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Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by failure of the RN to record, interpret and document the cardiac rhythm of 4 of 4 patients reviewed who were receiving continuous telemetry monitoring in a total sample of 31 (Patient #18, #22, #31).
Findings:

Review of the policy titled, Telemetry Monitoring (Policy CL 2.4), revealed in part that cardiac rhythm will be recorded, interpreted and documented on the initiation of telemetry monitoring, every four hours thereafter, and PRN as indicated by the patient's condition or change in cardiac rhythm.

Patient #18
Review of the medical record revealed an admit date of 10/28/19 with orders for telemetry monitoring. Further review of the medical record revealed that twice daily cardiac monitoring strips were in the chart, and included the following dates/times:
11/19/19, cardiac strips ran at 4:00 a.m. and 4:00 p.m.
11/18/19, cardiac strips ran at 3:00 a.m. and 4:00 p.m.
11/17/19, cardiac strips ran at 3:16 p.m. and 4:00 p.m.

Further review of the strips revealed no documented evidence that the cardiac rhythm was interpreted and documented on the strips. Further review of the medical record revealed no documented evidence that the patient's cardiac rhythm was interpreted and recorded every four hours.

On 11/20/19 at 9:15 a.m., interview with Patient #18's nurse, S7RN, revealed that cardiac strips are to be ran twice daily (once per shift) and the nurses are supposed to interpret the cardiac rhythm and document that information on the strips. At that time, the surveyor asked S7RN to review the patient's strips in the medical record and he confirmed there was no documented evidence that the strips were being interpreted by the nurses.

Patient #22
Review of the medical record revealed an admit date of 11/08/19 with orders for telemetry monitoring. Further review of the medical record revealed that cardiac monitoring strips were ran and placed in the chart every 12 hours.

Further review of the strips revealed no documented evidence that the cardiac rhythm was interpreted and documented on the strips. Further review of the medical record revealed no documented evidence that the patient's cardiac rhythm was interpreted and recorded every four hours.

Patient #31
Review of the medical record revealed an admit date of 11/11/19 with orders for telemetry monitoring. Further review of the medical record revealed that cardiac monitoring strips were in the chart, and included the following dates/times:
11/19/19, strips ran at 4:00 a.m. and 4:00 p.m.
11/18/19, strips ran at 2:57 a.m. and 4:00 p.m.
11/17/19, only one strip ran for the day at 4:15 a.m.
11/16/19, strips ran at 3:03 a.m. and 4:00 p.m.

Further review of the strips revealed no documented evidence that the cardiac rhythm was interpreted and documented on the strips by the nurses. Further review of the medical record revealed no documented evidence that the patient's cardiac rhythm was interpreted and recorded every four hours.

On 11/20/19 at 10:35 a.m., interview with S2DON revealed that he was aware of issues regarding the interpretation of telemetry strips. S2DON confirmed that strips are to be ran every four hours and placed on the medical records. S2DON further confirmed that the nurses are to interpret the strips, including rhythm and measurements, and document this information on the strips. He further stated that the hospital had updated the policy on telemetry monitoring to include interpretation of the rhythm strips by the nurses every four hours. When asked if the nurses were aware of this new policy, he stated that he had not inserviced the nurses yet.

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Based on record review and interview, the hospital failed to ensure that medical records were completed no later than 30 days after patient discharge.
Findings:

Review of the policy titled, Physician Notification of Incomplete Medical Records (Policy HIM-3.0), revealed in part that incomplete records after 30 days or as defined by the Medical Staff Rules and Regulations and Bylaws are considered delinquent. Delinquency statistics must be maintained by the HIM department and reported in compliance with CIHQ and CMS standards.

Review of the Medical Staff Rules and Regulations revealed that medical records that are incomplete 30 days after patient discharge are considered delinquent. When a physician has a medical record 30 days or greater from the date of discharge, the physician will be notified of delinquent medical records. The physician will be sent a letter requiring completion of the delinquent charts before 60 days delinquent. If the physician has any medical records in a delinquent status at 60 days post discharge then the physician's privileges may be suspended.

On 11/18/19 at 3:30 p.m., a list of all delinquent medical records was requested from S6HIM Director. At that time, S6HIM Director provided a list of 16 records that were delinquent, with only two of the records older than 30 days.

On 11/19/19 at 1:00 p.m., the surveyor requested 3 random discharged records to review (Patient #4, #5 and #6). Review of the records revealed the following:
Patient #4 was admitted on 08/15/19 and discharged on 09/13/19. There were multiple flagged tags in the chart, indicating physician signatures were needed. Further review of the record revealed consent forms, consultation reports, progress notes and telephone orders were not signed by the physician. Further review revealed no discharge summary was in the record.

Patient #5 was admitted on 08/14/19 and discharged on 09/04/19. Review of the record revealed multiple incomplete entries in the chart, including unsigned consultation reports, echocardiogram reports and physician progress notes. The unsigned discharge summary was dated 11/18/19.

Patient #6 was admitted on 06/29/19 and discharged on 09/24/19. Review of the record revealed multiple incomplete entries, including physician progress notes and multiple consultations. The unsigned discharge summary was dated 11/18/19.

On 11/19/19 at 3:00 p.m., the surveyor and S6HIM Director reviewed the above medical records and S6HIM Director confirmed the records were incomplete and delinquent greater than 30 days. When asked if she was aware that the above records were delinquent, because they were not on the delinquent list provided, she stated no. She further stated that the only delinquencies that she kept up with were for missing discharge summaries. When asked if she had a complete list of all delinquent records greater than 30 days, she stated no.

On 11/20/19 at 8:00 a.m., interview with S3DQM revealed that S2DON emails her the monthly QA data regarding delinquent medical records. Review of this data included the following:
October 2019, 41% delinquency rate
September 2019, 28% delinquency rate
August 2019, 10.53% delinquency rate
July 2019, 30% delinquency rate

On 11/20/19 at 8:30 a.m., interview with S1Administrator and S2DON revealed that they were aware of the problems with delinquent medical records, but stated that it was getting better. When S2DON was asked where the QA data came from regarding delinquent records, he stated the medical records staff gave it to him. At that time, the surveyor informed S2DON that the three random discharged charts that were sampled were not on the delinquency list provided by S6HIM Director. S1Administrator and S2DON revealed that they were unaware of that and confirmed that the QA data numbers were inaccurate. They further stated the hospital failed to have a system in place to track and complete delinquent medical records.

Based on record review and interview, the hospital failed to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed (review for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications).
Findings:

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

Review of the hospital policy titled, After Hours Preparation and Labeling of Medications (Policy PH 4.1) revealed in part that when the pharmacy is closed, all medication orders will be faxed/scanned to the pharmacy for order review by the pharmacist first thing the next morning. The Charge Nurse/Nursing Supervisor will have the medication order in hand when entering the medication room. Another nurse is required to witness on all Pyxis overrides.

On 11/19/19 at 2:00 p.m., interview with S5Pharmacist revealed that the hospital's pharmacy hours are Monday-Friday from 8 a.m.-5 p.m. and on weekends from 8:00 a.m.-12:00 p.m. When asked the procedure for performing first dose reviews for any new medications (non-emergent) ordered after pharmacy hours, S5Pharmacist stated that the RN supervisor will override the medication in the Pyxis (automated medication dispensing device) in order to obtain the inital dose of medication for the patient. S5Pharmacist further stated that the RN supervisor would review the medication and witnesses the first dose with the nurse. S5Pharmacist stated that the next morning, she would the review the medication. Further interview with S5Pharmacist confirmed that after pharmacy hours, patients with new medications (non-emergent) ordered are receiving the first doses of medication prior to a review by a pharmacist.

On 11/20/19 at 10:00 a.m., interview with S2DON confirmed first dose reviews were not being performed by the pharmacist on new medications that were ordered after pharmacy hours. S2DON stated that if the new medication is in the Pyxis, the nursing supervisor will override in order to obtain the new medication. S2DON confirmed that the nurses are administering the first doses of medication (ordered after pharmacy hours) prior to review by a pharmacist.

Based on record review and interview, the hospital failed to ensure identified medication errors were documented in the patient's medical record for 3 (Patient #1, #2, #3) of 3 patient records reviewed who had hospital identified medication errors.
Findings:

Review of the Medication Error Occurrence Reports for the past six months provided by S3DQM revealed that Patients #1, #2 and #3 were involved in medication errors. Review of the patients' records revealed no documentation of the medication errors or that the physician had been notified of the medication errors.

On 11/19/19 at 3:20 p.m., S3DQM reviewed the above patients medical records with the surveyor. S3DQM confirmed that there was no evidence the medication errors were recorded in the patient's medical record or that their physicians were notified of the medication errors.

Based on observation and interview, the hospital failed to ensure that equipment was maintained to ensure safety as evidenced by having 22 hospital beds with non-functioning nurse call systems in rooms used by patients.
Findings:

On 11/18/19 at 9:45 a.m., observation of room c revealed the side rails of the bed had a visible nurse call button which did not activate the call system when pressed. An interview at this time with S2DON confirmed that the nurse call system attached to the beds had been disabled and the patients were required to use a handheld device to activate the call system. He confirmed that this could cause confusion for patients attempting to activate the system and result in delayed calls. S2DON reported a total of 22 beds in the hospital had the non-functioning call systems.

Based on policy review, observation and interview, the hospital failed to ensure the infection control officer assured the system for controlling infections and communicable diseases of patients and personnel was implemented according to hospital policy and acceptable standards of infection control practices. This deficient practice is evidenced by:
1) Failure to maintain a sanitary environment;
2) Failure to ensure expired supplies were not available for patient use and
3) Failure to wear proper personal protective equipment.
Findings:


1) Failure to maintain a sanitary environment

Review of the hospital's policy ICP 08.02 titled, "Cleaning and Disinfection of Equipment, Devices and Supplies" revealed in part:
Purpose: To ensure that medical equipment is appropriately cleaned and disinfected prior to use to prevent the spread of infection or disease. Policy: B - Cleaning or the removal of all foreign material shall be accomplished. E - Medical equipment shall be cleaned when visibly dirty. I - Departments with permanently assigned equipment are to clean and maintain and disinfect their own equipment.

Review of the hospital's policy ICP 08.03 titled, "Management of Equipment, Devices and Supplies" revealed in part: Purpose - To prevent the spread of microorganisms by use of equipment, devices and supplies. Policy: All equipment MUST be cleaned at point of care. All shared equipment must be cleaned, with hospital approved cleaning agent, in between patient use.

On 11/18/19 at 9:35 a.m., observation of room a revealed a bedside commode covered in plastic with a dried, crumbly, brown substance on the top of the plastic.
On 11/18/19 at 9:40 a.m., observation of room b revealed a long strip of fabric tied to the call bell on the wall.
An interview at this time with S1Administrator confirmed that the above rooms were considered to be clean and ready for patient admission.
On 11/18/19 at 9:55 a.m., observation of room d revealed an IV pump that had dried debris on the pump. The pump was covered in plastic wrap.
On 11/18/19 at 10:00 a.m., observation of room e revealed a tube feeding pump with a smeared substance on the face of the pump. The pump was covered with a plastic wrap.
An interview at this time with S2DON confirmed that the plastic wrap on the pumps indicated that the rooms were considered to be clean and ready for patient admission.

Observation of the Respiratory Therapy Clean Equipment Room on 11/19/2019 at 8:15 a.m. revealed grime and hair on the EKG lead-wires and two Bi-Pap machines with their oxygen tubing in contact with the floor. During an interview at that time, S10RT confirmed the findings and acknowledged the equipment posed an infection control problem.


2) Failure to ensure expired supplies were not available for patient use

On 11/18/19 at 10:20 a.m., observation of the central supply room with S2DON on the 100-200 Hall revealed the following expired supplies:
(30) 18 gauge IV catheters, with expiration dates ranging from 09/2015 to 08/2017
(20) 24 gauge IV catheters, with an expiration date of 11/2015
(30) packages of Steri-strips, with an expiration date of 10/2018
Approximately (50) Acticoat dressings, with expiration dates from 2013-2015

At that time, S2DON confirmed the above expired supplies that were available for patient use.

3) Failure to wear proper personal protective equipment

Review of the hospital's policy ICP 04.03 titled, "Standard, Transmission Based and, Neutropenic Precautions and Discontinuation of Precautions" revealed in part:
Contact Precautions - Applies to patients with any of the following conditions and/or disease: Enteric Precautions (C-diff and other infectious diarrhea) - PPE use: Wear gowns and gloves when touching the patient and the patient's immediate environment or belongings.

Observation on 11/20/2019 at 9:12 a.m. revealed S9Tech assisting Patient #22 in the patient's room. Further observation revealed S9Tech was not wearing a gown as directed by the Enteric Contact Precaution sign on patient's door.

Observation on 11/20/19 at 9:16 a.m. revealed S9Tech exited patient #22's room to get a washcloth and returned to assisting Patient #22 without putting on the required disposable gown prior to entering the room for a second time.

During an interview at that time, S8OT, who was observing S9Tech with surveyor, acknowledged S9Tech did not wear a gown as was directed by the Enteric Precautions sign posted outside Patient #22's room when touching the patient or the patient's immediate environment or belongings per hospital policy.

During an interview on 11/20/2019 at 9:20 a.m., S9Tech acknowledged she did not wear a gown when touching the patient or the patient's immediate environment or belongings.

Review of Patient #22's medical record revealed, in part, an admit date of 11/08/2019 with a diagnosis of C-diff (Clostridium difficile) Colitis.

Based on observation and interview, the hospital failed to ensure that standards were maintained for surgical care procedures as evidenced by failing to follow manufacturer's instructions for the high-level disinfection of endoscopes.
Findings:

On 11/19/19 at 10:00 a.m., the procedure room was observed with S4RN, Procedure Room Supervisor. Observation of the manufacturer's instructions for the Enzymatic revealed the concentration should be ½ ounce per one gallon of water. The sink used for high level disinfection of the endoscopes was not marked for the water level. When asked about the process for diluting the enzymatic, S4RN revealed that a denture cup of enzymatic (8 ounces) was added to the water in the sink, which she said she eyeballed and guessed would be about 2 gallons. S4RN confirmed that the concentration level of the enzymatic could not be determined to be consistent with the manufacturer's instructions.