HospitalInspections.org

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

1) failure of the Governing Body to appoint a radiologist to serve as Director of the hospital's contracted Radiological Services. (See findings tag A-0546).

2) failure to develop policies and procedures to provide for the safety and health of patients and hospital personnel, to protect them from radiation hazards, during radiological procedures performed at the hospital. (See findings in tag A-0536).

30984

Based on contract review, record review, and interview, the hospital failed to ensure all physician's providing services to the hospital were credentialed and granted appropriate privileges when telemedicine services were furnished for radiological services. This deficient practice was evidenced by failure of the hospital to ensure that each physician furnishing radiological telemedicine services was granted privileges at the hospital for 3 (S6MD,S7MD,S8MD) of 3 physicians reviewed that had interpreted x-rays at the hospital.

Findings:

Review of the hospital's contracted services revealed a contract with an area mobile x-ray company to provide on location radiological services. Further review revealed the mobile x-ray service would provide on location mobile x-ray services and board certified specialists making interpretations. Additional review of the contract revealed, in part, the following addendum (dated 2/27/14): The Governing Body of the hospital whose patients are receiving the telemedicine services may, in accordance with section 482.22 (a) (4) of this part, grant privileges to physicians and practitioners employed at the distant telemedicine entity based upon such hospital's medical staff recommendations, such recommendations may rely on information provided by the distant site telemedicine entity.

Review of Patient #2's medical record revealed she had x-rays dated 8/30/16 and 9/7/16 that had been interpreted by S7MD.

Review of Patient #3's medical record revealed the patient had an x-ray dated 08/30/16 that had been interpreted by S6MD.

Review of Patient #4's medical record revealed the patient had an x-ray dated 9/4/16 that had been interpreted by S6MD.

Review Patient #5's medical record revealed a chest x-ray dated 8/24/16 had been interpreted by S6MD.

Review of Patient #6's medical record revealed the patient had an x-ray dated 09/08/16 that had been interpreted by S8MD.

Review of Patient #7's medical record revealed the patient had an x-ray dated 9/5/16 that had been interpreted by S6MD.


Review of a list of the hospital's credentialed physicians revealed the above mentioned radiologists did not have privileges at the hospital.

In an interview on 9/12/16 at 2:45 p.m. with S5HR, she verified S6MD, S7MD, and S8MD were not privileged at the hospital.

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient. This deficient practice is evidenced by failing to ensure registered nurses were obtaining admission orders from an admitting licensed practitioner prior to writing the admission orders in the medical record for 1 (#4) of 10 current patients reviewed for admission orders.

Findings:

Review of a document titled Standing Admission Orders revealed the following orders had to be selected by the person filling out the form: Diet, vital sign frequency, weight frequency, diagnostic test (x-ray), labs, consults, weight bearing status, precautions, specialty equipment, safety devices, blood glucose frequency, sliding scale coverage, continuing home medications, and oxygen.

In an interview on 9/12/16 at 1:44 p.m. with S9RN, she said she had filled out the admission orders sheet on 9/2/16 for Patient #4. S9RN said she based the selections on the pre-printed order form from Patient #4 ' s discharge records from another hospital. S9RN also said the doctor would usually come in later in the evening or the next day and sign the order sheet. S9RN said she filled out the whole sheet and did not get the choices or orders from a physician. S9RN verified she always completed the admission orders that way. S9RN said the physician knew the patients were being admitted but she would only ask the physician which orders to select on the admission orders if she had a question about something.

In an interview on 8/12/16 at 2:05 p.m. with S2DON, he said the nurses should have been notifying the physician to obtain the admission orders instead of the nurses making the choices on the admission order sheet.

Based on observation and interview, the hospital failed to ensure patients' medical records were stored where they were protected from water damage as evidenced by ten cardboard boxes of medical records being stored on top of filing cabinets in a room that was sprinklered.

Findings:

Observation on 9/12/16 at 4:03 p.m. of the medical record room revealed 11 cardboard boxes containing paper medical records stacked on the filing cabinets. Further observation revealed the room was sprinklered.

In an interview on 9/12/16 at 4:05 p.m. with S4MedRecords, she said the paper medical records stacked on the filing cabinets in cardboard boxes were not waterproof and would not be protected if the sprinkler was activated or there was a water leak from the ceiling.

Based on record review and interview, the hospital failed to ensure pre-printed protocols were dated, timed and authenticated promptly in the patient's medical record by the ordering practitioner or another practitioner responsible for the care of the patient for 3 (#2,#4,#7) of 8 current patients reviewed for sliding scale insulin orders.

Findings:

Review of Patient #2's admission orders, dated 8/29/16, revealed an order for sliding scale coverage per S10MD's Diabetic Protocol. Further review revealed no signed, dated and timed protocol was in the medical record.
Review of Patient #4's admission orders, dated 9/2/16, revealed an order for sliding scale coverage per S10MD's Diabetic Protocol. Further review revealed no signed, dated and timed protocol was in the medical record.
Review of Patient #7 's admission orders, dated 8/31/16, revealed an order for sliding scale coverage per S10MD's Diabetic Protocol. Further review revealed no signed, dated and timed protocol was in the medical record.

In an interview on 9/12/16 at 4:00 p.m. with S4MedRecords, she verified printed protocols and standing order sets should have been placed into the patients' medical records when the protocol or order set was utilized.

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.

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 After Hours/on Call, Policy Number 1.01, revealed in part:
2. Hours of operation are Monday through Friday 8:00 a.m. to 5:30 p.m. and Saturday 8:00 a.m. to 3:00 p.m.

In an interview on 9/12/16 at 3:15 p.m. with S3LPN, she said when a new medication is ordered at night and they have it in stock, the nurses just obtain the medication and give it to the patient and do not notify the pharmacist.

Review of the medical record for Patient #3 revealed he had an order on 8/30/16 at 10:07 p.m. for Rocephin 2 grams intravenous now and daily times 10 days.

In an interview on 9/13/16 at 10:00 a.m. with S3LPN, she said the Rocephin for Patient #3 was ordered at night and would have been pulled from stock. She said the pharmacist would not be notified of the new medication.

In an interview on 9/13/16 at 9:00 a.m. with S11Pharmacist, she said when a medication is ordered at night, the staff would pull it out of stock if it was available. S11Pharmacist verified the review for appropriateness was done retrospectively the next day by a pharmacist after the first dose had already been given to the patient.

Based on observation and interview, the hospital failed to ensure outdated, mislabeled, or otherwise unusable drugs were not available for patient use as evidenced by 2 of 2 vials of Levophed in the hospital's crash cart being expired.

Findings:

In an observation of the hospital's crash cart on 9/12/16 at 11:45 a.m., two vials of Levophed 1mg/ml were expired as of 9/1/16.

In an interview on 9/12/16 at 11:55 a.m. with S1Adm, she verified the 2 vials of Levophed in the crash cart had expired.

Based on occurrence report review, record review and interview, the hospital failed to ensure drug administration errors were documented in the patients' medical records for 1 (#9) of 2 patients reviewed for medication errors.

Findings:

Review of the hospital's occurrence reports revealed a medication error, involving Patient #9, had been discovered on 3/10/16 at 7:00 p.m. The report indicated Patient #9 had been admitted with positive blood cultures for MRSA. Further review revealed Patient #9 had not received IV Vancomycin (antibiotic) since 3/7/16. The Vancomycin had been ordered twice a day (every 12 hours) for a total of 22 doses. Patient #9 had missed 6 doses of Vancomycin at the time of discovery of the error. The report indicated Patient #9 had received 10 of the ordered 22 antibiotic doses.

Review of Patient #9's medical record revealed no documented evidence of an account of the medication error referenced in the occurrence report.

In an interview on 9/13/16 at 10:45 a.m. with S1Adm, she confirmed there was no
documentation of the medication error referenced above in Patient #9's medical record. S1Adm indicated the hospital had completed an incident report and it was not the hospital's practice to document medication errors in patient records. She further indicated the hospital had no policy directing staff to document an account of a discovered medication error in the patients' medical record.

Based on hospital policy/procedure review and interview, the hospital failed to develop policies/procedures to provide for the safety and health of patients and hospital personnel, to protect them from radiation hazards, during radiological procedures performed at the hospital.
Findings:
Review of the hospital's policies/procedures, presented as current, revealed no documented evidence of written radiological service policies/procedures to provide for the safety and health of patients and hospital personnel, to protect them from radiation hazards, during radiological procedures performed at the hospital.
In an interview on 9/13/16 at 2:15 p.m. with S1Adm, she confirmed the hospital had not adopted written radiological service policies/procedures to provide for the safety and health of patients and hospital personnel, to protect them from radiation hazards, during radiological procedures performed at the hospital.

Based on contract review, organizational chart review, and interview, the hospital failed to ensure Radiological Services were under the direction of a Radiologist as evidenced by failure of the Governing Body to appoint a Radiologist to serve as Director of the hospital's contracted Radiological Services.
Findings:
Review of the hospital's contracted services revealed a contract with an area mobile x-ray company to provide the hospital's on location x-ray services.
Review of the hospital's organizational chart revealed no documented evidence of an appointed Radiologist to serve as Director of the hospital's contracted Radiological Services.
Review of the hospital's list of credentialed physicians revealed no documented evidence of an appointed Radiologist serving as Director of the hospital's contracted Radiological Services.
In an interview on 9/13/16 at 2:15 p.m. with S1Adm, she confirmed the hospital's Governing Body had not appointed a Radiologist to serve as the Director of the hospital's contracted Radiological Services.

Based on record review, interview and observation, the hospital failed to ensure the infection control officer developed a system for controlling infections and communicable diseases of patients and personnel. This deficient practice is evidenced by:

1) failing to ensure a patient (#9) admitted with MRSA (Methicillin-resistant Staphylococcus aureus) bacteremia was placed on contact precautions as per the hospital's policies/procedures for 1 (#9) of 1 patients reviewed with a diagnosis of MRSA;

2) failing to ensure gloves were worn by nursing staff when obtaining a blood sample for blood glucose monitoring and during insulin administration 1 (# 7) of 1 patients observed.

Findings:

1) Failing to ensure a patient (#9) admitted with MRSA (Methicillin-resistant Staphylococcus Aureus) bacteremia was placed on contact precautions as per the hospital's policies/procedures.

Review of the hospital policy titled Infection Control, Isolation System, Policy #: IC4.001, revealed in part: Policy: It is the policy of this hospital to establish and maintain guidelines for isolation precautions of patients with communicable diseases and to establish a protocol/procedure for placing a patient in and removing a patient from isolation.

III. Purpose: .... Isolation guidelines are designed to prevent the spread of microorganisms among patients, personnel and visitors. Since the agent and host factors are more difficult to control, interruption of the chain of infection is directed primarily at transmission.

Procedure: The isolation system chosen by this facility shall consist of 2 major precaution classifications: 1. Standard Precautions: Applies to all patients regardless of their diagnosis or presumed infection status and are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection. Generally, it is not necessary for the attending to write and order for standard precautions, they are to be implemented by all personnel when contact with body fluids or substances is anticipated.

2. Transmission- based Precautions: Designed for patients documented or suspected to be infected with highly transmissible or epidemiological important pathogens for which additional precautions beyond standard precautions are needed to interrupt transmission. The 3 types of transmission based precautions are: a. Airborne precautions, b. Droplet precautions, and c. Contact precautions.

Review of the hospital policy titled Infection Control, Nursing Services, Policy #: IC5.014, revealed in part: Policy: The nursing services department recognizes the impact and responsibility of carrying out the practical aspects of infection prevention and control, as nurses are the only persons throughout the hospital that have direct contact with patients 24 hours a day.
Multi Drug Resistant Organisms: Appropriate clinical practices should be employed into all routine patient care using 4 parallel strategies: Infection prevention, Accurate and prompt diagnosis and treatment, Prevention of transmission. See management of patients with MRSA.

Review of Patient #9 ' s medical record revealed a pre-admission screening assessment, dated 3/1/16, completed by S12IC (infection control) indicating the patient had positive blood cultures for MRSA. Further review of the screening revealed the special needs/precautions section indicating the need for isolation precautions was left blank. Additional review revealed the patient had been admitted on 3/2/16 with an order for Vancomycin (antibiotic) IV every 12 hours for gram positive cocci bacteremia- with MRSA.

Review of Patient #9 ' s admit orders revealed the patient was not placed on contact precautions for his diagnosis of MRSA bacteremia (patient was admitted with positive blood cultures). The section on the admission orders for ordering isolation precautions was left blank.

In an interview on 9/13/16 at 1:30 p.m. with S12IC, she indicated it is the expectation that patients with MDROs, including MRSA, were to be placed on contact precautions. She confirmed Patient #9 should have been placed on contact precautions on admission. She further indicated nursing staff could place a patient on isolation precautions prior to calling the physician for an order. S12IC indicated staff should also call and notify her when a patient was admitted with an active infection requiring isolation precautions.
.
2) Failing to ensure gloves were worn by nursing staff when obtaining a blood sample for blood glucose monitoring and during insulin administration.

Review of the hospital policy titled, Infection Control, Nursing Services, Policy #: IC5.014, revealed in part: Policy: Nursing staff are responsible for functions essential to the prevention, recognition and management of infections. ....This is accomplished by practicing good aseptic technique, observing infection prevention and control policies and procedures and recognizing the potential risks associated with invasive procedures.
1. Adherence to the practice of standard precautions is expected of all nursing staff. Nursing staff serves as a role model for all healthcare workers in the use of personal protective equipment and adherence to established guidelines.

Review of the hospital policy titled, Infection Control , Cleaning of Point of Care Devices, Policy #: IC7.001, revealed in part: Glucometers: Gloves are to be worn when performing the finger stick procedure to obtain the sample of blood and are removed after the procedure, followed by hand hygiene.

On 9/13/16 at 10:50 a.m. an observation was made of S3LPN obtaining a blood sample for blood glucose monitoring, via finger stick, from Patient #7. S3LPN did not wear gloves when obtaining the blood sample for glucose monitoring for Patient #7.

On 9/13/16 at 11:10 a.m. an observation was made of S3LPN administering an insulin injection to Patient #7. S3LPN did not wear gloves when administering the insulin injection to Patient #7.

In an interview on 9/13/16 at 1:30 p.m. with S12IC, she indicated it is the expectation that gloves were to be worn by nursing staff when obtaining blood samples for blood glucose monitoring. She further indicated gloves should also be worn by nursing staff when administering injections.