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Based on record review and interview, the CAH failed to ensure drugs and biologicals were distributed and administered in accordance with accepted professional principles as evidenced by failing to ensure that 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 Louisiana Administrative Code, Professional and Occupational Standards,
Title 46: LIII, Pharmacist, Chapter 15, Hospital Pharmacy, §1511. Revealed in part:
Prescription Drug Orders
A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial
dose of medication, except in cases of emergency.

On 06/01/21 at 1:20 p.m., interview with S4Pharmacist revealed that the hospital pharmacy hours are Monday thru Friday from 7:00 a.m. until 4:00 p.m. S4Pharmacist stated that after pharmacy hours, contract pharmacy A reviews all medications prior to the first doses being administered. S4Pharmacist stated that the nurses know the first dose review has been performed when the medication name shows up under the patient's profile in the automated medication dispensing device. When asked if nurses were able to override the automated medication dispensing device in order to obtain the first dose of a medication prior to pharmacy review, she stated yes, but they were not supposed to do that.

On 06/01/21 at 1:45 p.m., interview with S6RN revealed that if a medication is not profiled under a patient's name in the automated medication dispensing device, the nurses are able to override in order to obtain the first dose of the medication for the patient. When asked if first doses of medications require a pharmacy review prior to administration, she stated no.

On 06/02/21 at 1:00 p.m., review of the medication override report (for past thee months) with S4Pharmacist revealed it contained multiple pages of medications that had been overridden. These medications included:
Patient #R1 - Order for Amoxicillin dated 5/24/21 at 1:30 p.m., administered at 1:50 p.m., reviewed by pharmacist at 2:21 p.m.
Patient #R2 - Order for Hydralazine 20mg IV dated 04/26/21 at 4:46 p.m., administered at 5:20 p.m., reviewed by pharmacist at 8:43 p.m.
Interview with S4Pharmacist at that time confirmed the above medications were not emergency medications and were not reviewed by a pharmacist prior to the administration of the first dose.

Based on record review and interview, the CAH failed to ensure medication variances and notification of the practitioner of medication variances were documented in the patients' records for 1 of 1 patient records reviewed for medication variances in the past six months.
Findings:

Review of the CAH's medication variance report for Patient #R3 dated 03/23/21 revealed Verapamil (heart medication) was drawn up and administered intravenously instead of Narcan (medication that treats opiod overdose). Review of Patient #R3's EMR, assisted by S9RN, revealed there was no documentation of the medication variance in the patient's medical record and no documentation of practitioner notification of the variance in the EMR. S9RN verified Patient #R3's EMR lacked the above referenced documentation.

As of exit on 06/03/21 at 2:30 p.m., the CAH was unable to provide a policy and procedure related to medication errors.

Based on observation, interview and record review, the CAH's infection prevention and control program failed to ensure a clean and sanitary environment that avoided potential transmission of infections was maintained. This deficient practice was evidenced by 1) failing to sanitize patient furnishing and patient care equipment; 2) failing to ensure expired patient use devices were discarded and not available for use; and 3) failing to ensure soiled surgical instruments were correctly processed for disinfection.
Findings:

1) On 06/01/2021 at 10:15 a.m., observation revealed room a with a sofa containing rips/tears which prevent proper sanitizing and an infusion pump with grime and debris on the body of the pump.

Interview on 06/01/2021 at 10:16 a.m., S2RN acknowledged the findings and confirmed the sofa could not be properly sanitized and the infusion pump was not clean.

2) On 06/01/21 at 10:40 a.m., observation of the crash cart on the Labor and Delivery unit revealed the following:
- 10 Miller and Mac laryngoscope blades of various sizes expired in 2019;
- 1 CO2 detector expired 06/2019
- Pediatric CO2 detector, expired 07/02/19
- Adult CO2 detector, expired 06/19/19
- ET tube, size 4.5, expired 11/14/19
- ET tube, size 4.5, expired 08/2018
- 2 ET tube, size 5.0, expired 03/2019
- ET tube, size 5.5, expired 05/2018
- ET tube, size 6.0, expired 11/2019
2 packages of electrodes expired 01/26/20


On 06/01/21 at 11:10 a.m., observation of the crash cart on the nursing unit revealed the following:
- 9 Miller and Mac laryngoscope blades of various sizes expired in 2019;
- 1 impedance threshold device (ITD) expired 06/2020
- 3 packages of electrodes, expired 12/22/19
- NS 500 ml, expired 12/2020
- NS 250 ml, expired 05/2021
- Adult CO2 detector, expired 08/22/18
- Pediatric CO2 detector, expired 10/2016

An interview with S5ADON confirmed the above expired respiratory supplies should not be available for patient use on the crash carts.

3) Review of policy titled, "Processing Soiled Instruments" revealed in part: to place surgical instruments in disinfectant, one ounce of disinfectant to each gallon of water.

On 6/2/21 at 10:10 a.m., an observation of the surgical disinfection area with S7ST. S7ST had surgical instruments soaking in a sink. Asked S7ST what chemical is being used to disinfect and showed me bottle of Ecophene. States that she uses one pump to 1 gallon of water and she uses 3 pumps/3 gallons in the sink. Asked how she knew there was 3 gallons of water in sink, and she said she was unsure, that it should be marked. Reviewed bottle of Ecophene and stated 1 ounce to 1 gallon. Pumped 3 pumps in measuring cup and measured 3 ounces.

Interview on 6/2/21 at 10:30 a.m., S1DON confirmed the sink should be marked with a fill line for the water.





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