HospitalInspections.org

25119




30984

Based on record reviews, observations and interviews, the hospital failed to meet the requirements for the Condition of Participation of Patient Rights as evidenced by:
1) Leaving a Dialysis patient unattended in their hospital room during Hemodialysis treatment multiple times (twice being unobserved/unattended for time intervals as long as 5 minutes while hemodialysis treatment was in progress). The contracted Dialysis service routinely staffed for 2 patients concurrently receiving Hemodialysis treatment in 2 separate rooms with a RN (registered nurse) and a PCT (patient care technician), thus ultimately making the RN responsible for the care and monitoring of both patients. This deficient practice had the potential to affect all 4 (#1, #2, #5, #6) current Hemodialysis inpatients reviewed out of a total sample of 30 (#1-#30) patients. (See findings under tag A-0144).
2) Failing to perform water testing for Chlorine at the point of care prior to initiation of Hemodialysis treatment. This deficient practice is evidenced by water testing for Chlorine being performed offsite at another facility and not repeating the test prior to initiating dialysis on the water source being utilized for Hemodialysis at inpatient facility. This deficient practice had the potential to affect all 4 (#1, #2, #5, #6) current Hemodialysis inpatients reviewed out of a total sample of 30 (#1-#30) patients. (See findings under tag A-0144).
An Immediate Jeopardy situation was identified on 12/12/16 at 5:09 p.m. due to the hospital:
1) Leaving a Dialysis patient unattended in their hospital room during Hemodialysis multiple times (twice being unobserved/unattended for time intervals as long as 5 minutes). The contracted Dialysis service routinely staffed for 2 patients concurrently receiving Dialysis in 2 separate rooms with a RN and a PCT, thus ultimately making the RN responsible for the care and monitoring of both patients. This deficient practice had the potential to affect all 4 (#1, #2, #5, #6) current Hemodialysis inpatients reviewed out of a total sample of 30 (#1-#30) patients. (See findings at tag 0-144).
2) Failing to perform water testing for Chlorine at the point of care prior to initiation of Dialysis. This deficient practice is evidenced by water testing for Chlorine being performed offsite at another facility and not repeating the test prior to initiating dialysis on the water source being utilized for Hemodialysis at the inpatient facility. This deficient practice had the potential to affect all 4 (#1, #2, #5, #6) current Hemodialysis inpatients reviewed out of a total sample of 30 (#1-#30) patients. (See findings at tag 0-144).S1CEO and S2CCO presented a written Corrective Action Plan for lifting the immediacy of the Immediate Jeopardy situation on 12/14/16 at 8:59 a.m. The written plan was reviewed by the survey team. S2CCO indicated the following actions had been taken: Dialysis Nursing Staff in-services had been held and the information covered had included review of the Declaratory Statement from the LSBN on the role of the RN in Dialysis. She indicated Dialysis nursing staff and Hospital "B" (provider of the hospital's contracted Hemodialysis services) had been instructed that Lafayette AMG Specialty Hospital's policy for nurse staffing for administering Dialysis was 1:1 (1 RN per patient in individual patient rooms). S2CCO further indicated they had informed Hospital "B" that they were responsible for ensuring staff coverage was available for breaks/lunch. She said they re-iterated that the Dialysis nurse can not leave the patient unattended for any length of time (per newly adopted policy). S2CCO presented staff in-service sign in sheets and documented competencies for the two RNs performing Dialysis on 12/14/16. Each staff member who had attended the in-service meeting had signed an attestation. She also presented staffing schedules for the next month for staff assigned to perform Dialysis. She indicated in-service education and competencies would be verified prior to staff performing Hemodialysis.

S2CCO presented a Dialysis log book for documenting point of care water Chlorine testing results. The results for the tests performed on 12/14/16 were noted in the log book. She indicated per new policies the point of care water testing for Chlorine was to be logged prior to starting. S2CCO indicated Hospital "B" had designated 2 machines (#8 and #9) for use at Lafayette AMG Specialty Hospital. S2CCO further indicated Hemodialysis nursing staff was to alert both the CEO and CCO if test results were higher than the acceptable range.

S2CCO presented the hospital's newly drafted/adopted/approved Hemodialysis policies and procedures. The survey team reviewed the policies and verified they had been approved by the hospital's Governing Body (emergency meeting held on 12/13/16 at 3:15 p.m.). S2CCO indicated 1:1 staffing for administering Dialysis (1 RN per patient in individual patient rooms), point of care water testing for Chlorine (with references for acceptable Chlorine levels), Infection Control Policies for administering Hemodialysis and Quality indicators to monitor staff adherence to Hemodialysis policies (a daily observation tool) and Infection control practices (infection control audits and check lists) were also discussed and approved at the meeting. S2CCO indicated Hospital "B" had modified their Hemodialysis policies to reflect the policies/procedures of Lafayette AMG Specialty Hospital.

Patient #2:
Observation on 12/14/16 from 9:48 a.m. to 10:16 a.m. of patient #2's hemodialysis treatment in progress revealed S8RN dialysis nurse in the patient's room. Review of the total chlorine testing log revealed a chlorine test of less than 0.1 ppm (parts per million) was documented prior to the patient starting treatment.

In an interview with S8RN at 9:50 a.m., he indicated that he conducted the Total Chlorine test after the water equipment was brought into the patient's room (point of use). S8RN indicated he received additional in-service and training on conducting Total Chlorine testing and dialysis staff to remain with the patient at all times during hemodialysis treatment. Further observation at 9:53 a.m. revealed S8RN performed a Total Chlorine correctly, per manufacturer's directions for use and obtained an acceptable result of less than 0.1 ppm.

Patient #5
Observation on 12/14/16 from 9:50 a.m. to 10:10 a.m. of Patient #5's hemodialysis treatment in progress revealed S6RN dialysis nurse was present in the patient's room. Review of the patient's treatment sheet revealed a Chlorine test of less than 0.1 ppm (parts per million) was conducted prior to the patient receiving treatment. Further review revealed hemodialysis orders for BFR (blood flow rate) - 350, DFR (dialysis flow rate)- 700, Dialysate- 2K, 2.5Ca, Dialyzer 160NRe, Run time- 3 hours. Dialysis orders were verified on the hemodialysis machine. Interview with S6RN at that time revealed that he had received in-service training this morning on conducting Chlorine testing, infection control measures, and was instructed that dialysis staff was to remain with the patient at all times during hemodialysis treatment. Further observation at 11:05 a.m. revealed S6RN perform a Chlorine water test using the proper technique for obtaining an acceptable result of less than 0.1 ppm.

Based on observations, interviews and corrective action plan review, the Corrective Action Plan was accepted on 12/14/16 at 11:33 a.m. The Immediacy of the Immediate Jeopardy situation was lifted though there was not enough evidence to determine sustainability of Compliance for the Condition of Patient Rights to be cleared. Noncompliance remains at the Condition Level.

Based on policy review and interview, the hospital's governing body failed to ensure that the medical staff was accountable to the governing body for the quality of care provided to patients. This deficient practice was evidenced by failure of the governing body to draft and approve policies for administration of Hemodialysis at Lafayette AMG Specialty Hospital.

Findings:

Review of the policies presented to the survey team as the current policies utilized for Hemodialysis revealed they were policies from Hospital "B" (the contracted Dialysis service provider). Further review revealed Lafayette AMG Specialty Hospital had not drafted and approved policies for the care of the Hemodialysis patient being dialyzed in their hospital.

In an interview on 12/13/16 at 1:28 p.m. with S5DialysisDir he indicated he did not have policies and procedures for water treatment system monitoring and staff actions to take if ranges and/or standards were not met or exceeded.

In an interview on 12/12/16 at 2:30 p.m. with S2CCO she confirmed the hospital used the Hemodialysis policies from Hospital "B". She indicated the hospital's governing body had not developed its own Hemodialysis policies.

30984

Based on record review, observations and interviews, the hospital failed to provide care in a safe setting as evidenced by:
1) Leaving a Dialysis patient unattended in their hospital room during Hemodialysis multiple times (twice being unobserved/unattended for time intervals as long as 5 minutes). This deficient practice had the potential to affect all 4 (#1, #2, #5, #6) current inpatients receiving Hemodialysis treatment out of a total of 30 (#1-#30) sampled patient records.
2) Failing to perform water testing for Chlorine at the point of care prior to initiation of Hemodialysis treatment. This deficient practice is evidenced by water testing for Chlorine being performed offsite at another facility and not repeating the test prior to initiating dialysis on the water source being utilized for Hemodialysis at inpatient facility. This deficient practice had the potential to affect all 4 (#1, #2, #5, #6) current inpatients receiving Hemodialysis treatment out of a total of 30 (#1-#30) sampled patient records.
3) Failing to meet the Louisiana State Board of Nursing declaratory statement on the role and scope of practice of the registered nurse in dialysis nursing adopted 11/20/96 and revised 12/03/03 which states, in part: The Board believes that every patient requiring hemodialysis has the right to professional nursing care. The registered nurse is responsible for the nature and quality of all nursing care a patient receives regardless of the dialysis setting. This deficient practice was evidenced by hemodialysis treatments being administered by patient care technicians to patients in individual patient rooms. This deficient practice had the potential to affect all 4 (#1, #2, #5, #6) current inpatients receiving Hemodialysis out of a total of 30 (#1-#30) sampled patient records.

Findings:

1) Leaving a Dialysis patient unattended in their hospital room during Hemodialysis multiple times.

Review of Patient #1's medical record revealed an admission date of 11/25/16 with an admission diagnosis of necrotizing fasciitis, status post extensive debridement. Further review revealed the patient also had co-morbid conditions of Stage III Chronic Kidney Disease and Anemia.
On 12/12/16 at 8:45 a.m., S3RN was observed administering Hemodialysis to Patient #1. S3RN was observed leaving Patient #1's room for 5 minutes. S3RN returned to Patient #1's room, obtained his telephone and left again for 5 minutes. There were no other staff members observing the patient.
On 12/12/16 at 9:13 a.m., S3RN, (the RN administering Hemodialysis to Patient #1) left the room and did not return until 9:17 a.m. There were no other staff members observing the patient.
On 12/12/16 at 9:36 a.m., S3RN (RN administering Hemodialysis for Patient #1) was observed at the nurse's station. He was not able to visualize/observe Patient #1 from where he was standing at the nurse's station.

In an interview on 12/12/16 at 10:10 a.m. with S3RN, he verified he and a PCT (patient care technician) were dialyzing patients in two different rooms. He said he would go to the other room to assist the PCT if needed. He verified when he went to the other Hemodialysis patient's room (located around the corner and down a hall) Patient #1 was left alone in the room, unobserved. He confirmed Patient #1 was not being monitored by any other staff when he left the room.

In an interview on 12/12/16 at 2:00 p.m. with S5DialysisDir (Director of Hospital "B" Dialysis Service), he reported Hospital "B" had provided the hospital's contracted Hemodialysis service for a year and a half. S5DialysisDir further reported he had consistently staffed with a RN and a tech (PCT) to dialyze the hospital's patients. He said he staffed with a RN and a PCT because of RN staffing availability issues. S5DialysisDir indicated if two patients required Hemodialysis he asked the hospital to put the patients either side by side or a room apart. S5DialysisDir indicated the RN was responsible for patient assessment, initiating dialysis and stopping dialysis. S5DialysisDir further indicated the tech was responsible for monitoring vital signs. S5DialysisDir reported the RN and the tech would swap patients if the RN needed to go to assess the tech's patient. S5DialysisDir verified he had been aware the patients being dialyzed on the morning of 12/12/16 had not been in rooms next to each other. He confirmed he had not staffed accordingly even though he knew the rooms were not next to each other. S5DialysisDir further reported S3RN had not received training regarding not leaving the Hemodialysis patient's room and not leaving the patient unattended while being dialyzed.

2) Failing to perform water testing for Chlorine at the point of care prior to initiation of Hemodialysis.

Review of the AAMI "American National Standard for Dialysate for Hemodialysis," 2004 (RD52:2004) revealed, in part:
ANSI/AAMI RD52:2004
6.2.5 Carbon adsorption: monitoring, testing frequency
Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours.
Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels [which is a maximum level of 0.1 mg/L (or ppm)].
Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly.

Patient #2:

Observations on 12/12/16 at 9:28 a.m. revealed the patient was receiving hemodialysis treatment and the treatment was being provided by S4PCT.

In an interview on 12/12/16 at 9:32 a.m., S4PCT indicated total chlorine testing was performed at Hospital "B" where the water treatment system was stored. S4PCT indicated total chlorine testing at the point of care prior to initiation of dialysis was not repeated.

In an interview on 12/12/16 at 11:16 a.m., S3RN indicated total chlorine testing and Reverse Osmosis (RO) machine performance monitoring was done on the fifth floor at Hospital "B" where the water treatment system was stored. S3RN indicated water treatment system testing and monitoring was not done at AMG Specialty Hospital.

In an interview on 12/12/16 at 2:00 p.m. with S5DialysisDir he indicated the water treatment equipment used for dialyzing patients was stored in the dialysis room at Hospital "B" . S5DialysisDir indicated the water treatment system consisted of RO machines, 2 carbon tanks and 2 sediment filters that were kept with the dialysis machines. S5DialysisDir indicated dialysis staff tested the water in the morning at Hospital "B" and the water tests were not repeated at AMG Specialty Hospital.

3) Failing to meet the Louisiana State Board of Nursing declaratory statement on the role and scope of practice of the registered nurse in dialysis nursing adopted 11/20/96 and revised 12/03/03.

Review of the Louisiana State Board of Nursing declaratory statement on the role and scope of practice of the registered nurse in dialysis nursing adopted 11/20/96 and revised 12/03/03 revealed, in part: After due deliberation, the Board took the following actions in order to safeguard the life and health of hemodialysis patients. The Board believes that every patient requiring hemodialysis has the right to professional nursing care. The registered nurse is responsible for the nature and quality of all nursing care a patient receives regardless of the dialysis setting. The nursing care of dialysis patients shall be supervised by a registered nurse who has training, experience, and documented current competence in the nursing care of patients with renal and end-stage disease and in hemodialysis techniques. Further review of this declaratory statement revealed, in part: Definition of Terms for the Purpose of This Document: Supervised, immediate supervision, readily available - "The registered nurse is physically present in the patient's room or on the floor with the patient, or in the dialysis unit".

Patient #2:
Observations on 12/12/16 at 9:28 a.m. revealed the patient was receiving hemodialysis treatment and the treatment was being provided by S4PCT.

In an interview on 12/12/16 at 9:32 a.m., S4PCT indicated she was assigned responsibility for administering hemodialysis treatment to Patient #2. S4PCT indicated S3RN was present at the hospital and was currently administering hemodialysis treatment to another patient.

Observations on 12/12/16 at 9:33 a.m. revealed S3RN came into Patient #2's room to check the patient's blood pressure and elevated heart rate. In an interview at this time S3RN indicated he was providing hemodialysis treatment to another patient and came to check on Patient #2 after being contacted by S4PCT. S3RN indicated he was the only RN for the two patients currently being dialyzed.

In an interview on 12/12/16 at 2:00 p.m. with S5DialysisDir (Director of Hospital "B" Dialysis Service), he reported he had consistently staffed with a RN and a PCT to dialyze the hospital's patients. S5DialysisDir indicated if two patients required Hemodialysis he asked the hospital to put the patients either side by side or a room apart. S5DialysisDir indicated the RN was responsible for patient assessment, initiating dialysis and stopping dialysis. S5DialysisDir further indicated the PCT was responsible for monitoring vital signs. S5DialysisDir indicated he was not aware of the Louisiana State Board of Nursing declaratory statement on the role and scope of practice of the registered nurse in dialysis nursing.

In an interview on 12/12/16 at 2:29 p.m., S2CCO indicated she was not aware of the Louisiana State Board of Nursing declaratory statement on the role and scope of practice of the registered nurse in dialysis nursing. S2CCO indicated the hospital will in-service staff on the Declaratory Statement from the LSBN on the role of the RN in Dialysis. S2CCO further indicated that Lafayette AMG Specialty Hospital's policy for nurse staffing for administering Dialysis will be revised to be 1:1 (1 RN per patient in individual patient rooms).

Based on QAPI program review and interview, the hospital's governing body failed to ensure that the program reflected the complexity of the hospital's organization and services. This deficient practice was evidenced by the hospital's failure to include Dialysis services (contracted service provided by Hospital "B") in the hospital's QAPI program.

Findings:

Review of the hospital's QAPI program documentation, presented as current by S2CCO (QAPI Director), revealed no documented evidence that the contracted Dialysis services provided by Hospital "B" were included in the hospital's QAPI program. Further review revealed issues identified with water testing for Chlorine levels (Water testing for Chlorine performed at an offsite location and not on the water supply at point of care) performed during Hemodialysis had not been identified as a problem area to be addressed in the hospital wide QAPI program. Additional review revealed RN staff leaving patients unattended during Hemodialysis had also not been identified as a problem area to be addressed in the hospital wide QAPI program.

In an interview on 12/12/16 at 2:00 p.m. with S5DialysisDir (Director of Dialysis services at Hospital "B"), he confirmed he was not collecting data for QA for this hospital. S2CCO, present during the interview, also indicated she had not collected any data for dialysis and had no dialysis PI projects.

In an interview on 12/14/16 at 12:00 p.m. with S2CCO, she confirmed the issues identified with water testing for Chlorine levels performed during Hemodialysis had not been identified as a problem area to be addressed in the hospital's QAPI plan. S2CCO also confirmed RN staff leaving patients unattended during Hemodialysis had not been an identified problem area to be addressed in the hospital's QAPI plan.

30984

Based on record reviews and interview, the Hospital failed to ensure the RN (registered nurse) supervised and evaluated the nursing care for each patient as evidenced by failure to document an interpretation of the cardiac monitoring telemetry readings for patients on telemetry for 2 (#3,#6) of 2 sampled patients reviewed for telemetry out of a total of 30 (#1-#30) sampled patient records.
Findings:
Review of the hospital policy titled, Telemetry Monitoring, Policy number K.11.06, revised 4/2016, revealed in part: Policy: A. The Hospital provides telemetry monitoring for patients on order of the attending physician. C. All Telemetry patients will be monitored through a central monitor located at the nurses' station or via bedside monitor by a competency verified RN, LPN, or monitor tech.
Procedure: 1.Cardiac Rhythms will be monitored by a qualified observer at all times. It is the responsibility of the assigned monitor technician to assure that a qualified observer covers in his/her absence during meal or break times. At no time is the central monitor to be left unattended. 4. Rhythm strips are printed every four hours on medical/surgical and high observation patients, or as ordered and in the event of an abnormal arrhythmia. 7. The nurse responsible for the patient is to be notified without delay if there is a significant change in cardiac rate and rhythm. All significant changes in cardiac rhythm are posted, fully identified, reported to the appropriate physician and faxed to the appropriate individuals upon request.
Review of the Nursing Telemetry Monitor Competency form reveled the following, in part: 1. Understands rhythm strips are printed every 4 hours on medical/surgical and high observation patients, or as ordered and in the event of an abnormal arrhythmia. 2. Understands proper procedure for documenting EKG strips to include posting a 6 second strip, document time, interpret interval, interpret QRS measurement, interpret QT interval, calculate heartache, and interpretation of the strip.
Patient #3
Review of Patient #3's medical record revealed an admission date of 12/2/16 with an admission diagnosis of Acute on Chronic Respiratory Failure. Further review revealed the patient had physician orders, dated 12/2/16, for continuous cardiac monitoring to begin on admission to the unit. Additional review of the patient ' s physician Telemetry orders revealed the following, in part: Rhythm strip documented every 8 hours or as ordered by MD below (additional choices were available for every 4 hours, every 6 hours and other) and as indicated to document arrhythmia's: patient name; date/time; rate; PR interval; QRS width; Regularity; Rhythm Interpretation. Ensure clear, readable strip is utilized.
Review of Patient #3 ' s printed telemetry rhythm strips revealed the strips were printed as ordered but there was no documented evidence of measurement of the PR interval (interval between the beginning of the P wave and the beginning of the QRS complex of an electrocardiogram) or the QRS width when the patient experienced arrhythmia's on the following dates/times referenced below:
12/8/16, at 11:30 a.m. and 3:00 p.m.: A-fib (atrial fibrillation);
12/9/16, at 7:00 a.m., 11:00 a.m., 3:00 p.m., 7:00 p.m. and 11:00 p.m.: A-fib;
12/10/16, at 3:00 a.m., 7:00 a.m., 11:00 a.m., 3:00 p.m., and 7:00 p.m.: A-fib;
12/11/16, 11:00 p.m.: A-fib;
12/12/16, 03:00 a.m.: A-fib.

Patient #6

Review of Patient #6's medical record revealed an admission date of 12/8/16 with an admission diagnosis of Acute Renal Failure with new onset Hemodialysis. Further review revealed the patient had physician orders, dated 12/8/16 at 2:07 p.m., for continuous cardiac monitoring to begin on admission to the unit. Additional review of the patient's physician Telemetry orders revealed the following, in part: Rhythm strip documented every 8 hours or as ordered by MD below (additional choices were available for every 4 hours, every 6 hours and other) and as indicated to document arrhythmias: patient name; date/time; rate; PR interval; QRS width; Regularity; Rhythm Interpretation. Ensure clear, readable strip is utilized.

Review of Patient #6's printed telemetry rhythm strips revealed the strips were printed as ordered but there was no documented evidence of measurement of the PR interval or the QRS width when the patient experienced arrhythmia's (A-fib) at the following times:
12/9/16 at 7:26 a.m. and 11:28 a.m.
12/10/16 at 5:43 a.m., 7:05 a.m. and 3:15 p.m.

In an interview on 12/13/16 at 9:16 a.m. with S2CCO, she confirmed rate, PR interval, QRS width, Regularity, and Rhythm Interpretation should have been assessed/measured and documented on all telemetry patients who had experienced arrhythmia's. S2CCO indicated the telemetry techs printed and reviewed the telemetry patients ' rhythm strips. She further indicated the nurse responsible for each telemetry patient was responsible for reviewing and initialing the rhythm strips to verify they had reviewed the strips.

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, #5, #6, #12, #23) of 18 sampled patients reviewed for care planning out of a total of 30 (#1- #30) sampled patient records .

Findings:

Review of the hospital policy titled, " Plan of Care", Policy Number: 2881002, revised 10/2016, revealed in part: 2. The admission assessment data and physician orders are the basis for the selection and individualization of the patient plan of care. a) The patient care plan will be personalized to meet individual patient care needs. 3. Each nursing care plan is based on identifying nursing diagnosis and are consistent with the therapies of other disciplines.

Patient #1
Review of Patient # 1's medical record revealed an admission date of 11/25/16 with an admission diagnosis of necrotizing fasciitis with extensive debridement. Further review revealed a comorbid diagnosis of Stage III Chronic Kidney Disease. Additional review Patient #1 was currently receiving Hemodialysis treatment.

Review of Patient #1's hospital nursing care plan revealed there were no problems identified for Hemodialysis on the patient's plan of care.

Patient #2:
Review of Patient #2's medical record revealed an admission date of 11/23/16. The patient had the diagnoses of end stage renal disease and was currently receiving hemodialysis treatment.

Review of Patient #2's hospital nursing care plan revealed there were no problems identified for Hemodialysis on the patient's plan of care.

Patient #3
Review of Patient # 3's medical record revealed an admission date of 12/2/16 with an admission diagnosis of Acute on Chronic Respiratory Failure. Further review revealed the patient had co-morbid diagnoses of Diabetes with unstable glucose (insulin dependent), Urinary Tract Infection (culture + for Proteus Mirabalis) and a right lateral heel pressure wound (infected with MRSA-MDRO). Additional review revealed the patient was being treated with Coumadin (anticoagulant).

Review of Patient #3's plan of care revealed the patient's actual infections - urinary tract infection and right lateral heel pressure wound infection were not addressed on the patient's plan of care. Additional review revealed the patient's risk for bleeding due to being treated with an anticoagulant (Coumadin) was also not addressed as a potential problem on the patient's care plan.


Patient #5:
Review of Patient #5's medical record revealed an admission date of 11/25/16. The patient had the diagnoses of end stage renal disease and was currently receiving hemodialysis treatment.

Review of Patient #5's hospital nursing care plan revealed there were no problems identified for Hemodialysis on the patient's plan of care.

Patient #6
Review of Patient # 6's medical record revealed an admission date of 12/8/16 with an admission diagnosis of Acute Renal Failure with new onset of Hemodialysis. Patient #6 was currently receiving Hemodialysis treatment.

Review of Patient #6's hospital nursing care plan revealed there were no problems identified for Hemodialysis on the patient's plan of care.

Patient #12
Review of Patient # 12's medical record revealed an admission date of 11/25/16 with an admission diagnosis of Left Transmetatarsal Amputation that is now dehisced with the wound non-healing. Further review revealed the patient had a co-morbid diagnosis of Diabetes. Review of the Physicians orders dated 12/05/16 revealed orders for Glipizide 10mg 2 Tablets by mouth Twice Daily, Metformin 500mg by mouth Twice Daily, and Accuchecks Twice Daily with sliding scale insulin.

Review of Patient #12's Interdisciplinary Plan of Care dated 11/25/16 revealed no problems were identified for Diabetes on the patient's plan of care.

Patient #23
Review of Patient #23's medical record revealed an admission date of 11/15/16 with an admission diagnosis of Infected Sacral Stage 4 Decubitus. Further review revealed the patient had a co-morbid diagnosis of Diabetes. Review of the Physicians orders dated 11/15/16 revealed orders for Levemir 15 units Sub-Q (subcutaneous) at Bedtime and Accuchecks every 6 hours with sliding scale insulin.

Review of Patient #23's Interdisciplinary Plan of Care dated 11/15/16 revealed no problems were identified for Diabetes on the patient's plan of care.

In an interview on 12/13/16 at 10:20 a.m. with S2CCO (Chief Clinical Officer), she confirmed patient care plans should reflect the total care provided to the patient.


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30364

Based on record reviews, interviews and observation, the hospital failed to provide adequate supervision of non-employee licensed dialysis nursing personnel as evidenced by:

1) failure to meet the Louisiana State Board of Nursing declaratory statement on the role and scope of practice of the registered nurse in dialysis nursing adopted 11/20/96 and revised 12/03/03 which states, in part: The Board believes that every patient requiring hemodialysis has the right to professional nursing care. The registered nurse is responsible for the nature and quality of all nursing care a patient receives regardless of the dialysis setting. The nursing care of dialysis patients shall be supervised by a registered nurse who has training, experience, and documented current competence in the nursing care of patients with renal and end-stage disease and in hemodialysis techniques. This deficient practice was evidenced by hemodialysis treatments being administered by patient care technicians to patients in individual patient rooms. This deficient practice had the potential to affect all 4 (#1, #2, #5, #6) current Hemodialysis inpatients reviewed out of a total of 30 (#1-#30) sampled patient records.
2) failure to clarify incomplete orders for Hemodialysis for 4 of 4 (#1,#2,#5,#6) sampled patients reviewed for Hemodialysis out of a total of 30 (#1-#30) sampled patient records; and
3) failure to document pre-dialysis assessment for 1 (#2) of 4 (#1,#2,#5,#6) sampled patients reviewed for Hemodialysis out of a total of 30 (#1-#30) sampled patient records.

Findings:


1) Failing to meet the Louisiana State Board of Nursing declaratory statement on the role and scope of practice of the registered nurse in dialysis nursing.


Review of the Louisiana State Board of Nursing declaratory statement on the role and scope of practice of the registered nurse in dialysis nursing adopted 11/20/96 and revised 12/03/03 revealed, in part: After due deliberation, the Board took the following actions in order to safeguard the life and health of hemodialysis patients. The Board believes that every patient requiring hemodialysis has the right to professional nursing care. The registered nurse is responsible for the nature and quality of all nursing care a patient receives regardless of the dialysis setting. The nursing care of dialysis patients shall be supervised by a registered nurse who has training, experience, and documented current competence in the nursing care of patients with renal and end-stage disease and in hemodialysis techniques. Further review of this declaratory statement revealed, in part: Definition of Terms for the Purpose of This Document: Supervised, immediate supervision, readily available - "The registered nurse is physically present in the patient's room or on the floor with the patient, or in the dialysis unit".

Patient #2:
Observations on 12/12/16 at 9:28 a.m. revealed the patient was receiving hemodialysis treatment and the treatment was being provided by S4PCT.

In an interview on 12/12/16 at 9:32 a.m., S4PCT indicated she was assigned responsibility for administering hemodialysis treatment to Patient #2. S4PCT indicated S3RN was present at the hospital and was currently administering hemodialysis treatment to another patient.

Observations on 12/12/16 at 9:33 a.m. revealed S3RN came into Patient #2's room to check the patient's blood pressure and elevated heart rate. In an interview at this time S3RN indicated he was providing hemodialysis treatment to another patient and came to check on Patient #2 after being contacted by S4PCT. S3RN indicated he was the only RN for the two patients currently being dialyzed.

In an interview on 12/12/16 at 2:00 p.m. with S5DialysisDir (Director of Hospital "B" Dialysis Service), he reported he had consistently staffed with a RN and a PCT to dialyze the hospital's patients. S5DialysisDir indicated if two patients required Hemodialysis he asked the hospital to put the patients either side by side or a room apart. S5DialysisDir indicated the RN was responsible for patient assessment, initiating dialysis and stopping dialysis. S5DialysisDir further indicated the PCT was responsible for monitoring vital signs. S5DialysisDir indicated he was not aware of the Louisiana State Board of Nursing declaratory statement on the role and scope of practice of the registered nurse in dialysis nursing.

In an interview on 12/12/16 at 2:29 p.m., S2CCO indicated she was not aware of the Louisiana State Board of Nursing declaratory statement on the role and scope of practice of the registered nurse in dialysis nursing. further indicated that Lafayette AMG Specialty Hospital's policy for nurse staffing for administering Dialysis will be revised to be 1:1 (1 RN per patient in individual patient rooms).


2) Failure to clarify incomplete orders for Hemodialysis.

Review of the Ordering Hemodialysis Policy and Procedure revealed, in part: Policy: 2. A written order for hemodialysis must be on the patient's chart prior to initiation of treatment. The order must include the following: Dialysis days and length of treatment, Type of dialyzer, Heparin requirement, BFR, DFR, Dialysate bath, Fluid removal requirement.

Patient #1:
Review of Patient #1's medical record revealed the patient had diagnoses of necrotizing fasciitis and chronic kidney disease stage III. Further review revealed the patient was currently receiving hemodialysis treatment.
Additional review of Patient #1's medical record revealed incomplete dialysis orders on 12/6/16 at 1:08 p.m., 12/8/16 at 2:25 p.m., 12/9/16 at 6:20 a.m. and 12/12/16 at 8:00 a.m. The orders were missing the Blood flow rate, Dialysate flow rate and type of dialyzer.

Patient #2:
Review of Patient #2's medical record revealed the patient had the diagnoses of end stage renal disease and was currently receiving hemodialysis treatment.

Review of the hemodialysis orders dated 12/06/16, 12/08/16, and 12/09/16 revealed no orders for for type of dialyzer, BFR, and DFR.

Patient #5:
Review of Patient #5's medical record revealed the patient had the diagnoses of end stage renal disease and was currently receiving hemodialysis treatment.

Review of the hemodialysis orders dated 12/06/16, 12/08/16, and 12/09/16 revealed no orders for type of dialyzer, BFR, and DFR.

Patient #6:
Review of Patient #6's medical record revealed the patient had diagnoses diagnosis which included acute renal failure with new onset hemodialysis. Further review revealed the patient was currently receiving hemodialysis treatment.
Additional review of Patient #6's medical record revealed an incomplete dialysis order on 12/8/16 at 2:30 p.m. The order was missing the Blood flow rate, Dialysate flow rate and type of dialyzer.

In an interview on 12/12/16 at 2:00 p.m., S5DialysisDir verified hemodialysis orders must include type of dialyzer, BFR, and DFR. S5DialysisDir indicated the dialysis RN should contact the physician for clarification of dialysis treatment orders as needed.

3) Failure to document pre-dialysis assessment.

Patient #2:
Review of Patient #2's medical record revealed the patient had the diagnoses of end stage renal disease and was currently receiving hemodialysis treatment.

Observations on 12/12/16 at 9:28 a.m. revealed the patient was receiving hemodialysis treatment and the treatment was being provided by S4PCT.

Review of the Hemodialysis Treatment record revealed the patient's treatment started at 8:04 a.m. Review of the Pre-Treatment Assessment revealed a complete assessment of the patient was not documented by a RN.

In an interview on 12/12/16 at 10:54 a.m., S3RN indicated he was the RN responsible for the care of Patient #2. S3RN indicated he performed the patient pre-treatment assessment, but he did not document the assessment. S3RN indicated he would go back later to document the assessment.





30984

Based on record reviews and interviews, the hospital failed to ensure all verbal orders had been authenticated within 10 days as required by the Medical Staff Bylaws for 3 (#1,#8,#10) of 10 patient medical records reviewed for authentication of verbal orders out of a total of 30 (#1-#30) sampled patients reviewed.

Findings:

Review of the Hospital's Medical Staff Bylaws and Rules and Regulations revealed in part: 5.8.9: All verbal/telephone orders must be signed within 10 days.


Review of the hospital policy titled, "Time Frames", revealed in part: I. Policy: The health record documentation shall be completed by the time of discharge. The following time frames and definitions shall apply: Physician health record completion responsibilities: Verbal Orders per State law in Louisiana: 10 days.

Patient #1
Review on 12/12/16 of Patient #1's Medication Reconciliation and Order Form revealed the order had been taken by a telephone order on 11/25/16 at 9:15 p.m. Further review revealed the order had not been authenticated by a physician.

Review on 12/12/16 of Patient #1's Telemetry Protocol Physician Orders revealed the order had been taken by a telephone order on 11/25/16 (not timed). Further review revealed the order had not been authenticated by a physician.

Patient #8
Review on 12/12/16 of Patient #8's Wound Care Physician Orders dated 11/29/16 as a telephone/verbal order revealed it had not yet been authenticated by a physician.

Patient #10
Review on 12/13/16 of Patient #10 physician's orders revealed an order written on 11/22/16 at 9:30 p.m. as a TO/RBO (Telephone Order/Read Back Order). Further review revealed the order had not been authenticated by a physician.

In an interview on 12/13/16 at 10:40 a.m. with S7HIM, she verified verbal/telephone orders should have been authenticated (signed, dated, and timed) by the ordering physician within 10 days.

30984

Based on policy review, observation, and interview, the hospital failed to ensure the infection control officer implemented a system for identifying, reporting, investigating, and controlling of infections and communicable diseases as evidenced by failing to ensure contracted dialysis staff (S3RN, S4PCT) providing Hemodialysis services were performing hand hygiene and using gloves during patient care for 2 (#1,#2) of 2 patients observed during dialysis out of a total sample of 30 patients.


Findings:

Review of the Infection Control in Dialysis Department policies and procedures revealed, in part: Purpose: Infection control is directed towards protecting the Hemodialysis Patients from infection and towards establishing principals that will protect personnel from acquiring bloodborne infections and other communicable disease. Guidelines: Personnel. 1. D. There is no eating, drinking, and smoking, applying of cosmetics or lip balm in the Hemodialysis Department.

Review of the hospital policy titled," Hand Hygiene" policy number R.18.02, revealed in part:
Employees engaged in direct patient contact shall adhere to the following guidelines regarding hand hygiene practices. The purpose of this policy is to provide guidelines to promote hand-hygiene practices and reduce transmission of pathogenic microorganisms to patient and staff.
Procedure: Indications for hand-washing and hand anti-sepsis: A. Indications for hand-washing and hand antisepsis: 1. In addition to traditional hand-washing with soap and water, the CDC is recommending the use of alcohol based hand rubs. 2. Wash with soap and water when hands are visibly soiled. 3. If hands are not visibly soiled, an alcohol based and rub may be used to decontaminate hands. 5. Use antimicrobial soap or alcohol rubs prior to all bedside invasive procedures (insertion of peripheral IV catheters, insertion of central lines, etc.),6. Prior to patient contact. 7. Before performing an aseptic task. 8. Prior to personal protective equipment application.
D. Decontaminate hands at the following times: 1.b. Before gloving. c. After glove removal d. Before and after each patient contact e. After handling contaminated objects. f. After contact with an inanimate environmental source likely to be contaminated. h. Before eating. l. When moving from one contaminated body part to another: healthcare worker will change gloves and perform hand hygiene and reapply gloves prior to moving to a clean body site.
G.1. Gloves should be used as an adjunct, not a substitute for hand hygiene. 2. Gloves should be changed and hand hygiene performed after using gloves for contaminated activities. 3. Gloves should be discarded and hand hygiene performed after caring for a single patient and when moving from from one procedure to another, or one patient to another.

Patient #1
In an observation on 12/12/16 8:45 a.m., S3RN was administering dialysis for Patient #1. Further observation revealed he drank water out of a plastic bottle and set it on top of the dialysis machine. He also touched the dialysis machine several times and did not wear gloves or sanitize his hands.

In an observation on 12/12/16 at 9:13 a.m., S3RN was administering dialysis for Patient #1. S3RN was observed touching the dialysis machine without gloves, then touching his cell phone, then touching the dialysis machine and then touching his cell phone again. He then left the room without first washing or sanitizing his hands.

In an observation on 12/12/16 at 9:29 a.m., S3RN was administering dialysis for Patient #1 and talking on his cell phone. S3RN touched the dialysis machine and then began typing on his phone again. He did not wash or sanitize his hands during the observation.

In an observation on 12/12/16 at 9:36 a.m., S3RN was administering dialysis for Patient #1. S3RN touched the dialysis machine and the blood lines and then stuck his hands in his pockets. He then donned clean gloves and touched her blood lines again. S3RN then removed his gloves and did not wash or sanitize his hand before scrolling through his telephone.

Patient #2
In an observations on 12/12/16 from 9:25 a.m. to 9:48 a.m., S4PCT was administering dialysis for Patient #2. S4PCT was observed touching the dialysis machine without gloves multiple times and did not wash or sanitize her hands.

In an interview on 12/12/16 at 2:00 p.m. with S5DialysisDir, he confirmed gloves should be worn when touching the machine or patient.

In an interview on 12/14/16 at 12:00 p.m. with S2CCO, she indicated hand hygiene was to be performed with glove changes.