HospitalInspections.org

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

1) The hospital failed to ensure radiology services were provided independent of the host hospital (Hospital "A") by failing to ensure radiology services were not provided by staff concurrently working at the host hospital (Hospital "A") and by not accompanying patients to Hospital "A" while radiological procedures were performed (see A-0529).


2) The hospital failed to develop Radiology policies and procedures that included safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital (see A-0535).

3) The hospital failed to ensure there was a Radiologist appointed by the Governing Body to supervise the Radiology Services on either a full-time, part-time, or consulting basis as evidenced by no documentation of a Director of Radiology for the hospital (see A-0546).

Based on record review and staff interview, the Hospital failed to ensure the patient received care in a safe setting as evidenced by failing to report and document an incident report when a patient was involved in an accident for 1 (#3) of 5 (#1-#5) sampled patients. Findings:

Review of the Hospital's policy titled, Incident/Occurrence Reporting, revised date of 3/2012, revealed in part the following: It is the policy of [Hospital] to formally report all unusual occurrences....Occurrences require written completion of an occurrence report. The hospital employee who identifies the occurrence is responsible for initiating the appropriate occurrence report and providing it to the immediate supervisor or department manager by the end of the working shift....The physician should be notified immediately if there is a suspected injury or patient safety is involved.
Reporting Patient Occurrences: Occurrences will be reported on the form most specific to the incident....There are six different categories and forms for reporting: 6. General Occurrence Report - This report is used to report the following types of incidents: g. Struck by/against an object....The completed form must be forwarded to the Risk Manager within 24 hours.

Review of the incident report log revealed Patient #3 was involved in an incident that occurred on 03/10/16.

Review of the incident report for Patient #3 dated 04/06/16 revealed the following:
Incident Date: 03/10/16.
Shift: AM
Description: Patient had completed therapy session and OT was preparing to transport patient back to room. Patient with bilateral lower extremity wound vacs hooked to IV pole. As therapist began to push wheelchair and IV, IV pole toppled forward. IV fell into therapist's right arm and tapped the patient on the back of the head. Therapist immediately inspected patient's head. No broken skin and/or redness noted. Patient report no dizziness and/or pain. Wound vacs removed from IV poke and patient returned to room. Requested to remain up in chair. Patient asking therapist if she is ok throughout.
Notes: Nurse Manager Follow Up: Director of Quality/Risk Management notified of incident. Investigation into incident performed. CT scan ordered and performed per MD order. Case discussed with family and S6Physician. No further follow up necessary.
There was no documented evidence why the incident report was not documented within 24 hours of the incident, as directed in the Hospital's policy.

Patient #3
Review of the medical record for Patient #3 revealed the patient was admitted to the hospital on 03/01/16 and discharged on 04/06/16. Review of the record revealed the patient was transferred from an acute care hospital for continued wound care, IV antibiotics, PT and OT. The record revealed the patient's diagnoses included Necrotizing Vasculopathy, Sepsis, and Pyoderma gangrenosum.

Review of the record revealed no documented evidence that the patient was involved in an accident or incident during her hospital stay.

In an interview on 10/11/16 at 3:55 p.m. S8OT stated she was involved in the incident where Patient #3 was hit with the wound vacs. S8OT stated the patient had 2 wound vacs and they have a clip that allows them to be hung on things. She stated she hung them on the IV pole and it tipped over (from weight) and hit her (S8OT) on her arm and then tapped Patient #3 on back of her head. She stated she assessed the patient's head and there was no redness, swelling or any break in the skin. S8OT stated the patient was more worried about her (S8OT). When asked when the incident occurred, she stated it was more toward the middle of March 2016. S8OT stated she thought of it as a "tap" and did not document anything about the incident when it happened. S8OT stated she documented the incident at a later date at the request of S7PA. S8OT confirmed she did not report the incident to anyone.


In an interview on 10/11/16 at 4:10 p.m., S4CEO confirmed S7PA asked S8OT to complete the incident report after another employee stated within hearing range of the patient's family that the patient was declining because she was hit on the head with a wound vac. S4CEO stated this incident happened on 04/02/16. S4CEO stated the PA put the incident in her note on that day and ordered a CT scan. S4CEO confirmed the incident report was not documented until 04/06/16. S4CEO confirmed the reporting and documentation of the incident report was not done within 24 hours of the incident as directed in the Hospital's policy. He stated he has done inservices to address the timely documentation of an incident (within 24 hours).

Based on record review, interviews and observations, the hospital failed to ensure that the RN supervised and evaluated the nursing care of each patient as evidenced by failure to ensure each patient was assessed at least every 24 hours by a RN as required by the Louisiana State Board of Nurse's Practice Act for 1 (#3) of 4 (#2, #3, #4, #5) sampled patients reviewed for RN assessments out of a total sample of 5.

Review of the LSBN's Practice Act revealed that RNs may delegate select nursing interventions to the LPN provided the patient is assessed by an RN every 24 hours.
Review of the Louisiana State Board of Nursing's "Administrative Rules Defining RN Practice LAC46:XLVII" revealed, in part,
"3703. Definition of Terms Applying to Nursing Practice ... Delegating Nursing Interventions - ... The registered nurse retains the accountability for the total nursing care of the individual. ... The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems.
The assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required.
a. Any situation where tasks are delegated should meet the following criteria: i. the person has been adequately trained for the task; ii. the person has demonstrated that the task has been learned; iii. the person can perform the task safely in the given nursing situation; iv. the patient's status is safe for the person to carry out the task; v. appropriate supervision is available during the task implementation; vi. the task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all.
b. The registered nurse may delegate to licensed practical nurses the major part of the nursing care needed by individuals in stable nursing situations, i.e. (that is), when the following three conditions prevail at the same time in a given situation: i. nursing care ordered and directed by R.N./M.D. (medical doctor) requires abilities based on a relatively fixed and limited body of scientific fact and can be performed by following a defined nursing procedure with minimal alteration, and responses of the individual to the nursing care are predictable; and ii. change in the patient's clinical conditions is predictable; and iii. medical and nursing orders are not subject to continuous change or complex modification..."

Review of the Hospital's policy titled Assessment/Re-Assessment, Interdisciplinary Scope of Services, provided as current policy by S3CCO on 10/11/16 at 12:30 p.m. revealed the initial nursing assessment would be conducted by an RN, but there were no provisions in the policy for an RN assessment at least once every 24 hours.


Patient #3
Review of the medical record for Patient #3 revealed the patient was admitted to the hospital on 03/01/16 and discharged on 04/06/16. Review of the record revealed the patient was transferred from an acute care hospital for continued wound care, IV antibiotics, PT and OT. The record revealed the patient's diagnoses included Necrotizing Vasculopathy, Sepsis, Pyoderma gangrenosum, Chronic Diastolic (congestive) Heart Failure, Protein-Calorie Malnutrition, Anemia, Malaise, and Squamous Cell Carcinoma of the Skin.

Review of the nursing assessments revealed no documented evidence of an assessment by an RN on the following dates: 03/23/16, 03/24/16, 03/25/16, and 03/26/16. Review of the nurse note for 03/27/16 revealed an RN assessment was done at 7:30 p.m. Further review of the nursing assessments revealed on 03/28/16, 03/30/16, and 04/03/16 there was no documented evidence of an RN assessment. Review of the nursing assessment on the day of discharge (04/06/16) revealed there was no RN assessment.


In an interview on 10/12/16 at 3:37 p.m. S2DON reviewed the medical record for Patient #3 for RN assessments. S2DON confirmed his expectation was an RN was to assess the patient at least once during a 24 hour period. He stated if an LPN was assigned during the day shift, an RN should be assigned at night. S2DON also stated when the LPN followed another LPN then the charge nurse should sign the note. S2DON indicated the hospital had a shortage of RNs due to staff turnover and within the last 2 months the RN positions had been filled. After reviewing the nursing assessments for Patient #3, he confirmed an RN assessment had not been done at least once every 24 hours on 03/23/16, 03/24/16, 03/25/16, 03/26/16, 03/28/16, 03/30/16, and 04/03/16.


In an interview on 10/12/16 at 3:48 p.m., S3CCO reviewed the medical record for Patient #3 and confirmed RN assessments were not done at least once every 24 hours. S3CCO stated they had an RN shortage at beginning of the year and had since filled those RN positions. S3CCO confirmed the Assessment policy indicated the RN was responsible for assessment and reassessment.

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Based on record review and interview, the hospital failed to ensure the nursing staff developed an individualized comprehensive plan of care for 5 of 5 (#1, #2, #3, #4, #5) sampled patient records reviewed. Findings:

Review of the hospital policy titled, Interdisciplinary Treatment Planning, policy number 854, revealed planned patient care shall be performed in a coordinated interdisciplinary manner by all patient care managers/disciplines upon admission and throughout hospitalization. The policy revealed the plan of care would be reviewed or revised weekly and as a change in patient condition warranted. The policy revealed patient problems, goals, and interventions would be identified and documented.

Patient #1
Review of the closed medical record for Patient #1 revealed the patient was 65 year old admitted to the hospital on 06/30/16 with diagnoses of Atypical Pneumonia with Sepsis, COPD Exacerbation, Acute Hypoxic Respiratory Failure, Severe Malnutrition, and Sjogren's Syndrome.
Review of the Weekly Interdisciplinary Team Conference/Plan of Care Reports dated 06/30/16, 07/03/16, and 07/10/16 revealed the section for Discharge Planning had been left blank on all 3 plans of care. Review of the Safety Section revealed the patient had a history of falls at home with report of a fall on 06/15/16. There was no documented evidence of any goals or interventions related to falls or patient safety.

In an interview on 10/13/16 at 12:35 p.m., S2DON reviewed the patient's medical record and confirmed the Weekly Interdisciplinary Team Conference/Plan of Care Report was the hospital's plan of care. S2DON confirmed the plan of care did not include goals or interventions related to patient safety or falls and the discharge planning section was blank.

Patient #3
Review of the medical record for Patient #3 revealed the patient was admitted to the hospital on 03/01/16 and discharged on 04/06/16. Review of the record revealed the patient was transferred from an acute care hospital for continued wound care, IV antibiotics, PT and OT. The record revealed the patient's diagnoses included Necrotizing Vasculopathy, Sepsis, Pyoderma gangrenosum, Chronic Diastolic (congestive) Heart Failure, Protein-Calorie Malnutrition, Anemia, Malaise, and Squamous Cell Carcinoma of the Skin.

Further review of the record revealed the patient had a functional decline 10 days prior to discharge (03/27/16).

Review of the Weekly Interdisciplinary Team Conference/Plan of Care Report dated 04/03/16 revealed the Medical, Safety, Bowel/Bladder, Respiratory/Gas Exchange, Skin Integrity/Circulation, Nutrition, Mobility, and Education sections were all left blank.

In an interview on 10/12/16 at 12:45 p.m. S4CEO stated the care plan process was not up to the hospital's standards and stated he had discussed the issue with the Nurse Manager. He stated the Nurse Manager had counseled nurses and was addressing the problem. S4CEO confirmed there was a problem with the care plan process and the care plans had not been done correctly. S4CEO confirmed Patient #3's plan of care had not been updated on 04/03/16 and did not address the patient's decline in condition.



Patient #2
Patient #2 was admitted to the hospital on 9/26/16 for Sepsis and Acute Renal Failure. Review of Patient #2's Weekly Interdisciplinary Team Conference/ Plan of care for 9/29/16 revealed a diagnosis of Sepsis with a current goal of resolve infection. No disciplines were checked to review documentation for interventions. There were no problems and/or interventions listed for the Acute Renal Failure diagnosis.


Patient #4
Patient #4 was admitted to the hospital on 9/23/16 for IV antibiotics related to Osteomyelitis Left Malleolar and Wound Care. Patient #4 was on Aspiration Precautions related to Possible Aspiration Pneumonia. Review of the Weekly Interdisciplinary Team Conference/Plan of Care for 10/09/16 revealed a problem was Fall after Pneumonia, the Current goal was resolve pneumonia and UTI. No disciplines were checked for documentation of interventions. With further review there was no documentation related to the patient being on Aspiration Precautions.


Patient #5
Patient #5 was admitted to the hospital on 9/22/16 with the diagnosis of Unhealed Wound to Right Lower Extremity and Urinary Retention with Foley Placement. Review of the Weekly Interdisciplinary Team Conference/Plan of Care Report for 10/09/16 revealed under the problem of Bladder/Bowel: Foley insertion 9/17. Current goal was no UTI. There was no discipline checked to refer to for interventions related to this problem.

An interview was conducted with S2DON on 10/13/16 at 1:00 p.m. He confirmed the goals could be more measurable for the above patients and all the patients' problems were not listed on the Plan of Care. He further stated the interventions are documented under the progress notes of the individual disciples such as nursing, dietary, occupational therapy etc.

Based on record review and interview, the hospital failed to ensure radiology services were provided independent of the host hospital (Hospital "A") by failing to ensure radiology services were not provided by staff concurrently working at the host hospital (Hospital "A"). Findings:

A review of the contracts provided by S4CEO revealed the hospital had a contract with Hospital "A" to provide Radiology services for patients.

On 10/12/16 at 12:00 p.m. S1COO was asked to provide the hospital's policies and procedures for Radiology. He stated this hospital did not have policies as they contracted with Hospital "A" to provide those services. He confirmed Hospital "A" radiology department provided portable radiology services in the Hospital and patients from this hospital were transported to Hospital "A" for procedures also.

In an interview on 10/12/16 at 12:45 p.m. S4CEO confirmed the hospital did not have policies and procedures for radiology services.

In an interview on 10/13/16 at 10:41 p.m., S5Radiology Manager of Hospital "A" confirmed the radiology department of Hospital "A" provided radiology services for the Hospital. He stated they provide portable x-rays in the Hospital. He confirmed his staff come to the Hospital with their equipment and provide x-rays concurrently when providing services to patients of Hospital "A". S5Radiology Manager also stated radiology technicians from his department come to the Hospital, pick up the Hospital's patient and transport the patient to radiology in Hospital "A". He stated the staff of the Hospital does not usually come with the patient to his department.

Based on record review and staff interview, the hospital failed to develop Radiology policies and procedures that included safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital.

Findings:

A review of the contracts provided by S4CEO revealed the hospital had a contract with Hospital "A" to provide Radiology services for patients.

On 10/12/16 at 12:00 p.m. S1COO was asked to provide the hospital's policies and procedures for Radiology. He stated this hospital did not have policies as they contracted with Hospital "A" to provide those services. He confirmed Hospital "A" radiology department provided portable radiology services in the Hospital and patients from this hospital were transported to Hospital "A" for procedures also.

In an interview on 10/12/16 at 12:45 p.m. S4CEO confirmed the hospital did not have policies and procedures for radiology services including policies for the safety of patients and staff during radiological procedures.

Based on record review and staff interview, the hospital failed to ensure there was a Radiologist appointed by the Governing Body to supervise the Radiology Services on either a full-time, part-time, or consulting basis as evidenced by no documentation of a Director of Radiology for the hospital.

Findings:

A review of the hospital's organizational chart, provided by S4CEO as a current organizational chart, revealed no documentation of a Radiologist as the Director of Radiology for the hospital.
A review of the list of credentialed physicians on the hospital's Medical Staff, provided by S3CCO as a current list, revealed no documented evidence that a Radiologist was identified as the Director of Radiology.

A review of the contracts, provided by S4CEO, revealed the hospital had a contract with Hospital "A" (Host Hospital) to provide Radiology services.

In an interview on 10/12/16 at 12:45 p.m. S4CEO confirmed the hospital did not have a Medical Director of Radiology appointed by the Governing Body. He confirmed the Hospital's radiology services were contracted with the host hospital (Hospital "A").

Based on record review and staff interview, the Hospital failed to ensure laboratory services including emergency laboratory services were provided in accordance with the hospital's policies and procedures as evidenced by failing to include the Hospital's contracted laboratory services in the Laboratory Services policy. Findings:

Review of the Hospital policy titled, Laboratory Services/Point of Care & Waived Testing, provided as the Hospital's policy for laboratory services by S1COO, revealed in part the following: All laboratory specimens will be obtained and processed through the laboratory with the exception of POCT and/or Waived testing. Exception: If a lab is required to be performed STAT and lab personnel cannot arrive to the facility within fifteen (15) minutes, [Hospital] staff will obtain the STAT specimen and assure delivery to the lab. Further review of the policy revealed the policy applied to the Hospital and the Hospital's offsite campus, and Hospital "B" another hospital with the same ownership.

There were no provisions in the policy that delineated the contracted laboratory services that were provided by Hospital "A", the host hospital.

In an interview on 10/11/16 at 2:40 p.m., S9RN, Charge Nurse stated routine labs were sent to, "Main Campus". S9RN confirmed "Main Campus" was Hospital "B", a separate LTAC hospital with the same ownership. He stated after Hospital "B" lab hours (close at 4:30 p.m. to 5:00 p.m. and they stop pick-ups at 2:00 p.m. due to traffic), Lab techs from Hospital "A" (Host hospital) come to the Hospital and draw stat labs or anything not routine.

On 10/12/16 at 2:45 p.m. S4CEO confirmed the hospital uses the lab at Hospital "B" for routine labs. He confirmed after hours labs and stat labs were done by Hospital "A".

In an interview on 10/13/16 at 10: 45 a.m., S10Lab Director at Hospital "A" confirmed her department provided stat lab testing for the Hospital. She stated the Hospital nursing staff brings specimens to Hospital "A" lab. S10Lab Director stated they only do stat labs and her staff does not come to this hospital. She stated anything after 3:00 p.m., and all stats go to Hospital "A".

In an interview on 10/13/16 at 10:52 a.m., S11RN confirmed the Hospital's nurses draw blood and take to the lab in Hospital "A".

In an interview on 10/13/16 at 10:55 a.m., S4CEO confirmed the Hospital's policy for Laboratory Services did not include provisions for the use of Hospital "A" for after hours and stat lab testing.

Based on record review and staff interview, the Hospital failed to ensure a discharge planning evaluation was done for 1(#1) of 5 (#1-#5) sampled patients. Findings:

Review of the Hospital policy titled, "Discharge Process, Interdisciplinary, Policy number 857, provided by S3CCO as the hospital's policy for discharge planning, revealed the following: Patient discharge is coordinated in advance by the Case Manager/Social Worker in collaboration with the treatment team, patient, and family. Further review of the policy revealed no documented evidence of any specific provisions related to discharge planning.

Patient #1
Review of the medical record for Patient #1 revealed the patient was admitted to the Hospital on 06/30/16 with diagnoses of Atypical Pneumonia with Sepsis, COPD Exacerbation, Acute Hypoxic Respiratory Failure, Severe Malnutrition, and Sjogren's Syndrome/Scleroderma. Review of the record revealed the patient was transferred to Hospital "A" on 07/12/16 for higher level of care.

Further review of the patient's record revealed no documented evidence of any discharge planning. Review of the record revealed no documented evidence of the IAA Social Services/Case Management form or any Case Management progress notes.

In an interview on 10/13/16 at 1:20 p.m., S12RN Case Manager stated discharge planning started on admission and was reviewed weekly. He stated it was documented on the Weekly Team Conference Report. He also stated it was documented in the team meetings and on last page of care plan. S12RN Case Manager was asked to review the record of Patient #1. He confirmed he was Case Manager at the time this patient was admitted. He confirmed there was no documentation of discharge planning in the record of Patient #1. After reviewing the discharge planning documented for another patient, he confirmed the IAA Social Services/Case Management form and the Case Management progress notes was where the discharge planning was documented.

In an interview on 10/13/16 at 4:00 p.m., S4CEO confirmed they were unable to find any documentation of discharge planning for this patient.