary Manager if more information was needed. She further indicated "if I can come in, I come in, and if not I complete the paperwork and send it in." When asked what she meant by "if I can come in", S10RD indicated she has other jobs and was available by phone 24 hours a day, 7 days a week, but she's not "physically available 24/7."

Based on observation, record review, and interview, the hospital failed to ensure culture supplies available for use were not expired as evidenced by having culture swabs that had expired in July 2011 available for use in the inpatient medication room. Findings:

Review of the hospital policy titled "Unit Guidelines", policy number IP2020, revised 03/25/13, and presented by S1Administrator as a current policy, revealed patient care supplies would be stored in designated storage areas as well as direct patient care areas. Further review revealed storage would be in a manner to prevent accidental contamination or compromise of the integrity of the packaging. There was no documented evidence that the policy addressed how expired patient care supplies would be handled.

Observation of the inpatient medication room on 04/23/13 at 11:30 a.m. with S3Pharmacist present revealed 2 BBL Culture Swab Plus Collection and Transport System for Aerobes and Anaerobes that had expired July 2011 available for use in the cabinet. This observation was confirmed by S3Pharmacist.

Based on observations, record reviews, and interviews, the hospital failed to ensure a radiologist was credentialed and approved by the Governing Body to supervise radiology services, and radiology film was stored in a manner to protect the film from fire and water damage as evidenced by having radiology film stored on open shelves.
Findings:
Review of the Governing Body Bylaws, Section 4B, presented by S1Administrator as the current bylaws, revealed "All appointments to the Medical Staff shall be for two years, renewable by the Board with formal reapplication through the Medical Staff organization." Section 5 states, "Applications for reappointment to the Medical Staff shall be processed as determined by the Medical Staff Bylaws."
Review of the Medical Staff Bylaws Article VII, Section A. Reappointment, Item 2., revealed "In order to continue appointment and clinical privileges the practitioner shall reapply and be reviewed at least every two years as outlined by the Medical Staff Office, except where delineated herein (Honorary and Visiting status)."
In a face-to-face interview on 04/23/13 at 11:30 a.m., S12Radiology Supervisor/QA, (quality assurance) indicated that the medical director of Radiology Services was S15Radiology Director.
Review of S15Radiology Director's credentialing file revealed the following:
1. A letter from the Governing Board indicating reappointment to Active Staff was granted to S15Radiology Director from 02/05/2010 through 02/2012.
2. An application completed for reappointment dated 10/2012.
3. A delineation of privileges form signed by S15Radiology Director on 10/23/12 and signed by the chief of staff dated 12/11/12.
4. A document containing signatures from the Medical Executive Committee recommending reappointment of S15Radiology Director to active staff dated 12/11/2012.
In a face-to-face interview on 04/25/13 at 2:30 p.m., S14Administrative Assistant indicated that the Governing Body meeting was "coming up," and that the recommendations for reappointment by the Governing Body for S15Radiology Director would be decided at that time. S14Administrative Assistant confirmed the Governing Board has not approved reappointment of privileges, and the active staff privileges for S15Radiology Director had been expired since 02/2012.
In a face-to-face interview on 04/25/13 at 3:15 p.m., S1Administrator indicated that physicians need to be approved by the Governing Body of the hospital to be considered as active staff at the hospital.
Observation in the Radiology Department office on 04/23/13 at 11:00 a.m. revealed 28 open metal shelves of radiology film. Observation on 04/23/13 at 11:20 a.m. in an adjoining room referred to as "the processing room" revealed open wooden shelves containing radiology film.
In a face-to-face interview on 04/23/13 at 11:30 a.m., S12Radiology Supervisor/QA indicated that the metal files were left open for the convenience of filing and retrieving radiology film, and that the wooden shelves did not have doors to cover the exposed files. S12Radiology Supervisor/QA also indicated that there were no back up files of radiology film, and there were about two years' worth of film stored in the area.

Based on record reviews and interviews, the hospital failed to ensure the 61 contracts or service agreements related to patient care were evaluated to assure that services provided enabled the hospital to comply with all applicable conditions of participation and standards for the contracted services. Finding:

Review of the list of contracts provided by S2Director of Nursing as the current list of services provided by contract or agreement revealed the hospital had 61 contracts or service agreements related to patient care.

Review of the contract with Company A for emergency water in the event of a local or national declared emergency or natural disaster revealed it had been agreed upon by the hospital on 08/19/11. Further review revealed the contract said in part:
(5) This agreement shall remain in effect for one (1) year from the Effective Date. A new Emergency Water Agreement, if needed, must be entered into by Customer each calendar year. Duration: One (1) year from the date of acceptance.
In an interview on 04/25/13 at 10:05 a.m. with S9DietaryManager, she stated she was over emergency preparedness at the hospital. She verified the contract for water with Company A had expired on 08/19/12. She also verified she did not have a current contract with a water supply company to supply water in an emergency situation when there was loss of water supply to the hospital.

In a face-to-face interview on 04/25/13 at 10:05 a.m., S1Administrator indicated he had never evaluated the contracted services and had no means of ensuring that the contracted services were provided efficiently, effectively, and safely.

Based on record reviews and interviews, the hospital failed to ensure a registered nurse (RN) administering and monitoring conscious sedation was evaluated for competency on an annual basis as required by Louisiana Revised Statute 37:911 for 1 of 4 RNs' personnel files reviewed for IV (intravenous) conscious sedation competency from a total of 14 employed RNs (S11). Findings:

Review of Louisiana State Board of Nursing's "Declaratory Statement On The Role And Scope Of Practice Of The Registered Nurse In The Administration Of Medication And Monitoring Of Patients During The Levels Of Procedural Sedation (Minimal, Moderate, Deep, And Anesthesia) As Defined Herein" revealed that in accordance with Louisiana Revised Statute 37:911 (ensure that the patient will receive safe and effective nursing care), re-enacted and amended in 2001, competencies for a RN to administer non-anesthetic medications and to monitor patients in minimal, moderate, and deep sedation levels must be evaluated initially during orientation and on an annual basis.

Review of the hospital policy titled "Conscious Sedation", policy number PCN-01, revised 05/05, revised 11/12, and contained in the nursing policy manual presented by S2DON (director of nursing) as the current nursing policies and procedures, revealed the RN or other health care professionals must have established competency as determined by Basic Life Support and orientation and competency in Conscious Sedation. There was no documented evidence that the hospital's policy required the RN's competency to be evaluated annually for administering and monitoring conscious sedation.

Review of S11RN's personnel file revealed she was hired 09/29/11. Further review revealed she had a simulated performance of demonstrating knowledge, technical skills, and critical thinking when caring for the patient receiving conscious sedation on 11/01/11. Review of her online transcript of computer training revealed S11RN completed the conscious sedation training on 11/02/11. There was no documented evidence she received training annually after her initial training of 11/01/11 and 11/02/11.

Review of Patient #21's medical record revealed she was a 62 year old female who presented to the Emergency Department on 01/08/13 with a chief complaint of right arm pain. Further review revealed she had a reduction of the right dislocated shoulder under conscious sedation. Further review revealed S11RN administered Propofol 40 mg IV (intravenous) on 01/08/13 at 8:30 p.m.

In a face-to-face interview on 04/25/13 at 9:00 a.m., S8RN indicated she provided the continuous monitoring of Patient #21 when she (Patient #21) received IV conscious sedation. S8RN confirmed S11RN administered the Propofol, because S8RN "felt more comfortable with S11RN giving Propofol while she (S8RN) monitored" the patient, since S11RN was an experienced Intensive Care Unit RN.

In a face-to-face interview on 04/25/13 at 1:50 p.m., S2DON confirmed S11RN did not have a competency evaluation for IV conscious sedation performed annually.

Based on record reviews and interviews, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care for each patient. The hospital failed to develop and implement a policy for patient assessments and wound assessments by the RN.
1) The RN failed to assess a patient after a procedure was performed prior to discharge for 6 of 6 patients' records reviewed who had procedures performed from a sample of 23 patients (#2, #3, #7, #8, #9, #10);
2) The RN failed to assess a patient's skin tear that included the measurement and appearance of the surrounding tissue for 1 of 1 patient reviewed with a wound from a sample of 23 patients (#16);
3) The RN failed to assess a patient's pulse oxygen saturation prior to and after a nebulizer treatment for 1 of 2 patients' records reviewed for nebulizer treatment administration from a sample of 23 patients (#14); and
4) The RN failed to ensure incentive spirometry was performed as ordered by the physician for 1 of 1 patient's record reviewed with orders for incentive spirometry from a sample of 23 patients (#20).
Findings:

1) The RN failed to assess a patient after a procedure was performed prior to discharge:
Patient #2
Review of Patient #2's medical record revealed he was a 53 year old male who had a flexible sigmoidoscopy performed on 03/28/13. Further review revealed no documented evidence of an assessment by the RN after his procedure and prior to discharge.

Patient #3
Review of Patient #3's medical record revealed he was 67 year old male who had a Treadmill Exercise Stress Test performed on 04/19/13. Further review revealed no documented evidence of an assessment by the RN after his procedure and prior to discharge.

Patient #7
Review of Patient #7's medical record revealed he was a 49 year old male who had a Treadmill Exercise Stress Test performed on 04/05/13. Further review revealed no documented evidence of an assessment by the RN after his procedure and prior to discharge.

Patient #8
Review of Patient #8's medical record revealed he was a 40 year old male who had a Treadmill Exercise Stress Test performed on 04/19/13. Further review revealed no documented evidence of an assessment by the RN after his procedure and prior to discharge.

Patient #9
Review of Patient #9's medical record revealed he was a 36 year old male who had a flexible sigmoidoscopy on 04/09/13. Further review revealed no documented evidence of an assessment by the RN after his procedure and prior to discharge.

Patient #10
Review of Patient #10's medical record revealed he was a 55 year old male who had a flexible sigmoidoscopy on 04/05/13. Further review revealed no documented evidence of an assessment by the RN after his procedure and prior to discharge.

In a face-to-face interview on 04/25/13 at 1:50 p.m., S2DON (director of nursing) indicated the RN should be assessing each patient after their procedure prior to discharging the patient.

In a face-to-face interview on 04/25/13 at 4:25 p.m., S2DON indicated the hospital did not have a policy that addressed when a patient assessment was to be performed by a RN.

2) The RN failed to assess a patient's skin tear that included the measurement and appearance of the surrounding tissue:
Review of Patient #16's medical record revealed she was an 80 year old female admitted on 03/24/13 with diagnoses of Cellulitis of the Right Lower Extremity, Chronic Edema, and Skin Tear With Weepy Lesion to the Left Lower Extremity. Further review revealed she was discharged on 03/28/13.

Review of Patient #16's "Nursing Admit Assessment" dated 03/24/13 at 11:15 p.m. revealed she had mild redness to the left lower extremity with a "weeping skin tear". There was no documented evidence of the measurements of the skin tear at admission and throughout the remainder of her stay.

In a face-to-face interview on 04/25/13 at 1:50 p.m., S2DON confirmed there was no measurement of Patient #16's skin tear at any time in her record, and the RN should have assessed and documented the appearance of the skin tear including a measurement.

In a face-to-face interview on 04/25/13 at 4:25 p.m., S2DON indicated the hospital did not have a policy that addressed wound assessments by the RN.

3) The RN failed to assess a patient's pulse oxygen saturation prior to and after a nebulizer treatment:
Review of the hospital policy titled "Aerosol Therapy", policy number RT-033, originated 03/01, and presented as a current policy by S6Respiratory Supervisor, revealed documentation of respiratory care treatment should include the medication, how long it was administered, the patient's pulse rate before and after therapy, breath sounds, adverse reactions if any, the degree of patient toleration and cooperation, and the results obtained.

Review of the "Respiratory Care Notes" revealed a space for documenting breath sounds and pulse oxygen saturation pre-procedure and post-procedure.

Review of Patient #14's medical record Review of Patient #14's medical record revealed he was a 70 year old male admitted on 03/12/13 with diagnoses of exacerbation of COPD (chronic obstructive pulmonary disease) and Acute Bronchitis.

Review of Patient #14's physician orders revealed an order on 03/12/13 at 9:00 a.m. for Albuterol 2.5/Atrovent 0.5 QID (four times a day) per nebulizer treatment. Review of Patient #14's "Respiratory Care Notes" revealed he received a nebulizer treatment on 03/12/13 at 8:00 p.m. administered by the RN with no documented evidence of his oxygen saturation prior to and post procedure. Further review revealed no documented evidence the RN signed her name as the person administering the treatment.

In a face-to-face interview on 04/24/13 at 10:25 a.m., S6Respiratory Supervisor indicated the nurses give nebulizer treatments at night. After review of Patient #14's medical record, she confirmed there was no documentation of Patient #14's oxygen saturation prior to and after his treatment on 03/12/13 at 8:00 p.m.

4) The RN failed to ensure incentive spirometry was performed as ordered by the physician:
Review of Patient #20's medical record revealed she was a 76 year old female admitted on 01/04/13 with diagnoses of COPD and Bronchitis.

Review of Patient #20's physician orders revealed an order on 01/07/13 at 7:00 a.m. for incentive spirometry QID. Review of her "Respiratory Care Notes" revealed she performed incentive spirometry on 01/07/13 at 7:20 a.m., 11:00 a.m., and 4:00 p.m. There was no documented evidence incentive spirometry was administered 4 times a day as ordered on 01/07/13.

In a face-to-face interview on 04/24/13 at 10:25 a.m., S6Respiratory Supervisor confirmed the physician's orders for QID incentive spirometry was not done on 01/07/13.

Based on record reviews and interviews, the hospital failed to ensure:
1) Medications were administered as ordered by the physician for 3 of 23 patients' records reviewed for medication administration from a sample of 23 patients (#11, #14, #20) and
2) Each verbal order received by the nurse contained a "read back" verification as required by hospital policy for 4 of 23 patients' medical records reviewed for verbal order read back verification from a sample of 23 patients (#5, #11, #14, #18).
Findings:

1) Medications were administered as ordered by the physician:
Review of the hospital policy titled "Administration Of medications", policy number P100.1, originated 05/09, and presented as the current policy for medication administration by S2DON (director of nursing), revealed nurses were encouraged to administer medications within one hour before to one hour after the standard administration time. Further review revealed the nurse was to indicate that a drug was given by drawing a line through the time on the MAR (medication administration record) and initial it. Further review revealed if the drug was not given, the nurse was to circle the time, place his/her initials next to the time, and document the reason for the omission briefly on the MAR and in detail in the nursing notes.

Patient #11
Review of Patient #11's medical record revealed he was a 68 year old male admitted on 03/15/13 with diagnoses of Gastroenteritis and Dehydration.

Review of Patient #11's physician orders revealed an order on 03/16 (with no documented evidence of the year) at 7:20 a.m. for Immodium 2 mg (milligrams) 2 tablets this A.M.and then 1 tablet QID (four times a day) and to change his IV (intravenous) fluids to Dextrose 5% (per cent) 1/2 Normal Saline with 10 mEq (milliequivalent) KCl (Potassium Chloride) at 100 cc/hr. (cubic centimeters per hour). Review of the MAR revealed no documented evidence that Patient #11 received 2 Immodium 2 mg tablets on 03/16/13 at 8:15 a.m. Further review revealed the IV was not changed until 9:30 a.m., 2 hours and 10 minutes after the order was received.

In a face-to-face interview on 04/25/13 at 1:50 p.m., S2DON confirmed documentation revealed that Patient #11 did not receive 2 tablets of Immodium as ordered. She further indicated the nurse should have changed Patient #11's IV within the hour that it was ordered to be changed.

Patient #14
Review of Patient #14's medical record revealed he was a 70 year old male admitted on 03/12/13 with diagnoses of exacerbation of COPD (chronic obstructive pulmonary disease) and Acute Bronchitis.

Review of Patient #14's "Admission Orders" on 03/12/13 at 9:00 a.m. revealed an order for Albuterol 2.5/Atrovent 0.5 QID. Review of Patient #14's MAR and "Respiratory Care Notes" revealed he received a respiratory treatment as ordered on 03/13/13 at 7:15 a.m., 3:15 p.m., and 7:30 p.m. There was no documented evidence he had a treatment four times a day as ordered on 03/13/13.

In a face-to-face interview on 04/24/13 at 10:25 a.m., S6Respiratory Supervisor confirmed Patient #14 did not receive 4 respiratory treatments as ordered by the physician on 03/13/13.

Patient #20
Review of Patient #20's medical record revealed she was a 76 year old female admitted on 01/04/13 with diagnoses of COPD and Bronchitis. Review of her "Admission Orders" on 01/04/13 at 3:00 p.m. revealed an order for Xopenex 1.25 mg nebulizer treatments every 8 hours.

Review of Patient #20's MAR and "Respiratory Care Notes" revealed she had Xopenex administered per nebulizer on 01/05/13 at 4:45 p.m. and 9:00 p.m., 4 hours and 15 minutes between treatments rather than 8 hours as ordered.

In a face-to-face interview on 04/24/13 at 10:25 a.m., S6Respiratory Supervisor confirmed Patient #20 received her respiratory treatment on 01/05/13 with less than 8 hours between treatments as ordered by the physician.

2) Each verbal order received by the nurse must contain "read back" verification as required by the hospital policy:
Review of the hospital policy titled "Orders/Verbal Orders", policy number NOP-11, revised 11/06, and presented by S16Admissions Representative as a current policy, revealed the written verbal order must be legible and include the date, time, the order, the name of the ordering practitioner, and the signature of the individual accepting the order. Further review revealed the order had to have the phrase "read back" as verification that the accepting professional did read back the order.

Patient # 5 Patient #5 was a 92-year-old female admitted on 12/28/12 with a diagnosis of terminal CHF (congestive heart failure).
Review of Patient's #5's medical record revealed telephone orders received on 01/01/13 at 4:45 p.m. (2 orders) and 01/01/13 at 6:45 p.m. had no documented evidence of read back verification by the nurse who received the order.
Review of Patient #5's medical record revealed the Medication Administration Record (MAR) did not have the year included in the date on the document.
Patient #11
Review of Patient #11's medical record revealed he was a 68 year old male admitted on 03/15/13 with diagnoses of Gastroenteritis and Dehydration.

Review of Patient #11's physician orders revealed verbal/telephone orders were received with no documented evidence of read back verification by the nurse receiving the order on 03/16/13 at 6:45 p.m., 03/16/13 at 10:10 p.m., 03/17/13 at 12:45 a.m., 03/17/13 at 9:50 p.m., 03/18/13 at 12:50 a.m., and 03/18/13 at 8:30 a.m.

Patient #14
Review of Patient #14's medical record revealed he was a 70 year old male admitted on 03/12/13 with diagnoses of exacerbation of COPD (chronic obstructive pulmonary disease) and Acute Bronchitis.

Review of Patient #14's physician orders revealed a telephone order received on 03/12/13 at 12:00 p.m. with no documented evidence of a read back verification by the nurse who received the order.

Patient #18 Patient #18 was a 67-year-old female admitted on 03/28/13 with a diagnosis of pneumonia.
Review of Patient #18's medical record revealed telephone orders received on 03/29/13 at 3:26 pm. and 04/01/13 at 9:40 p.m. had no documented evidence of read back verification by the nurse who received the order.
Review of Patient #18's MAR revealed it did not have the year included in the date on the document, and an order written on 03/30/13 did not have a time documented.
In a face-to-face interview on 04/25/13 at 1:50 p.m., S2DON indicated the nurse was supposed to document "read back" when receiving a verbal/telephone order.


31048

Based on record reviews and interview, the hospital failed to ensure discharge summaries were accurately documented as evidenced by having blanks left by the transcriptionist for the physician to complete prior to signing the discharge summary remaining blank after the physician signed his summary for 2 of 5 patients' records reviewed for complete discharge summaries from a sample of 23 patients (#11, #16). Findings:

Review of the Medical Staff Rules and Regulations, presented by S16Admissions Representative as the current Rules and Regulations, revealed the attending physician was responsible for a complete medical record for each inpatient under his/her care. Further review revealed the contents of the medical record were to be accurate, timely, and legible.

Patient #11
Review of Patient #11's medical record revealed he was a 68 year old male admitted on 03/15/13 with diagnoses of Gastroenteritis and Dehydration.

Review of Patient #11's "Discharge Summary" dictated on 03/18/13 and transcribed on 03/18/13 revealed a blank for S18Physician to fill in the doctor's name who was contacted at the hospital to which Patient #11 was being transferred. Further review revealed S18Physician signed the "Discharge Summary" on 03/25/13 at 8:00 a.m., and the blank remained with no documented evidence of the doctor's name as of the time of the record review on 04/23/13.

Patient #16
Review of Patient #16's medical record revealed she was an 80 year old female admitted on 03/24/13 with diagnoses of Cellulitis of the Right Lower Extremity, Chronic Edema, and Skin Tear With Weepy Lesion to the Left Lower Extremity.

Review of Patient #16's "Discharge Summary" dictated on 03/28/13 and transcribed on 03/28/13 revealed a blank for S18Physician to fill in information related to Unasyn being ordered. Further review revealed S18Physician signed the "Discharge Summary" on 03/29/13 at 7:00 a.m., and the blank remained with no documented evidence of the information related to Unasyn as of the time of the record review on 04/24/13.

In a face-to-face interview on 04/25/13 at 1:50 p.m., S2DON (director of nursing) confirmed the blanks in Patients' #11 and #16 discharge summaries were not completed at the time S18Physician signed the summaries.

Based on record reviews and interview, the hospital failed to ensure each patient having a procedure had a properly executed informed consent as evidenced by failing to disclose reasonable therapeutic alternatives and risks associated with such alternatives as required by Louisiana Revised Statute 40:1299.40 for 6 of 6 patients' records reviewed who had a procedure at the hospital from a sample of 23 patients (#2, #3, #7, #8, #9, #10). Findings:

Review of Louisiana Revised Statute 40:1299.40 Consent to Medical Treatment revealed the physician or other health care provider who will actually perform the contemplated medical or surgical procedure shall disclose reasonable therapeutic alternatives and risks associated with such alternatives.

Patient #2
Review of Patient #2's medical record revealed he was a 53 year old male who had a flexible sigmoidoscopy performed on 03/28/13. Review of his informed consent revealed no documented evidence that Patient #2 was informed of the reasonable therapeutic alternatives to the procedure and the risks associated with such alternatives.

Patient #3
Review of Patient #3's medical record revealed he was 67 year old male who had a Treadmill Exercise Stress Test performed on 04/19/13. Review of his informed consent revealed no documented evidence that Patient #3 was informed of the reasonable therapeutic alternatives to the procedure and the risks associated with such alternatives.

Patient #7
Review of Patient #7's medical record revealed he was a 49 year old male who had a Treadmill Exercise Stress Test performed on 04/05/13. Review of his informed consent revealed no documented evidence that Patient #7 was informed of the reasonable therapeutic alternatives to the procedure and the risks associated with such alternatives.

Patient #8
Review of Patient #8's medical record revealed he was a 40 year old male who had a Treadmill Exercise Stress Test performed on 04/19/13. Review of his informed consent revealed no documented evidence that Patient #8 was informed of the reasonable therapeutic alternatives to the procedure and the risks associated with such alternatives.

Patient #9
Review of Patient #9's medical record revealed he was a 36 year old male who had a flexible sigmoidoscopy on 04/09/13. Review of his informed consent revealed no documented evidence that Patient #9 was informed of the reasonable therapeutic alternatives to the procedure and the risks associated with such alternatives.

Patient #10
Review of Patient #10's medical record revealed he was a 55 year old male who had a flexible sigmoidoscopy on 04/05/13. Review of his informed consent revealed no documented evidence that Patient #10 was informed of the reasonable therapeutic alternatives to the procedure and the risks associated with such alternatives.

In a face-to-face interview on 04/25/13 at 1:50 p.m., S2DON (director of nursing) offered no explanation when informed the patients' informed consent for procedures performed at the hospital did not have the reasonable therapeutic alternatives to the procedure and the risks associated with such alternatives as required by Louisiana law.

Based on record reviews and interviews, the hospital failed to ensure all medical record entries were timed, dated, and authenticated by the author of the entry as required by hospital policy for 8 of 23 patient records reviewed for timing and dating entries from a sample of 23 patient records (#3, #6, #7, #8, #11, #15, #16, #19). Findings:

Review of the hospital policy titled "Orders/Verbal Orders", policy number NOP-11, revised 11/06, and presented as the current policy for dating and timing medical record entries by S16Admissions Representative, revealed all entries in the medical record must be legible, timed, dated, and authenticated.

Review of the Medical Staff Rules and Regulations, presented by S16Admissions Representative as the current Rules and Regulations, revealed all diagnostic and therapeutic orders for treatment must be legible, dated, timed, and authenticated.

Patient #3
Review of Patient #3's medical record revealed he was 67 year old male who had a Treadmill Exercise Test performed on 04/19/13. Review of Patient #3's "Exercise Stress Test Report" documented by S17Physician revealed no documented evidence of the date and time S17Physician signed the report.

Patient #6
Review of the medical record for Patient #6 revealed she was a 101 year old patient admitted to the hospital on 3/2/13 with the diagnosis of pressure ulcer on the left hip and cellulitis.
Review of the Physician's Orders for Patient #6 revealed the following order dated 03/05/13 with no time listed: Transfuse 2 u (units) PRBC (packed red blood cells) slowly. Hold fluids while gets blood then resume after blood completed.
In an interview on 04/26/13 at 9:00 a.m. with S2DON, she verified the blood order dated 03/05/13 was not timed by the physician. She stated not timing orders was an error.

Patient #7
Review of Patient #7's medical record revealed he was a 49 year old male who had a Treadmill Exercise Test performed on 04/05/13. Review of Patient #7's "Exercise Stress Test Report" documented by S17Physician revealed no documented evidence of the date and time S17Physician signed the report.

Patient #8
Review of Patient #8's medical record revealed he was a 40 year old male who had a Treadmill Exercise Test performed on 04/19/13. Review of Patient #8's "Exercise Stress Test Report" documented by S17Physician revealed no documented evidence of the date and time S17Physician signed the report.

Patient #11
Review of Patient #11's medical record revealed he was a 68 year old male admitted on 03/15/13 with diagnoses of Gastroenteritis and Dehydration.

Review of Patient #11's physician orders revealed orders written on "03/15" and "03/16" by S18Physician had no documented evidence of the year the order was written.

Patient #15
Review of the medical record for Patient #15 revealed she was an 80 year old female admitted on 03/15/13 with diagnosis which included multiple traumas resulting from a fall at home.
Review of the Physician's Orders for Patient #15 revealed the following physician's orders which had not been timed:
03/16/13- 3 inch ace wrap left foot, Claritin 1 po (by mouth) q (every) 24 hours prn (as needed) itching, Benadryl 25 1 po q 6 hours prn itching not resolved by Claritin, ok in recliner as tolerated.
03/17/13- Celebrex 200mg (milligrams) po q a.m., Narco 5/325 1 po q 4 hours prn mild to moderate pain, Cont (continue) Morphine for moderate to severe pain, Laxative of choice.
In an interview on 04/26/13 at 9:04 a.m. with S2DON, she verified the above mentioned orders for Patient #15 were not timed by the physician. She stated not timing orders was an error.
Patient #16
Review of Patient #16's medical record revealed she was an 80 year old female admitted on 03/24/13 with diagnoses of Cellulitis of the Right Lower Extremity, Chronic Edema, and Skin Tear With Weepy Lesion to the Left Lower Extremity. Review of the physician orders revealed an order written on "3/26" by S18Physician had no documented evidence of the year the order was written.

Patient #19
Review of Patient #19's medical record revealed she was a 63 year old female admitted on 01/03/13 with diagnoses of Dehydration with Hypernatremia and Urinary Tract Infection. Review of her physician orders revealed two orders written by S18Physician on "1/5" with no documented evidence of the year the order was written.

In a face-to-face interview on 04/25/13 at 1:50 p.m., S2DON indicated the date and time, including the year, should be documented on all medical record entries.


30364

Based on observation, record review, and interview, the hospital failed to ensure patients' medical records were protected from loss and destruction as evidenced by having patients' medical records stored on open shelves in the medical record room with no protection from potential water damage in the event the sprinkler system was activated. Findings:

Observation of the medical record room on 04/23/13 at 9:55 a.m. revealed open-fronted metal file racks that contained 7 rows each with 3 columns each that provided storage for patients' medical records. Further observation revealed the room was protected from fire by a sprinkler system. Further observation revealed there was no protection of the records from water damage in the event the sprinkler system became activated.

In a face-to-face interview on 04/23/13 at 9:55 a.m., S13Health Information Management Coordinator confirmed the hospital did not have a system in place to protect the patients' medical records from water damage if the sprinkler system became activated.

In a face-to-face interview on 04/23/13 at 3:00 p.m., S1Administrator indicated the hospital did not have a policy related to the protection of patients' medical records from water damage or loss.

Based on record reviews and interviews, the hospital failed to ensure the yearly program evaluation identified hospital practices and policies that were not implemented as evidenced by failure to have a radiologist credentialed and privileged by the medical staff to interpret radiological tests and failing to ensure the registered dietitian performed nutritional assessments in person when an assessment was triggered or ordered. Findings:

Review of the "Performance Improvement Annual Evaluation 2012" for July 2011 through June 2012 revealed annual statistics included that 1509 total meals were served and 3734 radiology procedures were performed. Further review revealed no documented evidence that the hospital's policies and procedures were reviewed as part of this evaluation.

Review of S15Radiology Director's credentialing file revealed he was privileged from 02/05/2010 through 02/2012.
In a face-to-face interview on 04/25/13 at 2:30 p.m., S14Administrative Assistant indicated that the Governing Body meeting was "coming up," and that the recommendations for reappointment by the Governing Body for S15Radiology Director would be decided at that time. S14Administrative Assistant confirmed the Governing Board has not approved reappointment of privileges, and the active staff privileges for S15Radiology Director had been expired since 02/2012.
In a face-to-face interview on 04/25/13 at 10:20 a.m., S9Dietary Manager indicated S10RD saw the patient in person when requested by the physician or if she (S10RD) saw a need for an onsite visit. S9Dietary Manager indicated "more often than not S10RD doesn't see the patient."

In a telephone interview on 04/25/13 at 11:05 a.m., S10RD indicated S9Dietary Manager gathers information for the nutritional assessment, and there's a nutritional screen done by the RN at admit. She further indicated S9Dietary Manager sends her the nutritional assessments scored by S9Dietary Manager as moderate to high risk. S10RD indicated she reviewed the information and called S9Dietary Manager if more information was needed. She further indicated "if I can come in, I come in, and if not I complete the paperwork and send it in." When asked what she meant by "if I can come in", S10RD indicated she has other jobs and was available by phone 24 hours a day, 7 days a week, but she's not "physically available 24/7."

In a face-to-face interview on 04/25/13 at 3:50 p.m., S12Radiology Supervisor and QA (quality assurance) Coordinator indicated it was not identified during the annual evaluation that S15Radiology Director was not currently credentialed and privileged and that nutritional assessments by S10RD were being done by fax rather than in-person visits.

Based on record reviews and interviews, the hospital failed to ensure that all patient care services affecting patient health and safety were evaluated annually. Findings:

In a face-to-face interview on 04/25/13 at 10:05 a.m., S1Administrator indicated he had never evaluated the contracted services providing patient care and had no means of ensuring that the contracted services were provided efficiently, effectively, and safely.

Based on record reviews and interviews, the hospital failed to ensure a system was developed to identify and monitor medication errors other than the staff nurses self-reporting medication errors. There were 4 medication errors identified during the survey that had not been identified by the hospital 3 of 23 patients' records reviewed for medication administration from a sample of 23 patients (#11, #14, #20). Findings:

Review of the "Performance Improvement Annual Evaluation 2012 revealed an opportunity for improvement included medication error monitoring for all medication errors, including errors not reaching patients, to help to identify any trends.

Review of the Performance Improvement data submitted by S12Radiology Supervisor and QA (quality assurance) Coordinator revealed the hospital had identified no medication errors in December 2012, and in January, February, and March 2013.

Patient #11
Review of Patient #11's medical record revealed he was a 68 year old male admitted on 03/15/13 with diagnoses of Gastroenteritis and Dehydration.

Review of Patient #11's physician orders revealed an order on 03/16 (with no documented evidence of the year) at 7:20 a.m. for Immodium 2 mg (milligrams) 2 tablets this A.M.and then 1 tablet QID (four times a day) and to change his IV (intravenous) fluids to Dextrose 5% (per cent) 1/2 Normal Saline with 10 mEq (milliequivalent) KCl (Potassium Chloride) at 100 cc/hr. (cubic centimeters per hour). Review of the MAR revealed no documented evidence that Patient #11 received 2 Immodium 2 mg tablets on 03/16/13 at 8:15 a.m. Further review revealed the IV was not changed until 9:30 a.m., 2 hours and 10 minutes after the order was received.

In a face-to-face interview on 04/25/13 at 1:50 p.m., S2DON confirmed documentation revealed that Patient #11 did not receive 2 tablets of Immodium as ordered. She further indicated the nurse should have changed Patient #11's IV within the hour that it was ordered to be changed.

Patient #14
Review of Patient #14's medical record revealed he was a 70 year old male admitted on 03/12/13 with diagnoses of exacerbation of COPD (chronic obstructive pulmonary disease) and Acute Bronchitis.

Review of Patient #14's "Admission Orders" on 03/12/13 at 9:00 a.m. revealed an order for Albuterol 2.5/Atrovent 0.5 QID. Review of Patient #14's MAR and "Respiratory Care Notes" revealed he received a respiratory treatment as ordered on 03/13/13 at 7:15 a.m., 3:15 p.m., and 7:30 p.m. There was no documented evidence he had a treatment four times a day as ordered on 03/13/13.

In a face-to-face interview on 04/24/13 at 10:25 a.m., S6Respiratory Supervisor confirmed Patient #14 did not receive 4 respiratory treatments as ordered by the physician on 03/13/13.

Patient #20
Review of Patient #20's medical record revealed she was a 76 year old female admitted on 01/04/13 with diagnoses of COPD and Bronchitis. Review of her "Admission Orders" on 01/04/13 at 3:00 p.m. revealed an order for Xopenex 1.25 mg nebulizer treatments every 8 hours.

Review of Patient #20's MAR and "Respiratory Care Notes" revealed she had Xopenex administered per nebulizer on 01/05/13 at 4:45 p.m. and 9:00 p.m., 4 hours and 15 minutes between treatments rather than 8 hours as ordered.

In a face-to-face interview on 04/24/13 at 10:25 a.m., S6Respiratory Supervisor confirmed Patient #20 received her respiratory treatment on 01/05/13 with less than 8 hours between treatments as ordered by the physician.

In a face-to-face interview on 04/25/13 at 1:50 p.m., S2Director of Nursing indicated she audited charts but had no specific audit focused on medication administration. She further indicated that she relied on the nursing staff to self-report medication errors.

In a face-to-face interview on 04/25/13 at 3:50 p.m., S12Radiology Supervisor and QA Coordinator indicated the hospital did not develop a system for identifying medication errors other than self-reporting by the nurse. She confirmed that medication error monitoring for all medication errors was an opportunity identified during the hospital's annual QA evaluation.