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Based on record review and interview, the hospital failed to ensure the Quality Assurance/Performance Improvement program measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of services and quality of care.
Findings:

Review of the hospital's Annual Performance Improvment Plan revealed in part that the hospital will collect data to identify priorities including high volume, high risk and problem prone areas. Standards are selected by ancillary departments and monitored monthly for safety and quality of services provided. The hospital utilizes a PI tracking tool available to all departments to report their findings.


On 08/10/16 at 1:35 p.m., S5RN provided the spreadsheet which contained the performance improvement indicators for the hospital. Review of the spreadsheet revealed it was dated 2015. Interview with S5RN at that time revealed that the Director of Quality for the hospital had resigned approximately 2-3 weeks ago and she was filling in as the interim Director of Quality Management. She stated that she was having a hard time locating all of the QA information. She further stated that the prior director must have forgotten to change the date on the quality indicators speadsheet.

Further review of the quality indicators spreadsheet revealed the following indicators were chosen, but no data had been collected and documented for the year of 2016 (but spreadsheet was dated 2015): restraints, patient safety, patient rights, organ donation, patient nutrition, case management, health information management, nursing, blood use, human resources, emploee health, medical staff, safety, security, fire prevention, hazardous materials, medical equipment, utilities and emergency management.

Interview with S5RN on 08/10/16 at 4:15 p.m. confirmed that she was unable to locate any data that had been collected related to the above quality indicators chosen by the hospital. S5RN confirmed that the hospital was not implementing its QAPI program.

Based on record review, observation and interview, the hospital failed to ensure an RN supervised and evaluated the nursing care for each patient as evidenced by:

1) The RN failed to ensure that wound care treatments were performed as ordered by the physician for 3 (#9, #10, #13 ) of 3 patient records reviewed for wound care;

2) The RN failed to ensure that assessments were performed of the drainage from a patient's wound VAC for 1 (#25) of 1 patient records reviewed with physician orders for a wound VAC;

3) The RN failed to ensure that patients were assessed prior to and after administration of PRN medications for 2 (#12 , #25) of 4 patient records reviewed for PRN medication administration;

4) The RN failed to ensure that physician orders were implemented & documented by failing to have documented evidence of daily weights in the medical record for 2 (#10, #13) of 2 current patient records reviewed out of a total sample of 30 patients.
Findings:


1) The RN failed to ensure that wound care treatments were performed as ordered by the physician for 3 ( #9, #10 #13) of 3 patient records reviewed for wound care

Patient #9
Review of the medical record for patient #9 revealed a physician telephone order dated 07/29/16 to apply Zinc Oxide four times daily to the patient's partial thickness wound of the natal cleft. Review of the patient's treatment TAR from 07/30/16 to 08/08/16 revealed no documented evidence that the patient received the treatment four times daily as ordered.

On 08/09/16 at 10:00 a.m., S2CNO reviewed the patient's record and confirmed that there was no documented evidence that the treatments were performed as ordered by the physician.

Patient #10
Review of the medical record for Patient #10 revealed he was admitted to the hospital on 04/12/16 with the diagnoses of Renal failure ( HD),S/P Respiratory Failure (tracheostomy capped), Anemia, COPD, CHF, HTN, and Diabetes.

Review of the admission orders dated 04/12/16 for Patient #10 revealed daily wound care (PEG site). Review of Patient #10's TARs revealed no documented evidence the PEG site care was performed on the following dates: 06/01, 06/07, 06/10, 06/11, 06/16, 06/21; 07/05, 07/08, 07/10, 07/23, 07/24/2016.

Patient #13
Review of the medical record for Patient #13 revealed she was admitted to the hospital on 07/03/16 with the diagnoses of Sepsis, ARF, Hypoglycemia, Sacral Decubitus, Recent CVA, and Pneumonia.
Review of the Physician's orders for Patient #13 dated 07/04/16 revealed an order (apply miconazole 2& powder, foam cleaner pat dry) for groin & peri area bid & prn. Review of Patient #13's TARs revealed treatment performed only once a day on the following dates: 07/05, 07/07, 07/08, 07/09, 07/17, 07/19, 07/22, 07/24, 07/28; 08/01, 08/04, 08/05. There was no documented evidence of treatment being performed on the following dates: 07/13, 07/14, & 08/02/2016.

In an interview on 08/09/16 at 12:30 p.m., S17LPN confirmed after review Patient#10's & Patient #13's TARs there was no documented evidence that the treatments were performed as ordered by the physician.

2) The RN failed to ensure that assessments were performed of the drainage from a patient's wound VAC for 1 (#25) of 1 patient records reviewed with physician orders for a wound VAC

Review of the hospital policy titled, Wound Vacuum-Negative Pressure Wound Therapy, presented as current policy by S2CNO revealed in part: Monitor and document (wound) fluid output on intake and output record every 12 hours.

Review of the medical record for patient #25 revealed the patient was admitted to the hospital on 07/01/16 with a diagnosis of left lower extremity cellulitis with orders for a wound VAC. Further review revealed physician orders dated 08/01/16 to change the wound VAC dressing every Monday and Thursday.

Review of the daily nursing assessment forms revealed no documented evidence that the wound drainage output was assessed and measured every 12 hours. Review of the nursing assessment form dated 08/09/16 at 7:00 a.m. revealed under the section titled, Wound Care, the nurse documented there was no drainage from the left lower extremity.

Review of the nursing assessment forms dated 08/04/16 - 08/07/16 revealed no documentation of an assessment regarding the patient's wound drainage. There was no output amounts documented. The notes revealed "Wound VAC in progress".

Review of the Wound Assessment and Documentation forms dated 08/01/16 and 08/08/16, completed by S14Wound Care RN, revealed no documented assessments of the wound drainage coming from the patient's wound VAC.

On 08/10/16 at 9:30 a.m., interview with S15RN revealed that the nurses do not measure and document the amount of drainage coming from the patient's wound VAC. She further revealed that the nurses should assess the color of the wound drainage on each shift. At that time, S15RN reviewed the patient's nursing assessment forms for the past week and confirmed she was unable to locate documentation that the patient's wound drainage was assessed every shift.

On 08/10/16 at 9:45 a.m., observation revealed the nurses station received a call from a staff member in the patient's room stating that the wound VAC canister was full of drainage and needed to be changed. At that time, S15RN stated that the patient's wound drains large amounts.

On 08/10/16 at 12:00 p.m., interview with S2CNO revealed that assessments of the patient's wound drainage, including amount, should be performed every shift. He further confirmed that this was not being performed.


3) The RN failed to ensure that patients were assessed prior to and after administration of PRN medications for 2 (#12 , #25) of 4 patient records reviewed for PRN medication administration

Patient #12
Review of patient #12's MAR dated 08/08/16 at 9:00 p.m. revealed the patient received Benadryl 25mg PRN. There was no documented assessment prior to giving the Benadryl or after administration of the medication to assess for effectiveness.

Review of patient #12's MAR dated 08/07/16 at 8:30 a.m. and 2:45 p.m. revealed the patient received Acetominophen 650mg PRN. There was no documented assessment prior to giving the doses of Acetominphen or after administration of the medication to assess for effectiveness.

On 08/08/16 at 12:45 p.m., S8RN reviewed patient 12's record and confirmed there was no documented evidence that assessments were performed prior to or after administering the above medications.

Patient #25
Review of patient #25's MAR dated 08/02/16 at 8:45 a.m. revealed the patient received a PRN dose of Hydrocodone 7.5mg for pain. On 08/03/16 at 4:00 p.m. and 7:49 p.m. the patient received two doses of the Hydrocodone 7.5 mg for pain. There was no documented assessment prior to giving the doses of Hydrocodone or after administration of the medication to assess for effectiveness.

On 08/10/16 at 2:00 p.m., interview with S2CNO stated that all patients who receive PRN medications should have an assessment performed prior to administration. He further stated that an assessment should be performed approximately 30 minutes after administration to ensure the medication was effective.


4) The RN failed to ensure that physician orders were implemented & documented daily weights for 2 (#10, #13) of 2 current patient records review out of total sample of 30 patients.

Review of the Hospital's Policy & Procedure titled " Nursing Assessment, Daily" presented by S1CEO as being current (12/14) read in part: The Daily Nursing Assessment flowsheet provides the historical and empirical data to support the nursing diagnosis and process. It provides a uniform system for documentation of a patient's condition based on the nursing process. It is a legal document that supports and guides nursing action within a 24 hour period. Evaluation a. A registered nurse supervises and evaluates the nursing care for each patient. Patient Assessment A. 2. Vital signs, intake, output, personal care, activity, and safety precautions are to be recorded as appropriate to the patient status and care.

Patient #10
Review of the medical record for Patient #10 revealed he was admitted to the hospital on 04/12/16 with the diagnoses of Renal failure ( HD),S/P Respiratory Failure (tracheostomy capped), Anemia, COPD, CHF, HTN, and Diabetes.

Review of admission orders for Patient #10 revealed on 04/12/16, an order for daily weight.
Further review of the vital signs record revealed no documented weights on the following dates: 06/21, 06/23, 06/25-27; 07/08, 07/15, 07/17, 07/18, 07/21, 07/23,07/25, 07/27, 07/30; 08/05/2016.

Patient #13
Review of the medical record for Patient #13 revealed she was admitted to the hospital on 07/03/16 with the diagnoses of Sepsis, ARF, Hypoglycemia, Sacral Decubitus, Recent CVA, and Pneumonia. Review of the admission orders dated 07/03/16 revealed the physician ordered for the patient to be weighed daily; however, the weight failed to be documented for 08/03/16.

In an interview on 08/09/16 at 10:35 a.m., S8RN confirmed that the weights for Patient #10 & Patient #13 were not documented in the medical records.

S8RN returned at 11:40 a.m. on 08/09/16, with 2 pages (listed all patients) of weights (weight board) for the dates 07/31/16-08/09/16 and stated all weights were documented on the weight board by CNA staff. S8RN confirmed the weights should have been recorded in the medical records.


31206

Based on record review and interview, the hospital failed to ensure drugs and biological's were prepared and administered in accordance with the orders of the practitioner responsible for the patient's care and as directed by hospital policy for 2 (#9, 10) of 3 patients (#9, #10, #13) reviewed for insulin administration per sliding scale.
Findings:

Patient #9
Review of the medical record for Patient #9 revealed the patient was admitted to the hospital on 07/28/16 with physician orders for capillary blood glucose checks before meals and at bedtime (6AM, 11AM, 4PM, 9PM) with Humalog insulin per sliding scale. The sliding scale included the following:
150-200 = 2 units
201-250 = 4 units

Review of the MAR dated 08/02/16 at 4:00 p.m. revealed there was no documented evidence that the patient's blood glucose was checked. Review of the MAR dated 08/02/16 at 9:00 p.m. revealed the nurse documented the patient's blood glucose was 150. There was no documented evidence in the record that the sliding scale insulin was administered as ordered.

Review of the MAR dated 08/03/16 at 6:00 a.m. revealed there was no documented evidence that the patient's blood glucose was checked.

Review of the MAR dated 08/05/16 at 4:00 p.m. revealed the nurse documented the patient's blood glucose was 161. There was no documented evidence in the record that the sliding scale insulin was administered as ordered.

On 08/09/16 at 10:00 a.m., S2CNO reviewed the patient's record and confirmed that there was no documented evidence that the patient's blood glucose was checked and sliding scale insulin administered as ordered by the physician.

Patient #10
Review of the medical record for Patient #10 revealed the patient was admitted to the hospital on 04/12/16 with diagnoses including diabetes mellitus. Admission orders revealed the physician ordered capillary blood glucose checks before meals and at bedtime with Humulin R sliding scale insulin subcutaneous as needed. The order revealed the following sliding (04/13/15) scale:
61-200 = 0 units
201-250 = 2 units
251-300 = 4 units
301- 350 = 6 units
351 -400 = 8 units
> 400 = 10 units
If BS less than 60 give one amp D50 and call Dr.

Review Patient #10's MARs revealed the following:
08/02 - BS @ 6:00 a.m. 209 - no documentation of insulin administrated.
08/05- BS @ 6:00 a.m. 234 - no documentation of insulin administered.
08/07- No documented BS @ 4:00 p.m.

In an interview on 08/09/16 at 9:30 a.m., S7RN confirmed after reviewing the MARs for Patient #10, the Sliding Scale was not followed as ordered and on 08/07/16, there was no documented evidence that a capillary blood sugar was performed at 4:00 p.m.




17450

Based on record review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable standards of practice, consistent with state law. This deficient practice was evidenced by failing to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist, before the first dose was dispensed, for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications.
Findings:

Review of the Louisiana Administrative Code, Professional and Occupational Standards,
Title 46: LIII, Pharmacist, Chapter 15, Hospital Pharmacy, §1511. Revealed in part:
Prescription Drug Orders
A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial
dose of medication, except in cases of emergency.

Review of the hospital policy titled, Automated Dispensing: Profiles and Overrides (Policy 130-27-054.2), revealed in part: Medications shall only be dispensed using the override function (of the automated dispensing unit) when waiting for a prospective medication review by a pharmacist could adversely affect the patient's clinical status (such as an emergency situation). A pharmacist must review all medication orders prior to the removal of any medications in the automated dispensing unit with the exception of emergency medications or any medications needed to maintain a disease state or would compromise the patients' outcome.

On 08/09/16 at 2:15 p.m., interview with S16Pharmacist revealed that the hospital pharmacy is not open 24 hours per day. She stated that usual pharmacy hours are 7:30 a.m.-4:00 p.m. on Monday thru Friday and 7:30 a.m.-12:30 p.m. on the weekends. When asked the procedure for performing first dose reviews of medications ordered after pharmacy hours, she stated that two clinicians review the order and a pharmacist would do a retrospective first dose review within 24 hours of the first dose being administered, usually the next morning. She stated that clinicians included nurses (for nursing medications) and respiratory therapists (for respiratory medications).

On 08/10/16 at 2:00 p.m., interview with S2CNO revealed that nurses perform the first dose review for medications that are ordered after the hospital pharmacy has closed. He further stated that the pharmacist would review all medication overrides the next morning and perform a retrospective review.

Based on observation, interview, and record review the hospital dietary staff failed to demonstrate proper food handling practices by failing to obtain temperatures of cooked foods prior to serving patients. This deficient practice had the potential to affect the 40 patients located at the main campus on the census during the time of the survey. Findings:

During the environmental tour of the hospital on 08/08/16 at 9:30 p.m. patient R1 voiced issues of cold temperatures of food being served at meal times.
Observation on 08/09/16 at 6:45 a.m. of the breakfast service revealed S12Cook plating food from the steam table to trays placed in a warmer by S11Cook. At approximately 7:10 a.m. surveyor asked S12Cook if temperatures had been taken prior to plating food on the patient trays, and she had stated that she forgot. This surveyor had asked S9DM for the Temperature Log Record and was shown a blank record document for Breakfast on 08/09/16. S9DM obtained a thermometer and checked the eggs on the steam table and obtained a temperature of 122 degrees. S9DM told surveyor that there was something wrong with the thermometer and obtained a second thermometer and checked the eggs on the steam table and did not receive an acceptable temperature and stated that the second thermometer was also bad. The food trays were placed in a warmer and transported to the central nurse ' s station for hall 100, 200, and 300.
Review of the hospital policy titled Recording Prepared Food Temperatures, document Number #150-03-018.1, revised date June 2007 revealed in part: It is the policy of the Food and Nutrition Services Department that all hot foods on the patient tray line and cafeteria line be checked for correct temperatures prior to serving and the food will be assessed for quality and appeal. A. Prior to serving, the temperature of all hot food will be checked using a food specific thermometer. B. The temperature of all hot foods will be recorded on the Food Temperature Evaluation Chart. C. If temperature of food is below 140 degrees Fahrenheit, it will be reheated prior to serving to meet standards, unless otherwise specified by the state.
Interview on 08/10/16 at 8:10 a.m. with S1CEO confirmed that S9DM was actually the Dietary Supervisor. S1CEO further stated the previous Dietary Manager had just resigned this past Friday 08/05/16 and S9DM was actually acting Dietary Manager.
Interview on 08/10/16 at 11:15 a.m. with S10Dietician confirmed that all dietary staff were annually trained on proper food techniques and confirmed the Breakfast food should have been reheated to the proper temperature before being served to the patients.

Based upon observations and interviews, the hospital failed to ensure the Infection Control Program was implemented related to the provision of a sanitary environment. This was evidenced by 1) the failure to appropriately clean patients rooms after discharge, and 2) failure to clean the accu-check container after blood was observed on the handle.
Findings:

1) On 08/08/16 at 1:15 p.m., observation of room a revealed there was no patient in the room and the bed was made. Interview with a housekeeper on the hall at that time revealed the room was clean and ready for a new patient. Further observations of the room revealed an old electrode sticker was stuck to the front of the nurse call bell/television remote. A suction canister was observed on the wall with measuring marks and dates written on the canister with a black marker. The dates written on the canister were 7/21, 7/22 and 7/23.

On 08/08/16 at 1:30 p.m., observation of room c with S5RN and S18Director of Plant Operations revealed the following: reddish brown drips down the wall beside the bed, a thick brown substance dripped down the front leg of the bedside chair and a brown substance on the nurse call bell. At that time, S5 and S18 confirmed the room was in need of further cleaning.

2) Observations on 8/10/16 at 1:05 p.m. revealed the plastic container containing the Accu-Check machine which was located at the nursing station on hall 2, had blood on the handle. Interview with S19RN and S20RN revealed when asked how the bloody handle should be cleaned, the staff did not know which disinfectant to use, the orange top wipes (contains a bleach solution) or the blue top wipes (antiviral/antibacterial). Further observations on 8/10/16 at 3:10 p.m. revealed these two accu-check machines had the backs taped to the front in order to hold the machine together. The accu-check machines could not be adequately disinfected with the tape in place.


17450