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Based on record reviews and interview, the hospital failed to ensure its grievance process was implemented in accordance with hospital policy as evidenced by failing to document, review/investigate, and resolve a patient representative's grievance for 1 (#3) of 1 patient grievance reported during the survey.
Findings:

Review of the policy titled "Grievance, Patient", presented as a current policy by S2DRM, revealed the Governing Board has appointed the Patient Advocate as responsible to execute the grievance program, in conjunction with the Grievance Committee. Further review revealed if the Patient Advocate, CEO, or medical Director determines that resolution of the grievance requires additional review and input into the resolution process, or if the patient is not satisfied with the actions taken to resolve the grievance, the Grievance Committee will be convened. All patient grievances will be investigated, and the results of the investigation will be reported back to the complainant. The policy defined a patient grievance as a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care when the complaint is not resolved at the time of the complaint by staff present, abuse or neglect, issues related to the hospital's compliance with the Conditions of participation, or a Medicare billing complaint related to rights and limitations provided by "42 CRF 489." The procedure for handling grievances was as follows: staff present who receive a grievance/concern from a patient/patient's legal representative will acknowledge receipt of the grievance by documenting the time and date on the Patient Concern Notification form, attempt to resolve the complaint at the time of receipt, document actions taken on the form, and forward the form to the Patient Advocate; the Patient Advocate/designee will record the concern/grievance on the designated tracking tool, summarize the unresolved concern on the tool, and immediately review and assess any reported abuse/neglect; the Patient Advocate or CEO/designee will review the grievance and assign follow-up to the appropriate Director/Manager and establish a date by which time a response is expected (if grievances are not resolved within seven days, the patient will be notified the Patient Advocate is still processing the grievance and provided the expected date of resolution; the Director/Manager to whom follow-up was assigned will investigate the grievance within 2 days and record findings of the investigation on the Grievance Process Tool; the Patient Advocate will review the results of the preliminary investigation, determine action to be taken, complete a written report on the Grievance Resolution Form, report to the patient the name of the hospital contact person, steps taken on behalf of the patient to investigate the grievance, results of the grievance, and the date of completion; mail a written report by certified mail if the complainant is not the patient or the patient has been discharged.

Review of the "2018 Grievance Log" and additional grievances not yet logged that were presented for review by S2DRM revealed no documented evidence that a grievance had been received and documented related to Patient #3.

In an interview on 07/06/18 at 10:12 a.m., S5CTRS indicated he is the patient advocate. He indicated typically if a patient has a complaint, nursing staff will ask him to speak with the patient. If it becomes a grievance, it has to go to nursing management, the CEO, and the Risk Manager. He indicated depending what the grievance is will determine who does the investigation. Within 2 days he gets back with the patient to let them know what's being done, and by the 7th day, a letter is sent to the patient. He indicated he never received a complaint/grievance from Patient #3 or his family or hospital staff.

In an interview on 07/06/18 at 2:30 p.m., S1CEO indicated the day Patient #3 was discharged, the former DON informed him that Patient #3's spouse and son wanted to speak with him about concerns they had regarding Patient #3's stay. He further indicated the concerns were that Patient #3 had fallen and that Patient #3 had asked for something for pain (not related to the fall), and they wanted to know why he didn't get the pain medication. S1CEO indicated the former DON was aware Patient #3's spouse had some concerns, and these concerns would have required the grievance process to be implemented. He confirmed, to his knowledge, that a grievance was not documented, reviewed, investigated, and a response sent to the complainant in accordance with hospital policy regarding Patient #3.

Based on record reviews and interviews, the hospital failed to ensure a patient was informed when the coroner determined he did not meet the criteria for emergency admission as evidenced by having Patient #3 maintained as an inpatient after the coroner determined he did not meet criteria for emergency admission and did not have a formal voluntary admission consent signed by the patient for 1 (#3) of 1 patient record reviewed with the CEC not being signed from a sample of 5 patients.
Findings:

Review of "2011 Louisiana Laws Revised Statutes Title 28 - Mental Health RS 28:53 - Admission by emergency certificate; extension" revealed a mentally ill person or a person suffering from substance abuse may be admitted and detained at a treatment facility for observation, diagnosis, and treatment for a period not to exceed fifteen days under an emergency certificate. Within seventy-two hours of admission, the person shall be independently examined by the coroner or his deputy who shall execute an emergency certificate which shall be a necessary precondition to the person's continued confinement. If, from his examination, the coroner concludes that the person is not a proper subject for emergency admission, then the person shall not be further detained in the treatment facility and shall be discharged by the director forthwith.

Review of the policy titled "Admission-Legal Status", presented as a current policy by S2DRM, revealed if a patient is admitted on a PEC, the patient must be examined by the coroner or his deputy to determine if the patient meets criteria to be further detained in the treatment facility. If the patient is not assessed to be dangerous to self or others or to be gravely disabled, the patient shall be discharged by the director of the facility.

Review of Patient #3's medical record revealed he was admitted on 06/08/18 and discharged on 06/11/18. Review of his PEC signed on 06/08/18 at 4:50 p.m. revealed Patient #3 had a history of depression and a recent onset of hopelessness and was making suicidal statements with thoughts to overdose. Further review revealed the physician examining Patient #3 determined him to be a danger to self.

Review of Patient #3's CEC revealed the coroner/deputy assessed him on 06/09/18 at 12:00 p.m. and determined he was not a proper subject for emergency admission.

Review of Patient #3's medical record revealed no documented evidence that a formal voluntary admission consent had been signed by Patient #3 or his representative.

In an interview on 07/05/18 at 1:10 p.m., S2DRM indicated once the coroner determines the patient doesn't need hospitalization the patient has to be discharged or has to sign a formal voluntary admission consent. She further indicated, after reviewing the paper copy of the medical record and the electronic medical record, she didn't see that formal voluntary admission consent had been signed by Patient #3.

In an interview on 07/06/18 at 9:07 a.m., S9MHNP indicated when the coroner assesses a patient as not needing admission, the patient is supposed to be released or asked if he/she wants to stay and, if so, sign a formal voluntary admission consent. She further indicated it was her understanding that the coroner would tell the nurse of his findings who would then inform the NP or the psychiatrist. S9MHNP indicated she was not informed of the coroner's findings regarding Patient #3.

In an interview on 07/06/18 at 9:35 a.m., S8Psych indicated the staff told him Patient #3's family was at the hospital and wanted him released. He further indicated someone (doesn't remember who) thought the 72 hours were in effect even once the coroner saw the patient and released him. He further indicated it was a "process failure." S8Psych indicated without signing a formal voluntary admission consent, the patient should have been released, and "they dropped the ball on it."

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by failing to have documented evidence of a patient fall with subsequent assessment and documentation of the assessment by the RN for 1 (#3) of 5 patient records reviewed for a fall from a sample of 5 patients.
Findings:

Review of the policy titled "Early Response To Change in Condition", presented as a current policy by S2DRM, revealed the RN will provide assessment data to the medical practitioner who will then give orders for treatment or additional assessment for a fall that results in pain or change in level of consciousness.

Review of the list of incidents related to falls since 05/01/18, presented by S2DRM, revealed no documented evidence Patient #3 was listed as having had a fall.

Review of Patient #3's "Psychiatrist Progress Note" documented by S9MHNP on 06/10/18 revealed Patient #3 was seen on the floor next to the wall stating "my leg gave out... it happens all the time." Further review revealed no documented evidence whether Patient #3 had fallen or slid to the floor.

Review of Patient #3's medical record revealed no documented evidence of a fall documented by the RN on 06/10/18 with a subsequent assessment for injury.

In an interview on 07/05/18 at 2:30 p.m., S3DON indicated if patient #3 had fallen or had to be helped to the floor, it would be documented in the nursing documentation. She further indicated she didn't recall Patient #3 having a fall.

In an interview on 07/06/18 at 9:07 a.m., S9MHNP indicated she saw Patient #3 on the floor against the wall. She further indicated she didn't know how he got to the floor other than his leg gave out.

Based on record review and interview, the hospital failed to ensure the nursing staff developed an individualized nursing care plan for each patient as evidenced by failing to include medical problems for which the patient was being treated in the plan for 1 (#3) of 5 patient records reviewed for a nursing care plan from a sample of 5 patients.
Findings:

Review of the policy titled "Treatment Planning", presented as a current policy by S2DRM, revealed the nursing staff is responsible for developing the Initial Treatment Plan no later than 8 hours of admission. The Treatment Plan shall identify mental health and physical problems and specify those to be addressed during the treatment episode.

Review of Patient #3's medical record revealed he had diagnoses of Severe Depression, Sciatica, Neuropathy, and Acute Exacerbation of Chronic Low Back Pain. Further review revealed medications were ordered for the treatment of pain related to the Sciatica and Low Back Pain and for Depression.

Review of Patient #3's Initial Ttreatment Plan developed on 06/09/18 by S11RN revealed no documented evidence that the plan included the medical diagnoses related to pain.

In an interview on 07/06/18 at 2:15 p.m., S3DON confirmed Patient #3's nursing care plan did not include the medical problems related to pain.

Based on record reviews and interview, the hospital failed to ensure the RN assigned the nursing care of each patient to nursing personnel in accordance with the specialized qualifications and competence of the nursing staff available as evidenced by having expired CPR certification for 1 (S11RN) of 4 (S3DON, S10RN, S11RN, S17MHT) nursing staff's personnel files reviewed for qualifications.
Findings:

Review of S11RN's personnel file revealed her CPR certification had expired on 05/31/18.

In an interview on 07/06/18 at 1:00 p.m., S16HRD indicated CPR certification is required for the nursing staff. She further indicated she had no documented evidence to present revealing that S11RN was currently certified in CPR.

Based on record reviews and interview, the DON failed to ensure non-employee licensed nurses working in the hospital were evaluated for competency as evidenced by failure to have documented evidence that S10RN's clinical activities were evaluated by an appropriately qualified hospital-employed RN for 1 (S10RN) of 2 (S10RN, S11RN) contracted nurses' personnel files reviewed for competency.
Findings:

Review of S10RN's personnel file revealed no documented evidence that she had been evaluated for competency in performing clinical activities by an appropriately qualified hospital-employed RN.

In an interview on 07/06/18 at 1:00 p.m., S16HRD indicated they took the competency evaluation done by the contracted agency for S10RN. She confirmed she had no documented evidence to present revealing that S10RN had been evaluated for competency in performiong clinical activities by a hospital-employed, competent RN.

Based on record reviews and interview, the hospital failed to ensure a medical H&P examination was completed and documented no more than 24 hours after admission as evidenced by having medical H&Ps being completed and documented more than 24 hours after admission for 3 (#1, #2, #3) of 5 patient records reviewed for a H&P from a sample of 5 patients.
Findings:

Patient #1
Review of Patient #1's medical record revealed he was admitted on 06/01/18, and his H&P was completed and documented on 06/05/18 , more than 24 hours after admission.

Patient #2
Review of Patient #2's medical record revealed he was admitted on 06/22/18, and his H&P was completed and documented on 06/24/18, more than 24 hours after admission.

Patient #3
Review of Patient #3's medical record revealed he was admitted on 06/08/18. Further review revealed no documented evidence of the date and time his H&P was completed and documented to determine whether it was done within 24 hours of admission.

In an interview on 07/06/18 at 11:35 a.m., S2DRM confirmed the above H&Ps were done more than 24 hours after admission. She confirmed there was no date and time documented when the NP completed the H&P for Patient #3, so she couldn't assure it was done within 24 hours af admission. She indicated the hospital recognized there was a problem with a group of NPs, and they ended the were ending the contract as of 07/15/18. She indicated it was probably April when they recognized it, and the NPs had been allowed to continue doing H&Ps since that time.

Based on observations, record review, and interviews, the infection control officer failed to ensure the infection control plan was implemented to control infections and communicable diseases of patients and personnel as evidenced by:
1) Failing to ensure an unidentified MHT removed her isolation gown upon exiting the room of a patient who was on contact precautions. The MHT was observed to be sitting in a chair in the hall outside the room of Patient R1, who was on contact precautions due to a diagnosis of Scabies, wearing an isolation gown on 07/05/18 at 9:25 a.m.
2) Failing to ensure S4MHT removed her contaminated gloves and performed hand hygiene before moving from one task to the next as observed on 07/05/18 at 9:40 a.m.
3) Failing to ensure S6MHT removed her contaminated gloves and performed hand hygiene between patient contact as observed on 07/05/18 at 10:05 a.m.
4) Failing to ensure expired vacutainers (specimen tubes used to collect blood samples) were discarded and not available for use as observed on 07/05/18 at 9:36 a.m. and 9:50 a.m.
Findings:

1) Failing to ensure an unidentified MHT removed her isolation gown upon exiting the room of a patient who was on contact precautions:
Observation on 07/05/18 at 9:25 a.m. revealed the door to the room occupied by Patient R1 had a sign posted of "Contact Isolation." Further observation revealed an unidentified MHT was seated in a chair in the hall outside Patient R1's room wearing a paper isolation gown.

Review of the CDC's guidelines for preventing and controlling scabies outbreaks revealed staff were to use contact precautions with protective garments (such as gowns, disposable gloves, shoe covers) when providing care to any patient with crusted scabies until successfully treated and should wash their hands thoroughly after providing care to any patient.

In an interview on 07/05/18 at 9:25 a.m., S2DRM indicated the MHT indicated to her that she wore the isolation gown while seated in the hall, because when Patient R1 tried to leave her room, Patient R1 would grasp the MHT's arms when she (MHT) went into the room to keep her from leaving the room. S2DRM confirmed the isolation gown should not be worn outside the room.

2) Failing to ensure S4MHT removed her contaminated gloves and performed hand hygiene before moving from one task to the next:
Observation on 07/05/18 at 9:40 a.m. revealed S4MHT was observed entering the nursing station from the hall while wearing gloves. She touched the door knob with gloved hands and went to the counter in the nursing station and touched 2 paper cups that were on the counter.

Review of the CDC's "Guidelines for Hand Hygiene in Health-Care Settings" revealed indications for handwashing and hand antisepsis were as follows: decontaminate hands before having direct contact with patients; decontaminate hands after contact with a patient's intact skin (such as when taking a pulse or blood pressure); decontaminate hands after contact with inanimate objects in the immediate vicinity of the patient; decontaminate hands after removing gloves.

In an interview on 07/05/18 at 9:40 a.m., S4MHT indicated she had just come from wiping the tables in the Day Room when she entered the nursing station. She confirmed she was supposed to remove her gloves after cleaning the tables and sanitize her hands before donning new gloves to clean the counter in the nursing station. S4MHT confirmed she opened the door to the nursing station with contaminated gloves.

3) Failing to ensure S6MHT removed her contaminated gloves and performed hand hygiene between patient contact:
Observation on 07/05/18 at 10:05 a.m. revealed S6MHT was taking patients' vital signs in the Day Room. Continuous observation revealed she wore the same glove from one patient to the next patient (observed her taking 2 patients' vital signs). She touched the blood pressure machine and the temperature probe with contaminated gloved hands. S6MHT wiped only a portion of the blood pressure cuff with a sanitizing wipe, then placed the wipe in the basket on top of the other blood pressure cuffs. S6MHT was observed to not change her gloves, sanitize her hands, and re-don gloves between patients and after cleaning contaminated items.

See CDC's "Guidelines for Hand Hygiene in Health-Care Settings" listed above under "2)".

In an interview on 07/05/18 at 10:05 a.m., S1CEO, who was present during the above observation, confirmed the observations made by the surveyor were breaches in infection control.

4) Failing to ensure expired vacutainers were discarded and not available for use:
Observation on 07/05/18 at 9:36 a.m. in the medication room on the "Geri Unit" revealed a cabinet contained 3 blue-top vacutainers on the shelf available for use that had expired on 05/31/18).

Observation in the Lab/Exam Room on 07/05/18 at 9:50 a.m. revealed a partially-filled tray of gold-top vacutainers available for use that had expired on 02/28/18.

In an interview on 07/05/18 at 9:36 a.m. and 9:50 a.m. during the above observations, S2DRM confirmed the vacutainers were expired and should not have been available for use.

Based on record reviews and interview, the hospital failed to ensure social service records provided an assessment of home plans and family attitudes, and community resource contacts as well as a social history as evidenced by failure to have psychosocial assessments completed within 48 hours of admission in accordance with hospital policy for 5 (#1, #2, #3, #4, #5) of 5 patient records reviewed for a psychosocial assessment from a sample of 5 patients.
Findings:

Review of the policy titled "Assessment/Reassessment", presented as a current policy by S2DRM, revealed the psychosocial history is obtained from the patient, family, and/or significant others by a licensed therapist and is in the patient's record within 48 hours of the patient's admission.

Patient #1
Review of Patient #1's medical record revealed he was admitted on 06/01/18. Further review revealed his psychosocial assessment was completed on 06/07/18 at 8:26 a.m., 6 days after admission rather than within 48 hours of admission.

Patient #2
Review of patient #2's medical record revealed he was admitted on 06/22/18. Further review revealed his psychosocial assessment was completed on 06/25/18 at 4:03 p.m., 3 days after admission rather than within 48 hours of admission.

Patient #3
Review of patient #3's medical record revealed he was admitted on 06/08/18 and discharged on 06/11/18, 3 days after admit. Further review revealed no documented evidence a psychosocial assessment was completed during his hospital stay.

Patient #4
Review of Patient #4's medical record revealed he was admitted on 06/30/18. Further review revealed no documented evidence a psychosocial assessment had been completed as of the date and time of the medical record review on 07/06/18 at 11:30 a.m. (6 days since admission).

Patient #5
Review of Patient #5's medical record revealed he was admitted on 06/30/18. Further review revealed his psychosocial assessment was completed on 07/03/18, 3 days after admission rather than within 48 hours of admission.

In an interview on 07/06/18 at 10:51 a.m., S13LCSW indicated she was brought in because there were issues with the department related to the department as a whole. She further indicated documentation or lack thereof "wouldn't surprise me." She indicated the psychosocial assessments were supposed to be done within 48 hours of admission. S13LCSW offered no explanation as to what actions or processes had been put in place to address the lack of timeliness in completing psychosocial assessments.

In an interview on 07/06/18 at 3:15 p.m., S2DRM indicated she couldn't find that a psychosocial assessment had been completed for Patient #4.

Based on record reviews and interview, the hospital failed to ensure each patient receioved a psychiatric evaluation that described attitudes and behavior which require change in order for the patient to function in a less restrictive setting as evidenced by having attitudes and behavior stated as "guarded" rather than in a descriptive manner for 1 (#1) of 5 patient records reviewed for a psychiatric evaluation from a sample of 5 patients.
Findings:

Review of Patient #1's psychiatric evaluation revealed it was completed and documented by S8Psych on 06/02/18 at 9:55 a.m. Further review revealed attitude and behavior assessment had choices of cooperative, guarded, irritable, withdrawn, indifferent, and other for the psychiatrist to select. Further review revealed S8Psych checked "guarded" and documented no description of attitudes and behavior which require change in order for the patient to function in a less restrictive setting.

In an interview on 07/06/18 at 9:38 a.m., S8Psych indicated documenting "guarded" referred to the behavior that is observed in the evaluation. He indicated Patient #1 was reluctant to be forthcoming in the evaluation and seemed mistrustful. he confirmed he didn't document this explanation in his evaluation of Patient #1.

Based on record reviews and interview, the hospital failed to ensure the patient's psychiatric evaluation included an estimate of intellectual functioning, memory functioning, and orientation and the manner used to test/assess the intellect, memory, and orientation in accordance with the hospital's evaluation form as evidenced by failing to document how concentration/attention span, intelligence, judgement, and insight were tested/assessed for 1 (#1) of 5 patient records reviewed for the psychiatric evaluation content from a sample of 5 patients.
Findings:

Review of the "Psychiatric Evaluation" form revealed the assessment of concentration/attention span, recent memory, remote memory, intelligence, judgement, and insight were to include how it was tested/assessed.

Review of Patient #1's Psychiatric Evaluation performed by S8Psych on 06/02/18 at 9:55 a.m. revealed no documented evidence of how concentration/attention span, intelligence, judgement, and insight were tested/assessed.

In an interview on 07/06/18 at 9:38 a.m., S8Psych confirmed he didn't document the means he used to test for concentration/attention span, intelligence, judgement, and insight.

Based on record reviews and interview, the hospital failed to ensure activity assessments were conducted by qualified therapists as evidenced by having no documented evidence S12RC possessed a degree in therapeutic recreation from a post-secondary institution or a degree in another field of study and had attained certification in accordance with the National Council for Therapeutic Recreation Certification requirements or had a minimum of 10 years' experience providing therapeutic recreational services. S12RC completed and documented the activity assessments for 3 (#1, #2, #3) of 5 patient records reviewed for activity assessments from a sample of 5 patients.
Findings:

Review of S12RC's personnel file revealed she had a Bachelor's degree in Psychology and a Master's degree in Public Administration. Further review revealed no documented evidence she was certified by the National Council for Therapeutic Recreation Certification. Further review revealed she was employed as an activity therapist in 2003 and 2004 and worked as an activity director in a nursing home from 2004 to 2007. There was no documented evidence she had a minimum of 10 years' experience providing therapeutic recreational services.

Review of the medical records of Patients #1, #2, and #3 revealed their activity assessments were conducted by S12RC.

In an interview on 07/06/18 at 2:15 p.m., S2DRM indicated S12RC was not qualified and should not be performing comprehensive therapeutic activities.