HospitalInspections.org

Based on record review and interview, the facility failed to meet the Condition of Participation for Governing Body. The hospital's governing body failed to ensure services within the hospital were furnished in a manner to ensure compliance with all applicable conditions of participation. This deficient practice was evidenced by:

1) the hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) Program specified the method and frequency of data collection for indicators as evidenced by no documented evidence of the method(s) and frequency of data collection and no quality indicators identified for hospital services. (See Findings A-0273)

2) the hospital failed to ensure data was collected to identify opportunities for improvement and changes that will lead to improvement, set its priorities for its performance improvement activities on high-risk, high-volume, or problem-prone areas, and take actions aimed at performance improvement, measure success with the actions, and track performance to ensure that improvements are sustained. This deficient practice was evidenced by no documentation of performance improvement activities and no tracking or trending of identified problems. (See Finding A-0283)

3) the hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) program established clear expectations of patient safety. This deficient practice was evidenced by falling to measure, analyze, and track adverse patient events and medication errors and implement preventive actions. (See Findings A-0286)

4) the hospital failed to ensure they conducted performance improvement projects as part of its Quality Assessment and Performance Improvement (QAPI) program. This deficient practice was evidenced by the hospital could not provide documented evidence of a completed performance improvement project the hospital had conducted as well as an ongoing project. (See Findings A-0297)

5) the hospital's governing body failed to ensure an ongoing program for quality improvement and patient safety was defined, implemented, and maintained. This deficient practice was evidenced by the hospital failing to develop and implement a quality assurance program for the hospital (See Findings A-0309).

Based on record review and interview, the Governing Body failed to ensure the members of the medical staff were accountable to the Governing Body for quality of care provided to patients. This deficient practice was evidenced by medical staff members not assessing and pronouncing death for 1 (#1) of 1 (#1) sampled patients reviewed for pronouncement of death from a total sample of 20. Findings:

Review of the hospital policy titled, Death of a Patient, revealed in part, in the event of a death within the hospital, the deceased will be pronounced dead by the attending physician or his designee within a reasonable amount of time.

Review of the Medical Staff Bylaws; Rule and Regulations revealed in part, 22. Pronouncement of death: Only a physician can pronounce a patient's death. Practitioners and coroners are not authorized by the medical staff to pronounce death.

Review of the Narrative Note for Patient #1 dated 12/12/2020 and timed 1931- while receiving report, summoned to patient's room by CNA due to "she isn't breathing". Immediately reported to room and upon assessment, patient was unresponsive with no pulse or respiration noted. Skin warm and pale with cyanosis noted. CPR initiated, emergency response called per 911. 1937- EMS took over by continuing CPR. CPR unsuccessful and remains in asystole, and pronounced expired.

A phone interview was conducted with S4MD on 04/06/2021 at 1:40 p.m. He reported he was the attending physician on Patient #1 and was notified of the patient's death. S4MD further stated he did not come to the hospital to pronounce the patient, EMS pronounced the patient and the Coroner's office was notified.

Based on record review and interview, the hospital's governing body failed to ensure the hospital's contracted QAPI program was furnished in a manner to ensure compliance with all applicable conditions of participation. This deficient practiced was evidenced by:

1. failing to ensure the Quality Assessment Performance Improvement (QAPI) Program specified the method and frequency of data collection for indicators as evidenced by no documented evidence of the method(s) and frequency of data collection and no quality indicators identified for hospital services; and
2. failing to ensure data was collected to identify opportunities for improvement and changes that will lead to improvement, set its priorities for its performance improvement activities on high-risk, high-volume, or problem-prone areas, and take actions aimed at performance improvement, measure success with the actions, and track performance to ensure that improvements are sustained as evidenced by no documentation of performance improvement activities and no tracking or trending of the identified problems; and
3. failing to ensure the Quality Assessment Performance Improvement (QAPI) program established clear expectations of patient safety. This deficient practice was evidenced by falling to measure, analyze, and track adverse patient events and medication errors and implement preventive actions; and
4. failing to ensure that it conducted performance improvement projects as part of its Quality Assessment and Performance Improvement (QAPI) program. This deficient practice was evidenced by the hospital could provide no documented evidence of a completed performance improvement project the hospital had conducted as well as an ongoing project; and
5. failing to ensure an ongoing program for quality improvement and patient safety was defined, implemented, and maintained. This deficient practice was evidenced by the hospital failing to develop and implement a quality assurance program for the hospital.

Findings:

1. Failing to ensure the Quality Assessment Performance Improvement (QAPI) Program specified the method and frequency of data collection for indicators as evidenced by no documented evidence of the method(s) and frequency of data collection and no quality indicators identified for hospital services.

Review of the hospital's QAPI records revealed no documented evidence of current data collection for quality indicators. Further review revealed a preliminary plan to submit to the Governing body for approval of medical records quality indicators.

2. Failing to ensure data was collected to identify opportunities for improvement and changes that will lead to improvement, set its priorities for its performance improvement activities on high-risk, high-volume, or problem-prone areas, and take actions aimed at performance improvement, measure success with the actions, and track performance to ensure that improvements are sustained as evidenced by no documentation of performance improvement activities and no tracking or trending of the identified problems.

Review of the hospital's QAPI records revealed no documented evidence of information on identifying the hospital's high risk, high-volume, or problem prone areas or actions to improve those areas.

3. Failing to ensure the Quality Assessment Performance Improvement (QAPI) program established clear expectations of patient safety. This deficient practice was evidenced by falling to measure, analyze, and track adverse patient events and medication errors and implement preventive actions.

Review of the QAPI information provided to the surveyor, revealed no information related to tracking and trending medication errors or adverse events.
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4. Failing to ensure that it conducted performance improvement projects as part of its Quality Assessment and Performance Improvement (QAPI) program. This deficient practice was evidenced by the hospital could provide no documented evidence of a completed performance improvement project the hospital had conducted as well as an ongoing project.

Review of the hospital's QAPI records revealed no documented evidence of any performance improvement projects (completed or ongoing).

5. Failing to ensure an ongoing program for quality improvement and patient safety was defined, implemented, and maintained. This deficient practice was evidenced by the hospital failing to develop and implement a quality assurance program for the hospital.

Review of the QAPI information provided to the surveyor revealed no defined, implemented or maintained QAPI program for quality improvement and patient safety.

In an interview on 04/06/2021 at 11:23 a.m. S5QA1 confirmed the hospital had no information on the current QAPI plan or Performance Improvement Projects. S5QA1 further stated she was consulted in January 2021 to start a QAPI program for the hospital and was currently in the planning phase. She went on to state she didn't have any data or information from the previous QA consultant.

In an interview with S1Adm on 04/07/2021 at 11:00 a.m. He reported the hospital had a "falling out" with the previous QAPI consultant (S14QA2). He went on to state she was supposed to do the hospital's QA program, but the hospital was unable to get in touch with her and was unable to obtain the hospital's QA information from her.

Based on record review and interview, the hospital failed to ensure the services performed under contract were provided in a safe and effective manner. This deficient practice was evidenced by providing no documented evidence that all services provided by contract had been evaluated for safety and efficiency.
Findings:


Review of the contract binder provided by the hospital as the current contracted services revealed no evidence of evaluations of the hospital's contracted services.

An interview was conducted with S1Adm 04/07/2021 at 11:00 a.m. He reported the facility had not evaluated the services under contract and could not provide any documentation of evaluation of their services.

Based on record review and interview, the hospital failed to maintain a list of all contracted services including scope and nature of services provided for the hospital.

Findings:

Review of the Contract binder provided to the surveyors revealed numerous outdated contracts and no longer utilized contractors by the hospital.

An interview was conducted with S1Adm on 04/07/2021 at 11:00 a.m. He reported he did not have a list of contracted services the hospital utilizes.

Based on records review and interviews, the hospital failed to meet the requirements of the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) as evidenced by:

1) the hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) Program specified the method and frequency of data collection for indicators as evidenced by no documented evidence of the method(s) and frequency of data collection and no quality indicators identified for hospital services. (See Findings A-0273)

2) the hospital failed to ensure data was collected to identify opportunities for improvement and changes that will lead to improvement, set its priorities for its performance improvement activities on high-risk, high-volume, or problem-prone areas, and take actions aimed at performance improvement, measure success with the actions, and track performance to ensure that improvements are sustained. This deficient practice was evidenced by no documentation of performance improvement activities and no tracking or trending of identified problems. (See Finding A-0283)

3) the hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) program established clear expectations of patient safety. This deficient practice was evidenced by falling to measure, analyze, and track adverse patient events and medication errors and implement preventive actions. (See Findings A-0286)

4) the hospital failed to ensure they conducted performance improvement projects as part of its Quality Assessment and Performance Improvement (QAPI) program. This deficient practice was evidenced by the hospital could not provide documented evidence of a completed performance improvement project the hospital had conducted as well as an ongoing project. (See Findings A-0297)

5) the hospital's governing body failed to ensure an ongoing program for quality improvement and patient safety was defined, implemented, and maintained. This deficient practice was evidenced by the hospital failing to develop and implement a quality assurance program for the hospital (See Findings A-0309).

Based on record review and interview, the hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) Program specified the method and frequency of data collection for indicators as evidenced by no documented evidence of the method(s) and frequency of data collection and no quality indicators identified for hospital services. Findings:

Review of the hospital's QAPI records revealed no documented evidence of current data collection for quality indicators. Further review revealed a preliminary plan to submit to the Governing Body for approval of medical records quality indicators.

In an interview on 04/06/2021 at 11:23 a.m. S5QA1 confirmed the hospital had no quality indicators for the QAPI plan. S5QA1 further stated she was consulted in January 2021 to start a QAPI program for the hospital and was currently in the planning phase. She went on to state she didn't have any data or information from the previous QA consultant.

In an interview with S1Adm on 04/07/2021 at 11:00 a.m. He reported the hospital had a "falling out" with the previous QAPI consultant (S14QA2). He went on to state she was supposed to do the hospital's QA program, but the hospital was unable to get in touch with her and was unable to obtain the hospital's QA information from her.

Based on record review and staff interviews, the hospital failed to ensure data was collected to identify opportunities for improvement and changes that will lead to improvement, set its priorities for its performance improvement activities on high-risk, high-volume, or problem-prone areas, and take actions aimed at performance improvement, measure success with the actions, and track performance to ensure that improvements are sustained as evidenced by no documentation of performance improvement activities and no tracking or trending of the identified problems. Findings:

Review of the hospital's QAPI records revealed no documented evidence of information on identifying the hospital's high risk, high-volume, or problem prone areas or actions to improve those areas.

In an interview on 04/06/2021 at 11:23 a.m. S5QA1 confirmed the hospital had no current QAPI plan. S5QA1 further stated she was consulted in January 2021 to start a QAPI program for the hospital and was currently in the planning phase. She went on to state she didn't have any data or information from the previous QA consultant.

In an interview with S1Adm on 04/07/2021 at 11:00 a.m. He reported the hospital had a "falling out" with the previous QAP1 consultant (S14QA2) . He went on to state she was supposed to do the hospital's QA program, but the hospital was unable to get in touch with her and was unable to obtain the hospital's QA information from her.

Based on record review and interview, the hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) program established clear expectations of patient safety. This deficient practice was evidenced by falling to measure, analyze, and track adverse patient events and medication errors and implement preventive actions.

Findings:

Review of the QAPI information provided to the surveyor, revealed no information related to tracking and trending medication errors or adverse events.

In an interview on 04/06/2021 at 11:23 a.m. S5QA1 confirmed the hospital currently didn't have any current information related to the hospital's QAPI plan. S5QA1 further stated she was consulted in January 2021 to start a QAPI program for the hospital and was currently in the planning phase. She went on to state she didn't have any data or information from the previous QA consultant.

In an interview with S1Adm on 04/07/2021 at 11:00 a.m. He reported the hospital had a "falling out" with the previous QAP1 consultant (S14QA2). He went on to state she was supposed to do the hospital's QA program, but the hospital was unable to get in touch with her and was unable to obtain the hospital's QA information from her.

Based on record review and staff interview, the hospital failed to ensure that the hospital conducted performance improvement projects as part of its Quality Assessment and Performance Improvement (QAPI) program. This deficient practice was evidenced by the hospital could not provide documented evidence of a completed performance improvement project the hospital had conducted as well as an ongoing project. Findings

Review of the hospital's QAPI records revealed no documented evidence of a performance improvement project.

In an interview on 04/06/2021 at 11:23 a.m. S5QA1 confirmed the hospital had no documentation of completed performance improvement projects and did not have an ongoing project in place at the present time. S5QA1 further stated she was consulted in January 2021 to start a QAPI program for the hospital and was currently in the planning phase. She went on to state she didn't have any data or information from the previous QA consultant.

In an interview with S1Adm on 04/07/2021 at 11:00 a.m. He reported the hospital had a "falling out" with the previous QAPI consultant (S14QA2). He went on to state she was supposed to do the hospital's QA program, but the hospital was unable to get in touch with her.

Based on record review and interview, the hospital's governing body failed to ensure an ongoing program for quality improvement and patient safety was defined, implemented, and maintained. This deficient practice was evidenced by the hospital failing to develop and implement a quality assurance program for the hospital.
Findings:

Review of the QAPI information provided to the surveyor revealed no defined, implemented or maintained QAPI program for quality improvement and patient safety.

In an interview on 04/06/2021 at 11:23 a.m. S5QA1 confirmed the hospital had no information on the current QAPI plan. S5QAPI further stated she was consulted in January 2021 to start a QAPI program for the hospital and was currently in the planning phase. She went on to state she didn't have any data or information from the previous QA consultant.

In an interview with S1Adm on 04/07/2021 at 11:00 a.m. He reported the hospital had a "falling out" with the previous QAPI consultant (S14QA2). He went on to state she was supposed to do the hospital's QA program, but the hospital was unable to get in touch with her and was unable to obtain the hospital's QA information from her.

Based on record review and interview, the hospital failed to ensure the medical staff conducted periodic appraisals of its members for 1(S4MD) of 3 (S4MD, S27MD, S28NP) current members of the medical staff.
Findings:

Review of the Medical Staff Bylaws, Rule and Regulations reveals in part: In order to continue appointment and clinical privileges the practitioner shall reapply and be reviewed every two years as outlined by the Medical Staff Office
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Review of Medical Staff credentialing files revealed that the hospital failed to conduct periodic appraisal and re-appointment of S4MD. Records provided indicate that he was appointed to the medical staff in 2015 and that no further re-evaluations, renewal of applications, or re-appointments were performed.

In a telephone interview on 04/07/2021 at 10:40 a.m., S25HR acknowledged the policy for medical staff reapplication and reappointment every 2 years. These specific records were requested twice, on 04/06/2021 at 3:15 p.m. and again during the phone interview. The re-appointment documents were not received prior to the survey exit.

Based on record review and interview, the facility failed to ensure enforcement of Medical Staff Bylaws, Rules and Regulations. This is evidenced by failure of staff physicians to examine 3 (#3, #9, and #14) of 3 (#3,#9,and #14) records reviewed for physician progress notes per the Medical Staff by-laws out of a total sample of 20 patients.

Findings:
Review of hospital's Medical Staff Bylaws, Rules and Regulation, revealed in part, the attending physician shall examine the patient at least 5-6 days per week for the duration of stay, and shall document each visit in the progress notes. The assigned medical physician regardless of who completed the History and Physical report, shall examine the patient initially upon admission and at least weekly thereafter and as condition warrants or as consulted for medical problems.

Review of Patient #3's medical record revealed physician progress notes on 02/ 24/2019, 03/03/2019, 03/08/2019, 03/21/2019, 03/22/2019, and 03/24/2019. On 04/06/2021 at 9:45 A.M, S12MR verified dates of progress notes and verified spans of 5 and 10 days the patient was not examined by the physician.

Review of Patient #9's medical record revealed physician progress notes on 02/24/2019, 03/03/2019, 03/08/2019, and 03/18/2019. On 4/6/2021 at 10:30 A.M, S12MR verified dates of progress notes and verified the 10-day span the patient was not examined by the physician.

Review of Patient #14's medical record revealed physician progress notes on 08/04/2020, 08/19/2020, 08/20/2020, 08/25/2020, 09/03/2020, and 09/07/2020. On 4/6/2021 at 2:15 P.M, S12MR verified dates of progress notes and verified spans of 9 and 15 days the patient was not examined by the physician.

Based on record review and interview, the hospital failed to have a Director of Nurses responsible for the operation of the services and supervision of nurses providing patient care.
This deficient practice was evidenced by:

1) failure of the hospital to have a Director of Nurses to adequately supervise and evaluate the nursing care at the hospital; and
2). failure of the hospital to have a job description for the Director of Nurses

Findings:

1). Failure of the hospital to have the Director of Nurses adequately supervise and evaluate the nursing care at the hospital; and

Review of LAC 48: I, Chapter 93: Licensing Standards for Hospitals revealed in part, There shall be an organized nursing service that provides 24-hour nursing services. The nursing services shall be under the direction and supervision of a registered nurse licensed to practice in Louisiana, employed full time, 40 hours per week.

Interview on 04/06/2021 at 9:15 a.m. with S2DON stated that she only worked 3 days a week. She did not sign any payroll sheet or time card because she was a salaried employee. She confirmed that she did not work full time, 40 hours a week at the hospital.

Review of the Nursing schedule for March 2021 revealed on March 27, 2021 and March 28, 2021 there were no staff nurses' names listed on the schedule, only the word, "nurse".

Review of the personnel files provided for S8RN, S9LPN, S10RN and S11RN revealed they all were agency (contract) nurses. There was no documentation the hospital had evaluated their competencies or any documentation the nurses had orientation provided by the hospital on their policies and procedures.

An interview was conducted with S2DON on 04/06/2021 at 2:00 p.m. She reported on March 27, 2021 from 7 a.m. to 7 p.m. (day shift). S10RN and S11RN provided care to the patients and they were agency (contract) nurses. The 7 p.m. to 7 a.m. shift (night shift) was worked by S8RN, who was also an agency (contract) nurse. S2DON further stated on March 28, 2021 S9LPN and S11RN provided nursing care on the day shift and S8RN and S10RN provided care on the night shift. Each shift had a staff CNA and there were 3 patients on the census. S2DON stated she was available by phone, but was not on site at the hospital. S2DON went on to state she had a nurse out on medical leave and was filling in the gaps in the schedule with agency (contract) nurses. S2DON also stated she had only been the DON for 1 month and was currently in the process of hiring nurses. S2DON verified she didn't have documentation of the agency(contract) nurses' competencies or orientation to the hospital policies and procedures. These nurses had been working through the agency(contract) prior to her becoming DON.

Review of personnel files for S2DON, S3IC, S16RN, and S17LPN revealed no documentation of any skill competencies. This included there was no documentation of competencies for the Director of Nurses.

An interview was conducted on 04/06/2021 at 3:30 p.m. with S2DON. S2DON confirmed S2DON, S3IC, S16RN and S17LPN did not have documented competencies. She further stated that she had only been at the hospital for about a month and was unaware the nursing staff did not have verified competencies documented.

2). Failure of the hospital to have a job description for the Director of Nurses

Review of the hospital's policy titled Staff Orientation, Training, Education and Evaluation given to surveyor by S12MRclerk revealed in part: New employees will be required to have an orientation period prior to being given full duties in his/her job function. This orientation will include awareness of each patient's rights and responsibilities; his/her own job description ...

S2DON
Review of the personnel record for S2DON revealed a date of hire 01/10/2020 there was no documentation for a job description for Director of Nurses.

Interview on 04/07/2021 at 9:15 a.m. with S12MRclerk confirmed that the personnel records were complete and there were no current job descriptions for S2DON.

Based on record review and interview, the hospital failed to have a Director of Nursing provide adequate supervision and evaluation of the nursing personnel, regardless of the mechanism through which those nursing personnel are providing services. This deficient practice was evidenced by failure of the Director of Nurses to have documentation of competencies for 8 (S2DON, S3IC, S8RN, S9LPN, S10RN, S11RN, S16RN, S17LPN) of 8 (S2DON, S3IC, S8RN, S9LPN, S10RN, S11RN, S16RN, S17LPN) nursing staff personnel records reviewed (including the DON).

Findings:
Review of the Nursing schedule for March 2021 revealed on March 27, 2021 and March 28, 2021 there were no staff nurses' names listed on the schedule, only the word, "nurse".

Review of the personnel files provided for S8RN, S9LPN, S10RN and S11RN revealed they all were agency (contract) nurses. There was no documentation the hospital had evaluated their competencies or any documentation the nurses had orientation provided by the hospital on their policies and procedures.

An interview was conducted with S2DON on 04/06/2021 at 2:00 p.m. She reported on March 27, 2021 from 7 a.m. to 7 p.m. (day shift). S10RN and S11RN provided care to the patients and they were agency (contract) nurses. The 7 p.m. to 7 a.m. shift (night shift) was worked by S8RN, who was also an agency(contract) nurse. S2DON further stated on March 28, 2021 S9LPN and S11RN provided nursing care on the day shift and S8RN and S10RN provided care on the night shift. Each shift had a staff CNA and there were 3 patients on the census. S2DON stated she was available by phone, but was not on site at the hospital. S2DON went on to state she had a nurse out on medical leave and was filling in the gaps in the schedule with agency(contract) nurses. S2DON also stated she had only been the DON for 1 month and was currently in the process of hiring nurses. S2DON verified she didn't have documentation of the agency (contract) nurses' competencies or orientation to the hospital policies and procedures. These nurses had been working through the agency (contract) prior to her becoming DON.

Review of personnel files for S2DON, S3IC, S16RN, and S17LPN revealed no documentation of any skill competencies. This included the Director of Nurses of the hospital.

An interview was conducted on 04/06/2021 at 3:30 p.m. with S2DON. S2DON confirmed S2DON, S3IC, S16RN and S17LPN did not have documented competencies. She further stated that she had only been at the hospital for about a month and was unaware the nursing staff did not have verified competencies documented.

30364

Based on record review, observation and interview, the hospital failed to ensure patients' paper medical records were stored in a secured area and where they would not be damaged if the sprinkler system was activated.

Findings:
Review of the hospital's policy titled, Medical Records-Creation/Control and Confidentiality revealed in part, the medical records will be safeguarded against loss, defacement, tampering or destruction by fire or water or use by unauthorized persons.

An observation on 04/05/2021 at 9:40 a.m. revealed a room containing 12 cardboard boxes stacked on the floor. The boxes contained discharged patients' paper medical records. The room was noted to have a sprinkler system.

In an interview on 04/05/2021 at 9:41 a.m. with S12MRclerk, she verified the medical records were in cardboard boxes and would not be protected if the sprinkler system was activated.

Based on interview, the hospital failed to have a system in place to code and index medical records to allow for timely retrieval by diagnosis and procedure in order to support medical care evaluation studies.

Findings:

In an interview with S12MRclerk on 04/07/2021 at 2:20 p.m., she said she could not pull up patients by diagnosis or procedure. She said she has not been able to do that for about the last year since they got a new system.

Based on record review and interview, the hospital failed to ensure that H&Ps (history and physical) were completed within 24 hours after admission for 6 (#3, #8, #9, #10, #13, #17) of 20 records reviewed.
Findings:

Review of the hospital's Medical Staff Bylaws, Rules and Regulations revealed in part: A complete history and physical examination shall be done within twenty-four (24) hours after admission of the patient.

Review of #3's medical record revealed an admit date of 02/18/2019. Further review revealed the H&P was completed on 03/21/2019.
Review of #8's medical record revealed an admit date of 07/25/2020. Further review revealed the H&P was completed on 07/27/2020.
Review of #9's medical record revealed an admit date of 02/22/2019. Further review revealed the H&P was completed on 02/24/2019.
Review of #10's medical record revealed an admit date of 05/29/2020. Further review revealed the H&P was not completed.
Review of #13's medical record revealed an admit date of 07/31/2020. Further review revealed the H&P was completed on 08/03/2020.
Review of #17's medical record revealed an admit date of 08/08/2020. Further review revealed the H&P was completed on 08/11/2020.

Interview on 04/06/2021 at 1:55 p.m., S12MRclerk reviewed the medical records and acknowledged the H&Ps for #3, #8, #9, #10, #13, and #17 were not completed within 24 hours after admission.

Based on record reviews and interview, 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 practitioner completed a discharge summary for 13 (#5, #6, #7, #8, #10, #11, #12, #13, #14, #15, #16, #17, #18) and failure to complete a discharge summary within 30 days for 1 (#4) of 17 closed patient records reviewed.
Findings:

Review of the hospital's "Discharge Policy" revealed in part: A discharge summary including primary diagnosis and all secondary diagnosis with pertinent procedures shall be written or dictated on all medical records of patients hospitalized over twenty-four hours, within thirty days of the discharge.

Review of #5's medical record failed to reveal evidence of a discharge summary.
Review of #6's medical record failed to reveal evidence of a discharge summary.
Review of #7's medical record failed to reveal evidence of a discharge summary.
Review of #8's medical record failed to reveal evidence of a discharge summary.
Review of #10's medical record failed to reveal evidence of a discharge summary.
Review of #11's medical record failed to reveal evidence of a discharge summary.
Review of #12's medical record failed to reveal evidence of a discharge summary.
Review of #13's medical record failed to reveal evidence of a discharge summary.
Review of #14's medical record failed to reveal evidence of a discharge summary.
Review of #15's medical record failed to reveal evidence of a discharge summary.
Review of #16's medical record failed to reveal evidence of a discharge summary.
Review of #17's medical record failed to reveal evidence of a discharge summary.
Review of #18's medical record failed to reveal evidence of a discharge summary.
Review of #4's medical record revealed a discharge date of 08/14/2020 and a discharge summary signed on 10/16/2020.

Interview on 04/06/2021 at 1:55 p.m., S12MRclerk reviewed the medical records and acknowledged there were no discharge summaries for (#5, #6, #7, #8, #10, #11, #12, #13, #14, #15, #16, #17, and #18). S12MRclerk acknowledged patient #4's discharge summary was not completed and signed within 30 days.

Based on record review and interview, the hospital failed to have a system in place to ensure medical records were completed within 30 days of discharge.

Findings:

Review of the hospital policy titled Incomplete/Delinquent Medical Records revealed in part:
A patient's medical record must be completed within 30 days of the patient's discharge.
The Administrator will send a letter to any physician noncompliant after thirty (30) allowing a three (3) days response. The letter will be sent by registered mail\. If the physician remains delinquent, the physician's privileges will be suspended until the medical record(s) are complete.

In an interview on 04/05/2021 at 2:08 p.m., S12MRclerk said the hospital had delinquent medical records greater than 30 days. She provided the survey with a list of delinquent medical records greater than 30 days. There were 56 delinquent records for S4MD dating back to 07/28/20.

In an interview with S1Adm, he said he did not send S4MD a certified letter or suspend his privileges for having delinquent medical records greater than 30 days.

44495


Based on observation and interview, the hospital failed to ensure unusable and undated drugs and biologicals were unavailable for patient use. This deficient practice was evidenced by:
1. Opened, undated topical medication in wound care cart; and
2. Direct observation of multi-dose blister cards of medications with broken foil packaging and medication replaced in the dose cell.
Findings:

1. Opened, undated medication in the wound care cart.

An observation was conducted on 04/05/2021 at 10:00 a.m. of the following opened, undated topical medications in the wound care cart and available for patient use:
Hydrogel ointment
Lidocaine ointment
Santyl ointment
Skin Protectant

An interview was conducted with S2DON on 04/06/2021 at 12:15 p.m. She reported there should not be opened, undated topical medications in the wound care cart.

2. Direct observation of multi-dose blister cards of medications with broken foil packaging and medication replaced in the dose cell.

Review of the hospital policy titled "Policy and Procedures for Medication Accountability" revealed in part: All medications in the practice should be stored according to the manufacturer's instructions. They should be checked for outdates, deterioration and appropriate location.

On 04/05/2021 at 10:00 a.m the following observations were made:
Two cards of Valium 5 mg with several open and taped medication unit dose cells with the medication still in the cell.
A card of temazepam 15 mg with several open foil cells and the medication still in the cell.
A card of clonazepam 1 mg with several open foil cells and the medication held in place with tape.
A card of buprenorphine/ naloxone 8-2mg with an open foil cell and the medication held in place with tape.

On 04/07/2021 at 11:13 am, an interview was conducted with S26Pharmacy. S26Pharmacy was present at the facility and verified that the medication cabinet contained blister cards with opened and unusable medication.

36293

Based on record reviews and staff interview, the hospital failed to ensure a qualified full-time, part-time or consulting radiologist supervised the hospital's Radiology Services.
Findings:

Review of the hospital's Bylaws listed Radiology Services as "Outsourced".

Review of the hospital's staffing list and physicians with privileges list failed to reveal a radiologist appointed to supervise the radiology services.

An interview was conducted on 04/06/2021 at 1:00 p.m. with S1Admin. He stated the hospital does not have a physician appointed to supervise the Radiology Services.

Based on record review and interview, the hospital failed to ensure the adequacy of its lab services. This deficient practice was evidenced by the lab failing to have a contract for the laboratory services with its lab provider and failing to have policies in place defining routine and stat lab.

Findings:

Review of the hospital's Bylaws listed the Lab Services as "Outsourced".

Review of the hospital's service provider contracts failed to reveal a contract with the hospital's lab provider or a current CLIA Certificate from the lab provider.

Review of the hospital's policy and procedure manual failed to reveal a policy defining the time frame for routine or stat labs ordered by the physician.

Interview on 04/07/2021 at 10:05 a.m., S2DON stated the hospital does not have a policy defining the timing for routine and stat lab.

Interview 4/7/21 at 11:10 a.m., S1Admin stated the hospital does not have a contract with its lab provider.

Based on observations and interviews, the hospital failed to ensure the supervisor of food and dietetic services ensured the daily management of the contracted dietary services, provided onsite in the hospital's kitchen, and food service area. This deficient practice was evidenced by:

1) failure to ensure the Dietary Manager was a full time employee;

2) failure to ensure the safe handling and storage of food;


Findings:

Surveyor requested Dietary policies and procedures for dietary and was given an incomplete policy with missing pages for staff and food storage and temperature monitoring logs. Missing pages were requested on 04/05/2021, 04/06/2021, and 04/07/2021. At the time of exit, the missing pages were not made available to surveyor.

1) Observation of the Kitchen area on 04/05/2021 at 12:15 p.m. revealed no employees in the kitchen area.

Interview on 04/05/2021 at 12:35 p.m. with S1Administrator confirmed there were no kitchen staff present until 1:00 p.m. He further stated that the Dietary Manager was not available today but thought she would be here tomorrow.

Review of the time sheet (03/14/2021-03/27/2021) for S6DM revealed the following:

03/17- 6:45 a.m. - 1:40 p.m.
03/20- 6:40 a.m. - 5:15 p.m.
03/21- 6:40 a.m. - 5:22 p.m.
03/23- 6:40 a.m. - 5:10 p.m.
03/26- 6:40 a.m. - 4:56 p.m.

Interview on 04/06/2021 at 8:30 a.m. with S6DM stated that she only worked 2-3 days a week and was not full time.

2) Observation of the kitchen area on 04/05/2021 at 12:20 p.m. revealed the following items in opened containers not dated when opened:
Refrigerator-
- gallon jar of mayonnaise
- small jar of mayonnaise
- jar of Thousand Island dressing
- Ranch Dressing
- plastic bag containing ham lunchmeat
- jar of hamburger dill pickles
- plastic bag with 5 rolls
- plastic tub of butter
- plastic bag of brown sugar
- plastic bag with 4 bread slices

Freezer-
- 4 plastic bags of fish fillets
- 2 bags of fish strips
- 3 boxes of turnip greens
- 4 plastic bags of unidentifiable contents
- 5 plastic bags of ham lunchmeat
- 3 plastic bags of turkey breast lunchmeat

Interview on 04/06/2021at 8:45 a.m. with S6DM confirmed the items listed were not dated and properly stored in the refrigerator and freezer.

Based on observation and interview, 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.

Findings:

These observations were conducted on 04/05/2021-04/07/2021.

Laundry Room

An observation was conducted of the sink in the laundry room having an "out of order" sign in the bowl of the sink. The surveyor was unable to turn the faucets. There was a large area of the ceiling with missing ceiling tiles.

Kitchen/Storage Area

An observation was conducted of peeling paint on the wall of the kitchen storage area and a rusted drainage pipe protruding from the floor. There were two sticky pad traps for rodents/bug on each side of the stove with one of the sticky pad traps having a large dead roach attached to the pad. There was an open metal rat trap behind the stove. In the kitchen storage area under the sink was a sticky pad trap with a plastic teaspoon of a brown substance in the spoon (peanut butter). There was a second sticky pad trap in the storage area with a dead lizard attached to the pad.

Main Patient hallway

An observation was conducted of a missing exit sign at the end of the hallway above an exit door. The sheetrock in the hallway, close to the exit door, had a hole in it.

Two cut square holes (in the sheetrock) were observed in the wall under the pull fire alarm near Patient Room 9. A security camera cord was hanging down the wall in the hallway at the opposite end of the hallway.

Numerous lights were not working in the main patient hallway. There were 9 lights in the main hallway and 4 were not functioning.

Room a
An observation was conducted of one of the lights not working in the Room a. On one of the corners of the room, sheetrock was missing and the metal corner was exposed. The metal bed in the room, had one of the side rails broken and hanging off.

Room b

An observation was conducted of tile cracked in the bathroom of Room b and the overhead light was zip tied together with one end of the light fixture exposed and the light bulbs and wiring could be visualized.

Room c

An observation was conducted of the privacy curtain being missing between beds in Room c along with a large area of dried white paint in the center of the bathroom floor. Rust was noted in the bottom of the bathroom sink. Dead bugs could be seen in the overhead light fixture.

Room d

An observation was conducted of missing or broken tile on the threshold to the room and on the floor there was an unattached large air vent tubing.

Nursing Station storage area (next to nurses' station)

The light was out in nursing station storage area which held one of the patients' nourishment refrigerators, wound care cart, and code cart.

There was numerous missing ceiling tiles in the storage room.

An observation was conducted on 04/06/2021 at 8:30 a.m. of a closet (located in the hallway in front of the Physical Therapy Department) was being opened by S5QA1 and a security camera fell off the wall.

Room e and f and hallway in front of Room e and f

These observation was conducted on 04/07/2021 at 10:00 a.m. and confirmed by the S1Adm

An observation was conducted of the light in the hallway in front of Room e and f not working. There was no lock on the two bathroom doors for Rooms e and f . The bathroom was a shared bathroom by Room e and f
The window unit (air conditioner) in Room f had no front panel covering the unit. Part of the curtains were on the floor in Room e.

An observation was conducted on 04/06/2021 at 8:30 a.m. A closet (located in the hallway close to the Physical Therapy Department) was being opened by S5QA1 and a security camera fell off the wall.

An interview was conducted with S1Adm on 04/07/2021 at 10:00 a.m. and he didn't have any comments about the findings.

Based on observations, record reviews, and interviews, the infection control officer failed to ensure the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented in accordance with hospital policy and acceptable standards of practice as evidenced by:

1) failing to maintain a sanitary environment

2) failure to ensure temperature logs were maintained on refrigerators and freezers containing food, and the chemical and temperature logs were maintained on the 3-compartment sink and dishwasher.

Findings:

1) failing to maintain a sanitary environment
Tour of the hospital on 04/05/2021 at 9:00 a.m. revealed the following:
- Clean linen closet with linens, gowns, towel and sheets uncovered. Dirty laundry bag on floor of linen closet.

- Hallway in front of PT room had a ceiling vent with a thick-crusted gray substance on the vent.

- ADL storage room contained 2 dirty box fans, bedside table with laminate pulled off table and rust on legs on bedside table. This storage room was for clean items.

- Laundry room with black substance of floor, dirty curtain and two socks on the floor, latex glove next to washer on floor, dirty floor buffer stored in room along with two Hoyer lifts. One Hoyer lift has rust on the metal areas. No hand sink in laundry room, sink with signage of "out of order" and surveyor unable to turn faucets on sink. Rust in bottom of sink. Cleanser system that dispenses cleaner next to washer approximately 1 foot from washer. Missing ceiling tile in laundry room. There were washed clothes in the washer and dried clothes in the dryer.

Observation on 04/06/2021 at 10:30 a.m. the washer and dryer still contained the same clothes, observation on 04/07/2021 at 9:00 a.m. revealed the washer and dryer continued to have the same load of clothes. The same clothes remained in both washer and dryer at the time of exit.

Interview on 04/06/2021 at 2:15 p.m. with S1Administrator confirmed the hospital did not use the washer and dryer and had a contract for linens with outside vendor.

- Kitchen area dining room with staff refrigerator with orange juice and a box of expired milk in cartons dated 03/01/2021 (March 1, 2021). Refrigerator with dry substances on the inside of the refrigerator door and the egg holder area. Steel prep table with debris on the table's shelves and the top of table. Sticky pads on kitchen floor with a roach on one sticky pad by the stove and an open rat trap behind the stove with another sticky pad trap next to it on the floor. The kitchen floor had debris all over the floor and the floor was sticky to walk on. Debris was located on the trays containing the clean cups and plates which were turn upside down on the trays. Rust was on the metal shelving where the plates were stored. 3 Plastic containers with lids, which were holding utensil, were located on the metal shelving. The lids on the plastic container were sticky with a substance on top of them. Storage room next to kitchen- had peeling paint coming off the wall. There was a plastic potato bin that had a substance on the lid. There was a sticky trap pad near the potatoes bin that has a lizard stuck to the pad. The sink in the storage room had a rusty pipe coming up from the floor. There was a sticky pad trap under the sink with a plastic spoon with a brown substance in the spoon (peanut butter).

- Patient hallway- The hallway vent was caked with dust.
- Room (b) had a sharp's container that had blood tubing sticking out of the top and was above the denoted full line. The bathroom floor was dirty; there was cracked tile on the wall of the bathroom. The windowsill in the bathroom had cigarette ashes on it. There was a wooden bedside table and a wooden TV table that could not be disinfected. Rust was on the bed and paint was peeling off the bed. Rust was on the bottom legs of the overhead bedside table.

- Room (c) had white dried paint splattered on the bathroom floor. Dead bugs were in the overhead light fixture. Rust in the bottom of the bathroom sink.
- Room (d) had large air vent tubing on floor in room.
-Nursing station had exposed wood on the countertop of the nurse's station and cannot be disinfected.
- Room (g) had wooden nightstands and one wooden TV stand that could not be disinfected properly.

- Room (a) The bathroom window was opened and the screened was pushed out.

2) failure to ensure temperature logs were maintained on refrigerators and freezers containing food, and chemical and temperature logs were maintained on the 3 compartment sink and dishwasher.

Surveyor requested Dietary policies and procedures for dietary and was given an incomplete policy with missing pages for staff and food storage and temperature monitoring logs. Missing pages were requested on 04/05/2021, 04/06/2021, and 04/07/2021. At the time of exit, the missing pages were not made available to surveyor.

Observation of the kitchen area on 04/05/2021 at 12:15 p.m. revealed the freezer temperature log contained no temperatures documented since 03/07/2021. Review of the 3 compartment sink logs revealed no entries since 04/03/2021 for the chemical log or the temperatures. Further review revealed no Chlorine log for the dishwasher since 04/03/2021. Further observation revealed no temperature on the logs since 03/30/2021 for the kitchen's refrigerator, vegetable refrigerator, upright freezer and chest freezer.

Interview on 04/06/2021at 8:45 a.m. with S6DM confirmed the temperature logs for the refrigerator; freezer, sink, and dishwasher should be documented daily.





















26351

Based on record review and interview, the facility failed to ensure a discharge planning evaluation was provided to each patient prior to discharge. This deficient practice was evidenced by the failure of the hospital to provide an evaluation for discharge planning for 3 (#3, #9, and #14) of 20 patients.
Findings:
Review of #3's medical record revealed no evaluation for discharge planning and no discharge plan. This was verified by S12MR on 04/06/2021 at 9:45 A.M.
Review of #9's medical record revealed no evaluation for discharge planning and no discharge plan. This was verified by S12MR on 04/06/2021 at 10:30 A.M.
Review of #14's medical record revealed no evaluation for discharge planning and no discharge plan. This was verified by S12MR on 04/06/2021 at 2:15 P.M.

Based on interview and record review, the hospital failed to ensure respiratory services were provided by personnel qualified to perform those services. This deficient practice was evidenced by no documented competencies for 4(S2DON, S3IC, S16RN, S17LPN) of 4 (S2DON, S3IC, S16RN, S17LPN) personnel files reviewed for respiratory competencies, of listed personnel who, by their discipline would be in a position to provide respiratory services. This deficiency was written on the recertification survey on 05/18/15 and 04/11/2018.

Findings:

Review of personnel files for S2DON, S3IC, S16RN, and S17LPN revealed no respiratory competencies.

Interview on 04/06/2021 at 3:30 p.m. with S2DON confirmed the nursing staff administered nebulizer treatments, monitored oxygen administration, suctioned patients and performed incentive spirometry. She further stated that she had only been there for about a month and was unaware the nursing staff did not have verified respiratory competencies documented.



26351