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Based on record review and interview, the facility failed to have a family member promptly notified of patient admission as evidenced by failure to document family notification of admission in 2 (#4 and #5) of 5 (#1-#5) patients sampled.
Findings:

A review of hospital policy titled "Patient Rights" revealed, in part: The patient has the right to, in part: 6. Have a family member or representative of his or her choice, and his or her own physician notified promptly of his or her admission to the hospital.

Patient #4
Review of Patient #4's medical record revealed an admission date 07/15/2023.

A review of Patient #4's medical record failed to reveal that a family member or representative of Patient #4 was notified promptly of his admission to the hospital.

On 07/24/2023 at 4:20 p.m., S2DON confirmed there was no evidence of Patient #4's family or care-giver having been notified of Patient #4's admit.

Patient #5
Review of Patient #5's medical record revealed an admission date 07/14/2023.

A review of Patient #5's medical record failed to reveal that a family member or representative of Patient #5 was notified promptly of his admission to the hospital.

On 07/24/2023 at 2:15 p.m., S2DON confirmed there was no evidence of Patient #5's family or care-giver having been notified of Patient #5's admit.

Based on record review and interview, the hospital failed to ensure each patient received care in a secure setting. This deficient practice is evidenced by failure to assure that personnel completed criminal background checks by an authorized agent of the Louisiana State Police in the manner required by R.S. 15:587.1 et seq. prior to hire or employment for all unlicensed personnel providing care for adults. This deficient practice was evidence by 1 (S13CNA) of 2 (S13CNA and S14CNA) personnel records reviewed regarding criminal background checks.
Findings:

Review of S13CNA's human resource file revealed a criminal background check completed by Company A. Further review revealed Company A was not an authorized agency of the Louisiana State Police.

In an interview on 07/25/2023 at 3:50 p.m., S1CCO verified the hospital recently started using Company A for all employee background checks. S1CCO verified Company A was not an approved contractor by the Louisiana State Police.

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care for each patient. This deficient practice is evidenced by:
1) failure to assess patient for change in status in 1 (#1) of 5 (#1-#5) patients sampled.
2) failure of the Registered Nurses to perform an adequate wound assessment pertaining to Negative Pressure Wound Therapy and percutaneous drain assessments for 2 (#1 and #5) of 5 (#1- #5) patients sampled.
3) failure to assess intake and output for 5 (#1-#5) of 5 (#1-#5) patients sampled.
4) failure to ensure each patient received chlorohexidine baths as ordered by physician in 5 (#1-#5) of 5 (#1-#5) patients sampled.
Findings:

1) Failure to assess and reassess patient with change in status in 1 (#1) of 5 (#1-#5) patients sampled.
Review of hospital policy titled "Assessment Reassessment" revealed, in part: Purpose, in part: 3. To ensure reassessments are completed at regular intervals as outlined in the policy and determined by the patient's response and significant changes in condition or diagnosis.

Review of Patient #1's medical record revealed Zofran 4 mg was administered intravenously per physician order on 05/11/2023 at 6:00 a.m. Continued review revealed a respiratory note dated 05/11/2023 at 7:41 a.m. that stated breathing treatment held. Patient was nauseated and actively vomiting. Increased head of bed and informed patient's nurse. Review of patient record failed to reveal the nurse documented the incident. Further review of medical record failed to reveal physician was notified of patient's episode of active vomiting.

In an interview on 07/25/2023 at 10: 23 a.m., S2DON confirmed patient record failed to reveal the nurse documented the incident and that the medical record failed to reveal Patient #1's physician was notified of patient's episode of active vomiting 05/11/2023 at 7:41 a.m.

2) failure of the Registered Nurses to perform an adequate wound assessment pertaining to Negative Pressure Wound Therapy and percutaneous drain assessments for 2 (#1 and #5) of 5 (#1- #5) patients sampled.
Review of hospital policy titled "Assessment Reassessment" revealed, in part: Purpose, in part: 1. To assure care provided to each patient is based on an assessment of the patient's physical, psychological, social, learning and discharge planning needs upon admission. 3. To ensure reassessments are completed at regular intervals as outlined in the policy and determined by the patient's response and significant changes in condition or diagnosis. 2. Clinical Staff, in part: D. Skin Reassessment, in part: a. The nurse reassesses the skin and wound(s) every shift and more frequently as appropriate to the condition of the patient.

Patient #1
Review of the electronic medical record for Patient #1 navigated by S2DON revealed the patient was admitted on 05/05/2023 with a diagnosis of Sepsis, pancreatitis, severe protein-calorie malnutrition and pancreatic fluid collection with a JP drain. The initial nursing assessment dated 05/05/2023 revealed right upper quadrant of back with IR placed peri-pancreatic fluid collection (Jackson-Pratt) drain with brown liquid in bag.

Further review of Patient #1's medical record failed to reveal any documentation of a JP drain described in the nursing shift assessments dated 05/06/2023 day and night shifts, 05/07/2023 day and night shifts, 05/08/2023 day shift, and consistently throughout admission.

In an interview on 07/25/2023 at 10:17 a.m., S2DON confirmed that Patient #1's medical record failed to reveal any documentation of a JP drain described in the nursing shift assessments dated 05/06/2023, day and night shifts, 05/07/2023, day and night shifts, 05/08/2023, day shift. S2DON further stated that the drain was inconsistently monitored throughout his admission.

Patient #5
A review of the electronic medical record for Patient #5 navigated by S2DON revealed the patient was admitted on 07/14/2023 with a diagnosis of HIV, rectal cancer, morbid obesity, enterocutaneous fistula s/p repair on 6/26/2023, wound dehiscence repair on 07/06/2023, abdominal staples opening and swelling to left leg. Further review revealed on 07/17/2023 Negative-Pressure Wound Therapy (NPWT) placed to buttock and sacrum by NP at 12:00 p.m. per nursing note. Continued review revealed a nursing assessment dated 07/15/2023 at 8:03 a.m. with an integument assessment stating no changes from previous assessment. Additional review failed to reveal documentation of a wound assessment.

Review of the electronic medical record for Patient #5 revealed the following in the nursing shift assessments:
07/17/2023 at 8:00 p.m. No documentation of Negative-Pressure Wound Therapy (NPWT) functionality and settings.
07/18/2023 at 8:00 a.m. No documentation of NPWT functionality and settings.
07/18/2023 at 10:30 p.m. No documentation of NPWT functionality and settings.
07/19/2023 day and night shift. No documentation of NPWT functionality and settings.
07/20/2023 day and night shift. No documentation of NPWT functionality and settings.
07/21/2023 day and night shift. No documentation of NPWT functionality and settings.
07/22/2023 day and night shift. No documentation of NPWT functionality and settings.
07/23/2023 day and night shift. No documentation of NPWT functionality and settings.
07/24/2023 day and night shift. No documentation of NPWT functionality and settings.

In an interview on 07/24/2023 at 4:00 p.m., S2DON confirmed that Patient #5's medical record failed to reveal documentation of a wound assessment on 07/15/2023 and NPWT functionality and settings on the nursing shift assessments of the dates listed.

3) Failure to assess intake and output as ordered by the physician for 5 (#1-#5) of 5 (#1-#5) patients sampled.
Review of hospital policy titled "Scope of Nursing, Clinical Services" revealed, in part: Purpose: to provide hospital staff with guidelines regarding functioning within their scope of practice. Procedure, in part: "Registered nursing" means the practice of the scope of nursing which is appropriate to the individual's educational level, knowledge, skills and abilities, including, in part: e), in part: executing health care regimens as prescribed by licensed physicians, dentists or other authorized prescribers.

Review of hospital policy titled "Indwelling Urinary Catheter Use and the Urinary Tract Infection (UTI) Prevention Bundle", revealed, in part: The nurse will subsequently monitor the urine output of the patient to ensure voiding is taking place.

A review of medical records revealed strict input and output monitoring ordered by the physician for Patients #1-#5. Further review of Patients #1-#5 medical records failed to reveal nursing staff was consistently monitoring intake and output every shift as ordered by the physician.

In an interview on 07/25/2023 at 8:36 a.m., Patient #5 reported that staff did not monitor his output. He has a colostomy and staff emptied the contents of the colostomy into opaque rubber bags and disposed of the bags without measuring the amount of the contents.

In an interview on 07/25/2023 at 10:07 a.m., S2DON confirmed nursing staff did not consistently monitor intake and output every shift as ordered by physician for Patients #1-#5.

4) Failure to ensure each patient received chlorohexidine baths as ordered by physician in 3 (#2, #3, and #4) of 5
(#1-#5) patients sampled.
Review of hospital policy titled "Scope of Nursing, Clinical Services" revealed, in part: Purpose: to provide hospital staff with guidelines regarding functioning within their scope of practice. Procedure, in part: "Registered nursing" means the practice of the scope of nursing which is appropriate to the individual's educational level, knowledge, skills and abilities, including, in part: e), in part: executing health care regimens as prescribed by licensed physicians, dentists or other authorized prescribers.

Review of the medical records of Patients #2, #3 and #4 revealed physician admit orders for Chlorhexidine baths daily.

In an interview on 07/25/2023 at 2:12 p.m., S2DON confirmed Patients #2, #3 and #4 physician admit orders for Chlorhexidine baths daily.

In an interview on 07/25/2023 at 12:18 p.m., S16HIM confirmed Patient #2's physician order and stated she was unable to print the order.

Review of the medical records failed to reveal that Patients #2, #3 and #4 received daily chlorohexidine baths as ordered by the physician.

In an interview on 07/25/2023 at 12:18 p.m., S3HIM confirmed the documentation for Patient #2's chlorohexidine baths included only 1 for his entire hospital admission and subsequently did not receive daily chlorohexidine baths as ordered by the physician.

In an interview on 07/25/2023 at 1:30 p.m., S2DON confirmed that patients #3 and #4 did not receive daily chlorohexidine baths as ordered by the physician.

Based on record review and interview the hospital failed to ensure nursing staff followed the policies and procedures of the hospital. This deficiency is evidenced by:
1) failure of the facility to provide orientation for 4 (S8NP, S9OT, S10PT, and S11SLP) of 4 (S8NP, S9OT, S10PT, and S11SLP) contracted personnel sampled for orientation.
2) failure of contracted staff to document NPWT placement on 1 (#5) of 5 (#1-#5) patients sampled.
3) failure of the nursing staff to refrain from the use of electronic devices while caring for patients on the unit as hospital policy dictates.
Findings:

1) Failure of the facility to provide orientation for 4 (S8NP, S9OT, S10PT, and S11SLP) of 4 (S8NP, S9OT, S10PT, and S11SLP) contracted personnel sampled for orientation.
Review of hospital document titled "Therapy Services Agreement, Company B" revealed, in part: 1. Duties and Obligations of Contract Company B, in part: f., in part: Contract Company B will ensure that Therapy personnel attend mandatory Hospital in-services.

Review of hospital document titled "Facility Professional Health Services Agreement, Company C" revealed, in part: 1. Services, in part: (a) Professional Services, in part: 14. Facility and Contractor agree that each will comply with all local, state, and federal laws, regulations and requirements which apply to their respective services.

Review of hospital document titled "Job Description, Wound Nurse" revealed, in part: B. Company Specific, in part: Completes annual health, safety and education requirements. Attends all mandatory in-services and staff meetings.
Communicates the mission, ethics, and goals of the hospital, as well as the focus statement of the department. Consistently follows departmental and hospital health, safety, security, hazardous materials policies and procedures.

Review of hospital document titled "Physician's Directory" revealed, in part: S8NP Wound Care.

Review of hospital document titled "Company B, Job description, Physical Therapist" revealed, in part: Essential clinical Functions, in part: 1. Continuing education, in part: d. Ensure orientations are completed.

Review of hospital document titled "Company B, Job description, Occupational Therapist" revealed, in part: Essential clinical Functions, in part: 1. Continuing education, in part: d. Ensure orientations are completed.

A review of S8NP's personnel file revealed date of hire 05/18/2023. Further review failed to reveal documented evidence that S8NP was appropriately oriented prior to providing care.

A review of S9OT's personnel file revealed date of hire 04/12/2023. Further review failed to reveal documented evidence that S9OT was appropriately oriented prior to providing care.

A review of S10PT's personnel file revealed date of hire 05/15/2023. Further review failed to reveal documented evidence that S10PT was appropriately oriented prior to providing care.

A review of S11SLP's personnel file revealed date of hire 01/05/2023. Further review failed to reveal documented evidence that S11SLP was appropriately oriented prior to providing care.

In an interview on 07/25/2023 at 3:30 p.m., S1CCO confirmed that S8NP, S9OT, S10PT, and S11SLP were not appropriately oriented prior to providing care.

In an interview on 07/25/2023 at 4:08 p.m., S16HIM stated that she didn't think the contracted staff needed to have orientation through their hospital because they had orientation at another adjoining hospital.

2) Failure of contracted staff to document NPWT placement on 1 (#5) of 5 (#1-#5) patients sampled.
Review of hospital policy titled "VAC Therapy" revealed, in part: Documentation: The nurse should document the following: 1. At the time of NPWT dressing changes or application, a complete wound assessment should be performed with the inclusion of how may pieces of foam were applied or removed from the wound base. 2. NPWT functionality and settings should be documented at least once a shift.

Review of hospital document titled "Job Description, Wound Nurse" revealed, in part: B. Company Specific, in part: Consistently follows departmental and hospital health, safety, security, hazardous materials policies and procedures.
Review of hospital document titled "Facility Professional Health Services Agreement, Company C" revealed, in part: 1. Services, in part: (a) Professional Services, in part: (ii) Provider will actively participate in the communication related to consulted patients.

Review of hospital document titled "Physician's Directory" revealed, in part: S17NP Wound Care.

A review of Patient #5's medical record revealed admission date 07/14/2023. Further review revealed S17NP order on 07/17/2023 for NPWT placement, setting at 125, to right buttock and sacrum. Continued review revealed a nurse's note dated 07/17/2023 at 12:00 p.m. indicating S17NP placed the NPWT.

Review of nurse practitioner note on 07/17/2023 failed to reveal documentation regarding NPWT placement. Further review failed to reveal the NPWT was placed, a complete wound assessment with the inclusion of how may pieces of foam were applied or removed from the wound base and documented settings as per hospital policy.

In an interview on 07/24/2023 at 1:38 p.m., S2DON confirmed the nurse practitioner note on 07/17/2023 failed to reveal documentation regarding NPWT placement as per hospital policy.

3) Failure of the nursing staff to refrain from the use of electronic devices while caring for patients on the unit as hospital policy dictates.
A review of hospital policy titled "Personal Cell Phone Usage" revealed, in part: Policy, in part: In addition to telephone services, many cell phones or personal electronic device providers offer additional functions and /or services including, but not limited to text messaging, web browsing, digital photography, audio-visual and television. Employees should not use any of these services except during breaks and lunches and in non-patient care areas. Definitions: Cell phone/cellular phone or persona electronic device-includes mobile phones, iPhone, iPad, smartphones or similar multi-application communication devices that allows for telecommunication or any manner of electronic communication and image or audio recording. Procedures, in part: Personal cellular phones are not to be used by employees while in their work areas.

Observations of hospital unit on 07/25/2023 at 8:36 a.m. revealed S6RN leaving a patient room with a white electronic device in the right ear.

In an interview on 07/25/2023 at 8:36 a.m., S1CCO confirmed the electronic device in S6RN's ear and stated this practice is against hospital policy and that the device should not be used while the nurse is on the unit caring for patients.

Based on record review and interview the hospital failed to appoint an Infection Control Director as evidenced by the hospital failing to have documentation of an appointment by the governing body.
Findings:

A review of the hospital's organizational chart revealed S1CCO as Infection Control Manager.

A review of Governing Body minutes failed to reveal evidence that the governing body appointed an Infection Control Professional to be responsible for the infection prevention and control program within the time period of 03/31/2023 to 07/25/2023.

In an interview on 07/25/2023 at 1:35 p.m., S1CCO stated that the hospital's governing body did not formally appoint an Infection Control Manager after 03/31/2023 when the former Infection Control Manager left the role.

Based on record review and interview, the hospital failed to ensure that all rehabilitation (rehab) services provided were documented in the patient's medical records in accordance with requirements at §482.24. This deficient practice is evidenced by failing to have documentation of a completed Physical Therapy (PT) evaluation and treatment in the medical record for 1 (#4) of 5 (#1-#5) patients sampled.
Findings:

Review of hospital document titled "Therapy Services Agreement, Company B" revealed, in part: 1. Duties and Obligations of Contract Company B, in part: Services, in part: Company B agrees to use its best efforts to evaluate Hospital's patient, within twenty four hours from Monday through Friday and within forty-eight hours on Saturday and Sunday of a receipt of a physician's written referral or order and, if it cannot perform the evaluation within the time specified on the specific day, Company B shall promptly notify the Hospital's designated representative.

Review of hospital document titled "Company B, Job description, Physical Therapist" revealed, in part: 5, in part: Ensures all patient care is performed according to applicable state and federal regulatory agencies as well as company policy. A. Screening is completed according to policy and procedures. B. Patient specific documentation is completed timely and in appropriate areas. C. Patient assessment is completed after establishing Physician orders. D. Patient specific documentation is filed and or recorded properly in the appropriate medical record.

Review of Patient #4's medical record revealed an admission date 07/15/2023 and a diagnosis of VRE, Multidrug resistant pseudomonas, infected wound, CVA with shunt. Continued review of Patient #4's medical record revealed physician orders dated 07/18/2024 for Physical Therapy Evaluation and Treatment. Further review of Patient #4's medical record failed to reveal evidence of documented Physical Therapy Evaluation and treatment as per orders placed on 07/18/2023.

In an interview on 07/26/2023 at 3:18 p.m., S16HIM confirmed there was no evidence of documented Physical Therapy Evaluation and treatment as per orders placed on 07/18/2023.