HospitalInspections.org

Based on records review and interview, the governing body failed to ensure that patients admitted for contracted hospice services were admitted based on the hospital's scope of service and admission criteria for 29 contracted hospice patients out of a total of 30 patients admitted to the main campus since 01/08/15. (see findings tag A-0083).

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Medical Records as evidenced by:

1) Failing to have an effective system in place to ensure medical records were completed within 30 days of discharge. The hospital also failed to ensure medical records for patients admitted for hospice inpatient care were included in review for delinquencies (see findings A-0438);

2) Failing to ensure completion of the History & Physical examination within 24 hours of admission. This was evidenced by the hospital's failure to provide documented evidence of a medical history and physical examination completed within 24 hours of admission for 9 (#22, #23, #24, #25, #26, #27, #28, #29, and #30) of 10 sampled patients who were admitted to a hospital bed for hospice inpatient services (see findings tag A-0458);

3) Failing to ensure the completion of Discharge Summaries within 30 days of discharge. This was evidenced by the hospital's failure to provide documented evidence of a discharge summary for 7 (#22, #23, #24, #25, #26, #28, #29) of 10 sampled patients who were admitted to the hospital bed for hospice inpatient services (see findings tag A-468).

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Radiology Services as evidenced by:

Failing to ensure there was a radiologist who was a member of the medical staff and supervised the radiology services on either a full-time, part-time, or consulting basis (see findings in tag A-0546).

Based on record review and interview, the governing body failed to ensure that patients admitted for contracted hospice services were admitted based on the hospital's scope of service and admission criteria for 29 contracted hospice patients out of a total of 30 patients admitted to the main campus since 01/08/15.

Findings:

Review of the Hospital Scope of Service revealed the following:
(The Hospital) provides continued acute care for catastrophically ill/injured patients through an interdisciplinary approach. The average length of stay is between 25-30 days. The most common patient diagnosis include respiratory failure with ventilator weaning, recalcitrant wounds, renal failure, acute neurological illness, injury and multisystem failure.
Patients shall be admitted according to (the hospital) admission criteria which are based on Interqual as well as the administrative and physician approval in order to allow the staff to maintain the optimum health and welfare of the patients.
Patient Care Goals:
1. To continue the healing process of the catastrophically ill patients in a safe environment where a comprehensive clinical team approach will provide care geared to maximize recovery.

Review of a list of Hospice Companies contracted to admit patient's to the hospital revealed 16 companies.

Review of a list provided by the hospital of the admissions and discharges at the hospital's main campus since 1/8/15 revealed 30 patients had been admitted. 1 patient was admitted on 1/20/15 and was classified as a LTAC (long term acute care) patient and 29 patients were admitted directly to hospice services.

In an interview on 3/10/15 at 9:30 a.m. with S3DirectorQuality, she said the hospice patients at the hospital were admitted directly as hospice patients. She said they were not LTAC patients. S3DirectorQuality also said LTAC patients were screened for admission using Interqual criteria, but not the hospice patients.

In an interview on 3/10/15 at 10:05 a.m. with S1CEO, he stated the hospice patients admitted to the hospital did not meet the current admission criteria according to the hospital's scope of service. He also said they were not screened to meet criteria as long term acute care patients and were directly admitted to hospice services. S1CEO also verified he was licensed as a hospital and not an inpatient hospice.

Based on record review and interview, the governing body failed to ensure the medical staff had written policies and procedures in place for the appraisal of emergencies, initial treatment, and referrals when appropriate. Findings:

Review of the Nursing Policy and Procedure Manual and the Leadership (Administrative) Policy and Procedure Manual, presented by S2DON (Director of Nursing) as the current manuals, revealed no policy and procedures for the appraisal of emergencies, initial treatment, and referrals, when appropriate, for the provision of emergency services.

In an interview on 3/12/15 at 4:45 p.m., S2DON indicated she was not aware the above-referenced policies were required at hospitals that do not provide emergency services. S2DON confirmed there were no policies and procedures at the hospital for providing emergency services at the hospital which included the appraisal of emergencies, initial treatment, and referrals when appropriate.

Based on record reviews and interviews, the hospital failed to ensure each patient was informed of all their rights prior to furnishing or discontinuing patient care as evidenced by having 5 of the required patient rights in accordance with the certification regulations omitted from the patient rights policy and the "Patient's Bill of Rights" signed by the patient upon admit. This was evident in 32 (#1 - #32) of 32 patient records reviewed.
Findings:

Review of the hospital policy titled "Patient Rights", policy number PO1-RR and revised April 2013, revealed the purpose of the policy was to ensure that each patient or family admitted to the hospital was aware of their guaranteed rights and their responsibilities. Further review revealed each patient or family will receive a copy of the Patient's Rights Policy upon admission. Review of the policy revealed the following required patient rights were not included in the hospital policy: the right to have family members or their representative and their own physician notified promptly of their admission; to be informed that the hospital does not have a physician on-site 24 hours a day, seven days a week; the right to receive care in a safe setting; the right to be free from abuse or harassment.

Review of the "Patient's Bill of Rights" signed by the patient or a family member upon admission and contained in their medical record revealed no documented evidence that the above patient rights were included.

In an interview on 03/12/15 at 1:05 p.m., S2DON offered no comment when informed that the hospital's patient rights policy and "Patient's Bill of Rights" didn't include all of the required patient rights.

Based on record reviews and interviews, the hospital failed to ensure each patient was informed of their right to file a grievance with the State agency that has licensure survey responsibility for the hospital and provided with a phone number and address for the State agency. This was evident in 32 (#1 - #32) of 32 patient records reviewed.
Findings:

Review of the hospital policy titled "Patient Rights", policy number PO1-RR and revised April 2013, revealed the patient will be encouraged and assisted throughout the period of their stay to exercise their rights as a patient and may voice grievances to the hospital staff, to an individual designated for such purpose, or to outside representatives of their choice. The patient or the individual designated by the hospital will be made aware of the state Department of Health to which you may address grievances.

Review of the "Patient's Bill of Rights" signed by the patient or a family member upon admission and contained in their medical record revealed the same information contained in the "Patient Rights" policy. There was no documented evidence that the phone number and address for the Department of Health and Hospitals, the state agency, was provided to the patient.

In an interview on 03/12/15 at 1:05 p.m., S2DON confirmed the "Patient's Bill of Rights" did not include the phone number and address for the Louisiana Department of Health and Hospitals.

Based on record reviews and interview, the hospital failed to ensure its grievance procedure was implemented according to hospital policy as evidenced by failure to have documented evidence of the investigation of 2 (R1, R2) of 4 grievances reviewed from a total of 9 grievances submitted from 08/01/14 through 02/25/15.
Findings:

Review of the hospital policy titled "Complaint and Grievance by Patient", policy number CO1-RR revised 07/11/13, revealed if a complaint is not resolved timely by the Hospital staff present, the complaint becomes a grievance. The staff member shall notify his/her supervisor and forward the completed Complaint Form to the Patient Ambassador. The Patient Ambassador will investigate the circumstances surrounding the concern or complaint. Once the investigation is completed, the findings will be discussed with the appropriate supervisor or department head and the CEO (Chief Executive Officer) for continued follow-up, recommendations, and/or action to be taken. The investigative process should be completed, corrective action taken, and a written response sent within 7 days of receipt of the complaint. If this timeframe cannot be met, the patient or family member shall be informed that the hospital is still working to resolve the grievance, and a follow-up written response will be sent in a stated number of days. The written response prepared by the Patient Ambassador will include a description of the issues raised by the grievance, a description of the steps taken to investigate the issue, the date the grievance was resolved and what steps were taken to resolve the grievance, and the name of the contact person at the hospital that the patient or designee can call with additional questions.

Patient R1
Review of Patient R1's "Complaint/Grievance Form", documented on 02/25/15 and investigated by S2DON on 02/27/15, revealed that Patient R1's daughters voiced complaints of a staff member being rude. Review of the investigation revealed that S2DON documented that that the employee would write a statement of the events that took place. Review of the entire documentation of the grievance, investigation, and response revealed no documented evidence of a written statement by the employee.

In an interview on 03/12/15 at 2:20 p.m., S3Director of Quality indicated she was responsible for the grievance procedure at the hospital. After reviewing the information regarding Patient R1's family's grievance, S3Director of Quality confirmed there was no written statement from the employee as stated in the investigation conducted by S2DON.

Patient R2
Review of the "Complaint/Grievance Log 2014", submitted as the current grievance log by S2DON, revealed a grievance (e-mailed to the Chief Executive Officer) had been received on 08/10/14 from the daughter of Patient R2. Further review revealed the description of the grievance was "Daughter perception of room stains in toilet; rounding document left on bedside table; response delay; perception of staff having a "bad attitude"." Further review revealed the complaint was resolved on 06/23/14 (prior to the date the complaint was received), and the response letter was sent on 09/17/14.

Review of an e-mail sent by the Patient Ambassador to S2DON revealed the Patient Ambassador had spoken with Patient R2's son and daughter who both expressed their concern for their mother's lack of care, specifically on weekends, and the care being provided by the nurse who has a "bad attitude" on the day of this e-mail.

There was no documented evidence presented of a "Complaint/Grievance Form", an investigation of the grievance, and a response letter sent to the complainant.

In an interview on 03/12/15 at 2:20 p.m., S3Director of Quality indicated the grievance was submitted before she was employed at the hospital. She further indicated she could find no documented evidence that a "Complaint/Grievance Form" had been completed, an investigation of the grievance had taken place, and a response letter was sent to the complainant. She further indicated the documentation of the grievance on the "Complaint/Grievance Log 2014" was entered incorrectly by her, indicating the date the grievance was submitted was incorrect.

Based on record reviews and interview, the hospital failed to ensure its grievance procedure was implemented according to hospital policy as evidenced by failure to have documented evidence that a resolution letter was sent to the complainant after completion of the investigation for 1 (R2) of 4 grievances reviewed from a total of 9 grievances submitted from 08/01/14 through 02/25/15.
Findings:

Review of the hospital policy titled "Complaint And Grievance By Patient", policy number CO1-RR revised 07/11/13, revealed the written response prepared by the Patient Ambassador will include a description of the issues raised by the grievance, a description of the steps taken to investigate the issue, the date the grievance was resolved
and what steps were taken to resolve the grievance, and the name of the contact person at the hospital that the patient or designee can call with additional questions.

Review of the "Complaint/Grievance Log 2014", submitted as the current grievance log by S2DON, revealed a grievance (e-mailed to the Chief Executive Officer) had been received on 08/10/14 from the daughter of Patient R2. Further review revealed the description of the grievance was "Daughter perception of room stains in toilet; rounding document left on bedside table; response delay; perception of staff having a "bad attitude"." Further review revealed the complaint was resolved on 06/23/14 (prior to the date the complaint was received), and the response letter was sent on 09/17/14.

Review of an e-mail sent by the Patient Ambassador to S2DON revealed the Patient Ambassador had spoken with Patient R2's son and daughter who both expressed their concern for their mother's lack of care, specifically on weekends, and the care being provided by the nurse who has a "bad attitude" on the day of this e-mail.

There was no documented evidence presented of a "Complaint/Grievance Form", an investigation of the grievance, and a response letter sent to the complainant.

In an interview on 03/12/15 at 2:20 p.m., S3Director of Quality indicated the grievance was submitted before she was employed at the hospital. She further indicated she could find no documented evidence that a "Complaint/Grievance Form" had been completed, an investigation of the grievance had taken place, and a response letter was sent to the complainant. She further indicated the documentation of the grievance on the "Complaint/Grievance Log 2014" was entered incorrectly by her, indicating the date the grievance was submitted was incorrect.

Based on record review and interview, the hospital failed to ensure the Quality Assurance (QA) 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 for indicators.
Findings:

Review of QA documentation provided on S3DirectorQuality's computer revealed information in a "dashboard" format, that listed quality indicators, a "B" (Goal Met) or and "R" (Goal not met) under most columns with a heading of a corresponding month. Further review revealed columns titled " Findings and Analysis", "Action Plan/Follow Up", "Responsible Party", and " QC (Quality Committee) Approved". Further review revealed no documentation of the method of data collection or the frequency of data collection for indicators.

In an interview 3/12/14 at 3:00 p.m. S3DirectorQuality reported that she did not have any documentation of the method and frequency of data collection for QA indicators. S3DirectorQuality reported she could not produce any raw data collected, as she just entered the data, provided by other staff members, into the computer.

Based on record review and interview, the hospital failed to ensure Quality Assurance (QA) Performance Improvement (PI) activities correctly identified medical errors as evidenced by errors in diabetic sliding scale orders identified by surveyors, not identifying and tracking "near misses" in medication orders and administration, and incorrectly counting 14 medication errors as only 1.
Findings:


Review of the medical records for Patient #6 and Patient #13, revealed the incorrect treatments for glucose readings below 70 were identified by surveyors 20 times for Patient #6 and 4 times for Patient #13. (See findings in A-0395) .

In an interview on 03/12/15 at 1:05 p.m., S2DON indicated she wasn't aware the nurses weren't following the physician orders for sliding scale insulin. She further indicated she doesn't perform chart audits related to sliding scale insulin orders.

In an interview on 3/12/15 at 4:30 p.m. S7PharmacyDirector reported that near misses (a close call or a near miss is an event, situation, or error that took place but was captured before reaching the patient) were not identified and incorporated into the medication error rate or the QA program.

Review of 1 of 2 medication variances reported for the last year revealed an error in transcribing Lopressor from the physician's order to the medication administration record. This resulted in the patient missing 14 doses of medication. This error was counted as 13 on the incident report, but as 1 of 2 medication errors reported for last year.

In an interview on 3/12/15 at 4:30 p.m., S3QualityDirector and S7PharmacyDirector reviewed the Incident report and confirmed that this was counted as 1 medication error in the calculation of the hospital's percentage of medication errors. S3QualityDirector and S7PharmacyDirector confirmed the medication errors discovered by surveyors had not been identified and counted in medication errors by the hospital.

Based on record review and interview, the hospital failed to ensure the Quality Assurance and Performance Improvement (QAPI) program included all services as evidenced by no documented evaluation or indicators for contracted services.
Findings:

Review of QAPI documentation revealed no indicators or evaluation of contracted services.

In an interview on 3/12/15 at 3:00 p.m. S3QualityDirector verified that there were no evaluations or indicators for any of the hospital's contracted services. S3QualityDirector reported she was not aware the hospital had to evaluate the contracted services provided and incorporate those evaluations into QAPI.

Based on record reviews and interviews, the hospital failed to ensure each physician providing on-call code coverage was credentialed in accordance with the contract between the hospital and ED (Emergency Department) Group B as evidenced by having physicians leading and giving orders during a code who were not credentialed and privileged by the hospital's Medical Staff and Governing Body for 2 (#18, #31) of 3 (#18, #21, #31) patient death records reviewed.
Findings:

Review of the "Agreement For On-Call Code Coverage" between the hospital and ED Group B, effective 10/20/01 and presented as the current agreement by S1CEO (Chief Executive Officer), revealed the hospital engaged ED Group B to provide on-call code coverage services through physicians who are appropriately licensed and credentialed to practice emergency medicine. Further review revealed ED Group B was to meet and continue to meet the criteria for medical staff appointment and reappointment set forth in the By-laws or policies of the Hospital or its medical staff. The ED physicians were to apply for and maintain clinical privileges to practice medicine at the hospital in accordance with the By-laws or policies of the hospital and its medical staff. There was no documented evidence indicating that the agreement was for ED physicians to provide on-call code coverage at the off-site campus only or at the off-site and main campuses.

Patient #18
Review of Patient #18's "Code Blue record" revealed he coded on 11/24/14 at 9:00 p.m. and was intubated by S18MD (Medical Doctor) at 9:09 p.m. Further review revealed S18MD was the physician leader during the code, and the additional physician who signed the record was S16MD.

Review of Patient #18's "Discharge/Death/Transfer Summary" documented by S16MD on 11/25/14 at 4:05 a.m. revealed S16MD documented "he was intubated rapidly, had full CPR (cardiopulmonary resuscitation) code protocol, and attended by S18MD and myself."

Review of S16MD's "Delineation of Privileges" signed by the Medical Director on 10/07/13 revealed he was not privileged to perform Cardiopulmonary Resuscitation.

Patient #31
Review of Patient #31's "Code Blue Record" revealed she coded on 12/29/14 at 4:28 p.m. Further review revealed the physician leader of the code was S17MD.

In an interview on 03/11/15 at 2:35 p.m., S11Medical Records indicated S18MD is an ED physician at Hospital A. He confirmed that S18MD was not credentialed and privileged to provide services at St. Theresa Specialty Hospital.

In an interview on 03/12/15 at 12:35 p.m., S11Medical Records confirmed S17MD was not credentialed and privileged to provide services at St. Theresa Specialty Hospital.

Based on record reviews and interviews, the hospital failed to ensure a medical history and physical examination (H&P) was completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, and when the H&P was recorded prior to admission, a physical examination of the patient was completed for any changes in the patient's condition according to the hospital's Medical Staff Rules and Regulations as evidenced by having no documented evidence of a physical examination being performed and documented when the H&P was recorded prior to admission for 2 (#6, #13) of 9 (#1, #2, #3, #5, #6, #7, #12, #13, #14) current inpatient records reviewed for a H&P from a total of 31 sampled patients and 9 (#22, #23, #24, #25, #26, #27, #28, #29,#30) of 10 (#4, #22, #23, #24, #25, #26, #27, #28, #29,#30) hospice patients sampled. Findings:

Review of the hospital's Medical Staff Rules and Regulations revealed each patient shall have a H&P completed no more than 30 days before or 24 hours after admission with documentation of the H&P placed in the medical record within 24 hours of admission. Further review revealed when a H&P was recorded prior to admission, a physical examination of the patient must be completed for any changes in the patient's condition and documented in the patient's medical record within 24 hours of admission. The H&P must be completed by a member of the Medical Staff of the hospital, or other qualified member of the Allied Health Staff of the hospital, in accordance with state law and hospital policy.

Review of the hospital's "History & (and) Physical Addendum" reviewed the following instructions: "Please review the attached History & Physical examination and indicate whether it reflects the patient's current status or note any changes in the patient's status since the History & Physical was written. In lieu of completing this form, a complete History & Physical can be dictated or written. ____ No changes to History & Physical ______ Changes to History & Physical."

Patient #2
Review of Patient #2's medical record revealed she was an 81-year-old female admitted to the hospital on 03/06/15 at 3:56 p.m. Diagnoses included Pneumonia, Urinary Tract Infection, Sepsis, and Dementia.

Review of Patient #2's H&P revealed it was performed on 03/08/15 at 5:25 p.m. by the physician.

Patient #6
Review of Patient #6's medical record revealed she was an 80 year old female admitted on 02/06/15 at 7:00 p.m. with diagnoses of Neurotic Diabetic Foot Wound and Osteomyelitis.

Review of Patient #6's H&P revealed it was performed on 01/30/15. Review of the "History & Physical Addendum" documented by S29MD (Medical Doctor) on 02/07/15 at 6:15 p.m. revealed the line before the words "Changes to History & Physical" had a check mark with a "+" (plus sign) written at the end of the statement. Further review revealed documentation written as follows: "My DC (discharge) from 2/6/15 in addition to original H&P will serve as LTAC (Ling Term Acute Care) H&P." There was no documented evidence that a physical examination had been performed as required by the Medical Staff Rules and Regulations. There was no documented evidence of a discharge note, as referenced to in S29MD's documentation, attached to the H&P.

In an interview on 03/12/15 at 1:05 p.m., S2DON (Director of Nursing) confirmed there was no evidence that a physical examination had been performed by S29MD as part of Patient #6's H&P.

Patient #13
Review of the medical record for Patient #13 was a 38 year old male admitted to the hospital 1/27/15 with diagnoses that included Diabetes Mellitus, Sepsis, Osteomyelitis-Right lower extremity, and Diabetic foot ulcer.

Review of Patient #13's H&P revealed it was performed on 1/19/15. Review of the "History & Physical Addendum" documented by the admitting physician on 1/28/15 revealed the line before the words "Changes to History & Physical" had a check mark with a a note that read, "Found to have osteomyelitis/fascitis. Started on abx (antibiotics). Will cont (continue) in LTAC (Long Term Acute Care). There was no documented evidence that a physical examination had been performed as required by the Medical Staff Rules and Regulations.

In an interview 3/12/15 at 1:07 p.m. S2DON confirmed there was no evidence of an exam had been performed by Patient #13's admitting physician as part of his admission H&P update.


Hospice Patients

Review of discharged patients' hospice records for Patients #22, #23, #24, #25, #26, #27, #28, #29 and #30 revealed they did not contain a history and physical.

In an interview on 3/12/15 at 9:05 a.m. with S11MedicalRecords, he said the hospital did not require the hospice patients to have a history and physical on admission until this week during the survey. He said he was unsure how many hospice patients' records were incomplete.


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Based on record reviews and interviews, the hospital failed to ensure a registered nurse (RN) supervised and evaluated the nursing care of each patient as evidenced by:

1) Failing to ensure the RN performed the patient's initial admission assessment and didn't delegate the responsibility to the LPN (Licensed Practical Nurse) for 2 (#6, #12) of 9 (#1, #2, #3, #5, #6, #7, #12, #13, #14) patient records reviewed for nursing admission assessments performed by the RN from a total of 31 sampled patients;

2) Failing to ensure the RN assessed each patient's wounds upon admission as evidenced by the hospital's practice requiring the skin assessment to be performed by the wound care nurse after the admission assessment had been performed (usually the day following admit) for 2 (#6, #12) of 9 (#1, #2, #3, #5, #6, #7, #12, #13, #14) patient records reviewed for skin assessments from a total of 31 sampled patients;

3) Failing to ensure physician orders for sliding scale insulin was administered as ordered for 2 (#6, #13) of 4 (#5, #6, #12, #13) patient records reviewed with sliding scale insulin orders from a total of 31 sampled patients; and

4) Failing to ensure the RN assessed the patient before delegating the care to the LPN in accordance with the Louisiana State Board of Nurses' (LSBN) "Administrative Rules Defining RN Practice LAC46:XLVII" as evidenced by the RN delegating the care of a patient with fluctuating capillary blood sugar readings with a low of 44 mg/dl (milligrams per deciliter) to the LPN for 1 (#6) of 4 (#5, #6, #12, #13) patient records reviewed with sliding scale insulin orders from a total of 31 sampled patients.

Findings:

1) Failing to ensure the RN performed the patient's initial admission assessment and didn't delegate the responsibility to the LPN:
Review of the hospital policy titled "Admission Of Patient To Inpatient Unit", policy number A01-G and revised 08/15/11, revealed that a registered nurse will perform the initial assessment of the patient upon admission to the nursing unit. A Nursing Assistant or LPN may assist in the assessment as directed by the RN. The RN will review the pre-admission data and initiate the Interdisciplinary Admission Team database.

Patient #6
Review of Patient #6's medical record revealed she was an 80 year old female admitted on 02/06/15 with diagnoses of Neurotic Diabetic Foot Wound and Osteomyelitis.

Review of Patient #6's "Admission Database" (the initial nursing assessment) revealed it was documented on 02/06/15 at 7:00 p.m. by S33LPN. Further review revealed the assessment was signed by S33LPN and the RN on 02/16/15 at 9:00 p.m.

Review of Patient #6's "24 Hour Patient Record" revealed an entry on 02/06/15 at 8:00 p.m. of "Assessment complete per flowsheet."

In an interview on 03/10/15 at 2:45 p.m., S10RN, Charge Nurse, confirmed Patient #6's admit nursing assessment was done by S33LPN and co-signed by the RN.

Patient #12
Review of Patient #12's medical record revealed he was a 54 year old male admitted on 03/09/15 with Osteomyelitis and Diabetes and a history of MRSA (Methicillin Resistant Staph Aureus), Chronic Systolic Heart Failure, Diabetic Neuropathy, and Hyperlipidemia.

Review of Patient #12's "Admission Database" documented by S15LPN on 03/09/15 at 9:55 p.m. revealed she documented the nursing assessment and signed it on 03/09/15 at 10:20 p.m. The RN signed the admit assessment on 03/09/15 at 11:00 p.m.

Review of Patient #12's "24 Hour Patient Record" revealed an entry on 03/09/15 at 10:30 p.m. by S15LPN of "Pt.'s (patient's) admission paperwork done."

In a telephone interview on 03/11/15 at 1:50 p.m., S15LPN confirmed she did the admit assessment of Patient #12. She indicated when she did Patient #12's admit assessment, the RN was not in the room with her. She indicated that she reports her assessment findings to the RN when her assessment is complete and gives the documentation to the RN.

In an interview on 03/12/15 at 1:05 p.m., S2DON (Director of Nursing) indicated the RNs were responsible for admitting patients. She further indicated that the RN has been allowed to just sign the LPN's admit assessment. S2DON presented the admit policy during the interview, and when informed that the policy says the RN can delegate the assessment to the LPN or Nursing Assistant, she had no explanation to offer.

2) Failing to ensure the RN assessed each patient's wounds upon admission as evidenced by the hospital's practice requiring the skin assessment to be performed by the wound care nurse after the admission assessment had been performed (usually the day following admit):
Review of the "Admission Database", the hospital's initial nursing admission assessment form, revealed no documented evidence of a section for assessment of the patient's skin or wounds.

Patient #6
Review of Patient #6's medical record revealed she was an 80 year old female admitted on 02/06/15 with diagnoses of Neurotic Diabetic Foot Wound and Osteomyelitis.

Review of Patient #6's "Admission Database" (the initial nursing assessment) revealed it was documented on 02/06/15 at 7:00 p.m. by S33LPN. There was no documented evidence that a skin or wound assessment was performed.

Review of Patient #6's "Photographic Wound Documentation" revealed the wounds were first assessed on 02/07/15 at 12:00 p.m. (17 hours after admission).

Patient #12
Review of Patient #12's medical record revealed he was a 54 year old male admitted on 03/09/15 with Osteomyelitis and Diabetes and a history of MRSA (Methicillin Resistant Staph Aureus), Chronic Systolic Heart Failure, Diabetic Neuropathy, and Hyperlipidemia.

Review of Patient #12's "24 Hour Patient Record" revealed an entry on 03/09/15 at 9:55 p.m. by S15LPN of Patient #12's dressing to his right foot being dry and intact, and a slipper sock was placed on his right foot. There was no documented evidence of an assessment of Patient #12's foot wound by an RN at the time of his admission assessment.

In a telephone interview on 03/11/15 at 1:50 p.m., S15LPN confirmed she did the admit assessment of Patient #12. She indicated she didn't unwrap his dressings to assess his wounds, because they had just medicated him. She further indicated she doesn't always remove the dressing to assess the wound. S15LPN indicated if a patient has wounds, the wound care nurse is supposed to assess the wounds.

In an interview on 03/12/15 at 1:05 p.m., S2DON confirmed the initial nursing admit assessment does not include an assessment of the skin or wounds. She indicated the wound care nurse performs the initial skin assessment. She further indicated the wound care nurse's skin assessment may not be done on the same day as the patient's admission.

3) Failing to ensure physician orders for sliding scale insulin was administered as ordered:
Patient #6
Review of Patient #6's medical record revealed she was an 80 year old female admitted on 02/06/15 with diagnoses of Neurotic Diabetic Foot Wound and Osteomyelitis.

Review of Patient #6's physician orders revealed the following sliding scale insulin orders:
02/06/15 at 3:00 p.m. - blood glucose monitoring AC (before meals) and HS (bedtime); administer Aspart Insulin according to high dose algorithm; for blood glucose less than 60 mg/dl: if patient alert and not NPO (nothing by mouth) give 4 ounces of orange juice or 4 Glucose Tablets, if patient is NPO or unresponsive give 1/2 amp D50 (Dextrose 50%) IVP (intravenous push) Stat, continue to recheck blood glucose every 15 minutes and repeat above if glucose is less than 70 mg/dl;
02/15/15 at 3:15 p.m. - blood glucose monitoring AC and HS; administer Humalog Insulin AC only according to low dose algorithm; for blood glucose less than 60 mg/dl: if patient alert and not NPO give 4 ounces of orange juice or 4 Glucose Tablets, if patient is NPO or unresponsive give 1/2 amp D50 IVP Stat, continue to recheck blood glucose every 15 minutes and repeat above if glucose is less than 80 mg/dl;
02/16/15 at 10:45 a.m. - no sliding scale Insulin at bedtime, only AC;
02/18/15 at 2:50 p.m. - clarification of above orders, change accuchecks to every AC only, not at bedtime;
02/21/15 at 6:00 p.m. - blood glucose monitoring every 4 hours overnight and every AC; Humalog Insulin per sliding scale at low dose algorithm; for blood glucose less than 60 mg/dl: if patient alert and not NPO give 4 ounces of orange juice or 4 Glucose Tablets, if patient is NPO or unresponsive give 1/2 amp D50 IVP Stat, continue to recheck blood glucose every 15 minutes and repeat above if glucose is less than 80 mg/dl;

Review of the "Diabetic Record", the "24 Hour Patient record", and the MARs (medication administration record) revealed the sliding scale insulin orders were not implemented as ordered when the blood glucose was below 70 mg/dl or 80 mg/dl by adding sugar (amount not documented) with the orange juice (amount not documented), serving a sandwich or crackers with the juice, and/or giving 1 amp of D50 IVP rather than 1/2 amp and not rechecking the blood glucose every 15 minutes and repeating the orders until the blood glucose was 70 or 80 mg/dl on the following dates and times:
02/08/15 at 6:00 a.m. - CBG (capillary blood glucose) 47 (mg/dl);
02/11/15 at 6:00 a.m. - CBG 44;
02/11/15 at 4:30 p.m. - CBG 40;
02/12/15 at 6:00 a.m. - CBG 36;
02/15/15 at 1:40 a.m. - CBG 42;
02/16/15 at 6:00 a.m. - CBG 54;
02/17/15 at 5:00 a.m. - CBG 50;
02/17/15 at 4:30 p.m. - CBG 44;
02/19/15 at 1:50 a. m. - CBG 28;
02/21/15 at 4:30 a.m. - CBG 24;
02/21/15 at 10:55 a.m. - CBG 21;
02/22/15 at 4:00 p.m. - CBG 42;
02/23/15 at 10:00 p.m. - CBG 58;
02/24/15 at 6:00 p.m. - CBG 44;
02/25/15 at 3:30 a.m. - CBG 38;
02/26/15 at 4:00 a.m. - CBG 50;
02/27/15 at 6:00 a.m. - CBG not checked;
03/01/15 at 3:30 p.m. - CBG 54;
03/05/15 at 6:00 a.m. - CBG 57;
03/07/15 at 6:00 a.m. - CBG not checked.

In a telephone interview on 03/11/15 at 1:50 p.m., S15LPN indicated she would have used 1 or 2 packets of sugar with the orange juice and doesn't remember specifically how much was given. She confirmed she didn't document the amount of sugar given. She further indicated as long as she's been nursing, she's always added sugar to orange juice when treating low blood glucose. S15LPN indicated the charge nurse usually says to give sugar and juice if the patient's awake, and sometimes she gives juice and graham crackers. She further indicated she's supposed to recheck the blood sugar in 20 to 30 minutes after the juice and sugar were given. After having the physician's order read to her, S15LPN confirmed she didn't follow the physician's order for treating Patient #6's low blood sugar.

In an interview on 03/12/15 at 1:05 p.m., S2DON indicated she wasn't aware the nurses weren't following the physician orders for sliding scale insulin. She further indicated she doesn't perform chart audits related to sliding scale insulin orders.

Patient #13
Review of the medical record for patient #13 revealed he was admitted to the hospital 1/27/15 with diagnoses that included Diabetes, Abnormal loss of weight, Acute renal failure, History of noncompliance with medical treatment, Sepsis Syndrome, and Volume depletion.

Review of Patient #13's physician orders revealed the following sliding scale insulin orders:
1/28/15 at 11:30 a.m. - blood glucose monitoring AC (before meals) and HS (bedtime); An order 2/17/15 at 10:00 a.m. ordered, in part, for blood glucose less than 60 mg/dl
:A. if patient alert and not NPO (nothing by mouth) give 4 ounces of orange juice or 4 Glucose Tablets, if patient is NPO or unresponsive give 1/2 amp D50 (Dextrose 50%) IVP (intravenous push) STAT (immediately),

Review of the "Diabetic Record", the "24 Hour Patient record", and the MARs (medication administration record) revealed the sliding scale insulin orders were not implemented as ordered when the blood glucose was below 70 mg/dl or 80 mg/dl by adding sugar (amount not documented) with the orange juice (amount not documented), serving a sandwich or crackers with the juice, and/or giving 1 amp of D50 IVP rather than 1/2 amp and not rechecking the blood glucose as follows:

2/04/15 at 11:30 a.m. CBG 51 , notatation on MAR only: "eating", no recheck of CBG documented.
2/16/15 at 11:30 a.m. CBG 34 , nursing notes read, "gave pt (patient) 2 4oz. O.J. to drink."
2/20/15 at 5:00 p.m. CBG 50 , nursing notes readm, "BS (blood sugar) 50. Pt asymptomatic. OJ (orange juice) x1 (times one) given. CBG was checked 1 hour later.
2/21/15 at 5:00 p.m. CBG 58 ,nursing notes read, "Blood sugar 58. Eating dinner. States feels a little weak..." Further review of the nursing notes showed no other interventions and a recheck of the CBG and hour later.

In an interview 3/12/15 at 1:07 p.m. S2DON verified the physician's orders were not being followed for the CBG reading documented above.




4) Failing to ensure the RN assessed the patient before delegating the care to the LPN in accordance with the LSBN's "Administrative Rules Defining RN Practice LAC46:XLVII":
Review of the Louisiana State Board of Nursing's "Administrative Rules Defining RN Practice LAC46:XLVII" revealed, in part, "3703. Definition of Terms Applying to Nursing Practice ... Delegating Nursing Interventions - ... The registered nurse retains the accountability for the total nursing care of the individual. ... The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. The assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required. ... b. The registered nurse may delegate to licensed practical nurses the major part of the nursing care needed by individuals in stable nursing situations, i.e. (that is), when the following three conditions prevail at the same time in a given situation: i. nursing care ordered and directed by R.N./M.D. (medical doctor) requires abilities based on a relatively fixed and limited body of scientific fact and can be performed by following a defined nursing procedure with minimal alteration, and responses of the individual to the nursing care are predictable; and ii. change in the patient's clinical conditions is predictable; and iii. medical and nursing orders are not subject to continuous change or complex modification...".
Review of the hospital policy titled "Assessment And Reassessment Of Patients", policy number A03-G and revised 01/25/12, revealed that patients are reassessed to determine their response to treatment, when a significant change occurs in patient condition, and when a significant change occurs in the patient's diagnosis. Assessment and reassessment data will be documented in the patient's medical record.

Patient #6
Review of Patient #6's medical record revealed she was an 80 year old female admitted on 02/06/15 with diagnoses of Neurotic Diabetic Foot Wound and Osteomyelitis.

Review of Patient #6's medical record revealed she was admitted by and her care was provided by S15LPN on 02/06/15 from 7:00 p.m. through 02/07/15 at 6:30 a.m. by S33LPN. There was no documented evidence of an assessment performed by the RN. Further review revealed she was assigned to an LPN on the day and night shifts of 02/07/15 with no documented evidence of an assessment by an RN to determine if she met the criteria established by the LSBN to have her care delegated to the LPN. During this period of time Patient #6 had several blood glucose checks that required sliding scale insulin to be given as ordered.

In an interview on 03/12/15 at 1:05 p.m., S2DON indicated a patient shouldn't be cared for by an LPN on back-to-back shifts. She further indicated a patient with unstable blood sugars shouldn't be assigned to an LPN.

Based on record reviews and interviews, the hospital failed to ensure each patient had a nursing care plan developed and kept current by the nursing staff as evidenced by not having all patients' medical problems for which they're being treated being included in their nursing care plan for 3 (#7, #12, #13) of 9 (#1, #2, #3, #5, #6, #7, #12, #13, #14) patient records reviewed for nursing care plans from a total of 31 sampled patients.
Findings:

Review of the hospital policy titled "Admission Of Patient To Inpatient Unit", policy number A01-G and revised 08/15/11, revealed that the RN is to initiate the patient care plan based on data obtained from the admission assessment within 24 hours of admission.

Patient #7
Review of Patient #7's medical revealed he was a 54 year old male admitted to the hospital 3/2/15 with diagnoses that included Cellulitis of left groin and thigh, Pneumonia, Pancreatitis, Acute renal failure, Alcohol Abuse, Malnutrition, Hepatitis C, Debility, Chronic Liver Disease, Hypertension, Thrombocytopenia, and a history of Seizures.

Review of Patient #7's admission orders included a Renal Diet. Further review of the patient's medical record revealed no nursing care plan that addressed his nursing needs related to diagnoses of Malnutrition, Acute Renal failure, or his ordered Renal diet.

Patient #12
Review of Patient #12's medical record revealed he was a 54 year old male admitted on 03/09/15 with Osteomyelitis and Diabetes and a history of MRSA (Methicillin Resistant Staph Aureus), Chronic Systolic Heart Failure, Diabetic Neuropathy, and Hyperlipidemia.
Review of his physician admit orders revealed orders for sliding scale insulin protocol.

Review of Patient #12's "Plan of Care" revealed no documented evidence that his plan included goals, interventions, and expected completion date for Diabetes.

Patient #13
Review of Patient #13's medical record revealed his was a 38 year old male admitted to the hospital 1/27/15 with Diabetes - Type 1, Diabetic Foot Ulcer (right dorsal foot extending to plantar), Osteomyelitis, Chronic Diarrhea, and Medical Noncompliance, Diabetic Neuropathy, and Weight loss.

Review of Patient #13's Admission Orders revealed the patient's ordered diet was a Diabetic low carb (carbohydrate) with fiber supplement, 2800 cal (calorie) ADA ( American Diabetes Association) with Glucerna- 1 can three times a day, and 2 peanut butter and sugar free jelly sandwiches as bedtime snack.

Review of Patient #13's "Plan of Care" revealed no documented evidence that his plan included goals, interventions, and expected completion date for his chronic diarrhea, diabetes, nutritional status/ordered diet, sensory deficient related to Diabetic neuropathy, or alteration in skin integrity/wounds.


In an interview on 03/12/15 at 1:05 p.m., S2DON (Director of Nursing) indicated she keeps having to stress to the nursing staff that patient care plans have to individualized for each patient. She confirmed that a patient on sliding scale insulin should have his/her care plan developed to include Diabetes.

Based on record review and interview, the hospital:
1) Failed to have an effective system in place to ensure medical records were completed within 30 days of discharge. The hospital also failed to ensure medical records for patients admitted for hospice inpatient care were included in review for delinquencies.
2) Failed to ensure paper medical records were protected from water damage in the event the sprinkler system was activated.

Findings:

1) Failing to have an effective system in place to ensure medical records were completed within 30 days of discharge.

Review of the Rules and Regulations of the Medical Staff provided by the hospital revealed in part:
11. The admitting physician must document in the Admission Note the need for admission and plan of care.
C. Medical Records
1. The attending physician shall be responsible for the preparation of a completed legible medical record for each patient. The record shall be identification data, medical history, physical examination, diagnostic and therapeutic orders, appropriate informed consent, clinical observations including results of therapy, progress notes, consultations and nursing notes, reports of procedures, tests and results including operative results, a report on the patient's rehabilitative potential, conclusions of termination of hospitalization to include relevant diagnosis, and clinical resume.
12. The attending physician shall complete the medical record at the time of the patient's discharge, to include progress notes, final diagnosis and discharge summary.
13. If the medical record is incomplete 30 days after discharge, a written notice shall be sent to the physician by the CEO notifying him that he has 7 days to complete the medical records or his admitting privileges will be suspended. Failure to complete the medical records that caused the relinquishment of clinical privileges within 30 days of relinquishment of such privileges shall constitute a voluntary resignation from the Medical Staff.

Review of a list provided by the hospital of delinquent medical records revealed 2 discharged patients' medical records were delinquent since January 2015.

Review of discharged patients' hospice records for Patients #22, #23, #24, #25, #26, #28 and #29 revealed they had been discharged greater than 30 days and did not contain a history and physical within 24 hours of admission or a discharge summary.

In an interview on 3/10/15 at 3:00 p.m. with S28MedicalRecordsClerk, she said the hospice patients' medical record delinquencies were not being counted in the delinquency rate.

In an interview on 3/12/15 at 9:05 a.m. with S11Medical Records, he said they were originally checking the discharged hospice patients' medical records for missing signatures on verbal orders but nothing else. He said the hospital did not require the hospice patients to have a history and physical on admission until this week. He said he was unsure how many hospice patients' records were incomplete. He said there were currently 2 delinquent medical records. He said one delinquent record was from a patient discharged on 1/2/15 so it was 70 days delinquent and the other record was at least 45 days delinquent. S11MedicalRecords said the bylaws required suspension of the physician with a delinquency after 30 days but no physician had ever been sent a letter or suspended to his knowledge. He said the hospital was going to begin to enforce the bylaws this month.

2) Failing to ensure paper medical records were protected from water damage in the event the sprinkler system was activated.

An observation on 3/9/15 at 11:00 a.m. of the medical records department at the main campus revealed 10 open shelves containing medical records. The room contained sprinklers in the ceiling.

In an interview on 3/12/15 at 9:05 a.m. with S11MedicalRecords, he said he did not currently have a method to protect medical records from water damage if the sprinkler system was activated. He said at least a year of discharged patients' medical records was stored on the open shelves but he did not know the exact number of records. S11MedicalRecords said it was at least a couple of hundred records.

Based on record reviews and interview, the hospital failed to develop a policy and procedure for verifying electronic signatures on history and physicals (H&P), discharge summaries, radiology reports, operative reports, and consults that were dictated and electronically signed by physicians for 1 (#6) of 9 (#1, #2, #3, #5, #6, #7, #12, #13, #14) current inpatient records and 1 (#18) of 3 (#18, #21, #31) death records reviewed for authentication of entries from a total of 31 sampled patients.
Findings:

Patient #6
Review of Patient #6's medical record revealed she was an 80 year old female admitted on 02/06/15 with diagnoses of Neurotic Diabetic Foot Wound and Osteomyelitis. Further review revealed the following entries in her medical record were electronically signed:
H&P electronically signed on 01/30/15;
Physician Progress Note electronically signed on 02/05/15 at 4:57 p.m.

Patient #18
Review of Patient #18's medical record revealed her Discharge/Death/Transfer Summary was electronically signed on 11/28/14 at 7:25 a.m. by S16MD (Medical Doctor).

In an interview on 3/12/15 at 9:30 a.m. with S11MedicalRecords, he said the hospital did not have any policies or methods for verifying electronic signatures although dictation for histories and physicals, discharge summaries, radiology reports, operative reports, and consults were signed electronically.


30364

Based on record reviews and staff interviews, the hospital failed to ensure all orders were dated, timed, and authenticated promptly by the practitioner for 2 of 31 sampled patients (#3, #5).
Findings:

Review of the Rules and Regulations of the Medical Staff of St. Theresa Specialty Hospital revealed, in part: D. General Conduct of Care. 1. All orders for treatment shall be in writing. A verbal order shall be considered to be in writing if given to a licensed nurse or licensed personnel as approved by the Medical Staff, functioning within their sphere of competence and signed by the responsible physician. All verbal and telephone order shall be "read back" to the physician to assure correctness. These personnel shall include Registered Nurses, Licensed Practical Nurses, Registered Respiratory Care Therapists, Physical Therapists, Occupational Therapists, Speech Therapists, Registered Dietitians, Pharmacists, and Psychologists and shall be restricted to orders specific to their discipline. The responsible physician shall authenticate such orders within the time frame specified by state law or if no stated law applies the responsible physician shall authenticate such orders within forty-eight (48) hours and failure to do so shall be brought to the attention of the Medical Director for appropriate action.

In an interview on 03/11/15 at 12:12 p.m., S2DON indicated state law allowed up to 10 days for orders to be signed by the physician. S2DON indicated all physician orders should be dated, timed, and authenticated within 10 days after being written.

Patient #5:

Review of the medical record revealed the patient was admitted to the hospital on 02/06/15. The patient was admitted to the hospital for rehabilitation services and to be weaned off the respiratory ventilator.

Review of the Physician's Orders revealed a telephone order dated 02/07/15 with instructions to place the patient on ventilator support at times of respiratory distress. Further review revealed this order was not dated, timed, and authenticated by the physician.

Review of a Rehabilitation Physician Order Form dated 02/13/15 revealed orders for physical therapy, occupational therapy, and speech therapy services. Further review revealed the orders were not dated, timed, and authenticated by the physician.

Review of the Physician's Order revealed a telephone order dated 02/18/15 to change an intravenous antibiotic (Vancomycin) to 1 gram every 18 hours. Further review revealed this order was not dated, timed, and authenticated by the physician.

In an interview on 03/11/15 at 12:13 p.m., S2DON indicated there was no evidence the orders were dated, timed, and authenticated by the physician.

Patient #3:

Review of the medical record revealed the patient was admitted to the hospital on 02/18/15. The patient had the diagnoses of osteomyelitis, left ankle surgery, obstructive sleep apnea, hypertension, and anemia.

Review of a Rehabilitation Physician Order Form dated 02/19/15 revealed orders for physical therapy and occupational therapy services. Further review of this form revealed the orders were not dated and timed when they were signed by the physician.

In an interview on 03/11/15 at 12:14 p.m., S2DON indicated there was no evidence the orders were dated and timed by the physician.

Based on record reviews and staff interviews, the hospital failed to ensure completion of the History & Physical examination within 24 hours of admission. This was evidenced by the hospital's failure to provide documented evidence of a medical history and physical examination completed within 24 hours of admission for 9 (#22, #23, #24, #25, #26, #27, #28, #29, and #30) of 10 sampled patients who were admitted to a hospital bed for hospice inpatient services.

Findings:

Review of the hospital Health Information Management policies and procedures revealed, in part:
Subject: Concurrent Analysis of Medical Records.
Policy: It shall be the policy of the hospital to perform concurrent analysis on in-house medical records to ensure completeness and accuracy of documentation prior to discharge.
Procedure: A. New admissions will be checked daily to verify a History & Physical is on the chart within 24 hours of admission.

Review of discharged patients' hospice records for Patients #22, #23, #24, #25, #26, #27, #28, #29 and #30 revealed they did not contain a history and physical.

In an interview on 3/12/15 at 9:05 a.m. with S11MedicalRecords, he said the hospital did not require the hospice patients to have a history and physical on admission until this week during the survey. He said he was unsure how many hospice patients' records were incomplete.

Based on record review and interview, the facility failed to ensure all information needed to provide appropriate care was contained in patients' medical records. This deficient practice was evidenced by not having hospice treatment plans available in the medical record for 2 (#22, #23) of 2 current hospice patients at the main campus of the hospital.

Findings:

Review of the medical record on 3/12/15 at 10:30 a.m. for Patient #22 revealed he was admitted to the hospital on 3/10/15 at 1:29 p.m. to receive hospice care. Further review revealed the hospice treatment plan from the hospice provider was not in the medical record.

Review of the medical record on 3/12/15 at 10:40 a.m. for Patient #23 revealed he was admitted to the hospital on 3/10/15 at 1:42 p.m. Further review revealed the hospice treatment plan from the hospice provider was not in the medical record.

In an interview on 3/12/15 at 10:45 a.m. with S30RN, she said the hospice treatment plans provided information about the care the hospice patient was to receive at the hospital. She verified that Patient #22 and Patient #23 did not have the hospice treatment plans on their medical records. She said some of the hospice companies charted on computers so they did not leave their paperwork on the medical records while the patient was at the hospital.

Based on records review and staff interviews, the hospital failed to ensure the completion of Discharge Summaries within 30 days of discharge. This was evidenced by the hospital's failure to provide documented evidence of a discharge summary for 7 (#22, #23, #24, #25, #26, #28, #29) of 10 sampled patients who were admitted to the hospital bed for hospice inpatient services.

Findings:

Review of the hospital Health Information Management policies and procedures revealed, in part: Subject: Discharge Record Analysis. Procedure: The Health Information Management Department must check for the following information when performing the analysis process for each record: A. The discharge summary shall be completed and signed within 30 days of discharge.

Review of discharged patients' hospice records for Patients #22, #23, #24, #25, #26, #28 and #29 revealed they had been discharged greater than 30 days and did not contain a discharge summary.

In an interview on 3/12/15 at 9:05 a.m. with S11MedicalRecords, he said the hospital did not require the hospice patients to have a discharge summary.

Based on staff interview, the hospital failed to ensure there was a radiologist who was a member of the medical staff and supervised the radiology services and interpreted the radiological tests on either a full-time, part-time, or consulting basis.
Findings:

In an interview on 3/12/15 at 12:50 p.m. S1CEO (Chief Executive Officer) reported that the hospital did not have a radiologist who was a member of the medical staff and supervised the radiology services for the hospital.

Based on record reviews and staff interviews, the hospital failed to have a laboratory services agreement that was signed by both parties for the hospital's main campus.
Findings:

Review of the hospital's Clinical Pathology Laboratories folder that was presented to the surveyors as a contracted service revealed no documented evidence of a laboratory services agreement.

In an interview on 03/12/15 at 10:52 a.m., S2DON indicated the services of Clinical Pathology Laboratories were utilized at the hospital's main campus. S2DON reviewed the information in the folder and indicated there was no evidence of a laboratory services agreement.

In an interview on 03/12/15 at 12:44 p.m., S1CEO indicated the laboratory services agreement should be in the Clinical Pathology Laboratories folder.

On 03/12/15 at 5:43 p.m., S1CEO presented a Laboratory Services Agreement between the hospital and Clinical Pathology Laboratories dated 03/01/14. Review of this agreement revealed it was not signed and dated by a representative from Clinical Pathology Laboratories.

Based on observation and interview, the hospital failed to ensure dietary services maintained and monitored safe practices for food storage as evidenced by expired nutritional supplements available for patient use at the offsite campus. Findings:

An observation on 3/09/15 at 11:00 a.m. revealed the following items were expired at the off-site hospital and were available for patient use:

2, 8-ounce cans of Homemade Vanilla Glucerna with an expiration date of 1/01/2014
4, 4-ounce containers of Ensure Chocolate Pudding with an expiration date of 2/01/14
4, 4-ounce containers of Ensure Chocolate Pudding with an expiration date of 4/01/14

In an interview on 3/09/15 at 11:15 a.m., S5Director of Respiratory indicated S6Materials Manager was responsible for maintaining the supply of nutritional supplements and responsible for rotating the supplies and discarding expired products. S5Director of Respiratory confirmed the above-referenced nutritional supplements were expired as stated, were available for patient use, and should not have been available for patient use.

In an interview on 3/11/15 at 12:20 p.m., S31RD (Registered Dietician) indicated S6Materials Manager was responsible for maintaining and rotating the nutritional supplement supply at the off-site hospital and was responsible for discarding any expired items. S31RD confirmed the expired nutritional supplements should have been discarded and should not have been available for patient use.

Based on record reviews and interview, the hospital failed to ensure its UR (Utilization Review) committee consisted of at least 2 doctors of medicine or osteopathy as evidenced by having one physician as a member of the UR committee.
Findings:

Review of the hospital policy titled "Utilization Review Plan" revealed no documented evidence that the composition of the UR committee was addressed.

Review of the "Utilization Review Committee Sign-In Sheet" dated 12/16/14, submitted by S3Director of Quality when the list of UR committee members was requested, revealed one physician was a member of the UR committee.

In an interview on 03/12/15 at 2:20 p.m., S3Director of Quality confirmed that only one physician was on the UR committee for the hospital.

Based on observation and interview, the hospital failed to ensure supplies were maintained to provide an acceptable level of safety and quality for patients as evidenced by expired laboratory test tubes available for patient use in the hospital medication rooms. Findings:

An observation on 3/09/15 at 10:00 a.m. in the main hospital's medication room revealed the following laboratory test tubes were expired and available for patient use:

10 blue top laboratory test tubes with an expiration date of 09/14.

In an interview on 3/09/15 at 10:00 a.m., S32RN confirmed the above referenced test tubes were expired as of 09/14 and were available for patient use. S32RN further confirmed the expired laboratory test tubes should not have been available for patient use.

An observation on 3/09/15 at 12:00 p.m. in the medication room at the off-site hospital's medication room revealed the following laboratory test tubes were expired and available for patient use:

1 package of unopened blue-top laboratory test tubes containing 100 tubes with an expiration date of 11/13
12 blue top tubes with an expiration date of 05/12
2 blue top tubes with an expiration date of 01/12
1 blue top tube with an expiration date of 07/13
1 blue top tube with an expiration date of 12/13
5 orange top tubes with an expiration date of 01/15

In an interview on 3/09/15 at 12:00 p.m., S5DirectorRespiratory confirmed the above-referenced laboratory test tubes were expired as written above and were available for patient use.

In an interview on 3/09/15 at 12:50 p.m., S12RN indicated S6MaterialsMgr was responsible for maintaining all supplies used at the hospitals for patients. S12RN confirmed the laboratory test tubes were expired and should not have been available for patient use.

Based on record review and interview, the hospital failed to ensure patients and/or responsible parties were counseled to prepare them for post hospital care and implementation of the discharge plan as evidenced by no documentation of education and/or counseling provided to patients and/or responsible parties regarding the list of all medications the patient should be taking after discharge, with clear indication of changes from the patient's pre-admission medications for 3 (#8, #9, #11) of 3 patients discharged home. Findings:

Patient #8
Patient #8 was a 73-year-old-female admitted to the hospital on 8/11/11 and discharged on 9/12/14. Diagnoses included ESRD (End Stage Renal Disease) and Osteomyelitis of the Lower Spine.

Review Patient #8's medical record revealed no documentation of counseling provided to the patient and/or responsible party which included education on the list of medications the patient was discharged home on which included a clear indication of the changes to Patient #8's pre-admission medications.

Patient #9
Patient #9 was a 61-year-old female admitted to the hospital on 8/20/14 and discharged on 9/09/14. Diagnoses included Stage IV Lunch Cancer, Intractable Nausea & Vomiting, Malnutrition, and Stage II Sacral Decubitus.

Review Patient #9's medical record revealed no documentation of counseling provided to the patient and/or responsible party which included education on the list of medications the patient was discharged home on which included a clear indication of the changes to Patient #9's pre-admission medications.

Patient #11
Patient #11 was a 79-year-old male admitted to the hospital on 1/02/15 and discharged on 1/30/15. Diagnoses included a sacral decubitus, osteomyelitis, and a subarachnoid hemorrhage.

Review Patient #11's medical record revealed no documentation of counseling provided to the patient and/or responsible party which included education on the list of medications the patient was discharged home on which included a clear indication of the changes to Patient #11's pre-admission medications.

In an interview on 3/11/15 at 2:00 p.m., S9CaseManagement indicated the patient's staff nurse or the case manager is responsible for providing medication discharge instructions. S9CaseManagement also indicated patients are provided, on discharge, a written list of the discharge medications with the name of the medication, dosage, frequency, special instructions/comments, and the time the next dose of the medication is due. S9CaseManagement further indicated the document, Interdisciplinary Patient Discharge Instructions, Instructions for Patient and Family, was the only document used to document the list of discharge medications and counseling involved with patients' discharge medications. S9CaseManagement confirmed she was not aware of the requirement for counseling the patients and/or responsible parties on the changes to the patients' pre-admission medications. S9CaseManagement confirmed there was no documentation in the medical records this practice was being implemented as part of the implementation of the discharge plan.

In an interview on 3/12/15 at 9:01 a.m., S3QualityDirector confirmed she was not aware of the requirement for counseling the patients and/or responsible parties on the changes to the patients' pre-admission medications when patients were discharged home. S3QualityDirector further confirmed there was no policy and procedure in place for counseling patients and/or responsible parties to prepare them for post hospital care regarding the list of all medications the patient should be taking after discharge, with clear indication of changes from the patient's pre-admission medications.

Based on record review and interview, the hospital failed to have a policy and procedure in place to provide to patients a list of Home Health Agencies and Skilled Nursing Facilities (SNF) (participating in the Medicare program) that were available to provide those services to patients who required them after discharge from the hospital for 2 (#8 and #10) of 3 medical records reviewed for the discharge planning process and implementation that required home health services after discharge from the hospital. Findings:

A review of the case management policies and procedures manual, presented by S9CaseManagement as the current manual, revealed no policy or procedure indicating that a list of Home Health Agencies and Skilled Nursing Facilities that participate in the Medicare program was required to be presented to patients during the discharge planning process for patients who required home health services or SNF services after discharge from the hospital.

Patients #8
Patient #8 was a 73-year-old-female admitted to the hospital on 8/11/11 and discharged on 9/12/14. Diagnoses included ESRD (End Stage Renal Disease) and Osteomyelitis of the Lower Spine.

A review of Patient #8's discharge planning screen and evaluation revealed no prior home health agency was utilized by Patient #8 prior to admission to the hospital.

A review of the physician's order dated 9/11/14 at 12:00 p.m. revealed an order for home health services for Patient #8.

A review of the medical record revealed no documentation the patient requested a particular home health or that a list of home health agencies available were presented to the patient. Further review of the medical record revealed that Home Health Company C was set up by the case manager.

Patient #9
Patient #9 was a 61-year-old female admitted to the hospital on 8/20/14 and discharged on 9/09/14. Diagnoses included Stage IV Lunch Cancer, Intractable Nausea & Vomiting, Malnutrition, and Stage II Sacral Decubitus,

A review of Patient #9's discharge planning screen and evaluation indicated Patient #9 had been on home health services prior to her admission to the hospital.

A review of the physician's order dated 9/08/14 at 1:40 p.m. revealed an order to "Consult Hospice Company D for home hospice."

A review of the medical record revealed no documentation the patient requested Hospice Company D or a list of home hospice agencies available were presented to the patient.

A review of S9CaseManagement's note dated 9/08/14 at 2:10 p.m. revealed, in part, "Patient and sister verbalized understanding (of the discharge plans) and are ok with Hospice Associates."

In an interview on 3/11/15 at 1:30 p.m., S9CaseManagement indicated the list of home health and/or hospice agencies she provides to patients who have no preference was a free senior resource guide booklet which was published locally and available to the general public. The other document S9CaseManagement indicated she presented to patients for hospice services was a list of hospice agencies "affiliated" with the hospital that provides hospice services to patients admitted to the hospital. S9CaseManagement confirmed she was not aware of any policy/procedure, requirement, and/or lists of Medicare participating home health agencies and/or SNFs required to be presented to patients who required the services after discharge from the hospital.

In an interview on 3/12/15 at 9:01 a.m., S3QualityDirector confirmed she was not aware of the requirement that a list of Medicare participating home health agencies and/or SNFs was to be presented to patients who required the services after discharge from the hospital. S3QualityDirector further confirmed there was no policy and procedure in place for providing patients with lists of Medicare participating home health agencies and SNFs.

Based on record reviews and staff interviews, the hospital failed to ensure therapy services were provided only under the orders of a physician for 3 (#1, #6, #15) of 8 (#1, #2, #3, #5, #6, #7, #13, #15) patients sampled with therapy orders from a total of 31 sampled patients. Findings:

Review of the hospital policy titled "Scope Of Physical Therapy program", policy number S02-RH and revised 05/02/11, revealed that physical therapy services were provided on an inpatient basis upon receipt of a physician's order.

Patient #1
Review of the medical record for Patient #1 revealed an order dated 3/5/15 at 11:15 a.m. for speech therapy to evaluate and treat with PMV trail (Passy-Muir Speaking Valve).

Review of the Speech Pathology Tracheostomy Speaking Valve Evaluation revealed it had been completed on 3/5/15. Treatments were documented on 3/6/15 at 2:00-2:30 p.m. and 5:30- 5:40 p.m. No physician documentation could be located ordering the treatment.

Patient #6
Review of Patient #6's medical record revealed she was an 80 year old female admitted on 02/06/15 with diagnoses of Neurotic Diabetic Foot Wound and Osteomyelitis.

Review of Patient #6's "Physician's Orders" revealed a telephone order documented on 02/11/15 at 2:00 p.m. as a late entry for 02/10/15 at 8:00 a.m. for the physical therapist to evaluate and treat for Misonix ultrasound debridement. There was no documented evidence of the frequency that debridements were to be performed.

In an interview on 03/11/15 at 12:25 p.m., S4DirectorRehab indicated the physician doesn't specify the frequency of the Misonix debridement when he gives the order, and she just "writes the frequency on her evaluation." She confirmed the physician's order did not include a frequency for performing Misonix debridements.

Patient #15:
Review of the medical record revealed the patient was admitted to the hospital on 02/16/15. The patient had the diagnoses of sepsis, stage IV decubitus ulcer, and malnutrition.

Review of the Physician's Order revealed a telephone order dated 03/02/15 for physical therapy to evaluate and treat the patient.

Review of the Physical Therapy Initial Evaluation form revealed the patient was evaluated on 03/02/15 with a treatment plan for therapy five times a week for two weeks.

Review of the medical record revealed no documented evidence of a physician's order for physical therapy services five times a week for two weeks.

In an interview on 03/11/15 at 12:26 p.m., S4DirectorRehab indicated a physician's order should be written for the frequency and duration of treatment after the initial evaluation.

In an interview on 03/11/15 at 1:04 p.m., S4DirectorRehab indicated she could not locate the patient's 03/02/15 physical therapy physician orders.


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Based on record reviews and interview, the hospital failed to ensure rehab services were provided in accordance with the patient's plan of care as evidenced by having physical therapy (PT) and occupational therapy (OT) services provided 4 times a week rather than 5 times a week as ordered by the physician for 1 (#6) of 8 (#1, #2, #3, #5, #6, #7, #13, #15) patients sampled with therapy orders from a total of 31 sampled patients.
Findings:

Review of the hospital policy titled "Priority Of scheduling Of Services", policy number P03-RH and revised 03/05/09, revealed the purpose of the policy was to provide optimum patient care and avoid scheduling confusion or conflicts. Further review revealed in scheduling patients with rehab needs, all rehab disciplines should assess the patient's needs and through team rounds and/or staffing identify priority services if there is a conflict.

Review of Patient #6's medical record revealed she was an 80 year old female admitted on 02/06/15 with diagnoses of Neurotic Diabetic Foot Wound and Osteomyelitis.

Review of Patient #6's "Rehabilitation Physician Order Form" dated 02/09/15 revealed physical therapy and occupational therapy were ordered 5 times a week for 4 weeks.

Review of Patient #6's "Physical Therapy Daily treatment Log" and "Occupational Therapy Daily treatment Log" revealed neither service was provided on 02/17/15 and was documented as "holiday." There was no documented evidence that Patient #6 had PT and OT services 5 times a week the week of 02/16/15.

In an interview on 03/11/15 at 12:25 p.m., S4DirectorRehab indicated the hospital considers therapy non-essential personnel, and they are not required to work during hurricanes and such. When asked about not providing services on a holiday, she indicated the therapists don't usually work on a holiday. She further indicated if visits can be made up on a Saturday, they sometimes will do that if they have prn (as needed) staff available. She confirmed that Patient #6's therapy services were not provided in accordance with her established plan of care. When the rehab staff list was reviewed, S4Director Rehab confirmed there was sufficient staff to provide coverage on the holiday.