HospitalInspections.org

Based on a record review and staff interview, the Critical Access Hospital failed to ensure documentation of a History and Physical examination which included a descriptive neurological examination indicating what tests were performed to assess neurological functioning for 4 (#3, #4, #16, #17) of 4 sampled patient's medical records reviewed for cranial nerve 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 the hospital's policy 1149 titled, "Neurological Assessment", revealed in part: A neurological assessment is performed on all patients at the time of admission.

Review of the hospital's pre-printed Medical History and Physical Examination form details the Cranial Nerves and the exam methods used for all twelve of the cranial nerves.

Review of Patient #3's history and physical failed to reveal a detailed cranial nerves assessment.

Review of Patient #4's history and physical failed to reveal a detailed cranial nerves assessment.

Review of Patient #16's history and physical failed to reveal a detailed cranial nerves assessment.

Review of Patient #17's history and physical failed to reveal a detailed cranial nerves assessment.

In an interview on 08/03/2022 at 8:45 a.m., S3RN Behavioral Unit Program Administrator stated the history and physical should contain a detailed assessment of the patient's cranial nerves and acknowledged Patients #3, #4, #16 and #17's history and physical did not contain a detailed cranial nerves assessment but merely listed cranial nerves with no issues.

Based on observations and interviews, the CAH failed to ensure the physical environment was maintained for the safety of the patients. This deficient practice is evidenced by: 1) failing to ensure the call bell feature worked on the patient's beds for 19 of 19 beds in the in-patient/swing-bed rooms, and 2) failing to ensure the behavioral health unit did not contain safety risks for the psychiatric patients admitted for being at risk for harm to self for 6 of 6 patient rooms.
Findings:

1) Observations on 08/01/2022 revealed the patient's hospital beds were equipped with a nurse call function on the inner and outer aspects of the head of the bed's side rails. Further observation revealed this nurse call function was not connected to the call bell system and was non-functioning.

In an interview on 08/02/2022 at 3:00 p.m., S1DON confirmed the call bell feature on the patient's beds were non-functioning for 19 of 19 patient beds.

2) Observations on 08/02/2022 at 1:40 p.m. of the behavioral unit patient rooms accompanied by S6Maintenance Director revealed the following ligature risks: Rooms a and b had metal brackets from the wall to the lower part of the desks which are potential ligature attachment points; 6 of 6 rooms had bathroom doors which meet flush with the top of the door frame and are potential ligature attachment points; and 6 of 6 rooms with open shelved cabinets which allowed access to the unsecured drop ceiling panels and ligature points above the moveable panels.

In an interview on 08/02/2022 at 2:00 p.m., S6Maintenace Director acknowledged the potential ligature attachment points.

Based on record review and interview, the CAH failed to ensure drugs and biologicals were distributed and administered in accordance with accepted professional principles as evidenced by failing to ensure that all medication orders (except in emergency situations) 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.

On 08/02/22 at 9:30 a.m., interview with S5Pharmacist revealed that the hospital pharmacy hours are Monday thru Friday from 8:00 a.m. until 4:00 p.m. S5Pharmacist stated that after pharmacy hours, contract pharmacy A reviews all medications prior to the first doses being administered. S5Pharmacist stated that the nurses know the first dose review has been performed when the medication name shows up under the patient's profile in the automated medication dispensing device. When asked if nurses were able to override the automated medication dispensing device in order to obtain the first dose of a medication prior to pharmacy review, she stated yes, but that did not happen often.

On 08/02/22 at 10:00 a.m., interview with S7LPN revealed that if a medication is not profiled under a patient's name in the automated medication dispensing device, the nurses are able to override in order to obtain the first dose of the medication for the patient, but only with a second nurse witnessing the dispensing.

On 08/02/22 at 1:00 p.m., review of the medication override report for the last 30 days with S5Pharmacist revealed it contained multiple pages of medications that had been overridden. These medications included:
Patient #10 - Order for Magnesium hydroxide dated 07/27/22 at 8:27 a.m., administered at 9:13 a.m., reviewed by pharmacist at 9:31 a.m.;
Order for apixaban dated 07/27/22 at 8:27 a.m., administered at 9:13 a.m., reviewed by pharmacist at 9:21 a.m.
Patient #10 - Order for Phos-NaK dated 07/31/22 at 7:46 a.m., administered at 9:03 a.m., reviewed by pharmacist at 9:29 a.m;
Order for lactulose dated 07/31/22 at 5:49 p.m., administered at 9:40 p.m., reviewed by pharmacist at 9:53 p.m;
Order for megestrol acetate dated 07/31/22 at 5:50 p.m., administered at 9:39 p.m., reviewed by pharmacist at 9:53 p.m.

Review of the Pharmacy Services Agreement with contracted Pharmacy A revealed Pharmacy A staff shall review and enter all medication Order Lines into Customer's hospital pharmacy information system with an average turnaround time of sixty (60) minutes for routine Order Lines, and an average turnaround time of fifteen (15) minutes for stat Order Lines.

On 08/02/22 at 3:20 p.m., an interview with S5Pharmacist confirmed the above medications were first dose routine orders and should have been reviewed by a pharmacist prior to administration.

Based on observation and interview, the CAH's infection prevention and control program failed to ensure a clean and sanitary kitchen environment was maintained to prevent potential transmission of infection by having uncovered scoops stored inside ice and dry food bins.

Findings:

On 08/01/2022 at 2:50 p.m., observation of the kitchen revealed an uncovered scoop was stored inside the ice machine with the ice in very close proximity to the scoop. Further observation of the food storage areas in the kitchen revealed storage bins containing sugar, flour, meal, beans and rice had uncovered scoops laying directly on top of the food product in the bins.

In an interview at this time, S4DM confirmed that the ice and food scoops should not be in contact with the ice and food products and should be placed in covered containers outside the storage containers.