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Based on interview and record review, the hospital failed to ensure the dispensation and administration of drugs and biologicals was implemented in accordance with accepted professional principles, hospital policy and the Louisiana State Board of Pharmacy as evidenced by failing to ensure its policies and procedures and hospital practice for dispensing and administering medications and biologicals followed the requirements of the Louisiana Board of Pharmacy regarding the pharmacist's review of medication orders prior to the first dose being administered except in emergencies. The hospital policies and practice allowed medications to be administered prior to the pharmacist's review when the pharmacy was closed. Findings:

Review of the "Louisiana Administrative Code Title 46 - Professional and Occupational Standards Part LIII: Pharmacists Chapter 15. Hospital Pharmacy" revealed that the pharmacist shall review the practitioner's medical order prior to dispensing the initial dose of medication, except in cases of emergency.

Review of the hospital policy # 11-10 titled "Pharmacist Review of Orders" dated 02/26/14 revealed in part: A pharmacist shall review the prescriber's original order before the initial dose is dispensed or removed from floor stock or from an automated dispensing cabinet, except in cases of emergency...First dose medications from traditional floor stock or from automated distribution units on nursing units will be obtained only in situations in which the patient would be harmed or their clinical care compromised if they did not receive the medication before a pharmacist is available. For example, these should be used only for stat orders and when the clinical need of the patient demands immediate administration of the medication...If a medication is obtained prior to pharmacist review, a second licensed individual authorized to administer medications will provide a double-check of the order and the medication retrieved.

On 09/12/17 at 10:30AM, an interview with S4 Pharmacist revealed the pharmacy is open daily from 8:00 a.m. until 4:30 p.m. The two staff pharmacists share on-call duties after hours and utilize a remote processing system from their homes to review patient records and conduct first dose reviews for new orders. She stated that it was her understanding that both stat orders and one-time dose orders were not subject to first dose review. She further stated that the system does allow for an override by the nurses prior to first dose review. When asked if the nurses ever override the system and administer medication prior to the first dose review by the pharmacist, she confirmed that this has happened on occasion, stating most of the time she is notified, but some nurses have administered medications without notifying her. S4 Pharmacist was unable to produce an override log for review.

Based on record review and interview, the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care of each patient as evidenced by failing to continuously monitor 5 of 5 patients who had orders for telemetry monitoring in a total sample of 23 (Patient #8, 11, 17, R1, R2).
Findings:

Review of the hospital policy and procedure titled, Telemetry (review date 02/27/17), revealed in part that telemetry monitoring is continuous until discontinued by a physician order. It is the primary nurse's responsibility to immediately check the patient and maintain a clear telemetry pattern at all times.

On 09/12/17 at 10:15 a.m., observation revealed no staff was in the nursing station. Further observations in the nursing station revealed cardiac telemetry monitors were in the station with two patients being monitored (Patient #8 and #11).

On 09/13/17 at 8:50 a.m., observation revealed no staff was in the nursing station. Further observations in the nursing station revealed cardiac telemetry monitors were in the station with three patients being monitored (Patient #17, R1 and R2).

On 09/13/17 at 9:10 a.m., interview with S5RN revealed a staff member should be sitting at the nurses station at all times to monitor the patients on continuous telemetry monitoring. She further stated that this does not occur at all times, but stated that she knew that her patients were "stable". S5RN further confirmed the above patients had orders for continuous telemetry monitoring.

Based on record review and interview, the CAH failed to ensure nursing care plans were developed and kept current for each inpatient for 7 (#1, #11, #15, #16, #17, #18, #20) of 10 patients reviewed for care planning.

Findings:

Review of the CAH policy titled Plan of Care, revised 02/27/17 revealed in part: The plan of care shall be individualized, based on the diagnosis and patient assessment. The plan of care shall address the learning needs of the patient and/or family. All nursing staff using the plan of care is responsible for interdisciplinary collaboration to establish goals and appropriate interventions, as well as ongoing evaluations and revisions.

Patient #1
Review of the medical record for patient #1 revealed the patient was admitted to the hospital on 08/16/17 with a diagnosis of Dehydration, ARF, HTN, Anorexia, Arthritis, GERD, Hypothyroidism, and Debility. Further review revealed physician order dated 08/16/17 for Foley catheter. Initial nursing assessment completed on 08/16/17 did not include care plan goals for the Foley catheter, and did not address goals or interventions for all admitting diagnosis.

Patient #11
Review of the medical record for patient #11 revealed the patient was admitted to acute care for Chest Pain, and Irregular Heartbeat. Further review of admission orders dated 09/11/17 revealed physician ordered telemetry monitor. Initial nursing assessment dated 09/11/17 did not address any care plan goals or interventions for cardiac and did not include telemetry monitoring.

Patient #15
Review of the medical record for patient #15 revealed the patient was admitted to the hospital on 06/28/17 with diagnosis of CHF, UTI, HTN, DM, OA, CAD, and Debility. Initial nursing assessment completed on 06/28/17 did not address care plan goals and interventions for all admitting diagnosis to include DM.

Patient #16
Review of the medical record for patient #16 revealed the patient was admitted to the hospital on 06/22/17 with diagnosis of Pancreatitis, HTN, CAD, DVT, DM, and GERD. Initial nursing assessment completed on 06/28/17 did not address care plan goals and interventions for all admitting diagnosis to include DM.

Patient #17
Review of the medical record for patient #17 revealed the patient was admitted to the hospital on 07/17/17 with diagnosis of Cellulitis, Sleep Apnea, HTN, DM, Obesity, and Stasis ulcers. Initial nursing assessment completed on 07/17/17 did not address care plan goals and interventions for all admitting diagnosis to include DM.

Patient #18
Review of the medical record for patient #18 revealed the patient was admitted to the hospital on 06/06/17 with diagnosis of Pneumonia, Anemia, DM, OA, HTN, GERD, Anxiety, and Pain. Initial nursing assessment completed on 06/06/17 did not address care plan goals and interventions for all admitting diagnosis to include DM.

Patient #20
Review of the medical record for patient #20 revealed the patient was admitted to the hospital on 06/03/17 with diagnosis of Hypo-magnesium, DM, Fecal Impaction, GI, and HTN. Initial nursing assessment completed on 06/03/17 did not address care plan goals and interventions for all admitting diagnosis to include DM.

In an interview on 09/12/17 at 2:40 p.m. with S2DON, he verified that care plans should have included all of the patients' problems and had interventions for the problems.