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Based on record review and interview, the hospital failed to meet the Condition of Participation relative to laboratory services by failing to ensure that the laboratory services were available 24 hours per day 7 days per week to patients hospitalized at St. Catherine Memorial Hospital. This was evidenced by the hospital's laboratory service agreement which stated that "STAT Phlebotomy Services/Courier Services will be available seven day a week between the hours of 8:00am to 9:00pm only".
(Cross reference to findings cited at A0582)

Based on record review, observations and interviews, the hospital failed to meet the Condition of Participation relative to Food and Dietetic Services as evidenced by:

1. Failing to ensure that there was a full-time employee who serves as the director of the food and dietetic services; (cross reference to findings cited at A0620)

2. Failing to ensure that there was a full-time employee who is responsible for the daily management of the dietary services including the safety practices for food handling; (cross reference to findings cited at A0620)

3. Failing to ensure that care plans were kept current relating to the unexplained weight gain and/or weight loss of 3 of 10 sampled patients (Patient #10's documented weight loss of 32 pounds in 3 days, Patient #6's documented weight gain of 51 pounds in 3 weeks, & Patient #8's documented weight gain of 18.8 pounds in 5 days). This was evidenced by the dietician's failure to identify and investigate the cause of and/or accuracy of the documented weight loss and/or weight gain for these patients in order to determine the appropriate interventions to implement relating to the nutritional needs of these patients. (cross reference to findings cited at A0620)

Based on record review and interviews the governing body failed to ensure the contracted services of laboratory and radiology had been included in the Quality Assurance/Performance Improvement (QA/PI)program resulting in no documented evidence identified problems with the availability of services after hours, the timeliness of the pick-up of specimens or the availability of reports for posting on charts had been monitored. Findings:

Review of the Quality Indicators and QA/PI data revealed no documented evidence laboratory or radiology services had been included in the performance improvement program.

Review of the laboratory services agreement with Advanced Clinical Laboratory under the section of services revealed.... "STAT Phlebotomy Services/Courier Services will be available seven day a week between the hours of 8:00am to 9:00pm only". Further review revealed no evidence to indicate that laboratory services were available 24 hours per day 7 days per week.

In a face to face interview on 01/27/10 at 10:15am S13 the Director of Nursing (DON) indicated laboratory tests are drawn and then transported via laboratory courier to the lab where they will be analyzed. The Director of Nursing reported that "Advanced Clinical Laboratory" is the name of the company who the hospital had contracted with to provide laboratory services which includes courier services. S13 reviewed the section of the contract with "Advanced Clinical Laboratory" relating to stat laboratory services and confirmed that the documentation in the contract indicated that stat phlebotomy services and courier services would only be provided between the hours of 8:00 a.m. and 9:00 p.m. and could provide no documentation to indicate that laboratory services were available to patients hospitalized at St. Catherine Memorial Hospital 24 hours per day 7 days per week. Further the DON indicated she was not aware that laboratory services were not available 24 hours per day 7 days per week and contacted "Advanced Clinical Laboratory" (at the request of the surveyor) by telephone on 1/27/10 at 10:35 a.m. and spoke with S11 (Med Tech). S11 (Med Tech from Advanced Clinical Laboratory) reported that "Advanced Clinical Laboratory" does not provide laboratory services 24 hours per day 7 days per week. S11 reported that laboratory services are provided 7 days a week from 8:00 a.m. till 9:00 p.m. and verified services are not provided to the hospital between the hours of 9:00 p.m. and 8:00 a.m.

In a face to face interview on 01/27/10 at 1:00pm S12, Assistant Administrator the hospital had entered into a contract with "Advanced Clinical Laboratory" to provide laboratory services to patient's hospitalized at St. Catherine Memorial Hospital and is the only contracted provider used as of the date and time of this interview. S12 reported she was not aware of the fact that Advanced Clinical Laboratory did not provide services 24 hours per day 7 days per week. The Assistant Administrator reported that if the patient needed stat (immediate) laboratory services, then he/she would be transferred out to a hospital.

Based on record review and interview, the hospital failed to ensure that ongoing assessments were conducted to determine if the use of physical restraints remained the least restrictive way to protect the patient's safety. This was evidenced by failing to provide evidence to indicate that continued evaluations were conducted by staff to determine whether or not the physical restraints could be safely discontinued and by failing to indicate that the symptoms necessitating the use of restraints have persisted for 1 of 1 patients reviewed for the use of restraints out of a total sample of 10 patients. Findings:

The medical record of Patient #9 was reviewed. This review revealed that Patient #9 was admitted to the hospital on 12/05/09. Documentation in the medical record revealed that Patient #9 was assessed to be disoriented/confused, hallucinating, agitated, and climbing over the side rails on 11/23/09 at 11:00 a.m. Documentation revealed that Patient #9 was placed in bilateral wrist restraints on 11/23/09 at 11:00 a.m. Documentation revealed that Patient #9 remained in bilateral wrist restraints on 11/24/09, 11/25/09, 11/26/09 & 11/27/09. Documentation revealed that Patient #9 was transferred from St. Catherine Memorial Hospital to a nearby hospital on 12/27/09 at 6:45 p.m. Review of the medical record revealed no documentation to indicate that continued evaluations were conducted by staff to determine whether or not the physical restraints could be safely discontinued. Further review revealed no documentation to indicate that the symptoms necessitating the use of restraints have persisted for Patient #9.

The Director of Nursing was interviewed on 1/27/10 at 3:00 p.m. The Director of Nursing reviewed the medical record of Patient #9 and confirmed that the patient was placed in bilateral wrist restraints on 11/23/09 at 11:00 a.m. and remained in bilateral wrist restraints on 11/24/09, 11/25/09, 11/26/09 & 11/27/09. The Director of Nursing reported that the documentation in the medical record does not indicate that ongoing evaluations were conducted by staff to determine whether or not the physical restraints could be safely discontinued. In addition, the Director of Nursing reported that the documentation does not indicate that the symptoms necessitating the use of restraints have persisted for Patient #9 for the entire amount of time that the patient was in the bilateral wrist restraints.

Based on record review and interviews the hospital failed to implement and monitor the process to ensure the medical staff had been credentialed according to the Medical Staff By-Laws as evidenced by a Podiatrist providing care to patients without documentation of being initially credentialed or privileged as a podiatrist (S3) and by having two physicians (S1, S2) reappointed without documented evidence of required peer reviews, proof of insurance, and OIG (Office of Inspector General and NPDB investigations) before being re-appointed to the medical staff for 3 of 3 physician personnel files reviewed. Findings:

Review of the personnel/credentialing file for Medical Director S1 revealed he had been re-appointed on 05/01/08. Further review of the credentialing file revealed no documented evidence the process for re-appointment had been performed. Further review revealed documented evidence of the following: privileges dated 05/01/08; OIG report 09/09/06; NBDB 2006 and liability insurance with an expiration date of 07/06/09.

Review of the personnel/credentialing file for Pulmonologist S2 revealed he had been credentialed in 02/11/08. Further review of the entire file revealed no documented evidence of an NPDB query or OIG report.

Review of the personnel/credentialing file for Podiatrist S3 revealed the following documentation: a copy of the Louisiana State Board of Medical Examiners for S3 with an expiration date of 08/31/2009, a copy of a Class 09 license from the pharmacy Board for Controlled Dangerous Substance with an expiration date of 09/01/2009, and a certificate for malpractice insurance with an expiration date of 08/01/09. Further review revealed a Delineation of Privileges form titled Internal Medicine without documented evidence of the name of the physician or the signature of the applicant; however documented evidence revealed the Medical Director S1 had signed and dated the form on 04/01/09. Review of the entire file revealed no documented evidence of a signed statement from the applicant (S3) indicating the applicant had read the terms of the Medical Staff By-Laws and Rules and Regulations; qualifications; specific status requests; references from three peers; current and active liability insurance; current licensure; and background references with the OIG (Office of Inspector General) and NPDB database as required by the medical staff own bylaws.

Review of the Medical Staff By-Laws, last revised 12/2000, revealed..... "Article VI, Section 6.1 Procedures for Appointment and Reappointment: The medical staff through its services, committees and officers, shall investigate, verify and consider each application for appointment...." Further review revealed the following was required for the credentialing process: an application form, acknowledgement and agreement with the Medical Staff By-Laws and Rules and Regulations, qualifications, requests for privileges, references, and professional sanctions, professional liability insurance.

In a face to face interview on 01/28/10 at 11:30am S12, Administrator, indicated S14, the Director of Human Resources, was the person responsible for the credentialing process for the medical staff. S12 reviewed the personnel/credentialing files of Physicians S1, S2, and S3 and verified that the credentialing process had not been performed and indicated maybe the Human Resource Director needed additional training. Further she verified the letter found in each of the physicians' files indicating the Governing Body, of which she is a member, had appointed the physicians to the medical staff without the required information. S12, the Administrator indicated the hospital does not have a Medical Executive Committee at the present time.

In a face to face interview on 01/28/010 at 1:00pm S14, the Human Resource Director, indicated she has been in this position for about two years and had no prior human resource experience. Further S14 indicated when she was put in Human Resources she utilized the process already in place which was the use of a tickler file. S14 could not explain to the surveyor why the credentialing process had not been completed for physicians S1, S2, or S3.

Based on record review and interview the facility failed to ensure the medical staff had a medical executive committee resulting in failure to implement a credentialing process for the appointment and reappointment of the medical staff as evidenced by the lack of documented evidence for 3 of 3 sampled physicians (S1, S2, S3). Findings:

Review of the Governing Board By-Laws dated 06/15/10 and the Medical Staff By-Laws dated 12/00 both revealed the hospital must have a Medical Executive Committee comprised of a majority of physicians.

The hospital could not submit documented evidence of Medical Executive Committee meetings.

Review of the personnel/credentialing files of physicians S1, S2, and S3 revealed no documented evidence the credentialing process had been performed as evidenced by the lack of applications, privileges, investigational reports current licensure, peer reviews or current liability insurance.

In a face to face interview on 01/28/10 at 3:00pm S12 the Administrator indicated since S1, the Medical Director, was the only physician on staff full time it was not possible to have a Medical Executive Committee. Further S12 explained the other physicians were on a consulting status and the physician who covered the medical director when he was out was not full-time. The Administrator indicated S1 was a member of both the Governing Board and the Performance Improvement Committees so anything he needed to discuss could be done in those meetings.

Based on record review and interviews the hospital failed to ensure RN (Registered Nurse) supervision of care as evidenced by: a) nursing staff failing to perform accurate patient weights resulting in the dietitian basing dietary recommendations on incorrect information (#6, #8, #10); b) nurses failing administer medication as ordered by the physician resulting in Lopressor being administered without assessment of blood pressure and pulse and in Lopressor being administered to a patient with a blood pressure outside of the ordered parameters (Patient #5); c) nurses failing to monitor lab orders resulting in untimely completion of laboratory tests (#1, #8); d) nurses failing to ensure justification for use of restraints had been documented and periodic release of restraints had been performed resulting in a patient being in restraints continually for a period of 5 days (Patient #9); e) nurses failing to ensure care plans were accurate and periodically re-evaluated resulting in dietary needs not identified and interventions implemented, and/or development of inappropriate interventions and expectations (#5, #6, #8, #9, #10) for 5 of 10 sampled patients. Findings:

a) failing to performing accurate patient weights resulting in the dietitian basing dietary recommendations on incorrect information
Patient#6: Review of the medical record revealed Patient #6 had been admitted to the hospital on 12/28/09 with a diagnosis of osteomyelitis. Review of the Admit Assessment dated 12/28/09 revealed a documented weight of 200 pounds. Review of the Nutritional Assessment dated 12/31/09 revealed a documented weight of 200 pounds which S15 the dietitian used to recommend a dietary plan to the physician. Review of the Nutritional Assessment dated 01/19/10 revealed a documented weight for Patient #6 as 251 pounds which indicated a weight gain of 51 pounds in 3 weeks. Further review of the entire medical record revealed no documented evidence the weight gain had been investigated by the dietitian or nursing staff or communicated to the physician in order to determine the appropriate plan and interventions in relation to the plan of care.

Patient #8: Medical record review revealed that Patient #8 was admitted to the hospital on 12/01/09 at 5:00 p.m. Documentation revealed that Patient #8 diagnoses included MRSA of the right shoulder and Endocarditis. Review of the documented weights of Patient #8 revealed that Patient #8's weight was documented as 135 pounds on 12/01/09 and 154.2 pounds on 12/06/09. This documentation indicated that Patient #8 gained 18.8 pounds in 5 days. Review of the medical record including the care plan for Patient #8 revealed no documentation to indicate that nursing or dietary staff had identified the unexplained weight gain of Patient #8 as an area that needed to be further investigated in order to determine the appropriate plan and interventions in relation to the plan of care.

Patient #10 Review of the medical record revealed Patient #10 was admitted to the hospital on 11/23/09 for Osteomyelitis, Diabetes Mellitus (DM) and Hypertension (HTN). Review of the Initial Nursing Assessment dated 11/23/09 revealed an admit weight of 286 pounds. Review of the Nutritional Assessment for Patient #10 dated 11/26/09 revealed a documented weight of 254 pounds which indicated a weight loss of 32 pounds in three days. Further review of the entire medical record revealed no documented evidence the weight gain had been investigated by the dietitian or nursing staff or communicated to the physician in order to determine the appropriate plan and interventions in relation to the plan of care.


b) nurses failing administer medication as ordered by the physician resulting in Lopressor being administered without assessment of blood pressure and pulse and in Lopressor being administered to a patient with a blood pressure outside of the ordered parameters
Review of the medical record revealed Patient #5 had been admitted on 01/06/10 with the primary diagnosis of decubitus ulcer an a secondary diagnosis which included HTN (Hypertension). Review of the Physician's Orders dated 01/06/10 revealed an order for Lopressor 25mg i tab (tablet) per PEG tube or mouth daily Hold if pulse less than or equal to 60 or SBP (Systolic Blood Pressure) less than or equal to 110.

Review of the MAR (Medical Administration Record) for Patient #5 revealed Lopressor has been administered to the patient without documented evidence the blood pressure or pulse had been assessed by the nurse before administration on the following dates and times:
01/12/10 at 9:00am, 01/13/10 at 9:00am; 01/16/10 at 9:00am, 01/17/10 at 9:00am, 01/18/10 at 9:00am, 01/19/10 at 9:00am, 01/20/10 at 9:00am, 01/21/10 at 9:00am, 01/22/10 at 9:00am, 01/23/10 at 9:00am, 01/24/10 at 9:00am, 01/25/10 at 9:00am and 01/26/10 at 9:00am.

Review of the Graphic Sheets for Patient #5 dated 01/06/10 through 01/26/10 revealed the blood pressure and pulse for #5 had been performed by the CNA (Certified Nursing Staff) at 7:00am. Further review of the Graphic sheet, MARs and the Nurses Notes revealed no documented evidence additional assessments of blood pressure and pulse had been performed before the administration of the Lopressor at 9:00am on 01/12/10, 01/13/10, 01/16/10, 01/17/10, 01/18/10, 01/19/10, 01/20/10, 01/21/10, 01/22/10, 01/23/10, 01/24/10, 01/25/10, and 01/26/10.

Review of the MAR for Patient #5 dated 01/14/10 revealed documented evidence of a blood pressure of 99/59 and a line marked through the 9:00am dose and the initials of the nurse indicating the medication had been administered. Further review of the nurses' notes dated 01/14/10 revealed no documented evidence an assessment of the patient had been performed after the medication had been administered until the 7:00pm vital signs had been taken.

In a face to face interview on 01/29/10 at 10:00am S11, the Director of Nurisng (DON) indicated before Lopressor is administered a blood pressure and pulse should be assessed by the nurse administering the medication and documented on the MAR, nursing notes or graph sheet. Further she indicated it is not a timely assessment to use the vital signs taken at 7:00am since medication administration can be performed up until 10:00am. The DON indicated the dose of Lopressor which had been administered to the patient when below the parameters should not have been given.

c) nurses failing to monitor lab orders resulting in untimely completion of laboratory tests
Patient #1:
Review of the medical record for Patient #1 revealed she was admitted to St. Catherine Memorial Hospital on 12/30/09 at 1:00 p.m. with the admitting diagnoses which included "wound infection lower extremity". Review of the admission orders revealed an order dated 12/30/09 at 1:00 p.m. to "culture all wounds upon admit". Review of the medical record revealed documentation indicating that the results of the wound culture were not completed until 1/07/10 at 1:50 p.m. which was greater than 8 days after the order was entered into the patient's medical record.

In a face to face interview on 1/27/10 at 10:10 a.m. S13, Director of Nursing, reviewed the medical record of Patient #1 and confirmed that the wound culture was ordered on 12/30/09 at 1:00 p.m. Further she indicated the results of the wound culture were dated 1/07/10 at 1:50 p.m. ; however she could not determine a reason for the delay in the processing of the wound culture.

S11 (Med Tech from Advanced Clinical Laboratory) was interviewed by telephone on 1/27/10 at 10:35 a.m. S11 reviewed the laboratory reports for Patient #1 and reported that the wound culture ordered for Patient #1 on 12/30/09 at 1:00 p.m. should have taken 5 days to process. When asked by the surveyor as to why the wound culture ordered for Patient #1 on 12/30/09 at 1:00 p.m. took 8 days to process, S11 reported that the delay was not a result of laboratory services provided by Advanced Clinical Laboratory. S11 reported that the wound culture did not arrive at Advanced Clinical Laboratory until 1/02/10 which was 3 days after being ordered. S11 reported that the results of the wound culture were reported to St. Catherine Memorial Hospital within 5 days of Advanced Clinical Laboratory's receipt of the specimen.

Patient #8:
Review of the medical record for Patient #8 revealed he had been admitted to St. Catherine Memorial Hospital on 12/01/09 at 5:00 p.m. with a diagnosis of MRSA of the right shoulder. Documentation on the admission orders revealed an order dated 12/01/09 at 5:00 p.m. to "culture all wounds upon admit". According to documentation in the medical record, the results of the wound culture were documented as "No growth in 48 hours" and dated 12/05/09 at 4:08 p.m. This revealed an inconsistent time frame in the reporting of the results in that 48 hours from the time of order would indicate that the results should have been reported on 12/03/09 (which would be 48 hours after being ordered) and not on 12/05/09.

In a face to face interview on 01/28/10 at 11:55am S13, Director of Nursing reviewed the medical record of Patient #8 and confirmed that the wound culture was ordered on 12/01/09 at 5:00 p.m.. Review of the results of the wound culture indicate that as of 12/05/09 at 4:08 p.m., there was "no growth in 48 hours". S13 confirmed that 48 hours after being ordered would indicate that the results should have been reported on 12/03/09; however the Director of Nursing reported that she could not determine why this report was dated 12/05/09 and not 12/03/09 unless there was a delay in processing the order.


d) nurses failing to ensure justification for use of restraints had been documented and periodic release of restraints had been performed resulting in a patient being in restraints continually for a period of 5 days
Review of the medical record of Patient #9 revealed that Patient #9 had been admitted to the hospital on 12/05/09. Documentation in the medical record revealed that Patient #9 was assessed to be disoriented/confused, hallucinating, agitated, and climbing over the side rails on 11/23/09 at 11:00 a.m. Documentation revealed that Patient #9 was placed in bilateral wrist restraints on 11/23/09 at 11:00 a.m. Documentation revealed that Patient #9 remained in bilateral wrist restraints on 11/24/09, 11/25/09, 11/26/09 & 11/27/09. Documentation revealed that Patient #9 was transferred from St. Catherine Memorial Hospital to a nearby hospital on 12/27/09 at 6:45 p.m. Review of the medical record revealed no documentation to indicate that continued evaluations were conducted by staff to determine whether or not the physical restraints could be safely discontinued. Further review revealed no documentation to indicate that the symptoms necessitating the use of restraints have persisted for Patient #9.

In a face to face interview on 1/27/10 at 3:00 p.m. S13, Director of Nursing, reviewed the medical record of Patient #9 and confirmed that the patient was placed in bilateral wrist restraints on 11/23/09 at 11:00 a.m. and remained in bilateral wrist restraints on 11/24/09, 11/25/09, 11/26/09 & 11/27/09. S13 reported that the documentation in the medical record did not indicate that ongoing evaluations were conducted by staff to determine whether or not the physical restraints could be safely discontinued. In addition, the Director of Nursing reported that the documentation does not indicate that the symptoms necessitating the use of restraints have persisted for Patient #9 for the entire amount of time that the patient was in the bilateral wrist restraints. Findings:


e) nurses failing to ensure care plans were accurate and periodically re-evaluated resulting in dietary needs not identified, interventions implemented, and/or inappropriate interventions and expectations
Patient #5
Review of the medical record for Patient #5 revealed she was a 67 year old female admitted on 01/06/10 for a decubitus ulcer and wound care. Further review revealed #5 had an indwelling catheter and a colostomy. Review of the Plan of Care dated 01/06/10 revealed Patient #5 had identified problems as follows: altered function and impaired mobility, interventions listed as assistance with ADLs (Activities of Daily Living), PT and OT assessments and expected outcome of functional independence for safe ADLs and mobility, and as of 01/27/10 no documented evidence of any re-evaluation date; altered bowel and bladder with appliance, interventions assess abdomen, bowel sounds appetite, straining, oozing of stool, bowel training and instruct on devices of ostomy and catheter, expected outcomes of formed BM (Bowel Movement) every 72 hours and bladder empty and infection prevented even though the patient had a colostomy and an indwelling catheter; and altered communicated due to auditory problems with no documented evidence of any interventions to be implemented. Further review of the plan of care revealed the patient had not been care planned for discharge planning even though the social worker documented the patient would be requiring a hospital bed and wheelchair for discharge in her progress notes.

Patient #6
Review of the medical record for Patient #6 revealed he was a 28 year old male admitted on 12/28/09 for osteomyelitis). Review of the Plan of Care dated 12/28/09 revealed Patient #6 had identified problems as follows: altered mobility, alteration on bowel and bladder, alteration in comfort, skin integrity due to pressure ulcers, and potential for infection. Further review revealed no documented evidence the interventions had been re-evaluated or if the goals had ever been met. Review of the Nutritional evaluation dated 12/28/09 for Patient #6 revealed weight of 200 pounds and a diet a recommended for restricting foods high in Vitamin K, albumin level, encouragement of fruit for dessert, no fried foods and skim milk. Review of the assessment dated 01/19/10 revealed the patient's weight at 251 pounds (a documented weight gain of 51 pounds in a 3 week period. Further review revealed no documented evidence the weight gain had been verified by a recheck of the weight, reported to the physician or included as a change in condition on the patient's care plan.


Patient #8
Medical record review revealed that Patient #8 was admitted to the hospital on 12/01/09 at 5:00 p.m. Documentation revealed that Patient #8 diagnoses included MRSA of the right shoulder and Endocarditis. Review of the documented weights of Patient #8 revealed that Patient #8's weight was documented as 135 pounds on 12/01/09 and 154.2 pounds on 12/06/09 indicating a weight gain of 18.8 pounds in 5 days. Review of the medical record including the care plan for Patient #8 revealed no documentation to indicate that nursing or dietary staff had identified the unexplained weight gain of Patient #8 as an area that needed to be further investigated in order to determine the appropriate plan and interventions in relation to the plan of care.

The Director of Nursing was interviewed on 1/27/10 at 2:05 p.m. The Director of Nursing reviewed the medical record of Patient #8 and reported that she felt that there was an error in documentation relating to Patient #8's weight. The Director of Nursing indicated that she did not believe that Patient #8 gained 18.8 pounds in 5 days. The Director of Nursing confirmed that there was no documentation in the medical record to indicate that staff had identified the unexplained weight gain of Patient #8 as an area that needed to be further investigated in order to determine the appropriate plan and interventions in relation to the plan of care.

Patient #9
Review of the medical record for Patient #9 revealed she was a 64 year old female admitted on 12/05/09 for cellulitis, Peripheral Vascular Disease (PVD) with a history of Diabetes Mellitus (DM) and a right foot amputation.
Review of the Plan of Care dated 12/05/09 revealed Patient #9 had identified problems as follows: altered function and impaired mobility, interventions listed as assistance with ADLs (Activities of Daily Living), PT and OT assessments and expected outcome of functional independence for safe ADLs and mobility, potential for falls, skin integrity due to pressure ulcer, potential for infection, and glucose metabolism and as of 01/28/10 no documented evidence of any re-evaluation date or attainment of goals.
Further review of the plan of care revealed #9 had not been care planned for nutrition, emotional problems adjusting to amputation or discharge planning even though the dietitian recognized poor appetite/low intake and ordered a 3 day calorie count and the social worker documented the patients behavior, use of restraints and possible need for NH (Nursing Home) placement.

Patient #10
Review of the medical record for Patient #10 revealed he was a 46 year old male admitted on 11/23/09 for osteomyelitis with a history of Diabetes Mellitus (DM) and Hypertension (HTN).
Review of the Plan of Care dated 11/23/09 revealed Patient #10 had identified problems as follows: potential for falls with the intervention of Patient/Family education regarding fall prevention with documented evidence on the plan of care or Patient Education record that neither the patient or the family had been instructed on fall prevention.

Review of the Nutritional Assessment dated 11/26/09 revealed Patient #10 had a low albumin and nutritional changes were recommended by the physician and ordered by the MD; however there was no evidence of the change in the patient's condition had been documented in the plan of care or had been discussed in the Interdisciplinary Team Treatment Plan.

Review of the Social Service Progress Note revealed two entries as follows: 11/24/09 at 11:45am "S10 was admitted to hospital on 11/23/09. Patient (Pt.) will return to apt (apartment) when dc'ed (discharged). Pt. lives alone and 12/15/09 1:00pm Pt. left facility against medical advice"; however there was no documented evidence discharge planning had been included in the identified needs in the plan of care.

Review of the initial assessment for Patient #10 dated 11/23/09 revealed no documented evidence of any uncooperative or depressed behavior; however on 12/15/09 the patient demanded to go home and left AMA (Against Medical Advise). Review of the Physician's Orders for Patient #10 dated 11/23/09 revealed an order for Celexa (an antidepressant) and then on 12/01/09 an order to hold Celexa; however there was no documentation of the patient's change in condition.

In a face to face interview on 01/28/10 at 1:00pm S15 the Dietitian indicated she remembered #10 complained all of the time and was non-compliant; however there was no documented evidence of non-compliance in the plan of care or interventions implemented.

Review of Policy #NP-141 dated 05/28/08 and submitted as the one currently in use, revealed...... "a care plan is established for all patients to properly identify the problems, goals and interventions of the nursing staff. Care plans individualized to reflect patient care. Care plans updated to reflect any changes in the patient's condition. Care plans updated when a problem is resolved....."

In a face to face interview on 01/29/10 at 10:00am S13 the Director of Nursing indicated the plan of care for the patients had not been monitored and she was aware the care plans needed improvement.

Based on record review and interview the hospital failed to implement appropriate interventions and update patients' individual plans of care to meet the identified needs of the patient and changes in patients' conditions as evidenced by a change in the patient's condition related to weight gain or loss (#6, #8), expecting the outcome of a patient with a colostomy to have formed stools every 72 hours through the use of bowel training and identification of communication problems due to hearing impairment without any documented interventions implemented (#5), identified problems of inability to cope with loss of a limb, nutrition, restraints, and discharge planning not care planned or interventions implemented documented (#9), identified problems of weight/nutrition, discharge planning, and behavior not care planned or documentation of interventions implemented (#10) for 5 of 10 sampled patients. Findings:

Patient #6
Review of the medical record for Patient #6 revealed he was a 28 year old male admitted on 12/28/09 for osteomyelitis). Review of the Plan of Care dated 12/28/09 revealed Patient #6 had identified problems as follows: altered mobility, alteration on bowel and bladder, alteration in comfort, skin integrity due to pressure ulcers, and potential for infection. Further review revealed no documented evidence the interventions had been re-evaluated or if the goals had ever been met.

Review of the Nutritional evaluation dated 12/28/09 for Patient #6 revealed weight of 200 pounds and a diet a recommended for restricting foods high in Vitamin K, albumin level, encouragement of fruit for dessert, no fried foods and skim milk. Review of the assessment dated 01/19/10 revealed the patient's weight at 251 pounds (a documented weight gain of 51 pounds in a 3 week period. Further review revealed no documented evidence the weight gain had been verified by a recheck of the weight, reported to the physician or included as a change in condition on the patient's care plan.

Patient #5
Review of the medical record for Patient #5 revealed she was a 67 year old female admitted on 01/06/10 for a decubitus ulcer and wound care. Further review revealed #5 had an indwelling catheter and a colostomy.

Review of the Plan of Care dated 01/06/10 revealed Patient #5 had identified problems as follows: altered function and impaired mobility, interventions listed as assistance with ADLs (Activities of Daily Living), PT and OT assessments and expected outcome of functional independence for safe ADLs and mobility, and as of 01/27/10 no documented evidence of any re-evaluation date; altered bowel and bladder with appliance, interventions assess abdomen, bowel sounds appetite, straining, oozing of stool, bowel training and instruct on devices of ostomy and catheter, expected outcomes of formed BM (Bowel Movement) every 72 hours and bladder empty and infection prevented even though the patient had a colostomy and an indwelling catheter; and altered communicated due to auditory problems with no documented evidence of any interventions to be implemented. Further review of the plan of care revealed the patient had not been care planned for discharge planning even though the social worker documented the patient would be requiring a hospital bed and wheelchair for discharge in her progress notes.

Patient #9
Review of the medical record for Patient #9 revealed she was a 64 year old female admitted on 12/05/09 for cellulitis, Peripheral Vascular Disease (PVD) with a history of Diabetes Mellitus (DM) and a right foot amputation.
Review of the Plan of Care dated 12/05/09 revealed Patient #9 had identified problems as follows: altered function and impaired mobility, interventions listed as assistance with ADLs (Activities of Daily Living), PT and OT assessments and expected outcome of functional independence for safe ADLs and mobility, potential for falls, skin integrity due to pressure ulcer, potential for infection, and glucose metabolism and as of 01/28/10 no documented evidence of any re-evaluation date or attainment of goals.
Further review of the plan of care revealed #9 had not been care planned for nutrition, emotional problems adjusting to amputation or discharge planning even though the dietitian recognized poor appetite/low intake and ordered a 3 day calorie count and the social worker documented the patients behavior, use of restraints and possible need for NH (Nursing Home) placement.

Patient #8
Medical record review revealed that Patient #8 was admitted to the hospital on 12/01/09 at 5:00 p.m. Documentation revealed that Patient #8 diagnoses included MRSA of the right shoulder and Endocarditis. Review of the documented weights of Patient #8 revealed that Patient #8's weight was documented as 135 pounds on 12/01/09 and 154.2 pounds on 12/06/09. This documentation indicated that Patient #8 gained 18.8 pounds in 5 days. Review of the medical record including the care plan for Patient #8 revealed no documentation to indicate that nursing or dietary staff had identified the unexplained weight gain of Patient #8 as an area that needed to be further investigated in order to determine the appropriate plan and interventions in relation to the plan of care.

S15 (Registered Dietician) was interviewed on 1/27/10 at 1:00 p.m. S15 reviewed the medical record of Patient #8 and reported that she felt that there was an error in documentation relating to Patient #8's weight. S15 reported that she did not believe that Patient #8 gained 18.8 pounds in 5 days. S15 confirmed that there was no documentation in the medical record to indicate that staff had identified the unexplained weight gain of Patient #8 as an area that needed to be further investigated in order to determine the appropriate plan and interventions in relation to the plan of care.

The Director of Nursing was interviewed on 1/27/10 at 2:05 p.m. The Director of Nursing reviewed the medical record of Patient #8 and reported that she felt that there was an error in documentation relating to Patient #8's weight. The Director of Nursing indicated that she did not believe that Patient #8 gained 18.8 pounds in 5 days. The Director of Nursing confirmed that there was no documentation in the medical record to indicate that staff had identified the unexplained weight gain of Patient #8 as an area that needed to be further investigated in order to determine the appropriate plan and interventions in relation to the plan of care.

Patient #10
Review of the medical record for Patient #10 revealed he was a 46 year old male admitted on 11/23/09 for osteomyelitis with a history of Diabetes Mellitus (DM) and Hypertension (HTN).
Review of the Plan of Care dated 11/23/09 revealed Patient #10 had identified problems as follows: potential for falls with the intervention of Patient/Family education regarding fall prevention with documented evidence on the plan of care or Patient Education record that neither the patient or the family had been instructed on fall prevention.

Review of the Nutritional Assessment dated 11/26/09 revealed Patient #10 had a low albumin and nutritional changes were recommended by the physician and ordered by the MD; however there was no evidence of the change in the patient's condition had been documented in the plan of care or had been discussed in the Interdisciplinary Team Treatment Plan.

Review of the Social Service Progress Note revealed two entries as follows: 11/24/09 at 11:45am "S10 was admitted to hospital on 11/23/09. Patient (Pt.) will return to apt (apartment) when dc'ed (discharged). Pt. lives alone and 12/15/09 1:00pm Pt. left facility against medical advice"; however there was no documented evidence discharge planning had been included in the identified needs in the plan of care.

Review of the initial assessment for Patient #10 dated 11/23/09 revealed no documented evidence of any uncooperative or depressed behavior; however on 12/15/09 the patient demanded to go home and left AMA (Against Medical Advise).

Review of the Physician's Orders for Patient #10 dated 11/23/09 revealed an order for Celexa (an antidepressant) and then on 12/01/09 an order to hold Celexa; however there was no documentation of the patient's change in condition.

In a face to face interview on 01/28/10 at 1:00pm S15 the Dietitian indicated she remembered #10 complained all of the time and was non-compliant; however there was no documented evidence of non-compliance in the plan of care or interventions implemented.

Review of Policy #NP-141 dated 05/28/08 and submitted as the one currently in use, revealed...... "a care plan is established for all patients to properly identify the problems, goals and interventions of the nursing staff. Care plans individualized to reflect patient care. Care plans updated to reflect any changes in the patient's condition. Care plans updated when a problem is resolved....."

In a face to face interview on 01/29/10 at 10:00am S13 the Director of Nursing indicated the plan of care for the patients had not been monitored and she was aware the care plans needed improvement.

Based on record review and interview, the hospital failed to 1) ensure that laboratory services were available 24 hours per day 7 days per week to patients hospitalized at St. Catherine Memorial Hospital and 2) ensure the timely completion of laboratory tests for 2 of 10 sampled patients (Patient #1, Patient #8) .Findings:

1. Failure to ensure that laboratory services were available 24 hours per day 7 days per week to patients hospitalized at St. Catherine Memorial Hospital.

The hospital's laboratory services agreement was reviewed. This review revealed that the hospital has contracted with "Advanced Clinical Laboratory" for laboratory services. Further review revealed no evidence to indicate that laboratory services were available 24 hours per day 7 days per week. Documentation under the section of services provided revealed documentation indicating in part "STAT Phlebotomy Services/Courier Services will be available seven day a week between the hours of 8:00am to 9:00pm only".

The Director of Nursing was interviewed on 1/27/10 at 10:15 a.m. relating to the process for obtaining and transporting ordered laboratory tests. The Director of Nursing reported that laboratory tests are drawn and then transported via laboratory courier to the lab where they will be analyzed. The Director of Nursing reported that "Advanced Clinical Laboratory" is the name of the company who the hospital has contracted with to provide laboratory services which includes courier services. The Director of Nursing reviewed the section of the contract with "Advanced Clinical Laboratory" relating to stat laboratory services and confirmed that the documentation in the contract indicated that stat phlebotomy services and courier services would only be provided between the hours of 8:00 a.m. and 9:00 p.m. The Director of Nursing could provide no documentation to indicate that laboratory services were available to patient's hospitalized at St. Catherine Memorial Hospital 24 hours per day 7 days per week. The Director of Nursing reported that she was not aware that laboratory services were not available 24 hours per day 7 days per week. The Director of Nursing contacted "Advanced Clinical Laboratory" (at the request of the surveyor) by telephone on 1/27/10 at 10:35 a.m. and spoke with S11 (Med Tech). S11 (Med Tech from Advanced Clinical Laboratory) reported that "Advanced Clinical Laboratory" does not provide laboratory services 24 hours per day 7 days per week. S11 reported that laboratory services are provided 7 days a week from 8:00 a.m. till 9:00 p.m. S11 reported that laboratory services are not provided between the hours of 9:00 p.m. and 8:00 a.m.

The hospital's Assistant Administrator was interviewed on 1/27/10 at 1:00 p.m. The Assistant Administrator reported that St. Catherine Memorial Hospital has entered into a contract with "Advanced Clinical Laboratory" to provide laboratory services to patient's hospitalized at St. Catherine Memorial Hospital. The Assistant Administrator reported that "Advanced Clinical Laboratory" is the only contracted laboratory service provider for St. Catherine Memorial Hospital as of the date and time of this interview. The Assistant Administrator reported that she was not aware of the fact that Advanced Clinical Laboratory did not provide services 24 hours per day 7 days per week. The Assistant Administrator reported that if the patient needed stat (immediate) laboratory services, then he/she would be transferred out to a hospital.


2. Failure to ensure the timely completion of laboratory tests for 2 of 10 sampled patients.

Patient #1: Medical record review revealed that Patient #1 was admitted to St. Catherine Memorial Hospital on 12/30/09 at 1:00 p.m. Documentation on the admission orders revealed that Patient #1's admitting diagnoses included "wound infection lower extremity". Documentation on the admission orders revealed an order dated 12/30/09 at 1:00 p.m. to "culture all wounds upon admit". Review of the medical record revealed documentation indicating that the results of the wound culture was not completed until 1/07/10 at 1:50 p.m. which was greater than 8 days after the order was entered into the patient's medical record.

The Director of Nursing was interviewed on 1/27/10 at 10:10 a.m. The Director of Nursing reviewed the medical record of Patient #1 and confirmed that the wound culture was ordered on 12/30/09 at 1:00 p.m. and the results of the wound culture were dated 1/07/10 at 1:50 p.m. The Director of Nursing reported that she could not determine a reason for the delay in the processing of the wound culture.

S11 (Med Tech from Advanced Clinical Laboratory) was interviewed by telephone on 1/27/10 at 10:35 a.m. S11 reviewed the laboratory reports for Patient #1 and reported that the wound culture ordered for Patient #1 on 12/30/09 at 1:00 p.m. should have taken 5 days to process. When asked by the surveyor as to why the wound culture ordered for Patient #1 on 12/30/09 at 1:00 p.m. took 8 days to process, S11 reported that the delay was not a result of laboratory services provided by Advanced Clinical Laboratory. S11 reported that the wound culture did not arrive at Advanced Clinical Laboratory until 1/02/10 which was 3 days after being ordered. S11 reported that the results of the wound culture were reported to St. Catherine Memorial Hospital within 5 days of Advanced Clinical Laboratory's receipt of the specimen.

Patient #8: Medical record review revealed that Patient #8 was admitted to St. Catherine Memorial Hospital on 12/01/09 at 5:00 p.m. Documentation revealed that Patient #8 had MRSA of the right shoulder. Documentation on the admission orders revealed an order dated 12/01/09 at 5:00 p.m. to "culture all wounds upon admit". According to documentation in the medical record, the results of the wound culture were documented as "No growth in 48 hours" and dated 12/05/09 at 4:08 p.m. This revealed an inconsistent time frame in the reporting of the results in that 48 hours from the time of order would indicate that the results should have been reported on 12/03/09 (which would be 48 hours after being ordered) and not on 12/05/09.

The Director of Nursing was interviewed on 1/28/10 at 11:55 a.m. The Director of Nursing reviewed the medical record of Patient #8 and confirmed that the wound culture was ordered on 12/01/09 at 5:00 p.m. and the results of the wound culture indicate that as of 12/05/09 at 4:08 p.m., there was "no growth in 48 hours". The Director of Nursing confirmed that 48 hours after being ordered would indicate that the results should have been reported on 12/03/09. The Director of Nursing reported that she could not determine why this report was dated 12/05/09 and not 12/03/09 unless there was a delay in processing the order.

Based on record review, observations and interviews, the hospital failed to 1) ensure that there was a full-time employee who serves as the director of the food and dietetic services; 2) ensure that there was a full-time employee who is responsible for the daily management of the dietary services including the safety practices for food handling; and 3) ensure that care plans were kept current relating to the unexplained weight gain and/or weight loss resulting in nutritional recommendations for treatment based on inaccurate information for 3 of 10 sampled patients (#6, #8, #10). Findings:

1. Failure to ensure that there was a full-time employee who serves as the director of the food and dietetic services.
Review of the hospital's list of key personnel revealed no evidence to indicate that there was a full-time employee who serves as the director of the food and dietetic services.

The hospital's Assistant Administrator was interviewed on 1/27/10 at 12:50 p.m. relating to the person designated to serve in the role of director of the food and dietetic services. The Assistant Administrator reported that S15 (Registered Dietician) is the person designated to serve in the role of director of food and dietetic services.

S15 (Registered Dietician) was interviewed on 1/27/10 at 1:00 p.m. S15 reported that she is the contracted registered dietician for St. Catherine Memorial Hospital. S15 reported that she provides services at St. Catherine Memorial Hospital on a part time basis. S15 reported that there is no person designated to function in the role of dietary manager or director of food and dietetic services at St. Catherine Memorial Hospital.

The Director of Nursing was interviewed on 1/27/10 at 2:00 p.m. relating to the person designated to serve in the role of director of the food and dietetic services. The Director of Nursing reported that S15 (Registered Dietician) is the person designated to serve in the role of director of food and dietetic services. The Director of Nursing indicated that dietary services is a contracted service and reported that she is not aware of any other staff member, other than S15, who functions in the role of director of food and dietetic services for the hospital. The Director of Nursing reported that S15 is a contracted dietician who provides services on a part time basis at St. Catherine Memorial Hospital. The Director of Nursing reported that St. Catherine Memorial Hospital does not employ a full time person to serve as the director of food and dietetic services.


2. Failure to ensure that there was a full-time employee who is responsible for the daily management of the dietary services including the safety practices for food handling.
In an interview with Patient #3 on 1/26/10 at 10:40 a.m., Patient #3 voiced multiple complaints relating to the quality and temperature of the food being served at the hospital. Patient #3 reported that the hot foods are not always served hot and the cold foods are not always served cold.

An observation on 1/27/10 at 11:40 a.m. revealed food trays being delivered to patient rooms by S16 (CNA). When asked by the surveyor as to the process utilized at the hospital to ensure that foods are being served to patients at the correct temperatures, S16 stated that she just delivers the food to the patients. S16 reported that she is not aware of any process to ensure that foods are being served to patients at the correct temperature. S16 indicated that she has not been made aware of any requirements relating to food temperatures. In addition, S16 reported that she is not aware of anyone obtaining the temperature of food prior to serving the food to patients. The temperature of the food on the meal tray being brought to Patient #3's room was tested by this surveyor in the presence of S16. The temperature of the mashed potatoes was 118 degrees Fahrenheit and the temperature of the milk was 50.4 degrees Fahrenheit.

S15 (Registered Dietician) was interviewed on 1/27/10 at 1:00 p.m. S15 reported that she is the contracted registered dietician for St. Catherine Memorial Hospital. S15 reported that the hot foods should be served at or above 120 degrees Fahrenheit and the milk should be at or below 40 degrees Fahrenheit.

Review of the sanitary conditions for hospital providers in the state of Louisiana revealed documentation indicating that In-room delivery temperatures shall be maintained at 120-F or above for hot foods and 50-F or below for cold items, except for milk which shall be stored at 41-F. Food shall be transported to the patients' rooms in a manner that protects it from contamination, while maintaining required temperatures.


3. Failure to ensure that care plans were kept current relating to the unexplained weight gain and/or weight loss of patients.

Patient#6: Review of the medical record revealed Patient #6 had been admitted to the hospital on 12/28/09 with a diagnosis of osteomyelitis. Review of the Admit Assessment dated 12/28/09 revealed a documented weight of 200 pounds. Review of the Nutritional Assessment dated 12/31/09 revealed a documented weight of 200 pounds which S15 the dietitian used to recommend a dietary plan to the physician. Review of the Nutritional Assessment dated 01/19/10 revealed a documented weight for Patient #6 as 251 pounds which indicated a weight gain of 51 pounds in 3 weeks. Further review of the entire medical record revealed no documented evidence the weight gain had been investigated by the dietitian or nursing staff or communicated to the physician in order to determine the appropriate plan and interventions in relation to the plan of care.

Patient #8: Medical record review revealed that Patient #8 was admitted to the hospital on 12/01/09 at 5:00 p.m. Documentation revealed that Patient #8 diagnoses included MRSA of the right shoulder and Endocarditis. Review of the documented weights of Patient #8 revealed that Patient #8's weight was documented as 135 pounds on 12/01/09 and 154.2 pounds on 12/06/09. This documentation indicated that Patient #8 gained 18.8 pounds in 5 days. Review of the medical record including the care plan for Patient #8 revealed no documentation to indicate that nursing or dietary staff had identified the unexplained weight gain of Patient #8 as an area that needed to be further investigated in order to determine the appropriate plan and interventions in relation to the plan of care.

Patient #10 Review of the medical record revealed Patient #10 was admitted to the hospital on 11/23/09 for Osteomyelitis, Diabetes Mellitus (DM) and Hypertension (HTN). Review of the Initial Nursing Assessment dated 11/23/09 revealed an admit weight of 286 pounds. Review of the Nutritional Assessment for Patient #10 dated 11/26/09 revealed a documented weight of 254 pounds which indicated a weight loss of 32 pounds in three days. Further review of the entire medical record revealed no documented evidence the weight gain had been investigated by the dietitian or nursing staff or communicated to the physician in order to determine the appropriate plan and interventions in relation to the plan of care.

S15 (Registered Dietician) was interviewed on 1/27/10 at 1:00 p.m. S15 reviewed the medical record of Patient #8 and reported that she felt that there was an error in documentation relating to Patient #8's weight. S15 reported that she did not believe that Patient #8 gained 18.8 pounds in 5 days. S15 confirmed that there was no documentation in the medical record to indicate that staff had identified the unexplained weight gain of Patient #8 as an area that needed to be further investigated in order to determine the appropriate plan and interventions in relation to the plan of care.

In a face to face interview on 01/27/10 at 2:05pm S13, Director of Nursing and after review of the medical record for Patient #8 reported that she felt that there was an error in documentation relating to Patient #8's weight. The Director of Nursing reported that she did not believe that Patient #8 gained 18.8 pounds in 5 days. S15 confirmed that there was no documentation in the medical record to indicate that staff had identified the unexplained weight gain of Patient #8 as an area that needed to be further investigated in order to determine the appropriate plan and interventions in relation to the plan of care. S13 reported the same explanation for Patients #6 and #10 to explain the large discrepancy in weight loss or gain.

Based on observations, interviews and record review, the hospital failed to ensure that all supplies and equipment were maintained in a manner to ensure an acceptable level of safety and quality. This was evidenced by 1) the hospital's failure to ensure that all direct care staff members including a staff member assigned to housekeeping duties were trained and knowledgeable in the proper use of the disinfecting product (Oxivir Tb) according to the manufacturer's instructions for disinfection; 2) the hospital's failure to ensure that all bed side-rails, rolling bedside tables and feeding pump poles designated to be clean were free of dirt and/or grime and/or sticky residue; and 3) the hospital's failing to ensure that all toilet paper dispensers in the patient bathrooms were in good repair. Findings:

1. Failure to ensure that all direct care staff members including a staff member assigned to housekeeping duties were trained and knowledgeable in the proper use of the disinfecting product (Oxivir Tb) according to the manufacturer's instructions for disinfection.

Observations on 1/26/10 at 1:30 p.m. revealed a housekeeping employee (S8) using a disinfecting agent (Oxivir Tb) to clean and disinfect patient care equipment and supplies. In an interview with S8 on 1/26/10 at 2:10 p.m., S8 indicated that he usually works on the floors in the hospital but was working as a housekeeper for the day. S8 reported that he uses the disinfectant (Oxivir Tb) to clean and disinfect patient care equipment and supplies. When asked if he (S8) had received any training relating to the proper use of the disinfectant (Oxivir Tb), S8 reported that he could not remember receiving any training relating to the proper use of the disinfecting product. S8 reported that he sprays the disinfecting product on to the surface and then wipes it off with a dry cloth. S8 indicated that he was not aware that the product needed to remain in contact with the surface area for a specific amount of time to ensure disinfection.

In interviews with S6 (CNA) and S7 (LPN) on 1/26/10 between 2:10 p.m. and 2:15 p.m., S6 and S7 reported that they could not remember receiving any training relating to the disinfecting product used at the hospital to disinfect patient care equipment and supplies. S6 and S7 reported that they were not aware that the disinfecting product needed to remain in contact with the surface area for a specific amount of time to ensure disinfection.

Review of the manufacturer's instructions for the disinfecting product used (Oxivir Tb) revealed the dwell times as 1 minute for bactericidal and virucidal; 5 minutes for tuberculocide; and 10 minutes for fungi.

Review of the personnel record of S6 (CNA) revealed no evidence to indicate that S6 had received any training and/or education relating to the hospital approved disinfecting product used to disinfect patient care equipment and supplies.

Review of the personnel record of S7 (LPN) revealed no evidence to indicate that S7 had received any training and/or education relating to the hospital approved disinfecting product used to disinfect patient care equipment and supplies.

Review of the personnel record of S8 (Housekeeping) revealed no evidence to indicate that S8 had received any training and/or education relating to the hospital approved disinfecting product used to disinfect patient care equipment and supplies.


2. Failure to ensure that all bed side-rails, rolling bedside tables and feeding pump poles designated to be clean were free of dirt and/or grime and/or sticky residue.

Observations on 1/26/10 between 10:15 a.m. and 10:45 a.m. revealed the following:

? Side-rails on the bed in Patient Room #113 were noted to have a sticky residue on the edge of the side-rails and a dirt/grime buildup was noted at the base of the bed frame. This finding was confirmed by the unit charge nurse at the time of the observation. Patient Room #13 was reported to be clean and ready for a new admit at the time of this observation.
? Rolling bedside table in Patient Room #108 was noted to have a dirt/grime buildup at the base of the table. This finding was confirmed by the unit charge nurse at the time of the observation. In addition, a missing piece of ceramic tile was noted in the bathroom behind the toilet in this room.
? Rolling bedside table in Patient Room #107 was noted to have a dirt/grime buildup at the base of the table. This finding was confirmed by the unit charge nurse at the time of the observation.
? Brownish colored sticky residue was noted at the base on three (3) feeding pump poles in the "clean supply room". The brownish colored sticky residue appeared to be dried feeding formula. This finding was confirmed by the supply manager at the time of the observation.


3. Failing to ensure that all toilet paper dispensers in the patient bathrooms were in good repair.

Observations on 1/26/10 between 10:15 a.m. and 10:45 a.m. revealed the following:

? Cover of the toilet paper dispenser was broken in the bathroom in Patient Room #112. This finding was confirmed by the unit charge nurse at the time of the observation.
? Cover of the toilet paper dispenser was broken in the bathroom in Patient Room #119. This finding was confirmed by the unit charge nurse at the time of the observation.

Based on observations, interviews and record review, the hospital's infection control officer failed to ensure that an effective infection control system was developed and implemented relating to 1) the investigation into the possible cause of the identified hospital acquired infections; 2) the training of personnel relating to the proper use of the disinfecting product (Oxivir Tb) used at the hospital to assist in the control of infections and communicable diseases; and 3) the cleaning of patient care equipment and supplies by failing to ensure that an effective surveillance system was in place to ensure that all bed side-rails, rolling bedside tables and feeding pump poles designated to be clean were free of dirt and/or grime and/or sticky residue and 4) the annual assessment for TB (Tuberculosis) for all employees resulting in 3 of 3 physicians and 3 of 8 employees with no documented evidence of screening (S1, S2, S3, S17, S18, S19). Findings:

1. Failure to ensure the investigation into the possible cause of the identified hospital acquired infections.

The hospital's infection control data including the "St. Catherine Memorial Hospital Infection Control Annual Summary 2009" was reviewed. This review revealed the following: "St. Catherine is an 18-bed long-term acute care facility, located in Eastern New Orleans. It services residents of Orleans and surrounding parishes. Most of the patients are admitted to the facility for long-term antibiotic therapy and wound care management. The average daily census is 11.9. The average length of stay is 45 days. The annual HAI (Hospital Acquired Infection) rate is 7.6%". Review of the data relating to the 4th quarter summary report revealed that the identified hospital acquired infection rate was 5.4% for October of 2009, 2.3% for November of 2009, and 0% for December of 2009. Review of the infection control data revealed documentation to indicate the identify of patient who acquired the hospital acquired infection and the type and location of the identified hospital acquired infections. However, this review of the infection control data revealed no documentation to indicate that measures were taken to identify the cause of the identified hospital acquired infections so that preventative measures could be implemented to assist in reducing/eliminating potential future hospital acquired infections.

The hospital's Infection Control Officer was interviewed on 1/27/10 between 1:20 p.m. and 1:40 p.m. relating to the steps taken by the hospital personnel to investigate the possible source and/or cause of the identified hospital acquired infections. The Infection Control Officer reported that she could not determine the cause of the identified hospital acquired infections and indicated that she was unable to provide documentation to indicate that an investigation had been conducted regarding the possible cause of the hospital acquired infections for the patients involved.


2. Failure to ensure the training of personnel relating to the proper use of the disinfecting product (Oxivir Tb) used at the hospital to assist in the control of infections and communicable diseases.

Observations on 1/26/10 at 1:30 p.m. revealed a housekeeping employee (S8) using a disinfecting agent (Oxivir Tb) to clean and disinfect patient care equipment and supplies. In an interview with S8 on 1/26/10 at 2:10 p.m., S8 indicated that he usually works on the floors in the hospital but was working as a housekeeper for the day. S8 reported that he uses the disinfectant (Oxivir Tb) to clean and disinfect patient care equipment and supplies. When asked if he (S8) had received any training relating to the proper use of the disinfectant (Oxivir Tb), S8 reported that he could not remember receiving any training relating to the proper use of the disinfecting product. S8 reported that he sprays the disinfecting product on to the surface and then wipes it off with a dry cloth. S8 indicated that he was not aware that the product needed to remain in contact with the surface area for a specific amount of time to ensure disinfection.

In interviews with S6 (CNA) and S7 (LPN) on 1/26/10 between 2:10 p.m. and 2:15 p.m., S6 and S7 reported that they could not remember receiving any training relating to the disinfecting product used at the hospital to disinfect patient care equipment and supplies. S6 and S7 reported that they were not aware that the disinfecting product needed to remain in contact with the surface area for a specific amount of time to ensure disinfection.

Review of the manufacturer's instructions for the disinfecting product used (Oxivir Tb) revealed the dwell times as 1 minute for bactericidal and virucidal; 5 minutes for tuberculocide; and 10 minutes for fungi.

Review of the personnel record of S6 (CNA) revealed no evidence to indicate that S6 had received any training and/or education relating to the hospital approved disinfecting product used to disinfect patient care equipment and supplies.

Review of the personnel record of S7 (LPN) revealed no evidence to indicate that S7 had received any training and/or education relating to the hospital approved disinfecting product used to disinfect patient care equipment and supplies.

Review of the personnel record of S8 (Housekeeping) revealed no evidence to indicate that S8 had received any training and/or education relating to the hospital approved disinfecting product used to disinfect patient care equipment and supplies.

The hospital's Infection Control Officer was interviewed on 1/27/10 between 1:20 p.m. and 1:40 p.m. relating to the cleaning and disinfecting of equipment and supplies used for patient care. When asked about the education/training provided to direct care personnel relating to the proper use of the disinfecting products used at the hospital to disinfect patient care equipment and supplies, the Infection Control Officer reported that she is not aware of any education and/or training being provided to the direct care personnel to ensure that they are knowledgeable in the proper use of the disinfecting products used at the hospital to disinfect patient care equipment and supplies.


3. Failure to ensure the cleaning of all patient care equipment and supplies by failing to ensure that an effective surveillance system was in place to ensure that all bed side-rails, rolling bedside tables and feeding pump poles designated to be clean were free of dirt and/or grime and/or sticky residue.

Observations on 1/26/10 between 10:15 a.m. and 10:45 a.m. revealed the following:

Side-rails on the bed in Patient Room #113 were noted to have a sticky residue on the edge of the side-rails and a dirt/grime buildup was noted at the base of the bed frame. This finding was confirmed by the unit charge nurse at the time of the observation. Patient Room #13 was reported to be clean and ready for a new admit at the time of this observation.

Rolling bedside table in Patient Room #108 was noted to have a dirt/grime buildup at the base of the table. This finding was confirmed by the unit charge nurse at the time of the observation. In addition, a missing piece of ceramic tile was noted in the bathroom behind the toilet in this room.

Rolling bedside table in Patient Room #107 was noted to have a dirt/grime buildup at the base of the table. This finding was confirmed by the unit charge nurse at the time of the observation.

Brownish colored sticky residue was noted at the base on three (3) feeding pump poles in the "clean supply room". The brownish colored sticky residue appeared to be dried feeding formula. This finding was confirmed by the supply manager at the time of the observation.

The hospital's Infection Control Officer was interviewed on 1/27/10 between 1:20 p.m. and 1:40 p.m. relating to the cleaning and disinfecting of equipment and supplies used for patient care. When asked about the surveillance system used at the hospital to monitor the effectiveness of staff members in regards to the cleaning and disinfecting of patient care equipment and supplies, the Infection Control Officer reported that there is no current system in place at the hospital to monitor the effectiveness of the cleaning and disinfecting of patient care equipment and supplies.


4) failing to ensure annual assessment for TB (Tuberculosis) had been performed for all employees

Review of the Physician personnel/credentialing files for S1, S2, and S3 revealed no documented evidence the physicians had ever been screened for TB.

Review of the personnel file for RN S17, PT (Physical Therapist S18 and Occupational Therapist S19 revealed no documented evidence any had been screened for TB within the last twelve months.

In a face to face interview on 01/28/10 at 1:00pm S14, Human Resource Director, indicated she was not aware physicians needed to be screened for TB and verified there was no documentation in their personnel/credentialing files. S14 indicated she sends out notices in the envelopes containing employee checks and posts notices on the bulletin board by the time clock concerning annual screenings. Further she indicated this information is sent to the Director of Nursing so she is aware of the delinquent staff.

Based on record review and interview the hospital failed to ensure medication had been administered as ordered by the physician resulting in 13 doses of Lopressor administered to a patient without a timely assessment of the Blood Pressure and Pulse and one dose of Lopressor being administered to a patient when the Blood Pressure was below the ordered parameters when administered (Patient #5) for 1 of 1 patients on Lopressor with parameters of the 10 sampled patients. Findings:

Review of the medical record revealed Patient #5 had been admitted on 01/06/10 with the primary diagnosis of decubitus ulcer an a secondary diagnosis which included HTN (Hypertension). Review of the Physician's Orders dated 01/06/10 revealed an order for Lopressor 25mg i tab (tablet) per PEG tube or mouth daily Hold if pulse less than or equal to 60 or SBP (Systolic Blood Pressure) less than or equal to 110.

Review of the MAR (Medical Administration Record) for Patient #5 revealed Lopressor has been administered to the patient without documented evidence the blood pressure or pulse had been assessed by the nurse before administration on the following dates and times:
01/12/10 at 9:00am, 01/13/10 at 9:00am; 01/16/10 at 9:00am, 01/17/10 at 9:00am, 01/18/10 at 9:00am, 01/19/10 at 9:00am, 01/20/10 at 9:00am, 01/21/10 at 9:00am, 01/22/10 at 9:00am, 01/23/10 at 9:00am, 01/24/10 at 9:00am, 01/25/10 at 9:00am and 01/26/10 at 9:00am.

Review of the Graphic Sheets for Patient #5 dated 01/06/10 through 01/26/10 revealed the blood pressure and pulse for #5 had been performed by the CNA (Certified Nursing Staff) at 7:00am. Further review of the Graphic sheet, MARs and the Nurses Notes revealed no documented evidence additional assessments of blood pressure and pulse had been performed before the administration of the Lopressor at 9:00am on 01/12/10, 01/13/10, 01/16/10, 01/17/10, 01/18/10, 01/19/10, 01/20/10, 01/21/10, 01/22/10, 01/23/10, 01/24/10, 01/25/10, and 01/26/10.

Review of the MAR for Patient #5 dated 01/14/10 revealed documented evidence of a blood pressure of 99/59 and a line marked through the 9:00am dose and the initials of the nurse indicating the medication had been administered. Further review of the nurses' notes dated 01/14/10 revealed no documented evidence an assessment of the patient had been performed after the medication had been administered until the 7:00pm vital signs had been taken.

In a face to face interview on 01/29/10 at 10:00am S11, the Director of Nurisng (DON) indicated before Lopressor is administered a blood pressure and pulse should be assessed by the nurse administering the medication and documented on the MAR, nursing notes or graph sheet. Further she indicated it is not a timely assessment to use the vital signs taken at 7:00am since medication administration can be performed up until 10:00am. The DON indicated the dose of Lopressor which had been administered to the patient when below the parameters should not have been given.

Based on interviews, observations and policy review, the hospital failed to ensure that medical records were stored in a location to ensure that unauthorized individuals cannot gain assess to the closed medical records. This was evidenced by the hospital's practice of storing closed medical records in filing cabinets in a room that also contained filing cabinets containing files/records from the long term care facility that is located in the same building as the hospital. Findings:

The medical records clerk (S9) was interviewed on 1/28/10 at 11:10 a.m. relating to the storage of medical records for patients who have been discharged from the hospital. S9 reported that the medical records are stored in a locked room in the long term care facility that is located in the same building as the hospital.

Observations of this medical record room on 1/28/10 at 11:10 a.m. revealed that there were a total of 15 file cabinets in this room. S9 reported that 11 of the 15 file cabinets contained medical records for patients who were discharged from the hospital. S9 reported that the other 4 file cabinets contained files/records that belonged to the long term care facility that is located in the same building as the hospital. When asked by the surveyor as to who had access to this room, S9 reported that the Administrator and the medical records personnel from the hospital and from the long term care facility had access to this medical records room.

The hospital's medical records department policy/procedure manual was reviewed. Page 2 of the medical records department policy/procedure manual documents information relating to the confidentiality and security of medical records. The following is documented, "The medical record of a patient is a legal document that contains privileged information that is to be treated with strict confidentiality at all times" and "Medical records will be maintained in a secure area to ensure that contents remain confidential to the staff members who have direct access".