HospitalInspections.org

Based on interview and record review, the hospital failed to submit a critical incident report to the Louisiana Department of Health regarding Patient #20. This deficient practice had the potential to affect the safety of any patients admitted to the hospital who have eloped.
Findings:

Review of a policy and procedure titled, "Incident Reporting" with an origination date of 09/2017 and last approved on 05/2023 revealed, in part, each incident report will be reviewed by the DON or designee and follow up acction and analysis/prevention will be documented.

Review of incident reports revealed an incident regarding Patient #20 who was admitted to the hospital on 02/13/2023 with a diagnosis of Bipolar Disorder, Unspecified. Further review revealed on 02/17/2023 Patient #20 eloped from the hospital via patio aa after kicking the gate open.

In an interview on 08/16/2023 at 12:20 p.m. S1Admin indicated he did not submit a self-report to the Louisiana Department of Health as per state rules and regulations.

Based on observation, interview and record review, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. This was evidenced by:
1) Failure to ensure the hospital was free of ligature risks;
2) Failure to ensure unpopulated areas of the hospital was properly secured; and,
3) Faillure to ensure door ii was locked and patio aa was secured for patients who smoked.
(See findings under Tag A0144)

Based on interview and record review, the hospital failed to meet the Condition of Participation for Utilization Review as evidenced by:
Failure to develop and implement a Utilization Review Plan and failure to establish and implement a Utilization Review Committee that included at least two practitioners.
(See findings in tag A-0654).

Based on record review and interview, the hospital's governing body failed to ensure the appointment and re-appointment of members of the medical staff for the hospital and the hospital's offsite location in accordance with the medical staff bylaws. This deficient practice is evidenced by failure to approve appointments for Medical Director for 2 (S7MD and S8MD) of 2 (S7MD and S8MD) physicians reviewed for appointment to Medical Director.
Findings:

Review of the Medical Staff By-Laws, 8.3, revealed, in part: Duration of Appointment and Reappointment. Except as otherwise provided in these bylaws. Initial appointments to the Medical Staff shall be provisional and for a period of two (2) years. Reappointments shall be for a period of up to two (2) Medical Staff years.

Review of Medical Staff By-Laws, 15.1.3, revealed, in part: Nominations, in part: The Nominating Committee, which shall consist of the Medical Director and on Active Medical Staff, shall nominate a slate of candidates for the Medical Director position to be chosen by election at the annual meeting.

Review of Unit A's Organizational Chart revealed Medical Director/Laboratory Director was S8MD.
Review of Unit B's Organizational Chart revealed Medical Director of Physical Medicine was S7MD.

Review of S8MD's credentialing file revealed a blank Louisiana Standardized Credentialing Application except for a Social Security Number on page 1, "Yes/No" answers to General Questions on page 9, and an Original Attestation Date 07/20/2019 with a signature. Further review revealed a document titled "Re-appointment to Medical Staff" indicating Active Privileges dated 08/01/2021 and signed by S27MBC and S28GBC.

Review of S8MD's credentialing file failed to reveal a reappointment to medical staff or an appointment to Medical Director.

A review of S7MD's credentialing file revealed a document dated 09/10/2019 titled "Re-Appointment to Medical Staff" addressed to S7MD. The document was signed by S8MD as MEC Board Chairman and S28GBC.

A review of S7MD's credentialing file revealed an undated document titled "Initial Appointment". Further review failed to reveal Delineation of Privileges, received or signed by the MEC.

A review of S7MD's credentialing file revealed a document dated 08/14/2023 and titled "Internal Medicine Privilege Request Form" signed by S7MD.
Further review revealed the document was signed by S5Admin on 08/15/2023, indicating approval for temporary privileges for a period not to exceed 120 days.
Continued review failed to reveal a signature by the Medical Director/MEC Designee indicating approval.

In an interview on 08/16/2023 at 2:40 p.m., S5Admin stated that S8MD and S7MD were not reappointed as Medical Staff or as Medical Directors. S5Admin reported that the previous hospital credentialing manager was no longer employed and that the hospital was in the process of hiring another credentialing manager.

In an interview on 08/16/2023 at 12:45 p.m., S1Admin stated he appointed S7MD as medical director by verbal agreement.

Based on record review and interview the hospital failed to ensure that the medical record contained documented evidence of patient notification of their rights. This is evidenced by failing to have the patient/patient representative/nurse sign the statement of Patient Acknowledgment of rights in 3 (#3, #5 and #6) of 7 (#1-#7) patients sampled for acknowledgement of patient rights.

A review of hospital policy #13676828 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, in part: Become informed of his/her rights as a patient in advance of, or when discontinuing, the provision of care.

Patient #3
Review of medical record revealed a document titled "Conditions of Admission and Consent for Medical Treatment" dated 04/14/2023. Further review revealed "Statement of patient Acknowledgment": (Patients should initial beside the appropriate items), in part: 2. I have received a copy of the Patient Rights and Responsibilities. The document failed to reveal evidence that the patient initialed beside the item "I have received a copy of the Patient Rights and Responsibilities".

Patient #5
Review of medical record revealed a document titled "Conditions of Admission and Consent for Medical Treatment" dated 06/22/2023. Further review revealed "Statement of patient Acknowledgment": (Patients should initial beside the appropriate items), in part: 2. I have received a copy of the Patient Rights and Responsibilities. The document failed to reveal evidence that the patient initialed beside the item "I have received a copy of the Patient Rights and Responsibilities".

Patient #6
Review of medical record revealed a document titled "Conditions of Admission and Consent for Medical Treatment" dated 06/21/2023. Further review revealed "Statement of patient Acknowledgment": (Patients should initial beside the appropriate items), in part: 2. I have received a copy of the Patient Rights and Responsibilities. The document failed to reveal evidence that the patient initialed beside the item "I have received a copy of the Patient Rights and Responsibilities".

In an interview on 08/16/2023 at 9:30 a.m., S23MR stated that the blank fields identified in Patient #3, #5 and #6's Statements of Patient Acknowledgment, indicated the patients were not made aware of their patient rights.

Based on observations and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by:
1) Failure to ensure the hospital was free of ligature risks;
2) Failure to ensure unpopulated areas of the hospital was properly secured; and,
3) Faillure to ensure door ii was locked and patio aa was secured for patients who smoked.
Findings:

1) Failure to ensure the hospital was free of ligature risks;

An observation on 08/14/2023 at 1:47 p.m. revealed the bathroom door in the anteroom of room ee of Unit B with regular door hinges presenting ligature risks.

An observation on 08/14/2023 at 1:55 p.m. on Unit B revealed the door to the room ff with regular hinges presenting ligature risks.

An observation on 08/14/2023 at 1:58 p.m. revealed the double doors gg on Unit B with regular hinges presenting ligature risks.

Observations on 08/14/2023 beginning 1:59 p.m. revealed on Unit B 19 toilets in rooms c, d, e, f, g, h, I , j, k, l, m, n, o, p, q, r, s, t, u, v with unsecured seats presenting ligature risks.

Observations on 08/14/2023 beginning at 1:59 p.m. revealed on Unit B boxed in toilet fixtures with drilled holes presenting ligature risks in rooms j, k, l, i, h, g, f, e, o, q, r and v.

Observations on 08/14/2023 beginning at 1:59 p.m. revealed on Unit B air conditioning vents in rooms c, d, e, f, g, h, I , j, k, l, m, n, o, p, q, r, s, t, u, v presenting ligature risks.

An observation on 08/14/2023 at 2:16 p.m. revealed on Unit B a large hinge on the door of the room ff presenting a ligature risk.

An observation on 08/14/2023 at 2:23 p.m. revealed on Unit B the camera monitor in the nurse's station. In an interview, S1Adminpsy indicated there was no staff member assigned to monitor the cameras 24/7 and that the nurse on duty monitors the cameras while performing other tasks.

An observation on 08/14/2023 at 2:24 p.m. on Unit B revealed many pieces of paper on the window of the nurse's station obstructing the view into the halls of the unit. In an interview on 08/14/2023 at 2:24 p.m. S1Adminpsy verified that the staff's view was obstructed.

In an interview on 08/14/2023 at 2:25 p.m. S1Adminpsy verified the findings of the observations.

2. Failure to ensure unpopulated areas of the hospital were properly secured; and,

An observation on 08/14/2023 at 12:50 p.m. revealed patients had access to an unsafe area of Unit A when the double doors to a vacant hall were unlocked. Further observation revealed the doors to Rooms a and b were unlocked.

An observation on 08/14/2023 at 12:50 p.m. revealed on Unit A, Room a with a bed and no mattress and a floor waxing machine stored in the room.

An observation on 08/14/2023 at 12:53 p.m revealed on Unit A, Room b a broken air conditioner with no cover and wires exposed, a maintenance cart with supplies, and a bathroom that was not maintained.

In an interview on 08/14/2023 at 12:54 p.m. S4DON confirmed that patients had access to the unsecured area which presented a potential risk to the safety of patients.

3. Failure to ensure door ii was locked and patio aa was secured for patients who smoked.

A tour of the hospital on 08/14/2023 at 1:15 p.m. revealed door ii was unlocked.

In an interview on 08/14/2023, S4DON indciated the door should be locked.

An observvation on 08/14/2023 at 1:16 p.m. revealed patio aa with a gate to the parking lot that was unlocked and open.

In an interview on 08/14/2023 at 1:16 p.m., S4DON indicated the patio gate should be locked.

Based on record review and interview the facility failed to periodically conduct appraisals of the medical staff. This deficiency is evidenced by the omission of peer evaluations for 2 (S7MD and S8MD) of 2 (S7MD and S8MD) members of the medical staff reviewed.
Findings:

S7MD
Review of S7MD's credentialing file failed to reveal evidence of peer reviews completed upon hire or every 24 months thereafter.

S8MD
Review of S8MD's credentialing file failed to reveal evidence of peer reviews completed upon hire or every 24 months thereafter.

In an interview on 08/16/2023 at 2:40 p.m., S5Admin stated that S8MD and S7MD did not have peer reviews completed. S5Admin reported that the previous hospital credentialing manager who previously ensured the peer reviews were completed was no longer employed with the hospital and that the hospital was in the process of hiring another credentialing manager.

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 medical physicians for 31 of the 31 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.

Review of Census dated 08/14/2023 for Unit A and Unit B revealed 31 patients.

Review of Unit A's Organizational Chart revealed Medical Director/Laboratory Director was S8MD.

Review of S8MD's credentialing file failed to reveal evidence the physician was credentialed with hospital privileges.

Review of Unit B's Organizational Chart revealed Medical Director of Physical Medicine was S7MD.

Review of S7MD's credentialing file failed to reveal evidence the physician was credentialed with hospital privileges.

In an interview on 08/16/2023 at 1:55 p.m., S5Admin verified S8MD was the attending medical physician on Unit A. S5Admin further stated that S8MD was not credentialed with hospital privileges.

In an interview on 08/16/2023 at 2:45 p.m., S1Admin verified S7MD was the attending medical physician on Unit B and rounded with his nurse practitioner 7 days a week. S1Admin further stated that S7MD was not credentialed with hospital privileges.

Based on record review and interview, the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care of each patient as evidenced by failing to conduct an assessment prior to and after administering PRN medications for 2 (#11 and #13) of 5 (#8, #10, #11, #12, and #13) patient records reviewed for PRN medications.
Findings:

Review of the hospital policy titled, "Assessment and Reassessment", effective date 05/2023 revealed, in part, POLICY: Nursing care is provided to patients based on an ongoing assessment of their nursing care needs, formulation of a plan of care, evaluation of the patient's response to, or outcomes resulting from the nursing care provided, and the capability of the patient or caregiver for continuing care. A. Nursing Documentation: 7. Reassessment of the patient shall be performed at regular intervals in the course of care by medical and nursing staff. Ancillary services involved in the patient's care also perform reassessments as dictated by the patient's needs. Reassessment shall take place when there is a significant change in a patient's condition or a change in diagnosis.

Patient #11
Review of Patient #11's medical record on 08/16/2023 revealed the nurse did not perform an assessment or reassessment before or after administering oxycodone for pain on 08/05/2023 at 9:00 a.m., 9:00 p.m.; 08/06/2023 at 9:10 a.m., 5:15 p.m., 11:35 p.m.; 08/07/2023 at 10:00 a.m., 9:00 p.m.; 08/08/2023 10:00 p.m.; 08/11/2023 at 1:00 a.m.; and 08/13/2023 at 9:45 a.m., 4:20 p.m.

Patient #13
Review of Patient #13's medical record on 08/16/2023 revealed the nurse did not perform an assessment or reassessment after administering oxycodone on 06/16/2023 at 5:15 a.m., 9:30 a.m., 1:30 p.m.; and on 06/20/2023 at 6:55 p.m., 10:30 p.m. and 3:15 a.m.

An interview on 08/16/2023 at 2:00 p.m. S4DON verified the nurse did not complete an assessment or reassessment as per hospital policy when administering oxycodone for pain on the following patients medical record: Patient #11 on 08/05/2023 at 9:00 a.m., 9:00 p.m.; 08/06/2023 at 9:10 a.m., 5:15 p.m., 11:35 p.m.; 08/07/2023 at 10:00 a.m., 9:00 p.m.; 08/08/2023 10:00 p.m.; 08/11/2023 at 1:00 a.m.; and 08/13/2023 at 9:45 a.m., 4:20 p.m; and Patient #13 on 06/16/2023 at 5:15 a.m., 9:30 a.m., 1:30 p.m.; and on 06/20/2023 at 6:55 p.m., 10:30 p.m. and 3:15 a.m.

Based on record review and interview, the hospital failed to ensure that the nursing staff developed, and kept a current, and individualized nursing care plan for each patient that reflected the patient's goals and the nursing care expected to meet the patient's needs. This deficient practice is evidenced by the failure to create individualized care plans based on comprehensive assessments on 6 (#1-#6) of 7 (#1-#7) patients reviewed for completed and updated care plans.
Findings:

A review of hospital policy #13676910 titled "Continuum of Care Plan" revealed, in part: Policy: To ensure that the needs of the patient and family/significant other(s) are met and have access to the appropriate setting and level of care, health care professionals, and type of medical, health and social series as needed. Procedure, in part: 1. the hospital provides a quality, coordinated continuum of care to match the needs of the population served with the appropriate care levels and services.

Patient #1
A review of Patient #1's medical record revealed an H & P prepared by S8MD. Further review revealed he was admitted on 08/07/2023 with a J-tube site with a colostomy bag placed over the site to collect drainage. Diagnoses included protein-calorie malnutrition.

A review of Patient #1's Plan of Care dated 08/08/2023-08/16/2023 failed to reveal a comprehensive and individualized nursing care plan that addressed the needs of a patient who had a J-tube site with a colostomy bag placed over the site to collect drainage and a diagnoses of protein-calorie malnutrition.

In an interview on 08/15/2023 at 1:5 p.m. S3DQ verified Patient #1's care plan failed to address the needs of a patient who had a J-tube site with a colostomy bag placed over the site to collect drainage and a diagnoses of protein-calorie malnutrition. S3DQ agreed that the care plan was not comprehensive and individualized.

Patient #2
A review of Patient #2's medical record revealed an admission date of 07/27/2023. Further review revealed an H & P that listed bacteremia, osteomyelitis, pain and antibiotic treatment in the impression and plan.

A review of Patient #2's Plan of Care dated 07/28/2023-08/15/2023 failed to reveal a comprehensive and individualized nursing care plan that addressed the needs of a patient with bacteremia, osteomyelitis, pain and antibiotic treatment.

In an interview on 08/15/2023 at 2:28 p.m., S3DQ verified that the care plan failed to address the needs of a patient with bacteremia, osteomyelitis, pain and antibiotic treatment. S3DQ agreed that the care plan was not comprehensive and individualized.

Patient #3
A review of Patient #3's medical record revealed an admission date of 04/14/2023. Further review revealed an H & P that listed PEG tube and the use of a Passy-Muir valve in the Assessment and Plan.

A review of Patient #3's Plan of Care dated 04/14/2023-05/01/2023 failed to reveal a comprehensive and individualized nursing care plan that addressed the needs of a patient with a PEG tube and a Passy-Muir valve.

In an interview on 08/15/2023 at 2:54 p.m., S3DQ verified that the care plan failed to address the needs of a patient with a PEG tube and a Passy-Muir valve. S3DQ agreed that the care plan was not comprehensive and individualized.

Patient #4
A review of Patient #4's medical record revealed an admission date of 06/23/2023. Further review revealed an H & P that described the patient's colostomy and suprapubic catheter.

A review of Patient #4's Plan of Care dated 06/23/2023-07/10/2023 failed to reveal a comprehensive and individualized nursing care plan that addressed the needs of a patient with a colostomy and a suprapubic catheter.

In an interview on 08/15/2023 at 2:52 p.m., S3DQ verified that the care plan failed to address the needs of a patient with a colostomy and a suprapubic catheter. S3DQ agreed that the care plan was not comprehensive and individualized.

Patient #5
A review of Patient #5's medical record revealed an admission date of 06/21/2023. Further review revealed an H & P that listed MRSA of right foot on antibiotic treatment.

A review of Patient #5's Plan of Care dated 06/22/2023-07/07/2023 failed to reveal a comprehensive and individualized nursing care plan that addressed the needs of a patient with MRSA of right foot on antibiotic treatment.

In an interview on 08/15/2023 at 3:10 p.m., S3DQ verified that the care plan failed to address the needs of a patient with MRSA of right foot on antibiotic treatment. S3DQ agreed that the care plan was not comprehensive and individualized.

Patient #6
A review of Patient #6's medical record revealed an admission date of 06/22/2023. Further review revealed an H & P prepared by S8MD that listed in the Assessment and Plan: sternal wound infection and diabetes requiring an insulin pump.

A review of Patient #6's Plan of Care dated 07/28/2023-08/15/2023 failed to reveal a comprehensive and individualized nursing care plan that addressed the needs of a patient with a sternal wound infection and diabetes requiring an insulin pump.

In an interview on 08/15/2023 at 3:34 p.m., S3DQ verified that the care plan failed to address the needs of a patient with a sternal wound infection and diabetes requiring an insulin pump. S3DQ agreed that the care plan was not comprehensive and individualized.

Based on record reviews and interviews, the hospital failed to ensure orders for medications included the indication for use on 3 (#15, #16, #17) of the 3 (#9, #15, #16, #17) records reviewed for medication orders. This deficient practice had the potential to impact any patient receiving medications on Unit B.
Findings:

Review of the Medical Staff's Rules and Regulations included, in part, medication orders must include the name of the drug, the dosage, the route and the frequency of administration. There must be a documented diagnosis, condition or indication for use of each medication ordered.

Patient #15

Review of Patient #15's medical record revealed an admit date of 08/04/2023 via a Physician's Emergency Certificate for danger to self, danger to others, gravely disabled and unable to seek voluntary admission.

Review of the physician's orders revealed the following, in part:

On 08/15/2023 an MD order for change Abilify 20mg. by mouth daily with no indications for use;

On 08/10/2023 an MD order for Change Abilify 17mg by mouth daily with no indications for use;

On 08/10/2023 an MD order for Haldol D 100mg intramuscularly every month with no indications for use;

On 08/05/2023 a verbal MD order for Increase Januvia n50mg by mouth daily and Increase Lantus 20mg sublingually every bedtime with no indications for use;

On 08/06/2023 a PMHNP order for Change Abilify 12mg by mouth daily with no indications for use;

On 08/08/2023 an MD order for Change Abilify 15mg by mouth every day with no indications for use.

Further review of Patient #18's medical record revealed the document given to patient upon discharge revealed a list of discharge medications with no indications for use.


Patient #16

Review of Patient #16's medical record revealed an admit date of 07/24/2023 at 3:15 p.m. via a Formal Voluntary Admission.

Review of the physician's orders revealed the following, in part:

On 07/25/2023 at 3:30 p.m. a verbal order for Topomax 50mg by mouth every bedtime with no indications for use documented; and Metformin 500mg by mouth every 6:30 a.m. and 4:30 p.m. with no indications for use documented;

On 7/25/23 an MD order for Haldol 2mg by mouth two times per day and Seroquel 100mg by mouth every bedtime with no indications for use;

On 07/27/2023 an MD order for change Haldol 2mg by mouth every montirngn and 5mg by mouth every bedtime with no indications for use documented;

On 07/31/2023 a telephone order for change Haldol 5mg by mouth two times per day with no indications for use documented;

On 08/01/2023 an MD order for change Haldol 5mg by mouth every a.m. and 7mg by mouth every bedtime and Seroquel 200mg by mouth every bedtime with no indications for use documented;;

On 08/03/2023 an MD order for change Seroquel 300mg by mouth every bedtime to 7mg by mouth two times per day with no indications for use documented;

On 08/09/2023 an MD order for change Seroquel 400mg by mouth every bedtime and change Haldol 7mg by mouth every a.m. and 10mg every bedtime with no indications for use documented; and,

On 08/14/2023 a NP order for change Haldol 10mg by mouth two times per day with no indications for use documented.

Patient #17

Review of Patient #17's medical record revealed an admit date of 08/02/2023 at 5:15 p.m. via a Physician's Emergency Certificate for danger to self, others and unwilling to sign in voluntarily.

Review of the physician's orders revealed the following, in part:

A verbal order on 08/07/2023 for Zofran 4mg every 6 hours as needed with no indications for use documented;

An MD order on 08/09/2023 for change Latuda 40mg by mouth daily with no indications for use documented;

An MD order on 08/10/2023 for change Seroquel 400mg by mouth every bedtime and no indications for use documented.

A telephone MD order on 08/13/2023 for increase Thorazine 50mg by mouth tree times per day with no indications for use documented.

Based on record review and interview, the hospital failed to ensure the completion of discharge summaries within 30 days of discharge. This deficient practice was identified for 3 (#7, #18, #19) of 4 (#7, #18, #19, #20) medical records reviewed for timely discharge summaries.
Findings:

Review of the approved Medical Staff's rules and regulations revealed, in part, medical records should be completed within 30 days of the patient's discharge from the hospital.

Review of the Medical Executive Committee meeting minutes of January 18, 2023 revealed the percentage of discharge summaries completed within 30 days remains at DS 86% with 14% delinquent, Summa 93% with 7% delinquent, and Psych 85% with 15% delinquent for the 4th quarter of 2022.

In an interview on 08/15/2023 at 2:24 p.m. S5Admin indicated there has been only 1 Medical Executive Committee meeting in 2023 so these delinquency rates are the most current data related to medical record compliance related to discharge summaries. Further interview indicated the hospital's quality improvement data benchmark for discharge summaries being within 30 days of discharge was 95% and the current delinquency rates are not meeting the benchmark.

Patient #7
Review of Patient #7's medical record revealed a discharge date of 06/21/2023.

Further review failed to reveal a discharge summary in the medical record.

In an interview on 08/15/2023 at 3:50 p.m., S3DQ verified that there was no discharge summary in Patient #7's medical record.

Patient #18
Review of Patient #18's medical record revealed a discharge date of 07/07/2023.

Further review revealed a discharge summary dated 08/04/2023 or 3 days delinquent based on the approved medical staff rules and regulations.

Patient #19
Review of Patient #19's medical record revealed a discharge date of 04/14/2023.

Further review revealed a discharge summary dated 05/22/2023 or 7 days delinquent based on the approved medical staff rules and regulations.

Based on observation and interview, the hospital failed to ensure all drugs and biologicals were kept in a secure area. This deficient practice is evidenced by:
1) failing to lock the crash cart drawers located in area 'ii' of Unit A.
2) failing to lock the medication cart on located in area 'jj' of Unit C.
Findings:

1) failing to lock the crash cart drawers located in area 'ii' of Unit A.
Observation of area 'ii' on Unit A with S4DON on 08/14/2023 at 12:20 p.m. revealed an unattended emergency code cart covered by a white sheet. Further observation failed to reveal the medicine draws were locked and secured.

In an interview on 08/14/2023 at 12:25 p.m., S3DQ confirmed the emergency code cart lock was broken which created an insecure area in which to store the emergency medications.

2) failing to lock the medication cart located in area 'jj' of Unit C.
Observations of area 'jj' on Unit C with S6UM on 08/15/2023 at 9:17 a.m., revealed an unattended nurses' medication cart. Further review failed to reveal the medication cart was locked and secured.

In an interview on 08/15/2023 at 09:15 a.m., S6UM verified the medication cart was unattended and unlocked. S6UM verified the medication cart should have been kept locked.

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 as evidenced by having expired medications.

Findings:

On 08/14/2023 at 12:30 p.m., observation of emergency code cart on Unit A revealed expired medications that included:
(2) red top vials with an expiration date of 02/28/2023.
(4) red top vials with an expiration date of 03/02/2023
(4) red top top vials with an expiration date of 11/13/2022.
Intravenous Dextrose with an expiration date of 06/07/2023.
Intravenous Dextrose with an expiration date of 06/31/2023.

In an interview on 08/14/2023 at 12:30 p.m., S4DON confirmed the above stated expired medications were available for patient use.

In an interview on 08/14/2023 at 12:33 p.m., S4DON confirmed the lab vials were expired and available for patient use.

Based on record review and interview the facility failed to adopt written policies and procedures to provide for the safety and health of patients and hospital personnel. The deficient practice is evidenced by failure to develop a policy for shielding of staff and the patients during radiologic procedures.
Findings:

Review of the policy and procedures titled, "Hazardous Materials and Waste Management Plan", effective 07/2023 revealed in part, MANAGEMENT OF SPECIFIC TYPES OF HAZARDOUS MATERIALS AND WASTE: 1. Ionizing, Non-Ionizing Radiation Producing Equipment and Radiation Materials: a. All radiological procedures are performed by contracted company. The contracted provider's policies and procedures will be followed as they apply to any radiation producing equipment or materials.

In interview on 08/16/2023 at 3:00 p.m., S4DON verified the policy did not address if staff would, or would not be present in the room for radiologic procedures and did not discuss shielding of staff and patients.

Based on observation and interview the hospital failed to have a current therapeutic diet manual readily available to nursing staff.
Findings:

Review of current therapeutic diet manual titled, "The Louisiana Academy of Nutrition and Dietetics Manual of Medical Nutrition Therapy 7th Edition", was publicized in 2015 and approved by the Licensed Dietitian 08/30/2017.

In an interview on 08/16/2023 at 2:55 p.m. S3DQ verified current dietitian has not reviewed current therapeutic diet manual that is available for the staff or Governing Body hasn't reviewed since 2017.

Based on interview and record review, the hospital failed to develop and implement a Utilization Review plan and failed to establish and implement a Utilization Review Ccommittee consisting of two or more practitioners. This deficient practice had the potential to affect any patients receiving care at the hospital.
Findings:

Review of the Medical Executive Committee meeting minutes revealed no minutes associated with a Utilization Review Committee meeting.

In an interview on 08/16/2023 at 2:03 p.m., S13SW indicated she had been employed at the hospital for 14 years; Further interview revealed there was no Utilization Review Plan and no Utilization Review Committee that included at least two practitioners.

Based on interview and record review, the hospital failed to review professional services provided to determine medical necessity and promote the most efficient use of available health facilities and services. This deficient practice had the potential to affect any patients receiving care at the hospital.
Findings:

Review of the Mmedical Eexecutive Ccommittee meeting minutes revealed no minutes associated with a review of professional services.

In an interview on 08/16/2023 at 2:03 p.m., S13SW indicated she had been employed at the hospital for 14 years; further interview revealed there had been no review of professional services provided at the hospital since she had been in the position of conducting utilization review of hospital services.

Based on observations and interviews the hospital failed to ensure the hospital environment was maintained in a sanitary condition and 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 Automated External Defibrillator (AED) had the required AED pads available for emergency use.
2) failing to ensure the hospital was maintained in a sanitary condition.
3) failing to ensure expired supplies were not available for patient use.
Findings:

1) Failing to ensure the Automated External Defibrillator (AED) had the required AED pads available for emergency use.
Observation of Unit A's emergency code cart on 08/14/2023 at 12:35 p.m. failed to reveal the Automated External Defibrillator (AED) had the required AED pads available for emergency use.

In an interview on 08/14/2023 at 12:45 p.m., S4DON confirmed the AED pads were not on the emergency code cart with the AED available for emergency use.

2) Failing to ensure the hospital environment was maintained in a sanitary condition.
Review of hospital policy #13676032 titled "Infection Control Plan" revealed, in part: Policy: Infection Control Program, in part: The infection control Program allows for a systemic, coordinated and continuous approach and is accomplished by: 3. Instituting changes as needed to reduce the healthcare acquired infections, including but not limited to:, in part: a. Limiting unprotected exposure to pathogens throughout the organization.

Observation of Unit A's area 'bb' on 08/14/2023 at 1:25 p.m. revealed therapy mats with taped areas of torn plastic that created an infection control risk.

In an interview on 08/14/2023 at 1:25 p.m., S4DON confirmed the torn plastic therapy mats and agreed this was an infection control risk.

Observation of Unit B's area 'ee' on 08/14/2023 at 1:50 p.m. revealed a mattress that was severely torn and an infection control risk.

Observation of Unit B's patient rooms e, h, i, and n revealed severely torn mattresses that were infection control risks.

In an interview on 08/14/2023 at 2:05 p.m., S1Admin confirmed the above stated torn mattresses and stated that the facility would replace the mattresses before patient use.

3) Failing to ensure expired supplies were not available for patient use.
Observation of Unit A's emergency code cart on 08/14/2023 at 12:35 p.m. revealed two 22-gauge hyperdermic needles with the expiration date of 03/31/2023.

In an interview on 08/14/2023 at 12:35 p.m., S4DON confirmed the above stated expiration dates and the availability for patient use and further stated the facility should discard the expired needles.

Observation of Unit A's area 'y' on 08/14/2023 at 12:55 p.m. revealed a sign on the door "Keep locked". Further observation revealed the room was unlocked and unattended. Continued observation revealed a V.A.C. Verilink cassette opened on the shelf next to the unopened cassettes. Further observation revealed the packaging had a statement that read "Do not use if opened".

In an interview on 08/14/2023 at 1:00 p.m., S4DON confirmed the V.A.C. Verilink cassette opened on the shelf and available for patient use and further stated the facility should discard the opened V.A.C. Verilink cassette.

Continued review of area 'y' revealed an Intravenous administration set with the expiration date of 06/01/2023.

In an interview on 08/14/2023 at 12:58 p.m., S4DON confirmed the above stated expiration date and the availability for patient use and further stated the facility should discard the expired Intravenous administration set.

Observations of Unit A's area 'z' on 08/14/2023 at 1:10 p.m. revealed 89, 3 cc syringes with the expiration date of 03/31/2023.

In an interview on 08/14/2023 at 1:10 p.m., S4DON confirmed the above stated expiration dates and the availability for patient use and further stated the facility should discard the expired 3 cc syringes.

Observation of Unit C's supply room revealed 7 Airlife PEEP (Positive End-Expiratory Pressure) Valves with the expiration date of 07/13/2023.

In an interview on 08/15/2023 at 8:59 a.m., S6UM confirmed the above stated expiration dates and the availability for patient use and further stated the facility should discard the expired PEEP valves.

Based on policy review, observation and interview, the hospital failed to develop and implement an effective system in controlling infections and communicable diseases of patients as evidenced by failing to implement methods to prevent transmission of infectious agents and evaluate the potential for outbreaks.
Findings:

Review of hospital policy #13676032 titled "Infection Control Plan" revealed, in part: Purpose, in part: To ensure that the organization has a functioning coordinated process in place, to reduce the risks of endemic and epidemic HAIs in patients and healthcare workers and to optimize use of resources through strong preventive program. The infection control Program at this hospital incorporates the following in ca continuing cycle, in part: Surveillance: Monitoring patients and healthcare workers for acquisition of infection and/or colonization. Policy, in part: Infection Control Program, in part: 1. Identifying and monitoring expected and unexpected infections early and implementing appropriate interventions. The interventions will: a. Identify infections present at the time of a patient admission and staff employment. Infection Control Function, in part: The infection control practitioner (or designee) has the authority to institute any surveillance, prevention or control measures or study when there is reason to believe that any patient, personnel or visitor may be in danger. This authority and responsibility includes, but may not be limited to, in part: Determine when isolation precautions, barrier precautions or environmental cultures are required and implement these processes. Develop and implement a system for surveillance and control of infections.

Review of Patient #3's medical record revealed a Pre-Admission Screening dated 04/10/2023. Further review revealed the patient had left lower lung with pseudomonas, sepsis Acinetobacter, acute cystitis. This patient was also diagnosed with Vancomycin-Resistant Enterococcus (VRE), Multi-Drug-Resistant Organisms (MDRO), Extended Spectrum Beta-Lactamase (ESBL), Methicillin-Resistant Staphylococcus Aerus (MRSA) and Carbapenem-Resistant Organisms (CRO).

Review of Patient #3's medical record failed to reveal isolation precautions for this patient during his admission.

Review of the hospital Infection Control Binder for April 2023 and May 2023 failed to reveal the above stated infection control information included in the surveillance data.

In an interview on 08/16/2023 at 3:30 p.m., S4DON reported that he was not employed with the hospital until June 2023 and would have included this data on the surveillance report.

In a telephone interview on 08/16/2023 at 12:25 p.m., S24IC reported that this patient should have been on isolation precautions. S24IC further stated the nursing staff should automatically put a patient with MRDO's on isolation.

Based on record review, and interview, the hospital failed to ensure ongoing discharge planning/discharge plans were documented in the patient's medical record for 2 (#5 and #6) out of 7 (#1-#7) patients reviewed for discharge planning.
Findings:

Review of hospital policy #13676027 titled "Discharge Planning and Transfers" revealed, in part: Purpose: To provide guidelines for an interdisciplinary discharge planning process and to identify specific needs a patient might have following discharge. Inpatient policy: Discharge Planning begins during the pre-admission phase of the patient's care to assure that the patient is referred to a proper environment for continuity of care. The Case Manager/Social Worker is responsible for initiating formal discharge planning upon admission of the patient. Procedure, in part: 1., in part: Discharge planning begins during the pre-admission phase of the assessment process. 4., in part: The interdisciplinary discharge plan will be initiated during the first patient care conference and documented on the care conference summary form in the medical record.

A review of Patient #2's medical record revealed an admission date of 07/27/2023. Further review of the Interdisciplinary Team Conference Form dated 07/27/2023 failed to reveal discharge planning.

A review of Patient #6's medical record revealed an admission date of 06/21/2023. Further review of the Interdisciplinary Team Conference Form dated 06/26/2023 failed to reveal discharge planning.

In an interview on 08/15/2023 at 2:30 p.m., S3DQ verified that Patient #2's and Patient #6's medical record failed to reveal discharge planning.