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Based on record review and interview, the hospital failed to meet the Condition of Participation of Patient Rights as evidenced by:1) failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for the patients admitted for acute inpatient psychiatric services by failing to ensure the patient's environment was free of ligature risks and safety hazards. (see findings at A-0144)
2) failing to ensure patients were free from abuse and/or harassment by failing to maintain an environment in a manner to assure an acceptable level of safety and quality for the patients admitted for acute inpatient psychiatric services by failing to ensure patients were protected from patients evaluated and admitted with aggressive and violent behaviors. (see findings at A-0145)

Based on record review and interview, the hospital failed to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for the patients admitted for acute inpatient psychiatric services by failing to ensure the patient's environment was free of ligature risks and safety hazards.

Findings:
Observation on 06/27/16 at 11:00 a.m. during a tour of the hospital revealed the following:Room a with 2 metal frame beds with multiple ligature risks and ¼ side rails x 4 on each bed.
Room b with 2 metal frame beds with multiple ligature risks.
Interview on 06/27/16 at 11:00 a.m. with S3LPN confirmed the metal frame beds in the patient rooms.
Interview on 06/27/16 at 1:20 p.m. with S1Administrator confirmed the metal frame beds in the patient rooms.

Based on record review and interview, the hospital failed to ensure patients were free from abuse and/or harassment by failing to maintain an environment in a manner to assure an acceptable level of safety and quality for the patients admitted for acute inpatient psychiatric services by failing to ensure patients were protected from patients evaluated and admitted with aggressive and violent behaviors.

Findings:
Review of the hospital policy titled Suspected Abuse and/or Neglect, Number PC-706, dated July 10, 2012 revealed in part: 1.) Abuse a. Physical contact or actions that result in injury or pain, such as hitting, pinching, yanking, shoving, pulling hair, etc.
Medical record review on 06/27/16 revealed patient #1 was admitted to the hospital on 05/16/16 by a PEC order from the emergency room physician. Documentation on the PEC revealed, patient #1 was violent and homicidal, became combative with group home staff, threatened to kill other residents, and had poor insight and judgement. Patient #1's diagnoses included: MR, Bipolar, Depression, Aggressive Behaviors, Intellect Disability and Schizophrenia. Documentation revealed patient #1 has had violent behaviors and was physically assaulting staff and other patients at group home.
Review of the CEC dated 05/15/16 revealed, patient #1 had a history of combative behaviors with the group home staff and had threatened to kill other residents.
Review of the Psychiatric Evaluation dated 05/17/16 revealed, S9Physician documented patient #1 was admitted as increased risk for harm to self and others. S9Physician further documented in his summary that patient #1 was a danger to self, and a danger to others, and easily agitated.
Review of the Initial Nursing Assessment for patient #1 dated 05/16/16 revealed, patient #1 was PEC'd for aggressive and violent behavior, fighting staff and other residents in group home. Patient #1 was placed on q 15 minute observation for safety.
Review of the Treatment Plan dated 05/16/16 for patient #1 revealed, patient #1 was care planned for Mood Disturbances, Altered Health Maintenance, and High Risk for Falls. There was nothing care planned about the patient's aggressive behaviors, violence toward others, and/or safety measures in place to protect other patients.
Review of the admission orders for patient #1 dated 05/16/16 revealed, patient #1 was placed on special precautions: Q 15 minute observations. Further review of the orders revealed an order dated 05/19/16 to place patient #1 on a 20 foot rule from all peers. Further review of the orders revealed an order dated 05/20/16 for "No Roommate."
Review of the Incident/Accident log for May 2016 reflected 8 Occurrence Reports involving patient #1 dated as follows:

-05/19 at 2:40 p.m. patient #1 hit roommate (patient #6)
-05/19/16 at 4:58 p.m. patient #1 hit another patient
-05/19/16 at 7:15 p.m. patient #1 fighting with staff
-05/20/16 at 3:42 p.m. patient #1 hit another patient
-05/21/16 at 4:20 p.m. patient #1 hit another patient
-05/23/16 at 10:45 a.m. patient #1 hit fighting with staff
-05/25/16 at 5:40 p.m. patient #1 hit another patient and staff
-05/28/16 at 7:40 p.m. patient #1 hit another staff
Review of the Daily Floor Census dated 05/16/16 revealed, the hospital had 6 empty beds at the time of patient #1's admission. Further review of the Daily Floor Census revealed, Patient #1 was admitted to room c) with patient #6 as a roommate. (Medical record review for patient #6 revealed patient #6 was admitted to the hospital on a voluntary formal admission on 05/09/16 with diagnoses that included Bipolar, Anxiety, Panic attacks, COPD Hypothyroid, Fibromyalgia, Chronic pain, HTN, and Depression).
Interview on 06/28/16 at 3:50 p.m. with S2DON confirmed patient #1 was admitted and placed in a room with a roommate. S2DON further stated that all patients are admitted and placed on q 15 minute observations. Surveyor asked S2DON why the hospital would put a patient admitted with violent and aggressive behaviors in a room with another patient when there were vacant rooms available. S2DON stated that she was not sure but there may have been repairs to the other rooms. Surveyor asked what safety measures were put in place to protect the other patient in the room with patient #1 and other patients in the hospital, S2DON did not answer. Surveyor asked S2DON why patient #1's care plan did not include aggressive and violent behaviors, or that patient #1 had 3 documented Incidents of hitting other patients and staff before a 20 foot rule was ordered on 05/19/16, and an order for no roommate on 05/20/16 only after patient #1 hit her roommate. S2DON did not reply to surveyors questions.
Interview on 06/29/16 at 11:00 a.m. with S11MHT confirmed that during the night patient's room doors are only cracked open to allow for privacy and rounds are made on all patients every 15 minutes.

Based on record review and interview, the hospital failed to ensure the training and experience of all personnel was adequate to meet the needs of the patient's as evidenced by failing to ensure all direct care staff were currently trained in de-escalation techniques prior to working with patients for 4 (S10AT, S11MHT, S13LPN, S14MHT) of 9 personnel records reviewed. This deficient practice had the potential to negatively impact the 11 patients on census at the time of survey. Findings:

Review of personnel record on 06/29/16 for S13LPN revealed date of hire was 05/19/16. There was no documentation in personnel folder for de-escalation training.

Interview on 06/29/16 at 10:10 a.m. with S13LPN confirmed that she had no current de-escalation training and stated that she was told hospital would set up a class to attend. S13LPN stated that she only worked PRN and had not been involved in de-escalating a patient's behaviors.

Review of personnel record on 06/29/16 for S10AT revealed date of hire was 05/26/16. There was no documentation in personnel folder for de-escalation training.

Interview on 06/29/16 at 10:35 a.m. with S10AT confirmed that he had no current de-escalation training and stated that he had an overview during orientation and was told hospital would set up a class to attend.


Review of personnel record on 06/29/16 for S11MHT revealed, date of hire was 05/19/16. There was no documentation in personnel folder for de-escalation training.


Interview on 06/29/16 at 11:00 a.m. by telephone with S11MHT confirmed that she had been through training at her other job, but not at this hospital. She was told that the hospital would set up a class for her to attend.


Review of personnel record on 06/29/16 for S14MHT revealed date of hire was 05/27/16. There was no documentation in personnel folder for de-escalation training.


S14MHT was unavailable for interview by telephone.


Interview on 06/29/16 at 11:35 a.m. with S1Administrator stated that the hospital policy, given to surveyor at that time titled 2016 Staff Development Plan and contained no date or reference number, listed that staff had 60 days from hire to complete EDGE training (de-escalation training).

31206

Based on record reviews and interviews, the hospital failed to ensure each patient had an individualized treatment plan that included all diagnoses/problems for which the patient was admitted for 3 (#3, #4, #5) of 3 patient records reviewed for nursing care plans from a total sample of 6 patients.


Findings:


Review of the Hospital's Policy titled "Treatment Plans", effective 10/18/12 and presented as a current policy by S2DON, revealed that each patient will have an individualized treatment plan developed under the direction of the psychiatrist. This comprehensive plan is initiated upon admission following assessments by the various disciplines and will reflect the individual's clinical needs, condition, functional strengths, and limitations.


Patient #3

Review of Patient #3's medical record revealed diagnoses that included: Alcohol dependence, Bipolar disorder NOS, Depression, Chronic back pain and Neuropathy. Review of Patient #3's "Master Treatment Plan" revealed the identified problems were Mood Disturbance, Potential for Relapse, and Alteration in health maintenance. There was no documented evidence that the problems of Chronic back pain and Neuropathy were identified on the Master Treatment Plan and that goals and interventions were developed to address these problems.


Patient #4

Review of Patient #4's medical record revealed diagnoses that included: Other stimulant dependence with stimulant-induced psychotic disorder, Opioid dependence, Bipolar disorder NOS. Further review of the fall risk assessment dated 06/26/16 revealed he was identified as high risk (>65) for falls. Review of Patient #4's H&P review of systems revealed problems of : SOB, nausea, and diarrhea. Review of Patient #4's "Master Treatment Plan" revealed the identified problems were Mood Disturbance and Potential for relapse for which a treatment plan was initiated. There was no documented evidence that the problems of SOB, nausea, diarrhea, and Potential for fall risk were identified on the Master Treatment Plan and that goals and interventions were developed to address these problems.


Patient #5

Review of Patient #5's medical record revealed diagnoses that included: Schizophrenia, Multiple Episodes in Acute Phase and Hypertension. Review of Patient #5's "Master Treatment Plan" revealed the identified problems were Alteration in thought processes. There was no documented evidence that the problems of Hypertension was identified on the Master Treatment Plan and that goals and interventions were developed to address these problems.


In an interview on 06/28/16 at 3:45 p.m., S2DON confirmed that the above problems should have been listed on the Master Treatment Plan for Patient #3, #4 & #5.

Based on record review and interview, the hospital failed to ensure all records contained a Discharge Summary. The hospital failed to ensure a Discharge Summary with outcome of hospitalization, disposition of care and provisions for follow-up care were documented for 1 (#1) of 3 discharge records reviewed from a total sample of 6.

Findings:
Medical record review on 06/27/16 at 12:25 p.m. revealed, patient #1 was admitted to the hospital on 05/16/16 by a PEC order from the emergency room physician for violent and homicidal behaviors. Documentation revealed patient #1 became combative with group home staff and threatened to kill the other residents. Patient #1's diagnoses were as listed: MR, Bipolar, Depression, Aggressive Behaviors, Intellect Disability, and Schizophrenia.
Review of the discharge orders dated 05/31/16 revealed, patient #1 was discharged to Evergreen Treatment Center and had discharge medications listed, Depakote level in 1 week, diet NAS no fried foods, and was signed by S7RN. There was no time, date or signature of patient to confirm participation in the development of the discharge summary.
Review of hospital policy titled Charting - Social Services, Document Number PC-603, dated October 18, 2012 revealed in part: 2) Discharge planning Documentation. a) D/C Criteria, b) Discharge plans including contacts made.
Interview on 06/28/16 at 8:25 a.m. with S6LPC confirmed that he had been doing some discharge planning on patients. S6LPC stated that he was familiar with patient #1 but did not do her discharge; he further stated that he had been in contact with the facility a few days prior to discharge and they were aware of her pending discharge. S6LPC gave surveyor copies of Multi-disciplinary notes dated 05/17/16 that he had documented that he spoke with the counselor at patient #1's group home. S6LPC further stated that there had been no other contact by him with the group home after 05/17/16 about the patients discharge.
Review of the hospital policy titled Ticket To Ride, Document Number PC-117, dated July 10, 2012 revealed in part: It is the responsibility of the charge RN to ensure the "Ticket To Ride" form is complete and accurate for all patients being transferred. 1). Ticket To Ride form must be completed on all patients being transferred or discharged. 2). Notify family of transfer. 3). Maintain original "Ticket To Ride" and send copy to receiving facility with patient. 4). In the event patient is being transferred to a facility: a) Before calling the transferring facility: i. Have chart available, ii. Assess the patient, include vital signs, iii. Complete the "Ticket To Ride" form. b) When communicating with the receiving facility include the following information: i. Situation ..., ii. Background ..., iii. Assessment ... c). All transfers require a verbal report giving the receiving facility the opportunity to ask questions or clarify information. d). Fax the transfer form to the receiving facility, if applicable.
Interview on 06/28/16 at 9:50 a.m. with S7RN confirmed that she was working the day patient #1 was discharged. S7RN further confirmed that the incomplete documentation on the Ticket To Ride discharge summary was hers. S7RN stated that she did not know why she did not complete the form. S7RN stated she remembers the police came and arrested patient #1 after patient #1 assaulted the transport driver. S7RN stated that when patient #1 asked the transport driver where she was being taken and was told back to the group home she became very aggressive and hit the transport driver. S7RN further stated that patient #1 was never outside of the building. Patient #1 was waiting in the foyer area when all of the above happened. S7RN stated that she was instructed by the S2DON after patient #1 hit the transport driver to call the police. S7RN stated that she remembers the police coming and arresting patient #1 and taking her to jail. S7RN confirmed again to surveyor that she did not know why she did not complete the discharge form or why she did not document anything about the incident.

Based on record review and interview, the hospital failed to meet the Condition of Participation of Discharge Planning as evidenced by:
1) failing to ensure an evaluation to include an assessment of the patient's post-discharge care needs being met was performed for 1 (#1) of 3 records reviewed for discharge planning from a total sample of 6. (see findings at A-0806)
2) failing to provide documented evidence relative to discussing the results of the discharge plan evaluation with the patient and/or the patient's representative for 1 (#1) of 3 records reviewed for discharge planning from a total sample of 6. (see findings at A-0811)
3) failing to ensure the medical record included a discharge planning evaluation that included information relative to the establishment of an appropriate discharge plan for 1 (#1) of 3 records reviewed for discharge planning from a total sample of 6. (see findings at A-0812)

Based on record review and interview, the hospital failed to ensure an evaluation to include an assessment of the patient's post-discharge care needs being met was performed for 1 (#1) of 3 records reviewed for discharge planning from a total sample of 6.

Findings:
Review of the hospital policy titled Discharge Planning, Document Number PC-301, dated October 18, 2012 revealed in part: The Case Manager will be the primary team member responsible for coordinating discharge planning. The Case Manager, along with the treatment team, will facilitate discharge planning for each patient. The discharge plan will focus on the following areas:

1) Review course treatment.
2) Review current medication regimen ...
3) Review community resources which can be used upon discharge.
4) Review of precipitating events and stressors which led to current hospitalization.
5) Help patients finalize living arrangements and aftercare before discharge.
The case manager along with other members of the treatment team will discuss and document discharge plans with the patient and family prior to discharge.
Record review on 06/27/16 at 12:25 p.m. revealed, patient #1 was admitted to the hospital on 05/16/16 by a PEC order from the emergency room physician for violent and homicidal behaviors, patient #1 became combative with group home staff and threatened to kill the other residents. Patient's diagnoses were as listed: MR, Bipolar, Depression, Aggressive Behaviors, Intellect Disability, and Schizophrenia.
Review of the Psychiatric Evaluation dated 05/17/16 by S9Physician documented that patient #1 stated that she no longer likes living at Evergreen anymore stating the reason as "Because the people are mean to me because they pull my hair and beat me up".
Review of Multi-Disciplinary Note dated 05/17/16 by S6LPC revealed plan for patient #1 to return to Evergreen Treatment Center. There was no other documentation to indicate that patient #1's post-discharge plans and/or a post-discharge assessment was discussed with the patient.
Review of the Physician discharge orders dated 05/31/16 revealed patient #1 was discharged to Evergreen Treatment Center and had discharge medications listed, Depakote level in 1 week, diet NAS no fried foods. Documentation revealed that S7RN discharged the patient. There was no time, date, assessment or signature of patient #1 and no documentation to indicate that patient #1 participated in the discharge plan and/or the discharge process.
Interview on 06/28/16 at 9:50 a.m. with S7RN confirmed that she was working the day patient #1 was discharged. S7RN verified the Ticket To Ride discharge summary was incomplete and stated that she did not know why she did not complete the form. S7RN stated that she remembers that the police came and arrested patient #1 after patient #1 assaulted the transport driver. S7RN stated that patient #1 was discharged and when patient #1 asked the transport driver where she was being taken and was told back to the group home she became very aggressive and hit the transport driver. S7RN further stated that patient #1 was never outside of the building. Patient #1 was waiting in the foyer area when all of the above happened. S7RN stated that she was instructed by S2DON after patient #1 hit the transport driver to call the police. S7RN stated that she remembers the police came and arrested the patient, and took the patient to jail. S7RN confirmed again that she did not complete the discharge form or document anything about the incident.
Interview on 06/28/16 at 12:30 p.m. with S9Physician revealed that patient #1 had severe behavior problems and that all the aggressive and violent episodes centered on the patient's not wanting to return to the group home. He further stated that because of her aggressive and violent behaviors no other facility would accept her and that was her major issue. Patient #1 would do better and we would talk to her about getting ready for discharge that's when she would get into a fight with someone because she knew she would not be discharged if she did that, she was very manipulative. Surveyor asked if anyone had spoken to the patient about her not wanting to return to the group home because she stated that they were mean to her. S9Physician stated that he was not sure if the counselor had spoken to the patient. S9Physician stated that he had mentioned it to her that she could not go because of her violent behaviors. He did not know if he had documented the full conversation in his notes with the patient. S9Physician stated that he did not find out about the incident at discharge until about a week later at the Med Executive Meeting, he further stated that if the hospital would have called him that he would have canceled the discharge order for the patient.
Interview on 06/28/16 at 8:25 a.m. with S6LPC confirmed that he had been doing some discharge planning on patients. S6LPC stated that he was familiar with patient #1 but did not do her discharge; he further stated that he had been in contact with the facility a few days prior to discharge and they were aware of her pending discharge. S6LPC gave surveyor copies of Multi-disciplinary notes dated 05/17/16 that he had documented that he spoke with the counselor at patient #1's group home. Surveyor asked S6LPC if he had spoken to the group home since 05/17/16, due to patient #1 documented multiple incidents of hitting other patients and staff and/or any changes that had occurred with patient #1. S6LPC stated that there was no other documentation that he had discussed discharge plans with the patient or the group home.
Interview on 06/27/16 at 3:10 p.m. with S2DON confirmed the discharge documentation for patient #1 was incomplete.

Based on record review and interview, the hospital failed to provide documented evidence relative to discussing the results of the discharge plan evaluation with the patient and/or the patient's representative for 1 (#1) of 3 records reviewed for discharge planning from a total sample of 6.

Findings:
Review of the hospital policy titled Discharge Planning, Document Number PC-301, dated October 18, 2012 revealed in part: The Case Manager along with other members of the treatment team will discuss and document discharge plans with the patient and family prior to discharge.
Medical record review on 06/27/16 at 12:25 p.m. revealed, patient #1 was admitted to the hospital on 05/16/16 by a PEC order from the emergency room physician for violent and homicidal behaviors, patient #1 became combative with group home staff and threatened to kill the other residents. Patient #1's diagnoses included: MR, Bipolar, Depression, Aggressive Behaviors, Intellect Disability, and Schizophrenia.
Review of the Psychiatric Evaluation dated 05/17/16 by S9Physician documented that patient #1 stated that she no longer likes living at Evergreen anymore "Because the people are mean to me because they pull my hair and beat me up".
Review of the Psychiatric Progress Note dated 05/26/16 by S9Physician revealed plan to ask LPC and D/C Planner to explore options available for placement, including Pinecrest if possible.
Review of Multi-Disciplinary Note dated 05/17/16 by S6LPC revealed plan for patient #1 to return to Evergreen Treatment Center. There was no other documentation to indicate that patient #1's post-discharge plans and/or a post-discharge assessment was discussed with the patient.

Interview on 06/28/16 at 9:50 a.m. with S7RN confirmed that she was working the day patient #1 was discharged. S7RN verified the Ticket To Ride discharge summary was incomplete and stated that she did not know why she did not complete the form. S7RN stated that she remembers that the police came and arrested patient #1 after patient #1 assaulted the transport driver. S7RN stated that patient #1 was discharged and when patient #1 asked the transport driver where she was being taken and was told back to the group home she became very aggressive and hit the transport driver. S7RN further stated that patient #1 was never outside of the building. Patient #1 was waiting in the foyer area when all of the above happened. S7RN stated that she was instructed by S2DON after patient #1 hit the transport driver to call the police. S7RN stated that she remembers the police came and arrested the patient, and took the patient to jail. S7RN confirmed again that she did not complete the discharge form or document anything about the incident.
Interview on 06/28/16 at 12:30 p.m. with S9Physician revealed that patient #1 had severe behavior problems and that all the aggressive and violent episodes centered on the patient's not wanting to return to the group home. He further stated that because of her aggressive and violent behaviors no other facility would accept her and that was her major issue. Patient #1 would do better and we would talk to her about getting ready for discharge that's when she would get into a fight with someone because she knew she would not be discharged if she did that, she was very manipulative. Surveyor asked if anyone had spoken to the patient about her not wanting to return to the group home because she stated that they were mean to her. S9Physician stated that he was not sure if the counselor had spoken to the patient. S9Physician stated that he had mentioned it to her that she could not go because of her violent behaviors. He did not know if he had documented the full conversation in his notes with the patient. S9Physician stated that he did not find out about the incident at discharge until about a week later at the Med Executive Meeting, he further stated that if the hospital would have called him that he would have canceled the discharge order for the patient.
Interview on 06/28/16 at 8:25 a.m. with S6LPC confirmed that he had been doing some discharge planning on patients. S6LPC stated that he was familiar with patient #1 but did not perform her discharge; he further stated that he had been in contact with the facility a few days prior to discharge and they were aware of her pending discharge. S6LPC gave surveyor copies of Multi-disciplinary notes dated 05/17/16 that he had documented that he spoke with the counselor at patient #1's group home. There was no documentation to indicate that S6LPC had discussed discharge plans with patient #1.
In an interview on 06/27/16 at 3:20 p.m., S4MR verified during a medical record review that there was no documented evidence relative to discussing the results of the discharge plan evaluation with the patient and/or the patient's representative. S4MR verified that there was no documentation to indicate that the case manager along with other members of the treatment team discussed and documented discharge plans with the patient and family prior to discharge that included community resources which can be used upon discharge, a review of precipitating events and stressors which led to the patient's current hospitalization, and discussions and assistance with locating alternative living arrangements after being made aware that the patient did not want to return to the group home she was residing in prior to hospitalization.

Based on record review and interview, the hospital failed to ensure the medical record included a discharge planning evaluation that included information relative to the establishment of an appropriate discharge plan for 1 (#1) of 3 medical records reviewed for discharge planning from a total sample of 6.

Findings:
Review of the hospital policy titled Discharge Planning, Document Number PC-301, dated October 18, 2012 revealed in part: The Case Manager will be the primary team member responsible for coordinating discharge planning. The Case Manager will be responsible in conjunction with other members of the multidisciplinary team for establishing discharge criteria and for formulating aftercare plans for each patient from the time of admission. The Case Manager, along with the treatment team, will facilitate discharge planning for each patient. The discharge plan will focus on the following areas:
1) Review course treatment.
2) Review current medication regimen ...
3) Review community resources which can be used upon discharge.
4) Review of precipitating events and stressors which led to current hospitalization.
5) Help patients finalize living arrangements and aftercare before discharge.

The case manager along with other members of the treatment team will discuss and document discharge plans with the patient and family prior to discharge.
Medical record review on 06/27/16 at 12:25 p.m. revealed, patient #1 was admitted to the hospital on 05/16/16 by a PEC order from the emergency room physician for violent and homicidal behaviors, patient #1 became combative with group home staff and threatened to kill the other residents. Patient #1's diagnoses included: MR, Bipolar, Depression, Aggressive Behaviors, Intellect Disability, and Schizophrenia.
Interview on 06/27/16 at 11:55 a.m. with S2DON stated that the hospital's discharge planner had left on 04/18/16 and S6LPC took over the role of discharge planner until recently when S10AT was hired and he will be the designated discharge planner.
Interview on 06/28/16 at 8:25 a.m. with S6LPC confirmed that he had been doing some discharge planning on patients. S6LPC stated that he was familiar with patient #1 but did not perform her discharge. S6LPC further stated that he had been in contact with the facility a few days prior to discharge and they were aware of her pending discharge. S6LPC gave surveyor copies of Multi-disciplinary notes dated 05/17/16 that he had documented that he spoke with the counselor at patient #1's group home. Surveyor asked S6LPC if he had spoken to the group home since 05/17/16 or if there had been any discussions relative to the multiple incidents involving patient #1. S6LPC indicated that he could provide no additional documentation or evidence to indicate that he had discussed discharge plans with the patient or any further discharge plans with the group home.

In an interview on 06/27/16 at 3:20 p.m., S4MR verified during a medical record review that there was no documented evidence relative to discussing the results of the discharge plan evaluation with the patient and/or the patient's representative. S4MR verified that there was no documentation to indicate that the case manager along with other members of the treatment team discussed and documented discharge plans with the patient and family prior to discharge that included community resources which can be used upon discharge, a review of precipitating events and stressors which led to the patient's current hospitalization, and discussions and assistance with locating alternative living arrangements after being made aware that the patient did not want to return to the group home she was residing in prior to hospitalization.

Based on record reviews and interviews, the hospital failed to meet the Conditions of Participation specified in §§482.1 through §§482.23 and §§482.25 through §§482.57. This is evidenced by:

1) the hospital's failure to meet the Condition of Patient Rights (482.13) as evidenced by:

A) failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for the patients admitted for acute inpatient psychiatric services by failing to ensure the patient's environment was free of ligature risks and safety hazards. (see findings at A-0144)
B) failing to ensure patients were free from abuse and/or harassment by failing to maintain an environment in a manner to assure an acceptable level of safety and quality for the patients admitted for acute inpatient psychiatric services by failing to ensure patients were protected from patients evaluated and admitted with aggressive and violent behaviors. (see findings at A-0145)


2) the hospital's failure to meet the Condition of Participation of Discharge Planning (482.43) as evidenced by:

A) failing to ensure an evaluation was performed to include an assessment of the patient's post-discharge care needs being met were performed for 1 (#1) of 3 records reviewed for discharge planning from a total sample of 6. (see findings at A-0806)
B) failing to provide documented evidence relative to discussing the results of the discharge plan evaluation with the patient and/or the patient's representative for 1 (#1) of 3 records reviewed for discharge planning from a total sample of 6. (see findings at A-0811)
C) failing to ensure the medical record included a discharge planning evaluation that included information relative to the establishment of an appropriate discharge plan for 1 (#1) of 3 records reviewed for discharge planning from a total sample of 6. (see findings at A-0812)

Based on record review and interview, the hospital failed to ensure patients admitted under a Physician's Emergency Certificate (PEC) were evaluated by a qualified licensed practitioner to ensure the patient had the capacity to make a knowing and voluntary consent to the admission prior to converting the patient's admission status from PEC to Formal Voluntary Admission (FVA) for 1 (#4) of 2 patients (#4, #5) whose records were reviewed for conversion from PEC to FVA from a sample of 6 patients.


Findings:


Review of the Hospital's Policy & Procedure titled "Admission" presented by S2DON as being current (revised 11/04/14) read in part: Formal Voluntary Admission- a voluntary admission indicates that the patient is voluntarily requesting admission and treatment. The psychiatrist agrees the patient meets admission criteria and meets provisions of LA R.S. 28.52. This form is not to be signed by patients arriving on a PEC, CEC, or judicial commitment; unless the psychiatrist agrees he/she is able to do so. Procedure: 3. A patent who signs a FVA, after initially admitted on a commitment, must have his/her rights and responsibilities reviewed, signed and documented at the time the FVA is signed.
Review of the Louisiana (La.) Revised Statutes (R.S.), Chapter 28 (Mental Health Laws) revealed the La. R.S. 28:52 (Voluntary admissions; general provisions) stated that no admission may be deemed voluntary unless the admitting physician determined that the person to be admitted had the capacity to make a knowing and voluntary consent to the admission. Further review revealed, that a knowing and voluntary consent shall be determined by the ability of the individual to understand that the treatment facility to which the patient is requesting admission is one for mentally ill persons or persons suffering from substance abuse, that he/she is making an application for admission, and the nature of his/her status and the provisions governing discharge or conversion to an involuntary status.


Review of Patient #4's medical record revealed, he was admitted to the hospital on 06/15/16 with the diagnoses of other stimulant dependency with stimulant-induced psychotic disorder, unspecified and a secondary diagnosis of Bipolar disorder, unspecified. Further review revealed a PEC was signed on 06/13/16 at 5:45 p.m. due to Patient #4 being a danger to himself, unwilling, unable to seek voluntary admission, and gravely disabled. Further review revealed a CEC was signed on 06/15/16 at 9:15 a.m. due to Patient # 4 being a danger to himself, unwilling, unable to seek voluntary admission, and gravely disabled. Patient #4's legal status was documented as PEC and CEC on the "Psychiatric Evaluation."


Review of Patient #4's "Formal Voluntary Admission" revealed, the form was signed by Patient #4 on 06/28/16 at 6:01 a.m. There was no documented evidence of a signature by S9Physician who was Patient #4's attending physician.


Review of Patient #4's medical record revealed, no documented evidence that S9Physicain (Patient #4's attending physician) determined and documented that Patient #4 had the capability to make a knowing and voluntary consent to his admission.


In an interview on 06/29/16 at 4:24 p.m., S2DON confirmed that Patient #4's current legal status was FVA which became effective after he signed the FVA admission form. S2DON confirmed after review of Patient #4's medical record that there was no assessment by S9Physician before Patient #4's status was changed to FVA.

31206

Based on record review and interview, the hospital failed to ensure the psychiatric evaluation was complete and signed by the Psychiatrist for 6 of 6 (#1,#2, #3, #4,#5, #6) record reviewed for psychiatric evaluation out of a total sample of 6 (#1-#6).

Findings:

Review of the "Psychiatric Evaluation" for patient #1, #2, #3, #4, #5, #6 revealed, the psychiatric evaluations were incomplete in that there was either no diagnosis and/or no signature of a qualified practitioner. Further review of the psychiatric evaluation revealed, an area on the top portion of the page which read in part: "submitted on (date) at (time) by S9Physician".
In an interview on 06/28/16 at 9:30 a.m., S2DON indicated that S9Physician's signature was represented by a submission at the top portion of the pages of the psychiatric evaluation. S2DON indicated that the computer program used by the hospital did not include a psychiatric diagnosis within the Psychiatric Evaluation. S2DON indicated the hospital's computerized program would not allow for a psychiatric diagnosis to be placed within the psychiatric evaluation. S2DON indicated that psychiatric diagnosis had to be entered separately.
In an interview on 06/29/16 at 2:55 p.m., S9Physician indicated the hospital's electronic medical records system did not allow him to electronically sign the psychiatric evaluations. S9Physician indicated an area on the top portion of the psychiatric evaluation was an indication of his electronic signature. S9Physician indicated that the program also did not allow for a mental health diagnosis. S9Physician reported the mental health diagnosis had be to placed on a separate page which was not part of the psychiatric evaluation. S9Physician indicated that he had voiced concerns to the hospital's administrative staff.
In an interview on 06/29/16 at 4:35 p.m., S2DON indicated that she and S1Administrator discovered on 06/29/16 after it was identified during the survey that S9Phsyician was not programmed into the system to electronically sign documents. S2DON indicated that the hospital's cooperate IT (Information Technology) Department was responsible for making sure that S9Physician had the capability to electronically sign documents in the medical records.

31206

Based on record reviews and interviews, the hospital failed to ensure each patient had an individual comprehensive treatment plan as evidenced by failure to include interventions and goals for all diagnoses for which the patient was being treated for 3 (#3, #4, #5) of 6 patient records reviewed for treatment plans from a total sample of 6 patients.
Findings:

Review of the Hospital's Policy titled "Treatment Plans", effective 10/18/12 and presented as a current policy by S2DON, revealed that each patient will be an individualized treatment plan developed under the direction of the psychiatrist. This comprehensive plan is initiated upon admission following assessments by the various disciplines and will reflect the individual's clinical needs, condition, functional strengths, and limitations.

Patient #3

Review of Patient #3's medical record revealed diagnoses that included: Alcohol dependence, Bipolar disorder NOS, Depression, Chronic back pain and Neuropathy.

Review of Patient #3's "Master Treatment Plan" revealed the identified problems were Mood Disturbance, Potential for Relapse, and Alteration in health maintenance. There was no documented evidence that the problems of Chronic back pain and Neuropathy were identified on the Master Treatment Plan and that goals and interventions were developed to address these problems.

Patient #4

Review of Patient #4's medical record revealed diagnoses that included: Other stimulant dependence with stimulant-induced psychotic disorder, Opioid dependence, Bipolar disorder NOS. Further review of the fall risk assessment dated 06/26/16 revealed he was identified as high risk for falls.

Review of Patient#4's H&P review of systems revealed problems of : SOB, nausea, and diarrhea.

Review of Patient #4's "Master Treatment Plan" revealed the identified problems were Mood Disturbance and Potential for relapse for which a treatment plan was initiated. There was no documented evidence to indicate the problems of SOB, nausea, diarrhea, and high fall risk were identified on the Master Treatment Plan and that goals and interventions were developed to address these problems.


Patient #5


Review of Patient #5's medical record revealed diagnoses that included: Schizophrenia, Multiple Episodes in Acute Phase and Hypertension.


Review of Patient #5's "Master Treatment Plan" revealed, the identified problems were Alteration in thought processes. There was no documented evidence to indicate Hypertension was identified on the Master Treatment Plan and that goals and interventions were developed to address this problem.


In an interview on 06/28/16 at 3:45 p.m., S2DON confirmed that the above problems should have been listed on the Master Treatment Plan for Patient #3, #4 & #5.

Based on record review and interview, the hospital failed to ensure treatment interventions were identified for problems for 1 (#1) of 1 patient records reviewed for safety measures for aggressive and violent behaviors from a total sample of 6.

Findings:
Record review on 06/27/16 at 12:25 p.m. revealed, patient #1 was admitted to the hospital on 05/16/16 by a PEC order from the emergency room physician for violent and homicidal behaviors, patient #1 became combative with group home staff and threatened to kill the other residents. Patient's diagnoses were as listed: MR, Bipolar, Depression, Aggressive Behaviors, Intellect Disability, and Schizophrenia.
Review of the CEC dated 05/15/16 revealed, patient #1 had a history of being combative with group home staff and threatened to kill the other residents.
Review of the Daily Floor Census revealed, the patient was admitted and placed in a room with patient #6, an elderly female. Further review of the Daily floor census sheet for 05/16/16 revealed 6 unoccupied beds available.
Review of the Incident/Accident log revealed 8 occurrences from 5/19/16 to 5/28/16 that involved patient #1 either assaulting another patient or staff. Hospital occurrence reports revealed as follows:
- 05/19/16 revealed patient #1 at 2:40 p.m. hit patient #7 (her roommate)
- 05/19/16 revealed patient #1 at 4:58 p.m. hit another patient in the head
- 05/19/16 revealed patient #1 at 7:15 p.m. hit staff member
- 05/20/16 revealed patient #1 at 3:42 p.m. hit another patient
- 05/21/16 revealed patient #1 at 4:20 p.m. hit another patient
- 05/23/16 revealed patient #1 at 10:45 a.m. hit staff member
- 05/25/16 revealed patient #1 at 5:40 p.m. hit staff member
- 0528/16 revealed patient #1 at 7:40 p.m. extremely aggressive toward other patients and hit staff.
Review of the Psych Evaluation dated 05/17/16 revealed, that the S9Physician noted that patient #1 was a danger to self and danger to others. S9Physician noted in his summary that patient #1 is easily agitated and is an increased risk for harm to self and others.
Review of the Treatment Plan dated 05/16/16 for patient #1 revealed, the patient was care planned for Mood Disturbances, Altered Health Maintenance, and High Risk for Falls. There was nothing care planned about the patient's aggressive behaviors, violence toward others, and/or safety measures in place to protect patient #1 or the other patients.

Based on record review and interview, the hospital failed to ensure there were adequate numbers of qualified professional and supportive staff to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures and engage in discharge planning. This was evidenced by the hospital's failure to have a qualified activity therapist on staff.


Findings:
In an interview on 06/29/16 at 10:49 a.m., S10AT indicated that his date of hire was 05/26/16. S10AT indicated that he is currently performing the duties of discharge planner and reported that he would start training for the hospital's Activity Therapist on 07/05/16. S10AT indicated that presently the hospital has no Activity Therapist. S10AT indicated that he currently only performed the activity assessment on patients admitted.


In an interview on 06/29/16 at 11:15 a.m., S2DON indicated that currently the hospital had no Activity Therapist. S2DON indicated the previous Activity Therapist ended her employment with the hospital on 04/18/16. S2DON indicated that the hospital was without an Activity Therapist from 04/18/16 to 05/26/16. S2DON indicated that the hospital efforts to recruit and hire an Activity Therapist have been unsuccessful. S2DON confirmed that S10AT was not a certified Recreational Therapist. S2DON indicated that the MHTs were currently conducting social activity group.

31206

Based on record review and interview, the hospital failed to provide consistent, individualized therapeutic activities by not having recreational therapy groups conducted by a person who was qualified/certified as a therapeutic recreational specialist.


Findings:


In an interview on 06/29/16 at 10:49 a.m., S10AT indicated that his date of hire was 05/26/16. S10AT indicated that he is currently performing the duties of discharge planner and reported that he would start training for the hospital's Activity Therapist on 07/05/16. S10AT indicated that presently the hospital has no Activity Therapist. S10AT indicated that he currently only performed the activity assessment on patients admitted.


In an interview on 06/29/16 at 11:15 a.m., S2DON indicated that currently the hospital had no Activity Therapist. S2DON indicated the previous Activity Therapist ended her employment with the hospital on 04/18/16. S2DON indicated that the hospital was without an Activity Therapist from 04/18/16 to 05/26/16. S2DON indicated that the hospital efforts to recruit and hire an Activity Therapist have been unsuccessful. S2DON confirmed that S10AT was not a certified Recreational Therapist. S2DON indicated that the MHTs were currently conducting social activity group.

Based on record review and interview, the hospital failed to ensure the recreational therapists were qualified to provide comprehensive therapeutic activities consistent with each patient's active treatment plan for patients who are currently receiving treatment within the hospital.


Finding:


In an interview on 06/29/16 at 10:49 a.m., S10AT indicated that his date of hire was 05/26/16. S10AT indicated that he is currently performing the duties of discharge planner and reported that he would start training for the hospital's Activity Therapist on 07/05/16. S10AT indicated that presently the hospital has no Activity Therapist. S10AT indicated that he currently only performed the activity assessment on patients admitted.


In an interview on 06/29/16 at 11:15 a.m., S2DON indicated that currently the hospital had no Activity Therapist. S2DON indicated the previous Activity Therapist ended her employment with the hospital on 04/18/16. S2DON indicated that the hospital was without an Activity Therapist from 04/18/16 to 05/26/16. S2DON indicated that the hospital efforts to recruit and hire an Activity Therapist have been unsuccessful. S2DON confirmed that S10AT was not a certified Recreational Therapist. S2DON indicated that the MHTs were currently conducting social activity group.