HospitalInspections.org

Based on record review and interview, the Governing Body failed appoint members to the medical staff in accordance with medical staff bylaws. The Governing Body appointed members to the medical staff without specific privileges delineated for 4 (S14MD, S15Physician, S16Physician, S17Physician) of 5 (S14MD, S15Physician, S16Physician, S17Physician, S18APRN) sampled credentialing files reviewed. Findings:

Review of the Medical Staff Bylaws, Rules & Regulations, approved on 05/06/15 revealed in part the following: Appointment to and subsequent membership on the Staff shall confer on the Member only such Clinical Responsibilities, Prerogatives, and other rights as have been granted by the Board in accordance with these Bylaws....Clinical Responsibilities may be granted only upon formal request on forms provided by the Hospital with subsequent processing and approval. Every Application for Staff appointment and reappointment must contain a request for the specific Clinical Responsibilities desired by the applicant. Every Practitioner providing direct clinical services within this Hospital shall be entitled to exercise only those Responsibilities specifically granted to him by the Board.

S14MD
Review of the credentialing file for S14MD (hospital's medical director) revealed the physician was reappointed to the medical staff by the Governing Body on 02/27/15. Review of the Credentialing Approval Form revealed the Committee of the Whole recommended active status, but failed to document approval or denial of the requested privileges. S20Associate Medical Director signed the section as Committee of the Whole Chairman on 02/27/15. Further review of the Credentialing Approval Form revealed the Governing Board approved S14MD as active staff and, "Privileges: Approved per the recommendations of the Committee of the Whole."


S15Physician
Review of the credentialing file for S15Physician revealed the physician was reappointed to the medical staff by the Governing Body on 02/27/15. Review of the Credentialing Approval Form revealed the Committee of the Whole recommended consulting status, but failed to document approval or denial of the requested privileges. S14MD signed the section as Committee of the Whole Chairman on 02/27/15. Further review of the Credentialing Approval Form revealed the Governing Board approved S14MD as consulting staff and signed the Governing Board Review section, but did not address the approval or denial of the requested privileges.


S16Physician
Review of the credentialing file for S16Physician revealed the physician was reappointed to the medical staff by the Governing Body on 02/27/15. Review of the Credentialing Approval Form revealed the Committee of the Whole recommended consulting status, but failed to document approval or denial of the requested privileges. S14 MD signed the section as Committee of the Whole Chairman on 02/27/15. Further review of the Credentialing Approval Form revealed the Governing Board approved S16Physician as consulting staff and, "Privileges: Approved per the recommendations of the Committee of the Whole" was signed by the Governing Body on 02/27/15.


S17Physician
Review of the credentialing file for S17Physician revealed the physician was reappointed to the medical staff by the Governing Body on 02/27/15. Review of the Credentialing Approval Form revealed the Committee of the Whole signed the form, but failed to indicate staff status or approval or denial of the requested privileges. S14MD signed the section as Committee of the Whole Chairman on 02/27/15. Further review of the Credentialing Approval Form revealed the Governing Board approved signed the Governing Board Review section, but did not address the approval or denial of the requested privileges or the staff status.

In an interview on 02/17/16 at 10:00 a.m., S1ADM reviewed the credentialing files of the above sampled physicians and confirmed the Medical Staff (Committee of the Whole) did not document approval of the requested privileges. S1ADM confirmed the Governing Body re-appointed the physicians to the Medical Staff without complete recommendations from the Medical Staff. S1ADM confirmed the hospital's by-laws for credentialing of physician had not been followed. S1ADM stated he could not find the Governing Body minutes from February, 2015 that indicated the re-appointments, so he reviewed them with the Governing Body in July, 2015. He confirmed the incomplete credentialing documents had not been identified.

Based on record review and staff interview, the Governing Body failed to ensure the medical staff was accountable to the Governing Body for the quality of care provided to patients as evidenced by the Governing Body failing to address delinquent psychiatric evaluations by the medical staff. Findings:

Review of the Medical Staff Bylaws, Rules & Regulations dated 11/12/13 revealed in part the following: 3. The psychiatric evaluation shall be completed within sixty (60) hours of admission.

Review of the hospital policy titled, "Psychiatric Evaluation" provided as current policy by S3RDCS revealed in part the following:
Purpose: To establish or rule out the presence of active psychiatric pathology, determine patient acuity when indicated, assess clinical status and to serve as a basis for any psycho/pharmacological regimen. To serve as a format for documentation of patient's diagnosis (AXIS I-V), pertinent findings, treatment plan interventions and recommendations.
Psychiatrist/LIP: Documents a complete Psychiatric Evaluation including Axis I-V, prognosis, recommended treatment interventions, and assessment findings on Psychiatric Evaluation form, or dictated in the appropriate format within 60 hours.

Review of the 2015 and 2016 HIM Report of Delinquent Psychiatric Evaluations revealed the following:
January - 2 (94%)
February - 1 (97%)
March - 6 (84%)
April - 6 (77%)
May - 4 (87%)
June - 7 (77%)
July - 0 (100%)
August - 3 (93%)
September - 4 (80%)
October - 8 (75%)
November - 1 (97%)
December - 3 (88%)
January 2016 - 5 (84%)

Review of the Performance Priority Measures Report for Health Information Management revealed the following for Psychiatric Evaluation conducted within 60 hours of admission (sample of 8 random records):
September 2015 - 62.5%
October 2015 - 62.5%
November 2015 - 87.5%
December 2015 - 100%
January 2016 - 62.5%

In an interview on 02/16/16 at 10:35 a.m. S5HIM Director stated she documents a report of delinquent psychiatric evaluations and she conducts a random sample of 8 records per month that also includes a measure for psychiatric evaluations within 60 hours of admission. S5HIM Director stated if patients are admitted to S14MD on Fridays, the psychiatric evaluation was not done by S14MD until Monday, resulting in the psychiatric evaluation not being done within 60 hours.
S5HIM Director confirmed the above numbers of delinquent psychiatric evaluations and indicated this was reported in the QAPI process. When asked what measures had been taken to address the problem of delinquent psychiatric evaluations, she stated a letter is sent to the physician, it was discussed at medical executive meetings, and they try not to give S14MD admits on Fridays. S5HIM Director confirmed they had used the same 3 measures all year (2015 to present) and she confirmed the measures had not been effective.

Review of the Committee of the Whole and the Governing Body minutes for the year 2015 and 2016 revealed no documented evidence that the Governing Body or the Medical Staff had identified the delinquent psychiatric evaluations as a problem, nor was there evidence of any corrective actions or attempts to resolve the problem.

In an interview on 02/16/16 at 12:15 p.m., S1ADM stated he had a meeting in January with S14MD and S18APRN regarding the delinquent psychiatric evaluations. He stated the outcome of the meeting was S18APRN was checking with the nursing board to see if she can do psychiatric evaluations. S1ADM confirmed there was no documentation of this meeting and he confirmed there was no documentation in any of the Governing Body minutes of the identified problem of delinquent psychiatric evaluations. S1ADM confirmed S12MD does not come to the hospital on weekends.

Based on observations and interview, the hospital failed to ensure patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for acute care psychiatric patients on a geriatric psychiatric unit. There were currently 18 patients receiving treatment at the time of the observations.

Findings:

On 02/15/16 at 1:00 p.m., the following observations were made in patients' rooms:

a. Room entry door and bathroom doors with 3 hinges with an area between the hinges that were a ligature risk in 8 of 10 patient rooms.
b. Crank beds with 3 cranks attached to the foot of 16 of the 20 beds on the unit.
c. Patient beds (16 of 20 beds) contained springs which had sharp points that could potentially be removed and the springs and the frame of the beds presented a potential anchor point ligature.
d. Elongated sink faucets in the patients' bathroom sinks (non-anti-ligature) in 8 of 10 patient bathrooms.
e. Mattresses with a plastic cover with a zipper down the backside center of the mattress, which could serve as an area to hide contraband for 16 of 20 beds observed.
f. Elongated, exposed flush valve plumbing with flanged handles on the toilets in 8 of 10 patient bathrooms.
g.Flanged and Paddle handles (secured in a downward position) on both room entry doors (front and back) and bathroom doors that were non-anti-ligature in 8 of 10 patient rooms.

Review of the hospital census dated 2/15/16 revealed 2 current inpatients were on suicide precautions.

In an interview on 02/15/26 at 1:15 p.m.,S3RDCS confirmed the above observations and agreed they could pose safety risks for acute care psychiatric patients on a geriatric psychiatric unit.

Based on record review and interview the hospital failed to ensure all direct care staff received and remained current in training based on the use of non-physical intervention skills for 2 (S7LPN, S8LPN) of 2 Agency staff personnel records reviewed for crisis prevention intervention training. Findings:

Review of the personnel files for S7LPN and S8LPN agency staff employed by the hospital revealed no documented evidence of current CPI (Crisis Prevention Intervention) or TIDE (Therapeutic Intervention De-Escalation Education) training.

In an interview on 2/16/16 at 12:10 p.m, S7LPN stated that she had no psychiatirc nursing experience and this was the first time that she had worked in a psychiatric hospital.

In an interview on 2/17/17 at 9:40 a.m., S6HR stated that the personnel records for S7LPN and S8LPN were complete. S6HR further stated that S7LPN's first day of work for the hospital was 2/15/16 and S8LPN had worked this past weekend (2/13/16). S6HR indicated S8LPN had last worked at the hospital in 7/2015.

In an interview on 2/17/17 at 12:00 p.m. with S2DON, she confirmed the hospital used agency nurses for staffing shortages. S2DON indicated the hospital had requested psychiatric experienced nurses but the agency had not always had psychiatric experienced staff available. S2DON indicated all of the documentation and certifications required by the hospital was acquired from the staffing agency by the hospital's Human Resources Department. S2DON was not aware that S7LPN and S8LPN had not received the required crisis prevention training.

30984

Based on record review and interview, the hospital failed to ensure the ongoing hospital wide QAPI program showed measureable improvement in indicators. This deficient practice was evidenced by the QAPI program's failure to formulate and implement a corrective action plan to address failure of the psychiatrist to complete psychiatric evaluations within the 60 hour time frame requirement.

Findings:

Review of the hospital policy titled, "Psychiatric Evaluation" provided as current policy by S3RDCS revealed in part the following:

Psychiatrist/LIP: Documents a complete Psychiatric Evaluation including Axis I-V, prognosis, recommended treatment interventions, and assessment findings on Psychiatric Evaluation form, or dictated in the appropriate format within 60 hours.

In an interview on 02/16/16 at 10:35 a.m. S5HIM Director stated she documents reports of delinquent records and delinquent psychiatric evaluations. S5HIM Director provided a list of the delinquent psychiatric evaluations for the year 2015 and 2016. S5HIM Director stated if patients are admitted to S14MD on Fridays, the psychiatric evaluation was not done by S14MD until Monday, resulting in the psychiatric evaluation not being done within 60 hours.
S5HIM Director stated they try not to give admits to S14MD on Fridays.

Review of the Delinquent Psychiatric Evaluations revealed the number of delinquent psychiatric evaluations was documented including the patient's medical record number. Review of the reports revealed the following:
2015 - 45 psychiatric evaluations not completed within 60 hours of admission.
2016 - January: 5 psychiatric evaluations not completed within 60 hours of admission.
S5HIM Director confirmed the above numbers of delinquent psychiatric evaluations. S5HIM Director also provided Quality Monitoring reports from September, 2015 to January, 2016 for review and indicated these reports reflected a random sample of medical records reviewed for 10 performance measures. S5HIM Director indicated this was reported in the QAPI process. Review of the reports revealed a sample of 8 records with the performance measure for psychiatric evaluations within 60 hours below the outcome measure of 90% each month except December, 2015. When asked what measures had been taken to address the problem of delinquent psychiatric evaluations, she stated a letter is sent to the physician, it was discussed at medical executive meetings, and they try not to give S14MD admits on Fridays. S5HIM Director confirmed they had used the same 3 measures all year (2015 to present) and she confirmed the measures had not been effective.

Patient #R7
Review of the medical record for Patient #R7 revealed the patient was admitted to the hospital on 11/27/15 at 2:30 p.m. Review of the psychiatric evaluation revealed it was dated/timed 11/30/15 at 12:15 p.m., 70 hours after the patient was admitted to the hospital. Review of the list of delinquent psychiatric evaluations revealed this patient's medical record number was not included in the list.


Patient #R8
Review of the medical record for Patient #R8 revealed the patient was admitted to the hospital on 11/27/15 at 12:00 p.m. Review of the psychiatric evaluation revealed it was dated/timed 11/30/15 at 9:00 a.m., 69 hours after the patient was admitted to the hospital. Review of the list of delinquent psychiatric evaluations revealed this patient's medical record number was not included in the list.

In an interview on 02/16/16 at 1:13 p.m. S3RDCS and S5HIM Director confirmed the psychiatric evaluations for Patient #R7 and #R8 were not done within 60 hours. S3RDCS stated they know there is a problem with psychiatric evaluations being done within 60 hours.

In an interview on 02/17/16 at 11:10 a.m. with S3RDCS, she indicated a corrective action plan to address the issue with psychiatric evaluations not being completed within 60 hours had not been implemented through the hospital wide QAPI program.

30984

Based on QAPI program review and interview, the hospital failed to ensure the hospital wide QAPI program focused on high-risk, high-volume and/or problem-prone areas. This deficient practice was evidenced by the hospital's failure to:
1) identify and address hospital nursing staff's failure to document patient vital sign assessments on the patients' MARs prior to medication administration as directed by the patient's MD orders and medication administration records.
2) formulate and implement a corrective action plan to address failure of the psychiatrist to complete psychiatric evaluations within the 60 hour time frame requirement.

Findings:


1) Failure to identify and address hospital nursing staff's failure to document patient vital sign assessments on the patients' MARs prior to medication administration as directed by the patient's MD orders and medication administration records.


Review of the medical records for current inpatients #2, #3, #4, #5 and #6 revealed vital signs had not been documented on the MARs prior to administration of the patients' antihypertensive medications as directed by MD order/Directive on the patients' medication administration record.

Review of the hospital's QAPI program documentation, presented as current by S2DON, revealed no documented evidence that failure of the nursing staff to document vital signs on the MARs prior to administration of the patients' antihypertensive medications (as directed by MD order/directive on the patients' medication administration record) had been identified as an issue that needed to be addressed through the hospital's QAPI program.

In an interview on 02/17/16 at 11:00 a.m. with S2DON, she confirmed failure of the nursing staff to document vital signs on the MARs prior to administration of the patients' antihypertensive medications as directed by MD order/directive on the patients' medication administration record had not been identified, prior to the survey, as an issue that needed to be addressed through the hospital's QAPI program.

2) Failure to formulate and implement a corrective action plan to address failure of the psychiatrist to complete psychiatric evaluations within the 60 hour time frame requirement.


Review of the hospital policy titled, "Psychiatric Evaluation" provided as current policy by S3RDCS revealed in part the following:
Purpose: To establish or rule out the presence of active psychiatric pathology, determine patient acuity when indicated, assess clinical status and to serve as a basis for any psycho/pharmacological regimen. To serve as a format for documentation of patient's diagnosis (AXIS I-V),pertinent findings, treatment plan interventions and recommendations.
Psychiatrist/LIP: Documents a complete Psychiatric Evaluation including Axis I-V, prognosis, recommended treatment interventions, and assessment findings on Psychiatric Evaluation form, or dictated in the appropriate format within 60 hours.

In an interview on 02/16/16 at 10:35 a.m. S5HIM Director stated she documents reports of delinquent records and delinquent psychiatric evaluations. S5HIM Director provided a list of the delinquent psychiatric evaluations for the year 2015 and 2016. S5HIM Director stated if patients are admitted to S14MD on Fridays, the psychiatric evaluation was not done by S14MD until Monday, resulting in the psychiatric evaluation not being done within 60 hours.
S5HIM Director stated they try not to give admits to S14MD on Fridays.

Review of the Delinquent Psychiatric Evaluations revealed the number of delinquent psychiatric evaluations was documented including the patient's medical record number. Review of the reports revealed the following:
2015 - 45 psychiatric evaluations not completed within 60 hours of admission.
2016 - January: 5 psychiatric evaluations not completed within 60 hours of admission.
S5HIM Director confirmed the above numbers of delinquent psychiatric evaluations. When asked what measures had been taken to address the problem of delinquent psychiatric evaluations, she stated a letter is sent to the physician, it was discussed at medical executive meetings, and they try not to give S14MD admits on Fridays.

Patient #R7
Review of the medical record for Patient #R7 revealed the patient was admitted to the hospital on 11/27/15 at 2:30 p.m. Review of the psychiatric evaluation revealed it was dated/timed 11/30/15 at 12:15 p.m., 70 hours after the patient was admitted to the hospital. Review of the list of delinquent psychiatric evaluations revealed this patient's medical record number was not included in the list.


Patient #R8
Review of the medical record for Patient #R8 revealed the patient was admitted to the hospital on 11/27/15 at 12:00 p.m. Review of the psychiatric evaluation revealed it was dated/timed 11/30/15 at 9:00 a.m., 69 hours after the patient was admitted to the hospital. Review of the list of delinquent psychiatric evaluations revealed this patient's medical record number was not included in the list.

In an interview on 02/16/16 at 1:13 p.m. S3RDCS and S5HIM Director confirmed the psychiatric evaluations for Patient #R7 and #R8 were not done within 60 hours. S3RDCS stated they know there is a problem with psychiatric evaluations being done within 60 hours.
In an interview on 02/17/16 at 11:10 a.m. with S3RDCS, she indicated a corrective action plan to address the issue with psychiatric evaluations not being completed within 60 hours had not been implemented through the hospital wide QAPI program.

Based on interview and record review, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as evidenced by:
1) failing to notify a patient's physician of the patient's complaints of "feeling like he was having a heart attack" for 1 (#R5) of 8 (#R1-#R8) random patient records reviewed;
2) failing to ensure a patient with a history of multiple falls had remained on 1:1 observation as directed per hospital policy for 1(#R2) of 1 patients reviewed for falls, and;
3) failing to document vital signs prior to administration of medications as directed per the patient's MD orders/medication administration record for 6 (#1, #2, #3, #4, #5 & #6) of 12 patient records reviewed.


Findings:

1) Failing to notify a patient's physician of the patient's complaints of "feeling like he was having a heart attack"

Review of hospital policy titled, Early Response Intervention to Deteriorating Patient Condition/Change in Condition, Policy #: CS-29, effective date: 1/11/2016, revealed in part:
Purpose: To establish a procedure that enables the healthcare staff to directly request additional assistance from trained individuals when a patient condition appears to be worsening to establish an effective course of action.
Policy: It is the policy of the facility to improve recognition and response to changes in a patient condition. This facility identifies unexpected acute illnesses which pose life threatening situations for our patients.
II. Early Intervention Plan/Criteria for calling Additional Response Assistance/Assessment: early recognition and response to early warning signs prior to a cardiopulmonary or respiratory arrest may assist in reducing patient mortality.
Early warning signs: cardiopulmonary or respiratory arrest: Chest discomfort; Discomfort in other areas of the upper body; Shortness of breath; Other symptoms may include breaking out in a cold sweat, nausea, or light-headedness.
Learn the signs, but also remember: Even if you ' re not sure it is a heart attack, you should still have it checked out. Fast action can save lives.
Nursing: A. Call the physician on site or on-call to provide appraisal/oversight of initial treatment; B. Call attending psychiatrist and appraise of situation. Document in medical record all processes.

Patient #R5
Review of Patient #5's medical record revealed an admission date of 8/24/15. Further review revealed the patient had a diagnosis of Atrial Fibrillation. Additional review revealed Patient #R5 had a cardiac pacemaker.

Review of Patient #R5's medical record revealed the following, in part:
8/25/15 03:50 a.m.: Pt. complained, "I know I'm having a heart attack. I need to get out of here." Vital signs: 146/68, 97.9, 73, 20, 98%. Will continue to monitor for distress; none noted at this time. Further review revealed no documentation of notification of the patient ' s MD of his complaints of "feeling like he was having a heart attack."

8/25/15 05:00 a.m.: Pt. very restless, frequently asks to go home. Explained why he couldn't go home. Pt. stood in middle of floor and said, "I'm having a stress heart attack." No signs/symptoms of distress. Will continue to monitor. Further review revealed no documentation of notification of the patient's MD of his complaints of "feeling like he was having a heart attack."

8/31/15 7:30 p.m.: Pt. was sitting in the community room in the geri-chair. MHT took patient to shower. After 3 minutes of showering patient, MHT noticed pt. respirations became abnormal and asked another MHT to get the RN-Charge. RN-Charge called out the pt.'s name while palpating for a pulse. The patient was pulseless and unresponsive. CPR initiated and an area ambulance company was called. Pt. was intubated, responsive, transported to an area hospital emergency department.

8/31/15 9:15 p.m.: Received call from the hospital Emergency Department nurse that Patient #R5 had expired.

In an interview on 2/16/16 at 3:48 p.m. with S2DON, she confirmed, after review of the patient's interdisciplinary notes, that there was no documentation of notification of the patient's MD of his complaints of feeling like he was having a heart attack on 2 separate occasions (03:50 a.m. and 5:00 a.m. on 8/25/16).

In an interview on 2/17/16 at 11:00 a.m. with S3RDCS, she agreed Patient #R5's nurse should have notified the patient's MD of his complaints of "feeling like he was having a heart attack" on 8/25/15 because it was not the nurse's call to determine whether or not the patient was having a heart attack.

2) Failing to ensure a patient with a history of multiple falls had remained on 1:1 observation, as directed per hospital policy, for 1(#R2) of 1 patients reviewed for falls.

Review of the hospital policy titled, Levels of Observations, Policy#: CS-23, effective date: 1/11/16, revealed in part: Purpose: The purpose of the policy is to provide staff with a framework for monitoring patients in the clinical area to ensure the safety of those patients.
Observation Levels: One to one observation: The staff should ensure the patient is visually within sight and within arm's reach of a staff member at all times and in all circumstances.
Rationale: The decision to utilize one of the observation levels is made based on the patient's needs and presenting symptomology. The following are considered when the decision for an observation level is made: Fall Risk.

Patient #R2
Review of Patient #R2's medical record revealed he was admitted on 12/4/15 with an admission diagnosis of Neurocognitive Disorder/Dementia. Further review revealed the patient was identified as at high risk for falls on admission.

Review of Patient #R2's multidisciplinary treatment plan, initiated 12/4/15 and updated 1/10/16, revealed high risk for falls was an identified problem on his plan of care.

Review of the hospital's incident logs for the past 6 months revealed Patient #R2 had fallen on 12/5/15, 12/13/15, 12/23/15, 1/2/16, 1/4/16 and 1/10/16. Further review revealed the patient had been placed on 1:1 supervision on 12/5/15 and discontinued 12/10/15.
Additional review revealed no further documentation of physician's orders for 1:1 status after Patient #R2 had fallen on 12/23/15, 1/2/16, 1/4/16 and 1/10/16.

In an interview on 2/16/16 at 9:00 a.m. with S3RDCS, she indicated Patient #R2 should have remained on 1:1 supervision status due to his frequent falls.

3) Failing to document patient vital signs prior to administration of medications as directed per the patient's MD orders/medication administration record.

Review of the Hospital's Policy & Procedure titled,"Medications" presented by S3RDCS as being current (01/16) read in part: Verifies that there is no contraindication for administering the mediations.

Patient #1
Review of the medical record for Patient #1 revealed the patient was admitted to the hospital on 02/11/16 with diagnoses that include Hypertension. Review of the MAR entries for Patient #1 dated 02/12/16 to 02/14/16 revealed the patient was receiving Lisinopril 20 milligrams daily at 9:00 a.m. Further review revealed a directive to note the patient's recent blood pressure on the MAR. Review of the MAR documentation revealed no recent blood pressure had been documented on 2/12/16, 02/13/16, and 2/14/16 when the patient's medication had been administered.
Further review of the MAR dated 02/12/16 to 02/14/16 revealed the patient was receiving Atenolol (Tenormin) 25 mg daily at 9:00 a.m. The MAR revealed a directive to note the patient's apical pulse on the MAR, next to the time given, to hold the dose if the pulse was less than or equal to 60, and to notify the MD. Review of the MAR documentation revealed no apical pulse had been documented from 02/12/16-02/14/16 when the patient's medication had been administered.

In an interview on 02/16/16 at 9:30 a.m., S2DON reviewed the medical record for Patient #1 and confirmed the nurses failed to document a blood pressure and pulse prior to the administration of the Lisinopril and Atenolol as directed on the MAR. S2DON confirmed this requirement was not written specifically in a policy, but was the expectation/standard of practice the nurse should follow when administering medications that affected the patient's blood pressure.



Patient #2
Review of Patient #2's MAR entries dated 2/13/16 and 2/14/16 revealed the patient was receiving Lisinopril 20 milligrams daily at 9:00 a.m. Further review revealed a directive to note the patient's recent blood pressure on the MAR. Review of the MAR documentation revealed no recent blood pressure had been documented on 2/13/16 and 2/14/16 when the patient's medication had been administered.

Additional review of Patient #2's MAR entries dated 2/13/16 and 2/14/16 revealed the patient was receiving Metoprolol Tartrate (Lopressor) 50 mg daily at 9:00 a.m. Further review revealed a directive to note the patient's apical pulse on the MAR, next to the time given, to hold the dose if the pulse was less than or equal to 60 and to notify the MD. Review of the MAR documentation revealed no apical pulse had been documented on 2/13/16 and 2/14/16 when the patient's medication had been administered.


Patient #3
Review of Patient #3's MAR entries dated 2/5/16- 2/10/16 revealed the patient was receiving Lisinopril 20 milligrams daily at 9:00 a.m. Further review revealed a directive to note the patient's recent blood pressure should be noted before administering and to hold for systolic blood pressure less than 90 and diastolic blood pressure less than 60. Review of the MAR documentation revealed no recent blood pressure had been documented from 02/05/16 and 02/10/16 when the patient's medication had been administered.

Additional review of Patient #3's MAR entries dated 02/05/16 and 02/10/16 revealed the patient was receiving Atenolol (Tenormin ) 25 mg daily at 9:00 a.m. Further review revealed a directive to note the patient's apical pulse on the MAR, next to the time given, to hold to the dose if the pulse was less than or equal to 60, and to notify the MD. Review of the MAR documentation revealed no apical pulse had been documented from 02/05/16-02/10/16 when the patient's medication had been administered.


Patient #4
Review of the medical record revealed Patient #4 was a 60 year old female admitted on 02/09/16 with severe Depression. Further review revealed medical diagnoses for Hypertension, Diabetes, Hypothyroidism, and Coronary Artery Disease. Further review of the physician's orders for 02/09/16 revealed an order for Coreg 12.5 mg BID (twice a day).
Review of the MAR for Patient #4 revealed Coreg 12.5 mg twice daily at 9:00 a.m. and 9:00 p.m. and to record the apical pulse on the MAR, next to the time given and to Hold if In an interview on 02/15/16 at 3:55 p.m.,S3RDCS confirmed that the apical pulse should be documented on the MAR next to the dose given. S3RCDS verified that the nursing staff had not been documenting the required apical pulse on Patient #4 from admit (02/09/16) to present (02/15/16).

Patient #5
Review of the medical record for Patient #5 revealed she was admitted to the hospital on 02/02/16 with Axis I Dx.- Schizophrenia, NOS and Axis III Dx. - HTN, Elevated Cholesterol, Decrease Thyroid, GERD, Depression.

Review of the Physician order/Admission Medication Reconciliation for Patient #5 revealed an order for Pindolol 5 mg po bid, hold if pulse < /= 60.
Review of the MAR for Patient #5 revealed no documented evidence that her pulse was monitored prior to administration of the medication.


Patient #6
Review of the medical record for Patient #6 revealed she was admitted to the hospital on 02/04/16 with Axis I Dx. Mood D/O due to CVA with major Depression like episode and Axis III Dx.- HTN. S/P MI, S/P CVA.
Review of the Physician order/Admission Medication Reconciliation for Patient #6 revealed an order for the following medications:
Amlodipine (Norvasc) 10 mg po daily (record apical pulse on MAR, next to time given Hold if Carvedilol (Coreg) 25 mg po bid (record apical pulse on MAR next to time given Hold if < /= 60 and notify MD).

Review of the MAR for Patient #6 revealed no documented evidence that her apical pulse was monitored prior to administration of the medications.

In an interview on 02/15/16 at 3:30 p.m., S2DON confirmed that the Nurses failed to follow parameters for administration of the medications by not obtaining and documenting Patient #5 and Patient#6's apical pulse prior to administrations of the medications as ordered.


Review of the medical record for Patient #5 revealed she was admitted to the hospital on 02/02/16 with Axis I Dx.- Schizophrenia, NOS and Axis III Dx. - HTN, Elevated Cholesterol, Decrease Thyroid, GERD, Depression.

Review of the Physician order/Admission Medication Reconciliation for Patient #5 revealed an order for Pindolol 5 mg po bid, hold if pulse < /= 60.
Review of the MAR for Patient #5 revealed no documented evidence that her pulse was monitored prior to administration of the medication.

Review of the medical record for Patient #6 revealed she was admitted to the hospital on 02/04/16 with Axis I Dx. Mood D/O due to CVA with major Depression like episode and Axis III Dx.- ASWD, HTN. S/P MI, S/P CVA.
Review of the Physician order/Admission Medication Reconciliation for Patient #6 revealed an order for the following medications:
Amlodipine (Norvasc) 10 mg po daily (record apical pulse on MAR, next to time given Hold if Carvedilol (Coreg) 25 mg po bid (record apical pulse on MAR next to time given Hold if < /= 60 and notify MD).

Review of the MAR for Patient #6 revealed no documented evidence that her apical pulse was monitored prior to administration of the medications.

In an interview on 02/15/16 at 3:30 p.m., S2DON confirmed that the nurses failed to follow parameters for administration of the medication by not obtaining and documenting Patient #5 and Patient#6's pulse prior to administration of the medications as ordered.









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17091

Based on record review and staff interview, the hospital failed to ensure a system was in place to allow for timely retrieval by diagnosis and procedure of patient medical records. Findings:

Review of the hospital policy titled, "Coding, Disease and Procedure Index" provided by S3RDCS as current policy, revealed in part the following: A Disease and Procedure Index will be maintained in the HCS system and can be retrievable by specific diagnosis or procedure.

In an interview on 02/16/16 at 10:35 a.m., S5HIM Director was asked to print a list of patients with a diagnosis of Diabetes Mellitus. S5HIM Director stated she was unable to provide a list of patients by any diagnosis. She stated she could provide an alphabetical list or a list by physician, but she was unable to print a list by diagnosis or diagnosis code.

Based on observation, record review, and staff interview the hospital failed to ensure the infection control officer developed a system for controlling infections and communicable diseases of patients and personnel. This deficient practice is evidenced by:

1. Failing to ensure proper hand hygiene and accepted standards of practice for infection control were followed during blood glucose monitoring for 1 of 1 finger sticks observed, and;

2. Failing to ensure a process was in place for prevention of communicable disease by the staff as evidenced by no documented evidence the physicians credentialed at the hospital were screened annually for TB (Tuberculosis) for 2 (S14MD, S17Physician) of 5 (S14MD, S15Physician, S16Physician, S17Physician, S18APRN) credentialed files reviewed out of a total of 11 credentialed physicians and APRNs on staff at the hospital.

Findings:

1. Observation on 02/16/16 at 12:00 p.m. revealed a finger stick on Patient #4 performed by S7LPN (Licensed Practical Nurse). S7LPN failed to wash/sanitize her hands prior to place a pair of gloves on. S7LPN after performing the finger stick removed the gloves without washing/sanitizing her hands. S7LPN returned the glucometer to the nurses' station placing it on a tray next to clean supplies. S7LPN cleaned the blood glucose meter with sani-wipes, placed the meter back on top of the cart. S7LPN failed to wash/sanitize her hands before and after donning of her gloves after cleaning the blood glucose meter.


Interview on 02/16/16 at 12:40 p.m. with S2DON stated that S7LPN was an Agency staff nurse but should be adhering to standard hand hygiene protocols.

In an interview on 02/16/16 at 2:40 p.m. with S3RDCS confirmed that the nurse should have never left the tray unattended in the room and should have performed and maintained proper hand hygiene with patient care and cleaning of the blood glucose meter before returning the meter to the clean tray.

2. Failing to ensure a process was in place for prevention of communicable disease by the staff as evidenced by no documented evidence the physicians credentialed at the hospital were screened annually for TB:

S14MD
Review of the credentialing file for S14MD (Medical Director) revealed the physician was initially appointed to the medical staff on 01/29/07. Review of the file revealed the last TB test was dated 07/30/14.


S17Physician
Review of the credentialing file for S17Physician revealed the physician was initially appointed to the medical staff on 01/13/11. Review of the file revealed the last TB test was dated 03/28/14.

There was no documented evidence in either file of annual TB screening.

In an interview on 2/17/16 at 10:00 a.m., S1ADM reviewed the credentialing files of S14MD and confirmed there was no documentation of annual TB screening in the files.






17091

Based on record reviews and interviews the Hospital failed to ensure that hospital policies were adhered to that incorporated the OPO (Organ Procurement Organization) and the hospital's definition of Clinical Triggers and Imminent Death and Timely Notification in order to identify potential donors as agreed upon by the hospital's OPO contract and in accordance with the Louisiana Uniform Anatomical Gift Act. Findings:


A review of the hospital's OPO signed contract, provided by S1ADM, as the current contract, revealed in part: By entering into this agreement, the Donor Hospital verifies that it will meet all obligations set forth in CMS 42CFR part 482.45. The contract revealed the Donor Hospital would be in compliance with the Louisiana Uniform Anatomical Gift Act. The contract revealed timely referral was defined as within 2 hours (ideally one hour) of when a Donor Hospital identifies a patient that meets the Donor Hospital's definition of "Clinical Triggers" for organ donation. The contract also revealed Imminent Death is defined as a Donor Hospital patient who meets the criteria for medically established "Clinical Triggers" for organ donor evaluation.

A review of the hospital policy titled, "Organ Donation Louisiana", as provided by S3RDCS (Regional Director of Clinical Services) as the most current, revealed the purpose of the policy was: "To comply with the Anatomical Gift Act, the Required Request Act, and the Definition of Death. To ensure that every death that occurs at the facility is reported to the Louisiana Organ Procurement Agency (LOPA), and that every death is evaluated for potential organ and/or tissue donation."
Review of the policy revealed: In the event of the unexpected death of a client, a nurse will contact LOPA in a timely manner after the patient's death is pronounced by the attending physician. Timely manner for non-ventilated patients: within 4 hours of cardiac arrest.
Further review of the policy revealed no documented evidence of the hospital's definition of Clinical Triggers or Imminent Death.

In an interview on 02/16/16 at 2:50 p.m., S3RDCS confirmed the hospital's policy for organ donation did not define clinical triggers or imminent death as outlined in the contract with LOPA. She confirmed the only time frame for notification of LOPA in the policy was within 4 hours of the patient's death.

Based on record review and staff interview, the hospital failed to ensure each patient received a psychiatric evaluation that was completed within 60 hours of admission as evidenced by:
1) failing to complete the psychiatric evaluation within 60 hours for 2 of 2 (#R7, #R8) random sampled patients reviewed for completion of psychiatric evaluations, and;
2) failing to ensure the psychiatric evaluation was completed in accordance with the medical staff bylaws, rules & regulations, and hospital policy for 2 (#1, #7) of 7 (#1-#7) current sampled patients and 2 of 2 (#R7, #R8) random sampled patients out of a total sample of 12.

Findings:

1) Failing to complete the psychiatric evaluation within 60 hours:

Review of the Medical Staff Bylaws, Rules & Regulations dated 11/12/13 revealed in part the following: 3. The psychiatric evaluation shall be completed within sixty (60) hours of admission.

Review of the hospital policy titled, "Psychiatric Evaluation" provided as current policy by S3RDCS revealed in part the following:
Purpose: To establish or rule out the presence of active psychiatric pathology, determine patient acuity when indicated, assess clinical status and to serve as a basis for any psycho/pharmacological regimen. To serve as a format for documentation of patient's diagnosis (AXIS I-V),pertinent findings, treatment plan interventions and recommendations.
Psychiatrist/LIP: Documents a complete Psychiatric Evaluation including Axis I-V, prognosis, recommended treatment interventions, and assessment findings on Psychiatric Evaluation form, or dictated in the appropriate format within 60 hours.

In an interview on 02/16/16 at 10:35 a.m. S5HIM Director stated she documents reports of delinquent records and delinquent psychiatric evaluations. S5HIM Director provided a list of the delinquent psychiatric evaluations for the year 2015 and 2016. S5HIM Director stated if patients are admitted to S14MD on Fridays, the psychiatric evaluation was not done by S14MD until Monday, resulting in the psychiatric evaluation not being done within 60 hours.
S5HIM Director stated they try not to give admits to S14MD on Fridays.

Review of the Delinquent Psychiatric Evaluations revealed the number of delinquent psychiatric evaluations was documented including the patient's medical record number. Review of the reports revealed the following:
2015 - 45 psychiatric evaluations not completed within 60 hours of admission.
2016 - January: 5 psychiatric evaluations not completed within 60 hours of admission.
S5HIM Director confirmed the above numbers of delinquent psychiatric evaluations. When asked what measures had been taken to address the problem of delinquent psychiatric evaluations, she stated a letter is sent to the physician, it was discussed at medical executive meetings, and they try not to give S14MD admits on Fridays.

Patient #R7
Review of the medical record for Patient #R7 revealed the patient was admitted to the hospital on 11/27/15 at 2:30 p.m. with a diagnosis of Severe Neurocognitive Disorder. Review of the psychiatric evaluation revealed it was dated/timed 11/30/15 at 12:15 p.m., 70 hours after the patient was admitted to the hospital. Review of the list of delinquent psychiatric evaluations revealed this patient's medical record number was not included in the list.


Patient #R8
Review of the medical record for Patient #R8 revealed the patient was admitted to the hospital on 11/27/15 at 12:00 p.m. with a diagnosis of Mild Vascular Neurocognitive Disorder. Review of the psychiatric evaluation revealed it was dated/timed 11/30/15 at 9:00 a.m., 69 hours after the patient was admitted to the hospital. Review of the list of delinquent psychiatric evaluations revealed this patient's medical record number was not included in the list.


In an interview on 02/16/16 at 1:13 p.m. S3RDCS and S5HIM Director confirmed the psychiatric evaluations for Patient #R7 and #R8 were not done within 60 hours. S3RDCS stated they know there is a problem with psychiatric evaluations being done within 60 hours.



2) Failing to ensure the psychiatric evaluation was completed in accordance with the medical staff bylaw, rules & regulations, and hospital policy:

Review of the hospital policy titled, "Psychiatric Evaluation" provided as current policy by S3RDCS revealed in part the following:
Psychiatrist/LIP: Documents a complete Psychiatric Evaluation including Axis I-V, prognosis, recommended treatment interventions, and assessment findings on Psychiatric Evaluation form, or dictated in the appropriate format within 60 hours.

Review of the Medical Staff Bylaws, Rules & Regulations dated 11/12/13 revealed in part the following: 3. The psychiatric evaluation shall be completed within sixty (60) hours of admission. In the case of a re-admission, a copy of the psychiatric evaluation with an appropriate update note will suffice if the patient is re-admitted within 30 days.


Review of the psychiatric evaluations for Patients #1, #7, #R7, and #R8 revealed the Axis V diagnosis was left blank. Review of the psychiatric evaluation for Patient #7 also revealed the sections titled, past psychiatric/chemical abuse history, past medical history/allergies, current medications, family psychiatric, social and developmental history were documented as, "see old record." Review of Patient #7's record revealed his psychiatric evaluation was dated 02/10/16 and the patient's previous admission was in September, 2015.

In an interview on 02/16/16 at 9:30 a.m. S2DON confirmed that Axis V was incomplete on the psychiatric evaluations for Patient #1 and #7. She stated she had addressed this with S14MD who told her the DSM does not require Axis V diagnosis any more. S2DON stated insurance companies still ask for Axis V diagnosis and confirmed the hospital policy required Axis V. S2DON confirmed S14MD documented, "see old record" on the psychiatric evaluation, and patient's previous admission was 09/21/15.

25119

Based on record review and interview the hospital failed to ensure each patient had an individualized, comprehensive treatment plan as evidenced by failure to include interventions and goals for medical diagnosis for which the patient was being treated for 3 (#1, #3,#4) of 7 (#1-#7) current sampled patients out of a total sample of 12.
Findings:
Review of the hospital policy titled, "Treatment Planning; Integrated/Multidisciplinary", provided by S2DON as current policy, revealed in part the following: The multi-disciplinary treatment team, under the direction and supervision of the attending physician, shall develop an integrated written, comprehensive Treatment Plan with specific goals and objectives necessary to address deficits identified in the assessment process. The Admitting Nurse revises and develops nursing and medical components of the treatment plan based on additional findings from patient assessments, problems, needs, strengths and limitations, and physician's orders.

Patient #1
Review of the medical record for Patient #1 revealed the patient was an 87 year old admitted to the hospital on 02/11/16 with a diagnosis of Neurocognitive Disorder. Review of the H&P dated 2/12/16 revealed the patient's medical diagnoses included Hypertension. Review of the physician orders and medication administration records revealed the patient was currently receiving blood pressure medications.
Review of the Multidisciplinary Integrated Treatment Plan for Patient #1 revealed the problem, "Alteration in health maintenance" was documented and "History of Hypertension" was checked. Further review of the Treatment Plan revealed no documented evidence of any short term goals or clinical interventions for the patient's Hypertension.

In an interview on 02/16/16 at 9:30 a.m. S2DON reviewed the medical record for Patient #1 and confirmed the Multidisciplinary Integrated Treatment Plan did not include short term goals and interventions for the patient's diagnosis of Hypertension.

Patient #3
Review of Patient #3's medical record revealed an admission date of 2/04/16 with co-morbid diagnosis of Diabetes, Asthma, and Hypertension.
Review of Patient #3's MAR revealed she was receiving Levemir (insulin-sub q injection; once a day at bedtime) and Apidra (insulin-sub q injection; 3 x a day ). Further review revealed the patient's capillary blood glucose levels were measured by fingerstick blood sampling twice a day. Additional review revealed the patient was also receiving Lisinopril (antihypertensive; once daily) and Atenolol (antihypertensive; once daily) for treatment of hypertension.
Review of Patient #3's multidisciplinary integrated treatment plan revealed Asthma and Hypertension were not addressed as individual problems on the patient's plan of care. Further review of the treatment plan revealed administration of the patients ordered insulin and frequency of capillary blood glucose monitoring were not included as specific interventions implemented for the management of the patient's Diabetes.

Patient #4
Review of the medical record revealed Patient #4 was a 60 year old female admitted on 02/09/16 with severe Depression. Further review revealed medical diagnosis for Hypertension, Diabetes, Hypothyroidism, and Coronary Artery Disease.

Review of the Multidisciplinary Integrated Treatment Plan Problem List dated 02/10/16 revealed Alteration in Health Maintenance R/T Diabetes, Coronary Artery Disease, Hypertension, and Gastro Esophageal Reflux Disease. The problem list had only blood sugar, CAD, and GERD checked. There were no interventions or goals documented.

In an interview on 02/15/16 at 3:10 p.m. with S3RDCS confirmed there were no interventions or goals listed for Patient #4. S3RDCS further stated that the treatment plan should be completed upon admission by the nurse.



30984

Based on record review and interview the hospital failed to ensure all direct care staff had appropriate skills and qualifications for providing patient care in a psychiatric setting as evidenced by 2 (S7LPN, S8LPN) of 2 agency staff not having training or experience in the psychiatric setting. Findings:

Review of S7LPN's personnel file revealed 2/15/16 was the first shift S7LPN had worked at the hospital. Further review revealed a check off list titled "Agency MHT Competency Orientation", dated 02/15/16 had been signed by S7LPN. Review of a document titled, Agency Orientation Guidelines, revealed in part: Orientation/Competencies, 2. Provide the appropriate orientation package, RN, LPN, or MHT. 3. Review and educate with the agency staff on all components of the education form. 5. Skills checklist must be completed.

Review of S8LPN's personnel file revealed that there was no documented evidence of assessment of competencies or completion of hospital orientation.

In an interview on 02/17/17 at 9:40 a.m. with S6HR, she indicated the personnel records for S7LPN and S8LPN were complete and there were no other forms or records. S6HR also indicated the nurse staffing agency usually sent over a packet on each person. S6HR indicated she did not know why S7LPN and S8LPN did not have a completed packet.

In an interview on 02/17/17 at 12:00 p.m. with S2DON, she confirmed the hospital used agency nurses to cover staffing shortages. S2DON stated that when an agency nurse came to the hospital, Human Resources collects all of the required documentation and certifications required by the hospital, from the agency. S2DON was not aware that S7LPN and S8LPN had not completed the required orientation training.