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Based on record review and interview, the hospital failed to ensure the Quality Assurance/Performance Improvement program measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of services and quality of care. The deficient practice was evidenced by failure to include all services/departments in their Performance Improvement Plan.
Findings:

Review of the hospital's Quality Assurance and Performance Improvement plan revealed in part that the program will utilize objective measures to monitor, evaluate and maintain the quality and safety of services provided to our patients. This program facilitates a multidisciplinary systemic performance improvement approach to identify and pursue opportunities to improve patient outcomes.

Further review of the plan revealed no documented quality indicators were developed for nuclear medicine, housekeeping, respiratory therapy, radiology or surgery. There was also no frequency and detail of data collection specified in the plan for any department.

Review of the hospital's monthly Performance Improvement Committee Minutes dated 01/26/22, 12/22/21 and 10/28/21 revealed it failed to have data from nuclear medicine, housekeeping, respiratory therapy, radiology or surgery.

On 02/16/22 at 1:30 p.m., interview with S3DOQ revealed that she was the director of the hospital's QAPI plan. When asked if there were documented quality indicators developed for nuclear medicine, housekeeping, respiratory therapy, radiology or surgery, she stated no. When asked if she was aware of the quality indicators that the housekeeping department was monitoring, S3DOQ stated she was unsure. When asked if all departments were participating in the monthly QAPI meetings and were submitting data in order to improve patient outcomes, she stated no.

Based on record review and interview, the hospital failed to ensure that a medical history and physical examination was completed and documented for each patient no more than 30 days before or 24 hours after admission or registration for 3 (Patient #12, 14, 15) of 6 records reviewed for completeness in a total sample of 20.
Findings:

Review of the Medical Staff Bylaws, Number 840-25.1, and revised 03/2018 revealed that a History and Physical must be completed by the admitting physician within 24 hours of admission.

Patient #12
Review of the electronic medical record with S2CNO for Patient #12 revealed an admit date of 02/13/2022. Further review of the record revealed no documented history and physical.

Patient #14
Review of the electronic medical record with S2CNO for Patient #14 revealed an admit date of 02/12/2022. Further review of the record revealed no documented history and physical.

Patient #15
Review of the electronic medical record with S2CNO for Patient #15 revealed an admit date of 02/13/2022. Further review of the record revealed no documented history and physical.

Interview on 02/16/22 at 10:45 a.m. with S2CNO confirmed that there were no documented H&P for patients #12, #14, and #15.

Based on record review and interview, the hospital failed to ensure the nursing staff develops, and keeps current, a nursing care plan for 1 (Patient #10) of 6 sampled patient records reviewed for care plans from a total sample of 20.
Findings:

Review of the hospital policy titled Nursing Care Plans, revised 10/2020 revealed in part: To establish a process for development and implementation of Nursing Care Plans to guide Nursing interventions and actions for all patients as appropriate. Nursing care planning begins when the patient is admitted to the facility and is continually updated throughout their stay in response to changes in the patient's condition and evaluation of goal achievement.

Review of the medical record for Patient #10 revealed the patient was admitted to the hospital on 02/15/2022 for Abdominal Pain and Shortness of Breath. Patient #10 had a history of CAD, heart failure, HTN and atrial fibrillation. Physician admit orders included the following current medications: Aspirin 81mg q day, Atorvastatin 20mg q hs, Plavix 75mg q day, Diltiazem 240 mg q day, Fosinopril 20 mg q hs, Furosemide 40 mg q day, Metoprolol Tartrate 100 mg BID and Pacerone 20 mg q day. The patient's current care plan reflected interventions for Safety, Acute Pain, and Discharge Planning. There was no documentation of care plans to address cardiac issues which included CAD, Heart Failure, HTN and Atrial Fibrillation.

Interview on 02/16/22 at 10:45 a.m. with S2CNO confirmed that there was no documentation to include all aspects of care for the patient to include cardiac problems.

Based on observation, record review and interview, the hospital failed to maintain medical records on each patient as evidenced by 1) failing to ensure medical records were protected from water and fire damage as evidenced by medical records being stored unprotected from possible water sprinkler damage on open shelving in the medical records room and 2) failing to ensure that patient medical records were completed within 30 days for 3 (S13MD, S14MD, S15MD) physicians reviewed with delinquent medical records past 30 days.
Findings:

1) Failing to ensure medical records were protected from water and fire damage as evidenced by medical records being stored unprotected from possible water damage on open shelving in the medical records room

On 02/15/22 at 1:30 p.m., observation of the medical records office with S11MR (Director) revealed a room containing paper medical records stored on large rolling cabinets from floor to ceiling. The sides of the cabinets were open. Further observations revealed sprinkler heads in the ceiling of the room over the open cabinets. At that time, interview with S11MR revealed the paper medical records were not scanned into the computer system and there was no back up of the records. When asked if the medical records were protected from water should the sprinklers activate, she stated no.

2) Failing to ensure that patient medical records were completed within 30 days for 3 (S13MD, S14MD, S15MD) physicians reviewed with delinquent medical records

Review of the Medical Staff Rules and Regulations revealed in part that all medical records will be completed within 30 days of the patient's discharge. Those medical records not completed within 30 days of discharge shall be considered delinquent.

Review of the policy titled, Delinquent and Incomplete Records, revealed in part that a notice of medical record delinquency will be sent by the Director of Medical Records to the responsible physician for any medical record not completed within 30 days.

On 02/15/22 at 1:20 p.m., interview with S11MR (Director) revealed that there was only one physician (S14MD) with delinquent medical records past 30 days. At that time, the surveyor asked S11MR to run a delinquency report. Review of the report revealed three physicians had delinquent medical records past 30 days. These included:
S13MD- 22 delinquent medical records with oldest deficiency 36 days
S14MD - 5 delinquent medical records with oldest deficiency 161 days
S15MD - 2 delinquent medical records with oldest deficiency 33 days

Interview with S11MR revealed that she was unaware of the other two physicians having delinquent medical records. When asked the procedure for completing delinquent medical records, S11MR stated a letter would be sent to the physician prior to 30 days for them to complete the record, and if it was not completed the physician would be suspended. S11MR stated that she thought that S14MD had been suspended, but she was not sure. When asked for a copy of the letters sent to the above physicians regarding delinquent medical records, S11MR was unable to locate the letters. S11MR further stated that S3DOQ may have sent the letters to the physicians.

On 02/15/22 at 2:00 p.m., interview with S3DOQ revealed that she assists S11MR with delinquent medical records. S3DOQ confirmed that there was no documented evidence that notices of medical record delinquencies had been sent to the above physicians. When asked if S14MD had been suspended due to delinquent medical records, S3DOQ stated no.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable standards of practice, consistent with state law. This deficient practice was evidenced by the hospital failing to have a policy and procedure 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.

Review of the hospital policy titled, Medication Administration Management, presented by the pharmacist revealed no provision for the pharmacist to review the prescriber's original order, or a direct copy thereof, before the initial dose is dispensed.

On 02/15/22 at 9:30 a.m., an interview with S12Pharmacist revealed that the hospital pharmacy is open Monday-Friday 7:30 a.m.-4:30 p.m., with on-call coverage for nights and weekends as well. S12Pharmacist stated that he has computerized access to hospital records at home and he checks his computer during the night to see if there are any new medication orders that need a first dose review. He further stated that the nurses can call him if needed, but frequently override the system and obtain newly ordered medications from the medication dispensing machine at the hospital and administer the medication to the patient without waiting for the pharmacist to review the medication prior to the first dose.

Review of the Overrride Report for 02/08/22 - 02/15/22 with S12Pharmacist confirmed numerous medications were removed from the Med-Dispense System using the override process, and were not reviewed by the pharmacist prior to the first dose.

Review of the above policy on 02/15/22 at 2:30 p.m. with S12Pharmacist confirmed the hospital had no current policy to ensure first dose reviews would be conducted by the pharmacist prior to administration.

Based on record review and interview, the facility failed to ensure drug administration errors were reported immediately to the attending physician and documented in the patient's medical record for 2 of 2 (#6, #7) sampled patients with medication variances reviewed with known medication errors out of a total sample of 20.
Findings:

Review of the hospital policy titled Medication Administration Management (review date of 04/21), Section 8 revealed, in part:
In the event a medication error occurs, the individual making or discovering the error must...
c. Notify the physician, and if appropriate, the nurse;
e. Document events objectively and accurately in the medical record;
g. Coordinate with CNO, RM, and physician for the notification of patient/family.

Review of two occurrence reports, provided by S3DOQ, revealed that Patient #6 had a missed dose of medication on 12/16/21 and Patient #7 was administered an incorrect medication on 12/29/21. Review of the medical records for Patients #6 and #7 revealed no documented evidence that the medication errors or physician notification of the errors were documented in the medical records.

In an interview on 02/16/22 at 1:30 p.m., S3DOQ reviewed the occurrence reports and medical records for Patient #6 and Patient #7. S3DOQ confirmed that the medication errors and physician notification of the errors were not documented in the patient's medical records. Further interview with S3DOQ confirmed that the errors should have been documented in the medical record, per hospital policy.

Based on record review and interview, the hospital failed to ensure that an individual who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program.
Findings:

Review of the personnel files revealed that S8ICC had no documented evidence of training, experience or certification in infection prevention and control.

On 02/16/22 at 12:55 p.m., an interview with S8ICC confirmed she had been oriented to the role by the prior ICC, but had not received any training and was not currently being supervised by anyone who is trained in infection prevention and control.