HospitalInspections.org

Based on record review and interview the hospital failed to ensure the Condition of Participation for Dietary Services was met by:
1) failing to ensure the hospital's Dietary Manager met State Regulation's Qualification Requirements (See findings cited at A0620).
2) failing to ensure the dietitian was available to meet the needs of the patients for 7 of 7 patients who scored greater than a 5 on the nutritional assessment (tool used by the hospital for triggering a dietary consult) of 25 sampled patients (#13, #17, #21, #22, #23, #24, #25). (See findings cited at A0621).
3) failing to ensure the dietitian supervised and evaluated the dietary department to ensure food temperatures were monitored daily, the dishwashing machine was monitored three times daily for quality of sanitizing dishes and cookware, and that policies and procedures were in place for the dietary department. (See findings cited at A0621)

Based on observation, record review and interview the hospital failed to ensure the Condition of Participation for Infection Control was met by:

Failing to ensure the person appointed as Infection Control Officer was qualified as evidenced by no documented evidence of training and assessment of competency in Infection Control and no documented of an infection control plan, policies and procedures, or infection control log (See findings at Tag A0748)

Failing to ensure the infection control officer implemented a system for identifying, reporting, investigating and controlling infections as evidenced by: 1) failing to maintain a clean environment resulting in dusty window sills and air-conditioning vents in patient rooms and patient care areas and water fountains with food particles; 2) failing to maintain a log of all patient and employee infections resulting in no documented evidence of trends related to infections or reported communicable diseases related to patients and/or employees; 3) failing to develop and implement an Infection Control Plan based on the hospital's patient population and the current guidelines of the Centers for Disease Control (CDC), Occupational Safety and Health Administration (OSHA) and/or Public Health as evidenced by no documented evidence of a plan, policies and procedures; 4) failing to ensure aseptic technique was followed during the administration of wound care for 1 of 1 patients observed for wound care of 3 with wounds out of 21 sampled patients; and 5) failing to perform surveillances to identify problems and implement corrective action for handwashing and aseptic technique as evidenced by observed lack of handwashing between patients (See findings at Tag A0749);

Failing to ensure a log related to infections and communicable disease had been maintained resulting in no documented evidence of trends or clusters related to infections, or reported communicable diseases related to patients and/or employees were identified (See findings at Tag A0750);

Failure of the medical staff, administration and infection control officer to ensure an annual evaluation of the infection control program had been conducted as evidenced by the hospital's inability to produce documented evidence of a review. As a result the hospital has continued to provide patient care without a written plan for infection control including policies and procedures based on the hospital's patient population and the current guidelines of the Centers for Disease Control (CDC), Occupational Safety and Health Administration (OSHA) and/or Public Health and identify problems and implement and monitor corrective action(s) taken (See findings at tag A0756).

Based on record review and interview the hospital failed to ensure nursing staff were knowledgeable in providing emergency care to patients in the hospital as evidenced by failure to know the liter flow needed for the use of an Ambu bag during cardio-pulmonary resuscitation and failure to identify the Automated External Defibrillator (AED) as equipment used in the hospital for patient's with Cardio-Pulmonary Arrest for 2 of 2 nurses surveyed for handling emergencies in the hospital (S4, S5). This practice has the potential to affect all patients in the hospital. Findings:

During a face to face interview on 8/03/2010 at 12:00 p.m., Registered Nurse S4 indicated if the Ambu was used to resuscitate a patient during respiratory arrest she would connect the bag to 2 or 3 liters of oxygen. During the same interview Licensed Practical Nurse S5 indicated she had been taught to use full liter flow of 15 liters when using the Ambu bag.

During face to face interviews on 8/03/2010 at 11:00 a.m. and again at 12:00 p.m., Registered Nurse S4 and Licensed Practical Nurse S5 verbalized emergency medical equipment nursing staff would use in the event of a cardio-pulmonary arrest for a patient in the hospital. During both interviews, neither S4 nor S5 indicated they (S4 or S5) would use the hospital's AED in response to patient in cardiopulmonary arrest. Both S4 and S5 indicated they had been trained in the use of AED.

Review of the hospital policy titled, "Automated External Defibrillator Use" revealed in part, "Purpose: To provide early defibrillation for life threatening arrhythmias. Automated External Defibrillators are available at the nurse's station in the Hospital and can be used by anyone trained in their use."

Based on record review and interview the hospital failed to ensure that training provided to all direct caregivers for restraint application included a competency assessment and return demonstration for the safe and proper application of patient restraints for 8 of 8 personnel files reviewed for restraint application training. This practice had the potential to affect all patients in the hospital. (S5, S6, S7, S13, S15, S17, S18, S19)
Findings:

Review of the personnel files for S5, LPN, S6, MHT(Mental Health Tech), S7, MHT, S13, RN, S15, MHT, S17, MHT, S18, MHT, and S19, MHT, revealed no documented evidence of a competency assessment and return demonstration for the safe application of patient restraints.

In interview on 08/04/10 at 3:50 p.m. S2, Director of Nurses, confirmed that the direct caregiver staff training did not include a return demonstration for the safe application of restraints. S2 indicated that the caregiver staff were oriented to the hospital restraint policy and procedure for restraint application, but had not been evaluated by an actual return demonstration of the safe application of restraints.

Based on record review and interview the hospital failed to: 1) ensure medical staff rules and regulations were enforced as evidenced by having 2 of 2 physicians that should have been suspended for delinquent medical records (as per rules and regulations) continue to admit and/or treat patients in the hospital (S26, S27) and 2) ensure all psychiatric evaluations had been performed by the psychiatrist (#1, #14, #15, #16, #17, #18, #20) for 6 of 21 sampled medical records which has the potential to affect all patients in the hospital. Findings:

Review of the hospital's Medical Staff Rules and Regulations presented by the hospital as current revealed in part, "Medical Records Completion: No medical record shall be filed until it is complete. Any physician having an unfinished record seven days after discharge shall be so notified by mail. . . If there are none of these extenuating circumstances and the record has not been completed within 30 days of discharge a second letter will be sent to the responsible practitioner advising that his admitting privileges have been suspended. If there are incomplete records remaining after 60 days of discharge, the responsible practitioner will lose staff privileges, restoration to be automatic upon completion of all records. . . "

Review of a list of Medical Records presented by HIM (Health Information Management) Director S11 as delinquent for greater than 30 days revealed 24 records. Further review revealed of those listed 5 were greater than 60 days delinquent. Two of the records listed as greater than 60 days delinquent belonged to Physician S26. Three of the records listed as greater than 60 days delinquent belonged to Physician S27.

During a face to face interview on 8/04/2010 at 1:40 p.m., HIM Director S11 indicated she had not sent any letters to any of the physicians that had delinquent records. S11 further indicated that according to the Medical Staff Rules and Regulations, Physician S26 and S27 should have both been suspended. S11 indicated both physicians were continuing to admit and care for patients in the hospital. S11 indicated she had been instructed by Administrator S1 and Director of Nursing S2 that the Medical Staff Rules and Regulations as were currently written were to be changed in the future and she had been instructed not to follow them. Administrator S1 confirmed that the Medical Staff Rules and Regulations had not been enforced.

During a telephone interview on 8/05/2010 at 1:10 p.m., Medical Director S26 indicated he had not been aware that medical records had been delinquent past 30 days. S26 indicated medical records should be completed timely and he expected them to be completed prior to 60 days.


2) ensure all psychiatric evaluations had been performed by the psychiatrist
Patient #1
Review of the "Physician's Admit Note/Psychiatric Evaluation" with no date or time (patient admitted 7/29/2010) revealed two distinct handwritings on the form with one signature- that of Psychiatrist S26.

Patient #14
Review of the "Physician's Admit Note/Psychiatric Evaluation" dated 08/02/10(no time documented) for Patient #14 revealed three different handwritings on the form with two signatures that of psychiatrist S26 and the Nurse Practitioner S31 documented.

Patient #15
Review of the "Physician's Admit Note/Psychiatric Evaluation" (no date or time documented) for Patient #15 revealed two different handwritings on the form with one signature of psychiatrist S26.

Patient #16
Review of the "Physician's Admit Note/Psychiatric Evaluation" 07/27/10 at (no time documented) for Patient #16 revealed three different handwritings on the form with two signatures that of the psychiatrist S26 and the Nurse Practitioner S31 documented.

Patient #17
Review of the "Physician's Admit Note/Psychiatric Evaluation" 07/09/10 at 10:00 (AM or PM not indicated) for Patient #17 revealed two different handwritings on the form with one signature that of psychiatrist S26 documented.

Patient #18
Review of the "Physician's Admit Note/Psychiatric Evaluation " (no date or time documented) for Patient #18 revealed two different handwritings on the form with one signature that of the psychiatrist S26 documented.

Patient #20
Review of the "Physician's Admit Note/Psychiatric Evaluation" (no date or time documented) for Patient #20 revealed two different handwritings on the form with one signature - that of Psychiatrist S26.

Review of the hospital's "Rules and Regulations of the Westend Hospital for Medical Staff, January 2, 2005" presented by the hospital as current revealed in part, "Within 24 hours of a patient's admission or transfer to the inpatient service, a physician shall personally examine the patient and record an appropriate history, physical examination, working diagnostic impression(s) and plan for treatment. The attending psychiatrist shall establish a personal and identifiable relationship with the patient if such was not established prior to the admission or transfer, examine the patient and perform a Psychiatric Evaluation within 60 hours of admission and is responsible for continuing evaluation of the care of the patient and plans for treatment. . . ."

In a face to face interview on 08/04/10 at 4:00pm S1 Administrator and LCSW (Licensed Certified Social Worker) indicated the Social Worker was assisting the psychiatrist in completing the Physician Admit/Psychiatric Evaluation. S1 further indicated the social worker performs her own assessment and gathering of information and if the Medical Staff Rules and Regulations state that the Psychiatric Evaluation should be performed by the MD, then that is who should be completing the forms.

Based on record review and interview the hospital failed to ensure a registered nurse with training in Cardiopulmonary Resuscitation (CPR) was available at all times onsite to conduct assessments of patient emergencies and provide emergency care to patients (S13, RN) for 7 out of 21 days reviewed for registered nurse staffing. This had the potential to affect all patients in the hospital.
Findings:

Review of the nursing staffing pattern from 06/05/10 to 08/02/10 revealed that S13, RN, was the only registered nurse onsite at the hospital on the following days: 06/16/10, 06/17/10, 06/30/10, 07/11/10, 07/15/10, 07/21/10, and 07/22/10.

Review of the personnel file for S13, RN, revealed a date of hire of 06/05/10. Review of S13's entire personnel file revealed no documented evidence of a Cardiopulmonary Resuscitation certification card.

Review of the CPR training in-services attendance form provided by S2, Director of Nurses (DON), revealed that S13, RN, attended a course for CPR certification on 08/03/10.

In interview on 08/05/10 at 10:00 a.m. S2, DON, confirmed that S13, RN, was the only registered nurse onsite at the hospital for the following days: 06/16/10, 06/17/10, 06/30/10, 07/11/10, 07/15/10, 07/21/10, and 07/22/10. S2 confirmed that S13, RN, was not certified in CPR until 08/03/10. S2 further confirmed that the hospital failed to ensure a registered nurse with documented training in CPR was available onsite at all times.

Review of the hospital policy titled "Cardiopulmonary Resuscitation; Basic Life Support, Policy #PC-16" revealed, in part, "D. CPR Training- 2. Hospital/Clinical Staff, a. CPR: All staff providing direct patient care must successfully complete a BLS (Basic Life Support) course at a level appropriate to their role, as determined by their department, prior to completion of their orientation and must thereafter be retrained every year in BLS."

Based on observation, record reviews and interviews, the hospital failed to ensure the registered nurse (RN) supervised and evaluated each patient's care by failing to:
1) reassess the patient after intervention for a low capillary blood glucose and failing to notify the physician (#10)
2) accurately assess and re-assess the nutritional status of an underweight and anemic patient resulting in the patient having to wait 12 days before an intervention of the addition of a dietary supplement to his diet (#16) and a patient failing to re-assessed after pending blood work had been received which would have triggered a dietary consult (#18) for 2 of 2 patients with inaccurate assessments for dietary needs of 25 sampled patients.
3) use aseptic technique was followed during the administration of wound care for 2 of 2 patients observed for wound care (#1, #3)
4) ensure a skin assessment was performed on a patient known to have a wound to her abdomen for 1 of 3 sampled patients with wounds out of a total sample of 8 patients that were located in the hospital at the time of the survey (#3).
5) remove patient's shoestrings which could be used to harm themselves or others for 1 of 1 days the unit was observed for environmental dangers (8/04/2010). Findings:

1) reassess the patient after intervention for a low capillary blood glucose and failing to notify the physician
Patient #10
The medical record for Patient #10 was reviewed. Patient #10 was admitted on 06/30/10 with diagnoses of Bipolar Disorder, Depression and Insulin Dependent Diabetes Mellitus. Review of Physicians Admit Orders revealed Accucheck twice daily with Novolin R per sliding scale:
0-60 = OJ (Orange Juice) or glucose
61-200 = 0 Units
201 - 300 = 5 Units
301- 400 = 10 Units

Review of the Medication Administration Record revealed an accucheck result on 07/10/10 of 58 with a nursing intervention of juice and snack. There was no documented evidence the physician was notified of the low blood sugar or a nursing assessment following the intervention with juice and snack.

S2, DON was interviewed face to face on 08/04/10 at 2:05pm. S2 reviewed the record and confirmed there was no documented evidence the physician was notified of the low blood sugar or a nursing follow up assessment after the change of the patient's status and nursing intervention.


2) accurately assess the nutritional status of an underweight and anemic patient resulting in the patient having to wait 12 days before an intervention of the addition of a dietary supplement to his diet
Patient #16
During a Community Group Session on 08/04/10 at 8:00am an observation was made of Patient #16 as appearing thin, clothes hanging very loose around his waist, eyes, slightly sunken into his head.

Review of the "Initial Nursing Assessment" dated 07/27/10 revealed Patient #16 had been admitted to the hospital for increased anxiety and agitation. Further review revealed his weight/height to be 166.2 pounds and 6 foot 3 inches; was on a mechanical soft diet, had poor oral hygiene, upper dentures with "one tooth remaining on the bottom". Review of the section titled "Eating and Nutrition" revealed a score of 4 (3 points for having a therapeutic diet order and 1 point for having chewing or swallowing difficulties). Further review revealed there were pending results for lab values. Review revealed in bold print on the assessment form "Total points of 5 or greater- Referral to MD (Medical Doctor) for Dietary Consult". Further review of the nursing noted revealed no documented evidence the patient's appearance as it related to his weight had been considered as a factor or an IBW calculated.

Review of the results of the CBC for Patient #16 drawn on 07/27/10 revealed a Red Blood Cell count of 3.99 (Expected Range 4.10-5.70); Hemoglobin (Expected Range 13.0-17.0); and Hematocrit (Expected Range 37.0-49.0) which were documented as "Out of Range".

Further review of the medical record for Patient #16 revealed no documented evidence the nutritional assessment had been re-evaluated after the results of the pending lab results had been received and filed in the medical record. According to the scoring guidelines for a nutritional consult, abnormal lab results would score 1 point, putting the nutritional score for Patient #16 at 5 and would have triggered a nutritional consult.

In a face to face interview on 08/05/10 at 11:00am RN S3 indicated she was the nurse who performed the initial nursing assessment on Patient #16. When asked about how she had arrived at the score of 4 for nutritional status for Patient #16, S3 verified she had not performed an IBW or considered the patient underweight even though he was 6'3" and weighed 166 pounds. Further she indicated the reason why she had not felt he was underweight was because he is a frequent patient to the hospital and has always been skinny.
S3 verified that the nutritional status had not been re-assessed after the results of the lab work had been obtained and agreed the results would have triggered a dietary consult.

Patient #18
Review of the "Physician's Admit Note/Psychiatric Evaluation" (no date/time documented) revealed the patient was admitted from home with symptoms of past suicidal ideation, decreased sleep, change in appetite, and mood swings. Further review revealed "Pt. (Patient) is drug-seeking".

Review of the "Initial Nursing Assessment" dated 04/05/10 revealed Patient #18 had been admitted to the hospital for increased anxiety and agitation. Further review revealed her weight/height to be 166 pounds and 5 foot 0 inches. Review of the section titled "Eating and Nutrition" revealed a score of 0 with pending results for lab values. Review revealed in bold print on the assessment form "Total points of 5 or greater- Referral to MD (Medical Doctor) for Dietary Consult". Further review of the nursing noted revealed no documented evidence the patient's appearance as it related to her weight, reported change in appetite or chemical dependence on pain medication had been considered as a factor when determining the need for a nutritional consult.

Review of the results of the Drug Abuse Screen with ETOH (Alcohol) for Patient #18 drawn on 04/07/10 revealed a positive result for Benzodiazepines and Ethanol.

Further review of the medical record for Patient #18 revealed no documented evidence the nutritional assessment had been re-evaluated after the results of the pending lab results had been received and filed in the medical record. According to the scoring guidelines for a nutritional consult, abnormal lab results would score 1 point, chemical dependence would score 3, and appearing overweigh would score a 1, putting the nutritional score for Patient #18 at 5 and would have triggered a nutritional consult.

In a face to face interview on 08/05/10 at 10:00pm RN S2 Director of Nursing (DON) indicated it is the responsibility of the RN to re-assess the patient for nutritional status when lab results are pending and also when any change in the patient ' s condition occurs which could effect the nutritional status of the patient.


3) failing to ensure aseptic technique was followed during the administration of wound care:

Patient #1:
Observations on 8/04/2010 at 2:05 p.m. revealed Registered Nurse S3 performing skin care
to Patient #1. Observations revealed a small skin tear measured by RN S3 as 1/4 inch long and located on the lower portion of the patient's abdomen on the left side beneath a skin fold. Further observation revealed RN S3 picking up a tube of Moisture Barrier Creme with her gloved hands and applying the cream onto the abdomen and perineal area of Patient #1. RN S3 was observed using the same gloved hand to apply the cream, pick up the tube to gather more cream, and applying more cream. Observations revealed RN S3 alternating touching the patient for skin care and the tube to obtain more cream with her contaminated gloves on three occasions during the process of providing skin care thus cross contaminating the tube of cream and the patient.

During a face to face interview on 8/04/2010 immediately after RN S3 completed skin care on Patient #1 (2:05 p.m. skin care), RN S3 indicated the tube of barrier cream that she was using on Patient #1 would be returned to general stock in the nursing station for use on all patients in need of barrier cream. This finding was reviewed with Director of Nursing S2 on 8/04/2010 at 3:00 p.m. S2 confirmed that cross contaminated supplies should be discarded and not used on other patients. S2 confirmed that contaminated gloved hands should not be used on clean supplies, thus cross contaminating the supplies.

Patient #3:
Observations on 8/04/2010 at 2:30 p.m. revealed Registered Nurse S3 performing skin care to Patient #3. Observations revealed Patient #3 to have two areas with wounds to the patient's abdomen. Registered Nurse S3 was observed cleansing, applying ointment, and dressing Patient #3's wounds with her gloved hands. Observations revealed S3 alternately touching Patient #3's wounds and supplies located in the hospital's wound care kit for general use in the hospital (on all patient's with wounds) with her gloved hands thus cross-contaminating hospital supplies and Patient #3's wounds.

During a face to face interview on 8/04/2010 at 3:00 p.m., Director of Nursing S2 indicated aseptic technique should be followed when providing wound care and measures should be taken to prevent cross contamination of supplies and wounds.


4) failing to ensure a skin assessment was performed on a patient known to have a wound to her abdomen:

Review of Patient #3's medical record revealed the patient was admitted to the hospital on 8/02/2010 with diagnoses that included Cortical Dementia, Major Depressive Disorder, and Psychosis. Further review revealed a photo had been taken of one of the two wounds located on Patient #3's abdomen. Patient #3's initial RN (Registered Nurse) assessment dated 8/02/2010 stated "sores to abd (abdomen) healing." Review of the entire medical record and Skin Assessment book located at the Nurse's station revealed no documented assessment of the wounds. Observations on 8/04/2010 (2 days after admission) revealed RN S3 performing a skin assessment on Patient #3 per surveyor request. RN S3 measured and described the wounds on Patient #3's abdomen as follows: 1 centimeter linear wound to the right side of Patient #3's umbilicus- open with minimal drainage and 1 wound located midline on the lower abdomen measuring 6.5 centimeters by 0.75 centimeters- open with minimal drainage.

RN S3 reviewed Patient #3's entire medical record. RN S3 confirmed there was no documented evidence on a photo being taken of patient #3's larger abdominal wound and no documented evidence in the entire medical record ,to include the skin assessment book, of measurements and/or a description of Patient #3's abdominal wounds. This finding was also confirmed by Director of Nursing S2 at 3:00 p.m. (8/04/2010) who further indicated all patients admitted to the hospital should have a complete and accurate skin assessment done at the time of their initial RN assessment.


5) failing to remove patient's shoestrings which could be used to harm themselves or others:

Observations on 8/04/2010 at 8:00 a.m., 10:15 a.m., and 1:00 p.m. revealed 2 patients out of a total census of 18 to have tennis shoes with shoe laces on.

During a face to face interview on 8/05/2010 at 11:00 a.m., MSW (Master's Social Worker)/ Administrator S1 indicated the hospital's practice had been to inform family members prior to patient's admissions that the patient would need to have shoes without strings. S1 indicated family members were instructed to bring tennis shoes with Velcro straps as opposed to tennis shoes with strings; however, family members would continue to bring patients' shoes with strings. S1 indicated staff had been educated on not allowing patients to keep their shoe strings due to the risk of using them to harm themselves or others. S1 confirmed there had been patients on the unit on 8/04/2010 with shoe strings.

Review of the hospital policy titled, "Patient Searches, EC-13" presented by the hospital as their current policy revealed in part, "To establish controls for maintaining the safety and security of the environment, and provide criteria and guidelines for the appropriate use of invasive patient procedures. All patients and their belongings will be searched by the Nurse or designated staff upon admission to the Hospital. This checklist is a part of the initial assessment process and will be placed in the patient's medical record. . .Items found in patient's possession during this search which are not allowed in the Hospital will be returned to family/significant other to take home, of (or) if no family is available, items will be placed in a container marked with the patient's name and returned upon discharge. . . Contraband (harmful material) generally defined as: e) weapons and firearms: guns, clubs, knives, chains, rope, cords. . ."

Based on record review and interview the hospital failed to ensure the plan of care had been implemented according to physician's orders as evidenced by the nursing staff placing patients in observation status without a written order for 4 of 21 sampled medical records (#2, #6, #15, #17). This practice has the potential to affect all patients int he hospital. Findings:

Patient #2
Review of Patient #2's medical record revealed the patient was admitted to the hospital on 8/02/2010 no diagnosis indicated. Further review revealed pre-printed admission orders with no date/time or signature. Review of these pre-printed orders revealed the area indicating "Precaution (Select at least one)" to have no identifying mark to indicated if the patient should be "1:1 (one on one), SP (Suicide Precautions), Q15 (every 15 minute checks), Q30 (every 30 minute checks), Qhr (every hour checks), or Fall (fall precautions)".

Patient #6
Review of Patient #6's medical record revealed the patient was admitted to the hospital on 5/14/2010 with diagnoses that included Major Depressive Disorder. Further review revealed pre-printed admission orders dated 5/17/2010 at 1300 (1:00 p.m.) with the area indicating "Precaution (Select at least one)" to have no identifying mark to indicated if the patient should be "1:1 (one on one), SP (Suicide Precautions), Q15 (every 15 minute checks), Q30 (every 30 minute checks), Qhr (every hour checks), or Fall (fall precautions)."

Patient #15
Review of the medical record for Patient #15 revealed she had been admitted to the hospital on 08/02/10 for schizophrenia. Review of the Physician's Admit Orders for Patient #15 dated/timed 08/02/10 at 3:45 (am or pm not documented) revealed in the section titled " Precautions" (type of observation for the patient) "Select at least one: 1:1, SP, Q15, Q30, QHR, FALL" revealed no documented evidence any type of observation had been ordered by the physician. Further review of the Physician's Order for 8/02/10 through 8/03/10 revealed no documented evidence the RN had notified the physician for a clarification of the order. Review of the Integrated Treatment Plan-Psychiatric Section for Patient #15 revealed "Short Term Goals b. Patient's presenting signs and symptoms will decrease by 80% within 14 days. 2. Interventions - Implement observations per MD orders" ; however there was no documented evidence the MD had ordered any type of observation. Review of the Observation Forms for Patient #17 revealed the staff had been observing and documenting on her every 15 minutes.

Patient #17
Review of the medical record for Patient #17 revealed she had been admitted to the hospital on 07/09/10 for depression related to the death of her daughter, mood swings, hallucinations, delusions and paranoia. Review of the Physician's Admit Orders for Patient #17 dated/timed 07/09/10 at 2:50pm revealed in the section titled "Precautions" (type of observation for the patient) "Select at least one: 1:1, SP, Q15, Q30, QHR, FALL" revealed no documented evidence any type of observation had been ordered by the physician. Further review of the Physician's Order for 07/09/10 through 8/03/10 revealed no documented evidence the RN had notified the physician for a clarification of the order. Review of the Integrated Treatment Plan-Psychiatric Section for Patient #17 revealed " Short Term Goals b. Patient's presenting signs and symptoms will decrease by 90% within 14 days. 2. Interventions - Implement observations per MD orders"; however there was no documented evidence the MD had ordered any type of observation.
Review of the Observation Forms for Patient #17 revealed the staff had been observing and documenting on her every 15 minutes.

In a face to face interview on 08/04/10 at 3:00pm RN S2 Director of Nursing (DON) indicated all orders should be clarified by the nurse with the MD before carrying out an order.

Based on record review and interview revealed the hospital failed to follow their policy and procedure for verbal orders as evidenced by nursing staff failing to read back orders to the physician ensure accuracy of the order(s) for 2 of 25 sampled medical records (#14, #17). Findings:

Patient # 14
Review of the Physician's Orders for Patient #14 revealed an order dated/timed 08/03/10 at 0100 (1:00am) with no documented evidenced the order to transfer the patient to the hospital for a blood transfusion which was communicated to one RN and documented by a second RN had been had been read back to the physician for accuracy. Further review of an order dated/timed 08/01/10 at 2005 (8:05pm) revealed an order to DC (discontinue) Klonopin, give Xanax 0.5mg po now, Xanax 0.25mg 3 times a day po, Risperdal 0.25mg po bedtime, Trazodone 25mg po bedtime prn (as needed) insomnia, May repeat Trazodone in 1 hour if still awake, and orthostatic BP (Blood Pressure) and pulse lying/standing now.

Patient #17
Review of the Physician's Orders for Patient #17 revealed an order dated/timed 07/20/10 at 1945 (7:45pm) for "Haldol 5mg with Ativan 1mg with Benadryl 25mg IM (Intramuscular) if refuses Risperdal M-tab every hs (hour of sleep) only. Further review revealed no documented evidence the verbal order had been read back to the physician to ensure accuracy.

Review of the hospital's "Rules and Regulations of the Westend Hospital for the Medical Staff, January 2, 2005" presented by the hospital as current revealed in part, "All verbal orders must be signed by the Attending Physician within 10 days of order . . ."

Review of the hospital policy titled, "Telephone and verbal orders, PC-45" presented by the hospital as current, revealed in part, "All telephone orders by physicians must be signed by the prescriber within 48 hours or the next business day."

In a face to face interview on 08/04/10 at 3:00pm RN S2 Director of Nursing) indicated the nurses should have read back all of the verbal orders.

Based on record review and interview the hospital failed to ensure medical records were completed within 30 days of discharge resulting in 24 medical records delinquent greater than 30 days for 2 of 2 physicians (S26, S27). Findings:

Review of a list of Medical Records presented by HIM (Health Information Management) Director S11 as delinquent for greater than 30 days revealed 24 records. Further review revealed of those listed 5 were greater than 60 days delinquent. Two of the records listed as greater than 60 days delinquent belonged to Physician S26. Three of the records listed as greater than 60 days delinquent belonged to Physician S27.

During a face to face interview on 8/04/2010 at 1:40 p.m., HIM Director S11 indicated medical records were considered delinquent 30 days after discharge when they were incomplete. S11 further indicated she had not sent any letters to any of the physicians that had delinquent records. S11 indicated she had been instructed by Administrator S1 and Director of Nursing S2 that the Medical Staff Rules and Regulations, as were currently written, were to be changed in the future and she had been instructed not to follow them. Administrator S1 confirmed that the Medical Staff Rules and Regulations had not been enforced regarding delinquent medical records..

During a telephone interview on 8/05/2010 at 1:10 p.m., Medical Director S26 indicated he had not been aware that medical records had been delinquent past 30 days. S26 indicated medical records should be completed timely and he expected them to be completed prior to 60 days.

Review of the hospital's Medical Staff Rules and Regulations presented by the hospital as current revealed in part, "Medical Records Completion: No medical record shall be filed until it is complete. Any physician having an unfinished record seven days after discharge shall be so notified by mail. . . If there are none of these extenuating circumstances and the record has not been completed within 30 days of discharge a second letter will be sent to the responsible practitioner advising that his admitting privileges have been suspended. If there are incomplete records remaining after 60 days of discharge, the responsible practitioner will lose staff privileges, restoration to be automatic upon completion of all records. . . "

Based on record review and interview the hospital failed to follow their policy and procedure for dating, timing and signing all entries into the medical records as evidenced by 1) failing to ensure all physicians were dating his/her Psychiatric Evaluations (#14); 2) failing to ensure all physicians were dating his/her discharge summaries (#18); 3) failing to ensure all dietary progress notes were timed (#17, #7); 4) failing to ensure patient's "Recertification for Continued In-Patient Stay" forms were not pre-signed and pre-dated for 1 of 25 sampled patients (#1); 5) failing to ensure diagnostic tests were labeled with Patient identifying information as evidenced by Electrocardiograms with no patient name or medical record number (#1, #2); 6) failing to ensure all staff documenting in the medical record of patients include the date, time, and signature for 2 of 21 sampled patients (#1, #20). Findings:

1) failing to ensure all physicians were dating his/her Psychiatric Evaluations

Patient #1
Review of the "Physician's Admit Note/Psychiatric Evaluation" for Patient #1 revealed no documented date or time the evaluation had been completed and signed by the physician.

Patient #14
Review of the Physician's Admit Note and Psychiatric Evaluation for Patient #14 dated 08/02/10 revealed no documented time the evaluation had been completed and signed by the physician.

Patient #17
Review of the "Physician's Admit Note/Psychiatric Evaluation" for Patient #14 revealed no documented date or time the evaluation had been completed and signed by the physician.

Patient #18
Review of the "Physician's Admit Note/Psychiatric Evaluation" for Patient #18 revealed no documented date or time the evaluation had been completed and signed by the physician.

Patient #20
Review of the "Physician's Admit Note/Psychiatric Evaluation" for Patient #20 revealed no documented date or time the evaluation had been completed and signed by the physician.


2) failing to ensure all physicians were dating his/her discharge summaries
Patient #18
Review of the Discharge Summary for Patient #18 revealed no documented date or time the document had been written or signed by the physician.

3) failing to ensure all dietary progress notes were timed
Patient #7
Review of the Dietary Progress Notes for Patient #24 dated 05/18/10 revealed no documented evidence of the time the note had been entered and signed by the dietary manager.

Patient #17
Review of the Dietary Progress Notes for Patient #17 dated 07/12/10 revealed no documented evidence of the time the note had been entered and signed by the dietary manager.

4) failing to ensure patient's "Recertification for Continued In-Patient Stay" forms were not pre-signed and pre-dated:

Review of Patient #1's medical record revealed the patient was admitted to the hospital on 7/29/2010 as a Non-Contested Admission for Cortical Dementia. Review of Patient #1's Psychiatric Evaluation with no date/time revealed Patient #1's estimated length of stay to be 10 - 14 days.

Review of Patient #1's "Recertification for Continued In-Patient Stay" form indicated "Patient has met (blank) % of treatment goals of the active treatment plan that is directed toward alleviation of the impairment which has precipitated the admission and need for continued stay/treatment. I certify that the continuation of Inpatient Psychiatric Hospitalization services are Medically Necessary and Reasonable Expected to improve the patient's condition or the continued diagnostic study and that this could not be done at a less intensive level of care. I have reviewed the medical needs, multidisciplinary observations, formulations and treatment interventions and have provided medical direction for the continued development of the Treatment Plan." Further review revealed the date of 8/09/2010 (5 days after the date of review on 8/04/2010) with Physician S26's signature.

This finding was confirmed by Director of Nursing S2 on 8/04/2010 at 3:00 p.m. who had no explanation as to why the form would have been signed and predated by the patient's physician.

Review of the hospital policy titled, "Provisions of Care, Treatment, and Services, PC-5" presented by the hospital as current, revealed in part, "Non-contested Admission. In the event an adult, age 18 or older, patient's mental or behavioral status prohibits his ability to understand and/or give his written consent, a Non-Contested Admission may be appropriate. The person accompanying the patient should be asked to sign the form. The psychohistories is also required to sign after examining the patient. . ."

5) failing to ensure diagnostic tests were labeled with Patient identifying information as evidenced by Electrocardiograms with no patient name or medical record number:

Review of the medical records for Patients #1 and #2 revealed an EKG (electrocardiogram) to be located in each medical record. Further review revealed no name or medical record number on either EKG. These findings were confirmed by Director of Nursing S2 on 8/04/2010 at 3:00 p.m. who further indicated EKGs should be labeled with the patient's name and medical record number.


6) failing to ensure all staff documenting the medical record of patients include the date, time, and signature:

Patient #1
Medical Record review revealed Patient #1 was admitted to the hospital on 7/29/2010 with diagnoses of Cortisol Dementia. Review of Patient #1's "Physician's Admit Note/Psychiatric Evaluation" revealed two different handwriting styles and only one signature- Physician S26. Review of the entire "Physician's Admit Note/Psychiatric Evaluation" for Patient #1 revealed no documented date or time.

Patient #20:
Medical Record review revealed Patient #20 was admitted to the hospital on 4/22/2010 with diagnoses of Bipolar Disorder. Review of Patient #20's "Physician's Admit Note/Psychiatric Evaluation" revealed two different handwriting styles and only one signature- Physician S26. Review of the entire "Physician's Admit Note/Psychiatric Evaluation" for Patient #20 revealed no documented date or time.

This finding was confirmed by the Director of Nursing and Hospital Administrator.

During a telephone interview on 8/05/2010 at 1:10 p.m., Medical Director S26 indicated he had not been aware that entries in medical records had not been dated and timed. S26 confirmed that all entries in patient's medical records should be dated and timed.

Based on record review (patient medical records, Medical Staff Bylaws) and interviews, the hospital failed to ensure all orders, including verbal orders, were timed, dated, and authenticated by the ordering physician for 6 of 21 sampled patients (Patients #7, #10, #12, #14, #16, #17) Findings:

Patient #7
Review of the Physician's Orders for Patient #7 revealed no documented evidence of the time the orders were written on 05/21/10 for an increase of Remeron to 45mg po (by mouth) every AM (morning).

Patient # 10
Review of the Physician's Orders for Patient #10 revealed no documented times the physician wrote the order written 07/03/10, 07/05/10, 07/09/10 and for the discharge order written 07/14/10.

Patient #12
Review of the Physician's Orders for Patient #12 revealed no documented time the verbal admit orders were written for the patient's medication on 06/13/10 and medication change orders written 01/22/10 and 01/25/10.

Patient #14
Review of the Physician's Orders for Patient #14 revealed no documented evidence of the time the orders were written on 08/01/10 for Klonopin i mg po (by mouth) BID (twice a day), Effexor ER 150mg po every morning and Lamictal 200mg po at bedtime.

Patient #16
Review of the Physician's Orders for Patient #16 revealed no documented evidence of the time time the orders were written on 06/25/10 for Accucheck BID (Twice a day).

Patient #17
Review of the Physician's Orders for Patient #17 revealed no documented evidence of the time the orders were written on 07/19/10 for Haldol, Benadryl and Ativan.

During a telephone interview on 8/05/2010 at 1:10 p.m., Medical Director S26 indicated he had not been aware that entries in medical records had not been consistently timed. S26 further confirmed that all entries should be dated and timed.

Based on record review and interview the hospital failed to ensure History and Physicals (H&P) had been placed in the medical record within 24 hours after admission as evidenced by H&Ps dictated greater than 24 hours after admission of the patient for 4 of 25 sampled medical records (Patients #5, #6, #13, #17). Findings:

Review of the medical record for Patient #5 revealed he had been admitted to the hospital on 08/02/10 with suicidal ideations and depression with a history of diverticulitis and BPH. Review of the History and Physical for Patient #5 revealed no documented time of the date it had been dictated or typed. Further review revealed no documented date or time it had been authenticated by the physician.

Review of the medical record for Patient #6 revealed she had been admitted to the hospital on 07/09/10 for weight loss, mood swings and hallucinations with a history of hypertension and COPD (Chronic Obstructive Pulmonary Disease). Review of the History and Physical for Patient #6 revealed it had been dictated by the physician on 07/09/10 and typed on 07/12/10 which was 72 hours after S6 had been admitted to the hospital.

Review of the medical record for Patient #13 revealed she had been admitted to the hospital on 06/25/10 for Bi-polar Disorder with a history of hypertension and diabetes. Review of the History and Physical for Patient #13 revealed it had been dictated by the physician on 06/25/10 and typed on 06/28/10 which was 72 hours after S13 had been admitted to the hospital.

Review of the medical record for Patient #17 revealed he had been admitted to the hospital on 07/09/10 for Bipolar Disorder with a history of hypothyroidism, Chronic Obstructive Pulmonary Disease (COPD) and hypertension. Review of the History and Physical for Patient #17 revealed it had been dictated on 07/09/10 and typed on 07/12/10 which was 72 hours after admission.

Review of the Medical staff By-Laws and Rules and Regulations submitted by the hospital as the ones currently in use revealed no documented evidence time frames had been addressed relating to completion of History & Physicals.

Based on interview, the hospital failed to ensure a radiologist was credentialed and appointed to the medical staff by having no documented evidence that a radiologist had been appointed to the medical staff. Findings:

In a face-to-face interview on 8/04/2010 at 3:30 p.m., Hospital Administrator S1 confirmed that the hospital did not have a radiologist appointed to the medical staff. S1 indicated that although the hospital had contracted radiology services, there had never been a radiologist credentialed or delineated privileges as the hospital.

Based on record review and interview the hospital failed to ensure the hospital's Dietary Manager met State Regulation's Qualification Requirements. Findings:

Review of Louisiana Hospital Licensing Regulation #L0860 revealed in part:
"B. The dietary manager shall:
1. be a qualified dietitian; or
2. be a graduate of a dietetic technician program, correspondence program or otherwise approved by the American Dietetics Association; or
3. have successfully completed a course of study, by correspondence or classroom, which meets the eligibility requirements for certification by the Dietary Manager's Association; or
4. have successfully completed a training course at a state approved school, vocational or university, which includes course work in foods and food service, supervision and diet therapy. Documentation of an eight-hour course of formalized instruction in diet therapy conducted by the employing facility's qualified dietitian is permissible if the course meets only the foods, food service and supervision
requirements. . ."

During a face to face interview on 8/05/2010 at 9:25 a.m., Dietary Manager S8 indicated she had worked as a cook in a hotel for 30 years prior to working at the hospital for the previous 4 1/2 years. S8 further indicated she had never had any training for her position as dietary manager at the hospital and no formal training in dietary.

Review of the personnel file for Dietary Manager S8 revealed no documented evidence she had any type of dietary training or assessment of competency to perform the tasks required in the job description for Dietary Manager.

Based on record review and interview the hospital failed to ensure:
1) that provisions for dietary consultation were made, when the dietician who was part time and worked only one day per month, and was not available for dietary consult, to meet the needs of the patients for 7 of 7 patients who scored greater than a 5 on the nutritional assessment of 21 sampled patients (#5, #6, #7, #8, #13, #17, #21).
2) the dietitian supervised and evaluated the dietary department to ensure food temperatures were monitored daily, the dishwashing machine was monitored three times daily for quality of sanitizing dishes and cookware, and that policies and procedures were in place for the dietary department. These two practices have the potential to affect all patients in the hospital. Findings:

1) that provisions for dietary consultation were made, when the dietician who was part time and worked only one day per month, and was not available for dietary consult, to meet the needs of the patients:

Review of the "Agreement" signed between the hospital and Dietician #S12 revealed in part, "Specific List of Duties and Responsibilities of (S12). 1. Review the performance for services through on site visits, to assist in compliance with all facility, state and federal standards. 2. Oversees Hospital Dietary Manager and provides direction, supervision, and education. . . 4. Visit and consult within 24 hours of physician's consult orders, and document in patient's chart accordingly. . . 9. Provides in-service training as needed. . . 14. Participates in preparation of Policies and Procedures for Food Services to stay in compliance of regulations of State and Federal agencies. . . "

Patient #5 The medical record for Patient #5 was reviewed. Review of the History and Physical dated 04/14/10 revealed Patient #5, with a diagnosis of Psychosis, had a weight loss of 16 pounds. Review of the In-Patient Nursing Assessment dated and signed by the Registered Nurse 04/14/10 at 0815 (8:15) revealed the Eating/Nutrition Screening total score was 6. Further documentation revealed "Total Points of 5 or greater-Referral to MD for Dietary Consult. " Review of the Physicians Orders revealed no documented evidence of an order for a Dietary Consult. Review of the Nutritional Therapy note signed by S14, Dietary Manager dated 04/14/10 8:50am revealed no documented evidence Patient #5's labs included a review of Albumin, BUN/Creatinine, Glucose, Sodium/Potassium and Hemoglobin/Hematocrit. There was no documented evidence of a review and calculation of Ideal Body Weight, Percentage of Weight Change, and estimated nutritional needs for calories, protein and fluid. Suggested Nutritional Therapy revealed, "offer Milk (Skim) at all meals for extra Protein & calories for help with weight gain. RD to follow as needed." Review of the entire medical record revealed no documented evidence that Patient #5 was ever evaluated by a Registered Dietician.
Patient #6:
Review of Patient #6's medical record revealed the patient was admitted to the hospital on 5/14/2010 with diagnoses that included Major Depressive Disorder. Further review revealed Patient #6's "Initial (RN) Nursing Assessment" dated 5/14/2010 to have a cumulative score of 7 (3 points for having a therapeutic diet, 3 points for having diabetes, and 1 point for having a change in appetite or food intolerance). Review revealed in bold print on the assessment form "Total points of 5 or greater- Referral to MD (Medical Doctor) for Dietary Consult". Review of Patient #6's Nutritional Therapy note as completed by Dietary Manager S8 dated 5/16/2010 revealed in part, "RD (Registered Dietician) to follow monthly, as needed". Review of Patient #6's physician's orders dated 5/14/2010 at 7:45 (a.m. versus p.m. not specified) revealed in part, "Nutrition Consult". Review of the entire medical record revealed no documented evidence Patient #6 was seen by the Registered Dietician within 24 hours of the physician's consult orders or at any time during his hospital stay. The patient was discharged on 5/22/2010.

Patient #7
Review of Patient #7's medical record revealed the patient was admitted to the hospital on 0516/10 with diagnoses that included Depression, GERD, and Hypertension (recent onset). Further review revealed Patient #7's "Initial (RN) Nursing Assessment" dated 05/16/10 to have a cumulative score of 6 (3 points for having therapeutic diet order and 3 points for having anorexia for a reported weight loss of 26 pounds). Review revealed in bold print on the assessment form "Total points of 5 or greater- Referral to MD (Medical Doctor) for Dietary Consult". Review of Patient # 7's "Nutritional Therapy" note as completed by Dietary Manager S8 dated 05/18/10 revealed in part, "RD (Registered Dietician) to follow monthly, as needed". Further review of medical record for Patient #7 including the physician's orders and progress notes dated 05/16/2010 through discharge revealed no documented evidence the MD had been informed of the need for a Dietary Consult by the Registered Dietitian.

Patient #8:
Review of Patient #8's medical record revealed the patient was admitted to the hospital on 5/06/2010 with diagnoses that included Cortical Dementia with delusions/behavior disturbances. Further review revealed Patient #8's "Initial (RN) Nursing Assessment" dated 5/06/2010 to have a cumulative score of 6 (3 points for having therapeutic diet order, 3 points for having a diagnosis of diabetes). Review revealed in bold print on the assessment form "Total points of 5 or greater- Referral to MD (Medical Doctor) for Dietary Consult". Review of Patient #8's "Nutritional Therapy" note as completed by Dietary Manager S8 dated 5/08/2010 revealed in part, "RD (Registered Dietician) to follow monthly, as needed". Review of Patient #8's physician's orders dated 5/06/2010 at 10:50 a.m. revealed in part, "Nutrition Consult". Review of the entire medical record revealed no documented evidence Patient #8 was seen by the Registered Dietician within 24 hours of the physician's consult orders.

Patient #13
Review of Patient #13's medical record revealed the patient was admitted to the hospital on 06/25/10 with diagnoses that included Bi-polar Disorder and Diabetes. Further review revealed Patient #13's "Initial (RN) Nursing Assessment" dated 06/25/10 to have a cumulative score of 6 (3 points for having therapeutic diet order and 3 points for having a diagnosis of diabetes) Review revealed in bold print on the assessment form "Total points of 5 or greater- Referral to MD (Medical Doctor) for Dietary Consult". Review of Patient # 13's "Nutritional Therapy" note as completed by Dietary Manager S8 dated 06/25/10 revealed in part, "RD (Registered Dietician) to follow monthly, as needed". Further review of medical record for Patient #13 including the physician's orders and progress notes dated 06/25/10 through 07/15/10 revealed no documented evidence the MD had been informed of the need for a Dietary Consult by the Registered Dietitian.

Patient #17
Review of Patient #17's medical record revealed the patient was admitted to the hospital on 07/09/10 with diagnoses that included Bipolar Disorder, HTN (Hypertension), Hypothyroidism and Chronic Obstructive Pulmonary Disease (COPD). Further review revealed Patient #17's "Initial Nursing Assessment" dated 07/09/10 to have a cumulative score of 6 (3 points for having therapeutic diet order, 1 point for appearing overweight, 1 point for a significant weight change and 1 point for chewing difficulties). Review of Patient # 17's "Nutritional Therapy" note as completed by Dietary Manager S8 dated 07/12/10 revealed in part, "RD (Registered Dietician) to follow monthly, as needed". Further review of medical record for Patient #17 including the physician's orders and progress notes dated 07/09/10 through 08/05/10 revealed no documented evidence the MD had been informed of the need for a Dietary Consult by the Registered Dietitian.

Patient #21:
Review of Patient #21's medical record revealed the patient was admitted to the hospital on 3/04/2010 with diagnoses that included Major Depressive Disorder. Further review revealed Patient #21's "Initial (RN) Nursing Assessment" dated 3/04/2010 to have a cumulative score of 9 (3 points for having therapeutic diet order, 3 points for having a diagnosis of malnutrition and diabetes, 1 point for appearing underweight, 1 point for having decreased oral intake for more than 2 weeks, and 1 point for having chewing difficulties). Review revealed in bold print on the assessment form "Total points of 5 or greater- Referral to MD (Medical Doctor) for Dietary Consult". Review of Patient # 21's "Nutritional Therapy" note as completed by Dietary Manager S8 dated 3/05/2010 revealed in part, "RD (Registered Dietician) to follow monthly, as needed". Review of Patient #21's physician's orders dated 3/04/2010 at 1600 (4:00 p.m.) revealed in part, "Nutrition Consult". Review of the entire medical record revealed no documented evidence Patient #21 was seen by the Registered Dietician within 24 hours of the physician's consult orders.

S2, Director of Nurses was interviewed face to face on 08/05/10 at 10:55am. S2 confirmed S14 Dietary Manager, who was at present the Housekeeper, did the Nutritional Therapy assessment, and she was not competent and trained to perform the dietary assessment. Further S14 should have made a referral to the Registered Dietician to assess Patient #5.
Review of the Personnel Record for S14 Housekeeper/Former Dietary Manager revealed a date of hire was 07/09/07 and Job Description for Dietary Manager. Further review of the record revealed no documented evidence S14 was trained and competent to serve as the Dietary Manager. Review of the Dietary Manager Job Description revealed in part, "3. Consults contract Dietician with special concerns and questions."
During a telephone interview on 8/05/2010 at 10:00 a.m., Dietician S12 indicated she was only able to visit the hospital one day per month because she lived a distance that took over two hours to reach the hospital. S12 further indicated that typically patient's with dietary consults ordered were already discharged from the hospital when she arrived for her monthly visit. S12 indicated her practice had been to have the Dietary Manager fax information to her regarding patients that were identified as needing a dietary consult. S12 indicated she would perform a dietary assessment based on the faxed materials without seeing the patients. S12 further indicated that she would see patients face to face for dietary consults on her monthly visits to the hospital; however, most often the patients would already be discharged from the hospital.

2) the dietitian supervised and evaluated the dietary department to ensure food temperatures were monitored daily, the dishwashing machine was monitored three times daily for quality of sanitizing dishes and cookware, and that policies and procedures were in place for the dietary department:

Observations on 8/04/2010 at 11:00 a.m. revealed a clip board hanging on the wall in the hospital's kitchen containing forms titled, "Temperature Log" with spaces for logging food temperatures for" breakfast, lunch, and supper". Review of the temperature logs from the dates of 7/02/2010 through 8/04/2010 revealed the forms were blank for 13 of the 32 days reviewed: 7/02/2010, 7/03/2010, 7/07/2010, 7/08/2010, 7/09/2010, 7/10/2010, 7/11/2010, 7/20/2010, 7/26/2010, 7/30/2010, 7/31/2010, 8/01/2010, and 8/03/2010. This finding was confirmed by Dietary Manager S8 on 8/04/2010 at 11:03 a.m., who further indicated food temperatures should be taken every day for every meal to ensure the food was safe for serving.

Review of a handout provided by the Dietary Manager regarding "AutoChlor Sanitizer Check Procedures" revealed in part, "Check Daily: 10:00 a.m., 2:00 p.m., 6:00 p.m. Check Product level in container and confirm yellow stopper pickup tube is in position. Cycle dishwasher and visually verify sanitizer is dispensing properly. With dry hands, dip test strip in rinse water solution. Compare strip with chart on vial. Minimum 50 - 100 ppm (parts per million) is required. Requirements: water temp. (temperature) 125 (degrees) F (Farenheit). Chlorine residual 50 ppm min. (minimum). Min (minimum) wash 52 sec (seconds). Rinse 25 sec (seconds)."

Review of logs provided by the Dietary Manager revealed no documented evidence of monitoring quality controls for the dishwashing machine. This finding was confirmed by Dietary Manager S8 on 8/04/2010 at 12:00 p.m. who further indicated the hospital had never documented quality control measurements for the Dishwashing machine since she worked at the hospital (4 1/2 years). S8 indicated she did not know how often the dishwashing machine may have been tested to ensure it was at a minimum of 50 - 100 ppm of chemical solution and that the water reached 125 degrees Farenheit.

Review of the entire Policy and Procedure Manual revealed no documented evidence of policies and procedures for a) monitoring food temperatures, b) ensuring proper monitoring of the dishwashing machine to ensure cookware and dishes were sanitized properly, c) Nutritional Risks Assessments, or d) Consultation of the Dietician. This finding was confirmed by the hospital's Director of Nursing S2 and Administrator S1.

During a telephone interview on 8/05/2010 at 10:00 a.m., Dietician S12 indicated she was only able to visit the hospital one day per month because she lived a distance that took over two hours to reach the hospital. S12 further indicated she had not been aware that food temperatures had not been monitored and logged daily in the kitchen and had also not been aware that the hospital's dishwashing machine had not been monitored for proper sanitation levels. S12 indicated she had no Quality Indicators that she had been monitoring for the Dietary Department and was unaware of the fact that there were no policies regarding a) monitoring food temperatures, b) ensuring proper monitoring of the dishwashing machine to ensure cookware and dishes were sanitized properly, c) Nutritional Risks Assessments, or d) Consultation of the Dietician.












20638

Based on observation and interview the hospital failed to ensure outdated lab supplies was not available for patient use by having expired blood tubes located in the hospital. Labs are ordered on all admitted patients so this practice has the potential to affect all patients in the hospital. Findings:

Observations on 8/03/2010 at 12:10 p.m. revealed the following laboratory tubes to be located in the lab supply storage area:
4 green top tubes with the expiration date of 3/2010,
1 red tiger top tube with the expiration date of 3/2010,
2 red top tubes with the expiration date of 10/2008,
and 4 Culture Bottles with the expiration date of 10/31/2010.
These findings were confirmed by Registered Nurse S4 who indicated the tubes should have been discarded at the time of their expiration.

Based on record review and interview the hospital failed to ensure the person appointed as Infection Control Officer was qualified as evidenced by no documented evidence of training and assessment of competency in Infection Control. Findings:

Review of the personnel file for RN S2 revealed she was assigned the duties of the Director of Nursing (DON), Infection Control Officer (ICO) and Quality Assurance/Performance Improvement Coordinator (QA/PI). Further review revealed no documented evidence of any specialized training in infection control. Further review revealed no documented evidence in the personnel file of S2 of the assessment of competency to perform the duties stated in the job description for the Infection Control Officer.

In a face to face interview on 08/05/10 at 1:30pm RN S2 DON verified she had no additional training in infection control. Further S2 indicated she was not familiar with either the Federal or State regulations for Infection Control.

Based on observation, record review and interview the hospital failed to ensure the infection control officer implemented a system for identifying, reporting, investigating and controlling infections as evidenced by: 1) failing to maintain a clean environment resulting in dusty window sills and air-conditioning vents in patient rooms and patient care areas and water fountains with food particles; 2) failing to maintain a log of all patient and employee infections resulting in no documented evidence of trends related to infections or reported communicable diseases related to patients and/or employees; 3) failing to develop and implement an Infection Control Plan based on the hospital's patient population and the current guidelines of the Centers for Disease Control (CDC), Occupational Safety and Health Administration (OSHA) and/or Public Health as evidenced by no documented evidence of a plan, policies and procedures; 4) failing to ensure aseptic technique was followed during the administration of wound care for 1 of 1 patients observed for wound care of 3 with wounds out of 21 sampled patients; and 5) failing to perform surveillances to identify problems and implement corrective action for handwashing and aseptic technique as evidenced by observed lack of handwashing between patients. Findings:

1) failing to maintain a clean environment
Observation of all patient rooms on 08/03/10 at 11:00am in the presence of RN S2 Director of Nursing (DON) revealed the window sills in all patient rooms had visible dust build-up on the ledges and the window latches; all air-conditioning vents had a thick layer of dust which when wiped forms a quarter sized damp ball; the air-conditioning ceiling vent in the hallway by the nurses' station had dust build-up and webs which blew downward when the air-conditioning unit was on; in the bathroom of room "a" revealed a strong urine odor, a large stained area next to the toilet and feces smeared on the wall next to the light switch; and large particles of food (egg) in the water fountain used by patients located outside of the activity room.

Review of the monitoring tool used by the Housekeeping Department revealed no documented evidence the air-conditioning vents, windows, water fountains or ceiling vents were included for monitoring of cleanliness. This was confirmed by the Housekeeping supervisor.

Review of the policy and procedure manual, infection control section, revealed no documented evidence any policies had been developed for the cleaning, disinfecting and/or monitoring of patient rooms and patient care areas.


2) failing to maintain a log of all patient and employee infections resulting in no documented evidence of trends related to infections or reported communicable diseases related to patients and/or employees
The hospital was unable to submit to the survey team an Infection Control Log.

In a face to face interview on 08/05/10 at 1:30pm RN S2 DON/IC verified there was no log for infection control. S2 indicated she collected lab results and monitored for antibiotic use, but does not enter or organize the data. Further S2 indicated the hospital does not have a nosocomial infection rate because the patients are screened for illness before admission and the majority of the community acquired infections noted on admit are urinary tract infections (UTI) from patients coming from the nursing home setting. S2 indicated there are no records kept for employee illness and there were no communicable infections reported last year and to the present.


3) failing to develop and implement an Infection Control Plan
Review of the policy and procedure manual section "Infection Control" revealed three policies as follows: "Linen, Patient Clothing Handling", Maintenance of Patient Washer" and Maintenance of Safety Razors".

Further review revealed no policy and procedure for reporting of communicable diseases, performance of surveillances, infection control logs, for employees reporting to duty with a possible communicable disease, disinfection of equipment used in patient care, and the process for maintaining a clean environment.

In a face to face interview on 08/05/10 at 1:30pm RN S2 DON verified there were no written plan or additional policies for infection control. Further S2 indicated the manual "Best Practices Evidence Based Nursing Procedures" by Lippincott, Williams and Wilkins dated 2007 was used as a reference for isolation precautions and hand hygiene. S2 indicated she thought the Lippincott manual was based on CDC guidelines.


4) failing to ensure aseptic technique was followed during the administration of wound care:
Observations on 8/04/2010 at 2:05 p.m. revealed Registered Nurse S3 performing skin care
to Patient #1. Observations revealed a small skin tear measured by RN S3 as 1/4 inch long and located on the lower portion of the patient's abdomen on the left side beneath a skin fold. Further observation revealed RN S3 picking up a tube of Moisture Barrier Creme with her gloved hands and applying the cream onto the abdomen and perineal area of Patient #1. RN S3 was observed using the same gloved hand to apply the cream, pick up the tube to gather more cream, and applying more cream. Observations revealed RN S3 alternating touching the patient for skin care and the tube to obtain more cream with her contaminated gloves on three occasions during the process of providing skin care thus cross contaminating the tube of cream and the patient.

During a face to face interview on 8/04/2010 at 3:00 p.m., Director of Nursing S2 indicated aseptic technique should be followed when providing wound care and measures should be taken to prevent cross contamination of supplies and wounds.


5) failing to perform surveillances
Observation of Community Group on 08/04/10 at 8:00am revealed a Mental Health Technician (MHT) who had to continually wipe the nose and mouth of one of the patients attending group. During this time the MHT opened the door, handed a tissue to another patient in group, and assisted one of the patients who needed to leave group to go to the bathroom. At no time did the employee was her hands or using waterless sanitizer.

In a face to face interview on 08/04/10 at 3:00pm RN S2 the Director of Nursing and the Infection Control Officer indicated the employee should have cleaned her hands between each patient. Further S2 indicated she does not perform handwashing surveillances in the hospital.

Based on record review and interview the hospital failed to ensure a log related to infections and communicable disease had been maintained resulting in no documented evidence of trends or clusters related to infections, or reported communicable diseases related to patients and/or employees. Findings:

The hospital was unable to submit to the survey team an Infection Control Log.

In a face to face interview on 08/05/10 at 1:30pm RN S2 DON/IC verified there was no log for infection control. S2 indicated she collected lab results and monitored for antibiotic use, but does not enter or organize the data. Further S2 indicated the hospital does not have a nosocomial infection rate because the patients are screened for illness before admission and the majority of the community acquired infections noted on admit are urinary tract infections (UTI) from patients coming from the nursing home setting. S2 indicated there are no records kept for employee illness.

Review of the policy and procedure manual submitted as the one currently in use revealed no documented evidence of a policy for an infection control log or the collection of any type of data.

Based on record review and interview the hospital failed to ensure the legal status documented in the patient's medical record was accurate for 1 of 21 patients reviewed for legal status (#3). Findings:

Review of Patient #3's medical record revealed the patient was documented as having a non-contested admission "Non-contested Admission: (Patient #3) being in need of admission to a treatment facility for diagnostic study and/or treatment and being unable to render full and knowing consent for voluntary admission, hereby states that he/she does not object to such admission. I hereby verify that (Patient #3) fulfills the criteria for non Contested admission according to LA. R.S. 28, Sec. 52.3". Further review revealed the line for placement of the physician's signature to be blank and the line for a witness signature to contain the signature of S30. Record review revealed no date and time on the form.

Review of Patient #3's Interdisciplinary Progress Note dated 8/02/2010 at 1400 (2:00 p.m.) revealed a notation by Case Manager S10 reading, "CM (Case Manager) discussed with pt. (Patient) her reason for admission. Pt. stated, "I am calling my lawyer and suing this place because you all cannot put me here against my will." Pt. explained that she has been treated fairly and her dtr (daughter) wants her to get better. Pt. mood was extremely labile "You're a jackass because you just keep talking to me. I want to break a window so I can cut my throat and if I can't do that I'll run out of here when the door opens. Pt. asked to calm down by staff and why was she so rude to staff. Pt stated, "I am sorry my dtr. did this to me and when I see her I will choke her. Pt. redirect (ed) and eventually calmed down and able to held a pleasant conversation."

During a face to face interview on 8/04/2010 at 2:30 p.m., Registered Nurse S3 and Administrator S1 indicated the form titled "Non Contested Admission" should have been signed by the patient's physician. S1 and S3 further indicated that because the patient had contested the admission, there should have been a phone call to the physician to determine if the patient should have been placed under a Physician's Emergency Certificate due to statements of harming herself and her daughter.

Based on record review and interview the hospital failed to ensure patient's psychiatric evaluations were completed within 60 hours of admission as evidenced by no documented date and/or time to indicated when the psychiatric evaluation was completed for 2 of 21 sampled patients (#1, #14, #20). Findings:

Patient #1
Medical Record review revealed Patient #1 was admitted to the hospital on 7/29/2010 with diagnoses of Cortisol Dementia. Review of Patient #1's "Physician's Admit Note/Psychiatric Evaluation" revealed two different handwriting styles and only one signature- Physician S26. Review of the entire "Physician's Admit Note/Psychiatric Evaluation" for Patient #1 revealed no documented date or time.

Patient #14
Medical Record review revealed Patient #14 was admitted to the hospital on 08/01/10 with diagnoses of depression and anxiety. Review of Patient #14's "Physician's Admit Note/Psychiatric Evaluation" revealed two different handwriting styles and only one signature- Physician S26.

Patient #15
Medical Record review revealed Patient #15 was admitted to the hospital on 08/03/10 with diagnoses of schizophrenia and verbal and physical aggression. Review of Patient #15's "Physician's Admit Note/Psychiatric Evaluation" revealed three different handwriting styles and two signatures- Physician S26 and NP S.

Patient #16
Medical Record review revealed Patient #16 was admitted to the hospital on 07/27/10 with diagnoses of past suicidal ideation, depression and anxiety. Review of Patient #16's "Physician's Admit Note/Psychiatric Evaluation" revealed three different handwriting styles and two signatures- Physician S26 and NP S .

Patient #17
Medical Record review revealed Patient #17 was admitted to the hospital on 07/09/10 with Bi-Polar Disorder. Review of Patient #17's "Physician's Admit Note/Psychiatric Evaluation" revealed two different handwriting styles and only one signature- Physician S26. Review of the entire "Physician's Admit Note/Psychiatric Evaluation" for Patient #14 revealed no documented date or time.

Patient #18
Medical Record review revealed Patient #18 was admitted to the hospital on 04/05/10 with diagnosis of schizoaffective disorder. Review of Patient #18's "Physician's Admit Note/Psychiatric Evaluation" revealed two different handwriting styles and only one signature- Physician S26. Review of the entire "Physician's Admit Note/Psychiatric Evaluation" for Patient #14 revealed no documented date or time.

Patient #20:
Medical Record review revealed Patient #20 was admitted to the hospital on 4/22/2010 with diagnoses of Bipolar Disorder. Review of Patient #20's "Physician's Admit Note/Psychiatric Evaluation" revealed two different handwriting styles and only one signature- Physician S26. Review of the entire "Physician's Admit Note/Psychiatric Evaluation" for Patient #20 revealed no documented date or time.

During a telephone interview on 8/05/2010 at 1:10 p.m., Medical Director S26 indicated the Admission Note and Psychiatric Evaluation were typically initiated by the Social Worker and/or Case Manager with additional evaluations by his Nurse Practitioner. S26 indicated he would finalize the Psychiatric Evaluation on patients admitted to the hospital. S26 indicated he had not been aware of the absence of dating, timing, and or signatures of staff involved in completing the Psychiatric Evaluation, that it had been an oversight on his part. S26 further indicated he had not been aware that the hospital's medical staff bylaws indicated it would be the duty of the psychiatrist to perform psychiatric evaluations on patients at the hospital.

Review of the hospital's "Rules and Regulations of the Westend Hospital for Medical Staff, January 2, 2005" presented by the hospital as current revealed in part, "Within 24 hours of a patient's admission or transfer to the inpatient service, a physician shall personally examine the patient and record an appropriate history, physical examination, working diagnostic impression(s) and plan for treatment. The attending psychiatrist shall establish a personal and identifiable relationship with the patient if such was not established prior to the admission or transfer, examine the patient and perform a Psychiatric Evaluation within 60 hours of admission and is responsible for continuing evaluation of the care of the patient and plans for treatment. . . ."

Based on record review and interview the hospital failed to ensure individualized treatment as evidenced by:
1) failing to identify sexual inappropriateness as a problem and implementing interventions related to sexual inappropriateness for 1 of 1 patients reviewed with a history of sexual inappropriateness. (Patient # 2).
2) failing to ensure patients level of observation was identified upon admission to the psychiatric hospital for 2 of 21 sampled patients (#2, #6). Findings:

1) failing to identify sexual inappropriateness as a problem and implementing interventions related to sexual inappropriateness for 1 of 1 patients reviewed with a history of sexual inappropriateness:

A verbal report was received by Social Worker S28 on 8/03/2010 at 2:00 p.m. regarding the patients (Census 18) located in the facility. Patient #2 was identified by S38 as being sent to the hospital from a nursing home for exhibiting aggressive behavior such as throwing water on other patients as well as inappropriate sexual behavior.

2) failing to ensure patients level of observation was identified upon admission to the psychiatric hospital:

Review of Patient #2's medical record revealed the patient was admitted to the hospital on 8/02/2010 no diagnosis indicated. Further review revealed pre-printed admission orders with no date/time or signature. Review of these pre-printed orders revealed the area indicating "Precaution (Select at least one)" to have no identifying mark to indicated if the patient should be "1:1 (one on one), SP (Suicide Precautions), Q15 (every 15 minute checks), Q30 (every 30 minute checks), Qhr (every hour checks), or Fall (fall precautions)".

Review of Patient #6's medical record revealed the patient was admitted to the hospital on 5/14/2010 with diagnoses that included Major Depressive Disorder. Further review revealed pre-printed admission orders dated 5/17/2010 at 1300 (1:00 p.m.) with the area indicating "Precaution (Select at least one)" to have no identifying mark to indicated if the patient should be "1:1 (one on one), SP (Suicide Precautions), Q15 (every 15 minute checks), Q30 (every 30 minute checks), Qhr (every hour checks), or Fall (fall precautions)."

Based on record review and interview the hospital failed to ensure treatment plans specify how often the social worker will provide group therapy to patient's whose treatment plans indicate group therapy as an intervention in their plan for 2 of 21 sampled patients (#2, #3). Findings:

Patient #2:
Review of Patient #2's medical record revealed the patient was admitted to the hospital on 8/02/2010 with diagnoses that included Seasonal Affective Disorder. Further review revealed problems identified in Patient #2's treatment plan to include with interventions that included "Provide group therapy as prescribed per psychiatrist". Review of Patient #2's entire medical record revealed no documented evidence of physician's orders to indicate the type of therapy to be provided or how often group therapy was to be provided to Patient #2.

Patient #3:
Review of Patient #3's medical record revealed the patient was admitted to the hospital on 8/02/2010 with diagnoses that included Cortical Dementia. Further review revealed problems identified in Patient #3's treatment plan to include "Alteration of Mood/Affect, Impaired Cognition, and Alteration in Health Maintenance" with interventions that included "Provide group therapy as prescribed per psychiatrist". Review of Patient #3's entire medical record revealed no documented evidence of physician's orders to indicate the type of therapy to be provided or how often group therapy was to be provided to Patient #3.

This finding was reviewed with Social Worker S28 on 8/04/2010 at 3:30 p.m. S28 confirmed that some patients were too cognitively impaired to engage or benefit from cognitive therapy and therefore other therapies would be more beneficial. S28 further confirmed that it was the practice at the hospital to document interventions for group therapy as "Provide group therapy as prescribed per psychiatrist" although there had been no documented physician's orders for group therapy.

Based on record review and interview the hospital failed to ensure a staff member on the psychiatric unit had the educational training required by the job description to perform case management duties as evidenced by hiring an employee with a degree in nutrition to function as a social worker for 1 of 2 case managers employed by the hospital (S10). Findings:

Review of the Case Manager job description revealed under the section "Qualifications" revealed.... "1. Bachelors Degree in a Social Sciences Field of Study 2. 6 months mental health experience preferred 3. CPI (Crisis Prevention Intervention) within 6 months of employment".
Further review revealed some of the responsibilities as assists social services department in assessment/reassessment of social and emotional factors, assists in patient care, group sessions, patient education, family communication, and documentation.

Review of the personnel file for "Case Manager" S10 revealed she had a Bachelor of Science (BS) degree in Nutrition. Further review revealed no documented evidence S10 had any training in social work or had been assessed for competency in the performance of her job duties.

In a face to face interview on 08/04/10 at 2:15pm indicated at the time S10 was hired there were no other applicants and she needed an employee.

Based on observation and interview the hospital failed to ensure the appropriateness of social services provided by 1 of 3 staff members observed for delivery of services (Mental Health Tech S6). Findings:

Observations on 8/04/2010 revealed Mental Health Technician (MHT) #S4 as the leader of the 8:00 a.m. patient group titled, "Community Meeting/ Goal Setting". The topic of the group was Goal Setting with questions directed to the patient population in reference to how they felt that morning, identifying their goal for the day, making a list of how to accomplish their goal, and who might be able to support them in achieving their goals. Observations revealed MHT S4 initiating conversation with patients that contained statements regarding:
1) watching out because the devil was always trying to get you.
2) it would be okay for you to get yourself a boyfriend. I won't get mad if you do.
3) getting old makes my (S4) boobs hang to my knees and that's not good.

During a face to face interview on 8/05/2010 at 9:15 a.m., Administrator and Social Work Director S1 confirmed the inappropriateness of statements initiated by Mental Health Technician S4 in patient group regarding devils, boyfriends, and sagging boobs. S1 indicated paranoid, delusional, and demented patients could be frightened by statements about the devil trying to get them. S1 indicated S4 had been inappropriate in the past and they had spoken with her; however, they had not known she continued with the inappropriate comments in groups.

Based on record review and interview the hospital failed to ensure all hospital services and operations had been included in the performance improvement process as evidenced Performance Improvement Committee Meeting Minutes failing to have documentation for Radiology, Laboratory, Respiratory, Dietary, Laundry, and Waste Management. Findings:

Review of the Performance Committee Meeting Minutes for 2010 revealed no documented evidence of participation from the following departments: Radiology, Laboratory, Respiratory, and Dietary. Further review revealed no documented evidence contracted services for Laundry, Waste Management, Pharmacy and Dietary had been monitored for performance.

In a face-to-face interview on 8/04/2010 at 3:30 p.m., Hospital Administrator S1 indicated there was no criteria established by the hospital for monitoring the contracts or the or the services provided via contract.

Based on record review and interview the medical staff, administration and infection control officer to ensure an annual evaluation of the infection control program had been conducted as evidenced by; 1) the hospital's inability to produce documented evidence of a review based on identified problems, implementation of corrective actions, and patient outcome and 2) continued failure of the hospital to develop a written plan for infection control including policies and procedures based on the hospital's patient population and the current guidelines of the Centers for Disease Control (CDC), Occupational Safety and Health Administration (OSHA) and/or Public Health. Findings:

1) the hospital's inability to produce documented evidence of a review
Review of the Infection Control Performance Quarterly Report for 2010 revealed the following annual analysis of 2009 .... " UTI (Urinary Tract Infection) and Pneumonia continue as the 2 top infection types for 2009. P.O. (by mouth) antibiotic therapy was the route of choice for treatment. New Infection Rate- Community Acquired was 15.5/1000 patient days; Infection Rate Hospital Acquired 1.7/1000 Patient Days. Plan Revisions on Analysis: Monitor present indicators. Re-in-service staff on fall prevention Conduct CPI (Crisis Prevention Intervention) for employees for recertification and new employees. "

S2 DON/IC verified no additional evaluation had been conducted which included evaluation of the plan, policies and procedures and identified problems and corrective actions taken throughout the year.


2) continued failure of the hospital to develop a written plan for infection control
Review of the policy and procedure manual section "Infection Control" revealed three policies as follows: "Linen, Patient Clothing Handling", Maintenance of Patient Washer" and Maintenance of Safety Razors".

In a face to face interview on 08/05/10 at 1:30pm RN S2 DON/IC verified there was no written plan for Infection Control, three written policies contained in the hospital-wide Policy and Procedure Manual concerning infection control and no yearly evaluation of the program which should have included evaluation of the plan, policies and procedures and identified problems and corrective actions taken throughout the year.