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Based on record review, policy review and interview, the hospital's Governing Body failed to ensure the enforcement of the Medical Staff Bylaws in regards to ensuring compliance with medical records services. This was evidenced by the licensed practitioner's failure to comply with Medical staff Rules and Regulations of completing patient's medical records within 30 days by failing to dictate discharge summaries for 9 (#10, #30, #R1, #R2, #R3, #R4, #R5, #R6, #R7) of 9 records reviewed for discharge summaries.

Findings:

Review of the Medical Staff Bylaws and Rules and Regulations approved by Governing Body on January 23, 2019 revealed 11.7 Medical Records (e) Discharge Summary (1) A discharge summary shall be recorded at the time of discharge unless awaiting tests results. Any inpatient that dies in the hospital shall have a recorded death summary. In all instances, the content of the medical record shall be sufficient to justify the diagnosis, warrant the treatment, and end result. In any event, the Discharge Summary must be completed within thirty (30) days of discharge. Policy: It is the policy of St. Landry Extended Care Hospital to ensure completion of medical records within 30 days of discharge. A. Notification of Incomplete/Delinquent Medical Records. 1. The Administrator or his designee shall notify each practitioner with a list of the practitioner's incomplete and delinquent medical records not less than bi-weekly (every two weeks). A first notice will accompany the list of incomplete and delinquent medical records once an incomplete medical record has been incomplete for eleven (11) days. 2. A second notice will accompany the list of incomplete and delinquent medical records once an incomplete medical record has been incomplete for twenty-one (21) days. This notice will list the medical record number, the patient name, the discharge date, the items requiring completion and the number of days that the record has been incomplete. B. Suspension: 1. once the medical record remains incomplete for thirty (30) days, the Administrator shall notify the practitioner that the practitioner's elective privileges have been automatically suspended. 4. The Automatic Suspension will remain in effect until the delinquent medical records have been verified as complete.

Review of patient #10 record revealed an admit date of 02/06/19 and was discharged on 02/11/19. There was no evidence of a dictated discharge summary in the medical record.

Review of patient #30 record revealed an admit date of 04/19/19 and was discharged on 04/30/19. There was no evidence of a dictated discharge summary in the medical record.

Review of patient #R1 record revealed an admit date of 07/10/18 and was discharged on 08/10/18. There was no evidence of a dictated discharge summary in the medical record.

Review of patient #R2 record revealed an admit date of 04/12/19 and was discharged on 04/15/19. There was no evidence of a dictated discharge summary in the medical record.

Review of patient #R3 record revealed an admit date of 03/19/19 and was discharged on 04/23/19. There was no evidence of a dictated discharge summary in the medical record.

Review of patient #R4 record revealed an admit date of 03/25/19 and was discharged on 05/06/19. There was no evidence of a dictated discharge summary in the medical record.

Review of patient #R5 record revealed an admit date of 03/29/19 and was discharged on 04/19/19. There was no evidence of a dictated discharge summary in the medical record.

Review of patient #R6 record revealed an admit date of 07/10/18 and was discharged on 08/10/18. There was no evidence of a dictated discharge summary in the medical record.

Review of patient #R7 record revealed an admit date of 04/01/19 and was discharged on 04/07/19. There was no evidence of a dictated discharge summary in the medical record.

Interview on 06/11/19 at 1:50 p.m. with S1Administrator confirmed that there were no physicians currently under suspension.

Based on record review and interviews, the hospital failed to ensure all drugs and biologicals were administered as ordered by the physician and according to acceptable standards of practice for patient records reviewed for 2 (#5, #19) of 18 medical records reviewed for medication administration from a total sample of 30 patient records.

Findings:

Review of the hospital policy titled "Medication Administration", Policy Number: 9-4.13.0 revised 07/25/18 revealed in part: All patient's medications will be administered per a physician's order and documented on a Medication Administration Record (MAR). The nurse who administers the medication shall document such by drawing a line through the time and initialing the time on the MAR as soon as possible following administration. Any drug that is withheld shall be circled and initialed on the MAR. The nurse shall document on the MAR or the nurse's narrative notes if necessary the reason the drug was not given. The physician must be notified if a medication or treatment is held without a specific order ...

Patient #5
Review of the medical record for patient #5 revealed admitted on 05/23/19 with a diagnosis of Sepsis, DM, HTN, ARF, and Anemia. Review of the physician's orders revealed an order for CBG before meals and at bedtime per Regular Human Insulin per sliding scale: 60-200= observation, 201-250= 4 units, 251-300= 6 units, 301-350= 8 units, 351-400= 10 units, 401-450= 12 units, >450=14 units and notify physician.

Review of the MAR dated 06/09/19 revealed no line or documentation on the MAR indicating the 0630 a.m. CBG had been done.

Review of the Diabetic Flow Chart dated 06/09/19 at 11:30 a.m. revealed a CBG documented of 300, but there was no documented evidence any insulin was given according to the physician sliding scale order. Further review revealed 06/09/19 4:30 p.m. CBG documented 235, but there was no documented insulin given according to the physician sliding scale order.

Interview on 06/11/19 at 9:45 a.m. with S2DON confirmed there was no documentation of any insulin given according to the physician sliding scale order.

Patient #19
Review of the medical record for patient #19 revealed admitted on 05/14/19 with a diagnosis of Poor Wound healing, PAD, COPD, DM, and HTN.

Review of the Physicians Orders dated 05/14/19 revealed order for Metoprolol Succinate 25 mg daily.

Review of the MAR dated 06/10/19 revealed Metoprolol Succinate 25 mg scheduled to be given at 9:00 a.m. The time on the MAR was circled indicating that the medication was not given, but "given" was documented on the MAR under the time with AP 57. Instructions on the MAR for standards of practice for Metoprolol Succinate revealed Record Apical Pulse on MAR next to time given and Hold if
Interview on 06/11/19 at 10:15 a.m. with S2DON confirmed there was no other documentation on the MAR or the Nurses Daily Flow Sheet to indicate if the medication was given or not. S2DON further stated that the medication should not have been given with an apical pulse of 57 and the physician should have been notified, but there was no documented evidence the physician was contacted.

Based on record review, and interview the hospital failed to ensure 6 Physicians (S7, S8, S9, S10, S11, S12) followed Medical Staff By-laws and hospital policies and procedures related to completion of medical records that were delinquent for greater than 30 days.

Findings:

Review of the Medical Staff Bylaws and Rules and Regulations approved by Governing Body on January 23, 2019 revealed 11.7 Medical Records (e) Discharge Summary (1) A discharge summary shall be recorded at the time of discharge unless awaiting tests results. Any inpatient that dies in the hospital shall have a recorded death summary. In all instances, the content of the medical record shall be sufficient to justify the diagnosis, warrant the treatment, and end result. In any event, the Discharge Summary must be completed within thirty (30) days of discharge.

Review of the Medical Records Chart Deficiency Listing dated 06/11/19 given to surveyor by S6HITech revealed the following physicians had delinquent records over 30 days:

S7 Physician - #2 records (56, 304 days)
S8 Physician - #2 records (35, 48 days)
S9 Physician - #1 record (119 days)
S10 Physician - #2 record (50, 52 days)
S11 Physician - #1 record (54 days)
S12 Physician - #1 records (41 days)

Interview on 06/11/19 at 1:50 p.m. with S1Administrator confirmed that he was unaware of delinquent records past 30 days that were not completed.

Based on record reviews and interviews, the hospital failed to ensure all patient records included documentation of outcomes of hospitalization, disposition of care, and provisions for follow-up care. This deficient practice was evidenced by failure of the hospital to ensure the treating licensed practitioner completed a discharge summary for 9 (#10, #30, #R1, #R2, #R3, #R$, #R5, #R6, #R7) of 9 patient records reviewed for discharge summaries.

Findings:

Review of the Medical Staff Bylaws and Rules and Regulations approved by Governing Body on January 23, 2019 revealed 11.7 Medical Records (e) Discharge Summary (1) A discharge summary shall be recorded at the time of discharge unless awaiting tests results. Any inpatient that dies in the hospital shall have a recorded death summary. In all instances, the content of the medical record shall be sufficient to justify the diagnosis, warrant the treatment, and end result. In any event, the Discharge Summary must be completed within thirty (30) days of discharge.

Review of patient #10 record revealed an admit date of 02/06/19 and was discharged on 02/11/19. There was no evidence of a dictated discharge summary in the medical record.

Review of patient #30 record revealed an admit date of 04/19/19 and was discharged on 04/30/19. There was no evidence of a dictated discharge summary in the medical record.

Review of patient #R1 record revealed an admit date of 07/10/18 and was discharged on 08/10/18. There was no evidence of a dictated discharge summary in the medical record.

Review of patient #R2 record revealed an admit date of 04/12/19 and was discharged on 04/15/19. There was no evidence of a dictated discharge summary in the medical record.

Review of patient #R3 record revealed an admit date of 03/19/19 and was discharged on 04/23/19. There was no evidence of a dictated discharge summary in the medical record.

Review of patient #R4 record revealed an admit date of 03/25/19 and was discharged on 05/06/19. There was no evidence of a dictated discharge summary in the medical record.

Review of patient #R5 record revealed an admit date of 03/29/19 and was discharged on 04/19/19. There was no evidence of a dictated discharge summary in the medical record.

Review of patient #R6 record revealed an admit date of 07/10/18 and was discharged on 08/10/18. There was no evidence of a dictated discharge summary in the medical record.

Review of patient #R7 record revealed an admit date of 04/01/19 and was discharged on 04/07/19. There was no evidence of a dictated discharge summary in the medical record.

Interview on 06/11/19 at 11:50 a.m. with S6HITech confirmed that there was no documented evidence that a discharge summary had been completed by the physician for (#10, #30, #R1, #R2, #R3, #R$, #R5, #R6, #R7) patient records.

Based on policy review, record review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable standards of practice. This deficient practice was evidenced by the hospital failing to ensure medication overrides were witnessed according to policy for 36 out of 104 overrides reviewed.
Findings:

Review of hospital policy 9-4.13.1 titled, "Automated Medication Dispensing Cabinet: MedDispense revealed in part:
Medication Removal- The medication override function should be used infrequently as the absence of a pharmacist review may increase the potential for a medication error. A witness is required for all manual overrides.

Review of the hospital "Profile Override History" from 04/01/2019 to 05/01/2019 revealed 36 overrides were not witnessed according to policy.

During an interview on 06/11/2019 at 1:40 p.m., S2DON acknowledged the override policy was not being followed.

Based on policy review, record review and interview, the hospital failed to ensure identified medication errors were documented in the patient's chart for 2 (#8, #12) of 3 patient records reviewed who had hospital identified medication errors (#8, #12, #13).
Findings:

Review of hospital policy 9-4.15.0 titled, "Medication Variance" revealed in part:
Protocol for Reporting Medication Variances - When a medication variance is discovered, the incident must be reported immediately to the charge RN. The variance should be reported to the physician as soon as possible. The drug administered in error/omitted in error and the action taken should be documented in the patient's medical record.

Patient #8
Review of hospital incident report log and Patient #8's medical record revealed on Aspirin 81 mg had been discontinued on 05/22/2109 and the medication was given on May 23, 24, and 25th. Further review revealed no documentation was in the medical record that a medication error had occurred or that the physician had been notified of the medication error.

Patient #12
Review of Patient #12's medical record revealed on 05/24/2019 Lovenox 40 mg SQ daily was to be given beginning on 5/24/2019 and the medication was not started until 05/25/2019. Further review revealed no documentation was in the medical record that a medication error had occurred or that the physician had been notified of the medication error.

During an interview on 06/11/2019 at 9:38 a.m., S2DON verified the physician notification of a medication error and a notation of the medication error should have been in medical record.

Based on observation and interview, the hospital failed to ensure equipment was maintained to ensure an acceptable level of safety as evidenced by having non-functioning nurse call bells located on the side rails of 24 of 24 patient beds.
Findings:

On 06/10/2019 at 12:10 p.m., observation of patient rooms a and b revealed a nurse call button on the bed's side rails which did not function when activation was attempted.

An interview with S1Administrator on 06/12/2019 at 9:15 a.m. revealed that 24 patient beds in the facility had the visible non-functioning call button feature on the side rails. S1Administrator confirmed that the rooms had call bells that were attached to cords plugged into the wall and placed within patient reach. S1Administrator further confirmed that the non-functioning call bells on the side rails could cause confusion for a patient or family member who was attempting to call for assistance.

Based on policy review, observation and interview, the hospital failed to maintain a system for preventing infections as evidenced by: 1) failing to maintain a sanitary hospital environment, and 2) a nurse failing to perform hand hygiene during wound treatment. Findings:

1. Failing to maintain a sanitary hospital environment

Review of the hospital policy titled, "Cleaning-Patient Room Transfer/Discharge revealed in part: Policy - All patient rooms will be cleaned when a patient has been discharged/transferred to another room. The room will be cleaned as soon as possible.

Review of the hospital policy titled, "Cleaning and Disinfecting of Equipment" revealed in part: Purpose- To define a process for the cleaning and disinfecting of equipment that will prevent the spread of infection and maintain a safe environment for patients, visitors and staff.
Definitions: Cleaning is a form of decontamination that renders the environmental surface safe to handle or use by removing organic matter, salts, and visible soil, all of which interfere with microbial inactivation. Disinfection is a process that is used on inanimate objects that kills or destroys nearly all disease-producing microorganisms...

On 06/10/19 at 11:45 a.m., observations during the initial tour of the facility revealed the following:
Room a - dried brown substance on the underside of the bedside toilet lid which was wiped off with a Saniwipe.

Room b - dried yellow substance noted on the front rim of the toilet, which was wiped off by S2DON using a paper towel. Grime and debris on the bed's air mattress electric pump which was suspended on the foot of the bed.

An interview with S2DON at this time confirmed the rooms had been terminally cleaned and were ready for a new admission.

Clean storage room - 6 of 6 feeding pumps with debris and dried tube feeding residue on the visible surfaces of the pumps. Portable suction device with grime and debris on the visible surfaces. Bed warmer with water stored in the reservoir. 3 of 3 electric fans with an accumulation of grime and debris on the fan blades and protective grates.

During an interview on 06/10/2019 at 12:15 p.m., S1Administrator confirmed the findings in the clean storage room and acknowledged the patient care equipment was not clean and disinfected.

2. Failing to perform hand hygiene during wound treatment

Review of the hospital's Hand Hygiene policy #8-5.0.0 revised 8/7/17 revealed the following procedure:
Staff will perform hand hygiene by washing hands with soap and water or using alcohol-containing antiseptic hand rub:
...after contact with body fluids or excretions, mucous membranes, non-intact skin and wound dressings ...before and after glove use ...

On 06/11/19 at 1:10 p.m., S3LPN was observed providing wound care for patient #2. After setting up the supplies, S3LPN performed hand hygiene, donned gloves and removed the old dressing from the wound. S3LPN discarded the old dressing and changed her gloves without performing hand hygiene. She cleaned the wound and again changed her gloves without performing hand hygiene. She then dressed the wound as ordered, and performed hand hygiene upon completion.
An interview with S2DON on 6/11/19 at 1:30 p.m. confirmed that hand hygiene should be performed each time gloves are changed when providing wound care.