HospitalInspections.org

Based on record reviews, contract reviews and interview the hospital failed to be in compliance with the Condition of Participation for Governing Body as evidenced by:
1) The Governing Body's failure to ensure the hospital's contracted services were performed to allow the hospital to demonstrate independant compliance with Conditions of Participation. (see finding at A0083).
2) Failing to ensure the patients right to privacy including the release or disclosure of the patient's presence in the facility or location in the hospital and personal information such as name and age as evidenced by hospital "b" physically placed a computer owned by hospital "b" inside of Louisiana Extended Care Hospital of Lafayette - Iberia Campus. This computer contained information/access on all patients from both hospitals and failed to allow the hospital to demonstrate independant compliance with Conditions of Participation. This was evidenced by patients of the Louisiana Extended Care Hospital of Lafayette- Iberia Campus being on a list of current hospital "b" patients provided to surveyor's and through interview with staff. (see findings at A0143)

3) Failing to ensure the Nursing Services had one well organized service with a plan of administrative authority and clear delineation of patient care responsibilities and failing to allow the hospital to demonstrate independant compliance of Conditions of Participation as evidenced by the acute care host hospital and the long term care hospital (hospital within a hospital) using the same staff for Telemetry monitoring. Acute care host hospital "b" monitored patients from the Louisiana Extended Care Hospital of Lafayette-Iberia Campus, thereby co-mingling staff between acute care host hospital "b" and Lousiana Extended Care-Iberia Campus long term care hospital. (see findings at A0386).

4) Failing to ensure emergency services were not dependent upon co-mingling of staff of 2 different hospitals on the same campus and failing to allow the hospital to demonstrate independant compliance with Conditions of Participation. Both campuses of Louisiana Extended Care Hospital of Lafayette, a long term care hospital is dependent on the host hospitals for Emergency Services as evidenced by having physicians from the host hospitals respond to and perform code blue procedures on the patients of Louisiana Extended Care Hospital. (see findings at A1104).

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


1) Failing to ensure the patients right to privacy including the release or disclosure of the patient's presence in the facility or location in the hospital and personal information such as name and age as evidenced by hospital "b" physically placed a computer owned by hospital "b" inside of Louisiana Extended Care Hospital of Lafayette - Iberia Campus. This computer contained information/access on all patients from both hospitals and failed to allow the hospital to demonstrate independent compliance with Conditions of Participation. This was evidenced by patients of the Louisiana Extended Care Hospital of Lafayette- Iberia Campus being on a list of current hospital "b" patients provided to surveyor's and through interview with staff. (see findings at A0143)

2) Failing to ensure the patients right to privacy including the release or disclosure of the patient's presence in the facility or location in the hospital and personal information such as name and age as evidenced by the name, age, room number and location of 11 (#R8 - #R18) of 11 (#R8 - #R18) random patients in the Hospital within the Hospital (Louisiana Extended Care - Iberia Campus) being presented to surveyor's on a list of acute care hospital "b" current patient list. The List also contained an admission diagnosis for 5 (#R8, #R9, #R10, #R15, #R18) of the 11 (#R8 - #R18) patients currently in the Louisiana Extended Care - Iberia Campus. (see findings at A0143)

3) Failing to ensure the patients right to privacy including the release or disclosure of the patient's presence in the facility or location in the hospital and personal information such as name and age as evidenced by having a Telemetry logbook where the Louisiana Extended Care - Iberia Campus patients' name, room number, physician's name, code status, age, sex, and diagnosis were documented on the log maintained inside acute care hospital "b". (see findings at A0143)

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

1) Failing to ensure the Nursing Services had one well organized service with a plan of administrative authority and clear delineation of patient care responsibilities and failing to allow the hospital to demonstrate independent compliance of Conditions of Participation as evidenced by the acute care host hospital and the long term care hospital (hospital within a hospital) using the same staff for Telemetry monitoring. Acute care host hospital "b" monitored patients from the Louisiana Extended Care Hospital of Lafayette-Iberia Campus, thereby co-mingling staff between acute care host hospital "b" and Louisiana Extended Care-Iberia Campus long term care hospital. (see findings at A0386).

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

1) Failing to ensure the patients right to privacy including the release or disclosure of the patient's presence in the facility or location in the hospital and personal information such as name and age as evidenced by hospital "b" physically placed a computer owned by hospital "b" inside of Louisiana Extended Care Hospital of Lafayette - Iberia Campus. This computer contained information/access on all patients from both hospitals and failed to allow the hospital to demonstrate independent compliance with Conditions of Participation This was evidenced by patients of the Louisiana Extended Care Hospital of Lafayette- Iberia Campus being on a list of current hospital "b" patients provided to surveyor's and through interview with staff. (see findings at A0441)

2) Failing to ensure the patients right to privacy including the release or disclosure of the patient's presence in the facility or location in the hospital and personal information such as name and age as evidenced by the name, age, room number and location of 11 (#R8 - #R18) of 11 (#R8 - #R18) random patients in the Hospital within the Hospital (Louisiana Extended Care - Iberia Campus) being presented to surveyor's on a list of acute care hospital "b" current patient list. The List also contained an admission diagnosis for 5 (#R8, #R9, #R10, #R15, #R18) of the 11 (#R8 - #R18) patients currently in the Louisiana Extended Care - Iberia Campus. (see findings at A0441)

3) Failing to ensure the patients right to privacy including the release or disclosure of the patient's presence in the facility or location in the hospital and personal information such as name and age as evidenced by having a Telemetry logbook where the Louisiana Extended Care - Iberia Campus patients' name, room number, physician's name, code status, age, sex, and diagnosis were documented on the log maintained inside hospital "b". (see findings at A0441)

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

1) Failing to ensure emergency services were not dependent upon co-mingling of staff of 2 different hospitals on the same campus and failing to allow the hospital to demonstrate independent compliance with Conditions of Participation. Both campuses of Louisiana Extended Care Hospital of Lafayette, a long term care hospital is dependent on the host hospitals for Emergency Services as evidenced by having physicians from the host hospitals respond to and perform code blue procedures on the patients of Louisiana Extended Care Hospital. (see findings at A1104).

Based on record reviews, contract reviews and interview the hospital failed to ensure the hospital's contracted services were performed to allow the hospital to demonstrate independent compliance with Conditions of Participation.
This was evidenced by Louisiana Extended Care Hospital of Lafayette signing a contract to purchase, and then purchasing laboratory and blood gas services, radiology and imaging services, emergency and code blue services, respiratory services and telemetry services from both Hospital "a" (Lafayette) and Hospital "b" (Iberia Campus).

Review of the "Purchased Services Agreement", dated 10/1/11, and presented to the surveyor as the most current agreement between Louisiana Extended Care Hospital of Lafayette (Lafayette Campus)long term acute care hospital and acute care host Hospital "a". This agreement revealed Louisiana Extended Care Hospital of Lafayette (Lafayette Campus) is purchasing laboratory and blood gas services, radiology and imaging services, medical staff services, emergency services and code blue response, and pharmacy services, from acute care Hospital "a".
This agreement further stipulated that acute care hospital "a" would respond to any code blue or emergency situations in long term care hospital Louisiana Extended Care Hospital of Lafayette -Lafayette Campus with physicians handling the emergency and code blue situations along with Louisiana Extended Care Hospital of Lafayette -Lafayette Campus support staff.

Review of the "Purchased Services Agreement", dated 6/1/10, and presented to the surveyor as the most current agreement between Louisiana Extended Care Hospital of Lafayette (Iberia Campus) long term acute care hospital and acute care Hospital "b". This agreement revealed Louisiana Extended Care Hospital of Lafayette (Iberia Campus) is purchasing laboratory and blood gas services, radiology and imaging services, medical staff services, emergency services and code blue response, pharmacy services, and telemetry services from acute care Hospital "b".
This agreement further stipulated that acute care hospital "b" would respond to any code blue or emergency situations in long term care hospital Louisiana Extended Care Hospital of Lafayette -Iberia Campus with physicians and hospital "b" support staff handling the emergency and code blue situations along with Louisiana Extended Care Hospital of Lafayette -Lafayette Campus support staff.

Based on observation, record review, and interview the hospital failed to ensure the patients right to privacy including the release or disclosure of the patient's presence in the facility or location in the hospital and personal information such as name and age as evidenced by

1) hospital "b" physically placed a computer owned by hospital "b" inside of Louisiana Extended Care Hospital of Lafayette - Iberia Campus. This computer contained information/access on all patients from both hospitals and failed to allow the hospital to demonstrate independent compliance with Conditions of Participation. This was evidenced by patients of the Louisiana Extended Care Hospital being on a list of current acute care hospital "b" patients provided to surveyor's and through interview with staff

2) the name, age, room number and location of 11 (#R8 - #R18) of 11 (#R8 - #R18) random patients in the Hospital within the Hospital (Louisiana Extended Care - Iberia Campus) being presented to surveyor's on a list of acute care hospital "b" current patient list. The List also contained an admission diagnosis for 5 (#R8, #R9, #R10, #R15, #R18) of the 11 (#R8 - #R18) patients currently in Louisiana Extended Care Hospital -Iberia Campus and

3) having a Telemetry logbook where the HWH (Louisiana Extended Care - Iberia Campus) patients' name, room number, physician's name, code status, age, sex, and diagnosis were documented on the log maintained inside acute care hospital "b". Findings:

1)

In an interview on 10/08/12 at 11:00 a.m. with S12DON, of acute care hospital "b", and S10HIM Director, hospital "b", both confirmed that a computer owned by hospital "b" was located within the "hospital within a hospital" (HWH) (Louisiana Extended Care Hospital - Iberia Campus). S12DON, hospital "b", and S10HIM Director, hospital "b", stated that the computer is used by Louisiana Extended Care Hospital Iberia Campus to enter orders for ancillary services contracted from the host hospital (hospital "b"). It was confirmed during the same interview that the HWH (Louisiana Extended Care Hospital - Iberia Campus) had access to all patient demographic, lab orders and results, and Radiology orders and results on all current patients and past patients of acute care hospital "b".

In an interview on 10/08/12 at 11:15 a.m. with S9IT (Information Technology), (hospital "b") he confirmed the computer located in the HWH (Louisiana Extended Care - Iberia Campus) belonged to hospital "b". He further confirmed that the computer has access to patient information for patients of hospital "b". S9IT stated that the computer program used by acute care hospital "b" had no capability to limit the access of the HWH (Louisiana Extended Care - Iberia Campus) to only patients admitted to the HWH.

In an interview on 10/09/12 at 8:55 a.m. with S8Quality (hospital "b") and S9IT (hospital "b") both stated that the computer owned by hospital "b" that is located in the HWH (Louisiana Extended Care - Iberia Campus) can access any lab result, radiology report, and demographic information from hospital "b".

2)

During the Entrance Conference at acute care hospital "b" (Host Hospital) on 10/08/12 at 10:00 a.m. a request was made for a list of current patients. Review of the list provided by S12DON revealed it contained the full name, age, room number and location of 11 (#R8 - #R18) of 11 (#R8 - #R18) patients in the Hospital within the Hospital (Louisiana Extended Care - Iberia Campus).The list was being presented to surveyor's on a list of hospital "b" current patient list. The List also contained an admission diagnosis for 5 (#R8, #R9, #R10, #R15, #R18) of the 11 (#R8 - #R18) patients currently in the HWH. This was confirmed by S12DON, hospital "b", on 10/08/12 at 11:00 a.m.

3)

On 10/09/12 at 9:15 a.m., a face-to-face interview was conducted with S15 Telemetry Technician (hospital "b") and an observation was made of the cardiac monitors. S15 stated she received patient information from Louisiana Extended Care - Iberia Campus by telephone when telemetry monitoring was initiated. S15 stated the nurse in Louisiana Extended Care - Iberia Campus provided the patient's name, diagnosis, code status, age, room number, and the physician's name of the patient to be monitored. An observation of the hospital "b" monitor revealed the patient's name, room number, age and physician's name were displayed on the screen. S15 stated she printed rhythm strips for all patients every 8 hours, documented the rhythm, posted the rhythm on a form to be filed in the patient's record, and delivered the strips to the patient's unit for filing. S15 verified Louisiana Extended Care - Iberia Campus was included in this process. S15 stated there is a log book for telemetry and all patients on telemetry, including Louisiana Extended Care - Iberia Campus patients, are logged in. Review of the Telemetry Log (hospital "b") book revealed the Louisiana Extended Care - Iberia Campus patient's name, room number, physician's name, code status, age, sex, and diagnosis were documented on the log. S15 stated if she needed to compare strips, or needed other information, she went to Louisiana Extended Care - Iberia Campus and reviewed the patient's record. S15 verified she had access to Louisiana Extended Care - Iberia Campus patient records.

Based on observation, record review and interview the hospital failed to ensure that Nursing Services had one well organized service with a plan of administrative authority and clear delineation of patient care responsibilities and failing to allow the hospital to demonstrate independent compliance with Conditions of Participation as evidenced by the acute care host hospital and Louisiana Extended Care Hospital of Lafayette -Iberia Campus a long term care hospital (hospital within a hospital) using the same staff for Telemetry monitoring. Acute Care hospital "b" monitored patients from long term care hospital Louisiana Extended Care Hospital of Lafayette- Iberia Campus, thereby co-mingling staff between acute care hospital "b" and long term care hospital Louisiana Extended Care Hospital of Lafayette- Iberia Campus.

Findings:


TELEMETRY

Observations/Interviews/Record Reviews from Louisiana Extended Care Hospital of Lafayette - Iberia Campus

During an observation of telemetry monitoring on 10/10/12 at 3:45 p.m., there were two (2) telemetry monitors noted inside the nursing station in the corner with one on the left and another one on the right. Further observation revealed Patient #3's and Patient #4's heart rate and rhythms were being monitored on the left telemetry monitor mounted on the wall while Patient #5's heart rate and rhythms were being monitored on the right telemetry monitor located on the countertop in the nurse's station.

In interviews on 10/10/12 from 3:45 p.m. through 4:10 p.m. and on 10/11/12 from 1:10 p.m. through 1:20 p.m., S16RN Charge Nurse confirmed there were 3 patients (#3, #4, #5) ordered by their primary physicians to be on telemetry monitoring. S16RN further confirmed there were 2 patients (#3, #4) being monitored by an ICU tech in acute care hospital "b". The charge nurse, S16RN, indicated there are no ICU services provided in this hospital. "These patients (#3, #4) are on our unit but are being monitored by a designated ICU tech in hospital "b"." S16RN, charge nurse further indicated the designated ICU tech (hospital "b") is responsible for watching the telemetry monitors continuously to identify any abnormal heart rates and/or heart rhythms for the patient. The ICU tech then notifies the charge nurse of any changes in the patient's heart rates and/or rhythms immediately. The charge nurse, S16RN, stated the nursing staff on the unit (Louisiana Extended Care - Iberia) is not responsible for our patients that are on telemetry monitoring that is being done by a designated ICU tech in hospital "b". The charge nurse, S16RN, further stated it is the primary responsibility of the ICU tech from hospital "b" that is designated to monitor our patients (#3, #4) heart rates and rhythms on the telemetry monitors.

During interviews on 10/10 /12 from 4:10 p.m. through 4:50 p.m. and on 10/11/12 at 8:30 a.m. and at 11:30 a.m., S18DON confirmed there were 3 patients (#3, #4, #5) ordered by their primary physicians to be on telemetry monitoring. S18DON verified there were 2 of the 3 patients (#3,#4) being monitored by a designated ICU tech from hospital "b". The DON, S18 indicated the hospital does not provide ICU services. S18DON further indicated these 2 patients (#3, #4) are on the unit but are being monitored by a designated ICU tech from hospital "b". S18DON reported it is the designated ICU tech from hospital "b" responsibly for continuously watching, monitoring, and/or identifying any abnormal heart rates and/or rhythms of the patients and to notify the charge nurse (at Louisiana Extended Care - Iberia) of any changes in the patients' (#3's, #4's) conditions immediately. The S18DON further stated the nursing staff on my unit are not primarily responsible to monitor the patients on telemetry monitoring in ICU (hospital "b"); They (nursing staff) are backup staff for the patients (#3, #4) being monitored by an ICU tech from hospital "b". The sole responsibility of the telemetry monitoring for these 2 patients (#3, #4) is the responsibility of the ICU tech in hospital "b". At this time, S18DON was presented the "Purchased Services Agreement" effective date of June 01, 2010 between hospital "b" (named) indicating telemetry services is provided secondary by ICU. S18DON confirmed the agreement indicated the Telemetry services included providing telemetry transmitters, to the extent available, and secondary monitoring of the patients at the hospital. S18DON further confirmed it was the primary responsibly of the nursing staff to provide telemetry monitoring for all patients in the hospital. The DON, S18 indicated the nursing staff failed to follow the agreement for hospital "b's" ICU tech to provide secondary telemetry monitoring for Patient #3 and Patient #4.

Review of the policy titled, "Telemetry Monitoring, Off-Site", policy number: 9-6.15.0, effective date of July, 2007, with no revised date-left blank, with no reviewed date on the policy, revealed the policy indicated its purpose was to outline the responsibilities for the care and management of patients being monitored by telemetry at an off-site location. The Off-site telemetry monitoring may be provided through a contracted service.

Observations/Interviews/Record Reviews from Hospital "b"

On 10/08/12 at 3:30 p.m. a face-to-face interview was conducted with S14 CCU (Critical Care Unit) Manager (hospital "b") and observations were made of the unit. S14 indicated the CCU was also responsible for telemetry monitoring for the hospital. S14 stated that hospital "b" had telemetry capability of 46. S14 stated they had 40 telemetry units for the hospital ("b") and 6 for Louisiana Extended Care Hospital of Lafayette - Iberia Campus. S14 stated the CCU (hospital "b") has a telemetry technician who monitors the telemetry and CCU patient cardiac rhythms 24 hours a day, 7 days a week. S14 stated Louisiana Extended Care - Iberia Campus had a remote display, but no one sits at the monitor in Louisiana Extended Care - Iberia Campus. S14 stated the telemetry tech (hospital "b") was responsible to monitor Louisiana Extended Care - Iberia Campus patients on telemetry as well as telemetry patients throughout the hospital. Observation of the CCU (hospital "b") revealed the cardiac monitors were located in a room to the rear of the nurse's station. S15 Telemetry Technician (hospital "b") stated CCU patients were on the first monitor, Louisiana Extended Care - Iberia Campus patients were on the second monitor, and the other 2 monitors were for telemetry patients throughout the hospital. Observation of the Louisiana Extended Care - Iberia Campus monitor revealed 2 patients from Louisiana Extended Care - Iberia Campus were currently being monitored by S15 Telemetry Technician.

On 10/09/12 at 9:15 a.m., a face-to-face interview was conducted with S15 Telemetry Technician (hospital "b") and an observation was made of the cardiac monitors. S15 stated she received patient information from Louisiana Extended Care - Iberia Campus by telephone when telemetry monitoring was initiated. S15 stated the nurse in Louisiana Extended Care - Iberia Campus provided the patient's name, diagnosis, code status, age, room number, and the physician's name of the patient to be monitored. An observation of the hospital "b" monitor revealed the patient's name, room number, age and physician's name were displayed on the screen. S15 stated she printed rhythm strips for all patients every 8 hours, documented the rhythm, posted the rhythm on a form to be filed in the patient's record, and delivered the strips to the patient's unit for filing. S15 verified Louisiana Extended Care - Iberia Campus was included in this process. S15 stated there is a log book for telemetry and all patients on telemetry, including Louisiana Extended Care - Iberia Campus patients, are logged in. Review of the Telemetry Log (hospital "b") book revealed the patient's name, room number, physician's name, code status, age, sex, and diagnosis were documented on the log. S15 stated if she needed to compare strips, or needed other information, she went to Louisiana Extended Care - Iberia Campus and reviewed the patient's record. S15 verified she had access to Louisiana Extended Care - Iberia Campus patient records.

On 10/09/12 at 9:15 a.m., in a face-to-face interview, S14 CCU Manager (hospital "b") stated Louisiana Extended Care - Iberia Campus had a monitor screen and they are primarily responsible for monitoring the patient's cardiac rhythms. S14 stated the CCU staff was "back up" for Louisiana Extended Care - Iberia Campus staff. S14 indicated there was no one staff member sitting at the monitor in Louisiana Extended Care - Iberia Campus. S14 indicated the CCU policy on Telemetry Monitoring included Louisiana Extended Care - Iberia Campus. S14 stated the CCU (hospital "b") provided the same services to Louisiana Extended Care - Iberia Campus as they did for any patient in the hospital ("b") on telemetry. S14 stated the CCU staff had access to Louisiana Extended Care - Iberia Campus, "They let us go look at their records if we need to." S14 stated she thought they could access Louisiana Extended Care - Iberia Campus patient's labs in the hospital computer (hospital "b")'s. S14 stated Louisiana Extended Care - Iberia Campus and the hospital used the same laboratory and respiratory services. S14 stated she was told, "We have a contract to assist Louisiana Extended Care - Iberia Campus to monitor their telemetry patients as back up. They are primarily responsible."

Review of the hospital "b" policy titled, Telemetry Monitoring, revised date of 08/10 and reviewed date of 09/12, provided by S14 as current hospital "b" CCU policy, revealed in part the following: "Telemetry Usage: Telemetry will be monitored on 2nd floor (Medical Inpatient), 3rd floor (Maternal/Child Health & Louisiana Extended Care - Iberia Campus), and 4th floor (Outpatient Surgery & Surgical Inpatient)...Procedure: 3. For admits to the floor or new orders for telemetry, the unit secretary or the nurse will go to ICU and obtain a telemetry box. Relay to ICU the patient's name, room number, diagnosis, physician, code status, IV infusions that are: antiarrhythmic (Lidocaine), vasoactive (Dopamine, Dobutrex), or cardiac effecting (Aminophylline) and any orders pertaining to Telemetry. 4. Telemetry Tech will record the above patient information in the Telemetry Log book. 8. Telemetry techs are responsible for continuously monitoring the patient's ECG (Electrocardiogram) pattern. They are also responsible for obtaining a rhythm strip every 8 hours or more frequently if indicated..."


Review of the "Purchased Services Agreement", dated 6/1/10, and presented to the surveyor as the most current agreement between Louisiana Extended Care Hospital of Lafayette ( Iberia Campus) long term acute care hospital and acute care Hospital "b". This agreement revealed Louisiana Extended Care Hospital of Lafayette (Iberia Campus) is purchasing laboratory and blood gas services, radiology and imaging services, medical staff services, emergency services and code blue response, pharmacy services, and telemetry services from acute care Hospital "b"..

Based on observation, record review, and interview the hospital failed to ensure the patients right to privacy including the release or disclosure of the patient's presence in the facility or location in the hospital and personal information such as name and age as evidenced by

1) hospital "b" physically placed a computer owned by hospital "b" inside of Louisiana Extended Care Hospital of Lafayette - Iberia Campus. This computer contained information/access on all patients from both hospitals and failed to allow the hospital to demonstrate independent compliance with Conditions of Participation. This was evidenced by patients of the Louisiana Extended Care Hospital being on a list of current acute care hospital "b" patients provided to surveyor's and through interview with staff

2) the name, age, room number and location of 11 (#R8 - #R18) of 11 (#R8 - #R18) random patients in the Hospital within the Hospital (Louisiana Extended Care - Iberia Campus) being presented to surveyor's on a list of acute care hospital "b" current patient list. The List also contained an admission diagnosis for 5 (#R8, #R9, #R10, #R15, #R18) of the 11 (#R8 - #R18) patients currently in Louisiana Extended Care Hospital -Iberia Campus and

3) having a Telemetry logbook where the HWH (Louisiana Extended Care - Iberia Campus) patients' name, room number, physician's name, code status, age, sex, and diagnosis were documented on the log maintained inside acute care hospital "b". Findings:

1)

In an interview on 10/08/12 at 11:00 a.m. with S12DON, of acute care hospital "b", and S10HIM Director, hospital "b", both confirmed that a computer owned by hospital "b" was located within the "hospital within a hospital" (HWH) (Louisiana Extended Care Hospital - Iberia Campus). S12DON, hospital "b", and S10HIM Director, hospital "b", stated that the computer is used by Louisiana Extended Care Hospital Iberia Campus to enter orders for ancillary services contracted from the host hospital (hospital "b"). It was confirmed during the same interview that the HWH (Louisiana Extended Care Hospital - Iberia Campus) had access to all patient demographic, lab orders and results, and Radiology orders and results on all current patients and past patients of acute care hospital "b".

In an interview on 10/08/12 at 11:15 a.m. with S9IT (Information Technology), (hospital "b") he confirmed the computer located in the HWH (Louisiana Extended Care - Iberia Campus) belonged to hospital "b". He further confirmed that the computer has access to patient information for patients of hospital "b". S9IT stated that the computer program used by acute care hospital "b" had no capability to limit the access of the HWH (Louisiana Extended Care - Iberia Campus) to only patients admitted to the HWH.

In an interview on 10/09/12 at 8:55 a.m. with S8Quality (hospital "b") and S9IT (hospital "b") both stated that the computer owned by hospital "b" that is located in the HWH (Louisiana Extended Care - Iberia Campus) can access any lab result, radiology report, and demographic information from hospital "b".

2)

During the Entrance Conference at acute care hospital "b" (Host Hospital) on 10/08/12 at 10:00 a.m. a request was made for a list of current patients. Review of the list provided by S12DON revealed it contained the full name, age, room number and location of 11 (#R8 - #R18) of 11 (#R8 - #R18) patients in the Hospital within the Hospital (Louisiana Extended Care - Iberia Campus).The list was being presented to surveyor's on a list of hospital "b" current patient list. The List also contained an admission diagnosis for 5 (#R8, #R9, #R10, #R15, #R18) of the 11 (#R8 - #R18) patients currently in the HWH. This was confirmed by S12DON, hospital "b", on 10/08/12 at 11:00 a.m.

3)

On 10/09/12 at 9:15 a.m., a face-to-face interview was conducted with S15 Telemetry Technician (hospital "b") and an observation was made of the cardiac monitors. S15 stated she received patient information from Louisiana Extended Care - Iberia Campus by telephone when telemetry monitoring was initiated. S15 stated the nurse in Louisiana Extended Care - Iberia Campus provided the patient's name, diagnosis, code status, age, room number, and the physician's name of the patient to be monitored. An observation of the hospital "b" monitor revealed the patient's name, room number, age and physician's name were displayed on the screen. S15 stated she printed rhythm strips for all patients every 8 hours, documented the rhythm, posted the rhythm on a form to be filed in the patient's record, and delivered the strips to the patient's unit for filing. S15 verified Louisiana Extended Care - Iberia Campus was included in this process. S15 stated there is a log book for telemetry and all patients on telemetry, including Louisiana Extended Care - Iberia Campus patients, are logged in. Review of the Telemetry Log (hospital "b") book revealed the Louisiana Extended Care - Iberia Campus patient's name, room number, physician's name, code status, age, sex, and diagnosis were documented on the log. S15 stated if she needed to compare strips, or needed other information, she went to Louisiana Extended Care - Iberia Campus and reviewed the patient's record. S15 verified she had access to Louisiana Extended Care - Iberia Campus patient records.

Based on observation, record review, and interview the hospital failed to ensure emergency services were not dependent upon co-mingling of staff of two different hospitals to demonstrate independence compliance with the Condition of Participation for Emergency Services. Louisiana Extended Care Hospital of Lafayette (Lafayette and Iberia campuses) are dependent on the host hospital for Emergency Services as evidenced by having physicians from the host hospital "a" respond to emergencies in the long term care hospital.

Findings:

Hospital "a"

Review of the Code Blue Log from Hospital "a" revealed there was a "code blue" in Louisiana Extended Care Hospital of Lafayette on 09/13/12 and on 09/17/12, and an emergency intubation on 09/16/12. Review of this log revealed that hospital "a" medical staff responded to these 2 code blues and intubated the patient.

Review of the medical record for patient #1 revealed a document titled "Cardiopulmonary Resuscitation" which revealed the following: "Date: 9/13/12. Time of Arrest: 1139 (11:39 a.m.). Location: LTAC (long-term acute care) Rm. (room) 918...Physician in Charge: S3MD...Pronounced: 1147 (11:47 a.m.) by: S3MD. Review of the ER staffing sheet from hospital "a" revealed S3MD was on duty in the ER at hospital "a" when he responded to a Cardiac Arrest in Louisiana Extended Care Hospital.

Review of the medical record for patient #2 revealed a document titled "Cardiopulmonary Resuscitation" which revealed the following: "Date: 9/17/12. Time of Arrest: 0540 (5:40 a.m.). Location: Room 920 (the ninth floor is leased by Louisiana Extended Care) ...Physician in Charge: (S5MD)..." Review of the ER staffing sheet from hospital "a" revealed S5MD was on duty in the ER at hospital "a" when he responded to a Cardiac Arrest in Louisiana Extended Care Hospital.

In an interview on 10/11/12 at 3:00 p.m. with S1Administrator he confirmed S5MD was not granted privileges to practice medicine by the Governing Body at Louisiana Extended Care.

Review of a Physician's Progress Note dated 9/16/12 at 1831 (6:31 p.m.) revealed S4MD documented an "Intubation Note." Review of the ER staffing sheet from hospital "a" revealed S4MD was on duty in the ER at hospital "a" when he intubated patient #2 in Louisiana Extended Care Hospital.


In an interview on 10/11/12 at 11:05 a.m. with S4MD, who was on duty in the ER of hospital "a", he stated that the ERMD who is on duty at hospital "a" does respond to Emergencies in Louisiana Extended Care Hospital of Lafayette.


In an interview on 10/11/12 at 11:05 a.m. with S13MD, who was on duty in the ER of hospital "a", he stated that the ERMD who is on duty at hospital "a" does respond to Emergencies in Louisiana Extended Care Hospital of Lafayette.


Review of a document contained in the medical record of patient #1 and patient #2 revealed a document titled "Statement of Patient Acknowledgement" which was signed by patient #1 on 9/11/12 at 7:30 p.m. and signed by patient #2 on 9/11/12 at 9:15 a.m. The document read as follows: "Official Notification: Emergency Services...Federal Regulations require that we advise you that a doctor of medicine or a doctor of osteopathy is not present at Louisiana Extended Care Hospital of Lafayette 24 hours per day, 7 days per week. The following procedures will be followed in the event you develop an emergency medical condition: Louisiana Extended Care Hospital of Lafayette has a physician on-call at all times to meet the emergency needs of our patients. The physician will be contacted via phone to coordinate medical care. The hospital has available at all times specially trained personnel capable of providing emergency care, including Registered Nurses trained in Advanced Cardiac Life Support, and other staff to respond to all medical emergencies. If you develop an emergency medical condition while you are in our hospital, and if a physician is not present, the Registered Nurse on duty will conduct an assessment of you, notify your doctor and will implement the appropriate emergency procedures. This may include implementing cardiopulmonary resuscitation and advanced cardiac life support until a physician arrives, or is available by phone, to assist with your care..."


Review of a hospital policy titled "Cardiac Code", policy number 9-2.0.0, effective July 2007, no date of last revision, read in part: "Purpose: To provide a process for administering Advanced Cardiac Life Support (ACLS) to individuals who have experienced a cardiopulmonary arrest (cardiac code). Policy: Hospitals within a Hospital. The cardiopulmonary resuscitation team shall include a registered nurse (charge nurse), LPN(s) (licensed practical nurse), and an emergency room physician. Other professionals responding to a cardiopulmonary arrest may include a physician and respiratory therapist(s), if available. Procedure: Staff identifying a patient in distress will call a code by the following:..Available personnel will notify the host hospital's operator; the facility operator will notify the ER of a code in the facility. The ER physician will respond to the code situation..."


Review of a hospital policy titled "Emergency Services", policy number 1-5.11.0, effective July 2007, no date of last revision, read in part: "Purpose: To address the management of emergency needs of patients...Policy: (name of parent corporation) hospitals do not operate an organized emergency room and have limited capacity to provide services for emergency medical conditions. The Governing Body has adopted the following policy and procedure to address how emergency patients shall be handled by the hospital staff. In the event a visitor, passer-by, patient, or staff member requires emergency care, the Hospital has staffed 24-hour RN coverage and CPR (cardiopulmonary resuscitation) trained personnel to provide emergency measures. These services will be provided within scope of practice of the staff. Procedure: In-patients: Upon presentation of a patient who complains of or exhibits an emergency medical condition, the Registered Nurse on duty shall complete an assessment of the patient. If necessary, a 'cardiopulmonary code' will be called according to policy. Current ACLS protocol will be followed until a physician arrives, or is available by phone, to assist with the patient's care..."


Review of a hospital policy titled "Emergency Intubation", policy number 4-6.4.0, effective June 2005, last revised 06/07, reads in part: "Purpose: To define a process for intubation during an emergency situation. Policy: The facility will identify appropriate adjuncts, to assure that it's patients receive optimal airway management techniques, during a medical emergency (i.e., Cardiopulmonary Arrest, Respiratory Failure). Procedure: 1. Staff identifying a patient in distress will call a code cardiac...3. If attending, primary care or host hospital emergency room physicians are not available within a reasonable time frame, approved individuals from the Cardiopulmonary Department may assess the patients' airway status and intubate if necessary..."


Review of the "Purchased Services Agreement", dated 10/1/11, and presented to the surveyor as the most current agreement between Louisiana Extended Care Hospital of Lafayette (Lafayette Campus)long term acute care hospital and acute care Hospital "a". This agreement revealed Louisiana Extended Care Hospital of Lafayette (Lafayette Campus) is purchasing laboratory and blood gas services, radiology and imaging services, medical staff services, emergency services and code blue response, and pharmacy services, from acute care Hospital "a".
This agreement further stipulated that acute care hospital "a" would respond to any code blue or emergency situations in long term care hospital Louisiana Extended Care Hospital of Lafayette -Lafayette Campus physicians handling the emergency and code blue situations along with Louisiana Extended Care Hospital of Lafayette -Lafayette Campus support staff. .

Hospital "b"

Observations/Interviews/Record Reviews from Hospital "b"

In an interview on 10/09/12 at 2:10 p.m. with S11RN, ER Director, (hospital "b") he stated that the ER Physician on duty at hospital "b" and a Supervisor (nursing) respond to Code Blue in the HWH. S11RN, ER Director, further stated that a Code Blue in the HWH is announced through the overhead paging system in hospital "b".

In an interview on 10/09/12 at 2:15 p.m. with S6MD, on duty in the ER at hospital "b", he stated that the ER Physician from hospital "b" does respond to Code Blue in the long term care hospital Louisiana Extended Care Hospital -Iberia Campus.

In an interview on 10/09/12 at 2:40 p.m. with S12DON (hospital "b") she stated the following on duty employee's from hospital "b" respond to Code Blue in the HWH: 1 RT, 1 Nursing Supervisor, and 1 ER MD. S12DON further stated that the ERMD responds even if there is only one Physician on duty in the ER.

Review of the "Purchased Services Agreement", dated 6/1/10, and presented to the surveyor as the most current agreement between Louisiana Extended Care Hospital of Lafayette ( Iberia Campus) long term acute care hospital and acute care Hospital "b". This agreement revealed Louisiana Extended Care Hospital of Lafayette (Iberia Campus) is purchasing laboratory and blood gas services, radiology and imaging services, medical staff services, emergency services and code blue response, pharmacy services, and telemetry services from acute care Hospital "b".

Observations/Interviews/Record Reviews from Louisiana Extended Care - Iberia Campus

Review of the "Patient Code Log" from January through September of 2012 revealed there were a total of seven (7) codes called at Louisiana Extended Care - Iberia Campus. The codes were as follows: there was one code called for the month of January (Random Patient #1 (R1) on 01/09/12), no codes called for the month of February, one code called for the month of March (Random Patient #2 (R2) on 03/18/12), no codes called for the month of April, one code called for the month of May (Random Patient #3 (R3) on 05/21/12), two codes called for the month June (Random Patient #4 (R4) on 06/02/12 and Random Patient #5 (R5) on 06/16/12), one code called for the month of July (Random Patient #6 (R6) on 07/19/12), no codes called for the month of August, one code called for the month of September (Random Patient #7 (R7) on 09/07/12), and no codes called for the month of October as of 10/11/12.

R1:
Review of the "Cardiopulmonary Resuscitation" form revealed Random Patient #1 coded on 01/09/12 at 4:55 a.m. (0455). Further review revealed S22ERMD from hospital "b" was the physician in charge during the code from 4:55 a.m. through 5:06 a.m. (0506)

R2:
Review of the "Cardiopulmonary Resuscitation" form revealed Random Patient #2 coded on 03/18/12 at 3:20 a.m. (0320). Further review revealed S21ERMD from hospital "b" was the physician in charge during the code from 3:20 a.m. through 3:30 a.m. (0330)

R4:
Review of the "Cardiopulmonary Resuscitation" form revealed Random Patient #4 coded on 06/20/12 at 12:45 a.m. (0045). Further review revealed S6 ERMD from hospital "b" was the physician in charge during the code from 12:45 a.m. through 1:04 a.m. (0104)-this is a different date (06/02/12) than what was recorded on the "Patient Code Log".

R5:
Review of the "Cardiopulmonary Resuscitation" form revealed Random Patient #5 coded on 06/16/12 at 9:30 a.m. (0930). Further review revealed S19ERMD from hospital "b" was the physician in charge during the code from 9:30 a.m. through 9:44 a.m. (0944).

R6:
Review of the "Cardiopulmonary Resuscitation" form revealed Random Patient #6 coded on 07/29/12 at 9:30 a.m. (0930). Further review revealed S20ERMD from hospital "b" was the physician in charge during the code from 9:30 a.m. through 9:36 a.m. (0936).

R7:
Review of the "Transfer Form" dated/timed 09/07/12 at 3:25 p.m. (1525) revealed Random Patient #7 was assessed with "...heart beat agonal breath...unresponsive...stop breathing...CPR in progress..." prior to transferring to ICU at 4:00 p.m. (1600). Review of the "Progress Notes" dated/timed 09/07/12 at 3:40 p.m. (1540) by S22ERMD indicated Random Patient #7 had respiratory arrest.

During interviews on 10/10/12 at from 2:05 p.m. through 2:45 p.m. and on 10/11/12 at 8:30 a.m. and from 12:10 p.m. through 12:35 p.m., from 1:00 p.m. through 1:30 p.m. and from 2:35 p.m. through 2:45 p.m., S18DON confirmed Random Patient #1 coded on 01/09/12 at 4:55 a.m. (0455) and S22ERMD from hospital "b" was the physician in charge during the code from 4:55 a.m. through 5:06 a.m. (0506). The DON, S18 further confirmed Random Patient #2 coded on 03/18/12 at 3:20 a.m. (0320) and S21ERMD from hospital "b" was the physician in charge during the code from 3:20 a.m. through 3:30 a.m. (0330). S18DON verified Random Patient #4 coded on 06/20/12 at 12:45 a.m. (0045) and S6 ERMD from hospital "b" was the physician in charge during the code from 12:45 a.m. through 1:04 a.m. (0104). The DON, S18 further verified Random Patient #5 coded on 06/16/12 at 9:30 a.m. (0930) and S19ERMD from hospital "b" was the physician in charge during the code from 9:30 a.m. through 9:44 a.m. (0944). S18 DON confirmed Random Patient #6 coded on 07/29/12 at 9:30 a.m. (0930) and S20ERMD from hospital "b" was the physician in charge during the code from 9:30 a.m. through 9:36 a.m. (0936). The DON, S18 further confirmed Random Patient #7 had CPR administered (coded) on 09/07/12 at 3:25 p.m. (1525) as indicated on the "Transfer Form". S18DON verified S22ERMD indicated Random Patient #7 had respiratory arrest documented on his "Progress Notes" dated/timed 09/07/12 at 3:40 p.m. (1540). S18DON indicated S6, S19, S20, S21, and S22 are ERMD's from hospital "b".

In an interview on 10/10/12 at 2:00 p.m., S23Assistant Administrator at Iberia Campus indicated all contracted ERMD's from hospital "b" respond to all cardiac codes called in the Louisiana Extended Care - Iberia Campus.