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Based on record review and interview the facility failed to ensure patient complaints were recognized as grievances. This deficient practice was evidenced by failing to correctly identify patient grievances for 2 (#1, #2) of 2 (#1, #2) patients reviewed for complaints/grievances from a total patient sample of 6.
Findings:

Review of facility policy revised 02/01/2023, titled "Patient Grievance Process" revealed, in part: Policy, in part: A grievance is defined as a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, and/or patient's rights. PROCEDURE: If the patient and/or family file a grievance allegation as defined above, the grievance process is initiated immediately.

Review of the Grievance/complaint log revealed no evidence of grievances related to Patient #1 and Patient #2.

In an interview on 04/01/2024 at 12:35 p.m. S4CD verified that Patient #1's sister called the facility upset that patient regarding Patient #1's medication. S4CD revealed that it had been past 30 days since discharge of Patient #1 so no resolution was given.

In an interview on 04/01/2024 at 3:10 p.m. S4CD verified that Patient #2's family called the facility multiple times upset regarding Patient #2's discharge plan due to Patient #2's decline in health and inability to care for herself.

In an interview on 04/03/2024 at 12:45 p.m., S1RADM confirmed that the grievance process should have been implemented for Patient #2.

Based on record review and interview the hospital failed to ensure each patient or patient representative consented to treatment and was informed of his or her patient rights. This deficient practice is evidenced by no signed consent for treatment or signed patient rights information form for 1(#3) of 6 (#1-#6) patients sampled.
Findings:

A review of facility policy revised date 09/01/2023 titled "Patient Rights Louisiana" revealed, in part: PURPOSE: To ensure that all patients are aware of their rights while being treated at this facility and to provide guidance to the program staff regarding the method for ensuring patient rights are respected and the method for restricting a patient's right if deemed necessary. PROCEDURE: 1. The patient is to be given a copy of the Patient's Rights as part of the Patient Handbook that is reviewed at the time of admission by a program staff member. The patient acknowledges receipt of their written statement of rights by signing the Statement of Patient Acknowledgement which becomes a part of the medical record.

A review of Patient #3's medical record revealed, in part, that patient was admitted on 03/22/2024. Further review failed to reveal evidence of a signed consent for treatment. Continued review failed to reveal evidence of a signed document indicating Patient #3 was informed of their patient rights.

In an interview on 04/02/2024 at 10:15 a.m. S3DON confirmed there was no evidence of a signed consent for treatment. S3DON further confirmed there was no evidence of a signed document that Patient #3 was informed of their patient rights.

Based on record review and interview, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services as evidenced by:
1) failure of the Registered Nurse to supervise, observe and evaluate the care provided by MHTs by rounding every 2 hours, and
2) Failure of the RN to document on the Nursing Shift Assessment a minimum of once per shift (See findings under Tag A0395)

Based on record review and interview the hospital failed to ensure the Registered Nurse evaluated the care of each patient on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy. This deficiency is evidenced by 1) failure of the Registered Nurse to supervise, observe and evaluate the care provided by MHTs by rounding every 2 hours on 4 (#3-#6) of 6 (#1-#6) patients. 2) Failure of the RN to document on the Nursing Shift Assessment a minimum of once per shift in 3 (#1, #2, #6) of 6 (#1-#6) patients' medical records reviewed.
Findings:

Review of hospital policy revised 03/01/2023, titled "Level of Observations", revealed, in part: PROCEDURE: 3. The Registered Nurse (RN) will conduct routine rounds to visually observe each patient for safety at least once every 2 hours (unless more often is warranted) and will validate rounds by initialing in the appropriate section (s) of the form.

Review of hospital policy revised 01/01/2023, titled "Documentation" revealed in part: Daily: The Registered Nurse (RN) documents or reviews the LPN/LVN documentation on the Nursing Shift Assessment a minimum of once per shift.

1) Review of Patient #3's medical record revealed on 03/29/2024 at 1:00 a.m. the RN didn't conduct a safety round every 2 hours as per hospital policy/procedure.

In an interview on 04/02/2024 at 11:28 a.m. S3DON verified the RN didn't conduct an every 2 hours safety round for Patient #3 on 03/29/2024 at 1:00 a.m.

Review of Patient #4's medical record revealed on 03/24/20024 at 5:00 p.m.; 03/25/2024 at 3:00 p.m. and 5:00 p.m.; and 03/29/2024 at 1:00 a.m. the RN didn't conduct safety rounds every 2 hours as per hospital policy/procedure.

In an interview on 04/02/2024 at 2:25 p.m. S3DON verified the RN didn't conduct an every 2 hours safety rounds for Patient #4 on 03/24/20024 at 5:00 p.m.; 03/25/2024 at 3:00 p.m. and 5:00 p.m.; and 03/29/2024 at 1:00 a.m.

Review of Patient #5's medical record revealed on 03/25/2024 at 3:00 p.m. and 5:00 p.m. the RN didn't conduct safety rounds every 2 hours as per hospital policy/procedure.

In an interview on 04/02/2024 at 4:15 p.m. S3DON verified the RN didn't conduct an every 2 hours safety rounds for Patient #5 on 03/25/2024 at 3:00 p.m. and 5:00 p.m.

Review of Patient #6's medical record revealed on 03/12/2024 at 9:00 p.m. and 11:00 p.m. the RN didn't conduct safety rounds every 2 hours as per hospital policy/procedure.

In an interview on 04/03/2024 at 10:10 p.m. S3DON verified the RN didn't conduct an every 2 hours safety rounds for Patient #6 on 03/12/2024 at 9:00 p.m. and 11:00 p.m.

2)Review of Patient #1's medical record revealed no Nursing Shift Assessment for 01/09/2024 night shift.
In an interview on 04/01/2024 at 1:00 p.m. S3DON verified Patient #1 did not have a nursing shift assessment for 01/09/2024 night shift.

Review of Patient #2's medical record revealed no Nursing Shift Assessment for 03/11/2024 day shift.

In an interview on 04/01/2024 at 3:30 p.m. S3DON verified Patient #2 did not have a nursing shift assessment for 03/11/2024 night shift.

Review of Patient #6's medical record revealed no Nursing Shift Assessment for 03/14/2024 night shift.

In an interview on 04/02/2024 at 9:55 a.m. S3DON verified Patient #6 did not have a nursing shift assessment for 03/14/2024 night shift.

Based on record review and interview the hospital failed to provide regular re-evaluation of the patient's condition to identify changes that required modification of the discharge plan. This deficiency is evidenced by failure of the hospital to address Patient #2's Mini Mental State Exam (MMSE) score of 11 which indicates 10-20 points: moderate dementia on treatment plan and at time of discharge.
Findings:

Review of hospital policy last revised 04/10/2021, titled "Treatment Planning: Integrated/ Multidisciplinary", revealed in part: PURPOSE: To document and implement objectives/ interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of patient's treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided.

Review of hospital policy last revised 01/01/2023 titled, "Documentation" revealed in part: Routine: 1. RN and/or Licensed Practical Nurse/Licensed Vocational Nurse (LPN/LVN) documents all extraordinary occurrences and special needs in the multidisciplinary progress notes and documents any notifications or issues reported to the physician or non-physician practitioner (NPP), as applicable. The daily nurse note is only for daily assessment and expected daily occurrences.

Review of Patient #2's medical record revealed a Mini Mental State Exam assessment and score of 11 which indicates moderate dementia. Further review revealed this was not addressed on the care plan and there was no documentation the patient was referred for evaluation and treatment after discharge.

In interview on 04/01/2023 at 3:10 p.m., S4CD verified both the hospital staff and the family of Patient #2 had expressed concerns about her decline in mental status and ability to care for herself after discharge. Furthermore S4CD verified there is no documentation in Patient #2's medical record that the MD was notified of staffs' concern.

In an interview on 04/03/2024 9:20 a.m., S3DON verified staff was concerned for Patient #2's safety upon discharge. Furthermore S3DON verified Patient #2 was discharged after the CEC was no longer in effect and the patient refused to sign a formal voluntary admission. There was no evidence the patient was referred for evaluation and treatment as an outpatient at the time of discharge

In an interview on 04/03/2024 9:20 a.m., S3DON verified staff was concerned for Patient #2's safety upon discharged.

Based on record review and interview, the hospital failed to ensure all patients treatments were within compliance of particular aspects of the patients' individualized treatment program as evidenced by failure to have documentation that a treatment team conference was held every 7 days in 1 (#1) of 6 (#1-#6) patients' medical records and that MD didn't signed 3 (#2, #4, #6) of the 6 (#1-#6) patients' medical records reviewed.
Findings:

Review of hospital policy last revised 04/10/2021, titled "Treatment Planning: Integrated/ Multidisciplinary", revealed in part: PURPOSE: To document and implement objectives/ interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of patient's treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided. 4. The treatment plan shall be signed by all members of the interdisciplinary team (IDT). If the patient is unable and/or willing to sign the treatment plan, the reason or circumstances of such inability or unwillingness shall be documented in the patient's medical record. Coordinating documentation of the treatment plan reviews and revisions to reflect patient progress and any discharge/continuing stay criteria every seven (7) days or at key decision points with multi-disciplinary treatment.

Review of Patient #1's medical record revealed that the treatment plan was initiated 12/29/2023, updated on 01/03/2024 and 01/11/2024.
In an interview on 04/03/2024 at 12:15 p.m. S3DON verified Patient #1's treatment plan was not updated every 7 days per hospital policy/procedure.

Review of Patient #2's medical record revealed no MD signature on the treatment plan.

Review of Patient #4's medical record revealed no MD signature on the treatment plan.

Review of Patient #6's medical record revealed no MD signature on the treatment plan.

In an interview on 04/03/2024 at 12:20 S3DON verified Patient #2, #4, #6's treatment plans were not signed by the MD.