HospitalInspections.org

Based on record reviews, observations, and interviews, the CEO failed to effectively manage the hospital as evidenced by:

1) Failing to ensure the requirements of the Condition of Participation of Patient Rights were met as evidenced by failing to ensure patients received care in a safe setting. This deficient practice was evidenced by:

a.) failure to ensure a patient admitted after attempting suicide had been observed at the ordered level of observation of every 15 minutes for 1 (#8) of 1 sampled patient incident reports reviewed for neglect of care from a total patient sample of 10 (#1- #10). Patient #8 subsequently attempted suicide in the hospital by strangulation with a drawstring from her shorts (contraband item) (See findings in tag A-0144).;

b.) failure to ensure a thorough investigation was completed after a patient's attempted suicide (#8), in the hospital, in order to assure appropriate corrective action was taken to protect other patients currently hospitalized who may have been at risk for self-harm (there were currently 9 patients on suicide precautions) for 1 (#8) of 1 patient record reviewed for abuse/neglect from a total patient sample of 10 (#1- #10). (See findings in tag A-0145).; and

c.) failure to ensure the use of restraint was in accordance with safe and appropriate restraint and seclusion techniques as per hospital policies and procedures for 1 (#6) of 3 (#6, #10, #R2) patient records reviewed for use of restraints. The Sheriff's department was called for assistance and 4 deputies assisted with "take-down" to administer a forced psychotropic medication which was not in accordance with hospital policy. (See findings in tag A-0167).

2) Failing to ensure the requirements of the Condition of Participation for Nursing Services were met as evidenced by:

a) failure of the RN to ensure a patient admitted after attempting suicide had been observed at the ordered level of observation of every 15 minutes for 1 (#8) of 1 sampled patient incident reports reviewed from a total patient sample of 10 (#1- #10). Patient #8 subsequently attempted suicide in the hospital.(See findings in tag A-0395).; and

b) failure of the RN to ensure a patient (#8) admitted after attempting suicide had not had access to a contraband item (a drawstring) that was used for self-harm. Patient #8 subsequently attempted suicide in the hospital by strangulation using the drawstring from her shorts. (See findings in tag A-0395).


In an interview on 8/5/19 at 4:00 p.m. with S1Adm and S2DON, they confirmed no investigation of Patient #8's attempted suicide by strangulation with the drawstring of her shorts (contraband item) in the hospital had been conducted. S1Adm and S2DON also confirmed they had not reviewed the video recordings of the day the incident occurred to identify possible causative/contributing factors.

In an interview on 8/6/19 at 10:00 a.m. with S1Adm and S13SSDir, they confirmed it was not hospital policy to contact the police department to assist with "take-down" of patients for forced medication administration. They reported there was a step by step process to follow if police action was needed and they were to call S2DON and S1Adm before contacting the police department.

An interview was conducted with S1Adm and S2DON on 8/6/19 at 11:45 a.m. During the interview, S1Adm and S2DON confirmed they still had not reviewed the video recording of the incident ( Patient #8's attempted suicide by strangulation) and had not conducted an investigation into possible causative/contributing factors that may have led to the incident. S1Adm and S2DON confirmed they had failed to remove the contraband item from the patient's possession. S1Adm and S2DON confirmed there were currently 9 of 18 total patients on suicide precautions on 8/6/19.

In an interview on 8/7/19 at 3:00 p.m. with S1Adm and S5SW they confirmed the hospital had not identified Patient #8's attempted suicide by strangulation in the hospital as an adverse patient event to be analyzed through the hospital's QAPI program. They further confirmed performance improvement indicators had not been established in order to assure appropriate corrective action was initiated in order to protect other patients currently hospitalized who may have also been at risk for self-harm.

Based on record review and interview, the governing body failed to ensure all services furnished in the hospital, including contracted services, were performed in a safe and effective manner. This deficient practice was evidenced by failing to ensure contracted services (Company "B" ( Mobile x-ray services), Company "C" (Patient Transport Services), Company "D" (Patient Transport Services), Ambulance Services, Language Translation Services, Stericycle Services, Linen Services, and Organ (organ, tissue and eye) Procurement Services) were included in the quality assurance and performance improvement (QAPI) program.

Findings:

Review of the list of contracted services, provided by S5SW, revealed contracted services were provided by the following companies: Company "B" ( Mobile x-ray services), Company "C" (Patient Transport Services), Company "D" (Patient Transport Services), Ambulance Services, Language Translation Services, Stericycle Services, Linen Services, and Organ (organ, tissue and eye) Procurement Services.

Review of the hospital's list of QA performance improvement indicators revealed there were no indicators for the following contracted services: Company "B" ( Mobile x-ray services), Company "C" (Patient Transport Services), Company "D" (Patient Transport Services), Ambulance Services, Language Translation Services, Stericycle Services, Linen Services, and Organ (organ, tissue and eye) Procurement Services.

In an interview on 8/7/19 at 3:00 p.m. with S1Adm and S5SW, they confirmed the hospital's QA plan had no performance improvement indicators for Company "B" ( Mobile x-ray services), Company "C" (Patient Transport Services), Company "D" (Patient Transport Services), Ambulance Services, Language Translation Services, Stericycle Services, Linen Services, and Organ (organ, tissue and eye) Procurement Services.

Based on record reviews, observations, and interviews, the hospital failed to meet the requirements of the Condition of Participation for Patient's Rights as evidenced by:

1) failure to ensure a patient admitted after attempting suicide had been observed at the ordered level of observation of every 15 minutes for 1 (#8) of 1 sampled patient incident reports reviewed for neglect of care from a total patient sample of 10 (#1- #10). Patient #8 subsequently attempted suicide in the hospital by strangulation with a drawstring from her shorts (contraband item) (See findings in tag A-0144).;

2) failure to ensure a thorough investigation was completed after a patient's attempted suicide (#8), in the hospital, in order to assure appropriate corrective action was taken to protect other patients currently hospitalized who may have been at risk for self-harm (there were currently 9 patients on suicide precautions) for 1 (#8) of 1 patient record reviewed for abuse/neglect from a total patient sample of 10 (#1- #10). (See findings in tag A-0145).; and

3) failure to ensure the use of restraint was in accordance with safe and appropriate restraint and seclusion techniques as per hospital policies and procedures for 1 (#6) of 3 (#6, #10, #R2) patient records reviewed for use of restraints. The Sheriff's department was called for assistance and 4 deputies assisted with "take-down" to administer a forced psychotropic medication which was not in accordance with hospital policy. (See findings in tag A-0167).

Based on record reviews, observation, and interview, the hospital failed to ensure patients at risk for harm to self or others were provided care in a safe setting as evidenced by:

1) failure to ensure a patient admitted after attempting suicide had been observed at the ordered level of observation of every 15 minutes for 1 (#8) of 1 sampled patient incident reports reviewed from a total patient sample of 10 (#1- #10). Patient #8 subsequently attempted suicide in the hospital by strangulation with a drawstring from her shorts (contraband item); and

2) failure to ensure the patients' physical environment was free of safety risks and did not afford opportunities for self -injury/harm to others.

Findings:

1) Failure to ensure a patient admitted after attempting suicide had been observed at the ordered level of observation of every 15 minutes.

Review of the hospital policy titled, "Assessment for High Risk Behavior - Nursing", revealed in part: Policy: Beacon Behavioral Hospital ensures that all patients are assessed for the presence of high-risk ideation and/or behavior (such as suicidal, aggressive and other tendencies) upon admission and on an ongoing basis throughout treatment.
The Inpatient Risk Assessment is based on the Beck Depression Scale and the Hoff Danger Assessment. it is conducted by qualified registered nurses, whose scope of practice includes such evaluation. The purpose of this assessment is to evaluate protective factors that lower risk, for example increased monitoring, a secure, safe environment, restricted access to means, etcetera. All findings are documented in the patient's medical record and communicated.
7. A. Levels of observation include: I. Close Observation ( observation every 15 minutes);
II. Line of Sight ( staff member maintains visual contact with the patient at all times; no barriers can be situated between them; staff maintains visual contact at all times, including when patient uses the bathroom);
III: One - to - One Observation ( staff member is assigned to one patient and must maintain visual contact with the patient at all times; no barriers can be situated between them; staff maintains visual contact at all times, including when patient uses the bathroom); this level of observation may be ordered at arm's length or not.
B. Precautions may include but are not limited to: I. Suicide, II. Elopement, III. Violent/Aggressive; IV. Sexual. Note: the Attending Licensed Practitioner may order special provisions.

Review of the hospital policy titled, "Precautions - Nursing", revealed in part: Precuaitons: All direct care staff members ( i.e. nurses, mental health technicians, counselors, etcetera) are fully trained on the components of all Precautions. In addition to to , an separate from, the Precautions applicable to a patient, the licensed prescriber will order a Level of Observation in accordance with the patient's individual needs, risk, and/or behaviors.
Suicide Precautions are utilized when a patient demonstrates or verbalizes an indication that he or she represents a danger to himself/herself or is contemplating self-injurious behavior. This determination may be based on actions or verbalizations by the patient, reports received fomr other individuals, and/or the patient's history.
The following are components of suicide precautions: Unit restriction: The patient is not allowed to leave the unit except for medical necessity and then only with orders from a licensed prescriber. In the event that the patient must leave the unit, the patient will be placed on at least 1:1 observation when off the unit.
Sharps restriction: Staff members are prohibited from providing those sharp items typically allowed for patient use with supervision and/or with time restrictions (e.g. razors). The patient on suicide precautions may not have access to items identified as sharp at any time. The use of items that may be modified for self-injurious behavior ( i.e. plastic silverware, etc.) shall be closely monitored by assigned staff member and accounted for after use.

Review of the Patient #8's medical record revealed the patient was admitted on 7/12/19. The patient's legal status was PEC on 7/12/19 due to an intentional overdose of 90 Clonazepam tablets (on the day of admission to the hospital), being dangerous to self, and unable to seek voluntary admission. Patient #8 had a history of Bipolar Disorder and having Suicidal Ideations. Further review revealed Patient #8 was CECd on 7/15/19 due to remaining suicidal and endorsing Suicidal Ideations.

Review of the hospital's incident reports from 1/1/18 - 8/5/19 revealed an incident report dated 7/20/19 at 7:30 p.m. indicating Patient #8 had attempted suicide by strangulation while being treated in the hospital. Further review of the incident report revealed the following: Patient #8 was found in her room with the string of her shorts wrapped around her neck twice, skin color blue and not responding. The patient required a sternal rub to become responsive. The patient had also cut her wrist with a toothpaste cap. Additional review revealed the patient had been seen 2 times prior to the suicide attempt, by staff, wearing the same shorts with the drawstring in them (contraband item).

Review of Patient #8's admission physician's orders, dated 7/12/19, revealed the patient was on ordered every 15 minute observations with suicide precautions.

Review of Patient #8's nurses' notes for the day shift (7:00 a.m. - 7:00 p.m.) of 7/20/19, revealed the patient had been documented as verbalizing suicidal ideations with no plan.

Review of Patient #8's 15 Minute Close Observation Form (documentation indicating the patient's location, activity, and behavior every 15 minutes), dated 7/20/19, revealed the following entries:
4:00 p.m.: 3 (in lounge), N (walking), 69 (cooperative);
4:15 p.m.: 3 (in lounge), C (reading/coloring), 69 (cooperative);
4:30 p.m.: 3 (in lounge), N (walking), 69 (cooperative);
4:45 p.m.: 3 (in lounge), N (walking), 72 (quiet);
5:00 p.m.: 1 (in room), X (other), 62 (threatening self-harm) and 74 (on floor); and
5:15 p.m.: 1 (in room), D (talking with peers) and E (talking with staff), 72 (quiet)

An observation was made on 8/6/19 at 11:30 a.m. of a video recording of Patient #8 on 7/20/19 from 4:00 p.m. - 5:07 p.m. ( time -frame preceding, during, and after the incident) Patient #8's location and activities were observed as follows:
4:00 p.m.: Patient #8 was seated in dayroom/lounge area and was observed getting up from the table and walking down the hall;
4:11 p.m.: Patient #8 was observed entering her room;
4:15 p.m.: MHT observed Patient #8;
4:30 p.m.: Patient - in room - no staff rounding observed;
4:31 p.m.: Patient in room - no staff rounding observed;
4:35 p.m.: Patient observed walking down the hall and back to room (S10MHT seated at the far end of the hall and Patient #8 could be visualized in the hallway at that time);
4:41 p.m - 4:56.: Patient - in room, no staff rounding observed;
4:58 p.m.: MHT in dining room, Patient #8 remains in room, no staff rounding observed;
5:04 p.m.: S9MHT observed carrying trash down the hall, passing by Patient #8's room;
5:07 p.m.: Staff observed with crash cart.

The reviewed video recording of Patient #8's activity and location was compared to the patient's documented 15 minute Close Observation Form. The comparison revealed the patient had been documented as being in the lounge area at 4:30 p.m. and 4:45 p.m. when in fact she was observed on video to have been in her room.

Further review of the video revealed Patient #8 was observed by MHT staff at 4:35 p.m. and S9MHT was observed taking out the trash at 5:04 p.m. glancing into Patient #8's room. Further observation revealed S9MHT went down the hall and returned to Patient #8's room with multiple staff members. S10MHT (assigned to supervise Patient #8) was observed seated at the far end of the hall during the time interval reviewed.
Based on video review, Patient #8 was not observed for a total of 29 minutes by MHT staff or nursing staff.

S2DON, present during review of the recording, confirmed the MHT staff should have been going to the patient's door and looking in to visualize Patient #8 when performing every 15 minute checks. S2DON further confirmed the documentation on Patient #8's 15 minute Close Observation Form was not accurate when compared to the video recording of the patient during the time-frame reviewed prior to and after the incident.

S1Adm, also present and assisting with video recording review, confirmed S10MHT could only visualize Patient #8's room doorway and the hall from the location where she was seated. S1Adm further confirmed the documentation on Patient #8's 15 minute Close Observation Form was not accurate when compared to the video recording of the patient during the time-frame reviewed prior to and after the incident.

In an interview on 8/6/19 at 10:00 a.m. with S1Adm and S13SSDir, they reported contraband searches started on admit. S1Adm confirmed it was the responsibility of all staff members to ensure the patient care environment was safe. S1Adm further confirmed all staff received training for identification of contraband and performing room searches for contraband.

In an interview on 8/7/19 at 8:44 a.m. with S3Psych, he indicated Patient #8 was hospitalized 2 ½ weeks prior to the survey. He reported Patient #8 had been a Bipolar Borderline patient type patient that takes experience to deal with. He further reported on 7/20/19 Patient #8 was found with a cord around neck, was sent to hospital and when she returned she was placed on 1:1 level of supervision and remained on 1:1 level of supervision until discharge. He reported he was notified of Patient #8's suicide attempt later in the day on the day that it had happened. He indicated if there is a medical issue the Medical MD is called and if the issue is psychiatric the staff calls him because he is the attending psychiatrist. He said a patient has to show sustained improvement not just expressing "I don't want to hurt myself anymore". He reported he errs on the conservative side of treatment, but every now and then there is an outlier.

In an interview on 8/7/19 at 9:55 a.m., with S10MHT, she indicated she remembered the incident when Patient #8 had attempted to strangle herself. S10MHT reported the patient was coloring and talking to staff that day. S10MHT explained Patient #8 had said she was going to the restroom when she passed by her to go to her room. S10MHT further reported she was seated in her station where she could see the doorways of rooms 109-113 and the hallway. S10MHT reported Patient #8's room was on the farther end of the hall. S10MHT indicated the incident had occurred when they were passing out dinner. S10MHT explained they had started putting trays on tables and were calling out room numbers and they realized Patient #8 was not there. She said S9MHT went to look for the patient and he indicated he didn't see Patient #8. S10MHT reported she knew Patient #8 was in her room so she went to the room and found her on the floor. She said Patient #8 was laying with her head near the foot of the bed and her legs were near the entry doorway of the bathroom. She reported the patient was laying on her stomach with the drawstring of her shorts wrapped around her neck. S10MHT said Patient #8 was blue and not responding so she ran to the nurses' station for help. S10MHT reported she ran for help first before removing the drawstring from the patient's neck. S10MHT confirmed patients were not allowed to have hoodies, sweatpants and scrub pants with drawstrings because they were considered contraband. She explained contraband checks were performed on admission, in the morning and evening, and after visitation.

In an interview on 8/7/19 at 10:29 a.m. with S6RN, she indicated Patient #8 had been admitted with suicidal ideations. S6RN confirmed she had been the charge nurse on 7/20/19 when Patient #8 had attempted suicide by strangulation. S6RN reported Patient #8 had seemed to be in a good mood when she first talked to her that morning although the patient had expressed she had thoughts of self-harm she did not have a plan. S6RN reported if the patient had seemed more depressed or had expressed a plan she would have notified the psychiatrist. S6RN confirmed Patient #8 had been on suicide precautions and had been on every 15 minute observations. S6RN explained she was in the nurses' station when the MHT came to get help during Patient #8's suicide attempt. S6RN indicated Patient #8 had been face down near the middle of the floor near the bathroom. S6RN explained Patient #8 had the drawstring of her shorts looped around her neck twice really tightly. S6RN indicated Patient #8's skin color was more pale than blue and she was unconscious. S6RN reported she had turned the patient over and had gone to get the code cart. S6RN indicated the MHTs and the LPN had gotten Patient #8 "to come to" by the time she had arrived with the code cart. S6RN reported she had seen Patient #8 wearing the shorts with the drawstring 2 times before. She confirmed the patient should not have had the shorts because they had a drawstring but she had not been aware the shorts had a drawstring in them. S6RN also reported the patient had a small cut on her wrist and she saw a small spot of blood on the floor. S6RN explained Patient #8 had indicated she had cut her wrist with the cap on her toothpaste. S6RN confirmed patients were not allowed to keep their toiletries in their room. She explained they were handed out so patients could brush their teeth and they were to return their toiletries to the MHTs after use. S6RN reported she had called 9-1-1, the doctor, and called the Administrator to report the incident. S6RN indicated she had completed an incident report that day.

In an interview on 8/7/19 at 10:52 a.m. with S9MHT, he confirmed he remembered Patient #8 and had been working the day she had attempted suicide. S9MHT reported he had just put the meal cart in the hallway. S9MHT explained S10MHT had asked him to wake up all of the patients, so he began knocking on patient doors to wake them up. S9MHT reported when he knocked on Patient #8's door there was no response. S9MHT said the lights were off in Patient #8's room and he had not seen her in the room so he told S10MHT he had not seen Patient #8. S9MHT confirmed patients' on every 15 minute observation levels were to be rounded on every 15 minutes and the nurses signed off on the sheets every 2 hours. S9MHT reported when Patient #8 had been found she had the drawstring ties from her shorts wrapped around her neck and she also had a nick on her wrist from the toothpaste cap. S9MHT confirmed patients were not allowed to have any items with drawstrings, no shoestrings, belts and were not allowed to keep toiletry items in their possession after use.

In an interview on 8/7/19 at 2:35 p.m. with S7RN, she reported the RN Charge nurse on each shift had to review the MHTs' patient observation sheets every 2 hours and must sign off on them at that time. S7RN explained the nursing staff was to also round every 2 hours on floor to observe patients. S7RN confirmed she had received training in Patient's Rights, Abuse/Neglect, Levels of Observation, Precautions, and Reporting of incidents (chain of command for reporting)/Completion of incident reports.S7RN indicated the Charge RN completed incident reports and reports up to S2DON.


2) Failure to ensure the patients' environment was free of safety risks and did not afford opportunities for self -injury/harm to others.

On 8/5/19 from 10:00 a.m. - 11:30 a.m. an observation was conducted of the patient care unit. The following safety risks were noted during the observation:

a. Room 113: large face panel on front of air conditioning unit was not secured to the wall exposing numerous ligature risks -numerous sharp metal elements, pipes and wiring behind front panel- potenial for self harm.

b. Rooms 110, 214: air conditioning unit with unlocked 5 inch square panel which exposed wiring - potential for self harm.

c. Rooms 127, 128: handle of toilet exposed, accessible to patients - potential ligature anchor point.
Patient #4, who was on suicide precautions, was observed in Room 128 with the door closed. S2DON, present during the observation, confirmed Patient #4 was in the room with the door closed. S2DON indicated patients on every 15 minute observations were allowed to go into their rooms with the door closed, even if they were on suicide precautions.

d. Rooms 129, 215, 216, 217, 218, and 219: Entire base of toilets exposed- potential ligature anchor point-linens or other items such as drawstrings could be secured around the base of the toilets.

e. Cabinets with multiple drawers and doors with "u" shaped open handles and a sink with a gooseneck faucet, flanged handles noted at the end of the 200 hall. This area presented multiple potential ligature anchor points. The cabinets and sink were located at the end of the hall, in an alcove that could not be directly visualized from the far end of the hallway (where the MHT was seated) and was also located in a blind spot for the 2 security cameras that recorded in that area.

Patient #R4 was observed walking the hallway in the area where the cabinets, gooseneck faucet, and flanged sink handles referenced above were located. Patient #R4 was on suicide precautions.

Patient #5, who was on suicide precautions, was in the room located directly beside the cabinets with multiple ligature anchor points.

f. The television in the lounge/dining room was noted to have exposed wires, accessible to patients.

g. Room 200 had a plastic bag in the waste basket - potential for harm- suffocation.

h. Rooms 210, 215, 220: activities of daily living basket with deodorant, mouthwash, shampoo, toothbrush, toothpaste in patient room - potential for harm.

S2DON, present during the observations referenced above, verified the surveyor findings and acknowledged the observed physical environment posed a safety risk to patients.




39791

Based on record review and interview, the hospital failed to ensure patients were free from abuse and neglect as evidenced by:

1) Failure to ensure neglect of care (Patient #8 attempted suicide by strangulation while hospitalized) was reported to LDH-HSS or a local law enforcement agency within 24 hours of the incident for 1 (#8) of 1 sampled patients reviewed for abuse/neglect.; and

2) Failure to ensure a thorough investigation was completed after a patient's attempted suicide in the hospital in order to assure appropriate corrective action was taken to protect other patients currently hospitalized who may have been at risk for self-harm (there were currently 9 patients on suicide precautions) for 1 (#8) of 1 patient record reviewed for abuse/neglect from a total patient sample of 10 (#1- #10).

Findings:

1) Failure to ensure neglect of care was reported to LDH-HSS or a local law enforcement agency within 24 hours of the incident:

Review of the State law R.S. 40:2009.20 revealed "Any person who is engaged in the practice of medicine, social service, facility administration, psychological services or any RN, LPN, nurses' aide, personal care attendant, respite worker, physician's assistant, physical therapist, or any other healthcare giver 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 24 hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect."

Review of the hospital's incident reports from 1/1/18 - 8/5/19 revealed an incident report, dated 7/20/19 at 7:30 p.m., indicating Patient #8 had attempted suicide by strangulation while being treated in the hospital. Further review of the incident report revealed the following: Patient was found in her room with the string of her shorts wrapped around her neck, skin color blue and not responding. The patient required a sternal rub to become responsive. The patient had also cut her wrist with a toothpaste cap (noted in the same incident report). Additional review revealed the patient had been seen 2 times prior to the suicide attempt, by staff, wearing the same shorts with the drawstring in them (contraband item).

Review of the Patient #8's medical record revealed the patient was admitted on 7/12/19. The patient's legal status was PEC on 7/12/19 due to an intentional overdose of 90 Clonazepam tablets, being dangerous to self, and unable to seek voluntary admission. The patient had a history of Bipolar Disorder and having Suicidal Ideations. Further review revealed the Patient was CEC on 7/15/19 due to remaining suicidal and endorsing Suicidal Ideations.

Review of Patient #8's admission physician's orders, dated 7/12/19, revealed the patient was on ordered every 15 minute observations with suicide precautions.

Review of Patient #8's nurses' notes for the day shift (7:00 a.m. - 7:00 p.m.) of 7/20/19, revealed the patient had been documented as verbalizing suicidal ideations with no plan.

An observation was made on 8/6/19 at 11:30 a.m. of a video recording of Patient #8 on 7/20/19 from 4:00 p.m. - 5:07 p.m. The patient was on ordered every 15 minute observations. The patient had been documented as being in the lounge area when in fact she was observed to have been in her room.

Based on the video review the patient was not observed for a total of 29 minutes by the MHT staff or nursing staff. S9MHT was observed taking out the trash at 5:04 p.m. glancing into Patient #8's room. Further observation revealed S9MHT went down the hall and returned to Patient #8's room with multiple staff members.

Review of the hospital's self- reports to LDH-HSS revealed no documented evidence the above referenced incident of neglect of care had been reported to LDH-HSS within 24 hours of discovery.

In an interview on 8/5/19 at 4:00 p.m. with S1Adm and S2DON, they confirmed the above referenced incident had not been reported to LDH-HSS within 24 hours of discovery.

2) Failure to ensure a thorough investigation was completed after a patient's attempted suicide (#8), in the hospital, in order to assure appropriate corrective action was taken to protect other patients currently hospitalized who may have been at risk for self-harm.

In an interview on 8/5/19 at 4:00 p.m. with S1Adm and S2DON, they confirmed no investigation of Patient #8's attempted suicide by strangulation with the drawstring of her shorts (contraband item), in the hospital, had been conducted. S1Adm and S2DON also confirmed they had not reviewed the video recordings of the day the incident occurred to identify possible causative/contributing factors.

Another interview was conducted with S1Adm and S2DON on 8/6/19 at 11:45 a.m. During the interview, S1Adm and S2DON confirmed they had still not reviewed the video recording of the incident and had not conducted an investigation into possible causes of the incident. S1Adm and S2DON confirmed they had failed to remove the contraband item from the patient's possession and acknowledged they had failed to conduct a thorough investigation to identify possible causative/contributing factors that may have led to the incident. S1Adm and S2DON confirmed there were currently 9 of 18 total patients on suicide precautions on 8/6/19.

Based on record review and interview, the hospital failed to ensure the use of restraint was in accordance with safe and appropriate restraint and seclusion techniques as per hospital policies and procedures for 1 (#6) of 3 (#6, #10, #R2) patient records reviewed for use of restraints.

Findings:

Review of the hospital policy titled "Restraint or Seclusion" revealed in part, the hospital proactively promotes the use of the least restrictive intervention necessary to ensure the safety and security of patients. Further review reveals Physical Holding for Medication Administration - If the patient is being held so that medication can be administered against the patient's will (that is, during "a forced psychotropic medication procedure") and/or the patient is held in such a manner that movement is restricted and the patient cannot easily remove or escape the grasp, the hold IS considered Restraint.
The policy does not state to call the Sheriff's department for assistance with a forced psychotropic medication procedure.

Review of the "Unusual Occurance/Incident Report" revealed on 5/12/19 at 9:45 p.m., Patient #6 became belligerent, defiant, cursing, and physically threatening staff. The Sheriff's department was called for assistance and 4 deputies assisted with "take-down" and the patient received Zyprexa 10 mg IM.

Review of Patient #6's electronic medical record on 8/5/19 at 1:45 p.m. navigated by S5SW revealed he was a 31 year old male admitted on 5/12/19 under a PEC for depression, suicidal thoughts, and substance abuse. Further review revealed a nursing note dated 5/12/19 at 10:10 p.m. 4 Sheriff's deputies arrived to assist with securing patient to administer Zyprexa 10 mg IM.

In an interview on 8/5/19 at 2:10 p.m. with S5SW, she revealed it is not the policy to call 9-1-1 for assistance with patient holds.

In an interview on 8/6/19 at 10:00 a.m. with S1Adm and S13SSDir, they confirmed it was not hospital policy to contact the police department to assist with "take-down" of patients for forced medication administration. They reported there was a step by step process to follow if police action was needed and they were to call S2DON and S1Adm before contacting the police department.

In an interview on 8/7/19 at 12:00 p.m. with S17MHT, she revealed on 5/12/19 she witnessed Patient #6 was held down by deputies to get an injection by his nurse.

Based on record review, observation, and interview, the hospital failed to ensure the hospital wide QAPI program set priorities aimed at performance improvement activities that focused on high-risk, high-volume, or problem-prone areas that affected health outcomes, patient safety, and quality of care. This deficient practice was evidenced by failure of the hospital's QAPI program to identify and address the following survey identified issues: nursing staff's failure to score SRA's accurately, failure to identify the glucose meter was not being disinfected properly between patients, and failure to identify the hospital's infection control program lacked surveillance for ensuring proper staff performance of hand hygiene and PPE usage as opportunities for improvement to be addressed through the hospital's QAPI program.

Findings:

Nursing - Suicide Risk Assessments inaccurately scored:
Review of sampled patient records ( #2, #4, and #8) revealed patients' suicide risk was not being assessed accurately on the SRA tool due to failure of the RN staff to include a patient's past suicide attempts and plans to determine scoring for level of suicide risk.

Infection Control Issues:
An observation of S8LPN was conducted on 8/6/19 at 4:20 p.m. S8LPN performed capillary blood glucose sampling, via fingerstick, on Patient #1, in the presence of S2DON. Following the capillary blood glucose test, S8LPN took an unlabeled, clear spray bottle which contained a liquid substance, and sprayed the blood glucose monitor with the solution. S8LPN then wiped the moniter down after spraying it with the liquid. S8LPN stated the solution was Spic and Span (a household cleaning agent).

Review of the current infection control program revealed the only documentation for the hospital's infection control program was of antibiotic stewardship and documentation of community versus hospital acquired infections.

An interview was conducted with S1Adm and S2DON on 8/07/19 at 9:15 a.m. They verified the hospital has not implemented an active surveillance program for hand hygiene and the use of appropriate PPEs to ensure the staff was taking effective measures to control infections for patients and/or personnel in the hospital.

In an interview on 8/7/19 at 3:00 p.m. with S1Adm and S5SW, they confirmed the above referenced survey identified problems had not been identified as opportunities for improvement to be addressed through the hospital wide QAPI program.

Based on record review and interview, the hospital failed to ensure the QAPI program analyzed adverse patient events that impacted patient safety and quality of care. This deficient practice was evidenced by failure of the hospital to conduct a thorough investigation after a patient's attempted suicide (#8) in the hospital to assure appropriate corrective action and performance improvement indicators were initiated in order to protect other patients currently hospitalized who may have been at risk for self-harm (there were currently 9 patients on suicide precautions) for 1 (#8) of 1 patient record reviewed for abuse/neglect from a total patient sample of 10 (#1- #10).

Findings:

Review of the hospital's incident reports from 1/1/18 - 8/5/19 revealed an incident report, dated 7/20/19 at 7:30 p.m. indicating Patient #8 had attempted suicide by strangulation while being treated in the hospital. Further review of the incident report revealed the following: Patient was found in her room with the string of her shorts wrapped around her neck, skin color blue and not responding. The patient required a sternal rub to become responsive. The patient had also cut her wrist with a toothpaste cap (noted in the same incident report). Additional review revealed the patient had been seen 2 times prior to the suicide attempt by staff wearing the same shorts with the drawstring in them (contraband item).

In an interview on 8/5/19 at 4:00 p.m. with S1Adm and S2DON, they confirmed no investigation of Patient #8's attempted suicide by strangulation with the drawstring of her shorts (contraband item) in the hospital had been conducted. S1Adm and S2DON also confirmed they had not reviewed the video recordings of the day the incident occurred to identify possible causative/contributing factors.

Another interview was conducted with S1Adm and S2DON on 8/6/19 at 11:45 a.m. During the interview, S1Adm and S2DON confirmed they still had not reviewed the video recording of the incident and had not conducted an investigation into possible causative/contributing factors that may have led to the incident. S1Adm and S2DON confirmed they had failed to remove the contraband item from the patient's possession. S1Adm and S2DON confirmed there were currently 9 of 18 total patients on suicide precautions on 8/6/19.

In an interview on 8/7/19 at 3:00 p.m. with S1Adm and S5SW they confirmed the hospital had not identified Patient #8's attempted suicide by strangulation in the hospital as an adverse patient event to be analyzed through the hospital's QAPI program. They further confirmed performance improvement indicators had not been established in order to assure appropriate corrective action was initiated in order to protect other patients currently hospitalized who may have also been at risk for self-harm.

Based on record reviews, observations, and interviews, the hospital failed to meet the requirements of the Condition of Participation for Nursing as evidenced by:

1) failure of the RN to ensure a patient admitted after attempting suicide had been observed at the ordered level of observation of every 15 minutes for 1 (#8) of 1 sampled patient incident reports reviewed from a total patient sample of 10 (#1- #10). Patient #8 subsequently attempted suicide in the hospital.(See findings in tag A-0395).; and

2) failure of the RN to ensure a patient (#8) admitted after attempting suicide had not had access to a contraband item (a drawstring) that was used for self-harm. Patient #8 subsequently attempted suicide in the hospital by strangulation using the drawstring from her shorts.(See findings in tag A-0395).

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39791

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by:

1) failure of the RN to ensure a patient admitted after attempting suicide had been observed at the ordered level of observation of every 15 minutes for 1 (#8) of 1 sampled patient incident reports reviewed from a total patient sample of 10 (#1- #10). Patient #8 subsequently attempted suicide in the hospital.;

2) failure of the RN to ensure a patient (#8) admitted after attempting suicide had not had access to a contraband item (a drawstring) that was used for self-harm. Patient #8 subsequently attempted suicide in the hospital by strangulation using the drawstring from her shorts.;

3) failure of the RN to ensure patients' suicide risk was assessed accurately on the SRA tool for 3 (#2, #4, #8) of 8 (#1-#8) sampled patients' records reviewed for SRA from a total patient sample of 10 (#1- #10); and

4) failure to follow physician's orders on 2 (#7,#9) of 10 medical records reviewed for physician's orders from a total patient sample of 10 (#1-#10).


Findings:

1) Failure to ensure a patient admitted after attempting suicide had been observed at the ordered level of observation of every 15 minutes.

Review of the hospital policy titled, "Assessment for High Risk Behavior - Nursing", revealed in part: Policy: Beacon Behavioral Hospital ensures that all patients are assessed for the presence of high-risk ideation and/or behavior (such as suicidal, aggressive and other tendencies) upon admission and on an ongoing basis throughout treatment.
The Inpatient Risk Assessment is based on the Beck Depression Scale and the Hoff Danger Assessment. it is conducted by qualified registered nurses, whose scope of practice includes such evaluation. The purpose of this assessment is to evaluate protective factors that lower risk, for example increased monitoring, a secure, safe environment, restricted access to means, etcetera. All findings are documented in the patient's medical record and communicated.
7. A. Levels of observation include: I. Close Observation (observation every 15 minutes);
II. Line of Sight ( staff member maintains visual contact with the patient at all times; no barriers can be situated between them; staff maintains visual contact at all times, including when patient uses the bathroom);
III: One - to - One Observation ( staff member is assigned to one patient and must maintain visual contact with the patient at all times; no barriers can be situated between them; staff maintains visual contact at all times, including when patient uses the bathroom); this level of observation may be ordered at arm's length or not.
B. Precautions may include but are not limited to: I. Suicide, II. Elopement, III. Violent/Aggressive; IV. Sexual. Note: the Attending Licensed Practitioner may order special provisions.

The following are components of suicide precautions: Unit restriction: The patient is not allowed to leave the unit except for medical necessity and then only with orders from a licensed prescriber. In the event that the patient must leave the unit, the patient will be placed on at least 1:1 observation when off the unit.
Sharps restriction: Staff members are prohibited from providing those sharp items typically allowed for patient use with supervision and/or with time restrictions (e.g. razors). The patient on suicide precautions may not have access to items identified as sharp at any time. The use of items that may be modified for self-injurious behavior ( i.e. plastic silverware, etc.) shall be closely monitored by assigned staff member and accounted for after use.

Review of the Patient #8's medical record revealed the patient was admitted on 7/12/19. The patient's legal status was PEC on 7/12/19 due to an intentional overdose of 90 Clonazepam tablets (on the day of admission to the hospital), being dangerous to self, and unable to seek voluntary admission. Patient #8 had a history of Bipolar Disorder and having Suicidal Ideations. Further review revealed Patient #8 was CEC'd on 7/15/19 due to remaining suicidal and endorsing Suicidal Ideations.

Review of the hospital's incident reports from 1/1/18 - 8/5/19 revealed an incident report dated 7/20/19 at 7:30 p.m. indicating Patient #8 had attempted suicide by strangulation while being treated in the hospital. Further review of the incident report revealed the following: Patient #8 was found in her room with the string of her shorts wrapped around her neck twice, skin color blue and not responding. The patient required a sternal rub to become responsive. The patient had also cut her wrist with a toothpaste cap. Additional review revealed the patient had been seen 2 times prior to the suicide attempt, by staff, wearing the same shorts with the drawstring in them (contraband item).

Review of Patient #8's admission physician's orders, dated 7/12/19, revealed the patient was on ordered every 15 minute observations with suicide precautions.

Review of Patient #8's nurses' notes for the day shift (7:00 a.m. - 7:00 p.m.) of 7/20/19, revealed the patient had been documented as verbalizing suicidal ideations with no plan.

Review of Patient #8's 15 Minute Close Observation Form (documentation indicating the patient's location, activity, and behavior every 15 minutes), dated 7/20/19, revealed the following entries:
4:00 p.m.: 3 (in lounge), N (walking), 69 (cooperative);
4:15 p.m.: 3 (in lounge), C (reading/coloring), 69 (cooperative);
4:30 p.m.: 3 (in lounge), N (walking), 69 (cooperative);
4:45 p.m.: 3 (in lounge), N (walking), 72 (quiet);
5:00 p.m.: 1 (in room), X (other), 62 (threatening self-harm) and 74 (on floor); and
5:15 p.m.: 1 (in room), D (talking with peers) and E (talking with staff), 72 (quiet)

An observation was made on 8/6/19 at 11:30 a.m. of a video recording of Patient #8 on 7/20/19 from 4:00 p.m. - 5:07 p.m. ( time -frame preceding, during, and after the incident. Patient #8's location and activities were observed as follows:
4:00 p.m.: Patient #8 was seated in dayroom/lounge area and was observed getting up from the table and walking down the hall;
4:11 p.m.: Patient #8 was observed entering her room;
4:15 p.m.: MHT observed Patient #8;
4:30 p.m.: Patient - in room - no staff rounding observed;
4:31 p.m.: Patient in room - no staff rounding observed;
4:35 p.m.: Patient observed walking down the hall and back to room (S10MHT seated at the far end of the hall and Patient #8 could be visualized in the hallway at that time);
4:41 p.m. - 4:56 p.m.: Patient - in room, no staff rounding observed;
4:58 p.m.: MHT in dining room, Patient #8 remains in room, no staff rounding observed;
5:04 p.m.: S9MHT observed carrying trash down the hall, passing by Patient #8's room;
5:07 p.m.: Staff observed with crash cart.

The reviewed video recording of Patient #8's activity and location was compared to the patient's documented 15 minute Close Observation Form. The comparison revealed the patient had been documented as being in the lounge area at 4:30 p.m. and 4:45 p.m. when in fact she was observed on video to have been in her room.

Further review of the video revealed Patient #8 was observed by MHT staff at 4:35 p.m. and S9MHT was observed taking out the trash at 5:04 p.m. glancing into Patient #8's room. Further observation revealed S9MHT went down the hall and returned to Patient #8's room with multiple staff members. S10MHT (assigned to supervise Patient #8) was observed seated at the far end of the hall during the time interval reviewed. Based on video review, Patient #8 was not observed for a total of 29 minutes by MHT staff or nursing staff.

S2DON, present during review of the recording, confirmed the MHT staff should have been going to the patient's door and looking in to visualize Patient #8 when performing every 15 minute checks. S2DON further confirmed the documentation on Patient #8's 15 minute Close Observation Form was not accurate when compared to the video recording of the patient during the time-frame reviewed prior to and after the incident.

S1Adm, also present and assisting with video recording review, confirmed S10MHT could only visualize Patient #8's room doorway and the hall from the location where she was seated. S1Adm further confirmed the documentation on Patient #8's 15 minute Close Observation Form was not accurate when compared to the video recording of the patient during the time-frame reviewed prior to and after the incident.


In an interview on 8/7/19 at 8:44 a.m. with S3Psych, he indicated Patient #8 was hospitalized 2 ½ weeks prior to the survey. He reported Patient #8 had been a Bipolar Borderline type patient that takes experience to deal with. He further reported on 7/20/19 Patient #8 was found with a cord around neck, was sent to hospital and when she returned she was placed on 1:1 level of supervision and remained on 1:1 level of supervision until discharge. He reported he was notified of Patient #8's suicide attempt later in the day on the day that it had happened. He indicated if there is a medical issue the Medical MD is called and if the issue is psychiatric the staff calls him because he is the attending psychiatrist. He said a patient has to show sustained improvement not just expressing "I don't want to hurt myself anymore". He reported he errs on the conservative side of treatment, but every now and then there is an outlier.

In an interview on 8/7/19 at 10:29 a.m. with S6RN, she indicated Patient #8 had been admitted with suicidal ideations. S6RN confirmed she had been the charge nurse on 7/20/19 when Patient #8 had attempted suicide by strangulation. S6RN reported Patient #8 had seemed to be in a good mood when she first talked to her that morning although the patient had expressed she had thoughts of self-harm she did not have a plan. S6RN reported if the patient had seemed more depressed or had expressed a plan she would have notified the psychiatrist. S6RN confirmed Patient #8 had been on suicide precautions and had been on every 15 minute observations. S6RN explained she was in the nurses' station when the MHT came to get help during Patient #8's suicide attempt. S6RN indicated Patient #8 had been face down near the middle of the floor near the bathroom. S6RN explained Patient #8 had the drawstring of her shorts looped around her neck twice really tightly. S6RN indicated Patient #8's skin color was more pale than blue and she was unconscious. S6RN reported she had turned the patient over and had gone to get the code cart. S6RN indicated the MHTs and the LPN had gotten Patient #8 "to come to" by the time she had arrived with the code cart. S6RN reported she had seen Patient #8 wearing the shorts with the drawstring 2 times before. She confirmed the patient should not have had the shorts because they had a drawstring but she had not been aware the shorts had a drawstring in them. S6RN also reported the patient had a small cut on her wrist and she saw a small spot of blood on the floor. S6RN explained Patient #8 had indicated she had cut her wrist with the cap on her toothpaste. S6RN confirmed patients were not allowed to keep their toiletries in their room. She explained they were handed out so patients could brush their teeth and they were to return their toiletries to the MHTs after use. S6RN reported she had called 9-1-1, the doctor, and called the Administrator to report the incident. S6RN indicated she had completed an incident report that day.

In an interview on 8/7/19 at 9:55 a.m., with S10MHT, she indicated she remembered the incident when Patient #8 had attempted to strangle herself. S10MHT reported the patient was coloring and talking to staff that day. S10MHT explained Patient #8 had said she was going to the restroom when she passed by her to go to her room. S10MHT further reported she was seated in her station where she could see the doorways of rooms 109-113 and the hallway. S10MHT reported the Patient #8's room was on the farther end of the hall. S10MHT indicated the incident had occurred when they were passing out dinner. S10MHT explained they had started putting trays on table and were calling out room numbers and they realized Patient #8 was not there. She said S9MHT went to look for the patient and he indicated he didn't see Patient #8. S10MHT reported she knew Patient #8 was in her room so she went to the room and found her on the floor. She said Patient #8 was laying with her head near the foot of the bed and her legs were near the entry doorway of the bathroom. She reported the patient was laying on her stomach with the drawstring of her shorts wrapped around her neck. S10MHT said Patient #8 was blue and not responding so she ran to the nurses' station for help. S10MHT reported she ran for help first before removing the drawstring from the patient's neck. S10MHT confirmed patients were not allowed to have hoodies, sweatpants and scrub pants with drawstrings because they were considered contraband. She explained contraband checks were performed on admission, in the morning and evening, and after visitation.

In an interview on 8/7/19 at 10:52 a.m. with S9MHT, he confirmed he remembered Patient #8 and had been working the day she had attempted suicide. S9MHT reported he had just put the meal cart in the hallway. S9MHT explained S10MHT had asked him to wake up all of the patients, so he began knocking on patient doors to wake them up. S9MHT reported when he knocked on Patient #8's door there was no response. S9MHT said the lights were off in Patient #8's room and he had not seen her in the room so he told S10MHT he had not seen Patient #8. S9MHT confirmed patients' on every 15 minute observation levels were to be rounded on every 15 minutes and the nurses signed off on the sheets every 2 hours. S9MHT reported when Patient #8 had been found she had the drawstring ties from her shorts wrapped around her neck and she also had a nick on her wrist from the toothpaste cap. S9MHT confirmed patients were not allowed to have any items with drawstrings, no shoestrings, belts and were not allowed to keep toiletry items in their possession after use.


In an interview on 8/7/19 at 2:35 p.m. with S7RN, she reported the RN Charge nurse on each shift had to review the MHTs' patient observation sheets every 2 hours and must sign off on them at that time. S7RN explained the nursing staff was to also round every 2 hours on floor to observe patients. S7RN confirmed she had received training in Patient's Rights, Abuse/Neglect, Levels of Observation, Precautions, and Reporting of incidents (chain of command for reporting)/Completion of incident reports.S7RN indicated the Charge RN completed incident reports and reports up to S2DON.


2) Failure of the RN to ensure a patient (#8) admitted after attempting suicide had not had access to a contraband item (a drawstring) that was used for self-harm.

Review of the Patient #8's medical record revealed the patient was admitted on 7/12/19. The patient's legal status was PEC on 7/12/19 due to having suicidal ideations, being dangerous to self and unable to seek voluntary admission. Further review revealed Patient #8 was CEC'd on 7/15/19 due to remaining suicidal and endorsing Suicidal Ideations.

Review of the hospital's incident reports from 1/1/18 - 8/5/19 revealed an incident report dated 7/20/19 at 7:30 p.m. indicating Patient #8 had attempted suicide, by strangulation, wrapping the drawstring of her shorts around her neck twice, while being treated in the hospital. Further review of the incident report revealed the patient had been seen 2 times prior to the suicide attempt, by staff, wearing the same shorts with the drawstring in them (contraband item).

Review of Patient #8's admission physician's orders, dated 7/12/19, revealed the patient was on ordered every 15 minute observations with suicide precautions.

Review of Patient #8's nurses' notes for the day shift (7:00 a.m. - 7:00 p.m.) of 7/20/19, revealed the patient had been documented as verbalizing suicidal ideations with no plan.

In an interview on 8/6/19 at 10:00 a.m. with S1Adm and S13SSDir, they reported contraband searches started on admit. S1Adm confirmed it was the responsibility of all staff members to ensure the patient care environment was safe. S1Adm further confirmed all staff received training for identification of contraband and performing room searches for contraband.

In an interview on 8/6/19 at 11:45 a.m., with S1Adm and S2DON, they confirmed the staff had failed to remove the contraband item from the patient's possession. S1Adm and S2DON confirmed there were currently 9 of 18 total patients on suicide precautions on 8/6/19.

In an interview on 8/7/19 at 9:55 a.m., with S10MHT, she indicated she remembered the incident when Patient #8 had attempted to strangle herself. S10MHT confirmed patients were not allowed to have hoodies, sweatpants and scrub pants with drawstrings because they were considered contraband. She explained contraband checks were performed on admission, in the morning and evening, and after visitation.

In an interview on 8/7/19 at 10:29 a.m. with S6RN, she indicated Patient #8 had been admitted with suicidal ideations. S6RN confirmed she had been the charge nurse on 7/20/19 when Patient #8 had attempted suicide by strangulation. S6RN reported she had seen Patient #8 wearing the shorts with the drawstring 2 times before. She confirmed the patient should not have had the shorts because they had a drawstring (contraband) but she had not been aware the shorts had a drawstring in them.

In an interview on 8/7/19 at 10:52 a.m. with S9MHT, he confirmed he remembered Patient #8 and had been working the day she had attempted suicide. S9MHT confirmed patients were not allowed to have any items with drawstrings, no shoestrings, and no belts because they were contraband.

In an interview on 8/7/19 at 2:35 p.m. with S7RN, she reported the MHT staff searched patients for contraband and also checked their belongings for contraband items on admission and as needed. S7RN confirmed she had received training in Patient's Rights, Abuse/Neglect, Room Searches, and Contraband.


3) Failure of the RN to ensure patients' suicide risk was assessed accurately on the SRA tool:


Review of the hospital policy titled, "Assessment for High Risk Behavior - Nursing", revealed in part: Policy: Beacon Behavioral Hospital ensures that all patients are assessed for the presence of high-risk ideation and/or behavior (such as suicidal, aggressive and other tendencies) upon admission and on an ongoing basis throughout treatment.
The Inpatient Risk Assessment is based on the Beck Depression Scale and the Hoff Danger Assessment. it is conducted by qualified registered nurses, whose scope of practice includes such evaluation. The purpose of this assessment is to evaluate protective factors that lower risk, for example increased monitoring, a secure, safe environment, restricted access to means, etcetera. All findings are documented in the patient's medical record and communicated.

Patient #2
Review of Patient #2's medical record revealed he was a 21 year old male with the diagnosis of Depression.

Review of Patient #2's PEC dated 8/04/19 and timed 8:30 p.m. revealed present illness was suicidal statement/note with plan (jump off bridge), multiple superficial scratches to arms with knife. Agitated/poor insight and judgement. Patient was listed as currently suicidal and dangerous to self and unwilling to seek voluntary admission.

Review Patient #2's Nursing Assessment dated 8/5/19 revealed the patient's presenting problem was in part, " Pt is 21 year old male presents to ED with SI. Pt was found walking toward a bridge after leaving note for mom saying that he needs help and finding it and will jump off a bridge and kill himself.."

Review of Patient #2's Self Harm/Suicide Risk Assessment dated 8/5/19 at 2:49 a.m. revealed the patient had a history of self harm in the last 72 hours. With further review of the suicide risk assessment the assessment revealed the patient did not have any thoughts/feelings of harming self and he did not have a plan. According to the SRA the patient's total score was 10, which indicated the patient was a low risk for suicide.

Patient #4
Review of Patient #4's medical record revealed the patient was admitted on 8/3/19, with admission diagnoses of Major Depressive Disorder, generalized Anxiety disorder, and Cannabais abuse. Further review revealed the patient's legal status was PEC due to complaints of depression and suicidal ideation without a plan, + for auditory and visual hallucination (seeing shadows/people), and being dangerous to self and unwilling to seek voluntary admission. The patient's status was documented as currently suicidal.

Review of Patient #4's admission Self Harm/Suicide Risk Assessment dated 8/3/19 at 9:30 a.m. revealed the following responses and scores:
1. History of attempt of self-harm? : No, Score 0 (Low Risk);
2. If yes, how recent? : 18+ Months or N/A, Score 0 (Low Risk);
3. Attempt resulted in medical or psychiatric treatment, other than this admission? : Answer: N/A, Score 0 (Low Risk);
4. Any thoughts/feelings of harming self? : No, Score; 0; Correct response should have been Yes, in the last 12 months (patient expressed SI when he was PEC on 8/3/19) Score: 3 High Risk
5. If Yes, how recent? Scored as 18 + months or N/A: Score: Correct response should have been less than 72 hours: Score 3 (High Risk);
6. How often does patient experience these thoughts/feelings?: Rarely or never: Score 0 (Low Risk);
7. Has the patient formulated a plan to harm self? : N/A, Score: 0 (Low Risk);
8. If Yes, does the patient have a means to carry out the plan? : N/A, Score: 0 (Low Risk);
9. Is patient capable of carrying out the plan? No or N/A, Score: 0 (Low Risk);
10. Can the patient state a reason to live? : Yes, Score: 0 (Low Risk)
11. Family, close friend, or significant other committed suicide? : No, Score: 0 (Low Risk)
12. If Yes, how recent? : N/A, Score: 0 (Low Risk)
13. How does patient feel about suicide? : Unacceptable: Score: 0 (Low Risk)
14. Staff's perception of patient's openness about responses above: Attempted to withhold/conceal: Score: 3 (High Risk).

Further review revealed of the SRA, performed by the admission nurse, revealed the patient had a total suicide risk assessment score of 3, which indicated the patient was a low risk for suicide (Score of 0-10) . The patient's total suicide risk should have been scored as a 9, based on responses taking into account the patient's history, which placed the patient in the upper level of the low risk category.

Patient #8
Review of Patient #8's medical record revealed the patient was admitted on 7/12/19. The patient's legal status was PEC on 7/12/19 due to an intentional overdose of 90 Clonazepam tablets (on the day of admission to the hospital), being dangerous to self, and unable to seek voluntary admission. The patient had a history of Bipolar Disorder and having Suicidal Ideations. Further review revealed the Patient was CEC on 7/15/19 due to remaining suicidal and endorsing Suicidal Ideations.

Review of Patient #8's admission Self Harm/Suicide Risk Assessment dated 7/12/19 at 6:15 p.m. revealed the following responses and scores:
1. History of attempt of self-harm? : Score 3 (High Risk),
2. If yes, how recent? : Attempt within last 72 hours (attempted drug overdose on the day of admission): Score 3 (High Risk)
3. Attempt resulted in medical or psychiatric treatment, other than this admission? : Answer: No (patient was sent to ED for treatment of overdose), Score: 1 (Mild Risk), response should have been: Yes, Score: 2 (Moderate risk)
4. Any thoughts/feelings of harming self? : Scored as in the last 12 months: 3 (High Risk);
5. If Yes, how recent? Less than 72 hours: Score 3 (High Risk);
6. How often does patient experience these thoughts/feelings? : Frequently: Score 2 (Moderate Risk);
7. Has the patient formulated a plan to harm self? : No, Score: 1; Correct response should have been Yes, score: 3 (High Risk);
8. If Yes, does the patient have a means to carry out the plan? : N/A, no score; Correct response should have been Yes, score: 3 (High Risk);
9. Is patient capable of carrying out the plan? No or N/A: no score: Correct response should have been Yes, Score: 3 (High Risk);
10. Can the patient state a reason to live? : Yes: no score
11. Family, close friend, or significant other committed suicide?: No; no score
12. If Yes, how recent? : N/A: no score
13. How does patient feel about suicide? : Uncertain: Score: 1 (Mild Risk)
14. Staff's perception of patient's openness about responses above: Appeared open: No score.

Further review revealed of the SRA, performed by the admission nurse, revealed the patient had a total suicide risk assessment score of 17, which indicated the patient was a moderate risk for suicide (Score of 11-29) . The patient's total suicide risk should have been scored as a 26, based on responses taking into account the patient's history, which placed the patient in the upper level of the moderate risk category.

Review of Patient #8's nurses notes, date 7/20/19, revealed Patient #8 had attempted suicide, by strangulation, while being treated in the hospital, on 7/20/19. Patient #8 was found in her room with the string of her shorts wrapped around her neck twice, skin color blue and not responding. The patient required a sternal rub to become responsive. The patient had also cut her wrist with a toothpaste cap.

In an interview on 8/5/19 at 2:29 p.m. with S4HIM, she confirmed Patient #4's SRA had been inaccurately scored due to failure to take the patient's PEC information indicating his history of present illness on 8/3/19 (date of admission) into account in scoring his suicide risk.

In an interview on 8/5/19 at 2:31 p.m. with S5SW, she indicated the SRA was based on the Standardized Beck Depression Scale and Hoff danger assessment for comprehensive risk assessment. She indicated a patient's Suicide Risk was scored as follows on the hospital's SRA tool: Score: 0-10 low risk; Scores: 11-29 moderate risk; and 30 and higher high risk.S5SW confirmed the patient's past history was not taken into account when scoring the SRA. She indicated it is based on the patient's responses at time of admit. S5SW explained the complete assessment for suicide risk/homicide risk was performed on admit and at discharge to assess for protective factors for home safety after discharge. S5SW indicated the nurses assessed patients for SI daily nurses as part of the screening section in the nurses' notes.

In an interview on 8/6/19 at 10:00 a.m. with S13SSDir, he reported the hospital had not had a stand alone policy prior to 8/5/16 regarding precipitant lethality not being incorporated into the SRA performed on admit. S13SSDir agreed patient history of suicide attempts, with plan, referenced in PEC/CEC documentation was relevant in assessing patient suicide risk. S13SSDir indicated patient PEC/CEC documentation was available to staff when admitting patients.


4) Failure to follow physician's orders:
Patient #7
Review of Patient#7's medical record revealed he was 58 year old male admitted on 7/29/19 with a comorbid diagnosis of Hypertension.

Review of Patient #7's electronic medical record navigated by S2DON on 8/06/19 at 3:45 p.m.

Review of the physician's order dated 7/31/19 revealed an order for Catapres Tablet 0.1 mg stat and take blood pressure 1 hour after administration.

Review of the MAR revealed the Catapres tablet 0.1 mg Stat was administered on 7/31/19 at 12:07.

Review of the Vital Signs EMR record revealed a blood pressure of 177/104 on 7/31/19 at 12:09 and the next blood pressure documented for Patient #7 was on 08/01/19 at 7:11 a.m.

An interview was conducted with S2DON on 8/05/19 at 3:45 p.m. and he confirmed there was no documentation of the patient's blood pressure being monitored within one hour after the stat dose of Catapres was administered.

Patient #9
Review of Patient #9's medical record revealed a 34 year old admitted on 7/24/19 with a comorbid diagnosis of Diabetes Mellitus. He was discharged on 7/29/19.

Review of Patient #9's electronic medical record navigated by S5SW on 8/6/19 at 10:20 a.m.

Review of the physician's orders dated 7/25/19 at 12:36 p.m. by S12NP revealed an order to discontinue accuchecks.

Review of Patient #9's Diabetes Monitoring record revealed 10 accucheck results after the discontinued accucheck order (between 7/25/19 and 7/28/19).

In an interview on 8/6/19 at 10:20 a.m. with S5SW, she verified 10 accucheck results after the discontinued accucheck order 7/25/19.

Based on record review and interview, the hospital failed to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital.

Findings:

Review of hospital policies and procedures, revealed no policy and procedure for the provision of safety of staff and patients during radiological services performed in the hospital.

In an interview 8/7/19 at 2:10 p.m. with S2DON, he verified the policies and procedures did not address the safety of hospital staff, patients, or visitors.

Based on record review and interview, the hospital failed to ensure a qualified full-time, part-time, or consulting radiologist supervised the radiology services of the hospital as evidenced by failure to have a radiologist appointed and privileged to supervise the radiology services provided by the hospital.

Findings:

Review of the Governing Body meeting minutes for the last year revealed no appointment/privileging of a radiologist to the medical staff on a full time, part time, or consulting basis. Further review revealed no appointment of a radiologist to supervise Radiological Services.

Review of the Medical Staff meeting minutes for the last year revealed no reference to the appointment or approval of a radiologist to supervise Radiological Services.

In an interview 8/5/19 at 9:30 a.m. with S1Adm, she reported the hospital did not have a medical director of Radiological Services.

Based on record review and interview, the hospital failed to have a current therapeutic diet manual approved by the dietitian and the medical staff readily available to all medical, nursing and food service personnel.

Findings:

Review of the survey requested policies, procedures, and documentation, requested upon survey entry, provided by S1Adm, revealed no documened evidence of a current therapeutic diet manual approved by the dietician and medical staff.

An interview was conducted with S1Adm on 8/7/19 at 9:30 a.m. She was unable to locate a current therapeutic diet manual. S1Adm stated the hospital must no longer have a therapeuitic diet manual.

Based on record review and interview, the hospital failed to ensure there was an established UR committee consisting of two or more practitioner members who were doctors of medicine or osteopathy, who did not have a financial interest in the hospital, and who were not professionally involved in the care of patients being reviewed to carry out the UR functions.

Findings:

Review of the administrative binder and survey requested materials/documents, presented by S1Adm, revealed no documented evidence of a list of Utilization Review Committee members and no documentation of UR meetings.

In an interview on 8/5/19 at 10:20 a.m. with S1Adm, she indicated S16UR performed the hospital's utilization review and her findings were presented at the hospital's committee of the whole meetings. S1Adm confirmed the hospital did not have a Utilization Review Committee. S1Adm further confirmed the hospital did not have doctors of medicine or osteopathy participating in Utilization Review.

Based on observation and interview, the hospital failed to ensure equipment/supplies were maintained at an acceptable level of safety and quality as evidenced by failing to ensure blood glucose monitor control solutions and test strips manufacturer's recommendations were followed, thereby affecting quality control on the blood glucose monitor used to check patients' blood sugar.

Findings:

Review of the hospital policy titled: "Capillary Blood Glucose Monitoring" presented as current policy revealed in part; before testing the capillary blood of a patient, the nurse will confirm that the quality control testing of the meter is current and within normal range.

True Metrix blood glucose monitor manufacture's recommendations revealed in part:
a) Control solution should not be used 3 months after first opening;
b) CAUTION! Ranges printed on test strip vial label are for Control Test results; and
c) CAUTION! If Control Test result is outside range, test again. If result is still outside range, system should not be used for testing blood.

On 8/5/19 at 11:15 a.m. review of the Control solution bottle revealed an opened date of 5/3/19 (94 days prior).

Review of the test strip vial label revealed Low control results 25 mg/dl to 55 mg/dl and High control results 274 mg/dl to 370 mg/dl.

Review of the Blood Glucose Daily Quality Control Log for July 2019 revealed Low control results outside range 7/1/19 to 7/22/19 with outside result ranges between 106 mg/dl and 124 mg/dl. Further review of High control results revealed results outside of range between 7/1/19 to 7/31/19 with result ranges between 62 mg/dl and 254 mg/dl. The log also had written on it that the Control Solution expires 90 days after opened.

Review of the Blood Glucose Daily Quality Control Log revealed August 2019 revealed High control results outside range 8/1/19 to 8/4/19 with outside result ranges between 59 mg/dl and 67 mg/dl.

In an interview on 8/5/19 at 11:15 a.m. with S2DON, he verified that the Blood Glucose Daily Quality Control Log results were outside of range for July 2019 and August 2019.

In an interview on 8/5/19 at 12:00 p.m. with S1Adm, she revealed the Glucose Control solutions should be opened for 30 days before disposal. She further stated she will instruct the staff not to use the blood glucose meter and purchased a new meter.

Based on record review, observations and interview, the facility failed to have an effective infection control program controlling the infections and communicable diseases of patients and personnel as evidenced by:
1. failing to ensure the hospital's single blood glucose monitor that was used to perform capillary blood glucose monitoring on all patients was appropriately disinfected between each patient use.; and
2. failing to ensure medications and equipment were stored in a sanitary manner in the hospital's medication cart; and
3. failing to have an active surveillance program for hand hygiene and the appropriate use of PPEs.

Findings:


1. Failing to ensure the hospital's single blood glucose monitor that was used to perform capillary blood glucose monitoring on all patients was disinfected between each patient use.

Review of the hospital policy titled "General Equipment and Textiles - Cleaning and Disinfecting" presented as current policy revealed in part the Environmental Protection Agency (EPA)-registered disinfectants that have microbiocidal activity against the pathogens most likely to contaminate the patient-care environment are used in accordance with manufacturer's instructions. The dwell time prescribed for the cleaner/disinfectant used must be observed, per manufacturer recommendations, for the disinfectant/cleaner to be effective. EPA-registered disinfectants will be utilized to clean and disinfect all items possible.

Review of the True Metrix owner's booklet (blood glucose monitor) revealed the manufacturer's instruction to disinfect the meter was to use fresh wipes (Super Sani-Cloth), making sure all outside surfaces of the meter remained wet for 2 minutes. Further review revealed instructions not to allow liquids to enter the Test Port or other openings in the meter. Additional review revealed the meter should be allowed to air dry thoroughly before using to test. Wash hands thoroughly again after handling meter. The user was instructed to verify that the System is working properly by performing an Automated Self-Test.
Note: Other disinfectants have not been tested. The effect of other disinfectants used interchangeably has not been tested with the meter. Use of disinfectants other than Super Sani-Cloth Wipes may damage meter.

An observation of S8LPN was conducted on 8/6/19 at 4:20 p.m. S8LPN performed a capillary blood glucose sampling, via fingerstick, on Patient #1, in the presence of S2DON. Following the capillary blood glucose test, S8LPN took an unlabeled, clear spray bottle which contained a liquid substance and sprayed the blood glucose monitor with the solution. S8LPN then wiped the moniter down after spraying it with the liquid. S8LPN stated the solution was Spic and Span (a household cleaning agent).

In an interview on 8/7/19 at 9:45 a.m. with S2DON, he verified the blood glucose monitor disinfectant guidelines had not indicated the cleaner used by S8LPN was an appropriate method to be used for disinfection of the meter.

In an interview on 8/7/19 at 3:30 p.m. with S1Adm and S5SW, they validated the glucometer was being cleaned with the wrong disinfectant and that the meter may have sustained damage from improper disinfection.

2. Failing to ensure medications and equipment were stored in a sanitary manner in the hospital's medication cart.

On 8/5/19 at 11:00 a.m. an observation was made of the hospital's medication cart. The following items were noted to be piled and stacked on top of one another in the bottom drawer of the cart:

a. An 8 ounce spray bottle of wound cleanser, unlabled, and partially used;
b. A box of feminine hygiene products (sanitary napkins);
c. An opened package of drinking straws;
d. Opened, unlabled bottles of Milk of Magnesia and Liquid Antacid;
e. A clear plastic bag filled with vacutainers used in blood sample collection;
f. A pill crushing device;
g. 2 nebulizer treatment machines;
h. A tube of moisture barrier cream, opened and unlabled;
i. A fabric eyeglass case;
j. A bottle of Contact Lens Solution, opened and unlabeled;
k. A packet of wet wipes, opened; and
l. packets of 4x4 gauze dressings.

S8LPN and S2DON were present during the observation and confirmed the above referenced findings. They agreed the items in the drawer that were not related to medications/medication administration had not belonged in the cart. S8LPN also agreed the items noted in the drawer were not stored in a sanitary manner.

3. Failing to have an active surveillance program for hand hygiene and appropriate use of PPEs.

Review of the current infection control program revealed the only documentation for the hospital's infection control program was of antibiotic stewardship and documentation of community versus hospital acquired infections.

An interview was conducted with S1Adm and S2DON on 8/07/19 at 9:15 a.m. They verified the hospital has not implemented an active surveillance program for hand hygiene and the use of appropriate PPEs to ensure the staff was taking effective measures to control infections for patients and/or personnel in the hospital.






39791

Based on interviews, the hospital failed to ensure patient care staff was educated on organ procurement, tissue and eye bank donation processes.
Findings:

Review of the nursing education records for S11RN and S18LPN revealed no training for organ procurement, tissue and eye bank donation processes.

An interview was conducted with S1Adm on 08/07/2019 at 4:00 p.m. She stated the patient care staff have not been educated on organ procurement, tissue and eye bank donation processes.

Based on record review and interview, the hospital failed to ensure respiratory services were under the direction of a doctor of medicine or osteopathy, on either a full-time or part-time basis, who had the knowledge, experience and capabilities to supervise and administer the service properly.

Findings:

Review of the hospital's organizational chart, presented as current by S1Adm, revealed no documented evidence of a physician director of the hospital's respiratory services.

In an interview on 8/5/19 at 10:20 a.m. with S1Adm, she confirmed the nursing staff performed respiratory services such as administering nebulizer treatments and administering oxygen if patients required oxygen for stabilization to transfer. S1Adm confirmed the hospital had no physician director appointed to supervise the respiratory services provided by the hospital.

Based on observations, record reviews and interviews, the hospital failed to meet the requirement of 482.13 (Patient's Rights). This deficient practice was evidenced by failure of the hospital to meet the requirements of the Condition of Participation for Patient's Rights due to failure of the hospital to ensure psychiatric patients were provided care in a safe setting as evidenced by:

a) failure to ensure a patient admitted after attempting suicide had been observed at the ordered level of observation of every 15 minutes for 1 (#8) of 1 sampled patient incident reports reviewed for neglect of care from a total patient sample of 10 (#1- #10). Patient #8 subsequently attempted suicide in the hospital by strangulation with a drawstring from her shorts (contraband item) (See findings in tag A-0144).; and

b) failure to ensure a thorough investigation was completed after a patient's attempted suicide (#8), in the hospital, in order to assure appropriate corrective action was taken to protect other patients currently hospitalized who may have been at risk for self-harm (there were currently 9 patients on suicide precautions) for 1 (#8) of 1 patient record reviewed for abuse/neglect from a total patient sample of 10 (#1- #10). (See findings in tag A-0145).

Based on record review and interview, the patients' treatment plans failed to have measurable short term and long range goals for 2 out of 2 ( #5, #7) patient's treatment plans reviewed for measurable goals.

Findings:

Review of the hospital's Policy for Multidisciplinary Treatment Plan revealed in part, "The Multidisciplinary Treatment Plan includes...short term and long-range goals (with specific target dates for achievement)."

Patient #5
Review of Patient #5's EMR, with S5SW as the navigator, revealed the patient is a 41 year old male with substance abuse and a suicide attempt.

Review of the Treatment Plan revealed a long term goal of "alleviate depressed mood and return to previous level of effective functioning and a short term goal of " Abstain from all non-prescribed mood altering chemicals.

An interview was conducted with S5SW on 8/07/19 at 10:00a .m. S5SWconfirmed the long range and short term goals were not measurable for this patient.


Patient #7
Review of Patient #7's EMR, with S5SW as the navigator, revealed Patient #7 was admitted to hospital on 7/28/19 with the admitting diagnosis of Psychosis. His presenting problem was listed as 57 year old male on a PEC, Pt presents to ER as Gravely disabled. OPC states, "Pt going to different churches and acting as a Eucharistic Minister when he is not assigned there. He has been banned from all Catholic churches in Ascension Parish...scaring children. Persistent in going to the churches despite ban on going."

Review of Patient#7's Treatment Plan revealed a Long range goal as, "Patient will return to normal level of function." The patient's short term goal was listed as, "Patient will comply with medication management."

An interview was conducted with S5SW on 8/6/19 at 3:45 p.m. S5SW confirmed the patient's long term and short term goals were not measurable.

Based on record reviews and interviews, the hospital failed to ensure the record of each patient who had been discharged contained discharge planning for 1 (#6) of 3 (#6, #9, #10) records reviewed for discharge treatment plans.

Findings:

Review of the Patient Handbook revealed, "Discharge and aftercare plans are an important part of your treatment. From the first day in our Program, we begin planning for your discharge and aftercare. Each patient, with the assistance of staff, will identify resources, support groups, and other appropriate services to help you make a healthy transition back into the community and to make decisions regarding follow-up to your mental health treatment."

Review of Patient #6's electronic medical record on 8/5/19 at 1:45 p.m. navigated by S5SW revealed he was a 31 year old male admitted on 5/12/19 at 6:05 p.m. under a PEC for depression, suicidal thoughts, and substance abuse. Discharged 5/14/19. Further review of the medical record failed to have any documented evidence of discharge planning.

In an interview on 8/5/19 at 2:10 p.m. with S5SW, she verified there were no discharge treatment planning notes in the medical records for Patient #6.