HospitalInspections.org

Based on record review and interview the hospital failed to meet the Condition of Participation for Emergency Services by failing to have emergency services under the direction of a qualified member of the medical staff. Findings:
Review of Governing Body meeting minutes for 2013 and 2014 to present revealed no documentation of an appointment to the position of Medical Director of Emergency Services.
In an interview on 7/8/14 at 3:50 p.m. S4Medical Records reported that she was responsible for credentialing documentation for the medical staff. S4Medical Records further reported that the hospital did not have an appointed Medical Director of Emergency Services, and had not had one for about a year. She explained that the regional medical director for the contracted company providing ER (Emergency Room) physicians had been sent reports of any problems that occurred in the ER. When questioned further she reported that S25MD was not on the hospital's medical staff. S4Medical Records explained that communication with him was through the company's director of credentialing and Quality Improvement.
Review of a list of the hospital's credentialed medical staff revealed S25MD was not listed as part of the hospital's Medical Staff.
In an interview 7/10/14 at 2:05 p.m. both S1Administrator and S4Medical Records verified that the hospital did not have an appointed Medical Director over Emergency Services

Based on observation and interviews, the hospital failed to ensure patient care equipment was maintained in safe operating condition as evidenced by failing to ensure regular periodic maintenance and safety checks were performed on the hospital's Respiratory Department equipment (2 Mechanical Ventilators, 2 Bi-Pap machines and 3 Croup Tents). Findings:

An observation of the hospital's Respiratory Department on 07/10/14 at 9:50 a.m. equipment storage room revealed the following equipment had expired safety inspection stickers dated 04/13:
- Mechanical Ventilators- 2.
-Bi-Pap -2
-Croup Tents-3

In an interview on 07/10/14 at 9:50 a.m., S19RRT(Registered Respiratory Therapist) indicated that the equipment was checked annually. S19RRT confirmed the equipment should have been checked and verified that it had not been inspected.

In an interview on 07/10/14 at 1:55 p.m., S1Administrator indicated that annual preventive maintenance and safety checks should have been performed on all patient care equipment by the hospital's contracted Bio-Medical Company.

Based on observation, interview, and policy review the hospital failed to ensure pharmaceutical services were administered according to accepted professional principles as evidenced by:
1.) Failing to ensure all drugs and biologicals were locked or stored in a locked room: crash cart unlocked in an unlocked room
2.) Failing to ensure all prescriber's orders were reviewed for appropriateness by a pharmacist before the first dose was dispensed.
Findings:
1.) All drugs and biologicals locked or stored in a locked room: crash cart unlocked in an unlocked room.

Review of the hospital policy entitled Crash Cart Control Checks, Policy #: A-16-01, last revised 7/19/2006, revealed the following, in part:
Policy:
The day charge nurse on each station is responsible for checking the crash cart and firing the defibrillator every day.
The crash cart should be locked at all times. If the cart is unlocked, a thorough inventory is to be made, supplies restocked and the cart should be relocked.
On 7/7/14 at 1:38 p.m., an observation was made of the crash cart in storage room " A " . It was noted to be unlocked. A broken, numbered lock was noted on the handle of the cart.
In an interview on 7/7/14 at 1:41 p.m. with S6RN, she confirmed the crash cart was stored in storage room " A " and the room was not locked. She verified the code cart should have been locked and confirmed that it was not locked and, in fact, the lock was broken. S6RN said she glanced at the crash cart at the start of the shift that morning and assumed it was locked because " the little key was on it " . She explained pharmacy was responsible for checking and re-stocking the code cart both daily and also after a code.
In an interview on 7/9/14 at 11:55 a.m. with S8Pharmacy, she confirmed the pharmacy was responsible for checking/restocking the crash carts both daily and after a code. She explained the pharmacy was the only department who had access to the numbered break-away locks. She said the crash carts remained unlocked until pharmacy checked them in the morning if they were opened during the night shift. She agreed the crash carts needed to be stored in a locked, secured area after they had been unlocked/accessed and not in the unattended, unlocked storage room.
2.) All prescriber's orders reviewed for appropriateness, by a pharmacist, before the first dose was dispensed.
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.
In an interview on 7/8/14 at 5:02 p.m. with S8Pharmacy she confirmed first dose review of newly prescribed medications was not currently being performed by pharmacy. She said medications ordered after hours and at night would have been reviewed by the patient ' s nurse and would have been given without pharmacist review. She explained the new medication would have been reviewed by the pharmacist the next day. S8Pharmacy said about a year ago the pharmacy board had notified the hospital that first dose review of new medications, by a pharmacist (prior to administration), was a regulation. S8Pharmacy said the Administrator had been told the hospital would be cited the next time they came if provisions had not been made to address the issue. She explained the Administrator had talked about possibly contracting a remote pharmacy but no provisions had been made yet.
In an interview on 7/10/14 at 1:58 p.m. with S1Administrator, he confirmed he had no contracted services with a remote pharmacy to perform first dose review on medications ordered after hours when pharmacy was not available, on-site, to review medications.

Based on record review and interview, the hospital failed to ensure Respiratory Therapy patient care policies and procedures were reviewed at least annually by hospital professional personnel. Findings:

Review of the hospital's Respiratory Therapy Manual revealed no documented evidence of policy/procedure review for the year of 2013.

In an interview on 07/10/14 at 9:50 a.m., S19RRT (Registered Respiratory Therapist) confirmed Respiratory Therapy policies and procedures were not reviewed annually. S19RRT indicated the policies and procedures were only reviewed and/or updated as practice(s) changed.

In an interview on 07/10/14 at 1:55 p.m., S1Administrator indicated that the patient care policies for Respiratory services should have been reviewed annually.

Based on record review and interview the hospital failed to ensure it's Quality Assurance (QA) program evaluated all services affecting patient health and safety, as evidenced by no documented quality assurance data that included all departments and contracted services.
Findings:

Review of the Organizational Performance Improvement Plan, provided by S4Medical Records, revealed the most current documented review of the QA plan was 1998. Further review revealed the following, in part:
Goals of Performance Improvement...
* Incorporate quality planning throughout the facility...
*The objectives, scope, organization, and mechanisms for overseeing the effectiveness of monitoring, assessing, evaluation, and problem-solving activities in the Performance Improvement Program are evaluated annually and revised as necessary.
...delegates the overnight responsibility for performance improvement activity monitoring, assessment, and evaluation of patient care services provided throughout the facility to the Quality Improvement Committee. As a part of the Organizational Performance Improvement Program, direct or indirect patient care departments of the hospital are responsible for performance improvement activities which included monitoring, assessment, and evaluation of the quality and appropriateness of patient care provided....As part of the hospital wide Performance Improvement Program, monitoring, assessment, and evaluation of key aspects and processes of care provided by departments other than medical staff will performed following the performance improvement review process.

Review of the Quality Improvement Committee meeting minutes dated 6/25/14 revealed, in part, the following agenda ...Review of Performance Improvement Reports: Complaints Received, Restraint Review, Dietary, Safety/Risk Management, and Radiology. Further review of documents from the 6/25/14 meeting revealed information from the above listed departments and indicators.

In an interview 7/10/14 at 3:50 p.m., S4Medical Records indicated she was not appointed as the QA Director, but that she was given the reports from various departments and typed the agenda, organized the reports, and was on the QA Committee. She further reported that the hospital had not had an appointed QA Director/Coordinator for years. S7Risk Manager and S4Medical Records reported that each hospital department was responsible for the development of their own performance improvement activities and what was to be monitored for the Quality Assurance Plan. Both S7Risk Manager and S4Medical Records verified that the hospital did not have a hospital wide Performance Improvement project . After a review of QA Committee meeting minutes for June 25, 2014, S7Risk Manager and S4Medical Records verified not all departments and patient care service areas were represented in the meeting. They further verified that, in part, there was no infection control, respiratory services, emergency services, surgical services, or contracted wound care services to name a few.

In an interview 7/10/14 at 4:15 p.m. with S7Risk Manger, S4Medical Records, S1Administrator, S3DON, and S5Compliance, S4Medical Records verified that Contracted services were not being evaluated. The interview group (as listed above) verified that there was no written plan which included an annual Performance Improvement Project for the hospital. They further verified that there was no documented QA plan, approved by the Governing Body that included ongoing monitoring and data collection with specifics of what would be monitored, problem prevention, identification, data analysis, identification of corrective actions, implementation of corrective actions, monitoring of corrective actions, and measures to improve quality on a continuous basis for all areas of the hospital.