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Based on record review and interview the hospital failed to comply with applicable federal laws and regulations related to the health and safety of patients. This deficient practice is evidenced by failure of the hospital to notify the Louisiana Department of Health (LDH) of a change in laboratory director within 30 days.
Findings:

A review of Clinical Laboratory Improvements Amendments of '88 reveals CFR 493.39: Requirement to notify the U.S. Department of Health and Human Services (HHS) or its designee (LDH) within 30 days of a director change.

A record review of the hospital's Clinical Laboratory Improvements Amendments (CLIA) Certificate of Waiver with an effective date of 11/26/2023, revealed S11Lab as the Laboratory Director.

A review of the hospital's personnel list and organizational chart failed to reveal S11Lab as an employee.

In an interview on 04/10/2024 at 9:15 a.m. S2Adm confirmed the above mentioned findings.

Based on record review, policy review and interview, the hospital failed to protect the patient's right to personal privacy. This deficient practice is evidenced by the facility releasing patient information without properly identifying the patient prior to the release.
Findings:

A review of facility policy, "Patient Rights," last reviewed 10/2006 revealed in part, Policy: The basic rights of human beings for independence of expression, decision, and action and concern for personal dignity and human relationships are always of great importance. It becomes a prime responsibility for hospitals to endeavor to assure that these rights are preserved for their patients. Purpose: ...intended to convey the rehab hospital's concern about the relationship between hospitals and patients and to emphasize the need for the observance of rights and responsibilities of patients. 3. Privacy and Confidentiality: The patient has the right, within the laws, to personal and informational privacy, as manifested by the following rights: To expect that any discussion or consultation involving his case will be conducted discreetly. To have his medical record read only by individuals directly involved in his treatment or in the monitoring of its quality and by other individuals only on his written authorization or that of his legally authorized representative. To expect all communications and other records pertaining to his care, including the source of payment for treatment, to be treated as confidential. A Patient's Bill of Rights: 5. The patient has the right to every consideration of his privacy concerning his own medical care program. Case discussion, consultation, examination, and treatment are confidential and should be conducted discreetly. Those not directly involved in his/her care must have permission of the patient. 6. The patient has the right to expect that communications and records pertaining to his/her care should be treated as confidential.

A medical record review with the S3DON navigating the electronic medical record (EMR) and paper medical record revealed in part, case management notes reflecting S5CM discussing Patient #1 via telephone conversation without properly identify which patient the call was in reference. Further, patient information was released to this individual without properly identifying to whom the information was being released. Case Management note on 01/23/2024 at 12:07 p.m. revealed, "Received a call from Governor's office of elderly affairs concerning Patient #1(name was removed). Was informed patient had no running water or electricity to the home." This note did not contain information as to whom was making this request. The medical record did not contain any written authorization by this agency to obtain information regarding Patient #1. Further, there was no indication that proper patient identification was performed. After S5CM made contact with Patient #1's daughter and the concerns regarding the elderly affairs information was discussed, S5CM note on 01/23/2024 at 12:07 p.m. revealed, "Called elderly protective services to confirm information and this was a miscommunication on my part and there part it was concerning another patient with the same last name." This note did not contain information as to the name or contact information of whom this information was discussed.

In an interview on 02/09/2024 at 4:24 p.m. Patient's #1's daughter revealed in part she received a 4 minute voice mail from S5CM regarding the facility being contacted by a state agency that was identified as Governor's office of elderly affairs, information that the patient would need to be placed in a nursing facility and the patient's current treatment and progression. Patient #1's daughter indicated she had not spoken with S5CM prior to this voice mail and she was upset this type of information would be left on a voice mail.

A review of the voice mail received by Patient #1's daughter revealed the above mentioned comments and was approximately 4 minutes in length.

In an interview on 04/11/2024 at 9:20 a.m. S5CM confirmed the above mentioned findings. She further confirmed there was no way to verify patient identification via a voice mail.

Based on record review and interview, the hospital failed to ensure each patient received care in a safe setting. This deficient practice was evidenced by 2 (S7CNA, S8CNA) of 2 (S7CNA, S8CNA) personnel records reviewed for criminal background check completion prior to hire was not performed by an authorized agent of the Louisiana State Police.
Findings:

La RS 40:1203.1 - 5 requires in part, all licensed health care providers shall request that a criminal history and security check be conducted on the non-licensed person, prior to any employer making an offer to employ or to contract with a non-licensed person to provide nursing care, health-related services or supportive assistance to any individual.

The Louisiana Office of State Police, Bureau of Criminal Identification and Information (Bureau), is the State's designated repository for criminal history information pursuant to the laws cited in La. R.S. 15:575 et seq. Any criminal event that is documented by the submission of fingerprints to the State is stored in the Louisiana Computerized Criminal History (LACCH) database. The Bureau may only release criminal history information stored in LACCH for noncriminal justice purposes when authorized by law. The Bureau is authorized to release criminal history information stored in LACCH to those employers and Authorized Agencies defined in La. R.S. 40:1203.1 as required by La. R.S. 40:1203.2.

Pursuant to La. R.S. 40:1203.7, Authorized Agencies must be domiciled in the state of Louisiana and must be certified by the La. Secretary of State's office. Authorized Agents must also be certified by the Bureau. Companies that perform background check services that are not domiciled in Louisiana nor certified through the Secretary of State's office and the Bureau are not authorized to request or receive criminal history information stored in LACCH. Additionally, Authorized Agents are not authorized to request criminal history information on behalf of national background check companies. La. R.S. 15:579 mandates the Bureau to issue rules and regulations consistent with the U.S. Dept. of Justice governing the privacy and security of criminal history records. To meet this requirement, the Bureau has adopted rules and regulations including those described in 28 Code of Federal Regulations (CFR) 20.21 which limits the release of criminal history information to only those agencies authorized by statute. Employers may contact LDH or the Bureau for a current list of Authorized Agencies.

A personnel file review on 04/11/2024 revealed S7CNA's date of hire was 03/10/2024 and S8CNA's date of hire was 03/02/2024. Initial hire criminal background checks were completed by Company A. This company was not an authorized agency approved by the Louisiana State Police for the use of conducting a criminal background check on a non-licensed employee of a licensed healthcare provider.

In an interview on 04/11/2023 at 12:15 p.m., S2Adm and S6CFO confirmed the above mentioned findings.

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by:
1) Failing to ensure capillary blood glucose levels were obtained for 1 (#1) of 3 (#1 #3) patients as ordered;
2) Failing to document interventions related to blood glucose results on 1 (#1) of 3 (#1 #3) patients;
3) Failing to ensure blood pressure readings were obtained appropriately on 1 (#1) of 3 (#1 #3) patients; and
4) Failing to ensure blood pressure and heart rate was documented prior to administering anti-hypertensive medications on 1 (#1) of 3 (#1 #3) patients.
Findings:

1) Failing to ensure capillary blood glucose levels were obtained for 1 (#1) of 3 (#1 #3) patients as ordered

A review of Patient #1 medical record revealed an order for Accuchecks before meals and at bedtime. A review of the Medication Administration Record (MAR) revealed no documentation of a blood glucose reading on the following dates and times: 01/15/2024 at 6:30 a.m. and 4:30 p.m.; 01/16/2024 at 6:30 a.m.,11:30 a.m.; 01/24/2024 at 11:30 a.m., 4:30 p.m.; 01/25/2024 at 6:30 a.m., 11:30 a.m.; 01/29/2024 at 4:30 p.m.; 01/30/2024 at 4:30 p.m.; 02/03/2024 at 6:30 a.m., 4:30 p.m.; 02/04/2024 at 6:30 a.m.; and 02/05/2024 at 6:30 a.m., 11:30 a.m., 4:30 p.m.

In an interview on 04/09/2024 at 1:30 p.m. S3DON confirmed the above mentioned findings.

2) Failing to document interventions related to blood glucose results on 1 (#1) of 3 (#1 #3) patients

A review of the sliding scale standing orders revealed a glucose reading of < 69 and symptomatic = call MD; < 70 and can swallow OJ and recheck in 30 minutes, or give one-half amp of D50 as needed; 70-199 = 0 units; 200-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units; 401-450 = 12 units.

A review of Patient #1 medical record revealed an order for insulin per sliding scale. A review of the MAR revealed no documentation for the amount of insulin administer or held on the following dates and times: 01/16/2024 at 4:30 p.m. with result of 222; 01/25/2024 at 4:30 p.m. with result of 275; 01/29/2024 at 11:30 a.m. with result of 434; and 02/04/2024 at 4:30 p.m. with result of 257

In an interview on 04/09/2024 at 1:30 p.m. S3DON confirmed the above mentioned findings.

3) Failing to ensure blood pressure readings were obtained appropriately on 1 (#1) of 3 (#1 #3) patients

A review of facility policy, "Blood Pressure Assessment," with a last review of 10/2022 revealed in part, Special Consideration: 3. Do not take a blood pressure in the arm of a patient who has any of the following without first consulting the nurse or physician: b. a fistula or dialysis catheter.

A review of Patient #1 medical record revealed a nursing progress note from 01/14/2024 indicating the patient having a left upper arm fistula. Further review revealed blood pressure readings via the left arm on the following dates: 01/19/2024 at 7:09 a.m. 146/51 Left Arm; 01/20/2024 at 6:00 p.m. 147/77 Left Arm; 01/21/2024 126/56 Left Arm; and 01/29/2024 at 8:20 p.m. 143/69 Left Arm.

In an interview on 04/09/2024 at 1:30 p.m. S3DON confirmed the above mentioned findings.

4) Failing to ensure blood pressure and heart rate were documented prior to administering anti-hypertensive medications on 1 (#1) of 3 (#1 #3) patients

A review of Patient #1's MAR revealed an order associated with the administration of amlodipine. The order included the documentation of a blood pressure and heart rate on the MAR upon the administration of this medication. The blood pressure and heart rate were not documented on the following dates: 01/15/2024 at 8:00 a.m.; 01/24/2024 at 8:00 a.m.; and 02/05/2024 at 8:00 a.m.

In an interview on 04/09/2024 at 1:30 p.m. S3DON confirmed the above mentioned findings.

Based on record review, policy review and interview, the hospital failed to ensure the nursing care plan for each patient was kept current and reflected the patient's goals and the nursing care to be provided to meet the patient's needs. This deficient practice was evidenced by 2 (#1, #2) of 3 (#1-#3) patient medical records reviewed not having a nursing care plan to reflect the patient's current physiologic condition.
Findings:

A review of facility policy, "Individual Plan of Care," with a last review on 01/2022 revealed in part, Policy: All patient will have an individualized plan of care that is individually tailored, integrated and coordinated by competent professional through licensure, training and experience. Purpose: To establish a comprehensive, goal-oriented, individualized plan for each patient served based on assessment of patient physical, cognitive, behavioral communicative, emotional, pharmacological, pain management, and social needs. Procedure: 1. Each patient has a care plan developed based on the initial assessment. A problem list is developed, and individualized plan is developed through the initial assessment. 2. The individualized care plan includes the following information presently: a. identified nursing problems from a head-to-toe assessment and the functional limitation and presenting need. 3. The patient's care plan is incorporated into the interdisciplinary care plan and problems and goal attainment is discussed at the weekly team conference.

A review of the EMR and paper medical record being navigated by S3DON revealed the following:
Patient #1:
Admission on 01/14/2024 at 5:45 p.m. Nursing admission progress note revealed in part, a skin tear to sacral area and left upper arm fistula. The plan of care revealed the nursing problem list being initiated on 01/23/2024. This would be 9 days after the admissions of the patient. The nursing problem list included risk for unstable blood glucose, alteration in fluid volume, and patient safety. The nursing problem list did not include any problem related to Impaired Tissue integrity (wound care) or Alterations in Skin Integrity.
Patient #2:
Admission on 03/21/2024 at 1:32 p.m. History and Physical revealed in part, the patient being admitted to acute care for Congestive Heart Failure with chronic left lower neuropathy. Recent hospitalization left him with generalized weakness. The patient was admitted to this facility to assist with improving the limitations that have occurred due to the recent hospitalization. Other history includes Atrial fibrillation and Hypertension. Patient was on fluid restrictions. The plan of care revealed the nursing problem list being initiated on 03/21/2024. The nursing problem list included Alteration in Comfort. The nursing problem list did not include problems related to the patient's current physiological condition or medical diagnosis.

In an interview on 04/11/2024 at 10:00 a.m. S3DON confirmed the above mentioned findings.

Based on observation, record review and interview, the hospital failed to maintain the drug storage area in accordance with accepted professional principles. This deficient practice is evidenced by:
1) Failing to secure Scheduled (narcotics) Drugs;
2) Failing to verify Scheduled (narcotics) Drugs at shift change;
3) Discharged patient medications co-mingled with floor stock medications and available for patient use;
4) Failing to remove expired floor stock medications and available for patient use; and
5) Failing to remove a medication available for patient use after it's beyond use date.
Findings:

A review of facility policy, "Medication Security and Storage," with an effective date of 04/2015 revealed in part, Purpose: To define, control, and secure the handling of all medications, including controlled substances so to conform to the policies of the Pharmacy and Therapeutic Committee, and Federal and State Regulations. Policy Statements: A. Medications will be stored in a manner consistent with manufacturer recommendations and applicable hospital regulations. B. All authorized personnel will be responsible for ensuring the proper storage of all medications and utilized in the care of their patients. D. All authorized personnel will be responsible for the control and security of medications and utilized in the care of their patients.

A review of facility policy, "Medication Administration," with a last review of 10/2022 revealed in part, Medication Orders 2. Nurse Responsibilities: Two nurses will count and verify that the narcotic stock is correct at the beginning and end of the shift using the Narcotic Administration Record. 6. Collect Medication from Medication Storage: Medications by Injection: Multi-dose vial expires 28 days after opened and must be labeled. Further there is a sign posted in the medication room which revealed in part, narcotic count is to be completed at the end of every shift (touched narcotics). The big narcotic count (all narcotics) is to be completed every Sunday. All narcotic discrepancies must be cleared within a reasonable timeframe as it a recommendation per state and to identify true discrepancies or diversion of narcotics. There was no indication as to a date of this sign being posted.

A review of facility policy, "Disposal of Discontinued or Unused Medications," with an effective date of 12/2016 revealed in part, 1. Any unused/expired medications will be placed in the pharmacy medication bins and recorded. All bins will be sent to Pro Med Waste Management once the bin has met capacity.

1) Failing to secure Scheduled (narcotics) Drugs

An observation of the medication room on 04/08/2024 at 11:10 a.m. revealed the following blister packaged Scheduled (narcotics) Drugs located in an unlocked cabinet of the medication room:
Clonaepam (Klonopin) 2mg tab, blister package of 4 tabs and a blister package of 21 tabs;
Morphine Sulfate 30mg extended release tab, blister package of 18 tabs;
Pregabalin (Lyrica) 25 mg tab, blister package of 13 tabs and a blister package of 6 tabs;
Pregabalin (Lyrica) 200mg tab, a blister package of 21 tabs and a blister package of 2 tabs;
Modafinil (Provigil) 200mg tab, a blister package of 2 tabs and a blister package 4 tabs;
Modafinil (Provigil) 100mg tab, a blister package of 16 tabs; and
Buprenorphin (Buprenex) 8mg tabs, a blister package of 7 tabs and a blister package of 3 tabs.

In an interview on 04/08/2024 at 11:35, S9RN confirmed the above mentioned findings.

2) Failing to verify Scheduled (narcotics) Drugs at shift change

A review of the hospital's Change of Shift Narcotic Count for 04/2024 revealed an incomplete log from 04/01/2024 till 04/05/2024. The log was missing a nurse signature for the Coming on Duty nurse at 6P on 04/01/2024 to 04/04/2024. The log was missing a nurse signature for the Going off Duty nurse at 6A on 04/01/2024, 04/03/2024 - 04/05/2024.

In an interview on 04/08/2024 at 11:35, S9RN confirmed the above mentioned findings.

3) Discharged patient medications co-mingled with floor stock medications and available for patient use

An observation of the medication room on 04/08/2024 at 11:10 a.m. revealed the following medications prescribed to patients that were not listed on the current census provided, co-mingled with floor stock and available for patient use:
Biotene oral rinse, open bottle;
Chlorhexidine Gluconate Oral Rinse 0.12% quantity 2 unopen bottles; and
Repatha Sureclick Pen 140mg/ml in an unsealed box.

In an interview on 04/08/2024 at 11:35, S9RN confirmed the above mentioned findings and medications being prescribed to a patient should be returned to the pharmacy upon the patient's discharge.

4) Failing to remove expired floor stock medications and available for patient use

An observation of the medication room on 04/08/2024 at 11:10 a.m. revealed the following expired medications:
a) Vancomycin 1g/200ml IV bag expiration 11/2023; and
b) Acetaminophen 650mg suppository, quantity 5, expiration 06/2023.

In an interview on 04/08/2024 at 11:35, S9RN confirmed the above mentioned findings.

5) Failing to remove a medication available for patient use after it's beyond use date

An observation of the medication room on 04/08/2024 at 11:10 a.m. revealed Insulin Glargine-Yfgn 100units/ml with an opening date sticker indicating 03/05/2024. Facility policy indicates discarding after 28 days.

In an interview on 04/08/2024 at 11:35, S9RN confirmed the above mentioned findings.

Based on observation and interview, the hospital failed to ensure facilities, supplies and equipment were maintained to an acceptable level of safety and/or quality. This deficient practice is evidenced by:
1) Observation of the glucose meter revealed tape and a sticky substance on its casing;
2) Observation of current glucose meter controls and test strips had no open date recorded;
3) Observation of television remote control with tape and brown substances on its edges;
4) Observation of mattress with dry, red substance on it;
5) Observation of mattresses and pillows with cracked and discolored coverings;
6) Observation of exposed wood on the hallway side of Room #a entry door;
7) Observation of wheelchair armrests with cracked and peeling covering;
8) Observation of an IV pole with brown flaky substances on the metal pole;
9) Observation of clothing on the floor of the patient laundry room;
10) Observation of an open gallon container of Great Value Distilled Water in the supply closet;
11) Failing to ensure expired supplies were not available for patient use; and
12) Failing to document daily refrigerator checks.

Observations during a tour of the facility on 04/08/2024 from 10:30 a.m. till 12:15 p.m. revealed the following:

1) Observation of the glucose meter revealed tape and a sticky substance on its casing

An observation of the Medline EVENCARE G3 Glucose Meter revealed the casing of the meter had tape and a sticky substance on it. This created a surface that could not be properly sanitized.

In an interview on 04/08/2024 at 12:01 p.m. S10LPN confirmed the above mentioned findings.

2) Observation of current glucose meter controls and test strips had no open date recorded

A review of facility policy, "Glucometer Quality Controls Testing," with an effective date of 03/2015 revealed in part, Policy: Quality Control on the glucometer will be performed to ensure accurate and reliable testing using the low and high level control solutions. Quality Control log is maintained on the nursing unit and results are monitored by the DON. Procedure: See manufactures instructions for use.

The EVENCARE G3 Blood Glucose Monitoring System User Guide revealed in part, notes regarding control solutions and test strips. The recording of the date on the bottle when opening a new bottle of control solution, discard any unused control solution 3 months after the opening date, and control solutions are good for 3 months after opening or until the expiration date on the bottle, whichever comes first. The recording of the date on the vial test strips when opening a new bottle and discard any unused test strips 6 months after opening. Vial test strips are good for 6 months after opening or until the expiration date on the bottle, whichever comes first.

An observation of the current EVENCARE Quality Controls and Test Strips revealed the bottles not being properly labeled with an open date.

In an interview on 04/08/2024 at 12:02 p.m. S2Adm confirmed the above mentioned findings.

3) Observation of television remote control with tape and brown substances on its edges

An observation of Room #a television remote control had tape holding its casing together and the tape had a yellow substance on it. This creates a surface that prohibits sanitary cleaning.

In an interview on 04/08/2024 at 10:35 a.m. S2Adm confirmed the above mentioned findings.

4) Observation of mattress with dry, red substance on it

An observation of Room #a mattress revealed the matteress covering had dry, red substance on its side.

In interview on 04/08/2024 at 10:35 a.m. S2Adm confirmed the above mentioned findings and the room had been recently cleaned.

5) Observation of mattresses and pillows with cracked and discolored coverings

An observation of Room #a and #b mattresses revealed cracking on the bottom of all corners of the mattress covering. The patient side of each mattress was partially discolored. A pillow located in Room #a had a cracked vinyl covering. All of these cracked surfaces prohibit sanitary cleaning.

In interview on 04/08/2024 at 10:45 a.m. S2Adm confirmed the above mentioned findings.

6) Observation of exposed wood on the hallway side of Room #a entry door

An observation of Room #a entry door had exposed and splintering wood on the hallway side which prohibits sanitary cleaning.

In interview on 04/08/2024 at 10:45 a.m. S2Adm confirmed the above mentioned findings.

7) Observation of wheelchair armrests with cracked and peeling covering

An observation of a wheelchair in therapy gym 2 revealed its vinyl covered armrests having cracked and peeling surfaces which prohibits sanitary cleaning.

In interview on 04/08/2024 at 10:50 a.m. S2Adm confirmed the above mentioned findings.

8) Observation of an IV pole with brown flaky substances on the metal pole

An observation of an IV pole in the storage closet revealed brown flaky spots on the entire metal pole and base.

In interview on 04/08/2024 at 10:55 a.m. S2Adm confirmed the above mentioned findings.

9) Observation of clothing on the floor of the patient laundry room

An observation of the patient laundry room revealed clothing piled up on the floor.

In interview on 04/08/2024 at 10:55 a.m. S2Adm confirmed the above mentioned findings.

10) Observation of an open gallon container of Great Value Distilled Water in the supply closet

An observation of the supply closet revealed an open gallon container of Great Value Distilled Water available for patient use. There was no indication of when the container was opened. This type of container would not be indicative of multi-patient use and once the container was opened, its contents were compromised.

In interview on 04/08/2024 at 10:52 a.m. S2Adm confirmed the above mentioned findings.

11) Failing to ensure expired supplies were not available for patient use

An observation of the crash cart revealed Zoll Stat-padz II Adult Electrodes attached to the cardiac defibrillator with an expiration of 02/12/2024.

An observation of the medication room reveal the following supplies expired and available for patient use:
a) Abbott Covid 19 Reagent expiring 11/2022;
b) Covid-19 Ag Card, Quantity 10, expired 12/07/2022; and
c) UTM-RT Specimen Collection Kit, Quantity 9, expired 09/30/2023.

In interview on 04/08/2024 at 11:05 a.m. and at 11:20 a.m. S2Adm confirmed the above mentioned findings.

12) Failing to document daily refrigerator checks

An observation of The Nutritional Room Refrigerator Temperature log for 03/2024 was not available and the log for 04/2024 had not been completed from 04/01/2024 to the present day.

In interview on 04/08/2024 at 11:08 a.m. S2Adm confirmed the above mentioned findings.