HospitalInspections.org

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Radiologic Services as evidenced by failing to appoint a qualified Radiologist on either a full-time, part-time or consulting basis to supervise the contracted radiology services provided to hospital patients. See findings in tag A-0546.

Based on record review and interviews the Governing Body failed to ensure that all services provided by contract and agreement were evaluated to identify quality and performance problems and/or implement appropriate corrective or improvement activities to ensure the monitoring and sustainability of those contracted services. This failed practice was evidenced by no evaluation of contracted linen services or dialysis services provided outside of the hospital.

Findings:

Review of Quality Assurance documentation revealed no quality indicators for services provided by contract or agreement.

In an interview 6/11/15 at 12:33 p.m. S2Quality reported the hospital's Quality Assurance program did not have any indicators for services provided by contract or agreement.

In an interview 6/11/15 at 3:10 p.m. S18Administrator reported that contracted services were not evaluated annually. S18Administrator reported he could not provide an evaluation for linen or dialysis services.

Based on record review and interview, the hospital failed to ensure patients had the right to be free from unnecessary restraints as evidenced by placing a patient in a waist restraint and side rails while in bed as a means of fall prevention for 1 (#7) of 5 (#2, #3, #4, #7, #8) patients reviewed for restraints.

Findings:

Review of the medical record for Patient #7 revealed she had been admitted to the hospital with diagnoses that included Leukocytosis, Hypoxia, Pneumonia and Urinary Tract Infection.

Review of the Patient Assessment Flow Sheet for Patient #7 revealed the following documentation on 4/28/15:
6:20 p.m. - Found on mat on floor by bed. Put back in bed. No injury noted. Nurse Manager and MD (medical doctor) notified.
7:00 p.m. - Found on mat on floor by bed. Put back in bed. Confused. No injury noted. Nurse Manager and S10MD notified. Soft waist restraint put on. Bed in low position with side rails x (times) 2. Low bed with mats.

Review of the medical record for Patient #7 revealed one of the alternative interventions listed before applying a waist restraint on 4/28/15 was increased observation. Patient #7 was documented as falling out of bed at 6:20 p.m. and 7:00 p.m. on 4/28/15 and being put into a waist restraint at 7:05 p.m. (5 minutes after last fall). Increased observation of Patient #7 was not documented until Patient #7 was placed into a waist restraint. Further review revealed alternatives prior to applying the waist restraint were selected from a preprinted list as concealing device/line (not the reason for the restraint), patient education and reorientation (documented on the order sheet as confused and unable to follow directions), and repositioning the patient.

Review of the medical record for Patient #7 revealed the waist restraint was documented as having been applied on 4/28/15 at 7:05 p.m. and removed on 5/1/15 at 5:45 p.m.

Review of the Restraint Procedure Check Sheet for Patient #7 dated 4/29/15 revealed in part:
Types of Restraints Ordered: Soft Wrist
Reason for Restraints: Falling OOB (out of bed).

Review of the preprinted Restraint Order Sheet revealed instructions to assess patients on admission and on an ongoing basis for their potential to fall and that patients considered at high risk may necessitate the use of restraint devices.

Review of the Patient Assessment Flow Sheet for Patient #7 dated 4/28/15 revealed at 7:00 p.m. she was assessed as being awake and alert.

Review of the care plan for restraints for Patient #7 revealed it had not been updated after the application of restraints on 4/28/15.

In an interview on 6/10/15 at 1:40 p.m. with S2Quality, she verified the documentation for Patient #7 did not show increased supervision or applicable documentation for alternatives for to the waist restraint on 4/28/15. S2Quality also verified the Restraint Order Sheet needed to be updated because it included a provision that patients considered at high risk for falls may necessitate the use of restraint devices. S2Quality also said fall prevention is not a reason for restraints.

Based on record review and interview, the hospital failed to ensure patients' plans of care were modified for the use of restraints for 4 (#2, #3, #4, #7) of 4 (#2, #3, #4, #7) patients reviewed for care planning for restraint usage.

Findings:

Review of Patient #2's medical record revealed he was admitted to the hospital on 4/15/15 and discharged on 4/23/15. Further review revealed he had been placed in soft wrist restraints on 4/15/15.

Review of Patient #3's medical record revealed she was admitted to the hospital on 5/15/15 and discharged on 5/25/15. Further review revealed she had been placed in soft wrist restraints on 5/15/15.

Review of Patient #4's medical revealed she was admitted to the hospital on 5/15/15 and discharged on 5/20/15. Further review revealed she had been placed in soft wrist restraints on 5/15/15.

Review of Patient #7's medical record revealed she was admitted to the hospital on 4/22/15 and discharged on 5/2/15. Further review revealed she had been placed in soft wrist restraints on 4/22/15.


Review of the care plans for Patient #2, Patient #3, Patient #4 and Patient #7 revealed no modifications to include restraint use as a problem.


In an interview on 6/9/15 at 1:16 p.m. with S1DON, she verified the patients' care plans were not individualized to include restraint use.

30984

Based on record review and interview, the hospital failed to ensure data was collected to identify opportunities for improvement and change that would lead to improvement in patient care as evidenced by failing to identify and develop corrective actions related to identified deficiencies in A. Restraint use, B. Consents, and C. not tracking re-admissions to the hospital within 30 days of discharge.

Findings:

A. Restraint use
Review of the medical record for Patient #7 revealed she had been admitted to the hospital with diagnoses that included Leukocytosis, Hypoxia, Pneumonia and Urinary Tract Infection.

Review of the Patient Assessment Flow Sheet for Patient #7 revealed the following documentation on 4/28/15:
6:20 p.m. - Found on mat on floor by bed. Put back in bed. No injury noted. Nurse Manager and MD (medical doctor) notified.
7:00 p.m. - Found on mat on floor by bed. Put back in bed. Confused. No injury noted. Nurse Manager and S10MD notified. Soft waist restraint put on. Bed in low position with side rails x 2. Low bed with mats.

Review of the medical record for Patient #7 revealed the waist restraint was documented as having been applied on 4/28/15 at 7:05 p.m. and removed on 5/1/15 at 5:45 p.m.

Review of the Restraint Procedure Check Sheet for Patient #7 dated 4/29/15 revealed in part:
Types of Restraints Ordered: Soft Wrist
Reason for Restraints: Falling OOB (out of bed).

In an interview on 6/10/15 at 1:40 p.m. with S2Quality, she verified the documentation for Patient #7 did not show increased supervision or applicable documentation for alternatives for to the waist restraint on 4/28/15. S2Quality also verified the Restraint Order Sheet needed to be updated because it included a provision that patients considered at high risk for falls may necessitate the use of restraint devices. S2Quality also said fall prevention is not a reason for restraints.


B. Consents


Review of the QAPI documentation, presented by S2Quality, revealed no documented evidence of identification of the hospital's failure to obtain consents from patients or their representative on each admission to the hospital.


In an interview 6/11/15 at 9:00 a.m. S1DON reported that a patient's consent from his/her Long Term record were copied and placed on the Acute Care Hospital chart. These consents, although some are almost 30 years old, were used for the current admission. S1DON indicated if there was a policy and procedure for consents, she would have to get it from the administrator. S1DON verfied that a new consent was not obtained for patients when they were admitted to the hospital.

In an interview on 6/11/15 at 12:33 p.m. S2Quality verified that the hospital's failure to obtain consents for each patient admission had not been identified as a problem.



C. Not tracking re-admissions to the hospital within 30 days of discharge.

Review of the QAPI documentation, presented by S2Quality, revealed no documented evidence of tracking of readmissions to the hospital within 30 days of discharge.

In an interview on 6/11/15 at 12:33 p.m. with S2Quality, she confirmed hospital readmissions within 30 days of discharge had not been analyzed, tracked or trended through QAPI. She agreed multiple hospital re-admissions should have been identified, tracked and trended.

Based on record review and interview, the hospital failed to employ methods to identify, measure, analyze and track medical errors as evidenced by failing to identify, measure, analyze and track near miss and close call medication errors.

Findings:

Review of S2Quality's QAPI documentation revealed the hospital had no method in place to identify, measure, analyze and track near miss and close call medication errors.
In an interview on 6/8/15 at 9:55 a.m. with S21Pharmacist, he confirmed the hospital had no method in place to identify, measure, analyze and track near miss and close call medication errors.
In an interview on 6/10/15 at 1:20 p.m. with S2Quality, she confirmed near miss and close call medication errors were not being monitored through QAPI.

Based on record review and interview, the hospital failed to ensure that it conducted performance improvement projects that were hospital specific as part of its QAPI (Quality Assurance Performance Improvement) program.

Findings:

Review of the QAPI records presented by S2Quality revealed no documented evidence of any hospital specific performance improvement projects.

In an interview on 6/11/15 at 12:33 p.m. with S2Quality, she indicated QAPI was not specific to hospital. S2Quality confirmed there were no hospital specific performance improvement projects.

Based on record review and interviews, the governing body failed to ensure that the hospital's QAPI (Quality Assessment Performance Improvement) program reflected the hospital's organization and services as evidenced by not having all hospital departments and services, including those services furnished under contract or agreement, involved in the QAPI Plan.

Findings:

Review of the hospital's QAPI documentation revealed no documented evidence that the following departments had been included in the QAPI Plan: Linen Services (contracted) and Dialysis (provided by agreement).

In an interview on 6/11/15 at 12:33 p.m. with S2Quality she confirmed the following services had not been included in the QAPI Plan: Linen Services (contracted) and Dialysis (provided by agreement).

Based on record review and interview the hospital failed to ensure the Medical Staff By-Laws included a requirement that a medical history and physical examination be completed and documented, by a physician or other qualified practitioner, for each patient no more than 30 days before or 24 hours after admission or registration. This deficient practice was evidenced by the absence of these requirements in the Medical Staff By-Laws.

Findings:

Review of the Medical Staff By-Laws, Rules, and Regulations, revision date 10/24/04, provided by S2Quality as current , revealed the following, in part:
"...Article II Purpose: It shall be the purpose of this organization to provide medical care and treatment, of highest quality, for all patients admitted to [name of hospital]. In order to maintain such service, each physician assumes responsibility for carrying out the following duties:...2. The adoption of by-laws conforming to the principles expressed by the Conditions for Participation in the Medicare Program and the Minimum Standards for Hospitals..." Further review revealed Attachment #3, "Rules and Regulations" revealed no requirement that a medical history and physical examination be completed and documented, by a physician or other qualified practitioner, for each patient no more than 30 days before or 24 hours after admission or registration.

In an interview 6/11/15 at 3:24 p.m. confirmed the Medical Staff by-laws and Rules & Regulations did not have a requirement related to every patient having a History and Physical within 30 days prior to admission or within 24 hours after admission.

Based on record review and interview the hospital failed to ensure the By-Laws of the Medical Staff included a requirement of an updated examination of the patient, including any changes in the patient's condition, to be completed and documented within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, when the medical history and physical examination are completed within 30 days before admission or registration. The updated examination of the patient, including any changes in the patient's condition, must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oromaxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy.

Findings:

Review of the Medical Staff By-Laws, Rules, and Regulations, revision date 10/24/04, provided by S2Quality as current , revealed the following, in part:
"...Article II Purpose: It shall be the purpose of this organization to provide medical care and treatment, of highest quality, for all patients admitted to [name of hospital]. In order to maintain such service, each physician assumes responsibility for carrying out the following duties:...2. The adoption of by-laws conforming to the principles expressed by the Conditions for Participation in the Medicare Program and the Minimum Standards for Hospitals..." Further review revealed Attachment #3, "Rules and Regulations" revealed no requirement that when the medical history and physical examination are completed within 30 days before admission or registration, an updated examination of the patient, including any changes in the patient's condition, was to be completed and documented within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia . The updated examination of the patient, including any changes in the patient's condition, must be completed and documented by a physician (as defined in section 1861(r) of the Act), an oromaxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy.


In an interview on 6/11/15 at 3:24 p.m. with S2Quality, she confirmed the Medical Staff by- laws and Rules & Regulations did not have a requirement related to every patient having an updated examination, including any changes in the patient's condition, to be completed and documented within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, when the medical history and physical examination was completed within 30 days before admission or registration. The updated examination of the patient, including any changes in the patient's condition, would be completed and documented by a physician an oromaxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy.

Based on record review and interview, the hospital failed to ensure a registered nurse (RN) was assigned to one unit to provide immediate availability for bedside care of a patient.

Findings:

Review of the assignment sheets for the hospital dated 4/14/15 revealed S12RN was taking care of Patient #8, Patient #12 and Patient #9 in the hospital. S12RN was also assigned to Patient #R1, Patient #R2 and Patient #R3 on a separate hall containing skilled nursing home patients.

In an interview on 6/8/15 at 9:10 a.m. with S19RN, he said when the hospital had patients, he took care of them with the nursing home patients. He also said he would be the only RN with a LPN (Licensed Practical Nurse) on the hospital unit.

In an interview on 6/9/15 at 10:30 a.m. with S12RN, he said he took care of patients on the skilled nursing wing and on the hospital unit at the same time. He said he worked with a LPN and was the only RN for the two units.

In an interview on 6/9/15 at 12:36 p.m. with S12RN, he said he was the only RN assigned to the building most of the time. He said other than the hospital in the building there was a Tuberculosis unit and two skilled nursing units. S12RN said when there was a patient coding (requiring cardio pulmonary resuscitation), he attended the code on the other unit. S12RN also said if a code was called in the other building on campus he attended that also.

An interview on 6/9/15 at 1:20 p.m. with S1DON revealed the RN on the hospital unit was the only RN assigned to patients in the building. S1DON verified the RN took care of patients on the skilled nursing unit and sometimes the Tuberculosis unit, if needed, while taking care of the hospital patients.

Based on record review and interview, the hospital failed to ensure the nursing staff developed, and kept current, individualized and comprehensive nursing care plans for each patient for 7 (#1, #2, #3, #4, #5, #6 #7) of 7 (#1, #2, #3, #4, #5, #6 #7) patients sampled for care planning out of a total sample of 30 patients.

Findings:

Patient #1
Review of the medical record for Patient #1 revealed he was admitted on 3/19/15 with diagnoses which included IDDM (Insulin Dependent Diabetes Mellitus) Type II with Hypoglycemia and Dementia with Psychosis.

Review of Care Plans for Patient #1 revealed no problems identified for IDDM (Insulin Dependent Diabetes Mellitus) Type II with Hypoglycemia and Dementia with Psychosis. Further review revealed the care plans for Patient #1 were documented on a pre-printed form with various choices for nursing diagnosis, interventions, goals and outcomes. The care plans were not specific, individualized, and contained no measurable goals.

Patient #2
Review of the medical record for Patient #2 revealed he was admitted on 4/15/15 with diagnoses which included a right lateral decubitus ulcer, a left heel decubitus ulcer and Schizophrenia.

Review of Care Plans for Patient #2 revealed no problems identified for wounds or Schizophrenia. Further review revealed the care plans for Patient #2 were documented on a pre-printed form with various choices for nursing diagnosis, interventions, goals and outcomes. The care plans were not specific, individualized, and contained no measurable goals.

Patient #3
Review of the medical record for Patient #3 revealed she was admitted on 5/15/15 with diagnoses which included Non-Insulin Dependent Diabetes Mellitus (NIDDM), Hypertension (HTN), Dementia and Bipolar Disorder.

Review of Care Plans for Patient #3 revealed no problems identified for NIDDM, HTN, Dementia or Bipolar Disorder. Further review revealed the care plans for Patient #3 were documented on a pre-printed form with various choices for nursing diagnosis, interventions, goals and outcomes. The care plans were not specific, individualized, and contained no measurable goals.

Patient #4
Review of the medical record for Patient #4 revealed she was admitted to the hospital on 5/15/15 with diagnoses which included IDDM, Tuberculosis, Hypertension, Bipolar Disorder, Paranoia and Psychosis.

Review of Care Plans for Patient #4 revealed no problems identified for IDDM (Insulin Dependent Diabetes Mellitus), Tuberculosis, Hypertension, Bipolar Disorder, Paranoia and Psychosis. Further review revealed the care plans for Patient #4 were documented on a pre-printed form with various choices for nursing diagnosis, interventions, goals and outcomes. The care plans were not specific, individualized, and contained no measurable goals.


Patient #5
Review of the medical record for Patient #5 revealed she was admitted on 5/1/15 with diagnoses which included COPD (Chronic Obstructive Pulmonary Disease), Hypertension, Tuberculosis and Chronic Paranoid Schizophrenia.
Review of Care Plans for Patient #5 revealed no problems identified for COPD, Hypertension, Tuberculosis and Chronic Paranoid Schizophrenia. Further review revealed the care plans for Patient #5 were documented on a pre-printed form with various choices for nursing diagnosis, interventions, goals and outcomes. The care plans were not specific, individualized, and contained no measurable goals.

Patient #6
Review of the medical record for Patient #6 revealed he was admitted on 4/22/15 with diagnoses which included Stage II decubitus, LLE (Left Lower Extremity) Cellulitis, CPS (Carbamoyl Phosphate Sythetase Deficiency) , Seizure Disorder, COPD (Chronic Obstructive Pulmonary Disease), Constipation, Dementia, PVD (Peripheral Vascular Disease), Anemia, Left Wrist Medication Burn, and Infected Left Heal Ducubitus Ulcer.

Review of Care Plans for Patient #6 revealed no problems identified for infection, wounds , COPD, Seizure Disorder, Dementia, PVD, or Anemia. Further review revealed the care plans for Patient #6 were documented on a pre-printed form with various choices for nursing diagnosis, interventions, goals and outcomes. The care plans were not specific, individualized, and contained no measurable goals.

Patient #7
Review of the medical record for Patient #7 revealed she was admitted on 4/22/15 with diagnoses which included COPD (Chronic Obstructive Pulmonary Disease) and Tuberculosis.
Review of Care Plans for Patient #7 revealed no problems identified for COPD or Tuberculosis. Further review revealed the care plans for Patient #7 were documented on a pre-printed form with various choices for nursing diagnosis, interventions, goals and outcomes. The care plans were not specific, individualized, and contained no measurable goals.

In an interview on 6/9/15 at 1:16 p.m. with S1DON, she verified the patients' care plans were not specific or individualized and were not all inclusive of the patients' diagnoses.

Based on record review and interview, the hospital failed to ensure that drugs and biologicals were administered in accordance with the orders of the physician and hospital policy as evidenced by:
1) failure to provide documentation that an order had been obtained for administration of intravenous Dextrose 50% for the treatment of hypoglycemia for 1 (#1) of 6 (#1,#2,#4,#9,
#11, #14) Insulin Dependent Diabetic patients reviewed;
2) failing to ensure a medication was not given in excess of the prescribed dosing schedule for 1 (#3) of 15 (#1- #15) patients reviewed for medication administration errors.
3) failure to administer a medication as ordered for 1 (#11) of 15 (#1- #15) patients reviewed for medication errors.

Findings:

1) Failure to provide documentation that an order had been obtained for administration of intravenous Dextrose 50% for the treatment of hypoglycemia.

Review of Patient #1's medical record revealed he was admitted to the hospital on 3/19/15. Further review revealed the patient had a diagnosis of IDDM (Insulin Dependent Diabetes Mellitus) Type II. Additional review revealed an order for accucheck with SSI (sliding scale insulin) q (every) six hours.

Review of Patient #1's nurses notes (Diabetic Chart section) revealed the following entries:
3/19/15 23:45 (11:45 p.m.): Glucometer results: 42, 1/2 ampule D50 (50% Dextrose) IVP (intravenous push) given.
3/20/15 02:00 a.m.: Glucometer results: 53, 1/2 ampule D50 (50% Dextrose) IVP (intravenous push).

Review of Patient #1's physician's orders revealed no documented evidence of an order for administration of D50 IVP for the dose administered 3/19/15 at 11:45 p.m. nor for the dose administered 3/20/15 at 02:00 a.m.

In an interview on 6/11/15 at 4:00 p.m. with S1DON, she confirmed, after review of Patient #1's medical record, that there were no documented physician orders for the above referenced IVP D50 doses (administered to the patient for treatment of hypoglycemia).


2) Failing to ensure a medication was not given in excess of the prescribed dosing schedule.

Review of the medical record for Patient #3 revealed she was admitted on 5/15/15. Further review revealed a Physician ' s Order for Dulcolax 10 mg (milligrams) by mouth every Monday, Wednesday, Friday and Sunday.

Review of the Medication Administration Record for Patient #3 revealed documentation that Dulcolax 10 mg had been given on 5/16/15 (Saturday) and 5/21/15 (Thursday).

In an interview on 6/10/15 at 9:48 a.m. with S1DON, she verified she could not find documentation as to why the extra doses of the Dulcolax had been given to Patient #3 on 5/16/15 and 5/21/15.


3) failure to administer a medication as ordered by the physician

Review of Patient #11's medical record revealed she was a 75-year-old female admitted to the hospital on 01/08/15 with CHF (Congestive Heart Failure) exacerbation, COPD (Chronic Obstructive Pulmonary Disease) exacerbation, and DMII. Patient #11 was transferred to another acute care hospital on 01/11/15 at 1:20 p.m.

Review of Patient #11's physician orders revealed an order dated 01/10/15 at 2:00 p.m. for Lasix 60 mg (milligrams) IM (intramuscular) every morning (scheduled for 7:00 a.m.) to begin on 11/11/15.

Review of Patient #11's entire medical record revealed the Lasix 60 mg, IM, was not given as ordered.
In an interview on 06/11/15 at 1:30 p.m., S1DON confirmed the dosage of Lasix 60 mg was not administered to Patient #11 as ordered and should have been administered as ordered.








31048

Based on record review and interview, the hospital failed to ensure the Medical Record Department was organized and staffed to meet the requirements of Federal and State laws and regulations. This deficient practice was evidenced by no hospital employee with the state required registration or accreditation supervising the Medical Record Department.
Findings:
Review of State of Louisiana Hospital Regulations (LA Title 48, Part I, Chapter 93, Subchapter H, Statute 9387.B) revealed the following: "Medical Records shall be under the supervision of a medical records practitioner (i.e., registered record administrator or accredited record technician) on either a full-time, part-time, or consulting basis."

Review of a hospital organizational chart revealed the Medical Records Department was under the direction of the DON (Director of Nursing).

Review of a Contract between the State of Louisiana/the Hospital and S11RHIT revealed a contract with an effective date of 7/1/12 and a termination date of 6/30/15. Further review revealed a brief description of Services to be provided as, "[S11RHIT] shall serve as qualified medical records practitioner, supervising the medical records department."


In an interview 6/9/15 at 1:30 p.m. S3MedicalRecords reported that she is the medical record employee, and another employee in her office is the admission staff, but also helps with medical records. S3MedicalRecords reported that she did not have specialized training, registration, or certification in Health Information/Medical Records. She stated she had on the job experience only. S3MedicalRecords reported that she does not have a supervisor, and reported to S1DON. S3MedicalRecords further reported S11RHIT (Registered Health Information Technician) was a contracted medical records consultant, but did not supervise the Medical Records Department.

In a phone interview 6/10/15 at 10:52 a.m. S11RHIT verified she had a contract with the hospital for consultative services in Medical Records. S11RHIT reported that she was not the director or supervisor of the Medical Record Department. S11RHIT further reported that she went to the hospital site every other quarter and her services included :
Follow-up on coding, has in the past reviewed and updated some policies and procedures, reviewed of files for confidentiality, release of information, and provides education regarding CMS (Centers for Medicare and Medicaid Services) guidance and updates. The RHIT reported that she had provided information to S3MedicalRecords pertaining to ICD-10 training (dual coding) for an upcoming training in August. S11RHIT reported that she was not aware that her contract gave a brief description of her services that included supervision of the Medical Record Department.

In an interview 6/11/15 at 3:30 p.m. The Administrator verified that S3MedicalRecords reported to S1DON.

Based on observation and interview, the hospital failed to ensure Hospital patients medical records were retained in a manner that would protect them from water damage in the event the sprinkler system was activated.

Findings:

In an observation 6/9/15 at 3:00 p.m., of the medical record department, Patient medical records were observed on top of a shelf in the office area of S3MedicalRecords, and all shelving (5 units that take up 3 of 4 walls as well as 2 in the middle of the records room). Patient medical records were also noted to be stacked on 2 tables in the middle of the records room. All records were either on open shelving or stacked uncovered on tables. A sprinkler system was noted in the office. Further observation revealed no means of protection in place to prevent water damage of the records if the sprinkler system was activated.

An observation on 6/9/15 at 3:10 p.m. with S3MedicalRecords revealed a large room in a different building from the medical records department. In this room, referred to as "the library" by S3MedicalRecords, were multiple cardboard file storage boxes. S3MedicalRecords said she was unable to determine how many records were in the room, and of the records, how many of them were hospital (Acute Care Unit) records. She reported the medical records for the hospital were separated from the LTC (Long Term Care) records with a rubber band, but were filed in the folder that contained the patient's LTC records. Further observation revealed a sprinkler system, but no protection from water damage. S3MedicalRecords verified none of the records were in any way protected from water damage.

Based on record review and interview, the hospital failed to ensure orders and protocols were dated, timed, and authenticated promptly in the patient's medical record by the ordering practitioner or another practitioner responsible for the care of the patient as evidenced by failure to place an authenticated, dated and timed copy of the hospital's Insulin Sliding Scale in each patient's chart for 5 (#1, #4, #9, #11, #14) of 5 patients reviewed who were receiving insulin per the hospital's sliding scale protocol.

Findings:

Review of the hospital's protocols revealed the hospital had an established Insulin Sliding Scale Protocol.

Patient #1
Review of Patient #1's medical record revealed he was admitted to the hospital on 3/19/15. Further review revealed the patient had a diagnosis of IDDM (Insulin Dependent Diabetes Mellitus) Type II. Additional review revealed an order for accucheck with SSI (sliding scale insulin) q (every) six hours.

Review of Patient #1's medical record revealed no documented evidence of inclusion of a copy of the hospital's Insulin Sliding Scale Protocol that had been authenticated, dated, and timed by the prescribing practitioner caring for the patient.


Patient #4
Review of Patient #4's medical record revealed she was admitted to the hospital on 5/15/15. Further review revealed the patient had a diagnosis of IDDM (Insulin Dependent Diabetes Mellitus) Type II. Additional review revealed an order for accucheck with SSI (sliding scale insulin) AC (before meals) and HS (hour of sleep).

Review of Patient #4's medical record revealed no documented evidence of inclusion of a copy of the hospital's Insulin Sliding Scale Protocol that had been authenticated, dated, and timed by the prescribing practitioner caring for the patient.

Patient #9
Review of the medical record for Patient #9 revealed he was a 66-year-old male admitted to the hospital on 03/26/15 with diagnoses which included Infected Left Heel Decubitus Ulcer, Unstageable; Osteomyelitis; and Insulin Dependent Diabetes Mellitus (IDDM), Type II. Patient #9 was transferred to another acute care hospital on 03/28/15.

Review of Patient #9's medical record revealed no documented evidence of inclusion of a copy of the hospital's Insulin Sliding Scale Protocol that had been authenticated, dated, and timed by the prescribing practitioner caring for the patient.

Patient #11
Review of Patient #11's medical record revealed she was a 75-year-old female admitted to the hospital on 01/08/15 with CHF (Congestive Heart Failure) exacerbation, COPD (Chronic Obstructive Pulmonary Disease) exacerbation, and DMII. Patient #11 was transferred to another acute care hospital on 01/11/15.

Review of Patient #11's medical record revealed no documented evidence of inclusion of a copy of the hospital's Insulin Sliding Scale Protocol that had been authenticated, dated, and timed by the prescribing practitioner caring for the patient.


Patient #14
Review of Patient #14's medical record revealed he was admitted to the hospital on 12/20/14. Further review revealed the patient had a diagnosis of IDDM (Insulin Dependent Diabetes Mellitus) Type II. Additional review revealed an order for accucheck q 6 hours with SSI (sliding scale insulin) per hospital protocol.

Review of Patient #14's medical record revealed no documented evidence of inclusion of a copy of the hospital's Insulin Sliding Scale Protocol that had been authenticated, dated, and timed by the prescribing practitioner caring for the patient.

In an interview on 6/8/15 at 2:01 p.m. with S1DON, she confirmed the hospital had an established Insulin Sliding Scale Protocol. S1DON agreed a copy of the hospital's Insulin Sliding Scale Protocol (authenticated, dated and timed by the prescribing practitioner) had not been present in the chart of each patient who had been receiving insulin per the hospital's sliding scale protocol.













31048

30420

Based on record review and interview the hospital failed to obtain properly executed consent forms for all patients admitted to the hospital. This deficient practice was evidenced by consents copied and placed on the hospital medical record in place of obtaining consents signed for the current hospital admission for 5 of 5 ( #5, #6 #7, #20, #30 ) medical records without current consents for admission to the hospital, of a total sample of 30.

Findings:


After requests on 6/9/15, 6/10/15, and 6/11/15 no policy and procedure related to obtaining consents in the hospital was provided.

Review of a typed medical records policy and procedure titled "The Conditions of Participation for Hospitals", provided in a binder by S3MedicalRecords as most current approved policy, revealed the following, in part:
"...All records must document the following (as appropriate):...5. Properly executed consent forms for procedures and treatments...

Review of a policy titled, "Acute Care Admissions", (Medical Records/Admission, 1995) revealed, in part the following: ....3. d. Patients covered by Medicare must have an "Important Message from Medicare" and Medicare Information forms completed, signed and placed on the patient's chart. (a) Patients unable to sign must have "Unable to Sign" on the forms and witnessed by two competent witnesses. e. Advance Directives must be on all charts. f. Consent for Restraints must be on all charts if restraints are ordered by the attending physician.


Patient #5
Review of the medical record for Patient #5 revealed she was admitted to the hospital on 5/1/15. Further review revealed the Consent for the Use of Safety/Protective-Devices/Restraints was dated 11/4/92.

Patient #6
Review of the medical record for Patient #6 revealed she was admitted to the hospital 4/22/15. Further review revealed a "Declaration for Qualified Patient Who Has not Previously Made Declaration", which designated no resuscitation was preferred for Patient #6, and signed by a cousin 10/28/02, an Advanced Directive signed by Patient #6 1/15/92, a "Consent for the use of Safety/Protective-Devices/Restraints" signed by Patient #6 and dated 11/5/92, an authorization to use certain identifiable patient information was signed by Patient #6 and dated 10/20/03.

Patient #7
Review of the medical record for Patient #7 revealed she was admitted to the hospital on 4/22/15. Further review revealed her General Consent for Medical and Surgical Treatment and For Release of Medical Information was dated 11/10/04.

Patient #20
Review of the medical record for Patient #20 revealed he was admitted to the hospital 4/29/14 for malnutrition. Further review revealed a Advanced Directive Acknowledgment signed by Patient #20, dated 9/2/11 with no witnesses, an acknowledgment of receipt of information ( Patient's rights, Smoking Regulations, Rules and Responsibilities, MDS [Minimum Data Set] Automation Process, Hospital Visitation, and Abuse and Neglect Policy], signed and dated by Patient #20 on 9/2/11, a general consent form for medical and surgical treatment signed and dated by Patient #20, Information regarding Restraint Use for Residents and Families signed and dated by Patient #20 9/2/11 (no witness), and an Informed Consent for Use of Chemical/Physical Restraints, signed and dated by Patient #20 (no witness). The patient identification label on the consents and acknowledgments contained Patient #20's name and the long term care patient identification number, which was different from the hospital number for his 4/29/14 admission.

Patient #30
Review of the medical record for Patient #30 revealed she was admitted to the hospital on 9/1/14. Further review revealed her General Consent for Medical and Surgical Treatment and For Release of Medical Information was dated 8/18/93 and her Consent for Treatment was dated 3/7/88.


In an interview 6/9/15 at 9:50 a.m. S3MedicalRecords reported she did not think they (the hospital) had a policy on consents- getting consents on admission to the hospital, who can consent for patients, etc. S3MedicalRecords reported there had been some correspondence with a DHH (Department of Health and Hospitals attorney about the consent forms, but nothing had been changed as of yet.

Review of the correspondence with a DHH attorney dated 1/16/15 and 1/22/15 and provided by S3MedicalRecords revealed the attorney indicated the same consent form could be used for the LTC (Long Term Facility) facility and the Hospital, as long as it indicated which provider for which it was used.

In an interview 6/11/15 at 9:00 a.m. S1DON reported that a patient's consent from his/her Long Term record were copied and placed on the Acute Care Hospital chart. These consents, although some are almost 30 years old, were used for the current admission. S1DON indicated if there was a policy and procedure for consents, she would have to get it from the administrator. S1DON verfied that a new consent was not obtained for patients when they were admitted to the hospital.

31048

Based on record review and interviews, the hospital failed to ensure each patient's medical record included a complete and comprehensive discharge summary for discharged and/or transferred patients for 3 of 3 (#9, #11, #21) medical records reviewed for discharge summaries in a total sample of 30 records. Findings:

Review of Policy Number 03-41.0-0000, with an issue date of 02/27/03, presented as current, entitled "Transfer and Discharge Summaries--Physician Responsibilities" revealed, in part:
"Policy: Discharge/transfer summaries should be appropriate and timely to ensure continuity of care. Ordinarily, a resident should not be transferred or received unless accompanied by adequate information.
Procedure: The attending physician will complete a comprehensive discharge summary for the resident's medical record within 30 days of discharge or transfer to another facility. This discharge summary will include at least the following: a description of any recent acute illness or program necessitating the move; a list of major medical diagnoses and problems; a summary of the clinical course while in the facility; pertinent physical and laboratory findings; a list of current medications; and any pertinent information about competence, mental status, and resident wishes or code status. The discharge/transfer summary for the resident coming to the facility from the acute hospital should describe the hospital course, as well as current diagnoses (and how these were arrived at), current medications, new or modified treatments, follow up care, and names of those physicians who treated or consulted on the individual while in the hospital.

Patient #9
Review of the medical record for Patient #9 revealed he was a 66-year-old male admitted to the hospital on 03/26/15 with diagnoses which included Infected Left Heel Decubitus Ulcer, Unstageable; Osteomyelitis; and Insulin Dependent Diabetes Mellitus (IDDM), Type II. Patient #9 was transferred to another acute care hospital on 03/28/15.

Review of Patient #9's medical record revealed there was no discharge summary in the record. Further review revealed a brief progress/transfer note by the physician dated 03/28/15 at 10:02 a.m. which documented: the patient's vital signs; patient was awake, alert, and in no acute distress; results of radiological exam revealed Osteomyelitis of calcaneous (heel); history of CAD (Coronary Artery Disease), Diabetes Mellitus, Type II (DMII), and Hypertension (HTN); the patient was transferred to (name of hospital) emergency room (ER) for Osteomyelitis; and the name of the physician at the receiving ER.


Patient #11
Review of Patient #11's medical record revealed she was a 75-year-old female admitted to the hospital on 01/08/15 with CHF (Congestive Heart Failure) exacerbation, COPD (Chronic Obstructive Pulmonary Disease) exacerbation, and DMII. Patient #11 was transferred to another acute care hospital on 01/11/15.

Review of Patient #11's medical record revealed there was no discharge summary in the record. Further review revealed a brief progress/transfer note by the physician dated 01/11/15 at 12:10 p.m. which documented: a few lab values; oxygen saturation level; vital signs with heart rhythm; weight; patient was wheezing; abdomen soft, non-tender; extremities with no edema (swelling); listed diagnoses as CHF exacerbation, COPD, DMII; patient was being transferred to another acute care facility for cardiac concerns.

Patient #21
Review of the medical record for Patient #21 revealed he was admitted to the hospital 9/7/14 with primary diagnoses of Hypernatremia and Dehydration. Secondary diagnoses included, in part, Hypernatremia, Hyperchloremia, Altered Mental Status, Seizure Disorder, and Acute Renal Insuffiency (ARI).Further review revealed he was transferred to another acute care hospital 9/17/15. No discharge summary was found in the medical record. Review of the Physician's progress notes revealed a transfer note dated 9/17/15 that documented the patient had a CBC that day, diagnoses of worsening ARI and dehydration. The transfer note indicated that the patient would be transferred to [name of hospital] ER for further care.

In an interview on 06/09/15 at 1:20 p.m., S3MedicalRecords indicated she was informed by the medical staff/administration discharge summaries were not required for patients being transferred out of the hospital back to their nursing home or transferred to another acute care hospital because the patients were "not discharged, only transferred." S3MedicalRecords also indicated she was informed that the only requirement for patients being transferred out of the hospital to another facility was a written transfer note in the Physician's Progress Notes. S3MedicalRecords confirmed there was only a brief transfer note in the Physician's Progress Notes and there was no discharge summary completed for Patient #9 and Patient #11.

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Radiologic Services as evidenced by failing to appoint a qualified Radiologist on either a full-time, part-time or consulting basis to supervise the contracted radiology services provided to hospital patients.

Findings:

Review of the hospital's organizational chart revealed no documented evidence that a credentialed Radiologist had been appointed by the Governing Body to supervise Radiology Services.

Review of the personnel file for with S4AsstAdm revealed no documented evidence of experience or training in Radiology. S4AsstAdm's educational background was a Bachelor of Science degree with an emphasis on social work.

In an interview on 6/10/15 at 9:21 a.m. with S4AsstAdmin, said he was manager of Radiological Services. S4AsstAdmin confirmed he had no background, experience or training related to Radiology. He also confirmed the Governing Body had not appointed a Radiologist to serve as Director of Radiological Services.

Based on personnel record review and interview, the hospital failed to ensure personnel using radiological equipment were deemed qualified by medical staff as evidenced by failure to evaluate skills competencies for 1(S8Radiology) of 1 Radiology employee whose personnel file was reviewed for qualifications. S8Radiology was the only Radiology Technician employed by the hospital.

Findings:

Review of the personnel file for with S8Radiology revealed no documented evidence of current skills competency evaluations.

In an interview on 6/10/15 at 9:21 a.m. with S4AsstAdmin, he indicated he was manager of Radiological Services. S4AsstAdmin confirmed he had no background, experience or training related to Radiology. He also confirmed he had not evaluated S8Radiology's skills competencies. He agreed S8Radiology's skills competencies should have been evaluated by a Radiologist or staff with a Radiological background who had been deemed competent to perform evaluations.

Based on record review and interview, the hospital failed to ensure the person designated as the infection control officer was qualified.

Findings:

Review of the personnel file for S20RN revealed no documented evidence of experience as an infection control officer or training in infection control.

In an interview on 6/10/15 at 11:10 a.m. with S20RN, she verified she was the infection control officer at the hospital. She said she did not have any certifications in infection control or any previous experience as an infection control specialist. S20RN said she had been reading infection control information, but she could not provide documentation of the training.

Based on record review and interview, the hospital failed to have written policies and procedures in place to address the hospital's organ, tissue, and eye procurement responsibilities. Findings:

Review of Policy Number 02-02.23-0000, entitled "Death of a Resident Protocol" dated 11/99, presented by S1DON as the only policy and procedures related to the death of patients, revealed, in part: "Objective: 1. To prepare the body properly after death. Equipment: 1. Death Certificate-kept on Building II, Ward A; 2. Death Packet-kept on Building II, Ward A; 3. Disposable gown; 4. Clean dressings, if needed; 5. Clean linen; 6. Body bag (if body sent to morgue).
Procedure: 1. Physician determines that death has occurred; 2. Bathe body. All tubing and dressings should be removed. Clean dressings should be applied as needed. personnel should use same infection control precautions; 3. Dentures are placed in the mouth; 4. The body should be dressed in a disposable gown and positioned on back with arms folded over abdomen; 5. The body should be covered with clean linen; 6. All components of death packet should be completed. Notice of death must be completed by Registered Nurse and sent to: a. Social Services; b. Medical Director; c. Medical Records; d. Administrator; 7. The death packet and death certificate should be taken to Guard House.
Procedure for Body sent to Morgue (At another facility): 1. Steps 1-3 from above should be followed; 2. Place body with underpad under rectal area; 3. Place arms on abdomen and lightly tie arms together; 4. Secure chin strap if necessary; 5. Place morgue tag from Death Packet on wrist and ankle; 6. Place body in a body bag; 7. Place morgue tag around neck on outside of body bag; 8. Notify ambulance service to take body to (name of sister facility); 9. A completed morgue slip is given to and left with the morgue attendant; 10. Notice of death contained in death packet must be completed by Registered Nurse and sent to as listed above on #6; 11. Take death packet to Guard House."

In an interview on 06/11/15 at 1:10 p.m., S1DON confirmed the above referenced policy was the only hospital policy related to patient deaths, and S1DON confirmed the above-referenced policy did not address the hospital's responsibilities for organ procurement and the policies and procedures should address the hospital's responsibility for organ, tissue, and eye procurement services.

Based on record review and interview, the hospital failed to procure an agreement and/or contract with an eye bank to cooperate in the retrieval, processing, preservation, storage and distribution of eyes from potential donors. Findings:

Review of the agreement between the hospital and the organ procurement agency revealed the organ procurement agency agreement did not include services for the procurement of eyes from potential donors.

In an interview on 06/11/15 at 8:45 a.m., S1DON indicated she was not aware of any agreement or contract with an eye bank for potential donation.

In an interview on 06/11/15 at 4:15 p.m., S18Administrator confirmed the hospital did not have an agreement or contract with an eye bank.

Based on record reviews and interviews, the hospital failed to ensure an individual with the necessary knowledge, experience, and capabilities had been designated as the Director of Rehabilitation (Rehab) Services and was responsible for supervising and administering the services.
Findings:

Review of the personnel file for with S4AsstAdm revealed no documented evidence of experience or training in Rehabilitation Services. S4AsstAdm's educational background was a Bachelor of Science degree with an emphasis on social work.

In an interview on 6/10/15 at 9:21 a.m. with S4AsstAdm, he confirmed he was manager of Rehabilitation Services. He also confirmed he had no experience or training in Rehabilitation Services.

Based on record reviews and interviews, the hospital failed to ensure that physical therapy (PT), occupational therapy (OT), and speech therapy-language pathology (ST) services were provided by qualified therapists as evidenced by failure to have current competency evaluations for 3 (S5PT, S6OT and S7ST) of 3 rehabilitation (rehab) employees whose personnel files were reviewed for qualifications from a total of 3 rehab employees.

Findings:

Review of the personnel files for S5PT, S6OT and S7ST revealed no documented evidence of current competency evaluations.

In an interview on 6/10/15 at 9:21 a.m. with S4AsstAdm, he confirmed he was manager of Rehabilitation Services. He also confirmed he had not conducted competency evaluations for S5PT, S6OT and S7ST. He agreed S5PT, S6OT and S7ST's competencies should have been evaluated by staff with a Rehab background who had been deemed competent to perform evaluations.