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Based on record review and staff interview, the hospital failed to ensure the QAPI (Quality Assessment Performance Improvement) program included an effective system to analyze, monitor, and track 1) delinquent records, and 2) new construction within the hospital. Findings:

1. Review of the QAPI program Quality Monitoring and Evaluation Indicators from July 2015 to October 2015 revealed incomplete data collected for monitoring delinquent medical records. Documentation revealed the total number of admissions for each month and how many charts were reviewed. The data did not include the total number of delinquent records.

Interview on 10/14/15 at 2:30 p.m.with S34Medical Records Director confirmed that she only reviewed approximately 20% of the admission records for each month. She further confirmed that she did not report the number of delinquent records to QAPI.

2. Review of the QAPI program Quality Monitoring and Evaluation Indicators from July 2015 to October 2015 revealed there was no data available for the new construction to the hospital that was started in July 2015.

Review of the current policies and procedures presented by S2DON as current, revealed no policy and procedure relevant to hospital construction, renovation, and the inclusion of the requirement for an ICRA to be performed prior to the beginning of any renovation and construction projects.

In an interview on 10/15/15 at 9:55 a.m., S1Administrator and S2DON indicated there had been discussion at meetings regarding the renovation and construction in the hospital. The ICO (Infection Control Officer) and/or housekeeping services would report any problems they noted during the renovation and construction process, but there was no documentation that the construction was included in the QAPI meetings.

Based on record review and interview, the hospital failed to ensure the skill and competence of all individuals providing direct patient care had been evaluated by failing to maintain documentation of current skills competency for 4 of 4 (S10RN, S27RN, S28RN, S29RN) nursing personnel records reviewed for competency. Findings:

Review of the personnel records of S10RN, S27RN, S28RN and S29RN revealed no documented evidence of current skills competency evaluations.

In an interview with S2DON on 10/15/15 at 11:20 a.m., she confirmed that the above nurses were currently employed by the hospital, but there was no documented evidence of any current skills competency evaluations for the nurses.

Based on record review, observation and interview, the hospital failed to ensure Medical Staff rules and regulations and Medical Records policies and procedures were followed related to 1) medical records being promptly completed and 2) protected from fire and water damage. This was evidenced by: 1) failure of the medical staff to follow medical records policies and procedures related to having 300 patient records that were incomplete dating back to December 2014, 2) failure to follow Medical Staff rules and regulations related to physicians with delinquent records and suspension, and 3) failure to ensure the medical records were protected from fire and water damage.
Findings:

Review of the policy titled, Incomplete Medical Records, presented as current by S34 Medical Records Director, revealed that the records of discharged patients are completed within a period of time that in no event exceeds 30 days following discharge.

Review of the Medical Staff rules and regulations, with a review date of 01/0615, revealed in part that the attending physician shall complete all parts of the patients' chart within 20 days from the date they are placed in the doctor's medical records slot. If they are not completed within this time frame, the physician shall be notified in writing by either the Chief of Staff, Administrator, or a member of the Board of Directors, that the record is delinquent and that the physician will be given an additional 10 days to complete the record. If the record is not completed within this grace period (30 days), all privileges of that physician will be suspended until the records are completed, including progress notes and signatures. Notification of this action shall be in writing to the attending physician by the Administrative Committee.

On 10/13/15 at 10:00 a.m., observations in the office of S35 Medical Records Clerk revealed multiple patient records on open shelving in her office that were not protected from fire or water damage. Further observations revealed the records dated back to December 2014. At that time, interview with S35 Medical Records Clerk revealed that delinquent medical records were on the shelves, but she was unsure of exactly how many. She stated that there were approximately 300 delinquent records on the shelves from 12 different physicians. S35 Medical Records Clerk further stated that when she sees the physicians at the hospital, she tries to catch them so they can complete their delinquent charts.

On 10/13/15 at 10:35 a.m., observations in the office of S36 Medical Records Clerk revealed approximately 400 patient medical records were on open shelves in the office. Interview with S36 Medical Records Clerk at that time revealed that these records were waiting to be scanned into the computer and were not protected from fire or water.

On 10/13/15 at 2:30 p.m., interview with S34 Medical Records Director revealed that the hospital had several delinquent records dating back to December 2014. She further revealed that she was unsure of the exact number or exact time frames of the delinquent records. Further interview revealed that no letters had been mailed to the physicians involved and no physicians had been suspended related to their delinquent records. Further interview confirmed that the medical records stored in the above clerks' offices were on open shelves and were not protected from fire or water damage.

Interview on 10/14/15 at 2:30 p.m. with S34 Medical Records Director revealed the following physicians had delinquent records past 30 days:

S20Physician - 1 record
S21Physician - 2 records
S22Physician - 36 records
S23Physician - 58 records
S24Physician - 10 records
S25Physician - 43 records
S26Physician - 150 records

On 10/15/15 at 1:00 p.m., interview with S1 Administrator confimed that he was unaware that the hospital had 300 delinquent medical records. S1 Administrator further confirmed that the physicians involved had not been notified in writing of their delinquencies and no physicians had been suspended.

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 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.

In an interview on 10/14/15 at 9:25 a.m. with S15Pharmacy Director, he confirmed that he was the pharmacist in charge. He further stated pharmacy hours were 7:00 a.m. to 5:30 p.m. Monday through Friday. During pharmacy hours, the hospital was providing first dose of medications for appropriateness. After hours and on the weekends, there was nothing in place for first dose review. S15Pharmacy Director further stated that the hospital did not have a policy for first dose review.

Interview on 10/15/15 at 9:40 a.m. with S1Administrator confirmed the hospital did not have a policy for first dose review in place.

Based on observation and interview, the hospital failed to ensure that the condition of the physical plant and overall hospital environment was maintained in a manner to ensure the safety and well being of patients and visitors. This deficient practice was evidenced by:
1. failing to ensure the hospital construction maintain a barrier to contain construction dust.
2. failing to ensure mechanical electrical panels remained locked.
Findings:

Observation on 10/12/15 from 11:10 a.m. to 12:20 p.m. of the 3rd floor patient care area revealed new construction in progress. There was a sheetrock barrier wall erected on one side of the hallway that separated newly remodeled patient rooms. Along the length of the hallway there were approximately 11 ceiling tiles missing revealing wires and overhead pipes. There was visible construction dust covering the floor, hand rails, equipment in the hallway, and walls. There were 3 electrical panel missing locking mechanisms accessible to the public. Panel box #1 contained circuit breakers, box #2 contained exposed low voltage wires, and box #3 contained circuit breakers. There was construction dust noticeable in the elevators and hallway leading from the back of the hospital doors to the Administration building. There was a carpeted floor mat at the rear door that contained white dusty footprints and the concrete covered pathway between the buildings also contained white dusty footprints.

Interview on 10/12/15 at 11:50 a.m. with S9Maintenance confirmed that the electrical panel boxes should be locked and he did not know why there were no locking mechanisms on the panels. S9Maintenance further stated that there was construction still in progress on the patient floor and the contractor probably had accessed the electrical panels and removed the locks. S9Maintenance further stated that he did not know why the ceiling tiles were removed.

Interview on 10/12/15 at 2:10 p.m. withS12Housekeeper stated that she was assigned to the 1st floor and had cleaned the hallways and elevators today.

In an interview on 10/15/15 at 9:55 a.m., S1Administrator and S2DON confirmed there was no policy and procedure relevant to hospital construction, renovation, demolition, etc., and there should have been.

Based on record review, observations, and interviews, the hospital failed to ensure that the person designated as infection control officer developed and implemented policies and procedures governing control of infections and communicable diseases. This deficient practice was evidenced by:

1) failure to provide documentation of evidence that the Infection Control Officer was qualified through education, training, experience, or certification;

2) failure to implement policies and procedures for monitoring, surveillance, and implementation of corrective actions, and ongoing evaluation of corrective actions for environmental concerns related to current renovations and construction in the hospital;

3) failure to have policies and procedures relevant to hospital construction, renovation, maintenance, demolition, and repair, including the requirement for an ICRA to define the scope of the project and need for barrier measures before a project gets under way;

4) failure to maintain a clean and sanitary environment for patients;

Findings:

1) failure to provide documentation of evidence that the Infection Control officer was qualified through education, training, experience, or certification

In an interview on 10/12/15 at 11:55 a.m., S1Administrator indicated that the designated Infection Control Officer, S39ICO, was out of the country on leave and was not available for this survey. He further indicated S39ICO was hired in 2010, and was designated as the Infection Control Officer in 2010.

Review of the personnel file for S39ICO revealed her resume which listed previous jobs starting in 05/00 and ending with "01/08-Present." There were no jobs listed which identified S39ICO as having prior experience in infection control practices.

Further review revealed there was no documented evidence that S39ICO had received ongoing training and education relative to the development, implementation, and evaluation of policies, procedures, and systems for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.

In an interview on 10/15/15 at 11:45 a.m., S1Administrator confirmed there were no further documents or documentation available which indicated and/or verified the qualifications, education, training, and experience for S39ICO.


2) failure to implement policies and procedures for monitoring, surveillance, and implementation of corrective actions, and ongoing evaluation of corrective actions for environmental concerns related to current renovations and construction in the hospital

Review of policy entitled "Environmental Services Policy and Procedures" with an effective date of 04/07/15, revealed, in part: Environmental Services Policy:

"Monitoring: Monitoring is used to assess the performance of the Environmental Services Staff to ensure the highest quality of patient care and most effective use of that department's resources. Appropriate monitoring criteria shall be established by the departmental supervisor and be reported to the Director. These criteria shall include at least the following on a routine basis: 1. Infection Control; 2. Cleaning of Patient Rooms and Discharges; 3. Care and Upkeep of Equipment; 4. Proper cleaning of hospital campus, ... and 5. Critical Areas (Surgery).

Reporting: To share meaningful information with other departments and/or committees as appropriate to ensure high quality patient care and effective utilization of hospital resources. Environmental Services Department will be made aware of the responsibility to report any incident contrary to accepted practice to their supervisor. Problems regarding departmental procedure shall be dealt with by Department Supervisor."

In an interview on 10/15/15 at 11:05 a.m., S1Administrator and S2DON confirmed there had been no information or data received by them and/or been made available to them from the Infection Control Officer and/or Housekeeping Department personnel that had identified problems related to the unclean and unsanitary environment related to the copious amount of particulate matter from the renovation and construction process observed on the patient unit.


3) failure to have policies and procedures relevant to hospital construction, renovation, maintenance, demolition, and repair, including the requirement for an ICRA to define the scope of the project and need for barrier measures before a project gets under way

Review of the current policies and procedures presented by S2DON as current, revealed no policy and procedure relevant to hospital construction, renovation, and the inclusion of the requirement for an ICRA to be performed prior to the beginning of any renovation and construction projects.

In an interview on 10/15/15 at 9:55 a.m., S1Administrator and S2DON indicated the designated S39ICO was out of the country on leave and was not available during this survey. S1Administrator and S2DON confirmed there was no policy and procedure relevant to hospital construction, renovation, demolition, etc., and there should have been.

In an interview on 10/15/15 at 9:55 a.m., S1Administrator and S2DON indicated there had been discussion at meetings regarding the renovation and construction in the hospital, and it was mentioned during the meetings that S39ICO and/or housekeeping services would report any problems they noted during the renovation and construction process. S1Administrator and S2DON confirmed there was no formal and/or documented ICRA performed at the hospital prior to the onset of renovations and construction, and there should have been.


4) failure to maintain a clean and sanitary environment for patients

Review of policy entitled "Environmental Services Policy and Procedures" with an effective date of 04/07/15, revealed, in part: Environmental Services Policy: The hospital should maintain a hygienic atmosphere and a level of cleanliness for the patients of the hospital as well as the visitors."

Observations on 10/12/15 at 11:30 a.m. of both crash carts on the third floor revealed the entire carts, including the monitors, had a thick coating of dust.

Observations on 10/12/15 at 11:40 a.m. of the IV room on the third floor revealed small plastic bins containing IV supplies were located in this room. Further observations in these bins revealed lint, construction dust and dead insects were in the bottom of them.

Observation on 10/12/15 from 11:10 a.m. to 12:20 p.m. of the 3rd floor patient care area revealed new construction in progress. There was a sheetrock barrier wall erected on one side of the hallway that separated newly remodeled patient rooms. Along the length of the hallway there were approximately 11 ceiling tiles missing revealing wires and overhead pipes. There was noted construction dust covering the floor, hand rails, equipment in the hallway, and walls.

Based on record review and interview, the hospital failed to ensure the infection control officer:

1) developed and implemented policies and procedures to minimize the risk of transmissions MDROs within the hospital;
2) had a system in place to designate patients known to be colonized or infected with a targeted MDRO and to notify receiving units and/or facilities and personnel prior to tranferring patients within the hospital or transferring patients to other facilities;
3) developed and implemented a policy and procedure for TB screening and surveillance for employees upon hire and annually for 3 (S10RN, S32RN, S33RN) of 5 (S10RN, S30RN, S31RN, S32RN, S33RN) personnel files reviewed for TB testing.

Findings:

1) developed and implemented policies and procedures to minimize the risk of transmissions of multi-drug resistant organisms within the hospital

Review of the current policies and procedures presented by S2DON as current, revealed no policy and procedure to minimize the risk of transmissions of multi-drug resistant organisms within the hospital.

In an interview on 10/15/15 at 9:55 a.m., S1Administrator and S2DON indicated the designated S39ICO was out of the country on leave and was not available during this survey. S1Administrator and S2DON confirmed there was no policy and procedure to minimize the risk of transmissions of multi-drug resistant organisms within the hospital, and there should have been.


2) failed to have a system in place to designate patients known to be colonized or infected with a targeted multi-drug resistant organism and to notify receiving units and/or facilities and personnel prior to tranferring patients within the hospital or transferring patients to other facilities.

Review of the current policies and procedures presented by S2DON as current, revealed no policy and procedure and/or system in place that would designate patients known to be colonized or infected with a targeted multi-drug resistant organism and to notify receiving units and/or facilities and personnel prior to the transferring patients within the hospital or transferring patients to other facilities.

In an interview on 10/15/15 at 9:55 a.m., S1Administrator and S2DON indicated the designated S39ICO was out of the country on leave and was not available during this survey. S1Administrator and S2DON confirmed there was no policy and procedure and or system in place that would designate patients known to be colonized or infected with a targeted multi-drug resistant organism, and notification prior to transfer of the patient, and there should have been.

3) developed and implemented a policy and procedure for TB screening and surveillance for employees upon hire and annually for 3 (S10RN, S32RN, S33RN) of 5 (S10RN, S30RN, S31RN, S32RN, S33RN) personnel files reviewed for TB testing.

Review of Public Health-Sanitary Code (Title 51, Part II, Chapter 5, 503) Mandatory Tuberculosis Testing revealed, in part, "A. All persons prior to or at the time of employment at any hospital...requiring licensing by the Department of Health and Hospitals...or any person prior to or at the time of commencing volunteer work involving direct patient care at any hospital...shall be free of tuberculosis in a communicable state... C...In order to remain employed or continue to work as a volunteer, shall be rescreened annually..."

Review of the hospital policy and procedure for new employee orientation revealed that all employees would receive a pre-employment TB skin test. On 10/15/15 at 11:10 a.m., interview with S2DON revealed that she was unable to locate a policy and procedure that addressed annual TB screenings, but stated that all staff should also receive annual TB skin tests.

Review of the personnel file for S10RN revealed the last documented TB skin test was on 08/11/14. Review of the personnel file for S32RN revealed the last documented TB skin test was on 04/11/12. Review of the personnel file for S33RN revealed the last documented TB skin test was on 05/12/14.

On 10/15/15 at 11:10 a.m., interview with S2DON confirmed that the above nurses are currently employed by the hospital. S2DON further confirmed that they had not received an annual screening or testing for TB.

Based on interview, the hospital failed to ensure the discharge planning process was reviewed in an ongoing manner through quality assurance and performance improvement activities which included tracking readmissions to the hospital and reviewing any readmissions for potential problems in the discharge planning process. Findings:

In an interview on 10/15/15 at 10:10 a.m., S38Case Manager confirmed that the hospital had no documented evidence that readmissions were tracked and reviewed for any potential problems in the discharge planning process. She further confirmed that readmissions was not an indicator that was being monitored through the hospital's quality assurance program.

On 10/15/15 at 10:10 a.m, interview with S3ADON revealed that he is also the director of case management. He confirmed that the hospital was not tracking readmissions to the hospital, and there was no data available regarding readmissions and the analyses of readmissions to the hospital. S3ADON further confirmed that the hospital did not review or monitor its discharge planning processes and procedures in an ongoing manner through quality assurance practices, and he was not aware of any quality assurance indicators that evaluated the discharge planning process for its effectiveness.

Based on record review and interview, the hospital failed to ensure there was an updated history and physical examination completed and documented within 24 hours after admission or registration for 3 (#16, #17, #18) of 6 ( #13, #14, #15, #16, #17, #18) records reviewed for completed and/or updated history and physical assessments by the physician prior to surgery.

Findings:

Review of the Medical Staff Rules and Regulations revealed, in part, the following: "...7. The attending physician shall be held responsible for the preparation of a complete medical record for each patient....8. A complete history and physical examination shall in all cases be written or dictated within twenty-four (24) hours after admission of the patient...9. The history and physical examination shall be recorded before any surgical operation is undertaken...

Patient #16
Review of the medical record for Patient #16 revealed a history and physical assessment had been completed on 09/22/15, and Patient #16 had a surgical procedure on 10/13/15. Further review revealed there was no documented update to the history and physical assessment by the physician on 09/22/15 prior to the surgical procedure.

Patient #17
Review of the medical record for Patient #17 revealed a history and physical assessment had been completed on 09/29/15, and Patient #17 had a surgical procedure on 10/12/15. Further review revealed there was no documented update to the history and physical assessment by the physician on 09/29/15 prior to the surgical procedure.

Patient #18
Review of the medical record for Patient #18 revealed a history and physical assessment had been completed on 10/08/15, and Patient #18 had a surgical procedure on 10/12/15. Further review revealed there was no documented update to the history and physical assessment by the physician on 10/12/15 prior to the surgical procedure.

In an interview on 10/13/15 at 1:45 p.m., S18OR Supervisor confirmed that the above-referenced patients did not have an updated history and physical examination by the physician documented in the medical records within 24 hours of the surgical procedure.

Based on record review and interview, the hospital failed to ensure a properly executed informed consent form for the operation was in the patient's chart before the surgical procedure 2 (#17, #18) of 6 ( #13, #14, #15, #16, #17, #18) records reviewed for properly executed informed consent form for the operation must be in the patient's chart before surgery. Findings:

Review of a document "Informed Consent for Surgery" revealed, in part, the following: "...A properly executed informed consent form for the surgery that is signed by the patient or someone acting on behalf of the patient and properly witnessed must be in the patient's chart before surgery except in emergencies. 2. A specific consent should include:...b. documentation of the licensed practitioner who will perform the procedure; c. Purpose of the treatment/procedure; e. Patient's diagnosis or condition for which the treatment/procedure is indicated; i. Reasonable therapeutic alternatives

Patient #17

Review of the medical record for Patient #17 revealed an incomplete surgical consent form was signed on 09/29/15, and Patient #17 had a surgical procedure on 10/12/15. Further review of the consent form revealed Item #3 and Item #5 were left blank and not completed.

Patient #18

Review of the medical record for Patient #18 revealed an incomplete surgical consent form was signed on 10/08/15, and Patient #18 had a surgical procedure on 10/12/15. Further review of the consent form revealed Item #2.B., Item #3, and Item #5 were left blank and not completed. Further review also revealed the blank requiring the physician's signature was blank and no signature by the physician was documented.

In an interview on 10/13/15 at 1:45 p.m., S18OR Supervisor confirmed that the above-referenced patients did not have a properly executed informed consent form on the medical record prior to the surgical procedures, and there should have been properly completed surgical consent forms on the medical records.

Based on record review and interview, the hospital failed to ensure that an ongoing program of activities was provided by a qualified activity professional for 2 of 2 patients (#1, #29) who were admitted to Swing Bed status in a total sample of 30. Findings:

Review of the medical records for patients #1 and #29 revealed that they were admitted to Swing Bed status. Further review of their records revealed no documented evidence that an ongoing program of activities were provided to the patients.

On 10/14/15 at 10:30 a.m., interview with S14 Medical/Surgical Director confirmed that patients admitted to Swing Bed status were not provided an ongoing program of activities. She further confirmed that the hospital did not employ a qualified activity professional.