The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

CHRISTUS ST PATRICK HOSPITAL 524 DR MICHAEL DEBAKEY STREET LAKE CHARLES, LA 70601 Aug. 27, 2015
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on record reviews and interviews, the hospital failed to ensure its grievance policy and process was implemented as evidenced by failure to have documented evidence that all patient grievances were reported to the Service Guarantee Coordinator to be investigated. This failed practice was evidenced by staff who were unable to verbalize the difference between a complaint and a grievance, and a process to ensure grievances were received by the SGC.
Findings:


Policy review revealed the following:
Definition of Complaint/Concern- An expression of dissatisfaction with some aspect of care and/or service. Complaint will have simple and obvious causes that can be addressed promptly, by hospital staff, to the patient's satisfaction.
Definition of a Grievance- A written complaint is always considered a grievance. This includes written complaints including email and fax from an inpatient, an outpatient, a released/discharged patient or a patient's representative regarding the patient care provided, abuse or neglect, or the hospital's compliance with CoPs... If a patient complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance for the purposes of these requirements. The Grievance Process: 1. The SGC will serve as the liaison between the patient/family and CHRISTUS St. Patrick Hospital. 2. All grievances will be reported to the Grievance Committee and reported to the Board of Directors via the Quality Committee...4. The recovery process will include, but not limited to the following process: * Every attempt will be made to address the complaint within the 1st business day...* The "Problem Resolution Form" is initiated by the SGC and forwarded to the Director/Manager of the respective department.* The Director/Manager will complete the "Patient Complaint Investigation From: and return to SGC within 7 business days...*Data collected is archived with secured access...*The written response will include the name of a contact person, steps taken to investigate the grievance, the result of the grievance process, and the date of the completion.

In an interview, 8/25/15 at 10:35 a.m. Patient #1 reported that it sometimes takes staff a long time to come help her. Patient #1 indicated after the call bell was answered via the intercom, it would take a long time to for staff to then come into her room to help her with mobility and/or getting up to the bedside commode or getting off the bedside commode. Patient #1's spouse, present during the interview, indicated it sometimes took up to 30-45 minutes for a staff person to come into the room after the call was answered. Patient #1 and her spouse indicated this had been reported to a young man from administration, but could not provide the name. The patient's spouse first reported they had spoken to the representative yesterday, but later clarified that it had actually been last week. He stated the days run together after having been in the hospital with his wife for 2 weeks.
Review of a grievance log revealed no grievance for Patient 1.
In an interview 8/25/15 at 11:45 a.m. S39VPAS reported he made weekly rounds on patients to check on their satisfaction with their care, then would share the information of problems and good works with other hospital leaders. He provided a form titled "Department Rounding Log" with notes on it. He indicated the one page with written notations on it was from last week's rounds. There were last names with a room number, with 2 stating the patient was sleeping and a third was the room number of Patient #1. Of the 3 notations under Patient 1's name, one read, "takes too long when you " . S39VPAS reported the note meant when she was on the toilet and she asked for help to get back in the bed, it would take too long for someone to come help. He reported he thought she may have said 10-15 minutes. S39VPAS reported that he passed this information on to the nurse manager of the unit. In regards to Patient #1's complaint about the delayed response to her call via the nurse call system, S39VPAS reported that he didn't consider this to be a grievance, but rather a complaint and it was passed on to the charge nurse so he did not think it needed to go any further. When asked if he was familiar with the hospital's grievance policy and procedure, S39VPAS responded, "Not entirely." He indicated he could not recall receiving education regarding the grievance process or the Grievance policy and procedure. His definition provided to the surveyors were as follows: "Grievance: if any harm was inflicted. Patient complains of something patient wants to have changed that we can effect immediately." He reported that patient grievances come to/go through the CNE. S39VPAS reported he was not aware of many complaints regarding delayed responses to call bells, maybe 2 or 3 patients. He reported that the new log for patient rounds was just implemented in July. S39VPAS reported he no longer had any notes from patient rounds regarding complaints, dissatisfaction, or positive remarks concerning staff and care prior to last week.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on record reviews and interview, the hospital failed to ensure in its resolution of a grievance the patient (or representative) received written notice of its decision that included the steps taken on behalf of the patient to investigate the grievance, results of the grievance process, and the date of completion for 3 of 3 (R4, R5, R9) patient grievances reviewed for a written notice of its decision.
Findings:

Review of hospital policy # RI-A-180, titled "Grievance Policy" (issue date 3/3/00, last review date 1/15), provided by S6RN as current, revealed the following in part: "(In reference to the grievance process)... The written response will include the name of a contact person, steps taken to investigate the grievance, the result of the grievance process, and the date of completion." Further review revealed a copy of a form letter that read, in part, Dear (Blank)... We have already begun our investigation of your concerns. I will serve as your liaison with the CHRISTUS St. Patrick Hospital Grievance Committee. Your concerns will be reviewed by our Grievance Committee and you will receive a written notice of the Committee's findings to include the name of a contact person, steps taken to investigate the grievance, the result of the grievance process and the date of competition...." A contact phone number was provided ,and the letter had the name of S35SGC typed at the bottom of the letter.


Patient R4
Review of a Problem Resolution document dated 9/3/14 documented a complaint from Patient R4 from the hospital website that included, in part, the unavailability of any nursing staff to address the constant alarm on the IV machine for approximately 7 hours, at which time the patient indicated she figured out how to turn off the power. Other complaint involved not being able to eat or drink form more than 4 hours "because the nurse forgot.", and blood tests not done on time. Documentation of findings of a record review and results of an interview with an unnamed nurse were noted under proceedings taken on behalf of the patient, with no evidence as to the investigator. Under action taken a notation dated 9/25/14 at 4:06 p.m. indicated the patient contact number had been disconnected. Review of a letter dated 9/15/14 and addressed to Patient R4 thanked the patient for taking the time to share her concerns about her care. It stated the hospital had already begun their investigation of her concerns, her concerns would be reviewed by the Grievance Committee and she would receive a written notice of the Committee's findings to include the name of a contact person, steps taken to investigate the grievance, the result of the grievance process, and the date of completion. Review of a letter dated 9/30/14 and addressed to Patient R4 revealed the following, in part : "...We do acknowledge your concerns about your stay. Please know that your concerns were reviewed by the Director and addressed with the staff involved and we continue to educate with ways to deal with situations such as this. The staff has acknowledged they understand your concerns for your care. We hope this conclusion meets your satisfaction, if not please contact me within seven days so we can discuss..." The letter provided a contact phone number and had a typed name and position of S35SGC.


Patient R5
Review of documentation of a grievance for Patient R5 revealed a document titled Problem Resolution for Complaints/Grievances , Patient/Family/Visitor/Associate with a date of 3/31/15 which documented the Patient R5's wife went to administration to complain about Patient R5 not receiving his pain medication during the night, and the staff nurse arguing with him. Another issue on the same form documented the patient felt a named staff member was picking a fight with him (the patient). Action taken on behalf of the patient was to call the RN Manger of Patient Care to talk with the patient's wife. No other documentation of any letter regarding the grievance was provided.


Patient R9
Review of documentation regarding a grievance submitted by Patient R9 revealed the date received was 4/7/15 and was related to infection control breeches by several different disciplines of staff and delay in outpatient treatment times for scheduled care. Further review revealed no documentation related to any investigation. Review of letters related to the grievance included one dated 4/17/15, on plain paper, acknowledging receipt of the grievance telling her her concerns would be reviewed by the Grievance committee and she would receive a written notification of the Committee's findings to include the name of a contact person, steps taken to investigate the grievance, the results of the grievance process, and the date of completion. A contact number was provided. The typed name and position of S35SGC was noted at the bottom of the letter. Another letter, on plain paper was dated 4/21/14 and addressed to Patient R9. The letter read, in part: "...We do acknowledge your concerns about your stay. Please know that your concerns were reviewed by the Director and addressed with the staff involved and we continue to educate with ways to deal with situations such as this. The staff has acknowledged they understand your concerns for your care. We hope this conclusion meets your satisfaction, if not please contact me within seven days so we can discuss..." The letter provided a contact phone number and had a typed name and position of S35SGC.

In an interview 8/27/15 at 10:40 a.m. S36RN reported she really didn't know the difference between a grievance and a complaint. She indicated a grievance needs to be addressed, it was an actual formal complaint. She reported if she received a complaint from a patient should would let the charge nurse know and ask her supervisior if they wanted to go talk with the patient. She stated, " There is probably a system for writing the complaint but I'm not thinking of it at this moment. We just tell our supervisor.

In an interview 8/27/15 at 11:15 a.m. S22RN reported she is frequently the charge nurse on her nursing unit.


In an interview 8/27/15 at 4:05 p.m. S35SGC, after review of documentation of the grievances listed above, confirmed the final letters did not inform the patient (or patient's representative) as to the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, or the date of completion. S35SGC reported that the letters sent to the patient or patient representative were generic letters that she filled in with the date and patient name. She reported that sometimes she individualized them by inserting the department in which the patient received care, but did not individualized them as to the steps taken to investigate or the results of the investigation.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0173
Based on record review and interview the hospital failed to ensure each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient was instituted and renewed as per hospital policy and procedure. This deficient practice was evidenced by incomplete and untied restraint orders for 1 of 1 (#4) patient record reviewed for restraints from a total sample of 5.
Findings:

Review of hospital policy 3.080, titled "Standardized Use of Restraint and or Seclusion", provided by S6RN as current, revealed in part, "Restraint Orders: Non-violent or non self-destructive ...4. A written order based on an examination by the LIP is entered into the record within 24 hours. The order must be time-limited, not to exceed 24 hours, and include clinical justification, date, time, and type of restraint. Renewal orders are issued no less than once each calendar day. Orders must contain clear a clinical rationale, type of restraint, behaviors to monitor for, and potential early release of restraints.

Review of Physician's Orders for Restraints for Patient #4 revealed 3 separate orders for soft wrist restraints dated 11/21/14, 11/22/14, and 11/23/14. Further review revealed the following:
A Physician's Restrain order dated 11/21/14 at 7:00 p.m. revealed the justification for restraints indicated was "Behavior disrupts environment so that treatment cannot take place." Further review revealed area #4 was blank: "Begin restraint: Date___Time____ Order expires calendar day after this date and time." The order was signed by S53MD 11/21/14 at 9:27 a.m.
A Physician's Restraint order dated 11/22/14, with no time of order documented, had justification for restraints marked as "Behavior disrupts environment so that treatment cannot take place" and "other (specify): Pull at lines and tubes." No begin restraint time or date was documented. The order was signed by S53MD with no date or time noted.
A Physician's Restraint order dated 11/23/14, with no time documented, indicated the justification as "Behavior disrupts environment so that treatment cannot take place" , and "Other (specify): pull at line and tubes." Section #4, Begin restraint date and time (order expires calendar day after this date and time) was blank. The order was signed by S53MD, with no date or time documented.

Review of the nursing documentation revealed on 11/21/14 at 10:00 a.m. " :soft wrist restraints applied ;patient behavior requiring restraints as 'Pulling at lines/Tubes, agitation' ."
11/22/14 patient was assessed q 2 hours with interventions listed, and the reason necessitating continuation of soft wrist restraints as, "Pulling at Lines/Tubes, Climbing out of Bed/Chair, and Agitation."
11/23/14 assessed q 2 hours with interventions, reason necessitating continuation of soft wrist restraints as, "Pulling at Lines/Tubes, Climbing out of Bed/Chair, and Agitation", until 11/24/14 at midnight (midnight of 11/23/14) when it was documented that Patient #4 met the criteria to remove the restraints and they were removed.

In an interview 8/27/15 at 2:03 p.m. S15RN and S52RN reviewed the Physician's Orders for restraints and the medical record for Patient #4. S52RN reported she could not explain why restraints were initiated at 10:00 a.m. and the order was dated and time 11/21/14 at 7:00 p.m. S15RN and S52RN verified the 3 order sheets were not completed correctly. S15RN reported the justification should have been "other: pulling lines and tubes" and not "behavior disrupts environment so that treatment cannot take place." S15RN confirmed the order did not have a date and time to begin in section 4, but reported it should have been completed, and would only be good for 24 hours from that time. S15RN and S52RN confirmed the orders dated 11/22/14 and 11/23/14 had no time the order was written, time the physician signed it, or a begin restraint time and date. The RN managers further confirmed the restraint order dated 11/23/14 did not indicate which type of restraint/least restrictive device was ordered. The RN managers confirmed the orders did not document the behaviors to be monitored, as required by hospital policy.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0202
Based on record reviews and interviews, the hospital failed to ensure the nursing staff had the education, training, and demonstrated knowledge of the safe application and use of all types of restraint as evidenced by failure to have documented evidence of competency evaluations for 5 (S8RN, S13RN, S14RN, S27RN, S36RN) of 5 RN personnel files reviewed for restraint application and 1 (S32CNA [certified nursing assistant]) of 1 CNA personnel file reviewed for monitoring patients in restraints.
Findings:

Review of the hospital policy titled "Competency Of Associates Policy - Louisiana", presented as a current policy by S26HR, revealed that annual competency assessment and documentation includes annual education modules and annual performance evaluations and related actions.

Review of "Skills Fair 2014", presented as the last skills fair documentation by S29CEd, revealed the skills fair was held on 10/28/14, 10/29/14, and 10/30/15 for nurses and, nurse aides along with other disciplines employed by the hospital and included restraints. No documented evidence was provided by the hospital of who assessed the competency of each nurse and CNA and an evaluation of each nurse's competency to perform the skills that were taught during the skills fair for S13RN, S14RN, S27RN, S36RN and S32CNA.

S8RN
Review of S8RN's personnel file revealed she was hired on 01/12/15. Review of her "Orientation Skills Checklist" revealed it included a self-assessment by S8RN with the method of assessment, date of assessment, and initials of the preceptor documented for each skill with no documented evidence whether S8RN was competent to perform application of restraints.

In an interview on 08/27/15 at 3:15 p.m., S29CEd indicated the staff goes through each station set up as part of the skills fair and takes a test. She further indicated if the skill required a return demonstration, the staff would be observed performing the skill. S29CEd indicated the test is scored by the educator, but the tests are not kept for each staff member's personnel file. She further indicated the observer who performed the competency evaluation did not sign that the observation was done and whether the skill had been performed correctly. She confirmed the hospital had no evidence to present of the competency evaluations for the application of restraints that were performed at the skills fair in October 2014.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on record reviews and interview, the hospital failed to ensure data collected to identify opportunities for improvement resulted in action taken to improve performance as evidenced by failure to analyze, track, and trend medication errors by nursing units and implement actions for improving processes and outcomes.
Findings:

Review of the hospital policy titled "Quality Management Plan", presented as a current policy by S6RN, revealed the goals and objectives included provisions for effective monitoring, measurement, and evaluation of patient care delivery and services with measurable action plans.

Review of incident report logs for 12/22/14 through 08/24/15 revealed a total of 102 medication errors. Review of the "PI (performance improvement) Activity Report Summary" titled "Medication Errors" revealed the total of Categories C and D errors for fiscal year 2014 (July 2014 through June 2015) was 29%. Review of the report for July 2015 (1st month of fiscal year 2015) revealed the total of Categories C and D errors was 50%.

In an interview on 08/27/15 at 12:55 p.m., S25Pharmacy indicated she was responsible for the medication error reporting function for the QAPI (quality assessment and performance improvement) program. She further indicated she looked at what the actual errors were and reported it to the Pharmacy and Therapeutic Committee meeting that had nurse managers in attendance. She further indicated she doesn't analyze the data to the extent of trending the data by individual nursing units, specific shifts, and specific nurses to determine if the errors are related to a particular nursing unit, shift, or nurse. She confirmed that no specific action was implemented to address the medication errors.
VIOLATION: QAPI PERFORMANCE IMPROVEMENT PROJECTS Tag No: A0297
Based on record reviews and interview, the hospital failed to ensure that the reason for conducting distinct improvement projects was documented for 2 Behavioral Health services projects reviewed.
Findings:

Review of the documentation of the Behavioral Health Services distinct improvement projects of "Usage of Notify Provider Intervention in Meditech" and "Meds Education Documentation" revealed no documented evidence of the reason the projects was selected for study.

In an interview on 08/27/15 at 1:10 p.m., S7CorpQA and S6RN confirmed the Behavioral Health services' distinct improvement projects did not include the reason the study was chosen.
VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
Based on interview, the governing body failed to ensure that all hospital departments and services including those services furnished under contract or arrangement were included in the hospital's QAPI (quality assessment and performance improvement) program as evidenced by failure to have quality indicators developed and implemented for its contracted linen service.
Findings:

In an interview on 08/27/15 at 5:30 p.m., S6RN confirmed that no quality indicators had been developed and implemented for the contracted linen service. This finding had been identified during a previous survey conducted on 02/04/15 and had not been corrected as of the date of this survey of 08/27/15.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient as evidenced by:
1) Failing to ensure the RNs implemented the physician-ordered Hypoglycemic Protocol for 1 (#2) of 2 (#2, #5) patient records reviewed with physician orders for [DIAGNOSES REDACTED] from a total sample of 5 patients.
2) Failing to ensure the RN assessed and documented each patient's wounds, including wound measurements and appearance, upon admission and every 12 hours in accordance with hospital policy for 2 (#2, #5) of 4 (#1, #2, #4, #5) patients with wounds from a total sample of 5 patients.
3) Failing to ensure the nurse performed and documented wound care as ordered by the physician for 2 (#2, #5) of 4 (#1, #2, #4, #5) patients with wounds from a total sample of 5 patients.
4) Failing to ensure the RN educated, observed, and documented the performance of wound care by the patient's spouse who performed wound care for 1 (#2) of 1 patient whose record review revealed that the spouse was performing wound care from a total of 4 patient records reviewed for wound care from a total sample of 5 patients.
5) Failing to develop a policy that addressed the time interval that a wound care consult had to be performed and the interval at which the wound had to be reassessed that resulted in a delay in the wound care consult being performed for 1 (#5) of 4 (#1, #2, #4, #5) patient records reviewed with orders for a wound care consult from a total sample of 5 patients.
Findings:

1) Failing to ensure the RNs implemented the physician-ordered Hypoglycemic Protocol:
Review of the hospital's "[DIAGNOSES REDACTED] Protocol", presented as the current protocol by S11RN, revealed if a patient is not on an insulin drip, the patient is responsive and able to take oral substance, and the patient has a blood glucose less than 70 mg/dl, one of the following should be given:
4 ounces of juice (not orange juice);
8 ounces of skim milk;
3 packets of sugar;
Glucose 40% gel 15 grams.
Further review revealed the [DIAGNOSES REDACTED] treatment follow-up required the nurse to repeat the blood glucose in 15 minutes and notify the provider of [DIAGNOSES REDACTED] and the 15 minute blood glucose result; if the blood glucose is less than 100 mg/dl at the 15 minute check, repeat the treatment for blood glucose less than 100 mg/dl and repeat the blood glucose check in 15 minutes; once the blood glucose is greater than 100 mg/dl, repeat the blood glucose in 1 hour; start IV to saline lock if no IV access.

Review of Patient #2's medical record revealed she was a [AGE] year old female admitted on [DATE] with severe pain in the perineum/perirectal area. Further review revealed her diagnoses included [DIAGNOSES REDACTED][DIAGNOSES REDACTED], Anemia of Renal Disease, and a history of [DIAGNOSES REDACTED]and Rectal [DIAGNOSES REDACTED] with Diverting Colectomy and Chemoradiation Therapy.

Review of Patient #2's "Medication Administration Record (MAR) revealed her blood glucose at 6:15 a.m. on 08/18/15 was 61 mg/dl and 65 mg/dl at 6:14 a.m. on 08/24/15.

Review of Patient #2's medical record revealed on 08/18/15 at S42RN documented that milk and graham crackers were consumed. Further review revealed on 08/24/15 at S43RN documented that some milk and graham crackers were given to Patient #2. There was no documented evidence in the medical record that S42RN or S43RN gave either juice other than orange juice, skim milk, 3 packets of sugar, or 15 grams of Glucose 40% gel, rechecked Patient #2's blood glucose in 15 minutes, and notified the provider of [DIAGNOSES REDACTED] and the 15 minute blood glucose result.

In an interview on 08/26/15 at 2:55 p.m., S14RN confirmed the nurse is supposed to give skim milk, recheck the blood glucose in 15 minutes, and notify the physician of the patient's initial blood glucose less than 70 mg/dl and the result taken 15 minutes after treatment of [DIAGNOSES REDACTED].

2) Failing to ensure the RN assessed and documented each patient's wounds, including wound measurements and appearance, upon admission and every 12 hours in accordance with hospital policy:
Review of the hospital policy titled "Patient Care System Assessments", presented as the current policy by S6RN, revealed that that admission data and assessment is information gathered on a new patient upon admit, and the shift assessment is a head-to-toe assessment utilized every 12 hours or more often as the patient condition changes. The admission assessment is to be completed within 8 hours of the patient's admission by the RN and includes the Braden Scale and integumentary assessment. A complete head-to-toe patient assessment must be completed every 12 hours and is to include assessment of the patient's integumentary system.

Patient #2
Review of Patient #2's medical record revealed she was a [AGE] year old female admitted on [DATE] with severe pain in the perineum/perirectal area. Further review revealed her diagnoses included [DIAGNOSES REDACTED]], Anemia of Renal Disease, and a history of [DIAGNOSES REDACTED]and Rectal [DIAGNOSES REDACTED] with Diverting Colectomy and Chemoradiation Therapy.

Review of Patient #2's admission assessment documented on 08/13/15 at 5:50 a.m. revealed no documented evidence of a wound. Review of her medical record revealed the first documented evidence of her wound was on 08/14/15 at 8:00 a.m. Review revealed Patient #2 had a deep, tunneled wound to the lower right gluteal fold with moist, darkened skin and reddened around the area. There was no documented evidence of the measurement of the wound.

Review of S4RN's (wound care nurse) documentation on 08/14/15 at 2:03 p.m., 32 hours and 13 minutes after admission, revealed Patient #2 had a granulating surgical wound to the left buttocks that was 5.0 cm (centimeters) in length, 1.0 cm in width, 1.5 cm deep, with a 5.0 cm squared wound area. The stage was documented as "full thickness", the greater portion appearance was 100% red granulation, the surrounding tissue was macerated, the periwound skin characteristic was "moderate", minimal serosanguineous drainage, no odor, and no wound bleeding. Wound comments included "Surgical wound from rectal CA . Pt is seeing (doctor's name) for wound care treatment and has home health. Epiboly to medial edge of wound. Healing will depend upon nutrition, comorbidities, and compliance."

Review of Patient #2's shift assessments performed every 12 hours revealed documentation of a deep, tunneled wound to the left gluteal fold from 08/15/15 through 08/26/15 at 7:20 a.m. with no documented evidence of the appearance of the wound that included measurements,the appearance of surrounding tissue and the periwound area, and the presence or absence of odor and drainage. The only documented wound measurements and description of the wound and surrounding tissue, drainage, and odor were documented by S4RN, the wound care nurse on 08/14/15, 08/17/15, and 08/24/15.

In an interview on 08/26/15 at 2:15 p.m., S13RN indicated she doesn't always measure a patient's wound when she does the nursing admit assessment.

In an interview on 08/26/15 at 2:55 p.m., S14RN (unit manager) indicated the expectation is that the RN will do a head-to-toe assessment that includes assessment of wounds. She further indicated the RN is supposed to photograph the wound and document the measurement of length. She confirmed that the width and depth of wounds are not measured upon admit.

Patient #5
Review of Patient #5's medical record revealed she was an [AGE] year old female admitted on [DATE] with a history of Sacral Decubitus Ulcer, on a wound vac at home, and presented secondary to worsening wound infection with evidence of Leukocytosis and early sepsis. She had a history of Diabetes, Hypernatremia, and was on Deep Vein Thrombosis Prophylaxis.

Review of Patient #5's admission assessment performed on 08/19/15 at 2:11 p.m. revealed she had a pressure ulcer to the medial sacrum. Review of the "Additional Integumentary Information" documented on the admission assessment revealed "Large, tunneled wound to coccyx. Edges crusted, wound bed gray. Cleaned w/NS (with Normal saline), packed w/ damp gauze, covered w/ Allevyn. Photos taken & placed in chart." Further review revealed 4 photographs were taken. There was no documented evidence of the wound measurements, whether or not there was drainage, and the presence or absence of odor.

Review of Patient #5's medical record revealed no documented evidence of a measurement of her wound until the first complex wound assessment was performed by S4RN on 08/21/15 at 12:46 p.m., 46 hours and 35 minutes after admission. Further review revealed a complex wound assessment was performed on 08/23/15 at 7:00 a.m. by an LPN .

In an interview on 08/26/15 at 3:20 p.m., S14RN confirmed Patient #5's admission nursing assessment did not include wound measurements. She indicated the photos taken only show a measurement of the length of the wound by placement of the ruler next to the wound. She further indicated the LPN who performed the complex wound assessment was a unit nurse and not a wound care nurse. S14RN indicated a complex wound assessment is not a delegable task and is not a designated role of the LPN.

3) Failing to ensure the nurse performed and documented wound care as ordered by the physician:
Patient #2
Review of Patient #2's medical record revealed she was a [AGE] year old female admitted on [DATE] with severe pain in the perineum/perirectal area. Further review revealed her diagnoses included [DIAGNOSES REDACTED]], Anemia of Renal Disease, and a history of [DIAGNOSES REDACTED]and Rectal [DIAGNOSES REDACTED] with Diverting Colectomy and Chemoradiation Therapy.

Review of Patient #2's physician's orders revealed the following orders:
08/14/15 at 2:02 p.m. - cleanse wound to left buttock with Normal saline, apply Aquacel AG (Silver) to wound bed, then 5 x 5 Allevyn and change every 48 hours and as needed;
08/17/15 at 3:08 p.m. - cleanse wound to left buttock with Normal Saline, skin prep to periwound, then apply Aquacel AG to to wound bed, then 5 x 5 Allevyn, change every 48 hours and as needed;
08/24/15 at 1:54 p.m. - cleanse wound to left buttock with Normal saline, wound cleanser daily and as needed.

Review of Patient #2's medical record revealed no documented evidence that wound care was performed on 08/18/15, 08/20/15, 08/21/15, 08/22/15, 08/23/15, 08/25/15, 08/26/15 as evidenced by documentation by the nurse that "pt only allows husband to change dressing" and no documentation whether the husband performed wound care on these days.

In an interview on 08/26/15 at 2:15 p.m., S13RN indicated Patient #2 would not allow her to perform wound care. She further indicated she did not recall getting a physician's order to allow Patient #2's spouse to perform wound care. She further indicated that the record should contain documentation that there had been observation of Patient #2's spouse performing the wound care.

Patient #5
Review of Patient #5's medical record revealed she was an [AGE] year old female admitted on [DATE] with a history of Sacral Decubitus Ulcer, on a wound vac at home, and presented secondary to worsening wound infection with evidence of Leukocytosis and early sepsis. She had a history of Diabetes, Hypernatremia, and was on Deep Vein Thrombosis Prophylaxis.

Review of Patient #5's physician orders revealed the following wound care orders:
08/19/15 at 5:17 p.m. - wound care to sacral area, cleanse with NS (Normal saline), pack with NS moist gauze, skin prep to periwound, then dry dressing, secure with tape. There was documented evidence of the frequency that wound care was to be performed.
08/21/15 at 10:44 a.m. - wound care to sacral area, cleanse with 1/4 Dakins, apply Santyl Nickel thickness, then 1/4 Dakins moist gauze, skin prep to periwound, then dry dressing, secure with paper tape. There was documented evidence of the frequency that wound care was to be performed.
08/24/15 at 2:12 p.m. - daily wet to dry dressing changes with 1/4 strength Dakin's Solution daily.
08/25/15 at 11:20 a.m. - wound care to sacral area, cleanse with 1/4 Dakins, then apply dry gauze, then 1/4 Dakins moist gauze, skin prep to periwound, then dry dressing, secure with paper tape. There was documented evidence of the frequency that wound care was to be performed.

Review of Patient #5's medical record on 08/26/15 revealed no documented evidence that wound care was performed on 08/20/15, 08/22/15, and 08/24/15.

In an interview on 08/26/15 at 3:20 p.m., S14RN confirmed the physician's orders did not include a frequency for wound care to be performed, and there was no clarification order obtained by the RN. She confirmed that wound care was not documented, and the expectation is that any care given to a patient has to be documented. S14RN indicated she was not aware that wound care wasn't being documented.

4) Failing to ensure the RN educated, observed, and documented the performance of wound care by the patient's spouse who performed wound care:
Review of Patient #2's medical record revealed she was a [AGE] year old female admitted on [DATE] with severe pain in the perineum/perirectal area. Further review revealed her diagnoses included [DIAGNOSES REDACTED]], Anemia of Renal Disease, and a history of [DIAGNOSES REDACTED]and Rectal [DIAGNOSES REDACTED] with Diverting Colectomy and Chemoradiation Therapy.

Review of Patient #2's medical record revealed no documented evidence that wound care was performed on 08/18/15, 08/20/15, 08/21/15, 08/22/15, 08/23/15, 08/25/15, 08/26/15 as evidenced by documentation by the nurse that "pt only allows husband to change dressing" and no documentation whether the husband performed wound care on these days. Further review revealed no documented evidence that the physician had ordered for the wound care to be performed by Patient #2's spouse. There was no documented evidence that Patient #2's spouse was educated by the RN on performing the ordered wound care and was observed by the RN performing the wound care to determine that he used proper technique and infection control practices.

Review of S4RN's (wound care nurse) "Complex Wound Assessment" performed on 08/17/15 at 3:19 p.m. revealed "spouse performs wound care."

In an interview on 08/26/15 at 2:55 p.m., S14RN (unit manager) indicated there should have been a physician's order to allow Patient #2's spouse to perform wound care, and he should have been taught by the RN and observed by the RN while performing wound care. She further indicated once S4RN (wound care nurse) documented that the spouse does wound care, she should have gotten an order from the physician.

5) Failing to develop a policy that addressed the time interval that a wound care consult had to be performed and the interval at which the wound had to be reassessed that resulted in a delay in the wound care consult being performed:
Review of the hospital policy titled "Wound Care Protocol", presented as a current policy by S6RN, revealed no documented evidence of the time interval that a wound care consult for the wound care nurse ordered by the physician had to be performed. There also was no documented evidence of the frequency at which the wound needed to be reassessed by the wound care nurse.

Review of Patient #5's medical record revealed she was an [AGE] year old female admitted on [DATE] with a history of Sacral Decubitus Ulcer, on a wound vac at home, and presented secondary to worsening wound infection with evidence of Leukocytosis and early sepsis. She had a history of Diabetes, Hypernatremia, and was on Deep Vein Thrombosis Prophylaxis.

Review of Patient #5's physician orders revealed an order on 08/19/15 at 12:44 p.m. for a wound ostomy continence nurse consult. Review of Patient #5's medical record revealed her wound assessment by the wound ostomy continence nurse was performed by S4RN on 08/21/15 at 12:46 p.m., 46 hours and 35 minutes after admission. There was no documented evidence of a wound measurement since her admission on 08/19/15.

In an interview on 08/26/15 at 3:20 p.m., S14RN confirmed the "Wound Care Protocol" policy did not include a time interval that the wound care consult had to be performed and the frequency at which the reassessment had to be performed. S14RN confirmed there was a delay in Patient #5's wound assessment by the wound ostomy continence nurse.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan for each patient as evidenced by failure to develop care plans for all medical conditions for which the patient is being treated for 3 (#2, #3, #5) of 5 (#1, #2, #3, #4, #5) patient records reviewed for care plans from a total sample of 5 patients.
Findings:

Patient #2
Review of Patient #2's medical record revealed she was a [AGE] year old female admitted on [DATE] with severe pain in the perineum/perirectal area. Further review revealed her diagnoses included [DIAGNOSES REDACTED]], [DIAGNOSES REDACTED], Anemia of Renal Disease, and a history of [DIAGNOSES REDACTED]and Rectal [DIAGNOSES REDACTED] with Diverting Colectomy and Chemoradiation Therapy. Further review revealed she had physician orders to check her blood glucose and implement sliding scale insulin orders before meals and at bedtime.

Review of Patient #2's medical record revealed no documented evidence that a nursing care plan had been developed that included problems, interventions, goals, and the target date expected for the goals to be met.

In an interview on 08/25/15 at 3:55 p.m., S10RN indicated when the nurse admits the patient, anything that is documented as abnormal will result in a suggestion of a problem for the care plan, and the nurse has to select that problem for an outcome and interventions to become part of the care plan. She further indicated an abnormal glucose is one item that does not auto-populate and has to be added as a problem by the nurse. S10RN indicated if the patient was assessed as having no pain at the time of the admit but was admitted for pain, the automatic problem of pain would not come up, and the nurse would have to add pain as a problem. She further indicated the nurse can select any problem to be added to the patient's care plan.

In an interview on 08/25/15 at 4:05 p.m., S11HI indicated the nurse selected outcomes, such as infection, optimal gas exchange, and skin integrity, for Patient #2, but he/she didn't attach the outcomes to a care plan that would have included interventions to be implemented.

Patient #3
Review of Patient #3's medical record revealed he was an [AGE] year old male with a history of chronic Hypertension and ESRD on maintenance Hemodialysis who presented to the emergency room with a one day history of severe Low Back Pain. A CT (computerized tomography) scan of the lumbar spine revealed suspicion of probable Diskitis and Vertebral [DIAGNOSES REDACTED]. Review of his History and Physical (H&P) revealed Gram-negative sepsis, Chronic hypertension, ESRD on Hemodialysis, Hypertensive Cardiovascular Disease, Anemia of chronic illness, and a prior history of Degenerative Arthritis, Nephrolithiasis, and Gout.

Review of Patient #3's nursing care plan revealed no documented evidence that pain (the reason for admission) was identified as a problem and interventions, goals, and a target date for goals to be met were developed. Further review revealed problems identified were impaired mobility, skin breakdown risk, altered nutritional intake, impaired ADLs (activities of daily living), impaired gait, impaired balance, impaired bed mobility, impaired comprehension, impaired strength, impaired tissue integrity, impaired transfer, potential for fall moderate risk, and potential for infection with no documented evidence of a target date for the goals to be met for any of the identified problems. There was no documented evidence of interventions to be implemented for altered nutritional intake, impaired gait, impaired balance, impaired comprehension, impaired strength, and impaired transfer. There was no documented evidence that pain (the reason for admission) was identified as a problem and interventions, goals, and a target date for goals to be met were developed.

In an interview on 08/26/15 at 3:50 p.m., S14RN confirmed no care plan was developed for pain for Patient #5.

Patient #5
Review of Patient #5's medical record revealed she was an [AGE] year old female admitted on [DATE] with a history of Sacral Decubitus Ulcer, on a wound vac at home, and presented secondary to worsening wound infection with evidence of Leukocytosis and early sepsis. She had a history of Diabetes, Hypernatremia, and was on Deep Veinous Thrombosis Prophylaxis. Further review revealed physician orders for blood glucose checks with sliding scale insulin orders before meals and at bedtime.

Review of patient #5's nursing care plan revealed no documented evidence that a nursing care plan had been developed for Diabetes with interventions, goals, and target date for goals to be met. Further review revealed problems identified were impaired ADLs, impaired comprehension,impaired expressive language, impaired memory, impaired mobility, impaired tissue integrity, acute pain, potential for fall high risk, potential for infection, skin breakdown risk, and altered nutritional intake with no documented evidence of the target date for the goals to be met for any of these identified problems. Further review revealed no documented evidence that interventions had been identified for impaired comprehension, impaired expressive language, and altered nutritional intake. Further review revealed no documented evidence that the goals were stated in measurable terms to allow one to be able to determine when the goal was met.

In an interview on 08/26/15 at 3:20 p.m., S14RN offered no explanation when informed that review of Patient #5;s medical record revealed no evidence that a nursing care plan was developed for Diabetes, and Patient #5 was having her blood glucose checked with orders for sliding scale insulin when needed.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure the RN (registered nurse) assigned the nursing care of each patient to other nursing personnel who had been evaluated for competency as evidenced by failure to have documented evidence of competency evaluations for 5 (S8RN, S13RN, S14RN, S27RN, S36RN) of 5 RN personnel files reviewed for competency and 1 (S32CNA [certified nursing assistant]) of 1 CNA personnel file reviewed for competency.
Findings:

Review of the hospital policy titled "Competency Of Associates Policy - Louisiana", presented as a current policy by S26HR, revealed that associates, contract/agency personnel, and volunteers must be competent and qualified to meet performance expectations and/or to provide quality patient care to the specific age patients they serve. They will be assessed initially and routinely to insure continuing competency. Components of the initial competency assessment include completion of a self-assessment, skills checklist, and validation by a qualified individual based on objective criteria. Annual competency assessment and documentation includes annual education modules and annual performance evaluations and related actions.

Review of "Skills Fair 2014", presented as the last skills fair documentation by SS29CEd, revealed the skills fair was held on 10/28/14, 10/29/14, and 10/30/15 for nurses and, nurse aides along with other disciplines employed by the hospital. No documented evidence was provided by the hospital of who assessed the competency of each nurse and CNA and an evaluation of each nurse's competency to perform the skills that were taught during the skills fair for S8RN, S13RN, S14RN, S27RN, S36RN and S32CNA.

S8RN
Review of S8RN's personnel file revealed she was hired on 01/12/15. Review of her "Orientation Skills Checklist" revealed it included a self-assessment by S8RN with the method of assessment, date of assessment, and initials of the preceptor documented for each skill with no documented evidence whether S8RN was competent to perform the skill or needed further education.

S13RN
Review of S13RN's personnel file revealed she was hired on 07/28/14. Review of her "2015 Associate Performance Review" revealed she partially met the goals for pressure ulcer prevention protocols.

S14RN
Review of S14RN's personnel file revealed she was hired on 07/16/12. Review of her "2015 Associate Performance Review" revealed she partially met the goals for hand hygiene and did not meet the wound protocol goals.

S27RN
Review of S27RN's "2015 Associate Performance Review" revealed she did not meet the goals for wound protocols and hand hygiene.

S36RN
Review of S36's personnel file revealed she was hired on 01/14/13. Further review revealed her CPR (cardiopulmonary resuscitation) had expired on [DATE] with no documented evidence presented by the hospital that it had been renewed. Review of her "2015 Associate Performance Review" revealed she did not meet the goals for wound protocols, bedside medication verification, and hand hygiene.

S32CNA
Review of S32CNA's personnel file revealed she was hired on 06/15/15. Further review revealed no documented evidence that she had been evaluated for competency in performing the duties of a CNA prior to being assigned direct patient care.

In an interview on 08/27/15 at 3:15 p.m., S29CEd indicated the staff goes through each station set up as part of the skills fair and takes a test. She further indicated if the skill required a return demonstration, the staff would be observed performing the skill. S29CEd indicated the test is scored by the educator, but the tests are not kept for each staff member's personnel file. She further indicated the observer who performed the competency evaluation did not sign that the observation was done and whether the skill had been performed correctly. She confirmed the hospital had no evidence to present of the competency evaluations that were performed at the skills fair in October 2014.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure that drugs and biologicals were prepared and administered in accordance with the orders of the practitioner responsible for the patient's care that resulted in a 56% (per cent) medication error rate for one medication for Patient #2. This failed practice was evident for 2 (#2, #3) of 5 (#1, #2, #3, #4, #5) patient records reviewed for medication administration from a total of 5 sampled patients.
Findings:

Review of the hospital policy titled "Medication Preparation and Labeling", presented as a current policy by S6RN, revealed that medications are prepared and administered pursuant to and in accordance with the orders of a licensed independent practitioner responsible for the patient's care, and in accordance with all applicable laws and regulations.

Review of the hospital policy titled "Electronic Medication Administration Record (eMAR) & (and) Bedside Medication Verification (BMV)", presented as a current policy by S6RN, revealed that the nurse will administer and document ordered medications in a safe, accurate, and timely manner allowing for patient privacy following the "5 Rights" (5R's) of administration, one of which is right dose.

Patient #2
Review of Patient #2's medical record revealed she was a [AGE] year old female admitted on [DATE] with severe pain in the perineum/perirectal area. Further review revealed her diagnoses included [DIAGNOSES REDACTED]], [DIAGNOSES REDACTED], Anemia of Renal Disease, and a history of [DIAGNOSES REDACTED]and Rectal [DIAGNOSES REDACTED] with Diverting Colectomy and Chemoradiation Therapy.

Review of Patient #2's physician orders revealed an order on 08/13/15 at 2:48 a.m. for Dilaudid injection 1 to 2 mg (milligrams) IV (intravenous) every 4 hours as needed for moderate to severe pain with the clinical indication of 0.5 mg for a pain score of 4 to 6 and 1 mg for a pain score of 7 to 10. There was no documented evidence that the order included a dose of 0.5 mg or the indication for 2 mg to be given. There was no documented evidence that a clarification order had been obtained by the nurse.

Review of Patient #2's eMARs from 08/13/15 at 5:37 a.m. through 08/25/15 at 2:17 p.m. revealed 31 medication errors had occurred when the nurse administered 0.5 mg without a physician's order, administered 1 mg for a pain scale of 4, 5, or 6, administered 1.5 mg without a physician's order, and administered 2 mg for a pain scale of 6, 7, 8, and 9. This resulted in a 56% medication error rate for this one medication for Patient #2.

In an interview on 08/26/15 at 2:15 p.m., S13RN indicated a clarification order should have been obtained from the physician related to the Dilaudid order. She confirmed that the Dilaudid medication error was not identified by any of the nurses who administered the medication and the pharmacist who acknowledged the physician's order.

In an interview on 08/26/15 at 2:55 p.m., S14RN indicated the medication dose and the clinical indication should be checked by each nurse prior to administering the medication.

In an interview on 08/27/15 at 12:55 p.m., S25Pharmacy confirmed the pharmacist did not identify the medication error related to Dilaudid for Patient #2.

Patient #3
Review of Patient #3's medical record revealed he was an [AGE] year old male with a history of chronic Hypertension and ESRD on maintenance Hemodialysis who presented to the emergency room with a one day history of severe Low Back Pain. A CT (computerized tomography) scan of the lumbar spine revealed suspicion of probable Diskitis and Vertebral [DIAGNOSES REDACTED]. Review of his History and Physical (H&P) revealed Gram-negative sepsis, Chronic hypertension, ESRD on Hemodialysis, Hypertensive Cardiovascular Disease, Anemia of chronic illness, and a prior history of Degenerative Arthritis, Nephrolithiasis, and Gout.

Review of Patient #3's physician's orders revealed an order on 08/16/15 at 6:14 p.m. for Dilaudid injection 0.5 mg to 1 mg IV every 4 hours as needed for moderate to severe pain with a clinical indication of 0.5 mg for a pain score of 4 to 6 and 1 mg for a pain score of 7 to 10.

Review of Patient #3's Dilaudid 1 mg IV was given on 08/17/15 at 7:38 p.m. for a pain level score of 6 rather than 0.5 mg as ordered.

In an interview on 08/26/15 at 3:50 p.m., S14RN confirmed the incorrect dose of Dilaudid was administered to Patient #3 on 08/17/15 at 7:38 p.m.
VIOLATION: QUALIFIED STAFF Tag No: A0547
Based on record reviews and interview, the hospital failed to ensure that the radiology technician was qualified to use radiologic equipment and administer procedures as evidenced by having S30CathLab's competency evaluated by a registered nurse rather than an individual qualified to perform the same duties as S30CathLab.
Findings:

Review of the hospital policy titled "Competency Of Associates Policy - Louisiana", presented as a current policy by S26HR, revealed that associates, contract/agency personnel, and volunteers must be competent and qualified to meet performance expectations and/or to provide quality patient care to the specific age patients they serve. The competency must be assessed by a qualified individual. Qualified individuals have equivalent or higher level of skill, competency, and educational level.

Review of S30CathLab's personnel file revealed his competency evaluation was performed on 06/20/14 and 08/11/14 by a registered nurse. There was no documented evidence that an individual with equivalent or higher level of skill, competency, and educational level had evaluated S30CathLab for competency in performing the duties of a cardiac catheter radiology technician.

In an interview on 08/27/15 at 3:25 p.m., S26HR confirmed S30CathLab's competency evaluation had been performed by a registered nurse rather than another qualified radiology technician or a radiologist.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on record review, observation, and interviews the hospital failed to ensure an infection control system was implemented to control infections and communicable diseases of patients and personnel. This deficient practice was evidenced by:
1) policies and practices that instructed staff to wear surgical scrubs in the OR and Cath Lab laundered at home;
2) staff with head and/or facial hair exposed in the OR and the Cath Lab;
3) a staff member not performing safe injection practices when a vial of Lidocaine was not disinfected with alcohol prior to piercing with a syringe and needle;
4) staff not performing hand hygiene before donning and/or removing gloves, and going from a contaminated surface to touching a patient and patient care items;
5) failing to implement tuberculosis (TB) screening and assessment in accordance with hospital policy for 1 (S20MD) of 3 (S19DO, S20MD, S54MD) physician credentialing files reviewed for TB testing.
Findings:


1) policies and practices that allow staff to wear surgical scrubs in the OR and Cardiac Catheterization Lab that were laundered at home; and
2) staff with head and/or facial hair exposed in the OR and the Cath Lab.

Review of Perioperative Standards and Recommended Practices for Inpatient and Ambulatory Settings (Association of periOperative Registered Nurses,2013 Edition) revealed, in part, the following:
"...AORN recommended practices for perioperative nursing practice...are based on principles of nursing science, microbiology, research, review of the scientific literature, and the opinions of knowledgeable experts...
Recommended Practices for Surgical Attire: ...
Recommendation II. Clean surgical attire, including shoes, head coverings, masks, jackets, and identification badges should be worn in the semi restricted and restricted areas of the surgical or invasive procedure setting... IIa. Facility-approved, clean, and freshly laundered or disposable surgical attire should be donned daily in designated dressing areas before entry or reentry into the semi restricted and restricted areas.
Recommendation III. All individuals who enter the semi restricted and restricted areas should wear freshly laundered surgical attire that is laundered at a health care-accredited laundry facility or disposable surgical attire provided by the facility and intended for use within the perioperative setting.
Recommendation IV: All personnel should cover head and facial hair, including side burns and the nape of the neck, when in semi restricted and restricted areas... IV.a. A clean, low-lint surgical head cover or hood that confines all hair and covers scalp skin should be worn...IVa.2. Reusable head coverings should be laundered in a health care-accredited laundry facility after each daily use.
Recommendation V: Surgical attire should be laundered in a health care-accredited laundry facility... Health care-accredited laundry facilities are preferred because they follow industry standards... An accredited health care facility laundering process includes monitoring correct measurement of chemical, sufficient water, correct temperature, mechanical action, and the duration of the washing cycle...Home laundering is not monitored for quality, consistency, or safety... V.a. Laundered surgical attire should be protected during transport to the practice setting to prevent contamination...

Review of a hospital "Plan for the Provision of Patient Care & Services", last revision date 5/15, and provided by S2CNE as current, revealed in part, "Recognized Standards/Guidelines Used: Applicable standards from the following organizations are used as guidelines for all aspects of care provided in the surgical services department: AORN..."


Review of Hospital Operating Room Policy # 701, titled, "Home Laundering of Scrub Uniforms",(issue date: 6/03, last review/approval 5/14), provided by S16RN as current, revealed the following in part: Policy: 1. Surgical Services Associates will be responsible for purchasing and laundering of their own scrubs. 2. Scrub suits are not considered personal protective equipment. Procedure:...2. ... It is the responsibility of the Associate to launder their scrub uniforms on a daily basis... "

Review of a document provided by S16RN titled Surgical Attire Plan-Phase 1 (hospital associates) revealed the following, in part:
Scrub Clothing * OR and SPD associates shall wear scrubs intended for use only within the department...Scrub attire will be laundered by associates...
Hair Covering * In OR, GI Lab, and SPD all possible head and facial hair should be covered when in semi-restricted and restricted areas..."


An observation 8/26/15 at 8:45 a.m., accompanied by S40RN, S41CathLab, S2CNE, and S15RN, was made from the large window in the Cath Lab control room. In the Cath Lab, during a cardiac procedure on Patient R7, S37MD was observed to have a fabric skull cap on his head, with hair exposed on the back of his head, below the skull cap approximately 1-2 inches. This observation was verified by S40RN and S41CathLab.

An observation 8/26/15 at 9:05 a.m., accompanied by S12RN, revealed Patient #R8 on the OR table being prepared for a surgical procedure. S41RN was performing circulator duties and was noted to have a paper bouffant surgical hat over a fabric skullcap. Both of the head covers were gathered in the back of S41RN's head and gathered/tied up together, leaving his hair exposed approximately 1 to 2 inches below the lower edge of the haircovers. Further observation revealed S44ST was also wearing a fabric headcover, covered by a paper bouffant cap with both gathered and tied together leaving approximately 1 to 2 inches of her hair exposed in the back of her head. S12RN, present during the observation confirmed the findings and reported that all hair should be covered. The OR educator reported that paper skull caps had been removed since, when worn, they left hair exposed. S12RN confirmed it was the hospital's policy that all hair was to be covered while in sterile areas.

In an observation in the Cath Lab at 8/27/15 at 8:30 a.m., accompanied by S40RN, S47CathLab, and S2CNE, revealed a cardiac procedure in progress, with S48CathLab next to S49MD and the sterile table (holding sterile supplies and instruments) with scrub apparel which included a regular mask tied on. Further observation revealed facial hair that was visible from the sides of his mask up to his ears. S49MD was observed to have a paper mask covering his mouth, with the top of the mask below the point of his nose, with his nares partially uncovered. Further observation revealed S30CathLab walked into the procedure room (with the door closing behind him), obtained supplies, then exited the room. S30CathLab's mask was observed to cover his mouth, but was below his nose, exposing his nares completely. These observations were verified by S40RN, S47CathLab, and S2CNE. S47CathLab verified that all hair should be covered while in procedure room during a procedure and when sterile supplies are open. S47CathLab reported that the staff home laundered their scrubs.

In an interview 8/26/15 at 9:30 a.m. S16RN confirmed she was the director of surgical services. S16RN reported surgical scrubs worn by OR, Cath Lab, and Special Procedures were still laundered at staffs' homes. S16RN reported that after their February 2015 survey in which the hospital's practice of home laundering of surgical scrubs was cited, the plan was to have scrubs provided by a certified linen service for all areas in which sterile procedures were performed. S16RN reported that the Surgery, Cath Lab, Special Procedures, and GI Lab followed AORN standards. S16RN did not provide an answer as to why the surgery department were still home laundering staff scrubs. S16RN reported that S39VPAS was in charge of the hospital practice of staff using home laundered scrub clothes in restricted areas.

In an interview 8/26/15 at 9:50 a.m. S47RN reported she had been assigned to the OR department for more than 20 years. S47RN indicated the staff had been washing their scrub clothes at home for years. The RN reported she had a home use washer and dryer, and had no specific parameters provided by the hospital for the laundering of scrubs for use in the OR. S47RN confirmed that there was no process required for the monitoring of control parameters in laundering her scrubs such as temperatures or detergent used.

In an interview 8/26/15 at 10:05 a.m. S39VPAS confirmed he had volunteered to assume responsibility for the correction of home laundered scrubs by staff (in sterile procedure/restricted areas). He reported that a system solution had been approved that week (week starting 8/24/15). S39VPAS reported he could not provide a reason the correction, had not been implemented already, other than they (the hospital) wanted to make sure they had a secure solution.

Review of a plan of correction for the hospital, submitted by the hospital in response to a deficiency cited 2/4/15. This POC was regarding the practice of use of home laundered scrubs in the ORs by staff. The POC documented a final decision would be made by 3/31/15 and hospital education/notification of staff would be completed and policy revision before switching to facility laundering practices.

3) a staff member not performing safe injection practices when a vial of Lidocaine was not disinfected with alcohol prior to piercing with a syringe and needle.

An observation 8/26/15 at 11:32 a.m. in the room of Patient #5, revealed S50MD performing wound care on a large sacral decubitus. During the procedure, S31RN was observed to open a new vial of Lidocaine with Epinephrine and draw the medication into a 10 ml syringe. S31RN failed to disinfect the rubber septum of the vial before penetrating it with the needle. S31RN verified she did not disinfect the vial after opening it, and before piercing the rubber septum with the syringe. S31RN indicated she was not aware the rubber septum had to be disinfected after opening for the first time, only after it was opened and used.


4) staff not performing hand hygiene before donning and/or removing gloves, and going from a contaminated surface to touching a patient and patient care items.

An observation 8/25/15 at 10:35 a.m. revealed S9LAB enter the room of Patient #1 without performing hand hygiene. Further observation revealed a sink with soap and water in Patient #1's bathroom, and a hand hygiene dispenser attached to the wall as you walked into the patient's room. S9LAB informed Patient #1 she was there to draw blood for lab work. S9LAB was observed to put on gloves, still with no hand hygiene performed. S9LAB applied a tourniquet to Patient #1's arm and palpated it, looking for a venipuncture site, reaches into her supply tray, obtains and alcohol swab and swabs Patient #1's arm. S9LAB then reaches into her supply cart and removes a needle and syringe, with the same gloves on that were used to touch the patient. S9LAB draws blood into a syringe, then injects the blood into a vacuum blood tube located in the middle of a tray of blood tubes (in the supply tray). S9LAB removed her gloves and exited the room, with no hand hygiene performed.

In an interview 8/25/15 at 10:45 am. S9LAB verified she did not perform hand hygiene after entering Patient #1's room, before donning her gloves, after removing her gloves, and before leaving the patient's room. S9LAB verified she reached into the clean venipuncture supply cart with the same gloves she had on when she touched the patient and drew her blood.

An observation 8/25/15 at 11:15 a.m. revealed S8RN enter the room of Patient #1. S8RN did not perform hand hygiene after entering Patient #1's room, and donned a pair of gloves, raised a bedside commode lid, then replaced it, Without performing hand hygiene and changing gloves, S8RN moved to the patient's side and palpated her abdomen. When Patient #1 complained of having some difficulty breathing, S8RN removed her gloves and indicated she was going to get a pulse oximeter to check the patient's oxygen levels. S8RN was observed to leave Patient #8's room without performing hand hygiene. S8RN was observed to don a new pair of gloves without performing hand hygiene on reentering Patient #1's room, picked up linens from the floor and place them in a plastic bag.. S8RN then removed her gloves and remove the pulse oximeter probe from Patient #1's finger without performing hand hygiene. The RN then moved the patient's blood pressure cuff and wrapped it around the side rail of the patient's bed, then moved the bedside table closer to the bed, within reach of the patient. The nurse rearranged the phone on the bedside table, handed the patient her water mug, and moved a canned drink and a boxed drink. The RN donned a glove on one and walked out of the room with the linen bag in the gloved hand. Once outside of the room she used waterless hand gel on her hands ( one gloved and one ungloved). In an interview at that time, S8RN indicated she did not realize she had not performed hand hygiene after walking into the room and before leaving the room. She indicated she also did not realize she had not performed hand hygiene before and after use of gloves, and after contaminating gloves and then moving to the patient or a more clean area without performing hand hygiene. S8RN confirmed she should have performed hand hygiene at each one of those times.

5) failing to implement TB screening and assessment in accordance with hospital policy:
Review of the "Tuberculosis Screening & (and) Assessment" form included in the physician's credentialing file revealed that each practitioner must provide documentation of PPD (purified protein derivative) testing done no less than every 12 months unless there is a documented history of positive PPD findings.

Review of S20MD's credentialing file revealed her last TB test was read on 06/06/11. There was no documented evidence in her file that she had a documented history of a positive PPD finding or a current TB test within the last 12 months.

No documented evidence of a current TB test result was provided by the hospital for S20MD as of the completion of the survey on 08/27/15 at 7:00 p.m.