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Tag No.: A0023
Based on record review and interview, the hospital failed to ensure that all personnel underwent criminal background checks by an authorized agent of the Louisiana State Police in the manner required by R.S. 15:587.1 et seq. prior to hire or employment for all unlicensed personnel providing care for adults and for all staff providing care to children. This deficient practice was evidence by 4 (S3RN, S4RN, S5MHT, S6MHT) of 4 (S3RN, S4RN, S5MHT, S6MHT) personnel records reviewed regarding criminal background checks.
Findings:
Review of S3RN, S4RN, S5MHT, and S6MHT human resource files revealed a criminal background check was completed by Company B, who is not an authorized agency of the Louisiana State Police.
In an interview on 06/20/2023 at 1:30 a.m. S7COO verified the hospital used Company B for all employee background checks.
In an interview on 06/20/2023 at 1:45 p.m., S8CEO indicated the hospital used Company B for all employee background checks and verified Company B was not an authorized agency of the Louisiana State Police.
Tag No.: A0131
Based on record review and interview the hospital failed to ensure the patient/patient's representative is given the information needed in order to make "informed" decisions regarding his/her care by failing to have signed Authorization/Consent forms for 1 (#2) of 5 (#1-#5) patients.
Findings:
Review of hospital policy titled, "Informed Consent", Policy number RI-1400, reviewed date 06/21/2022, and provided by S2RM as current, revealed in part the following .....Policy: It is the policy of Northlake Behavioral Health System (NBHS) to assure that informed consent for treatment is obtained on all patients prior to the initiation of treatment. It is also the policy of NBHS to assure that minor patients who are legally authorized to provide consent be given the opportunity to do so. In the absence of a parent, tutor, or a caretaker, the Director of the treatment facility (or designee) may provide temporary Consent for Treatment.
Review of the medical record of Patient #2 revealed no documented evidence that the patient/patient's representative signed Authorization/Consent forms for treatment.
In an interview on 06/19/2023 at 3:55 p.m. S1ADON verified Patient #2's Authorization/Consent forms for treatment were not signed by Patient #2's representative as required by hospital policy.
Tag No.: A0283
Based on record review and staff interview, the hospital failed to develop, implement, measure and track corrective action plans aimed at performance improvement to ensure that improvements are sustained. This deficiency is evidence by the hospital failing to use data collected to implement an action plan to prevent abuse/neglect and promote patient safety.
Findings:
Review of the hospital policy/QAPI Plan titled, "Quality Improvement Plan/Performance Improvement, Policy number QM-1000, reviewed date 06/01/2023, and provided by S2RM as current, revealed in part the following .....3.0 Objectives are: 3.2 To enhance, maintain and continually improve the quality of patient care through intra- and/or interdepartmental/service measurement and assessment of patient care, resolution of problems and on-going pursuit of opportunities to improve patient care. 3.3 To facilitate a proactive approach toward continuous quality improvement and evaluate actions taken to assure that desired results are achieved and sustained.
Review of the hospital's performance improvement minute meetings revealed quality indicator data was collected for January 2023 until May 2023. Further review failed to reveal steps taken to implement, measure and track corrective action plans aimed at performance improvement to ensure that improvements are sustained.
In an interview on 06/20/2023 at 1:45 p.m. S2RM verified that steps were not taken to implement, measure and track corrective action plans aimed at performance improvement to ensure that improvements are sustained.
Tag No.: A0286
Based on record review and interview, the hospital failed to implement performance improvement activities that track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. This deficient practice is evidenced by the hospital failing to utilize data collected to implement performance improvement activities with clear expectations for safety established.
Findings:
Review of the hospital policy/QAPI Plan titled, "Quality Improvement Plan/Performance Improvement, Policy number QM-1000, reviewed date 06/01/2023, and provided by S2RM as current, revealed in part the following .....3.0 Objectives are: 3.2 To enhance, maintain and continually improve the quality of patient care through intra- and/or interdepartmental/service measurement and assessment of patient care, resolution of problems and on-going pursuit of opportunities to improve patient care. 3.3 To facilitate a proactive approach toward continuous quality improvement and evaluate actions taken to assure that desired results are achieved and sustained.
Review of the hospital's performance improvement minute meetings revealed quality indicator data was collected for January 2023 until May 2023. Further review failed to reveal performance improvement activities that track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital.
In an interview on 06/20/2023 at 1:45 p.m. S2RM verifies that recommendations/action plans were not documented in the performance improvement minute meetings.
Tag No.: A0395
Based on record review and interview the registered nurse failed to supervise and evaluate the nursing care of each patient. This deficiency is evidenced by:
1) failure of the Charge Nurse to monitor observation levels and precautions in 2 (#1 and #3) of 5 (#1-#5) patients sampled.
2) failure of the MHT to physically round to make direct observation in 1 (#2) of 5 (#1-#5) patients sampled.
3) failure of the licensed nurse to determine the type of precaution for each new admission and during each shift on the basis of past behavior, present situation and current mental status in 1 (#3) of 5 (#1-#5) patients sampled.
Findings:
Review of hospital policy titled "Level of Observation and Precaution" revealed, in part: Policy: It is the policy of Northlake Behavioral Health (NBHS) to appropriately assess patients for high-risk behaviors and to order and maintain special precautions to protect the welfare of the patient. Purpose: To reduce the risk of patient harm to self or others as needed for patient condition, using active supervision. 1. Assignment of observation levels and precautions occur through doctor's order as appropriate per assessments, re-assessments and recommendations of the Treatment Team. 2. The RN Charge Nurse is directly responsible for monitoring observation levels and precautions, and for assigning staff to carry out the ordered observations and precautions. 3. The Unit RN Charge Nurse will physically round to make direct observation of each patient on the unit every two (2) hours, and will initial each patient' s individual observation sheet at the time this direct observation is conducted. 4. The RNS will monitor compliance with the observation and precaution status by staff during rounds. Types of observations, in part: 1) Routine (Q-15)-Directly observe location and activity of patient documented every 15 minutes. 2) Close Staff Sight (Q-10)-Directly observe location and activity of patient documented every 10 minutes. 3) Visual Contact (VC)-This level of observation requires that the patient is kept within an area with unobstructed views such that staff has the ability to obtain and maintain eyesight readily and the patient is accessible at all times. 4) One-to-One-This level of observation requires that an individual is supervised in close proximity. The 1:1 Level of observation differs from VC in that the individual is maintained within three to six feet, while all other elements of the VC level of observation are maintained. 5) Two-to-One (2:1)-Same procedure applies as with a 2:2 except patient will have two staff members within three to six feet of them. Procedures: C. Assessment of Levels of Observation and Precautions. 4. The licensed nurse, therapist or physician should determine the type of precaution with each new admission and during each shift on the basis of past behavior, present situation and current mental status. D. Documentation: 1. The initial Nursing Assessment will assess for precautionary risks.
1) Failure of the Charge Nurse to monitor observation levels and precautions in 2 (#1 and #3) of 5 (#1-#5) patients sampled.
Patient #1
Review of Patient #1's RN Progress note dated 04/21/2023, day and night shift, revealed level of observation: Day Shift-Close Staff Sight (Q-10). Night Shift-1:1.
Review of Patient #1's RN Progress note dated 04/22/2023, day and night shift, revealed level of observation: Day Shift-1:1. Night Shift-1:1.
Review of Patient #1's MHT Progress note dated 04/24/2023, day and night shift, revealed level of observation: Day Shift-1:1. Night Shift-1:1.
Review of Patient #1's Observation reports dated 04/21/2023, 04/22/2023, and 04/25/2023, failed to reveal the Charge Nurse physically rounded to make direct observation of Patient #1 on the unit every two (2) hours, and failed to initial Patient #1's individual observation sheet at the time this direct observation was conducted.
In an interview on 06/19/2023 at 2:00 p.m., S2RM confirmed that Patient #1's Charge Nurse failed to physically round to make direct observation of Patient #1 on the unit every two (2) hours, and failed to initial Patient #1's individual observation sheet at the time this direct observation was conducted.
Patient #3
Review of Patient #3's physician admit orders dated 04/20/2023 8:14 p.m., revealed level of observation: Close Staff Sight (Q-10).
Review of Patient #3's physician orders dated 04/22/2023 at 4:30 p.m. revealed level of observation: Visual Contact precautions.
Review of Patient #3's medical record revealed an incident report dated 04/22/2023 involving inappropriate sexual conduct with Patient #1. The incident report stated that Patient #1 accused Patient #3 of kissing him and instigating inappropriate sexual contact.
Review of Patient #3's Observation reports dated 04/21/2023, 04/22/2023, 04/23/2023, 04/25/2023, 04/26/2023, 04/27/2023, and 04/28/2023 failed to reveal the RN physically rounded to make direct observation of Patient #3 on the unit every two (2) hours. Further review failed to reveal that the charge nurse initialed Patient #3's individual observation sheet at the time the direct observation was conducted.
In an interview on 06/19/2023 at 2:00 p.m., S2RM confirmed that the Charge Nurse responsible for Patient #3 failed to physically round to make direct observation of Patient #3 on the unit every two (2) hours, and failed to initial Patient #3's individual observation sheet at the time this direct observation was conducted.
2) Failure of the MHT to physically round to make direct observation in 1 (#2) of 5 (#1-#5) patients sampled.
Review of Patient #2's Observation report dated 05/26/2023, failed to reveal the MHT physically rounded to make direct observation of Patient #2 and failed to document Patient #2's individual observation dated 05/26/2023 from 3:30 a.m. until 7:00 a.m.
In an interview on 06/19/2023 at 3:55 p.m., S1ADON verified that the MHT failed to physically round to make direct observation of Patient #2, and failed to document on Patient #2's observation sheet dated 05/26/2023 from 3:30 a.m. until 7:00 a.m.
3) Failure of the licensed nurse to determine the type of precaution for each new admission and during each shift on the basis of past behavior, present situation and current mental status.
Review of Initial Care Orders dated 04/20/2023 at 8:14 p.m. revealed Nursing Level of Observation and Precautions: Close Staff Sight (Q-10).
Review of Patient #3's medical record revealed a therapist progress note dated 04/21/2023 at 8:12 a.m. Further review revealed Patient #3's stepmother stated patient started viewing pornographic material on classmates Chromebook after hearing he would no longer be able to live with his stepmother. He also convinced a schoolmate into the restroom and attempted an inappropriate sexual act.
Review of Patient #3's medical record revealed an initial nursing assessment dated 04/21/2023 at 8:00 p.m. The assessment stated, in part: Client admitted to hospital after he approached another student at school and attempted to have him pull his pants down to have sex with him.
In an interview on 06/20/2023 at 2:46 p.m. S1ADON stated that the nurse should have addressed on admit the possible need for a higher level of observation for Patient #3 on the basis of recent past high risk behaviors.
48050
Tag No.: A0396
Based on record review and interview, the hospital failed to ensure that the nursing staff developed, and kept a current, and individualized nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs. This deficient practice is evidenced by the failure to update the care plans of 2 (#1 and #3) of 5 (#1-#5) patient reviewed for completed and updated care plans.
Findings:
Review of hospital policy titled "Treatment Planning" revealed, in part: Purpose: To assure that the patient/family/guardian, and all members of the treatment team have the opportunity to provide input into treatment planning and to assure development of a comprehensive and complete plan of care that serves as a guide for providing individualized treatment. F., in part: Updating the treatment Plan: 1. The treatment plan must be updated to reflect change in patient condition; the following requires modification of the treatment plan prior to scheduled update: a. newly diagnosed medical condition with ongoing treatment. b. A restraint or seclusion e. Implementation of a Behavior Support Plan.
Patient #1
Review of Patient #1's day shift-RN Progress Note, dated 04/21/2023, revealed Patient #1 was displaying odd bazaar behavior, laughing uncontrollably dancing around, pulled pants down and putting finger in his buttock area while exposing himself to peers. Attempted to break phone, cursing staff placed on phone rest for trying to break phone and behavior following call from mom. Put on 1:1 for inappropriate sexual behavior.
Review of Patient #1's night shift-RN Progress Note dated 04/21/2023, revealed Patient #1 was on unit, placed on 1:1. Further review revealed client was asked to "separate" from another patient this shift second to "potential inappropriate behavior".
Review of Patient #1's MHT Progress Note dated 04/22/2023, Patient is 1:1. Comments: David is being very sexual he's walking like a female and acting like a female. Patient #1 told Patient #3 to (the following statement in quotes is written exactly how it was written on MHT Progress note) "come kiss him again and he's saying he likes me talk about Jayden Hoe ask me can he kiss".
Review of Patient #1's Therapist Progress Note dated 04/22/2023, counselor was informed by MHT on Unit 'a', that patient#1 made an accusation of being forced to kiss, fondle and perform oral sex unto one another by the patient #3.
Review of Patient #1's MD Progress noted dated 04/24/2023 revealed the Assessment & Plan included Autism Spectrum Disorder as the number one diagnosis. Further review revealed that Patient #1 was placed in seclusion for safety concerns.
Review of Patient #1's MD Progress note dated 04/25/2023 revealed a narrative summary of examination with abnormal findings that included Autism Spectrum Disorder and hypersexual.
Review of Patient #1's Therapist Progress Note dated 04/24/2023-4:25 p.m.-5:34 p.m., revealed Patient #1 was presenting guarded and very agitated. Reports being angry with his mother. Patient #1 reported that he is mad because his mother has "unsubscribed" from the kissing video websites that he previously subscribed too, "she makes me mad, she can't do that! I know which ones and I am going to get them back on my tablet". Counselor has provided redirection to assist him in understanding that his behavior is disruptive to his family and others. Upon further exam David talked about having, what his mother states is a "lustful spirit" on him because no matter what anyone says he's going to watch his "kissing videos". He further states he wants to go to a group home. He admits to anger issues and desires to kiss a woman.
Review of Patient #1's medical record revealed the nursing staff failed to provide an individualized care plan that included Patient #1's diagnosis of autism and hyper-sexuality. Further review revealed the nursing staff failed to update Patient #1's care plan following the seclusion event and incidents that occurred on 04/21/2023 and 04/22/2023.
In an interview on 06/19/2023 at 2:45 p.m., S2RM confirmed that Patient #1's care plan was not an individualized care plan that included Patient #1's diagnosis of autism and hyper-sexuality. S2RM further stated that the care plan did not show evidence that the nursing staff updated Patient #1's care plan following the seclusion event and incidents that occurred on 04/21/2023 and 04/22/2023.
Patient #3
Review of Patient #3's medical record revealed a therapist progress note dated 04/21/2023 at 8:12 a.m. Further review revealed Patient #3's stepmother stated patient started viewing pornographic material on classmates Chromebook after hearing he would no longer be able to live with his step-mother. He also convinced a schoolmate into the restroom and attempted an inappropriate sexual act.
Review of Patient #3's medical record revealed an initial nursing assessment dated 04/21/2023 at 8:00 p.m. The assessment stated, in part: Client admitted to hospital after he approached another student at school and attempted to have him pull his pants down to have sex with him.
Review of Patient #3's medical record revealed an incident report dated 04/22/2023 involving inappropriate sexual conduct with Patient #1. The incident report stated that Patient #1 accused Patient #3 of kissing him and instigating inappropriate sexual contact.
Review of Patient #3's medical record revealed a provider progress note dated 04/25/2025 at 4:35 p.m.. The progress note stated patient was admitted to the hospital after he locked a student from school in the bathroom stall and repeatedly demanded the student pull his paints down.
Review of Patient #3's care plan dated 04/20/2023-04/28/2023, failed to reveal Inappropriate Sexual Behavior/hypersexuality listed as a problem on the care plan along with interventions, patient goals/ objectives, target dates, and status.
In an interview on 06/20/2023 at 11:23 a.m., S9MD reported that Patient #3 was hypersexual for his age but there was no evidence on camera of the incident that occurred on 04/22/2023.
In an interview on 06/20/2023 at 11:05 a.m., S2RM confirmed that Patient #3's care plan was not an individualized care plan that included Patient #3's diagnosis of hyper-sexuality. S2RM further stated that the care plan did not show evidence that the nursing staff updated Patient #3's care plan following the incident that occurred on 04/22/2023.
Tag No.: A0405
Based on record review and interview the psychiatric hospital failed to ensure drugs and biologicals were administered as ordered by the licensed practitioner and according to standard of care. This deficient practice is evidenced by failure to administer scheduled medications as ordered in 1(#1) of 5 (#1-#5) records reviewed for medication administration.
Findings:
A review of hospital policy titled "Nursing: Medication Administration" revealed, in part: Policy: Proper procedure for the safe administration of medication will be followed. Purpose: To provide conditions which promote safe and accurate medication administration. Procedure, in part: E. General Medication Administration Guidelines for all routes of administration: 1., in part: Set up medications/treatments according to the Medication Administration Record. 6., in part: Administration of medication is recorded after the medication is given utilizing the Medication Administration Record. Initial only after medication is administered. I. Guidelines for Documentation of Mediation Administration, in part: 1., in part: Procedure for Medication Administration Record. ii., in part: Time of administration, in part: f) The individual administering medication must initial the MAR after the medication is administered. h) For "MEDS NOT GIVEN" write the appropriate code in the block for that administration time.
Review of Patient #1's medical record revealed the following medications ordered by the physician on 04/21/2023 at 1:00 p.m: Abilify 15 mg po daily; Depakote 500 mg po BID; Tenex 2 mg po BID. Continued review revealed the Abilify was increased to 20 mg po daily on 04/24/2023 at 12:05 p.m.
Review of Patient #1's Medication Administration Record dated 04/24/2023 failed to reveal Patient #1 was administered Depakote 500 mg and Tenex 2 mg at 8:00 p.m. as ordered by the physician.
Review of Patient #1's Medication Administration Record dated 04/25/2023 failed to reveal Patient #1 was administered Abilify 20 mg at 8:00 a.m. as ordered by the physician.
Review of Patient #1's Medication Administration Record dated 04/27/2023 failed to reveal Patient #1 was administered Depakote 500 mg and Tenex 2 mg at 8:00 p.m. as ordered by the physician.
In an interview on 06/20/2023 at 1:00 p.m. S1ADON and S2RM confirmed that mediations that were detrimental to Patient #1's mental health treatment, were not administered as ordered by the physician.
Tag No.: A1655
Based on record review and interview, the hospital failed to ensure all progress notes recorded were signed and dated by the physicians and those significantly involved in active treatment modalities. This deficient practice is evidenced by:
1) failing to ensure the physician signed a recorded progress note in 1 (#3) of 5 (#1-#5) patients sampled.
2) failing to ensure the MHT signed a recorded progress note in 1 (#1) of 5 (#1-#5) patients sampled.
Findings:
1) failing to ensure the physician signed the progress note in 1 (#3) of 5 (#1-#5) patients sampled.
A review of hospital policy titled "Medical Staff Rules and Regulations" revealed, in part: D. Progress Notes, in part: b) All entries must be written with date, exact time, code, signature and title.
Review of Patient #3's medical record revealed a MD Progress Note dated 04/25/2023. Further review failed to reveal a signature indicating the name and title of the provider who recorded the note.
In an interview on 06/20/2023 at 11:30 a.m., S2RM confirmed there was no name or title of the provider who recorded the note.
2) failing to ensure the MHT signed the progress note in 1 (#1) of 5 (#1-#5) patients sampled.
A review of hospital job description titled :Mental health Technician" revealed, in part: Essential Functions, in part: Documents all group and individual services proved in a thorough, legible and professional manner to conform to all documentation and regulatory requirements.
A review of Patient #1's medical record revealed a MHT Progress Note dated 04/22/2023. Further review failed to reveal a signature indicating the name of the Mental Health Tech (MHT) who recorded the note.
In an interview on 06/20/2023 at 11:30 a.m., S1ADON confirmed there was no signature indicating the name of the MHT who recorded the note.
Tag No.: A1688
Based on record review and interview, the hospital failed to ensure each patient/patient representative participated in the discharge planning process. This deficient practice is evidenced by the physician or nurse failing to review the discharge medications and provide information sheets to the parents of 1 (#3) of 5 (#1-#5) patients sampled.
Findings:
A review of hospital policy titled "Discharge Planning and Process" revealed, in part: Policy, in part: It is the policy of Northlake Behavioral Health System (NBHS) to provide discharge instructions and continuity of care information for aftercare to all patients prior to their departure from the hospital. Purpose: To provide discharge instructions to the patient and after care provider concerning continued treatment needs (diagnosis, medication, appointments, etc.) Procedures, in part: 3. Nursing Service will complete the following at the time of discharge: b. The Unit Nurse (RN/LPN) will review the medications listed and provide the patient/family with medication information sheets. The nurse and patient/family will sign verifying this review.
A review of Patient #3's medical record revealed a discharge order sheet dated 04/28/2023 at 10:15 a.m. Further review revealed the following medications for discharge: Abilify 15 mg po q day, Prozac 40 mg po q day; Tenex 2 mg po BID; Clonidine 0.05 mg po q am; Clonidine 0.1 mg po q hs.
A review of Patient #3's medical record revealed a Continuity of Care document dated 04/25/2023 at 12:42 p.m. Further review revealed a section "The discharge medications were reviewed with patient/family and information sheets were provided". Continued review failed to reveal a nurse's signature verifying the discharge medications were reviewed with patient/family and information sheets were provided.
In an interview on 06/20/2023 at 2:05 p.m., S2RM confirmed that there was no documented evidence verifying a nurse reviewed the discharge medications with patient/family and information sheets were provided.