HospitalInspections.org

Based on record reviews and interview, the hospital failed to ensure compliance with State law as evidenced by having a patient admitted for treatment by physician's emergency certificate and failing to obtain a coroners certificate or formal voluntary admission within 72 hours for 1 (#1) of 3 (#1 - #3) patient records reviewed.
Findings:

Review of 2024 Louisiana Law Title 28 - Mental Health RS 28:53 revealed in part: G.(1) Upon admission of any person by emergency certificate to a treatment facility, the director of the treatment facility shall immediately notify the coroner of the parish in which the treatment facility is located of the admission ...(2)(a) Within seventy-two hours of admission, the person shall be independently examined by the coroner or his deputy who shall execute an emergency certificate, pursuant to Subsection B of this Section, which shall be a necessary precondition to the person's continued confinement.

Review of Patient #1's medical record revealed an admission date of 07/16/2024 at 4:30 p.m. after a suicide attempt in a group home. Diagnoses included intellectual disability, bipolar disorder, ADHD, and severe sexual abuse as a child. Admitted for depression and suicidal ideation. She was admitted with a physician's emergency certificate dated 07/14/2024 at 12:40 p.m. Continued review revealed a Formal Voluntary Admission signed by Patient #1 on 07/16/2024 at 5:00 p.m. and her attending physician on 07/17/2024 at 11:00 a.m.

Further review of Patient #1's medical record revealed a readmission date of 07/19/2024 at 2:00 p.m. after returning from the emergency department following a sexual assault during prior admission. She was admitted with a physician's emergency certificate signed by physician on 07/19/2024 at 5:45 a.m.

On 07/24/2024 at 10:05 a.m., Patient #1's medical record revealed a Formal Voluntary Admission signed by Patient #1 on 07/22/2024 at 9:05 a.m. On 07/24/24 at 10:05 a.m., Patient #1's medical record failed to reveal a signature by her attending physician on the Formal Voluntary Admission form.

On 07/24/2024 at 10:06 a.m., further review of Patient #1's medical record failed to reveal a coroner's emergency certificate.

In an interview on 07/24/2024 at 10:06 a.m., S1Adm verified Patient #1 had not been discharged. S1Adm confirmed Patient #1's medical record failed to reveal a coroner's emergency certificate. S1Adm confirmed Patient #1's medical record failed to reveal a signature by her attending physician on the Formal Voluntary Admission form indicating that he approved of a Formal Voluntary Admission.

In an interview on 07/24/2024 at 5:12 p.m., S1Adm verified he was unable to locate hospital policy and procedure in regards to documentation supporting legal status pertaining to the appropriate legal circumstances under which patients are admitted and treated.

Based on observation, record review, and interview, the hospital failed to meet the requirements of the Conditions of Participation (CoP) of Patient Rights. The hospital failed to protect and promote each patient's rights as evidenced by:
1) failure to prevent sexual assault of Patient #1 (See findings in A0144);
2) failure to ensure staff were rounding and monitoring patients which potentially led to patient elopement for 2 (#3, #R4) of 2 (#3, #R4) patients reviewed who eloped (See findings in A0145);
3) failure to ensure observations and precautions were implemented as ordered on 07/22/2024 for 5 (Patient #1, #R2-#R4, #R7) of 11 (Patient #1, #R2-#R4, #R7-#R13) Patient Observation Sheets reviewed and on 07/23/2024 for 11 (Patient #1, #R2-#R4, #R7-#R13) of 11 (Patient #1, #R2-#R4, #R7-#R13) Patient Observation Sheets reviewed (See findings in A0145);
4) failure to ensure all exit doors were secure (See findings in A0144);
5) failure to assess patients who were at high risk for intentional harm to self in 2 (#1 and #2) of 3 (#1-#3) patients reviewed (See findings in A0145);
6) failure to ensure the patient /patient representative was included in the development and implementation of the patient's plan of care for 2 (#1 and #3) of 3 (#1- #3) sampled patient records reviewed (See findings in A0130).

Based on record review and interview, the hospital failed to ensure the patient /patient representative's right to participate in the development and implementation of his or her plan of care was met. This deficient practice was evidenced by failure to ensure the patient /patient representative was included in the development and implementation of the patient's plan of care for 2 (#1 and #3) of 3 (#1- #3) sampled patient records reviewed.
Findings:

Review of the hospital's policy titled, "Patient Rights", approved 06/2024, revealed in part: Procedure, in part: ...All patients have the right to ...7. The right to participate in the development and implementation of his/her plan of care. 8. Make informed decisions regarding his/her care. 9. Be informed of his/her health status, be involved in care planning and treatment, and be able to request or refuse treatment.

Review of hospital policy titled, Master Treatment Plan/Weekly Update Treatment Plan", dated 06/2021, revealed in part: Procedure, in part: B. Treatment plans will be individualized to address patient specific problems, identified through clinical assessments. Master Treatment plans cannot be initiated until all assessments are documented ...D. The patient will be involved in the treatment planning process; will provide input in developing the Master Treatment Plan/Weekly Treatment Plan, and will attend treatment team meetings when appropriate. E. Family will be involved in the treatment process if the patient gives concent, when appropriate tp facilitate family involvement. F. The delivery of effective care and services depend on the following four 94) key processes being performed well: ...4. Modifying the treatment plan sas necessary to meet the changes in progress.

Patient #1
Review of Patient #1's medical record revealed an admission date of 07/16/2024 at 4:30 p.m. after a suicide attempt in a group home. Diagnoses intellectual disability, bipolar disorder, ADHD, and severe sexual abuse as a child. Admitted for depression and suicidal ideation.

Review of Patient #1's Treatment Plan, dated 07/16/2024 at 1:16 p.m. (approximately 3 hours before her admission) failed to reveal diagnoses. Further review revealed target dates of 07/23/2024 and 07/30/2024 for long-term goals pertaining to problems, Danger to Self and GERD.

Additional review failed to reveal the patient's or patient representative's signature indicating participation in this treatment plan.

In an interview on 07/24/2024 at 3:33 p.m., S1Adm and S3DON confirmed Patient #1's Treatment Plan was initiated before patient was admitted, was incomplete and failed to reveal the patient's or patient representative's signature indicating participation in this treatment plan.

Patient #3
Review of Patient #3's medical record revealed an admission date of 07/14/2024 at 1:34 a.m. after having auditory and visual hallucinations with aggressive behavior and trying to elope from the emergency department. Diagnosis schizophrenia.

Review of Patient #3's Treatment Plan, dated 07/18/2024 at 4:13 p.m. (approximately 4 days after his admission) revealed diagnosis paranoid type schizophrenia. Further review revealed target dates of 07/28/2024 and 07/29/2024 for long-term goals pertaining to problems psychotic symptoms, absent medical problems and coping skills.
Further review failed to reveal the patient's or patient representative's signature indicating participation in this treatment plan.

In an interview on 07/24/2024 at 2:20 p.m., S1Adm confirmed Patient #3's Treatment Plan was initiated approximately 4 days following admission and failed to reveal the patient's or patient representative's signature indicating participation in this treatment plan.

50453

Based on observations, record reviews, and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by:
1) failure to prevent sexual assault of Patient #1;
2) failure to ensure all exit doors were secure.
Findings:

Review of hospital's policy titled, "Patient Rights," approved 06/2024, revealed in part: [the hospital] supports and protects the basic human, civil, and constitutional rights of all patients. The principle of this policy is the patient's right to respect, dignity, and comfort. 18. The right to receive care in a safe setting.

Review of hospital's policy titled, "Unit Safety Rounds Checklist," approved 06/2024, revealed in part: Policy Statement: Safety is of utmost importance. The environment of care must be safe for psychiatric patient care. At the beginning of each shift, the Registered Nurse must oversee the environmental rounds to be done by the Mental Health Technicians. Any environmental issues that cannot be resolved immediately need to be addressed with the Registered Nurse. Any staff member may fill out work order request forms if necessary. Procedure: At the beginning of each shift, Mental Health Technicians must: 1. Make environmental rounds of their unit. Mental Health Tech Rounding Sheet includes ensuring Fire doors at stairwells auto close and latch. No Doorstops or doors are not propped open.

1) Failure to prevent sexual assault in Patient #1.
Review of Patient #1's medical record revealed Patient #1 was a 19 year old female who was admitted on 07/16/2024 at 4:30 p.m. after a suicidal attempt in a group home. Diagnosis included: Intellectual Disability, Bipolar, ADHD, and severe sexual abuse as a child. Admitted for depression and suicidal ideation.

Review of Patient #2's medical record revealed Patient #2 was a 49 year old male who was admitted on 07/17/2024 at 11:00 a.m. for suicidal and homicidal ideation. Diagnosis of schizoaffective disorder. Review of Patient #2's Psychiatric Evaluation from 07/18/2024 at 8:38 a.m. revealed Patient #2 had a previous conviction of rape with incarceration for 30 years. Further review revealed Patient #2 admit orders on 07/17/2024 at 12:00 p.m. with high suicide and high assault precautions.

During an interview on 07/23/2024 at 11:15 a.m. S3DON stated she did not think Patient #2 had a previous history of a sexual crime.

Review of self-report incident from 07/18/2024 revealed Patient #1 reported to S3DON that she was sexually assaulted by Patient #2. The self-report incident results revealed in part: Both patients (Patient #1 and Patient #2) were on Q15 observations prior to and during the event. The sexual assault allegation occurred on 07/18/2024 around 7:30 p.m. This incident of possible neglect is determined to be unsubstantiated. The unit was properly staffed an observation levels were consistent with the hospitals Q15 policy.

On 07/23/2024 at 3:37 p.m. the video footage was reviewed for the night of the incident that occurred on 07/18/2024 with S1ADM and S3DON. Review of the video footage for Unit C revealed the following:
Hallway Camera:
5:24 p.m. - Patient #2 on phone on floor in hallway a, across from room b.
5:34 p.m. - Patient #1 in hall across from Patient #2.
5:48 p.m. - S15RN left Unit C.
6:09 p.m. - S15RN returned to Unit C. (Gone 21 minutes)
6:39 p.m. - 1 oncoming MHT (S16MHT) arrives and both day MHT's leave the Unit C.
6:44 p.m. - 1 MHT (S16MHT) on the Unit C.
6:50 p.m. - S16MHT left the Unit C. There were no MHTs and only 1 RN (S15RN).
6:54 p.m. - S13MHT on Unit C.
7:01 p.m. - S13MHT and S15RN (1 RN and 1 MHT) on Unit C in room b.
7:05 p.m. - Patient #2 and Patient #1 in hallway a together talking.
7:15 p.m. - S16MHT leaves the Unit C.
7:16 p.m. - Patient #1 in room f.
7:18 p.m. - Patient #1 in hall sitting next to Patient #2.
7:18 p.m. - S16MHT returns to Unit C.
7:19 p.m. - Patient #1 in hall with Patient #2.
7:20 p.m. - S16MHT leaves again.
7:21 p.m. - MHT's have not made rounds since arriving on shift.
7:22 p.m. - S15RN talking to Patient #2 he wants the phone but the phone was broken by Patient #2 before shift change. S13MHT still in room b with S15RN.
7:23 p.m. - Patient #2 following Patient #1 down hallway a.
7:24 p.m. - S3DON arrives as charge nurse to relieve S15RN.
7:24 p.m. - Patient #2 talking to Patient #1
7:25 p.m. - Still no rounds. S3DON, S15RN, and S13MHT in room b.
7:26 p.m. - Patient #2 talking to Patient #1 -they are alone in hallway a.
7:26 p.m. - S16MHT back with food in room b.
7:27 p.m. - S16MHT left Unit C by back stairwell.
7:27:35 p.m. - Patient #2 exposes himself to Patient #1.
7:29 p.m. - Staff (2 RN and 1 Tech) still in room b, no rounds.
7:29 p.m. - Patient #2 walked to his room (room h).
7:29 p.m. - Patient #1 by room b looking in window.
7:30 p.m. - Patient #1 goes into room h.
7:30 p.m. - Staff still in room b. No rounds.
7:32 p.m. - Patient #2 and Patient #1 still in room h.
7:33 p.m. - Patient #1 walks out of room h into hallway a adjusting her pants and tying the waist while pulling them up.
7:33 p.m. - Patient #2 and Patient #1 in hallway a by elevator speaking.
7:36 p.m. - Staff still in room b. No rounds.
7:35 p.m. - Patient #1 pacing hallway a looking in room b.
7:36 p.m. - Staff still in room b. No rounds.
7:37 p.m. - Patient #1 in hallway a alone with Patient #3 and Patient #2.
7:39 p.m. - Staff still in room b. No rounds.
7:39 p.m. - Patient R2 walks out of room h and goes to room b.
7:40 p.m. - Patient #1 walks to room b and asking for a shower.
7:41 p.m. - S3DON walks out of room b into hallway a.
7:42 p.m. - S16MHT never returned. S13MHT still in room b.
7:43 p.m. - Patient #2 walked behind Patient #1 and S3DON.
7:44 p.m. - All staff in room b and Patient #1 and Patient #2 in the hallway a alone eating snacks.
7:46 p.m. - S15RN (day shift) leaves Unit C via elevator.
7:47 p.m. - S3DON made rounds. S13MHT in room b.
7:49 p.m. - Patient #1 sitting in hallway a.
7:50 p.m. - Staff still in room b.
7:51 p.m. - Patient #2 and Patient #1 in hallway a alone.
7:53 p.m. - S13MHT walks out of room b towards room c then back to room b.
7:54 p.m. - Patient #2 and Patient #1 in hallway a alone.
7:56 p.m. - Staff in room b. No rounds.
7:59 p.m. - S3DON out of room b.
8:00 p.m. - S13MHT takes a few patients to smoke including Patient #2.
8:01 p.m. - Patient #1 and S3DON speaking. Patient #1 tells S3DON that something happened (per S3DON).
8:05 p.m. - S3DON texting female MHT to come to Unit C. Also texting S16MHT to come up.
8:08 p.m. - Patient #1 asks to call mom. Phone is broken.
8:10 p.m. - Patient #1 sitting in chair head in hands in room b.
8:12 p.m. - S13MHT and other patients return from smoke break.
8:13 p.m. - Patient #2 leaning against wall by Patient #1 and S3DON.
8:14 p.m. - Patient #1 pulls chair closer into room b.
8:15 p.m. - S3DON taking report for another patient coming in.
8:15 p.m. - Patient #1 asks to use phone again.
8:16 p.m. - Patient #2 standing by room b.
8:17 p.m. - Patient #1 using S3DON phone.
8:18 p.m. - Patient #2 still by room b.
8:22 p.m. - Patient #2 keeps asking about a shower. Female MHT arrives to Unit C.
8:24 p.m. - Patient #2 following Patient #1 down hall. They are alone.
8:30 p.m. - Patient #1 leaning against wall outside room b.
8:34 p.m. - Patient #1 tells S3DON she was raped (per S3DON, some audio but muffled).
07/18/2024 - 8:36:14 p.m. nurses station (room b) view ends. No video available of the room b view after this point.

On 07/24/2024 at 9:00 a.m. the video footage was further reviewed for the night of the incident that occurred on 07/18/2024 with S1ADM and S3DON. Review of the video footage for Unit C revealed the following:
8:36 p.m. - Patient #2 leaning against wall looking into room b as S3DON and Patient #1 talk. Audio revealed Patient #2 saying he wanted his medications early. (S3DON stated she was on the phone with the police at this time).
8:40 p.m. - S13MHT is now by Patient #2.
8:42 p.m. - Another female tech is in room b with S3DON and Patient #1.
8:50 p.m. - Patient #2 goes to room c pacing with S13MHT.
8:52 p.m. - Patient #2 still in room c.
8:54 p.m. - Patient #2 leaves room c goes to room h by himself.
8:56 p.m. - NOPD on Unit C.
8:57 p.m. - S3DON speaking with the police. Patient #1 in room c with S13MHT.
8:58 p.m. - Patient #1 in room c with police and S3DON. Patient #1 explaining to police what occurred.
9:01 p.m. - S3DON and Patient #1 leave room c with police.
9:03 p.m. - Patient #2 in room c in cuffs with S13MHT. Patient #2 Calm.
9:26 p.m. - Patient #1 leaving Unit C for hospital. Left by Ambulance.
9:58 p.m. - SVU interviewing Patient #2.
Patient #2 remained in room c until he had to change his clothes for forensics.
07/19/2024
12:00 a.m. - Patient #2 had changed his clothes. His clothes went to SVU/forensics. Sitting in a chair in hallway a, with staff and SVU.
12:03 a.m. - Patient #2 and S3DON speaking. S3DON headed to put sheets on Patient #2's bed in room h. Patient #2 in hallway a alone. S13MHT was downstairs with SVU. S1ADM on the Unit C.
12:04 a.m. - S1ADM tells Patient #2 to stay away from the female patients. Patient #2 is calm.
12:05 a.m. - Patient #2 is by himself in hallway a.
12:08 a.m. - Patient #2 wants his medication for sleep.
12:08 a.m. - Patient #2 in room h by himself.
12:15 a.m. - S3DON checks on Patient #2.
12:30 a.m. - No rounds have been done on patients. S13MHT still off Unit C.
12:45 a.m. - S16MHT looked in room h then left Unit C.
1:10 a.m. - S18MHT looked in room h.
1:21 a.m. - S13MHT back on Unit C.
1:25 a.m. - S13MHT looked in room h.
1:42 a.m. - S13MHT positioned outside of room h and S3DON looked in on Patient #2 and gave him meds.
2:15 a.m. - no rounds since 1:42 a.m.
2:31 a.m. - S13MHT makes rounds.
3:00 a.m. - No rounds.
3:10 a.m. - S13MHT has not looked into room h.
3:11 a.m. - S13MHT gets up and makes rounds.
3:30 a.m. - police arrived to arrest Patient #2.

During an interview on 07/23/2024 at 3:46 p.m. S3DON confirmed RN should not have left unit before incoming RN arrived.

During an interview on 07/23/2024 at 4:08 p.m. S3DON and S1ADM confirmed that no rounds have been done since arriving on shift.

During an interview on 07/24/2024 at 10:05 a.m. S3DON stated she verbally put Patient #2 on 1:1. Video does not show he was on 1:1.

During an interview on 07/24/2024 at 10:33 a.m. S3DON confirmed rounds were not completed per order/policy.

During an interview on 07/24/2024 at 11:14 a.m. S3DON and S1ADM confirmed that rounds were not done on 07/19/2024 at 2:00 a.m., 2:15 a.m., or 3:00 a.m.

Reviewed the Patient Observation Records for the night of the incident on 07/18/2024 for Patient #1, Patient #2, and Patient #3 with S1ADM and S3DON.

Patient #1
Review of Patient #1's Patient Observation Record for 07/18/2024 revealed the following:
Q15 minute observations were signed by S13MHT as completed for 7:00 p.m., 7:15 p.m., 7:30 p.m., 7:45 p.m., 8:00 p.m., and 8:15 p.m.

During review of video footage on 07/23/2024 at 4:08 p.m. S1ADM and S3DON confirmed that these rounds were not performed.

Further review of Patient #1's Patient Observation Record revealed there are no documented Q15 minute observations from 8:30 p.m. until the patient left the Unit C at 9:26 p.m. There was also no Precaution level marked on the Patient Observation Record for Patient #1.

During an interview on 07/24/2024 at 3:15 p.m. S1ADM and S3DON confirmed there was no documentation of observations being performed and confirmed that Patient #1 should have been on Suicide Precautions.

Patient #2
Review of Patient #2's Patient Observation Record for 07/18/2024 revealed the following:
Q15 minute observations were signed by S13MHT as completed for 7:00 p.m., 7:15 p.m., 7:30 p.m., and 7:45 p.m.

During review of video footage on 07/23/2024 at 4:08 p.m. S1ADM and S3DON confirmed that these rounds were not performed.

Patient #2's Patient Observation Record revealed there are no documented Q15 minute observations on 07/18/2024 from 8:00 p.m. - 11:45 p.m. Patient #2's Patient Observation Record for 07/19/2024 revealed Q15 minute observations from 12:00 a.m. - 3:30 a.m. were signed by S13MHT as being completed. Further review also revealed no Precaution level marked on the Patient Observation Record for Patient #2.

Review of video footage with S1ADM and S3DON revealed that rounds were not made on Patient #2 by staff at 12:30 a.m., 1:00 a.m., 1:42 a.m. - 2:15 a.m., or at 3:00 a.m. The findings above were confirmed on 07/24/2024 during video footage review with S1ADM and S3DON.

Patient #3
Review of Patient #3's Patient Observation Record for 07/18/2024 revealed the following:
Q15 minute observations were signed by S13MHT as completed for 7:00 p.m. - 9:30 p.m. Further review revealed Q15 minute observations were not documented and are blank on the Patient Observation Record from 10:00 p.m. - 11:45 p.m.

During review of video footage on 07/23/2024 at 4:08 p.m. S1ADM and S3DON confirmed that these rounds were not performed.

Further review of Patient #3's Patient Observation Record for 07/19/2024 revealed Q15 minute observations from 12:00 a.m. - 3:45 a.m. were signed by S13MHT as being completed. There are no documented Q15 minute observations from 4:00 a.m. - 6:45 a.m. by staff on Patient #3. Further review also revealed no Precaution level or Level of Observation marked on the Patient Observation Record for Patient #3.

During an interview on 07/24/2024 at 3:20 p.m. S1ADM and S3DON confirmed there was no documentation of observations being performed via the Patient Observation Record and also confirmed that Patient #3 did not have a documented level of observation or precautions documented.

2) Failure to ensure all exit doors were secure.
On 07/24/2024 at 4:25 p.m. toured the back stairwell from floor 2 down to first floor with S1ADM. 1st floor back stairwell opens into back hallway with an exit door to front lobby and an exit door to exterior of facility. The back exit door upon inspection was found partially ajar. The door was not secured and could be opened from the outside. There was no alarm in place if door were to be opened.

During an interview on 07/24/2024 at 4:32 p.m. these findings were confirmed by S1ADM.

Based on observations, record review, and interview the hospital failed to provide an environment free from abuse/neglect. This deficient practice is evidenced by:
1) failure to ensure staff were rounding and monitoring patients which potentially led to patient elopement for 2 (#3, #R4) of 2 (#3, #R4) patients reviewed who eloped;
2) failure to ensure observations and precautions were implemented as ordered on 07/22/2024 for 5 (Patient #1, #R2-#R4, #R7) of 11 (Patient #1, #R2-#R4, #R7-#R13) Patient Observation Sheets reviewed and on 07/23/2024 for 11 (Patient #1, #R2-#R4, #R7-#R13) of 11 (Patient #1, #R2-#R4, #R7-#R13) Patient Observation Sheets reviewed;
3) failure to assess patients who were at high risk for intentional harm to self in 2 (#1 and #2) of 3 (#1-#3) patients reviewed.
Findings:

Review of hospital's policy titled, "Abuse and/or Neglect of Patients," approved 06/2024, revealed in part: Policy: It is the policy of [the hospital] that ... patients will be given competent and timely medical care. A. definitions, in part: Neglect - a form of abuse. The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. B. Prevention of Abuse and Neglect 3. Unit acuity is assessed every shift to determine that the staff to patient ration is appropriate to meet the specific needs of the patient. C. Identification or Abuse and/or Neglect 1. Inadequate supervision of patients whose physical or mental condition may result in poor judgment, and who are therefore at risk of injury or illness without supervision. D. Reporting Abuse and/or Neglect of Patients. Staff are required to report any incident which they believe might constitute abuse or neglect of patients. Because safety of patients is our first concern, a reasonable suspicion about the observed behavior is sufficient to warrant reporting the situation so that any necessary corrections can be made to prevent or reduce harm to the patient.

Review of hospital's policy titled, "Patient Rights," approved 06/2024, revealed in part: [the hospital] supports and protects the basic human, civil, and constitutional rights of all patients. The principle of this policy is the patient's right to respect, dignity, and comfort. 17. The right to be free from all forms of abuse and harassment.

Review of hospital policy titled, "Patient Observation Record," revealed in part: Patients must be observed at least every 15 minutes. The observation with documented location and behavior must be documented, verified by the observer's initials, at least every 15 minutes. Purpose: To ensure that the patient's safety and well-being are maintained and documented. To have a continuous record of patient behavior and location. Procedure: The RN is responsible for MHT assignments (Patient Observation Record) 1. A review of this record is performed every 2 hours. 2. A rounding of all patients is to be performed every 2 hours and documented on the Patient Observation Record ... The MHT is to note the Precaution Level ordered for each patient ... The MHT is to note the Level of Observation ordered for each patient.

1) Failure to ensure staff were rounding and monitoring patients which potentially led to patient elopement for 2 (#3, #R4) of 2 (#3, #R4) patients reviewed who eloped.
Review of hospital's policy titled, "Elopement," approved 06/2024, revealed in part: Policy Statement: Nursing personnel must report and investigate all reports of missing patients. Purpose: Establish guidelines and procedures when a patient has eloped. Procedure: Once it is confirmed that the patient has eloped the Registered Nurse must: 1. Notify the Director of Nursing who will notify the Administrator. 2. Notify the attending physician. 3. Notify law enforcement officials. 4. Notify patient's family or legal representative. 5. Complete and file an incident report and make appropriate notations in the patient's medical record. 6. The attending physician must give a verbal order or may write an order for discharge by elopement.

Review of incident log revealed 2 patient elopements for July 2024 (Patient #3 and #R1).

Patient #3:
Review of the Incident Report for Patient #3 revealed the patient eloped from the smoking patio while outside on 07/19/2024 at 12:00 p.m.

Review of Patient #3's medical record revealed he was admitted on 07/14/2024 with Paranoid Type Schizophrenia. Review of the Psychiatric evaluation revealed that Patient #3 attempted to elope from the ED prior to arrival. Review of physician orders failed to reveal orders for elopement precautions. Further review of physician orders revealed orders for close observation (Q15 minute) and low suicide precautions.

Further review of Patient #3's medical record review revealed a Nursing note from 07/19/2024 at 12:15 p.m. "upon return to unit from lunch, MHT asked if I had seen patient. Patient did not return from lunch. MHT back tracked to dining room/smoking area and could not locate patient.
12:20 p.m. DON called. 1:00 p.m. NOPD notified of missing patient. 1:32 p.m. unable to reach caregiver to notify of elopement. 1:35 p.m. spoke with grandmother. Note signed by RN at 2:18 p.m. on 07/19/2024.

During an interview on 07/24/2024 at 11:27 a.m. with S1ADM and S3DON confirmed the MHT who was observing the patient's smoking on the patio at the time of the incident, came inside from the patio and turned her back towards the patient's outside when Patient #3 eloped over the fence. S1ADM and S3DON confirmed that they immediately terminated employment with the MHT who was supposed to be observing Patient #3 at the time of his elopement.

Patient #R1:
Review of the Incident Report for #R1 revealed the patient eloped via the elevator on 07/04/2024. Census for Unit B on 07/04/2024 was 9 patients (including #R1) with 1 RN and 1 MHT.

On 07/24/2024 at 11:45 a.m. the video footage was reviewed for the incident involving #R1 that occurred on 07/04/2024 with S1ADM and S3DON. Video footage review on elopement that occurred at 5:19 p.m. (per incident report) actually occurred at 4:02 p.m. on 07/04/2024. Review of the video footage for Unit B revealed the following:
3:26 p.m. - S17MHT leaves Unit B per elevator. (Leaving 1 RN only on unit)
3:36 p.m. - S17MHT returns.
3:44 p.m. - #R1 pacing back and forth and lingering by elevator.
3:48 p.m. - No observations per RN or MHT for 15 minutes
3:49 p.m. - #R1 walking around in his underwear coming back from shower. No one is around.
3:55 p.m. - S17MHT leaving per elevator and glanced into #R1's room.
4:00 p.m. - #R1 is in regular clothes and socks on feet. No tech on unit.
4:02 p.m. - S17MHT comes back to Unit B. S17MHT does not wait for elevator door to close before turning the corner and #R1 enters elevator before the elevator doors close.

During an interview on 07/24/2024 at 11:55 a.m. S1ADM confirmed video not available for the 1st and 2nd floor for 07/04/2024.

During an interview on 07/24/2024 at 11:57 a.m. S3DON verified that S17MHT was the only MHT on the unit and left without having replacement to observe the patients. Reports the nurse should have come out of the nurses' station to perform observations.

During an interview on 07/24/2024 at 12:00 p.m. S1ADM reported he looked at video on the 07/04/2024 and did not see patient #R1 get off the elevator and exit facility.

During an interview on 07/24/2024 at 12:08 p.m. S1ADM confirmed that the RN signed the Patient Observation Record for RN rounding on 07/04/2024 indicating that rounds were completed on #R1 at 4:00 p.m. S1ADM confirmed that the video footage failed to reveal that the RN completed the 4:00 p.m. nursing observation and the documentation was falsified on the Patient Observation Record.

2) Failure to ensure observations and precautions were implemented as ordered on 07/22/2024 for 5 (Patient #1, #R2-#R4, #R7) of 11 (Patient #1, #R2-#R4, #R7-#R13) Patient Observation Sheets reviewed and on 07/23/2024 for 11 (Patient #1, #R2-#R4, #R7-#R13) of 11 (Patient #1, #R2-#R4, #R7-#R13) Patient Observation Sheets reviewed.
Review of Unit C census for 07/22/2024 revealed 11 patients (Patient #1, #R2-#R4, #R7-#R13)
Review of Patient Observation Record for Unit C on 07/22/2024 failed to reveal 5 (Patient #1, #R2-#R4, #R7) of 11 (Patient #1, #R2-#R4, #R7-#R13) patients with documented levels of Precautions or levels of Observations per physician orders.

Patient #1
Review of Patient #1's medical record revealed admit orders dated 07/19/2024 at 2:00 p.m. Further review revealed an order for Visual Contact and High Suicide precautions.

Review of Patient #1's Patient Observation Record for 07/22/2024 failed to reveal high suicide precautions or visual contact documented as per physician order.

Patient #R2:
Review of Patient #R2's Patient Observation Record for 07/22/2024 failed to reveal a documented level of precautions as per physician order.

Patient #R3:
Review of Patient #R3's Patient Observation Record for 07/22/2024 failed to reveal a documented level of observations or level of precautions as per physician order.

Patient #R4:
Review of Patient #R4's Patient Observation Record for 07/22/2024 failed to reveal a documented level of observations or level of precautions as per physician order.

Patient #R7:
Review of Patient #R2's Patient Observation Record for 07/22/2024 failed to reveal a documented level of precautions as per physician order.

During an interview on 07/24/2024 at 12:15 p.m., S1ADM and S3DON confirmed the findings above.

Review of Unit C census for 07/23/2024 revealed 11 patients (Patient #1, #R2-#R4, #R7-#R13)
Review of Patient Observation Record for Unit C on 07/23/2024 failed to reveal 11 (Patient #1, #R2-#R4, #R7-#R13) of 11 (Patient #1, #R2-#R4, #R7-#R13) patients with documented levels of Precautions or levels of Observations per physician orders.

During an interview on 07/24/2024 at 12:15 p.m., S1ADM and S3DON confirmed the findings above.

3) Failure to assess patients who were at high risk for intentional harm to self in 2 (#1 and #2) of 3 (#1-#3) patients reviewed.
Review of hospital policy titled, "Suicide Risk Assessment", approved 06/2024, revealed in part: Policy: All patients admitted to [hospital] will receive a Suicide Risk Screening. Patients who have a history of sucide attempts and/or have suicidal ideations, plans, or intent will receive a Suicide Risk Assessment and treatment plan interventions as described. Purpose in part: To provide guidelines for screening and assessment of suicide risk and initiation of interventions to maximize safety for patients. Procedure in part: 1. the admitting Registered Nurse (RN) will initiate the Suicide Risk Screening which will determine the need for completion of the Suicide Risk Assessment ...4. ...If [high risk] positive indicators are noted, 1:1 is recommended and the RN will notify the attending physician to assess need and order the 1:1 observation level.

Patient #1

Review of Patient #1's medical record revealed an admission date of 07/16/2024 at 4:30 p.m. after a suicide attempt in a group home. Diagnoses intellectual disability, bipolar disorder, ADHD, and severe sexual abuse as a child. Admitted for depression and suicidal ideation.

Review of Patient #1's History and Physical dated 07/17/2024 at 11:00 a.m., revealed patient with intellectual disability drank baby shampoo and attempted to choke herself with rubber band and a towel.

Review of Columbia Risk and Protective Factors screening tool dated 07/16/2024 at 5:00 p.m. revealed a score of 12 indicating patient was considered a high suicide risk. The screening revealed Patient #1 was a high suicide risk.

Review of Patient #1's Columbia-Suicide Severity Rating scale frequent screener document dated 07/16/2024 at 9:00 p.m. revealed Patient #1 remained depressed and continued to be a high suicide risk.

Review of Patient #1's Columbia-Suicide Severity Rating scale frequent screener document dated 07/17/2024 at 8:00 a.m. revealed Patient #1 continued to be a high suicide risk.

Continued review of Patient #1's medical record failed to reveal a Columbia-Suicide Severity Rating scale frequent screener document after 07/17/2024 at 8:00 a.m.

Review of Patient #1's admit orders dated 07/16/2024 and signed by the attending physician on 07/17/2024 at 11:00 a.m., revealed orders for Patient #1 to be placed on high risk suicide precautions.

Further review of Patient #1's medical record failed to reveal the recommended 1:1 observation level or suicide precautions noted on any of her observation sheets.

In an interview on 07/24/2024 at 3:15 p.m., S1Adm and S3DON confirmed the suicide risk assessment was not completed per hospital policy. S1Adm and S3DON verified Patient #1's medical record failed to reveal suicide precautions noted on any of the observation sheets. S3DON stated Patient #1 was not on 1:1 level of observation.

Patient #2

Review of Patient #2's medical record revealed an admission date of 07/17/2024 at 11:00 a.m. after having been released from another psychiatric hospital 2 days prior and endorsing suicidal and homicidal ideations. Diagnoses Schizoaffective Disorder, Bipolar type, Stimulant Use Disorder. Admitted for suicidal and homicidal ideations. Seeing shadows and hearing whispers.

Review of Patient #2's Psychiatric Evaluation dated 07/18/2024 at 8:38 a.m. revealed patient reported having thoughts of hurting himself with a plan to jump in the Mississippi River.

Review of Columbia Risk and Protective Factors screening tool dated 07/17/2024 at 1:00 p.m. revealed a score of 12 indicating patient was considered a high suicide risk. Patient #2 stated he would go into traffic. The screening revealed Patient #2 was a high suicide risk.

Continued review of Patient #2's medical record failed to reveal a Columbia-Suicide Severity Rating scale frequent screener document after 07/17/2024 at 1:00 p.m.

Review of Patient #2's Admission orders dated 07/17/2024 at 12:00 p.m. revealed orders for high-risk suicide precautions.

Further review of Patient #2's medical record failed to reveal the recommended 1:1 observation level or suicide precautions noted on any of his observation sheets.

In an interview on 07/24/2024 at 4:14 p.m., S1Adm confirmed the suicide risk assessment was not completed per hospital policy. S1Adm verified Patient #2's medical record failed to reveal suicide precautions and 1:1 observations noted on any of the observation sheets.




50453

Based on observation, record review, and interview the hospital failed to meet the Conditions of Participation (CoP) of Nursing Services. The deficient practice is evidenced by:
1) failure to ensure a registered nurse was physically present on each unit of the hospital at all times (See findings in A0392);
2) failure to ensure adequate numbers of nursing support staff on each unit per hospital policy (See findings in A0392);
3) failure to document patient rounding on 07/22/2024 Unit C for 5 (Patient #1, #R2-#R4, #R7) of 11 (Patient #1, #R2-#R4, #R7-#R13) patients per physician orders (See findings in A0398);
4) failure of the nursing staff to monitor the therapeutic effect of PRN medications in 2 (#1-#3) of 3 (#1-#3) patients reviewed for therapeutic assessment after medication administration (See findings in A405);
5) failure of nursing staff to document provider notification following Patient #3's elopement (See findings in A0398);
6) failure of the nursing staff to complete an Emergency Transfer Sheet in 1 (#1) of 3 (#1-#3) records reviewed (See findings in A0398).

Based on observations, record review and interview the hospital failed to ensure adequate numbers of licensed
registered nurses and nurse support staff were available to provide nursing care to all patients as evidenced by:
1) failure to ensure a registered nurse was physically present on each unit of the hospital at all times;
2) failure to ensure adequate numbers of nursing support staff on each unit per hospital policy.
Findings:

Review of hospital policy titled "Staffing Plans and Delivery of Care", dated 01/2021, revealed in part: Census: 1-12 patients requires: 1 Registered Nurse and 2 Mental Health Technicians.

1) Failure to ensure a registered nurse was physically present on each unit of the hospital at all times.
On 07/23/2024 at 2:58 p.m., hospital video review of Unit C, area gg, on 07/18/2024, navigated by S1Adm, revealed S15RN left the unit at 5:48 p.m., was gone for 21 minutes and returned at 6:09 p.m. leaving S17MHT alone with 10 (#1, #2, #3, #R2, #R3, #R4, #R5, #R6, #R14, and #R15) patients.

Review of Patient #1's medical record revealed Patient #1 was assessed as a high suicide risk.

Review of Patient #2's medical record revealed Patient #2 had a previous conviction of rape with incarceration. Further review revealed Patient #2 was a high suicide risk and high assault risk.

Review of Census revealed Patient #R8 was on detoxification precautions.

Review of Patient #R2's medical record revealed a high assault risk with orders to block the other bed in his room for the safety of the unit.

In an interview on 07/23/2024 at 3:46 p.m., S3DON confirmed S15RN should not have left unit leaving one MHT to care for 10 patients potentially creating an unsafe environment.

In an interview on 07/24/2024 at 3:15 p.m., S1Adm and S3DON confirmed Patient #1's high suicide risk assessment.

In an interview on 07/23/2024 at 11:15 a.m., S3DON stated she did not think Patient #2 had a previous history of a sex crime.

In an interview on 07/24/2024 at 4:14 p.m., S1Adm confirmed Patient #2's high suicide risk assessment.

In an interview on 07/23/2024 at 9:45 a.m., S7MHT stated Patient #R10's room was blocked because Patient #R10 did not know where he was and had been acting out, going in other patient's rooms and getting naked in the dayroom.

In an interview on 07/24/2024 at 1:00 p.m., S2DHR verified she personally trained S15RN. S2DHR stated the training included instructions not to leave the unit without first making sure another RN was present on the unit.

2) Failure to ensure adequate numbers of nursing support staff on each unit per hospital policy.
Review of Unit C census dated 07/18/2024, AM shift, revealed 10 patients. Staff included S15RN, S7MHT and S17MHT.

On 07/23/2024 at 2:58 p.m., a review of Hospital video dated 07/18/2024, navigated by S1Adm and S3DON, revealed Unit C, area gg. Continued review revealed S7MHT left unit at 5:18 p.m. leaving only 1 MHT (S17MHT) on the unit.

In an interview on 07/23/2024 at 12:30 p.m., S3DON reported there should always be 2 MHTs on the units.

Review of Unit C's staff assignment sheet dated 07/23/2024 for the AM shift, revealed S7MHT and S8MHT assigned to the 11 patients on the census.

On 07/23/2024 at 9:51 a.m., observation of Unit C failed to reveal S7MHT.

In an interview on 07/23/2024 at 9:52 a.m., S6RN confirmed she did not know if S7MHT was currently on Unit C and stated she did not know where he had gone.

On 07/23/2024 at 12:15 p.m., a review of hospital video of Unit C, area gg, navigated by S1Adm, dated 07/23/2024, revealed S7MHT walked out of Unit C into stairwell o at 9:27 a.m. Observations failed to reveal he spoke to S6RN or S8MHT before leaving. Continued review revealed S7MHT came back in from stairwell o, sat down for a minute in area d, then proceeded back down stairwell o at 9:36 a.m. Further review revealed S7MHT returned by elevator r at 9:54 a.m.

In an interview on 07/23/2024 at 12:30 p.m., S1Adm and S3DON confirmed S7MHT left the unit without notifying S6RN. S3DON stated S7MHT should not have left the unit without notifying S6RN and having someone to relieve his post.

In an interview on 7/24/24 at 1:19 p.m., S2DHR verified she personally trained S7MHT to let the RN know where he is. S2HDR stated the nurse should know where MHTs are at all times.

50453

Based on observations, record review and interview, the Director of Nursing failed to ensure all nursing staff adhered to the policies and procedures of the hospital. This deficient practice is evidenced by:
1) failure to document patient rounding on 07/22/2024 Unit C for 5 (Patient #1, #R2-#R4, #R7) of 11 (Patient #1, #R2-#R4, #R7-#R13) patients per hospital policy;
2) failure of the nursing staff to complete an Emergency Transfer Sheet in 1 (#1) of 3 (#1-#3) records reviewed;
3) failure of nursing staff to document provider notification following Patient #3's elopement.
Findings:

1) Failure to document patient rounding on 07/22/2024 Unit C for 5 (Patient #1, #R2-#R4, #R7) of 11 (Patient #1, #R2-#R4, #R7-#R13) patients per hospital policy.

Review of hospital policy titled, "Patient Observation Record," revealed in part: Patients must be observed at least every 15 minutes. The observation with documented location and behavior must be documented, verified by the observer's initials, at least every 15 minutes. Purpose: To ensure that the patient's safety and well-being are maintained and documented. To have a continuous record of patient behavior and location. Procedure: The RN is responsible for MHT assignments (Patient Observation Record) 1. A review of this record is performed every 2 hours. 2. A rounding of all patients is to be performed every 2 hours and documented on the Patient Observation Record ... The MHT is to note the Precaution Level ordered for each patient ... The MHT is to note the Level of Observation ordered for each patient.

Patient #1
Review of Patient #1's Patient Observation Record for 07/22/2024 failed to reveal documented RN rounding at 12:00 a.m., 2:00 a.m., 4:00 a.m., 6:00 a.m., 8:00 p.m., or 10:00 p.m. and no Q15 minute observations at 7:15 a.m., 7:30 a.m., or 7:45 a.m.

Patient #R2:
Review of Patient #R2's Patient Observation Record for 07/22/2024 failed to reveal documented RN rounding at 12:00 a.m., 2:00 a.m., 4:00 a.m., or 6:00 a.m.

Patient #R3:
Review of Patient #R3's Patient Observation Record for 07/22/2024 failed to reveal documented RN rounding at 12:00 a.m., 2:00 a.m., 4:00 a.m., or 6:00 a.m. and no Q15 minute observations at 7:15 a.m., 7:30 a.m., or 7:45 a.m.

Patient #R4:
Review of Patient #R4's Patient Observation Record for 07/22/2024 failed to reveal documented RN rounding at 12:00 a.m., 2:00 a.m., 4:00 a.m., or 6:00 a.m. and no Q15 minute observations at 7:15 a.m., 7:30 a.m., or 7:45 a.m.

Patient #R7:
Review of Patient #R2's Patient Observation Record for 07/22/2024 failed to reveal documented RN rounding at 12:00 a.m., 2:00 a.m., 4:00 a.m., or 6:00 a.m.

During an interview on 07/24/2024 at 12:15 p.m., S1ADM and S3DON confirmed the findings above.

2) Failure of the nursing staff to complete an Emergency Transfer Sheet in 1 (#1) of 3 (#1-#3) records reviewed.

Review of hospital policy titled, "Medical Emergency Transfer to Another Facility", dated 01/2024, revealed in part: Purpose: ...To provide the receiving facility with complete appropriate information to resume care of a transferred patient. Procedure, ...the Registered Nurse must: 3. Complete the Emergency Transfer Sheet ...

Review of Patient #1's medical record revealed a physician's RBVO order dated 07/18/2024 at 9:00 p.m. The order stated Transport to Hospital D for evaluation.

Observation of video dated 07/18/2024, navigated by S1Adm, revealed Patient #1 left Unit C at 9:26 p.m.

Review of Patient #1's medical record failed to reveal the nurse completed an Emergency Transfer Sheet per hospital policy regarding emergency transfers.

In an interview on 07/24/2024 at 3:45 p.m., S3DON verified that an Emergency Transfer Sheet was not completed for Patient #1 as per hospital policy.

3) Failure of nursing staff to document provider notification following Patient #3's elopement.

Review of hospital's policy titled, "Elopement," approved 06/2024, revealed in part: Policy Statement: Nursing personnel must report and investigate all reports of missing patients. Purpose: Establish guidelines and procedures when a patient has eloped. Procedure: Once it is confirmed that the patient has eloped the Registered Nurse must: 1. Notify the Director of Nursing who will notify the Administrator. 2. Notify the attending physician. 3. Notify law enforcement officials. 4. Notify patient's family or legal representative. 5. Complete and file an incident report and make appropriate notations in the patient's medical record. 6. The attending physician must give a verbal order or may write an order for discharge by elopement.

Review of Patient #3's medical record revealed no note documented in the medical record of nurse notification to provider.

During an interview on 07/24/2024 at 2:15 p.m. with S1ADM and S3DON confirmed there was no documentation in Patient #3's medical record that the provider was notified.

Based on record review and interview, nursing staff failed to administer PRN medications in accordance with accepted standards of practice. This deficiency is evidenced by failure of the nursing staff to monitor the therapeutic effect of PRN medications in 2 (#1-#3) of 3 (#1-#3) patients reviewed for therapeutic assessment after medication administration.
Findings:

Review of hospital policy titled "Nursing Shift Assessment & Nursing Daily Progress Note", dated 06/2024, revealed in part: Procedure: Nursing Daily Progress Note: ... F. PRN medication given with reason and follow-up results to medication.

Patient #1
Review of the electronic medical record for Patient #1, navigated by S1Adm, revealed an order for Ativan 2 mg PO q 6 hours PRN agitation. Review of the electronic medication administration record revealed on 07/17/2024 at 10:15 p.m., Ativan 2 mg by mouth was administered to Patient #1. Further review failed to reveal the reason why the Ativan was administered. Continued review failed to reveal documentation of the therapeutic effectiveness of the medication administered.

In an interview on 07/24/2024 at 2:53 p.m., S1Adm verified there was no documented indication for the administration of Ativan and there was no documented follow-up for therapeutic effectiveness of the Ativan administered to Patient #1.

Continued review of the electronic medical record for Patient #1 revealed an order for Benadryl 50 mg PO q 6 hours PRN agitation. Review of the electronic medication administration record revealed on 07/23/2024 at 12:47 p.m., Ativan 2 mg by mouth was administered and at 12:48 p.m., Benadryl 50 mg by mouth was administered to Patient #1. Further review failed to reveal documentation of the therapeutic effectiveness of either medications administered.

In an interview on 07/24/2024 at 3:36 p.m., S1Adm verified there was no follow-up documented for the therapeutic effectiveness of the Ativan and Benadryl administered to Patient #1.

Patient #3
Review of the electronic medical record for Patient #3, navigated by S1Adm, revealed an order for Ativan 2 mg PO q 6 hours PRN agitation. Review of the electronic medication administration record revealed on 07/14/2024 at 8:12 p.m., Ativan 2 mg by mouth was administered because Patient #3 was responding to internal stimuli with need for redirection. Further review failed to reveal documentation of the therapeutic effectiveness of the medication administered.

In an interview on 07/24/2024 at 2:01 p.m., S1Adm verified there was no follow-up documented for therapeutic effectiveness of the Ativan administered to Patient #3.