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Based on record review and interview, hospital failed to ensure the members of the medical staff were accountable to the Governing Body for quality of care provided to patients as evidenced by medical staff members not assessing and pronouncing death for 5 of 5 (#26, #27, #28, #29, #31) sampled patients reviewed for pronouncement of death by a medical staff member, from a total sample of 31.
Findings:

Review of the Medical Staff By-Laws, Rules & Regulations, provided by S8Quality as current, revealed in part the following: " ... 3.2 Who May Admit: A patient may be admitted to the hospital only by a member of the Medical Staff with appropriate privileges who shall be responsible for the care of any medical problem that may be present at the time of admission, or that may arise during hospitalization ... 3.4 Medical Responsibility: A. A member of the Medical Staff shall be responsible for the overall planning and continuity of medical care and therapy of each patient in the hospital, for the prompt completeness and accuracy of the medical record, for necessary special instructions, and for transmitting reports of the condition of the patient to the referring practitioner and to relatives of the patient ...Article II: Patient Death 4.1 Pronouncement A ... The body shall not be released from the hospital until the physician has made an entry in the progress notes noting the date and time of death.


Review of hospital policy #NSG-141 titled "Pronouncement of Death and Post Mortem Care", provided by S3Infection Control as current, revealed in part the following: Two registered nurses would perform an assessment to confirm that the patient was without signs of life, and what signs of life were to be included in the assessment. The Registered Nurse was to call the attending Physician, or his designee. "After the attending physician or his designee (who is also a credentialed physician on the medical staff) pronounces the patient is dead, notify family and LOPA." Further review revealed the policy instructed if the patient was a hospice patient, the hospice nurse was responsible for pronouncement of death, family notification, coroner notification, and LOPA notification. Further review revealed the Body Release form was to be signed by the funeral home representative upon release of the body from the hospital. Charting was to include, in part, who pronounced death, time of death, Items given to the family, items sent with the deceased (such as dentures), and the date and time the deceased was released to the funeral home and personal items sent with the funeral home.

Patient #26
Review of the medical record for Patient #26 revealed he was admitted 10/19/19 at 8:35 p.m. for Inpatient Hospice Care. Further review revealed nursing notes by S LPN as follows:
10/21/18 at 11:30 p.m.: Vital signs ceased. (Hospice company) called to notify.
10/21/18 at 11:40 p.m.: Contact made with Nurse from (Hospice Company). Stated she would be here shortly.
10/22/18 at 1:45 a.m.: Nurse (from hospice company) arrived on unit. Proper forms given to be completed; no family at bedside.
10/22/18 at 3:01 a.m.: Paperwork completed by (Hospice Company Nurse) nurse with (Hospice Company). Post Mortem Care completed.
10/22/18 at 3:30 a.m.: Remains sent to Morgue
Further review of the record revealed no nursing notes of the presence of a physician from the medical staff arriving to assess and/or pronounce the death of the patient.
Review of a "Notice of Death" form revealed the area for "Pronounced Dead by:" was blank. Further review revealed the coroner was notified by the Hospice Company LPN, as well as the patient's family.
Review of physician progress notes revealed a note dated 10/19/18 (no time) with a brief history and Physical. Another entry on the physician's progress note (no time of entry) read: "10/22/18 Pt. expired. TOD 1:30 a.m." The entry was signed by a member of the medical staff.

Patient # 27
Review of the medical record for Patient #27 revealed she was admitted 12/07/18 at 8:30 p.m. to S21MD for Inpatient Hospice care. Review of a Notice of Death form revealed she expired 12/07/18 at 11:30 p.m. and her death was pronounced via phone by a coroner's office staff member when notified by the Hospice company RN.

Patient # 28
Review of the medical record for Patient 28 revealed he was admitted 11/28/18 at 10:40 p.m. for inpatient hospice care. Review of nursing notes revealed the following on 11/29/18 -time illegible-Family requesting nurse states pt. not breathing or with pulse. RN at bedside assessed pt. Pt without pulse or respiratory rate. Unable to auscultate heart sounds. Hospice nurse and M.D. notified. 1:21 p.m.: Hospice nurse at bedside. 1:30 p.m.: Pt pronounced. TOD (time of death) 1:30 p.m. 4:00 p.m.: Funeral home here to pick up body. Further review revealed no documentation of an assessment by a physician, who pronounced death., or an entry by a staff physician regarding the pounce of death.

Patient # 29
Review of the medical record for Patient #29 revealed she was admitted 11/13/18 at 3:00 p.m. for inpatient hospice care. Review of Nursing notes revealed an entry 11/14/18 at 9:25 a.m. that documented, "Patient has no pulse. Hospice associate notified." No further notes or documentation was found regarding a pronouncement of death. Review of an electronic document titled "Final Report" authored by S23MD documented, in part, "The patient was placed on comfort care measures. He subsequently passed prior to a full face-to face history and physical was able to be performed." No documentation of the physician assessing and pronouncing the death of Patient #29 was found on the medical record.

Patient #31
Review of the medical record for Patient #31 revealed he was admitted 03/09/18 at 7:30 p.m. to S21MD for inpatient hospice care. Further review of the medical record revealed a notice of death form completed by S5RN which documented the patient's death 03/10/18 at 6:50 a.m. and pronounced by the hospice RN and a parish coroner's staff member via phone. Family notification was documented on the Notice of death form to have been completed via phone by the hospice nurse.

In an interview 12/12/18 at 10:28 a.m. S5RN reported the hospital admits hospice patients for the contracted hospice companies. She reported the care of the patient is accomplished by both the hospice nurse and hospital staff. The RN further reported hospital staff administers medications to hospice patients, and provides care such as vital sign assessments, comfort measures such as respiratory suctioning, and hygiene. The charge RN reported that when a patient expires the nurse on call for the hospice company the patient is registered with is notified, and the hospice nurse comes to the hospital to assess the patient and calls the coroner for a pronouncement over the phone. S5RN reported the hospice nurse, either an RN or an LPN coordinates the disposition of the body, usually to a funeral home, and if it is going to be awhile, the hospital staff takes the body to the host hospital's morgue, then they wouldn't have any paperwork regarding who picked-up the body or when.

In an interview 12/12/18 at 3:45 p.m. S7RN, who had reviewed the records with this surveyor, verified the above noted findings. She reported that when the hospital has hospice patients, the staff provides basic care such as medication administration, comfort measures, hygiene, and such, but that when the patient expires the hospice nurse is called and she handles the notification of the coroner for pronouncement of death and coordinates the disposition of the body. She reported the deaths are not usually pronounced by a hospital medical staff member. S7RN reported no one from the coroner's office was credentialed or privileged by the hospital.

Based on record review and interview, the governing body failed to ensure that patient services performed under contract were provided in a safe and effective manner independent of the host hospital. This deficient practice is evidenced by failing to ensure contracted services were not provided by staff concurrently working at the host hospital (Host Hospital "B") for in-patient hospital emergency services (Rapid Response Team and Code Blue Team) at the off-site location.
Findings:

Bridgepoint Continuing Care Hospital has 2 campuses. The main campus is located on the 7th floor of Host Hospital "A". The off-site campus is located on the 5th floor of Host Hospital "B".

A review was made of the contract between Bridgepoint Continuing Care Hospital and Host Hospital "B". The contract revealed in part:
3.1 Extent of Services: At the request of Hospital, Contractor agrees to provide the Services, as set forth in Attachment A to this Agreement, of the same quality and to the same extent that such Services are provided to Contractor's patients.
Attachment A revealed in part:
6. Code Coverage and other Emergency Services.

Review of the policy titled St. Theresa Specialty Hospital CODE BLUE, presented as current policy for Host Hospital "B" revealed in part, should a cardiac/respiratory arrest occur on the unit and BLS/ACLS is deemed appropriate, a general Code Blue call will be initiated.
Procedure for initiating Code Team includes the Code Team is notified by activating the "CODE" button above the patient's bed or dialing Host Hospital "B"s operator extension.

On 12/10/18 at 2:20 p.m. in an interview with S2COO revealed as part of their contract, the off-site campus of Host Hospital "B" uses the emergency response team (Code) team, which is staffed by Host Hospital "B" to respond to an emergency patient situation at Bridgepoint Continuing Care Hospital's off-site campus.

On 12/11/18 at 8:07 a.m. in an interview with S16RN, he said in the case of a declining status of a patient on the unit, a Rapid Response or a Code Blue would be called. The Rapid Response/ Code Blue team consists of Host Hospital "B" staff members (Respiratory Therapist, Anesthesiologist, Cardiologist, Certified Registered Nurse Anesthetist, Intensive Care Unit nurse, and nursing supervisor).

Based on record reviews and interviews, the hospital failed to ensure the patient or his/her representative had the right to make informed decisions regarding his/her care as evidenced by:
1) Failing to have documented evidence of a discussion with a patient or his/her family regarding the blood transfusion order and the decision to have the blood transfusion order written in accordance with hospital policy for 1 (#18) of 1 patient record reviewed with an order for blood transfusion from a sample of 31 patients.
2) Failing to have documented evidence of a discussion with a patient or his/her family regarding consent for treatment for 3(#5, #15, #19) of 5 (#5, #15, #18, #19, #22) patient records reviewed for treatment consents from a sample of 31 patients.
3) Failing to have documented evidence of a discussion with a patient or his/her family regarding consent for video monitoring.
4) Failing to honor a patient's request not to have video monitoring.

Findings:

1) Failing to have documented evidence of a discussion with a patient or his/her family regarding the blood transfusion order and the decision to have the blood transfusion order written in accordance with hospital policy for 1 (#18) of 1 patient record reviewed with an order for blood transfusion from a sample of 31 patients.

Review of hospital policy titled Consent for Medical Treatment presented as current policy revealed in part the responsible practitioner shall obtain an informed consent when he/she plans to perform any of the following procedures: All special interventions and/or procedures approved by Louisiana Continuing Care Hospital Medical Staff inclusive of Blood and Blood Product transfusions.

Review of hospital policy titled Blood Transfusion presented as current policy revealed in part, consent for transfusion of blood/blood products shall be signed by the patient or responsible party, witnessed and placed in the patient's chart once order is obtained. Further review revealed under Pre-transfusion: Consent for Transfusion indicates the patient or appropriate surrogate is informed of the risks and benefits of transfusion. Consent for the patient or appropriate surrogate signs transfusion of Blood and/or Blood Products, witnessed and placed in the patient's chart.

Review of the Rules and Regulations of the Medical Staff, provided by S8Quality as current, revealed in part, under 8.2 Blood Transfusions "Whenever a non-emergent blood transfusion is given; informed consent shall be provided in accordance with policy. It should include the rationale for the use of the particular blood component given."

Patient #18
Review of Patient #18's medical records revealed he was an 80-year-old admitted on 11/16/18 with a diagnosis of Bacteremia and Left Pelvis Fracture.

Further review of the medical record revealed a verbal order on 11/23/18 at 8:15 a.m. to transfuse one unit of PRBC (packed red blood cells) over 2 hours.

Further review of the medical record revealed the blood transfusion started on 11/23/18 at 6:20 p.m. and the transfusion completed on 11/23/18 at 9:25 p.m.

On 12/11/18 at 12:00 p.m. S15RN reviewed Patient #18's entire medical record and verified there was no consent for transfusion of blood in the medical record.


2) Failing to have documented evidence of a discussion with a patient or his/her family regarding consent for treatment for 3 (#5, #15, #19) of 5 (#5, #15, #18, #19, #22) patient records reviewed for treatment consents from a sample of 31 patients.

Review of hospital policy titled Consent for Medical Treatment presented as current policy revealed in part the purpose is to assure that the patient has opportunity for reasonable and informed participation in decisions involving his/her health care including collaboration with his/her physician in making these decisions.
The definition of informed consent is a consent obtained from the patient after being informed of the nature and risks of the proposed treatment and of the possible alternatives by the attending physician.
A written consent is required for all patients in the following circumstances: Inpatient Admission - each patient/legal representative seeking admission shall sign the admission consent for treatment form. By signing the bottom of this form, it indicates that they received all of the following items: Patient Rights; Advanced Directive Information; and Patient/Family Education Handbook.

Patient #5
On 12/10/18 at 3:50 p.m. a review of Patient #5's medical record revealed an admission date of 12/5/18 with a diagnosis of osteomyelitis.

Further review of Patient #5's medical record failed to reveal a signed consent for treatment on page 3 of 42.

In an interview on 12/10/18 at 3:50 p.m. S7RN verified the above findings after reviewing Patient #5's electronic and paper medical records.


Patient #15
A review of Patient #15's medical record revealed he was a 53-year-old admitted on 12/05/18 with a diagnosis of Acute Respiratory Failure.

Further review of Patient #15's medical record revealed no inpatient admission consents in the medical records.

On 12/11/18 at 9:00 a.m. in an interview with S16RN, in the presence of S15RN revealed S16RN stated he admitted Patient #15 on 12/05/18 and he verified there is no inpatient admission consent in the medical record of Patient #15.

Patient #19
A review of Patient #19's medical record revealed she was an 89-year-old admitted on 10/22/18 with a diagnosis of Sepsis.

Further review of Patient #19's medical record revealed no inpatient admission consents in the medical records.

On 12/11/18 at 12:10 a.m. in an interview with S15RN verified there was no inpatient admission consent in the medical record of Patient #19.

3) Failing to have documented evidence of a discussion with a patient or his/her family regarding consent for video monitoring.

A review of Patient #21, #23 and #24's medical records failed to reveal a signed video monitoring consent or documentation discussion and or permission within the medical record.

In an interview on 12/11/18 at 4:00 p.m. S5RN, S19UnitSec and S3Infection Control verified the patients noted above were currently being video monitored.

In an interview S3Infection Control verified the lack of documented consent for video monitoring.

4) Failing to honor a patient's request not to have video monitoring.

A review of Patient # 22's video monitoring consent revealed documentation stating the patient refused video monitoring on admit dated 11/7/18.

In an interview on 12/11/18 at 4:00 p.m. S5RN verified Patient #22 was being video monitored and the patient was now unable to give permission for video monitoring due to a change in mental status. S5RN verified Patient #22 has family, who could have given consent for video monitoring.

In an interview on 12/11/18 at 4:00 p.m. S3Infection Control verified the consent for video monitoring on admission states Patient #22 refused the video monitoring.

Based on record review and staff interview, the hospital failed to ensure radiologists providing interpretation of radiologic tests from the contracted hospital were credentialed and granted privileges to provide the services by the hospital's medical staff and governing body for 3 (S10MD, S12MD, S13MD) of 4 (S10MD, S11MD, S12MD, S13MD) contracted radiologists reviewed providing services to current hospital patients.

Findings:

Review of the hospital's current written agreement with the host hospital revealed radiology services were provided by the host hospital. There was no documented evidence in the written agreement of a provision related to the credentialing and privileging process of the radiologists.

Review of the list of credentialed/privileged physicians and practitioners, presented as current by S1CEO revealed S10MD, S12MD and S13MD were not listed as credentialed/privileged radiologists providing tele-radiology services for the hospital.

Patient#3
A review of Patient #3's medical record revealed the patient was admitted on 10/12/18 with a diagnosis of pressure ulcers. Further review revealed a Thoracic Spine x-ray was performed on 11/23/18 and read and electronically signed by S10MD.

Patient #16
A review of Patient #16's medical record revealed the patient was admitted on 12/04/18 with a diagnosis of Hemothorax (blood accumulates in the pleural cavity). Further review revealed a Chest x-ray was performed on 12/07/18 and read and electronically signed by S12MD.

Patient #17
A review of Patient #17's medical record revealed the patient was admitted on 11/03/18 with a diagnosis of Status-Post Right Femoral Fracture Repair. Further review revealed a Chest x-ray was performed on 11/05/18 and read and electronically signed by S12MD.

Patient #18
A review of Patient #18's medical record revealed the patient was admitted on 11/16/18 with a diagnosis of Bacteremia. Further review revealed an Abdominal and Pelvis CT Scan was performed on 11/24/18 and read electronically signed by S13MD.

On 12/12/18 at 9:50 a.m. in an interview S1CEO verified S10MD, S112MD and S13MD are not credentialed or privileged Radiologist by the facility.



39791

39791

Based on record review and interview, the hospital failed to ensure the nursing staff developed and kept current individualized and comprehensive care plans, addressing all active patient problems, for 6 (#6, #26, #27, #28, #29, #31) of 8 (#6, #25 #26, #27, #28, #29, #30, #31) patient records reviewed for care plans out of a total sample of 31 patients.
Findings:

Patient #6
Review of Patient #6's medical record revealed a 63-year-old admitted on 11/29/18 with a diagnosis of Acute Respiratory Failure. Further review revealed the patient is intubated and on a ventilator for respiratory support.

Review of Patient #6's current care plan with the guidance of S7RN verified ineffective airway clearance or any care plan related to mechanical ventilation were not identified as current problems to be addressed on the plan of care.


Patient #26
Review of the medical record for Patient #26 revealed he was admitted 10/19/19 at 8:35 p.m. for Inpatient Hospice care and expired 10/22/18. Further review revealed no nursing care plans in the medical record.

Patient # 27
Review of the medical record for Patient #27 revealed she was admitted 12/07/18 at 8:30 p.m. and expired 12/07/18 at 11:30 p.m. Further review revealed no documentation of nursing care plan(s).

Patient # 28
Review of the medical record for Patient 28 revealed he was admitted 11/28/18 at 10:40 p.m. for inpatient hospice care and expired 11/29/18 at 1:30 p.m. Further review revealed no documentation of nursing care plan(s).

Patient # 29
Review of the medical record for Patient #29 revealed she was admitted 11/13/18 at 3:00 p.m. for inpatient hospice care and expired 11/14/18 at 9:30 a.m. per a nursing note entry. Further review revealed no documentation of nursing care plan(s).

Patient #31
Review of the medical record for Patient #31 revealed he was admitted 03/09/18 at 7:30 p.m. for inpatient hospice care. and expired 03/10/18 at 6:50 a.m. Further review revealed no documentation of nursing care plan(s).

In an interview 12/12/18 at 3:45 p.m. S7RN, who reviewed the records with this surveyor, verified the above noted findings. S7RN reported that she had requested the full medical record and did not know why the nursing care plans were not present as part of the medical records for Patients#26, #27, #28, #29, and #31. S7RN reported there should have been care plans completed on all of the hospice patients.

Based on observation and interviews, the hospital failed to ensure medical records were stored in secure locations where they were protected from water and or fire damage as evidenced by:
1) Main campus having 12 uncovered cardboard boxes of patient records stored in a secure location with water sprinklers.
2) Off-site campus having medical records stored in an unsprinklered room.
Findings:

1) Main campus having 12 uncovered boxes of patient records stored in a secure location with water sprinklers.

On 12/12/18 at 2:30 p.m. a tour of the main campus Central Supply Storage area revealed the door was locked and contained 12 cardboard boxes of patient records boxed to be transported for offsite storage. The cardboard boxes were uncovered on a desk in a room with water sprinklers; therefore, the records are not protected from water damage.

In an interview on 12/12/18 at 2:30 p.m. S14MedRec and S2CCO verified the records were not protected from water damage.

2) Off-site campus having medical records stored in an unsprinklered room.

On 12/11/18 at 10:00 a.m. a tour of the off-site campus hospital's medical records department with S17HIM revealed medical records stored in an unsprinklered room and not protected from fire.

In an interview on 12/12/18 at 3:30 p.m. S14MedRec and S2CCO verified the records were not protected from fire damage.



39791

Based on observation and interview, the hospital failed to ensure that outdated, mislabeled or otherwise unusable drugs and biologicals were not available for patient use.

Findings:

On 12/10/18 at 11:30 a.m. an observation of a cabinet in the nurses' station revealed 1 Pro Stat Sugar Free liquid protein 30 fl. oz. bottle opened and dated 9/23/18 and 1- Pro Stat Sugar Free liquid pritein 30 oz. bottle opened and partially used without a date.

These findings were verified by S6RN.

On 12/10/18 at 11:50 a.m. a tour of the clean supply room with S7RN revealed 2 of 11 Oxepa 1.5 Calorie1 liter bottles expired on 1 August 2018.

S7RN verified the above expiration dates.

On 11:45 a.m. an observation of the wound care cart reveled 1 opened undated and partially used 30-gram tube of Collagenase Santyl.

S7RN verified the medication was opened and not dated.

Based on record review and staff interview, the hospital failed to ensure there was a Radiologist appointed by the Governing Body to supervise the Radiology Services on either a full-time, part-time, or consulting basis as evidenced by having no documentation indicating the hospital had a Director of Radiology for the hospital.

Findings:

A review of the Governing Body Minutes failed to reveal a Radiologist was appointed to supervise the Radiology Services either on a full-time, part-time, or consulting basis.

On 12/12/18 at 9:40 a.m. in an interview S3Infection Control and S1CEO confirmed the facility does not have an appointed Radiologist to supervise the Radiology Services.

38777

Based on observation, record review, and interview the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by:
1) failing to ensure the functionality of a nurse call button located on the handrails of 15 of 22 patient beds with call buttons on the hand rails at the main campus;
2) failing to ensure the functionality of a nurse call button located on the handrails of 14 of 14 patient beds with call buttons on the hand rails at the off-site campus; and
3) failing to ensure crash carts in the main campus hospital were checked daily for availability and function of equipment, supplies, and drugs, as evidenced by missing entries on the daily crash cart logs, and no suction equipment on either crash cart.

Findings:

1) Failing to ensure the functionality of a nurse call button located on the handrails of 15 of 22 patient beds with call buttons on the hand rails at the main campus.

On 12/12/18 at 8:30 a.m. an observation of the rooms with admitted patients at the main campus revealed 9 (a, b, c, d, e, h, i, k, o) out of 15 (a, b, c, d, e, f, g, h, i, j, k, l, m, n, o) beds failed to have a functioning call bell on the bed side rails.

On 12/12/18 at 9:45 a.m. an observation of the rooms with beds ready to accept patients at the main campus revealed 6 (7104, 7107, 7119, 7121, 7124 and 7125) of 7 (7104, 7107, 7108, 7119, 7121, 7124 and 7125) failed to have functioning bed rail call bells.

In an interview S9RN verified the above nonfunctioning call bells.

2) Failing to ensure the functionality of a nurse call button located on the handrails of 14 of 14 patient beds with call buttons on the hand rails at the off-site campus.

On 12/11/18 at 12:20 p.m. observation with S15RN revealed the side rail call bells do not function.

On 12/11/18 at 12:30 p.m. S15RN verified 14/14 beds have non-functioning call bells on the side rails. S16RN stated the call bells on the side rails never functioned at the hospital.

3) Failing to ensure crash carts in the main campus hospital were checked daily for availability and function of equipment, supplies, and drugs.

Review of the hospital policy #CSM 313 titled, "Agency-Code Cart Checking" revealed the following: "Purpose: To ensure a properly stocked and functional code cart is available to respond appropriately to patient code situations. Policy: Code carts will be checked daily. The daily checks will be recorded on the Crash Cart Checklist with documentation of the initials of the person performing the checks with corresponding signature ... Procedure: 1. All code carts are checked every day by the Charge Nurse or designee, utilizing the following steps: ...d. Ensure the defibrillator is readily available on top of each cart, e. Ensure that the defibrillator battery is charged ... g. user test each defibrillator h. Portable suction machine is present i. O2 tank is present and full j. Once all of the above is verified, the RN or designee will sign the checklist under the correct date and verify the lock tag number ...4. If any equipment is missing, it will be replaced immediately or the code cart will be taken out of circulation until the equipment is replaced or located and passes any relevant maintenance tests.

On 12/11/18 at 11:00 a.m. an observation of the odd room numbered hall Code Cart revealed the Daily Code Cart Checklist failed to have documentation that checks were conducted on the following dates:
September 1st,2nd, 10th, 15th, 16th, 24th, 25th, 28th-31st;
October 3rd-5th, 12th.16th, 30th, 31st;
November 3rd,4th,16th-18th, 20th-23th;
December 1st, 2nd.

In an interview 12/11/18 at 10:58 a.m. S4LPN verified the above findings.

An observation made 12/10/18 at 11:25 a.m. of the crash cart located on the hall, identified by S3Infection Control as " the even numbered hall". No suction machine or equipment was observed. A review of the "Crash Cart Daily Checklist" log revealed a page for each month. Further review revealed days with no documentation of the code cart being checked. The following months reviewed were missing documented checks:
December 2108: 3 of 9 days missing (1st, 2nd, 9th);
November 2018: 12 of 30 days missing (2nd- 4th,16th-18th,20th-23rd,28th, 30th);
October 2018: 12 of 31 days missing (2nd- 5th, 12th, 16th, 19th, 20th, 21st, 24th, 28th, 31st);
September 2018: 12 of 30 days missing (1st, 2nd, 10th, 13th, 15th, 16th, 19th, 20th, 25th, 28th-30th);
August 2018: 10 of 31 days missing (4th, 5th, 8th, 13th, 14th, 22nd, 23rd, 27th, 28th, 31st).

In an interview 12/10/18 at 11:45 a.m. S3Infection Control reviewed the log titled,
Crash Cart Daily Checklist", and verified there were days with no documentation of the code cart on the even numbered hall having been checked for the functioning and availability of emergency equipment and supplies/drugs.

In an interview 12/10/18 at 3:40 p.m. S6RN verified the hospital code carts did not have portable suction equipment. When asked about suction for emergencies that required clearing of an airway, she advised that all patient rooms had wall suction. When asked about a person that required emergency care that would include clearing an airway with suctioning not located in a patient room such as the hallway or other part of the hospital, she had no response.

In an interview 12/10/18 at 3:45 p.m. S2CCO verified all code carts should have suction equipment on it. S2CCO verified a daily check of the code cart should be done and documented, and as per the hospital policy and procedure there should be suction equipment and supplies on each cart and included in the daily checks.






39791

Based on observations, record review, and interview, the hospital failed to ensure the infection control program was implemented to prevent and control infections and communicable diseases as evidenced by:
1) failing to ensure equipment was clean to prevent infection and communicable disease; and
2) failing to ensure hand hygiene practices and sanitary environment were implemented in accordance with hospital and CDC guidelines.

Findings:

1) Failing to ensure equipment was clean to prevent infection and communicable disease.

On 11/10/18 at 11:15 a.m. a tour of the nurses' station medication area revealed a pill crusher on the counter above the medication refrigerator with white, brown and yellow substance on the portion used to crush the medication.

Further observation of the nurses' station revealed the medication refrigerator door and handle had a black and brown substance on it. The interior of the medication refrigerator contained a black substance on the gaskets and the shelving and bottom contained a brown and white substance.

S3Infection Control confirmed the findings and verified the facility does not have a policy for maintaining and cleaning the medication refrigerator.


2) Failing to ensure hand hygiene practices and sanitary environment were implemented in accordance with hospital and CDC guidelines.

Review of hospital policy titled Hand Hygiene presented as current policy revealed in part:
Hand hygiene must be performed:
b. Before direct patient contact;
e. Before contact with patient's intact skin;
h. After contact with equipment in the patient's immediate vicinity;
l. After any possible microbial contamination; and
q. Before and after all interactions with patients or their environment.

Review of the CDC's "Guideline for Hand Hygiene in Health-Care Settings" revealed hands should be washed or an alcohol-based hand rub should be used before having direct contact with patients, before inserting an invasive device (peripheral anesthesia block needle), after contact with a patient's intact skin, after contact with inanimate objects including medical equipment, and after removing gloves.

Patient #7
Patient #7 was a 75-year-old patient admitted on 11/12/18 for Cholecystitis.

Review of Patient #7's medical record revealed she was on contact isolation for a multiple antibiotic resistant bacteria to her drain.

On 12/10/18 at 11:15 a.m. an observation of Patient #7, who was on contact isolation, had her blood pressure taken at the nursing station by S20CNA. Patient #7's blood pressure was taken with the multi-patient use vital sign machine using a disposable cuff. The disposable cuff was placed back on the vital sign machine and brought into another patient's room. S20CNA did not perform hand hygiene after vital and did not clean the equipment. When S20CNA exited the room, she did perform hand hygiene or clean multi-patient use equipment.

On 12/10/18 at 11:30 a.m. in an interview with S3InfectionControl verified the findings regarding S20CNA.







39791

Based on record review and interview, the hospital failed to ensure Respiratory Care Services were under the direction of a Doctor of Medicine or Osteopathy on a full time or part time basis as evidenced by failure of the Governing Body to appoint a physician as Director of Respiratory Services.
Findings:

Review of a hospital organizational chart revealed no Respiratory Services Director listed.

Review of the hospital's provided contract list revealed no contract for a Respiratory Director.

Review of the Governing Body meeting minutes 2018 revealed no appointment of a Director of Respiratory Services.

In an interview 12/12/18 at 9:40 a.m. S18RT reported he was not sure who the Medical Director of Respiratory Services was.

In an interview 12/12/18 at 3:45 p.m. the S1CEO confirmed the hospital's Governing Board had not appointed a physician as Director of Respiratory Services.