HospitalInspections.org

Based upon review the Quality Assurance/Performance Improvement data, list of contracted services, and staff interview, the hospital failed to ensure a mechanism was in place to evaluate patient care services provided under contract through the Quality Assurance/Performance Improvement Plan. Findings:

Review of the list of contracted services and the Quality Assurance/Performance Improvement (QA/PI) Program revealed there failed to be documented evidence the contracted services were evaluated through the QA/PI Program. Interview with S1, Chief Operating Officer, on 05/21/13 at 11:10 AM, confirmed the contracted services were not review through the QA/PI Program.

Based upon review of patient rights admission information, policy and procedure, and staff interview, the hospital failed to ensure each patient was provided information on whom to contact to file a grievance. This was evidenced by: 1) failure to provide the patient or the patient's representative information on the internal grievance process, whom to contact in the hospital to file a grievance, and 2) the phone number and address for lodging a complaint with the state agency, regardless if the patient has first used the hospital's grievance process. Findings:

Review of the patient admission rights and responsibilities revealed the following paragraph "be informed in writing about the hospital's policies and procedures for initiation, review and resolution of patient complaint, including the address and telephone number of where to file complaints with the Department of Health and Human Services." There failed to be further information related to whom to contact to file a grievance, and a phone number and address of the Louisiana Department of Health and Hospitals in order to lodge a complaint directly with the state agency. Interview with S7, Business Office Manager, on 05/21/13 at 2:40 PM, revealed the patient rights and responsibilities form was the only information provided to the patient upon admission to the hospital related to the grievance process.

Review of the policy and procedure titled "Grievance Policy/Procedure" revised 5/1/2000, revealed the policy failed to identify the patient could lodge a complaint directly with the Louisiana Department of Health and Hospitals without first using the hospital's internal grievance process.

Review of personnel records and staff interview revealed the hospital failed to ensure the full-time employee, identified as the Dietary Manager (S19 Dietary Manager Trainee), was qualified by experience or training, to serve as the director of food and dietetic services and to be responsible for the daily management of the dietary services as evidenced by a lack of documented education and/or experience in dietary services. Findings:

Review of the personnel record for the hospital's Dietary Manager (identified as S19 Dietary Manager Trainee), revealed there failed to be documented evidence she had completed a course for Dietary Managers, nor was there documented evidence of her experience working as a Dietary Manager.

Interview, on 05/21/13 at 1:45PM, with S19 Dietary Manager Trainee confirmed she had not completed a course of study for Dietary Managers.

Interviews, on 05/21/13 at 3:25PM, with S1 Chief Operating Officer and S2 RN Director of Nursing, confirmed S19 Dietary Manager Trainee had not completed a course for Dietary Managers and also confirmed the hospital did not have a full-time Registered Dietitian.