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Based on record review and interview, the facility failed to meet the Condition of Participation for Governing Body. The hospital's governing body failed to ensure services within the hospital were furnished in a manner to ensure compliance with all applicable conditions of participation. This was evidenced by:

1. Failing to ensure compliance with the Condition of Participation of Medical Staff Services. The governing body failed to ensure to ensure an effective system was in place to ensure that each physician/practitioner providing services in the hospital was credentialed in accordance with the Medical Staff By-laws for 4 of 4 (S3MD, S32Physician, S22APRN, S23APRN) current credentialed medical staff (see findings in A-0083).


2. Failing to ensure compliance with the Condition of Participation of Radiology Services. The governing body failed to ensure there was a radiologist who was a member of the medical staff and supervised the radiology services of the hospital, and failed to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital by Company A and B on either a full-time, part-time, or consulting basis (see findings in A-0083).

3. Failing to ensure compliance with the Condition of Participation of Respiratory Services. The governing body failed to ensure the respiratory care services offered were appropriate for the scope and complexity of the services as evidenced by: a) not having a licensed Respiratory Therapist available for respiratory care services and procedures to assist with patient care; b) not having the scope of respiratory care services offered by the hospital defined in writing and approved by the medical staff, and; c) not having a director of respiratory care services who was a doctor of medicine or osteopathy with the knowledge, experience, and capabilities to supervise and administer the service properly on a full-time, part-time, or contractual basis credentialed and approved by the medical staff and appointed by the Governing Body. This deficient practice had the potential to affect all patients who had respiratory care needs or services ordered in the hospital (see findings in A-0083).

4. Failing to ensure compliance with the Condition of Participation of Medical Records. The governing body failed to employ adequately trained personnel to ensure for the prompt completion of medical records as evidenced by failure to employ a qualified director of the Medical Records Department as required by the Louisiana Hospital Licensing Standards, Chapter 93, Section 9387 B (see findings in A-0083).

5. Failing to ensure that the hospital's Quality Assessment Performance Improvement (QAPI) program reflected the the hospital's services as evidenced by failing to include all hospital departments and services, including services furnished by contract, in the QAPI program. The QAPI program failed to include hospital contracted services of Speech Therapy, Occupational Therapy, PICC (Peripherally Inserted Central Catheters) Line insertions, physician/mid-level practitioner services, Hemodialysis, Biomedical Equipment services, Biohazard waste disposal, Linen Services, Organ Procurement services, Radiology, Laboratory, and Respiratory services (see findings in A-0083).

6. Failing to ensure compliance with the Condition of Participation of Food and Dietetic Services. The governing body failed to ensure the qualified dietitian supervised the nutritional aspects of patient care as evidenced by: a) failing to have nutritional consults ordered by the physician conducted by the dietitian for 4 (#2, #3, #7, #8) of 7 (#2, #3, #4, #5, #7, #8, #9) sampled patient records reviewed for nutritional assessments from a total of 30 sampled records; b) failing to ensure the dietitian performed an assessment of the patient when consulted, and; c) failing to approve patient menus, provide consultation in food service management, and assist with quality improvement activities as directed in the contractual agreement (see findings in A-0083).

Based on records review and interviews, the hospital failed to meet the requirements of the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) as evidenced by:

1) Failing to ensure the QAPI Program specified the method and frequency of data collection for indicators as evidenced by no documented evidence of the method(s) and frequency of data collection and no quality indicators identified for hospital services (See Findings in A-0273).


2) Failing to ensure that data collected was used to identify opportunities for improvement and changes that would lead to improvement, set its priorities for its performance improvement activities on high-risk, high-volume, or problem-prone areas, and take actions aimed at performance improvement, measure success with the actions, and track performance to ensure that improvements are sustained as evidenced by no documentation of performance improvement activities, no corrective actions to address the problems that were reported, and no tracking or trending of the identified problems (See Findings in A-0283).


3) Failing to ensure the QAPI program established clear expectations of patient safety as evidenced by:
A) failing to ensure the effective implementation of an infection control surveillance program relative to infection control breeches and patient care equipment, failing to develop written corrective actions for problems identified with cleaning solutions;

B) failing to track and trend medication errors and determine a medication error rate, and:

C) failing to ensure all staff were trained on patient safety, medication errors, and near miss/close calls (See Findings in A-0286).


4) Failing to ensure the QAPI program reflected the the hospital's services as evidenced by failing to include all hospital departments and services, including services furnished by contract, in the QAPI program. The QAPI program failed to include hospital services of housekeeping, maintenance, and the contracted services of Speech Therapy, Occupational Therapy, PICC (Peripherally Inserted Central Catheters) Line insertions, physician/mid-level practitioner services, Hemodialysis, Biomedical Equipment services, Biohazard waste disposal, Linen Services,Organ Procurement services, Radiology, Laboratory, and Respiratory services (See Findings in A-0308).


5) Failing to ensure an ongoing program for quality improvement and patient safety was defined, implemented, and maintained as evidenced by failing to approve the QAPI program indicators and the frequency of data collection, failing to annually determine the number and type of performance improvement projects, and failing to actively review the results of QAPI data and reports (See Findings in A-0309).


31048

Based on record review and interviews, the hospital failed to meet the Condition of Participation for Medical Staff as evidenced by:

1) failing to ensure an effective system was in place to ensure that each physician/practitioner providing services in the hospital was credentialed in accordance with the Medical Staff By-laws for 4 of 4 (S3MD, S32Physician, S22APRN, S23APRN) current credentialed members of the medical staff (See Findings in A-0341).

2) failing to enforce its bylaws as evidenced by:
A) nurse practitioners writing orders, giving verbal orders and conducting history and physical assessments when medical staff bylaws prohibited such, and;
B) the physician failing to pronounce deceased patients for 4 of 4 (#10, #14, #21, #28) sampled death records reviewed out of a total sample of 30 (See Findings in A-0353).

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

1) failing to ensure the medical record service was appropriate to the scope and complexity of the services performed as evidenced by failure to employ a qualified director of the Medical Records as required by the Louisiana Hospital Licensing Standards, Chapter 93, Section 9387 B. (See Findings in A-0432).

2) failing to ensure patients' medical records were protected from water damage in the event the sprinkler system was activated. This deficient practice is evidenced by storing approximately 1,277 patient records on open shelving, on top of cabinets and on desks in sprinklered rooms (See Findings in A-0438).

3) failing to ensure a system was in place for prompt completion of medical records by failing to identify dating/timing of orders and medical record entries as incomplete medical records (See Findings in A-0438).

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

1) failing to ensure there was a radiologist who was a member of the medical staff and supervised the radiology services and interpreted the radiological tests on either a full-time, part-time, or consulting basis (See Findings in A-0546).

2) failing to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital by Company A and Company B (See Findings in A-0536).

Based on record review and interview, the hospital failed to meet the Condition of Participation for Food and Dietetic Services as evidenced by failing to ensure the qualified dietitian supervised the nutritional aspects of patient care as evidenced by:

1. Failing to have nutritional consults ordered by the physician conducted by the dietitian for 4 (#2, #3, #7, #8) of 7 (#2, #3, #4, #5, #7, #8, #9) sampled patient records reviewed for nutritional assessments from a total of 30 sampled records;

2. Failing to ensure the dietitian performed an assessment of the patient when consulted, and;

3. Failing to approve patient menus, provide consultation in food service management, and assist with quality improvement activities as directed in the contractual agreement. (See Findings in A-0621)

Based on observation, record review, and interview the hospital failed to meet the requirements for the Condition of Participation for Infection Control by failing to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases as evidenced by:

1) failing to ensure the Infection Control Officer (ICO) developed and implemented policies governing the control of infections and communicable diseases (See Findings in A-0748).

2) failing to ensure the infection control officer identified, reported, investigated, and controlled infections and communicable diseases (See Findings in A-0749).

3) failing to ensure the Administrator, Medical Staff, and the Director of Nursing were responsible for implementing successful corrective actions plans in affected problem areas for infection control practices (See Findings in A-0756).

Based on record review and interview, the hospital failed to meet the requirements for the Condition of Participation for Respiratory Care Services by failing to meet the needs of the patients in accordance with acceptable standards of practice as evidenced by:

1) failing to ensure appropriate respiratory care services were available for the scope and complexity of the services offered as evidenced by the hospital not providing appropriate types and numbers of qualified personnel to provide respiratory care services as evidenced by the hospital not having a licensed Respiratory Therapist employed by the hospital on a full-time, part-time, or contractual basis, and the hospital not defining, in writing, the scope of respiratory services approved by the medical staff. (See Findings in A-1152).

2) failing to ensure respiratory care services were under the direction of a doctor of medicine or osteopathy on a full-time, part-time, or contractual basis as evidenced by failure of the Medical Staff to credential and approve a physician and failure of the Governing Body to appoint a physician as Director of Respiratory Services (See Findings in A-1153).

3) failing to have any licensed Respiratory Therapists and appropriately trained nursing staff to care for patients with respiratory care needs as evidenced by the hospital having no Respiratory Therapist available to provide respiratory care services to patients at the hospital, and the hospital having no documentation the nursing staff was trained and assessed for competency in skills to provide respiratory care and procedures to patients. (See Findings in A-1154 and A-1161).

4) failing to have appropriate policies and procedures developed and approved by the medical staff (See Findings in A-1160).

Based on record review and interview, the Governing Body failed to ensure the members of the medical staff were accountable to the Governing Body for quality of care provided to patients as evidenced by medical staff members not assessing and pronouncing death for 4 of 4 (#10, #14, #21, #28) sampled patients reviewed for pronouncement of death from a total sample of 30. Findings:

Review of the Medical Staff By-Laws, Rules & Regulations revealed in part the following: B. Admission and Discharge of Patients: 6. In the event of the death of a patient, the deceased shall be pronounced dead by the attending physician or his/her designee within a reasonable period of time. The body shall not be released until an entry has been made and signed in the medical record of the deceased by a member of the medical staff. Further review of the Medical Staff By-Laws revealed membership on the Medical Staff would be extended to physicians.

Review of the hospital's policy titled, Death of A Patient, revealed in part, In the event of a death within the hospital, the deceased will be pronounced dead by the attending physician or his designee within a reasonable amount of time. All deaths must be referred to LOPA(Louisiana Organ Procurement Agency) in a reasonable amount of time (4 hours).

A member of the medical staff or his designee will release the body after pronunciation and an entry made into the medical record of the deceased.

Patient #10
Review of Patient #10's medical record revealed the patient was a 88 year old male admitted on 09/06/14 with the diagnoses of Pressure Ulcer and Pneumonia. Patient #10 expired on 09/24/14. Patient #10 had a DNR (Do Not Resuscitate) order on his medical record.

Review of Patient #10's Nurses Notes, dated 09/23/14 and timed 11:35 p.m., revealed in part, Called to pt. room per LPN (Licensed Practical Nurse), pt (patient) unresponsive, no resp.(respirations), no pulse, no heart or breath sounds auscultated (heard). Pt. was DNR status, DNR on chart. S21Coroner notified. DON (Director of Nurses) notified, stating she would notify pt's son of pt's status. Pt's son confirmed that pt was to be released to H.... Funeral Home in Mississippi. Notified funeral home of pending release of body pending arrival of coroner. notified of pt. status.
09/24/14 12:50 a.m.- S21Coroner arrived, pronounced pt at 12:55 a.m. Postmortem care implemented...

Patient #14
Patient # 14 was a 92 year old female admitted on 05/08/14 with the diagnosis of Sepsis. Further review of the medical record revealed the patient had a DNR order. The patient expired on 05/16/14.

Review of the Nurses' Notes, dated 05/16/14 at 5:30 a.m. revealed, Nurse at bedside with dtr(daughter), Pt (Patient) Resp (respirations) 0, no heart rate/pulse audible. Notified S20APRN (Advanced Practice Registered Nurse-Nurse Practitioner) of pt status. No code called per Advance Directive, DNR on chart. Awaiting S20APRN arrival to facility. Dtr. remains at bedside.

Review of the Nurses' Notes dated 05/16/14 at 6:35 a.m. revealed S20APRN present, pronounced pt death at 6:35 a.m.. Indwelling Foley removed. Dtr removed all personal belonging of pts. Body to released to R.....Funeral Home.

Review of Patient #14's Discharge Summary, dictated by S20APRN, revealed in part, I was contacted 05/16/14 at 5:30 a.m. and told by the nursing staff that the patient had no respiration and no heart rate. There was a DNR. I came in and saw her pupils were 4 mm (millimeters) dilated and fixed bilaterally. She had no respirations or apical pulse that could be auscultated. Her vital signs were undetectable. Assessment is cardiopulmonary arrest, duodenal neoplasm.

An interview was conducted with S19COO (Chief Operating Officer and Acting Administrator) and S2DON (Director of Nursing) on 05/13/15 at 3:00 p.m. They confirmed Patient #10 and #14 was not pronounced dead by a physician as required by the Medical Staff Bylaws per record review. S19COO and S2DON further reported most of the current nursing staff were recently employed with the hospital and was not employed with the hospital when the deaths occurred.


Patient #21
Review of the medical record for Patient #21 revealed the patient was an 88 year old male admitted to the hospital on 04/05/14 with diagnoses of Malnutrition, Secondary Malignant Neoplasm of Liver, Lung, and Adrenal Gland, Urinary Tract Infection, and Dehydration. Review of the record revealed the patient did not have an advance directive on admission.

Review of the Nurse's Notes dated 04/19/15 at 2:15 p.m., revealed the patient was found unresponsive with no respirations, no pulse, no heart beat or breath sounds. Code initiated and EMS (Emergency Medical Services) called. At 2:37 p.m. the code ceased at niece's request per advance directive, signed DNR. At 3:28 p.m. S20APRN at bedside - pronounced patient. At 5:00 p.m. Coroner states will not be out to hospital. At 6:00 p.m. the body was released to the funeral home.

Review of the Discharge Summary, dictated by S20APRN on 05/08/15 revealed, in part, the following: I was contacted later that afternoon at 2:15 p.m. and was told that Patient #21 had, in fact, coded. Ambulance was called as well as his Power of Attorney. At 2:37 p.m. the patient's power of attorney gave a verbal to make him a DNR. At that time he was in asystole (no heart beat) in two leads via the ambulance service. Strips printed showing at 2:42 p.m. CPR (Cardio Pulmonary Resuscitation) was stopped. I came in and saw him. His left pupil was fixed and dilated about 3 mm, due to his blindness you couldn't make out his right pupil. He had no blood pressure, no pulse, and no spontaneous respirations. Upon auscultation I was unable to detect apical pulse or any respirations. S3MD (Medical Director) was notified at 3:28 p.m.on the 19th. I spoke with him and the patient was pronounced at 3:28 p.m....

In an interview on 05/14/15 at 10:30 a.m. S2DON reviewed record for Patient #21 and confirmed there was no documented evidence that the patient's physician pronounced the patient dead and the record indicated the nurse practitioner pronounced patient.


Patient #28
Review of the medical record for Patient #28 revealed the patient was a 66 year old female admitted to the hospital on 02/05/14 with diagnoses of Sepsis, Pneumonia, Pancreatic Cancer, Laryngeal Cancer, Hypertension, Diabetes Mellitus, and Coronary Artery Disease. The record revealed the patient was a DNR on admission.

Review of the Nurse's Notes dated 02/12/14 at 4:20 p.m. revealed the patient had no respiration, no apical pulse, no heart or breath sounds auscultated. Patient's daughter at bedside. No code called as per advance directive, signed DNR order on chart. At 4:35 p.m. S23APRN pronounced death.

Review of the Discharge Summary dictated by S23APRN on 02/16/14 revealed the following: Patient #28 did expire on 02/12/14. At 4:20 p.m. she was found by the nursing staff to be without respirations and a pulse. At 4:35 p.m. she was pronounced dead. Pupils were fixed and dilated. S26Physician was notified and at that time she was pronounced. Patient #28's body was released to funeral home.

Review of the physician progress notes revealed S23APRN documented a death note on 02/12/14 at 4:35 p.m. The note revealed, "S26Physician notified patient pronounced at 4:35 p.m." The progress note was co-signed by S26Physician on 02/13/14 at 2:09 p.m.

In an interview on 05/18/15 at 3:48 p.m., S1Admin (Administrator-in-Training) reviewed the medical record for Patient #28 and confirmed there was no documented evidence the attending physician pronounced the patient.

In a telephone interview on 05/14/15 at 4:23 p.m., S3MD stated he does come in and pronounce some patients, and stated, if he did pronounce a patient, he wound document it in the patient's record and stated, "more than a signature." S3MD stated he did not recall the above sampled patients.





26351

Based on record review and interview, the hospital's governing body failed to ensure services within the hospital were furnished in a manner to ensure compliance with all applicable conditions of participation. This was evidenced by:

1. Failing to ensure compliance with the Condition of Participation of Medical Staff Services. The governing body failed to ensure to ensure an effective system was in place to ensure that each physician/practitioner providing services in the hospital was credentialed in accordance with the Medical Staff By-laws for 4 of 4 (S3MD, S32Physician, S22APRN, S23APRN) current credentialed medical staff. Findings:

Review of the Medical Staff By-laws (no date), provided as current by S19COO (Chief Operating Officer and Acting Administrator) as current, revealed in part the following:
Article III. Membership: Initial appointment and reappointment to the Medical Staff will be made by the Board. Initial appointments are provisional, will be for a period of one (1) year. Reappointment will be for a period of not more than two (2) years.
Article VI. Procedure for Appointment/Clinical Privileges Section 1. All applications for appointment/clinical privileges to the Medical Staff will be submitted in the form designated by the Medical Executive Committee and the Board. The application will be submitted by the practitioner to the Medical Staff Office. The application will be reviewed by the Credential Committee. The Credential Committee will review an application and make a recommendation to the Medical Executive Committee.
When the recommendation of the Medical Executive Committee is favorable to the practitioner, the Chief Executive Officer (CEO) will forward it, together with all supporting documentation to the Board. At its regular meeting after receipt of a favorable recommendation, the Board will act in the matter. If the Board's decision is to approve the application, then the CEO will notify the practitioner, the Chief of Staff and the Medical Director.
Article V. Section 1. Clinical Privileges: Every initial application for staff appointment and reappointment or application for clinical privileges must contain a request for the specific clinical privileges desired by the applicant. The evaluation of such requests will be based upon the qualifications documented, current licensure, relevant training and/or experience, mental and physical health status, competence, and peer recommendations including an appraisal by, and recommendation.
Article VII. Procedure for Reappointment/Renewal of Clinical Privileges
In order to continue appointment and clinical privileges the practitioner shall reapply and be reviewed every two years as outlined by the Medical Staff Office. All applications for reappointment to the Medical Staff will be submitted in the form designated by the Medical Executive Committee and approved by the Board. The process is outlined under the Appointment/Clinical Privileges process.

Review of the Medical Staff Rules & Regulations revealed the process for Specified Professional Personnel Staff (SPPS-Nurse Practitioners) status included the same process as appointment/reappointment to the Medical Staff, except the review and reappointments were to be conducted annually.


S3MD (Medical Director)
Review of the credentialing file for S3MD revealed a written agreement for the position of Chief of Staff, dated 04/03/15. The file also revealed a written agreement for the position of Medical Director dated 02/16/14, but it was only signed by S3MD. The credentialing file revealed an initial appointment application dated 04/11/11. The initial request for privileges on the record only included "Delineation of Privileges-page 2," and contained no documentation the requested privileges were accepted. The form also revealed S3MD had hand written in privileges for primary/general care hospital patients and arthrocentesis, but the privileges were not documented as accepted. The initial request for privileges was signed by S31Physician (Former Chief of Staff) on 08/25/11, the form was signed by a governing body member (S24Owner), but not dated. There was no documentation of medical staff recommendation for initial appointment, there was no documentation of governing body appointment to the medical staff, initial request for privileges, and no initial approval of privileges by MEC (Medical Executive Committee) and GB (Governing Body). There was no documented evidence of peer recommendations, curriculum vitae (CV), or continuing medical education in the application for initial appointment.
Review of the credentialing file revealed no documentation of an application for reappointment to the medical staff in 2012 when the initial appointment ended. The only document related to reappointment in 2012 was a Recommendations for Privileges form that was signed by S31Physician on 07/12/12 recommending active privileges. The form was also signed by a governing body member (S24Owner) granting active privileges on 07/23/12. There was no documented evidence of a request for privileges, peer recommendations, appraisals, or continuing medical education.
Review of the credentialing file revealed a Recommendations for Privileges form that was signed by S31Physician on 03/22/13 recommending active privileges. The form was also signed by a governing body member (S24Owner) granting active privileges on 03/22/13. There was no documented evidence of an application for reappointment, request for clinical privileges, peer recommendations, appraisals, or continuing medical education.
Review of the Governing Board Meeting Minutes dated 04/02/15 revealed the following: The Medical Staff re-appointments were approved as follows: S3MD, Medical Director/Acting Chief of Staff.

S32Physician
Review of the credentialing file for S32Physician revealed the physician was an orthopedic surgeon. The file revealed an initial appointment application dated 01/04/07 and included a delineation of privileges that was approved by the Chief of Staff and Governing Board. There was no documented evidence of any subsequent applications for reappointment.
There was no documented evidence of any request for delineation of privileges since 01/17/07.
There was no documented evidence of any request for clinical privileges, peer recommendations, appraisals, or continuing medical education since 01/04/07.
Review of the Governing Board Meeting Minutes dated 04/02/15 revealed the following: The Medical Staff re-appointments were approved as follows: S32Physician, Director of Ortho(Orthopedic) Services (One day before the "Recommendations for Privileges" form was signed on 04/03/15).

S22APRN (Advanced Practice Registered Nurse-Nurse Practitioner)
Review of the credentialing file for S22APRN revealed a written agreement between the hospital and S22APRN for the provision of services of a nurse practitioner dated 08/25/14.
Review of the file revealed a letter dated 07/16/14 from the Louisiana State Board of Nursing (LSBN) that approved S3MD as the collaborative physician. There was no documented evidence of the collaborative practice agreement. Review of the file revealed an application for appointment to the medical staff dated 07/28/14. Review of the Delineation of Privileges revealed clinical areas of practice (Cardiovascular, Central Nervous System, etc) were requested. The only procedure on the checklist was an EKG (electrocardiogram). There was no documented evidence that privileges were requested or approved to conduct patient history & physical assessments or give verbal orders/write orders for medications and treatments. There was no documented evidence of an appointment to the Medical Staff by the Governing Board.

S23APRN
Review of the credentialing file for S23APRN revealed a written agreement between the hospital and S23APRN for the provision of services of a nurse practitioner dated 07/18/11 that was signed only by S23APRN. Review of the credentialing file revealed no documented evidence that privileges were requested or approved to conduct patient history & physical assessments or give verbal orders/write orders for medications and treatments. There was no documented evidence of any subsequent applications for reappointment. There was no documented evidence of any request for delineation of privileges since 08/25/11.

In a telephone interview on 05/14/15 at 4:15 p.m., S30HR confirmed she was responsible for the credentialing files. She stated S3MD is acting as chief of staff and he can't reappoint himself so the Governing Body does it. S30HR confirmed S3MD did not submit a reappointment application. She confirmed their current process for reappointment did not include delineation of privileges or an application for reappointment. S30HR stated she checked the data bank and verified current licensure and the approval of privileges was signed by Chief of Staff and Governing Board. She confirmed privileges are not requested or approved on re-appointment. When informed that Medical Staff By-laws indicated the process for reappointment required an application and request/approval of privileges, she stated she was not aware of that. S30HR confirmed the above findings.



2. Failing to ensure compliance with the Condition of Participation of Radiology Services. The governing body failed to ensure there was a radiologist who was a member of the medical staff and supervised the radiology services of the hospital, and failed to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital by Company A and B on either a full-time, part-time, or consulting basis. Findings:

Review of the hospital's organizational chart revealed no documentation of a radiologist who supervised the radiology services of the hospital.

Review of the list of credentialed physicians on the Medical Staff, presented as a current list by S4MR (Medical Records) revealed no documented evidence that a radiologist was credentialed and privileged as a member of the Medical Staff.

Review of the contracts provided by S4MR revealed the hospital had a contract with Company A to provide radiologic services and Company B to provide radiologic ultrasound procedures.

Review of a policy and procedure entitled, "Radiology/Laboratory Services" dated 08/12, revealed, in part: "This facility does not house a laboratory or an x-ray department. These services are contracted to an outside company....Currently, we have a company that comes in to the facility to perform mobile x-rays. All services are bound to the requirements for licensure and infection control as set forth by the state of Louisiana, the CDC, and facility licensure. Each company or facility is responsible for the training and operation of the equipment. Any issues are reported to the company manager for correction.... The hospital has a contract that provides for the assurance of qualified personnel to perform the requested services. That contract is in the contract binder for the facility....The staff of the outsourced services must follow infection control protocol, proper hand washing, protection from infectious material for staff and patients. Exposure to any radiologic material outside the normal operating amounts must be reported and equipment checked by the contracted company according to the manufacturer's instructions. This is the responsibility of the contracted company."

Further review of the policies and procedures manual revealed there were no policies and procedures to address the safety of patients and staff during radiologic procedures regarding safety standards for at least the following: Adequate shielding for patients, personnel and facilities; Security of radioactive materials, including determining who may have access to; Proper storage of radiation monitoring badges when not in use; and Methods of identifying pregnant patients.

In an interview on 05/13/15 at 1:50 p.m., S19COO (Chief Operating Officer and Active Administrator) confirmed there was no Radiologist on staff at the hospital on a full-time, part-time, or consulting basis.

In an interview on 05/18/15 at 11:30 a.m., S1Admin confirmed the hospital did not have a credentialed and privileged Radiologist on its medical staff to supervise radiologic services at the hospital. S1Admin also confirmed the radiologists for Company A and Company B interpreting radiological tests were not credentialed and privileged by the hospital's Medical Staff and Governing Body. S1Admin confirmed there were no further policies and procedures in place to address patient and staff safety during radiologic procedures performed at the hospital.



3. Failing to ensure compliance with the Condition of Participation of Respiratory Services. The governing body failed to ensure the respiratory care services offered were appropriate for the scope and complexity of the services as evidenced by: a) not having a licensed Respiratory Therapist available for respiratory care services and procedures to assist with patient care; b) not having the scope of respiratory care services offered by the hospital defined in writing and approved by the medical staff, and; c) not having a director of respiratory care services who was a doctor of medicine or osteopathy with the knowledge, experience, and capabilities to supervise and administer the service properly on a full-time, part-time, or contractual basis credentialed and approved by the medical staff and appointed by the Governing Body. This deficient practice had the potential to affect all patients who had respiratory care needs or services ordered in the hospital. Findings:

Review of the hospital's policy entitled, "Respiratory Therapy-General," revealed, in part: "The Director of Respiratory Therapy, who is a physician, will monitor the outcomes of the respiratory therapy and provide input as needed." The policy also revealed, "The nursing staff at this facility performs all respiratory therapy. Any references to respiratory therapist may be substituted with nursing staff. We reserve the right to contract the services of a respiratory therapist as needed."

Review of the hospital's organizational chart revealed no documentation of a Director of Respiratory Care Services.

Review of the list of active medical staff revealed no documentation that a Director of Respiratory Care Services was credentialed and approved by the Medical Staff and appointed by the Governing Body.

Review of the current staff roster for the hospital employees presented by S4MR (Medical Records) revealed there was no Respiratory Therapist listed on the hospital staff roster.

In an interview on 05/13/15 at 1:50 p.m., S19COO (Chief Operating Officer and Acting Administrator) confirmed there was no Respiratory Therapist available at the hospital for providing services on a full-time, part-time, or contractual basis, and there was no scope of diagnostic and/or therapeutic respiratory services offered by the hospital defined in writing, and approved by the Medical staff. S19COO confirmed there was no director of respiratory care services who was a doctor of medicine or osteopathy credentialed and approved by the medical staff and appointed by the Governing Body.

In an interview on 05/18/15 at 12:30 p.m., S1Admin confirmed there was no Respiratory Therapist available at the hospital to provide respiratory care services, and there had not been a Respiratory Therapist on staff since she had been employed at the hospital in 02/13. S1Admin also confirmed there was no scope of diagnostic and/or therapeutic respiratory services offered by the hospital defined in writing, and approved by the Medical staff and there should have been.



4. Failing to ensure compliance with the Condition of Participation of Medical Records. The governing body failed to employ adequately trained personnel to ensure for the prompt completion of medical records as evidenced by failure to employ a qualified director of the Medical Records Department as required by the Louisiana Hospital Licensing Standards, Chapter 93, Section 9387 B. Findings:

Review of the Louisiana Hospital Licensing Standards, Chapter 93, Section 9387 B, revealed in part: Medical records shall be under the supervision of a medical records practitioner (i.e., registered record administrator or accredited record technician) on either a full-time, part-time or consulting basis.

In an interview on 05/15/15 at 9:35 a.m., S4MR (Medical Records) confirmed she was responsible for medical records and stated she had no credentials for medical records. She stated S33RHIA (Registered Health Information Administrator) has credentials and she worked at Hospital "A." S4MR stated she had, "Never laid eyes on her." S4MR stated she sends S33RHIA parts of the patient's medical record by fax and S33RHIA does the coding. S4MR stated S33RHIA provided direction to her on coding only.

Review of the personnel record for S4MR revealed a date of hire of 08/06/01 and no documented evidence of any credentials in medical records.

In an interview on 05/15/15 at 11:15 a.m., S24Owner stated S33RHIA is a Registered Health Information Administrator and she was contracted to provide services at this hospital and Hospital "A." He stated he found out during the survey conducted at Hospital "A" that S33RHIA was not doing all they had contracted her to do. At this time S24Owner and S19COO (Chief Operating Officer) were unable to provide the last name of S33RHIA. The contract with S33RHIA, her credentials, and her full name were requested for review.

Review of the written agreements with S33RHIA and the hospital provided by S24Owner revealed the agreement was for coding consulting services only and was dated 03/08/10. Review of the written agreement revealed S33RHIA signed her name with the credentials of RHIA behind her name. There was no documentation of her credentials provided for review.

In an interview on 05/15/15 at 11:50 a.m., S24Owner stated she spoke to S33RHIA and she informed him she was not doing medical records. S24Owner confirmed she was contracted for coding services only.


5. Failing to ensure that the hospital's Quality Assessment Performance Improvement (QAPI) program reflected the the hospital's services as evidenced by failing to include all hospital departments and services, including services furnished by contract, in the QAPI program. The QAPI program failed to include hospital contracted services of Speech Therapy, Occupational Therapy, PICC (Peripherally Inserted Central Catheters) Line insertions, physician/mid-level practitioner services, Hemodialysis, Biomedical Equipment services, Biohazard waste disposal, Linen Services, Organ Procurement services, Radiology, Laboratory, and Respiratory services. Findings:

Review of the hospital's Quality Assessment and Improvement policy dated 06/05 revealed in part the following: This facility monitors the quality of care being provided to the patients at this facility. Services related to patient care that will be monitored include contracted services.

Review of the hospital's Organization Wide Quality Quality Assurance, dated 01/02/01, revealed in part the following: The facility has an organization-wide quality assurance plan which encompasses all organized services related to patient care.

Review of the hospital's Quarterly QAURRM (Quality Assurance/Utilization Review/Risk Management) meeting minutes for the year 2014 revealed no documented evidence that the following services were included in the QAPI program: Speech Therapy, Occupational Therapy, PICC (Peripherally Inserted Central Catheters) Line insertions, physician/mid-level practitioner services, Hemodialysis, Biomedical Equipment services, Biohazard waste disposal, Linen Services, Organ Procurement services, Radiology, Laboratory, and Respiratory services.

In an interview on 05/18/15 at 9:50 a.m. S1Admin confirmed she was responsible for the QAPI program for the hospital. She confirmed all hospital services as indicated above were not included in the QAPI program.

6. Failing to ensure compliance with the Condition of Participation of Food and Dietetic Services. The governing body failed to ensure the qualified dietitian supervised the nutritional aspects of patient care as evidenced by: a) failing to have nutritional consults ordered by the physician conducted by the dietitian for 4 (#2, #3, #7, #8) of 7 (#2, #3, #4, #5, #7, #8, #9) sampled patient records reviewed for nutritional assessments from a total of 30 sampled records;
b) failing to ensure the dietitian performed an assessment of the patient when consulted, and;
c) failing to approve patient menus, provide consultation in food service management, and assist with quality improvement activities as directed in the contractual agreement. Findings:

Review of the hospital policy titled "Nutritional Consultation/Education," contained in the policy manual presented as the current hospital policies by S2DON (Director of Nursing), revealed the dietitian consults with patients giving written and verbal instructions for following a personalized nutrition therapy plan when ordered by the physician. The order is communicated to the Department of Food and Nutrition Services in the manner outlined for the Physician's Diet Orders and Diet Changes. No policy related to physician diet orders and diet changes was presented during the survey by administration.

Review of the hospital policy titled "Assessing Nutritional Status Of Patients," contained in the policy manual presented as the current hospital policies by S2DON, revealed that the assessment of the nutritional status of patients is performed by a qualified dietitian as part of the total care rendered when patients are identified to be at high nutritional risk or as requested by the attending physician. Both subjective and objective information relative to food intake habits and patterns, physical, biochemical, and medical aspects of the patient are recorded on the Nutrition Assessment form by the dietitian, and this form becomes a part of the patient's medical record. Further review of the policy revealed no documented evidence of the manner in which patients would be assessed for high nutritional risk.

Review of the hospital policy titled, "Menu Planning," dated 01/02/11 revealed in part the following: All menus for patient food service are planned and meet the approval of a qualified registered dietitian.

Review of the written agreement for dietitian services between the hospital and S7RD dated 12/05/12 revealed the responsibilities of the RD included reviewing the patient's medical history, assessing the patient's nutritional needs, and assessing, planning, and implementing medical nutrition therapy care for all appropriate patients. The agreement also revealed the responsibilities of the RD included providing consultation in food service management including menu planning, food purchasing and preparation, personnel management, equipment, sanitation and safety. The agreement included a provision that the RD would assist with quality improvement activities.

Review of the medical records for Patients #2, #3, #7, #8 revealed the physician had ordered an evaluation by the Dietician. Review of the patients' record revealed the evaluations had not been done as ordered.
In an interview on 05/13/15 at 2:40 p.m. S2DON (Director of Nursing) confirmed the RD's assessment was incomplete for Patient #2.

In an interview on 05/13/15 at 9:05 a.m., S8DM (Dietary Manager) indicated she faxes dietary consults to S7RD once the nurse informs her of the ordered consult. She confirmed that she never faxed a dietary consult to S7RD for Patients #3 and #7. S8DM indicated she doesn't regularly check patients' charts for a dietary consult order and relies on the nurse to notify her when an order is received.

In an interview on 05/13/15 at 9:15 a.m., S2DON confirmed the medical records of Patients #3 and #7 did not have a completed nutritional assessment performed by S7RD. She indicated the nurses are supposed to notify S8DM when a dietary consult is ordered by the physician.

In an interview on 05/14/15 at 10:30 a.m., S2DON reviewed the medical record for Patient #8 and confirmed an RD consult was ordered on 05/01/15 and there was no documented evidence it was done.
In an interview on 05/14/15 at 11:00 a.m. S8DM provided a faxed cover sheet indicating she had faxed S7RD information on Patient #8 on 05/04/15. S8DM was unable to explain why the evaluation had not been done yet.


In an interview on 05/14/15 at 12:05 p.m., S8DM stated when a dietitian consult is requested, she faxes the physician orders, nursing admission assessment, H&P, Lab reports, and the patient's face sheet to S7RD. She stated S7RD then faxes back an evaluation. When asked if S7RD came to the hospital to see the patients she was evaluating, she stated not while she was at the hospital. S8DM stated she did not know if S7RD comes when she was not there. When asked if she had ever seen S7RD, she stated, "Once when she first started." S8RD stated she did not remember if she saw her at the hospital or met her somewhere else.

On 05/15/15 at 1:12 p.m., S8DM provided a copy of the patient menus. She stated the menus came from the company that provides their food. She confirmed no RD had approved the menus.

In a telephone interview on 05/15/15 at 1:15 p.m., S7RD was asked how she conducted the dietitian consults. She stated the hospital staff faxed her the medical record and she sends the evaluation back. S7RD stated, "I have the entire medical record." S7RD confirmed she does not see the patient and stated she had never been to this hospital. S7RD confirmed she documents an assessment of the patient's nutritional needs from the medical record only.
S7RD stated she had never been to this hospital and she only did clinical nutritional evaluations. She stated she had never provided any training/education to the dietary staff or assessed the competency of the dietary staff. S7RD stated she does not do anything with the operation of the kitchen. S7RD confirmed she does not approve patient menus.

Based on record review and interview, the hospital failed to provide documentation for: the prompt review and resolution of a complaint or grievance; written notice of the outcome of the grievance investigation which contained the contact person; the steps taken on behalf of the patient to investigate the grievance; the results of the grievance process; and the date of completion. This deficient practice was evidenced by no documentation of the above referenced items for 2 (R1, R2) of 2 grievances identified by S1Admin for 2014. Findings:

Review of a Policy entitled "Grievance Process/Complaints" provided by S2DON (Director of Nursing) as the current policy, with no dates documented on policy, revealed the following, in part:
Purpose: The purpose of this policy is to provide and describe a uniform mechanism for managing all patients complaints/grievances regarding care and services received at our facility. Depending on the nature and severity of the complaint/grievance, different processes may be required for review and resolution.
Hospital Related Complaints:

1) The facility has designated the Director of Nursing as the person responsible to review complaints or grievances if the incident occurred in the hospital or involved hospital services. The DON may designate someone to follow up on the complaint of grievance at their discretion. The DON will manage patient complaints and grievances involving the hospital which are not directly related to a practitioner's clinical practice or judgment, allegations of harm or injury, or physician behavior, conduct or impairment. As relevant, the DON may share information about the complaint of grievance with the practitioner, Chief of Staff, CEO (Chief Executive Officer) or any other department that may have the need to know. After the initial investigation is performed, it will be determined if further investigation should be done. The DON will be the contact person with the complainant during the review process unless otherwise noted. For complaints or grievances that occur while the patient is an inpatient, the review process will begin on the next business day of receipt of notice. If the complaint is received after discharge, the acknowledgement will be done within 2 business days after receipt, usually by telephone if possible. For all grievances: Once the investigation is completed, the investigator will provide the patient or their representative with a written notice of any relevant information, findings, actions relevant to the situation, date of completion, and any contact person for follow up. If the grievance is unable to be resolved within 7 days of receipt, the DON or designee will contact the patient or representative by phone with an update and every two weeks thereafter until resolved. A grievance is considered resolved when the patient/representative is satisfied with the actions taken. Appropriate documentation is necessary due to the fact that the complainant may not achieve personal resolution. All incidences will be reported in the Quality meetings and reviewed by the Governing Body.

2) Risk Management issues will be advised of issues that may require recommendations in the area of clinical practice, clinical judgment, or allegations of harm or injury have been alleged or identified. It will be reviewed to see if protocols were followed. All research shall be documented and tracked for Quality reporting to the Hospital Compliance Administration."

R1
Review of R1's documentation of a grievance revealed a document dated 09/22/14, entitled "Grievance" with the documentation of the patient's name. Further review revealed the following documentation: "Wife stopped by to speak, stated 'he came here walking and got home and couldn't walk.' His heels had a rash on them. Then stated, 'well it's nothing against you or Trish but I'm suing this place because of Lisa and David, every time I came here they told me a different story about him. Said that diesel from son was why he had a rash on his back.' (MD diagnosed Stephen-Johnson Syndrome). Provided (name of complainant) with human resource department number." The document's author was identified as S1Admin.
In an interview on 05/18/15 at 10:55 a.m., S1Admin confirmed she presented all of the documentation regarding the grievance for R1.
R2
Review of R2's documentation of a grievance revealed a document dated 12/08/15, entitled "Grievance" with the documentation of the patient's name. Further review revealed the patient's wife asked the hospital staff to remain in the room with the patient at all times while she went out of the hospital to get something to eat because of concerns the patient would fall. The RN (Registered Nurse) placed a chair alarm on the patient and left the room. It was noted the patient fell "within a few minutes." The patient's wife returned very upset because the patient had fallen and the hospital staff had not remained in the room with the patient at all times. The patient was assessed and there were no apparent injuries to the patient; the Nurse Practitioner was contacted and the patient was sent to an emergency room for evaluation and treatment. The patient was returned to the hospital, and he apparently had a negative exam which included a CT scan of the head, without contrast, x-rays of the right arm. All examinations and tests were negative for any injuries. The patient was placed on a one-on-one with staff members when family members were not present."
Further review of the document revealed "Wife left and went home to get some rest. Returned the next day in much better spirits and no complaints." The document's author was identified as S1Admin.
In an interview on 5/18/15 at 11:00 a.m., S1Admin confirmed she presented all of the documentation regarding the grievance for R2.
In an interview on 05/18/15 at 11:10 a.m., S1Admin confirmed she was responsible for the grievance process at the hospital, and there were no grievances for 2015. S1Admin also confirmed the policies and procedures presented were current, and she confirmed the policies and procedures for the grievances for R1 and R2 were not followed, and should have been.

Based on record reviews and interview, the hospital failed to implement its policy for do not resuscitate (DNR) orders as evidenced by failure to have documented evidence by the physician of a discussion with the patient or legal authorized representative that included the reasons for the order for 2 (#3, #7) of 2 patient records reviewed with physician orders for do not resuscitate from a total sample of 30 patients. Findings:

Review of the hospital policy titled "No Code Blue," contained in the policy manual presented as the current hospital policies by S2DON (Director of Nursing), revealed that a "No Code Order" may be written by the physician in either of the following circumstances: 1) a patient has designated through "Advance Directives" or "Durable Power of Attorney for Health" that he/she desires no extraordinary or resuscitative measures be employed or 2) for a patient who, in the considered judgment of the physician and such physician consultants as appropriate (two physicians are required), is in a terminal condition and/or death is imminent and with the concurrence of the responsible family member(s) decision makers and only after they have confirmation by a physician of their choice. Further review revealed the choice must be supported by adequate documentation of the reasons for the decision in the physician progress notes and the decision must be communicated to the nursing staff.

Patient #3
Review of Patient #3's medical record revealed he was a 92 year old male admitted on 04/29/15 with admit diagnoses of COPD (Chronic Obstructive Pulmonary Disease), CHF (Congestive Heart Failure), and Aspiration Pneumonia. Review of his History and Physical Examination documentation revealed diagnoses of Benign Prostatic Hypertrophy (BPH), Hypertension, COPD (Chronic Obstructive Pulmonary Disease), Anemia, and GERD (Gastroesophageal Reflux Disease).

Review of Patient #3's medical record revealed a "Living Will Declaration" signed by Patient #3 on 10/31/08 that included the following information: "If at any time I should be in a continual profound comatose state with no reasonable chance of recovery or have an incurable injury, disease, or illness certified to be terminal and irreversible condition by two physicians, who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life-sustaining procedures are utilized and where the application of life-sustaining procedures would serve only to prolong artificially the dying process, I direct that such procedures (including but not limited to artificial means of respiration, hydration, and nutrition) be withheld or with-drawn and that I be permitted to die naturally with only the administration or the performance of any medical procedure deemed necessary to provide me with comfort care."

Review of Patient #3's "Physician's Orders" revealed an order written by S3MD (Medical Director) on 04/30/15 (no time documented) of "Do Not Resuscitate."

Review of Patient #3's "No Code" Status Acknowledgement revealed it was signed by Patient #3 and witnessed by S1Admin and S25LPN (Licensed Practical Nurse) on 04/29/15 acknowledging "a discussion with the physician and give permission to the physician and nursing staff for a "No Code" which means that no attempt will be made in resuscitation to sustain life in the event of a cardiac or respiratory arrest."

Review of Progress Notes documented by S3MD on 04/30/15 at 6:00 p.m. and 05/08/15 at 9:00 p.m. revealed no documented evidence of a discussion with Patient #3 or his family members of the reasons for the decision for the "No Code" order.

Patient #7
Review of Patient #7's medical record revealed she was an 88 year old female admitted on 05/07/15 with diagnoses of Left Lower Lobe Pneumonia, Coronary artery Disease (CAD), Anxiety, Hypothyroidism, Hyperlipidemia, and IBS (Irritable Bowel Syndrome).

Review of Patient #7's medical record revealed a "No Code" Status Acknowledgement signed by Patient #7 and witnessed by S1Admin and S14LPN on 05/07/15. Further review revealed a physician's order written by S3MD on 05/08/15 at 10:20 p.m. to "Do Not Resuscitate per family request."

Review of the entire medical record revealed no documented evidence of the discussion S3MD had with Patient #7's family members to include which family members were spoken to by S3MD regarding Patient #7's DNR order.

In an interview on 05/13/15 at 4:00 p.m., S2DON (Director of Nursing) indicated she could find no documentation of discussions held by S3MD with Patient #3 and Patient #7's family members. She confirmed that the hospital policy requires the discussion to be documented and the patient to be examined by two physicians before implementation of the DNR order.

Based on record review and interview, the hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) Program specified the method and frequency of data collection for indicators as evidenced by no documented evidence of the method(s) and frequency of data collection and no quality indicators identified for hospital services. Findings:

Review of the hospital's Quality Improvement Initiatives, dated 01/02/01, revealed in part the following: Collection of data: Data collection will be a uniform and systematic process and will ensure that only relevant, useful and necessary data is collected....Tools for data collection will be formatted and data collected will be used by the facility to design and assess new processes, assess dimensions of performance, measure the level of performance and stability of existing processes, identifying areas of improvement in existing processes and if the results of changes improved the processes. The collection of data will use a scientific approach for collecting the information and use statistical control methods for evaluation and comparisons of findings....

Review of the hospital's Quarterly QAURRM (Quality Assurance/Utilization Review/Risk Management) meeting minutes for the year 2014 revealed the only documentation of a quality indicator was the indicators for medical records which included: History & Physical (H&P) dictated within 24 hours of admission, Discharge Summaries completed within 30 days of discharge, all entries signed, and Progress notes indicate the patient was seen no less than 4 times a week. There was no documented evidence of any written methodology for the medical record indicators. The hospital was unable to provide any documentation of any other quality indicators. The only documentation of QAPI was the QAURRM quarterly meeting minutes.

In a telephone interview on 05/13/15 at 12:15 p.m. S1Admin confirmed she was involved in QAPI since she was the Director of Nursing (DON) until February when the former administrator resigned. She stated she makes notes of her review activities and reports to the QAURRM quarterly meetings from her notes. She stated the former administrator would take minutes from what was reported and she typed the quarterly QAURRM minutes. S1Admin confirmed those minutes were the QAPI reports. She confirmed she had no quality indicators for her monitoring activities and she had no methodology for collecting or analyzing data. S1Admin stated she has a form she uses to review blood transfusions but she only reports the number of transfusions. She confirmed there was no written methodology for the data collection.

In an interview on 05/15/15 at 9:35 a.m. S4MR (Medical Records) provided documentation of her data collection for the above identified indicators. She stated she had used this same form since 2003 and confirmed there was no written methodology for this data collection. S4MR also stated she had not done the data collection for this year yet. After reviewing the data from the 4th quarter of 2014 she confirmed the H&P indicator and the Discharge Summary indicator were well below the stated threshold of 100%. When asked if any corrective action had been done, she stated she talked to the former administrator and she talked to the nurse practitioner.

Based on record review and staff interviews, the hospital failed to ensure that data collected was used to identify opportunities for improvement and changes that will lead to improvement, set its priorities for its performance improvement activities on high-risk, high-volume, or problem-prone areas, and take actions aimed at performance improvement, measure success with the actions, and track performance to ensure that improvements are sustained as evidenced by no documentation of performance improvement activities, no corrective actions to address the problems that were reported, and no tracking or trending of the identified problems. Findings:

Review of the hospital's Quality Improvement Initiatives, dated 01/02/01, revealed in part the following: The facility will identify important processes and functions that affect health care outcomes, efficient use of all facility resources and customer satisfaction. The focus is on high-risk, high-volume and/or problem-prone activities. Examples include the following: Patient/physician satisfaction surveys (required), personal care and support services, patient/caregiver education, infection control, training of infusion therapy staff, wound care, safety management, utilization review, equipment maintenance, results of clinical record review, occurrence of patient/staff related accidents or incidents.

Review of the hospital's Quarterly QAURRM (Quality Assurance/Utilization Review/Risk Management) meeting minutes for the year 2014 revealed a report of the problems identified under the following categories: Transfers to Acute, Blood Transfusions, AMA (Against Medical Advice), Adverse Drug Reactions, Deaths, PICC (Peripherally Inserted Central Catheter) Lines, Wound Vac, Grievances, Infection Control, Dietary, Wound Care, Therapy, Risk Management, Testing/Appointments, Pharmacy, Discharge Planning, and Miscellaneous. There was no documented evidence of performance improvement activities, no corrective actions to address the problems that were reported, and no tracking or trending of the identified problems. There was no quantitative analysis of any of the identified problems. There was no documented evidence that patient or physician satisfaction was included.

In a telephone interview on 05/13/15 at 12:15 p.m. S1Admin confirmed she was involved in QAPI since she was the Director of Nursing (DON) until February when the former administrator resigned. She stated she makes notes of her review activities and reports to the QAURRM quarterly meetings from her notes. She stated the former administrator would take minutes from what was reported and she typed the quarterly QAURRM minutes. S1Admin confirmed those minutes were the QAPI reports. She confirmed there were no quality indicators for any monitoring activities and no methodology for collecting or analyzing data. S1Admin confirmed there was no documentation of any corrective action plans and stated she addressed any problems identified with the staff involved. She confirmed there was no tracking and trending of any problems identified. She confirmed the only indicator that had any quantitative analysis was medical records which documented a percentage of incomplete records.

In an interview on 05/18/15 at 9:33 a.m. S1Admin provided hand written notes on transfusion, laboratory, (problems that arise), incident reports, medication variance, falls (incident report & change of condition form). She stated she uses a transportation log because she does not have any tools. She stated she also reviews AMAs (Against Medical Advice), expired patient records, and adverse events. She stated the monitoring she does for wound vacs is basically if they are using any. S1Admin provided a copy of a physician order with a medication error in which penicillin was given to a patient that was allergic to the medication. When asked what corrective action was taken after this incident, she stated she, "wrote the nurse up." She stated no incident report was done, and stated she, "was behind" on reviewing medication errors. She stated, "I have a lot of errors" and was unable to provide a medication error rate. After reviewing a copy of the above QAPI policies, S1Admin asked where the surveyor had found the policies and asked to make a copy of the QAPI policies. S1Admin confirmed the hospital had no quality indicators for any hospital services that were provided directly or by contract. She stated the discharge planner sends out the patient satisfaction surveys and she (S1Admin) sends them to the corporate office. She confirmed the patient satisfaction surveys were not included in the QAPI program. S1Admin confirmed there was no corrective action plan for medical records delinquencies other than talking to the medical staff.

Based on observation, record review and interview, the hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) program established clear expectations of patient safety as evidenced by:
1) Failing to ensure the effective implementation of an infection control surveillance program relative to infection control breeches and patient care equipment, failing to develop written corrective actions for problems identified with cleaning solutions.

2) Failing to track and trend medication errors and determine a medication error rate.

3) Failing to ensure all staff were trained on patient safety, medication errors, and near miss/close calls. Findings:

Review of the hospital's Quality Improvement Initiatives, dated 01/02/01, revealed in part the following: The facility will identify important processes and functions that affect health care outcomes, efficient use of all facility resources and customer satisfaction. The focus is on high-risk, high-volume and/or problem-prone activities. Examples include the following: Patient/physician satisfaction surveys (required), personal care and support services, patient/caregiver education, infection control, training of infusion therapy staff, wound care, safety management, utilization review, equipment maintenance, results of clinical record review, occurrence of patient/staff related accidents or incidents.

1) Failing to ensure the effective implementation of an infection control surveillance program relative to infection control breeches and patient care equipment, failing to develop written corrective actions for problems identified with cleaning solutions:

During the survey from 05/12/15 through 05/18/15 the following infection control breeches were observed:
1) failing to ensure the hospital staff implemented hand hygiene practices in accordance with hospital policies and procedures when administering nebulizer treatments for 1 (#2) of 1 observation of providing a nebulizer treatment, when flushing a saline lock for 1 (#7) of 1 observation of flushing a saline lock from a sample of 30 patients, when performing wound care for 1 of 1 (#1) observation of providing wound care, and when disposing of soiled linen for 1 of 1 (S11CNA, Certified Nursing Assistant) observation of staff disposing of soiled linen,
2) failing to implement infection control practices in performing intravenous (IV) therapy for 1 (#7) of 1 observation of discontinuing an IV piggyback from a sample of 30 patients.
3) failing to implement contact isolation precautions for 1 of 1 (#5) sampled patients on contact precautions.
4) failing to ensure that equipment available for patient use was not torn/taped to ensure effective infection control cleaning/disinfecting.

Review of the QAURRM quarterly meeting minutes for 2014 (Only QAPI documents provided for review for implementation of the QAPI program) revealed no documented evidence that the QAPI program had identified any problems related to infection control, or the above observed breeches in infection control.

In an interview on 05/14/15 at 3:20 p.m. S16ICN (Infection Control Nurse) stated she did environmental rounds and submitted the results to the Administrator. She confirmed she had not identified the above breeches during her rounds. She stated she and S17ICC (Infection Control Consultant) had identified a problem with the dilution of the cleaning solutions used by housekeeping and stated they are monitoring this. S16ICN was asked for documentation of the monitoring of this problem. She stated they did not have anything in writing and confirmed there was no documentation of an indicator, methodology, or corrective actions.


2) Failing to track and trend medication errors and determine a medication error rate:

Review of the hospital's Quarterly QAURRM (Quality Assurance/Utilization Review/Risk Management) meeting minutes for the year 2014 revealed the only documentation of medication errors was under the Risk Management section and the documentation included a brief statement on the error. There was no documented evidence of any tracking, trending, corrective actions, or a medication error rate.

In an interview on 05/18/15 at 9:33 a.m., S1Admin provided hand written notes on incident reports and medication variances. She stated she uses a transportation log because she does not have any tools. She provided a copy of a physician order with a medication error for Patient #19 and stated penicillin was given to a patient that was allergic to the medication. When asked what corrective action was taken after this incident, she stated she, "wrote the nurse up." She stated no incident report was done, and stated she, "was behind" on reviewing medication errors. She stated, "I have a lot of errors" and was unable to provide a medication error rate. She stated she makes notes of her review activities and reports to the QAURRM quarterly meetings from her notes. She stated the former administrator would take minutes from what was reported and she typed the quarterly QAURRM minutes. S1Admin confirmed those minutes were the QAPI reports. She confirmed there were no quality indicators for any monitoring activities and no methodology for collecting or analyzing data. S1Admin confirmed there was no documentation of any corrective action plans and stated she addressed any problems identified with the staff involved. She confirmed there was no tracking and trending of any problems identified.

3) Failing to ensure all staff were trained on patient safety, medication errors, and near miss/close calls:

In a telephone interview on 05/12/15 at 12:15 p.m. S1Admin was asked if widespread staff training for patient safety, medication errors, close calls was provided to all staff, she stated, "I don't know." S19COO (Chief Operating Officer and Acting Administrator) was present for the interview and stated he would look and check with other staff for documentation of the staff training.

In an interview on 05/13/15 at 11:25 a.m., S25LPN (Licensed Practical Nurse) stated a near miss was, "almost giving the wrong medication." She stated she reported all medication errors to the charge nurse and stated the RN (Registered Nurse) writes the incident report. S25LPN confirmed she had not received training on near miss/close calls or medication errors from the hospital.

Review of the personnel records for S25LPN, S27RN, S28RN, S29LPN, S14LPN, and S2DON (Director of Nursing) revealed no documented evidence of any training or inservice on patient safety, medication errors, or near miss/close calls.

On 05/18/15 at 5:25 p.m., S1Admin was unable to provide documentation of any training or inservice on patient safety, medication errors, or near miss/close calls.

Based on record review and staff interview, the hospital failed to ensure that it conducted performance improvement projects as part of its Quality Assessment and Performance Improvement (QAPI) program. The hospital could provide no documented evidence of a completed performance improvement project that it had conducted as well as an ongoing project. Findings:

Review of the hospital policy titled, Quality Assessment and Improvement dated 06/05, and Quality Improvement Program dated 01/02/01, revealed no documented evidence of any provisions for selecting and conducting performance improvement projects.

Review of the hospital QAPI records revealed no documented evidence of any performance improvement projects.

In an interview on 05/13/15 at 12:15 p.m., S1Admin confirmed the hospital had no written performance improvement projects and did not have an ongoing project in place at the present time.

Based on record review and staff interview, the hospital's governing body failed to ensure the Quality Assessment Performance Improvement (QAPI) program reflected the the hospital's services as evidenced by failing to include all hospital departments and services, including services furnished by contract, in the QAPI program. The QAPI program failed to include hospital services of housekeeping, maintenance, and the contracted services of Speech Therapy, Occupational Therapy, PICC (Peripherally Inserted Central Catheters) Line insertions, physician/mid-level practitioner services, Hemodialysis, Biomedical Equipment services, Biohazard waste disposal, Linen Services, Organ Procurement services, Radiology, Laboratory, and Respiratory services. Findings:

Review of the hospital's Quality Assessment and Improvement policy dated 06/05 revealed in part the following: This facility monitors the quality of care being provided to the patients at this facility. Services related to patient care that will be monitored include contracted services, nosocomial infections, and medication administration.

Review of the hospital's Organization Wide Quality Quality Assurance, dated 01/02/01, revealed in part the following: The facility has an organization-wide quality assurance plan which encompasses all organized services related to patient care.

Review of the hospital's Quarterly QAURRM (Quality Assurance/Utilization Review/Risk Management) meeting minutes for the year 2014 revealed no documented evidence that the following services were included in the QAPI program: Housekeeping, Maintenance, Speech Therapy, Occupational Therapy, PICC (Peripherally Inserted Central Catheters) Line insertions, physician/mid-level practitioner services, Hemodialysis, Biomedical Equipment services, Biohazard waste disposal, Linen Services, Organ Procurement services, Radiology, Laboratory, and Respiratory services.

In an interview on 05/18/15 at 9:50 a.m. S1Admin confirmed she was responsible for the QAPI program for the hospital. She confirmed all hospital services as indicated above were not included in the QAPI program. She stated she was not able to to do all she was responsible for and stated she had asked for help/resources to do the job. S1Admin confirmed the QAPI program had no written quality indicators and the quarterly reports identified as the QAURRM, were minutes that were documented by the former administrator from what was reported in the meeting. S1Admin confirmed there were no corrective action plans for any identified problems and stated when problems are found on chart audits she, "writes up the staff."


31048

Based on record review and staff interview, the hospital's governing body failed to ensure an ongoing program for quality improvement and patient safety was defined, implemented, and maintained as evidenced by failing to approve the QAPI program indicators and the frequency of data collection, failing to annually determine the number and type of performance improvement projects, and failing to actively review the results of QAPI data and reports. Findings:

Review of the hospital's Organization Wide Quality Quality Assurance, dated 01/02/01, revealed in part the following: The Medical Executive committee shall forward the information to the Governing Board of Director for review and recommendations.

Review of the hospital's Quality Improvement Monitoring and Responsibility policy, dated 01/02/01 revealed in part the following: Responsibility for the quality improvement program rests with the Governing Board of Directors. Governing Board of Directors: Assumes ultimate responsibility for the quality of care provided, At least annually, receives reports on all quality improvement activities, including the assessment of the effectiveness of quality improvement activities in identifying the quality of care, opportunities to improve patient care, and appropriate use of resources....The quality improvement reporting path flows upward from the staff, to the Quality Improvement Director, to the Administrator, to the Governing Board of Directors.

Review of the Governing Board Meeting Minutes for 2014 and 2015 revealed meetings were conducted on the following dates only: 02/26/14, 03/04/15, and 04/02/15. Further review of the Governing Board Meeting Minutes dated 04/11/13 revealed no mention of QAPI. There was no documented evidence in the meeting minutes, that the Governing Board reviewed any QAPI data or approved any quality indicators, data collection procedures, or identified and approved any QAPI projects. There was no mention of QAPI in any of the Governing Board meeting minutes.

In an interview on 05/15/15 at 3:15 p.m., S19COO (Chief Operating Officer & Acting Administrator) confirmed he was the comptroller and a member of the Governing Board. S19COO confirmed there was no documented evidence that the Governing Board reviewed any QAPI data or approved any quality indicators, data collection procedures, or identified and approved any QAPI projects. S19COO was unable to explain how the Governing Board was responsible for the QAPI program, or how QAPI information was evaluated by the Governing Board.

Based on record review and staff interview, the Hospital's Governing Body failed to ensure adequate resources were allocated for measuring, assessing, improving, and sustaining the hospital's performance improvement functions as evidenced by no budgeted funds allocated to the Quality Assessment Performance Improvement (QAPI) program and insufficient staff designated to conduct the QAPI functions of the hospital. Findings:

Review of the hospital's Quality Improvement Monitoring and Responsibility policy, dated 01/02/01 revealed in part the following: Responsibility for the quality improvement program rests with the Governing Board of Directors. Governing Board of Directors: Authorizes adequate resources and support to establish and maintain an organization wide quality improvement program, Assumes ultimate responsibility for the quality of care provided...

Review of the hospital budget for the year ending August 31, 2015 provided by S19COO (Chief Operating Officer, Comptroller, and Acting Administrator) as current, revealed no documented evidence of any funds allocated for the hospital's QAPI program.

In an interview on 05/15/15 at 3:15 p.m., S19COO (Chief Operating Officer & Acting Administrator) confirmed he was the comptroller and a member of the Governing Board. S19COO confirmed there were no funds allocated by the Governing Board for the QAPI program. He confirmed the Administrator was responsible for the QAPI program.

Review of the hospital's organizational chart revealed the following:
Listed under the Director of Nursing was a position for QA/Risk Management/Infection Control Coordinator/Charge Nurse. There was no person's name identified for this position on the chart. Under this position was listed the RN (Registered Nurse), then the LPN (Licensed Practical Nurse).

Review of the roster of current staff revealed no documented evidence of a staff or contractor identified as QA/Risk Management/Infection Control Coordinator/Charge Nurse.

In an interview on 05/15/15 at 9:35 a.m., S4MR (Medical Records) stated she was responsible for medical records for the hospital including the QAPI activities related to medical records. She stated she had not done any QAPI data collection for this year because she has not had time to do so. S4MR stated she was also responsible for central supply and was the office manager. S4MR provided the QAPI audit forms for 2014 and stated it was the same indicators she had used since 2003.

In an interview on 05/18/15 at 9:50 a.m. S1Admin confirmed she was responsible for the QAPI program for the hospital. S1Admin provided hand written notes on transfusion, laboratory, (problems that arise), incident reports, medication variance, falls (incident report & change of condition form). She stated she uses a transportation log because she does not have any tools. She stated she also reviews AMAs (Against Medical Advice), expired patient records, and adverse events. She stated the monitoring she does for wound vacs is basically if they are using any. S1Admin provided a copy of a physician order with medication error of in which penicillin was given to a patient that was allergic to the medication. When asked what corrective action was taken after this incident, she stated she, "wrote the nurse up." She stated no incident report was done, and stated she, "was behind" on reviewing medication errors. She confirmed all hospital services as indicated above were not included in the QAPI program. She stated she was not able to to do all she was responsible for and stated she had asked for help/resources to do the job. S1Admin confirmed the QAPI program had no written quality indicators and the quarterly reports identified as the QAURRM, were minutes that were documented by the former administrator from what was reported in the meeting. S1Admin confirmed there were no corrective action plans for any identified problems and stated when problems are found on chart audits she, "writes up the staff."

Based on record review and interviews, the hospital failed to ensure an effective system was in place to ensure that each physician/practitioner providing services in the hospital was credentialed in accordance with the Medical Staff By-laws for 4 of 4 (S3MD, S32Physician, S22APRN, S23APRN) current credentialed medical staff. Findings:

Review of the Medical Staff By-laws (no date), provided as current by S19COO (Chief Operating Officer and Acting Administrator) as current, revealed in part the following:
Article III. Membership: Initial appointment and reappointment to the Medical Staff will be made by the Board. Initial appointments are provisional, will be for a period of one (1) year. Reappointment will be for a period of not more than two (2) years.
Article VI. Procedure for Appointment/Clinical Privileges Section 1. All applications for appointment/clinical privileges to the Medical Staff will be submitted in the form designated by the Medical Executive Committee and the Board. The application will be submitted by the practitioner to the Medical Staff Office. The application will be reviewed by the Credential Committee. The Credential Committee will review an application and make a recommendation to the Medical Executive Committee.
When the recommendation of the Medical Executive Committee is favorable to the practitioner, the Chief Executive Officer (CEO) will forward it, together with all supporting documentation to the Board. At its regular meeting after receipt of a favorable recommendation, the Board will act in the matter. If the Board's decision is to approve the application, then the CEO will notify the practitioner, the Chief of Staff and the Medical Director.
Article V. Section 1. Clinical Privileges: Every initial application for staff appointment and reappointment or application for clinical privileges must contain a request for the specific clinical privileges desired by the applicant. The evaluation of such requests will be based upon the qualifications documented, current licensure, relevant training and/or experience, mental and physical health status, competence, and peer recommendations including an appraisal by, and recommendation.
Article VII. Procedure for Reappointment/Renewal of Clinical Privileges
In order to continue appointment and clinical privileges the practitioner shall reapply and be reviewed every two years as outlined by the Medical Staff Office. All applications for reappointment to the Medical Staff will be submitted in the form designated by the Medical Executive Committee and approved by the Board. The process is outlined under the Appointment/Clinical Privileges process.

Review of the Medical Staff Rules & Regulations revealed the process for Specified Professional Personnel Staff (SPPS-Nurse Practitioners) status included the same process as appointment/reappointment to the Medical Staff, except the review and reappointments were to be conducted annually.


S3MD (Medical Director)
Review of the credentialing file for S3MD revealed a written agreement for the position of Chief of Staff, dated 04/03/15. The file also revealed a written agreement for the position of Medical Director dated 02/16/14, but it was only signed by S3MD.
The credentialing file revealed an initial appointment application dated 04/11/11. The initial request for privileges on the record only included "Delineation of Privileges-page 2," and contained no documentation the requested privileges were accepted. The form also revealed S3MD had hand written in privileges for primary/general care hospital patients and arthrocentesis, but the privileges were not documented as accepted. The initial request for privileges was signed by S31Physician (Former Chief of Staff) on 08/25/11, the form was signed by a governing body member (S24Owner), but not dated. There was no documentation of medical staff recommendation for initial appointment, there was no documentation of governing body appointment to the medical staff, initial request for privileges, and no initial approval of privileges by MEC (Medical Executive Committee) and GB (Governing Body). There was no documented evidence of peer recommendations, curriculum vitae (CV), or continuing medical education in the application for initial appointment.
Review of the credentialing file revealed no documentation of an application for reappointment to the medical staff in 2012 when the initial appointment ended. The only document related to reappointment in 2012 was a Recommendations for Privileges form that was signed by S31Physician on 07/12/12 recommending active privileges. The form was also signed by a governing body member (S24Owner) granting active privileges on 07/23/12. There was no documented evidence of a request for privileges, peer recommendations, appraisals, or continuing medical education.
Review of the credentialing file revealed a Recommendations for Privileges form that was signed by S31Physician on 03/22/13 recommending active privileges. The form was also signed by a governing body member (S24Owner) granting active privileges on 03/22/13. There was no documented evidence of an application for reappointment, request for clinical privileges, peer recommendations, appraisals, or continuing medical education.
There was no documented evidence of a current application for reappointment, request for clinical privileges, peer recommendations, appraisals, or continuing medical education.
Review of the Governing Board Meeting Minutes dated 04/02/15 revealed the following: The Medical Staff re-appointments were approved as follows: S3MD, Medical Director/Acting Chief of Staff.

S32Physician
Review of the credentialing file for S32Physician revealed the physician was an orthopedic surgeon. The file revealed an initial appointment application dated 01/04/07 and included a delineation of privileges that was approved by the Chief of Staff and Governing Board.
There was no documented evidence of any subsequent applications for reappointment.
There was no documented evidence of any request for delineation of privileges since 01/17/07.
There was no documented evidence of any request for clinical privileges, peer recommendations, appraisals, or continuing medical education since 01/04/07.
The only documents in the credentialing file since 01/17/07 were the "Recommendations for Privileges" forms dated 02/19/08, 08/30/11, 07/23/12, 03/22/13, and 04/03/15.

Review of the Governing Board Meeting Minutes dated 04/02/15 revealed the following: The Medical Staff re-appointments were approved as follows: S32Physician, Director of Ortho(Orthopedic) Services (One day before the "Recommendations for Privileges" form was signed on 04/03/15).

S22APRN (Advanced Practice Registered Nurse-Nurse Practitioner)
Review of the credentialing file for S22APRN revealed a written agreement between the hospital and S22APRN for the provision of services of a nurse practitioner dated 08/25/14.
Review of the file revealed a letter dated 07/16/14 from the Louisiana State Board of Nursing (LSBN) that approved S3MD as the collaborative physician. There was no documented evidence of the collaborative practice agreement.
Review of the file revealed an application for appointment to the medical staff dated 07/28/14. Review of the Delineation of Privileges revealed clinical areas of practice (Cardiovascular, Central Nervous System, etc) were requested. The only procedure on the checklist was an EKG (electrocardiogram). There was no documented evidence that privileges were requested or approved to conduct patient history & physical assessments or give verbal orders/write orders for medications and treatments. The form was checked "Accepted" and signed by the Medical Staff (S3MD) and the Governing Board (S24Owner) on 08/29/14.
There was no documented evidence of continuing medical education and no documentation of appointment to the Medical Staff by the Governing Board.

S23APRN
Review of the credentialing file for S23APRN revealed a written agreement between the hospital and S23APRN for the provision of services of a nurse practitioner dated 07/18/11 that was signed only by S23APRN.
Review of the credentialing file for S23APRN revealed an initial appointment application dated 07/15/11. Review of the Delineation of Privileges revealed clinical areas of practice (Cardiovascular, Central Nervous System, etc) were requested. The only procedure on the checklist was an EKG. There was no documented evidence that privileges were requested or approved to conduct patient history & physical assessments or give verbal orders/write orders for medications and treatments. The form was not checked "Accepted," but was signed by the Medical Staff (S31Physician) on 08/25/11, and the Governing Board (S24Owner) on 09/02/11. Review of the "Recommendations for Privileges" form revealed the Chief of Staff recommended provisional privileges on 08/25/11, the form was signed by the Governing Board (S24Owner) on 08/25/11 also.
There was no documented evidence of any subsequent applications for reappointment.
There was no documented evidence of any request for delineation of privileges since 08/25/11.
There was no documented evidence of any request for clinical privileges, peer recommendations, appraisals, or continuing medical education since 08/25/11.
The only documents in the credentialing file since 08/25/11 were the "Recommendations for Privileges" forms dated 07/23/12, 03/22/13, and 04/03/15.
Further review of the credentialing file revealed no documented evidence of a DEA (Drug Enforcement Agency) license and no current CPR (Cardio Pulmonary Resuscitation) certification.
In a telephone interview on 05/14/15 at 4:15 p.m., S30HR confirmed she was responsible for the credentialing files. She stated S3MD is acting as chief of staff and he can't reappoint himself so the Governing Body does it. S30HR confirmed S3MD did not submit a reappointment application. She confirmed their current process for reappointment did not include delineation of privileges or an application for reappointment. S30HR stated she checked the data bank and verified current licensure and the approval of privileges was signed by Chief of Staff and Governing Board. She confirmed privileges are not requested or approved on re-appointment. When informed that Medical Staff By-laws indicated the process for reappointment required an application and request/approval of privileges, she stated she was not aware of that. S30HR confirmed the above findings.

Based on record review and interview, the Medical Staff failed to enforce its bylaws as evidenced by:
1) nurse practitioners writing orders, giving verbal orders and conducting history and physical assessments when medical staff bylaws prohibited such, and;

2) the physician failing to pronounce deceased patients for 4 of 4 (#10, #14, #21, #28) sampled death records reviewed out of a total sample of 30. Findings:

Review of the hospital's Medical Staff By-Laws, Rules & Regulations (no date) revealed in part the following:
Article III. - Membership on the Medical Staff is a privilege which may be extended only professionally competent physicians who continuously meet the qualifications, standards, and requirements set forth in these Bylaws.
B. Admission and Discharge of Patients: 6. In the event of the death of a patient, the deceased shall be pronounced dead by the attending physician or his/her designee within a reasonable period of time. The body shall not be released until an entry has been made and signed in the medical record of the deceased by a member of the Medical Staff.
E. Specified Professional Personnel Staff: 1. Definition: The Specified Professional Staff shall consist of non-hospital employee, such as Psychologist, Perfusionist, Physician Assistants, Nurse Practitioner....who are either employees or independent contractors of members of the Medical Staff hereinafter referred to as "sponsoring practitioners." The sponsoring practitioner bears ultimate responsibility for patient care. a. A member of the Specified Professional Personnel Staff (SPPS) may not: Prescribe medications or treatment; he/she can only communicate prescribed medication or treatment orders from the sponsoring practitioner. SPPS may not communicate medication or treatment prescriptions based on standing or blanket orders issued by the sponsoring practitioner.... b. Additionally, unless qualified by licensure and training, and granted specific permission by the Medical Executive Committee, SPPS may not: 1. Perform any invasive procedure. 2. Independently accomplish a patient history or physical examination. c. 1. All entries in patient charts made by SPPS must be countersigned by the sponsoring practitioner within twenty-four (24) hours.

Review of the medical record for Patient #2 revealed the patient was a current patient in the hospital and the admission orders dated 04/23/15 at 12:20 p.m. were documented by S22APRN (nurse practitioner). The orders were co-signed by S3MD (Medical Director), but the signature was not dated or timed. Further review of the physician's orders revealed S22APRN gave verbal orders for medications on 04/23/15 (4 verbal orders) and 1 on 04/24/15, 05/04/15, 05/06/15, and 05/07/15. Review of the physician orders revealed S23APRN wrote orders on 04/27/15 for lab tests, medication orders on 04/29/15 and 05/01/15. The orders revealed S3MD had co-signed but had not dated or timed his signature.
Further review of the record revealed S22APRN conducted the History & Physical (H&P)assessment on 04/23/15 at 1:30 p.m.. The H&P was co-signed by S3MD with no date/time of the signature.

Review of the medical record for Patient #5 revealed the patient was a current patient in the hospital and was admitted on 04/21/15. Review of the physician's orders revealed verbal orders were documented from the nurse practitioners on 04/21/15 (Foley), 04/23/15 (wound cultures, x-rays, medications), 04/26/15 (medications), 05/01/15 (medications), 05/02/15 (medications, restraints, 1:1 observation), 05/04/15 (medications, labs). The verbal orders were signed by S3MD, but there was no date/time documented for the signature. Further review of the physician's orders revealed S22APRN and S23APRN wrote orders for medications and treatments on 04/23/15, 04/26/15, 04/29/15, 05/04/15, and 05/11/15.
Further review of the record revealed S22APRN conducted the H&P assessment on 04/22/15 at 12:40 p.m. The H&P was co-signed by S3MD with no date/time of the signature.

In an interview on 05/14/15 at 10:00 a.m., S2DON (Director of Nursing) reviewed the above medical records and confirmed the verbal and written orders documented by S22APRN and S23APRN. She stated the nurse practitioner is usually called first and stated S3MD only comes to the hospital one day a week.
Review of the credentialing files for S22APRN and S23APRN revealed no documented evidence of privileges to order medications, give verbal orders, or conduct H&Ps.

In a telephone interview on 05/14/15 at 4:15 p.m. S30HR (Human Resources/Billing) confirmed she was responsible for credentialing files. She confirmed the privileges for the nurse practitioners indicated only the clinical areas (Central Nervous System, Gastrointestinal, etc), and the only procedure listed on the privileges was an EKG (electrocardiogram). She confirmed there was no documented evidence of privileges requested or approved for ordering medications, giving verbal orders, or conducting history & physicals.

In a telephone interview on 05/14/15 at 4:23 p.m. S3MD confirmed he was currently the Chief of Staff and Medical Director at the hospital. He stated he signed verbal orders when he was in the building. S3MD stated the nurse practitioners (S22APRN & S23APRN) write orders and give verbal orders just like he does. He stated he signs their orders when he is there. He stated the nurse practitioners call him when they have questions, but they do not call and get verbal orders from him. S3MD confirmed the nurse practitioner conduct and document the H&Ps and he co-signed them. S3MD stated he had not read the Medical Staff By-laws, Rules & Regulations. After informing him of the above Medical Staff By-laws and Rules & Regulations, he stated he was not aware of these rules and confirmed the current practices of the nurse practitioners writing orders and conducting H&Ps was not in compliance with the medical staff rules. S3MD stated he could not believe the hospital had not revised the By-laws. S3MD stated he had a practice away from the hospital and confirmed he was onsite at the hospital 1 day a week.

2) The physician failing to pronounce deceased patients:

Patient #10
Review of Patient #10's medical record revealed the patient was a 88 year old male admitted on 09/6/14 with the diagnoses of Pressure Ulcer and Pneumonia. Patient #10 expired on 09/24/14. Patient #10 had a DNR (Do Not Resuscitate) order on his medical record.

Review of Patient #10's Nurses Notes, dated 09/23/14 and timed 11:35 p.m., revealed in part, Called to pt. (patient) room per LPN (Licensed Practical Nurse), pt unresponsive, no resp. (respirations) no pulse, no heart or breath sounds auscultated. Pt. was DNR status, DNR on chart. S21Coroner notified. DON (Director of Nurses) notified, stating she would notify pt's son of pt's status. Pt's son confirmed that pt was to be released to H.... Funeral Home in (Mississippi). Notified funeral home of pending release of body pending arrival of coroner. notified of pt. status.
09/24/14 12:50 a.m.- S21Coroner arrived, pronounced pt at 12:55 a.m. Postmortem care implemented...


Patient #14
Patient #14 was a 92 year old female admitted on 05/8/14 with the diagnosis of Sepsis. Further review of the medical record revealed the patient had a DNR order. The patient expired on 05/16/14.

Review of the Nurses' Notes, dated 5/16/14 at 5:30 a.m. revealed, Nurse at bedside with dtr(daughter), Pt (Patient) Resp (respirations) 0, no heart rate/pulse audible. Notified S20APRN (Advanced Practice Registered Nurse-Nurse Practitioner) of pt status. No code called per Advanced Directive, DNR on chart. Awaiting S20APRN arrival to facility. Dtr. remains at bedside.

Review of the Nurses' Notes dated 05/16/114 at 6:35 a.m. revealed S20APRN present, pronounced pt death at 6:35 a.m. Indwelling Foley removed. Dtr removed all personal belonging of pts. Body to released to R.....Funeral Home.

Review of Patient #14's Discharge Summary, dictated by S20APRN, revealed in part, I was contacted 05/16/14 at 5:30 a.m. and told by the nursing staff that the patient had no respiration and no heart rate. There was a DNR. I came in and saw her pupils were 4 mm (millimeters) dilated and fixed bilaterally. She had no respirations or apical pulse that could be auscultated. Her vital signs were undetectable. Assessment is cardiopulmonary arrest, duodenal neoplasm.

An interview was conducted with S19COO (Chief Operating Officer and Acting Administrator) and S2DON (Director of Nursing) on 05/13/15 at 3:00 p.m. They confirmed Patient #10 and #14 was not pronounced dead by a physician as required by the Medical Staff Bylaws per record review. S19COO and S2DON further reported most of the current nursing staff were recently employed with the hospital and was not employed with the hospital when the deaths occurred.


Patient #21
Review of the medical record for Patient #21 revealed the patient was an 88 year old male admitted to the hospital on 04/05/14 with diagnoses of Malnutrition, Secondary Malignant Neoplasm of Liver, Lung, and Adrenal Gland, Urinary Tract Infection, and Dehydration. Review of the record revealed the patient did not have an advance directive on admission.

Review of the Nurses' Notes dated 04/19/15 at 2:15 p.m. the patient was found unresponsive with no respirations, no pulse, no heart beat or breath sounds. Code initiated and EMS (Emergency Medical Services) called. At 2:37 p.m. the code ceased at niece's request per advance directive signed DNR. At 3:28 p.m. S20APRN at bedside - pronounced patient. At 5:00 p.m. Coroner states will not be out to hospital. At 6:00 p.m. the body was released to the funeral home.

Review of the Discharge Summary, dictated by S20APRN on 05/08/15 revealed in part the following: I was contacted later that afternoon at 2:15 p.m. and was told that Patient #21 had, in fact, coded. Ambulance was called as well as his Power of Attorney. At 2:37 p.m. the patient's power of attorney gave a verbal to make him a DNR. At that time he was in asystole (no heart beat) in two leads via the ambulance service. Strips printed showing at 2:42 p.m. CPR (Cardio Pulmonary Resuscitation) was stopped. I came in and saw him. His left pupil was fixed and dilated about 3 mm; due to his blindness you couldn't make out his right pupil. He had no blood pressure, no pulse, and no spontaneous respirations. Upon auscultation I was unable to detect apical pulse or any respirations. S3MD was notified at 3:28 p.m. on the 19th. I spoke with him and the patient was pronounced at 3:28 p.m....

In an interview on 05/14/15 at 10:30 a.m. S2DON reviewed record for Patient #21 and confirmed there was no documented evidence that the patient's physician pronounced the patient dead and the record indicated the nurse practitioner pronounced patient.


Patient #28
Review of the medical record for Patient #28 revealed the patient was a 66 year old female admitted to the hospital on 02/05/14 with diagnoses of Sepsis, Pneumonia, Pancreatic Cancer, Laryngeal Cancer, Hypertension, Diabetes Mellitus, and Coronary Artery Disease. The record revealed the patient was a DNR on admission.

Review of the Nurses' Notes dated 02/12/14 at 4:20 p.m. revealed the patient had no respiration, no apical pulse, no heart or breath sounds auscultated. Patient's daughter at bedside. No code called as per advance directive, signed DNR order on chart. At 4:35 p.m. S23APRN pronounced death.

Review of the Discharge Summary dictated by S23APRN on 02/16/14 revealed the following: Patient #28 did expire on 02/12/14. At 4:20 p.m. she was found by the nursing staff to be without respirations and a pulse. At 4:35 p.m. she was pronounced dead. Pupils were fixed and dilated. S26Physician was notified and at that time she was pronounced. Patient #28's body was released to funeral home.

Review of the physician progress notes revealed S23APRN documented a death note on 02/12/14 at 4:35 p.m. The note revealed, "S26Physician notified patient pronounced at 4:35 p.m." The progress note was co-signed by S26Physician on 02/13/14 at 2:09 p.m.

In an interview on 05/18/15 at 3:48 p.m., S1Admin reviewed the medical record for Patient #28 and confirmed there was no documented evidence the attending physician pronounced the patient.

In a telephone interview on 05/14/15 at 4:23 p.m., S3MD stated he does come in and pronounce some patients and stated if he did pronounce a patient he wound document it in the patient's record and stated, "more than a signature." S3MD stated he did not recall the above sampled patients.

25065

Based on record reviews and interviews, the hospital failed to ensure a registered nurse (RN)supervised and evaluated the nursing care for each patient as evidenced by :

1) The Registered Nurse failed to obtain daily weights as ordered by the physician on 4 (#1, #3, #4, #7) of 4 patients patients' records reviewed for daily weights from a sample of 30 patients.
2) The Registered Nurse failed to maintain strict I and O (Intake and Output) as ordered by the physician for patients (Patient #1) out of a sample of 30 patients.
3) The RN failed to ensure physician orders were implemented for: oxygen (#3); rotating saline lock sites (#3, #7); thromboembolytic (TED) hose (#3, #7); and failed to ensure physician's orders were implemented for sliding scale insulin for 1 (#4) of 3 (#4, #18, #30) patients' records reviewed for implementation of physician orders from a sample of 30 patients.
4) The RN failed to assess patient wounds and obtain orders for wound care for 3 of 3 (#2, #5, #27) current sampled patients reviewed with wounds out of a total sample of 30. Findings:

1) The Registered Nurse failed to obtain daily weights as ordered by the physician:

Review of the hospital policy titled "Patient Weight," contained in the policy manual presented as the current hospital policies by S2DON (Director of Nursing), revealed that patients will be weighed on admission and weekly unless ordered more frequently.

Patient #1
Patient #1 was a 68 year old male admitted to the hospital on 04/15/15 for wound care.

Review of the Physician Admission Orders dated 04/15/15, and timed 9:00 a.m., for Patient #1 revealed an order for daily weights.

Review of the Graphic Sheets dated 04/15/15 to 05/12/15 revealed the patient's weight was not monitored on the following days: 05/01/15, 05/04/15, 05/07/15, 05/09/15, 05/11/15, and 05/12/15.

Patient #3
Review of Patient #3's medical record revealed he was a 92 year old male admitted on 04/29/15 with admit diagnoses of COPD (Chronic Obstructive Pulmonary Disease), CHF (Congestive Heart Failure), and Aspiration Pneumonia. Review of his History and Physical Examination documentation revealed diagnoses of Benign Prostatic Hypertrophy (BPH), Hypertension, COPD (Chronic Obstructive Pulmonary Disease), Anemia, and GERD (Gastroesophageal Reflux Disease).

Review of Patient #3's "Admission Orders" revealed an order to weigh daily. Review of Patient #3's "Graphic Sheet" revealed no documented evidence that his weight was assessed by the RN on 04/30/15, 05/01/15, 05/02/15, 05/04/15, 05/05/15, 05/07/15, 05/08/15, 05/09/15, 05/10/15, and 05/11/15.

Patient #4
Review of Patient #4's medical record revealed he was a 63 year old male admitted to the hospital on 04/27/15. Diagnoses included: IDDM (Insulin Dependent Diabetes Mellitus), Uncontrolled; Muscle Weakness; Unsteady Gait; Osteoarthritis; GERD (Gastroesophageal Reflux Disease); Hypertension; and Hypothyroidism.

Review of the Patient #4's "Admission Orders" revealed an order to weigh daily. Review of Patient #4's medical record and the Patient Weight documentation sheet kept at the nurse's station revealed no documented evidence that his weight was assessed by the RN on 05/09/15, 05/10/15, and 05/11/15.

Patient #7
Review of Patient #7's medical record revealed she was an 88 year old female admitted on 05/07/15 with diagnoses of Left Lower Lobe Pneumonia, Coronary artery Disease (CAD), Anxiety, Hypothyroidism, Hyperlipidemia, and IBS (Irritable Bowel Syndrome).

Review of Patient #7's "Admission Orders" revealed an order to weigh daily. Review of Patient #7's "Graphic Sheet" revealed no documented evidence that her weight was assessed by the RN on 05/08/15, 05/09/15, 05/10/15, and 05/11/15.

An interview was conducted with S2DON on 5/13/15 at 2:30 p.m. She confirmed the weights were not documented in the medical records on the above listed dates.



2) The Registered Nurse failed to maintain strict I and O (Intake and Output) as ordered by the physician:

Patient #1
Patient #1 was a 68 year old male admitted to the hospital on 04/15/15 for wound care.

Review of the Physician Admission Orders dated 04/25/15 at 5:35 p.m. revealed an order for Strict I and O (Intake and Output).

Review of the Fluid Intake and Output Sheet revealed Strict I and O were not documented on the following days: 04/27/15, 04/28/15, 04/29/15, 05/01/15, 05/02/15, 05/06/15 and 05/11/15.

An interview was conducted with S2DON on 05/13/15 at 2:30 p.m., she confirmed strict I and O was not done accurately on Patient #1.


3) The RN failed to ensure physician orders were implemented for oxygen (#3); rotating saline lock sites (#3, #7); and thromboembolytic (TED) hose (#3, #7); and failed to ensure physician's orders were implemented for sliding scale insulin for 1 (#4) of 3 (#4, #18, #30)

Oxygen:
Patient #3
Review of Patient #3's medical record revealed he was a 92 year old male admitted on 04/29/15 with admit diagnoses of COPD, CHF, and Aspiration Pneumonia. Review of his History and Physical Examination documentation revealed diagnoses of BPH, Hypertension, COPD, Anemia, and GERD.

Review of Patient #3's "Admission Orders" revealed an order for Oxygen per nasal cannula at 2 liters per minute continuously. Review of Patient #3's "Physician's Orders" revealed an order on 05/03/15 at 9:15 a.m. to wean oxygen to keep the oxygen saturation greater than 92% (per cent).

Review of Patient #3's "Daily Nursing Record" revealed oxygen was administered per nasal cannula at various rates between 0.5 liters to 1.5 liters when her oxygen saturation was below 92% on 05/03/15 with no documented evidence of a physician's order other than 2 liters per minute per nasal cannula. Further review revealed oxygen was administered when her oxygen saturation was above 92% on 05/03/15 and 05/05/15. Further review revealed oxygen was administered with no documented evidence of the oxygen saturation to determine if it was below 92% in accordance with physician orders on 05/05/15, 05/06/15, 05/07/15, 05/08/15, and 05/10/15.

Rotating Saline Lock Sites:
Patient #3
Review of Patient #3's medical record revealed he was a 92 year old male admitted on 04/29/15 with admit diagnoses of COPD, CHF, and Aspiration Pneumonia. Review of his History and Physical Examination documentation revealed diagnoses of BPH, Hypertension, COPD, Anemia, and GERD.

Review of Patient #3's "Physician's orders" dated 04/29/15 at 6:30 p.m. revealed an order to start a saline lock and maintain with 3 milliliters flush every shift, as needed, and before and after IV (intravenous) medications. Further review revealed the saline lock site was to be rotated every 72 to 96 hours and as needed.

Review of patient #3's "Medication/Treatment Administration Record" (MAR) and nursing narrative notes revealed a saline lock was inserted to the left forearm on 04/30/15 at 4:00 a.m. Further review revealed the saline lock was rotated on 05/03/15, and there was no documented evidence the site was rotated until 05/08/15 (120 hours rather than within 72 to 96 hours as ordered).

Patient #7
Review of Patient #7's medical record revealed she was an 88 year old female admitted on 05/07/15 with diagnoses of Left Lower Lobe Pneumonia, CAD, Anxiety, Hypothyroidism, Hyperlipidemia, and IBS.

Review of Patient #7's "Physician's Orders" revealed an order on 05/07/15 at 6:30 p.m. to start IV access, maintain saline lock, and rotate site every 3 days. Review of her MAR and nursing narrative notes revealed her saline lock was started on 05/07/15 at 7:15 p.m. Further review revealed no documented evidence that the saline lock was rotated on 05/10/15 in accordance with physician orders.

Thromboembolytic Hose:
Patient #3
Review of Patient #3's medical record revealed he was a 92 year old male admitted on 04/29/15 with admit diagnoses of COPD, CHF, and Aspiration Pneumonia. Review of his History and Physical Examination documentation revealed diagnoses of BPH, Hypertension, COPD, Anemia, and GERD.

Review of Patient #3's "DVT/PE (deep vein thrombosis/pulmonary embolus) Prophylaxis" revealed an order on 04/29/15 at 2:15 p.m. for TED stockings to both legs, thigh-high, to be on at 6:00 a.m. and removed at 9:00 p.m. Review of the entire medical record revealed no documented evidence that TED hose had ever been applied.

Patient #7
Review of Patient #7's medical record revealed she was an 88 year old female admitted on 05/07/15 with diagnoses of Left Lower Lobe Pneumonia, CAD, Anxiety, Hypothyroidism, Hyperlipidemia, and IBS.

Review of Patient #7's "Admission Orders" revealed an order for TED hose. Review of the entire medical record revealed no documented evidence that TED hose had ever been applied.

In an interview on 05/13/15 at 9:15 a.m., S2DON (Director of Nursing) confirmed that Patients #3 and #7 had not had TED hose applied since their admission.

Sliding Scale Insulin Orders:
Patient #4
Review of Patient #4's medical record revealed he was a 63 year old male admitted to the hospital on 04/27/15. Diagnoses included: IDDM (Insulin Dependent Diabetes Mellitus), Uncontrolled; Muscle Weakness; Unsteady Gait; Osteoarthritis, GERD Gastroesophageal Reflux Disease), Hypertension; and Hypothyroidism.
Review of a policy entitled, "Hypoglycemia" (low blood sugar) dated 07/12 presented by S4MR (Medical Records) as current, revealed, in part: "Purpose: The purpose of this policy is to serve as a guideline for intervention in case of a hypoglycemic event and is not intended to override orders given by a staff practitioner. Policy: In the event of a hypoglycemic reaction, there are established immediate interventions to be initiated to promote optimal results in the event of an impending crisis situation. Procedure: 1.c. If the reading is less than 60 and the patient is alert, provide the next meal if it is scheduled within the next hour....recheck every 15 minutes until it is above 70 or there is a decline in consciousness, then recheck immediately. Recheck every 5 minutes until above 70. 1.e. "....give 1 mg (milligram) Glucagon injection and start a venous access if none present. Recheck the sugar in 5 minutes..."1.g. Notify the physician/practitioner of the events and interventions with the response to interventions. Document with specific times and the date for each intervention and the patient's response and all relevant information."
Review of Patient #4's medical record revealed the following physician orders for "Sliding Scale for Insulin Administration: The patient is to have the following administered for the specified blood glucose ranges taken via accucheck. Blood glucose 0-60: Give orange juice and call MD/NP (Nurse Practitioner)/PA (Physician Assistant).
Review of Patient #4's nurse's notes dated 04/29/15 at 2:00 a.m., revealed the following: "Hypoglycemic episode, CBG (capillary blood glucose) 51. Pt. symptomatic, able to consume 100%, one can Ensure, will reassess. Skin diaphoretic (sweating) and clammy, delayed response upon initial assessment." 04/29/15 at 3:00 a.m.: "CBG rechecked, 51, more alert, no diaphoresis noted." 04/29/15 at 4:00 a.m.: "CBG rechecked, 58, awake, alert, and oriented times four, juice given, will reassess. Skin warm and dry to touch, no complaints..." 04/29/15 at 5:30 a.m.: "In bed, no acute distress noted. Skin warm and dry to touch, right forearm heplock, patent and secure, flushed easily. CBG 67, asymptomatic, respirations even and unlabored..." 04/29/15 at 6:30 a.m.: S23APRN (Advanced Practice Registered Nurse-Nurse Practitioner) notified of hypoglycemic episode, new orders given..." 04/29/15 at 7:08 a.m.: "Up on side of bed, diaphoretic, unable to comprehend, verbally unresponsive, assisted to bed. Hypokit Glucagon injection 1 mg IM (intramuscular) given in right deltoid (arm muscle) for CBG 51. Tolerated without difficulty. S23APRN notified. No additional orders given." 04/29/15 at 7:45 a.m.: CBG 73, more alert...responsive verbally." 04/29/15 at 11:10 a.m.: made aware of pt blood glucose 53, pt diaphoretic, alert, answering questions appropriately, able to feed patient apple juice, apple sauce, and tuna sandwich. LPN (Licensed Practical Nurse) at bedside to continue monitoring." 04/29/15 at 11:23 a.m.: "Accucheck (blood glucose reading) 58, pt. stable, communicating, will continue to assess." 04/29/15 at 12:00 a.m.: "Blood sugar 52, S23APRN notified, order to give Glucagon injection, order carried out, continue to monitor. Pt awake, alert, and oriented times four, responding appropriately." 04/29/15 at 1:45 a.m.: "Blood sugar 112, resting quietly, no acute distress noted." 04/29/15 at 5:30 a.m.: "Blood sugar 49, Glucagon injection administered. Patient is awake, alert and oriented times four, skin warm and dry. Continue to monitor." 04/29/15 at 5:40 a.m.: "Blood sugar 136. Assisted to bathroom, had bowel movement. No distress noted. Gait is slow and unsteady. Close observation ongoing."

In an interview on 05/18/15 at 12:15 p.m., S1Admin reviewed all of the above entries in Patient #4's medical record and confirmed the nursing staff did not follow the physician's orders for "Blood glucose 0-60, give orange juice and call MD/NP/PA, and did not follow the hospital's policy and procedure for hypoglycemia, and the nursing staff should have followed the physician's orders and the hospital's policy and procedures for hypoglycemia.


4) The RN failed to assess patient wounds and obtain orders for wound care for 3 of 3 (#2, #5, #27) current sampled patients reviewed with wounds out of a total sample of 30.

Review of the hospital policy titled, "Wound Care" (no date) revealed in part the following: There are pictures taken of the wound initially and weekly, unless otherwise indicated to show progress. The wound description will include size, depth, color, drainage, odor (if applicable), treatment performed, tolerance to treatment, changes and any other characteristics noted. There will be an order written for any treatment performed to the wound. The wound is assessed daily by the registered nurse or the physical therapist with documentation.


Patient #2
Review of the medical record for Patient #2 revealed the patient was a 68 year old female admitted to the hospital on 04/23/15 with a diagnosis of Wound Care. Review of the History & Physical (H&P) revealed the following: complicated patient. Plan of care: Abdominal incision/wound, decubitus ulcer left buttock, Diabetes Mellitus-poorly controlled, Hypertension, Asthma, Obesity, Degenerative Joint Disease, Osteoarthritis, Chronic Pain. Wound care, bariatric bed. Labs, Chest X-Ray, cultures pending. Admitted for wound care for abdominal. Incision. Has history of colon Ca (cancer) approx. 30 years ago & had a colostomy. Developed an abdominal hernia last year that ruptured in September. Had colostomy revision 11/20/14 and final abdominal surgery 12/20/14. Developed infection; wound vac discontinued 2 weeks ago and incision left open.

Review of the admission orders dated 04/23/15 at 12:20 p.m. revealed an order for a consult for PT (Physical Therapy), WCS (Wound Care Services), and wound debridement.

Review of the wound photos/assessments documented by the RN on admission (04/24/15) revealed the patient's wounds were photographed and an assessment documented for the following wounds:
Abdominal surgical incision - 0.5 cm. (centimeter) X 0.5 cm., scant, purulent drainage with pink wound bed
Left ischium bottom (no photo) - 2 cm. X 2 cm., pressure ulcer stage II, scant serosanguinous drainage.
Left ischium top (no photo) - 3 cm. X 3 cm., pressure ulcer stage II, scant serosanguinous drainage.
Right buttock (no photo) - 2.5 cm. X 3 cm., pressure ulcer stage II, scant serosanguinous drainage.

Review of the wound photos/assessments documented by the RN on 05/01/15 (1 week later) revealed the following:
Right buttock - 1" (inch) X 1" no drainage. Photo attached.
L (Left) buttock wound I & II - I: 0.5 X 0.5; II: 1.0 X 1.0 no drainage checked. There was no documented evidence of a photo or wound assessment of the abdominal wound.
Review of the wound photos/assessments documented by the RN on 05/04/15 (3 days later) revealed the following
L buttock wound I & II - I: 1.5 X 0.5; II: 1.0 X 0.5 no drainage checked. There was no documented evidence of a photo or wound assessment of the abdominal wound.

Review of the daily nursing assessments revealed the wound locations were identified on the nursing flow sheets, but there was no documented evidence of daily wound assessments.

Review of the PT evaluation revealed no debridement was indicated.

Review of the record revealed there was no wound care ordered for any of the patient's wounds until 05/05/15 when Exuderm (Duoderm-Hydrocolloid) dressing was ordered to be applied to the buttocks every 3 days.
Review of the Wound Treatment Records revealed the Exuderm was the only wound care provided and it was done on 05/05/15, 05/08/15, and 05/12/05.

In an interview on 05/13/15 at 2:40 p.m., S2DON stated the patient had wound care and stated to look on the wound treatment record. S2DON reviewed wound treatment records and confirmed the only treatment documented was the Exuderm that was started on 05/05/15. She confirmed the patient's admitting diagnosis was wound care and none was ordered until 05/05/15. She stated the main wound concern was with wounds on her buttocks. S2DON stated the nurses did clean and dress the abdominal surgical wound. She confirmed there were no orders for this wound care and no documentation that the nurse performed it. She confirmed daily wound assessments were not documented and weekly wound assessments and photos were not done as directed in the policy.

Patient #5
Review of the medical record for Patient #5 revealed the patient was a 92 year old female admitted to the hospital on 04/21/15 with a diagnosis of Decubitus Ulcer buttock/Unstageable.
Review of the admission orders dated 04/21/15 revealed the patient had decubitus wounds to the left hip, right heel, and left buttock. PT, WCS, Wound Debridement were ordered by the physician.
Review of the Daily Nursing Record from 04/21/15 to present revealed no documented evidence of daily wound assessments by the RN.
Review of the wound photos/assessments documented on admission (04/21/15) revealed the patient's wounds were photographed and an assessment documented as follows by S25LPN (Licensed Practical Nurse) for the following wounds:
Left hip (no type of wound identified), size: 6 X 4, no other wound assessment documented.
Buttocks (no specific location and no type of wound identified), size: 1.5 X 1.5, 4.5 X 7.0, no other wound assessment documented.
Right heel (no type of wound identified), size: 5.5 X 7, no other wound assessment documented.
Review of the weekly wound assessments/photos dated 04/27/15, documented by S14LPN revealed the wounds assessed and photographed were as follows:
Right heel wound - size: 6 X 7, with moderate serosanguinous drainage with slight odor. Slough was documented in the wound bed. The type of wound was not documented.
Left hip - pressure ulcer checked, but no stage identified. Size: 5.4 X 3.8, small, bloody drainage.
Sacrum, Left buttock - size: 2.4 X 4.6, small, serosanguinous drainage with slight odor. The wound bed was documented as slough and black/brown eschar.
Review of the weekly wound photographs dated 05/11/15 revealed an LPN documented she took photographs of the Right heel, and 2 photos with no documentation of the location.

Further review of the record revealed on 04/24/15, S6PT documented a debridement of the left buttocks on 04/24/15. The note revealed the wound bed was 4.5 cm. X 7.0 cm. with tunnel at 6 O'clock position, and debridement performed down to 4 cm. depth without finding viable tissue. A general surgeon consult was requested.

Review of the wound care orders and wound treatment records revealed there were no changes in the wound care since 04/24/15 when the wound was identified as not progressing. The wound care orders revealed the only change was to apply Iodoform packing gauze into the tunnel. Further review of the record revealed the patient did not see the general surgeon until 05/12/15.

In an interview on 05/13/15 at 2:00 p.m., S6PT confirmed he did debridements on Patient #5 and the last time he debrided the wounds he was not comfortable going any further and thought the wounds were not progressing. He confirmed he documented wound care orders on 04/24/15 after the last debridement. He stated he did not change the wound care after that because he was not asked to. He stated he only evaluates a patient when asked to do so by the staff, and does not re-evaluate wounds unless he is asked to.

In an interview on 05/14/15 at 10:00 a.m., S2DON stated they realized they needed wound care training (a wound nurse) and that is why S1Admin is at a wound care course. She confirmed there were no new wound care orders after 04/24/14 when PT debrided the wound and indicated the wound was not improving. She stated they tried to get the patient a surgery consult with a physician in another city (city 30 minutes away), but since the patient had to go by geri (geriatric) chair, he would not go to the emergency room to see her. She further stated they had to find someone else, and that was why it was not done until 05/12/15.

In an interview on 05/18/15 at 11:00 a.m., S1Admin reviewed the wound care documentation for Patient #5. S1Admin stated the LPN can photograph the wound but the RN must measure, stage, and assess the wound. She confirmed Patient #5 had no documentation of wound assessments by the RN. She confirmed the wounds were not measured correctly and confirmed wound progress could not be assessed from the assessments. After reviewing the daily nursing assessments she confirmed a daily wound assessment was not being documented, and she confirmed the nursing staff were identifying the location of the wound on their flow sheets, but they were not documenting an assessment of the wound.

Patient #27
Review of the medical record for Patient #27 revealed the patient was a 70 year old female admitted to the hospital on 05/14/15 with a diagnosis of unstageable decubitus ulcer to sacrum. Review of the admission orders dated 05/14/15 revealed an order for wound care orders per the Physical Therapist.
Review of the Initial Nursing Assessment revealed no documentation of a wound assessment.
Review of the Daily Nursing Record dated 05/16/15 and 05/17/15 revealed no documented evidence of daily wound assessments by the RN.
Review of the wound photos/assessment documented on admission (05/14/15) revealed the patient's wounds were photographed and an assessment documented by the RN. The assessment revealed the wound was located sacral, size was 8 cm. W (width) X 7 cm. L (length), with slight odor, black/brown eschar.
Review of the record revealed a Debridement Progress Note dated 05/15/15 revealed S6PT debrided the sacral wound at 7:00 p.m. The note revealed the top layer of eschar was removed and Santyl was applied followed by Optifoam and an ABD pad, and then secured with Medfix tape.
Review of the wound treatment record revealed the following: Sacral Wound: Cleanse wound with Dakins & apply Santyl to wound bed, cover with Optifoam and ABD. Secure with Medfix tape. Change dressing twice a day.

Review of the physician's orders revealed no documented evidence of wound care orders.
In an interview on 05/18/15 at 3:27 p.m., S1Admin reviewed the patient's medical record, and she confirmed the daily wound assessments were not documented. She also confirmed there were no physician's orders for wound care.


26351




31048

Based on record reviews and interviews, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan for each patient as evidenced by having nursing care plans that were not individualized with all diagnoses for which the patient was being treated and having goals not stated in measurable terms to determine when a patient's goal was met for 2 of 2 (#3, #7) patient records reviewed for nursing care plans from a total sample of 30 patient records. Findings:

Review of the hospital policy titled "Professional Plan Of Care," contained in the policy manual presented as the current hospital policies by S2DON (Director of Nursing), revealed that an individualized nursing plan of care shall be initiated within 24 hours of admission. The plan must include specific, individualized, measurable goals and interventions, specific services to be provided including frequency and duration, and action steps to achieve the goals. Care plans will be reviewed and updated on an ongoing basis.

Patient #3
Review of Patient #3's medical record revealed he was a 92 year old male admitted on 04/29/15 with admit diagnoses of COPD (Chronic Obstructive Pulmonary Disease), CHF (Congestive Heart Failure), and Aspiration Pneumonia. Review of his History and Physical Examination documentation revealed diagnoses of Benign Prostatic Hypertrophy (BPH), Hypertension, COPD (Chronic Obstructive Pulmonary Disease), Anemia, GERD (Gastroesophageal Reflux Disease). Further review revealed physician orders for wound care to the right upper extremity on 04/30/15 at 11:45 a.m.

Review of Patient #3's care plan revealed a care plan was developed for impaired gas exchange, impaired skin integrity, and potential for injury related to falls. Further review revealed no documented evidence that a care plan was developed for Hypertension, Anemia, and GERD.

Review of Patient #3's care plan for impaired gas exchange revealed the long term goal was that the patient will have improved gas exchange indicated by respiratory rate, oxygen saturations, and improved endurance. There was no documented evidence of the parameters to be used in assessing his respiratory rate, oxygen saturation, and endurance to determine when the goal would be met.

Review of Patient #3's care plan for impaired skin integrity revealed the long term goals were stated as "patient will show signs on healing by ____; pt. (patient) will practice skin precaution techniques by 25." There was no documented evidence that these goals were stated in measurable terms that could be used to determine when the goals were met.

Review of Patient #3's care plan for potential for injury related to falls revealed the long term goals were stated as "Patient will demonstrate safe gait practices by 25; pt. will not self injure r/t (related to) falls by 25." There was no documented evidence that these goals were stated in measurable terms that could be used to determine when the goals were met.

Patient #7
Review of Patient #7's medical record revealed she was an 88 year old female admitted on 05/07/15 with diagnoses of Left Lower Lobe Pneumonia, Coronary artery Disease (CAD), Anxiety, Hypothyroidism, Hyperlipidemia, and IBS (Irritable Bowel Syndrome). Further review revealed she was prescribed Metformin and had orders for Accuchecks before meals, at bedtime, and as needed.

Review of Patient #7's care plan revealed a care plan was developed for impaired gas exchange, alteration in immune system related to respiratory infection, and potential for injury related to falls. Further review revealed no documented evidence that a care plan was developed for Anxiety, Diabetes, IBS, Hypothyroidism, and Hyperlipidemia.

Review of Patient #7's care plan for impaired gas exchange revealed the long term goal was that the patient will have improved gas exchange indicated by respiratory rate, oxygen saturations, and improved endurance within 25 days. There was no documented evidence of the parameters to be used in assessing her respiratory rate, oxygen saturation, and endurance to determine when the goal would be met.

Review of Patient #7's care plan for alteration in immune system related to respiratory infection revealed the long term goal was that the patient will have no signs and symptoms of infection by 06/02/15. There was no documented evidence of which signs and symptoms were to be assessed to determine when the goal would be met.

Review of Patient #7's care plan for potential for injury related to falls revealed the long term goals were stated as "Patient will demonstrate safe gait practices by 06/01/15; pt. will not self injure r/t falls by 06/02/15." There was no documented evidence that these goals were stated in measurable terms that could be used to determine when the goals were met.

In an interview on 05/13/15 at 3:05 p.m., S2DON confirmed the medical records of Patients #3 and #7 did not have care plans developed for all diagnoses for which these patients were being treated, and the goals were not stated in measurable terms.

Based on record reviews and interviews, the hospital failed to ensure that drugs and biologicals were administered in accordance with physician orders for 3 of 3 (#2, #3, #7) patient records reviewed for medication administration from a total of 30 sampled patient records. Findings:

Review of the hospital policy titled "Medication Administration," contained in the policy manual presented as the current hospital policies by S2DON (Director of Nursing), revealed that the apical pulse will be checked prior to the administration of any digitalis medication. If the pulse is below 60, the medication will be held, and the physician will be notified. Apical pulse rate is to be recorded on the MAR (Medication Administration Record). Further review revealed that all medication administration will be documented on the MAR. Stat medications are to be given within 30 minutes, and Now medications are to be given within 60 minutes. Further review revealed that all medication orders shall include the time and date the order was written and received. Antibiotic therapy should not be delayed to fit the standard administration schedule, and the time interval will be started from the first dose. A variance of 30 minutes before and 30 minutes after the scheduled time for administration of the medication is acceptable, with the exception of those doses scheduled to be given before or after meals.

Patient #2
Review of the medical record for Patient #2 revealed the patient was a 68 year old female admitted to the hospital on 04/23/15 with a diagnosis of Wound Care.

Review of Patient #2's physician's orders revealed orders for the following medication:
04/24/15 Rocephin (Antibiotic) 1 gram IM (Intramuscular) QD (Every Day) for 5 days. Diagnosis: Pneumonia.

Review of the Medication Administration Record (MAR) revealed the Rocephin was not administered on 04/27/15 and 04/28/15 (Day 4 and 5).

In an interview on 05/13/15 at 2:40 p.m., S2DON reviewed the medical record for Patient #2 and confirmed the Rocephin was not administered as ordered. She confirmed the physician's order indicated the Rocephin should have been administered on 04/27/15 and 04/28/15. S2DON confirmed the omission had not been identified as a medication error.


Patient #3
Review of Patient #3's medical record revealed he was a 92 year old male admitted on 04/29/15 at 2:30 p.m. with admit diagnoses of COPD (Chronic Obstructive Pulmonary Disease), CHF (Congestive Heart Failure), and Aspiration Pneumonia. Review of his History and Physical Examination documentation revealed diagnoses of Benign Prostatic Hypertrophy (BPH), Hypertension, COPD (Chronic Obstructive Pulmonary Disease), Anemia, and GERD (Gastroesophageal Reflux Disease).

Review of Patient #3's physician's orders revealed orders for the following medications:
04/29/15 at 2:30 p.m. - Lactobacillus tablet 1 by mouth before meals; Metoprolol 50 mg (milligrams) by mouth every 12 hours; Duonebs inhalant every 6 hours;
04/29/15 at 6:05 p.m. - Duoneb treatment every 8 hours; Solumedrol 125 mg IVP (intravenous push) every 12 hours x (times) 4 doses, 80 mg IVP every 12 hours x 3 doses, 40 mg IVP every 12 hours x 2 days, 40 mg IVP every day x 2 days, then discontinue Solumedrol;
04/30/15 (no time documented) - Lasix 20 "QOD" (every other day), with no documented evidence of the route of administration and no clarification order by the nurse;
05/05/15 at 12:30 p.m. - OsCal one tablet every day.

Review of Patient #3's MARs revealed a notation of "Check blood pressure, check apical pulse, hold if <60" (less than 60) with the listing of Metoprolol. Further review revealed no documented evidence of the apical pulse at 9:00 a.m. on 04/30/15, the blood pressure and apical pulse at 9:00 a.m. on 05/01/15 and 05/02/15, the apical pulse at 9:00 a.m. on 05/15/15, 05/07/15, 05/08/15, 05/09/15, and 05/11/15 and at 9:00 p.m. on 05/03/15, 05/04/15, 05/06/15, 05/07/15, and the blood pressure at 9:00 p.m. on 05/11/15. Further review revealed no documented evidence that Patient #3 received Lactobacillus before any meal on 04/30/15 and 05/04/15. Further review revealed no documented evidence that Patient #3 received his Duoneb treatment at 5:00 p.m. as scheduled on 05/03/15 and 05/04/15.

Review of Patient #3's MAR revealed he received his first dose of Solumedrol IVP on 04/30/15 at 4:00 a.m. (9 hours and 55 minutes after it was ordered). Further review revealed he received Solumedrol 80 mg IVP at 4:00 a.m. and 4:00 p.m. on 05/02/15, and when the third dose was due at 4:00 a.m. on 05/03/15, Patient #3 was given 40 mg IVP. Only 2 doses of 80 mg IVP were administered rather than 3 doses as ordered. Further review revealed he was administered Solumedrol 40 mg IVP on 05/03/15 at 4:00 a.m. and 4:00 p.m. and 40 mg IVP at 4:00 a.m. on 05/04/15 and 05/05/15. He did not receive Solumedrol 40 mg IVP every 12 hours for 2 days and 40 mg IVP every day for 2 days as ordered by the physician. A total of 4 doses were missed.

Review of Patient #3's MARs revealed Lasix was listed to be administered by mouth with no documented evidence of a clarification order to determine the route of administration desired by the physician. Further review revealed OsCal was first administered at 9:00 a.m. on 05/06/15, rather than as ordered on 05/05/15 at 12:30 p.m.

In an interview on 05/13/15 at 3:05 p.m., S2DON indicated OsCal should have been administered the day it was ordered, and a clarification order should have been obtained to determine the route of administration for Lasix. She confirmed the vital signs were not assessed prior to administering Metoprolol, and Solumedrol and Duonebs were not administered as ordered by the physician.

Patient #7
Review of Patient #7's medical record revealed she was an 88 year old female admitted on 05/07/15 with diagnoses of Left Lower Lobe Pneumonia, Coronary artery Disease (CAD), Anxiety, Hypothyroidism, Hyperlipidemia, and IBS (Irritable Bowel Syndrome).

Review of Patient #7's physician's admit medication orders dated 05/07/15 at 2:40 p.m. revealed Xanax 0.25 mg by mouth BID (twice a day) did not have a check mark next to it, while all the other medications listed had a check mark. There was no "special instructions" written in the column for any of the medications, and there was no documented evidence whether the medications listed were to be continued or discontinued. Further review revealed a typed note at the bottom of the page above the space for the physician's signature that stated "The above medications have been reviewed by me and approved with noted changes if applicable."

Review of Patient #7's physician's orders revealed an order on 05/07/15 at 7:40 p.m. for Seroquel 25 mg by mouth BID and Coreg 12.5 mg by mouth BID and a typed order on 05/07/15 at 9:40 p.m. to start Seroquel and Xanax on 05/08/15 with no documented evidence of the dose, route, and frequency that the medications were to be administered.

Review of Patient #7's MARs revealed a notation of "Check blood pressure, check apical pulse" with the Coreg order. Further review revealed no documented evidence of the blood pressure and apical pulse for the 9:00 a.m. dose on 05/11/15 and the apical pulse for the 9:00 p.m. dose on 05/11/15. Further review revealed Xanax was listed as 0.25 mg twice a day with no documented evidence of a clarification order to determine the specific dose, route, and frequency for administration.

In an interview on 05/13/15 at 3:05 p.m., S2DON confirmed Patient #7's vital signs were not assessed prior to administering Coreg, and a clarification order should have been written regarding the administration of Xanax.





25065

Based on record review and interview, the hospital failed to ensure the medical record service was appropriate to the scope and complexity of the services performed as evidenced by failure to employ a qualified director of the Medical Records Department as required by the Louisiana Hospital Licensing Standards, Chapter 93, Section 9387 B. Findings:

Review of the Louisiana Hospital Licensing Standards, Chapter 93, Section 9387 B, revealed in part: Medical records shall be under the supervision of a medical records practitioner (i.e., registered record administrator or accredited record technician) on either a full-time, part-time or consulting basis.

In an interview on 05/15/15 at 9:35 a.m., S4MR (Medical Records) confirmed she was responsible for medical records and stated she had no credentials for medical records. She stated S33RHIA (Registered Health Information Administrator) has credentials and she worked at Hospital "A." S4MR stated she had, "Never laid eyes on her." S4MR stated she sends S33RHIA parts of the patient's medical record by fax and S33RHIA does the coding. S4MR stated S33RHIA provided direction to her on coding only.

Review of the personnel record for S4MR revealed a date of hire of 08/06/01 and no documented evidence of any credentials in medical records.

In an interview on 05/15/15 at 11:15 a.m., S24Owner stated S33RHIA is a Registered Health Information Administrator and she was contracted to provide services at this hospital and Hospital "A." He stated he found out during the survey conducted at Hospital "A" that S33RHIA was not doing all they had contracted her to do. At this time S24Owner and S19COO (Chief Operating Officer) were unable to provide the last name of S33RHIA. The contract with S33RHIA, her credentials, and her full name were requested for review.

Review of the written agreements with S33RHIA and the hospital provided by S24Owner revealed the agreement was for coding consulting services only and was dated 03/08/10. Review of the written agreement revealed S33RHIA signed her name with the credentials of RHIA behind her name. There was no documentation of her credentials provided for review.

In an interview on 05/15/15 at 11:50 a.m., S24Owner stated she spoke to S33RHIA and she informed him she was not doing medical records. S24Owner confirmed she was contracted for coding services only.

Based on observation, interviews and record review, the hospital:
1) failed to ensure patients' medical records were protected from or water damage in the event the sprinkler system was activated. This deficient practice is evidenced by storing approximately 1,277 patient records on open shelving, on top of cabinets and on desks in sprinklered rooms.

2) failed to ensure a system was in place for prompt completion of medical records by failing to identify dating/timing of orders and medical record entries as incomplete medical records. Findings:

1) Failed to ensure patients' medical records were protected from or water damage in the event the sprinkler system was activated. This deficient practice is evidenced by storing approximately 1,277 patient records on open shelving, on top of cabinets and on desks in sprinklered rooms:

Review of the hospital policy titled, "Form and Retention of Record" dated 03/11, revealed in part the following: Medical records are maintained for each patient in our facility. The records are written accurately as to the care provided and prescribed for each patient in his/her own separate chart. The records are promptly completed, filed and remain accessible. The records are secured as to maintain the integrity of the record and its contents and security....The record is stored in an area secure from water, damage, fire, or other potential threats to the stability of the record.

On 05/15/15 at 9:35 a.m. an observation of the medical records storage room was made with S4MR (Medical Records). The room was observed to have a sprinkler head extending from a pipe attached to the ceiling S4MR confirmed the room was sprinklered. Open wooden shelving was observed to contain discharged patient medical records. Fifty eight cardboard boxes were observed to be stacked on the opposite side of the room from the open shelving. The boxes contained discharged patient medical records. S4MR stated all discharged patient medical records since the hospital opened in 2001 until present were stored in this room. S4MR confirmed the patient records stored in this room were not protected from water damage in the event the sprinkler system was activated. S4MR indicated approximately 1,277 patient records were stored in this room.

On 05/15/15 at 10:00 a.m., an observation of the office of S4MR (Medical Records Office) was made with S4MR. The room was observed to have sprinkler head extending from a pipe attached to the ceiling. Approximately 27 records were observed on a cart and on a desk. S4MR confirmed confirmed these patient records were stored in this room until they were completed and filed in the medical records storage room. S4MR confirmed these records were not protected from water damage in the event the sprinkler system was activated.


2) Failed to ensure a system was in place for prompt completion of medical records by failing to identify dating/timing of orders and medical record entries as incomplete medical records:
Review of the hospital policy titled, "Content of Record" dated 2012, revealed in part the following: All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with the hospital policies and procedures. All entries will be dated and timed as well as authenticated with a signature.

Review of 5 of 5 sampled current patient records revealed the physicians orders, verbal orders, and nurse practitioner orders were signed/co-signed by S3MD but did not include the date/time they were authenticated for Patients #1, #2, #3, #5, and #7.

Review of the Performance Improvement Indicators for the medical records department for 2014 revealed an indicator for, "all entries signed." There was no documented evidence of any data collected, tracked, or trended for dating/timing of medical record entries.

In an interview on 05/15/15 at 10:15 a.m., S4MR stated she considered a record complete when the doctor or the nurse practitioner signed the orders and the entries (H&P, progress notes, discharge summary, etc.). She stated she does not consider the lack of a date or time on orders or medical record entries as incomplete or delinquent because, "I can't get him to date or time." S4MR confirmed there was no process in place to identify records that were incomplete due to a lack of a date or time on an entry or an order, and it was not addressed with the physician.

25065

Based on record reviews and interviews, the hospital failed to ensure all orders, including verbal orders, were dated, timed, and authenticated by the practitioner in accordance with hospital policies for 4 (#1, #3, #5, #7) of 5 patient records reviewed for authentication of physician orders from a sample of 30 patients. Findings:

Review of the hospital policy titled "Orders For Treatment," contained in the policy manual presented as the current hospital policies by S2DON (Director of Nursing), revealed that all orders dictated over the telephone shall be signed by the appropriately authorized person to whom dictated with the name of the practitioner per his/her name. The responsible practitioner shall authenticate verbal or telephone orders within 48 hours, and failure to do so shall be brought to the attention of the Executive Committee for appropriate action. Further review revealed a registered nurse or licensed practical nurse will be responsible for ensuring all orders written on the patient's chart are transcribed, dated, timed, and signed by the authorized recipient accurately and completely.

Review of the hospital policy titled "Signing Verbal Orders," contained in the policy manual presented as the current hospital policies by S2DON, revealed that all verbal orders will be signed within 72 hours of documentation in the patient's medical record.

Patient #1
Patient #1 was a 68 year old male admitted on 04/15/15 with the diagnosis of Wound Care.

Review of Patient #1's Physician Orders revealed the following orders were not dated and time when the orders were authenticated:
Physician Standing Orders dated 4/15/15 at 9:00 a.m.
S3MD's Sliding Scale for Insulin Administration Standard Order dated 04/15/15 at 9:00 a.m.
CBC (Complete Blood Count) and CMP (Complete Metabolic Profile) tomorrow dated 05/10/15.
Clonidine 0.2 mg (milligrams) po (by mouth) now increase b/p (blood pressure) 208/92 dated 05/06/15 at 9:30 p.m.
Hydralazine 25 mg i (1) po BID (twice a day) dated 05/09/15 at 4:20 p.m.
Clonidine 0.1 mg po now X 1 dose BP (blood pressure) 180/79. Start Cozar 100 mg i po daily in the a.m. dated 05/04/15 at 6:30 p.m.
Strict I and O (Intake and Output) dated 04/25/15 at 5:35 p.m.
Change Lantus to 20 Units Q (every) HS (at bedtime). No a.m. dose. CBC and CMP tomorrow dated 04/26/15 at 7:30 a.m.

An interview was conducted with S2DON on 05/13/15 at 2:30 p.m. S2DON reported S3MD did not date and time when he authenticated the above orders for Patient #1.

Patient #3
Review of Patient #3's medical record revealed he was a 92 year old male admitted on 04/29/15 with admit diagnoses of COPD (Chronic Obstructive Pulmonary Disease), CHF (Congestive Heart Failure), and Aspiration Pneumonia. Review of his History and Physical Examination documentation revealed diagnoses of Benign Prostatic Hypertrophy (BPH), Hypertension, COPD (Chronic Obstructive Pulmonary Disease), Anemia, GERD (Gastroesophageal Reflux Disease).

Review of Patient #3's "Admission Orders" revealed they were received by telephone order on 04/29/15 at 2:15 p.m. Further review revealed no documented evidence of the date or time that the physician authenticated the telephone order.

Review of Patient #3's "Physician's Orders revealed two orders written by S3MD (Medical Director) on 04/30/15 with no documented evidence of the time the order was written.


Patient #5
Review of the medical record for Patient #5 revealed the patient was a 92 year old female admitted to the hospital on 04/21/15 with a diagnosis of Decubitus Ulcer to the buttock/unstageable.
Review of the admission orders revealed S3MD signed the orders, but did not date/time his authentication.
Review of the resuscitation orders and the DVT/PE (Deep Vein Thrombosis/Pulmonary Embolism) Prophylaxis orders revealed S3MD signed and dated the ordered but did not document the time.
Review of the physician orders written by S3MD revealed the following orders did not have documentation of a time:
04/24/15 - Cleocin 600 IV Q (every) 8 hours X 10 d.(days) Consult Liner for wound eval(surgical).
04/25/15 - verbal order for IV fluids signed but not dated or timed.
04/30/15 - D/C (Discontinue) Bactrim.
04/30/15 - Duonebs Q 4 hours X 3 days, then QID (four times a day). O2 (Oxygen) 2LNC (2 liters per nasal cannula) keep sats > 92%. (Oxygen saturation greater than). Lasix 40 mg. IV (intravenous injection) Q 12 hours X2. CXR (Chest X-ray) in a.m. "Eval Wheezing."
CBC, BNP, Renal, Liver (lab tests) in a.m. Solumedrol 40 IV Q 12 hours X 2.

In an interview on 05/14/15 at 10:00 a.m. S2DON confirmed the above orders were not timed by S3MD.

Patient #7
Review of patient #7's medical record revealed she was an 88 year old female admitted on 05/07/15 with diagnoses of Left Lower Lobe Pneumonia, Coronary artery Disease (CAD), Anxiety, Hypothyroidism, Hyperlipidemia, and IBS (Irritable Bowel Syndrome).

Review of Patient #7's "Admission Orders" revealed they were received by telephone order on 05/07/15 at 2:40 p.m. Further review revealed no documented evidence of the date or time that the physician authenticated the telephone order.

Review of Patient #7's "Physician's Orders" revealed two telephone orders received on 05/07/15, one that had no documented evidence of the time the order was received by the nurse, and one order received on 05/08/15 (no documented evidence of the time the order was received) that had not been authenticated by the physician as of 05/12/15 (5 days and 4 days respectively since the order was received and not within 48 or 72 hours in accordance with hospital policy). Further review revealed an order written on 05/11/15 with no documented evidence of the time the order was written by the physician.

In a telephone interview on 05/14/15 at 4:23 p.m. S3MD confirmed he was currently the Chief of Staff and Medical Director at the hospital. He stated he signed verbal orders when he was in the building. S3MD stated he had not read the Medical Staff By-laws, Rules & Regulations. S3MD confirmed he did not date/time orders and signatures and stated, "Do you know how many I have to sign?"


26351

Based on observations and interview, the hospital failed to ensure all drugs and biologicals were kept in a secure area as evidenced by drugs and biologicals being stored in central supply with a key available to all employees. Findings:

An observation was conducted on 05/12/15 at 10:35 a.m. of the Central Supply Room. The room was locked and was unlocked by S2DON (Director of Nursing). S2DON reported the keys to the supply room are kept in the desk drawer in the office, which everyone had access to. On the top of the cabinet in Central Supply were bottles of medications as follows: Vitamin C, Magnesium Citrate, Docusate Sodium, Fish Oil, Ferrous Sulfate, Biscodyl, Ranitidine and Loperamide. In a separate locked cabinet in central supply were numerous different medications: Vitamin C, Magnesium Citrate, Naproxen, Ultratuss, Loperamide. If the cabinet next to the locked medicine cabinet was opened, the surveyor was able to insert her hand and remove medications from the locked medication cabinet.

An interview was conducted with S2DON on 05/12/15 at 10:44 a.m. She reported the central supply keys were available to all employees. The keys were located in the front office in an unlocked desk in an unlocked office, but the keys to the locked medicine cabinet in central supply were only available to the nurses on the nurse key ring. She acknowledged the medications were not secured since the keys to central supply were available to anyone and the locked medicine cabinet was able to be breeched without having a key by opening a cabinet next to the locked medicine cabinet and reaching your hand into the cabinet and withdrawing medications.

An interview was conducted with S19COO (Chief Operating Officer and Acting Administrator) on 05/12/15 at 11:30 a.m. He acknowledged the medications were not secured since the keys to central supply were available to anyone. S19COO reported he was not aware medications could be removed from the medication cabinet without unlocking the cabinet by reaching into the cabinet next to the locked medication cabinet.

Based on record review and interview, the facility failed to ensure drug administration errors were reported immediately to the attending physician and documented in the patient's medical record for 1 (Patient #16) of 2 (Patient #16 and Patient #20) medication variances reviewed with known medication errors. Findings:

Review of the hospital's policy on Reporting Medication Errors revealed in part, No copies of this Medication Variance Report will be placed in the patient's medical record, however, medication errors will be documented (recorded) in the patient's medical record.

Patient #16

Patient #16 was a 62 year old female admitted on 02/23/15 with the diagnoses of Psoriasis, Pulmonary Hypertension, and COPD (Chronic Obstructive Pulmonary Disease Exacerbation.

Review of the Medication Variance Form, dated 03/7/15 and timed at 9:00 p.m., revealed Patient #16 was administered 10 extra doses of Clobetasol 0.05 % ointment.

Review of the Physician order, dated 02/23/15 at 3:30, revealed an order for Clobetasol ointment BID (twice a day) x 7 days (apply to psoriasis).

Review of the MAR (Medication Administration Record) revealed Patient #16 received Clobetasol ointment BID from 02/23/15 until 03/07/15 (once a day on 02/23/15 and twice on the other days) Patient #16 received 10 extra doses of the medication.

Review of the Patient #16's medical record revealed no documentation the physician was notified of the 10 extra doses of Clobetasol and no documentation of the medication error was documented in the patient's record.

An interview was conducted with S2DON (Director of Nursing) on 05/14/15 at 1:20 p.m. She reported she was not aware of the medication variance since she was appointed as Director of Nurses a few days ago.

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

Review of the contracts provided by S19COO (Chief Operating Officer and Active Administrator) revealed the hospital had a contract with Company A to provide radiological services and Company B to provide radiologic ultrasound procedures.

Review of the hospital's policy entitled, "Radiology/Laboratory Services," dated 08/12, and provided by S4MR (Medical Records) as the hospital's current policy related to radiologic services, revealed the following, in part: "The hospital has a contract that provides for the assurance of qualified personnel to perform the requested services. ....The actions of the radiological services are monitored by the nurses and the DON (Director of Nursing) tracks issues as they present to the facility. This is kept for review and actions through the QA (Quality Assurance) committee." It further stated, "The staff of the outsourced services must follow infection control protocol, proper hand washing, protection from infectious material for staff and patients. Exposure to any radiologic material outside of the normal operating amounts must be reported and equipment checked by the contracted company according to the manufacturer's instructions. This is the responsibility of the contracted company."

Further review of the policies and procedures manual revealed there were no policies and procedures to address the safety of patients and staff during radiologic procedures regarding safety standards for at least the following: Adequate shielding for patients, personnel and facilities; Security of radioactive materials, including determining who may have access to; Proper storage of radiation monitoring badges when not in use; and Methods of identifying pregnant patients.

In an interview on 05/18/15 at 11:00 a.m., S1Admin confirmed there were no further policies and procedures in place to address patient and staff safety during radiologic procedures performed at the hospital.

Based on record review and interview, the hospital failed to ensure there was a radiologist who was a member of the medical staff that supervised the radiologic services and procedures performed at the hospital by Company A and Company B on either a full-time, part-time, or consulting basis. Findings:

Review of the list of credentialed physicians on the Medical Staff, presented as a current list by S4MR (Medical Records) revealed no documented evidence that a radiologist was credentialed and privileged as a member of the Medical Staff.

Review of the contracts provided by S4MR revealed the hospital had a contract with Company A to provide radiologic services and Company B to provide radiologic ultrasound procedures.

Review of a policy and procedure entitled, "Radiology/Laboratory Services" dated 08/12, revealed, in part: "This facility does not house a laboratory or an x-ray department. These services are contracted to an outside company....Currently, we have a company that comes in to the facility to perform mobile x-rays. All services are bound to the requirements for licensure and infection control as set forth by the state of Louisiana, the CDC, and facility licensure. Each company or facility is responsible for the training and operation of the equipment. Any issues are reported to the company manager for correction.... The hospital has a contract that provides for the assurance of qualified personnel to perform the requested services. That contract is in the contract binder for the facility....The staff of the outsourced services must follow infection control protocol, proper hand washing, protection from infectious material for staff and patients. Exposure to any radiologic material outside the normal operating amounts must be reported and equipment checked by the contracted company according to the manufacturer's instructions. This is the responsibility of the contracted company."

In an interview on 05/13/15 at 1:50 p.m., S19COO (Chief Operating Officer and Active Administrator) confirmed there was no Radiologist on staff at the hospital on a full-time, part-time, or consulting basis.

In an interview on 05/18/15 at 11:30 a.m., S1Admin confirmed the hospital did not have a credentialed and privileged Radiologist on its medical staff to supervise radiologic services at the hospital. S1Admin also confirmed the radiologists for Company A and Company B interpreting radiological tests were not credentialed and privileged by the hospital's Medical Staff and Governing Body.

Based on record review and interview, the hospital failed to ensure there was a written description of laboratory services provided by the hospital available to the medical staff. Findings:

Review of the laboratory policies and procedure and contracts for laboratory services, presented as current by S4MR (Medical Records), revealed no written description of laboratory services provided by the hospital available to the medical staff.

In an interview on 05/13/15 at 1:50 p.m., S19COO (Chief Operating Officer and Acting Administrator) confirmed there was no written description of laboratory services provided including those furnished on routine and stat basis, either directly or under an arrangement with an outside facility, available to the medical staff.
In an interview on 05/18/15 at 11:21 a.m., S1Admin confirmed there was no written description of laboratory services provided including those furnished on routine and stat basis, either directly or under an arrangement with an outside facility, available to the medical staff.

Based on record reviews, observations, and interviews, the hospital failed to ensure the daily dietary services managed by S8DM (Dietary Manager) were provided in accordance with hospital policies and procedures as evidenced by:

1) Failing to ensure food was stored in accordance with hospital policies and procedures for food storage and temperature as evidenced by having food items stored in the refrigerator, the kitchen, and the storage closet that were not labeled, having the soiled linen hamper next to the sugar container, not maintaining the log of the water temperature and chlorine checks for the 3-compartment sink, having expired food items and a dented can of food stored in the storage closet, and keeping leftovers more than 24 hours.

2) Failing to ensure all equipment and utensils used in the preparation and serving of food was properly cleaned, sanitized, and stored as evidenced by having serving and cooking utensils stored in an open container with the available lid not able to be closed securely, having a build-up of dust on the water/ice machine grill, and having caked-on black substance build-up on frying pans, baking pans, and the range.

3) Failing to ensure the dietary manager observed proper infection control practices when checking temperatures of food on the steam table as evidenced by cleaning the thermometer with a used cloth that was lying on the near-by counter and returning the thermometer to its storage case and not washing her hands between each job.

4) Failing to ensure food was transported to the patient's room in a manner that maintained required temperatures as evidenced by delivering patients' meal trays to the patients' rooms on a rolling cart that had no means to maintain food temperatures to assure that hot foods were at 120 degrees F (Fahrenheit) or above and cold foods were at or below 50 degrees Fahrenheit. Findings:

Review of the hospital policy titled "Sanitation And Infection Control," presented as a current policy from the Food And Nutrition manual by S8DM, revealed that the Director of the Department of Food and Nutrition Services is responsible for supervising sanitation, housekeeping procedures, and personnel in such a manner as to create and maintain an environment that is safe for the storage, preparation, and serving food and which meets the standards established by federal, state, local, and other appropriate regulatory agencies.

1) Failing to ensure food was stored in accordance with hospital policies and procedures for food storage and temperature:
Review of the hospital policy titled "Food Preparation," presented as a current policy by S8DM, revealed refrigerator temperatures shall be maintained at or below 41 degrees F (Fahrenheit) and freezers at or below 0 degrees F.

Review of the hospital policy titled "Food Storage," presented as a current policy by S8DM, revealed the dry storage area must be clean, orderly, and well-lighted. Each refrigeration unit must be equipped with an indication thermometer accuracy to +2 degrees and situated so that it can be easily and readily observed for reading. Any damaged or leaking cans are removed from the storage areas, discarded, or returned for credit.

Review of the hospital policy titled "Utilization Of Leftovers," presented as a current policy by S8DM, revealed if a sufficient amount of food item is left over, and the cook determines that it can be used within 24 hours, it will be placed in a container, sealed, dated, and initialed by the cook and placed in the refrigerator. Pre-cooked items which have not been held on the steam table and are of sufficient quantities for later utilization will be stored in the freezer. If the refrigerated item is not used within 24 hours, it will be discarded.

Observation of the refrigerator in the kitchen on 05/12/15 at 10:20 a.m. revealed 2 containers of liquid on the top shelf with no label of the contents, the date the liquid was prepared, and the date when the liquid was placed in the refrigerator. Further observation revealed a plastic bag of biscuits on the third shelf of the refrigerator was opened and not secured tightly. Further observation revealed a white bin in the kitchen that was not labeled with the contents and when the item would expire or need to be discarded. Further observation revealed the bin for dirty linens was placed next to the sugar bin.

In an interview on 05/12/15 at 10:20 a.m., S8DM indicated the liquid in the containers was tea, and she confirmed the containers were not appropriately labeled. She confirmed the biscuits were not securely closed to prevent contamination. S8DM confirmed the flour in the white bin was not labeled, and it was good for one month. She confirmed that without a label indicating when the flour was placed in the container or the date it was to be discarded, staff would not know when the flour was no longer able to be used. S8DM indicated the ice machine is supposed to be cleaned once a month, and she confirmed the presence of dust build-up on the grill. She further indicated the hamper for dirty linens should not be stored in the clean food supply area.

In an interview on 05/12/15 at 10:35 a.m., S8DM indicated she doesn't keep a log of the water temperature and the check of chlorine for the 3-compartment sink used to wash dishes.

Observation on 05/12/15 at 10:50 a.m. revealed 3 containers on a rack to the left of the range that were not labeled.

In an interview on 05/12/15 at 10:50 a.m., S8DM indicated the liquid in the containers was cooking oil, and it should be labeled.

Observation in the storage closet on 05/12/15 at 10:50 a.m. revealed the closet was dimly lit, and the door had to be propped open for the surveyor to be able to read labels on containers. Further observation in the storage closet revealed the following:
4 plastic storage bins that were covered with sticky lids;
One 6 pound 9 ounces can of "Salad Sliced Beets" was dented;
Containers of noodles, sugar packets, creamer, and Splenda with no evidence of the current date when the items were placed in the container;
1 box containing 8 bottles of 6 fluid ounces "Cajun Chef Sport Peppers," that had expired November 2007;
1 bag of frosting mix labeled "1/8/14" with no date of expiration on the package;
One 18-ounce bag of Bread Pudding Mix opened and in a plastic wrap labeled as opened 05/26/13;
One 10.7 ounces Buttercreme Frosting Mix that expired March 2012.

All the above observations were confirmed at the time of the observation by S8DM.

Observation on 05/12/15 at 11:20 a.m. revealed the thermometer outside the refrigerator showed a temperature of 42 degrees F.

In an interview on 05/12/15 at 11:20 a.m., S8DM indicated she would have to put a thermometer inside the refrigerator, because the outside reading may not be accurate.

Observation of food contained in the refrigerator on 05/13/15 at 9:10 a.m. revealed a container of diced tomatoes and a container of sliced carrots with a label of 05/11/15. Further observation revealed the two thermometers inside the refrigerator showed temperatures of 40 degrees F and 32 degrees F, while the outside refrigerator thermometer revealed a temperature of 45 degrees F. Observation of food contained in the freezer revealed red beans with a date of 04/20/15, beef stew with a date of 05/04/15, and meat sauce with a date of 04/15/15.

In an interview on 05/13/15 at 9:10 a.m., S8DM confirmed the differences in thermometer readings on 05/13/15. She indicated that leftovers were good for 48 hours, and it was alright to immediately freeze food if she knew it wouldn't be used within 48 hours. She had no explanation when informed that the hospital policy revealed that leftovers were to be discarded if not used within 24 hours.

2) Failing to ensure all equipment and utensils used in the preparation and serving of food was properly cleaned, sanitized, and stored:

Review of the hospital policy titled "Food Preparation," presented as a current policy by S8DM, revealed that all food shall be served, stored, prepared, and distributed in the most sanitary conditions to prevent foodborne illness. Manual washing of dishes in the 3-compartment sink should have a water temperature of 75 degrees F with 50 ppm (parts per million) of Hypochlorite or 12.5 ppm of Iodine with hot water immersion at 170 degrees F for at least 30 seconds. Convenient and suitable pre-cleaned utensils shall be provided and used to minimize handling of food at all points where food is prepared.

Review of the hospital policy titled "Handling Ice," presented as a current policy by S8DM, revealed that the ice machine located in the kitchen will be cleaned and sanitized by department personnel on a regular basis.

Observation of the water/ice machine in the kitchen on 05/12/15 at 10:20 a.m. revealed a build-up of dust on the grill.

In an interview on 05/12/15 at 10:20 a.m., S8DM indicated the ice machine is supposed to be cleaned once a month, and she confirmed the presence of dust build-up on the grill.

Observation on 05/12/15 at 10:50 a.m. revealed a plastic bin of cooking/serving utensils on the shelf in the kitchen that was open to air, and S8DM attempted to place on the lid on the container (after it was brought to her attention by the surveyor), the lid did not fit securely. Further observation revealed 3 baking pans and 3 frying pans on the rack with caked-on black residue on the bottom and sides (inside and outside) of the pan. Further observation revealed the range had caked-on black residue on it. These observations were confirmed by S8DM.

3) Failing to ensure the dietary manager observed proper infection control practices when checking temperatures of food on the steam table and not washing her hands between performing each job:

Review of the hospital policy titled "Handwashing Technique," presented as a current policy from the Food And Nutrition manual by S8DM, revealed that hands should be washed after each job performed before starting another job to prevent cross contamination.

Observation of S8DM checking the temperature of food on the steam table on 05/12/15 at 11:15 a.m. revealed S8DM placed the thermometer in the food container, wiped the thermometer afterwards with a dish towel that was lying on the counter, and placed the thermometer in its case without cleaning the thermometer.

Observation on 05/12/15 at 12:00 p.m. revealed S8DM used 2 dish towels to carry a pan of peas from the range to the steam table and used one of the contaminated dish towels to wipe the thermometer after checking food temperatures before placing the thermometer in its case.

Observation continuously from 10:20 a.m. through 12:00 p.m. on 05/12/15 in the kitchen revealed S8DM performing several duties, including following surveyor during tour of kitchen, cooking/stirring food on the range, and checking temperature of food on the steam table, without washing her hands before moving from one job to the next.

4) Failing to ensure food was transported to the patient's room in a manner that maintained required temperatures to assure that hot foods were at 120 degrees F or above and cold foods were at or below 50 degrees F:

Review of the hospital policy titled "Food Preparation," presented as a current policy by S8DM, revealed that in room delivery temperatures of hot food shall be maintained at 120 degrees F or above and cold foods, except milk (which should be 41 degrees F or below), maintained at 50 degrees F or below. Further review revealed food shall be transported to the patient rooms in a manner that protects the food from contamination while maintaining the proper temperature.

In an interview on 05/13/15 at 9:05 a.m., S8DM indicated that patient meals were delivered to their room on an open cart that had no means to keeps hot foods hot and cold foods cold.

Based on record reviews and interviews, the hospital failed to ensure the qualified dietitian supervised the nutritional aspects of patient care as evidenced by:
1) failing to have nutritional consults ordered by the physician conducted by the dietitian for 4 (#2, #3, #7, #8) of 7 (#2, #3, #4, #5, #7, #8, #9) sampled patient records reviewed for nutritional assessments from a total of 30 sampled records;

2) failing to ensure the dietitian performed an assessment of the patient when consulted, and;

3) failing to approve patient menus, provide consultation in food service management, and assist with quality improvement activities as directed in the contractual agreement. Findings:

Review of the hospital policy titled "Nutritional Consultation/Education," contained in the policy manual presented as the current hospital policies by S2DON (Director of Nursing), revealed the dietitian consults with patients giving written and verbal instructions for following a personalized nutrition therapy plan when ordered by the physician. The order is communicated to the Department of Food and Nutrition Services in the manner outlined for the Physician's Diet Orders and Diet Changes. No policy related to physician diet orders and diet changes was presented during the survey by administration.

Review of the hospital policy titled "Assessing Nutritional Status Of Patients," contained in the policy manual presented as the current hospital policies by S2DON, revealed that the assessment of the nutritional status of patients is performed by a qualified dietitian as part of the total care rendered when patients are identified to be at high nutritional risk or as requested by the attending physician. Both subjective and objective information relative to food intake habits and patterns, physical, biochemical, and medical aspects of the patient are recorded on the Nutrition Assessment form by the dietitian, and this form becomes a part of the patient's medical record. Further review of the policy revealed no documented evidence of the manner in which patients would be assessed for high nutritional risk.

Patient #2
Review of the medical record for Patient #2 revealed the patient was a 68 year old female admitted to the hospital on 04/23/15 with diagnosis of Wound Care. The record revealed the patient also had diagnoses of Abdominal Incision/Wound, Decubitus Ulcer Left Buttock, Diabetes Mellitus-poorly controlled , Hypertension, Asthma, Obesity, Degenerative Joint Disease, and Chronic Pain.
Review of the admission orders dated 4/23/15 at 12:20 p.m. revealed an order for a evaluation by the dietician.
Review of the patient's record revealed a form titled, "Medical Nutrition Therapy Initial Assessment Form" dated 04/27/15 and signed by S7RD (Registered Dietitian). Review of the form revealed the following sections were left blank: Height, Ideal body weight, BMI (Body Mass Index), Kcal needs/24 hours, Protein needs/24 hours, Impression of nutritional risk, Assessment, Recommendations/Plan. Review of the form revealed the following: Admit weight: 348 pounds, Multiple decubitus. Diagnosis: Diabetes Mellitus, Hypertension, Obesity.
In an interview on 05/13/15 at 2:40 p.m. S2DON (Director of Nursing) confirmed the RD's assessment was incomplete.

Patient #3
Review of Patient #3's medical record revealed he was a 92 year old male admitted on 04/29/15 with admit diagnoses of COPD (Chronic Obstructive Pulmonary Disease), CHF (Congestive Heart Failure), and Aspiration Pneumonia. Review of his History and Physical Examination documentation revealed diagnoses of Benign Prostatic Hypertrophy (BPH), Hypertension, COPD (Chronic Obstructive Pulmonary Disease), Anemia, GERD (Gastroesophageal Reflux Disease).

Review of Patient #3's physician admit orders of 04/29/15 at 2:15 p.m. revealed an order for a Dietitian consult. Review of the entire medical record revealed no documented evidence that a nutritional assessment had been performed by S7RD (Registered Dietitian).

Patient #7
Review of patient #7's medical record revealed she was an 88 year old female admitted on 05/07/15 with diagnoses of Left Lower Lobe Pneumonia, Coronary artery Disease (CAD), Anxiety, Hypothyroidism, Hyperlipidemia, and IBS (Irritable Bowel Syndrome).

Review of Patient #7's physician admit orders of 05/07/15 at 2:40 p.m. revealed an order for a Dietitian consult. Review of the entire medical record revealed no documented evidence that a nutritional assessment had been performed by S7RD (Registered Dietitian).

In an interview on 05/13/15 at 9:05 a.m., S8DM (Dietary Manager) indicated she faxes dietary consults to S7RD once the nurse informs her of the ordered consult. She confirmed that she never faxed a dietary consult to S7RD for Patients #3 and #7. S8DM indicated she doesn't regularly check patients' charts for a dietary consult order and relies on the nurse to notify her when an order is received.

In an interview on 05/13/15 at 9:15 a.m., S2DON confirmed the medical records of Patients #3 and #7 did not have a completed nutritional assessment performed by S7RD. She indicated the nurses are supposed to notify S8DM when a dietary consult is ordered by the physician.


Patient #8
Review of the medical record for Patient #8 revealed the patient was a 62 year old female admitted to the hospital on 05/01/15 with a diagnosis of Urinary Tract Infection (UTI). Review of the admission orders dated 05/01/15 at 1:10 p.m. revealed an RD consult was ordered.
Review of the record revealed no documented evidence that it was done.
In an interview on 05/14/15 at 10:30 a.m., S2DON reviewed the patient's medical record and confirmed an RD consult was ordered on 05/01/15 and there was no documented evidence it was done.
In an interview on 05/14/15 at 11:00 a.m. S8DM provided a faxed cover sheet indicating she had faxed S7RD information on Patient #8 on 05/04/15. S8DM was unable to explain why the evaluation had not been done yet.


2) Failing to ensure the dietitian performed an assessment of the patient when consulted:

Review of the written agreement for dietitian services between the hospital and S7RD dated 12/05/12 revealed the responsibilities of the RD included reviewing the patient's medical history, assessing the patient's nutritional needs, and assessing, planning, and implementing medical nutrition therapy care for all appropriate patients.

Review of the hospital policy titled, "Assessing Nutritional Status of Patients" dated 01/02/01 revealed in part the following: The assessment of the nutritional status of patients is performed by a qualified dietitian as part of the total care rendered when patients are identified to be at high risk or as requested by the attending physician. Both subjective and objective information relative to food intake habits and patterns, physical, biochemical, and medical aspects of the patient are recorded on the Nutrition Assessment form by the dietitian, which becomes a part of the patient's medical record.

In an interview on 05/14/15 at 12:05 p.m., S8DM stated when a dietitian consult is requested, she faxes the physician orders, nursing admission assessment, H&P, Lab reports, and the patient's face sheet to S7RD. She stated S7RD then faxes back an evaluation. When asked if S7RD came to the hospital to see the patients she was evaluating, she stated not while she was at the hospital. S8DM stated she did not know if S7RD comes when she was not there. When asked if she had ever seen S7RD, she stated, "Once when she first started." S8RD stated she did not remember if she saw her at the hospital or met her somewhere else.

In a telephone interview on 05/15/15 at 1:15 p.m., S7RD was asked how she conducted the dietitian consults. She stated the hospital staff faxed her the medical record and she sends the evaluation back. S7RD stated, "I have the entire medical record." S7RD confirmed she does not see the patient and stated she had never been to this hospital. S7RD confirmed she documents an assessment of the patient's nutritional needs from the medical record only.

3) Failing to approve patient menus, provide consultation in food service management, and assist with quality improvement activities as directed in the contractual agreement:

Review of the written agreement for dietitian services between the hospital and S7RD dated 12/05/12 revealed the responsibilities of the RD included providing consultation in food service management including menu planning, food purchasing and preparation, personnel management, equipment, sanitation and safety. The agreement also included a provision that the RD would assist with quality improvement activities.

Review of the hospital policy titled, "Menu Planning," dated 01/02/11 revealed in part the following: All menus for patient food service are planned and meet the approval of a qualified registered dietitian.

On 05/15/15 at 1:12 p.m., S8DM provided a copy of the patient menus. She stated the menus came from the company that provides their food. She confirmed no RD had approved the menus.

In a telephone interview on 05/15/15 at 1:15 p.m., S7RD stated she had never been to this hospital and she only did clinical nutritional evaluations. She stated she had never provided any training/education to the dietary staff or assessed the competency of the dietary staff. S7RD stated she does not do anything with the operation of the kitchen. S7RD confirmed she does not approve patient menus.





25065

Based on record reviews, observation, and interview, the hospital failed to ensure the current therapeutic diet manual was readily available to all medical, nursing, and food service personnel as evidenced by having the diet manual stored in the medical record department which is locked for the day when the person responsible for medical records leaves for the day. The diet manual used by the hospital was not the approved Mayo Clinic Diet Manual as stated in the hospital's policies and procedures. Findings:

Review of the hospital policy titled "Diet Manual," contained in the policy manual presented as the current hospital policies by S2DON (Director of Nursing), revealed the approved guide for ordering and serving of all diets and for all practices and procedures related to clinical nutritional care is the Mayo Clinic Diet Manual. The diet manual is located in the Food and Nutrition Manager's office and other areas as deemed appropriate.

Observation on 05/13/15 at 9:25 a.m. revealed the diet manual was on the shelf in the medical records department. Further observation revealed the manual was the "Louisiana Dietetic Association's Manual of Medical Nutrition Therapy 6th edition."

In an interview on 05/13/15 at 9:25 a.m., S4MR (Medical Records) confirmed that the diet manual is stored in the medical records department, and the department is locked when she isn't at the hospital. She confirmed that the diet manual is not accessible to the medical, nursing, and food service personnel when she is not at the hospital.

Based on observations and interview the hospital failed to ensure all patient medical equipment was inspected, tested and maintained to ensure the equipment's safety and reliability. Findings:

Review of the hospital's policy for Hydrocollator Pack revealed in part, Equipment Care, The thermostat is usually set at the factory to maintain the constant temperature. This should be calibrated annually and checked on a regular monthly maintenance schedule.

Review of the hospital's policy for Medical Equipment Management Program revealed in part, 1. All electrical equipment with patient, or public access, whether it is patient care, or nonpatient care, is tested periodically for electrical safety by the Biomedical Company.

An observation was conducted in the Rehabilitation gym on 05/12/15 at 11:00 a.m. of a Paraffin Wax Bath and a Hydrocollator Packs with the last safety inspection sticker located on the equipment as stating the next inspection was due 03/14.

Observations in the following rooms revealed the patient care equipment had expired (03/14/14) biomedical stickers: Patient #4's room: bed; Patient #8: bed; Patient #11's room: IV (Intravenous) pump, bed, and nebulizer.

An interview was conducted with S19COO (Chief Operating Officer and Acting Administrator) on 05/13/15 at 3:30 p.m. He reported the contracted Biomedical company could not inspect the medical equipment until the end of the month. S19COO reported he did not know when the last time the equipment in the hospital was inspected for safety.

An interview was conducted with S6PT (Physical Therapist) on 05/13/15 at 3:30 p.m. S6PT revealed the Hydrocollator Pack was used frequently on the hospital's patients. S6PT further reported he was not sure when the machine was inspected last. S6PT could not provide a temperature log for the Hydrocollator Packs to determine if the temperature of the equipment was being monitored.


31048

Based on record review and interview, the hospital failed to ensure the Infection Control Officer (ICO) developed and implemented policies governing the control of infections and communicable diseases. Findings:

Review of the policies and procedures provided by S16ICN (Infection Control Nurse) as current, revealed, in part, there were no policies and procedures for each specific type of isolation, and no policies and procedures for the construction, renovation, maintenance, demolition, and repairs to the environment including the requirement for an infection control risk assessment (ICRA) to define the scope of the project and need for barrier measures before a project gets underway.

In an interview on 05/14/15 at 2:00 p.m., S16ICN indicated that S17ICC (Infection Control Consultant) was the designated Infection Control Officer for the hospital, and she provided services on a contractual, part-time basis for the hospital.

In an interview on 05/14/15 at 4:00 p.m., S16ICN confirmed there were no policies and procedures in place at the hospital for each specific type of isolation and no policy and procedures in place for the construction, renovation, and repairs to the environment which included an ICRA, and S16ICN agreed there should have been these policies and procedures in place.

Based on record reviews, observations, and interviews, the hospital failed to ensure the infection control officer identified, reported, investigated, and controlled infections and communicable diseases as evidenced by:

1) Failing to ensure the hospital staff implemented hand hygiene practices in accordance with hospital policies and procedures when disposing of soiled linen for 1 of 1 (S11CNA, Certified Nursing Assistant) observation of staff disposing of soiled linen; when administering nebulizer treatments for 1 (#2) of 1 observation of providing a nebulizer treatment, when flushing a saline lock for 1 (#7) of 1 observation of flushing a saline lock; and when performing wound care for 1 of 1 (#1) observation of providing wound care.

2) Failing to implement infection control practices in performing intravenous (IV) therapy for 1 (#7) of 1 observation of discontinuing an IV piggyback from a sample of 30 patients.

3) Failing to implement contact isolation precautions for 1 (#5) of 1 sampled patients on contact precautions.

4) Failing to ensure that equipment available for patient use was not torn/taped to ensure effective infection control cleaning/disinfecting:

Findings:

1) Failing to ensure the hospital staff implemented hand hygiene practices.

Review of the hospital policy titled "Exposure Control Plan," contained in the policy manual presented as the current hospital policies by S2DON (Director of Nursing), revealed that frequent hand washing by employees should be performed in the following situations: before and after the provision of direct and indirect patient care, after handling soiled or contaminated materials, and after removing gloves.

S11CNA (Certified Nursing Assistant)
On 05/12/15 at 10:55 a.m. an observation was made of S11CNA removing soiled linen from a patient's room. S11CNA was observed walking down the hall toward the rear exit of the hospital. S11CNA was observed to have one glove on her right hand holding a blue bag of soiled linen. S11CNA was observed to open the rear exit door and leave the building with the soiled linen bag. S11CNA was observed to prop the rear exit door open with a brick and proceed to an adjacent area to dispose of the linen. S11CNA was observed to return through the propped open rear exit door without the glove on, and proceed to patient room #5 to answer a call light. S11CNA confirmed she did not wash her hands after taking the soiled linen to the outside linen cart and removing her glove.

Patient #7
Observation on 05/12/15 at 1:00 p.m. revealed S13RN (Registered Nurse) flushing a saline lock for Patient #7. She donned gloves without first washing her hands or using sanitizer. Further observation revealed when she completed the procedure, S13RN removed her gloves and walked out the room without washing her hands. In an interview on 05/12/15 at 1:00 p.m., S13RN confirmed she didn't wash her hands before donning gloves and didn't wash her hands before leaving Patient #7's room.

Patient #2
Observation on 05/12/15 at 1:05 p.m. revealed S14LPN (Licensed Practical Nurse) washed her hands in the medication room. She then touched the door knob to close the medication room door, touched to the door knob of the nursing station to open and close it, and touched the door knob to open the door to Patient #2's room. S14LPN then donned gloves without washing her hands or using hand sanitizer. She then added the medication to the nebulizer and placed the mask on Patient #2's face. In an interview on 05/12/15 at 1:05 p.m., S14LPN confirmed she didn't wash her hands after having touched contaminated surfaces and before donning gloves.


Patient #1
An observation was conducted on 05/14/15 at 11:15 a.m. of wound care on the patient's right lateral heel by S25LPN. The patient was observed to be sitting in a wheelchair in his room. S25LPN was observed to wash her hands and place a blue pad on the floor and place the patient's foot on top of the blue pad. A box of gloves and the wound care supplies were also placed on the blue pad on the floor. S25LPN donned a pair of non-sterile gloves, removed the patient's shoe, sock, and rolled the TED (Thrombo Embolic Disease) hose up, and removed the dressing from the patient's foot. S25LPN removed her gloves and donned another pair of gloves (without washing her hands). S25LPN cleaned the wound and applied a dressing to the wound. S25LPN then removed her gloves and placed them in a red biohazard bag. S25LPN donned another pair of gloves (without washing her hands) and pulled the TED hose down over the patient's foot, re-placed the patient's sock and shoe. S25LPN stated, "It is easier to do like this than with patient in the bed." S25LPN removed her gloves and discarded the supplies, rolled up the blue pad and placed them in the red biohazard bag. The bag was tied and placed on the floor. S25LPN then washed her hands. S25LPN donned one glove, picked up the red biohazard bag, left the room, went down the hall to the other side of the building to the biohazard room. Upon arrival at the biohazard room, the door was found to be locked. S25LPN stated they usually have a red garbage can in the patient's room, but there was none in the patient's room. S25LPN confirmed she did not wash her hands after she removed her gloves during the wound care. She also confirmed the best practice would be to put the patient in bed and perform the wound care there instead of on the floor.


2) Failing to implement infection control practices in performing IV therapy:

Review of Patient #7's medical record revealed she was an 88 year old female admitted on 05/07/15 with diagnoses of Left Lower Lobe Pneumonia, Coronary artery Disease (CAD), Anxiety, Hypothyroidism, Hyperlipidemia, and IBS (Irritable Bowel Syndrome). Further review revealed a physician's order dated 05/07/15 at 6:30 p.m. to flush the saline lock with Normal Saline every shift and as needed with no documented evidence of the amount of Normal Saline to be used and no clarification order obtained by the nurse.

Review of the Medication Administration Record (MAR) revealed the saline lock was to flushed with 3 ml (milliliters) Normal Saline every shift and as needed.

Observation on 05/12/15 at 1:00 p.m. revealed S13RN (Registered Nurse) flushing Patient #7's saline lock. Further observation revealed S13RN removed the IV piggyback tubing from the saline lock. Further observation revealed S13RN inserted a syringe of 10 ml of 0.9% (per cent) Sodium Chloride into the saline lock without wiping the saline lock hub with alcohol. Further observation revealed S13RN injected the entire 10 ml into the saline lock rather than 3 ml as ordered by the physician.

In an interview on 05/12/15 at 1:00 p.m., S13RN indicated she didn't use an alcohol wipe when flushing the saline lock, because she had just removed the IV piggyback tubing and didn't touch the saline lock hub between removing the tubing and flushing the hub. She confirmed she flushed with 10 ml 0.9% Sodium Chloride rather than 3 ml.

3) Failing to implement contact isolation precautions for 1 (#5) of 1 sampled patients on contact precautions:

Patient #5
During an observation on 05/14/15 at 11:35 a.m., Patient #5 was observed to have a "Contact Precautions" sign affixed to the door of her room. Review of the contact precautions signed revealed the following: Before Care: Private room preferred. Cohort with same disease if necessary. Perform hand hygiene. Wear gown to enter the room. Discard gowns in the room. Do not re-use. Wear gloves when entering room. Change after contact with infective material. After Care: Discard linen in a container in the room until it can be taken to soiled utility room, laundry, or other designated area. At 11:35 a.m. S25LPN was observed to remove a patient gown from the linen cart that was positioned in the hallway outside the shower room. S25LPN was observed to put the gown on with the opening to the back, left the gown untied, and entered Patient #5's room. S25LPN was observed to wash her hands in the patient's bathroom, removed the gown, then carry it down the hall to a soiled linen receptacle. S25LPN stated the isolation supply cart (located outside of Patient #5's room) was locked and she did not have a key to the cart. S25LPN stated the cart had been locked since yesterday when she had accidentally locked it. S25LPN stated the staff had been using patient gowns and were disposing of them in the soiled linen receptacle in the hall. S25LPN confirmed this practice was not in accordance with the contact precautions procedure. Observation of the isolation cart with S25LPN revealed a box of gloves was located on top of the cart and all drawers of the cart were locked and could not be opened.

4) Failing to ensure that equipment available for patient use was not torn/taped or missing laminate covering to ensure effective infection control cleaning/disinfecting:

On 05/12/15 at 10:20 a.m. an observation was made of patient room #9 with S14LPN and revealed the over bed table had a 1-2 inch area of missing laminate from the top surface with a rough, splintered surface exposed. S14LPN confirmed the exposed area could not be disinfected.

On 05/12/15 at 10:35 a.m. an observation was made of patient room #10 with S13RN and revealed the shower chair stored in the bathroom had tape residue on the arms of the chair. S13RN confirmed the adhesive residue on the arms of the chair and confirmed the chair should have been cleaned since the room was ready for patient use. A geri chair in the patient room was observed to have a reusable incontinence pad in the seat of the chair. The pad had creases indicating it had been used. S13RN confirmed the pad looked soiled to her and stated it should have been removed after use. S13RN also confirmed the vinyl covering of the geri chair was cracked on the left arm rest and was torn on the right arm rest. S13RN confirmed the arm rests could not be disinfected with the torn vinyl covering.

On 05/12/15 at 10:40 a.m. an observation of the clean equipment room was made with S13RN. Two wheelchairs were observed to have torn vinyl covering in the arm rests. S13RN confirmed the armrests could not be disinfected with the torn covering.

On 05/12/15 at 11:05 a.m. an observation of patient room #7 revealed the overbed table had a 2-3 inch area of peeling, missing vinyl with a rough surface exposed. S13RN confirmed the vinyl covering of the overbed table was missing and peeling and the surface of the table could not be disinfected.


31048




17091

Based on record review and interview, the hospital failed to ensure an OPO (Organ Procurement Organization) was notified of a patient's death for 2 (Patient #10 and Patient #14) out of 2 patients' deaths reviewed. Findings:

Review of the hospital's policy for LOPA (Louisiana Organ Procurement Agency) revealed in part, Every death will be reported to the Louisiana Organ Procurement Agency. The physician, charge nurse, nurse caring for the patient or a hospital representative will place the call to facilitate donor evaluation. A LOPA Recovery Coordinator can be reached 24 hours a day, 7 days a week...All deaths require completion of Louisiana "Consent for Anatomical Gift" form, even if the legal next-to-kin declines donations. The nurse caring for the patient is responsible for filling out the form.


Patient #10
Review of Patient #10's medical record revealed the patient was a 88 year old male admitted on 09/6/14 with the diagnoses of Pressure Ulcer and Pneumonia. Patient #10 expired on 09/24/14. Patient #10 had a DNR (Do Not Resuscitate) order on his medical record.

Review of Patient #10's Nurses Notes, dated 09/23/14 and timed 11:35 p.m., revealed in part, Called to pt. (patient) room per LPN (Licensed Practical Nurse), pt unresponsive, no resp. (respirations) no pulse, no heart or breath sounds auscultated. Pt. was DNR status, DNR on chart. S21Coroner notified. DON (Director of Nurses) notified, stating she would notified pt's son of pt's status. Pt's son confirmed that pt was to be released to H.... Funeral Home in McComb, MS (Mississippi). Notified funeral home of pending release of body pending arrival of coroner. notified of pt. status.
09/24/14 12:50 a.m.- S21Coroner arrived, pronounced pt at 12:55 a.m. Postmortem care implemented...

Further review of the medical record revealed no documentation the LOPA information was presented to the family, the "Consent for Anatomical Gift" form was filled out, or LOPA was notified of the patient's death.

Patient #14
Patient #14 was a 92 year old female admitted on 05/8/14 with the diagnosis of Sepsis. Further review of the medical record revealed the patient had a DNR (Do Not Resuscitate ) order. The patient expired on 05/16/14.

Review of the Nurses' Notes, dated 05/16/14 at 5:30 a.m. revealed, Nurse at bedside with dtr (daughter), Pt (Patient) Resp (respirations) 0, no heartrate/pulse audible. Notified S20APRN (Advanced Practice Registered Nurse-Nurse Practitioner) of pt status. No code called per Advanced Directive, DNR on chart. Awaiting S20APRN arrival to facility. Dtr. remains at bedside.

Review of the Nurses' Notes dated 05/16/14 at 6:35 a.m. revealed S20APRN present, pronounced pt death at 6:35 a.m. Indwelling Foley removed. Dtr removed all personal belonging of pts. Body to released to R.....Funeral Home.

Review of Patient #14's Discharge Summary, dictated by S20APRN, revealed in part, I was contacted 05/16/14 at 5:30 p.m. and told by the nursing staff that the patient had no respiration and no heart rate. There was a DNR. I came in and saw her pupils were 4 mm (millimeters) dilated and fixed bilaterally. She had no respirations or apical pulse that could be auscultated. Her vital signs were undetectable. Assessment is cardiopulmonary arrest, duodenal neoplasm.

Further review of the medical record revealed no documentation the LOPA information was presented to the family, the "Consent for Anatomical Gift" form was filled out, or LOPA was notified of the patient's death.

An interview was conducted with S19COO (Chief Operating Officer and Acting Administrator) and S2DON on 5/13/15 at 3:00 p.m. S19COO and S2DON further reported most of the current nursing staff were recently employed with the hospital and was not employed with the hospital when the deaths occurred.

Based on record review and interview, the hospital failed to have appropriate organization of services as evidenced by occupational therapy consult not being conducted when ordered by the physician for 3 of 3 (#2, #5, #11) patients reviewed for therapy services out of a total of 30 sampled patients. Findings:

Patient #2
Review of the medical record for Patient #2 revealed the patient was a 68 year old female admitted to the hospital on 04/23/15 with a diagnosis of Wound Care.

Review of the physician admission orders for Patient #2 dated 04/23/15 at 12:20 p.m., revealed an order for an Occupational Therapy consult.

Review of the patient's record revealed no documented evidence that the Occupational Therapy consult was done.

In an interview on 05/13/15 at 2:40 p.m. S2DON (Director of Nursing) reviewed the medical record for Patient #2 and confirmed the Occupational Therapy consult was not done.

Patient #5
Review of the medical record for Patient #5 revealed the patient was a 92 year old female admitted to the hospital on 04/21/15 with a diagnosis of Decubitus Ulcer buttock/ Unstageable.
Review of the admission orders dated 04/21/15 revealed an order for an Occupational Therapy consult.

Review of the patient's record revealed no documented evidence that the Occupational Therapy consult was done.

In an interview on 05/14/15 at 10:00 a.m., S2DON reviewed the medical record for Patient #5 and confirmed the Occupational Therapy consult was not done.

Patient #11
Patient #11 was a 68 year old female admitted on 04/11/15 for a Closed Fracture of the Right Ankle.

Review of the Physician Admission Orders for 04/11/15 at 8:00 a.m. revealed an order for an Occupational Therapist consult.

Review of the entire medical record for Patient #11 revealed a consult by Occupational Therapy was not conducted.

An interview was conducted on 05/13/15 at 12:00 p.m. with S4MR (Medical Records). She reviewed Patient #11's medical record and reported the consult was not conducted and she was not sure why it wasn't accomplished.





26351

Based on record review and interview, the hospital failed to appoint a Director of Rehabilitation Services to properly supervise and administer the rehabilitation services of the hospital. Findings:

Review of the minutes for the Governing Body revealed no documentation that S6PT (Physical Therapist) was appointed Director of Rehabilitation Services.

An interview was conducted with S19COO (Chief Operating Officer and Acting Administrator) on 05/13/15 at 2:30 p.m. He reported S6PT was the Director of Rehabilitation Services.

An interview was conducted with S6PT on 05/13/15 at 2:45 p.m. He reported he did not think he was the Director of Rehabilitation Services since he was contracted, but he was the only Physical Therapist at the hospital. S6PT confirmed he had not been appointed by the Governing Body of the hospital as the Director of Rehabilitation Services.

Based on record review and interview, the hospital failed to ensure the respiratory care services offered were appropriate for the scope and complexity of the services as evidenced by: 1) not having a licensed Respiratory Therapist available for respiratory care services and procedures to assist with patient care; and 2) not having the scope of respiratory care services offered by the hospital defined in writing and approved by the medical staff. This deficient practice had the potential to affect all patients who had respiratory care needs or services ordered in the hospital. Findings:

Review of the hospital's policy, dated 04/02, entitled, "Respiratory Therapy-General," revealed, in part: "The nursing staff at this facility performs all respiratory therapy. Any references to respiratory therapist may be substituted with nursing staff. We reserve the right to contract the services of a respiratory therapist as needed."

Review of the current staff roster for the hospital employees presented by S4MR (Medical Records) revealed there was no Respiratory Therapist listed on the hospital staff roster.

In an interview on 05/13/15 at 1:50 p.m., S19COO (Chief Operating Officer and Acting Administrator) confirmed there was no Respiratory Therapist available at the hospital for providing services on a full-time, part-time, or contractual basis, and there was no scope of diagnostic and/or therapeutic respiratory services offered by the hospital defined in writing, and approved by the Medical staff.

In an interview on 05/18/15 at 12:30 p.m., S1Admin confirmed there was no Respiratory Therapist available at the hospital to provide respiratory care services, and there had not been a Respiratory Therapist on staff since she had been employed at the hospital in 02/13. S1Admin also confirmed there was no scope of diagnostic and/or therapeutic respiratory services offered by the hospital defined in writing, and approved by the Medical staff and there should have been.

Based on record review and interview, the hospital failed to ensure there was a director of respiratory care services who was a doctor of medicine or osteopathy with the knowledge, experience, and capabilities to supervise and administer the service properly on a full-time, part-time, or contractual basis credentialed and approved by the medical staff and appointed by the Governing Body. Findings:

Review of the hospital's organizational chart revealed no documentation of a Director of Respiratory Care Services.

Review of the list of active medical staff revealed no documentation that a Director of Respiratory Care Services was credentialed and approved by the Medical Staff and appointed by the Governing Body.


Review of the hospital's policy entitled, "Respiratory Therapy-General," revealed, in part: "The Director of Respiratory Therapy, who is a physician, will monitor the outcomes of the respiratory therapy and provide input as needed."

In an interview on 05/13/15 at 1:50 p.m., S19COO (Chief Operating Officer and Acting Administrator) confirmed there was no director of respiratory care services who was a doctor of medicine or osteopathy credentialed and approved by the medical staff and appointed by the Governing Body.

Based on record review and interview, the hospital failed to ensure there was an adequate number of Respiratory Therapists and other personnel who met the qualifications to provide respiratory care services to patients in the hospital as evidenced by no licensed Respiratory Therapists on staff at the hospital. Findings:

Review of the hospital's Organization Chart revealed Respiratory Services were provided under "Ancillary Services."

Review of the current staff roster for the hospital employees presented by S4MR (Medical Records) revealed there was no Respiratory Therapist listed on the hospital staff roster.

Review of the policies and procedures manual presented as current by S4MR (Medical Records) revealed the hospital's policies included policies and procedures for respiratory care services at the hospital.

In an interview on 05/13/15 at 1:50 p.m., S19COO (Chief Operating Officer and Acting Administrator) confirmed there was no licensed Respiratory Therapist available at the hospital or providing services on a full-time, part-time, or contractual basis to patients in the hospital, and respiratory care services were provided by the nursing staff only.

Based on record review and interview, the hospital failed to ensure there were appropriate written policies for the delivery of respiratory care services that were developed and approved by the medical staff as evidenced by no respiratory care services policy for obtaining and interpreting pulse oximetry readings, and no policy and procedure for the administration of oxygen therapy ordered on an as-needed (PRN) basis. Findings:

Review of the Respiratory Therapy policies and procedures, presented by S4MR (Medical Records) as current, included the following policies: Chest Physical Therapy (dated 01/02/01); Cough and Deep Breathe Instructions (dated 01/02/01); IPPB (dated 01/02/01); Home Equipment Referrals (dated 01/02/01); Incentive Spirometry (dated 03/03); Oxygen Therapy (dated 01/02/01); BIPAP (Bi-Level Positive Airway Pressure), dated 01/02/01; Intubation (dated 01/02/01); Olympic Trach Button (dated 01/02/01); Tracheostomy Care (dated 01/02/01); Suctioning of the Airway (dated 01/02/01); Blood Gases (dated 01/02/15); Pharmacology Drugs (dated 01/02/01); and Patient and Family Education (dated 01/02/01).

Further review of the Respiratory Policies and Procedures, presented by S4MR as current, revealed there was no policy and procedure for obtaining pulse oximetry readings, and no policy and procedure for the administration of oxygen therapy ordered on an as-needed(PRN) basis.

In an interview on 05/18/15 at 12:30 p.m., S1Admin confirmed the nursing staff was providing all of the respiratory care services at the hospital as there was no Respiratory Therapist on staff, and there were no policies and procedures for pulse oximetry and the administration of oxygen therapy on an as needed basis, and there should have been.

Based on record review and interview, the hospital failed to ensure the staff responsible for providing respiratory therapy services (nursing staff) were trained and assessed for competencies for 6 (S1, S2, S25, S27, S28, and S29) of 6 nursing personnel files reviewed. Findings:

A review of the policies and procedures provided by S4MR (Medical Records) as current, revealed there was no policy and procedure for obtaining and interpreting oxygen saturation levels by pulse oximetry, and there was no policy and procedure and/or protocol for administering oxygen therapy on a PRN basis when the prescribing physician had not written parameters for when to administer oxygen therapy according to patients' oxygen saturation levels.

A review of the pre-printed set of physician admit orders revealed, in part, the orders for oxygen therapy: "Oxygen: nc (nasal cannula)/face mask prn (as needed)/2L/3L Other: __."

A review of the pre-printed set of physician admit orders revealed, in part, the orders for oxygen saturation: "Check O2 SATs: __Q (every) 12 hours; __Q8 hours; __Q4 hours; PRN (as needed or indicated)."

A review of medical records revealed the following patients had orders for checking oxygen saturation levels by pulse oximetry and oxygen therapy ordered PRN: #2, #5, #15, #17, #22, #24, #26, #28, #29. Further review of the orders for the above-referenced patients revealed the ordering physician circled or checked the applicable orders for obtaining oxygen saturation levels and administering oxygen therapy on a PRN basis and did not order any parameters for the oxygen saturation levels which would warrant the implementation of oxygen therapy as ordered on a PRN basis.

In an interview on 05/18/15 at 12:20 p.m., S1Admin indicated if any of the nurses required training for any respiratory therapy services performed at the hospital, she would provide the training to the nursing staff. When asked if she had been deemed competent by a Respiratory Therapist or a qualified physician, she replied, "no."
When asked how does the nursing staff determine when to administer oxygen therapy on a PRN basis, S1Admin indicated from her past experience, the usual practice is to apply oxygen if the oxygen saturation levels are below 92%.

S1Admin confirmed there were no policies and procedures and/or protocols for administering oxygen therapy on a PRN basis when the physician did not specify in the orders what parameters were to be implemented. S1Admin also confirmed there was no documentation in the nursing personnel files reviewed that the nurses were trained and assessed for competencies in providing respiratory care services, and there should have been.

Based on observation, record review, and interview, the hospital failed to ensure the Administrator, the Medical Staff, and the Director of Nursing were responsible for ensuring that the hospital-wide quality assessment and performance improvement (QAPI) program and training programs addressed problems identified by the infection control nurse or officer were responsible for the implementation of successful corrective action plans in affected problem areas as evidenced by failing to ensure the effective implementation of an infection control surveillance program relative to infection control breeches and patient care equipment and failing to develop written corrective actions for problems identified with cleaning solutions. Findings:

During the survey from 05/12/15 through 05/18/15 the following infection control breeches were observed:
1) failing to ensure the hospital staff implemented hand hygiene practices in accordance with hospital policies and procedures when administering nebulizer treatments for 1 (#2) of 1 observation of providing a nebulizer treatment, when flushing a saline lock for 1 (#7) of 1 observation of flushing a saline lock from a sample of 30 patients, when performing wound care for 1 (#1) of 1 observation of providing wound care, and when disposing of soiled linen for 1 of 1 (S11CNA, Certified Nursing Assessment) observation of staff disposing of soiled linen,

2) failing to implement infection control practices in performing intravenous (IV) therapy for 1 (#7) of 1 observation of discontinuing an IV piggyback from a sample of 30 patients.

3) failing to implement contact isolation precautions for 1(#5) of 1 sampled patients on contact precautions,

4) failing to ensure that equipment available for patient use was not torn/taped to ensure effective infection control cleaning/disinfecting.

In an interview on 05/14/15 at 3:20 p.m. S16ICN (Infection Control Nurse) stated she did environmental rounds and submitted the results to the Administrator. She confirmed she had not identified the above breeches during her rounds. She stated she and S17ICC (Infection Control Consultant) had identified a problem with the dilution of the cleaning solutions used by housekeeping and stated they are monitoring this. S16ICN was asked for documentation of the monitoring of this problem. She stated they did not have anything in writing and confirmed there was no documentation of an indicator, methodology, or corrective actions.