P A M Specialty Hospital of Covington

“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: 47397 Based on record review, and interview the facility failed to ensure patient care in a safe setting. The deficient practice is evidenced by: 1) failure to ensure the hospital completed criminal background checks by an authorized agent of the Louisiana State Police in the manner required by R.S. 15:587.1 et seq. prior to hire or employment for 12 (S5CNA, S11CNA, S12CNA, S23CNA, S24CNA, S25CNA, S26CNA, S27CNA, S28CNA, S29CNA, S30CNA, and S31CNA) of 12 (S5CNA, S11CNA, S12CNA, S23CNA, S24CNA, S25CNA, S26CNA, S27CNA, S28CNA, S29CNA, S30CNA, and S31CNA) non-licensed direct care staff; and 2) failure to review the LDH- Louisiana Adverse Action List Search website every six months for 12 (S5CNA, S11CNA, S12CNA, S23CNA, S24CNA, S25CNA, S26CNA, S27CNA, S28CNA, S29CNA, S30CNA, and S31CNA) of 12 (S5CNA, S11CNA, S12CNA, S23CNA, S24CNA, S25CNA, S26CNA, S27CNA, S28CNA, S29CNA, S30CNA, and S31CNA) non-licensed direct care staff. Findings: Review of hospital’s policy # NSG 02 titled “Abuse and Neglect-Internal and External”, last revised 03/20/2024, revealed in part: Policy: The hospital supports the patient’s right to receive care in a safe setting and will act to protect vulnerable patients, including the protection of the patient’s emotional and physical health and safety. The hospital maintains a policy to prevent ...allegations of abuse, neglect, or mistreatment ... Review of hospital’s policy # QM 19 titled “Patient Rights and Responsibilities”, last revised 10/21/2024, revealed in part: Procedures, 6. Patients’ Rights: Patients have the rights to: ...n) Receive care in a safe setting ... Review of hospital’s document titled, “Covington Employee Roster 10/28/2024” revealed 12 CNAs (S5CNA, S11CNA, S12CNA, S23CNA, S24CNA, S25CNA, S26CNA, S27CNA, S28CNA, S29CNA, S30CNA, and S31CNA). 1) Failure to ensure the hospital completed criminal background checks by an authorized agent of the Louisiana State Police in the manner required by R.S. 15:587.1 et seq. prior to hire or employment for 12 (S5CNA, S11CNA, S12CNA, S23CNA, S24CNA, S25CNA, S26CNA, S27CNA, S28CNA, S29CNA, S30CNA, and S31CNA) of 12 (S5CNA, S11CNA, S12CNA, S23CNA, S24CNA, S25CNA, S26CNA, S27CNA, S28CNA, S29CNA, S30CNA, and S31CNA) non-licensed direct care staff. Review of the personnel file of S11CNA revealed a hire date of 05/21/2024. Review of the personnel file of S12CNA revealed a hire date of 06/12/2007. Review of criminal background checks for S11CNA and S12CNA revealed the background checks were completed by Company A. Further review revealed Company A was not an authorized agency of the Louisiana State Police. In an interview on 10/30/2024 at 4:19 p.m., S32HR stated the hospital used Company A for all employee background checks. S32HR confirmed background checks for S5CNA, S11CNA, S12CNA, S23CNA, S24CNA, S25CNA, S26CNA, S27CNA, S28CNA, S29CNA, S30CNA, and S31CNA were completed by Company A. S32HR verified Company A was not an approved contractor by the Louisiana State Police. 2) Failure to review the LDH- Louisiana Adverse Action List Search website every six months for 12 (S5CNA, S11CNA, S12CNA, S23CNA, S24CNA, S25CNA, S26CNA, S27CNA, S28CNA, S29CNA, S30CNA, and S31CNA) of 12 (S5CNA, S11CNA, S12CNA, S23CNA, S24CNA, S25CNA, S26CNA, S27CNA, S28CNA, S29CNA, S30CNA, and S31CNA) non-licensed direct care staff. Review of LAC: Title 48, Chapter 92, Direct Service Worker Registry, revealed in part, the following: 9202. C. Licensed and/or certified health care providers shall access the registry to determine if there is a finding that a prospective hire, or currently employed or contracted DSW, has been determined to have committed exploitation, extortion, abuse or neglect of an individual being supported, or misappropriated the individual’s property or funds. If there is such a finding on the registry ...a current employee [shall not] have continued employment as a DSW with the licensed and/or certified health care provider. Further review revealed, 9231. Health Care Provider Responsibilities, ...3. access the registry in accordance with the provisions of §9202.C-C.1. B. The health care provider shall: have a written policy/process to check the DSW registry on the department’s designated database at least every six months to determine if any currently employed or contracted DSW or trainee has been placed on the registry with a finding that he/she has been determined to have committed abuse or neglect of an individual being supported or misappropriated the individual’s property or funds or committed exploitation or extortion of an individual being supported. 1. The provider shall follow the agency’s process in demonstration of compliance with this procedure... Review of the personnel file for S12CNA revealed a hire date of 06/12/2007. Continued review failed to reveal evidence the hospital reviewed the LDH- Louisiana Adverse Action List Search website every six months. In an interview on 10/30/2024 at 4:20 p.m., S32HR stated the hospital searched the LDH- Louisiana Adverse Action List Search website before hire for unlicensed staff but the hospital did not review the LDH- Louisiana Adverse Action List Search website every six months thereafter. S32HR verified the hospital failed to review the LDH-Louisiana Adverse Action List Search website every six months for S5CNA, S11CNA, S12CNA, S23CNA, S24CNA, S25CNA, S26CNA, S27CNA, S28CNA, S29CNA, S30CNA, and S31CNA.”

“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: 47397 Based on record review and interview, the facility failed to ensure the registered nurse provided adequate supervision of the patient’s care as evidenced by failure to accurately assess Patient #4 for sepsis risk. Findings: Review of hospital’s policy # NSG 36, titled “Nursing Documentation”, last revised 03/20/2024, revealed in part: Policy: The nursing services department will provide a uniform method of documentation that follows Joint Commission standards and federal/state regulations. Procedure: ...Current Status: Describe the patient’s physical status using the selections provided ...RN Screening Assessment: ...Note if the patient is at risk for any problems related to safety. If the answer is yes-complete the appropriate risk assessment. Review of Patient #4’s medical record revealed an admit date 10/26/2024. Review of History and Physical dated 10/27/2024 revealed patient was recently treated for left-sided pneumonia, paroxysmal atrial fibrillation, heart failure, and acute kidney injury before admission to LTAC. Vital signs were documented with respirations 22 breaths per minute. Further review revealed the following Lab results dated 10/25/2024: WBC 17.0. Review of Patient #4’s Lab results dated 10/27/2024 revealed WBC 20.9 10^3/uL and on 10/28/2024 his WBC was 29.2 10^3/uL. Review of Patient #4’s nursing assessment dated 10/28/2024 at 7:17 p.m. revealed a respiratory assessment indicating a labored respiratory pattern on vapotherm 20 liters per minute. A cardiovascular assessment revealing an irregular heart rate on telemetry monitoring showing atrial fibrillation. A Sepsis Screening tool titled “Systemic Inflammatory Response Syndrome (SIRS): Two or more of the following. The tool indicated if two or more of the following symptoms were present, the physician was to be notified. The symptoms included HR >90 beats per minute, RR >20 breaths per minute, temperature >100.9 and WBC > 12,000. The Sepsis Screening tool indicated Patient #4 had “None” of these symptoms. In an interview on 10/30/2024 at 10:54 a.m. S22RC verified the Sepsis Screening tool was not accurate and should have indicated that Patient #4 had a respiratory rate greater than 20 (22) and a white blood count greater than 12 (17 and 20.9). S22RC confirmed the physician should have been notified per the Sepsis Screening tool instructions.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 47397 Based on record review and interview, the nursing staff failed to ensure the nursing care plan reflected the patient’s goals and nursing care to be provided. The deficient practice is evidenced by failure of the nursing staff to include significant acute and chronic conditions in the plan of care for 4 (#1-#4) of 4 (#1-#4) patients sampled. Findings: Review of hospital’s policy #NSG 14, titled “Care Plan”, last reviewed 03/2024, revealed in part: Purpose: ...To provide guidelines for initiating, customizing, and following a goal-directed plan of care. Policy: The care plan for each individual patient shall be coordinated with his/her medical provider’s plan of care and will indicate what care is needed and how it can be be best achieved. Procedure: ...3. The care plan will include the identified patient problems, the goals to work toward, and the interventions to be utilized. Review of hospital’s policy # NSG 36, titled “Nursing Documentation”, last revised 03/20/2024, revealed in part: Purpose: The Nursing Plan of Care is reviewed for effectiveness in meeting departmental and hospital goals and objectives...RN Assessment Summary: Care Plan: List all functional patient problems requiring intervention by nursing staff. Patient #1 Review of the medical record for Patient #1 revealed admission on 04/16/2024 and discharged acutely on 04/30/2024 to a higher level of care due to decreased level of consciousness and lethargy. The History and Physical completed on 04/17/2024 listed the following diagnoses in the Assessment and Plan: s/p Acute rapid response due to unresponsiveness with profound hypotensive episode, Progressive physical decline with failure to thrive, multifactorial, including frequent falling and fractures, Acute hypoxic respiratory failure d/t acute on chronic diastolic heart failure with low ejection fraction, Recent left femur fracture, left wrist fracture, Significant 3 Vessel CAD with history of MI, low ejection fraction and recent stents. Paroxysmal Atrial Fibrillation, Liver transplant recipient on immunosuppressant therapy, Chronic mild normocytic anemia, Severe protein calorie malnutrition with failure to thrive in an adult and vascular dementia. Further review of the History and Physical revealed provider called to bedside on 04/17/2024 at 1:30 p.m. for rapid response and found patient unresponsive in bed with marked pallor and thready pulse, respirations agonal and systolic blood pressure in the 50s. Patient was placed in Trendelenburg, status post respiratory support with Ambu-bag due to worsening hypoxia in the 80s. Patient transitioned to nasal cannula. Infused 2 L fluids. Mean arterial pressure increased from 51 to 72 without pressors. Patient’s systolic blood pressure increased to 100, and patient was sleeping comfortable. Wife was present at the bedside. Review of Critical labs dated 04/29/2024 at 9:40 p.m. revealed Rapamune (sirolimus-prophylaxis of transplant rejection) level of 46.2 (normal levels between 5-15). Review of the nursing care plan dated 04/17/2024-04/19/2024 failed to reveal the following problems and related goals and interventions: s/p acute rapid response due to unresponsiveness, Recent left femur fracture, left wrist fracture, Significant 3 vessel CAD with history of MI, low ejection fraction, and recent stents, Paroxysmal Atrial Fibrillation, Liver transplant recipient on immunosuppressant therapy and anemia. In an interview on 10/30/2024 at 2:34 p.m., S22RC confirmed the above findings and verified the care plan did not include all of Patient #1’s identified patient problems, the goals to work toward, and the interventions to be utilized. Patient #2 Review of the medical record for Patient #2 revealed admission on 10/11/2024 for Dysphagia and Hypoxic Respiratory Failure. The History and Physical completed on 10/12/2024 listed the following diagnoses in the Assessment and Plan: Hyponatremia, Dysphagia, Paroxysmal Atrial Fibrillation, Hypertension, Congestive Heart Failure, and Anemia. Review of the nursing care plan initiated on 10/11/2024 failed to reveal the following problems and related goals and interventions: Risk for infection, Anemia, Paroxysmal Atrial Fibrillation, Hypertension, and Congestive Heart Failure. In an interview on 10/29/2024 at 3:21 p.m., S20CNO confirmed the above findings and verified the care plan did not include all of Patient #2’s identified patient problems, the goals to work toward, and the interventions to be utilized. Patient #3 Review of the medical record for Patient #3 revealed admission on 04/12/2024 for Cytomegaloviral Disease; Acute on Chronic Respiratory Failure, and Panctyopenia. Patient #3 expired on 05/04/2024. The History and Physical completed on 04/13/2024 listed the following diagnoses in the Assessment and Plan: Acute on Chronic Respiratory Failure with Hypoxia, Interstitial Pulmonary Disease, Cytomegaloviral Disease, Coronary Artery Disease, new onset Paroxysmal Atrial Fibrillation/Flutter, Thrombocytopenia, Diastolic Heart Failure secondary to arrhythmia and pulmonary disease, Kidney Transplant recipient on Chronic Immunosuppressant Therapy, Chronic Kidney Disease, Severe Protein Calorie Malnutrition, Diabetes Mellitus Type 2, and Hypertension. Review of the nursing care plan initiated on 04/12/2024-05/01/2024 failed to reveal the following problems and related goals and interventions: Cytomegaloviral Disease, Coronary Artery Disease, new onset Paroxysmal Atrial Fibrillation/Flutter, Thrombocytopenia, Diastolic Heart Failure secondary to arrhythmia and pulmonary disease, Kidney Transplant recipient on Chronic Immunosuppressant Therapy, Chronic Kidney Disease, Diabetes Mellitus Type 2, and Hypertension. In an interview on 10/30/2024 at 12:45 p.m., S33DQI confirmed the above findings and verified the care plan did not include all of Patient #3’s identified patient problems, the goals to work toward, and the interventions to be utilized. Patient #4 Review of the medical record for Patient #4 revealed admission on 10/26/2024. On 10/29/2024, Patient #4 was transferred to a higher level of care for atrial fibrillation with rapid ventricular response and large volume melena. The History and Physical completed on 10/27/2024 listed the following diagnoses in the Assessment and Plan: Debility, Left-sided pneumonia, Acute Kidney Injury, Chronic Kidney Disease Stage 3, Chronic combined systolic and diastolic heart failure, Acute on chronic hypoxic respiratory failure, COPD, Interstitial lung disease, Normocytic Anemia, Paroxysmal atrial fibrillation, Diabetes mellitus type 2, Coronary Artery Disease, Hyperlipidemia, Obstructive sleep apnea, GERD, and Hypothyroidism. Review of Patient #4’s Lab results revealed the following: 10/27/2024-WBC 20.9 10^3/uL. Hemoglobin/Hematocrit 6.9/22. 10/28/2024-WBC 29.2 10^3/uL. Hemoglobin/Hematocrit 7.7/24.3. BUN 132. Creatinine 2.15. Glucose level 163. Review of the nursing care plan dated 10/26/2024-10/29/2024 failed to reveal the following problems and related goals and interventions: Risk for infection, Anemia, Diabetes, Hyperlipidemia, GERD, Acute Kidney Injury, Chronic Kidney Disease Stage 3, and Hypothyroidism. In an interview on 10/30/2024 at 11:05 a.m., S22RC confirmed the above findings and verified the care plan did not include all of Patient #4’s identified patient problems, the goals to work toward, and the interventions to be utilized. 50453”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 47397 Based on observations, record review and interview, the Director of Nursing failed to ensure all nursing staff adhered to the policies and procedures of the hospital. This deficient practice is evidenced by: 1) failure of nursing staff to document provider notification for increased heart rate and decreased blood pressure per physician orders in 1 (#4) of 4 (#1-#4) patients sampled; and 2) failure to titrate O2 for decreased oxygen saturation less than 90% per physician orders in 1 (#1) of 4 (#1-#4) patients sampled. Findings: Review of hospital’s policy # NSG 02 titled “Abuse and Neglect-Internal and External”, last revised 03/20/2024, revealed in part: Definitions: Neglect/Mistreatment: Failure to provide the prescribed medical care and treatment for their physical and mental health needs. Actions by an employee contrary to prescribed treatment ... 1) Failure of nursing staff to document provider notification for increased heart rate and decreased blood pressure per physician orders in 1 (#4) of 4 (#1-#4) patients sampled. Review of Patient #4’s physician orders dated 04/17/2024 revealed the following: Notify MD of pulse ...>120 ... Notify MD of systolic blood pressure less then 90 ... Review of Patient #4’s medical record revealed a telemetry monitor Trend Review dated 10/29/2024 at 9:08 a.m. with the following blood pressures and heart rates: 4:59 a.m.-Blood Pressure-85/53. 5:03 a.m.-Heart Rate-121 7:59 a.m.-Blood Pressure-87/53 7:59 a.m.-Heart Rate-128 8:00 a.m.-Heart Rate-125 8:15 a.m.-Heart Rate-122 8:30 a.m.-Heart rate-124 8:45 a.m.-Blood Pressure-84/40 Review of nursing notes and nursing assessments on 10/29/2024 for the time-period 4:59 a.m.-8:45 a.m., failed to reveal documentation the provider was notified as per Patient #4’s physician orders dated 04/17/2024. In an interview on 10/30/2024 at 10:30 a.m., S22RC verified the nursing notes and nursing assessments on 10/29/2024 for the time-period 4:59 a.m.-8:45 a.m., failed to reveal documentation the provider was notified of the above findings per Patient #4’s physician orders dated 04/17/2024. 2) Failure to titrate oxygen liters per minute for decreased oxygen saturation less than 90% per physician orders in 1 (#1) of 4 (#1-#4) patients sampled. Review of Patient #1’s physician orders dated 04/16/2024 revealed the following: Oxygen Therapy Continuously. Oxygen Deliver: Nasal Cannula. Liters per minute to keep oxygen saturation greater than 90%. Review of vital signs log for Patient #1 revealed the following: 04/20/2024 oxygen saturation 86% at 7:30 p.m. 04/26/2024 oxygen saturation 88% at 6:43 p.m. 04/29/2024 oxygen saturation 87% at 6:19 a.m. Review nursing notes and assessments on 04/20/2024, 04/26/2024, and 04/29/2024 failed to reveal documentation the oxygen liters per minute were adjusted or other interventions to increase the oxygen saturation to greater than 90% per physician order. In an interview on 10/30/2024 at 1:12 p.m., S22RC verified nursing notes and assessments on 04/20/2024, 04/26/2024, and 04/29/2024 for patient #1 failed to reveal documentation the oxygen liters per minute were adjusted or other interventions to increase the oxygen saturation to greater than 90% per physician order.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 47397 Based on record review and interview, the nursing staff failed to follow hospital policy and standard of care for medication administration. The deficient practice is evidenced by failure to follow up for effectiveness after administration of PRN medication in 2 (#2, #3) of 4 (#1-#4) patients sampled. Findings: Review of hospital’s policy # NSG 29 titled “Medication Administration Record and Medication Administration”, last revised 03/20/2024, revealed in part: MAR Procedure ...Reassessment and documentation of patient response to PRN medications: Patient response to PRN medications will be assessed within 4 hours after administration. Patient response to PRN medications will be documented in the patient care record. Patient #2 A review of Patient #2’s medical record revealed an order for Acetaminophen 325 mg (2 tablets) by mouth every 6 hours as needed for pain. Review of Patient #2’s medication administration record revealed Patient #2 was administered Acetaminophen 650 mg by mouth on 10/21/2024 at 10:00 p.m. Further review of Patient #2’s medical record failed to reveal a re-evaluation of the effectiveness of the Acetaminophen documented within 4 hours of administration per policy. In an interview on 10/29/2024 at 3:55 p.m. S20CNO confirmed the above finding and verified there was no documented re-evaluation of the effectiveness of the medications listed above within 4 hours of administration as per policy. Patient #3 A review of Patient #3’s medical record revealed the following orders: Tramadol 50 mg by mouth every 12 hours PRN for pain. Morphine Sulfate 2 mg/ml, IV push every 2 hours PRN for air hunger. Review of Patient #3’s medication administration record revealed Patient #3 was administered the following PRN medications: Tramadol 50mg by mouth on 05/03/2024 at 12:10 a.m. Morphine Sulfate 2mg IV push on 05/03/2024 at 9:28 p.m. Morphine Sulfate 2mg IV push on 05/04/2024 at 3:34 a.m. Morphine Sulfate 2mg IV push on 05/04/2024 at 6:46 a.m. Further review of Patient #3’s medical record failed to reveal a re-evaluation of the effectiveness of the medications listed above within 4 hours of administration per policy. In an interview on 10/30/2024 at 12:57 p.m. S33DQI confirmed the above findings and verified there was no documented re-evaluation of the effectiveness of the medications listed above within 4 hours of administration as per policy. 50453”