HospitalInspections.org

Bringing transparency to federal inspections

23515 HIGHWAY 190

MANDEVILLE, LA 70448

PATIENT RIGHTS

Tag No.: A0115

B


48050

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 observation per MD order on 8 (#F3, RF3-RF9) of 8 (#F3, RF3-RF9) patients observed on video footage (see findings under Tag A0144); and 2) failure to ensure safe staff to patient ratio (see findings under Tag A0144); and 3) failure to provide distance precautions per hospital policy (see findings under Tag A0144).

An Immediate Jeopardy (IJ) was identified on 02/28/2024 at 5:30 p.m. and reported to SF1CEO, SF2DON, SF3ADON, SF4RM, SF13COO, and SF14CD.

The Immediate Jeopardy (IJ) situation was the result of the hospital's failure to ensure patient safety. The hospital's failure to maintain adequate supervision of patients created the potential for serious harm/injury.

On 02/29/2024 at 12:06 p.m., SF2DON presented the plan for lifting the immediacy of the IJ. The plan included revisions to the current policy including employee conduct and work place rules, review of camera footage with new auditing tool, and re-education of the nursing staff and medical providers on the policy changes.

On 02/29/2024 at 2:06 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: CARE IN SAFE SETTING

Tag No.: A0144

47397


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 observation per MD orders/Hospital policy on 8 (#F3, RF3-RF9) of 8 (#F3, RF3-RF9) patients observed on video footage;
2) failure to ensure safe staff to patient ratio;
3) failure to provide distance precautions per hospital policy.
Findings:

1) Failure to provide observation per MD orders on 8 (#F3, RF3-RF9) of 8 (#F3, RF3-RF9) patients observed on video footage.
Review of hospital policy titled "Level of Observation and Precaution" last revised, 01/22/2024, revealed in part: Policy: It is the policy of [the Hospital] to appropriately assess patients for high risk behaviors and to order and maintain special precautions to protect the welfare of the patient. Purpose, in part: To reduce the risk of patient harm to self or others as needed for patient condition, using active super vision. 2. The RN Charge Nurse is directly responsible for monitoring observation levels and precautions, and for assigning staff to carry out the ordered observations and precautions. 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. Types of Observation, in part: 2) Close Staff Sight (Q-10)-To directly observe location and activity of patient documented every ten minutes. 3) Visual Contact (VC)-This level of observation requires that the patient is kept within an area with unobstructed views such that staff has the ability to obtain an maintain eyesight readily and the patient is accessible at al times.

In an interview on 02/28/2024 at 3:00 p.m. SF2DON and SF4RM confirmed a census of 9 on Unit FA, 1 patient on hallway Ff, the other 8 (#F3, RF3-RF9) on hallway Fe. SF2DON and SF4RM further verified that on hallway Fe, 1 patient on visual contact in room Fb and the remaining patients on Q 10 minute observations. SF2DON and SF4RM verified the staff on the night shift of 02/27/2024 included SF9RN, SF7MHT, SF10MHT, SF11MHT and SF12Safety as relief and making intermittent unit rounds.

In an interview on 02/28/2024 at 3:08 p.m., SF2DON and SF3DON confirmed the following 8 patients on the night shift of 01/27/2024 on hallway Fe on Unit FA:
-Patient F3 in room Fa
-Patient RF3 in room Fd
-Patient RF4 in room Fa
-Patient RF5 in room Fa
-Patient RF6 in room Fb
-Patient RF7 in room Fd
-Patient RF8 in room Fb (VC)
-Patient RF11 (new admit) in room Fd
Room c was not occupied.

On 02/28/2024 from 2:15 p.m.-4:15 p.m., a review of video footage dated 01/27/2024 from 9:00 p.m.-2:10 a.m., revealed Unit FA, hallway Fe. Review of video footage attended by SF2DON, SF3ADON, SF4RM and SF15QC. The following was observed:

-No direct observations made for room Fa during the following periods:
10:02 p.m.-10:52 p.m.
11:20 p.m.-12:07 a.m.
12:07 am-12:40 a.m.
12:40 a.m.-1:55 a.m.

-No direct observations made for room Fb during the following periods, of note Patient RF8 was on Visual Contact in room Fb and an MHT was sitting in a chair across from room Fb. The times reflect when the MHT did not go into the room and directly observe:
9:00 p.m.-9:23 p.m.
9:23 p.m.-10:52 p.m.
10:59 p.m.-12:07 p.m.
12:07 am-1:36 a.m.
1:36 a.m.-1:55 a.m.

-No direct observations made for room Fd during the following periods:
9:00 p.m.-9:23 p.m.
9:23 p.m.-10:52 p.m.
11:23 p.m.-12:07 a.m.
12:15 a.m.-12:38 a.m.
12:38 a.m.-1:36 a.m.
1:36 a.m.-1:55 a.m.

Further observations of the video footage revealed the following:
-12:45 a.m.-12:57 a.m.-1 MHT observed going into supply closet and retrieving a pillow. Then moving chair behind door of room Fa. MHT then observed getting into chair with pillow and head on wall in what appears to be a state of sleep for approximately 15 minutes.
-1:00 a.m.-2:07 a.m.-1 MHT leaves unit, leaving 1 MHT to observe all the patients including the patient on VC in room Fb for over an hour.

In an interview on 02/28/2024 at 4:14 p.m. SF15QC and SF4RM confirmed SF9RN signed observation sheets but did not actually round per video footage. SF4RM also verified that the video footage revealed that patients were not observed per MD order or hospital policy. SF2DON and SF4RM stated that the MHTs should not be napping when they should be observing patients. SF2DON and SF4RM confirmed that 1 MHT had left the unit for over an hour leaving the other MHT alone to observe all the patients including the patient on VC precautions.

2) Failure to ensure safe staff to patient ratio.
Review of Hospital policy titled Nursing Staffing plan revised on 02/20/2020 revealed, in part: Purpose: To provide adequate coverage to meet the patient care needs while maintaining safety for patients and staff. Procedure, in part: Coverage, in part: Basic coverage includes a RN charge nurse, LPN for Adult Unit and Mental Health Technicians. 3. Staffing Mix-Direct care staffing mix is comprised of RN/LPN/MHT.

Review of hospital policy titled "Staff Assignments" last revised 02/01/2024 revealed in part: Purpose: To assure the accountability and delivery of individualized nursing care in accordance to patient need. Procedure, in part: C. Form Completion, in part: During 1:1 assignment, the staff person cannot be assigned other duties.

Observations of Adult Unit FB on 02/26/2024 at 11:05 a.m. revealed a census of 20 with 1 RN and 1 MHT on 1:1 and 2 MHTs assigned to the remaining patients. Observations failed to reveal a 4th MHT, a unit clerk or a medication nurse.

Review of staffing matrix revealed a census of 20 for 7:00 a.m. to 7:00 p.m. shift required 1 RN, 1 Med nurse, 3 MHTs, 1 unit clerk for a total of 6 staff with 5 direct care staff.

In an interview on 02/26/2024 at 1:40 P.M., SF2DON and SF4RM confirmed that there was no unit clerk or medication nurse on Unit FB for the 7:00 a.m. to 7:00 p.m shift on 02/26/2024. SF2DON verified that because of acuity level there should have been 3 MHTs assigned to the remaining patients, since 1 of the MHTs was on a 1:1 and cannot be assigned other duties. SF2DON and SF4RM verified staffing on the day shift of 02/26/2024 did not meet the staffing grid requirements.

3) Failure to provide distance precautions per hospital policy.
Review of Plan of Correction dated to be completed 02/26/2024 revealed the following, in part: ...no one MHT can have two patients that are assigned distance precaution from each other.

Review of assignment sheets for Unit FB provided by SF5MHT dated 02/26/2024, revealed a census of 20. Further review revealed SF5MHT was assigned 9 patients. Continued review revealed 2 patients, RF1 and RF2, were on distance precautions from each other.

In an interview on 02/26/2024 at 11:08 a.m., SF6RN confirmed SF5MHT had 2 patients that were on distance precautions from each other which is against hospital policy.

Review of Assignment sheet for Unit FC dated 02/26/2024, revealed a census of 18. Further review revealed SF9MHT was assigned 4 patients. Continued review revealed 2 patients, RF9 and RF10, were on distance precautions from each other.

In an interview on 02/28/2024 at 2:00 p.m., SF2DON verified the SF9MHT should not have 2 patients on distance precautions from each other, it is against hospital policy

In an interview on 02/26/2024 at 1:40 P.M., SF2DON and SF4RM confirmed that the MHTs should not have 2 patients on distance precautions from each other and that this practice is against hospital policy.

RN SUPERVISION OF NURSING CARE

Tag No.: A0395

48050

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 Nurse to supervise, observe and evaluate 8 (#F3, #RF3, #RF4, #RF5, #RF6, #RF7, #RF8, #RF11) patients per hospital policy.
Findings:

Review of hospital policy # TX.7-1001, titled "Level of Observation and Precaution", last revised on 01/22/2024, 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 camera video footage dated 02/27/2024 night shift revealed MHTs not performing observation rounding and not maintaining observation levels ordered by MD for 8 (#F3, #RF3, #RF4, #RF5, #RF6, #RF7, #RF8, #RF11) of 8 (#3, #RF3, #RF4, #RF5, #RF6, #RF7, #RF8, #RF11) patients on Unit FA Hallway Fe.

Review of 8 (#F3, #RF3, #RF4, #RF5, #RF6, #RF7, #RF8, #RF11) of 8 (#3, #RF3, #RF4, #RF5, #RF6, #RF7, #RF8, #RF11) patients' observation sheet dated 02/27/2024 revealed observations completed by the MHTs even though camera video footage didn't support observational rounding.

In an interview on 02/28/2024 at 4:10 p.m. SF4RM and SF15QC confirmed that the camera video footage of Unit FA Hallway Fe revealed that the RN on duty night shift of 02/27/2024 did not supervise and evaluate MHTs job duties as per hospital 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 failure to ensure a Registered Nurse made all patient care assignments.
Findings:

Review of hospital policy titled "Staff Assignments" last revised 02/01/2024 revealed in part: Purpose: To assure the accountability and delivery of individualized nursing care in accordance to patient need. Procedure, in part: A. Accountability. 1. In accordance to regulatory requirements, the unit is operating under the licensure of the RN. The RN assumes hospital and legal responsibility for the delegation of duties and the supervision of the delivery of nursing care while on duty. 2. The RN is responsible for the appropriateness, completeness and accuracy of the assignment sheet ...3. This is an important document that may be used for administrative follow-up, investigations or legal proceedings and must be treated as such by being legible, complete, and accurate. B. Process, in part: 2. b. Assignments include: Staff assigned to each patient. RN Charge Nurse must complete assignment sheets and update when needed.

Review of Assingment sheet for Adult Unit FB dated 02/26/2024 revealed a census of 20.

Observations of Adult Unit FB on 02/26/2024 at 11:05 a.m. revealed 1 RN (SF6RN), 1 MHT on 1:1 and 2 MHTs assigned to the remaining patients. Observations failed to reveal a 4th MHT, a unit clerk or a medication nurse.

In an interview on 02/26/2024 at 11:08 a.m., SF6RN, the charge nurse on Unit FB, stated that a patient was sent to the ER around 9:30 a.m. and the MHT who was on 1:1 was pulled to accompany the other patient to the ER. SF6RN reported the MHTs then got together and divvied up the patient assignments between them. SF6RN reported she was busy with giving report to the ER and completing medication rounds making it difficult for her to assign patients to the remaining MHTs.

In an interview on 02/26/2024 at 1:40 P.M., SF2DON and SF4RN confirmed that the MHTs should not have divided patients for assignments but SF6RN should have re-assigned the patients to the remaining MHTs and updated the assignment sheet per policy.

SUPERVISION OF CONTRACT STAFF

Tag No.: A0398

47397




48050

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 4 (#RF4, #RF5, #F3, #RF3) of the 8 (#F3, #RF3, #RF4, #RF5, #RF6, #RF7, #RF8, #RF11) patients' observation sheets reviewed.
Findings:

Review of hospital policy # TX.7-1001, titled "Level of Observation and Precaution", last revised on 01/22/2024, 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 FA's patient observations sheets dated 02/27/2024 was conducted on 02/28/2024 at 4:00 p.m. revealed SF9RN's initial on the following patients #RF4, #RF5, #F3, #RF3 at the following times: 1:10 a.m., 1:20 a.m., 1:30 a.m., 1:40 a.m., 1:50 a.m., and 2:00 a.m. The review of video camera footage for Unit FA Hallway Fe revealed SF9RN did not observe patients #RF4, #RF5, #F3, #RF3 at the following times: 1:10 a.m., 1:20 a.m., 1:30 a.m., 1:40 a.m., 1:50 a.m., and 2:00 a.m. even though SF9RN initialed the observation forms.

In an interview on 02/28/2024 at 4:14 p.m., SF4RM and SF15QC verified SF9RN had initialed the observation sheets for patients #RF4, #RF5, #F3, #RF3 at 1:10 a.m., 1:20 a.m., 1:30 a.m., 1:40 a.m., 1:50 a.m., and 2:00 a.m. SF4RM and SF15QC confirmed SF9RN had initialed the observation sheets when direct observations were not conducted per video camera footage.