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Based on record reviews and interviews, the CAH failed to ensure services were furnished in accordance with written policies as evidenced by:
1) Failure to document the investigation of a grievance and to submit a resolution response to the complainant for 1 (#3) of 1 grievance reviewed.
2) Failure to include in the current policy for patient passes or leaves the process the nursing staff was to implement to assure patient care was provided during the time the patient was off-site for a medical appointment. This resulted in a patient being left off-site after a medical appointment without transportation for more than 3 hours without needed assistance with toileting and no lunch provided for 1 (#3) of 2 (#2, #3) patient records with an off-site medical appointment from a sample of 5 patients.
Findings:

1) Failure to document the investigation of a grievance and to submit a resolution response to the complainant:
Review of the policy titled "Patient Complaint & (and) Patient Grievance Resolution Process", presented as a current policy by S2CQO, revealed that a patient grievance was defined as a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care when the complaint is not resolved at the time of the complaint by staff present. Grievances will be acknowledged in writing. Following investigation a follow up letter will be sent within 15 working days of becoming aware of the grievance. Grievances are documented via complaint form or through the hospital internet site and forwarded to the Director of Quality Resources or member of the Executive team. The Executive team will serve as the Grievance Committee to review and resolve the grievance. The Director of Quality resources will promptly inform the patient and/or the patient's representative of the procedure for review, investigation, and resolution of the grievance. In the event a grievance is not promptly resolved, the Director of Quality resources will provide an update and inform the patient or the patient's representative that the hospital is still working to resolve the grievance and will follow-up with a written response as soon as possible and give an estimated number of days. The resolution of the grievance will be provided to the patient by written notice. This written notice will contain contact information to the Director of Quality and/or the Chief Executive Officer, steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. The grievance is considered resolved when the patient is satisfied with the actions taken on their behalf or when the hospital has taken appropriate and reasonable actions on the patient's behalf in order to resolve the patient's grievance.

Review of the "Complaints & Grievances" list from 05/01/17 to 09/17/17, presented by S3CQO, revealed the list did not designate whether the patients listed had a complaint or a grievance. Further review revealed Patient #3's grievance listed the department involved as Case Management, the reason for the event was transport to clinic appointment off campus, whether resolved was answered "Yes", and the column for written response was blank.

Review of the "Complaint Resolution Form: Administration", presented by S3CQO after a request was made to view grievances received from 05/01/17 to 09/17/17, revealed the complaint was documented as Patient #3 had an appointment in Laplace, Louisiana, and Company A picked him up for at 10:00 a.m. for an 11:00 a.m. appointment. Further review revealed Patient #3 was finished with his appointment about 12:00 p.m. As of 2:45 p.m., he had not been picked up by Company A. Further review revealed patient #3 did not have lunch, and his daughter had to get someone to assist her to help him to the bathroom several times, because he was so weak. Documentation revealed that Patient #3's daughter was told that the driver with Company A had gone to Baton Rouge to get another patient and was not available, so the company would have to get a van from Slidell. Further review of the documentation revealed that S10LCSW documented that the driver with Company A could not pick up the patient due to his home being flooded. S10LCSW called Company A three times and spoke with a manager and a dispatcher. The manager informed S10LCSW that there was no driver available, and he had to have a driver come from Slidell to pick up Patient #3. S10LCSW documented that Patient #3 was soiled upon his arrival to the hospital, and he cleaned immediately and provided lunch. Further review revealed S3CQO documented that she discussed the grievance with S2CNO who spoke with the patient's family before discharge. S2CNO was currently working on a patient/family expectation guide for when a patient has a physician appointment outside the hospital campus. Discussions were planned with Administration related to other transportation strategies. The family's role and when a staff member may need to escort the patient will also be addressed in the guide. There was no documented evidence that a resolution letter was sent to Patient #3's daughter.

Review of documentation by S2CNO dated 05/19/17 revealed that she met with Patient #3's daughter and son regarding the above event. At the time Patient #3's daughter questioned why her father was "lowered to the floor" the night he was trying to get out of bed and voiced complaints that his care was delayed because his medication wasn't right, and he wasn't able to participate in therapy, the they didn't see the doctor every day, and that a family member was told not to stay with the patient, because it made him more confused. Further review revealed S2CNO documented that she reviewed the medical record, debriefed with staff members, received feedback on the issues stated above, and created an action plan for process improvement. There was no documented evidence presented of the interviews conducted and an investigation of all issues voiced by Patient #3's daughter.

In an interview on 0-9/18/17 at 3:30 p.m. with S2CNO and S3CQO, S3CQO indicated when they get a patient or family complaint, if they are able to resolve it at the time, it remains a complaint. She further indicated if they're not able to resolve it at the time the complaint is made, it becomes a grievance. She indicated when they first got the information, it was reported that Company A picked him up, and he had not had lunch and was soiled upon his return to the hospital. S2CNO indicated when Patient #3 returned, he and his daughter were really upset. The daughter began to complain about his care. S3CQO confirmed she did not send a resolution response to Patient #3's daughter.

In an interview on 09/21/17 at 10:46 a.m. with S2CNO and S3CQO, S2CNO indicated she met with Patient #3's daughter before the patient left. The daughter reported that someone had said someone told them they shouldn't stay with the patient. S2CNO indicated she asked the nurses about this. She did a review of the record and brought it to the quality meeting. One of the action plans was to create the brochure that addressed the expectations for off-site appointments. S2CNO presented documentation of her investigation. She confirmed she didn't document any interviews with staff and had no documentation of an investigation of all issues discussed during her meeting with Patient #3's daughter (listed above). S2CNO confirmed the grievance process was not implemented in accordance with hospital policy.

2) Failure to include in the current policy for patient passes or leaves the process the nursing staff was to implement to assure patient care was provided during the time the patient was off-site for a medical appointment. This resulted in a patient being left off-site after a medical appointment without transportation for more than 3 hours without needed assistance with toileting and no lunch provided for 1 (#3) of 2 (#2, #3) patient records with an off-site medical appointment from a sample of 5 patients.

Review of the policy titled "Patient Passes Or Leaves", presented as a current policy by S9RN, revealed patients admitted to the hospital are permitted to leave the hospital on a therapeutic pass only upon the written order of their physician to go to a physician's office or another facility for diagnostic tests or treatment requiring care pertinent to the patient's skilled treatment plan. Transportation of the patient on pass is the responsibility of the patient and/or family. Wheelchair van accommodations will be set up by the hospital upon recommendation by occupational/physical therapy for transport. A family member of the patient must accompany the patient to the appointment.

Review of patient #3's medical record revealed he left for an off-site medical appointment with S12MD on 05/12/17 at 10:15 a.m. and returned at 3:24 p.m. Review of a grievance documented revealed Patient #3 was in a diaper and had to use the rest room several times, and his daughter had to get someone to assist her, because he was so weak. Further review revealed did not have lunch, so someone from another facility had to get him some lunch. When he returned to the hospital at 3:24 p.m., it was documented that he had to be bathed, and lunch was provided.

Review of the pamphlet titled "Home away from Home Skilled Care, Close-to-Home", presented as the newly developed pamphlet by S2CNO on 09/21/17 at 10:46 a.m., revealed "if you need to follow-up with a specialist during your stay, we will schedule appointments and help you coordinate transportation. There was no documented evidence that the pamphlet addressed any information related to how assistance with toileting and meals would be provided during the time that the patient was off-site.

In an interview on 09/18/17 at 3:30 p.m., S2CNO indicated they had a pamphlet created after this event to give to skilled patients about how off-site appointments would be handled. She further indicated they had discussions with administration and staff, but the current policy was not revised, and no new policy was developed that addressed how patient care would be provided during off-site medical appointments.

Based on record reviews and interviews, the CAH failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:
1) The RN failed to assess each patient prior to delegating the care of the patient to a LPN in accordance with the LSBN's "Administrative Rules Defining RN Practice LAC46:XLVII" for 1 (#3) of 5 (#1 - #5) patient records reviewed for RN supervision of care from a sample of 5 patients.
2) The RN failed to assess a patient upon the patient's return to the hospital after an off-site medical appointment for 2 (#2, #3) of 2 patient records reviewed for patients having an off-site medical appointment from a sample of 5 patients.
Findings:

1) The RN failed to assess each patient prior to delegating the care of the patient to a LPN:
Review of the Louisiana State Board of Nursing's "Administrative Rules Defining RN Practice LAC46:XLVII" revealed, in part, "3703. Definition of Terms Applying to Nursing Practice ... Delegating Nursing Interventions - ... The registered nurse retains the accountability for the total nursing care of the individual. ... The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. The assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required. a. Any situation where tasks are delegated should meet the following criteria: i. the person has been adequately trained for the task; ii. the person has demonstrated that the task has been learned; iii. the person can perform the task safely in the given nursing situation; iv. the patient's status is safe for the person to carry out the task; v. appropriate supervision is available during the task implementation; vi. the task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all. b. The registered nurse may delegate to licensed practical nurses the major part of the nursing care needed by individuals in stable nursing situations, i.e. (that is), when the following three conditions prevail at the same time in a given situation: i. nursing care ordered and directed by R.N./M.D. (medical doctor) requires abilities based on a relatively fixed and limited body of scientific fact and can be performed by following a defined nursing procedure with minimal alteration, and responses of the individual to the nursing care are predictable; and ii. change in the patient's clinical conditions is predictable; and iii. medical and nursing orders are not subject to continuous change or complex modification...".

Review of Patient #3's "Patient Progress Notes" revealed his nursing care was provided by a LPN on the day shift (7:00 a.m. to 7:00 p.m.) of 05/12/17, on the night shift (7:00 p.m. on 05/12/17 to 7:00 a.m. on 05/13/17) of 05/12/17, and on the day shift of 05/13/17 (7:00 a.m. to 7:00 p.m.) with no documented evidence of an assessment by a RN to determine if Patient #3's medical condition was such that his care could be delegated to a LPN.

In an interview on 09/21/17 at 11:12 a.m., S3CQO confirmed Patient #3 was cared for by a LPN on 05/12/17 and 05/13/17 without having a RN assess him prior to delegating the care to a LPN.

2) The RN failed to assess a patient upon the patient's return to the hospital after an off-site medical appointment:
Review of the policy titled "Patient Passes Or Leaves", presented as a current policy by S9RN, revealed that documentation included assessment of the patient prior to leaving the hospital, the date and time the patient leaves on pass, the date and time the patient returns to the hospital, and any changes in the patient's condition upon return.

Patient #2
Review of Patient #2's "Patient Progress Notes", revealed an entry on 08/18/17 at 4:50 p.m. by S10LCSW that she scheduled Patient #2 for an off-site appointment with the surgeon on 08/24/17.

Review of Patient #2's medical record revealed an entry on 08/24/17 at 12:00 p.m. by S8LPN that Patient #2 was off the unit via w/c. Further review the next entry was at 1:30 p.m. by S8LPN of the intravenous assessment and at 1:35 p.m. that Patient #2's side rails were up, the bed was in a low position, and the bed was locked. There was no documented evidence that Patient #2 was assessed upon his return from the off-site visit, and there was no documented evidence of the time of his return.

In an interview on 09/21/17 at 10:44 a.m., S8LPN confirmed she didn't document the time that Patient #2 returned to the hospital from his off-site appointment. She indicated she "absolutely" should have documented it.

In an interview on 09/21/17 at 11:08 a.m., S3CQO confirmed there was no documented assessment of Patient #2 by the nurse upon his return from his off-site appointment on 08/24/17.

Patient #3
Review of Patient #3's "Patient Progress Notes" documented on 05/12/17 at 10:15 a.m. by S8LPN revealed that he left the unit via w/c with Company A (for an off-site medical appointment). Further review revealed S8LPN documented at 3:24 p.m. that Patient #3 was back to the unit with Company A, was placed in his room, changed and bathed, and Xanax administered for signs of anxiety. There was no documented evidence of an assessment by the nurse upon his return from the off-site medical appointment.

In an interview on 09/21/17 at 11:12 a.m., S3CQO indicated S8LPN did not document an assessment of Patient #3 when he returned from the off-site medical appointment on 05/12/17.

Based on record reviews and interview, the CAH failed to ensure all drugs were administered in accordance with written and signed orders as evidenced by failure to administer medication ordered at bedtime due to the medication not being available for 1 (#5) of 5 (#1 - #5) patient records reviewed for medication administration from a sample of 5 patients.
Findings:

Review of Patient #5's medical record revealed she was admitted on 09/14/17 with diagnoses of CVA and Debility. Review of her physician orders revealed an order on 09/14/17 at 8:00 a.m. for Primidone 100 mg per PEG at bedtime.

Review of Patient #5's MAR revealed Primidone 100 mg was not administered on 09/15/17 at 9:00 p.m. with a note of "med not available."

Review of "Patient Progress Note" for Patient #5 on 09/16/17 at 7:50 a.m. revealed an entry by S13RPh that the RN had called on 09/15/17 requesting Primidone, and S13RPh asked the nurse to search the Omnicell (medication dispensing unit). Once this was done by the nurse, Primidone was not located, so S13RPh directed the nurse to hold the medication, since it was not available.

Review of Patient #5's medical record revealed no documented evidence that the nurse notified the physician that Primidone was being held on 09/15/17.

In an interview on 09/21/17 at 11:15 a.m., S3CQO confirmed the above findings. She indicated that the nurse should have notified the physician to obtain an order to hold the medication.

Based on record reviews and interviews, the CAH failed to ensure the patients' medical records contained pertinent information necessary to monitor the patient's progress as evidenced by failure to have documented evidence of reports from off-site physician examinations and consulted physicians for 1 (#3) of 2 (#2, #3) patient records reviewed with off-site medical appointments from a sample of 5 patient records.
Findings:

Review of the policy titled "Consultations", presented as a current policy by S2CNO, revealed that when the consultation is complete and the report is written, the report remains in the chart under the tag marked "consultation."

Review of the "Medical Staff Rules and regulations", presented as the current rules and regulations by S3CQO, revealed that consultations shall show evidence of a review of the patient's record by the consultant, pertinent findings on examination of the patient, and the consultant's opinion and recommendations. The report shall be made a part of the patient's record.

Review of Patient #3's medical record revealed a physician's order on 05/10/17 for a therapeutic pass for a neurology office visit and an order on 05/15/17 to consult orthopedics for a left wrist fracture.

Review of Patient #3's "Patient Progress Notes" dated 05/12/17 at 3:24 p.m. by S8LPN revealed "also informed S14MD of S12MD states 'Pt (patient) does not need to be on anti-seizure medication and he needs a repeat CT scan in 3 months. S14MD also informed that PT has had improvement in CT scan." There was no documented evidence in Patient #3's medical record of a signed report by S12MD related to this information.

Review of Patient #3's "Physician's Progress Notes" dated 05/16/17 at 3:30 p.m. revealed an entry by S11MD that an ortho consult was dictated. Further review revealed documentation included that the left distal radius fracture was stable, a splint was applied, it was alright to use his left arm to ambulate with a walker, and he (S11MD) will return to apply a cast. Review of the medical record revealed no documented evidence of the dictated consult as referenced by S11MD in his note on 05/16/17 at 3:30 p.m.

In an interview on 09/21/17 at 9:36 a.m., S2CNO indicated there was not a copy of a note/report from S12MD. She further indicated if a copy had been presented, it would have been scanned into the medical record.

In an interview on 09/21/17 at 9:53 a.m., S3CQO indicated there was no documentation of a dictated consult by S11MD as stated in his physician progress note.

In an interview on 09/21/17 at 10:15 a.m., S8LPN indicated Patient #3 came back from his appointment with S12MD with a note, but it wasn't an official note documented or signed by S12MD. She further indicated recommendations were written on a plain piece of paper that indicated Patient #3 didn't need to be on anti-seizure medication, and he needed a CT scan in 3 months. S8LPN indicated she called S12MD's office to confirm the written information and spoke with S12MD's nurse. She then called S14MD to tell him what the nurse had said.

In an interview on 09/21/17 at 10:46 a.m. with S2CNO and S3CQO, S3CQO indicated the nurse should have gotten a signed recommendation from S12MD.