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Based on record reviews, observation, and interview, the hospital failed to ensure patients at risk for harm to self or others were provided care in a safe setting as evidenced by:
1. failure to ensure observation levels of psychiatric patients were documented every 15 minutes by the MHTs as ordered by the physician for 9 (#8, #9, #10, #R1, #R2, #R3, #R4, #R5, #R6) of 9 patients observed and reviewed for documentation of observations as ordered from total sample of 10; and
2. failure to ensure the patients' physical environment was free of safety risks and did not afford opportunities for self -injury/harm to others.

Findings:

1. Failure to ensure observation levels of psychiatric patients were documented every 15 minutes by the MHTs as ordered by the physician.

Review of the hospital policy titled, "Levels of Observation", Policy Number: PC-1013, revealed in part: Purpose: To maintain the safety of each patient and the stability of the therapeutic milieu. Policy: All patients are monitored as to their location and activity at regular intervals. The degree of monitoring is dependent upon the individual patient's assessed psychiatric condition. Procedure: All patients admitted to the hospital will be assigned routine level of observation unless the physician orders a special level of observation. A. Routine levels of observation: 1. All patients are monitored a minimum of once every 15 minutes. 2. Location of patients is monitored at each change of shift by a staff member from the off-going shift together with a member of the on-coming shift. Location is noted on observation sheet for appropriate shift.

Review on 09/19/2022 at 10:55 a.m., of the Patient Observation Records for Patients #8, #9, #10, #R1, #R2, #R3, #R4, #R5, and #R6, dated 09/19/2022, revealed the following:

Patient #8
Review of Patient #8's Observation Record revealed the patient was on ordered q 15 minute observations. Further review of Patient #8's observation sheet revealed the patient's last observation was documented at 9:15 a.m. (1 hour and 40 minutes without q 15 minute documentation).

Patient #9
Review of Patient #9's Observation Record revealed the patient was on ordered q 15 minute observations. Further review of Patient #9's observation sheet revealed the patient's last observation was documented at 9:00 a.m. (1 hour and 55 minutes without q 15 minute documentation).

Patient # 10
Review of Patient #10's Observation Record revealed the patient was on ordered q 15 minute observations. Further review of Patient #10's observation sheet revealed the patient's last observation was documented at 9:45 a.m. (1 hour and 10 minutes without q 15 minute documentation).

Patient #R1
Review of Patient #R1's Observation Record revealed the patient was on ordered q 15 minute observations. Further review of Patient #R1's observation sheet revealed the patient's last observation was documented at 9:45 a.m. (1 hour and 10 minutes without q 15 minute documentation).

Patient #R2
Review of Patient #R2's Observation Record revealed the patient was on ordered q 15 minute observations. Further review of Patient #R2's observation sheet revealed the patient's last observation was documented at 9:45 a.m. (1 hour and 10 minutes without q 15 minute documentation).

Patient #R3
Review of Patient #R3's Observation Record revealed the patient was on ordered q 15 minute observations. Further review of Patient #R3's observation sheet revealed the patient's last observation was documented at 10:30 a.m. (25 minutes without q 15 minute documentation).

Patient #R4
Review of Patient #R4's Observation Record revealed the patient was on ordered q 15 minute observations. Further review of Patient #R4's observation sheet revealed the patient's last observation was documented at 9:45 a.m. (1 hour and 10 minutes without q 15 minute documentation).

Patient #R5
Review of Patient #R5's Observation Record revealed the patient was on ordered q 15 minute observations. Further review of Patient #R5's observation sheet revealed the patient's last observation was documented at 9:45 a.m. (1 hour and 10 minutes without q 15 minute documentation).

Patient #R6
Review of Patient #R6's Observation Record revealed the patient was on ordered q 15 minute observations. Further review of Patient #R6's observation sheet revealed the patient's last observation was documented at 9:45 a.m. (1 hour and 10 minutes without q 15 minute documentation).

At the time of review of the above referenced patients' observation sheets one MHT was observed with the patients in the commons area room and the other MHT was with Patient #10 in her room. Patient #10 had been observed acting out on the unit and had required a PRN medication to calm her. The MHT with Patient #10 was observed with theclipboard with all of the patients' q 15 minute observation sheets in her hand.

In an interview on 09/19/2022 at 11:00 a.m. with S4AdmAssist, present during the observation, she reported the hospital was staffed at the time of the observation with 2 MHTs. She reported one of the MHTs was with the patients in the commons area room and the other MHT was with Patient #10 who had been acting out and had required a PRN medication to calm her. She verified the MHT with Patient #10 had the clipboard with all of the patients' q 15 minute observation sheets. She agreed the MHT in the commons room should have been managing the other patients' q 15 minute observations. S4AdmAssist verified the above referenced patients' observation records had not been completed every 15 minutes as ordered and were not completed in real time.

In an interview on 09/21/2022 at 9:03 a.m. with S3DON, he confirmed patients' q 15 minute observations should be completed in real time and should indicate the patients' location and activity every 15 minutes. He reported in the past the hospital's patient observation tool had a spot where the nursing staff would check the observation sheets in the morning, afternoon, and in the evening to ensure accuracy of the patient observation records. He said the nurses would would sign off on them after they were reviewed. He reported that "fell by the wayside" when they started doing hourly rounds.


2. Failure to ensure the patients' physical environment was free of safety risks and did not afford opportunities for self -injury/harm to others.

Observations of the inpatient unit on 09/19/2022 at 10:15 a.m. revealed the following safety risks in the patient care environment:

a. Toilet seats in all patient rooms and in the shower room that had openings in the center, that were able to be lifted creating 3 ligature anchor points (both sides of the seat as well as the base of the seat).;

b. Multiple cloth patient gowns with strings to secure them present in patient rooms #102, #103, and #109. The cloth patient gowns with strings to secure them were also noted in the clean linen storage room, available for patient use.; and

c. A rigid, formed plastic leg/foot brace and 3 ACE bandage wraps that were approximately 3-4 feet long observed on the shelf in Room #104.

In an interview on 09/19/2022 at 11:00 a.m. with S4AdmAssist, present during the observation, she confirmed the toilet seats in all patient rooms and in the shower room had openings in the center that were able to be lifted. She also confirmed there were multiple cloth patient gowns with strings to secure them present in patient rooms #102, #103, and #109 and in the clean linen storage room. S4AdmAssist verified the rigid, formed plastic leg/foot brace and 3 ACE bandage wraps that were approximately 3-4 feet long were present in Room #104. S4AdmAssist acknowledged the items could pose a safety risk in the patient care environment.

In an interview on 09/21/2022 at 9:03 a.m. with S3DON, he confirmed the ace wraps and the rigid, formed plastic leg/foot brace should have been confiscated immediately when it was not in use by the patient.

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 allegations of abuse for 1 (O2) of 3 (O1, O2, O3) occurrence reports reviewed involving possible patient 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 occurrence report O2 revealed on 06/04/2022 at 7:15 a.m. #R8 and #R9 "got into a physical altercation after #R9 became delusional and believed he had been raped in the shower."

In interview on 09/21/2022 at 9:30 a.m., S3DON stated that he did not report the incident to Department of Health and Hospitals or law enforcement. He also verified upon review of the occurrence, it should have been reported even though the investigation revealed no evidence of neglect and neither patient suffered harm.

Based on record review and interview, the psychiatric hospital failed to ensure all staff had education and training to provide for the safety needs of the patient population served. This deficiency is evidenced by the failure to ensure de-escalation training and training in the use of restraints and seclusion for 3 (S3DON, S5CNA, S6RN) of 5 (S3DON, S5CNA, S6RN, S11LPN, and S13RN) direct care staff.
Findings:

Review of Compass Health 2022 Staff Development Plan reveals in part, "2. Within thirty (30) days of hire . . .Inpatient Staff (including RNs, LPNs, MHTs, MHT/Drivers, Social Services, Activity Directors, Nursing Management and Social Services Management) shall successfully complete the Inpatient Online Learning Curriculum including:Abuse and neglect, Change in Conditions, Restraint and Seclusion, Patient Rights . . . 3. Within sixty (60) days of hire: Employees with direct patient care responsibilities will obtain and maintain current certification in Environmental De-Escalation Guidance education (EDGE). Employees must attend certification classes which are routinely held on-site."

S3DON
Review of the personnel file for S3DON contained no documentation of de-escalation training or documentation of proficiency in the use of restraints and seclusion.

In telephone interview on 09/21/2022 9:38 a.m., S3DON verified it was his responsibility to provide all training and evaluation of the direct care staff.

On 09/21/2022 at 12:05 p.m. the surveyor notified S1Adm and S2RMgr that the personnel file for S3DON was incomplete and requested they contact human resources or S3DON to ensure we received his entire record. At 12:40 p.m. S2RMgr returned with documentation of S3DON's ACLS training and stated they did not have any other documented training.

S5CNA and S6RN
Review of the provided records for the 2 agency contracted direct care workers S5CNA and S6RN revealed no documentation of current de-escalation training or documentation of proficiency in the use of restraints and seclusion.

In telephone interview on 09/21/2022 at 9:15 a.m., S3DON verified the only orientation provided for contract employees was immediately prior to the employee starting the first shift at the hospital and consisted of orientation to the surroundings and providing access to a binder with the policies in the nursing station. S3DON stated it was the responsibility of the agency that employed them to assure their staff were trained and competent.

Based on record review and interview, the hospital's governing body failed to ensure the hospital's QAPI (quality assurance performance improvement) program reflected the complexity of the hospital's organization and services. This deficient practice was evidenced by failure of the hospital to include all services in the QAPI plan.

Findings:

Review of the quality assurance performance improvement indicators from the Governing Body Meeting on 03/24/2022 revealed the Outpatient Clinic and Respiratory Services were not included in the program.

In telephone interview on 09/21/2022 at 9:31 a.m., S3DON verified respiratory services and the outpatient clinic were not included in the QAPI indicators. He stated the outpatient clinic has a separate QAPI plan.

Based on record review, observations, and interview, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services as evidenced by:

1.Failure to ensure the RN supervised the care of each patient. This deficient practice is evidenced by failure of the nursing staff to obtain admission and other patient care orders from a physician or LP for 1(#R7) of 1 (#R7) sampled records reviewed with nursing staff to determine the admission process, from a total patient sample of 10 (See findings tag A-0395); and

2. Failure to ensure non-employee RNs working as charge nurses were supervised by an appropriately qualified hospital employed RN. This deficient practice is evidenced by staffing with non-employee RNs as the only RN on shift for 8 shift assignment schedules reviewed from 09/01/2022 - 09/15/2022. The hospital also failed to ensure the non-employee RNs were appropriately oriented to the hospital's policies and procedures prior to providing patient care. (See findings tag A-0398).

Based on record review, observation and interview, the hospital failed to ensure the RN supervised the care of each patient as evidenced by:
1. failure of the nursing staff to obtain admission and other patient care orders from a physician or LP for 1 (#R7) of 1 (#R7) sampled records reviewed with nursing staff, to determine the admission process, from a total patient sample of 10;
2. failure of the RN to ensure a patient (#7) was assessed for elopement risk after exhibiting elopement risk behaviors for 1(#7) of 1 sampled patients reviewed for elopement from a total patient sample of 10. Patient #7 subsequently eloped through the hospital's exit door within 2 hours and 35 minutes of admission.; and
3. failure of the nursing staff to institute preventative measures to ensure the physical separation and increased observation of 2 (#4 and #11) patients discovered engaging in sexual intercourse.

Findings:

1.Failure of the nursing staff to obtain admission and patient care orders from a physician or LP.

Review of the Rules and Regulations of the Medical Staff Bylaws revealed in part, under Section 3. Medical Records, #12, "A physician's routine orders, when applicable to a given patient, shall be reproduced in detail on the order sheet of the patient's record, dated and signed by a physician with Medical Staff privileges..." and under Section 4: Prescription of Treatment, #3, " ...All orders dictated over the telephone shall not be accepted until the physician giving the order has been correctly identified by the staff receiving the order, who shall sign the dictated order upon transcription ..."

Review of Patient #R7's medical record on 09/21/2022 at 11:00 a.m. revealed he was admitted to the hospital on 09/21/2022 at 10:30 a.m. with an admission diagnosis of Methamphetamine induced psychosis.

Review of Patient #R7's admission orders, dated 09/21/2022 at 10:30 a.m., revealed the pre-printed orders had boxes that could be checked for ordering laboratory tests, frequency of vital sign assessments, diet, and special precautions. The following orders had been checked on Patient #R7's admit orders: Vital signs: Routine and Diet: NAS.

Further review revealed a section with the heading Medication Orders with choices for low dose, medium dose and high dose PRN medication doses for controlling psychosis exacerbation and/or extreme anxiety. The following medications/dose levels were listed: Haldol, Ativan, and Benadryl IM q 6 hours (medium and high dose) or q 8 hours (low dose) as needed for psychosis exacerbation or Zyprexa by mouth every 6 hours (medium and low dose) or every 12 hours (high dose) as needed for anxiety. The medium dose had been checked on Patient #R7's admit orders.
Additional review of the admit orders revealed the following statement in bold-faced lettering below the above referenced medication orders section: The physician will order either high, medium, or low dose. There will be no nursing discretion regarding which dose to give; only 1 box should be checked.

Another section of the orders above the signature section revealed the following: Physician Certification: On this date, I have reviewed the medical needs, multidisciplinary observations, formulations and treatment interventions and have provided medical direction for the continued development of the treatment plan. I certify that the patient is appropriate for inpatient level of care prescribed. The order was written as a VO/TO S12MD on 09/21/2022 at 10:30 a.m. The order had not been authenticated by S12MD at the time of the record review with S13RN.

In an interview on 09/21/2022 at 9:03 a.m. with S3DON, he reported prior to admitting a patient the hosptial received a new admit patient's packet from the transferring hospital. He explained the patient's medication list is validated through the patient's pharmacy and they run it by the admitting MD. He further explained the LPN generates the chart. He explained the admitting nurse chooses orders for the patient's diet, observation level, and labs on the pre-printed admit orders. He explained usually the admit nurse chooses the patient diet based on diagnoses, such as if a patient is Diabetic then they choose the NCS diet. He said if the patient has HTN or a cardiac diagnosis the nurse chooses the NAS diet. S3DON reported as far as admit lab orders, the admit nurse chooses the labs based on what labs had been done at the transferring hospital and some are chosen based on standing lab orders for new admits.

In an interview on 09/21/2022 at 11:28 a.m. with S12MD, he explained when a new patient is admitted, the nursing staff reviews the patient and they call or text him or the NP calls him and they review the patient's routine medications from the medication reconciliation form. The admit nurse then faxes the list to pharmacy. S12MD reported the admitting LPNs pick the newly admitted patient's level of observation, diet, and labs. He explained when the patient is evaluated by the physician, the orders are reviewed and changes are made. He reported the patient levels of observation are every 15 minutes or 1:1. He reported if patients are exhibiting behaviors and need a higher level of observation, the staff can call him for an order for 1:1 level of observation. S12MD explained most of the time the admit orders are initiated as standing orders, but he may change out the orders after evaluation of patient. He reported if a patient has a cardiac diagnosis or HTN the admitting nurse places the patient on a NAS diet and if they are Diabetic the admitting nurse places them on a NCS diet.

In an interview on 09/21/2022 at 11:50 a.m. with S13RN, during review of newly admitted Patient #R7's admit orders, she explained the admitting nurse reviews the patient's record from the transferring hospital. She reported the review would include review of the patient's PEC/CEC documentation, labs drawn at the hospital, patient history, chief complaint from the transferring hospital, pregnancy test results, EKG results, UDS results, alcohol level results, and medical clearance documentation. S13RN explained the pre-printed admit orders with options to choose different labs, diets, frequency of vital signs, and levels of observation are standing orders. She further explained when admitting a new patient the nurse chooses the patient's labs from the list of possible labs on the pre-printed form, after reviewing the patient's labs from the transferring hospital. She reported there are standing routine labs they perform on admit here and those labs are also chosen by the admitting nurse if they were not done at the transferring hospital. S13RN reported if the patient has a cardiac diagnosis or HTN the admitting nurse places the patient on a NAS diet and if they are Diabetic the admitting nurse places them on a NCS diet. She indicated Patient #R7's chosen diet was a NAS diet. S13RN also explained there were three levels of PRN medications listed on the pre-printed admit orders that could be chosen for management of patients' experiencing psychosis exacerbation and/or extreme anxiety. She reported most of their patients fell into the category of medium dose range. She said when the patient was evaluated by the physician, usually within 24 hours, the level of PRN medications could be changed based on the physician's evaluation. She showed the surveyor that the medium dose (Haldol, Ativan, and Benadryl IM q 6 hours as needed for psychosis exacerbation or Zyprexa by mouth every 6 hours as needed for extreme anxiety) had been checked off for Patient #R7 by the admitting nurse.

2. Failure of the RN to ensure a patient (#7) was assessed for elopement risk after exhibiting elopement risk behaviors.

Review of the hospital policy titled, "Elopement Precautions", Policy Number PC-1015, revealed the following, in part; Patients that are assessed as being high risk for elopement will be placed on elopement precautions.

Review of Patient #7's medical record revealed he was admitted on 07/07/2022 at 5:15 p.m. with an admission diagnosis of Psychosis and Amphetamine Use disorder - Severe.

Review of hospital provided self-reports to LDH-HSS for alleged abuse/neglect revealed Patient #7 had eloped from the hospital on 07/07/2022 at 7:50 p.m.

Review of the investigation of Patient #7's elopement revealed the following documentation of video footage review by S3DON:
7:49 p.m.: Patient #7 was seen pacing in the day room.
7:49:40 p.m.: Patient #7 was seen pushing on the patio door.
7:50:10 p.m.: Patient #7 left the day room and walked towards the hall.
7:50:44 p.m.: Patient #7 was seen pushing on the back door.
7:50:46 p.m.: Patient #7 is seen opening the door and eloping.
7:50:52 p.m.: Patient #7 is seen slamming the exit door closed and running away.

Description of incident: On 07/07/2022, at approximately 7:50 p.m., S7MHT, while standing near the shower room door, witnessed Patient #7 elope out of the patient hallway rear exit by pressing/kicking it open; S7MHT immediately notified S8RN (Charge Nurse) of the elopement and proceeded to the exit to check it's integrity and went outside to look for Patient #7; S8RN followed to assist S7MHT on the search after directing S9LPN to notify the Sheriff's Department. Patient #7 was seen running along the neighborhood fence line, which was reported to the Sheriff's Department; all other patients were accounted for and the rear exit door was secured, undamaged.

Review of a handwritten statement from S7MHT on 07/08/2022, revealed the following: "Around 7:30 p.m. I was sitting in front of the shower room door with a patient in the shower. Around 7:50 PM, came to ask to Patient #7 came and asked to go smoke. We told him as soon as [the] patient was done in the shower we was going to bring them out. Patient #7 got mad, pushed the wet floor sign down, went in the day room and kicked on the patio door. I called Patient #7 to please pickup sign; He picked it up and put it on the railing. Patient #7 was upset because we could not bring him out right away... I heard a bang as I as coming out of the shower room, seen patient going out back door."

Further review of the incident investigation revealed no documented evidence that staff had re-assessed Patient #7's elopement risk when he was agitated, pacing, and pushing on the exit doors prior to eloping and no measures were taken to increase the patient's level of observation.

In an interview on 09/21/2022 at 9:03 a.m. with S3DON, he reported he had investigated Patient #7's elopement in 07/2022. He explained Patient #7 had put his full weight behind kicking the exit door and he was able to kick the door open. S3DON confirmed Patient #7 had been exhibiting elopement risk behaviors such as going to the doors, pushing on them, and pacing, prior to eloping. He indicated in hindsight Patient #7 should have been re-assessed for elopement risk and they could have increased his level of observation/kept the patient away from the exit doors to attempt ot prevent his elopement. He reported the patient had been taken into police custody after he eloped and confirmed Patient #7 did not return to the hospital after his elopement.

3. Failure of the nursing staff to institute preventative measures to ensure the physical separation and increased observation of 2 (#4 and #11) patients discovered engaging in sexual intercourse.

Review of the medical record for Patient #4 revealed she was involuntarily admitted on 06/27/2022 with documetation of a Physician's Emergency Order and later a Coroner's Emergency Order with a diagnosis of bipolar disorder.

Review of the medical record for Patient #11 revealed he was involuntarily admitted on 06/29/2022 with documetation of a Physician's Emergency Order and later a Coroner's Emergency Order with a diagnosis of paranoid schizophrenia.

Review of the occurence report revealed on 07/05/2022 at 1:48 a.m. Patient #4 and Patient #11 were discovered while engaging in sexual intercourse. The two patients were discovered by S19MHT during 15 minute observations. The plan of action included re-educating staff on policies PC-803. PC-1013, and PC-1411 and the necessity to educate new patients on their expected behavior while on the unit as related to the Patient Handbook on 07/18/2022.

Review of the orders for Patient #4 and Patient #11 revealed no new orders related to the incident.

In interview on 09/21/2022 at 9:25 a.m., S3DON verified he had investigated the occurence and had self-reported the incident to the Louisiana Department of Health. He stated the intercourse was planned and consenual and there was no evidence of neglect by staff. S3DON also verified no additional interventions or orders were requested such a change in observation status or changing the location of the patient rooms to allow increased visualization. S3DON verified those interventions could have been easily initiated but they did not think they were necessary because Patient #4 and Patient #11 were not openly affectionate after the occurrence.
















44495

Based on record review and interview, the hospital failed to ensure non-employee RNs working as charge nurses were supervised by an appropriately qualified hospital employed RN and were appropriately oriented to the hospital's policies and procedures prior to providing care. This deficient practice is evidenced by staffing with non-employee RNs as the only RN on shift for 8 shift assignment schedules reviewed from 09/01/2022 - 09/15/2022 and failure to ensure the non-employee RNs were appropriately oriented to the hospital's policies and procedures prior to providing patient care.

Findings:

Review of hospital's staffing assignment documentation from 09/01/2022 - 09/15/2022 (15 days/30 shifts) revealed an Agency RN was the hospital's Charge RN for 8 shifts. Further review revealed the Agency RNs were the only RNs working on those days. On 09/05/2022 both the day shift and the night shift were covered by Agency RNs.

In an interview on 09/20/2022 at 9:30 a.m. with S1CEO, she confirmed the above referenced findings regarding staffing with Agency RNs as Charge Nurses. S1CEO confirmed the Agency RNs were the only RNs present on the referenced shifts. She reported the hospital frequently relied upon staffing agencies to provide nursing staff to cover shifts in the hospital.

In an interview on 09/21/2022 at 9:03 a.m. with S3DON, he confirmed Agency RNs have been used for shift coverage. He further confirmed they are the only RNs working on the referenced shifts. S3DON verified the only orientation provided for contract employees was immediately prior to the employee starting the first shift at the hospital and consisted of orientation to the surroundings and providing access to a binder with the policies in the nursing station. S3DON stated it was the responsibility of the agency that employed them to assure their staff were trained and competent.

Based on record review and interview, the hospital failed to ensure records for controlled substances were current and performed according to hospital policy.
Findings:

Review of hospital policy Pharm-003, "Minimizing Drug Diversion revealed in part, "All narcotics are counted and signed for at the change of shifts."

Review of the form titled "Shift Verification of Controlled Substances Count" revealed spaces for the documentation of date, time, signature of on-coming nurse, signature of off-going nurse, count correct and comments/documentation.

During tour of the medication room on 09/19/2022 at 10:40 a.m. review of the current Shift Verification of Controlled Substances Count sheet revealed the following:

1. On 09/02/2022 at 12:50 a.m. S9LPN recorded the addition of 9 packs of Suboxone. She signed as both the on-coming and off-going nurse and indicated the count was correct.
2. On 09/02/2022 at 6:00 a.m. S10LPN signed as the on-coming nurse with no off-going nurse signature and did not indicate if the count was correct and did not enter comments.
3. On 09/02/2022 at 6:00 p.m. S10LPN signed as the off-going nurse with no on-coming nurse signature and did not indicate if the count was correct and did not enter comments.
4. On 09/03/2022 at 6:00 a.m. S10LPN signed as the on-coming nurse with no off-going nurse signature and did not indicate if the count was correct and did not enter comments.
5. On 09/03/2022 at 6:00 p.m. S10LPN signed as the off-going nurse with no on-coming nurse signature and did not indicate if the count was correct and did not enter comments.
6. On 09/04/2022 at 6:00 a.m. S10LPN signed as the on-coming nurse with no off-going nurse signature and did not indicate if the count was correct and did enter comments.
7. On 09/06/2022 at 6:00 a.m. S11LPN signed as the on-coming nurse with no off-going nurse signature and did not indicate if the count was correct and commented "8 left. Given 1."
8. On 09/06/2022 at 6:00 p.m. no one counted the narcotics.
9. On 08/07/2022 at 6:00 a.m. S10LPN signed as the on-coming nurse with no off-going nurse signature and did not indicate if the count was correct and commented,"8."
10. On 09/07/2022 at 6:00 p.m. S10LPN signed as the off-going nurse with no on-coming nurse signature and no indication if the count was correct and no comments.
11. On 08/08/2022 at 6:00 a.m. S10LPN signed as the on-coming nurse with no off-going nurse signature and did not indicate if the count was correct and no comments.
12. On 09/09/2022 at 6:00 a.m. S14LPN signed as the off-going nurse with no on-coming nurse and did not indicate if the count was correct and commented" 8 Suboxone."

In interview on 09/20/2022 at 10:48 a.m., S2RMgr verified the narcotics should be counted at the change of shift at 6:00 a.m. and 6:00 p.m. by 2 nurses. S2RMGr verified the narcotic counts were not performed according to hospital policy.

Based on observation and interview, the hospital failed to ensure emergency equipment was maintained to ensure an acceptable level of safety and quality. This deficiency is evidenced by the failure of nursing personnel to perform daily checks on the code cart and AED.

Findings:

Review of the form titled "Emergency Cart Inventory Log" revealed in part, "The Emergency Cart Inventory shall be checked daily by assigned staff. Staff member initials indicate they have verified the inventory is present and in proper working condition."

Tour of the facility guided by S11LPN on 09/19/2022 at 10:30 a.m. revealed the Emergency Cart Inventory Log was incomplete. The cart was not checked on 09/02/2022 and 09/14/2022. S11LPN verified the findings.

In interview on 09/21/2022 at 9:48 a.m., S3DON verified the emergency cart was supposed to be checked daily.

Based on interview and record review, the hospital failed to ensure the person designated as the Infection Control Officer had acquired specialized training in infection control as evidenced by S3DON having no documentation of specialized training in infection control.

Findings:

Review of the personnel file of S3DON revealed APIC membership began 02/01/2022. Review of the Infection Control Officer Checklist revealed he had not completed any of the modules of specialized training in Infection Control.

In an interview 09/21/2022 at 9:10 a.m., S3DON confirmed he was the hospital's IC nurse, but had not completed the educational program.

On 09/21/2022 at 12:40 p.m. S2RMgr verified there was no addition information they could provide to complete the educational requirements in the personnel file of S3DON.

Based on record review, observation and interview, the hospital failed to ensure a system for controlling infections and communicable diseases of patients and personnel was established. This deficient practice was evidenced by:
1. failure to obtain isolation orders and failure to document when isolation precautions were initiated on a symptomatic inpatient (#3) who tested positive for COVID-19 on the second day of her hospital stay for 1 (#3) of 1 total sampled patients reviewed for being COVID-19 +/requiring isolation from a total patient sample of 10.; and
2. failure to maintain equipment in a sanitary manner.

Findings:

1. Failure to obtain isolation orders and failure to document when isolation precautions were initiated on a symptomatic inpatient (#3) who tested positive for COVID-19 on the second day of her hospital stay.

Review of the hospital's policy titled, "COVID-19 Response Plan", revealed the following, in part: Monitoring of Patients: If a patient develops signs of fever or respiratory infection: a. Place patient on isolation precautions in a designated isolation area. b. Obtain order to place on isolation precautions.

Review of Patient #3's medical record revealed an admission date of 02/05/2022 at 06:33 a.m. with an admission diagnosis of Depression with Suicidal Ideation.

Review of Patient #3's MD orders revealed the following orders:
02/06/2022 9:00 p.m. COVID-19 test per protocol patient complains of no taste or smell and positive for cough.
Further review of Patient #3's MD orders revealed no documented evidence of an order to place the patient in isolation for COVID-19.

Review of Patient #3's medication administration record revealed the patient tested positive for COVID-19 on 02/06/2022 at 9:00 p.m.

Review of Patient #3's nursing notes entries for 02/06/2022 - 02/07/2022 revealed no documented evidence of when COVID-19 isolation precautions were initiated after the patient tested positive for COVID-19 on 02/06/2022 at 9:00 p.m. via COVID-19 rapid test. Further review revealed the first entry documented indicating the patient was in isolation for being COVID-19 positive was on 02/07/2022 at 2:30 p.m.

In an interview on 09/20/2022 at 1:00 p.m. with S1CEO, she verified there was no documentation in the patient's record indicating when Patient #3 was placed on isolation precautions for COVID-19. She also verified there was no MD order to place the patient in isolation for COVID-19.

2. Failure to maintain equipment in a sanitary manner.

On 09/19/2022 at 10:30 a.m. an observation was made of 2 box fans with a gray dust-like coating on the surface of the grate. The fans were stored in the clean supply closet. S4AdmAssist, present during the observation, confirmed the fans were not clean and were covered in a gray dust-like coating.

On 09/19/2022 at 11:10 a.m. an observation was made of a box fan in the nurses' station that had gray dust-like coating on the grate of the fan as well as a yellow colored dried on substance on the surface of the fan. S4AdmAssist, present during the observation, confirmed the fans were not clean and were covered in a gray dust-like coating.

Based on record reviews and interviews, the hospital failed to ensure the nursing staff providing respiratory care were trained and determined to be competent in performance of respiratory care functions. This deficient practice was evidenced by failure to have documented evidence of education and evaluated competency in the administration of metered dose inhalers for 1 (S6RN-Agency) of 2 (S6RN-Agency, S11LPN) sampled personnel records reviewed for performance of respiratory services/respiratory competencies.

Findings:

Review of the hospital policy titled,"Respiratory Care Services", Policy Number: PC-1410, revealed the following, in part: Purpose of this policy is to provide for nursing staff with guidance to deliver respiratory care to patients in the psychiatric unit. Responsibility: 1. Nursing staff will administer nebulizer treatments and metered dose inhalers and inhalation therapy. 2. The RN will perform or delegate respiratory care services. i delegate must have demonstrated competence and ii. services must be within the scope of the delegate's scope of practice.

Review of Patient #9's medical record revealed an admission date of 09/18/2022 at 12:25 p.m. with a co-morbid diagnosis of Asthma.

Further review of Patient #9's medical record revealed an MD order for Albuterol AER HFA for Ventolin HFA - 1 puff q 6 hours.

Review of Patient #9's nurses notes revealed the following entries by S6RN - Agency:
09/19/2022 10:00 p.m. Patient #9 assessed. Presents with wheezing to bilateral lungs and shortness of breath. Inhaler albuterol administered as ordered with some effectiveness.

09/20/2022 05:00 a.m. Patient remained in bed most of shift. Presents with auditory bilateral lung wheezing. Complains of shortness of breath. Denies pain. Vitals stable. Medications administered and tolerated.

Review of S6RN - Agency's personnel information, obtained from the staffing agency per surveyor's request, revealed no documented evidence of skills competencies for the administration of metered dose inhalers.

In an interview on 09/20/2022 at 1:00 p.m. with S1CEO, she reported she had requested S6RN - Agency's personnel file from the staffing agency. S1CEO confirmed she did not have a personnel file on S6RN - Agency and had no documented hospital assessed skills competencies for S6RN.

In an interview on 09/21/2022 at 9:03 a.m. with S3DON, he stated it was the responsibility of the agency that employed them to assure their staff were trained and competent. He agreed Agency nurses should have competencies assessed at the hospital as well as at the staffing agency. He confirmed he had not been assessing the Agency nurses' skills competencies.

Based on record review and interview, the facility failed to document a complete individualized treatment plan in a timely fashion. This deficiency is evidenced by failure of the hospital to document a treatment plan with goals, proposed interventions, and discharge criteria that was created during the time of inpatient care for 3 (#4, #6, #11) of 3(#4, #5, #11) treatment care plans reviewed.
Findings:

Review of the hospital policy PC501, "Treatment Plans," reveals in part:

B) Initial Treatment Plan
1) Within 24 hours of admission, a nurse completes an initial treatment plan that is based on an assessment of presenting problems that is based on physical health, emotional and behavioral status. This initial treatment plan is utilized to implement immediate treatment objectives. . . .
C) Master Treatment Plan
1) A multidisciplinary Treatment Team Meeting is held to develop a comprehensive, individualized Master Treatment Plan ...
2) The Master Treatment Plan is based on the findings of each contributing discipline, which describes the patient's problems, strengths, clinical needs, and the patient's goals for treatment.
3) The Master Treatment Plan contains:
a) The patient's diagnosis
b) The patient's length of stay
c) The problems to be addresses
d) The strengths to be utilized
e) Long-term goal of treatment for each problem
f) Short-term goals (objectives) of treatment for each problem, written in objective and measurable terms with expected dates of achievement stated.
g) Staff Interventions
h) Discharge Criteria- The type and frequency of interventions used to obtain the objectives are specified and the staff members are identified. . . .

8) Each problem of the treatment plan is addressed, updated, revised or resolved and documented weekly during treatment team.

Review of the 24 Hour Chart Audit Form reveals in part, "Treatment Plan initiated within 8 hours of admit . . . Treatment Plan completed within 24 hours of admit . . . Master Treatment Plan completed in 5 days."

Patient #4
Review of the medical record for patient #4 revealed voluntary admission on 02/08/2022 with a diagnosis of major depressive disorder and discharge on 02/16/2022.

Review of the Master Treatment Plan Cover Sheet reveals the treatment team consisted of 1 social worker, 1 licensed practical nurse, the Activities Director, and the attending physician. The document had no diagnosis, no problems, no goals and no discharge criteria for the patient. The document was signed 2/21/2022.

Review of the Treatment Team Plan Review revealed the problem list. There was no documented diagnosis, no proposed interventions, no goals and no indication the patient had met the goals, and no discharge criteria. The document was signed 02/15/2022.

Patient #6
Review of the medical record for Patient #6 revealed involuntarily admitted on 06/22/2022 with a diagnosis of schizoaffective disorder, bipolar type and was discharged on 06/29/2022.

Review of the Master Treatment Plan Cover Sheet reveals the treatment team consisted of 2 registered nurses, 1 licensed practical nurse, the Activities Director, and the attending physician. The document had no diagnosis, no problems, no goals and no discharge criteria for the patient. The document was signed 07/21/2022.

Review of the Treatment Team Plan Review revealed the problem list. There was no documented diagnosis, no proposed interventions, no goals and no indication the patient had met the goals, and no discharge criteria. The document was dated 06/28/2022- the day prior to discharge.

Patient #11
Review of the medical record for Patient #11 revealed involuntary admission on 06/29/2022 with a diagnosis of paranoid schizophrenia and discharge on 07/08/2022.

Review of the Master Treatment Plan Cover Sheet reveals the treatment team consisted of 1 registered nurse and 2 licensed practical nurses. The document had no diagnosis, no problems, no goals and no discharge criteria for the patient. The document was not signed by the physician. The space for the patient's signature documented, "Pt d/c- N/A."

Further review of the chart revealed no Treatment Team Plan Review.

In telephone interview on 09/21/2022 at 9:54 a.m., S3DON verified the Master Treatment Plan Cover Sheet was the initial working treatment plan developed within 5 days of admission. S3DON also verified the only other document containing the treatment plan would be the Treatment Team Plan Review which should contain the goals, interventions and discharge criteria. S3DON verified here were no other documents in the paper chart or electronic record that would be used in conjunction with the 2 forms to provide the missing documentation.

Based on record review and interview, the hospital failed to document twice yearly testing of emergency preparedness training.

Findings:

Review of the emergency preparedness documents presented to the surveyors after entrance on 09/19/2022 revealed no evidence emergency preparedness training drills were performed.

In interview on 09/21/2022 at 2:15 p.m., S2RMgr verified there were no documented emergency drills including fire drills performed in the past year.

Based on record review and interview, the hospital failed to participate in and analyze a full scale community-based exercise and conduct a secondary exercise of choice in the past two years
.
Findings:

Review of the emergency preparedness documents presented to the surveyors after entrance on 09/19/2022 revealed no evidence emergency preparedness exercises had been conducted.

In interview on 09/19/2022 at 2:45 p.m., S1Adm verified the hospital evacuated prior to Hurricane Ida in August of 2021 but she did not know if the emergency preparedness director at that time had prepared a report.

In interview on 09/21/2022 at 12:40 p.m., S2RMgr verified there was no documentation of any emergency preparedness exercises in the past 2 years.