Northern Louisiana Medical Center

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 38777 Based on observation, record reviews and interview, the hospital failed to meet the requirement of the Condition of Participation for the QAPI program. This deficient practice is evidenced by failure of the hospital’s QAPI to identify the hospitals facility management deficient practice of not being able to identify the last time the air filters for all the operating rooms, all intensive care unit rooms and all emergency department rooms were changed or the air pressure measured and documented as a problem or area to ensure the proper air quality was being provided to these sensitive patient care areas. (See findings A-283)”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 38777 Based on observations, review of hospital documentation 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 was evidenced by: 1) A bat being identified in an occupied patient room: and 2) Failing the ensure the air filters for all the operating rooms, all intensive care unit rooms and all emergency department rooms were changed and or the air pressure measured and documented to ensure the proper air quality was being provided to these sensitive patient care areas. (See findings A- 0724)”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 38777 Based on observation, record reviews and interview, the hospitals QAPI failed to identify the hospitals facility management deficient practice of not being able to identify the last time the air filters for all the operating rooms, all intensive care unit rooms and all emergency department rooms were changed or the air pressure measured and documented as a problem or area in need of improvement to be address through the QAPI Program to ensure the proper air quality was being provided to these sensitive patient care areas. Findings: An observation of the air return vents in the ICU isolation rooms Patient Room a and b, c, d, and e revealed the air return vents were covered with a grey fuzzy substance and the main air vents blowing into the rooms contained a dark non fuzzy substance on the vents. In an interview on 05/14/2024 at 10:40 a.m. S2Main verified the dirty air vents. In an interview on 05/14/2024 at 10:43 a.m., S6EVS stated the EVS staff are responsible for cleaning the vents and they use a duster. She denies have the ability to being able to vacuum the vents or wipe then with a damp cloth. She also verified the dirty air vents. In an interview on 05/14/2024 at 11:00 a.m. S7RN denied knowing who checked the ventilation and filters for the operating room department and suites. A tour of the OR with S7RN and S2Main at 11:05 revealed the air return vents in OR 1, 2 and 3 to have internal louvers that were covered in a grey fuzzy substance. Looking through the return vents from the OR looked as though there were filters behind the metal vents. S2Main and S7RN denied knowing who was responsible for cleaning the vents or when they were cleaned last. In an interview on 5/14/2024 at 11: 20 a.m. S2Main verified the only filters that may exist for the ICU/ isolation rooms and OR would likely be on the roof at the air intakes. In an interview on 05/14/ 2024 at 12:30 p.m. S2Main stated he has been here for 3 months and he checked with one of his maintenance guys who has been at the hospital about 2 years and he does not recall the filters being changed. S2Main also stated he checked and could not find any documentation of the filters being changed or any air pressures being monitored before and after the filters. On 05/14/2024 at 1:45 p.m. an observation of the OR, ICU and ED air intake filters revealed they were all covered in greyish and black fuzzy substance and the filters lacked a date on them to note when they were changed last. In an interview on 05/14/2024 at 1:45 p.m. S2Main verified all the dirty air filters and the lack of any dates or documentation when they were changed last. A review of the maintenance logs for the last 6 months failed to reveal any maintenance related to the ventilation system or air filters. In an interview on 5/15/2024 at 9:04 a.m., S8Qual Rehab stated the only facility management area reviewed is EOC monthly rounds and the dirty filters and ventilation were not identified as an issue. She further stated she was not aware there was not documentation related to changing the filters or monitoring of the air pressure for the ICU, OR and ED.”

“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: 38777 Based on observations, review of hospital documentation 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 was evidenced by: 1) A bat colony being identified in the hospital and one flying into in an occupied patient’s room: and 2) Failing the ensure the air filters for all the operating rooms, all intensive care unit rooms and all emergency department rooms were changed and or the air pressure measured and documented to ensure the proper air quality was being provided to these sensitive patient care areas. Findings 1) A bat colony being identified in the hospital and one flying into in an occupied patient’s room. In an interview on 05/14/2024 at 9:10 a.m. S2Main admitted the hospital has an issue with bats and stated the hospital just signed a contract with Company A on 05/09/2024. A review of the signed contract with Company A dated 5/9/2024 revealed a proposal with a 1 year warranty against re-infestation. In an interview on 05/14/2024 at 9:45 a.m. S1CNO admitted a bat was located on the 3rd floor patient care area. She denied knowing if the bat had made it into a patient room. A tour of the hospital was conducted between 10:00 am and 11:35 am with S2Adm, who verified all findings during the tour. An observation of Patient Room e was tagged as closed. Inside the room it was noted to have ceiling tiles removed. S2Main verified there was an Ozone machine in the ceiling to aid with the smell which was believed to be from the bats. In an interview on 05/14/2024 at 10:10 a.m. S3LPN stated she heard about the bats. She also stated Patient Rooms e and f were initially blocked off due to smell but Patient Room f is better and in use. In an interview on 05/14/2024 at 10:17 a.m. S5RN stated she was aware of a bat in the hospital on 05/07/2024 and in Patient #1’s room, while he was in the bed. She stated a male employee caught the bat but she did not know who he was. She denied Patient #1 having any issues due to the bat entering the room. In an interview on 05/14/2024 at 2:40 p.m. S2Main stated Company A has received confirmation of payment and will be onsite Monday, 5/20/2024, to start the removal of the bats. He also provided a copy of the check for the required down payment to start the removal. 2) Failing the ensure the air filters for all the operating rooms, all intensive care unit rooms and all emergency department rooms were changed and or the air pressure measured and documented to ensure the proper air quality was being provided to these sensitive patient care areas. An observation of the air return vents in the ICU isolation rooms Patient Room a and Patient Room b, Patient Rooms c, d, and e revealed the air return vents to be covered with a grey fuzzy substance and the main air vents blowing into the rooms contained a dark non fuzzy substance on the vents. In an interview on 05/14/2024 at 10:40 a.m. S2Main verified the dirty air vents. In an interview on 05/14/2024 at 10:43 a.m. S6EVS stated the EVS staff are responsible for cleaning the vents and they use a duster. She denies have the ability to being able to vacuum the vents or wipe then with a damp cloth. She also verified the dirty air vents. In an interview on 05/14/2024 at 11:00 a.m. S7RN denied knowing who checked the ventilation and filters for the operating room department and suites. A tour of the OR with S7RN and S2Main at 11:05 revealed the air return vents in OR 1, 2 and 3 to have internal louvers that were covered in a grey fuzzy substance. Looking through the return vents from the OR looked as though there were filters behind the metal vents. S2Main and S7RN denied knowing who was responsible for cleaning the vents or when they were cleaned last. In an interview on 5/14/2024 at 11: 20 a.m. S2Main verified the only filters that may exist for the ICU/ isolation rooms and OR would likely be on the roof at the air intakes. In an interview on 05/14/ 2024 at 12:30 p.m. S2Main stated he has been here for 3 months and he checked with one of his maintenance guys who has been at the hospital about 2 years and he does not recall the filters being changed. S2Main also stated he checked and could not find any documentation of the filters being changed or any air pressures being monitored before and after the filters. On 05/14/2024 at 1:45 p.m. an observation of the OR, ICU and ED air intake filters revealed they were all covered in greyish and black fuzzy substance and the filters lacked a date on them to note when they were changed last. In an interview on 05/14/2024 at 1:45 p.m. S2Main verified the all the dirty air filters and the lack of any dates or documentation when they were changed last. A review of the maintenance logs for the last 6 months failed to reveal any related to the ventilation system or air filters. In an interview on 5/15/2024 at 9:04 am S8Qual Rehab stated the only facility management area reviewed is EOC monthly rounds and the dirty filters and ventilation were not identified as an issue. She further stated she was not aware there was not documentation related to changing the filters or monitoring of the air pressure for the ICU, OR and ED.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 17450 Based on observation and interview, the hospital failed to develop and implement an effective system in controlling infections and communicable diseases of patients as evidenced by failing to maintain a sanitary environment. Findings: On 04/16/2024 at 12:00 p.m., observation of the 3rd floor unoccupied patient rooms with S1Director of Quality revealed the following: - Room a had old pieces of tape stuck to the side rails. - Room b had old pieces of tape stuck to the side rails. Upon opening the overbed tabletop, a large area of a dried brown substance was observed in the tray. - Room c had a foul odor in the room. - Room d had old pieces of tape stuck to the side rails. Dust and debris was observed on the bottom stand of the overbed table. A bedside commode in the room had a dried brown substance on the front near the seat. - Room e had old pieces of tape stuck to the side rails. A dried reddish brown substance was dripped down the wall near the light switch. Interview with S1Director of Quality at that time revealed that the above rooms had been cleaned and should have been ready for a patient. S1Director of Quality further stated that the rooms were in need of further cleaning. Further observations of the 3rd floor revealed Room f had a foul odor in the room. At that time, S1Director of Quality stated that the hospital was having issues with bats getting in the walls in this area and the odor was from bat excrement. She further stated that the odor comes and goes and when the odor occurs, the room is blocked off and not used for patients. On 04/16/2024 at 12:50 p.m., observation of the 2nd floor unoccupied rooms with S1Director of Quality revealed the following: - Room g had old tape residue on both siderails - Room h had old pieces of tape stuck to the siderails. The bedside chair had a large tear in the vinyl seat which was unable to be adequately disinfected. Interview with S1Director of Quality at that time revealed that the above rooms had been cleaned and should have been ready for a patient. S1Director of Quality further stated that the rooms were in need of further cleaning. On 04/16/2024 at 2:00 p.m., interview with S2CEO revealed that the bat excrement odor in Room f has been ongoing for approximately two weeks. She stated that they were unsure where the bats were entering the hospital walls. S2CEO revealed that the hospital was in need of further action to combat the bats entry into the hospital to prevent further sanitary issues.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 36293 Based on policy review, record review and interview, the hospital failed to ensure patient complaints, requiring further investigation, were recognized as grievances. This deficient practice was evidenced by failing to correctly identify patient grievances for 1 (#2) of 1 patient reviewed for complaints/grievances from a total patient sample of 3. Findings: Review of the hospital’s policy titled, “Complaint Grievance” revealed in part: 1. A grievance is a “written or verbal complaint by a patient or the patient’s representative, regarding the patient’s care ... Patient complaints that are considered grievances also include situations where a patient or a patient’s representative telephones the hospital or health clinic with a complaint regarding the patient’s care ... A grievance may include a situation where the patient or his or her representative phones the hospital or health clinic with a concern that constitutes a grievance (i.e., the care provided to the patient ... All verbal or written complaints regarding discrimination, abuse, neglect, patient harm, or health clinic or hospital compliance with federal regulations, are grievances. Review of Patient #2’s medical record revealed the patient was admitted for obervation on 02/07/2024 and was received on the third floor at 6:00 p.m. Review of the hospital’s Complaint Grievance Logs failed to reveal Patient #2. In an interview on 02/27/2024 at 2:05 p.m., S3RN stated he received a call from Patient #2’s daughter on the morning of 02/08/2024. The patient’s daughter complained that her mother had not been seen by the staff, had not her vital signs taken and had not had anything to drink prior to this phone call. This information was received by the daughter from her mother during a telephone conversation and was relayed to S3RN during their telephone conversation. S3RN reported to this surveyor that he did not initiate a grievance report regarding this complaint. S3RN reviewed the hospital’s grievance policy and acknowledged a grievance report and investigation should have been initiated following this complaint.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 36293 Based on record review and interviews, the hospital failed to ensure the Quality Assurance/Performance Improvement (QAPI) program measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of hospital services and operations. This deficient practice was evidenced by failing to ensure operations of the vacuum system in the surgical center was monitored following the equipment failure of the vacuum pumps. Finding: Review of the hospital’s policy titled, “Medical Air and Vacuum System Failure Policy” revealed in part: ... the following procedure will be followed. Procedure-1.Communication a. In the event of a medical vacuum system failure, notify all affected departments and key personnel immediately. Departments: Respiratory Therapy; Surgery; Labor and Deliver; Recovery; Intensive Care Unit; Emergency Department; Nursing Units; Cath Lab, and One Day Surgery. Key Personnel: Respiratory Therapist; Plant Operations; Administration and Nursing Administration. 2. Response b. Respiratory Therapy in conjunction with Nursing Administration and the effected department directors will evaluate alternative methods to address patient needs including the need for portable compressors, portable suction devices and any other medical gas supplies needed to sustain patient care until services can be restored. In an interview on 02/26/2024 at 12:15 p.m., S4RN Nursing Director of Surgical Services stated the main vacuum system in the surgical center has been inoperable since October or November of 2023 and that the replacement vacuum pumps have arrived and are awaiting installation. S4 continued to state that the surgical center and its post anesthesia recovery area are currently using the stand-alone Stryker-Neptune suctions systems located in each operating suite and these devices were already in use for intraoperative suctioning of liquids and vapors. Observations 02/26/2024 at 1:45 p.m. of the Materials Management Warehouse located on the ground floor revealed two large crated boxes containing the Busch replacement vacuum pumps. In an interview on 02/26/2024 at 3:00 p.m., S2Chief Quality Officer stated she was unaware that the main vacuum system in the surgical center was inoperable. In an interview on 02/26/2024 at 3:30 p.m., S1CEO stated she was made aware in late December of 2023 that the surgical center’s main vacuum system was inoperable but did not forward the information to S2 or the QAPI department. She continued to state the new pumps have arrived and are to be installed this week in the surgery center.”