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Based on record reviews and interviews, the hospital failed to ensure its Governing Body was effective in ensuring the hospital was compliant with the Condition of Participation for Governing Body as evidenced by S3MD not assessing a patient after a fall and not transferring the patient to the emergency department for evaluation in a timely manner for 1 (#1) of 4 (#1, #2, #3, #4) patients reviewed (See findings A0049).

Based on record review and interview, the Governing Body failed to ensure the members of the medical staff were accountable to the Governing Body for quality of care provided to patients. This deficient practice was evidenced by S3MD not assessing a patient after a fall and not transferring the patient to the emergency room for evaluation in a timely manner for 1 (#1) of 4 (#1, #2, #3, #4) patients reviewed.

Findings:

Review of Patient #1's medical record revealed an admission date of 10/19/2023. Review of the history and physical dated 10/20/2023 revealed in part, scabbed lesion to LLE (anterior just above ankle) with erythema surrounding area; bruise to right upper, inner thigh. Review of the initial nursing assessment dated 10/20/2023 revealed in part, integumentary system warm/dry and erythema with blotchy areas. Review of the nursing shift assessment dated 10/20/2023 at 11:01 a.m. revealed in part, skin color: normal; findings: skin tear, small skin tear on left inner ankle, healing well; wounds: no wounds.

Review of the incident report revealed in part, Patient #1 had a fall on 10/22/2023 at 10:30 p.m. and was found on the floor by the bathroom door. Patient #1 had already been put to bed. Further review revealed no apparent injuries to Patient #1. S3MD was notified at 10:48 p.m.

Review of the multidisciplinary note dated 10/22/2023 at 10:50 p.m. revealed in part, 10:30 p.m. while rounding, patient found on floor near bathroom door. Patient #1 asked what happened, Patient #1 was unable to verbalize why she was lying on the floor. Patient #1 had no obvious injuries to her body, no cuts, or open areas with skin assessment. Vitals taken at this time, BP 165/73; respirations 18; heart rate 71; temperature 97.4; and O2 sat 99%. Patient #1 very confused with conversation but denies any pain, staff assisted Patient #1 from floor to bed at this time. Neuro checks also began at this time. Patient #1 able to move all extremities with no problems. At 10:46 p.m. notified S3MD of incident, no new orders noted.

Review of the nursing shift assessment dated 10/23/2023 at 3:15 p.m. revealed in part, skin color: normal; findings: bruises, some bruises to BUE possibly from blood draws; wounds: no wounds. Review of the nursing shift assessment dated 10/23/2023 at 10:02 p.m. revealed in part, skin color: normal; findings: bruises, BLE bruises scattered, present; wounds: no wounds.

Further review of Patient #1's medical record revealed there were no medical progress notes on 10/23/2023.

Review of the multidisciplinary note dated 10/23/2023 at 8:15 p.m. revealed in part, Patient #1's family member stated she was going to send an ambulance to take Patient #1 to the hospital for medical evaluation claiming she probably has a broken hip. Upon assessment by charge RN tonight, Patient #1 has a very small bruise to her left hip. Patient #1's family member sent out police for a wellness check who made us call the medical doctor, S3MD. S3MD instructed the charge RN to send Patient #1 out to Hospital B for x-ray of her hip but to not send a full patient packet due to manipulative and demanding family member potentially showing up at emergency department.

Review of the multidisciplinary noted dated 10/23/2023 at 11:08 p.m. revealed in part, Patient #1's family member called police claiming her mother has broken her hip and needs to be sent out for assessment. Officer presents for wellness check. S1Adm made aware. Officer taken to Patient #1's room. When he asked if Patient #1 was in pain, Patient #1 nodded, patted her right hip and said "hip". ADLs had just been performed, Patient #1 rolled back and forth to change diaper without any complaints. No new bruising noted. Officer requests that EMS is called to assess Patient #1. S1Adm consulted, wants S3MD consulted. S3MD aware of Patient #1's history, the fall last night, and the family member's behaviors thru the weekend. Notified Officer on site requesting EMS assessment. S3MD orders noted: To Hospital B for x-rays, ED assessment, and EKG, CPK, CKMB, and troponin. Also ordered no psychiatric medical records be sent with Patient #1, nurse is to give emergency department and EMS verbal reports. Officer escorted off unit. Emergency department physician given verbal report. EMS notified. Patient #1 off unit by approximately 10:05 p.m. per stretcher per EMS in stable condition.

In a phone interview on 01/23/2024 at 4:00 p.m. S5RN stated Patient #1's family member called the hospital over and over again insisting Patient #1 had something broken. S5RN stated the charge RN assessed Patient #1 and Patient #1 had a small bruise to her hip. S5RN stated the police came to the hospital for a wellness check on Patient #1. S5RN stated the police made the staff call the physician. S5RN stated that is when the physician ordered Patient #1 to be sent to the emergency department for x-ray of Patient #1's hip.

In an interview on 01/25/2024 at 9:57 a.m. S4QD verified the physician did not assess Patient #1 on 10/23/2023 (the day after the fall).

Review of Patient #1's emergency department visit on 10/23/2023 at Hospital B revealed in part, Patient #1 arrives to emergency department via EMS from Hospital A due to right hip and right side pain that began yesterday. EMS reports Hospital A stated Patient #1 "fell". Patient #1 is poor historian, Patient #1 appears to be altered but unsure of Patient #1's baseline. Patient #1 does report right hip pain and stated that she was told she fell but doesn't remember the accident. Patient #1 has noticeable bruising on arms, upper chest, upper back, and on left upper buttock all in various stages of healing. Patient #1 can't give information on how any of the bruises have been obtained. Location of bruises: Left Side: Shoulder- yellow; Upper arm- yellow; Upper chest- yellow; Lateral elbow- light purple/blue center; Inner upper arm- dark purple; Dorsal forearm- light blue ; Knuckles- middle finger- blue; Outer buttock- yellow/purple center; Upper back by shoulder area- yellow/purple. Right Side: Shoulder- yellow / red center; Upper breast/chest area- yellow / purple center; Forearm- purple; Upper arm - yellow 2nd bruise yellow / purple center; Pointer and middle knuckle (2nd & 3rd) - purple; Dorsal side of hand - 2 bruises both purple. Differential diagnosis includes but is not limited to fall, hip fracture, head injury, knee fracture, ankle fracture. Patient #1's laboratory exam is unremarkable for any significant acute abnormalities. Patient #1 was found to have right femoral neck fracture on CT. Wet read of ankle and knee are negative. CT head was placed and is negative for any head bleed.

Based on observation, record reviews and interviews, the hospital failed to ensure care in a safe setting. This deficient practice was evidenced by:
1.) a patient obtaining injuries of unknown origin while admitted for 1 (#2) of 4 (#1, #2, #3, #4) patients reviewed;
2.) failing to screen staff for convictions that bar employment in healthcare facilities in the State of Louisiana for 1 (S7MHT) of 4 (S7MHT, S8MHT, S9MHT, S10MHT) personnel files reviewed; and
3.) failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients for safety risks.

Findings:

1.) A patient obtaining injuries of unknown origin while admitted for 1 (#2) of 4 (#1, #2, #3, #4) patients reviewed

Review of Patient #2's medical record revealed an admission date of 12/26/2023 and a discharge date of 01/05/2024. Review of the history and physical dated 12/27/2023 revealed in part, review of systems: integumentary system: negative and musculoskeletal: other: limited movement of left arm and hand. Physical exam: appearance: well nourished; other: lying in bed with left hand/fingers contracted and left arm held close to chest; skin: no bruises. Review of the initial nursing assessment dated 12/26/2023 revealed in part, posture: other: left hand contracted/bedbound; musculoskeletal: amputation: bilateral AKA; other: left hand contracted; integumentary system: no significant findings.

Review of the medical progress note dated 01/02/2024 revealed in part, history of present illness: left arm contracted chronically, right hand is bruised but non-tender, does not know how it happened. No other complaints at this time, nurse agrees. Skin: no rashes/lesions; other: right hand bruises, no LOM and non-tender, x-ray not indicated. Review of the medical progress note dated 01/04/2024 revealed in part, history of present illness: the bruise on her right arm is resolving, left humerus is bruised and tender. No other complaints at this time, nurse agrees. Skin: no rashes/lesions; other: right hand bruises, no LOM and non-tender, x-ray not indicated, bruise on left humerus. Plan: x-ray left shoulder and humerus.

Review of the physician order dated 01/04/2024 revealed in part, routine, x-ray of left humerus and left shoulder, indication: bruise on left arm and patient complains of left shoulder pain.

Review of the radiology report dated 01/05/2024 revealed in part, impression: age-indeterminate left proximal humerus fracture on limited exam. Recommend CT.

Review of the nursing shift assessment dated 01/05/2024 revealed in part, skin: bruises; other: left hand and shoulder; no new skin issues.

In an interview on 01/25/2024 at 10:30 a.m. S2DON verified Patient #2 was admitted to Hospital A with no skin issues. S2DON verified Patient #2 was discharged from Hospital A with multiple fractures. S2DON stated they did not know how Patient #2 was injured during her hospital stay.

Review of Patient #2's medical record from Nursing Home D revealed a skin inspection report dated 12/25/2023 with findings of skin intact. Further review revealed on 01/05/2024 at 2:30 p.m. Nursing Home D advised Hospital A that Patient #2 needed to be seen at the emergency department for CT to rule out fracture prior to returning to Nursing Home D. Nursing Home D would not accept Patient #2 back in facility until further imaging was completed.

Review of Patient #2's emergency department visit dated 01/05/2024 at Hospital B revealed in part, Patient #2 was seen for a right hand injury. Differential diagnosis is broad but includes fracture, contusion, strain; x-rays of right hand negative for fracture. Discharge Clinical Impression: contusion of right hand.

Further review of Patient #2's medical record from Nursing Home D revealed Patient #2 arrived to Nursing Home D on 01/05/2024. Review of the nursing note dated 01/05/2024 at 8:25 p.m. revealed in part, Patient #2 arrived to facility via ambulance from Hospital B with multiple bruises and swelling amongst multiple body parts. Patient #2 noted to be guarded and reported pain. Review of the nursing note dated 01/05/2024 at 11:00 p.m. revealed in part, at 8:40 p.m. full body audit was completed and as follows: Right hand: deep purple bruising noted to first second and third fingers with swelling. Purple and yellowish bruising to dorsum of hand, deep purple bruising noted to palm of hand. Right Side: red/yellow bruising on side close to right breast, multiple scattered dime size yellow bruises noted to right side. Right elbow: red bruising to elbow Left Arm: deep purple swelling to left upper arm with extensive swelling noted. Purple and yellow bruising to back of left arm. Purple bruising noted under left arm. Chest: red/yellow bruising noted to center of chest between breast and extending across entire chest. At 9:10 p.m. nurse practitioner was notified and wanted Patient #2 to be asked if Patient #2 wanted to be evaluated by another hospital so that Nursing Home D could know how Patient #2 needed to be treated. At 9:30 p.m., after much discussion of situation, Patient #2 agreed to be seen at another hospital.

Review of Patient #2's discharge summary dated 01/09/2024 from Hospital E revealed in part, hospital course: 67-year-old female was admitted for multiple medical issues as documented below, pneumonia, subacute to chronic intra-articular fractures of the base of the proximal phalanges 3 and 4, and subacute to chronic left comminuted humeral head fracture with associated soft tissue swelling amongst others. Patient was started on empiric antibiotics with improvement in her respiratory status. Orthopedics evaluated the patient for aforementioned conditions and recommended to continue symptomatic treatment and supportive care with no other acute interventions. Patient is being discharged on oxygen and doxycycline to complete antibiotic course for pneumonia.

2.) Failing to screen staff for convictions that bar employment in healthcare facilities in the State of Louisiana for 1 (S7MHT) of 4 (S7MHT, S8MHT, S9MHT, S10MHT) personnel files reviewed.

Review of the memo HHS 24-S-12 released 12/18/2023 regarding Criminal Convictions that Bar Employment of Unlicensed Persons or Ambulance Personnel revealed in part, "It is the responsibility of all employers that employ non-licensed persons or ambulance personnel to know which convictions bar employment. Louisiana Revised Statute 40:1203.3 covers criminal convictions that bar an employer from hiring a non-licensed person or ambulance personnel. Those criminal convictions are listed in the following table: . . . RS 14:34."

Review of personnel files was performed on 01/25/2024. The review revealed 1 unlicensed staff member with a disqualifying criminal record. S7MHT was hired on 05/31/2022. Review of the personnel file for S7MHT revealed a criminal background check was performed on 05/20/2022. The criminal background check revealed S7MHT had previously been arrested for aggravated battery with dangerous weapon (R.S.14:34). The facility hired S7MHT without further investigating if S7MHT was convicted of aggravated battery (R.S.14:34).

In an interview on 01/25/2024 at 1:20 p.m. S11HRD verified she did not have any documentation on the aggravated battery charge on S7MHT's criminal background check. She stated since it was over 10 years ago, she did not request documentation on conviction or dismissal and did not investigate further.

3.) Failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients for safety risks.

Observation on 01/17/2024 at 12:12 p.m. revealed two patient beds in Room 101 had an area under the bed which was unlocked and open and could conceal contraband.

In an interview during the observation, S2DON verified the above stated findings.

Based on record review and interview, the hospital failed to provide a patient access to their medical record. This deficient practice was evidenced by failing to provide a copy of a patient's medical record upon request according to hospital policy for 1 of 1 (Patient #1) medical records reviewed for access to their medical records from a total sample of 4.

Findings:

Review of the hospital's policy titled, "Patient Right to Request Access or Amendment to Records" revealed in part, specific requirements for releasing records in Louisiana: 1. Health care providers must provide a patient with a copy of his or her medical record within a reasonable period of time not to exceed fifteen days after the provider's receipt of the patient's request.

Review of Patient #1's medical record revealed there was a request for a copy of the medical record dated 11/20/2023.

In an interview on 01/23/2024 at 3:31 p.m. S6HIM stated she received the request for a copy of Patient #1's medical record. S6HIM stated she received the signed consent on 12/01/2023. S6HIM stated she faxed the request and consent to Company C on 12/01/2023. S6HIM stated she had not followed up with Company C on the status of this request.

In an interview on 01/25/2024 at 2:31 p.m. S2DON stated she spoke with Company C regarding this medical record request. S2DON stated Company C sent a disk on 01/05/2024. S2DON stated Company C told her that the disk was returned to them. S2DON verified 01/05/2024 was more than 15 days and out of compliance.

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by:
1.) failing to administer pain medication in a timely manner to a patient reporting pain for 1 (#1) of 4 (#1, #2, #3, #4) patients reviewed; and
2.) failing to document assessments appropriately according to the patient's condition for 1 (#2) of 4 (#1, #2, #3, #4) patients reviewed.

Findings:

1.) Failing to administer pain medication in a timely manner to a patient reporting pain for 1 (#1) of 4 (#1, #2, #3, #4) patients reviewed.

Review of the psychiatric progress note dated 10/23/2023 at 6:17 a.m. revealed in part, Patient #1 says she is hurting in her right leg. She is on pain meds, but they haven't been started yet and they are verifying them, today.

Review of the physician order dated 10/23/2023 at 12:21 p.m. Hydrocodone/Acetaminophen (Lortab) 5mg-325mg PO every six hours PRN Indication: pain.

Review of the multidisciplinary note dated 10/23/2023 at 10:08 p.m. revealed in part, at 9:46 p.m. Patient #1 reported right leg pain 8/10. Review of the medication administration record dated 10/23/2023 at 9:46 p.m. revealed Patient #1 was given Hydrocodone/Acetaminophen (Lortab) 5mg-325mg for pain; pain scale: 8.

In an interview on 01/25/2024 at 9:57 a.m. S4QD confirmed Patient #1 reported pain in the morning of 10/23/2023; pain medication order was dated and timed 10/23/2023 at 12:21 p.m.; and Patient #1 received PRN pain medication on 10/23/2023 at 9:46 p.m.

2.) Failing to document assessments appropriately according to the patient's condition for 1 (#2) of 4 (#1, #2, #3, #4) patients reviewed.

Review of Patient #2's medical record revealed an admission date of 12/26/2023. Review of the history and physical dated 12/27/2023 revealed in part, extremities: other: bilateral AKA. Review of the nursing shift assessment dated 12/27/2023 at 1:47 a.m. revealed in part, fall precautions in place: nonskid footwear. Review of the nursing shift assessment dated 12/28/2023 at 4:50 p.m. revealed in part, fall precautions in place: nonskid footwear. Review of the nursing shift assessment dated 12/28/2023 at 7:45 p.m. revealed in part, at risk for fall precautions: nonskid footwear. Review of the nursing shift assessment dated 12/29/2023 at 11:09 a.m. revealed in part, fall precautions in place: nonskid footwear. Review of the nursing shift assessment dated 12/29/2023 at 9:00 p.m. revealed in part, at risk for fall precautions: nonskid footwear. Review of the nursing shift assessment dated 12/30/2023 at 8:00 p.m. revealed in part, at risk for fall precautions: nonskid footwear. Review of the nursing shift assessment dated 01/01/2024 at 7:12 p.m. revealed in part, fall precautions in place: ambulate with assist. Review of the nursing shift assessment dated 01/02/2024 at 11:17 a.m. revealed in part, fall precautions in place: nonskid footwear. Review of the nursing shift assessment dated 01/03/2024 at 11:32 a.m. revealed in part, fall precautions in place: nonskid footwear. Review of the nursing shift assessment dated 01/04/2024 at 4:29 a.m. revealed in part, fall precautions in place: nonskid footwear. Review of the nursing shift assessment dated 01/04/2024 at 12:11 p.m. revealed in part, fall precautions in place: nonskid footwear.

In an interview on 01/22/2024 at 3:27 p.m. S2DON verified the fall precaution of non-skid footwear documentation on RN shift assessments was unacceptable documentation for Patient #2 due to Patient #2 having bilateral AKA.

In an interview on 01/22/2024 at 4:01 p.m. S2DON verified the fall precaution of ambulate with assist documentation on RN shift assessments was unacceptable documentation for Patient #2 due to Patient #2 having bilateral AKA.

Based on observation and interview, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors.

Findings:

Observation on 01/17/2024 at 12:12 p.m. of the hospital revealed peeling paint to the bottom of the walls in the hallway and to multiple entrance doors of patient rooms.

In an interview during the observation, S2DON verified the above stated findings.

Based on observation and interview, the infection control officer failed to ensure the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented. This deficient practice was evidenced by the hospital failing to maintain a sanitary environment.

Findings:

Observation on 01/17/2024 at 12:12 p.m. of the hospital revealed dead bugs in the light fixtures of Room 101 and the bathroom. Dead bugs were also observed between the plexi-glass and window in the dining room. There were 2 chairs in the dining room with the seat covers torn and could not be disinfected.

In an interview during the observation, S2DON verified the above stated findings.