HospitalInspections.org

Based on interviews and record review, the REH failed to ensure that an individual was appointed by the governing body, or responsible individual, as the infection preventionist/infection control professional responsible for the infection prevention and control program. This deficient practice was evidenced by failing to appoint S3IC as the REH infection preventionist/infection control professional.
Findings:

In an interview on 02/04/2025 at 8:26 AM, S3IC indicated that she was the REH infection preventionist/infection control professional.

Review of REH documentation provided by S2ADM revealed no evidence S3IC was appointed as the infection preventionist/infection control professional responsible for the infection prevention and control program.

In an interview on 02/04/2025 at 10:47 AM, S2ADM confirmed the REH had no evidence S3IC was appointed as the infection preventionist/infection control professional responsible for the infection prevention and control program.

Based on interviews and record review, the REH failed to ensure that an individual was appointed by the governing body, or responsible individual, as the leader of the antibiotic stewardship program. This deficient practice was evidenced by failing to appoint S10PHM as the leader of the REH antibiotic stewardship program.
Findings:

In an interview on 02/04/2025 at 9:51 AM, S2ADM indicated that S10PHM was the leader of the REH antibiotic stewardship program.

Review of REH documentation provided by S2ADM revealed no evidence S10PHM was appointed as the leader of the antibiotic stewardship program.

In an interview on 02/04/2025 at 10:47 AM, S2ADM confirmed the REH had no documented evidence S10PHM was appointed as the leader of the antibiotic stewardship program.

Based on record review and interview the REH failed to ensure patients were free from all forms of abuse or harassment as evidenced by failure to assure that personnel completed criminal background checks by an authorized agent of the Louisiana State Police in the manner required by R.S. 15:587.1 et seq. prior to hire or employment for 1 (S7EST) of 2 (S7EST and S6PAR) non-licensed direct care staff reviewed.
Findings:

Review of personnel list provided by REH provider revealed S7EST listed as an Emergency Services Technician.

Review of S7EST's personnel file revealed date of hire 03/04/2024. Continued review revealed criminal background check dated 02/29/2024 completed by Company A. Further review revealed Company A was not an authorized agency of the Louisiana State Police.

During an interview on 02/05/2025 at 10:50 AM S2ADM verified the REH utilized Company A for S7EST's background check. S2ADM verified Company A was not an approved contractor by the Louisiana State Police.