United Medical Healthwest-New Orleans

“CONTRACTED SERVICES CFR(s): 482.12(e)(1) The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. This Standard is not met as evidenced by: 44495 Based on record review and interview, the governing body failed to ensure contracted services were provided in a safe and effective manner. The deficient practice is evidenced by failure of the facility to establish a policy addressing the procedure to be followed when patients are transported outside the hospital for medical care. Findings: Review of the medical record for Patient #3 revealed admission on 02/26/2024 and discharged on 03/18/2024. Further review revealed the Patient #3 had no discharge orders. In interview on 04/18/2024 at 2:15 p.m., S3DON explained Patient #3 was taken unchaperoned to an appointment at another facility via the contracted transport and never returned. The incident was investigated and the facility determined that the patient had left AMA. During the interview, S3DON verified she did not know if the facility had a policy requiring patients who were taken to offsite care to be chaperoned, but stated a chaperone was routinely provided for the offsite visits, but in this case, the driver left without the chaperone. On 04/18/2024 at 2:15 p.m., the surveyor requested the transport policy or a policy for offsite medical care. In interview on 04/18/2024 at 3:25 p.m., S3DON verified the policy could not be found.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 44495 Based on observation and record review, the facility failed to ensure it was capable of informing each patient of his/her rights in a manner that he/she could understand. The deficient practice is evidenced by failure to ensure interpreter services were available if required. Findings: Review of Policy 14424767, “Communication, Non-English Speaking,” last approved 05/2017, revealed in part, “If language or communication barriers exist between staff and patients, arrangements shall be made for interpreters of for the use of other mechanisms to ensure adequate commenication between patients and staff.” On 04/17/2024 at 12:23 p.m., S3DON tried to use the tablet used for translation services, but stated her passcode was not correct. Review of the contract for translation services revealed the contract was from 10/29/2012 and renewed and annually. Further review of the contract revealed the services were billed monthly and there was a surcharge if the average monthly use was below the projected usage in the agreement. On 04/18/2024 at 10:00 a.m., the surveyor request proof of monthly payments to the translating service. On 04/18/2024 at 3:45 p.m., S1Adm verified she had not received proof the facility was still paying for the service and stated there was no one there that knew the access code to show that it was still active.”

“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: 44495 Based on record review and interview, the facility failed to report all incidents of possible abuse or neglect. The deficient practice is evidenced by failure to report possible abuse or neglect as required by R.S. 40:2009.20 in 1(#3) of 1 reviewed incident where the patient did not return to the facility as planned. Findings: Review of LA R.S. 40:2009.20 revealed in part, “Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, licensed practical nurse, nurse’s aide, home- and community-based service provider employee or worker, personal care attendant, respite worker, physician’s assistant, physical therapist, or any other direct caregiver having knowledge that a consumer’s physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect.” Review of the medical record for Patient #3 revealed the documentation in the patient’s medical record ended on 03/18/2024. There were no discharge orders and no discharge summary. In interview on 04/18/2024 at 2:15 p.m., S3DON verified that the patient left the facility but was not discharged. On 03/18/2024 the patient was transported unchaperoned from the facility to a physician’s appointment at Hospital B. Once the nursing staff realized the patient had been transported without a chaperone, two members of the staff traveled to Hospital B to look for him, but could not find him. The police, physician, and the patient’s daughter were notified of the missing person. An in investigation was conducted and it was determined that the transport driver left without the chaperone. The patient was considered to have left against medical advice because they felt he was at baseline despite a history of bipolar disease with psychotic features. S3DON verified the staff involved were disciplined, but a self- report of possible neglect was not generated because management felt the facility was not responsible for the incident.”

“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: 44495 Based on record review and interview, the facility failed to provide a nursing care plan per hospital policy. The deficient practice is evidenced by failure to develop a nursing care plan within 8 hours of admission for 1(#3) of 3 (#1-#3) reviewed patient records. Findings: Review of Policy #14224971 “Patient Care Standards,” last approved 02/2015, revealed in part, “A total physical and emotional assessment will be made for each patient immediately upon admission. Assessment will be ongoing. A nurses admission and assessment record” will be filled out for each patient admitted within 2 hours of admission and completed within eight (8).” Review of the medical record for Patient #3 revealed admission on 02/26/2024 at 9:45 p.m. Review of the nursing assessment revealed it was completed 02/29/2024 at 4:01 p.m. In interview on 04/18/2024 at 1:56 p.m., S3DON verified the assessment was not completed within 8 hours.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 44495 Based on record review and interview, the facility failed to ensure patient assignments were completed daily at the start of each shift. the deficient practice is evidenced by failure of the nursing staff to complete the assignments at the begining of the shift on the first day of the survey. Findings: During the entrance conference on 04/17/2024, Nurse Staffing Assignemnts were requested for the past 2 months. On 04/17/2024 at 12:05 p.m., the surveyor reviewed the provided documents and noted the Nursing Assignment for the current shift was not provided. On 04/17/2024 at 12:16 p.m., the surveyor requested the document from S3DON. S3DON then asked S4RN who verified she was working on the assignments and would provide them shortly.”

“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: 44495 Based on record review and interview, the hospital failed to ensure nursing staff followed hospital policies. The deficient practice is evidenced by: 1) failure to perform glucometer controls on 5 of 12 reviewed days and failure to report or repeat an out of range control result; and 2) failure to ensure a staff registered nurse provided supervision of contract nurses. Findings: 1) Failure of nursing staff to perform glucometer controls on 5 of 12 reviewed days and failure to report or repeat an out of range control result. Review of Policy #14224970, “Glucometer Quality Controls Testing,” last approved 03/2015, revealed in part, “Quality Control testing will be performed nightly by the nursing staff. Quality control log is maintained on the nursing unit and results are monitered by the DON. . . . PROCEDURE- See manufacture’s instructions for use.” There was no information in the policy of the procedure for out of range results. Review of the Glucometer Maintenance Quality Control Record from 04/05/2024 through 04/16/2024 revealed the controls were not performed 04/07/2024, 04/08/2024, 04/11/2024, 04/14/2024, and 04/16/2024. Further review revealed on 04/05/2024 at 11:00 p.m. a low control of 39 was documented which was out of the standard range of 42-72. There was no documentation that the result was repeated or a supervisor notified. At the time of discovery on 04/17/2024 at 12:23 p.m., S3DON verified the above findings. 2) Failure to ensure a staff registered nurse provided supervision of contract nurses. Review of the Daily Staffing Assignement sheet for 03/10/2024 for the evening shift revealed the only Registered Nurse on the assignment sheet was an agency nurse. In interview on 04/18/2024 at 1:30 p.m., S3DON verified the agency nurse was the charge nurse for the evening. S3DON stated that S1ADM was frequently at the facility all night and was a Registered Nurse. S3DON verified there was no documention S1Adm had supervised the care provided by the agency nurse.”

“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: 44495 Based on record review and interview, the facility failed to ensure prn medications were given according to standard of care. The deficient practice is evidenced by failure to re-evaluate the patient for efficacy of the medication after administration. Findings: Review of Policy #14198058, “Medication Administration,” last approved 01/2022, revealed in part, “14. Patient response to medications is documented on back of MAR or in nurse’s notes . . . “ Review of the Medication Administration Record for Patient #2 revealed an order for oxycodone 5 milligram- give one by mouth every 4 hours as needed. The medication was administered on 04/13/2024 at 6:25 p.m. for pain 7 of 10. The response to the medication was not documented. The medication was also administered on 04/17/2024 at 6:00 p.m. and the reason for administration and the response were not documented. In interview on 04/18/2024 at 2:55 p.m., S3DON verified the documentation was not per standard of care and hospital policy.”

“VERBAL ORDERS FOR DRUGS CFR(s): 482.23(c)(3)(i) If verbal orders are used, they are to be used infrequently. This Standard is not met as evidenced by: 44495 Based on record review and interview, the facility failed to ensure verbal orders were documented according to hospital policy and standard of care. The deficient practice is evidenced by verbal orders documented without identifying the prescribing practitioner in 1(#2) of 3 (#1-#3) reviewed medical records. Findings: Review of Policy #14968023, “Acceptance of Physician’s Telephone/ Verbal Orders,” revealed in part, “The licensed professional taking the order shall note confirmed verbal or telephone order, date and time, physician’s name, and sign the entry with first initial, last name, and credentials of the person order on the physician order sheet.” Review of the orders for Patient #2 revealed the following orders documented on 04/10/2024 by S10RN: -Oxycodone 10 mg tab. Give one tablet by mouth one hour prior to wound care. -Benadryl 25 mg tab. Give one tablet by mouth twice a day as needed for itching. -Juven BID. Liquacel 30 ml TID by mouth. -Ensure TID. Large portions no pork or gelatin. The orders were not documented as verbal orders or telephone orders and did not have the name of the prescribing practitioner. In interview on 04/18/2024 at 2:53 p.m., S3DON verified the orders were not documented as verbal orders and did not have the name of the prescribing practitioner.”

“CONTENT OF RECORD: DISCHARGE SUMMARY CFR(s): 482.24(c)(4)(vii) [All records must document the following, as appropriate:] Discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care. This Standard is not met as evidenced by: 44495 Based on record review and interview, the hospital failed to meet requirements for medical records. The deficient practice is evidenced by failure to include a discharge summary in the medical record for 1(#3) of 1 reviewed record of a patient who was no longer at the facility. Findings: Review of the medical record for Patient #3 revealed the patient was admitted on 02/26/2024 with a diagnosis of spinal trauma. On 03/18/2024 the patient was transported to a medical visit at a facility outside the hospital and never returned. Review of the medical record on 04/18/2024 failed to reveal a discharge summary with the outcome of the hospitalization and provisions for follow-up csre. In interview on 04/18/2024 at 2:49 p.m., S3DON verified there was no discharge summary and no discharge order because the patient was not discharged by the physician.”

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 44495 Based on observation and interview the facility failed to ensure stock medications were handled according to standard of care. The deficient practice is evidenced by 1) failure to the nursing staff to label all multi-dose bottles with the date of opening or a beyond use date; 2) failure to discard unusable influenza vaccinations; 3) failure to monitor temperature on the medication refrigerator and document medications were discarded when the temperature was out of range. Findings: 1) Failure to the nursing staff to label all multi-dose bottles with the date of opening or a beyond use date Direct observation on 04/17/2024 at 10:05 a.m. revealed the following open multi-dose bottles with no open date and no beyond use date: Magnesium oxide 400mg B12 1000 mg Vitamin A 10,000 units Bisacodyl 5 mg Vitamin D3 50,000 iu Ferrous sulfate 325 mg Vitamin C250 mg Simethicone 80 mg Maalox 400 mg Nexium 20 mg Tylenol 325 mg Melatonin 3 mg Folic Acid 400 mcg Renal Caps Aspirin 81 mg- 2 bottles Fish oil 1000 mg Probiotics Diphenhydramine 25 mg Loratadine 10 mg Thiamine 100 g MVI Calcium Carbonate 500 mg In interview on 04/17/2024 at 10:45 a.m., S11CP verified the findings. S11CP verified it was standard of care for health care facilities to label open stock medications with the date of opening or the beyond use date, but was not aware of the facility’s policy because the contracted pharmacy did not supply or manage the over the counter stock medications for the facility. In interview on 04/18/2024 at 3:09 p.m., S3DON verified it was standard of care to label the open stock medications with the date of opening or beyond use date. S3DON verified she was not aware of the hospital’s established beyond use date and could not find a policy that addressed the issue. S3DON called a second pharmacist at the contracted pharmacy and was told the hospital’s administration handled the management of the over the counter medications. 2) Failure of the hospital to discard unusable influenza vaccinations. Tour of the medication room on 04/17/2024 between 10:05 a.m. and 11:15 a.m. revealed a box of influenza vaccination syringes with part of the box frozen to the back of the refrigerator. In interview on 04/18/2024 at 11:33 a.m., S3DON was verified the finding and stated they should have already been thrown away because it was too late to be administering flu shots. 3) Failure of the hospital to monitor temperature on the medication refrigerator and document items were discarded when the temperature was out of range. Review of Policy #15153723, “Refrigerator Guidelines,” last approved 03/2024, revealed in part, “Medicine refrigerator: -Only refrigerated medications are allowed in Medication Refrigerator. -Temperature range for refrigerator should remain between 36 -40 degrees F. -Temperatures are recorded twice a day on Log (attached) by designated staff member. -If the temperature falls out of the acceptable range, troubleshooting may include adjusting the temperature dial or contacting maintenance. Troubleshooting should be documented on the log.” Tour of the facility on 04/17/2024 at 10:30 a.m., revealed the refrigerator contained Novalog insulin, Glargin YFGN insulin, and influenza vaccinations. The refrigerator was noted to have a large buildup of ice in the back of the refrigerator. Review of the April 2024 log for the refrigerator revealed the statement, “Temperature must be 40 degrees or below.” Documentation revealed refrigerator temperature was not checked on 04/02/2024, 04/03/2024, 04/04 /2024, 04/07/2024, 04/12/2024, 04/13/2024, 04/14/2024, and 04/16/2024. The refrigerator was checked once on 04/01/2024, 04/05/2024, 04/06/2024, 04/08/2024, 04/09/2024, 04/10/2024, 04/11/2024, and 04/15/2024. Of those dates the refrigerator was out of range on 04/08/2024 when the temperature was documented as 50 degrees F, and 04/15/2024 when the temperature was documented as 52 degrees F. The log contained no documentation of troubleshooting or notification of maintenance. In interview on 04/17/2025 at 10:35 a.m., S3DON verified the refrigerator had not been properly maintained.”

“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: 44495 Based on observation and interview, the hospital failed to maintain the facility and supplies to an acceptable level of safety and quality. The deficient practice is evidenced by 1) failure to provide hot water for handwashing in the patient nourishment room; and 2) Using tape to hold the battery in the temporal thermometer. Findings: Tour of the facility on 04/14/2024 between 10:05 a.m. and 11:15 a.m. revealed there was no water released from the faucet in the patient nourshiment room when the knob for hot water was turned and the temporal thermometer in the rolling basket with the blood pressure cuff had tape holding the battery case closed. In interview on 04/17/2024 at 10:59 a.m., S3DON verified the tape on the thermometer. In interview on 04/17/2024 at 2:45 p.m., S3DON verified the hot water had been disconnected because the faucet was used as an eye wash station.”

“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: 44495 Based on record review and interview the hospital failed to ensure food was maintained to prevent bacterial growth. The deficient practice is evidenced by 1) failure to maintain the temperature log for the patient nourishment refrigerator; 2) failure to prevent storage of previously consumed items in the patient nourishment refrigerator; 3) failure to monitor the temperature of food served at the facility. Findings: Review of Policy #15153723, “Refrigerator Guidelines,” last approved 03/2024, revealed in part,” Patient nourishment refrigerator: . . . Temperatures are recorded daily on Log (attached) by designated staff member. . . .Partially consumed food cannot be returned to the refrigerator/freezer for later consumption.” 1) Failure of the facility to maintain the temperature log for the patient nourishment refrigerator. Tour of the facility on 04/17/2024 between 10:05 a.m. and 11:15 a.m. revealed the logs on the patient nourishment refrigerator temperature was not checked on 04/01/2024 - 04/06/2024. 04/09/2024, 04/13/2024, and 04/14/2024. In interview on 04/17/2025 at 11:14 a.m., S5RN verified the logs were not filled out every day. 2) Failure of the hospital to prevent storage of previously consumed items in the patient nourishment refrigerator. Direct observation on 04/17/2024 at xx revealed a styrofoam cup with a straw from a fast food chain with approximately 80% of the contents consumed. In interview on 04/17/2025 at 11:14 a.m., S4RN verified the partially consumed drink was an infection control issue. 3) Failure to monitor the temperature of food served at the facility. Review of Policy #14224659, Food Delivery,” last approved 03/2015, revealed in part, “PERFORMANCE IMPROVEMENT: 1. PI tasks, such as checking food line for temperature, texture, and accuracy of preparation as well as sanitation testing will be performed by the nursing staff, 2, Random food temperature checks will be performed by a member of the Nutritional Staff.” During tour of the facility on 04/17/2024 at 11:13 a.m., the surveyor noted the metal cart used for distributing meals was sitting unattended near the nursing desk. At 11:23 a.m. S7PCT began moving the cart down the hall and began to distribute the meals without checking the temperature. In interview on 04/17/2024 at 11:24 a.m., S7PCT verified the staff were not instructed to check the temperatures before distributing the meals. S7PCT verified the temperatures were only checked before they left the kitchen.”

“COMPLIANCE WITH LAWS CFR(s): 482.11(a) The hospital must be in compliance with applicable Federal laws related to the health and safety of patients. This Standard is not met as evidenced by: 48051 Based on record review and interview the hospital failed to comply with applicable federal laws and regulations related to the health and safety of patients. This deficient practice is evidenced by failure of the hospital to notify the Louisiana Department of Health (LDH) of a change in laboratory director within 30 days. Findings: A review of Clinical Laboratory Improvements Amendments of ‘88 reveals CFR 493.39: Requirement to notify the U.S. Department of Health and Human Services (HHS) or its designee (LDH) within 30 days of a director change. A record review of the hospital’s Clinical Laboratory Improvements Amendments (CLIA) Certificate of Waiver with an effective date of 11/26/2023, revealed S11Lab as the Laboratory Director. A review of the hospital’s personnel list and organizational chart failed to reveal S11Lab as an employee. In an interview on 04/10/2024 at 9:15 a.m. S2Adm confirmed the above mentioned findings.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 48051 Based on record review, policy review and interview, the hospital failed to protect the patient’s right to personal privacy. This deficient practice is evidenced by the facility releasing patient information without properly identifying the patient prior to the release. Findings: A review of facility policy, “Patient Rights,” last reviewed 10/2006 revealed in part, Policy: The basic rights of human beings for independence of expression, decision, and action and concern for personal dignity and human relationships are always of great importance. It becomes a prime responsibility for hospitals to endeavor to assure that these rights are preserved for their patients. Purpose: ...intended to convey the rehab hospital’s concern about the relationship between hospitals and patients and to emphasize the need for the observance of rights and responsibilities of patients. 3. Privacy and Confidentiality: The patient has the right, within the laws, to personal and informational privacy, as manifested by the following rights: To expect that any discussion or consultation involving his case will be conducted discreetly. To have his medical record read only by individuals directly involved in his treatment or in the monitoring of its quality and by other individuals only on his written authorization or that of his legally authorized representative. To expect all communications and other records pertaining to his care, including the source of payment for treatment, to be treated as confidential. A Patient’s Bill of Rights: 5. The patient has the right to every consideration of his privacy concerning his own medical care program. Case discussion, consultation, examination, and treatment are confidential and should be conducted discreetly. Those not directly involved in his/her care must have permission of the patient. 6. The patient has the right to expect that communications and records pertaining to his/her care should be treated as confidential. A medical record review with the S3DON navigating the electronic medical record (EMR) and paper medical record revealed in part, case management notes reflecting S5CM discussing Patient #1 via telephone conversation without properly identify which patient the call was in reference. Further, patient information was released to this individual without properly identifying to whom the information was being released. Case Management note on 01/23/2024 at 12:07 p.m. revealed, “Received a call from Governor’s office of elderly affairs concerning Patient #1(name was removed). Was informed patient had no running water or electricity to the home.” This note did not contain information as to whom was making this request. The medical record did not contain any written authorization by this agency to obtain information regarding Patient #1. Further, there was no indication that proper patient identification was performed. After S5CM made contact with Patient #1’s daughter and the concerns regarding the elderly affairs information was discussed, S5CM note on 01/23/2024 at 12:07 p.m. revealed, “Called elderly protective services to confirm information and this was a miscommunication on my part and there part it was concerning another patient with the same last name.” This note did not contain information as to the name or contact information of whom this information was discussed. In an interview on 02/09/2024 at 4:24 p.m. Patient’s #1’s daughter revealed in part she received a 4 minute voice mail from S5CM regarding the facility being contacted by a state agency that was identified as Governor’s office of elderly affairs, information that the patient would need to be placed in a nursing facility and the patient’s current treatment and progression. Patient #1’s daughter indicated she had not spoken with S5CM prior to this voice mail and she was upset this type of information would be left on a voice mail. A review of the voice mail received by Patient #1’s daughter revealed the above mentioned comments and was approximately 4 minutes in length. In an interview on 04/11/2024 at 9:20 a.m. S5CM confirmed the above mentioned findings. She further confirmed there was no way to verify patient identification via a voice mail.”

“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: 48051 Based on record review and interview, the hospital failed to ensure each patient received care in a safe setting. This deficient practice was evidenced by 2 (S7CNA, S8CNA) of 2 (S7CNA, S8CNA) personnel records reviewed for criminal background check completion prior to hire was not performed by an authorized agent of the Louisiana State Police. Findings: La RS 40:1203.1 - 5 requires in part, all licensed health care providers shall request that a criminal history and security check be conducted on the non-licensed person, prior to any employer making an offer to employ or to contract with a non-licensed person to provide nursing care, health-related services or supportive assistance to any individual. The Louisiana Office of State Police, Bureau of Criminal Identification and Information (Bureau), is the State’s designated repository for criminal history information pursuant to the laws cited in La. R.S. 15:575 et seq. Any criminal event that is documented by the submission of fingerprints to the State is stored in the Louisiana Computerized Criminal History (LACCH) database. The Bureau may only release criminal history information stored in LACCH for noncriminal justice purposes when authorized by law. The Bureau is authorized to release criminal history information stored in LACCH to those employers and Authorized Agencies defined in La. R.S. 40:1203.1 as required by La. R.S. 40:1203.2. Pursuant to La. R.S. 40:1203.7, Authorized Agencies must be domiciled in the state of Louisiana and must be certified by the La. Secretary of State’s office. Authorized Agents must also be certified by the Bureau. Companies that perform background check services that are not domiciled in Louisiana nor certified through the Secretary of State’s office and the Bureau are not authorized to request or receive criminal history information stored in LACCH. Additionally, Authorized Agents are not authorized to request criminal history information on behalf of national background check companies. La. R.S. 15:579 mandates the Bureau to issue rules and regulations consistent with the U.S. Dept. of Justice governing the privacy and security of criminal history records. To meet this requirement, the Bureau has adopted rules and regulations including those described in 28 Code of Federal Regulations (CFR) 20.21 which limits the release of criminal history information to only those agencies authorized by statute. Employers may contact LDH or the Bureau for a current list of Authorized Agencies. A personnel file review on 04/11/2024 revealed S7CNA’s date of hire was 03/10/2024 and S8CNA’s date of hire was 03/02/2024. Initial hire criminal background checks were completed by Company A. This company was not an authorized agency approved by the Louisiana State Police for the use of conducting a criminal background check on a non-licensed employee of a licensed healthcare provider. In an interview on 04/11/2023 at 12:15 p.m., S2Adm and S6CFO confirmed the above mentioned findings.”

“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: 48051 Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by: 1) Failing to ensure capillary blood glucose levels were obtained for 1 (#1) of 3 (#1 #3) patients as ordered; 2) Failing to document interventions related to blood glucose results on 1 (#1) of 3 (#1 #3) patients; 3) Failing to ensure blood pressure readings were obtained appropriately on 1 (#1) of 3 (#1 #3) patients; and 4) Failing to ensure blood pressure and heart rate was documented prior to administering anti-hypertensive medications on 1 (#1) of 3 (#1 #3) patients. Findings: 1) Failing to ensure capillary blood glucose levels were obtained for 1 (#1) of 3 (#1 #3) patients as ordered A review of Patient #1 medical record revealed an order for Accuchecks before meals and at bedtime. A review of the Medication Administration Record (MAR) revealed no documentation of a blood glucose reading on the following dates and times: 01/15/2024 at 6:30 a.m. and 4:30 p.m.; 01/16/2024 at 6:30 a.m.,11:30 a.m.; 01/24/2024 at 11:30 a.m., 4:30 p.m.; 01/25/2024 at 6:30 a.m., 11:30 a.m.; 01/29/2024 at 4:30 p.m.; 01/30/2024 at 4:30 p.m.; 02/03/2024 at 6:30 a.m., 4:30 p.m.; 02/04/2024 at 6:30 a.m.; and 02/05/2024 at 6:30 a.m., 11:30 a.m., 4:30 p.m. In an interview on 04/09/2024 at 1:30 p.m. S3DON confirmed the above mentioned findings. 2) Failing to document interventions related to blood glucose results on 1 (#1) of 3 (#1 #3) patients A review of the sliding scale standing orders revealed a glucose reading of < 69 and symptomatic = call MD; < 70 and can swallow OJ and recheck in 30 minutes, or give one-half amp of D50 as needed; 70-199 = 0 units; 200-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units; 401-450 = 12 units. A review of Patient #1 medical record revealed an order for insulin per sliding scale. A review of the MAR revealed no documentation for the amount of insulin administer or held on the following dates and times: 01/16/2024 at 4:30 p.m. with result of 222; 01/25/2024 at 4:30 p.m. with result of 275; 01/29/2024 at 11:30 a.m. with result of 434; and 02/04/2024 at 4:30 p.m. with result of 257 In an interview on 04/09/2024 at 1:30 p.m. S3DON confirmed the above mentioned findings. 3) Failing to ensure blood pressure readings were obtained appropriately on 1 (#1) of 3 (#1 #3) patients A review of facility policy, “Blood Pressure Assessment,” with a last review of 10/2022 revealed in part, Special Consideration: 3. Do not take a blood pressure in the arm of a patient who has any of the following without first consulting the nurse or physician: b. a fistula or dialysis catheter. A review of Patient #1 medical record revealed a nursing progress note from 01/14/2024 indicating the patient having a left upper arm fistula. Further review revealed blood pressure readings via the left arm on the following dates: 01/19/2024 at 7:09 a.m. 146/51 Left Arm; 01/20/2024 at 6:00 p.m. 147/77 Left Arm; 01/21/2024 126/56 Left Arm; and 01/29/2024 at 8:20 p.m. 143/69 Left Arm. In an interview on 04/09/2024 at 1:30 p.m. S3DON confirmed the above mentioned findings. 4) Failing to ensure blood pressure and heart rate were documented prior to administering anti-hypertensive medications on 1 (#1) of 3 (#1 #3) patients A review of Patient #1’s MAR revealed an order associated with the administration of amlodipine. The order included the documentation of a blood pressure and heart rate on the MAR upon the administration of this medication. The blood pressure and heart rate were not documented on the following dates: 01/15/2024 at 8:00 a.m.; 01/24/2024 at 8:00 a.m.; and 02/05/2024 at 8:00 a.m. In an interview on 04/09/2024 at 1:30 p.m. S3DON confirmed the above mentioned findings.”

“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: 48051 Based on record review, policy review and interview, the hospital failed to ensure the nursing care plan for each patient was kept current and reflected the patient’s goals and the nursing care to be provided to meet the patient’s needs. This deficient practice was evidenced by 2 (#1, #2) of 3 (#1-#3) patient medical records reviewed not having a nursing care plan to reflect the patient’s current physiologic condition. Findings: A review of facility policy, “Individual Plan of Care,” with a last review on 01/2022 revealed in part, Policy: All patient will have an individualized plan of care that is individually tailored, integrated and coordinated by competent professional through licensure, training and experience. Purpose: To establish a comprehensive, goal-oriented, individualized plan for each patient served based on assessment of patient physical, cognitive, behavioral communicative, emotional, pharmacological, pain management, and social needs. Procedure: 1. Each patient has a care plan developed based on the initial assessment. A problem list is developed, and individualized plan is developed through the initial assessment. 2. The individualized care plan includes the following information presently: a. identified nursing problems from a head-to-toe assessment and the functional limitation and presenting need. 3. The patient’s care plan is incorporated into the interdisciplinary care plan and problems and goal attainment is discussed at the weekly team conference. A review of the EMR and paper medical record being navigated by S3DON revealed the following: Patient #1: Admission on 01/14/2024 at 5:45 p.m. Nursing admission progress note revealed in part, a skin tear to sacral area and left upper arm fistula. The plan of care revealed the nursing problem list being initiated on 01/23/2024. This would be 9 days after the admissions of the patient. The nursing problem list included risk for unstable blood glucose, alteration in fluid volume, and patient safety. The nursing problem list did not include any problem related to Impaired Tissue integrity (wound care) or Alterations in Skin Integrity. Patient #2: Admission on 03/21/2024 at 1:32 p.m. History and Physical revealed in part, the patient being admitted to acute care for Congestive Heart Failure with chronic left lower neuropathy. Recent hospitalization left him with generalized weakness. The patient was admitted to this facility to assist with improving the limitations that have occurred due to the recent hospitalization. Other history includes Atrial fibrillation and Hypertension. Patient was on fluid restrictions. The plan of care revealed the nursing problem list being initiated on 03/21/2024. The nursing problem list included Alteration in Comfort. The nursing problem list did not include problems related to the patient’s current physiological condition or medical diagnosis. In an interview on 04/11/2024 at 10:00 a.m. S3DON confirmed the above mentioned findings.”

“PHARMACY ADMINISTRATION CFR(s): 482.25(a) [§482.25 Condition of Participation: Pharmaceutical Services .....The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service.] §482.25(a) Standard: Pharmacy Management and Administration The pharmacy or drug storage area must be administered in accordance with accepted professional principles. This Standard is not met as evidenced by: 48051 Based on observation, record review and interview, the hospital failed to maintain the drug storage area in accordance with accepted professional principles. This deficient practice is evidenced by: 1) Failing to secure Scheduled (narcotics) Drugs; 2) Failing to verify Scheduled (narcotics) Drugs at shift change; 3) Discharged patient medications co-mingled with floor stock medications and available for patient use; 4) Failing to remove expired floor stock medications and available for patient use; and 5) Failing to remove a medication available for patient use after it’s beyond use date. Findings: A review of facility policy, “Medication Security and Storage,” with an effective date of 04/2015 revealed in part, Purpose: To define, control, and secure the handling of all medications, including controlled substances so to conform to the policies of the Pharmacy and Therapeutic Committee, and Federal and State Regulations. Policy Statements: A. Medications will be stored in a manner consistent with manufacturer recommendations and applicable hospital regulations. B. All authorized personnel will be responsible for ensuring the proper storage of all medications and utilized in the care of their patients. D. All authorized personnel will be responsible for the control and security of medications and utilized in the care of their patients. A review of facility policy, “Medication Administration,” with a last review of 10/2022 revealed in part, Medication Orders 2. Nurse Responsibilities: Two nurses will count and verify that the narcotic stock is correct at the beginning and end of the shift using the Narcotic Administration Record. 6. Collect Medication from Medication Storage: Medications by Injection: Multi-dose vial expires 28 days after opened and must be labeled. Further there is a sign posted in the medication room which revealed in part, narcotic count is to be completed at the end of every shift (touched narcotics). The big narcotic count (all narcotics) is to be completed every Sunday. All narcotic discrepancies must be cleared within a reasonable timeframe as it a recommendation per state and to identify true discrepancies or diversion of narcotics. There was no indication as to a date of this sign being posted. A review of facility policy, “Disposal of Discontinued or Unused Medications,” with an effective date of 12/2016 revealed in part, 1. Any unused/expired medications will be placed in the pharmacy medication bins and recorded. All bins will be sent to Pro Med Waste Management once the bin has met capacity. 1) Failing to secure Scheduled (narcotics) Drugs An observation of the medication room on 04/08/2024 at 11:10 a.m. revealed the following blister packaged Scheduled (narcotics) Drugs located in an unlocked cabinet of the medication room: Clonaepam (Klonopin) 2mg tab, blister package of 4 tabs and a blister package of 21 tabs; Morphine Sulfate 30mg extended release tab, blister package of 18 tabs; Pregabalin (Lyrica) 25 mg tab, blister package of 13 tabs and a blister package of 6 tabs; Pregabalin (Lyrica) 200mg tab, a blister package of 21 tabs and a blister package of 2 tabs; Modafinil (Provigil) 200mg tab, a blister package of 2 tabs and a blister package 4 tabs; Modafinil (Provigil) 100mg tab, a blister package of 16 tabs; and Buprenorphin (Buprenex) 8mg tabs, a blister package of 7 tabs and a blister package of 3 tabs. In an interview on 04/08/2024 at 11:35, S9RN confirmed the above mentioned findings. 2) Failing to verify Scheduled (narcotics) Drugs at shift change A review of the hospital’s Change of Shift Narcotic Count for 04/2024 revealed an incomplete log from 04/01/2024 till 04/05/2024. The log was missing a nurse signature for the Coming on Duty nurse at 6P on 04/01/2024 to 04/04/2024. The log was missing a nurse signature for the Going off Duty nurse at 6A on 04/01/2024, 04/03/2024 - 04/05/2024. In an interview on 04/08/2024 at 11:35, S9RN confirmed the above mentioned findings. 3) Discharged patient medications co-mingled with floor stock medications and available for patient use An observation of the medication room on 04/08/2024 at 11:10 a.m. revealed the following medications prescribed to patients that were not listed on the current census provided, co-mingled with floor stock and available for patient use: Biotene oral rinse, open bottle; Chlorhexidine Gluconate Oral Rinse 0.12% quantity 2 unopen bottles; and Repatha Sureclick Pen 140mg/ml in an unsealed box. In an interview on 04/08/2024 at 11:35, S9RN confirmed the above mentioned findings and medications being prescribed to a patient should be returned to the pharmacy upon the patient’s discharge. 4) Failing to remove expired floor stock medications and available for patient use An observation of the medication room on 04/08/2024 at 11:10 a.m. revealed the following expired medications: a) Vancomycin 1g/200ml IV bag expiration 11/2023; and b) Acetaminophen 650mg suppository, quantity 5, expiration 06/2023. In an interview on 04/08/2024 at 11:35, S9RN confirmed the above mentioned findings. 5) Failing to remove a medication available for patient use after it’s beyond use date An observation of the medication room on 04/08/2024 at 11:10 a.m. revealed Insulin Glargine-Yfgn 100units/ml with an opening date sticker indicating 03/05/2024. Facility policy indicates discarding after 28 days. In an interview on 04/08/2024 at 11:35, S9RN confirmed the above mentioned 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: 48051 Based on observation and interview, the hospital failed to ensure facilities, supplies and equipment were maintained to an acceptable level of safety and/or quality. This deficient practice is evidenced by: 1) Observation of the glucose meter revealed tape and a sticky substance on its casing; 2) Observation of current glucose meter controls and test strips had no open date recorded; 3) Observation of television remote control with tape and brown substances on its edges; 4) Observation of mattress with dry, red substance on it; 5) Observation of mattresses and pillows with cracked and discolored coverings; 6) Observation of exposed wood on the hallway side of Room #a entry door; 7) Observation of wheelchair armrests with cracked and peeling covering; 8) Observation of an IV pole with brown flaky substances on the metal pole; 9) Observation of clothing on the floor of the patient laundry room; 10) Observation of an open gallon container of Great Value Distilled Water in the supply closet; 11) Failing to ensure expired supplies were not available for patient use; and 12) Failing to document daily refrigerator checks. Observations during a tour of the facility on 04/08/2024 from 10:30 a.m. till 12:15 p.m. revealed the following: 1) Observation of the glucose meter revealed tape and a sticky substance on its casing An observation of the Medline EVENCARE G3 Glucose Meter revealed the casing of the meter had tape and a sticky substance on it. This created a surface that could not be properly sanitized. In an interview on 04/08/2024 at 12:01 p.m. S10LPN confirmed the above mentioned findings. 2) Observation of current glucose meter controls and test strips had no open date recorded A review of facility policy, “Glucometer Quality Controls Testing,” with an effective date of 03/2015 revealed in part, Policy: Quality Control on the glucometer will be performed to ensure accurate and reliable testing using the low and high level control solutions. Quality Control log is maintained on the nursing unit and results are monitored by the DON. Procedure: See manufactures instructions for use. The EVENCARE G3 Blood Glucose Monitoring System User Guide revealed in part, notes regarding control solutions and test strips. The recording of the date on the bottle when opening a new bottle of control solution, discard any unused control solution 3 months after the opening date, and control solutions are good for 3 months after opening or until the expiration date on the bottle, whichever comes first. The recording of the date on the vial test strips when opening a new bottle and discard any unused test strips 6 months after opening. Vial test strips are good for 6 months after opening or until the expiration date on the bottle, whichever comes first. An observation of the current EVENCARE Quality Controls and Test Strips revealed the bottles not being properly labeled with an open date. In an interview on 04/08/2024 at 12:02 p.m. S2Adm confirmed the above mentioned findings. 3) Observation of television remote control with tape and brown substances on its edges An observation of Room #a television remote control had tape holding its casing together and the tape had a yellow substance on it. This creates a surface that prohibits sanitary cleaning. In an interview on 04/08/2024 at 10:35 a.m. S2Adm confirmed the above mentioned findings. 4) Observation of mattress with dry, red substance on it An observation of Room #a mattress revealed the matteress covering had dry, red substance on its side. In interview on 04/08/2024 at 10:35 a.m. S2Adm confirmed the above mentioned findings and the room had been recently cleaned. 5) Observation of mattresses and pillows with cracked and discolored coverings An observation of Room #a and #b mattresses revealed cracking on the bottom of all corners of the mattress covering. The patient side of each mattress was partially discolored. A pillow located in Room #a had a cracked vinyl covering. All of these cracked surfaces prohibit sanitary cleaning. In interview on 04/08/2024 at 10:45 a.m. S2Adm confirmed the above mentioned findings. 6) Observation of exposed wood on the hallway side of Room #a entry door An observation of Room #a entry door had exposed and splintering wood on the hallway side which prohibits sanitary cleaning. In interview on 04/08/2024 at 10:45 a.m. S2Adm confirmed the above mentioned findings. 7) Observation of wheelchair armrests with cracked and peeling covering An observation of a wheelchair in therapy gym 2 revealed its vinyl covered armrests having cracked and peeling surfaces which prohibits sanitary cleaning. In interview on 04/08/2024 at 10:50 a.m. S2Adm confirmed the above mentioned findings. 8) Observation of an IV pole with brown flaky substances on the metal pole An observation of an IV pole in the storage closet revealed brown flaky spots on the entire metal pole and base. In interview on 04/08/2024 at 10:55 a.m. S2Adm confirmed the above mentioned findings. 9) Observation of clothing on the floor of the patient laundry room An observation of the patient laundry room revealed clothing piled up on the floor. In interview on 04/08/2024 at 10:55 a.m. S2Adm confirmed the above mentioned findings. 10) Observation of an open gallon container of Great Value Distilled Water in the supply closet An observation of the supply closet revealed an open gallon container of Great Value Distilled Water available for patient use. There was no indication of when the container was opened. This type of container would not be indicative of multi-patient use and once the container was opened, its contents were compromised. In interview on 04/08/2024 at 10:52 a.m. S2Adm confirmed the above mentioned findings. 11) Failing to ensure expired supplies were not available for patient use An observation of the crash cart revealed Zoll Stat-padz II Adult Electrodes attached to the cardiac defibrillator with an expiration of 02/12/2024. An observation of the medication room reveal the following supplies expired and available for patient use: a) Abbott Covid 19 Reagent expiring 11/2022; b) Covid-19 Ag Card, Quantity 10, expired 12/07/2022; and c) UTM-RT Specimen Collection Kit, Quantity 9, expired 09/30/2023. In interview on 04/08/2024 at 11:05 a.m. and at 11:20 a.m. S2Adm confirmed the above mentioned findings. 12) Failing to document daily refrigerator checks An observation of The Nutritional Room Refrigerator Temperature log for 03/2024 was not available and the log for 04/2024 had not been completed from 04/01/2024 to the present day. In interview on 04/08/2024 at 11:08 a.m. S2Adm confirmed the above mentioned findings.”