HospitalInspections.org

Based upon record review and interviews the hospital failed to ensure a list of all contracted services, including the scope and nature of the services to be provided, was maintained as evidenced by a lack of a documented list. Findings:

The surveyors requested a list of all contracted services (which was to include the scope and nature of services provided); however; hospital staff failed to supply such a list.

Interviews, 10/22/13 at 10:45AM, with S1 Administrator and S30 Administrative Assistant confirmed there was not a list of all contracted services, including the scope and nature of services provided, maintained by the hospital.

Subsequent interview, on 10/24/13 at 1:00PM, with S1 Administrator revealed the previous Chief Financial Officer (CFO), identified as S31 CFO, had assumed responsibility for all contracted services and left employment without leaving information relative to the list of contracted services.

Based upon review of incident/accident reports, reports of abuse and neglect reported to the Health Standards Section, 2 of 8 medical records (#5, #6), policies and procedures, and staff interviews, the hospital failed to follow state law LA. R.S. 40:2009.20 related to reporting to the Health Standards Section an incident which occurred on 10/15/13 where patients #5 and #6 were allowed to elope from the hospital. Findings:

Review of the incident/accident reports revealed on 10/15/13, at 11:05 a.m., patients #5 and #6 escaped out of an unlocked door on the adolescent unit, pulled a chair up to a 12 foot chain link fence and eloped from the hospital without staff knowledge. Review of the forms titled "Quality/Risk Management Report of Event" revealed "(patient #5 and patient #6) walked off the day unit and out the door. They used a chair to climb the fence. It was 5 minutes before staff discovered them gone. Patient's (#5) mom (and patient #6's mother), probation officer, physician, and (local) police notified. They were spotted approximately a mile down the road. They were returned at 4:46 p.m. All parties notified of return." Review of the form titled "Code White/Code Green Event/Drill Critique Report" revealed "Comments: It appears that the unit door was left un-locked. Clients put a chair to the fence and went over the fence." Review of the incidents of abuse and neglect that were reported to Health Standards Section revealed there failed to be documented evidence this incident was reported to the Health Standards Section within 24 hours of occurrence.

Review of LA. R.S. 40:2009.20 revealed "B. (1) Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, licensed practical nurse, nurse's aide, home and community based service provider employee or worker, personal care attendant, respite worker, physician's assistant, physical therapist, or any other direct care 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 twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect..."

Interview with S2, DON (Director of Nursing) on 10/22/13 at 2:10 p.m. revealed when asked if patient elopements were reported to Health Standards Section within 24 hours, she replied elopements would only be reported if the patient was not returned to the hospital.

Interview with S1, CEO (Chief Executive Officer) on 10/22/13 at 2:30 p.m. revealed he was under the impression that if the local law enforcement agency was notified of an elopement, the hospital would not be required to notify Health Standards.

Review of the medical records for patients #5 and #6 revealed they were on line of site observation. The hospital failed to identify they were neglectful in providing line of sight observation for patients #5 and #6 which provided the opportunity for the patients to elope from the hospital.

Based upon review of 4 of 8 physician credential files and staff interview, the hospital failed to ensure physicians S17, S18, S19 and S20, who were contract Radiologists, had documented evidence of current licensure. Findings:

Review of the physician credential files revealed Radiologist S17's license expired 7/31/12, Physician S18's license expired 8/31/12, Physician S19's license expired 8/31/12, and Physician S20's license expired on 1/31/13.

Interview on 10/24/13 at 10:30 a.m. with S29 physician credentialing, confirmed Radiologists S17, S18, S19 and S20 did not have current licensure in their credential files.

Based upon review of personnel files and staff interviews, the hospital failed to ensure the Dietary Managers were qualified through education and specialized training. This was evidenced by Dietary Managers S3 and S4 being assigned as managers over dietary services when neither employees had any current dietary certification (S3 expired 12/93) and no documented dietary education or specialized training (S4). Findings:

In an interview on 10/24/13 at 11:30 a.m. with S4 Interim Dietary Manager revealed she had been assigned to the duties/responsibilities of Dietary Manager 13 months ago as a result of the previous resignation of the Dietary Manager. According to S4 her educational background included a high school diploma, and on the job-training . She stated she had no certification in food services and had been enrolled in an on-line approved certification program by the American Dietetic Association since June or July of 2013. According to S4, S8 is a Registered Dietician who is contracted by the facility to provide dietary services to the facility.
In an interview on 10/24/13 at 11:40 a.m. with S3 Interim Director of Housekeeping & Dietary Manager revealed she had been assigned to the duties/responsibilities of Dietary Manager 13 months ago as a result of the previous resignation of the Dietary Manager. S3 stated she had prior food services experience with certification at one time however her certification had expired approximately 10 years ago. According to S3, she had been enrolled in an on-line approved certification program by the American Dietetic Association since June or July of 2013.
Review of the personnel file of S3 Interim Director of Housekeeping & Dietary Manager revealed no job description only training hours/certification from previous employment; 22 hours of training in Louisiana School Food Training Program in 1991, Nutrition Work shop 1992, and American School Food Service Association Certification Program with an expiration of 12/1993. There was no documented evidence of current training/certification in dietary services.
Review of the personal file of S4 Interim Dietary Manager revealed a job description for Director of Food Services. Further review of the file revealed no documented evidence she had any type of dietary training and/or certification.
Review of the job description for the Dietary Manager states in part; position qualifications:
(1 Must be a member of the Dietary Managers Association.
(2 Ability to perform managerial and dietetic functions accurately and professionally.
(5. Must have 45 hours of continuing education every 3 years.
In an interview on 10/24/13 at 1:00 p.m. with S1 Administrator it was confirmed S3 and S4 both performed the duties/responsibilities of Dietary Manager since the resignation of the prior Dietary Manager approximately 13 months ago. S1 Administrator further confirmed S3 & S4 were enrolled in on-line course to obtain certification and the necessary training required to performed the duties of Dietary Manager.

Based on record reviews and staff interviews the hospital failed to ensure each patient received a comprehensive treatment plan as evidenced by 3 of 8 patients (#s 5, 6, 8), without current and updated comprehensive master treatment plans that included interventions for elopement (#s 5, 6) and aggressive behaviors (#8). Findings:

1) Review of the medical record for patient #5 revealed a 16 year old female admitted to the hospital on 9/27/13 with a diagnosis of Impulse Control Disorder. Review of the nursing progress notes revealed on 10/15/13, the patient eloped from the hospital at 11:05 a.m. by escaping out of an unlocked door on the girls adolescent unit and climbing over a fence. Upon return to the hospital at 4:46 p.m., the patient was placed on unit restriction. Review of the Master Treatment Plan revealed the plan failed to be updated related to the elopement on 10/15/13 and the patient being placed on unit restriction.

2) Review of the medical record for patient #6 revealed a 16 year old female admitted to the hospital on 10/10/13 with a diagnosis of Oppositional Defiant Disorder, Borderline Intellectual Functioning, and limited social and adaptive coping skills. Review of the nursing progress notes revealed on 10/15/13 at 11:05 a.m., the patient eloped from the hospital by escaping from an unlocked door on the girls adolescent unit and climbing over a fence. Upon return to the hospital at 4:46 p.m., the patient was placed on unit restriction. Review of the Master Treatment Plan revealed the plan failed to be updated related to the elopement on 10/15/13 and the patient being placed on unit restriction.

3) Review of patient #8's medical record revealed a 27 year-old-male admitted 08/16/13 with a diagnosis of psychosis. Review of a Master Treatment Plan, dated 08/16/13, revealed a page titled "Master Treatment Plan Problem List". Under a section, dated 08/16/13, titled "Problem Title", was written "Gravely Disabled". No further updates were documented in the Master Treatment Plan.

Review of a physician progress note, dated 09/17/13, S34 Psychiatrist documented Patient #8 "entered the examination room" without S34 Psychiatrist's awareness, and when S34 Psychiatrist turned around, Patient #8 hit him in his left eye causing a cut. Review of multidisciplinary progress notes, dated 08/19/13, revealed Patient #8 attacked a Licensed Practical Nurse (LPN), (name unknown), while patients were outside without any expressed reason.

Interview, 10/22/13 at 10:00AM, with S13 Mental Health Technician (MHT), revealed Patient #8 had kicked and struck out at staff and other patients as well as hitting his own head against the wall.

Interview, 10/24/13 at 11:00AM, with S7 Registered Nurse (RN) confirmed Patient #8's Master Treatment Plan had not been updated since the admission on 08/16/13. Continued interview with S7 RN confirmed there lacked documented evidence in the Master Treatment Plan that Patient #8's "aggressive" behaviors had been addressed.

Based on record reviews and interviews the hospital failed to ensure patients' Master Treatment Plans were based on their individual strengths and disabilities as evidenced by the lack of a Master Treatment Plan for 1 of 8 patients (#8) with aggressive behaviors such as kicking and striking staff and other patients. Findings:

Review of patient #8's medical record revealed a 27 year-old-male admitted 08/16/13 with a diagnosis of psychosis. Review of a Master Treatment Plan, dated 08/16/13, revealed a page titled "Master Treatment Plan Problem List". Under a section, dated 08/16/13, titled "Problem Title", was written "Gravely Disabled". Review of page 2 of 9, of the Master Treatment Plan (dated 08/16/13), revealed "III. PATIENT ASSETS/STRENGTHS", a check mark was placed next to "Verbal Skills" that indicated Patient #5's only documented assets/strength. Continued review of the Master Treatment Plan, page 2 of 9, revealed "IV. PATIENT/LIABILITIES", "Family Conflict" and "Chronic Mental Illness" were selected as the only weaknesses/liabilities. No further updates were documented in the Master Treatment Plan.

Review of a physician progress note, dated 09/17/13, revealed S34 Psychiatrist documented Patient #8 "entered the examination room" without S34 Psychiatrist's awareness, and when S34 Psychiatrist turned around, (name of Patient #8) hit him in his left eye causing a cut". Review of multidisciplinary progress notes, dated 08/19/13, revealed Patient #8 attacked a Licensed Practical Nurse (LPN), (name unknown), without any expressed reason, while the patients were outside on a smoke break.

Interview, 10/22/13 at 10:00AM, with S13 Mental Health Technician (MHT), revealed Patient #8 had kicked and struck at staff and other patients as well as hitting his own head against the wall. S13 MHT further stated Patient #8 had also hit him (S13 MHT).

Interview, 10/24/13 at 11:00AM, with S7 Registered Nurse (RN) confirmed Patient #8's Master Treatment Plan had not been updated since the admission on 08/16/13. Continued interview with S7 RN confirmed there lacked documented evidence in the Master Treatment Plan that Patient #8's "aggressive" behaviors had been addressed. S7 RN agreed treatment plans did not take into consideration Patient #8's strengths and weaknesses.

Based upon observations, reviews of hospital policies, Adult Men Weekday Program Schedule, medical records of 2 of 2 Therapeutic Activity assessments for patients who were on unit restriction and 1:1 Status (#8, #9 Random Patient), and interviews, the hospital failed to ensure all patients received assessments/evaluations for a program of therapeutic activity directed toward restoring and maintaining their optimal levels of physical and psychosocial functioning. Findings:

Observations conducted on the Male Adult Psychiatric Unit revealed, 10/21/13 at 10:20AM, there were 2 male patients (#8 and #9 Random Patient) who were on unit restriction and were on 1:1 observation (one Mental Health Technician-MHT for each patient and always at arms length from patient). Subsequent observations, 10/21/13 at 2:30PM through 3:15PM, revealed #8 and #9 Random Patient remained on the unit with their MHTs during the recreational activity period; however, neither were offered any sort of therapeutic activity. Further observations, 10/22/13 at 10:00AM and 10/23/13 at 2:30PM, on the Male Psychiatric Unit revealed #8 and #9 Random Patient remained on the unit without the benefit of any therapeutic activity.

Review of hospital policy, #AS-11-030 titled "Progress Reporting, Recreational Therapy", revealed: "PURPOSE: To ensure patient's needs are being met in a proper and timely manner. POLICY: To ensure patient's progress and treatment are assessed on a regular basis and in a timely manner. PROCEDURE: 1. The Recreational Therapist or Recreational Tech will make daily documentation of treatment given focusing on the results of the treatment, assessment of progress and significant changes. 2. Report any significant changes to the appropriate staff verbally as well as in writing."

Review of hospital policy, #AS-11-029 titled "Monitoring Process, Recreational Therapy", revealed: "PURPOSE: To ensure that the treatment is appropriate for the development of appropriate leisure and social skills...PROCEDURE: 1. Observation of measurable (task oriented) goals while giving treatment daily..."

Review of hospital policy, #AS-11-028 titled "Treatment Plan and Goals, Recreational Therapy", revealed: "PURPOSE: To develop an individualized treatment plan to improve functional behaviors necessary for future leisure/social involvement. POLICY: Treatment plan and goals for each patient will reflect continuity of care process designated for that individual to improve social, physical, emotional, spiritual and cognitive functional behaviors. PROCEDURE: 1. The section entitled 'Recreation' found in the Master Treatment Plan
form will be completed with input from the patient and with Recreational Therapist or Recreation Tech. Short term goal(s) will be developed which are in a measurable context. The therapist will write the following: a. A targeted date to begin the intervention; 2. A completion date when the goal has been met;...2. The Treatment Plan is formulated to meet patient needs to include, but not limited to: a. Leisure Education...e. Interaction/Socialization Skills...4. The treatment plan will utilize the patient's strengths to achieve their optimal functional level..."

Review of "Adult MEN Weekday Program Schedule" revealed recreation activity was scheduled twice a day Monday through Friday. The morning session was scheduled from 9:30AM through 10:20AM; and the afternoon session was from 2:30PM through 3:15PM.

As noted above, observations conducted, 10/21/13-10/24/13, revealed #8 and #9 Random Patient both remained on the unit per psychiatrist order; however neither received any form of recreational activity.

Review of Patient #8's Master Treatment Plan, under the section titled "Recreation". revealed: "Long term Goal Patient will learn Recreational activities that assist in improving the overall level of functioning positive coping skills and self-esteem of the patient. Short Term Goals ... Patient will attend Recreational Activity groups, daily and participate free from threats to others or aggressive behavior for '3' consecutive days...Interventions Provide recreational activity groups daily and encourage participation in physical activities, arts and crafts to improve mood and deal with life stressors such as--(this area was left blank, not completed by staff)..."

Review of #9 Random Patient's Master Treatment Plan, Recreation Section, revealed Long Term and Short Term Goals were established but not conducted as the patient was on unit restriction and could not leave the unit.

Interview, 10/23/13 at 2:15PM, with S32 Recreational Tech (RT) confirmed Patient #8 did not receive any type of recreational activity. S32 RT further stated when patients were on unit restriction they did not attend recreational activities. The surveyor questioned S32 RT relative to Patient #8's Master Treatment Plan and that it stated that patient #8 would receive daily recreational activity; and what type of activity patient #8 could participate in; S32 RT stated he did not know what type of activity would be useful for patient #8. S32 RT confirmed patient #8's Master Treatment Plan for Recreation was not implemented nor was it developed based on patient #8's needs.

The hospital failed to ensure all patients received recreational activities based upon their need(s) regardless if they were on unit restriction or had off unit privileges.