HospitalInspections.org

Based on record review and interview, the hospital's governing body failed to ensure the appointment and re-appointment of members of the medical staff was in accordance with the medical staff bylaws for 4 of 4 medical staff members (S4MD, S5FNP, S6MD, S7MD) reviewed.
Findings:

Review of the medical staff bylaws revealed:
3.4 (a) Duration and Renewal of Initial and Modified Appointments:
All initial appointments...shall be for a period of up to two (2) years.
3.4 (b) Reappointments:
Reappointments to the medical staff shall be for a period of not more than two (2) years.

Review of the credentialing file for S4MD revealed that he was initially appointed to the medical staff on 12/17/09; however, there was no time period documented for the initial appointment term. There failed to be documented evidence the physician was reappointed to the medical staff every two years as indicated in the medical staff bylaws.

Review of the credentialing file for Radiologist S7MD revealed the initial medical staff appointment was dated 02/18/14; however, there was no time period documented for the initial appointment term. There failed to be documented evidence the physician was reappointed to the medical staff every two years as indicated in the medical staff bylaws.

Review of the credentialing files for S5FNP and S6MD revealed no documented evidence to indicate that they were appointed to the medical staff.

On 12/07/16 at 9:00 a.m., an interview with S2Program Director confirmed there was no end date or time frame for the initial appointment for S4MD and S7MD. She further confirmed there had been no re-appointment of S4MD and S7MD by the governing body, and there were no appointments conducted by the governing body for S5FNP and S6MD.

Based upon record review and interviews, the hospital failed to provide to each patient a telephone number and address for lodging a grievance directly with the state agency. This was evidenced by the failure to include this information in admission packets provided to patients #1-#13 upon admission.
Findings:

Review of the admission packet provided to each patient upon admission to the hospital revealed information related to the patient's right to file a grievance directly with the state agency, Louisiana Department of Health, Health Standards Section failed to be provided.

Interview on 12/06/16 at 10:30 a.m. with S2Program Director revealed she was not aware this information had to be provided to the patient.

25119

Based on observation and interview, the hospital failed to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for the patients admitted for acute inpatient psychiatric services by failing to ensure the patient's environment was free of ligature risks and safety hazards. This deficient practice had the potential to negatively impact the 17 patients on census.
Findings:

Observations on 12/05/16 at 12:40 p.m. revealed the following:
1) All of the patient rooms' inner bathroom doors were secured with 3 hinges on each door that were separated widely enough to facilitate potential ligature. The bathroom doors had downward facing paddle handles on both sides of the doors that were a potential ligature risk.
2) All of the patient rooms contained 4 wall mounted outlets that were uncovered and presented a potential safety risk of electrocution to patients with psychiatric diagnoses.
3) Rooms "g" and "h" contained a metal frame hospital bed with two sets of ¼ side rails on each side of the bed. The bedframe had multiple ligature risks, including the headboard and footboard, that were potential ligature risks.Interview on 12/07/16 at 8:20 a.m. with S3DON confirmed the door hinges on all the patients' bathroom doors, outlets in the patient rooms, and metal hospital beds in rooms "g" and "h" were potential ligature and hazard risks. When asked if a patient could get a bed sheet and hang themselves on the above ligatures, she stated "I bet they could."

Based on record review and interview, the medical staff failed to examine the credentials of members of the medical staff for appointment and reappointment in accordance with the medical staff bylaws for 4 of 4 members of the medical staff (S4MD, S5FNP, S6MD, S7MD).
Findings:

Review of the medical staff bylaws revealed:
3.4 (a) Duration and Renewal of Initial and Modified Appointments:
All initial appointments...shall be for a period of up to two (2) years.
3.4 (b) Reappointments:
Reappointments to the medical staff shall be for a period of not more than two (2) years.

Review of the credentialing record for S4MD, Medical Director, revealed that he was initially appointed to the medical staff on 12/17/09; however, there was no time period documented for the initial appointment term. Further, there was no re-appointment documented by the medical staff since the original appointment.

Review of the credentialing record for S7MD, a radiologist who provided services off-site, revealed that he was initially appointed to the medical staff on 02/28/14 as supervisor of the ionizing radiology services; however, there was no time period documented for the initial appointment term. Further, there was no documented evidence that S7MD was aware of and agreed to the appointment by the governing body.

Review of the credentialing records for S5FNP and S6MD revealed no documented evidence to indicate the members of the medical staff were initially appointed to the medical staff.

There was no documented evidence to indicate the medical staff had examined the credentials of (S4MD, S5FNP, S6MD, S7MD) for medical staff membership and no evidence to indicate that recommendations were made to the governing body for medical staff membership. In addition, there was no documented evidence of health statements for any of the medical staff.

On 12/07/16 at 9:00AM, an interview with S2Program Director confirmed there was no end date or time frame for the initial appointment for S4MD and there had been no re-appointment of S4MD by the governing body; there was no documented evidence of an agreement from S7MD for his supervisory appointment; there were no initial appointments conducted by the governing body for S5FNP and S6MD. In addition, S2Program Director confirmed that there was no indication the medical staff had examined the credentials of (S4MD, S5FNP, S6MD, S7MD) for medical staff membership and no indication the medical staff made recommendations to the governing body for medical staff membership.

Based on record review and interview, the hospital failed to ensure that radiology services were supervised by a radiologist as evidenced by the governing body's failure to have a signed agreement with the consulting radiologist providing the services.
Findings:

Review of a signed agreement between the hospital and the contracted provider of radiology services revealed that S7MD was identified as the radiologist who would read the xrays obtained for the hospital's patients.

Review of the credentialing record for Radiologist S7MD revealed that he was appointed to the medical staff on 02/28/14 as supervisor of the ionizing radiology services; however, there was no documented evidence that S7MD was aware of and agreed to the appointment by the governing body.

On 12/07/16 at 9:00AM, an interview with S2Program Director confirmed there was no documented evidence indicating that Radiologist S7MD had agreed to the appointment as supervisor of radiology services.

Based on record review and interview, the hospital failed to maintain copies of radiology reports on the medical record for 1 (#16) of 2 patients (#15, #16) reviewed who received radiology services in a total sample of 16.
Findings:

Review of the medical record for patient #16 revealed a physician's order dated 02/01/16 at 6:10 p.m. for an xray of the right hand the next morning. Review of the nurse notes dated 02/02/16 at 11:45 a.m. revealed the xray was obtained at that time. Further review of the medical record revealed no documented evidence that xray results were received and placed on the medical record.

On 12/06/16 at 4:15 p.m., an interview with S3DON confirmed there were no results of the xray report contained within the medical record of patient #16, and no documented evidence that the physician was aware of the results of the xray.

Based upon record review and interview, the hospital failed to ensure the Master Treatment Plan identified short-term and long range goals for 2 of 13 records reviewed (#1, #2). Findings:

1) Review of patient #1's Medical Record revealed the patient was admitted on 11/25/16 for Auditory Hallucinations and Schizoaffective Disorder Bipolar Type with Psychotic Features. Review of the Master Treatment Plan revealed the Problem list identified 1) Suicidal Ideation, 2) Mood Liability, 3) Auditory hallucinations, and 4) Substance Abuse. Further review of the treatment plan revealed there were no goals or interventions developed.

2) Review of patient #2's Medical Record revealed the patient was admitted on 11/30/16 for ADHD, Bipolar with psychotic features, and Mild Mental Retardation. Review of the Master Treatment Plan revealed problem #1 was identified as Mood Liability; however, there were no goals or interventions developed for the problem.

Interview on 12/07/16 at 9:00 a.m. with S8RN revealed when the patient is admitted, the Registered Nurse was to develop the initial Master Treatment Plan and identify short term and long term goals, and interventions.

Based upon record review and interview, the hospital failed to ensure the Master Treatment Plan identified active treatment measures for identified problems for 2 of 13 records reviewed (#1, #2). Findings:

1) Review of patient #1's Medical Record revealed the patient was admitted on 11/25/16 for Auditory Hallucinations, Schizoaffective Disorder Bipolar Type with Psychotic Features. Review of the Master Treatment Plan revealed the Problem list identified 1) Suicidal Ideation, 2) Mood Liability, 3) Auditory hallucinations, and 4) Substance Abuse. Further review of the treatment plan revealed there were no active treatment approaches identified on the plan.

2) Review of patient #2's Medical Record revealed the patient was admitted on 11/30/16 for ADHD, Bipolar with psychotic features, and Mild Mental Retardation. Review of the Master Treatment Plan revealed problem #1 was identified as Mood Liability; however, there were no active treatment approaches identified.

Interview on 12/07/16 at 9:00 a.m. with S8RN during review of the electronic medical records for patients #1 and #2 revealed active treatment approaches were to be completed during the patients admission.