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Based on record review and interview, the hospital failed to ensure a patient grievance was identified and investigated for 1 (Patient #2) of 1 patient reviewed for complaints/grievances from a total patient sample of 5 ( #1- #5).

Findings:

A list/log of the hospital's patient grievances was requested from S6Asst at survey team entry. S6Asst indicated the hospital currently had no list/log of patient complaints/grievances.

Review of Patient #2's medical record revealed the patient had been admitted on 10/1/19 with admission diagnoses of Sepsis, Fournier's Gangrene to pelvic area with purulent, foul-odored drainage, Necrotizing Fasciitis, debility, and Diabetes Mellitus Type II with skin complications. Additional review revealed the patient was on contact isolation precautions.

Review of Patient #2's medical record revealed the following nurses' note entry dated 10/1/19 at 8:45 p.m.: Upon entering room, patient asleep, easily aroused, complains of being hot, offered fan, patient declined. Additional review revealed no documented evidence of any further actions taken after offer of the fan was declined.

In an interview on 10/3/19 at 10:42 a.m. with S6Asst, she said the air conditioning had not been working for several weeks. S6Asst indicated patients in the hospital have complained about the heat. S6Asst confirmed she has not logged the complaints in a grievance log.

In an interview on 10/3/19 at 11:51 a.m. with S3CNA, she said patients have complained about the heat and lack of hot water.

In an interview on 10/4/19 at 3:30 p.m. with Patient #2, she said she had complained many times to the staff about it being extremely hot in her room. Patient #2 said she had complained to the nurse today but she did not know her name. She said the staff will turn up the fans but it does not help. Patient #2 said it was miserable but she guessed there was nothing she could do about it. The patient was observed to have two fans blowing on her during the interview and the room was felt to be noticeably warm by the surveyor.

In an interview on 10/3/19 at 3:40 p.m. with S2DON, she agreed the Patient #2's complaints regarding her room being hot should have been logged as grievances and should have been investigated.

Based on observations, review of hospital documentation and interviews , the hospital failed to meet the Condition of Participation relative to the physical environment as evidenced by failing to ensure the overall hospital environment was maintained in a manner to ensure the safety and well being of patients. This was evidenced by:

1) the hospital failing to ensure the generator was working to provide emergency electricity for the hospital in the event of power failure including electricity for patients' intravenous pumps, electric beds, lighting, air conditioning, nurse call systems and emergency exit signs. This deficient practice could potentially affect 2 (#1, #2) of 2 current patients and any patient admissions (see findings A-0724); and

2) the hospital failing to ensure the emergency fire alarm was functioning correctly. This deficient practice could potentially affect 2 (#1, #2) of 2 current patients and any patient admissions (see findings A-0724); and

3) the hospital failing to ensure adequate air conditioning was provided to all 13 patient rooms (see findings A-0724).


Findings:

1) The hospital failed to ensure the generator was working to provide emergency electricity for the hospital in the event of power failure including electricity for patients' intravenous pumps, electric beds, lighting, air conditioning, nurse call systems and emergency exit signs.

An interview was conducted with S5FireMarshal (Louisiana Office of State Fire Marshal deputy) on 10/3/19 at 1:00 p.m. He reported that on 10/3/18 at 11:55 a.m., he had S7Maintenance attempt to perform a generator function test. He said his observation revealed the generator was unable to function due to the natural gas piping lacking complete installation. He said that according to S7Maintenance, the natural gas piping is expected to be fully installed in approximately two days. S5FireMarshal said in an interview at 1:00 p.m. with S6Asst, she explained she was not sure of the exact date, but she approximated a date of August 1, 2019 as the day the natural gas piping was disconnected to the generator. S5FireMarshal said the failure of the generator to function properly causes the dedicated electrical receptacle for all patient care rooms to lack electricity as well as all life safety emergency lighting throughout the facility to lack electrical power.

Review of the Generator Testing Log provided by the hospital revealed the last Monthly Building Load Test (running generator for 30 minutes) had been performed on 7/4/19.

Review of Patient #2's medical record revealed the patient had been admitted on 10/1/19 with admission diagnoses of Sepsis, Fournier's Gangrene to pelvic area with purulent, foul-odored drainage, Necrotizing Fasciitis, debility, and Diabetes Mellitus Type II with skin complications. Further review revealed Patient #2 was receiving Zosyn per intravenous infusion every 8 hours. Additional review revealed the patient was on contact isolation precautions.

Review of Patient #1's medical record revealed the patient had been admitted on 9/30/19 with admission diagnosis including Endocaditis and Sepsis. Further review revealed Patient #1 was receiving Vancomycin 750 mg in 250 milliliters of 5% Dextrose solution per intravenous infusion every 12 hours.

Observation of Patient #1's and Patient #2's rooms on 10/3/19 at 1:30 p.m. revealed Patient #1 and Patient #2 required electricity for their IV pumps, electric beds, air conditioning, lighting, and the nurse call feature. Observation of the hallways revealed exit signs illuminated by electricity. S8LPN verified the patients required the previously mentioned electrical items for their care.

In an interview on 10/3/19 at 1:20 p.m. with S5FireMarshal, he said the emergency exit signs in the hallways of the hospital did not have batteries and would not be illuminated without electricity.

In an interview on 10/3/19 at 2:00 p.m. with S1Adm, he said he did not have a time frame for when the generator would be repaired because the city would not turn on the gas to the building. He said he was hoping to have the generator repaired by tomorrow.

An Immediate Jeopardy situation was declared to S1Adm, S2DON and S6Asst on 10/3/19 at 2:40 p.m. related to the non-functioning generator. A plan to remove the immediacy was not presented to the survey team before exiting at 4:00 p.m. The Immediate Jeopardy situation remained in place.

A plan of removal from the hospital was received on 10/4/19 at 3:53 p.m. The leaks in the gas line to the generator were repaired by the plumbing company. The city completed pressure testing on 10/4/19. A contractor connected the gas line to the generator and tested the generator. Once the generator was working it was placed on auto.

In an interview on 10/7/19 at 8:39 a.m. with S7 Maintenance, he said the generator had been repaired and tested and it was functioning correctly. An observation revealed when the power to the hospital was disconnected the generator started within 10 seconds. Further observation revealed the hospital lights, exit signs and equipment requiring electricity were functional. At 9:00 a.m. S2DON was informed that the immediacy of the Immediate Jeopardy situation had been removed.

Based on observation, record review and interview, the hospital failed to ensure facilities and equipment were maintained to ensure an acceptable level of safety and quality. This deficient practice is evidenced by:

1) the hospital failing to ensure the generator was working to provide emergency electricity for the hospital in the event of power failure including electricity for patients' intravenous pumps, electric beds, lighting, air conditioning, nurse call systems and emergency exit signs. This deficient practice could potentially affect 2 (#1, #2) of 2 current patients and any patient admissions; and

2) the hospital failing to ensure the emergency fire alarm was functioning correctly. This deficient practice could potentially affect 2 (#1, #2) of 2 current patients and any patient admissions; and

3) the hospital failing to ensure adequate air conditioning was provided to all 13 patient rooms; and

4) the hospital failing to ensure hot water was provided to all patients' bathrooms for showering and handwashing; and

5) failing to ensure the only bathroom with a shower area for patients was maintained to an acceptable level of quality by having no cold water to the sink, tar from a roof repair that had dripped onto the floor tiles, the toilet lid taped shut and an approximately 1 1/2 inch piece of the smooth surface in the shower being chipped exposing the surface beneath which could not be properly disinfected.

Findings:

1) The hospital failing to ensure the generator was working to provide emergency electricity for the hospital in the event of power failure.

An interview was conducted with S5FireMarshal (Louisiana Office of State Fire Marshal deputy) on 10/3/19 at 1:10 p.m. He reported that on 10/3/18 at 11:55 a.m., he had S7Maintenance attempt to perform a generator function test. He said his observation revealed the generator was unable to function due to the natural gas piping lacking complete installation. He said that according to S7Maintenance, the natural gas piping is expected to be fully installed in approximately two days. S5FireMarshal said in an interview at 1:00 p.m. with S6Asst, she explained she was not sure of the exact date, but she approximated a date of August 1, 2019 as the day the natural gas piping was disconnected to the generator. S5FireMarshal said the failure of the generator to function properly causes the dedicated electrical receptacle for all patient care rooms to lack electricity as well as all life safety emergency lighting throughout the facility to lack electrical power.

Review of the Generator Testing Log provided by the hospital revealed the last Monthly Building Load Test (running generator for 30 minutes) had been performed on 7/4/19.

Review of Patient #2's medical record revealed the patient had been admitted on 10/1/19 with admission diagnoses of Sepsis, Fournier's Gangrene to pelvic area with purulent, foul-odored drainage, Necrotizing Fasciitis, debility, and Diabetes Mellitus Type II with skin complications. Further review revealed Patient #2 was receiving Zosyn per intravenous infusion every 8 hours. Additional review revealed the patient was on contact isolation precautions.

Review of Patient #1's medical record revealed the patient had been admitted on 9/30/19 with admission diagnosis including Endocaditis and Sepsis. Further review revealed Patient #1 was receiving Vancomycin 750 mg in 250 milliliters of 5% Dextrose solution per intravenous infusion every 12 hours.

Observation of Patient #1's and Patient #2's rooms on 10/3/19 at 1:30 p.m. revealed Patient #1 and Patient #2 required electricity for their IV pumps, electric beds, air conditioning, lighting, and the nurse call feature. Observation of the hallways revealed exit signs illuminated by electricity. S8LPN verified the patients required the previously mentioned electrical items for their care.

In an interview on 10/3/19 at 1:20 p.m. with S5FireMarshal, he said the emergency exit signs in the hallways of the hospital did not have batteries and would not be illuminated without electricity.

In an interview on 10/3/19 at 2:00 p.m. with S1Adm, he said he did not have a time frame for when the generator would be repaired because the city would not turn on the gas to the building. He said he was hoping to have the generator repaired by tomorrow.


2) The hospital failing to ensure the emergency alarm was functioning correctly.

In an observation on 10/3/19 at 10:26 a.m., 2 local Fire Department vehicles were in the hospital parking lots with their lights flashing.

In an interview on 10/3/19 at 10:28 a.m. with S6Asst, she said the fire trucks were called because of a false fire alarm.

Based on an interview on 10/3/19 at 10:50 a.m. and documentation provided by S5FireMarshal, he reported on 10/3/19 at 10:15 a.m. he noticed the fire alarm panel had been silenced while demonstrating there was a non audible alarm and trouble indicator. S5FireMarshal said he walked the hospital and found no smoke detectors or pull stations activated to trigger the fire alarm. S5FireMarshall said he reset the fire alarm panel with the intention of clearing the silenced trouble and alarm indicators. After resetting the alarm, S5FireMarshall said the alarm became active causing the strobe lights and horns to activate throughout the facility. He said the local Fire Department arrived shortly at the hospital and in an interview with the Fire Chief, he said within the past month there had been numerous false alarms, some days at least four in one day. S5FireMarshal reported he advised the hospital staff to perform fire watch around the clock until the alarm panel had been repaired and was functioning properly.

In an interview on 10/3/19 at 2:00 p.m. with S1Adm, he said he was not sure when the alarm panel would be repaired.


3) The hospital failing to ensure adequate air conditioning was provided to all 13 patient rooms.

Observations of the hospital beginning on 10/3/19 at 10:35 a.m. revealed of the 13 patient rooms only rooms K, L and M had permanent working air conditioning units and room H had a temporary air conditioning unit. Patient #1 was observed in room H and Patient #2 was observed in room M. Patient #2 had 2 portable fans blowing on her and the room was felt to be noticeably warm by the surveyor.

In an interview on 10/3/19 at 10:42 a.m. with S6Asst, she said the air conditioner only worked in rooms K, L, M and the nursing station. She said the air had not been working for several weeks. She said the owner of the building was not fixing the air conditioning unit. She said the hospital had 1 patient in room H and 1 in room M. S6Asst said the patient in room H had a portable air conditioning unit.

In an interview on 10/3/19 at 11:51 a.m. with S3CNA, she said several patients have complained about the heat in the hospital.

In an interview on 10/4/19 at 3:30 p.m. with Patient #2, she said she had complained many times to the staff about it being extremely hot in her room. Patient #2 said she had complained to the nurse today but she did not know her name. She said the staff will turn up the fans but it does not help. Patient #2 said it was miserable but she guessed there was nothing she could do about it.


4) The hospital failing to ensure hot water was provided to all patients' bathrooms for showering and handwashing.

Observations of the hospital beginning on 10/3/19 at 10:35 a.m. revealed all of the patient bathrooms water temperatures were between 58-60 degrees Fahrenheit when the hot water knob on the sink was turned to the on position. Further observation revealed the only patient bathroom with hot water temperatures above 90 degrees Fahrenheit was in room K.

In an interview on 10/3/19 at 10:28 a.m. with S6Asst, she said there was a gas leak to the Hospital around Father's Day (June 16th) and since then there has been only been hot water in the kitchen and patient room K. She said all of the patients used room K to shower.



5) failing to ensure the only bathroom with a shower area for patients was maintained to an acceptable level of quality

In an observation on 10/3/19 at 11:15 a.m. of the bathroom of room K (only shower with hot water) the following was noted:
a) only 1 of 2 overhead lights functional
b) no cold water to the sink
c) black tar like substance had dripped from a pipe going into the ceiling onto the floor tiles on about half of the room
d) the toilet lid was taped shut
e) the shower was a preformed smooth surface insert with approximately 1 ½ inches of the smooth surface missing on the seat area exposing a fibrous section that could not be adequately disinfected.

In an interview with S6Asst on 10/3/19 at 11:20 a.m., she said the tar on the pipe and floor came from when they replaced the roof of the hospital which was several months ago. She said they taped the toilet shut so the patients could not use it. She said she did not know why the cold water was not working in the sink or how long the light had been broken.