HospitalInspections.org

Based on record review and interview, the hospital's governing body failed to ensure the appointment and re-appointment of members of the medical staff for the hospital's offsite location in accordance with the medical staff bylaws. This deficient practice is evidenced by failure to approve appointments for S9Physician, and S10Physician.

Findings:

Review of the Medical Staff By-Laws, approved by S4MD dated 01/16/2023, revealed in part: Article VI, Medical Staff Section 1. Medical Staff: There shall be established within the Hospital a Medical Staff, which shall consist of all physicians and Allied Health Professionals who have been granted the right to exercise Clinical Privileges within the hospital.

Review of the Governing Board Meeting minutes for January 11, 2023, March 08, 2023, and July 12, 2023 revealed no appointments for S9Physician, and S10Physician to the medical staff for the hospital.

In an interview on 07/26/2023 at 11:40 a.m. with S1CEO confirmed there was no documentation in the Governing Body minutes for the above dates to appoint S9Physician and S10Physician to the hospital staff.

Based on observations and interviews, the hospital failed to ensure that patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients for ligature risks.

Findings:

Observations were conducted on 07/24/2023 - 07/26/2023 of the main campus in Jennings. The following were identified as ligature risks:

8 out of 10 patient room bathrooms had a toilet seat that was capable of being raised creating anchoring points at the hinge. These toilets were in rooms A, B, C, D, E, F, G, and H.

18 out of 20 total patient beds were hospital-style non-electronic beds with numerous anchoring points. These beds were in rooms A, B, C, D, E, F, G, H, and J.

2 out of 20 total patient beds were sleigh bed type which had an opening from the bottom of the bed to the floor making the bed an anchoring point. These beds were in room I.

In an interview on 07/26/2023 at 8:25 a.m. S3ADON verified 8 out of 10 patient room bathrooms had a toilet seat that was capable of being raised creating anchor points at the hinge.

In an interview on 07/25/2023 at 1:13 p.m. S2DON verified there were 18 hospital-style non-electronic beds with numerous anchoring points and 2 sleigh beds which had an opening from the bottom of the bed to the floor making the bed an anchoring point.

Observation was conducted on 07/25/2023 at 8:17 a.m. - 9:05 a.m. of the offsite in Crowley. The following were identified as ligature risks:

8 out of 8 patient room bathrooms had a toilet seat that was capable of being raised creating anchoring points at the hinge.

Room N had a gap between the toilet and the wall making the toilet an anchoring point.

12 of 14 total patient beds were sleigh bed type which had an opening from the bottom of the bed to the floor making the bed an anchoring point. These beds were in rooms M, N, O, P, Q, and R.

In an interview on 07/25/2023 at 8:17 a.m. - 9:05 a.m. S8CC verified all patient room bathrooms had a toilet seat that was capable of being raised creating anchor points at the hinge. S8CC also verified there was a gap between the toilet and wall in room N.

In an interview on 07/25/2023 at 2:04 p.m. S2DON verified there were 12 sleigh beds which had an opening from the bottom of the bed to the floor making the bed an anchoring point.

Based on record review and interview, the hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) Program specified the method and frequency of data collection for indicators as evidenced by:

1. failing to include data was collected and incorporated from offsite location to be included in the hospitals Quality Assessment Performance Improvement (QAPI) Program.

2. failing to ensure data collected by the pharmacy for medication overrides in the hospital was included in the hospitals Quality Assessment Performance Improvement (QAPI) Program.

Findings:

Review of the hospital policy titled "Performance Improvement Committee, dated july 2012, revealed in part: Purpose- It is the responsibility of the hospital to provide quality care in an environment where patient safety is of the utmost importance. Responsibilities- a. Ensure processes and activities (those that affect outcomes, patient safety, and/or organizational functions most significantly) within the hospital are measured, assessed, and improved systematically.

1. Failing to include data was collected and incorporated from offsite location to be included in the hospitals Quality Assessment Performance Improvement (QAPI) Program.

Review of the Quality Assessment Performance Improvement data given to surveyor revealed dates from January to July 2023 failed to include data from the offsite location to reflect outcomes and measurements for the hospitals Quality Assessment Performance Improvement (QAPI) Program.

In an interview on 07/26/2023 at 9:15 a.m. with S2DON, she stated that the offsite did their own data collection but it was not included in the hospitals Quality Assessment Performance Improvement (QAPI) Program.

2. Failing to ensure data collected by the pharmacy for medication overrides in the hospital was included in the hospitals Quality Assessment Performance Improvement (QAPI) Program.

Review of the hospital's QAPI records revealed no documented evidence of current data collection that included quality indicators for medication overrides were included in the hospitals data.

In an interview on 07/26/2023 at 11:00 a.m. S2DON confirmed medication overrides were not included in the hospital quality indicators for the QAPI plan.

Based on record review and interview, the hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) program established clear expectations of patient safety. This deficient practice was evidenced by falling to measure, analyze, and track medication overrides and implement preventive actions.

Findings:

Review of the QAPI information provided to the surveyor, revealed no information related to tracking and trending medication overrides.

Review of the Override Transaction Profile for May 2023 revealed 247 overrides, June 2023 156 overrides, and July 2023 178 overrides. There was no documentation to include data for the QAPI to measure, track, and implement corrective actions.

In an interview with S2DON on 07/26/2023 at 11:00 a.m. confirmed there was no documentation the hospital was tracking and trending medication overrides.

Based on record review and interview, the hospital's governing body failed to ensure an ongoing program for quality improvement and patient safety was defined, implemented, and maintained that included the pharmacy and medication overrides.

Findings:

Review of the QAPI information provided to the surveyor revealed no defined, implemented or maintained QAPI program for quality improvement and patient safety that include pharmacy and medication overrides.

In an interview with S2DON on 07/26/2023 at 11:00 a.m., she confirmed the hospital had no information on the current QAPI plan that included pharmacy indicators for medication overrides.

Based on record review and interview, the hospital failed to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed (review for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications).

Findings:

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

Review of the hospital policy titled, Medication Reconciliation, Policy Number 10-1.12.0, dated January 2018 revealed in part: A routine reconciliation of the patient profile maintained in the AMS unit with new orders upon data entry shall be performed by an authorized representative of Carmichael's for each patient residing at facility.

Review of the list of medication overrides (from the electronic medication dispensing system) provided by S2DON revealed for May 2023 247 overrides, June 2023 156 overrides, and July 2023 178 overrides.

Interview on 07/25/2023 at 10:20 a.m. with S2DON confirmed the overrides for each month were high but some of the overrides were due to afterhours admits and weekends. She further stated that if the hospital received an admission after 3:00 p.m. on Friday's the medications were not reviewed until the following Monday morning.

In an interview on 07/25/2023 at 1:40 p.m. with S5RpH confirmed there were numerous overrides at the hospital but due to late admissions and weekend admits the medications were not reviewed until the next morning or if on a weekend was not done until the following Monday morning.

Based on record review and interview, the hospital failed to ensure the temperature of the patients' nourishment refrigerator was monitored to ensure safety.

Findings:

Review of the hospital's policy titled "Cleaning, Disinfection and Sterilization" revealed in part, Procedures: Routine Cleaning: Refrigerator 1. All refrigerators will have thermometers to monitor temperature regulation. 2. Refrigerator temperatures are monitored daily.

Review of the patients' nourishment refrigerator temperature log revealed no documentation of the refrigerator temperatures being checked on the following dates: May 12-14, 22, 23, 26-28, 30, and 31; June 5, 6, 8-30; July 8, 9, 14-16, and 22.

In an interview on 07/25/2023 at 9:04 a.m. S8CC verified there was no documentation of the refrigerator temperatures being checked on the above stated dates.

Based on record review and interview, the hospital failed to demonstrate the staff member assigned to the infection prevention and control program was an individual qualified through education, training, experience or certification.
Findings:

Review of human resource file for S2DON assigned as the infection prevention and control professional revealed no evidence of certification or training regarding Infection Control to demonstrate competency.

In an interview on 07/26/2023 at 9:20 a.m. S2DON indicated she is the infection control coordinator for the facility. She further indicated she has not completed education online or in-person regarding infection control practices.

Based on observations and interviews the hospital failed to ensure the use of methods for preventing and controlling the transmission of infections within the hospital. The deficient practice is evidenced by:
1. Failure to ensure proper storage of clean linen and pillows;
2. Failure to disinfect patient equipment; and
3. Failure to have policies and procedures related to the proper cleaning of patient laundry washing machines.

Findings:

1. Failure to ensure proper storage of clean linen and pillows.

In an observation on 07/24/2023 at 11:23 a.m. - 12:10 p.m. of the clean linen closet at the main campus in Jennings revealed a plastic bin overfilled with patient blankets that was uncovered and 6 pillows that were not bagged or covered.

In an interview during the observation, S8CC verified the above stated findings.

In an observation of the linen storage room on 07/25/2023 at 08:30 a.m. revealed shelves of linen uncovered.

In an interview on 07/25/2023 at 8:03 a.m. S3ADON verified the uncovered shelving in the linen storage room.

In an observation on 07/25/2023 at 8:17 a.m. - 9:05 a.m. of the clean workroom at the offsite in Crowley revealed 3 pillows that were not bagged or covered.

In an interview during the observation, S8CC verified the above stated finding.

2. Failure to disinfect patient equipment.

In an observation on 07/24/2023 at 11:23 a.m. - 12:10 p.m. of the clean linen closet at the main campus in Jennings revealed a foam wedge that did not have an outside covering and could not be disinfected.

In an interview during the observation, S8CC verified the above stated findings.

3. Failure to have policies and procedures related to the proper cleaning of patient laundry washing machines.

In an observation of the patient laundry room on 07/25/2023 at 08:35 a.m. revealed no cleaning logs for the two, patient laundry washing machines. Further observation revealed no directions or procedures of how the laundry washers should be cleaned, when the laundry washers should be cleaned, or how the next staff member is aware the laundry washer has been cleaned after last use.

In an interview on 07/26/2023 at 8:25 a.m. DON indicated the facility does not have a policy and procedure regarding the handling and cleaning of the patient laundry washer. She further indicated the facility had no policy and procedure regarding the cleaning of the laundry washer, no documentation of the laundry washer being cleaned between patients, and no procedure in place to notify staff the laundry washer had been cleaned after last use.


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