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Based on record review and interview, the hospital failed 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 all unlicensed personnel providing care for adults and for all staff providing care to children. This deficient practice was evidence by 14 (S2RM, S1DON, S7RN, S5CN, S16MHT, S4RN, S6CN, S11MHT, S12MHT, S14MHT, S15MHT, S13MHT, S3CN, S20LCSW) of 14 (S2RM, S1DON, S7RN, S5CN, S16MHT, S4RN, S6CN, S11MHT, S12MHT, S14MHT, S15MHT, S13MHT, S3CN, S20LCSW) personnel records reviewed regarding criminal background checks.
Findings:

Review of S2RM, S1DON, S7RN, S5CN, S16MHT, S4RN, S6CN, S11MHT, S12MHT, S14MHT, S15MHT, S13MHT, S3CN, S20LCSW human resource files revealed a criminal background check completed by Company A not an authorized agency of the Louisiana State Police.

In an interview on 05/02/2023 at 8:50 a.m., S19HR verified the hospital used Company A for all employee background checks.

In an interview on 05/03/2023 at 9:05 a.m., S17CEO indicated the hospital used Company A for all employee background checks and verified Company A was not approved contractor by the Louisiana State Police.

Based on record review and interview, the hospital failed to meet the requirements for the Condition of Participation (CoP) for Patient's Rights as evidenced by failure to ensure all patients received care in a safe setting. This deficient practice was evidenced by the hospital allowing S12MHT to continue to work on the adolescent unit after he was named the alleged perpetrator in 2 separate incidents involving the physical abuse of Patient #2 and Patient #4. (See findings under A-144).

Based on record review and interview, the hospital failed to ensure the patient /patient representative's right to participate in the development and implementation of his or her plan of care was met. This deficient practice is evidenced by failure to ensure the patient/patient's representative was included in the development and implementation of the patient's plan of care for 1 (#2) of 5 (#1-#5) sampled patient records reviewed.
Findings:

Review of the hospital's policy titled, "Patient and Family Rights", revealed the following in part: Policy: The facility protects and promotes each patient's rights according to LAC-48:2 Chapter 93 9319 Patient Rights and privacy. Every patient shall have the following rights, none of which shall be abridged by the hospital or any of its staff. The hospital administrator shall be responsible for developing and implementing policies to protect patient rights and to respond to questions and grievances pertaining to patient rights. Patients and families are advised of the following rights upon admission to the facility, in part: 7. The right to articipate in the development and implementation of his/her plan of care. 8. Every patient or his or her representative (as allowed by state law) has the right to make informed decisions regarding his or her care. 9. The patient's rights include being informed of his/her health status, be involved in care planning and treatment, and be able to request or refuse treatment.

Review of Patient #2's medical record revealed the patient was admitted on 02/08/2023 with an admission diagnosis of Major Depressive Disorder; Oppositional Defiant Disorder and Attention Deficit Hyperactivity Disorder. Further review revealed Patient #2 was discharged on 04/24/2023. Review of Patient #2's treatment plan dated 02/16/2023-04/23/2023, failed to reveal a signature by Patient #2 or Patient #2's representative indicating Patient #2 participated in the development and implantation of his plan of care. Further review failed to reveal a reason why Patient #2 or Patient #2's representative did not sign the treatment plan within the time span of 02/16/2023-04/23/2023.

In an interview on 05/03/2023 at 1:20 p.m., S1DON confirmed that there were no signatures on the care plans for the time span of 02/16/2023-04/23/2023. S1DON reported there was no documented reason why Patient #2 or Patient #2's representative did not sign the treatment plan within the time span of 02/16/2023-04/23/2023.

Based on observation and interview the hospital failed to ensure each patient's right to care in a safe setting. This deficient practice is evidenced by:

1) The hospital allowing an alleged perpetrator access to adolescent patients after he was named in 2 separate incidents involving the physical abuse of 2 (#2, #4) out of 5 (#1-#5) patients sampled; and
2) The hospital failing to review/investigate S13MHT concerns of MHTs being aggressive, not nice.
Findings:

1) The hospital allowing an alleged perpetrator access to adolescent patients after he was named in 2 separate incidents involving the physical abuse of 2 (#2, #4) out of 5 (#1-#5) patients sampled;

Review of hospital policy titled "Seclusion and Restraint" revealed, in part: The facility's policy in regard to seclusion and restraint is to provide therapeutic treatment, with dignity and respect in the least restrictive environment that provides for patient safety. Definitions, in part: Chemical Restraint, in part: Defined as a mediation used as a restriction to manage the patient's behavior or restrict the patent's freedom of movement and is not a standard treatment for dosage fort the patient's medical or psychiatric condition. Physical Restraint, in part: Defined as any manual method or physical or mechanical device material, or equipment attached or adjacent to the patient's body that he/she cannot easily remove that restricts freedom of movement or normal access to one's body. Procedure, in part: Seclusion and restraint offer protection and are used only in preservation of patient's rights, dignity, and well-being. Seclusion and /or restraint is never utilized as a punitive action or for the convenience of the staff. D. All episodes of seclusion and/or restraint require a physician's or psychiatric mental health nurse practitioner's order. I. Patient Comfort: Seclusion and/or restraints shall not be used in a manner that causes undue physical discomfort, harm, or pain to the patient.

Review of Staff Schedule dated Tuesday, 05/02/2023, revealed S12MHT was listed on the schedule to work the night shift on unit b.

Patient #2
Review of Patient #2's medical records revealed admission date: 02/08/2023. Date of Birth: 10/16/2009. Diagnosis: Major Depressive Disorder, Recurrent, severe, Oppositional Defiant Disorder, Attention-Deficit Hyperactivity Disorder. Review of nursing assessment dated 04/22/2023 revealed a note stating that at approximately 7:50 p.m. staff was asked by the nurse to redirect Patient #2 to his room. Patient went to his room reluctantly and continued to try to come out of room to fight peer. Patient was then put in therapeutic hold for less than 1 min. When patient was allowed out of his room, he then stated that the staff member choked him and placed his arm behind his back where his elbow touched the back of his neck. Nurse assessment of injury noted slight red bruising around neck. Patient #2 stated his pain was 9/10 in right shoulder.

Review of the hospital's self-reported physical abuse incident dated 04/22/2023 involving Patient #2 revealed S12MHT as the alleged perpetrator. Further review revealed the self-report dated 04/22/2023 listed no prior accusations listed for S12MHT. Review of hospital self-report dated 01/30/2023 revealed S12MHT was the alleged perpetrator in a physical abuse incident involving Patient #4. S2RM decided not to include S12MHT's involvement in the incident occurring on 01/30/2023 on the report dated 04/22/2023 because the facility determined corrective action was not deemed necessary for S12MHT.

Review of Patient #2's Medical Progress note prepared by S8NP dated 04/23/2023 revealed an assessment. Review of the assessment revealed, in part: Neck with petechial bruising noted to medial and bilateral sides. Bruising noted to head. Right shoulder pain, constant and mild. Right shoulder with petechial bruising.

In an interview on 05/02/2023 at 2:38 p.m., S1DON and S2RM stated that a therapeutic hold is considered a Primary Restraint Technique, which entails the staff holding the patient from behind interlocking the patient's arms behind the back. S2RM demonstrated a therapeutic hold as was described. S1DON stated this is the standard move. Both S1DON and S2RM stated the therapeutic hold should not cause bruising around the neck or shoulder if done correctly. S1DON and S2RM confirmed S12MHT was the staff who held Patient#2 in the therapeutic hold that caused the neck and shoulder bruising. S1DON and S2RM considered S12MHT well versed on therapeutic hold because he was a certified "Handle with Care" trainer.

In an interview on 05/03/2023 at 9:15 a.m. S8NP stated she documented her assessment completed on 04/23/2023 at 4:00 p.m., exactly what she had seen on the neck, head and right shoulder of Patient #2.

Patient #4
Review of Patient #4's medical record revealed the patient was admitted on 01/24/2023. Date of Birth: 10/15/2009. Diagnosed with Bipolar v. unspecified mood disorder; ODD; unspecified anxiety, ADHD, Asthma. Review of Patient #4's nursing progress note dated 1/30/2023 at 7:12 p.m. revealed patient became agitated and aggressive toward other patients. His behavior escalated and he was placed in PRT hold and taken to his room where Benadryl 50 mg IM was administered. At 7:50 p.m., patient was noted to be cooperative and in the day room. Review of Patient #4's nursing progress note dated 1/31/2023 at 11:00 a.m. revealed Patient #4 reported to S13MHT that on 01/30/2023 during the night shift, S12MHT hit Patient #4 in the chest and back. The note further stated that Patient #4 reported S12MHT held Patient #4 on the bed, making it hard for him to breathe and would not let him up. At 2:00 p.m. it was documented in the nursing progress notes that Patient #4 reported he felt his shoulders were dislocated.

In a phone interview on 05/03/2023 at 10:40 a.m. S14MHT stated her position at hospital was Mental Health Technician. S14MHT recalled the event that took place on 01/30/2023 because she had picked-up this rotation. S14MHT reported she had heard from other staff that Patient #4 was being aggressive and was lifted up in the air by S12MHT and brought into his room where he was put in PRT and a code white was called. S14MHT and S16MHT went to Patient #4's room for the code white. When S14MHT entered into the room, Patient #4 was laying face down on the bed with his arms held while medication was administered. S14MHT recalled he had complaints of the injection hurting him. S14MHT left the room as soon as the injection was administered to tend to other patients.

In an interview on 05/02/2023 at 2:45 p.m., S1DON confirmed S12MHT was on the schedule for the adolescent unit on the night shifts dated 05/02/2023 and 05/03/2023. S1DON explained that S12MHT was not taken off of the schedule because the hospital completed their investigation and they determined the allegations against S12MHT were unsubstantiated.

2) The hospital failing to review/investigate S13MHT work concerns.
Review of S13MHT human resource file revealed a form titled "60-Day New Hire Touch Point Review". Review of the form titled "60-Day New Hire Touch Point Review" revealed a new hire questionnaire to be be completed 60 days after hire. The form contained several questions about the orientation process and concerns the new hire might have during her employement. Review of the form titled "60-Day New Hire Touch Point Review" revealed in part:
2. What kind of feedback have you received from the your mentor?
Negative, MHTs are not nice
3. Has the facility met your expectations thus far?
No. I have seen things that are not right
4. Has anything happened that might cause you to leave the facility?
MHT being aggressive
7. Can you tell us what team members were helpful?
No teamwork is being done
Review of the form revealed that S13MHT expressed concern about MHTs being aggressive, not nice.
In interview on 05/02/2023 at 3:20 p.m. S19HR verified that the employee's concerns were not investigated or addressed by leadership.

In interview on 05/02/2023 at 3:45 p.m. S1DON verified that she was not aware of the employee's concerns of MHTs being aggressive, not nice, and no teamwork as listed on the form titled "60-Day New Hire Touch Point Review".



48050

48050

Based on record review and interview, the facility failed to ensure that all patients were free from all forms of abuse. Furthermore, the facility failed to create and maintain a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect as evidenced by failing to administer corrective actions involving the physical abuse of 2 (#2 and #4) out of 5 (#1-#5) patients sampled.
Findings:

Review of the hospital's policy titled, "Patient and Family Rights", revealed the following in part: Policy: The facility protects and promotes each patient's rights according to LAC-48:2 Chapter 93 9319 Patient Rights and privacy. Every patient shall have the following rights, none of which shall be abridged by the hospital or any of its staff. The hospital administrator shall be responsible for developing and implementing policies to protect patient rights and to respond to questions and grievances pertaining to patient rights. Patients and families are advised of the following rights upon admission to the facility, in part: 17. The right to be free from all forms of abuse and harassment. 18. The right to receive care in a safe setting.

Review of the hospital self-reported physical abuse incident dated 04/22/2023 involving Patient #2 revealed S12MHT as the alleged perpetrator. Further review revealed the self-report dated 04/22/2023 listed no prior allegations of abuse for S12MHT. Review of hospital self-report dated 01/30/2023 revealed S12MHT was the alleged perpetrator in a physical abuse incident involving Patient #4. Both reports were completed by S2RM. Review of Medical Progress note prepared by S8NP dated 04/23/2023 revealed an assessment. Review of the assessment revealed, in part: Neck with petechial bruising noted to medial and bilateral sides. Bruising noted to head. Right shoulder pain, constant and mild. Right shoulder with petechial bruising. Review of Plan revealed instructions to monitor and continue Motrin. Patient to follow-up with PCP PRN.

In an interview on 05/02/2023 at 2:45 p.m., S1DON and S2RM reported there was no corrective action regarding the incident involving Patient #2 because S1DON assessed the neck area and disagreed that there was bruising. S1DON stated she had not previously read the medical progress note that described Patient #2's neck, head and shoulder injuries documented by S8NP. S1DON reviewed S8NP's assessment of Patient #2 on 05/02/2023 at 2:51 p.m. with this surveyor. S1DON further stated she would have taken corrective action if she had read S8NP's assessment previously. S2RM stated she would have included S12MHT on the incident report if she had known the results of S8NP's assessment. S1DON confirmed S12MHT was on the schedule for the adolescent unit night shifts for 05/02/2023 and 05/03/2023.

Based on record review and interview the facility failed to ensure that a medication that was not standard treatment for the patient's medical or psychiatric condition, was not used as a restraint for staff convenience. This deficient practice is evidenced by administering Benadryl intramuscularly as a chemical restraint to 1 (#4) of 5 (#1-#5) patients sampled.
Findings:
Review of hospital policy titled "Seclusion and Restraint" revealed, in part: The facility's policy in regard to seclusion and restraint is to provide therapeutic treatment, with dignity and respect in the least restrictive environment that provides for patient safety. Definitions, in part: Chemical Restraint, in part: Defined as a medication used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment for dosage for the patient's medical or psychiatric condition. Seclusion and /or restraint is never utilized as a punitive action or for the convenience of the staff. I. Patient Comfort: Seclusion and/or restraints shall not be used in a manner that causes undue physical discomfort, harm, or pain to the patient.

Review of hospital policy titled "Emergency Services" revealed, in part: Procedure: A. Appropriate observation of patients will ensure that any early warning signs of change or deterioration will be identified by staff. Some common early warning signs of change or deterioration in a patient's condition include, in part: b. Irritability c. Acting out behavior.

Review of Patient #4's medical record revealed the patient was admitted on 01/24/2023. Date of Birth: 10/15/2009. Diagnosed with Bipolar v. unspecified mood disorder; ODD; unspecified anxiety, ADHD, Asthma.

Review of Patient #4's Medical Progress note dated 01/29/2023 revealed patient with Strep Pharyngitis. Started Amoxicillin 500 mg PO BID x 10 days and Ibuprofen 600 mg PO TID q 8 hours prn pain. Cepacol throat lozenges 1-2 PO Q 2 hours PRN.

Review of Patient #4's nursing progress note dated 1/30/2023 at 7:12 p.m. revealed patient became agitated and aggressive toward other patients. His behavior escalated and he was placed in PRT hold and taken to his room where Benadryl 50 mg IM was administered. The note further stated that at 7:50 p.m. patient was cooperative in the day room. Further review failed to reveal an order for restraint or a completed restraint packet with details of the event.

Review of Patient #4's medical record failed to reveal Benadryl was a standard medicine for Patient #4 and failed to reveal Benadryl was a scheduled medication for Patient #4.

Review of Patient #4's medical record revealed a Practitioner Order Sheet dated 01/30/2023 7:20 p.m. Review of the Practitioner Order Sheet revealed an order for Benadryl 50 mg IM NOW x 1 for increased agitation. Further review revealed the order was signed by the physician on 01/31/2023 at 10:00 a.m.

Review of Patient #4's psychiatry progress note dated 01/31/2023 revealed patient "flipped out" the night before requiring a PRN for agitation after finding out his Grandmother decided she did not want patient to return home and requested long term placement.

In an interview on 05/02/2023 at 4:50 p.m., S2RM reported that there should have been a restraint order signed and a restraint packet completed. S2RM stated they do not have a policy on restraint holds and they need one. S2RM confirmed that a physician was not notified of the patient warning signs of deterioration.

In a phone interview on 05/03/2023 at 10:40 a.m. S14MHT stated her position at hospital was Mental Health Technician. S14MHT recalled the event that took place on 01/30/2023 because she had picked-up this rotation. S14MHT reported she had heard Patient #4 was being aggressive and was lifted up in the air by S12MHT and brought into his room where he was put in PRT and a code white was called. S14MHT and S16MHT went to Patient #4's room for the code white. When S14MHT entered into the room, Patient #4 was laying face down on the bed with his arms held while medication was administered. S14MHT recalled he had complaints of the injection hurting him. S14MHT left the room as soon as the injection was administered to tend to other patients.

Based on record review and interview, the hospital failed to ensure the use of restraint was in accordance with a written modification to the patient's plan of care as evidenced by failure of the nursing staff to revise the patient's plan of care to include the use of restraint and the injuries sustained from the use of restraint for 2 (#2, #3) of 5 (#1-#5) patient records sampled.
Findings:

Review of hospital policy titled "Seclusion and Restraint" revealed, in part: The facility's policy in regard to seclusion and restraint is to provide therapeutic treatment, with dignity and respect in the least restrictive environment that provides for patient safety. Definitions, in part: Chemical Restraint, in part: Defined as a mediation used as a restriction to manage the patient's behavior or restrict the patent's freedom of movement and is not a standard treatment for dosage fort the patient's medical or psychiatric condition. Physical Restraint, in part: Defined as any manual method or physical or mechanical device material, or equipment attached or adjacent to the patient's body that he/she cannot easily remove that restricts freedom of movement or normal access to one's body. Procedure, in part: Seclusion and restraint offer protection and are used only in preservation of patient's rights, dignity, and well-being. Seclusion and /or restraint is never utilized as a punitive action or for the convenience of the staff. D. All episodes of seclusion and/or restraint require a physician's or psychiatric mental health nurse practitioner's order. I. Patient Comfort: Seclusion and/or restraints shall not be used in a manner that causes undue physical discomfort, harm, or pain to the patient.

Patient #2
Review of Patient #2's treatment plan dated 04/23/2023, failed to reveal an updated treatment plan that reflected the injuries sustained during restraint on 04/22/2023. Further review of Patient #2's medical record revealed that Patient #2 was discharged on 04/24/2023 after Patient #2's father's upon seeing the injuries sustained to Patient #2's neck, shoulder and head on 04/22/2023.

In an interview on 05/03/2023 at 1:20 p.m., S1DON confirmed that there was no update regarding the injuries sustained during restraint on 04/22/2023 on the treatment plan dated 04/23/2023. S1DON further stated that all changes in the patient's medical condition should be reflected on the treatment plan.

Patient #3
Review of a nursing re-assessment progess note dated 03/03/2023 revealed, in part, at 10:00 a.m. Patient #3 refused to listen to staff when asked to move a chair, became verbally aggressive and attempted to physically assault staff but was able to be quickly escorted to the quiet room where he was able to be successfully verbally de-escalaated.

Review of Patient #3's multidisciplinary treatment plan revealed no update related to the demonstration of aggression on 03/03/2023.

In an interview on 05/03/2023 at 1:20 p.m., S1DON indicated all treatment plans should be updated if there was a change in behavior or other incident related to the care of t he patients.

Based on record review and interview the hospital failed to ensure the use of physical restraint was performed according to hospital policy. This deficient practice is evidenced by failure to obtain signed physician orders for restraints in 2 (#2 and #4) of 5 (#1-#5) reviewed patient records where notification was required.
Findings:

Review of hospital policy titled "Seclusion and Restraint" revealed, in part: The facility's policy in regard to seclusion and restraint is to provide therapeutic treatment, with dignity and respect in the least restrictive environment that provides for patient safety.
Definitions, in part: Physical Restraint, in part: Defined as any manual method or physical or mechanical device material, or equipment attached or adjacent to the patient's body that he/she cannot easily remove that restricts freedom of movement or normal access to one's body. Procedure, in part: D. All episodes of seclusion and/or restraint require a physician's or psychiatric mental health nurse practitioner's order. G. Written Order: An order for seclusion and/or restraint shall specify type of restraint/seclusion, the rationale for use, shall not be a PRN order, and shall be time limited to 4 hours for adults and 2 hours for adolescents and shall be signed by the physician or psychiatric mental health nurse practitioner as soon as possible after the order is written. I. PatientComfort: Seclusion and/or restraints shall not be used in a manner that causes undue physical discomfort, harm, or pain to the patient. Seclusion/Restraint Debriefing: Staff: Following the initiation of each episode of seclusion/restraint, all staff directly involved will be provided with the opportunity to participate in a debriefing session. The debriefing session will be initiated by the charge nurse. Patient, in part: The charge RN or designee meets with the patient to discuss the events or "triggers" which led up to the use of seclusion and/or restraint. Documentation, in part: Responsible Staff: Registered Nurse. Action to be Taken: Document in the medical record and Seclusion/Restraint flow sheet, the following: Behavior exhibited prior to seclusion and /or restraint.; Less restrictive intervention attempted and patient's response, including medications.; Rationale for use of seclusion and/or restraint.; Type of restrictive intervention, i.e. seclusion, type of restraint (5-Point restraint in locked seclusion).; Behavior required for release.; Patient's feelings and/or response.; Time of initiation and cessation.; Time provider was notified.; Time performed face to face evaluation and consult with physician.; Debriefing session with identified triggers and alternative coping mechanism.; Behavior after return to unit.; Nursing Staff: Completes Seclusion and Restraint flow sheet with documentation noting safety check, circulation status, nutrition, toileting, personal hygiene, ROM, safety, comfort measures, behavior, and vital signs. Documentation is noted every 15 minutes on the flow sheet. Staff: Completes an incident report which will allow for performance improvement review.

Patient #2
Review of seclusion/Restraint progress note dated 4/21/2023 revealed a Code White was called at 10:50 a.m. when patient #2 continued to punch wall after being asked to stop. Patient was assisted to floor and held by staff, informed that he would continue to be held until he stopped trying to self-harm. Patient agreed and physical hold was released.
Review of Medical records dated 04/21/2023 failed to reveal a physician's signature for Physical Restraint order.

In an interview on 05/02/2023 at 12:50 p.m., S1DON confirmed there was no order, signed by a physician, for the use of physical restraints.

Patient #4
Review of nursing progress note dated 1/30/2023 at 7:12 p.m. revealed patient became agitated and aggressive toward other patients. His behavior escalated and he was placed in PRT hold and taken to his room. Benadryl 50 mg IM administered. Further review failed to reveal an order for restraint or a restraint packet with details of the event. Continued review failed to reveal a debriefing session initiated by the charge nurse. Continued review failed to reveal a restraint debriefing for staff or patient. The review failed to reveal documentation concerning less restrictive interventions attempted and patient's response or a completed Seclusion and Restraint flow sheet with documentation noting safety check, circulation status, nutrition, toileting, personal hygiene, ROM, safety, comfort measures, behavior, and vital signs.

In an interview on 05/02/2023 at 4:50 p.m., S2RM reported that there should have been a restraint order signed and a restraint packet completed. S2RM stated they do not have a policy on restraint holds and they need one.

Based on record review and interview, the hospital failed to ensure staff were adequately trained in the safe application of physical restraint as evidenced by the hospital failing to use physical restraint techniques that do not cause harm or injury. A review of hospital data identified a pattern of physcial abuse allegations involving 2 (#2 and #4) of 5 (#1-#5) patients sampled.
Findings:

Review of hospital policy titled "Seclusion and Restraint" revealed, in part: The facility's policy in regard to seclusion and restraint is to provide therapeutic treatment, with dignity and respect in the least restrictive environment that provides for patient safety. Definitions, in part: Chemical Restraint, in part: Defined as a mediation used as a restriction to manage the patient's behavior or restrict the patent's freedom of movement and is not a standard treatment for dosage fort the patient's medical or psychiatric condition. Physical Restraint, in part: Defined as any manual method or physical or mechanical device material, or equipment attached or adjacent to the patient's body that he/she cannot easily remove that restricts freedom of movement or normal access to one's body. Procedure, in part: Seclusion and restraint offer protection and are used only in preservation of patient's rights, dignity, and well-being. Seclusion and /or restraint is never utilized as a punitive action or for the convenience of the staff. I. Patient Comfort: Seclusion and/or restraints shall not be used in a manner that causes undue physical discomfort, harm, or pain to the patient.

A review of records reveals the hospital had submitted 2 self-reports dated 01/30/2023 (involving Patient #4) and 04/22/23 (involving Patient #2). The self-reports were concerning 2 separate incidences of physical abuse allegations involving the same staff member, S12MHT. Both incidences involved the use of Therapeutic Holds.

In an interview on 05/02/2023 at 2:55 p.m., S1DON and S2RM stated the two events involving S12MHT were a pattern of physical abuse allegations involving the same staff. S2RM reported they should have created an action plan that included adequate training in the safe application of physical restraint. S2RM stated they do not have a policy on safe restraint holds and they need one.

Based on record review and interview, the hospital failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program that measured, tracked and analyzed adverse patient events on 2 (#3 and #4) of 2 (#3 and #4) adverse reports reviewed.
Findings:

Patient #4
Review of the Hospital Abuse/Neglect Initial Report dated 02/01/2023 regarding Patient #4 revealed, in part, an allegation whereby S12MHT picked up Patient #4 by his arms and he couldn't breathe; then S12MHT put him on the bed facedown. Patient #4 further indicated he was screaming for S12MHT to stop and S12MHT responded "no". Patient #4 indicated S12MHT began hitting and punching him. The report further indicated following an investigation by hospital staff, the allegation was unsubstantiated.

Review of the Quality Assurance and Performance Improvement minutes failed to reveal evidence that this allegation of an adverse patient event was discussed, tracked, or analyzed to prevent future occurrences.

Patient #3
Review of a Hospital Abuse/Neglect Initial Report dated 04/24/2023 regarding Patient #3 revealed, in part, an allegation whereby S12MHT was accused of choking the patient and placed his arm behind his back where his elbow touched the back of his neck and hit his head against the wall twice. Further review revealed under Section 12 asking, in part, did the aggressor have a history of this behavior revealed a response of, "No. S12MHT had no history of inappropriate interaction with patients".The report further indicated following an investigation by hospital staff, the allegation was unsubstantiated.

Review of Patient #3's Medical Progress note prepared by S8NP dated 04/23/2023 revealed an assessment. Review of the assessment revealed, in part: neck with petechial bruising noted to medial and bilateral sides. Bruising noted to head. Right shoulder pain, constant and mild. Right shoulder with petechial bruising.

In an interview on 05/03/2023 at 9:15 a.m. S8NP stated she documented exactly what she had seen on the neck, head and right shoulder of Patient #3.

Review of the Quality Assurance and Performance Improvement minutes provided for the year 2022 and year to date 2023 failed to reveal evidence that the hospital measured, tracked, and analyzed adverse patient allegations to determine their causes and prevent future occurrences.

In an interview on 05/03/2023 at 10:05 a.m., S2RM confirmed that the hospital failed to track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning through the hospital for 2022 and 2023.

Based on record review and interview, the hospital failed to have adequate numbers of mental health technicians to provide care to all patients as needed. This deficient practice was evidenced by 1 (01/09/2023 day shift) of 5 days (01/09/2023, 01/21/2023, 02/04/2023, 05/25/2023 and 03/17/2023) sampled when the hospital failed to meet the minimal staffing requirements as per the approved staffing grid.
Findings:

Review of the policy and procedure titled, "Staffing Plan" approved on 01/01/2013 and last revised in 02/2021 revealed, in part, the staffing plan was created to establish guidelines to anticipated needs of the nursing staff and units to provide for safe delivery of care to the patients with fiscally responsible guidelines. Further review revealed S1DON, nursing leadership, and S2RM creates a master schedule for each discipline. The master schedule is adjusted up or down as needed, to provide for patient needs and ensure positive patient outcomes.

Review of the nursing staffing grid revealed, in part, for a census of 16 patients on the adult units, there should be 2 RNs and 2 BHAs for the day and evening shifts.

Review of the nursing daily staffing schedule for unit a on 01/09/2023 revealed, in part, a census of 16 patients with a total of 3 staff members including 2 RNs and 1 MHT.

In interview on 05/03/2023 at 12:15 p.m., S1DON verified the unit was short by 1 MHT.

Based on record review and interview the hospital failed to ensure nursing staff administered drugs and biologicals according to accepted standards of practice. This deficiency is evidenced by staff administrating medication without physician order in 1 (#4) of 5 (#1-#5) patients sampled.
Findings:

Review of hospital policy titled "Emergency Services" revealed, in part: Procedure: A. Appropriate observation of patients will ensure that any early warning signs of change or deterioration will be identified by staff. Some common early warning signs of change or deterioration in a patient's condition include, in part: b. Irritability c. Acting out behavior.

Review of S5CN's Nursing Reassessment Progress Note dated 01/20/2023 at 7:12 p.m. (11 minutes before the order was obtained from the physician) revealed Patient #4 was placed in PRT hold and received an injection of Benadryl 50 mg IM for failing to clean up his area and follow directions, and for agitation, aggression, cursing and screaming.

Review of nursing order dated 01/30/2023 at 7:23 p.m. (11 minutes after the Bendryl was administered) revealed a verbal order for "Benadryl 50 mg IM now increased agitation x 1. The order was signed by S5CN on 01/20/2023 at 7:20 p.m. and noted by and LPN on 01/30/2023 at 7:22 p.m. The physician signature was dated 01/31/2023 at 10:00 a.m.

In an interview on 5/2/2023 at 4:50 p.m., S2RM confirmed that a physician was not notified of the patient warning signs of deterioration until after the Benadryl was administered.