HospitalInspections.org

Based on observation, interview and record review, the hospital failed to meet the Condition of Participation for Patient Rights as evidenced by:

1) Failing to ensure patients received care in a safe setting by:

a) failing to maintain ordered observation levels on patients admitted with acute psychiatric medical conditions for 11 of 20 psychiatric patients reviewed out of a total sample of 30. This was evidenced by:

A-1-failing to ensure a patient (Patient #4) on the psychiatric unit was visually observed every 15 minutes as documented by a mental health technician (MHT) resulting in Patient #4 not being visualized for 30 minutes at which time she (Patient #4) attempted to hang herself with a pillow case.

A-2 -by failing to observe 10 current patients (#1, #2, #3, #16, #17, #R1, #R2, #R3, #R4 & #R5) every 15 minutes as ordered on the psychiatric unit. (See findings under tag A-0144);

b) failing to ensure patients determined to be a danger to themselves or others were not allowed to elope from the Recovery Unit, Emergency Department and the hospital, requiring police involvement for their return, for 4 (#18, #19,#27,#28) of 4 patients reviewed for elopements out of a total sample of 30. (See findings under tag A-0144).

c) failing to ensure the physical environment in the Emergency Department (ED) and the psychiatric unit did not provide opportunities for self-harm of the psychiatric patients.
(See findings under tag A-0144).

2) Failing to ensure direct care staff had education, training and demonstrated knowledge based on the specific needs of the patient population as evidenced by failing to ensure all direct care staff received and remained current in training based on the use of nonphysical intervention skills for 6 (S5MHT, S9RN, S10RN,S19RN,S20RN, S35RN) of 9 direct care staff personnel records reviewed for crisis prevention intervention training. (See findings under tag A-0200).

Based on record review, interviews and observations, the hospital failed to ensure patients received care in a safe setting by:

a) failing to maintain ordered observation levels on patients admitted with acute psychiatric medical conditions for 11 of 20 psychiatric patients reviewed out of a total sample of 30. This was evidenced by:

A-1 failing to ensure a patient (Patient #4) on the psychiatric unit was visually observed every 15 minutes as documented by a mental health technician (MHT) resulting in Patient #4 not being visualized for 30 minutes at which time she (Patient #4) attempted to hang herself with a pillow case and;

A-2 by failing to observe 10 current patients (#1, #2, #3, #16, #17, #R1, #R2, #R3, #R4 & #R5) every 15 minutes as ordered on the psychiatric unit.

b) failing to ensure patients determined to be a danger to themselves or others were not allowed to elope from the Recovery Unit, Emergency Department and the hospital, requiring police involvement for their return, for 4 (#18, #19,#27,#28) of 4 patients reviewed for elopements out of a total sample of 30.

c) failing to ensure the physical environment in the Emergency Department (ED) and the Recovery Unit did not provide opportunities for self-harm of the psychiatric patients.


Findings:

A) Failing to provide required observation levels.
Review of the hospital policy titled Close Observation, 1:1's, Revised 7/15/09, revealed in part:
Close Observation: staff observes and documents the patient's behavior every fifteen (15) minutes while awake and every thirty (30) minutes while asleep.
Constant Observation: constant visual observation of the identified patient by an assigned staff member. The patient must remain within the line of sight of the staff member at all times.
A-1
Patient #4
Review of the medical record for Patient #4 revealed she had been triaged in the ED on 2/11/15 at 10:30 a.m. She was assessed as being potentially violent and hearing auditory hallucinations that commanded violence.
Review of the psychiatric unit Nursing Admission Assessment for Patient #4 dated 2/11/15 revealed in part:
Patient is tearful, sobbing at present. Patient states she has been non-compliant, states is lonely and sad and "all of my family isn't right". Patient affect flat, mood depressed. Pt states suicidal ideations stating "I want to die. I am tired of living this life".
Statements of intent to harm self? Yes
Experiencing auditory hallucinations that command self-harm? Yes
Current suicide potential- Thoughts
Placed on precautions? Q 15 (observe every 15 minutes)

Review of an incident report written by S1Administrator revealed Patient #4 had been admitted on 2/11/15 to the Recovery Unit (psychiatric unit) with a diagnosis of Psychosis and combative behavior. On 2/12/15 at 10:22 a.m., the patient's roommate notified staff that Patient #4 had hung herself in the bathroom using a pillowcase. A code blue was called and the patient was transferred to the Emergency Department and later to another hospital for a higher level of care.
In an interview on 5/13/15 at 9:48 a.m. with S1Administrator, she said the video of Patient #4's hanging incident revealed the staff did not do the 15 minute observations like they were supposed to because S6MHT (Mental Health Technician) did not go into the room to check the patient but instead stood outside of a closed door (entry to patient's room) while Patient #4 was inside the room crying. S1Administrator also said S6MHT falsely documented that she had observed her twice. S1Administrator said the hospital did some education after the incident but there was obviously still a problem with observations being performed as required. S1Administrator also verified Patient #4 had eloped from the Emergency Department on two separate admissions before the 2/11/15 admission.

A-2 by failing to observe 10 current patients (#1, #2, #3, #16, #17, #R1, #R2, #R3, #R4 & #R5) every 15 minutes as ordered on the psychiatric unit

Review of the medical record for Patient #1 revealed he was a current patient that had a Physician Emergency Certificate (PEC) dated 5/10/15 that listed him as being depressed, tearful, positive for suicidal ideations and auditory hallucinations. Further review revealed a Suicide Risk Screening dated 5/10/15 that had questions related to patient suicide risk factors. Based on the answers, the patients were either categorized as Low Risk requiring routine monitoring, Moderate Risk requiring close observation or High Risk requiring constant observation. Patient #1 was selected as a moderate risk.

Review of the medical record for Patient #2 revealed he was a current patient admitted on 5/7/15 for bizarre behavior and noncompliance with his medications. His diagnosis was listed as Schizophrenia. Patient #2 also had a history of seizures.

In an interview on 5/12/15 at 10:43 a.m. with S7RN, she said she was the charge nurse of the psychiatric unit. She said Patient #1 and Patient #2 were close observation which meant they had increased observation levels greater than every 15 minutes. S7RN said she was not sure why the 2 patients were on those increased levels. When asked if staff members were assigned to the close observation patients she said, "No." She said everybody in the unit watches the patients. When asked where Patient #1 and Patient #2 were, she said she did not know.

An observation on 5/12/15 at 10:44 a.m. with S3PsychMgr revealed Patient #2 was in a group meeting and Patient #1 could not be located. S6MHT was in the hall and was asked where Patient #1 was and she said she did not know. At 10:53 a.m., Patient #1 was located coming out of the bathroom in his room. There had been no staff observing him.

Review on 5/12/15 at 10:45 a.m. of the Q 15 (every 15) Minute Observation Sheets dated 5/12/15 revealed no documentation that the males on the unit ( #1, #2, #3, #16, #17, #R1, #R2, #R3, #R4, #R5) had been observed for 45 minutes from 10:00 a.m. until 10:45 a.m.

In an interview on 5/12/15 at 10:48 a.m. with S6MHT, she said she was doing the Q 15 minute checks on the female patients. When S6MHT provided documentation of the observations, the 10 male patients on the unit had not had the 15 minute checks documented since 10:00 a.m. (45 minutes). When asked if she had done the observations, S6MHT said S5MHT had been responsible for observations of the male patients and she was only responsible for the females. S6MHT said she just obtained the Q 15 minute observation sheets on the men at 10:45 a.m. from the desk at the nurse's station.

In an interview on 5/12/15 at 10:50 a.m. with S5MHT, he said he had not observed the men on the unit since 10:00 a.m. He said he had gone to mop up water from a shower that had overflowed and gone into the hall. He said he had verbally told S6MHT to watch the patients.

In an observation on 5/12/15 at 1:20 p.m., Patient #1 was in his room with the door closed. He was not being observed.

In an observation on 5/12/15 at 1:45 p.m., S5MHT was at Patient #1's bedside sitting in the patient's wheelchair. S5MHT had his head leaned back and his eyes closed.

In interviews on 5/12/15 at 1:50 p.m., S5MHT said he thought S6MHT had been watching the men every 15 minutes on the unit since 10:00 a.m. S6MHT said she thought S5MHT had been watching the men on the unit. S7RN said she was in charge, but she did not know who was watching the men. When asked where the Q15 Minute Observation Sheets were for the men on the unit, they could not be located until the surveyor asked if they had been thrown away on accident. S6MHT removed the observation sheets from the trash and said she must have accidentally thrown them away earlier. Further review revealed there was no documentation of Q 15 minute observations since 10:45 a.m. (3 hours and 5 minutes). At the bottom of the document was a statement, "Nurse to sign off every hour to assure quality care is provided." S7RN verified she had not done or initialed the 1 hour verifications all day on the patients (since 7:45 a.m.).

In an interview on 5/12/15 at 1:20 p.m. with S3PsychMgr, she said Patient #1 was on increased precautions because he had a moderate suicide risk assessment. She said Patient #2 was on increased precautions because he had seizures. She said close observation meant within line of sight at all times.

In an interview on 5/12/15 at 1:40 p.m. with S6MHT, she said close observation meant to keep a close eye on the patients but not within arm's length. She said she did not know what the policy said, but they were supposed to pay more attention to the close observation patients than the 15 minute observation patients.

In an interview on 5/12/15 at 1:44 p.m. with S7RN, she said in her opinion, close observation meant to keep the patients in line of sight. She said she was not sure what the policy said.

In an interview on 5/12/15 at 1:46 p.m. with S11MHT, she said close observation was going from room to room back and forth continuously. She said she did not know what the policy said.

In an interview on 5/12/15 at 2:10 p.m. with S4PsychDir (Psychiatric Director), she said the intent of the moderate risk on the suicide risk assessment was for the moderate risk to be in visual sight at all times. She said the risk assessment tool was incorrect and did not match the policy guidelines. She agreed the suicide tool had the moderate risk observation level at the same level (every 15 minutes) as the low risk assessment. She said someone with a moderate risk for suicide should be in line of sight at all times. S4PsychDir also agreed there was a system breakdown for staff performing patient observations.

In an interview on 5/12/15 at 2:15 p.m. with S3PsychMgr, she agreed there was a system breakdown with maintaining observation levels in the psychiatric unit. She verified there was no system in place to assign responsibility for patients with increased observation levels or for the every 15 minute checks. S3PsychMgr also verified the nurses were supposed to be reviewing the observation sheets once per hour to verify it had been done correctly, but that was also not being done consistently.

In an interview on 5/12/15 at 2:00 p.m. with S1Administrator, she said the infrastructure was broken. She said the Recovery Unit (psychiatric unit) probably did not have access to the psychiatric policies because of how they were in the computer. S1Administrator also said the observation levels were not maintained as intended on the psychiatric unit. S1Administrator verified there was no difference in the observation levels between the low risk and the moderate risk on the suicide assessment but there should have been.

In an interview on 5/15/15 at 10:05 a.m. with S8Psychiatrist, he said a patient with a moderate suicide risk should have been observed more frequently than every 15 minutes. He agreed there were problems with the staff maintaining observation levels on the patients in the psychiatric unit.


b) Failing to prevent patients determined to be a danger to themselves or others from eloping from the Recovery Unit, the ED and the hospital, requiring police involvement for their return.

Review of the hospital policy titled, Patients Awaiting Psychiatric Evaluation, Effective 2/20/04, revealed the only mention of how psychiatric patients were to be monitored was: Maintain patient safety; Utilize restraints only if patient is a danger to self, staff or others (refer to restraint policy); Call local law enforcement agency, if there is potential danger to patient, staff or others.
Further review revealed no guidance/guidelines for making the room safe for psychiatric patients, management of patient clothing and personal items (contraband searches/confiscation), guidance on levels of observation or type of observation to initiate, and protocols to protect/prevent the PEC patient from eloping.

Patient #18
Review of Patient #18's medical record revealed an admission date of 2/17/15, legal status: PEC, with the following diagnoses: Psychosis, Amphetamine Use and Attention Deficit Disorder.

Review of Patient #18's initial screening upon admission to the Recovery Unit revealed the following, in part:
Violent/Assaultive Potential: Have violent or aggressive behavior: Yes
Self harm potential: Potentially lethal suicide attempt made in last 24-48 hours: Yes; Statements of intent to harm self: Yes; Plan to harm self: No;

Review of Patient #18's Suicide Risk Screening, completed upon admission, revealed the following: Suicide Risk: Moderate; Close Observation Level.

Review of Patient #18's elopement incident reports revealed the following:
2/19/15, 12:00 p.m.: Location: Psychiatric; Type of Occurrence: Elopement
Brief factual description: It was noted that patient was nowhere to be found in the unit. The window pane was pushed away from the frame. Local police notified and pt. was apprehended and brought back to the Recovery unit; Physician's Treatment: Give Seroquel XR now and every a.m.
2/19/15, 2:55 p.m.: Location: Psychiatric; Type of occurrence: Elopement
Brief Factual Description: Pt. was outside in the yard during a smoke break, pt. was trying to scale the fence related to "I hear a baby crying on the other side of the fence!" Pt. was impossible to redirect. Eventually he grabbed the tops of the two slats and pulled them down and got through the hole in the fence. Local police department was alerted and apprehended the pt. at the front of the hospital and escorted pt. back to the unit. Orders received from psychiatrist to call him if current medications ordered do not help pt. Pt. is placed on 1:1 monitoring status for his safety.

Review of Patient #18's Recovery Unit Daily Nursing Notes revealed the following entries:
2/19/15, 11:56 a.m.: Pt. asked if he could leave then asked if he could sign himself out, then said, "I don't feel like this place is doing me any good. It's not doing anybody any good!" Explained to pt. the process of commitment but he seemed confused when asked if he could sign himself out. Pt. asked for some of his clothes. Explained to pt. that if he could verbally contract about not trying to elope that he could have some of his clothing. Pt. eventually contracted with a nod of his head. Pt. was also informed that that if he were to elope that he would be brought back to the unit. Pt. verbalized understanding, will monitor closely for safety.
2/19/15, 11:58 a.m.: Recovery Daily Notes: Pt. managed to elope, likely through the window in his room when the plexi-pane was pushed out and the hurricane screen opened and shut when he got out, but was brought back to the unit by local police. Pt. is being debriefed by S2DON, at this time. Pt will be kept in gowns and monitored 1:1 from this point on until seen by the Psychiatrist. Psychiatrist was alerted at 11:41 a.m. Awaiting further orders. Will continue to monitor for safety.
2/19/15, 12:20 p.m.: Pt. was outside with S2DON and male MHT so that he could smoke. It was reported that pt. was climbing the fence. Pt. continues to be monitored 1:1 for safety.
2/19/15, 1:21 p.m.: Pt. trying to go to his room to lie down, but redirection is difficult. Pt. was sitting on the bed, by the window, peeling away the glue from the other window pane that is not boarded up.
2/19/15, 3:30 p.m.: While outside during a smoke break, pt. was making repeated attempts to scale the fence in the yard. "I hear a baby crying on the other side of the fence!" Pt. was impossible to redirect. Eventually he grabbed the tops of the two slats and pulled them down and got through the hole in the fence. Local police department was alerted and apprehended the pt. at the front of the hospital and escorted pt. back to the unit. Orders received from psychiatrist to call him if current medications ordered do not help pt. Pt. is placed on 1:1 monitoring status for his safety.
In an interview on 5/14/15 at 12:41 p.m. with S2DON, he indicated Patient #18 had been on close observation (q 15 minute checks) at the time of his first elopement. S2DON explained Patient #18 had worked on removing the caulking from around the plexiglass window panes in his room, in between the q 15 minute checks. S2DON indicated the patient had timed his elopement attempts in between the q 15 minute checks. He also indicated that if the IT (instrument technology) staff told had not told him (S2DON) someone was outside of the window, the patient would have gotten further away from the hospital. He explained the psychiatrist had medicated the patient and he had been allowed to go back on the smoke deck in an effort to de-escalate the patient. He indicated the patient had gone over the fence when he was taken out to smoke. S2DON said after the 1st elopement Patient #18 was placed on 1:1 supervision (within arm's length per S2DON's definition). He said the patient grabbed the top of the fence planks, after attempting to scale the fence, and exited through a hole in the fence made when the planks pulled away. S2DON indicated Patient #18 had made it to Hwy. (Highway) 190 (approximately 150-200 yards) when the police caught up with him. He confirmed the hospital had not employed security guards or police officers. S2DON explained local police offers were called to handle elopements and/or escalating situations involving patients and staff.
Patient #19
Review of Patient #19's medical record revealed an admission date of 3/30/15, legal status: PEC, with diagnoses including the following: Schizophrenia, Acute Psychosis and Paranoid Delusions (demons chasing him).
Review of Patient #19's medical record revealed an order, dated 3/30/15, for monitor and document behavior observations. Further review revealed no documented evidence of a prescribed level of observation.
Additional review of Patient #19's medical record revealed the level of suicide risk on the Suicide Risk Assessment , completed on admit, was left blank. Recovery Unit staff indicated this assessment was used to determine level of observation based upon level of suicide risk.
Review of the Hospital's incident reports for elopements revealed Patient #19 eloped from the Recovery Unit on 4/4/15 at 3:15 p.m. after attempting to leap over the nurses' station to grab the nurse. He kicked through the locked doors of the entry to the Recovery Unit. He left the building and was returned to the hospital by local police.
Review of Patient #19's nurses notes, dated 4/4/15 at 4:03 p.m., revealed the patient was returned to the Recovery Unit by the local police department after he eloped on 4/4/15 at 3:15 p.m. Further review revealed no documented evidence of increased level of supervision post elopement (4/4/15). Additional review revealed the patient was put on 1:1 supervision on 4/5/15 at 1:11 p.m. due to increased need for prompting to have patient take/swallow his medications.
In an interview on 5/15/15 at 9:00 a.m. with S1Administrator, she confirmed nothing had been done to reinforce the doors of the Recovery Unit after Patient #19 had kicked them open and eloped from the unit.
Patient #27
Review of Patient #27's medical record revealed an admission date of 5/21/14 at 2:01 a.m., legal status: PEC, with admission diagnoses including Drug Induced Psychosis and Poly-Substance Abuse (PCP-[Angel Dust], Cocaine and Marijuana). He was discharged on 5/28/14.
Further review revealed the patient was admitted to the Recovery unit and placed on q 15 minute observations for safety.
Review of the hospital ' s incident reports for elopement revealed Patient #27 had eloped from the Recovery Unit on 5/21/14 at 2:35 p.m. (day of admission) after pushing his way into the nurses' station to grab cigarettes, rushing to the back entrance of the unit, kicking open the back door and kicking at the fence. He was brought back into the unit to use the phone and he then rushed the main entrance to the unit, kicked open the locked doors and exited the unit and the hospital when there was no answer to his phone call. He was brought back to the hospital by local police in restraints. He was subsequently medicated and placed in restraints at the hospital.
Patient #28
Review of Patient #28's medical record revealed an admission date of 3/14/15, legal status: PEC, with the following admission criteria: Danger to Self, Gravely Disabled and Detox. Further review revealed the patient was initially assessed on 3/14/15 in the hospital's ED. Additional review revealed Patient #28 eloped, naked, from the ED on 3/14/15 at 12:00 p.m. after hitting the nurse in the chest . Patient #28 was subsequently returned to the hospital by local police.

In an interview on 5/13/15 at 4:50 p.m. with S9RN she confirmed she provided care to psychiatric patients in the ED. She indicated that they attempted to talk to the patients in an effort to de-escalate them. S9RN said when patients "make up their mind to run" they don't stop them. She said the local police were called to bring the patients back to the hospital after elopement. S9RN also confirmed she had no current CPI training.
In an interview on 5/13/15 at 4:54 p.m. with S10RN (ED nurse), she confirmed that she provided care for psychiatric patients in the ED. S10RN indicated that the direct care staff tried to "talk patients down" when they were being treated in the ED. She said the ED staff did not stop eloping patients. S10RN said the local police were called to bring the patients back to the hospital after elopement. S10RN confirmed she had no current CPI training.
In an interview on 5/14/15 at 12:41 p.m. with S2DON, he confirmed not all direct care staff working the ED and the Recovery Unit had current CPI training. He also indicated all direct care staff in the Recovery Unit and direct care staff who cared for patients with psychiatric diagnoses/issues should have CPI training.
In an interview on 5/15/15 at 9:26 a.m. with S18RN (ED Nurse Manager), she said there had been no elopements from the ED to her knowledge since January of this year. S18RN indicated direct care staff attempted to "talk patients down", but did not attempt to stop patients from eloping from the ED. She said it was hospital policy to call the local police department to bring the patients who had eloped back to the hospital.

In an interview on 5/15/15 at 9:30 a.m. with S1Administrator, she indicated the staff 's mentality was to not stop patients who were attempting to elope. She said they called the local police department. S1Adminstrator acknowledged lack of staff training was a contributing factor to the issues with patient elopements. She indicated all direct care hospital staff (Recovery Unit, ED staff and any staff pulled to work in ED) should have been trained in CPI (Crisis Prevention Intervention-training of choice for this hospital) techniques which could assist them in prevention of patient elopements. S1Administrator confirmed some of the staff had not been trained in CPI and/or their training had lapsed.

In an interview on 5/15/15 at 9:40 a.m. with S3PsychMgr (Recovery Unit Manager), she said she thought there was maybe only 1 elopement this year. S3PsychMgr confirmed elopements were not included in QAPI (quality assurance performance improvement).

In an interview on 5/15/15 at 10:00 with S2DON, he indicated there had been more than 1 elopement from the hospital since January 2015, but he wasn ' t sure how many had occurred. S2DON also indicated the hospital did not have detailed policies for watching/management of psychiatric patients in the ED.
In an interview on 5/15/15 at 10:18 a.m. with S19RN, she indicated that she worked in the ED. She also indicated that her CPI training had expired in April or May of 2014. S19RN confirmed that she had provided care for patients with psychiatric diagnoses/issues in the ED. S19RN said patients attempting to elope from the ED were not stopped by staff. She said the local police were called to find the patients. S19RN indicated the police brought the patients back.

In an interview on 5/15/15 at 10:30 a.m. with S1Administrator, she indicated that she thought there had been 3 elopements this year. S1Administrator indicated she was working on compiling a list of elopements.

In an interview on 5/15/15 at 11:00 a.m. with S16Quality, she indicated elopements were not addressed as adverse/sentinel events nor were they addressed as an indicator for QAPI (quality assurance performance improvement).

Review of the list of elopements prepared (during the survey) by S1Administrator revealed the following patients had eloped:|
ED:Patient #4: eloped from ED on two separate admissions before the 2/11/15 admission (information provided by and verified by S1Administrator ).
Patient #28: eloped 3/4/15.
Recovery Unit:
Patient #18: eloped twice on 2/19/15;
Patient #19: eloped on 4/4/15;
Patient #27: eloped on 5/21/14.
Further review of the elopement list revealed all accounts of the number of elopements provided by various hospital staff, referenced in interviews above, had been inaccurate.

3) Failing to ensure the physical environment in the Emergency Department (ED) and the psychiatric unit did not provide opportunity for self-harm of the psychiatric patients.

An observation of the Emergency Department on 5/12/2015 at 9:45 a.m. revealed a bathroom located between two exam rooms. Observation revealed the bathroom had ligature risks including exposed overhead sprinkler pipes from the ceiling and a gooseneck faucet. Further observation revealed there was an electrical box that was not locked, plastic garbage bags in 2 trash cans and a glass mirror that could be broken. The bathroom could also be locked from the inside.

In an interview on 5/12/2015 at 10:05 a.m. with S20RN, she said when the ED had psychiatric patients, they used the bathroom mentioned above. She said the staff would sit outside the door and the patients were allowed to close the door. She said they never went into the bathroom with the psychiatric patients or left the door cracked. She verified there were several ligature risks and that the glass mirror could be broken and used to cause self-harm or as a weapon. She also confirmed the plastic bags could be used for suffocation or strangulation. S20RN also said there was a tool to unlock the door if needed. Observation revealed S20RN had difficulty using the tool to unlock the door.

Observations on 5/12/2015 from 10:30 a.m. until 11:00 a.m. of the psychiatric unit revealed the following safety hazards:
- A clean linen room was located on a hall that was accessible by patients. Further observation revealed the door to the room was not closed and no staff member was present in the room or in the hallway. Patients were in and out of rooms and the hallway. The room contained sheets, pillow cases, blankets and bathing supplies. Included in the bathing supplies were 2 disposable razors on a sink and 31 razors in an unlocked drawer.

- An observation room with the door unlocked that contained a bed with a metal frame and springs and wires that were removable. Further observation revealed a fluorescent light fixture with plastic covers in the ceiling that could be removed and several ceiling tiles that were not permanently fixed.

- An unlocked room with "Staff Only" written on the open door. Inside was a glass coffee pot, cooking utensils and glass plates. Further review revealed a tote bag with mesh pockets on the side containing a bottle of Aleve (pain relief medication).
- An unlocked seclusion room that had a large hole in the wall exposing insulation, non-ligature door hinges and a standard door knob on the bathroom door.

- Rooms a,b,c,d,e,f,g,h,i,j,and k had beds with metal bed frames that contained springs and wire that could be removed. The bathrooms contained gooseneck faucets and glass mirrors. Further observation revealed each room contained upper windows made of breakable glass.

- Room i had one bed with side rails that could be a ligature risk.

- Rooms d and j had screws in a metal shower enclosure that were not tamper resistant and contained sharp points.

-An unobserved and unsecured housekeeping cart in an unrestricted hallway containing a bottle of Virex (disinfectant), a bottle of bleach and a can of Comet (powdered cleaning product).

In an interview on 5/12/15 at 11:00 a.m. with S3PsychMgr, she verified the above mentioned items were safety hazards. She said the hospital had realized there were a lot of safety risks on the unit, but they did not have the money to fix everything at once. S3PsychMgr also verified the hospital had not put anything in place to mitigate the risks until they could be corrected.


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Based on record review and interview, the hospital failed to ensure direct care staff had the education, training and demonstrated knowledge based on the specific needs of the patient population as evidenced by failing to ensure all direct care staff received and remained current in training based on the use of nonphysical intervention skills for 6 (S5MHT, S9RN, S10RN,S19RN,S20RN, S35RN) of 9 direct care staff personnel records reviewed for crisis prevention intervention training.
Findings:
Review of the Personnel files for S9RN, S10RN, S19RN, and S20RN, employed in the Emergency Department (ED), revealed no documented evidence of current CPI (crisis prevention intervention) training (CPI was the program of choice for this hospital).
Review of the personnel files for S5MHT and S35RN, employed in the psychiatric unit, revealed no documented evidence of current CPI training.
In an interview on 5/13/15 at 4:50 p.m. with S9RN (ED nurses), she confirmed she had no current CPI training. S9RN also confirmed she had provided care for psychiatric patients in the ED.
In an interview on 5/13/15 at 4:54 p.m. with S10RN (ED nurse), she confirmed she had no current CPI training. S10RN also confirmed she had provided care for psychiatric patients in the ED.
In an interview on 5/14/15 at 12:41 p.m. with S2DON, he confirmed not all direct care staff working the ED and the Recovery Unit had current CPI training. He also indicated all direct care staff who provided care for patients with psychiatric diagnoses/issues should have CPI training.
In an interview on 5/14/15 at 1:21 p.m. with S1Administrator she said the hospital had previously had a complete lack of orientation and unit specific orientation had been lacking for a long time, as well. She confirmed skills competencies should have been assessed at the hospital for all staff. S1Administrator indicated CPI training for hospital direct care staff was not currently at 100%. She said staff without CPI training should not be providing hands on care for patients in the psychiatric unit. It is her expectation for all staff that provide direct patient care in the ED and psychiatric unit to have CPI training.
In an interview on 5/15/15 at 9:00 a.m. with S13HR (Human Resources Director), she confirmed S5MHT had not been present at CPI training and was therefore not currently trained. S13HR reviewed and confirmed the above referenced employee CPI training findings. S5MHT was currently providing hands on care for patients in the psychiatric unit(verified per observation and record review).
In an interview on 5/15/15 at 10:18 a.m. with S19RN, she indicated that she worked in the ED. She also indicated that her CPI training had expired in April or May of 2014. S19RN confirmed that she had provided care for patients with psychiatric diagnoses/issues in the ED.

Based on record review, observation and interview, the hospital failed to meet the Condition of Participation for Medical Records as evidenced by:

1) failing to ensure the Quality Assessment and Performance Improvement (QAPI) Program measured, analyzed and tracked adverse patient events. This deficient practice is evidenced by failing to analyze elopements by 4 (#18, #19, #27, #28) psychiatric patients and an attempted suicide and elopement by a psychiatric patient (#4). (See findings in tag A-0286);

2) failing to ensure data collected for indicators was accurate. This deficient practice is evidenced by quality data for incomplete medical records on the psychiatric unit being incorrectly listed as 3 deficient records in the April 2015 QI Narrative Report. (See findings in tag A-0273)

Based on record review and interview, the hospital failed to ensure data collected for indicators was accurate. This deficient practice is evidenced by quality data for incomplete medical records on the psychiatric unit being incorrectly listed as 3 deficient records in the April 2015 QI Narrative Report.
Findings:

Review of the QI Narrative Report for April 2015 revealed 3 medical records in the Recovery Unit were listed as incomplete.

In an observation on 5/14/15 at 1:40 p.m. on the Recovery Unit (psychiatric unit), a cabinet in the nurse's station had over 100 medical records stacked on multiple shelves. The records were dated from January to the present.

In an interview on 5/14/15 at 11:00 a.m. with S12MedicalRecords, she said she had just found out there was a cabinet in the Recovery Unit full of delinquent medical records. She said she was unaware medical records were in the cabinet and did not include them in her delinquency rates.

In an interview on 5/15/15 at 10:15 a.m. with S16Quality, she said she was unaware of the incorrect numbers from medical records.

Based on record review and interview, the hospital failed to ensure action plans were implemented by the Quality Assurance Committee and the results of the actions evaluated.
Findings:

Review of the QAPI Data provided by the hospital revealed identified the following problems and corrective actions:
-Incomplete medical records greater than 30 days listed as 130 for the acute unit. The corrective action was listed as " Report to medical staff. " The result of the action was listed as " continue to monitor. "
-5 medication errors were identified for April 2015. The corrective action was listed as " Missed dose 3 and Wrong dose 2. " The results of the action taken were listed as " continue to monitor. "
-Medication Reconciliation Form completed for applicable patients upon admission was 23 of 40 on the Recovery Unit. The corrective action listed was " Notified Manager. " The results of the actions taken were listed as " Quarterly. "
- The % of medications that are verified by the patient ID band and Bar Code system on the Acute and Recovery Unit was 82% on the Acute Unit and 86% on the Recovery Unit. The corrective action was listed as " Pharmacist does daily review to check for bad NC numbers or scans. Pharmacist scans items upon arrival from wholesaler. " The result of the action taken was listed as " Continue to monitor. "
-The number of patient injuries was listed as 2 patient falls on the Recovery Unit. There was no corrective action or results of action listed.

In an interview on 5/15/15 at 10:15 a.m. with S16Quality, she said when a problem was identified the quality committee would tell the specific manager where the problem occurred about the problem. She said she was not notified by the department managers about the corrective actions they had taken.

In an interview on 5/15/15 at 12:15 p.m. with S1Administrator, she said there was not an effective program for Quality Assessment at the hospital. S1Administrator said they were just crunching numbers.

Based on record review and interview, the hospital failed to ensure the Quality Assessment and Performance Improvement (QAPI) Program measured, analyzed and tracked adverse patient events. This deficient practice is evidenced by failing to analyze elopements by 4 (#18, #19, #27, #28) psychiatric patients and an attempted suicide and elopement by a psychiatric patient (#4).
Findings:

Review of an incident report written by S1Administrator revealed Patient #4 had been admitted on 2/11/15 to the Recovery Unit (psychiatric unit) with a diagnosis of Psychosis and combative behavior. On 2/12/15 at 10:22 a.m., the patient's roommate notified staff that Patient #4 had hung herself in the bathroom using a pillowcase. A code blue was called and the patient was transferred to the Emergency Department and later to another hospital for a higher level of care.

In an interview on 5/13/15 at 9:48 a.m. with S1Administrator, she said the video of Patient #4's hanging incident revealed the staff did not do the 15 minute observations like they were supposed to because S6MHT (Mental Health Technician) did not go into the room to check the patient but instead stood out of a closed door while Patient #4 was inside the room crying. S1Administrator also said S6MHT falsely documented that she had observed her twice. S1Administrator said the hospital did some education after the incident but there was obviously still a problem with observations being performed as required. S1Administrator also verified Patient #4 had eloped from the Emergency Department on two separate admissions before the 2/11/15 admission.

Review of medical records for patients in the psychiatric unit and Emergency Department revealed Patient #18, Patient #19, Patient #27 and Patient #28 eloped from the hospital.

The hospital's QAPI data was reviewed. This review revealed no evidence to indicate the failure of staff to accurately observe psychiatric patients as ordered was being evaluated through the hospital's QAPI program. This review also revealed that the elopements were not being evaluated through the hospital's QAPI program.

In an interview on 5/15/15 at 10:15 a.m. with S16Quality, she verified the attempted suicide and the elopements were not analyzed for QAPI.

Based on record review and interview, the hospital failed to enforce bylaws to carry out its responsibilities relative to the completion of medical records that are delinquent for a period of greater than 30 days.
Findings:

Review of the Hospital Bylaws revealed in part:
A. Medical Records: When a member fails to complete medical records within the time prescribed by the Medical Staff Rules and Regulations, he/she shall be given a warning. If the member fails to complete the medical record within 15 days after receiving the warning, a temporary suspension in the form of withdrawal of admitting or consulting privileges shall be automatically imposed by the Administrator and shall remain in effect until such medical records are complete. Failure to complete the records within 6 months after receiving a warning shall be deemed a voluntary resignation of the member's Medical Staff membership and privileges.

Review of the hospital Medical Staff Rules and Regulations revealed in part:
20. All medical records must be completed within 30 days from the date of the patient's discharge. Those medical records not completed within 15 days of discharge shall be considered delinquent. Physicians will be notified of their delinquent records. With this internal standard, the hospital will ensure that records are completed within 30 days.

Review of a list of delinquent medical records provided by the hospital revealed the following:
Delinquent after 30 days:
S25Physician- 23 records
S26Physician- 7 records
S27Physician- 10 records
S28Physician- 1 records
Delinquent records incomplete after 60 days:
S25Physician- 11 records
S26Physician- 2 records
S27Physician- 12 records
Delinquent records incomplete after 90 days:
S29Physician- 2 records
S30Physician- 12 records
S31Physician- 5 records
S27Physician- 2 records
S32Physician- 9 records

In an observation on 5/14/15 at 1:40 p.m. on the Recovery Unit (psychiatric unit), a cabinet in the nurse's station had over 100 medical records stacked on multiple shelves. The records dated from January to the present.

In an interview on 5/13/15 at 10:30 a.m. with S12MedicalRecords, she said she had been director of medical records for approximately 2 years. She said the hospital policy was to send a letter to the physician after 30 days and present the delinquent charts to medical staff. She said a second letter should be sent saying they have so many days to comply or their privileges would be suspended. She said she never sent the second letter and nobody has ever been suspended.

In an interview on 5/13/15 at 12:45 p.m. with S1Administrator, she verified there was a problem with delinquent medical records and no physicians had been suspended as per the hospital bylaws.

In an interview on 5/14/15 at 11:00 a.m. with S12MedicalRecords, she said she had just found out there was a cabinet in the Recovery Unit full of delinquent medical records. She said she was unaware medical records were in the cabinet and did not include them in her delinquency rates.

In an interview on 5/14/15 at 2:05 p.m. with S3PsychMgr, she said there was no system for getting the medical records current on the Recovery Unit and they were not organized. She estimated there were over 100 medical records in the cabinet dating back to January 2015.

Based on record review and interview, the hospital failed to meet the Condition of Participation for Nursing Services as evidenced by failing to ensure nursing care was assigned in accordance with the specialized competence of the nursing staff available as evidenced by failing to provide training required by the Louisiana State Board of Nursing for Registered Nurses administering Diprovan (general anesthetic) by 3 (S9RN, S10RN, S19RN) of 3 Emergency Department (ED) staff reviewed. (See findings under tag A-0397)

Based on record review and interview, the hospital failed to ensure the nursing staff developed and kept current individualized and comprehensive nursing care plans for each patient for 5 (#1, #2,#16, #22,#R5) of 5 (#1, #2,#16, #22,#R5) patients sampled for care planning out of a total sample of 30 patients (#1-#30) and 1 random patient (#R5).
Findings:

Patient #1
Review of Patient #1's medical record revealed he was admitted on 5/10/15 with admission diagnoses of Anxiety, Depression and Schizophrenia. Further review revealed the patient had the following co-morbid conditions Hypertension, Diabetes Mellitus, Hemorrhoids and Hypercholesterolemia.

Review of Patient #1's care plan revealed Hypertension, Diabetes Mellitus, Hemorrhoids and Hypercholesterolemia had not been addressed in the plan of care.


Patient #2
Review of Patient #2's medical record revealed he was admitted on 5/7/15 with an admission diagnosis of Altered Thought Processes. Further review revealed the patient had a Seizure Disorder.

Review of Patient #2's care plan revealed risk for seizures had not been addressed in the plan of care.


Patient #16
Review of Patient #16's medical record revealed he was admitted on 5/9/15 with an admission diagnoses of Drug Induced Mood Disorder. Further review revealed the patient also had a medical diagnosis of Cirrhosis of the Liver.

Review of Patient #16's care plan revealed Cirrhosis of the Liver had not been addressed in the plan of care.


Patient #22
Review of Patient #22's medical record revealed she was admitted on 5/11/15 with an admission diagnosis of Post Partum Depression. Further review revealed the patient was 1 week status post Cesarean Section delivery with a dressed abdominal incision. Additional review revealed risk for infection was also an identified problem.

Review of Patient #22's care plan revealed risk for infection and impaired skin integrity related to C-section surgical incision had not been addressed in the plan of care.


Patient #R5
Review of Patient #R5's medical record revealed he was admitted on 4/28/15 with an admission diagnosis of Altered Thought Processes-rule out Psychotic Episode. Further review revealed the patient also had a medical diagnosis of Hypertension.

Review of Patient #R5's care plan revealed Hypertension had not been addressed in the plan of care.


In an interview on 5/15/15 at 10:15 a.m. with S1Administrator she confirmed the above referenced patients' care plans should have included all diagnoses, both psychiatric and medical.

Based on record review and interview, the hospital failed to ensure nursing care was assigned in accordance with the specialized competence of the nursing staff available as evidenced by failing to provide training required by the Louisiana State Board of Nursing for Registered Nurses administering Diprovan (general anesthetic) for 3 (S9RN, S10RN, S19RN) of 3 Emergency Department (ED) staff reviewed.
Findings:

1) Failing to provide training required by the Louisiana State Board of Nursing for Registered Nurses administering Diprovan (Propofol).

Review of the Louisiana State Board of Nursing Declaratory Statement on the Role and Scope of Practice of the Registered Nurse in the Administration of Medication and Monitoring of Patients During the Levels of Intravenous Procedural/Conscious Sedation (Minimal, Moderate, Deep, and Anesthesia) as Defined Herein, Based on Louisiana Revised Statute 913 (14) Board Approved 3/16/2005, Revised 4/9/15, revealed in part:
It is within the scope of practice for a RN to administer non-anesthetic medications, up to and including moderate (conscious sedation), and to monitor patients in minimal, moderate and deep sedation levels as defined by TJC (The Joint Commission), provided the RN is specifically trained and demonstrated knowledge, skills and abilities in accordance with the following provisions in various settings to include inpatient and outpatient environments.
A. The RN (non-Certified Registered Nurse Anesthetist) (non-CRNA) shall have documented education and competency to include:
-Knowledge of sedative drugs and reversal agents, their dosing, onset, duration, potential adverse reactions, drug compatibility, contraindications, and physiologic effects.
-Demonstration of the acquired knowledge of anatomy, physiology, pharmacology, and basic cardiac arrhythmia recognition; the ability to recognize complications of undesired outcomes related to sedation/analgesia; appropriate interventions in compliance with standards of practice, emergency protocol or guidelines
-Possession of the requisite knowledge and skills to perform and evaluate pre-procedure baseline, intra-procedure, and post-procedure clinical assessment of the patient undergoing sedation/analgesia.
-Demonstration of the knowledge of age specific considerations in regard to assessment parameters, potential complications, and appropriate interventions according to institutional protocol or guidelines.
-Application of the principles of accurate documentation in providing a comprehensive description of patient responses and outcomes.

Patient #4
Review of the ED record for Patient #4 dated 2/12/15 revealed the following entries:
11:20 a.m. (S10RN) Diprovan drip initiated to RAC (right antecubital vein) at 5mcg/kg/min (microgram/kilogram/minute) at this time.
11:38 a.m. (S9RN) Pt noted to be restless, moving arms and legs, Diprovan increased to 10 mcg/kg/min.
12:17 p.m. (S9RN) Diprovan 15mcg/kg/min
12:30 p.m. (S9RN) Diprovan increased to 30 mcg/kg/min

Review of the Medical Record for Patient #4 revealed no orders for the Diprovan administered on 2/12/15 or titration of the Diprovan.

In an interview on 5/12/15 at 4:50 p.m. with S9RN, she said she initiated Diprovan on patients and did not have competencies or training from the hospital on the administration of Propofol.

In an interview on 5/12/15 at 4:54 p.m. with S10RN, she said she did not have training or competencies from the hospital on Diprovan. She also verified she administered Propofol in the ED.

Patient # 20
Review of Patient #20 ' s medical record revealed the following Emergency Room Physician orders, dated 2/26/15:
Propofol 5 mcg/kg/min-01:54 a.m.;
Increase Propofol to 10mcg/kg/min (3ml/hr)-02:05 a.m.;
Propofol increase to 15 mcg/kg/min-02:24 a.m.

Review of the ED record for Patient #20, dated 2/26/15, revealed the following nurses ' note entries:
01:54 a.m.: Diprovan (Propofol) drip started at 5 mcg/kg/min (3 ml/hr) signed S19RN;
02:05 a.m.: Diprovan drip increased to 10mcg/kg/min (6 ml/hr) signed S19RN;
02:24 a.m.: Increased Diprovan 15 mcg/kg/min (9ml/hr) signed S19RN.

Review of S19RN 's personnel record revealed no documented evidence of skills competencies for administration of Diprovan.

In an interview on 5/15/15 at 10:18 a.m. with S19RN, she indicated that she was a full time employee in the ED. S19RN confirmed she had administered Diprovan. She also confirmed she had no specific training and no current skills competencies for administration of Diprovan.

In an interview on 5/14/15 at 1:15 p.m. with S1Administrator, she said the hospital had no training for the Registered Nurses on Diprovan, no protocols on titration and no policies for administration.

In an interview on 5/14/15 at 1:10 p.m. with S2DON, he said he assumed the nurses had competencies for the administration of Diprovan drips from other hospitals.

In an interview on 5/14/15 at 2:12 p.m. with S15Pharmacist, he said he did not have any protocols or policies for the administration of critical drips including Diprovan.

Based on observation, record review and interview, the hospital failed to meet the Condition for Participation for Medical Record Services as evidenced by:

1) failing to employ a qualified director of the Medical Records Department as required by the Louisiana Hospital Licensing Standards, Chapter 93, Section 9387 B. (see tag A-0432).

2) failing to ensure patient's medical records were protected from fire and/or water damage. This deficient practice is evidenced by storing 10 years of medical records in an unsprinklered room containing records stored on open shelving, on top of cabinets and on desks (see findings tag A-0438).

3) failing to enforce governing body bylaws to ensure discharged patient's medical records were completed within 30 days of discharge. The hospital also failed to have a system in place to accurately track the number of deficient medical records. (see findings tag A-0438).

Based on record review and interview, the hospital:
1) failed to employ a qualified director of the Medical Records Department as required by the Louisiana Hospital Licensing Standards, Chapter 93, Section 9387 B.

2) failed to employ adequate personnel to ensure prompt completion and filing of medical records.
Findings:

1) Failing to employ a qualified director of the Medical Records Department.

Review of the Louisiana Hospital Licensing Standards, Chapter 93, Section 9387 B, revealed in part: Medical records shall be under the supervision of a medical records practitioner (i.e., registered record administrator or accredited record technician) on either a full-time, part-time or consulting basis.

Review of the personnel file for S12Medical Records revealed no certifications or accreditations as a medical records practitioner.

In an interview on 5/13/15 at 10:30 a.m. with S12MedicalRecords, she said she had no certification in medical records management.

In an interview on 5/13/15 at 12:30 p.m. with S1Administrator, she verified S12MedicalRecords was not qualified to be the supervisor of the Medical Records Department.

2) Failing to employ adequate personnel to ensure prompt completion and filing of medical records.

An observation was made on 5/13/15 at 11:00 a.m. of the medical record room. There were multiple metal filing cabinets with doors that could be closed that were opened. Further observation revealed 22 open shelves containing records and 22 shelving units with greater than 10 records stacked on top of each. There was also a desk with approximately 120 medical records stacked in 10 piles.

In an observation on 5/14/15 at 2:00 p.m. on the psychiatric unit, there were approximately 100 plus paper medical records stacked on shelves in the nurse's station in a cabinet.

Review of the electronic medical records of discharged patients greater than 30 days revealed Patient #4's (discharged 2/12/15), Patient #18's (discharged 2/26/15), Patient #19's (discharged 4/8/15) and Patient #28's (discharged 3/24/15) medical records did not contain documents such as 15 minute observation sheets, admission orders and care plans. Upon request, paper documentation of the missing documentation was provided by S12MedicalRecords.

In an interview on 5/13/15 at 10:30 a.m. with S12MedicalRecords, she said she had 2 people working with her. She said 1 person does outpatient coding and release of information and the other does the Emergency Department coding. She said the hospital had taken 2 of her staff from her and they were months behind on scanning the paper portions of the medical records into the computer. She said they had been partially electronic for about 2 years and the electronic portion of the medical records were not complete records. She said they have not scanned any of the paper parts of acute records or Recovery Unit in the computer yet. She said they had 120 or 173 delinquent records, she was not sure. S12MedicalRecords also said the only time they could really scan in portions of the medical records was when they could use a LPN who was being canceled from his/her shift at the hospital because of low census. She verified she did not have enough staff for prompt completion of medical records at the hospital.

Based on observation, interviews and record review, the hospital:
1) failed to ensure patient's medical records were protected from fire and/or water damage. This deficient practice is evidenced by storing 10 years of medical records in an unsprinklered room containing records stored on open shelving, on top of cabinets and on desks.

2) failed to enforce governing body bylaws to ensure discharged patient's medical records were completed within 30 days of discharge. The hospital also failed to have a system in place to accurately track the number of deficient medical records on the Recovery Unit.
Findings:

1) Failed to ensure patient's medical records were protected from fire and/or water damage.

An observation was made on 5/13/15 at 11:00 a.m. of the medical record room. The room did not contain a sprinkler system and several of the ceiling tiles had stains from water leaks. There were multiple metal filing cabinets with doors that could be closed but were open. Further observation revealed 22 open shelves containing records and 22 shelving units with greater than 10 records stacked on top of each. There was also a desk with approximately 120 medical records stacked in 10 piles.

In an interview on 5/13/15 at 10:30 a.m. with S12MedicalRecords, She verified the medical records were not protected from fire or water. She said there was 10 years of medical records in the room and they ran out of room for medical record storage. She said some of the metal filing cabinets that have doors cannot be closed because they are crammed full of records.

2) Failing to ensure discharged patient's medical records were completed within 30 days of discharge.

Review of the Hospital Bylaws revealed in part:
A. Medical Records: When a member fails to complete medical records within the time prescribed by the Medical Staff Rules and Regulations, he/she shall be given a warning. If the member fails to complete the medical record within 15 days after receiving the warning, a temporary suspension in the form of withdrawal of admitting or consulting privileges shall be automatically imposed by the Administrator and shall remain in effect until such medical records are complete. Failure to complete the records within 6 months after receiving a warning shall be deemed a voluntary resignation of the member's Medical Staff membership and privileges.

Review of the hospital Medical Staff Rules and Regulations revealed in part:
20. All medical records must be completed within 30 days from the date of the patient's discharge. Those medical records not completed within 15 days of discharge shall be considered delinquent. Physicians will be notified of their delinquent records. With this internal standard, the hospital will ensure that records are completed within 30 days.

Review of a list of delinquent medical records provided by the hospital revealed the following:
Delinquent after 30 days:
S25Physician- 23 records
S26Physician- 7 records
S27Physician- 10 records
S28Physician- 1 records
Delinquent records incomplete after 60 days:
S25Physician- 11 records
S26Physician- 2 records
S27Physician- 12 records
Delinquent records incomplete after 90 days:
S29Physician- 2 records
S30Physician- 12 records
S31Physician- 5 records
S27Physician- 2 records
S32Physician- 9 records

In an observation on 5/14/15 at 1:40 p.m. on the Recovery Unit (psychiatric unit), a cabinet in the nurse's station had over 100 medical records stacked on multiple shelves. The records were dated from January to the present.

In an interview on 5/13/15 at 10:30 a.m. with S12MedicalRecords, she said she had been director of medical records for approximately 2 years. She said the hospital policy was to send a letter to the physician after 30 days and present the delinquent charts to medical staff. She said a second letter should be sent saying they have so many days to comply or their privileges would be suspended. She said she never sent the second letter and nobody has ever been suspended.

In an interview on 5/13/15 at 12:45 p.m. with S1Administrator, she verified there was a problem with delinquent medical records and no physicians had been suspended as per the hospital Bylaws.

In an interview on 5/14/15 at 11:00 a.m. with S12MedicalRecords, she said she had just found out there was a cabinet in the Recovery Unit full of delinquent medical records. She said she was unaware medical records were in the cabinet and did not include them in her delinquency rates.

In an interview on 5/14/15 at 2:05 p.m. with S3PsychMgr, she said there was no system for getting the medical records current on the Recovery Unit and they were not organized. She estimated there were over 100 medical records in the cabinet dating back to January 2015.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with acceptable standards of practice. This deficient practice was evidenced by failing to ensure 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.

A copy of the hospital policy for Pharmacist review of medications was requested, but none was provided by the hospital.

In an interview on 5/13/15 at 12:08 p.m. with S15Pharmacist, he said physicians can enter orders in the computer and during pharmacy hours they will go to the pharmacist for review. He said if handwritten during the day, they nurse will hand deliver the order to the pharmacy or enter it into the computer system themselves. If after pharmacy hours, he said the order was entered into the system and a retrospective review was done the next day. S15Pharmacist said the first dose would have already been given before he reviewed it. He stated the pharmacy hours were Monday through Friday from 8:00 a.m. until 5:00 p.m. and on weekends and holidays he came in for a few hours until his work was done. S15Pharmacist said he was not doing first dose review at night and on weekends but he was aware it was a requirement by CMS (Centers for Medicare and Medicaid Services) and the Pharmacy Board of Louisiana.

Based on record review and interview, the hospital failed to ensure drug administration errors were reported to the attending physician and documented in the patient's medical record for 1 (#R6) of 1 patients sampled with known medication errors.
Findings:

Review of identified medical errors at the hospital revealed Patient #R6 received the incorrect dose of Coreg (medication for heart failure or high blood pressure) twice on 4/6/15.

Review of the medical record for Patient #R6 by S2DON revealed there was no documentation of physician notification of the medication error in the medical record.

In an interview on 5/13/15 at 1:10 p.m. with S2DON, he said medical errors and physician notification was not documented in patient's medical records.

Based on record review and interview, the hospital failed to ensure a qualified staff member was designated as the infection control officer to develop and implement policies governing the control of infections and communicable diseases.
Findings:

Review of the job description for Infection Control Coordinator given to the surveyor by S13HR (Human Resources) revealed in part: 2) Experience-1 year of experience in the field of infection control in the acute care setting.

Review of the personnel record on 5/14/2015 at 1:00 p.m. for S17Infection Control revealed no current job description for Infection Control Coordinator. Further review revealed a Personnel Action Request form dated 5/9/2014 for transfer from the Recovery Unit to Infection Control/Intake Nurse/Dictation RN. Additional review revealed no documented evidence of the one year of experience in the field of Infection Control in the acute care setting that was listed as a requirement for the Infection Control Officer position in the hospital.

On 5/15/2015 at 9:00 a.m. numerous attempts were made to request information for the qualifications of S17Infection Control by this surveyor. At approximately 11:50 a.m. S2DON gave the surveyor copies of a certificate for 15.75 contact hours for Infection Control: Putting the Pieces Together dated 7/24-25/2014. Attached was a course objective for " Putting the Pieces Together " 15.5 contact hours dated 6/27-28/2013 and 2nd session dated 7/8-9/2013.

Interview on 5/12/2015 at 11:20 a.m. with S1Administrator revealed that S17 Infection Control had just recently started working as the Infection Control Officer for the hospital.

Interview on 5/12/2015 at 3:05 p.m. with S17Infection Control officer confirmed that she had no previous experience in Infection Control, and had transferred from the Recovery Unit.

Based on observation, interview and policy review, the infection control officer failed to implement a system for identifying and controlling infections. This deficient practice is evidenced by:
1) failing to ensure that nursing staff disinfected/cleaned a multiple patient use glucometer.
2) failing to ensure sharps containers were emptied to prevent potential needle sticks.
Findings:

1) Failure to ensure that nursing staff disinfected/cleaned a multiple patient use glucometer.

Observation on 5/13/2015 at 11:00 a.m. revealed S26LPN took the multi-use glucometer and used it to obtain a capillary blood sugar on Patient #8. S26LPN then returned the glucometer to the nurse ' s station and placed it on the counter without cleaning or disinfecting it. S25RN then picked up the contaminated glucometer and she was observed using it on another patient (Patient #9).

Interview on 5/13/2015 at 12:30 p.m. with S25RN confirmed that the glucometer should have been cleaned with Super Sani-Cloth germicidal wipes between each patient use. S25RN indicated that the wipes were kept at the nurse's station.

Interview on 5/15/2015 at 11:45 a.m. with S2DON, she confirmed that the facility did not have a policy for cleaning the multi-use glucometers. The facility was using the manufacturer's suggestion for cleaning and disinfecting.

Review of the Manufacturer's Manual for the hospital glucometer revealed, in part: Guide to cleaning and disinfecting the ACCU-CHEK Inform II system. The meter should be cleaned and disinfected between each patient use (page 124).

2) Failing to ensure sharps containers were emptied to prevent potential needle sticks.
Review of the facility policy titled Handling of Bio hazardous Waste, Document Number #3011, revealed in part: Disposal of Sharps: Bio hazardous sharps waste disposal containers for disposing of needles, sharps and blood specimens will be used. Snap or tape the lid of a three-quarters (3/4) filled container, prior to discarding. The policy was not specific as to who was responsible for discarding the sharps containers.
Observation during the initial tour of the ED (Emergency Department) on 5/12/2015 at 10:05 a.m. revealed 2 wall mounted sharps containers with contents above the full line in exam room #1.
Interview on 5/12/2015 at 10:05 a.m. with S20RN confirmed that Housekeeping was responsible for changing the sharps containers when full. S20RN did not know why the sharps containers had not been changed.
Interview on 5/13/2015 at 10:55 a.m. with S23Housekeeping confirmed that housekeeping was responsible for changing the sharps containers when full. S23Housekeeeping further stated that she was unaware that the sharps containers were full in the ED. S23Housekeeping verified that the sharps containers were closed and placed in a red bag and then placed in the Bio-hazard box.