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23515 HIGHWAY 190

MANDEVILLE, LA 70448

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

30984


Based on observations and interviews, the hospital failed to ensure that patients received care in a safe setting. This deficient practice was evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for acute care psychiatric patients admitted for being a danger to self or others.

Findings:

On 5/9/16 at 2:20 p.m., the following observations were made:
Esplanade II Unit
Rooms L4, L5, L6, L8, L9, L18, L31, L32 and L33: Bedroom entry door hinges separated widely enough to facilitate potential ligature risk. The beds in patient rooms were noted to be dressed with bed linens.

Decatur Unit
On 5/9/16 at 2:50 p.m., the following observations were made:
Rooms 04, 05, 06, 08, 09, 18, 31, 32 and 33: Bedroom entry door hinges separated widely enough to facilitate potential ligature risk. The beds in patient rooms were noted to be dressed with bed linens.

In an interview on 5/11/16 at 1:25 p.m. with S2DON, she confirmed patients could at times, be alone in their rooms, unobserved, for 10-15 minutes at a time depending on what type of ordered observation level they were on. She also confirmed the video monitoring system on the patient care units were not constantly manned by an assigned staff member. She indicated the video was used for retrospective review and not for continuous surveillance. S2DON verified all patient beds were dressed with linens. She agreed the 3 hinges separated widely enough to provide a potential ligature point on the patient room entry doors (on Esplanade I,II,III and Decatur Units) were a safety risk.

In an interview on 5/11/16 at 1:44 p.m. with S1Adm, he indicated the bedroom doors opening onto the hallways were considered to be a " commons " area and monitored by the staff. He confirmed the only units that did not have the 3 hinges on the patient room entry doors were Cypress and Willow (Adolescent Units) because they had been remodeled. He confirmed Esplanade Units I,II and III and Decatur Unit still had the 3 hinges on the patient room entry doors.

Esplanade I Unit
On 5/11/16 at 3:05 p.m., the following observations were made:
Rooms 4, 5, 6, 8, 9, 18, 31,32 and 33: Bedroom entry door hinges separated widely enough to facilitate potential ligature risk. The beds in patient rooms were noted to be dressed with bed linens. The above referenced findings were confirmed by S1Adm who was present during the observations. He agreed he could see how the hinges could potentially be a patient safety risk.

Esplanade III Unit
On 5/11/16 at 3:10 p.m., the following observations were made:
Rooms M4, M5, M6, M8, M9, M18, M31, M32 and M33: Bedroom entry door hinges separated widely enough to facilitate potential ligature risk. The beds in patient rooms were noted to be dressed with bed linens. The above referenced findings were confirmed by S1Adm who was present during the observations. He agreed he could see how the hinges could potentially be a patient safety risk.

QAPI GOVERNING BODY, STANDARD TAG

Tag No.: A0308

Based on record review and interview, the hospital's governing body failed to ensure the QAPI program reflected the complexity of the hospital's services as evidenced by failing to include all contracted services and outpatient services in the QAPI program. Findings:

Review of the list of the Contracted Services for the hospital revealed Laundry, Linens and Radiology were contracted services.

Review of the current quality indicators being monitored in the QAPI program revealed no documented evidence of quality indicators for the contracted services of Radiology, Laundry, Linens and Intensive Outpatient Program (IOP).

In an interview on 05/11/16 at 9:30 a.m., S20DirRisk confirmed the contracted services of Radiology, Laundry and Linens were not currently included in the QAPI monitoring. He further reported outpatient services for Intensive Outpatient Program was not included in the hospital's QAPI monitoring.

FORM AND RETENTION OF RECORDS

Tag No.: A0438

Based on observation and interview, the hospital failed to have a system in place to ensure that original medical records were stored and maintained where the medical records were protected from fire and water damage. This failed practice was evidenced by original medical records (over 1000 medical records) being stored in open double-sided metal file cabinets in the Medical Records Department with no visible means noted to protect the original medical records in the file cabinets from fire and water damage.

Findings:

An observation on 05/09/16 at 1:40 p.m. with S7HIMDir, was made of the Medical Records Department. The observation revealed over 1000 medical records were stored in multiple open filing cabinets (5 double-sided open file cabinets containing an approximate total of 240 shelves) throughout the Medical Records Department with no means to protect the medical records in the open metal file cabinets from fire and water damage.

In an interview on 05/09/16 at 2:00 p.m. with S7HIMDir she indicated that the patient medical records in the Medical Records Department were the original patient medical records and that no electronic medical record (scanning) system was in place yet at the hospital. S7HIMDir indicated that the Medical Records Department did not have a policy in place that addressed the protection of the original medical records from fire and water damage. She further indicated that the hospital did not have a system or safe guards in place that addressed the protection of the original medical records, presently stored in the open metal file cabinets in the Medical Record Department from fire and water damage. .

CONTENT OF RECORD: ORDERS DATED & SIGNED

Tag No.: A0454

Based on record review and interview, the hospital failed to ensure verbal/telephone seclusion orders were co-signed/authenticated within 24 hours, in accordance with the hospital's policy time limits for 1(#8) of 2 (#1, #8) medical records reviewed for restraints and seclusion orders. This deficient practice was evidenced by 2 seclusion initiation orders and 1 seclusion renewal order for Patient #8 not dated and timed to demonstrate the seclusion order was authenticated within the 24 hours required by hospital policy.

Findings:

Review of the Medical Staff Rules and Regulations revealed that it was the responsibility of the Medical Staff to authenticate verbal orders with timed, dated, and legible signatures.


Review of hospital policy #TX.7-0102, titled "Restraint/Seclusion, (effective date 1/2/13 , last revision 4/22/15), provided by S1Adm as current, revealed the following, in part: "...E. Initiation of R/S, 4. In an emergency, the Nursing Supervisor/Charge Nurse: a. May initiate a seclusion/restraint as a protective measure provided that a physician order is obtained as soon as possible, but no longer than 1 hour after the initiation of the seclusion/restraint; telephone order must be co-signed within 24 hours..."


Patient #8
Review of the medical record for Patient #8 revealed a manual hold was used on her 3/25/16 11:35 a.m.-11:48 a.m. when Patient #8 became physically and verbally aggressive towards staff, and was then placed in locked seclusion 11:49 a.m.- 1:05 p.m. Further review revealed a telephone order from S13MD ,taken by S14RN, 3/25/16 at 12:48 p.m. The order was authenticated with the signature of S12APRN with no date or time documented. Review of a Seclusion/Restraint Order 3/25/16 revealed a manual hold was used at 3:05 p.m. - 3:11 p.m., then Seclusion was implemented at 3:11 p.m. with no discontinuation documented. A telephone order from S13MD was documented at 3:28 p.m. by S14RN at 3:28 p.m. Further review of the order revealed the telephone order was authenticated by S12APRN with no date and time documented with her signature. Review of a Restraint/Seclusion renewal order 3/25/16 at 5:11 p.m. revealed the order was a telephone order from S15MD, taken by S14RN 3/25/16 at 5:15 p.m. Further review of the order revealed the order was authenticated by S12APRN with no date or time documented with her signature.

In an interview 5/11/16 S4QualityMgt. and S2DON, after review of the 3 restraint and seclusion orders for Patient #8 dated 3/25/16, verified that the authenticating practitioner's signature was that of S12APRN on all 3 orders. S4QualityMgt. and S2DON confirmed that it could not be determined that the orders were cosigned within 24 hours because there was no date and time of S12APRN's signature, as was required by the hospital policy. S4QualityMgt. and S2DON verified that all signatures by medical staff should be dated and timed.

PHARMACY: REPORTING ADVERSE EVENTS

Tag No.: A0508

Based on record review and interview, the hospital failed to ensure errors in medication administration were documented in the medical record for 2 (Patient #1 and Patient #R2) of 3 patients (Patient #1, Patient #R1, and Patient #R2) reviewed for known medication errors out of a sample of 11 patients. Findings:

Review of the hospital's policy titled, Medication Errors, Policy #: Tx.3-1100, revealed in part, C. Patient Record Documentation: The RN will write a progress note entry to document the medication event (do not state "medication error"), assessment/monitoring of the patient, and notification of physician and supervisor.

Review of the Medication Error Report revealed documentation of Medication Errors for Patient #1 and Patient #R2. Further review of the Medication Error Report revealed Patient #1 was not administered Klonopin 1 mg po TID on 2/27/16 and 2/28/16 and Patient #R2 was not administered Medtronidazole 500 mg po BID on 1/8/16.

Review of the Patient #1 and Patient #R2 medical record revealed no documentation in the patient's medical record of the medication errors.

An interview was conducted with S6RNMgr on 5/10/16 at 2:00 p.m. She reported after review of Patient #1's and Patient #R2 medical records, there was no documentation in the medical records of the medications errors.

RADIOLOGIC SERVICES

Tag No.: A0528

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

1) The hospital failed to develop Radiology policies and procedures that included; safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital. (see A-0535)

2) The hospital failed to ensure there was a Radiologist appointed by the Governing Body to supervise the Radiology Services on either a full-time, part-time, or consulting basis as evidenced by no documentation of a Director of Radiology for the hospital. (see A-0546)

SAFETY POLICY AND PROCEDURES

Tag No.: A0535

Based on record reviews and interview, the hospital failed to develop Radiology policies and procedures that included; safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital.

Findings:

A review of the contracts provided by S1Adm revealed the hospital had a contract with a mobile medical radiology service to provide mobile radiology services for patients.

A review of the hospital's Policy and Procedure Manuals provided by S1Adm, as the most current, revealed no documented evidence of any policies and procedures related to radiology services.

In an interview on 05/11/16 at 8:30 a.m. with S1Adm he was asked if the hospital had any Radiology policies and procedures that included; policies addressing safety precautions against radiation hazards for staff and patients when radiological services were performed on patients in the hospital. S1Adm indicated that the hospital had a contract for Radiology Services and that the hospital had no Radiology policies and procedures in place that related to radiology services or to the safety precautions against radiation hazards for staff and patients during radiology procedures. S1Adm further indicated that the hospital had no Radiology policies and procedures at all.

RADIOLOGIST RESPONSIBILITIES

Tag No.: A0546

Based on record reviews and interview the hospital failed to ensure there was a Radiologist appointed by the Governing Body to supervise the Radiology Services on either a full-time, part-time, or consulting basis as evidenced by no documentation of a Director of Radiology for the hospital.

Findings:

A review of the hospital's organizational chart, provided by S1Adm as a current organizational chart, revealed no documentation of a Radiologist as the Director of Radiology for the hospital.
A review of the list of credentialed physicians on the hospital's Medical Staff, provided by S1Adm as a current list, revealed no documented evidence that a Radiologist was identified as the Director of Radiology.

A review of the Governing Body meeting minutes revealed no documentation that the Governing Body had appointed a Radiologist as the Director of Radiology for the hospital.
A review of the contracts, provided by S1Adm, revealed the hospital had a contract with a mobile medical company to provide radiology services.

In an interview on 05/11/16 at 8:30 a.m. with S1Adm he was asked for documentation of the appointment of a Director of Radiology for the hospital. S1Adm indicated that the hospital had a contract with a mobile medical company to provide radiology services and that the mobile medical company had radiologists who were credentialed by the hospital. S1Adm indicated that the hospital's Governing Body had not appointed any of these credentialed Radiologists as the hospital's Director of Radiology. S1Adm further indicated that the hospital's Governing Body had not appointed any Radiologist as Director of Radiology Services to supervise the radiology services for the hospital.

INFECTION CONTROL PROFESSIONAL

Tag No.: A0748

Based on record review and interview, the hospital failed to ensure that the designated Infection Control Officer was qualified through experience, ongoing education and/or training to be responsible for the development and implementation of the hospital's Infection Control Program.
Findings:
A review of the Infection Control Officer's employee file (S8ICRN) revealed that S8ICRN was designated as the Infection Control Officer in January 2016. S8ICRN's infection control training/experience and/or qualifications, as noted in her employee file included in part: a prior infection control position in 2009 for one year and a 3 day CDC (Centers for Disease Control and Prevention) course in 2009. A further review of S8ICRN's employee file revealed no further documented evidence of any other infection control training/experience since 2009 or any current infection control training/experience since she was appointed the Infection Control Officer in January 2016.
In an interview on 05/11/16 at 11:30 a.m. with S8ICRN she indicated that she was the designated Infection Control Officer for the hospital. S8ICRN indicated that she had no further infection control training to present and had no prior experience in infection control other then the prior infection control position in 2009 for one year and the 3 day CDC (Centers for Disease Control and Prevention) course in 2009. S8ICRN further indicated that her prior job experiences after 2009 were in Home Health.

INFECTION CONTROL PROGRAM

Tag No.: A0749

Based on record review, observation, and interview, the hospital failed to ensure the infection control officer developed a system for controlling infections and communicable diseases of patients. This deficient practice is evidenced by:

1) failing to follow up, in a timely manner, on an Office of Public Health Investigator ' s letter requesting immediate contact relative to an important health matter for an inpatient (#2) for 1 of 11 current inpatients reviewed.
2) failing to ensure a sanitary environment was maintained to avoid sources and transmission of infections and communicable diseases as evidenced by an unclean environment and unclean crash cart.

3) failing to ensure a medication vial was dated when it was opened or when it would expire.

4) failing to ensure food was not stored in a refrigerator/freezer designated for medications.

Findings:

1) Failing to follow up, in a timely manner, on an Office of Public Health Investigator ' s letter requesting immediate contact relative to an important health matter for an inpatient (#2).

Review of the Office of Public Health website revealed the following information describing the function of the Disease Investigations Section : The Disease Investigations Section (DIS) conducts investigations of and develops prevention and control guidelines for general communicable diseases of public importance. The major categories of conditions followed by DIS include: a) foodborne illnesses b) respiratory diseases c) waterborne diseases and d) emerging infectious diseases. DIS is organized with the Infectious Diseases Branch of the Division of Communicable Disease Control. DIS provides the following services: leads multijurisdictional investigations of disease outbreaks; consultation and assistance to local health departments and state partners regarding the investigation and control of infections and outbreaks of public importance; consultation to local health jurisdictions regarding public health mandates to prevent and control communicable diseases; and produces evidence based guidelines to prevent infections and control outbreaks.

Review of Patient #2 ' s medical record revealed an admission date of 5/6/16 with an admission diagnosis of Psychosis.
Further review revealed a notification letter from the Louisiana Department of Health and Hospitals, Office of Public Health, Disease Investigations Section, instructing Patient #2 to immediately contact the Disease Investigation Specialist/Health Services Representative (contact number provided in letter) regarding an important health matter. The letter further indicated the matter concerned Patient #2 ' s personal health and required immediate attention. Additional review revealed the letter contained no specific information indicating the disease process/health matter that required imediate attention.The letter did not have a date or time. The letter head had the current Governor ' s name and the current MD Director of Louisiana Department of Health and Hospitals.

Additional review of Patient #2 ' s entire medical record (from admission on 5/6/16-5/9/16) revealed no documented evidence of follow-up by the hospital staff, on the Office of Public Health letter, as of 5/9/16 at 2:55 p.m.

In an interview on 5/9/16 at 3:00 p.m. with S5MD she indicated she was just rounding on Patient #2 for the first time. S5MD indicated she had not seen the letter from Office of Public Health on Patient #2 ' s chart. S5MD further indicated she was not sure what the letter from Office of Public Health was in reference to. S5MD questioned why the Office of Public Health would have sent out that type of letter to the patient and was unsure of the possible health issues it could be referencing.

In an interview on 5/9/16 at 3:05 p.m. with S3RN, charge nurse of Patient#2 ' s unit, he indicated he had not seen the letter from Office of Public Health on Patient #2 ' s chart and asked where the surveyor had " found the letter " . He further indicated he did not know whether any follow up had been done regarding the letter.

In an interview on 5/10/16 at 1:15 p.m. with S2DON, she indicated the admissions nurse should have passed on the information about the letter from Office of Public Health to the receiving unit if the letter was in the patient ' s admission packet. She further indicated the unit nurse should have also " picked up on the letter " and passed the information on to the patient ' s physician. S2DON indicated S8ICRN (Infection Control Nurse) should have been notified about the letter in Patient #2 ' s medical record and she confirmed S8ICRN had not been informed prior to being told about it by S2DON on 5/9/16.

In an interview on 5/10/16 at 2:20 p.m. with S5MD she indicated S9PH (Public Health Investigator) told her she had been trying to get in touch with Patient #2 since 4/28/16 due to a positive RPR result of 1:64 Dilutions. She said she had been unable to find him and had sent letters to his house. S5MD indicated Patient #2 ' s mother had sent the letters with him when he went to an area hospital for evaluation and treatment prior to his admission to this hospital. S5MD indicated Patient #2 ' s mother had brought the Office of Public Health letter to this hospital, as well, on 5/8/16. S5MD indicated when she had been asked about the Office of Public Health letter (on Patient #2 ' s chart) on 5/9/16 at 3:00 p.m. that was the first she had heard about the letter. S5MD also indicated Patient #2 had been admitted to this hospital due to exhibiting symptoms of being off balance and staring off into space. S5MD explained Patient #2 had no psychiatric history prior to 4 months ago. She said he was exhibiting signs of early Dementia and his eyes were not reactive to light. S5MD indicated Patient #2 ' s symptoms were suggestive of Neurosyphilis.

In an interview on 5/10/16 at 3:14 p.m. with S2DON, she indicated Patient #2 was being admitted to an area hospital for treatment of the positive RPR result of 1:64 Dilutions. S2DON indicated the hospital had done an extensive workup and a brain scan on Patient #2. She further indicated the patient was being seen by an infectious disease specialist.

In an interview on 5/11/16 at 10:45 a.m. with S8ICRN, she indicated that the RN should have completed the Infection Control Report form, according to hospital protocol, regarding the patient with the letter from OPH (Office of Public Health). She indicated that all completed Infection Control Report forms should be sent to the Infection Control Officer (S8ICRN) for review and follow-up as needed.

In an interview on 5/11/16 at 12:07 p.m. with S8ICRN, she indicated as of 5/9/16 she had not been notified of Patient #2 ' s letter from Office of Public Health regarding an Infectious Disease Investigator attempting to contact Patient #2 regarding a health issue. S8ICRN indicated S2DON had told her about the letter after surveyors had inquired about the letter on 5/9/16. S8ICRN indicated if she had been notified of the letter she would have followed up with S9PH, would have notified the patient ' s MD, and the nursing supervisor. She indicated she would have documented her actions in the patient ' s record and she would have also retained documentation in her infection control records as well.

In an interview on 5/11/16 at 2:12 p.m. with S17RN, she indicated she wanted to clarify that Patient #2 had given her the letter from Office of Public Health on Sunday (5/8/16). S17RN indicated she immediately knew the letter from the Office of Public Health was probably related to a disease process that could be transmitted. S17RN said the patient had told her he needed to leave immediately. S17RN indicated she had explained to Patient #2 that the Public Health Office was closed until Monday (5/9/16) and they would take care of it then. S17RN indicated she had made 3 copies of the letter: one for nursing, one for the MD and the original was given back to the patient. S17RN said she had told S3RN about the letter. She indicated the infection control nurse should also have been notified about the letter.


2) Failing to ensure a sanitary environment was maintained.

An observation was conducted on 5/09/16 at 2:55 p.m. of the crash cart on Esplanade II building. The crash cart had a thick layer of dust on the top of the crash cart and on the suction machine located on the side of the crash cart. S3RN and S4Quality Mgt confirmed the observation.

An observation was conducted on 5/09/16 at 3:00 p.m. of rooms 8 and 9 in the Decatur building. A thick layer of dust was observed on the windowsills and shelving in the rooms. The observations were confirmed by S1Adm.

3) Failing to ensure medication multi use vial was dated when it was opened or when it was to expire.

Review of the hospital's policy titled, Medication Administration, Policy #NS-5048, revealed in part, All opened medication containers including oral liquids, injectables, topicals, ophthalmics, otics, and inhalers must have the calculated beyond use expiration date indicated on the primary container. The nurse opening a multi use container is responsible for calculating and recording the beyond use expiration date.

An observation was conducted on 5/09/16 at 3:00 p.m. in the Decatur wing Pharmacy's refrigerator of a vial of mult use ppd (purified protein derivative) not labeled with the date of when the vial was opened or when the vial would expire.

An interview was conducted with S19LPN on 5/09/16 at 3:00 p.m. She confirmed the vial was opened and not dated with an open date or an expiration date on the vial or the vial's box.

4) Failing to ensure food was not stored in a refrigerator/freezer designated for medications.

An observation was conducted on 5/09/16 at 2:00 p.m. of a bottle of coke in the freezer section of the refrigerator in Esplanade II's pharmacy.

An interview was conducted with S18LPN on 5/09/16 at 2:00 p.m. She reported the refrigerator/freezer in the pharmacy was designated for medications only. She further reported the bottle of coke should not be in the refrigerator with medications.



30172

DIRECTOR OF RESPIRATORY SERVICES

Tag No.: A1153

Based on record reviews and interviews, the hospital failed to ensure a physician was appointed as the Medical Director of the hospital's Respiratory Care services. This deficient practice was evidenced by failure of the hospital's Governing Body to appoint a physician to serve as Medical Director of the hospital's Respiratory Care services.

Findings:
A review of the hospital's organizational chart, as provided by S1Adm as the current organizational chart, revealed no documented evidence of a physician appointed to serve as the Medical Director of the hospital's Respiratory Care services.

A review of the hospital's Governing Body meeting minutes revealed no documented evidence that a Medical Director had been appointed to serve as the Director of the hospital's Respiratory Care services.

In an interview on 05/10/16 at 2:30 p.m. with S2DON, she indicated the hospital's nursing staff provided respiratory care services to patients, as ordered by a physician, to include: nebulizer administration, inhaler administration, and oxygen treatments.

In an interview on 05/11/16 at 8:30 a.m. with S1Adm he indicated that the hospital's Governing Body had not appointed a physician to serve as Medical Director of the hospital's Respiratory Care services.