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Based on record review and interview, the governing body failed to ensure the hospital, which is located within a hospital, independently met the requirement for emergency services as evidenced by the hospital utilizing the host hospital's emergency room physicians during "Code" (cardio respiratory arrest) procedures.

Findings:

Review of the Louisiana Hospital Licensing Standards (LAC48:I. Chapter 93, Section 9305 L-3) revealed 3. Staff of the hospital within a hospital shall not be co-mingled with the staff of the host hospital for the delivery of services within any given shift.

Review of a contract between the hospital and the host hospital (Hospital "A") revealed in part: 13. Code Blue Coverage- Hospital "A" will provide "code blue" coverage consistent with Hospital A's Code Blue Procedure, policy number TX-A-062, a copy of which is attached hereto as Exhibit C and incorporated herein.

In an interview on 1/22/19 at 3:30 p.m. with S5ClinOper, she said if a patient coded in their hospital the ED doctor from Hospital "A" would come to the code. When asked who takes precedent if the ED doctor in the host hospital was coding a patient in the ED and there was a coding patient in her hospital, she said she did not know. S5ClinOper said it was a new process and they were working on it.

In an interview on 1/23/19 at 1:00 p.m. with S2CNO, he said the ED physicians at Hospital "A" would code the patients in their hospital in the event of a code blue. He said if the ED Doctors were busy, the hospitalist at the host hospital would come run the code.

Based on record review, observations, and interviews, the hospital failed to ensure patients had the right to privacy as evidenced by failure to follow policies and procedures for the use of the video monitoring system that allowed live and unrecorded video for 2 of 2 (#7, R1) patients on video monitors.
Findings:

Review of the hospital policy titled patient rights and responsibilities presented as current policy revealed in part, patients had the right to have personal privacy respected.

Review of the policy titled Video Monitoring Policy presented as current policy revealed in part, patient must be safeguarded when video monitoring is in use. Procedure 5. Turn the camera off during bathing, procedures, and at any time that privacy is indicated.


Patient #7
Patient #7 is an 87 year old admitted on 01/11/19 with a diagnosis of encephalopathy and confusion.

On 01/23/19 at 9:00 a.m. an observation from the hallway on the side of the nursing station revealed a clear view of a large color video monitor with patient #7 laying in his bed supine on half of the screen. Visitors and staff noted to be frequently using this hallway with a clear view of the monitor screen.


Patient #R1
Patient #R1 is an 89 year old admitted on 01/17/19 with bilateral pneumonia, suspected aspiration, and urinary tract infection.

On 01/23/19 at 9:00 a.m. an observation from the hallway on the side of the nursing station revealed a clear view of a large color video monitor with patient #R1 in the process of having cares, he was laying on his side with his buttock and foley exposed.


On 01/23/19 at 9:10 a.m. an interview with S5ClinOper confirmed there is an unobstructed view of the large color video monitor from a hallway frequented by staff, and visitors.

Based on record review and interview, the hospital failed to ensure non-employee licensed nurses working in the hospital were evaluated for competency for 2 (S8RN, S9RN) of 2 contracted staff.

Findings:

Review of S8RN's and S9RN's personnel records revealed no documented competencies for telemetry, code blue, emergency preparedness, hand washing, bloodborne pathogens, proper mask fit, or hospital equipment.


In an interview on 1/23/19 with S6HR, she said for full time employees the hospital did competencies for telemetry, code blue, emergency preparedness, hand washing, bloodborne pathogens, proper mask fit, and hospital equipment. S6HR verified the 2 contract nurses did not have these competencies.

Based on observation and interview, the hospital failed to ensure there was a qualified individual who was responsible for the daily management of the dietary services within the hospital.
Findings:

On 01/23/19 at 12:10 p.m. and observation revealed the lunch trays in the process of being handed out.

On 01/23/19 at 12:11 p.m. an interview with S7RD revealed no meal temperatures were taken. When S7RD was asked if he monitored any of the meal temperatures when the meals were brought to the floor he replied "no".

Based on record review, observation and interview, the hospital failed to ensure supplies were maintained to ensure an acceptable level of safety and quality. This deficient practice is evidenced by failing to stock 2 of 2 code carts as per the hospitals inventory list.

Findings:

Review of hospital policy titiled Crash Carts / Defibrillators presented as current policy states in part, the house supervisor is responsible for seeing that the crash cart is restocked. The crash cart is to be taken to Central Supply for cleaning and cart replenishment. Once stocked again with supplies, return the cart to the nursing unit. The Nursing staff will immediately complete a crash cart daily check to ensure the cart is in order and to document the new lock number.

Observation of code cart 1 on 1/22/19 at 11:00 a.m. with S3Qual revealed the following items missing as per the inventory list:
Roll of EKG paper
Adult Ambu bag
Carbon Dioxide detector
7.0 Endotracheal tube
2 of 2 Intravenous extension tubings
16 french foley

Observation of code cart 2 on 1/22/19 at 11:00 a.m. with S4NsgSuper revealed the following items missing as per the inventory list:
Sharps cointainer
1 of 2 Carbon Dioxide detectors missing. The one in the cart had been expired since 9/16.
6.0, 6.5 snd 7.5 Endotracheal tubes
3 and 4 MAC intubation blades
2 of 2 primary fluid tubing
Safety goggles
6 foot suction tubing

In an interview on 1/22/19 at 11:20 a.m. with S3Qual, she verified the items were missing from code cart 1. She stated a locked cart indicates a restocked cart and the charge nurse was to verify all the items on the inventory list at the beginning of each month.

In an interview on 1/22/19 at 11:25 a.m. with S4NsgSuper, she verified the above mentioned items were missing from code cart 2. She said the charge nurse should have been checking the code cart for supplies at the beginning of each month.


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