HospitalInspections.org

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements for the Condition of Participation of Patient Rights as evidenced by:

1. Failing to provide the same basic rights relative to comfort, dignity, and personal privacy for all patients. This deficient practice was evidenced by the hospital's failure to provide 6 (Patient #9, #10, #11, #12, #13, and #14) of 51 current inpatients convenient access to a bathroom for personal hygiene activities and access to their room during daytime hours. (see findings in tag A-0143)

2. Failing to provide care in a safe setting by the hospital's failure to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for patients admitted for acute inpatient psychiatric services as evidenced by failing to ensure the patients' environment was free of ligature risks and safety hazards (after being cited for this violation on the 07/30/15 survey). (see findings in tag A-0144)

3. Failing to obtain approval from the Health Standards Section of DHH in advance of beginning construction/remodeling of patient bathrooms on the Adult Psychiatric Unit (Patient rooms a. and b.{west wing} and c.{east wing}) and construction/remodeling of the restraint/seclusion room on the Adolescent Psychiatric Unit. This construction/remodeling affected 6 patients (Patient #9, #10, #11, #12, #13, and #14) who were admitted and assigned to patient rooms at a time when the bathrooms in these patient rooms were under construction and closed from patient use. (see findings in tag A-0144)

Based on observation and interview, the hospital failed to ensure all patients admitted for inpatient psychiatric services received the same standard of care as evidenced by failing to provide the same basic rights relative to comfort, dignity, and personal privacy. This was evidenced by the hospital's

1. failure to provide 6 (Patient #9, #10, #11, #12, #13, and #14) of 51 current inpatients convenient access to a bathroom for personal hygiene activities and access to their room during daytime hours and

2. failure to provide direct bathroom access, within a vestibule, for 1 (#5) of 1 patient who was observed to be placed in a room for the use of seclusion and restraint on the Adolescent Psychiatric Unit.

Findings:

1. Failure to provide patients convenient access to a bathroom for personal hygiene activities and access to their room during daytime hours.

An observation was conducted on 4/6/16 at 11:00 a.m. of Patient rooms a, b and c. Patient rooms a, b and c had the bathrooms gutted and the bathroom's door locked from patient access. Two patients resided in each room. Patients' rooms a and b were on the west wing and Patient room c was on the east wing. The survey team had to wait approximately 5 minutes to conduct an observation of the seclusion room bathroom on the Adult Psychiatric Unit because it was in use by one of the patients currently without direct access to his own bathroom due to construction/remodeling.

An interview was conducted with S2DON on 4/6/16 at 11:00 a.m. She reported the patients in Room a and b use the bathroom in the seclusion room on west wing when they need to shower and use the bathroom. The patients in Room c use the bathroom in the seclusion room on the east wing. S2DON further reported if the bathroom for the seclusion room is occupied, the patients use the seclusion bathroom on the other hall. She went on to report if the seclusion rooms' bathrooms were occupied the hospital would have to close off another patient room and have the patient use the bathroom in that patient room. When questioned if the patients needed to lie down during the day and construction was going on in their bathrooms, where could they have a quiet area, S2DON reported the patient would be given access to the quiet room on the east wing. S2DON further indicated the 6 patients (Patient #9, #10, #11, #12, #13, and #14) assigned to rooms a, b and c did not have access to their rooms between the hours of 7a.m.-8 a.m. and 3:00 p.m. to 4:00 p.m. while the construction crews were working in their rooms.

An interview was conducted with Patient #9 on 4/6/16 at 12:00 p.m. He reported he resided in Room a. When questioned if he had problems accessing a bathroom when he needed a bathroom, he reported sometimes he had to wait to use the bathroom because the bathroom in the seclusion room was occupied. He went on to report before the surveyor spoke to him, he was waiting to use the bathroom.

An interview was conducted with S1Administrator on 4/6/16 at 12:15 p.m. He reported the construction on the bathrooms in rooms a, b, and c started on 2/15/16, which was approximately 1.5 months ago. S1Administrator reported the bathroom renovation completion date was Wednesday (4/6/16), but construction was halted on 4/4/16 due to the survey process. He further indicated, based upon the level of progress with the remodel of the bathrooms, that the projected completion date was not going to be met.


2. Failure to provide direct bathroom access, within a vestibule, for 1 (#5) of 1 patient who was observed to be placed in a room for the use of seclusion and restraint on the Adolescent Psychiatric Unit.


An observation was made on 4/4/16 at 11:05 a.m. of the room in use as the restraint/seclusion room on the Adolescent Unit. The room did not have an anteroom or vestibule with direct access to a bathroom.
On 4/4/16 at 3:30 p.m. Patient #5 was observed being placed in the above referenced room in use as the restraint/seclusion room after elopement attempts times 2. The room is located across the hall from the nearest bathroom available for patient use. Patients in seclusion/restraint had to be walked across the hall in front of the unit's main entry double doors to provide bathroom access.
In an interview on 4/5/16 at 1:23 p.m. with S2DON, she confirmed patients requiring the restraint /seclusion room, on 4/4/16, had to be walked across the hall of the Adolescent unit (by the unit's main entry door) to provide bathroom access. She also confirmed the room in use as the restraint/seclusion room on the Adolescent Unit did not have a vestibule with direct access to a bathroom. S2DON further confirmed Patient #5, while in seclusion, had been walked across the hall in front of the unit's main entry double doors to provide bathroom access.

26351


Based on observation and interview, the hospital failed to ensure patients received care in a safe setting as evidenced by

1) failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for patients admitted for acute inpatient psychiatric services. This deficient practice was evidenced by failure to ensure the patients' environment was free of ligature risks and safety hazards (after being cited for this violation on the 07/30/15 survey); and

2) failing to obtain approval from the Health Standards Section of DHH in advance of beginning construction/remodeling of patient bathrooms on the Adult Psychiatric Unit (Patient rooms a. and b.{west wing} and c.{east wing}) and construction/remodeling of the restraint/seclusion room on the Adolescent Psychiatric Unit. This construction/remodeling affected 6 patients (Patient #9, #10, #11, #12, #13, and #14) who were admitted and assigned to patient rooms at a time when the bathrooms in these patient rooms were under construction and closed from patient use.

Findings:

1. Failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for patients admitted for acute inpatient psychiatric services. This deficient practice was evidenced by failure to ensure the patients' environment was free of ligature risks and safety hazards (even after being cited for this violation on the 07/30/15 survey)

An observation was conducted on the adolescent unit on 4/04/16 at 11:00 a.m. The following safety and ligature risks were identified and confirmed by S2DON.

All patient mattresses had zippers at the end of the mattresses. An interview was conducted with S2DON on 4/4/16 at 11:10 a.m. She reported all of the mattresses in the hospital had zippers located at the end of the mattress.
All patient platform beds were bolted to the wall with non-tamper resistant screws.
4 pencils where found slipped in the cushions of the chairs used for group therapy.
A TV was anchored to the wall in the hallway where group therapy was conducted. The electrical cords for the TV were hanging down and posed a ligature risk.
The three exit doors to the unit had arm hinges protruding from the top of the doors.
The ceiling of the seclusion room in use on 4/04/16 was not monolithic. The ceiling had individual tiles that could be lifted.
One of the electrical outlets in the seclusion room in use on 4/04/16 was not a GFI outlet providing opportunity for potential electrical shock.
The door of the seclusion room had 3 hinges spaced apart widely enough to provide for a potential ligature point/ligature risk.

An observation was conducted on the West Unit on 4/04/16 at 12:00 p.m. The following safety and ligature risks were identified and confirmed by S2DON.


The seclusion room bathroom (Room e) had grab rails on the wall and a soap dish in the bathtub that posed a ligature risk. The faucet was gooseneck and the knobs in the bathtub protruded. Hand rails affixed to the bathroom wall provided a space which could be used to anchor an item for as ligature point, posing a ligature risk. The toilet seat was loose on the toilet. The door to the bathroom had 3 hinges spaced apart which could be used to anchor an item posing a ligature risk. The sink had a flange type faucet that could be used as a potential ligature point. The bathroom door had a round door knob that could be used as a potential ligature point. S2DON confirmed the above ligature risks and confirmed the patients in Room a and b were currently using this bathroom on a routine basis as the bathrooms in their respective rooms were gutted for renovations.

All patient rooms except Room a and b, were observed to have round door knobs and 3 hinges on the corridor doors spaced apart, which could be used to anchor an item posing a ligature risk. The sinks in the patient rooms were observed to have flanged faucets and 2 round handles for hot and cold water that could be used as potential ligature points. S2DON confirmed all the rooms except for Room a and b were the same and had multiple ligature points.

The bathrooms (bathtub/shower and toilet) in the patient rooms on the West unit except for Room a and b, had the following: gooseneck faucet with protruding knobs for the water, soap dish with a hand grip, and 3 hinges on the bathroom door spaced apart, which could be used to anchor an item posing a ligature risk. The bathroom doors were observed to have round door knobs with non-tamper resistant screws.

The exit doors in the unit had arm hinges protruding from the top of the doors.

An observation was conducted on the East Unit on 4/04/16 at 12:30 p.m. The following safety and ligature risks were identified and confirmed by S2DON.

The exit doors in the unit had arm hinges protruding from the top of the doors including the laundry room.

The seclusion room bathroom (Room f) on the East wing had exposed plumbing for the toilet, grab bars located on the wall next to the toilet. The thermostat had the protective box removed and was exposed. The faucet was gooseneck and the water knobs were flanged. The shower also had handrails affixed to the wall with space to provide a ligature point. The shower also had a vertical rail where a shower cord could be attached that provided a potential ligature point. The door to the bathroom was observed to have 3 hinges spaced
apart, and a round door knob all of which could be used to anchor an item for a ligature risk. The light cover over the sink was observed to be unsecured, providing potential access to fluorescent bulbs. Two non-tamper resistant screws were observed to be protruding from the front of the wooden cabinet housing the sink. An electrical outlet with a red plate was observed to not be a GFI outlet. The mirror over the sink was observed to have non-tamper resistant screws. S2DON confirmed patients were allowed to shower in this room and use the bathroom without the staff present in the bathroom. S2DON confirmed the patients in Room c and d were currently using this bathroom routinely as their respective bathrooms were gutted for renovations.

The bathrooms in the patient rooms on the East unit except for Room c and d, had the following: gooseneck faucet with protruding knobs for the water, soap dish with a hand grip, and 3 hinges on the bathroom door spaced apart, which could be used to anchor an item posing a ligature risk. The sinks in the patient rooms were observed to have a gooseneck faucet and flanged handles for the hot and cold water, all of which could be used as a potential ligature point.

Room h and Room i were observed to have round door knobs and 3 hinges spaced apart, all of which could be used to anchor an item posing a ligature risk.

6 of a total of 13 handrails located in the halls of the East unit were noted to be loose, pulling from the walls.

The outside area had a wooden fenced-in basketball court area. The wooden fence had numerous nail heads protruding from the wood board slats. The wooden fence was also observed to have a loose board that was warped inward approximately 3 feet from the ground with two nails protruding from the board. These findings were confirmed by S2DON.


2. Failing to obtain approval from the Health Standards Section of DHH in advance of beginning construction/remodeling of patient bathrooms on the Adult Psychiatric Unit (Patient rooms a. and b.{west wing} and c.{east wing}) and construction/remodeling of the restraint/seclusion room on the Adolescent Psychiatric Unit. This construction/remodeling affected 6 patients (Patient #9, #10, #11, #12, #13, and #14) who were admitted and assigned to patient rooms at a time when the bathrooms in these patient rooms were under construction and closed from patient use.

An observation was conducted on 4/6/16 at 11:00 a.m. of Patient rooms a, b and c. The bathrooms of Patient rooms a., b. and c. were gutted and the bathroom doors were locked to prevent patient access. Two patients resided in each room. Patients' rooms a. and b. were on the west wing and Patient room c. was on the east wing.

An interview was conducted with S1Administrator on 4/6/16 at 12:15 p.m. He reported the construction on the bathrooms in rooms a., b., and c. began on 2/15/16, which was approximately 1.5 months ago. S1Administrator reported the bathroom renovation completion date was Wednesday (4/6/16), but construction had been halted on 4/4/16 due to the survey. He further indicated, based upon the level of progress with the remodel of the bathrooms, that the projected completion date was not going to be met.
An observation was made on 4/4/16 at 11:05 a.m. of the restraint/seclusion room temporarily in use during the construction/remodel of the restraint seclusion room on the Adolescent Psychiatric Unit. The room in use at the time of the observation did not have an anteroom or vestibule with direct access to a bathroom. S2DON indicated the unit's "real" restraint/seclusion room that was currently being remodeled had been enlarged and a vestibule had been added.

A request was made to the hospital administration team (S1Administrator and S2DON), by the surveyors while onsite (4/4/16-4/6/16), for documentation of State (DHH) approval for the construction/remodel plans of the bathrooms in patient rooms a., b. and c. on the Adult Psychiatric Unit and the restraint/seclusion room on the Adolescent Psychiatric Unit referenced above. The team also requested any communication with State Office, including email communication, regarding the construction/remodel. The hospital administrative team failed to produce any documented evidence of DHH prior approval, in advance of beginning the construction/remodel of the patient bathrooms and/or the restraint/seclusion room on the Adolescent Psychiatric Unit referenced above.


30984

Based on record review and interviews, the hospital failed to ensure an effective system was in place to ensure that each physician/practitioner providing services in the hospital was credentialed in accordance with the Medical Staff By-laws for 7 of 7 (S7MD, S9Psychiatrist, S10APRN, S11MD, S12APRN, S13APRN, S14MD) current credentialed medical staff reviewed.

Findings:

Review of the Medical Staff Bylaws provided by S4AdmAssistant as current revealed in part the following:
Article III. Medical Staff Membership:
Appointment to and subsequent membership on the Medical Staff shall confer on the Member only such clinical responsibilities, prerogatives, and other rights as have been granted by the Board in accordance with these Bylaws.
Article V. Allied Health Professionals:
Each AHP shall meet the same responsibilities as required for Physician Medical Staff Members....
Article VI. Procedure for Appointment:
Each Application for appointment to the Staff shall be in writing, submitted on the prescribed form, and signed by the applicant. The Medical Staff, through its Services, committees, and officers, shall investigate, verify, and consider each Application for appointment or reappointment to any staff status....The Medical Staff shall consider each Application for appointment, reappointment, and Responsibilities, and each request for modification of Medical Staff category using the standards set forth in these Bylaws and Rules. The Board shall be ultimately responsible for granting membership and Responsibilities.
The Application shall be submitted to the Health Information Management office, which shall initially process the Application and then submit it to the Credentials function of the MEC, or its designee, to have all information verified.
Specific Information Required: 3 Peer References, Continuing medical education for the past two years, professional liability insurance.
Section 11-The Reappointment Process:
A. Application: Within a reasonable period of time prior to the expiration of the Member's two-year appointment (but not less than one hundred twenty (120) days), the Administrator/CEO or his designated representative, such as the HIM office, shall provide each Member with an approved Application for Reappointment form which must be completed and returned within thirty (30) days to the Administrator/CEO for review on behalf of the Credentials function of the MEC. Information to be available for review shall include at least the following: Evidence of continuing licensure, training, education, and experience....Evidence of professional liability coverage....


S7MD
On 04/04/16 at 11:05 a.m., during an observation of the Adolescent Unit, S7MD was observed in the nurse's station. S2DON also present, stated today was S7MD's first day.

Review of the credentialing file for S7MD revealed no documented evidence of an appointment to the medical staff by the Governing body. Review of the file revealed an application for initial appointment dated 03/16/16. Review of the Delineation of Privileges revealed the form was checked approved and signed by the administrator and the medical executive committee, but there was no date of the approvals.

In an interview on 04/05/16 at 11:45 a.m., S4AdmAssistant provided Governing Body Minutes dated 04/05/16 (today) with no time documented that revealed, "Members present via conference call." The minutes revealed the Governing Board approved S7MD as medical director effective 04/01/16.

In an interview on 04/05/16 at 1:45 p.m., S1Adm stated he and the former medical director signed the delineation of privileges, but confirmed there was no date of their approval/signature on the form. S1Adm confirmed a conference call was done today to approve the appointment of S7MD to the medical staff and medical director.


S9Psychiatrist
Review of the credentialing file for S9Psychiatrist revealed the Governing Body appointed the physician to the medical staff on 09/24/15. Review of the file revealed an application for initial appointment dated 06/23/15. Review of the Delineation of Privileges revealed the form was checked approved and signed by the administrator and the medical executive committee, but there was no date of the approvals. Review of the file revealed only 2 references and no documented evidence of continuing education for the past 2 years.

In an interview on 04/05/16 at 11:40 a.m., S4AdmAssistant and S3HIM reviewed the credentialing file for S9Psychiatrist and confirmed the Delineation of Privileges form was not dated when signed by the administrator and MEC. They both confirmed there was no documentation of continuing education and there were only 2 references. S4AdmAssistant and S3HIM confirmed they were not aware that 3 references and 2 years of continuing education were required.


S10APRN
Review of the credentialing file for S10APRN revealed S10APRN was reappointed to the medical staff on 07/15/15 for a two year term. Review of the credentialing file revealed no documented evidence of a reappointment application and no references.

In an interview on 04/05/16 at 11:40 a.m., S4AdmAssistant and S3HIM reviewed the credentialing file for S10APRN and confirmed there was no documentation of a reappointment application, no references, and no continuing education. S4AdmAssistant and S3HIM confirmed they were not aware that an application and references were required on reappointment.


S11MD
Review of the list of medical staff provided by S4AdmAssistant revealed S11MD was a family practice physician.
Review of the credentialing file for S11MD revealed no documented evidence of Governing Body reappointment to the medical staff. Review of the credentialing file revealed a request for consulting clinical privileges was requested by S11MD with the following privileges requested: Respiratory Services Director, Respiratory Supervision to include, but not limited to respiratory treatments, policy review, and ordering, Adult Psychiatry, Adolescent Psychiatry, Geriatric Psychiatry, Addictive Disease, Partial Hospitalization Program, Intensive and Outpatient Services Program. The privileges form was signed/dated on 03/02/15 by S1Adm and the hospital medical director at the time. Further review of the credentialing file revealed no documented evidence of a reappointment application, continuing education, references, or malpractice insurance.

In an interview on 04/05/16 at 11:45 a.m., S4AdmAssistant provided Governing Body minutes dated 04/05/16 (today) with no time indicated that revealed, "Members present via conference call. Approval: S11MD, Medical Director Respiratory Therapy....Governing Board reviewed and officially recognized S11MD as the Medical Director Respiratory Therapy services effective March 5, 2015."

In an interview on 04/05/16 at 1:10 p.m., S4AdmAssistant and S3HIM reviewed the credentialing file for S11MD and confirmed the request for privileges was inaccurate and S11MD was not a psychiatrist and did not provide any psychiatric services at the hospital. S4AdmAssistant and S3HIM confirmed there was no documentation of a reappointment application, continuing education, references, or current malpractice insurance.


S12APRN
Review of the credentialing file for S12APRN revealed S12APRN was reappointed to the medical staff on 02/16/16 for a two year term. Review of the Delineation of Privileges revealed the form was checked approved and signed by the administrator and the medical executive committee, but there was no date of the approvals. Review of the credentialing file revealed no documented evidence of a reappointment application and only 2 references. There was no documented evidence of continuing education.

In an interview on 04/05/16 at 1:10 p.m., S4AdmAssistant and S3HIM reviewed the credentialing file for S12APRN and confirmed there was no documentation of a reappointment application or continuing education. Both confirmed there were only 2 references. S4AdmAssistant and S3HIM confirmed there was no date on the Delineation of Privileges approval by the MEC and the Administrator.

S13APRN
Review of the credentialing file for S13APRN revealed S13APRN was appointed to the medical staff on 02/29/16 for a two year term. Review of the Delineation of Privileges revealed the form was checked approved and signed by the administrator and the medical executive committee, but there was no date of the approvals. Review of the credentialing file revealed only 2 references.

In an interview on 04/05/16 at 1:10 p.m., S4AdmAssistant and S3HIM reviewed the credentialing file for S12APRN and confirmed there were only 2 references. 4AdmAssistant and S3HIM confirmed there was no date on the Delineation of Privileges approval by the MEC and the Administrator.

S14MD
Review of the credentialing file for S14MD revealed he was reappointed to the medical staff on 02/16/16 with consulting privileges for a two year term. Review of the Delineation of Privileges revealed the form was checked approved and signed by the administrator and the medical executive committee, but there was no date of the approvals. Review of the credentialing file revealed no documented evidence of a reappointment application and there was no continuing education.

In an interview on 04/05/16 at 1:10 p.m., S4AdmAssistant and S3HIM reviewed the credentialing file for S14MD and confirmed there was no reappointment application or continuing education submitted. Both confirmed there was no date on the Delineation of Privileges approval by the MEC and the Administrator.

In an interview on 04/05/16 at 1:45 p.m., the above findings were reviewed with S1Adm. S1Adm confirmed he and the medical director had not dated their approvals on the delineation of privileges forms. S1Adm confirmed the above files did not have reappointment applications. S1Adm also confirmed the delineation of privileges for S11MD was inaccurate. S1Adm confirmed the medical staff bylaws had not been followed in the appointment and reappointment of the above medical staff members.

30984

Based on observation, record review and interview, the hospital failed to ensure a RN supervised and evaluated the care of each patient as evidenced by:
1) failing to ensure a patient (#5) who had attempted to elope from the Adolescent Unit had been placed on elopement precautions immediately after an elopement attempt for 1 (#5) of 1 patients reviewed for elopements.
2) failing to ensure patient Blood Pressure (Patient #1, # 7) was assessed prior to administration of blood pressure medication for 2 of 2 (#1, #7) sampled patient records reviewed for documentation of medication administration.


Findings:


1) Failing to ensure a patient (#5) who had attempted to elope from the Adolescent Unit had been placed on elopement precautions immediately after an elopement attempt.


Review of the hospital policy titled, "Precaution Levels and Record", Policy NO: RC-006, revealed in part:
Policy: A precautionary measure and/or level that determine the minimum frequency of nursing observation and degree of independent activity within behavioral milieu will be ordered for each patient. Nursing staff may increase the frequency of observations in response to changes in patient condition while waiting to discuss this with the physician/licensed independent practitioner.

Procedure: Nursing staff may place the patient on special precautions at any time. The treatment team must review precautions and levels of observation and documentation of the review must be present in the progress notes and treatment plan.
Precautions: Elopement Precautions: Patients at risk will be monitored to the degree that is clinically appropriate.; The physician/licensed independent practitioner or nurse may institute monitoring of patient when assessment reveals the patient is at risk of elopement.;
A sign will be posted on the door of the unit.; Documentation shall include rationale for monitoring, ongoing assessment of elopement risk, patient response to monitoring, and discontinuation of monitoring.


Patient #5
Review of Patient #5's medical record revealed an admission date of 3/31/16 with admission diagnoses of Bipolar Disorder and Oppositional Defiant Disorder.

Review of Patient #5's medical record revealed the patient had attempted to elope from the Adolescent Unit twice on 4/04/16 at 3:20 p.m. Further review revealed he had been placed in seclusion in 4 point restraints on 4/04/16 at 3:30 p.m.

Review of Patient #5's Q15 minute observation sheets (completed by MHTs) dated 4/4/16 and his entire medical record revealed no documented evidence of initiation of elopement precautions immediately after his elopement attempts on 4/04/16 at 3:20 p.m.

Review of Patient #5's physician's orders revealed in part: 4/05/16 at 10:25 a.m.: Place on elopement precautions.

In an interview on 4/05/16 at 11:41 a.m. with S2DON, she confirmed Patient #5 had attempted to elope twice on 4/04/16. She indicated he had kicked open the doors and managed to go into the outdoor space adjacent to the Adolescent Unit. She said Patient #5 had been talked into coming back into the unit, but he then proceeded to attempt to kick open a second set of double doors to try to elope again. S2DON indicated Patient #5 had then been placed in 4 point restraints in the seclusion room, after the second elopement attempt, to try to calm him.


2) failing to ensure patient BP was assessed prior to administration of blood pressure medication:

Patient #1
Review of the medical record for Patient #1 revealed the patient was a 48 year old admitted to the hospital on 03/29/16 with a diagnosis of Major Depressive Disorder.

Review of the MAR and the physician orders for Patient #1 revealed the patient was being treated with Coreg 25 mg. twice a day. Review of the MAR dated 04/04/16 revealed, "check blood pressure and pulse" was written under the Coreg order. Further review of this MAR revealed the Coreg was held at 9:00 a.m. due to the patient's blood pressure was 98/69. Review of the MAR revealed the 9:00 p.m. dose was administered, but there was no documentation of the patient's blood pressure or pulse. Further review of the MARs revealed on 04/01/16 the Coreg was administered at 9:00 p.m. and there was no documentation of the patient's blood pressure or pulse.

In an interview on 04/05/16 at 3:30 p.m., S2DON confirmed her expectation was that the nurse would document the patient's blood pressure and pulse on the MAR prior to administering blood pressure medications. She stated she had recently instructed the nurses to write in, "check blood pressure and pulse" on the MAR. After reviewing the MARS for Patient #1, she confirmed the nurses had failed to document the patient's blood pressure and pulse prior to administering the Coreg on 04/04/16 and 04/01/16.


Patient #7
Review of Patient #7's medical record revealed an admission date of 4/04/16 with admission diagnoses of Major Depressive Disorder and Cocaine abuse. Further review revealed Patient #7 also had a diagnosis Hypertension.

Review of Patient #7's MAR revealed the patient was being treated with Lisinopril 20 mg tablet by mouth q day at 9:00 a.m. Further review revealed the patient was also receiving Amylodipine 10 mg by mouth q day at 9:00 a.m. and Clonidine 0.1 mg tablet by mouth every 6 hours times 72 hours. The Clonidine order had the following parameters: Hold if SBP less than 100, DBP less than 60 and pulse less than 60.
In an interview on 4/06/16 at 8:40 a.m. with S6LPN, she indicated nursing staff utilized the patient vital signs assessed by the MHTs on their morning rounds to determine whether or not a blood pressure medication should be given or held. S6LPN confirmed they did not assess the patient's blood pressure prior to administering blood pressure medications. She indicated the MHTs usually assessed patient vital signs around 7:30 a.m. or 8:00 a.m.

Based on record review, observation and interview, the hospital failed to ensure all patient medical records were properly stored in secure locations where they were protected from fire, water damage and other threats. This deficient practice was evidenced by the storage of approximately 200 patient medical records stored in cardboard boxes stacked on the floor, unprotected from fire and water damage. Findings:

Review of the hospital policy titled, Safekeeping of the Medical Record, revealed in part, It is the responsibility of the staff of the hospital to protect patient's medical records from fire, water damage and to safeguard the medical record and its contents against loss, defacement, tampering, and from use by unauthorized individual.

An observation was conducted on 4/5/16 at 8:30 a.m. of the medical records room. In the corner of the room approximately 200 patient medical records were observed in cardboard boxes stacked on top of each other. The room had a sprinkler system located in the ceiling.

An interview was conducted with S3HIM on 4/5/16 at 8:40 a.m. She reported the medical records were requested from the storage facility for review. She confirmed the 200 medical records were not protected from water and fire damage.

Based on Louisiana Administrative Code, contract review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable standards of practice, consistent with state law. This deficient practice was evidenced by failing to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist, before the first dose was dispensed, for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications.

Findings:

Review of the Louisiana Administrative Code, Professional and Occupational Standards,
Title 46: LIII, Pharmacist, Chapter 15, Hospital Pharmacy, §1511. Revealed in part:
Prescription Drug Orders
A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial
dose of medication, except in cases of emergency.

Review of the hospital's contract with Contracted Pharmacy "A" revealed no provisions for
the Consulting pharmacist to review medications before the first dose was dispensed and
administered.


Review of the hospital's policy titled After-Hour Medication Stock With or Without
Pharmacy Review revealed no provisions for a first dose review of the patient's medications by the pharmacist after pharmacy hours.


In an interview on 04/04/16 at 2:50 p.m., S17Pharmacist stated she was one of the two pharmacist contracted to provide pharmacy services at the hospital. S17Pharmacist stated the contracted pharmacy hours of operation were from 8:00 a.m. until 6:00 p.m. Monday through Friday, 9:00 a.m. through 3:00 p.m. Saturday and Sunday. She verified there was no process in place for the pharmacist to conduct a first dose review of medications by a pharmacist after pharmacy working hours. S17Pharmacist stated if a medication was ordered at night or after the pharmacist had left, it would not be reviewed until the next day retrospectively after the dose had already been dispensed and administered. S17Pharmacist confirmed the hospital frequently had newly admitted patients after hours and physicians wrote new orders at all hours. S17Pharmacist further indicated she was aware of the requirement for the pharmacist to conduct a review of all first dose medications.

In an interview on 04/04/16 at 3:45 p.m., S16LPN stated the hospital frequently has new admissions after pharmacy hours and stated she faxes the orders to pharmacy, but she overrides the automated dispensing machine and administers the medication. She stated if the prescribed medication was not in the system, she would call pharmacy or the physician. S16LPN confirmed the pharmacist does not review the patient's medications until the next day. She stated the physicians come in at all hours and it was not unusual to get new medication orders after the pharmacist was gone.

Based on record review and interview, the hospital failed to ensure errors in medication administration were documented in the medical record for 4 of 4 patients (#R5, #R6, #R7, #R8) reviewed for known medication errors out of a sample of 14 patients. Findings:

Review of the hospital's policy titled Medication Errors/Adverse Drug Events, Policy number PHR-127 revealed when a medication error occurs the physician was to be notified immediately and the error was to be recorded in the progress note and the MAR.

Review of the hospital policy titled, "Medication Errors/Variances", Policy number: MM-011, revealed in part: 3. Documentation in the medical record shall include the following: Error made; any adverse reaction; date and time of notification of physician/LIP, their response, verbal or written orders; nursing follow-up; and patient response.

Patient #R5
Review of Patient #R5's medical record revealed an admission date of 10/16/15 with an admission diagnosis of Major Depression, recurrent, severe. Further review revealed Patient #R5 was 15 years old.
Review of the hospital's occurrence reports revealed a medication error involving Patient #R5. Further review revealed Patient #R5 had received 15 mg (Adult dose) of Remeron (antidepressant used to treat insomnia) by mouth at hour of sleep without a physician's order for the medication.
Review of Patient #R5's medical record revealed no documented evidence of an account of the medication error referenced in the occurrence report.
In an interview on 4/5/16 at 3:40 p.m. with S2DON, she confirmed the above referenced medication error had not been documented in the patient's medical record. S2DON also confirmed medication errors should be documented in the patient's records.


Review of the list of Medication Variances for the last 3 months provided by S8QAPI Coordinator/Emergency Preparedness revealed patients #R6, #R7, and #R8 had medications variances.

Patient #R6
Review of the medication variance report dated 01/30/16 for Patient #R6 revealed 2 medications were omitted due to the physician's orders were not noted and the medications were not placed on the MAR. The variance report revealed the patient had missed several doses of Zofran and Claritin. Review of the medical record for Patient #R6 revealed no documented evidence of the medication error, nor was there documentation in the record that the physician was notified of the error.

Patient #R7
Review of the medication variance report dated 02/27/16 for Patient #R7 revealed the incorrect dose of Lithium was administered to the patient at 9:00 p.m. Review of the medical record for Patient #R6 revealed no documented evidence of the medication error, nor was there documentation in the record that the physician was notified of the error.

Patient #R8
Review of the medication variance report dated 03/01/16 revealed medications were omitted due to the physician wrote the orders for the medications only on the medication consult form. The medical consult form revealed Claritin and Flonase were ordered for the patient on 02/25/16. The variance report revealed the medication orders were not found until 03/01/16. Review of the medical record for Patient #R8 revealed no documented evidence of the medication error, nor was there documentation in the record that the physician was notified of the error.

In an interview on 04/05/16 at 3:25 p.m., S2DON reviewed the medical records for Patients #R6, #R7, and #R8 and confirmed the medication errors were not documented in the patient's medical record and confirmed the medication error and the physician notification should have been documented in the patient's record.






30984

Based on record review and interview, the hospital failed to ensure radiological services were under the direction of a Radiologist as evidenced by failure of the Governing Body to appoint a member of the medical staff, specialized in radiology, as Medical Director of the hospital's Radiological Services.
Findings:
Review of the hospital's medical staff roster revealed no documented evidence of any medical staff specialized in radiology.
In an interview 4/5/16 at 2:00 p.m. S1Administrator reported the job description for the hospital's Medical Director included that he or she would oversee Radiology Services.
Review of the job description of the Medical Director, signed by S7MD and dated 4/1/16, revealed a job summary that included "...Oversees Laboratory and Radiology services."
Review of the credentialing file for S7MD revealed his area of specialty was Psychiatry. Further review revealed no specialized training in radiology. Review of privileges approved for S7MD did not include any related to radiology, with the exception of ordering diagnostic testing.
In an interview 4/6/16 at at 11:15 a.m. S7MD verified that he was responsible for overseeing the radiology services for the hospital. S7MD verified that his area of specialty was Psychiatry, and did not include Radiology.

Based on record review, observation, and interview, the hospital failed to ensure the infection control officer developed a system for controlling infections and communicable diseases of patients and personnel. This deficient practice is evidenced by:

1) failing to ensure accepted standards of practice for infection control were followed during blood glucose monitoring. This deficient practice is evidenced by failing to properly disinfect a glucometer before and after obtaining a capillary blood glucose reading (Patient #7).

2) failing to ensure all hospital staff was free of TB in a communicable state. This deficient practice was evidenced by the hospital's failure to include the medical staff in TB screening as per state regulation and hospital policy for 5 of 7 (S10APRN, S11MD, S12APRN, S13APRN, S14MD) credentialing records reviewed.

3) failing to ensure a sanitary environment was maintained to avoid sources and transmission of infections and communicable diseases as evidenced by having dirty and clean items stored together, unclean environment and opened, unlabeled supplies in the environment of care available for patient use.

Findings:

1) Failing to ensure accepted standards of practice for infection control were followed during blood glucose monitoring as evidenced by failing to properly disinfect a glucose meter.

Review of the hospital policy titled, "Disinfection of Department Based Patient Care Equipment ", Policy number: IC-12, revised 3/2016, revealed in part:
Purpose: To outline the process for cleaning, disinfecting and storing patient care equipment.
Procedure: 9. Glucometers will be cleaned with an alcohol pad between each patient usage and weekly with germicidal disposable wipes.

Documentation found at FDA.gov relative to Blood Glucose Monitoring Systems revealed the following under the section of "Validated Cleaning and Disinfection Procedures": "Please note that 70% ethanol solutions are not effective against viral blood-borne pathogens".

On 4/6/16 at 11:45 a.m. an observation was made of S6LPN performing blood glucose monitoring on Patient #7. S6LPN was observed cleaning the glucose meter with alcohol before and after she had obtained the patient's capillary blood glucose sample.

In an interview on 4/6/16 at 11:50 a.m. with S2DON, she confirmed the hospital's current policy was to clean the capillary glucose meter with alcohol prior to and after each patient use. She agreed the capillary blood glucose meter should be disinfected with a germicidal agent between patients and not just cleaned with an alcohol wipe. S2DON further agreed the hospital policy guiding staff to clean the glucose meter with alcohol before and after each patient use needed to be revised to instruct staff to disinfect the glucose meter with a germicidal agent in-between patient use.


2) Failing to ensure all hospital employees and medical staff were free of TB in a communicable state:

Review of the Louisiana Public Health Sanitary Code, Title 51, Part II. The Control of Diseases - Health Examinations for Employees, Volunteers and Patients at Certain Medical Facilities, Section 503, Mandatory Tuberculosis Testing, revealed in part: All persons prior to or at the time of employment, involved in providing direct patient care, shall be free of tuberculosis in a communicable state as evidenced by either 1. A negative purified protein derivative skin test for TB, 2. A normal chest x-ray, if the skin or a blood assay for TB is positive, or 3. A statement from a licensed physician certifying that the individual is non-infectious if the x-ray is other than normal.

Review of the hospital's policy titled, "Infection Control" policy number IC-09a, approval date of 02/29/16 revealed in part the following:
All qualified applicants for employment shall be screened for presence of infection with M. Tuberculosis using the PPD skin test. At the time of hire, all employees will receive baseline Mantoux PPD skin testing. The exclusion will be those with a history of a positive PPD test, disease treatment, preventive therapy, or has proof of a PPD done within the past 12 months....A TB screening questionnaire will be filled out to screen for symptomatology. Baseline testing for TB will be performed upon hire and following potential exposure for all healthcare workers. The need for annual screening will be determined at the time of the annual risk assessment, according to CDC guidelines.

S10APRN
Review of the credentialing file for S10APRN revealed S10APRN was reappointed to the medical staff on 07/15/15 for a two year term. Review of the credentialing file revealed the only TB test was dated 07/26/12.

In an interview on 04/05/16 at 11:40 a.m., S4AdmAssistant and S3HIM reviewed the credentialing file for S10APRN and confirmed there was no documentation of a TB test since 07/26/12. S4AdmAssistant stated employees were required to have annual TB testing and she stated she had requested a current TB test from S10APRN, but she had not provided one.

S11MD
Review of the credentialing file for S11MD revealed S11MD was reappointed to the medical staff on 04/05/16 (today) for a two year term. Review of the credentialing file revealed no documented evidence of a TB test.

In an interview on 04/05/16 at 1:10 p.m., S4AdmAssistant and S3HIM reviewed the credentialing file for S11MD and confirmed there was no documentation of a TB test in the credentialing record.

S12APRN
Review of the credentialing file for S12APRN revealed S12APRN was reappointed to the medical staff on 02/16/16 for a two year term. Review of the credentialing file revealed the only TB test was dated 01/02/14.

In an interview on 04/05/16 at 1:10 p.m., S4AdmAssistant and S3HIM reviewed the credentialing file for S12APRN and confirmed there was no documentation of a TB test since 01/02/14.

S13APRN
Review of the credentialing file for S13APRN revealed S13APRN was appointed to the medical staff on 02/29/16 for a two year term. Review of the credentialing file revealed S13APRN documented the following on the Statement of Health form dated 02/24/16: TB test last done late 2013/early 2014. Further review of the file revealed no documented evidence of a TB test.

In an interview on 04/05/16 at 1:10 p.m., S4AdmAssistant and S3HIM reviewed the credentialing file for S12APRN and confirmed there was no documentation of a TB test and there should have been one obtained for the initial application.

S14MD
Review of the credentialing file for S14MD revealed he was reappointed to the medical staff on 02/16/16 with consulting privileges for a two year term. Review of the credentialing file revealed the only TB test was dated 01/17/14.

In an interview on 04/05/16 at 1:10 p.m., S4AdmAssistant and S3HIM reviewed the credentialing file for S14MD and confirmed there was no documentation of a TB test since 01/17/14.



3) Failing to ensure a sanitary environment was maintained:

Unsanitary Conditions:
An observation was conducted on 4/4/16 at 12:30 p.m. of Room j and k's shower curtains. The shower curtains were light in color and had a brown substance on the shower curtains. S2DON confirmed the shower curtains needed to be cleaned.

An observation was conducted on 4/4/16 at 12:30 p.m. of Room j's room and bathroom. In the bathroom the toilet bowl had a brown substance on the sides of the bowl and the bathroom floor and patient's room floor had dirt on the floors. S2DON confirmed the findings.

An observation was conducted on 04/04/16 at 12:35 p.m. of Room l's bathroom. The floor was observed to have a brown substance on the floor that was removable. The wall in the room was observed to have areas of a brown substance. S2DON confirmed the floors and walls were not clean.

An observation was conducted on 04/04/16 at 12:40 p.m. of Room m. S2DON confirmed the room had just been cleaned by the housekeeping staff. Clear paper and brown debris were noted on the floor near the head of the first bed. Debris was also noted on the floor by the wall and adjacent to the second bed. S2DON confirmed the findings and then requested the housekeeping staff to return to the room and removed the debris and paper.

An observation was conducted on 04/04/16 at 12:40 p.m. of Room b. The vent in the ceiling of the room was observed to have a large accumulation of a tan substance. S2DON confirmed the findings.

An observation was conducted on 04/04/16 at 12:45 p.m. of Room b. The vent in the ceiling of the room was observed to have a large accumulation of a tan substance. An accumulation of a brown substance was noted at the foot of the first bed. S2DON confirmed the findings.


An observation was conducted on 04/04/16 at 12:47 p.m. of Room h. The soap dish in the shower was observed to have a brown substance and a black substance was observed on the light switch plate. An area on the wall outside of Room h was observed to have a red/brown substance smeared on the wall. S2DON confirmed the findings.


Dirty and Cleaned items stored in the same area:

An observation was conducted on 04/4/16 at 11:05 a.m. of the adolescent unit's supply room. Stored in the supply room was fresh fruit, individualized snack packs of crackers, unused hygiene supplies along with the used patient hygiene supplies stored in individualized open bins. S2DON confirmed clean items should not be stored with dirty items.

An observation was conducted of the patient laundry room on 4/04/16 at 12:15 p.m. Washing machines were located in this room along with bags of dirty linen. Also stored in the laundry room were clean wheelchairs and walkers. S2DON confirmed clean items should not be stored with dirty items.


Opened, unlabeled items available for patient use:

An observation was conducted of the medication room on the adolescent unit on 4/4/16 at 11:20 a.m. During the observation an opened, unlabeled (no date or time) gallon container of drinking water was noted to be stored on the floor of the medication room. S15RN confirmed the water had been opened and was unlabeled. She indicated the water was available for patient use if the water supply was interrupted during the ongoing construction on the unit. S15RN further indicated she had no idea when the bottle of water had been opened.

An observation was conducted of the medication room on the adolescent unit on 4/04/16 at 11:25 a.m. An open, half empty, bottle of Gatorade was observed in the medication room. There was no date indicating when the Gatorade was opened. S2DON reported the Gatorade was sometimes ordered by the physician as an electrolyte replacement. S2DON confirmed the bottle was opened and not labeled.

An observation was conducted of the medication room on the West unit on 4/04/16 at 3:30 p.m. with S6LPN. An opened vial of Humulin R Insulin was observed in the medication cart. The vial was not dated when opened and did not include a date of expiration. S6LPN confirmed the vial of insulin had been opened and was not dated when opened. S6LPN confirmed the vial was stored in an area where it could be used and stated she had no idea when the vial was opened. S6LPN also stated there was one current patient on sliding scale insulin.


26351





17091

26351


Based on record review and interview, the hospital failed to ensure each patient received a psychiatric evaluation that included an inventory of the patient's assets in a descriptive manner and not an interpretive fashion for 3 (Patient #1, #6, #7) of 8 current patients reviewed for strengths/assets in the psychiatric evaluation out of a total of 14 sampled patient medical records.
Findings:

Patient #1
Review of the medical record for Patient #1 revealed the patient was a 48 year old admitted to the hospital on 03/29/16 with a diagnosis of Major Depressive Disorder.
Review of the Psychiatric Evaluation conducted on 03/30/16 by S9Psychiatrist revealed the only patient asset that was identified was "able to perform ADLs" (Activities of Daily Living).


Patient #6
Review of the medical record for Patient #6 revealed the patient was a 57 year old male admitted to the hospital on 04/04/16 with the diagnosis of Depression.

Review of his Psychiatric Evaluation conducted on 04/04/16 by S9Psychiatrist revealed the only patient asset that was identified was "able to perform ADLs" (Activities of Daily Living).


Patient #7
Review of the medical record for Patient #7 revealed the patient was a 57 year old male admitted to the hospital on 04/04/16 with diagnoses of Major Depressive Disorder and Cocaine abuse.

Review of his Psychiatric Evaluation conducted on 04/05/16 by S9Psychiatrist revealed the only patient asset that was identified was "able to perform ADLs" (Activities of Daily Living).

In an interview on 04/05/16 at 3:30 p.m., S2DON reviewed the above medical records and confirmed the Psychiatric Evaluations only included the one asset of "able to perform ADLs." S2DON confirmed the above Psychiatric Evaluations were not individualized and did not include personal attributes that could be useful in developing a treatment plan.



30984

Based on record review and interview, the hospital failed to ensure the nursing staff developed and kept current an individualized and comprehensive treatment plan for 2 (#5,#7) of 2 patients reviewed out of a total sample of 8 current inpatients (on both the Adult and Adolescent units) reviewed for comprehensive treatment plans.

Findings:

Patient #5
Review of Patient #5 's medical record revealed an admission date of 3/31/16 with admission diagnoses of Bipolar Disorder and Oppositional Defiant Disorder. Patient #5 was an inpatient on the Adolescent unit.

Review of Patient #5 's medical record revealed the patient had attempted to elope from the Adolescent Unit on 4/4/16 at 3:20 p.m. Further review revealed he had been placed in seclusion in 4 point restraints on 4/4/16 at 3:30 p.m.

Additional review of Patient #5 's medical record revealed the patient had sustained a fall in the dayroom of the Adolescent unit on 4/4/16 at 7:30 p.m.

Review of Patient #5 's physician 's orders revealed in part:
4/4/16 at 8:00 p.m.: Consult medical secondary to fall;
4/5/16 at 10:25 a.m.: Place on elopement precautions.


Review of Patient #5 's Multidisciplinary Treatment Plan revealed no documented evidence that risk for falls was identified as a problem to be addressed on the patient 's plan of care after he had sustained a fall on the evening of 4/4/16. Further review revealed elopement risk also had not been addressed as an identified problem after the patient 's elopement attempt on the afternoon of 4/4/16.
In an interview on 4/5/16 at 11:41 a.m. with S2DON, she confirmed Patient #5's Multidisciplinary Treatment Plan should have been updated after the patient 's fall and elopement attempt.

Patient #7
Review of Patient #7's medical record revealed an admission date of 4/4/16 with admission diagnoses of Major Depressive Disorder and Cocaine abuse. Further review revealed Patient #7 also had a diagnosis of chronic pain. Patient #7 was an inpatient on the Adult unit.

Review of Patient #7's Multidisciplinary Treatment Plan revealed no documented evidence that chronic pain/pain control was identified as a problem to be addressed on the patient's plan of care
In an interview on 4/5/16 at 11:41 a.m. with S2DON, she confirmed Patient #7's Multidisciplinary Treatment Plan should have included chronic pain/pain control as an identified problem to be addressed on the patient's plan of care.