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Based on record review and interview, the governing body failed to ensure contracted services were provided in a safe and effective manner. The deficient practice is evidenced by failure of the facility to establish a policy addressing the procedure to be followed when patients are transported outside the hospital for medical care.
Findings:

Review of the medical record for Patient #3 revealed admission on 02/26/2024 and discharged on 03/18/2024. Further review revealed the Patient #3 had no discharge orders.

In interview on 04/18/2024 at 2:15 p.m., S3DON explained Patient #3 was taken unchaperoned to an appointment at another facility via the contracted transport and never returned. The incident was investigated and the facility determined that the patient had left AMA. During the interview, S3DON verified she did not know if the facility had a policy requiring patients who were taken to offsite care to be chaperoned, but stated a chaperone was routinely provided for the offsite visits, but in this case, the driver left without the chaperone.

On 04/18/2024 at 2:15 p.m., the surveyor requested the transport policy or a policy for offsite medical care.

In interview on 04/18/2024 at 3:25 p.m., S3DON verified the policy could not be found.

Based on observation and record review, the facility failed to ensure it was capable of informing each patient of his/her rights in a manner that he/she could understand. The deficient practice is evidenced by failure to ensure interpreter services were available if required.
Findings:

Review of Policy 14424767, "Communication, Non-English Speaking," last approved 05/2017, revealed in part, "If language or communication barriers exist between staff and patients, arrangements shall be made for interpreters of for the use of other mechanisms to ensure adequate commenication between patients and staff."

On 04/17/2024 at 12:23 p.m., S3DON tried to use the tablet used for translation services, but stated her passcode was not correct.

Review of the contract for translation services revealed the contract was from 10/29/2012 and renewed and annually. Further review of the contract revealed the services were billed monthly and there was a surcharge if the average monthly use was below the projected usage in the agreement.

On 04/18/2024 at 10:00 a.m., the surveyor request proof of monthly payments to the translating service.

On 04/18/2024 at 3:45 p.m., S1Adm verified she had not received proof the facility was still paying for the service and stated there was no one there that knew the access code to show that it was still active.

Based on record review and interview, the facility failed to report all incidents of possible abuse or neglect. The deficient practice is evidenced by failure to report possible abuse or neglect as required by R.S. 40:2009.20 in 1(#3) of 1 reviewed incident where the patient did not return to the facility as planned.
Findings:

Review of LA R.S. 40:2009.20 revealed in part, "Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, licensed practical nurse, nurse's aide, home- and community-based service provider employee or worker, personal care attendant, respite worker, physician's assistant, physical therapist, or any other direct caregiver having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect."

Review of the medical record for Patient #3 revealed the documentation in the patient's medical record ended on 03/18/2024. There were no discharge orders and no discharge summary.

In interview on 04/18/2024 at 2:15 p.m., S3DON verified that the patient left the facility but was not discharged. On 03/18/2024 the patient was transported unchaperoned from the facility to a physician's appointment at Hospital B. Once the nursing staff realized the patient had been transported without a chaperone, two members of the staff traveled to Hospital B to look for him, but could not find him. The police, physician, and the patient's daughter were notified of the missing person. An in investigation was conducted and it was determined that the transport driver left without the chaperone. The patient was considered to have left against medical advice because they felt he was at baseline despite a history of bipolar disease with psychotic features. S3DON verified the staff involved were disciplined, but a self- report of possible neglect was not generated because management felt the facility was not responsible for the incident.

Based on record review and interview, the facility failed to provide a nursing care plan per hospital policy. The deficient practice is evidenced by failure to develop a nursing care plan within 8 hours of admission for 1(#3) of 3 (#1-#3) reviewed patient records.
Findings:

Review of Policy #14224971 "Patient Care Standards," last approved 02/2015, revealed in part, "A total physical and emotional assessment will be made for each patient immediately upon admission. Assessment will be ongoing. A nurses admission and assessment record" will be filled out for each patient admitted within 2 hours of admission and completed within eight (8)."

Review of the medical record for Patient #3 revealed admission on 02/26/2024 at 9:45 p.m. Review of the nursing assessment revealed it was completed 02/29/2024 at 4:01 p.m.

In interview on 04/18/2024 at 1:56 p.m., S3DON verified the assessment was not completed within 8 hours.

Based on record review and interview, the facility failed to ensure patient assignments were completed daily at the start of each shift. the deficient practice is evidenced by failure of the nursing staff to complete the assignments at the begining of the shift on the first day of the survey.
Findings:

During the entrance conference on 04/17/2024, Nurse Staffing Assignemnts were requested for the past 2 months.

On 04/17/2024 at 12:05 p.m., the surveyor reviewed the provided documents and noted the Nursing Assignment for the current shift was not provided.

On 04/17/2024 at 12:16 p.m., the surveyor requested the document from S3DON. S3DON then asked S4RN who verified she was working on the assignments and would provide them shortly.

Based on record review and interview, the hospital failed to ensure nursing staff followed hospital policies. The deficient practice is evidenced by: 1) failure to perform glucometer controls on 5 of 12 reviewed days and failure to report or repeat an out of range control result; and 2) failure to ensure a staff registered nurse provided supervision of contract nurses.
Findings:

1) Failure of nursing staff to perform glucometer controls on 5 of 12 reviewed days and failure to report or repeat an out of range control result.

Review of Policy #14224970, "Glucometer Quality Controls Testing," last approved 03/2015, revealed in part, "Quality Control testing will be performed nightly by the nursing staff. Quality control log is maintained on the nursing unit and results are monitered by the DON. . . . PROCEDURE- See manufacture's instructions for use." There was no information in the policy of the procedure for out of range results.

Review of the Glucometer Maintenance Quality Control Record from 04/05/2024 through 04/16/2024 revealed the controls were not performed 04/07/2024, 04/08/2024, 04/11/2024, 04/14/2024, and 04/16/2024.

Further review revealed on 04/05/2024 at 11:00 p.m. a low control of 39 was documented which was out of the standard range of 42-72. There was no documentation that the result was repeated or a supervisor notified.

At the time of discovery on 04/17/2024 at 12:23 p.m., S3DON verified the above findings.

2) Failure to ensure a staff registered nurse provided supervision of contract nurses.

Review of the Daily Staffing Assignement sheet for 03/10/2024 for the evening shift revealed the only Registered Nurse on the assignment sheet was an agency nurse.

In interview on 04/18/2024 at 1:30 p.m., S3DON verified the agency nurse was the charge nurse for the evening. S3DON stated that S1ADM was frequently at the facility all night and was a Registered Nurse. S3DON verified there was no documention S1Adm had supervised the care provided by the agency nurse.

Based on record review and interview, the facility failed to ensure prn medications were given according to standard of care. The deficient practice is evidenced by failure to re-evaluate the patient for efficacy of the medication after administration.
Findings:

Review of Policy #14198058, "Medication Administration," last approved 01/2022, revealed in part, "14. Patient response to medications is documented on back of MAR or in nurse's notes . . . "

Review of the Medication Administration Record for Patient #2 revealed an order for oxycodone 5 milligram- give one by mouth every 4 hours as needed. The medication was administered on 04/13/2024 at 6:25 p.m. for pain 7 of 10. The response to the medication was not documented. The medication was also administered on 04/17/2024 at 6:00 p.m. and the reason for administration and the response were not documented.

In interview on 04/18/2024 at 2:55 p.m., S3DON verified the documentation was not per standard of care and hospital policy.

Based on record review and interview, the facility failed to ensure verbal orders were documented according to hospital policy and standard of care. The deficient practice is evidenced by verbal orders documented without identifying the prescribing practitioner in 1(#2) of 3 (#1-#3) reviewed medical records.
Findings:

Review of Policy #14968023, "Acceptance of Physician's Telephone/ Verbal Orders," revealed in part, "The licensed professional taking the order shall note confirmed verbal or telephone order, date and time, physician's name, and sign the entry with first initial, last name, and credentials of the person order on the physician order sheet."

Review of the orders for Patient #2 revealed the following orders documented on 04/10/2024 by S10RN:
-Oxycodone 10 mg tab. Give one tablet by mouth one hour prior to wound care.
-Benadryl 25 mg tab. Give one tablet by mouth twice a day as needed for itching.
-Juven BID. Liquacel 30 ml TID by mouth.
-Ensure TID. Large portions no pork or gelatin.

The orders were not documented as verbal orders or telephone orders and did not have the name of the prescribing practitioner.

In interview on 04/18/2024 at 2:53 p.m., S3DON verified the orders were not documented as verbal orders and did not have the name of the prescribing practitioner.

Based on record review and interview, the hospital failed to meet requirements for medical records. The deficient practice is evidenced by failure to include a discharge summary in the medical record for 1(#3) of 1 reviewed record of a patient who was no longer at the facility.
Findings:

Review of the medical record for Patient #3 revealed the patient was admitted on 02/26/2024 with a diagnosis of spinal trauma. On 03/18/2024 the patient was transported to a medical visit at a facility outside the hospital and never returned.

Review of the medical record on 04/18/2024 failed to reveal a discharge summary with the outcome of the hospitalization and provisions for follow-up csre.

In interview on 04/18/2024 at 2:49 p.m., S3DON verified there was no discharge summary and no discharge order because the patient was not discharged by the physician.

Based on observation and interview the facility failed to ensure stock medications were handled according to standard of care. The deficient practice is evidenced by 1) failure to the nursing staff to label all multi-dose bottles with the date of opening or a beyond use date; 2) failure to discard unusable influenza vaccinations; 3) failure to monitor temperature on the medication refrigerator and document medications were discarded when the temperature was out of range.
Findings:

1) Failure to the nursing staff to label all multi-dose bottles with the date of opening or a beyond use date

Direct observation on 04/17/2024 at 10:05 a.m. revealed the following open multi-dose bottles with no open date and no beyond use date:

Magnesium oxide 400mg
B12 1000 mg
Vitamin A 10,000 units
Bisacodyl 5 mg
Vitamin D3 50,000 iu
Ferrous sulfate 325 mg
Vitamin C250 mg
Simethicone 80 mg
Maalox 400 mg
Nexium 20 mg
Tylenol 325 mg
Melatonin 3 mg
Folic Acid 400 mcg
Renal Caps
Aspirin 81 mg- 2 bottles
Fish oil 1000 mg
Probiotics
Diphenhydramine 25 mg
Loratadine 10 mg
Thiamine 100 g
MVI
Calcium Carbonate 500 mg

In interview on 04/17/2024 at 10:45 a.m., S11CP verified the findings. S11CP verified it was standard of care for health care facilities to label open stock medications with the date of opening or the beyond use date, but was not aware of the facility's policy because the contracted pharmacy did not supply or manage the over the counter stock medications for the facility.

In interview on 04/18/2024 at 3:09 p.m., S3DON verified it was standard of care to label the open stock medications with the date of opening or beyond use date. S3DON verified she was not aware of the hospital's established beyond use date and could not find a policy that addressed the issue. S3DON called a second pharmacist at the contracted pharmacy and was told the hospital's administration handled the management of the over the counter medications.

2) Failure of the hospital to discard unusable influenza vaccinations.

Tour of the medication room on 04/17/2024 between 10:05 a.m. and 11:15 a.m. revealed a box of influenza vaccination syringes with part of the box frozen to the back of the refrigerator.

In interview on 04/18/2024 at 11:33 a.m., S3DON was verified the finding and stated they should have already been thrown away because it was too late to be administering flu shots.

3) Failure of the hospital to monitor temperature on the medication refrigerator and document items were discarded when the temperature was out of range.

Review of Policy #15153723, "Refrigerator Guidelines," last approved 03/2024, revealed in part, "Medicine refrigerator: -Only refrigerated medications are allowed in Medication Refrigerator. -Temperature range for refrigerator should remain between 36 -40 degrees F. -Temperatures are recorded twice a day on Log (attached) by designated staff member. -If the temperature falls out of the acceptable range, troubleshooting may include adjusting the temperature dial or contacting maintenance. Troubleshooting should be documented on the log."

Tour of the facility on 04/17/2024 at 10:30 a.m., revealed the refrigerator contained Novalog insulin, Glargin YFGN insulin, and influenza vaccinations. The refrigerator was noted to have a large buildup of ice in the back of the refrigerator.

Review of the April 2024 log for the refrigerator revealed the statement, "Temperature must be 40 degrees or below." Documentation revealed refrigerator temperature was not checked on 04/02/2024, 04/03/2024, 04/04 /2024, 04/07/2024, 04/12/2024, 04/13/2024, 04/14/2024, and 04/16/2024. The refrigerator was checked once on 04/01/2024, 04/05/2024, 04/06/2024, 04/08/2024, 04/09/2024, 04/10/2024, 04/11/2024, and 04/15/2024. Of those dates the refrigerator was out of range on 04/08/2024 when the temperature was documented as 50 degrees F, and 04/15/2024 when the temperature was documented as 52 degrees F. The log contained no documentation of troubleshooting or notification of maintenance.

In interview on 04/17/2025 at 10:35 a.m., S3DON verified the refrigerator had not been properly maintained.

Based on observation and interview, the hospital failed to maintain the facility and supplies to an acceptable level of safety and quality. The deficient practice is evidenced by 1) failure to provide hot water for handwashing in the patient nourishment room; and 2) Using tape to hold the battery in the temporal thermometer.
Findings:

Tour of the facility on 04/14/2024 between 10:05 a.m. and 11:15 a.m. revealed there was no water released from the faucet in the patient nourshiment room when the knob for hot water was turned and the temporal thermometer in the rolling basket with the blood pressure cuff had tape holding the battery case closed.

In interview on 04/17/2024 at 10:59 a.m., S3DON verified the tape on the thermometer.

In interview on 04/17/2024 at 2:45 p.m., S3DON verified the hot water had been disconnected because the faucet was used as an eye wash station.

Based on record review and interview the hospital failed to ensure food was maintained to prevent bacterial growth. The deficient practice is evidenced by 1) failure to maintain the temperature log for the patient nourishment refrigerator; 2) failure to prevent storage of previously consumed items in the patient nourishment refrigerator; 3) failure to monitor the temperature of food served at the facility.
Findings:

Review of Policy #15153723, "Refrigerator Guidelines," last approved 03/2024, revealed in part," Patient nourishment refrigerator: . . . Temperatures are recorded daily on Log (attached) by designated staff member. . . .Partially consumed food cannot be returned to the refrigerator/freezer for later consumption."

1) Failure of the facility to maintain the temperature log for the patient nourishment refrigerator.

Tour of the facility on 04/17/2024 between 10:05 a.m. and 11:15 a.m. revealed the logs on the patient nourishment refrigerator temperature was not checked on 04/01/2024 - 04/06/2024. 04/09/2024, 04/13/2024, and 04/14/2024.

In interview on 04/17/2025 at 11:14 a.m., S5RN verified the logs were not filled out every day.

2) Failure of the hospital to prevent storage of previously consumed items in the patient nourishment refrigerator.

Direct observation on 04/17/2024 at xx revealed a styrofoam cup with a straw from a fast food chain with approximately 80% of the contents consumed.

In interview on 04/17/2025 at 11:14 a.m., S4RN verified the partially consumed drink was an infection control issue.

3) Failure to monitor the temperature of food served at the facility.

Review of Policy #14224659, Food Delivery," last approved 03/2015, revealed in part, "PERFORMANCE IMPROVEMENT: 1. PI tasks, such as checking food line for temperature, texture, and accuracy of preparation as well as sanitation testing will be performed by the nursing staff, 2, Random food temperature checks will be performed by a member of the Nutritional Staff."

During tour of the facility on 04/17/2024 at 11:13 a.m., the surveyor noted the metal cart used for distributing meals was sitting unattended near the nursing desk. At 11:23 a.m. S7PCT began moving the cart down the hall and began to distribute the meals without checking the temperature.

In interview on 04/17/2024 at 11:24 a.m., S7PCT verified the staff were not instructed to check the temperatures before distributing the meals. S7PCT verified the temperatures were only checked before they left the kitchen.