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Based on record review and interview, the hospital failed to ensure patient complaints were recognized as grievances. This deficient practice was evidenced by failure of the hospital to submit a grievance report on behalf of Patient #1 and his wife's complaint.
Findings:

A review of hospital policy titled "Patient & Family Grievances" revealed, in part: C. Complaint/Grievance Process Post-Discharge, in part: In the event the Administrative Representative receives a complain post discharge, then the complaint shall be handled as grievance as noted above in Section B, Grievance. An Event will be entered in the log and the appropriate manner will be notified for investigation.

Review of incident log revealed an Incident Report Form dated 04/23/2023 at 7:30 a.m. involving Patient #1. The report reveals the patient was found on the floor from bed at 6:15 a.m. on 04/23/2023. Further review revealed there was no injury. Further review revealed PICC line displacement with bleeding from the PICC site related to the fall. Overview of the incident stated: Patient hit call light and was found on floor next to bed by CNA. There was blood, urine and fecal material on and near patient. Patient had removed brief and PICC line was out of patient arm. Patient was cleaned and linens changed once placed back in bed, LUE @ PICC site wrapped in gauze, US obtained. Provider was notified of fall at 6:40 a.m. and that patient having increased confusion and was ordered to send patient out acute. Patient wife was called at 6:45 a.m. to inform of fall but did not answer.

Review of the Grievance/complaint log for 04/23/2023 revealed no evidence of a grievance related to Patient #1.

In a telephone interview on 06/06/2023 at 2:15 p.m., complainant reported she called the facility when she got the message that Patient #1 was found unconscious with blood from pulling out his lines and feces all over him. Spoke with S4UM about the fall and wanted to speak with S1Assist. Regarding the discussion with S1Assist, she stated that S1Assist was apathetic about Patient #1's care after the fall but that he said he would file a grievance on Patient #1's and her behalf regarding her complaint about Patient #1's care after the fall. Complainant reported she has not received a phone call or letter regarding both grievances.

In an interview on 06/06/2023 at 8:30 a.m., S4UM confirmed there was no grievance filed for Patient #1 regarding the incident that occurred on 04/23/2023.

Based on record review and interview, the hospital failed to ensure written notice of a decision, in its resolution of a grievance, that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion, was received by the complainant. This deficient practice was evidenced by:
1) Failure of the hospital to ensure a written notice of the decision, in resolution of a grievance was received in 1 (#1) of 1 patients reviewed for grievances from a total patient sample of 5.
Findings:

A review of hospital policy titled "Patient Rights & Responsibilities", revealed in part: Purpose: to ensure all hospital staff and contract staff shall observe these patients' rights. Policy, in part: The statement of patient rights shall include, but is not limited to the patient's right to: be provided with a written notice of the grievance determination that contains the name of the hospital contact person, the steps taken on his/her behalf to investigate the grievance, the results of the grievance and the grievance completion date.

A review of hospital policy titled "Patient & Family Grievances" revealed, in part: The Administrative Representative will review the concern and note any additional steps taken to resolve the patient/family/representative grievance. The report is submitted to the administrator. The patient/family/representative will be kept informed of all efforts made to resolve their grievance and wool receive a written acknowledgment within 5 days of receipt from the hospital Administrator (designee). If a resolution is not reached the patient/family/representative will be informed that the hospital is still working on resolution and a written response is forth coming and will be forwarded to complainants within 30 days of original receipt of the grievance. Once a final decision is made a written response will be provided the complainant within 5 working days. The response will not exceed 30 days from the original receipt of the grievance.

Review of the hospital's complaints/grievances log revealed a grievance dated 04/20/2023 filed by Patient #1 and his wife regarding concerns about Patient #1's care and services provided during hospitalization. Staff members complained about having to provide help. Staff members discussing patient information in the hallway. Family having to deliver /bring food to facility due to not liking food provided. Female doctor telling patient to get up on his own out the bathroom. Nurse or wound care nurse wrapped foot wound with same dirty gauze.

The grievance investigation was documented by S4UM and listed the address of the person initiaing the complaint: 10707 Industrial Plex Blvd. Apt 7, Baton Rouge, LA 70809. Continued review revealed the patient was only to be assigned to charge nurse or a staff nurse at sage. The Unit manager was to check on patient when working at hospital to ensure care is provided timely. Staff education was scheduled for next unit meeting about professionalism. Further review revealed the grievance was resolved on 05/18/2023 and date of representative was notified in writing on 04/21/2023.

Review of letter dated 04/21/2023 written by S1Assist revealed a confirmation of Patient #1's feedback regarding concerns of care and service. The letter further states a review and investigation of Patient #1's concerns was underway, and that Patient #1 could expect a letter to be mailed by May 21, 2023 outlining the findings. Review of Patient #1's address written at the top of the letter was 15539 Majorie Drive, Baton Rouge, LA 70819. This was not the same address as in the grievance report.

Review of letter dated 05/18/2023 written by S1Assist revealed a letter stating the investigation was concluded and a list of 5 grievances with actions taken. Review of Patient #1's address written at the top of the letter was 15539 Majorie Drive, Baton Rouge, LA 70819. This was not the same address as in the grievance report. Attached to the letter was a certified mail receipt dated 05/18/2023 with a tracking number. Review of delivery status by surveyor using tracking number provided on certified mail receipt revealed that as of 06/07/2023 the letter had not been delivered.

In a telephone interview on 06/06/2023 at 2:15 p.m., Complainant reported that Patient #1 had a rough time from the start of rehab. On the 2nd or 3rd night Patient #1 asked for bathing wipes and was treated inappropriately for asking for wipes. An RN training a nurse told the new nurse that Patient #1 cannot get up and he should be left in bed. Just leave him there she said. He was kept confined with no physical therapy. S1Assist gave her his cell phone number in case she had questions and she believes he blocked her calls. Complainant stated she has not received anything, not a phone call or letter from S1Assist.

In an interview on 06/06/2023 at 3:00 p.m., S1Assist stated he did not follow-up on the certified letter when he did not receive a delivery receipt. S1Assist reported that he did not track the letter or try contacting Patient #1 or his wife by phone or email to confirm that the letter was received and that the grievance was resolved. S1Assist reported he did not realize the address on the letter was different then the address on the grievance.

Based on record reviews and interviews, the hospital failed to ensure the patient or her representative had the right to make informed decisions regarding her care. This deficient practice is evidenced by failing to have documented evidence of a physician discussion with the patient, the family member/legal representative, or agent and/or her family regarding a PICC insertion order and the decision to have the PICC inserted in 1 (#5) of 5 (#1-#5) patient records reviewed.
Findings:

Review of hospital policy titled "Informed Consent" revealed, in part: Procedure, in part: In the case of procedures/treatments authorized to be perfomed by a clinician who is not a physician the clinician performing the procedure will obtain informeed consent. The informed consent will include: explanation of patients current medical condition requiring procedure or treatment, the risks and benefits and alternatives to the procedure or treatment and the risks and benefits of those alternatives, the opportunity to ask questions and be provided a resposne to those questions.

Review of Patient #5's medical record revealed patient admitted on 05/25/2023 with Anoxic Brain Injury following cardiac arrest and PEA. Further review revealed provider assessment indicating Patient #5 was unresponsive 2/2 ventilator.

Review of Physician orders dated 05/26/2023 at 10:30 a.m. revealed an order for PICC line on Patient #5.

Review of PICC Insertion Record dated 05/26/2023 at 12:05 p.m. revealed a PICC line was inserted into the brachial vein of the right arm of Patient #5 at 12:00 p.m.

Review of Patient #5's medical record revealed an Informed Consent Special Procedure-PICC/Midline document dated 05/26/2023 at 12:00 p.m. Further review revealed a section on the document: "I have explained the matters indicated above relating to the procedure, local analgesic and the risk, consequences and alternatives. The patient and/or the relative indicated understanding and consented to the procedures described above." Further review failed to reveal evidence of a signature by the physician indicating that the physician did explain the matters indicated relating to the procedure, local analgesic and the risk, consequences and alternatives and that the patient and/or the relative indicated understanding and consented to the procedures described above. Continued review revealed a "patient or legally responsible person" signature line with "Verbal Consent from patient" written on signature line.

In an interview on 06/05/2023 at 9:45 a.m., S4UM confirmed there was no evidence of a physician signature indicating that the matters relative to the PICC procedure were explained to the patient.

Based on record review and interview, the hospital failed to ensure patients received care in a safe setting as evidenced by failure to activate the bed alarms of 2 (#1 and #4) of 5 (#1-#5) high fall risk patients sampled. This deficient practice may have contributed to falls in Patients #1 and #4.
Findings:

Review of hospital policy titled "Fall Precautions" revealed, in part: Policy, in part: 3. A patient is considered to be AT RISK for falls if she/he meets any one of the following criteria: b. is mobile and also cognitively impaired. Procedure, in part: 5. Observations for risk factors shall also occur, in part: ii. On a daily basis, and iii. As needed, whenever there is a change in a patient's condition/ status. 8. Initiation of Fall Risk orders to include, in part: iii. Initiation of bed/chair alarm.

Review of hospital policy titled "Application of Wheelchair and bed Alarms", in part: Procedure, in part: 2. The RN will determine the need, based on the comprehensive admit assessment, for a bed or chair alarm. 3. If a staff member witnesses a patient performing an activity (Getting out of bed without assistance), that compromises the Patient's safety, the fall prevention protocol is implemented. A bed or chair alarm may be applied at this time and the patient and family are educated on safety measures.

Patient #1
A review of Patient #1's medical record revealed a Daily Nursing Assessment dated 04/22/2023. Further review revealed the following entries:
12:30 a.m.: Patient sitting up on side of bed, asked patient if he needed anything and he said "yes". Nurse asked what he needed and he requested his wheelchair. Nurse told patient he was going to use the bedpan instead since he was having so much difficulty. Patient was having difficulty with following commands and was only focused with trying to sit up on side of bed. When asked why he wants to he stated, "I don't know", patient states he will sit on side of bed all night and bed alarm was turned on.
1:15 a.m.: Bed alarm sounded, patient still on side of bed but on very edge, asked patient to get in bed and try to rest because he had not slept yet, patient finally agreed and laid in bed. This entry failed to reveal evidence that the bed alarm was re-activated.
3:15 a.m.: Patient called and CNA entered room to answer, she came to get nurse and said he would not say what he wanted. Upon seeing the patient, he was again sitting on edge of bed but did not know what he called for. Patient was repositioned back in bed and asked again what he called for he then said he wanted a shake. Bed in lowest position, call light in reach, safety maintained. This entry failed to reveal evidence that the bed alarm was re-activated.
5:05 a.m.: Patient found lying half off bed with legs hanging on side of bed and brief off with milkshake spilled on floor, patient linens changed and floor cleaned and patient placed back in bed. This entry failed to reveal evidence that the bed alarm was re-activated.

In an interview on 06/06/2023 at 1:05 p.m., S4UM confirmed that there was no documented evidence that Patient #1's bed alarm was activated as per hospital policy to prevent falls. S4UM reported that the bed alarm should have been activated because the patient was cognitively impaired and at high risk for falls.

Patient #4
Review of Patient #4's Daily Nursing Assessment dated 05/31/2023 revealed special precautions, bed alarm. Further review of fall risk assessment revealed Patient #4 was high risk for falls.

Further review of Patient #4's Daily Nursing Assessment dated 05/31/2023 revealed the following entries:
8:15 a.m.: Respiratory therapist at bedside. This entry failed to reveal evidence that the bed alarm was activated.
9:30 a.m.: To room to administer patient scheduled medication. Patient found sitting on floor. Doctor at beside. Patient assessed per MD. Patient assisted back to bed. No injury noted. This entry failed to reveal evidence that the bed alarm was activated.
10:00 a.m.: Patient in chair at nurses' station.
12:15 p.m.: Patient back to bed. No acute distress noted. This entry failed to reveal evidence that the bed alarm was activated.
1:30 p.m.: Resting with eyes closed. No acute distress. This entry failed to reveal evidence that the bed alarm was activated.
2:30 p.m.: Call to room per respiratory therapist. Patient on floor near bed. Patient said he was trying to go outside to smoke. Patient placed back to bed per help of other nursing staff. This entry failed to reveal evidence that the bed alarm was activated.

In an interview on 06/06/2023 at 11:45 a.m., S4UM stated that the if the bed alarm had been on it would have alerted staff both times that the patient was attempting to get out of bed.

Based on observation, record review and interview, the hospital failed to ensure patients had the right to be free from restraints. This deficient practice is evidenced by:
1) The hospital staff pre-meditatively ordering restraints in the morning for the evening shift before determining the need for restraints for 1 (#5) of 1 patients sampled for restraint use.
2) The hospital's unwarranted use of restraints on Patient #5 on 06/05/2023, 06/04/2023, 06/03/2023, 06/02/2023, 06/01/2023, 05/31/2023, 05/29/2023, 5/28/2023 , 05/27/2023, 05/26/2023, and 05/25/2023.
Findings:

A review of hospital policy titled "Restraints" revealed, in part: Policy, in part: The hospital utilized the lease restrictive measures for patient safety. B. The hospital recognizes that all patientgts have the right to be free from physical or mental abuse, and corporal punishment. E. Restraints will only be used when less restrictive interventions have been determined to be ineffective to protect the patient. F. Restraint use will only be imposed upon receipt of appropriate physician orders or other licensed independent practitioner, when needed to ensure the immediate physical safety of the patient, a staff member, or others and will be discontinued at the earliest time possible. I. Restraint orders will not be written or accepted as aPRN or standing order. Procedure, in part: A. Indications, in part: Prior to the initiation and/or continued use of a restraint in acute medical and surgical care as a measure to prevent patient injury, the patient must be assessed and assessment documented as to the need for restraints and risks associated with the behaviors that indicate the need for restraints. Orders, in part: Restraint use will be initiated upon the order of a Physician or other Licensed independent practitioner who is responsible for the care of the patient and authorized to order restraints. Continuation of Restraint orders, in part: the attending physician or other licensed independent practitioner who is responsible for the care of the patient will perform in-person assessments of a restrained patient at least once every 24 hours, at which time restraint will either be reordered or discontinued as indicated.

1) The hospital staff pre-meditatively ordering restraints in the morning for the evening shift before determining the need for restraints for 1 (#5) of 1 patients sampled for restraint use.
A review of Patient #5's medical record on 06/06/2023 at 9:00 a.m., revealed restraint order sheet dated 06/06/2023 at 5:05 p.m. The restraint order sheet indicated the patient was uncooperative, attempting to remove trach, tubes, IVs catheters, etc. The restraint sheet further indicated alternatives to restraints tried including educating the patient, repositioning and increased observation. Further review of restraint order sheet revealed the steps of the restraint procedure were completed. Continued review failed to reveal a physician signature although the line for the signature dated 06/06/2023 and timed: 5:05 p.m. The nursing signature/RBVO signature line dated 06/06/2023 and timed: 5:05 p.m.

In an interview on 06/06/2023 at 10:00 a.m., S4UM stated a pre-written restraint order should not have been completed without Patient #5 exhibiting high safety-risk behaviors necessitating the use of restraints and without an in-person assessment of a practitioner.

2) The hospital's unwarranted use of restraints on Patient #5 on 06/05/2023, 06/04/2023, 06/03/2023, 06/02/2023, 06/01/2023, 05/31/2023, 05/29/2023, 5/28/2023 , 05/27/2023, 05/26/2023, and 05/25/2023.
Observation of Patient #5 on 06/06/2023 at 8:55 a.m. revealed patient on a ventilator, sleeping, no movement, does not open eyes on command. Patient #5 was in restraints.

A review of provider notes dated 06/05/2023-05/27/2023 revealed patient was either calm and in no distress, or sleeping. No evidence of agitation or high-risk behaviors documented in provider notes.

A review of Patient #5's medical record revealed Patient #5 admitted on 05/25/2023 at 6:00 p.m. Further review revealed restraint orders written on the following dates and times: 06/06/2023 at 5:05 p.m.; 06/05/2023 at 5:10 p.m.; 06/04/2023 at 5:15 p.m.; 06/03/2023 at 5:20 p.m.; 06/02/2023 at 5:25 p.m.; 06/01/2023 at 5:30 p.m.; 05/31/2023 at 5:35 p.m.; 05/29/2023 at 5:40 p.m.; 5/28/2023 at 5:50 p.m.; 05/27/2023 at 5:55 p.m.; 05/26/2023 at 6:00 p.m.; and 05/25/2023 at 8:45 p.m.

In an interview on 06/06/2023 at 10:00 a.m., S4UM confirmed that Patient #5 had been in restraints since admission and that documentation does not reveal evidence that restraint use was warranted every day since admission.

Based on record review and interview, the hospital failed to ensure an effective system was in place to ensure that each physician/practitioner providing services in the hospital was credentialed as evidenced by failing to credential the attending physician for 12 of the 12 patients on the census.
Findings:

A review of hospital policy titled "Medical Staff Credentialing and Privileging" revealed, in part: Policy: As defined in our facility's medical staff bylaws, policy and procedures, and current federal and state rules and regulations, physicians and dentists wishing to treat patients in our facility must have a medical staff appointment and appropriate clinical practice privileges. 4. Temporary Privileges, in part: c., in part: temporary privileges are granted for a period not to exceed ninety days.

Review of S6MD's personnel file on 06/05/2023 revealed date of hire 01/06/2023. Further review revealed a document titled "Temporary Privileges Request" dated 01/06/2023 for Sage Specialty Hospital and signed by S6MD. The document stated that S6MD's temporary privileges were approved for a period not to exceed 120 days although the policy states temporary privileges are granted for a period not to exceed 90 days. Continued review of S6MD's personnel file fail to reval an approved Privileges Request document.

In an interview on 06/05/2023 at 2:45 p.m. S1Assist confirmed that S6MD's temporary privileges were no longer valid and S6MD was not credentialed to practice at Sage Memorial Hospital.

Based on record review and interview the registered nurse failed to supervise and evaluate the nursing care of each patient. This deficiency is evidenced by:
1) Failure of nursing staff to document a post-fall assessment in 1 (#1) of 5 (#1-#5) patients sampled.
2) Failure of nursing staff to notify physician/provider, the patient's family, and Administration on call immediately after a fall in 1 (#1) of 5 (#1-#5) patients sampled.
3) Failure of nursing staff to address abnormal vital signs in 1 (#1) of 5 (#1-#5) patients sampled.
Findings:

1) Failure of nursing staff to document a post-fall assessment in 1 (#1) of 5 (#1-#5) patients sampled.
Review of hospital policy titled "Fall Precautions" revealed, in part: Procedure, in part: 9. Any time a patient may fall the following actions are to be taken: a. Assess the patient's physical condition post fall, by Registered Nurse. DO NOT attempt to move the patient if a head, neck or spine trauma is suspected.

A review of Patient #1's nurses noted dated 04/22/2023 at 5:05 a.m. (04/23/2023) revealed the following documentation as written by the nurse: Pt found laying half off bed, with legs hanging on side of bed and brief off with milkshake spilled on floor. Pt linens changed and floor cleaned and pt placed back in bed. 5:08 a.m: Pt found sitting on side of bed, bed alarm on, safety maintained. 6:10 a.m.: Report given to RN. Further review of nurses note dated 04/22/2023 failed to reveal a post-fall assessment.

In an interview on 06/06/2023 at 12:31 p.m., S4UM confirmed that Patient #1's nurse's note dated 04/22/2023 failed to reveal evidence of a post-fall assessment immediately following Patient #1's fall at 5:05 a.m. on 04/23/2023.

2) Failure of nursing staff to notify physician/provider, the patient's family, and Administration on call immediately following a fall in 1 (#1) of 5 (#1-#5) patients sampled.

Review of hospital policy titled "Fall Precautions" revealed, in part: Procedure, in part: 9. Any time a patient may fall the following actions are to be taken: d. Notify the physician, the patient's family, and Administration on call.

A review of Patient #1's nurses noted dated 04/22/2023 at 5:05 a.m. (04/23/2023) revealed the following documentation as written by the nurse: Pt found laying half off bed, with legs hanging on side of bed and brief off with milkshake spilled on floor. Pt linens changed and floor cleaned and pt placed back in bed. 5:08 a.m: Pt found sitting on side of bed, bed alarm on, safety maintained. 6:10 a.m.: Report given to RN. Further review of nurses note dated 04/22/2023 failed to reveal the physician, the patient's family, and Administration on call were immediately notified of Patient #1's fall.

In an interview on 06/06/2023 at 12:31 p.m., S4UM confirmed that Patient #1's nurse's note dated 04/22/2023 failed to reveal evidence that the physician, the patient's family, and Administration on call were immediately notified following Patient #1's fall at 5:05 a.m. on 04/23/2023.

3) Failure of nursing staff to address abnormal vital signs in 1 (#4) of 5 (#1-#5) patients sampled.

A review of hospital policy titled "Vital Sign Policy" revealed, in part: Vital signs and Sepsis Screening: Reporting and interpretation of vital signs may be used a screening tool for sepsis. The following vital signs with known or suspected infection should be discussed with the Physician/LIP. Systolic blood pressure <90 mmHg. Systolic blood pressure decreases >40 mmHg from baseline. Heart rate >90 bpm. Respiratory rate >20/min. When to Notify the PHYSICIAN/LIP: Unless otherwise ordered, notify the Physician/LIP if the following occurs: Systolic blood pressure greater than 40 mmHg from baseline. Heart rate greater than 120 bpm. Rn is to assess Patient experiencing the above.

Review of Patient #4's medical record revealed admission date: 04/15/2023. Further review revealed a sputum culture report dated 05/24/2023 with MRSA and E. Coli isolates noted.

Review of Patient #4's Vital Signs Records revealed vital signs dated 05/31/2023 at 2:00 p.m. The measurements documented read: Blood Pressure 72/33. Pulse 125. Respirations 22.

Review of Patient #4's medical record failed to reveal the above vital signs were discussed with a physician/LIP.

In an interview on 06/06/2023 at 11:50 a.m., S4UM confirmed that Patient #4's medical record failed to reveal evidence that the abnormal vital signs documented on 05/31/2023 at 2:00 p.m. were discussed with a physician/LIP.

Based on record review and interview, the hospital failed to ensure all hospital orders were signed, dated and timed by the physician or licensed practitioner. This deficient practice was evident for 1 (#1) of 5 (#1-5) open medical records reviewed for unsigned, dated and timed orders.
Findings:

A review of hospital policy titled "Acceptance of Physician's Telephone/Verbal Orders", revealed, in part: B., in part: 3. Verbal/Telephone orders are to be co-signed by the Physician as soon as possible or at least within 10 days.

A review of Patient #5's medical record revealed a verbal order for a PICC line with procedural instructions dated 05/26/2023. Further review failed to reveal the physician signed the verbal order.

In an interview on 06/06/2023 at 10:30 a.m., S4UM confirmed there was no physician signature and stated the physician should have signed within 10 days per policy.

Based on record review and interview the hospital failed to provide for the nutritional needs of the individual patient in accordance with recognized dietary practices. This deficiency is evidenced by the failure of the hospital to provide a special diet for 2 (#3 and R1) of 2 (#3 and R1) patients reviewed with orders for a therapeutic diet.
Findings:

Review of hospital policy titled "Meal Service" revealed, in part: 1. Patient meals may be provided through a contract service or employed staff.

Review of hospital contracted services revealed dietary services provided by group 'a'. Further review revealed a signed contract between hospital and group 'a'.

A review of hospital policy titled "Nutritional Services" revealed, in part: Policy, in part: 3. The registered dietician will check patient food portions on a random basis to ensure adequate nutrition for the patient population. 4. Patient food trays will be prepared by the Dietary Department according to Physician Orders.

A review of group 'a' policy titled "Professional Staffing" revealed, in part: The dining services department will employ sufficient staff, with appropriate competencies and skills sets to carry out the functions of food and nutrition services, taking into consideration the resident assessments, individual plans of care and the number, acuity and diagnosis of the resident population. Procedures, in part: 1., in part: The qualified dietitian, other clinically qualified nutrition professional, will provide guidance and oversight to the Dining Services department for the consistent preparation and service of all regular and therapeutic diets.

A review of R1's meal ticket on 06/05/2023 at 12:00 p.m. revealed R1 was on a CCD (Carbohydrate Consistent Diet). Review of the portions listed on the ticket revealed 2 cups Red beans and Sausage. 1 cup White Rice.

A review of Patient #3's meal ticket on 06/05/2023 at 12:00 p.m. revealed Patient #3 was on a CCD (Carbohydrate Consistent Diet). Review of the portions listed on the ticket revealed 2 cups Red beans and Sausage. 1 cup White Rice.

In an interview on 06/05/2023 at 12:05 p.m., C3CNA stated she noticed that all the meals lately have consisted of a regular diet for every patient.

In an interview on 06/05/2023 at 12:30 p.m., S4UM stated that the portion sizes on the meal trays of Patient R1 and Patient #3 were double the size they should be for a Carbohydrate Consistent Diet. The Red beans and sausage should be 1 cup and the rice should be ½ a cup.

In an interview on 06/05/2023 at 3:30 p.m. S5DT agreed that the portion sizes on the meal trays of R1 and Patient #3 were double the appropriate size for a Carbohydrate Consistent Diet. S5DT reported the diabetic patient should not be served food trays containing a regular diet.

Based on record review and interview the hospital failed to appoint an Infection Control Director as evidenced by the hospital having no documentation of appointment by the governing body.
Findings:

A review of the hospital's organizational chart revealed S7IC as Infection Control Consultant.

A review of Governing Body minutes failed to reveal evidence that the governing body appointed an Infection Control Professional to be responsible for the infection prevention and control program.

In an interview on 06/06/2023 at 3:35 p.m., S1Assist stated that the hospital's governing body did not formally appoint an Infection Control Professional.

Based on record review and interview, the hospital failed to demonstrate that an individual (or individuals), who is qualified through education, training, or experience in infectious diseases and/or antibiotic stewardship, is appointed by the governing body as the leader(s) of the antibiotic stewardship program and that the appointment is based on the recommendations of medical staff leadership and pharmacy leadership. This deficient practice is evidenced by the hospital failing to have documentation of an appointment by the governing body.
Findings:

A review of Governing Body minutes failed to reveal evidence that the governing body appointed an Infection Control Professional to be responsible for the Antibiotic Stewardship program.

In an interview on 06/06/2023 at 3:35 p.m., S1Assist stated that the hospital's governing body did not formally appoint an Infection Control Professional to be responsible for the Antibiotic Stewardship program.

Based on record review and interview, the hospital failed to provide an antibiotic stewardship program that adhered to nationally recognized guidelines, as well as best practices, for improving antibiotic use. This deficient practice is evidenced by the hospital failing to appropriately dose 2 antibiotics in 1(#1) of 1 patient sampled for antibiotic stewardship program adherence.
Findings:

Review of hospital policy titled "Antibiotic Stewardship Program" revealed, in part: Policy, in part: The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Definitions: Antibiotic Stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. 1. This is accomplished through improving antibiotic prescribing, administration, and management practices thus reducing inappropriate use to ensure that residents receive the right antibiotic for the right indication, dose, and duration.

Review of provider discharge summary dated 04/24/2023 and Progress note dated 04/22/2023 revealed patient was to have his medications "renally dosed" due to a diagnosis of kidney disease and up trending creatinine.

Review of Patient #1's lab work dated 04/17/2023 revealed BUN 88 (reference 7-18) Creatinine 2.45 (reference 0.70-1.30) and eGFR 31 (reference 60-120).

Review of Patient #1's medication administration record dated 04/23/2023 revealed patient was receiving Daptomycin 582 mg intravenously at bedtime. Review of Federal Drug Administration recommendations revealed a renal dose of Daptomycin is 4 mg/ kg every 48 hours.

Continued review of Patient #1's medication administration record dated 04/23/2023 revealed patient was receiving Cefepime 2 gm intravenously every 8 hours. Review of Federal Drug Administration recommendations revealed a renal dose of Cefepime is 2 gm every 24 hours.

In an interview on 06/06/2023 at 1:40 p.m. S4UM stated she did not know why the medications were not changed to renal doses.