HospitalInspections.org

Based on record review, observation and interview, the hospital failed to ensure care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for patients admitted for acute inpatient psychiatric services. Findings:


Review of the policy for Room Checks, Policy EOC-20 revealed in part, Nursing staff members will check patient rooms in the inpatient facility on a daily basis between 7 a.m. and noon to check patient housekeeping/hygiene habits and to check for any potentially dangerous articles and contraband. Room checks include searching drawers, looking under mattresses, etc. There was no documented evidence the procedure for room checks had been revised since the previous survey when the same hazards were identified.


In an interview on 4/13/15 at 1:45 p.m., S1DON (Director of Nursing) stated the hospital was currently revising the Acuity Policy again to include provisions to mitigate the environmental risks until all environmental changes can be installed. She stated parts have been ordered but all corrections/changes have not been done yet. She confirmed the Governing Body minutes revealed the policy was revised and approved. She stated they did discuss the changes that were going to be made to the policy for the suicidal risks and all agreed. She confirmed the policy was still under revision and had not been approved by the Governing Body. S1DON provided a copy of the policy in revision. She stated the revisions included adding a suicide risk scale to be done every 12 hours that assessed the patient that was suicidal as low, moderate, or high risk. The revision included the following: Low - routine every 15 minute checks; Moderate - Every 10 minute checks, and; High - 1:1 observation required. S1DON stated the acuity scale on the 24-Hour Daily Nursing Assessment had been changed to include the Suicide Risk Scale on each shift (Every 12 hours).


An observation was conducted on 4/13/15 at 2:15 p.m. with S1DON (Director of Nursing). Upon entering the day room, Patient #F8 and #F9 were observed sitting in the day room with no staff present. There was no staff observed to have visual observation of the patients in the day room.. A pencil was observed lying on the table in the day room. An unlocked drawer was observed to have of box of sharpened colored pencils with over 20 pencils in the box. A plastic knife was observed in another unlocked drawer. S1DON confirmed the pencils and the knife should not be left in areas where the patients have access them. Review of the medical records for Patient #F8 and Patient #F9 revealed both patients had primary diagnoses of Schizoaffective disorder and were on every 15 minute observation levels.


An observation was then made of the Soiled Utility Room across from the Nursing Station on 04/13/15 at 2:20 p.m. with S1DON. The door of the room was labeled "Biohazard" and was not locked. Inside the room mop handles, mop heads, red plastic bags, and a mop bucket were observed in the room. S1DON confirmed the Soiled Utility Room was to be kept locked at all times.


An observation was conducted on 04/13/15 at 2:28 p.m. of the shower rooms. The shower room had 3 shower stalls with each shower stall having a shower head attached to approximately a 6 foot long shower hose (hand held shower head). The knobs on the showers had a handle that presented a ligature risk also. In the ceiling of the shower room was a 3 tiered metal vent, which also was a ligature risk. S1DON confirmed the observations. S8COO (Chief Operating Officer & Intake Coordinator) was also present for the observations and stated a cover for the vent had been ordered. She confirmed patients were allowed to go into the shower rooms alone and stated the staff stand out in the ante room. The doors to the shower rooms were observed to have 4 sets of open ended pinned hinges on each door. The handle on the outside of the doors was a solid metal lip pull that represented a ligature and safety risk. The screws for the hinges, door closers, and handles were not tamper resistant. S1DON confirmed the observations of the door hinges, handles, and screws.


In an observation on 04/13/15 at 2:40 p.m. with S1DON, the doors to the patients' rooms and the bathroom doors were observed to have door hinges set apart widely enough to allow for potential ligature. The door handles on patient room doors and bathroom doors were positioned in a downward fashion to potentially facilitate ligature over the door frame. The screws for the hinges and the door handles were not tamper resistant. S1DON confirmed the above observations as potential ligature points and stated the hospital had ordered the hinges and door handles but they were not in yet.


An observation was conducted on 04/13/15 at 2:45 p.m. of the chest of drawers in every patient room. The drawers in room 21 the drawers of the chest could easily be removed. Also in Room 21 there were 3 wooden drawers that were broken and had visible splinters. In Room 16 a drawer was observed to have a portion of the face of the drawer broken away with large exposed splintering of bare wood. In all the patient bathrooms the toilet plumbing was visible and the sinks had goose-neck faucets. All the patients' beds had springs that were removable. The observation was confirmed by S1DON.


In an observation with S1DON on 04/13/15 at 2:50 p.m., the lids on the toilet tanks were not secured in the restroom near the seclusion room and patient rooms D-17, 22, and 24. S1DON confirmed the toilet lids had not been secured.


In an observation with S1DON on 04/13/15 at 2:55 p.m., a large fire extinguisher was discovered in an unlocked window case in the hallway. Patients' rooms were next to the unlocked fire extinguisher. S1DON confirmed the fire extinguisher was accessible to the patients and stated they planned to move it into an office on that hall. Over the fire extinguisher a 10 inch by 2 inch sign protruding from the wall (Indicating the fire extinguisher was located there) was observed to be loosely secured to the wall. S1DON confirmed the sign could easily be pulled off the wall and used as a weapon.


Patient #F7
Review of the medical record for Patient #F7 revealed the patient was a 45 year old male admitted to hospital on 4/10/15 at 11:35 a.m. under a PEC (Physician Emergency Certificate) for riding his bicycle into traffic in an attempt to kill himself. The PEC dated 04/09/15 at 11:51 p.m. revealed the patient presents after allegedly riding bicycle into car to kill himself. The PEC revealed the patient was currently suicidal, was dangerous to self, and unwilling/unable to seek voluntary admission. Review of the record revealed a CEC (Coroner's Emergency Certificate) dated 4/12/15 at 11:30 a.m. documented the patient was currently suicidal, was dangerous to self, and unwilling/unable to seek voluntary admission. The patient's admitting diagnosis was Bipolar Disorder.

Review of the admission orders revealed verbal orders were given by S11APRN (Advanced Practice Registered Nurse) to the RN for Every 15 minute observations and no order for suicide precautions. The Psychiatric Evaluation dated 4/10/15 at 11:50 a.m. revealed the Treatment Plan problems identified for the patient were: suicidal, psychosis, and depression.
Review of the nursing initial assessment revealed the only documentation related to suicidality was under the section, "Observation and Precautions" and the nurse checked Low, Suicidal, and Close Observation.

In an interview on 4/14/15 at 1:25 p.m. S1DON stated the hospital does not have a risk assessment for suicidal precautions. She confirmed that each nurse makes an assessment of suicidality but she has no scale or guide for the staff to use. She confirmed the nurse checked Low and Suicidal and close observations. S1DON confirmed on the physician orders a verbal order was given for every 15 minute observations and fall precautions. She confirmed suicide precautions was not checked. She confirmed they had no definitions or guidance for what Low, Moderate, or High risk meant. She stated it was each nurse's interpretation or assessment. After reviewing the psych eval, PEC and CEC all indicating the patient was suicidal, she confirmed suicide precautions were not done for this patient. She provided the hospital's Suicide Precaution policy that indicated the nurse may put a patient on nursing suicide precautions and physician must be notified immediately. The policy revealed no definition of low, moderate, high risk for suicide. The policy revealed that times conducive to a suicide attempt were the first few days after hospitalization. S1DON was unable to explain why the patient was only every 15 minute observations on admit and no suicide precautions were ordered or implemented.

Review of the hospital's plan of correction revealed the MHT (Mental Health Technicians) would conduct daily walk-through rounds at the beginning of each shift to ascertain safety of the unit. The plan of correction revealed the Environment of Care (EOC) designee would perform weekly environmental tours to identify potential safety hazards. Review of the hospitals' documentation of environmental rounds revealed none of the above identified safety hazards and ligature points were included in the forms used for the EOC rounds.





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Based on interviews and record reviews, the Governing Body failed to ensure that the hospital's QAPI (Quality Assessment Performance Improvement) program reflected all the hospital's organization and services as evidenced by not having quality indicators implemented and approved by the Governing Body for all the hospital's services, including those services furnished under contract. This failed practice was evidenced by no documented evidence in the Governing Body's meeting minutes, dated 03/31/15, or in the QAPI revised binder that the Governing Body had been presented with and/or had approved any of the QAPI program's quality indicators for any contracted/non-contracted services.
Findings:
A review of the hospital's "Quality Assurance Performance Improvement" binder, as provided by S1DON and S9ADM Asst as the revised binder revealed in part: The aim of the QAPI program is to reflect the complexity of the hospital's organization and to involve all hospital departments and services including those services furnished under contract or agreement. A review of the QAPI binder revealed that the hospital had over 22 contracted services. A review of the binder revealed a form labeled, "Quality Monitoring and Evaluation Indicator Development- Contracted Services". A further review of the form revealed 5 contracted services (Housekeeping, Infection Control, Pharmacy, Dietary, Respiratory) were listed on the form, all with the same 4 quality indicators: #1) Monthly monitoring for the specific service (no measurable quality indicators were listed); #2) Completed in a timely manner (no measurable quality indicators were listed); #3) Staff educated on contracted service (no other measurable quality indicators were listed); and #4) Any concerns/findings with contracted service. A further review of the hospital's "Quality Assurance/Performance Improvement" binder reveled no documented evidence of quality indicators for any other contracted service. The review of the binder further revealed no documented evidence of the entire hospital department's (non-contracted) quality indicators developed and approved by the Governing Body.
A review of the Governing Body meeting minutes, dated 03/31/15 and provided by S1DON as the most recent meeting minutes since the recertification survey on 03/04/15, revealed no documented evidence that the Governing Body was presented with and /or approved the QAPI program's quality indicators for all the hospital's contracted/non-contracted services.
In an interview on 04/15/15 at 11:30 a.m. with S1DON, S3CEO, S9ADM Asst, S1DON indicated that S9ADM Asst had been designated as the QAPI officer for the hospital. S1DON indicated that she and S9ADM Asst were responsible for developing and implementing the QAPI program's quality indicators for all the hospital's services (contracted and non-contracted). S1DON and S9ADM Asst indicated that they were still in the process of developing/revising the QAPI program's quality indicators for all the hospital's services (contracted/non-contracted services). S1DON, S3CEO and S9ADM Asst indicated that the hospital's Governing Body had not been presented with and the Governing Body had not approved the QAPI program's quality indicators for any the hospital's contracted/non-contracted services. S1DON and S9ADM Asst further indicated that the QAPI program's quality indicators had therefore not been implemented yet in the hospital as of 04/15/15.



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Based on interviews and record reviews, the hospital failed to ensure that policies were developed that incorporated the OPO (Organ Procurement Organization) and the hospital's definition of Clinical Triggers and Imminent Death in order to identify potential donors as agreed upon by the hospital's OPO contract and in accordance with the Louisiana Uniform Anatomical Gift Act.
Findings:

A review of the hospital policy titled, "Organ Donation", Policy number LD-15, revised dated of 11/01/11 provided by S1DON as the most current, revealed in part the following:
To ensure that every death that occurs at the Hospital is reported to the OPO and that every death is evaluated for potential organ and/or tissue donation....Charge Nurse on the unit: In the event a patient dies while at the Hospital, the OPO in notified within 1 hour of his/her death pronouncement. Notification must be made within 4 hours of cardiac arrest....For the purpose of monitoring the Organ/Tissue donation protocol a copy of the completed OPO forms and the patient death certificate will be sent by the Nursing Department to the Quality Improvement Coordinator for the purpose of maintaining quality control.
There was no other verbiage noted in the policy defining "Clinical Triggers or Imminent Death."

A review of the hospital's OPO signed contract dated 01/21/10 and provided by S1DON, as the current contract, revealed in part: Through the agreement, the parties seek to assure that families are afforded the opportunity to donate organs and tissues, in compliance with the Louisiana Uniform Anatomical Gift Act and CMS. "Clinical Triggers" is defined as any patient who is intubated and connected to a functioning ventilator, and has intact cardiac circulation, and meets a Glasgow Coma Scale of 5 or less, or other objective evaluation method, that indicates that a patient has a significant neurological deficit. Imminent Death is defined as a Donor Hospital patient who: meets the criteria for medically established "Clinical Triggers" for organ donor evaluation, or is being evaluated for a diagnosis of brain death as demonstrated by a neurological examination consistent with the diagnosis of brain death; or is under the orders of a physician to have cardiopulmonary sustaining therapies discontinued, pursuant to a decision made by an appropriate patient family decision maker. Timely referral is defined as a telephone call to the OPO by appropriate donor hospital staff within one hour of when a Donor Hospital identifies a patient that meets the Donor Hospital's definition of "Clinical Triggers: for organ donation.

In an interview on 04/15/15 at 8: 45 a.m. S1DON (Director of Nursing) reviewed the hospital's policy and procedure for Organ Donation and confirmed the policy had not been revised as indicated in the hospital's plan of correction, and did not include the hospital's clinical triggers for OPO notification or a provision that defined imminent death.