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Based on observation and interview, the hospital failed to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for the patients admitted for acute inpatient psychiatric services by failing to ensure the patient environment was free of ligature risks and safety hazards. This deficient practice had the potential to negatively impact the 11 patients on the adult psychiatric unit.

Findings:
On 10/14/19, the following observations were made during the initial tour from 1:05 p.m. to 1:46 p.m. of the Adult Psychiatric Unit:
1) Hinges on the doors leading to both activity rooms and the patient bathroom in large activity room that were separated widely enough to facilitate potential ligature risks. Door knobs also noted on these doors and not within view of staff;
2) Gooseneck faucet on the sink in the large activity room. Patient #R1, Patient #4, Patient #R2, and Patient #10 observed sitting in the large activity room with no staff located near this area at the time of the initial observations. Observation of the patient bathroom accessible only through this large activity room and not within view of staff revealed another sink with a gooseneck faucet and a grab bar with a gap between the wall and the grab bar wide enough to facilitate potential ligature risks;
3) Three exposed, accessible cords from a cable box in the small day room;
4) Non-tamper proof screws throughout the unit;
5) Tiled ceiling in shower room noted with unsecured tiles;
6) Three patient mattresses were noted to have zippers;
7) Picnic table touching the exterior fence noted during tour of the outdoor space for patient use;
8) Four nails driven through a board on the top of the toilet covering plumbing in a patient bathroom was noted with the pointed part of nails sticking through the board, allowing the board to be easily lifted off entirely and exposing plumbing/pipes;
9) Door leading to the seclusion room area was observed to be open with a door knob that could not be locked. Further observation of this area accessible to patients revealed unsecured ceiling tiles; an unlocked, patient accessible bathroom with exposed plumbing/pipes on the back of the toilet and bottle of all purpose cleaner; an unlocked, patient accessible dirty linen room noted to contain mops, cleaning agents, plastic bags, two portable fans with power cords, a computer monitor with power cord, wire hangers, cords from vital sign equipment; the seclusion room was unlocked and patient accessible with a ripped mattress and a metal framed bed with four metal legs and numerous metal holes. Non-tamper proof screws, door knobs, and door hinges set apart widely enough to allow for potential ligature noted throughout the seclusion area.


In an interview on 10/14/19 at 1:45 p.m., S13RN confirmed the environmental issues referenced above were potential risks to patient safety for the patients receiving care on the Adult Psychiatric Unit. S13RN confirmed there was no staff present in the activity rooms with patients and the areas were not continuously monitored in any area. She confirmed patients were not observed in bathrooms or shower rooms. S13RN further stated that any of the patients could walk into the seclusion area because there was no lock on the door leading to the area. She stated that any of the 11 patients on the unit would have access to all hazards and ligature risks identified in this area and were not visible to staff. S13RN confirmed the patients were not watched consistently.

Based on record review and interview the hospital failed to ensure its Medical Staff Bylaws were enforced. This deficient practice was evidenced by telephone orders not countersigned by the ordering Physician within 48 hours for 3 (#4, #13, #18) of 18 (#1-18) medical records reviewed for authenticated telephone orders from a total sample of 30.
Findings:

Review of the Medical Staff Bylaws/Rules and Regulations revealed in part: D. Medical Records 1.b. An order will also be considered to be "in writing and signed in ink" if the order is dictated by a Physician in person or over the telephone to an authorized person, recorded, and signed by that person on the appropriate order sheet, and countersigned by the ordering Physician within 48 hours.

Review of hospital policy #O.15.06 titled "Authentication of Medical Record", provided by S1Adm as current, revealed in part, the policy applied to all medical and clinical staff that made enteries into the Medical Record. Further review revealed the policy read, "All entries in the medical record must be dated, timed, and authenticated with credentials (if applicable) by the author of the entry. When authenticating verbal and/or telephone orders previously ordered, the date and time of the authentication should be reflective of the date and time the signature is made...B. At a minimum the following are authenticated H & P, Progress Notes, Physician Orders, Operative/Procedure Report, if applicable, Consultations, and Discharge Summaries, D, Every Medical Record Entry must be dated, times, author identified, and when required authenticated...D.5. Practitioners must date and time their authentication when signing a verbal/telephone order...F. All orders including verbal orders, must be timed, dated, authenticated by the ordering practitioner or another practitioner who is responsible for the care of the patient and is authorized to write orders..."

Patient #4
Review of Patient #4's medical record on 10/15/19 at 10:00 a.m. revealed telephone orders that had not been countersigned by the ordering Physician dated 10/1/19 at 4:00 p.m. and 10/2/19 at 3:45 p.m.

During an interview on 10/16/19 at 11:20 a.m., S2DON reviewed telephone orders for Patient #4 dated 10/1/19 at 4:00 p.m. and 10/2/19 at 3:45 p.m. and said they were not countersigned by the ordering physician. S2DON confirmed that all telephone orders should be countersigned by the ordering Physician within 48 hours as per the hospital's Medical Staff Bylaws/Rules and Regulations.

Patient #13
Review of the medical record, 10/15/19, for Patient #13 revealed telephone or verbal orders taken by a licensed nurse as follows: 09/24/19 -telephone order from S19MD, 09/25/19- verbal order from S20PA, and 09/25/19- telephone from S19MD. Further review revealed no authentication signature of the PA, and of S20PA.

In an interview 10/05/19 at 10:50 a.m. S21RN verified the above noted orders had not been authenticated by the physician.


Patient #18
Review of Patient #18's medical record revealed admission telephone orders dated 10/8/19 at 3:45 p.m. were not countersigned by the ordering physician.


In an interview on 10/16/19 at 1:05 p.m. with S1Adm and S2DON, they verified the admission telephone orders dated 10/8/19 at 3:45 p.m. were not countersigned by the ordering physician within 48 hours as per the hospital's Medical Staff Bylaws/Rules and Regulations. S1Adm confirmed the Medical Staff By-laws Rule and Regulations required all medical orders to be dated, timed, and signed. She also confirmed the rules and regulations required the ordering physician to countersign telephone orders within 48 hours.


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Based on record reviews and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient as evidenced by failure of the RN to obtain patient admission orders from an authorized physician or licensed independent practitioner for 1 (#8) of 1 (#8,) patients sampled for the admission process from a total patient sample of 30 (#1-#30).

Findings:
Patient #8: Review of the hospital's document titled Psychiatric Admit Orders revealed the orders were pre-printed sheets with boxes next to various orders that could be "checked" to indicate an order had been selected. Further review revealed the selections included orders for diet, precautions, labs, consults, and weights.

Review of Patient #8's Psychiatric Admit Orders dated 10/4/19 revealed diet was regular puree, labs selected were CBC with differential, urine drug screen, urinalysis with C & S if indicated, Chem12, TSH, Zonegran, and weights on admit and every Saturday.

During an interview on 10/15/19 at 10:10 a.m., S13RN reviewed the medical record for Patient #8 and stated she completed the admission paperwork, including the Psychiatric Admit Orders for Patient #8. She said she completed the Psychiatric Admit Orders based on information received from the admitting facility and considered these to be "standing orders". She said that she called the physician and discussed medications, diagnosis, and precautions based on how the patient was acting. She confirmed she selected the diet based on medications the patient was taking, for example she would write low sodium diet if they are on blood pressure medication. She said she would select labs to be drawn based on what labs they had at drawn at the previous facility. She said she selected Patient #8's labs because he was admitted from a physician's office.


In an interview 10/16/19 @10:00 a.m. S15RN reported it is her practice that when a patient is admitted she completes the following orders on the Physician's Admission order sheet: diets, medication list, treatments obtained from information on the patient's discharge summary from the referral facility. She reported there were labs that are automatically ordered on admission, as well as lab orders to be done weekly. She reported patient weights are assessed on admission and weekly, unless they were being weighed daily at the referring facility, then daily weights would be entered on the physician's order sheet. S15RN reported she would call the physician and go over the medications, allergies, and admission diagnosis with the physician, but did not review the other orders she chose with the physician. S15RN reported she did not remember for which patients she had written admission orders.

On 10/16/19 at 11:10 a.m., S2DON stated the nurses admitting patients should be going over every single item on the checklist with the physician when completing the Admit Orders and Psychiatric Admit Orders.


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Based on record reviews and interviews, the hospital failed to ensure the nursing staff developed, and kept current, an individualized nursing care plan for each patient. This deficient practice was evidenced by failure of the nursing staff to include all identified medical diagnoses and failure to include nursing 4 (#1, #13, #14, #15 ) of 6 (#1, #5, #13, #14, #15, #17) sampled patient records reviewed for nursing care plans from a total patient sample of 30.
Findings:


Review of the hospital policy number 1.9.02 titled Plan of Care presented as current policy revealed in part: "The patient care plan will be personalized to meet individual patient care needs. Additional problems unique to the patient may be included and reassessed whenever warranted by the patient's condition ....Each patient's nursing care plan is based on identified nursing diagnosis and are consistent with the therapies of other disciplines. The care plans are also based on patient care needs and standards ....A written plan of care is initiated for each patient within 24 hours of admission. Patient care planning will include interventions, therapy, and education specific to the patient's health care needs, discharge planning, continuing care needs, and any potential referrals/consultations. The patient's family members will be included in all educational and discharge planning activities ....The care plan will be reviewed daily and revised as necessary ....Care plans will be individualized ....Documentation of all patient care planning is recorded in the patient's medical record ...Patient outcomes and response to treatment/implementation of patient care planning is evaluated and documented daily.

Patient #1
Review of Patient #1's medical record revealed an admission date 10/3/19 with an admitting diagnosis of MRSA (resistant bacterial infection) to right thumb. Additional review revealed Patient #1 was a diabetic with accuchecks.

Review of Patient #1's plan of care revealed Diabetes was not addressed as an identified problem on the patient's care plan.

In an interview on 10/16/19 at 11:00 a.m. with S2DON, she verified Diabetes was not identified as a problem on Patient #1's care plan.

Patient #13
Review of Patient #13's medical record revealed he was admitted 09/24/19 and had diagnoses that included, in part, Coronary Artery Disease, Paroxysmal Afib, Hypertension, Diabetes Mellitus, Chronic Kidney Disease IV, Benign prostatic hyperplasia, and Depression. Further review revealed a nursing Care plan that included an actual or risk for alteration in nutrition related to Dental issues, with no documentation of what dental issues the patient had. Further review revealed no care plan for Diabetes even though the patient was getting accuchecks and required insulin injections 4 times a day. Patient #13's diagnoses of HTN, PAF, Peripheral Edema, CAD, or AVF (for future dialysis use (altered circulation), or Depression. A blank care plan titled "Knowledge Deficit" was attached to the other care plans but had no documentation as activated, goals, or interventions.


Patient #14
Review of the Patient #14's medical record revealed she was admitted to the hospital with diagnoses that included in part Bacteremia, poor surgical wound healing, Supraventricular tachycardia, Large B-cell lymphoma, decreased enteral intake, severe protein malnutrition, Gastritis, and Duodenal ulcer, Odynophagia (painful swallowing), and mediport complications. Review of her admission orders included, in part, Specialty Mattress, Regular Diet, Thickened liquids, Aspiration Precautions, Dietary Assessment and recommendation, PICC line Flush 10 ml Normal Saline followed by 1 ml heparin (100Units/ml) every 12 hours, PICC care per policy, Calmoseptine to buttocks excoriation BID and PRN soiling. Review of Patient #14's nursing care plan revealed no care plan for alteration in nutrition , alteration in comfort, altered circulation (related to her irregular heart rate/rhythm), did not include care planning for her PICC care and assessment, and her knowledge deficient/education care plan was blank.

In an interview 10/15/19 at 11:30 a.m. S21RN reviewed the medical records of Patients #13 and 14 and their nursing care plans. S21RN verified the care plans did not address all of the patients' needs, goals, and interventions.



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Based on record review, observations, and interviews, the RN failed to ensure the nursing care of each patient was assigned to personnel in accordance with the patient's needs and specialized qualification and competencies of the available nursing care staff as evidenced by failure to have documented evidence of competencies for monitoring the central telemetry monitor for 1 out of 1 (S16UnitSec) Unit Secretary reviewed for telemetry monitoring competencies. Findings:

Review of the hospital policy for Staff Competency revealed in part, " In order to provide quality patient care, all employees shall be competent to fulfill their assigned responsibilities. Each member is assigned clinical and/or managerial responsibilities based on educational preparation, applicable State/Federal Licensing Laws and Regulation, and an assessment of current competence. An evaluation of a staff member's competence is conducted during the orientation process, three months post-employment and annually thereafter. The evaluation includes an objective assessment of the individual's performance in delivering patient care services and/or modalities in accordance with patient needs."

Review of the hospital's policy for Telemetry Monitoring revealed in part, "Cardiac rhythms will be monitored by a qualified observer at all times. It is the responsibility of the assigned Monitor Technician to assure that a qualified observer covers in his/her absence during meal or break times."

Observations were made through out the survey from 10/14/19, 10/15/19 and 10/16/19 of S16UnitSec monitoring the central telemetry monitor in the nursing station with Patient #19's telemetry strip visible on the central telemetry monitor.

Review of the personnel file for S16UnitSec with S17HR revealed no evidence of competencies for monitoring the central telemetry monitor at the nursing station.

An interview was conducted with S2DON on 10/16/19 at 11 a.m. She reported when the last annual competencies fair was conducted in 2018, skills for monitoring the central telemetry monitor were not assessed for S16UnitSec.

Based on record review and interview, the hospital failed to administered drugs and biologicals by accepted standards of practice as evidenced by failing to monitor a patient's pulse prior to administering Digoxin for 1 out of 1(Patient #19) patient's medical record reviewed for the administration of Digoxin out of a total sample of 30 (#1-#30).
Findings:

Review of the policy titled, Orders Automatic Stop, revealed in part, "Digitalis and derivatives- All patients receiving digitalis or any derivatives thereof shall have a pulse check daily before administration and recorded on the medication sheet. If pulse is below 60 the drug may be withheld and the physician shall be notified."

Review of Patient #19's medical record revealed the patient was admitted on 9/12/19 with the diagnosis of Endocarditis of the Tricuspid Valve. Review of the Patient #19's physician's orders dated 9/24/19 revealed an order for Digoxin 0.125 mg po q day.

Review of Patient #19's Medication Adminstration Record revealed Digoxin 0.125 mg Tab, tablet by mouth once daily. Review of the MAR revealed no pulse was documented at 9:00 a.m. on 10/15/19 when the Digoxin was administered. Review of the MAR for 10/11/19 at 6:00 a.m. revealed Digoxin was administered without documentation of the patient's pulse on the MAR also.

An interview was conducted with S2DON on 10/16/19 at 8:45a.m. She confirmed the nurses are trained to document the patient's pulse on the MAR prior to administrating Digoxin and the physician will look for the patient's pulse prior to administration of the Digoxin on the MAR. She further stated the nurses were taught to take a patient's pulse prior to administrating Digoxin in nursing school.

Based on record review and interview, the hospital failed to employ a qualified director of the Medical Records Department as required by the Louisiana Hospital Licensing Standards, Chapter 93, Section 9387 B.

Findings:
Review of the Louisiana Hospital Licensing Standards, Chapter 93, Section 9387 B, revealed in part: Medical records shall be under the supervision of a medical records practitioner (i.e., registered record administrator or accredited record technician) on either a full-time, part-time or consulting basis.

In an interview on 10/14/19 at 3:12 p.m. with S14MR, she said she was responsible for medical records and has been handling medical records for 20 years. She stated she had no credentials and the only person over her was S1Adm. She denied knowledge of the hospital having a contract with a registered record administrator or accredited record technician.

Review of the current organizational chart presented by S1Adm on 10/16/19 at 8:35 a.m. read: Medical Records Coordinator/Coding S22 MedicalRecords, S18Consultant.

Review of personnel file for S18Consultant revealed the following: Hire Date was 12/3/12 for the Rehabilitation Hospital; Payroll/Status Change Notice done 10/18/17 for this hospital; No evidence of orientation or competencies for this hospital.

Review of the personnel file for S22Medical Records revealed no certifications or accreditations as a medical records practitioner.

In an interview on 10/15/19 at 12:39 p.m., S1Adm acknowledged S18Consultant was identified as the consultant for medical records, but stated S18Consultant had not functioned in this capacity or been to this location since 2017. S1Adm verified the only medical records staff were S14MR and S22MedicalRecords and neither were qualified to supervise the Medical Records Department.

Based on record review and interview, the hospital failed to ensure prompt completion of medical records no later than 30 days after discharge and failed to enforce consequences for delinquent medical records as set forth in the hospital's Medical Staff Bylaws and Rules and Regulations.

Findings:

Review of the hospital's Medical Staff Bylaws/Rules and Regulations Section B. Delinquency in Completing Records revealed in part:
2. Medical records should be completed within 30 days of the patient's discharge from the hospital.
3. The Department of Medical Records/HIM for the in-patient program will periodically issue to each Practitioner a report specifying the delinquent records requiring completion by the Practitioner. The Practitioner must go to the Department of Medical Records/HIM and complete all available records identified in the report within two weeks of the report date. In rare instances and for good cause shown, the Medial Director or Administrator may extend the two week period as necessary to prevent hardship. If the records are not completed within such period, the Director of Medical Records/HIM will mail a Notice to the delinquent Practitioner informing him or her that her or she will be suspended if the delinquent records are not completed within seven days ...
5. If the medical records are not thereafter completed within the seven-day period, then Medical Records/HIM Department shall issue a Notice of Temporary Suspension for Medical Record Deficiencies, which may have the effect of temporarily suspending the affected Member's privileges in accordance with the terms and procedures in the Medical Staff Bylaws...

Review of a list of delinquent medical records provided by the hospital revealed the following:
Delinquent after 30 days:
S3MD - 3 records
S4MD - 10 records
S5NP - 1 records
S7NP - 2 records
S8MD - 2 records
S9NP - 3 records
S10MD - 2 records
S11MedDir - 2 records
Delinquent records incomplete after 60 days:
S3MD - 2 records
S4MD - 3 records
S5NP - 1 records
S6NP- 1 record
S9NP - 1 records
S12MD - 1 records
Delinquent records incomplete after 90 days:
S3MD - 1 records
S5NP - 1 records
S6NP- 1 record
S9NP - 1 records

In an interview on 10/14/19 at 3:12 p.m. with S14MR, she stated no written notifications regarding deficient patient records had been sent to any physicians or practitioners and there had been no suspension of the physician/practitioner's privileges for incomplete charts as referenced in the hospital's Medical Staff Bylaws and Rules and Regulations. She was unable to provide a total number of records that were delinquent and said there were approximately 20 records that were delinquent and dated as far back as June of this year.

In an interview on 10/15/19 at 12:39 p.m., S1Adm confirmed there were delinquent records for patients with discharges dating as far back as June of 2019 and no consequences for the delinquent medical records were enforced as set forth in the hospital's Medical Staff Bylaws and Rules and Regulations.

Based on record review, observation and interview, the hospital failed to ensure the infection control officer assured the system for controlling infections and communicable disease of patients and personnel was implemented according to hospital procedure and acceptable standards of infection control practices. This deficient practice is evidenced by:
1) failure to maintain a sanitary environment in the hospital; and
2) failure to ensure housekeeping staff were trained and competent in cleaning rooms of patients on isolation precautions.
Findings:

1) Failure to maintain a sanitary environment in the hospital.

Review of the hospital policy number N.14.21.06 titled Multiple-Dose Medications presented as current policy revealed in part, Multiple-dose medications are clearly marked by the manufacturer with an expiration date The manufacturer's expiration date is applicable if the container is unopened and stored per recommendations. Once the container is opened, a beyond-use date must be applied to it. The following guidelines should be followed: A. The Healthcare Professional first puncturing the vial or opening the medication container must initial the vial/medication container, and place the date of first use of the container. B. Use a new sterile technique each time a Multiple-Dose Container is accessed. C. Avoid touch contamination of the medication. D. Store the medication as recommended by the Manufacturer. E. Ointments used for multiple-doses should be labeled the day of opening and checked monthly for expiration according to the manufacturer expiration date.

Not dated when opened oral supplements

An observation was conducted on 10/14/19 at 2:10 p.m. of the nutrition/medication room which revealed an opened 1 quart bottle of fruit punch flavored ProMod. The bottle had a sticky substance to the sides and bottom of the bottle. S2DON confirmed the observation.

An observation was conducted on 10/14/19 at 2:15 p.m. of a medication cart in the nutrition/medicine room behind the nursing station. In the medicine cart the following opened and not dated (when opened) oral supplements were observed: Promod, Lactulose, and a 10 ounces can of Thick It. S2DON confirmed the observation.


Not dated when opened topical medications

An observation of the wound care was conducted on 10/14/19 at 2:20 p.m. of the wound care cart which revealed the following opened (punctured) medication tubes and not dated (when opened) were as followed:
1 half empty 30 gram tube of Venelex ointment labeled with Patient #R3;
1 half empty 30 gram tube of Venelex ointment;
1 half empty 30 gram tube of Mometazone Furoate cream 0.1%;
1 almost empty 4 ounce tube of A&D Ointment;
1 half-empty 22 gram tube of mupirocin 2% ointment; and
1 16 fl oz. bottle of Betadine 10% Povidone-Iodine.
S2DON confirmed the medication cart observation and stated Patient #R3 was discharged over a week ago.

Open window in hospital
An observation was conducted on the hospital tour on 10/14/19 at 2:00 p.m. of Room 26, which was designated as a dirty storage area. The window in Room 26 did not have a screen and was opened approximately 4 inches wide. Stored in the dirty storage area were 2 recliners for the patients' visitors, trash cans, and numerous bedside tables. S2DON confirmed the observation.


2) Failure to ensure housekeeping staff were trained and competent in cleaning rooms of patients on isolation precautions.

An observation 10/15/19 at 10:20 a.m. on the patient care unit of the offsite location revealed S24HK gathering equipment from a housekeeping cart preparing to enter a patient room with a "Contact Precautions" sign on door. S24HK was observed to wear gloves, but no isolation gown. When asked what PPE she wore and her procedure for cleaning a patient's room with the isolation precaution sign, she explained her cleaning procedure, but did not verbalize PPE use. S24H reviewed the posted signage on the door which had large lettering at the top of the sign that read, "Contact Precautions". Further review of the sign said, "Stop. DO NOT ENTER. Visitors report to Nurses' Station for Assistance. Hand Hygiene: Perform appropriate hand hygiene before donning required PPE. Personal Protective Equipment (PPE): When Entering a Patient Room- You Must Wear: *Gown, *Gloves (Change glove after coming in contact with grossly contaminated materials, body sites, etc.) "S24HK said she was not aware of this. She reported she had worked there for a couple of weeks.

In an interview 10/15/19 at 11:20 a.m. S25HKMgr reported she was the manager of the contracted housekeeping service. She reported her company was new, and would like to know what she needed to do related to Infection Control training for herself and staff. S25HKMgr. confirmed she had not conducted infection control training for staff related to cleaning in the hospital.

In an interview 10/15/19 at 2:05 p.m. S23IC reported she could not provide any documentation of infection control training, orientation, or competencies for housekeeping staff at either hospital location.


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