HospitalInspections.org

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Radiologic Services as evidenced by:
Failing to ensure there was a radiologist who was a member of the medical staff that supervised the contracted radiology services on either a full-time, part-time, or consulting basis (see findings in tag A-0546).

Based on record review and interview, the governing body failed to ensure contracted services were performed in a safe and effective manner as evidenced by failing to ensure all contracted services were included in the quality assurance and performance improvement (QAPI) plan.
Findings:
Review of the hospital's contract with another area hospital titled, "Agreement for Hospital Contract Services" revealed the following, in part: In addition to the services of the Leased Employee, Contractor will provide its personnel to perform the services listed on this contract. Contractor shall provide Dialysis and Wound Care Services as needed.

The list of the hospital's current contracted services, presented by S1Administrator, was reviewed and compared to the QAPI documentation provided by S1Administrator. Further review of the hospital's QAPI documentation revealed quality indicators were not included for the following services provided through contractual agreement: Dialysis Services and Wound Care Services.
In an interview on 10/7/15 at 8:42 p.m. with S1Administrator, she confirmed Dialysis Services and Wound Care Services were provided through contractual agreement. She also confirmed quality indicators for Dialysis Services and Wound Care Services were not included in the hospital's QAPI plan.

30984

Based on record review, observation and interview, the hospital failed to ensure patients received care in a safe setting as evidenced by having a non-functional nurse call feature on the handrails of patients' beds for 21patient beds available on the unit for patient use.
Findings:
On 10/5/15 at 10:32 a.m. an observation was made of 21 patient beds (available for patient use) with a non-functional nurse call light feature on the beds' handrails.
In an interview (at the time of the observation) on 10/5/15 at 10:35 a.m. with S3RN, she confirmed the bedrails had a non-functional nurse call feature. She indicated the patients were instructed to use the handheld nurse call light.
In an interview on 10/5/15 at 11:50 a.m. with S1Administrator she confirmed the nurse call feature on the handrails of 21 current patient beds (in use at the time of the survey) was non-functional. S1Administrator indicated patients were instructed to use the hand held nurse call light. She agreed the non-functional handrail call light could cause confusion for a patient/patient's family attempting to call for assistance.

Based on policy review, observation and interview, the hospital failed to ensure patients had the right to confidentiality of his or her clinical records. This deficient practice is evidenced by failing to ensure an unattended computer screen accessible to visitors, patients and staff did not contain private patient information for 4 (#13, #18, #19, #20) of 14 current patients.

Findings:

Review of the hospital policy titled,"Confidentiality" revealed in part:
Patient information must be held within the strict terms of confidentiality.

Observation on 10/5/15 at 10:30 a.m. revealed a computer located in a common use hallway accessible by patients, visitors and staff. On the following occasions, the computer was unattended by a staff member and the following patients' information was on the screen:

An observation on 10/5/15 from 10:49 a.m. until 10:58 a.m. revealed Patient #20's lab information was on the computer screen.

An observation on 10/5/15 at 12:50 p.m. revealed Patient #19's lab orders were on the computer screen.

An observation on 10/5/15 at 1:30 p.m. revealed Patient #13's medications were on the computer screen.

An observation on 10/7/15 at 1:05 p.m. revealed Patient #18's orders were on the computer screen.

In an interview on 10/5/15 at 1:30 p.m. with S2DON, he verified that patient's information should not be able to viewed by people passing the above mentioned computer screen.

Based on record review, observation and interview, the hospital failed to ensure all patients had the right to be free from restraints. This deficient practice is evidenced by 2 (#1, #3) of 2 (#1, #3) patients reviewed for restraints being enclosed in Vail beds as a means of fall prevention.

Findings:

Review of the hospital policy titled "Enclosure Bed" revealed in part:
Enclosure bed- is a frame and fabric that attaches securely to the bed and has an opening for the mattress to be inserted. It completely encloses the bed like a tent with netting.

Patient #1
Review of the History and Physical for Patient #1 dated 9/18/15 revealed she was transferred to the hospital for ongoing medical management, pulmonary management and low-level rehabilitation. Further review revealed Patient #1 had suffered a head injury.

In an observation on 10/5/15 at 11:00 a.m., Patient #1 was in a Vail bed with the sides closed. The side rails of Patient #1's bed were observed to be elevated.

Review of the physician's orders for Patient #1 revealed an order for a Vail bed on 9/21/15 at 10:00 a.m. No indication for use of the bed was written.

In an interview on 10/5/15 at 11:00 a.m. with S11LPN, she said Patient #1 was in the Vail bed and was unable to get out of the bed on her own accord. She verified the Vail bed was being used as a restraint device for fall prevention and wandering.

In an interview on 10/5/15 at 2:05 p.m. with S3RN, she said Patient #1 was in a Vail bed because she was a safety hazard. S3RN said the Vail bed kept Patient #1 from falling.

In an interview on 10/5/15 at 1:31 p.m. with S2DON, he said Patient #1 was in a Vail bed because she tried to get out of bed and was a fall risk. S2DON said the Vail bed was for fall precautions.

In an interview on 10/5/15 at 2:30 p.m. with S14FNP, she said Patient #1 was in a Vail bed because she was a fall risk. S14FNP verified the Vail bed was a type of physical restraint.

Patient #3
Review of the medical record for Patient #3 revealed he was admitted for intravenous antibiotics. Further review revealed he had an altered mental status due to neurosyphilis.

Review of the physician's orders dated 10/2/15 at 11:55 a.m. for Patient #3 revealed he had an order to place him 1:1 during day hours of 7:00 a.m. until 11:00 p.m.

An observation on 10/5/15 at 3:00 p.m. revealed Patient #3 had a Vail bed in place in his room. Patient #3 was observed during the day shifts on 10/5/15 and 10/6/15 with a 1:1 sitter.

In an interview on 10/5/15 at 1:31 p.m. with S2DON, he said Patient #3 was in a Vail bed because he tried to get out of bed and was a fall risk. S2DON said Patient #3's Vail bed was used for fall precautions. S2DON said Patient #3 was 1:1 with a staff member during the day, but the hospital did not have the staff at night so they used the Vail bed to restrain him.

In an interview on 10/5/15 at 2:30 p.m. with S14FNP, she said Patient #3 was in a Vail bed because he was a fall risk due to dementia and confusion. S14FNP said he was 1:1 during the day because there was better staff coverage. S14FNP said they did not want to restrain Patient #3 during the day.

Based on record review, observation and interview, the hospital failed to ensure the use of restraints (Vail bed) was in accordance with a written modification to the patient's plan of care for 1 (#1) of 2 (#1, #3) current patients with restraints.

Findings:

Review of the hospital policy titled "Enclosure Bed" revealed in part:
Enclosure bed- is a frame and fabric that attaches securely to bed and has an opening for the mattress to be inserted. It completely encloses the bed like a tent with netting.

In an observation on 10/5/15 at 11:00 a.m., Patient #1 was in a Vail bed with the sides closed. The upper side rails of the bed were elevated.

Review of the physician's orders for Patient #1 revealed an order for a vail bed on 9/21/15 at 10:00 a.m.

In an interview on 10/5/15 at 11:00 a.m. with S11LPN, she said Patient #1 was in the Vail bed and was unable to get out of the bed on her own accord. She verified the Vail bed was being used as a restraint device.


Review of Patient #1's nursing care plan revealed no interventions listed for restraints.

In an interview on 10/6/15 at 9:55 a.m. S15RN, she verified there should have been a problem identified for restraints in Patient #1's care plans but there was not.

Based on record review and interview, the hospital failed to ensure data collected was used to monitor the effectiveness and safety of services and quality of care as evidenced by failing to breakdown aggregated data into subsets to allow for comparison of performance among hospital units. This deficient practice is evidenced by failing to compare staff performance of hand hygiene on the floor and in the Intensive Care Unit.

Findings:

Review of the QAPI data presented by S1Administrator revealed no documented evidence that staff hand hygiene performance data had been compiled into subsets for comparison between the floor and the Intensive Care Unit.

In an interview 10/7/15 at 9:00 a.m. with S1Administrator, she confirmed hand hygiene performance data had not been compiled into subsets for comparison between the floor and the Intensive Care Unit.

Based on record review, interview and observation, the hospital failed to set priorities for high-risk, high volume and problem prone areas as evidenced by:
1) failure to identify and implement corrective action relative to errors in administration of insulin for 3 (#2, #10,#11) of 5 patients reviewed for insulin administration;
2) failure to identify and implement corrective action relative to deficiencies in Infection Control practices related to Isolation Precautions/Practices.

Findings:

1) Medication errors related to insulin administration.

Patient #2
Review of the medical record for Patient #2 revealed 1 documented error in administration of sliding scale insulin (missed doses) on 9/22/15, identified during the survey process, by the survey team.

Patient #10
Review of the medical record for Patient #10 from 10/1/15 through 10/5/15 revealed 5 documented errors in administration of sliding scale insulin (missed doses) , identified during the survey process, by the survey team.

Patient #11
Review of the medical record for Patient #11 from 9/21/15 through 10/5/15 revealed 4 documented errors in administration of sliding scale insulin (missed doses), identified during the survey process, by the survey team.

Review of the Quality Improvement Report presented by S1Administrator as the hospital 's QAPI documentation revealed no documented evidence of indicators specifically addressing medication errors involving insulin administration (missed doses of sliding scale insulin).


2) Failure to identify and implement corrective action relative to deficiencies in Infection Control Practices related to Isolation Precautions/Practices.

During multiple observations, from 10/5/15-10/7/15, the following infection control issues were noted:
In an observation on 10/5/15 at 10:45 a.m., S17Respiratory performed patient care on Patient #21 and removed his gloves. He then donned new gloves and suctioned the tracheotomy on Patient #18 who was on contact isolation. S17Respiratory also did not don a gown when caring for Patient #18.

In an observation on 10/5/15 at 10:49 a.m., S17Respiratory emptied a used suction container for Patient #18. He then removed his gloves and donned new gloves without washing or sanitizing his hands. S17Respiratory then touched the tracheotomy collar on Patient #21.

In an observation on 10/7/15 at 1:30 p.m., S17Respiratory was performing care on Patient #21. S17Respiratory removed his gloves, donned new gloves without washing or sanitizing his hands and suctioned the tracheotomy of Patient #18.

In an interview on 10/7/15 at 10:00 a.m. with S2DON, he agreed hand hygiene should have been performed after glove removal and a gown should have been worn when coming in contact with Patient #18.

An observation was made on 10/7/15 at 1:17 p.m. of S9CNA removing trash and soiled linen bags from contact isolation patient rooms. S9CNA was observed bringing bags of soiled linen and trash out of Room "B" (contact isolation). She was handling the trash bare handed. She placed the bags of soiled linens and trash on a rolling cart that also held used patient meal trays. S9CNA was then observed going directly into Room "A" (contact isolation) without donning a gown, performing hand hygiene or putting on gloves prior to entering Room "A" . The gowns and gloves were located on the outside of the room entry door. S9CNA exited the room after retrieving bags of soiled linens and trash. S9CNA again handled the bags of soiled linens and trash bare handed. She placed the bags on the cart and wheeled the cart to the soiled utility room. She discarded the bags of soiled linens and trash in the soiled utility room. She did not wipe down the cart after use and wheeled it around the corner into a hallway. S9CNA was then observed, without performing hand hygiene, rolling the patient lift into Room "C" (patient was not on contact precautions). S9CNA was observed rolling the patient from Room "C" into the commons area. S9CNA was not observed gloving or performing hand hygiene throughout the observation.

In an interview on 10/7/15 at 1:50 p.m. with S2DON, after review of the above observations, he confirmed S9CNA had not followed the hospital's contact isolation precautions. He said he had not audited staff compliance with the use of personal protective equipment lately. S2DON indicated, based upon the above referenced observations, that he needed to initiate monitoring of staff compliance with use of personal protective equipment for patients in isolation. S2DON verified appropriate use of personal protective equipment for isolation precautions was not currently identified as a problem to be addressed through QAPI in the form of performance improvement projects. He indicated was not currently monitoring staff for appropriate use of personal protective equipment.

Review of the Quality Improvement Report presented by S1Administrator as the hospital's QAPI documentation revealed breaks in Infection Control practices related to appropriate use of personal protective equipment was not identified as an area of deficient practice in need of performance improvement. Additional review revealed no documented evidence of a corrective action plan to improve hand hygiene performance (hand hygiene compliance had declined to 62% in the 1st quarter of 2015; hand hygiene compliance was 75% in the 2nd quarter of 2015; no data was available for the 3rd quarter of 2015).

In an interview on 10/7/15 at 8:50 a.m. with S1Administrator, she indicated there had been no performance improvement action plans initiated relative to medication errors because the hospital had been below their established goals/thresholds. S1Administrator indicated she had been unaware of errors relative to missed doses of sliding scale insulin. She indicated that she was surprised that the survey team had discovered 10 medication errors (missed doses of sliding scale insulin) on 3 different patients (#2, #10, #11). S1Administrator also confirmed there was no documented action plan for improving hand hygiene compliance.

31048

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

(1) Failing to assign staff to continuously monitor telemetry patients. This deficient practice had the potential to affect 1 (#6) of 3 (#6, #18, #21) current patients on telemetry monitoring; and
(2) Failing to ensure telemetry strips were interpreted by nurses as per hospital policy for 3 (#6, #18, #21) of 3 (#6, #18, #21) current patients on telemetry; and
(3) Failing to ensure patients vital signs were assessed as ordered for 1 (#21) of 1 active sampled patients for vital signs ordered every 2 hours out of a total sample of 30 patients (#1-#30); and
(4) Failing to ensure patients with indwelling urinary catheters were evaluated for the continuing need of the catheter in accordance with the hospital's policy and procedures for 2 (#2, #21) of 2 active sampled patients, and failing to ensure there was a practitioner's order documented in the medical record for the placement of an indwelling urinary catheter for 1 (#21) of 2 (#2, #21) active sampled patients reviewed for indwelling urinary catheters in a total sample of 30 patients (#1-#30); and
(5) Failing to ensure CBG assessments were done as ordered by the physician for 1 (#11) of 4 active sampled patients reviewed for CBG assessments out of a total sample of 30 patients (#1-#30).

Findings:

(1) Failing to assign staff to continuously monitor telemetry patients.

Review of the hospital policy titled Telemetry revealed in part:
Definition: A method for remotely monitoring cardiac rhythms on non-critical patients by a centralized monitoring station.

Review of the medical record for Patient #6 revealed she had an order for telemetry dated 10/1/15 at 9:00 a.m.

In an observation on 10/7/15 at 11:15 a.m., a telemetry monitor was in the nurse's station with Patient #6, Patient #21 and Patient #18 being monitored. Further observation revealed no staff member was in the nurse ' s station observing the telemetry monitor.

On 10/7/15 from 1:00 p.m.-1:30 p.m., an observation was made of Patient #6's telemetry monitor (located in the central nursing station). The low alarm limit was observed to be set at 40 beats per minute. During the time of the observation the patient's heartrate dipped to 36 beats/minute and no staff member acknowledged the decreased heart rate. The patient's monitor also alarmed twice indicating the patient's telemetry leads were not connected. S16Secretary's back was to the telemetry monitor and she was observed taking off orders. None of the hospital staff was observed viewing/responding to Patient #6's telemetry monitor for the duration of the observation.
In an interview on 10/7/15 at 11:16 a.m. with S16Secretary, she said Patient #6, Patient #21 and Patient #18 were being telemetry monitored. She said Patient #18 and Patient #21 were being monitored in the Intensive Care Unit, but Patient #6 was not. She said no person was assigned to continuously monitor the telemetry screen. S16Secretary said she would watch for artifact or abnormal rhythms on the screen and notify the nurses if she saw anything unusual, but she did not have current training for reading telemetry strips. S16Secretary also verified there were many times when no staff member was in the nurse ' s station where the telemetry monitor was located.

In an interview on 10/7/15 at 1:00 p.m. with S1Administrator, she verified she did not have a staff member assigned to continuously monitor the telemetry screen for patients being monitored outside of the Intensive Care Unit.


(2) Failing to ensure telemetry strips were interpreted by nurses as per hospital policy.

Review of the hospital policy titled Telemetry revealed in part:
Definition: A method for remotely monitoring cardiac rhythms on non-critical patients by a centralized monitoring station.
3. Rhythm strips are recorded as follows:
a. Admission of the patient
b. Every shift
c. PRN rhythm changes, arrhythmias, significant events
d. Rhythm strips printed for the medical record will include the following measurements: rate, PR interval, QRS, Qt interval, rhythm interpretation and nurse's initials.
Person responsible: RN, LPN

Review of telemetry strips in the patients' medical records revealed no interpretations or initials of the nurse who printed the telemetry strips for Patient #18 and Patient #21 from 9/29/15 through 10/7/15 and Patient #6 from 10/2/15 through 10/7/15.

In an interview on 10/7/15 at 1:57 p.m. with DON, he verified the nurses were not initialing or interpreting the cardiac strips as per the hospital policy.



(3) Failing to ensure patients vital signs were assessed as ordered for 1 (#21) of 1 active sampled patients for vital signs ordered every 2 hours

Patient #21
A review of Patient #21's medical record revealed she was admitted to the hospital on 09/14/15 with diagnoses Acute Respiratory Failure with Ventilator Support; Diastolic Heart Failure; Chronic Pulmonary Heart Disease; Atrial Fibrillation; Severe Protein-Calorie Malnutrition; Myasthenia Gravis; and Diabetes Mellitus. Further review revealed a practitioner's order dated 09/14/15 at 5:00 p.m. to assess vital signs every two hours.

Review of the medical record revealed the following vital signs were not documented in the medical record at two-hour intervals as ordered:
09/16/15 at 8:30 a.m., 1:00 p.m., 3:00 p.m., 5:00 p.m.
09/17/15 at 9:00 a.m., 11:00 a.m., 3:00 p.m., 6:00 p.m.
09/21/15 at 3:00 a.m., 7:00 a.m.; 9:00 a.m., 11:00 a.m., 1:00 p.m., 3:00 p.m., 5:00 p.m.
09/23/15 at 9:00 p.m.
09/25/15 at 7:00 a.m., 9:00 a.m., 11:00 a.m., 1:00 p.m., 3:00 p.m., 5:00 p.m., 7:00 p.m.
09/28/15 at 8:00 p.m., 10:00 p.m., 12:00 a.m.
09/20/15 at 2:00 a.m., 4:00 a.m., 6:00 a.m.
10/01/15 at 7:30 a.m.
10/02/15 at 12:00 p.m., 2:00 p.m., 4:00 p.m., 6:00 p.m.
10/04/15 at 8:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m.
10/05/15 at 1:00 p.m.
10/06/15 at 3:00 a.m., 7:00 a.m.

In an interview on 10/06/15 at 3:30 p.m., S4RN reviewed the entire medical record for Patient #21 and confirmed there was no documentation of the patient's vital signs at the above-referenced dates and times, and there was no documentation as to why the vital signs were not assessed every two hours as ordered and there should have been documentation in the medical record.



(4) Failing to ensure patients with indwelling urinary catheters were evaluated for the continuing need of the catheter in accordance with the hospital's policy and procedure for care of patients with indwelling urinary catheters for 2 (#2, #21) of 2 active sampled patients and failing to ensure there was a practitioner's order documented in the medical record for the placement of an indwelling urinary catheter for 1 (#21) of 2 (#2, #21) active sampled patients reviewed for indwelling urinary catheters.

Review of a policy entitled Catheter (Foley) Care, presented by S1Administrator as current, revealed, in part: "...Documentation: 1. Document indication for continued catheter use daily."

A review of a policy entitled Catheterization (Female, Male), presented by S1Administrator as current, revealed, in part: "...Urinary Catheter Management Protocol . . . 3. Evaluate daily for need of urinary catheter; must document each shift medical necessity for continued need. Discontinue as soon as possible to ensure there are not urinary retention issues."

Patient #2
A review of the medical record for Patient #2 revealed she was admitted to the hospital on 09/22/15. Further review of the medical record revealed the patient had an indwelling urinary catheter inserted on 09/02/15 prior to admission to this hospital.

A review of the medical records revealed there was no documentation of the daily or per shift evaluation of the need or the medical necessity for the patient to continue with the indwelling urinary catheter in place as per hospital policy and procedure.

In an interview on 10/06/15 at 2:35 p.m., S4RN reviewed the entire medical record and confirmed there was no documentation of the daily or per shift evaluation of the need or the medical necessity for the patient to continue with the indwelling urinary catheter in place and stated there should have been documentation.


Patient #21
A review of the medical record for Patient #21 revealed she was admitted on 09/14/15. Further review revealed the patient was not admitted to the hospital with an indwelling urinary catheter.

A review of the medical record revealed a bladder scan was performed on 09/15/15 at 1:02 p.m. Review of the Nurse's Notes revealed an indwelling urinary catheter was placed in Patient #21 on 09/15/15 at 1:40 p.m. Further review revealed there was no documentation of the daily or per shift evaluation of the need or the medical necessity for the patient to continue with the indwelling urinary catheter in place as per hospital policy and procedure.

A review of the practitioner's orders revealed there was no documented order in the patient's medical record for the insertion of an indwelling urinary catheter nor was there any documentation in the practitioner's progress notes documenting the placement of an indwelling urinary catheter in Patient #21.

In an interview on 10/07/15 at 4:30 p.m., S12RN reviewed the entire medical record and confirmed there was no documented order in the patient's medical record for the insertion of an indwelling urinary catheter nor was there any documentation in the practitioner's progress notes documenting the placement of an indwelling urinary catheter in Patient #21 and there should have been an order documented. S12RN also confirmed there was no documentation of the daily or per shift evaluation of the need or the medical necessity for the patient to continue with the indwelling urinary catheter in place as per hospital policy and procedure.



(5) Failing to ensure CBG assessments were done as ordered by the physician for 1 (#11) of 4 active sampled patients reviewed for CBG assessments.

Review of Patient #11's medical record revealed he was admitted to the hospital on 09/11/15. Diagnoses included Osteomyelitis, Ankle/Foot and Diabetes Mellitus. Further review revealed a practitioner's order dated 09/11/15 for CBG levels to be obtained daily before meals and at bedtime.

Further review of Patient #11's medical record revealed no documentation that CBG levels were obtained on the following dates and times:
09/15/15 for prior to noon meal
09/16/15 for prior to supper meal
09/20/15 for prior to breakfast meal
09/23/15 for prior to lunch meal
09/30/15 for prior to supper meal

In an interview on 10/07/15 at 10:30 a.m., S4RN reviewed the entire medical record for Patient #11 and confirmed the above referenced CBG assessments were not documented in the medical record, and she further confirmed there was no documentation in the medical record as to why the CBG levels were not obtained and there should have been documentation in the medical record.

30984

Based on record review and interview, the hospital failed to ensure the nursing staff developed, and kept current individualized and comprehensive nursing care plans for each patient for 4 of 4 (#2, #6, #7, #8) patients sampled for care planning out of a total sample of 30 patient records reviewed.

Findings:

Review of the hospital policy titled Care Plan, revised: 7/14, revealed the following:
Definition: The individual patient plan of care is a plan for nursing care that has been developed to meet specific nursing care problems identified from the patient assessment. The patient care problems are identified using either the North American Nursing Diagnosis Association list of accepted Nursing Diagnoses or an established problem list.
Policy: 1. Every patient must have a plan of care established within 24 hours of admission. 2. The RN must initiate the plan of care on admission. The RN or LPN can add or resolve standards as is necessary to keep the plan of care for the patient current.
Objective: To meet the patient's nursing care needs utilizing established standards of care.

Patient #2
Review of the medical record for Patient #2 revealed she was admitted to the hospital on 09/22/15 with the diagnoses of Status-Post a Colostomy for Colovescular Fistula; Myelodisplastic Syndrome; Status-Post Thrombosis of Lower Leg and Pulmonary Filter Placement; Diminished Nutritional Status; Diabetes Mellitus. Further review revealed she was admitted for ongoing medical management, for low-level rehabilitation, wound care, nutritional support, and respiratory care. The patient also had an indwelling urinary catheter.

Review of the medical record on 10/06/15 at 10:45 a.m. revealed the following care plans were document in Patient #2's medical record: Altered Mobility, Ostomy, and Surgical Wound. Further review revealed Patient #2 was not care planned for Diabetes Mellitus, Alternation in Nutritional Status, Alteration in Respiratory Status, Diabetes Mellitus, and Alteration in Genitourinary Function.

In an interview on 10/06/15 at 10:50 a.m., S4RN reviewed Patient #2's entire medical record and confirmed Patient #2 did not have comprehensive care plans (which included all of Patient #2's medical needs and management) implemented. S4RN agreed Patient #2 should have been care planned for Diabetes Mellitus, Nutrition, Respiratory, and Genitourinary care needs.

Patient #6
Review of the medical record for Patient #6 revealed she had been admitted on 10/1/15 at 4:45 p.m. with diagnosis which included a urinary tract infection with sepsis. Patient #6 was on contact precautions.

Review of the care plans for Patient #6 revealed no problem identified for infection or contact precautions.

Patient #7
Review of the medical record for Patient #7 revealed she was admitted on 9/22/15 with diagnoses which included left knee infection status post flap, Peripheral Artery Disease, Anxiety and Depression.

Review of Patient #7's care plan revealed no identified problem for Anxiety and Depression. The care plan was not specific and not individualized to the patient's needs.

Patient #8
Review of the medical record for Patient #8 revealed she was admitted on 9/10/15 with diagnoses which included right foot wound infection, Congestive Heart Failure, Renal Failure with Hemodialysis and Diabetes Mellitus Type II.

Review of Patient #8's care plan revealed no identified problem for Congestive Heart Failure and Hemodialysis. The care plan was not specific and not individualized to the patient's needs.

In an interview on 10/6/15 at 9:12 a.m. with S2DON, he confirmed Anxiety and Depression were not care planned as identified problems for Patient #7. He said he wouldn ' t have care planned those diagnoses and the staff wouldn ' t have either. He indicated Anxiety and Depression would not have been care planned because almost all of the patients were on medication for Anxiety and Depression. S2DON also confirmed Congestive Heart Failure and Hemodialysis were not addressed as problems on Patient #8 ' s care plan. He agreed Congestive Heart Failure and Hemodialysis should have been addressed as problems on Patient #8 ' s plan of care.





31048

31048

Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered in accordance with the orders of the practitioner for 3 (#2, #10, #11) of 5 patients reviewed for sliding scale insulin administration out of a total sample of 30 patients reviewed (#1-#30).

Findings:

Review of the document entitled "Subcutaneous Sliding Scale Insulin (SSSI) Physician Orders" revealed, in part, for "Low Dose" dose regimen the following parameters were to be followed: For Blood Glucose Levels:
Less than 70 (See #4 below)
70-120, give 0 units of regular insulin
121-150, give 2 units of regular insulin
151-200, give 3 units of regular insulin
201-250, give 5 units of regular insulin
251-300, give 8 units of regular insulin
301-350, give 10 units of regular insulin
351-400, give 15 units of regular insulin
Greater than 400, give 20 units of regular insulin and call MD

Patient #2

Review of the medical record for Patient #2 revealed she was admitted on 09/22/15 with a diagnosis which included Diabetes Mellitus. Review of the practitioner's orders dated 09/22/15 revealed the above-referenced "Low Dose" sliding scale for regular insulin was to be administered to Patient #2.

On 09/22/15, the 11:00 p.m. the CBG assessment result was 155 mg/dL, which required 3 Units of insulin per the practitioner's orders for sliding scale insulin. Review of the medical record revealed no documentation that the regular insulin had been administered to Patient #2 as ordered.

In an interview on 10/05/15 2:15 p.m., S3RN reviewed Patient #2's entire medical record and confirmed there was no documentation in the medical record that the insulin had been administered as ordered and should have been, and there should have been documentation as to why the patient had not received the insulin as ordered per the sliding scale orders.


Patient #10
Review of Patient #10's medical record revealed the following missed doses of insulin (not administered as ordered per Patient #10's Sliding Scale):

10/1/15 4:30 p.m.: capillary blood glucose: 135mg/dl; no coverage documented (should have been 2 units of Regular Humulin Insulin per the patient's (sliding scale) protocol. Further review revealed no documented reason for not administering Insulin coverage as directed per the patient's sliding scale.

10/2/15 9:21 p.m.: capillary blood glucose: 131mg/dl; no coverage documented (should have been 2 units of Regular Humulin Insulin per the patient's (sliding scale) protocol. Further review revealed no documented reason for not administering Insulin coverage as directed per the patient's sliding scale.

10/3/15 11:49 p.m.: capillary blood glucose: 127 mg/dl; no coverage documented (should have been 2 units of Regular Humulin Insulin per the patient's (sliding scale) protocol. Further review revealed no documented reason for not administering Insulin coverage as directed per the patient's sliding scale.

10/4/15 9:00 p.m.: capillary blood glucose: 137 mg/dl; no coverage documented (should have been 2 units of Regular Humulin Insulin per the patient's (sliding scale) protocol. Further review revealed no documented reason for not administering Insulin coverage as directed per the patient's sliding scale.

10/5/15 9:22 p.m.: capillary blood glucose: 121 mg/dl; no coverage documented (should have been 2 units of Regular Humulin Insulin per the patient's (sliding scale) protocol. Further review revealed no documented reason for not administering Insulin coverage as directed per the patient's sliding scale.

In an interview on 10/6/15 at 11:03 a.m. with S11LPN, she confirmed no coverage was administered on the days referenced above when insulin coverage was indicated per the patient's sliding scale. She also reviewed the patient's electronic medical record, including nursing notes, and found no documented evidence of reasons for not administering coverage as directed per Patient #10's sliding scale. She indicated a reason should have been documented when coverage was not administered.


Patient #11
Review of the medical record for Patient #11 revealed he was admitted on 09/11/15 with a diagnosis which included Diabetes Mellitus. Further review revealed the practitioner's orders dated 09/11/15 ordered the above referenced "Low Dose" sliding scale insulin to be administered.

The following CBG readings required regular insulin to be administered to Patient #11 per the practitioner's orders:
09/21/15 at 9:35 p.m. was 156 mg/dL: required 3 units of regular insulin
09/30/15 at 9:29 p.m. was 215 mg/dL: required 5 units of regular insulin
10/01/15 at 9:11 p.m. was 214 mg/dL: required 5 units of regular insulin
10/05/15 at 9:45 p.m. was 186 mg/dL: required 3 units of regular insulin

Review of the medical record revealed no documentation the above-referenced doses of regular insulin had been administered as ordered to Patient #11.

In an interview on 10/05/15 2:15 p.m., S3RN reviewed Patient #11's entire medical record and confirmed there was no documentation in the medical record that the insulin had been administered as ordered and should have been. She further confirmed there was no documentation in Patient #11's medical record indicating why the regular insulin for the sliding scale had not been administered as ordered by the practitioner and there should have been documentation regarding why the patient had not received the regular insulin as ordered.

Based on record review and interview, the hospital failed to have a system in place to ensure verbal/telephone orders were dated, timed and authenticated within 10 days by the ordering practitioner.
Findings:

Review of the hospital policy titled Medical record content revealed in part:
Verbal or telephone orders must be countersigned by the healthcare provider issuing the order within 10 days, according to Louisiana law.
All physicians' orders must be signed within ten days of the order being given.

Review of the rules and regulations of the Medical Staff revealed in part:
2. All clinical entries in the patient's medical record shall be accurately dated and authenticated.
Delinquent Medical Records
1. A record is considered incomplete for 14 days from the date filed in the physician's box. A record is considered delinquent after it has been in the physician's box 15 days or more.
2. Seven (7) days after notice to the physician to the physician of delinquent records (if the records have not been completed) the physician is automatically suspended and so advised by certified mail.

Review of three random discharged patients' medical records revealed in part the following verbal/telephone orders had not been authenticated by the ordering practitioner:
Telephone order for a Do Not Resuscitate for Patient #R1 dated 7/23/15.
Telephone order for dietary for Patient #R2 dated 4/14/15 at 1:15 p.m.
Telephone order for blood glucoses for Patient #R3 dated 8/21/14 at 5:30 p.m.

Review of the current patient records revealed none of the unsigned verbal/telephone orders had been flagged for physician's to sign.

In an interview on 10/7/15 at 9:00 a.m. with S7MedRecords, she said she did not check the current or discharged patients' medical records for authentication of verbal and telephone orders. She said she was not aware she needed to check the medical records to ensure that the physicians were cosigning verbal orders. After reviewing multiple random discharged patients' medical records, S7MedRecords verified each contained several verbal/telephone orders that had not been authenticated. She said there was no system in place to ensure verbal orders had been cosigned. She said there were 129 patients discharged from 4/6/15 through 10/6/15 and she would guess almost every one of the records were delinquent for no authentication of verbal orders.

In an interview on 10/7/15 at 9:11 a.m., S2DON said there was a problem with the physicians authenticating verbal/telephone orders in the medical records. He said he thought S7MedRecords checked for the physicians' signatures. S2DON said he told the staff to put stickers in the chart to notify the physicians, but he was not sure if they were doing it or not.

Review of current patient's medical records for Patient #2, Patient #11, and Patient #21 revealed the following verbal orders were not authenticated, dated and/or timed.

Patient #2
09/23/15 at 6:30 p.m.; 09/24/15 at 9:30 a.m.; 9/24/15 at 10:10 a.m.; 09/25/15 at 3:05 p.m.

In an interview on 10/06/15 at 10:50 a.m., S4RN confirmed the above referenced verbal orders were not authenticated, dated, timed according to the hospital's policy and procedures.

Patient #11
09/11/15 at 3:45 p.m. and 4:00 p.m.; 09/11/15 at 6:25 p.m.; 09/17/15 at 8:00 a.m.

In an interview on 10/06/15 at 2:20 p.m., S4RN confirmed the above referenced verbal orders were not authenticated, dated, timed according to the hospital's policy and procedures.

Patient #21
09/15/15 (no time); 09/16/15 at 10:55 a.m.; 09/20/15 at 6:05 p.m.; 09/21/15 at 3:45 p.m.; 09/22/15 at 3:15 p.m.; 09/23/15 at 5:45 p.m.; 09/23/15 (time not legible)

In an interview on 10/06/15 at 4:10 p.m., S4RN confirmed the above referenced verbal orders were not authenticated, dated, timed according to the hospital's policy and procedures.




31048

Based on policy review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable standards of practice, consistent with state law. This deficient practice was evidenced by failing to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist, before the first dose was dispensed, for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications.

Findings:

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

Review of the hospital policy titled Dispensing: General, Policy no. 11-01, revealed in part:
A pharmacist shall review the prescriber's original order, or a direct copy therof, before the initial dose is dispensed unless a licensed independent practitioner with appropriate clinical privileges controls the ordering, preparation, and administration or in urgent situations when the resulting delay would harm the patient, including situations in which the patient experiences a sudden change in clinical status.

In an interview on 10/6/15 at 8:45 a.m. with S13Pharmacist, he said the pharmacy was open at the hospital from 8:00 a.m. until 4:30 p.m. Monday through Friday and he was on call if needed otherwise. S13Pharmacist verified the pharmacy did not do a first dose review on all new medication orders before the first dose was dispensed to the patients. He said if an order was written at night after he had left the hospital, he did not review it until the next morning. S13Pharmacist said if a new medication was ordered on a patient on a Friday evening, it would not be reviewed it until Monday morning.

Based on policy review, observation and interview, the hospital failed to ensure only authorized personnel had access to areas where drugs and biologicals were stored. This deficient practice was evidenced by propping open the door to a medication room where medications were accessible.

Findings:

Review of the hospital policy titled Medication Management- Storage, Policy No. 09-01, revealed in part:
All drugs and biologicals must be kept in a locked room or container.
All drugs and biologicals must be stored in a manner to prevent access by non-authorized individuals.
Whenever persons without legal access to the drugs and biologicals have access to or could gain access to the drugs or biologicals stored in an area, the hospital is not in compliance with the requirement to store all drugs and biologicals in a locked storage area.

An observation on 10/5/15 at 10:20 a.m. of the medication room revealed it was located on a hall used by staff, patients and visitors. Further observation revealed the door to the medication room was propped open by a garbage can. Inside the room were patients' medications in bins and individual patients' medications in an unlocked cabinet.

In an interview on 10/5/15 at 10:40 a.m. with S11LPN, she said the door to the medication room should have been locked.

In an interview on 10/6/15 at 8:45 a.m. with S13Pharmacist, he said the medication room should be locked at all times.

Based on record reviews and interviews, the hospital failed to ensure there was a radiologist who was a member of the medical staff that supervised the contracted radiology services on either a full-time, part-time, or consulting basis.
Findings:
Review of the Review of the hospital contract titled, "Agreement for Hospital Contract Services" revealed the following, in part: In addition to the services of the Leased Employee, Contractor will provide its personnel to perform the services listed on this contract. Contractor shall provide Radiology Services as needed.
Further review of the contract revealed no documented evidence of provision, by the contractor, of a Radiologist to serve as Director of the hospital's Radiological Services.

In an interview on 10/5/15 at 12:50 p.m. with S1Administrator, she indicated the hospital's Radiological Services were provided through contractual agreement. She confirmed the Governing Body had not appointed a Radiologist to serve as Director of Radiological Services.

Based on record review and interview, the hospital failed to ensure the designated infection control officer was qualified through ongoing education, training or experience.

Findings:

Review of the personnel record for S2DON revealed no documentation of training in infection control.

In an interview on 10/7/15 at 10:00 a.m. with S2DON, he verified he had been the infection control officer for a year at the hospital. S2DON said he did not have any certifications or documented training in infection control. S2DON said he did not have any previous experience as an infection control officer.

30984


Based on observation, interview and record review, the hospital failed to implement and maintain an active hospital wide program for the prevention, control and investigation of infections and communicable diseases. This deficient practice was evidenced by:
1) failing to ensure a current patient (Patient #7) was placed on C.difficile specific isolation precautions while C.difficile cultures were pending for 1 (#7) of 1 patients reviewed for C.difficile; and
2) failing to ensure staff donned appropriate personal protective equipment and performed hand hygiene upon entry/exit of patient rooms who were on contact precautions; and
3) failing to ensure staff performed hand hygiene between glove changes.

Findings:
1.Failing to ensure a current patient (Patient #7) was placed on C.difficile specific isolation precautions while C.difficile cultures were pending.
Patient #7
Review of Patient #7's electronic medical record revealed she was admitted on 9/22/15. Further review revealed the patient began having diarrhea stools on 9/25/15.

Review of Patient#7's physician orders revealed an order written on 9/26/15 at 12:30 p.m. for C.difficile cultures times 3 or 1st positive (culture). Additional review of the patient's medical record revealed no documented evidence of the patient being placed on C. difficile precautions while stool cultures to rule out C. difficile were pending.

Review of Patient #7's culture results revealed the 1st culture to rule out C.difficile was obtained on 9/27/15 at 12:15 p.m. Further review revealed the 3rd C.difficile culture was resulted as negative (final culture) on 9/27/15 at 11:12 a.m.

In an interview on 10/6/15 at 11:41 a.m. with S11LPN, she confirmed, after review of the patient's electronic medical record, that the patient had not been placed on C.difficile contact precautions while the stool cultures were pending. S11LPN indicated Patient #7 should have been placed on C.difficile specific isolation precautions until all three of the C.dificile cultures had been resulted as negative.

2) Failing to ensure staff donned appropriate personal protective equipment and performed hand hygiene upon entry/exit of patient rooms who were on contact precautions
Review of the hospital policy titled, "Hand Hygiene", revealed the following, in part:
Policy: 1. Hands are to be washed immediately or as soon as possible with soap nad water whne hands with or without gloves are visibly soiled.
2. Hands are to be cleaned by hand washing with soap and water or by hand antisepsis with an alcohol based waterless antiseptic agent. a. Before direct patient contact; b. After removing glove; e. After contact with blood, body fluids, mucous membranes, non-intact skin and wound dressings.
Review of the Hospital policy titled,"Standard Precautions" revealed the following, in part:
2.Gloves: a. Wear gloves (clean, non-sterile gloves are adequate) wen touching blood, body fluids, secretions, excretions, and contaminated items.; b. put on gloves before touching mucous membranes and non-intact skin.; d. remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another patient. Wash hands immediately to avoid transfer of microorganisms to other patients or environments.
Review of the hospital policy titled,"transmission Based Precautions", revealed te following, in part: 3. Contact Precautions: In addition to Satndard Precautions, use for specified patients known or suspected to be infected or colonized with epidemiologically important micro-organisms that can be transmitted by direct contact with the patient (hand or skin-to-skin), or direct (touching) with envronmental surfaces or patient care items in the patient care environment. b. Gloves and handwashing.i.....wear a gown when entering the room if you anticipate your clothing wll have sbstantial contact with the patient, environmental surfaces, or items in the patient's room, or if the patient has diarrhea, an ileostomy, a colostomy, or wound drainage not contained in a dressing. ii. remove the gown prior to leaving the patient's environment. 4. General Requirements: b. All linen is considered contaminated.
An observation was made on 10/7/15 at 1:17 p.m. of S9CNA removing trash and soiled linen bags from contact isolation patient rooms. S9CNA was observed bringing bags of soiled linen and trash out of Room "B" (contact isolation). She was handling the trash bare handed. She placed the bags of soiled linens and trash on a rolling cart that also held used patient meal trays. S9CNA was then observed going directly into Room "A" (contact isolation) without donning a gown, performing hand hygiene or putting on gloves prior to entering Room "A" . The gowns and gloves were located on the outside of the room entry door. S9CNA exited the room after retrieving bags of soiled linens and trash. S9CNA again handled the bags of soiled linens and trash bare handed. She placed the bags on the cart and wheeled the cart to the soiled utility room. She discarded the bags of soiled linens and trash in the soiled utility room. She did not wipe down the cart after use and wheeled it around the corner into a hallway. S9CNA was then observed, without performing hand hygiene, rolling the patient lift into Room "C " (patient was not on contact precautions). S9CNA was observed rolling the patient from Room "C" into the commons area. S9CNA was not observed gloving or performing hand hygiene throughout the observation.
In an interview on 10/7/15 at 1:50 p.m. with S2DON, after review of the above observations, he confirmed S9CNA had not followed the hospital's contact isolation precautions. He indicated she should have donned a gown and gloves upon entry into the contact isolation patients' rooms. He also indicated gloves should have been worn and hand hygiene should have been performed after glove removal by S9CNA when handling contact isolation patients' soiled linens and trash. S2DON also said the cart should have been wiped down after use, prior to storage. He said he had not audited staff compliance with use of personal protective equipment lately. S2DON indicated, based upon the above referenced observations,that he needed to perform staff observations for compliance with use of personal protective equipment for patients in isolation.
3) Failing to ensure staff performed hand hygiene between glove changes.

In an observation on 10/5/15 at 10:45 a.m., S17Respiratory performed patient care on Patient #21 and removed his gloves. He then donned new gloves and suctioned the tracheostomy on Patient #18 that was on contact isolation. S17Respiratory also did not don a gown when caring for Patient #18.

In an observation on 10/5/15 at 10:49 a.m., S17Respiratory emptied a used suction container for Patient #18. He then removed his gloves and donned new gloves without washing or sanitizing his hands. S17Respiratory then touched the tracheostomy collar on Patient #21.

In an observation on 10/7/15 at 1:30 p.m., S17Respiratory was performing care on Patient #21. S17Respiratory removed his gloves, donned new gloves without washing or sanitizing his hands and suctioned the tracheostomy of Patient #18.

In an interview on 10/7/15 at 10:00 a.m. with S2DON, he agreed hand hygiene should have been performed after glove removal and a gown should have been worn when coming in contact with Patient #18.

Based on interview and record review, the hospital failed to ensure there was a system in place and implemented to ensure patients and/or responsible parties were counseled to prepare them for post hospital care and implementation of the discharge plan as evidenced by no documentation of education and/or counseling provided to patients and/or responsible parties regarding the list of all medications the patient should be taking after discharge, with clear indication of changes from the patient's pre-admission medications for patients discharged home. This failed practice had the potential to affect all patients admitted and discharged to home from the hospital.

Findings:

In an interview on 10/07/15 at 1:30 p.m., S8DCPlanner indicated, upon discharge, patients were provided with discharge instructions which included a list of the medications the attending physician ordered for the patients at discharge, and would typically involve only the medications the attending physician was responsible for providing for patients during the patients' hospital stay. She also indicated she was not aware of the requirement for counseling the patients and/or responsible parties on the changes to the patients' pre-admission medications when patients were discharged home. S8DCPlanner confirmed there was no policy and procedure in place for counseling patients and/or responsible parties to prepare them for post hospital care regarding the list of all medications the patient should be taking after discharge, with clear indication of changes from the patient's pre-admission medications. S8DCPlanner confirmed this practice had not been implemented at the hospital and should have been.

Review of the discharge instruction sheets provided by S8DCPlanner as current, revealed there was no evidence of a system in place for documenting clear indications of changes from the patients' pre-admission medications and post discharge medications.

Review of the medical records for discharged patients #14, #15, #16, and #17 revealed no documentation of patients and/or responsible parties had been counseled to prepare them for post hospital care regarding the list of all medications the patient should be taking after discharge, with clear indication of changes from the patients' pre-admission medications.

Based on interview the hospital failed to ensure the discharge planning process was reviewed in an ongoing manner through quality assurance and performance improvement activities which included tracking readmissions to the hospital and reviewing any readmissions for potential problems in the discharge planning process.

In an interview on 10/07/15 at 1:25 p.m., S8DCPlanner confirmed the hospital did not review or monitor its discharge planning processes and procedures in an ongoing manner through quality assurance practices, and she was not aware of any quality assurance indicators that evaluated the discharge planning process for its effectiveness.

In an interview on 10/07/15 at 1:31 p.m., S1Administrator confirmed the hospital was not tracking readmissions to the hospital, and there was no data available regarding readmissions and the analyses of readmissions to the hospital.

Based on record review and interview, the hospital failed to appoint a Director of Respiratory Services that was credentialed by the medical staff and approved by the Governing Body.

Findings:

Review of the medical staff credential files and the Governing Body meeting minutes revealed there was no Medical Director of Respiratory Services credentialed by the medical staff and approved by the Governing Body.

In an interview on 10/08/15 at 9:00 a.m., S1Administrator confirmed there was no physician on staff approved by the medical staff and appointed by the Governing Body as Director of Respiratory Services at the hospital.