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Based on record review and interview, the hospital failed to ensure the medical staff was accountable for the quality of care provided to patients. This deficient practice was evidenced by the failure to provide psychiatric progress notes as dictated by hospital policy on 1 (#1) of 3 (#1 - #3) patient medical records reviewed.
Findings

A review of hospital policy, "Documentation," Policy Number: IM-005, with an effective date of 02/05/2015, last revised on 02/01/2017 and last reviewed 09/19/2024, revealed in part: "Policy: It is the policy of Seaside Health System that the medical record is a legal document, an accounting record and the blueprint for treatment during hospitalization. The patient's record is the sole document from which third party payers decide upon payment. Increased scrutiny by external review agencies and accrediting bodies' necessitates a careful and planned approach to documentation. A problem-oriented record that clearly identifies the need for treatment based on admission criteria for that level of care, as well as the critical problems to which all staff will be documenting is required. The best safeguard to avert denial of reimbursement and assure smooth and collegial relationships with review organizations and managed care representatives is to document in the prescribed time frame, and with sufficient frequency to substantiate both that the treatment was provided and that the treatment program is providing treatment of required intensity. The expectation is that the medical record will reflect the patient's illness in behavioral specific terminology and support why the patient cannot be treated at a lower level of care.
Procedure: Documentation should present a concise, problem-oriented record with representation from all disciplines. Key documents include physician admission orders, history and physical exam, a psychiatric evaluation, psychological evaluation if applicable, nursing assessment, a psychosocial assessment, nutritional assessment and recreational therapy assessment. Assessments must include an evaluation, summary and recommendations for treatment. If complete assessment information cannot be obtained, then the information gathered and reason for its in-completeness will be noted. Assessments are completed prior to the development of the multi-disciplinary treatment plan. 4. Psychiatric Progress Notes: Psychiatric Progress Notes should minimally be completed five times per week (Psychiatric Evaluation may count as one) by the psychiatrist or appropriately licensed provider. It should denote whether it was a continuing care visit or treatment team visit. It should contain: a. Updated behaviors, symptoms, mental status, physical status and medications; b. Patient Interview; c. Identified problems in contract to admission; d. Reason for continued stay; e. Plan."

A review of Patient #1's medical record failed to reveal 5 Psychiatric Progress Notes per week as the above policy indicated. Documentation of Psychiatric Progress Notes were as follows, counted by calendar week (Sunday - Saturday) and admission/discharge weeks were not considered full weeks in this review for 5 notes per week:
Week of 01/16/2025 (day of admission) - 01/18/2025: Psychiatric Progress note on 01/16/2025, 01/17/2025 and 01/18/2025;
Week of 01/19/2025 - 01/25/2025: Psychiatric Progress note on 01/22/2025, 01/23/2025, 01/24/2026, and 01/25/2025. Total Psychiatric entries: 4;
Week of 01/26/2025 - 02/01/2025: Psychiatric Progress note on 01/29/2025, 01/30/2025 and 02/01/2025. Total Psychiatric entries: 3;
Week of 02/02/2025 - 02/08/2025: Psychiatric Progress note on 02/03/2025, 02/07/2025, and 02/08/2025. Total Psychiatric entries: 3;
Week of 02/09/2025 - 02/15/2025: Psychiatric Progress note on 02/11/2025 and 02/15/2025. Total Psychiatric entries: 2;
Week of 02/16/2025 - 02/22/2025: Psychiatric Progress note on 02/17/2025 and 02/22/2025. Total Psychiatric entries: 2;
Week of 02/23/2025 - 03/01/2025: Psychiatric Progress note on 02/28/2025 and 03/01/2025. Total Psychiatric entries: 2; and
Week of 03/02/2025 - 03/05/2025 (day of discharged). Psychiatric Progress note on 03/03/2025 and 03/04/2025.

In an interview on 03/06/2025 at 3:00 PM, S3DON confirmed the above mentioned findings.

Based on record review and interview, the hospital failed to ensure the patient's right to participate in the development and implementation of his or her plan of care. This deficient practice was evidenced by the failure to document patient participation in 1 (#1 - #3) of 3 (#1 - #3) medical records reviewed for patient participation in the development of a plan of care.
Findings:

A review of hospital policy, "Multidisciplinary Treatment Plans," Policy Number PC-018, with an effective date of 07/01/2015, last revision on 02/27/2019 and last reviewed on 11/11/2021, revealed in part: "Policy: It is the policy of Seaside Health System to provide an individualized plan of care that is based on assessment of the patient's mental, physical, and psychosocial needs and that is reflective of a multidisciplinary approach to patient care. Procedure: 2. The Master Treatment Plan shall be completed within 3 to 5 days of admission and consist of the following: o. Reflect the patient's opportunity for participation in the treatment planning process. q. Patient/Guardian Participation: Patients/Guardians are involved in the development of the Treatment Plan and every review. The Master Treatment Plan problems, goals and interventions should be reviewed with the patient/guardian as appropriate. This is evidenced by the patient's signature and/or guardian's signature within 5 days of admission. 4. The patient signs the Treatment Plan and updates indicating that he/she has discussed his/her Treatment Plan with the Team and had the opportunity to have input. 5. Patients are encouraged to participate in the development of their treatment plan and continued care."

A review of Patient #1's medical record revealed the document, "Multidisciplinary Integrated Master Treatment Plan (Con't)," with a date of completion on 01/20/2025. The document failed to reveal a signature of the patient or any indication the patient was unwilling or unable to participate.

In an interview on 03/05/2025 at 4:00 PM, S2AADN and S4ADON confirmed the above mentioned findings.

Based on observation, record review and interview, the hospital failed to ensure the patient's right to receive care in a safe setting. This deficient practice was evidenced by:
1) Failure to ensure items considered contraband were not allowed in the patient care area;
2) Failure to ensure allegations and/or suspicion of abuse and/or neglect were reported to the Louisiana Department of Health (LDH) Health Standards Section (HSS) within 24 hours of the hospital becoming aware of the allegations; and
3) Failure to ensure all healthcare workers who provide direct care to patients received education and training of the hospital's workplace violence plan at orientation and at least annually education.
Findings:

1) Failure to ensure items considered contraband were not allowed in the patient care area

A review of hospital policy, "Contraband," Policy Number: PC-042, being effective on 02/01/2017 and last revised on 12/21/2023, revealed in part: "Policy: It is the policy of Seaside Health System (SHS) that staff shall ensure the strict control of contraband and unauthorized use of permitted items in order to provide a secure and safe environment for patients, staff, and visitors. 1. Contraband shall be defined and controlled according to applicable state laws, rules, regulations, and SHS policies and procedures. The most restrictive definition shall prevail. Only the hospital administrator of designee shall authorize exception to this policy or respective procedures. 2. Contraband shall include articles permissible for patient or staff use but which may be harmful or dangerous if misapplied, altered, or kept in excess amounts. 4. The nurse shall have the authority to prevent the introduction of any unlisted items pending review of the Hospital administrator or designee. 5. Contraband list: a. The following is a list of items but is not limited to that are considered contraband. They are prohibited from being brought into SHS by staff or patients. They may not be sent in packages or brought into the facility by any visitors. vii. Tools. c. To further ensure safety of the patients, this list may be expanded on a case-by-case basis."

A review of the hospital's Initial Report to HSS, dated 02/14/2025 revealed an incident on 02/11/2025 at 5:36 PM involving Patient #1 being in the possession of safety scissors. A review of the hospital's incident log confirmed the findings of the hospital's Initial Report. This would be considered contraband and have the potential use for self-injurious behavior and/or harm to others.

A review of a written statement provided by S1ADM on 03/06/2025 at 11:30 AM, revealed the scissors were not the provider's scissors, Patient #1's room and the entire unit was searched for additional contraband.

In an interview on 03/06/2025 at 11:30 AM, S3DON confirmed the above mentioned findings, it was suspected the scissors arrived on the unit via items Patient #1's mother brought to the facility for Patient #1's use doing recreational activities, and the scissors were not identified during a belongings search prior to Patient #1 receiving personal items from a family member.

2) Failure to ensure allegations and/or suspicion of abuse and/or neglect were reported to the Louisiana Department of Health (LDH) Health Standards Section (HSS) within 24 hours of the hospital becoming aware of the allegations

Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report allegations and/or suspicion of abuse and/or neglect within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or LDH. This statute would include any issue under review for the determination whether the facility failed to take prudent action to prevent, and/or respond to an alleged occurrence such as a potential self-injurious behavior or an elopement.

A review of hospital policy, "Contraband," Policy Number: PC-042, being effective on 02/01/2017 and last revised on 12/21/2023, revealed in part: "Policy: It is the policy of Seaside Health System (SHS) that staff shall ensure the strict control of contraband and unauthorized use of permitted items in order to provide a secure and safe environment for patients, staff, and visitors. 1. Contraband shall be defined and controlled according to applicable state laws, rules, regulations, and SHS policies and procedures. The most restrictive definition shall prevail. Only the hospital administrator of designee shall authorize exception to this policy or respective procedures. 2. Contraband shall include articles permissible for patient or staff use but which may be harmful or dangerous if misapplied, altered, or kept in excess amounts. 4. The nurse shall have the authority to prevent the introduction of any unlisted items pending review of the Hospital administrator or designee. 5. Contraband list: a. The following is a list of items but is not limited to that are considered contraband. They are prohibited from being brought into SHS by staff or patients. They may not be sent in packages or brought into the facility by any visitors. vii. Tools. c. To further ensure safety of the patients, this list may be expanded on a case-by-case basis."

A review of the hospital's Initial Report to HSS, dated 02/14/2025 revealed an incident on 02/11/2025 at 5:36 PM involving Patient #1 being in the possession of safety scissors. A review of the hospital's incident log confirmed the findings of the hospital's Initial Report. This would be considered contraband and have the potential use for self-injurious behavior and/or harm to others. The Initial Report was received by HSS on 02/14/2025 at 3:23 PM. The requirement to report allegations and/or suspicion of abuse and/or neglect within 24 hours of receiving knowledge of the allegation was not met.

A review of a hospital document titled, "Incident Report Form (IRF)," dated 03/01/2025, revealed Patient #2 followed a staff member out of an exit door and lobby of the hospital at approximately 4:13 PM. Patient #2 was able to elope. As of 03/05/2025 at 10:05 AM, this elopement had occurred 4 days prior to the review of this incident report and had not been reported to HSS. The requirement to report allegations and/or suspicion of abuse and/or neglect within 24 hours of receiving knowledge of the allegation was not met.

In an interview on 03/05/2025 at 10:15 AM, S4ADON confirmed the above mentioned findings.

In an interview on 03/06/2025 at 7:45 AM, S1ADM confirmed the above mentioned findings and further indicated the above mentioned elopement would be reported today.

3) Failure to ensure all healthcare workers who provide direct care to patients received education and training of the hospital's workplace violence plan at orientation and at least annually education.

A review of hospital policy, "Workplace Security," Policy Number 6.6, with an effective date of 01/01/2014 and no revisions, did not reveal any references to the hospital's "Workplace Violence Prevention Program Plan 2025."

A review of the hospital's "Workplace Violence Prevention Program Plan 2025," revealed in part: "Training, Education, & Resources: All new employees are required to go through hospital orientation. All current employees go through annual education. Documentation will be placed in the employees' personnel file kept by Human Resources."

A record review of 3 (S9MHT, S10MHT, S11MHT) of 3 (S9MHT, S10MHT, S11MHT) new hire personnel records since 12/15/2024 did not reveal evidence of the hospital's Workplace Violence Prevention Program Plan's training, education, and resources review. A record review of 2 (S7RN, S8LPN) of 2 (S7RN, S8LPN) current personnel records did not reveal evidence of the hospital's Workplace Violence Prevention Program Plan's training, education, and resources review.

In an interview on 03/06/2025 at 4:00 PM, S5HR confirmed the above mentioned findings.

In an interview on 03/06/2025 at 4:20 PM, S1ADM confirmed the above mentioned findings.

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient. This deficient practice was evidenced by:
1) Failure of the Registered Nurse to document the performance of patient observations every 3 hours in 1 (#1) of 3 (#1 - #3) medical records reviewed;
2) Failure to document an assessment of the patient after an identified incident in 1 (#1) of 3 (#1 - #3) medical records reviewed;
3) Failure to document the contact of a provider upon a change in the condition of 1 (#3) of 3 (#1 - #3) medical records reviewed; and
4) Failure to appropriately document the transfer of a patient in 1 (#3) of 3 (#1 - #3) medical records reviewed.
Findings:

1) Failure of the Registered Nurse to document the performance of patient observations every 3 hours in 1 (#1) of 3 (#1 - #3) medical records reviewed

A review of hospital policy, "Patient Observations," Policy Number: Nur-032, with an effective date of 12/13/2013, last revised on 12/21/2023 and last reviewed 06/28/2024, revealed in part: "Policy: It is the policy of Seaside Health System to observe patients for safety, signs of life, location and behavior. Definitions: 1. Standard Observation: Visual contact and signs of life are observed between staff member and patient at least every 15 minutes. This observation must be documented in real time per every visual contact performed. Procedure: 2. A nurse must round on each patient every 3 hours. Rounding includes performing an observation of the patient with or without the MHT present. Signs of life must be observed."

A review of Patient #1's medical record revealed an order for Standard Observation Every 15 minutes. A review of the observation logs titled "Seaside Health System Day Observational Checklist" and "Seaside Health System Night Observational Checklist" revealed no documentation of Nursing Rounds being completed on 01/25/2025 at 3:00 PM, 02/12/2025 at 3:00 AM and 6:00 AM, 02/18/2025 at 6:00 AM, and 02/23/2025 at 6:00 AM.

In an interview on 03/05/2025 at 4:00 PM, S4ADON confirmed the above mentioned findings.

2) Failure to document an assessment of the patient after an identified incident in 1 (#1) of 3 (#1 - #3) medical records reviewed

A review of hospital policy, "Incident Reporting," Policy Number: CMP-013, with an effective date of 02/51/2015, last revised on 12/19/2023, and no date available for last reviewed, revealed in part: "Policy: 4. If the incident involves an injury or suspected injury, the injured party will be assessed by the nurse and the appropriate healthcare provider will be notified for further actions. 5. If the incident involves a patient, the necessary information is to be entered in the medical record. Document precisely what occurred."

A review of hospital policy, "Contraband," Policy Number: PC-042, being effective on 02/01/2017 and last revised on 12/21/2023, revealed in part: "Policy: It is the policy of Seaside Health System (SHS) that staff shall ensure the strict control of contraband and unauthorized use of permitted items in order to provide a secure and safe environment for patients, staff, and visitors. 1. Contraband shall be defined and controlled according to applicable state laws, rules, regulations, and SHS policies and procedures. The most restrictive definition shall prevail. Only the hospital administrator of designee shall authorize exception to this policy or respective procedures. 2. Contraband shall include articles permissible for patient or staff use but which may be harmful or dangerous if misapplied, altered, or kept in excess amounts. 4. The nurse shall have the authority to prevent the introduction of any unlisted items pending review of the Hospital administrator or designee. 5. Contraband list: a. The following is a list of items but is not limited to that are considered contraband. They are prohibited from being brought into SHS by staff or patients. They may not be sent in packages or brought into the facility by any visitors. vii. Tools. c. To further ensure safety of the patients, this list may be expanded on a case-by-case basis."

A review of the hospital's Initial Report to HSS, dated 02/14/2025 revealed an incident on 02/11/2025 at 5:36 PM involving Patient #1 being in the possession of safety scissors. A review of the hospital's incident log confirmed the findings of the hospital's Initial Report. This would be considered contraband and have the potential use for self-injurious behavior and/or harm to others.

A review of Patient #1's medical record did not reveal any documentation related to the assessment of the patient after the identified incident or any documentation related to the patient being in the possession of safety scissors.

In an interview on 03/05/2025 at 3:00 PM, S4ADON confirmed the above mentioned findings.

3) Failure to document the contact of a provider upon a change in the condition of 1 (#3) of 3 (#1 - #3) medical records reviewed

A review of hospital policy, "Acute Changes in Patient Conditions," Policy Number: PC-038, with an effective date of 07/01/2016, last revised on 11/11/2021 and last reviewed 11/11/2021, revealed in part: "Procedure: 1. Upon admission, staff will assess and document the patient's status. After assessment is completed, the documented norms will be accepted as the patient's current baseline. 3. In the event of a Medical Acute change in the patient's condition: Staff should make all necessary attempts to do the following: b. perform general assessment; administer first aid if required. d. Obtain Vital Signs g. Notify attending physician as appropriate 4. Medical changes in patient condition may include but are limited to: b. Difficulty breathing h. Chest Pain 7. The physician must be notified on all episodes of acute changes in patient conditions. 8. Any acute changes in the patient's condition will also be documented in the nurse's notes, located in the patient's chart. 9. A complete assessment, including vitals must be taken following any acute change in the patient condition event.dd."

A review of Patient #3's medical record revealed the patient being admitted on 02/09/2025 at 6:20 PM for opioid dependence and detox. The patient had vital signs performed at upon arrival. A nursing note entry on 02/09/2025 at 7:30 PM revealed in part: "33 y/o WM admitted to Seaside on FVA for detox from heroin and meth abuse. Notes: though pt arrived at 1820, this nurse had not arrived yet. Vitals upon arrival were 120/83, 106, 20, 98% 99.0. First attempt at assessment was at 1930 and pt. was laying in bed with the blanket over his head refusing to answer questions. Pt told nurse to return later and refused to participate. CIWA=3 at this time but was UTA pupil size. Pt later c/o chest pain, difficulty breathing, and was sweating profusely. Was sent to [Hospital A] via EMS at 2121." The medical record failed to include a complete assessment of the patient and the documentation of provider contact related to the acute changes of this patient.

In an interview on 03/06/2025 at 10:23 AM, S13RNAS confirmed the above mentioned findings.

4) Failure to appropriately document the transfer of a patient in 1 (#3) of 3 (#1 - #3) medical records reviewed

The hospital was unable to provide a policy related to the transfer of a patient to higher level of care or the return of a patient from a higher level of care. However, the hospital was able to provide the documents titled, "Memorandum of Transfer" and "Memorandum of Return." These documents had information related to the patient's current condition with a brief assessment upon the transfer and the return of a patient.

A review of Patient #3's medical record failed to reveal the above mentioned documentation related to Patient #3's transfer to Hospital A and his subsequent return from Hospital A.

In an interview on 03/06/2025 at 10:30 AM, S13RNAS confirmed the above mentioned findings.

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 was evidenced by the Registered Nurse failing to delegate and assign nursing responsibilities to Mental Health Technicians.
Findings:

A review of hospital policy, "Nursing Assignments," Policy Number NUR-029, with an effective date of 02/01/2017, last revised on 10/19/2020 and last reviewed on 07/02/2024, revealed in part: "Responsibility: It is the responsibility of the Director of Nursing and/or designee to implement this policy. It is the responsibility of the Director of Nursing to disseminate this information to employees under their direction. Policy: It is the policy of Seaside Health System to ensure that all nursing assignments are designed to accomplish optimal, achievable level of nursing care and a safe patient environment. Procedure: 1. An RN plans, supervises, and evaluates the nursing care of the patients. 2. An RN Delegates and assigns nursing responsibilities to RNs, LPNs, MHTs, that are commensurate with the competence and qualifications of each staff member. 3. The Assignment Sheet is completed at the beginning of each shift and kept in a binder. Assignments take into consideration unexpected emergencies (i.e. fire/disaster, staff education, removal of patient in an emergency, and restraint). 4. Staffing must be maintained to ensure all assignments are carried out."

A review of daily assignment sheets from 03/01/2025 to 03/05/2025 did not reveal which patients were assigned to each individual MHT.

In an interview on 03/05/2025 at 11:00 AM, S4ADON confirmed S6MHTS will make the MHT assignments.

In an interview on 03/05/2025 at 12:54 PM S6MHT confirmed he makes the MHT shift assignments.

In an interview on 03/05/2025 at 1:08 PM, S7RN confirmed the MHT's make their assignments and this is usually accomplished by the MHTs assigning the male patients to the male MHTs and female patients to the Female MHTs. S7RN further indicated the Female MHTs generally end up with male patients because male patients usually outnumber the female patients.

Based on record review and interview, the hospital failed to administer drugs in accordance with accepted standards of practice. This deficient practice was evidenced by the failure to document the effects of an administered as needed medication in 2 (#1, #2) of 3 (#1 - #3) patient medical records reviewed.

A review of hospital policy, "Administration of Medications," Policy Number: NUR 002, with an effective date of 07/17/2015, last revised on 11/11/2021 and last reviewed 07/03/2024, did not reveal a procedure for the documentation of the effectiveness after an as needed medication was administered. Further the hospital was unable to produce a policy and procedure related to the documentation of the effectiveness after an as needed medication was administered.

A review of Patient #1's medical record revealed the following as needed medications on the Medication Administration Worksheet being administered with no subsequent documentation of effectiveness follow up:
01/16/2025: Ricola Honey Lemon Echinacea, 1 cough drop by mouth every 2 hours as needed, administered at 4:30 PM, no effectiveness documented;
01/22/2025: Ibuprofen tab, 400 mg tablet by mouth every 6 hours as needed for pain, administered at 6:00 AM, no effectiveness documented;
01/27/2025: Ricola Honey Lemon Echinacea, 1 cough drop by mouth every 2 hours as needed, administered at 9:00 AM and 3:00 PM, no effectiveness documented either dose;
01/27/2025: Capsaicin Cream 0.1% apply to affected area three times daily as needed for pain, administered at 9:00 AM, no effectiveness documented;
01/28/2025: Ricola Honey Lemon Echinacea, 1 cough drop by mouth every 2 hours as needed, administered at 9:00 AM, no effectiveness documented;
01/31/2025: Ricola Honey Lemon Echinacea, 1 cough drop by mouth every 2 hours as needed, administered at 9:00 AM, no effectiveness documented;
02/01/2025: Ricola Honey Lemon Echinacea, 1 cough drop by mouth every 2 hours as needed, administered at 9:00 AM and 11:30 AM, no effectiveness documented on either dose;
02/02/2025: Ricola Honey Lemon Echinacea, 1 cough drop by mouth every 2 hours as needed, administered at 9:00 AM, no effectiveness documented;
02/03/2025: Ibuprofen tab, 400 mg tablet by mouth every 6 hours as needed for pain, administered at 4:15 PM, no effectiveness documented;
02/10/2025: Ricola Honey Lemon Echinacea, 1 cough drop by mouth every 2 hours as needed, administered at 9:00 AM and 11:00 AM, no effectiveness documented on either dose;
02/11/2025: Cyclobenazprine (Flexeril) Tab 10mg, give one-half tab (5mg) by mouth twice daily as needed, administered at 9:00 AM; no effectiveness documented;
02/12/2025: Cyclobenazprine (Flexeril) Tab 10mg, give one-half tab (5mg) by mouth twice daily as needed, administered at 9:00 AM; no effectiveness documented;
02/16/2025: Ricola Honey Lemon Echinacea, 1 cough drop by mouth every 2 hours as needed, administered at 9:00 AM, 11:00 AM and 2:00 PM, no effectiveness documented on each dose;
02/21/2025: Capsaicin Cream 0.1% apply to affected area three times daily as needed for pain, administered at 9:00 AM, no effectiveness documented;
02/22/2025: Capsaicin Cream 0.1% apply to affected area three times daily as needed for pain, administered at 9:00 AM, no effectiveness documented;
02/24/2025: Ricola Honey Lemon Echinacea, 1 cough drop by mouth every 2 hours as needed, administered at 9:00 AM, 11:00 AM and 1:00 PM, no effectiveness documented on each dose;
02/25/2025: Ricola Honey Lemon Echinacea, 1 cough drop by mouth every 2 hours as needed, administered at 9:00 AM, 11:00 AM, 1:00 PM, and 3:00 PM no effectiveness documented on each dose;
02/12/2025: Cyclobenazprine (Flexeril) Tab 10mg, give one-half tab (5mg) by mouth twice daily as needed, administered at 9:00 PM; no effectiveness documented; and
03/03/2025: Ibuprofen tab, 400 mg tablet by mouth every 6 hours as needed for pain, administered at 4:50 AM, no effectiveness documented.

In an interview on 03/06/2025 at 1:00 PM S4ADON confirmed the above mentioned findings.

Based on record review and interview, the hospital failed to ensure a medical history and physical was completed and placed on the medical record within 24 hours of admissions on 1 (#2) of 3 (#1 - #3) patient medical records reviewed.

A review of hospital policy, "Documentation," Policy Number: IM-005, with an effective date of 02/05/2015, last revised on 02/01/2017 and last reviewed 09/19/2024, revealed in part: "Policy: It is the policy of Seaside Health System that the medical record is a legal document, an accounting record and the blueprint for treatment during hospitalization. The patient's record is the sole document from which third party payers decide upon payment. Increased scrutiny by external review agencies and accrediting bodies' necessitates a careful and planned approach to documentation. A problem-oriented record that clearly identifies the need for treatment based on admission criteria for that level of care, as well as the critical problems to which all staff will be documenting is required. The best safeguard to avert denial of reimbursement and assure smooth and collegial relationships with review organizations and managed care representatives is to document in the prescribed time frame, and with sufficient frequency to substantiate both that the treatment was provided and that the treatment program is providing treatment of required intensity. The expectation is that the medical record will reflect the patient's illness in behavioral specific terminology and support why the patient cannot be treated at a lower level of care.
Procedure: Documentation should present a concise, problem-oriented record with representation from all disciplines. Key documents include physician admission orders, history and physical exam, a psychiatric evaluation, psychological evaluation if applicable, nursing assessment, a psychosocial assessment, nutritional assessment and recreational therapy assessment. Assessments must include an evaluation, summary and recommendations for treatment. If complete assessment information cannot be obtained, then the information gathered and reason for its in-completeness will be noted. Assessments are completed prior to the development of the multi-disciplinary treatment plan. 2. History and Physical Examination: the history and physical exam is completed within 24 hours and includes the complete systems review and comprehensive neurologic screening. The neurologic exam should include cranial nerves, sensory-moto functions, coordination, and deep tendon reflexes. The history and physical impressions can substantially support the necessity of hospitalization by identifying physical illness or medical complications exacerbated by a psychiatric condition."

A review of Patient #2's medical record revealed an admission date of 02/26/2025 at 2:26 PM. A review of the document titled, "New Patient Evaluation/History and Physical," revealed the completion of this exam on 02/28/2025 at 9:15 AM. This would be approximately 43 hours after the admission of the patient.

In an interview on 03/06/2025 at 1:00 PM S4ADON confirmed the above mentioned findings.

Based on observation and interview, the hospital failed to maintain the condition of the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients are assured. This deficient practice was evidenced by the failure to clean the ventilation system's vents of a grey, fuzzy substance resembling dust.
Findings:

Observations during a hospital walk-through on 03/05/2025 from 12:35 PM to 1:25 PM revealed the hospital's ventilation system having a grey, fuzzy substance resembling dust accumulated on ceiling vents and the surrounding ceiling in Rooms "a," "b" and "c."

In an interview on 03/05/2025 and present during the hospital walk-thru, S4ADON confirmed the above mentioned findings.