HospitalInspections.org

Based on observation and interview, the hospital failed to ensure patients had the right to personal privacy. This deficient practice is evidenced by the facility failing to provide window coverings for 3 of 22 patient rooms.
Findings:

Observation on 10/22/18 at 10:25 a.m. revealed the following:

Room "a" had no window curtains or blinds, which allowed visual exposure into the room from outside the facility.

Room "c" had no window curtains or blinds, which allowed visual exposure into the room from outside the facility.

Room "g" had 1 curtain which didn't cover the window and allowed visual exposure into the room from outside the facility and the other window in the room had no curtain.

On 10/23/18 at 1 p.m., S2DON and S10Plant/Dir acknowledged the window coverings in rooms "a", "c" and "g" failed to provided privacy by allowing visual exposure into the rooms from outside the facility.

Based on observation and interview, the hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety for 22 of 22 acute care psychiatric patients currently on census.
Findings:

a. Entry doors for 22 of 22 patient rooms (Rooms a, b, c, d, e, f, g, h, i, j, k, l, m, n, o, p, q, r, s, t, u, and v) with 3 hinges separated widely enough to facilitate a ligature risk by tying around the hinge between the door and door jam.

b. All patient room entrance doors and bathroom doors had the base on which the handle was placed that was flat and around which a tie could be used as a ligature.

c. All patient room bathrooms had ligature points at the exposed toilet plumbing around which a tie could be placed and brought over the water tank.

d. All patient room bathrooms had ligature points at the face of the water tank where large zip-ties were fastened around the toilet's water tank to prevent removal of the tank's lid.

e. All patient rooms had ligature points at the top of the bathroom door and doorframe union where a knotted item could be placed above the door and by then closing the door, would create a point where the knot would be fastened between the top of the door and the door frame.

f. A ligature point in room "j" where the AC wall unit's power cord is exposed approximately 5 feet up the wall and a tie could be fastened around the wire between the wall and the unit.

g. A ligature point at the top wall-drawer that pulls out in room "s" where a tie could be looped around the drawer.

h. All patient rooms had non-tamper resistant screws in the entry and bathroom door faceplates and doorknobs.

i. All patient rooms had ceiling light fixtures with glass light bulbs accessible to patients.

During an observation tour of all the patient rooms on 10/23/18 at 1 p.m. with S2DON and S10Plant/Dir, the ligature points were confirmed for : all the patient's entry door hinges; the patient's entry and bathroom door knobs; the patient's exposed toilet plumbing and zip-ties on all the toilets; the AC electric wire in room "j"; the union at the top of the bathroom door and doorframe; and the pull out drawer in room "s". S2DON and S10Plant/Dir also confirmed at this time, the non-tamper resistant screws in the entry and bathroom door faceplates and knobs, and the accessible glass light bulbs in all the patient rooms.

Based on record review and interview, the hospital failed to ensure the training and experience of all personnel was adequate to meet the needs of the patient's as evidenced by:
1) failing to ensure all direct care staff were currently trained in de-escalation techniques prior to working with patients for 4 (S4RN, S5MHT, S12MHT, S14MHT) of 12 personnel records reviewed and
2) failing to ensure all nursing staff were trained and competent in respiratory therapy for 3 (S4RN, S11RN, S13RN) of 7 nursing staff personnel records.
This deficient practice had the potential to impact the 22 patient's on census at the time of survey.
Findings:

1) Failing to ensure all direct care staff were currently trained in de-escalation techniques prior to working with patients for 4 (S4RN, S5MHT, S12MHT, S14MHT) of 12 personnel records reviewed

Review of personnel record on 10/24/18 for S4RN revealed date of hire was 06/08/18. There was no documentation in the personnel folder for de-escalation training.

Review of personnel record on 10/24/18 for S5MHT revealed date of hire was 07/25/18. There was no documentation in the personnel folder for de-escalation training.

Review of personnel record on 10/24/18 for S12MHT revealed date of hire was 04/17/18. There was no documentation in the personnel folder for de-escalation training.

Review of personnel record on 10/24/18 for S14MHT revealed date of hire was 07/18/18. There was no documentation in the personnel folder for de-escalation training.

Interview on 10/24/18 at 12:45 p.m. with S3Exec/Asst. confirmed S4RN, S5MHT, S12MHT, and S14MHT did not have current de-escalation training.

2) Failing to ensure all nursing staff were trained and competent in respiratory therapy for 3 (S4RN, S11RN, S13RN) of 7 nursing staff personnel records

Review of personnel record on 10/24/18 for S4RN revealed date of hire was 06/08/18. There was no documentation in the personnel folder for respiratory competency/training.

Review of personnel record on 10/24/18 for S11RN revealed date of hire was 02/15/16. There was no documentation in the personnel folder for respiratory competency/training.

Review of personnel record on 10/24/18 for S13RN revealed date of hire was 04/16/18. There was no documentation in the personnel folder for respiratory competency/training.

Interview on 10/24/18 at 1:45 p.m. with S3Exec/Asst. confirmed there was no documentation in the personnel folder for respiratory competency/training for S4RN, S11RN, and S13RN.

Based on record review, observation, and interview, the hospital failed to ensure the registered nurse supervised and evaluated the nursing care for each patient as evidenced by failure of the RN to ensure that inpatients were observed and documented on every 15 minutes as ordered (Patient #3, 5, 6, 8, 9, R7, R8, R9, R10)
Findings:

1. On 10/22/18 at 10:20 a.m. an observation was made of the inpatient psychiatric unit. During the observation an interview was conducted with S6MHT regarding the current patient assignments. S6MHT indicated she had been assigned responsibility for the patients on the chemical dependency unit and all patients were on every 15 minute observations.

At that time, the surveyor asked to review patient observation sheets. Review of these sheets revealed:
Patient R7's last documented check was at 7:00 a.m.
Patient R8's last documented check was at 6:30 a.m.
Patient R9's last documented check was at 7:00 a.m.
Patient R10's last documented check was at 7:00 a.m

Further review of the observation sheets revealed that S6MHT had documented every 15 minute checks on patients #3, 5, 6, 8 and 9 up until 11:45 a.m. that day.

At this time, interview with S6MHT confirmed that Patients R7-R10's observation sheets were not current. When asked why Patients #3, 5, 6, 8 and 9 had observations up until 11:45 that day, she had no response.

2. On 10/23/18 at 1:30 p.m., an observation was made of the inpatient psychiatric unit. An interview was conducted with S6MHT. She stated she was responsible for observing the patients on the chemical dependency unit and all patients were on every 15 minute observations.

At that time, the surveyor asked to review patient observation sheets. Review of these sheets revealed:
Patient 5's last documented check was at 11:00 a.m.
Patient R8's last documented check was at 11:00 a.m.
Patient R10's observation sheet was documented up until 2:15 p.m.

On 10/23/18 at 1:35 p.m., S2DON reviewed the above observation sheets and confirmed that they were not current. S2DON stated that all patients on the unit were on every 15 minute checks and the observation sheets should be current and not documented ahead of time.

Based on record review and interview, the hospital failed to ensure that a Registered Pharmacist was appointed as the director of Pharmaceutical Services as evidenced by the failure of the hospital to notifiy S8Pharmacist that he had been appointed as the Director.
Findings:

Review of the hospital's organizational chart and governing body meetings for 2018 revealed no documented evidence of a Registered Pharmacist being appointed as the Director of Pharmaceutical Services at the hospital.

On 10/23/18 at 9:00 a.m., interview with S1Administrator revealed that S8Pharmacist was the director of Pharmaceutical Services for the hospital. At that time, S1Administrator reviewed S8Pharmacist's contract and confirmed that there was no documented evidence in the contract that he was Director or Pharmaceutical Services at the hospital.

On 10/23/18 at 9:15 a.m., phone interview with S8Pharmacist revealed that he was the hospital's consultant pharmacist and came to the hospital once per month for 2-3 hours. When asked if he was the Director of Pharmaceutical Services and responsible for all pharmacy services at the hospital, he stated that he was not aware of this.

Based on record review and interview, the hospital failed to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed (review 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, Title 46 Professional and Occupational Standards, Part LIII Pharmacist, Chapter 15 Hospital Pharmacy, Section: 1511: Prescription Drug Orders, Item 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 the hospital policy titled, Automated Medication Dispensing System, revealed in part that any new admit can be entered as an ad hoc patient to gain access to medications required to treat the immediate needs of the patient.

Review of the hospital policy titled, New Medication Order Handling, revealed that after a physican has written a medication order, a copy is faxed to the pharmacy. The pharmacist will add this medication to the patient's profile and will review for any possible drug interactions or food and drug interactions with previously ordered medications.

Review of the hospital's Dispensing Pharmacy Agreement with Pharmacy A revealed no documented evidence that first dose reviews would be performed.

Review of the contract with the Consultant Pharmacist, S8Pharmacist, revealed no documented evidence that first dose medication reviews would be performed.

On 10/22/18 at 11:20 a.m., interview with S7LPN revealed that the hospital did not have an on-site pharmacy. She indicated when an initial dose of a new medication (that was not an emergent medication) was ordered for a patient, the order is faxed to Pharmacy A. S7LPN stated that if the medication profile is not loaded in the automated med cart when it is time to administer, the staff can "over-ride" in order to remove the medication from the cart. S7LPN confirmed that the medication is administered prior to pharmacy review.

On 10/23/18 at 10:20 a.m., interview with S9LPN revealed that if she gets a physician order for a new medication that is not loaded in the automated med cart, she will "over-ride" in order to administer the medication to the patient. She further stated that sometimes it takes Pharmacy A a long time to profile the patients medications in the automated med cart.

On 10/24/18 at 8:40 a.m., S2DON confirmed that the nursing staff was able to "over-ride" medications in the automated med dispensing cart to administer first doses prior to pharmacy review. He further revealed that he was aware that Pharmacy A took a long time to profile medications in the automated cart and was aware that the nurses were over-riding to obtain first doses of medications prior to pharmacy review.

Based on record review, observation and interview, the hospital failed to ensure that scheduled medications were locked in a secured area as evidenced by failure of the nurses to ensure that vials of Ativan were stored securely under double lock.
Findings:

Review of the hospital policy titled, Nursing Unit Medication Dispensing Areas Inspections, revealed in part that controlled substances are stored in a double locked cabinet.

On 10/22/18 at 11:20 a.m., observation in the medication refrigerator in the medication room with S7LPN revealed 13 vials of Ativan 2mg/mL were stored in a small unlocked box in an unlocked refrigerator. At that time, S7LPN confirmed the Ativen was not double locked.

On 10/22/18 at 2:45 p.m., interview with S2DON confirmed that the Ativan vials in the medication refrigerator should be locked in the small metal box within the locked refrigerator.

Based on record review, 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 and/or unusable medications in the med cart and 2) having multi-dose vials of medications with no label indicating first puncture date.
Findings:

Review of the hospital policy titled, Nursing Unit Medication Dispensing Areas Inspections, revealed in part that all medications stored on the unit will be in date. There are no medications belonging to discharged patients on the unit.

Review of the hospital policy titled, Multi-Dose Injectables, revealed in part that all multi-dose injectables will be dated and initialed upon first use.

1) Having expired and/or unusable medications in the med cart

On 10/22/18 at 11:20 a.m., observation of the medication cart with S7LPN revealed it included the following medications:
- Linzess 145mcg bottle with a sticker indicating Patient #R1's name on it with a date of 11/08/16 on the label.
- Small plastic bag containing 20 Haldol 5mg vials with a sticker indicating Patient #R2's name with a fill date of 05/22/17.
- Two vials of Vitamin B-12 with a sticker indicating Patient #R3's name on it with an expiration date of 09/18
- One bottle of Paxil 25mg with a sticker indicating Patient #R4's name with an expiration date of 01/29/18
- One Prolixin vial 125mg that was opened with no label indicating first puncture date. Patient #R5's sticker was on the vial with a fill date of 09/06/17 and expiration date of 09/18.
- One box of Nicotine Lozenges with a sticker indicating Patient #R6's name with a fill date of 03/05/16 and expiration date of 05/17
- Two Telmisartan 40mg tabs with expiration dates of 01/18 and 02/18
- One Trazadone 50mg tab with expiration date of 09/18
- Quetiapine Fumarate ER 300mg tab with expiration date 7/11/18
- Aripiprazole 5mg tab with expiration date 09/18
- Olanzapinie 5mg tab with expiration date 09/12

Interview with S7LPN at that time revealed that the above medications belonged to discharged patients. She further confirmed that they were available for patient use.

Further review of the above medication cart revealed approximately 10 more medications that were stored in the cart with stickers on the med labels for discharged patients. S7LPN confirmed the medication cart contained multiple medications for discharged patients.

On 10/22/18 at 2:45 p.m., interview with S2DON confirmed that expired medications and discharged patient medications should not be stored in the medication cart and available for use. When asked who was responsible for checking the cart for expired and unusable medications, he stated that he was responsible.

On 10/23/18 at 9:15 a.m., interview with S8Pharmacist revealed that he checks the medication cart monthly, but does not put his hand on every medication. He stated that he mainly checks for expired medications.

2) Having multi-dose vials of medications with no label indicating first puncture date

On 10/22/18 at 11:20 a.m., observation of the medication room revealed a vial of Humulin R insulin in the medication refrigerator with no label indicating first puncture date.

Based on record review and interview, the hosptial failed to have a system in place to identify and report medication errors by failing to identify medication errors for 2 of 2 patients (Patient #6, 9) reviewed for medication administration.
Findings:

Review of the medication variance reports for the past 6 months revealed no medication errors had been identified.

Patient #6
Review of the current physician orders revealed the orders included Norvasc 5mg every day at 6:00 a.m. (ordered 10/11/18).

Review of the October 2018 MAR revealed no documented evidence that the patient received Norvasc on 10/13/18 or 10/17/18.

Patient #9
Review of the current physician orders revealed the orders included:
Prozac 60mg every day at 9:00 a.m. (ordered 10/15/18)
Lisinopril 20mg every day at 6:00 a.m. (ordered 10/17/18)

Review of the October 2018 MAR revealed no documented evidence that the patient received Prozac on 10/19/18 or Lisinopril on 10/20/18.

On 10/24/18 at 10:30 a.m., SDON reviewed the above patient's MARS and confirmed there was no documented evidence that the medications were given as ordered. S2DON stated that the above were medication errors. When asked who is responsible for reviewing the MARS for possible medication errors, he stated that the night nurses should check them. He further stated that he is not very familiar with the night nurses duties.

Based on record review and staff interview, the hospital failed to ensure there was a Radiologist appointed by the Governing Body to supervise the Radiology Services on either a full-time, part-time, or consulting basis as evidenced by having no documentation indicating the hospital had a Director of Radiology for the hospital.
Findings:

A review of the hospital's organizational chart, provided by S2DON as a current organizational chart, revealed no documentation of a Radiologist as the Director of Radiology for the hospital.

Review of the Governing Board minutes dated 04/27/18, revealed no physician had been appointed as director of the hospital's contracted radiological services.

A review of the list of credentialed physicians on the hospital's Medical Staff, provided by S3Exec/Asst. as a current list, revealed no documented evidence that a Radiologist was identified as the Director of Radiology.

Interview on 10/22/18 at 10:45 a.m. with S1Administrator confirmed that the hospital did not currently have an appointed Director of Radiology.

Based on record review and staff interview, the Hospital failed to ensure patient History and Physical examination documentation included a descriptive neurological examination indicating what tests had been performed to assess patient neurological functioning for 8 ( Patient #1, 2, 3, 4, 5, 7, 8, 9) of 10 (Patient #1 - 10) sampled patients' records comprehensively reviewed for neurological assessments. The absence of this information limits the clinician's ability to accurately diagnose the patient's condition and to provide a measure of baseline function, thereby potentially adversely affecting care.
Findings:

Review of Patient #1's History and Physical dated 8/15/18 failed to reveal the cranial nerves were assessed and the "Neuro" portion was left blank.

Review of the History and Physical "Neuro" portion for Patient #2, Patient #3, Patient #4, Patient #5, Patient #7, Patient #8, and Patient #9 revealed a check box was marked for CN (Cranial Nerves) II-XII Intact. Further review failed to reveal descriptive details of how the cranial nerves were assessed.

In an interview on 10/23/18 at 2:45 p.m., S2DON verified the cranial nerve assessment was not descriptive and lacked the methodology used for the neurological examination.

Based on record review and interview, the hospital failed to ensure each patient received a psychiatric evaluation that included an inventory of the patient's assets in a descriptive manner and not an interpretive fashion for 5 (#4, 5, 7, 8, 9) of 6 current patients reviewed for strengths/assets in the psychiatric evaluation out of a total of 10 sampled patient medical records.
Findings:

Patient #4
Review of the medical record for patient #4 revealed the patient was a 57 year old admitted to the hospital on 10/17/18 with a diagnosis of chemical dependency. Review of the Psychiatric Evaluation conducted on 10/18/18 by S16MD revealed Strength/Asset section of the Psychiatric Evaluation was left blank.

Patient #5
Review of the medical record for patient #5 revealed the patient was a 40 year old admitted to the hospital on 10/10/18 with a diagnosis of chemical dependency. Review of the Psychiatric Evaluation conducted on 10/10/18 by S15APRN revealed the only patient asset that was identified was "motivated for treatment".

Patient #7
Review of the medical record for patient #7 revealed the patient was a 55 year old admitted to the hospital on 10/07/18 with a diagnosis of chemical dependency. Review of the Psychiatric Evaluation conducted on 10/08/18 by S16MD revealed strengths/assets marked were: "support of family/friends", "capable of independent living", "motivated for treatment", and "physical health".

Patient #8
Review of the medical record for patient #8 revealed the patient was a 53 year old admitted to the hospital on 10/13/18 with a diagnosis of chemical dependency. Review of the Psychiatric Evaluation conducted on 10/14/18 by S15APRN revealed the only patient asset that was identified was "motivated for treatment".

Patient #9
Review of the medical record for patient #9 revealed the patient was a 68 year old admitted to the hospital on 10/05/18 with a diagnosis of chemical dependency. Review of the Psychiatric Evaluation conducted on 10/06/18 by S15APRN revealed the only patient asset that was identified was "motivated for treatment".

Interview on 10/23/18 at 2:45 p.m. with S2DON confirmed the strengths and assets were not individualized for each patient and did not include personal attributes that could be useful in developing a treatment plan.