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Based on observation, record review and interview, the hospital failed to ensure drugs and biologicals were administered in accordance with orders of the practitioners responsible for the patient's care. This deficient practice is evidenced by:
1) failure of the nursing staff to administer insulin for blood glucose levels per physician's orders for sliding scale insulin for 2 (#1,#2) of 4 (#1,#2,#4,#5) insulin dependent patients out of a total sample of 5 diabetics; and
2) failure of the nursing staff to obtain a physician's order before administering a dose of insulin for 1(#2) of 4 (#1,#2,#4,#5) insulin dependent patients out of a total sample of 5 diabetics.

Findings:

1) Failure of the nursing staff to administer insulin for blood glucose levels per physician's orders for sliding scale insulin.

Patient #1
Review of Patient #1's medical record revealed he was admitted on 06/03/19 with diagnoses of Major Depressive Disorder, recurrent, severe, with psychotic symptoms, Alcohol Dependence, Cannabis Dependence, and Other Stimulant Dependence.

Review of Patient #1's physician orders revealed an order from S3MD on 06/04/19 at 11:35 p.m. as follows: Humulin R Solution 100 U/ml sliding scale, CBG 60-180 mg/dl give no insulin; 181-250 mg/dl give 2 units; 251-300 mg/dl give 4 units; 301-350 mg/dl give 6 units; 351-400 mg/dl give 8 units; 401- 0450 mg/dl give 10 units; < 60 give 4 oz. orange juice or 1 mg Glucagon; > 450 notify MD.

Review of S5LPN's documentation revealed on 06/06/19 at 11:30 a.m. Patient #1's CBG was 360 mg/dl, and she administered Humulin R 6 U rather than 8 U as ordered.

Review of S6LPN's documentation on 06/07/19 at 2:26 a.m. revealed she administered Humulin R 2 U with no documented evidence of a CBG result that warranted the dose (no CBG was documented).

Review of S7LPN's documentation revealed Patient #1's CBG was 50 mg/dl on 06/09/19 at 5:55 a.m. and 50 mg/dl on 06/10/19 at 5:21 a.m. Further review revealed S7LPN gave a snack to Patient #1 on each of these days rather than 4 oz. orange juice or 1 mg Glucagon as ordered.

Review of S5LPN's documentation on 06/11/19 at 6:00 a.m. revealed Patient #1's CBG was 52 mg/dl, and she gave him Glucerna and graham crackers rather than 4 oz. orange juice or 1 mg Glucagon as ordered.


Patient #2
Review of Patient #2's medical record revealed she had been admitted on 6/3/19 at 12:05 p.m. with diagnosis including Type I diabetes.

Review of Patient #2's medical record revealed an order on 6/3/19 at 11:52 p.m. for sliding scale insulin with Humulin R every 6 hours as needed for high blood sugar as follows:
60-180 no insulin
181-250 2 units
251-300 4 units
301-350 6 units
401-450 10 units
Over 450, notify doctor

Review of Patient #2's Diabetes Monitoring sheet dated 6/7/19 (no time) revealed a blood glucose of 492 mg/dl. Further review of Patient #2's medical record revealed there was no documentation that the physician had been notified of the elevated blood glucose level as ordered.

In an interview on 6/11/19 at 3:13 p.m. with S2DON, she verified physician notification should have been documented when Patient #2's blood glucose was greater than 450 mg/dl.


2) Failure of the nursing staff to obtain a physician's order before administering a dose of insulin.

Review of Patient #2's medical record revealed an order on 6/3/19 at 11:52 p.m. for sliding scale insulin with Humulin R every 6 hours as needed for high blood sugar. Further review revealed if the blood glucose was over 450 mg/dl the doctor was to be notified. No dose of insulin for a blood glucose over 450 mg/dl was on the order.

In an observation on 6/11/19 at 1:00 p.m., S5LPN was observed obtaining a blood glucose level from Patient #2. S5LPN then said the level was above 600 and placed a call to the physician. Before the physician returned the call, S5LPN was observed administering 10 units of Humulin R to Patient #2.

In an interview on 6/11/19 at 1:10 p.m. with S5LPN, she verified she did not obtain an order for Patient #2 to receive 10 units of Humulin R from the physician before she gave the insulin to the patient. S5LPN also verified Patient #2's sliding scale orders were to call the MD for an order if the blood glucose was over 450 mg/dl.

In an interview on 6/11/19 at 3:13 p.m. with S2DON, she verified S5LPN should have obtained an order for Patient #2's insulin when the blood glucose was greater than 450 mg/dl.




30364

Based on record review, observation and interview, the hospital failed to ensure individual patient nutritional needs were met in accordance with recognized dietary practices. This deficient practice was evidenced by not offering alternative meals for a patient with continuous elevated blood glucose levels for 1 (#2) of 5 (#1, #2, #3, #4, #5) diabetic patients sampled.

Findings:

Review of Patient #2's medical record revealed she had been admitted on 6/3/19 at 12:05 p.m. with diagnosis including Type I diabetes.

Review of Patient #2's admission orders revealed an order dated 6/3/19 at 12:05 p.m. for special diet- Low Concentrated Sweets.

Review of Patient #2's Treatment Plan dated 6/3/19 revealed a problem identified as: Other specified personal risk factors, not elsewhere classified. The short term goal was listed as the patient would maintain blood glucose levels within defined target ranges for patient, between 80-200 during hospitalization. Interventions included Dietary consult as needed and individual nursing education to educate on disease process/symptom management/mind body connection. No adjustments had been made to the treatment plan with multiple elevated blood glucose levels from 6/3/19 through 6/11/19.

Review of the patient menus revealed they were titled Diet Regular/Regular. Further review revealed the following lunch choices during the survey:
Tuesday 6/11/19- Fried chicken, mashed potatoes with brown gravy, Seasoned green beans, Texas toast, Iced cherry cake and a beverage.
Wednesday 6/12/19 - Meatballs and Spaghetti, Italian vegetables, Italian tossed salad, garlic bread, cake and a beverage.

Review of Patient #2's Diabetes Monitoring revealed the following:
6/3/19 - 510 mg/dl
6/4/19 - 356 mg/dl, 339 mg/dl, 588 mg/dl, 515 mg/dl, 336 mg/dl
6/6/19 - 306 mg/dl, 300 mg/dl
6/7/19 - 456 mg/dl, 492 mg/dl
6/8/19 - 345 mg/dl, 407 mg/dl, 292 mg/dl, 270 mg/dl
6/9/19 - 344 mg/dl, 335 mg/dl, 325 mg/dl
6/10/19 - 342 mg/dl
6/11/19 - 441 mg/dl, 417 mg/dl, >500

Review of Patient #2's medical record revealed a Dietary Assessment dated 6/7/19 (4 days after admission). S11Dietician provided education on food choices and the importance of keeping sugar within normal limits.

In an interview on 6/11/19 at 1:02 p.m. with Patient #2, she said she just had a blood glucose reading of greater than 500. She said she is a diabetic and had been since she was four years old. She said her sugar levels were never this uncontrolled at home and it is because of the food the hospital is serving. Patient #2 said she controls her sugar levels based on her carbohydrate intake at home. She said she is not getting a diabetic diet and she has too many carbohydrates. She said they were trying to manage her sugar levels with insulin, not her diet.

In an interview on 6/12/19 at 8:41 a.m. with S11Dietician, she said when the doctor writes an order for a dietary consult, she does an evaluation but otherwise does not consult every diabetic. She said they get the meals from the nursing home next door and it was a liberated diet. She said if a person is diabetic, she asks them to choose wisely. She said they are working on a variety. She said the facility was able to meet the needs of the patients' dietary needs. She said the "regular" diet is double portions and the diabetics get single portions.

In an observation of Patient #2 on 6/12/19 at 11:52 p.m., she was eating lunch with the other patients. Further observation revealed she had same portions as other clients. The meal contained spaghetti, meatballs, a roll and cake.

In an interview on 6/12/19 at 1:40 p.m. with S4LPN (dietary manager), she said there were not alternative choices in meals for diabetic patients. S4LPN agreed there should be a better choice than spaghetti, rolls and cake for diabetics such as chicken or no sugar deserts. She also could not find documentation of Patient #2's increased blood glucoses being addressed other than insulin administration and a dietary consult 4 days after admission. S4LPN could not locate any nursing education on diet for Patient #2.











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Based on interview, the hospital failed to ensure a current therapeutic diet manual, approved by the dietitian and medical staff was readily available to all medical, nursing, and food service personnel.

Findings:

A request was made on 6/12/19 at 1:50 p.m. for the hospital's therapeutic diet manual but none was provided.

In an interview on 6/12/19 at 1:50 p.m. with S4LPN (dietary manager), she said the hospital did not have a therapeutic diet manual.

Based on observation and interview, the hospital failed to ensure the facilities and equipment was maintained to ensure an acceptable level of safety and quality.

Findings:

An observation on 6/11/19 at 12:00 p.m. of the female shower room revealed a section of the ceiling above the shower that was detached was hanging down from the ceiling. The section contained screws and it was not determined what the contents were behind the panel.

An observation on 6/11/19 at 12:01 p.m. of the male and female shower rooms revealed a black, spotty substance located on the exhaust fan and on the upper walls. The perimeter of the ceilings were surrounded by a rusted metal band.

An observation on 6/11/19 at 12:04 p.m. of the smoking section revealed a chair with over half of the upholstery missing on the seat exposing foam padding which can't be disinfected. Further observation revealed a second chair with a hole in the upholstery.

In an interview on 6/11/19 at 12:04 p.m. with S1Adm, he verified the above mentioned findings.

Based on record reviews and interviews, the hospital failed to ensure the patients' progress notes contained recommendations for revisions in the treatment plan as indicated as evidenced by failure to documented evidence that the treatment plan was revised when the patient continually did not attend scheduled, ordered group therapy for 5 (#1, #2, #3, #4, #5) of 5 patient records reviewed for group therapy from a sample of 5 patients.
Findings:


Patient #1
Review of Patient #1's medical record revealed he was admitted on 06/03/19 with diagnoses of Major Depressive Disorder, recurrent, severe, with psychotic symptoms, Alcohol Dependence, Cannabis Dependence, and Other Stimulant Dependence.

Review of Patient #1's physician orders revealed verbal orders by S10NP on 06/03/19 at 10:20 p.m. for group psychotherapy daily, activity therapy daily, and nursing education group daily.

Review of Patient #1's progress notes revealed he did not attend recreational group on 06/03/19, 06/06/19, 06/07/19, 06/08/19, and 06/11/19. There was no documented evidence therapeutic activity group therapy was provided on 06/04/19, 06/05/19, 06/09/19, and 06/10/19. Further review revealed he didn't attend a nursing education group on 06/05/19 and did attend a nursing education group on 06/09/19. Further review revealed he didn't attend a social services group on 06/07/19. Of 11 groups documented, Patient #1 attended 3 of the groups. There was no documented evidence that group psychotherapy, activity therapy, and nursing education group attendance or absence was documented daily as ordered for Patient #1. There was no documented evidence that alternative options were offered or attendance at group was encouraged by staff when Patient #1 didn't attend groups.

Review of Patient #1's treatment plan revealed problems identified were suicidal ideations, hallucinations, emotional lability, and other psychoactive substance abuse. Interventions for all identified problems included nursing education group daily, activity group daily, and social services psychotherapy group twice a day. There was no documented evidence that the treatment plan was revised to provide other interventions and revised goals to address Patient #1's continued lack of attending groups.

In an interview on 06/12/19 at 12:55 p.m., S4LPN reviewed Patient #1's medical record and confirmed there was no documentation of an offer of other therapeutic groups when he didn't attend scheduled groups. She confirmed Patient #1's treatment plan was not implemented, the orders weren't followed, and the treatment plan wasn't revised.

Patient #2
Review of Patient #2's medical record revealed she had been admitted on 6/3/19 at 12:05 p.m. with diagnosis including Bipolar Disorder, Depressed without psychosis.

Review of Patient #2's admission orders revealed an order dated 6/3/19 at 12:05 p.m. for nursing education group daily, psychotherapy group (social worker) daily, and activity therapy group daily.

Review of Patient #2's treatment plan revealed group therapy was not included.

Review of Patient #2's activity notes revealed she did not attend activity group on 6/4/19, psychotherapy group on 6/5/19, 6/6/19, 6/8/19, 6/9/19 or 6/10/19 and nursing education group on 6/4/19, 6/6/19 otr 6/10/19.
Further review revealed no notes as to why Patient #2 did not attend the groups or why the groups were not held. There was also no documented evidence that the treatment plan was revised to include groups or provide other interventions and revised goals to address Patient #2's continued lack of attending groups.

Patient #3
Review of Patient #3's medical record revealed she had been admitted on 5/31/19 at 11:20 p.m. with diagnosis including Schizoaffective Disorder Bipolar Type.

Review of Patient #3's admission orders dated 5/31/19 at 11:22 p.m. revealed orders for nursing education group daily, psychotherapy group (social worker) daily, and activity therapy group daily.

Review of Patient #3's treatment plan revealed she would attend nursing education group daily, psychotherapy group (social worker) daily, and activity therapy group daily.

Review of Patient #3's activity notes revealed she did not attend activity group on 6/1/19, 6/3/19, 6/4/19 or 6/5/19, psychotherapy group on 6/1/19, 6/2/19, 6/3/19, or 6/5/19 and nursing education group on 6/3/19 or 6/4/19.
Further review revealed no notes as to why Patient #3 did not attend the groups or why the groups were not held. There was also no documented evidence that the treatment plan was revised to provide other interventions and revised goals to address Patient #3's continued lack of attending groups.

Patient #4
Review of Patient #4's medical record revealed he was admitted on 6/6/19 at 8:19 p.m. with diagnosis including Paranoid Schizophrenia and Diabetes.

Review of Patient #4's physician's orders dated 6/6/19 at 5:24 p.m. revealed orders for nursing education group daily, psychotherapy group (social worker) daily, and activity therapy group daily.

Review of Patient #4's treatment plan revealed she would attend nursing education group daily, psychotherapy group (social worker) daily, and activity therapy group daily.

Review of Patient #4's activity notes revealed she did not attend activity group on 6/10/19, psychotherapy group on 6/8/19 or 6/10/19 and nursing education group on 6/11/19.
Further review revealed no notes as to why Patient #3 did not attend the groups or why the groups were not held. There was also no documented evidence that the treatment plan was revised to provide other interventions and revised goals to address Patient #3's continued lack of attending groups

Patient #5
Review of Patient #5's medical record revealed she was admitted on 03/21/19 and discharged on 03/28/19 with diagnoses of Schizoaffective Disorder, Chronic kidney disease, Edema, Hyperlipidemia, Hypertensive chronic kidney disease with Stage 1 through Stage 4 chronic kidney disease, Long term use of insulin, Noncompliance with medication regimen, Type 2 Diabetes Mellitus with diabetic chronic kidney disease, and Atrial fibrillation.

Review of Patient #5's physician orders revealed orders from S10NP for activity therapy daily, individual psychotherapy as needed, and nursing education group daily.

Review of Patient #5's group notes revealed she did not attend recreational group on 03/21/19 and attended on 03/24/19 but was irritable. Further review revealed attended a social service group on 03/21/19 but didn't participate. Further review revealed she didn't attend nursing education groups on 03/21/19, 03/22/19, and 03/24/19 and attended on 03/23/19 but refused to participate and was asked to leave group on 03/26/19 due to being disruptive and verbally aggressive. There was no documented evidence that recreational and nursing education groups were provided daily as ordered and social services psychotherapy group twice a day as included in the treatment plan. There was no documented evidence that alternative options were offered or attendance at group was encouraged by staff when Patient #5 didn't attend groups.

Review of Patient #5's treatment plan revealed problems identified were at risk for violence to others, delusional disorders, and emotional lability. Interventions for all identified problems included nursing education group daily, activity group daily, and social services psychotherapy group twice a day. There was no documented evidence that the treatment plan was revised to provide other interventions and revised goals to address Patient #5's continued lack of attending groups.

In an interview on 06/12/19 at 2:30 p.m., S4LPN confirmed there was no other activity offered when Patient #5 didn't attend the scheduled groups. She confirmed Patient #5's treatment plan was not implemented, the orders weren't followed, and the treatment plan wasn't revised.

In an interview on 6/12/19 at 12:50 p.m. with S2DON, she said the issue with group notes not being completed was part documentation and part some groups were not being done. She verified there should have been a note as to why a patient did not attend group if a group was actually held.

Based on record reviews and interviews, the hospital failed to ensure there was an adequate number of qualified therapists and support personnel to provide comprehensive therapeutic activities consistent with each patient's active treatment program as evidenced by:
1) Failing to have a qualified CTRS available to provide daily therapeutic activity as ordered by the physician. S9CTRS worked part-time and was not available to provide daily therapeutic activity therapy as ordered by the physician for 2 (#1, #5) of 5 patient records reviewed for activity therapy from a sample of 5 patients. S9CTRS did not have current certification in BLS and CPI as required by hospital policy.
2) Failing to ensure S8MHT was qualified to provide therapeutic activity therapy in accordance with the LDH's rule for therapeutic recreational therapists as authorized by R.S.36:254 and R.S. 40:2100-2115. S8MHT did not have a degree in therapeutic recreation from an accredited post-secondary institution, a degree in another field of study and had also attained certification in accordance with the National Council for Therapeutic Recreation Certification requirements, a minimum of 10 years' experience providing therapeutic recreational services, or was currently employed as a therapeutic recreational specialist 2 per Louisiana Civil Service requirements. S8MHT provided therapeutic recreational therapy to 2 (#1, #5) of 5 patients whose records were reviewed for recreational therapy from a sample of 5 patients.
Findings:

1) Failing to have a qualified CTRS available to provide daily therapeutic activity as ordered by the physician and failing to have S9CTRS currently certified in BLS and CPI as required by hospital policy:
Review of the hospital policy titled "Staff Orientation and Ongoing Training", presented as a current policy by S2DON, revealed staff members that provide direct care to patients are required to complete training and certification in nationally accredited programs designed to teach and/or enhance skills related to managing an escalating individual, de-escalation practices, and safe techniques that may be utilized with an individual that is physically acting out. Examples of programs include MOAB and CPI. Additionally, all staff members that provide direct care are required to be certified in BLS. Recertification must be maintained throughout employment, in accordance with the sponsoring organization's requirements, but not less than every 12 months.

Patient #1
Review of patient #1's physician orders revealed an order on 06/03/19 at 10:20 p.m. for activity therapy daily.

Review of Patient #1's (admitted 06/03/19) medical record revealed S9CTRS provided therapeutic activity group therapy on 06/06/19 and 06/08/19. Further review revealed S8MHT (who was not qualified to provide such therapy) provided therapeutic activity group therapy on 06/03/19, 06/07/19, and 06/11/19. There was no documented evidence therapeutic activity group therapy was provided on 06/04/19, 06/05/19, 06/09/19, and 06/10/19.

Patient #5
Review of Patient #5's physician orders revealed an order on 03/21/19 at 4:48 a.m. for activity therapy daily.

Review of Patient #5's medical record (admitted 03/21/19 and discharged on 03/28/19) revealed recreational group therapy was conducted by S9CTRS on 03/21/19 and 03/24/19. There was no documented evidence therapeutic recreational therapy was provided on 03/22/19, 03/23/19, 03/25/19, 03/26/19, 03/27/19, and 03/28/19.

Review of S9CTRS' personnel file revealed his CPI certification expired on 03/31/19, and his BLS certification expired on 10/31/18.

In an interview on 06/12/19 at 12:55 p.m., S4LPN confirmed the above-listed group note documentation for Patients #1 and #5. She indicated S9CTRS comes in part time 3 or 4 times a week to do assessments and groups.

In an interview on 06/12/19 at 3:35 p.m. with S1Adm and S2DON present, S1Adm confirmed the computer system had no current CPI and CPR certification for S9CTRS. S2DON indicated the physician orders activity therapy once a day and confirmed S9CTRS doesn't come daily.

2) Failing to ensure S8MHT was qualified to provide therapeutic activity therapy in accordance with the LDH's rule for therapeutic recreational therapists as authorized by R.S.36:254 and R.S. 40:2100-2115:
Review of the LDH's rule for Therapeutic Recreational Therapists (LAC 48:I.9501) printed in the Louisiana Register in August 2015 revealed an individual who provides therapeutic recreational services shall have the following qualifications: a degree in therapeutic recreation from an accredited post-secondary institution; or a degree in another field of study and has also attained certification in accordance with the National Council for Therapeutic Recreation Certification requirements; or a minimum of 10 years' experience providing therapeutic recreational services; or be currently employed as a therapeutic recreational specialist 2 per Louisiana Civil Service requirements. Individuals currently providing therapeutic recreational services who do not meet the qualifications of §9501.G.1-2.d shall have two years from the effective date of this Rule to qualify as therapeutic recreational therapists.

Review of S8MHT's personnel file revealed she did not have a college degree and was not certified in accordance with the National Council for Therapeutic Recreation Certification requirements. Further review revealed she worked as a resident activity director at a nursing home from February 2012 to June 2012 and from June 2006 to June 2008. She was hired at the hospital on 12/10/14 as a MHT and driver and had provided activity therapy. S8MHT had 6 years and 10 months experience providing therapeutic recreational activity. There was no documented evidence that S8MHT had 10 years' experience providing therapeutic recreational services as required by the LDH's rule for Therapeutic Recreational Therapists.

In an interview on 06/12/19 at 3:35 p.m., S2DON indicated she wasn't aware of what was required of the recreational therapist. She further indicated administration doesn't see activity done by S8MHT as activity therapy. She provided no explanation for the patients not receiving activity therapy as ordered daily if S9CTRS doesn't come daily, and she doesn't view the activity therapy done by S8MHT as activity therapy.