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Based on record review and interview, the hospital failed to ensure an evaluation of the patient in seclusion was conducted within 1 hour after initiation of restraint and/or seclusion and included an evaluation of the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition and the need to continue or terminate the seclusion for 1 (#3,) of 3 (#2, #3, #8) active sampled patients reviewed for the use of restraint/seclusion out of a total sample of 12. Findings:

Review of the hospital policy titled, Seclusion and Restraint, policy number NU.452, revision date of 10/26/12, verified as current by S2Acting DON (Director of Nursing) revealed in part the following: ....III. Procedure....E. A registered nurse may initiate a seclusion and/or restraint order only in an emergency situation and must then immediately notify the physician and/or psychiatric mental health nurse practitioner for the order. The physician, psychiatric mental health nurse practitioner, or a trained registered nurse must see and evaluate the patient face-to-face to perform an assessment within 1 hour after the initiation of the seclusion and/or restraint. This evaluation should be documented in the chart and include patient's immediate situation, patient's reaction to the intervention, patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion. The RN completing the face-to-face evaluation must consult with the treating physician as soon as possible after the evaluation and document such.

Patient #3
Review of the patient's medical record revealed the patient was a 35 year old male admitted to the hospital on 01/15/13 under a PEC (Physician Emergency Certificate) for threatening, aggressive behavior. The patient's diagnoses included Acute Exacerbation of Chronic Paranoid Schizophrenia and Antisocial Personality Disorder.

Review of the Seclusion Restraint Forms revealed the following:
01/15/13 at 5:15 p.m. the patient was placed in 4 point restraints and locked seclusion for being verbally abusive, danger to others, agitated, combative and disruptive. The record revealed the patient was released from restraints and seclusion at 7:00 p.m. (1 hour, 45 minutes). The Face-to-Face evaluation within 60 minutes section was left blank. Review of the Interdisciplinary Progress Notes revealed no documented evidence of an evaluation of the patient's medical condition or the patient's reaction to the interventions.

01/16/13 at 11:25 a.m. the patient was placed in 4 point restraints and locked seclusion for being dangerous to self/others, agitated, combative and disruptive, and having overt actions toward staff. The record revealed the patient was released from restraints and seclusion at 1:45 p.m. (2 hours, 20 minutes). The Face-to-Face evaluation within 60 minutes section was dated 01/16/13 (no time) and signed by S22APRN (Advanced Practice Registered Nurse). Further review of the patient's record revealed no documented evidence of the results of a face-to-face evaluation done within one hour of implementing the restraints and seclusion.

01/17/13 at 11:30 a.m. the patient was placed in locked seclusion for being a danger to others, agitated, and disruptive. The record revealed the patient was released from seclusion at 12:30 p.m. (1 hour). The Face-to-Face evaluation within 60 minutes section was dated/timed 01/17/13 at 11:45 a.m. Review of the Interdisciplinary Progress Notes revealed no documented evidence of an evaluation of the patient's medical condition or the patient's reaction to the interventions.

01/19/13 at 9:50 a.m. the patient was placed in locked seclusion for being a danger to self/others, agitated, and disruptive, and having overt actions toward staff. The record revealed the patient was released from seclusion at 10:50 a.m. (1 hour). The Face-to-Face evaluation within 60 minutes section was dated/timed 01/19/13 at 10:05 a.m. Review of the Interdisciplinary Progress Notes revealed no documented evidence of an evaluation of the patient's medical condition or the patient's reaction to the interventions.

01/19/13 at 5:45 p.m. the patient was placed in locked seclusion for being agitated and disruptive/out of control. The record revealed the patient was released from seclusion at 9:45 p.m. (4 hours). The Face-to-Face evaluation within 60 minutes section was dated/timed 01/19/13 at 6:00 p.m. Review of the Interdisciplinary Progress Notes revealed no documented evidence of an evaluation of the patient's medical condition or the patient's reaction to the interventions.

01/20/13 at 10:50 a.m. the patient was placed in locked seclusion for being a danger to others, agitated, disruptive/out of control, and having overt actions toward staff. The record revealed the patient was released from restraints and seclusion at 12:10 p.m. (1 hour, 20 minutes). The Face-to-Face evaluation within 60 minutes section was left blank. Review of the Interdisciplinary Progress Notes revealed no documented evidence of an evaluation of the patient's medical condition or the patient's reaction to the interventions.

01/23/13 at 9:48 a.m. the patient was placed in 4 point restraints and locked seclusion for being dangerous to self/others, agitated, combative and disruptive, and having overt actions toward staff. The record revealed the patient was released from restraints and seclusion at 1:15 p.m. ( 3 hours, 30 minutes). The Face-to-Face evaluation within 60 minutes section was dated/timed 01/23/13 at 9:55 a.m. Further review of the patient's record revealed no documentation of the results of the face-to-face evaluation done within one hour of implementing the restraints and the seclusion.

On 01/29/13 at 3:55 p.m., S2Acting DON was interviewed. After reviewing the record for Patient #3, she verified the Seclusion Restraint forms were not completed on the above restraint/seclusion episodes for the face-to-face evaluations. S2Acting DON verified the results of the face-to-face evaluation within one hour of implementing restraint and/or seclusion did not include an evaluation of the patient's medical condition and did not include the patient's reaction to the interventions.

On 01/30/13 at 2:20 p.m. Patient #3 was observed to be yelling and cursing at staff, and punching the door to his room. The patient was observed to be placed in seclusion. At 2:43 p.m. the patient was observed in 4 point restraints and locked seclusion.

Based on record review and staff interview, the hospital failed to develop and implement corrective action plans to improve performance for identified quality indicators. Findings:

Review of the hospital policy/QAPI Plan titled, Plan for Improving Organizational Performance, Policy number IOP.002, revision date of 11/12/07, and provided by S1ADM (Administrator) as current, revealed in part the following: ....II. Objective: 3. assure that there is improvement where suboptimal elements of care and service are identified.....8. assure the implementation of action to improve quality of care, treatment, and services. VII. Facility-Wide Performance/Outcome Indicators. The following performance/outcome indicators are collected and analyzed on a regular basis for potential performance improvement activity. 1. Occurrence Reports 2. Medication Errors 3. Seclusion/Restraint Reports 4. The use of Medication/Adverse Drug Reactions 5. Medical Record Review Findings 6. Utilization Management Findings 7. Infection Control Reports 8. Safety and Security Reports 9. Adverse Treatment Outcomes (AMAs [Left against medical advise], Regressive Transfers, Elopements, Suicide Attempts, Frequent Readmission). 10. Major Medical Events/Death 11. Patient/Family Dissatisfaction 12. Patient Rights Issues 13. Evaluation of Contracted Services.

Review of the hospital's Performance Improvement documents revealed quality indicator data was collected for January through November 2012.
Review of the Medical Records indicators revealed the Discharge Summary within 30 days, MD (physician) orders dated, timed, signed, and MD progress notes dated, timed, signed consistently were below the goal percentage for 2012.
Review of the Patient Satisfaction indicators revealed the survey were consistently below the goal percentage for 2012.
Review of the inpatient incidents revealed the numbers and categories of incidents were identified and tracked.
Review of the laboratory indicators revealed the lab results reported within 24 hours was consistently below the goal percentage for 2012.

Review of the performance improvement documents revealed no documented evidence of any corrective action plans or any performance improvement activities to address the indicators that were being monitored and tracked.

In a face-to-face interview on 01/31/2013 at 10:13 a.m. S1ADM (Administrator) verified there were multiple quality indicators with data collection and tracking of the indicators, but there were no corrective action plans for the data collected. S1ADM stated they were transitioning their performance improvement to S26RN and they will revise indicators to keep those that are problematic and drop the rest. S1ADM verified the only corrective action plans the hospital had begun were the corrective action plans done after the last complaint survey and the follow up survey.

Based upon review of Allied Health Professional Credential Files for the Advanced Practice Registered Nurse (APRN) and the Respiratory Therapist (RT), Allied Health Professional Policy and Procedure Manual, and staff interview, the hospital failed to ensure: 1) 2 of 3 Allied Health Professional Credential Files (S13APRN, S27RT) failed to contain evidence of current licensure, 2) 2 of 3 Allied Health Professional Credential Files (S13APRN, S14APRN) failed to have collaborative agreements with the supervising physician. Findings:

Review of the Allied Health Professional Policy and Procedure Manual revealed:
Article III-General Qualifications: "#1. Be currently licensed and/or certified by the appropriate specialty Board in the State of Louisiana."
Article IV-Categories, #2. Dependent Allied Health Professionals: "A. This category of practitioners shall consist of certified and licensed physician's assistants, nurse practitioners and other clinical technicians who are employees of an Active Medical Staff Appointee or a corporation controlled by the Active Medical Staff member." "The employer of the individual seeking approval as a Dependent Allied Health Professional shall present a concise, written statement of requested clinical duties and responsibilities of said individual to the Medical Executive Committee for review and complete the other necessary application forms..."

Review of the credential file for S13APRN revealed the Registered Nurse Licensure and the Advanced Practice Registered Nurse licensure both expired 1/31/12, Controlled Dangerous Substance Licensure expired 08/01/11, and the Drug Enforcement Agency License expired on 04/30/12. A letter dated 07/06/12 from the Louisiana State Board of Nursing identified adding S10MD (Medical Doctor) to the prescriptive authority privileges and that the collaborative practice agreement was in accordance with State Board Rules; however, the collaborative practice agreement with the supervising physician S10MD was not in S13APRN's credential file.

Review of the credential file for S14APRN revealed the medical staff application was from another hospital and signed by a "sponsoring" physician who was not on the hospital's medical staff. Interview with S8 on 01/29/13 at 1:35 PM, revealed when questioned the name of the sponsoring physician, S8 replied the signature did not look familiar, confirmed this physician was not on the hospital staff, and added "he could be from a sister hospital". There also failed to be evidence S14APRN had a collaborative practice agreement with a sponsoring physician who was on the hospital's medical staff.

On 01/30/13 at 11:00 AM, S8HR provided for review a credential for S27RT and stated S27RT was the hospital's Respiratory Therapist; however, had not worked at the hospital "for some time". Review of the credential file for S27RT revealed the Respiratory Therapy license expired on 12/31/12. The credential file also failed to identify a sponsoring physician.

Based upon review of Medical Staff Bylaws, Allied Health Professional Policy and Procedure manual, Physician and Allied Health Professional Credential Files, and staff interview, the medical staff failed to ensure the clinical privileges for each staff category was delineated for 4 of 4 physician credential files (S9MD, S10MD, S11MD, and S12MD) and 2 of 2 Allied Health Professionals Advanced Practice Registered Nurse (APRN) (S13APRN S14APRN). Findings:

Review of the Medical Staff Bylaws, Article V-Delineation of Clinical Privileges, Section 1: Criteria, "Each initial application of Staff appointment must contain a request for the specific privilege desired by the applicant. The initial determination as to clinical privileges shall be based upon the applicant's education and training, demonstrated competence and references. The applicant also bears the burden of establishing his qualifications and competency in relation to the privileges sought. Each Medical Staff member shall exercise only those clinical privileges specifically granted to him/her by the Medical Staff and the Board." These bylaws were approved by the hospital's medical director S11MD on June 15th, 2012.

Review of the Allied Health Professional Policy and Procedure Manual revealed
Article IV-Categories, #2. Dependent Allied Health Professionals: "A. This category of practitioners shall consist of certified and licensed physician's assistants, nurse practitioners and other clinical technicians who are employees of an Active Medical Staff Appointee or a corporation controlled by the Active Medical Staff member." "The employer of the individual seeking approval as a Dependent Allied Health Professional shall present a concise, written statement of requested clinical duties and responsibilities of said individual to the Medical Executive Committee for review and complete the other necessary application forms..."

Review of the physician credential files for S9MD, S10MD, S11MD and S12MD, and the Allied Health Professionals Advanced Practice Registered Nurse files for S13APRN and S14APRN revealed the clinical privileges failed to be identified.

Interview with S8HR on 01/29/13 at 1:40 PM, revealed she was responsible for the physician's credentialing process. When asked if she required the physicians to submit a delineation of clinical privileges, S8HR responded "no".

Based on interviews and record reviews, the hospital failed to ensure the pharmacy distributed medications in accordance with applicable standards of practice and consistent with Federal and State laws when the it failed to ensure all first doses of medications were not administered to patients before being reviewed by a pharmacist for known allergies, therapy contraindications, dose and route of administration, directions for use, duplication of therapy, interactions, and optimum therapeutic outcomes for all patients admitted after pharmacy working hours.
Findings:

Review of the "Louisiana Administrative Code Title 46 - Professional and Occupational Standards Part III: Pharmacists Chapter 15. Hospital Pharmacy", revealed, in part, "...1511. 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...". Further review of definitions listed revealed, in part, "...(13) "Drug regimen review" means and includes, but is not limited to, the following activities: (a) Review of the prescription drug order and patient record for [i] known allergies, [ii] therapy contraindications, [iii] dose and route of administration, and [iv] directions for use, (b) Review of the prescription drug order and patient record for duplication of therapy, (C) Review of the prescription drug order and patient record for interactions, and (d) Review of the prescription drug order and patient record for proper utilization including over- or under-utilization, and optimum therapeutic outcomes...".

Review of a hospital pharmacy policy titled Order Processing: Pharmacy (Policy number 10-14.11.0), with an effective date of January 2004 and presented as current by S2Acting DON, revealed, in part: "A pharmacist shall review the prescriber's original order, or a direct copy thereof, before the initial dose is dispensed (with the exception of emergency orders when time does not permit).
In a phone interview 1/30/13 at 9:50 a.m., S21Pharmacist, reported that a pharmacist is available 24 hours 7 days a week. The pharmacist said that orders are faxed to the pharmacist (located offsite) and the pharmacist reviews and enters the orders (electronically) into the medication system, which is then available on the medication dispensing machine in the hospital. He verified that all orders should be reviewed by the pharmacist before medication is administered. The pharmacist said that if the staff had questions there was always a pharmacist on duty in which to call.
Review of a report provided by the hospital titled Adverse Drug Reactions/Medication Variance Summary, Pharmacy Performance Improvement Project, presented to the Medical Executive Meeting 10/2012 revealed, in part, the following: Total Overrides by month for 2012:
January 441 February 315 March 416 April 485 May 641 June 460 July 434 August 568 September 381
Review of a list of medication/profile override history for December 2012 and January 2013 provided by S3DON (faxed 1/31/13 at 11:19 a.m. by the pharmacy) revealed that in December, 2012 there were 225 overrides on the medication dispensing machines at the hospital and 190 overrides in January 2013. These copies were provided in request for a report of medications given to patients in which there was not a pharmacy review for December 2012 and January 2013.
In a face to face interview 1/29/13 at 8:20 a.m. S2ActingDON verified that nurses are supposed to give an initial dose of medication only after a pharmacist had reviewed the order and entered the order into the patient's profile (electronically) that would then show up on the medication dispensing machine, unless it was an emergency. S2ActingDON reported that the order was faxed to the pharmacy, but sometimes they (the nurses) would call the pharmacist. The DON (Director of Nursing) reported that nurses did not always wait for the pharmacist to review and enter the medication into the patient's profile before giving a new medication.
In a face to face interview 1/29/13 at 8:24 a.m. S16LPN confirmed that he was a medication nurse and reported that if he received a new order and the medication is in the hospital he would override it, give the medication, and not have to wait for the pharmacy approval . He explained that to override a medication in the dispensing machine, two nurses had to verify in the machine that it was being given, and give a reason. When asked if all of the medications overridden in the machine were in an emergency he said no. The LPN( Licensed Practical Nurse) was asked if he was aware that new medications were to be reviewed by a pharmacist before the first dose was given, he indicated that he was not aware of that.
In a face to face interview on 1/29/13 at 12:45 p.m. S23LPN reported she was a medication nurse and part of the process for new orders for a patient included faxing the order to the pharmacy. She stated that it usually took anywhere from 5-30 minutes for the pharmacy to enter the medication into the patient's profile on the medication dispensing machine. She said that sometimes in order to get the medication on schedule she would override the order (enter the medication into the dispensing machine) so that she could go ahead and give it. She said it took 2 nurses to override the machine if no order had been entered by the pharmacist. When asked if she was aware that new medication orders were to be reviewed by a pharmacist before the first dose was administered except in an emergency, she said she was not.
In a face to face interview on 1/29/13 at 12:55 p.m. S24LPN confirmed that she was a medication nurse. She verified that she sometimes would override a medication order in the medication dispensing machine to give a newly ordered medication or medications to a new patient. She said she did not know that the hospital policy was to have a pharmacist review new orders before they were administered, with the exception of emergencies.

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Based upon review of personnel files and staff interview, the hospital failed to ensure the designated infection control officer S4RN (Registered Nurse) was qualified through education, training, experience or certification. Findings:

Review of the personnel file for S4RN revealed there failed to be evidence this employee had a job description specific for an infection control officer. S4RN's prior work history failed to identify any past experience with infection control nor was there evidence the employee had obtained any education, training or certification in infection control.

Interview with S4RN on 01/30/13 at 10:20 a.m., revealed she had been the Infection Control Officer since October 2012 and confirmed she has had no prior experience, had not obtained any type of certification, and had not received any training or ongoing education in infection control.

Based on record review and interview, the hospital failed to ensure a process was in place for prevention of communicable disease by the staff as evidenced by no documented evidence the physicians and APRNs (Advance Practice Registered Nurse) credentialed at the hospital were screened for TB (Tuberculosis) for 6 of 6 (S9MD, S10MD, S11MD, S12MD, S13APRN, S14APRN) credentialed files reviewed out of a total of 6 credentialed physicians and APRNs on staff at the hospital. Findings:

Review of the credentialing files for S9MD, S10MD, S11MD, S12MD, S13APRN, S14APRN revealed no documented evidence of the results of a TB screening.

On 01/31/13 at 12:00 p.m. S8HR Director (Human Resource Director) verified she was responsible for credentialing of physicians and APRNs. S8HR Director verified S9MD, S10MD, S11MD, S12MD, S13APRN, S14APRN had no documented evidence of the results of a TB screening. S8HR Director verified they did not have a process in place to screen physicians and APRNs and stated she did not know the physicians and APRNs had to have TB tests.

Based upon review of infection control program data, quality assurance/performance improvement data, and staff interview, the hospital failed to ensure the quality assurance program addressed problems identified by the infection control officer as evidenced by failure to develop an action plan to address the problems of an increase in Urinary Tract Infections on the geriatric population. Findings:

Interview with S4RN on 01/30/13 at 10:20 AM, revealed through review of the Health Care Acquired and the Community Acquired infections, it was identified there was an increase in Urinary Tract Infections related to the hospital's geriatric population.

Review of the infection control information submitted to Quality Assurance Program and the Medical Executive Committee revealed there failed to be an action plan developed to address the increase in geriatric Urinary Tract Infections.

Based upon review of physician credential files, Medical Executive Committee Meeting Minutes, and staff interview, the hospital failed to ensure a physician was appointed as the director of respiratory care services. Findings:

Review of the credential files for physicians S9MD, S10MD, S11MD, and S12MD revealed there failed to be documented evidence a physician was appointed as the director of Respiratory Care Services. Review of the Medical Executive Committee Meeting Minutes from 01/01/2012 through 01/29/2013 revealed there failed to be documented evidence a physician was appointed as the director of Respiratory Care Services.

Interview with S2Acting DON on 01/30/13 at 9:45 AM revealed when asked if a physician had been appointed as the director for respiratory services, she replied "no".

Based upon review of 1 of 11 random patient medical records, Allied Health Professional Credential Files, Respiratory Therapy Policies and Procedures, lists of employees, and staff interviews, the hospital failed to ensure a Respiratory Therapist was on staff at the hospital. Findings:

Review of the respiratory therapy policies and procedures revealed a policy titled Intermittent Aerosol Therapy, part N, "Assess and document all appropriate variables before and after each treatment (breath sounds, respirations, and side effects during therapy)." and part R "Chart the treatment performed and results observed on the respiratory treatment notes. Insert the notes into the patient's chart in the respiratory care section."

Review of the medical record for patient #R11 revealed on 01/26/13 at 3:20 PM, the physician ordered for the patient to receive respiratory therapy treatments twice a day with the medication Xopenex 0.63 milligrams. Further review of the medical record for R11 revealed the only documentation related to the Xopenex aerosol respiratory treatments was the date and time the medication was administered on the Medication Administration Record.

Review of the lists of employees and Allied Health Professionals revealed a Respiratory Therapist failed to be identified. Interview with S8HR on 01/30/13 at 11:00 AM, revealed when asked if the hospital had a Respiratory Therapist on staff, S8HR replied at first "no", then approximately 30 minutes later supplied a credential file for S27RT.

Review of the credential file for S27RT revealed the respiratory therapist was initially appointed on 11/19/09; however, the respiratory license expired on 12/31/12. Interview with S8HR on 01/30/13, 11:50 AM, revealed when asked about when the last time S27RT provided oversight of the respiratory therapy services, S8HR replied "it has been a long time".

Interview with S2Acting DON on 01/30/13 at 9:30 AM, revealed when asked who performed respiratory treatments, S2DON replied "the nursing staff". Further interview with S2Acting DON revealed when asked who performed respiratory therapy competency evaluations and educational inservices, she replied the "nursing staff". Interview with S15RN (Registered Nurse) and S16 LPN (Licensed Practical Nurse) on 01/30/13 at 9:45 AM, revealed when asked if they had received any inservices or competencies from a respiratory therapist regarding respiratory care services, both replied "no" and that they had prior experience at another hospital.

Based upon review of the list of contracted services, contracts, and staff interview, the hospital failed to ensure a Psychologist was available to provide psychological services to the patient population. Findings:

Review of the list of contract services revealed a Psychologist failed to be identified. Review of the contract book revealed a tab identifying "Psychologist"; however, the tab was empty. Interview with S8HR Director on 01/30/13 at 1:20 PM, revealed the hospital had a contract with a Psychologist but the contract had been removed for review by the hospital's corporate personnel in October 2012 and was not returned.