HospitalInspections.org

Based on record review and interview, the hospital failed to ensure that the governing body implemented and monitored policies for the hospital's total operation and for ensuring policies were administered so as to provide quality health care in a safe environment.


Findings:


Review of the hospital's Governing Body Bylaws revealed in part:
Article VII. Administration

The board shall appoint a CEO (Chief Executive Officer) of the hospital who shall serve as the administrator and shall be responsible for the day-to-day operation of the Hospital, shall be responsible for the realization of quality..

7.2 Authority and Duties
The authority of the CEO shall include the responsibility for carrying out all policies as established by the board; Establishing, reviewing and where appropriate, adjusting charges within the policies established by the Board.


Review of the hospital Performance Improvement/Quality Assurance Plan revealed in part:
In an effort to meet the goals, the hospital will develop and initiate an ongoing performance improvement program designed to objectively and systematically monitor and evaluate the quality and appropriateness of patient care, pursue opportunities to improve patient care, and resolve identified problems.


Review of the Quality Assurance (QA) Binder for the hospital with S2DON revealed no data had been collected from the various departments of the hospital to track, trend and analyze for performance improvement since June 2014 (limited data collected for 6/14 but not trended and analyzed).


Review of the hospital policy titled Scope of Service, Department: Emergency Room- Nursing Service, Number: 5, Revised 2/08, revealed in part:
Staffing: 2 RN's (Registered Nurse), 1 LPN (Licensed Practical Nurse) and 1 CNA (Certified Nursing Assistant)


Review of the staffing schedules for the hospital (Emergency Department and Inpatient Unit) with S4Compliance revealed that on 12/19/14 an agency Registered Nurse (RN) worked from 11 p.m. until 7a.m. with a Licensed Practical Nurse (LPN). Further review revealed she was the only RN in the hospital and it was her first shift at the hospital and she had no previous Emergency Department (ED) experience. Further review of the staffing schedules revealed the following:

12/10/14- 1 agency RN (1st shift worked at the hospital) and 2 LPNs from 7 a.m. - 7 p.m.
12/12/14- 1 RN and 1 LPN from 7 a.m. - 7 p.m.
12/25/14- 1 agency RN with 1 CNA from 7 p.m. - 7 a.m.


Review of documentation provided by the hospital revealed there was no organized infection control program and the infection control officer was not qualified.


In an interview on 2/10/15 at 10:37 a.m. with S1CEO, he verified the hospital policies were approved annually but not reviewed for accuracy. S1CEO also agreed there was no organized QA program or infection control program at the hospital. S1CEO said there were several shifts where there was only one RN working at the hospital but there was no alternative because several of the staff had quit at one time.

Based on observations, records review and interviews, the hospital failed to meet the requirements of the Condition of Participation of the Provision of Services as evidenced by:


1. Failing to implement a hospital wide infection control program (see findings tag C-0278); and


2. Failing to ensure the hospital's Infection Control Officer (S6Infection Control) was trained and/or experienced in infection control practices (see findings tag C-0278)

Based on record review and interview, the hospital failed to ensure that health care services were furnished in accordance with appropriate written policies. This deficient practice is evidenced by hospital policy requiring two Registered Nurses per shift but staffing the Hospital with one Registered Nurse (RN) on 4 separate shifts resulting in a Registered Nurse being shared between the inpatient unit and the Emergency Department of the hospital.


Findings:


Review of the hospital policy titled Staffing Patterns, Emergency Room, Number: 15, Revised 8/04, revealed in part:

The Emergency Room is staffed by 1 Registered Nurse (RN) 24 hours a day 7 days a week.
The Emergency Room Nurse has the assistance of another Registered Nurse at a minimum. A Licensed Practical Nurse (LPN) and Nurse Aide (CNA) are on duty for assistance as census dictates.


Review of the hospital policy titled Scope of Service, Department: Emergency Room- Nursing Service, Number: 5, Revised 2/08, revealed in part:

Staffing: 2 RN's, 1 LPN and 1 CNA.


Review of the staffing schedules for the hospital (Emergency Department and Inpatient Unit) with S4Compliance revealed the following:

12/10/14- 1 agency RN (1st shift worked at the hospital) and 2 LPNs from 7a.m. - 7p.m.
12/12/14- 1 RN and 1 LPN from 7:00 a.m. - 7:00 p.m.
12/19/14- 1 agency RN (1st shift worked at the hospital) 11 p.m. - 7a.m. with 1 LPN.
12/25/14- 1 agency RN with 1 CNA from 7p.m. - 7a.m.


In an interview on 2/6/15 at 10:00 a.m., with S2DON, she said there were several shifts when there was one RN working in the hospital although there should have been at least two working. S2DON also said it was difficult to determine who worked on certain days before 12/15/14 because the previous DON did not keep staffing schedules beyond the month. S2DON also said staffing with an agency nurse as the only RN in the hospital when it was their first shift was unacceptable.

Based on record review and interview, the hospital failed to ensure policies and procedures were reviewed and revised annually as evidenced by the governing body approving three separate hospital policies dictating staffing patterns that contained different staffing requirements.


Findings:


Review of the hospital's Governing Body Bylaws revealed in part:
Article VII. Administration

The board shall appoint a CEO (Chief Executive Officer) of the hospital who shall serve as the administrator and shall be responsible for the day-to-day operation of the Hospital, shall be responsible for the realization of quality..

7.2 Authority and Duties
The authority of the CEO shall include the responsibility for carrying out all policies as established by the board; Establishing, reviewing and where appropriate, adjusting charges within the policies established by the Board.


Review of the hospital policy titled Staffing Patterns, Emergency Room, Number: 15, Revised 8/04, revealed in part:

The Emergency Room is staffed by 1 Registered Nurse (RN) 24 hours a day 7 days a week.
The Emergency Room Nurse has the assistance of another Registered Nurse at a minimum. A Licensed Practical Nurse (LPN) and Nurse Aide (CNA) are on duty for assistance as census dictates.


Review of the hospital policy titled Scope of Service, Department: Emergency Room- Nursing Service, Number: 5, Revised 2/08, revealed in part:

Staffing: 2 RN ' s, 1 LPN and 1 CNA


Review of the hospital policy titled Nursing Service, Scope of Service: Age/Complexity of Patients Served, read in part:

Staffing: 2 RN ' s (one assigned to the medical floor and one assigned to the ER), 1 LPN, and 1 CNA (day shift only and per patient load).


In an interview on 2/6/15 at 1:45 p.m., with S2DON, she said the hospital policies were to be reviewed annually and updated but they had obviously not been updated.


In an interview on 2/10/15 at 10:37 a.m., with S1CEO, he said that the hospital policies and procedures were approved annually, but the hospital policies were not read and reviewed annually for accuracy. He said the staff assumed if the policies had been approved the year before they were accurate.

Based on observation and interview, the hospital failed to ensure drugs and biologicals were stored and maintained in a secured area as evidenced by having medications in an unlocked and unsupervised room that was accessible to the public.


Findings:


Observation of the hospital's Medication Room on 02/06/15 at 11:00 a.m. revealed a room with the door propped open with door stopper which contained an unlocked 6 drawer medication cart.


Drawer #5 of the cart contained the following:
28 Tylenol 325mg (milligrams) caplet.
117 Ibuprofen 200mg tablet.
6 Mag-AL- Plus (Magnesium -Aluminum) 30ml (milliliters).
34 Loperamide (Imodium) HCL 2mg.
6 Bacitracin Ointment 19 grams.
24 Simethicone 80mg chewable tablets.


In an interview on 02/06/15 at 11:00 a.m., S7RN confirmed the door to the medication room was left unlocked and the medications were not secured.


In an interview on 02/06/15 at 11:30 a.m., S2DON confirmed the medications in the cart were accessible to the public and not secured.

Based on record review, interviews and observations, the hospital failed to ensure that there was a system in place for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel as evidenced by:


1) Failing to implement a hospital wide infection control program.


2) Failing to ensure the hospital's Infection Control Officer (S6Infection Control) was trained and/or experienced in infection control practices;


3) Failing to maintain a sanitary physical environment;


4) failing to ensure that staff practiced universal precautions by staff wearing dirty gloves in the hallway.


Findings:


1). Failing to implement a hospital wide infection control program


Review of the hospital's Infection Control data revealed no evidence to indicate that the hospital was tracking, trending and/or investigating infections. In addition, there was no evidence to indicate the hospital had a system in place to monitor infection control practices and implement corrective action once breaches had been identified.


In an interview on 02/09/15 at 11:00 a.m., the Infection Control Coordinator (S6Infection Control) verified there was no effective system in place to track, trend and investigate infections and/or to monitor infection control practices and implement corrective action once breaches were identified.


In an interview on 02/10/15 at 10:30 a.m., S1CEO confirmed that there was no effective infection control program at the hospital.


2) Failing to ensure the hospital's Infection Control Officer (S6Infection Control) was trained and/or experienced in infection control practices.


Review of the Infection Control Coordinator's personnel file revealed S6Infection Control was hired as a staff nurse in July of 2011 and appointed as the Interim Infection Control Coordinator in December of 2013. Review of the job description for Infection Control Coordinator revealed the following information:

Duty hours: 8 hours per week for duty of hours or more if necessary.

Education: Formal education in Infection Control such as APIC (Association for Professionals in Infection Control) conferences.

Experience: One year experience in Infection Control and Employee Health.
The last page of the job description was noted to be signed/dated by S6InfectionControl on 08/29/14 and S1CEO (Chief Executive Officer) on 01/16/15.


In an interview on 02/09/15 at 11:00 a.m., S6Infection Control indicated she was appointed as Interim Infection Control Coordinator in December of 2013.

S6Infection Control reported that she had no prior experience, training and/or education specific to running an infection control program at a hospital. S6InfectionControl reported that she learned about infection control on her own but had no documentation of the education. S6InfectionControl reported that she attended an APIC conference but was unable to recall the date and had no documented evidence of attendance.

S6InfectionControl indicated the hospital's administrative staff informed her that her appointment as Infection Control Coordinator was temporary and would continue until a replacement was found.

S6InfectionControl reported that she had not signed a job description for being an infection control nurse so she was not aware of her duties and responsibilities as the Infection Control Coordinator. S6InfectionControl indicated that she accessed the job description from the hospital's website in order to find out the amount of time to allocate for infection control duties.

S6InfectionControl indicated she was not aware of the hospital's policies/procedures relative to infection control and had printed policies from the hospital's website after the first day of this survey.

S6InfectionControl reported that she was not aware of how to properly identify, report, investigate and/or control infections and communicable diseases of patients and personnel.

S6InfectionControl indicated she was not aware if the hospital had an Infection Control Committee. S6InfectionControl reported that she currently had not been allocated any time for her infection control duties due to staff shortages.


In an interview on 02/09/15 at 1:00 p.m., S6InfectionControl indicated that she had apparently signed a job description as the infection control nurse during her annual evaluation but was not aware it was a job description for that position.


In an interview on 02/10/15 at 10:30 a.m., S1CEO confirmed that S6InfectionControl was appointed as the interim Infection Control Coordinator in December of 2013. S1CEO confirmed that S6Infection Control had no prior experience, training and/or education in Infection Control. S1CEO confirmed that the hospital had only one Infection Control meeting since her appointment and due to the Nursing shortage S6InfectionControl had not been allotted time to perform her duties.


3) Failing to maintain a sanitary physical environment.

Observation of the hospital on 02/06/15 at 10:30 a.m., revealed 2 bags of trash on the floor in the hallway (acute area) next to a patient's room. The bags were manually tied with a hole noted on the side of one of the bags. Further observation revealed an area across from where the bags were located with two separate piles of trash against the wall. In one pile of trash a folded 4 x 4 was noted with visible blood approximately the size of a quarter and paper, plastic and food particles were noted in both piles along with dust and dirt particles. S2DON confirmed the observation.


An observation on 02/06/15 at 10:30 a.m., revealed a dirty suction tubing with rigid tip connected to a suction canister in a clean room. The suction tubing was noted to be dark purple in color.

In an interview on 02/06/15 at 10:30 a.m., S2DON confirmed the room had been cleaned and ready for admission of a patient. She indicated the suction catheter appeared to be dirty and should not have been left in the room nor should it have been connected to the canister.


An observation of the clean supply room on 02/05/15 at 10:30 a.m. revealed a boxed fan with visible matted gray matter on the blades and frame. S2DON confirmed the observation.


4) Failing to ensure that staff practiced universal precautions by staff wearing dirty gloves in the hallway.

Observation on 02/06/15 at 11:00 a.m., revealed S9Housekeeping exiting a patient room with gloves on and a mop in her hand. S9Housekeeper placed the mop on the housekeeping cart, walked around the corner and accessed a keypad lock to the IV (intravenous) room with the gloves on and then removed the gloves after entering the room. S7RN confirmed that S9Housekeeper had failed to remove her gloves after cleaning a patient room and accessed the keypad to the IV room with dirty gloves.

31206


Based on record review and interview, the hospital failed to ensure that the nursing care was provided in accordance with the specialized qualifications and competence of the nursing staff as evidenced by:

1) assigning a Registered Nurse (RN) from an agency with no Emergency Department (ED) experience as the only RN in the hospital;

2) failing to ensure that an ED assessment was performed by a RN;

3) failing to ensure all Registered Nurses working in the hospital had current training in Advanced Cardiac Life Support (ACLS), Pediatric advanced Life Support, and Cardiopulmonary Resuscitation (CPR) for 12 ( S13RN, S14RN, S15RN, S16RN, S17RN, S18RN, S19RN, S20RN, S21RN, S22RN, S23RN, S24RN) of 20 registered nurses employed at the hospital.


Findings:


1) Assigning a Registered Nurse (RN) from an agency with no Emergency Department (ED) experience as the only RN in the hospital.

Review of the staffing schedules for the hospital (Emergency Department and Inpatient Unit) with S4Compliance revealed the following:

12/19/14- Agency RN #1 (1st shift worked at the hospital) worked from 11 p.m. - 7 a.m. with 1 Licensed Practical Nurse (LPN).


Review of payroll with S4Compliance revealed the night shift (7 p.m. - 7 a.m.) on 12/19/14 was the first shift Agency RN #1 had worked at the hospital.


In an interview on 2/10/15 at 1:53 p.m., with Agency RN #1, she said that she worked for Staffing Agency "A" . She said she worked her first shift at the hospital on 12/19/14 and was the only RN in the hospital from 11:00 p.m. to 7:00 a.m. She said she is not an emergency room nurse and she was over the emergency room from 11:00 p.m. until 7:00 a.m. on 12/19/14. She said she did not have ACLS or PALS. She said her orientation consisted of being shown around the unit an hour before her shift. She also said she did not have access to narcotics in the medication dispensing machine.


2) Failing to ensure that an ED assessment was performed by a RN.


Review of the hospitals Policy & Procedure titled Triage presented by S2DON as being current (revised 2005) read in part: The assigned emergency room nurse or her designee (RN only) is to perform all triage assessments and acuity level for patients that present for emergency services.


Review of Patient #5's ED record revealed a 53 year old female, who presented to the hospital's ED on 01/27/15 at 4:01 p.m. with the chief complaint of Sore throat. The triage nurse documentation read in part: "Triage nurse (S13RN) (as written); triage start date/time 19:11 (7:11 p.m.); patient arrived at 01/27/15 16:01 (4:01 p.m.)." Triage assessment & vital signs were electronically documented by S8LPN. Patient #5 was discharged from the CAH's ED at 17:15 (5:15 p.m.) on 01/27/15.


Review of the Nursing Schedule for the date of 01/27/15 revealed S13RN worked from 7 p.m. - 7 a.m.


A written document presented by S4Compliance revealed a list of the Nursing Staff who worked on 01/27/15 with the time each staff member clocked in and out for time worked. Review of this document revealed S13RN worked from 18:49 on 01/27/15 till 07:25 on 01/28/15.


In an interview on 02/10/15 at 4:00 p.m., S2DON confirmed the triage assessment was initiated and completed by S8LPN and S13RN was not on duty at the time that Patient#5 was treated in CAH's ED. S2DON indicated the CAH's policy was not followed; only RNs are to perform triage assessment and assign acuity level.


3) Failing to ensure all Registered Nurses working in the hospital had current training in Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support, and Cardiopulmonary Resuscitation (CPR).


Review of the hospital policy titled Provision of Patient Care, Revised 2011, revealed in part:
West Feliciana Parish Hospital is a 22 bed general/acute care hospital providing the following services: ACLS (Advanced Cardiac Life Support) /PALS (Pediatric Advanced Life Support) /TNCC (Trauma Nursing Care Course) Certified Nursing Staff.


Review of a list provided by S2DON of certifications of the RNs at the hospital revealed the following certifications were not current:

ACLS: S15RN
PALS: S13RN, S16RN, S17RN, S18RN, S19RN, S20RN, S21RN, S22RN, S23RN, 24RN
CPR: S14RN


In an interview on 2/10/15 at 8:44 a.m., with S2DON, she verified the above mentioned registered nurses did not have the current required certifications as listed.

Based on record review and interview, the hospital failed to meet the Condition of Participation for Periodic Evaluation and QA (Quality Assurance) Review by failing to have an effective hospital wide Quality Assurance (QA) Program. This deficient practice is evidenced by the hospital's failure to track, trend, and analyze indicators from each department of the hospital or identify problems relative to performance improvement (see findings tag C-0336).

Based on record review and interview, the hospital failed to have an effective Quality Assurance (QA) Program as evidenced by failing to track, trend, and analyze indicators from each department of the hospital or identify problems relative to performance improvement.


Findings:


Review of the hospital Performance Improvement/Quality Assurance Plan revealed in part:


In an effort to meet the goals, the hospital will develop and initiate an ongoing performance improvement program designed to objectively and systematically monitor and evaluate the quality and appropriateness of patient care, pursue opportunities to improve patient care, and resolve identified problems.


The FOCUS-PDCA Model shall be applied when opportunities for improvement are identified.

F- Find an opportunity;
O- Organize a team;
C- Clarify the current processes;
U- Understand the root causes;
S- Select the improvement process.

P- Plan the change;
D- Do test (carry out change);
C- Check analysis of data;
A- Act to implement changes.


Goals and Objectives:

A. Assure that the highest achievable quality of patient care is delivered throughout the hospital.

The Performance Improvement Council shall meet on a quarterly basis at the Medical Executive Committee and shall maintain a record of its proceedings and activities. The minutes shall reflect conclusions, recommendations, and advisors representing other departments as appropriate.

C. Responsibilities:

The Performance Improvement Council Shall:

3. Assist in the development of screening mechanisms and review of outcomes of monitoring and evaluation activities to include but not limited to:

Staffing variances, Patient Safety, Surgical Case Review- Endoscopic and Tissue review, Transfusion/Blood utilization Review, Drug Utilization Review, Mortality/Morbidity Review, Utilization Review, Medical Records Review, swing Beds Regulations, Transfer Process, Patient satisfaction and unexpected outcomes.

4. Review findings of Performance Improvement activities by committees including but not limited to:

Pharmacy and Therapeutics, Safety/Disaster/Risk Management, Infection Control, Emergency Care Services, Leadership, Medical Record Review.


Review of the Quality Assurance Binder for the hospital with S2DON revealed no data had been collected from the various departments of the hospital to track, trend and analyze for performance improvement since June 2014 (limited data collected for 6/14 but not trended and analyzed).


Review of the Performance Improvement Committee Meeting Minutes dated 4/22/14 and 6/24/14 revealed the only topics discussed were patient satisfaction, employee satisfaction, communication between staff, the billing process, dietary (scanning staff badges instead of having a meal ticket), and obtaining a new glucometer.


Review of the Performance Improvement Committee Meeting Minutes dated 9/9/14 revealed the only topics discussed was patient satisfaction, employee satisfaction, communication between staff and new glucometers.


In an interview at 2/6/15 at 10:00 a.m. with S2DON, she said she was not sure who was over the Performance Improvement program. S2DON also verified the facility did not currently have endoscopy capabilities which were listed in the Quality Assureance plan to be reviewed.


In an interview on 2/6/15 at 3:41 p.m. with S4Compliance, she said there was no organized meeting of the QA committee since September 2014 and no data had been trended or analyzed. She verified there were no indicators for any department in the hospital and no identified or potential problems were being tracked, trended and analyzed for performance improvement.


In an interview on 2/10/15 at 8:32 a.m. with S2DON, she verified there was not an effective performance improvement program at the hospital. She said there was no universal system that incorporated all departments of the hospital.

Based on record review and interview, the hospital failed to ensure the effective implementation of a quality assurance program that included the collection and analyzing of data relative to hospital acquired infections and medication therapy.


Findings:


Review of the hospital's Policy titled CDC Definitions for Health-Care Associated Infection Infections/Surveillance/Hospital Wide presented by S6InfectionControl as being current (12/07) read in part:

Health Care Associated Infection surveillance data is collected prospectively and retrospectively by the Infection Control Nurse. Total House Surveillance will be carried out to monitor Health Care Associated Infections. The rationale for selecting this specific surveillance approach is: to identify infection that are high volume. To identify device related infections. By implementing these indicators, record on all HEALTH-CARE-ASSOCIATED-INFECTION in every area of the hospital are recorded. The results are collected and compared to aggregate results throughout the year to help identify a trend. In addition this information may be used to monitor priority-directed, targeted surveillance, problem oriented surveillance and to assist in the development of performance, focused standard and for health care workers education.


Review of the infection control data presented by S6InfectionControl as collection data for Quality Review revealed a section (12 columns divided into months for 2014) titled # of health-care assoc.(associated) infections. The numerical digit "0" was recorded for each of the last 12 months (2014). There was no documentation to indicate that medication therapy was being evaluated.


Review of the Quality Assurance (QA) meeting minutes revealed the last meeting was held on 09/09/14 with no documented evidence that the Infection Control data was reported and evaluated through the QA Program.


In an interview on 02/09/15 at 11:00 a.m., S6InfectionControl confirmed that the columns on the above mentioned document contained "0". S6Infection Control indicated that data relative to hospital acquired infections is not being collected and analyzed by the hospital. S6Infection Control confirmed the hospital had no documented evidence of data being collected for medication therapy.


In an interview on 02/09/15 at 1:00 p.m., S2DON, after reviewing of the Quality Review data, confirmed the hospital had no system in place for the collection and analyzing of hospital acquired infections or medication therapies.