HospitalInspections.org

Based on observation, record review, and interview the hospital failed to meet the Conditions of Participation (CoP) of Patient Rights. This deficient practice was evidenced by:
1) Failed to complete 15 minute observation checks by the CGT and 2 hour observation checks by RN on 19 (#3, #5, #7-#23) of 19 (#3, #5, #7-#23) patients with physician orders for 15 minute observation checks during a 3 hour time interval; and
2) Failed to increase supervision of patients with known aggressive behaviors resulting in patient injury.
(See findings under Tag A0144).

An Immediate Jeopardy (IJ) situation was identified on 10/12/2023 at 4:15 p.m. and reported to S1CEO, S2AADM, S3AADM, S4TQM, S5TQM, S6TQM, and S7TQM. The Immediate Jeopardy situation was a result of the hospital failing to complete 15 minute observation checks by CGT and 2 hour observation checks by the RN. The Immediate Jeopardy situation was also the result of the hospital failing to increase the supervision of patients with known aggressive behaviors resulting in patient injury.

On 10/12/2023 at 9:08 p.m. S1CEO presented the plan for lifting the immediacy of the IJ situation and the plan included the following:
1. The Director of Nursing Security issued a directive (attached) effective at 9:00 pm on 10/12/23 for a Correctional Guard Therapeutic-Lieutenant (CGT-LT) to be assigned to House #3. The assigned CGT-LT shall physically monitor 15-minute checks to ensure the Correctional Guard Therapeutic (CGT) staff complete rounds appropriately and document accurately.
2. In addition, a CGT-Captain has been assigned to the camera room in House #4 to observe House #3 for a secondary layer to ensure the CGT-LTs and CGTs are following the directive.
3. The Assistant Clinical Director gave a verbal directive to S22MD to review the current observational status of House #3 clients to ensure each client has the appropriate level of supervision. Any supervision level changes needed will occur on 10/13/23.

On 10/13/2023 at 11:08 a.m. S4TQM provided via email the documentation S22MD had provided. S22MD confirmed the treatment team had reviewed the observation levels of all patients on House #3. The assessment included chart review, reports from staff, and talking to all patients with history of aggressive and self-injurious behavior. S22MD further confirmed all current patients on House #3 are on appropriate level of observation and supervision.

On 10/13/2023 at 3:50 p.m. S4TQM provided via email the documentation training that has taking place:
1. East Director of Nursing retrained in person on 10/12/23 to House #3 D Team Nursing and CGTs to ensure rounds are being conducted by Nursing and Nursing-Security. Signed attestations are attached.
2. By 10/18/23, all CGTs, Psych-Aids, and Nursing staff on the East Division will receive retraining to ensure rounds are being conducted.

Documentation of staff training and signed attestations were reviewed as part of the referenced plan for IJ removal.

Observations during a facility tour on 10/16/2023 from 11:20 a.m. to 12:15 p.m. revealed House #3 having a S29CGTL- Lieutenant on duty, patients on RPM having up to date RPM logs, House #3 CGT log currently up to date, and House #3 being monitored from the main camera room on House #4 by S30CGTC-Captain.

A medical record review was performed of the patients identified in S22MD's attestation as having recent RPM changes. Confirmed current level observation as to what was being performed by the staff.

On 10/16/2023 at 3:45 p.m. the Immediate Jeopardy was removed.

Based on observation, record review, and interview, the hospital failed to provide care in a safe setting. The deficient practice is evidenced by:
1) Failure to complete 15 minute observation checks by the CGT and 2 hour observation checks by RN on 19 (#3, #5, #7-#23) of 19 (#3, #5, #7-#23) patients with physician orders for 15 minute observation checks during a 3 hour interval;
2) Failure to increase supervision of patients with known aggressive behaviors resulting in patient injury;
3) Failure to protect Patient #7 from harm by others resulting in bodily injury; and
4) Failure to appropriately monitor a Patient #2 on continuous visual observation (CVO) 15 feet distance.
Findings:

1) Failure to complete 15 minute observation checks by the CGT and 2 hour observation checks by RN on 19 (#3, #5, #7-#23) of 19 (#3, #5, #7-#23) patients with physician orders for 15 minute observation checks over a 3 hour interval

A review of facility policy PC-NUR-12 Provisions of Care, Treatment, and Services - Observation and Precautions, section V. Procedure: Routine Observation Procedure revealed in part, Item D. Routine checks are every 15 minutes. Item Nursing Care: B. An employee shall be assigned to monitor the patient routinely and document the patient's behavior at 15 minute intervals as per orders. At all times documentation shall be completed on the Psychiatric Aide/CGT Assignment Sheet. Item Documentation: C. Nursing staff shall document the initiation of the Psychiatric Aide Assignment Sheet, record observations of patients at least every 2 hours, and date and initial in the appropriate section.

An observation on 10/12/2023 at 11:30 a.m. of Hall A video recorded on 09/30/2023 from 2:45 a.m. to 3:25 a.m. revealed a S27CGT sitting on a chair at the beginning of Hall A, next to the day room. S27CGT line of sight was directed down the corridor with patient rooms on the right and the shower/restroom on the left at the far end of hall. S27CGT remains in this chair from 2:45 a.m. until 3:22:10 a.m. with very little body movement change. The video shows Patients #3 and #8 moving on the hallway, in and out of their assigned room and standing in Patient # 7's doorway for extended periods of time. At 3:20:10 a.m., Patients #3 and #8 entered Patient #7's room. Of note, patient #7's room is on the right side of the hall at the far end, opposite the restroom. At 3:22:10 a.m. Patient #7 is attacked in his bed by Patients #3 and #8. From 2:45 a.m. to 3:22:10 a.m. there is no staff movement noted on Hall A.

In an interview on 10/12/2023 at 11:45 a.m. S4TQM, S5TQM, S6TQM and S7TQM confirmed hospital staff had not walked Hall A or performed 15 minute patient observations as ordered during the above mentioned time frame.

A record review of House #3 CGT Log Book revealed entries being authenticated by S26CGT every 15 minutes on 09/30/2023 from 00:15 a.m. to 3:15 a.m. The entries revealed: 0015 Security check made all secure S26CGT; 0030 H/C 31pts. 5 sets of keys, 1H/H scanner S26CGT; 0045 Security check made all secure S26CGT; 0100 Security check made all secure S26CGT; 0115 Security check made all secure S26CGT; 0130 H/C 31pts. 5 sets of keys, 1H/H scanner S26CGT; 0145 Security check made all secure S26CGT; 0200 locker check complete, all locked & secure S26CGT; 0215 Security check made all secure S26CGT; 0230 H/C 31pts. 5 sets of keys, 1H/H scanner S26CGT; 0245 Security check made all secure S26CGT; 0300 Security check made all secure S26CGT; and 0315 Security check made all secure S26CGT.

A record review of House #3 nurse log 09/29/2023 6:00 p.m. - 6:00 a.m. revealed an entry for, "1800, 2000, 2200, 2400, 0200, 0400 RN rounds." Also, an entry indicated 2 patients on 1:1 observation status located on another hall. S17RN was identified as the nurse on the unit during this shift.

In an interview on 10/12/2023 at 3:00 p.m. S5TQM confirmed S4TQM, S5TQM, S6TQM and S7TQM had reviewed video of Hall A recorded on 09/30/2023 from 00:13 a.m. until 3:22:10 a.m. (time of the altercation). S5TQM confirmed the last 15 minute observation check was conducted on 09/30/2023 at 00:13 a.m. and hospital staff had not conducted 15 minute observation checks of Hall A from 00:30 a.m. until 3:22:10 a.m. S5TQM also confirmed a nurse had not performed observation rounds on Hall A during this time. S5TQM confirmed all 19 patients on Hall A of House #3 had a physician order for Routine Observation during this documented time frame. S5TQM confirmed Hall A patient's observation checks were documented as being performed by an entry on the nurse's log for 2:00 a.m. and on the CGT's log for being performed every 15 minutes. S5TQM confirmed S17RN and S26CGT as the staff authenticating these entries in the logs.

2) Failure to increase supervision of patients with known aggressive behaviors resulting in patient injury

A medical record review of Patient #8 revealed a pattern of aggressive behavior. Incidents for 09/2023 were reviewed. These behaviors occurred in the evening hours in 4 of the 5 incidents. Additionally, in 5 of 5 of the incidents, all occurred unprovoked. Patient #8's level of observation was ordered as Routine Observation during all of these incidents. The incidents included an unprovoked attack of another patient on 09/07/2023 at 9:50 p.m.; an unprovoked attack of another patient on 09/08/2023 at 9:50 p.m.; an unprovoked attack of another patient involved in a separate altercation on 09/17/2023 at 9:15 p.m.; and an unprovoked attack of another patient involved in a separate altercation on 09/29/2023 at 8:30 p.m.; and an unprovoked attack of another patient on 09/30/2023 at 3:22 a.m. None of the previously mentioned behaviors resulted in a treatment change or restrictive patient management/observation. The last mention attack resulted in patient injury requiring outside emergency medical attention.

In an interview on 10/12/2023 at 10:10 a.m. S7TQM confirmed the above mentioned incidents did not result in treatment changes to Patient #8's level of observation.

3) Failure to protect Patient #7 from harm by others resulting in bodily injury

An observation of video from 09/30/2023 from 2:45 a.m. to 3:25 a.m. revealed, in part: At 3:20:10 a.m. Patients #3 and #8 entered Patient #7's room while he was sleeping. They each have an object in there hand. Patient #3 appeared to have a pillowcase with an object placed in it and Patient #8 appeared to have a sock with an object placed in it. At approximately 3:22:10 a.m. Patients #3 and #8 began striking patient #3 with the objects they each carried into the room. The striking of the patient continued for approximately 17 seconds before the CGTs could remove the 2 aggressors from Patient #7's room.

A medical record review of Patient #7 revealed the injuries that resulted from the incident included a fracture of the right hand, a fracture of the nasal bone, swelling right forehead/orbital area, and right ocular abrasion.

In an interview on 10/12/2023 at 11:30 a.m. S4TQM. S5TQM, S6TQM, and S7TQM confirmed the above mentioned observations and injuries to patient #7.

4) Failure to appropriately monitor a patient on continuous visual observation (CVO) 15 feet distance

A review of facility policy PC-NUR-12 Provisions of Care, Treatment, and Services - Observation and Precautions, section V. Procedure: Routine Observation Procedure revealed in part, section I. Definitions C. Continuous Visual Observation at 15 feet: The patient is continually observed from a distance of not more than 15 feet from the assigned staff Member. Section V. Procedure Continuous Visual Observation at 15 feet in distance, Nursing Care item A. An employee shall be assigned to visually monitor the patient continuously and document patient's behavior at 15 minute intervals. Item B. The staff shall maintain observation at all times unless relieved by another staff member. Documentation, item D. The nurse assigned to the patient shall perform routine observation checks (at least every 2 hours) and document finding on flow sheet followed by date and initials in appropriate section of form. Item E. RN assigned to patient shall perform routine observation checks at the beginning and end of shift.

A review of the Hospital Abuse/Neglect Initial Report revealed Patient #2 was able to make his way to the restroom with bed blanket, wrap one end of the blanket around his neck, and wedge the blanket into the door in an attempt to hang himself.

An observation of the restroom on House #1 on 10/05/2023 at 11:30 a.m. revealed the restroom having individual, stalled toilet areas with a wood door on the front of each stall. The stall walls and the wood door were approximately 5 feet in height. The doors on each stall had square edges along the top and hinged to the stall walls. There is a gap where each door is hinged to the stall wall. This gap created a ligature point.

A medical record review of Patient #2 revealed an admit date of 08/23/2023 under judicial hold for evaluation of competency to stand trial. The patient's diagnosis was Schizophrenia. The patient was currently on CVO of not more than 15 feet for aggressive behaviors. The patient was scheduled to be discharge on 10/04/2023 to the parish from which he was arrested because he had been deemed competent to stand trial. A nursing note on 10/03/2023 at 12:30 p.m. revealed, "Client was pacing, saying, "I can't do this anymore." And saying he has to stay awake. Asked to be placed in locked seclusion." Patient remained in open door seclusion for 2 minutes being observed by S24CGT. Patient then exited the room and said "Never-mind, I don't need that." The nurse note also indicated the MD was notified of behavioral changes at this time.

An observation on 10/09/2023 at 10:25 a.m. of House #2 video recorded on 10/03/2023 beginning at 12:15 p.m. revealed, in part: At 12:27:50 p.m. Patient #2 was in the pod of the sleeping dormitory with two CGT's present. S23CGT was assigned to Patient #2 and S25CGT was present for RPM of another patient in same pod. Patient #2 is observed placing a bulky jacket on with his back to both CGT's present. At the same time as the jacket was being buttoned up, Patient #2 grabbed a blanket and placed it under his jacket. He immediately placed his hands into the pockets of the jacket to hold the blanket in place and to disguise the bulkiness in the front of his body. Patient #2 immediately walked to the restroom. S23CGT follows but does not enter the restroom with the patient. S23CGT remained outside the door of the restroom in the corridor. Patient #2 remained in the restroom for approximately 68 seconds. After the exit from the restroom, the video reflected the encounter previously mentioned with the nurse and the 2 minutes he kept himself in seclusion. Over the next 30-40 minutes, Patient #2 makes trips in and out of the restroom. Each time he remains in the restroom a few minutes and on each occasion, S23CGT does not accompany the patient in the restroom. Patient #2 continued moving around the ward with his hands in the front pockets of the jacket from 12:27:50 p.m. till 1:23:15 p.m. Of note, the bulkiness of the jacket appeared to the surveyor as something being under the jacket. Patient #2 entered the restroom at 1:23:15 p.m. with S23CGT remaining outside the door of the restroom. During the next 24 minutes and 24 seconds, S23CGT remained outside the restroom door. S23CGT opened the door and looked into the restroom 3 times-1:27:10 p.m., 1:36:40 p.m. and 1:45:51 p.m. S23CGT opened the door to the restroom at 1:47:39 p.m. and although she did not enter, she maintained an open doorway at this point. S25CGT entered the restroom at 1:48:55 p.m. Of note, this was 25 minutes and 40 seconds from the time Patient #2 initially entered the restroom. S23CGT entered the restroom at 1:48:55 p.m. S25CGT exited the restroom and motioned for assistance at 1:49:14 p.m. S23CGT and S25CGT exited the restroom at 1:49:30 p.m. with Patient #2. Patient #2 was not wearing a coat upon exit from the restroom. Patient #2 was walking with assistance at this point, but eventually stopped walking and the CGT's lowered him to the floor. The CGTs picked up Patient #2 and carried him to his bed where extra staff eventually arrives to assist with him. This staff included a nurse, NP, and MD.

A record review of the Client Incident, Injury, and Data Reporting Form from 10/03/2023 at 1:50 p.m. revealed, in part: C25CGT indicated, "I walked into the restroom with S23CGT to check on Patient #2. I then noticed the patient with a blanket wrapped around his neck and a portion of the blanket was wedged between the door."

In an interview on 10/09/2023 at 11:15 a.m. S4TQM. S5TQM, S6TQM, and S7TQM confirmed the findings of the video review.

In an interview on 10/05/2023 at 11:30 a.m. S8DON and S12CGT confirmed the restroom door is never locked. The patients have free access to the restroom. S12CGT further confirmed if a patient's on a RPM - 1:1 Direct, 2:1 Direct, or CVO at 15 feet, the CGT must follow the patient into the restroom to keep a constant visual on the patient. S12CGT also confirmed a female CGT would follow a male patient into the restroom and privacy would be granted from outside the stall door but not outside the restroom.

Based on observation, record review and interview, the hospital failed to ensure patients were kept free of all forms of abuse or harassment. This deficient practice is evidenced by:
1) Failure to ensure staff followed appropriate de-escalation training;
2) Failure to timely report allegations of physical abuse (Patients #1, #7) and physical injury (Patient #7) to LDH-HSS;
3) Failure to fully investigate incidents; and
4) Failure to ensure staff properly reported all forms of abuse.
Findings:

1) Failure to ensure staff followed appropriate de-escalation training

A review of Louisiana Department of Health (LDH) Policy Number 76.3, "LDH Abuse and Neglect," described physical abuse, in part, as physical contact such as hitting, slapping, pinching, kicking, choking, scratching, pushing, or the twisting of head, arms or legs; physical force which is unnecessary or excessive; and the inappropriate use of restraint.

A review of the Corrections Guard-Therapeutic (CGT) Job Duties and Responsibilities revealed in part, the CGT adheres to all rules, regulations, policies, and procedures of LDH, OBH, Eastern Louisiana Mental Health System, Civil service and Nursing/Security.

An email review from 10/19/2023 at 10:51 a.m., S19TrM revealed the hospital's Abuse/Neglect policy governs what staff cannot do to a patient/client. CPI is utilized for verbal de-escalation and physical skills to bring a crisis to a peaceful resolution. CPI training is provided upon hire and annually in the birth month for direct-care staff. The hospital also teaches an additional course on verbal and non-verbal de-escalation.

Patient #1:
An observation on 10/18/2023 at 9:45 a.m. of video of the incident on 08/22/2023 at approximately 6:11 p.m. revealed the altercation involving Patient #1 and the CGT Staff on Hall B. Video confirmation revealed S14CGT swinging his fist and making contact with Patient #1. The video also confirmed S15CGT slapping Patient #1 in the face multiple times.

In an interview on 10/18/2023 at 09:45 a.m. S4TQM, S5QTM, S6QTM, S7TQM, and S9PM confirmed the above mentioned findings on the video. They also confirmed this would not be considered an appropriate response of a CGT.

Patient #7:
An observation on 10/16/2023 at 10:50 a.m. of video of the incident on 09/29/2023 at approximately 8:27 p.m. revealed an altercation involving Patients #3, #7, and #8 on House3DR. Video confirmation revealed S16CGT swinging his fist, but not making contact with Patient #7.

In an interview on 10/16/2023 at 10:50 a.m. all present for the video review S4TQM, S5QTM, S6QTM, S7TQM, S9PM, S10DONSec, and S13CGT confirmed the above mentioned findings on the video. They also confirmed this would not be considered an appropriate response of a CGT.

2) Failure to timely report allegations of physical abuse (Patients #1, #7) and physical injury (Patient #7) to LDH-HSS

Review of the Louisiana Revised Statutes, Title 40. Public Health and Safety, Chapter 11, State Department of Health and Hospitals revealed "Department" shall mean the Department of Health and Hospitals. "Unit" means the
Medicaid fraud control unit created within the office of criminal law of the Department of Justice and which is certified by the secretary of the United States Department of Health, Education and Welfare. Regarding §2009.20. Duty to make complaints; penalty; immunity, "Abuse" is the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including but not limited to sexual abuse, or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered. "Neglect" is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer's well-being. Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, ... having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report.

Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report these allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Department of Health and Hospitals (LDH) (or the Medicaid Fraud Unit as applicable). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence.

Patient #1
A review of a Hospital Abuse/Neglect Initial Report prepared on 09/01/2023, revealed an incident occurring on 08/22/2023 and the hospital date of discovery as 08/31/2023. The hospital was unable to provide documentation this report was sent to the HSS on 09/01/2023. An HSS email confirmation revealed the report was received and an ID number was assigned on 09/20/2023 at 11:37 a.m. The hospital did not notify HSS within 24 hours upon the discovery of the allegation of abuse/neglect as required.

In an interview on 10/17/2023 at 11:15 a.m. S13PM confirmed she had not received a confirmation email from HSS regarding the receipt of a Hospital Abuse/Neglect Initial Report on 09/01/2023. S13PM further confirmed she made contact with HSS on 09/20/2023 to request an ID number to attach the hospital final report for HSS and this is when she became aware HSS had never received an Initial Report. S13PM confirmed the email from 09/20/2023 at 11:37 a.m. was the first email she had received from HSS regarding this initial report.

In an interview on 10/17/2023 at 11:50 a.m. S4TQM confirmed the Hospital Abuse/Neglect Initial Report was completed on 09/01/2023, but it was not submitted appropriately by the staff completing the report. Therefore the Hospital Abuse/Neglect Initial Report was not submitted to HSS within 24 hours of the facility becoming aware of the allegation of abuse/neglect as required.

Patient #7
A review of a Hospital Abuse/Neglect Initial Report prepared on 10/09/2023, revealed an incident occurring on 09/30/2023 and the hospital date of discovery as 09/30/2023. An HSS email confirmation revealed the report was received and an ID number was assigned on 10/09/2023. The hospital did not notify HSS within 24 hours upon the discovery of the allegation of abuse/neglect as required.

In an interview on 10/17/2023 at 11:50 a.m. S4TQM confirmed the Hospital Abuse/Neglect Initial Report was not submitted to HSS within 24 hours of the facility becoming aware of the allegation of abuse/neglect as required.

3) Failure to fully investigate incidents

A review of Louisiana Department of Health (LDH) Policy Number 76.3, "LDH Abuse and Neglect," described physical abuse, in part, as physical contact such as hitting, slapping, pinching, kicking, choking, scratching, pushing, or the twisting of head, arms or legs; physical force which is unnecessary or excessive; and the inappropriate use of restraint.

A review of the Corrections Guard-Therapeutic (CGT) Job Duties and Responsibilities revealed in part, the CGT adheres to all rules, regulations, policies, and procedures of LDH, OBH, Eastern Louisiana Mental Health System, Civil service and Nursing/Security.

A record review of the hospital incident log revealed Patients #3, #7, and #8 being involved in a seperate inicident on 09/29/2023 at approximately 8:27 p.m.

An observation on 10/16/2023 at 10:50 a.m. of video of the incident on 09/29/2023 at approximately 8:27 p.m. revealed an altercation involving Patients #3, #7, and #8 in House3DR. Video confirmation revealed S16CGT swinging his fist, but not making contact with Patient #7. The actions of S16CGT were not identified on the hospital's Client Incident, Injury, and Data Reporting Form regarding this incident. The saff did not identify the incident during the initial investigation of this incident or on the initial video review of this incident. The staff identified these findings while reviewing video to recreate a timeline of events for the surveyor.

In an interview on 10/16/2023 at 10:50 a.m. S4TQM confirmed the above mentioned findings on the video. S4TQM further confirmed these findings were identified 10/13/2023 while conducting video review of related incidents between the patients in the above mentioned findings. S4TQM confirmed the above findings were not identified during the initial investigation of the is incident. S4TQM confirmed this would not be considered an appropriate response of a CGT.

4) Failure to ensure staff properly reported all forms of abuse

A review of Louisiana Department of Health (LDH) Policy Number 76.3, "LDH Abuse and Neglect," revealed in part, Section VIII. Duty to Report Abuse, Item A: Louisiana law mandates reporting of abuse with violations of this law subject to criminal penalties. Item B revealed in part, any employee of LDH who has knowledge of possible abuse of a client, or who receives a complaint of abuse from a client ... shall report in accordance with the provisions of this policy, applicable law, and the facility's internal policy and procedures.

A review of the Corrections Guard-Therapeutic (CGT) Job Duties and Responsibilities revealed in part, the CGT adheres to all rules, regulations, policies, and procedures of LDH, OBH, Eastern Louisiana Mental Health System, Civil service and Nursing/Security.

An observation on 10/18/2023 at 9:45 a.m. of Hall B video recorded on 08/22/2023 from 6:08 p.m. till 6:13 p.m. revealed, in part: S21CGT was completing head counts and rounds. At approximately 6:10:54 p.m. Patient #1 is seen following S21CGT. They exchange words and patient #1 begins to hit S21CGT. S21CGT appeared to be trying to protect herself by grabbing at Patient #1's hands. S20CGT arrives at 6:11:00 p.m. to assist with the altercation. S20CGT is able to get between Patient #1 and S21CGT. S20CGT is able to grab Patient #1 from the side and place his arms around the patient. S20CGT also appeared to move the patient and attempted shield the patient from physical contact with other staff members that arrived to assist, but began to strike the patient. S14CGT arrived to assist, but began hitting Patient #1 with a closed fist to the face. S14CGT initiated 3 swings at Patient #1 before he was physically moved by S28CGT away from the altercation. S15CGT came to assist, but she began to slap Patient #1 in the facial area. S20CGT attempted to shield Patient #1 from S15CGT. S20CGT is eventually able to walk Patient #1 to the seclusion room by 6:11:55 p.m.

A record review of the 08/22/2023 ELMHS Response to HSS final report revealed S20CGT indicating in his investigative statement, in part, he did not report he saw S15CGT hitting Patient #1 because he thought S21CGT would identify when completing an incident report. The writer of the ELMHS Response to HSS final report was S13PM.

Based on observation, record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient. This deficient practice is evidenced by falsified documentation of observation checks being performed by the CGT and RN on 19 (#3, #5, #7-#23) of 19 (#3, #5, #7-#23) patients with physician orders for Routine Observation checks over a 3 hour time span.
Findings:

A review of facility policy PC-NUR-12 Provisions of Care, Treatment, and Services - Observation and Precautions, section V. Procedure: Routine Observation Procedure revealed in part, Item D. Routine checks are every 15 minutes. Item Nursing Care: B. An employee shall be assigned to monitor the patient routinely and document the patient's behavior at 15 minute intervals as per orders. At all times documentation shall be completed on the Psychiatric Aide/CGT Assignment Sheet. Item Documentation: C. Nursing staff shall document the initiation of the Psychiatric Aide Assignment Sheet, record observations of patients at least every 2 hours, and date and initial in the appropriate section.

An observation on 10/12/2023 at 11:30 a.m. of Hall A video recorded on 09/30/2023 from 2:45 a.m. to 3:25 a.m. revealed a S27CGT sitting on a chair at the beginning of Hall A, next to the day room. S27CGT line of sight was directed down the corridor with patient rooms on the right and the shower/restroom on the left at the far end of hall. S27CGT remains in this chair from 2:45 a.m. until 3:22:10 a.m. with very little body movement change. The video shows Patients #3 and #8 moving on the hallway, in and out of their assigned room and standing in Patient # 7's doorway for extended periods of time. At 3:20:10 a.m., Patients #3 and #8 entered Patient #7's room. Of note, Patient #7's room is on the right side of the hall at the far end, opposite the restroom. At 3:22:10 a.m. Patient #7 is attacked in his bed by Patients #3 and #8. From 2:45 a.m. to 3:22:10 a.m. there is no staff movement noted on Hall A.

A record review of House #3 CGT Log Book revealed entries being authenticated by S26CGT every 15 minutes on 09/30/2023 from 00:15 a.m. to 3:15 a.m. The entries revealed: 0015 Security check made all secure S26CGT; 0030 H/C 31pts. 5 sets of keys, 1H/H scanner S26CGT; 0045 Security check made all secure S26CGT; 0100 Security check made all secure S26CGT; 0115 Security check made all secure S26CGT; 0130 H/C 31pts. 5 sets of keys, 1H/H scanner S26CGT; 0145 Security check made all secure S26CGT; 0200 locker check complete, all locked & secure S26CGT; 0215 Security check made all secure S26CGT; 0230 H/C 31pts. 5 sets of keys, 1H/H scanner S26CGT; 0245 Security check made all secure S26CGT; 0300 Security check made all secure S26CGT; and 0315 Security check made all secure S26CGT.

A record review of House #3 nurse's log from 09/29/2023 6:00 p.m. - 6:00 a.m. shift revealed an entry for, "1800, 2000, 2200, 2400, 0200, 0400 RN rounds." S17RN was identified as the nurse on the unit during this shift.

In an interview on 10/12/2023 at 3:00 p.m. S5TQM confirmed S4TQM, S5TQM, S6TQM and S7TQM had reviewed video of Hall A recorded on 09/30/2023 from 00:13 a.m. until 3:22:10 a.m. (time of the altercation). S5TQM confirmed the last 15 minute observation check was conducted on 09/30/2023 at 00:13 a.m. and hospital staff had not conducted 15 minute observation checks of Hall A from 00:30 a.m. until 3:22:10 a.m. S5TQM also confirmed a nurse had not performed observation rounds on Hall A during this time. S5TQM confirmed all 19 patients on Hall A of House #3 had a physician order for Routine Observation during this documented time frame. S5TQM confirmed Hall A patient's observation checks were documented as being performed by an entry on the nurse's log for 2:00 a.m. and on the CGT's log for being performed every 15 minutes. S5TQM confirmed S17RN and S26CGT as the staff authenticating these entries in the logs.

Based on record review and interview, the hospital failed to ensure the nursing staff developed, and kept current, an individualized nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs. This deficient practice is evidenced by the failure to update the nursing care plans on 1 (#7) of 8 (#1-#8) sampled patients reviewed for completed and updated nursing care plans.
Findings:

A review of facility policy number Nursing-2008-## titled, "Short Term Medical Problems," revealed in part, under the section Guidelines, Item A. Short Term Medical Problem Plans shall be initiated by Nursing Service following the medical diagnosis and treatment interventions by the medical doctor.

A medical record review on 10/11/2023 at 3:45 p.m. revealed Patient #7 injuries sustained on 09/30/2023 included a closed nasal fracture and right hand fracture. There was no documentation indicating patient #7's nursing care plan had been updated to include these medical diagnosis' or treatment interventions.

In an interview on 10/11/2023 at 3:45 p.m. S6TQM confirmed there had been no update to Patient #7's nursing care plan.