HospitalInspections.org

Based on record review and interview the psychiatric hospital failed to ensure patients (or their representatives) were informed of their patient rights. This is evidenced by failure to have documentation that 2 (#1 and #3) of 3 ( #1-#3) patients (or their representatives) reviewed for patient rights were informed of their patient rights.
Findings:

Review of psychiatric hospital's policy #1.11 titled "Rights of All Patients", dated 07/2021, revealed in part: "Procedure, in part: 2. Upon admission, the patient is provided with notification of their rights. 3. Documentation that the patient was given notification of their rights must be kept in the patient's permanent medical record. Patient Rights, in part: 15. The right to be informed of your rights and responsibilities in advance of furnishing or discontinuing care."

Patient #1
Review of Patient #1's medical record revealed an admission date of 01/02/2025 with diagnoses of Schizoaffective, bipolar type, and Urinary Tract Infection (UTI) with urinary catheter. Continued review failed to reveal documentation that Patient #1 was notified of their patient rights.

In an interview on 02/18/2025 at 3:05 PM, S1DON confirmed Patient #1's medical record failed to reveal evidence they were notified of their patient rights.

Patient #3
Review of Patient #3's medical record revealed an admission date of 11/20/2024 with diagnoses of Schizoaffective, bipolar type, and Psychosis. Continued review failed to reveal documentation that Patient #3 was notified of their patient rights.

In an interview on 02/18/2025 at 4:20 PM, S1DON confirmed Patient #3's medical record failed to reveal evidence they were notified of their patient rights.

Based on observation, record review, and interview, the facility failed to ensure patient care in a safe setting. This deficient practice is evidenced by failure to ensure 9 (#R1-#R9) patients on suicide precautions were not exposed to ligature risks in patient care area room B.
Findings:

Review of psychiatric hospital's policy #BH1117 titled "General Facility Safety and Patient Management", last revised 10/20/24, revealed in part: "Policy: Universal Behavioral Health Hospitals' environment shall be maintained in a safe, clean and orderly manner and designed to optimize positive self-regard. The facility shall be routinely checked to protect patients, visitors, and staff from potential safety hazards."

Review of psychiatric hospital's policy #BH1119 titled "Contraband and Restricted Articles" last revised 10/30/2024, revealed in part: "Policy, in part: It is the policy of Universal Behavioral Health Hospital to define as contraband those items that could pose potential safety risks to patients or threaten the integrity of the milieu. Procedure, in part: Items considered to be restricted shall include, but shall not be limited to: Bags, plastic bags."

Review of psychiatric hospital's policy #1.11 titled "Rights of All Patients", dated 07/2021, revealed in part: "Patient Rights, in part: 30. The right to receive care in a safe setting."

Review of psychiatric hospital's census dated 02/18/2025 revealed Patients #R1-#R9 were on suicide precautions.

On 02/18/2025 at 9:27 AM, Observation of room B revealed a 7-10 gallon trash receptacle lined with a plastic trash bag noted with a blue bag with fabric handles overflowing from the top of the receptacle. Over the trash receptacle was a blue sign that indicated use of paper bags only with an arrow pointing to the trash receptacle.

In an interview on 02/18/2025 at 9:27 AM, S1DON and S2RM confirmed that the plastic garbage bag and the blue bag with fabric handles were a ligature risk and should not be accessible to new patients who were brought to room B on admission.

Based on record review and interview, the hospital failed to ensure the Registered Nurse supervised and evaluated the care of each patient on an ongoing basis, in accordance with the accepted standards of nursing practice and hospital policy. This deficient practice is evidenced by failure of the Registered Nurse to document observations on 1 (#2) of 3 (#1-#3) patients every 2 hours per hospital policy.
Findings:

Review of psychiatric hospital's policy #8.08, titled "Observation Precautions", last updated 01/2024, revealed in part: "Documentation, in part: Charge nurse or designee will make rounds every 2 hours and sign the observation sheet to ensure that MHT's are observing their assigned patient, filling the form out correctly and not charting ahead."

Review of Patient #2's medical record revealed an admission date of 02/06/2025 with diagnoses of MDD, and Suicidal Ideations with a plan. Further review revealed precaution level "Suicide".

A review of Patient #2's Close Observation sheets failed to reveal the registered nurse documented observations every 2 hours as required by hospital policy on the following dates and times:

02/07/2025 from 6:15 AM-5:45 PM
02/15/2025 from 6:15 AM-3:45 PM

In an interview on 02/18/2025 at 1:57 PM, S1DON confirmed the Registered Nurse failed to document patient observations every 2 hours per hospital policy on Patient #2.

Based on record review and interview, the hospital failed to ensure the nursing staff developed an individualized nursing care plan for each patient. This deficient practice was evidenced by failure of the nursing staff to include medical diagnoses in the plan of care for 1 (#2) of 3 (#1-#3) patient care plans reviewed.
Findings:

Review of psychiatric hospital's policy #1.11 titled "Rights of All Patients", dated 07/2021, revealed in part: 43. The right to a treatment plan that is set up to meet your individual needs."

Review of psychiatric hospital's policy #1.10 titled "Rights of Involuntary Patients", last reviewed 09/2018, revealed in part: "Procedure, in part: 2. All patients receiving mental health services pursuant to the provisions of the Louisiana Mental Health Code have the following rights, in part: c. to individualized treatment plans."

Review of Patient #2's medical record revealed an admission date of 02/06/2025 with diagnoses of Human Immunodeficiency Virus (HIV) (on Biktarvy), obesity, substance abuse, MDD, anemia , gunshot wound (history of), nicotine dependence and Suicidal Ideations with a plan.

Review of Patient #2's Multidisciplinary Integrated Treatment Plan failed to reveal active problems pertaining to HIV, a medical problem requiring intervention.

In an interview on 02/18/2025 at 2:15 PM, S1DON confirmed Patient #2's treatment plan was not set up up meet his individual needs as required by hospital policy.

Based on observation, record review and interview, the psychiatric hospital failed to ensure a registered nurse assigned the nursing care of each patient to other personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available. This deficient practice is evidenced by failure to ensure an RN made all patient care assignments.
Findings:

Review of psychiatric hospital's policy #3.14, titled "Assignment of Patient Care", dated 01/2021, revealed in part: "Procedure, in part: 2. The RN on each shift will assess each patient's needs before making assignments to other nursing staff. Completion of the "Unit Assignment Sheet" will be accomplished by the Charge RN in collaboration with the lead MHT".

Observations on 02/18/2025 at 9:15 AM revealed S6MHT sitting at a table in the milieu filling out a document titled "Unit Assignments" dated 02/18/2025 for the psychiatric hospital census of 24.

In an interview on 02/18/2025 at 9:15 AM S6MHT stated she was trying to finish making the assignments for the day.

In an interview on 02/18/2025 at 9:21 AM, S1DON confirmed S6MHT was not a Registered Nurse and completed the assignment sheet dated 02/18/2025. S1DON stated the Registered Nurse should assign the nursing care of each patient but on this day the Registered Nurse was PRN (as needed) will look at assignments made by MHT and sign the sheet.

Based on observation and interview, the hospital failed to have an effective infection prevention and control program as evidenced by failing to have a clean and sanitary environment.
Findings:

Review of psychiatric hospital's policy #1.11 titled "Rights of All Patients", dated 07/2021, revealed in part: Rights which May Not Be Limited in part: 5. Safe and sanitary housing."

On 02/18/2025 at 9:23 AM, observation of room A revealed a half opened Styrofoam-like box of old-appearing food on the floor near the wall by the door with trash strewn around it.

In an interview on 02/18/2025 at 9:23 AM, S1DON confirmed the old food and trash on the floor was unsanitary and should not be in room A.

Based on observation, record review and interview the hospital failed to provide re-evaluation of the patient's condition to identify changes that required modification of the discharge plan. This deficiency is evidenced by failure of the hospital to identify changes that required modification of the discharge plan in 2 (#1 and #2) of 3 (#1-#3) patients reviewed.
Findings:

Review of psychiatric hospital's policy #2.12 titled, "Discharge Criteria/Discharge Planning Standards", dated 01/2021, revealed in part: "Procedure in part: 1. Individualized criteria for discharge are determined by the attending psychiatrist in charge of the patient's treatment and the interdisciplinary treatment team. The following criteria must be met in order to discharge a patient in part: c. There is no longer need for skilled observation and treatment. d. there is no longer an indication of impaired mental and/or physical function or mood alteration which is sufficient to interfere substantially with the patient's capacity to meet the demands of the family, educational, occupational, and social environment. e. patient has achieved maximum benefit as an inpatient and the care and treatment required by the patient can be effectively rendered on an outpatient basis or in a less restrictive seitting. f. Patient is returning to stable family and/or living situation.

Review of psychiatric hospital's policy #3.11 titled, "Discharge Planning", last updated 01/2024, revealed in part: "Procedure, in part: 3. The discharge plan will address the individual needs of the patient, be realistic and achievable, and include, but not be limited to, the following: a. Aftercare. b. Disposition. c. Education/Teaching Needs."

Review of psychiatric hospital's policy #5.24 titled, "Social Work Plan and Services", last updated 01/2024, revealed in part: "Procedure in part: Goals in part: 3. To ensure that treatment and discharge planning takes into account the patient's family and community resources.

Review of psychiatric hospital document titled, "Social Worker Job Description", last revised 07/2022, revealed in part: "Once they have determined the mental health status and treatment history of their patients, psychiatric social workers are responsible for overall case management. This can include ensuring their Patients receive the mental health support they need by, in part: Coordinating safe and effective discharges when the time comes for patients to transition to a different treatment facility or back home."

Review of psychiatric hospital document titled, "Discharge Planner Job Description", undated, revealed in part: Regularly re-evaluate a patient's condition to identify necessary modification of the discharge plan, and complete the discharge planning process in a timely manner prior to discharge. Prepare patients and their caregivers to be active partners/participants in post-discharge care. Provide discharge instructions to patient upon discharge. Conduct safety planning with patient upon discharge."

Patient #1
Review of Patient #1's medical record revealed an admission date of 01/02/2025 with diagnoses of Schizoaffective, bipolar type, and Urinary Tract Infection (UTI) with urinary catheter. Hospital Insurance was Medicare and Medicaid.

Review of Patient #1's Psychosocial Assessment dated 01/03/2025 at 11:30 AM revealed a recent discharge from another psychiatric facility on 12/31/2024 after a stay of several days. Patient's sister expressed frustration that she was not included in the discharge planning and that the patient was returned to her care without proper follow-up. Patient was unable to provide any relevant information due being disorganized. Patient was unable to authorize whether his sister could be called.

Review of Patient #1's discharge plan dated 01/03/2025 revealed patient had a catheter placement. Further review revealed decreased oral intake and risk for falls requiring assistance with bathing and ADLs daily/PRN.

In an interview on 02/19/2025 at 11:08 AM, S1DON verified Patient #1's medical record failed to reveal the urinary catheter was removed before discharge.

Review of Patient #1's Initial Discharge Planning and Collateral Contact dated 01/10/2025 revealed documentation that the patient's sister reported he was unable to care for himself and his house was in bad shape. Sister reported that he is unable to perform ADLs and stated she would rather the patient not discharge back to her house.
Documentation of current outpatient services revealed a psychiatrist.
No PCP or specialists listed, only N/A.
Listed under Barriers to a successful discharge plan: "Unable to identify at this time." Other recommended follow-up revealed N/A.

Review of Patient #1's Discharge Follow up dated 01/17/2025 at 12:09 PM revealed in part: Discharge medications included clonazepam (benzodiazepine) 0.5 mg oral tablet twice daily. Divalproex sodium (mood stabilizer that requires blood level monitoring) 250 mg oral tablet delayed release twice daily. Paliperidone (antipsychotic) 3 mg oral tablet extended release at bedtime.
Suicide Prevention, in part: Patient calm, compliant with discharge. Patient denies SI, HI, AVH. Patient understands the importance of crisis planning.
Patient understands that all follow-up appointments are recommended 5-7 days following discharge. Patient discharging home with sister with home health referral.
Patient transporting via Medicaid.
Further review revealed documentation the patient was self-ambulatory and required no assistive devices.

In an interview on 02/19/2025 at 11:08 AM, S1DON confirmed Patient #1 discharged home without a wheelchair even though he required the use of a wheelchair during his admission.

Review of Psychiatric Progress note dated 01/16/2025 (the day before discharge) revealed Patient #1 presented with significant psychiatric deterioration characterized by marked thought disorder and behavioral disorganization. The clinical presentation was notable for bizarre behaviors and significant impairment in cognitive functioning. Patient demonstrated marked difficulty with basic activities of daily living (ADLs), requiring staff assistance for basic self-care needs. There was evidence of severe thought disorder manifesting as thought blocking and notably delayed speech patterns. The patient's cognitive status showed significant impairment, with disorientation to time, place, and situation. Review of Patient #1's medical record failed to reveal a Psychiatric Progress note for 01/17/2025.

Review of Patient #1's Daily Nursing Note dated 01/17/2025 (day of discharge) revealed he appeared disheveled and unkempt. Sensorium clouded. Speech mumbled and delayed. Mood anxious. Affect anxious sullen and flat. Thought processes blocked and slowed. Thought content blocked and slowed. Perceptual disturbance was auditory.
Further review revealed Patient #1's gait/balance was jerking/unstable when walking or standing. Required use of assistive devices. Patient needed assistance with bed/wheel chair and toilet transfers.
Continued review revealed patient was anxious, flat and sullen. Patient was responding to internal stimuli. Patient was mumbling with slow delayed responses. Foley catheter was in place and patient was on 1:1 observations.

In an interview on 02/19/2025 at 2:45 PM, S1DON confirmed Patient #1's Discharge Follow-up dated 01/17/2025, Nursing Note dated 01/17/2025 and the Psychiatric Progress note dated 01/16/2025.

Review of Patient #1's Social Worker Progress Note dated 01/14/2025 at 3:23 PM revealed the discharge planner spoke with his outpatient psychiatrist who was concerned about his discharge. The discharge planner informed the psychiatrist of the discharge plan to go home with hospice care. The psychiatrist requested to speak with Patient #1. The discharge planner brought the phone into patient's room and he proceeded to blame the psychiatrist for his admission and stated his medications were messed up because of the psychiatrist. Patient #1 stated he was stuck in a psychological war and that he was being toured by his mind. Patient agreed to go to a rehab swing bed.

Review of Patient #1's Psychiatric Progress Notes dated 01/09/2025, 01/11/2025, 01/12/2025, 01/15/2025, and 01/16/2025 failed to reveal provider discussed discharge plans with patient or family.

Review of Patient #1's discharge follow-up, social worker progress notes, and discharge planning notes failed to reveal modifications to the discharge plan regarding the following:
- significant psychiatric deterioration characterized by marked thought disorder and behavioral disorganization the day before discharge,
-required urinary catheter care,
-marked difficulty with basic activities of daily living,
-need for ambulatory assistive devices,
-cognitive status that showed significant impairment, with disorientation to time, place, and situation,
-patient was responding to internal stimuli on the day of discharge.

In an interview on 02/18/2025 at 12:32 PM, S9DSS reported social services had been short staffed until the end of January.

Patient #2
Observation of hospital entrance on 02/18/2025 at 11:30 AM revealed Patient #2 returning after having been discharged on the same day at 10:15 AM. Patient #2 was expressing concern regarding the incorrect address provided to his transportation driver.

In an interview on 02/18/2025 at 11:35 AM, Patient #2 stated the social worker gave the driver the wrong address. She gave the driver the address of Shelter D instead of his brother's home. Patient #2 explained he had told the social worker yesterday afternoon that he wanted to go to his brother's home and that he did not want to go to the shelter. When he left at 10:15 AM he thought he was going to his brother's home until the driver told him the address he was being transported to was Shelter D. Patient #2 reported he did not speak to a social worker before he was discharged at 10:15 AM.

Observation of hospital entrance on 02/18/2025 at 11:40 AM revealed Patient #2 still waiting with driver for social worker too obtain correct address of his brother.

Observation of hospital entrance on 02/18/2025 at 11:45 AM revealed S5DP spoke with Patient #2 and stated she would not send him to his brother's home without speaking to his brother. S5DP stated he had to go to Shelter D where he could call his brother to get a ride. Patient #2 stated he did not want to go to the Shelter D. S5DP stated if he chose not to go to Shelter D and to wait for her to call his brother, she would have to redo all the paper work and and that would take a while. Patient #2 decided to go the shelter after social worker said she had to redo all of the paper work, which would take a while.

In an interview on 02/18/2025 at 11:50 AM, S5DP stated the discharge paper work included discharge planning and documents pertaining to Shelter D. She did not call the brother today because he was going to Shelter D. S5DP reported she was not aware Patient #2 did not want to go to shelter because she did not speak to Patient #2 before he left the hospital on 02/18/2024.

Review of Patient #2's medical record revealed an admission date of 02/06/2025 with diagnoses of HIV, substance abuse, MDD, and Suicidal Ideations with a plan.

Review of Patient #2's physician orders dated 02/17/2025 at 3:58 PM revealed the following: Discharge home 02/18/2025 with current medications and follow-up care.

Review of Patient #2's Discharge Follow-up dated 02/18/2025 and signed by nurse at 9:30 AM revealed discharge destination was "Shelter". Further review failed to reveal evidence S5DP spoke with Patient #2 on 02/18/2025.

In an interview on 02/18/2025 at 12:32 PM, S9DSS verified the discharge planner should always speak with patients before they leave the hospital. S9DSS confirmed the discharge plan should have been modified. S9DSS reported that when Patient #2 asked S5DP to call his brother on 02/18/2025 she should have called the brother to confirm his agreement with Patient #2's discharge to his home.

In an interview on 02/19/2025 at 10:38 AM, S1DON verified Patient #2's physician orders indicated Patient #2 was to discharge home 02/18/2025 with current medications and follow-up care.

Based on record review and interview the psychiatric hospital failed to assess its discharge planning process on a regular basis as evidenced by failure to complete an ongoing, periodic review of a representative sample of discharge plans to ensure that the plans are responsive to the patient post-discharge needs.
Findings:

Review of psychiatric hospital's policy #2.12 titled, "Discharge Criteria/Discharge Planning Standards", dated 01/2021, revealed in part: "Policy, in part: It is the policy of the hospital to define Discharge Planning Standards and responsibilities of the interdisciplinary staff for maintaining those standards. Purpose, in part: To ensure the continuity of care and effective utilization of resources."

Review of psychiatric hospital's documents provided by S1DON and S2RM failed to reveal evidence of an ongoing, periodic review of a representative sample of discharge plans including those patients who were admitted within 30 days of a previous admission, to ensure that the plans are responsive to the patient post-discharge needs.

During an interview on 02/19/2025 AT 10:42 AM, S1DON confirmed the psychiatric hospital has never implemented an ongoing, periodic review of a representative sample of discharge plans to assess its discharge planning process.