HospitalInspections.org

Based on record review and interview, the Governing Body failed to meet the requirement for Condition of Participation of the Governing Body as evidenced by failing to have a governing body which is effective in carrying out the responsibilities for the conduct of the hospital.

1. The Governing Body failed to ensure patient services performed under contract were provided in a safe and effective manner independent of the host hospital (Hospital "A") by failure to ensure contracted services were not provided by staff concurrently working at the host hospital (Hospital "A") for radiology, endoscopy, anesthesiology, and dietary services (See findings in A0083).

2. The Governing Body failed to ensure the hospital had clear facility specific written policies and procedures for appraisal of emergencies, treatment and referral as appropriate for hospitals without emergency departments and met applicable state licensure requirements. This deficient practice is evidenced by the hospital, which is located within a hospital, utilizing the host hospital's (Hospital A's) Emergency Room physician and Anesthesiologist during Code Blue (cardiopulmonary arrest) procedures. The hospital failed to ensure a policy and procedure was in place to address the appraisal of emergencies, initial treatment, and referral when appropriate of visitors, staff, or anyone not admitted to the hospital (see findings in A0093).

3. The Governing Body failed to ensure all physicians and CRNAs providing services in the hospital were credentialed and granted appropriate privileges. This deficient practice was evidenced by the contract emergency room physicians and CRNAs from the host hospital (Hospital A) providing care in the Hospital in case of an emergency not being credentialed in the Hospital and granted appropriate privileges for 5 of 5 emergency room physicians (S15MD*, S16MD*, S29MD*, S30MD*, S34MD*) and 3 of 3 CRNAs (S17CRNA*, S25CRNA*, S32CRNA*) (see findings in A0045).

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Nursing Services as evidenced by:

1. Failing to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:
a) failure to ensure Diprivan (Propofol) was titrated per the Ramsay Sedation Scale as ordered by the physician for 1 of 1 (#4) current hospitalized patients and 1 of 1 (#30) closed patient records with Diprivan Infusions out of a total sample of 30;
b) Administering Diprivan (Propofol) without clarifying an incomplete physician's order for 1 of 1 (#4) current sampled patient receiving Diprivan out of 30 sampled patients;
c) Administering Levophed without clarifying an incomplete physician's order for 1 of 1 (#4) current sampled patient receiving Levophed out of a total of 30 sampled patients;
d) failure to assess and monitor a patient after a bedside PEG tube placement for 1 of 1 (#4) sampled patients reviewed for bedside endoscopic PEG tube placement out of a total sample of 30;
e) failure to ensure each patient was assessed at least every 24 hours by a RN as required by the Louisiana State Board of Nurse's Practice Act as evidenced by having patient care provided by LPNs without documented evidence of a RN assessment at a minimum of every 24 hours for 3 (#20, #21, #22) of 3 (#20, #21, #22) patient records reviewed for an RN assessment every 24 hours, of a total of 30 sampled patients;
f) failure to ensure a registered nurse performed the initial patient admission assessment for 2 (#5, #20) of 6 (#4, #5, #6, #20, #21, #22) patient records reviewed for an initial RN assessment of a total of 30 sampled patients. (see findings at A-0395);

2. Failing to provide adequate supervision of non-employee licensed dialysis nursing personnel for 2 of 2 sampled hemodialysis patients (#2, #29) in a total of 30 sampled patients as evidenced by physician orders for dialysis not obtained or clarified before treatment was delivered. (see findings at A-0398)

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Radiology Services as evidenced by:

1) The hospital failed to develop Radiology policies and procedures that included; safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital. (see A-0535)

2) The hospital failed to ensure there was a Radiologist appointed by the Governing Body to supervise the Radiology Services on either a full-time, part-time, or consulting basis as evidenced by no documentation of a Director of Radiology for the hospital. (see A-0546)

Based on record review and interview, the Governing Body's failure to ensure all physicians and CRNAs providing services in the hospital were credentialed and granted appropriate privileges. This deficient practice was evidenced by the contract emergency room physicians and CRNAs from the host hospital (Hospital A) providing care in the Hospital in case of an emergency not being credentialed in the Hospital and granted appropriate privileges for 5 of 5 emergency room physicians (S15MD*, S16MD*, S29MD*, S30MD*, S34MD*) and 3 of 3 CRNAs (S17CRNA*, S25CRNA*, S32CRNA*). Findings:

Review of the Governing Body provided by S1ADM as current revealed in part the following: Medical Staff
7.01 Organization....Only a licensed practitioner with clinical privileges either granted by this Board or otherwise granted temporary privileges shall be responsible for the diagnosis and treatment of any patient who has been admitted to the hospital....

Review of the Medical Staff Bylaws provided as current by S2CNO revealed in part the following:
Article II
Medical Staff Membership
2.1 - Nature of Medical Staff Membership
Only professional, competent LIPs who continuously meet the qualifications, standards, and requirements set forth in these Bylaws may become or remain Members of the Medical Staff. Only Medical Staff members or practitioners who have been granted privileges in accordance with the Bylaws may admit or provide services to patients in the hospital.

Review of the hospital's list of credentialed physicians provided by S2CNO on 10/04/16 at 10:00 a.m., revealed no documented evidence that S15MD*, S16MD*, S29MD*, S30MD*, S34MD*, S17CRNA*, S25CRNA*, and S32CRNA* were credentialed members of the hospital's medical staff.

Review of the sampled patient records revealed services had been provided by the above physicians and CRNAs as follows:
Patient #4 - Intubation by S25CRNA* on 09/02/16. PEG Placement (anesthesia) by S32CRNA* on 09/05/16.
Patient #14 - Intubated by S17CRNA* on 08/23/16. Pronounced dead by S16MD* on 09/13/16.
Patient #15 - Conducted Code Blue and intubated on 08/21/16 by S15MD*.
Patient #16 - Conducted Code Blue on 03/05/16 by S29MD*. Pronounced dead by S34MD* on 03/05/16.
Patient #17 - Conducted Code Blue on 09/08/16 by S30MD*.

In an interview on 10/05/16 at 3:20 p.m., S2CNO and S7RN (Outgoing CNO) reviewed the above medical records and confirmed the above services were provided by members of the medical staff of Hospital "A" and confirmed the above medical staff were not credentialed members of this hospital's medical staff. S7RN confirmed the physicians and CRNAs should have been credentialed by this hospital and stated he thought they were.



30420

Based on record review and staff interview, the Hospital failed to ensure the medical staff was accountable to the Governing Body for the quality of care provided to patients as evidenced by the medical staff failing to follow the Medical Staff Rules & Regulations for the pronouncement of patient death for 2 (#14, #16) of 4 (#14, #15, #16, #17) sampled death records reviewed out of a total sample of 30 patients. Findings:

Review of the Medical Staff Rules & Regulations dated 03/14/13 revealed in part the following:
Admission and Discharge: 9. In the event of a Hospital patient death, the deceased will be pronounced dead by the attending physician or another physician designated by the attending physician within a reasonable time....The body will not be released until an entry has been made and signed in the medical record of the deceased by a physician appointee of the Staff.


Patient #14
Review of the medical record for Patient #14 revealed the patient was admitted to the hospital on 08/12/16 with diagnoses of End Stage HIV, Diabetes Mellitus, Dementia, and Stage IV Necrotic Decubitus. Review of the record revealed the attending physician was S33MD. Review of the record revealed the patient sustained a cardiac arrest on 09/13/16 at 4:49 a.m. and a Code Blue was called. Further review of the record revealed the patient was pronounced dead by S16MD* (ER Physician from Hospital "A") on 09/13/16 at 4:59 a.m.

In an interview on 10/05/16 at 3:00 p.m., S2CNO and S7RN (Outgoing CNO) reviewed the medical record for Patient #14 and confirmed the patient was pronounced dead by S16MD*, an ER physician from Hospital "A". Both confirmed the patient was not pronounced by a credentialed member of the hospital's medical staff as directed in the Medical Staff Rules & Regulations.


Patient #16
Review of the medical record for Patient #16 revealed the patient was admitted to the hospital on 03/02/16 with diagnoses of Respiratory Failure, Hypotension, and Septic Shock. Review of the record revealed on 03/05/16 at 4:30 a.m., the patient's daughter, "came by and made patient a DNR."
Review of the nurse's notes revealed the following:
05/03/16 at 6:30 a.m.: No blood pressure registering on monitoring, no pulse felt, PEA at 15 on the monitoring. Infusions stopped/tube feeding stopped. Charge RN notified, will contact S24MD (patient's attending physician) and patient's daughter.
05/03/16 at 6:30 a.m.: Contacted S24MD regarding patient condition. Will attempt to get an ER MD to come and pronounce patient.
05/03/16 at 6:45 p.m.: S34MD* at bedside to pronounce patient. S34MD* states he will put a note in ___ (Hospital A's electronic medical record system).

Based on record review and interview, the Governing Body failed to ensure patient services performed under contract were provided in a safe and effective manner independent of the host hospital (Hospital "A") by failure to ensure contracted services were not provided by staff concurrently working at the host hospital (Hospital "A") for radiology, endoscopy, anesthesiology, and dietary services. Findings:

Review of the Louisiana Hospital Licensing Standards (LAC48:I. Chapter 93, Section 9305 L-3) revealed 3. Staff of the hospital within a hospital shall not be co-mingled with the staff of the host hospital for the delivery of services within any given shift.

The Hospital is a hospital within a hospital and has a lease and purchase service agreement with Hospital "A", which is the host hospital.

Review of the Cooperative Endeavor Lease Agreement and Letter of Intent dated 05/16/16 between Hospital "A" and the Hospital revealed in part the following:
4.2 - Radiology Services: Hospital "A" shall provide upon written order of a member of the hospital's medical staff, routine and stat radiological services including CT scans and MRIs for patients of the LTACH through Hospital "A" radiology department....
5.1 Dietary & Nutritional Support Services: Hospital "A" shall provide or make available through Hospital A's then current dietary provider, dietary services to LTACH's patients. The dietary services shall include all meals, nutritional supplements, supplementary food services, and delivery and pick up services.....

Radiology Services:
In an interview on 10/04/16 at 8:15 a.m., S1ADM confirmed the hospital's radiology services were provided by Hospital "A" as outlined in the lease agreement. S1ADM confirmed the radiology staff of Hospital "A" come into the hospital to perform portable radiology procedures while concurrently working in Hospital "A". She also stated patients are transported to Hospital "A" when the procedure cannot be performed as a portable.

On 10/04/16 at 4:45 p.m. an observation was made at the nurse's station with S8HIM. Transportation staff from Hospital "A" were observed to be transporting a Hospital patient by stretcher to Hospital "A". S8HIM confirmed the observation and stated the transportation staff of Hospital "A" come into the Hospital to pick up and return patients for procedures in radiology.


Endoscopy Services:
Review of the medical record for current hospitalized Patient #4 revealed the patient had a PEG tube placement performed in the patient's room on 09/05/16 at 10:45 a.m. Review of the patient's record revealed an Anesthesia Record from Hospital "A" dated 09/05/16 and documented by S32CRNA*. Review of the anesthesia consent for the procedure revealed the consent was witnessed by S18RN* (Endoscopy Nurse) on 09/05/16 at 8:35 a.m.

In an interview on 10/04/16 at 10:40 a.m., S7RN (Outgoing CNO) reviewed the patient's medical record and confirmed the PEG tube placement was done in the patient's room by staff from Hospital "A". S7RN confirmed S18RN* was from Hospital "A" endoscopy and the CRNA on the Anesthesia record was from Hospital "A". He confirmed both were concurrently working in Hospital "A" when the procedure was performed in the patient's room. S7RN stated staff from Hospital "A" has conducted bedside bronchoscopy and endoscopy in the hospital. He confirmed nurses from endoscopy come with the physician and assist with the procedures. S7RN stated the endoscopy nurse's documentation of the procedure would be found in Hospital A's electronic medical record.


In an interview on 10/04/16 at 11:05 a.m., S26RN* stated she was the Chief Nursing Office for Hospital "A". S26RN* stated she was just made aware that her nursing staff was coming to this hospital to provide services. She stated she had been informed that there was no co-mingling of staff between the two hospitals. S26RN* stated the written agreement did not include provisions to share staff.


In an interview on 10/04/16 at 2:10 p.m., S18RN* was interviewed. S18RN* stated she did not remember Patient #4 but she does assist with procedures performed in the hospital while employed with Hospital "A". S18RN* stated the computers from Hospital "A" do not work in this hospital, so she makes notes of the procedure and enters them into the electronic medical record when she returns to Hospital "A". S18RN* confirmed she had performed bedside bronchoscopies in this hospital.



Anesthesiology Services:
Review of the medical record for current hospitalized Patient #4 revealed the patient was in severe respiratory distress on 09/02/16 at 9:35 a.m. and Anesthesia was consulted for stat intubation. Review of the record revealed an anesthesia record from Hospital "A" that revealed the patient was intubated by S25CRNA* on 09/02/16 at 9:55 a.m.

Review of the list of credentialed practitioners provided by S2CNO revealed no documented evidence that S25CRNA* was credentialed by the medical staff and governing body to provided services to the hospital's patients.

In an interview on 10/04/16 at 10:40 a.m., S7RN (Outgoing CNO) reviewed the patient's record and confirmed S25CRNA* had intubated the patient on 09/02/16. He stated he was told all the CRNAs were credentialed by the hospital. After review of the list of credentialed staff, he confirmed S25CRNA* was not included in the list.


Dietary Services:
On 10/03/16 at 12:00 p.m., S5Dietary* was observed removing meal trays from an insulated cart and taking the trays into patient rooms. S5Dietary* confirmed at the time of the observation that she was employed by Hospital "A" and she was delivering the patients' noon meals.

In an interview on 10/04/16 at 2:20 p.m., S22LPN, Dietary Manager confirmed the patients' meals were delivered and picked up to and from patient rooms by the dietary staff of Hospital "A" while they were working concurrently in Hospital "A".


30420

Based on record reviews and interview, the hospital's governing body failed to ensure services performed under contract were provided in a safe and effective manner as evidenced by failure to include all contracted services in the hospital's QAPI program.
Findings:

Review of the QAPI plan presented as current revealed no documented evidence all contracted services were included in the hospital's QAPI plan. (Examples of contracted services not included in the program: dialysis services and biomedical services).

In an interview on 10/06/16 at 12:40 p.m., S2CNO confirmed not all contracted services were included in the hospital's current QAPI plan.

Based on record review and interview, the Governing Body's failure to ensure the hospital had clear facility specific written policies and procedures for appraisal of emergencies, treatment and referral as appropriate for hospitals without emergency departments and met applicable state licensure requirements. This deficient practice is evidenced by the hospital, which is located within a hospital, utilizing the host hospital's (Hospital A's) Emergency Room physician and Anesthesiologist during Code Blue (cardiopulmonary arrest) procedures. The hospital failed to ensure a policy and procedure was in place to address the appraisal of emergencies, initial treatment, and referral when appropriate of visitors, staff, or anyone not admitted to the hospital.
Findings:

As of survey exit, 10/06/16, no policy or procedure, reviewed and approved by the Medical Staff and Governing Body, for the appraisal of emergencies, initial treatment, and referral when appropriate, that included persons not admitted to the hospital had been provided.

Review of the Hospital's current Code Blue policy, Policy # (Left blank), effective date of 12/2014, revealed in part, Procedure: A Code Blue will be called for any person who has known or suspected cardiac and/or respiratory arrest in the hospital. Code Blue Team: The code Blue Team will be identified by the charge nurse each shift for successful cardiopulmonary resuscitation for all patients in arrest. The Team will consist of the following:
a. Physician
b. Nurse Assigned to Patient or Designated Code Team RN.
c. ICU designated RN
d. Respiratory Therapists
Members of the Team and Their Duties
Team Leader: When the patient's Attending Physician or designee is present at the time of the code, s/he is considered the team leader or may assign team leader responsibility to the appropriate physician. Intensivist/House Physician acts as the leader of the Code Blue Team and has overall responsibility for all decisions made in which the primary concern is the resuscitation of the patient. Establishes an airway and ventilation, Anesthesia intubates if necessary. Anesthesia determines proper tube placement by checking breath sounds and/or using appropriate detectors....
Unit Nursing Staff: The unit nursing staff will make emergency equipment available, prepare and administer medications and complete the Code Blue documentation forms.
Respiratory Therapists: The therapist responding to the Code Blue will be designated each shift by the Director of Respiratory Therapy or designee. Establish patent airway until physician takes over. Ventilates patient with manual resuscitating device....


Review of the Hospital's Code Blue policy, revealed no indication the Emergency Room physicians from the host hospital, Hospital "A", were running and conducting the emergency cardiopulmonary arrests for the Hospital.

Review of the written agreement between the Hospital (Facility within a Facility) and the host hospital (Hospital "A") dated 05/16/16, revealed in part the following: Section 4.5 Physician Code Response: Hospital "A" shall cause its then-scheduled physician code responder to respond to a Code Blue in the LTACH that is announced facility wide.

In an interview on 10/03/16 at 1:55 p.m., S4RN, Charge Nurse stated the charge nurse ran the Code Blue until the physician arrived. He confirmed a Code Blue was called over the intercom. When asked who attended the Code Blue, he stated the ER physician from Hospital "A" and an anesthesiologist for Hospital "A". He stated sometimes an ER nurse from Hospital "A" also comes to the Code Blue. S4RN indicated respiratory therapy responded to the Code Blue, but they were hospital employees.

In an interview on 10/03/16 at 3:35 p.m., S27RT, Director of Respiratory Therapy stated the ER physician and Anesthesiologist from Hospital "A" respond to all of the hospital's Code Blue situations. He stated the ER physician and Anesthesiologist bring their own resuscitation supplies. S27RT stated if the patient's physician was present on the unit he/she would run the Code Blue. S27RT stated the majority of the hospital's Codes were run by the ER physicians from Hospital "A".

In an interview on 10/04/16 at 10:00 a.m., S2CNO confirmed Code Blue situations in the hospital were responded to by the ER physician and Anesthesiologists from Hospital "A". S2CNO indicated they had a contract with Hospital "A" to provide those services.

Review of the medical record for Patient #14 revealed the patient was found without a pulse on 09/13/16 at 4:50 a.m. and a Code Blue was called. Review of the record revealed the physician conducting the code was S16MD*. Further review of the record revealed the patient expired at 4:59 a.m.

Review of the medical record for Patient #15 revealed the patient was found without a pulse or respirations on 08/21/16 at 1:45 a.m. and a Code Blue was called. Review of the record revealed the physician conducting the code was S15MD*. Review of the record revealed the Code Blue ended at 1:58 a.m. and the patient survived.

Review of the medical record for Patient #16 revealed the patient was found without a pulse or respirations on 03/05/16 at 3:15 a.m. and a Code Blue was called. Review of the record revealed the physician conducting the code was S29MD*. Review of the record revealed the Code Blue ended at 3:45 p.m. and the patient survived.


Review of the medical record for Patient #17 revealed the patient was found without a pulse or respirations on 09/08/16 at 3:25 p.m. and a Code Blue was called. Review of the record revealed the physician conducting the code was S30MD*. Review of the record revealed the Code Blue ended at 3:28 a.m. and the patient survived.

Review of the list of credentialed physicians for the Hospital provided by S2CNO on 10/04/16 as the current list of physician on the medical staff, revealed no documented evidence that S15MD*, S16MD*, S29MD*, or S30MD* were credentialed members of the hospital's medical staff.

In an interview on 10/05/16 at 3:15 p.m., S2CNO and S7RN (Outgoing CNO) reviewed the above patient medical records and confirmed the Code Blue was conducted by ER physicians from Hospital "A" and the above physicians were not credentialed members of the hospital's medical staff.

In an interview on 10/05/16 at 2:18 p.m., S26RN*, Chief Nursing Officer of Hospital "A" provided the Emergency Department physician coverage for Hospital "A". The ER physician coverage indicated only one ER physician and one Nurse Practitioner were on duty in the Emergency Room of Hospital "A" from 3:00 a.m. to 6:00 a.m.

In an interview on 10/06/16 at 9:30 a.m. S1ADM verified that the hospital did not have a dedicated emergency department. S1ADM verified the hospital did not have a policy and procedure, for the appraisal of emergencies, initial treatment and referral when appropriate for visitors, staff, or any other persons not admitted to the hospital.


30420

Based on record review and staff interview, the Hospital failed to follow their policy and procedure for initiating a Do Not Resuscitate (DNR) Order as evidenced by:
1) The RN accepting a verbal order for DNR status for 2 (#4, #15) of 3 (#4, #15, #16) sampled patients reviewed for DNR out of a total sample of 30;
2) The physician failing to document a DNR order for 1 (#16) of 3 (#4, #15, #16) sampled patients reviewed for DNR, and;
3) The physician failing to document in the progress notes the DNR discussion with the family, Power of Attorney and/or patient before DNR status was implemented for 2 (#4, #16) of 3 (#4, #15, #16) sampled patients reviewed for DNR status out of a total of 30 sampled medical records. Findings:

Review of the hospital policy titled, Do Not Resuscitate (DNR) Orders, Policy Number NSG-302, revised dated of May 13, 2013 revealed in part the following:
It is the responsibility of the attending physician to address the question of a "Do Not Attempt resuscitation" order with the patient, and/or family/significant other.
Discussion about "Do Not Attempt Resuscitation (DNR)" and "Additional Limitations" may be initiated by the patient, family, legitimate surrogate and other members of the health care team.
A nurse may not take a verbal or telephone order for DNR/Limited DNR status.
All orders pertaining to the "Resuscitation Status" of the patient should be ordered on the "Physician's Order/Advance Directive" Sheet. The attending physician or designee completes, signs and dates the "Physician's Order/Advance Directive Order" Sheet....A summary of the medical situation and discussion should be documented in the Progress Notes.
Decision to "Do Not Attempt Resuscitation (DNR)" or Additional Limitations must be discussed with the patient and/or legitimate surrogate and documented in the patient's Progress Notes by the attending physician or physician designee. For patients who are not competent, the Progress Notes should document that a "Do Not Attempt Resuscitation (DNR)" and Additional Limitations status were discussed with the family and agreed upon by the legitimate surrogate.


1) The RN accepting a verbal order for DNR status:

Patient #4
Review of the medical record for Patient #4 revealed the patient was a current hospitalized patient that was admitted to the hospital on 08/26/16 with diagnoses of Septic Shock, Protein Calorie Malnutrition, Acute Renal Failure, Dementia, Hypertension, and Debility.

Review of the admission orders dated 08/26/16 revealed the patient was a full code (indicating all measures of resuscitation would be attempted).

Review of the Physician Progress Note dated/timed 09/13/16 at 11:12 a.m. revealed the following: Lengthy meeting with family. Discussed treatment options including hospice, DNR, they are considering - still not agreeing to transfusion - H/H 4/13....Prognosis poor - patient is hospice appropriate.

Review of the Physician Orders dated/timed 09/13/16 at 12:12 p.m. revealed a telephone order was documented by S23RN that revealed the following: "Patient is DNR per son." The order was signed by the attending physician on 09/14/16 at 10:50 a.m.

In an interview on 10/05/16 at 2:50 p.m., S2CNO and S7RN reviewed the medical record for Patient #4 and confirmed the RN documented the patient was a DNR per the son on a telephone order. After review of the hospital's policy, both confirmed the RN was not permitted to receive a verbal order for a DNR status. S2CNO and S7RN confirmed the physician only documented DNR and Hospice was discussed but there was no documented evidence in the progress notes that the family agreed to the DNR status.



Patient #15
Review of the medical record for Patient #15 revealed the patient was an 83 year old admitted to the hospital on 08/06/16 with a diagnosis of Acute Febrile Illness and Respiratory Failure. Review of the admission orders revealed the patient was a full code. Further review of the record revealed the patient was found to be not breathing and pulseless on 08/21/16 at 1:45 a.m. The record revealed the patient was successfully resuscitated and was placed on a ventilator.

Review of the physician's orders revealed a telephone order dated/timed 08/23/16 at 2:45 p.m. documented as received by S4RN. The order revealed the following: Patient is a DNR. The order was signed by the attending physician on 08/24/16 at 12:57 p.m.

Review of the progress notes dated 08/24/16 at 1:26 p.m. revealed, "DNR as discussed with son 08/23/16." Further review of the record revealed the patient was extubated on 09/02/16 at 1:40 p.m. and expired on 09/02/16 at 2:15 p.m.

In an interview on 10/05/16 at 3:15 p.m., S2CNO and S7RN reviewed the medical record for Patient #15 and confirmed the RN documented the patient was a DNR as a telephone order. After review of the hospital's policy, both confirmed the RN was not permitted to receive a verbal order for a DNR status.


2) The physician failing to document a DNR order:

Patient #16
Review of the medical record for Patient #16 revealed the patient was an 80 year old admitted to the hospital on 03/02/16 with diagnoses of Respiratory Failure, Hypotension, and Septic Shock. Review of the record revealed the patient was a full code. Further review of the record revealed the patient sustained an observed cardiac arrest on 03/05/16 at 3:15 a.m. and was successfully resuscitated.

Review of the nurse's notes dated 03/05/16 at 4:30 a.m. revealed the following: "Spoke with S24MD regarding patient's status, notified him that patient coded at 3:15 a.m. and pulse was regained, patient is now maxed out on Levophed at 30 mcg/minute and blood pressure is still 70's/10's. Also notified S24MD daughter came by and made patient a DNR. S24MD gave no further orders for patient at this time.

Review of the nurse's notes dated 03/05/16 at 4:45 a.m. revealed the following: Daughter at bedside. Explained to daughter patient condition at this time. Explained to daughter DNR status, terms and care of patient. Daughter agrees to DNR. DNR signed by daughter, witnessed by 2 RNs.

Review of the nurse's notes dated 03/05/16 at 6:30 a.m. revealed the following: No blood pressure registering on monitoring, no pulse felt, PEA at 15 on the monitoring. Infusions stopped/tube feeding stopped. Charge nurse notified, will contact S24MD and patient's daughter.

Further review of the record revealed no documented evidence of a physician's order for the DNR status.

In an interview on 10/05/16 at 3:30 p.m., S2CNO and S7RN reviewed the medical record for Patient #16 and confirmed the only documentation in the medical record related to the DNR was done by the RN. Both confirmed there was no do documented evidence of a physician's order for the DNR status.



3) The physician failing to document in the progress notes the DNR discussion with the family, Power of Attorney and/or patient before DNR status was implemented:

Patient #4
Review of the medical record for Patient #4 revealed the patient was a current hospitalized patient that was admitted to the hospital on 08/26/16 with diagnoses of Septic Shock, Protein Calorie Malnutrition, Acute Renal Failure, Dementia, Hypertension, and Debility.

Review of the admission orders dated 08/26/16 revealed the patient was a full code (indicating all measures of resuscitation would be attempted).

Review of the Physician Progress Note dated/timed 09/13/16 at 11:12 a.m. revealed the following: Lengthy meeting with family. Discussed treatment options including hospice, DNR, they are considering - still not agreeing to transfusion - H/H 4/13....Prognosis poor - patient is hospice appropriate. There was no documented evidence in the progress notes that the patient/family agreed with the DNR status.

Review of the Physician Orders dated/timed 09/13/16 at 12:12 p.m. revealed a telephone order was documented by S23RN that revealed the following: "Patient is DNR per son." The order was signed by the attending physician on 09/14/16 at 10:50 a.m.

In an interview on 10/05/16 at 2:50 p.m., S2CNO and S7RN reviewed the medical record for Patient #4 and confirmed the RN documented the patient was a DNR per the son on a telephone order. S2CNO and S7RN confirmed the physician only documented DNR and Hospice was discussed but there was no documented evidence in the progress notes that the family agreed to the DNR status.


Patient #16
Review of the medical record for Patient #16 revealed the patient was an 80 year old admitted to the hospital on 03/02/16 with diagnoses of Respiratory Failure, Hypotension, and Septic Shock. Review of the record revealed the patient was a full code. Further review of the record revealed the patient sustained an observed cardiac arrest on 03/05/16 at 3:15 a.m. and was successfully resuscitated.

Review of the nurse's notes dated 03/05/16 at 4:30 a.m. revealed the following: "Spoke with S24MD regarding patient's status, notified him that patient coded at 3:15 a.m. and pulse was regained, patient is now maxed out on Levophed at 30 mcg/minute and blood pressure is still 70's/10's. Also notified S24MD daughter came by and made patient a DNR. S24MD gave no further orders for patient at this time.

Review of the nurse's notes dated 03/05/16 at 4:45 a.m. revealed the following: Daughter at bedside. Explained to daughter patient condition at this time. Explained to daughter DNR status, terms and care of patient. Daughter agrees to DNR. DNR signed by daughter, witnessed by 2 RNs.

Review of the nurse's notes dated 03/05/16 at 6:30 a.m. revealed the following: No blood pressure registering on monitoring, no pulse felt, PEA at 15 on the monitoring. Infusions stopped/tube feeding stopped. Charge nurse notified, will contact S24MD and patient's daughter.

Further review of the record revealed no documented evidence of a physician's order for the DNR status. Review of the physician's progress notes revealed no documented evidence of a discussion of the DNR or that the patient's family agreed with the DNR status.

In an interview on 10/05/16 at 3:30 p.m., S2CNO and S7RN reviewed the medical record for Patient #16 and confirmed the only documentation in the medical record related to the DNR was done by the RN. Both confirmed there was no do documented evidence of a physician's order for the DNR status, nor was there documentation in the physician's progress notes of the DNR.

Based on record reviews and interviews, the hospital failed to ensure each order for restraints used to ensure the physical safety of the non-violent or non-self-destructive patient was renewed every calendar day as authorized by hospital policy for 1 (#24) of 3 patients reviewed with restraints.

Findings:

Review of the hospital policy titled Restraints, Policy # CSM-112, revealed in part:
Medical Management: Ensure the safety of nonviolent patient. Renewal of the order every calendar day.

Review of the medical record for Patient #24 revealed the patient was in soft wrist restraints on 5/28/16 and 5/29/16. Further review revealed there were no physician's orders for the restraints on 5/28/16 and 5/29/16.

In an interview on 10/5/16 at 2:50 p.m. with S20CMDirector, she said the order for renewal of restraints for nonviolent patients should have been rewritten every 24 hours.

Based on record reviews and interview, the hospital failed to ensure the QAPI Program measured, analyzed, and tracked adverse patient events.
Findings:

Review of the hospital QAPI information revealed no documented evidence adverse patient events were included in the program.

In an interview on 10/06/16 at 12:32 p.m., S2CNO indicated adverse patient events should be included in hospital performance improvement activities. S2CNO confirmed there was no documented evidence adverse patient events were included in the hospital QAPI program.

Based on record review, interviews and observations, the hospital failed to ensure that the RN supervised and evaluated the nursing care of each patient as evidenced by:

1) Failing to ensure Diprivan (Propofol) was titrated per the Ramsay Sedation Scale as ordered by the physician for 1 of 1 (#4) current hospitalized patients and 1 of 1 (#30) closed patient records with Diprivan Infusions out of a total sample of 30;

2) Administering Diprivan (Propofol) without clarifying an incomplete physician's order for 1 of 1 (#4) current sampled patient receiving Diprivan out of 30 sampled patients;

3) Administering Levophed without clarifying an incomplete physician's order for 1 of 1 (#4) current sampled patient receiving Levophed out of a total of 30 sampled patients;

4) Failing to assess and monitor a patient after a bedside PEG tube placement for 1 of 1 (#4) sampled patients reviewed for bedside endoscopic PEG tube placement out of a total sample of 30;

5) Failing to ensure each patient was assessed at least every 24 hours by a RN as required by the Louisiana State Board of Nurse's Practice Act as evidenced by having patient care provided by LPNs without documented evidence of a RN assessment at a minimum of every 24 hours for 3 (#20, #21, #22) of 3 (#20, #21, #22) patient records reviewed for an RN assessment every 24 hours, of a total of 30 sampled patients;

6) Failing to ensure a registered nurse performed the initial patient admission assessment for 2 (#5, #20) of 6 (#4, #5, #6, #20, #21, #22) patient records reviewed for an initial RN assessment of a total of 30 sampled patients;

7) Failing to document post-mortem care for 2 (#14, #15) of 4 (#14, #15, #16, #17) sampled death records reviewed, and;

8) Failing to document the signature of the nurse administering controlled drugs for 1 of 1 (#5) current sampled hospice patients out of a total sample of 30.
Findings:


1) Failing to ensure Diprivan (Propofol) was titrated per the Ramsay Sedation Scale as ordered by the physician.
Review of the Hospital policy titled, Propofol Administration, Policy # NSG-232 revealed in part the following: Level of sedation should be monitored by use of RAMSEY scale every hour and recorded in the EMR, along with the patient's vital signs....
Patient #4
Review of the medical record for Patient #4 revealed the patient was admitted to the hospital on 08/26/16 and was currently an inpatient. The patient's diagnoses included Septic Shock and Multiple Decubitus Ulcers. Review of the record revealed the patient went into respiratory distress and was intubated on 09/02/16 at 10:05 a.m. The record revealed the patient was started on Diprivan 10 mcg/kg/minute at 10:05 a.m. and the Ramsey Scale was 3. At 10:41 a.m. the dose of the Diprivan was increased to 15 mcg/kg/minute and the Ramsey Scale was 3. At 10:43 a.m. the Diprivan dose was increased to 20 mcg/kg/minute but there was no documentation of a Ramsey Scale score. The nurse's notes revealed at 12:00 p.m. the Diprivan dose was increased to 40 mcg/kg/minute and there was no documentation of a Ramsey Scale score. The nurse's notes revealed at 4:00 p.m. the Diprivan infusion was still at 40 mcg/kg/minute with no documentation of a Ramsey Scale score.
Review of the nurse's notes dated 09/03/16 revealed the Diprivan was infusing at 30 mcg/kg/minutes but there was no documentation of a Ramsey score.
Review of the nurse's notes dated 09/04/16 revealed the patient received the Diprivan infusion on both shifts but the only documentation of a Ramsey score was at 10:00 p.m. and the dose was 15 mcg/kg/minute. Further review of the nurse's documentation revealed the Diprivan infusion was discontinued on 09/05/16 at 12:47 p.m. to assess the patient's status for extubation.
Review of the nurse's notes revealed the Diprivan infusion was resumed on 09/07/16 at 7:42 p.m. at a rate of 20 mcg/kg/minute. There was no documented evidence of a Ramsey Score.
Review of the nurse's notes dated 09/08/16 revealed the Diprivan infusion was continued but there was no documentation of a Ramsey Score. Further review of the nurse's notes revealed no mention of the Diprivan Infusion on 09/09/16 through 09/12/16 and there was no documentation indicating the infusion was discontinued.
Review of the nurse's notes dated 09/13/16 at 8:00 a.m. revealed the Diprivan was infusing at 20 mcg/kg/minute but there was no documentation of a Ramsey Score. The nurse's note dated/timed 09/13/16 at 7:00 p.m. revealed the Diprivan was infusing at 25 mcg/kg/minute but there was no documentation of a Ramsey Score.
Review of the nurse's notes dated 09/14/16 at 7:40 a.m. revealed the Diprivan was infusing at 20 mcg/kg/minute but there was no documentation of a Ramsey Score.

In an interview on 10/03/16 at 1:55 p.m., S4RN, Charge Nurse reviewed the medical record including the EMR and confirmed the Ramsey Scale scores were not documented when the Diprivan was titrated. S4RN provided a report from the EMR for Patient #4 that revealed the dates of the Ramsey Scores. Review of the report revealed no documented evidence of any Ramsey Scores from 09/02/16 at 6:49 p.m. to 09/17/16 at 8:00 a.m. S4RN confirmed the Ramsey Scores had not been documented in accordance with the hospital's policy.

Patient #30
Review of Patient #30's physician's order for Propofol dated 4/18/16 at 11:32 p.m. revealed:
Awaken the patient every shift or more frequently as indicated to assess neuro status, pain level and readiness to wean from Propofol. To awaken decrease Propofol by10 mcg/kg/min every 15 min until patient reaches light sedation. Titrate to Ramsey score.

Review of Patient #30's medical record revealed the following entries:
4/20/16- 8:43 a.m. -Diprivan infusing at 30mcg/kg/min
4/20/16- 11:50 a.m. - Diprivan decreased to 20 mcg/kg/min

In an interview on 10/06/16 at 10:40 a.m. with S31RN, she said she decreased Patient #30's Diprivan on 4/20/16 because his blood pressure had increased. She verified there was no order to decrease the Diprivan if the blood pressure increased. S31RN also verified a Ramsay score was not documented or used to titrate the Diprivan.


2) Administering Diprivan (Propofol) without clarifying an incomplete physician's order:

Review of the Hospital's policy titled High Observation Drips, Policy # CSM163 revealed in part the following:
RN will initiate a High Observation Drip once a Physician order has been obtained. The Physician will write parameters for titration in the order for a titrating medication.

Review of the Hospital policy titled, Propofol Administration, Policy # NSG-232 revealed in part the following: RN's may administer and titrate, in accordance with an order of an authorized prescriber, Propofol to intubated patients in critical care settings....

Patient #4
Review of the medical record for Patient #4 revealed the patient was admitted to the hospital on 08/26/16 and was currently an inpatient. The patient's diagnoses included Septic Shock and Multiple Decubitus Ulcers. Review of the record revealed the patient went into respiratory distress and was intubated on 09/02/16 at 10:05 a.m. The record revealed the patient was started on Diprivan 10 mcg/kg/minute at 10:05 a.m.

Review of the physician orders revealed the following order for the Diprivan/Propofol infusion:
09/02/16 at 10:22 a.m. telephone order documented by S4RN as received from S24MD. Propofol injection 10 mg/1ml IV Q daily PRN titrate to sedation while on ventilator. Further review of the order revealed the pharmacist had changed the order to read as follows: Propofol injection 10 mg/1ml IV Q daily PRN titrate per protocol to Ramsey 3. There was no documented evidence of the starting dose, what dose to increase the infusion by, and how often to increase/decrease the infusion.

Further review of the physician orders revealed an order for Propofol/Diprivan as follows:
09/12/16 at 10:20 a.m. entered electronically by S24MD: Orders for low dose Diprivan prn.... There was no documented evidence of the dosage to infuse the Diprivan infusion at.

In an interview on 10/05/16 at 3:00 p.m. S7RN (Outgoing CNO) reviewed the medical record for Patient #4 and confirmed the orders for the Diprivan infusion were not specific to include the starting dose, the dose to increase the infusion by, and how often to increase the infusion. S7RN stated it was due to an order entry error. S7RN confirmed there was no dosage ordered on the Diprivan infusion ordered on 09/12/16.


3) Administering Levophed without clarifying an incomplete physician's order:

Patient #4
Review of the medical record for Patient #4 revealed the patient was admitted to the hospital on 08/26/16 and was currently an inpatient. The patient's diagnoses included Septic Shock and Multiple Decubitus Ulcers. Review of the record revealed the patient went into respiratory distress and was intubated on 09/02/16 at 10:05 a.m. The record revealed the patient was started on Levophed at 12 mcg/minute at 11:19 a.m. on 09/02/16.

Review of the physician orders dated/timed 09/02/16 at 11:17 a.m. revealed a telephone order was documented by S4RN as received from S24MD and revealed the following: Norepinephrine (Levophed) Injection 8 mg IV Q daily PRN Titrate to keep systolic blood pressure greater than 90. Further review of the order revealed the pharmacist had changed the order to read as follows: Norepinephrine Injection 8 mg in Dextrose 5% 250 ml. IV titrate per protocol Q daily. Titrate to keep systolic blood pressure greater than 90. There was no documented evidence of the starting dose, what dose to increase the infusion by, and how often to increase/decrease the infusion.

In an interview on 10/05/16 at 3:00 p.m. S7RN (Outgoing CNO) reviewed the medical record for Patient #4 and confirmed the orders for the Norepinephrine (Levophed) infusion were not specific to include the starting dose, the dose to increase the infusion by, and how often to increase the infusion. S7RN stated it was due to an order entry error.


4) Failing to assess and monitor a patient after a bedside PEG tube placement:

In an interview on 10/04/16 at 11:00 a.m. with S2CNO, the hospital's policy for bedside PEG tube placement was requested for review. S2CNO confirmed the hospital did not have a policy for bedside PEG tube placement.

Patient #4
Review of the medical record for Patient #4 revealed the patient was admitted to the hospital on 08/26/16 and was currently an inpatient. The patient's diagnoses included Septic Shock and Multiple Decubitus Ulcers. Review of the nursing documentation revealed the following:
09/05/16 at 10:31 p.m. - Patient prepped for PEG placement, will continue to monitor. The entry was electronically signed by S37RN. Further review of the nurse documentation for 09/05/16 on the 7 a.m. to 7 p.m. shift revealed the only entry was at 12:47 p.m. regarding turning the Propofol infusion off to assess the patient before attempting intubation. There was no documented evidence of any monitoring of the patient after the PEG tube placement.

Review of the record revealed an Anesthesia Record documented by S32CRNA* that revealed the starting anesthesia time was 10:27 a.m. and ending anesthesia time was 10:50 a.m. Review of the documentation by S18RN*, endoscopy nurse from Hospital "A" revealed the patient was discharged from the procedure at 10:53 a.m. and report was given to the bedside nurse who would continue to monitor the patient.

In an interview on 10/05/16 at 3:00 p.m. S7RN (Outgoing CNO) reviewed the medical record for Patient #4 and confirmed S37RN did not document any monitoring of the patient after the PEG tube placement and the care of the patient was turned back over to her.



5) Failure to ensure each patient was assessed at least every 24 hours by a RN as required by the Louisiana State Board of Nurse's Practice Act:

Review of the LSBN's Practice Act revealed that RNs may delegate select nursing interventions to the LPN provided the patient is assessed by an RN every 24 hours.

Patient # 20
Review of the medical record for Patient #20 revealed no RN assessments documented from 6/17/16 - 6/21/16.

Patient #21
Review of the medical record for Patient #21 revealed no RN assessments documented from 8/30/16 - 9/9/16.

Patient #22
Review of the medical record for Patient #22 revealed the patient had been admitted on 4/23/16 and discharged on 4/28/16. Further review revealed after the initial admission RN assessment on 4/23/16 there was no documented RN assessment throughout the entire hospitalization.

In an interview on 10/5/16 at 1:32 p.m. with S2CNO, she verified a RN should have performed a patient assessment every 24 hours.


6) Failing to ensure a registered nurse performed the patient's admission assessment:

Review of the facility policy titled Admission of a patient, Policy # ADM-101, revealed in part: An RN will perform an initial assessment of the patient upon the admission to the nursing unit.


Patient #5
Review of the medical record for Patient #5 revealed the patient was admitted to the hospital on 10/01/16 as an inpatient hospice patient with a diagnosis of Metastatic B Cell Lymphoma. Review of the initial nursing assessment/admission assessment revealed an LPN had performed the assessment. Further review of the nursing documentation revealed no documented evidence of any nursing assessments done by the RN.

Review of the written agreement between the Hospital and the Hospice Agency for Patient #5 revealed the following: Hospital shall ensure that a registered nurse is readily available to provide direct patient care twenty-four (24) hours a day....

In an interview on 10/04/16 at 8:30 a.m., S4RN Charge Nurse stated they treat hospice patients like any other patient admitted to the hospital.

Review of the electronic medical record with S8HIM on 10/04/16 at 9:00 a.m., revealed no documented evidence of any assessments by the RN. S8HIM confirmed the initial admission assessment was conducted by an LPN and there was no documented evidence of any assessments done by an RN.


Patient #20
Review of the medical record for Patient #20 revealed an LPN performed the admission assessment on 6/16/16.

In an interview on 10/05/16 at 1:32 p.m. with S2CNO, she verified a RN should have performed the initial patient's admission assessments.


7) Failing to document post-mortem care:

Review of the Hospital policy titled, Pronouncement of Death & Post Mortem, Policy # NSG141 revealed in part the following: After the physician pronounces the patient dead....Clean body if needed. Apply adhesive bandages to puncture sites. Replace soiled dressings. Place dentures in mouth as soon as possible, if applicable. Place the body in a supine position, arms at sides and head on pillow. Elevate the head of the bed slightly to prevent discoloration from blood settling in face....

Patient #14
Review of the medical record for Patient #14 revealed the patient was admitted to the hospital on 08/12/16 with a diagnosis of End Stage HIV. Review of the record revealed the patient expired in the hospital on 09/13/16 at 4:59 a.m. Review of the nursing documentation revealed no documented evidence that any post-mortem care was provided.

In an interview on 10/05/16 at 3:00 p.m., S2CNO reviewed the medical record for Patient #14 and confirmed there was no documentation of post-mortem care of the patient's body.


Patient #15
Review of the medical record for Patient #15 revealed the patient was admitted to the hospital on 08/06/16 with a diagnosis of Respiratory Failure. Review of the record revealed the patient expired in the hospital on 09/09/16 at 2:15 p.m. Review of the nursing documentation revealed no documented evidence that any post-mortem care was provided.

In an interview on 10/05/16 at 3:15 p.m., S2CNO reviewed the medical record for Patient #15 and confirmed there was no documentation of post-mortem care of the patient's body.


8) Failing to document the signature of the nurse administering controlled drugs:

Patient #5
Review of the medical record for Patient #5 revealed the patient was admitted to the hospital as a hospice patient on 10/01/16 with a diagnosis of Metastatic B Cell Lymphoma. Review of the physician orders revealed Morphine 2 mg. IV push every 4 hours as needed for pain and Ativan 0.5 mg. IV push every 4 hours as needed for anxiety were ordered by the attending physician.

Review of the nurse's notes revealed only LPNs had documented assessments of the patient from admission to 10/04/16.

Review of the Medication Log Report and the nurse's notes revealed no documentation of the nurse that administered the Morphine 2 mg. IV push on the following dates: 10/01/16 at 11:08 p.m., 10/02/16 at 3:43 a.m., 10/02/16 at 7:09 p.m., 10/02/16 at 9:33 p.m., 10/03/16 at 4:14 a.m., 10/03/16 at 6:34 a.m., 10/03/16 at 8:07 p.m., and 10/04/16 at 6:45 a.m.

In an interview on 10/04/16 at 9:00 a.m., S8HIM reviewed the EMR and confirmed there was no signature of the nurse that administered the Morphine on the above dates. S8HIM stated she had asked the nurse to review the EMR for a different view or report and the RN was unable to provide documentation of the nurse that administered the Morphine on the above dates.

In an interview on 10/05/16 at 3:40 p.m., S7RN (Outgoing CNO) reviewed the EMR for Patient #5 and confirmed there was no signature of the nurse administering the Morphine on the above dates and there should have been initials of the administering RN.



17091




30420

Based on record reviews and interview, the hospital failed to ensure that the nursing staff developed and kept current a nursing care plan for each patient as evidenced by failing to individualize the patient's nursing care plan to include all the patient's medical diagnoses for which the patient was being treated, and failing to update/revise the plan of care when the patient's condition changed for 4 of 4 (#3, #4, #5, #6) sampled patient medical records reviewed for care planning out of a total sample of 30 patients.
Findings:

Review of the Hospital policy titled, Patient Assessment/Reassessment (#CSM 114, origin date 12/2012) provided as current, revealed that Nursing assessments were completed and documented in the medical record within 12 hours of admission. The primary care needs for each patient were determined by the initial assessment as documented in the Nursing Care Record. Further assessments considered such factors as functional, nutritional, psychosocial, and environmental/safety needs, self-care, educational, cultural, and discharge planning needs to identify and prioritize the patient's need for care. Assessment is ongoing as appropriate throughout the hospital stay and continues through discharge. The admitting RN oversees the completion of the initial assessment and development of an appropriate Plan of Care. Nursing will re-assess each patient every shift or as warranted by the patient's medical condition and document on the Nursing Care Records. While primary treatment is not provided for patients needing care form emotional, behavioral disorders... these conditions may be present in patients who are admitted for care of medical/surgical conditions. The special need of these patients will be assessed and included in the Plan of Care.


Patient #3
Review of the medical record for Patient#3 revealed she was admitted to the hospital 09/13/16. Her diagnoses included Chronic kidney disease, history of Intracranial hemorrhage, Hypertension, Diabetes Mellitus, Depression, MRSA sepsis, and she obtained her nutrition through a PEG tube. The admission history and physical revealed the patient mental status could not be assessed. Review of the care plans for Patient #3 revealed no goal time frames were documented for any of the care plans. Review of the care plans revealed the following: Wound Care plan - no individualized nursing diagnosis or goals, High Infection Risk- no goal time frames, Management of Pain- no goal time frames, Potential for Injury related to CVA, Fall Risk, and Poor judgment/poor safety awareness- no goals identified, Nursing and Pharmacy- no goals identified, Patient/Family participation in Plan of care and discharge planning- no goal timelines documented. No care plan was developed for the patient's diabetes, hypertension, potential for depression, mental deficits, or nutritional status/needs.

In an interview 10/04/16 at 1:20 p.m. Patient #3 reported that she had just gotten her memory back a couple of days ago. She reported she had a "bleed in my brain", and could not remember her admission to the hospital.

In an interview 10/06/16 at 9:30 a.m. S1ADM and S2CNO verified the above finding after a review of the patient's care plans. S1ADM and S2CNO verified that the care plans were not individualized to the patient, goals did not have time frames, and did not address all of the patient's needs.


Patient #4
Review of the medical record for Patient #3 revealed the patient was admitted to the hospital on 08/26/16 with diagnoses of Septic Shock with Altered Status, Moderate Protein Calorie Malnutrition, Sacral, Hip and Heel Pressure Ulcer, Acute Renal Failure, Debility, Hypernatremia, Metabolic Acidosis, Dementia, and Hypertension. Further review of the record revealed the patient was put on contact precautions on 09/09/16 and Enteric Precautions were added on 09/24/16 when the patient was found to have C. difficile. Review of the record revealed the patient had sputum and blood cultures with pseudomonas identified on 09/22/16.

Review of the Interdisciplinary Plan of Care revealed the only goal identified for the patient's wounds was, "Provide environment to facilitate tissue oxygenation, tissue nutrition and remove cellular waste." The plan of care did not include specific goals or interventions that addressed the patient's multiple wounds. Review of the plan of care revealed the only goal related to infection was, "Decrease risk of hospital acquired infection by providing environment to facilitate decrease in bacterial load." There was no update to the plan of care when the patient was placed on contact precautions and when the patient was placed on enteric precautions. There were no problems, goals or interventions identified for nutritional risk factors. The plan of care was not updated when the patient had a PEG tube placed on 09/05/16.

In an interview on 10/05/16 at 3:10 p.m., S2CNO confirmed the Interdisciplinary Plan of Care was not updated with the above patient problems, the plan of care was not individualized, and the plan of care was not updated with the isolation precautions.


Patient #5
Review of the medical record for Patient #5 revealed the patient was admitted to the hospital on 10/01/16 for inpatient hospice care with a diagnosis of Metastatic B Cell Lymphoma. Review of the Interdisciplinary Plan of Care revealed no documented evidence that the patient was a hospice patient. Review of the Plan of Care revealed Management of Pain was identified as a problem, but there was no documentation that the patient was receiving inpatient hospice services. Review of the Plan of Care revealed the problem of Psychosocial/alteration in coping mechanism related to end of life was left blank. Further review of the record revealed no documented evidence of the hospice agency's initial plan of care.

In an interview on 10/05/16 at 3:40 p.m., S7RN reviewed the Plan of Care for Patient #5 and confirmed the Plan of Care was incomplete and did not include problems/goals/interventions related to inpatient hospice care.


Patient #6
Review of the medical record for Patient #6 revealed the patient was admitted to the Hospital on 09/27/16 with diagnoses of Acute on Chronic Respiratory Failure, Panic Disorder, Acute COPD, Multiple Intubations from Reactive Airway Disease, and AIDS.

Review of the record revealed the patient had received PRN doses of the following medications daily since admission:
Lorazepam 1 mg. IV every 4 hours as needed for anxiety.
Haloperidol 2 mg. IV every 4 hours as needed for agitation.
Alprazolam 10 mg. by mouth twice a day as needed for anxiety.

Review of the Interdisciplinary Plan of Care revealed the reason for admission was Ventilator Weaning, Respiratory Management, and IV Antibiotics. Review of the care plan revealed the section for Respiratory Therapy, including ventilator management was left blank. There was no documented evidence that the patient's anxiety, panic disorder and agitation were included in the plan of care.

In an interview on 10/05/16 at 3:45 p.m., S2CNO reviewed the patient's medical record and confirmed the Plan of Care was incomplete and did not include the above identified problems. S2CNO confirmed the plan of care had not been individualized to meet the identified needs of the patient.


30420

Based on record reviews and interviews, the hospital failed to provide adequate supervision of non-employee licensed dialysis nursing personnel for 2 of 2 sampled hemodialysis patients (#2, #29) in a total of 30 sampled patients.
Findings:


Patient #2:
Review of the medical record revealed the patient was admitted to the hospital on 09/24/16 and had the diagnosis of end stage renal disease.

Review of the Physician Orders revealed an order dated 09/24/16 for hemodialysis treatment Tuesday, Thursday, and Saturday. Further review of the orders revealed:
Duration: 3 hours, 30 minutes
Bath: Sodium 140
Dialyzer: F160
There were no blood flow rate (BFR) or dialysate flow rate (DFR) orders.

Review of the Patient Treatment Record-Acute Treatment record dated 09/24/16 revealed the following:
Duration: 3 hours
Bath: Sodium 135
Dialyzer: F180
The BFR was 250 and DFR was 500.

Review of the Physician Orders revealed an order dated 09/26/16 for hemodialysis treatment Tuesday, Thursday, and Saturday. Further review of the orders revealed:
Dialyzer: F160
Bath: Potassium 4.0

Review of the Patient Treatment Record-Acute Treatment record dated 09/29/16 revealed the following:
Dialyzer: F180
Bath: Potassium: 3.0

Review of the Patient Treatment Record-Acute Treatment record dated 10/01/16 revealed the following:
Potassium: 2.0

In an interview on 10/05/16 at 2:11 p.m., S13RN indicated the physician wrote the orders for dialysis treatment. S13RN indicated physician orders for dialysis treatment should have orders for BFR and DFR. S13RN indicated the dialysis RN should review, verify, and follow dialysis orders each treatment. S13RN indicated the dialysis RN should contact the physician for clarification of dialysis treatment orders as needed. The above dialysis treatment issues were reviewed with S13RN. S13RN indicated the dialysis treatment orders were not followed and there was no documented evidence the physician was contacted to clarify the orders.


Patient #29
Review of the dialysis orders for Patient #29 revealed no orders for the BFR or the DFR.
Review of the Dialysis treatment sheet for Patient#29 dated 9/2/16 revealed the BFR was administered at 400 ml/min and the DFR at 800 ml/min.

Review of Patient #29's dialysis orders dated 9/3/15 revealed an order for the BFR 400 ml/min and DFR 800 ml/min. Review of the treatment sheet dated 9/5/16 revealed the DFR was administered at 500 ml/min with no documentation as to why the rate was not programmed as ordered.

In an interview on 10/6/16 at 10:02 a.m. with S20CMDirector, she verified there was no order in Patient #29's medical record for a dialysate blood flow or dialysate rate on 9/2/16. She also verified there was no documentation on 9/5/16 as to why the dialysate flow rate had been altered from the physician's order.


30364

Based on record reviews and interviews, the hospital failed to ensure medical records included a properly executed informed consent for procedures and treatments. This deficient practice was evidenced by informed consents that were not completed as per hospital policy when information required was omitted in the informed consent, required information areas were left blank, and/or informed consents were not obtained for procedures/treatments performed for 3 of 3 (#4,#10, #19) current patient records reviewed for properly executed informed consents from a total sample of 30.

Findings:

A review of the hospital policy titled "Consent for Medical Treatment", ( #ADM-11, effective 04/10/13, no revision date(s)), provided by S1ADM as current, revealed in part the following: "Definitions:... 1) Informed Consent- Consent obtained from the patient after being informed of the nature and risks of the proposed treatment and of the possible alternatives by the attending physician...A written consent is required for all patients in the following circumstances:...Non-Routine Tests, Treatments and/or Procedures..." Further review revealed, with regards to Informed Consent, prior to the commencement of each procedure requiring informed consent, the physician was to write a noted in the patient's chart which stated, at a minimum, that the physician had discussed the procedure, advised the patient of the risks involved, alternative treatments, and any risks involved in alternative treatment(s). Information that must be conveyed to the patient in a manner they could understand included: 1) an explanation of the procedure to be performed and the expected results,2) a description of the anticipated risks and discomforts, 3) Probable benefits, 4) Disclosure of possible alternatives and associated risk, 5) an offer to answer the patient's questions...


Patient #4
Review of the medical record for Patient #4 revealed the patient was a current hospitalized patient that was admitted to the hospital on 08/26/16 with diagnoses of Septic Shock, Protein Calorie Malnutrition, Acute Renal Failure, Dementia, Hypertension, and Debility. Review of the record revealed a PEG tube procedure was performed in the patient's room on 09/05/16. Review of the Anesthesia Consent for the procedure dated 09/05/16 revealed the following sections of the consent form were left blank:
Anesthesia Procedure and Purpose (including the type of anesthesia to be used).
Therapeutic Alternative and Risks Associated Therewith.
Material Risks of Treatment/Procedure.
Review of the consent form revealed the only sections completed were the signature of the Anesthesiologist, telephone consent obtained from patient's son, and the signature of two witnesses.

In an interview on 05/04/16 at 10:40 a.m., S7RN (Outgoing CNO) reviewed the medical record for Patient #4 and confirmed the Anesthesia Consent was incomplete and did not include the type of anesthesia that was used, nor did the consent include alternatives and risks of procedure. S7RN confirmed the staff of Hospital "A" performed the PEG procedure for this patient at the bedside on 09/05/16.


Patient #10

Review of the medical record for Patient#10 revealed the patient was a current hospital patient with an admission date of 09/06/16. Further review revealed Patient #10 had a peripheral IV placed, after a failed attempt of the placement of a central venous catheter on 9/25/16. The attempted CVC placement and subsequent peripheral IV placement were performed by S28MD*, anesthesiologist. A consent form for Patient #10 was noted to be for Anesthesia (General, Monitored, Epidural/Spinal, Bier Block, Axillary Block, Interscalene Block, or other Regional Anesthesia). Further review of the consent form revealed no description of the placement of a CVC, the risks involved, the patient's condition/reason for which the placement was recommended, the alternative(s) to the procedure, the risks of the alternative(s)/ not having the procedure performed, or the location (hospital) the procedure was to be performed. The consent was signed by the patient's daughter, with no designation of her relationship to the patient, a reason the patient did not sign, or a witness to the signature of consent. No other consent form for the procedure of the placement of a CVC was found.
Further review of Patient #10's medical record revealed she had a surgical debridement of a pressure ulcer to her left heel on 09/30/16. A consent with Hospital A's information on it (name and form #) for the surgical debridement on 09/30/16 had no material risks of the treatment/procedure documented. All check boxes in this area were blank. (for attachments of risks). No attachments were found. The procedure consent was signed by the Advanced Practice RN performing the debridement procedure.

In an interview 10/06/16 at 9:30 a.m., after review of the consents on the medical record of Patient #10, S1ADM and S2CNO verified the consents were obtained on another provider's consent forms, and were not properly executed. S1ADM verified the consent for the CVC placement did not address the procedure, or any of the components of a properly executed procedure and was obtained on an incorrect procedure form (anesthesia). S1ADM and S2CNO verified that the consent for surgical debridement was for a procedure at the bedside in this hospital, so should have been on a consent form identifying the procedure was to be performed in this hospital. S1ADM reported that this hospital (Louisiana Continuing Care Hospital) did not have consent forms of it's own, and that of hospital "A" were used.


Patient #19

Review of the medical record for Patient #19 revealed the patient was a current hospitalized patient that was admitted to the hospital on 09/21/16 with diagnoses of Sepsis with Right Foot Osteomyelitis and Achilles Tenosynovitis. Review of the record revealed a wound debridement was done on the patient's right heel pressure ulcer on 09/24/16. Review of the consent form for the debridement procedure dated 09/24/16 revealed the section for the Material Risks of Treatment/Procedure was left blank. There was no documented evidence in the consent form of the Material Risks of the procedure.

In an interview on 10/05/16 at 3:00 p.m., S2CNO and S7RN reviewed the medical record for Patient #19 and confirmed the informed consent for the wound debridement dated 09/24/16 did not include the material risks of the procedure and confirmed the consent form was not properly executed.


30420

Based on record review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable standards of practice, consistent with state law. This deficient practice was evidenced by failing to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist, before the first dose was dispensed, for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications for 1 (#1) of 1 patient reviewed for an override in the medication distribution cabinet.

Findings:

Review of the Louisiana Administrative Code, Professional and Occupational Standards,
Title 46: LIII, Pharmacist, Chapter 15, Hospital Pharmacy, §1511. Revealed in part:
Prescription Drug Orders
A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial
dose of medication, except in cases of emergency.


Review of the hospital policy titled Pyxis-Override Medications, Policy Number: 02.05, revealed in part: All medication dispensed via automated dispensing cabinets or floor stock will be reviewed by a pharmacist prior to administration to a patient.

Review of physician's orders for Patient #1 dated 10/3/16 at 11:08 p.m. revealed an order for Calcium Carbonate 1000 mg PRN.

Review of an override report the automated medication dispensing machine revealed a Calcium Carb Chew 500 mg was removed for Patient #1 at 10:15 p.m. on 10/3/16.

In an interview on 10/5/16 at 9:50 a.m. with S10Pharm, he said the Calcium for Patient #1 on 10/3/16 was pulled from the automated dispensing machine by the nurse at 10:15 p.m. He verified the medication was not reviewed for first dose before the dose was administered because the pharmacy hours were from 8:00 a.m. until 4:00 p.m. Monday through Friday and from 8:00 a.m. until 12:00 p.m. on the weekends. He said the pharmacist did not do a first dose review on medications ordered after hours unless the nurse had a specific question about a medication or it was unavailable in the automated machine. He verified this deficient practice had been cited at the last survey and said the previous owners had hired a company to do first dose review at night but decided it was too expensive after about 6 months and canceled the service.

This was cited at the recertification survey dated 12/4/13 and re-cited during the follow-up survey dated 1/23/14.

Based on record review and staff interview, the hospital failed to develop Radiology policies and procedures that included; safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital.

Findings:

A review of the contracts provided by S1ADM revealed the hospital had a contract with Hospital "A" to provide Radiology services for patients.

In an interview on 10/03/16 at 3:00 p.m., S1ADM confirmed the hospital's Radiology services were provided by written agreement with Hospital "A", the host hospital. S1ADM confirmed Hospital "A" provided procedures in the hospital and the hospital patients were also transported to Hospital "A" for radiology procedures. The hospital's policies and procedure for Radiology services were requested for review.

In an interview on 10/04/16 at 7:55 a.m., S2CNO stated the hospital did not have any policies and procedures related to Radiology services. She stated the Radiology services were contracted through Hospital "A" and they would have their policies. S2CNO confirmed the hospital had no Radiology policies and procedures in place that related to radiology services or to the safety precautions against radiation hazards for staff and patients during radiology procedures.

Based on record review and staff interview, the hospital failed to ensure there was a Radiologist appointed by the Governing Body to supervise the Radiology Services on either a full-time, part-time, or consulting basis as evidenced by no documentation of a Director of Radiology for the hospital.

Findings:

A review of the hospital's organizational chart, provided by S1ADM as a current organizational chart, revealed no documentation of a Radiologist as the Director of Radiology for the hospital.
A review of the list of credentialed physicians on the hospital's Medical Staff, provided by S1ADM as a current list, revealed no documented evidence that a Radiologist was identified as the Director of Radiology.

A review of the Governing Body meeting minutes revealed no documentation that the Governing Body had appointed a Radiologist as the Director of Radiology for the hospital.
A review of the contracts, provided by S1ADM, revealed the hospital had a contract with Hospital "A" (Host Hospital) to provide Radiology services.

In an interview on 10/03/16 at 3:55 p.m., S1ADM confirmed the hospital's Radiology services were provided by contract with Hospital "A", the host hospital. S1ADM confirmed the hospital had no Director of Radiology since the radiology services were contracted. S1ADM confirmed the hospital's Governing Body had not appointed any of the credentialed Radiologists as the hospital's Director of Radiology to supervise the Radiology services for the hospital.

Based on record review and interviews, the hospital failed ensure the Utilization Committee had two or more practitioners who were not involved in the patient's care to carry out the Utilization Review (UR) functions. Findings:

In an interview on 10/05/16 at 11:00 a.m., S1ADM stated the hospital's case managers do the daily utilization review. She stated the hospital did have a HIM/UR/Ethics committee.

In an interview on 10/05/16 at 11:05 a.m. S20CMDirector and S19CM confirmed they were conducting daily utilization review of inpatients. Both indicated they had attended one UR committee meeting about 2-3 months ago. S20CMDirector stated the UR committee was going to meet next month and confirmed the meetings were to be done quarterly. S19CM stated S21MD was on the committee along with herself, S20CMDirector and S1ADM. S20CMDirector indicated she had recently moved to this position and she was not aware of any UR committee or reporting prior to the last meeting, 2-3 months ago. Both were asked to provide documentation of committee members and minutes for last meeting. They were unable to provide documentation of the meeting or members of the UR committee at this time.

In an interview on 10/05/16 at 1:50 p.m., S2CNO provided a sign in sheet titled Ethics & Utilization Review dated 07/14/16 at 2:00 p.m. Those signing the form as in attendance included S21MD, S28RN, S19CM, and S1ADM. S2CNO also provided the hospital's committee calendar that revealed the UR committee was combined with HIM and Ethics and the committee consisted of the following: Chairman (S21MD), Administrator, Nursing Administrator, Education, Case Manager, Director Case Management, and Quality (Vacant). There was no documented evidence of two physicians on the committee. S2CNO confirmed the UR committee of the hospital included only 1 physician, S21MD.


S2CNO also provided a form titled Utilization Management Committee Dashboard Report. Review of this form revealed the meeting was called to order at 2:00 p.m. and adjourned at 3:00 p.m. Review of the form revealed the only physician in attendance was S21MD. The form revealed there was no old minutes reviewed and no old business was discussed. The only documentation of new business was the following: "As this was our first meeting, a detailed review of the dashboard was done and what the indicators will reveal. The importance for maintaining this information was also discussed." There was no documented evidence of any review of UR data. S2CNO confirmed the meeting dated 07/14/16 was a "set up" meeting and included only 1 physician. S2CNO confirmed the UR committee of the hospital included only 1 physician, S21MD.

Based on record review and staff interview, the Hospital failed to ensure a Utilization Review Plan was developed and implemented as evidenced by failing to have a written plan or policy for utilization review, failing to conduct UR committee meetings for the past 12 months, and failing to provide documentation of UR for the past 12 months.

Findings:

In an interview on 10/05/16 at 11:00 a.m., S1ADM stated the hospital's case managers do the daily utilization review. She stated the hospital did have a HIM/UR/Ethics committee.

In an interview on 10/05/16 at 11:05 a.m. S20CMDirector and S19CM confirmed they were conducting daily utilization review of inpatients. Both indicated they had attended one UR committee meeting about 2-3 months ago. S20CMDirector stated the UR committee was going to meet next month and confirmed the meetings were to be done quarterly. S19CM stated S21MD was on the committee along with herself, S20CMDirector and S1ADM. S20CMDirector indicated she had recently moved to this position and she was not aware of any UR committee or reporting prior to the last meeting, 2-3 months ago. Both were asked to provide the Utilization Review Plan or Policy for review. After reviewing the policy and procedure manual on her desk, S19CM confirmed she did not have a UR Plan or Policy. S20CMDirector and S19CM were unable to provide documentation of the meeting or UR Plan/Policy at this time.

In an interview on 10/05/16 at 1:50 p.m., S2CNO provided a sign in sheet titled Ethics & Utilization Review, dated 07/14/16 at 2:00 p.m. Those signing the form as in attendance included S21MD, S38RN, S19CM, and S1ADM. S2CNO also provided the hospital's committee calendar that revealed the UR committee was combined with HIM and Ethics and the committee consisted of the following: Chairman (S21MD), Administrator, Nursing Administrator, Education, Case Manager, Director Case Management, and Quality (Vacant). S2CNO also provided a form titled Utilization Management Committee Dashboard Report, dated 07/14/16. Review of this form revealed the meeting was called to order at 2:00 p.m. and adjourned at 3:00 p.m. Review of the form revealed there was no old minutes reviewed and no old business was discussed. The only documentation of new business was the following: "As this was our first meeting, a detailed review of the dashboard was done and what the indicators will reveal. The importance for maintaining this information was also discussed." There was no documented evidence of any review of UR data. S2CNO confirmed the meeting dated 07/14/16 was a "set up" meeting and did not include any review of utilization reports. S2CNO confirmed she was unable to provide documentation of a UR plan or policy and she was unable to provide evidence of any other UR committee meetings.

Based on observation and interview, the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by failing to ensure the functionality of a nurse call button located on the handrails of the beds for 27 of 29 beds in the facility currently in use or available for use. Of these 27 beds, 18 were currently in use at the time of entry to the survey.
Findings:

On 10/03/16 at 10:30 a.m. an observation was made of Room "1" with S4RN (Charge Nurse). The bed was observed to have a button with a white cross inside a red box in the side rail of the bed. S4RN confirmed the white cross button was a nurse call button, but the button was not working. He stated they use the call light on the cord attached to the wall. He confirmed the hospital had multiple beds of this style and none of the call buttons located in the side rails of the beds were functional.

Observations were made 10/03/16 at 1:35 p.m. with S2CNO of all beds in patient rooms in the hospital. These observations revealed 27 of the 29 available beds in the hospital had nurse call buttons on the handrails. When asked if it would be possible for a patient who may be sedated and/or confused to press the white cross button on the handrail of the bed thinking they are calling for assistance without the nursing staffs knowledge due to the call button not working, S2CNO confirmed that was possible.

In an interview 10/03/16 at 2:45 p.m. S38RN , past clinical coordinator/educator and charge nurse, reported that the call system plugs were not connected to the call system (plugs located in the patient room walls at head of bed) for any of the patient beds.

Based on record review and interview, the hospital failed to ensure a qualified person was designated as the infection control coordinator/officer to develop and implement policies governing control of infections and communicable diseases. This failed practice was evidenced by
1) appointment an infection control officer (S12ICC) with no documented evidence of specialized education, training, or certification in the development or oversight of an infection control program, and
2) no documentation of any nationally recognized guidelines on which the hospital's infection control policies and procedures were based.
Findings:


1) Appointment of an infection control officer (S12ICC) with no documented evidence of specialized education, training, or certification in the development or oversight of an infection control program.

Review of the personnel record for S12ICC revealed no documented evidence of specialized education, training or certification in the development or oversight of an infection control program.

In an interview 10/03/16 at 2:25 p.m. S12ICC reported that she was new to the Infection Control Coordinator position. S12ICC reported that she planned to take classes in the coordination of an infection control program, but had not yet taken any. S12ICC reported that she was not registered to take any infection control program training as of the time of this interview.

In an interview 10/06/16 at 9:30 a.m. S1ADM verified S12ICC did not have specialized infection control experience or training for overseeing an infection control program. S1ADM verified S12ICC was not yet enrolled or registered for infection control training on the oversight of an infection control program.

2) No documentation any nationally recognized guidelines on which the hospital's infection control policies and procedures were based.

Review of the hospital Infection Control Plan, 2016, provided by S12ICC as current, revealed no documentation of nationally recognized guidelines on which the infection control policies and procedures were based.

In an interview 10/06/16 at 1:30 p.m. S12ICC verified she could provide no documentation of nationally recognized guidelines on which the infection control policies and procedures were based.

30420

Based on record review, observation, and interview the hospital failed to ensure a system for identifying, reporting, investigation, and controlling communicable diseases of patients and personnel was developed and implemented as evidenced by:
1) no policies and procedures to ensure patient care equipment was cleaned and disinfected correctly and to ensure staff reported potentially contagious signs and symptoms to appropriate hospital personnel; and
2) observations of breeches in infection control that included: a) staff not washing their hands after glove removal, when exiting an enteric isolation patient room, and b) placing patient pillows on a Biohazard waste container in a patient's room during wound care, then placing the contaminated pillows directly in the patient's bed with her, following wound care, and c) a box of isolation PPE (masks), opened and placed next to handwashing sink on hall, allowing water to splash on and into box of masks.
Findings:


1) No policies and procedures to ensure patient care equipment was cleaned and disinfected correctly and to ensure staff reported potentially contagious signs and symptoms to appropriate hospital personnel:

Review of infection control policies and procedures revealed no policies and procedures as to how and when patient care equipment and point of care testing devices were to be cleaned and disinfected.

An observation 10/03/16 at 10:20 a.m. revealed a soiled storage closet of patient care equipment such as bedside commodes, numerous IV pumps, and feeding pumps, full enough that one could not step into the closet. S4RN, charge nurse present for the tour, verified the observation and reported that someone from maintenance came and cleaned the equipment every few days. He reported that he didn't know if there was a policy or procedure related to who was responsible to clean the equipment, when, and how it was to be cleaned and disinfected.

In an interview 10/06/16 at 1:30 p.m. S12ICC reported the hospital did not have a procedure for cleaning and disinfecting equipment used on more than one patient, including the blood glucose machines, to ensure that all equipment was appropriately disinfected after use by or on each patient.

As of the survey exit 10/06/16 no policy and/or procedure for the cleaning and disinfection of patient care equipment or point of care testing equipment (capillary blood glucose machines) was provided for review.


2) Observations of breeches in infection control:

An observation on 10/03/16 at 10:15 a.m. revealed Patient #4's hallway door contained signage indicating the patient was on Enteric Precautions. S36Housekeeper was observed in the room of Patient #4 with gown, mask, and gloves on. 36Housekeeper was observed to remove his gown, gloves, and mask and exit the room. S36Housekeeper was then observed to walk through the nurse's station and down the opposite hallway, pick up wet floor signs, and move the mop bucket down the hallway. S36Housekeeper was not observed to wash his hands after removing the gloves used is an enteric precautions room. In an interview with S36Housekeeper at the time of the observation, he confirmed he had not washed his hands after removing his gloves.

An observation 10/03/16 at 10:20 a.m. revealed a box of isolation PPE (masks), opened and placed next to handwashing sink on hall "a", allowing water to splash on and into box of masks.

In an interview 10/03/16 at 10:25 a.m. S4RN verified the opened isolation masks next to the sink. He reported that the masks should not be there, and could be contaminated .

An observation 10/05/16 at 2:05 p.m. revealed wound care was performed by S35RN and S22LPN on Patient # 3 in her room. During the observation from 1:25 p.m. to 2:05 p.m. two pillows with pillow cases on them were observed to be on top of a large, rigid biohazard waste container(in the patient's room). After the completion of the wound care, the patient was repositioned in the bed, with S22LPN placing the pillows from on top of the biohazard container in the bed with the patient.

In an interview 10/05/16 at 2: 05 p.m. S22LPN and S35RN verified that the pillows were placed on the biohazard container, and then removed and placed directly onto the bed with the patient without cleaning and disinfecting the pillows and changing the pillow cases. Both nurses agreed that the pillows should not have been placed on the biohazard container,should be considered contaminated, and not used on the patient before cleaning and disinfecting.