HospitalInspections.org

Based on record review and interview, the hospital failed to meet the requirements for the Condition of Participation of Governing Body as evidenced by failing to have a governing body which is effective in carrying out its responsibilities for the conduct of the hospital. This is evidenced by:

1. The Governing Body's failure to ensure that patient services performed under contract were provided in a safe and effective manner independent of the host hospital; by failing to ensure contracted services were not provided by staff concurrently working at the host hospital (Hospital A) for laboratory services, radiology services, echocardiograms and ultrasounds. (see findings at A0083)2. The Governing Body's failure to ensure the hospital had clear facility specific written policies and procedures for appraisal of emergencies, treatment and referral as appropriate for hospitals without emergency departments and met applicable state licensure requirements. This deficient practice is evidenced by the hospital, which is located within a hospital, utilizing the host hospital's policies, emergency room physician, an ICU nurse, a respiratory therapist and a nursing supervisor during "code blue" (cardio respiratory arrest) procedures. (see findings at A0093)
3. The Governing Body's failure to ensure all physicians providing services to the hospital were credentialed and granted appropriate privileges. This deficient practice is evidenced by the hospital allowing telemedicine services to be furnished for radiological services by uncredentialed physician for 4 (S6Radiologist, S7Radiologist, S8Radiologist, S9Radiologist) of 4 radiologists reviewed that had interpreted x-rays at the hospital. (see findings at A0052)

Based on record review and interview, the hospital failed to ensure all physicians providing services to the hospital were credentialed and granted appropriate privileges when

1) telemedicine services were furnished for radiological services that each physician was granted privileges at the hospital for 4 (S6Radiologist, S7Radiologist, S8Radiologist, S9Radiologist) of 4 radiologists reviewed that had interpreted x-rays at the hospital.

2) Host hospital (Hospital A) ER physicians responding to "code blue" were not credentialed.
Findings:

1) telemedicine services were furnished for radiological services that each physician was granted privileges at the hospital for 4 (S6Radiologist, S7Radiologist, S8Radiologist, S9Radiologist) of 4 radiologists reviewed that had interpreted x-rays at the hospital.

Review of a radiology report dated 4/20/16 for Patient #R1 revealed the radiologist that had interpreted the film was S6Radiologist.
Review of a radiology report dated 4/26/16 for Patient #R2 revealed the radiologist that had interpreted the film was S7Radiologist.
Review of a radiology report dated 2/25/16 for Patient #R3 revealed the radiologist that had interpreted the film was S8Radiologist.
Review of a radiology report dated 3/18/16 for Patient #R4 revealed the radiologist that had interpreted the film was S9Radiologist.

Review of a list of credentialed physicians at the hospital revealed the above mentioned radiologists did not have privileges at the hospital.

In an interview on 5/10/16 at 2:00 p.m. with S2VPSpecialty, he verified S6Radiologist, S7Radiologist, S8Radiologist and S9 Radiologist did not have privileges at the hospital to interpret x-rays.

2) Host hospital (Hospital A) ER physicians responding to "code blue" were not credentialed.

In an interview on 5/16/16 at 12:55 p.m. with S13Administrator, she said none of Hospital "A's" ED physicians were currently credentialed or privileged at 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:

1) failing to ensure contracted services were not provided by staff concurrently working at the host hospital (Hospital "A" ) for laboratory services, radiology, echocardiograms and ultrasounds.

2) failing to gather, analyze, track and trend data for all contracted services in the Quality Assurance/Performance Improvement program.

Findings:

1) Failing to ensure contracted services were not provided by staff concurrently working at the host hospital (Hospital "A") for laboratory services, radiology, echocardiograms and ultrasounds.

Extended Care of Southwest Louisiana is located on the 3rd floor of Hospital "A".

A review was made of a contract between the hospital and Hospital "A". Services to be provided by Hospital "A" included Non-Invasive services (Echo, Ultrasound), Radiology, and Laboratory services.

In an interview on 5/16/16 at 12:55 p.m. with S13Administrator, she said if the hospital needed a STAT laboratory test, a staff member working at Hospital "A" would come into the hospital and obtain the blood from the patient and do the required testing. S13Administrator also said staff from Hospital "A" would come into Extended Care of Southwest Louisiana and perform portable x-rays, ultrasounds and echocardiograms.


2) Failing to gather, analyze, track and trend data for all contracted services in the Quality Assurance/Performance Improvement program.


Review of the Quality Assurance/Performance Improvement data provided by the hospital revealed no data had been gathered, analyzed , tracked and trended for the following contracted services: Dialysis, wound care, dietary, infectious waste collection, housekeeping or linen services.

In an interview on 5/10/16 at 9:00 a.m. with S10RD, she said she was the dietician for the hospital and over the QAPI program at the hospital since January 2016. S10RD verified all of the hospital ' s contracted services were not included in QAPI data.

Based on record review and interview, the hospital failed to ensure they maintained a list of all contracted services including the scope and nature of the services provided and demonstrating compliance with regulations independently of any other facility.

Findings:

Review of a list of the hospitals contracted services revealed no contracts listed with Hospital "A".

In an interview on 5/9/16 at 3:30 p.m. with S1DON, she said the hospital had a list of contracts, but it did not appear to be complete and updated. S1DON said the contract with Hospital "A", where her hospital rented space, was not included on the current contract list.

S1DON verified the hospital contracted with Hospital "A" for medical supplies, wound care, laboratory services, non-invasive services, oncology, physical medicine, radiology, surgical services, respiratory services and code blue coverage. S1DON also said she could not locate all of the current contracts. She said she thought there was another binder with contracts, but she was not sure where it was located. S1DON said she could not be certain which contracts were missing from the current list although she knew some of the contracts on the list were old and not currently in use.

Based on record review and interview, the governing body failed to ensure the hospital had clear facility specific written policies and procedures for appraisal of emergencies, treatment and referral as appropriate for hospitals without emergency departments and met applicable state licensure requirements. This deficient practice is evidenced by the hospital, which is located within a hospital, utilizing the host hospital's policies, emergency room physician, an ICU nurse, a respiratory therapist and a nursing supervisor during "code blue" (cardio respiratory arrest) procedures.

Findings:

Extended Care of Southwest Louisiana is a hospital leasing space on the 3rd floor of Hospital "A".

Review of the Louisiana Hospital Licensing Standards (LAC 48:I. Chapter 93, Section 9305 L-3) revealed:
3. Staff of the hospital within a hospital shall not be co-mingled with the staff of the host hospital for the delivery of services within any given shift.

Review of the hospital policy titled Code Blue revealed in part:
Procedure: 1. Notify nurse's station by calling on the intercom or by pressing the Code Blue button located on the wall in the patient's room. Alternatively, the Hospital "A" dedicated phone may be used to dial 5555. The Hospital "A" Code Blue team, including the ER physician will respond.
Further review revealed no provision in the policy for providing physician coverage if the ER physician from Hospital "A" was busy with a patient and unable to attend the Code Blue at Extended Care of Southwest Louisiana.

Review of the hospital contract with Hospital "A" revealed the following verbiage:
13. Code Blue Coverage: Hospital "A" will provide "Code Blue" coverage consistent with Hospital "A" Code Blue Procedure, Policy Number TX-A-062.

Review of the Hospital "A" Policy and Procedure titled Code Blue Procedure, Policy Number TX-A-062, revealed in part:
Procedure
1. Person recognizing cardio respiratory arrest will activate "Code Blue" by pushing code blue button in patient room. The RN caring for the patient continues supervision of CPR until "code" team (from Hospital " A " ) arrives and the attending RN stays with patients during entire code.
4. The Code Blue Team will respond to codes in the hospital and follow ACLS guidelines according to the scope of practice of the licensed health care team. The code blue response team for inpatients consists of: ER physician, Critical Care Nurse, Respiratory Therapy and Nursing Supervisor.

Review of a list of Physician's with privileges at the hospital revealed no ER physicians from Hospital "A" were privileged.

Review of a Cardio Pulmonary Resuscitation Record for Patient #1 dated 1/1/16 revealed a code was called overhead at 5:40 p.m. CPR was also documented as having begun at that time. Further review revealed the code was called at 6:10 p.m. and the patient expired. The physician coding the patient was S11Physician (a physician from the Emergency Department at Hospital "A"). There was no documentation as to which staff members had attended the code with the code team.

In an interview on 5/9/16 at 2:15 p.m. with S1DON, she said when a Code Blue was called, the staff at the hospital initiated CPR and then Hospital "A" code team responded including the ER doctor. S1DON said ICU nurses and ER nurses, the nursing supervisor and respiratory therapists from Hospital "A" also responded to the code blue.

In an interview on 5/10/16 at 1:50 p.m. with S12CNE (Chief Nursing Executive at Hospital "A"), she said there was a code team at the hospital consisting of an ER physician, the ICU charge nurse, a respiratory therapist and the house nursing supervisor. She said the code team responded to codes at Extended Care of Southwest Louisiana. S12CNE said there were two ED physicians working in the ED at all times. She also said if both ED physicians were involved in a multiple trauma situation when a code was called neither of them would be able to leave their patients and respond to the code at Extended Care of Southwest Louisiana Hospital.

In an interview on 5/16/16 at 12:55 p.m. with S13Administrator, she said the Hospital's Code Blue policy did not address a backup plan if the host hospital's ED physician was busy with another patient and could not attend a Code Blue. S13Administrator said the code blue team consisted of an ED physician, a nurse from ICU, the house supervisor and a respiratory therapist. She said Hospital "A" was contracted with the hospital to provide Code Blue services. S13Administrator also said none of Hospital "A's" ED physicians were currently credentialed or privileged at the hospital.

Based on record review, observation and interview, the hospital failed to ensure all patients had the right to be free from restraints. This deficient practice is evidenced by 1 (#3) of 1 (#3) patients reviewed for restraints being enclosed in Vail bed as a means of fall prevention (Repeat deficiency from 10/08/15 survey).

Findings:

Review of the hospital policy titled Enclosure Bed revealed in part:
Enclosure bed- is a frame and fabric that attaches securely to MSH bed and has an opening for the mattress to be inserted. It has openings for tubing, such as Foley catheter or oxygen. It completely encloses the bed like a tent with netting. The netting can withstand a patient pushing or leaning on it without danger.
Objective: To provide a safe secure environment for a cognitively impaired patient at risk for injury from a fall.

Review of the medical record for Patient #3 revealed he was a 67 year old man admitted on 2/5/16 for therapy following a hemorrhagic stroke.

Review of the physician's orders for Patient #3 revealed an order dated 2/9/16 for 24 hour sitter care due to repeated falls. An order dated 2/10/16 was written for a vail bed. An order dated 2/12/16 had been written to discontinue sitter care and to continue the vail bed. Further review revealed orders for a Vail bed as a restraint dated 2/11/16 through 2/16/16 and 2/18/16 through 2/25/16. The clinical reasons listed for the restraints were interfering with treatment/equipment, confusion, getting out of bed/chair without needed assistance and unsafe mobility.

In an interview on 5/10/16 at 9:40 a.m. with S1DON, she said Patient #3 originally had sitters because he was a fall risk. S1DON said the hospital could not afford sitters and did not have the staff to provide a sitter 24 hours a day. S1DON said the vail bed had been ordered for fall prevention on 2/11/16 and discontinued on 2/25/16. S1DON verified the order listed the restraint as a means to prevent the patient from interfering with treatment/equipment, but that was not true. S1DON verified the vail bed could not keep Patient #3 from pulling his intravenous lines or Foley catheter, it was just used to keep him from falling. S1DON said he was unable to get out of the bed on his own.

Based on record review and interview, the hospital failed to ensure the use of restraints (Vail bed) was in accordance with a written modification to the patient's plan of care for 1 (#3) of 1 (#3) patient reviewed for restraints. (Repeat deficiency from 10/08/15 survey).

Findings:

Review of the medical record for Patient #3 revealed he was a 67 year old man admitted on 2/5/16 for therapy following a hemorrhagic stroke.

Review of the physician's orders for Patient #3 revealed an order dated 2/9/16 for 24 hour sitter care due to repeated falls. An order dated 2/10/16 was written for a vail bed. An order dated 2/12/16 had been written to discontinue sitter care and to continue the vail bed. Further review revealed orders for a Vail bed as a restraint dated 2/11/16 through 2/16/16 and 2/18/16 through 2/25/16.

Review of Patient #3's care plans revealed restraint use had not been identified as a problem and a plan of care developed.

In an interview on 5/10/16 at 9:40 a.m. with S1DON, she said Patient #3's care plan did not include the use of restraints but it should have.

Based on record review and interview, the hospital failed to ensure the Quality Assurance/Performance Improvement program measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of services and quality of care.

Findings:

Review of the Hospital's 2016 QAPI data revealed the hospital had not set goals for the following indicators: New or worsened pressure ulcer rates, dialysis, readmissions, % of patients with falls, % of patients with falls resulting in a major injury, telemetry strips interpreted, accucheck/insulin, catheterization, care plans, vital signs, refrigerator temperatures, speech services, wound vac dressing changes or ET assessment.

Review of the Hospital's 2016 QAPI data revealed the hospital had not collected data for the following indicators: Dialysis, critical lab results within 120 minutes of receipt, % of patients with falls, telemetry strips interpreted, accucheck/insulin, catheterization, care plans, vital signs, refrigerator temperatures, wound vac dressing changes or ET assessment.


In an interview on 5/10/16 at 9:00 a.m. with S10RD, she said she was the dietician for the hospital and over the QAPI program at the hospital since January 2016. S10RD verified the QAPI program at the hospital was not complete and representative of the hospitals functioning. S10RD also verified there were many indicators without established goals or without collected data.

Based on policy review, observation and interviews, the hospital failed to ensure the registered nurse supervised and evaluated the nursing care of each patient as evidenced by:

1. failing to assign staff to continuously monitor telemetry patients. This deficient practice had the potential to affect 4 (#2, #5, #R5, #R6) of 4 current patients on telemetry monitoring (Repeat deficiency from 10/08/15 survey); and

2. failing to ensure each patient was assessed at least every 24 hours by a registered nurse as required by the Louisiana State Board of Nurses' Practice Act. This deficient practice is evidenced by having patient care provided by licensed practical nurses without documented evidence of a RN assessment at a minimum of every 24 hours for 2 (#2, #4) of 5 current sampled patients reviewed for RN assessments.


Findings:

1. Failing to assign staff to continuously monitor telemetry patients.

Review of the Policy titled Telemetry, revealed in part:
Definition: A method for remotely monitoring cardiac rhythms on non-critical patients by a centralized monitoring station.
3. The Telemetry monitoring station will be attended at all times.
Person Responsible: RN, LPN

Review of documentation provided by the hospital revealed that on 5/9/16 there were 4 patients that were being monitored on telemetry (#2, #5, #R5, #R6).

In an observation on 5/9/16 at 10:00 a.m., the centralized telemetry monitor located in the nurses ' station was unattended by a nurse or any other staff member. S4Secretary was in the nurses ' station but had her back to the monitor and was on the telephone.

In an observation on 5/9/16 at 10:30 a.m., the telemetry monitor in the nurses ' station was unattended by a nurse or any other staff member. S4Secretary was in the station, but was entering labs into the computer. A chair was blocking her view of the telemetry monitor screen.

In an observation on 5/9/16 at 12:44 p.m., the telemetry monitor in the nurses' station was unattended by a nurse.

In an observation on 5/9/16 at 4:30 p.m., the telemetry monitor in the nurses' station was unattended by a nurse.

In an observation on 5/9/16 at 5:00 p.m. there were no staff members in or around the nursing station.

In an interview on 5/9/16 at 12:44 p.m. with S4Secretary, she said she was the unit secretary for the hospital. S4Secretary said she was not trained to interpret EKG strips. S4Secretary said nobody was assigned to watch the telemetry monitor and there was not always a staff member in the nurses ' station.

In an interview on 5/9/16 at 2:15 p.m. with S1DON, she said telemetry is monitored only at the nurses ' station. S1DON said the charge nurse or the unit secretary listens for alarms or arrhythmias. She said S4Secretary was not trained to interpret electrocardiogram strips or rhythms. S1DON also verified a nurse trained to interpret electrocardiogram strips was not always in the nurses ' station.

2. Failing to ensure each patient was assessed at least every 24 hours by a registered nurse as required by the Louisiana State Board of Nurses' Practice Act.

Review of the LSBN's Practice Act revealed that RNs may delegate select nursing interventions to the LPN provided the patient is assessed by an RN every 24 hours.

Review of the medical record for Patient #2 revealed she was a current patient that had been admitted on 3/24/16 with osteomyelitis of the left foot. Further review revealed from 5/6/16 at 7:00 p.m. until 5/8/16 at 7:00 a.m. (36 hours) Patient #2 had only been assessed by S3LPN and S5LPN. There was no documented assessment by a registered nurse during the previously mentioned time frame.

Review of the nurses' notes for Patient #4 revealed she was a current patient that had been admitted on 4/14/16 with osteomyelitis. Further review revealed from 5/6/16 at 7:00 p.m. until 5/8/16 at 7:00 a.m. (36 hours) Patient #4 had only been assessed by S3LPN and S5LPN. There was no documented assessment by a registered nurse during the previously mentioned time frame.

In an interview on 5/10/16 at 8:24 a.m. with S1DON, she said a RN was supposed to assess a patient at least once every 24 hours if the patient was being taken care of by LPNs. S1DON said she did not have a policy on RN's assessments of patients.

Based on policy review, observation and interview, the facility failed to ensure the confidentiality of patient records. This deficient practice is evidenced by failing to ensure unauthorized individuals at Hospital "B" could not gain access to patient's records at Extended Care of Southwest Louisiana.

Findings:
In an observation on 5/16/16 at 1:50 p.m., S14RN at the hospital was able to access the census at Hospital "B" on her computer. S14RN randomly chose a patient (#R7) and opened their medical record. S14RN was able to view Patient #R7's medication administration record, nurse ' s notes, and laboratory results.

In an observation at Hospital "B" on 5/17/16 at 10:00 a.m., S15RN was able to obtain a census at Extended Care of Southwest Louisiana Hospital. S15RN then randomly chose a patient (#5) and was able to access the medical record.

In an interview on 5/16/16 at 1:50 p.m. with S14RN, she said she was able to access medical records at Hospital "B" .

In an interview on 5/16/16 at 2:35 p.m. with S13Administrator, she said she was unaware the staff could access random patients medical records at Hospital "B" . She said there would be no need for the staff to have access to medical records at Hospital "B".

In an interview on 5/16/16 at 3:18 p.m. with S16MedicalRecords, she said the nurses at the hospital could access parts of Hospital "B's" patient's medical records. S16MedicalRecords said there would be no reason to be able to access random patient's records at Hospital "B" but that was the way the system was set up when they moved in December 2015. She also said there were no safeguards in place to prevent employees from accessing the medical records at Hospital "B". S16MedicalRecords said she was not sure if the nurses at Hospital "B" could access random patient's medical information at her hospital, but she was thinking they probably could.

In an interview on 5/16/16 at 3:30 p.m. with S17AsstMR (Assistant Director Medical Records) at Hospital "B", she said if a nurse wanted to view a patient's medical record at Extended Care of Southwest Louisiana they could.

Based on record review and interview, the hospital failed to ensure all verbal orders were authenticated by the ordering practitioner within 10 days as required by state regulations and hospital policy for 2 (#3, #5) of 5 patients sampled. The hospital also failed to ensure verbal orders were dated and timed when authenticated by the ordering practitioner for 2 (#3, #5) of 5 patients sampled.

Findings:

Review of the hospital policy titled Transcription of Medical Orders revealed in part:
2. Telephone and verbal orders must be signed by the physician within 10 days.

Patient #3
Review of Patient #3's physician's orders dated 2/11/16 revealed a verbal order to change his formula to Glucerna. The verbal order had been authenticated but the signature had not been dated and timed.

Review of Patient #3's physician's orders dated 2/12/16 revealed a verbal order to discontinue sitter care and continue the vail bed. The verbal order had never been signed by the physician.

Review of Patient #3's telephone orders for restraints dated 2/22/16, 2/23/16, and 2/25/16 revealed the verbal orders had not been signed by the physician.

Review of Patient #3's physician's orders dated 2/25/16 revealed a verbal order for a diet change. The verbal order had never been signed by the physician.

Patient #5
Review of Patient #5's physician's orders dated 5/2/16 revealed a verbal order that had been written at 5:00 p.m. The verbal order had been authenticated but the signature had not been dated and timed.

In an interview on 5/10/16 at 1:30 p.m. with S1DON, she verified physician ' s verbal orders should have been signed, dated and timed within 10 days of the order.