HospitalInspections.org

Based on record reviews, observations, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Governing Body as evidenced by:

1) Failing to ensure medical staff members were re-appointed and temporary privileges were granted in accordance with the Medical Staff By-laws for 5 (S15, S16, S17, S21, S32) of 6 (S10, S15, S16, S17, S21, S32) physician credentialing files reviewed from a total of 10 credentialed physicians that resulted in patients' care being provided by physicians who were not currently credentialed and privileged as members of the Medical Staff (S21, S32) and for 2 (S18, S19) of 2 physician credentialing files reviewed and 1 (S20) of 1 nurse practitioner file reviewed for temporary privileges from a total of 2 physicians with temporary privileges and 3 nurse practitioners (NP) with temporary privileges (see findings in tag A0046).

2) Failing to ensure the medical staff was accountable for providing quality of care to patients as evidenced by failure of the physician to follow La. R.S. (Louisiana Revised Statute) 9:111 and hospital policy relating to pronouncement of death. The physician failed to assess the irreversible cessation of spontaneous respiratory and circulatory functions and determining and pronouncement of the patients' death for 4 (#11, #12, #13, #15) of 4 patients who expired while admitted to the hospital (#11, #12, #13, #15) from a total sample of 30 patient records (see findings in tag A0049).

3) Failing to ensure that patients admitted for contracted hospice services were admitted based on the hospital's scope of service and admission criteria for 5 (#11, #12, #13, #14, #15) of 5 hospice patient records reviewed for admission criteria from a total of 30 patient records (see findings in tag A0083).

4) Failing to ensure that services performed under a contract were provided in a safe and effective manner as evidenced by failure to have documented evidence of an evaluation of the hospital's services provided by contract (see findings in tag A0084).

Based on record reviews and interviews, the hospital failed to ensure the requirements for the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) were met as evidenced by:

1) Failing to ensure opportunities for improvement identified during the survey had been identified through its QAPI program as evidenced by:
a) Failure to ensure the medical staff was accountable for providing quality of care to patients as evidenced by failure of the physician to follow La. R.S. (Louisiana Revised Statute) 9:111 and hospital policy relating to pronouncement of death. The physician failed to assess the irreversible cessation of spontaneous respiratory and circulatory functions and determining and pronouncement of the patients' death for 4 (#11, #12, #13, #15) of 4 patients who expired while admitted to the hospital (#11, #12, #13, #15) from a total sample of 30 patient records.
b) Failure to ensure medical staff members were re-appointed and temporary privileges were granted in accordance with the Medical Staff By-laws for 5 (S15, S16, S17, S21, S32) of 6 (S10, S15, S16, S17, S21, S32) physician credentialing files reviewed from a total of 10 credentialed physicians that resulted in patients' care being provided by physicians who were not currently credentialed and privileged as members of the Medical Staff (S21, S32).
c) Failure to ensure each patient was provided written notice at the beginning of a planned or unplanned inpatient stay that there is no doctor of medicine or osteopathy present in the hospital 24 hours a day, seven days per week, as required by 42 CFR 489.20(w) as evidenced by having no documented evidence that each inpatient was provided written notice that a physician was not present 24 hours a day, seven days per week, for 10 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10) of 10 current inpatient medical records reviewed for notification in writing from a total sample of 30 patient records (see findings in tag A0283).

2) Failing to ensure data collected for its QAPI program was used to identify opportunities for improvement and changes that will lead to improvement and implement actions aimed at performance improvement as evidenced by failure to develop interventions to improve identified problems with hand hygiene, compliance with documentation of the reason why a medication wasn't given when it was circled on the medication administration record (MAR), and medication errors (see findings in tag A0283).

3) Failing to ensure patient safety as evidenced by having hand hygiene compliance reported below the set goal of 85% (compliance) monthly for the year of 2015. The hospital could not provide documentation of development and implementation of corrective interventions and ongoing evaluation of the interventions for success and sustainability (see findings in tag A0286).

4) Failing to ensure its QAPI program involved all hospital departments and services including those services furnished under contract or agreement as evidenced by failure to have quality indicators developed for radiology services, laboratory services, linen services, and housekeeping (see findings in tag A0308).

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

1) Failing to ensure La. R.S. (Louisiana Revised Statute) 9:111 and hospital policy relating to pronouncement of death was followed by physicians as evidenced by delegating the assessment of irreversible cessation of spontaneous respiratory and circulatory functions and determining and pronouncement of the patients' death to the nurse for 4 (#11, #12, #13, #15) of 4 patients who expired while admitted to the hospital (#11, #12, #13, #15) from a total sample of 30 patient records (see findings in tag A0347) and

2) Failing to ensure the medical staff examined the credentials and made recommendations to the governing body on the reappointment of medical staff members in accordance with the Medical Staff By-laws for 5 (S15, S16, S17, S21, S32) of 6 (S10, S15, S16, S17, S21, S32) physician credentialing files reviewed from a total of 10 credentialed physicians. This resulted in patients' care being provided by physicians who were not currently credentialed and privileged as members of the Medical Staff (S21, S32) (see findings in tag A0341).

3) Failing to ensure temporary privileges were granted in accordance with the Medical Staff By-laws for 2 (S18, S19) of 2 physician credentialing files reviewed and 1 (S20) of 1 nurse practitioner file reviewed for temporary privileges from a total of 2 physicians with temporary privileges and 3 nurse practitioners (NP) with temporary privileges as evidenced by failure to have documented evidence of the Medical Director's review and approval of requested privileges prior to the administrator's review. (see findings in tag A0341).

Based on observations, interviews and record reviews, the hospital failed to ensure the requirements for the Condition of Participation for Infection Control were met as evidenced by:
1. Failure to ensure the infection control officer developed and implemented infection control policies that were based on nationally recognized guidelines. (see findings at A-748)
2. Failure to ensure the infection control officers developed and implemented a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. This deficient practice was evidenced by:

1. failure to have a current infection control plan;

2. failure to ensure expired dialysis supplies were not available for use;

3. failure to identify, analyze, develop a corrective plan, and monitor for success and sustainability, when hand hygiene surveillance results were below the targeted goal (85%) from January 2015 through June 2015;

4. failure to provide provisions for hand hygiene in all areas of patient care;

5. failure to ensure nurses were trained and competent to adhere to infection control procedures when accessing a PICC (peripherally inserted central catheter) and drawing blood cultures;

6. failure to include Physicians, mid-level practitioners, and contract employees in the hospital's Tuberculosis (TB) surveillance program;

7. failure to have a respiratory protection program that detailed worksite-specific procedures and elements for required respirator use, and failed to ensure respiratory fit testing was provided at regular intervals to personnel at risk;

8. failure to conduct infection control related Environmental Rounds, by the Infection Preventionist or designee as per the hospital policy;

9. failure to ensure hand hygiene was performed by 1 of 1(S1Physician) physician observed examining a patient, and 2 of 2(S3DON, S23RN) RNs (Registered Nurses) observed drawing blood cultures. (See findings at A-749)


3. Failure of the Chief Executive Officer, the Medical Staff, and the Director of Nursing to ensure the hospital-wide quality assessment and performance improvement (QAPI) program and training programs addressed problems identified by the infection control officer(s). This deficient practice was evidenced by no action plan developed, implemented, and evaluated for success and sustainability, hospital-wide, for hand hygiene compliance below the hospital's targeted goal of 85% January 2015 through June 2015. (See findings at A-0756)

Based on record reviews and interviews, the governing body failed to ensure medical staff members were re-appointed and temporary privileges were granted in accordance with the Medical Staff By-laws for 5 (S15, S16, S17, S21, S32) of 6 (S10, S15, S16, S17, S21, S32) physician credentialing files reviewed from a total of 10 credentialed physicians that resulted in patients' care being provided by physicians who were not currently credentialed and privileged as members of the Medical Staff (S21, S32) and for 2 (S18, S19) of 2 physician credentialing files reviewed and 1 (S20) of 1 nurse practitioner file reviewed for temporary privileges from a total of 2 physicians with temporary privileges and 3 nurse practitioners (NP) with temporary privileges.
Findings:

Review of the Medical Staff By-laws, presented as the current By-laws by S3DON (Director of Nursing), revealed that a re-application form will be sent to each applicant at least 2 months prior to the re-appointment due date. If the applicant fails to return the re-appointment application by the due date, the member shall be deemed to have resigned membership to the medical staff at the end of the current staff appointment. Information required from the applicant for re-appointment includes a re-appointment application, current Louisiana medical license, current DEA (Drug Enforcement Administration) certificate, and current Louisiana CDS (Controlled and Dangerous Substance) license. The claims history of each applicant for re-appointment will be verified with the National Practitioner Data Bank. All applicants are processed only after the medical staff office receives a completed, verified application. Further review revealed the administrator or designee of the hospital, on the recommendation of the Medical Director or authorized designee, has the authority to grant temporary privileges to a physician, osteopath, podiatrist, or allied professional on request of a member of the active staff for a period of no more than 120 days. Further review revealed the process and procedure for granting temporary privileges, initial appointment, re-appointment, and modification of privileges for allied health professionals is the same as that documented in the By-laws for physicians.

Re-appointment of physicians:
Review of the list of credentialed list of physicians presented by S3DON revealed no documented evidence that S21Physician and S32Physician were included in the list.

S15Physician
Review of S15Physician's credentialing file revealed he was appointed to the Medical Staff on 07/13/13. Further review revealed a letter was sent to S15Physician on 07/16/15 informing him that any re-appointment paperwork not received by the hospital by 07/31/15 would result in his voluntary resignation from the medical staff. There was no documented evidence that a re-application packet had been sent to S15Physician 2 months prior to his re-appointment date as required by the Medical Staff By-laws.

S16Physician
Review of S16Physician's credentialing file revealed he was appointed to the Medical Staff on 07/18/13. Further review revealed a letter was sent to S16Physician on 07/16/15 informing him that any re-appointment paperwork not received by the hospital by 07/31/15 (his re-appointment date was 07/18/13 and not 07/31/15) would result in his voluntary resignation from the medical staff. There was no documented evidence that a re-application packet had been sent to S16Physician 2 months prior to his re-appointment date as required by the Medical Staff By-laws.

S17Physician
Review of S17Physician's credentialing file revealed he was appointed to the Medical Staff on 07/20/13. Further review revealed a letter was sent to S17Physician on 07/16/15 informing him that any re-appointment paperwork not received by the hospital by 07/20/15 would result in his voluntary resignation from the medical staff. There was no documented evidence that a re-application packet had been sent to S17Physician 2 months prior to his re-appointment date as required by the Medical Staff By-laws.

S21Physician
Review of S21Physician's credentialing file revealed he was appointed to the Medical Staff effective 05/02/13. Further review revealed no documented evidence that a re-application packet had been sent to him 2 months prior to re-appointment, and there was no documented evidence that S21Physician was currently credentialed and privileged as a member of the Medical Staff.

Review of Patient #2's (a current inpatient) medical record revealed a physician's order from S10Medical Director on 07/17/15 at 12:00 p.m. to consult S21Physician.

S32Physician
Review of S32Physician's credentialing file revealed he appointed to the Medical Staff effective 08/01/12. Further review revealed he requested temporary privileges on 08/05/14 (3 days after his appointment had expired). The request for temporary privileges was signed by the administrator on 08/05/14 with no documented evidence of a signature indicating it was reviewed by the Medical Director. Further review revealed the copy of his CDS license in his file had expired 09/01/14. There was no documented evidence that S32Physician was currently credentialed and privileged as a member of the Medical Staff.

In an interview on 07/30/15 at 10:15 a.m., S10Medical Director indicated S32Physician is a nephrologist who consults on dialysis patients at the hospital. He confirmed that S21Physician and S32Physician are currently seeing patients at the hospital.

In a telephone interview on 07/30/15 at 1:45 p.m. with S2HR (Human Resource) Director present, S33Credentialing Officer indicated she doesn't keep a copy of the re-application packet sent to physicians at the time of re-appointment, so she can't say when the re-application packets were sent to the above-listed physicians. When asked about the process for credentialing, S33Credentialing Officer indicated she scans the forms to S2HR Director (who is the credentialing contact person in the hospital) to have them presented for signature at the Medical Executive Committee and Governing Body meetings. She further indicated she completed the process "on her end and S2HR Director knows what to do." When asked whose responsibility it was to do a final check of the credentialing file, S33Credentialing Officer indicated it was S2HR Director's responsibility. S2HR Director indicated she sends the credentialing file back to S33Credentialing Officer when "I'm done, so the final eyes are done by S33Credentialing Officer."

Temporary privileges:
S18Physician
Review of S18Physician's "Temporary Privileges Request" revealed he requested temporary privileges on 06/05/15. Further review revealed the administrator granted privileges on 06/13/15 prior to S10Medical Director reviewing the request and signing her approval on 07/16/15.

S19Physician
Review of S19Physician's "Temporary Privileges Request" revealed he requested temporary privileges on 05/30/15. Further review revealed the administrator granted privileges on 05/30/15 prior to S10Medical Director reviewing the request and signing her approval on 06/01/15.

S20NP
Review of S20NP's credentialing file revealed she requested temporary privileges on 07/17/15 . Further review revealed S10Medical Director approved the request on 07/17/15 with no documented evidence that privileges had been approved by the administrator as required by the Medical Staff By-laws.

In a telephone interview on 07/30/15 at 1:45 p.m. with S2HRDirector present, S33Credentialing Officer indicated she knows that the administrator and Medical Director can sign on different dates, as long as the request is signed before the physician or NP practices. She further indicated she thought as long as the Medical Director signed the request, she thought it was alright not to have the administrator's signature. She couldn't explain why the temporary privileges were being signed by the administrator prior to the request being reviewed and approved by the Medical Director.

Based on record reviews and interviews, the hospital failed to ensure the medical staff was accountable for providing quality of care to patients as evidenced by failure of the physician to follow La. R.S. (Louisiana Revised Statute) 9:111 and hospital policy relating to pronouncement of death. The physician failed to assess the irreversible cessation of spontaneous respiratory and circulatory functions and determining and pronouncement of the patients' death for 4 (#11, #12, #13, #15) of 4 patients who expired while admitted to the hospital (#11, #12, #13, #15) from a total sample of 30 patient records.
Findings:

Review of La. R.S. 9:111. Definition of death revealed, in part, "... A. A person will be considered dead if in the announced opinion of a physician, duly licensed in the state of Louisiana based on ordinary standards of approved medical practice, the person has experienced an irreversible cessation of spontaneous respiratory and circulatory functions...". Added by Acts 1976, No. 233, §1; Acts 2001, No. 317, §1; Acts 2010, No. 937, §1, eff. July 1, 2010.

Review of the hospital policy titled "Patient Death/Organ Donation", presented as a current policy by S3DON (Director of Nursing), revealed a physician must pronounce a patient dead. The attending physician may delegate this to another physician who may be in the hospital at the time of death.

Patient #11
Review of Patient #11's medical record revealed she was a 59 year old female admitted on 07/06/15 with diagnoses of Hepatitis C, Cirrhosis, Hypertension Varices, and Hospice. Further review revealed an order for DNR (do not resuscitate).

Review of Patient #11's nursing narrative notes for 07/07/15 revealed documentation by S23RN (registered nurse) at 5:45 p.m. that no respirations or heart rate were noted, and the hospice nurse was called by S3DON. Further review revealed at 7:00 p.m. S27RN documented that the hospice nurse was at the bedside, and "time of death recorded in Hospice nurse notes 1900 (7:00 p.m.)." At 8:30 p.m. S27RN documented that the funeral home attendant was present for transport of Patient #11 to the funeral home. Review of the hospice nurse's documentation for 07/07/15 revealed no documented evidence of Patient #11's death and the time death was pronounced.

Review of Patient #11's entire medical record revealed no documented evidence that a physician was present to pronounce death as required by La. R.S. 9:111 and that the physician was notified of Patient #11's death.

Review of Patient #11's "Rehab Physician Progress Notes" dated 07/08/15 at 8:15 a.m. revealed an entry by S10Medical Director that Patient #11 "expired last night @ (at) 7:00 p.m. (with) family around."

Patient #12
Review of Patient #12's medical record revealed she was a 40 year old female admitted on 04/20/15 for hospice inpatient care for symptom management with a diagnosis of HIV (Human Immunodeficiency Virus). Further review revealed an order for DNR. A telephone order was received from S10Medical Director on 04/24/15 at 10:00 p.m. to release the body to the funeral home.

Review of Patient #12's nursing narrative notes for 04/24/15 revealed documentation by the RN that Patient #12 was found unresponsive at 6:20 p.m. with "signs of life", and the hospice nurse was notified. Further documentation revealed that the hospice nurse arrived at 7:15 p.m., and the body was released to the funeral home at 8:40 p.m.

Review of Patient #12's entire medical record revealed no documented evidence that a physician was present to pronounce death as required by La. R.S. 9:111.

Review of Patient #12's "Rehab Physician Progress Notes" dated 04/27/15 at 9:15 a.m. revealed an entry by S10Medical Director that "Pt (patient) expired on Friday 4/24/15 @ 6:45 (no indication of a.m. or p.m.), pt's family was present @ the time."

Patient #13
Review of Patient #13's medical record revealed she was a 72 year old female admitted on 08/27/15 with diagnoses of Dementia and Failure To Thrive with orders for comfort measures only.

Review of Patient #13's nursing notes revealed the RN documented on 08/27/15 at 6:45 p.m. that Patient #13 had no respirations and no pulse, and she called the hospice nurse. Further review revealed the RN documented at 7:30 p.m. that the hospice nurse was present and called the coroner and S11Physician to notify of Patient #13's death.

Review of Patient #13's entire medical record revealed no documented evidence that a physician was present to pronounce death as required by La. R.S. 9:111.

Patient #15
Review of Patient #15's medical record revealed he was an 80 year old male admitted on 10/31/14 to hospice with diagnoses of CHF (Congestive Heart Failure), COPD (Chronic Obstructive Pulmonary Disease), and ESRD (End Stage Renal Disease) and an order for DNR.

Review of Patient #15's nursing notes on 11/03/14 revealed the LPN (licensed practical nurse) documented at 12:45 p.m. that the patient had expired, the RN Supervisor was informed, and the hospice company was informed. There was no documented evidence that the attending physician was notified.

Review of Patient #15's entire medical record revealed no documented evidence that a physician was present to pronounce death as required by La. R.S. 9:111.

In an interview on 07/30/15 at 8:50 a.m., S3DON indicated that a hospice nurse told her that a hospice nurse can pronounce death with a phone call to the hospice Medical Director or Coroner. She confirmed that above patients' deaths were not pronounced by a physician who was onsite at the time of death.

In an interview on 07/30/15 at 1:20 p.m., S1Administrator indicated he wasn't aware that a physician did not come to the hospital to pronounce a patient's death

Based on record reviews and interviews, the governing body failed to ensure that patients admitted for contracted hospice services were admitted based on the hospital's scope of service and admission criteria for 5 (#11, #12, #13, #14, #15) of 5 hospice patient records reviewed for admission criteria from a total of 30 patient records.
Findings:

Review of the hospital policy titled "Scope Of service And Goals For The facility", presented as a current policy by S9VP (Vice-President) Clinical, revealed that services would be provided to patients ages 18 to geriatric of any ethnic background or health status who meet Inpatient Admission Criteria.

Review of the hospital policy titled :Medical Necessity Criteria For Admission", presented as a current policy by S9VP Clinical, revealed that admission criteria required a medical condition that requires in-patient treatment and/or monitoring that allows the patient to participate in an individualized program of remedial therapy. There must also be a reasonable expectation that the patient will benefit from such participation. Further review revealed that program services were designed to treat conditions resulting from head trauma, spinal cord injury, peripheral nerve damage, stroke, degenerative neurological conditions, and muscular, orthopedic, and speech disorders resulting from illness, injury, burns, amputations, or surgical treatment.

Review of the hospital policy titled "General Rehab Admission Guidelines", presented as a current policy by S9VP Clinical, revealed that rehab admission was to provide appropriate and adequate in-patient services to those requiring assistance in compensating for disability, weakness, and decreased functional skills for day-to-day living. The patient is required to be able to participate in at least 15 hours of therapy in a 7 day period, requiring at least 2 therapy disciplines, one of which must be either physical therapy or occupational therapy.

Patient #11
Review of Patient #11's medical record revealed she was a 59 year old female admitted on 07/06/15 with diagnoses of Hepatitis C, Cirrhosis, Hypertension Varices, and Hospice. There was no documented evidence that Patient #11 met the admission criteria for the rehab hospital.

Patient #12
Review of Patient #12's medical record revealed she was a 40 year old female admitted on 04/20/15 for hospice inpatient care for symptom management with a diagnosis of HIV (Human Immunodeficiency Virus). There was no documented evidence that Patient #12 met the admission criteria for the rehab hospital.

Patient #13
Review of Patient #13's medical record revealed she was a 72 year old female admitted on 08/27/15 for hospice with diagnoses of Dementia and Failure To Thrive with orders for comfort measures only. There was no documented evidence that Patient #13 met the admission criteria for the rehab hospital.

Patient #14
Review of Patient #14's medical record revealed she was an 83 year old female admitted on 12/12/14 to hospice with diagnoses of End Stage CHF (Congestive Heart Failure). There was no documented evidence that Patient #14 met the admission criteria for the rehab hospital.

Patient #15
Review of Patient #15's medical record revealed he was an 80 year old male admitted on 10/31/14 to hospice with diagnoses of CHF, COPD (Chronic Obstructive Pulmonary Disease), and ESRD (End Stage Renal Disease). There was no documented evidence that Patient #15 met the admission criteria for the rehab hospital.

In an interview on 07/30/15 at 8:50 a.m., when asked how hospice patients met the admission criteria for the rehab hospital, S3DON (Director of Nursing) indicated that was a question for someone above her in administration.

In an interview on 07/30/15 at 10:15 a.m., S10Medical Director indicated she admits hospice patients to the hospital. When asked how hospice patients meet the admission criteria for the rehab hospital, she indicated "they're not rehab, we just provide a bed and nursing care." She further indicated admitting hospice patients to the rehab hospital had been "going on for quite a few years, it's a decision made on a higher level."

In an interview on 07/30/15 at 1:20 p.m., S1Administrator indicated he thought it was appropriate to admit hospice patients to the rehab hospital, because "it's a contracted service and we don't provide the care, they're not admitted." When informed that the record review of Patients #11, #12, #13, #14, and #15 revealed the hospital nursing staff provided the nursing care, and admit orders were written by S10Medical Director, S1Administrator indicated he couldn't explain why hospice patients were being admitted without meeting the hospital's admission criteria.

Based on record review and interview, the governing body failed to ensure that services performed under a contract were provided in a safe and effective manner as evidenced by failure to have documented evidence of an evaluation of the hospital's services provided by contract.
Finding:

The hospital could provide no documented evidence that the services provided under contract had been evaluated to determine if the services were provided in a safe and effective manner.

In an interview on 07/30/15 at 2:35 p.m., S7RN indicated she was responsible for the quality assessment and performance improvement (QAPI) program at the hospital. She further indicated that no one at the hospital had conducted evaluations of the services provided under contract to determine that they had been provided in a safe and effective manner.

Based on record reviews and interviews, the hospital failed to ensure each patient was provided written notice at the beginning of a planned or unplanned inpatient stay that there is no doctor of medicine or osteopathy present in the hospital 24 hours a day, seven days per week, as required by 42 CFR 489.20(w) as evidenced by having no documented evidence that each inpatient was provided written notice that a physician was not present 24 hours a day, seven days per week, for 10 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10) of 10 current inpatient medical records reviewed for notification in writing from a total sample of 30 patient records.
Findings:

Review of the "Conditions Of Service" (informed consent form) signed by Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10 or their representative revealed no documented evidence that the consent included notification that there was no doctor of medicine or osteopathy present in the hospital 24 hours a day, seven days per week.

In an interview on 07/30/15 at 8:50 a.m., when asked if patients were informed in writing that a physician wasn't present in the hospital 24 hours a day, seven days per week, S3 DON (Director of Nursing) indicated she thought the "Emergency Care Services" form that stated "at times when there is no physician present" would cover the notification. She confirmed the hospital did not have a method of informing patients in writing that specifically informed the patient that a physician was not present 24 hours a day, seven days per week.

Based on record reviews and interviews, the hospital failed to ensure that the "Do Not Resuscitate" (DNR) policy was implemented for 1 (#8) of 1 current inpatient with written orders for DNR from a total of 10 current inpatient records reviewed for DNR orders and 3 (#11, #12, #15) of 5 (#11, #12, #13, #14, #15) closed medical records reviewed for DNR orders from a total sample of 30 patient records. The physician failed to obtain an evaluation of the patient from a consulting physician to determine if a DNR order was medically appropriate and to document a discussion with the patient or her representative relative to DNR.
Findings:

Review of the hospital policy titled "Do Not Resuscitate", presented as a current policy by S3DON (Director of Nursing), revealed the purpose of the policy was to establish procedures when decisions concerning DNR or "Terminal care" orders must be made. The procedure required the patient's attending physician and a consulting physician to determine if a DNR or Terminal Care order is medically appropriate, based on the patient's underlying terminal illness or irreversible medical condition. If the attending physician and the consulting physician determine that a DNR or Terminal Care order is medically appropriate, the physician must then discuss the matter with the patient, explaining the basis for and the consequences of, a DNR or terminal Care order. If the patient is incompetent, this discussion must be held with the patient's family or legal guardian. All such discussions must be noted in the patient's medical record. The notation of the discussion must include at least the following information: persons present, information conveyed by the physician, date and time of the conference with the patient/family, and the decision of the family and legal guardian.

Patient #8
Review of Patient #8's "Pre-Screening Screening" revealed she was a 53 year old female admitted on 07/28/15 with a diagnosis of Cerebral Artery Occlusion Not Otherwise Specified (Stroke with right body involvement - left brain). Further review revealed her co-morbidities included Dysphagia, Osteoarthrosis, Hypertensive Renal Not Otherwise Specified without Renal Failure, Morbid Obesity, and Hyperlipidemia. Further review revealed she was never married and lived at home with family/relatives.

Review of Patient #8's "Initial Nursing Assessment" completed on 07/28/15 revealed that Patient #8 was unable to understand simple questions or statements and unable to express single words or simple phrases. Patient #8 was aphasic.

Review of Patient #8's "Physician's Orders" revealed an order written by S10Medical Director on 07/29/15 at 10:45 a.m. for DNR. There was no documented evidence of an assessment of Patient #8 by a consulting physician to determine if the DNR order is medically appropriate, based on the patient's underlying terminal illness or irreversible medical condition. Review of her entire medical record revealed no documented evidence of a discussion by S10Medical Director with Patient #8's mother that included information conveyed regarding DNR, the date and time of the conference, and the decision of Patient #8's mother regarding the DNR order.

Patient #11
Review of Patient #11's medical record revealed she was a 59 year old female admitted on 07/06/15 with diagnoses of Hepatitis C, Cirrhosis, Hypertension Varices, and Hospice. Further review revealed an order for DNR (do not resuscitate). There was no documented evidence of Patient #11 being assessed by a second physician to determine if the DNR order is medically appropriate, based on the patient's underlying terminal illness or irreversible medical condition. Review of her entire medical record revealed no documented evidence of a discussion by the physician with Patient #11 or her appropriate family member(s) that included information conveyed regarding DNR, the date and time of the conference, and the decision of Patient #11 or her family regarding the DNR order.

Patient #12
Review of Patient #12's medical record revealed she was a 40 year old female admitted on 04/20/15 for hospice inpatient care for symptom management with a diagnosis of HIV (Human Immunodeficiency Virus). Further review revealed an order for DNR. There was no documented evidence of Patient #12 being assessed by a second physician to determine if the DNR order is medically appropriate, based on the patient's underlying terminal illness or irreversible medical condition. Review of her entire medical record revealed no documented evidence of a discussion by the physician with Patient #12 or her appropriate family member(s) that included information conveyed regarding DNR, the date and time of the conference, and the decision of Patient #12 or her family regarding the DNR order.

Patient #15
Review of Patient #15's medical record revealed he was an 80 year old male admitted on 10/31/14 to hospice with diagnoses of CHF (Congestive Heart Failure), COPD (Chronic Obstructive Pulmonary Disease), and ESRD (End Stage Renal Disease) and an order for DNR. There was no documented evidence of Patient #15 being assessed by a second physician to determine if the DNR order is medically appropriate, based on the patient's underlying terminal illness or irreversible medical condition. Review of her entire medical record revealed no documented evidence of a discussion by the physician with Patient #15 or his appropriate family member(s) that included information conveyed regarding DNR, the date and time of the conference, and the decision of Patient #15 or his family regarding the DNR order.

In an interview on 07/30/15 at 10:15 a.m., S10Medical Director indicated she was familiar with the hospital's policy regarding DNR orders. After reviewing the hospital policy, S10Medical Director indicated she had a conversation with Patient #8's mother and sister but didn't document the discussion as required by hospital policy. She further indicated the DNR order for Patient #8 "came from the hospital where she came from", meaning the hospital from which Patient #8 was transferred. She confirmed that Patient #8 was not evaluated by a consulting physician to determine if the DNR order was medically appropriate as required by hospital policy. S10Medical Director confirmed she writes a DNR order for the hospice patients who are admitted at the hospital and doesn't document a discussion with the patient or their appropriate family member and doesn't have a consulting physician evaluate the patient once they're admitted to determine if the DNR is medically appropriate.

Based on record reviews and interview, the hospital failed to ensure it had an ongoing quality assessment and performance improvement (QAPI) program that showed measurable improvement in indicators and measured, analyzed, and tracked quality indicators and other aspects of performance that assess processes of care, hospital services, and operations. The governing body failed to specify the frequency and detail of data collection to be used in its QAPI program.
Findings:

Review of the hospital's policy titled "Performance Improvement and Patient Safety Plan", presented as a current policy by S7RN (registered nurse), revealed that the hospital's approach to Performance Improvement and Patient Safety is guided by, but not limited to, the Joint Commission standards of compiling and analyzing data, and the governing body is ultimately accountable for the safety and quality of care, treatment, and services. Further review revealed that a systematic process is used to assess collected data in order to determine whether specifications for newly designed processes were met and the level of performance and stability of important existing processes. Collected data is reported monthly and analyzed quarterly.

Review of three quality indicators selected for review, % (per cent) of compliance with documenting the reason why medication not given was circled on the MAR (medication administration record), number of medication errors, and hand hygiene compliance, revealed no documented evidence of the method and frequency of data collection for each indicator, such as chart audits or observations, that collected data was analyzed and tracked, and the data was broken down by hospital units to allow comparison of performance among units of the hospital. There was no documented evidence that data was collected the 1st quarter of 2015 for the % of compliance with documenting the reason why medication not given was circled on the MAR.

Review of monthly Handwashing Tracking Sheets for January through July 2015 revealed 5 observations were made each month with no documented evidence of a method for documenting which staff member was observed in order to identify if the same individual had repetitive breaches in hand hygiene.

Review of a Professional Practice/Medical Executive Committee Meeting agenda dated 07/17/15 and attached 2015 Nursing Dashboard revealed reports for Hand Hygiene Compliance for the first quarter and 2nd quarter of 2015 as follows: April 73%, May 73%, and June 20% with the total 2nd quarter compliance of 55% . The areas of summary of findings, action for Improvement, Responsible person, date of implementation, and follow-up where all blank.

In an interview 7/30/15 at 11:40 a.m. S7RN and S3DON both verified the findings in the hospital's Infection Control hand hygiene surveillance. S7RN verified there was no action plan documented, or records of any corrective interventions of the identified problem of hand hygiene breaches by all disciplines of staff in the hospital.

In an interview on 07/30/15 at 2:35 p.m. with S7RN and S3DON (Director of Nursing) present, S7RN indicated she was responsible for the QAPI program at the hospital with S3DON collecting the data. S3DON indicated she had no data collection to present prior to her becoming DON. S3DON indicated she audited patient records, but she didn't have any system or tool developed to ensure consistency in chart auditing. She further indicated the reason medications weren't being given was not being tracked, and type of medication errors wasn't being tracked or analyzed to determine if the same nurse was making medication errors.

Based on record reviews and interviews, the hospital failed to ensure:
1) Opportunities for improvement identified during the survey had been identified through its QAPI program as evidenced by:

a) Failure to ensure the medical staff was accountable for providing quality of care to patients as evidenced by failure of the physician to follow La. R.S. (Louisiana Revised Statute) 9:111 and hospital policy relating to pronouncement of death. The physician failed to assess the irreversible cessation of spontaneous respiratory and circulatory functions and determining and pronouncement of the patients' death for 4 (#11, #12, #13, #15) of 4 patients who expired while admitted to the hospital (#11, #12, #13, #15) from a total sample of 30 patient records.

b) Failure to ensure medical staff members were re-appointed and temporary privileges were granted in accordance with the Medical Staff By-laws for 5 (S15, S16, S17, S21, S32) of 6 (S10, S15, S16, S17, S21, S32) physician credentialing files reviewed from a total of 10 credentialed physicians that resulted in patients' care being provided by physicians who were not currently credentialed and privileged as members of the Medical Staff (S21, S32).

c) Failure to ensure each patient was provided written notice at the beginning of a planned or unplanned inpatient stay that there is no doctor of medicine or osteopathy present in the hospital 24 hours a day, seven days per week, as required by 42 CFR 489.20(w) as evidenced by having no documented evidence that each inpatient was provided written notice that a physician was not present 24 hours a day, seven days per week, for 10 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10) of 10 current inpatient medical records reviewed for notification in writing from a total sample of 30 patient records.

2) Data collected for its quality assessment and performance improvement program (QAPI) was used to identify opportunities for improvement and changes that will lead to improvement and implement actions aimed at performance improvement as evidenced by failure to develop interventions to improve identified problems with hand hygiene, compliance with documentation of the reason why a medication wasn't given when it was circled on the medication administration record (MAR), and medication errors.
Findings:

Review of the hospital's policy titled "Performance Improvement and Patient Safety Plan", presented as a current policy by S7RN (registered nurse), revealed that when opportunities for improving performance are identified, a proactive systematic approach is used to redesign the involved process or to design a new process.

1) Opportunities for improvement identified during the survey had been identified through its QAPI program:

a) Failure to ensure the medical staff was accountable for providing quality of care to patients as evidenced by failure of the physician to follow La. R.S. (Louisiana Revised Statute) 9:111 and hospital policy relating to pronouncement of death:

Review of La. R.S. 9:111. Definition of death revealed, in part, "... A. A person will be considered dead if in the announced opinion of a physician, duly licensed in the state of Louisiana based on ordinary standards of approved medical practice, the person has experienced an irreversible cessation of spontaneous respiratory and circulatory functions...". Added by Acts 1976, No. 233, §1; Acts 2001, No. 317, §1; Acts 2010, No. 937, §1, eff. July 1, 2010.

Review of the hospital policy titled "Patient Death/Organ Donation", presented as a current policy by S3DON (Director of Nursing), revealed a physician must pronounce a patient dead. The attending physician may delegate this to another physician who may be in the hospital at the time of death.

Review of the medical records of Patients #11, #12, #13, and #15 revealed no documented evidence that a physician was present to pronounce death.

In an interview on 07/30/15 at 8:50 a.m., S3DON indicated that a hospice nurse told her that a hospice nurse can pronounce death with a phone call to the hospice Medical Director or Coroner. She confirmed that above patients' deaths were not pronounced by a physician who was onsite at the time of death.

In an interview on 07/30/15 at 1:20 p.m., S1Administrator indicated he wasn't aware that a physician did not come to the hospital to pronounce a patient's death

b) Failure to ensure medical staff members were re-appointed and temporary privileges were granted in accordance with the Medical Staff By-laws that resulted in patients' care being provided by physicians who were not currently credentialed and privileged as members of the Medical Staff:

Review of the Medical Staff By-laws, presented as the current By-laws by S3DON (Director of Nursing), revealed that a re-application form will be sent to each applicant at least 2 months prior to the re-appointment due date. If the applicant fails to return the re-appointment application by the due date, the member shall be deemed to have resigned membership to the medical staff at the end of the current staff appointment. Information required from the applicant for re-appointment includes a re-appointment application, current Louisiana medical license, current DEA (Drug Enforcement Administration) certificate, and current Louisiana CDS (Controlled and Dangerous Substance) license. The claims history of each applicant for re-appointment will be verified with the National Practitioner Data Bank. All applicants are processed only after the medical staff office receives a completed, verified application.

Re-appointment of physicians:
Review of the list of credentialed list of physicians presented by S3DON revealed no documented evidence that S21Physician and S32Physician were included in the list.

Review of the credentialing files of S15Physician, S16Physician, S17Physician revealed their re-appointment dates had passes with no documented evidence of re-appointment prior to the date, and there was no documented evidence that a re-appointment packet had been sent to the physicians at least 2 months prior to the expiration of the appointment.

S21Physician
Review of S21Physician's credentialing file revealed he was appointed to the Medical Staff effective 05/02/13. Further review revealed no documented evidence that a re-application packet had been sent to him 2 months prior to re-appointment, and there was no documented evidence that S21Physician was currently credentialed and privileged as a member of the Medical Staff.

Review of Patient #2's (a current inpatient) medical record revealed a physician's order from S10Medical Director on 07/17/15 at 12:00 p.m. to consult S21Physician.

S32Physician
Review of S32Physician's credentialing file revealed he appointed to the Medical Staff effective 08/01/12. Further review revealed he requested temporary privileges on 08/05/14 (3 days after his appointment had expired). The request for temporary privileges was signed by the administrator on 08/05/14 with no documented evidence of a signature indicating it was reviewed by the Medical Director. Further review revealed the copy of his CDS license in his file had expired 09/01/14. There was no documented evidence that S32Physician was currently credentialed and privileged as a member of the Medical Staff.

In an interview on 07/30/15 at 10:15 a.m., S10Medical Director indicated S32Physician is a nephrologist who consults on dialysis patients at the hospital. He confirmed that S21Physician and S32Physician are currently seeing patients at the hospital.

In a telephone interview on 07/30/15 at 1:45 p.m. with S2HR (Human Resource) Director present, S33Credentialing Officer indicated she doesn't keep a copy of the re-application packet sent to physicians at the time of re-appointment, so she can't say when the re-application packets were sent to the above-listed physicians. When asked about the process for credentialing, S33Credentialing Officer indicated she scans the forms to S2HR Director (who is the credentialing contact person in the hospital) to have them presented for signature at the Medical Executive Committee and Governing Body meetings. She further indicated she completed the process "on her end and S2HR Director knows what to do." When asked whose responsibility it was to do a final check of the credentialing file, S33Credentialing Officer indicated it was S2HR Director's responsibility. S2HR Director indicated she sends the credentialing file back to S33Credentialing Officer when "I'm done, so the final eyes are done by S33Credentialing Officer."

c) Failure to ensure each patient was provided written notice at the beginning of a planned or unplanned inpatient stay that there is no doctor of medicine or osteopathy present in the hospital 24 hours a day, seven days per week, as required by 42 CFR 489.20(w):

Review of the "Conditions Of Service" (informed consent form) signed by Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10 or their representative revealed no documented evidence that the consent included notification that there was no doctor of medicine or osteopathy present in the hospital 24 hours a day, seven days per week.

In an interview on 07/30/15 at 8:50 a.m., when asked if patients were informed in writing that a physician wasn't present in the hospital 24 hours a day, seven days per week, S3 DON (Director of Nursing) indicated she thought the "Emergency Care Services" form that stated "at times when there is no physician present" would cover the notification. She confirmed the hospital did not have a method of informing patients in writing that specifically informed the patient that a physician was not present 24 hours a day, seven days per week.

2) Data collected for its quality assessment and performance improvement program (QAPI) was used to identify opportunities for improvement and changes that will lead to improvement and implement actions aimed at performance improvement:

Review of three quality indicators selected for review, % (per cent) of compliance with documenting the reason why medication not given was circled on the MAR, number of medication errors, and hand hygiene compliance, revealed the following:
Total number of medication errors increased from 8 in the 1st quarter to 13 in the 2nd quarter of 2015;
Hand hygiene compliance decreased from 73% in the 1st quarter to 55% in the 2nd quarter of 2015;
% compliance with documenting the reason why medication not given was circled on the MAR was 93% with a target value of 95% with no documented evidence that data was collected for the 1st quarter and for May of 2015.

Review of corrective action plans presented by S7RN revealed no documented evidence that corrective action was developed or implemented to address the identified opportunity for improvement related to % compliance with documenting the reason why medication not given was circled on the MAR. Further review revealed the medication error corrective action was to include continuation of daily MAR audits, education of staff on medication management and policy, and developing and implementing an end of shift self-auditing practice to address preventing errors.

In an interview on 07/30/15 at 2:35 p.m. with S7RN and S3DON (Director of Nursing) present, S3DON indicated the corrective action to address medication errors had not been implemented yet.

Review of monthly Handwashing Tracking Sheets for January through July 2015 revealed 5 observations were made each month with no documented evidence of a method for documenting which staff member was observed in order to identify if the same individual had repetitive breaches in hand hygiene.

Review of a Professional Practice/Medical Executive Committee Meeting agenda dated 07/17/15 and attached 2015 Nursing Dashboard revealed reports for Hand Hygiene Compliance for the first quarter and 2nd quarter of 2015 as follows: April 73%, May 73%, and June 20% with the total 2nd quarter compliance of 55% . The areas of summary of findings, action for Improvement, Responsible person, date of implementation, and follow-up where all blank.

In an interview 7/30/15 at 11:40 a.m. S7RN and S3DON both verified the findings in the hospital's Infection Control hand hygiene surveillance. S7RN verified there was no action plan documented, or records of any corrective interventions of the identified problem of hand hygiene breaches by all disciplines of staff in the hospital.

Based on record review, observations, and interview, the hospital's governing body failed to ensure patient safety as evidenced by having hand hygiene compliance reported below the set goal of 85% (compliance) monthly for the year of 2015. The hospital could not provide documentation of development and implementation of corrective interventions and ongoing evaluation of the interventions for success and sustainability.
Findings:

Review of monthly Handwashing Tracking Sheets for January through July 2015 revealed the following:

January- 4 of 5 observations of staff did not perform hand hygiene before direct patient contact. 1 of 5 staff members did not perform hand hygiene after patient contact and glove removal. Staff observed included the following disciplines and/or care areas: nursing, Physical Therapy, and physicians.

February- 2 of 5 observations revealed no hand hygiene before patient contact, and 2 of 5 did not perform hand hygiene after patient contact and/or glove removal. (nurse, CNA (Certified Nurses Aid)).

March- 3 of 5 observations revealed no hand hygiene performed before patient care (Physician, Nurse, CNA).

April- 4 of 5 observations revealed no hand hygiene performed before patient care (CNA, Nurse, Occupational Therapy)

May- 3 of 5 observations revealed no hand hygiene before patient care (CNA, Physicians), and 1 did not perform hand hygiene after patient contact and/or glove removal (physician).

June- 4 of 5 observed staff did not perform hand hygiene before direct patient contact (CNA, physician, nurse, Occupational Therapy staff).

Review of a 2015 Nursing Dashboard report, attached to meeting agendas of the Governing Board Meetings for 4/17/15 and 5/4/15, revealed Hand Hygiene Compliance Rates for January-67%, February- 73%, March-80 %, compared to a target percentage of 85%. The 1st quarter overall compliance rate was 73%. Another page, untitled, was stapled to the reports and documented the following: "Hand hygiene Compliance Rate is very low for Jan. (January) 3 nurses, 1 MD (Medical Doctor), and 1 P.T. (Physical Therapist). Only 1 (a nurse) used hand sanitizer prior to contact with a pt. (patient). This is the area that is lacking the most. The P.T. did not wash his hands following pt contact..." in a block next to this message was, " Educate all staff (nursing, therapy, and physicians) about hand hygiene and its importance in preventing the spread of infection. High alert needs to be placed on hand hygiene prior to pt contact/doning gloves."

Review of a Professional Practice/Medical Executive Committee Meeting agenda dated 7/17/15 and attached 2015 Nursing Dashboard revealed reports for Hand Hygiene Compliance for the first quarter and for the 2nd quarter as follows: April 73%, May 73%, and June 20%, and for the 2nd quarter 55% compliance. The areas of summary of findings, action for Improvement, Responsible person, date of implementation, and follow-up where all blank.

In an interview 7/30/15 at 11:40 a.m. S7RN and S3DON both verified the findings in the hospital's Infection Control hand hygiene surveillance. S7RN verified there was no action plan documented, or records of any corrective interventions of the identified problem of hand hygiene breeches by all disciplines of staff in the hospital.

Based on record reviews and interview, the hospital failed to ensure that its current quality assessment and performance improvement (QAPI) project had documentation of the data collected to provide evidence of the measurable progress achieved on the project thus far. Findings:

Review of the hospital's "2015 PI (performance improvement) Project", presented by S7RN (registered nurse) as their current project, revealed that the hospital had selected medical necessity compliance as its project. Review of the report presented revealed directions for the focus study and the required documentation to be reviewed. The hospital could provide no documented evidence of the data used to compile scores obtained for January through May 2015.

In an interview on 07/30/15 at 2:35 p.m. with S7RN and S3DON (Director of Nursing) present, S7RN and S3DON confirmed that they did not have any data to present that was used to determine the compliance with the project thus far.

Based on record reviews and interview, the governing body failed to ensure its quality assessment and performance improvement (QAPI) program involved all hospital departments and services including those services furnished under contract or agreement as evidenced by failure to have quality indicators developed for radiology services, laboratory services, linen services, and housekeeping.
Findings:

Review of the quality indicators developed revealed no documented evidence that quality indicators had been developed for the services of radiology, laboratory, linen, and housekeeping.

In an interview on 07/30/15 at 2:35 p.m., S7RN (registered nurse) confirmed that quality indicators were not developed for the services provided by contract, such as radiology, laboratory, linen, and housekeeping.

Based on record review and interview, the governing body failed to determine the number of distinct improvement projects that would be conducted annually.
Findings:

Review of the hospital's policy titled "Performance Improvement and Patient Safety Plan", presented as a current policy by S7RN (registered nurse), revealed no documented evidence that the governing body determined the number of distinct improvement projects that would be conducted annually.

In an interview on 07/30/15 at 2:35 p.m., S7RN confirmed that she could provide no documented evidence that the governing body had determined the number of distinct improvement projects that would be conducted annually.

Based on record reviews and interviews, the hospital failed to ensure:

1) The medical staff examined the credentials and made recommendations to the governing body on the reappointment of medical staff members in accordance with the Medical Staff By-laws for 5 (S15, S16, S17, S21, S32) of 6 (S10, S15, S16, S17, S21, S32) physician credentialing files reviewed from a total of 10 credentialed physicians. This resulted in patients' care being provided by physicians who were not currently credentialed and privileged as members of the Medical Staff (S21, S32).

2) Temporary privileges were granted in accordance with the Medical Staff By-laws for 2 (S18, S19) of 2 physician credentialing files reviewed and 1 (S20) of 1 nurse practitioner file reviewed for temporary privileges from a total of 2 physicians with temporary privileges and 3 nurse practitioners (NP) with temporary privileges.
Findings:

Review of the Medical Staff By-laws, presented as the current By-laws by S3DON (Director of Nursing), revealed that a re-application form will be sent to each applicant at least 2 months prior to the re-appointment due date. If the applicant fails to return the re-appointment application by the due date, the member shall be deemed to have resigned membership to the medical staff at the end of the current staff appointment. Information required from the applicant for re-appointment includes a re-appointment application, current Louisiana medical license, current DEA (Drug Enforcement Administration) certificate, and current Louisiana CDS (Controlled and Dangerous Substance) license. The claims history of each applicant for re-appointment will be verified with the National Practitioner Data Bank. All applicants are processed only after the medical staff office receives a completed, verified application. Further review revealed the administrator or designee of the hospital, on the recommendation of the Medical Director or authorized designee, has the authority to grant temporary privileges to a physician, osteopath, podiatrist, or allied professional on request of a member of the active staff for a period of no more than 120 days. Further review revealed the process and procedure for granting temporary privileges, initial appointment, re-appointment, and modification of privileges for allied health professionals is the same as that documented in the By-laws for physicians.

1) The medical staff examined the credentials and made recommendations to the governing body on the reappointment of medical staff members in accordance with the Medical Staff By-laws:
Review of the list of credentialed list of physicians presented by S3DON revealed no documented evidence that S21Physician and S32Physician were included in the list.

S15Physician
Review of S15Physician's credentialing file revealed he was appointed to the Medical Staff on 07/13/13. Further review revealed a letter was sent to S15Physician on 07/16/15 informing him that any re-appointment paperwork not received by the hospital by 07/31/15 would result in his voluntary resignation from the medical staff. There was no documented evidence that a re-application packet had been sent to S15Physician 2 months prior to his re-appointment date as required by the Medical Staff By-laws.

S16Physician
Review of S16Physician's credentialing file revealed he was appointed to the Medical Staff on 07/18/13. Further review revealed a letter was sent to S16Physician on 07/16/15 informing him that any re-appointment paperwork not received by the hospital by 07/31/15 (his re-appointment date was 07/18/13 and not 07/31/15) would result in his voluntary resignation from the medical staff. There was no documented evidence that a re-application packet had been sent to S16Physician 2 months prior to his re-appointment date as required by the Medical Staff By-laws.

S17Physician
Review of S17Physician's credentialing file revealed he was appointed to the Medical Staff on 07/20/13. Further review revealed a letter was sent to S17Physician on 07/16/15 informing him that any re-appointment paperwork not received by the hospital by 0720/15 would result in his voluntary resignation from the medical staff. There was no documented evidence that a re-application packet had been sent to S17Physician 2 months prior to his re-appointment date as required by the Medical Staff By-laws.

S21Physician
Review of S21Physician's credentialing file revealed he was appointed to the Medical Staff effective 05/02/13. Further review revealed no documented evidence that a re-application packet had been sent to him 2 months prior to re-appointment, and there was no documented evidence that S21Physician was currently credentialed and privileged as a member of the Medical Staff.

Review of Patient #2's (a current inpatient) medical record revealed a physician's order from S10Medical Director on 07/17/15 at 12:00 p.m. to consult S21Physician.

S32Physician
Review of S32Physician's credentialing file revealed he appointed to the Medical Staff effective 08/01/12. Further review revealed he requested temporary privileges on 08/05/14 (3 days after his appointment had expired). The request for temporary privileges was signed by the administrator on 08/05/14 with no documented evidence of a signature indicating it was reviewed by the Medical Director. Further review revealed the copy of his CDS license in his file had expired 09/01/14. There was no documented evidence that S32Physician was currently credentialed and privileged as a member of the Medical Staff.

In an interview on 07/30/15 at 10:15 a.m., S10Medical Director indicated S32Physician is a nephrologist who consults on dialysis patients at the hospital. He confirmed that S21Physician and S32Physician are currently seeing patients at the hospital.

In a telephone interview on 07/30/15 at 1:45 p.m. with S2HR (Human Resource) Director present, S33Credentialing Officer indicated she doesn't keep a copy of the re-application packet sent to physicians at the time of re-appointment, so she can't say when the re-application packets were sent to the above-listed physicians. When asked about the process for credentialing, S33Credentialing Officer indicated she scans the forms to S2HR Director (who is the credentialing contact person in the hospital) to have them presented for signature at the Medical Executive Committee and Governing Body meetings. She further indicated she completed the process "on her end and S2HR Director knows what to do." When asked whose responsibility it was to do a final check of the credentialing file, S33Credentialing Officer indicated it was S2HR Director's responsibility. S2HR Director indicated she sends the credentialing file back to S33Credentialing Officer when "I'm done, so the final eyes are done by S33Credentialing Officer."

2) Temporary privileges were granted in accordance with the Medical Staff By-laws:
S18Physician

Review of S18Physician's "Temporary Privileges Request" revealed he requested temporary privileges on 06/05/15. Further review revealed the administrator granted privileges on 06/13/15 prior to S10Medical Director reviewing the request and signing her approval on 07/16/15.

S19Physician
Review of S19Physician's "Temporary Privileges Request" revealed he requested temporary privileges on 05/30/15. Further review revealed the administrator granted privileges on 05/30/15 prior to S10Medical Director reviewing the request and signing her approval on 06/01/15.

S20NP
Review of S20NP's credentialing file revealed she requested temporary privileges on 07/17/15 . Further review revealed S10Medical Director approved the request on 07/17/15 with no documented evidence that privileges had been approved by the administrator as required by the Medical Staff By-laws.

In a telephone interview on 07/30/15 at 1:45 p.m. with S2HRDirector present, S33Credentialing Officer indicated she knows that the administrator and Medical Director can sign on different dates, as long as the request is signed before the physician or NP practices. She further indicated she thought as long as the Medical Director signed the request, she thought it was alright not to have the administrator's signature. She couldn't explain why the temporary privileges were being signed by the administrator prior to the request being reviewed and approved by the Medical Director.

Based on record reviews and interviews, the hospital failed to ensure La. R.S. (Louisiana Revised Statute) 9:111 and hospital policy relating to pronouncement of death was followed by physicians as evidenced by delegating the assessment of irreversible cessation of spontaneous respiratory and circulatory functions and determining and pronouncement of the patients' death to the nurse for 4 (#11, #12, #13, #15) of 4 patients who expired while admitted to the hospital (#11, #12, #13, #15) from a total sample of 30 patient records.
Findings:

Review of La. R.S. 9:111. Definition of death revealed, in part, "... A. A person will be considered dead if in the announced opinion of a physician, duly licensed in the state of Louisiana based on ordinary standards of approved medical practice, the person has experienced an irreversible cessation of spontaneous respiratory and circulatory functions...". Added by Acts 1976, No. 233, §1; Acts 2001, No. 317, §1; Acts 2010, No. 937, §1, eff. July 1, 2010.

Review of the hospital policy titled "Patient Death/Organ Donation", presented as a current policy by S3DON (Director of Nursing), revealed a physician must pronounce a patient dead. The attending physician may delegate this to another physician who may be in the hospital at the time of death.

Patient #11
Review of Patient #11's medical record revealed she was a 59 year old female admitted on 07/06/15 with diagnoses of Hepatitis C, Cirrhosis, Hypertension Varices, and Hospice. Further review revealed an order for DNR (do not resuscitate).

Review of Patient #11's nursing narrative notes for 07/07/15 revealed documentation by S23RN (registered nurse) at 5:45 p.m. that no respirations or heart rate were noted, and the hospice nurse was called by S3DON. Further review revealed at 7:00 p.m. S27RN documented that the hospice nurse was at the bedside, and "time of death recorded in Hospice nurse notes 1900 (7:00 p.m.)." At 8:30 p.m. S27RN documented that the funeral home attendant was present for transport of Patient #11 to the funeral home. Review of the hospice nurse's documentation for 07/07/15 revealed no documented evidence of Patient #11's death and the time death was pronounced.

Review of Patient #11's entire medical record revealed no documented evidence that a physician was present to pronounce death as required by La. R.S. 9:111 and that the physician was notified of Patient #11's death.

Review of Patient #11's "Rehab Physician Progress Notes" dated 07/08/15 at 8:15 a.m. revealed an entry by S10Medical Director that Patient #11 "expired last night @ (at) 7:00 p.m. (with) family around."

Patient #12
Review of Patient #12's medical record revealed she was a 40 year old female admitted on 04/20/15 for hospice inpatient care for symptom management with a diagnosis of HIV (Human Immunodeficiency Virus). Further review revealed an order for DNR. A telephone order was received from S10Medical Director on 04/24/15 at 10:00 p.m. to release the body to the funeral home.

Review of Patient #12's nursing narrative notes for 04/24/15 revealed documentation by the RN that Patient #12 was found unresponsive at 6:20 p.m. with "signs of life", and the hospice nurse was notified. Further documentation revealed that the hospice nurse arrived at 7:15 p.m., and the body was released to the funeral home at 8:40 p.m.

Review of Patient #12's entire medical record revealed no documented evidence that a physician was present to pronounce death as required by La. R.S. 9:111.

Review of Patient #12's "Rehab Physician Progress Notes" dated 04/27/15 at 9:15 a.m. revealed an entry by S10Medical Director that "Pt (patient) expired on Friday 4/24/15 @ 6:45 (no indication of a.m. or p.m.), pt's family was present @ the time."

Patient #13
Review of Patient #13's medical record revealed she was a 72 year old female admitted on 08/27/15 with diagnoses of Dementia and Failure To Thrive with orders for comfort measures only.

Review of Patient #13's nursing notes revealed the RN documented on 08/27/15 at 6:45 p.m. that Patient #13 had no respirations and no pulse, and she called the hospice nurse. Further review revealed the RN documented at 7:30 p.m. that the hospice nurse was present and called the coroner and S11Physician to notify of Patient #13's death.

Review of Patient #13's entire medical record revealed no documented evidence that a physician was present to pronounce death as required by La. R.S. 9:111.

Patient #15
Review of Patient #15's medical record revealed he was an 80 year old male admitted on 10/31/14 to hospice with diagnoses of CHF (Congestive Heart Failure), COPD (Chronic Obstructive Pulmonary Disease), and ESRD (End Stage Renal Disease) and an order for DNR.

Review of Patient #15's nursing notes on 11/03/14 revealed the LPN (licensed practical nurse) documented at 12:45 p.m. that the patient had expired, the RN Supervisor was informed, and the hospice company was informed. There was no documented evidence that the attending physician was notified.

Review of Patient #15's entire medical record revealed no documented evidence that a physician was present to pronounce death as required by La. R.S. 9:111.

In an interview on 07/30/15 at 8:50 a.m., S3DON indicated that a hospice nurse told her that a hospice nurse can pronounce death with a phone call to the hospice Medical Director or Coroner. She confirmed that above patients' deaths were not pronounced by a physician who was onsite at the time of death.

In an interview on 07/30/15 at 1:20 p.m., S1Administrator indicated he wasn't aware that a physician did not come to the hospital to pronounce a patient's death

Based on record reviews and interviews, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care of each patient as evidenced by:
1) Failing to ensure patients were assessed for and their nursing care plan implemented for elimination (#2, #6), use of an ankle ace wrap (#6), blood glucose levels (#2, #4), weights (#2), Clostridium Difficile (C. Diff) (#9), and wounds (#2) as ordered by the physician for 4 (#2, #4,#6, #9) of 10 (#1 - #10) active patient records reviewed for nursing assessments from a total of 30 sampled records.
2) Failing to ensure labs were drawn as ordered by the physician for 2 (#2, #3) of 10 (#1 - #10) active patient records reviewed for lab work from a total of 30 sampled records.
3) Failing to ensure the nurse clarified standing physician orders for medications ordered for constipation to be given by mouth or suppository without an indication of when to administer each for 6 (#1, #2, #3, #4, #5, #6) of 10 (#1 - #10) active patient records reviewed for medication orders from a total sample of 30 patients.
4) Failing to ensure the nurse obtained a clarification order for blood pressure/pulse parameters to be reported for antihypertensive medications listed on the medication administration record (MAR) with directions to monitor the blood pressure/pulse for 5 (#2, #3, #4, #6, #7) of 10 (#1 - #10) active patient records reviewed for medication orders from a total sample of 30 patients.
Findings:

1) Failing to ensure patients were assessed for and their nursing care plan implemented:
Elimination:
Patient #2
Review of Patient #2's medical record revealed he was a 66 year old male admitted on 07/17/15 with diagnoses of Late effect CVA (Cerebrovascular Accident), Osteoarthrosis, and Chronic Airway Obstructive Disease.

Review of Patient #2's physician admit standing orders revealed orders for Lactulose by mouth twice daily as needed for constipation and Dulcolax suppository, 1 per rectum, daily as needed for constipation.

Review of Patient #2's nursing admission assessment documented on 07/17/15 at 1:00 p.m. revealed his last bowel movement was 07/16/15. Review of his "Graphic Sheet" and nursing documentation revealed no documented evidence that Patient #2 had a bowel movement on 07/17/15, 07/18/15, 07/19/15, 07/20/15, and 07/21/15.

Review of Patient #2's nursing note revealed an intervention was to be taken if he had no bowel movement in 2 days. There was no documented evidence that interventions were implemented and the physician notified when Patient #2 had no bowel movement for 3 days. On 07/20/15 at 5:00 p.m. Patient #2 was administered Lactulose. There was no documented evidence of Patient #2's response to the Lactulose. On 07/21/15 at 6:30 p.m. Patient #2 had not had a bowel movement, and a Dulcolax suppository was administered at 7:30 p.m. Documentation revealed that Patient #2 had not had a bowel movement as a result of the laxative at 8:00 p.m. On 07/22/15 at 3:00 a.m. Patient #2 was documented as straining to have a bowel movement and refused digital removal. Further review of the nursing notes revealed that the nurse documented she would get an enema ordered by the physician in the a.m. There was no documented evidence that a physician was notified that Patient #2 had not had a bowel movement for more than 5 days with Lactulose and a Dulcolax suppository being administered without results.

Patient #6
Review of Patient #6's medical record revealed she was a 56 year old female admitted on 07/14/15 with diagnoses of Debility, Hypertension, Diabetes Mellitus, Espohageal Reflux, Lumbago, Osteoarthritis, and Depression.

Review of Patient #6's physician admit standing orders revealed orders for Lactulose by mouth twice daily as needed for constipation and Dulcolax suppository, 1 per rectum, daily as needed for constipation.

Review of Patient #6's "Graphic Sheet" revealed she did not have a bowel movement on 07/15/15, 07/16/15, 07/17/15, 07/20/15, 07/21/15, and 07/22/15. There was no documented evidence that interventions were implemented and the physician notified that Patient #6 did not have a bowel movement for 3 days from 07/15/15 through 07/17/15. Review of her nursing notes revealed she was administered Lactulose on 07/22/15 at 5:25 p.m. for complaints of constipation with no effect noted at 6:00 p.m. There was no documented evidence that the physician was notified that Patient #6 did not have a bowel movement for 3 days from 07/20/15 through 07/22/15 with no effect from the ordered intervention.

In an interview on 07/30/15 at 8:50 a.m., S3DON (Director of Nursing) indicated the nurse is supposed to intervene if a patient hasn't had a bowel movement in 2 days. She further indicated the nurse should have called the physician to report when a patient had not had a bowel movement in 2 days and the ordered intervention was not effective.

Ankle ace wrap:
Review of Patient #6's medical record revealed she was a 56 year old female admitted on 07/14/15 with diagnoses of Debility, Hypertension, Diabetes Mellitus, Espohageal Reflux, Lumbago, Osteoarthritis, and Depression.

Review of Patient #6's physician orders revealed an order on 07/15/15 (no time documented when the order was written) for a left ankle Ace wrap figure eight. Review of the nursing documentation revealed no documented evidence of a nursing assessment of the left ankle that required an Ace wrap to be applied.

In an interview on 07/30/15 at 8:50 a.m., S3DON indicated there should be nursing documentation of an assessment that addressed the reason for Patient #6's ankle to require an Ace wrap.

Blood glucose levels:
Patient #2
Review of Patient #2's medical record revealed he was a 66 year old male admitted on 07/17/15 with diagnoses of Late effect CVA (Cerebrovascular Accident), Osteoarthrosis, and Chronic Airway Obstructive Disease.

Review of Patient #2's MAR (medication administration record) revealed Accuchecks were documented on 07/19/15 at 9:00 p.m. and on 07/20/15 at 6:00 a.m. Review of his physician orders revealed no documented evidence of a physician order to check capillary blood glucose levels.

Patient #4
Review of the medical record for Patient #4 revealed she was admitted to the hospital 06/24/15 with a primary diagnosis of CVA and a diagnosis of Diabetes Mellitus.
Review of Physician's Admit orders revealed an order for an 1800 calorie ADA (American Diabetic Association) diet, dental soft and vital signs q (every) shift. Further review revealed no orders to check Patient #4's blood glucose, with or without a frequency indicated.
Review of a Physician's Insulin Order (Standard Orders for Diabetic Patients, non-dialysis) revealed the patient was to receive Novolog Insulin on a sliding scale. The orders included interventions for blood sugar results below 69, below 70, and the sliding scale doses for blood sugar above 70. Further review revealed no indication of how often the patient's blood sugar should be checked prior to obtaining a blood sugar level.
Review of Patient #4's MAR revealed a handwritten entry "accu', followed by a check mark (accucheck) AC (before meals) & HS (at bedtime). No initials were noted with the entry, as with other printed orders on the MAR.
Review of a Diabetic Flow Sheet for Patient #4 revealed her accucheck (Capillary Blood Glucose or CBG) was performed 4 times a day.
In an interview on 07/30/15 at 8:50 a.m., S3DON, when asked about Accuchecks being done without physician orders, indicated "I can't speak to that , I would have to look at the chart." During the interview S3DON was requested to review the records and bring any findings to the surveyor. As of the exit conference on 07/30/15 at 5:40 p.m., S3DON had not presented physician orders for the Accuchecks to be done for the above listed patients.
Weights:
Patient #2
Review of Patient #2's medical record revealed he was a 66 year old male admitted on 07/17/15 with diagnoses of Late effect CVA (Cerebrovascular Accident), Osteoarthrosis, and Chronic Airway Obstructive Disease.

Review of Patient #2's physician admit orders dated 07/17/15 at 12:00 p.m. revealed an order to weigh upon admit and then weekly. Review of his "Initial Nursing Assessment" revealed he was weighed at admit. Review of his "Graphic Sheet" revealed he was weighed on 07/19/15. There was no documented evidence that Patient #2 was weighed weekly as ordered as evidenced by failure to have a documented weight on 07/26/15.

In an interview on 07/30/15 at 8:50 a.m., S3DON confirmed Patient #2 was not weighed weekly as ordered, and she couldn't give a reason for it not being done.

C.Diff.:
Review of the medical record for Patient #9 revealed she was a 68 year old female admitted to the hospital on 06/23/15 at 4:30 p.m. Diagnoses included CVA, Left Brain, Aphasia, Dysphagia Unspecified, Hypertension, and Clostridium Difficile.
Review of the medical record for Patient #9 revealed there was no documentation in the medical record to indicate at what point Patient #9 was symptomatic or asymptomatic for C. Diff. with regards to the patient having diarrhea.
In an interview on 07/29/15 at 3:00 p.m., S3DON reviewed the entire medical record and confirmed there was no documentation in the medical record that could distinguish whether or not the patient was symptomatic or asymptomatic for signs and symptoms of C. Diff. S3DON indicated there should have been documentation in the medical record to identify if/when the patient was symptomatic or asymptomatic.
Wounds:
Review of Patient #2's medical record revealed he was a 66 year old male admitted on 07/17/15 with diagnoses of Late effect CVA (Cerebrovascular Accident), Osteoarthrosis, and Chronic Airway Obstructive Disease.

Review of Patient #2's physician orders revealed an order on 07/17/15 at 3:30 p.m. to consult wound care.

Review of Patient #2's wound assessment performed by S31Contract Wound RN on 07/17/17 (no time documented) revealed Patient #2 had an "Abration, Proximal R BKA (right below the knee amputation), full thickness, length 5 cm (centimeters), width 0.5 cm, no odor, granulation tissue 100% (per cent), undermining none, tunneling none, wound edge flat and intact, periwound intact, periedema 0 cm." Further review revealed wound care treatment was to clean the wound with wound cleanser, apply antibiotic ointment to tissue, apply foam dressing as a secondary dressing, secure with silk tape, and change the dressing every other day. The "Wound Documentation/Progress Notes" documented by S31Contract Wound RN was signed by the physician on 07/20/15 (no documented evidence of the time the physician signed the note). Review of the physician orders revealed the above treatment was written as a telephone order on 07/21/15 at 6:30 a.m. by S27RN. There was no documented evidence of a physician's order for wound care for 3 days after S31Contract Wound RN assessed Patient #2's wound.

Review of the nursing notes and MARs for Patient #2 revealed no documented evidence that wound care was performed on 07/19/15 and 07/21/15.

In an interview on 07/30/15 at 8:50 a.m., S3DON indicated the contract wound care nurse is supposed to obtain and write wound treatment orders received from the physician.

2) Failing to ensure labs were drawn as ordered by the physician:
Review of the hospital policy titled "Venipuncture", presented as a current policy by S7RN, revealed that that the lab sample was to be sent immediately with written and verbal instruction that it is a Stat lab. Further review revealed the hospital was to follow-up quickly for the results and get them to the patient's physician as soon as possible. There was no documented evidence of the time interval that labs ordered "now" were to be done.

Patient #2
Review of Patient #2's medical record revealed he was a 66 year old male admitted on 07/17/15 with diagnoses of Late effect CVA (Cerebrovascular Accident), Osteoarthrosis, and Chronic Airway Obstructive Disease.

Review of Patient #2's physician orders revealed an order on 07/20/15 at 11:10 a.m. to draw a potassium level now. Review of lab results revealed the potassium level was drawn on 07/20/15 at 1:30 p.m. and received by the contract lab at 2:06 p.m. The results were faxed to the hospital on 07/20/15 at 2:23 p.m.

In an interview on 07/30/15 at 8:50 a.m., S3DON indicated an order to draw a lab "now" should be handled as a Stat order. She confirmed that the potassium level should have been drawn sooner than 2 hours 20 minutes after the order was written.

Patient #3
Review of the medical record for Patient #3 revealed she was a 65 year old female admitted on 07/23/15 with a diagnosis of Debility. Other diagnoses included Hypertension, Diabetes Mellitus Type II, Early Dementia Unspecified Without Behavioral Disturbance, Hyperlipidemia, Depressive Disorder, Macular Degeneration, and History of Falls.
Review of the physician's admission orders dated 07/23/15 at 4:00 p.m. revealed an order for a prealbumin level. Review of the medical record for Patient #3 on 07/28/15 revealed there was no documented evidence of a prealbumin level in the medical record.
In an interview on 07/29/15 at 10:40 a.m., S3DON (Director of Nursing) confirmed Patient #3's medical record did not contain the results of the prealbumin test ordered. She indicated the prealbumin test was included on the lab requisition, but the lab did not perform the pre-albumin test.
3) Failing to ensure the nurse clarified standing physician orders for medications ordered for constipation to be given by mouth or suppository without an indication of when to administer each:
Patient #1
Review of the medical record revealed the patient was a 35 year old male admitted to the hospital on 05/16/15. The patient had the diagnosis of Non-traumatic Brain Injury.

Review of the Physician's Orders revealed orders for Lactulose 30 cc (cubic centimeters) by mouth, twice daily as needed for constipation and Dulcolax suppository 1 per rectum, daily as needed for constipation. There was no documented evidence of a clarification order that indicated when the oral medication was to be administered versus when the suppository was to be inserted.

Patient #2
Review of Patient #2's medical record revealed he was a 66 year old male admitted on 07/17/15 with diagnoses of Late effect CVA (Cerebrovascular Accident), Osteoarthrosis, and Chronic Airway Obstructive Disease.

Review of Patient #2's physician admit standing orders revealed orders for Lactulose by mouth twice daily as needed for constipation and Dulcolax suppository, 1 per rectum, daily as needed for constipation. There was no documented evidence of a clarification order that indicated when the oral medication was to be administered versus when the suppository was to be inserted.

Patient #3
Review of the medical record for Patient #3 revealed she was a 65 year old female admitted on 07/23/15 with a diagnosis of Debility. Other diagnoses included Hypertension, Diabetes Mellitus Type II, Early Dementia Unspecified Without Behavioral Disturbance, Hyperlipidemia, Depressive Disorder, Macular Degeneration, and History of Falls.
Review of the Physician's Orders revealed orders for Lactulose 30 cc (cubic centimeters) by mouth, twice daily as needed for constipation and Dulcolax suppository 1 per rectum, daily as needed for constipation. There was no documented evidence of a clarification order that indicated when the oral medication was to be administered versus when the suppository was to be inserted.

Patient #4
Review of the medical record for Patient #4 revealed she was admitted to the hospital 06/24/15 with a primary diagnosis of CVA. Other diagnoses included Dysphasia, Dysarthria, Diabetes Mellitus, Hypertension, Morbid Obesity, Urinary Tract Infection (UTI), and Neurogenic Bladder.

Review of Physician's Admit orders revealed, in part, the following medications checked: 2. Lactulose 30 cc by mouth, twice daily as needed for constipation. 3. Dulcolax suppository 1 per rectum, daily as needed for constipation. There was no documented evidence
of a clarification order that indicated when the oral medication was to be administered versus when the suppository was to be inserted.

Patient #5
Review of the medical record revealed the patient was a 57 year old female admitted to the hospital on 07/24/15. The patient had the diagnoses of Anoxic Brain Damage, Diabetes Mellitus Type 2, Hypertension, End Stage Renal Disease, and Depressive Disorder.

Review of the Physician's Orders revealed orders for Lactulose 30 cc by mouth, twice daily as needed for constipation and Dulcolax suppository 1 per rectum, daily as needed for constipation. There was no documented evidence of a clarification order that indicated when the oral medication was to be administered versus when the suppository was to be inserted.

Patient #6
Review of Patient #6's medical record revealed she was a 56 year old female admitted on 07/14/15 with diagnoses of Debility, Hypertension, Diabetes Mellitus, Espohageal Reflux, Lumbago, Osteoarthritis, and Depression.

Review of Patient #6's physician admit standing orders revealed orders for Lactulose by mouth twice daily as needed for constipation and Dulcolax suppository, 1 per rectum, daily as needed for constipation. There was no documented evidence of a clarification order that indicated when the oral medication was to be administered versus when the suppository was to be inserted.

In an interview on 07/30/15 at 8:50 a.m., S3DON gave no explanation for the nursing staff not requesting a clarification order from the physician to indicate when the oral medication versus the suppository should be given for constipation.

4) Failing to ensure the nurse obtained a clarification order for blood pressure/pulse parameters to be reported for antihypertensive medications listed on the MAR with directions to monitor the blood pressure/pulse:
Patient #2
Review of Patient #2's medical record revealed he was a 66 year old male admitted on 07/17/15 with diagnoses of Late effect CVA (Cerebrovascular Accident), Osteoarthrosis, and Chronic Airway Obstructive Disease.

Review of Patient #2's physician's orders revealed orders for Amlodipine 10 mg by mouth daily, Hydralazine 50 mg by mouth three times a day, and Sotalol 80 mg by mouth twice a day. Review of the MAR revealed directions for each of these medications to monitor the blood pressure and/or apical pulse prior to administration. There was no documented evidence of a physician's order with parameters for blood pressure/apical pulse at which the medication needed to be held or the physician notified.

Patient #3
Review of the medical record for Patient #3 revealed she was a 65 year old female admitted on 07/23/15 with a diagnosis of Debility. Other diagnoses included Hypertension, Diabetes Mellitus Type II, Early Dementia Unspecified Without Behavioral Disturbance, Hyperlipidemia, Depressive Disorder, Macular Degeneration, and History of Falls.
Review of Patient #3's physician orders revealed orders for Lisinopril 20 mg (milligrams) po (by mouth) every evening; HCTZ (Hydrochlorothiazide) 12.5 mg po every 8 hours, Hydralazine 25 mg tabs, 1 by mouth every 8 hours, and Amlodipine 10 mg po daily with directions on the MAR to monitor blood pressure/pulse with no indication when to hold the medication or to notify the physician.
Patient #4
Review of the medical record for Patient #4 revealed she was admitted to the hospital 06/24/15 with a primary diagnosis of CVA. Other diagnoses included Dysphasia, Dysarthria, Diabetes Mellitus, Hypertension, Morbid Obesity, Urinary Tract Infection (UTI), and Neurogenic Bladder.
Review of Patient #4's MAR revealed the following medications,with the notation "Advise to monitor blood pressure and/or apical pulse" with each of the following medications: Carvedilol (Coreg) 25 mg tab- one by mouth daily, Valsartin (Diovan) 160 mg- take 2 tablets (320 mg) by mouth daily, Amlodipine (Norvasc) 10 mg, take 1 tablet by mouth daily, Clonidine (Captapres ) 0.1 mg every 8 hours prn (as needed) for SBP (systolic blood pressure) greater than 180, Nitrostat 0.4 mg dissolve 1 tablet under tongue as needed for chest pain. May repeat every 5 minutes up to 3 times, notify doctor if no relief. Further review of these orders revealed no parameters for the point at which the medication should be held, and/or the physician notified. Review of physician's orders revealed no indication of what parameters were acceptable for monitoring the patient's blood pressure and apical pulse (as advised on the MAR) or when to hold the medication and/or notify the physician.
Patient #6
Review of Patient #6's medical record revealed she was a 56 year old female admitted on 07/14/15 with diagnoses of Debility, Hypertension, Diabetes Mellitus, Espohageal Reflux, Lumbago, Osteoarthritis, and Depression.

Review of Patient #6's physician's orders revealed orders for Norvasc 5 mg by mouth daily and Labetalol HCL 300 mg by mouth three times a day. Review of the MAR revealed directions for each of these medications to monitor the blood pressure and/or apical pulse prior to administration. There was no documented evidence of a physician's order with parameters for blood pressure/apical pulse at which the medication needed to be held or the physician notified.

Review of Patient #6's physician orders revealed an order on 07/24/15 at 2:00 p.m. to hold Labetalol for blood pressure of 119/55. Review of the nursing documentation revealed her blood pressure was 115/59 at 6:00 a.m. on 07/22/15 with no documented evidence that the physician was notified regarding holding the Labetalol.

Patient #7
Review of the medical record revealed the patient was a 79 year old female admitted to the hospital on 07/15/15. The patient had the diagnoses of Hypertension, Subarachnoid Hemorrhage, Atrial Fibrillation, and Chronic Airway Obstruction.

Review of the Physician's Orders revealed orders for Diltiazem (Cardizem) 30 mg every 6 hours and Metoprol (Lopressor) 50 mg two times daily.

Review of Medication Administration Record revealed, in part: Diltiazem (Cardizem) 30 mg. Advise to monitor blood pressure and/or apical pulse prior to administration. Metoprol (Lopressor) 50 mg two times daily. Advise to monitor blood pressure and/or apical pulse prior to administration. There was no documented evidence of a physician's order with parameters for blood pressure/apical pulse at which the medication needed to be held or the physician notified.

In an interview on 07/30/15 at 8:50 a.m., S3DON indicated when a patient's blood pressure is low, the nurse will call the physician. She confirmed they have no standing parameters for blood pressure and/or apical pulse when the physician is to be notified or the medication held. She had no explanation to offer when informed that Patient #6's Labetalol was held for a blood pressure of 119/55, and Patient #6's blood pressure was lower (115/59) two days earlier without the physician being notified.


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30420

Based on record reviews and interviews, the hospital failed to ensure the nursing staff developed, and kept current individualized and comprehensive nursing care plans for 5 (#2, #3, #4 , #6, #7) of 10 (#1 - #10) patient records reviewed for nursing care planning from a total sample of 30 patient records.
Findings:

Patient #2
Review of Patient #2's medical record revealed he was a 66 year old male admitted on 07/17/15 with diagnoses of Late effect CVA (Cerebrovascular Accident), Osteoarthrosis, and Chronic Airway Obstructive Disease.

Review of Patient #2's physician admit standing orders revealed orders for Lactulose by mouth twice daily as needed for constipation and Dulcolax suppository, 1 per rectum, daily as needed for constipation.

Review of Patient #2's nursing admission assessment documented on 07/17/15 at 1:00 p.m. revealed his last bowel movement was 07/16/15. Review of his "Graphic Sheet" and nursing documentation revealed no documented evidence that Patient #2 had a bowel movement on 07/17/15, 07/18/15, 07/19/15, 07/20/15, and 07/21/15.

Review of Patient #2's nursing note revealed an intervention was to be taken if he had no bowel movement in 2 days. There was no documented evidence that interventions were implemented and the physician notified when Patient #2 had no bowel movement for 3 days. On 07/20/15 at 5:00 p.m. Patient #2 was administered Lactulose. There was no documented evidence of Patient #2's response to the Lactulose. On 07/21/15 at 6:30 p.m. Patient #2 had not had a bowel movement, and a Dulcolax suppository was administered at 7:30 p.m. Documentation revealed that Patient #2 had not had a bowel movement as a result of the laxative at 8:00 p.m. On 07/22/15 at 3:00 a.m. Patient #2 was documented as straining to have a bowel movement and refused digital removal. Further review of the nursing notes revealed that the nurse documented she would get an enema ordered by the physician in the a.m. There was no documented evidence that a physician was notified that Patient #2 had not had a bowel movement for more than 5 days with Lactulose and a Dulcolax suppository being administered without results.

Review of Patient #2's nursing care plan revealed no documented evidence that a care plan was developed for elimination.

In an interview on 07/30/15 at 8:50 a.m., S3DON confirmed that Patient #2's nursing care had not been revised to include the development of a nursing care plan for elimination when Patient #2 began to have problems with constipation.

Patient #3
Review of the medical record for Patient #3 revealed she was a 65 year old female admitted on 07/23/15 with the diagnosis of Debility. Other diagnoses included Hypertension, Diabetes Mellitus Type II, Early Dementia Unspecified Without Behavioral Disturbance, Hyperlipidemia, Depressive Disorder, Macular Degeneration, and History of Falls. Further review revealed Patient #3 was on a daily dose of insulin as well as sliding scale insulin. Patient #3 had her blood glucose levels assessed before meals, at bedtime, and as warranted.

Review of Patient #3's care plan revealed the following areas identified as "Nursing Problem Areas": (1) Glucose Metabolism Altered; The short-term goal was documented as "Blood glucose remains within normal limits. "The long-term goal was documented as "Patient/caregiver verbalizes understanding of disease process, diet and medications. "Interventions documented were: "Assess and monitor blood glucose level and prior history of diabetes and Assess for ongoing needs related to disease, medications, diet & (and) provide education as needed." There was no further documentation on the nursing care plan to individualize the pre-printed standardized care plan form for Patient #3. Further review of the nursing care plan revealed Patient #3 was not care planned for her diagnosis of Hypertension or her diagnosis of Impaired Vision.
In an interview on 07/29/15 at 1:30 p.m., S3DON (Director of Nursing) confirmed Patient #3 was not care planned for her diagnoses of Hypertension and Impaired Vision and should have been. S3DON confirmed the nursing care plan was not individualized for Patient #3.
Patient #4 Review of the medical record for Patient #4 revealed she was a current patient, admitted to the hospital 06/24/15 with a primary diagnosis of Cerebral Vascular Accident (CVA). Other diagnoses included Aphasia, Hypertension, Diabetes Mellitus, Morbid Obesity, Urinary Tract Infection, and Dysarthria.
Review of Patient #4's medication reconciliation form (for home medications) revealed the patient was taking Miralax (laxative) daily at home. Review of Patient #4's MAR revealed she received Miralax daily in the hospital. Further review of the MAR (medication administration record) revealed the patient received Insulin twice a day, and had a sliding scale order for more Insulin if needed.
Review of Patient #4's nursing care plans revealed short term goals (STG) and long term goals (LTG) were preprinted, at times did not match the nursing diagnosis, and were not measurable. An example of this was the nursing problem area of "Elimination", Altered, with "Bladder, checked. STG was " I & O WNL" ( Intake and Output within normal limits) with no definition of what normal limits for patient #4 was. The LTGs were "no skin breakdown", and "soft, formed BM (bowel movement) Qod (every other day) or WNL for patient". The LTG for bowel function was not related to the problem checked by nursing staff. There was no long term goal for alteration in Bladder function. The care plan for Infection or High Risk for Infection (UTI) written to the side, and for Altered elimination related to bladder function did not address the care of the patient's Foley catheter or for assessing for ability of removal. In the care area checked of Comprehension and Expressive Speech Deficit, the interventions checked included " Assist with/encourage use of glasses/lens/hearing aids, Obtain large print materials, Ensure adequate lighting; keep frequently used items within easy reach. Visual and hearing impairment were not checked. For the Glucose Metabolism, Altered care plan, interventions include "assess for ongoing needs related to disease, medications, diet, and provide education as needed." No specific signs and symptoms, diet, medications were specified to individualize the care plan to the patient. A STG was "Blood glucose WNL", with no notation of what was normal for Patient #4, or outside what parameters should the physician be notified, or other interventions instituted. There was no care plan related to the patient's Hypertension, although she was on multiple anithypertensives.
Patient #6 Review of Patient #6's medical record revealed she was a 56 year old female admitted on 07/14/15 with diagnoses of Debility, Hypertension, Diabetes Mellitus, Espohageal Reflux, Lumbago, Osteoarthritis, and Depression.

Review of Patient #6's physician admit standing orders revealed orders for Lactulose by mouth twice daily as needed for constipation and Dulcolax suppository, 1 per rectum, daily as needed for constipation. Further review revealed orders for antihypertensive medications Accuchecks before meals and at bedtime.

Review of Patient #6's "Graphic Sheet" revealed she did not have a bowel movement on 07/15/15, 07/16/15, 07/17/15, 07/20/15, 07/21/15, and 07/22/15. There was no documented evidence that interventions were implemented and the physician notified that Patient #6 did not have a bowel movement for 3 days from 07/15/15 through 07/17/15. Review of her nursing notes revealed she was administered Lactulose on 07/22/15 at 5:25 p.m. for complaints of constipation with no effect noted at 6:00 p.m. There was no documented evidence that the physician was notified that Patient #6 did not have a bowel movement for 3 days from 07/20/15 through 07/22/15 with no effect from the ordered intervention.

Review of Patient #6's nursing care plan revealed her plan for elimination included interventions of assessing abdomen, bowel sounds, bowel movements, appetite, and any straining at stool or oozing of stool at the same time each day and to establish a bowel program. There was no documented evidence of what was to be included as part of the bowel program. Further review revealed no documented evidence that a nursing care plan was developed for Hypertension and Diabetes Mellitus for which physician orders were written.

In an interview on 07/30/15 at 8:50 a.m., S3DON (Director of Nursing) indicated the physician usually orders the specifics of the bowel program for each patient. She confirmed no physician orders were present for a bowel program for Patient #6. S3DON indicated no nursing care plan was developed for Diabetes Mellitus and Hypertension.

Patient #7
Review of the medical record revealed the patient was a 79 year old female admitted to the hospital on 07/15/15. The patient had the diagnoses of Hypertension, Subarachnoid Hemorrhage, Atrial Fibrillation, and Chronic Airway Obstruction.

Review of the patient's Care Plan revealed no documented evidence of specific interventions for Hypertension.

In an interview on 07/30/15 at 8:41 a.m., S3DON indicated there was no evidence that a care plan for Hypertension was developed.


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Based on observations, record reviews, and interviews the hospital failed to ensure patient care assignments were made in accordance with the patients' needs and the specialized qualifications and competence of the nursing staff available. This deficient practice was evidenced by no current competencies for 4 (S3DON [Director of Nursing], S23RN[Registered Nurse], S28RN, S29LPN Licensed Practical Nurse]) of 6 (S3DON, S12RT[Respiratory Therapist], S23RN, S28RN, S29LPN, S30CNA [Certified Nursing Assistant]) direct care staff files reviewed for current skills competencies.
Findings:


Review of hospital policy # I-B.2.18 titled Staff Competency (Issued 10/06, Previous review dates of 3/14 and 2/15) , provided 7/30/15 at 2:11 p.m. by S9VP Clinical (Vice President of Clinical Services) as current, revealed in part: "In order to provide quality patient care, all employees shall be competent to fulfil their assigned responsibilities. Each member is assigned clinical and/or managerial responsibilities based on ...an assessment of current competence. An evaluation of each staff member's competence is conducted during the orientation process, three months post employment, and annually thereafter. The evaluation includes an objective assessment of the individual's performance in delivering patient care services and/or modalities in accordance with patient needs... The nursing unit competency tool is utilized by the preceptor in the unit orientation phase. The tool provides competency-based guidelines relative to specific nursing units, skills, and job responsibilities, nursing care, equipment and procedures. Employee is in orientation function, under the guidance ad directives of the preceptor, until they are competent to fulfill assigned duties and responsibilities as determined by the Registered Nurse(RN)/Director of Nursing (DON)...Competency of employees are re-evaluated annually by the appropriate Department Director with the specified unit competency tool."


S3DON
Review of the personnel file for S3DON revealed a hire date of 3/25/15. Further review revealed a Position Description for a Registered Nurse that included a competency evaluation form. The form documented it was prepared by HR (Human Resources) and dated 3/25/15. No competencies were documented as having been evaluated, and signature lines for the employee and for the supervisor were blank. Further review revealed a self-assessment of specific skills for a registered nurse. No evaluation and verification of competency was documented by a supervisor or other authorized hospital staff.

S23RN
Review of the personnel file for S23RN revealed a hire date of 7/2/15. Further review revealed a signed acceptance for the position of an RN Charge Nurse. A blank New Hire Orientation Agenda was noted, with no documented evidence of any nursing skills competency evaluation. S23RN was observed to be the Charge RN 7/28/15 and 7/29/15 during the survey.


S28RN
Review of the personnel file for S28RN revealed a hire date of 6/29/15 as the ADON (Assistant Director of Nursing)/Clinical Educator. Further review revealed no competencies evaluated and verified by hospital staff. Review of a New Hire Orientation Agenda was blank, with no signature by S28RN or an Educator's signature. Review of an email dated 7/16/15 revealed S28RN resigned her position as ADON/Clinical Coordinator.

S29LPN
Review of the personnel files for S29LPN revealed a hire date of 8/25/10. Further review revealed no current skills competency validation in her file.

Review of a hospital policy titled , "PICC Line Management"( Policy # NSG 4.76, issued 10/06, revised 2/2015), provided by S3DON 7/28/15 at 4:30 p.m. as current, revealed, in part, "Important Factors: A. Maintain strict sterile technique when manipulating the catheter, and the infusion line joints to prevent contamination of the IV (intravenous) system."

Review of a hospital policy titled, " Central Venous Catheter" (Policy #NSG 4.24, no issue date, revision date of 2/2015), provided by S3DON as current, revealed the following, in part: "The policy addresses maintenance of the central venous catheter and site in preventing central line associated blood stream infections and systemic and local site hospital acquired infections....Maintenance:...5. Blood Specimen Collection...c. Scrub the hub with chlorhexidene for 30 seconds using a twisting motion..."

An observation 7/28/15 at 2:45 p.m. revealed S3DON entered Patient #7's room and explained that she needed to draw blood cultures from the patient. S3DON, with gloves on, wiped the patient's skin on her hand with alcohol wipes, and attempted to perform venipuncture with a "butterfly" access device. The end of the tubing on the butterfly device, used to inject blood into the culture bottle (opposite end of the collection tubing from the needle inserted into the patient's skin/vein) was observed to be lying on the bare cloth pad placed under the patient at the level of her hips. No barrier to maintain asepsis was observed. After the 1st unsuccessful attempt, S3DON changed gloves after putting the butterfly needle apparatus in a sharps box. S3DON was observed to not perform hand hygiene after she removed her gloves, and before donning a clean pair in preparation for another attempt at obtaining blood peripherally for blood cultures. During the 2nd attempt to obtain blood (from the patient's right forearm) for the blood cultures, the end of the tubing of the blood drawing device was again lying on the underpad under the patient's buttocks.

An observation 3/28/15 at 3:25 p.m. revealed S23RN in Patient #7's room readying supplies , in order to draw blood cultures from the patient's PICC line. S23RN, before gloving, left the patient's room, stating, "I'm going to see if we have some chlorhexidene." Upon reentering the patient's room, S23RN stated, "They said we just use alcohol." S23RN proceeded to prep the access ports of the PICC line by cleaning with alcohol wipes prior to access. Upon competition of the procedure, S23RN removed her gloves, and was observed with her hands in her scrub jacket pockets while stating she was looking for syringes of flush. S23RN left the room without performing hand hygiene, then returned with prefilled syringes of saline flush. She donned gloves without performing hand hygiene and flushed the patient's PICC line port. S23RN removed her left glove, picked up the culture bottles in her right hand, and left the patient's room without performing hand hygiene. S23RN walked from the patient's room to the nurses' station, where she grabbed a lanyard with keys on it, walked to the medication room, unlocked the door and entered. No hand hygiene was performed prior to entering the medication room. S23RN verified she had not performed hand hygiene before exiting the patient's room and before touching the drawer that held the medication/workroom keys on a lanyard, and the door to the medication/workroom. S23RN reported that she did not remember not performing hand hygiene when she removed her gloves, left the patient's room, and upon reentering the room and donning clean gloves prior to flushing the patient's PICC line. S23RN reported she used alcohol to clean central line ports prior to access.

S3DON and S23RN were unable to provide a current hospital policy for obtaining Blood Cultures when one was requested.

No competency verifications for S3DON and S23RN with respect to drawing blood cultures, or care and maintenance of a PICC line or Central Intravenous Line.

Review of a hospital policy titled , "PICC Line Management"( Policy # NSG 4.76, issued 10/06, revised 2/2015), provided by S3DON 7/28/15 at 4:30 p.m. as current, revealed, in part, "Important Factors: A. Maintain strict sterile technique when manipulating the catheter, and the infusion line joints to prevent contamination of the IV (intravenous) system."

Review of a hospital policy titled, " Central Venous Catheter" (Policy #NSG 4.24, no issue date, revision date of 2/2015), provided by S3DON as current, revealed the following, in part: "The policy addresses maintenance of the central venous catheter and site in preventing central line associated blood stream infections and systemic and local site hospital acquired infections....Maintenance:...5. Blood Specimen Collection...c. Scrub the hub with chlorhexidene for 30 seconds using a twisting motion..."

In an interview 7/30/15 at 4:30 p.m. S2HR Director (Human Resource Director) reported that all nurses are supposed to have hospital orientation before they report to the nursing unit. When asked about competencies, S2HR Director reported that a nurse fills out a self-evaluation and that serves as his/her competency to start providing care with a preceptor. S2HR Director reported that a Department Specific Competency Based Clinical Orientation tool is provided to the nurse, and it is completed by the nurse's preceptor(s). S2HR Director provided a copy of this competency tool. After review of the personnel files listed above, S2HR Director confirmed that the files did not contain a completed competency tool in the nurse's files. S2HR Director reported that the nurse would keep the tool with them during the 90 day orientation, at which time the competency should be complete. S2HR Director could not answer why S23RN was functioning as a charge nurse without a preceptor when her orientation and competencies evaluation was not yet completed.

Based on record reviews, observations, and interview, the hospital failed to ensure the drug storage area was administered in accordance with hospital policy as evidenced by failure to maintain security of the drug storage area by keeping the keys to the door in an unlocked drawer in the nursing station that was accessible to unlicensed staff.
Findings:

Review of the hospital policy titled "Medication Security and Storage, presented as a current policy by S3DON (Director of Nursing), revealed that only authorized personnel shall have access to locked areas where medications are stored. Further review revealed all authorized personnel will be responsible for the control and security of medications utilized in the care of their patients.

Observation in the nursing station on 07/28/15 at 3:30 p.m. revealed S23RN (registered nurse) took the drug storage room keys from an unlocked drawer in the nursing station while the surveyor was seated next to the drawer. Further observation revealed S23RN returned the narcotic keys to the same drawer.

Observation in the nursing station on 07/28/15 at 3:33 p.m. revealed S23RN took the drug storage room keys from an unlocked drawer in the nursing station while the surveyor and the unit clerk were present in the nursing station. Further observation revealed S23RN returned the narcotic keys to the same drawer.

Observation on 07/29/15 at 1:15 p.m. revealed the drug storage room keys were in an unlocked drawer in the nursing station.

In an interview on 07/30/15 at 8:50 a.m., when informed of three observations of the drug storage room keys being in an unlocked drawer in the nursing station, S3DON indicated she wasn't sure what the hospital policy was in relation to storage of the narcotic keys. When asked for further clarification, S3DON confirmed the RN was expected to ensure that medications were secure.

Based on record review and interview, the hospital failed to appoint and approve a qualified and credentialed radiologist as director over radiology services provided by the hospital. Findings:

A review of the physician roster, provided by the hospital as current by S2HR Director (Human Resource Director) revealed there was no credentialed physician identified as the radiologist who was director over radiology services.

Review of the physician credentialing files revealed there was no credentialed radiologist approved and appointed by the Governing Body to serve as director over radiology services provided by the hospital.

In an interview on 07/30/15 at 4:00 p.m., S9VP Clinical (Vice President of Clinical Services) confirmed there was no credentialed radiologist approved and appointed by the Governing Body to serve as director over radiology services.

Based on record review and interview the hospital failed to ensure the infection control officer developed and implemented infection control policies that were based on nationally recognized guidelines.
Findings:

Review of Infection Control documents, provided by the hospital, revealed no documentation of what nationally recognized guidelines on which the Infection Control policies and procedures were based.

In an interview 7/28/15 at 9:05 a.m. S7RN, after reviewing Infection Control documents provided, verified there was no documentation of nationally recognized guidelines on which the hospital policies and procedures were based.

Based on observations, record reviews, and interviews, the hospital failed to ensure the infection control officers developed and implemented a system for identifying, reporting,
investigating, and controlling infections and communicable diseases of patients and personnel. This deficient practice was evidenced by:

1. failure to have a current infection control plan;

2. failure to ensure expired dialysis supplies were not available for use;

3. failure to identify, analyze, develop a corrective plan, and monitor for success and sustainability, when hand hygiene surveillance results were below the targeted goal (85%) from January 2015 through June 2015;

4. failure to provide provisions for hand hygiene in all areas of patient care;

5. failure to ensure nurses were trained and competent to adhere to infection control procedures when accessing a PICC (peripherally inserted central catheter) and drawing blood cultures;

6. failure to include Physicians, mid-level practitioners, and contract employees in the hospital's Tuberculosis (TB) surveillance program;

7. failure to have a respiratory protection program that detailed worksite-specific procedures and elements for required respirator use, and failed to ensure respiratory fit testing was provided at regular intervals to personnel at risk.;

8. failure to conduct infection control related Environmental Rounds, by the Infection Preventionist or designee as per the hospital policy;

9. failure to ensure hand hygiene was performed by 1 of 1 physician observed examining a patient, and 2 of 2 RNs (Registered Nurses) observed drawing blood cultures.
Findings:

1. Failure to have a current infection control plan.

Review of a hospital policy and procedure, titled Infection Prevention and Control Plan (Policy # III-D.4.04), issue date 10/06, revision date 12/10, and previous review dated 12/10, provided by S7RN (Registered Nurse) as current, revealed no documentation of review or approval since 2010.

Review of a document titled Infection Control Plan 2014, United Medical Rehabilitation Hospital, provided by S9VP Clinical (Vice President of Clinical Services), revealed in part, under Healthcare Epidemiology Priority Focus Areas, H. Infection Control Plan Evaluation: "The Infection Control Plan is reviewed annually by Infection Prevention Specialist, Professional Practice Committee (PPC) Medical Executive (MEC) and Governing Board."
Further review revealed no documented evidence that the plan had been reviewed and approved for the current year, 2015. S9VP Clinical verified that the document was titled Infection Control Plan 2014, and there was no evidence that it had been reviewed and approved for the current year of 2015.

In an interview 7/30/15 at 4:00 p.m. S7RN reported she was the interim Infection Preventionist for the hospital. S7RN reported that the hospital could not provide a current Infection Control Plan. S7RN confirmed that no MEC or Governing Board meeting minutes indicating a current Infection Control Plan had been reviewed or approved.

2. Failure to ensure expired dialysis supplies were not available for use.

Observation of the dialysis room on 07/28/15 at 10:25 a.m. revealed an unlocked cabinet that contained the following expired and unlabeled solutions/supplies used for dialysis:
Minncare Cold sterilant that was opened and labeled as expired on 07/30/15 with the manufacturer's expiration date of June 2015;
Myron L Company NIST Traceable Conductivity Standard Solution opened on 06/16/15 and labeled as expired on 07/16/15;
One container labeled "disinfectant" with fluid present with no documented evidence on the label of what type of disinfectant was present in the container;
One container of Water Check RC Residual Chlorine Reagent Strips with bleach indicator placed on top of the cabinet in the room that was not dated when opened with a label that read "use within 3 months after opened."

In an interview on 07/28/15 at 11:00 a.m., S3DON confirmed the above findings. She indicated that the cabinet containing dialysis fluids and supplies should be kept locked.

3. Failure to identify, analyze, develop a corrective plan, and monitor for success and sustainability, when hand hygiene surveillance results were below the targeted goal (85%) from January 2015 through June 2015.

Review of monthly "Handwashing Tracking Sheet" for January through July 2015 revealed the following:
January- 4 of 5 observations of staff did not perform hand hygiene before direct patient contact. 1 of 5 staff members did not perform hand hygiene after patient contact and glove removal. Staff observed included the following disciplines and/or care areas: nursing, Physical Therapy, and physicians.
February- 2 of 5 observations revealed no hand hygiene before patient contact, and 2 of 5 did not perform hand hygiene after patient contact and/or glove removal. (nurse, CNA (Certified Nurses Aide)).
March- 3 of 5 observations revealed no hand hygiene performed before patient care (Physician, Nurse, CNA).
April- 4 of 5 observations revealed no hand hygiene performed before patient care (CNA, Nurse, Occupational Therapy)
May- 3 of 5 observations revealed no hand hygiene before patient care (CNA, Physicians), and 1 observation where staff did not perform hand hygiene after patient contact and/or glove removal (physician).
June- 4 of 5 observed staff did not perform hand hygiene before direct patient contact (CNA, physician, nurse, Occupational Therapy[O.T.] staff).

Review of a 2015 Nursing Dashboard report, attached to meeting agendas of the Governing Board Meetings for 04/17/15 and 05/04/15, revealed Hand Hygiene Compliance Rates for January-67% (per cent), February- 73%, March-80 %, compared to a target percentage of 85%. The 1st quarter overall compliance rate was 73%. Another page, untitled, was stapled to the reports and documented the following: "Hand hygiene Compliance Rate is very low for Jan. (January) 3 nurses, 1 MD (Medical Doctor), and 1 P.T. (Physical Therapist). Only 1 (a nurse) used hand sanitizer prior to contact with a pt. (patient). This is the area that is lacking the most. The P.T. did not wash his hands following pt (patient) contact..." in a block next to this message was, "Educate all staff (nursing, therapy, and physicians) about hand hygiene and its importance in preventing the spread of infection. High alert needs to be placed on hand hygiene prior to pt contact/doning gloves."

Review of a Professional Practice/Medical Executive Committee Meeting agenda dated 07/17/15 and attached 2015 Nursing Dashboard revealed reports for Hand Hygiene Compliance for the first quarter and for the 2nd quarter as follows: April 73%, May 73%, and June 20%, and for the 2nd quarter 55% compliance. The areas of summary of findings, action for Improvement, Responsible person, date of implementation, and follow-up were all blank.

In an interview on 07/30/15 at 11:40 a.m., S7RN and S3DON (Director of Nursing) verified the findings in the hospital's Infection Control hand hygiene surveillance. S7RN verified there was no action plan documented, or records of any corrective interventions of the identified problem of hand hygiene breeches by all disciplines of staff in the hospital.

No documentation of staff education on hand hygiene was provided.

4. Failure to provide provisions for hand hygiene in all areas of patient care.

An observation 07/28/15 at 9:50 a.m. revealed a common patient shower room with an empty paper towel dispenser mounted on the wall across from the shower stalls. Further observation revealed no sink, soap dispenser, or waterless hand hygiene gel in the shower room. An observation of the hall in the vicinity of the shower room revealed no waterless hand hygiene gel/dispenser or sink for handwashing. S25LPN (Licensed Practical Nurse) verified there were no facilities or supplies in which staff and patients could perform hand hygiene in the patient care area of the patients' shower room.

An observation made 07/28/15 at 11:15 a.m. in the Occupational Therapy room revealed no sink in the room for hand hygiene. Further observation revealed the mounted waterless hand hygiene gel was completely empty. S24OT, present during the observations, confirmed the hand hygiene gel dispenser was empty. S24OT reported she noticed it was empty the day before (07/27/15), but had not changed it or notified anyone that it was empty. S24OT verified that the empty dispenser was the only way to perform hand hygiene in the O.T. gym.

An observation on 07/28/15 at 2:20 p.m. of the wall-mounted hand hygiene gel dispenser located at the nurses' station revealed the dispenser was completely empty. An attempt to obtain hand hygiene gel from the dispenser confirmed this. Nurses in the nursing station discussed who was responsible for refilling the dispenser, and one of them stated that the nurses were responsible for refilling the hand gel dispensers.

An observation on 07/28/15 at 3:37 p.m. revealed the hand hygiene gel dispenser located at the nurses' station remained empty.

5. Failure to ensure nurses were trained and competent to adhere to infection control procedures when accessing a PICC (peripherally inserted central catheter) and drawing blood cultures.

Review of a hospital policy titled , "PICC Line Management"( Policy # NSG 4.76, issued 10/06, revised 2/2015), provided by S3DON 07/28/15 at 4:30 p.m. as current, revealed, in part, "Important Factors: A. Maintain strict sterile technique when manipulating the catheter, and the infusion line joints to prevent contamination of the IV (intravenous) system."

Review of a hospital policy titled, " Central Venous Catheter" (Policy #NSG 4.24, no issue date, revision date of February 2015, provided by S3DON as current, revealed the following, in part: "The policy addresses maintenance of the central venous catheter and site in preventing central line associated blood stream infections and systemic and local site hospital acquired infections....Maintenance:...5. Blood Specimen Collection...c. Scrub the hub with chlorhexidene for 30 seconds using a twisting motion..."

An observation 07/28/15 at 2:45 p.m. revealed S3DON entered Patient #7's room and explained that she needed to draw blood cultures from the patient. S3DON prepared for the procedure by removing the top, covering the rubber septum of the 2 culture bottles, and cleaning them with alcohol wipes. S3DON, with gloves on, wiped the patient's skin on her hand with alcohol wipes, and attempted to perform venipuncture with a "butterfly" access device. The end of the tubing on the butterfly device (opposite the end in the patient's skin), used to insert into the culture bottle, was observed to be lying on the bare cloth pad under the patient at the level of her hips. No barrier to maintain asepsis was observed. After the 1st unsuccessful attempt, S3DON changed gloves after putting the butterfly needle apparatus in a sharps box. S3DON was observed to not perform hand hygiene after she removed her gloves, and before donning a clean pair in preparation for another attempt at obtaining blood peripherally for blood cultures. During the 2nd attempt to obtain blood (from the patient's right forearm) for the blood cultures, the end of the tubing of the blood-drawing device was again lying on the underpad under the patient's buttocks.

An observation 07/28/15 at 3:25 p.m. revealed S23RN in Patient #7's room readying supplies that included alcohol wipes, in order to draw blood cultures from her PICC line. S23RN, before gloving, left the patient's room, stating, "I'm going to see if we have some chlorhexidene." Upon re-entering the patient's room, S23RN stated, "They said we just use alcohol." S23RN proceeded to prep the access ports of the PICC line by cleaning with alcohol wipes prior to access. Upon competition of the procedure, S23RN removed her gloves, and was observed with her hands in her scrub jacket pockets while stating she was looking for syringes of flush. S23RN left the room without performing hand hygiene, then returned with prefilled syringes of saline flush. She donned gloves without performing hand hygiene and flushed the patient's PICC line port. S23RN removed her left glove, picked up the culture bottles in her right hand, and left the patient's room without performing hand hygiene. S23RN walked from the patient's room to the nurses' station, where she grabbed a lanyard with keys on it, walked to the medication room, unlocked the door and entered. No hand hygiene was performed prior to entering the medication room. S23RN verified she had not performed hand hygiene before exiting the patient's room and before touching the drawer that held the medication/workroom keys on a lanyard, and the door to the medication/workroom. S23RN reported that she did not remember not performing hand hygiene when she removed her gloves, left the patient's room, and upon re-entering the room and donning clean gloves prior to flushing the patient's PICC line. S23RN reported she used alcohol to clean central line ports prior to access.

On 07/28/15 at 3:45 p.m. S23RN and S3DON were asked for a hospital policy for Blood Cultures, but were unable to provide a policy. S3DON reported she could not remember that she did not perform hand hygiene after removing her gloves and before donning a clean pair between venipuncture attempts. S3DON reported that the policy was to use alcohol on central lines, including PICC lines.

Review of the personnel files for S3DON and S23RN revealed no verification of skills competencies for maintenance and accessing a PICC or Central Venous Catheter, drawing blood cultures, or any other nursing skills for RNs.

6. Failure to include Physicians, mid-level practitioners, and contract employees in the hospital's Tuberculosis (TB) surveillance program.

Review of Public Health-Sanitary Code (Title 51, Part II, Chapter 5, 503) Mandatory Tuberculosis Testing revealed, in part, "A. All persons prior to or at the time of employment at any hospital...requiring licensing by the Department of Health and Hospitals...or any person prior to or at the time of commencing volunteer work involving direct patient care at any hospital...shall be free of tuberculosis in a communicable state... C...In order to remain employed or continue to work as a volunteer, shall be rescreened annually..."

Review of a hospital Policy, titled "Subject: Tuberculosis Surveillance Plan" ( Policy # IC4.05, issue date 4/15) revealed the TB Surveillance Program would be conducted for all employees, contract personnel, and volunteers.

In an interview 7/30/15 at 4:30 p.m. S2HR Director (Human Resources Director) verified that she was responsible in the hospital for credentialing information and files, in addition to staff personnel files. S2HR Director reported the hospital's TB Surveillance Plan pertained to hospital employees, but did not include physicians, or midlevel practitioners such as Advanced Practice Registered Nurses. S2HR Director reported that the hospital offered the TB testing to physicians and independent practitioners, but did not require them to be tested or screened for TB.

7. Failure to have a respiratory protection program that detailed worksite-specific procedures and elements for required respirator use, and failed to ensure respiratory fit testing is provided at regular intervals to personnel at risk.

Review of hospital policies and procedures revealed no evidence of a respiratory protection program that detailed required worksite-specific procedures and elements for required respirator use.

In an interview 07/30/15 at 9:45 a.m., S3DON reported the hospital did not perform fit-testing for respirators or N-95 respiratory masks. S3DON further reported the hospital did not have a respiratory protection program, as they did not admit patients with TB. When asked what the procedure was if a patient, after admission, was suspected of or found to have TB or another respiratory diagnosis requiring respiratory isolation, she responded, "I hadn't thought about that."

8. Failure to conduct infection control related Environmental Rounds, by the Infection Preventionist or designee as per the hospital policy.

Review of a hospital policy titled "Surveillance, Prevention, and Control of Infection, Subject: Infection Prevention and Control Plan" (Policy #; III-D.4.04, issue date of 10/06, revision date 12/10, Previous review: 12/10), provided by S3DON as current, revealed in part, Healthcare Epidemiology Priority Focus Areas, E: Environmental Rounds are performed in the hospital by the Infection Preventionist, DON, or Quality/Risk at least quarterly.

In an interview on 07/29/15 at 10:00 a.m., S3DON reported she had not conducted any environmental rounds for the month of July. S3DON indicated she would look for documentation of Infection Control Environmental Rounds prior to the month of July.

Review of Infection Control indicators in the QAPI (Quality Assessment and Performance Improvement) documents revealed no Environmental Rounds indicator.

No documented evidence of Infection Control Environmental rounds were provided during the survey.


9. Failure to ensure hand hygiene was performed by 1 of 1 physician observed examining a patient, and 2 of 2 RNs observed drawing blood cultures.

Review of hospital policy #III-D.4.16, titled Hand Hygiene (issued 10/06, revised 7/2010, no review date) revealed in part, that hands should be disinfected before and after gloving, between patients, between separate procedures on any one patient, at the beginning and end of shift, and any time asepsis is required and there is doubt regarding hand cleanliness.

An observation on 07/28/15 at 11:15 a.m. in the Occupational Therapy Room revealed S21Physician examined Patient #2 by auscultating his chest with a stethoscope under the patient's shirt. S21Physician, after speaking with the patient, walked over to Patient #5, spoke with her and auscultated her lungs, with the stethoscope on her skin and under her clothing. S21Physician exited the room after speaking with Patient #5. S21Physician did not wear gloves during his time in the Occupational Therapy room. At no time was S21Physician observed to perform hand hygiene or disinfect his stethoscope before, between, or after examining Patients #2 and #5. An interview with S21Physician after he left the Occupational Therapy room, and was walking down the hallway towards the nurse's station, was attempted. When asked for verification that he had not performed any hand hygiene before, between, or after patient contact, he replied, "Thank you" and walked away.

In an interview 07/28/15 at 11:20 a.m., S24OT, present during the time S21Physician was in the Occupational Therapy room and examined Patients #2 and #5, verified that S21Physician had examined both patients in the Occupational Therapy room, did not wear gloves, had not performed hand hygiene at any time while in the room, and had not disinfected his stethoscope before or after using it on both patients' skin.

An observation 07/28/15 at 2:45 p.m. revealed S3DON entered Patient #7's room and explained that she needed to draw blood cultures from the patient. S3DON, with gloves on, wiped the patient's skin on her hand with alcohol wipes, and attempted to perform venipuncture with a "butterfly" access device. After the 1st unsuccessful attempt, S3DON changed gloves after putting the butterfly needle apparatus in a sharps box. S3DON was observed to not perform hand hygiene after she removed her gloves, and before donning a clean pair in preparation for another attempt at obtaining blood peripherally for blood cultures.

An observation on 07/28/15 at 3:25 p.m. revealed S23RN in Patient #7's room readying supplies to draw blood cultures from her PICC line. S23RN, before gloving, left the patient's room, stating, " I'm going to see if we have some chlorhexidene." Upon reentering the patient's room,S23RN proceeded to prep the access ports of the PICC line by cleaning with alcohol wipes prior to access. Upon competition of the procedure, S23RN removed her gloves, and without performing hand hygiene was observed with her hands in her scrub jacket pockets while stating she was looking for syringes of flush. S23RN left the room without performing hand hygiene, then returned with prefilled syringes of saline flush. She donned gloves without performing hand hygiene and flushed the patient's PICC line port. S23RN removed her left glove, picked up the culture bottles in her right hand, and left the patient's room without performing hand hygiene. S23RN walked from the patient's room to the nurses' station, where she grabbed a lanyard with keys on it, walked to the medication room, unlocked the door and entered. No hand hygiene was performed prior to entering the medication room. S23RN verified she had not performed hand hygiene before exiting the patient's room and before touching the drawer that held the medication/workroom keys on a lanyard, and the door to the medication/workroom. S23RN reported that she did not remember not performing hand hygiene when she removed her gloves, left the patient's room, and upon reentering the room and donning clean gloves prior to flushing the patient's PICC line.

Based on record review and staff interview, the hospital failed to ensure the Quality Assessment and Performance Improvement (QAPI) program reassessed the effectiveness of its discharge planning process as evidenced by failing to include quality indicators that monitored and evaluated the discharge planning process.
Findings:

Review of the hospital's QAPI program information revealed no documented evidence for assessment of readmissions included an evaluation of whether the readmissions were potentially due to problems in discharge planning or the implementation of discharge plans.

In an interview on 07/30/15 at 12:42 p.m., S7RN (Registered Nurse) confirmed the hospital's assessment of readmissions did not include an evaluation of whether the readmissions were potentially due to problems in discharge planning or the implementation of discharge plans. S7RN indicated the hospital will have to develop and add quality indicators to its QAPI program to monitor this issue.

Based on record review and interview the hospital failed to ensure 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, was appointed.
Findings:

Review of the governing board meeting minutes revealed no documented evidence of the appointment of a director of respiratory care services.

In an interview 7/29/15 at 10:15 a.m. S3DON (Director of Nursing) reported that she thought the Director of Respiratory Services might be S21Physician.

In an interview 7/30/15 at 10:15 a.m. S10Medical Director reported that she thought maybe S21Physician was director of Respiratory Services.

A review of the credentialing file for S21Physician revealed no documentation of his appointment as Director of Respiratory Services.

In an interview 7/30/15 at 1:30 p.m.,S1Administrator reported that he did not know who was the director of Respiratory Services.

In a phone interview 7/30/15 at 3:10 p.m. S12RT (Respiratory Therapist) reported that she was not sure who the physician director of Respiratory Services was.

Based on record review and interview, the Chief Executive Officer, the Medical Staff, and the Director of Nursing failed to ensure the hospital-wide quality assessment and performance improvement (QAPI) program and training programs addressed problems identified by the infection control officer(s). This deficient practice was evidenced by no action plan developed, implemented, and evaluated for success and sustainability, hospital-wide, for hand hygiene compliance below the hospital's targeted goal of 85% since January 2015. Findings:

Review of monthly "Handwashing Tracking Sheet" for January through July 2015 revealed the following:
January- 4 of 5 observations of staff did not perform hand hygiene before direct patient contact. 1 of 5 staff members did not perform hand hygiene after patient contact and glove removal. Staff observed included the following disciplines and/or care areas: nursing, Physical Therapy, and physicians.
February- 2 of 5 observations revealed no hand hygiene before patient contact, and 2 of 5 did not perform hand hygiene after patient contact and/or glove removal. (nurse, CNA (Certified Nurses Aid)).
March- 3 of 5 observations revealed no hand hygiene performed before patient care (Physician, Nurse, CNA).
April- 4 of 5 observations revealed no hand hygiene performed before patient care (CNA, Nurse, Occupational Therapy)
May- 3 of 5 observations revealed no hand hygiene before patient care (CNA, Physicians), and 1 did not perform hand hygiene after patient contact and/or glove removal (physician).
June- 4 of 5 observed staff did not perform hand hygiene before direct patient contact (CNA, physician, nurse, Occupational Therapy staff).

Review of a 2015 Nursing Dashboard report, attached to meeting agendas of the Governing Board Meetings for 4/17/15 and 5/4/15, revealed Hand Hygiene Compliance Rates for January-67%, February- 73%, March-80 %, compared to a target percentage of 85%. The 1st quarter overall compliance rate was 73%. Another page, untitled, was stapled to the reports and documented the following: "Hand hygiene Compliance Rate is very low for Jan. (January) 3 nurses, 1 MD (Medical Doctor), and 1 P.T. (Physical Therapist). Only 1 (a nurse) used hand sanitizer prior to contact with a pt. (patient). This is the area that is lacking the most. The P.T. did not wash his hands following pt contact..." in a block next to this message was, " Educate all staff (nursing, therapy, and physicians) about hand hygiene and its importance in preventing the spread of infection. High alert needs to be placed on hand hygiene prior to pt contact/doning gloves."

Review of a Professional Practice/Medical Executive Committee Meeting agenda dated 7/17/15 and attached 2015 Nursing Dashboard revealed reports for Hand Hygiene Compliance for the first quarter and for the 2nd quarter as follows: April 73%, May 73%, and June 20%, and for the 2nd quarter 55% compliance. The areas of summary of findings, action for Improvement, Responsible person, date of implementation, and follow-up where all blank.

In an interview 7/30/15 at 11:40 a.m. S7RN and S3DON both verified the findings in the hospital's Infection Control hand hygiene surveillance. S7RN verified there was no action plan documented, or records of any corrective interventions of the identified problem of hand hygiene breeches by all disciplines of staff in the hospital.