HospitalInspections.org

25119

Based on record review and interview, the hospital failed to ensure allegations of abuse and/or neglect were reported timely to the appropriate State Agencies for 3 (#F4, #F6, and #F7) of 4 grievances reviewed. Findings:

Review of the Hospital Grievance Log dated November 2015 revealed only 4 incidents related to allegations of abuse and/or neglect since the hospitals plan of correction date of 11/19/15.

During the review of the hospitals investigations on 11/30/15 at 2:20 p.m. SF1CEO gave surveyor documents for patient #F4 and stated that she had just been made aware of the incident on 11/15/15 was not reported to State Office within 24 hours after discovery. SF1CEO further stated that SF4DCS from the corporate office had been working with the grievance process and was on her way to the hospital and she could answer surveyor questions and provide other documentation.

Interview on 11/30/15 at 3:05 p.m. with SF4DCS confirmed that the investigation had been completed but did not know why State Office had not been contacted and it was not documented on the Hospital Abuse/Neglect Report form dated 11/16/15.

This surveyor was made aware by another surveyor doing a record review of an alleged sexual abuse incident between patient #F6 and #F7 that had allegedly occurred at 11:30 a.m. on 11/29/15.

Interview on 11/30/15 at 2:20 p.m. with SF1CEO stated that she had just been made aware of the incident. This surveyor requested documents from the incident.

Review of the incident report for patient #F6 dated 11/29/15 revealed alleged sexual abuse between patient #F6 and #F7 had occurred on 11/28/15. Patient #F6 made staff aware of allegation on 11/29/15 at 11:30 a.m. Further review of Nursing Reassessment Note dated 11/29/15 at 11:35 a.m. revealed that SF10RN documented that SF2DON was notified of incident at 12:00 p.m. on 11/29/15.

Review of the incident report for patient #F7 dated 11/29/15 had the same dated time of incident 11/28/15 with date of discovery 11/29/15 at 11:30a.m.

Interview on 11/30/15 at 3:05 p.m. with SF4DCS confirmed that the investigation had been initiated but could not explain why State Office had not been notified.

Review of the policy titled Identifying and Reporting Patient Abuse and Neglect, Document Number RI-00-007, revised date 05/15/15 revealed in part: D. Quality Risk Management Coordinator/Administrator/Director of Nursing-Designee. 2. Reports alleged or suspected cases of patient abuse or neglect in accordance with any appropriate laws, as follows: a. All allegations regarding minors must be reported ...within 24 hours of receiving. b. Report allegations regarding any patient to the Louisiana Department of Health and Hospitals.




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Based on record reviews and interviews, the DON failed to ensure that all nursing unit RNs and Intake staff received re-education on the admission process, obtaining a physician's order for the patient's observation status, and obtaining a physician's order to admit each patient as evidenced by having no documented evidence of re-education of SF11LPN (Intake staff) and the RNs who work each unit who are responsible for admitting patients when the Intake staff are off duty. This resulted in 3 (#F6, #F7, #F9) of 5 (#F1, #F2, #F6, #F7, #F9) patient records reviewed for physician orders to admit and the patient's observation status not having documented evidence of the date, time, and physician or NP who gave the order to admit and ordered the patient's observation status from a total sample of 9 patients.
Findings:

Review of the "Sign In Sheet" of a presentation on 11/17/15 by SF2DON on "Admissions Process, Observation Status, Admission Order", revealed 3 Intake staff members and SF5RN (House Supervisor) attended the in-service. There was no documented evidence that SF11LPN, an Intake staff member, had attended the in-service. Further review revealed no documented evidence that any of the unit RNs had attended the in-service. Attached to the in-service "Sign In Sheet" was a blank copy of the "Physician's Admit Order" that included the at the top of the form "Order To Admit: Unit Nurse To Call Physician/Clinician". Further review of the "Physician's Admit Order" form revealed the section titled "Order To Admit" had no designated area for the nurse or physician to sign with a date and time. Below the section of "Order To Admit" was "Admission Orders" that included a place to document the provisional diagnosis, the observation status, vital signs, diet, medical consults, lab, chest x-ray, and EKG orders, the signature for the nurse obtaining the orders with the date and time, and the signature of the physician with the date and time.

Review of the hospital policy titled "Assessment/Treatment of Patients", presented as a current policy by SF4DCS, revealed that at the time of admission, the physician will give an order for required Observation Status. The attending physician or his designee will either verbally or in writing, issue an order for required observation status.

Patient #F6
Patient #F6 was a 14 year old male admitted on 11/24/15 under a CEC signed 11/13/15 at 8:40 a.m. due to being suicidal and a danger to self. Review of his "Physician's Admit Order" revealed no documented evidence of a verbal or telephone order to admit Patient #F6. Further review revealed the "Admission Orders" were signed by SF13RN on 11/24/15 at 8:30 p.m. with no documented evidence whether SF6NP gave a verbal or telephone order that was read back by SF13RN for the admission and the observation status. SF6NP signed the order on 11/25/15 at 4:00 p.m.

In an interview on 11/30/15 at 1:40 p.m., SF5RN confirmed that SF13RN did not document a verbal or telephone order to admit Patient #F6 or for his observation status.

Patient #F7
Review of Patient #F7's medical record revealed he was a 12 year old male admitted on 11/23/15 under a PEC signed on 11/23/15 at 8:50 p.m. due to being suicidal and a danger to self. Review of his "Physician's Admit Order" revealed no documented evidence of a verbal or telephone order to admit Patient #F7. Further review revealed SF14Psychiatrist signed the order to admit on 11/24/15 at 12:00 p.m. Further review of the "Physician's Admit Order" revealed the "Admission Orders" were signed by SF12RN on 11/24/15 at 12:54 a.m. with no documented evidence of which practitioner gave the order to admit Patient #F7 and the date and time the verbal or telephone order was received. Further review revealed SF14Psychiatrist signed this section of the order on 11/24/15 at 12:00 p.m.

Patient #F9
Review of Patient #F9's medical record revealed he was a 17 year old male admitted on 11/24/15 as a FVA. Review of his "Physician's Admit Order" revealed SF11LPN documented a telephone order to admit received from SF14Psychiatrist with no documented evidence of the date and time the telephone order was received. Review of the section titled "Admission Orders" revealed SF12RN documented she obtained the physician orders for Patient #F9's observation status and treatment on 11/24/15 at 8:20 p.m. with no documented evidence of the practitioner who gave the order and whether it was received verbally or by telephone. A NP signed the admission orders on 11/25/15 at 6:30 a.m.

In an interview on 12/01/15 at 3:00 p.m., SF1CEO confirmed she had no documentation to present to show that SF11LPN and the unit RNs had attended the re-education in-service on the admission process, obtaining a physician's order for the patient's observation status, and obtaining a physician's order to admit each patient. After review of the medical record review findings related to the admit and observation level orders for Patients #F6, #F7, and #F9, SF1CEO indicated these items were presented during the in-service.

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Based on record reviews, observations, and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:
1) Failing to ensure the RN monitored the patient observations performed by the MHTs as evidenced by physician orders for Patients #F6 and #F7 to maintain a 10 feet distance restriction not being maintained during an observation on 11/30/15 at 1:55 p.m. in the hall of the Boys' Unit.
2) Failing to ensure the RN reviewed the MHT observation records for accuracy and signed the form indicating his/her review as evidenced by having no documented evidence of dates on the forms, signatures of the RN, restrictions of distance and sexual precautions when indicated, and the observation status that was ordered to assure the MHT knew what type of observation and special precautions were needed for each patient being observed for 3 (#F6, #F7, #F9) of 5 (#F1, #F2, #F6, #F7, #F9) patient record reviewed for RN supervision of the MHTs' observation of patients from a total sample of 9 patients.
3) Failing to ensure the RN clarified a physician's order for sexual precautions since the hospital did not have a sexual precaution policy for 1 (#9) of 1 patient with physician orders for sexual precautions from a total of 9 sampled patients.
4) Failing to ensure that patients on "Special Observation Q (every) 5 Minutes" were not allowed in their patient rooms without staff supervision as required by hospital policy as evidenced by SF5RN and SF7LeadMHT indicating patients with Q 5 minutes observations did not have staff supervision during sleeping hours when the MHT left the patient's room to make observations of other patients who were on Q 15 minutes observations.
Findings:

1) Failing to ensure the RN monitored the patient observations performed by the MHTs as evidenced by physician orders for Patients #F6 and #F7 to maintain a 10 feet distance restriction not being maintained during an observation on 11/30/15 at 1:55 p.m. in the hall of the Boys' Unit:
Review of Patient #F6's "Physician's Orders" revealed an order on 11/29/15 at 11:40 a.m. for Patient #F6 to have no roommate and keep a 10 feet distance from his past roommate, Patient #F7, at all times.

Observation on 11/30/15 at 1:55 p.m. revealed the boys on the Boys' Unit were lined up against the wall in the hall waiting to use the bathroom with SF7LeadMHT, SF8MHT, and SF9MHT present. Further observation revealed Patient #F6 and Patient #F7 were observed to be 7 feet apart from one another rather than 10 feet as ordered.

In an interview on 11/30/15 at 1:55 p.m., SF7LeadMHT confirmed Patient #F6 and Patient #F7 were 7 feet from one another rather than 10 feet as ordered.

In an interview on 11/30/15 at 1:56 p.m., SF8MHT indicated he was aware that Patients #F6 and #F7 were to be kept 10 feet apart from one another.

In an interview on 11/30/15 at 1:58 p.m., SF9MHT indicated he was aware that Patients #F6 and #F7 were to be kept 10 feet apart from one another.

2) Failing to ensure the RN reviewed the MHT observation records for accuracy and signed the form indicating his/her review as evidenced by having no documented evidence of dates on the forms, signatures of the RN, restrictions of distance and sexual precautions when indicated, and the observation status that was ordered to assure the MHT knew what type of observation and special precautions were needed for each patient being observed:
Review of the hospital policy titled "Assessment/Treatment of Patients", presented as a current policy by SF4DCS, revealed that the Charge RN is responsible for assigning the staff members to perform designated special observation status for each patient on his/her assigned unit. Further review revealed that documentation included the Charge Nurse will be responsible for assignment of staff to carry out ordered status. When patient exhibits acting out behaviors, a narrative note must be charted by the assigned MHT on page 2, Narrative Summary, and notes on the Tech Sheet Narrative Summary should reflect notification of behaviors to the RN/LPN and be signed by the RN/LPN. Review of the entire policy revealed no documented evidence that the RN was required to review the MHT observation record for accuracy and completeness and sign the form unless he/she was informed of a narrative note being written.

Review of the MHT Observation Record revealed the top of the form had a place to document the observation status, allergies, vital signs, diet, per cent of breakfast, lunch, and dinner consumed, the date, and check boxes for precautions, including assault, suicide, elopement, sexual, seizure, fall risk, Q5, and 1:1 (one-to-one). Further review revealed the section with the times listed included a column for the time, behavior, location, initial of MHT, and initial of RN. The bottom section of the form had lines for staff's initials and signature.

Patient #F6
Review of Patient #F6's MHT observation record revealed no dates on 3 of the forms and no indication that he was to maintain 10 feet distance restriction from Patient #F7 at all times. All 3 forms had been signed by a RN. Review of the MHT observation form begun upon admit on 11/24/14 from 7:00 p.m. through 11:00 p.m. had no documented evidence that a RN had reviewed the documentation by the MHT. Further review revealed from 7:50 p.m. through 8:40 p.m. revealed the only documentation was "N" under location (which was defined as "with nurse") with no documentation in the columns for behavior and initials of MHT and RN.

In an interview on 11/30/15 at 2:35 p.m., SF5RN and SF7LeadMHT confirmed the MHT observation records of Patient #F6 had not been dated and did not include the directive that Patients #F6 and #F7 were to maintain at least 10 feet distance between them at all times.

Patient #F7
Review of Patient #F7's MHT observation records revealed 4 records had no documented evidence of the date and that a 10 feet distance restriction was to be maintained from Patient #F6. All 4 observation records had been signed by a RN.

Patient #F9
Review of Patient #F9's MHT observation records revealed 3 forms were not dated and had been signed by a RN as having reviewed the documentation. Further review revealed Patient #F9 had physician orders for sexual precautions on 11/26/15 at 10:40 a.m. with no documented evidence of sexual precautions being checked on the observation records for dates after 11/26/15 (these records had been signed by a RN).

In an interview on 12/01/15 at 3:40 p.m., SF1CEO indicated the MHT observation records should be dated and include any special precautions or directives, such as sexual precautions and maintenance of a distance restriction when ordered.

3) Failing to ensure the RN clarified a physician's order for sexual precautions since the hospital did not have a sexual precaution policy:
Review of Patient #F9's "Child/Adolescent Integrated Assessment/Psychosocial" dated 11/24/15 revealed he had a history of inappropriate sexual behavior with small children. Review of his "Physician's orders" revealed an order on 11/26/15 at 10:40 a.m. to place him on Status C (every 5 minutes) with OUP and sexual precautions.

There was no documented evidence of a clarification order by a nurse to determine what the physician's expectations were in relation to sexual precautions.

Review of Patient #F9's MHT observation records revealed no documented evidence of sexual precautions being checked on the observation records for dates after 11/26/15 (these records had been signed by a RN).

In an interview on 11/30/15 at 3:00 p.m., SF7LeadMHT could not explain what sexual precautions included relative to the MHT's observation of Patient #F9.

In an interview on 12/01/15 at 10:00 a.m., SF1CEO confirmed the hospital did not have a sexual precaution policy. She indicated the physician should not be writing such an order without having a policy in place or clarifying what he means by sexual precautions.

4) Failing to ensure that patients on "Special Observation Q (every) 5 Minutes" were not allowed in their patient rooms without staff supervision as required by hospital policy as evidenced by SF5RN and SF7LeadMHT indicating patients with Q 5 minutes observations did not have staff supervision during sleeping hours when the MHT left the patient's room to make observations of other patients who were on Q 15 minutes observations:
Review of the hospital policy titled "Assessment/Treatment of Patients", presented as a current policy by SF4DCS, revealed that Special Observations Q 5 Minutes, Status C, requires the patient to be visualized every 5 minutes by a staff member. This is designed for patients who are viewed at risk for impulsive acts and need close monitoring by the staff. Further review revealed that all patients on observation status C will not be allowed in their patient rooms without staff supervision.

In an interview on 11/30/15 at 2:35 p.m. with SF5RN and SF7LeadMHT present, when asked if patients on Status C had staff supervision throughout the night, SF7LeadMHT indicated the MHT sits in a chair by the room of patients on Status C, but continuous staff supervision isn't done at times when the MHT has to leave to do the every 15 minutes checks on other patients assigned to him/her. SF5RN indicated he asked what staff supervision meant in regards to night hours, and the former CEO told him "it means per Status C which is every 5 minutes."

In an interview on 12/01/15 at 3:40 p.m., SF1CEO indicated the way the Status C observation policy is written, it would mean the "patient would be observed like line of sight" at night.

Based on record reviews and interviews, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan for each patient as evidenced by failing to revise the care plan for 2 patients (#F6, #F7) who were placed on distance restriction of 10 feet from one another and for 1 patient (#F9) who was placed on sexual precautions from a total of 5 (#F1, #F2, #F6, #F7, #F9) patient records reviewed for nursing care plans from a total of 9 sampled patients.
Findings:

Review of the hospital policy titled "Master Treatment Planning and review", presented as a current policy by SF4DCS, revealed that the first step in the process includes creating an initial plan of care, treatment, and services that is appropriate to the patient's specific needs. To continue to meet the patient's unique needs, the plan is maintained and revised based on the patient's response.

Patient #F6
Patient #F6 was a 14 year old male admitted on 11/24/15 under a CEC signed 11/13/15 at 8:40 a.m. due to being suicidal and a danger to self. Review of his "Master Treatment Plan Problem List" dated 11/24/15 revealed the problem of danger to self with suicidal ideation.

Review of Patient #F6's "Nursing Reassessment Notes" documented by SF10RN on 11/29/15 at 11:30 a.m. revealed that Patient #F6 reported to her and SF7LeadMHT at 11:10 a.m. that after going to bed last night, Patient #F7 had performed oral sex on him. Further review revealed SF10RN reported the allegation to SF6NP who ordered at 11:40 a.m. that Patient #F6 have no roommate and be kept at a 10 feet distance at all times from Patient #F7.

Review of Patient #F6's nursing care plan on 11/30/15 revealed no documented evidence that it had been revised to include inappropriate sexual behavior and a 10 feet distance restriction from Patient #F7.

In an interview on 11/30/15 at 2:25 p.m., SF5RN indicated the nurse was responsible for medical updates to the nursing care plan, and the social worker was responsible for psychiatric updates to the care plan.

Patient #F7
Review of Patient #F7's medical record revealed he was a 12 year old male admitted on 11/23/15 under a PEC signed on 11/23/15 at 8:50 p.m. due to being suicidal and a danger to self.

Review of Patient #F7's "Master Treatment Plan Problem List" dated 11/23/15 revealed the problem of danger to self due to Depression.

Review of Patient #F7's "Nursing Reassessment Notes" documented by SF10RN on 11/29/15 at 11:30 a.m. revealed that Patient #F7 reported that he (Patient #F7) had accidentally walked in on Patient #F6 while Patient #F6 was in the bathroom. SF10RN requested Patient #F7 to write a statement of what happened. Review of Patient #F7's statement revealed that Patient #F6 "ripped the covers off of me and he ripped my shorts down to ankles and started to play with my penis."

Review of Patient #F7's nursing care plan on 11/30/15 revealed no documented evidence that it had been revised to include inappropriate sexual behavior and a 10 feet distance restriction from Patient #F6.

Patient #F9
Review of Patient #F9's medical record revealed he was a 17 year old male admitted on 11/24/15 as a FVA.

Review of Patient #F9's "Child/Adolescent Integrated Assessment/Psychosocial" dated 11/24/15 revealed he had a history of inappropriate sexual behavior with small children. Review of his "Physician's Orders" revealed an order on 11/26/15 at 10:40 a.m. to place him on Status C (every 5 minutes) with OUP and sexual precautions.

There was no documented evidence of a clarification order by a nurse to determine what the physician's expectations were in relation to sexual precautions.

Review of Patient #F9's "Active Psychiatric problem List" dated 11/24/15 revealed problem #1 was Low Mood with suicidal ideations, and he had a problem of being a danger to others.
There was no documented evidence that his nursing care plan, which was reviewed on 11/30/15, included a history of inappropriate sexual behavior and was revised to include sexual precautions when they were ordered.

In an interview on 11/30/15 at 3:00 p.m., SF7LeadMHT could not explain what sexual precautions included relative to the MHT's observation of Patient #F9.

In an interview on 12/01/15 at 10:00 a.m., SF1CEO confirmed the hospital did not have a sexual precaution policy. She indicated the physician should not be writing such an order without having a policy in place or clarifying what he means by sexual precautions.

In an interview on 12/01/15 at 3:40 p.m., SF1CEO indicated the nurse should have updated the nursing care plan when allegations of inappropriate sexual behavior and orders for 10 feet distance restriction were received for Patients #F6 and #F7 and when Patient #F9 was ordered to be on sexual precautions.



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