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Based on record review and interview the governing body failed to perform periodic evaluations of medical staff to ensure compliance with all federal regulations. This deficiency is evidenced by 1) failure to document compliance with COVID vaccine mandate for three members of the medical staff: and 2) failure to reassess medical staff and delineate privileges at least every 24 months.
Findings:

1)Failure to document compliance with COVID vaccine mandate for three members of the medical staff.

Review of hospital policy "Rehabilitation Hospital of Jennings COVID-19 Plan," revealed in part,
1. Rehabilitation Hospital of Jennings has developed the following policies and procedures to ensure all staff are fully vaccinated or have a qualifying exemption . . .
1. Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following hospital staff, who provide any care, treatment, or other services for the hospital and/or its patients:
Hospital employee
Licensed practitioners
Students, trainees, and volunteers and
Individuals who provide care, treatment, or other services for the hospital and/or its patients, under contract or by other arrangement. . . .
Infection Control will request a copy of the COVID-19 vaccination card once final dose is administered. All vaccination cards or a printout from LINKS will be placed in each employee's health file."

Review of the COVID vaccination report revealed 96 total employees with 100% either vaccinated or with approved exemption. Review of the vaccination records provided revealed no documented vaccination for S9MD, S10MD, S11MD.

In interview on 10/18/2022 at 9:45 a.m., S2HIM verified the missing vaccination information and the physicians were active medical staff. She said the hospital had been given verbal confirmation from the physicians that the vaccinations were performed but had not received a copy for their health file. Vaccination verification for each physician was provided on 10/18/2022.

2) Failure to reassess medical staff and delineate privileges at least every 24 months.

Review of the medical staff records of S9MD, S10MD, S11MD, and S12MD revealed privileges were not delineated every 24 months or with reappointment to the medical staff.

In interview on 10/19/2022 at 11:45 a.m., S2HIM verified the medical staff privileges were delineated only with initial appointment.

Based on record review and interview the facility failed to ensure verbal orders were properly documented in the medical record. This deficiency is evidenced by 1) failure to document an order for transfusion of blood in 1 (#8) of 1 medical record reviewed with a blood transfusion; and 2) failure to document an order for capillary glucose checks for 1 (#14) of 30 medical records reviewed.
Findings:

Patient #8
Review of the medical record for Patient #8 navigated by S4IC revealed a telephone order was taken on 10/13/2022 8:40 a.m. for "Type and Cross for 2 units PRBCs one time only for one day" from S9MD. Further review of both the electronic and paper record failed to reveal an order to transfuse the blood.

Review of the paper medical record revealed one unit of blood was transfused on 10/13/2022. The form that came with the blood indicated the blood was ordered for crossmatch on 10/13/2022 at 11:08 a.m. and transfusion began at 1:10 p.m.

In interview on 10/19/2022 at 1:30 p.m. S1DON reviewed the chart and verified there was no order for the transfusion of the blood but did point out documentation that the physician was aware.

2) Failure to document an order for capillary glucose checks.

Patient #14
Review of the electronic medical record for patient #14 navigated by S1DON revealed the patient had capillary blood glucose checks on 07/08/2022, 07/09/2022, and 07/10/ 2022.

Review of the orders for Patient #14 revealed no orders for capillary blood glucose checks.

During the record review on 10/18/2022 at 4:00 p.m. S1DON verified there was no order for the capillary blood glucose checks. She stated the physician and staff were aware the patient's past medical history had indicated he was diabetic, but the patient denied he was diabetic and had requested it be removed from his medical record. The physician had ordered a HbA1C and was aware the checks were being performed to confirm or deny the presence of diabetes.

Based on record review and interview the hospital failed to ensure drug administration errors were properly documented in the medical record. This deficiency is evidenced by the failure to include documentation in the medical record for 2 of 3 reviewed occurrence reports involving medication errors.
Findings:

Review of the hospital policy titled "Medication Variance" effective 04/2001 revealed in part,
"A. Classification of Medication Variance- A medication variance is considered to have occurred when: . . .
4. A patient's medication is omitted. . . .
B 3. Attending physician is notified of variance and orders obtained.
4. Document actions to counteract possible effects of variance (e.g. B/P monitor q 15 minutes x 2hours).
5. All medication variances must be documented and charted as follows:
a. Document appropriately on Mar.
b. Document medication given in the nursing note.
c. Document completed assessment of patient including vital signs possible side effects/ reactions or any antidotes.
6. Do not chart Incident report filled."

Patient # 12
Review of the medication variance report involving Patient #12 revealed an order was written on 09/16/2022 to increase the patient's Lexapro from 10 mg daily to 20 mg at bedtime each night but the dose was not changed until 09/20/2022. The report does not indicate the physician was notified.

Review of the electronic medical record for Patient #12 navigated by S1DON revealed an order on 09/13/2022 at 2:10 p.m. for "Escitalopram Oxalate Tablet 10mg. Give one tablet by mouth one time a day." Further review of the electronic record revealed no further electronic orders. Review of the paper record of orders revealed an order on 09/16/2022 at 11:00 a.m. for "(up arrow) Lexapro to 20 mg p.o. and give @HS."

Review of the MAR and the nurse's notes revealed no documentation the wrong dose was given for 4 days and there is no documentation the physician was notified.

During the record review on 10/18/2022 at 3:00 p.m. S1DON verified there was no documentation of the medication variance in the medical record and there was no documentation in the medical record or the incident report that the physician was notified. S1DON stated legal counsel had advised them not to document any of the incidents in the patient's medical record.

Patient #13
Review of the medication variance report involving Patient #13 revealed an order was written to hold the patient's Rivastigmine patch from 08/26/2022 until 08/29/2022. On 08/28/2022 at 4:30 p.m. a nurse performing chart audits discovered the order had been missed and the patient was still receiving the medication. The report indicated the physician was notified and the medication was discontinued.

Review of the medical record for Patient #13 navigated by S1DON revealed an order on 08/16/2022 at 4:36 p.m. for" Rivastigmine Patch 24 hour 13.3 mg/24hr." Further review of the electronic medical record revealed no other orders for the Rivastigmine. Review of the paper record revealed an order placed on 08/26/22 at 9:30 a.m., "Hold Rivastigmine patch over W/E - Do not restart until I can assess her on Mon."

Review of the MAR revealed the medication was stopped on 08/28/2022. There was no notation on the MAR or nurse's notes that the medication was given when it should have been held. There was also no notation in the record that the physician was notified of the medication variance.

During the record review on 10/18/2022 at 3:37 p.m. S1DON verified there was no documentation of the medication variance in the medical record and there was no documentation in the medical record the physician was notified.

Based on observation, and interview the hospital failed to ensure all supplies were maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by failing to ensure expired supplies were not available for patient use.

Findings:

On 10/17/2022 at 11:50 a.m. a tour of the medicine room revealed a plastic bin with 43 sterile gloves expired 8/2022.

In an interview on 10/17/2022 at 11:50 a.m. S1DON verified the expired gloves and they were available for staff use.