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.

OCEANS BEHAVIORAL HOSPITAL OF BATON ROUGE 11135 FLORIDA BLVD BATON ROUGE, LA June 6, 2011
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on record review and interview, the hospital failed to ensure the infection control officer was qualified through education, training, experience, or certification as evidenced by no documented training in infection control, no documented evidence of experience, or any certification/continuing education in the designated infection control officers personnel record. Findings:

Review of the personnel record of S17LPN, (Infection Control Officer for the hospital), on 06/02/11 at 9:00 a.m. revealed no "Job Description" for Infection Control Officer, no documented training in infection control, no documented evidence of experience, or any certification/continuing education in infection control.

Review of an Oceans Behavioral Hospital Job Description for Infection Control Nurse, date written March 2008, presented as a current job description, read in part: "...Minimum Qualifications: Must have at least 1 year experience working with an APIC (Association for Professionals in Infection Control and Epidemiology) Registered Nurse performing surceillence [sic] in an acute medical/surgical setting and/or an acute psychiatric setting. Must be familiar with surveillance techniques, reporting requirements for communicable diseases, data collection, and compilation of data..."

In an interview with S1Administrator on 06/02/11 at 9:20 a.m. she confirmed there was no documented evidence of a "Job Description" for Infection Control Officer, no documented training in infection control, no documented evidence of experience, or any certification/continuing education in infection control in the personnel record of S17LPN, Infection Control. S1Administrator reviewed the regulations regarding the qualifications of the Infection Control Officer. S1 Administrator stated S17LPN does not meet the qualifications of an Infection Control Officer.

On 06/02/11 at 2:30 p.m. (at the time of exit) S1 Administrator presented a document titled "Infection Control Mentor's Checklist for New ICP (Infection Control Professional)." Review of the document revealed documentation that S17LPN had "reviewed" 11 of 25 Topics on the sheet. The line titled "the above orientation program was conducted by" revealed no signature of a qualified ICP. All items were dated 08/24/10.
VIOLATION: MEDICAL STAFF RESPONSIBILITIES Tag No: A0358
Based on record review and interview, the hospital failed to ensure the medical staff bylaws included a requirement that the medical history and physical (H&P) examination must be completed and documented in the medical record within 24 hours after admission as evidenced by the bylaws allowing the H&P to be completed within 24 to 72 hours after admission. Findings:

Review of the "General Rules and Regulations of the Medical Staff", approved 04/19/06 and presented by Operational Manager S2 as their current rules and regulations, revealed, in part, "...Medical History and Physical Examination of the Patient - The history shall incorporate the chief complaints, details of present illness, review of systems, medical history and family history. ... The history shall be a record of the information provided by the patient or his agent. The foregoing is to be written or dictated within twenty-four (24) to seventy-two (72) hours after admission...".

In a face-to-face interview on 06/02/11 at 8:35 am, Operational Manager S2 confirmed the Medical Staff Rules and Regulations were not correct related to the completion of the H&P's. He further indicated the H&P's must be completed and in the patient's record within 24 hours after admission.
VIOLATION: APPROVAL OF MEDICAL STAFF BYLAWS Tag No: A0354
Based on record review and interview, the hospital failed to ensure the revised medical staff bylaws were approved by the governing body prior to implementing them. Findings:

Review of the revised Medical Staff Bylaws presented by Operational Manager S2 as their current Medical Staff Bylaws revealed no documented evidence of the date they were effective and the date they were approved by the governing body.

In a face-to-face interview on 06/02/11 at 8:35 am, Operational Manager S2 indicated the Medical Staff Bylaws were revised and approved by the Medical Executive Committee on 01/25/11. S2 further indicated the governing body had not had a meeting to approve the revised Medical Staff Bylaws. S2 confirmed the medical staff was functioning under the revised bylaws that had not been approved by the governing body.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
Based on observation, record review and interview, the hospital failed to meet the Condition of Participation for Medical Records by:

1) failing to ensure it employed personnel who possessed adequate education, skills, qualifications and experience to ensure compliance with the regulations related to Medical Records. This was evidenced by observation of the hospital having approximately 400 of the 800 medical records in the medical records department being 30 days or more delinquent. (see findings at A0432)

2) failing to ensure that medical records were properly stored in secure locations where they are protected from fire and/or water damage as evidenced by having approximately 800 medical records stored in the medical records department either on the floor or on open shelves which would expose them to flooding and/or fire sprinkler activation. (see findings at A0438)

3) failing to ensure that medical records were promptly completed within 30 days of discharge by having approximately 800 medical records in the medical records department. Approximately 400 of those medical records were flagged as incomplete with some delinquent since 2009. (see findings at A0438 and A0469)
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0196
Based on record review and interview, the hospital failed to ensure the nursing staff demonstrated competence in the application of restraints as evidenced by failure to have documentation of the observation of the application of restraints to determine competency for 1 of 1 LPN (licensed practical nurse) reviewed for competency of application of restraints from a total of 9 LPNs (S16) and 1 of 1 RN (registered nurse) reviewed from a total of 5 RN's on staff (S11). Findings:

Review of the hospital form titled "Seclusion and Restraint Competency Validation" revealed, in part, "I _______ (line to enter employee's name) have received training and orientation on the proper policy and procedure for the use of Seclusion and Restraints... I was given the opportunity to ask questions and review safety issues. Reviewed the following: Tx (treatment) spec (specifications)... Doctor's Order for S & r (seclusion and restraints); Code green debriefing; S & r Flow Sheet; S & R intervention...". Further review revealed no documented evidence that observation of the application of restraints was performed by the employee and competency assessed by the supervisor.

RN S11
Review of RN S11's personnel file revealed she was hired on 09/24/10. Review of the "Seclusion and Restraint Competency Validation" revealed it was signed by RN S11 and Infection Control Officer S17 on 12/08/10. Further review of the entire personnel revealed no documented evidence that RN S11 had been observed applying restraints and determined to be competent.

LPN S16
Review of LPN S16's personnel file revealed she was hired on 02/23/11. Review of the "Seclusion and Restraint Competency Validation" revealed it was signed by LPN S16 on 02/23/11. Further review revealed no documented evidence of a signature by LPN S16's supervisor or preceptor. Further review of the entire personnel revealed no documented evidence that LPN S16 had been observed applying restraints and determined to be competent.

In a face-to-face interview on 06/02/11 at 9:15am, Administrator S1 confirmed the personnel records of RN S11 and LPN S16 had no evidence that they had been observed applying restraints and determined to be competent.

Review of the hospital policies titled "Orientation / Reorientation", revised 07/10 and "Job Descriptions and Competencies", revised 07/10 revealed no documented evidence that orientation to and assessment of competency with the application of restraints was included in hospital or job-related orientation.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on record review and interviews, the hospital failed to ensure the nursing care was assigned according to the competence of the nursing staff by failing to have documented evidence of the assessment of competency for 2 of 2 nurses reviewed from a total of 14 nurses on staff at the hospital (S11, S16). Findings:

RN S11
Review of RN S11's personnel file revealed she was hired on 09/24/10. Further review revealed the following tests had been completed by RN S11 with no documented evidence that the test answers were reviewed and determined to be correct to assure competency: Corporate Compliance Mandatory Inservice; Worksheet/Age Specific Care; Geriatrics Specific Test; Disability Specific Competency Chemical Dependency; Clinical Criteria of Physical Assault, Rape, Sexual Molestation, Domestic Abuse, Abuse of Elders and Children, and Neglect; Working With the Chronically Mentally Ill Patient; Environment of Care; Tuberculosis Orientation Post-Test; Blood-Borne Pathogens Post-Test; Hand Hygiene and Hand Washing Post-Test; Suicide Assessment Five Step Evaluation and Triage Post-Test; Restriction of Patient's Rights Test; Confidentiality; HIPAA (health insurance portability and accountability act) Quiz; and Patient Fall Competency. Further review revealed all tests were completed by RN S11 on 12/08/10, 2 months and 14 days after her date of hire, rather than prior to beginning her job assignment as required by hospital policy.
Review of RN S1's personnel file revealed no documented evidence of a 90 day performance evaluation as required by hospital policy.

LPN S16
Review of LPN S16's personnel file revealed she was hired on 02/23/11. Further review revealed the following tests had been completed by LPN S16 with no documented evidence that the test answers were reviewed and determined to be correct to assure competency: Corporate Compliance Mandatory Inservice; Restriction of Patient's Rights Test; HIPAA Quiz; Tuberculosis Orientation Post-Test; Blood-Borne Pathogens Post-Test; Suicide Assessment Five Step Evaluation and Triage Post-Test; Geriatrics Specific Test; Clinical Criteria of Physical Assault, Rape, Sexual Molestation, Domestic Abuse, Abuse of Elders and Children, and Neglect; Worksheet/Age Specific Care; Working With the Chronically Mentally Ill Patient; Disability Specific Competency Chemical Dependency; Confidentiality; Hand Hygiene and Hand Washing Post-Test; Environment of Care; Grievance Procedure Competency Test; and Patient Fall Competency. Further review revealed all tests were completed by LPN S16 on her date of hire 02/23/11.
Review of LPN S16's personnel file revealed no documented evidence of a 90 day performance evaluation as required by hospital policy.

In a face-to-face interview on 06/02/11 at 9:15am, Administrator S1 indicated a test used as determination of competency should be scored and signed by the person reviewing the test. S1 confirmed there was no documented evidence in the personnel files of RN S11 and LPN S16 of an assessment of competency prior to their performing job duties.

In a face-to-face interview on 06/02/11 at 9:20am, Human Resource/Medical Records Director S12 confirmed she had not received a 90 day performance evaluation from the DON (director of nursing) for RN S11 and LPN S16.

Review of the hospital policy titled "Orientation / Reorientation", revised 07/10 and submitted by Human Resource/Medical Records Director S12 as their current policy for orientation and assessment of competency, revealed, in part, "...The general orientation to individual and department job responsibilities must be conducted by the HR (human resource) Director and department head within five working days after the employee begins work in the department. ... Clinical employees are required to complete the clinical portion of the hospital orientation prior to beginning the job assignment. ... It will be the responsibility of the Department Head to identify deficiencies noted on the appropriate competency checklist and provide the resources to enable the new employee to become proficient. ... The completed competency checklist must be returned to the Human Resources Department as soon as orientation is complete...".

Review of the hospital policy titled "Job Descriptions and Competencies", revised 07/10 and submitted by Human Resource/Medical Records Director S12 as their current policy for assessment of competency, revealed, in part, "...The determination of clinical competency must begin prior to hiring an employee via a review of the potential employee's completed application, education and previous work experience; reference checks; personal interviews by the Department Head; and primary source verification of licensure, certification and/or registration. The initial competence assessment continues during general orientation and clinical orientation... Documentation of competency is required to be on file in the Human Resource Department...".
VIOLATION: ORGANIZATION AND STAFFING Tag No: A0432
Based on observation, record review and interview the hospital failed to ensure it employed personnel who possessed adequate education, skills, qualifications and experience to ensure compliance with the regulations related to Medical Records. This was evidenced by observation of the hospital having approximately 400 of the 800 medical records in the medical records department being 30 days or more delinquent. Findings:

In an interview on 06/01/11 at 1:45 p.m. with S12 Medical Records Director she stated she took over the job of Medical Records Director in April 2010. S12 stated she had no prior training or experience in Medical Records prior to April 2010. S12 Medical Records Director further stated that since April 2010 she has received no supervision/training from a qualified person.

Review of the personnel record of S12 Medical Records Director on 06/02/11 at 9:10 a.m. revealed no documented evidence of any prior experience in HIM. In an interview on 06/02/11 at 9:15 a.m. with S1Administrator she confirmed S12 Medical Records Director had no documented evidence of any prior experience in HIM and does not meet the requirements of the Oceans Behavioral Hospital Job Description for Health Information Management Director.

Review of the Oceans Behavioral Hospital Job Description for Health Information Management Director, written 11/2004, revised 08/2006, revealed in part: "Specific Experience Requirements: At least 1 year supervisory experience and 5 years psychiatric HIM (health information management) dept. (department) experience is required to adequately perform duties in this position. Specific Educational Requirements: High school diploma with additional training in Health Information Management department functions (i.e. certified health information management technician or other such certification or training). Special Skill, License and Knowledge Requirements: Extensive/broad knowledge is required for this position..."
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on observation, record review and interview, the hospital failed to ensure:

1) that medical records were properly stored in secure locations where they are protected from fire and/or water damage as evidenced by having approximately 800 medical records stored in the medical records department either on the floor or on open shelves which would expose them to flooding and/or fire sprinkler activation.

2) that medical records were promptly completed within 30 days of discharge by having approximately 800 medical records in the medical records department. Approximately 400 of those medical records were flagged as incomplete with some delinquent since 2009.

Findings:

1) In an observation made on 06/01/11 at 1:45 p.m. with S12Medical Records Director there were 34 cardboard boxes of medical records each containing approximately 10 medical records stored on the floor of the medical records department. In the same observation it was noted that there were approximately 450 medical records stored on open shelves made of wood with no doors.

In an interview on 06/01/11 at 1:45 p.m. with S12Medical Records Director she confirmed that there were approximately 800 medical records that were not stored in a secure location that would protect them from fire/sprinkler activation and approximately 340 of those medical records were stored on the floor which would not afford protection from flooding. S12 Medical Records Director stated that the records had been stored on the floor since she took over the job in April 2010.

In an interview on 06/01/11 at 1:50 p.m. with S2 Operations Manager he confirmed that approximately 800 medical records were not properly stored in secure locations where they are protected from fire and/or water damage.

2) In an observation and interview on 06/01/11 with S12Medical Records Director on 06/01/11 at 1:45 p.m. it was noted that there were approximately 800 medical records stored in the medical records department.

In an interview with S1Administrator, S2 Operations Manager, and S12 Medical Records Director it was confirmed that approximately 400 of the medical records were flagged as incomplete (signatures, order authentication, discharge summary signatures, etc.). S12 Medical Records Director stated that the records had been stored on the floor since she took over the job in April 2010.

Review of documentation relating to the 34 boxes of medical records on the floor of the medical records department listed 160 of the approximately 340 medical records as being delinquent. The document was titled "Missing Signatures on the Following Sheets."

In an interview on 06/01/11 at 1:45 p.m. with S12Medical Records Director she stated that these records had been reviewed and the reason for the record being delinquent had been identified but no corrective action had been taken. During the same interview S12 Medical Records Director stated that there was no documentation related to the reason approximately half of the 450 records on the shelves were delinquent.

In an interview on 06/01/11 at 1:45 p.m. S12 Medical Records Director stated that she had been the Medical Records Director since April 2010. S12 confirmed she had no prior experience relating to Medical Records and had no supervision/training from anyone since taking over the position.

In an interview on 06/01/11 at 1:50 with S2 Operations Manager he confirmed the last visit by the contracted RHIA was in December 2009. He further stated the hospital was "not aware" the RHIA was not providing the contracted services.

In an interview on 06/02/11 at 9:10 a.m. with S1 Administrator she stated she contacted the contracted RHIA and was informed that the RHIA was told her services "were no longer needed" in late 2009.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on record review and interview, the hospital's QAPI (Quality Assurance Performance Improvement) program failed to ensure the accuracy of QAPI data by failing to identify and capture medication errors that occurred during the provision of patient care as evidenced by survey findings relating to medication errors that occurred for 2 of 15 patients whose medical record was reviewed for medication administration out of a total sample of 26 patients. Findings:

Medical record review on 5/31/11 revealed a total of twenty-four (24) medication errors that occurred during the provision of care provided to Patient #1. The patient was admitted to Oceans Behavioral Hospital of Baton Rouge on 5/23/11. Review of the medical record revealed orders dated 5/23/11 at 3:00 p.m. for 100 mg of Metoprolol Succinate to be administered daily. Review of the medication administration record revealed that 50 mg of Metoprolol Succinate was administered to the patient (not the 100 mg as ordered) on 5/24/11, 5/25/11, 5/26/11, 5/27/11, 5/28/11, 5/29/11, 5/30/11 and 5/31/11 resulting in eight (8) medication errors. Further review of the medication administration record revealed that 5 mg of Flexeril was administered to the patient at 9:00 p.m. on 5/23/11, 9:00 a.m. & 9:00 p.m. on 5/24/11, 9:00 a.m. & 9:00 p.m. on 5/25/11, 9:00 a.m. & 9:00 p.m. on 5/26/11, 9:00 a.m. & 9:00 p.m. on 5/27/11, 9:00 a.m. & 9:00 p.m. on 5/28/11, 9:00 a.m. & 9:00 p.m. on 5/29/11, 9:00 a.m. & 9:00 p.m. on 5/30/11, and 9:00 a.m. on 5/31/11. Review of the medical record revealed no orders for Flexeril for this patient. This record review revealed a total of twenty-four (24) medication errors for this patient (eight (8) medication errors in relation to the wrong dose of Metoprolol Succinate being administered and sixteen (16) medication errors in relation to the administration of Flexeril in the absence of a practitioner's order).

S1 (Administrator) and S2 (Registered Nurse/Operational Manager) were interviewed on 5/31/11 at 11:10 a.m. S1 and S2 reviewed the medical record of Patient #1 and confirmed the twenty-four (24) medication errors for Patient #1. S1 and S2 reported the medication errors were not previously identified by staff (prior to the surveyor's review). S1 and S2 reported that a medication variance form had not been completed as of the date and time of this interview. S1 and S2 confirmed the failure of hospital personnel to identify and report these medication errors would result in the hospital's QAPI data being inaccurate relating to the overall medication error rate.

Medical record review on 5/31/11 revealed a medication error that occurred during the provision of care to Patient #26. Review of the medical record revealed orders dated 5/31/11 at 10:26 p.m. for 1 tablet of 37.5/150/200 Stalevo to be administered three times daily. Review of the medication administration record revealed the initial dose of Stalevo was not administered to the patient until 3:00 p.m. on 6/01/11 resulting in one (1) missed dose. Documentation on the medication administration record revealed the Stalevo was not available for administration at 9:00 a.m. on 6/01/11.

S18 (Licensed Practical Nurse) was interviewed on 6/02/11 at 9:55 a.m. S18 reviewed the medication administration record of Patient #26 and confirmed the Stalevo was not administered as ordered at 9:00 a.m. on 6/01/11 due to the medication not being available for administration. S18 reported that she did not complete a medication variance report for this medication error.

Review of hospital policies/procedures relating to medication administration revealed that a medication variance report should be completed on all medication errors.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**






Based on record review and interview, the registered nurse failed to ensure the supervision and evaluation of care as evidenced by:

1. Failing to ensure that laboratory tests were completed as ordered by the prescribing practitioner for 2 of 15 patients sampled for laboratory testing out of a total sample of 26 patients (Patient # 4 & Patient #16). Findings:

Patient # 4: Review of the admission orders for patient # 4 dated 05/13/11 at 1540 (3:40 p.m.) revealed patient # 4 was admitted by S20 MD. Further review of the orders revealed the physician ordered under "Lab and Diagnostics" an "Admit Panel" which consisted of the following lab tests upon admission: U/A (urinalysis), CBC (complete blood count), BMP (basic metabolic panel), TSH (thyroid stimulating hormone), T4 free (active thyroxine - [DIAGNOSES REDACTED]), RPR (rapid plasma reagin), Folate level, and Vitamin B level.

Review of the Laboratory results revealed the "collected" date was 05/18/11, five days after being ordered by the physician.

In an interview on 06/01/11 at 11:10 a.m. with S2 Operations Manager he confirmed the labs ordered by the physician on 05/13/11 were not collected by the lab until 05/18/11, five days after being ordered. S2 Operations further confirmed the missed lab order was not picked up by nursing on the 24 hour chart check and there was no documented evidence of notification of the physician that the ordered labs were not performed upon admission as ordered.

Patient #16: Medical record review revealed the patient was admitted to Oceans Behavioral Hospital of Baton Rouge on 5/03/11. The patient's diagnoses included [DIAGNOSES REDACTED]]. Review of the medical record revealed admission orders dated 5/03/11 at 1:20 p.m. under "Lab and Diagnostics" for an "Admit Panel" which consisted of a U/A, CBC, BMP, TSH, T4 free, RPR, Folate Level, Vitamin B Level. Review of the medical record revealed the "Admit Panel" was not collected until 5/05/11 resulting in a one day delay in the collection of these ordered laboratory tests.

S2 (Registered Nurse/Operations Manager) was interviewed on 6/01/11 at 3:10 p.m. S2 reviewed the medical record of Patient #16 and confirmed the delay in the collection of the ordered laboratory tests. S2 reported that the laboratory tests should have been obtained in the early a.m. on 5/04/11.


2. Failing to ensure the accuracy of 24 hour chart checks as evidenced by failing to identify inaccuracies relating to medication administration records for 2 of 15 patients (#1 & #9) sampled for 24 hour chart checks out of a total sample of 26 patients. This resulted in Patient #1 having a total of twenty-four (24) medication errors and Patient #9 having a medication omitted during hospital stay. Findings:

Patient #1: Medical record review revealed the patient was admitted to Oceans Behavioral Hospital of Baton Rouge on 5/23/11. Review of the medical record revealed inaccuracies in the medication administration record for the dates of 5/23/11 through 5/31/11. This resulted in a total of twenty-four (24) medication errors for Patient #1. Eight (8) medication errors in relation to the wrong dose of Metoprolol Succinate being administered as the wrong dose was documented on the medication administration record and sixteen (16) medication errors in relation to the administration of Flexeril as Flexeril was documented on the medication administration record in the absence of a practitioner's order.

S1 (Administrator) and S2 (Registered Nurse/Operational Manager) were interviewed on 5/31/11 at 11:10 a.m. S1 and S2 reviewed the medical record of Patient #1 and confirmed that the wrong dose of Metoprolol was administered to the patient on 5/24/11 thru 5/31/11 and confirmed that the Flexeril was administered in the absence of a practitioner's order from 5/23/11 thru 5/31/11. S1 and S2 reported that the medication errors were not previously identified by staff (prior to the surveyor's review) and had been missed during the 24 hour chart check. S1 and S2 reported that the medication administration records were inaccurate from 5/24/11 thru 5/31/11 which contributed to the 24 medication errors for Patient #1.

Patient #9: Medical record review revealed patient #9 was admitted to Oceans Behavioral Hospital of Baton Rouge on 4/15/11. Review of the medical record revealed an order dated 4/15/11 at 3:50 p.m. to continue all home medications. Review of the patient's home medications reflected the patient was currently prescribed Albuterol 2.5 mg aerosol treatment 1 vial per nebulizer every 4 hours. Review of the hospital's Admission Reconciliation Form dated 4/15/2011 at 3:50 p.m. revealed the Albuterol medication had not been transcribed to the reconciliation form nor had it been transcribed to the medication administration record. Review of the 24 hour chart checks that were completed revealed the medication omission was overlooked on the night shift on 4/15/11 and on 4/16/11. There was no documentation to reflect the patient received Albuterol medication during his hospital stay.

Interview with S1, Administrator on 6/1/11 at approximately 9:30 a.m., S1 confirmed the above findings. S1 stated it was determined during the internal investigation that patient #9 did not receive Albuterol medication during his stay in the hospital, and S1 confirmed the medication omission was overlooked during the 24 hour chart checks.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**







Based on record review and interview, the registered nurse failed to ensure that drugs and biologicals were administered in accordance with the orders of the prescribing practitioner for 3 of 15 patients (#1, #9 & #26) whose medical record was reviewed for medication administration out of a total sample of 26 patients and failed to ensure the prescribing practitioner was notified of medication errors that occurred during the provision of care for 2 of 15 patients (#1 & #26) whose medical record was reviewed for medication administration out of a total sample of 26 patients. Findings:

Patient #1: Medical record review revealed the patient was admitted to Oceans Behavioral Hospital of Baton Rouge on 5/23/11. The patient's diagnoses included [DIAGNOSES REDACTED][DIAGNOSES REDACTED]; Seizure Disorder; Peptic ulcer disease; Chronic kidney disease; Post CVA with right hemiparesis and aphasia; Hypoproteinemia; and Congestive heart failure. Review of the medical record revealed orders dated 5/23/11 at 3:00 p.m. for 100 mg of Metoprolol Succinate to be administered daily. Review of the medication administration record revealed that 50 mg of Metoprolol Succinate was administered to the patient (not the 100 mg as ordered) on 5/24/11, 5/25/11, 5/26/11, 5/27/11, 5/28/11, 5/29/11, 5/30/11 and 5/31/11 resulting in eight (8) medication errors. Further review of the medication administration record revealed that 5 mg of Flexeril was administered to the patient at 9:00 p.m. on 5/23/11, 9:00 a.m. & 9:00 p.m. on 5/24/11, 9:00 a.m. & 9:00 p.m. on 5/25/11, 9:00 a.m. & 9:00 p.m. on 5/26/11, 9:00 a.m. & 9:00 p.m. on 5/27/11, 9:00 a.m. & 9:00 p.m. on 5/28/11, 9:00 a.m. & 9:00 p.m. on 5/29/11, 9:00 a.m. & 9:00 p.m. on 5/30/11, and 9:00 a.m. on 5/31/11. Review of the medical record revealed no orders for Flexeril for this patient. This record review revealed a total of twenty-four (24) medication errors for this patient (eight (8) medication errors in relation to the wrong dose of Metoprolol Succinate being administered and sixteen (16) medication errors in relation to the administration of Flexeril in the absence of a practitioner's order). There was no documentation in the medical record to indicate that the ordering practitioner had been notified of the medication errors prior to this record review on 5/31/11.

S1 (Administrator) and S2 (Registered Nurse/Operational Manager) were interviewed on 5/31/11 at 11:10 a.m. S1 and S2 reviewed the medical record of Patient #1 and confirmed that the wrong dose of Metoprolol was administered to the patient on 5/24/11 thru 5/31/11 and confirmed that the Flexeril was administered in the absence of a practitioner's order from 5/23/11 thru 5/31/11. S1 and S2 reported that the medication errors were not previously identified by staff (prior to the surveyor's review) and confirmed that the ordering practitioner had not been notified of the medication errors prior to this interview.

Patient #9: Medical record review revealed the patient was admitted to Oceans Behavioral Hospital of Baton Rouge on 4/15/11. Review of physician's orders revealed an order dated 4/15/11 at 3:50 p.m. for Spiriva 18 MCG (1 capsule) daily at 9:00 a.m. and an order for Spiriva Handihaler device which is required to give the medication. Further review of the medical record reflected the Spiriva medication could not be given as ordered because the Spiriva Handihaler was not available.

Interview with S1, Administrator on 6/1/11 at approximately 9:30 a.m. confirmed the above findings. Further interview with S8, LPN on 4/16/11 at approximately 11:20 a.m. confirmed the Spiriva medication was available but could not be given because the Spiriva Handihaler was not available.

Interview with S19, Registered Pharmacist, on 6/2/11 at approximately 10:38 a.m. revealed that normally the Spiriva Handihaler is available in stock and usually there were 2 available at all times. #S19 revealed he was not aware that the Spiriva Handihaler device was not available.

Patient #26: Medical record review revealed the patient was admitted to Oceans Behavioral Hospital of Baton Rouge on 5/31/11. The patient's diagnoses included [DIAGNOSES REDACTED][DIAGNOSES REDACTED], and Anemia. Review of the medical record revealed orders dated 5/31/11 at 10:26 p.m. for 1 tablet of 37.5/150/200 Stalevo to be administered three times daily. Review of the medication administration record revealed that the initial dose of Stalevo was not administered to the patient until 3:00 p.m. on 6/01/11 resulting in one (1) missed dose. Documentation on the medication administration record revealed the Stalevo was not available for administration at 9:00 a.m. on 6/01/11. There was no documentation to indicate the ordering physician was notified of the omitted dose of Stalevo.

S18 (Licensed Practical Nurse) was interviewed on 6/02/11 at 9:55 a.m. S18 reviewed the medication administration record of Patient #26 and confirmed the Stalevo was not administered as ordered at 9:00 a.m. on 6/01/11 due to the medication not being available for administration. S18 reported that she did not complete a medication variance report for this medication error.
VIOLATION: PHARMACY ADMINISTRATION Tag No: A0491
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**






Based on record review and interview, the hospital failed to ensure that pharmacy services were provided in accordance with acceptable standards of practice as evidenced by the pharmacist's failure to accurately record practitioner's orders onto the medication administration record for 3 of 15 patients (#1, #4 & #9) whose medical record was sampled for medication administration out of a total sample of 26 patients and failed to ensure that medications ordered by the licensed practitioner were available for administration to patients for 2 of 15 patients (#9 and #26 ) whose medical records were sampled for medication administration out of a total sample of 26 patients. Findings:

1. Failing to accurately record practitioner's orders onto the medication administration record.

Patient #1: Medical record review revealed the patient was admitted to Oceans Behavioral Hospital of Baton Rouge on 5/23/11. Review of the medical record revealed orders dated 5/23/11 at 3:00 p.m. for 100 mg of Metoprolol Succinate to be administered daily. Review of the pre-printed medication administration record generated by pharmacy revealed that 50 mg of Metoprolol Succinate was to be administered to the patient. Documentation indicated that the nurse administered the 50 mg of Metoprolol Succinate as printed on the medication administration record on 5/24/11, 5/25/11, 5/26/11, 5/27/11, 5/28/11, 5/29/11, 5/30/11 and 5/31/11 and not the 100 mg as ordered. This resulted in eight (8) medication errors. Further review of the medication administration record (generated by pharmacy) revealed that 5 mg of Flexeril was to be administered to the patient. Documentation indicated that the nurse administered the 5 mg of Flexeril as documented on the medication administration record on 5/23/11, 5/24/11, 5/25/11, 5/26/11, 5/27/11, 5/28/11, 5/29/11, 5/30/11 and 5/31/11. Review of the medical record revealed no orders for Flexeril for this patient. This record review revealed a total of twenty-four (24) medication errors for this patient (eight (8) medication errors in relation to the wrong dose of Metoprolol Succinate being administered and sixteen (16) medication errors in relation to the administration of Flexeril in the absence of a practitioner's order).

S1 (Administrator) and S2 (Registered Nurse/Operational Manager) were interviewed on 5/31/11 at 11:10 a.m. S1 and S2 reviewed the medical record of Patient #1 and confirmed that the wrong dose of Metoprolol was administered to the patient on 5/24/11 thru 5/31/11 and confirmed that the Flexeril was administered in the absence of a practitioner's order from 5/23/11 thru 5/31/11. S2 reported the Metoprolol and Flexeril were inaccurately recorded onto the medication administration record by the contracted pharmacy service provider.

Patient #4: Review of the medical record for patient # 4 on 06/01/11 at 9:05 a.m. revealed the patient was admitted on [DATE] at 1540 (3:40 p.m.). Review of the admission orders revealed there were medication orders by the attending physician from the Medication Reconciliation Sheet and a MAR (Medication Administration) generated by the pharmacy.

Further review of the medical record revealed the patient was transferred to an acute care hospital and readmitted to Oceans Behavioral hospital on [DATE] at 1550 (3:50 p.m.). Review of the admission orders for 05/21/11 revealed medication orders by the attending physician from the Medication Reconciliation Sheet.

Review of the MAR revealed the pharmacy continued the Medication Orders on the MAR from the previous admit. The MAR was corrected by nursing prior to any medication administration. Further review revealed the physician had added Cipro 500 mg po bid (twice a day).

This resulted in patient # 4 being administered Cipro prior to the drug regimen being reviewed by a pharmacist for the addition of Cipro for the evening dose on 05/21/11 and both doses that had been administered on 05/22/11. The MAR was not corrected until 05/23/11. Review of the Medication Reconciliation sheet/physicians medication order sheet for the 05/21/11 admission revealed no documented evidence of it being faxed to pharmacy.

The contracted pharmacist (S19) was interviewed on 6/02/11 at 10:40 a.m. S19 reviewed the medical records of Patients #1 and #4 and confirmed that the pharmacy generated medication administration records were inaccurate as the information on the medication administration record was not in accordance with the orders of the licensed practitioner for the hospitalization s of these patients. When asked if the pharmacy had completed a medication variance report relating to the medication errors that occurred during the provision of care for Patient #1 or Patient #4, S19 indicated that the pharmacy did not complete any medication variance reports for these two patients.

Patient #9: Medical record review revealed patient #9 was admitted to Oceans Behavioral Hospital of Baton Rouge on 4/15/11. Review of the medical record revealed an order dated 4/15/11 at 3:50 p.m. to continue all home medications. Review of the patient's home medications reflected the patient was currently prescribed Albuterol 2.5 mg aerosol treatment 1 vial per nebulizer every 4 hours. Review of the hospital's Admission Reconciliation Form dated 4/15/2011 at 3:50 p.m. revealed the Albuterol medication had not been transcribed to the reconciliation form nor had it been transcribed to the medication administration record. There was no documentation to reflect the patient received Albuterol medication during his hospital stay.

Interview with S1, Administrator on 6/1/11 at approximately 9:30 a.m. confirmed the above findings. S1 stated it was determined during the internal investigation that patient #9 did not receive Albuterol medication during his stay in the hospital.

2. Failing to ensure that medications ordered by the licensed practitioner were available for administration to patients.

Patient #26: Medical record review revealed the patient was admitted to Oceans Behavioral Hospital of Baton Rouge on 5/31/11. Review of the medical record revealed orders dated 5/31/11 at 10:26 p.m. for 1 tablet of 37.5/150/200 Stalevo to be administered three times daily. Review of the medication administration record revealed that the initial dose of Stalevo was not administered to the patient until 3:00 p.m. on 6/01/11 resulting in one (1) missed dose. Documentation on the medication administration record revealed the Stalevo was not available for administration at 9:00 a.m. on 6/01/11.

S18 (Licensed Practical Nurse) was interviewed on 6/02/11 at 9:55 a.m. S18 reviewed the medication administration record of Patient #26 and confirmed the Stalevo was not administered as ordered at 9:00 a.m. on 6/01/11 due to the medication not being available for administration.

Patient #9: Medical record review revealed the patient was admitted to Oceans Behavioral Hospital of Baton Rouge on 4/15/11. Review of physician's orders revealed an order dated 4/15/11 at 3:50 p.m. for Spiriva 18 MCG (1 capsule) daily at 9:00 a.m. and an order for Spiriva Handihaler device which is required to give the medication. Further review of the medical record reflected the Spiriva medication could not be given as ordered because the Spiriva Handihaler was not available.

Interview with S1, Administrator on 6/1/11 at approximately 9:30 a.m., S1 confirmed the above findings. Further interview with S8, LPN on 4/16/11 at approximately 11:20 a.m. confirmed the Spiriva medication was available but could not be given because the Spiriva Handihaler was not available.

Interview with S19, Registered Pharmacist, on 6/2/11 at approximately 10:38 a.m. revealed that normally the Spiriva Handihaler is available in stock and usually there were 2 available at all times. #S19 revealed he was not aware that the Spiriva Handihaler device was not available.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the hospital failed to follow their policy and procedure for informed consents by failing to have a patient sign a Hospital Care consent and Authorization/Consent Form for treatment for 1 of 4 patients whose medical record was reviewed for Formal Voluntary Admission out of a total of 26 sampled patients (#2). Findings:

Review of the Hospital's policy for Intake Screening and Admissions Process in part revealed, "...Reviews completes and obtains patient signature for: Formal Voluntary Admission ( if applicable), Authorization/Consent forms..."

Review of Patient #2's medical record revealed she was admitted on [DATE] and continued at time of the survey to receive treatment in the hospital for the diagnoses of Psychosis. Review of the medical record revealed that Patient #2 was admitted on a formal voluntary admission.

Review of the Patient #2's medical record revealed no patient signature on the Authorization/Consent Form or the Hospital Care Consent Form.

An interview was conducted with S1Administrator on 05/31/11 at 10:45 a.m. S1 confirmed the patient's signature was not on the Authorization/Consent Form or the Hospital Consent Form and the patient's signature should have been obtained on admission to the hospital. S1 went on to state when a consent was not signed by a patient, the admitting nurse documents in the Nursing Notes why the consent was not obtained. S1 reviewed the patient's Nurses Notes and stated she was unable to find documentation why the patient's consent was not obtained.
VIOLATION: CONTENT OF RECORD - DISCHARGE DIAGNOSIS Tag No: A0469
Based on observation, record review and interview the hospital failed to ensure that medical records were promptly completed within 30 days of discharge by having approximately 800 medical records in the medical records department. Approximately 400 of those medical records were flagged as incomplete with some delinquent since 2009. Findings:

In an observation and interview on 06/01/11 with S12Medical Records Director on 06/01/11 at 1:45 p.m. it was noted that there were approximately 800 medical records stored in the medical records department.

In an interview with S1Administrator, S2 Operations Manager, and S12 Medical Records Director it was confirmed that approximately 400 of the medical records were flagged as incomplete (signatures, order authentication, discharge summary signatures, etc.). S12 Medical Records Director stated that the records had been stored on the floor since she took over the job in April 2010.

Review of documentation relating to the 34 boxes of medical records on the floor of the medical records department listed 160 of the approximately 340 medical records as being delinquent. The document was titled "Missing Signatures on the Following Sheets."

In an interview on 06/01/11 at 1:45 p.m. with S12Medical Records Director she stated that these records had been reviewed and the reason for the record being delinquent had been identified but no corrective action had been taken. During the same interview S12 Medical Records Director stated that there was no documentation related to the reason approximately half of the 450 records on the shelves were delinquent.

In an interview on 06/01/11 at 1:45 p.m. S12 Medical Records Director stated that she had been the Medical Records Director since April 2010. S12 confirmed she had no prior experience relating to Medical Records and had no supervision/training from anyone since taking over the position.

In an interview on 06/01/11 at 1:50 with S2 Operations Manager he confirmed the last visit by the contracted RHIA was in December 2009. He further stated the hospital was "not aware" the RHIA was not providing the contracted services.

In an interview on 06/02/11 at 9:10 a.m. with S1 Administrator she stated she contacted the contracted RHIA and was informed that the RHIA was told her services "were no longer needed" in late 2009.

Review of the revised Medical Staff Bylaws, revised by the Medical Staff on 01/25/11 and not yet approved by the Governing Body, revealed, in part, " ... Section 4: Automatic Suspension And Expulsion ... A. Medical Records Practitioners must complete the patients medical records within 30-days of each patient's discharge or such period as the Medical Executive Committee may prescribe. ... Medical records that the Practitioner fails to complete within the 30-day (or other) period will be considered delinquent. The Medical Records department Supervisor/Director shall notify Practitioners in writing of incomplete medical records nearing delinquent status. This notification shall remind the Practitioner that his or her Clinical Responsibilities will be automatically suspended in the event that he does not complete the medical records within five (5) days following receipt of notice. If the Practitioner fails to complete medical records after such notification, all of his Clinical Responsibilities will be automatically suspended. ... Practitioners whose Clinical Responsibilities are automatically suspended shall not be permitted to admit any patients, pr perform consults, or other procedures, assist or otherwise treat any patients unless such patients were admitted to the Hospital prior to the imposition of the automatic suspension. The Medical Records department Supervisor/Director shall notify the President or Medical Director immediately upon a suspended Practitioner ' s completion of the delinquent medical records. At that time, the Practitioner's Clinical Responsibilities will be reinstated ... " .

In a face-to-face interview on 06/02/11 at 8:35 am, Operational Manager S2 indicated the Medical Staff had revised their bylaws which was approved by the Medical Executive Committee on 01/25/11. He further indicated the Governing Board had not met since the bylaws had been revised to review and approve the revised bylaws.
VIOLATION: QUALIFIED DIETITIAN Tag No: A0621
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review (medical records and the hospital's policy and procedures) and interview, the hospital failed to ensure the medical staff collaborated with the registered dietician to meet the nutritional needs of the patient for 1 out 11 active patients reviewed (Patient #6) out of a sample size of 26 and failed to develop and implement a system, according the the hospital's policy, to identify which patients were classified as in urgent need of a dietary consult by the registered dietician. Findings:

Patient #6: Review of the medical record revealed the patient was admitted on [DATE] with the diagnoses of Increase confusion, Dementia and Hallucinations and was sent to an acute care hospital on [DATE] for evaluation of dehydration, hypokalemia, and leukocytosis.

Review of the Nursing Initial Interview and assessment dated [DATE] revealed the patient was 66 inches tall and weighed 118 pounds. Under the section labeled Any Score of 10 or above requires a Nutritional Consult revealed Malnutrition was checked with an assigned score of 10, Must be Fed was checked with an assigned score of 2, Poor skin integrity/ < 18 on Braden Scale was checked with an assigned score of 5. The patient's total score was 17.

An interview was conducted on 06/01/11 at 11:30 a.m. with S6 Registered Dietician (RD) and the Nutritional Consult/assessment she performed was reviewed. She confirmed the score of the Nutritional Assessment by the nurse was a 17. Review of the hospital policy for a nutritional consult revealed an urgent nutritional consult was not defined in the policy and this was confirmed by S6RD. S6RD reviewed her nutritional assessment of Patient #6 and stated due to on admit Patient #6's Blood Urea Nitrogen (BUN) was slightly elevated (05/21/11 lab results: BUN was as 21 with a reference range of 8-20 mg/dL) and his history of poor intake she recommended an appetite stimulant and to increase his fluid intake more. S6RD reviewed the 05/29/11 Chemistry lab work for Patient #6 with his BUN at a critical level of 107, with a reference range of 5-25 mg/dL. S6RD stated when she made the dietary recommendations for a patient, she flagged the chart for the physician and highlighted the recommendations that needed a physicians order to institute.

Review of the Physician orders revealed no orders for an appetite stimulate or to increase the patient's fluid intake more.

An interview was conducted with S1Administrator on 06/01/11 at 9:45 a.m. She reviewed Patient #6's physician orders and stated there were no orders for the patient indicating the physician reviewed the RD's nutritional recommendations for the patient.


Patient #7: Review of the medical record revealed the patient was admitted on [DATE] with the diagnoses of Major depressive disorder, recurrent; and Substance abuse history with overuse of opiates, possible addictive behavior.

Review of the Nursing Initial Interview and assessment dated [DATE] revealed the patient was 65 inches tall and weighed 133 pounds. Under the section labeled Any Score of 10 or above requires a Nutritional Consult revealed "Diabetes" was checked with an assigned score of 5, and "Other:Poor Appetite" was checked with an assigned score of 5. The patient's total score was 10.

Review of the Medical Nutrition Therapy Notes revealed the Registered Dietician (S6) conducted a nutritional consult on Patient #7 on 5/30/11.

The hospital approved policy/procedure titled "TX-Diet-01:Nutritional Assessment" was reviewed. The policy documents the Registered Dietician will provide nutritional assessment and/or counseling, education and instructions to patients within 5 days (inpatient) or 5 sessions (partial hospitalization /outpatient). The policy further documents that patients admitted with urgent nutrition needs may require a recommendation from Registered Dietician within 24 hours of admission. The policy failed to define the criteria for nursing to use to determine if the patient's condition warranted a recommendation by the Registered Dietician within 5 days of admission or within 24 hours of admission. In addition, the numerical score on the "Nursing Initial Interview and Assessment" form failed to define this as well.
VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
Based on observation, record review and interview the hospital failed to ensure the Medical Staff By-Laws were enforced as evidenced by failing to notify physicians of medical records approaching 30 days delinquent and failing to suspend admission privileges for physician's with delinquent medical records per the Medical Staff By-Laws. Findings:

In an observation and interview on 06/01/11 with S12Medical Records Director on 06/01/11 at 1:45 p.m. it was noted that there were approximately 800 medical records stored in the medical records department.

In an interview with S1Administrator, S2 Operations Manager, and S12 Medical Records Director it was confirmed that approximately 400 of the medical records were flagged as incomplete (signatures, order authentication, discharge summary signatures, etc.). S12 Medical Records Director stated that the records had been stored on the floor since she took over the job in April 2010.

Review of documentation relating to the 34 boxes of medical records on the floor of the medical records department listed 160 of the approximately 340 medical records as being delinquent. The document was titled "Missing Signatures on the Following Sheets."

In an interview on 06/01/11 at 1:45 p.m. with S12Medical Records Director she stated that these records had been reviewed and the reason for the record being delinquent had been identified but no corrective action had been taken. During the same interview S12 Medical Records Director stated that there was no documentation related to the reason approximately half of the 450 records on the shelves were delinquent.

In an interview on 06/01/11 at 1:45 p.m. S12 Medical Records Director stated that she had been the Medical Records Director since April 2010. S12 confirmed she had no prior experience relating to Medical Records and had no supervision/training from anyone since taking over the position.

In an interview on 06/01/11 at 1:50 with S2 Operations Manager he confirmed the last visit by the contracted RHIA was in December 2009. He further stated the hospital was "not aware" the RHIA was not providing the contracted services.

In an interview on 06/02/11 at 9:10 a.m. with S1 Administrator she stated she contacted the contracted RHIA and was informed that the RHIA was told her services "were no longer needed" in late 2009.

In an interview on 06/01/11 with S1Administrator, S2 Operations Manager, and S12 Medical Records Director all confirmed there had been no notification to any physician regarding delinquent records and no suspension of any physician had occurred as a result of the numerous medical records delinquent dating back to 2009.

Review of the revised Medical Staff Bylaws, revised by the Medical Staff on 01/25/11 and not yet approved by the Governing Body, revealed, in part, " ... Section 4: Automatic Suspension And Expulsion ... A. Medical Records Practitioners must complete the patients' medical records within 30-days of each patient's discharge or such period as the Medical Executive Committee may prescribe. ... Medical records that the Practitioner fails to complete within the 30-day (or other) period will be considered delinquent. The Medical Records department Supervisor/Director shall notify Practitioners in writing of incomplete medical records nearing delinquent status. This notification shall remind the Practitioner that his or her Clinical Responsibilities will be automatically suspended in the event that he does not complete the medical records within five (5) days following receipt of notice. If the Practitioner fails to complete medical records after such notification, all of his Clinical Responsibilities will be automatically suspended. ... Practitioners whose Clinical Responsibilities are automatically suspended shall not be permitted to admit any patients, perform consults, or other procedures, assist or otherwise treat any patients unless such patients were admitted to the Hospital prior to the imposition of the automatic suspension. The Medical Records department Supervisor/Director shall notify the President or Medical Director immediately upon a suspended Practitioner's completion of the delinquent medical records. At that time, the Practitioner's Clinical Responsibilities will be reinstated ... " .

In a face-to-face interview on 06/02/11 at 8:35 am, Operational Manager S2 indicated the Medical Staff had revised their bylaws which was approved by the Medical Executive Committee on 01/25/11. He further indicated the Governing Board had not met since the bylaws had been revised to review and approve the revised bylaws.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on record review and interviews, the hospital failed to ensure the infection control officer implemented a system for controlling communicable diseases of personnel as evidenced by failure to have documented current TB (tuberculosis) testing and results for 2 of 2 physicians reviewed from a total of 6 credentialed physicians (S5, S13), 2 of 2 nurse practitioners reviewed from a total of 4 credentialed nurse practitioners (S14, S15), and 1 of 1 LPN (licensed practical nurse) reviewed from a total of 9 LPNs on staff (S16). Findings:

Review of the credentialing file for Physicians S5 and S13, the credentialing file for Nurse Practitioners S14 and S15, and employee file for LPN S16 revealed no documented evidence that a TB test had been administered and read.

In a face-to-face interview on 06/01/11 at 3:40pm, Operational Manager S2 indicated the hospital did not have a policy regarding the requirement for physicians to be tested for TB, and it was not a part of the medical staff bylaws. S2 further indicated the hospital did require physicians to be TB tested . He could offer no explanation for the credentialing files of S5, S13, S14, and S15 not having evidence of TB testing and reading of results.

In a face-to-face interview on 06/02/11 at 9:15am, Administrator S1 confirmed the personnel file of LPN S16 had no evidence that a TB test had been administered and read.

Review of the hospital policy titled "Selection Of Employees", revised 07/10 and submitted by Human Resource/Medical Records Director S12 as the current policy related to TB testing, revealed, in part, "...Together with the Employee Health Nurse or Designee is responsible for ensuring all prospective employees complete the appropriate medical examinations... Medical exams shall include, at a minimum, any test or examination required by federal/state law and may include, at the discretion of the facility, ... PPD (purified protein derivative)...".

Review of the "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005" published by the CDC (Centers for Disease Control) revealed, in part, "...The following are HCWs (health-care workers) who should be included in a TB screening program: ...Nurses ... Physicians...".