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Based on observation and interview, the hospital failed to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for the patients admitted for psychiatric services by failing to ensure the patient's environment was free of ligature risks and safety hazards. Findings:

Observations made on 04/24/17 from 10:30 a.m. to 12:20 p.m. on patient care unit Oakcrest, wards 1-4 revealed the following:

Oakcrest Ward I
Observation of the ward revealed 25 bed capacity with 4 beds in six cubicles separated by a half wall and one cubicle with 1 bed. All bed were metal frame beds.

Observation of the Day Room revealed an open metal cabinet built into the wall that contained a water valve that could be used as a ligature point.. There were multiple metal pipes affixed to the lower part of the ceiling that could be used as ligature points.

Observation of the patient bathroom revealed 5 toilet stalls and 5 sinks with exposed plumbing. The faucets on the sink are not ligature-proof. The entrance door to the patient bathroom was observed to have 4 hinges with space between each hinge that could be used as ligature points.

Observation of the patient shower room revealed 3 of the 4 shower walls had an approximate 3 inch circular opening in the walls between the stalls that could be use as a ligature point. There was 1 toilet in the room that had exposed plumbing. The entrance door to the patient bathroom was observed to have 4 hinges with space between each hinge that could be used as ligature points.

Observation of the bedroom area revealed each bed had a rusted metal cabinet next to it with multiple bent, sharp metal edges that could cut a person. Some cabinets were open, some were locked, and one was closed with the key in the lock. The key could be used as a weapon.

The above observations were confirmed by S19IC at the time of the observation.


Oakcrest Ward II
Observation of the ward revealed 25 bed capacity with 4 beds in six cubicles separated by a half wall and one cubicle with 1 bed. All bed were metal frame beds.

Observation of the Day Room revealed multiple metal pipes affixed to the lower part of the ceiling that could be used as ligature points.

Observation of the patient bathroom revealed 5 toilet stalls and 5 sinks with exposed plumbing. The faucets on 4 of the 5 sinks are not ligature-proof. The entrance door to the patient bathroom was observed to have 4 hinges with space between each hinge that could be used as ligature points.

Observation of the patient shower room revealed there was 1 toilet in the room that had exposed plumbing. The entrance door to the patient bathroom was observed to have 4 hinges with space between each hinge that could be used as ligature points. An unlocked cabinet built into the wall adjacent to the entrance door was observed to have multiple plumbing/water valves that could be used as ligature points.

The above observations were confirmed by S19IC at the time of the observation.


Oakcrest Ward III
Observation of the ward revealed 25 bed capacity with 4 beds in six cubicles separated by a half wall and one cubicle with 1 bed. All bed were metal frame beds.

Observation of the Day Room revealed multiple metal pipes affixed to the lower part of the ceiling that could be used as ligature points.

Observation of the patient bathroom revealed 5 toilet stalls and 5 sinks with exposed plumbing. The faucets on 4 of the 5 sinks are not ligature-proof. The entrance door to the patient bathroom was observed to have 4 hinges with space between each hinge that could be used as ligature points. An unlocked cabinet built into the wall adjacent to the entrance door was observed to have multiple plumbing/water valves that could be used as ligature points.

Observation of the patient shower room revealed there was 1 toilet in the room that had exposed plumbing. The entrance door to the patient bathroom was observed to have 4 hinges with space between each hinge that could be used as ligature points.

The above observations were confirmed by S19IC at the time of the observation.


Oakcrest Ward IV
Observation of the ward revealed 25 bed capacity with 4 beds in six cubicles separated by a half wall and one cubicle with 1 bed. All bed were metal frame beds.

Observation of the Day Room revealed multiple metal pipes affixed to the lower part of the ceiling that could be used as ligature points.

Observation of the patient bathroom revealed 5 toilet stalls and 5 sinks with exposed plumbing. The faucets on the sinks were not ligature-proof. The entrance door to the patient bathroom was observed to have 4 hinges with space between each hinge that could be used as ligature points.

Observation of the patient shower room revealed there was 1 toilet in the room that had exposed plumbing. The entrance door to the patient bathroom was observed to have 4 hinges with space between each hinge that could be used as ligature points.

The above observations were confirmed by S19IC at the time of the observation.


Observations made on 4/24/17 from 10:30 a.m. - 12:15 p.m. on patient care unit Evangeline -Wards III and IV revealed the following:

Evangeline Ward III
Television on stand in "Quiet Room" noted to have wires and cords exposed- potential ligature risk.
13 screws in metal window facings non-tamper resistant.
Bed in seclusion room had 4 metal legs- potential ligature anchor point

Shower Room 1
Metal sheeting in shower noted to be lifted at left lower edge with non- tamper resistant screw partially unscrewed from the sheeting.
8 Screws (4 in each mirror) securing the two mirrors in the shower room were non- tamper resistant

Evangeline Ward IV
Room #2: door frame and door face plate secured with non-tamper resistant screws
Room #7: door frame and door face plate secured with non-tamper resistant screws

The above referenced findings were confirmed with S14RNMgr during the observations.


Dorthea Dix
Observation on 04/24/17 at 11:00 a.m. of Dorthea Dix-Unit 1 revealed 4 rooms with 4 beds and 2 rooms (room 105 had 3 beds and room 107 had 2 beds) with bathrooms inside the room. All entry doors and inner bathroom doors had 3 hinges with an area between the hinges that were a ligature risk, all beds had metal frames with wire springs with sharp points that could potentially be removed and the springs and the frame of the beds presented an area for ligature risk, and a single shower knob that was a ligature risk.

Further observation of Dorthea Dix-Unit 2 revealed the unit had 4 rooms with 4 beds with entry doors and inner bathroom doors that had 3 hinges with an area between the hinges that could be used as a ligature risk. All beds had metal frames with wire springs with sharp points that could potentially be removed and the springs and the frame of the beds presented an area for ligature risk. The shower faucet was observed to be a single shower knob that was a ligature risk.

Interview on 04/24/17 at 11:30 a.m. with S7PM confirmed the environmental findings on Dorthea Dix, Units 1 and 2. S7PM stated that there had been no incidents reported that he was aware of on either unit concerning ligature risks.

Cedarview -Unit 1

Observations made on 04/24/17 from 10:00 a.m. to 11:30 a.m. on patient care unit Cedarview Unit 1 revealed the following:

An observation made the Cedarview Unit revealed two locked units, with 24 patients were currently admitted to Unit 1 only. Further observation revealed a shower room with a shower stall, and on the other side of the shower wall was a bathtub with a protruding faucet that was a ligature risk. Further observation revealed one water handle to the right of the faucet that had a large screw protruding from the middle of the handle. The handle to the left of the bathtub faucet was missing and had a large metal screw, approximately protruding 3-4 inches out from the hole in the wall where the water knob would normally be.

S4RN and S5RN, both present for the interview, confirmed the observation of metal screws protruding from the handle areas of the bathtub. S5RN agreed that, although the bathtub is not used, it is still accessible to patients and the faucet was not a ligature free faucet, and the protruding large screws were a ligature and safety risk.


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30984

Based on record review and interview, the hospital failed to report alleged allegations of abuse to the Department of Health and Hospitals within 24 hours of receipt of the allegation for 1 (#2) of 1 patients reviewed for allegations of sexual abuse out of a total sample of 19 (#1-#19).

Findings:

Review of the hospital policy titled, Policy Regarding Incident Reporting, provided by S1ADM as the hospital's Abuse/Neglect policy revealed the following: The purpose of this policy is to establish an internal reporting process that expedites the notification and investigation of abuse, neglect, exploitation, extortion and CEO sensitive incidents....
C. Reporting time frames: Verbal reporting of incidents shall be made through ELMHS to the DHH Office of Aging and Adult Services/Adult Protective Services when indicated within 1 hour....The verbal report must be followed by a written Client Incident, Injury and Data Reporting form....Allegations of physical or sexual abuse are to be immediately reported to the local sheriff's office investigative unit....
There was no documented evidence of a provision for the notification of allegations of abuse/neglect to the LDH-Health Standards Section.

Review of Patient #2's medical record revealed an admission date of 01/25/17 with admission diagnoses including Schizophrenia and mild intellectual disability.

Review of the hospital's incident reports revealed the following report, dated 03/24/17 (discovery date), recounting Patient #2's report of alleged sexual abuse by another patient (#R2) to hospital staff. Patient #2 alleged that Patient #R2 came into his room and started kissing on him and touching him. Further review revealed an incident report with Patient #R2's acknowledgement that he had entered Patient #2's room and kissed and touched him after the day shift left. Additional review revealed a 3rd incident report involving a witness' (Patient #R3) statement confirming Patient #R2 had entered Patient #2's room and kissed and touched him after the day shift left.

Review of Patient #2's medical record revealed the following Progress Note entries, in part:
03/24/17 5:00 p.m. Social Service Note: Patient reported to staff that Patient #R2 was coming into his room at night "kissing and touching him and it leads to other things" This writer asked Patient #2 if he was a willing participant and patient stated,"No". Patient was asked why he didn't report this to staff. Patient stated,"I did, but they eating and they don't believe me." Patient stated he told both C and D teams.

03/24/17 5:00 p.m. CGT (corrections guard therapeutic) note: Patient #2 and Patient #R3 state to staff that Patient #R2 came into room after B team leaves and kisses and touches on him (Patient #2) in unwant(ed) area of his body.

03/24/17 5:05 p.m.: Patient #2 reported to this nurse that Patient #R2 came into his room last night and began kissing and touching him. Patient reports, "I don't want him around me".

In an interview on 04/26/17 at 1:50 p.m. with S1ADM, he indicated he had not reported the above referenced allegations to LDH-HSS (Louisiana Department of Health - Health Standards Section) within 24 hours of discovery. S1ADM indicated Critical Incidents were reported to LDH-HSS. S1ADM indicated the alleged sexual abuse had not been viewed as a Critical Incident and he felt that was where the disconnect had occurred regarding reporting to LDH-HSS.

30984

Based on record review and interview, the hospital failed to ensure the use of restraints or seclusion was in accordance with a written modification to the patient's plan of care for 3 of 3 (#4, #16, #17) sampled patients reviewed for the use of restraints out of a total sample of 19 patients.
Findings:

Review of the hospital's policy titled, Seclusion and Restraint Usage, approved date of 11/01/16 revealed the treatment plan would only be revised if an episode of Seclusion or Restraint extended for 48 hours. There was no documented evidence of a provision to update the patient's treatment plan after the use of restraints. Further review of the policy revealed a restraint was considered the application of physical force to an individual to restrict his or her freedom of movement and the physical force may be applied by human touch or mechanical device.

Patient #4
Review of the medical record for Patient #4 revealed an admission date of 04/03/17 with diagnoses including Impulse Control Disorder, Depressive Disorder, Antisocial Personality Disorder and mild intellectual disability. Further review revealed the patient had been admitted under a PEC to this facility from another facility on 04/03/17 due to physical aggression, severe property destruction, self-injurious behaviors, temper outbursts, violent acts, and sexual abuse (both perpetrator and victim). The patient was CEC on 04/04/17 for homicidal/violent behavior and being unwilling/unable to seek voluntary admission, dangerous to others, homicidal and violent.

Further review revealed Patient #4 was placed into 4 point restraints on 04/21/17 at 10:00 a.m. for violent/aggressive behavior-threatening staff and other patients. Patient #4 was documented as having been removed from the restraints at 1:30 p.m.

Review of Patient #4's plan of care revealed there had been no modification for the use of restraints on 04/21/17.

In an interview on 04/25/17 at 3:00 p.m. with S14RNMgr, she verified Patient #4's plan of care had not been updated to include the use of restraints. She confirmed the care plan should have been modified to reflect the use of restraints.


Patient #16
Review of the medical record for Patient #16 revealed the patient was a 23 year old admitted to the hospital's Oakcrest unit on 03/24/17 under Judicial-not competent to proceed status (pre-trial) with a diagnosis of Schizophrenia.

Review of the record revealed Patient #16 was placed in a manual hold on 04/14/17 at 7:36 a.m. by staff after the patient demonstrated assaultive behavior toward the staff.

Review of the plan of care for Patient #16 revealed there had been no modification for the use of restraints (Manual hold) on 04/14/17.

In an interview on 04/25/17 at 2:40 p.m., S20RN Mgr reviewed the medical record for Patient #16 and confirmed the plan of care had not been updated with the use of a manual hold. S20RN Mgr. stated the staff had been instructed to update the plan of care with the use of restraints and confirmed a manual hold was considered a restraint.


Patient #17
Review of the medical record for Patient #17 revealed the patient was a 32 year old admitted to the hospital's Oakcrest unit on 04/04/17 under Judicial-not competent to proceed status (pre-trial) with a diagnosis of Schizoaffective Disorder.

Review of the record revealed Patient #17 was placed in a manual hold on 04/04/17 at 9:08 a.m. for throwing slippers at staff. The record also revealed Patient #17 was again placed in a manual hold on 04/04/17 at 6:50 p.m. for attempting to escape from the unit when the door was opened.

Review of the plan of care for Patient #17 revealed there had been no modification for the use of restraints (Manual hold) on 04/04/17.

In an interview on 04/25/17 at 3:55 p.m., S20RN Mgr reviewed the medical record for Patient #7 and confirmed the plan of care had not been updated with the use of manual holds. S20RN Mgr. and S17DON, who was also present for the interview, confirmed the plan of care should have been updated with the use of the manual holds.

Based on policy review, record review, and interview, the medical staff failed to ensure its accountability to the governing body for the quality of medical care provided to patients. This deficient practice was evidenced by failure of the physician to perform a Suicide Risk Assessment on a patient after a change in condition, as set forth in hospital policy, for 1 (#2) of 3 (#2, #6, #16) patients reviewed out of a total sample of 19 patients.

Findings:

Review of the hospital policy titled Suicide Risk Assessment, Department: Medical Staff, Policy #: MS-09 (ELMHS#99-144) revealed in part: Purpose: To develop guidelines for the assessment and reassessment of suicide risk. Policy: It is the policy of ELMHS to assess clients for risk of suicide at the time of admission and every 6 months thereafter and as warranted by a change in the client's status. Procedure: A. Suicide Risk Assessment Guidelines 1. The Suicide Risk Assessment form based on the American Psychiatric Association guidelines for the Assessment and Treatment of patients with Suicidal behaviors, shall be completed to determine suicide risk level by an assessment of risk factors, protective factors, and conducting a suicide inquiry. B. Completion of Suicide Risk Assessment Form. 1. Identify Risk Factors that may be modified by checking all that apply. 2. Identify protective factors that may be enhanced by checking all that apply. The presence of Protective Factors may not counteract significant risk factors. 3. Complete a suicide inquiry by asking specific questions about suicidal thoughts, plans, behaviors, and intent. 4. Determine level of risk. The overall risk of suicide is based on clinical judgment since no study has identified one factor or set of risk factors as specifically predictive of suicide or other suicidal behaviors.
5. If suicide risk is identified as moderate to high, safety precautions may be implemented.


Review of Patient #2's medical record revealed an admission date of 01/25/17 with admission diagnoses including Schizophrenia and mild intellectual disability.

Further review of Patient #2's medical record revealed the following Restrictive Management Progress Note entries:
03/28/17 4:45 p.m.: Patient threatening to "kill self" went into room and started choking self with leg of jeans and biting on hands. Patient repeated self even after direction, Redirected to dayroom. Repeats "I want to kill myself" and bites on hand. New orders for 1:1 per Psychiatrist.

04/10/17 3:15 p.m.: Patient came over stating,"I'm going to commit suicide" Patient immediately walked past the monitor station to his room. This writer asked security to come assist with patient. Patient was found in his room placing a sheet around his neck and tying it. Patient was noted to turn red. Security intervened by assisting patient unwrap the sheet from around his neck. Patient was asked to come to the dayroom to be isolated. Further review revealed the patient was placed on 1:1 Direct for Suicidal gestures on 4/10/17 at 3:30 p.m.

Review of Patient #2's Medical record revealed one Suicide Risk Assessment had been performed on 01/25/17 on admission. Further review of the Suicide Risk Assessment revealed the following areas had been chosen (indicated by a check mark): Suicidal Behavior: categories within the box: History of prior attempts, Aborted attempts, Self-injurious behavior- a handwritten note within the box indicated multiple times; Psychiatric Disorder: categories within the box- mood disorder, psychotic disorder, post traumatic stress disorder, traumatic brain injury, other;
Alcohol/Substance Abuse; and Current symptoms: categories within the box: anhedonia, impulsivity, command hallucinations, anxiety/panic; Protective factors: left blank; Suicide Inquiry: suicidal ideation, plan, behavior, intent: documented with a handwritten entry-denies.
Risk level/Intervention: Assessment of risk level is based on clinical judgment after assessing of risk factors, protective factors, and suicidal inquiry. Risk Level: Low; Interventions: N/A (not applicable).
Additional review of the patient's medical record on 4/25/17 revealed no documented evidence that subsequent Suicide Risk Assessments had been performed after the above referenced changes in the patient's status, as warranted by hospital policy.

In an interview 04/25/17 at 3:00 p.m. with S14RNMgr, she confirmed additional Suicide Risk Assessments should have been performed by the physician on Patient #2 after the above referenced incidents (suicidal threats with suicidal gestures) due to changes in the patient's status.

Based on record review and interview, the hospital failed to ensure discharge summaries were developed/entered/written by the MD/DO or another qualified practitioner with admitting privileges for 3 of (#7, #9, #10) of 5 (#7, #8, #9, #10, #11) discharge records reviewed for discharge summaries out of a total sample of 19. Findings:

Review of the medical record for Patient #7 on 04/25/17 revealed the discharge summary was developed/entered/written by S22SW.

Review of the medical record for Patient #9 on 04/25/17 revealed the discharge summary was developed/entered/written by S26LCSW.

Review of the medical record for Patient #10 on 04/25/17 revealed the discharge summary was developed/entered/written by S25SWSupervisor.

Interview on 04/25/17 at 2:20 p.m., S8SSDirector indicated that discharge summaries were documented and written by the social worker. S8SSDirector gave this surveyor a copy of the ELMHS SS policy and procedure titled Discharge Planning/Aftercare/Continuity of Care: c. East division intermediate and forensic division social workers are required to dictate, or type the Doctor's Discharge Summary within 3 working days after discharge.

Review of the Medical Staff Bylaws given to this surveyor on 04/25/17 at 4:15 p.m. by S7PM revealed the following: Article XVIII Discharge Summary, Discharge Summaries shall be completed within 30 days of discharge. The Social Worker shall prepare the summary within 3 working days. The attending psychiatrist will review the summary. The Social Worker and attending psychiatrist shall sign and date the summary within 30 days of discharge. The psychiatrist will ensure the competency of the social worker by reviewing 3 summaries to ensure the adequacy of the discharge summaries and attest to the completeness and thoroughness of the summary. The Director of Social Services will maintain the competency assessment completed by the psychiatrist in the social workers competency file.

Interview on 04/26/17 at 8:20 a.m. with S1ADM confirmed the copy of the MEC Bylaws were the most current and stated that they were reviewed and revisions were made to the Discharge Summary process at the MEC meeting on 04/25/17.

Based on DEA narcotic storage requirement review, observation, and interview, the hospital failed to ensure all drugs and biologicals were kept in a secured area and locked. This deficient practice was evidenced by storage of Lorazepam (Schedule IV controlled substance) in an unlocked refrigerator on 2 (Evangeline III and Evangeline II) of 3 care units observed.

Findings:

Review of the DEA Practitioner's Manual, Section III- Security Requirements-Required Controls, revealed in part: Title 21 CFR Section 1301.71 (a) requires that all registrants provide effective controls and procedures to guard against theft and diversion of controlled substances.......Practitioners are required to store stocks of Schedule II through V controlled substances in a securely locked, substantially constructed cabinet.

On 4/24/17 at 11:05 a.m. an observation was made of the medication room on patient care unit Evangeline III. Further observation revealed 38 vials of Lorazepam 2 mg/ml injectable were being stored in an open box in an unlocked refrigerator. The findings were confirmed by S12LPN during the observation. S12LPN also confirmed the refrigerator should have been locked.


On 4/24/17 at 12:05 p.m. an observation was made of the medication room on patient care unit Evangeline II. Further observation revealed 17 vials of Lorazepam 2 mg/ml injectable were being stored in an open box in an unlocked refrigerator. The findings were confirmed by S11LPN during the observation. S11LPN also confirmed the refrigerator should have been locked.

Based on policy review and interview, the hospital failed to ensure drug administration errors, including errors that resulted in no or insignificant harm to the patient, were documented in the patient's medical record.

Findings:

Review of the hospital policy titled," Medication Administration", Policy Number: MM-17, revealed in part: C. Medication Errors: 1. Any medication error will necessitate the filling out of an Incident Report. 2. The three key types of medication errors are dispensing or administration. 3. A medication error is an incorrect drug, drug dose, dosage form or quantity..... 4. The pharmacy Director or designee must review all medication errors. 5. The physician must review the Incident Report and record comments. Additional review of the policy revealed no directive for documentation of all medication errors in patient medical records.

In an interview on 04/26/17 at 1:30 p.m. with S10RNDirector, she indicated medication errors were not currently documented in the patient's medical record.

Based on record review and staff interview, the hospital failed to ensure there was a Radiologist appointed by the Governing Body to supervise the Radiology Services on either a full-time, part-time, or consulting basis as evidenced by no documentation of a Director of Radiology for the hospital.

Findings:

A review of the hospital's organizational chart, provided by S1Administrator as a current organizational chart, revealed no documentation of a Radiologist as the Director of Radiology for the hospital.

A review of the list of credentialed physicians on the hospital's Medical Staff revealed 5 radiologists. Further review revealed no documented evidence that a Radiologist was identified as the Director of Radiology.

Review of the credentialing file for S3MD, provided by the hospital when a request was made for the credentialing file for the Director of Radiology, revealed his latest reappointment to the staff as a consultant was granted by the Governing Board for the period of 01/01/17 through 12/31/18. Further review revealed approved privileges were X-RAY Interpretation/Consultation. No documentation of a designation of Director of Radiology, or that he would be responsible for the supervision of radiological services.

Review of an agreement between Hospital A and and ELMHS revealed they would, in part provide radiological services to ELMHS patients. Further review revealed no provision for a radiologist to serve as the Director of Radiological Services.

In an interview 04/23/17 at 9:15 a.m. S2MD confirmed the hospital did not have a Medical Director of Radiology appointed or approved by the Governing Body. She confirmed the Hospital's radiology services were contracted with the host hospital (Hospital "A"), where the hospital patients had their X-rays performed.

In an interview 04/26/17 at 12:10 p.m. S1ADM and S6MD confirmed the was not a radiologist appointed by the Governing Board to supervise the radiology services received by the hospital's patients.

Based on observation and interview, the hospital failed to ensure the condition of the physical plant and the overall hospital environment was maintained in such a manner that the safety and well-being of patients was assured.
Findings:

Observations made on 04/24/17 from 10:30 a.m. - 12:15 p.m. on patient care unit Evangeline -Wards II, III, and IV revealed the following:

Evangeline Ward II
Threshold of Seclusion room rusted with a raised, rough surface.

Shower Room 3
Brown substance/stain noted on tiles of shower 1.
Sharp edges noted on the door facing, at floor level, in the shower room.
Large rectangular section of missing floor tile noted in toilet stall #1.
Missing sections of ceramic tile noted on side walls and on the walls behind the toilets in both toilet stalls.
Bathroom threshold noted to have jagged, rough edges.


Evangeline Ward III
Shower Room 1
Air vent above doorway covered with a thick coating of a gray, dust-like substance.
Broken ceramic tiles with rough edges noted on both the floor and on the wall in both bathroom stalls.
Broken ceramic tiles with rough edges noted surrounding the shower drains and on the floor of both shower stalls.
Large bolt protruding from the wall to the right of one of the bathroom lavatories.

Metal sheeting used to cover the entry to the former tub room noted to be rusted with jagged edges on both sides of the sheet metal at the level of the floor.

Shower Room 2
Broken ceramic tiles with rough edges noted surrounding the drains, the floor of the shower, and the wall of both shower stalls.
Door frame rusted at the base of the frame.
Door noted to have an open quarter sized hole (where former locking mechanism was located) with sharp edges.

Air conditioning vent located in the hallway across from Shower Room 2 was noted to be covered in a gray, dust-like substance.

Evangeline Ward IV
Medication room: dead winged insects noted in both of the overhead fluorescent lights.

The above referenced findings were confirmed with S14RNMgr during the observations.


Observations made on 04/24/17 from 10:30 a.m. - 11:15 p.m. on patient care unit Oakcrest -Wards I revealed the following:

Oakcrest I
Observation of the bathroom revealed the walls of all the stalls had missing paint with exposed metal surfaces. Peeling paint was observed over the sink near the entrance door.
Observation of the bedroom area revealed each patient bed (25 beds) had a metal cabinet beside the bed. The metal cabinets were observed to have exposed metal surfaces and rust colored areas.

Observation of the recereation room located between Ward I and Ward II revealed a table with the corner of the table broken off with exposed particle board.

The above referenced findings were confirmed with S19IC during the observation.

Based on record review and staff interview, the hospital failed to ensure psychological services were provided to meet the needs of the the patients as evidenced by failing to conduct psychological screenings in accordance with hospital policy for 2 of 2 (#6, #16) sampled patients reviewed for psychological screening out of a total sample of 19.
Findings:

Review of the hospital's time frames for assessments revised date of 11/28/16, provided by S17DON as the current time frames for assessments revealed in part the following: Psychological Evaluation: This is done upon referral from a physician with the time frame for completion dependent upon urgency of situation....Psychological evaluation referrals will be assigned to the appropriate staff members in (10) working days or less. The evaluation will be completed within (20) working days....

Patient #6
Review of the medical record for Patient #6 revealed the patient was a 60 year old admitted to the hospital on 01/05/17 under Judicial-not competent to proceed status (pre-trial) with a diagnosis of Unspecified Psychosis.
Review of the record revealed a psychological screening dated 02/08/17 signed by S21Psychologist. Review of the screening revealed the following: "Patient #6 was admitted on 01/05/17, but due to staff shortage, he was not seen by the Psychology Department until 02/08/17" (24 working days after admission).

In an interview on 04/25/17 at 11:20 a.m., S17DON reviewed the medical record and confirmed the psychological assessment dated 02/08/17 was not done timely and indicated the reason for the delay was staff shortage.


Patient #16
Review of the medical record for Patient #16 revealed the patient was a 23 year old admitted to the hospital's Oakcrest unit on 03/24/17 under Judicial-not competent to proceed status (pre-trial) with a diagnosis of Schizophrenia.
Review of the record revealed no documented evidence of a psychological screening.

In an interview on 03/25/17 at 2:40 p.m., S20RN Mgr reviewed the patient's medical record and confirmed there was no documentation of a psychological screening on the record and confirmed it had been over 20 calendar days since the patient was admitted. S20RN Mgr confirmed there should have been a psychological screening done for this patient.

Based on record review and staff interview, the hospital failed to ensure the psychosocial services were provided in accordance with the hospital policy as evidenced by failing to conduct the initial psychosocial assessments within the time frame directed in the policy for 3 (#2, #6, #16 ) of 4 (#2, #6, #16, #17) sampled patients reviewed for psychosocial assessments out of a total sample of 19.

Findings:

Review of the hospital's time frames for assessments revised date of 11/28/16, provided by S17DON as the current time frames for assessments revealed in part the following: Initial Psychosocial Assessments: Dictated in 15 working days and signed/on the chart 30 calendar days.

Patient #2
Review of Patient #2's medical record revealed an admission date of 01/25/17 with admission diagnoses including Schizophrenia and mild intellectual disability. Review of the record revealed a psychosocial assessment dated 02/13/17 (20 days after admission).

Patient #6
Review of the medical record for Patient #6 revealed the patient was a 60 year old admitted to the hospital on 01/05/17 under Judicial-not competent to proceed status (pre-trial) with a diagnosis of Unspecified Psychosis.
Review of the record revealed a psychosocial assessment dated 03/27/17 (57 working days after admission) and signed by S22SW. Further review of the record revealed no documented evidence of any attempts to conduct the initial psychosocial assessment prior to 03/27/17.

In an interview on 04/25/17 at 11:00 a.m., S20RN Mgr (Manager of the unit) reviewed the patient's record and confirmed the psychosocial assessment was not done within the required time frame and there was no documentation of why the initial assessment was delayed.

In an interview on 04/25/17 at 11:10 a.m., S22SW arrived on the unit and reviewed the medical record for Patient #6. S22SW confirmed she had conducted the initial psychosocial assessment on 03/27/17 and the assessment was not done within 15 working days of admission as required. S22SW stated she had tried to assess the patient prior to 03/27/17, but stated she had not documented any of the attempts. S22SW stated the patient refuses to cooperate and would not come to her office. S22SW stated the initial psychosocial assessment was, "a lot late."


Patient #16
Review of the medical record for Patient #16 revealed the patient was a 23 year old admitted to the hospital on 03/24/17 under Judicial-not competent to proceed status (pre-trial) with a diagnosis of Schizophrenia.
Review of the record revealed no documented evidence of an initial psychosocial assessment.

In an interview on 03/25/17 at 2:40 p.m., S20RN Mgr reviewed the patient's medical record and confirmed there was no initial psychosocial assessment on the record and confirmed it had been over 30 calendar days since the patient was admitted.