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Based on record reviews and interview, the hospital failed to ensure personnel met applicable standards required by State regulations for hospital personnel. This deficient practice is evidenced by failure to have documented evidence of a check/review of the Louisiana Department of Health and Hospital's "Louisiana State Adverse Actions List Search" before hire and every 6 months after the initial search for 3 of 3 (S1Adm, S16MHT, S17DM) unlicensed personnel files reviewed from a sample of 10 personnel files reviewed.

Findings:

Review of the Louisiana Department of Health and Hospital's "Louisiana State Adverse Actions List Search" revealed, in part, "Employers must use the DSW registry to determine if there is a finding that a prospective hire has abused or neglected an individual being supported, or misappropriated the individual 's property or funds. If there is such a finding on the registry, the prospective employee shall not be hired.
The provider shall check the registry every six months to determine if any currently employed direct service worker or trainee has been placed on the registry with a finding that he/she has abused or neglected an individual being supported or misappropriated the individual 's property or funds."

Review of the personnel files for S1Adm with a hire date of 9/10/18, S16MHT with a hire date of 10/11/17, and S17DM with a hire date of 2/10/14 revealed the DSW registry was not checked at the time of their hire. Further review revealed no documented evidence the registry was checked every 6 months after their hire dates.

In an interview on 7/18/19 at 12:10 p.m. with S14HR, she confirmed a check of the DSW adverse action registry was not checked prior to hire nor every 6 months after hire on all unlicensed personnel providing direct care to patients. She confirmed no check of the registry was done for S1Adm, S16MHT, and S17DM. S14HR reported it was an oversight.

Based on record reviews, interviews, and observations, the hospital failed to ensure its Governing Body was effective in ensuring the hospital was compliant with the Condition of Participation for Governing Body as evidenced by:

1) Failure of the Governing Body to ensure the Condition of Participation of Infection Control was met as evidenced by:

a) failure of the hospital's Infection Control Officer to ensure the hospital's single glucose meter that is used to perform capillary blood glucose monitoring on all patients was disinfected between each patient use. This deficient practice was evidenced by failure of S10LPN to disinfect the glucose meter after performing capillary blood glucose sampling on Patient #6 (who had co-morbid diagnoses of blood borne pathogens Hepatitis B and Hepatitis C) and reporting the blood glucose meter was only disinfected once a day with alcohol. This practice placed the 3 current Diabetic patients (#2, #5, and #6) and all future Diabetic patients at risk for transmission of blood borne pathogens. (See findings in tag A-0749).

b) failure to ensure a qualified person or persons was/were designated as infection control officer(s) to develop and implement policies governing control of infections and communicable diseases as evidenced by failure to have documented evidence of experience or training in the oversight of an infection control program for S2DON, designated as infection control officer (See findings in A-0748);

c) failure to ensure the infection control officer implemented a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel as evidenced by:
1) failure to ensure hand hygiene was performed in accordance with hospital policy and procedure;
2) failure to ensure no injectable medications and biologicals were placed and stored in the specimen refrigerator;
3) failure to maintain a clean and sanitary environment;
4) failure to develop and implement a surveillance program of practices that could affect/prevent spread of infection that included more than just hand hygiene practices. (See findings in A-0749)


2) Failure of the Governing Body to ensure the requirements of the Condition of Participation of Nursing Services were met as evidenced by:

a)1) failure of the nursing staff to obtain admission and other patient care orders from a physician for 3 (#4, #5, #6) of 3 (#4, #5, #6) records reviewed for physician orders from a total sample of 10 records; (See findings in A-0395)
b) failure of the RN to ensure the condition of patients' skin was accurately assessed on admit and ongoing, to ensure skin impairments and potential for skin breakdown was identified and monitored to evaluate for worsening for 3(#1, #2, #7) of 3 current sampled patients reviewed for skin assessments from a total sample of 10; (See findings in A-0395) and
c) failure of the nursing staff to notify the physician for acute changes in a patient's oxygen saturation for 1 (# ) of 10 patients sampled. (See findings in A-0395).


30984

Based on policy review and interview, the hospital's governing body failed to ensure there were written policies in place for appraisal of persons (non-inpatient) experiencing a medical emergency that included initial treatment and referral, when appropriate, due to emergency services not being part of the services provided by the hospital.

Findings:

Review of the hospital's policies revealed no written policies addressing appraisal of non-inpatient persons experiencing medical emergencies, initial treatment of those persons, and referral when appropriate.

In an interview on 7/18/19 at 3:42 p.m. with S5CorpRN, she confirmed the hospital had no written policies for appraisal of non-inpatient persons experiencing medical emergencies, initial treatment of those persons, and referral when appropriate.

Based on observation, record review, and interview, the hospital failed to ensure each patient's right to personal privacy during personal hygiene activities. This deficient practice was evidenced by failure to provide privacy in the shower or whirlpool tub stall during hygiene activities (showering/bathing). This deficient practice had the potential to affect all 12 current inpatients receiving care in the hospital at the time of the observation. This deficiency was cited on a previous survey on 6/18/19.

Findings:

On 6/13/19 from 10:30 a.m. to 11:40 a.m. an observation was conducted of the patient care unit which included an observation of the patient shower room. Three deep, recessed tiled shower stalls/bays and 1 room with a whirlpool tub were noted in the shower room. Two of the shower stalls/bays were side by side and one shower stall/bay was located across from the 2 side by side shower stalls/bays. The whirlpool tub room was located to the left of the shower room entry door. Further observation revealed there were no means in place to protect the patients' privacy while showering/bathing in the shower stalls/bays and whirlpool room.

An interview on 7/17/19 at 9:00 a.m. with S1Adm, he stated the hospital did order curtains for the bathroom, but the curtains have not been installed.

Based on record reviews, observation, and interview, the hospital failed to ensure patients at risk for harm to self or others were provided care in a safe setting as evidenced by:
1) Failure to ensure observation levels of psychiatric patients were documented every 15 minutes by the MHTs as ordered by the physician for 6 (#2, #3, #4, #5, #6, #7) of 7(#1, #2, #3, #4, #5, #6, #7) patients reviewed for documentation of observation as ordered from total sample of 10; and
2) Failure to ensure the patients' physical environment was free of safety risks and did not afford opportunities for self -injury/harm to others.

Findings:

1) Failure to ensure observation levels of psychiatric patients were documented every 15 minutes by the MHTs as ordered by the physician.

Review of the hospital policy titled, "Levels of Observation", Policy Number: PC-1013, revealed in part: Purpose: To maintain the safety of each patient and the stability of the therapeutic milieu. Policy: All patients are monitored as to their location and activity at regular intervals. The degree of monitoring is dependent upon the individual patient's assessed psychiatric condition. Procedure: All patients admitted to the hospital will be assigned routine level of observation unless the physician orders a special level of observation. A. Routine levels of observation: 1. All patients are monitored a minimum of once every 15 minutes. 2. Location of patients is monitored at each change of shift by a staff member from the off-going shift together with a member of the on-coming shift. Location is noted on observation sheet for appropriate shift.

Patient #2
Review of Patient #2's medical record revealed the patient had been admitted on 7/2/19 with an admission diagnosis of Dementia with behavioral disturbances.

Review of Patient #2's psychiatric evaluation, dated 7/3/19, revealed the patient's history of present illness indicated the patient was easily angered, easily agitated, walking and pacing and was considered a danger to others and gravely disabled.

Review of Patient #2's 15 Minute Checks 12 hour shift Patient Observation Record dated 7/13/19 revealed the patient was on every 15 minute observations. Further review revealed the patient had observations documented at 4:30 p.m. and then not again until 6:00 p.m. The patient had no observations documented for 1 hour and 30 minutes. Further review of Patient #2's medical record revealed no documentation that the patient was transferred or off the unit from 4:30 p.m. until 6:00 p.m. on 7/13/19.

Patient #3
Review of Patient #3's medical record revealed the patient had been admitted on 7/8/19 with an admission diagnosis of psychosis.

Review of Patient #3's 15 minute checks for 12 hour shift Patient Observation Record dated 7/11/19 revealed the patient was on every 15 minute checks. Further review revealed the patient had observations documented at 7:30 p.m. and then not again until 10:00 p.m. The patient had no observations documented for 2 hours and 30 minutes. Further review revealed Patient #3's 15 minute checks for 12 hour shift Patient Observation Record dated 7/12/19, revealed the patient was on every 15 minute checks. Further review revealed the patient had observations documented at 2:00 p.m. and then not again until 3:00 p.m. The patient had no observations documented for 1 hour. Further review of Patient #3's medical record revealed no documentation that the patient was transferred or off the unit from 7:30 p.m. until 10:00 p.m. on 7/11/19 and 2:00 p.m. until 3:00 p.m. on 7/12/19.

Patient # 4
Review of Patient # 4's medical record revealed an admission date of 7/1/19, under PEC, with an admission diagnosis of Bipolar disorder, Schizophrenia, Auditory Hallucinations, and Polysubstance Abuse.

Review of Patient # 4's 15 minute checks for 12 hour shift Patient Observation Record dated 7/12/19, revealed the patient was on every 15 minute observations. Further review revealed the patient had observations documented at 2:00 p.m. and then not again until 3:00 p.m. The patient had no observations documented for 1 hour. Further review of Patient # 4's medical record revealed no documentation that the patient was transferred or off the unit from 2:00 p.m. until 3:00 p.m. on 7/12/19.

Patient #5
Review of Patient #5's medical record revealed an admission date of 7/10/19 with an admission diagnosis of Bipolar disorder, current episode depressed, severe, without psychotic features. Further review revealed suicidal ideation with a recent Percocet overdose.

Review of Patient #5's 15 minute checks for 12 hour shift Patient Observation Record dated 7/12/19 revealed the patient was on every 15 minute observations. Further review revealed the patient had observations documented at 4:15 p.m. and then not again until 10:00 p.m. The patient had no observations documented for 5 hours and 45 minutes. Further review of Patient #5's medical record revealed no documentation that the patient was transferred or off the unit from 4:15 p.m. until 10:00 p.m. on 7/12/19.

Patient # 6
Review of Patient #6's medical record revealed an admission 6/29/19 under PEC, with an admission diagnosis of Major Depression with Suicidal Ideation.

Review of Patient #6's 15 minute checks for 12 hour shift Patient Observation Record dated 7/13/19, revealed the patient was on every 15 minute observations. Further review revealed the patient had observations documented every 15 minutes through 4:30 p.m. and then not again until 6:00 p.m. The patient had no observations documented for 1 and 1/2 hours. Further review of Patient #6's medical record revealed no documentation that the patient was transferred or off the unit from 4:30 p.m. until 6:00 p.m. on 7/13/19.

Patient #7
Review of Patient #7's medical record revealed the patient had been admitted on 7/9/19 with an admission diagnosis of Vascular Dementia with behavioral disturbances.

Review of Patient #7's 15 Minute Checks 12 hour shift Patient Observation Record dated 7/11/19 revealed the patient was on every 15 minute observations. Further review revealed the patient had observations documented at 7:30 p.m. and then not again until 10:00 p.m. The patient had no observations documented for 2 hours and 30 minutes. Further review of Patient #7's medical record revealed no documentation that the patient was transferred or off the unit from 7:30 p.m. until 10:00 p.m. on 7/11/19.

In an interview on 7/16/19 at 11:30 a.m. with S4RN, he reported he "walked the halls" to check on the MHTs' observation sheets to ensure they were being completed accurately. He indicated he could not keep a routine schedule for checking the observation sheets for accuracy during his shift and explained that was why he walked the halls periodically.

In an interview on 7/18/19 at 8:00 a.m. with S11RN, she explained she checked the MHTs' observation sheets for accuracy every 30 minutes during her shift and signed off on them at the end of her shift. S11RN reported the patient's location and activity should have been documented on the observation sheets every 15 minutes. S11RN indicated the RN should not sign off on incomplete patient observation sheets.

In an interview on 7/18/19 at 12:26 p.m. with S18QA, she reported staff training gaps had been identified. S18QA indicated failure of staff to document patient observations, as ordered every 15 minutes, had been an ongoing issue.



2) Failure to ensure the patients' environment was free of safety risks and did not afford opportunities for self -injury/harm to others.

On 7/16/19 from 10:30 a.m. until 11:40 a.m. an observation was conducted of the patient care unit. The following safety risks were observed during the observation:

a. During the observation of the patient care unit the surveyor pressed the lock bar on the exit door which was located on the far end of the unit on the hallway where all patient rooms were located. The door opened without resistance. The exit door led to an open field that was not bordered by any type of enclosed barrier or fence. S5CorpRN and S6CorpHealth were present during the observation and confirmed the door was unlocked and could be used as a means for patient elopement.

b. Silver "school type" desk top bells that had been taken apart, with the silver dome covering having been removed leaving the sharp metal parts inside the bell exposed, was noted on a patient bedside table in Room 101 and Room 108. S5CorpRN confirmed the sharp parts of metal could pose a safety risk to patients.

c. The television in the group room was observed to have exposed cables/cords that were accessible to patients. S5CorpRN and S6CorpHealth agreed the cords could pose a risk to patient safety.

d. The Shower Room had a corner ceramic tile which was cracked on the bottom. The cracked ceramic tile left a sharp edge. S5CorpRN confirmed the sharp ceramic tile could pose a safety risk to patients.

e. The two bedside tables in room 101 were cracked and one bedside table in room 103 was cracked. S5CorpRN confirmed the cracked plastic could be broken off of the cracked bedside tables and could pose a safety risk to patients.

Review of Patient #R1's medical record revealed an admission date of 3/21/19 with an admission diagnoses of Bipolar and Schizophrenia.

Further review of the medical record revealed the following nursing note entry, dated 3/25/19 at 3:00 a.m., "8:25 p.m. patient comes to nursing station with superficial scratches on both inner forearms, left side of neck, and face which she states was self-inflicted with the use of a piece of plastic she broke off of the corner of her drawer in her room and she then swallowed the plastic so she could go to the hospital ...she was then put on 1:1 observation because of her intent."

On 7/18/19 at 12:00 p.m. S5CorpRN verified the findings in Patient #R1's medical records.


30420




39791

Based on record review, observation, and interview, the hospital failed to ensure the hospital wide QAPI program set priorities aimed at performance improvement activities that focused on high-risk, high-volume, or problem-prone areas that affected health outcomes, patient safety, and quality of care. This deficient practice was evidenced by failure of the hospital's QAPI program to identify and address the following survey identified issues: nursing staff admitting patients and ordering medications without a physician's/licensed independent practitioner's order, failure to identify the glucose meter was not being disinfected between patients, failure to accurately assess patients' nutritional risk, failure to refer patients at nutritional risk for a consult with a registered dietician, and failure to assess patient skin condition on admission and ongoing as opportunities for improvement to be addressed through the hospital's QAPI program.

Findings:

Review of sampled patient records, observation of a nurse initiating an order for a medication (adding it to a previously signed off order), and interview of nursing staff regarding the process for obtaining orders for admit and for medications revealed nursing staff was admitting patients and ordering medications without a physician's/licensed independent practitioner's order. The orders were being documented as telephone/verbal orders read back without actually calling the physician/licensed independent practitioner.

Observation of nursing staff ( S10LPN) performing capillary blood glucose sampling on Patient #6 (who had co-morbid conditions of Hepatitis B and Hepatitis C) and interviews during the observation revealed nursing staff was not disinfecting the hospital's single blood glucose meter between patient uses resulting in the declaration of an Immediate Jeopardy situation on 7/17/19 at 10:19 a.m.. Failure of the nursing staff to disinfect the meter between patients placed the three current Diabetic patients (Patients #2, #5, and #6), all future Diabetics, and any other patients receiving capillary blood glucose sampling at risk for transmission of blood borne pathogens.

Review of sampled patients' medical records revealed nutritional screens were not being scored accurately (Patients #1, #2, and #5) and patients with at risk scores (Patients #5 and #7) were not being referred for consults with a registered dietician.

Review of sampled patient records (Patients #1, #2, and #7) revealed skin assessments were not being performed on admit, risk for skin breakdown was not being identified and preventive measures were not being initiated, and skin assessments were not being documented using descriptive terms to indicated an accurate depiction of patient skin condition.

In an interview on 7/18/19 at 3:09 p.m. with S18QA, she confirmed the above referenced survey identified problems had not been identified as opportunities for improvement to be addressed through the hospital wide QAPI program.

Based on record review and interview, the hospital failed to ensure the QAPI program established indicators, time-frames for compliance, and tracked performance to ensure that improvements were sustained when addressing adverse patient events that impacted patient safety and quality of care. This deficient practice was evidenced by failure of the hospital to implement staff education related to issues identified after review of a patient's death (Patient #8) in the hospital on 5/7/19. The hospital also failed to educate staff on deficient practice areas cited on a complaint survey on 6/18/19 including falls, seclusion/restraint, suicide risk assessments and levels of observation.

Findings:

Review of a Root Cause Analysis conducted to review Patient #8's death on 5/7/19 revealed the following, in part: Human factors relevant to the outcome: 1.The MHT stated she opened the door to the patient's room at 06:00 a.m., 06:15 a.m., 06:30 a.m., and 06:45 a.m. but did not go into the patient's room and up to the bed to check on the patient. She stated she thought the patient was sleeping. 2 ... ... 3. Medication reconciliation/MD order completed on 4/30/19 indicated to continue Novolin R insulin 5 units 3 times a day before meals with a sliding scale. The sliding scale did not have documented parameters to alert nursing staff when to notify the physician of elevated blood glucose levels. MD was not notified of any blood glucose results. MD order was not followed for hour of sleep blood glucose check. Staff administered sliding scale insulin at hour of sleep on 5/4/19, 5/5/19, and 5/6/19 along with Levemir. Order was for blood glucose check at hour of sleep and administration of Levemir.

In an interview on 7/18/19 at 12:26 p.m. with S18QA, she reported the hospital had just received the letter and report on 7/5/19 from CMS regarding the survey conducted in 6/18/19. S18QA confirmed staff education regarding fall documentation post incident, unwitnessed falls or falls with head impact requiring initiation of neuro checks, seclusion/restraint including 1 hour face to face evaluation by RNs, Suicide Risk Assessments, Types of Precautions and Levels of Observation/Staff Supervision of patient training had not been completed as of 7/18/19. S18QA further confirmed staff education related to potential issues with orders for sliding scale insulin, blood glucose parameters and physician notification, and capillary blood glucose monitoring had also not been completed. She indicated the staff in-services had been rescheduled due to the tropical storm the weekend before and the arrival of the survey team on 7/16/19.

Based on record reviews, observations, and interviews, the hospital failed to ensure the requirements of the Condition of Participation of Nursing Services were met as evidenced by:

1) failure of the nursing staff to obtain admission and other patient care orders from a physician for 3 of 3 (#4, #5, #6) records reviewed for physician orders from a total sample of 10 records. (See findings in A-0395);

2) failure of the RN to ensure the condition of patients' skin was accurately assessed on admit and ongoing, to ensure skin impairments and potential for skin breakdown was identified and monitored to evaluate for worsening for 3(#1, #2, #7) of 3 current sampled patients reviewed for skin assessments from a total sample of 10 (See findings in A-0395); and

3) failure of the nursing staff to notify the physician for acute changes in a patient's oxygen saturation for 1 (#5) of 1 patient record reviewed for physician notification of an acute change in patient condition, of 10 patients sampled. (See findings in A-0395).


30984

Based on record review, observation and interview, the hospital failed to ensure the RN supervised the care of each patient as evidenced by:
1) failure of the nursing staff to obtain admission and other patient care orders from a physician for 3 (#4, #5, #6) of 3 (#4, #5, #6) records reviewed for physician orders from a total sample of 10 records; and
2) failure of the RN to ensure the condition of patients' skin was accurately assessed on admit and ongoing, to ensure skin impairments and potential for skin breakdown was identified and monitored to evaluate for worsening for 3( #1, #2, #7 ) of 3 current sampled patients reviewed for skin assessments from a total sample of 10; and
3) failure of the nursing staff to notify the physician for acute changes in a patient's oxygen saturation for 1 (# ) of 10 patients sampled.

Findings:


1) Failure of the nursing staff to obtain admission and patient care orders from a physician.

Review of hospital policy #PC-1407 titled "Verbal/Phone Orders", effective 7/10/12 and provided by S7CorpComp as current, revealed in part that the objective of the policy was to maintain a high level of accuracy and safety in following physician's or Licensed Independent Practitioner orders. Further review revealed the procedure included the following steps, in part: 1"The nurse is to repeat the order to the physician or Licensed Independent Practitioner after receiving it for verification. 2. RN or LPN must sign the physician's or LIP's name with theirs after the last order, including date and time...7. All orders will be checked/noted by the nurse and signed with name, date, and time..."

Review of the Rules and Regulations of the Medical Staff Bylaws revealed in part, under Section 3. Medical Records, #12, "A physician's routine orders, when applicable to a given patient, shall be reproduced in detail on the order sheet of the patient's record, dated and signed by a physician with Medical Staff privileges..." and under Section 4: Prescription of Treatment, #3, " ...All orders dictated over the telephone shall not be accepted until the physician giving the order has been correctly identified by the staff receiving the order, who shall sign the dictated order upon transcription ..."

Patient #4
Review of the medical record for Patient #4 revealed she was admitted to the hospital on 7/7/19 at 6:15 p.m.

Review of Patient #4's admission orders revealed the order sheet with a date and time of 7/7/19 at 7:30 a.m. revealed orders that included laboratory tests, frequency of vital sign assessments, diet, and "Fall: precautions. as having been received as a verbal/telephone order received from S19Physch. Further review revealed a handwritten physician's order dated 7/7/19 at 6:15 p.m. that read, "Patient accepted per S19Psych to Compass Behavioral Impatient Hospital", signed by an LPN as a telephone/verbal order received from S19Psych.

Review of the "Medication Reconciliation/MD Order" dated 7/7/19, listed Neurontin 600 mg p.o. TID for nerve pain and Cymbalta 30 mg. BID for Depression and nerve pain. A handwritten note read, "*NOTE: Pt. denies taking any home meds x 1 year." The Medication Reconciliation/MD Order was signed by S4RN 7/7/19 at 7:30 a.m. as an telephne or verbal order received from S19Psych. The order was signed/authenticated by S19Psych 7/8/19.

Review of a page titled "S19Psych's Standing Orders" dated and timed 7/7/19 at 7:30 a.m. revealed the following orders were checked for medications that included Maalox 30 mg by mouth every 4 hours as needed for dyspepsia, *Acetaminophen 650 mg. by mouth every 6 hours as needed for pain or temp >101 F,* Okay to crush meds, *Haldol 5 mg by mouth every 4 hours prn psychosis. If patient refuses PO, give Haldol 5 mg IM every 4 hours prn Psychosis, *Ativan 2 mg PO every 4 hours prn anxiety. If patient refuses PO, give Ativan 2 mg IM every 4 hours prn anxiety, and *Diphenhydramine 50 mg PO every 4 hours prn itching, prevention of dystonia. If patient refuses PO, give Diphenhydramine 50 mg IM every 4 hours prn itching, prevention of dystonia. Further review revealed the standing order sheet contained other medication orders that were not checked as initiated.

Review of an order sheet titled, "Detox Protocol Standing Orders:" revealed orders circled to be initiated for medications. Further review revealed the orders were signed by S4RN 7/7/19 as received as from S19Psych via telephone.


In an interview 7/16/19 at 2:30 p.m., after reviewing the order sheets, for Patient #4, S4RN confirmed this was his signature dated 7/7/19 on the preprinted order sheets for Patient #4. S4RN reported he had not actually written these orders, but signed them as the charge RN after the LPN wrote them. S4RN reported the usual process was for a nurse to fill in the orders, using information about a patient, obtained from records received from the transferring hospital. S4RN said he only signed on the nurse's signature line under the verbal/telephone order taken as the charge RN when an LPN wrote the orders. When asked to confirm that patient care orders were not obtained from the physician, he verified the nurses chose the orders and did not notify the physician to obtain orders. S4RN stated, "Then we'd have to call the doctor each time."

Patient #5
Review of Patient #5's medical record revealed an admission date of 7/10/19.

Review of Patient #5's admission orders revealed the order sheet with a date and time of 07/10/19 at 2:00 p.m. The bottom of the order sheet had TORB S19Psych, per S3RN.

Further review of the admission orders revealed in the middle of the page a box checked and dated 07/15/19 which selected Loperamide 2 mg by mouth after each loose stool, no more than 16 mg in any 24 hour period. RBTO S19Psych, per S22LPN (an order was entered on the admission order page 5 days after the admission and the orders were signed by the physician).

In an interview on 07/18/19 at 1:00 p.m with S5CorpRN, she verified the Loperamide order should not have been added to a previously written and authenticated order page.

Patient #6
Review of the medical record for Patient #6 revealed he was admitted to the hospital 6/28/19 with a diagnosis of Major Depressive Disorder with suicidal ideations. Further review revealed the patient had medical diagnoses that also included history of a CVA with Left hemiparesis, Diabetes, Hepatitis B, Hepatitis C, Hypertension, and a lung nodule.

Review of the standing order sheet dated 6/28/19 at 1:35 a.m. revealed prn orders for Maalox, Acetaminophen, and Ibuprofen if unable to give Acetaminophen, Haldol, Ativan, and Diphenhydramine. Further review revealed an order for "Loperamide 2 mg. by mouth after each loose stool, no more than 16 mg. in any 24-hour period; Notify S20MD if patient has > 2 consecutive loose stools" was not checked off.

An observation made 7/17/19 at 8:15 a.m. revealed S10LPN obtained the medical chart of Patient #6, who had complained of diarrhea, checked the box next to the Loperamide prn order on the standing order sheet which was documented as a telephone order with a date of 6/28/19 at 1:35 a.m. and was signed by S19Psych's signed with a date and time of 6/28/19 at 4:00 p.m. S10LPN verified she had filled in an order on an order sheet that had been completed and noted on 6/28/19 without the Loperamide ordered at that time. She verified she implemented this order on her own, without calling the physician to obtain the order. S10LPN reported the nurses don't usually call the physician for orders, unless he is present onsite.

An observation 7/17/19 at 8:22 a.m. revealed S10LPN removed Loperamide 2 mg from the automated medication dispensing machine and left the nursing station to administer the medication to Patient #6.

In an interview 7/17/19 at 9:25 a.m. S11RN reported she wrote the admission orders, including checking specific standing orders because she knows what orders S19Psych prefers, and she also uses the patient's records from the sending hospital choose diets and medications they are already taking. She reported if the patient has an allergy to one of the drugs the physician usually uses, then she would call him for clarification.

In an interview 7/17/19 at 2:48 p.m., when asked if he was called for orders on each patient admitted, S19Psych reported the nurses were supposed to call him for all orders.


2) Failure of the RN to ensure the condition of patients' skin was accurately assessed on admit and ongoing, to ensure skin impairments and potential for skin breakdown was identified and monitored to evaluate for worsening.

Patient #1
Review of Patient #1's medical record revealed an admission date of 7/2/19. Further review revealed Patient #1 was wheelchair bound and had a brace on her right leg due to being status post ORIF for a right tibia fracture.

Review of Patient #1's nurses' notes revealed the following entry: 7/13/19 5:20 a.m.: Blister to outer right upper thigh where leg splint is rubbing on skin. Area cleaned and Neosporin and 4x4 wound dressing applied to site.

Review of Patient #1's physician's orders, dated 7/16/19 10:40 a.m., revealed the following: Apply skin barrier cream to right lateral thigh extremity every day and as needed as a skin protectant. Leave open to air and notify MD if no improvement.

On 7/17/19 at 10:15 a.m. an observation was made of Patient #1. The patient was seated in a wheelchair with an immobilizer brace noted to be surrounding the back and sides of her right leg from her ankle up to her thigh. The brace was open down the front and was fastened with plastic clamps and straps. Further observation revealed a Telfa pad dressing was noted on the inner aspect of the patient's left leg, located above the patient's knee. S11RN, present at the time of the observation, indicated the patient had developed a blister on her left leg due to the immobilizer's upper, outer left edge rubbing against her left leg (the opposite leg).

Further review of Patient #1's medical record revealed no documented evidence that the patient's potential for skin breakdown under the immobilizer brace was identified as an issue requiring initiation of skin breakdown preventive measures. Additional review revealed no documented evidence of ongoing assessments of the condition of Patient #1's skin under the immobilizer splint.

Review of Patient #1's discharge skin assessment revealed the blistered area on the patient's left knee, identified on 7/13/19, was not noted on the patient's discharge skin assessment.

Patient #2
Review of Patient #2's medical record revealed an admission date of 7/2/19. Further review revealed Patient #2 was receiving aspirin therapy as an anticoagulant.

Review of Patient #2's Admit Skin Assessment, dated 7/2/19, revealed the entry indicating Skin Impairment was marked as none and the choice for contusion was left blank.

Review of Patient #2's Systems 12 hour Shift Note documentation on 7/2/19 revealed an entry indicating the patient had contusions. Further review revealed there was no description of the location, number, or appearance of the contusions.

Patient #7
Review of Patient #7's medical record revealed an admission date of 7/9/19.

Review of Patient #7's Admit Skin Assessment revealed the assessment form had been left blank.

In an interview on 7/17/19 at 10:30 a.m. with S7CorpComp, she agreed Patient #1 was at risk for skin breakdown due to the immobilizer splint and should have had ongoing skin assessments initiated to monitor for potential skin breakdown. S7CorpComp also agreed nursing staff shoud have initiated wound prevention measures to decrease Patient #1's risk of skin breakdown under the knee immobilizer. S7CorpComp confirmed documentation of contusions should have included location, size, number, and a description of the appearance of the contusion such as color. S7CorpComp further confirmed nursing staff was to complete skin assessments on all patients upon admission and at discharge.


3) Failure of the nursing staff to notify the physician for acute changes in oxygen saturation.

Review of the Patient Care Policy titled "Emergency Services", presented as current policy, stated in part: under procedure, Early Warning Criteria for a Deterioration in Condition. The following criteria indicates, but is not limited to, early warning signs of a deterioration in a patient's condition: ...Acute change in Oxygen Saturation <90... Under Initial Treatment of Persons with Emergencies it states in part, the hospital has evaluated the patient population it routinely cares for in order to anticipate potential emergency care so that the facility can provide safe and adequate initial treatment of an emergency. ...The physician is to be notified for further instructions...

Review of Patient #5's medical record revealed an admission date of 7/10/19. Further review revealed Patient #5 had the following co-morbid conditions: Diabetes and Asthma.

Review of the Graphic Record revealed an admission set of vital signs on 07/10/19 at 2:00 p.m. with heart rate of 120 bpm and oxygen saturation of 82%. Further review of the Graphic Record revealed vital signs were not completed on 07/10/19 at 10:00 p.m. There is "none" typed in this column. The next set of vital signs were completed on 07/11/19 at 8:00 a.m. (18 hours after the saturation of 82%) with heart rate of 99 bpm and oxygen saturation of 92%.

Review of the progress notes failed to reveal the nurse notified the physician of the oxygen saturation at 82% on 07/10/19.

In an interview on 07/16/19 at 2:25 p.m. with S5CorpRN, she verified the physician should have been notified for Patient #5's oxygen saturation of 82% on 07/10/19


30984




39791

Based on record review and interview, the hospital failed to ensure a qualified full-time, part-time, or consulting radiologist supervised the radiology services of the hospital as evidenced by failure to have a radiologist appointed and privileged to supervise the radiology services provided by the hospital.

Findings:

Review of the Governing Body meeting minutes for the last year revealed no appointment/privileging of a radiologist to the medical staff on a full time, part time, or consulting basis. Further review revealed no appointment of a radiologist to supervise Radiological Services.

Review of the Medical Staff meeting minutes for the last year revealed no reference to the appointment or approval of a radiologist to supervise Radiological Services. Further review revealed no approval of membership or privileges for a radiologist to the medical staff.

In an interview 07/16/19 at 9:15 a.m. S1Adm reported the hospital did not have a director of Radiological Services.

Based on record review and interview, the hospital failed to ensure a qualified dietician was available to supervise the nutritional aspects of patient care. This deficient practice was evidenced by failure of the hospital to have a qualified dietician.

Findings:

Review of the hospital's organizational chart and list of current employees revealed there was no current registered dietician listed as being employed by the hospital.

In an interview on 7/16/19 at 10:00 a.m. with S1Adm, he reported the hospital's previous dietician had left in May 2019. S1Adm confirmed he had not hired a registered dietician at the time of the interview.

In an interview on 07/18/19 at 10:30 a.m. with S17DM, she confirmed the hospital did not currently have a dietician. She further revealed the former dietician left in May of 2019 and did not return to work.

Based on record reviews and interviews, the hospital failed to ensure individual patient nutritional needs were met in accordance with recognized dietary practices. This deficient practice was evidenced by failure to ensure patients' admit nutritional assessments were scored accurately for 3 (#1, #2, #5) of 7 (#1-7) patients reviewed for nutritional assessment, and failure to ensure patients who triggered the need for a nutritional assessment received a nutritional assessment by a registered dietitian within 72 hours, in accordance with hospital policy, for 3 (#5, #6, #7) of 7 (#1-7)patient records reviewed for nutritional assessment by a registered dietitian from a current inpatient sample of 7 (#1 - #7) and of a total sample of 10.

Findings:

Review of the hospital policy titled," Diet Orders", Policy Number: PC-1301, revealed in part: Policy: To provide patients with prescribed diets and nutritional needs. Procedure: 2. Upon admission, the nurse will complete nutritional nursing screening and consult the Registered Dietician for a nutritional assessment if the patient scores a "3" or greater. 3. Registered Dietician shall complete assessment within 72 hours.

Review of the Inpatient Nutritional Screening Tool revealed the following screening categories with associated point values:
1. Critical Diagnosis Triggers: Anorexia, Bulimia, Diabetes, Malnutrition, AIDS, Open Wounds, Renal Failure, Hypertension, CAD, and Liver Disease: Score: 3;
2. Vomiting/Diarrhea greater than 3 days: Score: 2;
3. Difficulty Chewing/Swallowing: Score: 2;
4. Therapeutic Diet Order: Score: 1;
5. Above/Below desirable body weight: Score: 1;
6. Food Allergies: Score: 1;
7. Patient's perception of body size contradicts actual presentation: Score: 1;
8. Weight fluctuations; (+/- 10 pounds in 1 month): Score: 1;
9. Decreased food intake greater than 2 weeks: Score: 1; and
10. Alcohol/Drug Abuse: Score: 1

Total Points: A score of 1-2 total points: No nutritional follow-up needed.
A score of 3+: Refer and fax a copy within 24 hours for Registered Dietician to perform assessment within 72 hours.

Patient #1
Review of Patient #1's medical record revealed an admission date of 7/2/19. Further review revealed the patient was obese and was status post ORIF (open reduction internal fixation) surgery for treatment of a right tibia fracture. The patient also had a co-morbid diagnosis of Hypertension.

Review Patient #1's admission orders, dated 7/2/19, revealed an order for a NAS (no added salt) mechanical soft modified consistency diet.

Review of Patient #1's Inpatient Nutritional Screening Tool, completed on 7/2/19 at 2:00 p.m., revealed the patient had a diagnosis of Hypertension which was considered a critical diagnosis and she should have been scored a "3" instead of a "0" on that section. Further review revealed the patient was on a therapeutic diet (NAS) and should have been scored a "1" for that section and she was scored "0". The patient also scored a "0" for being above/below ideal body weight despite the patient being obese. The patient should have been scored a "1" for that section instead of "0". The patient should also have been scored a "1" instead of a "0" for difficulty chewing/swallowing due to requiring a mechanical soft diet. The correct total score should have been "6" instead of "1" which would have triggered a nutritional consult with a registered dietician.

Further review of Patient #1's medical record revealed no documented evidence that a consult for an assessment of Patient #1, by a registered dietician, had been ordered.

Patient #2
Review of Patient #2's medical record revealed an admission date of 7/2/19 with an admission diagnosis of Dementia and co-morbid conditions of Anemia, Diabetes Mellitus, Hypertension, and Coronary Artery Disease.

Review of Patient #2's admission orders revealed an order for a NCS (no concentrated sweets)/NAS (no added salt) diet, Accu-checks twice a day, and Metformin 500 mg by mouth twice a day for treatment of Diabetes Mellitus.

Review of Patient #2's Inpatient Nutritional Screening Tool, completed on 7/2/19 at 2:00 p.m., revealed the patient had the following diagnoses which fell into the critical diagnosis category: Diabetes, CAD, and HTN. Further review revealed that section of the tool was marked with a score of "0"and should have been scored "3". The patient was on a therapeutic diet and should have been scored a "1" for that section and he was scored "0". The patient also scored a "1" because he was above/below ideal body weight. The correct total score should have been "5" instead of "1" which would have triggered a nutritional consult with a registered dietician.

Further review of Patient #2's medical record revealed no documented evidence that a nutritional consult with a registered dietician had been requested.

Patient #5
Review of Patient #5's medical record revealed an admission date of 7/10/19 with an admission diagnosis of Bipolar disorder, current episode depressed, severe, without psychotic features. Further review revealed the patient was Diabetic.

Review of Patient #5's medical history indicated the patient used tobacco and had a history of substance abuse.

Review of Patient #5's admission orders, dated 7/10/19, revealed the patient had an order for a NCS (no concentrated sweets)/NAS (no added salt) diet, Accu-checks twice a day, and Metformin 500 mg by mouth twice a day for treatment of Diabetes Mellitus.

Review of Patient #5's Inpatient Nutritional Screening Tool, completed on 7/10/19 at 8:20 p.m., revealed the patient had the following diagnoses which fell into the critical diagnoses category: Diabetes. Further review revealed that section of the tool was marked with a score of "3". The patient abuses drugs and/or alcohol should have been scored a "1" for that section and he was scored "0". The correct total score should have been "4" instead of "3".

Further review of Patient #5's medical record revealed no documented evidence that a nutritional consult with a registered dietician had been requested.

Patient #6
Review of Patient #6's medical record revealed an admission date of 6/28/19 with an admission diagnosis of Major Depressive disorder with Suicidal Ideations. Further review revealed the patient had medical diagnoses that included Diabetes (Type II), recent CVA with Left hemiparesis, Hepatitis B, Hepatitis C, Hypertension, and Substance Abuse.

Review of Patient #6's admission orders, dated 6/28/19, revealed the patient had an order for a No added salt/No concentrated sweets diet, capillary blood glucose checks twice a day, and Metformin 1000 mg. by mouth twice a day. Further review of his admission orders revealed he had two medications ordered for hypertension, and aspirin daily as a blood thinner.

Review of Patient #6's Nutritional Assessment completed by the RN on admission, on 7/9/19 at 4:01 a.m., revealed the patient had a total score of "5" due to his diagnosis of Diabetes, and current abuse of drugs.

Further review of Patient #6's medical record revealed no documented evidence a request for a consult with a registered dietician had been sent, or documentation of a dietary consult.


Patient #7
Review of Patient #7's medical record revealed an admission date of 7/9/19 with an admission diagnosis of Vascular Dementia. Further review revealed the patient has Dysphagia.

Review of Patient #7's admission orders, dated 7/9/19, revealed the patient had an order for a mechanical soft diet.

Review of Patient #7's Inpatient Nutritional Screening Tool, completed on 7/9/19 at 7:14 p.m., revealed the patient had a score of "3" due to dysphagia and a therapeutic diet order (mechanical soft diet) which triggered a need for a nutritional consult with a registered dietician.

Further review of Patient #7's medical record revealed no documented evidence a request for a consult with a registered dietician had been sent.

In an interview on 7/16/19 at 10:00 a.m. with S1Adm, he reported the hospital's previous dietician had left in May 2019. S1Adm confirmed he had not hired a registered dietician at the time of the interview. S1Adm indicated the hospital's food service provider had registered dieticians available if a dietician's services were needed.

In an interview on 7/17/19 at 10:30 a.m. with S7CorpComp, she confirmed the above referenced patients should have had referrals for an assessment by a registered dietician. She also confirmed the nutritional screening tool had not been scored correctly on Patient #2. S7CorpComp indicated patients on modified consistency diets with diagnoses of Diabetes and issues with swallowing should have been an automatic trigger for a consult with a registered dietician.

In an interview on 7/18/19 at 8:00 a.m. with S11RN, she confirmed the hospital had not had a registered dietician since around May 2019. When asked what actions were taken if a patient triggered for a consult with a registered dietician she replied, "I call the doctor."

In an interview on 7/18/19 at 12:26 p.m. with S18QA, she reported the dietician available through the hospital's food service provider was supplied as a resource to the Dietary Manager. S18QA confirmed the food service provider's dieticians were not available to perform inpatient nutritional assessments.


30420




39791

Based on record review and interview, the hospital failed to ensure the UR committee included two members who were doctors of medicine or osteopathy who were not directly involved in patient care at the hospital.

Findings:

Review of the hospital policy titled," Utilization Review Policy", revealed in part: Organization and Composition of the Committee: No less than two members of the UR Committee shall be physicians. The UR Committee may not include: Physicians may not participate in the review of any cases in which he/she has been or anticipated being professionally involved.

Review of the UR documentation presented by S1Adm revealed no documented evidence that the UR committee included two physician members who were doctors of medicine or osteopathy that were not directly involved in patient care. The two physician members of the UR committee were S19Psych and S20MD.

Interview on 7/17/19 at 2:48 p.m. with S19Psych, he indicated he knew there was a UR committee but he had not participated in the meetings.

In an interview on 7/17/19 at 3:10 p.m. with S1Adm, he indicated the UR committee gave S19Psych UR reports. S1Adm confirmed the hospital's UR committee did not have two physician members who were not directly involved in patient care.

Based on observation, record review and interview, the hospital failed to meet the requirements of the Condition of Participation for Infection Control as evidenced by:

1) failure of the hospital's Infection Control Officer to ensure the hospital's single glucose meter that is used to perform capillary blood glucose monitoring on all patients was disinfected between each patient use. This deficient practice was evidenced by failure of S10LPN to disinfect the glucose meter after performing capillary blood glucose sampling on Patient #6 (who had co-morbid diagnoses of blood borne pathogens Hepatitis B and Hepatitis C) and reporting the blood glucose meter was only disinfected once a day with alcohol. This practice placed the 3 current Diabetic patients (#2, #5, #6) and all future Diabetic patients at risk for transmission of blood borne pathogens (See findings in tag A-0749);and

2) failure to ensure a qualified person or persons was (were) designated as infection control officer(s) to develop and implement policies governing control of infections and communicable diseases as evidenced by failure to have documented evidence of experience or training in current infection control practice for S2DON, reported as infection control officer (See findings in tag A-0748); and

3) failure to ensure the infection control officer implemented a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel as evidenced by:
a) Failure to ensure hand hygiene was performed in accordance with hospital policy and procedure;
b) Failure to ensure no injectable medications and biologicals were placed and stored in the specimen refrigerator;
c) Failure to maintain a clean and sanitary environment;
d) Failure to develop and implement a surveillance program of practices that could affect/prevent spread of infection that included more than just hand hygiene practices (See findings in A-0749).

Findings:

1) Failure of the hospital's Infection Control Officer to ensure the hospital's single glucose meter that is used to perform capillary blood glucose monitoring on all patients was disinfected between each patient use.


An Immediate Jeopardy situation was identified on 7/17/19 at 10:19 a.m. and reported to S1Adm, S5CorpRN, and S7CorpComp. The Immediate Jeopardy situation was a result of the hospital's Infection Control Officer failing to ensure the hospital's single glucose meter that is used to perform capillary blood glucose monitoring on all patients was disinfected between each patient use placing the 3 current Diabetic patients (#2, #5, #6) and all future Diabetic patients at risk for transmission of blood borne pathogens.

On 7/17/19 at 4:45 p.m. S1Adm, S5CorpRN, and S7CorpComp presented the 1st plan for lifting the immediacy of the IJ situation and the plan included the following:

1.Licensed nursing personnel will be trained on glucose meter cleaning and disinfection. Licensed nursing personnel are the only staff members who perform capillary blood glucose monitoring.

2.All licensed nursing personnel, including as needed licensed nursing personnel, will complete a post-test to determine efficacy of training after in-service training including a review of Blood -borne Pathogen, Infection Control, and Glucose Testing/Finger-stick policies. Licensed nursing staff will not be allowed to work until training has been completed.

3.Compliance monitoring to include implementation of a Performance Improvement indicator to determine whether staff was cleaning and disinfecting the glucose meter between each patient use. Monitoring of scheduled a.m. and p.m. capillary blood glucose sampling would be conducted weekly to ensure the glucose meter was being disinfected between each patient use.

Review of staff education documentation presented to the survey team revealed licensed nursing staff education had begun on 7/17/19 at 1:00 p.m. Content of the in-service education was reviewed as well as the sign-in sheets and post-test documentation. S5CorpRN indicated a return demonstration had also been part of the in-service education. Further review revealed all full-time licensed nursing staff had been educated with the exception of one nurse. S5CorpRN indicated the one nurse who had not been in-serviced at the time of the review was coming in later that day.

In an interview on 7/17/19 at 4:50 p.m. with S5CorpRN, she indicated there were no capillary blood glucose tests due until the scheduled morning capillary blood glucose monitoring on 7/18/19.

The IJ remained in place on 7/17/19 due to the need for the following: observation of staff performance of glucose monitoring and proper disinfection of the meter, staff interviews verifying in-service education, and completion of required modifications to the monitoring plan to include increased frequency of monitoring and determination of the staff member who would be responsible for monitoring of compliance.

In an interview 7/18/19 at 8:05 a.m. S10LPN, after an observation of her properly performing a capillary glucose test on Patient #6 and disinfection of the glucometer, reported she had received training the day prior (7/17/19) on proper techniques and frequency of disinfection of the glucometer , infection control policies and procedures, blood borne pathogens, and the procedure for blood glucose monitoring via finger stick.

In an interview 7/18/19 at 8:10 a.m. S11RN reported she had attended staff training yesterday (7/17/19) that included, in part, disinfection of the glucose meter between patient use, infection control policies/procedures, blood borne pathogen training, and blood glucose monitoring via finger stick.


On 7/17/19 at 10:50 a.m. S1Adm, S5CorpRN, and S18QA presented the 2nd plan for lifting the immediacy of the IJ situation. The revised plan indicated there would be indefinite monitoring of 100 % of opportunities for monitoring of cleaning of the blood glucose meter. Further review revealed the staff member responsible for compliance monitoring would be S15RN (Interim DON).

The Immediate Jeopardy was lifted on 7/18/19 at 10:53 a.m. However, there was not enough evidence to determine sustainability of compliance with the Condition of Participation for Infection Control for the Condition to be cleared. Noncompliance remains at the Condition Level.




30420

Based on record reviews and interview, the hospital failed to ensure a qualified person or persons was (were) designated as infection control officer(s) to develop and implement policies governing control of infections and communicable diseases. This deficient practice was evidenced by failure to have documented evidence of experience and training in current infection control practice for S2DON, designated as infection control officer.

Findings:

Review of the Medical Staff meeting minutes and Governing Body meeting minutes revealed S2DON was appointed as Infection Control Officer in June of 2018.

Review of the personnel file of S2DON, with the assistance of S14HR, revealed no documented evidence of prior experience in implementation/supervision of an infection control program or documentation of specialized training in development and/or coordination of an infection control program. S14HR, assisting with the personnel review, verified the findings.

In an interview on 7/16/19 at 9:15 a.m., S1Adm reported S2DON was the Infection Control Officer for the hospital, but was on leave at the time of the survey. S1Adm verified S2DON was the only Infection Control Officer and no one had assumed her duties at this time.

Based on observations, record reviews, and interviews, the hospital failed to ensure the infection control officer implemented a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel as evidenced by:
1) failure to ensure the hospital's single glucometer that was used to perform capillary blood glucose monitoring on all patients was disinfected between each patient use; and
2) failure to ensure hand hygiene was performed in accordance with hospital policy and procedure; and
2) failure to ensure no injectable medications and biologicals were placed and stored in the specimen refrigerator; and
3) failure to maintain a clean and sanitary environment; and
4) failure to develop and implement a surveillance program of practices that could affect/prevent spread of infection that included all patient care areas.
Findings:

1) Failure of the hospital's Infection Control Officer to ensure the hospital's single glucose meter that was used to perform capillary blood glucose monitoring on all patients was disinfected between each patient use.

Review of hospital policy and procedure #IC-300 titled, "Cleaning, Disinfection, and Sterilization", effective 10/18/12, last revised July 2019 revealed in part, under Accu-Check and Glucometer (page 4 of 7), Procedure: "Clean and disinfect according to instructions in equipment manual (see attachment A). Use EPA-approved disinfectant where disinfectant solution is called for.", and frequency was documented as before and after each patient use." Further review revealed Attachment A was as follows: "Cleaning and Disinfecting the McKesson True Metrix Pro Professional Monitoring Blood Glucose Meter. To Clean and Disinfect: * wash hands * Set up a clean staging area by laying an unused disinfecting wipe on a clean surface, Put on gloves ...To CLEAN: Using only a disinfectant product with and EPA* reg. no of 9480-4, rub the entire outside of the meter using 3 circular wiping motions with moderate pressure on the front, back, left side, right side, top, and bottom of the meter. Repeat as needed until all surfaces are visible clean.
*To DISINFECT: Using fresh wipes, make sure all outside surfaces of the meter remain wet for 2 minutes ... *Remove gloves and wash hands. * Let meter air dry thoroughly on the unused disinfecting wipe before putting it away or using to test.

In an interview on 7/16/19 at 11:45 a.m. S9LPN reported, as the medication nurse, part of her duties included performing the CBG testing on patients during her shift and had completed all 3 required tests earlier that morning. S9LPN reported she cleaned the glucometer at the end of her shift with alcohol.

An observation made on 7/17/19 at 8:11 a.m. of S10LPN performing a capillary blood glucose on Patient #6 revealed once in Patient #6's room, S10LPN placed the glucometer, glucometer (nylon) case, and tray of supplies (lancet devices, alcohol, glucometer, etc.) on the patient's bed. During the testing, Patient #6 confirmed he had complaints of diarrhea, and reported the symptoms had been present for 2 days. After the CBG was completed, S10LPN was observed picking up the glucometer from Patient #6's bed and placing it inside its storage case, then placed that case in the supply tray. She then was observed removing her gloves and taking the supply tray back to the nurse's station where she reached into her uniform pocket and removed a badge and scanned it to open the door to the nurses' station. Once in the nurses' station, S10LPN placed the supply tray on top of the Medication Cart, then obtained Patient #6's medical record. S10LPN did not disinfect the glucometer or sanitize her hands before, during or after obtaining the capillary blood glucose.

In an interview on 7/17/19 at 8:20 a.m., when asked how and when the glucometer was cleaned, S10LPN reported she cleaned it with alcohol, at night, but added it probably should have been cleaned between patients. S10LPN verified she had not cleaned the glucometer, its case or the tray, all of which were placed on Patient #6's bed.

Review of the medical record for Patient #6 revealed his diagnoses included Hepatitis B and Hepatitis C.

In an interview on 7/17/19 at 9:25 a.m. S11RN reported she occasionally does accuchecks (CBGs). The charge RN reported that she would also perform the CBGs on a patient if a patient had an emergency or signs and symptoms of a very high or low blood sugar. S11RN reported that is the only glucometer used to perform CBGs on patients in the hospital. The charge RN verified there were currently 3 patients with diagnoses that included Diabetes receiving CBGs (all BID), but any of the patients potentially could have a CBG performed on them if they had an emergency or change in condition that would require a capillary blood glucose be performed to rule out a high or low blood glucose.

In an interview 7/16/19 at 11:45 a.m. S9LPN reported she cleaned the glucometer once a day using alcohol wipes. S9LPN reported that there were currently 3 patients receiving capillary blood glucose testing using the glucometer and each had already had their tests performed before breakfast. S9LPN reported they would be performed again that evening prior to the dinner meal.


2) Failure to ensure hand hygiene was performed in accordance with hospital policy and procedure and CDC Guidelines;

Review of the CDC's "Guideline for Hand hygiene in Health-Care Settings" revealed indications for handwashing and hand antisepsis were as follows: 1) when hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water; 2) if hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations; 3) decontaminate hands before having direct contact with patients; 4) decontaminate hands before donning sterile gloves when inserting a central intravascular catheter; 5) decontaminate hands before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure; 6) decontaminate hands after contact with a patient's intact skin (such as taking a pulse or blood pressure, and lifting a patient); 7) decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled; 8) decontaminate hands if moving from a contaminated body site to a clean body site during patient care; 9) decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; 10) decontaminate after removing gloves; 11) before eating and after using a restroom, wash hands with a non-antimicrobial soap and water or with an antimicrobial soap and water.

Review of hospital Policy and Procedure 3IC-201: Standard Precaution, effective July 2, 2012, provided as current revealed, in part, hands should be washed after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves were worn. Hands should be immediately washed after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments. Gloves must be worn when touching blood, body fluids, secretions, excretions, and contaminated items. Gloves must be changed between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Gloves must be removed promptly after use, before touching non-contaminated items and environmental surfaces.

Review of the Infection Control Plan revealed the hospital's policies and procedures were based on, in part, the CDC guidelines.

An observation on 7/16/19 at 11:28 a.m. revealed S9LPN donned a pair of gloves to examine soiled equipment. After touching the equipment S9LPN reached into her pocket to get the keys to open the medication room. She then unlocked and opened the door, then she removed her gloves, but did not perform hand hygiene prior to touching anything else. S9LPN verified she had not performed hand hygiene prior to donning gloves or after removing them.

An observation was made on 7/17/19 at 8:11 a.m. of S10LPN performing a capillary blood glucose on Patient #6. S10LPN donned gloves, without performing hand hygiene. After completing the capillary glucose test, S10LPN picked up the glucometer from the bed, placed the glucometer inside its storage case, and then placed that case in the supply tray. She removed her gloves and took the supply tray back to the nurses station where she reached into her uniform pocket and removed a badge and scanned it to open the door to the nurses' station. S10LPN then placed the supply tray on top of the Medication Cart, then pulled Patient #6's medical record, wrote orders, faxed them to the pharmacy, then washed her hands.
In an interview at the time of the observation, S10LPN confirmed she did not perform hand hygiene prior to donning her gloves, or after removing them, or before touching other items.

3) Failure to maintain a clean and sanitary environment.

Review of hospital Policy and Procedure 3IC-201, titled, "Standard Precaution", effective July 2, 2012, provided as current, revealed, in part under Patient-care equipment: Reusable equipment is cleaned prior to use with another patient.
Single-use items are discarded immediately after use in the appropriate receptacle.

A Tour of facility was conducted beginning on 7/16/19 between 10:30 a.m.- 11:25 a.m. with S5CorpRN and S6CorpHealth. The following findings were observed and verified during the tour by S5CorpRN and S6CorpHealth:
.
Laundry room- commercial sized washer and dryer, and S5CorpRN reported housekeeping usually laundries the hospital linens, but right now the MHTs were doing laundry, as the hospital currently had no housekeeping staff. No quality control logs documenting indicators such as washer and dryer temperatures were observed in the laundry room. S5CorpRN and S6CorpHealth were unable to provide quality logs for laundry processed in the hospital.

Rooms labeled Visitor//Consultation : 1st one (on right) contained equipment that included a wheelchair with old soiled tape on the back of the chair, a wheelchair with tears in the arms leaving inner foam exposed, a pair of drapes partially folded sitting on the Geri-chair with no indication if they had been cleaned, a thin layer of grayish white substance similar to the appearance of dust on 2 of the wheelchairs, a Geri-chair with tears in both arms, leaving inner foam cushioning exposed, a soiled blue cushion/ pad in the shape and size of a chair seat pad on top of a wheelchair, a sock over a wheelchair arm, an empty white disposable plastic cup, a broken umbrella with no name, removed wheelchair foot pedals with a dark brown and gray substance on the pedals sitting in the Geri-chair, and debris on the floor of the room.

Patient Shower Room: Rusted door frame into the toilet room to the right on entry, around the left side of the door frame approximately2-3 inches high, and areas of exposed sheetrock.

Patient rooms:
101-Sink with blue, white, and yellow substance with the appearance of spot and drip formation, bed closest to window with a dried round spot of a clear brownish-yellow substance.
102- Room not cleaned, both beds unmade. S5CorpRN verified the room was not blocked, did not currently have a patient assigned to the room, and stated it should have been cleaned when the last patient was discharged.
103- Floor with dark marks and debris.
104- No patient assigned to the room, bathroom with debris on floor, bathroom sink with whitish/brown dried liquid substance dried in a splatter pattern. The beds had dried splatters of a whitish/brown substance on the bases.
106-. The fiberglass wall segments at the head of the beds were noted to be soiled with brownish- gray areas. Bathroom with brown substance on wall and smeared approximately 8 inches down the wall.
107- A vinyl covered foam breakaway door (attached with Velcro) between the bedroom and the bathroom was noted to have a smear of a brownish-orange/red dried substance on the room side of the door.
108- Bedside table closest to window with inset drawer pulls with gritty debris and light grey powdery substance in all three drawer pull insets.
109-Two smudges of dried dark reddish/brown substance on wall by window approximately 1- 1 ½ inches long and ½- 1 inch wide.
111- Top drawer of bedside table by window broken, walls with a patch, but without paint or other covering that would allow use of disinfecting cleaners without disrupting the patch material.

Patient names were written on an adhesive-backed paper label and attached to a plastic name plate which housed an inset area in which a piece of paper could be inserted slide a paper beside each room. There were remnants of part of previous adhesive backed paper labels stuck to the plastic plates which could not be disinfected. S5CorpRN, present for the observations verified all observations and noted that areas of residual tape, paper labels, and plaster repairs not painted or covered with other type of sealant could not be properly cleaned and disinfected.

An observation in the medication room with S9LPN on 7/16/19 from 11:28 a.m. until 12:25 p.m. revealed the following:
-Biological specimen refrigerator (with large orange Biohazard label on front of door) contained 2 bagged urine specimens, a box of vials of TB Purified Protein injectable used for TB Skin tests, 2 boxes of individual doses of Influenza vaccine, 1 box of Risperdal Consta injectable (antipsychotic medication) 12.5 mg with a first name only written on the side of the box, 1 Novalog Flex Pen with a discharged patient's label on the baggie containing the flex pen.
In cabinets:
- a 16 ounce bottle of Sprite, a small can of Pringles potato chips, and the empty wrapper of a large (7 ounce) Hersey's Chocolate Bar,
- A bottle of 1000 ml sterile water for irrigation, labeled for single use, opened and partially used;
-a 100 ml bottle of Normal Saline, labeled for single use, opened;
-25 25guage butterfly needles (with tubing attached) opened and attached to a vacutainer holder, in a portable blood drawing tray;
-4 patient belongings plastic bags filled with clothing, with no names on them, on the floor behind the medication cart;
- a case of 24 250ml (1.2 kg) cartons of DiabeticSource AC dietary supplement with an expiration date of 9/18;
-an Incruse Ellipta (62.5 mcg) inhaler- single patient with a discharged patient's label on the container;
-A large tube of Permethrin Cream 5 %, opened with a discharged patient's on the carton;
An Advair Diskus 100/50 inhaler (unused) with no patient name, and an expiration date of 12/2018;
-16 sets of blood culture bottles (1 set= 1 aerobic and I anaerobic) with an expiration date of 8/18;
-5 faded and spotted rubber tourniquets single use tourniquest
- 6 sets of blood culture bottles with an expiration date of 3/21/19;
- 1 culture bottle set with an expiration date of 1/24/19;
-5 urine culture collection sets with an expiration date of 8/18;
-Blood collection/vacutainer tubes: 3 red top tubes, with separator material expiration of 12/16, 3 Gold top tubes with an expiration of 10/18/18, 4 purple top tubes with an expiration date of 12/8/18, 2 Blue top tubes with an expiration of 1/16;
A Hydrofiber wound dressing (unopened) with an expiration date of 11/16;

An observation of the medication cart revealed a large amount of debris in drawers, with each drawer having areas of thick mostly dried substance in the bottom of the drawers. A metal trash bin attached to the side of the medicine cart had the top of the bin taped open to the top edge of the cart surface with layered soiled silk tape.
These above referenced observations were verified by S9LPN, present throughout the observation. S9LPN reported she was not sure what the fabric or clothing in the bags were, or who they belonged to, but she thought they might have belonged to patients. She verified nothing should be in the biological refrigerator except lab specimens. S9LPN verified all expiration dates found during the observation. S9LPNLPN also found a box of single use rubber tourniquets identical to the old faded ones found in the blood draw equipment trays and verified they were single use only.

4) Failure to develop and implement a surveillance program of practices that could affect/prevent spread of infection that included all patient care areas.

Review of the Infection Control Binder revealed infection control surveillance activities were documented as 3 hand hygiene opportunities per month. Further review revealed patient infections were listed and criteria applied to determine if the infections were hospital acquired or community acquired. No other surveillance activities were documented in the binder.

Review of Medical Staff and Governing Body meeting minutes revealed Infection Control reporting included the number of infections each month, broken down into Hospital Acquired Infections versus Community Acquired Infections. Further review revealed no other surveillance activity reported.

In an interview on 7/18/19 at 2:35 p.m., S15RN reported she usually worked as the DON at a sister hospital, but would be assuming the duties of the DON and Infection Control Officer from that day on, until S2DON returned from leave, but was not sure how long that would be. She reported she was not familiar with the procedures in this hospital and how S2DON kept her infection control information. S15RN reviewed the Infection Control Binder for the hospital, and verified there was documentation that 3 opportunities for hand hygiene each month were observed and documented. She agreed that with a census of 12 patients, with the ability to have up to 20 patients, and the services the hospital provided, that 3 opportunities would not provide a true picture of hand hygiene compliance. S15RN verified the hospital provided its own laundry service for hospital linens, and provided its own dietary services with a kitchen onsite. S15RN verified that no documentation of surveillance activities for laundry services, any infection control practices from dietary services, PPE use, safe injection practices, housekeeping practices, or environmental surveillance could be provided.


39791

Based on observations, record review, and interview, the hospital failed ensure patients' discharge needs were reassessed when there were factors that affected continuing care or the appropriateness of the discharge plan. This deficient practice was evidenced when Patient #6 was returned to the hospital after not staying at his planned discharge destination and no reassessment, evaluation, or plan was documented 8 days after the patient's attempted discharge on 7/09/19. This failed practice was found for 1 (#6) of 3 (#6, #9, #10) patient records reviewed for discharge evaluation and planning from a total sample of 10 (#1-#10).
Findings:

Review of hospital Policy PC-301 titled "Discharge Planning" revealed in part that the case manager, along with the treatment team would facilitate discharge planning for each patient. The discharge planning was to include focus areas, in part, that included a review of community resources which could be utilized upon discharge, a review of precipitating events and stressors which led to the current hospitalization, and helping patients finalize living arrangements and aftercare before discharge. The case manager, along with other team members were to discuss and document the discussion of discharge plans with the patient prior to discharge. The purpose of that contact was to finalize living arrangements and aftercare plans.


Patient #6
Review of the medical record for Patient #6 revealed an admission form dated 6/28/19 completed by the admitting RN. Further review revealed a computer generated Face sheet for Patient #6 with his medical record number with "Episode 2" next to it. The admission date for the computer generated Face sheet was 7/9/19. Review of a nursing note dated 7/09/19 documented, "pt returned from attempt to place at New Orleans mission discharge canceled per S19Pscyh"

Review of Patient #6's Progress note 7/10/19 at 1:25 p.m. by S19Psych revealed, in part, the follow notes, "pt reports: I went to the group home and it was not a good place. It was a bunch of homeless people. It was not right for me. I had to leave there and they are still looking for a place." On the same plan was, "still very depressed inc [increase] Zoloft to 150 ..."

Further review of Patient #6's medical record revealed no other notes related to the patient's return from the discharge, a discharge planning evaluation, discharge planning notes, or treatment team notes. Review of Patient #6's treatment plan did not include any problem related to no income and homelessness, or other discharge needs.


In an interview 7/18/19 at 11:00 a.m. S23SW confirmed he was the hospital's only social worker. He reported S25AC and S26AD did the discharge planning. When asked if he supervised S25AC and S26AD both activities staff, he reported he was more a figurehead and really didn't supervise them. When asked about why Patient #6 was brought back to the hospital after he left with the hospital transportation, S23SW reported the driver brought the patient back to the hospital and told S25AC the patient was acting out when they reached the shelter in New Orleans by refusing to stay, and saying he didn't want to stay. S23SW reported the transport driver was told to bring the patient back to the hospital, so they considered that an interruption in his stay (admission). He reported they (discharge staff) were working on getting him into a nursing home or a men's shelter, as he was evicted from his last home prior to his admission, had no income, and was currently homeless. S23SW reported he wanted to get him into a nursing home or men's shelter so he would have a case worker that could help him with his finances. He reported there was a team meeting on Monday (2 days before this interview) and there should be discharge notes but he only entered notes on his computer and did not enter them into the medical record.
A request was made of S23SW for his notes or any other notes related to discharge planning or social work notes for Patient #6, but none were provided to surveyors.

In an interview 7/18/19 at 11:32 a.m. S25AC reported Patient #6 had been discharged and taken to a shelter in New Orleans 7/9/19 by one of their drivers, but the driver returned with the patient because it was too early for the patient to get in line to get a bed at the shelter; it wasn't open yet. She reported that a screening for Nursing Home placement needed to be done, but no one here could do it, she wasn't trained to do that. S25AC confirmed that sometimes patients were discharged to the location of a shelter, where the patient would have to wait in a line to see if they could get a bed, and sometimes there may not be a bed available. When asked if she was saying that sometimes the patients were discharged to the street without a confirmed place to go, she answered, "Yes". S25AC reported she did not know where they were with Patient #6's discharge planning, they were kind of on a stand-still on his discharge planning.

In an interview 7/18/19 at 11: 40 a.m. S26 AD reported she was the Activity Director and was just starting to train to do discharge planning. She reported Patient #6 returned to the hospital last week when they tried to send him to a shelter, because he was in a wheelchair, and it wasn't an appropriate placement for him. She reported that the patient still needed a screening form completed for nursing home placement but no one knew how to do it.

In an interview 7/18/19 at 12:10 p.m. S5CorpRN reported no Treatment Team meeting notes could be found for this patient. She reported S23SW said there were not any notes on Patient #6. S5CorpRN further reported there were no discharge note or notes from providers, discharge planning/social services, or nurses that documented his reason for return to the hospital, or the plans for the length of his stay, discharge notes or plans that provided information regarding the discharge, return, or future discharge needs for Patient #6. S5CorpRN confirmed no discharge needs evaluation or reevaluation for Patient #6 could be located or provided.

Based on record review and interview, the hospital failed to ensure a Respiratory Care Services Director was appointed and privileged to supervise and administer the service. This deficient practice was evidenced by failure to have a doctor of medicine or osteopathy with the knowledge, experience, and capabilities appointed and privileged to supervise and administer the hospital's respiratory care services on either a full-time or part-time basis.

Findings:

Review of the Medical Staff Bylaws revealed, in part, under Section 8. "Medical", "...2. The Medical Staff shall nominate and approve a Director of Respiratory Services..."

Review of the hospital's organizational chart revealed there was no Director of Respiratory Services indicated on the chart.

In an interview on 7/16/19 at 10:00 a.m., S1Adm confirmed the hospital had not appointed a Director of Respiratory Services.

Based on record reviews and interview, the hospital failed to ensure the nursing staff were trained and determined to be competent to administer metered dose respiratory inhalers. This deficient practice was evidenced by failure to have documented evidence that education and evaluation of competency had been conducted for 4 (S4RN, S9LPN, S10LPN, S11RN) of 4 nurses' employee files reviewed for education and competency to administer metered dose respiratory inhalers.

Findings:

Review of the hospital policy titled, "Respiratory Care Services in Conjunction with Nursing ", presented as current policy, revealed in part: The psychiatric program policy is to provide Respiratory Services to patients in situations demonstrating clinical need. Further review revealed nursing staff was to administer nebulizer treatments, metered dose inhalers, and inhalation therapy. The policy failed to include a procedure for administration of metered dose inhalers.

Review of the personnel files of S4RN, S9LPN, S10LPN, and S11RN revealed no documented evidence that each nurse had received education and had been evaluated for competency in administering metered dose inhalers.

In an interview on 7/16/19 at 11:40 a.m. with S4RN, he stated the hospital does not supply metered dose inhalers to the patients. He further stated if a patient brought his/her own metered dose inhaler, they (nursing staff) would give the patient their inhaler if the patient asked for it and the patient self-administered the medication.

In an interview on 7/16/19 at 12:00 p.m. with S9LPN, she stated if the physician ordered a metered dose inhaler and the patient needed it, they would supply the patient with the inhaler (metered dose inhalers were noted to be in the medication dispensing machine).

In an interview on 7/18/19 at 1:00 p.m. with S5CorpRN, she indicated there was no policy regarding metered dose inhaler administration. S5CorpRN confirmed nursing staff had no training and no skills competency evaluations regarding metered dose inhalers.

Based on observations, record reviews and interviews, the hospital failed to meet the requirement of 482.42 (Infection Control) ,482.23 (Nursing Services) and 482.12 (Governing Body) as evidenced by:

1) Infection Control
a) failure of the hospital's Infection Control Officer to ensure the hospital's single glucose meter that is used to perform capillary blood glucose monitoring on all patients was disinfected between each patient use. This deficient practice was evidenced by failure of S10LPN to disinfect the glucose meter after performing capillary blood glucose sampling on Patient #6 (who had co-morbid diagnoses of blood borne pathogens Hepatitis B and Hepatitis C) and reporting the blood glucose meter was only disinfected once a day with alcohol. This practice placed the 3 current Diabetic patients (#2, #5, and #6) and all future Diabetic patients at risk for transmission of blood borne pathogens. (See findings in tag A-0749).

b) failure to ensure a qualified person or persons was/were designated as infection control officer(s) to develop and implement policies governing control of infections and communicable diseases as evidenced by failure to have documented evidence of experience or training in current infection control practice for S2DON, reported as infection control officer (See findings in tag A-0748);

c) failure to ensure the infection control officer implemented a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel as evidenced by:
1) failure to ensure hand hygiene was performed in accordance with hospital policy and procedure;
2) failure to ensure no injectable medications and biologicals were placed and stored in the specimen refrigerator;
3) failure to maintain a clean and sanitary environment;
4) failure to develop and implement a surveillance program of practices that could affect/prevent spread of infection that included more than just hand hygiene practices. (See findings in A-0749)


2) Nursing Services
a) failure of the nursing staff to obtain admission and other patient care orders from a physician for 3 (#4, #5, #6) of 3 (#4, #5, #6) records reviewed for physician orders from a total sample of 10 records (See findings in A-0395);

b) failure of the RN to ensure the condition of patients' skin was accurately assessed on admit and ongoing, to ensure skin impairments and potential for skin breakdown was identified and monitored to evaluate for worsening for 3(#1, #2, #7) of 3 current sampled patients reviewed for skin assessments from a total sample of 10 (See findings in A-0395); and

c) failure of the nursing staff to notify the physician for acute changes in a patient's oxygen saturation for 1 (# ) of 10 patients sampled. (See findings in A-0395).


3) Governing Body
a) failure of the Governing Body to ensure the Condition of Participation of Infection Control was met (see findings in A-0043); and

b) failure of the Governing Body to ensure the requirements of the Condition of Participation of Nursing Services were met (see findings in A-0043).



30984

Based on record review and interview, the hospital failed to ensure patient History and Physical examination documentation included a descriptive neurological examination indicating what tests had been performed to assess patient hearing for 7 (1, #2, #3, #4, #5, #6 #7) of 7 (#1, #2, #3, #4, #5, #6, #7) sampled patient records reviewed comprehensively for neurological assessments from a total sample of 10.

Findings:

Review of the Medical Staff Bylaws revealed in part, under Medical Records, page 46, "The History and Physical must contain information pertinent to the thorough evaluation of the patient's medical condition and health screening needs. The minimal required elements of the H & P should include ...a complete neurological examination must be recorded at the time of the admission physical examination including a detailed description of gross testing for cranial nerves II though XII, and assessment, and a plan..."

Patient #1
Review of Patient #1's medical record revealed an admission date of 7/2/19.

Review of Patient #1's History and Physical revealed the patient's assessment of Cranial Nerve VIII, Auditory Function, had been documented as hearing intact left and right with no methodology for assessment of hearing documented.

Patient #2
Review of Patient #2's medical record revealed an admission date of 7/2/19.

Review of Patient #2's History and Physical revealed the patient's assessment of Cranial Nerve VIII Auditory Function had been documented as hearing intact left and right with no methodology for assessment of hearing documented.

Patient #3
Review of Patient #3's medical record revealed an admission date of 7/08/19.

Review of Patient #3's History and Physical revealed the patient's assessment of Cranial Nerve VIII Auditory Function had been documented as hearing intact left and right with no methodology for assessment of hearing documented.

Patient #4
Review of Patient #4's medical record revealed an admission date of 7/07/19.

Review of Patient #4's History and Physical revealed the patient's assessment of Cranial Nerve VIII Auditory Function had been documented as hearing intact left and right with no methodology for assessment of hearing documented.

Patient #5
Review of Patient #5's medical record revealed an admission date of 7/10/19.

Review of Patient #5's History and Physical revealed the patient's assessment of Cranial Nerve VIII Auditory Function had been documented as hearing intact left and right with no methodology for assessment of hearing documented.

Patient #6
Review of Patient #6's medical record revealed an admission date of 6/28/19.

Review of Patient #6's History and Physical revealed the patient's assessment of Cranial Nerve VIII Auditory Function had been documented as hearing intact left and right with no methodology for assessment of hearing documented.

Patient #7
Review of Patient #7's medical record revealed an admission date of 7/9/19.

Review of Patient #7's History and Physical revealed the patient's assessment of Cranial Nerve VIII Auditory Function had been documented as hearing intact left and right with no methodology for assessment of hearing documented.

In an interview on 7/18/19 at 3:00 p.m. with S5CorpRN, she agreed the methodology for assessing patients' hearing should have been documented.



30420




39791

Based on record review and interview, the hospital failed to ensure each patient had a comprehensive, individualized treatment plan that was kept current and updated/revised with changes in patient condition for 5 ( #1, #2, #5, #6 #7) of 7 (#1, #2, #3, #4, #5, #6, #7) patient records reviewed for treatment plans from a total sample of 10.

Findings:

Review of the hospital policy titled, "Treatment Plans", Policy Number: PC-501, revealed in part: Purpose: To identify, evaluate, and update care and services appropriate to an individual's specific needs in order to promote therapeutic progress and provide treatment direction. Policy: Each patient will have an individualized interdisciplinary treatment plan developed under the direction of the psychiatrist. This comprehensive plan is initiated upon admission following assessments by the various disciplines and will reflect the individual's clinical needs, condition, functional strengths, and limitations. The treatment plan will coordinate treatment interventions and outline individualized short-term and long-term goals to evaluate therapeutic progress. The plan will be revised throughout the patient's hospitalization to reflect progress toward treatment goals.
Procedure: ....10. All newly identified patient problems or diagnoses will be incorporated into the plan of care and the treatment plan will be modified to reflect these changes.

Patient #1
Review of Patient #1's medical record revealed an admission date of 7/2/19. Further review revealed Patient #1 was wheelchair bound and had a brace on her right leg due to being status post ORIF for a right tibia fracture. Additional review revealed Patient #1 had developed a blister above her left knee due to the immobilizer brace rubbing against the patient's other leg.

Review of Patient #1's physician's orders, dated 7/16/19 10:40 a.m., revealed the following: Apply skin barrier cream to right lateral thigh extremity every day and as needed as a skin protectant. Leave open to air and notify MD if no improvement.

Review of Patient #1's interdisciplinary treatment plan revealed potential for skin breakdown under the immobilizer brace and actual impaired skin integrity related to the blister that had formed from the brace rubbing on the patient's other leg had not been identified as problems to be addressed on the patient's plan of care.

Patient #2
Review of Patient #2's medical record revealed an admission date of 7/2/19. Further review revealed Patient #2 had the following co-morbid conditions: Anemia, Diabetes, Pain, Contusions, and was receiving aspirin therapy as an anticoagulant.

Review of Patient #2's interdisciplinary treatment plan revealed Anemia, Diabetes, Pain, Contusions, and risk for bleeding related to being treated with aspirin (anticoagulant) were not identified as problems to be addressed on the patient's plan of care.

Patient #5
Review of Patient #5's medical record revealed an admission date of 7/10/19. Further review revealed Patient #5 had the following co-morbid conditions: Diabetes and Asthma.

Review of Patient #5's interdisciplinary treatment plan revealed Diabetes and Asthma were not identified as problems to be addressed on the patient's plan of care.

Patient #6
Review of Patient #6's medical record revealed an admission date of 06/28/19. Further review revealed Patient #6 had the following co-morbid conditions: Diabetes, Hypertension, History of a CVA, Hepatitis B, Hepatitis C, Lung nodule. Review of his H & P revealed he had left arm and leg weaknesses. Review of a patient assessment by S21RN revealed the patient used a cane, walker, or wheelchair for ambulatory needs. Further review revealed Patient #6 was homeless upon admission.

Review of Patient #6's interdisciplinary treatment plan revealed his Diabetes, Hypertension, Positive status of Hepatitis B, Hepatitis C, his assistance needs with ADLs , and his needs for living arrangements and other resources upon discharge were not identified as problems to be addressed on the patient's plan of care.

Patient #7
Review of Patient #7's medical record revealed an admission date of 7/9/19. Further review revealed the patient had dysphagia and was on a modified consistency diet (mechanical soft) due to swallowing issues.

Review of Patient #7's interdisciplinary treatment plan revealed dysphagia and modified consistency diet were not identified as problems to be addressed on the patient's plan of care.

In an interview on 7/17/19 at 10:30 a.m. with S7CorpComp, she agreed the patients' comprehensive treatment plans should have addressed all of the patients' problems and should have been revised with changes in the patients' condition.


30420




39791

Based on record review and interviw, the hospital failed to ensure psychological services were available to meet the needs of the patients. This deficient practice was evidenced by failure of the hospital to have a full-time, part-time, or consulting psychologist to provide psychological services.

Findings:

Review of the hospital's organizational chart and list of licensed independent providers revealed no documented evidence there was a full-time, part-time, or consulting psychologist available to provide psychological services.

In an interview on 7/16/19 at 10:00 a.m. with S1Adm, he confirmed the hospital did not have a full-time, part-time, or consulting psychologist to provide psychological services.