HospitalInspections.org

Based on record review and interviews, the hospital failed to implement its grievance process to ensure patient grievances were resolved promptly for 3 of 3 patient grievances reviewed from a total of 27 complaints listed on the log from 05/02/11 through 07/19/11 (S2, S7, R1). Findings:

Review of the log presented by Director of Quality Services and Infection Control S2 when the grievance log was requested revealed 27 complaints were listed. Further review revealed none of the 27 listed were determined to be a grievance.

Patient #2
Review of the "Case Review" ( the form "used by Quality Management personnel to document the complaint/resolution process") revealed the following:
Date & (and) Time Received - 06/17/11; no documented evidence of the time;
Date of Service - 06/13/11;
Unit / Rm # (room number) - room "g";
Patient - Patient #2;
Informant / Relation to Patient - Self;
(Narrative) - "Patient #2 called in with complaint, stating her stay at Teche was horrible. Starting from ER (emergency room): (1) dry blood on bars, nurse apologize and wiped off. MS (med/surg): room "g", this room was nasty also, tray in room was had food on it, nasty and sticky, ask nurse for wipes, and gloves so she could clean room and bathroom It took her (2) hours to clean room and everything she needed to touch. She also states there were boogers on night stand. Blood stains on surface of walls. Even food tray from dietary was fifty. "It was a nightmare from hell how disgusting hospital was and is". ... Former Director of Housekeeping S14 spoke with Patient #2, and he advised the room would be shut down for cleaning....". Initials of Patient Advocate S6.
Initial Investigation / Review findings: " Patient remained dissatisfied throughout stay with cleanliness and or ability to clean. Multiple attempts were made to satisfy requests with no change in her perception. In an effort not to exasperate situation after, Former Director of Housekeeping S14, housekeeping manager spoke with patient and due to her increased agitation regarding cleanliness staff provided patient with any request for additional towels and gloves. Patient had wiped all fixtures, furniture, and walls and appeared to be more content". Signed by Director of Med/Surg S9.

There was no documented evidence of an investigation, that the complaint received after the patient was no longer in the facility had been forwarded to the Director of Quality Management as per hospital policy, the resolution of the grievance, and contact with Patient #2 regarding the outcome of the investigation and resolution.

Review of an e-mail sent by Director of Med/Surg S9 to Patient Advocate S6 on 07/25/11 at 2:51pm revealed the follow up to the case review for Patient #2 was completed.

In a telephone interview on 07/27/11 at 8:55am, RN (registered nurse) S4 indicated Patient #2 had complained to the registration clerk in the E.D. about dried blood on the stretcher siderail. S4 further indicated she apologized to Patient #2 and cleaned the siderail of the dried blood that was present. S4 indicated Patient #2 seemed satisfied and offered no further complaints. S4 confirmed that she did not report this occurrence to anyone and did not notify housekeeping of her findings.

In a face-to-face interview on 07/27/11 at 9:30am, Patient Advocate S6 indicated she received a phone call from Patient #2 while she (#2) was still an inpatient on 06/13/11. S6 indicated Patient #2 complained of the terrible experience she had starting with the E.D. and continuing in room "g". S6 indicated Patient #2 complained of the food tray and said that she had asked the nurse to get her some wipes and gloves. S6 indicated Patient #2 said the nurse offered to clean the area, but she (#2) wanted to do it herself. Patient Advocate S6 indicated she notified former Director of Housekeeping S14, former Assistant Manager of Housekeeping S18, and Director of Med/Surg S9 of Patient #2's complaints. S6 indicated former Director of Housekeeping S14 spoke with Patient #2, but he didn't give S6 any documentation of the meeting. S6 indicated S14 and S18 were no longer employed at the hospital. S6 indicated Patient #2 called her back after she had been discharged on 06/17/11. S6 indicated she completed the case review and sent it to Director of Med/Surg S9 to handle. S6 indicated she would consider Patient #2's initial complaints a grievance. S6 confirmed there was no investigation documented, and she had not had any contact Patient #2 since the phone call on 06/17/11. S6 further confirmed there had been no written response regarding the grievance investigation and resolution sent to Patient #2. Patient Advocate S6 indicated she was not knowledgeable of the federal regulations regarding the submission and investigation of a grievance. S6 further indicated she had been delegated the grievance process by the CEO (chief executive officer) and had on-the-job training provided by her predecessor and DON (director of nursing) S10.

In a face-to-face interview on 07/27/11 at 11:05am, Director of Med/Surg S9 indicated the response written by her on the case review was not based on a conversation with Patient #2. S9 indicated she had no interaction with Patient #2 while she was an inpatient or after her discharge.

Patient #7
Review of Patient #7's "Case Review" revealed Patient #7 was admitted on 07/14/11, and his power of attorney issued a complaint on 07/15/11. Further review revealed the complaint was that Patient #7 began having difficulty breathing while in ICU (intensive care unit), and he yelled out for assistance. Further review revealed Patient #7 was ignored by the nurse sitting in the station. Further review revealed Patient #7 had not received his HIV (human immunodeficiency virus) medications the previous night or the morning of this complaint on 07/15/11. Further review revealed Patient Advocate S6 forwarded the complaint to Director of Critical Care S3. Documentation by S3 revealed he spoke with Patient #7's power of attorney on 07/21/11 at 10:00am at which time "everything is great and that we have wonderful people here and that he is very satisfied with service...". There was no documented evidence of an investigation of the complaints.

In a face-to-face interview on 07/26/11 at 3:30pm with Patient #2 and his power of attorney, Patient #2 indicated he was having trouble breathing, and the staff ignored him. Patient #2 further indicated he pressed the button for assistance, and he could see the nurses at the station from his room, but he couldn't get anyone to come into the room. By the conclusion of the interview, both Patient #2 and his power of attorney indicated that they had spoken with the physician and were now satisfied and didn't consider this a grievance.

In a face-to-face interview on 07/27/11 at 9:30am, Patient Advocate S6 indicated Patient #7's power of attorney came to her office to make the complaint about ICU. S6 further indicated she went to meet with the patient after she listened to the report from the power of attorney. S6 indicated Patient #7 complained that he had trouble breathing, and the nurse ignored him. Patient #7 indicated he thought he was treated that way because he was HIV positive. S6 confirmed she did not document her discussion with Patient #7.

In a face-to-face interview on 07/27/11 at 11:20am, Director of Critical Care S3 indicated he had spoken with the nurse who provided care for Patient #2 on the night of 06/14/11. S3 further indicated the nurse told him every time Patient #2 called out, he (the nurse) would tell him he was fine, but Patient #2 didn't like that answer. When asked by the surveyor if the nurse went to the bedside to assess Patient #2 or just answered him from the nursing station, S3 indicated he didn't know. S3 indicated he didn't ask the nurse if he went to Patient #2's bedside at these times. When asked by the surveyor about the length of time between the complaint being made and S3's investigation, S3 indicated he had 10 days to respond. He could offer no explanation regarding how he could determine if a complaint was actually a grievance if he didn't respond immediately to attempt to correct it.

Patient R1
Review of Patient R1's "Case Review" revealed she was a patient on 04/29/11 and 04/30/11. Further review revealed Patient Advocate S6 received a call on 05/09/11 stating that she was admitted for an allergic reaction to medications, and while at the hospital a nurse who provided care for her was telling her information to another person in the hospital. Further review revealed Patient R1 provided a description of the nurse, five feet four inches with dark brown hair and medium build, but she didn't know her name.

Review of the "Initial Investigation / Review findings" documented by Director of Med/Surg S9 revealed, in part, "Spoke with Patient R1, she states she cannot identify the nurse and the party who allegedly was given the information is unwilling to come forward with any info. I assured her that all staff are educated annually on HIPPA policy and would re-educate based on her concerns. ... told Patient R1 should she be able to provide any other identifying specific info to please call back...". Further review revealed no documented evidence of an investigation to attempt to determine if this had actually happened.

In a face-to-face interview on 07/27/11 at 9:30am with Patient Advocate S6 and Director of Quality Services and Infection Control S2 present, S6 indicated she forwarded the information to Director of Med/Surg S9 after she received the call. S6 further indicated she considered the investigation complete, because S9 had returned the resolution to her. S2 indicated she would consider a breach of confidentiality a quality of care issue which according to policy should have been sent to her. S2 could not remember receiving this complaint. Patient Advocate S9 confirmed there was no documented evidence that an investigation had been done, and a written response had not been sent to Patient R1.

Review of the hospital policy titled "Patient Grievance Reporting, Resolution, and Tracking/Trending", effective 08/19/09 and submitted by Director of Quality Services and Infection Control S2 as their current policy for grievances, revealed, in part, "...Definition Concern / Complaint - These terms can be used interchangeably to refer to an issue raised by a patient or family member. Patient Grievance - A formal, written or verbal grievance that is filed by a patient, when a patient issue (complaint or concern) cannot be resolved promptly by staff present. ...B. Patient Complaint / Concern Resolution Process ... 2. Upon receipt, the Patient Representative shall confer with the appropriate department manager to review, investigate and follow-up (except for those anonymously reported) with the patient or family verbally within 10 working days of receipt of the complaint with the exception of complaints that endanger the patient (i.e. abuse or neglect)-- these shall be addressed immediately. 3. Complaints regarding quality of care are reported to Director of Quality Management. ... 4. Every effort will be made to resolve the complaint at the lowest level possible. It is the responsibility of each staff member to respond promptly to any complaint voiced by patients and their families. The staff member receiving the complaint will notify his/her supervisor when the issue cannot be immediately resolved. ... 5. Each patient and/or family member making a complaint will receive a response from the facility staff that addresses the complaint in a timely manner. ... 8. The complaint and problem resolution / follow up will be documented. This documentation will include: Name of person voicing a complaint/how to contact; Patient name; Nature of Complaint; Date of service; Pertinent Investigational Information; Resolution of Complaint/Follow Up; Signature of Staff Person addressing complaint; Attached to this policy is ... a "Case Review form" ... that will be used by Quality Management personnel to document the complaint/resolution process. 9. This documentation will be forwarded to the Director of Quality Management or designated staff member for review. ... 11. Any complaint received after a patient is no longer in the facility's system will be documented by the staff member receiving the complaint and forwarded to the Director of Quality Management who will ensure that the appropriate staff follows up on the complaint consistent with the procedures above. ... C. Grievance Reporting / Resolution Process ... 4. The Patient Representative will contact the complainant and provide information regarding the steps taken on behalf of the patient to investigate the grievance and access to the following persons to facilitate resolution of the complaint: Patient Representative; ... Director of Human Resources; CEO (chief executive officer). 5. Subsequent contact by the Patient Representative with the patient or family who has filed a grievance will be documented... 7. Each person filing a formal grievance will be sent a written response identifying the results of the grievance process and the date of completion in language understandable to the patient or family. ... E. Patient Representative Function Description ... 2. Scope of Service: The Patient Representative will investigate all complaints received from patients, guardians or family members as appropriate. 3. Responsibilities: ... Investigates complaints within 24 hours of notification and assists in providing resolution of the issue utilizing facility resources; Provides feedback to the individual presenting the complaint. Is knowledgeable about patient rights...".

Based on record review and interview, the hospital failed to ensure its grievance policy addressed all components required in the written notice sent to patients by failure to include the hospital contact person and the steps taken to investigate the grievance. Findings:

Review of the hospital policy titled "Patient Grievance Reporting, Resolution, and Tracking/Trending", effective 08/19/09 and submitted by Director of Quality Services and Infection Control S2 as their current policy for grievances, revealed, in part, "... 7. Each person filing a formal grievance will be sent a written response identifying the results of the grievance process and the date of completion in language understandable to the patient or family...". Further review revealed no documented evidence that the written response required the name of the hospital contact person and the steps taken to investigate the grievance to be included.

In a face-to-face interview on 07/26/11 at 10:45am, Director of Quality Services and Infection Control confirmed this finding.

Based on record review and interview, the hospital failed to ensure the hospital policy was followed for obtaining a patient's informed consent by: 1) failure to document the reason the patient was unable to sign the consent for services for 1 of 8 sampled patients (#3); 2) failure to obtain informed consent prior to the administration of packed red blood cells for 1 of 1 patient reviewed with blood administration from a total of 8 sampled patients (#6); and 3) failure to inform the patient of the description/nature of the treatment, the reasonable therapeutic alternatives and risks associated with the alternatives, the risks of no treatment, and failure to document the patient's condition for which the treatment was recommended for 1 of 1 patient reviewed with blood administration from a total of 8 sampled patients (#6). Findings:

1) Failure to document the reason the patient was unable to sign the consent for services:
Review of Patient #3's medical record revealed she was a 43 year old female admitted on 07/07/11 with diagnoses of sepsis, hypertension, HIV (human immunodeficiency virus) positive, and osteoarthritis.
Review of Patient #3's "Consent For Services and Financial Responsibility" revealed it was signed by someone other than the patient. Further review revealed a blank labeled "If Other than Patient, Indicate Relationship and Reason Patient is Unable to Sign". Further review revealed no documented evidence that the relationship to the patient and the reason the patient was unable to sign had been completed.

In a face-to-face interview on 07/25/11 at 3:00pm, Director of Quality Services and Infection Control Officer S2 confirmed the above finding.

2) Failure to obtain informed consent prior to the administration of packed red blood cells:
Review of Patient #6's medical record revealed he was a 76 year old male admitted on 07/14/11.
Review of Patient #6's "Physician's Orders" revealed an order on 07/18/11 at 8:00am to transfuse one unit of PRBCs (packed red blood cells) over 2 hours.
Review of the "Blood Utilization Record" revealed the PRBCs were initiated on 07/18/11 at 1:50pm.
Review of the "Patient Consent to Blood and/or Blood Products and Acknowledgement of Receipt of Medical Information" revealed Patient #6 signed the consent on 07/19/11 at 1:30pm, the day after the blood was administered.

In a face-to-face interview on 07/26/11 at 3:50pm, Director of Quality Services and Infection Control Officer S2 confirmed there was no informed consent obtained from Patient #6 prior to him receiving a unit of PRBCs on 07/18/11.

Review of the hospital policy titled "Blood Administration and Reactions", last reviewed 12/10 and submitted by Director of Quality Services and Infection Control Officer S2, revealed, in part, "...A consent form shall be signed prior to blood transfusion...".

3) Failure to inform the patient of the description/nature of the treatment, the reasonable therapeutic alternatives and risks associated with the alternatives, the risks of no treatment, and failure to document the patient's condition for which the treatment was recommended:
Review of Patient #6's "Patient Consent to Blood and/or Blood Products and Acknowledgement of Receipt of Medical Information" signed by the physician on 07/18/11 at 2:00pm and by Patient #6 on 07/19/11 at 1:30pm revealed the following items were blank (no documented evidence of anything written in the blank): description, nature of treatment/procedure; patient condition ("patient's diagnosis, description of the nature of the condition or ailment for which the medical treatment, surgical procedure or other therapy described in item number 2 is indicated and recommended"); and reasonable therapeutic alternatives and the risks associated and the risks of no treatment.

Review of Patient #6's "Patient Consent to Central Venous & (and) Pulmonary Artery Catheterization and Acknowledgement of Receipt of Medical Information", signed by the physician on 07/22/11 with no documented evidence of the time of his signature and signed by Patient #6 on 07/22/11 at 10:45am, revealed the treatment was "transfuse platelets". Further review revealed no documented evidence that the description, nature of the treatment/procedure, the patient condition for which the treatment was indicated, and reasonable therapeutic alternatives and the risks associated and the risks of no treatment had been completed and discussed with Patient #6 prior to him signing his consent.

In a face-to-face interview on 07/26/11 at 3:50pm, Director of Quality Services and Infection Control Officer S2 confirmed all the information required on the informed consents had not been completed. S2 further indicated the hospital did not have a separate blood consent policy.

Review of the hospital policy titled "Consent for Medical or Surgical Treatment", revised 01/03 and reviewed 03/09 and submitted by Director of Quality Services and Infection Control Officer S2 as one of their policies for informed consent, revealed, in part, "...Policy A patient must give his/her informed consent before hospital, medical, dental or surgical care, treatment or procedures can be performed. ... II. Procedure for Handling Consents A. No procedure will be performed unless there is written expressed or implied consent. B. No hospital employee shall have a patient sign a consent form or witness such a consent form unless the physician represents that he had provided the patient the information contained in the consent or the patient acknowledges that such information has been provided...".

Review of the hospital policy titled "Informed Consent For Operations and Other Procedures", policy number 500.06 reviewed 03/09 and submitted by Director of Quality Services and Infection Control Officer S2 as one of their policies for informed consent, revealed, in part, "...In order for a valid informed consent to be obtained, ... the physician must describe and discuss the following requirements with the patient: the nature of the patient's condition; the general nature of the proposed medical treatment or surgery; the risks of the proposed medical treatment or surgery; reasonable therapeutic alternatives and material risks associated with these alternatives, the risk of no treatment...".

Based on observations, record review, and interviews, the hospital failed to develop quality indicators for the contracted housekeeping department to assess the services provided that resulted in: 1) having caked-on dust on wall air vents and portable fans in the E.D. and a collection of dust on the surfaces of equipment in the E.D. and the med/surg unit; 2) having stretcher/bed siderails with dried blood and/or an unidentifiable dried substance in the E.D. and med/surg unit; 3) having a non-functioning paper towel dispenser and a non-functioning foot pedal for the trash receptacle in room "b" in the E.D.; 4) having bag(s) of soiled linen stacked on the floor in rooms "e" and "j"; 5) having IV (intravenous) poles, rolling blood pressure monitors, bedside tables, bedside commodes, floor scales, and rolling weight chair with rust, chipped paint, and/or dried dirt or unidentifiable substance present in the E.D. or med/surg unit; and 6) having room "h" with soiled towels on the floor and handrail, a pool of water leading from the sink to the entrance of the room, and a used bar of soap on the sink. Findings:

Review of the "Quality Improvement Program 2010 Annual Evaluation" and the "Performance Improvement Plan 2010" revealed no documented evidence that the contracted services of housekeeping had quality indicators developed to measure, analyze, and track their performance.

1) Caked-on dust on wall air vents and portable fans in the E.D. and a collection of dust on the surfaces of equipment in the E.D. and the med/surg unit:
Observation of room "a" in the E.D. on 07/25/11 at 9:45am, with Assistant Administrator S1 present, revealed the following: a) the wall air vent with caked-on dust that could be removed when rubbed by the surveyor; b) a layer of dust on the surface of the crash cart as well as the screen of the monitor; a layer of dust on the computer keyboard housed on a stand in the room; c) a portable fan with a soiled, dusty screen. These observations were confirmed by S1.

Observation of room "b" in the E.D. on 07/25/11 at 9:55am, with Assistant Administrator S1 and Director of Quality Services and Infection Control S2 present, revealed the following: a) the surfaces of the computer keyboard, two crash carts and monitor screen, and stretcher had a collection of dust; b) portable fan with caked-on dust and dried substance on the top, bottom, and back of the screen. These findings were confirmed by S1 and S2.

Observation of room "c" in the E.D. on 07/25/11 at 10:10, with Assistant Administrator S1 and Director of Quality Services and Infection Control S2 present, revealed the wall air vent and a portable fan had caked-on dust. This finding was confirmed by S2.

Observation of room "d" in the E.D. on 07/25/11 at 10:20, with Assistant Administrator S1 and Director of Quality Services and Infection Control S2 present, revealed the collection of dust on stretcher handrails and bottom of stretcher (used to store patient belongings). This was confirmed by S1.

Observation of room "g" on 07/25/11 at 10:40am with Director of Quality Services and Infection Control S2 present, revealed a rolling pole with a PCA (patient controlled analgesia) pump attached that had a collection of dust on the base. Further observation revealed the computer keyboard and monitor had a layer of dust. These findings were confirmed by S1.

2) Stretcher/bed siderails with dried blood and/or an unidentifiable dried substance in the E.D. and med/surg unit:
Observation of room "b" in the E.D. on 07/25/11 at 9:55am, with Assistant Administrator S1 and Director of Quality Services and Infection Control S2 present, revealed the siderail of the stretcher had dried substance present (betadine versus blood). This was confirmed by S1 and S2.

Observation of room "c" in the E.D. on 07/25/11 at 10:10, with Assistant Administrator S1 and Director of Quality Services and Infection Control S2 present, revealed the stretcher siderails had an unidentifiable dried substance present. This was confirmed by S2 who indicated that the presence of dried blood presented infection control issues.

Observation of room "i" (med/surg unit) on 07/25/11 at 10:40am with Director of Quality Services and Infection Control S2 present, revealed the left lower siderail had an accumulation of dust and a dried bug present. This was confirmed by S1.

3) Non-functioning paper towel dispenser and a non-functioning foot pedal for the trash receptacle in room "b" in the E.D.:
Observation of room "b" in the E.D. on 07/25/11 at 9:55am, with Assistant Administrator S1 and Director of Quality Services and Infection Control S2 present, revealed the following: a) the paper towel dispenser was non-functioning as evidenced by inability to obtain paper towels; b) the trash receptacle had a non-functioning foot pedal which required one to use one's hand to open the lid. These findings were confirmed by S1 and S2.

4) Bag(s) of soiled linen stacked on the floor in rooms "e" and "j":
Observation of room "e" in the E.D. on 07/25/11 at 10:20, with Assistant Administrator S1 and Director of Quality Services and Infection Control S2 present, revealed a bag of soiled linen on the floor, the sink had caked-on dirt and dead bugs, and a mop was propped against the wall with the mop head on the floor. This finding was confirmed by S2.

Observation of room "j" on 07/25/11 at 10:40am, with Director of Quality Services and Infection Control S2 present, revealed eleven plastic bags of soiled linen stacked on the soiled floor. This was confirmed by S2 who indicated the bags of linen should not be on the floor.

5) IV poles, rolling blood pressure monitors, bedside tables, bedside commodes, floor scales, and rolling weight chair with rust, chipped paint, and/or dried dirt or unidentifiable substance present in the E.D. or med/surg unit:
Observation of room "c" in the E.D. on 07/25/11 at 10:10, with Assistant Administrator S1 and Director of Quality Services and Infection Control S2 present, revealed the following: a) portable bedside commode with peeled paint and rust; b) IV pole with rust on the pole and the 5-prong stand with visible dirt/stain. These findings were confirmed by S2 who indicated that the presence of dried blood and rust presented infection control issues.

Observation of room "g" on 07/25/11 at 10:40am with Director of Quality Services and Infection Control S2 present, revealed a rolling pole with a PCA pump attached that had a dried substance that looked like blood. Further observation revealed the siderail of the stretcher had had a green sticky substance on the upper part of the siderail. Further observation revealed the bedside table had a layer of dried unidentifiable substance on it, and the overbed table had an unidentifiable sticky substance present. These findings were confirmed by S1 who indicated these findings presented infection control issues.

Observation of the med/surg unit on 07/27/11 at 12:00pm, with Director of Quality Services and Infection Control S2 present, revealed 22 IV poles available for patient use with rust and/or chipped paint present; 36 bedside tables available for patient use with rust present; one portable bedside commode available for patient use with rust; 3 blood pressure monitors on rolling stands presently in use with rust and/or dirt present; one floor scale presently used to weigh patients with the base rusted; and one rolling chair used to currently weigh patients with the foot stand with rust and chipped paint. These observations were confirmed by S1.

6) Room "h" with soiled towels on the floor and handrail, a pool of water leading from the sink to the entrance of the room, and a used bar of soap on the sink:
Observation of room "h" on 07/25/11 at 10:40am with Director of Quality Services and Infection Control S2 present, revealed soiled towels on the floor and one hand towel laying on the handrail in the shower stall. Further observation revealed a pool of water leading from the sink to the door entrance. Further observation revealed an open, used bar of soap on the sink edge. These findings were confirmed by S1 who was unable to determine how long it had been since room "h" had been used or cleaned.

In a face-to-face interview on 07/27/11 at 4:35pm, Assistant Administrator S1 indicated the contracted housekeeping service was supposed to perform quality checks and present the information to the hospital. S1 further indicated this was to be accomplished by the department managers completing a scored assessment, but the scored assessment tool was never created by and presented to the managers by the contracted housekeeping service. S1 confirmed there was no documented evidence that the contracted housekeeping service had identified any of the above-mentioned areas of concern.

Review of the "Performance Improvement Plan 2010", presented by Director of Quality Services and Infection Control S2 as their current QAPI (quality assessment performance improvement) plan, revealed, in part, "...Contracted Services The medical staff, employees, and contracted services participate in identifying opportunities for improvement, data collection, multidisciplinary teams and implementing actions to sustain improvements. Performance monitors must be done al contracted services. The monitors/indicators must reflect how effective the contract services are relative to quality of service, high volume, high risk and problem prone or safety issues inherent in its processes...".

Based on observations, record review, and interviews, the hospital failed to ensure that corrective action was taken to improve safety and environmental cleanliness concerns identified in the emergency department (E.D.) and failed to ensure accurate safety and cleanliness rounds were performed to identify opportunities for improvement and actions needed for improvement on the med/surg unit. Findings:

Review of the "Environment of Care / Patient Safety Rounds Tool" completed by Director of Critical Care S3 for the E.D. on 06/27/11 revealed the following: 1) are the floors, walls, counters clean? - answered by ?? (2 question marks); 2) IV (intravenous) poles were noted to have corroded wheels and bases; 3) are areas free of horizontal dust? - answered yes; 4) are air vents clean? - answered yes; 5) are walls/doorways without chips? - answered multiple chips noted. Further review revealed no documented evidence that the identified areas of concern had been reported or the items had been replaced.

Observation on 07/25/11 at 9:45am, with Assistant Administrator present, revealed caked-on dust on wall air vents and portable fans, a collection of dust on the surfaces of equipment, stretcher/bed siderails with dried blood and/or an unidentifiable dried substance, a non-functioning paper towel dispenser and a non-functioning foot pedal for the trash receptacle in room "b", bag(s) of soiled linen stacked on the floor in room "e", boxed items stored on the floor in room "f", a portable bedside commode with peeled paint and rust, and an IV pole with rust on the pole and the 5-prong stand with visible dirt/stain, all in the E.D.

Review of the "Environment of Care / Patient Safety Rounds Tool" completed in June 2011 with no documented evidence of the person performing the round revealed no documented evidence of any identified environmental or patient safety concerns.

Observation of room "g" on 07/25/11 at 10:40am with Director of Quality Services and Infection Control S2 present, revealed a rolling pole with a PCA (patient controlled analgesia) pump attached that had a collection of dust on the base. Further observation revealed the computer keyboard and monitor had a layer of dust. These findings were confirmed by S1.

Observation of room "i" (med/surg unit) on 07/25/11 at 10:40am with Director of Quality Services and Infection Control S2 present, revealed the left lower siderail had an accumulation of dust and a dried bug present. This was confirmed by S1.

Observation of room "j" on 07/25/11 at 10:40am, with Director of Quality Services and Infection Control S2 present, revealed eleven plastic bags of soiled linen stacked on the soiled floor. This was confirmed by S2 who indicated the bags of linen should not be on the floor.

Observation of room "g" on 07/25/11 at 10:40am with Director of Quality Services and Infection Control S2 present, revealed a rolling pole with a PCA pump attached that had a dried substance that looked like blood. Further observation revealed the siderail of the stretcher had had a green sticky substance on the upper part of the siderail. Further observation revealed the bedside table had a layer of dried unidentifiable substance on it, and the overbed table had an unidentifiable sticky substance present. These findings were confirmed by S1 who indicated these findings presented infection control issues.

Observation of the med/surg unit on 07/27/11 at 12:00pm, with Director of Quality Services and Infection Control S2 present, revealed 22 IV poles available for patient use with rust and/or chipped paint present; 36 bedside tables available for patient use with rust present; one portable bedside commode available for patient use with rust; 3 blood pressure monitors on rolling stands presently in use with rust and/or dirt present; one floor scale presently used to weigh patients with the base rusted; and one rolling chair used to currently weigh patients with the foot stand with rust and chipped paint. These observations were confirmed by S1.

In a face-to-face interview on 07/27/11 at 4:50pm, Director of Quality Services and Infection Control S2 indicated she performed infection control rounds quarterly. S2 indicated she did not look for rust, chipped paint, or corroded equipment when she did her infection control rounds. S2 indicated she should have done this, because these items would be unable to be cleaned and would be an infection control risk.

In a face-to-face interview on 07/27/11 at 1:55pm, Director of Plant Operations S11 indicated if the safety rounds identified maintenance problems, a work order would be generated. S11 further indicated if the problem was a housekeeping issue, he would refer it o the housekeeping director and did not follow-up on the housekeeping issues. S11 indicated it was up to the manager to request replacement of rusted or corroded items.

In a telephone interview on 07/27/11 at 4:45pm, Director of Plant Operations S11 confirmed that he had never received a work order from the E.D. or the Med/Surg unit to replace items due to rust or corrosion.

Review of the "Performance Improvement Plan 2010", presented by Director of Quality Services and Infection Control S2 as their current QAPI (quality assessment performance improvement) plan, revealed, in part, "...How to Implement Steps in Process ... Plan the improvement; Prioritize processes to be reviewed; ... Do the implementation of process; Identify fast improvement opportunities and make the changes; Pilot changes; Measure outcomes of change; Check results; Review and analyze data to determine if change led expected outcome; Act to Hold Gains and Foster Continuous Improvement...".

Based on record review and interviews, the hospital failed to ensure the RN (registered nurse) supervised and evaluated the nursing care of each patient as evidenced by: 1) failure to ensure the LPN (licensed practical nurse) assessed a patient's apical heart rate prior to administering Metoprolol for 1 of 1 patient reviewed with Metoprolol ordered by the physician from a total sample of 8 patients (#2) and 2) failure to ensure the RN performed neurological assessments according to hospital policy for 1 of 2 patients reviewed with orders for neurological assessments from a total sample of 8 patients ( #2). Findings:

1) Failure to ensure the LPN assessed a patient's apical heart rate prior to administering Metoprolol:
Review of Patient #2's medical record revealed she was admitted on 06/12/11 with diagnoses of syncope and collapse, TIA (transischemic attack) versus generalized weakness, elevated blood pressure, and anxiety.
Review of Patient #2's "Emergency Department Routine Orders" dated 06/12/11 at 8:20pm revealed an order for Metoprolol 50 mg (milligrams) orally twice a day.
Review of the "Medication Administration Record" for Patient #2 revealed LPN S5 administered Metoprolol on 06/13/11 at 9:00am. Further review revealed no documented evidence that Patient #2's apical pulse had been checked prior to administering the medication.

Review of the "Nursing 2010 Drug Handbook", submitted by Director of Quality Services and Infection Control S2 as the reference used by nurses on the nursing units for drug information, revealed a nursing consideration for Metoprolol was to "always check patient's apical pulse rate before giving drug. If it's slower than 60 beats / (per) minute, withhold drug and call prescriber immediately".

In a face-to-face interview on 07/27/11 at 9:05am, LPN S5 indicated she was not aware that a patient's apical pulse needed to be checked prior to administering Metoprolol. S5 confirmed she did not assess Patient #2's apical pulse before administering the medication.

Review of the hospital policy titled "Medication Administration", revised 12/03 and reviewed 05/09 and submitted by Director of Quality Services and Infection Control S2, revealed, in part, "...The apical pulse will be taken prior to the administration of a Digitalis preparation. If the pulse is below 60, the medication will be held and the physician consulted. Apical pulse rates will be recorded in the proper location on the Medication Administration Record...". Further review revealed no documented evidence that the need to check the apical pulse prior to administering Metoprolol was addressed in the medication administration policy.

2) Failure to ensure the RN performed neurological assessments according to hospital policy:
Patient #2
Review of Patient #2's medical record revealed she was admitted on 06/12/11 with diagnoses of syncope and collapse, TIA (transischemic attack) versus generalized weakness, elevated blood pressure, and anxiety.
Review of Patient #2's "Emergency Department Routine Orders" dated 06/12/11 at 8:20pm revealed an order to admit to observation and perform neuro (neurological) checks every 4 hours.
Review of Patient #2's "Nursing Assessment" revealed she was admitted to the floor from E.D. (emergency department) at 10:00pm on 06/12/11 by RN S7. Further review revealed a neuro assessment was performed by S7 during the admission assessment.
Review of the "Multidisciplinary Progress Notes" revealed RN S7 performed a neuro assessment at 10:30pm. Further review revealed S7 documented "no deficits. no changes" on 06/13/11 at 2:40am and 6:00am. There was no documented evidence of a neuro assessment, as ordered every four hours, performed according to hospital policy by a RN on 06/13/11 at 2:30am and 6:30am.
Review of Patient #2's "Med/Surg Nursing Flow Sheet" dated 06/13/11 revealed LPN S5 performed a neuro assessment at 7:45am.
Review of the "Multidisciplinary Progress Notes" for 06/13/11 revealed no documented evidence that a neuro assessment had been performed every four hours as ordered by the physician.

In a face-to-face interview on 07/27/11 at 9:05am, LPN S5 indicated she did not perform neuro assessments for the remainder of the shift on 06/13/11 for Patient #2 after her initial assessment.

Review of the hospital policy titled "Lippincott Manual of Nursing Procedures", reviewed 08/09 and submitted by Director of Quality Services and Infection Control S2, revealed, in part, "...In an effort to provide safe and effective treatment, Teche Regional Medical Center has adopted the Lippincott Nursing Procedure as a guide when performing nursing procedures. This manual is located on all nursing units and is readily available to all nursing staff".

Review of the chapter titled "Neurologic Care" in the "Lippincott Manual of Nursing Procedures" revealed, in part, "...Neurologic assessment supplements the routine measurement of temperature, pulse rate, and respirations by evaluating the patient's level of consciousness (LOC), pupillary activity, and orientation to person, place, and date. ... Evaluating motor function Identify the patient's strength on a scale of 0 to 5... If the patient is conscious, test his grip strength in both hands. ... Test arm strength... Test leg strength... Flex and extend the extremities on both sides to evaluate muscle tone. Test the plantar reflex in all patients. ... Completing the neurologic examination ... His pulse pressure - the difference between systolic pressure and diastolic pressure - is especially important because widening pulse pressure can indicate increasing ICP (intracranial pressure). ... Documentation ... Record the patient's LOC and orientation, pupillary activity, motor function, and routine vital signs as your facility's policy directs...".

Based on record review and interviews, the hospital failed to ensure the nursing staff implemented the physician's plan of care for each patient by failure to perform neuro checks and obtain labs as ordered for 2 of 8 sampled patients (#2, #5). Findings:

Patient #2
Review of Patient #2's medical record revealed she was admitted on 06/12/11 with diagnoses of syncope and collapse, TIA (transischemic attack) versus generalized weakness, elevated blood pressure, and anxiety.
Review of Patient #2's "Emergency Department Routine Orders" dated 06/12/11 at 8:20pm revealed an order to admit to observation and perform neuro (neurological) checks every 4 hours.
Review of Patient #2's "Nursing Assessment" revealed she was admitted to the floor from E.D. (emergency department) at 10:00pm on 06/12/11 by RN S7. Further review revealed a neuro assessment was performed by S7 during the admission assessment.
Review of the "Multidisciplinary Progress Notes" revealed no documented evidence of a neuro assessment performed by a RN on 06/13/11 at 2:30am and 6:30am as ordered.
Review of Patient #2's "Med/Surg Nursing Flow Sheet" dated 06/13/11 revealed LPN S5 performed a neuro assessment at 7:45am.
Review of the "Multidisciplinary Progress Notes" for 06/13/11 revealed no documented evidence that a neuro assessment had been performed every four hours as ordered by the physician.

In a face-to-face interview on 07/27/11 at 9:05am, LPN S5 indicated she did not perform neuro assessments for the remainder of the shift on 06/13/11 for Patient #2 after her initial assessment.

Patient #5
Review of Patient #5's medical record revealed he was admitted on 05/04/11 with diagnoses of altered mental status, diabetes mellitus, and hypertension.
Review of Patient #5's "Emergency Department Routine Orders" dated 05/04/11 at 2:15pm revealed an order for neuro checks every two hours.
Review of Patient #5's "Med/Surg Nursing Flow Sheet" and the "Multidisciplinary Progress Notes" for 05/04/11, 05/05/11, 05/06/11, and 05/07/11 revealed no documented evidence neuro checks were performed every two hours as ordered.

In a face-to-face interview on 07/26/11 at 10:40am, Director of Quality Services and Infection Control S2 confirmed the neuro checks for Patient #5 were not done as ordered by the physician.

In a face-to-face interview on 07/27/11 at 10:20am, RN S7 confirmed she did not document neuro checks for Patient #5 every two hours as ordered. S7 indicated she did not remember if she was aware that neuro checks were ordered every two hours.

Review of Patient #5's "Physician's Orders" revealed an order on 05/10/11 at 7:55pm for a CBC (complete blood count), CMP (comprehensive metabolic profile), and Magnesium level in the morning. Review of the lab results revealed no documented evidence that the CBC, CMP and Magnesium level were drawn on 05/11/11 as ordered.

In a face-to-face interview on 07/26/11 at 10:40am, Director of Quality Services and Infection Control S2 confirmed the blood was not drawn to run the above-ordered labs for Patient #5.

Based on record review and interviews, the hospital failed to ensure the nursing staff were assessed for competency and/or were certified in CPR (cardiopulmonary resuscitation) according to hospital policy for 2 of 5 nurses' files reviewed (emergency department and med/surg unit) from a total of 56 nurses employed in the emergency department and med/surg unit (S4, S7, S13). Findings:

RN (registered nurse) S4
Review of RN S4's personnel file revealed a hire date of 06/17/08. Further review revealed her CPR certification expired on 06/30/11.
In a face-to-face interview on 07/27/11 at 3:35pm, Director of Human Resources S15 confirmed the expiration of RN S4's CPR card.

RN S7
Review of RN S7's personnel file revealed a hire date of 06/08/10. Review of RN S7's "Medical/Surgical Unit Competency RN" revealed the following skills performance was precepted and S7 assessed as competent by LPN S16 between 07/05/10 and 07/25/10: wound care, including staging of the pressure ulcer (can only be performed by RN and not able to be delegated to LPN); inserting/starting/maintaining IVs (intravenous fluids); operation of an IV pump; medication policies review; blood/blood products (LPN cannot initiate blood); respiratory, including oxygen set up and sputum collection; performing EKGs (electrocardiogram); applying and maintaining telemetry; insertion and maintenance of a nasogastric tube; maintaining surgical drains; and emptying collection chambers and measuring output on all drains. There was no documented evidence that a RN had assessed the competency of RN S7. Further review revealed no documented evidence of the director's signature on the competency assessment.

In a face-to-face interview on 07/27/11 at 3:15pm, Director of Med/Surg S9 confirmed RN S7's competency assessment was performed by LPN S16, and she (S9) did not sign the assessment. S9 could offer no explanation for allowing a LPN to precept and assess the competency of a RN.

RN S13
Review of RN S13's personnel file revealed a hire date of 03/28/11. Review of the "90-Day Competency Assessment", sent to Director of Med/Surg S9 on the day of this survey which was later than 90 days after hire, revealed RN S13 was precepted by and assessed for competency by LPN S16 and RN S17.

In a face-to-face interview on 07/27/11 at 4:10pm, Director of Med/Surg S9 confirmed she did not have the competency assessment for RN S13 within 90 days of her hire date as required by hospital policy.

Review of the hospital policy titled "Competency Assessment Program", revised 01/01/07 and reviewed 03/01/10 and submitted by Director of Human Resources S15, revealed, in part, "...Competency assessment shall include the following components: ...Department orientation, Job-specific orientation...C. The Human Resources Department shall document the following competency of new hires: ... 3. Competency-based orientation, whereby new staff members are assessed initially for basic skills, knowledge and behaviors and are oriented to the hospital's methods for performing their duties in their respective departments. 4. 90-Day competency assessments which are assessed by the appropriate department manager and are then summarized and presented to the Board of Trustees at their monthly meeting. ... D. Department Managers direct the department and assume responsibility for staff competency by: ... 3. Observing and documenting competency of each employee on an on-going basis... E. Employees maintain an acceptable level of competency by: ... 3. Successfully completing a skills checklist to be performed in the initial 90 days of employment with a return demonstration of competency in all areas required. ... 7. Completion of all annual training (...BLS [basic life support]...) as required by position and department...".

Based on record review and interview, the hospital failed to ensure medications were administered as ordered by the physician for 1 of 8 sampled patients (#7). Findings:

Review of Patient #7's medical record revealed he was admitted on 07/14/11 at 7:30am with diagnoses of syncope, hypotension, dehydration, and atrial fibrillation.

Review of Patient #7's "Home Medication Form" revealed the following medications were ordered to be continued: Intelence 200 mg (milligrams) by mouth daily; Acyclovir one tablet by mouth daily; and Viread 300 mg by mouth daily.

Review of Patient #7's MAR (medication administration record) revealed no documented evidence that Intelence, Acyclovir, and Viread were administered on 07/14/11 as ordered. Review of the MAR for 07/15/11 revealed a notation that "pt. (patient) wants to take in am".

In a face-to-face interview on 07/26/11 at 2:25pm, Director of Critical Care S3 indicated when medications were ordered daily, they were administered at 9:00am. S3 confirmed Patient #7 did not receive his medication as ordered.

Based on observation, record review, and interviews, the hospital failed to ensure the physical environment of the emergency department (E.D.) and the medical/surgical (med/surg) unit was maintained to assure the safety and well-being of patients as evidenced by: 1) having cluttered hallways in the E.D. that could present a safety hazard when transporting patients in the E.D.; 2) having caked-on dust on wall air vents and portable fans in the E.D. and a collection of dust on the surfaces of equipment in the E.D. and the med/surg unit; 3) having stretcher/bed siderails with dried blood and/or an unidentifiable dried substance in the E.D. and med/surg unit; 4) having a non-functioning paper towel dispenser and a non-functioning foot pedal for the trash receptacle in room "b" in the E.D.; 5) having bag(s) of soiled linen stacked on the floor in rooms "e" and "j"; 6) having boxed items stored on the floor in room "f"; 7) having IV (intravenous) poles, rolling blood pressure monitors, bedside tables, bedside commodes, floor scales, and rolling weight chair with rust, chipped paint, and/or dried dirt or unidentifiable substance present in the E.D. or med/surg unit; and 8) having room "h" with soiled towels on the floor and handrail, a pool of water leading from the sink to the entrance of the room, and a used bar of soap on the sink. Findings:

1) Cluttered hallways in the E.D. that could present a safety hazard when transporting patients in the E.D.:
Observation of the E.D. on 07/25/11 at 9:45am, with Assistant Administrator S1 present, revealed an H-shaped area with a hall on each side of the nursing station and a hall in front of the nursing station. Further observation revealed the short hall to the right of the nursing station (when facing the station) had rooms "a", "b", "c", and "d". The hall to the left of the nursing station had patient rooms as well as the hall in front of the nursing station. Further observation revealed the hallway in front of the nursing station had a business office monitor (used for registration) attached to a rolling stand, a chair placed in front of the monitor, a tall file cabinet used to store E.D. forms, a blood pressure monitor on a rolling stand plugged into the wall, two soiled linen carts with soiled linen inside with one of the lids open, a personal protective equipment cart, a red biohazard container spaced along the wall opposite the nursing station. Further observation revealed an alcove at the end of the hall that had rooms "a", "b", "c", and "d" where 2 wheelchairs and an open clean linen cart were stored(covering was folded and placed on top of the cart leaving the linen open to air and accessible to anyone walking in the hall).

In a face-to-face interview on 07/25/11 at 9:45am, Administrator S1 confirmed the presence of the above-mentioned items that were placed in the E.D. hallway present a safety hazard for patients ambulating to or being transported to patient rooms.

2) Caked-on dust on wall air vents and portable fans in the E.D. and a collection of dust on the surfaces of equipment in the E.D. and the med/surg unit:
Observation of room "a" in the E.D. on 07/25/11 at 9:45am, with Assistant Administrator S1 present, revealed the following: a) the wall air vent with caked-on dust that could be removed when rubbed by the surveyor; b) a layer of dust on the surface of the crash cart as well as the screen of the monitor; a layer of dust on the computer keyboard housed on a stand in the room; c) a portable fan with a soiled, dusty screen. These observations were confirmed by S1.

Observation of room "b" in the E.D. on 07/25/11 at 9:55am, with Assistant Administrator S1 and Director of Quality Services and Infection Control S2 present, revealed the following: a) the surfaces of the computer keyboard, two crash carts and monitor screen, and stretcher had a collection of dust; b) portable fan with caked-on dust and dried substance on the top, bottom, and back of the screen. These findings were confirmed by S1 and S2.

Observation of room "c" in the E.D. on 07/25/11 at 10:10, with Assistant Administrator S1 and Director of Quality Services and Infection Control S2 present, revealed the wall air vent and a portable fan had caked-on dust. This finding was confirmed by S2.

Observation of room "d" in the E.D. on 07/25/11 at 10:20, with Assistant Administrator S1 and Director of Quality Services and Infection Control S2 present, revealed the collection of dust on stretcher handrails and bottom of stretcher (used to store patient belongings). This was confirmed by S1.

Observation of room "g" on 07/25/11 at 10:40am with Director of Quality Services and Infection Control S2 present, revealed a rolling pole with a PCA (patient controlled analgesia) pump attached that had a collection of dust on the base. Further observation revealed the computer keyboard and monitor had a layer of dust. These findings were confirmed by S1.

3) Stretcher/bed siderails with dried blood and/or an unidentifiable dried substance in the E.D. and med/surg unit:
Observation of room "b" in the E.D. on 07/25/11 at 9:55am, with Assistant Administrator S1 and Director of Quality Services and Infection Control S2 present, revealed the siderail of the stretcher had dried substance present (betadine versus blood). This was confirmed by S1 and S2.

Observation of room "c" in the E.D. on 07/25/11 at 10:10, with Assistant Administrator S1 and Director of Quality Services and Infection Control S2 present, revealed the stretcher siderails had an unidentifiable dried substance present. This was confirmed by S2 who indicated that the presence of dried blood presented infection control issues.

Observation of room "i" (med/surg unit) on 07/25/11 at 10:40am with Director of Quality Services and Infection Control S2 present, revealed the left lower siderail had an accumulation of dust and a dried bug present. This was confirmed by S1.

4) Non-functioning paper towel dispenser and a non-functioning foot pedal for the trash receptacle in room "b" in the E.D.:
Observation of room "b" in the E.D. on 07/25/11 at 9:55am, with Assistant Administrator S1 and Director of Quality Services and Infection Control S2 present, revealed the following: a) the paper towel dispenser was non-functioning as evidenced by inability to obtain paper towels; b) the trash receptacle had a non-functioning foot pedal which required one to use one's hand to open the lid. These findings were confirmed by S1 and S2.

5) Bag(s) of soiled linen stacked on the floor in rooms "e" and "j":
Observation of room "e" in the E.D. on 07/25/11 at 10:20, with Assistant Administrator S1 and Director of Quality Services and Infection Control S2 present, revealed a bag of soiled linen on the floor, the sink had caked-on dirt and dead bugs, and a mop was propped against the wall with the mop head on the floor. This finding was confirmed by S2.

Observation of room "j" on 07/25/11 at 10:40am, with Director of Quality Services and Infection Control S2 present, revealed eleven plastic bags of soiled linen stacked on the soiled floor. This was confirmed by S2 who indicated the bags of linen should not be on the floor.

6) Boxed items stored on the floor in room "f":
Observation of room "f" in the E.D. on 07/25/11 at 10:20, with Assistant Administrator S1 and Director of Quality Services and Infection Control S2 present, revealed five boxes stored on the floor, and there were two packages plus a box containing fifteen packs of suture and a glove on the floor. These findings were confirmed by S2.

7) IV poles, rolling blood pressure monitors, bedside tables, bedside commodes, floor scales, and rolling weight chair with rust, chipped paint, and/or dried dirt or unidentifiable substance present in the E.D. or med/surg unit:
Observation of room "c" in the E.D. on 07/25/11 at 10:10, with Assistant Administrator S1 and Director of Quality Services and Infection Control S2 present, revealed the following: a) portable bedside commode with peeled paint and rust; b) IV pole with rust on the pole and the 5-prong stand with visible dirt/stain. These findings were confirmed by S2 who indicated that the presence of dried blood and rust presented infection control issues.

Observation of room "g" on 07/25/11 at 10:40am with Director of Quality Services and Infection Control S2 present, revealed a rolling pole with a PCA pump attached that had a dried substance that looked like blood. Further observation revealed the siderail of the stretcher had had a green sticky substance on the upper part of the siderail. Further observation revealed the bedside table had a layer of dried unidentifiable substance on it, and the overbed table had an unidentifiable sticky substance present. These findings were confirmed by S1 who indicated these findings presented infection control issues.

Observation of the med/surg unit on 07/27/11 at 12:00pm, with Director of Quality Services and Infection Control S2 present, revealed 22 IV poles available for patient use with rust and/or chipped paint present; 36 bedside tables available for patient use with rust present; one portable bedside commode available for patient use with rust; 3 blood pressure monitors on rolling stands presently in use with rust and/or dirt present; one floor scale presently used to weigh patients with the base rusted; and one rolling chair used to currently weigh patients with the foot stand with rust and chipped paint. These observations were confirmed by S2.

8) Room "h" with soiled towels on the floor and handrail, a pool of water leading from the sink to the entrance of the room, and a used bar of soap on the sink:
Observation of room "h" on 07/25/11 at 10:40am with Director of Quality Services and Infection Control S2 present, revealed soiled towels on the floor and one hand towel laying on the handrail in the shower stall. Further observation revealed a pool of water leading from the sink to the door entrance. Further observation revealed an open, used bar of soap on the sink edge. These findings were confirmed by S1 who was unable to determine how long it had been since room "h" had been used or cleaned.

Review of the hospital policy titled "Fire Safety Plan", revised 01/06 and presented by Assistant Administrator S1, revealed, in part, "...Teche Regional Medical Center has established a Fire Safety Policy for the sole purpose of supporting and maintaining a fire-safe environment of care. ...H. Emergency procedures that address: ... Ensuring free and unobstructed exits. ... Ensuring free and unobstructed access to emergency services and for fire, police and other emergency forces...".

Review of the hospital policy titled "Vents and Diffusers", policy number ES-70 presented by Assistant Administrator S1, revealed, in part, "...To maintain a clean and attractive environment that enhances the image of the facility and controls dust which can serve as a carrier for germs... When dust is excessive, use the vacuum cleaner (and attachments) to remove the loose dust from the vent or diffuser. ... When using the all purpose cleaner, if the vent or diffuser cannot be removed, wet a cleaning cloth and wring it as dry as possible. ... Wipe the outside of the vent or diffuser with the damp cloth until all soil has been removed. Carefully dry the unit. ... Carefully replace the vent or diffuser being sure to properly lock it into place ...".

Review of the hospital policy titled "Utility Room, Clean", policy number ES-68 presented by Assistant Administrator S1, revealed, in part, "...Clean and refill dispensers ... Open the paper towel dispenser ...To remove loose paper dust, remove any paper towels and clean the inside of the dispenser using a damp cloth and cleaning solution. Replace paper towels. ... Do not overfill... Check to be sure the towels release easily. Close and lock the dispenser... Clean the outside of the dispenser with a damp cloth and cleaning solution. Report any broken or malfunctioning units to Plant Operations. Clean the sink Apply disinfectant to the interior surfaces of the sink. Clean the inside of the sink, the exterior surface of the sink and all metal faucets and handles using a clean cloth dampened with the disinfectant cleaner. ... Clean the floor Inspect the floor for debris and wet spots. ... remove any gum or sticky residue from the floor by gently prying it loose with the putty knife. ... Dust mop the floor. ... Dip the mop into the solution and wring out excess liquid. Clean the edges of the floor. ... Be sure to mop under and behind furniture including waste containers. ... Clean up ... Bag soiled mop heads and cleaning cloths for laundry...".

Review of the hospital policy titled "Laundry and Linen", policy number ES-79 presented by Assistant Administrator S1, revealed, in part, "...All dirty linen is bagged and placed in the soiled utility room, which is located on each floor. Dirty linen is picked up in large container and placed in appropriate area to await laundry service pick up. Clean linen is delivered and stored in linen room that is separate from chemical and has a locked door. This door should be locked upon exiting the room. ... Clean linen is stored on each floor in the appropriate area, remaining covered at all times...".

Review of the hospital policy titled "Tubs and Showers, Clean", policy number ES-66 presented by Assistant Administrator S1, revealed the policy did not address who was responsible for disposing of soiled towels after use by a patient, who was responsible for cleaning the shower room, and how soon after use it was to be cleaned.

Review of the hospital policy titled "Patient Room, Occupied Clean", policy number ES-57 presented by Assistant Administrator S1, revealed, in part, "...Damp dust the doors and wall features ... Clean the room furnishings If accessible, clean the interior and exterior of all furnishings. Be sure to open up and clean all drawers. ... Dust mop the floor ... Wet mop the floor...".

Review of the hospital policy titled "Patient Room, Discharge Clean", policy number ES-56 presented by Assistant Administrator S1, revealed, in part, "...High dust wall articles High dust the tops of items along the patient room and restroom wall (picture frames, clocks, etc.) that are at or above your shoulder height; Damp dust the doors and wall features ... Clean the room furnishings Clean the interior and exterior of all furnishings. Be sure to open up and clean all drawers. Clean the patient Bed Clean the mattress with a clean cloth and disinfectant cleaner. ... Clean the exposed bedsprings and frame. ... Clean the headboard, footboard, side rails and bed controls with a quaternary cleaner. Pay particular attention to the areas that are visible soiled and surfaces frequently touched touched surfaces such as bed controls, bed rails and TV controls. ... Dust mop the floor ... Wet mop the floor...".

Based on observations, record review, and interviews, the infection control officer failed to implement the system for identifying and controlling infections and communicable diseases as evidenced by failure to maintain a sanitary hospital environment in the emergency department (E.D.) and the medical/surgical (med/surg) unit. Findings:

Observation of the E.D. on 07/25/11 at 9:45am, with Assistant Administrator S1 present, revealed two soiled linen carts in the hall across from the nursing station. Further observation revealed one of the linen carts had the lid open with soiled linen inside. Further observation revealed an open clean linen with the covering folded and placed on top of the cart, leaving the linen open to air and accessible to anyone walking in the hall. This was confirmed by S1.

Observation of room "a" in the E.D. on 07/25/11 at 9:45am, with Assistant Administrator S1 present, revealed the following: a) the wall air vent with caked-on dust that could be removed when rubbed by the surveyor; b) a layer of dust on the surface of the crash cart as well as the screen of the monitor; a layer of dust on the computer keyboard housed on a stand in the room; c) a portable fan with a soiled, dusty screen. These observations were confirmed by S1.

Observation of room "b" in the E.D. on 07/25/11 at 9:55am, with Assistant Administrator S1 and Director of Quality Services and Infection Control S2 present, revealed the following: a) the surfaces of the computer keyboard, two crash carts and monitor screen, and stretcher had a collection of dust; b) portable fan with caked-on dust and dried substance on the top, bottom, and back of the screen. Further observation revealed the siderail of the stretcher had dried substance present (betadine versus blood). Further observation revealed the paper towel dispenser was non-functioning as evidenced by the inability to obtain paper towels, and the trash receptacle had a non-functioning foot pedal which required one to use one's hand to open the lid. These findings were confirmed by S1 and S2. S2 indicated these findings would present infection control issues.

Observation of room "c" in the E.D. on 07/25/11 at 10:10, with Assistant Administrator S1 and Director of Quality Services and Infection Control S2 present, revealed the wall air vent and a portable fan had caked-on dust. Further observation revealed: 1) the stretcher siderails had an unidentifiable dried substance present; 2) the portable bedside commode had peeled paint and rust; 3) the IV pole had rust on the pole and the 5-prong stand had visible dirt/stain. These findings were confirmed by S2 who indicated that the presence of dried blood and rust presented infection control issues.

Observation of room "d" in the E.D. on 07/25/11 at 10:20, with Assistant Administrator S1 and Director of Quality Services and Infection Control S2 present, revealed the collection of dust on stretcher handrails and bottom of stretcher (used to store patient belongings). This was confirmed by S1.

Observation of room "e" in the E.D. on 07/25/11 at 10:20, with Assistant Administrator S1 and Director of Quality Services and Infection Control S2 present, revealed a bag of soiled linen on the floor, the sink had caked-on dirt and dead bugs, and a mop was propped against the wall with the mop head on the floor. This finding was confirmed by S2.

Observation of room "g" on 07/25/11 at 10:40am with Director of Quality Services and Infection Control S2 present, revealed: 1) a rolling pole with a PCA (patient controlled analgesia) pump attached that had a a dried substance that looked like blood and a collection of dust on the base; 2) the siderail of the stretcher had a green sticky substance on the upper part of the siderail; 3) the bedside table had a layer of dried unidentifiable substance on it; 4) the computer keyboard and monitor had a layer of dust and 5) the overbed table had an unidentifiable sticky substance present. These findings were confirmed by S1 who indicated these findings presented infection control issues.

Observation of room "h" on 07/25/11 at 10:40am with Director of Quality Services and Infection Control S2 present, revealed soiled towels on the floor and one hand towel laying on the handrail in the shower stall. Further observation revealed a pool of water leading from the sink to the door entrance. Further observation revealed an open, used bar of soap on the sink edge. These findings were confirmed by S1 who was unable to determine how long it had been since room "h" had been used or cleaned.

Observation of room "i" (med/surg unit) on 07/25/11 at 10:40am with Director of Quality Services and Infection Control S2 present, revealed the left lower siderail had an accumulation of dust and a dried bug present. This was confirmed by S1.

Observation of room "j" on 07/25/11 at 10:40am, with Director of Quality Services and Infection Control S2 present, revealed eleven plastic bags of soiled linen stacked on the soiled floor. This was confirmed by S2 who indicated the bags of linen should not be on the floor.

Observation of the med/surg unit on 07/27/11 at 12:00pm, with Director of Quality Services and Infection Control S2 present, revealed 22 IV poles available for patient use with rust and/or chipped paint present; 36 bedside tables available for patient use with rust present; one portable bedside commode available for patient use with rust; 3 blood pressure monitors on rolling stands presently in use with rust and/or dirt present; one floor scale presently used to weigh patients with the base rusted; and one rolling chair used to currently weigh patients with the foot stand with rust and chipped paint. These observations were confirmed by S1.

Review of the "Infection Control Nursing Units Surveillance" performed by Director of Quality Services and Infection Control S2 on 12/13/10 for the med/surg unit revealed the following: area clean - yes; equipment clean - yes; clean linen supply covered and stored to avoid contamination - yes; soiled linen properly stored - yes; supplies and items off floor - yes.

Review of the "Infection Control Nursing Units Surveillance" performed by Director of Quality Services and Infection Control S2 on 03/25/11 for the E.D. revealed the following: paper towels available - yes; area clean - yes; equipment clean - yes; clean linen covered and stored to avoid contamination - yes; ceiling vents clean - yes; soiled linen properly stored - yes; infectious waste covered - yes; supplies and items off floor - yes.

In a face-to-face interview on 07/27/11 at 4:50pm, Director of Quality Services and Infection Control S2 indicated she performed infection control rounds quarterly. S2 further indicated she did different departments according to a rotation schedule. S2 confirmed the two above-cited surveillances done for E.D. and med/surg were performed by her. S2 indicated she did not look for rust, chipped paint, or corroded equipment when she did her infection control rounds. S2 indicated she should have done this, because these items would be unable to be cleaned and would be an infection control risk.

Review of the hospital policy titled "Infection Prevention Plan 2011", submitted by Director of Quality Services and Infection Control S2 as their current infection control plan, revealed, in part, "...B. Data Collection: ... 5. To perform routine surveillance inspections and activities to identify risk factors associated with hospital acquired infections and patient safety issues. ... 7. To evaluate and monitor findings and revise techniques and procedures as necessary. ... 9. To evaluate and monitor findings and revise techniques, practices and procedures as necessary. ...".