HospitalInspections.org

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Radiologic Services as evidenced by:
Failing to ensure there was a radiologist who was a member of the medical staff that supervised the radiology services and interpreted the radiological tests on either a full-time, part-time, or consulting basis. (see findings in tag A-0546)

Based on record review and staff interview, the Governing Body failed to ensure the Medical Staff had written policies and procedures for the appraisal of emergencies, including initial treatment and referrals.

Findings:
On 01/06/15 and 01/07/15 multiple requests were made to S43RN for the hospital's policy for emergency services. No policy/procedure was provided related to emergency services.

In an interview on 01/07/15 at 12:38 p.m., S43RN and S1ADM stated the hospital did not have policies and procedures for emergency services. S1ADM stated, "We call 911."

Based on record review and interview, the hospital failed to identify and investigate grievances as evidenced by failure to initiate the grievance process for 1 (#11) of 2 patients who left the hospital against medical advice.

Findings:
Review of the policy titled,"Grievance Resolution", revealed the following, in part:
30.1 Purpose and Scope:
To protect and promote the rights of each patient, a process has been established to promptly resolve patient grievances. This process is delegated to a grievance committee.
30.2 Policy:
If the patient care complaint cannot be resolved at the time of the compliant by the staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance.

Review of the policy titled, "Patient Leaving Against Medical Advice", revealed the following, in part:
Purpose:
To provide guidelines for hospital staff when a choice is made by a patient to reject their prescribed treatment plan and leave the hospital/self-discharge.
Procedure:
A Risk Management Pro (Incident/Occurrence) report is completed when a patient self-discharges/leaves against medical advice.

Patient # 11:

Review of Patient #11's medical record revealed an admission date of 10/20/14 and diagnoses included the following: deconditioning, progressive weakness- lower extremities, congestive heart failure, coronary artery disease and fall with head trauma. Further review revealed Patient #11 had left the hospital AMA (against medical advice) on 11/04/14.

Review of the hospital's Risk Monitor Pro Incident Tracking System revealed a complaint had been entered involving Patient #11. Review of the complaint revealed the patient's daughter complained of a nurse being rude and the person answering the call bell not allowing request to be finished prior to turning off the call light. The patient left AMA on 11/04/14 as a result of this incident.

Review of Patient #11's nurses notes revealed the following in part:
11/04/14 at 14:45 (2:45 p.m.) Received call from employee in admissions asking me why we were not answering patient's call bell. I went immediately to the patient's room to find daughter packing up the patient's belongings and screaming that she can take better care of her mother at home and that she was a nurse and we were not caring for her mother as she wanted. The daughter was irate and screaming. I spoke to DON (former) and she went to speak with daughter.
11/04/14 15:20 (3:20 p.m.) had daughter sign AMA, daughter requested copy. I made a copy for her and placed original on Risk Management's desk.
11/04/14 17:00 (5:00 p.m.) Out of building with daughter, AMA, in satisfactory condition.

In an interview on 1/07/15 at 3:20 p.m. with S1ADM, he confirmed a complaint had been generated in the Risk Monitor Pro Incident Tracking System. He also confirmed the grievance process had not had been initiated nor had an investigation been conducted into the reason why the family's desired to leave AMA.

In an interview on 1/07/15 at 3:50 p.m. with S3DON/QA she confirmed that Patient #11 leaving AMA should have generated an initiation of the grievance process and an investigation should have been conducted.

Based on observations, record review, and interviews, the hospital failed to ensure patient's rights to privacy were protected as evidenced by failing to ensure the presence of video surveillance in the patients' rooms had been discussed with the patient/responsible party for 1 (#6) of 3 (#1, #6, #7) patients currently under video surveillance.

Findings:
Review of the hospital policy titled, "Videotaping or Photographing Patients," number RM 24, revised date of 12/30/14, revealed in part the following: Continuous photographing or recording of a patient, patient room, or any portion of a PAM (Post Acute Medical) facility is never allowed....Definition: For the purpose of this policy, "photographing" or any variation of the word "photograph" shall be defined as any videotaping, still photography, video-phone captures or voice recordings.

Observations from the nursing station on 01/05/15 at 1:50 p.m. revealed video monitoring was available in rooms 219, 220, 221, 222, and 223. The video monitors were observed to be positioned above the telemetry monitors in the nurse's station. Patients #1, #6, and #7 were visible on the video monitor feed and were observed in their beds or sitting on the side of the bed (#6). The video monitor screens were visible to any persons walking through the nurse's station. Patients #1, #6, and #7 were the only patients currently under video surveillance.

In an interview with S44LPN at 1:50 p.m., she stated the person assigned to monitor the telemetry monitors was also assigned to monitor the video surveillance of patients. S44LPN confirmed Patients #1, #6, and #7 were currently under video surveillance. When asked why the patients were being video monitored, she stated they use the video monitoring if the patient was confused or had a tracheostomy.

Review of the medical records of Patient #1, #6, and #7 revealed no documented evidence that the presence of video surveillance in the patient's rooms had been discussed with the patient and/or responsible party. Review of the, "Admissions Agreement/Conditions of Treatment" consent form revealed the following: "Consent for Photograph and/or Filming: I authorize the facility to take a photograph of the below named patient for the purpose of identification. I have been advised that if a patient leaves the facility and is considered to be at risk, the photograph may be released to appropriate authorities to assist in locating the patient. I understand that from time to time, it is important to photograph/videotape or mechanically record a patient's particular procedure or treatment for the advancement of medical care and education, and that reasonable efforts will be made to keep all materials confidential if such recordings of my (the patient's) procedure or treatment are made. I understand that I may withdraw this consent at anytime except to the extent those actions have been taken in reliance thereon."

In an interview on 01/06/15 at 12:00 p.m., Patient #6 was observed to be alert and cognitive. The patient was observed to be ambulatory with the use of a cane. Patient #6 reported that no one from the hospital had spoke to him about video monitoring, nor had anyone informed him that he was being monitored by video. Patient #6 stated he knew there was a video camera in the ceiling over his bed because he knew what a video camera looked like, but he did not know if it was on and working or not. An observation at the time of the interview revealed an object with a lens mounted in the ceiling over the foot of the bed and pointed at the patient's bed.

In an interview on 01/07/15 at 3:11 p.m. S3DON/QA confirmed that the images on the monitor screen could be viewed by any person in the nursing station, even those that were not involved in the patients' care and/or by hospital staff. S3DON/QA confirmed the patient should have been informed of the video surveillance.

Based on observation, record review and interview, the Governing Body failed to ensure that the hospital's QAPI (Quality Assessment Performance Improvement) program reflected the hospital's organization and services as evidenced by not having all hospital departments and services, including those services furnished under contract, involved in the QAPI Program. The governing body failed to ensure the QAPI program included monitoring of radiology services, contracted nursing services, and organ procurement.

Findings:
Review of the "Post Acute Medical System Performance Improvement Plan 2014" revealed in part the following: The goals of the Performance Improvement Plan are to: 7. Set priorities for performance improvement and ensure that the disciplines representing the scope of care, treatment and services across the hospital work collaboratively to plan and implement improvement activities....The Performance Improvement Plan identifies assessment and improvement activities for all patients receiving care within the PAM (Post Acute Medical) system, as well as PAM patients who receive care through contract services....

Review of the QAPI records revealed no documented evidence that the contracted services or organ procurement were included in the QAPI program.

An observation and record review on 01/06/15 at 10:30 a.m. revealed the hospital had a radiology department with stationary and portable x-ray equipment and the department was staffed with a radiology technician. Review of the hospital contracts revealed the hospital also contracted with Company A for remote interpretation of x-ray reports, and also had a contract for mobile radiology services. Review of the QAPI records revealed the only monitoring of radiology services was the number/type of procedures that were done per month. There was no documented evidence of any quality indicators for radiology services.

Observation, interview and record review during the survey revealed contracted (non-employee) nursing staff were utilized as current staff during all three days of the survey. Review of the QAPI records revealed no documented evidence of quality indicators related to contracted nursing services.

In an interview on 01/07/15 at 11:30 a.m., S3DON/QA confirmed the QAPI program did not include quality indicators for all the hospital's services, including contracted services. S3DON/QA confirmed the only monitoring of radiology services was the reporting of the number of procedures performed per month. S3DON/QA confirmed contracted nursing staffing was not included in the QAPI program. At 12:30 p.m., S3DON/QA confirmed organ procurement was not included in the QAPI program.

Based on record reviews and interviews the hospital failed to ensure that the nursing staff developed and maintained a current nursing care plan to include nursing interventions based on each patient's nursing care needs and not solely on those needs related to the admitting diagnosis, as evidenced by failing to develop comprehensive, individualized care plans with interventions for 5 (#6, #7, #10, #20, #22) of 12 (#1, #2, #3, #6, #7, #9, #10, #15, #16, #20, #22, #25) patients reviewed for care plan/interventions out of 30 sampled patients.

Findings:
A review of the hospital policy titled, "Team Conference," provided by S3DON/QA as the hospital's Care Plan Policy and as the most current, revealed in part: The purpose is to provide a comprehensive assessment of the patient upon admission and at regular intervals to determine the most appropriate level of care based on current and future anticipated care, services and functional level. To evaluate the patient's response/progress to current interdisciplinary care plan and goals; revise/modify as needed to best meet all the needs of the patient.

Patient #6
Review of the medical record for Patient #6 revealed the patient was a 57 year old male admitted to the hospital on 12/05/14 with diagnoses of Calcaneal Fracture, Osteomyelitis, status post Open Reduction Internal Fixation (ORIF), and Hypertension.

Review of the Admission Plan of Care dated 12/05/14 revealed the following health care problems were identified: Pain, Safety, and Skin/Wound related to a PICC (Peripherally Inserted Central Catheter). There was no documented evidence of any interventions checked for the identified problems.


Patient #7
Review of the medical record for Patient #7 revealed the patient was a 54 year old male admitted to the hospital on 12/26/14 with diagnoses of Coronary Artery Disease, Coronary Artery Bypass Graft, Osteomyelitis of Left Middle Finger, Diabetes Mellitus, End Stage Renal Disease with Hemodialysis, Mitral Valve Disease and Atrial Fibrillation.

Review of the Admission Plan of Care dated 12/05/14 revealed the following health care problems were identified: Pain, Safety, Skin/Wound related to incisions, and discharge planning. There was no documented evidence of any interventions checked for Skin/Wound or Pain. There was no documented evidence that cardiovascular, nutrition, or hemodialysis was identified on the plan of care as health care problems with goals and interventions. Review of the patient's medical record revealed the patient was receiving hemodialysis, was on a renal diet, and was on telemetry.


Patient #10
A review of the medical record for Patient #10 revealed the patient was a 85 year old male admitted to the hospital on 12/31/14 with diagnoses of AMS (altered mental status), weakness, UTI (urinary tract infection), abdominal distension, and hydronephrosis. Patient #10's other medical conditions/diagnoses included in part: severe PVD (peripheral vascular disease) with status post re-vascularization of the right lower extremity from a prior admit to the hospital on 12/18/14, malnutrition, and hypertension. Patient #10 was admitted to the hospital for further evaluation and management. The patient's medications included in part: Plavix 75 mg daily, Toprol XL 50 mg daily, Lovenox 40 mg daily, and Vancomycin 1500 mg IV (intravenous) therapy every 18 hours. Patient #10 had an initial nursing assessment performed/documented by S35RN on 12/31/14.

A review of Patient #10's care plan revealed in part: the patient was care planned for: functional difficulties due to decline in ADL's (activities of daily living) and mobility, pain, safety (fall) risk, discharge planning and skin integrity. There was no evidence in the patient's care plan that Patient #10 was care planned for hypertension, PVD, or genitourinary needs. There was no documented evidence on the "Daily Nursing Re-Assessment 12 Shift" nursing notes (from 12/31/14 to 1/05/15) that Patient #10's pedal pulses were assessed by the nursing staff.

A review of Patient #10's Interdisciplinary Patient Care Conference record (care plan review record according to hospital policy) revised and dated 1/06/15 revealed the patient's goals included in part: improve glycemic control, pain management, fall prevention, improve renal function, monitor for infection, continue nutrition therapy, and maintain skin integrity. There was no documented evidence of any interventions noted for the patient to achieve these goals.

In an interview on 1/05/15 at 4:30 p.m. with S20LPN she indicated that she had been caring for Patient #10. S20LPN was asked if Patient #10 had been care planned for hypertension, genitourinary needs or PVD. Patient #10's care plan was reviewed in the presence of S20LPN. S20LPN indicated that there was no care plan initiated for Patient #10's hypertension, genitourinary needs or PVD. S20LPN was asked if LPN's were allowed to update or revise patient care plans. S20LPN indicated that if an LPN identified a patient care need not addressed in the current patient's care plan, they would discuss the care need with an RN. S20LPN indicated that she was not aware of Patient #10's diagnoses of PVD.

In an interview on 1/06/15 at 5:00 p.m with S4NurseMgr, he indicated that a patient's care plan should include all the patient's diagnosed medical conditions. S4NurseMgr further indicated that Patient #10's care plan should have included a care plan for hypertension, genitourinary needs and PVD.

Patient #20
Review of the medical record for Patient #20 revealed the patient was a 61 year old male admitted to the hospital on 12/23/14 with diagnoses of Severe Burns with multiple debridements, Bilateral Lower Extremity Amputations, Hypertension, Alcoholism, Gastroesophageal Reflux Disease and Peripheral Vascular Disease. The record revealed the patient was receiving all nutrition and medicines by PEG (Percutaneous Esophageal Gastrostomy) tube, and was receiving antihypertensive medications.

Review of the Admission Plan of Care dated 12/23/14 revealed the following health care problems were identified: Psychosocial/Spiritual/Education, Safety, Functional/Musculoskeletal, Skin/Wound related to wounds, and Gastrointestinal. There was no documented evidence of any interventions checked for Psychosocial/Spiritual/Education, Safety, Functional/Musculoskeletal, Skin/Wound or Gastrointestinal. There was no documented evidence that nutrition, or cardiovascular was identified on the plan of care as health care problems with goals and interventions.

In an interview on 01/07/15 at 1:40 p.m., S4Nurse Mgr, reviewed the medical records for Patients #6, #7, and #20 and confirmed the plan of care did not include interventions for the identified problems and all the patient's current problems were not included in the plan of care.

In an interview on 01/07/15 at 8:55 a.m., S3DON/QA stated the nursing staff should update the plan of care with any changes. S3DON/QA confirmed that nursing interventions should be included for identified problems. S3DON/QA stated she had focused on the goals (with nursing staff) and stated the goals were being updated weekly by the Interdisciplinary Team. S3DON/QA stated any co-morbidities or other diagnoses that were currently being treated with medications or treatments should be included in the plan of care.


Patient #22
A review of the medical record for Patient #22 revealed the patient was a 71 year old male admitted to the hospital on 11/04/14 with diagnoses of Pneumonia, Chronic Respiratory Failure and Elevated Cardiac Enzymes. Patient #22's other medical conditions/diagnoses included in part: a tracheostomy with ventilator dependency, feeding tube placement for malnutrition, diabetes, obesity, decubitus ulcer, CAD (coronary artery disease) and hypertension. Patient #22 was admitted to the hospital for respiratory management, intravenous therapy and wound care. The patient's medications included in part: Plavix 75 mg daily, Lovenox 100 mg every 12 hours, Dopamine drip 400 mg, Lopressor 25 mg every 8 hours, Levemir 100 units at bedtime and Novolog Insulin on a sliding scale.

A review of Patient #22's care plan revealed in part: the patient was care planned for pain, safety risk, respiratory (ventilator dependent), discharge planning and skin integrity. There was no evidence in the patient's care plan that Patient #22 was care planned for hypertension, diabetes, CAD or malnutrition

A review of Patient #22's Interdisciplinary Patient Care Conference record (care plan review record according to hospital policy) revised and dated 1/04/15 revealed the patient's goals included in part: improve glycemic control, pain management, improve renal function, improve wounds, maintain tracheostomy airway, monitor for infection, continue nutrition therapy, and maintain skin integrity. There was no documented evidence of any interventions noted for the patient to achieve these goals.

In an interview on 1/07/15 at 9:30 a.m. with S39RN she indicated that she had been caring for Patient #22. S39RN was asked if Patient #22 had been care planned for hypertension, diabetes, CAD or malnutrition. Patient #22's care plan was reviewed in the presence of S39RN. S39RN indicated that there was no care plan initiated for Patient #22's hypertension, diabetes, CAD or malnutrition. S39RN was asked who was responsible for updating or revising patient care plans. S39RN indicated that it was a team effort and the patient's care needs were discussed at the patient's Interdisciplinary Patient Care Conference each week. S39RN indicated that a patient's admitting problems were care planned and not always a patient's other medical conditions, unless they were presenting a problem upon admit.


17091

Based on interviews and record reviews the hospital failed to ensure that contracted (non-employee) nursing staff had received hospital orientation and had completed a hospital competency skills checklists. This failed practiced was evidenced by no documentation of a hospital orientation or a hospital-based competency skills checklists for 8 of 8 (S26CNA, S30CNA, S22LPN, S45LPN, S46LPN, S47LPN, S31RN, S40RN) contracted (non-employee) nursing staff's files reviewed out of more than 60 contracted (non-employee) nursing staff files. The hospital's census was 23 patients out of a total capacity of 50.

Findings:
A review of the hospital's "Agency Personnel Orientation" packet, provided by S3DON/QA and S42StaffCoord, revealed in part: An Agency Orientation sign-in sheet indicating that the contracted (non-employee) nursing staff had received and read the hospital's policies, An Agency Staff Orientation Checklist indicating that the contracted (non-employee) nursing staff was familiar with the assignment board, the hospital's floor plan, the "call" system, the code and log books, the medication room, critical lab reporting, the hospital forms, the glucometer and the intravenous pumps, and An Agency Personnel Performance Evaluation form.

A review of 8 (eight) random contracted (non-employee) nursing staff files (S26CNA, S30CNA, S22LPN, S45LPN, S46LPN, S47LPN, S31RN, S40RN) on 1/07/15 at 1:40 p.m. with S42StaffCoord, in the presence of S11HR, revealed that all 8 of the random contracted (non-employee) nursing staff files reviewed, contained, in part, the following identical forms: an "Agency Orientation" signed (single sheet) form indicating that the contracted (non-employee) nursing staff had received and read the hospital's policies; an "Agency Staff Orientation Checklist" (single sheet) form indicating that the contracted (non-employee) nursing staff was familiar with the assignment board, the hospital's floor plan, the "call" system, the code and log books, the medication room, critical lab reporting, the hospital forms, the glucometer and the intravenous pumps. The CNA's (S26CNA and S30CNA) circled N/A (not applicable) for medication room, critical lab reporting, glucometer and intravenous pumps; an "Agency Personnel Performance Evaluation" form (single sheet) completed by a hospital-employed staff after the first shift worked by the contracted (non-employee) nursing staff; and a self-completed competency skills checklists from the contracted (non-employee) nursing staff's agency.

In an interview on 1/07/15 at 2:00 p.m. with S42StaffCoord, in the presence of S11HR, she indicated that she was responsible for maintaining the contracted (non-employee) nursing staff profile folders. S42Staff Coord indicated that she presently had over 60 contracted (non-employee) nursing staff (RN, LPN, CNA) who were considered eligible to work. S42Staff Coord indicated that she was not aware of any other hospital orientation requirement or skills competency checklists form required for the contracted (non-employee) nursing staff. S42StaffCoord indicated that a hospital competency skills checklist was not required on contracted (non-employee) staff and that the hospital always accepted the contract agency's competency skills checklists for the contracted (non-employee) staff.

In an interview on 1/07/15 at 9:20 a.m. with S40RN, she indicated that she was a contracted (non-employee) nurse. S40RN indicated that she began working as a contract RN at the hospital in October 2014. S40RN was asked if the hospital provided her with a hospital orientation and if she completed a hospital-based competency skills checklist prior to her being assigned patients. S40RN indicated that the first time she worked at the hospital, a hospital-employed RN oriented her to the hospital before she was assigned patients. S40RN further indicated that she had not completed a hospital-based competency skills checklist with anyone here at the hospital prior to her being assigned patients. S40RN indicated that she completed a self-competency skills checklist through her contract agency when she was first employed by the contract agency. S40RN further indicated that she was not asked to complete a hospital-based competency skills checklist before she was assigned patients and did not remember having to demonstrate any competency skills with a hospital-employed RN.

In an interview on 1/07/15 at 2:15 p.m. with S3DON/QA she was asked about the hospital's use of contracted staff. S3DON/QA indicated that the hospital used contracted staff (RN, LPN, CNA) frequently during the week. S3DON/QA was asked about a hospital orientation and a hospital-based competency skills checklists for the contracted (non-employee) nursing staff. S3DON/QA indicated that the hospital did not have a formal/structured orientation for contracted (non-employee) nursing staff. and that the hospital accepted the contract agency's competency skills checklists for contracted staff. S3DON/QA indicated that she had been employed at the hospital for about 8 weeks and was aware that this was not an acceptable practice.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered according to current nursing standards and hospital policy for 7 (#6, #7, #10, #20, #22, #28, #29) of 13 (#1, #2, #3, #5, #6, #7, #10, #12, #14, #20, #22, #28, #29) medical records reviewed for medication administration out of a sample of 30.

Findings:
Review of the hospital's policy titled, "MAR Medication and Administration", with no policy number and with a revised date of September 2014, revealed in part the following:
III. Documentation of Scheduled Medications:
A. Upon administration of the medications, the nurse will document in the MAR (Medication Administration Record) at assigned time slots.
B. Current B/P (Blood Pressure) must be documented along with time administered in assigned time slots when administering cardiovascular drugs.
C. Heart rate must be documented along with time administered in assigned time slot when administering Digoxin....


Patient #6
Review of the medical record for Patient #6 revealed the patient was a 57 year old male admitted to the hospital on 12/05/14 with diagnoses of Calcaneal Fracture, Osteomyelitis, status post Open Reduction Internal Fixation (ORIF), and Hypertension.

Review of the physician's orders revealed Norvasc (blood pressure medication) 5 mg (milligrams) by mouth twice a day was ordered on 12/06/14. Review of the physician's orders also revealed Coreg (blood pressure medication) 12.5 mg. with breakfast and dinner was ordered on 12/09/14.

Review of the MARs for Patient #6 revealed Coreg 12.5 mg was administered on 12/25/14, 12/26/14, 12/27/14, 12/29/14, 12/30/14, 12/31/14, 01/01/15, 01/02/15, 01/03/15, and 01/04/15 without a documentation of the assessment of the patient's blood pressure on the MAR. The MAR revealed Norvasc 5 mg was administered on 12/25/14, 12/26/14, 12/27/14, 12/29/14, 12/30/14, 12/31/14, 01/02/15, and 01/04/15 without a documentation of the assessment of the patient's blood pressure on the MAR.

Patient #7
Review of the medical record for Patient #7 revealed the patient was a 54 year old male admitted to the hospital on 12/26/14 with diagnoses of Coronary Artery Disease, Coronary Artery Bypass Graft, Osteomyelitis of Left Middle Finger, Diabetes Mellitus, End Stage Renal Disease with Hemodialysis, Mitral Valve Disease and Atrial Fibrillation.

Review of the physician's orders revealed Norvasc (blood pressure medication) 5 mg (milligrams) by mouth at bedtime was ordered on 12/29/14. Review of the physician's orders also revealed Lopressor (blood pressure medication) 25 mg. twice a day was ordered on 12/31/14.

Review of the MARs for Patient #7 revealed Norvasc 5 mg was administered on 12/31/14, 01/02/15, and 01/03/15 without a documentation of an assessment of the patient's blood pressure on the MAR. The MAR revealed Lopressor 25 mg. was administered on 12/31/14, 01/01/15, 01/02/15, and 01/03/15 without a documentation of an assessment of the patient's blood pressure on the MAR.


Patient #10
Review of the medical record for Patient #10 revealed the patient was a 85 year old male admitted to the hospital on 12/31/14 with diagnoses of AMS (altered mental status), weakness, UTI (urinary tract infection), abdominal distension, and hydronephrosis. Patient #10's other medical conditions/diagnoses included in part: severe PVD (peripheral vascular disease) with status post re-vascularization of the right lower extremity from a prior admit to the hospital on 12/18/14, malnutrition, and hypertension. Patient #10 was admitted to the hospital for further evaluation and management. The patient's medications included in part: Plavix 75 mg daily, Toprol XL 50 mg daily, Lovenox 40 mg daily, and Vancomycin 1500 mg IV (intravenous) therapy every 18 hours.

A review of Patient #10's MAR from 12/31/14 to 1/05/15 revealed that Patient #10 was administered his daily blood pressure medicine, Toprol XL 50 mg as ordered. A further review of Patient #10's MAR revealed no documented evidence that the patient's blood pressure assessment was documented on the MAR prior to the administration of his daily blood pressure medicine, Toprol XL 50 mg, from 12/31/14 to 1/05/15.

In an interview on 1/05/15 at 4:30 p.m. with S20LPN she indicated that she had been caring for Patient #10. S20LPN indicated that she was not aware that a patient's blood pressure assessment had to be documented on the patient's MAR when administering blood pressure medicine.


Patient #20
Review of the medical record for Patient #20 revealed the patient was a 61 year old male admitted to the hospital on 12/23/14 with diagnoses of Severe Burns with multiple debridements, Bilateral Lower Extremity Amputations, Hypertension, Alcoholism, Gastroesophageal Reflux Disease and Peripheral Vascular Disease.

Review of the physician's orders revealed Norvasc 5 mg per PEG (Percutaneous Esophageal Gastrostomy) every day and Lopressor 50 mg. twice a day was ordered on 12/24/14.

Review of the MARs for Patient #20 revealed Norvasc 5 mg was administered on 01/01/15, 01/02/15, and 01/04/15 without a documentation of an assessment of the patient's blood pressure on the MAR. The MAR revealed Lopressor 50 mg. was administered on 12/31/14, 01/01/15, 01/02/15, 01/04/15, and 01/06/15 without a documentation of an assessment of the patient's blood pressure on the MAR.

In an interview on 01/07/15 at 1:40 p.m., S4NurseMgr, reviewed the medical records for Patients #6, #7, and #20 and confirmed the patients' blood pressure were not assessed and documented on the MAR with the administration of blood pressure medications. S4Nurse Mgr confirmed it was expected that patient's blood pressures would be checked prior to administration of blood pressure medications.

Patient #22
A review of the medical record for Patient #22 revealed the patient was a 71 year old male admitted to the hospital on 11/04/14 with diagnoses of Pneumonia, Chronic Respiratory Failure and Elevated Cardiac Enzymes. Patient #22's other medical conditions/diagnoses included in part: a tracheostomy with ventilator dependency, feeding tube placement for malnutrition, diabetes, obesity, decubitus ulcer, CAD (coronary artery disease) and hypertension. Patient #22 was admitted to the hospital for respiratory management, intravenous therapy and wound care. The patient's medications included in part: Plavix 75 mg daily, Lovenox 100 mg every 12 hours, Dopamine drip 400 mg, Lopressor 25 mg every 8 hours, Levemir 100 units at bedtime and Novolog Insulin on a sliding scale.

A review of Patient #22's MAR from 1/01/15 to 1/06/15 revealed that Patient #22 was administered his blood pressure medicine, Lopressor 25 mg, as ordered. A further review of Patient #22's MAR revealed no documented evidence that the patient's blood pressure assessment was documented on the MAR prior to the administration of his blood pressure medicine, Lopressor 25 mg, from 1/01/15 to 1/06/15.

In an interview on 1/07/15 at 9:30 a.m. with S39RN she indicated that she had been caring for Patient #22. S39RN indicated that she was not aware that a patient's blood pressure assessment had to be documented on the patient's MAR when administering blood pressure medicine.

Patient #28
Review of the medical record for Patient #28 revealed the patient was admitted to the hospital on 12/31/14 with an admit diagnoses for Ventilator Weaning. The patient also had a history of Osteoarthritis, Hypothyroidism, Cerebral Vascular Disease, and Trans-Ischemic Attacks.
Review of the Physicians orders dated 12/31/14 revealed an order for Clonidine HCL 0.1 mg (milligram) three times daily and Coreg 12.5 mg with breakfast and dinner.
Review of the Patient #28's MAR revealed Clonidine HCL 0.1 mg was administered on 1/01/15, 1/02/15 (1400, 2100), 1/03/15, 1/04/15 (0900, 2100), 1/05/15 and 1/06/15 without the patient's blood pressure assessment being documented on the patient's MAR.
Patient #29
Review of the medical record for Patient #29 revealed the patient was admitted to the hospital on 12/15/14 with an admit diagnoses for Ventilator Weaning. The patient also had a history of Prostate Cancer and Mental Retardation.
Review of the Physicians orders dated 12/15/14 revealed an order for Coreg 6.25 mg twice a day.
Review of Patient #29's MAR revealed Coreg 6.25 mg was administered on 1/01/15, 1/02/15, 1/03/15, 1/04/15, and 1/06/15 (1630) without the patient's blood pressure assessment being documented on the patient's MAR.


25119




30172

Based on observations, interviews and record reviews, the hospital failed to ensure that patient's medical records were stored in locations or in a manner where the medical records were protected from damage from water. This failed practice was evidenced by patient medical records being stored in the Medical Records Department and in the Physician Dictation room on open shelving racks in rooms that had a sprinkler system.

Findings:
A review of the hospital policy titled "Protection of Medical Records", provided by S3DON/QA, as the most current, revealed in part: The hospital will ensure that reasonable efforts are made to protect medical records throughout the hospital.

An observation on 1/06/15 at 9:30 a.m., in the presence of S7HIM, of the (locked) Medical Records Department revealed the following: 12 (twelve) open ended shelving racks (each approximately 6 feet tall and 5 feet wide) containing over 1000 patient medical records stored on the open ended shelving racks that had an overhead sprinkler system in place in the room.

An observation on 1/06/15 at 9:45 a.m., in the presence of S7HIM, of the (locked) Physician Dictation room revealed the following; 4 (four) open ended shelving racks (each approximately 6 feet tall and 4 feet wide) containing over 40 patient medical records stored on the open ended shelving racks that had an overhead sprinkler system in place in the room.

In an interview on 1/06/15 at 10:00 a.m. with S7HIM, she indicated that she was responsible for the patient's medical records in the Medical Records Department. S7HIM indicated that all patient medical records were originals and that the hospital did not have the capability to scan or electronically store patient medical records. S7HIM indicated that she also placed patient medical records in the Physician Dictation room for physicians to complete and that the patient's medical records could be left in the Physician Dictation room for up to 30 days. S7HIM indicated that the patient's medical records stored in the Medical Record Department and in the Physician Dictation room were not protected from water damage in the event the sprinkler system was activated. S7HIM further indicated that she thought S10PlantOper/EnvServ was in the process of contracting with a Remediation Service Company to restore patient medical records in the event they were damaged by water.

In an interview on 1/06/15 at 2:45 p.m. with S10PlantOper/EnvServ he indicated that the hospital had no system in place to protect patient medical records from water damage in the event the sprinkler systems were activated in the Medical Record Department or the Physician Dictation room. S10PlantOper/EnvServ indicated that the hospital was in the process of contracting with a Remediation Service Company to restore patient medical records in the event they were damaged by water. S10PlantOper/EnvServ indicated that the hospital had no system in place, at this time, that prevented patient medical records from water damage in the event the sprinkler systems were activated in the Medical Record Department or the Physician Dictation room and only had tentative plans to restore the patient medical records through a Remediation Service Company contract in the event that they were damaged from water.

Based on interview and record review, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with acceptable standards of practice for 54 medications from October 2014 to December 2014. This deficient practice was evidenced by failing to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist, before the first dose was dispensed for; therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications.

Findings:
Review of the hospital's policy for, "Obtaining Medications in the Absence of a Pharmacist", revealed in part: When the pharmacy department is closed and a medication is ordered and must be be administered to a patient, whose clinical status would be jeopardized if the medication were withheld until the pharmacy re-opens, that medication may be obtained by authorized nursing staff (upon completion of a standardized review of the order by two licensed staff). Alternately, a licensed, independent practitioner may order, prepare and administer the medication. To ensure adequate safety, control and accountability of dispensing and administration of new medications orders after pharmacy hours, all new orders received after the pharmacy is closed must be reviewed by the health care providers specified in this policy and must meet the following criteria:
Correct patient
Appropriate medication, dose, frequency and route of administration
Therapeutic duplication
Known or potential allergies or sensitivity
Laboratory values interactions
Contraindications/safety concerns
Variation from the drug use guidelines or best clinical practice criteria.
If any medication safety concerns are identified, the medication must not be administered. The prescribing physician or the on-call pharmacist must be contacted immediately...
Any high alert medication may be administered after pharmacy hours, but must be reviewed and verified by the on-call pharmacist or by 2 licensed staff members. All new routine clinical medication orders (example include, but not limited to- IV anti-infective's; anti-hypertensive's; insulin; or hypoglycemic) may be administered after pharmacy hours, but must be reviewed and verified by:
RN (Registered Nurse) charge nurse and a second nurse -or-
On-call pharmacist-or-
House physician.

Review of the Hospital's policy for, "After Hours Pharmacy Audit Procedures", revealed in part: The audit procedure to determine compliance to the policies and procedure for pharmacy after-hours new medication orders will be performed by the pharmacist each morning. Discrepancies identified in the audit procedure will be reconciled as soon as possible. Discrepancies that may place the patient in imminent danger, e.g. wrong drug or documented allergy to the selected medication will be rectified by the pharmacist immediately. The following document will be reviewed by the pharmacist in completing the audit of new orders after pharmacy hours:
a. Medication Orders
b. Automated Dispensing Machine (ADM) Override Report. The ADM override report is:
ADM override is reviewed by the pharmacist each morning.

Review of the Override Report for 1/05/15 for Patient R1, revealed an override for Metoprolol Tartrated 25 mg (milligrams) tab( tablet) and Diltiazem HCL 60 mg tab.

Review of the Override Report for 1/05/15 for Patient #22, revealed an override for Tigecycline 50 mg injection and Sodium Chloride 0.9% 100 ml (milliliters).

An interview was conducted with S12RPh on 1/06/15 at 9:45 a.m. He reported the pharmacy was opened Monday through Friday from 8 a.m. to 4:30 p.m. and on Saturday and Sunday from 8 a.m. to 12 p.m. He further reported if a medication was started on a patient after the pharmacy was closed, it was the nurse's responsibility to review the medication prior to administering the medication. The medication must be checked by two nurses prior to administration. Two nurses must override the medication dispensing system to obtain the medication. S12RPh also reported, once the pharmacy reopened, the pharmacist reviews all the overrides after the medication had been administered to the patient.

Based on record reviews and interviews the hospital failed to ensure all compounding of drugs and biologicals were performed under the supervision of a pharmacist. This practice was evidenced by most IV (intravenous) antibiotic piggybacks ordered after pharmacy hours were being mixed by staff nurses in the hospital setting.

Findings:
Review of the hospital's policy for, "Pharmaceutical Compounding -Sterile Preparations", revealed in part: 2. All intravenous (IV) solutions with additives will be prepared and dispensed by pharmacy; with the exception of after-hours, "stat" IV preparations. During the pharmacy's normal business hours, all IV admixtures will be prepared in the Laminar Airflow Workbench (LAFW ) or Barrier Isolator Hood (BIH). 3. Only qualified staff members who have completed IV admixture competency assessments may prepare IV admixtures. Compounding personnel are responsible for ensuring that CSPs (Compounding Sterile Preparations) are accurately identified, measured, diluted and mixed and are packaged, sealed, labeled, stored, dispensed and distributed. 4. It is the responsibility of the compounding supervisor to ensure the following: Personnel are adequately educated, instructed and skilled to perform their jobs. Ingredients contain correct quantities, identities and quality. Open/partial containers are properly dated and stored. Bacterial endotoxins are minimized. Proper and adequate sterilization is used. Equipment is clean, accurate and appropriate. Potential harm from added substances is evaluated prior to dispensing. Packaging is appropriate for sterility and stability. The compounding environment maintains the sterility of pre-sterilized items. Labels are appropriate and complete. Beyond use date are appropriate and based on valid scientific criteria. Correct compounding procedures are used. Deficiencies in compounding can be rapidly identified and corrected...
An interview was conducted with S12RPh on 1/06/15 at 9:45 a.m. He reported the pharmacy was open from 8:00 a.m. to 4:30 p.m. Monday through Friday and 8:00 a.m. to 12:00 p.m. on Saturday and Sunday. He reported after the pharmacy was closed for the night, the nurses mixed the Lasix drips and some antibiotics with Normal Saline. He further reported this occurred when pharmacy was closed and it was usually new physician antibiotic orders the nurses had to mix. He went on to report when the pharmacy reopened, the pharmacist would look at the override report from the Medication Dispensing Machine and review the medications that were administered to the patients while the pharmacy was closed.

Review of a list of medications from October 2014 to December 2014, provided by S12RPh, revealed there were 54 incidences of medications that the nurses had to mix during the 3 month time period. Forty-seven (47) of the medications were antibiotics and had to be added to 100 cc (cubic centimeters) - 250 cc of IV solutions. The rest of the medications were Lasix or Bicarbonate medications added to an IV solutions to deliver a drip to a patient.

An interview was conducted with S35RN on 1/07/15 at 9:15 a.m. She reported, after pharmacy hours, the nurses had to mix their own antibiotic piggybacks. For example, if a physician obtained a positive culture and he wanted a new antibiotic started on a patient, typically the nurses had to mix the antibiotic piggyback. S35RN went on to report it was mostly antibiotics the nurses had to mix themselves after the pharmacy closed on the weekends or after hours on weekdays.
An interview was conducted with S4Nurse Mgr on 1/06/15 at 4:00 p.m. He reported, after the hospital's pharmacy was closed, the nurses had to mix Lasix drips, Vancomycin and other antibiotic intravenous solutions. He further reported the nurses usually added the antibiotics to 250 cc (cubic centimeters) IV bags of Normal Saline.

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

Findings:
Review of the hospital policy titled, "Radiology Medical Director", policy number RAD 102, revised date of 09/2013 revealed in part the following: The Medical Director of Radiology will meet or exceed the qualifications as outlined in the following statement. 1. Shall be certified by the American Board of Radiology or eligible for certification. 2. Shall have a license to practice in the state of Louisiana and be a member in good standing of the State and Parish Medical Society. 3. Must be a member of the medical staff of Post Acute Medical Specialty Hospital of Lafayette and be designated as the Medical Director of Radiology....

During the entrance conference on 01/05/15 at 11:24 a.m., S1ADM stated the hospital had portable x-ray equipment and employed radiology technicians to perform the x-rays.

On 01/06/15 at 9:55 a.m., an observation and interview was made in the Radiology department with S27Rad Tech. S27Rad Tech stated she was employed on an "as needed basis" by the hospital as a radiology technician. S27Rad Tech stated S29Rad Coord was the hospital's full time radiology technician but she was on leave and she (S27Rad Tech) was working for her. S27Rad Tech also stated the hospital had a contract for mobile x-rays. S27Rad Tech verified the hospital had 1 stationary x-ray machine and 1 portable x-ray machine.

Review of the list of credentialed physicians on the Medical Staff and the list of Medical Executive Committee Members for 2014, presented as a current list by S3DON/QA, revealed no documented evidence that a radiologist was credentialed and privileged as the Director of Radiology.

Review of the contracts provided by S3DON/QA revealed the hospital had a contract with Company A to provide remote interpretation of radiology tests.

In an interview on 01/05/15 at 5:00 p.m. with S1ADM he indicated that the hospital did not have a physician designated as the Director of Radiology. S1ADM indicated that the hospital had many contracted radiologists credentialed by the Medical Staff. S1ADM further indicated that the Governing Body had not appointed a physician or any of the credentialed radiologists as the Director of Radiology. S1ADM indicated that he was not aware that the hospital had to have a Director of Radiology since radiology was a contracted service.


30172

Based on observations, interviews and record reviews the hospital's Dietary Department failed to ensure that established infection control dietary policies and procedures were monitored and maintained for safe and sanitary food handling practices. This failed practice was evidenced by observations:

Findings:
1) large clean baking pans (x 6) not stored upside down on the clean storage racks,
2) a large container of cornmeal and a large container of sugar stored next to sink where raw meat was prepared,
3) dietary staff (S23Cook and S24Cook) observed during food preparation going (back and forth) from the food prep area to the dirty dishwashing room to wash dirty utensils and/or pots without changing their plastic aprons or performing hand hygiene after removing gloves when leaving the dirty dishwashing room and before returning to the food prep area to continue to prepare food for patient consumption,
4) discolored antibacterial wipes in 1 of 2 containers mounted on the kitchen wall and used by staff for disinfecting the kitchen area and an observation of the second antibacterial container being empty,
5) a used mop head stored in the mop bucket in the same room where food items were also stored,
6) cleaning chemicals and cleaning equipment and food items being stored together on the same shelf in a storage room and in the same room and
7) a patient meal in a styrofoam container stored in a 155 degree Fahrenheit warming cabinet.

A review of the hospital policy titled, "Infection Control in Food Service", provided by S8RD/DM as the most current, revealed in part: The Dietary Department will maintain infection prevention and control practices and educate staff on appropriate precautions to be taken when performing assigned duties. The Dietary Director will be responsible for monitoring compliance with infection control prevention and control practices, including education and practice issues and strict adherence by staff in infection control practices in food preparation.

In an interview on 1/06/15 at 12:35 p.m. with S8RD/DM she indicated that she was the Director of the Dietary Department and a Registered Dietician. S8RD/DM was made aware of the observations in the Dietary Department regarding infection control breaches. S8RD/DM indicated that those practices were not acceptable infection control practices.

Based on observations and interview, the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by failing to ensure the functionality of a nurse call button located on the handrails of the beds on the High Observation Unit and the General Care Unit.

Findings:
On 01/05/15 at 12:45 p.m., an observation was made in room 105. Bed A was observed
to have a button labeled "Nurse" on the handrail of the bed. The button was noted to be non-functional as it failed to activate any type of nurse call system. S47LPN was interviewed at the time of this observation and confirmed the button labeled, "Nurse" located on the handrails of the inpatient bed was not functioning when pressed. S47LPN indicated that the hospital does have a nurse call system which includes a cord with a button and reported that patients are instructed to use this call system. When asked if it would be possible for a patient who may be sedated and/or confused to press the button on the handrail of the bed labeled "Nurse" thinking they are calling for assistance without the nursing staffs knowledge due to the call button not working, S47LPN indicated yes that would be possible.

On 01/05/15 at 1:00 p.m., an observation was made in the High Observation Unit. All 5 beds in the unit were observed to have a button labeled "Nurse" on the handrail of the bed. The button was noted to be non-functional as it failed to activate any type of nurse call system. S28LPN was interviewed at the time of the observation and confirmed the button labeled, "Nurse" located on the handrails of the inpatient bed was not functioning when pressed. S28LPN indicated that the hospital does have a nurse call system which includes a cord with a button and reported that patients are instructed to use this call system. S28LPN further stated, "If the family needs us, they just come get us."

In an interview on 01/06/15 at 2:35 p.m., S10Plant Oper/Env Serv confirmed the "Nurse" call button located in the hand rails on some of the hospital's beds was not connected to the nurse call system and was non-functional. At 4:05 p.m., S10Plant Oper/Env Serv provided a list of room numbers that indicated there were 5 beds on the General Care Unit that had a "Nurse" call button in the hand rails of the bed. The list also indicated all 5 beds on the High Observation Unit that had a non-functioning "Nurse" call button in the hand rails of the patient beds.

26351

Based on observations, record reviews and interviews, the hospital failed to ensure the effective implementation of policies/procedures relative to infection control to include a system for identifying, reporting, investigating, prevention,and controlling infections and communicable diseases of patients and personnel. This was evidenced by the hospital's:

Findings:
1) failure to ensure that 1of 1 (S22 LPN) nursing staff failing to disinfect/clean a multiple patient use glucometer and perform hand hygiene after donning gloves.

2) failure to maintain a sanitary physical environment as evidenced by:
a. having food delivery cart with soiled trays stored in a biohazardous storage room and
transported back to dietary without being cleaned.
b. having patients care equipment with noted dust and drip marks on equipment cleaned
and ready for patient use.
c. nursing personnel transporting a leaking bag of trash and mopping the floor with a towel.

3) failure to place in contact isolation a patient who was identified with a microorganism that required isolation precaution.

4) Dietary Department's failure to ensure that established infection control dietary policies and procedures were monitored and maintained for safe and sanitary food handling practices.

Findings:
1) failure to ensure that 1of 1 (S22 LPN) nursing staff failing to disinfect/clean a multiple patient use glucometer and perform hand hygiene after donning gloves.
An observation on 01/06/15 at 11:50 a.m. was made of S22LPN performing a glucometer blood test on Patient #27 in the patient's room. S22LPN removed the glucometer from the storage case, performed the finger stick, and placed the glucometer back into the storage case. S22LPN removed her gloves at the door and was noted not to have performed hand hygiene. S22LPN at no time was noted to have disinfected/cleaned the glucometer after performing the finger stick on Patient #27. S22LPN was observed entering the room of Patient #R2 at which time she sanitized her hands before the donning of gloves. S22LPN removed the glucometer from the storage case, performed the finger stick, and placed the glucometer back in the storage case. S22LPN removed her gloves at the door, sanitized hands and proceeded to the medication room.

Continued observation of S22LPN at 12:20 p.m., revealed she returned to the medication room, placed the glucometer and storage case on the counter top in the medication room. S22LPN was noted not to have disinfected/cleaned the glucometer after returning to the medication room.

In an interview on 01/06/15 at 12:30 p.m., S22LPN confirmed that she did not wash/sanitize her hands after removing her gloves upon leaving the room of Patient #27. S22LPN indicated that she was nervous and just forgot to wash/sanitize her hands after removing her gloves. S22LPN indicated the glucometer was cleaned at the end of the day by the night shift and/or wiped down when soiled.

In an interview on 01/06/15 at 4:30 p.m., S5IC(Infection Control) confirmed that the glucometer should be cleaned/disinfected after each patient use. S5IC indicated that the glucometer is cleaned/disinfected with Sani-cloth after each patient use with the exception of patients on contact isolation and/or with C-diff (Clostridium Difficile). S5IC indicated that a plastic isolation bag is placed on the glucometer, and cleaned after removal of the bag with Sani-cloth or Clorox wipes (C-diff.).

2) failure to maintain a sanitary physical environment as evidenced by:
a. having food delivery cart with soiled trays stored in a biohazardous storage room and
transported back to dietary without being cleaned.
b. having patients care equipment with noted dust and drip marks on equipment cleaned
and ready for patient use.
c. nursing personnel transporting a leaking bag of trash and mopping the floor with a towel.
2a). An observation on 01/05/15 at 12:10 p.m. revealed a locked room labeled "Biohazardous Waste" the following items were noted to be present in the room:
1). 3 trash carts with trash bags.
2). 1 large bio-hazardous bin with red bags.
3). wired racked delivery meal cart with 2 patient trays (dirty)
4). countertop was noted to contain; (1) IVAC (intravenous infusion pump), (2) wound vac in red bags, a bag of Christmas decorations and a plastic bag with a pair of slippers (brown) and a blue piece of clothing.

An observation of the staff during patient lunch meal passing on 01/06/15 at 11:30 a.m. revealed the following: after completion of the meal pass, S26CNA pushed the wire racked delivery meal cart into the room labeled, "Biohazardous Waste". In an interview at the time of the observation, S26CNA confirmed the meal delivery cart was always placed in the soiled utility room (Biohazardous Waste room) after all meal trays had been delivered to the patients.

In an interview on 01/06/15 at 12:10 p.m., S9Dietary indicated all meal trays were returned to the dietary department on the delivery wire cart to an area designated for the return of dirty meal trays. S9Dietary indicated the dietary staff was responsible for cleaning the cart after the removal of all soiled trays. S9Dietary indicated that Sani cloth was used to clean the wire racked delivery meal cart. She indicated that after cleaning, the cart was stored in the dry storage area until the next meal was delivered.

2b). An observation was conducted on 01/05/15 at 1:00 p.m. of the hospital's supply room and revealed the following: 2 kangaroo feeding pumps noted to have an accumulation of dust on both machines. Another feeding pump was noted to have drip markings on the front panel with a tag which indicated the machine was cleaned. S32LPN confirmed the findings at the time of the observation and indicated that the equipment was supposed to have been cleaned and ready for patient use if it was located in the clean supply room.

An observation was conducted of the code cart in the nursing station on 01/05/15 at 1:15 p.m., and revealed the defibrillator located on top of the code cart had an accumulation of dust on the machine. An EKG (Electrocardiogram) machine located next to the code cart was noted to also have an accumulation of dust on the top of the machine. S32LPN verified the defibrillator and EKG machine were dirty.
2c). Nursing personnel transporting a leaking bag of trash and mopping the floor with a towel:
An observation was conducted on 01/05/15 at 4:05 p.m. from the nurse's station on the General Care Unit. S30CNA was observed leaving Patient #1's room with a plastic bag of trash. The bag of trash was observed to be leaking a liquid substance on the hallway floor from Patient #1's room, down the hall in front of the nurse's station, and around the corner to the soiled utility room. S30CNA was then observed to take a patient care towel, without gloves on, and mop up the liquid that leaked from the trash bag on the hall floors. S30CNA was interviewed at the time of the observation and confirmed she had removed a trash bag from Patient #1's room and the trash bag leaked an unknown liquid on the hallway floors. S30CNA stated, "The patient wasn't on precautions."

3) failure to place in contact isolation a patient who was identified with a microorganism that required isolation precaution.
Patient #5
Review of Patient #5's medical record revealed she was admitted on 01/02/15 for status post Laminectomy Dehiscence with positive wound cultures for pseudomonas and staphylococcus.
Review of the patient's medical record revealed Patient #5's admission orders had an order dated 01/02/15 for universal precautions only.
An observation conducted on 01/06/15 at 9:00 a.m., revealed Patient #5's room did not have any signage indicating the patient was on isolation precautions.
An interview was conducted with S21LPN/IC (Infection Control Nurse) on 01/06/15 at 9:15 a.m. She reported the nurse whom admitted the patient should either have; called S5IC or looked at the CDC (Center of Disease Control) guidelines posted in a notebook on the unit to determine the appropriate isolation for the patient. S21LPN/IC agreed Patient #5 should be on contact isolation and not only on universal precautions.
An interview was conducted with S3DON/QA on 01/06/15 at 11:00 a.m. She verified Patient #5 should be on contact isolation and the patient was currently only on universal precautions.
4) Dietary Department failure to ensure that established infection control dietary policies and procedures were monitored and maintained for safe and sanitary food handling practices. This failed practice was evidenced by observations of:
1) large clean baking pans (x 6) not stored upside down on the clean storage racks,
2) a large container of cornmeal and a large container of sugar stored next to sink where raw meat was prepared,
3) dietary staff (S23Cook and S24Cook) observed during food preparation going (back and forth) from the food prep area to the dirty dishwashing room to wash dirty utensils and/or pots without changing their plastic aprons or performing hand hygiene after removing gloves when leaving the dirty dishwashing room and before returning to the food prep area to continue to prepare food for patient consumption,
4) discolored antibacterial wipes in 1 of 2 containers mounted on the kitchen wall and used by staff for disinfecting the kitchen area and an observation of the second antibacterial container being empty,
5) a used mop head stored in the mop bucket in the same room where food items were also stored,
6) cleaning chemicals and cleaning equipment and food items being stored together on the same shelf in a storage room and in the same room. and
7) a patient meal in a styrofoam container stored in a 155 degree Fahrenheit warming cabinet.

A review of the hospital policy titled, "Infection Control in Food Service", provided by S8RD/DM as the most current, revealed in part: The Dietary Department will maintain infection prevention and control practices and educate staff on appropriate precautions to be taken when performing assigned duties. The Dietary Director will be responsible for monitoring compliance with infection control prevention and control practices, including education and practice issues and strict adherence by staff in infection control practices in food preparation.

In an interview on 1/06/15 at 12:35 p.m. with S8RD/DM she indicated that she was the Director of the Dietary Department and a Registered Dietician. S8RD/DM was made aware of the observations in the Dietary Department regarding infection control breaches. S8RD/DM indicated that those practices were not acceptable infection control practices.



31206



30172

Based on interviews and record reviews the hospital failed to ensure that policies were developed that incorporated the OPO (Organ Procurement Organization) and the hospital's definition of Clinical Triggers, Imminent Death and Timely Notification in order to identify potential donors as agreed upon by the hospital's OPO contract and in accordance with the Louisiana Uniform Anatomical Gift Act. This failed practice was evidenced by no documentation in the hospital's "Organ and Tissue Donation" policy that included a definition of Clinical Triggers, Imminent Death and Timely Notification.

Findings:
A review of the hospital policy titled, "Organ and Tissue Donation", as provided by S1ADM as the most current, revealed in part: The hospital has an agreement with an OPO for identification and referral of potential organ, tissue and eye donors. The OPO will be notified in a timely manner of all patients whose death is imminent.
There was no other verbiage noted in the policy defining "Clinical Triggers, Imminent Death and Timely Notification".

A review of the hospital's OPO signed contract dated 12/10/13 and provided by S1ADM, as the current contract, revealed in part: By entering into this agreement, the Donor Hospital agrees to meet all the obligations set forth by the Louisiana Uniform Anatomical Gift Act and CMS. Timely referral is defined as within 2 hours or less of when a Donor Hospital identifies a patient that meets the criteria for medically established "Clinical Triggers/ Imminent Death" for organ donation evaluation as established by the Donor Hospital's definition of "Clinical Triggers/Imminent Death".

In an interview on 1/07/15 at 9:15 a.m with S39RN she indicated that she worked the High Observation Unit at the hospital. She indicated that it was a 5 bed unit that had the "more critical" patients, to include patients on ventilators. S39RN was asked about the hospital's OPO policy and the clinical triggers that identified possible "imminent death" patients and the timeliness of notifying the hospital's OPO of possible "imminent death" patients in regard to potential organ donation. S39RN indicated that she did not remember exactly what the hospital's OPO policy's definition was on "imminent death" or if the hospital had a policy that defined "imminent death". She further indicated that they (staff) did not notify the OPO until after the patient had died and was not aware of an OPO agreement/requirement to notify the OPO of a patient's "imminent death". S39RN indicated that the clinical triggers of "imminent death" could be related to several patient factors and she did not think the hospital policy had defined clinical triggers for "imminent death". S39RN further indicated that they (staff) try to call the OPO in a timely manner after a patient had died and was not sure if the hospital policy specified an exact time frame.
S39RN further indicated that Patient #22 had a poor prognosis according to S14MedDir/QA's progress notes,dated 1/05/15 and the patient was unable to be weaned from the ventilator and was unstable.

In an interview on 1/07/15 at 9:35 a.m. with S41MD, he indicated that he was one of Patient #22's attending physicians. S41MD further indicated that Patient #22 would be defined as "imminent death".

In an interview on 1/07/15 at 12:30 p.m. with S3DON/QA, she was made aware of the interviews with S39RN and S41MD. S3DON/QA indicated that the hospital's OPO policy needed to be revised to include the definitions on "Clinical Triggers, Imminent Death and Timely Notification". She further indicated that staff and physicians needed to be in-serviced on the hospital's OPO contract/policy.