HospitalInspections.org

Based on record review and interview the Hospital failed to meet the requirements for the Condition of Participation for Patient Rights as evidenced by:

1) failing to ensure patients received care in a safe setting as evidenced by 3 of 3 patients under Physicians Emergency Certificate (PEC) in the ER (emergency room) not being monitored on direct visual observation per hospital policy. (#3, #4, #5) (see findings at A0144)

2) failing to maintain the physician ordered constant visual observation of 1 of 4 sampled patients (#14) on the Geriatric Behavioral Health Unit in a total sample of 32 as evidenced by observation of the patient being alone in his room with a family member and no hospital staff on 11/01/11 at 1:40 p.m. (see findings at A0144)

3) failing to maintain the physician ordered constant visual observation of 1 of 4 sampled patients (#14) on the Geriatric Behavioral Health Unit in a total sample of 32 as evidenced by observation of the MHT (Mental Health Technician) exiting the dayroom leaving patient # 14 with no constant visual observation on 11/01/11 at 10:59 a.m.(see findings at A0144)

4) failing to follow hospital policy for documenting 15 minute observations of patients as evidenced by a random review of observation flowsheets on 11/01/11 at 10:59 a.m. on the Geriatric Psychiatric Behavioral Health Unit of the 10 patients in the dayroom revealed 10 of 10 observation flowsheets (patient # R1, #R2, #R3, #R4, #R5, #R6, #R7, #14. #15, and #16) had no documented evidence of observation since 11/01/11 at 9:15 a.m. (see findings at A0144)

On 10/31/11 at 4:30 p.m. the hospital was notified of an Immediate Jeopardy. The Immediate Jeopardy situation was:

The hospital failed to ensure that patients identified as being a risk to self are monitored on continuous visual observation per the hospital's policy when in the Emergency Room (ER). This was evidenced by three patient's (#3, #4, #5), all under Physician's Emergency Certificate and identified as Suicidal and Danger to Self by a physician, being monitored by one ER Technician from a position in the hall where it was not possible to visually observe all three patients at the same time. All three of the patient rooms contained a call bell cord, Telemetry monitor with approximately 5' power cord, ophthalmoscope/otoscope with approximately 4' cords and a power cord approximately 5' in length all of these items could be potentially harmful objects for suicidal patients.
On 11/02/11 at 2:15 p.m. the hospital submitted a Plan of Removal for the Immediate Jeopardy. The Plan included the following:

1) Patients cited in the Immediate Jeopardy were discharged from the Emergency Department by 10 p.m. Completion Date: October 31, 2011.

2) A. The policy PE-130 Addressing Settings Behavioral Needs in Ambulatory and Inpatient Settings was reviewed and revised (Attachment A). A new policy ED-A4 Addressing Behavioral Health Needs and Identifying Suicide/Homicidal Risk Patients was developed to specifically provide guidelines for the patient in the emergency department who has behavioral health needs and is identified as a suicidal/homicidal risk (Attachment B). Completion Date: November 1, 2011.

B. A location in the Emergency Department has been identified to relocate the PEC (physician emergency certificate) and/or CEC (coroner's emergency certificate) patient that creates the opportunity for the employee to provide direct observation to multiple patients. This location is rooms 3, 4, 5, and 6 located on the south side of the Emergency Department. Each room is a bay type room currently divided by curtains and could be visualized by one employee. However, the patient to employee ratio will be determined by the primary and charge nurse based on the patient acuity (e.g. agitation level, signs and symptoms of escalation or changes in condition). Completion Date: November 1, 2011.

C. PEC and/or CEC patients have been relocated to rooms 3, 4, 5, and 6 with an employee to provide direct observation. Overflow patients will be one-to-one ratio of staff to patients to ensure direct line of sight observation. Completion Date: November 1, 2011.

D. The primary and only responsibility for the employee providing the observation will be to do the direct observation. Staff will be provided relief for lunch and breaks. Employees providing the observations will have a radio with a direct line to the nurse's station to be used if they need any backup assistance. Completion Date: November 1, 2011.

E. Staff responsible for performing the observation will not leave their post for any reason. For example, they will not escort any of the patients to the bathroom or to other care areas. The bathroom door is equipped with a specialty "release mechanism" (rescue hardware) to prevent patients from locking themselves in the bathroom. When the patient is in the bathroom, the door will remain with a small crack to ensure patient safety. Completion Date: November 1, 2011.

F. Emergency Staffs will be educated on (Attachment C): Completion Date: November 2, 2011.

a. Revised Policy ED-4 Addressing Behavioral Health Needs and Identifying Suicide/Homicidal Risk Patients.

b. New location where PEC and/or CEC patients will be located.

c. Environmental Checklist 080-0018 (Attachment D).

d. Revised role of the observation staff:
-Never leave post
-Communication with other staff members (call for assistance, use radio)
-Enhance direct line of sight
-Not involved in any other aspects of patient care
-Escorting to the bathroom

e. Education will begin immediately. Beginning November 1, 2011 staff who will be assigned to the PEC and/or CEC patients as an observer, primary nurse or charge nurse will complete the training. Beginning November 2, 2011 staff who have not completed the education will not be allowed to work until the training is complete.

G. Auditing and Monitoring of the corrective action plan will be coordinated by the ED (emergency department) Nurse Director using the ED Patient Observation Audit (Attachment E) to include the following: (Completion Date November 2, 2011)

a. Beginning November 2, 2011 daily until 100% compliance has been achieved for two weeks, the ED Nurse Manager, or designee (e.g. Charge Nurse), will conduct a concurrent audit of:
-Appropriate location of any PEC or CEC patient.
-Observer and nurse's station has working radio communication.
-Adherence to revised role of the observer.
-Direct observation of all patients is possible from where the observer is.
-Environmental Checklist.

b. Audits will be reviewed by the Nurse Manager. Immediate corrective actions will be taken for any deficient practice. Once 100% compliance has been achieved for two weeks, weekly random audits will be conducted by the Nurse Manager, or designee until 100% compliance has been achieved for 3 months.

The Immediate Jeopardy was lifted on 11/01/11 at 2:45 p.m. after a Plan of Removal was submitted by the hospital. Deficient practice remains at the Condition level.

Based on record review and interview the hospital: 1) failed to ensure patients received care in a safe setting as evidenced by 3 of 3 patients under Physicians Emergency Certificate (PEC) in the ER (emergency room) not being monitored on direct visual observation per hospital policy. (#3, #4, #5) 2) failed to maintain the physician ordered constant visual observation of 1 of 4 sampled patients (# 14) on the Geriatric Behavioral Health Unit in a total sample of 32 as evidenced by observation of the patient being alone in his room with a family member and no hospital staff on 11/01/11 at 1:40 p.m. and 3) failed to maintain the physician ordered constant visual observation of 1 of 4 sampled patients (#14) on the Geriatric Behavioral Health Unit in a total sample of 32 as evidenced by observation of the MHT (Mental Health Technician) exiting the dayroom leaving patient # 14 with no constant visual observation on 11/01/11 at 10:59 a.m. and 4) failed to follow hospital policy for documenting 15 minute observation of patients as evidenced by a random review of observation flowsheets on 11/01/11 at 10:59 a.m. on the Geriatric Psychiatric Behavioral Health Unit of the 10 patients in the dayroom revealed 10 of 10 observation flowsheets (patient # R1, #R2, #R3, #R4, #R5, #R6, #R7, #14. #15, and #16) had no documented evidence of observation since 11/01/11 at 9:15 a.m. Findings:


1) In an observation and interview on 10/31/11 at 12:15 p.m. in the ER with S2Director of Quality and Patient Safety; S5RN Director of Emergency Services; and S6RN, ER Manager, it was confirmed that the patients in Room # (ff), # (gg), and # (hh) were all under PEC.

Review of the medical record of patient # 3 revealed the patient was admitted on 10/29/11 at 00:47 (12:47 a.m.). Review of the medical record for patient #3 revealed the patient was triaged on 10/29/2011 at 00:50 (12:50 a.m.) as a Level 2 - Emergent patient. Further review of the triage note revealed the following: "Admits to suicidal thoughts...Admits to auditory hallucinations...Patient is a suicide risk ..." Review of the Nursing History of Present Illness dated/timed 10/29/11 at 1:01 a.m. revealed: "SI (suicidal ideations) with plan to take uppers and downers at same time...AH (auditory hallucinations) "telling me negative things, like not to get help"...Review of the ER Physician's History of Present Illness revealed: "...Expresses suicidal ideation. Has suicidal thoughts but no real plan. History of prior suicide attempts. History of previous self inflicted lacerations."

Further review of the medical record for patient #3 revealed the patient was placed under PEC on 10/29/11 at 2:10 a.m. Review of the PEC revealed the physician documented that patient #3 was Suicidal and Dangerous to Self.

Patient #3 was in ER Room # (ff) and the ER Tech was located in the hallway outside the room and was responsible for direct visual observation of patient #3.

Review of the medical record of patient #4 revealed the patient was admitted on 10/29/11 at 22:28 (10:28 p.m.). Further review of the medical record for patient #4 revealed the patient was triaged at 22:30 (10:30 p.m.) as a Level 3 - Urgent. Further review of the Nursing Assessment revealed: "Patient has expressed thoughts of hurting self...This patient has been identified as a risk to self or others...observation in progress; suicidal risk precautions in progress...States "I just want to die: ..." Review of the History of Present Illness documented by the ER Physician on 10/30/11 at 1:19 revealed in part: "...Expresses suicidal ideation...Has definite suicidal thoughts and has a plan..."

Further review of the medical record for patient #4 revealed the patient was placed under PEC on 10/30/11 at 12:10 a.m. Review of the PEC revealed the physician documented that patient #4 was Suicidal and Dangerous to Self.

Patient #4 was in ER Room # (gg) and the ER Tech was located in the hallway outside the room and was responsible for direct visual observation of patient #4.

Review of the medical record of patient #5 revealed the patient was admitted on 10/30/11 at 13:46 (1:46 p.m.). Further review of the medical record for patient #5 revealed the patient was triaged at 13:57 (1:57 p.m.) as a Level 2 - Emergent. Further review of the Triage documentation revealed the Chief Complaint was documented as "Suicide Attempt." Review of the Nursing Assessment dated timed 10/31/11 at 11:20 a.m. revealed: "Patient reports suicide plan, which includes: stabbing herself with a knife..." Review of the ER Physicians Assessment under "Psychiatric" revealed "...Suicidal Ideation..."

Further review of the medical record for patient #5 revealed the patient was placed under PEC on 10/30/11 at 1522 (3:22 p.m.) Review of the PEC revealed the physician documented that patient #5 was Suicidal and Dangerous to Self.

Patient #5 was in ER Room # (hh) and the ER Tech was located in the hallway outside the room and was responsible for direct visual observation of patient #5.

The initial surveyor observation of patients #3, #4, and #5 was made on 10/31/11 at 12:15 p.m. As this surveyor crossed the area where S7ER Tech, was seated it was noted that none of the 3 patients could be visualized. Room # (ff) and # (gg) were separated from the ER Tech to her left by the clean utility room and across the hall. Patient #5 was in Room # (hh), across the hallway slightly to the right from S7ER Tech, and the patient (#5) was seated to the right against the wall inside the room.

The second surveyor observation of patients #3, #4, and #5 was made on 10/31/11 at 12:32 p.m. As this surveyor crossed the area where S7ER Tech, was seated it was noted that none of the 3 patients could be visualized. Room # (ff) and # (gg) were separated from the ER Tech to her left by the clean utility room and across the hall. Patient #5 was in Room # (hh), across the hallway slightly to the right from S7ER Tech, and the patient (#5) was seated to the right against the wall inside the room.

Another surveyor observation was made on 10/31/11 at 1:11 p.m. S8ER Tech, was now seated in the same location as the previous ER Tech. S8ER Tech was interviewed at this time. S8ER Tech, was asked what precautions the 3 patients (#3, #4, and #5) were on and she replied they were on suicide precautions. S8ER Tech, was asked if she could, from her present position, see any of the 3 patients. S8ER Tech replied "no". S8ER Tech was asked by this surveyor if she had received report on patient's #3, #4, and #5. S8ER Tech replied that she had and was told by S9RN Charge Nurse that "patient #3 was well behaved, patient #4 was well behaved and sleeping, and patient #5 was well behaved". S8ER Tech was asked what was the hospital policy for patients under PEC to which she replied "all PEC'd patients are on continuous visual observation". S6RN, ER Manager, present for the observations and interview, stated "these patients are at risk and need direct visual observation".

In an observation/interview on 10/31/11 at 1:11 p.m. with S2Director of Quality and Patient Safety; S5RN, Director of Emergency Services; S6RN, ER Manager and S8ER Tech, it was confirmed that Room # (ff), # (gg), and # (hh) all contained the following: an approximately 5' long nurse call bell cord, an approximately 5' long power cord for the Cardiac Monitor, an opthalmoscope and otoscope with an approximately 4' long cord for each, and an approximately 4' long power cord for the opthalmoscope/otoscope all of these items could be potentially harmful objects for suicidal patients.

In an interview with S7ER Tech on 10/31/11 at 1:15 p.m. she stated that assignments are on the white board. S7ER Tech stated that patients #3, #4, and #5 were on q (every) 15 minute observation. During the same interview S7ER Tech confirmed the patients in Room # (ff), # (gg), and # (hh) were not under continuous visual observation and that she "has to get up to go check on them".

In an interview on 10/31/11 at 1:32 p.m. with S9RN Charge Nurse, he stated the assignments made for the PEC'd patients are on the white board. He further confirmed that one (1) ER Tech was assigned the direct visual observation on three (3) patients (#3, #4, and #5). S9RN further stated that the ER Techs can "swap out every two hours". S9RN Charge Nurse reviewed the ER policy for observation of PEC'd patients. S9RN Charge Nurse then stated that "one ER Tech cannot do direct visual observation of three patients".

In an interview on 10/31/11 at 2:01 p.m. with S5RN, Director of Emergency Services, she stated the ER Techs do "roving" checks on the patients. S5RN, Director of Emergency Services, further confirmed that the Baton Rouge General Medical Center hospital policy read "place patient in direct visual observation..."

Review of the Baton Rouge General Observation Flowsheets for patients #3, #4, and #5 revealed each of the q 15 minute incremental observations done since 12:00 a.m. on 10/31/11, with one exception at 10:45 a.m., had been done by the same ER Tech in 2 hour blocks, indicating one (1) ER Tech had been assigned all three (3) PEC'd patients.

Review of a Baton Rouge General Medical Center policy titled "Addressing Behavioral Health Needs and Identifying Suicide Risk Patients", policy number PE-130, effective 4/07, last revised 10/11, presented as current hospital policy, read in part: "Purpose: To establish a system for identifying patients at risk for suicide and addressing behavioral health needs of patients within the Baton Rouge General Healthcare System. Policy...4. Emergency Department:...B. All patients that present to the ED with complaints and/or signs and symptoms of behavioral or emotional health needs will be assessed by the registered nurse during triage to determine the suicidal/homicidal risk potential. Any patients identified as a potential risk to themselves or others should be triaged as a Priority Level 2. Staff will implement the following suicidal/homicidal risk precautions for patients identified as a risk: a. Notify the attending physician. b. Place patient in direct visual observation of an appropriately trained staff member. c. Secure patient belongings and perform a room survey to remove potentially harmful objects...C. Suicidal/homicidal risk precautions will continue until the patient enters a psychiatric inpatient unit, transfers or discharges, or are discontinued by the physician...D...Patients should be monitored through constant observation, during which the patient must be visualized by a staff member at all times. Documentation will occur at a minimum of every 15 minutes..."

2) Review of the medical record for patient #14 revealed he was admitted to the Geriatric Behavioral Health Unit on 10/25/11 at 8:15 a.m. under PEC. Review of the physician orders dated 10/28/11 at 10:32 a.m. revealed S31MD, Psychiatrist, had ordered "(arrow up) increase obs. (observation) to constant obs. "Line of Sight" with same precautions".

On 11/01/11 at 1:40 p.m. an observation was made of patient #14 being alone in his room with a family member. No staff member had constant visual observation of patient #14 until 1:43 p.m. when S32LPN entered the room of patient #14 and then remained at a location where she could see patient #14.

S29VP Clinical Services was present for and confirmed the findings of this observation on 11/01/11 at 1:40 p.m. to 1:43 p.m.

Review of a hospital policy titled "Observation of Patients", policy number BHS TX NSG 11, no effective date, last revised 10/11, presented as current hospital policy, read in part: " Purpose: To maintain the safety and security of patients and the therapeutic milieu. Policy:...Constant Observation ("Line of Sight"). 1. A patient that is identified as being at a higher level of risk may be monitored through Constant Observation, during which the patient must be visualized by a staff member at all times..."

3) Review of the medical record for patient #14 revealed he was admitted to the Geriatric Behavioral Health Unit on 10/25/11 at 8:15 a.m. under PEC. Review of the physician orders dated 10/28/11 at 10:32 a.m. revealed S31MD, Psychiatrist, had ordered "(arrow up) increase obs. (observation) to constant obs. "Line of Sight" with same precautions".

In an observation on 11/01/11 at 10:59 a.m. the MHT (Mental Health Technician) exited the dayroom leaving patient # 14 with no constant visual observation.

S29VP Clinical Services was present for and confirmed the findings of this observation on 11/01/11 at 10:59 a.m.

Review of a hospital policy titled "Observation of Patients", policy number BHS TX NSG 11, no effective date, last revised 10/11, presented as current hospital policy, read in part: " Purpose: To maintain the safety and security of patients and the therapeutic milieu. Policy:...Constant Observation ("Line of Sight"). 1. A patient that is identified as being at a higher level of risk may be monitored through Constant Observation, during which the patient must be visualized by a staff member at all times..."

4) In an observation/record review on 11/01/11 at 10:59 a.m. a random review of observation flowsheets on the Geriatric Psychiatric Behavioral Health Unit of the 10 patients in the dayroom revealed 10 of 10 observation flowsheets (patient # R1, #R2, #R3, #R4, #R5, #R6, #R7, #14. #15, and #16) had no documented evidence of observation since 11/01/11 at 9:15 a.m.

In an interview on 11/01/11 at 10:59 a.m. with S29VP Clinical Services and S3RN, Director of Behavioral Health Services, the above findings were confirmed.

Review of a hospital policy titled "Observation of Patients", policy number BHS TX NSG 11, no effective date, last revised 10/11, presented as current hospital policy, read in part: " Purpose: To maintain the safety and security of patients and the therapeutic milieu. Policy: All BHU (behavioral health unit) patients are monitored at least every 15 minutes...The Charge Nurse or designee is responsible for ensuring the appropriate level of observation is maintained and documented...Observation. ("15 Minute Checks"). 1. At least every 15 minutes...shall observe each patient. 2. At the time of observation, the staff member will document on the Observation Flow Sheet the location and activity of each patient observed..."

Based on record review and interview the hospital failed to include monitoring of post-anesthesia assessments as part of their chart audit process resulting in 3 of 3 post-anesthesia medical records failing to have documented evidence post anesthesia patients had been evaluated within 48 hours after surgery according to hospital policy and procedure. (#28, #29, #31). Findings:

Review of the Pre-operative Anesthesia Record for Patient #29 dated 10/31/11 revealed a 22 year old female who had an excision of hydroadenitis of the left axilla and right groin under general anesthesia which was completed at 10:54am and she was transferred to PACU (Post Anesthesia Care Unit). Further review revealed no documented evidence Patient #29 had been assessed by the person administering the anesthesia or his/her designee as evidenced by the section titled "Post-Op Evaluation" being left completely blank.

Review of the Pre-operative Anesthesia Record for Patient #28 dated 10/31/11 revealed a 48 year old male who had a knee arthroscopy under general anesthesia which was completed at 8:40am and was transferred to PACU (Post Anesthesia Care Unit) at 8:41am. Further review revealed no documentation Patient #28 had been assessed by the person administering the anesthesia or his/her designee for within 48 hours post-anesthesia which included cardiovascular function, level of consciousness, follow-up care and observations and complications occurring during the post anesthesia recovery. This was evidenced by the CRNA (Certified Registered Nurse Anesthetist) documenting "as per pre-op" and a check in the box indicating no apparent anesthesia complications in the section titled "Post-Op Evaluation" dated/timed 11/01/11 at 1315 (1:15pm).

Review of the Pre-operative Anesthesia Record for Patient #31 dated 10/31/11 revealed a 51 year old female who had a debridement and skin graft of the back and upper extremities under general anesthesia which was completed at 12:00pm and was transferred to PACU (Post Anesthesia Care Unit) at 12:10pm. Further review revealed no documentation Patient #31 had been assessed by the person administering the anesthesia or his/her designee for within 48 hours post-anesthesia which included cardiovascular function, level of consciousness, follow-up care and observations and complications occurring during the post anesthesia recovery. This was evidenced by the CRNA (Certified Registered Nurse Anesthetist) documenting "as per pre-op" and a check in the box indicating no apparent anesthesia complications in the section titled "Post-Op Evaluation" dated/timed 11/01/11 at 1325 (1:25pm).

In a telephone interview on 11/02/11 at 9:00am Chief Anesthesiologist S30 indicated he thought post-anesthesia assessments were part of the indicators being monitored by the nurses.

In a face to face interview on 11/02/11 at 9:15am S2 Director of Quality verified post-anesthesia evaluations were not being monitored by Quality Assurance at the present time. Further S2 indicated monitoring of anesthesia was being performed by personnel in the Anesthesiology office.

Based on record review and interview the hospital failed to implement any Performance Improvement policy or procedure after identifying Emergency Rooms used for patients designated "at risk" to themselves or others were not being made environmentally safe as evidenced by the failure to remove potentially harmful objects from the rooms of 3 patients (#3, #4, #5) on suicide precautions. Findings:

In an observation and interview on 10/31/11 at 12:15 p.m. in the ER with S2Director of Quality and Patient Safety; S5RN Director of Emergency Services; and S6RN, ER Manager, it was confirmed that the patients in Room # (ff), # (gg), and # (hh) were all under PEC.

Review of the medical record of patient # 3 revealed the patient was admitted on 10/29/11 at 00:47 (12:47 a.m.). Review of the medical record for patient #3 revealed the patient was triaged on 10/29/2011 at 00:50 (12:50 a.m.) as a Level 2 - Emergent patient. Further review of the triage note revealed the following: "Admits to suicidal thoughts...Admits to auditory hallucinations...Patient is a suicide risk ..." Review of the Nursing History of Present Illness dated/timed 10/29/11 at 1:01 a.m. revealed: "SI (suicidal ideations) with plan to take uppers and downers at same time...AH (auditory hallucinations) "telling me negative things, like not to get help"...Review of the ER Physician's History of Present Illness revealed: "...Expresses suicidal ideation. Has suicidal thoughts but no real plan. History of prior suicide attempts. History of previous self inflicted lacerations."

Further review of the medical record for patient #3 revealed the patient was placed under PEC on 10/29/11 at 2:10 a.m. Review of the PEC revealed the physician documented that patient #3 was Suicidal and Dangerous to Self.

Patient #3 was in ER Room # (ff) and the ER Tech was located in the hallway outside the room and was responsible for direct visual observation of patient #3.

Review of the medical record of patient #4 revealed the patient was admitted on 10/29/11 at 22:28 (10:28 p.m.). Further review of the medical record for patient #4 revealed the patient was triaged at 22:30 (10:30 p.m.) as a Level 3 - Urgent. Further review of the Nursing Assessment revealed: "Patient has expressed thoughts of hurting self...This patient has been identified as a risk to self or others...observation in progress; suicidal risk precautions in progress...States "I just want to die: ..." Review of the History of Present Illness documented by the ER Physician on 10/30/11 at 1:19 revealed in part: "...Expresses suicidal ideation...Has definite suicidal thoughts and has a plan..."

Further review of the medical record for patient #4 revealed the patient was placed under PEC on 10/30/11 at 12:10 a.m. Review of the PEC revealed the physician documented that patient #4 was Suicidal and Dangerous to Self.

Patient #4 was in ER Room # (gg) and the ER Tech was located in the hallway outside the room and was responsible for direct visual observation of patient #4.

Review of the medical record of patient #5 revealed the patient was admitted on 10/30/11 at 13:46 (1:46 p.m.). Further review of the medical record for patient #4 revealed the patient was triaged at 13:57 (1:57 p.m.) as a Level 2 - Emergent. Further review of the Triage documentation revealed the Chief Complaint was documented as "Suicide Attempt." Review of the Nursing Assessment dated timed 10/31/11 at 11:20 a.m. revealed: "Patient reports suicide plan, which includes: stabbing herself with a knife..." Review of the ER Physicians Assessment under "Psychiatric" revealed "...Suicidal Ideation..."

Further review of the medical record for patient #5 revealed the patient was placed under PEC on 10/30/11 at 1522 (3:22 p.m.) Review of the PEC revealed the physician documented that patient #4 was Suicidal and Dangerous to Self.

Patient #5 was in ER Room # (hh) and the ER Tech was located in the hallway outside the room and was responsible for direct visual observation of patient #5.

In an observation/interview on 10/31/11 at 1:11 p.m. with S2Director of Quality and Patient Safety; S5RN, Director of Emergency Services; S6RN, ER Manager and S8ER Tech, it was confirmed that Room # (ff), # (gg), and # (hh) all contained the following: an approximately 5' long nurse call bell cord, an approximately 5' long power cord for the Cardiac Monitor, an opthalmoscope and otoscope with an approximately 4' long cord for each, and an approximately 4' long power cord for the opthalmoscope/otoscope.

In an interview on 11/01/11 at 8:30 a.m. with S2Director of Quality and Patient Safety; S5RN, Director of Emergency Services; and S29VP Clinical Services, it was stated that the hospital had identified that the environment of care for high risk patients in the Emergency Room (ER) were not being properly screened by staff. It was also confirmed that the problem was identified "months" ago. S2Director of Quality and Patient Safety stated that a form for staff to use when placing an "at risk" patient into a room in the ER had been developed but not yet approved. She further confirmed that no training or implementation regarding the identified problem had begun as of this date.

Review of a Baton Rouge General Medical Center policy titled "Addressing Behavioral Health Needs and Identifying Suicide Risk Patients", policy number PE-130, effective 4/07, last revised 10/11, presented as current hospital policy, read in part: "Purpose: To establish a system for identifying patients at risk for suicide and addressing behavioral health needs of patients within the Baton Rouge General Healthcare System. Policy...4. Emergency Department:...B. All patients that present to the ED with complaints and/or signs and symptoms of behavioral or emotional health needs will be assessed by the registered nurse during triage to determine the suicidal/homicidal risk potential. Any patients identified as a potential risk to themselves or others should be triaged as a Priority Level 2. Staff will implement the following suicidal/homicidal risk precautions for patients identified as a risk:..c. Secure patient belongings and perform a room survey to remove potentially harmful objects..."

Based on record review and interview the hospital's Medical Staff failed to ensure credentialing of physicians included specific duties and privileges for each physician as evidenced by use of non-specific vague core privileges for 3 of 3 orthopedic surgeons reviewed (S33, S34, S35). Findings:

Review of Core Privileges for Orthopedic Surgeons presented by the hospital as current revealed "Orthopedic Surgery Core Privileges: Privileges include being able to admit, work up, and provide non-surgical and surgical care to all patients of al ages to correct or treat various conditions, illnesses, or injuries of the musculoskeletal system, including the provision of consultation."

Credentialing files for Orthopedic Surgeons S33, S34 and S35 were reviewed with Physician S36 Medical Director of Quality and Patient Safety and S37 Vice President of Quality. All reviewed were credentialed using core privileges as listed above.

During a face to face interview on 11/02/2011 at 9:00 a.m., Medical Director of Quality and Patient Safety S36 and Vice President of S37 indicated the Core Privileges used for Orthopedic Surgeons in the hospital were vague and failed to outline specific duties and privileges. S36 and S37 confirmed it would be difficult to determine which specific privileges would be able to be performed by each surgeon.

Review of the hospital's Medical Staff Bylaws revealed in part, "Each individual who has been given an appointment to the Medical Staff or the Hospital shall be entitled to exercise only those clinical privileges specifically recommended by the Credential's Committee, medical Executive Committee, and approved and granted by the Board. . . The clinical privileges recommended to the Board shall be based upon the applicant's education, training, experience, demonstrated competence and judgment, references and other relevant information, including an appraisal by the chairman of the clinical Department in which such privileges are sought. The applicant shall have the burden of establishing his/her qualifications for and competence to exercise the clinical privileges he/she requests. . ."

Based on record review and interview the hospital failed to ensure Medical Records were complete for 1 of 32 sampled patients (Patient #32). Findings:

Review of Patient #32's medical record revealed the patient was admitted to the Emergency Department on 10/16/2011 at 1857 (6:57 p.m.) with Respiratory Failure and Cardiac Arrest. Further review revealed Patient #32's "Disposition" note to indicate "Condition: Death in department. . . Unable to contact family of patient's death. Social Services notified. coroner's Office contacted. Coroner's office will be conduct (conducting) autopsy." Review of the entire medical record revealed no documented evidence of the name and title of the "Social Service's" employee notified.

Face to face interviews were conducted with Director of Quality S2 on 11/02/2011 at 8:40 a.m. and Social Services Supervisor S17 on 11/02/2011 at 8:45 a.m. S2 indicated she (S2) had made contact with the 10/16/2011 scheduled nursing staff on the evening of 11/01/2011. S2 indicated the nursing staff on duty 10/16/2011 had reported that they could not recall which Social Worker they had spoken with on 10/16/2011 regarding the disposition of Patient #32's body. S17 indicated that she (S17) had made contact on the evening of 11/01/2011 with the only three social workers on duty 10/16/2011 during the time that Patient #32 had been in the Emergency Department and none of the three social workers claimed to have been told of any needs regarding deceased Patient #32. Both S2 and S17 confirmed that documentation in the Medical Record of Patient #32 had not been complete due to having no name of the Social Service's employee notified by Emergency Department Staff of the patient's (#32) death, the inability of Emergency Department staff to contact the patient's (#32) family members, or the disposition of the body to the Coroner's office.

Based on record review and interview the hospital failed to ensure cumulative exposure to radiation was checked prior to employment as per hospital policy for 4 of 5 Radiology Technologists reviewed (S23, S24, S25, S26). Findings:

Review of the hospital policy titled, "Personnel Monitors, # IV-015, last reviewed 8/11" presented by the hospital as current revealed in part, "Prior to employment , a request of any previous radiation exposure must be obtained and reviewed by the Radiation Safety Officer and/or Radiation Physicist."

Review of Radiology Technologist S23 revealed a date of hire of 1/24/2011. Further review revealed a request for radiation exposure history was mailed on 1/25/2011 to prior locations of employment/training where radiation exposure may have occurred. Review of the entire personnel file revealed no receipt of prior employment exposure reports and no further documented attempts by Baton Rouge General Hospital Radiology Department to obtain the employee's previous radiation exposure history to review prior to employment.

Review of Radiology Technologist S24 revealed a date of hire of 1/24/2011. Further review revealed a request for radiation exposure history was mailed on 1/25/2011 to prior locations of employment/training where radiation exposure may have occurred. Review of the entire personnel file revealed no receipt of prior employment exposure reports and no further documented attempts by Baton Rouge General Hospital Radiology Department to obtain the employee's previous radiation exposure history to review prior to employment.

Review of Radiology Technologist S25 revealed a date of hire of 12/24/2009. Further review revealed a request for radiation exposure history was mailed on 12/15/2009 to prior locations of employment/training where radiation exposure may have occurred. Review of the entire personnel file revealed no receipt of prior employment exposure reports and no further documented attempts by Baton Rouge General Hospital Radiology Department to obtain the employee's previous radiation exposure history to review prior to employment.

Review of Radiology Technologist S26 revealed a date of hire of 11/30/2009. Further review revealed a request for radiation exposure history was mailed on 8/04/2010 to prior locations of employment/training where radiation exposure may have occurred. Review of the entire personnel file revealed no receipt of prior employment exposure reports and no further documented attempts by Baton Rouge General Hospital Radiology Department to obtain the employee's previous radiation exposure history to review prior to employment.

During a face to face interview on 11/02/2011 at 11:30 a.m., Director of Diagnostic Services S27 and Quality Manager of Diagnostic Services S28 confirmed the above findings. S27 indicated hospital policy stated Radiology Employees' previous radiation exposure reports for new employees must be obtained and reviewed prior to employment. S27 indicated it had been difficult for the hospital to obtain the cooperation of other facilities in providing the reports. S27 indicated the hospital had no documented evidence of any second attempts to obtain radiation exposure reports on new hires after the first attempt. S27 indicated there had been no review of prior radiation exposure of Radiology Technologist S23, S24, S25, or S26 prior to employment.

Based on observation, record review, and interview the infection control officer failed to ensure the policy for terminal cleaning of isolation rooms was enforced by failing to ensure beds used for Isolation patients were thoroughly cleaned/disinfected upon discharge of a patient and in preparation to admit new patients for 1 of 1 Isolation beds observed for cleansing on the Medical Psychiatric Floor (Room (ii). Findings:

Observations on 10/31/2011 at 1305 (1:05 p.m.) revealed House Keeper S39 to use hospital approved disinfectant with a sit time of 7 minutes to clean an Isolation Room Bed (Room ii) post discharge of a patient in preparation for a new admission. Observations revealed S39 to clean the entire top of the mattress and the bottom 1/3 of the mattress near the head and bottom 1/3 of the mattress near the foot. Observations revealed no cleaning of the bottom middle 1/3 of the mattress.

During a face to face interview on 10/31/2011 at 1310 (1:10 p.m.), House Keeping Supervisor S38 confirmed that the entire top and bottom of mattresses should be disinfected between patients.

Review of the hospital policy titled, "Isolation Terminal Cleaning, #14, last revised 4/13/2011" revealed in part, "Clean entire bed with the first rag. . . Entire mattress (all sides). . ."

Based on record review and interview the hospital failed to follow their policy and procedure for post anesthesia evaluations as evidenced by: 1) failing to perform a post anesthesia evaluation on a patient who had received general anesthesia and was discharged the same day as the surgery for 1 of 1 patients discharged on the same day as surgery (#29) and 2) failing to perform and document a post anesthesia evaluation on a patient who had received general anesthesia which included cardiovascular function, level of consciousness, follow-up care and observations and complications occurring during the post anesthesia recovery for 2 of 2 inpatients surgery patients out of 3 surgery patients (#28, #31) out of a total sample of 32 sampled medical records. Findings:

1) failing to perform a post anesthesia evaluation on a patient who had received general anesthesia and discharged the same day as the surgery

Review of the "Pre-operative Anesthesia Record" used by the Anesthesia Department of the hospital revealed the form was utilized for both pre-op and post anesthesia assessment as evidenced by a section at the bottom of the form titled "Post-op Evaluation". Further review revealed the form contained a series of check boxes for the following categories: Airway, Mental Status, Neuro/Muscular and no apparent anesthesia complications.

Review of the Pre-operative Anesthesia Record for Patient #29 dated 10/31/11 revealed a 22 year old female who had an excision of hydroadenitis of the left axilla and right groin under general anesthesia which was completed at 10:54am and she was transferred to PACU (Post Anesthesia Care Unit). Further review revealed no documented evidence Patient #29 had been assessed by the person administering the anesthesia or his/her designee as evidenced by the section titled "Post-Op Evaluation" being left completely blank.

In a telephone interview on 11/02/11 at 9:00am S30 Chief Anesthesiologist MD verified the post-op evaluation should be documented on the "Pre-operative Evaluation Form" in the section labeled "Post-Op Evaluation".

Review of policy number ASA 03 titled "Anesthesia Care: Pre-operative, Introspective, Postoperative" last revised 08/10 and submitted as the one currently in use, revealed ......."O. Outpatients only: A post-anesthesia follow-up evaluation shall be conducted prior to the patient's discharge, and documented in the medical record that includes the following: a. Cardiopulmonary status; b. Level of consciousness; c. Complications occurring during the post-anesthesia recovery; and d. Follow-up care needed and patient instructions given. P. Post-operative documentation in the medical record includes: a. Respiratory function; b. Cardiovascular function; c. Mental status; d. Temperature; e. Pain; f. Nausea and vomiting; and g. Post-operative hydration".

2) failing to perform and document a post anesthesia evaluation on a patient who had received general anesthesia which included respiratory function, cardiovascular function, mental status, pain, temperature, nausea/vomiting and postoperative hydration
Patient #28
Review of the Pre-operative Anesthesia Record for Patient #28 dated 10/31/11 revealed a 48 year old male who had a knee arthroscopy under general anesthesia which was completed at 8:40am and was transferred to PACU (Post Anesthesia Care Unit) at 8:41am. Further review revealed no documentation Patient #28 had been assessed by the person administering the anesthesia or his/her designee for within 48 hours post-anesthesia which included cardiovascular function, level of consciousness, follow-up care and observations and complications occurring during the post anesthesia recovery. This was evidenced by the CRNA (Certified Registered Nurse Anesthetist) documenting "as per pre-op" and a check in the box indicating no apparent anesthesia complications in the section titled "Post-Op Evaluation" dated/timed 11/01/11 at 1315 (1:15pm).

Patient #31
Review of the Pre-operative Anesthesia Record for Patient #31 dated 10/31/11 revealed a 51 year old female who had a debridement and skin graft of the back and upper extremities under general anesthesia which was completed at 12:00pm and was transferred to PACU (Post Anesthesia Care Unit) at 12:10pm. Further review revealed no documentation Patient #31 had been assessed by the person administering the anesthesia or his/her designee for within 48 hours post-anesthesia which included cardiovascular function, level of consciousness, follow-up care and observations and complications occurring during the post anesthesia recovery. This was evidenced by the CRNA (Certified Registered Nurse Anesthetist) documenting "as per pre-op" and a check in the box indicating no apparent anesthesia complications in the section titled "Post-Op Evaluation" dated/timed 11/01/11 at 1325 (1:25pm).

In a telephone interview on 11/02/11 at 9:00am Chief Anesthesiologist S30 indicated all post-op surgery patients are seen within 48 hours after surgery. Further he indicated his staff performing the assessments should be documenting according to the policy of the hospital. Further S30 indicated documenting "as per pre-op" was not appropriate.

Review of policy number ASA 03 titled "Anesthesia Care: Pre-operative, Intraoperative, Postoperative" last revised 08/10 and submitted as the one current in use, revealed ....... "Inpatients only: A post-anesthesia follow-up report shall be written by the individual who administers the anesthesia, or qualified designee, within 48 hours (calculated beginning at the point the patient is moved into the designated recovery area except in cases where post-operative sedation is necessary for the optimum medical care of the patient (ICU-Intensive Care Unit) after the inpatient surgery that includes the following: a. Cardiolpulmonary status; b. Level of consciousness; c. Follow-up care and observations; and d. Complications occurring during the post-anesthesia recovery".