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23515 HIGHWAY 190

MANDEVILLE, LA 70448

PATIENT RIGHTS

Tag No.: A0115

Based on observation, record review, and interview the facility failed to meet the requirements for the Condition of Participation (CoP) for Patients' Rights. The deficient practice is evidenced by: 1) failure to provide the ordered level of observation and restrictions for patients with aggressive behavior based on 4 (IR6, IR7, IR8, IR9) of 6 (IR1, IR3, IR6, IR7, IR8, IR9) reviewed patient to patient abuse incident reports and of 5 (S18MHT, S21MHT, S22MHT, S23MHT, and S24MHT) of 5 interviewed mental health technicians who were not of aware of restrictions for the patients under their care (see findings under Tag A0144) ; and 2) failure to screen staff for convictions that bar employment in healthcare facilities in the State of Louisiana for 5 (S7MHT,S8MHT,S9MHT,S13MHT,S32MHT)of 21 (S6MHT- S13MHT, S15MHT- S20MHT, S25RN S26RN, S30MHT-S35MHT) personnel files reviewed (see findings under Tag A0144); and 3) failure to ensure each patient is assigned to the care of a mental health technician (see findings under Tag A0144); and 4) failure to protect patients from abuse by appropriately screening staff through review of a criminal background check in 2 (IR4, IR5) of 3 (IR2, IR4, IR5) reviewed incident reports of staff to patient abuse from a total of 9 reviewed incident reports (see findings under Tag A0145).

An Immediate Jeopardy (IJ) was identified on 01/22/2024 at 11:20 a.m. and reported to S1CEO, S4RN, and S5RM.

The Immediate Jeopardy (IJ) situation was the result of the hospital's failure to ensure patient safety. The hospital's failure to maintain the ordered level of observation and distance precautions for patients with aggressive behavior endangered all patients in the hospital and created the potential for serious injury.

On 01/22/2024 at 3:25 p.m., S5RM presented the plan for lifting the immediacy of the IJ. The plan included revisions to the current policy including the documentation of restrictions, provisions to ensure MHTs are not assigned 2 patients with restrictions from each other, and re-education of the nursing staff and medical providers on the policy changes.

On 01/23/2024 at 12:15 p.m. after direct observation, record review and interview, the IJ was removed for the failure to maintain the ordered level of observation and restrictions; however, there was not enough evidence to determine sustainability of compliance for the Condition of Patient Rights to be cleared. Therefore, noncompliance remains at the Condition Level.

PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING

Tag No.: A0130

Based on record review and interview, the facility failed to ensure each patient was allowed to actively participate in his/her plan of care. The deficient practice is evidenced by failure to document patient participation or refusal of participation in care planning for 3(#3, #5, #9) of 10 (#1-#10) reviewed patient records.
Findings:

Patient #3
Review of the medical record for Patient #3 revealed the patient was admitted on 07/25/2023 with diagnosis of paranoid schizophrenia and was discharged on 01/02/2023.

Review of the multidisciplinary plan of care for Patient #3 revealed the treatment plans for 11/25/2023 and 11/30/2023 were not signed by the patient and there is no indication the patient refused to participate.

In interview on 01/18/2024 at 2:16 p.m., S4RN verified the care plans for Patient #3 were not signed and there was no indication the patietn refused to participate.

Patient #5
Review of the medical record for Patient #5 revealed admission on 07/29/2023 with a diagnosis of schizophrenia and dementia, and was currently still admitted to the facility.

Review of the multidisciplinary plan of care for Patient #5 revealed the treatment plans for 09/28/2023, 10/30/2023, 11/30/2023 and 01/03/2024 were not signed and there was no indication the patient refused to participate.

In interview on 01/22/2023 between 9:40 a.m. and 9:45 a.m., S4RN verified the treatment plans were not signed and there was no indication the patient refused to participate.

Patient #9
Review of the medical record for Patient #9 revealed admission on 10/06/2023 with a diagnosis of unspecified mood disorder and, and was currently still admitted to the facility.

Review of the multidisciplinary plan of care for Patient #9 revealed the treatment plan for 11/13/2023 was not signed and there was no indication the patient refused to participate.

In interview on 01/22/2023 at 4:00 p.m., S4RN verified the treatment plan was not signed and there was no indication the patient refused to participate.

PATIENT RIGHTS: INFORMED CONSENT

Tag No.: A0131

Based on record review and interview, the facility failed to ensure each patient's right to informed consent. The deficient practice is evidenced by failure to document the patient's refusal to sign admission consents for 1 (#5) of 10 (#1-#10) reviewed medical records.
Findings:

Review of the medical record for Patient #5 revealed admission on 07/29/2023 with a diagnosis of schizophrenia and dementia.

Review of the admission consents for Patient #5 revealed a sticky note with "Refused to Sign," on the assignment of benefits sheet. The form for acknowledgement of the restraint and seclusion policy, the form for acknowledgement of the privacy practices, patient rights and responsibilities, receipt of video surveillance protocol and receipt of the grievance procedures, and the form for advanced directives/ organ donor information was not signed by patient #5 and there was no indication he refused to sign.

In interview on 01/22/2024 between 9:40 a.m. and 9:45 a.m., S4RN verified the forms were to be signed by the patient or documented the patient refused to sign. S4RN also verified if the patient refuses to cooperate at the time of admission, the staff are supposed to retry at a later time.

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

Based on observation, record review, and interview, the hospital failed to ensure care in a safe setting. The deficient practice is evidenced by: 1) failure to provide the ordered level of observation and restrictions for patients with aggressive behavior based on 4 (IR6, IR7, IR8, IR9) of 6 (IR1, IR3, IR6, IR7, IR8, RI9) reviewed patient to patient abuse incident reports and of 5 (S18MHT, S21MHT, S22MHT, S23MHT, and S24MHT) of 5 interviewed mental health technicians who were not of aware of restrictions for the patients under their care; ; and 2) failure to screen staff for convictions that bar employment in healthcare facilities in the State of Louisiana for 5 (S7MHT,S8MHT,S9MHT,S13MHT,S32MHT)of 21 (S6MHT- S13MHT, S15MHT- S20MHT, S25RN S26RN, S30MHT-S35MHT) personnel files reviewed; and 3) failure to ensure each patient is assigned to the care of a mental health technician.

Findings:

Review of hospital policy titled "Level of Observation and Precaution", dated 05/09/2022, revealed, in part, "Types of Observations: . . 4) One to One (1:1)- this level of observation requires that an individual is supervised in close proximity. The 1:1 level of observation differs from VC in that the individual is maintained within three to six feet, while all other elements of the VC level of observation are maintained. . . . Types of Precautions: . . . 7) Distance Precaution (Distance)-to minimize risk of physical contact between two (2) or more patients. A distance between them of a minimum of eight (8) feet shall be maintained at all times, as is physically reasonable. The goal is always re-adjust physical space/location to maintain the eight (8) foot distance."

1)Failure to provide the ordered level of observation and precautions for patients with aggressive behavior


A review of self-reported incidents of patient to patient abuse was performed. The review revealed 4 (IR6, IR7, IR8, IR9) of 6 (IR1, IR3, IR6, IR7, IR8, RI9) critical incidents involved failure to provide the level of observation and restrictions ordered by the licensed practitioners.


Incident Report 6 (IR6)
Review of IR6 revealed on 12/19/2023 at 8:35 a.m., Patient #6 and Patient #7 were in the dining room eating when Patient #6 walked up behind Patient #7 and began hitting Patient #7 in the head. Further review of the report revealed the facility found the allegation of neglect was unsubstantiated and stated, "Both of the patients were being properly monitored per their MD orders."


Review of the orders for Patient #7 revealed an order from 11/14/2023 at 6:00 a.m. placing Patient #6 on distance precautions from Patient #7.


In interview on 01/22/2024 at 10:33 a.m., S5RM verified the nursing staff neglected to monitor the patients per the physician's orders.


Incident Report 7 (IR7)
Review of IR7 revealed on 01/11/2023 at 3:10 p.m., "Patient #1 enters the foyer area from the dayroom to get in line for a snack. Patient #5 is yelling and Patient #1 tells him to shut up as he standing in line. Patient #5 responds "I will not be quiet I have rights." It is unclear who hit whom first but both patients put their hands up and contact was made. The incident happened in a blind spot. Staff immediately intervened and separated the patients," and "Patients were separated for safety reasons and distance precautions orders were continued." Further review of the incident report revealed, "The allegation of neglect is unsubstantiated due to the staff intervening and separating the patients. Both of the patients were being properly monitored per their MD orders."


In interview on 01/22/2024 at 10:33 a.m. S5RM was questioned about the statement, "distance precautions were continued," S5RM verified that Patient #1 and Patient #5 had an earlier physical altercation and were placed on distance precautions at that time which were still in effect. S5RM verified the nursing staff neglected to monitor the patients as ordered.


Incident Report 8 (IR8)
Review of the provided incident reports revealed IR8 occurred on 12/03/2023 at 12:30 p.m. Review of IR8 revealed in part, "Patient #9 and Patient #10 were trying to attack Patient #8."


Review of the assignment sheet for the unit on 12/03/2023 revealed S27MHT was assigned one to one observation of Patient #9.


Review of the observation sheet for Patient #9 on 12/03/2023 revealed S27MHT signed the observation sheet from 11:45 a.m. until 7:00 p.m. with no double signature to indicate someone else had briefly monitored the patient.


Review of the statement by S27MHT on 12/03/2023 revealed in part, "I was by the lock seclusion room, when I was asked to come back to the unit. When I got on the unit, Patient #10 and Patient #9 was trying to fight Patient #8."


In interview on 01/22/2024 at 2:10 p.m., S4RN verified the neglect. S27MHT admitted to being off the unit and there is no documentation another staff member was watching Patient #9 who was on one to one observation.


Incident Report 9 (IR9)
Review of IR9 revealed it covered two critical events on Unit E for 12/03/2023 at 11:59 a.m. and 5:51 p.m., Patient #9 and Patient #10 attacked R1 in both events. The investigation report found the allegation of neglect in the care of Patient #9, Patient #10 and R1 to be unsubstantiated.


Review of the assignment sheet for Unit E on 12/03/2023 revealed S14MHT was assigned to observe Patient #8 who was on one to one observation.


Review of the observation sheet from the incident report for Patient #8 for 12/03/2023 revealed S14MHT had signed the observation sheet until 5:30 p.m. and the observations stop at that point. There is no time stamp on the copy to indicate what time the observation sheet was copied to be included in the incident report.

Review of the final observation sheet in the medical record revealed S14MHT had been the only MHT who signed the observation sheet indicating he provided the one to one observation of Patient #8 from 1:00 p.m. until 7:00 p.m. Further review revealed at 5:51 p.m. Patient #8 was lying down in his bedroom.


Review of the investigation into the incident at 5:51 p.m. revealed S14MHT stated, "I walked off the unit into the nursing station to bring in another incident report. When I walked back onto the floor, Patient R1 was sitting on the bed and Patient #10 and Patient #9 were standing in front of him trying to hit him when I went to help . . ."


In interview on 01/22/2024 at 2:15 p.m., S4RN verified the neglect. S14MHT admitted he had left the unit, entered the nursing station, and participated in a critical event while he was supposed to be providing one to one observation of Patient #8 in his bedroom. S4RN verified the investigation did not include the neglect of observation of other patients on the unit during the critical event.

After review of the incident reports revealed the patients were not properly monitored in the past, direct observations and interviews were performed on Unit A on 01/22/24 between 8:55 a.m. and 9:15 a.m.

Direct observation on Unit A at 8:55 a.m. accompanied by S4RN revealed S18MHT leaving the unit with a box of trash on a rolling chair headed away from the unit.


In an interview on 01/22/24 at 9:00 a.m., in the presence of S4RN, S21MHT verified she was unable to identify which of her assigned patients were on distance precautions. S21MHT reported she did not have a staff sheet with her to assist in identifying which patients were on distance precautions.


In an interview on 01/22/2024 at 9:08 a.m., in the presence of S4RN, S18MHT stated S21MHT was watching his patients while he was taking out the trash. S18MHT reported he had one patient on distance precautions. A review of staffing sheet with S18MHT and S4RN revealed S18MHT had two patients on distance precautions.

In an interview on 01/22/2025 at 9:10 a.m., S21MHT verified she did not know that S18MHT's assigned patients were on distance precautions.

In an interview on 01/22/2025 at 9:16 a.m., in the presence of S4RN, S23MHT verified she was unable to identify which of her assigned patients were on distance precautions. S23MHT verified she was not able to identify which patients should be distanced from her patients. S23MHT verified each patient to be distanced was identified by a medical record number on her assignment sheet and she was unable to identify each patient by medical record number.

In an interview on 01/22/2024 at 9:24 a.m., in the presence of S4RN, S22MHT reported she had no patients on distance precautions. A review of staffing sheet with S22MHT and S4RN revealed S22MHT had three patients on distance precautions.

In an interview on 01/22/2024 at 9:26 a.m., in the presence of S4RN, S24MHT reported she had one patient on distance precautions. S24MHT verified she was unable to identify which patients should be distanced from her patient.

In an interview on 01/22/2024 at 9:28 a.m., S4RN verified S18MHT, S21MHT, S22MHT, S23MHT and S24MHT did not know they had patients on distance precautions and were unable to identify which patients should be distanced. S4RN verified this was a patient safety issue.

An Immediate Jeopardy (IJ) was identified on 01/22/2024 at 11:20 a.m. and reported to S1CEO, S4RN, and S5RM.

The Immediate Jeopardy (IJ) situation was the result of the hospital's failure to ensure patient safety. The hospital's failure to maintain the ordered level of observation and distance precautions for patients with aggressive behavior endangered all patients in the hospital and created the potential for serious injury.

On 01/22/2024 at 3:25 p.m., S5RM presented the plan for lifting the immediacy of the IJ. The plan included:

-Revision to Policy TX.7-1001 titled" Level of Observation and Precaution." The revisions included instructions on steps to be taken by staff to maintain the distance precautions.

-Re-education would begin for all direct care staff on the different precautions and how to maintain them per the revised policy. The re-education would begin immediately with the 2 shifts for 01/22/2023 and be completed once the 2 shifts on 01/13/2024 were re-educated prior to the start of each shift.

-Re-education of nursing staff on patient assignments. The patient assignments will be made by a registered nurse.

-Assurance that staff accepting patient assignments know each patient and the precautions ordered for that patient. Each patient's assignment sheet will continue to have the medical record number of each patient he/she is to be distanced noted under precautions.

-Each patient's precautions will also be added to the bed list and will be reviewed daily by the charge nurse and revised as needed.

-Mental Health Technicians will not be assigned two patients that are on distance precautions from each other.

-Providers were to be informed of the changes to the policy via an audiovisual conference on 01/22/2023.

A review and reconciliation through observation, record review, and interview of nursing staff and providers on 01/23/2023 revealed all direct care staff observed and interviewed had been re-educated. All staff were able to verbalize the revisions to the policy, demonstrate knowledge of their assigned patient's level of observation and precautions, and explain to the surveyor which of their patients where on distance precautions and from whom they were to be distanced. Review of the provided documents revealed changes to the policy, a list of providers who acknowleded the re-education, and a list of staff who were re-educated.

On 01/23/2023 at 12:15 p.m., the IJ was removed.


2) Failure to screen staff for convictions that bar employment in healthcare facilities in the State of Louisiana

Review of the memo HHS 16-2-016 released 12/12/1016 regarding Criminal Convictions that Bar Employment of Unlicensed Persons or Ambulance Personnel revealed in part, "It is the responsibility of all employers that employ non-licensed persons or ambulance personnel to know which convictions bar employment. Louisiana Revised Statute 40:1203.3 covers criminal convictions that bar an employer from hiring a non-licensed person or ambulance personnel. Those criminal convictions are listed in the following table: . . . R.S.14:64 . . . R.S.40:966, R.S. 40:967, R.S.40:968, R.S.40:8969"

Review of personnel files was performed between 01/11/2024 and 01/23/2024. The review 4 staff with disqualifying criminal records and one unlicensed direct care provider who did not have a criminal background check.
S7MHT was hired on 10/09/2023. Review of the personnel file for S7MHT revealed a criminal background check was performed on 10/05/2023. The criminal background check revealed S7MHT had previously plead guilty to armed robbery (R.S.14:64). The facility hired S7MHT without consulting the list of convictions that bar employment in a healthcare facility.

S8MHT was hired on 09/25/2023. Review of the personnel file for S8MHT revealed a background check was performed on 09/19/2023. The criminal background check revealed S8MHT had several felony convictions including possession of marijuana (R.S.40:966), possession of cocaine and distribution of schedule II narcotics (R.S.40:967). The facility hired S8MHT without consulting the list of convictions that bar employment in a healthcare facility.

S9MHT was hired on 09/13/2021 and terminated on 01/02/2024. A background check was not performed.

S13MHT was hired on 08/08/2023 and terminated on 01/15/2024. Review of the personnel file for S13MHT revealed a background check was performed on 08/18/2023. The criminal background check revealed convictions for possession of Schedule I, Schedule II, Schedule III and Schedule IV controlled dangerous substances (R.S.40:966, R.S. 40:967, R.S.40:968, R.S.40:8969).

S32MHT was hired 1/25/2021 and terminated on 01/22/2024. Review of the personnel file for S32MHT revealed an initial background check was performed on hire and a second one was performed on 01/11/2023. The criminal background check revealed 2 convictions for possession of Schedule I controlled dangerous substances and 2 convictions for possession of Schedule II controlled dangerous substances (R.S.40:966 and R.S.40:967).S32MHT was documented on schedules and observation sheets as having worked on Unit E, which houses adolescents.

In interview on 01/11/2024 at 3:40 p.m., S1CEO and S2COO verified S7MHT and S8MHT had convictions that barred employment in healthcare facilities in the State of Louisiana.
In interview on 01/17/2024 at 4:13 p.m., S6HR verified a new criminal background check was required for all rehired personnel. S6HR verified S9MHT did not have a criminal background check before he was rehired.

In interview on 01/18/2024 at 9:15 a.m. S6HR verified S13MHT was terminated because of the convictions that barred employment in healthcare facilities in the State of Louisiana.

In interview on 01/22/2024 at 1:30 p.m. S4RN verified S32MHT was terminated because of the convictions that barred employment in healthcare facilities in the State of Louisiana.

3) Failure to ensure each patient is assigned to the care of a mental health technician.

Review of hospital Policy # NS-1005, titled "Nursing Staffing Plan", revised 02/20/2020, revealed in part, "Purpose: To provide adequate coverage to meet the patient care needs while maintaining safety for patients and staff. Definitions . . . Basic coverage-the minimum resources necessary to provide routine care."

Review of Unit C's assignment sheet dated 01/19/2024 revealed a census of 15. Further review revealed the assignment of patient care for the unit had not been performed.

Review of Unit F's assignment sheet dated 01/19/2024 revealed a census of 10. Further review revealed Patient R18 without an assigned mental health technician.

Review of Unit A's assignment sheet dated 01/20/2024 revealed a census of 17. Further review revealed Patient R5 without an assigned mental health technician.

Review of Unit B's assignment sheet dated 01/21/2024 revealed a census of 20. Further review revealed the fields on the assignment sheet titled "Day Shift-Staff/Title," "Patients Assigned" and "RN signature" were blank except for the name of one mental health technician assigned six patients.

Review of Unit B's assignment sheet dated 01/22/2024 revealed a census of 20. Further review revealed Patient R19 without an assigned mental health technician.

Review of Unit B's assignment sheet dated 01/23/2024 revealed a census of 20. Further review revealed Patient R20 without an assigned mental health technician.

In an interview on 01/22/2024 at 2:30 p.m., S4RN confirmed the above assignment sheets dated 01/19/2024-01/22/2024 failed to reveal documented evidence that all patients were assigned a mental health technician.

In an interview on 01/23/2024 at 12:30 p.m., S4RN confirmed the above assignment sheet dated 01/23/2024 failed to reveal documented evidence that all patients were assigned a mental health technician.



47397

PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT

Tag No.: A0145

Based on record review and interview, the facility failed to ensure each patient was free from abuse, neglect and harassment. The deficient practice is evidenced by 1) failure to protect patients from abuse by appropriately screening staff through review of a criminal background check in 2 (IR4, IR5) of 3 (IR2, IR4, IR5) reviewed incident reports of staff to patient abuse from a total of 9 reviewed incident reports; and 2) failure to appropriately monitor a patient after administration of a prn behavioral medication to ensure resolution of the behavior in 1(IR3) of 9 (IR1-IR9) reviewed incident reports.
Findings:

1) Failure to protect patients from abuse by appropriately screening staff through review of a criminal background check

Review of the memo HHS 16-2-016 released 12/12/1016 regarding Criminal Convictions that Bar Employment of Unlicensed Persons or Ambulance Personnel revealed in part, "It is the responsibility of all employers that employ nonlicensed persons or ambulance personnel to know which convictions bar employment. Louisiana Revised Statute 40:1203.3 covers criminal convictions that bar an employer from hiring a nonlicensed person or ambulance personnel. Those criminal convictions are listed in the following table: . . . R.S.14:64 . . ."

Incident Report 4
Review of IR4 revealed on 12/26/2023 at 1:21 a.m., S9MHT and S11MHT pulled Patient #5 on the floor to his room and locked him in without cause. S9MHT and S11MHT were terminated for physical abuse of Patient #5. The investigation results substantiated the allegations of abuse or neglect against all the staff involved but failed to find neglect of responsibility on the part of the facility because all staff involved had been properly trained and were up-to-date with yearly education related to their jobs.

Review of the personnel file for S9MHT was performed on 01/17/2024. The review revealed S9MHT was initially hired in September 2019 and then re-hired 12/16/2021.Further review of the personnel file revealed the orientation and the criminal background check were not repeated when S9MHT was rehired.

In interview on 01/18/2024 at 4:00 p.m., S2COO stated the repeat orientation was not required if the staff returned within a few months.

In interview on 01/18/1014 at 4:03 p.m., S6HR verified S9MHT did not have a repeat background check performed before he was hired on 12/16/2021. S6HR verified a new background check should have been done. S6HR verified S9MHT was not properly screened prior to re-hire.

Incident Report 5
Review of IR5 revealed on 01/09/2024 at 9:20 p.m., Patient #1 spit on S7MHT and S7MHT then hit Patient #1 in the face. S7MHT was immediately terminated. The investigation report found the allegation of abuse against S7MHT was substantiated but found the allegation of neglect on the part of the facility was not substantiated because they had properly trained S7MHT.

Review of the criminal background check in the personnel file for S7MHT revealed 2009 S7MHT plead guilty to armed robbery (R.S. 14:64) and was to be on parole after incarceration until 8/1/2024.

In interview on 01/11/2024 at 3:40 p.m., S1CEO and S2COO verified S7MHT had a history of violence and should not have been hired.

2) Failure to appropriately monitor a patient after administration of a prn behavioral medication to ensure resolution of the behavior

Review of the medical record for Patient #4 revealed he was assigned to bedroom #1. On 12/30/2023 from 7:20 a.m. until 8:00 a.m. he was in the hallway. Further review revealed Patient #4 had a below the knee amputation and was known to pace when in pain or aggravated. There was no documentation of problems with Patient #4 on the morning of 12/30/2023 prior to the incident.

Review of the medical record for Patient #3 revealed he was assigned to bedroom #2. On the morning of 12/30/2023, Patent #3 was slamming doors and screaming, "That mother fucker with one leg keeps walking in and out. At 7:30 a.m. and Patient #3 was given 10 mg of Zyprexa by mouth as ordered for agitation.

Review of IR3 revealed on 12/30/2023 at 8:16 a.m., "Patient #3 was standing next to Patient #4 in the dining room waiting on medication pass when he said something that appeared to agitate Patient #4. Patient #4 became verbally aggressive towards Patient #3 and Patient #3 walked closer to Patient #4 and got in his face. Patient #4 shoved Patient #3 to the floor, during the fall Patient #3 hit his head on one of the seats to the dining table." Patient #3 was sent to a local acute care hospital for evaluation and required surgery for a fractured femur. Further review of the incident report revealed the facility found that the allegation of neglect was unsubstantiated.

In interview on 01/18/2024 at 3:25 p.m., S4RN reviewed the record and verified Patient #3 had been given a prn medication that was part of his regular regime for behavior. S4RN verified the incident occurred just before the time the nurse was required to perform a follow up for effectiveness. S4RN verified Patient #3 should have been observed after the administration of the medication and should not have been allowed near Patient #4 until it was confirmed the medication had provided the desired effect. S4RN verified this was neglect on the part of the staff.

QUALITY IMPROVEMENT ACTIVITIES

Tag No.: A0283

Based on record review and interview, the hospital failed to identify opportunities for improvement related to reported cases of alleged patient abuse/neglect. The deficient practice is evidenced by 1) failure to recognize neglect in 7 (IR3- IR9) of 9 reviewed reported incidents of alledged abuse/neglect; and 2) failure to investigate associated incidents involving patient safety documented in the investigations.
Findings:

1)Failure to recognize neglect

Incident Report 3 (IR3)
Review of the medical record for Patient #4 revealed he was assigned to bedroom #1. On 12/30/2023 from 7:20 a.m. until 8:00 a.m. he was in the hallway. Further review revealed Patient #4 had a below the knee amputation and was known to pace when in pain or aggravated. There was no documentation of problems with Patient #4 on the morning of 12/30/2023 prior to the incident.

Review of the medical record for Patient #3 revealed he was assigned to bedroom #2. On the morning of 12/30/2023, Patent #3 was slamming doors and screaming, "That mother fucker with one leg keeps walking in and out. At 7:30 a.m. and Patient #3 was given 10 mg of Zyprexa by mouth as ordered for agitation.

Review of IR3 revealed on 12/30/2023 at 8:16 a.m., "Patient #3 was standing next to Patient #4 in the dining room waiting on medication pass when he said something that appeared to agitate Patient #4. Patient #4 became verbally aggressive towards Patient #3 and Patient #3 walked closer to Patient #4 and got in his face. Patient #4 shoved Patient #3 to the floor, during the fall Patient #3 hit his head on one of the seats to the dining table. Patient #3 was sent to a local acute care hospital for evaluation and required surgery for a fractured femur. Further review of the incident report revealed the facility found that the allegation of neglect was unsubstantiated.

In interview on 01/18/2024 at 3:25 p.m. S4RN reviewed the record and verified Patient #3 had been given a prn medication that was part of his regular regime for behavior. S4RN verified the incident occurred just before the time the nurse was required to perform a follow up for effectiveness. S4RN verified Patient #3 should have been observed after the administration of the medication and should not have been allowed near Patient #4 until it was confirmed the medication had provided the desired effect. S4RN verified this was neglect on the part of the staff.


Incident Report 4 (IR4)
Review of IR4 revealed on 12/26/2023 at 1:21 a.m., S9MHT and S11MHT pulled Patient #5 on the floor to his room and locked him in without cause. S9MHT and S11MHT were terminated for physical abuse of Patient #5. The investigation results substantiated the allegations of abuse or neglect against all the staff involved but failed to find neglect of responsibility on the part of the facility because all staff involved had been properly trained and were up-to-date with yearly education related to their jobs.

Review of the personnel file for S9MHT was performed on 01/18/2024. The review revealed S9MHT was initially hired in September 2019 and then re-hired 12/16/2021.Further review of the personnel file revealed the orientation and the criminal background check were not repeated when S9MHT was rehired.

In interview on 01/18/2024 at 4:00 p.m., S2COO stated that the repeat orientation was not required if the staff returned within a few months.

In interview on 01/18/1014 at 4:03 p.m., S6HR verified S9MHT did not have a repeat background check performed before he was hired on 12/16/2021. S6HR verified a new background check should have been done. S6HR verified the facility was negligent and did not properly screen S9MHT prior to re-hire.

Incident Report 5 (IR5)
Review of IR5 revealed on 01/09/2024 at 9:20 p.m. Patient #1 spit on S7MHT and S7MHT then hit Patient #1 in the face. S7MHT was immediately terminated. The investigation report found the allegation of abuse against S7MHT was substantiated by found the allegation on neglect on the part of the facility was not substantiated because they had properly trained S7MHT.

Review of the criminal background check in the personnel file for S7MHT revealed 2009 S7MHT plead guilty to armed robbery (R.S. 14:64) and was to be on parole after incarceration until 8/1/2024.

In interview on 01/11/2024 at 3:40 p.m., S1CEO and S2COO verified S7MHT had a history of violence and should not have been hired.

Incident Report 6 (IR6)
Review of IR6 revealed on 12/19/2023 at 8:35 a.m., Patient #6 and Patient #7 were in the dining room eating when Patient #6 walked up behind Patient #7 and began hitting Patient #7 in the head. Further review of the report revealed the facility found the allegation of neglect was unsubstantiated and stated, "Both of the patients were being properly monitored per their MD orders."

Review of the orders for Patient #7 revealed an order from 11/14/2023 at 6:00 a.m. placing Patient #6 on distance precautions from Patient #7.

In interview on 01/22/2024 at 10:33 a.m., S5RM verified Patient #7 was not monitored per the physician's orders and the nursing staff was negligent in its observation of the patients.

Incident Report 7 (IR7)
Review of IR7 revealed on 01/11/2023 at 3:10 p.m., "Patient #1 enters the foyer area from the dayroom to get in line for a snack. Patient #5 is yelling and Patient #1 tells him to shut up as he standing in line. Patient #5 responds "I will not be quiet I have rights." It is unclear who hit whom first but both patients put their hands up and contact was made. The incident happened in a blind spot. Staff immediately intervened and separated the patients," and "Patients were separated for safety reasons and distance precautions orders were continued." Further review of the incident report revealed, "The allegation of neglect is unsubstantiated due to the staff intervening and separating the patients. Both of the patients were being properly monitored per their MD orders."

In interview on 01/22/2024 at 10:33 a.m. S5RM was questioned about her statement, "distance precautions were continued." S5RM verified that Patient #1 and Patient #5 had an earlier physical incident and were placed on distance precautions at that time and the precautions were still in effect at the time of the second altercation. S5RM verified the orders for distance were not followed and the nursing staff was negligent in its observation of the patients.

Incident Report 8 (IR8)
Review of the provided incident reports revealed on 12/03/2023, IR9 occurred at 11:59 a.m. and 5:51 p.m. and IR8 occurred on 12/03/2023 at 12:30 p.m. on the same unit. Review of IR8 revealed in part, "Patient #9 and Patient #10 were trying to attack Patient #8."

Review of the assignment sheet for the unit on 12/03/2023 revealed S27MHT was assigned one to one observation of Patient #9.

Review of the observation sheet for Patient #9 on 12/03/2023 revealed S27MHT signed the observation sheet from 11:45 a.m. until 7:00 p.m. with no double signature to indicate someone else had briefly monitored the patient.

Review of the statement by S27MHT on 12/03/2023 for IR9 revealed in part, "I was by the lock seclusion room, when I was asked to come back to the unit. When I got on the unit, Patient #10 and Patient #9 was trying to fight Patient #8."

In interview on 01/22/2024 at 2:10 p.m., S4RN verified S27MHT was neglegent in his observation of Patient #9. S27MHT admitted to being off the unit and there is no documentation another staff member was watching Patient #9 who was on one to one observation.

Incident Report 9 (IR9)
Review of IR9 revealed on 12/03/2023 at 11:59 a.m. and 5:51 p.m., Patient #9 and Patient #10 attacked R1. The investigation report found the allegation of neglect was unsubstantiated in the care of Patient #9, Patient #10 and R1.

Review of the assignment sheet for the unit on 12/03/2023 revealed S14MHT was assigned to observe Patient #8 who was on one to one observation.

Review of the observation sheet from the incident report for Patient #8 for 12/03/2023 revealed S14MHT had signed the observation sheet from 1:00 p.m. until 5:30 p.m. and the observations stop at that point. There is no time stamp on the copy to indicate what time the observation sheet was copied to be included in the incident report.

Review of the final observation sheet in the medical record revealed S14MHT had been the only MHT providing one to one observation of Patient #8 from 1:00 p.m. until 7:00 p.m. Further review revealed at 5:51 p.m. Patient #8 was in bedroom #4 lying down.

Review of the investigation into the incident which occured at 5:51 p.m. revealed S14MHT stated, "I walked off the unit into the nursing station to bring in another incident report. When I walked back onto the floor, Patient R1 was sitting on the bed and Patient #10 and Patient #9 were standing in front of him trying to hit him when I went to help . . ."

In interview on 01/22/2024 at 2:15 p.m., S4RN verified S14MHT admitted he had left the unit, entered the nursing station, and participated in a critical event while he was supposed to be providing one to one observation of Patient #8. S4RN verified the investigation did not include investigation into possible neglect of observation of other patients on the unit during the critical event.

2) Failure to investigate associated incidents involving patient safety documented in the investigations.

Review of the documents included in the investigation of IR1, which occured on Unit E, revealed a MHT Progress note for Patient #10 which revealed under the section for additional comments, "Took staff members' things out the closet and acted violent when told to give them back."

Review of the documents included in the investigation of IR9 revealed a statement from S14MHT which revealed in part, "While in the seclusion room Patient R1 got a piece of metal from inside there so we got the weapon from him."

In interview on 01/22/2024 at 11:25 a.m., S5RM was asked about the above statements found in the investigations. S5RM verified she had not read them and they were not investigated.

In interview on 01/22/2024 at 1:30 p.m., S4RN verified he was not aware of an unlocked closet on Unit E that was used by the mental health technitians and stated an interview with the MHT would not be possible because he was no longer working at the facility.

RN SUPERVISION OF NURSING CARE

Tag No.: A0395

Based on record review and interview the hospital failed to ensure the Registered Nurse evaluated the care of each patient on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy. This deficiency is evidenced by failure of the Registered Nurses to supervise, observe and evaluate 3 (#R2, #R3 and #R4) patients per hospital policy.
Findings:

Review of hospital policy # TX.7-1001, titled "Level of Observation and Precaution", last revised on 05/09/2022, revealed, in part: Policy, in part: to appropriately assess patients for high risk behaviors ...Purpose, in part: To reduce the risk of patient harm to self or others as needed for patient condition, using active supervision. 2. The RN Charge Nurse is directly responsible for monitoring observation levels and precautions ...3. The Unit RN Charge Nurse will physically round to make direct observation of each patient on the unit every two hours and will initial each patient's individual observation sheet at the time this direct observation is conducted. 4. The RNS will monitor compliance with the observation and precaution status by staff during rounds. Active Supervision, in part: a. Maintaining the patient's level of observation/precaution at all time. b. Maintaining staff and patient safety through conscious and deliberate observation, both subjective and objective. Look for evidence of changes in the physical environment ...or presence of contraband. Observe what the patient is doing. Listen to what they are saying ....

Review of Unit A document titled "Census", dated 01/19/2024 revealed a census of 17. The census revealed R2 was on the following precautions: Close Sight Staff (every 10 minutes); and Unpredictable Behavior Precautions.

Review of Patient #R2's observation sheet dated 01/19/2024 failed to reveal observations completed by a Registered Nurse between 10:10 a.m.-7:50 p.m.

Review of Unit A document titled "Census", dated 01/19/2024 revealed a census of 17. The census revealed R3 was on the following precautions: Close Sight Staff (every 10 minutes); and Unpredictable Behavior Precautions.

Review of Patient #R3's observation sheet dated 01/19/2024 failed to reveal observations completed by a Registered Nurse between 10:10 a.m.-7:50 p.m.

Review of Unit B document titled "Census", dated 01/20/2024 revealed a census of 20. The census revealed R4 was on the following precautions: Close Sight Staff (every 10 minutes) and Unpredictable Behavior Precautions.

Review of Patient #R4's observation sheet dated 01/20/2024 failed to reveal observations completed by mental health technician at 6:20 p.m., 6:30 p.m., 6:40 p.m., 6:40 p.m., and 7:00 p.m.

In an interview on 01/22/2024, S4RN confirmed that the observation sheets for R2, R3, and R4 failed to reveal observations completed as per policy.

PATIENT CARE ASSIGNMENTS

Tag No.: A0397

Based on record review and interviews the hospital failed to ensure a registered nurse assigned the nursing care of each patient to other nursing personnel in accordance with the patient's needs. This deficiency is evidenced by failing to ensure a Registered Nurse made all patient care assignments.
Findings:

Review of hospital policy # NS-1065, titled "Staff Assignments", revised 03/05/2020, revealed, in part, "Procedure . . . B. Process . . . 3. A designated Mental Health Technician initiates the assignment sheet; however, the RN Charge Nurse must review the assignments for completeness and appropriateness and sign as approving the delegation of these functions as noted. "

Review of hospital Job Description titled "Registered Charge Nurse", dated 09/2023, revealed, in part, "Responsibilities . . . Oversee as well as supervises direct care staff, makes assignments ...."

Review of Assignment Sheet for Unit B dated 01/21/2024 failed to reveal the schedule was completed for the day shift. Further review failed to reveal evidence a Registered Nurse reviewed the assignment sheet on the day shift.

Review of Assignment Sheet for Unit C dated 01/19/2024 failed to reveal the schedule was completed for the day shift. Further review failed to reveal evidence a Registered Nurse reviewed the assignment sheet on the day shift.

In an interview on 01/22/2024 at 9:06 a.m. S4RN verified the Registered Nurses did not complete staffing assignments for any of the hospital units. S4RN verified the Mental Health Technicians (MHT) split up levels of observation and the nurse signs the assignment sheet once the MHTs made the assignments.

S4RN reviewed the assignment sheets for 01/17/2024, 01/18/2024, 01/19/2024, 01/20/2024, 01/21/2024, and 01/22/2024. S4RN verified the MHTs had completed the daily schedules.

In an interview on 01/22/2024 at 10:30 a.m., S5RM verified the hospital policy titled "Staff Assignments" failed to meet federal regulations for hospitals which requires the Registered Nurse to assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available.

SUPERVISION OF CONTRACT STAFF

Tag No.: A0398

47397


Based on record review and interview, the director of nursing services failed to ensure nursing care was provided according to hospital policy. This deficient practice is evidenced by the Charge Nurse initialing observation sheets before direct observations were conducted on 16 (#1, #5, #8, #9, #10, #R1, #R3, #R6, #R7, #R9, #R10, #R11, #R14, #R15, #R16 #R17) of 23 (#1,#3, #4, #5, #8, #9, #10, #R1, #R2, #R3, #R5, #R6, #R7, #R8, #R9, #R10, #R11, #R12, #R13, #R14, #R14, #R16, and #R17) patient observation sheets reviewed.
Findings:

Review of hospital policy # TX.7-1001, titled "Level of Observation and Precaution", last revised on 05/09/2022, revealed, in part, "Policy . . . to appropriately assess patients for high risk behaviors ...3. The Unit RN Charge Nurse will physically round to make direct observation of each patient on the unit every two hours and will initial each patient's individual observation sheet at the time this direct observation is conducted."

Review of Unit A's patient observations sheets dated 01/22/2024 was conducted on 01/22/2024 at 9:00 a.m. The review revealed S29RN initialed the observation sheets of patients #1, #5, #R3, #R6, #R7, #R9, #R10, #R11, #R14, #R15, #R16 #R17 at the following times: 9:00 a.m., 10:50 a.m., 12:50 p.m., 2:50 p.m., 5:00 p.m., and 7:00 p.m.

In an interview on 01/22/2024 at 1:00 p.m., S4RN verified S29RN had initialed the observation sheets for patients #1, #5, #R3, #R6, #R7, #R9, #R10, #R11, #R14, #R15, #R16 and #R17 at 9:00 a.m., 10:50 a.m., 12:50 p.m., 2:50 p.m., 5:00 p.m., and 7:00 p.m. S4RN confirmed S29RN had initialed the observation sheets before direct observation was conducted.

Review of the patient observation sheets for the patients #8, #9, #10, and #R1 for 12/03/2023 provided in the documents for IR8 and IR9 revealed the nurse had initialed the observation sheets prior to each MHT's documentation of the observations.The observation sheets appear to have been individually collected near the end of the shift for inclusion in the critical event investigations.

In interview on 01/22/2024 at 1:30 p.m., S4RN compared the observation sheets collected before the end of the shift to the completed observation sheets found in the medical record of the patients #8, #9, #10, and #R1. S4RN verified either the observation sheets were signed earlier in the shift by the registered nurse or the registered nurse signed incomplete sheets at the end of the shift.

Treatment Plan

Tag No.: A1640

Based on record review and interview, the hospital failed to ensure each patient had an individualized and comprehensive treatment plan for 1 (#2) of 1 (#2) patient treatment plans reviewed. This deficiency is evidenced by failure to include all medical diagnoses as part of an individualized and comprehensive treatment plan.
Findings:

Review of hospital policy #TX.1-0200, titled "Treatment Planning", revised 06/30/2021, revealed, in part, "Definitions: Plan of Care (POC): the individualized treatment plan, developed for each active problem/goal area that includes objectives, and interventions specific to the stated problem...B, in part: Treatment Planning Process:...treatment planning goals ...Prioritizing patient needs for treatment. Review of all intercurrent Medical Diagnoses. 3., . . . The Treatment Planning forms ...a. Acute Care/Extended Care Treatment Plan . . .Intercurrent medical conditions/Medical Problems. "

Review of Patient #2's medical record revealed a Medical History and Physical dated 05/27/2023. Further review revealed a medical history of intellectual disability. Further review revealed Intellectual Disability listed under the section "Assessment/Plan".

Review of Patient #2's Psychiatric Evaluation dated 05/27/2023 revealed Intellectual Disability as part of the History of Present Illness.

Review of Patient #2's Psychosocial Assessment dated 05/28/2023 revealed patient with current cognitive deficits.

Review of Patient #2's Supplemental Multidisciplinary Treatment Plan/Update for Judicially Committed Patients dated 06/27/2023, failed to reveal Intellectual Disability under the section Medical Diagnoses.

Review of Patient #2's Integrated Individual Care Plan, last updated 07/20/2023, failed to reveal a diagnoses of Intellectual Disabilty.

Review of Patient #2's Multidisciplinary Treatment Plan, last updated 1/10/2024, failed to reveal a problem related to Intellectual Disability. The section titled "Medical Diagnosis" revealed "none".

In an interview on 01/18/2024 at 2:15 p.m., S4RN confirmed that Patient #2's History and Physical and Psychiatric Evaluation included the medical diagnosis "Intellectual Disability". S4RN also verified the Master Treatment Plan, Multidisciplinary Treatment Plan, Integrated Individual Care Plan and Supplemental Multidisciplinary Treatment Plan/Update for Judicially Committed failed to include evidence of Patient #2's diagnosis of intellectual disability.