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Based on record review and interview, the hospital failed to ensure the patient's right to personal privacy. This deficient practice was evidenced by the hospital's failure to obtain documentation in 3 (#1 - #3) of 3 (#1 - #3) medical records reviewed related to the patient's opportunity to agree, prohibit, or restrict the disclosure of protected patient personal information.
Findings:

A review of hospital policy, "Delivery of Services: Medical Records," Policy 02-01-01, adopted 03/2017 with no revisions, revealed in part: "Confidentiality: All patient records and information shall be safeguarded to ensure patient confidentiality in accordance with federal and Louisiana state laws and regulations."

A review of hospital policy, "Delivery of Services: Medical Records-General," Policy 02-01-02, adopted 03/2017 with no revisions, revealed in part: "Confidentiality: The patient record is a confidential document and will only be released with authorized written consent."

A review of Patient #1 - #3's medical records did not reveal documentation of the patient opportunity to agree, prohibit, or restrict the disclosure of protected patient personal information.

In an interview on 12/09/2024 at 2:15 PM, S11LPN confirmed the above mentioned findings.

In an interview on 12/10/2024 at 10:45 PM, S1Adm confirmed the above mentioned findings and further confirmed the hospital does not have procedure in place to document at patient's opportunity to agree, prohibit, or restrict the disclosure of protected patient personal information.

Based on record review and interview, the hospital's Governing Body failed to ensure the Quality Assurance and Performance Improvement (QAPI) Program reflects the complexity of the hospital's organization and services, which includes all hospital departments and services, including services furnished under contract or arrangement, within its QAPI Program. This deficient practice was evidenced by the hospital failing to ensure indicators related to Safety and Risk Management, Plant Operations and Preventative Maintenance were tracked and analyzed to ensure quality improvement and patient safety.
Findings:

A review of hospital policy, "Quality Assessment & Performance Improvement," Policy 02-02-01, Adopted 03/2017 and no revisions, revealed in part: "Policy: The hospital has an effective, written and ongoing hospital-wide program designed to assess and improve the quality of patient care. The Performance Improvement Plan is approved by the Governing Board and is overseen ultimately by the Governing Body via reports from the Performance Improvement Committee. Procedure: The Performance Improvement Committee will collect indicator data from the designated department heads on a monthly basis, the committee chair (DON), will compile the data into a report for the Administrator to present to the Medical Staff. The Committee will make recommendations for improving patient care, addressing problem indicators (corrective action), and overall improvement of services. 4. Indicators will be evaluated at least annually and revised as needed. Indicators are set based on identified areas of patient care that need improvements or as corrective action to identified problems. All hospital departments and clinical areas will be included in the tracking and monitoring process, as indicators are identified and needed. All hospital department and clinical areas will be included in the tracking and monitoring process, as indicators are identified and needed. Administration, Nursing, HIM/Medical Records, Pharmacy, Plant Operations: Housekeeping, Safety and Risk Management.Safety and Risk Managment inclucdes-falls, med errors, employee injuries, fire and disaster drills, inspections and physical plant issues."

A review of the hospitals incident reports revealed the following fall data: 07/2024 - 1 fall, 08/2024 - 2 falls, 09/2024 - 2 falls, 10/2024 - 6 falls, 11/2024 - 2 falls.

A review of PI Committee Meeting Minutes from 04/2024, 07/2024, and 10/2024 did not reveal indicators related to Plant Operations or Safety and Risk Management- falls and inspections.

In an interview on 12/10/2024 at 10:00 AM, S1Adm confirmed the above mentioned findings and confirmed the facility should be tracking and analyzing indicators from all departments and services of the hospital.

Based on observation and interview, the hospital failed to maintain the condition of the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients were assured. This deficient practice was evidenced by:
1) Failure to ensure routine and preventative maintenance and testing activities are performed;
2) Failure to ensure lighting sources were in working order; and
3) Ceiling tiles sagging and currently damp to touch, ceiling tiles containing brownish colored staining and a ceiling tile missing.
Findings:

1) Failure to ensure routine and preventative maintenance and testing activities are performed

A review of facility policy, "Physical Environment of Facility," Policy 00-04-01, adopted 03/2017, revealed in part: "Electrical Appliances: Any and all electrical appliances brought into the hospital must be inspected and tagged by Plant Operations personnel prior to any use. New Equipment: Any new mechanical or electrical equipment will be logged into the inventory record of Plant Operations and tagged as approved for useas indicated above. The inventory record will include a maintenance schedule for safety inspections and calibration and a reporting mechanism for reporting of malfunctions. Calibrations of electrical equipment will be done and documented at least annually, unless manufacturer recommendations are different. All equipment will be serviced at least annually."

Observations during a facility walk through on 12/09/2024 from 9:55 AM to 11:15 AM revealed the following equipment: a) Cardinal Scale 708 (patient scale) in Room "l" with an attached label indicating its last preventative maintenance check was perform 10/2022 by BES, LLC; b) Welch Allyn Vital Sign Monitor on a rolling cart in the nurses' station which appeared to be non-functioning and there was no label attached to indicate the monitor was on a preventative maintenance schedule; c) Phillips Automatic Defibrillator (AED) located on the crash cart in the nurses' station with no indication the monitor was on a preventative maintenance schedule. A request was made for a preventative maintenance schedule for all medical equipment available for patient use in the hospital and no documentation was provided by the hospital.

In an interview on 12/09/2024 and present during the hospital walk-thru, S2DON confirmed the above mentioned findings and also indicated she would defer the answer of a preventative maintenance program to the S1Adm. S2DON further confirmed the AED was just received by the hospital and placed in service with a new battery and new chest pads. S2DON was unaware if the equipment had been placed on the facility's inventory record.

In an interview on 12/09/2024 at 11:00 AM, S3LPN and S8LPN both confirmed the Welch Allyn Vital Sign Monitor was not functioning.

In an interview on 12/09/2024 at 11:15 AM, S1Adm confirmed the Welch Allyn Vital Sign Monitor was not functioning, she indicated she was unaware the vital sign monitor was not functioning, the hospital currently does not have an ongoing preventative maintenance program and she did not have an inventory of the hospital's medical equipment available for patient use.

2) Failure to ensure lighting sources were in working order

Observations during a facility walk through on 12/09/2024 from 9:55 AM to 11:15 AM revealed fluorescent light fixtures non-functioning in Room "b" entry area and above the patient bed in Room "i."

In an interview on 12/09/2024 and present during the hospital walk-thru, S2DON confirmed the above mentioned findings.

3) Ceiling tiles sagging and currently damp to touch, ceiling tiles containing brownish colored staining and a ceiling tile missing

Observations during a facility walk through on 12/09/2024 from 9:55 AM to 11:15 AM revealed a ceiling tile in the bathroom of Room "h" that appeared to be sagging and currently wet. (Note: the hospital's location was currently receiving rain and had received rain during the prior 2 days). Other observations revealed ceiling tiles with brown stains resembling water markings in Room "d" - 4 ceiling tiles in the main bedroom, Room "f" - 3 ceiling tiles in the main bedroom, Room "j" - 2 ceiling tiles in the restroom, and Room "k" - 4 ceiling tiles and 1 ceiling tile missing.

In an interview on 12/09/2024 and present during the hospital walk-thru, S2DON confirmed the above mentioned findings.

Based on observation, record review and interview, the hospital failed to ensure supplies were maintained to ensure an acceptable level of safety and quality. This deficient practice was evidenced by:
1) Failure to ensure an automatic blood pressure monitor was intended for hospital setting use; and
2) Failure to ensure expired supplies were not available for patient use.
Findings:

1) Failure to ensure an automatic blood pressure monitor was intended for hospital setting use

Observations during a facility walk though on 12/10/2024 at 11:15 AM revealed an Omron Blood Pressure Monitor 3 Series, Model BP7150, on the vital sign cart and available for patient use.

A review of the Omron Blood Pressure Monitor's original manufacturer's box and the instruction manual revealed this blood pressure monitor's intended use was for home use only.

In an interview on 12/10/2024 at 11:15 AM, S3LPN and S2DON confirmed the above mentioned findings and further confirmed the facility had purchased the monitor on 12/09/2024.

2) Failure to ensure expired supplies were not available for patient use

Observations during a facility walk through on 12/09/2024 from 9:55 AM to 11:15 AM revealed wall mounted soap and hand sanitizer dispensing stations with expired contents. The dispenser's locations and the expiration date of the contents were:
a) Main entry hallway had 4 stations with Medline Spectrum Hand Sanitizer 1 liter containers, expired 11/2022 and 1 station with Medline Spectrum Hand Sanitizer 1 liter container expired 04/2024;
b) Medline Hand Soap dispenser with 1 Liter containers located in patient restrooms: Room "b" expired 11/28/2024 and Room "f' expired 10/2023; and
c) Medline Hand Soap dispenser with 1 Liter containers located at the hand sink in the patient rooms: Rooms "b" and "i" expired 10/2023, Rooms "f" and "j" expired 05/2023 and Room "h" expired 02/2023.

In an interview on 12/09/2024 and present during the hospital walk-thru, S2DON confirmed the above mentioned findings.