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Based on record review and interview the hospital's governing body failed to review and respond to grievances. This deficiency is evidenced by the failure of the governing body to review and respond to the majority of the grievances submitted.
Findings:

On 04/20/2022 a review of the grievances for the past 6 months was performed by the surveyor. The presented file contained grievances on a form titled, "Universal Behavioral Health Hospital Grievance Report." All of the grievances were submitted while the clients were admitted. Most were unaddressed complaints, but the area titled, "Response to the Patient" was not filled out on the majority of the forms.

Interview on 04/20/2022 between 11:30 a.m. and 11:45 a.m., the grievances were reviewed with S2DON and she verified the failure to review and resolve grievances.

Based on record review and interview the facility failed to provide care in a safe setting. This deficiency is evidenced by: 1) failure of the facility to ensure doors to the exterior of the building were locked and resulted in one (Pt. #3) of two (Pt. #3, Pt. #5) patient elopements; and 2) failure to document orientation to hospital policies and procedures in 4 ( S2DON, S8Diet, S9LPN, S10DON) of 9 (S2DON, S5MHT, S6MHT, S8Diet, S9LPN, S10FDON, S11SW, S12MHT, S13RN) personnel files reviewed.
Findings:

1) Failure of the facility to ensure doors to the exterior of the building were locked.

Review of the medical record for Pt. #3 revealed he was involuntarily admitted on 04/17/2022. The interventions ordered were every 15 minute observation and he was not an elopement risk.

Review of the occurrence report indicated he left the facility through an unlocked door.

In interview on 04/20/2022 at 8:30 a.m. S1CEO verified that the door was not locked.

2) Failure to document orientation to hospital policies and procedures.

Review of the personnel files for S2DON, S8Diet, S9LPN, and S10DON revealed no documentation of orientation related to the review of the policies and procedures of the hospital.

In interview on 04/20/2022 at 9:38 a.m., S1CEO verified the personnel files were incomplete.

Based on record review and interview, the hospital failed to ensure all incidents of abuse, neglect, and/or harassment were reported and analyzed, and the hospital was in compliance with applicable local, State, and Federal Laws and Regulations. This deficient practice was evidenced by the hospital's failure to report abuse related to one (Pt. #4) of one (Pt. #4) reviewed patient records involving abuse within 24 hours to the Department of Health and Hospitals or law enforcement.

Findings:

Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report these allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Louisiana Department of Health (LDH) (or the Medicaid Fraud Unit as applicable). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence.

Review of the occurence report for the date 12/28/2021 and timed 10:43 p.m. revealed S6MHT hit a patient. The report indicates the physician was called once with no response and S7FDON was notified. There was no notification of the local police, the family, or Louisiana Department of Health.

In interview on 04/19/2022 at 1:50 p.m., S3UR verified the incident was not reported and provided the name of the S6MHT. S3UR stated that S6MHT clocked out within 15 minutes of the incident and never returned. S3UR verified all staff involved in the occurance report are no longer active staff.

Based on record review and interview the hospital failed to ensure seclusion techniques were implemented in accordance with hospital policy. This deficiency is evidenced by failure of the nursing staff to follow hospital policy and use the approved forms for seclusion in one (Pt. #3) of two (Pt. #3 and Pt. #5) reviewed patients placed in seclusion.
Findings:

Review of the orders for Patient #3 revealed on 04/17/2022 at 3:35 p.m., verbal orders were given for "seclusion for the safety of self and others."

Review of the nursing narrative notes revealed on 04/17/2022 at 3:45 p.m. the patient was escorted to the seclusion room and one to one monitoring was initiated. Further review revealed the patient was released from seclusion on 04/17/2022 at 5:45 p.m.

In interview on 04/19/2022 at 9:15 a.m., S2DON verified the patient had been placed in seclusion and nurse had not followed hospital policy.

Based on record review and interview the hospital failed to ensure a one hour face to face evaluation was performed by a physician, other licensed practitioner, or a trained registered nurse. This deficiency is evidenced by the failure to document a one hour face to face evaluation in one (Pt. #3) of two (Pt. #3 and Pt. #5) reviewed patients placed in seclusion.
Findings:

Review of the medical record for Patient #3 revealed the patient was placed in seclusion on 04/17/2022 at 3:45 p.m. and released at 5:45 p.m.

Further review of the medical record revealed a one hour face to face evaluation was not performed as required.

In interview on 04/19/2022 at 9:15 a.m., S2DON verified the nurse did not follow hospital policy for the seclusion event.

Based on record review and interview the hospital failed to ensure the trained registered nurse consulted the attending physician responsible for the care of the patient as soon as possible after the completion of the 1-hour face-to-face evaluation. This deficiency is evidenced by a delay in notification of the physician in 1(Pt. #5) of 1(Pt. #5) reviewed patient record with a 1-hour face to face evaluation.
Findings:

Review of the medical record for Patient #5 revealed on 02/25/2022 at 10:15 p.m. Patient #5 was placed in seclusion. The 1-hour face to face was completed on 02/25/2022 at 11:35 p.m. and the patient was released from seclusion at that time. The attending physician was notified on 02/26/2022 at 5:23 a.m.

In interview on 04/20/2022 at 11:45 a.m., S2DON verified there was a delay of several hours before notifying the attending physician of the 1-hour face to face evaluation.

Based on record review and interview the facility failed to measure, analyze and track adverse patient events. This deficiency is evidenced by failure of the nursing staff to fill out occurrence reports for 2 occurrences involving one (Pt. #3) of six ( Pt. #1, Pt. #2, Pt. #3, Pt, #4, Pt. #5, and Pt. #6) patients reviewed.
Findings:

Review of Patient #3's medical record revealed involuntary admission on 04/17/2022. Ordered interventions included every 15 minute observations and behavioral and violence precautions.

Review of the nursing notes for Patient #3 revealed on 04/17/2022 at 3:30 p.m., Patient #3 removed the cover plate on the light switch in his room and touched the wires to start a fire on paper from the bathroom.

Further review of the nursing notes revealed on 04/17/2022 at 4:55 p.m., Patient #3 was in seclusion and was noted to be in possession of a crack pipe which was taken from him.

In interview on 04/19/2022 at 9:20 a.m. S2DON verified she had not received an occurrence report for either event and they were not in the occurrence report bin for her review.

Based on record review and interview the facility failed to ensure the registered nurse assigned 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 deficiency is evidenced by failure to document nursing assignments for the 24 days prior to entry.

Review of the binder on the nursing station labeled, "Nursing Assignments," revealed the last completely filled out unit assignment was the p.m. shift on 03/24/2022.

In interview on 04/19/2022 between 10:45 a.m. and 10:50 a.m. S4MHT and S5MHT verified that the patients were not assigned to them. The observation sheets were printed and stacked and the mental health technicians decided which patients they would follow for the shift.

In interview on 04/20/2022 at 9:45 a.m., S3UR verified that if the nursing assignments were done, they would have been placed in the binder. S3UR verified the unit nursing assignments were rarely done by the registered nurse in charge.

Based on record review and interview the hospital failed to to employ a full time director of food and dietetic services.
Findings:

Review of the personnel files revealed the hospital did employ a contract dietician for consultations as needed.

In interview on 04/19/2022 at 11:54, S1CEO verified there was no full time employee trained to manage the dietary services.

Based on observation and interview the hospital failed to employ methods for preventing and controlling the transmission of infections within the hospital. This deficiency is evidenced by the failure of the hospital staff to document food was maintained at recommended temperatures to prevent bacterial growth and spoilage.
Findings:

Louisiana Administrative Code, title 51 Chapter 13 Section 1307, reveals in part"food stored for hot holding and service shall be held at a temperature of 135 degrees Fahrenheit or higher with the exception of roast beef. If roast beef is cooked in accordance with Section 1305.A.6 of this Chapter the minimum holding temperature shall be 130 degrees Fahrenheit." and Chapter 13 Section 1309 reveals in part, "Food stored for cold holding and service shall be held at a temperature of 41 degrees Fahrenheit or below."

Direct observation of the distribution of food on 04/18/2022 at 12:05 p.m. revealed the temperature of the served food was not checked and there was no facility log indicating the temperatures were checked in the past few months. At that time, S3UR stated that she would inquire about the logs from the contracted provider.

In interview on 04/19/2022 at 11:54 a.m., S1CEO verified the temperature of the served food was not checked prior to being served.

Based on record review and interview the facility failed to develop and implement policies and procedures to ensure all staff are fully vaccinated for COVID-19. This deficient practice was evidenced by:
1. failure to ensure 100% vaccination rate, excluding those staff who have been granted exemptions to the vaccination requirements, 60 days after implementation of CMS Omnibus COVID-19 Health Care Staff Vaccination Regulations.;
2. failure to ensure medical exemptions confirm all information specifying which of the authorized or licensed COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications;
3. failure to develop a contingency plan for staff who are not fully vaccinated for COVID-19.

Findings:

1. Failure to ensure 100% vaccination rate, excluding those staff who have been granted exemptions to the vaccination requirements, 60 days after implementation of CMS Omnibus COVID-19 Health Care Staff Vaccination Regulations.

On 04/20/2022 a review of the vaccination information for all individuals who provide care, treatment, or other services for the center and/or its patients was performed. The total number of individuals providing care for the facility was 69. There were 9 religious exemptions and 3 medical exemptions. The calculated vaccination rate provided by the facility was 100% but was recalculated as 95.6 % after the medical exemptions were found to be invalid.

On 04/20/2022 at 9:38 a.m., S1CEO and S3UR verified the above calculations and acknowledged the facility was below the 100% vaccination rate as required by CMS Omnibus COVID-19 Health Care Staff Vaccination Regulations.

2. Failure to ensure medical exemptions requested were by a practitioner acting within the scope of their practice with recognized clinical contraindications and confirmed all information specifying which of the authorized or licensed COVID-19 vaccines were clinically contraindicated.

Review of the policy titled, "CMS Omnibus COVID-19 Healthcare Staff Vaccination," revealed, in part: "Medical Exemption: to be reviewed by medical provider. Documentation must be signed by a licensed provider and is acting within the respective scope of practice. Documentation must contain all information specifying which of the authorized COVID-19 vaccines are clinically contraindicated and the recognized clinical reason for the contraindications. A statement by the practitioner recommending that the staff member be exempt. The following conditions qualify for medical exemption:

* severe allergic reaction (anaphylaxis) after a previous dose of or to a component of the COVID-19 vaccine, including Polyethylene Glycol (PEG). (Please describe in detail on form and contraindication to alternatives, such as the Johnson & Johnson vaccine, which does not contain PEG.)

* Immediate allergic reaction to a previous dose or known (diagnosed) allergy to a component of the vaccine (Please describe in detail on form and contraindication to alternative vaccines.)"

In interview on 04/20/2022 at 9:15 a.m., S1CEO verified the 3 medical exemption requests were not for recognized contraindications to the vaccine, did not specify which vaccine was clinically contraindicated, and one was not filled out by a practitioner within the scope of her practice.

3. Failure to develop a contingency plan for staff who are not fully vaccinated for COVID-19.

Review of the policy titled,"CMS Omnibus COVID-19 Healthcare Staff Vaccination," failed to reveal a contingency plan for staff who were not fully vaccinated.

In interview on 04/20/2022 at 12:30 p.m., S1CEO verified the policy did not include a contingency plan for the unvaccinated staff.