HospitalInspections.org

Based on record review and interview, the hospital failed to ensure all patient care is provided by or in accordance with the orders of a practitioner who meets the medical staff criteria and who has been granted privileges in accordance with those criteria by the governing body, and who is working within the scope of those granted privileges by allowing Emergency Room Physician's from hospital "a" (host hospital), who have not been granted privileges by the Governing Body, to respond to "Code Blue" and direct treatment of patients. Findings:

On 05/19/10 at 10:05 a review of the last 3 "Code Blue" sheets for the hospital was conducted with S2CCO.

Review of the Code Blue sheet for R1 revealed the patient was attended during the Code and Intubated by S8MD (from host hospital "a").

In an interview with S2CCO on 05/19/10 at 10:10 a.m. she stated that S8MD was not credentialed at the hospital but was an ER MD from host hospital "a".

In an interview with S1Administrator on 05/18/10 at 12:15 p.m. he confirmed that none of the ER Physician's from hospital "a" who respond to Code Blue at the hospital have been granted privileges at the hospital.

Review of a hospital policy titled "Code Blue", policy number CG301.00.00, effective 10/1991, last revised 2006, presented as current hospital policy reads in part: "Purpose: To set in operation an organized plan for treating cardiopulmonary arrest......Policy: B. The Code Blue page is answered by:.....the Respiratory therapist, and possibly emergency room physician, from (hospital "a") Code Blue Team....E....staff will then call (hospital "a") operator to announce "Code Blue to Cornerstone"......C. Code Blue Team:.....The physician or Respiratory Therapist from (hospital "a") will maintain the airway, obtain ABG's (arterial blood gases), administer oxygen, intubate if necessary, and set up for ventilator use..."

Based on record review and interview, the hospital's Governing Body failed to ensure that all services provided under contract were provided in a manner that permits the hospital to comply with all applicable standards for the contracted services. This was evidenced by the hospital's Governing Body's failure to develop and approve policies/procedures for contracted services through host hospital "a" for Radiology Services, Housekeeping Services, Laboratory Services and Dietary Services. Findings:

The hospital's policies/procedures were reviewed on 5/18/10. This review revealed no evidence to indicate that the Governing Body of Cornerstone Hospital of Southwest La had developed, reviewed, and approved any policies/procedures for the contracted services relative to Radiology Services, Housekeeping Services, Laboratory Services, and Dietary Services.

The Chief Clinical Officer was interviewed on 5/18/10 at 10:35 a.m. When asked for the policies/procedures for Radiology Services, Housekeeping Services, Laboratory Services and Dietary Services, the Chief Clinical Officer reported that Cornerstone Hospital of Southwest La has contracted Radiology Services, Housekeeping Services, Laboratory Services and Dietary Services with the host hospital (Hospital A) and uses the host hospital's policies/procedures for these services. The hospital failed to develop and approve their own specific policies and procedures for the contracted services.

Based on record review and interview, the hospital's Governing Body failed to ensure that written policies/procedures relating to emergency services were properly developed and implemented as evidenced by the hospital's policies/procedures allowing physicians and respiratory therapists from the host hospital (Hospital "a") to respond to cardiopulmonary emergencies of patients in the hospital. Findings:

On 05/19/10 at 10:05 a review of the last 3 "Code Blue" sheets for the hospital was conducted with the hospital's Chief Clinical Officer.

Review of the Code Blue sheet for R1 revealed the patient was attended during the Code and Intubated by S8MD (from hospital "a").

In an interview with the hospital's Chief Clinical Officer on 05/19/10 at 10:10 a.m., the Chief Clinical Officer indicated that S8MD was not credentialed at Cornerstone Hospital of Southwest LA but was a physician who works in the emergency department at the host hospital (hospital "a").

In an interview with the Administrator on 05/18/10 at 12:15 p.m., the Administrator confirmed that none of the ER Physician's from hospital "a" who respond to cardiopulmonary emergencies at Cornerstone Hospital of Southwest La have been credentialed and granted privileges at Cornerstone Hospital of Southwest La.

Review of a hospital policy titled "Code Blue", policy number CG301.00.00, effective 10/1991, last revised 2006, presented as current hospital policy reads in part: "Purpose: To set in operation an organized plan for treating cardiopulmonary arrest......Policy: B. The Code Blue page is answered by:.....the Respiratory therapist, and possibly emergency room physician, from (hospital "a") Code Blue Team....E....staff will then call (hospital "a") operator to announce "Code Blue to Cornerstone"......C. Code Blue Team:.....The physician or Respiratory Therapist from (hospital "a") will maintain the airway, obtain ABG's (arterial blood gases), administer oxygen, intubate if necessary, and set up for ventilator use..."

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Based on record reviews and interviews the hospital failed to: 1) ensure that a patients request for Do Not Resuscitate (DNR) was promptly handled by not notifying the physician responsible for the care of 2 of 6 patients (#1, #16) of the request for DNR, which resulted in a 5 day delay for patient #1 to have a DNR order written and a 1 day delay in patient #16 having a DNR order written and 2) ensure the physician documented in the physician's progress notes the discussion with the patient/patient's representative regarding the DNR decision for 3 of 6 patients with or requesting DNR status. (#1, #15, #16) Findings:

1) Patient #1

Review of the medical record of patient #1 revealed that she was cognitive to make her own decisions. Further review of the medical record revealed that upon admission on 05/13/10 patient #1 declared her wishes to be DNR.

In an interview on 05/18/10 with S2CCO she stated that if patient #1 should suffer cardiopulmonary arrest her DNR request would be honored.

In an interview on 05/18/10 at 9:40 a.m. with S5RN, Charge Nurse, he stated that his report sheet indicated that patient #1 is a "full code". S5RN reviewed the DNR form on the record and indicated that "Full Code" is checked, then it is made into an "X" and DNR is checked. S5RN stated that the form is "ambiguous" therefore he would still consider patient #1 to be a "Full Code" and would perform all resuscitative measures if patient #1 were to have cardiopulmonary arrest.

In an interview on 05/18/10 at 9:45 a.m. with S2CCO she confirmed that she is one of two witnesses who signed the DNR form on 05/13/10. S2CCO indicated that patient #1 was able to make decisions and her family was in the room when patient #1 notified nursing staff of her wishes to be a DNR. S2CCO further stated that she did not notify the physician responsible for the care of patient #1 of the DNR request. S2CCO further confirmed that as of the time of this interview (5 days after patient #1 expressed her wish to be DNR) that the physician responsible for the care of patient #1 still had not signed the order making patient #1 a DNR nor had he documented in the physician's notes any discussions with the patient/patient's representative regarding discussions about the DNR.

In an interview on 05/18/10 at 9:45 a.m. with S11LPN, assigned the care of patient #1 for 05/18/10, stated she "was not aware of the DNR policy." S11LPN stated she had been told in report that patient #1 was a "Full Code". S11LPN then reviewed the DNR form for patient #1. S11LPN then stated patient #1 was a "Full Code" then quickly stated patient #1 was DNR.

In a telephone interview on 05/18/10 at 2:30 p.m. with S7MD, Medical Director, he stated that the patients request on 05/13/10 should have been followed through and the delay was "unacceptable." S7 reported he was not notified of the patient #16's request for DNR on 5/17/10 at 3:10 p.m. nor did he notice the form in the physician's order section requesting the DNR. S7 indicated that he expected to be notified of the patient #16's requests by the end of the shift that same day. S7MD further indicated that he does not know the hospital policy for DNR.

In a telephone interview on 05/18/10 at 2:35 p.m. with S6MD, covering for the attending physician S10MD, stated that he rounded this morning on patient #1 and #16 and was not notified of the patients' request for DNR nor did he notice the form, in the physicians order section, requesting DNR. S6MD indicated that he expected to be notified of the patient's (#1, #16) requests within 24 hours.

In an interview on 05/19/10 at 1:10 p.m. with S10MD, attending physician for patient #1, he indicated that he had been off since patient #1 was admitted but there was a physician covering for him in his absence. S10MD stated that the covering physician should have been notified of the DNR request of patient #1 by the nursing at the time of declaration.

Patient #16:

Review of the medical record of patient #16 revealed he was able to make his own decisions. Further review revealed there was a DNR order written on 5/17/10 at 1510 (3:10 p.m.) that had not been signed by a physician as of 5/18/19 at 1:50 p.m...

Another face to face interview was held with S2CCO on 5/18/10 at 1:45 p.m. and 1:50 p.m.. She verified Patient #15 had a DNR requested on 5/3/10 there was no documentation in the record that the physician had documented in his physician's note #15's DNR request on 5/3/10 as per the DNR policy. She confirmed Patient #16 made his request for a DNR order on 5/17/10 at 3:10 p.m..and the physician should had been notified of #16's request during that shift.

2) Patient #15:

Review of the #15's medical record on 5/18/10 revealed he was able to make his own decisions and requested a DNR order written on 5/3/10. The physician signed the DNR order on 05/3/10. Further review revealed there was no documentation in the physician's progress notes written that a discussion with the patient/patient's representative regarding the DNR decision written on 5/3/10.

Review of a hospital policy titled "Do Not Resuscitate (DNR) Order" ,policy number CC303.00.00, effective 09/91, last revised 2006, presented as current hospital policy, reads in part: "Purpose: 1. To establish a mechanism for reaching decisions regarding the withholding of resuscitative measures on patients.....2. To clarify to physicians, hospital staff, family members and the patient in the decision to withhold resuscitation measures. 3. To prescribe the appropriate orders, documentation, and physician notes to be written in the patient's record when a "do not resuscitate" decision has been reached....Policy: "Do Not Resuscitate" (DNR) means that Cardiopulmonary Resuscitation (CPR) and other life-sustaining measures......will not be initiated.....5. In the event that the physician is not in-house when the decision is reached to make the patient "DNR" status, a verbal or telephone order may be accepted by an RN and verified by another licensed personnel. The verbal/telephone order should reflect both of the RN's signatures. The verbal DNR order should be flagged and cosigned on the physician's next visit..."

Based on record reviews and interview the hospital failed to ensure the revision for the policy and procedure for Blood Administration was changed following a sentinel event for 1 of 1 patients with a sentinel event related to Blood Administration in a total sample of 20. Findings:

Review of a Root Cause Analysis and Action Plan in response to a Sentinel Event revealed that on 01/13/10 at 1600 (4:00 p.m.) a unit of Blood was started on patient R4 by a single nurse. The cause of the Sentinel Event is documented as "the nurse administering the blood did not check the blood at the bedside."

Review of a hospital policy titled "Blood and Blood Product Administration", policy number ND 106.00.00, effective 09/1991, last revised 08/2006, presented as current hospital policy reads in part: "Purpose:...2. To provide safe transfusion therapy through selected patient assessment and nursing intervention. Policy: Blood and Blood Product administration is initiated by a Registered Nurse......Procedure:....9. Obtain blood or blood product. a) Match patient identification form to unit of blood. 10. Check blood or blood product, verifying identification data. .....14. Check unit of blood or blood product, requisition form and patient's identification band to match: a) Patient's name. b) Patient's identification number. c) Unit number. d) ABO and Rh type. e) Expiration date. f) Ask patient to identify himself...."

In an interview on 05/19/10 at 9:25 a.m. with S2CCO she stated that the policy "should be for 2 nurses to check the Blood at the bedside. She further confirmed that the policy does not indicate that 2 nurses are required to check blood at the bedside. S2CCO further stated that it would be important to add "2 nurses to check Blood or Blood products at the bedside" to the Blood Administration policy. S2CCO could offer no explanation as to why the policy change had not been done.

Based on record reviews and interview the hospital failed to staff according to the hospital's staffing grid. This has the potential to affect all patients in the hospital. Findings:


Review of the nursing staffing records on 05/19/10 at 11:10 a.m. with S2CCO for 05/03/10 - 05/17/10 revealed the following:

Shift/Date Staffing Grid Nursing Level Actual Nursing Level

05/04/10 Night shift patient census 27 8 staff required 7
05/05/10 Night shift patient census 27 8 staff required 7
05/14/10 Night shift patient census 27 8 staff required 7

Review of a hospital policy titled "Nursing Staffing Plan, policy number A103.00.00, effective 10/1992, last revised 09/2006, presented as current hospital policy, reads in part: "Purpose: To ensure there is a written staffing plan for each nursing unit to provide the appropriate level of nursing care.....Policy: Addition of Staff: If the number of nursing personnel scheduled is less than the staffing guidelines dictates as necessary, it is the responsibility of the Charge Nurse and or Clinical Coordinator to make every effort to locate the needed nursing staff for the upcoming shift..."

These findings were confirmed with S2CCO at the time of the finding.

Based on record reviews and interviews, the Registered Nurse failed to supervise and evaluate the care provided to 8 of 20 sampled patients. This was evidenced by:

1. Failing to ensure that nursing staff obtains timely written results of radiology reports and places the report in the medical record so that physicians involved in the care of the patient have access to the information necessary to monitor the patient's condition. This was evidenced by the failure to have a radiology report on the patient's medical record in a timely manner for 1 of 20 sampled patients (#1) which resulted in a delay (a delay of 12 hours and 09 minutes) in notification of the physician of a potential small bowel obstruction. Findings:

Patient #1: Review of the medical record for patient #1 on 05/17/10 at 11:03 a.m. revealed the physician responsible for the care of patient #1 ordered a CXR (chest x-ray) "today" on Saturday May 15th, 2010 and a KUB (anterior view of the abdomen) on Sunday May 16th, 2010.

Further review of the medical record revealed that neither x-ray report was on the medical record of patient #1 as of 05/17/10 at 11:03 a.m.

In an interview on 05/17/10 at 11:35 a.m. with S2CCO she confirmed that the radiology reports were not on the medical record of patient #1.

Review of the radiology report for the CXR (chest x-ray) ordered on Saturday May 15th, 2010 at 11:40 a.m. revealed it was approved on Monday May 17th, 2010 at 6:34 a.m. by the Radiologist. This was a delay of 30 hours and 54 minutes.

Review of the radiology report for the KUB (abdomen x-ray) ordered on Sunday May 16th, 2010 at 10:00 a.m. revealed it was approved on Monday May 17th, 2010 at 10:19 a.m. by the Radiologist. This was a delay of 12 hours and 09 minutes.

In an interview on 05/17/10 at 11:35 a.m. with S2CCO she was asked to provide the hospital policy regarding Radiology reports. On 05/17/10 S2CCO produced a policy from hospital "a" titled "Required Records and Reports." S2CCO stated that the hospital uses the Policy and Procedures from hospital "a" because they furnish the contracted radiology service.

During the same interview S2CCO stated that if any Radiology studies are done on the weekend "we will not get the printed report until Monday." She further stated "I don't like that we have to wait until Monday."

In an interview on 05/17/10 with S1Administrator and S2CCO both stated that "the policy of (hospital "a") is the policy of this hospital."

In an interview with S2CCO on 05/17/10 at 3:00 p.m. she indicated that she could find no hospital policy for Cornerstone Hospital regarding X-ray reports and when they should be placed on the chart. She further confirmed that there was no policy defining when the physician ordered CXR on Saturday May 15th, 2010, ordered as "today" should have been performed or had results on the medical record of patient #1.

In an interview on 05/18/10 at 8:45 a.m. with S6MD, the physician who ordered the CXR on Saturday May 15th, 2010, ordered as "today", stated the X-ray report should have been on the chart the next day for his review.

Review of the radiology report for the CXR revealed an approval time of 05/17/10 at 6:34 a.m. by a radiologist at hospital "a".

Review of the radiology report for the KUB revealed an approval time of 05/17/10 at 10:19 a.m. by a radiologist at hospital "a". Further review of the "Impression" documented by the Radiologist revealed "Numerous Dilated Small Bowel loops in the Left Abdomen. This could represent Small Bowel Obstruction."


2. Failing to implement follow up interventions including verifying the accuracy of documented significant variations in the recorded weights and/or notifying the physician of changes in the patient's condition such as a significant weight gain or weight loss. This was noted in the medical records of 6 of 20 patient records reviewed for weight gain/weight loss out of a total sample of 20. (Patient #1, Patient #5, Patient #9, Patient #11, Patient #18, Patient #20). Findings:

Patient #1: Review of the medical record of patient #1 on 05/17/10 at 11:00 a.m. revealed the Initial nursing assessment had a documented weight for patient #1 of 154 pounds on the admission date of 05/13/10. Review of the Pharmacy Data Sheet had a documented weight of 168 pounds on the admission date of 05/13/10. Review of the vital signs graphic sheet had a documented weight of 168 pounds on the admission date of 05/13/10. Review of the Dietician's assessment sheet had a documented weight of 154 pounds on the admission date of 05/13/10. Review of the Physician's Admission orders dated 05/13/10 revealed a documented weight of 154 pounds.

In an interview with S2CCO on 05/17/10 at 11:35 a.m. she could offer no explanation of the different weights for patient #1 all documented as being on 05/13/10.

Patient #5: Review of the medical record revealed that the patient weighed 198 pounds on 4/27/10, 191 pounds on 4/28/10, 200 pounds on 4/30/10, 180 pounds on 5/03/10, and 193 pounds on 5/04/10.

The Chief Clinical Officer was interviewed on 5/17/10 at 1:30 p.m. The Chief Clinical Officer reviewed the medical record of Patient #5 and confirmed that there were significant variations in the recorded weights of Patient #5. The Chief Clinical Officer reported that she would have expected the nursing staff to follow up on the weight variations in order to determine the accuracy of the recorded weights and/or the cause of the variation in weights. The Chief Clinical Officer reported that she felt that the recorded weights were not accurate and stated that the reason for the variations had more to do with the process or techniques used by nursing staff to weight the patient such as failing to ensure that the scales are zero'd out prior to weighing the patient.

Patient #9: Review of the medical record revealed that the patient weighed 135 pounds on 5/12/10, 123.6 pounds on 5/13/10, and 133.6 pounds on 5/15/10.

The Chief Clinical Officer was interviewed on 5/18/10 at 10:20 a.m. The Chief Clinical Officer reviewed the medical record of Patient #9 and confirmed that there were significant variations in the recorded weights of Patient #9. The Chief Clinical Officer reported that she would have expected the nursing staff to follow up on the weight variations in order to determine the accuracy of the recorded weights and/or the cause of the variation in weights. The Chief Clinical Officer reported that she felt that the recorded weights were not accurate and stated that the reason for the variations had more to do with the process or techniques used by nursing staff to weight the patient such as failing to ensure that the scales of Zero'd out prior to weighing the patient.

Patient #11: Review of the medical record for patient #11 on 05/18/10 at 10:15 a.m. revealed the Physician Admission Orders dated 04/28/10 for #11 documented her weight was as 121 pounds. Review of the vital signs sheet revealed a weight of 121 pounds for 04/28/10. Review of the Pharmacy Data sheet revealed a weight of 148.8 pounds for 04/28/10. Review of the Dietary assessment sheet revealed a weight of 121 pounds for 04/28/10. Review of the Initial Nursing Assessment sheet revealed a weight of 121 pounds for 04/28/10.

In an interview on 05/18/10 at 3:10 p.m. with S2CCO she could not explain the 27.8 pound weight discrepancy on different documentation for the same day for patient #11.

Patient #18: Review of the medical record for patient #18 on 05/18/10 at 1:30 p.m. revealed the Physician Admission Orders dated 03/22/10 for #18 documented her weight was as 186 pounds. Review of the vital signs sheet revealed a weight of 189 pounds for 03/28/10. Further review of the vital signs sheet revealed a weight of 157.8 pounds for 03/30/10.

In an interview on 05/18/10 at 3:10 p.m. with S2CCO she could not explain the 31.2 pound weight discrepancy in a two day period for patient #18.

Patient #20: Review of the medical record for patient #20 on 05/19/10 at 10:20 a.m. revealed the Initial Nursing assessment dated 02/18/10 for #20 documented her weight was as 255 pounds. Review of the vital signs sheet revealed a weight of 255 pounds for 02/18/10. Further review of the vital signs sheet revealed a weight of 263 pounds for 02/19/10.

In an interview on 05/19/10 at 10:30 a.m. with S2CCO she could not explain the 8 pound weight discrepancy in a one day period for patient #20.

In an interview on 05/18/10 at 8:15 a.m. with S7MD, Medical Director, he stated that weights affect what the physicians do from a therapeutic standpoint and they should be accurate.

Based on record reviews and interview the hospital failed to ensure the policy and procedure for Blood Administration was followed for 1 of 1 patients with a sentinel event related to Blood Administration in a total sample of 20. Findings:

Review of a Root Cause Analysis and Action Plan in response to a Sentinel Event revealed that on 01/13/10 at 1600 (4:00 p.m.) a unit of Blood was started on patient R4 by a single nurse. The cause of the Sentinel Event is documented as "the nurse administering the blood did not check the blood at the bedside."

Review of a hospital policy titled "Blood and Blood Product Administration", policy number ND 106.00.00, effective 09/1991, last revised 08/2006, presented as current hospital policy reads in part: "Purpose:...2. To provide safe transfusion therapy through selected patient assessment and nursing intervention. Policy: Blood and Blood Product administration is initiated by a Registered Nurse......Procedure:....9. Obtain blood or blood product. a) Match patient identification form to unit of blood. 10. Check blood or blood product, verifying identification data. .....14. Check unit of blood or blood product, requisition form and patient's identification band to match: a) Patient's name. b) Patient's identification number. c) Unit number. d) ABO and Rh type. e) Expiration date. f) Ask patient to identify himself...."

In an interview on 05/19/10 at 9:25 a.m. with S2CCO she stated that the policy "should be for 2 nurses to check the Blood at the bedside. She further confirmed that the policy does not indicate that 2 nurses are required to check blood at the bedside. S2CCO further stated that it would be important to add "2 nurses to check Blood or Blood products at the bedside" to the Blood Administration policy. S2CCO could offer no explanation as to why the policy change had not been done.

Based on medical record reviews and interviews, the hospital failed to ensure that all entries entered into the medical record were timed and dated for 2 of 5 patients (#4, #5) whose medical records were reviewed for the timing and dating of entries out of a total sample of 20 patients. Findings:

Patient #4: Medical record review revealed physician orders dated 5/14/10 and 5/17/10 that were not timed that were not timed.

Patient #5: Medical record review revealed physician orders dated 4/28/10, 4/29/10, 4/30/10, 5/01/10, 5/02/10, 5/07/10, 5/10/10, 5/13/10 and 5/14/10 that were not timed and progress notes dated 4/30/10, 5/01/10, 5/03/10 5/05/10, 5/07/10, 5/10/10 and 5/17/10 that were not timed.

In an interview with the Chief Clinical Officer on 5/17/10 at 2:25 p.m., the Chief Clinical Officer confirmed that the above entries were not timed by the physician.

Based on record review and interview the hospital failed to ensure that patient records contain appropriate documentation of reports necessary to monitor the patient's condition and that this information was included in patient records in a prompt manner so that health care staff involved in the care of the patient have access to the information necessary to monitor the patient's condition by failing to ensure Radiology reports were on the patients medical record in a timely manner for 1 of 20 sampled patients (#1) which resulted in a delay (a delay of 12 hours and 09 minutes) in notification of the physician of a potential small bowel obstruction. Findings:

Review of the medical record for patient #1 on 05/17/10 at 11:03 a.m. revealed the physician responsible for the care of patient #1 ordered a CXR (chest x-ray) on Saturday May 15th, 2010 at 11:40 a.m. and a KUB (anterior view of the abdomen) on Sunday May 16th, 2010 at 10:00 a.m..

Further review of the medical record revealed that neither x-ray report was on the medical record of patient #1 as of 05/17/10 at 11:03 a.m.

In an interview on 05/17/10 at 11:35 a.m. with S2CCO she confirmed that the radiology reports were not on the medical record of patient #1.

Review of the radiology report for the CXR (chest x-ray) ordered on Saturday May 15th, 2010 at 11:40 a.m. revealed it was approved on Monday May 17th, 2010 at 6:34 a.m. by the Radiologist. This was a delay of 30 hours and 54 minutes.

Review of the radiology report for the KUB (abdomen x-ray) ordered on Sunday May 16th, 2010 at 10:00 a.m. revealed it was approved on Monday May 17th, 2010 at 10:19 a.m. by the Radiologist. This was a delay of 12 hours and 09 minutes.

In an interview on 05/17/10 at 11:35 a.m. with S2CCO she was asked to provide the hospital policy regarding Radiology reports. On 05/17/10 S2CCO produced a policy from hospital "a" titled "Required Records and Reports" that reads in part: "B. All reports of radiological interpretations and consultations are included in the patient's medical record within 24 hours...." S2CCO stated that the hospital uses the Policy and Procedures from hospital "a" because they furnish the contracted radiology service.

Based on record review and interview the hospital failed to ensure that all medication orders were clarified prior to dispensing for 2 of 20 patients (#1, #18) by having medication orders without indication for use. Findings:

Patient #1

Review of the medical record for patient #1 on 05/18/10 at 2:45 p.m. revealed the following orders:
1) Alprazolam .5 - 1 mg (milligram) po (by mouth) Q (every) 6 hours prn.
2) Geodon 20 mg PO/IM (intramuscular) Q 12 (hours) prn.

In an interview with S2CCO on 05/18/10 at 3:15 p.m. she confirmed that there was no documented indication of what the medication should be administered for.

It was requested that S2CCO provide hospital policy on several occasions concerning medication orders. As of the time of exit no hospital policies were presented.

Patient #18

Review of the medical record for patient #18 on 05/18/10 at 1:30 p.m. revealed the following orders:

1) 03/30/10 at 2135 (9:35 p.m.) - May have Ativan 1 -2 mg q 4 hours agitation.

In an interview with S2CCO on 05/18/10 at 3:15 p.m. she confirmed that there was no documented indication of when to administer 1 mg and when to administer 2 mg.

It was requested that S2CCO provide hospital policy on several occasions concerning medication orders. As of the time of exit no hospital policies were presented.

Based on observation and interview, the hospital failed to ensure that all facilities, supplies, and equipment was maintained in a manner to ensure an acceptable level of safety and quality. This was evidenced by:

1. Failing to date Glucometer Control Solution when opened. These Control solutions are used to test accurate functioning of the Glucometers. Failure to ensure the Control Solutions are not expired by dating the bottle when opened could affect Quality Control testing and therefore all Diabetic patients in the hospital. Findings:

In an observation made on 05/18/10 at 12:15 p.m. it was noted that the Quality Control Solutions in 1 of 2 Glucometers on the nursing station counter had no documented date of when the Quality Control Solutions were initially opened.

This finding was confirmed by S5RN, Charge Nurse, at the time of the finding.

Review of a hospital policy titled "Accu-Data Blood Glucose Testing/Accu-Check Advantage monitor Maintenance and Testing", number CI301.00.00, effective 08/2003, last revised 09/2006, presented as current hospital policy, reads in part: "Purpose" To monitor the blood glucose levels of patients in our facility and to maintain the equipment in a clean and functional manner......Procedure:.....Running Controls:...Verify the expiration date on the controls...


2. Failing to ensure that the handrails on a bed were in good repair and failing to ensure that the outflow vents on the air conditioning units were clean and free of dirt/grime/residue buildup. Findings:

Observations on 5/17/10 between 10:50 a.m. and 11:00 a.m. revealed the following:

- A broken section of plastic was noted to be on the handrail on the bed in Patient Room #112. Sharp jagged edges were noted on the section of the handrail that was broken.
- The outflow vents on the air conditioning units in Patient Room #'s 109 and 112 were noted to have a build up of dirt/grime/residue.

In an interview with the Administrator on 5/17/10 at 11:10 a.m., the Administrator confirmed the above findings. The Administrator reported that the handrail on the bed in Patient Room #112 would need to be repaired and that all outflow vents on the air conditioning units would need to be cleaned.

Based on record reviews and interview, the hospital failed to ensure the person designated in writing as the infection control officer was a qualified professional with specialized ongoing infection control training. S9, Infection Control Officer, failed to have documentation to support required ongoing education and training in infection control courses or local and national meetings organized by recognized infection control professional societies. Findings:

Review of S9 ' s personnel file on 5/19/10 revealed there was no documented evidence of the ongoing education and training demonstrated by participation in infection control courses, inservices, or in local and national meetings organized by recognized professional societies.
In interview with S1, Administrator on 5/19/10 at 9:40 a.m., he verified S9 had no documented evidence of her ongoing infection control education and training. He denied knowledge if S9ICO had ongoing infection control education and training. He indicated if S9 had infection control education and training then it would be at the corporate office. S1 further indicated he was unable to access S9 ' s education and training from the corporate office. The surveyor at this time requested S9 ' s ongoing infection control education and training from the corporate office. The surveyor requested S9 ' s ongoing infection control education and training from the corporate office for a second time at 12:00 p.m. from S1, Administrator. There was no documentation of S9 ' s ongoing infection control education and training presented to the surveyor prior to exit at 2:00 p.m. on 5/19/10.
Review of the policy titled, " Infection Prevention and Control Plan " Policy Number: IC-1, Revision Date: 10/08, 1/10, Effective Date: 8/08, with no reviewed date pps 1, 2, read, " ...II. Infection Control Officer shall be appointed to lead the Infection Control Program. The Infection Control Officer is qualified by experience and education and will be either a Registered Nurse who has attained certification in infection control."

Based on record reviews and interviews, the hospital ' s infection control officer failed to ensure the infection control system was developed and implemented relating to preventing/reducing the infections of central venous lines as evidenced by failing to ensure the outdated central lines' dressings were monitored, identified, reported and investigated for 7 outdated central line dressings identified from January through May 19, 2010. Findings:

The hospital's infection control data (electronic medical record) was reviewed from December, 2009 to May 19, 2010. This review revealed daily central line dressings were being monitored by S9, ICO. The Daily Value Focus Meeting Minutes were presented as the current daily central line monitoring by S9 from January to May 19, 2010 and revealed the following:
1/19/10 had (1) observation of a port dressing that needed to be changed,
2/1/10 had (1) observation of a central line dressing needed to be changed,
March, 2010 had no (0) central line dressing changes needed to be changed,
4/12/10 had (1) observation of a pic line dressing needed to be changed,
4/19/10 had two (2) observations of central line dressings that needed to be changed,
May, 2010 had no (0) central line dressing changes needed to be changed.

Review of the Patient Care/Clinical Risk Forms presented as the current reports written by S2, CCO on the nursing staff of the outdated central line dressings from January through May 19, 2010 read as follows:
January, 2010 - had no (0) documentation of the 1/19/10 observation of the (1) central line dressing that needed to be changed,
2/5/10 had (1) report written of the dressing that need to be changed,
March, 2010 - had no (0) documentation of dressing changes that needed to be changed,
4/10/10 had (1) report written of the the PICC line dressing needed to be changed,
4/12/10 had (2) reports written for the dressing not applied according to orders and PICC line dressing was not changed and
April, 2010 had no (0) documentation of the 4/19/10 observations of the (2) central line dressings that needed to be changed, and
May, 2010- had (0) no documentation of outdated dressing changes from May 1 to May 19, 2010.

There was a total of (5) outdated central line dressing that needed to be changed that were identified by S9, ICO on the Daily Value Focus Meeting Minutes from January through May 19, 2010. There were no (0) Daily Value Focus Meeting Minutes documented for the (2) outdated central line dressings identified by S2, CCO on the Patient Care/Clinical Risk forms for 4/10 and 4/12, which made a total of (7) outdated central line dressings identified from January to May 19, 2010. There were (3) Patient Care/Clinical Risk forms missing for the (1) outdated central line dressing on 1/19/10 and the (2) outdated central line dressings on 4/19/10.

The infection control data was reviewed and revealed there was no documentation of the Daily Value Focus (Meeting Minutes) made by S9, ICO for the monitoring of the daily central line dressings from December, 2009 through May 19, 2010. Review of the Patient Care /Clinical Risk Forms from December, 2009 to May 19, 2010 revealed there was no documentation presented by S9ICO and/or S2CCO of the daily central line dressing monitoring, findings or reports for the central line dressings that were identified as outdated. This review of the infection control data revealed no documentation to indicate what measures were taken to identify and determine the cause of why the (7) outdated central line dressings that were not changed by the nursing staff, so that preventative measures could be implemented to assist in reducing/eliminating the potential future hospital health-care associated infection risks related to infections of the central venous lines.

During an interview with S2, CCO on 5/19/10 at 10:50 a.m., she reviewed the Daily Value Focus Meeting Minutes and Patient Care/Clinical Risk forms both present as current from January to May 19, 2010. She verified there were (7) outdated central line dressings identified from January through May 19, 2010. She was unable to provide documentation of the (1) outdated central line dressing identified on 1/19/10 or the (2) identified on 4/19/10 by S9ICO. She had no reason why there was no documentation of the (1) outdated central line dressings on 1/19/10 or the (2) on 4/19/10. She reported she had no documentation of the reports from S9ICO of the daily monitoring of the central line dressings or the outdated central line dressings reported by S9ICO from January through May 19, 2010. She stated she had no documentation of the nursing staff reports that were written for the outdated dressing lines that were identified from January to May 19, 2010. S2 indicated no trends were identified on the (7) outdated central line dressings that were identified from January through May 19, 2010. She verified and agreed there were trends identified on the (2) outdated dressings identified on 1/19 and 2/1; 4/10 and 4/12; and on 4/19. S2 reported these trends identified on 1/19 and 2/1; 4/10 and 4/12; and 4/19 should have been reported to the ICO, (S9) to review and evaluate the program. S2, CCO indicated there was no tracking, trending, reporting, reviewing or evaluating of the (7) outdated central line dressings identified from January to May 19, 2010.

The Infection Control Officer (ICO) S9, was interviewed on 5/19/10 between 12:55 p.m. and 1:15 p.m. relating to the steps taken by her to monitor, investigate, report and evaluate the possible source and/or cause of why the (7) outdated central line dressings were not changed by the nursing staff as per policy every 72 hours. S9, ICO reviewed the Daily Value Focus Meeting Minutes from December, 2009 to May 19, 2010. S9 reported this was the current daily central line dressing monitoring that she had conducted from January to May, 2010. She verified there was missing daily observations of the central line dressings from January through May 19, 2010 (30 for January, 27 for February, 31 for March, 28 for April, and 19 for May). She indicated she did not document her daily central line monitoring. She continued she reported all of the outdated central line dressings identified during the daily monitoring of the central line dressings to S2. Then, S2, CCO reports the outdated line dressings identified by her (S9) to the staff nurse on the Patient Care/Clinical Risk Form. She continued the outdated central line dressings are changed by her (S9ICO) during the observation, S2, CCO and/or staff nurse. She verified there were (5) outdated dressings identified in her Daily Value Focus Meeting Minutes from January through May, 2010. She reviewed the Patient Care/Clinical Risk forms presented as the current reports written by S2, CCO when informed of the outdated central line dressings noted during her daily monitoring of the dressings. She verified there were no (0) Daily Value Focus Meeting Minutes for the (2) outdated central line dressings documented by S2, CCO on the Patient Care/Clinical Risk Forms for 4/10 and 4/1 She had no documentation of the Daily Value Focus Meeting Minutes for the (2) outdated central line dressings noted by S2 on 4/10 or 4/12. She reported that she informs S2 verbally of her outdated central line dressings, so she has no documentation of her daily monitoring of the central line dressings. She reviewed and verified there was no documentation of the Patient Care/Clinical Risks Forms for the (2) outdated central line dressings on 4/19/10. She indicated she did not have S2 ' s documentation of the Patient Care/Clinical Risk Forms. She had no reason or explanation as to why S2CCO did not write the Clinical Risk Forms for the (2) outdated central line dressings identified on 4/19/10. She reviewed and verified there were (7) outdated central line dressings identified by S9, ICO and/or S2, CCO from January to May 19, 2010. She verified that (5) of the (7) outdated central line dressings were identified in the same month, April. She indicated S2 did not report there were (5) outdated central line dressings noted in April. She agreed this was a trend that should had been reported to her to be tracked, reviewed and evaluated. S9 reviewed and verified there was no documentation of an investigation, report and/or evaluation conducted by S2, CCO or herself (S9) of why nursing staff had (7) outdated central line dressings identified on the Patient Care/Clinical Risk Forms and Daily Value Focus Meeting Minutes from January through May 19, 2010. She reported she was unable to provide documentation to indicate that an investigation had been conducted regarding the possible cause as to why the (7) central line dressings were not changed by the nursing staff every 72 hours. S9 indicated the infection control program was last reviewed and analyzed in 2005. She reported there was no infection control issues identified from 2005 until presently, May 19, 2010. She agreed there was incomplete, inaccurate and incorrect data collected with no tracking, trending and analysis of the infection control system. S9 further agreed there was no system in place to accurately monitor, track, trend, investigate, report, and evaluate the effectiveness of the infection control program without the complete and accurate data collected from the daily monitoring of the central line dressings to identify, report and investigate the possible source/cause of why the central line dressings were outdated.

Review of the personnel file on 5/19/10 revealed S9' s Job Description for Infection Control read, " Position Summary- Responsibility to assess, plan, organize, develop, implement and evaluate the infection control programs and their activities in accordance with current federal, state and local standards. Monitor infection control practices and procedures throughout the facility to ensure all personnel and medical staff are compliant. Evaluate effectiveness of the program, gather and analyze data and report outcomes to appropriate committees. Position Minimum Qualifications-Knowledge of regulatory standards and compliance requirements. Education and/or Experience- Minimum nursing degree from an accredited school or nursing. Must have at least two (2) years clinical experience in an acute hospital or other related healthcare facility. Must possess a working knowledge of epidemiology, microbiology, infectious disease, and aseptic technique to include standard/universal precautions. Essential Job Function and Responsibilities-Assess, plan, develop, organize, implement, evaluate, coordinate and direct the infection control and employee health programs in accordance with the local, state and federal regulations. Regular surveillances to assess and ensure compliance with standard operating procedures; frequent rounds on the patient care units; Develop, review and revise IC and EH program plans and policies and procedures. Implement and track compliance with. Collect, analyze and report data to Infection Control committee, quality council, MEC and Governing Board. Additional Responsibilities-Participate in hospital wide patient safety program identifying risks to patient safety and reducing healthcare errors. "
Review of the policy titled, " Infection Prevention and Control Plan " Policy Number: IC-1, Revision Date: 10/08, 1/10, Effective Date: 8/08, with no reviewed date pps 1, 2, read, " ...II. Infection Control Officer shall be appointed to lead the Infection Control Program. The Infection Control Officer is qualified by experience and education and will be either a Registered Nurse who has attained certification in infection control. The Infection Control Officer is responsible for the ongoing hospital-wide process to collect and evaluate (through surveillance) information about infections in the hospital. Surveillance activities may be delegated to a nurse if the Infection Control Officer is a physician. III. Scope of Plan- The Infection Prevention and Control Plan will be evaluated on an annual basis. This plan should also be reviewed and revised as needed any time the emergence of new infection control issues. The Quality Improvement Committee (QIC), Medical Executive Committee (MEC), and Governing Board (GB) will review and approve the Infection Control Plan on an annual basis .... V. Performance Improvement-Infection control is integrated into the hospital ' s quality assessment and improvement efforts. Primary responsibility for the execution of the plan rests with the Infection Control Officer that includes the collection of surveillance data. Data collected encompasses both patient care and employee health services. Data is collected ongoing. Risks, rates, and trends in health care-associated infections are tracked and trended over time. This information is used to improve prevention and control activities and to reduce health care-associated infection rates to the lowest possible levels. The infection control program works collaboratively with the employee health program to reduce the transmission of infections from staff to patient. Employee health data is also aggregated, tracked, and trended over time to identify opportunities for improvement. The following infection control information is currently reported at least quarterly through the organization ' s performance improvement activities: Central Line Associated Bloodstream Infection (CLABSI) rate/1000 Central Line Days; VI. Infection Control Committee- on a monthly basis the interdisciplinary Performance Improvement (PIC) Committee will address issues concurrently and assist with tracer, monitoring, and other related activity. The IC Committee will meet at a minimum of once per quarter or monthly. The IC Committee is responsible for the implementation and oversight of the IC Plan. VII. Responsibilities- The ICP responsibilities include: A. Surveillance- 1. Implements targeted surveillance system, 3. Tracks, trends, analyzes and reports data to IC Committee and QIC, 4. Maintains organized and accurate records, 5. Reports data timely to NHSN... " .
Review of the Infection Control Manual -2005 presented as the current Infection Control Manual, Table of Contents read, " IC.5, Tab 5, The infection control program evaluates the effectiveness of the infection control interventions and, as necessary, redesigns the infection control interventions. " Further review revealed page 1 of 2, and page 2 of 2 titled, " Communication of Infection Prevention & Control Information, Policy #: ICM.05.100.4, Effective Date: May, 2005 with no reviewed or revised dates read, " Procedure- 1. The Infection Control Coordinator is responsible for managing the infection control program. He/she is responsible for surveillance, monitoring, and reporting of infection control issues, concerns, and information to appropriate individuals, departments, and/or agencies. a. Reports to IC Committee and EOC Committee as needed: 2) Surveillance data trends, c. Disseminate information to staff results of surveillance, recommended changes, and enforcement of standards, through inservices, orientation and education, memos or personal counseling. 3. The Department Heads shares with their staff Infection Control information, issues, concerns through their scheduled staff meeting, or personal counseling. 4. Staff and personnel are responsible for IC issues and concerns of non-compliance to standard of care. " The Policy titled, " Infection Control Plan " , Policy #: ICM.05.100.5, Effective Date: May, 2005 with no revised or reviewed dates, pages 1 to 4 read, " This plan describes the infection control program, which is designed to provide for the coordination of all infection surveillance, prevention and control activities, and patient safety, with the end goal of identifying and reducing the risks of infections, especially health care-associated infections, in patients, and healthcare workers. The Infection Control Plan will be reviewed annually to determine its effectiveness in meeting the goals of the program. The Infection Control Practitioner is a qualified individual that manages the ongoing infection control program. Qualifications include appropriate education and training. Experience and certification (CIC) in infection control is strongly desired. The infection control practitioner ' s role includes the daily collaborative efforts in areas relating to infection control throughout the hospital. Surveillance- The Infection Control program includes the collection of surveillance data. Data collected encompasses both patient care and employee health services. Data is collected ongoing for those infections identified as being most significant in the long term acute care setting (LTAC) and for the patient base cared for by the organization. These include device-related infections such as Primary Bloodstream Infection (PBSI). Due to the longer length of stay in the LTAC setting, all health care-associated infections identified through routine surveillance activities are monitored, tracked, trended and reported. Surveillance activities include ongoing assessment and management of infection control processes. Performance Improvement-Risks, rates, and trends in health care-associated infections are tracked and trended over time. This information is used to improve prevention and control activities and to reduce health care-associated infection rates to the lowest possible levels. Management systems including staff and data systems assist in achieving the objectives. Such systems support activities including data collection, data analysis, interpretation, and presentation of findings using statistical tools. The following infection control information is currently reported at least quarterly through the organization ' s performance improvement activities: Health care-associated infection rate per 1000 patient days, Heath care-associated Primary bacteremia rate/1000 Central Line Days " .

Based on interview, the hospital failed to appoint a Director of the Respiratory Department to supervise and administer the services. Findings:

In an interview with S2CCO on 05/18/10 at 9:50 a.m. she was asked to notify the Director of Respiratory that the surveyor's wanted to interview him/her. S2CCO went to hospital "a" and brought in the Director of Respiratory from that hospital.

In an interview on 05/18/10 at 9:55 a.m. with the Director of Respiratory from hospital "a" he was asked what his title at Cornerstone Hospital of Southwest LA was and he replied "none."

(cross reference findings at A0083)

Based on record review (personnel files ) and interview the hospital failed to have policies and procedures to ensure the qualifications, licensure consistent with State law, education, training and experience of personnel authorized to perform each type of respiratory care service were checked prior to allowing respiratory personnel from hospital "a" to treat patients in the hospital. This has the potential to affect all patients in the hospital. Findings:

In an interview on 05/18/10 at 1:10 p.m. with S1Administrator it was confirmed that the hospital does not maintain a personnel file or verify qualifications, licensure consistent with State law, education, training and experience of respiratory personnel.

(cross reference findings at A0083)

Based on review of the hospital's current QA/PI (Quality Assurance/Performance Improvement) data and interviews with staff, the hospital failed to measure, analyze, and track quality indicators for all hospital departments and contracted services. Findings:

The hospital's QA/PI data, including the meeting minutes for the most recent 2 meetings, were reviewed. Review of this data revealed no documentation to indicate that measurable quality indicators were implemented and tracked in relation to the following service areas: Radiology Services (which is a contracted service), Housekeeping Services (which is a contracted service), Laboratory Services (which is a contracted service) and Physical Environment.

The Quality Director was interviewed on 05/19/10 at 10:45 a.m. The Quality Director confirmed that there was no evidence to indicate that specific measurable quality indicators relating to Radiology Services, Housekeeping Services, Laboratory Services and Physical Environment were being measured, analyzed, and tracked.

Based on review of the hospital's QA/PI (Quality Assurance/Performance Improvement) data and interviews with staff, the hospital failed to set priorities for its performance improvement activities that focused on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas that affect health outcomes and quality of care. This was evidenced by:

1. Failing to identify the need to implement quality indicators and monitor the effectiveness of services in regards to obtaining accurate weights on patients and following up on significant changes in a patients weight. This was noted in the medical records of 6 of 20 patient records reviewed for weight gain/weight loss out of a total sample of 20. (Patient #1, Patient #5, Patient #9, Patient #11, Patient #18, Patient #20). Findings:

Deficiencies were identified relating to the hospital's failure to ensure that accurate weights were consistently obtained on patients and/or failing to follow up on significant changes in a patients weight.

Review of the QAPI data revealed no evidence to indicate that quality indicators were developed, implemented and monitored in regards to the previously identified breakdowns with obtaining weights and/or follow up on patients with significant weight changes.

In an interview with the Quality Director on 5/19/10 at 10:45 a.m., the Quality Director confirmed that there have been previously identified problems with the accuracy of patient weights. The Quality Director reported that the hospital's QAPI program failed to identify the need to implement quality indicators and monitor the effectiveness of services in regards to obtaining accurate weights on patients and following up on significant changes in a patients weight.

2. Failing to identify the need to implement quality indicators and monitor the effectiveness of services in regards to diagnostic and radiology services ordered on weekends. This was noted in the medical records of 1 of 20 patient records reviewed for diagnostic and radiology services out of a total sample of 20. (Patient # 1). Findings:

Deficiencies were identified relating to the hospital's failure to ensure that diagnostic data and/or results from radiology services was/were available for treatment team review in a timely manner for tests ordered on weekends.

Review of the QAPI data revealed no evidence to indicate that quality indicators were developed, implemented and monitored in regards to the hospital's failure to ensure that diagnostic data and/or results from radiology services was/were available for treatment team review in a timely manner for tests ordered on weekends.

In an interview with the Quality Director on 5/19/10 at 10:45 a.m., the Quality Director confirmed that she had been made aware of problems relating to diagnotic test results not being available for review on weekends. The Quality Director reported that the hospital's QAPI program failed to identify the need to implement quality indicators and monitor the effectiveness of services in regards to diagnostic data and/or results from radiology services not being available for treatment team review in a timely manner for tests ordered on weekends.

Based on observation, record review and interview, the hospital failed to ensure that unauthorized individuals cannot gain access to or alter patient records by failing to 1) ensure the electronic patient record system shared with the host hospital has appropriate security safeguards in place to ensure that names of patient's in the host hospital (hospital "a") could not be accessed. This has the potential to breech the confidentially of all patients in hospital "a" who have a physician who also admits at Cornerstone Hospital of Southwest LA; and 2) ensure that the medical record of a hospitalized patient (Patient #4) was secure and not accessible to unauthorized individuals. Findings:

1. Failing to ensure the electronic patient record system shared with the host hospital has appropriate security safeguards in place to ensure that names of patient's in the host hospital (hospital "a") could not be accessed. This has the potential to breech the confidentially of all patients in hospital "a" who have a physician who also admits at Cornerstone Hospital of Southwest LA.

In an interview/observation with S4 on 05/17/10 at 2:15 p.m. she accessed the computer system shared by the hospital and the host hospital (hospital "a"). S4 stated that the only information that could be viewed was information regarding the patient's in Cornerstone Hospital of Southwest LA.

During the same observation S4 was asked by the surveyor to pull up a list of patients by physician. The list displayed included names and room numbers of patients in hospital "a".

S4 confirmed the findings on 05/17/10 at 2:47 p.m.


2. Failing to ensure that the medical record of a hospitalized patient (Patient #4) was secure and not accessible to unauthorized individuals. Findings:

In an observation on 5/18/10 at 10:40 a.m., the medical record of Patient #4 was noted to be placed on a charting table located in the hallway outside of Patient #4's assigned hospital room. The medical record of Patient #4 was unattended with no staff members present. The hallway outside of Patient #4's assigned room where the medical record was left unattended was a public access area and not a restricted area.

The unit charge nurse (S5) was interviewed on 5/18/10 at 10:45 a.m. S5 confirmed that the medical record of Patient #4 was was left unattended in a public access area with no staff members present.