HospitalInspections.org

Based on observation, record review and interview, the hospital failed to meet the Condition of Participation for Nursing Services as evidenced by:

1. Failing to assess each patient at least every 24 hours and with a change in condition. (See findings in A-0395);

2. Failing to follow the standard of practice in accordance with LSBN by delegating the performance of CBG testing to unlicensed personnel-CNAs. (See findings in A-0395);

3. Failing to ensure the telemetry rhythm was continuously monitored with physician orders for telemetry alarm settings. (See findings in A-0395);

4. Failing to ensure each patient had a comprehensive skin assessment at the time of admit that included the measurement and staging of wounds and the peri-wound skin condition (See findings in A-0395);

Based on observation, record review and interview, the hospital failed to meet the requirements for the Condition of Participation of Infection Control as evidenced by failing to ensure the infection control officer implemented the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel as evidenced by:

1. Failing to maintain a sanitary environment related to cleaning and disinfecting environmental surfaces, equipment, and furniture as evidenced by breaches in infection control practices during cleaning of equipment after patient use and cleaning and disinfecting a patient room after a patient diagnosed with C-diff was discharged. (see findings in tag A0749).


2. Failing to mitigate risks associated with patient infections present upon admission by failing to ensure the appropriate use of personal protective equipment (PPE) and hand hygiene. (see findings in tag A0749)

Based on record review and interview, the hospital failed to ensure the use of restraints were in accordance with the order of a physician or other Licensed Independent Practitioner who is responsible for the care of the patient as evidenced by having restraint orders without documented evidence of the date and time the physician signed the verbal order to determine the physician performed an in-person assessment of a restrained patient at least once every 24 hours in accordance with hospital policy and having verbal restraints orders that were not signed by the physician for 2 (#2, #5) of 2 patient records reviewed with restraints from a total of 5 sampled patients.
Findings:

Review of the hospital policy titled "Restraints," revised March 2015 and presented as a current policy by S5QA/IC, revealed that restraint use will only be imposed upon receipt of appropriate physician orders or other Licensed Independent Practitioner when needed to ensure the immediate physical safety of the patient, a staff member, or others and will be discontinued at the earliest time possible. Further review revealed the attending physician or other Licensed Independent Practitioner who is responsible for the care of the patient will perform an in-person assessment of a restrained patient at least once every 24 hours, at which time the restraint will be either reordered or discontinued as indicated.

Patient #2
Review of Patient #2's medical record revealed a telephone physician order for restraints, mitts to both hands, on 01/12/16 at 8:30 p.m. due to Patient #2 being uncooperative, to prevent injury of self, and attempting to remove his condom catheter and peripheral IV to the left forearm. Daily telephone restraints orders were received from 01/13/16 through 02/01/16. Review of the "Restraint Order Sheet" for 01/12/16, 01/13/16, 01/14/16, 01/15/15, 01/16/16, 01/17/16, 01/19/16, 01/20/16, 01/21/16, 01/22/16, 01/24/16, 01/25/16, 01/26/16, 01/27/16, 01/28/16, 01/29/16, 01/30/16, 01/31/16, and 02/01/16 revealed all orders were received by telephone from S24MD with no documented evidence of the date and time that S24 signed the telephone orders. Further review revealed the telephone restraint order received on 01/18/16 and 01/23/16 had no signature, date, or time by S24MD.
In an interview on 02/02/16 at 1:05 p.m., S11RN confirmed the restraint orders weren't dated and timed when signed by S24MD. She also confirmed the orders on 01/18/16 and 01/23/16 had not been signed by S24MD.

Patient #5
Review of Patient #5's medical record revealed an initial telephone physician order for soft wrist, mitt restraints on 11/24/15 at 8:30 p.m. due to Patient #5 being uncooperative, combative, attempting to pull out his feeding tube, indwelling urinary catheter, and IV. The medical restraint orders were implemented to prevent Patient #5 from injuring himself by pulling out his feeding tube, indwelling urinary catheter, and IV. There were multiple restraint orders for soft wrist and mitt restraints due to Patient #5's history of dementia and repeated attempts to pull out his medical devices. Review of the "Restraint Order Sheet" for 11/28/15, 11/30/15, 12/02/15, 12/06/15, 12/07/15, 12/08/15, 12/09/15, 12/10/15, 12/11/15, 12/12/15, 12/14/15, 12/21/15, 12/22/15, 12/23/15, 12/24/15, 12/27/15, 12/28/15, 12/29/15, 12/30/15, 12/31/15, 01/02/16, 01/04/16, 01/05/16, 01/06/16, 01/07/16 revealed the orders were signed by S24MD, but were not timed and dated. Review of the "Restraint Order Sheet" for 12/25/15, 12/26/15, 01/01/16, taken as a verbal order from S24MD, revealed S24MD had not signed, dated, or timed the restraint order sheet. Review of the "Restraint Order Sheet" for 12/11/15 signed by S26Physician revealed the order was not dated or timed. Review of the "Restraint Order Sheet" for 12/02/15 by S26Physician revealed the order was timed.

In an interview on 02/03/16 at 10:50 a.m., S6ACCO confirmed the above-referenced Restraint Order Sheets were not signed, dated, and timed as indicated, and the orders should have been authenticated, dated, and timed by the ordering physician.


31048

Based on record review, observation and interview, the hospital failed to ensure the RN supervised and evaluated the nursing care for each patient as evidenced by:

1. The RN failed to assess each patient at least every 24 hours and with a change in condition for 3 (#1, #2, #5) of 5 (#1 - #5) patient records reviewed for RN assessments from a total of 5 sampled patients and 7 random patients. Patients #1 and #2 were current inpatients at the time of the survey.

2. The RN failed to follow the standard of practice in accordance with LSBN by delegating the performance of CBG testing to unlicensed personnel (CNAs) for 2 (#2, #R1) of 2 patient records reviewed for CBG testing from a total of 5 sampled patients and 7 random patients. Patients #2 and #R1 were current inpatients at the time of the survey.

3. The RN failed to ensure the telemetry rhythm was continuously monitored with physician orders for telemetry alarm settings as evidenced by having no physician order or a nurse's clarification order for telemetry alarm settings and the monitor tech also responsible for other duties that took him/her away from the telemetry monitor for 1 (R2) of 1 patient observed with physician orders for telemetry from a total of 5 sampled patients and 7 random patients. Patient #R2 was a current inpatient at the time of the survey.

4. The RN failed to ensure each patient had a comprehensive skin assessment at the time of admit that included the measurement and staging of wounds and the peri-wound skin condition for 1 (#4) of 5 patient records reviewed for wound assessments and care from a total sample of 5 patients. Patient #4 was a current inpatient at the time of the survey.

5. The RN failed to ensure physician orders were implemented for obtaining weights (#1, #2, #3, #5), sliding scale Insulin (#2, #R2), wound cultures (#5), catheter care (#5), turning patient every 2 hours (#5), and providing a indwelling urinary catheter strap as ordered on admission (#5) for 4 (#1, #2, #3,#5) of 5 sampled patient records and 2 (#R1,#R2) of 2 random patient records reviewed for implementation of physician orders from a total of 5 sampled patients and 7 random patients.
Findings:

1. The RN failed to assess each patient at least every 24 hours and with a change in condition:

Review of the hospital policy titled "Assessment and Reassessment," revised November 2015 and presented as a current policy by S3CCO, revealed that a RN will perform and document the initial admission assessment and thereafter a head-to-toe assessment in every 24 hour period.

Review of LSBN's "Declaratory Statement On The Role And Scope of Practice Of Registered Nurses Delegating Intravenous Therapy Intervention" revealed that RNs may delegate select nursing interventions provided the patient is assessed by an RN every 24 hours.

Patient #1
Review of Patient #1's medical record revealed he was admitted on 01/20/16 at 9:00 p.m. Review of his "Daily Nursing Assessment Special Precautions" revealed no documented evidence that a RN assessed Patient #1 on 01/26/16, 01/30/16, and 01/31/16.
In an interview on 02/02/16 at 1:05 p.m., S11RN confirmed, after reviewing the medical record, that the patient was not assessed by a RN on 01/26/16, 01/30/16, and 01/31/16.

Patient #2
Review of Patient #2's medical record revealed he was admitted on 01/12/16 at 8:00 p.m. Review of his "Daily Nursing Assessment Special Precautions" revealed no documented evidence that a RN assessed Patient #2 on 01/17/16, 01/20/16, 01/21/16, 01/26/16, and 01/30/16.

In an interview on 02/02/16 at 1:05 p.m., S11RN confirmed, after reviewing the medical record, that the patient was not assessed by a RN on 01/17/16, 01/20/16, 01/21/16, 01/26/16, and 01/30/16.
Patient #5
Review of Patient #5's medical record revealed he was admitted on 11/24/15. Review of his "Daily Nursing Assessment Special Precautions" revealed no documented evidence that a RN assessed Patient #5 on 11/30/15, 12/24/15, 01/02/16, 01/17/16. Further review of the medical record for Patient #5 revealed documentation in the medical record by S28LPN on 01/01/16 at 7:00 p.m. Patient #5 had a "large dark blue, left medial thigh (upper) bruise noted. Also left anterior medial large firm area noted. No redness, no warmth, no tenderness noted. Charge nurse made aware." Further review of the medical record revealed there was no evidence the charge nurse, S14RN, assessed the patient's thigh and bruised areas and reported it to the physician.
In an interview on 02/02/15 at 4:00 p.m., S6ACCO reviewed the medical record and confirmed there was no documented evidence that a RN performed an assessment on Patient #5 on the above-referenced dates, and S14RN did not perform an assessment of Patient #5 after receiving the report from S28LPN regarding the patient's bruising and large firm area noted.

2. The RN failed to follow the standard of practice in accordance with LSBN regarding the delegation of CBG testing with physician orders for sliding scale insulin:

Review of a letter written on 02/20/95 by the Executive Director of LSBN revealed that only routine one-touch glucose monitoring may be performed by unlicensed personnel, and unlicensed personnel may not perform one-touch monitoring when insulin to scale is ordered.

Patient #2
Review of Patient #2's "Admission Orders" received on 01/12/16 at 4:00 p.m. revealed an order for CBGs AC/HS to Insulin Sliding Scale Protocol.

Observation on 02/01/16 at 5:03 p.m. revealed S9CNA performed a CBG test on Patient #2.

Patient #R1
Review of Patient #R1's "Admission Orders" received on 01/27/16 at 4:50 p.m. revealed an order for CBGs AC/HS to Insulin Sliding Scale Protocol.

Observation on 02/01/16 at 4:50 p.m. revealed S8CNA performed a CBG test on Patient #R1.

In an interview on 02/01/16 at 5:09 p.m., S14RN confirmed both Patient #2 and Patient #R1 had physician orders for sliding scale insulin.

In an interview on 02/02/16 at 1:55 p.m., S12RN indicated when the CNA does a CBG test, the nurse administers the required Insulin without rechecking the blood glucose level. She further indicated she was aware the RN couldn't delegate CBG testing for patients on sliding scale insulin to CNAs.

In an interview on 02/02/16 at 2:30 p.m. with S2CCO and S5QA/IC present, S5QA/IC indicated she wasn't aware that CNAs couldn't perform CBG testing on patients with orders for sliding scale insulin.

3. The RN failed to ensure a physician's order was obtained for the alarm settings of the telemetry monitor and failed to ensure the telemetry rhythm was continuously monitored:

Review of Patient #R2's admit physician orders received by telephone order on 02/01/16 at 5:30 p.m. revealed an order for telemetry for 48 hours. There was no documented evidence of an order with the alarm range at which the telemetry monitor was to be set.

Observation on 02/02/16 at 2:25 p.m. revealed the telemetry monitor was positioned on the counter at the nursing station with the a red light flashing. Further observation revealed no staff member was observing the cardiac rhythm on the telemetry monitor.

In an interview on 02/02/16 at 2:25 p.m., S16WC indicated she was not the monitor tech and further indicated S11RN was the monitor tech. At the time S16WC indicated S11 was the monitor tech, S11RN entered the nursing station and indicated the monitor tech who worked earlier in the shift left, and S16WC just came on duty. The S16WC was asked what the blinking red light meant, she indicated it meant the patient was moving (the heart rate was noted to be 143 with no audible sound present). When asked what the alarms were set at, S16WC indicated she didn't know, and she didn't know how to check the alarms on the monitor.

Observation in the nursing station on 02/02/16 at 3:50 p.m. revealed no cardiac rhythm was seen on the telemetry monitor screen, and S29Educator was kneeling in front of the monitor screen and was speaking with someone on the phone about the monitor.

In an interview on 02/02/16 at 3:50 p.m., S29Educator indicated when she tried to set the audio on the monitor, after turning the monitor off and rebooting it, the screen didn't display Patient #R2's rhythm.

Observation on 02/02/16 at 3:52 p.m. revealed Patient #R2 was in her bed with no observable portable means of monitoring her cardiac rhythm as ordered by the physician. Continuous observation from 3:50 p.m. to 4:00 p.m. revealed Patient #R2's cardiac rhythm was not monitored.

In an interview on 02/02/16 at 4:42 p.m., S6ACCO indicated the hospital has 4 bedside monitors that can be used to monitor cardiac rhythm in a patient's room, and a staff member would have to be assigned at the bedside to monitor the rhythm. She further indicated she nor S5QA/IC were notified that the monitor was out of service for 10 minutes. She further indicated the nurses never get orders for parameters from the physician, and the monitor is set to alarm for a heart rate less than 60 beats per minute or greater than 100 beats per minute. S6ACCO indicated an irregular rhythm has a spoken warning, and the light remains blinking until the verbal warning results in a reset. S5QA/IC, who entered the interview once it had begun, confirmed no verbal warning was given when the light was observed to be flashing red when the heart rate was elevated.

Review of S16WC's personnel file revealed her return demonstration on telemetry competency was performed on 01/29/15. Further review revealed she was able to "return demonstrate proper set-up of telemetry monitor... entering patient data and start/stop monitoring." There was no documented evidence that she had education on and evaluation of competency for setting individualized patient alarms on the telemetry monitor.

4. The RN failed to ensure each patient had a comprehensive skin assessment at the time of admit that included the measurement and staging of wounds and the peri-wound skin condition:

Review of the hospital policy titled "Initial Assessment/Reassessment of Wounds", presented as a current policy by S5QA/IC, revealed that wounds were to be assessed at the time of admission by the RN and assessed by the wound care nurse upon consult. There was no documented evidence that the policy addressed the time interval that the consult had to be performed after it was ordered by the physician.

Review of Patient #4's medical record revealed his nursing admit assessment was documented on 01/16/16 at 3:45 p.m. Further review revealed the admit nurse documented under "Wound Description" (columns for type, stage, location, color, odor, drainage, measurements, surrounding tissue) in the column titled "Location" "sacrum, (R) (right) chest x 2 (times 2), nose, lips." There was no documented evidence of an assessment of any the wounds that described the type, stage, color, odor, drainage, measurements, and surrounding tissue.

Review of Patient #4's nursing assessment of 01/17/16 revealed the wound description section on the night shift (6:00 p.m. to 6:00 a.m.) revealed scabbed sores to lips, nose, and mouth, sacral dressing intact, and right flank dressing intact. There was no documented evidence of wound descriptions that described the type, stage, color, odor, drainage, measurements, and surrounding tissue.

Review of S20RN's (wound care nurse at Hospital A) assessment performed on 01/18/16, 2 days after admit of 01/16/16, revealed pressure ulcers to the lips and nose caused by the endotracheal tube and nasogastric tube while Patient #4 was in intensive care at the acute care hospital, surgical incision wounds to the right upper back status post Pleurodesis (times 2) and Thoracotomy, and a pressure ulcer to the sacrum with the following documented assessment: size 9 cm (centimeters) by 6 cm by unknown depth, 54 cm area unknown volume, non-granulating tissue 10% (per cent), slough loosely adherent 90%, unstageable, periwound erythema and maceration, wound edge indistinct, no odor, undermining unknown, tunneling unknown.

In an interview on 02/03/16 at 1:30 p.m., S5QA/IC indicated the wound care nurse has 72 hours to do a wound consult when ordered. She further indicated the admit nurse should have assessed Patient #4's wound at admit with staging and measurements included. She had no explanation to offer regarding the hospital policy for physician-ordered wound consults not addressing the time interval at which the consults had to be performed.

5. The RN failed to ensure physician orders were implemented for obtaining weights, sliding scale insulin, wound cultures, telemetry, catheter care, turning patient every 2 hours, and providing a indwelling urinary catheter strap as ordered on admission.

Weights:
Review of the physician admit orders for Patients #1, #2, #3, #5 revealed orders to weigh daily.

Review of Patient #1's graphic sheet revealed documentation of the scale not working on 01/28/16, 01/29/16, and 01/31/16 and patient refused hoyer lift on 02/01/16. There was no documented evidence of a documented weight on 01/21/16, 01/22/16, 01/23/16, 01/24/16, 01/27/16, and 01/30/16. There was no documented evidence the nurse was notified that the scale was not working and no documentation that the physician was notified that weights were not assessed daily.

Review of Patient #2's graphic sheet revealed no documented evidence of an assessment of his weight on 01/16/16, 01/20/16, 01/21/16, 01/22/16, and 01/31/16.

Review of Patient #3's graphic sheet revealed no documented evidence that she was weighed as ordered on 01/19/16, 01/20/16, 01/21/16, and 01/22/16.

In an interview on 02/02/16 at 1:05 p.m., S11RN indicated daily weights that are ordered are done at 5:00 a.m. by the night shift and documented on graphic sheet. She further indicated it was never reported to her that the scale was not working. A11RN confirmed Patients #1, #2, and #3 were not weighed daily as ordered by the physician.

Patient #5
Review of Patient #5's medical record revealed on 11/24/15 the physician ordered weights to be done on admission and every week. Further review of the medical record revealed weights were not obtained as ordered on 11/30/15, 12/01/15, 12/08/15, and 12/15/15.

In an interview on 02/02/16 at 1:30 p.m., S6ACCO reviewed the medical record and confirmed the above-referenced weekly weights were no documented in the medical record, and the weights should have been obtained and documented.


Sliding Scale Insulin:
Patient #2
Review of Patient #2's physician orders revealed an order to assess CBG AC/HS to Insulin Sliding Scale as follows: 0-60 D50W 1 amp, repeat CBG 10 minutes then call MD. Review of Patient #2's nursing note by S11RN of 01/23/16 at 4:30 p.m. revealed his CBG was 33 and recheck revealed 38. Further review S11RN administered 1 amp (ampule) of D50 IVP (Dextrose 50 intravenously). There was no documented evidence S11RN reassessed Patient #2's CBG in 10 minutes and notified the physician as per orders.

In an interview on 02/02/16 at 1:05 p.m., S11RN confirmed she didn't recheck Patient #2's blood sugar in 10 minutes as ordered, and she didn't notify the physician as ordered.

Patient #R2
Review of Patient R2's medical record revealed an order to assess CBG AC/HS to Insulin Sliding Scale as follows: 0-60 D50W 1 amp, repeat CBG 10 minutes then call MD. Review of the nurse's note on 02/01/16 at 5:20 a.m. revealed her CBG was 25, and D50 1 amp was administered IV. There was no documented evidence her CBG was reassessed in 10 minutes and the physician notified as ordered.

In an interview on 02/02/16 at 4:03 p.m., S15LPN indicated Patient #R2's CBG was reassessed at 6:30 a.m. and was 119. He confirmed the physician's order was not implemented, because her CBG wasn't reassessed in 10 minutes, and there was no evidence that the physician was notified of the low blood sugar.

Wound Cultures:

Patient #5

Review of Patient #5's medical record revealed on 11/24/15 the physician ordered a culture of all wound sites within 48 hours of admit (patient admitted on 11/24/15). Further review of the medical record revealed no evidence wound cultures were obtained within 48 hours of admission, and the first wound cultures were obtained on 01/08/16.
In an interview on 02/02/16 at 4:07 p.m., S6ACCO reviewed the medical record and confirmed the cultures of the wound sites were not completed within 48 hours of admission as ordered by the physician and the cultures should have been obtained as ordered.

Catheter Care:
Patient #5
Review of a policy and procedure entitled Prevention of Catheter Associated Urinary Tract Infections, presented by S5QA/IC as current, revealed in part: " ... 5. Routine personal hygiene should be provided to the urinary meatus with soap and water only at each shift. More frequent cleaning is necessary if the patient has diarrhea. "

Review of Patient #5's medical record revealed on 11/24/15 the physician ordered indwelling urinary catheter care to be performed daily and as needed. Further review revealed there was no evidence in the medical record catheter care had been performed on 12/01/15 at 6:00 a.m.
In an interview on 02/02/16 at 3:25 p.m., S6ACCO reviewed the medical record and confirmed there was no evidence in the medical record the patient had received catheter care on 12/01/15 at 6:00 a.m. and catheter care should have been performed.
Turn Patient Every 2 Hours:
Patient #5
Review of Patient #5's medical record revealed on 11/24/15 the physician ordered the patient to be turned every two hours. Further review revealed there was no evidence the patient had been turned on 12/03/15 at 1:00 a.m., 3:00 a.m., 5:00 a.m.; on 12/04/15 at 7:00 p.m., 9:00 p.m., 11:00 p.m., 1:00 a.m., 3:00 a.m., and 5:00 a.m.
In an interview on 02/02/16 at 2:30 p.m., S6ACCO reviewed the medical record and confirmed there was no evidence the patient had been turned on the above-referenced dates and times, and the patient should have been turned every two hours.
Urinary Catheter Strap:
Patient #5
Review of Patient #5's medical record revealed on 11/24/15 the physician ordered a leg strap for the indwelling urinary catheter to be applied on admission. Further review of the medical record revealed there was no evidence in the medical record the leg strap had been placed on the patient from the date of admission on 11/24/15 through 12/01/15.

In an interview on 02/02/16 at 2:55 p.m., S6ACCO reviewed the medical record and confirmed there was no evidence in the medical record the patient had received a catheter strap as ordered by the physician on admission.


31048

Based on record review and interview, the hospital failed to ensure the RN developed and kept current a nursing care plan for each patient as evidenced by failing to have an accurate nursing care plan that included a plan for all conditions for which the patient was being treated for 2 (#1, #2) of 5 patient records reviewed for nursing care plans from a total sample of 5 patient records.
Findings:

Patient #1
Review of Patient #1's medical record revealed he was admitted with diagnoses of UTI and Sacral Wound. Review of his "Initial Nursing Assessment" performed on 01/20/16 at 10:00 p.m. by S14RN revealed he had a history of GERD, he was incontinent of urine and had a 16 French Condet catheter, and he was incontinent of bowel and was on a bowel program with rectal stimulation every Monday, Wednesday, and Friday.

Review of Patient #1's physician admit orders revealed a nutritional assessment was ordered.

Review of Patient #1's "Vital Signs / Intake & (and) Output Records" from admit on 01/20/16 to 02/01/16 (13 days) revealed 10 days with output greater than intake.

Review of Patient #1's H&P performed by S24MD on 01/21/16 revealed a diagnosis of Moderate Malnutrition.

Review of Patient #1's "Interdisciplinary Plan of Care revealed no documented evidence that S14RN developed a nursing care plan at admit for altered nutrition, altered bowel elimination, altered urine elimination, and GERD. Further review revealed no documented evidence that the nursing care plan was revised to include a plan for fluid volume deficit.

In an interview on 02/02/16 at 1:05 p.m., S11RN confirmed the nursing care plan did not include a plan for GERD, fluid volume deficit, altered nutrition, altered bowel elimination, and altered urine elimination. She indicated his medical condition and assessment warranted these care plans to be developed and implemented.

Patient #2
Review of Patient #2's medical record revealed he was admitted with diagnoses of Severe Malnutrition, Metabolic Encephalopathy, Diabetes Mellitus, Hypotension, Hypoglycemia, history of Hypertension, and Left BKA.
Review of his medical record revealed he was ordered to have Accuchecks done AC/HS with Insulin administration per sliding scale.
Review of Patient #2's nursing care plan revealed no documented evidence he had a care plan developed related to Diabetes, Hypotension, and Hypertension.

In an interview on 02/02/16 at 1:05 p.m., S11RN confirmed Patient #2 did not have a nursing care plan developed for Diabetes, Hypotension, and Hypertension.



31048

Based on record review and interview, the hospital failed to ensure nursing care was provided by qualified nursing personnel as evidenced by:

1) Failing to evaluate the competency of performing CBG testing and CPR for 2 (S8, S9) of 2 CNA's personnel files reviewed for competency from a total of 8 CNAs employed at the main campus.

2) Failing to evaluate the competency of 1 (S15LPN) of 1 LPN's personnel file reviewed for competency from a total of 20 LPNs employed at the main campus.
Findings:

1) Failing to evaluate the competency of performing CBG testing and CPR:

Review of the hospital's "Position Description / Performance Evaluation" for the job title of CNA, presented as the current job description for CNA by S5QA/IC, revealed that the CNA will be able to demonstrate an ability to assist physicians with procedures and perform services requiring technical and manual skills under the direction of the RN. Further review revealed regulatory requirements included current CPR certification. There was no documented evidence that performing CBG testing was listed as an area requiring competency for the CNA.

S8CNA Review of S8CNA's personnel file revealed she was hired on 10/01/13. Review of her competency evaluation signed by S6ACCO on 02/01/16 (day of survey entrance) revealed the sections of Personal Care, Integumentary, Documentation/Reporting, Infection Control, Communication/Rights, Environment, and safety and rehabilitation had no documented evidence of the date the skills were observed by S6ACCO. Review of the "Precision Xceed Pro Blood Glucose Monitor Operator Training Checklist," revealed no documented evidence whether she was trained as an "operator" or a "trainer." Review of the "Learning Assessment/Test" revealed no documented evidence that the test had been checked for correct answers, and the score (passing score 85 per cent or above) was not documented.

S9CNA Review of Patient #9's personnel file revealed she was hired on 04/16/14. Further review revealed no documented evidence that she was currently certified in CPR as required by her job description. Review of the "Precision Xceed Pro Blood Glucose and B-Ketone Monitor Learning Assessment" revealed no documented evidence that the test had been checked for correct answers. Review of her "Learning Assessment/Test" (for the CBG testing) revealed no documented evidence that the test had been checked for correct answers, and the score (passing score 85 per cent or above) was not documented.
In an interview on 02/02/16 at 2:30 p.m., S5QA/IC indicated the CBG assessments performed for both S8CNA and S9CNA were incomplete, since the test was not scored. She further indicated it was not an appropriate competency evaluation. S5QA/IC confirmed S9CNA's file did not have evidence that she was currently certified in CPR.

2) Failing to evaluate the competency of the LPN:

Review of the personnel file for S15LPN revealed there were no current documented skills and competencies assessed and evaluated by a RN for S15LPN.

In an interview on 02/03/15 at 6:00 p.m., S3CCO reviewed S15LPN's personnel file and confirmed there was no documentation that a current skills and competencies evaluation by a RN for S15LPN had been performed, and there should have been one for S15LPN.


31048

Based on record review and interview, the hospital failed to ensure non-employee licensed nurses working in the hospital were adequately supervised by an appropriately qualified hospital-employed RN as evidenced by having S12RN, a contracted RN, working as the charge nurse with no other hospital-employed RN present during the night shifts on 01/08/16, 01/30/16, and 01/31/16.
Findings:

Review of the "Assignment Sheet" for 01/08/16, 01/30/16, and 01/31/16, presented by S5QA/IC, revealed S12RN worked the night shift as the charge nurse. Further review revealed no other hospital-employed RN was present during these shifts.

In an interview on 02/02/16 at 1:55 p.m., S12RN indicated she is an agency nurse contracted through Company C and has been working at the hospital since about May 2015.
She confirmed that she worked as the Charge Nurse on the night shift of 01/08/16, 01/30/16, and 01/31/16 and was the only RN present in the hospital.

In an interview on 02/02/16 at 4:56 p.m., S6ACCO indicated she needs RNs for nights as Charge Nurse and has had no applicants. She further indicated she pulls from Hospital A when she can. S6ACCO indicated she wasn't aware that a contracted agency RN had to be supervised by a hospital-employed RN.

Based on record review and interview, the hospital failed to ensure medical records were promptly completed as evidenced by having a delinquency rate of 59% with records dated back to 03/25/14.Findings:

Review of the list of delinquent records presented by S1ADM revealed 14 physicians had delinquent medical records. Further review revealed many records were discharges from 2014 and 2015, with the longest date of discharge was 03/25/14.

In an interview on 02/03/16 at 2:40 p.m., S1ADM indicated the delinquency rate at the main campus was 56% and at Hospital A (off-site) was 76%, for a total delinquency rate stated of 59% (computation equals 66%). He further indicated S26Physician is the only physician who was sent a letter regarding a time limit for completing records or suspension will be enforced. He confirmed there is no specific procedure for handling delinquent records.

In an interview on 02/03/16 at 2:50 p.m., S25Physician indicated he was the Chief Medical Officer. He further indicated he wasn't really aware of the delinquency rate, but he knew the hospital was working on it. He further indicated he wasn't aware of the delinquent records of physicians at Hospital A.

Based on record review and interview, the hospital failed to ensure the staff documented complications during the patient's stay for 1 (#5) of 5 records reviewed. Findings:

Review of the incident reports for Patient #5 revealed he slipped out of his bed on 12/16/15. Review of the patient's medical record revealed the incident was not documented in Patient #5's medical record.

In an interview on 02/02/16 at 3:35 p.m., S6ACCO confirmed there was no documentation in the medical record of the incident that occurred on 12/16/15, and the medical record should have had the incident documented in the patient's medical record.

Based on observation, record review and interview, the hospital failed to ensure the infection control officer implemented the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel as evidenced by:

1. Failing to maintain a sanitary environment related to cleaning and disinfecting environmental surfaces, equipment, and furniture as evidenced by breaches in infection control practices during cleaning of equipment after patient use and cleaning and disinfecting a patient room after a patient diagnosed with C-diff was discharged.

2. Failing to mitigate risks associated with patient infections present upon admission by failing to ensure the appropriate use of personal protective equipment (PPE) and hand hygiene.

3. Failing to implement hospital staff-related measures related to staff immunization status for designated infectious diseases, such as TB for 4 (S11, S14, S15, S27) of 4 personnel records reviewed for TB surveillance from a total of 6 personnel records reviewed.


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4. Failing to ensure contact isolation precautions were documented in the medical record for 1 (#5) of 3 (#1, #3, #5) patient records reviewed for isolation precautions from a total of 5 sampled patients.
Findings:
1. Failing to maintain a sanitary environment related to cleaning and disinfecting environmental surfaces, equipment, and furniture as evidenced by breaches in infection control practices during cleaning of equipment after patient use and cleaning and disinfecting a patient room after a patient diagnosed with C-diff was discharged.

Observation on 02/01/16 at 2:54 p.m. revealed S6ACCO used her contaminated gloved hands to clean the overbed table with a " Microkill+ Disinfecting, Deodorizing, Cleaning Wipes with Alcohol " (Wipe).

Observation on 02/01/16 at 4:50 p.m. revealed S8CNA performed a CBG check on Patient #R1. After washing her hands she donned gloves, picked up the contaminated glucometer, and placed it on the cart outside the room. With the same gloved hands used to touch the bedside table in the patient's room and the contaminated glucometer, S8CNA used a Wipe to clean the glucometer and did not clean the cart surface where the contaminated glucometer had been placed.

Observation on 02/01/16 at 5:03 p.m. revealed S9CNA perform a CBG on Patient #2. Further observation revealed S9CNA rolled the patient's bedside table close to the door and cleaned the glucometer with contaminated gloved hands (gloves used to perform the CBG).

Review of the hospital policy titled "Guidelines for Transmission Based Isolation Precautions", presented as a current policy by S5QA/IC, revealed that when common use of equipment for multiple patients on Contact Precautions is unavoidable, the equipment should be cleaned and disinfected before use on another patient.

In an interview on 02/02/16 at 2:30 p.m. with S5QA/IC, S5QA/IC indicated she was the Infection Control nurse. She confirmed the above observations were breaches in infection control practices.

Observation on 02/03/16 at 8:10 a.m. revealed S19RT performed hand hygiene and donned gloves to perform a nebulizer treatment for Patient #4. She took the face mask out of the plastic bag hanging on the wall behind the patient's bed and administered the Duoneb treatment for about 10 minutes. S19RT then removed her gloves after the treatment and having cleaned Patient #4's mouth. Without performing hand hygiene after removing her gloves, S19RT auscultated Patient #4's lungs and then washed her hands. No observation was made of S19RT cleaning the nebulizer equipment after use before placing it in the plastic bag hanging on the wall behind the patient's bed.

Review of the hospital policy titled "Hand Held Nebulizer", presented as a current policy by S5QA/IC, revealed that after use, the device is to be disassembled and the mouthpiece and nebulizer cup rinsed with water and dried. The entire unit is then to be placed in a bag maintained in the patient's room.

Review of the CDC's (Centers For Disease Control and Prevention) "Guideline for Hand Hygiene in Health-Care Settings", dated 10/25/02, revealed handwashing and hand antisepsis was indicated as follows:

1) when hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids;

2) if hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands;

3) decontaminate hands before having direct contact with patients;

4) decontaminate hands before donning sterile gloves when inserting a central intravascular catheter;

5) decontaminate hands after contact with a patient's intact skin;

6) decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care;

7) decontaminate gloves after removing gloves.

In an interview on 02/03/16 at 8:28 a.m., S19RT indicated doesn't clean the nebulizer between use. She confirmed she didn't wash her hands after she removed her gloves before auscultating the patient's lungs.

Observation on 02/03/16 at 9:20 a.m. through 12:03 p.m. revealed the following observations of S21HK, contracted with Housekeeping Company A, cleaning a patient's room at Hospital A after the patient, diagnosed with C-diff, was discharged:

9:36 a.m. - changed gloves without hand hygiene before redonning gloves to clean the remainder of the monitor wires; changed gloves without hand hygiene before redonning gloves to wipe the other monitor wires; changed gloves without hand hygiene before redonning gloves to clean the bottom of the IV pole and stand; changed gloves without hand hygiene before redonning gloves to clean the remainder of the IV pole rolling stand base and wheels; changed gloves without hand hygiene before redonning gloves to reclean the IV pole rolling stand base and wheels; changed gloves without hand hygiene before redonning gloves to clean the bedside table; changed gloves without hand hygiene before redonning gloves to clean the remainder of the bedside table;

9:58 a.m. - with gloved hands wiped the telephone with Wipes and immediately dried the telephone with a dry cloth without allowing the Wipe solution to remain wet for 3 minutes as required by the manufacturer's guidelines to kill C-diff spores;

10:00 a.m. - with gloved hands placed the contaminated dry cloths in the red-bagged container on the housekeeping cart located outside the door of the patient room; changed gloves without hand hygiene before redonning gloves and got clean dry cloths from the housekeeping cart and brought them into the room; with the same gloved hands, placed the contaminated sharps container in the bin on the housekeeping cart with no visible sign indicating "biohazard";

10:04 a.m. - changed gloves without hand hygiene before redonning gloves, to clean the cabinets above the sink;

10:07 a.m. - removed gowns, gloves, and mask and walked into hall to get a new container of bleach spray; sanitized hands after getting the spray and donned a new gown, gloves, and mask; continued to clean the cabinets above the sink; observation revealed S21HK did not clean with a bleach Wipe the back side of the wall of the right upper cabinet over the sink; with contaminated gloves she touched the housekeeping cart to get a new container of Wipes; placed the Wipes on the cleaned overbed table and changed her gloves without hand hygiene; wiped the inside of the cabinet door with a dry cloth but no observation was made of S21HK cleaning the inside of the cabinet door with a Wipe first;

10:23 a.m. - no observation was made of S21HK cleaning the lower back wall of the left lower cabinet below the counter with the sink; S21HK used Wipes (red-capped Wipes not indicated for disinfecting for C-diff) to clean the outside doors of the upper cabinet after having used the blue Wipes (used for C-diff) previously;

11:00 a.m. - cleaned the lower glass of the windows with Spic and Span and a dry cloth; when asked if she has cleaned it with a bleach Wipe, she answered "No"; wiped the ledge of the window with the dry cloth; placed the cloth in a bin on the housekeeping cart with contaminated gloved hands; sprayed the recliner with bleach with no observation of the recliner foot rest or the cushion being raised to clean the inside area of the recliner; sprayed the recliner wheels with bleach and immediately wiped with a cloth (did not remain wet for 3 minutes as required to kill C-diff);

11:10 a.m. - Removed gown, gloves, and mask and used hand sanitizer and went to the bathroom in the hall; after gowning, masking, and gloving, S21HK placed the bleach container (touched with contaminated gloves) used in the room on the housekeeping cart outside the room; sprayed the second chair in the room with bleach and immediately wiped the surface without leaving the solution on the chair for a 3 minute contact time;

11:32 a.m. - S21HK indicated they only have one housekeeping cart, and the other housekeeper took the cart down the hall (cart had been contaminated by S21HK while cleaning the discharge room of a patient with C-diff); no observation was made of S21HK cleaning the top panes of the windows and the shades covering the windows;

11:42 a.m. - sprayed the underside of the mattress (not all areas were visibly wet) with bleach and immediately wiped it with a dry cloth (not allowed to remain on surface for 3 minutes); observation revealed S21HK made a hole in her gown used for isolation to hang the bottle of bleach spray; during the observation S22Supervisor, Housekeeping Supervisor with Housekeeping Company A indicated S21HK should have all the needed supplies in the room and shouldn't have to leave the room to obtain supplies or to touch the housekeeping cart for supplies;

11:50 a.m. - S21HK sprayed the bed surface that holds the mattress with bleach and immediately wiped with a cloth (not allowed to remain on surface for 3 minutes);

Review of the label on Spic and Span revealed no documented evidence that it contained bleach and could be used to kill C-diff spores.

Review of the label on "Micro-Kill Bleach Germicidal Bleach Wipes" revealed a 3 minute contact time is required to kill C-diff spores.

In an interview on 02/03/16 at 11:56 a.m., S22Supervisor, Housekeeping Supervisor with Housekeeping Company A indicated they do not clean the window shades in the patient rooms.

In an interview on 02/03/16 at 12:00 p.m., S5QA/IC indicated she had not performed a competency evaluation of the contracted housekeepers related to infection control practices.


2. Failing to mitigate risks associated with patient infections present upon admission by failing to ensure the appropriate use of personal protective equipment (PPE) and hand hygiene.

Review of the hospital policy titled "Guidelines for Transmission Based Isolation Precautions", presented as a current policy by S5QA/IC, revealed that gowns and gloves should be worn when caring for patients on Contact Precautions. Further review revealed gloves then gowns should be removed, and hand hygiene performed before leaving the patient care environment.

Observation on 02/01/16 at 2:54 p.m. revealed S6ACCO and S13DME Patient #R7's room who was on Contact Precautions. Continuous observation revealed both S6ACCO and S13DME had their protective gowns untied and flapping as they moved from one task to another, thus exposing their personal clothing while they repositioned Patient #R7. Further observation revealed S13DME removed his gown by pulling it over his head rather than tearing it at the neck. He also removed his gloves and exited the room to use hand sanitizer, rather than washing his hands in the sink located at the door of the room.

In an interview on 02/02/16 at 2:30 p.m. with S5QA/IC and S3CCO present, S5QA/IC indicated she was the Infection Control nurse. She confirmed the above observations were breaches in infection control practices.

Observation on 02/01/16 at 4:50 p.m. revealed S8CNA performed a CBG check on Patient #R1. After gloving appropriately, S8CNA used her gloved hands to touch the door knob to open the door to get a supply that she forgot. With the contaminated gloved hands, she performed the patient's CBG.

Observation on 02/02/16 at 10:10 a.m. revealed S7PT performing wound care to the right great toe amputation site of Patient #3. S7PT gathered supplies in the hall on the cart, donned a gown, sanitized hands, and donned gloves. S7PT held folds of skin at Patient #3's right groin to observe excoriated skin to the right groin. With same contaminated gloves, S7PT rubbed the skin on Patient #3's back and said Patient #3 had a skin tear earlier but it had healed. While wearing the same contaminated gloves used to assess the right groin and back, S7PT removed the patient ' s dressing from her right foot, cleaned the site with normal saline, and applied Santyl ointment with a sterile Q-tip. While wearing the same contaminated gloves, S7PT pressed on the incision site on the right foot with dark red blood oozing from the site. She then dressed the wound while wearing the same contaminated gloves. S7PT then touched the patient ' s back and lifted her head to place it on a pillow with while wearing the same contaminated gloves. At 10:39 a.m. S12RN entered Patient #3's room with PPE to assist with repositioning the patient. S7PT applied cream to Patient #3's buttocks with the same contaminated gloves used to perform wound care, then removed gloves, washed her hands, and redonned gloves to assist with repositioning the patient.

In an interview on 02/02/16 at 10:50 a.m., S7PT confirmed she didn ' t change gloves during the entire procedures documented above. She asked " how would I do that? ... I guess I need to be more focused. " She confirmed her actions were breaches in infection control.

In an interview on 02/02/16 at 2:30 p.m. with S5QA/IC and S3CCO present, S5QA/IC indicated she was the Infection Control nurse. She further indicated she had not observed S7PT performing wound care to assess her competency with maintaining infection control practices.

Observation on 02/03/16 at 8:30 a.m. revealed S20RN, wound care RN at Hospital A, performing PICC site care on Patient #R6. She washed her hands, gloved, used Clorahexidine Wipes to clean entire right arm and wiped PICC tubing and ports. She then removed her gloves and redonned gloves without performing hand hygiene. With gloved hands S20RN removed the PICC dressing, removed her gloves, and applied sterile gloves without performing hand hygiene. After cleaning the catheter insertion site with the prep swab, S20RN cleaned the area surrounding the insertion site with the same prep swab, and rewiped the insertion site with the same swab after it had touched the outer area of the arm. After the procedure S20RN changed gloves to discard trash and did not perform hand hygiene after removing gloved and before redonning gloves.

Review of the hospital policy titled "PICC Line Management", presented as a current policy by S5QA/IC, revealed the procedure included the following: clean off skin debris at the catheter insertion site with a Clorahexidine swab, beginning at the catheter exit site and moving outward in a circular motion 2 to 3 inches; repeat the procedure with additional alcohol swabs.

In an interview on 02/03/16 at 8:50 a.m.. S20RN confirmed the above breaches in infection control.

3. Failing to implement hospital staff-related measures related to staff immunization status for designated infectious diseases, such as TB:
Review of the personnel files for S11RN, S14RN, S15LPN, S27RN revealed there were no TB tests and/or surveillance completed for 2015.

Review of the Louisiana "Public Health - Sanitary Code" revealed any employee at a medical facility who has a negative purified protein derivative (PPD) skin test for tuberculosis shall be rescreened annually by either a PPD test or a completed questionnaire asking of the patient pertinent questions related to active tuberculosis symptoms.

In an interview on 02/03/16 at 5:10 p.m., S5QA/IC indicated the hospital was behind in getting annual TB tests and/or surveillance and confirmed the above-referenced employees did not have TB tests and/or surveillance performed in 2015, and agreed they should have been completed.


4. Failing to ensure contact isolation precautions were documented in the medical record:
Review of the medical record for Patient #5 revealed the final report for a wound culture and sensitivity performed on the patient's Stage III decubitus confirmed Patient #5 had a diagnosis of MRSA. Further review of the medical record revealed there was no documentation the patient had been placed on isolation contact precautions.
In an interview on 02/02/16 at 4:07 p.m., S6ACCO reviewed the medical record and confirmed there was no documentation that the patient was placed on isolation contact precautions, and agreed it should have been documented in the medical record.

Based on record review and interview, the hospital failed to ensure timely implementation of a discharge plan for 1(#5) of 5 (#1, #5, R3, R4, R5) records reviewed for discharge planning by failing to validate with the patient's physician all medications that were to be continued when the patient was discharged home. Findings:

Patient #5
Review of the medical record for patient #5 revealed he was an 82-year-old male admitted to the hospital on 11/24/15 from a rehabilitation hospital with diagnoses of Moderate Malnutrition, Dementia, History of Atrial Fibrillation, Hypertension, Dysphagia, Generalized Weakness, Urinary Tract Infection, Benign Prostatic Hypertrophy (BPH), Diabetes (Insulin Requiring), Decubiti, and status post a left craniotomy with ventriculoperitoneal shunt placed on 09/22/15 due to a fall sustained resulting in an intracranial hemorrhage. The patient was admitted to the hospital with a feeding tube in place for the diagnosis of dysphagia. The patient was also admitted to the hospital with an indwelling urinary catheter. The patient was identified as positive for MRSA (Methicillin-Resistant Staphylococcus Aureus on 01/12/16. The patient was discharged to home on 01/18/16 (Monday).

Review of the patients discharge orders dated 01/18/16, revealed, in part: under the medications section, "Medication Reconciliation attached." Review of the "Current/Home Medications, Medication Reconciliation and Order Form" revealed the medication, Keppra, (anti-seizure) was ordered and continued on admission to the hospital and during the patient's hospital stay. In the column "Continue on Discharge/Transfer," Keppra was marked as not to be continued on discharge at home. Further review of the medication order form revealed there was no order for an oral antibiotic. Review of the physician's order sheets revealed there was no order for an oral antibiotic to be continued at home upon discharge from the hospital to complete the treatment regime for the MRSA infection.

In an interview on 02/03/16 at 12:15 p.m., S6ACCO indicated the nurse who discharged Patient #5 assumed the patient was not to continue on Keppra because he was on Depakote (another anti-seizure medication), and she did not clarify with the physician if the patient was to continue on Keppra once he was discharged home. S6ACCO indicated she had discussed the oral antibiotic order for Patient #5 at discharge, and S24Physician indicated he "assumed the nurse would convert the intravenous antibiotics to an oral antibiotic" when the patient was discharged. S6ACCO confirmed and agreed the discharge process was not implemented correctly, and the nurse should have verified if Keppra was to be continued at home with the physician, and the physician should have written an order (prescription) for the oral antibiotics.

In an interview on 02/03/16 at 12:35 p.m., S18LCSW indicated S24Physician had discussed in the treatment team meeting on Thursday, 01/14/16, he deemed it appropriate to have Patient #5 complete the antibiotic course (completion on 01/21/16) with oral antibiotics if the patient was otherwise appropriate for discharge on 01/18/16. Review of the physician orders forms and the "Discharge Orders" form revealed there was no physician's order for oral antibiotics to be ordered for the patient when he was discharged home. Review of the "Medication Reconciliation and Order Form" revealed there was no oral antibiotic prescribed for Patient #5.

Based on record review and interview, the hospital failed to ensure there was a policy and procedure in place and a mechanism in place for the ongoing reassessment of its discharge planning process. Findings:
Review of the hospital policies and procedures revealed there was no policy and procedure in place to reassess readmissions to the hospital for potential problems in the discharge planning process.
Review of the data provided for discharge planning data reported monthly and/or quarterly to the Quality Assurance committee revealed the data being collected and reported on an ongoing basis included the number of discharges and their discharge dispositions.
In an interview on 02/03/16 at 12:35 p.m., S18LCSW indicated the only data she collects and reports to the Quality Assurance committee are the discharge numbers and discharge disposition statistics.
In an interview on 02/03/16 at 5:15 p.m., S5QA/IC indicated the hospital does track 30-day readmissions. She also indicated the readmission data was captured in their software data base. S5QA/IC indicated there were informal discussions among the interdisciplinary team members if a problem with the discharge process was reported. S5QA/IC confirmed there was no specific policy and procedure, no formal tracking and analysis of readmissions to the hospital related to the discharge planning process for the purpose of identifying if the discharge planning process was a contributing factor to a patient's readmission.