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Based on record review and interview the Governing Body failed to ensure the hospital developed,implemented,and approved policies and procedures for nursing personnel response to Code Blue emergencies to ensure that adequate RN coverage was maintained on every nursing unit while Code Blue emergencies were managed. Nursing staff made attempts to obtain clarification of the current Hospital's Emergency policy but failed to receive written, approved policies or directives related to RN's who had to respond to codes when it required the RN to leave their nursing unit without RN coverage. Findings:

Review of a Code Blue Response of the current hospital policy titled Code Blue, policy MS-03, effective 08/29/06, last revised 12/01/08, approved 12/18/08, and presented as current hospital policy reads in part: "II. Purpose. A. The purpose of this policy is to provide clear and consistent protocol to secure immediate medical response and coordination of care, including necessary mobilization of additional medical services for patients, visitors and staff at Eastern Louisiana Mental Health System (ELMHS).....III. Scope. System wide management of imminent medical emergencies at Eastern Louisiana Mental Health System Campuses, excluding Forensic After Care Clinic. IV. Policy. It is the policy of East Louisiana Mental Health System to initiate a "Code Blue" when there is a requirement for Advanced Cardiac Life Support (ACLS), Basic Life Support (BLS), use of the Heimlich maneuver, or any other medical emergency that requires restoration of respiration. V. Procedure. B. Code Response. 1. Personnel....c. Cedarview Unit I will respond to all code activations on the Jackson campus, with the exception of CRU, ITU, and ASSA. (forensic units) d. Fire Station responds to all Codes on the Jackson campus and ASSA......2. Zones.....6. Zone Six (6) - Patient Property Building, Magnolia Building, 200 Building, Cedarview Unit I, Parker Building, Dorothy Dixon (D.D.) Building, Laundry, Environmental Services/Maintenance/Warehouse, Power House."

Further review of the same policy revealed a site map with the following printed on it: "Cedarview Unit I responds to all Code Blues except ASSA, ITU, and CRU with defibrillator and Code Bag."

Review of a Code Blue Record dated 6/12/2010 at 1555 (3:55 pm) revealed a Code Blue was called in the Parker Building which is connected to Cedarview Unit I Unit I by a locked door and a hall which is approximately 225 feet long. Review of the Code Blue record revealed S16RN responded to the Code Blue that was called for an employee that was found to be on the floor, in distress,diaphoretic and unresponsive. Record review revealed S16 RN from Cedarview Unit I was the Code Leader and S15 RN from Gabriel Unit I was the Code Recorder. The documentation by S16 RN revealed Acadian Ambulance arrived at 4:20 pm and a code green, return to normal operations, was called at 4:20 pm.

Review of the RN staffing sheet on 6/12/2010 for Cedarview Unit I and the 6:00 am to 6:00 pm Nursing Location Sheet revealed S16 Cedarview Unit I was the only RN assigned to the unit at the time the Code Blue was called at 3:55 pm. Review of the staffing sheet for Gabriel Unit I revealed S15 RN was the only RN on Gabriel Unit 1 at the time of her response to the Code Blue.

An Immediate Jeopardy situation was identified and S1 Administrator and S24 Director Quality Management were notified of the Immediate Jeopardy on 9/10/2010 at 4:30 p.m. The Immediate Jeopardy situation was a result of the facility's failure to ensure a Registered Nurse was immediately available to all patients by having a hospital policy that requires an RN assigned on a locked unit to be responsible to respond to medical emergencies on the facility grounds, other buildings, and locked units. Staffing for evenings, nights, weekends/holidays requires RN's assigned to locked units to leave the unit(s) with no RN and patients under the care of unlicensed personnel.

An interview was held with S15 RN on 9/10/2010 at 11:45 am. She indicated she was working on the Gabriel Unit 1 when a Code Blue was called in the Parker Building on 6/12/2010. She was unable to recall the number of patients on her unit that day. She reported the RN Building Manager instructed her to respond to the code at the Parker Building. S15 indicated she turned the keys to her locked unit over to the RN Building Manager who was also working on one of the three units in Gabriel Building when she left to respond to the Code Blue. She further indicated Gabriel consists of 3 locked units. S15 also reported that a few minutes after she had arrived at Parker Building the RN Building Manager from Gabriel whom she had given her keys to when she left the unit, was also in attendance at the Code Blue. She added this left 1 RN in Gabriel Building for 3 locked units. S15 indicated she was gone from her unit on 6/12/2010 for approximately 20 minutes. She expressed concerns about leaving one RN or no RN ' s on a unit while she responded to a Code Blue. She indicated she had spoken to the DON on numerous occasions before the 6/12/2010 code requesting clarification in writing about Code Blue attendance when there was only one RN on a unit. She added she had not received the clarification in writing she requested.

An interview was held with S16 RN on 9/9/10 at 9:05 am. She indicated she works from 7:00 am to 7:00 pm on Cedarview Unit I Unit 1. She further indicated she left Cedarview Unit I to respond to a Code Blue in the Parker Building on 6/12/2010 at 3:55 pm. She added when she left Cedarview Unit I to respond to the code, two psychiatric aids from Cedarview Unit I accompanied her to Parker Building. S16 reported no RN was on the Cedarview Unit I during her absence. She indicated a RN from Gabriel Unit 1 arrived at Parker Building to assist her about 15 minutes after the Code Blue had been called. S16 added that she was absent from Cedarview Unit I for approximately one and a half hours, which included the time for the paperwork she needed to complete for the Code Blue on 6/12/2010. She added there was no other RN available to replace her on Cedarview Unit I during her absence. S16 expressed concern about leaving her patients unattended without a nurse when she responded to the Code Blue. S16 RN added that the hospital policy requires a RN to be on each unit at all times, and also requires her to respond to a Code Blue. S16 indicated she heard by " word-of-mouth " after the 6/12/2010 Code Blue that she could remain on Cedarview Unit I if she was the only nurse on the unit. She again repeated that according to the written hospital policy she was required to respond to a Code Blue and added that if she did not respond to the code, as she had been told by " word-of-mouth " then she would be in violation of hospital policy. S16 RN reported she contacted S3 DON verbally and in writing about the code situation related to having to respond to a code and leaving her unit without a RN. She indicated neither her supervisor nor administration had informed her of a different directive other than hospital policy.

Review of a letter from S16 RN to S5 RN Manager, S3 DON, S2 Executive Nurse, S22 MD Clinical Director, S23 Assistant CEO and S1 Administrator on 6/13/2010 revealed during the code blue on 6/12/2010 a staff nurse arrived to the code approximately 5 to 10 minutes after the code was called and that the house manager arrived approximately 20 to 25 minutes after code blue had been called. She further indicated " ...it is opting [sic?] impossible and unsafely challenging to deliver proper care during the midst of a code without proper staff from nursing services ... " The documentation from the letter further revealed that according to the hospital policy and procedure guidelines, a Cedarview nurse is to respond to all code blue emergencies on the ground as well as the clinical oversight and to the unit they are assigned to work. The documentation revealed " ...I have been advised and informed that I am not to leave this building, which by definition means leaving a locked door between myself and the unit. If this occurs, I will be held liable for any mishaps that happen on the unit if a nurse isn't present ... "

Review of a letter dated 6/13/2010 from S16 RN to S5, RN Building Manager, S3 DON, S2 Executive Nurse, S22 MD Clinical Director, S23 Assistant CEO, and S1 CEO revealed a request for additional staff on weekends and when only one nurse is assigned to a unit. Further review of this letter revealed documentation of S16 RN requesting documentation of the hospital ' s policy and procedure that the staffing is correctly allocated combined with her concern about her nursing license being "...on the line ... "

Review of an e-mail correspondence dated 6/15/2010 presented by S3 DON revealed he acknowledged receipt of the letter from S16 RN on 6/13/2010 and indicated he would discuss her concerns with the Executive Nurse. The documentation further revealed S16 RN would receive a formal response.

Review of a letter from S3 DON to S16 RN on 6/18/2010 revealed he questioned if the issue was of S16 RN leaving her patients or having someone accompany her to a code. The documentation further revealed " ...Nursing Administration does not factor just RN's into staff matrix. For instance, one RN and 5 PA's for 20 patients will provide a patient ratio of 1:3.3, which is an acceptable, even generous staffing when considering our units reflecting a 1:4.5 with increased acuity ... "

Review of e-mail correspondence, furnished by the DON, between S15 RN and S3 DON revealed on 6/22/2010, S15 requested written guidelines and clarification regarding " ... leaving her unit, responding to Code Blues after hours, and on weekends since policy and procedure states that a Cedarview nurse is to respond to all codes as this was a conflict with nursing policy that indicates a RN will be on the building at all times, and who other than the grounds house manager is to respond to codes at Cedarview ... "

Review of a handwritten letter, furnished by the DON, from S15 RN to the DON on 7/7/2010 revealed another request for a response in writing regarding Code Blues and leaving the unit since she would have been the only RN on Cedarview that weekend.

Review of a letter, furnished by the DON, from S3 DON to S15 RN 7/9/2010 with carbon copies to S2 Executive Nurse and the Administrator revealed the following guidelines the East Division Nursing Management Team is currently using: " ...When only to one nurse is on Cedarview, the nurse on Cedarview will respond to Code Blues on Cedarview and Parker only. However, should a catastrophic crisis occur, as always follow the directives of your supervisor. The house manager/ designee will go to Cedarview, retrieve the code bag and transport the code bag to the code blue site. Both of Evangeline and Gabriel or required to assign one nurse each shift to respond to code blues at the east division. Thus, you were assured to have additional staff should a code blue occur in your area. Should you need additional clarification, you may contact your RN Manager ... "

Review of the Executive Nurse Council, East Division Meeting Minutes on 7/01/2010 revealed a sign in sheet for the attendance at the meeting were S3 DON, S5 RN Cedarview Unit I House Manager, S6 RN Gabriel House Manager, S4, RN Evangeline House Manager, S8 RN Night House Supervisor. Review of the agenda for the meeting revealed Code Blue had been discussed. Further review of the meeting minutes revealed " ... When there is only one nurse on Cedarview Unit I, the Cedarview Unit I nurse cannot be responsible for attending Code Blues on other buildings. For all future Code Blues, a nurse must be assigned each shift from Evangeline and Gabriel Buildings to assist in all Code Blues, wherever located. This means the RN Manager/designee will get the code bag/Life-pak from Cedarview Unit I and bring it to the code site. The other two nurses are who are assigned from EH (Evangeline) and GH (Gabriel) will attend the code as well due to the downsizing of the East division. The Code Blue Policy is awaiting revision. The building managers indicated they are aware of this procedure. The RN Managers are to educate their staff on these procedures ... "

Review of the Staff Meeting minutes for June 2010 that S6 RN Gabriel House Manager for Gabriel House presented revealed documentation she informed her staff that " ...Per S3 DON: Effective immediately when a Code Blue is called the house manager must respond and go to Cedarview Unit I clinic and get the code bag, then report to the location of the code. "

An interview was held with S6 RN Gabriel House Manager on 9/7/2010 at 1:55 PM. She indicated all RN's are assigned to a specific zone in the event of a Code Blue. She added that with the downsizing,or closing of Cedarview Unit II, for patients and staff, the DON had instructed the managers to assign a RN to respond to Code Blues on the campus. S6 RN further indicated she had no documentation or policy from the DON about the RN assignments. S6 RN added there should be a RN on each unit at all times. She indicated one RN cannot cover a unit and also respond to a Code Blue on another unit.

Review of the Nurse's Meetings for Cedarview Unit I for June, July and August 2010 revealed no documentation the staff nurses had been informed of the Executive Nurse Council, East Division Meeting on 7/01/2010 that a RN from Cedarview Unit I would not be expected to attend a Code Blue on a different unit if she were the only RN on Cedarview Unit I.

An interview was held with S5, RN Cedarview Building Manager on 9/7/10 at 12:45 pm. She indicated she was not certain of the final outcome from the Executive Nurse Council, East Division Meeting on 7/01/2010 that she attended about RN response to Code Blue, as she had not been notified in writing by upper management. She further indicated she had received nothing in writing about a change in hospital policy relating to Code Blue. She added she had verbally informed her staff about not responding to a Code Blue if they were the only RN on the unit. She had nothing in writing from Nursing Administration to support this directive. S5 indicated she had no documentation in her monthly meeting minutes to indicate that she had informed her staff about not responding to a Code Blue if there was only one RN on Cedarview Unit I. She added her staff knows to notify administration if there is only one nurse on the unit from a directive given by S3 DON. S5 RN Building Manager indicated she works 8 hour shifts and leaves the unit at 3:00 pm Monday through Friday. She reported when she is off work at 3:00 pm Cedarview Unit I has one RN on the unit. An additional interview was held with S5 RN Cedarview Building Manager on 9/10/2010. She indicated she had discussed her nurses concerns about the Code Blue response with S3 DON in June 2010 after the downsizing, closing, of Cedarview Unit II.

A telephone interview was conducted with S9 RN House Supervisor on 9/10/2010 at 9:05 am. He indicated that as the house supervisor he was responsible for the entire hospital during his shift. He indicated as of this conversation, a lone Cedarview Unit I RN cannot respond to a code on another unit. He added he had received verbal communication that this is what was expected but had received nothing in writing. S9 RN reported he attends all codes when he is on duty. He further indicated he visits all units in the hospital during his shift when he is not covering a unit as a staff nurse. S9 RN House Supervisor added when he works as a staff nurse he also is the house supervisor. He indicated he works as a staff nurse/house supervisor approximately 10% to 15% of his shifts. He further indicated in the event that a problem arises that he needs to respond to as the house supervisor, he would have to leave the unit he was covering if there was not another RN to cover his unit.

An interview was held with S2 RN Executive Nurse on 9/7/10 at 1:10 pm. She indicated there is only one RN staff nurse on Cedarview Unit I and 1 RN Building Manager on Cedarview Unit I who leaves at 3:00 pm Monday through Friday. She further indicated the most current revision to the hospital policy related to Code Blue was adopted on 12/18/2008. S2 RN added the DON met with the RN Managers on 7/01/2010 at the Executive Nurse Council, East Division Meeting Minutes and according to the meeting minutes " ... When there is only one nurse on Cedarview Unit I, the Cedarview Unit I nurse cannot be responsible for attending Code Blues on other buildings. For all future Code Blues, a nurse must be assigned each shift from Evangeline and Gabriel Buildings to assist in all Code Blues, wherever located. This means the RN Manager/designee will get the code bag/Life-pak from Cedarview Unit I and bring it to the code site. The other two nurses that are assigned from EH (Evangeline) and GH (Gabriel) will attend the code as well due to the downsizing if the East division. The Code Blue Policy is awaiting revision. The building managers indicated they are aware of this procedure. The RN Managers are to educate their staff on these procedures ... " She indicated the only code change was from a verbal directive from the Nursing Division about how Code Blues were to be handled on the East Division. She indicated there was nothing in writing related to this directive that had been given to all staff at the hospital. S2RN Executive Nurse reported the verbal directive to nursing staff never went to the Governing Body to become policy.

An interview was held with S2, Executive Nurse and S3 DON on 9/8/10 at 9:15 am. After review of the System Nursing Leadership Council Meeting on 8/18/2010 they indicated the issue about Code Blue had not been discussed because the attendance at the meeting did not have a quorum. S3 DON indicated that a RN is alone on the units from 3:45 pm, when the day RN Manager leaves for the day, to 6:45 am when the evening RN House Supervisor comes to work. He further indicated that the nursing department does not have the authority to change hospital policy; however they can make recommendations to the Governing Body. He added that nurses should always follow hospital policy. S3 indicated he had addressed the Code Blue concerns at the 7/1/2010 meeting with the RN Managers. S3 DON indicated he had instructed all the RN managers to notify the staff nurses that if they were the only nurse on a unit they were not expected to respond to a Code Blue. He indicated that he had no documentation from the RN Managers that all staff had been informed after the 7/01/2010 meeting. He further indicated that he did not have a written directive or revised code policy for the RN Managers to disseminate to their staff. S2 and S3 reported that the hospital policy was different than the meeting minutes he and the RN Managers discussed at the 7/01/2010 meeting. S3 DON added that he expects staff to follow the most current directive until hospital policy can be changed. S3 DON indicated he had also spoken to S13 Medical Director in approximately June of 2010 about revision to the code blue policy.

An additional interview was held with S2, Executive Nurse and S3 DON on 9/8/10 at 9:55 am. After a view of the Code Blue that occurred in Parker Building on 6/12/2010 they indicated that two nurses from Gabriel had also responded to the code. They acknowledge that when S15 RN and S16 RN responded to that Code Blue the patients on their assigned units of Cedarview Unit I and Gabriel Unit I were left without a RN and their patients were left in the care of psychiatric aides.

A telephone interview was held with S2 Executive Nurse on 9/9/2010 at 10:10 am. She indicated in the event that a RN was required to obtain narcotics from the pharmacy; the RN should call the house manager for coverage so that she/he would not leave the unit without a RN. She further indicated that the unit would not be fully staffed if the only RN on the unit attends a Code Blue on another locked unit. S2 indicated the hospital policy and procedure is that a RN is to oversee the care of patients but added there was no specific policy related to the only RN leaving a locked unit to respond to a Code Blue or to obtain medications from the pharmacy.

An interview was held with S13 Medical Director on 9/08/2010 at 10:10 am. She indicated Cedarview Unit II had been closed 5/10/2010 due to consolidating and closing of units and that the code situation had been addressed when the last patients left Cedarview Unit II. She further indicated that Cedarview Unit I is the only unit now open in the Cedarview Building. S13 reported she had verbally discussed the Code Blue response with the Administrator and the DON in approximately June of 2010. She indicated it had been decided that the house supervisor was to get the code pack that included the Life pack and drugs to bring to a code. She further indicated this was a temporary fix until policy and procedures could be changed and approved by the Medical Executive Committee. S13 indicated there was no Medical Executive Committee meeting in July 2010. She further indicated that as of this interview the hospital policy and procedure related to Code Blue and RN responses had not been changed.

During an interview with S1 Administrator on 9/7/10 at 2:10 pm he indicated that after 3:00 pm when the RN Managers are off duty, there is one RN assigned to each unit. He indicated that staff RN's, LPN's and psychiatric aides work 12 hours shifts at the hospital. He added a RN cannot leave a unit unattended. He further indicated the Executive Nurse has the authority to change policy for nursing with either a verbal or written directive after approval from Administration or the Governing Body. He clarified that a nursing directive is different from hospital policy. S1 Administrator indicated he would have expected a policy change request or directive from Nursing Administration to go out to staff for a life threatening situation. He reported the Medical Director had been working on revisions to the hospital's policy and procedure relating to the code policy, but had been out on extensive leave because of a tragedy. He added that he should have given this responsibility to someone else.

The Immediate Jeopardy was removed on 9/14/10 at 11:45 am after an acceptable Plan of Removal that included:

1. Code Blue Policy and Procedure revised.

Revisions included

a. Assignment to bring Code bag with Lifepak from Control center at Bienville is the responsibility of the Emergency Response Team (ERT). At the beginning of each shift the shift Captain will assign an ERT member the responsibility for the entire shift.
b. Clarified that RN's will respond to all codes in their " Zones" unless they are the only Nurse assigned to a ward or Unit.
c. At the beginning of each shift a Registered Nurse will be assigned as the"floating" Nurse and assigned the responsibility of responding to all Code Blues.
d. All Nursing staff in TQM (total quality management), Education and Administration will respond to all Code Blues.
e. The Clinic Nursing Staff will respond to all Code Blues.

2. Code Blue Policy and Procedure approved by Medical Executive committee and Chief Executive Officer. Committee meeting at 10:30 a.m. 09/14/10.

3. Revised policy disseminated to Nurse Managers and Majors. Nurse managers meeting 09/14/10.

a. Managers given the responsibility to disseminate to all shifts.
b. Managers passed new revised Code Blue policy to all staff, noting key changes.
c. Staff signed acknowledgement / verification of receipt forms.
d. Nursing staff monitored all signed forms and compared to Table of Organization to ensure all Nursing staff have been advised.
e. Distribution of new policy will start today 09/14/10 with day shift and will be completed on Night shift today 09/14/10 prior to Nursing taken [sic] shift at night. The next two teams/shifts will be trained on Thursday 09/16/10 prior to accepting the ward.
f. Nursing staff that is off during the initial training will be trained upon return and prior to taking a ward.

4. Code Blues will be monitored and documented by TQM staff to ensure policy and procedure followed. Monitoring conducted by code blue Multi-Disciplinary Review and kept on hand with Medical Director. The review is an analysis of the code.

5. Nursing Administration will conduct random daily surveys for Nursing staff for a three week period or until 100% achieved compliance noted. After three weeks and 100% compliance then we will revert to weekly random Survey ' s for 3 months or until 100% compliance achieved [sic].

6. New revised code blue policy will be distributed as part of initial orientation and Nurse competency training. Records maintained by Staff Education and Training Department.

7. New revised code blue policy will be posted to the ELMHS intranet site.

Review of the By Laws of the Governing Body, Eastern Louisiana Mental Health System, signed by the CEO on 05/26/10, presented as current Governing Body By Laws, revealed in part: "Article One.....the Governing Body, administrative staff, and medical staff adopt these bylaws as the framework through which their responsibilities will their responsibilities will be discharged and their interrelationships will be governed. Article Two. Governing Body......2.2 Duties and Responsibilities of the Governing Body are as follows:....2.2.3 provide organizational planning, establish policy, and provide for hospital/system management and planning; 2.2.5 set expectations for the hospital/system and manage processes to assess, improve, maintain....the quality of the System's governance, management, clinical, and support activities; 2.2.6 provide for resources needed to maintain safe and quality care, treatment and services;....Article Three. Chief Executive Officer.....3.2 Responsibilities. The CEO shall serve as the on-site Governing Body representative and shall manage the hospital effectively and efficiently. In addition, the CEO shall: 3.2.9 develop System programs to meet identified patient needs...3.2.17 assure System compliance with applicable laws and regulations."

Based on record review and interviews the hospital failed to ensure patient safety by not assigning a RN to every patient Unit at all times by 1) assigning only a LPN (Licensed Practical Nurse) to a locked unit without direct RN supervision for 83 of 184 shifts reviewed between 6/01/ 2010 and 8/31/2010 2) when the only RN was required to go to pharmacy to obtain patient medications. Findings:

1) Review of the daily nurse staffing sheets for 6/01/2010 through 8/31/ 2010 revealed S20LPN and S21LPN were assigned to one of the 3 locked units which contain between 19 and 30 patients (Evangeline Unit 2 houses 30 patients, Evangeline Unit 3 houses 19 patients and Evangeline Unit 4 houses 26 patients) for 83 of 184 shifts during the period with no RN to supervise patient care. S20LPN worked days and S21LPN worked nights.

Review of the daily staffing sheets for June 1st, 2010 through August 31st, 2010 revealed the following:

06/03/10 S20LPN was assigned Evangeline Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/03/10 S21LPN was assigned to the Evangeline Unit as one of the nurses from 7 p.m. - 7 a.m. The assignments were not written on the form to indicate what unit was assigned to S21LPN.

06/04/10 S20LPN was assigned Evangeline Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/04/10 S21LPN was assigned Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/08/10 S20LPN was assigned Evangeline Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/08/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/09/10 S20LPN was assigned Evangeline Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/09/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/12/10 S20LPN was assigned Evangeline Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/12/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/13/10 S20LPN was assigned Evangeline Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/13/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/14/10 S20LPN was assigned Evangeline Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/14/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/17/10 S20LPN was assigned Evangeline Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/17/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/18/10 S20LPN was assigned Evangeline Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/18/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/22/10 S20LPN was assigned to the Evangeline Unit as one of the 4 nurses from 7 p.m. - 7 a.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

06/22/10 S21LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/23/10 S20LPN was assigned to the Evangeline Unit as one of the nurses from 7 a.m. - 7 p.m. The assignments were not written on the form to indicate what nurse was assigned to Unit 4 or to S20LPN.

06/23/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/26/10 S20LPN was assigned Evangeline Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/26/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/27/10 S20LPN was assigned Evangeline Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/27/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/28/10 S20LPN was assigned to the Evangeline Unit as one of the 4 nurses from 7 a.m. - 7 p.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

06/28/10 S21LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

07/01/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

07/02/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

07/03/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/04/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. and Evangeline Unit 4 from 7 p.m. - 10 p.m. with no RN to supervise patient care to S21LPN.

07/06/10 S20LPN was assigned to the Evangeline Unit as one of the 4 nurses from 7 a.m. - 7 a.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

07/06/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/07/10 S20LPN was assigned to the Evangeline Unit as one of the nurses from 7 a.m. - 7 a.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

07/07/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/10/10 S20LPN was assigned to the Evangeline Unit as one of the nurses from 7 a.m. - 7 a.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

07/10/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/11/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

07/11/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/12/10 S20LPN was assigned to the Evangeline Unit as one of the nurses from 7 a.m. - 7 p.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

07/12/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/16/10 S20LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/20/10 S20LPN was assigned to the Evangeline Unit as one of the nurses from 7 a.m. - 7 p.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

07/20/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/21/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

07/21/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/24/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

07/24/10 S21LPN was assigned to the Evangeline Unit as one of the nurses from 7 p.m. - 7 a.m. The assignments were not written on the form to indicate what unit was assigned to S21LPN.

07/25/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

07/25/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/26/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

07/26/10 S21LPN was assigned EvangelineUnit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/29/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

07/29/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/30/10 S20LPN was assigned to the Evangeline Unit as one of the nurses from 7 a.m. - 7 p.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

08/03/10 S21LPN was assigned to the Evangeline Unit as one of the nurses from 7 p.m. - 7 a.m. The assignments were not written on the form to indicate what unit was assigned to S21LPN.

08/04/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

08/07/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

08/07/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

08/08/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

08/08/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

08/09/10 S20LPN was assigned to the Evangeline Unit as one of the nurses from 7 a.m. - 7 p.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

08/09/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

08/12/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

08/12/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

08/13/10 S20LPN was assigned to the Evangeline Unit as one of the nurses from 7 a.m. - 7 p.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

08/13/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

08/17/10 S20LPN was assigned to the Evangeline Unit as one of the nurses from 7 a.m. - 7 p.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

08/17/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

08/18/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

08/18/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

08/21/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

08/21/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

08/22/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

08/22/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

08/23/10 S20LPN was assigned to the Evangeline Unit as one of the nurses from 7 a.m. - 7 p.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

08/23/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

08/26/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

08/26/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

08/27/10 S20LPN was assigned to the Evangeline Unit as one of the nurses from 7 a.m. - 7 p.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

08/27/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

In an interview on 09/09/10 at 9:30 a.m. with S3DON he confirmed that there were shifts with no RN physically present on each Unit to supervise patient care on each locked Unit.

In an interview on 09/09/10 at 10:10 a.m. with S2Executive Nurse she stated that she was aware that an LPN was staffing one of the 3 locked Units in Evangeline building for the past few months.

2) An interview was held with S16 RN on 9/9/10 at 9:05 am. S16RN indicated approximately once a week, after 3:00 pm, when the RN Building Manager is off duty and S16 is the only nurse on Cedarview Unit I, she is required to obtain narcotics/controlled medications such as Klonopin or Ativan from the pharmacy. She reported pharmacy does not deliver narcotics to Cedarview Unit I. S16 reported she notified the RN House Supervisor in the past that she needed to leave the unit to go to the pharmacy; however there was never another RN available to relieve her. She added that she needed the medications for her patients. She added it takes her about 3 minutes to get to the pharmacy and 3 minutes to return. She indicated Cedarview Unit I is left without a RN and with psychiatric aides in attendance when she has to go to the pharmacy to obtain narcotics/controlled medications. She added psychiatric aides cannot obtain narcotics from pharmacy and pharmacy does not deliver narcotics to the unit.

A telephone interview was held with S2 Executive Nurse on 9/9/2010 at 10:10 am. She indicated in the event that a RN was required to obtain narcotics from the pharmacy; the RN should call the house manager for coverage so that she/he would not leave the unit without a RN. She further indicated that the unit would not be fully staffed if the only RN on the unit attends a Code Blue on another locked unit. S2 indicated the hospital policy and procedure is that a RN is to oversee the care of patients but added there was no specific policy related to the only RN leaving a locked unit to respond to a Code Blue or to obtain medications from the pharmacy.

Based on medical record review and interviews the hospital failed to identify through the QA process problems related to RN's leaving their units with unlicensed personnel.Findings:

1. RN's assigned to locked units being required to leave the unit(s) with no RN and psychiatric patients left under the care of unlicensed personnel when responding to a Code Blue and/or when going to pharmacy to obtain narcotics.(See Deficiency cited under A0395 and A0392)

An interview was held on 9/09/2010 at 1:40 pm with S24 and S24 Quality Assurance. They indicated QA had not identified any staffing problems relating to RN Code Blue responses and units being left under the care od unlicensed personnel. She added there were no performance indicators related to staffing for Code Blue RN responses by the Quality Assurance Department.

Based on record review and interview the Hospital failed to meet the Condition of Participation for Nursing by:

1) failing to ensure every inpatient unit within the hospital complex maintained a Registered Nurse (RN) physically present on each psychiatric patient unit to ensure the immediate availability of a RN for the emergency management and/or application of restraints on patients whose behavior presents an imminent risk. This was evidenced by the only RN assigned to Cedarview Unit 1 and the only RN assigned to Gabriel Unit 1 leaving their assigned locked patient care units on 06/12/10 at 3:55 p.m. to respond to a Code Blue in another area located away from their assigned unit and building. The Code Blue was in the Parker Building which is connected to Cedarview Unit I by a locked door and a hall which is approximately 225 feet long and the Gabriel building is approximately 600 feet across a street, leaving 52 patients in the care of unlicensed personnel. (see findings at A0395)


An Immediate Jeopardy situation was identified on 09/10/10 at 4:30 p.m. The Administrator was notified on the Immediate Jeopardy on 09/10/10 at 4:30 p.m.

An Immediate Jeopardy situation was identified and S1 Administrator and S24 Director Quality Management were notified of the Immediate Jeopardy on 9/10/2010 at 4:30 p.m. The Immediate Jeopardy situation was a result of the facility's failure to ensure a Registered Nurse was immediately available to all patients by having a hospital policy that requires an RN assigned on a locked unit to be responsible to respond to medical emergencies on the facility grounds, other buildings, and locked units. Staffing for evenings, nights, weekends/holidays requires RN ' s assigned to locked units to leave the unit(s) with no RN and patients under the care of unlicensed personnel.

The Immediate Jeopardy was lifted on 9/14/10 at 11:45 a.m. after the hospital submitted an acceptable Plan of Removal which included:

1. Code Blue Policy and Procedure revised.
Revisions included

a. Assignment to bring Code bag with Lifepak from Control center at Bienville is the responsibility of the Emergency Response Team (ERT). At the beginning of each shift the shift Captain will assign an ERT member the responsibility for the entire shift.
b. Clarified that RN's will respond to all codes in their "Zones" unless they are the only Nurse assigned to a ward or Unit.
c. At the beginning of each shift a Registered Nurse will be assigned as the "floating" Nurse and assigned the responsibility of responding to all Code Blues.
d. All Nursing staff in TQM (total quality management), Education and Administration will respond to all Code Blues.
e. The Clinic Nursing Staff will respond to all Code Blues.

2. Code Blue Policy and Procedure approved by Medical Executive committee and Chief Executive Officer. Committee meeting at 10:30 a.m. 09/14/10.

3. Revised policy disseminated to Nurse Managers and Majors. Nurse managers meeting 09/14/10.

a. Managers given the responsibility to disseminate to all shifts.
b. Managers passed new revised Code Blue policy to all staff, noting key changes.
c. Staff signed acknowledgement / verification of receipt forms.
d. Nursing staff monitored all signed forms and compared to Table of Organization to ensure all Nursing staff have been advised.
e. Distribution of new policy will start today 09/14/10 with day shift and will be completed on Night shift today 09/14/10 prior to Nursing taken [sic] shift at night. The next two teams/shifts will be trained on Thursday 09/16/10 prior to accepting the ward.
f. Nursing staff that is off during the initial training will be trained upon return and prior to taking a ward.

4. Code Blues will be monitored and documented by TQM staff to ensure policy and procedure followed. Monitoring conducted by code blue Multi-Disciplinary Review and kept on hand with Medical Director. The review is an analysis of the code.

5. Nursing Administration will conduct random daily surveys for Nursing staff for a three week period or until 100% achieved compliance noted. After three weeks and 100% compliance then we will revert to weekly random Survey ' s for 3 months or until 100% compliance achieved [sic].

6. New revised code blue policy will be distributed as part of initial orientation and Nurse competency training. Records maintained by Staff Education and Training Department.

7. New revised code blue policy will be posted to the ELMHS intranet site.

The Administrator was notified of the acceptance of the Plan of Removal at 11:45 a.m. on 09/14/10.


The deficient practice remains at a standard level.

Based on record review and interviews the hospital failed to ensure a RN was assigned to every inpatient Unit at all times by 1) assigning only an LPN (Licensed Practical Nurse) to a locked unit without direct RN supervision for 83 of 184 shifts reviewed between 6/01/ 2010 and 8/31/2010 and 2) the hospital allowing a RN to leave the patient unit, without having another RN cover the unit, when the RN was required to go to pharmacy to obtain patient medications. Findings:


1) Review of the daily nurse staffing sheets for June 1st, 2010 through August 31st, 2010 revealed S20LPN and S21LPN were assigned to one of the 3 locked units which contain between 19 and 30 patients (Evangeline Unit 2 houses 30 patients, Evangeline Unit 3 houses 19 patients and Evangeline Unit 4 houses 26 patients) for 83 of 184 shifts during the period. S20LPN worked days and S21LPN worked nights.

Review of the daily staffing sheets for June 1st, 2010 through August 31st, 2010 revealed the following:

06/03/10 S20LPN was assigned Evangeline Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/03/10 S21LPN was assigned to the Evangeline Unit as one of the nurses from 7 p.m. - 7 a.m. The assignments were not written on the form to indicate what unit was assigned to S21LPN.

06/04/10 S20LPN was assigned Evangeline Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/04/10 S21LPN was assigned Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/08/10 S20LPN was assigned Evangeline Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/08/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/09/10 S20LPN was assigned Evangeline Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/09/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/12/10 S20LPN was assigned Evangeline Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/12/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/13/10 S20LPN was assigned Evangeline Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/13/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/14/10 S20LPN was assigned Evangeline Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/14/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/17/10 S20LPN was assigned Evangeline Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/17/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/18/10 S20LPN was assigned Evangeline Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/18/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/22/10 S20LPN was assigned to the Evangeline Unit as one of the 4 nurses from 7 p.m. - 7 a.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

06/22/10 S21LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/23/10 S20LPN was assigned to the Evangeline Unit as one of the nurses from 7 a.m. - 7 p.m. The assignments were not written on the form to indicate what nurse was assigned to Unit 4 or to S20LPN.

06/23/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/26/10 S20LPN was assigned Evangeline Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/26/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/27/10 S20LPN was assigned Evangeline Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/27/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/28/10 S20LPN was assigned to the Evangeline Unit as one of the 4 nurses from 7 a.m. - 7 p.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

06/28/10 S21LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

07/01/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

07/02/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

07/03/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/04/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. and Evangeline Unit 4 from 7 p.m. - 10 p.m. with no RN to supervise patient care to S21LPN.

07/06/10 S20LPN was assigned to the Evangeline Unit as one of the 4 nurses from 7 a.m. - 7 a.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

07/06/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/07/10 S20LPN was assigned to the Evangeline Unit as one of the nurses from 7 a.m. - 7 a.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

07/07/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/10/10 S20LPN was assigned to the Evangeline Unit as one of the nurses from 7 a.m. - 7 a.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

07/10/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/11/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

07/11/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/12/10 S20LPN was assigned to the Evangeline Unit as one of the nurses from 7 a.m. - 7 p.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

07/12/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/16/10 S20LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/20/10 S20LPN was assigned to the Evangeline Unit as one of the nurses from 7 a.m. - 7 p.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

07/20/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/21/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

07/21/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/24/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

07/24/10 S21LPN was assigned to the Evangeline Unit as one of the nurses from 7 p.m. - 7 a.m. The assignments were not written on the form to indicate what unit was assigned to S21LPN.

07/25/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

07/25/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/26/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

07/26/10 S21LPN was assigned EvangelineUnit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/29/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

07/29/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/30/10 S20LPN was assigned to the Evangeline Unit as one of the nurses from 7 a.m. - 7 p.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

08/03/10 S21LPN was assigned to the Evangeline Unit as one of the nurses from 7 p.m. - 7 a.m. The assignments were not written on the form to indicate what unit was assigned to S21LPN.

08/04/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

08/07/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

08/07/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

08/08/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

08/08/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

08/09/10 S20LPN was assigned to the Evangeline Unit as one of the nurses from 7 a.m. - 7 p.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

08/09/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

08/12/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

08/12/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

08/13/10 S20LPN was assigned to the Evangeline Unit as one of the nurses from 7 a.m. - 7 p.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

08/13/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

08/17/10 S20LPN was assigned to the Evangeline Unit as one of the nurses from 7 a.m. - 7 p.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

08/17/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

08/18/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

08/18/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

08/21/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

08/21/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

08/22/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

08/22/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

08/23/10 S20LPN was assigned to the Evangeline Unit as one of the nurses from 7 a.m. - 7 p.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

08/23/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

08/26/10 S20LPN was assigned Evangeline Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

08/26/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

08/27/10 S20LPN was assigned to the Evangeline Unit as one of the nurses from 7 a.m. - 7 p.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

08/27/10 S21LPN was assigned Evangeline Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

In an interview on 09/09/10 at 9:30 a.m. with S3DON he confirmed that there were shifts with no RN physically present on each Unit to supervise patient care on each locked Unit.

In an interview on 09/09/10 at 10:10 a.m. with S2Executive Nurse she stated that she was aware that an LPN was staffing one of the 3 locked Units in Evangeline building for the past few months.


2) An interview was held with S16 RN on 9/9/10 at 9:05 am. S16 indicated approximately once a week she is required to obtain narcotics such as Klonopin or Ativan from the pharmacy after 3:00 pm when the RN Manager, who is located on her unit, is off duty. She reported pharmacy does not deliver narcotics to Cedarview I. S16 reported she notified the house manager in the past that she needed to leave the unit to go to the pharmacy; however there was never another RN available to relieve her. She added that she needed the medications for her patients. S16 RN indicated she usually went to the pharmacy to obtain the narcotics for her patients that had been transferred from another unit. She added it takes her about 3 minutes to get to the pharmacy and 3 minutes to return. She indicated Cedarview I is left without a RN and only psychiatric aids when she has to go to the pharmacy to obtain narcotics. She added psychiatric aides cannot obtain narcotics from pharmacy and pharmacy does not deliver narcotics to the unit.

A telephone interview was held with S2 Executive Nurse on 9/9/2010 at 10:10 am. She indicated in the event that a RN was required to obtain narcotics from the pharmacy; the RN should call the house manager for coverage so that she/he would not leave the unit without a RN. She further indicated that the unit would not be fully staffed if the only RN on the unit attends a Code Blue on another locked unit. S2 indicated the hospital policy and procedure is that a RN is to oversee the care of patients but added there was no specific policy related to the only RN leaving a locked unit to respond to a Code Blue or to obtain medications from the pharmacy.

Based on record review and interviews the hospital failed to ensure every inpatient unit within the hospital maintained a Registered Nurse (RN) physically present in each patient unit to ensure the immediate availability of a RN for the bedside care of each patient. This was evidenced by the only RN assigned to Cedarview Unit 1 and the only RN assigned to Gabriel Unit 1 leaving their assigned locked units on 06/12/10 at 3:55 p.m. to respond to a Code Blue, leaving 52 patients in the care of unlicensed personnel. Findings:

1) Review of a Code Blue Response of the current hospital policy titled Code Blue, policy MS-03, effective 08/29/06, last revised 12/01/08, approved 12/18/08, and presented as current hospital policy reads in part: "II. Purpose. A. The purpose of this policy is to provide clear and consistent protocol to secure immediate medical response and coordination of care, including necessary mobilization of additional medical services for patients, visitors and staff at Eastern Louisiana Mental Health System (ELMHS).....III. Scope. System wide management of imminent medical emergencies at Eastern Louisiana Mental Health System Campuses, excluding Forensic After Care Clinic. IV. Policy. It is the policy of East Louisiana Mental Health System to initiate a "Code Blue" when there is a requirement for Advanced Cardiac Life Support (ACLS), Basic Life Support (BLS), use of the Heimlich maneuver, or any other medical emergency that requires restoration of respiration. V. Procedure. B. Code Response. 1. Personnel....c. Cedarview Unit I will respond to all code activations on the Jackson campus, with the exception of CRU, ITU, and ASSA. (forensic units) d. Fire Station responds to all Codes on the Jackson campus and ASSA......2. Zones.....6. Zone Six (6) - Patient Property Building, Magnolia Building, 200 Building, Cedarview Unit I, Parker Building, Dorothy Dixon (D.D.) Building, Laundry, Environmental Services/Maintenance/Warehouse, Power House."

Further review of the same policy revealed a site map with the following printed on it: "Cedarview Unit I responds to all Code Blues except ASSA, ITU, and CRU with defibrillator and Code Bag."

Review of a Code Blue Record dated 6/12/2010 at 1555 (3:55 pm) revealed a Code Blue was called in the Parker Building which is connected to Cedarview Unit I Unit I by a locked door and a hall which is approximately 225 feet long. Review of the Code Blue record revealed S16RN responded to the Code Blue that was called for an employee that was found to be on the floor, in distress, diaphoretic and unresponsive. Record review revealed S16 RN from Cedarview Unit I was the Code Leader and S15 RN from Gabriel Unit I was the Code Recorder. The documentation by S16 RN revealed Acadian Ambulance arrived at 4:20 pm and a code green, return to normal operations, was called at 4:20 pm.

Review of the RN staffing sheet on 6/12/2010 for Cedarview Unit I and the 6:00 am to 6:00 pm Nursing Location Sheet revealed S16 was the only RN assigned to Cedarview Unit I at the time the Code Blue was called at 3:55 pm. Review of the staffing sheet for Gabriel Unit I revealed S15 RN was the only RN on Gabriel Unit 1 at the time of her response to the Code Blue.

An Immediate Jeopardy situation was identified and S1 Administrator and S24 Director Quality Management were notified of the Immediate Jeopardy on 9/10/2010 at 4:30 p.m. The Immediate Jeopardy situation was a result of the facility's failure to ensure a Registered Nurse was immediately available to all patients by having a hospital policy that requires an RN assigned on a locked unit to be responsible to respond to medical emergencies on the facility grounds, other buildings, and locked units. Staffing for evenings, nights, weekends/holidays requires RN ' s assigned to locked units to leave the unit(s) with no RN and patients under the care of unlicensed personnel.

An interview was held with S15 RN on 9/10/2010 at 11:45 am. She indicated she was working on the Gabriel Unit 1 when a Code Blue was called in the Parker Building on 6/12/2010. She was unable to recall the number of patients on her unit that day. She reported the RN Building Manager instructed her to respond to the code at the Parker Building. S15 indicated she turned the keys to her locked unit over to the RN Building Manager who was also working on one of the three units in Gabriel Building when she left to respond to the Code Blue. She further indicated Gabriel consists of 3 locked units. S15 also reported that a few minutes after she had arrived at Parker Building the RN Building Manager from Gabriel whom she had given her keys to when she left the unit, was also in attendance at the Code Blue. She added this left 1 RN in Gabriel Building for 3 locked units. S15 indicated she was gone from her unit on 6/12/2010 for approximately 20 minutes. She expressed concerns about leaving one RN or no RN ' s on a unit while she responded to a Code Blue. She indicated she had spoken to the DON on numerous occasions before the 6/12/2010 code requesting clarification in writing about Code Blue attendance when there was only one RN on a unit. She added she had not received the clarification in writing she requested.

An interview was held with S16 RN on 9/9/10 at 9:05 am. She indicated she works from 7:00 am to 7:00 pm on Cedarview Unit I Unit 1. She further indicated she left Cedarview Unit I to respond to a Code Blue in the Parker Building on 6/12/2010 at 3:55 pm. She added when she left Cedarview Unit I to respond to the code, two psychiatric aids from Cedarview Unit I accompanied her to Parker Building. S16 reported no RN was on the Cedarview Unit I during her absence. She indicated a RN from Gabriel Unit 1 arrived at Parker Building to assist her about 15 minutes after the Code Blue had been called. S16 added that she was absent from Cedarview Unit I for approximately one and a half hours, which included the time for the paperwork she needed to complete for the Code Blue on 6/12/2010. She added there was no other RN available to replace her on Cedarview Unit I during her absence. S16 expressed concern about leaving her patients unattended without a nurse when she responded to the Code Blue. S16 RN added that the hospital policy requires a RN to be on each unit at all times, and also requires her to respond to a Code Blue. S16 indicated she heard by " word-of-mouth " after the 6/12/2010 Code Blue that she could remain on Cedarview Unit I if she was the only nurse on the unit. She again repeated that according to the written hospital policy she was required to respond to a Code Blue and added that if she did not respond to the code, as she had been told by " word-of-mouth " then she would be in violation of hospital policy. S16 RN reported she contacted S3 DON verbally and in writing about the code situation related to having to respond to a code and leaving her unit without a RN. She indicated neither her supervisor nor administration had informed her of a different directive other than hospital policy. S16 further indicated approximately once a week, after 3:00 pm, when the RN Building Manager is off duty and S16 is the only nurse on Cedarview Unit I, she is required to obtain narcotics/controlled medications such as Klonopin or Ativan from the pharmacy. She reported pharmacy does not deliver narcotics to Cedarview Unit I. S16 reported she notified the RN House Supervisor in the past that she needed to leave the unit to go to the pharmacy; however there was never another RN available to relieve her. She added that she needed the medications for her patients. She added it takes her about 3 minutes to get to the pharmacy and 3 minutes to return. She indicated Cedarview Unit I is left without a RN and with psychiatric aides in attendance when she has to go to the pharmacy to obtain narcotics/controlled medications. She added psychiatric aides cannot obtain narcotics from pharmacy and pharmacy does not deliver narcotics to the unit.

Review of a letter from S16 RN to S5 RN Building Manager, S3 DON, S2 Executive Nurse, S22 MD Clinical Director, S23 Assistant CEO and S1 Administrator on 6/13/2010 revealed during the Code Blue on 6/12/2010 S15RN arrived to the code approximately 5 to 10 minutes after the code was called and that the house supervisor arrived approximately 20 to 25 minutes after Code Blue had been called. She further indicated " ...it is opting [sic?] impossible and unsafely challenging to deliver proper care during the midst of a code without proper staff from nursing services ... " The documentation from the letter further revealed that according to the hospital policy and procedure guidelines, " ...A Cedarview Unit I nurse is to respond to all Code Blue emergencies on the ground as well as the clinical oversight and to the unit they are assigned to work. " The documentation revealed " ...I have been advised and informed that I am not to leave this building, which by definition means leaving a locked door between myself and the unit. If this occurs, I will be held liable for any mishaps that happen on the unit if a nurse isn ' t present ... "

Review of a letter dated 6/13/2010 from S16 RN to S5, RN Building Manager, S3 DON, S2 Executive Nurse, S22 MD Clinical Director, S23 Assistant CEO, and S1 CEO revealed a request for additional staff on weekends and when only one nurse is assigned to a unit. Further review of this letter revealed documentation of S16 RN requesting documentation of the hospital ' s policy and procedure that the staffing is correctly allocated combined with her concern about her nursing license being " ...on the line ... "

Review of an e-mail correspondence dated 6/15/2010 presented by S3 DON revealed he acknowledged receipt of the letter from S16 RN on 6/13/2010 and indicated he would discuss her concerns with the Executive Nurse. The documentation further revealed S16 RN would receive a formal response from him.

Review of a letter from S3 DON to S16 RN on 6/18/2010 revealed he questioned if the issue was of S16 RN leaving her patients or having someone accompany her to a code. The documentation further revealed " ...Nursing Administration does not factor just RN ' s into staff matrix. For instance, one RN and 5 PA ' s for 20 patients will provide a patient ratio of 1:3.3, which is an acceptable, even generous staffing when considering our units reflecting a 1:4.5 with increased acuity ... "

Further review of e-mail correspondence, furnished by the DON, between S15 RN and S3 DON revealed on 6/22/2010, S15 requested written guidelines and clarification regarding " ... leaving her unit, responding to Code Blues after hours, and on weekends since policy and procedure states that a Cedarview Unit I nurse is to respond to all codes as this was a conflict with nursing policy that indicates a RN will be on the building at all times, and who other than the grounds house manager is to respond to codes at Cedarview Unit I ... "

Review of a handwritten letter, furnished by the DON, from S15 RN to the DON dated 7/7/2010 revealed another request for a response in writing regarding Code Blues and leaving the unit since she would have been the only RN on Cedarview Unit I that weekend.

Review of a letter, furnished by the DON, from S3 DON to S15 RN 7/9/2010 with carbon copies to S2 Executive Nurse and the Administrator revealed the following guidelines the East Division Nursing Management Team is currently using: " ...When only one nurse is on Cedarview Unit I, the nurse on Cedarview Unit I will respond to Code Blues on Cedarview Unit I and Parker only. However, should a catastrophic crisis occur, as always follow the directives of your supervisor. The house manager/ designee will go to Cedarview Unit I, retrieve the code bag and transport the code bag to the Code Blue site. Both of Evangeline and Gabriel are required to assign one nurse each shift to respond to Code Blues at the east division. Thus, you were assured to have additional staff should a Code Blue occur in your area. Should you need additional clarification, you may contact your RN Manager ... "

Review of the Executive Nurse Council, East Division Meeting Minutes on 7/01/2010 revealed a sign in sheet for the attendance at the meeting were S3 DON, S5 RN Cedarview Unit I House Manager, S6 RN Gabriel House Manager, S4, RN Evangeline House Manager, S8 RN Night House Supervisor. Review of the agenda for the meeting revealed Code Blue had been discussed. Further review of the meeting minutes revealed " ... When there is only one nurse on Cedarview Unit I, the Cedarview Unit I nurse cannot be responsible for attending Code Blues on other buildings. For all future Code Blues, a nurse must be assigned each shift from Evangeline and Gabriel Buildings to assist in all Code Blues, wherever located. This means the RN Manager/designee will get the code bag/Life-pak from Cedarview Unit I and bring it to the code site. The other two nurses are who are assigned from EH (Evangeline) and GH (Gabriel) will attend the code as well due to the downsizing of the East division. The Code Blue Policy is awaiting revision. The building managers indicated they are aware of this procedure. The RN Managers are to educate their staff on these procedures ... "

Review of the Staff Meeting minutes for June 2010 that S6 RN Gabriel House Manager for Gabriel House presented revealed documentation she informed her staff that " ...Per S3 DON: Effective immediately when a Code Blue is called the house manager must respond and go to Cedarview Unit I clinic and get the code bag, then report to the location of the code. "

An interview was held with S6 RN Gabriel House Manager on 9/7/2010 at 1:55 PM. She indicated all RN ' s are assigned to a specific zone in the event of a Code Blue. She added that with the downsizing, or closing of Cedarview Unit II, for patients and staff, the DON had instructed the managers to assign a RN to respond to Code Blues on the campus. S6 RN further indicated she had no documentation or policy from the DON about the RN assignments. S6 RN added there should be a RN on each unit at all times. She indicated one RN cannot cover a unit and also respond to a Code Blue on another unit.

Review of the Nurse ' s Meetings for Cedarview Unit I for June, July and August 2010 revealed no documentation the staff nurses had been informed of the Executive Nurse Council, East Division Meeting on 7/01/2010 that a RN from Cedarview Unit I would not be expected to attend a Code Blue on a different unit if she were the only RN on Cedarview Unit I.

An interview was held with S5, RN Cedarview Building Manager on 9/7/10 at 12:45 pm. She indicated she was not certain of the final outcome from the Executive Nurse Council, East Division Meeting on 7/01/2010 that she attended about RN response to Code Blue, as she had not been notified in writing by upper management. She further indicated she had received nothing in writing about a change in hospital policy relating to Code Blue. She added she had verbally informed her staff about not responding to a Code Blue if they were the only RN on the unit. She had nothing in writing from Nursing Administration to support this directive. S5 indicated she had no documentation in her monthly meeting minutes to indicate that she had informed her staff about not responding to a Code Blue if there was only one RN on Cedarview Unit I. She added her staff knows to notify administration if there is only one nurse on the unit from a directive given by S3 DON. S5 RN Building Manager indicated she works 8 hour shifts and leaves the unit at 3:00 pm Monday through Friday. She reported when she is off work at 3:00 pm Cedarview Unit I has one RN on the unit. An additional interview was held with S5 RN Cedarview Building Manager on 9/10/2010. She indicated she had discussed her nurses concerns about the Code Blue response with S3 DON in June 2010 after the downsizing, closing, of Cedarview Unit II.

A telephone interview was conducted with S9 RN House Supervisor on 9/10/2010 at 9:05 am. He indicated that as the house supervisor he was responsible for the entire hospital during his shift. He indicated as of this conversation, a lone Cedarview Unit I RN cannot respond to a code on another unit. He added he had received verbal communication that this is what was expected but had received nothing in writing. S9 RN reported he attends all codes when he is on duty. He further indicated he visits all units in the hospital during his shift when he is not covering a unit as a staff nurse. S9 RN House Supervisor added when he works as a staff nurse he also is the house supervisor. He indicated he works as a staff nurse/house supervisor approximately 10% to 15% of his shifts. He further indicated in the event that a problem arises that he needs to respond to as the house supervisor, he would have to leave the unit he was covering if there was not another RN to cover his unit.

An interview was held with S2 RN Executive Nurse on 9/7/10 at 1:10 pm. She indicated there is only one RN staff nurse on Cedarview Unit I and 1 RN Building Manager on Cedarview Unit I who leaves at 3:00 pm Monday through Friday. She further indicated the most current revision to the hospital policy related to Code Blue was adopted on 12/18/2008. S2 RN added the DON met with the RN Managers on 7/01/2010 at the Executive Nurse Council, East Division Meeting Minutes and according to the meeting minutes " ... When there is only one nurse on Cedarview Unit I, the Cedarview Unit I nurse cannot be responsible for attending Code Blues on other buildings. For all future Code Blues, a nurse must be assigned each shift from Evangeline and Gabriel Buildings to assist in all Code Blues, wherever located. This means the RN Manager/designee will get the code bag/Life-pak from Cedarview Unit I and bring it to the code site. The other two nurses that are assigned from EH (Evangeline) and GH (Gabriel) will attend the code as well due to the downsizing if the East division. The Code Blue Policy is awaiting revision. The building managers indicated they are aware of this procedure. The RN Managers are to educate their staff on these procedures ... " She indicated the only code change was from a verbal directive from the Nursing Division about how Code Blues were to be handled on the East Division. She indicated there was nothing in writing related to this directive that had been given to all staff at the hospital. S2RN Executive Nurse reported the verbal directive to nursing staff never went to the Governing Body to become policy.

An interview was held with S2, Executive Nurse and S3 DON on 9/8/10 at 9:15 am. After review of the System Nursing Leadership Council Meeting on 8/18/2010 they indicated the issue about Code Blue had not been discussed because the attendance at the meeting did not have a quorum. S3 DON indicated that a RN is alone on the units from 3:45 pm, when the day RN Building Manager leaves for the day, to 6:45pm when the evening RN House Supervisor comes to work. He further indicated that the nursing department does not have the authority to change hospital policy; however they can make recommendations to the Governing Body. He added that nurses should always follow hospital policy. S3 indicated he had addressed the Code Blue concerns at the 7/1/2010 meeting with the RN Managers. S3 DON indicated he had instructed all the RN Managers to notify the staff nurses that if they were the only nurse on a unit they were not expected to respond to a Code Blue. He indicated that he had no documentation from the RN Managers that all staff had been informed after the 7/01/2010 meeting. He further indicated that he did not have a written directive or revised code policy for the RN Managers to disseminate to their staff. S3 DON could offer no explanation why a written directive to the nursing staff had not been issued. S2 and S3 reported that the hospital policy was different than the meeting minutes he and the RN Managers discussed at the 7/01/2010 meeting. S3 DON added that he expects staff to follow the most current directive until hospital policy can be changed. S3 DON indicated he had also spoken to S13 Medical Director in approximately June of 2010 about revision to the Code Blue policy. As of the survey entrance on 09/07/2010 the policy had not been revised and approved by the Governing Body.

An additional interview was held with S2, Executive Nurse and S3 DON on 9/8/10 at 9:55 am. After a view of the Code Blue that occurred in Parker Building on 6/12/2010 they indicated that two nurses from Gabriel had also responded to the code. They acknowledge that when S15 RN and S16 RN responded to that Code Blue the patients on their assigned units of Cedarview Unit I and Gabriel Unit I were left without a RN and their patients were left in the care of psychiatric aides.

A telephone interview was held with S2 Executive Nurse on 9/9/2010 at 10:10 am. She indicated in the event that a RN was required to obtain narcotics from the pharmacy; the RN should call the house manager for coverage so that she/he would not leave the unit without a RN. She further indicated that the unit would not be fully staffed if the only RN on the unit attends a Code Blue on another locked unit. S2 indicated the hospital policy and procedure is that a RN is to oversee the care of patients but added there was no specific policy related to the only RN leaving a locked unit to respond to a Code Blue or to obtain medications from the pharmacy.

An interview was held with S13 Medical Director on 9/08/2010 at 10:10 am. She indicated Cedarview Unit II had been closed 5/10/2010 due to consolidating and closing of units and that the code situation had been addressed when the last patients left Cedarview Unit II. She further indicated that Cedarview Unit I is the only unit now open in the Cedarview Building. S13 reported she had verbally discussed the Code Blue response with the Administrator and the DON in approximately June of 2010. She indicated it had been decided that the house supervisor was to get the code pack that included the Life pack and drugs to bring to a code. She further indicated this was a temporary fix until policy and procedures could be changed and approved by the Medical Executive Committee. S13 indicated there was no Medical Executive Committee meeting in July 2010. She further indicated that as of this interview the hospital policy and procedure related to Code Blue and RN responses had not been changed.

During an interview with S1 Administrator on 9/7/10 at 2:10 pm he indicated that after 3:00 pm when the RN Managers are off duty, there is one RN assigned to each unit. He indicated that staff RN ' s, LPN ' s and psychiatric aides work 12 hours shifts at the hospital. He added a RN cannot leave a unit unattended. He further indicated the Executive Nurse has the authority to change policy for nursing with either a verbal or written directive after approval from Administration or the Governing Body. He clarified that a nursing directive is different from hospital policy. S1 Administrator indicated he would have expected a policy change request or directive from Nursing Administration to go out to staff for a life threatening situation. He reported the Medical Director had been working on revisions to the hospital ' s policy and procedure relating to the code policy, but had been out on extensive leave because of a tragedy. He added that he should have given this responsibility to someone else.

The Immediate Jeopardy was removed on 9/14/10 at 11:45 am after an acceptable Plan of Removal that included:

1. Code Blue Policy and Procedure revised.

Revisions included

a. Assignment to bring Code bag with Lifepak from Control center at Bienville is the responsibility of the Emergency Response Team (ERT). At the beginning of each shift the shift Captain will assign an ERT member the responsibility for the entire shift.
b. Clarified that RN ' s will respond to all codes in their " Zones " unless they are the only Nurse assigned to a ward or Unit.
c. At the beginning of each shift a Registered Nurse will be assigned as the " floating " Nurse and assigned the responsibility of responding to all Code Blues.
d. All Nursing staff in TQM (total quality management), Education and Administration will respond to all Code Blues.
e. The Clinic Nursing Staff will respond to all Code Blues.

2. Code Blue Policy and Procedure approved by Medical Executive committee and Chief Executive Officer. Committee meeting at 10:30 a.m. 09/14/10.

3. Revised policy disseminated to Nurse Managers and Majors. Nurse managers meeting 09/14/10.

a. Managers given the responsibility to disseminate to all shifts.
b. Managers passed new revised Code Blue policy to all staff, noting key changes.
c. Staff signed acknowledgement / verification of receipt forms.
d. Nursing staff monitored all signed forms and compared to Table of Organization to ensure all Nursing staff have been advised.
e. Distribution of new policy will start today 09/14/10 with day shift and will be completed on Night shift today 09/14/10 prior to Nursing taken [sic] shift at night. The next two teams/shifts will be trained on Thursday 09/16/10 prior to accepting the ward.
f. Nursing staff that is off during the initial training will be trained upon return and prior to taking a ward.

4. Code Blues will be monitored and documented by TQM staff to ensure policy and procedure followed. Monitoring conducted by Code Blue Multi-Disciplinary Review and kept on hand with Medical Director. The review is an analysis of the code.

5. Nursing Administration will conduct random daily surveys for Nursing staff for a three week period or until 100% achieved compliance noted. After three weeks and 100% compliance then we will revert to weekly random Survey ' s for 3 months or until 100% compliance achieved [sic].

6. New revised Code Blue policy will be distributed as part of initial orientation and Nurse competency training. Records maintained by Staff Education and Training Department.

7. New revised Code Blue policy will be posted to the ELMHS intranet site.

An interview was held on 9/09/2010 at 1:40 pm with S24 and S24 Quality Assurance. They indicated QA had not identified any staffing problems relating to RN Code Blue responses. S24 Director of Quality indicated she had heard from S2 Executive Nurse about the Nurse Council, East Division Meeting on 7/01/2010. She further indicated about one month ago she found out about the " situation " when the hospital had responded to an inquiry from state office on 7/14/2010 about concerns of nurses that were assigned to Cedarview Unit I leaving patients to respond to a Code Blue. She added there was no performance indicators related to staffing for Code Blue RN responses by the Quality Assurance Department.

Review of the Medical Executive Committee meeting minutes revealed no meeting was held in June 2010 and the meeting held in July 2010 revealed the only agenda item discussed was credentialing. The August 2010 meeting minutes revealed the June 2010 Code Blue had been discussed. The documentation revealed the Code Blue was " ...non- life threatening medical emergency ... " Further review revealed no documentation related to revisions to the hospital policy about locked units being left unattended by a RN and patients being left in the care of psychiatric aides when a RN responds to a medical emergency.

Based on observation and interview the hospital failed to ensure the facilities are maintained to acceptable level of safety and quality by 1) having a wasp nest with live wasps on it in 1 of 2 seclusion rooms 2) having spots of the ceiling falling in the hallway between Cedarview and Parker buildings and 3) having a hole in the ceiling in the Cedarview building. Findings:

1) On 09/07/10 at 11:15 a.m. an observation was made in the Cedarview building in 1 of 2 seclusion rooms that there was a wasp nest with live wasps on it near the window area.

This finding was confirmed by S12RN at the time of the finding.

2) On 09/08/10 at 10:00 a.m. an observation was made in the hallway between Parker building and Cedarview building that there were in the ceiling measuring approximately 2' X3'; 1' X 8'; 1' X 10'; and a 2' round hole.

These findings were confirmed by the DON at the time of the finding.

3) On 09/07/10 at 11:10 a.m. an observation was made in the Cedarview building that the ceiling above the Day Room had 2 holes measuring approximately 2' X 1'.

These findings were confirmed by S14PA at the time of the finding.

Based on record review and interviews the hospital failed to ensure every inpatient unit within the hospital maintained a Registered Nurse (RN) physically present in each patient unit to ensure the immediate availability of a RN for the bedside care of each patient. This was evidenced by 1) the only RN assigned to Cedarview Unit 1 and the only RN assigned to Gabriel Unit 1 leaving their assigned locked units on 06/12/10 at 3:55 p.m. to respond to a Code Blue, leaving 52 patients in the care of unlicensed personnel 2) assigning only an LPN (Licensed Practical Nurse) to a locked unit without direct RN supervision for 83 of 184 shifts reviewed between 6/01/ 2010 and 8/31/2010 and 3) the hospital allowing a RN to leave the patient unit, without having another RN cover the unit, when the RN was required to go to pharmacy to obtain patient medications. Findings:


1) Review of a Code Blue Response of the current hospital policy titled Code Blue, policy MS-03, effective 08/29/06, last revised 12/01/08, approved 12/18/08, and presented as current hospital policy reads in part: "II. Purpose. A. The purpose of this policy is to provide clear and consistent protocol to secure immediate medical response and coordination of care, including necessary mobilization of additional medical services for patients, visitors and staff at Eastern Louisiana Mental Health System (ELMHS).....III. Scope. System wide management of imminent medical emergencies at Eastern Louisiana Mental Health System Campuses, excluding Forensic After Care Clinic. IV. Policy. It is the policy of East Louisiana Mental Health System to initiate a "Code Blue" when there is a requirement for Advanced Cardiac Life Support (ACLS), Basic Life Support (BLS), use of the Heimlich maneuver, or any other medical emergency that requires restoration of respiration. V. Procedure. B. Code Response. 1. Personnel....c. Cedarview Unit I will respond to all code activations on the Jackson campus, with the exception of CRU, ITU, and ASSA. (forensic units) d. Fire Station responds to all Codes on the Jackson campus and ASSA......2. Zones.....6. Zone Six (6) - Patient Property Building, Magnolia Building, 200 Building, Cedarview Unit I, Parker Building, Dorothy Dixon (D.D.) Building, Laundry, Environmental Services/Maintenance/Warehouse, Power House."

Further review of the same policy revealed a site map with the following printed on it: "Cedarview Unit I responds to all Code Blues except ASSA, ITU, and CRU with defibrillator and Code Bag."

Review of a Code Blue Record dated 6/12/2010 at 1555 (3:55 pm) revealed a Code Blue was called in the Parker Building which is connected to Cedarview Unit I Unit I by a locked door and a hall which is approximately 225 feet long. Review of the Code Blue record revealed S16RN responded to the Code Blue that was called for an employee that was found to be on the floor, in distress, diaphoretic and unresponsive. Record review revealed S16 RN from Cedarview Unit I was the Code Leader and S15 RN from Gabriel Unit I was the Code Recorder. The documentation by S16 RN revealed Acadian Ambulance arrived at 4:20 pm and a code green, return to normal operations, was called at 4:20 pm.

Review of the RN staffing sheet on 6/12/2010 for Cedarview Unit I and the 6:00 am to 6:00 pm Nursing Location Sheet revealed S16 was the only RN assigned to Cedarview Unit I at the time the Code Blue was called at 3:55 pm. Review of the staffing sheet for Gabriel Unit I revealed S15 RN was the only RN on Gabriel Unit 1 at the time of her response to the Code Blue. (Gabriel Unit and Parker Hall are approximately 600 - 700 feet apart)

An Immediate Jeopardy situation was identified and S1 Administrator and S24 Director Quality Management were notified of the Immediate Jeopardy on 9/10/2010 at 4:30 p.m. The Immediate Jeopardy situation was a result of the facility's failure to ensure a Registered Nurse was immediately available to all patients by having a hospital policy that requires an RN assigned on a locked unit to be responsible to respond to medical emergencies on the facility grounds, other buildings, and locked units. Staffing for evenings, nights, weekends/holidays requires RN ' s assigned to locked units to leave the unit(s) with no RN and patients under the care of unlicensed personnel.

An interview was held with S15 RN on 9/10/2010 at 11:45 am. She indicated she was working on the Gabriel Unit 1 when a Code Blue was called in the Parker Building on 6/12/2010. She was unable to recall the number of patients on her unit that day. She reported the RN Building Manager instructed her to respond to the code at the Parker Building. S15 indicated she turned the keys to her locked unit over to the RN Building Manager who was also working on one of the three units in Gabriel Building when she left to respond to the Code Blue. She further indicated Gabriel consists of 3 locked units. S15 also reported that a few minutes after she had arrived at Parker Building the RN Building Manager from Gabriel whom she had given her keys to when she left the unit, was also in attendance at the Code Blue. She added this left 1 RN in Gabriel Building for 3 locked units. S15 indicated she was gone from her unit on 6/12/2010 for approximately 20 minutes. She expressed concerns about leaving one RN or no RN ' s on a unit while she responded to a Code Blue. She indicated she had spoken to the DON on numerous occasions before the 6/12/2010 code requesting clarification in writing about Code Blue attendance when there was only one RN on a unit. She added she had not received the clarification in writing she requested.

An interview was held with S16 RN on 9/9/10 at 9:05 am. She indicated she works from 7:00 am to 7:00 pm on Cedarview Unit I Unit 1. She further indicated she left Cedarview Unit I to respond to a Code Blue in the Parker Building on 6/12/2010 at 3:55 pm. She added when she left Cedarview Unit I to respond to the code, two psychiatric aids from Cedarview Unit I accompanied her to Parker Building. S16 reported no RN was on the Cedarview Unit I during her absence. She indicated a RN from Gabriel Unit 1 arrived at Parker Building to assist her about 15 minutes after the Code Blue had been called. S16 added that she was absent from Cedarview Unit I for approximately one and a half hours, which included the time for the paperwork she needed to complete for the Code Blue on 6/12/2010. She added there was no other RN available to replace her on Cedarview Unit I during her absence. S16 expressed concern about leaving her patients unattended without a nurse when she responded to the Code Blue. S16 RN added that the hospital policy requires a RN to be on each unit at all times, and also requires her to respond to a Code Blue. S16 indicated she heard by " word-of-mouth " after the 6/12/2010 Code Blue that she could remain on Cedarview Unit I if she was the only nurse on the unit. She again repeated that according to the written hospital policy she was required to respond to a Code Blue and added that if she did not respond to the code, as she had been told by " word-of-mouth " then she would be in violation of hospital policy. S16 RN reported she contacted S3 DON verbally and in writing about the code situation related to having to respond to a code and leaving her unit without a RN. She indicated neither her supervisor nor administration had informed her of a different directive other than hospital policy. S16 further indicated approximately once a week, after 3:00 pm, when the RN Building Manager is off duty and S16 is the only nurse on Cedarview Unit I, she is required to obtain narcotics/controlled medications such as Klonopin or Ativan from the pharmacy. She reported pharmacy does not deliver narcotics to Cedarview Unit I. S16 reported she notified the RN House Supervisor in the past that she needed to leave the unit to go to the pharmacy; however there was never another RN available to relieve her. She added that she needed the medications for her patients. She added it takes her about 3 minutes to get to the pharmacy and 3 minutes to return. She indicated Cedarview Unit I is left without a RN and with psychiatric aides in attendance when she has to go to the pharmacy to obtain narcotics/controlled medications. She added psychiatric aides cannot obtain narcotics from pharmacy and pharmacy does not deliver narcotics to the unit.

Review of a letter from S16 RN to S5 RN Building Manager, S3 DON, S2 Executive Nurse, S22 MD Clinical Director, S23 Assistant CEO and S1 Administrator on 6/13/2010 revealed during the Code Blue on 6/12/2010 S15RN arrived to the code approximately 5 to 10 minutes after the code was called and that the house supervisor arrived approximately 20 to 25 minutes after Code Blue had been called. She further indicated " ...it is opting [sic?] impossible and unsafely challenging to deliver proper care during the midst of a code without proper staff from nursing services ... " The documentation from the letter further revealed that according to the hospital policy and procedure guidelines, " ...A Cedarview Unit I nurse is to respond to all Code Blue emergencies on the ground as well as the clinical oversight and to the unit they are assigned to work. " The documentation revealed " ...I have been advised and informed that I am not to leave this building, which by definition means leaving a locked door between myself and the unit. If this occurs, I will be held liable for any mishaps that happen on the unit if a nurse isn ' t present ... "

Review of a letter dated 6/13/2010 from S16 RN to S5, RN Building Manager, S3 DON, S2 Executive Nurse, S22 MD Clinical Director, S23 Assistant CEO, and S1 CEO revealed a request for additional staff on weekends and when only one nurse is assigned to a unit. Further review of this letter revealed documentation of S16 RN requesting documentation of the hospital ' s policy and procedure that the staffing is correctly allocated combined with her concern about her nursing license being " ...on the line ... "

Review of an e-mail correspondence dated 6/15/2010 presented by S3 DON revealed he acknowledged receipt of the letter from S16 RN on 6/13/2010 and indicated he would discuss her concerns with the Executive Nurse. The documentation further revealed S16 RN would receive a formal response from him.

Review of a letter from S3 DON to S16 RN on 6/18/2010 revealed he questioned if the issue was of S16 RN leaving her patients or having someone accompany her to a code. The documentation further revealed " ...Nursing Administration does not factor just RN ' s into staff matrix. For instance, one RN and 5 PA ' s for 20 patients will provide a patient ratio of 1:3.3, which is an acceptable, even generous staffing when considering our units reflecting a 1:4.5 with increased acuity ... "

Further review of e-mail correspondence, furnished by the DON, between S15 RN and S3 DON revealed on 6/22/2010, S15 requested written guidelines and clarification regarding " ... leaving her unit, responding to Code Blues after hours, and on weekends since policy and procedure states that a Cedarview Unit I nurse is to respond to all codes as this was a conflict with nursing policy that indicates a RN will be on the building at all times, and who other than the grounds house manager is to respond to codes at Cedarview Unit I ... "

Review of a handwritten letter, furnished by the DON, from S15 RN to the DON dated 7/7/2010 revealed another request for a response in writing regarding Code Blues and leaving the unit since she would have been the only RN on Cedarview Unit I that weekend.

Review of a letter, furnished by the DON, from S3 DON to S15 RN 7/9/2010 with carbon copies to S2 Executive Nurse and the Administrator revealed the following guidelines the East Division Nursing Management Team is currently using: " ...When only one nurse is on Cedarview Unit I, the nurse on Cedarview Unit I will respond to Code Blues on Cedarview Unit I and Parker only. However, should a catastrophic crisis occur, as always follow the directives of your supervisor. The house manager/ designee will go to Cedarview Unit I, retrieve the code bag and transport the code bag to the Code Blue site. Both of Evangeline and Gabriel are required to assign one nurse each shift to respond to Code Blues at the east division. Thus, you were assured to have additional staff should a Code Blue occur in your area. Should you need additional clarification, you may contact your RN Manager ... "

Review of the Executive Nurse Council, East Division Meeting Minutes on 7/01/2010 revealed a sign in sheet for the attendance at the meeting were S3 DON, S5 RN Cedarview Unit I House Manager, S6 RN Gabriel House Manager, S4, RN Evangeline House Manager, S8 RN Night House Supervisor. Review of the agenda for the meeting revealed Code Blue had been discussed. Further review of the meeting minutes revealed " ... When there is only one nurse on Cedarview Unit I, the Cedarview Unit I nurse cannot be responsible for attending Code Blues on other buildings. For all future Code Blues, a nurse must be assigned each shift from Evangeline and Gabriel Buildings to assist in all Code Blues, wherever located. This means the RN Manager/designee will get the code bag/Life-pak from Cedarview Unit I and bring it to the code site. The other two nurses are who are assigned from EH (Evangeline) and GH (Gabriel) will attend the code as well due to the downsizing of the East division. The Code Blue Policy is awaiting revision. The building managers indicated they are aware of this procedure. The RN Managers are to educate their staff on these procedures ... "

Review of the Staff Meeting minutes for June 2010 that S6 RN Gabriel House Manager for Gabriel House presented revealed documentation she informed her staff that " ...Per S3 DON: Effective immediately when a Code Blue is called the house manager must respond and go to Cedarview Unit I clinic and get the code bag, then report to the location of the code. "

An interview was held with S6 RN Gabriel House Manager on 9/7/2010 at 1:55 PM. She indicated all RN ' s are assigned to a specific zone in the event of a Code Blue. She added that with the downsizing, or closing of Cedarview Unit II, for patients and staff, the DON had instructed the managers to assign a RN to respond to Code Blues on the campus. S6 RN further indicated she had no documentation or policy from the DON about the RN assignments. S6 RN added there should be a RN on each unit at all times. She indicated one RN cannot cover a unit and also respond to a Code Blue on another unit.

Review of the Nurse ' s Meetings for Cedarview Unit I for June, July and August 2010 revealed no documentation the staff nurses had been informed of the Executive Nurse Council, East Division Meeting on 7/01/2010 that a RN from Cedarview Unit I would not be expected to attend a Code Blue on a different unit if she were the only RN on Cedarview Unit I.

An interview was held with S5, RN Cedarview Building Manager on 9/7/10 at 12:45 pm. She indicated she was not certain of the final outcome from the Executive Nurse Council, East Division Meeting on 7/01/2010 that she attended about RN response to Code Blue, as she had not been notified in writing by upper management. She further indicated she had received nothing in writing about a change in hospital policy relating to Code Blue. She added she had verbally informed her staff about not responding to a Code Blue if they were the only RN on the unit. She had nothing in writing from Nursing Administration to support this directive. S5 indicated she had no documentation in her monthly meeting minutes to indicate that she had informed her staff about not responding to a Code Blue if there was only one RN on Cedarview Unit I. She added her staff knows to notify administration if there is only one nurse on the unit from a directive given by S3 DON. S5 RN Building Manager indicated she works 8 hour shifts and leaves the unit at 3:00 pm Monday through Friday. She reported when she is off work at 3:00 pm Cedarview Unit I has one RN on the unit. An additional interview was held with S5 RN Cedarview Building Manager on 9/10/2010. She indicated she had discussed her nurses concerns about the Code Blue response with S3 DON in June 2010 after the downsizing, closing, of Cedarview Unit II.

A telephone interview was conducted with S9 RN House Supervisor on 9/10/2010 at 9:05 am. He indicated that as the house supervisor he was responsible for the entire hospital during his shift. He indicated as of this conversation, a lone Cedarview Unit I RN cannot respond to a code on another unit. He added he had received verbal communication that this is what was expected but had received nothing in writing. S9 RN reported he attends all codes when he is on duty. He further indicated he visits all units in the hospital during his shift when he is not covering a unit as a staff nurse. S9 RN House Supervisor added when he works as a staff nurse he also is the house supervisor. He indicated he works as a staff nurse/house supervisor approximately 10% to 15% of his shifts. He further indicated in the event that a problem arises that he needs to respond to as the house supervisor, he would have to leave the unit he was covering if there was not another RN to cover his unit.

An interview was held with S2 RN Executive Nurse on 9/7/10 at 1:10 pm. She indicated there is only one RN staff nurse on Cedarview Unit I and 1 RN Building Manager on Cedarview Unit I who leaves at 3:00 pm Monday through Friday. She further indicated the most current revision to the hospital policy related to Code Blue was adopted on 12/18/2008. S2 RN added the DON met with the RN Managers on 7/01/2010 at the Executive Nurse Council, East Division Meeting Minutes and according to the meeting minutes " ... When there is only one nurse on Cedarview Unit I, the Cedarview Unit I nurse cannot be responsible for attending Code Blues on other buildings. For all future Code Blues, a nurse must be assigned each shift from Evangeline and Gabriel Buildings to assist in all Code Blues, wherever located. This means the RN Manager/designee will get the code bag/Life-pak from Cedarview Unit I and bring it to the code site. The other two nurses that are assigned from EH (Evangeline) and GH (Gabriel) will attend the code as well due to the downsizing if the East division. The Code Blue Policy is awaiting revision. The building managers indicated they are aware of this procedure. The RN Managers are to educate their staff on these procedures ... " She indicated the only code change was from a verbal directive from the Nursing Division about how Code Blues were to be handled on the East Division. She indicated there was nothing in writing related to this directive that had been given to all staff at the hospital. S2RN Executive Nurse reported the verbal directive to nursing staff never went to the Governing Body to become policy.

An interview was held with S2, Executive Nurse and S3 DON on 9/8/10 at 9:15 am. After review of the System Nursing Leadership Council Meeting on 8/18/2010 they indicated the issue about Code Blue had not been discussed because the attendance at the meeting did not have a quorum. S3 DON indicated that a RN is alone on the units from 3:45 pm, when the day RN Building Manager leaves for the day, to 6:45 p.m. when the evening RN House Supervisor comes to work. He further indicated that the nursing department does not have the authority to change hospital policy; however they can make recommendations to the Governing Body. He added that nurses should always follow hospital policy. S3 indicated he had addressed the Code Blue concerns at the 7/1/2010 meeting with the RN Managers. S3 DON indicated he had instructed all the RN Managers to notify the staff nurses that if they were the only nurse on a unit they were not expected to respond to a Code Blue. He indicated that he had no documentation from the RN Managers that all staff had been informed after the 7/01/2010 meeting. He further indicated that he did not have a written directive or revised code policy for the RN Managers to disseminate to their staff. S3 DON could offer no explanation why a written directive to the nursing staff had not been issued. S2 and S3 reported that the hospital policy was different than the meeting minutes he and the RN Managers discussed at the 7/01/2010 meeting. S3 DON added that he expects staff to follow the most current directive until hospital policy can be changed. S3 DON indicated he had also spoken to S13 Medical Director in approximately June of 2010 about revision to the Code Blue policy. As of the survey entrance on 09/07/2010 the policy had not been revised and approved by the Governing Body.

An additional interview was held with S2, Executive Nurse and S3 DON on 9/8/10 at 9:55 am. After a view of the Code Blue that occurred in Parker Building on 6/12/2010 they indicated that two nurses from Gabriel had also responded to the code. They acknowledge that when S15 RN and S16 RN responded to that Code Blue the patients on their assigned units of Cedarview Unit I and Gabriel Unit I were left without a RN and their patients were left in the care of psychiatric aides.

A telephone interview was held with S2 Executive Nurse on 9/9/2010 at 10:10 am. She indicated in the event that a RN was required to obtain narcotics from the pharmacy; the RN should call the house manager for coverage so that she/he would not leave the unit without a RN. She further indicated that the unit would not be fully staffed if the only RN on the unit attends a Code Blue on another locked unit. S2 indicated the hospital policy and procedure is that a RN is to oversee the care of patients but added there was no specific policy related to the only RN leaving a locked unit to respond to a Code Blue or to obtain medications from the pharmacy.

An interview was held with S13 Medical Director on 9/08/2010 at 10:10 am. She indicated Cedarview Unit II had been closed 5/10/2010 due to consolidating and closing of units and that the code situation had been addressed when the last patients left Cedarview Unit II. She further indicated that Cedarview Unit I is the only unit now open in the Cedarview Building. S13 reported she had verbally discussed the Code Blue response with the Administrator and the DON in approximately June of 2010. She indicated it had been decided that the house supervisor was to get the code pack that included the Life pack and drugs to bring to a code. She further indicated this was a temporary fix until policy and procedures could be changed and approved by the Medical Executive Committee. S13 indicated there was no Medical Executive Committee meeting in July 2010. She further indicated that as of this interview the hospital policy and procedure related to Code Blue and RN responses had not been changed.

During an interview with S1 Administrator on 9/7/10 at 2:10 pm he indicated that after 3:00 pm when the RN Managers are off duty, there is one RN assigned to each unit. He indicated that staff RN ' s, LPN ' s and psychiatric aides work 12 hours shifts at the hospital. He added a RN cannot leave a unit unattended. He further indicated the Executive Nurse has the authority to change policy for nursing with either a verbal or written directive after approval from Administration or the Governing Body. He clarified that a nursing directive is different from hospital policy. S1 Administrator indicated he would have expected a policy change request or directive from Nursing Administration to go out to staff for a life threatening situation. He reported the Medical Director had been working on revisions to the hospital ' s policy and procedure relating to the code policy, but had been out on extensive leave because of a tragedy. He added that he should have given this responsibility to someone else.

The Immediate Jeopardy was removed on 9/14/10 at 11:45 am after an acceptable Plan of Removal that included:

1. Code Blue Policy and Procedure revised.

Revisions included

a. Assignment to bring Code bag with Lifepak from Control center at Bienville is the responsibility of the Emergency Response Team (ERT). At the beginning of each shift the shift Captain will assign an ERT member the responsibility for the entire shift.
b. Clarified that RN ' s will respond to all codes in their " Zones " unless they are the only Nurse assigned to a ward or Unit.
c. At the beginning of each shift a Registered Nurse will be assigned as the " floating " Nurse and assigned the responsibility of responding to all Code Blues.
d. All Nursing staff in TQM (total quality management), Education and Administration will respond to all Code Blues.
e. The Clinic Nursing Staff will respond to all Code Blues.

2. Code Blue Policy and Procedure approved by Medical Executive committee and Chief Executive Officer. Committee meeting at 10:30 a.m. 09/14/10.

3. Revised policy disseminated to Nurse Managers and Majors. Nurse managers meeting 09/14/10.

a. Managers given the responsibility to disseminate to all shifts.
b. Managers passed new revised Code Blue policy to all staff, noting key changes.
c. Staff signed acknowledgement / verification of receipt forms.
d. Nursing staff monitored all signed forms and compared to Table of Organization to ensure all Nursing staff have been advised.
e. Distribution of new policy will start today 09/14/10 with day shift and will be completed on Night shift today 09/14/10 prior to Nursing taken [sic] shift at night. The next two teams/shifts will be trained on Thursday 09/16/10 prior to accepting the ward.
f. Nursing staff that is off during the initial training will be trained upon return and prior to taking a ward.

4. Code Blues will be monitored and documented by TQM staff to ensure policy and procedure followed. Monitoring conducted by Code Blue Multi-Disciplinary Review and kept on hand with Medical Director. The review is an analysis of the code.

5. Nursing Administration will conduct random daily surveys for Nursing staff for a three week period or until 100% achieved compliance noted. After three weeks and 100% compliance then we will revert to weekly random Survey ' s for 3 months or until 100% compliance achieved [sic].

6. New revised Code Blue policy will be distributed as part of initial orientation and Nurse competency training. Records maintained by Staff Education and Training Department.

7. New revised Code Blue policy will be posted to the ELMHS intranet site.

An interview was held on 9/09/2010 at 1:40 pm with S24 and S24 Quality Assurance. They indicated QA had not identified any staffing problems relating to RN Code Blue responses. S24 Director of Quality indicated she had heard from S2 Executive Nurse about the Nurse Council, East Division Meeting on 7/01/2010. She further indicated about one month ago she found out about the " situation " when the hospital had responded to an inquiry from state office on 7/14/2010 about concerns of nurses that were assigned to Cedarview Unit I leaving patients to respond to a Code Blue. She added there was no performance indicators related to staffing for Code Blue RN responses by the Quality Assurance Department.

Review of the Medical Executive Committee meeting minutes revealed no meeting was held in June 2010 and the meeting held in July 2010 revealed the only agenda item discussed was credentialing. The August 2010 meeting minutes revealed the June 2010 Code Blue had been discussed. The documentation revealed the Code Blue was " ...non- life threatening medical emergency ... " Further review revealed no documentation related to revisions to the hospital policy about locked units being left unattended by a RN and patients being left in the care of psychiatric aides when a RN responds to a medical emergency.


2) Review of the daily staffing sheets for June 1st, 2010 through August 31st, 2010 revealed the following:

06/03/10 S20LPN was assigned Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/03/10 S21LPN was assigned to the Unit as one of the nurses from 7 p.m. - 7 a.m. The assignments were not written on the form to indicate what unit was assigned to S21LPN.

06/04/10 S20LPN was assigned Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/04/10 S21LPN was assigned Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/08/10 S20LPN was assigned Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/08/10 S21LPN was assigned Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/09/10 S20LPN was assigned Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/09/10 S21LPN was assigned Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/12/10 S20LPN was assigned Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/12/10 S21LPN was assigned Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/13/10 S20LPN was assigned Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/13/10 S21LPN was assigned Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/14/10 S20LPN was assigned Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/14/10 S21LPN was assigned Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/17/10 S20LPN was assigned Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/17/10 S21LPN was assigned Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/18/10 S20LPN was assigned Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/18/10 S21LPN was assigned Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/22/10 S20LPN was assigned was assigned to the Unit as one of the nurses from 7 p.m. - 7 a.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

06/22/10 S21LPN was assigned Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/23/10 S20LPN was assigned to the Unit as one of the nurses from 7 a.m. - 7 p.m. The assignments were not written on the form to indicate what nurse was assigned to Unit 4.

06/23/10 S21LPN was assigned Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/26/10 S20LPN was assigned Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/26/10 S21LPN was assigned Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/27/10 S20LPN was assigned Unit 4 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

06/27/10 S21LPN was assigned Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

06/28/10 S20LPN was assigned was assigned to the Unit as one of the nurses from 7 a.m. - 7 p.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

06/28/10 S21LPN was assigned Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

07/01/10 S20LPN was assigned Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

07/02/10 S20LPN was assigned Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

07/03/10 S21LPN was assigned Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/04/10 S21LPN was assigned Unit 2 from 7 p.m. - 7 a.m. and Unit 4 from 7 p.m. - 10 p.m. with no RN to supervise patient care.

07/06/10 S20LPN was assigned was assigned to the Unit as one of the nurses from 7 a.m. - 7 a.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

07/06/10 S21LPN was assigned Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/07/10 S20LPN was assigned was assigned to the Unit as one of the nurses from 7 a.m. - 7 a.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

07/07/10 S21LPN was assigned Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/10/10 S20LPN was assigned was assigned to the Unit as one of the nurses from 7 a.m. - 7 a.m. The assignments were not written on the form to indicate what unit was assigned to S20LPN.

07/10/10 S21LPN was assigned Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/11/10 S20LPN was assigned Unit 2 from 7 a.m. - 7 p.m. with no RN to supervise patient care.

07/11/10 S21LPN was assigned Unit 2 from 7 p.m. - 7 a.m. with no RN to supervise patient care.

07/12/10 S20LPN was assigned was assigned t