HospitalInspections.org

Based on record review and interview, the hospital failed to ensure each physician/practitioner providing services in the hospital, including radiologists performing telemedicine (radiology) services, was credentialed and privileged, by the Governing Body for 1 (S4Rad) of 2 (S4Rad, S10Rad) radiologists' credentialing files reviewed for credentialing and privileging.

Findings:

A review of Patient # 5's Medical Record revealed an x-ray report for left ankle and an x-ray for left foot dated 05/12/2021 and electronically signed as read by S4Rad.

A review of Patient # 30's Medical Record revealed an x-ray report for left hip dated 04/26/2021 and electronically signed as read by S4Rad.

In an interview on 05/19/2021 at 11:40 a.m., S9Adm verified S4Rad has yet to be credentialed and privileged by the Governing Board.

Based on record review and interview, the hospital failed to ensure all patient medical records were promptly completed as evidenced by 1) failing to have completed medical records 30 days after discharge and 2) failing to ensure the medical record contained the Louisiana Organ procurement Agency (LOPA) Notification of referral and the authorization of Release and Remains form within 30 days.

Findings:

1) Failing to have completed medical records 30 days after discharge.
A review of the hospital Medical Staff Bylaws dated November 2020 revealed in part:
J. Discharge Summary
1. A discharge summary shall be entered into or dictated on all medical records as soon after discharge as possible but not to exceed 30 days following patient discharge.

On 05/18/2021 a review of following patient medical records failed to reveal a completed discharge summary within the medical record 30 days after discharge.
Patient #12 admitted 04/16/2021 at 7:30 pm and died 04/17/2021;
Patient #15 admitted 10/23/2020 and died 10/29/2020;
Patient #20 admitted 2/17/2021 and transferred 2/28/2021.

In an interview on 05/18/2021 at 3:35 p.m. S2DON verified Patient #12 and Patient #15's medical record failed to contain a documented discharge summary within 30 days after discharge.

In an interview on 5/18/2021 at 4:12 p.m. S7OT verified Patient #20's medical record failed to contain a documented discharge summary within 30 days after discharge.


2) Failing to ensure the medical record contained the Louisiana Organ procurement Agency (LOPA) Notification of referral and the authorization of Release and Remains form within 30 days.

A review of the hospital policy titled Patient Death last reviewed 04/2021 revealed in part:
2. Complete "Authorization of Release and Removal of Remains" form prior to release of body. Original copy stays with patient chart, copy sent with body to funeral home.

A review of the hospital policy titled Organ and Tissue Donation last reviewed 03/2020 revealed in part:
All deaths require completion of the Louisiana "Notification of Death" form or the hospital's equivalent death paperwork.

On 05/18/2021 a review of the following patient medical records failed to reveal the Louisiana Organ procurement Agency (LOPA) Notification of referral and the authorization of Release and Remains form within 30 days.
Patient #12 admitted 04/16/2021 at 7:30 pm and died 04/17/2021;
Patient #14 admitted 04/03/2020 and died 04/08/2020.

In an interview on 05/18/2021 at 3:35 p.m. S2DON verified Patient #12 and Patient #14's medical records failed to contain the Louisiana Organ procurement Agency (LOPA) Notification of referral and the authorization of Release and Remains form within 30 days.

Based on record review, observation, and interview the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality. This deficient practice was evidenced by failure of staff to record temperatures in the patient nourishment refrigerator 7 of 17 days in the current month, 2 of 17 days on the medication refrigerator and 2 out of 17 on the specimen refrigerator. The hospital also failed to ensure the staff maintained refrigerator temperatures within the acceptable range.
Findings:

Review of facility infection control policy titled "Refrigerator Guidelines," dated 03/2015, reveals, "Temperatures are to be recorded daily on Log(attached) by designated staff member," and "Temperature range for the refrigerator should remain between 34- 40 degrees Fahrenheit."

Nourishment Refrigerator
Record review on 05/17/2021 at 10:50 a.m. of the nourishment refrigerator log dated May 2021 revealed that the refrigerator temperature was not recorded 7 (05/01, 05/02, 05/08, 05/09, 05/10, 05/15,05/16) of 17 days of the current month. At 10:50 a.m. S2DON verified that the refrigerator log was not complete and verified someone was assigned to check it each day. Further review of the record revealed the temperature was consistently recorded as 41 degrees Fahrenheit, outside acceptable range. This was verified as outside of the acceptable range by S2DON on 05/19/2021 at 9:03 a.m.

Direct observation on 05/17/2021 at 10:50 AM revealed the temperature inside the patient nourishment refrigerator was 45 degrees Fahrenheit. Re-evaluation at 11:06 a.m. revealed an internal temperature of 45 degrees Fahrenheit. This temperature was verified by S9UnSec, who placed a new thermometer in the refrigerator. Re-evaluation at 11: 17 a.m. revealed an internal temperature of 50 degrees Fahrenheit. S9UnSec verified the temperature and indicated the temperature knob in the refrigerator had been adjusted to a level too cold that causes problems. S9UnSec stated that she had set it correctly. Re-evaluation at 12:45 p.m. revealed the temperature was 50 degrees Fahrenheit.

Direct observation on 05/18/2021 at 7:55 AM, the temperature was 41-42 degrees Fahrenheit. This was verified by S2DON who stated the problem was fixed and that the refrigerator was 41 degrees Fahrenheit.

In an interview on 05/19/2021 at 9:03 a.m., S2DON verified that the temperature in the patient nourishment refrigerator should be checked daily, should be between 36 and 40 degrees Fahrenheit and that 41 degrees Fahrenheit is outside of acceptable range.

Specimen Refrigerator
Review of a log titled Specimen Refrigerator Log 2021, Month May 2021, revealed a notation at the top of the log that the temperature must be between 36-40 degrees (Fahrenheit).

In an observation on 05/17/2021 at 10:55 a.m. in the medication room revealed a specimen refrigerator. The temperature on the inside thermometer was 42 degrees Fahrenheit. On the refrigerator log for the month, the temperatures were listed at 41 degrees on 05/02, 05/03, 05/04, 05/10, 05/11, and 05/12. The temperatures were listed at 42 degrees on 05/01, 05/06, 05/07, 05/08, 05/09, 05/14, 05/15, and 05/16. Further review revealed the temperatures were not documented on 2 (05/05,05/13) of 17 days of the current month.

In an interview on 05/19/2021 at 10:07 a.m., S2DON verified that the temperature in the patient specimen refrigerator should be checked daily and should be between 36 and 40 degrees Fahrenheit and that 41 and 42 degrees Fahrenheit is outside of acceptable range.


Medication Refrigerator
Review of a Medication Refrigerator Log for May revealed no temperatures were documented on 2 (05/16, 05/17) of 17 days of the current month.

In an interview on 05/19/2021 at 10:15 a.m., S2DON verified that the temperature in the patient medication refrigerator should be checked daily and placed on the log.

Based on observations and interviews, the infection control officer failed to ensure the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented in accordance with hospital policy and acceptable standards of practice. This deficient practice was evidenced by the hospital:
1) failing to ensure staff followed proper hand hygiene before and during patient care;
2) failing to ensure clean equipment was not stored in a dirty environment, the laundry room and the linen stored in a closet within the laundry room was covered;
3) failing to ensure upholstered equipment was not torn preventing them from being thoroughly disinfected; and
4) failing to ensure all Occupational Therapy equipment was clean and free from rust.

Findings:
1) Failing to ensure staff followed proper hand hygiene before and during patient care;
An observation of S8LPN performing blood glucose checks revealed she:
- Cleaned the bedside table with Cavi Wipes, removed her gloves, did not sanitizer her hands and placed clean items on the beds side table;
- She entered the patient's room identified the patient by checking the patient's armband, removed her gloves and failed to sanitize her hands, cleaned the glucometer, removed her gloves and applied clean gloves without sanitizing her hands.
- After completing the blood glucose check S8LPN washed her hands and then obtained a paper towel from the dispenser in the patient's room and wiped down the wet counter top where she just washed her hands and proceeded to move the cart with her supplies down the hall without sanitizing her hands.
- S8LPN proceeded to another patient room and verified the patient without wearing gloves or sanitizing her hands.
- S8LPN then obtained gloves from inside the patient room and placed them on her hands without sanitizing her hands.
- S8LPN then proceeded to remove the glove on her left hand, picked up the glucometer strip bottle and obtained a new strip with her ungloved hand and did not sanitize. She the replaced the glove on her left hand and completed the glucometer check.

In an interview on 05/18/2021 at 11:25 a.m. S8LPN verified the above information and stated she failed to sanitize her hands between changing gloves.

2) Failing to ensure clean equipment was not stored in a dirty environment, the laundry room and the linen stored in a closet within the laundry room was covered;

A review of the hospital policy titled: Laundry and Linen Requirements revealed in part:
C. Clean linen is covered during transport and storage.

An observation of the laundry room revealed 1 IV pump, 2 feeding pumps and 2 O2 concentrators and 1 bedside commode covered with clear plastic and 2 uncovered bedside tables.
Further observation revealed the clean linen door within the laundry room was open and the linen was stored uncovered on open shelves.

In an interview on 05/17/2021 at 10:55 a.m. Don verified the items stored in the laundry room were clean and ready for patient use. She also verified the linen was uncovered and ready for patient use.


3) Failing to ensure upholstered equipment was not torn preventing them from being
thoroughly disinfected.

In an observation at 05/17/2021 at 10:35 a.m. of the therapy room revealed the upholstery was torn on the therapy table and 3 wedges preventing them from being adequately disinfected.

In an interview on 05/19/2021 at 9:05 a.m. with S2DON, she verified the torn upholstery on the physical therapy table and wedges would prevent them from being disinfected.

4) Failing to ensure all Occupational Therapy equipment was clean and free from rust.
An observation of the OT room revealed the arm bike and rickshaw were noted to be rusty and dirty.
In an interview on 05/17/2021 at 9:30 a.m. Mai Lu, OT verified the above information and stated the staff was responsible for cleaning between patient use.














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The hospital failed to ensure a person was appointed as the leader of the antibiotic stewardship program and failed to develop and implement a hospital-wide antibiotic stewardship program, based on nationally recognized guidelines, to monitor and improve the use of antibiotics.

Findings:

Review of the hospital policy titled Antibiotic Stewardship Program revealed the following in part:
Purpose: The purpose of the antimicrobial stewardship is to promote the appropriate use of antimicrobials by selecting the appropriate agent, dose, duration and route of administration in order to improve patient outcomes, while minimizing toxicity and the emergence of antimicrobial resistance.

In an interview on 05/18/2021 at 10:16 a.m. with S2DON, she said she was the infection control officer for the hospital. She said the hospital did not do an antibiotic stewardship as of now, but the pharmacist was going to help put that in place. She said the hospital did have a policy but could not provide any documentation of data reviewed or collected.