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Based on record review and interviews, the hospital failed to ensure a patient's grievance was thoroughly reviewed as evidenced by failure to have documented evidence that a patient grievance submitted by Patient #3 was thoroughly reviewed and investigated. There was no documented evidence that interviews had been conducted with staff RNs providing care to Patient #1, the security officer who handcuffed Patient #3, the access center personnel who was involved in finding placement at an inpatient facility for Patient #3, and the RN who arranged for placement. This was evident in the review of 1 (#3) of 1 grievance.
Findings:

Review of the policy titled "Patient Grievance Management", presented as a current policy by S1DPS, revealed that investigation of complaints will begin within 24 hours to address the specific issue/concerns that were communicated by the patient/family. Written response of findings will be documented on the Grievance Form and sent to the Patient Relations Department within 72 hours.

Review of a grievance received on 07/07/17 submitted by Patient #3 to S9PRM revealed that Patient #3 indicated her psychiatrist had advised her to go to the ER after she had informed her psychiatrist that she was having thoughts of suicide. Further review revealed that shortly after she was PEC'd, she was informed that she would be sent to an inpatient facility. Patient #3 informed the nurse that she would like to be sent to a specific hospital that was covered by her insurance plan. Further review revealed that when Patient #3 was informed that she was being sent to a facility in Lake Charles, she refused to go, and the staff called security. Patient #3 indicated that 4 security officers went into her room and handcuffed her. Documentation revealed that she complained to the officers that the cuffs were too tight, but no adjustments were made, and she was left with a bruised and swollen arm. She reported that was still experiencing pain and swelling in her arm a week later, went to an urgent care clinic, and was diagnosed with a contusion of the right forearm.

Review of the Patient Grievance Form documented by S9PRM revealed reports were documented from S2ERM and S10MSEP. There was no documented evidence that interviews were conducted with the RNs who provided care to Patient #3, the security officer who actually handcuffed Patient #3, S8Access who handles inpatient placement for PEC'd patients, and the RN who actually received placement at the Lake Charles facility.

In an interview on 11/21/17 at 9:55 a.m., S1DPS indicated the initial grievance investigation was done by S9PRM, Manager of Patient Relations, who is no longer employed. He further indicated he was involved in the investigation on the "back end" related to the handcuffing situation. He indicated he didn't receive the CAD report documented by the sergeant who actually handcuffed Patient #3 until 11/20/17, and he had not been given the authority yet to release it to the surveyor. S1DPS confirmed the investigation was not thorough and didn't include interviews with all staff and security officers involved in Patient #3's care on 06/23/17 and 06/24/17.

A request was made to interview the sergeant who handcuffed Patient #3 and to review the report documented by the sergeant. This request was not met as of the time of exit on 11/21/17 at 2:15 p.m.

Based on observations, record reviews, and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by failing to have a safe patient room and bathroom free of ligature and safety risks for patients who were PEC'd in the ER due to being suicidal and a danger to self and having physician orders for suicide and elopement precautions. This was evident for 2 (#1, #2) of 2 PEC'd patients (assessed as suicidal and a danger to self) observed on 11/17/17 and 11/20/17 in the ER.
Findings:

Observation on 11/17/17 at 11:30 a.m. with S1DPS and S2ERM present revealed Patient #1 (who was PEC'd due to being suicidal and a danger to self and ordered to be on suicide and elopement precautions) was in Room "a" with his mother and grandmother at his bedside. Further observation revealed S3PCA was seated in a chair across the hall from the entrance to Room "a". Room "a" had a glass front that allowed S3PCA to view Patient #1. Further observation revealed ligature risks in the room that included the wires extending from the cardiac monitor hanging freely, the suction tubing hanging from the machine, and a curled stretchable cord hanging from what looked like an otoscope. Further observation revealed 3 boxes of gloves mounted on the wall that were filled with gloves that could be a risk for suffocation. There were 4 plastic bags with disposable blood pressure cuffs and a plastic bag with oxygen tubing in a bin on the table in the room. The plastic bags presented a risk for suffocation.

Observation on 11/17/17 at 12:05 p.m., Patient #1 was observed going to the bathroom near Room "b" alone with no staff present while he was in the bathroom.

Observation on 11/20/17 at 9:50 a.m. in Room "b" revealed Patient #2 (who was PEC'd due to being suicidal and a danger to self and ordered to be on suicide and elopement precautions) was sitting up in the bed with S4PCA at the bedside. Further observation revealed the room had a mounted sharps container on the wall and a mounted container of Purell hand sanitizer on the wall at the foot of the stretcher, both which were safety risks for a suicidal patient.

Observation of the bathroom outside Room "b" on 11/20/17 at 9:52 a.m. revealed the trash can had a plastic liner which could be used for suffocation. Further observation revealed a container of Purell hand sanitizer was mounted on the wall, the towel dispenser had sharp serrated edges in the area where the paper towel was released, the sink and toilet plumbing were not contained, and the screws in the room were not tamper-resistant, all which presented safety risks for a suicidal patient. These observations were confirmed by S6CNO as risks for safety for PEC'd patients.

Review of the policy titled "Suicide Prevention Plan", presented as a current policy by S1DPS, revealed that staff were to maintain a safe and therapeutic environment for all patients. All potential ligatures and sharps were to be removed from the environment, and the Safe Environment Guidelines contained in Attachment A were to be utilized. Review of Attachment A revealed the following was to be done: room placement not near an exit or exit stairwell or fire pull station; patient use of bathroom must have patient verbal confirmation continuously with staff during use; remove plastic liners from trash cans; all cords need to be removed/secured; all sharps containers are removed (if can't be removed, a new sharp container must be placed in the room on admit and will be changed when it one-fourth filled); all glove boxes/gloves are removed; secure all supplies in the room that are sharps/plastics/ligature prone.

In an interview on 11/17/17 at 11:30 a.m., S3PCS indicated her role as a PCA Sitter is to monitor the patient every 15 minutes. She further indicated she doesn't go into the bathroom with the patient when he/she goes to the bathroom unless the patient requires assistance or supervision. S3PCA confirmed that Patient #1 went to the bathroom alone during the time she was observing him.

In an interview on 11/17/17 at 11:50 a.m., S2ERM indicated Patient 31 was ordered to be on every 15 minute observations and didn't have to be in the line of sight of staff.

In an interview on 11/17/17 at 12:00 p.m. S1DPS confirmed the ER does not have a psych safe room.

In an interview on 11/20/17 at 9:58 a.m., S2ERM asked the surveyor what the problem was with having a plastic liner in the trash can, and S6CNO answered and told him it presented an opportunity for suffocation.

In an interview on 11/20/17 at 10:10 a.m., S5DIP presented a container of Purell hand sanitizer with the label attached. She confirmed that Purell hand sanitizer had an active ingredient of Ethyl alcohol 70% and could be a safety risk to suicidal patients.

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:
1) The RN failed to reassess each PEC'd patient who was suicidal and a danger to self for suicide risk every 8 hours as required by hospital policy for 3 (#1, #2, #3) of 4 (#1, #2, #3, #8) patient records reviewed for suicide risk reassessment of patients who were PEC'd due to being assessed as suicidal and having orders for suicide precautions.
2) The RN failed to ensure the patient's Suicide Monitoring Record, used by the PCA to document every 15 minute observations, included the patient's ordered level of observation and special precautions ordered by the physician for 4 (#1, #2, #3, #8) of 4 patient records reviewed for observation monitoring by the PCA.
Findings:

1) The RN failed to reassess each PEC'd patient who was suicidal and a danger to self for suicide risk every 8 hours as required by hospital policy:
Review of the policy titled "Suicide Prevention Plan, presented as a current policy by S1DPS, revealed that reassessment of suicidality will occur every 8 hours by the RN for any patient on suicide precautions or who exhibits a sudden or significant change in mental status.

Patient #1
Review of Patient #1's ER record revealed he presented to hospital's off-site campus ER on 11/16/17 at 1:18 p.m. and was ordered to be on Level 1 Standard Observation (monitor and observe minimally every 15 minutes) and on suicide and elopement precautions at 1:03 p.m. on 11/16/17. Further review revealed he was assessed for suicide risk on 11/16/17 at 1:18 p.m. at the off-site campus. Patient #1 was transferred to Tulane medical center's ER on 11/16/17 at 4:38 p.m. and was PEC'd on 11/17/17 at 9:30 a.m. due to being suicidal and a danger to self. There was no documented evidence that he was reassessed for suicide risk from the time of his initial assessment, and he was transferred to an inpatient facility on 11/17/17 at 12:09 p.m. (more than 22 hours without a reassessment of suicide risk rather than every 8 hours as required by hospital policy).

Patient #2
Review of Patient #2's ER record revealed she presented to the ER on 11/19/17 at 6:25 p.m.. She was PEC'd on 11/19/17 at 8:45 p.m. as suicidal and dangerous to self. Further review revealed physician orders were received on 11/19/17 at 6:31 p.m. for Level 1 Standard Observation and suicide and elopement precautions. Further review revealed she was assessed for suicide risk on 11/19/17 at 6:54 p.m. and 6:58 p.m. There was no documented evidence that Patient #2 was reassessed for suicide risk as of record review on 11/20/17 at 9:40 a.m. (more than 14 hours).

Patient #3
Review of patient #3's ER record revealed she presented to the ER on 06/23/17 at 3:36 p.m. and was transferred to an inpatient facility on 06/24/17 at 6:08 p.m. Further review revealed a suicide risk assessment was done on 06/23/17 at 3:42 p.m. and 4:30 p.m. There was no documented evidence that Patient #3 was reassessed for suicide risk from 4:30 p.m. on 06/23/17 through the time of transfer on 06/24/17 at 6:08 p.m. (more than 25 hours).

In an interview on 11/21/17 at 11:20 a.m. with S1DPS and S2ERM present, S2ERM confirmed the above findings after he reviewed the ER records of patients #1, #2, and #3. He indicated the RN does a shift assessment (every 12 hours) but was not required to do a suicide risk assessment after the initial suicide risk assessment was done. He further indicated he didn't know that the policy required a suicide risk assessment to be done every 8 hours by the RN.

2) The RN failed to ensure the patient's Suicide Monitoring Record, used by the PCA to document every 15 minute observations, included the patient's ordered level of observation and special precautions ordered by the physician:
Review of the policy titled "Suicide Prevention Plan, presented as a current policy by S1DPS, revealed that suicide precautions are to be clearly indicated on the assignment sheet and specific rounds sheets.

Patient #1
Review of Patient #1's Suicide Monitoring Record for 11/16/17 and 11/17/17 revealed no documented evidence that the level of observation and special precautions ordered by the physician were documented.

Patient #2
Review of Patient #2's Suicide Monitoring Record for 11/19/17 revealed no documented evidence that elopement precautions, which were ordered by the physician, were documented on the monitoring record. Further review revealed the Suicide Monitoring Record for 11/20 17 had no documented evidence of the level of observation and special precautions ordered by the physician.

Patient #3
Review of Patient #3's Suicide Monitoring Record for 06/23/17 revealed suicide precautions which were ordered by the physician were not documented on the monitoring record. Further review revealed the record for 06/24/17 had no documented evidence of the level of observation and special precautions ordered by the physician.

Patient #4
Review of Patient #4's Suicide Monitoring Record for 06/23/17 and 06/24/17 revealed no documented evidence of the level of observation and special precautions ordered by the physician.

In an interview on 11/21/17 at 11:20 a.m. with S1DPS and S2ERM present, S2ERM confirmed the above findings after he reviewed the ER records of patients #1, #2, #3, and #8.