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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 failing to ensure contracted services were not provided by staff concurrently working at the host hospital (Hospital A) for Laboratory, Radiology, Respiratory, Rehabilitation services, and Pharmacy. (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) policies and emergency room physicians during code blue (cardiopulmonary arrest) procedures. (see findings in A0093)

3. The Governing Body failed to ensure all physicians and nurse practitioners providing services in the hospital were credentialed and granted appropriate privileges. This deficient practice was evidenced by the contract emergency room physicians from the host hospital (Hospital A) providing care in Hospital B in case of an emergency and not being credentialed in Hospital B and granted appropriate privileges for 11 of 11 emergency room physicians (S24MD, S25MD, S26MD, S27MD, S28MD, S29MD, S30MD, S31MD, S32MD, S33MD, S34MD) and 7 of 7 emergency room nurse practitioners (S35APRN, S36APRN, S37APRN, S38APRN, S39APRN, S40APRN, S41APRN). (see findings in A0045)

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

Failing to ensure the organization of the medical records service was appropriate to the scope and the complexity of services provided as evidenced by failing to ensure the medical records department was under the supervision of a qualified individual (see Finding in A0432).

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

1. Failing to ensure radiology services were provided independent of the host hospital (Hospital A) by failing to ensure radiology services were not provided by staff concurrently working at the host hospital (Hospital A) and by not accompanying patients to Hospital A while radiological procedures were performed. (see findings in A0529)

2. Failing to develop policies and procedures that addressed safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures. (see findings in A0536)

Based on record review and interview, the hospital failed to meet the requirements of Conditions of Participation for Laboratory Services as evidenced by:

1. Failing to have facility specific policies/procedures relative to laboratory services

2. Failing to provide laboratory services without the staff concurrently working for the host hospital. (see findings in A0582)

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

1. Failing to ensure there was adequate emergency room physicians/practitioner coverage between the Host hospital and the Hospital within a Hospital. (See finding in A1101).

2. Failing to ensure emergency services policies and procedures were evaluated, updated and revised on an ongoing basis. (See Findings in A1104).

Based on record review and interview, the hospital failed to meet the requirement for Condition of Participation of Rehabilitation Services as evidenced by

1. Failing to ensure rehabilitation services performed under contract were provided in an effective manner independent of the host hospital (Hospital A) by failing to ensure services were not provided by staff concurrently working at the host hospital. (see Findings in A1124)

2. Failing to have facility specific policies/procedures relative to rehabilitation services. (see Findings in A1124)

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

1. Failing to ensure Respiratory Services performed under contract were provided in an effective manner independent of the host hospital (Hospital A) by failure to ensure services were not provided by staff concurrently working at the host hospital (see Findings in A1152).

2. Failing to have facility specific policies/procedures relative to respiratory services (see Findings in A1152).

Based on record review and interview, the Governing Body's failure to ensure all physicians and nurse practitioners providing services in the hospital were credentialed and granted appropriate privileges. This deficient practice was evidenced by the contract emergency room physicians from the host hospital (Hospital A) providing care in Hospital B in case of an emergency not being credentialed in Hospital B and granted appropriate privileges for 11 of 11 emergency room physicians (S24MD, S25MD, S26MD, S27MD, S28MD, S29MD, S30MD, S31MD, S32MD, S33MD, S34MD) and 7 of 7 emergency room nurse practitioners (S35APRN, S36APRN, S37APRN, S38APRN, S39APRN, S40APRN, and S41APRN). Findings:

Review of the Governing Body by-laws revealed in part, The Governing Body, pursuant to these By-laws, delegated the authority to render initial appointment, reappointment and renewal or modification of clinical privilege decisions to a committee of the Governing Board, that shall consist of at least 2 of its governing body members. Following a positive recommendation from the Medical Executive Committee on the application, the committee of the governing board reviews and evaluates the qualifications and competence of the practitioner applying for appointment, reappointment or renewal or modification, of clinical privileges and renders it decision.

An interview was conducted with S3IC/QA on 9/13/16 at 3:15 p.m. She reported the emergency physicians and NPs that work in Hospital A's (host hospital) emergency room are the physicians and NPs that respond to cardiopulmonary codes (Code Blue) at Hospital B.

Review of the Emergency room schedule for physicians and Nurse Practitioners for June, July and August 2016 for Hospital A and review of the list of credentialed physicians and NPs for Hospital B revealed none of the emergency room physicians or NPs for Hospital A were credentialed by Hospital B.

An interview was conducted with S1CEO on 9/14/16 at 9:30 a.m. He confirmed none of the Emergency room Physicians and/or NPs from Hospital A are credentialed by Hospital B.

Based on record review and interview, The Governing Body's failure 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 laboratory, radiology, respiratory, rehabilitation services, and pharmacy. 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.

Hospital B is a hospital within a hospital and has a lease and purchase service agreement with Hospital A, who is the host hospital.

Review of the Lease and Purchase Service Agreement dated 06/11/02 between Hospital A and Hospital B revealed in part, Leased space and Cost for Services and Supplies, Pharmacy, Lab, Physical Therapy,...Radiology,...Respiratory...With regards to Code Blue situations: When to Respond: Upon request Who is to Respond: Emergency Room Physicians, Laboratory Personnel and Respiratory Personnel (from Hospital A).

An interview was conducted with S10Lab on 9/13/16 at 12:30 p.m. She reported she was the Lab Director for Hospital A. S10Lab indicated that her staff from Hospital A also work in Hospital B at the same time. She explained that the lab technicians perform venipunctures on the patients in Hospital A and on patients in Hospital B while working on the same shift at Hospital A.

Review of the contract between the host hospital (Hospital A) and Hospital B revealed no specific information on how the laboratory at Hospital A would provide services to Hospital B.

An interview was conducted with S11Pharmacy on 9/13/16 at 12:40 p.m. He reported he was the Pharmacy Director for Hospital A. S11 indicated that his pharmacist at Hospital A concurrently functions as the pharmacist at Hospital B at the same time. He explained that Hospital A's pharmacists supply the medication, review the patients' medication orders and stock the medication automated distribution units for Hospital B.

An interview was conducted with S13RehServices on 9/13/16 at 12:45 p.m. She reported she was the Director of Rehabilitation Services at Hospital A. She further reported her therapists evaluated all the patients in Hospital B and provided therapy in their rooms or in Hospital A's gym. This service is provided by the therapist to Hospital B's patients while also providing services to Hospital A's patients. There are times when Hospital A's patients are co-mingled with Hospital B's patients when therapy services are being provided.

An interview was conducted with S14RAD 9/14/16 at 3:20 p.m. He reported he was the Director of Radiology for Hospital A. He reported Hospital A staff will go to Hospital B and transport patients to Hospital A's radiology department to perform radiological procedures. This is all done concurrently while working for Hospital A.

An interview was conducted with S22RT on 9/15/16 at 8:15 a.m. He reported he was the Director of Respiratory Services for Hospital A. He reported his respiratory therapists provide respiratory services including ventilatory care for the patient's in Hospital B while concurrently providing care for patients in Hospital A. He reported he considered Hospital B another patient floor to Hospital A.

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 during code blue (cardiopulmonary arrest) procedures. Findings:

Review of Hospital B's Current Code Blue policy, Policy # CL-1.10, revealed in part, The hospital will have trained personnel available to respond to a cardiopulmonary emergency in an expeditious and organized fashion...Procedure: A. Code Blue Team Organization. 1. Staff member that are ACLS providers create the code team. The Code Blue Team, identified on shift by shift basis, consists of an ACLS RN and ACLS Respiratory Therapist, who respond to to all Code Blue Situations...2. ACLS Staff Responsibilities: a. Registered Nurse: Assumes Team Leader Role and Initiates ACLS protocols. b. Respiratory Therapist: Assumes ventilatory responsibilities, to include emergency intubation...D1...The Team Leader RN is responsible for taking steps to secure immediate medical direction. Until a physician assumes responsibility for medical direction, the ACLS RN has the authority to initiate and/or supervise appropriate definitive emergency therapy...

Review of the Hospital's Code Blue policy, Policy #CL -1.10 revealed no indication the emergency room physicians, nurses, and respiratory therapist from the host hospital, Hospital A, were running and conducting the emergency cardiopulmonary arrests for Hospital B.

An interview was conducted with S3IC/QA on 9/13/16 at 3:15 p.m. She reported the Code Blue process in the hospital as once an emergency is identified with a patient the staff starts CPR and brings the code cart to the patient's room. A code is called over the intercom, which includes Hospital A and Hospital B. The emergency room physicians, nurses and respiratory therapists from Hospital A come to the code. The emergency room physician from Hospital A runs the code. Sometimes the nurses from Hospital B participate in the code and sometimes the nurses from Hospital A participate. S3IC/QA identified the need to revise the hospital's Code Blue policy because it did not match the current practice in the hospital.

Based on record review and interview, the hospital failed to have ongoing quality assurance program that measured, analyzed and track quality indicators as evidenced by failing to be able to produce the quality assurance information from the previous quality assurance committee in order to assess and analyze progress of the current services and operations of the hospital. Findings:

Review of the Quality Improvement Committee minutes revealed minutes from one meeting in April 26, 2016. The meeting reviewed Turnover rate, Medical Record Deficiencies rate, Infections, Disaster Plans, Fire Drills, Utilization Review, Drug error/Drug reactions, Employee Health, Falls, Joint Commission, and Patient Surveys information.

An interview was conducted with S3IC/QA on 9/14/16 at 4:30 p.m. She reported she was unable to locate any information on Quality Assurance from the prior administration. She further stated she was only able to locate the meeting minutes from April 2016. S3IC/QA reported she took over the position approximately two months ago.

Based on record review and interview, the Governing Body failed to have the Quality Assurance Performance Improvement Plan reflect the complexity of the hospital services as evidenced by not including the following contracted services: Radiology, Laboratory, Housekeeping, Linens, Dietary and Pharmacy. Findings:

Review of the hospitals Strategic Quality Plan revealed in part, This Strategic Quality Plan (SQP) is our roadmap to achieving the level of Operational Excellence needed to realize that vision. It is collaborative effort of corporate, hospital, medical staff, and division leadership, which applies to all departments, services and practitioners throughout the hospital. The SQP is the central performance improvement plan in the organization and encompasses the inter-related functions and processes of clinical, governance, operational and support services....Formal Governance Structure, Governing Body: The ultimate responsibility for performance improvement rest with the Hospital governing board. The authority and responsibility for the day-to-day operations and performance improvement activity is delegated to the hospital quality council and hospital leadership, including the leadership of the Medical Executive Committee.

Review of the current Key Performance Indicators-Clinical Quality-August 2016, provided by S1CEO as the current indicators being monitored by QA revealed the following contracted services were not included: Pharmacy, Linen, Housekeeping, Laboratory, Dietary and Radiology.

An interview was conducted with S1CEO on 9/14/16 at 10:00 a.m. He reported that Pharmacy, Lab, Dietary, Housekeeping, Linen and Radiology report to the Quality Assurance Committee at the host hospital (Hospital A), but does not participate in the QAPI at Hospital B.

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) Failure to ensure each patient was assessed at least every 24 hours by the 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 4 of (#1, #2, #3, #4) 5 current sampled patient records reviewed for RN assessments.

2) Failure to ensure staff assigned to monitor telemetry patients were continuously monitoring the current inpatients on telemetry monitoring. This deficient practice had the potential to affect 5 (#1, #3, #4, #5 & R1) current patients reviewed for telemetry/cardiac monitoring out of a total of 8 patients currently on telemetry monitoring in the hospital.

3) Failure to ensure patients were weighed daily as ordered by the physician for 4 (#1, #3, #4, #5) of 5 patients reviewed for daily weight orders.
Findings:

1) Failure to ensure each patient was assessed at least every 24 hours by the 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.
Review of the Louisiana State Board of Nursing's "Administrative Rules Defining RN Practice LAC46:XLVII" revealed, in part,
"3703. Definition of Terms Applying to Nursing Practice ... Delegating Nursing Interventions - ... The registered nurse retains the accountability for the total nursing care of the individual. ... The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems.
The assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required.
a. Any situation where tasks are delegated should meet the following criteria: i. the person has been adequately trained for the task; ii. the person has demonstrated that the task has been learned; iii. the person can perform the task safely in the given nursing situation; iv. the patient's status is safe for the person to carry out the task; v. appropriate supervision is available during the task implementation; vi. the task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all.
b. The registered nurse may delegate to licensed practical nurses the major part of the nursing care needed by individuals in stable nursing situations, i.e. (that is), when the following three conditions prevail at the same time in a given situation: i. nursing care ordered and directed by R.N./M.D. (medical doctor) requires abilities based on a relatively fixed and limited body of scientific fact and can be performed by following a defined nursing procedure with minimal alteration, and responses of the individual to the nursing care are predictable; and ii. change in the patient's clinical conditions is predictable; and iii. medical and nursing orders are not subject to continuous change or complex modification..."

Review of the Hospital's policy on Nursing Assignments, Policy A103.01.00 revealed in part, ...3. The RN assesses the patient's needs, plans the nursing care, and documents the plan of care...6. The RN will evaluate the care of the patient...

Review of the Hospital's policy on Nursing Staff Responsibilities, Policy A 107.00.00 revealed in part, ... All nursing staff members are required to work within their scope of practice...The responsibilities of each registered nurse will include, but are not limited to the following: a. Assessment of patients, initial and ongoing.


Patient #1
Review of the medical record for Patient #1 revealed the patient was admitted to the hospital on 09/08/16 admitting diagnoses included: Infected Surgical Incision; Associated Dx: Dementia, Neuropathy, Insomnia, GERD, HTN, A-fib, CHF. Review of her Daily Nursing Assessment revealed on 09/10/16 & 09/11/16 the nursing assessment was performed by LPNs. The Daily Nursing Assessment was noted to have a RN signature (RN Assessment/Care Plan Review) with no documentation of an assessment completed by the RN in the 24 hour period.


Patient #2
Review of the medical record for Patient #2 revealed the patient was admitted to the hospital on 12/09/15 with the diagnoses of Large Sacral Decubitus Ulcer, Osteomyelitis, and End Stage Renal Disease. During her hospital stay she experienced a cardiopulmonary arrest and was transferred to the host hospital's Intensive Care Unit for a higher level of care on 01/06/16. Review of the Daily Nursing Assessment dated 12/10/15, 12/12/15, 12/14/15, 12/15/15, 12/18/15, 12/19/15, 12/20/15, 12/23/15, 12/28/15, and 12/29/15 revealed the nursing assessments on the above 24 hour periods were performed by LPNs. The Daily Nursing Assessments were noted to have a RN signature (RN Assessment/Care Plan Review) with no documentation of an assessment completed by the RN in the 24 hour period.

An interview was conducted with S3IC/QA on 9/14/16 at 1:00 p.m. She reported the registered nurse charge nurse on the night shift is suppose to sign the Daily Nursing Assessment Sheet if an RN has not taken care of the patient in a 24 hour period. When questioned what the signature meant, she reported it meant the RN agreed with the LPN's assessment of the patient. When questioned about the documentation of the assessment by the RN and the time of the RN assessment, S3IC/QA reported there was no documentation, just a signature of the RN. She confirmed Patient #2 above dated Nursing Assessments were performed by LPNs and there was no documented evidence of a RN assessment.


Patient #3
Review of the medical record for Patient #3 revealed the patient was admitted to the hospital on 09/02/16 admitting Primary Diagnoses included: Post-Op. Resp. Failure/Acute Kidney Disease/Groin Perineum 2nd Chronic kidney disease stage II. Review of his Daily Nursing Assessment revealed The Daily Nursing Assessments dated 09/03/16, 09/04/16, 09/05/16, 09/07/16, 09/08/16, 09/10/16, 09/11/16 & 09/12/16 were performed by LPNs. The Daily Nursing Assessment was noted to have a RN signature (RN Assessment/Care Plan Review) with no documentation of an assessment completed by the RN in the 24 hour period. Next to the Registered Nurse signature was a typed message stating "RN signature required if not assigned to an RN in 24 hour period".


Patient #4
Review of the medical record for Patient #4 revealed the patient was admitted to the hospital on 08/19/16 admitting diagnoses included: Acute Kidney Injury, ( HD 07/16), Multivessel coronary artery disease with severe mitral regurgitation, respiratory failure (tracheostomy). Review of her Daily Nursing Assessment revealed on 08/26/16, 08/27/16, 08/28/16, 08/31/16, 09/09/16 & 09/10/16, the nursing assessment was performed by LPNs. The Daily Nursing Assessment was noted to have a RN signature (RN Assessment/Care Plan Review) with no indication if the patient was assessed by the RN within a 24 hour period.

In an interview on 09/15/16 at 8:30 a.m., S16RN indicated that all patients are to be assessed by an RN at least every 24 hours. S16RN indicated that if a LPN is assigned to a patient for both shifts (12 hrs.), the RN must perform an assessment. S16RN indicated that a RN would co-sign The Daily Nursing Assessment if he/she agreed with the LPN's assessment. S16RN indicated that if the RN disagreed with the assessment and/or had any changes the RN would document any disagreement and/or changes in the narrative nurses notes. S16RN indicated that the above Patients #1, #3 and #4 were assigned to LPNs on the stated dates and The Daily Nursing Assessment was co-signed by a RN. S16RN indicated there was no evidence that the patients were assessed by a RN within a 24 hour period.


2) Failure to ensure staff assigned to monitor telemetry patients were continuously monitoring the current inpatients on telemetry monitoring.

Review of the Hospital's Policy & Procedure titled " Telemetry Monitoring Admission, Discharge, Criteria" presented as being current (7/14) read in part: 9. The Tele Monitor Tech will inform the patient's primary nurse of any irregular or malignant arrhythmia noted on the telemetry patient.


Patient #1
Review of Patient #1's medical record revealed the patient was admitted to the hospital on 09/08/16 admitting diagnoses included HTN, A-fib, CHF. Further review revealed an admission order, dated 09/08/16 for telemetry monitor.

Patient #3
Review of Patient #3's medical record revealed the patient was admitted to the hospital on 09/02/16 admitting Primary Diagnoses included: Post-op. Resp. failure/Acute Kidney Disease/groin perineum 2nd Chronic kidney disease stage II. Further review revealed an admission order, dated 09/02/16 for telemetry monitor.

Patient #4
Review of the Patient #4's medical record revealed the patient was admitted to the hospital on 08/19/16 admitting diagnoses included Multivessel coronary artery disease with severe Mitral regurgitation. Further review revealed an admission order, dated 08/19/16 for telemetry monitor.

On 09/14/16 from 11:00 a.m.- 11:55 a..m., an observation of the central telemetry monitors (located in the nursing station) revealed the following:
11:03 a.m., S49MT was sitting at the front desk with the telemetry monitors to her right side on the corner of the nurses' station. S49MT was noted to be placing a patient's record together and not observing the telemetry monitors at the time of this observation.
11:05 a.m., S49MT exited the nurses' station. S16RN was observed sitting at the station with her back to the monitors.
11:08 a.m. - 11:15 a.m.., S16RN was noted to be facing away from the telemetry monitors.
11:25 a.m.- 11:28 a.m., No staff present in the station.
11:31 a.m.- 11:41 a.m., S49MT in the station (answering the phone & call lights) and at no time was observed to be looking in the direction of the monitors.
11:41 a.m., S49MT briefly exited the station and walked in the hall toward the nourishment room. 11:43 a.m.. She returned. No staff was present at the station.
11:45 a.m., S49MT was observed walking to the back of the station near the sink. No one observed watching the telemetry monitors.
11:48 a.m., S49MT turned her duties over to S42MT.
11:55 a.m., S42MT was observed in the back area of the station transferring medical records to the chart rack. Not observing the telemetry monitors.

Observations on 09/15/16 of the telemetry monitors revealed from 9:00 a.m. to 9:22 a.m., S49MT was answering the phone, talking to visitors/staff, pulling patients' medical records (for physician), transcribing orders and not looking in the direction of the monitors.

In an interview on 09/14/16 at 12:30 p.m., S16RN indicated S42MT and S49MT responsibilities included monitoring of patients on telemetry. S16RN indicated that the MTs observed the telemetry monitor and reports any problems and/or changes to the patient's nurse or the Charge Nurse. S16RN indicated that it is the responsibility of the Charge Nurse to observe the telemetry monitors during the MT's lunch time. S16RN indicated that if the MT steps away from the desk it is the responsibility of any nurse who is in the station to observe the monitors.

In an interview on 09/15/16 at 11:35 a.m., S2CNO indicated that the responsibilities of S42MT and S49MT as monitor technicians include printing out strips (telemetry) and placing them in the medical records (telemetry), notifying the nurse if the patient was off the monitor and of changes with rhythms. S2CNO indicated they were also responsible for assisting with answering the phones and call lights. S2CNO indicated that continuous monitoring of patients on telemetry was not provided by the nursing staff.

In an interview on 09/15/16 at 12:05 p.m., S49MT indicated that her duties as a Unit Secretary and Monitor Technician included taking off doctor's orders, faxing orders if needed, putting in lab orders, putting in radiology orders, putting in orders for consultations, maintaining nourishment supplies, maintaining patient care supplies, answering phones and call lights, thinning charts and monitoring patients on telemetry. S49MT indicated that she is able to manage her Unit Secretary duties and still monitor the patients on telemetry because the monitor alerts (alarms) when something is wrong. During the interview, S49MT indicated there were currently 8 patients on telemetry monitoring. Observations at the time of this interview revealed 7 patients' tracing on the central telemetry monitor screen. After checking, S49MT indicated that R#1 had no visual tracing. S49MT indicated that R#1 was in physical therapy and was off the telemetry monitor at the time of the observation. When asked what time the patient was taken off the telemetry monitor, S49MT paged S44CNA to check R#1's room. At this time, a telemetry tracing appeared for R#1 with no formed wave complex (QRS).

In an interview on 09/15/26 at 12:15 p.m., S44CNA indicated that after checking R#1 was in her room (in bed). S44CNA indicated that one of the patient's electrodes on the top of her chest was off and she replaced it.

In an interview on 09/15/16 at 12:20 p.m., S43LPN indicated that she was the nurse assigned to R#1 and she was not sure when the patient went to/returned from Physical Therapy. S43LPN indicated that R#1 was in her room at 10:50 a.m. and she had directed the therapist to place R#1 back on telemetry. S43LPN indicated that she was not aware that R#1 was not on telemetry monitoring until it was brought to her attention by the surveyor. S43LPN indicated that once the therapist returned R#1 to her room she never checked the telemetry monitor.

3) Failure to ensure patients were weighed daily as ordered by the physician for 4 (#1, #3, #4, #5) of 5 patients reviewed for daily weights.

Review of the Hospital's Policy & Procedure titled "Weight Policy" presented as being current (05/10) read in part: Procedure: 2. All daily weights are to be completed by the 11-7 Nursing Assistants. 6. Bedbound patients may be weighed on a bed scale. 7. Weights are recorded on the Graphic Records or Daily Weight Sheet by the nurse.

Patient #1
Review of the admission orders for Patient #1 revealed an order for daily weights. Further review of documented daily weights revealed no documented weights on 09/09/16, 09/10/16, 09/11/16, 09/12/16 and 09/15/16.

Patient #3
Review of the admission orders for Patient #3 revealed an order for daily weights. Further review of documented daily weights revealed no documented weights on 09/04/16, 09/06/16, 09/09/16, 09/10/16, 09/11/16, 09/12/16 and 09/13/16.

Patient #4
Review of the admission orders for Patient #4 revealed an order for daily weights. Further review of documented daily weights revealed no documented weights on 09/02/16, 09/03/16, 09/05/16 and 09/14/16.

Patient #5
Review of the admission orders for Patient #5 revealed an order for daily weights. Further review of documented daily weights revealed no documented weights on 09/05/16, 09/06/16, 09/11/16 and 09/14/16.

In an interview on 09/15/16 at 8:45 a.m., S16RN confirmed that there was no documented evidence of daily weights for Patient #1, #3, #4 and #5 on dates listed above.







31206

Based on record review and interview, the hospital failed to ensure the organization of the medical record services was appropriate to the scope and the complexity of services provided as evidenced by failing to ensure the medical records department was under the supervision of a qualified individual. Findings:

Review of the hospital policy, Scope of HIM Department, HIM-1.0, revealed in part, Purpose: To delineate the duties and responsibilities of the Health Information Management (HIM) Department. The HIM Department is staffed by trained personnel who cover the department during regular business hours... Conducts qualitative and quantitative analysis of each patient's medical record to assure it consistency and timely completeness.

An interview was conducted with S1CEO on 9/15/16 at 9:00 a.m. He reported currently the Medical Records duties are handled by different employees. S3IC/QA audits the medical records and S47HR handles the patients' medical information requests. When questioned on who was over Medical Records, S1CEO reported he guessed he was.

Review of S1CEO's personnel file revealed no training or experience in Health Information Management.

An interview was conducted with S3IC/QA on 9/15/16 at 11:00 a.m. When questioned if she audited medical records for completeness and/or deficiencies she reported she did not.

Based on observations and interview, the hospital failed to protect patients' medical records from fire and water damage as evidenced by storing patients' medical records on open shelving and on the floor in sprinkled rooms. Findings:

An observation was conducted on 9/15/16 at 9:30 a.m. of the medical records department. The medical records were kept on open shelving in a sprinkled room not protected from water and fire damage.

An interview was conducted with S46Case Manager on 9/15/16 at 9:30 a.m. She reported approximately one year worth of medical records are kept on the open shelving.

An observation was conducted on 09/15/16 at 9:35 a.m. of approximately 30 medical records stacked on the floor in the physicians' dictation room. The physician's dictation room was sprinkled. The medical records were not protected from water and fire damage.

Based on record review and interview, the hospital failed to meet the Condition of Participation for Pharmaceutical Services as evidenced by

1. Failing to ensure a pharmacist was responsible for developing, supervising and coordinating pharmacy services while not concurrently working for the host hospital (Hospital A). (See findings in A0492)

2. Failing to have facility specific policies/procedures relative to pharmaceutical services. (See Findings in A0492).

Based on record review and interview, the hospital failed to ensure a pharmacist was responsible for developing, supervising and coordinating pharmacy services while not concurrently working for the host hospital (Hospital A). Findings:

Review of the hospital's policies for Pharmacy revealed the policies were not specific for Hospital B. The policies were specific to Hospital A and did not address Pharmacy services being supplied for Hospital B.

An interview was conducted with S11Pharmacy on 9/13/16 at 12:40 p.m. He reported he was the Pharmacy Director for Hospital A. He further reported his pharmacist for Hospital A staffed Hospital B at the same time, working simultaneously for both hospitals. Hospital A's pharmacists supplied the medication, reviewed the patients' medication orders and stocked the medication automated distribution units. S11Pharmacy reviewed Hospital B's policy which was provided as being the current policies for Hospital B and reported he had not seen these policies before. S11Pharmacy reported they used the policies from Hospital A.

Based on record review and interview, the hospital failed to ensure radiology services were provided independent of the host hospital (Hospital A) by failing to ensure radiology services were not provided by staff concurrently working at the host hospital (Hospital A). Findings:

Review of the hospital's policies for Radiology revealed the policies were not specific for Hospital B. The policies were specific to Hospital A and did not address Radiology services being supplied for Hospital B.

An interview was conducted with S10MD 9/14/16 at 3:20 p.m. He reported he was the Director of Radiology for Hospital A (Host Hospital). He reported his staff goes to Hospital B and transports patients to the radiology department to perform radiological procedures. He also reported the staff at Hospital B does not accompany the patients to the radiology department. This is all done concurrently while working for Hospital A.

Based on record review and interview, the hospital failed to develop policies and procedures that addressed safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures. Findings:


Policies and procedures for radiology services were requested from Hospital B, the hospital was unable to provide any policies or procedures that addressed safety precautions against radiation hazards for their staff or patients.

An interview was conducted with S3IC/QA on 9/14/16 at 3:40 p.m. She reported she was unable to locate any policies for radiology services for the hospital.

An interview was conducted S14Rad on 9/14/16 at 3:20 p.m. He reported he was the Director of Radiology for the host hospital (Hospital A). He further reported he has never seen or reviewed radiology policies for Hospital B, he uses the policies from Hospital A (Host Hospital).

Based on record review and interview, the hospital
1. failed to have facility specific policies/procedures relative to laboratory services and
2. failed to provide laboratory services without the staff concurrently working for the host hospital.

Finding:
1. failed to have facility specific policies/procedures relative to laboratory services and

Review of the Laboratory Policies presented by Hospital B revealed the policies were not specific for the hospital.

An interview was conducted with S10Lab on 9/14/16 at 3:15 p.m. She reviewed the Lab policies presented by Hospital B to the surveyor as the current Lab procedures. She reported she had never seen the policies before. She further stated the policies were general and must be Corporate policies for Hospital B. She indicated the policies were not specific to Hospital B's services.

2. failed to provide laboratory services without the staff concurrently working for the host hospital

An interview was conducted with S10Lab on 9/13/16 at 12:30 p.m. She reported she was the Lab Director for Hospital A. She further reported her staff worked in Hospital A as well as Hospital B at the same time. She also reported the lab technicians would perform venipunctures on the patients in Hospital A and Hospital B on the same shift.

Review of the contract between the host hospital (Hospital A) and Hospital B revealed no specific details on how Hospital A would provide lab services to Hospital B.

Based on record reviews and interview, the hospital failed to ensure that the designated Infection Control Officer was qualified through experience, ongoing education and/or training to be responsible for the development and implementation of the hospital's Infection Control Program. Findings:

Review of the current Job Description for Lead Infection Control revealed in part, Education and/or Experience...Minimum of six months of Infection Control experience in an institutional environment with supervisory or management responsibilities. Minimum three years experience in epidemiology principles and infection control principles.

Review of S3IC/QA personnel record revealed she was hired in the last 3 months as the hospital infection control officer. With further review of S3IC/QA personnel record revealed she was orientated on 8/9/16 and 8/10/16 at a sister hospital in Texas for her job duties in Infection Prevention Program, QAPI, Patient Safety Program, Employee Health and Safety and Risk Management.

An interview was conducted with S3IC/QA on 9/14/16 at 9:30 a.m. She reported she had no formal training in infection control and no previous training or experience in infection control except for her two day orientation related to her current job title.

31206


Based on observations and interview, the hospital failed to ensure the infection control officer developed a system for investigating and controlling infections and communicable diseases of patients and personnel as evidenced by:
1) failing to ensure the hospital staff followed acceptable infection control standards of practice regarding patients requiring contact precautions.
2) failing to ensure that staff prevented contamination of IV lines after administration of IV antibiotics.
3) failing to provide a sanitary environment.
Findings:

1) failing to ensure the hospital staff followed acceptable infection control standards of practice regarding patients requiring contact precautions:

An observation on 09/15/16 at 9:50 a.m. of Patient #1's room revealed signage on the door indicating that Patient #1 was on contact precautions. An isolation caddy was also noted hanging on the patient's door with PPE items in it. An isolation gown was noted to be hanging on a hook near two plastic containers.

In an interview at the time of the observation, S16RN indicated an isolation gown hanging in the room was used and should have been placed in the soiled linen receptacle (Patient's room) after one use. S16RN removed the gown placing it in the soiled linen receptacle in the patient's room.


2) failing to ensure that staff prevented contamination of IV lines after administration of IV antibiotics (sterility with IV lines after completion of IV piggyback).

Observation on 09/15/16 at 9:50 a.m., of Patient #1's room revealed IV tubing (primary) hanging with a piggyback (Meroprnem 500 mg IV every 8 hours) which was last administered at 7:00 a.m. The tubing was noted to be disconnected from the central line and the patient end of the tubing was not properly capped. The patient end of the tubing was stuck in the top port of the piggyback after disconnection. At the time of this observation, S16RN confirmed that the IV tubing was contaminated and was available for use by staff at next administration time (3:00 p.m.). S16RN indicated that the patient connector end should have been capped off with a sterile adapter cap. S16RN discarded the IV set in the trash. S16RN indicated that the used isolation gown and the contaminated IV tubing was a breech in Infection Control Practices. An interview on 09/15/16 at 11:10 a.m., S2CNO indicated the hospital had no Policy & Procedure on IV maintenance which addressed the proper way to maintain sterility of tubing used on heparin lock flushes. S2CNO indicated that changing the tubing and the connection and disconnection of IV piggybacks are understood infection control practices. S2CNO indicated that all IV tubings when not in use and are to be used again, should be capped off with a sterile cap.

3) Failing to provide a sanitary environment.

An observation was conducted on 9/13/16 at 11:00 a.m. of Room "a". The silver metal paper towel dispenser and the safety railing in the bathroom were noted to have surface rust. In addition, there was a caked white substance on the head of the nozzle on the hopper.

An observation was conducted on 9/13/16 at 11:05 a.m. in the Clean Utility Room of a clean bed top stored on the floor.

An observation was conducted in the Nutrition Room on 9/13/16 at 11:10 a.m. There was a dark substance on the floor around the bottom of the refrigerator and there was debris on the floor.

An observation was conducted on 9/13/16 at 11:15 a.m. of the bathroom in Room "b". The faucet in the tub had a white hard substance caked on the faucet resulting in the inability to ensure for disinfection.

An observation was conducted on 9/13/16 at 11:20 a.m. of Room "c". A built-in bench covered with vinyl was in the room for guests. The vinyl on the bench was ripped resulting in the inability to ensure for disinfection. The wall unit had exposed particle board which was also unable to be disinfected.

The above observations were confirmed by S3IC/QA.

Based on record review and interview, the hospital failed to ensure there was adequate emergency room physicians/practitioner coverage between the Host hospital and the Hospital within a Hospital. Findings:

Review of the Emergency Room Call Schedule for Hospital A (Host Hospital) revealed for June, July and August 2016 an Emergency Room Physician covered from 6 a.m. to 6 p.m. and then another physician took over the Emergency Room from 6 p.m. to 6 a.m. An APRN worked from 10 a.m. to 8:00 p.m. and another APRN worked from 2 p.m. to 12:00 a.m. With review of the schedule of emergency services revealed from 12:00 a.m. to 10:00 a.m. only one Emergency Room practitioner was available for emergences in the host hospital (Hospital A) and the hospital within a hospital, Hospital B.

An interview was conducted with S12CNO Host Hospital on 9/13/16 at 1:00 p.m. She reported the she was the Chief Nursing Officer for the Host Hospital (Hospital A). She further stated Hospital A has a contract with a Emergency Physician Group to provide emergency services in Hospital A and B. When questioned about the services offered by Hospital A, she reported the hospital has a 12 bed Intensive Care Unit and the average emergency room visits per month are between 2300- 2700 a month. With review of the Emergency Room schedule for Hospital A with S12CNO, she confirmed there was a 10 hour time period where there was only one ED physician/practitioner covering the Emergency Room for Hospital A and Hospital A's inpatients and Hospital B's inpatients. When questioned if there was a policy related to if two emergencies occurred simultaneously at Hospital A and Hospital B, she reported there was not a policy.

Based on record review and interview, the hospital failed to ensure emergency services policies and procedures were evaluated, updated and revised on an ongoing basis. Findings:

Review of Hospital B's Current Code Blue policy, Policy # CL-1.10, revealed in part, The hospital will have trained personnel available to respond to a cardiopulmonary emergency in an expeditious and organized fashion...Procedure: A. Code Blue Team Organization. 1. Staff member that are ACLS providers create the code team. The Code Blue Team, identified on shift by shift basis, consist of an ACLS RN and ACLS Respiratory Therapist, who respond to to all Code Blue Situations...2. ACLS Staff Responsibilities: a. Registered Nurse: Assumes Team Leader Role and Initiates ACLS protocols. b. Respiratory Therapist: Assumes ventilatory responsibilities, to include emergency intubation...D1...The Team Leader RN is responsible for taking steps to secure immediate medical direction. Until a physician assumes responsibility for medical direction, the ACLS RN has the authority to initiate and/or supervise appropriate definitive emergency therapy...

An interview was conducted with S3IC/QA on 9/13/16 at 3:15 p.m. She reported the Code Blue process in the hospital was once a emergency is identified with a patient the staff starts CPR and brings the code cart to the patient's room. A code is called over the intercom, which includes Hospital A and Hospital B. The emergency room physicians, nurses and respiratory therapists from Hospital A come to the code. The emergency room physician from Hospital A runs the code. Sometimes the nurses from Hospital B participate in the code and sometimes the nurses from Hospital A participate. S3IC/QA identified the need to revise the hospital's Code Blue policy because it did not match the current practice in the hospital.

With review of the Hospital's Code Blue policy, Policy #CL -1.10 revealed no indication the emergency room physicians, nurses, and respiratory therapist from the host hospital, Hospital A, were running and conducting the emergency cardiopulmonary arrests for Hospital B.

Based on record review and interview, the hospital failed to ensure rehabilitation services performed under contract were provided in an effective manner independent of the host hospital (Hospital A) by failure to ensure services were not provided by staff concurrently working at the host hospital (Hospital A) and the hospital had specific policies for rehabilitation services. Findings:

Review of the policies for Rehabilitation Services revealed the policies were not specific for the hospital.

An interview was conducted with S13RehServices on 9/13/16 at 12:45 p.m. She reported she was the Director of Rehabilitation Services at Hospital A. She further reported her therapists evaluated all the patients in Hospital B and provided therapy in their rooms or in Hospital A's gym. This service is provided concurrently by the therapist while providing services in Hospital A.

An interview was conducted with S13RehServices on 9/14/16 at 2:00 p.m. She reviewed the hospital's rehabilitation services policies and stated she had not seen the policies before, she uses the Host Hospital's policies.

Based on record review and interview, the hospital failed to ensure Respiratory Services performed under contract were provided in an effective manner independent of the host hospital (Hospital A) by failure to ensure services were not provided by staff concurrently working at the host hospital and the hospital failed to ensure the hospital had specific policies for Respiratory Services. Findings:

Review of the hospital's policies for respiratory services revealed the policies and procedure were not specific for the hospital.

An interview was conducted with S22RT on 9/15/16 at 8:15 a.m. He reported he was the Director of Respiratory Services for Hospital A. He reported his respiratory therapists provide respiratory services including ventilatory care for the patient's in Hospital B while concurrently providing care for patients in Hospital A. He reported he considered Hospital B another patient floor to Hospital A. S22RT further reported with review of Hospital B's respiratory care policies he stated he was not familiar with these policies and the policies looked like corporate policies. S22RT reported he used the host hospital's policies and integrated some specific policies for Hospital B into the host hospital's policies. He went on to say he was not sure if the policies he used had been approved by the Governing Body of Hospital B.