Lane Regional Medical Center

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to provide care in a safe setting. This deficient practice is evidenced by the hospital failing to perform every 15 minute observation checks on 3 (#13, #19, #20) of 4 (#13, #14, #19, #20) patients under a Physician’s Emergency Commitment (PEC) in March 2024. Findings: Review of hospital policy revised 02/2021 titled “Guidelines for Treatment of patient under Physicians Emergency Commitment (PEC), Coroners Emergency Commitment (CEC), Oder of Protective Custody (OPC) in Emergency Department” revealed in part: STANDARD: Patient who are placed under a PEC, CEC, OPC will require the following measures. C. Place in a room under direct observation. 2. Location and activity will be documented every 15 minutes by ER staff member. Review of the PEC/CEC Observation Flow Sheet for Patient #13 dated 03/26/2024 revealed every 15 minute observations were completed at 3:15 p.m. even though Patient #13 didn’t leave the ED until 4:28 p.m. In an interview on 04/15/2024 11:00 a.m., S4EDD verified the patient was not in the ED after 4:28 p.m. Review of the PEC/CEC Observation Flow Sheet for Patient #19 dated 03/26/2024 revealed every 15 minutes observations were not done on Patient #19 who was OPC from time of arrival at 4:43 p.m. until 7:00 p.m. In an interview on 04/15/2024 12:30 p.m., S4EDD verified above missing documentation. Review of the PEC/CEC Observation Flow Sheet for Patient #20 dated 03/27/2024 revealed every 15 minutes observations were completed at 9:15 a.m. even though Patient #20 didn’t leave the ED until 9:44 a.m. Furthermore there are every 15 minute observations documented at 3:00 a.m. and 3:15 a.m., although Patient #20 didn’t arrive to the ED until 3:21 a.m. In an interview on 04/15/2024 at 12:45 p.m., S4EDD verified above missing and extra documentation.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to ensure patients were free from abuse and failed to ensure all incidents of abuse, neglect, and/or harassment were reported and analyzed, and the hospital was in compliance with applicable local, State, and Federal Laws and Regulations. This deficient practice was evidenced by the hospital’s failure to investigate and report abuse within 24 hours to the Department of Health and Hospitals or law enforcement for 1 (#13) of 2 (#13, #14) patients reviewed for mandatory reporting. Findings: Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report abuse/neglect allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Louisiana Department of Health (LDH). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence. Review of hospital policy revised 02/2022 titled “Patient Rights” revealed in part: The physicians and all personnel of the hospital are obligated to observe the basic human rights of all patients admitted to the hospital. The following policies have been developed in an effort to meet this obligation to the patient and to our community. Procedures have been developed by the Board of Trustees, Medical Staff, and departments of the hospital to assure that these rights are preserved. 11. Patients have the right to receive care in a safe setting. 32. Patients have a right to be free from mental, physical, sexual, and verbal abuse, neglect, and exploitation. Review of Incident Report Log for March 2024 revealed, in part, “2 PEC ED Elopement Patients.” In an interview on 04/11/2024 at 10:17 a.m. S1QD indicated during the investigation regarding the elopement of Patient #13, she did not report to LDH with 24 hours of discovery because the patient returned to the ED with police 20 minutes after eloping.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to ensure a nurse supervised and evaluated the nursing care for each patient. This deficient practice is evidenced by: 1. Failure to assess patients’ response to interventions. 2. Failure to reassess vital signs at a minimum every 2 hours per policy. 3. Failure to reassess vital signs within 30 minutes of discharge from emergency department per policy. 4. Failure to document a reassessment every 2 hours per policy. Findings: Review of hospital policy revised 02/2021 titled “Assessment of Patients” revealed in part: Department: ER, basic data collection at triage physical assessment within 15 minutes, completion of record at discharge or transfer, and reassessment every 2 hours or as indicated. Review of hospital policy revised 07/2012 titled “Emergency Room Standard of Care” revealed in part: STANDARD: All patients admitted to the ER will be assessed on admission by RN. Based on the individual needs of the patient, care planning, implementation of nursing interventions, and the evaluation of the effects of those interventions will occur. D. Vital signs will be reassessed a minimum of every two hours and as needed based on patient condition. A full set of vital signs including pulse, respirations, temperature, blood pressure, O2 saturation will be obtained upon admission and within 30 minutes of discharge from the ED. Patient #16 Review of Patient #16 electronic medical record revealed the temperature to be documented as 89 degrees on 03/23/2024 at 3:54 p.m. with warming interventions initiated at 4:19 p.m. Further review revealed no documented evidence of a nurse reassessing the patient #16’s condition in relation to the low temperature, nor interventions performed prior to Patient #16 transferring to another facility on 03/23/2024 at 7:08 p.m. In an interview on 04/15/2024 at 11:30 a.m. S4DD verified above missing documentation and confirmed patient #16 temperature should have been reassessed. Patient #9 Review of Patient # 9 electronic medical record revealed a full set of vital signs were documented during triage on 04/02/2024 at 5:55 p.m. Further review revealed vital signs were documented again at 10:15 p.m. which is not within the 2 hour minimum per policy. Review of the nursing assessment of Patient #9 revealed an assessment was documented on 04/02/2024 at 5:56 p.m. Further review revealed there was no reassessment documented which is not within the 2 hour minimum per policy. In an interview on 04/15/2024 at 10:30 a.m. S4DD verified these findings. Patient #2 Review of Patient # 2 electronic medical record revealed the last set of vital signs were documented on 03/17/2024 at 7:16 p.m. Patient #2 left Against Medical Advice on 03/17/2024 at 8:57 p.m. Further review revealed vital signs were not documented within 30 minutes prior to patient #2 leaving the ED per policy. I n an interview on 04/11/2024 at 1:20 p.m. S4DD verified these findings.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 48050 Based on observation, policy review, and interview, the facility failed to ensure supplies and equipment were maintained to ensure an acceptable level of safety and/or quality. This deficient practice is evidenced by hospital failing to ensure crash cart checks were appropriately stocked checked for expired supplies monthly. Findings: Review of hospital policy reviewed 02/2024 titled Defibrillator and Crash Carts Checks revealed in part, STANDARD: The crash cart/emergency drug boxes are to be checked at least daily for verification of lock. The defibrillator is to be tested at least daily to ensure proper functioning. This is the responsibility of the charge nurse. The crash cart is checked daily for verification of seal. Supplies will be checked for out of dates by nursing service personnel each month and supplies will be replaced as needed. The daily and monthly checks are recorded on the Log Sheet. Tour of the facility on 04/11/2024 at 10:40 a.m. revealed Crash Cart Inventory Logs were missing checks on the pediatric code cart log for March 2024 and Adult Crash Cart Log for May 2023, August 2023, November 2023, December 2023, and March 2024. In an interview on 04/11/2024 at 11:30 a.m. S4EDD verified that the Crash Cart Inventory Logs were missing the above monthly checks for the Adult and Pediatric Code Carts.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to ensure infection control standards were maintained. The deficient practice is evidence by failure of the facility to maintain temperature and/or humidity controls within range of hospital policy. Findings: Review of hospital policy reviewed 10/2020 titled “Storage of Sterile Supplies” revealed in part Once cooled, sets are distributed to their respective area and placed within closed cabinets. If not stored in cabinets, sets are to be covered with dust cover, either by each package or a cart that has a dust cover. Storage areas must be monitored and controlled daily for temperature and humidity. Sterilized items stored outside of the Sterile Processing Department are located in a designated room/area that is monitored for temperature and humidity. Temperature and humidity will be checked and documented every 24 hours. Should the temperature or humidity be out of range currently or in the last 24 hours, it is event related. The packages are to be inspected for moisture, integrity and contamination. If currently out of range, recheck the range after one hour. If the range remains out of compliance, notify Plant Operations and the house supervisor. Document accordingly on the department log. EMERGENCY ROOM: 1. Check storage areas (rooms 1, 2, 8, 10, 12) each day on the “A” (7a-7p) shift for temperature and humidity compliance. 3. If temperature or humidity are noted out of range within the last 24 hours or currently, it is event related. Do the following a. inspect packages for moisture and contamination b. contaminated or compromised packages are to be sent to Central Sterile for reprocessing. C. recheck the temperature and humidity after one hour. Tour of the facility on 04/11/2024 at 10:40 a.m. revealed a large cabinet with no doors in Room a that stored sterile instruments. Further review revealed a Central/Sterile Equipment Daily Temp/Humidity Log that documented dates with humidity at of the normal range of 30-70%. The following dates humidity was not within normal range (30-70%) 01/02/2024 -01/05/2024, 01/10/2024, 01/13/2024-01/22/2024, 02/14/2024, 02/19/2024, 02/20/2024, 02/29/2024, and 03/19/2024. There was no comment or follow up regarding out of range humidity In an interview at the time of discovery, S4EDD verified sterile instruments should be placed in closed cabinets or covered with dust cover, either by each package or a cart that has a dust cover per hospital policy. S4EDD also verified the above dates were out of range for humidity and there is no documented follow-up. In an interview on 04/11/2024 at 11:40 a.m., S1QD revealed that if the temperature/humidity were out of range it could affect the sterile instruments.”