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Based on record review, observation and interview, the hospital failed to ensure care in a safe setting. This deficient practice was evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for patients admitted for acute inpatient psychiatric services due to being a danger to themselves and/or others. This deficient practice had the potential to affect all 18 current inpatients receiving care in the hospital.

Findings:

Observations of the hospital on 4/3/18 beginning at 1:00 p.m. revealed the following safety hazards:
a) The porcelain lids to the toilet bowl tanks were unsecured and able to be removed in room 101, 103, and 104.
b) Light covers for the overhead fluorescent lights were unsecured allowing access to the bulbs which could be used as a cutting instrument if broken.
c) 2 boards on the outdoor patio were buckled and were a tripping hazard for 18 of 18 current patients on fall precautions.
d) All entrance doors and bathroom doors on patient rooms #101-#110 contained continuous hinges with non-tamper resistant screws.
e) Observation on 4/5/18 at 12:40 with S9HKSup revealed patient room #102 had two crank beds. One crank bed had 2 cranks and one bed had 3 cranks. Room #103 had two crank beds, each crank bed had three handles attached to the foot of the bed. The beds all contained multiple exposed bars on the frames and springs. The rooms were unlocked and accessable by all patients.

Review of the hospital's document titled, "Baton Rouge Ligature Risk Assessment/Reduction Action Plan", revealed in part: crank beds were scored as a "3". A "3" indicates the hospital beds' springs, frames, and hand cranks are a High Risk for a ligature point.

In interview on 4/5/18 at 12:35 with S9HKSup, he stated there are 2 rooms with crank beds. He stated these beds were used for Geriatric patients only.

In an interview on 4/3/18 at 1:15 p.m. with S2DON, he verified the above-mentioned findings.



39791

Based on record reviews and interview, the hospital failed to ensure patients' weights were transcribed into the patients' medical record for 2 (#9, #12) of 5 patients medical records reviewed.

Findings:

Review of the hospital's "Documentation" policy revealed in part: Policy: Inpatient nursing personnel document patient's progress every shift, incorporating the elements of the nursing process and patient's treatment goals and progress within the patient's medical record. Routine: RN/LVN/LPN ...Documents the application and execution of physician's orders.

Patient #9
Review of Patient #9's medical record revealed an admission date of 3/19/18. Patient #9 had diagnoses that included Major Depression and alteration of mood.

Review of Patient #9's admission orders, dated 3/19/18, revealed in part: Weight on admit and then twice a week.

Review of Patient #9's Admit Nursing Assessment dated 3/19/18 revealed a documented weight of 152 lbs.

Review of Patient #9's Vital Signs and I & O sheets dated 3/19/18 - 4/3/18 revealed a documented weight of 152 lbs. Further review of the Vital Signs and I & O sheet for Patient #9 revealed no additional weights had been obtained as ordered and documented in the patient's medical record .

Patient #12
Review of the medical record for patient #12 revealed she was admitted to the hospital 03/23/18 with admission orders that included to weigh on admission and then every Wednesday and Saturday. Further review of the medical record revealed no weight record after the admission weight through the end of the survey, 4/5/18. Patient #12 had 4 weights not documented in her record.

On 4/4/18 at 3:10 p.m., an interview was conducted with S2DON. When asked for the additional weights for Patients #9 and #12, S2DON reviewed the patients' charts and verified their weights were not documented. S2DON presented several worksheets dated 3/21/18, 3/24/18, 3/28/18, 3/31/18, and 4/3/18 that contained all of the current patient's names, vital signs and their weights. He explained the worksheet was a useful tool the staff used to capture all of the patients' vital signs on one form. Then, the MHTs were to transcribe the data into the patients' medical record. S2DON stated the worksheets were stored in his office and were not a part of the patients' records. When asked, S2DON stated the night charge nurse was responsible for ensuring the night MHTs transcribed the patients weights onto the Vital Signs and I & O sheet in the patient's chart. He also added two lead night MHTs and the night charge RN were terminated in the last two weeks who were responsible for ensuring the data was transcribed onto the patients' chart. He stated since then, no one had communicated that responsibility to the current night shift. S2DON acknowledged he was made aware upon the surveyor's request for Patient #9's additional weights. He verified staff had not transcribed Patients' #9 and #12's weights into their medical record. He also verified the night nurse who had conducted the 24 hour chart checks on Patients #9 and #12's medical records should have noticed the weights for those patients had not been transcribed onto the Vital Signs and I & O sheet.





30420

Based on record review and interview, the hospital:
1) Failed to ensure near misses and close calls of medications were collected, tracked and trended for patient Quality Assurance and Performance Improvement (QAPI); and
2) Failed to ensure the physician was timely notified after a medication error for 1 (#R5) of 2 (#R4, R5) patients reviewed for known medication errors.

Findings:

1) Failed to ensure near misses and close calls of medications were collected, tracked and trended for patient Quality Assurance and Performance Improvement.

Review of the QAPI data revealed no tracking and trending of medication "near misses" and "close calls."

In an interview on 4/4/18 at 3:25 p.m. with S3Pharmacist, he stated he collected data monthly on near misses for internal pharmacy use. He stated quarterly he presented reports containing numbers of near misses to the hospital, but not specific data.

In an interview on 4/4/18 at 3:33 p.m. with S2DON regarding tracking and trending of medication "near misses", S2DON stated they do receive the quarterly data from S3Pharmacist but they do not track and trend the medication "near misses".

In an interview on 4/4/18 at 3:40 p.m. with S4Corporate, she verified data for medication "near misses" and "close calls" was not collected for tracking and trending purposes for quality assurance.

2) Failed to ensure the physician was timely notified after a medication error.

Review of the hospital policy titled, "Medication Management", revealed in part: before medication administration, a licensed nurse verifies that the medication selected for administration is the correct one based on the medication order, prescriber instructions, MAR (medication adminstration record) and product label.

Review of a medication variance report provided by the hospital for Patient #R5 revealed an order dated 11/30/17 at 9:50 p.m. to begin Trileptal and to discontinue Remeron. Further review revealed a confirmation fax containing above order dated 11/30/17 at 10:37 p.m. Further review revealed the order was not changed on the medication profile. Therefore between 11/30/17 and 12/3/17, Patient #R5 did not receive the ordered medication and continued to receive the discontinued medication. Additional review revealed medication variance report was completed on 12/3/17 at 2:15 a.m. by S15LPN. S2DON was notified on 12/5/17 and S14Psychiatrist was also not notified until 12/5/17 (more than 48 hours after the medication error was identified).

In an interview on 4/5/18 at 12:15 p.m. with S2DON, he reviewed Patient #R5's medical record and was unable to find documentation of the medical errors or the physician's notification.

In an interview on 4/5/18 at 3:45 p.m. with S2DON, he was reported both he and S14Psychiatrist were informed of the medication error more than 48 hours after the medication error was identified. S2DON verified this was unacceptable.

Based on record review and interview, the hospital failed to ensure radiological services was under the direction of a radiologist. This deficient practice was evidenced by failure of the hospital to appoint a radiologist to supervise/direct the hospital's contracted radiological services.

Findings:

Review of the hospital's contracted services revealed a contract with an area mobile x-ray service.

Review of the hospital's Governing Board meeting minutes, dated 1/25/18, revealed S11MD had been appointed as director of the hospital's contracted radiological services.

Review of S11MD's credentialing file revealed the MD's specialty was internal medicine and not radiology.

In an interview on 4/5/18 at 9:00 a.m. with S1Adm, she confirmed the hospital did not currently have a radiologist appointed to supervise/direct the hospital's contracted radiological services.

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

Findings:

Observations on 4/3/18 at 1:18 p.m. and 4/4/18 at 8:45 a.m. were made of the hospital's environment with S2DON. The following observations were made:
a.) The bathroom faucets in patient rooms #101, #103 and #107 were observed to have poor water pressure that slowly trickled out after being turned on; and
b.) The hospital's courtyard was observed to have several wavy plank boards and two plank boards on the patio that were buckled.

During the observations on 4/3/18 at 4/4/18, S2DON verified the above findings.

Based on record review, observation, and interview the infection control officer failed to ensure the hospital's system for controlling infections was implemented by hospital staff. This deficient practice was evidenced by:
1) Breeches in hand hygiene and glove use by staff; and
2) Staff failing to demonstrate knowledge on decontaminating a patient's room post C. diff infection.

Findings:

1) Breeches in hand hygiene and glove use by staff.

Review of CDC guidelines for Hand Hygiene in Healthcare Settings revealed, in part, hand hygiene should be performed afer contact with inanimate objects in the immediate vicinity of the patient, and after glove removal.

An observation 4/4/18 at 12:25 p.m., of the patient dining room, revealed patients seated at tables eating their noon meal. Further review revealed S12MHT walked out of dining area, wearing gloves with a wadded paper towel in her hand into the hallway, lifted a rubber cover off a large rubber garbage can, threw a paper product into the garbage, replaced the lid, then walked back to a patient table wearing the same gloves without removing or changing gloves and without performing hand hyiene. S5IC/DM and S2DON, both present during the observation, verified the PPE and hand hygiene breeches. Both S5IC/DM and S2DON confirmed the MHT should have removed her gloves, perform hand hygiene before touching anything else, and should have, after performing hand hygiene, donned another pair of gloves before assisting patients with their food and meal.

In an observation on 4/4/18 at 3:00 p.m. with S4Corporate at the nursing station revealed S6LPN donned clean gloves without first sanitizing her hands. She then placed one pill in a medication cup for Patient #12. Patient #12 was observed placing her lips on the cup which she then placed in S6LPN's gloved hand. S6LPN was then observed entering the medication room while still wearing the same gloves and opened medication drawers for two separate patients and picked up a prescription bottle from another patients medication drawer.

In an interview on 4/5/18 at 3:30 p.m. with S4Corporate, he verified the practice above by S6LPN was not following proper hand hygiene policies.

2) Staff failing to demonstrate knowledge on decontaminating a patient's room post C. difficile infection.

Review of the hospital's policy titled,"Management of Patients with Clostridium Difficile", policy number: IC-02.04, revealed in part: Purpose: To prevent and control the transmission of Clostridium difficile (C. difficile) infection in hospitalized patients. Cleaning and Decontamination: a. The environment (patient room) ... must be thoroughly cleaned with a chlorine-containing cleaning agent or other sporicidal agent.

On 4/5/18 at 8:50 a.m., an interview was held with S8HK (housekeeping). S8HK stated he had been employed for 3 months and had recieved orientation training. S8HK stated he was the floor technician and would have to clean the patient's beds and other areas at times. When asked what solution was used to disinfect a room after a C. diff. expsoure, S8HK reported he had not heard of C. diff., although recalling he was trained on "so many diseases." S8HK had shown the surveyor a bottle of Virex II 256 and floor cleaner in which he cleaned the patient's room. When asked if there was any bleach solution onsite, S8HK stated the hospital did not have any bleach on site and was not allowed to clean with it. S8HK added that his supervisor, S9HKSup (housekeeping supervisor) would inform him on the solution to use when having to disinfect a room after a patient who had an infectious disease.

On 4/5/18 at 9:00 a.m., an interview was held with S9HKSup. He stated there had not been any bleach onsite to use for disinfection as far as he could recall. When asked how the patient rooms were cleaned after a patient who had C. diff., he had shown a bottle of Virex TB. S9HKSup stated Virex TB was all he had known to use to clean the rooms after a C. Diff exposure. During the interview, S7HK was walking down the hall. S9HKSup asked S7HK, what she had used to clean patient rooms post C. diff infection. S7HK stated the rooms were cleaned with bleach wipes. S7HK went to the "back" to retrieve a container of Micro Kill Bleach Wipes. S9HKSup stated S5IC/DM would inform him of the patient rooms that required additional cleaning.

On 4/5/18 at 9:55 a.m., an interview was held with S7HK. S8HK was present. S7HK stated she had received training during orientation and annually on how to decontaminate a patient's room post C. diff. exposure. S7HK stated that she was trained to clean the hard surfaces with bleach. When asked, S7HK stated she did not know what the floors in the patient's room were cleaned with. S7HK stated the floor techs mopped the floors.

In an interview on 4/5/18 at 10:34 a.m., with S5IC/DM, she stated after a C. diff. exposure, all surfaces and the floors were cleaned with bleach and water. She stated the hospital had bleach that was stored in the shed outside in the back of the building. She acknowledged staff training included decontamination or a patient's room after a C. diff. exposure. After being made aware the housekeeping staff's responses, S5IC/DM verified the staff should have known bleach was available for staff use. S5IC/DM also verified the housekeeping staff should have known how to decontaminate a patient's room after a C. diff. exposure.



34161

Based on record review and interview, the hospital failed to ensure the mental status examination on the psychiatric evaluation included supportive information used to determine level of function. This deficient practice was evidenced by failure to include supportive information on the psychiatric evaluation that was utilized for assessment of insight and judgement for 2 ( #2, #6) of 3 (#1,#2,#6) patient records reviewed for psychiatric evaluations.

Findings:

Patient #2
Review of Patient #2's medical record revealed an admission date of 3/15/18 with an admission diagnosis of Dementia with Behavior Disorder. The patient's legal status was PEC.

Review of Patient #2's Psychiatric Evaluation, dated 3/16/18, revealed the patient's insight and judgement were both documented as gravely impaired. Further review of the patient's psychiatric evaluation revealed no supportive information/methodology utilized for determining the patient's insight and judgement.


Patient #6
Review of Patient #6's medical record revealed an admission date of 3/26/18 with an admission diagnosis of Dementia with Behavior Disorder. The patient's legal status was CEC.

Review of Patient #6's Psychiatric Evaluation, dated 3/27/18, revealed the patient's insight and judgement were both documented as limited. Further review of the patient's psychiatric evaluation revealed no supportive information/methodology utilized for determining the patient's insight and judgement.

In an interview on 4/5/18 at 8:40 a.m. with S2DON, he confirmed, after review of the above referenced psychiatric evaluations, that there was no documented evidence of supportive information/methodology utilized for determining the patients' insight and judgement.

Based on record review and interview, the hospital failed to ensure information gained from assessing/evaluating patients had been utilized to create an individualized treatment plan as set forth in hospital policy. This deficient practice was evidenced by failure to include the frequency of nursing education in the interventions for addressing potential for impaired coagulation and failure to include signs and symptoms to monitor for patients at risk for bleeding due to anticoagulant therapy for 2 (#1,# 2) of 3 (#1,#2,#6) sampled patients reviewed for anticoagulant therapy.

Findings:

Review of the hospital policy titled,"Treatment Planning", policy number: CS-02, revealed in part: The multidisciplinary 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 treatment process. The treatment plan shall be initiated as a component of the admissions process with continual development and formulation by the attending physician and multi-disciplinary team, with the patient's involvement, throughout the course of treatment. The treatment plan includes defined problems and needs, measureable goals and objectives based on assessed needs, strengths and limits, frequency of care, treatment and services, facilitating factors and barriers, and transition criteria to lower levels of care. Procedure: Revising and developing nursing and medical components of the treatment plan based on additional findings from patient assessments, problems, needs, strengths, limitations, and physician's orders.

Patient #1
Review of Patient #1's medical record revealed an admission date of 3/22/18 with an admission diagnosis of major Depression. Further review revealed the patient had a co-morbid medical condition of Atrial Fibrillation. Additional review revealed the patient was receiving Plavix (anticoagulant) and was on bleeding precautions.

Review of Patient #1's treatment plan revealed the patient had been care planned for potential for impaired coagulation. Further review of the interventions revealed nursing staff was to educate the patient on the safe use of sharps and precautions x (times) 50-60 minutes and the frequency of number of times per day and the number of weeks for patient education was left blank. Additional review revealed the choices for assess for bleeding/bruising every shift for duration of treatment and assess for purple fingers/toes/tarry stools daily and as needed for duration of treatment were left blank.


Patient #2
Review of Patient #2's medical record revealed an admission date of 3/15/18 with an admission diagnosis of Dementia with behavior disorder. Further review revealed the patient was receiving aspirin (blood thinner ) and was on bleeding precautions.

Review of Patient #2's treatment plan revealed the patient had been care planned for potential for impaired coagulation. Further review of the interventions revealed nursing staff was to educate the patient on the safe use of sharps and precautions x (times) 50-60 minutes. Further review revealed the frequency of number of times per day for patient education and the number of weeks was left blank. Additional review revealed the choices for assess for bleeding/bruising every shift for duration of treatment and assess for purple fingers/toes/tarry stools daily and as needed for duration of treatment were left blank.

In an interview on 4/4/18 at 2:20 p.m. with S1Adm, she confirmed, after review of the above referenced patient treatment plans, that the frequency of interventions and the signs/symptoms for bleeding had been left blank and they should have been completed.