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Based on record review and interview, the hospital failed to ensure each patient was informed of their right to file a grievance with the State agency that has licensure survey responsibility for the hospital and provided with a phone number and address for the state agency.
Findings:

Review of the hospital policy titled "Patient Bill of Rights/Patient Responsibilities", reviewed/revised 04/21/14, revealed that the patient had the right to register a complaint or grievance knowing that the presentation of such a complaint will not itself compromise future care. There was no documented evidence in this policy that patients would be informed of their right to file a grievance with the State Licensure Agency.

Review of the Patient Guide booklet, given to all patients on admission to the hospital, revealed that patients had the right to file complaints with KEPRO or the Office of Quality and Patient Safety/Joint Commission. There was no documented evidence that the phone number and address for the Department of Health and Hospitals, the state agency, was provided to the patient.

On 04/21/15 at 11:40 a.m. interview with S3 Quality Assurance Director confirmed that patients are not provided the phone number and address for the Louisiana Department of Health and Hospitals, should they desire to file a grievance with them.

Based upon observations, review of medical records and policies and procedures, and staff interviews, the Registered Nurse failed to supervise and evaluate the nursing care for 1 of 5 patients (#1) as evidenced by: 1) failure to properly instruct visitors on how to don Personal Protective Equipment when visiting patient #1 who was on isolation for tuberculosis, 2) failure to ensure patient #1's soft wrist restraints were monitored and applied correctly to ensure the patient was unable to pull medical lines out, and 3) failure to ensure patient #1's respiratory breathing treatment mask was properly placed on the patient's mouth and nose.
Findings:

1) On 04/22/15 at 10:20 a.m., observation revealed the daughter of patient #1 came to the nurses station and asked S12RN if she could visit her father. S12RN stated yes. At that time, patient #1's daughter asked S12RN if she needed to put anything special on since a sign on her father's door stated the patient was in isolation. S12RN instructed the patient's daughter to put on a gown, gloves and mask prior to entering the room. S12RN did not get up from his seat or instruct the patient's daughter on the correct application of the personal protective equipment. Interview with S12RN at that time revealed that patient #1 was in isolation, with droplet precautions, due to a diagnosis of tuberculosis.

2) Observations on 04/23/15 at 10:30 a.m. revealed S13RN was in the process of administering patient #1's medications via the Dobhoff tube. During this process, the patient, who had bilateral wrist restraints on that were tied to the bed frame, was able to reach up with his restrained hand and scratch his nose in the area right above the dobhoff tube insertion site. The patient then reached up and grabbed and patted S13RN's hands while he was administering the medications. Interview with S13RN during this observation revealed that the patient had wrist restraints on "to keep him from removing his IV lines and the Dobhoff tubing".

Review of patient #1's medical record revealed, according to the Patient Assessment Report, that the bilateral soft wrist restraints were initiated on 04/21/15 at 8:00 a.m. The restraints were to be released every two hours for 10 minutes and the patient's status was to be monitored every 15 minutes. Review of the nursing notes from 04/21/15 to 04/24/15 revealed the RN documented the restraints were released every two hours for ten minutes; however, there was no documentation the patient's status was monitored every 15 minutes. Interview with S15RN/1 East Nurse Manager on 04/22/15 at 10:10 a.m. revealed the electronic medical record system automatically identifies the monitoring of the patient's status every 15 minutes; however, the nursing staff do not document this monitoring.

Review of the Policy and Procedure titled "Restraint and Seclusion", effective date 03/2007, revealed "H. Periodically Assessing, Assisting and Monitoring the Patient in Restraint or Seclusion: iv) Immediately after restraints are applied, a qualified Registered Nurse makes an assessment to ensure restraints were: properly and safely applied..." "v) A qualified Registered Nurse must assess the patient at established timeframes. Assessment, as appropriate to the type of restraint or seclusion, includes:...Ongoing monitoring is performed. Monitoring includes, but is not limited to:...whether the restraint has been appropriately applied, removed, or reapplied."

There failed to be documentation in patient #1's medical record that the RN assessed the patient's bilateral soft wrist restraints to ensure they were properly and safely applied as evidenced by the patient's ability to reach his nasal area where the Dobhoff tubing was taped in place.

3) Observations on 04/24/15 at 9:50 a.m. revealed patient #1 was lying supine in bed with a respiratory breathing treatment in progress; however, the treatment mask was on top of his head instead of on the mouth and nose area. There failed to be evidence the RN had assessment patient #1 to ensure the respiratory treatment mask was properly applied to ensure the patient was receiving the respiratory medication.

Based on record review and interview, the hospital failed to ensure the nursing staff followed the plan of care for 1 of 5 patients (#1) and developed and kept current individualized and comprehensive nursing care plans for 3 of 5 (#2, 3, 4) patients sampled. Findings:

Patient #1
Review of the medical record revealed the patient was admitted to the hospital on 03/31/15 with the diagnosis of pleural effusion and transferred to the Skilled Nursing Unit on 04/6/15. On 04/07/15, the patient was transferred back to acute care with the subsequent diagnosis of tuberculosis and development of failure to thrive. The patient was placed on droplet precautions isolation.

Review of the patient's plan of care revealed on 04/07/15 Airborne Isolation was identified with interventions "Patient or caregiver education provided on precautions." On 04/22/15 at 10:20 a.m., observation revealed the daughter of patient #1 came to the nurses station and asked S12RN if she could visit her father. S12RN stated yes. At that time, patient #1's daughter asked S12 RN if she needed to put anything special on since a sign on her father's door stated the patient was in isolation. S12RN instructed the patient's daughter to put on a gown, gloves and mask prior to entering the room. S12RN did not get up from his seat or instruct the patient's daughter on the correct application of the personal protective equipment.

Further review of patient #1's plan of care revealed the problem "Restraint use non-violent non-seft destruction behavior" and "Potential for Injury" due to the restraints. The interventions included "Assess and Monitor".

Observations on 04/23/15 at 10:30 a.m. revealed S13RN was in the process of administering patient #1's medications via the Dobhoff tube. During this process, the patient, who had bilateral wrist restraints on that were tied to the bed frame, was able to reach up with his restrained hand and scratch his nose in the area right above the dobhoff tube insertion site. The patient then reached up and grabbed and patted S13RN's hands while he was administering the medications. Interview with S13RN during this observation revealed that the patient had wrist restraints on "to keep him from removing his IV lines and the Dobhoff tubing".

Patient #2
Review of the medical record revealed the patient was admitted to the hospital on 04/15/15 with diagnoses of dehydration, fever, weakness and congestive heart failure. During his hospitalization, the patient was also diagnosed with the flu and put on isolation with droplet precautions.

Review of the patient's plan of care revealed that dehydration, fever nor the flu diagnosis was addressed on the care plan, as well as isolation precautions. The care plan was not comprehensive or individualized.

Patient #3
Review of the medical record revealed the patient was admitted to the hospital on 04/19/15 with diagnoses of febrile Neutropenia, sepsis and ovarian cancer on chemotherapy. The patient was placed on reverse isolation precautions.

Review of the patient's plan of care revealed that medical-surgical standards of care were addressed which included the following general interventions: monitor critical values, turn every two hours, medical-surgical general nursing assessments, vital signs, assess pain, skin assessments, intake and output, administer medications, fall risk assessment. The patient's care plan did not address the patient's specific admitting diagnoses, her diagnosis of cancer with current chemotherapy nor the isolation precautions. The plan of care was not comprehensive or individualized.

Patient #4
Review of the medical record revealed the patient was admitted to the hospital on 04/19/15 with diagnoses of acute gallstone pancreatitis with cholecystitis and sepsis. Further review of the record revealed the patient's blood cultures were positive for MRSA and the patient was placed on contact precautions.

Review of the patient's plan of care revealed that medical-surgical standards of care were addressed which included the following general interventions: monitor critical values, turn every two hours, medical-surgical general nursing assessments, vital signs, assess pain, skin assessments, intake and output, administer medications, fall risk assessment. The patient's care plan did not address the patient's admitting diagnoses nor his diagnosis of MRSA, requiring contact precautions. The care plan was not comprehensive or individualized.

On 04/23/15 at 2:00 p.m., interview with S3 Quality Assurance Director confirmed that the hospital was aware that the computerized care plans were not individualized. S3 Quality Assurance Director further confirmed that the care plans for patients #1, 2, 3, and 4 were not specific and comprehensive and did not address all diagnoses of the patients.

Based on record review, observation and interview, the hospital failed to develop an effective system to identify and control infections and communicable diseases of patients and failed to maintain a sanitary environment as evidenced by:
1. failing to ensure S7CNA removed contaminated linens from patient #1's isolation room in a red biohazard bag.
2. failing to ensure S11CNA removed contaminated gloves prior to handling clean linen.
3. failing to clean the Wireless on Wheels computers (WOW) between patient rooms.
4. failing to instruct a family member on the correct application of personal protective equipment involving a patient (#1) who was diagnosed with tuberculosis and was in isolation.
Findings:

1. Observations on 4/22/15 at 10:20 a.m. revealed S7CNA was observed to exit patient #1's droplet precautions isolation room holding contaminated linens and depositing them into a laundry barrel. Interview with S7CNA during this observation revealed there was not a red bio-hazard bag in the isolation room in which to place the contaminated linens.

2. On 04/23/15 at 9:35 a.m., observation revealed S11CNA exited a patient #1's isolation room while wearing gloves and holding dirty linen. The CNA was observed to walk all the way down the hall with the dirty linen and placed them in a laundry barrel. Further observations revealed S11CNA then went to the clean linen cart, while wearing the same contaminated gloves, pulled the covering off the cart and removed clean linen. The CNA then reentered the patient's room while still wearing the same gloves.

3. Review of the hospital policy titled Guidelines for Cleaning/Disinfection of Patient Care Equipment (IC 4.106), with an effective date of 06/10 revealed that patient care equipment will be cleaned or low level disinfected between patients.

On 04/23/15 at 9:45 a.m., observation revealed S12RN exited a patient's room with the rolling Wireless on Wheels computer (WOW) and proceeded to enter another patient's room without cleaning the WOW.

On 4/23/15 at 10:25 a.m., observation revealed S15RN exited a patient's room with the rolling Wireless on Wheels computer (WOW) and proceeded to enter another patient's room without cleaning the WOW.

On 04/24/15 at 11:00 a.m., interview with S3Quality Assurance Director revealed that the WOW should be cleaned each time it comes out of a patient's room and prior to entering another patient's room. S3 further revealed that the hospital did not have a policy that specifically addressed the cleaning of the WOWs.

4. On 04/22/15 at 10:20 a.m., observation revealed the daughter of patient #1 came to the nurses station and asked S12RN if she could visit her father. S12RN stated yes. At that time, patient #1's daughter asked S12 RN if she needed to put anything special on since a sign on her father's door stated the patient was in isolation. S12RN instructed the patient's daughter to put on a gown, gloves and mask prior to entering the room. S12RN did not get up from his seat or instruct the patient's daughter on the correct application of the personal protective equipment. Interview with S12RN at that time revealed that patient #1 was in isolation with droplet precautions due to a diagnosis of tuberculosis.