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The hospital failed to meet the Condition of Participation for compliance with federal, state and local laws as evidenced by failure to comply with 42 CFR ?489.53(a)(8) and Louisiana Revised Statutes 40:2104 (A), (B) & 40:2107 (B). The hospital failed to provide complete information to determined the ownership status of this hospital as requested.

Findings:

The Louisiana Department of Health and Hospitals (DHH), acting on behalf of CMS, has requested numerous times for hospital representatives to provide complete ownership and transaction information and supporting documents for transactions involving changes in ownership structure since October 1, 2012. DHH has not received the required information and supporting documents to process the change of ownership/information and establish current ownership of this hospital. Subsequently, CMS plans to terminate the Medicare provider agreement of this hospital for failure to furnish ownership information. See 42 CFR ?489.53(a)(8). CMS will proceed to terminate the provider agreement of this hospital within the timelines set forth in the termination notice letter unless all the required information is provided to DHH. See 42 CFR ?420.206.

In addition, a license to operate a hospital in Louisiana is non-transferrable and non-assignable. The hospital has not submitted the required documentation to change the licensing information of this hospital prior to transferring the hospital to new owners.

Based on observation, medical record review, review of Governing Body Bylaw Policy and Procedure, and staff interview, the Governing Body failed to meet the Condition of Participation by failing to be responsible for the conduct of the hospital as evidenced by:
1) Failed to ensure, implement, and maintain an effective, ongoing, hospital-wide, data driven quality assessment and performance improvement program that included all departments of the hospital and services (including services furnished under contract or agreement) (See A-0263).
2) Failed to ensure the Infection Control Program incorporated all departments of the hospital for the prevention, control, and investigation of infections (See A-0743).
3) Failing to ensure drugs and biological's were controlled and distributed according to acceptable standards of practice and consistent with State Law (See A-0490).

Based on the review of the Governing Body Bylaws, Performance Improvement Policies and Procedures, and interview with S1 Administrator, the hospital failed to meet the Condition of Participation for Quality Assurance/Performance Improvement by not implementing and maintaining an effective, ongoing, hospital-wide, data driven quality assessment and performance improvement program that included all departments of the hospital and services (including services furnished under contract or agreement) The hospital failed to maintain and demonstrate evidence of its QA/PI program for review as evidenced by:

1) the hospital failed ensure the program requirements were met as evidenced by not having measurable improvement quality indicators that included all departments of the hospital and services including services furnished under contract agreement. (see A-0273);

2) the hospital failed as part of its QA/PI program, to conduct performance improvement projects (see A-0297)

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

1) Failing to ensure the registered nurse (RN) supervised and evaluated the care of each patient as evidenced by:
a) The RN failed to assess and document the patients' respiratory status, including symmetry of chest wall expansion, respiratory rate and depth, sputum production, and lung sounds, with the use of physician-ordered incentive spirometry (a device used to assist the patient in deep breathing) according to the nurses' resource manual "Clinical Nursing Skills Techniques" for 1 of 5 current inpatients' records reviewed for respiratory services from a total of 26 sampled patients (#4);
b) The RN failed to assess each patient at least every 24 hours as required by the hospital policy for 1 of 5 current inpatients' records reviewed for RN assessment every 24 hours from a total of 26 sampled patients (#3);
c) The RN failed to ensure the patients' bowel patterns were assessed to assure the physician-ordered bowel program was implemented as ordered for 3 of 5 current patients' records reviewed for implementation of the bowel program from a total of 26 sampled patients (#1, #3, #5); and
d) The RN failed to ensure physician orders were implemented as ordered related to accuchecks, lab specimen collections, wheelchair cushions, and SCDs (sequential compression device) for 3 of 5 current inpatients' records reviewed for implementation of physician orders from a total of 26 sampled patients (#2, #3, #5) (see findings in tag A0395) and

2) Failing to ensure non-employee licensed nurses working in the hospital were supervised by a hospital-employed RN as evidenced by contract agency RNs working the night shift as the only RN present in the hospital. The hospital failed to ensure the contract agency RNs were trained and oriented on the hospital's policies and procedures to which they must adhere while working (see findings in tag A0398).

Based on review of physician credential files, Governing Body meeting minutes, and interview with hospital staff, the hospital failed to meet the Condition of Participation related to Radiology Services as evidenced by:

1) Failing to have a credentialed radiologist supervise radiology services;

2) Failing to ensure the hospital's contract for radiological services with Company E provided for 24 hours/7 days a week coverage as evidenced by the contract stating Company E would provide services to the hospital's patients during normal business hours, Monday through Friday from 8:00 a.m. to 4:00 p.m. The contract allowed for procedures performed outside these times to be performed at Company E's earliest availability;

3) Failing to develop policies and procedures that provided for the safety of patients and personnel during radiological testing performed by Company E

Based on observations, record reviews, and interviews, the hospital failed to meet the Condition of Participation related to Laboratory Services as evidenced by:

1) Failing to ensure lab services were provided under a current CLIA (Clinical Laboratory Improvement Amendments) certificate and under a current contract with a lab provider. The hospital failed to ensure policies and procedures had been developed that addressed the procedure for identifying the patient prior to the lab draw, how to handle stat physician orders and the time interval for the specimen to be drawn when ordered stat, how to report critical lab values, and who was responsible for checking for expired lab supplies and the subsequent disposal of such items (see findings in tag A0582);

2) Failing to ensure policies and procedures were developed so appropriate action could be taken if the hospital was notified that blood or blood components it received were at risk of transmitting HIV (human immunodeficiency virus) or HCV (hepatitis C virus) (see findings in tag A0592).

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Infection Control as evidenced by:
1) Failing to designate individuals as Infection Control Program officers who were trained or qualified to develop and implement policies governing control of infections and communicable diseases (see findings in tag A0748);
2) Failing to develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.

a) The infection control officer failed to ensure the Infection Control Program incorporated all departments of the hospital as evidenced by not developing and implementing a hospital- wide program that included all departments of the hospital for the prevention, control, and investigation of infections; and

b) The infection control officer failed to ensure the maintenance of a sanitary physical environment related to food sanitation, disposal of regulated and non-regulated waste, storage of soiled items in clean equipment rooms, over-filled sharps boxes, and torn therapy mats (see findings in tag A0749); and

Based on review of Performance Improvement policies and procedures and interview with S1 Administrator the hospital failed to show ensure the QA/PI program requirements were met as evidenced by not having measurable improvement quality indicators that included all departments of the hospital and services including services furnished under contract agreement. Findings:

Interview on 2/25/13 at 3:300 PM with AdministratorS1 revealed she was coordinator of Quality Assurance/ Performance Improvement for the hospital. AdministratorS1 was asked at that time to provide QA information to the survey team.

On 2/28/13 at 1:10 PM, AdministratorS1 revealed during a follow up interview that only Nursing services and Infection Control had gathered data for QA. AdministratorS1 confirmed there was no data collected from therapy services, environment of care, social services, d/c planning, pharmacy, radiology, lab services, housekeeping or laundry services. AdministratorS1 also stated the first quarterly QA/PI meeting would be held in April 2013 even though AdministratorS1 acquired the facility November 2012 at which time the Governing Body Bylaws and hospital wide policies and procedures that were in place from the previous owner were reviewed and approved 11/19/12.

Review of the Performance Improvement policies and procedures (policy # PI 1.001) revealed "the Governing Body has the ultimate responsibility and authority to establish, maintain and support the PI (performance improvement) program". Further review of the policy revealed "Monthly, departments are responsible to submit to the PI Director/ Administrator, results of quality data collection..."

Based on the review of the Governing Body Bylaws, Performance Improvement Policies and Procedures, and interview with S1 Administrator, the hospital failed as part of its QA/PI program, to conduct performance improvement projects.

Findings:

Interview on 2/25/13 at 3:300 PM with S1 Administrator revealed she was coordinator of Quality Assurance/ Performance Improvement for the hospital. S1 Administrator was asked at that time to provide QA information to the survey team.

On 2/28/13 at 1:10 PM, S1 Administrator revealed during a follow up interview that the first quarterly QA/PI meeting would be held in April 2013 even though S1 Administrator acquired the facility November 2012 at which time the Governing Body Bylaws and hospital wide policies and procedures that were already in place from the previous owner were reviewed and approved 11/19/12. S1 Administrator further stated there was not a Performance Improvement project underway currently.

Review of the Performance Improvement policies and procedures (policy # PI 1.001) revealed "III Procedure-A. Governing Board: the Governing Body has the ultimate responsibility and authority to establish, maintain and support the PI (performance improvement) program".

Based on record reviews and interviews, the hospital failed to ensure the registered nurse (RN) supervised/furnished and evaluated the care of each patient as evidenced by:

1) The RN failed to assess and document the patients' respiratory status, including symmetry of chest wall expansion, respiratory rate and depth, sputum production, and lung sounds, with the use of physician-ordered incentive spirometry (a device used to assist the patient in deep breathing) according to the nurses' resource manual "Clinical Nursing Skills Techniques" for 1 of 5 current inpatients' records reviewed (#4) and 3 of 5 closed medical records reviewed (#8,#12, #15) for respiratory services from a total of 26 sampled patients;

2) The RN failed to assess each patient at least every 24 hours as required by the hospital policy for 1 of 5 current inpatients' records reviewed (#3) and 1 of 18 closed medical records (#14) reviewed for RN assessment every 24 hours from a total of 26 sampled patients;

3) The RN failed to ensure the patients' bowel patterns were assessed to assure the physician-ordered bowel program was implemented as ordered for 3 of 5 current patients' records reviewed for implementation of the bowel program from a total of 26 sampled patients (#1, #3, #5);

4) The RN failed to assess and document the respiratory rate prior to and after nebulizer treatments for 2 of 5 closed medical records reviewed for nebulizer treatments from a total of 26 sampled patients (#15, #25); and

5) The RN failed to ensure physician orders were implemented as ordered related to accuchecks, lab specimen collections, wheelchair cushions, and SCDs (sequential compression device) for 3 of 5 current inpatients' records (#2, #3, #5) and 1 of 18 closed medical records (#17) reviewed for implementation of physician orders from a total of 26 sampled patients.

Findings:

Review of the hospital's policy titled "Assessment/Reassessment", presented by LPNS6 (licensed practical nurse) as the current assessment policy, revealed a RN will conduct, at a minimum, a reassessment every 24 hours including but not limited to the review and update of the "Plan of Care". Further review revealed a reassessment may be specified related to the patient's treatment, the patient's response to treatment, and a significant change in the patient's condition. Further review revealed no documented evidence of the time interval that RN was to reassess a patient after treatment or a significant change in condition.

1) The RN failed to assess and document the patients' respiratory status, including symmetry of chest wall expansion, respiratory rate and depth, sputum production, and lung sounds, with the use of physician-ordered incentive spirometry:
In a face-to-face interview on 02/27/13 at 4:30 p.m., RNS11 indicated the nurses performed respiratory therapy services at the hospital, as they did not have a respiratory therapist on staff. She further indicated the nursing staff have not had orientation or training for respiratory services performed by the nursing staff.

In a face-to-face interview on 02/27/13 at 4:34 p.m., RNS11 indicated the hospital did not have a policy for the use of incentive spirometers, and there was no policy that identified the manual "Clinical Nursing Skills Techniques" as their resource guide. She further indicated this book was kept at the nursing station and available as the reference guide for the nurses.

Review of the "Clinical Nursing Skills Techniques" by Perry and Potter, fourth edition revealed the following information related to incentive spirometry on pages 434 through 437:
1) Incentive spirometry assists the patient in deep breathing with the advantage being that the patient receives visual feedback about the depth of their breaths;
2) Assess the patient's respiratory status, including symmetry of chest wall expansion, respiratory rate and depth, sputum production, and lung sounds;
3) Observe the patient's ability to use the incentive spirometry by return demonstration and assess if the patient is able to achieve the target volume or frequency;
4) Document the lung sounds before and after incentive spirometry, the frequency of the use, the volumes achieved, and any adverse effects;
5) Gerontological considerations include that older adults may have difficulty coordinating the use of the IS and may require additional time to learn the procedure; older adults have an increased respiratory rates and must be observed for hyperventilation and fatigue.

Patient #4
Review of the open medical record for Patient #4 revealed an admit date of 02/22/13 with a diagnosis of AKA (above the knee amputation) right leg. Further review revealed he was transferred for inpatient rehabilitation for safety, wheel chair mobility, transfer training, balance, and endurance. Review of the physician orders revealed an order on 02/25/13 at 11:00 a.m. for I. S. (incentive spirometry) every 2 hours W/A (while awake) when not in therapies.

Review of the February 2013 MAR (medication administration record), where "I. S. to bedside every 2 hours W/A when not in therapy" was hand written, revealed only a nurse's initials once on 02/25/13, 02/26/13 and 02/27/13 . Further review revealed there was no documented evidence of an assessment by the nurse regarding how the patient tolerated the use of the I.S., what his base-line lung function was, and if there was improvement in lung function.

Interview on 02/28/13 at 10:00 a.m. with RNS11 confirmed there was not an assessment record, however, the assessment could be documented in Nurse Notes. Review of Nurse Notes with RNS11 confirmed there was no documentation of an assessment following the use of I. S. for Patient #4.

Patient #8
Review of Patient #8's medical record revealed she was a 47 year old female admitted on 10/26/12 with a diagnosis of Debility and Shortness of Breath and discharged on 12/05/12. Review of her physician orders revealed an order on 11/08/12 at 10:26 a.m. for incentive spirometry every 2 hours while awake when not in therapies.

Review of Patient #8's MAR (medication administration record) revealed I.S. was not initiated until 11/09/12. Further review of the MARs and the nurses' notes revealed no documented evidence Patient #8 had an assessment of her respiratory status when using the I.S. that included her respiratory rate and depth and the tidal volume achieved with the use of the I.S.

Patient #12
Review of Patient #12's medical record revealed he was a 76 year old male admitted on 12/17/12 with diagnoses of Lumbar Stenosis, Spinal Stenosis, and Lumbar Status Post Kyphoplasty and was discharged on 01/04/13. Review of his physician orders revealed an order on 12/18/12 at 10:05 a.m. for I.S. every 2 hours while awake when not in therapies.

Review of Patient #12's MARs and nurses' notes revealed no documented evidence Patient #12 had an assessment of his respiratory status when using the I.S. that included his respiratory rate and depth and the tidal volume achieved with the use of the I.S.

Patient #15
Review of Patient #15's medical record revealed he was an 88 year old male admitted on 12/14/12 with a diagnosis of Debility secondary to Pneumonia. Review of his physician orders revealed an order on 12/17/12 at 10:22 a.m. for I.S. every 2 hours while awake when not in therapies.

Review of Patient #15's MARs and nurses' notes revealed no documented evidence Patient #15 had an assessment of his respiratory status when using the I.S. that included his respiratory rate and depth and the tidal volume achieved with the use of the I.S.

In a face-to-face interview on 02/28/13 at 2:25 p.m., DONS2 (director of nursing) indicated a patient's tidal volume achieved with the use of I.S. should be assessed and documented.

2) The RN failed to assess each patient at least every 24 hours:
Review of the "Daily Staffing Sheet", used daily to make assignments for staff, revealed the note typed at the bottom as follows: "Each patient must have a documented assessment completed by an RN at least once in a 24 hour period. To achieve this, the day LPN should report off to the night RN. It is acceptable for an RN to complete the patient's physical assessment, document the assessment and hand over primary care of that patient to an LPN if necessary".

Patient #3
Review of Patient #3's medical record revealed she was a 73 year old female admitted on 02/08/13 with diagnoses of Dementia, Debility, and Deconditioning.

Review of Patient #3's "24 Hr. (hour) Nursing Assessment" for 02/25/13 revealed no documented evidence she was assessed by an RN for the 24 hour period. Her nursing assessments were performed by LPNS7 and LPNS16.

Patient #14
Review of Patient #14's medical record revealed she was a 63 year old female admitted on 11/09/12 with a diagnosis of Debility secondary to Right Lower Extremity Cellulitis. Further review revealed she had a history of Stroke, Congestive Heart Failure (CHF), Peripheral Neuropathy, Obstructive Sleep Apnea, and Schizophrenia.

Review of Patient #14's "24 Hr. Nursing Assessment" for 11/24/12 revealed no documented evidence she was assessed by an RN for the 24 hour period.

In a face-to-face interview on 02/28/13 at 6:05 p.m., DONS2 had no comment or explanation regarding the patients not being assessed every 24 hours by an RN

3) The RN failed to ensure the patients' bowel patterns were assessed to assure the physician-ordered bowel program was implemented as ordered:
Review of the hospital's "Standing Admission Orders" revealed a column for the nurse to place her initials if the physician ordered the specific medication or test and a column for the nurse's initials if the physician did not order the medication or test. Further review revealed number 27 included the nurse was to record a patient's bowel movement every day, and if no bowel movement in 3 days, begin the Bowel Program. Further review revealed the Bowel Program was a choice of the following: Surfak 240 mg (milligrams) orally twice a day or Dulcolax 5 mg orally twice a day or Dulcolax 10 mg suppository per rectum every day prn (as needed) or Fleets Enema times 1 daily as needed for constipation. There was no documented evidence how the nurse was to decide which of the 4 choices to use for a specific patient.

Patient #1
Review of Patient #1's medical record revealed she was a 47 year old female admitted on 02/15/13 with a diagnosis of Urinary Tract Infection.

Review of Patient #1's "Standing Admission Orders" received by telephone order on 02/15/13 at 8:30 p.m. revealed an order to record the bowel movements every day and to begin the Bowel Program if no bowel movement in 3 days.

Review of Patient #1's "7 Day Graphic Sheet" revealed she had a bowel movement on 02/15/13 and no bowel movement on 02/16/13 and 02/17/13. Review of the "PRN Medication Record" revealed LPNS7 administered Dulcolax 5 mg orally at 8:15 a.m. on 02/18/13. There was no documented evidence that an RN assessed Patient #1's bowel movement status prior to LPNS7 administering the Dulcolax before it met the physician criteria for administration.

Patient #3
Review of Patient #3's medical record revealed she was a 73 year old female admitted on 02/08/13 with diagnoses of Dementia, Debility, and Deconditioning.

Review of Patient #3's "Standing Admission Orders" received by telephone order on 02/08/13 at 11:00 a.m. revealed an order to record the bowel movements every day and to begin the Bowel Program if no bowel movement in 3 days.

Review of Patient #3's "7 Day Graphic Sheet" and nurses' notes revealed she did not have a bowel movement on 02/08/13, 02/09/13, 02/10/13, and by 5:00 p.m. on 02/11/13 and was given Surfak 240 mg orally on 02/11/13 at 5:00 p.m. Further review of the Bowel Protocol" sheet revealed DONS2 gave Dulcolax 5 mg orally on 02/11/13 at 10:30 a.m. with no documented evidence in the nurses' notes that the Dulcolax was given and whether there were results from it. Further review revealed the nurse documented on 02/12/13 at 5:30 a.m. that a Dulcolax suppository was given due to no bowel movement in 5 days. There was no documented evidence the physician was notified that no results were obtained with the use of the bowel program that was implemented. Review of the "7 Day Graphic Sheet" revealed Patient #3 had 3 bowel movements on 02/12/13, none on 02/13/13 and 02/14/13, 1 on 02/15/13, and 2 on 02/16/13. Review of the "Bowel Protocol" sheet revealed she was offered and refused a Dulcolax suppository on 02/16/13 (had a bowel movement on 02/15/13 and should not have received or been offered treatment), received a Dulcolax suppository on 02/17/13 but had 2 bowel movements on 02/16/13. Further review revealed she had no bowel movement on 02/17/13 and 02/18/13 and was given a Dulcolax suppository on 02/19/13 at 9:45 a.m. (not 3 days without a bowel movement as ordered) by an LPN. There was no documented evidence of an RN assessment of Patient #3 prior to her receiving a Dulcolax suppository prior to going 3 days without a bowel movement. Further review revealed Patient #3 had a bowel movement on 02/22/13 and was given Surfak 240 mg orally on 02/23/13 at 8:00 a.m. and on 02/24/13 at 8:00 a.m. (not 3 days since a bowel movement on either day). There was no documented evidence of an RN assessment prior to LPNS6 giving the Surfak when it had not been 3 days since Patient #3 had a bowel movement. She had a bowel movement on 02/25/13 and was given Surfak 240 mg orally on 02/26/13 at 8:00 a.m.

Patient #5
Review of Patient #5's medical record revealed she was a 75 year old female admitted on 02/11/13 with an admit diagnosis of Late Effect CVA.

Review of Patient #5's "Standing Admission Orders" received by telephone order on 02/11/13 with no documented evidence of the time the order was received revealed an order to record the bowel movements every day and to begin the Bowel Program if no bowel movement in 3 days.

Review of Patient #5's "Bowel Protocol" sheet revealed she was given Surfak 240 mg orally on 02/19/13 at 8:50 a.m. by LPNS6. Review of Patient #5's "7 Day Graphic Sheet" and "24 Hour Nursing Assessment: revealed no documented evidence that the an assessment of bowel movements was documented on the night shift of 02/18/13. There was no documented evidence that Patient #5 did not have a bowel movement in 3 days when Surfak was administered on 02/19/13 (one bowel movement on 02/16/13, none on 02/17/13, and none documented on 02/18/13). There was no documented evidence of an assessment by an RN on 02/19/13 of Patient #5's bowel status.

In a face-to-face interview on 02/26/13 at 4:05 p.m., LPNS6 indicated she always starts with Surfak, but if the patient was constipated she would give an enema or a Dulcolax suppository. She further indicated she chose which medication to use from the choices listed in the bowel program. She further indicated the physician did not give a specific order.

In a telephone order on 02/26/13 at 3:15 p.m., Contract PharmacistS12 with Company A indicated Surfak was a stool softener and Dulcolax was a laxative and stronger. He further indicated the bowel program order should be clarified, since the drugs have different purposes.

In a face-to-face interview on 02/28/13 at 2:25 p.m., DONS2 indicated the nurses use their judgment when deciding which of the bowel programs orders to use. She further indicated the nurses prefer to use the oral route first. DONS2 confirmed there was no physician order obtained to clarify which specific medication he wanted given for each patient regarding the bowel program.

In a telephone interview on 02/28/13 at 3:30 p.m., PharmacistS13 with Company B indicated he never clarified the bowel program medication orders with the physician.

4) The RN failed to assess and document the respiratory rate prior to and after nebulizer treatments:
Patient #15
Review of Patient #15's medical record revealed he was an 88 year old male admitted on 12/14/12 with a diagnosis of Debility secondary to Pneumonia. Review of his "Medication Reconciliation List" received by telephone order on 12/14/12 at 4:00 p.m. revealed an order for Albuterol Sulfate 2.5 / 3 ml (milliliters) per inhalation every 4 hours.

Review of Patient #15's "Respiratory Treatment Sheet" revealed no documented evidence the nebulizer treatments were administered on 12/19/12 at 12:00 a.m. and 4:00 a.m. as ordered. Further review of the "Respiratory Treatment Sheet" from 12/14/12 through 8:00 p.m. on 12/19/12 revealed no documented evidence that the respiratory rate was assessed before and after each treatment as required on the sheet.

Patient #25
Review of Patient #25's medical record revealed she was a 53 year old female admitted on 10/19/12 and discharged on 11/14/12. Review of her physician orders revealed an order on 10/30/12 at 3:40 a.m. for nebulizer treatments with Albuterol 3.0 mg (milligrams) and Atrovent 0.5 mg once stat and then as needed every 6 hours for shortness of breath or wheezing. Further review revealed an order on 10/30/12 at 10:50 a.m. for Albuterol 90 mcg (micrograms) per inhaler 2 puffs every 4 hours as needed for cough, wheezing, or shortness of breath.

Review of Patient #25's "Respiratory Treatment Sheet" revealed she had nebulizer treatments on 11/11/12 at 8:00 a.m. and 9:00 p.m. with no documented evidence of an assessment of her respiratory rate before and after his treatment. Further review revealed she complained of shortness of breath on 11/04/12 at 8:00 a.m. and was administered a nebulizer treatment. There was no documented evidence of a re-assessment of her respiratory status until 5:00 p.m., 9 hours after the treatment was administered. Further review revealed Patient #25 complained of shortness of breath on 11/11/12 at 8:00 a.m. and was administered a nebulizer treatment. There was no documented evidence she was re-assessed until 2 hours later at which time she complained of shortness of breath and the physician was notified.

In a face-to- face interview on 02/28/13 at 2:25 p.m., DONS2 indicated the nurses should be assessing the respiratory rate before and after respiratory treatments.

5) The RN failed to ensure physician orders were implemented as ordered related to accuchecks, lab specimen collections, wheelchair cushions, and SCDs:
Patient #2
Review of Patient #2's medical record revealed she was a 76 year old female admitted on 02/01/13 with a diagnosis of Status Post Right Hip Fracture with Open Reduction Internal Fixation.

Review of Patient #2's physician orders revealed an order on 02/12/13 at 11:02 a.m. for stool for occult blood times 3 (means to collect 3 separate stool samples).

Review of Patient #2's lab result form revealed the stool specimen collected on 02/18/13 was negative. Review of the nurses' notes revealed the second stool specimen was collected on 02/23/13 at 9:15 a.m. Further review revealed the results of the second stool specimen were not received prior to her discharge on 02/25/13. Further review revealed no documented evidence the physician was notified prior to discharge that the result of the second stool specimen had not been received and that the third stool specimen had not been collected, so arrangements could be made for collection of the third specimen after discharge.

In a face-to-face interview on 02/27/13 at 3:05 p.m., DONS2 confirmed there was no documentation if Patient #2's medical record that her physician was notified that all 3 stool specimens had not been collected and results reported prior to her discharge. DONS2 indicated the discharging nurse should have notified the physician of this prior to the discharge.

Patient #3
Review of Patient #3's medical record revealed she was a 73 year old female admitted on 02/09/13 with diagnoses of Dementia, Debility, and Deconditioning.

Review of Patient #3's physician orders revealed the following orders:
02/08/13 at 12:28 p.m. - pressure relieving wheelchair cushion and SCDs to lower extremities while in bed;
02/21/13 at 10:25 a.m. - urinalysis with culture and sensitivity today;
02/25/13 at 10:41 a.m. - call lab today for final urinalysis sensitivities from 02/21/13 and notify physician with results.

Review of Patient #3's MARs and nurses' notes revealed the pressure relieving wheelchair cushion ordered on 02/08/13 was not implemented until 01/11/13. Further review revealed the SCD ordered on 02/08/13 was not implemented until 02/11/13. There was no documented evidence the physician was notified of the delay in implementing the orders.

Review of Patient #3's medical record revealed no documented evidence the results of the sensitivities of the urinalysis collected on 02/21/13 had been checked for prior to the physician's order to call the lab for the results on 02/25/13.

Patient #5
Review of Patient #5's medical record revealed she was a 75 year old female admitted on 02/11/13 with an admit diagnosis of Late Effect CVA.

Review of Patient #5's physician orders revealed the following orders:
02/12/13 at 10:30 a.m. - BNP (B Type Natriuretic Peptide) with next lab draw and Magnesium and TSH (thyroid stimulating hormone) on 02/15/13; Iron, Ferritin, TIBC (total iron-binding capacity), Folate, and Vitamin B 12 on 02/15/13;
02/13/13 at 9:00 a.m. - o.k. to do BNP on 02/14/13;
02/13/13 at 10:53 a.m. - o.k. to obtains labs ordered for 02/15/13 on 02/14/13;
02/14/13 at 10:51 a.m. - draw labs Iron, Ferritin, TIBC, TSH, Vitamin B12, Folate, Magnesium on 02/15/13.

Review of the lab results for Patient #5 revealed the BNP was collected on 02/14/13 at 8:45 a.m.. Further review revealed the TSH, Vitamin B12, Ferritin, Folate, TIBC, and Magnesium were collected on 02/15/13 at 8:30 a.m.

Review of Patient #5's nurses' notes for 02/13/13 revealed the nurse had 3 unsuccessful attempts to draw her blood and received an order to draw the BNP on 02/14/13. Review of her nurses' notes for 02/14/13 revealed no documented evidence of an attempt to draw blood as ordered on 02/14/13. There was no documented evidence why the TSH, Vitamin B12, Ferritin, Folate, TIBC, and Magnesium were not drawn at the same time the BNP was drawn on 02/14/13.

In a face-to-face interview on 02/28/13 at 2:25 p.m., DONS2 indicated all the labs ordered for Patient #5 on 02/14/13 were to be collected in the same color tube, so the nurse should have been able to draw them as ordered.

Patient #17
Review of Patient #17's medical record revealed he was a 70 year old male admitted on 11/14/12 with the diagnosis of Debility and discharged on 11/30/12. Further review revealed he had a past medical history of Atrial Fibrillation, Depression (Bipolar), Diabetes Mellitus, Hypertension, Malnutrition, Osteoarthritis, Urinary Retention, Gastrointestinal Bleed with Esophagitis, and Sepsis.

Review of Patient #17's admission orders received by telephone on 11/14/12 at 11:45 a.m. revealed accuchecks were not ordered as evidenced by the nurse's initials in the column titled "not ordered". Further review revealed an order on 11/15/12 at 12:15 p..m. to copy accuchecks to the chart and on 11/16/12 at 1:05 p.m. to place the accuchecks on the chart. There was no documented evidence of a clarification order by the nurse to the physician to determine the frequency that he wanted the accuchecks to be done.

Review of Patient #17's MAR revealed accuchecks were done from the time of admit before meals and at bedtime without evidence of a physician's order to do so.

In a face-to-face interview on 02/28/13 at 2:25 p.m., DONS2 confirmed the accuchecks were done for Patient #17 without a clarification order being received.



25065

Based on record reviews and interviews, the hospital failed to ensure non-employee licensed nurses working in the hospital were supervised by a hospital-employed RN as evidenced by contract agency RNs working the night shift as the only RN present in the hospital. The hospital failed to ensure the contract agency RNs were trained and oriented on the hospital's policies and procedures to which they must adhere while working. Findings:

Review of the hospital policies and procedure presented by S1 Administrator that were approved 11/19/13 (no policy number) revealed "All non-employee nurses must be supervised by a hospital RN".

Review of the "Daily Staffing Sheet" for 02/11/13 through 02/25/13 presented by Human Resources DirectorS3 revealed the following RNs were listed for the respective nights shifts:
02/24/13 - Company C Contract RNS10 with DONS2;
02/18/13 - Company C Contract RNS8 with DONS2;
02/19/13 - Company C Contract RNS9 with DONS2 from 6:00 p.m. to 10:00 p.m. and RNS11 from 10 :00 p.m. to 6:00 a.m. on 02/20/13;
02/24/13 - Company C Contract RNS10 with DONS2.

In a telephone interview on 02/27/13 at 2:27 p.m., RNS8 contracted through Company C indicated she worked on 02/18/13 with a certified nursing assistant and was the only RN present on the night shift.

In a telephone interview on 02/27/13 at 2:35 p.m., RNS10 contracted through Company C indicated she had contracted with the hospital about two-and-a-half weeks ago. She further indicated she had a tour of the hospital before she worked which included where the crash cart was located and how to do the charting. RNS10 indicated she was given a packet of information but had no classroom-type orientation or training. She further indicated she had worked on 02/14/13 and 02/24/13 and was the only RN present on both night shifts.

In a telephone interview on 02/27/13 at 2:45 p.m., RNS9 contracted through Company C indicated she had worked 2 shifts at the hospital, one of which was 02/19/13. When asked about the orientation she had received, RNS9 indicated she had a brief orientation by the RNS11 who was the day nurse she was relieving. RNS9 indicated the brief orientation consisted of a walk-around tour showing her the location of supplies, linen, the medication room, the MARs (medication administration record), and how to count narcotics. She further indicated it "was not like a standard hospital, it was a little different". When asked what she meant by "a little different", RNS9 indicated she didn't have a general orientation, but she was shown where the hospital policies were located. RNS9 indicated there was a LPN (licensed practical nurse) and a certified nursing assistant with her on her first night, and she was the only RN on both nights that she worked.

In a face-to-face interview on 02/28/13 at 1:00 p.m., AdministratorS1 indicated they used contract agency RNs on the night shift, and they worked alone with no hospital-employed RN present to supervise them. She further indicated the contract agency nurses did not have the same orientation that a hospital-employed nurse received.

In a face-to-face interview on 02/28/13 at 2:25 p.m., DONS2 indicated she should have worked with the contract agency RNs but didn't. She confirmed that she wrote her name on the staffing assignment sheet, because she anticipated working those shifts. DONS2 indicated she should have corrected the nursing assignment sheets to reflect that the agency contract nurses worked alone, but she (DONS2) didn't have the opportunity to make the corrections.

Review of personnel files for RNS8, RNS9, and RNS10 who were contracted through Company C revealed orientation occurred on the day RNS9 and RNS10 actually worked the first time, 02/18/13 and 02/19/13 respectively. Further review revealed RNS8 received orientation the day before working the 7:00 p.m. to 7:00 a.m. shift on 02/14/13. The orientation for each contract nurse failed to reveal documented evidence that policies and procedures related to Nursing Services was covered.









25065

Based on record reviews and interviews, the hospital failed to ensure medications were administered as ordered by the physician for 1 of 5 current inpatients' records (#5) and 1 of 18 closed medical records (#6) reviewed for medication administration from a total of 26 sampled patients. There were 9 medication errors identified during the survey that had not been identified by the pharmacist or nursing staff. Findings:

Patient #5
Review of Patient #5's medical record revealed she was a 75 year old female admitted on 02/11/13 with an admit diagnosis of Late Effect CVA.

Review of Patient #5's "Standing Admission Orders" received by telephone order on 02/11/13 with no documented evidence of the time the order was received revealed an order to perform accuchecks ac and hs (before meals and at bedtime). Further review revealed sliding scale insulin was not ordered by the physician.

Review of Patient #5's "Medication Reconciliation List" verified by telephone order on 02/11/13 with no documented evidence of the time the order was received revealed an order for Naproxen 250 mg orally three times a day (TID). Review of her physician orders revealed an order on 02/12/13 at 10:30 a. to change the Naproxen to 250 mg orally TID prn pain and Omeprazole 20 mg orally every day. Further review revealed an order on 02/13/13 at 10:53 a.m. for Cipro 500 mg orally twice a day (BID) for four days. Further review revealed an order on 02/22/13 at 11:07 a.m. to start Prozac 10 mg orally every day when available.

Review of Patient #5's "Accucheck Treatment Record" revealed sliding scale subcutaneous orders were typed as follows with no documented evidence of the type of insulin to administer: 151 to 173 give 2 units; 174 to 203 give 3 units; 204 to 233 give 4 units; 234 to 263 give 5 units; 264 to 293 give 6 units; 294 to 323 give 7 units; 324 to 353 give 8 units; 354 to 380 give 9 units; greater than or equal to 381 give 10 units and notify the physician. Further review revealed Contract RNS8 with Company C administered 5 units of insulin on 02/18/13 at 8:00 p.m. for a blood sugar reading of 240 with no documented evidence of the type of insulin administered. Review of the nurses' notes for 02/18/13 revealed Contract RNS8 with Company C documented that she gave 5 units of Regular Insulin at 9:00 p.m. Further review of the "Accucheck Treatment Record" revealed Contract RNS9 with Company C administered 3 units of insulin on 02/19/13 at 8:00 p.m. with no documented evidence of the type of insulin administered. Review of the nurses' notes for 02/19/13 revealed no documented evidence of a note by Contract RNS9 with Company C regarding the administration of insulin.

Review of Patient #5's "PRN Medication Record" revealed Naproxen 250 mg was listed to be given once orally TID prn pain and not TID as ordered by the physician. There was no documented evidence Naproxen was given as ordered on 02/11/13 and the morning of 02/12/13 before the order was changed to prn at 10:30 a.m. Further review revealed no documented evidence Omeprazole was administered as ordered on 02/14/13. Review of the MAR revealed Cipro was given on 02/13/13 at 8:00 a.m. when it wasn't ordered until after that time on 02/13/13 at 10:53 a.m. Further review revealed Prozac was not given until 02/23/13 at 8:00 a.m. but was ordered on 02/22/13 at 11:07 a.m.

Patient #6
Review of Patient #6's medical record revealed she was an 80 year old female admitted on 11/09/12 with a diagnosis of Late Effect CVA. Review of her "Medication Reconciliation List" received by telephone order on 11/09/12 at 3:00 p.m. revealed an order for Pravastatin 40 mg orally at bedtime. Review of the physician orders revealed a telephone order on 01/16/12 at 8:00 p.m. to hold the Pravastatin 40 mg until available.

Review of Patient #6's MARs revealed Pravastatin was not administered on 11/16/12 and 11/17/12 with a note of "not available" written.

In a face-to-face interview on 02/28/13 at 2:25 p.m., DONS2 indicated she did not have any medication variances that had been documented since the last survey. She confirmed the above identified medication errors.

Based on observations, record reviews, and interviews, the hospital failed to ensure patient medical records were stored in locations where they were protected from water damage that could occur if the hospital's sprinkler system was activated. Findings:

Observation in the medical record room on 02/28/13 at 10:50 a.m. revealed 14 boxes of patients' financial records and 2 boxes of patients' medical records stored in cardboard boxes stacked on the floor in the medical record room.

In a face-to-face interview on 02/28/13 at 10:50 a.m., Medical Records CoordinatorS5 indicated she had started to box the patients' records about 1 week ago in preparation of them being sent to storage. She further indicated the medical record room had a sprinkler system, and the records in the boxes would not be protected from water damage if the sprinkler system was activated.

Based on record reviews and interviews, the hospital failed to have a system of coding and indexing medical records that allowed for timely retrieval by diagnosis and procedure. Findings:

Review of the list of discharged patients presented by Human Resources DirectorS3 as the list of all discharged patients since the hospital was acquired by the present owner on 11/09/12 revealed the list was hand-written. Further review revealed the list included the patient's name, discharge date, medical record number, account number, and discharge status.

In a face-to-face interview on 02/28/13 at 10:50 a.m., Medical Record CoordinatorS5 indicated the hospital did not have an electronic medical record system. She further indicated all information requested needed to be pulled either by the patient's name or the date of service. She further indicated the hospital could not pull medical record information according to the patient's diagnosis or procedure.

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

Failing to ensure drugs and biological were controlled and distributed according to acceptable standards of practice and consistent with State law.
1)The current owner of the hospital did not apply for a CDS (Controlled and Dangerous Substance) license and a DEA (Drug Enforcement Agency) license. This resulted in the hospital receiving and dispensing drugs without a license to do so;
2) The hospital did not have a current contract for the pharmaceutical services provided to the hospital until 02/14/13 (hospital had no pharmacy contract from the date of sale of 11/09/12 until 02/14/13). This resulted in medication orders for the hospital's bowel program that were not specific not being clarified by a nurse or pharmacist prior to the medication being administered for 4 of 5 current patients' records reviewed for specific medication orders from a total of 25 sampled patients (#1, #2, #3, #5); and
3) The pharmacist failed to ensure medications were administered as ordered by the physician. There were 7 medication errors identified during the survey that had not been identified by the pharmacist or nursing staff for 1 of 5 current inpatients' records (#5) reviewed for medication administration from a total of 25 sampled patients (see findings in tag A0500).

Based on interviews, the hospital failed to ensure drugs and biological were controlled and distributed according to acceptable standards of practice and consistent with State law.
1)The current owner of the hospital did not apply for a CDS (Controlled and Dangerous Substance) license and a DEA (Drug Enforcement Agency) license. This resulted in the hospital receiving and dispensing drugs without a license to do so;

2) The hospital did not have a current contract for the pharmaceutical services provided to the hospital until 02/14/13 (hospital had no pharmacy contract from the date of sale of 11/09/12 until 02/14/13). This resulted in medication orders for the hospital's bowel program that were not specific not being clarified by a nurse or pharmacist prior to the medication being administered for 4 of 5 current patients' records reviewed for specific medication orders from a total of 26 sampled patients (#1, #2, #3, #5); and

3) The pharmacist failed to ensure medications were administered as ordered by the physician. There were 9 medication errors identified during the survey that had not been identified by the pharmacist or nursing staff for 1 of 5 current inpatients' records (#5) and 1 of 18 closed medical records (#6) reviewed for medication administration from a total of 26 sampled patients.

Findings:

1)The current owner of the hospital did not apply for a CDS license and a DEA license:
Review of the LAC 46: LIII. Chapters 25, 27, and 31, revealed, in part, "...FINAL RULE Department of Health and Hospitals Board of Pharmacy Controlled Dangerous Substances...
Title 46
PROFESSIONAL AND OCCUPATIONAL STANDARDS
Part LIII. Pharmacists
Subchapter B. Licenses
?2705. Licenses and Exemptions
E. Facilities. The issuance of a CDS license to a facility, and the renewal thereof, shall require the possession of a valid and verifiable license or other credential issued by the department, or its successor.

?2707. Licensing Procedures
D. Maintenance of CDS Licenses
1. A CDS license is valid only for the entity or person to whom it is issued and shall not be subject to sale, assignment or other transfer, voluntary or involuntary, nor shall a license be valid for any premises other than the business location for which it is issued.
2. In order to maintain a CDS license, the applicant shall maintain a federal license required by federal law to engage in the manufacture, distribution, prescribing, or dispensing of controlled substances. ...
5. A facility changing ownership shall notify the board in writing 15 calendar days prior to the transfer of ownership.
a. A change of ownership is evident under the following conditions:
i. sale;
ii. death of a sole proprietor;
iii. the addition or deletion of one or more partners in a partnership;
iv. bankruptcy sale; or
v. a 50 percent, or more, change in ownership of a corporation, limited liability company, or association since the issuance of the original CDS license.
b. The new owner(s) shall submit a properly completed application, with all required attachments and appropriate fee, to the board.
c. Upon the receipt of the new CDS license, the previous licensee shall:
i. notify the board of the transaction, including the identity of the new owner(s); and
ii. surrender his CDS license to the board.
d. A CDS license is not transferable from the original owner to a new owner.
e. A change in ownership may require an inspection by the board or its designee.
AUTHORITY NOTE: Promulgated in accordance with R.S. 40:972.
HISTORICAL NOTE: Promulgated by the Department of Health and Hospitals, Board of Pharmacy, LR 34:2131 (October 2008).

In a face-to-face interview on 02/27/13 at 11:30 a.m., AdministratorS1 indicated that she purchased the hospital on 11/09/12. She further indicated she had not applied for a CDS and DEA license, because the DEA license application specifically asked for the hospital license number, and she didn't have a hospital license yet.

2) The hospital did not have a current contract for the pharmaceutical services provided to the hospital until 02/14/13 which resulted in medication orders for the hospital's bowel program that were not specific not being clarified by a nurse or pharmacist prior to the medication being administered:
In a face-to-face interview on 02/27/13 at 11:30 a.m., AdministratorS1 indicated she never negotiated a contract with Company B, because the pharmacist with Company B refused to negotiate a contract with the hospital. She further indicated she had negotiated a contract with Company A for pharmaceutical services on 02/14/13.

In a telephone interview on 02/28/13 at 3:30 p.m., PharmacistS13 with Company B indicated he never negotiated a contract with AdministratorS1. He further indicated he kept calling, but no one would return his calls. He further indicated he had never discontinued services with the hospital, and as far as he was aware, Company B was still supplying medications to the hospital.

Review of the hospital's "Standing Admission Orders" revealed a column for the nurse to place her initials if the physician ordered the specific medication or test and a column for the nurse's initials if the physician did not order the medication or test. Further review revealed number 27 included the nurse was to record a patient's bowel movement every day, and if no bowel movement in 3 days, begin the Bowel Program. Further review revealed the Bowel Program was a choice of the following: Surfak 240 mg (milligrams) orally twice a day or Dulcolax 5 mg orally twice a day or Dulcolax 10 mg suppository per rectum every day prn (as needed) or Fleets Enema times 1 daily as needed for constipation. There was no documented evidence how the nurse was to decide which of the 4 choices to use for a specific patient.

Patient #1
Review of Patient #1's medical record revealed she was a 47 year old female admitted on 02/15/13 with a diagnosis of Urinary Tract Infection.

Review of Patient #1's "Standing Admission Orders" received by telephone order on 02/15/13 at 8:30 p.m. revealed an order to record the bowel movements every day and to begin the Bowel Program if no bowel movement in 3 days.

Review of Patient #1's "7 Day Graphic Sheet" revealed she had a bowel movement on 02/15/13 and no bowel movement on 02/16/13 and 02/17/13. Review of the "PRN Medication Record" revealed LPNS7 (licensed practical nurse) administered Dulcolax 5 mg orally at 8:15 a.m. on 02/18/13.

Patient #2
Review of Patient #2's medical record revealed she was a 76 year old female admitted on 02/01/13 with a diagnosis of Status Post Right Hip Fracture with Open Reduction Internal Fixation.

Review of Patient #2's "Standing Admission Orders" received by telephone order on 02/01/13 at 7:45 p.m. revealed an order to record the bowel movements every day and to begin the Bowel Program if no bowel movement in 3 days.

Review of Patient #2's "7 Day Graphic Sheet" revealed she had no bowel movement on 02/12/13, 02/13/13, 02/14/13, and 02/15/13. Review of his "Bowel Protocol" sheet revealed Patient #2 received Dulcolax 5 mg orally on 02/15/13 by DONS2 (director of nursing) at 8:45 a.m. and a Dulcolax suppository 10 mg per rectum on 02/16/13 at 6:00 a.m.

Patient #3
Review of Patient #3's medical record revealed she was a 73 year old female admitted on 02/08/13 with diagnoses of Dementia, Debility, and Deconditioning.

Review of Patient #3's "Standing Admission Orders" received by telephone order on 02/08/13 at 11:00 a.m. revealed an order to record the bowel movements every day and to begin the Bowel Program if no bowel movement in 3 days.

Review of Patient #3's "7 Day Graphic Sheet" and nurses' notes revealed she did not have a bowel movement on 02/08/13, 02/09/13, 02/10/13, and by 5:00 p.m. on 02/11/13 and was given Surfak 240 mg orally on 02/11/13 at 5:00 p.m. Further review of the Bowel Protocol" sheet revealed DONS2 gave Dulcolax 5 mg orally on 02/11/13 at 10:30 a.m. with no documented evidence in the nurses' notes that the Dulcolax was given and whether there were results from it. Further review revealed the nurse documented on 02/12/13 at 5:30 a.m. that a Dulcolax suppository was given due to no bowel movement in 5 days. There was no documented evidence the physician was notified that no results were obtained with the use of the bowel program that was implemented. Review of the "7 Day Graphic Sheet" revealed Patient #3 had 3 bowel movements on 02/12/13, none on 02/13/13 and 02/14/13, 1 on 02/15/13, and 2 on 02/16/13. Review of the "Bowel Protocol" sheet revealed she was offered and refused a Dulcolax suppository on 02/16/13 (had a bowel movement on 02/15/13 and should not have received or been offered treatment), received a Dulcolax suppository on 02/17/13 but had 2 bowel movements on 02/16/13. Further review revealed she had no bowel movement on 02/17/13 and 02/18/13 and was given a Dulcolax suppository on 02/19/13 at 9:45 a.m. (not 3 days without a bowel movement as ordered). Further review revealed Patient #3 had a bowel movement on 02/22/13 and was given Surfak 240 mg orally on 02/23/13 at 8:00 a.m. and on 02/24/13 at 8:00 a.m. (not 3 days since a bowel movement on either day). She had a bowel movement on 02/25/13 and was given Surfak 240 mg orally on 02/26/13 at 8:00 a.m.

Patient #5
Review of Patient #5's medical record revealed she was a 75 year old female admitted on 02/11/13 with an admit diagnosis of Late Effect CVA( cerebrovascular accident).

Review of Patient #5's "Standing Admission Orders" received by telephone order on 02/11/13 with no documented evidence of the time the order was received revealed an order to record the bowel movements every day and to begin the Bowel Program if no bowel movement in 3 days.

Review of Patient #5's "Bowel Protocol" sheet revealed she was given Surfak 240 mg orally on 02/19/13 at 8:50 a.m. by LPNS6. Review of Patient #5's "7 Day Graphic Sheet" and "24 Hour Nursing Assessment: revealed no documented evidence that the an assessment of bowel movements was documented ion the night shift of 02/18/13. There was no documented evidence that Patient #5 did not have a bowel movement in 3 days when Surfak was administered on 02/19/13 (one bowel movement on 02/16/13, none on 02/17/13, and none documented on 02/18/13).

In a face-to-face interview on 02/26/13 at 4:05 p.m., LPNS6 indicated she always starts with Surfak, but if the patient was constipated she would give an enema or a Dulcolax suppository. She further indicated she chose which medication to use from the choices listed in the bowel program. She further indicated the physician did not give a specific order.

In a telephone order on 02/26/13 at 3:15 p.m., Contract PharmacistS12 with Company A indicated Surfak was a stool softener and Dulcolax was a laxative and stronger. He further indicated the bowel program order should be clarified, since the drugs have different purposes.

In a face-to-face interview on 02/28/13 at 2:25 p.m., DONS2 indicated the nurses use their judgment when deciding which of the bowel programs orders to use. She further indicated the nurses prefer to use the oral route first. DONS2 confirmed there was no physician order obtained to clarify which specific medication he wanted given for each patient regarding the bowel program.

In a telephone interview on 02/28/13 at 3:30 p.m., PharmacistS13 with Company B indicated he never clarified the bowel program medication orders with the physician.

3) The pharmacist failed to ensure medications were administered as ordered by the physician:
Patient #5
Review of Patient #5's medical record revealed she was a 75 year old female admitted on 02/11/13 with an admit diagnosis of Late Effect CVA.

Review of Patient #5's "Standing Admission Orders" received by telephone order on 02/11/13 with no documented evidence of the time the order was received revealed an order to perform accuchecks ac and hs (before meals and at bedtime). Further review revealed sliding scale insulin was not ordered by the physician.

Review of Patient #5's "Medication Reconciliation List" verified by telephone order on 02/11/13 with no documented evidence of the time the order was received revealed an order for Naproxen 250 mg orally three times a day (TID). Review of her physician orders revealed an order on 02/12/13 at 10:30 a. to change the Naproxen to 250 mg orally TID prn pain and Omeprazole 20 mg orally every day. Further review revealed an order on 02/13/13 at 10:53 a.m. for Cipro 500 mg orally twice a day (BID) for four days. Further review revealed an order on 02/22/13 at 11:07 a.m. to start Prozac 10 mg orally every day when available.

Review of Patient #5's "Accucheck Treatment Record" revealed sliding scale subcutaneous orders were typed as follows with no documented evidence of the type of insulin to administer: 151 to 173 give 2 units; 174 to 203 give 3 units; 204 to 233 give 4 units; 234 to 263 give 5 units; 264 to 293 give 6 units; 294 to 323 give 7 units; 324 to 353 give 8 units; 354 to 380 give 9 units; greater than or equal to 381 give 10 units and notify the physician. Further review revealed Contract RNS8 with Company C administered 5 units of insulin on 02/18/13 at 8:00 p.m. for a blood sugar reading of 240 with no documented evidence of the type of insulin administered. Review of the nurses' notes for 02/18/13 revealed Contract RNS8 with Company C documented that she gave 5 units of Regular Insulin at 9:00 p.m. Further review of the "Accucheck Treatment Record" revealed Contract RNS9 with Company C administered 3 units of insulin on 02/19/13 at 8:00 p.m. with no documented evidence of the type of insulin administered. Review of the nurses' notes for 02/19/13 revealed no documented evidence of a note by Contract RNS9 with Company C regarding the administration of insulin.

Review of Patient #5's "PRN Medication Record" revealed Naproxen 250 mg was listed to be given once orally TID prn pain and not TID as ordered by the physician. There was no documented evidence Naproxen was given as ordered on 02/11/13 and the morning of 02/12/13 before the order was changed to prn at 10:30 a.m. Further review revealed no documented evidence Omeprazole was administered as ordered on 02/14/13. Review of the MAR revealed Cipro was given on 02/13/13 at 8:00 a.m. when it wasn't ordered until after that time on 02/13/13 at 10:53 a.m. Further review revealed Prozac was not given until 02/23/13 at 8:00 a.m. but was ordered on 02/22/13 at 11:07 a.m.

Patient #6
Review of Patient #6's medical record revealed she was an 80 year old female admitted on 11/09/12 with a diagnosis of Late Effect CVA. Review of her "Medication Reconciliation List" received by telephone order on 11/09/12 at 3:00 p.m. revealed an order for Pravastatin 40 mg orally at bedtime. Review of the physician orders revealed a telephone order on 01/16/12 at 8:00 p.m. to hold the Pravastatin 40 mg until available.

Review of Patient #6's MARs revealed Pravastatin was not administered on 11/16/12 and 11/17/12 with a note of "not available" written.

In a face-to-face interview on 02/28/13 at 2:25 p.m., DONS2 indicated she did not have any medication variances that had been documented since the last survey. She confirmed the above identified medication errors.

Based on record reviews and interviews, the hospital failed to ensure the hospital's contract for radiological services with Company E provided for 24 hours/7 days a week coverage as evidenced by the contract stating Company E would provide services to the hospital's patients during normal business hours, Monday through Friday from 8:00 a.m. to 4:00 p.m. The contract allowed for procedures performed outside these times to be performed at Company E's earliest availability. Findings:

Review of the contract with Company E, effective 11/06/12 and presented by AdministratorS2 as the current contract for radiological services, revealed Company E would provide radiological services during normal business hours of 8:00 a.m. to 4:00 p.m. Monday through Friday. Further review revealed procedures performed outside these scheduled service hours would be performed at Company E's earliest availability. Further review revealed Company E would make reasonable efforts to respond to stat services within one hour from the time of notification. Review of the contract revealed both parties agreed and understood that Company E's availability could be delayed due to circumstances beyond Company E's control such as inclement weather, traffic congestion, mechanical breakdowns, accidents, and illness. In the event of a delay, Company E would contact the hospital to advise them of the delay.

In a face-to-face interview on 02/28/13 at 1:00 p.m., AdministratorS1 confirmed the hospital had a contract with Company E to provide radiological services. When asked about the operating hours in the contract being Monday through Friday from 8:00 a.m. to 4:00 p.m. with no specific time frame for the provision of services outside these hours, AdministratorS1 had no comment.

Based on record reviews and interviews, the hospital failed to develop policies and procedures that provided for the safety of patients and personnel during radiological testing performed by Company E. Findings:

Review of the hospital's policy titled "X-Ray/EKG (electrocardiogram) Ordering", policy number N 2.017 presented as the current radiology policy by AdministratorS1 when all radiology policies were requested, revealed the policy addressed the procedure for ordering the procedure once it was ordered by the physician and completing the request slip. Further review revealed no documented evidence of a policy and procedure that addressed how patients and personnel would be provided safety during the performance of radiological tests by Company E in the hospital.

In a face-to-face interview on 02/28/13 at 1:00 p.m., AdministratorS1 confirmed the policy submitted for radiology was the only hospital policy. She further confirmed the hospital did not have policies and procedures developed that addressed how patients and personnel would be provided safety during the performance of radiological tests by Company E in the hospital.

Based on review of physician credential files, Governing Body meeting minutes and interview with staff, the hospital failed to ensure a radiologist was credentialed to supervise radiology services .

Findings:

Review of physician credentialing files failed to reveal a radiologist who was designated and/or approved to supervise radiology services by the Governing Body. Review of Governing Body meeting minutes dated 11/09/12, 11/19/12, and 2/18/13 revealed no documented evidence of a radiologist being approved or credentialed.

Interview on 2/28/13 at 4:35 PM with AdministratorS1 confirmed the hospital did not have a radiologist credentialed to supervise radiology services.

Based on observations, record reviews, and interviews, the hospital failed to ensure lab services were provided under a current CLIA (Clinical Laboratory Improvement Amendments) certificate and under a current contract with a lab provider. The hospital failed to ensure policies and procedures had been developed that addressed the procedure for identifying the patient prior to the lab draw, how to handle stat physician orders and the time interval for the specimen to be drawn when ordered stat, how to report critical lab values, and who was responsible for checking for expired lab supplies and the subsequent disposal of such items.

Findings:

In a face-to-face interview on 02/26/13 at 9:10 a.m., AdministratorS1 indicated she did not have a current CLIA (Clinical Laboratory Improvement Amendments) certificate. She further indicated a hospital license was required to obtain a CLIA certificate, and she had not obtained a hospital license yet.

Review of the contract for Company D presented by AdministratorS1 revealed it was an offer to provide clinical laboratory testing services with pricing terms for each test attached and was signed by AdministratorS1 on 02/06/13. There was no documented evidence of a signature of the representative of Company D. Further review revealed a "sticky note" attached with hand-writing that read "requested full contract with terms, responsibilities, guidelines, etc. (and so on) not received at this point".

Review of the contract with Hospital A, signed by a former Administrator, revealed a contract was executed on 01/30/09 between Hospital A and Hospital B for laboratory and blood gas services, radiology and other imaging services, emergency services, nuclear medicine, and other services. Further review revealed the contract renewed on an annual basis automatically.

Review of the policies and procedure for lab presented by DONS2 as the current policy (Policy Number N 2.02 Lab Ordering) revealed the policy addressed the process for noting the required lab on the non-MAR (medication administration record), completing a lab requisition, preparation of the lab tubes, obtaining the lab specimen, and notifying the courier to pick up the specimen. There was no documented evidence of the procedure for identifying the patient prior to the lab draw, how to handle stat physician orders and the time interval for the specimen to be drawn when ordered stat, how to report critical lab values, and who was responsible for checking for expired lab supplies and the subsequent disposal of such items.

Observation of the small lab area adjacent to the nursing station on 02/25/13 at 10:36 a.m. with Director of NursingS2 (DON) present revealed 118 vacutainers (1.8 milliliter size) used for anticoagulation studies that had expired 01/13.

In a face-to-face interview on 02/28/13 at 1:00 p.m., AdministratorS1 indicated Specialty Rehabilitation Hospital of Luling was formerly Hospital B. She further indicated she purchased the hospital on 11/09/12 and had not negotiated a new contract with Hospital A and did not have a signed contract with Company D. AdministratorS1 indicated the hospital did not have policies and procedures for lab that addressed how physician orders for stat lab draws would be handled, the reporting of critical lab values, and the responsibility of the staff to ensure lab supplies were not expired. She further indicated it was the hospital's responsibility to check for and dispose the expired lab supplies.

Based on record reviews and interviews, the hospital failed to ensure policies and procedures were developed so appropriate action could be taken if the hospital was notified that blood or blood components it received were at risk of transmitting HIV (human immunodeficiency virus) or HCV (hepatitis C virus). Findings:

Review of the hospital's lab policies and procedures presented by Director of NursingS2 (DON) revealed no documented evidence of a policy and procedure for notification of patients who had received blood or blood components that were at risk of transmitting HIV or HCV.

In a face-to-face interview on 02/28/13 at 1:00 p.m., AdministratorS1 confirmed the lab policy presented by DONS2 was the only policy the hospital had for lab services. She indicated the hospital did not have a policy for notifying patients who had received blood or blood components that were at risk of transmitting HIV or HCV.

Based on observations, record reviews, and interviews, the hospital failed to ensure there was a full-time employee who served as the dietary manager and was responsible for the daily management of the dietary services. Observations revealed expired patient nourishments contained in the patient nourishment refrigerator and available for use. The hospital failed to develop policies and procedures that addressed safety practices for food handling, emergency food supplies, the orientation and training of the dietary staff, and the incorporation of the dietary department service to QAPI (quality assessment and performance improvement). Findings:

Review of the hospital policy titled "Care of Patients" for the dietary department, policy number D 2.001 and presented as a current policy by AdministratorS1, revealed all nourishments/supplements will be checked on a daily basis for expiration dates. Further review revealed if items were expired, they would be properly discarded. Further review revealed no documented evidence that the policy addressed when dated items in the refrigerator, such as sandwiches, would be considered expired and should be discarded. Review of the entire policy revealed no documented evidence that policies and procedures had been developed that addressed safety practices for food handling, emergency food supplies, the orientation and training of the dietary staff, and the incorporation of the dietary department service to QAPI.

Observation on 02/25/13 at 10:45 a.m. in Room "w" with Director of NursingS2 (DON) present revealed the patient nourishment refrigerator contained the following food items that were expired and should have been discarded but were available for patient use:
1) 3 one-half pints of skim milk had expired on 02/21/13;
2) 1 one-half pint of skim milk had expired on 02/12/13;
3) 2 sandwiches wrapped in plastic wrap dated 02/11/13 and 2 sandwiches dated 02/19/13;
4) 1 Styrofoam cup with liquid that was not labeled with contents and the date the item was placed in the refrigerator;
5) 1 unwrapped sandwich dated 02/08/13'
6) 1 opened carton of skim milk dated 02/21/13.
All above observations were confirmed during the observation by DONS2.

Interview on 2/28/13 at 10:10 AM with S3 Human Resources staff confirmed the Hospital did not have a full time or part time employee who managed day to day operations of dietary services.

Based on interview of staff, the hospital failed to have a U. R. (Utilization Review) committee that consisted of 2 or more physicians as evidenced by indicating in the UR plan there would only be no less than 1 physician on the committee. The hospital failed to form a committee that did not have a financial interest in the hospital. Findings:

Interview with AdministratorS1 on 2/28/13 at 1:30 PM revealed the UR committee consisted of only 1 physician which was the hospital's Medical Director, herself, and S17 with Company F. When Administrator S1 was asked if she was the sole owner of the hospital, she confirmed that she was and was unaware that the UR committee could not have a member that had financial interest in the hospital.

Based on record review, and interview, the hospital failed to develop and implement a comprehensive plan to ensure the safety and well-being of patients during emergency situations. The hospital failed to have a contract in place for a primary and secondary receiving hospital in the event of a disaster. The hospital failed to have a contract or arrangements for emergency water and food supply. The hospital failed to have a contract with an ambulance service to be used for transporting patients during an evacuation. The hospital failed to provide disaster training drills to its employees. This deficient practice has the potential to affect all of the patients admitted to this hospital.
Findings:
Review of the hospital emergency preparedness plan, presented by AdministratorS1, as the current emergency preparedness plan, revealed a document stating "On November 19, 2012, the newly formed Governing Board of Specialty Rehabilitation Hospital adopted the policies and procedures that are currently in place and utilized in the ordinary course of hospital operations." Further review of the hospital's emergency preparedness plan revealed that the plan "shall be tested and updated via drills at least twice annually."
In an interview on 02/28/13 at 2:45 p.m., AdministratorS1 confirmed there was no plan or contract in place to transfer patients from this hospital to another hospital in the event of an emergency evacuation. AdministratorS1 further indicated that she was "working on" finding hospitals to evacuate patients to in the event of a disaster.
In an interview on 02/28/13 at 2:49 p.m., AdministratorS1 confirmed that the water they are receiving at the hospital is not an emergency supply of water for the patients, and the water received at the hospital is for "us" to use on a daily basis. AdministratorS1 further indicated there is no current contract for an emergency supply of water for the patients in the hospital. AdministratorS1 also indicated there was no contract for emergency food supplies for the patients in the event of a disaster. AdministratorS1 further indicated in any disaster event, the hospital is evacuated and does not shelter in place, and therefore, no emergency food and water supply would be needed.
In an interview on 02/28/13 at 2:51 p.m., AdministratorS1 indicated there were no disaster drills performed at the hospital.

Based on observations, record reviews, and interviews, the hospital failed to ensure all supplies and equipment were maintained to ensure an acceptable level of safety and quality.
1) The hospital failed to ensure all electrical and biomedical equipment used by or for patients had been inspected for electrical safety prior to use and at least annually as required by the hospital's policy.
2) The hospital failed to ensure all central supply items used for patients were available for use as evidenced by having prep solutions, hydrogen peroxide, suture strips, Kaltostat cotton, culture collection systems, sterile saline used for nebulizer treatments, and foley catheter trays that were expired and in Room "g" or in cabinets in an area adjacent to the nursing station that were available for use.
Findings:

1) All electrical and biomedical equipment used by or for patients had been inspected for electrical safety prior to use and at least annually as required by the hospital's policy:
Review of the hospital policy titled "Equipment Inspection", presented by Director of NursingS2 (DON) as the current policy for equipment safety inspections, revealed it was hospital policy to routinely assess the proper function of equipment in direct patient contact to ensure it was functioning properly and was safe for patient use. Further review revealed prior to patient use, all equipment was to be inspected for safe use initially and annually. Further review revealed if equipment was physically damaged or in poor condition, it was to be tagged "Do Not Use" and removed from the clean, ready-to-use equipment site. The equipment was not to be placed in the clean, ready-to-use site until it passed inspection for safety of use.

Observation of Room "a" on 02/25/13 at 10:00 a.m. revealed the Hydrocollator Steam Pack and the refrigerator used to store therapy items had no evidence of a biomedical or safety check inspection sticker attached. This observation was confirmed by DONS2.

Observation in Room "d" on 02/25/13 at 10:25 a.m. with DONS2 present revealed 3 patient beds stored with a label attached indicating the beds were not ready for use. Further observation revealed clean, ready-to-use equipment was stored in this room.

Observation in Room "c" on 02/25/13 at 10:27 a.m. with DONS2 present revealed the air conditioner safety inspection sticker indicated the inspection had not been performed since 09/11.

Observation in Room "f" on 02/25/13 at 10:45 a.m. with DONS2 present revealed no documented evidence that an electrical safety inspection had been performed on the television, and the inspection sticker on the DVD (dissociated vertical deviation) indicated it had not been inspected since 03/08.

Observation in Room "g" on 02/25/13 at 11:00 a.m. with DONS2 and Central Supply ClerkS14 present revealed a Hospira IV (intravenous) Pump and a nebulizer with no evidence that either had been biomedically and safety inspected. DONS2 confirmed during the observation that both items were available for use and should have been inspected.

Observation of the medication refrigerator/freezer on 02/25/13 at 11:05 a.m. revealed it had not been inspected for electrical safety since 09/10.

Observation on 02/25/13 at 11:45 a.m. with DONS2 present revealed the television in Room "v" had no evidence that it had been inspected for electrical safety, and the air conditioner had not been inspected for electrical safety since 10/10. Further observation in Room "u" revealed the television had not been inspected for electrical safety since 09/11.

Observation of patient rooms on 02/25/13 at 11:50 a.m. with DONS2 present revealed the following:
a) Room "t" with a SCD (sequential compression device) pump that had not been biomedically and electrical safety inspected since 08/18/08; the air conditioner had no evidence that it had ever been inspected for electrical safety; the television had not had an electrical safety inspection since 10/09;
b) Room "s" with an air conditioner that had not been inspected for electrical safety since 09/11; the television had no evidence that it had ever been inspected for electrical safety;
c) Room "p" with a television with the electrical safety inspection sticker covered and unable to read the date; the air conditioner had not been inspected since 09/11;
d) Room "q" with no evidence the television had ever been inspected for electrical safety; the air conditioner had not been inspected since 09/11;
e) Room "o" with a television and air conditioner that had not been inspected for electrical safety since 09/11;
f) Room "n" with a television with the electrical safety inspection sticker covered and unable to read the date; the air conditioner had not been inspected since 09/11;
g) Room "k" with a television and air conditioner that had not been inspected for electrical safety since 09/11;
h) Room "l" with an air conditioner that had no evidence that it had ever been inspected for electrical safety; the television had not been inspected since 10/10;
i) Room "j" with an air conditioner that had no evidence that it had ever been inspected for electrical safety; the television had not been inspected since 09/11;
j) Room "i" with a bed with a label attached indicating the bed was not ready for use; the television had not been inspected since 09/11; the date on the inspection sticker on the air conditioner was not readable;
k) Room "h" with an air conditioner that had no evidence that it had ever been inspected for electrical safety.

In a face-to-face interview on 02/26/13 at 9:10 a.m., AdministratorS1 indicated she had someone perform checks of the patient equipment but wasn't aware she had to have electrical safety checks performed.

2) All central supply items used for patients were available for use:
Review of the hospital policy titled "Infection Control" for the nursing department, policy number N 2.051 and presented by DONS2 as a current policy, revealed supplies used were disposable, used for one patient, and discarded after use.

In a face-to-face interview on 02/26/13 at 9:10 a.m., AdministratorS1 was asked for the hospital policy that addressed the expired supplies found in Room "g". This policy was never presented by AdministratorS1 by the time of exit on 02/28/13.

Observation of items stored in the cabinet above the counter in the small lab supply area adjacent to the nursing station on 02/25/13 at 10:36 a.m. revealed 1 partially-filled bottle of 16 ounces Povidone-Iodine Prep Solution that had expired 06/12. Further observation in the cabinet under the sink in this same area revealed 2 unopened 16 ounces bottles of Povidone-Iodine Prep Solution that had expired 01/13.

Observation in Room "g" on 02/25/13 at 11:00 a.m. with DONS2 and Central Supply ClerkS14 present revealed the following items were expired:
a) 2 boxes of Coloplast protective skin barrier wipes (46 packets) had expired 01/13;
b) 3 Bacti-Swab Microorganism Collection and Transport System had expired 02/24/13; this was confirmed during the observation by Central Supply ClerkS14;
c) 30 sterile 0.9% (per cent) Sodium Chloride solution for nebulizer treatments had expired 08/12; 10 sterile 0.9% Sodium Chloride solution for nebulizer treatments had expired 04/10; 7 sterile 0.9% Sodium Chloride solution for nebulizer treatments had expired 09/12; these were all confirmed during the observation by Central Supply ClerkS14;
d) 1 Bard Closed System Foley Catheter Tray expired 09/12;
e) 1 Starswab II Collection and Transport System had expired 11/11/11; this was confirmed during the observation by Central Supply ClerkS14;
f) One opened 4 ounce bottle of Hydrogen Peroxide; during the observation Central Supply ClerkS14 indicated the Hydrogen Peroxide had been used and returned to the shelf, since it had not expired yet;
g) 1 box of 1/4 inch suture strips had expired 02/11;
h) Kaltostat cotton was opened and had expired 08/12.

In a face-to-face interview on 02/25/13 at 11:35 a.m., Central Supply ClerkS14 indicated she checked for expiration dates every month and couldn't explain how the expired items were overlooked.

In a face-to-face interview on 02/26/13 at 9:10 a.m., AdministratorS1 indicated she had just hired Central Supply ClerkS14, and she (Central Supply ClerkS14) had not been trained yet. AdministratorS1 further indicated she thought the person in that position previously had checked for expired items and discarded them.

In a face-to-face interview on 02/27/13 at 4:35 p.m., Human Resources CoordinatorS3 indicated Central Supply ClerkS14 had not been oriented to central supply yet. She further indicated that the nurses had been responsible for ordering supplies and checking for expired items.

Based on interview with hospital staff the hospital failed to designate individuals as Infection Control Program officers who were trained or qualified to develop and implement policies governing control of infections and communicable diseases. Findings:

Interview on 02/27/13 at 12:05 p.m. with DONS2 (director of nursing) and LPNS4 (licensed practical nurse), Case Manager, revealed the Infection Control committee consisted of the 2 of them. When asked what training either of them had completed, both revealed neither of them had infection control training.

Based on observations, record reviews, and interviews, the infection control officer failed to develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.

Findings:

1) The infection control officer failed to ensure the Infection Control Program incorporated all departments of the hospital as evidenced by not developing and implementing a hospital- wide program that included all departments of the hospital for the prevention, control, and investigation of infections; and
2) The infection control officer failed to ensure the maintenance of a sanitary physical environment related to food sanitation, disposal of regulated and non-regulated waste, storage of soiled items in clean equipment rooms, over-filled sharps boxes, and torn therapy mats.
Findings:

1) The infection control officer failed to ensure the Infection Control Program incorporated all departments of the hospital:

Interview on 02/27/13 at 12:05 p.m. with DONS2 (director of nursing) and LPNS4 (licensed practical nurse) Case Manager revealed the Infection Control committee consisted of the 2 of them. When asked what training either of them had completed, both revealed neither of them had infection control training. DONS2 was asked about the Infection Control Program. She stated the program was the typed instructions on the front of the Infection Control Binder which was: if a patient had a known infection upon admit, initiate the infection control worksheet; worksheets will be put in a binder by room number; anytime a patient was put on antibiotics or had a positive culture, update the infection control worksheet appropriately; place a copy of the culture with the worksheet; when a patient is discharged, pull out the worksheet and put it behind the discharge tab; be sure to educate patient and family on an new diagnosis that the patient may have and document it in the nurse notes; update the care plans accordingly.
Review of the Infection Control Binder during the interview revealed no culture results were placed with the worksheet of patients with known infections for which antibiotic treatment was ordered. Further review revealed no data was collected from areas of the hospital that should be, such as housekeeping, maintenance, and other activities to ensure that the hospital maintained a sanitary environment.
Other questions asked during the interview included whether there was an infection control log kept in order to trend; if there was investigation of each infection to determine effectiveness of the selected treatment or possible source of hospital acquired infections; was there any surveillance conducted to identify infectious risks or communicable disease problems at any particular location.
DONS2 and LPNS4 Case Manager confirmed that the committee did not investigate the infection or treatment to determine effectiveness and that there was no documented evidence of any type of surveillance that would include personnel hand hygiene to identify risks or disease problems in all departments of the hospital.
2) The infection control officer failed to ensure the maintenance of a sanitary physical environment related to food sanitation, disposal of regulated and non-regulated waste, storage of soiled items in clean equipment rooms, over-filled sharps boxes, and torn therapy mats:
Review of the hospital policy titled "Care of Patients" for the dietary department, policy number D 2.001 and presented as a current policy by AdministratorS1, revealed all nourishments/supplements will be checked on a daily basis for expiration dates. Further review revealed if items were expired, they would be properly discarded. Further review revealed no documented evidence that the policy addressed when dated items in the refrigerator, such as sandwiches, would be considered expired and should be discarded.

Review of the hospital policy titled "Disposal of Sharps Container", presented by DONS2 as a current policy, revealed when sharps container contents had reached the manufacturer's fill line, the container was to be discarded. Further review revealed the filled sharps container was to be removed by the nursing staff and placed in red biohazard bag and discarded in the designated biohazard waste area. Further review revealed the DON was to do weekly surveillances of proper disposal of sharps containers.

Review of the hospital policy titled "Nursing Services", policy number IC 5.006 and presented by DONS2 as a current policy, revealed needles/sharps were to be disposed of in approved rigid containers which were not allowed to become more than three-fourths full before they were disposed.

Review of the hospital policy titled "Infectious Waste Management", policy number IC 7.010 and presented by DONS2 as the current policy, revealed infectious waste would be segregated from other waste by containing it in disposable plastic red bags labeled as biohazardous. Further review revealed the bag was to be securely tied. Needles and sharps were to be contained in disposable, rigid, puncture-resistant, leak-proof containers which were snapped closed when three-fourths full, and labeled as biohazardous waste. Further review revealed infectious waste was to be double-bagged, tied, and placed in corrugated boxes furnished by the disposal contractor, and the boxes were to be closed and stacked in a storage area that was identified with a printed biohazard symbol on the door.

Review of the hospital policy titled "Physical Therapy Department", policy number IC 5/013 and presented by DONS2 as the current policy, revealed facility wheelchairs and cushions would be cleaned as needed and cleaned and disinfected upon patient discharge. Further review revealed no documented evidence that the condition of and the cleaning and disinfecting of the therapy mats was addressed in the policy.

Observation of Room "b" on 02/25/13 at 10:10 a.m. revealed paper and a glove on the floor. Further observation revealed 2 uncovered boxes overflowing with biohazard bags, and 1 red filled biohazard bag on the floor. Further observation revealed 1 biohazard bag contained in the box was open with biohazard items visible in the bag. Observation of the large rolling soiled linen cart contained in Room "b" revealed 2 soiled linen bags were not tied and secured.

In a face-to-face interview on 02/25/13 at 10:10 a.m., Director of NursingS2 (DON) indicated the biohazard boxes should not be overflowing. She further indicated they had never contained the biohazard boxes with a lid once they were filled. She further indicated all bags, both linen and biohazard, should be tied to ensure the contents don't spill out.

Observation of Room "e" on 02/25/13 at 10:20 a.m. revealed the room contained clean equipment . Further observation revealed a large black garbage bag filled with clothing was open and in Room "e".

In a face-to-face interview on 02/25/13 at 10:20 a.m., DONS2 indicated Room "e" was used for storing clean patient equipment. She further indicated the bag of clothing had been donated by individuals outside the hospital to be used for patients who were admitted and had no clothing. She further indicated the clothing had not been washed before being stored in Room "e", and they would wash it before it was given to a patient. DONS2 confirmed this practice allowed dirty items to be stored with clean items which was a breach in infection control practice.

Observation of Room "d" on 02/25/13 at 10:25 a.m. revealed 2 patient beds ready for use and 3 patient beds with signs stating they were not ready for use. Further observation revealed on top of a cabinet was 2 dirty buffer pads and an opened 1 quart container of Equity (labeled to use as a restorer for buffing and burnishing).

In a face-to-face interview on 02/25/13 at 10:25 a.m., DONS2 indicated the buffer pads and Equity cleaner should not be stored in a clean supply room.

Observation of Room "c" on 02/25/13 at 10:27 a.m. revealed no patient was admitted to the room. Further observation revealed a used tube of toothpaste on the sink in the bathroom and paper towels in the garbage can in the bathroom.

In a face-to-face interview on 02/25/13 at 10:27 a.m., DONS2 indicated the room was ready for a patient to be admitted, so there should not have been any items in the bathroom.

Observation of the lab area adjacent to the nursing station on 02/25/13 at 10:35 a.m. with DONS2 present revealed the sharps box was overfilled. Observation of Room "o" on 02/25/13 at 11:50 a.m. with DONS2 present revealed the sharps box was filled beyond the marked line indicating that the box needed to be changed.

Observation on 02/25/13 at 10:45 a.m. in Room "w" with Director of NursingS2 (DON) present revealed the patient nourishment refrigerator contained the following food items that were expired and should have been discarded but were available for patient use:
1) 3 one-half pints of skim milk had expired on 02/21/13;
2) 1 one-half pint of skim milk had expired on 02/12/13;
3) 2 sandwiches wrapped in plastic wrap dated 02/11/13 and 2 sandwiches dated 02/19/13;
4) 1 styrofoam cup with liquid that was not labeled with contents and the date the item was placed in the refrigerator;
5) 1 unwrapped sandwich dated 02/08/13'
6) 1 opened carton of skim milk dated 02/21/13.
All above observations were confirmed during the observation by DONS2.

Observation of the utility closet on 02/25/13 at 11:50 a.m. revealed 2 bags of dirty linen on the floor and a bin overflowing with garbage.

In a face-to-face interview on 02/25/13 at 11:50 a.m., DONS2 indicated the dirty linen should be taken from the closet to Room "b". She further indicated the garbage was more than a day's worth of garbage and should have been emptied.

Observation of Room "r" on 02/25/13 at 2:00 p.m. revealed the center of the therapy mat had a raised area that felt like it had been patched, and the side had several torn/wear edges and an area that was also raised

In a face-to-face interview on 02/25/13 at 2:00 p.m., Physical TherapistS15, when asked how she could be certain the therapy mat was cleaned effectively with torn edges and patches, she indicated she didn't know "about cleanliness when disinfecting". She further indicated she wasn't aware that the surface of the therapy mat couldn't be torn.


25065

Based on review of all credentialed physicians files, Governing Body meeting minutes, and interview with hospital staff, the hospital failed to ensure a physician was designated as Director of Respiratory Services as evidenced by not having documented evidence there was a physician designated as Director of Respiratory Services. Findings:

Review of the credentialing files of the listed physicians provided by the hospital revealed that privileges for respiratory services were not requested. Review of the Governing Body meeting minutes dated 02/18/13 revealed a physician was recommended for Respiratory Director and medical staff membership. Interview with AdministratorS1 on 02/28/13 at 4:35 p.m. confirmed there was not a Respiratory Services Director designated by the Governing Body.

Based on record reviews and interviews, the hospital failed to ensure respiratory orders were implemented as written by the physician for 3 of 6 discharged patients' medical records and 5 active patients' medical records reviewed for respiratory orders from a total of 26 sampled patients (#14, #15, #25). Findings:

Patient #14
Review of Patient #14's medical record revealed she was a 63 year old female admitted on 11/09/12 with a diagnosis of Debility secondary to Right Lower Extremity Cellulitis. Further review revealed she had a history of Stroke, Congestive Heart Failure (CHF), Peripheral Neuropathy, Obstructive Sleep Apnea, and Schizophrenia.

Review of Patient #14's physician orders revealed an order on 11/12/12 at 10:40 a.m. for humidified oxygen per nasal cannula at 2 liters at bedtime and every day as needed to keep her oxygen saturation greater than (>) 90% (per cent).

Review of Patient #14's MAR (medication administration record) revealed a check mark in the column on 11/24/12 and 11/25/12 indicating oxygen was administered at 2 liters per nasal cannula every day to keep her oxygen saturation > 90%. Review of Patient #14's "7 Day Graphic Sheet" revealed on 11/24/12 her oxygen saturation for the a.m. shift was 93%, and she was on 2 liters of oxygen per nasal cannula. Further review revealed her oxygen saturation on the a.m. shift on 11/25/12 was 95%, and she was on 2 liters of oxygen per nasal cannula (oxygen was not ordered during the day if the oxygen saturation was > 90%).

Review of Patient #14's "Patient Assessment" dated 11/24/12 at 8:30 a.m. revealed her oxygen saturation was 95%, and she was on 2 liters of oxygen per nasal cannula (oxygen was not ordered during the day if the oxygen saturation was > 90%).

Patient #15
Review of Patient #15's medical record revealed he was an 88 year old male admitted on 12/14/12 with a diagnosis of Debility secondary to Pneumonia.

Review of Patient #15's "Standing Admission Orders", received by telephone order by Director of NursingS2 (DON) on 12/14/12 at 4:00 p.m., revealed an order for oxygen at ___ (space to enter the number of liters ordered was blank) liters per nasal cannula or mask to keep the oxygen saturation > or equal to 90%. Further review revealed no documented evidence the order was clarified to determine the amount of oxygen the physician wanted to be delivered.

Review of Patient #15's "Medication Reconciliation List" received by telephone order by DONS2 on 12/14/12 at 4:00 p.m. revealed an order for Albuterol Sulfate 2.5 / 3 ml (milliliters) per inhalation nebulizer every 4 hours.

Review of the "Physician Orders" dated 12/17/12 at 10:22 a.m. revealed an order for oxygen at 2 liters per nasal cannula as needed to keep the oxygen saturation > 90%. Further review revealed an order dated 12/19/12 at 12:15 p.m. to change the order to oxygen at 2 liters per nasal cannula as needed for shortness of breath.

Review of Patient #15's nurses' notes revealed the following dates and times that oxygen was documented as administered at 4 liters per nasal cannula with no documented evidence of a physician's order for the oxygen:
12/15/12 at 6:00 a.m. (oxygen saturation was 98%), 1:00 p.m., 4:00 p.m., 5:30 p.m., 7:00 p.m. (oxygen saturation > 96%), 11:00 p.m.;
12/16/12 at 6:00 a.m., 3:00 p.m., 7:00 p.m.;
12/17/12 at 6:40 a.m. and 10:00 a.m.

Review of Patient #15's nurses' notes revealed no documented evidence that Patient #15's oxygen had been discontinued or an assessment of his oxygen saturation at or below 90% on 12/17/12 at 10:22 a.m. when an order was received for oxygen to maintain his saturation > 90%. Further review revealed his oxygen was administered on 12/17/12 at 6:00 p.m. and on 12/18/12 at 6:00 a.m. with no documented evidence of his oxygen saturation that warranted the oxygen to be administered. Further review revealed Patient #15's oxygen saturation on 12/18/12 at 6:30 p.m. was 98%, and oxygen was administered at 2 liters per nasal cannula (oxygen was ordered to maintain the oxygen saturation > 90%). Further review revealed he had oxygen administered when his oxygen saturation was 96% on 12/19/12 at 6:00 a.m.

Patient #25
Review of Patient #25's medical record revealed she was a 53 year old female admitted on 10/19/12 and discharged on 11/14/12. Review of her physician orders revealed an order on 10/22/12 at 11:20 a.m. for humidified oxygen per nasal cannula at 2 liters every night at bedtime. Further review revealed an order on 10/30/12 at 3:40 a.m. for nebulizer treatments with Albuterol 3.0 mg (milligrams) and Atrovent 0.5 mg once stat and then as needed every 6 hours for shortness of breath or wheezing. Further review revealed an order on 10/30/12 at 10:50 a.m. for Albuterol 90 mcg (micrograms) per inhaler 2 puffs every 4 hours as needed for cough, wheezing, or shortness of breath.

Review of Patient #25's MARs and nurses' notes revealed no documented evidence oxygen was administered at bedtime and throughout the night on 10/25/12, 11/11/12, and 11/14/12.

In a face-to-face interview on 02/27/13 at 4:30 p.m., RNS11 (registered nurse) indicated the nursing staff did not have orientation or training on providing respiratory services. She further indicated the nurses provided incentive spirometry, oxygen administration, and nebulizer treatments when they were ordered by the physician.

In a face-to-face interview on 02/28/13 at 2:25 p.m., Director of NursingS2 confirmed the above findings after reviewing the patients' medical records. She indicated if a patient's oxygen saturation was > 90%, the patient should not have had oxygen administered during the day according to the physician's orders.