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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 telemedicine services were furnished for radiological services. This deficient practice was evidenced by failure of the hospital to ensure that each physician furnishing radiological telemedicine services was granted privileges at the hospital.

Findings:

Review of the hospital's contracted services revealed a contract with a mobile X-ray company to provide on location radiological services.

Review of the list of the hospital's credentialed physicians, presented as current by S1Adm, revealed the hospital had not credentialed and privileged any radiologists.

In an interview on 05/25/2022 at 10:31 a.m., S1Adm confirmed the hospital's radiological services were provided via contract with a mobile X-ray company. S1Adm indicated X-rays obtained by the mobile X-ray service would have been interpreted by radiologists affiliated with the mobile X-ray service. S1Adm confirmed none of the radiologists were credentialed and privileged by this hospital.

Based on observation and interview, the hospital failed to ensure patients received care in a safe setting as evidenced by the hospital failing to have medical gas piping and a vacuum system to service all of the medical needs of the patients.

Findings:
A review of the Life Safety Codes Revealed in part:

NFPA 99:5.1 Category 1 Piped Gas and Vacuum Systems.

NFPA 99:5.1.1* Applicability.

NFPA 99:5.1.1.1 These requirements shall apply to health care facilities that require Category 1 systems as referenced in Chapter 4.

NFPA 99:4.1.1* Category 1. Facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers shall be designed to meet system Category 1 requirements as defined in this code.

On 05/24/2022 from 7:30 a.m. - 8:15 a.m. an observation was made of the hospital's 10 single occupancy inpatient rooms. Further observation of rooms 113, 114, 115, 116, 117, 118, 119, 120, 121, and 122 revealed there were no piped oxygen outlets available for administration of oxygen in the patient rooms.

In an interview at 2:20 p.m. on 05/23/2022 with S1Adm, stated she was aware of the need for a completed piped gas assessment and has completed it on the SFM (State Fire Marshall's) web site. She also stated she communicated via phone with SFM office to correct a typo and re-submit the assessment on the SFM web site. She states she re-submitted the assessment Friday, 06/20/2022. She also stated that she is aware that we are writing hospitals for this and she already has a plan of correction.

Based on record review and interview, the hospital failed to ensure initial reports of allegations of patient abuse/neglect of care were reported to Louisiana Department of Health within 24 hours of awareness of the allegation, as required by LDH-HSS, for 1 (#30) of 1 sampled patients reviewed for self-reports of incidents of alleged neglect of care to LDH-HSS from a total patient sample of 30.

Findings:

Review of the LDH hospital/licensed provider Abuse/Neglect Initial Report form revealed the self-report form was to be completed and submitted via email to HSS within 24 hours of awareness of an allegation of abuse/neglect.

Review of the hospital's incident reports revealed the following incident report, dated 08/11/2021, indicating Patient #30 had eloped from the hospital and had walked 1.1 miles to her mother's home (per Google mapping of the distance between the address of the patient's mother's home referenced in the incident report and the hospital), at 8:15 p.m. while on one on one supervision (staff assigned to be with patient at all times) for safety.

Further review revealed the following: Pre-event parameter: Disoriented. Other occurrences - fall, elopement.
Description of event: Incident occurred 08/11/2021 at 8:15 p.m.: Pt. had a fall earlier after dinner. Pt. very impulsive, and gets up without notice. On 08/11/2021 - Pt. had one on one supervision with tech and pt. in room. Pt in room with aide at door till 8:15 p.m. Night shift tech given report and went to room and pt. not in room. Staff began looking for patient. Pt. got through the window. Staff went in vehicle to look for pt. DON notified at 8:30 p.m.
8:45 p.m.: Pt. sister notified pt. missing.
9:00 p.m.: Sister called and informed pt. was found under Mom's carport porch and that patient was not coming back.

Additional review of documentation, provided by S2DON, related to the elopement of Patient #30 revealed no documented evidence that the patient's elopement had been reported as alleged abuse/neglect of care to LDH-HSS within 24 hours of discovery.

In an interview on 05/25/2022 at 11:15 a.m. with S1Adm, she confirmed the elopement of Patient #30 occurred while the patient was on one on one supervision for safety had not been reported to LDH-HSS as an alleged abuse/neglect of care incident. She indicated Patient #30 had told the CNA assigned to supervise her one on one that she could not sleep with someone watching her. She indicated the CNA had left the room and the patient had removed the screen from the window and had "log-rolled" herself out of the window of her hospital room (per video review of the incident). She reported Patient #30 had walked to her mother's home when she left the hospital. S1Adm indicated she had not been aware that she needed to report the incident to LDH-HSS as alleged neglect of care. She further reported the CNA assigned to the patient had not supervised the patient as ordered and had been terminated.

Based on QAPI (quality assurance performance improvement) documentation review and interview, the hospital failed to identify opportunities for improvement. This deficient practice was evidenced by failing to identify and address issues related to tracking delinquent medical records per individual physicians and failure to document delinquency rates (30-60-90-day delinquency rates) as issues to be addressed through the hospital wide QAPI program

Findings:

Review of the hospital's QAPI plan and PI indicators revealed tracking of delinquent medical records per individual physicians and failure to document delinquency rates (30-60-90-day delinquency rates) had not been identified as areas in need of improvement to be addressed through the hospital's QAPI program.

In an interview on 05/23/2022 at 2:30 p.m. with S1Adm, she stated the hospital had not kept a complete list of delinquent medical records, broken down by time period of delinquency for records (30-60-90-day delinquency rates), and individual physician delinquency rates, or corrective actions taken.

In an interview on 05/25/2022 at 12:50 p.m. with S1Adm, she confirmed they had known there were issues with medical records being incomplete but they were so busy during the pandemic and handling so many crises, like their former building flooding, that they didn't track and trend the medical record issues as a PI indicator for QA. She confirmed there were no corrective actions taken to bring deficient medical records into compliance.

Based on record review, observations, and interviews, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care of each patient as evidenced by failure to ensure a Patient (#30) placed on one on one supervision for safety was observed, as ordered, by assigned staff for 1(#30) of 1 sampled patients reviewed for elopement from a total patient sample of 30. This failure resulted in Patient #30, who was impulsive, disoriented, had an unsteady gait, and had a history of a recent fall, being able to elope from the hospital by climbing out of the window and walking 1.1 miles to her mother's home at 8:15 p.m. in the evening.

Findings:

Review of Patient #30's Assessment notes revealed the following entries:
08/11/2021 4:30 pm: Pt. transferred from a hospital in New Orleans. Pt is obese and has incision to left side of head. Family came with pt. S14MedDir notified. Pt. is one on one due to brain mass. Pt. has unsteady gait.
5:00 p.m.: Pt. at nurse station due to impulsive.
5:30 p.m.: Pt. fell getting up out of wheelchair. Pt. has one on one sitter and denies pain. Pt. will be closely monitored due to mental issue - unstable.

Further review of Patient #30's medical record revealed the pt. had the following fall risk indicators: confused, disoriented, impaired judgement, unsteady on feet - fall risk outcome: high risk is 45 points or more. Patient #30's score was 50.

Review of the hospital's incident reports revealed the following incident report, dated 08/11/2021, indicating Patient #30 had eloped from the hospital and had walked to her mother's home (1.1 miles per Google mapping of the distance between the address in the incident report and the hospital), at 8:15 p.m., while on one on one supervision (staff assigned to be with patient at all times) for safety.
Further review revealed the following: Pre-event parameter: Disoriented. Other occurrences - fall, elopement.
Description of event: Incident occurred 08/11/2021 at 8:15 p.m.: Pt. had a fall earlier after dinner. Pt. very impulsive, and gets up without notice.
On 08/11/2021 - Pt. had one on one supervision with tech and pt. in room. Pt. in room with aide at door till 8:15 p.m. Night shift tech given report and went to room and pt. not in room. Staff began looking for patient. Pt. got out through the window. Staff went in vehicle to look for pt.
DON notified at 8:30 p.m.
8:45 p.m.: Pt. sister notified pt. missing.
9:00 p.m.: Sister called and informed pt. was found under Mom's carport porch and that patient was not coming back.

In an interview on 05/24/2022 at 2:30 p.m. with S2DON, she confirmed Patient #30 had eloped from the hospital, after review of the incident report documentation. S2DON further confirmed, after review of Patient #30's medical record, that Patient #30 had been on one on one staff supervision for safety when she eloped. S2DON indicated she had not been DON at the time of the incident.

In an interview on 05/25/2022 at 11:15 a.m. with S1Adm, she confirmed Patient #30 had eloped while on one on one supervision for safety. She indicated Patient #30 had told the CNA assigned to supervise her one on one that she could not sleep with someone watching her. She indicated the CNA had left the room and the patient had removed the screen from the window and had "log-rolled" herself out of the window of her hospital room (per video review of the incident). She reported Patient #30 had walked to her mother's home when she left the hospital. S1Adm confirmed the CNA had not supervised the patient one on one as ordered. She further reported the CNA assigned to the patient had been terminated for failure to supervise the patient as ordered.

Based on record review and interview, the hospital failed to ensure the organization of the medical record service was appropriate to the scope and complexity of the services performed as evidenced by:
1. failure of the hospital to employ a qualified director of the Medical Records Department that was HIM or RHIA certified; and
2. failure of the hospital to maintain an accurate list of delinquent medical records reflecting the time period of delinquency (30-60-90-day delinquency rates), the individual physician delinquency rate, and/or corrective action taken.

Findings:

1. Failure of the hospital to employ a qualified director of the Medical Records Department that was HIM or RHIA certified.
.
Review of the hospital's contracts revealed a contract dated 05/09/2017 with S5MR, who was an RHIA.

In an interview on 05/23/2022 at 12:40 p.m. with S1Adm, she stated that there was no one person over medical records.

In a telephone interview on 05/24/2022 at 1:00 p.m. with S5MR, she confirmed that she was RHIA certified, but was no longer contracted with the hospital. She further stated that her last contact with the hospital was in 2018.

2. Failure of the hospital to maintain an accurate list of delinquent medical records reflecting the time period of delinquency (30-60-90-day delinquency rates), the individual physician delinquency rate, and/or corrective action taken.

On 05/23/2022 a request for a list of delinquent medical records for review was made to S1Adm.

In an interview on 05/23/2022 at 2:30 p.m. with S1Adm, she stated the hospital had not kept a complete list of delinquent medical records, time period of delinquency for records (30-60-90-day delinquency rates), individual physician delinquency rates, or corrective actions taken.

In an interview on 05/25/2022 at 12:50 p.m. with S1Adm, she confirmed they had known there were issues with medical records being incomplete but they were so busy during the pandemic and handling so many crises, like their former building flooding, that they didn't address the medical record issues.

Based on interviews and record reviews, the hospital failed to ensure medical records were properly executed related to the informed consent for procedures and treatments and patient rights. This deficient practice was identified for 3 (#1, #3 and #4) of 4 ( #1-#4) current sampled patient records from a total patient sample of 30 (#1- #30).

Findings:

Review of the policy and procedure titled, "Patient Rights and Privacy" revealed, in part, the purpose was to ensure all staff of the hospital and all of its programs understand and respect the rights of all patients. Patient's Rights applies to all hospital programs including inpatient and outpatient rehabilitation hospital. Further review revealed the procedure, in part, A. Upon admission to the program, notification of Medicare Rights is obtained for each patient. Rights will be explained by designated staff in simple terms that the patient clearly understands; B. Upon admission to the hospital, an initial consent to treat will be obtained prior to initiation of admission paperwork or evaluations; and, D. The Informed Consent page that is signed will be maintained in the patient's medical record.

Patient #3
Review of Patient #3's medical record on 05/23/2022 revealed he was admitted on 05/17/2022 with diagnoses in part, unilateral lower limb below knee amputation and burn of 3rd degree of right foot. Further review revealed the admission paperwork which included, in part, Explanation of Patient Rights and the Hospital Care Consent were left blank with no signatures or dates upon admit as per policy.

In interview on 05/23/2022 at 12:34 p.m., S3RN indicated the Explanation of Patient Rights and Hospital Care Consent should have been completed with signatures and dates. S3RN verified the admission paperwork had not been signed or dated upon admit as per policy.

Patient #1
Review of Patient #1's medical record on 05/23/2022 revealed he was admitted on 05/17/2022. Further review revealed the admission paperwork which included in part, Explanation of Patient Rights and Hospital Care Consent were left blank with no signatures or dates until 05/23/2022.

Patient #4
Review of Patient # 4's medical record on 05/23/2022 revealed he was admitted on 05/17/2022. Further review revealed the admission paperwork which included in part, Explanation of Patient Rights, Hospital Care Consent, were left blank with no signatures or dates until 5/23/2022.

In interview on 05/24/2022 at 9:55 a.m., S2DON verified the admit paperwork for Patients #1, #3 and #4 was not signed and dated upon admit as per policy.

In interview on 05/24/2022 at 9:55 a.m., S1Adm and S2DON verified the admit paperwork for Patient #3 was not translated into his only language of Spanish.

Based on record reviews and interviews, the hospital failed to ensure patient discharge summaries describing the outcome of the patient's hospitalization, disposition of care, and provisions for follow-up care was in the patient's record within 30 days of discharge for 2 (#20, #21) of 15 discharged records from 30 (#1-#30) total sampled patient records reviewed.

Findings:

Review of the hospital's Medical Staff By-laws, Policy Number 00-06-01, adopted 3/2017 revealed in part: Section 3: Each member of the medical staff shall: Prepare and complete within thirty (30) days of discharge all patient related medical records of other records required by the hospital, State of Louisiana, Medicare/Medicaid, or other third party agency. Section 5: Automatic Suspension: Failure to maintain specific "appointment" criteria, including appropriate certification of insurance, shall result in an automatic suspension. Automatic suspension shall be triggered if one of the following happens: d. Failure to complete a patient's medical chart, including history and physical and/or discharge summary within 30 days of discharge. An applicant shall remain on such suspension until compliance for the above is met. An applicant shall have 14 days to correct that above infraction before their Medical Staff privileges are revoked.

Patient #20
Review of Patient #20's medical record revealed he had been admitted on 03/03/2022 and discharged on 03/22/2022. Further review revealed there was no documented discharge summary in the medical record.

Patient #21
Review of Patient #21's medical record revealed he had been admitted on 04/12/2022 and discharged on 04/22/2022. Further review revealed there was no documented discharge summary in the medical record.

In an interview on 05/24/2022 at 10:30 a.m. with S2DON, confirmed the above referenced patients had no discharge summaries in their medical records.

Based on record review and interview, the hospital failed to ensure a qualified full-time, part-time or consulting radiologist was appointed to supervise the radiology services of the hospital.

Findings:

Review of a list of credentialed physicians and providers provided by the hospital failed to reveal a credentialed radiologist.

Review of the governing body meeting minutes revealed no documentation of the appointment of a radiologist who supervised the radiology services of the hospital.

In an interview on 05/25/2022 at 10:27 a.m., S1Adm reported the hospital did not have a credentialed radiologist appointed to supervise radiology services. S1Adm reported that radiological services were provided to patients by a mobile X-ray service that performed mobile X-rays in the hospital.

Based on interview and record review, the hospital failed to ensure the dietary service director responsible for the hospitals daily management of dietary services, established, maintained, and reported all aspects of the Dietary Services through the hospital's QA program.

Findings:

In an interview on 05/23/2022 at 2:00 p.m. with S1Adm, she stated that the contracted RD (S4RD) was the designated Dietary Manager for the hospital.

In an interview on 05/23/2022 at 2:30 p.m. with S4RD, she stated that she was unaware that she was the designated DM, she further stated that she was contracted for Dietary consults, assessments, and evaluations, and did not contribute to the hospital QA program.

In an interview on 05/32/2022 at 3:10 p.m. with S1Adm, she stated that S6DM, the SNF Dietary Manager functioned as the hospital's Dietary Manager.

In an interview on 05/24/2022 at 12:15 p.m. with S6DM, she stated that she was the appointed Dietary Manager for the hospital since it had opened in January/February of this year as well as the SNF DM. She further stated that she only oversees the meals and diets for the hospital, she does not participate in the hospital's QA, and does not follow-up with any patient dietary issues.

In an interview on 05/24/2022 at 3:00 p.m. with S1Adm, she confirmed that the Dietary Manager should be reporting to the QA program on Dietary Services.

Based on observations and interviews, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors. This deficient practice was evidenced by failure to maintain the physical plant in good repair and failure to maintain a safe patient care environment.

Findings:

Observations conducted on 05/23/2022 at 10:00 a.m. revealed the fluorescent light in front of the nurses' station was filled with standing water, causing the cover of the light to bow from the weight of the collected water. Further observation revealed the sides of the fluorescent cover were rippled and there were rust colored stains on the metal frame of the light. There was a continuous dripping water leak noted to be coming from the light fixture. There were 5 new (wet), gray-colored water stained ceiling tiles surrounding the leak. S19Maint confirmed the above referenced finding on 05/23/2022 and reported there had been an elbow joint changed from the air conditioner drain and the leak was possibly associated with that repair.

On 05/24/2022 multiple additional observations from 07:00 a.m. - 3:30 p.m. revealed the fluorescent light in front of the nurses' station was still filled with standing water, causing the cover of the light to bow from the weight of the collected water.

05/24/2022 at 7:20 a.m. 2 - Oxygen cylinders were observed to be free-standing in the equipment storage room, unchained and not contained in a rack.

On 05/24/2022 from 7:30 a.m. - 8:15 a.m. an observation was made of the hospital's 10 single occupancy inpatient rooms. Further observation revealed the following:

Room 114
Ceiling tile missing in the bathroom leaving ductwork and wiring in ceiling exposed.

Room 118
a. Water stained ceiling tile by the vent/light in the bathroom.
b. 3 stained ceiling tiles in the room.

Room 119
Wall call lights on both walls not working when pressed. S3RN, present during the observation, reported S19Maint had told her the call lights were shorted out and were in need of repair.

Room 121
a. Water stained ceiling tile by the vent/light in the bathroom.
b. Call light working, but audible alert was delayed after pressing the button when the call light was tested.

Room 122
a. Water stained ceiling tile noted in the corner of the ceiling.
b. Foot pedals for wheelchair dusty and stored on the floor.
c. Wall behind bed noted to have a large pitted area with crumbling sheetrock/plaster.

S3RN, present during the observation, confirmed the above referenced observations of disrepair in the physical plant and the potential safety risks in the patient care environment.

Based on interview and record review, the hospital failed to ensure the person designated as the Infection Control Officer had acquired specialized training in infection control as evidenced by S2DON (Director of Nursing) having no documentation of specialized training in infection control.

Findings:

Review of the personnel file of S2DON revealed no documentation of specialized training in Infection Control.

In an interview 05/25/2022 at 12:30 p.m. with S2DON, she confirmed she was the hospital's IC nurse, but would have oversight from S18ICCon. She reported that she had assumed the position of Infection Control Coordinator when she started as DON. S2DON confirmed she had no documentation of specialized training in infection control.

In an interview on 05/25/2022 at 12:45 p.m. with S18ICCon, she reported she was not currently the appointed IC Officer responsible for the hospital's infection control program.

Based on record review, observation, and interview, the hospital failed to develop, implement, and maintain an active, hospital-wide program for the prevention, control, and investigation of infections and communicable diseases as evidenced by:
1. failing to ensure hospital staff (S15LPN) adhered to hospital infection control policies during performance of wound care for 1(#3) of 1 sampled patients observed for wound care, from a current patient sample of 4 (#1-#4) and a total patient sample of 30.
2. failing to ensure patient care was provided in a sanitary environment and that expired lab supplies and IV tubing with open packaging was not available for use.

Findings:
1. Failing to ensure hospital staff adhered to hospital infection control policies during performance of wound care.

Review of the hospital policy titled, "Quality Assessment and Performance Improvement: Infection Control", Policy Number: 02-02-03, revealed in part: Decontaminate hands before having direct contact with patients. Decontaminate hands after contact with body fluids or excretions, non-intact skin, and wound dressings. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. Decontaminate hands after removing gloves.

On 05/25/2022 at 7:50 a.m. an observation was made of S15LPN performing Patient #3's wound care and dressing change on the patients' left leg BKA incision. During the observation, S15LPN placed the wound care supply basket on the patient's over bed table without first disinfecting the table or putting a barrier on the table to place the wound care supply basket on. S15LPN was then observed removing the old dressing, cleansing the incision with wound wash, applying Bactroban to the incision with his gloved finger, and dressing the site with a Telfa pad and gauze wrap. S15LPN changed his gloves after each task and failed to perform hand hygiene with each glove change. He also failed to perform hand hygiene prior to exiting Patient #3's room. Further observation revealed S15LPN failed to disinfect Patient #3's over bed table when he removed the wound care supply basket. S15LPN was observed carrying the wound care supplies back to the medication room and he placed the basket on the counter without disinfecting the basket prior to placing it on the counter in the clean area of the medication room.

In an interview on 05/25/2022 at 10:30 a.m. with S2DON, she indicated it was her expectation that staff would perform hand hygiene before and after glove usage and when changing tasks. She also confirmed there should have been a barrier, such as a blue pad, placed on Patient #3's over bed table before placing the wound care supply basket on the table. She verified the table should have been disinfected after wound care was completed and the basket should have been wiped down prior to placing it on the counter in the clean area of the medication room.

2. Failing to ensure patient care was provided in a sanitary environment and that expired lab supplies and IV tubing with open packaging was not available for use.

Review of the hospital policy titled "Quality Assessment and Performance Improvement Infection Control- Therapy Services", Policy Number 02-02-03, revealed in part: Accord rehab Hospital's Infection Control Program includes methods for identifying potential contaminants and minimizing patient infections through cross contamination through contact with linens, equipment, or hardware.
All washable equipment, furniture, and hardware will be cleaned and disinfected daily by housekeeping and therapy staff according to guidelines outlined in housekeeping policies. Countertops, sinks, tables and chairs will be cleaned between patient use and twice daily.
Cleaning and Disinfecting Environmental Surfaces in Healthcare Facilities: At a minimum, hospital staff shall clean housekeeping surfaces (example: floors, tabletops) on a regular basis, when spills occur, and when these surfaces are visibly soiled. Disinfect (or clean) environmental surfaces on a regular basis and when visibly soiled.
Other infection prevention practices: 6. Appliances such as refrigerators and microwaves will be cleaned weekly, or as needed.

Observations of the hospital conducted on 05/24/2022 from 7:30 a.m. - 8:25 a.m. revealed the following:
Supply Room:
a. 3 vials of Total Fix specimen collection kits expired in 10/2021, available for use.
b. "Y" blood administration set tubing in a package that was torn and available for use.
S3RN, present at the time of the observation, verified the expired supplies and damaged package and confirmed the items should have been discarded and should not be available for use.

Patient Dining Room/Nutritional Area:
c. Patient refrigerator noted to have orange colored stains in the drawers and yellow colored stains on the shelves. Further observation of the refrigerator revealed a staff thermal lunch bag on the top shelf. S3RN, present at the time of the observation, verified staff lunch bags and staff food should not be stored in the patient refrigerator and the refrigerator needed to be cleaned.
d. Microwave oven noted to have crusted food residue and crumbs on the floor, sides and top of the interior of the microwave. S3RN, present at the time of the observation, verified the microwave needed to be cleaned.

Patient Assessment Area:
e. Wheelchair scale noted to have scotch tape on the bed of the scale and whitish particulate matter noted on the surface of the base of the scale. S3RN, present at the time of the observation, verified the scale needed to be cleaned.

Patient Room:
f. Room 121 - bedspread noted to have yellow circular stains and pulls with loose threads and winged insects in light fixture in the bathroom. S3RN, present at the time of the observation, verified the stains and pulled threads on the bedspread and the insects in the light fixture.

Occupational Therapy Room:
g. Walk-in tub noted to have a fine layer of grayish white residue on the inner surfaces (floor and sides) and on the lip of the top of the tub. S3RN, present at the time of the observation, verified the walk-in tub needed to be cleaned/disinfected.
h. a portable air compressor with a layer of grayish white residue on the surface and jumper cables were noted on the bedside nightstand. S3RN, present at the time of the observation, verified the compressor and jumper cables should not be stored in the Occupational Therapy Room.

Based on record review, and interview, the hospital failed to ensure ongoing discharge planning/discharge plans were documented in the patient's medical record for 4 (#1, #5, #8, #9) out of 4 patients reviewed for discharge planning out of a sample of 30 patients.

Findings:

Review of the hospital policy titled "Discharge Planning" revealed, in part: Accord Rehab Hospital's social services department shall provide discharge planning for each patient from the point of admission. Each & Every patient will be evaluated for post-hospitalization needs at time of preadmission screening and the case manager or designated staff will work with the patient, patient's family and IDT to ensure that the patient is released to a safe environment, with the follow up services and equipment needed.
Procedure: Discharge planning begins upon and even prior to admission and is documented on an ongoing basis throughout the course of the patient's hospitalization by either the case manager or the IDT.

1. Review of Patient #1's medical record revealed the patient was admitted with a medical history of parkinson, dementia, lack of coordination, abnormal posture, and muscle wasting atrophy. Additional review of Patient #1's medical record revealed no documented evidence of ongoing discharge planning/discharge plans.

2. Review of Patient #5's medical record revealed the patient was admitted with a medical history of diabetes, anxiety, major depressive disorder, decline in mobility, and decreased strength and range of motion. Additional review of Patient #5's medical record revealed no documented evidence of ongoing discharge planning/discharge plans.

3. Patient #8's medical record revealed the patient was admitted with a medical history of heart failure, lack of coordination, muscle wasting atrophy, and abnormality in gait and mobility. Additional review of Patient #8's medical record revealed no documented evidence of ongoing discharge planning/discharge plans.

4. Review of Patient #9's medical record revealed the patient was admitted with a medical history of hypertensive heart disease, muscle wasting atrophy, dysphagia, lack of coordination, and hemiplegia. Additional review of Patient #9's medical record revealed no documented evidence of ongoing discharge planning/discharge plans.

In an interview on 05/25/2022 at 8:52 p.m., S2DON confirmed there was no documented evidence of ongoing discharge planning/discharge plans in Patient #1, Patient #5, Patient #8, and Patient #9's medical records.

Based on record review and interview, the hospital failed to maintain documented evidence of training for nursing personnel assigned to perform specific respiratory procedures. This deficient practice was evidenced by failure of the hospital to maintain documented evidence of respiratory service training for 3 (S2DON, S3RN, S15LPN) of 3 nursing personnel records reviewed.

Findings:

Review of hospital policy titled, "Respiratory Care: Delivery of Services" revealed in part: Any services rendered by licensed nursing staff are under the supervision and direction of the licensed respiratory therapist and licensed nursing staff has documentation of demonstrated competency in the provision of the ordered services. Competency evaluations are performed by the respiratory therapist at least annually for nursing staff.

Review of the personnel records for S2DON, S3RN, and S15LPN revealed no documented evidence of demonstrated competency in the provision of respiratory services.

In an interview on 05/25/2022 at 12:03 p.m., S2DON confirmed that there was no documented evidence of current competency evaluations performed by a respiratory therapist for S2DON, S3RN and S15LPN.

Based on observation, record review, and interview the hospital failed to develop and implement policies and procedures to ensure all staff are fully vaccinated for COVID-19 and to ensure staff complied with the contingency plan for unvaccinated staff. This deficient practice was evidenced by:
1.failure to ensure unvaccinated staff, with religious exemptions, complied with the contingency plan for staff who are not fully vaccinated for COVID-19. This was evidenced by failure of unvaccinated staff to wear a N-95 mask at all times when working at the hospital for 3 (S8RehDir, S15LPN, and S16MD) of 3 unvaccinated staff observed during the survey. ;
2. failure to maintain documented evidence of vaccination status for all employees for 2 (S4RD, S17PTA) of 6 (S2DON, S4RD, S8RehDir, S15LPN, S16MD, and S17PTA) sampled personnel reviewed for COVID-19 vaccine status; and
3. failure to ensure the hospital policy for COVID-19 vaccine medical exemptions included all required information specifying which of the authorized or licensed COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications.

Findings:

1.Failure to ensure unvaccinated staff, with religious exemptions, complied with the contingency plan for staff who are not fully vaccinated for COVID-19 requiring them to wear a N-95 mask at all times when working at the hospital.

On 05/23/2022, S15LPN was observed numerous times throughout the day. S15LPN was not wearing the required N-95 mask, due to being unvaccinated against COVID-19, at any time during the observations.

On 05/23/2022, S16MD was observed unmasked at the nurses' station. S16MD was not wearing the required N-95 mask due to being unvaccinated.

On 05/24/2022 at 1:30 p.m. an interview was conducted with S8RehDir and she was not wearing the required N-95 mask due being unvaccinated.

On 05/25/2022 at 7:50 a.m., S15LPN was observed performing Patient #3's wound care. S15LPN was wearing a surgical mask and not the required N-95 mask.

On 05/25/2022 at 11:00 a.m. S15LPN was observed performing Patient #3's accu-check. S15LPN was wearing a surgical mask and not the required N-95 mask.

In an interview on 05/25/2022 at 12:30 p.m. with S1Adm and S18ICCon, they verified unvaccinated staff with approved exemptions were required to wear N-95 masks at all times when they were working. They verified the mask requirement was part of the hospital's contingency plan for staff who are not fully vaccinated in order to prevent the spread of COVID-19 by unvaccinated staff.

2. Failure to maintain documented evidence of vaccination status for all employees.

In an interview on 05/25/2022 at 12:30 p.m., during review of the employee COVID -19 vaccine documentation, S1Adm, S2DON, and S18ICCon confirmed they had no documented evidence of current vaccination status for S4RD and S17PTA.

3. Failure to ensure the hospital policy for COVID-19 vaccine medical exemptions included all information specifying which of the authorized or licensed COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications.

Review of the hospital policy for COVID-19 vaccine medical exemption requests revealed the policy failed to include all information, to be completed by a licensed provider, specifying which of the authorized or licensed COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications for each of the vaccines

In an interview on 05/25/2022 at 12:30 p.m. with S1Adm, S2DON, and S18ICCon, they confirmed the hospital policy for medical exemption requests failed to include all information specifying which of the authorized or licensed COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications for each of the vaccines.