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Based on interviews, the hospital failed to ensure that patients received care in a safe setting as evidenced by failing to ensure all new staff received education and training prior to providing patient care.

Findings:

In an interview on 09/02/2022 at 9:40 a.m. S8RN verified she had not yet started any orientation paperwork, had not reviewed any policies or procedures and she was in orientation on the unit. S8RN stated she was responsible for completing some of the IV medications, PICC Lines and had already completed a physical assessment on Patient #3, #5 and #8.

In an interview on 09/02/2022 at 9:50 a.m. S2DON verified S8RN had not completed any orientation paperwork to include review of policies and procedures nor had she completed a competency evaluation on S8RN.

Based on record reviews and interviews, the hospital failed to ensure that verbal/telephone orders were used infrequently and was not a common practice as evidenced by the frequent use of verbal/telephone orders by the admitting physicians for 5 (#1-5) of 5 (#1-5 records reviewed for verbal/ telephone orders.

Findings:

A review of Patient #1's Medical Record revealed verbal orders on the following dates: 08/20/2022, 08/22/2022, 08/24/2022, 08/25/2022, 08/27/2022 and 08/29/2022.

A review of Patient #2's Medical Records revealed verbal orders on the following dates: 08/20/2022, 08/22/2022, 08/23/2022, 08/24/2022, and 08/25/2022.

A review of Patient #3's Medical Record revealed verbal orders on the following dates: 08/24/2022, 08/25/2022, and 08/30/2022.

A review of Patient #4's Medical Record revealed verbal orders on eh following dates: 08/20/2022, 8/21/2022, 08/22/2022, 08/24/2022, and 08/25/2022.

A review of Patient #5's Medical Record revealed verbal orders on the following dates: 08/20/2022, 08/23/2022, 08/24/2022, 08/25/2022 and 08/29/2022.

In an interview on 09/02/2022 at 12:50 p.m. S2DON verified all orders reviewed were verbal orders. She also verified that she did not see any orders that were not verbal orders.

Based on record review and interview, the hospital failed to ensure all hospital orders were signed, dated and timed by the physician or licensed practitioner. This deficient practice was evident for 5 (#1-5) of 5 (#1-5) open medical records reviewed for unsigned, dated and timed orders.

Findings:

A review of hospital policy titled Nursing, Signing Verbal Orders revealed in part:
All telephone and verbal physician orders will be signed in a timely manner. The method of authentication of orders will comply with the Medical Staff By Laws Rules and Regulations. A system of tracking will be established to ensure orders are signed within established time frames.
Procedures:
All verbal orders will be signed within 72 hours of documentation in the patient's medical record.

On 09/02/2022 a review of Patient #1's Medical Record revealed verbal admit orders were written on 08/19/2022 and other verbal orders on the following dates: 08/20/2022., 08/22/2022, 08/24/2022, 08/25/2022, 08/27/2022 and 08/29/2022 were not signed by the physician or licensed practitioner.

On 09/02/2022 a review of Patient #2's Medical Records revealed verbal admit orders were written on 08/18/2022 and other verbal orders on the following dates: 08/20/2022, 08/22/2022, 08/23/2022, 08/24/2022, and 08/25/2022 were not signed by the physician or licensed practitioner.

On 09/02/2022 a review of Patient #3's Medical Record revealed the verbal orders on the following dates: 08/24/2022, 08/25/2022, and 08/30/2022 were not signed by the physician or licensed practitioner.

On 09/02/2022 a review of Patient #4's Medical Record revealed the verbal orders on the following dates: 08/20/2022, 8/21/2022, 08/22/2022, 08/24/2022, and 08/25/2022 were not signed by the physician or licensed practitioner.

On 09/02/2022 a review of Patient #5's Medical Record revealed the verbal orders on the following dates: 08/20/2022, 08/23/2022, 08/24/2022, 08/25/2022 and 08/29/2022 were not signed by the physician or licensed practitioner.

In an interview on 09/02/2022 at 12:50 p.m. S2DON verified the above mentioned verbal orders were not signed by the physician or licensed practitioner within the hospital's required 72 hours.

Based on interview, record review and observation, the hospital failed to meet the requirements of the Condition of Participation for Pharmaceutical Services as evidenced by:

1) The hospital failed to ensure the pharmacy services met the needs of the patient 24 hours a day 7 days a week by not having medications available for administration after hours for 10 (#1-10) of 10 (#1-10) current patients and all potential admits. (See findings A- 493)

2) The hospital 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. (See findings A- 500)

Based on record review, pharmacy contract, and interviews, the hospital failed to ensure the pharmacy services met the needs of the patient 24 hours a day 7 days a week by not having medications available for administration after hours for 10 (#1-10) of 10 (#1-10) current patients and all potential admits.

Findings:

A review of the Pharmacy Provider Agreement between Pharm A and Southeast Regional Medical Center reveals in part:
Whereas, Pharm A and SRMC desire to enter into this agreement whereby Pharm A will supply to patients within SRMC confines, the following:
A drug delivery system for SRMC patients to encompass all oral, and internal, IV medications (and/or medical equipment and supplies as SRMC desires), to comply with SRMC policies and procedures.
b. Pharmacist on call 24 hours a day; 7 days a week.
i. Participate in the system for the distribution and control of all controlled substances and assist in destruction of unused controlled medications.
j. Pharm A agrees to deliver routine medications by the next scheduled dose and will provide all medication deliveries as necessary to accommodate the patients' needs.

A review of the Pharmacy Director Job Descriptions revealed in part:
2. Ensures that the pharmacy services are available 24 hours per day- on call services.
4. Maintains and adequate drug supply and drug delivery system.
Prepares and fulfills daily prescriptions/ orders for oral medications, narcotics, IV medications, IV pumps and other supplies and medications as needed.

In an interview on 09/02/2022 at 9:20 a.m. S3AsstAdm denied the hospital having a policy or procedure for receiving medications after hours, or stat medications after hours since the contracted pharmacy was currently not open.

In an interview on 09/02/2022 at 10:00 a.m. S2DON stated that on August 23, 2022 the second day she worked with S4LPN they called S9Pharm on the speaker phone because they were running low on Oxycodone 2mg and needed to get some. She stated that S9Pharm instructed them that he was no longer working for the contracted pharmacy. S2DON stated she had to get the medications from a local pharmacy. She said that S10MD came to the hospital and wrote prescriptions for the medications and the prescriptions were delivered to the local pharmacy.
During the interview this surveyor at 10:20 a.m. asked S2DON to fax over a request for the last three weeks of orders that were sent to be filled and were filled by the contracted pharmacy.

In an interview on 09/02/2022 at 11:35 a.m. S1CNO stated if after hours medications are needed but medication could not be obtained after hours, the nursing staff would notify the provider and if needed the patient would be transferred out to a local emergency department.

In an interview on 09/02/2022 at 1:50 p.m. this surveyor asked S1DON if she received the documents requested in the fax sent to the contracted pharmacy. She stated, "No."

On 09/02/2022 at 2:00 p.m. S2DON called S9Pharm and he stated he had not received the faxed request as he was not at the pharmacy. He stated the pharmacy was locked up and they were in transition to replace him with a new pharmacist. S9Pharm stated S2DON would have to call S11Adm to get someone to open the building and check the fax. S9Pharm also stated that staff should be using the alternative method to obtain medications

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.

Findings:

On 09/02/2022 a review of Patient #1-5's medical record failed to reveal any documentation related to the first medication dose being 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.

A review of all medication documentation as provided by S1CNO and S2DON failed to reveal the first dose review.

In an interview on 09/02/2022 at 1:20 p.m. CNO stated she was not aware of any medication first dose reviews being communicated with the hospital, documented on the patient's medical record or elsewhere.

Based on observations 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 deficient practice was evidenced by failure to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors by the hospital:

1) failing to ensure the condition of the physical plant and overall environment was maintained to ensure the safety and well-being of the patients ( See finding A-701); and

2) failing to ensure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72 (See findings A-709); and

3) failing to ensure that the automatic sprinkler system had supervised valves that will sound a local alarm if closed (See findings A- 709); and

4) failing to ensure that the complete, supervised, automatic sprinkler system was functional without interruption (See findings A-709); and

5) failing to provide electrical wiring and equipment in accordance with NFPA 70 (See findings A- 709).

Based on observations and staff interview, the hospital failed to ensure the condition of the physical plant and overall environment was maintained to ensure the safety and well-being of the patients.

Findings:

On 09/01/2022 A tour of the hospital between 9:45 a.m. and 10:45 a.m. with S3AsstAdm revealed:
1) S5Maint changing ceiling tiles in the clean utility room. Multiple ceiling tiles noted to have water stains and both light fixtures were noted to have water stains in the light globes.

In an interview S5Maint stated he has been employed 2 months. He verified the damaged ceiling tiles and light fixtures.

In an interview on 09/01/2022 S3AsstAdm verified the ceiling was wet from water damage. She stated they had contacted the owner multiple times about the roof leaking. She said sometimes the repairs work and sometimes they do not. S3AsstAdm verified the equipment in the room was clean and available for patient use. She verified clean patient equipment should not be in the room until they knew for sure the roof was repaired.

2) An observation of the small clean storage closet revealed 12 visible dead roaches on the floor with 6 IV poles, 2 bedside toilets and 2 oxygen concentrators.

In an interview on 09/01/2022 at 9:50 a.m. S3AsstAdm verified the dead roaches and clean equipment that was available to staff for patient use.

3) Extra patient and patient family shower room was noted to have a dead roach on the floor and roach body parts in the tub.

In an interview on 09/01/2022 at 10:52 a.m. S3AsstAdm verified the shower room contained a dead roach and roach body parts.

4) An observation of patient room 9 which was available for patient use revealed the mattress to have multiple shreds in the cover.

In an interview on 09/01/2022 at 10:55 a.m. S3AsstAdm verified the room was available for patient use and the mattress had multiple shreds in the cover and it could not effectively be cleaned between patients.

5) An observation of patient room 8 revealed soft spot near the window with bubbling peeling paint.

In an interview on 09/01/2022 at 10:00 a.m. S3AsstAdm verified the soft spot and bubbling peeling paint.

6) An observation of room 4 revealed surge protector cords stretched across the patient room passing in front of the patient bathroom causing a trip hazard. Noted was an empty electrical receptacle behind the bed not being used.

In an interview on 09/01/2022 at 10:05 a.m. S3AsstAdm verified the electrical cords across the floor as a trip hazard.

7) An observation of patient room 3 revealed surge protector cords across the floor in front of the patient bed and bathroom door causing a trip hazard. Also noted was the corner of the exterior wall and bathroom wall with a soft spot, peeling paint and damp to touch. Lastly, 3 of the electrical outlets were non- functioning.

In an interview on 09/01/2022 at 10:07 a.m. S3AsstAdm verified the electrical cords, non- functioning outlets and soft damp wall with peeling paint.

8) Patient room 1 revealed the bathroom door to have damaged wood with excessive splintering noted at the bottom.

In an interview on 09/01/2022 at 10:10 a.m. S3AsstAdm verified the damaged bathroom door.

Based on observation and interview the hospital failed to ensure that the life safety from fire requirements are met as evidenced by :
1) The hospital failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72.

2) The hospital failed to assure that the automatic sprinkler system had supervised valves that will sound a local alarm if closed.


3) The hospital failed to assure that the complete, supervised, automatic sprinkler system was functional without interruption.



4) Based on visual observation, the hospital failed to provide electrical wiring and equipment in accordance with NFPA 70.


These deficient practices have the potential to affect 10 of 10 current and any additional patients admitted to the hospital.

Findings:

1) The hospital failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72.

NFPA 72: 10.3.2 System components shall be installed, tested, and maintained in accordance with the manufacturer's published instructions and this Code.

NFPA 72:10.4.1.2 State or local licensure regulations shall be followed to determine qualified personnel. Depending on state or local licensure regulations, qualified personnel shall include, but not be limited to, one or more of the following: (1) Personnel who are registered, licensed, or certified by a state or local authority.

LAC 55:V:3033. Fixed Fire Suppression and Fire Detection and Alarm Systems and Equipment... B. All existing required fixed fire suppression systems including kitchen, pre-engineered and engineered systems, and fire detection and alarm systems shall be certified, hydrostatically tested, inspected, integrated, maintained and serviced in an operational condition in accordance with the manufacturer's installation manuals, specifications, and per the inspection, testing and maintenance chapters of the applicable codes and standards adopted in L.A.C.55:V.103 or noted in these rules.

Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect ten of ten patients.

During the facility tour on September 1, 2022 between the hours of 12:30 p.m. to 3:00 p.m. and on September 2, 2022 between the hours of 2:45 p.m. to 5:15 p.m. the fire alarm system was yellow tagged by a licensed company on August 24, 2022 due to a external trouble alarm believed to be related to the phone line supervision being inactive.

The interview with the Administrator revealed the facility was aware that the fire alarm supervision was lacking due to the phone line service being disconnected. The administrator was in the process of restoring the fire alarm analog phone line by arranging a meeting to discuss the previous phone company accounts with the phone company on Monday September 5, 2022.


2) The hospital failed to assure that the automatic sprinkler system had supervised valves that will sound a local alarm if closed.

NFPA 101:9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

NFPA 101:19.3.4.3.2 Emergency Forces Notification.


NFPA 101:19.3.4.3.2.1 Fire department notification shall be accomplished in accordance with 9.6.4.

NFPA 101:9.6.4 Emergency Forces Notification.

NFPA 101:9.6.4.1 Where required by another section of this Code, emergency forces notification shall be provided to alert the municipal fire department and fire brigade (if provided) of fire or other emergency.

NFPA 101:9.6.4.2 Where fire department notification is required by another section of this Code, the fire alarm system shall be arranged to transmit the alarm automatically via any of the following means acceptable to the authority having jurisdiction and shall be in accordance with NFPA 72, National Fire Alarm and Signaling Code:
(1) Auxiliary fire alarm system
(2) Central station fire alarm system
(3) Proprietary supervising station fire alarm system
(4) Remote supervising station fire alarm system

NFPA 101:9.6.4.3 For existing installations where none of the means of notification specified in 9.6.4.2(1) through (4) are available, an approved plan for notification of the municipal fire department shall be permitted.

Based on visual observation the facility failed to assure that the automatic sprinkler system had supervised valves that will sound a local alarm if closed. A direct result, of the fire alarm system being notified of the emergency, is protection of life and property. This deficiency has the potential to affect ten of ten patients.

During the facility tour on September 1, 2022 between the hours of 12:30 p.m. to 3:00 p.m. and on September 2, 2022 between the hours of 2:45 p.m. to 5:15 p.m. the fire alarm system is lacking supervision to a remote station due to the fire alarm analog phone service being inactivated by the phone company.

The interview with the Administrator revealed the facility was aware that the fire alarm supervision was lacking due to the phone line service being disconnected. The administrator was in the process of restoring the fire alarm analog phone line by arranging a meeting to discuss the previous phone company accounts with the phone company on Monday September 5, 2022.

3) The hospital failed to assure that the complete, supervised, automatic sprinkler system was functional without interruption.

L.R.S. 40:1578.6 (C)
This inspector deems that a serious life hazard exists due to the lack of a require operative (fire alarm system/sprinkler system). Therefore, the 2012 edition of the life safety code shall be implemented as per the following:

NFPA 101:9.6.1.6 (F.A.) K 346 OR NFPA 25:15.5.2 (A.S.) K 354
"Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period or a sprinkler system is out of service for more than 10 hours in a 24-hour period, the authority having jurisdiction shall be notified. The facility shall be evacuated or an approved fire watch shall be provided."
Facility shall implement a fire watch in accordance with State Fire Marshal Guidelines, a copy of said guidelines given to Assistant Administrator and said fire watch shall remain in effect until the system is back in service and an inspection has been conducted by this office.

NFPA 101:9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

NFPA 101:19.3.4.3.2 Emergency Forces Notification.


NFPA 101:19.3.4.3.2.1 Fire department notification shall be accomplished in accordance with 9.6.4.

NFPA 101:9.6.4 Emergency Forces Notification.

NFPA 101:9.6.4.1 Where required by another section of this Code, emergency forces notification shall be provided to alert the municipal fire department and fire brigade (if provided) of fire or other emergency.

NFPA 101:9.6.4.2 Where fire department notification is required by another section of this Code, the fire alarm system shall be arranged to transmit the alarm automatically via any of the following means acceptable to the authority having jurisdiction and shall be in accordance with NFPA 72, National Fire Alarm and Signaling Code:
(1) Auxiliary fire alarm system
(2) Central station fire alarm system
(3) Proprietary supervising station fire alarm system
(4) Remote supervising station fire alarm system

NFPA 101:9.6.4.3 For existing installations where none of the means of notification specified in 9.6.4.2(1) through (4) are available, an approved plan for notification of the municipal fire department shall be permitted.

Based on visual observation and documentation the facility failed to assure that the complete, supervised, automatic sprinkler system was functional without interruption. In the event of failure, an approved fire watch shall be implemented if the facility is not fully evacuated until the system is returned to service. The fire alarm system offers advanced warning in a fire/smoke emergency. This deficiency could potentially affect ten of ten patients.


During the facility tour on September 1, 2022 between the hours of 12:30 p.m. to 3:00 p.m. and on September 2, 2022 between the hours of 2:45 p.m. to 5:15 p.m. the fire alarm system is lacking supervision to a remote station due to the fire alarm analog phone service being inactivated by the phone company.

The interview with the Administrator revealed the facility was aware that the fire alarm supervision was lacking due to the phone line service being disconnected. The administrator was in the process of of restoring the fire alarm analog phone line by arranging a meeting to discuss the previous phone company accounts with the phone company on Monday September 5, 2022. The LSC Specialist discussed with the Assistant Administrator and furnished a copy of the fire watch guidelines and logs to be completed while the Hospital is occupied. The LSC Specialist informed the Assistant Administrator to notify the local fire department that their fire alarm lacking supervision and a fire watch is being conducted to assign a designated person to contact the fire department in the event of a fire emergency.




4) Based on visual observation, the hospital failed to provide electrical wiring and equipment in accordance with NFPA 70.

Based on visual observation, the facility failed to provide electrical wiring and equipment in accordance with NFPA 70. Improper wiring creates a high risk of injury and/or death. The deficiency has the potential to affect ten of ten patients.

During the hospital tour on September 1, 2022 between the hours of 12:30 p.m. to 3:00 p.m. and on September 2, 2022 between the hours of 2:45 p.m. to 5:15 p.m. the patient room identified as number three did have one active electrical receptacle being used to supply power via trip lite 1363A/ UL- 60601-1. However, the other two electrical receptacle were not functioning. The clean supply room suspended mounted light fixture lens had a large water stain indicating the roof had leaked rain water within the electrical suspended ceiling mounted light fixture.

NFPA 101: 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

LAC 55:V:105. Required Inspections of Wiring, Gas Piping and Fire Extinguishers
D. In order to assure that the electrical wiring in any structure or movable will not cause a fire or explosion, the electrical wiring in any structure, watercraft or movable shall be inspected and, if necessary, repaired by a licensed electrical contractor in accordance with the National Electrical Code
E. In order to assure that any structure, watercraft or movable is safe from hazards caused by gas piping, all gas piping shall be inspected and, if necessary, repaired by a licensed plumber or mechanical contractor in accordance with the applicable National Fuel Gas Code of the National Fire Protection Association and the provisions of the Louisiana Revised Statutes.
F. The inspections required by this regulation for electrical wiring and gas piping shall be made at the time of the initial installation and thereafter as required based upon a visual inspection by the fire marshal or his designated representative.

The interview with the Assistant Administrator discussed revealed the hospital was unaware two of three electrical receptacles in patient room number three being inoperable. LSC Specialist discussed providing a electrical certificate from a licensed electrician on a company letterhead with the licensed electrician's license number and signature. The letter shall indicate all the electrical wiring within the facility had either been repaired, replaced or inspected and appears to be in accordance with the NEC /NFPA 70.