Name   Joy Callahan, Administrative Assistant   [CPN]
E-mail    jcallaha@dhh.la.gov
Facility Name  Southeast Louisiana Hospital (SELH)
Facility COO:  Patricia Gonzales
Facility Address:  23515 Highway 190 - Mandeville, LA  70448

Jt Com Org ID#    1511 

# Beds - Adult (Civil only)    118
# Beds - Child & Adol (Civil only)    30
# Beds - Forensic    0
# Beds - Geriatric    0
# Beds - MR/DD    0
# Beds - Sex Offender    0
# Beds - Sub Abuse    0
# Beds - Total (all Civil & For)    148
# Beds - CMS Distinct    118
# Units - Total    4
# Staff - Total    540

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    9/22-25/09
Survey Days (e.g., Mon - Weds)    Tues - Fri
Number of Surveyors   3
Priority Focus Areas   
Last Survey Ending Date   7/14/06

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)   Robert D. Beckmann, CHFM, CHSP -
Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks)  Donald S. Geeze, MD, MPH - Focused on hanging hazards, infection control issues, med mangement, physician legibility, deferrals in the H&P and proper documentation for temporary privileges. (more details in 2009 SLH survey notes below and his surveyor profile).
Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks)   Lynn K. Smith, MBA, RN - Thorough, basically read the entire chart.  Does rigorous interviews for Data Use and Competency  Wanted to know if pts were asked about pain each shift. (more details in 2009 SLH survey notes below and her surveyor profile).

# of Non-Compliant Standards    8 (HAP: 1 Direct/ 7 Indirect) {BHC: Direct/ Indirect} [1 Clarified]

APR/NPSG Cites 

• NPSG.01.01.01, EP 2 Observed in Acute M at Southeast Louisiana Hospital site:

-A patient reported she had normally been administered medication without staff asking either her name or date of birth, noting, "Everybody here knows me."  There was no picture of her in the medication tray.
-A patient stated she was normally administered medication by staff calling her name and then asking her birth date (one identifier).  The picture that was supposed to have been used as a second identifier was missing./Direct/

MM/PC  Cites

• MM.01.01.03, EP 2 / Observed in Medication Management session at Southeast Louisiana Hospital site: A Condition of Participation does not apply to this observation.  Staff reported that there was no policy requiring a second person check the dose and type of insulin prior to administration, despite its having been classified as a high risk medication with dispensing and administration being specifically identified as "high alert failures". - Indirect (clarified) - / Surveyor #2

RC/RI  Cites

IC/WT Cites

HR/LD Cites

• HR 01.02.05,EP 1- During employee file review and staff discussions it was determined that primary source verification had not been completed before or on the date of employment.  The personnel file of the contract respiratory therapist, dietician and social worker did not evidence the documented print of the primary source verification.  All of these licenses were verified during survey.
  

IM/PI Cites

EC/EM//LS Cites 

• EC 02.06.01/ EP 1 -The shower mixer valve in the patient restroom was contained in a lockable cabinet to minimize the risk of hanging.  Patient rooms contained plastic switchplate covers secured with non-tamper proof screws allowing easy access to live electricity.  One patient had used tape to repair such a cover that had cracked, exposing live wires.
  
  
• EC.02.06.01, EP 20- - Observed in DNP at Southeast Louisiana Hospital site:
   -The outdoor area used by patients contained a standing body of water with high weeds.  The water contained numerous mosquito larvae which posed a risk of transmitting communicable diseases (yellow fever, malaria).
  -The outside area used by patients was littered with a variety of trash, including half-eaten fruit, food wrappers, empty cigarette packages and cigarette butts.
  / Indirect / 
  
• LS.02.01.10, EP 5 - Observed in the building tour at Southeast Louisiana Hospital site:
  -The fire door located in the two hour separation between the school and the patient living area did not close or latch properly.
  -Small sample size.  There was only one two-hour separation at the facility./ Indirect /  Surveyor #1
• LS.02.01.10, EP 9 - Observed in the building tour at Southeast Louisiana Hospital site:
  -There was a conduit that penetrated the two-hour separation between the school and the patient living area that was not properly sealed.
  -There were wires that penetrated the two-hour separation between the school and the patient living area that were not properly sealed./ Indirect/  Surveyor #1
• LS.02.01.30, EP 18 - Observed in the building tour at Southeast Louisiana Hospital site:
  -There were two conduits that penetrated the smoke partition wall leading into the D3 Unit that were not properly sealed.
  -There was a conduit that penetrated the smoke partition wall leading into the D1 Unit that was not properly sealed.
  -There was a conduit that penetrated the smoke partition wall leading into the D1 A Hall Unit that was not properly sealed.
  -There was a conduit that penetrated the smoke partition wall leading into the D1 B Hall Unit that was not properly sealed.
  -There was a conduit that penetrated the smoke partition wall leading into the A1 Unit that was not properly sealed.
  -There was a conduit that penetrated the smoke partition wall leading into the A1 A Hall Unit that was not properly sealed./ Indirect/  Surveyor #1

IF an emergency management tracer was conducted using a mass casualty simulation, please indicate which scenario was used.   

MS/NR Cites (Stnd#/EP#/Brief Descrip/Surveyor)

**Surveyor Compliments (Policies, Procedures, etc noted by which surveyor)

• Nurse surveyor loved social services competency checklist format
• Physician surveyor was impressed with privileging request forms

Preliminary Survey Result    Some Requirements for Improvement

**Misc Comments, Suggestions, Etc    **Misc Comments, Suggestions, Etc

• 2009 SLH Survey Notes (more details on surveyor activities and surveyors)
• Clarification: Challenge to Joint Commission Citation of MM.01.01.03 (Insulin double check)

EP Related to Direct Impact Findings:
1- NPSG.01.01.01, EP 2

EP Related to Inirect Impact Findings:
1- MM.01.01.03, EP 2
2- HR 01.02.05,EP 1
3- EC 02.06.01/ EP 1
4- EC.02.06.01, EP 20
5- LS.02.01.10, EP 5
6- LS.02.01.10, EP 9
7- LS.02.01.30, EP 18