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Based on record review, observations, and interview, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services as evidenced by:
1) failure of nursing staff to perform and document accurate wound assessments on 1 (#2) of 3 (#1-#3) patients sampled;
2) failure of nursing staff to administer medications ordered by the physician for a time span of 12 days for 1 (#2) of 3 (#1-#3) patients sampled.
(See findings tag A-0395).

Based on record review and interview, the facility and its staff failed to ensure the health and safety of all patients. This deficient practice was evidenced by failure to ensure each employee's personnel file had documented evidence they were free of TB (tuberculosis) in a communicable state, as required per Louisiana Public Health Sanitary Code, Title 51, Part II., for 1 (S9LPN) of 7 (S2DON, S5LPN, S6PCT, S7RN, S8RN, S9LPN and S10PCT) personnel records reviewed.
Findings:

Review of facility policy titled "TB Screening (Employees)" revealed, in part: Policy. All employees, volunteers, agency, and long-term contracted personnel will receive screening for tuberculosis (TB) infection yearly. Licensed independent practitioners (LIPs) will also be offered yearly screening fro TB.

Review of the Louisiana Public Health Sanitary Code, Title 51, Part II. The Control of Diseases - Health Examinations for Employees, Volunteers and Patients at Certain Medical Facilities, Section 503, Mandatory Tuberculosis Testing, revealed in part:

A. [formerly paragraph 2:022] All persons, including employees, students or volunteers, having no history of latent tuberculosis infection or tuberculosis disease, prior to or at the time of employment, beginning clinical rotations in the healthcare profession, or volunteering at any hospital or nursing home (as defined in Parts XIX and XX of the Sanitary Code, respectively, herein, and including intermediate care facilities for the developmentally disabled) requiring licensing by the Louisiana Department of Health or at any Louisiana Department of Health, Office of Public Health (LDH-OPH) parish health unit or an LDH-OPH outpatient health care facility, whose duties include direct patient care, shall be free of tuberculosis in a communicable state as evidenced by either:
1. a negative purified protein derivative skin test for tuberculosis, 5 tuberculin unit strength, given by the Mantoux method or a blood assay for Mycobacterium tuberculosis approved by the United States Food and Drug Administration;
2. a normal chest X-ray, if the skin test or a blood assay for Mycobacterium tuberculosis approved by the United States Food and Drug Administration is positive; or
3. All initial screening test results and all follow-up screening test results shall be kept in each employee's, Student's, or volunteer's health record or facility's personnel record.
D. Annually, but no sooner than 6 months since last receiving tuberculosis educational information (more fully described at the end of this sentence) or symptom screening, all employees, students in the healthcare professions, or volunteers at any medical or 24-hour residential facility requiring licensing by LDH or at any hospital or nursing home (as defined in Parts XIX and XX of the Sanitary Code, respectively, herein, and including intermediate care
facilities for the developmentally disabled) requiring licensing by the LDH or at any LDH-OPH parish health unit or and LDH-OPH out-patient health care facility shall receive, at a minimum, educational information explaining the health concerns, signs, symptoms, and risks of tuberculosis.

A review of S9LPN's personnel file revealed a hire date of 01/18/2022. Further review failed to reveal documentation that S9LPN received yearly screening for tuberculosis infection.

In an interview on 09/19/2023 at 11:06 a.m., S11Admin confirmed no evidence S9LPN received yearly screening for tuberculosis infection.

Based on record review and interview, the hospital failed to ensure the hospital's direct care staff had periodic recertification related to CPR (cardiopulmonary resuscitation). This deficient practice is evidenced by 1 (S9LPN) of 7 (S2DON, S5LPN, S6PCT, S7RN, S8RN, S9LPN and S10PCT) employees sampled who was delinquent in CPR certification.
Findings:

A review of S9LPN's personnel file revealed a hire date of 01/18/2022. Further review failed to reveal documentation of current CPR certification.

In an interview on 09/19/2023 at 1:00 p.m., S2DON confirmed S9LPN's personnel file failed to reveal documentation of current CPR certification.

Based on record review, observation, and interview, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by:
1) failure of nursing staff to perform and document accurate wound assessments on 1 (#2) of 3 (#1-#3) patients sampled;
2) failure of nursing staff to administer medications ordered by the physician for a time span of 12 days for 1 (#2) of 3 (#1-#3) patients sampled.
3) failure of nursing staff to provide education related to prevention of pressure ulcers to a high risk patient as per Braden Scale protocol on 1 (#1) of 3 (#1-#3) patients sampled.
Findings:

1) Failure of contracted staff to perform and document an accurate wound assessment on 1 (#2) of 3 (#1-#3) patients sampled.
Review of hospital policy titled "Skin Care Prevention: revealed, in part: Policy: Identify measures needed in the care of patents with potential for alteration in skin integrity. High Risk, in part: A. Skin Hygiene and Inspection, in part: Inspect the skin every 2-4 hours for signs and symptoms of breakdown; note any changes from the admission assessment on nurse's notes.

Review of hospital policy titled "Patient Care Standards" revealed, in part: Assessments, in part: B. Admits, in part: 1. Initial admit-in assessments will be documented an will include, in part: d. skin (color, temperature, dryness and edema, integrity). C, in part: Routine assessments will be done at the beginning of each shift and PRN. , in part: 1. Head-to-toe systems review. 6. Assessments according to patient care plan and department patient care standards. II. Planning, in part: E. Hygiene, in part: b. skin inspection Q shift.

Review of Patient #2's medical record revealed a History and Physical completed by S4MD on 09/07/2023. Further review revealed S4MD's assessment and plan included the sutures to left great toe status post amputation were to be removed on 09/11/2023.

Review of Patient #2's medical record revealed nursing assessment dated 09/14/2023 failed to reveal documentation of surgical incision related to left great toe amputation. The assessment revealed that the wound was warm, dry and intact. Nursing assessments completed 09/08/2023, 09/09/2023, 09/10/2023, 09/13/2023, and 09/15/2023 revealed the wound was warm and not intact. The documentation further stated "See Wound Sheet".

Review of Patient #2's medical record failed to reveal a Wound Care Sheet for Patient #2's entire admission(09/06/2023-09/18/2023).

In an interview on 09/18/2023 at 11:40 a.m., S2DON confirmed that there was no Wound Care Assessment Sheet completed in Patient #2's chart for her entire admission (09/06/2023-09/18/2023). S2DON confirmed the sutures had not been removed as was planned per the physcian's History and Physical.

Observation of Patient #2's left foot conducted by the surveyor revealed an amputated left great toe with sutures surrounded by a black substance, with yellowish, red drainage to the top of the boot that laid on the wound. Further observation revealed red and swollen area around the amputation and across the top of the foot.

In an interview on 09/18/2023 at 11:44 a.m., Patient #2 reported her foot was hot and tender to touch.

In an interview on 09/18/2023 at 11:45 a.m., S3LPN assessed Patient #2's foot at surveyors request and confirmed that Patient #2's foot was red, swollen, hot and painful to touch. S3LPN further stated that previous staff failed to identify that Patient #2's foot was red, swollen, hot and painful to touch. S3LPN reported that S4MD was on the unit and that she would immediately notify S4MD of her assessment findings related to Patient #2's left foot.

In an interview on 09/18/2023 at 12:21 p.m., S4MD stated he was having Patient #2 immediately transferred to Hospital A for treatment of painful, red, swollen foot s/p amputation.

In an interview on 09/19/2023 at 3:02 p.m., S3LPN reported she had spoken with Patient #2's nurse at Hospital A and was told Patient #2 was admitted with infection of the left foot and is on the telemetry unit being treated with Vancomycin.

2) Failure of nursing staff to administer medications ordered by the physician to 1 (#2) of 3 (#1-#3) patients sampled.
Review of hospital policy titled "Medication Administration" revealed, in part: Policy: Medications will be administered only by a physician's order. Medication Orders, in part: 2. Nurse Responsibilities, in part: Nurse will seek clarification on any ambiguous order by contacting the physician who wrote the order. V. Medication Administration Record, in part: 3. It is the responsibility of the nurse to transcribe and review all medications onto the MAR and to verify that the order is correctly transcribed if transcribed by the unit secretary. 5. The transcribed medication order must include, in part, the medication times to be administered and the transcribing nurse's initials. 16. At twelve hour and midnight chart checks, the nurse will, in part: Compare the original orders to the MAR.

Review of Patient #2's medication orders dated 09/06/2023 revealed rosuvastatin 40 mg tablet take 1 tablet in the morning by mouth.

Review of Patient #2's Medication Administration Report (MAR) dated 09/06/2023-09/18/2023, revealed Atorvastatin Tab 20 mg. Give one tablet by mouth *substitution for rosuvastatin 40 mg.

Further review of Patient #2's Medication Administration Report (MAR) dated 09/06/2023-09/18/2023, failed to reveal documentation that patient #2 received the medication on 09/06/2023-09/18/2023 (12 days).

In an interview on 09/18/2023 at 1:26 p.m., S2DON confirmed that the medication was not administered for 12 days. S2DON further stated that the medication was on the MAR but not administered to the patient because there was no "time of administration" indicated on the MAR. S2DON further stated the medication was not given because nurses could not pull the medication from the Omnicell because the pharmacy did not put a time on the MAR. S2DON reported that the nurses should have called the pharmacy to notify them of the error to make sure Patient #2 received her ordered medication.

3) Failure of nursing staff to provide education related to prevention of pressure ulcers to a high risk patient and family as per Braden Scale protocol on 1 (#1) of 3 (#1-#3) patients sampled.

Review of hospital policy titled "Patient/Family Education" revealed, in part: Policy: Patient teaching and subsequent evaluation is the responsibility of all members of the team. Procedure, in part: 1. The patient's learning needs, abilities, preference and readiness to learn are assessed at admission by all disciplines. 8. Patients are educated about rehab techniques through family/patient conferences and individualized sessions with family members.

Review of Patient #1's medical record revealed a Braden Pressure Ulcer Risk Scale dated 06/03/2023. Further review revealed Pressure ulcer, high risk identified. Further review revealed the following: "Pressure Ulcer precaution needs to be added to the Patient learning preference tile."

Review of Patient #1's "Patient Preferences Learning Status Records" dated 06/03/2023, failed to reveal pressure ulcer precautions were added to Patient #2's learning preference tile.

In an interview on 09/18/2023 at 3:30 p.m., S2DON confirmed that nursing staff did not follow the Braden Protocol requiring pressure ulcer precautions to be added to Patient #1's learning preference tile.

In an interview on 09/19/2023 at 2:12 p.m., Patient #1's brother stated the facility did not speak to him about pressure ulcer precautions.

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 1 (#2) of 3 (#1-#3) patients reviewed for completed and updated care plans.
Findings:

A review of hospital policy titled "Individual Plan of Care" revealed, in part: Policy: All patients will have an individualized plan of care that is individually tailored, integrated and coordinated.

Review of Patient #2's medical record revealed a History and Physical completed by S4MD on 09/07/2023. Further review revealed S4MD's assessment and plan included that Patient #2 was status post left great toe amputation.

Review of Patient #2's finalized care plan failed to reveal wound care as a part of the interdisciplinary plan of care.

In an interview on 09/18/2023 at 2:45 p.m., S2DON stated that wound care should have been included in the plan of care. S2DON confirmed that Patient #2's care plan was not comprehensive and individualized.

Based on record review and interview the hospital failed to ensure nursing staff followed the policies and procedures of the hospital. This deficiency is evidenced by:
1) failure of the hospital to provide orientation for 1 (S5LPN) of 1 (S5LPN) contracted personnel sampled for orientation;
2) failure of the hospital to complete performance evaluations on 1 (S9LPN) of 2 (S5LPN and S9LPN) LPN personnel files reviewed for performance evaluations.
Findings:

1) Failure of the hospital to provide orientation for 1 (S5LPN) of 1 (S5LPN) contracted personnel sampled for orientation.
A review of hospital policy titled "Orientation and Training" revealed, in part: Policy: It is the policy of the hospital to provide orientation programs for all new employees and to conduct or support training programs as deemed appropriate.

Observations on between 09/18/2023 and 09/19/2023 revealed S5LNP was working on the unit in the role of LPN.

A review of S5LNP's personnel file revealed S5LPN was an agency nurse. Further review failed to reveal documented evidence that S5LNP was appropriately oriented prior to providing care.

In an interview on 09/19/2023 at 1:07 p.m., S11Admin stated that every employee, including agency, must go through the hospital orientation process.

In an interview on 09/19/2023 at 1:48 p.m., S2DON confirmed that S5LNP did not undergo the orientation process as per hospital policy.

2) Failure of the hospital to complete performance evaluations on 1 (S9LPN) of 2 (S5LPN and S9LPN) LPN personnel files reviewed for performance evaluations.

A review of hospital policy titled "Performance Program" revealed, in part: Policy, in part: To provide managers with the tools necessary to guide each employee's growth and development in performing job responsibilities and achieving maximum productivity. Procedure, in part: 2. Performance appraisals shall be conducted after (3) months of employment for new employees, and transferred/promoted employees, and again each year at June.

A review of S9LPN's personnel file failed to reveal documented evidence of a completed performance evaluation.

In an interview on 09/19/2023 at 1:55 p.m., S2DON confirmed there was no evidence of a completed performance evaluation for S9LPN.