HospitalInspections.org

Based on record review and interview, the hospital failed to comply with applicable state regulations. This deficient practice was evidenced by failure of the hospital to use the State's designated repository (The Louisiana Office of State Police, Bureau of Criminal Identification and Information) for criminal history information pursuant to the laws cited La R.S.15: 575 on the non-licensed personnel prior to employment for 2 of 2 (S12CNA, S13CNA) non-licensed personnel records reviewed.
Findings:

The Louisiana Office of State Police, Bureau of Criminal Identification and Information (Bureau), is the
State ' s designated repository for criminal history information pursuant to the laws cited in La. R.S.
15:575 et seq. Any criminal event that is documented by the submission of fingerprints to the State is
stored in the Louisiana Computerized Criminal History (LACCH) database.
The Bureau is authorized to release criminal history information stored in LACCH to those employers and
Authorized Agencies defined in La. R.S. 40:1203.1 as required by La. R.S. 40:1203.2
Employers may request criminal history information stored in LACCH in one of three ways: (1) use of the
Bureau ' s Internet Background Check (IBC) website (https://ibc.dps.louisiana.gov/), (2) via Authorized
Agents, and (3) submission of applicants ' fingerprints.

Review of the personnel records for S12CNA and S13CNA revealed their criminal background checks were conducted by Company "A." Review of the Louisiana Office of State Police authorized agencies to perform criminal background checks revealed Company "A" was not an authorized agency.

An interview was conducted with S14HR Director on 02/01/2024 at 1:10 p.m. S14HR Director confirmed that the background checks performed for the unlicensed staff at the hospital, including S12CNA and S13CNA, were not from an authorized agency of the Louisiana Office of State Police.

Based on record review and interview, the hospital failed to meet the Condition of Participation for Governing Body. The hospital's governing body failed to provide needed funding to ensure services and supplies within the hospital were furnished in a manner to ensure compliance with all applicable conditions of participation. This deficient practice was evidenced by:

1) failing to ensure that supplies and services provided or performed under contract and vendor agreements were provided in an effective manner as evidenced by failure of the governing body to pay vendors and contracts for supplies required to care for the patients of the hospital. As a result, many vendors placed provision of supplies and services on credit holds and failed to ship supplies. The lack of supplies and services resulted in: a) cancellations and delays in treatment for patients requiring endoscopy, b) cancellations and delays in surgical services, c) cancellations and delays in special procedures, d) refusal of transfer admissions and ED diversions for patients requiring endoscopy and surgical services which required pacemaker supplies, e) failure to obtain specialized equipment for patients with pressure sores, and f) a delay in the discharge of a client who required ambulance services for transportation home (see findings at A-0084)

2) Failing to ensure that patient treatments were not delayed due to inadequate supplies related to credit holds with vendors. As a result, (a) Patients #1, 2, 3 were uable to obtain specialized air loss mattressess recommended to prevent further decline in wound status, (b) Patient #4 was unable to receive angioplasty to a dialysis fistula and (c) Patient #6 had a delay in PEG tube placement (See findings at A-0144)

3) Failing to maintain supplies needed to perform needed procedures and as a result, Patient #4 was unable to receive an ordered angioplasty procedure (See findings at A-0529);
Failing to perform preventive maintenance on the bone density machine and the mammogram machine since 2021 (See findings at A-0537);
Failing to ensure that radiology staff were checked monthly for radiation exposure as evidenced by no badge checks for radiology staff since October 2023 (See findings at A-0538)

4) Failing to ensure necessary laboratory supplies were maintained to provide adequate laboratory services (See findings at A-0582)

5) Failing to maintain, or have available, supplies for surgical services such as Spine/Orthopedics, Cardiovascular and Endoscopy services. As a result, patient procedures were cancelled or delayed due to lack of available supplies to perform needed procedures. (See findings at A-0941)

6) Failing to ensure its integrated services were properly supplied to provide the patients with appropriate diagnostic and care interventions (See findings at A-1103).

As a result of this noncompliance, on 01/30/2024 at 5:00 p.m., S1CEO was informed of the Immediate Jeopardy situation that existed. The lack of supplies caused delays in treatment for surgical patients and patients requiring endoscopy and special procedures. Patients were refused admittance to this hospital due to these lack of services, which were held out to the public as being available.

Based on observation and interview, the hospital failed to ensure that supplies and services provided or performed under contract and vendor agreements were provided in an effective manner as evidenced by failure of the governing body to pay vendors and contracts for supplies required to care for the patients of the hospital. As a result, many vendors placed provision of supplies and services on credit holds and failed to ship supplies. The lack of supplies and services resulted in: 1) cancellations and delays in treatment for patients requiring endoscopy, 2) cancellations and delays in surgical services, 3) cancellations and delays in special procedures, 4) refusal of transfer admissions and ED diversions for patients requiring endoscopy and surgical services which required pacemaker supplies, 5) failure to obtain specialized equipment for patients with pressure sores, and 6) a delay in the discharge of a client who required ambulance services for transportation home.
Findings:

On 01/29/2024 at 8:20 a.m., interview with SF1CEO revealed the hospital has been having issues for several months with obtaining supplies due to accounts payable problems. SF1CEO stated that the hospital is on credit hold for many supply vendors and is unable to obtain needed supplies to meet the needs of the patients.

Further interview with SF1CEO revealed the hospital was currently on GI diversion due to not being able to obtain endoscopy tubing due to vendor credit holds.The hospital declined to accept two patient transfers needing gastrointestinal services over the last 24 hours due to lack of endoscopy tubing. SF1CEO also stated that the hospital was also unable to perform any procedures involving pacemakers due to being on credit hold with the vendor for pacemakers and pacemaker leads. SF1CEO stated two orthopedic surgeries had been canceled the past week due to credit holds with the vendor.

1. On 01/29/2024 at 8:30 a.m., an interview with SF2CNO revealed the hospital had been out of endoscopy tubing for about a week and one patient had a delay in PEG tube placement as a result (Patient #6).

Review of Patient #6's medical record with S18RN revealed the patient was admitted to the hospital on 01/10/2024 with nausea and vomiting and had been unable to keep food down for two weeks. A gastroenterology consult was requested on 01/11/2024 for elevated liver enzymes, and was consulted a second time on 01/19/2024 for PEG tube placement. Patient #6 initially declined the procedure on 01/21/2024, and again on 01/22/2024.
On 01/25/2024, the nursing home refused to admit the patient if she didn't have a PEG tube or was not fully eating or drinking. On 01/26/2024, the patient agreed to the PEG procedure, but was unable to have it done due to lack of endoscopy tubing supplies in the endoscopy department. S18RN revealed that a local gastroenterologist brought supplies to the facility on 01/27/2024 and the PEG procedure was conducted that day.
S18RN (who cared for Patient #6) confirmed that the patient's needed PEG procedure was delayed for one day due to unavailability of endoscopy supplies related to vendor credit holds.

2. On 01/29/2024 at 8:20 a.m., during the opening entrance conference, S1CEO confirmed that the hospital did not currently have pacemaker supplies for cardiovascular surgical procedures due to credit holds, and that they were also on credit hold with the supplier for shoulder implant surgeries. S2CNO confirmed that two shoulder surgeries this week have been canceled at the ambulatory surgery center due to credit holds. She further stated surgical buttons for ENT procedures were unavailable due to vendor holds.

On 01/29/2024 at 2:45 p.m., an interview with S10RN/Director of Surgery confirmed that one surgical procedure for a shoulder arthroscopy had been canceled for today and another one canceled for Wednesday at the ambulatory surgery center due to a credit hold with Arthrex, the supplier. She further confirmed that ENT supplies were on vendor hold due to credit issues. She stated that she recently began completing an Incident Report for all canceled surgeries for tracking purposes. Review of incident reports for surgery revealed two shoulder surgeries were canceled 01/25/2024 in OR due to credit hold with Tournier, the implant supplier.

On 01/30/2024 at 2:00 p.m., an interview with S17Purchasing confirmed that the following vendors providing supplies for surgical services were currently on credit hold: : Erbe (endo tubing); Zimmer, Stryker, Osteogen, Tournier, Globus, Medtronic, Ulrich, Enovis, Arthrex (orthopedics, spines, implants); Medtronic, Abbott, Boston Scientific (pacemakers and leads for Transcatheter Aortic Valve Replacement); Medline, Medtronic, Boston Scientific (surgical mesh); Medtronic (ENT buttons).

On 01/31/2024 at 10:00 a.m., interview with S8MD (Cardiology) confirmed that the hospital was out of pacemakers due to payment issues with the vendor. When asked what would be done if a patient needed an emergency pacemaker, he stated that he could use a temporary pacemaker until the patient was transferred out to another hospital. S8MD stated this could delay treatment for the patient. S8MD further stated that there are other supplies that the cath lab is out of, but there are "workarounds", stating these "workarounds" are not optimal.

S8MD also stated that he had not been paid for his on-call time for October through December 2023. He stated that he informed administration that if he didn't receive his payment soon, he would not be taking any more call.

Review of the daily report for 01/31/2024 revealed 3 of 7 scheduled surgeries were canceled on this day in the OR - two transcatheter aortic valve replacements (TAVR) and one spine; in addition, one case was canceled at the ambulatory surgery center. All four were canceled due to credit hold issues with the vendors. On 02/01/2024 at 2:00 p.m., an interview with S10RN/Director of Surgery confirmed that the above surgeries had been canceled due to unavailable supplies related to vendor hold issues.

On 01/31/2024 at 1:35 p.m., an interview with S9MD (Medical Director of Surgical Services) confirmed that last week, he had to cancel two TAVR surgeries that were scheduled for this week that had been on the schedule for 2-3 weeks prior to the scheduled procedures. He confirmed that you can't do that specific surgery if there is no pacemaker available, and the pacemaker supplies have been on credit hold for a while. S9MD stated he had personally contacted the representative and thought he would be able to get the pacemaker leads, then found out the hospital didn't have the catheters either, so he had to have the patients go to another hospital to have the surgeries performed. He further stated that it has become a big problem getting the balloons from Medtronic. He stated that he used the last closure device yesterday, and will have to cancel two surgeries for the next week if the hospital does not get anymore delivered soon.

Further interview with S9MD revealed that the supply vendors are owed a large amount of money, and they will only bring supplies if the hospital pays up front. He further stated that the OR usually keeps a good supply of all sizes of heart valves on the shelf, but most of them were expired and the Medtronic representative removed them without any replacements. He also stated the vendor Edwards is also on credit hold.

On 02/05/2024 at 11:00 a.m., an interview with S10RN/Director of Surgery confirmed that a surgery had been canceled for the coming Friday for an endovascular aneurysm repair (EVAR) due to the vendor representative not supplying a stent for the procedure due to vendor hold issues. She confirmed they still did not have pacemaker supplies available for TAVR procedures.

3. On 01/30/2024 at 12:50 p.m., interview with S4Director of Radiology and S5Special Procedures Tech confirmed that the Special Procedures department was still having issues with obtaining needed supplies. S4Director of Radiology and S5Special Procedures Tech stated that the department was out of left intrajugular dialysis catheters and multiple sizes of angioplasty balloons. S5Special Procedures Tech revealed that in the past week, a physician was unable to perform an angioplasty on Patient #4, who had a clotted dialysis fistula, due to not having the needed supplies due to credit holds with the vendor.

Review of the medical record for Patient #4 revealed the patient was admitted to the hospital ICU on 01/23/2024 with diagnoses including ESRD and dyspnea with fluid overload related to missed hemodialysis treatments.

Review of the physician orders revealed an order for the patient to have a fistulogram and PTA (angioplasty used to restore blood flow to the fistula) on 01/26/2024. Further review of the medical record revealed that the fistulogram was performed but not the PTA. The record further revealed that the patient had another procedure on 01/26/2024 to insert a temporary hemodialysis catheter to the right groin.

On 02/05/2024 at 11:30 a.m., interview with S4Director of Radiology revealed that the physician was unable to perform the PTA on 01/26/2024 due to lack of angioplasty balloons to perform the procedure. As a result, Patient #4 had to have another procedure on 01/26/2024 to insert a temporary hemodialysis catheter so the patient could receive dialysis treatments. S4Director of Radiology confirmed the lack of supplies caused a delay in the patient's treatment.

On 01/31/2024 at 10:30 a.m., an interview was conducted with S6MD (Medical Director of Radiology). S6MD stated that there has been financial issues with obtaining supplies for approximately 8-10 months. S6MD stated the Special Procedures department is currently out of left sided dialysis catheters and certain sizes of angioplasty balloons. S6MD further stated that they are also running low on biopsy needles of different sizes and bone marrow needles and kits. S6MD stated that being out these supplies delays diagnosis and treatment for the patients who are waiting on these procedures.

S6MD further stated that there would be stints where the vendors would be paid and supplies would arrive and then the supplies would diminish again. S6MD stated that the hospital cannot go much longer like this and that it will eventually fall like a "house of cards".

4. Review of the daily report for 01/29/2024 revealed that the hospital declined to accept two patient transfers needing gastrointestinal services over the last 24 hours due to lack of endoscopy tubing.

On 01/29/2024 at 4:00 p.m., an interview with S2CNO stated the hospital currently does not have the required endoscope supplies or pacemaker supplies to provide services for patients presenting to the Emergency Department or transfer requests from other facilities because they are on purchasing hold with their suppliers due to lack of payment.

Review of the transfer denial records revealed:
On 01/28/2024 at 1217, a patient with lower GI bleed was denied transfer due to no GI services.
On 01/28/2024 at 1304, a patient with a foreign body ingestion was denied transfer due to no ENT or GI endo services.

Review of the daily report for 02/04/2024 revealed one transfer was declined over the past 24 hours for a patient needing an ERCP due to lack of endoscopy tubing needed to conduct the procedure.

Review of the transfer denial record revealed:
On 02/03/2024 at 1826, a patient with nausea and vomiting needing an ERCP was denied transfer due to no GI services.

Review of the daily report for 02/05/2024 revealed one transfer was declined over the past 24 hours for a patient needing gastointestinal evaluation due to unavailability of gastrointestinal services.

Review of the transfer denial record revealed:
On 02/04/2024 at 2148, a patient needing a GI evaluation was denied transfer due to no GI services.

Review of the daily report for 02/04/2024 revealed one transfer was declined for a patient needing an ERCP due to lack of endoscopy tubing needed to conduct the procedure.

Review of the daily report for 02/05/2024 revealed one transfer was declined for a patient needing gastrointestinal evaluation due to unavailability of gastrointestinal services.

5. On 01/29/2024 at 10:00 a.m., interview with S2CNO revealed that the company that supplies specialty beds was on credit hold and the hospital was unable to obtain specialty low air loss beds for patients with wounds.

Review of the medical record for Patient #1 revealed the patient was admitted on 01/11/2024 with a large wound to the right foot with 3rd and 4th metatarsal exposed. Further review revealed the patient was currently on the ventilator in the ICU. Review of the wound care nurses note dated 01/17/2024 revealed the patient would benefit from a specialty low loss air bed to maintain skin integrity.

Review of the medical record for Patient #2 revealed the patient was admitted on 01/14/2024 with diagnoses including sepsis and acute hypoxic respiratory failure. Review of the wound care nurses note dated 01/18/2024 revealed a deep tissue injury with intact blister to the coccyx was identified, measuring 6.0 cm x 6.0 cm. The note revealed the patient was on a standard waffle air mattress overlay.
Review of the wound care nurses note dated 01/31/2024 revealed the patient's pressure injury was now unstageable with drainage, measuring 7.5cm x 13.8cm. The note further stated that the patient would benefit from a low loss specialty bed, but remained on a standard waffle air mattress.

Review of the medical record for Patient #3 revealed the patient was admitted on 12/30/2023 with a sacral wound with exposed bone. Further review of the record revealed the patient was on a standard waffle air mattress.

On 01/31/2024 at 11:30 a.m., interview with the hospital's wound care nurse, S7RN, revealed that there were multiple patients in the hospital with pressure sores/wounds (including Patients #1, 2 and 3) who would benefit from a specialized low loss air mattress. S7RN further stated that she is unable to obtain the specialized mattresses for these patients because of a credit hold with the vendor who supplied them.

6. On 01/29/2024 at 10:15 a.m., S2CNO revealed that the local ambulance provider had canceled their contract for transfers of non-emergent patients due to credit hold.

Review of the daily reporting form dated 02/02/2024 revealed a patient had discharge orders and required a wheelchair van for transportation home. The ambulance declined the transfer due to credit hold.

Based on record review and interview, the hospital failed to meet the Condition of Participation for Patient Rights.
Patients were delayed treatment due to inadequate supplies related to credit holds with vendors. As a result, 1) Patients #1, 2, 3 were uable to obtain specialized air loss mattressess recommended to prevent further decline in wound status, 2) Patient #4 was unable to receive angioplasty to a dialysis fistula and 3) Patient #6 had a delay in PEG tube placement (See findings at A-0144).

Based on record review and interview, the hospital failed to meet the Condition of Participation for Patient Rights. Patients were delayed treatment due to inadequate supplies related to credit holds with vendors. As a result, 1) Patients #1, 2, 3 were unable to obtain specialized air loss mattresses recommended to prevent further decline in wound status, 2) Patient #4 was unable to receive angioplasty of a dialysis fistula and 3) Patient #6 had a delay in PEG tube placement.
Findings:

Patient #1
Review of the medical record for Patient #1 revealed the patient was admitted on 01/11/2024 with a large wound to the right foot with 3rd and 4th metatarsal exposed. Further review revealed the patient was currently on the ventilator in the ICU. Review of the wound care nurses note dated 01/17/2024 revealed the patient would benefit from a specialty low loss air bed to maintain skin integrity.

Patient #2
Review of the medical record for Patient #2 revealed the patient was admitted on 01/14/2024 with diagnoses including sepsis and acute hypoxic respiratory failure. Review of the wound care nurses note dated 01/18/2024 revealed a deep tissue injury with intact blister to the coccyx was identified, measuring 6.0 cm x 6.0 cm. The note revealed the patient was on a standard waffle air mattress overlay. Review of the wound care nurses note dated 01/31/2024 revealed the patient's pressure injury was now unstageable with drainage, measuring 7.5cm x 13.8cm. The note further stated that the patient would benefit from a low loss specialty bed, but remained on a standard waffle air mattress.

Patient #3
Review of the medical record for Patient #3 revealed the patient was admitted on 12/30/2023 with a sacral wound with exposed bone. Further review of the record revealed the patient was on a standard waffle air mattress.

On 01/31/2024 at 11:30 a.m., interview with the hospital's wound care nurse, S7RN, revealed that there were multiple patients in the hospital with pressure sores (including Patients #1, 2 and 3) who would benefit from a specialized low loss air mattress. S7RN further stated that she is unable to obtain the specialized mattresses for these patients because of a credit hold with the vendor who supplied them.

Patient #4
On 01/31/2024 at 10:30 a.m., an interview was conducted with S6MD (Medical Director of Radiology). S6MD stated that there has been financial issues with obtaining supplies for approximately 8-10 months. S6MD stated the Special Procedures department is currently out of left sided dialysis catheters and certain sizes of angioplasty balloons. S6MD further stated that they are also running low on biopsy needles of different sizes and bone marrow needles and kits. S6MD stated that being out these supplies delays diagnosis and treatment for the patients who are waiting on these procedures.

Review of the medical record for Patient #4 revealed the patient was admitted to the hospital ICU on 01/23/2024 with diagnoses including ESRD and dyspnea with fluid overload related to missed hemodialysis treatments.

Review of the physician orders revealed an order for the patient to have a fistulogram and PTA (angioplasty used to restore blood flow to the fistula) on 01/26/2024. Further review of the medical record revealed that the fistulogram was performed but not the PTA. The record further revealed that the patient had another procedure on 01/26/2024 to insert a temporary hemodialysis catheter to the right groin.

On 02/05/2024 at 11:30 a.m., interview with S4Director of Radiology revealed that the physician was unable to perform the PTA on 01/26/2024 due to lack of angioplasty balloons to perform the procedure. As a result, the patient had to have another procedure on 01/26/2024 to insert a temporary hemodialysis catheter so the patient could receive dialysis treatments. S4Director of Radiology confirmed the lack of supplies caused a delay in the patient's treatment.

Patient #6
Review of the medical record with S18RN revealed Patient #6 was admitted to the hospital on 01/10/2024 with nausea and vomiting and had been unable to keep food down for two weeks. A gastroenterology consult was requested on 01/11/2024 for elevated liver enzymes, and was consulted a second time on 01/19/2024 for PEG tube placement. Patient #6 initially declined the procedure on 01/21/2024, and again on 01/22/2024. On 01/25/2024, the nursing home refused to admit the patient if she didn't have a PEG or was not fully eating or drinking. On 01/26/2024, the patient agreed to the PEG procedure, but was unable to have it done due to lack of endoscopy tubing supplies in the Endoscopy area. On 01/27/2024, a local gastroenterologist brought supplies to the facility and conducted the PEG procedure. S18RN (who cared for the patient on the floor) confirmed that the patient's needed PEG procedure was delayed for one day due to unavailability of supplies related to vendor credit holds.

Surveyor: Amburn, Heather
Based on record review and interview, the hospital failed to ensure that nurses in the ICU had documented skills checks to ensure competence for 2 of 2 ICU nurses whose personnel files were reviewed (S19RN, S20RN).
Findings:

Review of the personnel files for S19RN and S20RN revealed they they worked in the ICU. Further review of their files revealed no documented skills check offs to ensure competence with specific skills required in the ICU.

On 02/01/2024 at 10:55 a.m., an interview with S21RN/Director of Critical Care confirmed that the above RNs had no documented skills check offs to demonstrate competence with skills specific to the ICU. Further interview with S21RN revealed that none of the nurses working in the ICU had documented evidence of skills competencies.

Based on record review and interview, the hospital failed to meet the Condition of Participation for Radiology. This was evidenced by the hospital:
1) Failing to maintain supplies needed to perform needed procedures and as a result, Patient #4 was unable to receive an ordered angioplasty procedure (See findings at A-0529);
2) Failing to perform preventive maintenance on the bone density machine and the mammogram machine since 2021 (See findings at A-0537);
3) Failing to ensure that radiology staff were checked monthly for radiation exposure as evidenced by no badge checks for radiology staff since October 2023 (See findings at A-0538).

Based on record review and interview, the hospital failed to maintain, or have available, radiologic services according to the needs of the patients as evidenced by failing to ensure adequate supplies for all radiological services held out to the public as provided by the hospital.
Findings:

On 01/29/2024 at 8:20 a.m., interview with S1CEO revealed the hospital was has been having issues for several months with obtaining supplies due to accounts payable problems. S1CEO stated that the hospital is on credit hold for many supply vendors and is unable to obtain needed supplies to meet the needs of the patients.

On 01/30/2024 at 12:50 p.m., interview with S4Director of Radiology and S5Special Procedures Tech confirmed that the Special Procedures department was still having issues with obtaining needed supplies. S4Director of Radiology and S5Special Procedures Tech stated that the department was out of left intrajugular dialysis catheters and multiple sizes of angioplasty balloons and have been for over a month. S5Special Procedures Tech revealed that in the past week, a physician was unable to perform an angioplasty on Patient #4, who had a clotted dialysis fistula, due to not having the needed supplies due to credit holds with the vendor.

On 01/31/2024 at 10:30 a.m., an interview was conducted with S6MD (Medical Director of Radiology). S6MD stated that there has been financial issues with obtaining supplies for approximately 8-10 months. S6MD stated the Special Procedures department is currently out of left sided dialysis catheters and certain sizes of angioplasty balloons. S6MD further stated the department is also running low on biopsy needles of different sizes and bone marrow needles and kits. S6MD stated that being out these supplies delays diagnosis and treatment for the patients who are waiting on these procedures.

S6MD further stated that there would be stints where the vendors would be paid and supplies would arrive and then the supplies would diminish again. S6MD stated that the hospital cannot go much longer like this and that it will eventually fall like a "house of cards".

Review of the medical record for Patient #4 revealed the patient was admitted to the hospital ICU on 01/23/2024 with diagnoses including ESRD and dyspnea with fluid overload related to missed hemodialysis treatments.

Review of the physician orders revealed an order for the patient to have a fistulogram and PTA (angioplasty used to restore blood flow to the fistula) on 01/26/2024. Further review of the medical record revealed that the fistulogram was performed but not the PTA. The record further revealed that the patient had another procedure on 01/26/2024 to insert a temporary hemodialysis catheter to the right groin.

On 02/05/2024 at 11:30 a.m., interview with S4Director of Radiology revealed that the physician was unable to perform the PTA on 01/26/2024 due to lack of angioplasty balloons to perform the procedure. As a result, Patient #4 had to have another procedure on 01/26/2024 to insert a temporary hemodialysis catheter so the patient could receive dialysis treatments. S4Director of Radiology confirmed the lack of supplies caused a delay in the patient's treatment.

Based on record review and interview, the hospital failed to ensure that all radiology equipment received periodic inspections as evidenced by failing to perform preventive maintenance on the bone density machine and the mammogram machine since 2021.
Findings:

Review of the preventive maintenance for all equipment in radiology revealed the last inspection documented for the bone density machine and the mammogram machine was in 2021.

On 02/01/2024 at 11:00 a.m., interview with S4Director of Radiology revealed that the manufacturers recommendations indicate that the bone density and mammogram machines should be inspected once per year. S4Director of Radiology confirmed that these machines were used on patients in the hospital but there was no documented evidence they had been inspected since 2021.

Based on record review and interview, the hospital failed to ensure that radiology staff were checked monthly for radiation exposure as evidenced by failing to perform monthly badge checks for radiology staff since October 2023.
Findings:

Review of the log provided by S4Director of Radiology indicating staff radiation exposure revealed that last check was performed on 10/14/2023.

On 02/01/2024 at 11:00 a.m., interview with S4Director of Radiology revealed that hospital policy indicates that staff radiation levels are to be checked monthly per the use of badge tests. Further interview with S4Director of Radiology confirmed that there was no documented evidence that staff badge tests for radiation have been performed since 10/14/2023. S4Director of Radiology further stated that the badges were placed in the outgoing mail, but the vendor who was supposed to sort the mail had not been paid, so the mail was not being sorted and mailed out timely.

Based on observation, record review and interview, the hospital failed to meet the Condition of Participation for Laboratory. The hospital failed to ensure necessary laboratory supplies were maintained to provide adequate laboratory services (See findings at A-0582).

Based on record review and interview with laboratory director, the hospital failed to ensure the laboratory supplies necessary were maintained to provide adequate laboratory services.
Findings:

Review of laboratory records on 01/29/2024 revealed the following tests in which the laboratory was unable to obtain the supplies necessary for testing: T3, PTH, Hepatitis B, Cortisol, Procalicitonin; and, all Cepheid molecular PCR reagents (Streptococcal-A, COVID, COVID/Flu/respiratory syncytial virus combination).

In an interview 02/01/2024 at 10:00 a.m., S3Director of Laboratory services stated the laboratory department has been unable to obtain necessary supplies for numerous laboratory services due to vendor hold for non-payment. S3Director stated the laboratory notifies administration and corporate in Dallas when there is a critical need for laboratory supplies but the payment issues are not always resolved, resulting in the laboratory being unable to perform testing required or referencing testing to another laboratory which can delay results.

36293

Based on observation and interview, 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 side rails of 151 of 278 patient beds.
Findings:

On 01/29/2024 at 10:45 a.m., observations of unoccupied inpatient rooms with S2CNO revealed the patient beds had non-functional nurse call buttons on the side rails of the beds. The nurse call button on the beds were pressed by the surveyors during the observations and no alert of any type was generated when it was pressed.

An interview at that time with S2CNO reported that 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. S2CNO agreed that having the non-functional nurse call feature available for use could result in potential confusion when calling for staff assistance.

In an interview on 02/01/2024 at 3:30 p.m., S1CEO stated there were a total of 151 patient beds with non-functional nurse call buttons on the side rails of the beds.

Based on 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:

1. Observations of the hospital's main campus during the initial tour on 01/29/2024 at 10:45 a.m. with S2CNO revealed the following:
- Room a had grime/debris on the upper surfaces of bathroom wall call bell switch.
- Room b had grime/debris on the upper surfaces of bathroom wall call bell switch, and brownish streaks on the bathroom wall.
- Room c had grime/debris on the pulse oxymetry finger-probe.
- Room d had grime/debris covering the ledge over the electrical outlets, the oxygen wall outlets and the suction outlet; food particles on the bedside table; and brown streaks on the privacy curtain adjacent to the patient's toilet.
- A vital signs machine located in the hallway on 6S telemetry had grime and debris covering the base of the machine.
- An old shower room in the hallway of 5S telemetry used to store clean equipment had foul sewer odor, with some pieces of equipment uncovered.
- Room f had a strong foul odor in the bathroom with a partially covered potty chair inside; room g contained a potty chair that was not covered and a partially used syringe of flush sitting on an uncovered IV pole
- Room h shower stall had a detached shower hose laying on the floor, a partially covered shower chair with the plastic cover pulled back sitting inside the shower, an uncovered potty chair in the bathroom, and a plastic cap laying in the sink
- Room i contained an uncovered IV pole
- Room j had a used roll of tape in the window sill, red splatters on the wall and an old dried grape on the floor beside the bedside chair
- Room k had a blue sticky substance on the side rails, a syringe behind the chair and 2 bugs were observed crawling on the wall behind the bed
- Room l had old tape on the side rails and a red substance splattered across the window blinds
- Room m had a brown substance on the overbed table, thick build-up of dust on the window sill and two needle caps on the floor.

An interview at this time with S2CNO confirmed the above rooms were considered to be cleaned and ready for a new admit. She further confirmed that clean equipment should be covered.

2. Observations in the OR on 01/29/2024 at 1:20 p.m. with S10RN/Director of Surgery revealed the following:
- The anesthesia cart in the hybrid room had multiple black hairs on it. Further observations revealed multiple black hairs on the floor of the OR suite. Interview with S10RN at that time revealed the room had been cleaned.
- The foam cover on the table in the cysto room had multiple tears in it, and was unable to be adequately disinfected. The foam leg holders also had tears in it. Interview with S10RN at that time confirmed that the foam covers needed to be replaced, but there were financial issues with the vendor who supplies them.

3. Observations of the offsite Behavioral Health unit with S2CNO and S22Psych Director on 1/30/2024 beginning at 8:15 a.m. revealed the following:
- Room e had grime and debris on floor around and under the bed; and the return air vent in ceiling was completely covered in a thick layer of dust/debris
- Room n had thick build up of grime and debris in all corners of the room and a screw in the floor
- Room o had thick build up of dirt and grime on the floor and old trash on the floor
- Room p had a white substance on the floor behind the bed, dirt and grime in all corners of the room, and old candy paper on the floor
- Room q had dirt, grime and old food crumbs on the floor and a fabric pillow on the shelf that was unable to be adequately disinfected
- The nourishment room on the geriatric unit had a refrigerator with the temperature measuring 50 degrees farhrenheit. A fast food beverage and a homemade loaf of bread (undated) was in the refrigerator. The freezer contained a staff member's food container. The temperature log taped to the refrigerator was last documented on 01/27/2024, but log indicated daily temp checks.
- The nourishment room on the adult unit revealed multiple spills and splatters on the cabinets and door frame. The drawers containing condiments had multiple food spills and debris in the drawers.
- The seclusion room had multiple dead bugs/spiders on the floor. The toilet in the seclusion area was coated in a thick black substance.

An interview at this time with S2CNO and S22Psych Director confirmed the above patient rooms were considered to cleaned and ready for a patient admit. They further confirmed the above rooms were in need of further cleaning.


36293

.

Based on record review and interview, the hospital failed to meet the Condition of Participation for Surgical Services. The hospital failed to maintain, or have available, supplies for surgical services such as Spine/Orthopedics, Cardiovascular and Endoscopy services. As a result, patient procedures were cancelled or delayed due to lack of available supplies to perform needed procedures. (See findings at A-0941).

Based on observation, record review and interview, the surgical services provided were not appropriate to the scope of services offered as evidenced by failing to maintain supplies necessary for providing the surgical services offered.
Findings:


On 01/29/2024 at 8:20 a.m., during the opening entrance conference, review of the daily report for 01/29/2024 and interview with S1CEO and S2CNO revealed that the hospital declined to accept two patient transfers needing gastrointestinal services over the last 24 hours due to lack of endoscopy tubing related to vendor credit holds. S1CEO confirmed that the hospital did not currently have pacemaker supplies for cardiovascular surgical procedures requiring the availability of a pacemaker due to credit holds, and they were also on credit hold with the supplier for shoulder implant surgeries. S2CNO confirmed that two shoulder surgeries this week have been canceled at the ambulatory surgery center due to credit holds. She further stated surgical buttons for ENT procedures were unavailable due to vendor holds.

On 01/29/2024 at 2:45 p.m., an interview with S10RN/Director of Surgery confirmed that one surgical procedure for a shoulder arthroscopy had been canceled for today and another one canceled for Wednesday at the ambulatory surgery center due to a credit hold with Arthrex, the supplier. She further confirmed that ENT supplies were on vendor hold due to credit issues. She stated that she recently began completing an Incident Report for all canceled surgeries for tracking purposes. Review of incident reports for surgery revealed two shoulder surgeries were canceled 01/25/2024 in OR due to credit hold with Tournier, the implant supplier.

On 01/30/2024 at 2:00 p.m., an interview with S17Purchasing confirmed that the following vendors providing supplies for surgical services were currently on credit hold: : Erbe (endo tubing); Zimmer, Stryker, Osteogen, Tournier, Globus, Medtronic, Ulrich, Enovis, Arthrex (orthopedics, spines, implants); Medtronic, Abbott, Boston Scientific (pacemakers and leads for Transcatheter Aortic Valve Replacement); Medline, Medtronic, Boston Scientific (surgical mesh); Medtronic (ENT buttons).

Review of the daily report for 01/31/2024 revealed 3 of 7 scheduled surgeries were canceled on this day in the OR - two transcatheter aortic valce replacements (TAVR) and one spine; in addition, one case was canceled at the ambulatory surgery center. All four were canceled due to credit hold issues with the vendors. On 02/01/2024 at 2:00 p.m., an interview with S10RN/Director of Surgery confirmed that the above surgeries had been canceled due to unavailable supplies related to vendor hold issues.

On 01/31/2024 at 1:35 p.m., an interview with S9MD (Medical Director of Surgical Services) confirmed that last week, he had to cancel two TAVR surgeries that were scheduled for this week that had been on the schedule for 2-3 weeks prior to the scheduled procedures. He confirmed that you can't do that specific surgery if there is no pacemaker available, and the pacemaker supplies have been on credit hold for a while. S9MD stated he had personally contacted the representative and thought he would be able to get the pacemaker leads, then found out the hospital didn't have the catheters either, so he had to have the patients go to another hospital to have the surgeries performed. He further stated that it has become a big problem getting the balloons from Medtronic. He stated that he used the last closure device yesterday, and will have to cancel two surgeries for the next week if the hospital does not get anymore delivered.

Further interview with S9MD revealed that the vendors are owed a large amount of money, and they will only bring supplies if they pay up front. He further stated they usually keep a good supply of all sizes of heart valves on the shelf, but most of them were expired and the Medtronic representative removed them without any replacements. They will have to call if they have an aortic aneurysm and need a valve. He stated the vendor Edwards is also on credit hold.

Review of the daily report for 02/04/2024 revealed one transfer was declined for a patient needing an endoscopic retrograde cholangio pancreatography (ERCP) due to lack of endoscopy tubing needed to conduct the procedure.

Review of the daily report for 02/05/2024 revealed one transfer was declined for a patient needing gastointestinal evaluation due to unavailability of gastrointestinal services.

On 02/05/2024 at 11:00 a.m., an interview with S10RN/Director of Surgery confirmed that a surgery had been canceled for the coming Friday for an endovascular aneurysm repair (EVAR) due to the vendor representative not supplying a stent for the procedure due to vendor hold issues. She confirmed they still did not have pacemaker supplies available for TAVR procedures.

Review of the medical record for Patient #6 and interview with S18RN revealed Patient #6 was admitted to the hospital on 01/10/2024 to 3 North Med/Surg with nausea and vomiting and had been unable to keep food down for two weeks. A gastroenterology consult was requested on 01/11/2024 for elevated liver enzymes, and was consulted a second time on 01/19/2024 for percutaneous endoscopic gastrostomy (PEG) tube placement. Patient #6 initially declined the procedure on 01/21/2024, and again on 01/22/224. On 01/25/2024, the nursing home refused to admit the patient if she didn't have a PEG or was not fully eating or drinking. On 01/26/2024, the patient agreed to the PEG procedure, but was unable to have it done due to lack of endoscopy tubing supplies in the Endoscopy area. On 01/27/2024, a local gastroenterologist brought supplies to the facility and conducted the PEG procedure. S18RN, confirmed that the patient's needed PEG procedure was delayed for one day due to unavailability of supplies related to vendor credit holds.

Based on record review and interview, the hospital failed to meet the Condition of Participation for Emergency Services as evidenced by failing to ensure its integrated services were properly supplied to provide the patients with appropriate diagnostic and care interventions (See findings at A-1103).

Based on record review and administrative interview, the hospital failed to ensure its integrated services were properly supplied to provide its patients with appropriate diagnostic and care interventions. This deficient practice was evidenced by the hospital failing to have the required endoscope and pacemaker supplies to prevent the unnecessary transfer and diversion of patients from their emergency department.
Findings:

On 01/29/2024 at 8:20 a.m., during the opening entrance conference, review of the daily report for 01/29/2024 and interview with S1CEO and S2CNO revealed that the hospital declined to accept two patient transfers needing gastrointestinal services over the last 24 hours due to lack of endoscopy tubing related to vendor credit holds. S1CEO further revealed that the hospital did not currently have pacemaker supplies for cardiovascular surgical procedures due to credit holds, and patients needing those services would also be diverted to another hospital.

On 01/29/2024 at 4:00 p.m., an interview with S2CNO stated the hospital currently does not have the required endoscope supplies or pacemaker supplies to provide services for patients presenting to the Emergency Department because they are on purchasing hold with their suppliers due to lack of payment.

Review of the transfer denial records revealed:
On 01/28/2024 at 1217, a patient with lower GI bleed was denied transfer due to no GI services.
On 01/28/2024 at 1304, a patient with a foreign body ingestion was denied transfer due to no ENT or GI endo services.

Review of the daily report for 02/04/2024 revealed one transfer was declined over the past 24 hours for a patient needing an ERCP due to lack of endoscopy tubing needed to conduct the procedure.

Review of the transfer denial record revealed:
On 02/03/2024 at 1826, a patient with nausea and vomiting needing an ERCP was denied transfer due to no GI services.

Review of the daily report for 02/05/2024 revealed one transfer was declined over the past 24 hours for a patient needing gastointestinal evaluation due to unavailability of gastrointestinal services.

Review of the transfer denial record revealed:
On 02/04/2024 at 2148, a patient needing a GI evaluation was denied transfer due to no GI services.