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Based on record reviews and interviews, the hospital failed to ensure all patients were admitted to the hospital only on the recommendation of a licensed practitioner as evidenced by failing to consult a provider to make a final decision for admission or denial on 1 (#1) of 6 (#1 - #6) patient medical records reviewed.
Findings:

A review of facility policy "Initial Screening and Criteria for Admission," Policy Number NUR 2:001/ADM 1.003, revised 05/11/2023, revealed in part, Procedure #5. The attending Psychiatrist or designee will make final decision for admission or denial of patients to facility.

A medical record review of Patient #1 revealed the patient being admitted on 11/27/2023 at 7:50 p.m. The admission orders were dated and timed for 11/27/2023 at 9:47 p.m. These orders were noted as being received by Telephone Order Read Back S5MD and signed by S7RN 11/27/2023 at 9:47 p.m. A progress noted on 11/28/2023 at 8:23 a.m. by S6NP revealed in part, "I was notified of admit on 11/28/2023 at 12:06 a.m." There was no documentation regarding the contact of a provider or provider review of initial screening to make a decision on approval or denial of admissions.

In telephone interviews on 01/03/2023 at 2:40 p.m. and 01/04/2023 at 10:15 a.m. S7RN confirmed in both interviews, the documented date and time on the Admission Orders/24 Hour Orders of 11/27/23 at 9:47 p.m. was incorrect. S7RN confirmed she made contact with S6NP on 11/28/2023 at 12:06 a.m. and a psychiatric NP around the same time. S7RN was unable to give the name or exact time of the contact with the Psychiatric NP because she was unable to remember. S7RN confirmed this was the first contact she had made with the two providers in regards to the admission of this patient. S7RN revealed she would not obtain the admissions orders and this would take place with intake staff. S7RN confirmed she was the night shift RN and the night shift RN would be the intake staff and admissions nurse.

In an interview on 01/04/2023 at 10:20 a.m. S8RNIntake confirmed the Admission Orders/24 Hour Orders and the orders are used by S5MD as his standing orders upon admission. S8RNIntake indicated these orders are checked off by the admitting nurse and the date and time at the top of the orders would be used as the time the provider was contacted. S8RNIntake further acknowledge there would be no other documentation in regards to the admitting provider being contacted. S8RNIntake confirmed the contact of the provider for approval or denial of an admission is completed by the Intake RN during on the day shift. S8RNIntake confirmed the 7:00 p.m. - 7:00 a.m. RN supervisor or unit nurse on duty would make contact with the provider regarding approval or denial of admission.

In an interview on 01/04/2023 at 7:30 a.m. S2DON confirmed the night shift RN on the unit would make contact with the admitting provider for approval or denial of an admission. S2DON also confirmed there is no documentation a provider was contacted regarding Patient #1 admissions until 11/27/2023 at 12:06 a.m.

Based on record review and interview the hospital failed to meet the Conditions of Participation (CoP) of Nursing Services. This deficient practice was evidenced by:
1) Failure to obtain orders from a physician or licensed practitioner upon admissions; and
2) Failure to document receiving admission orders from a qualified physician or licensed practitioner on 3 (#2, #4, #5) of 6 (#1 -#6) patient medical records reviewed.
(See findings under Tag A0395)

Based on record review and interview the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient. This deficient practice is evidenced by:
1) Failure to obtain orders from a physician or licensed practitioner upon admissions; and
2) Failure to document receiving admission orders from a qualified physician or licensed practitioner on 3 (#2, #4, #5) of 6 (#1 -#6) patient medical records reviewed.
Findings:

1) Failure to obtain orders from a physician or licensed practitioner upon admissions

A medical record review of Patient #1 revealed the patient being admitted on 11/27/2023 at 7:50 p.m. The admission orders were dated and timed for 11/27/2023 at 9:47 p.m. These orders were noted as being received by Telephone Order Read Back S5MD and signed by S7RN 11/27/2023 at 9:47 p.m. A progress noted on 11/28/2023 at 8:23 a.m. by S6NP revealed in part, "I was notified of admit on 11/28/2023 at 12:06 a.m." The patient was admitted to the hospital for approximately 4 hours without a practitioner's orders.

In telephone interviews on 01/03/2023 at 2:40 p.m. and 01/04/2023 at 10:15 a.m. S7RN confirmed in both interviews, the documented date and time written on the Admission Orders/24 Hour Orders of 11/27/2023 at 9:47 p.m. was incorrect. S7RN confirmed she made contact with S6NP on 11/28/2023 at 12:06 a.m. and a psychiatric NP (nurse practitioner) around the same time. S7RN was unable to give the name or exact time of the contact with the Psychiatric NP because she was unable to remember. S7RN confirmed this was the first contact she had made with the two NP's in regards to the admission of this patient. S7RN confirmed she completed the admission orders for Patient #1 by placing the checks by each item and these orders were not completed by a physician or NP. S7RN confirmed she was the night shift RN and the night shift RN would be the intake staff and admissions nurse.

In an interview on 01/04/2023 at 10:20 a.m. DON confirmed Patient #1's above mentioned time frames regarding admissions and NP contact. DON confirmed the approximate 4 hour time frame of the patient being admitted with no physicians' admission orders.

2) Failure to document receiving admission orders from a qualified physician or licensed practitioner on 3 (#2, #4, #5) of 6 (#1 -#6) patient medical records reviewed

A review of facility policy, "Transcription of Physician Orders," Policy Number NUR 6:012, effective 03/01/2018 revealed in part, Procedure 5. Item e-i. The receiver of a telephone order documents the order immediately on the prescriber order form including the date, time, authorized prescriber's name/receivers name, status, and signature.

A medical record review revealed Admission Orders/24 Hour Orders being initiated with no indication of which physician or licensed practitioner initiated the admission orders. The last entry on the order set is written as TROB Dr. ____. The entries on each patient are as follows:
Patient #2 admission's orders failed to reveal an initiating practitioner on 11/19/2023 at 5:30 p.m. and the admission orders were signed by the provider on 11/20/2023 at 9:00 a.m.
Patient #4 admission's orders failed to reveal an initiating practitioner on 01/03/2024 at 2:00 p.m. and the admission orders were signed by the provider on 01/04/2024 at 5:30 a.m.
Patient #5 admission's orders failed to reveal an initiating practitioner on 01/03/2024 at 12:00 noon and the admission orders were signed by the provider on 01/04/2024 at 5:00 a.m.

In an interview on 01/04/2023 at 11:30 a.m. S2DON confirmed the above mentioned findings on the medical records.

Based on record review and interview, the hospital failed to ensure nursing staff administered drugs and biologicals according to accepted standards of practice. This deficient practice is evidenced by staff administrating medication without a physician order in 1 (#1) of 6 (#1-#6) patients sampled.
Findings:

A medical record review of Patient #1 revealed an order set, Admission Orders/24 Hour Orders being initiated on 11/27/2023 at 9:47 p.m. The order set was initiated and signed by S7RN as telephone read back orders from S5MD. These orders included an order for Trazadone 50mg PO QHS PRN insomnia being initiated. The medication administration record revealed Trazadone 50mg being administered on 11/27/2023 at 10:00 p.m. A nursing assessment by S7RN and documented as being completed on 11/27/2023 at 9:47 p.m. revealed an entry for Trazadone 50mg being received by Patient #1 at 10:00 p.m.

In telephone interviews on 01/03/2023 at 2:40 p.m. and 01/04/2023 at 10:15 a.m. S7RN confirmed in both interviews, the documented date and time on the Admission Orders/24 Hour Orders of 11/27/23 at 9:47 p.m. was incorrect. S7RN confirmed she made contact with S6NP on 11/28/2023 at 12:06 a.m. and a psychiatric NP around the same time. S7RN was unable to give the name or exact time of the contact with the Psychiatric NP because she was unable to remember. S7RN confirmed this was the first contact she had made with the two providers in regards to the admission of this patient and she had not contacted S5MD.

In an interview on 01/04/2023 at 9:15 am S2DON confirmed Patient #1 had been administered Trazadone 50mg on 11/27/2023 at 10:00 p.m. and the medication was administered prior to the providers being contacted upon admission of the patient.

Based on record review and interview the hospital failed to ensure all hospital orders were signed, dated, and timed by the physician or licensed practitioner. This deficient practice was evidenced by 1 (#1) of 6 (#1 - #6) patient medical records reviewed.
Findings:

A review of facility policy, "Transcription of Physician Orders," Policy Number NUR 6:012, effective 03/01/2018 revealed in part, Procedure 5. Item b. Telephone orders must be signed, dated and timed by the physician with 48 hours of the order being given.

A medical record review of Patient #1 revealed the Admission Orders/24 Hour Orders were not signed by the physician or licensed practitioner per hospital policy.

In an interview on 01/03/2023 at 3:00 p.m. S2DON confirmed the orders had not been signed by the physician or licensed practitioner within 48 hours.

Based on record review and interview the hospital failed to demonstrate orders and protocols are consistent with nationally recognized evidenced based guidelines. This deficient practice is evidenced by 1 (#1) of 6 (#1-#6) patient medical records reviewed having admission order sets being completed by the registered nurse.
Findings:

A medical record review of Patient #1 revealed an admission order set titled Admission Orders/24 Hour Orders. The order set consist of 26 line item entries with boxes to check off to initiate an order. The options include Admit to___; Legal Status: pick option; Program: pick option; Precaution: pick option; Diet: pick option; Consults: Medical Physician and Other:___; Consult Dietician for: ___; Diagnostic Tests Required: pick option; For All Diabetic Patients: pick options; Activities as Tolerated; and 17 as needed medications that can give an option to each; and the last option is TORB Dr. ___.

In an interview on 01/04/2023 at 10:15 a.m. S7RN confirmed when she admits a patient, she completes this order set on admission by checking each item down the page. S7RN confirmed it is not completed with the physician going down the page reviewing each item. S7RN also confirmed the physician's name is placed in the TRBO fill in blank. S7RN confirmed this is S5MD standing orders and this is what is used for admissions.

In an interview on 01/04/2023 at 10:20 a.m. S8RNIntake confirmed the Admission Orders/24 Hour Orders and their use as standing admission orders for S5MD. S8RNIntake also confirmed these orders are checked off by the admitting nurse without reviewing each item with the admitting physician or licensed practitioner.

Based on record review and interview, the hospital failed to ensure patient safety related to drugs and biologicals being controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This deficient practice was evidenced by failing to ensure 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: Item A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial dose of medication, except in cases of emergency.

A review of facility policy "Pharmacists Review of New Orders," Pharmacy Policy Number: P1.007 and submitted by S10Pharm revealed in part, all new medication orders shall be reviewed by a licensed pharmacist prior to medication being passed to patient: Only medication orders that have been reviewed and approved by a licensed pharmacist are approved to be given to patients.

A medical record review of Patient #1 revealed an order set, Admission Orders/24 Hour Orders being initiated on 11/27/2023 at 9:47 p.m. The order set was initiated and signed by S7RN as telephone read back orders from S5MD. These orders included an order for Trazadone 50mg PO QHS PRN insomnia being initiated. The medication administration record revealed Trazadone 50mg being administer on 11/27/2023 at 10:00 p.m. A nursing assessment by S7RN and documented as being completed on 11/27/2023 at 9:47 p.m. revealed an entry for Trazadone 50mg being received by Patient #1 at 10:00 p.m. The medical record failed to reveal any documentation related to the first medication dose being 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.

In telephone interviews on 01/03/2023 at 2:40 p.m. and 01/04/2023 at 10:15 a.m. S7RN confirmed in both interviews, the documented date and time on the Admission Orders/24 Hour Orders of 11/27/23 at 9:47 p.m. was incorrect. S7RN confirmed she made contact with S6NP on 11/28/2023 at 12:06 a.m. and a psychiatric NP around the same time. S7RN was unable to give the name or exact time of the contact with the Psychiatric NP because she was unable to remember. S7RN confirmed this was the first contact she had made with the two providers in regards to the admission of this patient and she had not contacted S5MD. S7RN also confirmed there had been no contact with a registered pharmacist to review and approve this medication.

In an interview on 01/04/2023 at 9:15 am S2DON confirmed Patient #1 had been administered Trazadone 50mg on 11/27/2023 at 10:00 p.m., this was prior to the providers being contacted and receiving admission orders and she was unaware of a first dose review being performed by pharmacist.