HospitalInspections.org

36293


Based on observation and interview, the hospital failed to ensure patients at risk for harm to self or others were provided care in a safe setting as evidenced by failing to ensure rooms were free of ligature points and tamper proof screws.
Findings:

Observation on 09/30/19 at 10:45 a.m. of patient room g revealed the shower faucet was torn away from the shower wall in the bathroom. Observation of patient room h revealed a part of the door handle was missing from the bathroom door, creating a hole in the door. Interview at this time with S1DON confirmed the above items created a ligature point.

Observation on 09/30/2019 at 10:50 a.m., accompanied by S1DON, revealed ligature points at the water valves and inlets supply pipe to the toilets in all the patient's bathrooms. Continued observation revealed non-tamper proof screws in the latch plates of the entry doors and bathroom doors in all the patient rooms.

During an interview on 09/30/2019 at 11:30 a.m., S1DON acknowledged all the patient rooms contained the ligature points in the bathrooms and non-tamper proof screws in the entry and bathroom doors.

Observation on 09/30/2019 at 11:35 revealed ligature points at water valve and inlet for supply to the toilets; the interior aspect of the doorknobs; and the sprinkler head in room a and room b.

During an interview on 09/30/2019 at 11:40, S1DON acknowledged the multiple ligature points located in rooms a and b.

Based on record review and interview, the RN failed to follow the hospital policy for monitoring the condition of the patient who was in seclusion for 1 (#3) of 1 patient reviewed who was placed in seclusion.
Findings:

Review of the hospital policy #2044 for Restraint/Seclusion dated 10/2013, section titled Patient Monitoring/Assessment/Reassessment revealed, in part.....The patient should be monitored continuously through direct observation and every 15 minute documentation in the medical record and will include the following: toileting, range of motion, hygiene, fluids/nutrition, circulation checks, vital signs, respiratory status, cardiac status, skin integrity, pain score, physical and psychological status...

Review of the hospital policy #2049 for Seclusion and Restraint Flowsheet Use dated 10/2013, section titled Documentation revealed, in part....Every 15-minutes an assessment must be completed and documented by licensed staff. The information collected must be assessed by the RN...Record vitals every 15 minutes to include blood pressure, pulse, respirations and temperature.

Review of the seclusion/restraint telephone orders for patient #3 dated 09/21/19 at 14:40 signed by S2MD revealed: continuous face-to-face observation and continuous video monitoring with every 15 minute checks documented on the Restraint and Seclusion Flow Sheet; and an order for vital signs parameters for notification of physician (blood pressure, temperature, pulse)...

Review of the Restraint/Seclusion Log revealed that patient #3 was placed in seclusion on 09/21/19 from 14:45 until 16:45. Review of the Restraint/Seclusion Flowsheet revealed that visual monitoring was noted every 15 minutes during the 2 hour period by S9RN. There was no evidence that the vital signs and needs assessments were documented.

On 10/02/19 at 2:30p.m., the written nurse notes documented by S9RN for patient #3 while in seclusion were presented by S1DON. Review of the nurse notes revealed that assessments and vital signs were documented by S9RN on 09/21/19 at 15:00 and 15:30.
Interview with S1DON at this time confirmed that the assessments should have been completed by the RN every 15 minutes while in seclusion.

Based on record review, and interview the hospital failed to ensure that medical records were completed no later than 30 days after patient discharge.
Findings:

Review of the hospital policy titled, Discharge Procedures, revealed in part that if record has not been completed in 30 days after discharge, physicians will receive a verbal notification of their delinquent records. The CEO will get a montly report of staff deficiencies documented on the PI tool.

On 10/02/19 at 10:30 a.m., interview with S8Medical Records Clerk revealed that he was responsible for delinquent medical records. When asked the number of delinquent medical records at the hospital, he pointed to a shelf containing approximately 75 records. When asked if he knew the specific number, he stated no. When asked for the oldest delinquent record, he then was observed to look thru the records to locate the oldest. S8Medical Records Clerk stated the most delinquent record was dated 06/05/19. When asked if he had any documentation related to the deliquency dates, he stated no. He stated that he only kept documentation of the total number of delinquent charts by non-physician staff, but did not keep a total of delinquencies for the physicians. At that time, the surveyor reviewed the delinquent medical records on the shelf and counted 31 medical records delinquent over 30 days, with the oldest being dated 04/09/19.

Further interview with S8Medical Records Clerk revealed that he notifies the physicians and staff of the delinquent medical records by text and phone calls. He further stated that he gives the total amount of delinquent records to S2DON monthly but was not sure what she did with that information.

On 10/02/19 at 10:40 a.m., interview with S1DON revealed that S8Medical Records Clerk provides her monthly with a total amount of delinquent medical records that she uses for her QA data. When asked is she does anything else with this information, she stated no.

Review of the monthly QA data submitted by medical records revealed the following:
August 2019, 31 delinquent medical records over 30 days
July 2019, 6 delinquent medical records over 30 days
June 2019, 23 delinquent medical records over 30 days
May 2019, 17 delinquent medical records over 30 days

On 10/02/19 at 12:30 p.m., interview with S7Program Director revealed that she was also the supervisor of medical records. S7Program Director stated that she was unsure why the delinquent medical records had not been completed and acknowledged the policy was not being followed.

Based on record review and interview, the hospital failed to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed (review 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, 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.

Review of the hospital policy titled, Automated Medication Dispensing System, revealed in part that any new admit can be entered as an ad hoc patient to gain access to medications required to treat the immediate needs of the patient.

Review of the hospital policy titled, Medication Administration and MD Orders for Medication, revealed in part that that for medication orders received after regular pharmacy hours and would require administration of the medication prior to the start of business for the pharmacy and given that this medication is available in the formulary, there will be an on-call pharmacist available to review these orders prior to the nurse administering the medication.

Review of the contract with the Consultant Pharmacist, S5Pharmacist, revealed no documented evidence that first dose medication reviews would be performed.

On 10/01/19 at 3:30 p.m., interview with S3LPN revealed that the hospital did not have an on-site pharmacy. She indicated when an initial dose of a new medication (that was not an emergent medication) was ordered for a patient, the order was faxed to Pharmacy A. S3LPN stated that if the medication is a "stock" medication and available at the hospital, the first dose would be administered to the patient prior to the first dose review by the pharmacist. S3LPN stated that the pharmacist would review the medication when the pharmacy opened back up the next morning.

On 10/02/19 at 9:40 a.m., interview with S6LPN revealed that if a new order is received after the off-site pharmacy (Pharmacy A) is closed, the first dose of the medication would be obtained from the hospital's stock medication and administered to the patient. S6LPN further stated that the pharmacist would review the medication the next morning.

On 10/02/19 at 2:00 p.m., S1DON confirmed first dose reviews were not being performed by the pharmacist on new medications that were ordered after pharmacy hours (6:00 p.m.). S1DON stated that is the new medication is a stock medication at the hospital, the nurses will administer the first dose prior to pharmacy review.

Based on observation and interview, the hospital failed to ensure that outdated, mislabeled or otherwise unusable drugs and biologicals were not available for patient use as evidenced by 1) having expired and/or unusable medications available for patient use, 2) having multi-dose vials of medication that were unlabeled with first puncture date and/or had gone beyond the time frame allowed for use after the first puncture, and 3) taping narcotic medications back into the medication pill pack.
Findings:

On 10/01/19 at 8:45 a.m., observation of the medication room refrigerator with S1DON revealed the following:
Humulin R vial labled with an 08/20/19 open date
Levelmir vial labeled with an 08/16/19 open date
Tubersol vial labeled with an 08/29/19 open date
Humalog U-100 vial labeled with an 08/13/19 open date
Lantus 100u/mL vial labeled with an 08/10/19 open date

Interview with S1DON at that time confirmed that the above medication vials should have been discarded 28 days after the open date. S1DON further confirmed that the medications should have not been available for patient use.

On 10/01/19 at 9:00 a.m., observation of the medication storage cabinets in the medication room with S1DON revealed multiple expired medications and included the following:
Ipratropium Bromide, 4 individually packaged doses with expiration date of 01/2019
Ipratropium Bromide, one full box with expiration date of 08/2019
Ranitidine, one bottle with expiration dte of 09/2019
Dermal Wound Cleanser bottle with expiration date of 09/2017
Lotrimin powder with expiration date of 05/2018
Sensicare cream, one tube with expiration date of 09/2016
Hydrogel tube with expiration date of 01/2018

On 10/01/19 at 9:25 a.m., observation of the medication cart with S1DON revealed the following:
Lidocaine, 50mL vial labeled with an open date of 08/16/19
Lidocaine, 50mL vial labeled with an open date of 06/20/18
Sterile Water, 10mL vial labeled with an open date of 08/14/19
Cyanocobalamin 1000mcg/10mL opened vial with no label indicating first puncture date
Aristada ER 882mg/3.2mL, 2 syringes with expiration date of 08/2019
Aristada ER 1064 mg/3.9mL, 2 syringes with expiration date of 08/2019

Interview with S1DON at that time confirmed the above expired and unusable medications. S1DON further confirmed these medications should not have been available for patient use.

Further interview with S1DON at 10/01/19 at 10:00 a.m. revealed that the hospital's consultant pharmacist should be checking for expired and unusable medications monthly. S1DON further stated that she was unable to locate a policy for expired medications or unusable medications (labeling multi-dose vials with first puncture date).

On 10/01/19 at 10:45 a.m., observation of the locked narcotic cabinet with S3LPN revealed the following:
Temazepam 15mg tablets, total of 19 pills in medication package with 2 pills taped back into package
Chlordiazpx 25mg , total of 35 pills in medication package with 1 pill taped back into package
Lorazepam 1mg tablets, 54 total pills with 2 pills taped back into package

Interview with S3LPN at that time revealed that she was aware that narcotic medications should not be taped back into the medication punch package if not used on a patient. On 10/01/19 at 1:00 p.m., interview with S1DON confirmed that narcotic medications should not be taped back into the medication punch packages.

On 10/02/19 at 9:15 a.m., observation of the lab room with S1DON revealed the following expired medications stored in the cabinet:
Aristada 882mg , expiration date of 05/2019
Aristada 441, expiration date of 06/201919
Latuda 120mg , expiration date of 06/2019
Abilify 400mg (2 boxes), expiration date of 07/2019
Latuda 60mg, expiration date of 05/2019
Latuda 60mg (2 boxes), expiration date of 07/2019

Interview with S1DON at that time revealed that the above medications were sampled medications that S2Physician brought to the hospital from her office. S1DON revealed that the medications were available for patient use, but were expired. When asked if the hospital had an inventory of the sampled medication, she stated no. She further revealed that the consultant pharmacist did not have access to these medications.

Based on record review and interview, the hospital failed to ensure identified medication errors were documented in the patient's chart for 2 (#10, #R1) of 2 patient records reviewed who had hospital identified medication errors.
Findings:

Patient #10
Review of Medication Safety Event Report Form dated 02/27/19 revealed that Patient #10 was administered Cogentin for three days instead of Haldol, which was ordered by the physician. Further review of the record revealed no documentation of the medication error or that the physician had been notified of the medication error.

Patient #R1
Review of Medication Safety Event Report Form dated 07/01/19 revealed that Patient #R1 failed to receive three days of Clozaril 100mg daily, as ordered by the physician. Further review of the record revealed no documentation of the medication error or that the physician had been notified of the medication error.

On 10/01/19 at 10:40 a.m., S1DON reviewed the above patient records and confirmed there was no evidence the medication errors were recorded in the patient's medical record or that their physicians were notified of the medication errors.

36293


Based on observation and interview, the hospital failed to maintain a system for controlling infections and communicable diseases by failing to maintain a sanitary environment.
Findings:

Observation on 09/30/2019 at 10:50 a.m., accompanied by S1DON revealed the following:
Room c contained three walkers, an oxygen concentrator and a geri-chair with multiple surfaces covered with grime and debris.
Room d had a pillow with tear/rips to its vinyl covering on bed number B.
Room e had a mattress with tear/rips to its vinyl covering.
Room f had 9 of 12 chairs with tear/rips to their vinyl covering.

During an interview on 08/30/2019 at 11:00 a.m., S1DON acknowledged the dirty equipment designated as clean and the tear/rips to the vinyl covering of the furniture and pillow prevented them from being properly sanitized.