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Based on record review and interview, the hospital failed to ensure each patient received care in a secure setting. This deficient practice is evidenced by failure to assure that personnel completed criminal background checks by an authorized agent of the Louisiana State Police in the manner required by R.S. 15:587.1 et seq. prior to hire or employment for 2 (S1MHTand S2MHT) of 2 (S1MHT and S2MHT) personnel records reviewed regarding criminal background checks.
Findings:

Review of S1MHT's human resource file revealed a hire date of 05/16/2022. Further review revealed a criminal background check completed by Company A. Further review revealed Company A was not an authorized agency of the Louisiana State Police.

Review of S2MHT's human resource file revealed a hire date of 12/13/2021. Further review revealed a criminal background check completed by Company A. Further review revealed Company A was not an authorized agency of the Louisiana State Police.

In an interview on 08/09/2023 at 1:50 p.m., S8RM verified the hospital recently started using Company A for all employee background checks. S8RM verified Company A was not an approved contractor by the Louisiana State Police.

Based on record review and interview, the hospital failed to ensure that the nursing staff developed, and kept a current, and individualized nursing care plan for each patient that reflected the patient's goals and the nursing care expected to meet the patient's needs. This deficient practice is evidenced by the failure to create individulaized care plans based upon comprehensive assessments on 2 (#1 and #5) of 5 (#1-#5) patients reviewed for completed and updated care plans.
Findings:

Review of hospital policy #: BPC 005 titled "Interdisciplinary Plan of Care" revealed, in part: Policy: Each patient shall have a documented plan of care formulated from interdisciplinary assessments within 72 hours of admission. Each plan is individualized based on the patient's needs, strengths, limitations and goals. Procedure, in part: 1. The attending physician completes the initial assessment and documents a preliminary plan of care within 24 hours of the patient's admission. 4. A plan of Care is based upon comprehensive assessments and continuing reassessment of the patient's needs and includes: a. Substantiated diagnosis b. Clearly defined problems and needs statements.

Patient #1
A review of Patient #1's medical record revealed she was admitted on 06/30/2023 and discharged on 08/02/2023 with the diagnoses of (PTSD) post-traumatic stress disorder, Obesity, Prediabetes, Hyperlipidemia, Consequences of early trauma, physical abuse, sexual abuse.

A review of Patient #1's Plan of Care dated 06/30/2023-08/02/2023 failed to reveal a comprehensive and individualized nursing care plan that addressed the needs of a patient with the diagnosis of PTSD.

In an interview on 08/09/2023 at 11:55 a.m. S7NS verified Patient #1's care plan failed to address the needs of a patient with the diagnosis of PTSD. S7NS agreed that the care plan was not comprehensive and individualized.

Patient #5
A review of Patient 5's medical record revealed she was admitted on 05/18/2023 and discharged on 07/26/2023 with the diagnoses of reactive depression and PTSD (post-traumatic stress disorder).

A review of Patient #1's Plan of Care dated 05/18/2023-07/26/2023 failed to reveal a comprehensive and individualized nursing care plan that addressed the needs of a patient with the diagnosis of PTSD.

In an interview on 08/09/2023 at 9:55 a.m. S7NS verified Patient #5's care plan failed to address the needs of a patient with the diagnosis of PTSD. S7NS agreed that the care plan was not comprehensive and individualized.