HospitalInspections.org

Based on record review and interview, the hospital failed to ensure patients were kept free of all forms of abuse or harassment. This deficient practice is evidenced by the hospital failing to report potential allegations of abuse/neglect related to 2 (#3, #4) of 2 (#3, #4) patients reviewed for elopement to LDH-HSS (Louisiana Department of Health - Health Standards Section) within 24 hours of the awareness of this potential allegation.
Findings:

Review of the Louisiana Revised Statutes, Title 40. Public Health and Safety, Chapter 11, State Department of Health and Hospitals revealed "Department" shall mean the Department of Health and Hospitals. "Unit" means the Medicaid fraud control unit created within the office of criminal law of the Department of Justice and which is certified by the secretary of the United States Department of Health, Education and Welfare. Regarding §2009.20. Duty to make complaints; penalty; immunity, "Abuse" is the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including but not limited to sexual abuse, or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered. "Neglect" is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer's well-being. Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, ... having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report.

Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report these allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Department of Health and Hospitals (LDH) (or the Medicaid Fraud Unit as applicable). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence.

A review of incident logs from 01/01/2024 to 07/01/2024 revealed Patient #3 eloped on 06/24/2024 and Patient #4 eloped on 06/24/2024. A review of the hospital's self-reports to LDH-HSS did not reveal the elopements being self-reported.

In an interview on 07/01/2024 at 3:15 p.m. S3DQRM confirmed the above mentioned findings.

Based on record review, policy review and interview, the hospital failed to follow hospital policy and standard of care for medication administration. The deficient practice was evidenced by nursing personnel failing to follow up on the effectiveness of as needed (PRN) medication administration in 1 (#2) of 3 (#1-#3) reviewed medical records.
Findings:

A review of facility policy, "Assessment/Reassessment," Policy NO: POC-07 with an Original Date of Issue: 09/2017 and Date of Last Revision: 02/2023, revealed in part, Policy: All patients admitted to the hospital will receive a thorough assessment and evaluation. Reassessments: " ...each patient is reassessed as necessary based on the patient's plan for care or change in their condition, including change in the patient's level of paint. Reassessment are also to be based on the patient's diagnosis; desire for care, treatment and services, response to previous care, treatment and services. In addition, the reassessment and reassessment information includes the patient's perception of the effectiveness of, and any side effects related to their medication."

A review of facility policy, "Medication Administration and Records," Policy Number: PHR-159, with an Origination Date: 09/2017 and no revisions, revealed in part, 2.0 Statement of Policy: 2.1 Guidelines for proper documentation of administered medications, omitted medications, and response to as needed (PRN) medications will be outlined. 4.2 Medication Administration Procedure: 4.2.3 Analgesic Therapy and As Needed Medication Monitoring: All medications that have been administered PRN must also have documentation of the result and effectiveness.

A review of Patient #2's electronic medical record (EMR) revealed a nursing note from 06/30/2024 at 4:15 p.m. with S5RN documenting, " ... pt (patient) having chills. T 101.9. Will notify MD." A nursing note created on 07/01/2024 at 7:07 p.m. and signed on 07/01/2024 at 7:08 p.m. was entered for 06/30/2024 for 4:24 p.m. and documented by S5RN, "This nurse sent message to S6NP, re: pt symptoms. Waiting on response." A review of medications revealed the administration of acetaminophen 650mg tablet on 06/30/2024 at 4:27 p.m. for a temperature of 101.9º F (38.8º C). The View Flowsheet revealed a documented temperature of 101.9º F on 06/30/2024 at 4:15 p.m. There was no documentation related to a follow up of the effectiveness of the administration of the acetaminophen or contact being made with the provider. The next documented temperature of 103.1º F (39.5º C) was on 06/30/2024 at 9:31 p.m. and this was the first documentation related provider acknowledgement of the patient having an elevated temperature. This was over 5 hours from the time of initial elevated temperature and the acetaminophen administration.

In an interview on 07/02/2024 at 1:00 p.m. S3DQRM confirmed the above mentioned findings.

Based on observation and interview, the hospital failed to maintain the condition of the physical plant and hospital environment in such a manner to ensure the safety and well-being of patients. This deficient practice was evidenced by the discoloration and liquid staining of ceiling tiles of Room #i.
Findings:

Observations during a tour of the hospital on 07/01/2024 from 10:30 a.m. to 11:45 a.m. revealed the medication room of Room #i having 4 ceiling tiles surround a ventilation duct being discolored and liquid stained.

In an interview during the tour, S2CNO confirmed the above mentioned findings.

Based on observation, policy review, and interview, the hospital failed to maintain all equipment in a manner to ensure an acceptable level of safety and/or quality. This deficient practice was evidenced by the hospital failing to ensure glucometer control testing was performed on 1 (Room #l) of 3 (Rooms #i, #l, #m) glucometers reviewed for quality control testing.
Findings:

A review of the FreeStyle Precision Pro Operator's Manual revealed Item 4-1 Operating Guidelines for Control Solution Testing: When To Test with Control Solutions: As required by your facility's quality policy.

A review of hospital policy, "Waived Testing," no policy number, with an Original Date of Approval: 04/2023 and Date of Last Revision: 07/03/2023 revealed in part, Policy: The hospital performed quality control checks for waived testing on each procedure. The hospital maintains records for waived testing. The following waived tests are performed at this hospital: 6. Blood Glucose Monitoring. Procedure: c. If manufacturers' manuals or package inserts are used as the policies or procedures for each waived test, they are enhanced to include specific operational policies (that is, detailed quality control protocols and any other institution specific procedures regarding the test or instrument).

The hospital did not provide written information regarding the frequency of performing the quality control testing. The above mentioned policy and operator's manual referred to one another as to the frequency.

A review of the Room #l's Glucometer Log for 06/2024 revealed 10 (06/13 - 06/17/2024, 06/22 - 06/23/2024, 06/28 - 06/30/2024) of 30 (06/01 - 06/30/2024) days missing documentation of a quality control performance.

In an interview on 07/01/2024 at 10:35 a.m. S2CNO confirmed the above mentioned findings. Further S2CNO confirmed the quality controls should be performed daily.

Based on observation and interview, the hospital failed to ensure the hospital environment was maintained in a clean and sanitary condition to avoid sources and transmission of infection. This deficient practice was evidenced by:
1) Failing to ensure the hospital was maintained in a clean and sanitary condition; and
2) Failing to ensure all equipment was maintained in a clean and sanitary condition.
Findings:

1) Failing to ensure the hospital was maintained in a clean and sanitary condition

Observations during a tour of the hospital on 07/01/2024 from 10:30 a.m. to 11:45 a.m. revealed the following conditions that would prohibit the proper sanitary cleaning in patient care areas:
A. Cracked and peeling mattress coverings located in Rooms #a, #b, #f, #j, and #k;
B. Black substances in the grove between the shower pan and wall coverings of the showers located in Rooms #d, #f, and #g;
C. The top surface of 2 nightstands were swollen, bubbled/blistered, and cracked in Room #j;
D. The metal coverings surrounding the packaged thermal air conditioners (PTAC) contained a brown substance that resembled rust in Rooms #b, #c, #d, #e, #f, #j, and #k; and
E. Peeling and chipped paint and wall damage exposing the underlying dry wall in Room #b to the left the entry door, Room #h to the right of phone #1 and phone #2, and Room #j to the right of the bathroom mirror.

In an interview during the tour, S2CNO confirmed the above mentioned findings.

2) Failed to ensure all equipment was maintained in a clean and sanitary condition

Observations during a tour of the hospital on 07/01/2024 from 10:30 a.m. to 11:45 a.m. revealed a FreeStyle Precision Pro Glucose Meter in Room #l nursing station with tape and sticky substance on the outside covering. This would prohibit the proper sanitary cleaning of this glucose meter.

In an interview during the tour, S2CNO confirmed the above mentioned finding.