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Based on record review and interview, the hospital failed to ensure the patient /patient representative's right to participate in the development and implementation of his or her plan of care was met. This deficient practice was evidenced by failure to ensure the patient care plan was completed and that the patient /patient representative was included in the development and implementation of the patient's plan of care for 3 (#1, #4 and #5) of 5 (#1- #5) sampled patient records reviewed.
Findings:

Review of the hospital's policy titled, "Patient Rights", revealed the following in part: Policy: Beacon Behavioral Hospital is committed to upholding the rights of the patient, as enumerated by State and Federal Regulations and Laws. In accordance with Louisiana Licensing Regulations for Hospitals Section 9319 every patient has the right to: 7. Participate in the development and implementation of his/her plan of care. 8. Make informed decisions regarding his/her care. 10. Be informed of his/her health status, be involved in care planning and treatment, and be able to request or refuse treatment.

Review of hospital's policy titled, "Multidisciplinary Treatment Plan" revealed, in part: Policy: At Beacon Behavioral Hospital members of all disciplines participate in developing, implementing, and evaluating an individualized Multidisciplinary Treatment plan. Procedure. Inpatient, in part: 3. Over the three days following admission, the patient will be assessed by members of other disciplines including, but not limited to: a. Medicine b. Psychiatry c. Social Services d. Activity Therapy.

Patient #1
A review of Patient #1's Treatment Plan Update by L5LSW dated 01/06/2023 at 2:14 p.m. revealed a Tentative Discharge Date of 01/06/2023.

Treatment Discharge Plan: Follow Up on Deferred Problems; Medication Management; Follow Up on Medical Issues.

Clinical Summary, in part: Sending to ER for medical.

Further review failed to reveal the patient's or patient representative's signature indicating participation in this care plan update.

In an interview on 05/31/2023 at 2:20 p.m., S4HIM confirmed that the Treatment Plan Update failed to reveal the patient's or patient representative's signature indicating participation in this care plan update.

Patient #4
Review of Patient #4's medical record revealed the patient admitted on 12/29/2023 at 4:07 a.m. after his wife brought him to the emergency room. His admission diagnosis: Alzheimer's Dementia with behavioral disturbances. Further review of Nursing Admission Assessment dated 12/29/2022 revealed the patient was not responsive to questions and stared without responding. Confused and appeared aphasic without the mental capacity to sign consents.

Review of Patient #4's Master Treatment Plan failed to reveal evidence of a signature indicating that the patient or the power of attorney (POA) participated in the care plan. Further review revealed signatures of a nurse and a recreation therapist. The care plan was blank except for the Reason for Admission and the two signatures.

In an interview on 05/31/2023 at 1:10 p.m., S4HIM confirmed the care plan was incomplete and did not include evidence of a signature indicating the patient or patient representative participated in the treatment plan.

Patient #5
Review of Patient #5's medical record revealed the patient admitted on 05/17/2023 at 7:30 p.m. with an admission diagnosis of Dementia with behavioral disturbances. Further review revealed the patient was confused and unable to make decisions. Additional review revealed the patient's cousin listed as power of attorney (POA).

Review of S5LSW 's notes revealed the following entry: 05/19/2023 11:30 a.m. SW telephone to Patient #5's POA to follow up on patient's treatment and to obtain collateral. SW expressed the POA's report of Patient #5 coming from a memory care center where she had fallen and had an elevated glucose as well as an UTI.

Review of S8RN's notes revealed the following entry: 05/23/2023 12:37 p.m. Received call from POA with concerns of how patient was doing, that Patient #5 had a cochlear implant and wanted to know if her hearing aid was on charger and would like to speak with S5LSW.

Review of S5LSW's notes revealed the following entry: 05/23/2023 1:14 p.m. LSW spoke with POA and gave an update on the patient's treatment. Explained to POA that the charger was not found and talked about following up at Hospital 'c' to see if it was there.

Review of Patient #5's medical record revealed transport by EMS to Hospital 'd' on 05/24/2023. Further review revealed Patient #5 was administered 2.5 liters of Sodium Chloride and 1 gram of Rocephin and then discharged back to Beacon Behavioral Hospital.

Review of Patient #5's Master Treatment Plan failed to reveal evidence of a signature indicating that the patient or the POA participated in the care plan. Further review failed to reveal evidence that the POA's concerns regarding the Patient #5's hearing aids addressed in the care plan. Continued review failed to reveal an updated care plan following the transport to the emergency room.

In an interview on 05/31/2023 at 9:00 a.m., S1Admin confirmed there was no patient or patient representative signature indicating participation in the treatment planning. S1Admin stated Patient #5 lived in a nursing home and the facility was unsure of her Power of Attorney. S1Admin stated that there was no evidence on the care plan of Patient #5's hearing loss or that she had gone to the emergency room.

Based on record review and interview, the facility failed to have a family member promptly notified of patient admission. This deficiency is evidenced by failure to follow the wishes of a patient to notify family of admission in 1 (#1) of 5 (#1-#5) patients sampled.
Findings:

Review of hospital policy titled "Patient Rights" revealed, in part: In accordance with Louisiana Licensing Regulations for Hospitals 9319 every patient has the right to, in part: 2. Have a family member, chosen representative and/or his or her own physician notified promptly of admission to the hospital.

Review of Patient #1's medical records revealed patient admitted on 01/01/2023.

A review of Patient #1's Nursing Admission Assessment dated 01/02/2023 at 1:34 a.m. revealed the patient was uncooperative with extreme aggression and sedated upon arrival. Further review revealed that Patient #1's POA was his daughter.

Continued review revealed the patient requested the facility call his daughter and gave them her phone number.

A review of nurse note dated 01/03/2023 at 6:00 p.m. revealed the daughter of Patient #1 contacted the DON twice on this day expressing her concern over the admission of her father to a psychiatric facility. The nurse reported that Patient #1's daughter stated that she was not adequately advised that he would go to Beacon Behavioral Hospital. The daughter reported she did not want her father moved back to the memory care facility on the weekend since typically there are fewer staff and communication on the weekend.

In a telephone interview on 05/31/2023 at 12:02 p.m., the complainant stated Facility 'a' and hospice said they couldn't control her father and sent him to Hospital 'e' who sent him to the psychiatric facility. Complainant reported that she could not speak with a physician on 01/01/2023 because of a holiday. Complainant reported she continued to call several times and finally reached someone on 01/03/2023. Was told her POA was not validated. Spoke with S5LSW and was told patient would be in the hospital for 10-14 days.

Based on record review and interview, the hospital failed to have adequate numbers of mental health technicians to provide care to all patients as needed. This deficient practice was evidenced by 1 (05/30/2023 day shift) of 2 days (05/30/2023 and 05/31/2023) observed when the hospital failed to meet the minimal staffing requirements as per the approved staffing grid.
Findings:

Review of census dated 05/30/2023 revealed 22 patients.

Review of hospital Staffing Matrix #1 that was provided by S1Admin on 05/30/2023 during the entrance conference revealed a census of 22 requires 2 RNs, 1 LPN and 4 MHTs on the day shift and the night shift.

Review of hospital Staffing Matrix #2 that was provided by S7DON on 05/31/2023 after surveyor questioned that the hospital may be short-staffed according to the original Matrix provided, revealed a census of 22 requires 1 RN, 1 LPN and 4 MHTs on the day shift and the night shift.

Review of the nursing staff schedule dated 05/30/2023 revealed 1 RN and 1 LPN scheduled for the day shift.

Review of the MHT staff schedule dated 05/30/2023 revealed 5 MHTs scheduled for the day shift.

Observation of patient hallway on 05/30/2023 at 1:05 p.m. revealed Patient #5 sitting in her wheelchair unattended. Patient was not able to communicate where she was supposed to be at this time. Further observations revealed no MHTs in the hallway or in the day room.

In an interview on 05/30/2023 at 1:10 p.m., S3MHT who had just walked on to the unit, reported she could not find 2 of the scheduled MHTs which left 3 MHT's to bring the 22 patients to their rooms for rest time.

In an interview on 05/30/2023 at 1:20 p.m., S2COR stated that one MHT had left for lunch and the other MHT had gone on an errand.

In an interview on 05/30/2023 at 2:10 p.m., S1Admin verified the hospital was short 1 RN and 1 MHT on 05/30/2023.

In an interview on 05/31/2023 at 10:05 a.m., S7DON stated they were not short 1 RN on 05/30/2023 according to the Staffing Matrix #2.

In an interview on 05/30/2023 at 12:50 p.m., S6LPN stated that the facility has had an MHT staffing shortage. With the MHT shortage, she reports having to pass trays and take out trash as compared to having the ability to focus on patient care when the MHT staffing is appropriate.

Based on observation, record review and interview the registered nurse failed to ensure the proper execution of physician orders. This deficient practice is evidenced by:
1) Failure of the nursing staff to provide the observation level as ordered by the physician in 5 (#1-#5) of 5 (#1-#5) patients.
2) Failure of the nursing staff to discharge Patient #1 to the emergency room for medical evaluation as noted on Discharge Summary and Treatment Plan Update.
Findings:

1) Failure of the nursing staff to provide the observation level as ordered by the physician in 5 (#1-#5) of 5 (#1-#5) patients.
A review of hospital policy titled "Levels of Observation" revealed, in part: Policy: Beacon Behavioral Hospital recognizes that many risks may be decreased by providing an appropriate Level of Observation to meet the patient's individual needs. In the inpatient setting, surveillance of common areas (such as hallways, dayrooms, etc.) may be monitored via camera. At no time is this type of surveillance to be used as a replacement of the levels of observation for any patient, who must be directly observed, in-person, according to orders. Line of Sight requires continuous observation. Close Observation is the routine Level of Observation applied to patients that are not considered at risk and in need of increased supervision. At least every 15 minutes a staff member directly visually observes the patient. Line of Sight is defined as maintaining visual observation of a patient at all times. If assigned more than one line of Sight patient and at least one patient needs go use the bathroom, shore, or leave the group for another reason, the staff member maintain Line of Sight must enlist the assistance of another staff member, to ensure that all patients on Linde of Sight are maintained within visual range of staff. When the assistance of another staff member is necessary, there should be verbal acknowledgement of the change in activity. Although visualization is continuous, the staff member documents or electronically enters the patient's location and general activity at least every 15 minutes.

Patient #1
A review of Patient #1's medical records revealed patient admitted on 01/01/2023 and discharged on 01/06/2023.

A review of Patient #1's Nursing Admission Assessment dated 01/02/2023 revealed observation status: Line of Sight.

Review of Patient #1's observation sheets failed to reveal observations occurred every 15 minutes as per hospital policy on the following days: 01/02/2023, 01/03/2023, 01/04/2023, 01/05/2023, and 01/06/2023.

Patient #2
A review of Patient #2's medical records revealed patient admitted on 05/24/2023.

A review of Patient #2's physician orders dated 05/30/2023 revealed 15 minute observation daily.

Review of Patient #2's observation sheets failed to reveal observations occurred every 15 minutes as per hospital policy on the following days: 05/25/2023, 05/26/2023, 05/27/2023, 05/28/2023, and 05/29/2023.

Patient #3
A review of Patient #3's medical records revealed patient admitted on 12/23/2022 and discharged 01/03/2023.

A review of Patient #3's Nursing Admission Assessment dated 12/23/2022 revealed Observation Status: Observation every 15 minutes daily until discontinued by physician.

Review of Patient #3's observation sheets failed to reveal observations occurred every 15 minutes as per hospital policy on the following days: 12/23/2022, 12/24/2022, 12/25/2022, 12/26/2022, 12/27/2022, 12/28/2022, 12/29/2022, 12/30/2022, 12/31/2022, 01/01/2023, 01/02/2023, 01/03/2023.

Patient #4
A review of Patient #4's medical records revealed patient admitted on 12/29/2022 and expired at the facility on 12/31/2022.

A review of Patient #4's Nursing Admission Assessment dated 12/29/2022 revealed Observation Status: Line of Sight daily until discontinued by physician.

Review of Patient #4's observation sheets failed to reveal observations occurred every 15 minutes as ordered by the physician on the following days: 12/29/2022, 12/30/2022, and 12/31/2022.

Patient #5
A review of Patient #5's medical records revealed patient admitted on 05/17/2023.

A review of Patient #5's physician orders dated 05/25/2023 revealed Line of Sight Daily until discontinued by physician.

On 5/30/2023 at 1:05 p.m.-1:10 p.m., observation of the unit revealed Patient #5 sitting in Geri-chair in the hallway alone and unattended. Patient was unable to communicate where she was supposed to be at this time.

In an interview on 05/30/2023 at 1:10 p.m., S3MHT stated the observation level of this patient was "Line of Site" and that Patient #5 should not have been left alone.

In an interview on 05/30/2023 at 1:20 p.m., S2MHTCOR stated that Patient #5 is observation level "Line of Sight". S3MHTCOR defined "Line of Sight" to mean that the patient is in the line of sight of an MHT or nurse at all times.

Review of Patient #5's observation sheets failed to reveal observations occurred every 15 minutes as ordered by the physician on the following days: 05/18/2023, 05/19/2023, 05/20/2023. 05/21/2023, 05/23/2023, 05/26/2023, 05/27/2023, 5/28/2023, and 05/29/2023.

In an interview on 05/31/2023 at 10:50 a.m., S4HIM confirmed patients' #1-#5 observation sheets failed to reveal that observations had occurred every 15 minutes as per hospital policy.

2) Failure of the nursing staff to discharge Patient #1 to the emergency room for medical evaluation as noted on Discharge Summary and Treatment Plan Update.
A review of hospital policy titled "Discharge of the Patient" revealed, in part: Procedure. 1. The authorized licensed prescriber issues an order for discharge, designating the date and time of discharge, as well as the patient's destination, as appropriate. 3. The nurse transcribes the orders and initiates the Discharge Instructions Form. 9. The patient is asked to sign the Discharge Instructions to indicate that the instructions were reviewed with, and that a copy was recieved by the patient.

A review of Patient #1's Discharge Summary prepared by S12MD dated 01/05/2023 at 10:20 a.m. revealed, in part: Mental Status at Time of Discharge: Appearance: disheveled. Behavior: Anxious. Speech: normal t/r/v. Affect: anxious. Thought Process: circumstantial. Thought Content: appropriate. Insight and Judgment: fair to poor. Memory: intact.
Continued review revealed Summary of overall condition at the time of discharge (psychiatric, mental and physical), in part: Unable to assess SI/HI/AVH upon discharge. Patient is rambling illogically, appears RIS. Per staff he keeps trying to pull off his clothes, he is agitated and combative with staff.

Sending to ER for medical.

A review of Patient #1's Discharge Instructions prepared by S13DON on 01/05/2023 at 12:11 p.m. revealed, in part: Discharge Status: routine.

Discharge to: Facility 'a'. Follow-up with Hospice 'b'. Further review failed to reveal patient's or patient representative's signature indicating receipt of these instructions.

A review of Patient #1's Treatment Plan Update by L5LSW dated 01/06/2023 at 2:14 p.m. revealed a Tentative Discharge Date of 01/06/2023.

Treatment Discharge Plan: Follow Up on Deferred Problems; Medication Management; Follow Up on Medical Issues.

Clinical Summary, in part: Sending to ER for medical.

Further review failed to reveal patient's or patient representative's signature indicating participation in this care plan update.

In an interview on 05/31/2023 at 2:28 p.m., S4HIM confirmed that the Treatment Discharge Plan failed to reveal the patient's or the patient representative's signature indicating participation in this care plan update.

In an interview on 05/31/2023 at 12:02 p.m., the complainant stated that L5LSW called on 01/05/2023 to say her father had to leave that day, said they were discharging him because there was nothing more they could do for him. Complainant stated that there was no mention of her father going to ER for medical evaluation. He went to Facility 'a' from Beacon via ambulance.

Based on record reviews and interviews, the hospital failed to ensure a patient discharge summary was completed within 30-days of discharge for 1 (#4) of 5 (#1-#5) patients sampled.
Findings:

Review of the hospital's medical and professional staff bylaws revealed, in part: Medical Records: Practitioner's must complete their patients' medical records within 30-days of each patient's discharge or such period as the Medical Executive Committee may prescribe.

Review of Patient #4's medical record revealed an admit date of 12/29/2022 and an expired date of 12/31/2022.

Further review revealed there was no documented discharge summary in the medical record.

In an interview on 05/31/2023 at 1:10 p.m., S4HIM confirmed Patient #4's medical record did not contain a discharge summary.

In an interview on 05/31/2023 at 3:15 p.m., S1Admin confirmed discharge summaries should be completed within 30-days of discharge.