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Based upon review of Contract Services, Policies and Procedures, and staff interview, the hospital failed to ensure: 1) Policies and Procedures were developed related to patient and personnel safety while providing portable x-rays by the Radiology Contractor, 2) A full-time, part-time or consulting Radiologist was on staff, and 3) The contract for Laboratory Services identified the parameters for turn around time for stat laboratory testing. Findings:

1) Review of the list of contract services revealed Hospital A provided radiology services. Review of Policy # 637.1 titled "Radiology Services" revised 06/30/14, revealed:
"Policy: (Hospital) staff will work closely with (Hospital A), (Hospital B), and (Hospital C) radiology departments to ensure that radiology procedures are performed in the most appropriate effective manner."
"Procedure: 1. Orders for any procedure performed by the Radiology Department will be transcribed and carried out according to the department requirements. (Hospital B and Hospital C) will require a phone call to schedule all radiology procedures. (Hospital A) requires a phone call and a written written request for all procedures. 2. The RN will consult with the ordering physician, the radiologist, and/or the patient's psychiatrist regarding any special patients needs in preparation for or during the procedure (portable x-ray, sedation, etc.).

Interview with S2 Director of Nursing on 08/13/15 at 9:40 a.m. revealed the hospital did not have a policy and procedure related to safety provisions to ensure patients and personnel were not exposed to ionizing radiology procedures.

2) Review of the Medical Staff Roster revealed there failed to be a full-time, part-time or consultant Radiologist on staff. Interview with S2 Director of Nursing on 08/13/15 at 11:10 a.m. confirmed a Radiologist was not on staff.

3) Review of the Laboratory Contract revealed there failed to be parameters that identified the turn around time for stat blood testing results.

Based on record review, observation and interview, the hospital failed to meet the requirements for the Condition of Participation for Patient Rights by failing to ensure patients received care in a safe setting as evidenced by:
1. Failing to have a system in place to ensure all staff were aware of the observation levels of the patients and failing to provide Level 2 observations for patients who required constant eye contact observations for 6 of 6 current patients (#4, 5, 8, 11, 14, 15) reviewed in a total sample of 15. (See findings in tag A-144)
2. Failing to ensure the physical environment was maintained in a manner to assure a safe setting for the acute geriatric patient population of 8 patients at the time of observation on 08/10/15. Ligature hazards were present in 7 of 7 psychiatric patient hospital rooms. (See findings in tag A-144)

Based on record review, observation and interview, the hospital failed to ensure patients received care in a safe setting as evidenced by:
1) Failing to have a system in place to ensure that all staff were aware of observation levels for 6 of 6 current psychiatric patients (#4, #5, #8, #11, #14, #15) who required Level 2 observations (constant eye contact) in a total sample of 15, and
2) Failing to ensure the physical environment was maintained in a manner to assure a safe setting for the acute geriatric patient population of 8 patients at the time of observation on 08/10/15. Findings:
1) Review of the hospital policy titled Patient Level of Monitoring and Special Precautions, dated 01/2012, and presented as current by S2 Director of Nursing revealed in part that in order to provide protection to patients, three levels of staff monitoring are provided:
Level 1, constant monitoring with arms-length;
Level 2, constant monitoring within view;
Level 3, monitoring on a routine basis every 15 minutes.

Review of the hospital policy titled Fall Risk Assessment, Prevention and Management, dated 05/04/11, and presented as current by S2 Director of Nursing revealed in part that upon admission, a nurse will assess each patient at risk for falls using the modified Morse Fall Scale risk assessment. The fall risk assessment has three levels (scores):
High risk, score 20 or higher, Level 1 - constant monitoring;
Moderate risk, score of 10-19, Level 2 - constant monitoring-within view;
Low risk, score of 0-9, Level 3 - routine monitoring-every 15 minutes.

Patient #8
Review of the medical record for patient #8 revealed an admit date of 07/23/15 with admitting diagnoses including psychosis and dementia. Review of the admission orders dated 07/23/15 revealed that the physician ordered the patient's observation level to be a Level 2 (eye contact).

Review of the patient's "Close Observation" flow sheets from the date of admission (07/23/15) until 08/11/15 revealed that the MHTs (mental health techs) were documenting that the patient was on Level 3 observations, routine monitoring every 15 minutes. The flow sheet dated 07/30/15 from 8:30 a.m. until 2:30 p.m. revealed no documented evidence that the patient was observed.

On 08/11/15 at 3:40 p.m., observation revealed patient #8 walked into her room which was at the opposite end of the hall as the nurse's station, and shut the door. The patient was not within view of any staff on the unit and there was no staff in the room. At 3:50 p.m., observation revealed the patient exited her room and asked the surveyor where she was supposed to go. The patient was still not in view of any staff.

Patient #15
Review of the medical record for patient #15 revealed an admit date of 08/12/15 with an admitting diagnosis of Schizoaffective disorder. Review of the admission orders revealed that the physician ordered the patient's observation level to be a Level 2 (eye contact).

On 08/13/15 at 12:35 p.m., observation revealed patient #15 was at the end of a hall trying to open the exit door. The patient was not in sight of any staff.

Patients #4, #5, #11, #14
Review of the medical records of patients #4, 5 and 14 revealed current physicians' orders for the patients to be on Level 2 observations, indicating eye contact at all times. Review of the record for patient #11 revealed a fall risk assessment (dated 08/12/15) with a score of 13, indicating the patient was to be on Level 2 observations.

Review of the "Close Observation" flow sheets dated 08/12/15 for patients #4, #11 and #14 revealed the MHTs documented that the above patients were on Level 3 observations, routine monitoring every 15 minutes. Review of the "Close Observation" flow sheet dated 08/12/15 for patient #5 revealed the level of observation was not noted.

On 08/12/15 at 3:30 p.m., interview with S7RN/Charge Nurse revealed that the nurses instruct the mental health techs on the observation levels of the patients. The surveyor requested from S7RN/Charge Nurse a list of current patients and their observation levels. S7RN/Charge Nurse stated that the observation levels would be noted in each patient's chart and there was no list completed with this information. Further interview with S7RN/Charge Nurse revealed that there were currently only two patients who were on Level 2 observations (eye contact): Patient #4 and Patient #14. S7RN/Charge Nurse stated that all other patients were to receive routine observations every 15 minutes.

On 08/12/15 at 4:00 p.m., interview with the 3 MHTs (Mental Health Techs) who were on duty (S8MHT, S9MHT and S10MHT) revealed that there were only two patients who were currently on Level 2 observations: Patient #4 and Patient #5. The MHTs further revealed that the hospital's policy for Level 2 observations stated to keep those patients in constant eye contact. They stated that all other patients received routine observations every 15 minutes.

On 08/13/15, review of the staff assignment sheet dated 08/12/15, 7PM-7AM shift, revealed that 2 MHTs (Mental Health Techs) worked the night shift. Further review revealed that one MHT was responsible for 6 patients, which included Patients #5 and #14 who were roommates and were on Level 2 observations (eye contact). The other MHT was responsible for the other 5 patients on the unit, which included Patients #4, #11 and #15, who were all in separate rooms and were ordered to be in eye contact at all times, Level 2 observations

On 08/13/15 at 9:20 a.m., interview with S2 Director of Nursing revealed that the night shift is normally staffed with two MHTs. S2 Director of Nursing confirmed that two MHTs worked the night shift on 08/12/15. S2 Director of Nursing further revealed that there was not enough staff at night to watch all 5 patients who were on observation Levels of 2 and required constant eye contact. S2 Director of Nursing stated that the two MHTs sit in the hall during the night shift, but were unable to keep each patient who required Level 2 observations in sight, as ordered by the physician.

On 08/13/15 at 9:30 a.m., S2 Director of Nursing reviewed the "Close Observation" flow sheets from 08/12/15 for patients #4, #5, #11 and #14 with the surveyor. S2 Director of Nursing confirmed that the flow sheets did not reflect the increased levels of observation required, as ordered by the physician. S2 Director of Nursing confirmed that there was no documented evidence that the patients were in eye contact of the staff at all times. Further interview with S2 Director of Nursing revealed there was a lack of communication among the staff regarding observation levels of the patients.

2) Observations made during the environmental tour on 08/10/15 at 9:30 a.m. revealed rooms #1 through #7 had the following ligature hazards: All patient outside doors and bathroom doors had three separate hinges on the door jams; all bathroom sink faucets had goose neck spouts and flange hot and cold handles; all bathroom sinks had exposed pipes; all patients beds had upper and lower side rails.

Interview with S2 Director of Nursing on 08/11/15 at 10:10 a.m. revealed when asked if the hospital had a policy for use of the bed rails for the geriatric population, S2 Director of Nursing replied "no".




10808

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as evidenced by:
1) failing to ensure admission orders were not written by a registered nurse instead of a licensed independent practitioner privileged to write orders for 1 (#11) of 15 patients sampled; and
2) failing to assess prior to and after administering PRN (as needed) medications for 3 of 3 patients reviewed (#5, #6, #8) in a total sample of 15.

1) Failing to ensure admission orders were not written by a registered nurse instead of a licensed independent practitioner privileged to write orders.

Review of the hospitals preprinted document titled Admission Orders revealed various orders that had to be selected from various choices by the person completing the form. The Admission Orders for Patient #11 dated 8/11/15 at 7:00 p.m. revealed various admission orders had an "x" written in a space next to them indicating they had been selected as an order:
Observation level of every 15 minutes, Orthostatic vital signs, low sodium diet, Tylenol 500 mg (milligrams) q (every) 4 hours as needed for pain/fever, Milk of Magnesia 30 cc (milliliters) po (by mouth) every 24 hours as needed for constipation, Maalox 30 cc by mouth every 6 hours as needed for indigestion, Dulcolax suppository 1 per rectum as needed for constipation if free of cramps, DNR (Do not Resuscitate) code status, and group therapies.
Further review revealed a statement at the bottom of the document, "Copied Orders IOP (intensive outpatient) of WM (West Monroe) / S11Psychiatrist/ S12RN."

In an interview on 8/12/15 at 1:00 p.m. with S4LPN (licensed practical nurse), she said Patient #11 was admitted on 8/11/15 but the staff was unable to get in touch with S11Psychiatrist until 9:50 a.m. on 8/12/15 to approve orders and medications.

In an interview on 8/12/15 at 1:15 p.m. with S2 Director of Nursing, she said the registered nurse filled out sections of the Admission Orders sheet for patients because they knew what the doctor usually wanted or it was based off of the paperwork that came from the previous hospital or place the patient was admitted from. S2 Director of Nursing said when the nurses filled out the admission sheet, they usually faxed it to the doctor and he approved or disapproved it. S2 Director of Nursing verified if the staff was unable to get in touch with S11Psychiatrist last night he could not have given a verbal order or approved the admission orders that had been selected on the Admission Orders sheet for Patient #11.

In an interview on 8/12/15 at 2:30 p.m. with S11Psychiatrist, he verified he did not give or review the admission orders for Patient #11 with the nursing staff on 8/11/15.


2) failing to assess prior to and after administering PRN (as needed) medications for 3 of 3 patients reviewed (#5, #6, #8).

Review of the hospital policy titled, Medication Policy and Procedure, presented as current by S2 Director of Nursing revealed in part that when administering PRN medications, the nurse must initial and put in the time of administration in the block on the correct date and the response to PRNs are charted.

Patient #5
Review of the medical record for patient #5 revealed the patient received the following PRN (as needed) medications: Maalox 30cc on 08/09/15, Tylenol 500mg on 08/10/15 at 9:30 a.m. and 2:50 p.m. and Norco (narcotic) 7.5mg on 08/11/5 and 08/12/15. Further review of the record, including the nurses notes and MAR (medication administration record), revealed no documented evidence of an assessment prior to or after administering the PRN medications.

On 08/13/15 at 10:30 a.m., interview with S2 Director of Nursing confirmed that there were no assessments performed prior to or after administering the above PRN medications.

Patient #6
Review of the medical record for patient #6 revealed the patient received Ambien (hypnotic) 10mg PRN (as needed) at bedtime every night from 05/07/15 - 05/12/15. Further review of the record revealed the patient received Xanax (anti-anxiety) 0.5mg PRN twice on 05/12/15 and Ultram 50mg PRN on 05/09/15 - 05/12/15. There was no documented evidence in the record, including nurses notes and MAR, that an assessment was performed prior to or after administering the PRN medications.

Patient #8
Review of the medical record for patient #8 revealed the patient received Ultram 50mg on 07/23/15, Ativan (anti-anxiety) 0.5mg on 07/23/15 and Geodon (antipsychotic) 10mg on 07/27/15. There was no documented evidence in the record, including nurses notes and MAR, that an assessment was performed prior to or after administering the above PRN (as needed) medications.

On 08/12/15 at 3:30 p.m., review of patient #8's record with S4LPN (licensed practical nurse) confirmed that there were no documented assessments prior to or after administering all PRN medications.

On 08/13/15 at 10:30 a.m., interview with S2 Director of Nursing confirmed that she was aware that there was a problem with the nursing staff documenting assessments prior to and after administering PRN medications.








17450

Based on record review and interview, the hospital failed to ensure medications were administered in accordance with the orders of the practitioner and hospital policies and procedures. This deficient practice is evidenced by the nursing staff not documenting rationale for holding patients' ordered medications or physician notification of the missed doses for 2 (#4, #6) of 10 patients reviewed for medication administration.

Findings:

Review of the hospital policy titled Medication Policy and Procedure, Procedure/Policy code: 3.103, revealed in part:
G. 5. If the medication is not given, the nurse circles her initials. The reason the medication was not given must be charted by the nurse using the legend on the MAR (medication administration record).

Review of the MAR for Patient #4 dated 8/11/15 revealed the following medications had been circled at 8:00 p.m. to indicate they had not been given: Namenda 28 mg (milligrams), Eplevenone 50 mg, and Isosorbide Mononitrate 120 mg. Further review revealed no documentation that the physician had been notified.

Review of the MAR for Patient #6 revealed she had the 8:00 p.m. doses on 5/6/15 circled to indicate it had not been given for Coreg 3.125 ½ tab (tablet), Flexeril 10 mg and Amlodipine 5 mg. Further review revealed no documentation as to why the medications had not been given or that the physician had been notified.

In an interview on 8/12/15 at 3:43 p.m. with S2 Director of Nursing, she said if the nurse did not give a medication, it should have been circled on the MAR and the physician should have been notified. S2 Director of Nursing also said there should have been documentation as to why the medication had not been given.

Based on observation and interview, the facility failed to ensure medical records dating back to 2006 were protected from water damage in the event the sprinkler system was activated.

Findings:

An observation of the medical records office on 8/12/15 at 8:25 a.m. revealed the ceiling contained sprinklers that would activate if there was a fire in the building. Further observation revealed 4 open shelving units approximately 6 feet high with 3 sections containing 6 shelves of paper medical records and 5 sections containing 7 shelves of paper medical records. Observation of the back wall of the room revealed a wooden shelving unit approximately 12 feet long with 7 open shelves containing paper medical records.

Observation of a storage room located on the first floor revealed 42 cardboard boxes stacked on the floor. Further observation revealed the storage room had a sprinkler system in the ceiling.

In an interview on 8/12/15 at 8:30 a.m. with S6 Medical Records, she said she was over the medical records department. S6 Medical Records verified the medical records in the medical records office were not covered to protect them from water damage if the sprinkler system was activated. S6 Medical Records also verified the medical records in the storage unit on the first floor were in cardboard boxes. S6 Medical Records said there were no electronic copies of the paper records. S6 Medical Records said the hospital had no offsite storage and there were medical records dating back to 2006. S6 Medical Records could not provide the number of records in the building.

Based on record review and interview, the hospital failed to ensure all patients' medical record entries were authenticated, dated and timed by the person responsible for providing the service for 4 (#5, 6, 8, 10) of 4 patients sampled. Findings:

Patient #5
Review of the medical record revealed patient #5 had verbal orders obtained on the following dates that were signed by the physician, but not timed: 07/23/15, 07/27/15, 07/31/15.

Patient #6
Review of the medical record for patient #6 revealed patient #6 had verbal orders on the following dates that were signed by the physician but not dated or timed: 05/06/15, 05/08/15, 05/14/15, 05/15/15. There was a verbal order dated 05/10/15 that was not authenticated by the physician, dated or timed. Further review of the record revealed the History and Physical was dated but not timed.

Patient #8
Review of the medical record for patient #8 revealed verbal admitting orders were obtained on 07/23/15 that were signed by the physician, but not dated or timed.

Patient #10
Review of the medical record for patient #10 revealed a verbal order dated 06/18/15 that was not authenticated, dated or timed. There was a verbal order dated 06/06/15 that was signed by the physician, but not dated or timed.

On 08/13/15 at 10:00 a.m., interview with S6 Medical Records confirmed that the above patients' physician orders were not authenticated, dated and/or timed. S6 Medical Records further revealed that she was aware that the hospital had a problem with the physicians signing, dating and timing orders.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable standards of practice, consistent with state law. This deficient practice was evidenced by failing to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist, before the first dose was dispensed, 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 hospital policy titled Medication Policy and Procedure, Procedure/Policy Code: 3.103, revealed in part:
L. Pharmacy not present
1. If patient receives order after pharmacy has closed for the day. The order will be filled as follows:
a. Routine medication - Secure meds from the night stock cabinet or do not give until the a.m. dose. This will allow the pharmacist time to review all of the patients meds.

In an interview on 8/12/15 at 10:00 a.m. with S5Pharmacist, he said his pharmacy hours were 9:00 a.m. until 6:00 p.m. Monday through Friday and 9:00 a.m. through 2:00 p.m. on Saturday and closed on Sunday. S5Pharmacist said he always went to the pharmacy at around 11:00 p.m. at night to check for new orders that had been faxed. S5Pharmacist said he did not do a first dose review on all medications before they were administered.

In an interview on 8/12/15 at 10:50 a.m. with S4LPN (licensed practical nurse), she said if a patient was admitted on a Sunday morning when the pharmacy was closed, the nurses would pull as many of the medications from the stock doses at the hospital and fax the MAR (medication administration record) to the pharmacy. S4LPN said the pharmacist would review the MAR usually at 11:00 p.m. and the medications that were in stock would have already been given.

Based upon review of Contract Services, Policies and Procedures, Medical Staff Roster, and staff interview, the hospital failed to meet the Condition of Participation for Radiology Services as evidenced by:

1. Failure to develop policies and procedures related to ionizing radiological services to ensure the services were provided in a safe manner for patients and personnel (A535), and

2. Failure to ensure a full-time, part-time, or consulting Radiologist provided supervision of the Radiology Services (A546).

Based upon review of Contract Services, Policies and Procedures, and staff interview, the hospital failed to develop policies and procedures related to radiology services to ensure ionizing radiological procedures were provided in a safe manner for patients and personnel. Findings:


Review of the list of contract services revealed Hospital A provided radiology services. Review of Policy # 637.1 titled "Radiology Services" revised 06/30/14, revealed:
"Policy: (Hospital) staff will work closely with (Hospital A), (Hospital B), and (Hospital C) radiology departments to ensure that radiology procedures are performed in the most appropriate effective manner."
"Procedure: 1. Orders for any procedure performed by the Radiology Department will be transcribed and carried out according to the department requirements. (Hospital B and Hospital C) will require a phone call to schedule all radiology procedures. (Hospital A) requires a phone call and a written written request for all procedures. 2. The RN will consult with the ordering physician, the radiologist, and/or the patient's psychiatrist regarding any special patients needs in preparation for or during the procedure (portable x-ray, sedation, etc.).

Interview with S2 Director of Nursing on 08/13/15 at 9:40 a.m. revealed the hospital did not have a policy and procedure related to safety provisions to ensure patients and personnel were not exposed to ionizing radiology procedures.

Based upon review of Contract Services, Medical Staff Roster, Policies and Procedures, and staff interview, the hospital failed to ensure a consulting radiologist supervised radiology services and interpreted radiological testing. This was evidenced by the failure to have a Radiologist either appointed to the Medical Staff or on contract to provide supervision of the radiological services. Findings:

Review of the list of contracted services revealed Radiological Services were provided by contract; however, the contract failed to identify a Radiologist who was responsible for the service. Review of the Medical Staff Roster revealed a Radiologist was not on the Medical Staff.

Review of the Policy Number 637.1 titled "Radiology Services" revised 06/30/14 revealed there failed to be documented evidence a Radiologist was responsible for interpreting radiology testing.

Interview with S2 Director of Nursing on 08/13/15 at 10:55 a.m. revealed Hospital A provides portable x-ray services. It was confirmed through interview with S2 Director of Nursing the hospital did not have a full-time, part-time, or consulting Radiologist on the Medical Staff.

Based on policy review, observation and interview, the facility failed to ensure the infection control officer developed a system for identifying and controlling infections and communicable diseases of patients and personnel. This deficient practice is evidenced by:
1) failing to ensure the nursing staff changed gloves and sanitized their hands between clean and dirty activities; and
2) failing to ensure the hospital had policies in place to minimize the risk of development and transmission of multidrug resistant organisms (MDROs) within the hospital.

Findings:

1) Failing to ensure the nursing staff changed gloves and sanitized their hands between clean and dirty activities.

In an observation on 8/12/15 at 11:10 a.m., S4LPN (licensed practical nurse) put on gloves in the medication room. S4LPN then wiped the glucometer with a disinfecting wipe, touched the doorknob to the medication room, and then performed a finger stick on Patient #3 for a blood glucose reading, touched the door knob to the medication room and her keys. S4LPN did not change or remove her gloves during the entire observation.

In an observation on 8/12/15 at 2:30 p.m., S4LPN was performing a dressing change on Patient #5's right foot. S4LPN was observed changing her gloves three times during the procedure but did not sanitize her hands between glove changes.

In an interview on 8/13/15 at 12:20 p.m. with S2 Director of Nursing, she said the staff should have sanitized or washed their hands between glove changes.

2) Failing to ensure the hospital had policies in place to minimize the risk of development and transmission of multidrug resistant organisms (MDROs) within the hospital.

Review of the hospital policies and procedures revealed no policies and procedures to minimize the risk of development and transmission of multidrug resistant organisms within the hospital.

In an interview on 10/11/15 at 1:40 p.m. with S2 Director of Nursing, she said the hospital did not have any policies and procedures to minimize the risk of development and transmission of MDRO's

Based on record review and interview, the hospital failed to ensure there was a director of respiratory care services who was a doctor of medicine or osteopathy.
Findings:

Review of the organizational chart for the hospital revealed no medical director of Respiratory Services listed.

S2 Director of Nursing was interviewed on 08/11/15 at 3:00 p.m. S2 Director of Nursing reported that Respiratory Services are offered at the hospital and provided by the nursing staff. S2 Director of Nursing verified that there was no medical director of Respiratory Services at the hospital.