HospitalInspections.org

Based on record reviews and interviews, the hospital failed to ensure each patient was informed of all their rights prior to furnishing or discontinuing patient care as evidenced by having 1 of the required patient rights in accordance with the certification regulations omitted from the patient rights policy and the "Patient's Bill of Rights" signed by the patient upon admit. This was evident in 30 (#1 - #30) of a total sample of 30 patient records reviewed.

Findings:

Review of the hospital policy titled "Patient Rights & Responsibilities", revised 1/11, revealed in part: The hospital respects the rights of the patient, recognizes that each patient is an individual with unique health care needs, because of the importance of respecting each patients' personal dignity, provides considerate, respectful care focused on the patient's individual needs. The hospital assists the patient in the exercise of his/her rights and informs the patient of any responsibilities incumbent on him/her in the exercise of those rights. The hospital acknowledges and affirms the rights of the patient's and family.

Review of the "Patients' Rights and Responsibilities", given to the patient or a family member upon admission revealed no documented evidence that the patient rights to be free from all forms of abuse and harassment and receive care in a safe setting were included.

In an interview on 11/14/18 at 10:30 a.m., S10RN confirmed that the hospital's "Patients' Rights and Responsibilities" did not include for the patient to be free from all forms of abuse and harassment and receive care in a safe setting.

Based on record review and interview, the hospital failed to ensure the Quality Assurance/Performance Improvement program measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of services and quality of care. This deficient practice was evidenced by failure to include all services/departments in their Performance Improvement Plan.
Findings:

Review of the Hospital's "Performance Improvement Plan 2018" revealed in part:

Director Quality/Risk Management - The director is responsible for and provides leadership for:

5. Maintaining a current organization-wide Performance Improvement Plan with relating policies and procedures.

Review of the quarterly Performance Improvement Plan minutes failed to reveal the House Keeping Department was included in their organization-wide plan.

During an interview on 11/15/18 at 11:30 a.m., S10RN Quality Director confirmed their Performance Improvement Plan did not include the housekeeping department.

Based on record review and interview the hospital failed to ensure physicians followed Medical Staff By-Laws and hospital policies and procedures related to completion of medical records that were delinquent for greater than 30 days. The hospital failed to ensure medical records were properly stored in secure locations where they were protected from fire, water damage and other threats.

Findings:

Based on record review, observation, interviews and the hospital:

1) Failed to enforce governing body by-laws to ensure discharged patient's medical records were completed within 30 days of discharge.

Review of Medical Staff By-Laws dated 2018 revealed:
-All medical records reflecting the absence of required items of information 72 hours after the patient's discharge shall be considered incomplete.
-All medical records must be completed within 30 days from the date of the patient's discharge.
-Those medical records not completed within 30 days of discharge shall be considered delinquent.
-Once a month the Director of Medical Records will count all incomplete medical records. A letter will be sent to the responsible physician notifying him/her of those records which are incomplete over 15 days and those records which are delinquent (incomplete over 30 days).

Review of the hospital policy titled Incomplete and Delinquent Medical Records-Physicians dated 01/18 revealed in part, records that are incomplete for more than 30 days after discharge are considered delinquent.
Notify physicians through personal communication and/or phone call of total number of incomplete records and specify how many are 15-29 days old and how many are already over 30 days.
A certified letter will be sent to each physician with incomplete records greater than 15 days old and they will be given a time frame not to exceed 30 days of discharge to complete these records. If after the time frame, the charts remain incomplete, the Chief of Staff and the Chief Executive Officer will be notified and a letter will be sent from the CEO suspending the physician's admitting privileges until the charts are completed.

On 11/13/18 at 1:40 p.m. in an interview with S3MedRecords revealed she did not have a current number of how many charts were incomplete.

On 11/14/18 at 2:30 p.m. in an interview with S3MedRecords revealed a verbal list of delinquent records which indicated 90 medical records are > 90 days delinquent. It was further revealed the hospital did not have any physicians with privileges suspended for delinquent medical records. It was further revealed S3MedRecords was unable to produce any certified letters sent to physicians regarding incomplete or delinquent records.

On 11/14/18 at 4:20 p.m. a typed list of delinquent records indicated the following:
3 medical records > 30 days
2 medical records > 60 days
1 medical record > 90 days
84 medical records > 120 days


2) Failed to ensure patient's medical records were protected from fire and/or water damage. This deficient practice was evidenced by:

a) Storing medical records in the medical records department, a sprinklered room, which contained 1,503 records stored on open shelving, on top of cabinets, and on desks.

b) Storing medical records in an on-site metal warehouse unsprinklered room, 4200 square feet in diameter, containing approximately 2500 banker's boxes of records stored on open shelving.

c) Storing medical records in an off-site metal warehouse unsprinklered room containing 1615 boxes of records stored on open shelving.


Review of the hospital policy titled Record Storage, last reviewed 1/17 and presented as current revealed, in part, the hospital is responsible for providing measures to protect medical records from fire, rain, and other destructive exposure and for providing a secure storage place to safeguard records from loss, theft, tampering, or other unauthorized use.
Procedure:
1. Active records are stored in the Health Information Management Department. Records that have been inactive for five years are purged annually.
2. Inactive records are boxed and labeled accordingly. A log is kept in the department of those records moved to the warehouse for ease in retrieval.
3. When the warehouse storage area is at its capacity, the oldest records are moved to off-site storage as the newer records are placed in the warehouse.

Review of the hospital policy tiled Retention of Medical Records, last reviewed 1/18 and presented as current revealed in part, at the end of each year, charts from five years before are purged, indexed, boxed, and sent to the warehouse behind the hospital. When the warehouse storage area is at its capacity, the oldest records are moved to off-site storage as the newer records are placed in the warehouse. The off-site storage company is Hathorn.

Review of the policy titled Security of Medical Records, last reviewed 1/18 and received as current policy revealed, in part, protection is also provided against damage by fire and water. The mobile shelves can be locked to form a "box" to help prevent further water or fire damage to the records housed in the main hospital building.

On 11/14/18 at 9:15 a.m. measurements of the on-site storage area containing medical records was received from S7MaintSupervisor (60' x 70'). The open shelves were measured, boxes were counted, and the approximate sum was calculated to be 2500 bankers boxes filled with medical records.

On 11/15/18 at 11:30 a.m. a letter was presented from S3MedRecords from the outside storage facility stating there are 1615 boxes of medical records stored at their facility which is unsprinkled.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable standards of practice, consistent with state law. This deficient practice was evidenced by failing to ensure all medication orders were reviewed by a pharmacist, before the first dose was dispensed, for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications.

Findings:

Review of the Louisiana Administrative Code, Professional and Occupational Standards,
Title 46: LIII, Pharmacist, Chapter 15, Hospital Pharmacy, §1511. Revealed in part:
Prescription Drug Orders
A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial
dose of medication, except in cases of emergency.

Review of pharmacy policy titled Preparing & Dispensing of Medication as current policy revealed, in part, the responsibilities of the director of pharmacy states, "On these units, a physician medication orders is reviewed by a pharmacist during pharmacy hours via electronic scan prior to removal by nursing. All medication orders are reviewed for the following: ...3. Appropriateness of the medication, dose, frequency and route of administration ...Once an order has been reviewed and verified by a pharmacist, the medication will appear on the patient's profile for the nurse to select for removal. If the medication is required in an urgent situation or when pharmacy is closed, the nurse may select the "override" key to bypass the pharmacist review process. All medications removed from Pyxis utilizing the "override" function will require a 2nd nurse to witness and verify that the medicine being removed has been verified against the physician order. These orders are reviewed by the pharmacist immediately when the order is received, either following an emergency situation or opening of pharmacy department on the morning following administration of the medication.

Review of hospital policy titled Pharmacy Hours of Operation/On Call Hours revealed in part a pharmacist will be available on a 24 hour basis to dispense medications not available in automated dispensing cabinets.
Pharmacy hours: 7:00 a.m. - 7:00 p.m. weekdays and 7:00 a.m. - 3:00 p.m. weekends and holidays.
Pharmacy on-call hours: 7:00 p.m. - 7:00 a.m. weekdays and 3:00 p.m. weekends and holidays.

On 11/13/18 at 1:45 p.m. in an interview with S8Pharmacist it was revealed that the pharmacy hours of pharmacy coverage was Monday thru Friday from 7:00 a.m. to 7:00 p.m.; weekends and holiday hours from 7:00 a.m. to 3:00 p.m. It was further revealed that when a pharmacist is not on site, two nurses perform first dose review.

On 11/14/18 at 1:30 p.m. in an interview with S11Pharmacist revealed a pharmacist did not perform a first does review after hours, 2 nurses (LPN or RN) perform first dose review before overriding medication for afterhours new admissions and new medication orders. It was further revealed there was no limitation to only emergency drugs that can be overridden or administered before first dose review by a pharmacist.

Based on record review, observation, and interview, the hospital failed to ensure outdated, mislabeled, or otherwise unusable drugs and biologicals were not be available for patient use.
Findings:

Review of the policy titled Medication Storage/Security last reviewed 10/18 revealed expired, damaged, and/or contaminated medications-medications are monitored by pharmacy and removed when expired.

A pharmacist or pharmacy technician inspects designated drugs storage areas on a regular basis. In departments where medication is used/stored to assure that no unapproved medications are stocked, to assure that minimal quantities of approved medications are stocked and to assure that all stocked medications are in date (have not expired). During the inspection, he/she also looks for medications located in non-designated areas of the department

Observation of room "l" on 11/13/18 at 11:10 a.m., revealed one 20 milliliter bottle of 1% lidocaine with an expiration date of 1 April 2018 and two saline 10 milliliter flushes with expirations dates of 7/1/18 and 8/1/18

Observation of room "q" on 11/13/18 at 11:20 a.m. revealed a 30-ounce bottle of Pro-Stat with an open date of 7/19/18 (manufacturer states to discard 3 months after opening).

During an interview on 11/13/18 at 11:22 a.m., S1CNO acknowledged the expired medications should not be available for patient use.

Based on policy review, observation and interview, the hospital failed to ensure the infection control officer assured the system for controlling infections and communicable diseases of patients and personnel was implemented according to hospital policy and acceptable standards of infection control practices. This deficient practice is evidenced by:

1) failure to ensure expired supplies were not available for use; and
2) failure to ensure hand hygiene practices were implemented in accordance with hospital policy and CDC guidelines;
3) failure to maintain a sanitary environment in the hospital.

Findings:

1) Failure to ensure expired supplies were not available for use

Review of hospital policy titled Use of Single-Use & Multiple-Use Sterile Products last revised 10/18 revealed in part, multiple dose vials will be treated as single dose vials; single-use sterile products (vials, ampules and sterile irrigation solutions) will be use whenever possible. Single use sterile products will be used only once and the remainder destroyed.

Review of the policy titled Medication Storage/Security last reviewed 10/18 and revealed expired, damaged, and/or contaminated medications-medications are monitored by pharmacy and removed when expired.
A pharmacist or pharmacy technician inspects designated drugs storage areas on a regular basis. In departments where medication is used/stored to assure that no unapproved medications are stocked, to assure that minimal quantities of approved medications are stocked and to assure that all stocked medications are in date (have not expired). During the inspection, he/she also looks for medications located in non-designated areas of the department.


2) Failure to ensure hand hygiene practices were implemented in accordance with hospital policy and CDC guidelines

Review of the hospital infection control manual revealed in part: D. 4. b. Gloves are changed between patients. Remove gloves before leaving the patient room/area so as not to contaminate the environment. Wash hands after removing gloves.

Review of the hospital policy titled Hand Hygiene last reviewed 07/18 revealed in part, the hospital practices are to use the current CDC guidelines.

Review of the CDC's "Guideline for hand Hygiene in Health-Care Settings" revealed in part, hands should be washed or an alcohol-based hand rub should be used before having direct contact with patients, before inserting an invasive device, after contact with a patient's intact skin, after contact with inanimate objects in the immediate vicinity of the patient, and after removing gloves.

On 11/14/18 at 10:25 a.m. observation of S5RN performing a dressing change on Patient #27 who was a 48 year old admitted on 11/12/18 with an admitting diagnosis of UTI; and a history which included a dehisced incisional hernia repair. The dressing change revealed S5RN did no hand hygiene when she changed gloved during the dressing change and it was further revealed the "Safecleans" wound cleanser bottle was handled by S5RN with clean and dirty gloves during dressing change.

On 11/14/18 at 10:40 a.m. an observation of S4LPN, who performed an accucheck on Patient #22, a 64 year old admitted on 11/09/18 with a diagnosis of CHF and DM revealed S4LPN wiped Patient #22's finger with an alcohol wipe, S4LPN then blew on Patient #22's finger with her mouth to dry the alcohol, then S4LPN stuck Patient #22's finger with a lancet. Following the accucheck, S4LPN did not remove dirty gloves or perform hand hygiene; S4LPN exited Patient #22's room then opened the nursing station door with dirty gloves.

On 11/14/18 at 12:30 p.m. in an interview with Cindy Juneau, Director of Infection Control verified the findings of the wound care by S5RN and the accucheck by S4LPN.

3) failure to maintain a sanitary environment in the hospital.

Review of the hospital policy titled "Cleaning Patient Room After Discharge", reviewed 07/18, revealed in part: 4. Clean all walls and floors using a disinfectant. 5. Spray room with disinfectant. 6. Clean bed first by: d. clean floor and head of bed, bed base, side and coasters with disinfectant. 7. Clean other furniture with disinfectant as follows: b. clean lights, etc. 8. Scrub floors with disinfectant being sure to get corners of room and closet. 9. Wipe down all patient equipment ...place clear bag over patient care equipment.

A tour of the main hospital campus on 11/13/18 from 10:10 a.m. to 11:15 a.m., accompanied by S1CNO revealed the following infection control concerns:

- observation of room "a", revealed floor dirty with trash and lint, A/C vent dirty with lint, infusion pump had tape residue and grime on the top around tubing chamber compartment and was not covered in a bag per policy.

- observation of room "b", revealed a hole in the wall above the base board by the bathroom door, A/C vent dirty with lint, 2 infusion pumps with grime on the top and a yellowish thick film around the tubing chamber compartment and was not covered in a bag per policy.

- observation of room "c", revealed chipped paint on the room door frame and the bathroom door frame, A/C vent dirty with lint, counter top under the window ledge had broken and missing pieces, sheet rock on the wall had cracks, bed "a" tape on left bed rail, tape residue on infusion pump with grime around tubing chamber compartment, bed "b" infusion pump had dried brownish substance inside chamber compartment and was not covered in a bag per policy.

- observation of room "d", revealed counter top had broken and missing pieces under the window, A/C vent dirty with lint, infusion pump with tape residue and grime on the top and yellowish thick film around tubing chamber compartment and was not covered in a bag per policy, grime on the O2 flowmeter and telephone by the bed.

- observation of room "e", revealed paint cracking and missing on the walls, chipped paint on the room door frame and the bathroom door frame, baseboard by the bathroom door loose, shower floor had brownish stains, sheet rock cracking on the walls in the bathroom, hole in the wall behind room door, A/C vent dirty with lint, walls had missing chips of paint, bed "a" pulse ox finger probe with sticky brownish substance on the inside and outside of the probe, bed "b" had debris and sticky grime inside the bedside table vanity compartment.

- observation of room "f", revealed room door frame and bathroom door frame with missing chipped paint, walls missing paint chips, ceiling tiles stained, bed "a" infusion pump with grime and yellowish sticky substance inside the tubing chamber compartment and was not covered in a bag per policy, bed "b" infusion pump with grime and yellowish sticky substance inside the tubing chamber compartment and was not covered in a bag per policy.

- observation of room "g", revealed chipped paint on the room door frame and bathroom door frame, baseboard by the bathroom door loose, shower floor had brownish stains, stains in the lavatory sink, A/C vent dirty with lint and had paper trash inside vent cover, paint chipped on the over bed lights, sheet rock cracked on the wall by the TV.

- observation of room "h", revealed a hole in the sheet rock by the bathroom door, chipped paint on the room door frame and bathroom door frame, baseboard loose by the bathroom door, countertop by the lavatory had broken missing pieces, missing paint chips on the walls, A/C vent dirty with lint, vacuum meter had brownish stains on and inside of canister, infusion pump had tape residue and grime on the top and yellowish sticky substance around tubing chamber compartment, and was not covered in a bag per policy.

- observation of room "i", revealed A/C vent dirty with lint, missing paint chips on the wall above the bed, grime on the O2 flowmeter, infusion pump had tape residue on the side and was not covered in a bag per policy.

- observation of room "j", revealed A/C vent had chipped paint on the frame and vent was dirty with lint, grime on the telephone earpiece by the bed.

- observation of room "k", revealed A/C vent dirty with lint and trash inside of vent, bedside toilet was not covered in a bag.

- observation of room "l", revealed sterile gloves with 10/2007, 09/2015, and 12/2016 expiration dates, biopatch expiration date 04/2018, tegaderm dressing (x3) expired 01/2016, infusion set expiration date 11/2017, infusion pump with grime on top and face and not covered in a bag per policy.

- observation of room "m", revealed pulse oximeter, finger probe and EKG leads had tape residue, 2 rolls of disposable rolls of tape used and left at bedside, open irrigation catheter and oral airway packages open, neonatal suction package opened, and infusion pump was not covered in a bag per policy.

Interview on 11/13/18 at 11:15 a.m. with S1CNO confirmed that rooms (#a - #m) were cleaned and should be ready for patients and that all equipment when cleaned was placed in a clear plastic bag.

Interview on 11/15/18 at 11:10 a.m. by telephone with S6HKSupervisor confirmed that all of the rooms should have been cleaned and ready for new patients. S6HKSupervisor further stated that after the rooms are cleaned by housekeeping and ready for use the House Keeping Supervisor will go behind to check the rooms. S6HKSupivisor stated that he did not know the rooms were not clean, he further stated that sometimes staff will go into the rooms after they have been cleaned and leave trash.

Review of the hospital's policy titled "Infection Control - Expiration Date for Sterile Items revealed in part: To assure sterility of patient care items. b) Items purchased as sterile should be used according to the manufacturer's directions. This may be either a designated expiration date, or a day-to-day expiration date such as "sterile unless the integrity of the package is compromised." h) If the sterile wrap is not 100% intact, or the contents show deterioration or are out of date, the pack contents should not be used.

Observation of the Operating Room Suites on 11/14/18 at 2:20 p.m., accompanied by S2RN, revealed the following:
- observation of room "n", revealed tears/rips to the vinyl covering on the surgical table's arm board, 4 used syringes with visible liquid inside, 1 open tube of bacitracin ointment and open package of gauze on top of the anesthesia cart, tape wrapped around the pulse-oximeter finger probe, debris covered oral airway and a pair of scissors left on the ventilator, bed warming unit with dust and grime on the surfaces, cautery cart with dust and grime on the surfaces and plug ports of the device, grime buildup on the surfaces of both the primary and secondary anesthesia gas tubing connectors, orthopedic patella pins package with an expiration date of 6/26/18 and packaged orthopedic clamping device with an expiration date of 6/26/18.

During an interview on 11/14/18 at 2:35 p.m., S2RN confirmed the equipment in room "n" was not sanitized and the expired patient use equipment should not have been available for use.

- observation of room "p" revealed one of six endoscopy stylets had its exposed forceps touching the wall, open syringe on the medication cart, oxygen and suction stand upper surfaces was covered with grime, vital signs/anesthesia monitoring equipment had dust and grime on its surfaces, defibrillator surfaces were covered with dust and grime.
During an interview on 11/14/18 at 2:50 p.m., S2RN confirmed the equipment in room "p" was not sanitized.

- observation of room "o" revealed SurgArm board with tears and crack, open and soiled suction wand on the ventilator, one open syringe a used and open tube of eye lubricant on the anesthesia medication cart, cautery cart with tape on the surface and grime build up on the top and face of the cart.

During an interview on 11/14/18 at 3:10 p.m., S2RN confirmed the equipment in room "o" was not sanitized.









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39791

Based on record review and interview, the hospital failed to ensure all pre-anesthesia evaluations were performed within 48 hours prior to administration of anesthesia by a person qualified to administer anesthesia for each patient by failing to include the type of medications for induction for 1 (Patient #28) of 5 (Patients #18, 19, 26, 28 and 29) medical records reviewed for patients who received anesthesia out of a total of 30 medical records reviewed.
Findings:

Review of Patient #28's medical record revealed an admit date of 11/12/18 for abdominal pain with a planned laparoscopic cholecystectomy surgery on 11/13/18.

Review of Patient #28's "Consent for Anesthesia Services" failed to indicate the type of medication for induction. Further review failed to reveal the person authorized to administer the anesthesia was not identified and did not sign the consent.

During an interview on 11/15/18 at 11:30 a.m., S1CNO confirmed the type of medication for induction was not documented on the consent and the pre-anesthesia evaluation was not completed 48 hours prior to the administration of anesthesia.

Based on record review and staff interview, the Hospital failed to ensure a post-anesthesia evaluation was completed and documented by a practitioner qualified to administer anesthesia to was made after the patient was taken to PACU, but prior to 48 hours and/or discharge. The deficient practice was evidenced by no time entered for the post-anesthesia evaluation for 1 (Patient #29) of 5 (Patients #18, 19, 26, 28 and 29) sampled patients reviewed for post-anesthesia out of a total sample of 30.
Findings:

Review of Patient #29's medical record revealed a right lumpectomy with axillary dissection on 11/12/18.

Review of Patient #29's Anesthesia Record failed to reveal a documented time for the post-anesthesia evaluation.

During an interview on 11/15/18 at 11:30 a.m., S1CNO confirmed the post-anesthesia evaluation was not completed after the patient was taken to PACU but prior to 48 hours and/or discharge.

Based on record review and interview, the hospital failed to develop policies and procedure to address the right of patients admitted to swing beds regarding the right to choose his/her personal attending physician.
Findings:

Review of the Patient Rights and Responsibilities documents, presented by the hospital as the current patient right given to all patients (acute inpatient and swing bed) revealed no documented evidence for swing bed patient's rights to choose his/her personal attending physician.

During an interview on 11/14/18 at 3:30 p.m., S10RN Quality Director acknowledged the hospital did not have a process or policies in place to notify swing bed patients the right to choose his/her personal attending physician.

Based on record review and interview, the hospital failed to address, in the swing bed patient's rights and notify swing bed patients, of the right to refuse to perform services for the facility; perform services for the facility, if he or she chooses when the facility has documented the need or desire to work in the plan of care. This was evidenced by the hospital failing to include the provision for work in the Patient Rights and Responsibilities, which is given to the swing bed patients upon admission.
Findings:

Review of the Patient Rights and Responsibilities documents, presented by the hospital as the current patient right given to all patients (acute inpatient and swing bed) revealed no documented evidence for swing bed patient's rights regarding work.

During an interview on 11/14/18 at 3:30 p.m., S10RN Quality Director acknowledged the patient's rights regarding work were not included in the rights provided to the swing bed patients.

Based on record review and interview, the hospital failed to address, in the swing bed patient's rights and notify swing bed patients, of the right to send and promptly receive mail that is unopened and to have access to stationery, postage, and writing implements at the patient's own expense This was evidenced by the hospital failing to include this right in the Patient Right and Responsibilities which is given to the swing bed patients upon admission.
Findings:

Review of the Patient Rights and Responsibilities document, presented by the hospital as the current patient right given to all patients (acute inpatient and swing bed) revealed no documented evidence for swing bed patient's rights regarding mail.

During an interview on 11/14/18 at 3:30 p.m., S10RN Quality Director acknowledged the hospital did not have a process or policies in place to notify swing bed patients the right to send and promptly receive mail.