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Based on record review and interview, the hospital failed to ensure personnel met applicable standards required by State regulations for hospital personnel. This deficient practice is evidenced by 1) failure to ensure that all unlicensed staff had criminal background checks conducted by an agency authorized by Louisiana State Police and 2) failure to have documented evidence of a check/review of the Louisiana Department of Health's "Louisiana Adverse Action Website" before hire and every 6 months after for 2 of 2 unlicensed personnel files reviewed (S10CNA, S11CNA).
Findings:

Review of the Louisiana Revised Statute Title 40-Public Health and Safety, RS 40:1203.2-Employment of nonlicensed persons revealed in part that "Authorized Agency" means a private entity authorized by the Office of State Police to conduct the criminal history checks provided for in this part.

Review of the Louisiana Department of Health's "Louisiana Adverse Action Website" revealed, in part that all licensed and/or certified providers that employ unlicensed direct care staff that meet the provisions of LAC 48:1, Chapter 92 related to Direct Service Workers are required to check the Adverse Actions Website prior to hire and every six months thereafter to assure that a finding of abuse, neglect or misappropriation of property has not been placed against a prospective hire or a currently employed or contracted DSW.

Review of the personnel files for S10CNA (hire date of 08/06/21) and S11CNA (hire date of 07/06/18) revealed that they had background checks conducted upon hire by an agency that was not authorized by the Louisiana State Police. Further review of their personnel files revealed no documented evidence that the registry was checked at the time of their hire and/or every six months after hire.

On 12/08/21 at 11:55 a.m., interview with S2COO confirmed that the hospital was not using a State Police approved agency to conduct background checks. S2COO further confirmed that there was no documented evidence that the Louisiana State Adverse Actions site had been checked at any time for the above unlicensed staff.

Based on record review, and interview, the hospital failed to ensure the Emergency Department (ED) direct care staff received the education, training and demonstrated knowledge in the use of non-physical intervention skills for 6 (S4EDD, S14RN, S16RN, S17RN, S18RN S19RN) of 6 employee personnel files reviewed for documentation of training.
Findings:

Review of employee personnel files revealed no documentation training for non-physical intervention skills for S4EDD, S14RN, S16RN, S17RN, S18RN and S19RN.

Interview on 12/08/21 at 11:10 a.m. with S3DON confirmed that none of the ED RN staff had training in non-physical intervention skills.

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by failure of the RN to record, interpret and document the cardiac rhythm for 2 (#1, #10) of 2 patients reviewed who were receiving continuous telemetry monitoring in a total sample of 20.
Findings:

Review of the policy titled Telemetry Monitoring revealed in part that a rhythm strip record will be ran every four hours on all telemetry patients and placed on the chart.

Patient #1
Review of the patient's electronic medical record with S12Clinical IT revealed an admit date of 12/05/21 with orders for continuous telemetry monitoring. Review of the medical record revealed that rhythm strips dated 12/05/21 at 12:01 p.m. and at 11:46 p.m. and 12/06/21 at 6:28 a.m. and 12:15 p.m. were in the record with no documented evidence of interpretation of the rhythms. Further review of the medical record, including nurses notes, revealed no documented evidence of the patient's rhythm strip interpretation every four hours.

Patient #10
Review of the patient #10's medical record revealed an admit date of 12/03/21 with orders for continuous telemetry monitoring. Review of the medical record revealed that rhythm strips from 12/03/2021 to 12/08/2021 were in the record with no documented evidence of interpretation of the rhythms. Further review of the medical record, including nurses notes, revealed no documented evidence of the patient's rhythm strip interpretation every four hours.

On 12/08/21 at 8:30 a.m., interview with S3DON revealed that the ward clerk runs strips every four hours and gives the strips to the nurses. S3DON further revealed that the nurses should be interpreting the rhythm strips and documenting their interpretation on the strips. S3DON confirmed the above patient records did not have documented evidence of rhythm strip interpretation every four hours.

Based on record review and interview, the RN failed to ensure the nursing care of each patient was assigned to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the available nursing care staff. The deficient practice was evidence by the hospital failing ensure documentation of any competences for 5 out of 5 (S10CNA, S11CNA, S13CNA, S14RN, S15RN) personnel records reviewed for competencies.
Findings:

Review of the following personnel records revealed no evidence of documentation of skills competencies; S10CNA, S11CNA, S13CNA, S14RN, S15RN.

On 12/08/21 at 12:35 p.m., interview with S3DON revealed that he was aware that competencies were not being conducted for all staff. S3DON further confirmed that above staff had no documented evidence of competency check offs.

Based on review of the hospital's policy, medical record review and interview, the physician failed to ensure a medical H&P (history and physical) examination was completed and documented on the medical record within 24 hours after admission for 1 (#7) of 20 patients' medical records reviewed.
Findings:

Review of the hospital's policy titled, "History and Physical" revealed in part: A written (dictated and transcribed or hand written) patient history and physical examination must be readily available with 24 hours of admission and in the medical record.

Review of the medical record for Patient #7 revealed an admit date of 12/03/2021. S20Physician completed and signed the H&P on 12/05/2021.

Based on observation and interview, the hospital failed to ensure that outdated, mislabeled or otherwise unusable drugs and biologicals were not available for patient use as evidenced by 1) having expired medications and 2) failing to label medications once they are open or prepared for use.
Findings:

1.Observation of the supply room on 12/06/2021 at 10:50 a.m. accompanied by S3DON revealed: 1-500cc Normal Saline expired 07/202; 4-500cc Normal Saline expired 11/2021; 1-500cc Normal Saline expired 12/2021; 3-1000cc ½ Normal Saline with 20 mEq of potassium; and 3-18 French Foley catheter trays expired 09/30/2021.

During an interview at this time, S3DON acknowledged the findings and stated the expired items should not be available for patient use.

2. Observation of the supply room on 12/06/2021 at 10:50 a.m. accompanied by S3DON revealed 1-Liter Normal Saline bottle opened and not dated.

During an interview at this time, S3DON stated the opened bottle of saline should have been dated.

Observation of the CT (Computed Tomography) room on 12/06/2021 at 2:05 p.m. revealed a contrast warmer containing a prepared syringe that was unlabeled and not dated.

In an interview on 12/06/2021at 2:10 p.m., S23CT acknowledged the contrast in the syringe was not labeled or dated.

Based on observation, interview and policy review, the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by failing to ensure the functionality of a nurse call button located on the handrails of 25 of 25 patient beds.
Findings:

On 12/06/2021 at 11:00 a.m., an observation of unoccupied inpatient rooms (a,b,c,d,e,f,g,h,i, and j) revealed the patient bed had a non-functional nurse call feature (a red cross symbol) on the side rail of the bed. The red cross symbol was pressed during the observation and no alert of any type was generated when it was pressed.

An interview at this time with S3DON confirmed the red cross nurse call feature on the side rails of the inpatient beds was not functional. S3DON reported patients/patient families were instructed to use the nurse call feature on the corded call light located at the patient's bedside to call for staff assistance. The surveyor discussed the possibility of patient/patient family/visitor confusion with having the non-functional nurse call feature available for use as well as the nurse call feature on the corded call light and the potential of the non-functional nurse call feature being pressed to summon help from staff. S3DON agreed that having the non-functional nurse call feature available for use could result in potential confusion when calling for staff assistance.

On 12/07/21 at 2:20 p.m., a follow-up interview with S3DON confirmed all 25 of the current hospital's inpatient beds had a non-functional nurse call feature on the hand rails.

Based on policy review, observation and interview, the hospital failed to develop and implement an effective system in controlling infections and communicable diseases of patients as evidenced by failing to maintain a sanitary environment.
Findings:

Review of the hospital policy titled, Environmental Services General Cleaning and Sanitation, revealed in part: All patient and non-patient rooms shall be thoroughly cleaned and/or disinfected. All equipment including electrical cords and wheels shall be wet-cleaned with approved germicide, daily before returning to storage.

Review of the hospital's policy titled, Dishmachine (7.6), revealed in part: Run racks of dishes and flatware through the dishmachine. Air-dry all items. Do not stack or nest wet items.

Observations of the hospital on 12/06/21 at 10:50 a.m., accompanied by S3DON, revealed the following patient rooms had been cleaned by housekeeping and were ready for a patient:
- Room h had a sofa with rip/tears to the vinyl covering which prevents proper sanitizing
- Room k had brown splatters on the wall behind the bed
- Room n had a dried yellow substance on the bathroom wall. Brown splatters were observed on the wall behind the bed. An IV pump in the room was covered with a plastic bag. Upon removal of the bag by S3DON, observation revealed a brown substance on the pump that was easily wiped off with an alcohol swab by S3DON. Interview with S3DON at that time revealed that a plastic bag on the pump indicates the machine was clean and ready to use on a patient.
- Room o had a brown substance on the television remote control that was easily wiped off with an alcohol swab by S3DON.
- Clean equipment supply room had 3-vital sign machines with debris and grime on the frames;

Observation on 12/06/21 at 1:35 p.m. of x-ray room 2 revealed a pillow on the exam table with rips/tears to the vinyl covering which prevents proper sanitation.
During an interview at this time, S21Xray acknowledged the findings.

Observation on 12/06/21 at 2:15 p.m. of the ultrasound exam room revealed a pillow on the exam table with the vinyl covering missing from the pillow.
During an interview at this time, S22Ultrasound acknowledged the findings.

Observation on 12/06/21 at 4:00 p.m. of the kitchen dish storage area revealed a tray of bowls which were stored face down and wet on the interior. During an interview at this time, S24Dietary acknowledged the findings and confirmed the bowls should have been dry.

Observation on 12/07/21 at 10:10 a.m. of the rehabilitation building accompanied by S25OT revealed the following:
room l had grime and debris on the ultrasound's wand and cord and rips/tears to the vinyl covering of the Lift Table and the Plint Table; room m had grime and debris on the ultrasound's wand and cord.
During an interview on 12/07/2021 at 10:30 a.m., S25OT ackowledged the above findings.


17450

Based on observation and interview, the hospital failed to ensure that standards were maintained for surgical care procedures as evidenced by failing to maintain a sterile environment by failing to properly clean equipment maintained in the operating room.
Findings:

During an observation on 12/07/21 at 2:15 p.m. of operating room 1, accompanied by S26RN, the following was observed: tape on the arm board of the operating table; thick layer of dust and debris on the operating table's frame; grime and debris on the COVIDIEN foot control; grime and debris on the Stryker Laparoscopic tower (trial model); grime and debris on the Stryker Laparoscopic tower; anesthesia ventilator with grime and debris on the surfaces and 2 rolls of used tape on the top of the ventilator; grime and debris on the electrocardiogram; and grime and debris on the power cord and base of the Storz endoscopic tower.

In an interview at that time, S26RN acknowledged the findings above. After review of the housekeeper's log, S26RN confirmed the room had been cleaned.