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Tag No.: A0144
Based on observation, record review, and interview the facility failed to ensure patient care in a safe and secure setting. The deficient practice is evidenced by:
1) failure to assure that personnel completed criminal background checks by an authorized agent of the Louisiana State Police in the manner required by R.S. 15:587.1 et seq. prior to hire or employment for 8 (S3MHT, S5MHT, S6MHT, S7MHT, S8MHT, S9MHT, S11MHT and S19MHT) of 14 (S1MHT, S2MHT, S3MHT, S4MHT, S5MHT, S6MHT, S7MHT, S8MHT, S9MHT, S10MHT, S11MHT, S16MT, S19MHT, and S22MHT) non-licensed direct care staff;
2) failure to review the LDH- Louisiana Adverse Action List Search website before hire and every six months for 7 (S3MHT, S4MHT, S8MHT, S11MHT, S16MHT, S19MHT and S22MHT) of 14 (S1MHT, S2MHT, S3MHT, S4MHT, S5MHT, S6MHT, S7MHT, S8MHT, S9MHT, S10MHT, S11MHT, S16MT, S19MHT, and S22MHT) non-licensed direct care staff;
3) failure to ensure each employee's personnel file had documented evidence they were free of TB (tuberculosis) in a communicable state, as required per Louisiana Public Health Sanitary Code, Title 51, Part II., for 1 (S8MHT) of 18 (S1MHT, S2MHT, S3MHT, S4MHT, S5MHT, S6MHT, S7MHT, S8MHT, S9MHT, S10MHT, S11MHT, S16MT, S19MHT, S22MHT, S12RN, S13RN, S14RN, and S15RN) personnel records reviewed.
Findings:
1) Failure to assure that personnel completed criminal background checks by an authorized agent of the Louisiana State Police in the manner required by R.S. 15:587.1 et seq. prior to hire or employment for 8 (S3MHT, S5MHT, S6MHT, S7MHT, S8MHT, S9MHT, S11MHT and S19MHT) of 14 (S1MHT, S2MHT, S3MHT, S4MHT, S5MHT, S6MHT, S7MHT, S8MHT, S9MHT, S10MHT, S11MHT, S16MT, S19MHT, and S22MHT) non-licensed direct care staff.
Review of the personnel files of S3MHT, S5MHT, S6MHT, S7MHT, S8MHT, S9MHT, S11MHT and S19MHT revealed criminal background checks completed by Company A. Further review revealed Company A was not an authorized agency of the Louisiana State Police.
In an interview on 10/18/2023 at 10:42 a.m., S12HR verified the facility previously utilized Company A for employee background checks. S8RM verified Company A was not an approved contractor by the Louisiana State Police.
2) Failure to review the LDH- Louisiana Adverse Action List Search website before hire and every six months for 7 (S3MHT, S4MHT, S8MHT, S11MHT, S16MT, S19MHT and S22MHT) of 14 (S1MHT, S2MHT, S3MHT, S4MHT, S5MHT, S6MHT, S7MHT, S8MHT, S9MHT, S10MHT, S11MHT, S16MT, S19MHT, and S22MHT) non-licensed direct care staff.
Review of the personnel files of S3MHT, S4MHT, S8MHT, S11MHT, S16MT, S19MHT and S22MHT failed to reveal evidence the facility reviewed the LDH- Louisiana Adverse Action List Search website before hire for S16MT and S22MHT and every six months for S3MHT, S4MHT, S8MHT, S11MHT, S16MT, S19MHT and S22MHT.
In an interview on 10/18/2023 at 10:13 a.m., S12HR verified the facility failed to review the LDH- Louisiana Adverse Action List Search website before hire for S16MT and S22MHT and every six months for S3MHT, S4MHT, S8MHT, S11MHT, S16MT, S19MHT and S22MHT.
3) Failure to ensure each employee's personnel file had documented evidence they were free of TB (tuberculosis) in a communicable state, as required per Louisiana Public Health Sanitary Code, Title 51, Part II., for 1 (S8MHT) of 18 (S1MHT, S2MHT, S3MHT, S4MHT, S5MHT, S6MHT, S7MHT, S8MHT, S9MHT, S10MHT, S11MHT, S16MT, S19MHT, S22MHT, S12RN, S13RN, S14RN, and S15RN) personnel records reviewed.
A review of S8MHT's personnel file revealed date of hire 07/26/2021. Further review failed to reveal evidence that S8MHT was free of TB (tuberculosis) in a communicable state, as required per Louisiana Public Health Sanitary Code, Title 51, Part II.
In an interview on 10/18/2023 at 10:00 a.m., S12HR confirmed that S8MHT's personnel file failed to reveal evidence that S8MHT was free of TB (tuberculosis) in a communicable state, as required per Louisiana Public Health Sanitary Code, Title 51, Part II.
Tag No.: A0166
Based on record review and interview, the hospital failed to ensure the use of restraints was in accordance with a written modification to the patient's plan of care for 1 (#5) of 9 (#1-#9) patients sampled for restraint/manual holds.
Findings:
Review of the hospital policy titled, "Restraint/Seclusion" revealed in part: Purpose, in part: To provide guidelines for the appropriate, safe and limited use of seclusion and restraints. C. Treatment planning, in part: ...strategies for prevention of restraint/seclusion use will be incorporated into the Plan of Care, in part: c. Seclusion/restraint risks and factors that could minimize the use of seclusion/restraints are identified ...This information along with information obtained from multidisciplinary assessments will be utilized to formulate preventative strategies for patient identified with psychiatric conditions and/or high risk behaviors that are a danger to self or others. 2. Master Treatment plan, in part: b. Behavioral objectives will be developed to address target behavior. C. Staff interventions for the management of the behaviors ...will be identified. 3. Following MTP, in part: If patient's condition changes ...this can be noted in the progress noted until treatment plan update.
Review of Patient #5's medical record revealed a physician order dated 09/13/2023 for physical restraint due to extremely agitated and violent behavior. The patient was in a manual hold until the staff administered PRN medication.
Review of Patient #5's Multidisciplinary Treatment Plan failed to reveal documented evidence that the patient's treatment plan had been revised after the above referenced physical hold on 09/13/2023.
In an interview on 10/17/2023 at 2:05 p.m., S18ADON verified there were no treatment plan revisions concerning the above referenced physical hold that occurred on 09/13/2023.
Tag No.: A0168
Based on record review and interview, the hospital failed to ensure orders for restraints were executed in accord with hospital policy. The deficient practice is evidenced by failure of the physician to authenticate restraint orders within 24 hours of initiation for 2 (#5 and #9) of 2 (#5 and #9) patients reviewed with restraint/seclusion orders.
Findings:
Review of the hospital policy titled, "Restraint/Seclusion" revealed in part: Purpose, in part: To provide guidelines for the appropriate, safe and limited use of seclusion and restraints. E. Initiation of R/S, in part: 4. In an emergency, the Nursing Supervisor/Charge Nurse, in part: a. May initiate a seclusion/restraint as a protective measure ...telephone order must be co-signed with 24 hours by the ordering MD.
Patient #5
Review of the medical record for Patient #5 revealed the patient was placed in a physical restraint on 09/13/2023 at 11:15 p.m. Review of the form titled Seclusion/Restraint Order revealed Patient #5 was extremely agitated and violent when told he needed to go to bed. Was taken to room for safety after punching TV and breaking plexiglass. Was held by staff until PRN was given.
Further review of the form revealed the orders were given by S23DNP over the telephone on 09/13/2023 at 11:50 p.m. Continued review failed to reveal the provider signed the orders.
Review of the medical record for Patient #5 revealed the patient was placed in a physical restraint on 09/30/2023 at 4:36 p.m. Review of the form titled Seclusion/Restraint Order revealed Patient #5 was very upset when asked to refrain from using the phone outside of phone time. He began kicking and punching the exit door repeatedly.
Further review of the form revealed the orders were given by S24NP over the telephone on 09/30/2023 at 4:36 p.m. Continued review failed to reveal the provider signed the orders.
Patient #9
Review of the medical record for Patient #9 revealed the patient was placed in a physical restraint on 09/11/2023 at 7:50 p.m., 8:05 p.m., 8:20 p.m., and 8:35 p.m. Review of the form titled Seclusion/Restraint Order revealed Patient #9 was extremely violent and aggressive, attacking staff after a phone call from his mother. He continued with violence and aggression, hitting and kicking staff.
Further review of the forms revealed the 4 orders were given by S23DNP over the telephone on 09/11/2023 at 7:55 p.m. Continued review failed to reveal the provider signed the orders.
Review of Patient #9's Doctor's Order Sheet revealed a telephone order given by S23DNP dated 09/11/2023 at 7:55 p.m. The order read: Give Benadryl 50 mg IM, Haldol 5 mg IM and Ativan 2 mg IM for uncontrollable violence/aggression. 1 x dose only, continue to hold until patient is calm and cooperative.
Further review failed to reveal the provider signed the telephone order for Benadryl 50 mg IM, Haldol 5 mg IM and Ativan 2 mg IM for uncontrollable violence/aggression.
In interview on 10/17/2023 at 2:57 p.m., S17RM verified the above-mentioned restraint orders for Patients #5 and #9 were not signed within 24 hours as per hospital policy by the provider who gave the telephone order. S18ADON confirmed the order for the chemical restraint for Patient #9 was not signed by the provider who gave the telephone order.
Tag No.: A0178
Based on record review and interview the facility failed to perform a face-to-face evaluation within one hour of initiation of restraint/seclusion for 1 (#9) of 2 (#5 and #9) patients reviewed for restraint/seclusion initiation.
Findings:
Review of the facility policy titled, "Restraint/Seclusion" revealed in part: Purpose, in part: To provide guidelines for the appropriate, safe and limited use of seclusion and restraints. H, in part: Face-To-Face Evaluation, in part: 1. A Physician or Qualified RN (QRN), conducts an in-person, face-to-face assessment of the patient in restraint/seclusion within 1 hour of initiation and documents findings on the One Hour Face-to-Face Evaluation.
Review of Patient #9's medical record revealed an admission date of 08/24/2023 with a diagnosis of conduct disorder, Oppositional Defiant Disorder, Attention Deficit Hyperactivity Disorder, and Intermittent Explosive Disorder.
Further review revealed Patient #9 was placed in physical restraint on 09/11/2023 at 7:50 p.m., 8:05 p.m., 8:20 p.m., and 8:35 p.m. and was later found to have resulted in a fracture of left distal tibia. The physician was notified of the need for one-hour face-to-face evaluation on 09/11/2023 at 7:55 p.m.
Continued review of Patient #9's medical record revealed the one-hour face-to-face evaluation occurred on 09/12/2023 at 5:00 a.m.
In an interview on 10/18/2023 at 1:07 p.m., S20QC verified the one-hour face-to-face evaluation was not completed within one hour of the initiation of physical restraint.
Tag No.: A0286
Based on record review and interview, the hospital failed to ensure the hospital wide QAPI program's performance improvement program implemented preventive actions. This deficient practice is evidenced by the lack of an implemented preventive action plan following an increase in patient safety incidents and injuries.
Findings:
Review of facility document dated 2023, titled "Performance Improvement Plan", revealed in part: Cycle of Continuous Improvement, in part: ACT, in part: Request corrective actions on significant differences between actual and planned results. Analyze the differences to determine their root causes. Determine where to apply changes that will include improvement of the process or service. Continuous Performance Improvement Activities, in part: Performance improvement involves two primary activities, in part: 2. Conducting performance improvement initiatives and taking action where indicated, including the design of new services and the improvement of existing services. Section 3 Goals and Objectives, in part: to carefully prioritize identified problems and set goals for their resolution; To achieve measurable improvement in the highest priority areas; To develop, adopt or modify necessary tools, such as practice guidelines, survey instruments and quality indicators. Section 4 Performance Measurement, in part: Continuous Quality Improvement involves taking action as needed based on the results of the data analysis and the opportunities for performance they identify. Characteristics of a Performance Indicator, in part: Assessment, in part: Once the performance of a process has been measured, assessed and analyzed, the information gathered by the above performance indicators is used to identify a continuous quality improvement initiative to be undertaken. Appendix B Performance Monitoring Indicators, in part: Patient injuries; Restraint/Seclusions.
A review of August 2023 Performance Improvement meeting for July revealed 141 Incidents, the highest number of incidents for the last 6 months.
A review of September 2023 Performance Improvement meeting for August revealed 37 Self-Reports, the highest number of self-reports for the last 6 months.
A review of facility incident report dated 09/27/2023 revealed Patient #5 was moved to the seclusion room where the patient repeatedly hit the back of his hand against the wall. This resulted in a self-inflected "boxer fracture" to the right hand.
A review of facility incident report dated 09/19/2023 revealed on 09/12/2023, Patient #9 received an injury during a manual hold by S19MHT resulting in fracture of left distal tibia.
A 6 month review of facility performance improvement meetings dated March 2023-September 2023, failed to reveal the performance indicator "Patient Injuries; Restraints/Seclusions" as per facility Performance Improvement plan. Further review failed to reveal Continuous Quality Improvement actions taken to prevent incidents and patient injuries based on the results of the data analysis.
In an interview on 10/18/2023 at 1:00 p.m., S20QC confirmed that the Performance Improvement findings do not include patient injuries related to restraints / seclusion incidents. S20QC reported the facility did not have documented actions taken to prevent incidents and patient injuries on the Performance Improvement meeting minutes.