HospitalInspections.org

Based on record review and interview, the hospital failed to ensure that all unlicensed staff had criminal background checks conducted by an agency authorized by Louisiana State Police for 2 (S7Dietary Manager, S9Recreational Therapist)of 2 unlicensed staff whose personnel files were reviewed.
Findings:

Review of the Louisiana Revised Statute Title 40-Public Health and Safety, RS 40:1203.2-Employment of nonlicensed persons revealed in part that "Authorized Agency" means a private entity authorized by the office of state police to conduct the criminal history checks provided for in this part.

Review of the personnel files for S7Dietary Manager and S9Recreational Therapist revealed that they had background checks conducted upon hire by an agency that was not authorized by the Louisiana State Police.

On 11/28/18 at 3:25 p.m., interview with S1DON confirmed that she was not aware that background checks were to be conducted by an agency authorized by the Louisiana State Police.

Based on record review and interview, the hospital failed to ensure the RN supervised and evaluated care for 1 patient (#23) of 3 (#22, #23, #24) charts reviewed for initial nursing assessments out of a total of 30 patient's charts reviewed.
Findings:

The DON did not provide the requested hospital policy regarding the initial assessment by a RN.

Review of patient #23's chart revealed the patient was admitted to the Intensive Care Unit on 11/25/18 at 2:25 p.m. with a diagnosis of Urosepsis. Further review failed to reveal a RN performed an initial assessment.

Interview on 11/28/18 at 12:05 p.m. with S13RN revealed the initial nursing assessment must be completed within 5 hours. S13RN continued to state that an initial assessment was not performed for Patient #23.

Based on record review and interview, the hospital failed to ensure nursing personnel were qualified and competent to provide nursing care to each patient as evidenced by failing to have documented evidence of skills competency testing for 5 (S2RN, S5RN, S6RN, S8RN, S14RN) of 5 nursing personnel whose personnel and training records were reviewed.
Findings:

Review of the personnel files for S2RN, S5RN, S6RN, S8RN and S14RN with S1DON revealed no documented evidence of annual skills competency assessments.

On 11/28/18 at 2:00 p.m., an interview with S1DON confirmed the above staff had no documented skills competency assessments.

Based on record review and interview, the hospital failed to ensure that drugs were administered as ordered by the physician as evidenced by failure of the RN to ensure PRN medications were administered as ordered for 2 of 2 records (Patient #1, #2) reviewed for PRN medication administration in a total sample of 30.
Findings:

Patient #1
Review of the medical record revealed the patient was admitted to the hospital psychiatric unit on 11/21/18 with physician orders for Thorazine 50mg by mouth every four hours PRN anxiety.

Review of the patient's medication administration record dated November 2018 revealed the patient received Thorazine 50mg on the following dates:
11/22/18 at 8:45 p.m.
11/24/18 at 9:00 a.m.
11/25/18 at 8:45 a.m. and 8:00 p.m.

Review of the patient's record revealed no documented evidence of the reason the patient was administered the medication on the above dates.

On 11/27/18 at 1:30 p.m., S2RN reviewed the patient's record and confirmed that there was no documented evidence of the patient's behavior prior to or after giving the above PRN Thorazine doses. S2RN further stated that there was no documented evidence that the medication was administered for anxiety as ordered by the physician.

Patient #2
Review of the medical record revealed the patient was admitted to the hospital psychiatric unit on 11/16/18. Review of the physician orders revealed orders for Haldol 5mg intramuscular every 6 hours PRN agitation and Ativan 2mg intramuscular every 6 hours PRN agitation.

Review of the patient's medication administration record dated November 2018 revealed the patient received Haldol 5mg and Ativan 2mg intramuscular on 11/18/18 at 9:00 a.m. Further review of the patient's nurses notes dated 11/18/18 at 9:00 a.m. revealed the patient refuses medications by mouth "so IM (intramuscular) medications were administered". There was no documentation in the nurses notes as to what PRN medications the patient was administered.

On 11/27/18 at 10:20 a.m., S2RN reviewed the patient's record and confirmed that there was no documented evidence that the patient was administered the Haldol and Ativan for agitation, as per physician orders.

Based on record review and interview, the hospital failed to ensure medical records were promptly completed for 1(#26) of 6(#17, #26, #27, #28, #29, #30) patient charts reviewed for timely completion of a discharge summary and no later than 30 days after discharge.
Findings:

Review of Patient #26's chart revealed a discharge date of 8/30/18 and the discharge summary completed on 10/02/18.

During an interview on 11/28/18 at 12:00 p.m., S12RN Nurse Manager confirmed Patient #26's discharge summary was not completed within 30 days of discharge.

Based on record review and interview, the hospital failed to ensure all compounding, packaging, and dispensing of drugs and biologicals were under the supervision of a pharmacist by failing to ensure personnel had training, including competency assessment and evaluation of skill in aseptically preparing compounded medications. This deficient practice was evidenced by the hospital having untrained nursing staff preparing compounded medications.
Findings:

Review of S8RN and S14RN's personnel and training files failed to reveal the nurses were trained in preparing compounded medications.

Interview with S11Pharmacist on 11/26/18 at 4:15 p.m. revealed the pharmacy compounds medications from 8:30 a.m. to 5:00 p.m. S11Pharmacists stated the nurses on the obstetrics ward mix Pitocin/Oxytocin after hours.

Interview with obstetric ward nurses S8RN and S14RN revealed they mix a Pitocin/Oxytocin vial with 1000 milliliters of normal saline to administer to their patients when the pharmacy is closed.

Based on observation and interview, the hospital failed to ensure that outdated, mislabeled or otherwise unusable drugs and biologicals were not available for patient use as evidenced by having expired medications in 5 of 6 crash carts observed.
Findings:

On 11/26/18 at 11:55 a.m., observations with S1DON and S11Pharmacist revealed the following expired medications on the crash cart on the inpatient medical unit:
(2) Succinylcholine 20mg/mL, expired 11/1/18
(1) Vasostrict 20u/mL, expired 10/18
(2) Atropine Sulfate 0.1mg/mL, expired 6/1/18
(4) Atropine Sulfate 0.1mg/mL, expired 9/1/18
(1) Dopamine 400mg/250mL bag, expired 8/18
(2) Amiodorone 150mg/3mL, expired 8/18
(4) Norepinephrine 4mg/4mL, expired 3/18
(1) Flumazeril 0.5mg/5mL, expired 6/18
(2) Diphenhydramine 50mg/mL, expired 4/18
(2) Propanolol 1mg/mL, expired 3/18
(3) Lidocaine 20mg/mL, expired 4/1/18
(1) Sodium Bicarb 1meq/mL, expired 5/1/18

Interview with S11Pharmacist during the above observations revealed that all crash carts in the hospital are supposed to be checked monthly by pharmacy staff.

On 11/26/18 at 12:05 p.m., observations with S11Pharmacist revealed the following expired medications on the crash cart on the intensive care unit:
(2) Sodium Bicarb 50meq, expired 9/18
(2) Dopamine bags 400mg/250mL, expired 8/18
(1) Lidocaine 100mg/5mL, expired 8/18
(3) Magnesium Sulafate 1gm/100mL, expired 9/18
(2) Amiodorone 900mg/18mL, expired 8/18

On 11/26/18 at 12:30 p.m., observations with S3RN revealed the following expired medications on the crash cart on the obstetrics unit:
(4) Atropine Sulfate 1mg, expired 9/1/18
(2) Magnesium Sulfate 1gm/100mL, expired 9/18
(2) Amiodorone 150mg/3mL, expired 8/18

On 11/26/18 at 2:30 p.m., interview with S1DON confirmed that the above crash carts had expired medications on them that were available for patient use.

On 11/26/18 at 2:45 p.m., observation with S6RN revealed the following expired medicaltions on the crash cart in operating room #1:
(2) Atropine Sulfate 0.1mg.mL, expired 03/01/18
(2) Atropine Sulfate 0.1mg/mL, expired 09/01/18

On 11/26/18 at 2:55 p.m., observation with S6RN revealed the following expired medicaltions on the crash cart on the post anesthesia care unit:
(5) Atropine Sulfate 0.1mg/mL, expired 09/01/18

On 11/26/18 at 3:00 p.m., interview with S6RN confirmed that the above crash carts had expired medications on them that were available for patient use.







20310

Based on record review and interview, the hospital failed to ensure identified medication errors were promptly documented in the patient's chart for 2 of 2 patients (#3 and #25) reviewed who had hospital identified medication errors.
Review of the Hospital's Variance/Occurrence Report revealed the following medication errors:

Patient #3 was given Alprazolam 0.25mg by mouth at 09:00 on 11/19/18 when patient was supposed to get Klonopin 0.25 mg.

Patient #25 was administered Coreg at the wrong time. Timing of medication from 9:00 p.m. to 5:00 p.m. was discovered during a chart review by the hospital.

Review of Patient #3's chart failed to reveal the medication error was promptly documented in the patient's chart.

Review of Patient #25's chart failed to reveal the medication error was promptly documented in the patient's chart.

During an interview on 11/28/18 at 11:05 a.m., S12RN Nurse Manager confirmed the medication error for Patient #3 was not recorded in the chart.

During an interview on 11/28/18 at 1:55 p.m., S1DON confirmed the medication error for Patient #25 was not recorded in the chart.

Based on record review, observation and interview, the hospital failed to ensure the infection control officer assured the system for controlling infections and communicable disease of patients and personnel was implemented according to hospital procedure and acceptable standards of infection control practices. This deficient practice is evidenced by failure to maintain a sanitary environment in the hospital.
Findings:

On 11/26/18 at 11:30a.m., initial tour of the medical/surgical nursing unit and ICU revealed the following:

Room a - Tears in the arms of 2 chairs; built up dust and lint in the air vent on the ceiling.
Room b - Infusion pump with grime on exterior surfaces and tubing chamber compartment. HVAC vent register and return grate covered with dust and debris.
Room c - Dirty (not covered with a plastic bag) SCD machine
Room d - Infusion pump with grime on exterior surfaces and tubing chamber compartment. HVAC vent register and return grate covered with dust and debris.
Room e - Rips/tears to vinyl covering of armchair. HVAC vent register and return grate covered with dust and debris.
Room f - Grime and particles on the HVAC wall unit controls. Sticky residue on the bottom of the bedside table.
Room g - Tears in the seat of the chair.
Room h - 2 infusion pumps with grime and debris on the exterior surfaces and tubing chamber compartment. SCD machine not covered with a plastic bag.
Room i - Brown substance on the light switch in the bathroom.
ICU room j- Pulse ox probe on floor, 2 infusion pumps, dirty, not covered with bags. Bedside toilet not covered with bag.

Interview at this time with S12RN Nurse Manager acknowledged findings and stated plastic bags are to be placed over patient use equipment which has been sanitized.


Review of the hospital's In-Service 3A: Basic Sanitation Practices - Sanitation Procedures for dishes in the dietary department revealed:

The four step sanitizing procedure involves: Clean, Rinse, Sanitize, Air Dry.

Observation of the hospital's kitchen on 11/27/18 at 9:35 a.m., accompanied by S7Dietary Manager, revealed the following:

Ice machine with a black speckled substance along the top of inner aspect of the door and the door frame
4 wire cooking racks with thick grime and debris on the surfaces
Thick grime and debris on the outer surfaces and ledges of the oven
Thick grime and debris on the inlet of the steamer
Residual food particles on the large, medium and small baking pans
Spice shelf surfaces covered with grime and food particles
Large and medium sized steam table pots stored wet
Plastic drinking cups stored wet
Plate covers with residual food on the surfaces and stored wet

During an interview on 11/27/18 at 10:10 a.m., S7Dietary Manager acknowledged the findings.