HospitalInspections.org

Based on record review and interview, hospital b failed to ensure that every patient was notified and informed of their patient rights as evidenced by having a blank patient rights form in the chart in 1 (#6) of 5 (#6 - #10) sampled patient records reviewed.
Findings:

A review of hospital b's policy titled "Patient Rights Louisiana" revealed, in part: Policy: Every client shall receive a written copy of the Patient Rights and sign the "Acknowledgment of Rights" form stating they reviewed and understand their rights.

A review of Patient #6's medical records revealed an admission date of 04/06/2023. Further review revealed a blank Patient Rights form and failed to reveal a documented reason regarding why the form was not completed.

In an interview on 04/19/2023 at 12:30 p.m., S7CTRS confirmed that there was no evidence of a signed Patient Rights form and no evidence of documentation stating the reason why the form was not signed.

Based on records review and interview, hospital b failed to ensure patients were notified of their right to make informed decisions as evidenced by having a blank Authorization and Informed Consent Form in 1 (#6) of 5 (#6 - #10) patients sampled for records review.
Findings:

A review of hospital b's policy titled "Patient Rights Louisiana" revealed, in part: Governing Board, in part:
Mandates facility to recognize and respect patient rights including, in part: The right to informed consent.

A review of Patient #6's medical record revealed an admission date of 04/06/2023. Further review revealed a blank Authorization and Informed Consent Form and failed to reveal a documented reason for the incomplete form.

In an interview on 04/19/2023 at 12:30 p.m., S7CTRS confirmed that there was no evidence of a signed Authorization and Informed Consent Form and no evidence of a documented reason why the form was not signed.

Based on observation, record review and interview, hospital a failed to ensure patients received care in a safe setting. This deficient practice was evidenced by:
1) 1 (#5) patient of 5 (#1 - #5) patient's medical records reviewed for transfer from the bed to a geri-chair sustained a skin tear; and,
2) 1 (#1) patient of 5 (#1 - #5) patient's medical records reviewed revealed an incident of self-harm with a staple obtained from a packet provided by the hospital.
3) Hospital a and hospital b failed to comply with state laws as evidence by failure to publicly display required signage to advise the public regarding workplace violence.
Findings:

Review of a policy and procedure titled, "Disclosure of Unanticipated Outcomes" in the category of Patient Rights revealed, in part, the purpose of the policy was to delineate procedures for notifying persons of unanticipated outcomes. To provide informal information to patients and patient's representative, when applicable, of healthcare related occurrences during treatment that result in negative/unexpected outcomes or may affect the patient's overall care results. Policy: It is policy that the physician, in consultation with Administration, will promptly and openly discuss any unanticipated outcomes of care, treatment, and services with the patient/family/legally authorized representative/designee. The Department Head reviews incident and actions taken. Evaluates if occurrence could result in negative outcome of care. The RN notifies the physician of unanticipated outcome that requires discussion with patient and/or legal decision maker.

Review of a policy and procedure titled, "Patient's Rights" revealed, in part, 6. Each patient's personal confidentiality, privacy, and security shall be assured and protected within treatment services provided and the environment of care. 7. Patients have a right to an environment of care that preserves human dignity and contributes to a positive self-image. 8. Patient have the right to be free from mental, physical, sexual and verbal abuse, neglect, and/or exploitation.

Review of a policy and procedure titled, "Disclosure of Unanticipated Outcomes" in the category of Patient Rights revealed, in part, the purpose of the policy was to delineate procedures for notifying persons of unanticipated outcomes. To provide informal information to patients and patient's representative, when applicable, of healthcare related occurrences during treatment that result in negative/unexpected outcomes or may affect the patient's overall care results. Policy: It is policy that the physician, in consultation with Administration, will promptly and openly discuss any unanticipated outcomes of care, treatment, and services with the patient/family/legally authorized representative/designee. The Department Head reviews incident and actions taken. Evaluates if occurrence could result in negative outcome of care. The RN notifies the physician of unanticipated outcome that requires discussion with patient and/or legal decision maker.

Review of the policy and procedure titled "Disclosure of Unanticipated Outcomes" revealed, in part, unanticipated outcomes of care related to sentinel events (even if the outcome was not death or permanent loss of function) considered reviewable include, in part: suicide, suicide attempt requiring medical intervention, or self-abuse requiring medical intervention. The policy also revealed the RN documents the occurrence in the multidisciplinary progress notes, fills out an incident report form regarding the occurrence, routes to risk management, and notifies the physician of the occurrence.

1) 1 (#5) patient of 5 (#1 - #5) patient's medical records reviewed for transfer from the bed to a geri-chair sustained a skin tear; and,

Patient #5
In an interview on 04/17/2023 at 11:10 a.m., S1CEO indicated the hospital has equipment such as lifts, wheelchairs, walkers and other durable medical equipment to meet the needs of patients who are unable to safely transfer and ambulate.

Review of an Incident/Accident Report dated 03/09/2023 at 6:00 a.m. revealed, in part, 2 MHTs were assisting Patient #5 to a Geri-chair without using a lift. The report further indicated Patient #5 was resisting and in the process of transfer, received a skin tear on her right forearm. Further review of the incident report revealed the physician and family representative were not notified of Patient #5's injury and the Director of Nursing did not sign the incident report.

In an interview on 04/18/2023 at 10:10 a.m. S2DON verified the physician and family representative were not notified of the incident with injury. S2DON further verified she did not review or sign the incident report.

2) 1 (#1) patient of 5 (#1 - #5) patient's medical records reviewed revealed an incident of self-harm with a staple obtained from a packet provided by the hospital.

Patient #1
Review of Patient #1's medical record revealed an incident of self-harm on 03/15/2023 at 4:00 p.m. The nurse reported Patient #1 stated that she wished to commit suicide. A picture on the chart dated 03/15/2023, showed two lacerations on Patient #1's left arm with no change in physician's orders noted. The Multi-Disciplinary Note on 03/15/2023 at 4:15 p.m. stated, "Pt attempted to cut her wrist with a staple from a packet provided with handbook. Following that pt. took some metal out of the wall where other made a hole and pulled metal pieces to harm herself." An incident/accident report was not completed on this incident.

In an interview on 04/18/2023 at 1:45 p.m., S15RN, verified there was no incident report completed related to the 03/15/2023 incident on Patient #1.

3) Hospital a and hospital b failed to comply with state laws as evidence by failure to publicly display required signage to advise the public regarding workplace violence.

Pursuant to R.S. 40:2199.11 through 2199.19, relative to licensed healthcare facilities; to establish duties and requirements of licensed healthcare facilities with respect to addressing and preventing workplace violence; to require the posting of certain cautionary signage at licensed healthcare facilities; to require and provide with respect to healthcare workplace violence prevention plans; to require reporting of acts of workplace violence occurring at licensed healthcare facilities; to prohibit retaliation by certain employers in connection with reporting of healthcare workplace violence.

Hospital a
A tour of the hospital a on 04/18/2023 between 10:00 a.m. and 11:00 a.m. revealed no evidence of signage as per R.S. 40:2199 through 2199.19 requiring hospitals to provide within public view language related to workplace violence.

In an interview on 04/18/2023 during the tour, S1CEO verified there were no signs throughout the hospital as required by the Workplace Violence legislation.

Hospital b
A tour of hospital b on 04/19/2023 between 8:30 a.m. and 10:00 a.m. revealed no evidence of signage as per R.S. 40:2199 through 2199.19 requiring hospitals to provide within public view language related to workplace violence.

In an interview on 04/19/2023 at 2:00 p.m., S6DCS b confirmed there is no Workplace Violence Signage throughout the building.


48051

Based on record review and interview, the hospital failed to ensure patients were free from abuse and failed to ensure all incidents of abuse, neglect, and/or harassment were reported and analyzed, and the hospital was in compliance with applicable local, State, and Federal Laws and Regulations. This deficient practice was evidenced by the hospital's failure to report abuse within 24 hours to the Department of Health and Hospitals or law enforcement for 2 (R2, R3) of 2 (R2, R3) patients reviewed for mandatory reporting.
Findings:

Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report abuse/neglect allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Louisiana Department of Health (LDH) (or the Medicaid Fraud Unit as applicable). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence.

Review of the Grievance Report for March, 2023 revealed 2 patients (R2, R3) filed grievances with the hospital on 03/10/2023 related to patient care. Further review revealed the hospital investigated the grievances which were resolved on 03/15/2023; final letters were sent to Random Patient #2 and Random Patient #3 on 03/15/2023.

Review of the final grievance letters sent to Random Patient #2 and Random Patient #3 revealed, in part, 1. You stated that staff members were treating patients without dignity and professionalism; 2. Additionally, you reported that the staff and nurses do not treat the patients with respect. They are rude and extremely disrespectful. We have completed a thorough investigation into your concerns and our response to your concerns and actions taken are below: 1. With internal investigation, this allegation has been substantiated, as a result of findings the employee has been termination; 2. The importance of treating everyone that we serve with respect and dignity has been addressed with all staff member.

In an interview on 04/18/2023 at 12:09 p.m. S3HR verified S5MHT was the employee terminated for verbal abuse as a result of the 2 patient's (R2, R3) grievances.

In an interview on 04/18/2023 at 12:25 p.m. S3HR verified S5MHT was not reported to the Louisiana Adverse Action web site and a self-report of substantiated abuse was not submitted to LDH.

In an interview on 04/18/2023 at 1:32 p.m., S1CEO verified the substantiated allegation of abuse was not submitted to LDH.

40548

Based on record review and interview, the hospital failed to ensure a Registered Nurse supervised and evaluated the nursing care of each patient as evidenced by:
1) Failure to assess patients every shift for 1 (#5) of 5 (#1 - #5) patient's records reviewed;
2) Failure to identify goals and nursing interventions for 2 (#2, #5) of 5 (#1 - #5) patient's records reviewed for assessment;
3) Failure to administer insulin in accordance with hospital b's policy for 4 (#6, #7, #8, #9) of 5 (#6 - #10) diabetic patient's records reviewed;
4) Failure to address a documented abnormal capillary blood glucose (CBG) level on 1 (#6) of 5 (#6 - #10) diabetic patient records reviewed; and,
5) Failure to ensure that the CBG level was checked as ordered by the physician on 1 (#6) of 5
(#6 - #10) diabetic patient records reviewed.
Findings:

Review of the policy and procedure titled, "Assessment Process Inpatient" effective 01/11/2016 and last revised on 02/01/2020 revealed, in part, as part of the admission process, the RN completes the appropriate screenings and assessment scale to identify patient needs for consults and additional services. The multidisciplinary treatment integration is then completed by the social services department who will 1. Review cumulative assessment data to date; 2. Within 96 hours, will scribe a clinical impression that represents a relative interpretation of the findings and creates a clinical portrait of the patient; and, 3) Recommends prioritization of identified patient care needs and presenting problems with clinical justifications for treatment with tentative discharge criteria.

1) Failure to assess patients every shift for 1 (Pt. #5) patient of 5 (Pt. #1-#5) patient's records reviewed:

Review of Patient #5's medical record revealed, in part, a History and Physical examination completed on 03/07/2023 which indicated Patient #5 had an unstable gait and required the use of a geri-chair.

Review of Patient #5's medical record revealed on 03/09/2023 at 10:30 a.m., S7RN failed to document a nursing shift assessment regarding fall precautions for Patient #5.

2) Failure to identify goals and nursing interventions for 2 (Pt #2, Pt. #5) patients of 5 (Pt. #1-#5) patient's records reviewed for assessment;

Patient #5:
Review of Patient #5's medical record revealed, in part, a multi-disciplinary treatment plan that included the problem list of 1) Aggressive Behavior; 2) Failure to Thrive; 3) Potential for Skin Breakdown; 4) left blank, and 5) Alteration in perception. Further review of the multi-disciplinary treatment plan revealed no nurse's signature, and no short/long term goals with nursing interventions or response to interventions.

Patient #2:
Review of Patient #2's medical record revealed, in part, admitting diagnoses of Overdose and Suicidal Ideations with initial physician's orders for suicide and fall precautions. Further review of the multi-disciplinary treatment plan revealed no nursing documentation of short/long term goals, or interventions related to the risks and prevention of self-harm or falls.

In an interview on 04/18/2023 at 1:15 p.m., S15RN verified there were no nursing short/long term goals or interventions documented in the multi-disciplinary treatment plan related to the precautions ordered by the physician.


48051

3) Failure to administer insulin in accordance with hospital b's policy for 4 (#6, #7, #8, #9) of 5 (#6 - #10) diabetic patient's records reviewed;

Review of hospital b's policy titled "Sliding Scale Insulin Administration" revealed, in part: Purpose: To provide guidelines regarding the administration of the correct dose of insulin based on the measurement of capillary blood glucose levels (CBG) and the monitoring and treatment of high blood sugar/hyperglycemia and low blood sugar/hypoglycemia. Procedure, in part: Insulin requires a double check method verifying correct medication and dose by two registered nurses (RNs) or RN and licensed practical nurse (LPN)/licensed vocational nurse (LVN) prior to administration. THE DOUBLE CHECK METHOD OF CORRECT INSULIN DOSING IS DEFINED AS FOLLOWS, in part: After the RN/LPN/LVN who is to administer the insulin has documented the calculated dose and has initialed the MAR a second licensed nurse performing the double check method also places his/her initials next to the dose to be administered.

Patient #6:

A review of Patient #6's Insulin Flow Sheet revealed that on 04/17/2023, Patient #6's CBG level was 204 and 4 units of insulin were administered at 11:30 a.m. by S12LPN. Continued review of the Insulin Flow Sheet failed to reveal that a registered nurse verified the dose. Further review revealed that on 04/18/2023, Patient #6's CBG level was 267 and 8 units of insulin were administered at 9:00 p.m. by S13LPN. Additional review failed to reveal that a registered nurse verified the dose.

In an interview on 04/19/2023 at 12:10 p.m., S8RN confirmed that there was no evidence of the "Double Check Method" for verification of Patient #6's Insulin doses given on 04/17/2023 and 04/18/2023.

Patient #7:

Review of Patient #7's medical record revealed an admit date of 03/31/2023. Further review revealed Patient #7 was diagnosed, in part, with Dementia and Diabetes Mellitus.

Review of Patient #7's medical record revealed a physician's order dated 04/01/2023 for insulin sliding scale with coverage per protocol.

Review of Patient #7's Oceans Practitioner's Orders Insulin Sliding Scale revealed, in part:
Capillary Blood Glucose.
201-250 = 4 units

Review of Patient #7's Insulin Flow Sheet revealed, in part, on 04/13/2023 at 21:00 CBG level result of 244 with no documentation of insulin given, on 04/14/2023 at 06:30 CBG level result of 224 with no documentation of insulin given, and on 04/14/2023 at 11:30 CBG level result of 228 with no documentation of insulin given.

In an interview on 04/17/2023 at 1:13 p.m., S15RN, Director of Quality confirmed that there was no evidence Patient #7 received insulin per sliding scale coverage protocol. S15RN, Director of Quality confirmed Patient #7 should have received insulin as ordered.

Patient #8:

Review of Patient #8's medical record revealed an admit date of 04/04/2023. Further review revealed Patient #8 was diagnosed, in part, with Dementia and Diabetes Mellitus.

Review of Patient #8's medical record revealed a physician's order dated 04/04/2023 for insulin sliding scale with coverage per protocol.

Review of Patient #8's Oceans Practitioner's Orders Insulin Sliding Scale revealed, in part:
Capillary Blood Glucose. Frequency: AC (before meals) & HS (hour of sleep) (30 minutes before scheduled meals).
251-300 = 8 units
351-400 = 12 units
Capillary Blood Glucose greater than 400, call MD for orders and recheck CBG in 30 minutes.

Review of Patient #8's Insulin Flow Sheet revealed, in part, on 04/07/2023 at 06:40 CBG level result of 574. Review of Patient #8's medical record revealed orders to give insulin and recheck CBG and to call back with abnormal results. Further review of Patient #8's medical record revealed no documented evidence the patient's CBG was rechecked until 11:30.

Review of Patient #8's Insulin Flow Sheet revealed, in part, on 04/08/2023 at 11:30 CBG level result of 274 and insulin held due to nausea and vomiting. Further review of Patient #8's medical record revealed no documented evidence the patient's physician was notified that insulin was held due to nausea and vomiting.

In an interview on 04/20/2023 at 9:09 a.m., S6DCS confirmed Patient #8's medical record failed to contain documented evidence the patient's CBG was rechecked as ordered on 04/07/2023. S6DCS confirmed there was no evidence the physician was notified that insulin was held due to nausea and vomiting.

Patient #9:

Review of Patient #9's medical record revealed an admit date of 04/13/2023. Further review revealed Patient #9 was diagnosed, in part, with Dementia and Diabetes Mellitus.

Review of Patient #9's History and Physical Examination dated 04/14/2023 at 8:00 a.m. revealed, in part: Assessment/Plan: Diabetes Mellitus Type 2 with Hyperglycemia. Insulin sliding scale with coverage per protocol.

Review of Patient #9's medical record revealed, in part, no CBG level results from 04/13/2023 until 04/15/2023 at 06:00.

Review of Patient #9's medical record revealed a physician's order dated 04/15/2023 for insulin sliding scale with coverage per protocol.

Review of Patient #9's Oceans Practitioner's Orders Insulin Sliding Scale revealed, in part:
301-350 = 10 units.

Review of Patient #9's Insulin Flow Sheet revealed, in part, on 04/15/2023 at 06:00 CBG level result of 375 with no documentation of insulin given. Further review revealed no CBG level results 04/15/2023 at hour of sleep and 04/16/2023 prior to breakfast.

In an interview on 04/17/2023 at 2:44 p.m., S15RN, Director of Quality confirmed Patient #9 did not have capillary blood glucose monitored as ordered by the physician.

4) Failure to address a documented abnormal capillary blood glucose (CBG) level on 1 (#6) of 5 (#6 - #10) diabetic patient records reviewed.

Review of hospital b's policy titled "Glucometer Method for Obtaining CBGs", revealed, in part: Perform Blood Glucose Test-Directions, in part: Low result reading should be immediately reported to the physician or non-physician practitioner (NPP). Follow the Manufacturer's guide for identification of the low results. Other reasons to retest could be: in part: (1) A low blood glucose result but patient does not have symptoms of low blood sugar.
The nurse questions the result. Record results on CBG monitoring log. The results of any CBG testing performed by the MHT must be communicated to the licensed nurse by the MHT. The licensed nurse will document nursing interventions performed in progress notes.

Review of Patient#6's Insulin Flow Sheet revealed documentation that on 04/17/2023 at 4:30 p.m., Patient #6 had a CBG level of 18. Further review did not reveal evidence of a nurse's signature verifying the MHT communicated the result. Continued review revealed the next documented CBG level was 04/17/2023 at 9:00 p.m. A review of Patient #6's nurses' notes dated 04/17/2023 failed to reveal documentation addressing the abnormal CBG level noted on the Patient Insulin Flow Sheet.

In an interview on 04/19/2023 at 12:20 p.m., S6DCS stated that the nurse should have retested Patient#6's CBG level since the reading was documented at 18.

5) Failure to ensure that the CBG level was checked as ordered by the physician on 1 (#6) of 5
(#6 - #10) diabetic patient records reviewed.

Review of hospital b's policy titled "Glucometer Method for Obtaining CBGs", revealed, in part: Purpose: To establish procedural guidelines for obtaining capillary blood glucose levels (CBG's) for the purpose of diagnosis and treatment. Policy: CBG's will be performed with physician orders by licensed nursing staff and mental health tech (MHTs) who are deemed competent to perform the procedure.

Review of Patient #6's medical record failed to reveal a "Before bedtime" CBG level on 04/15/2023 and a "Before dinner" CBG level on 04/16/2023. A review of the nurses' notes on 04/15/2023 and 04/16/2023 failed to reveal a reason for neglecting to measure the CBG level on Patient #6.

In an interview on 04/19/2023 at 12:20 p.m., S6DCS confirmed that Patient #6 did not have a CBG level for "Before bedtime" on 04/15/2023 and "Before dinner" on 04/16/2023. S6DCS further confirmed that the nurses notes failed to reveal a reason why the CBG levels were not measured as per the physician's order.

Based on record review and interview, hospital b failed to ensure that staff followed the policies and procedures for the use of verbal orders. This deficient practice was evidenced by the failure of the ordering physician to sign verbal orders in 1 (#6) of 5 (#6 - #10) patients sampled for records review.
Findings:

A review of hospital b's policy titled "Verbal Orders", revealed in part:
Procedure, in part: 5. Prescribers will authenticate the order within the timeframes specific to the state in which the order is executed. Louisiana - within 10 days of date order is given.

A review of Patient #6's medical record revealed a verbal order on 04/07/2023 at 06:00 a.m. per S10RN for S11MD.
The order was for an Insulin Sliding Scale with Accuchecks AC & HS (30 minutes before scheduled meals).
Indications for use: Diabetes type II with Hyperglycemia. Further review failed to reveal S11MD signed the verbal orders.

In an interview on 04/19/2023 at 10:15 a.m., S6DCS confirmed the orders were not signed and stated that the physician should have signed the verbal orders since they were written over 10 days ago.

Based on record review and interviews, hospital b failed to ensure each patient had an individualized, comprehensive treatment plan for 3 (#6, #8, #9) of 5 (#6 - #10) patients sampled as evidenced by failing to include medical and nursing diagnoses as part of an individualized, comprehensive treatment plan.
Findings:

A review of hospital b's document titled "Treatment Planning: Integrated/Multidisciplinary", revealed, in part:
Purpose: To document and implement treatment objectives/interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of patient's treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided. Policy, in part: The multi-disciplinary treatment team, under the direction and supervision of the attending physician, shall develop an integrated written, comprehensive Treatment Plan with specific goals and objectives necessary to address deficits and cultivate strengths identified in the assessment process. Initiating individualized treatment problem/nursing diagnosis list as identified in the assessment. Revising and developing nursing and medical components of the treatment plan based on additional findings from patient assessments, problems, needs, strengths and limitations, and physician orders.

Patient #6:

A review of Patient #6's list of medical diagnoses included the following: Diabetes (Type II), GERD, HLD, HTN, PTSD, Right AKA (wheel chair bound), Bladder Cancer.

Further review of Patient #6's medical record revealed that on 04/19/2023 at 6:00 a.m., patient obtained a skin tear during transfer from bed to chair, requiring a gauze wrapping to right wrist in order to stop the bleeding.

A review of Patient #6's medical record revealed a document titled "Inpatient Treatment Plan Review and Update with Physician Certification". Further review failed to reveal evidence of identified physical problems including Type II Diabetes and an Above Knee Amputation (AKA-wheel chair bound).

In an interview on 04/19/2023 at 12:10 p.m., S8RN stated that the treatment plan should have included risk for unstable glucose level, impaired skin integrity and impaired physical mobility in order for the treatment plan to be individualized and complete.

Patient #9:

A review of Patient #9's list of medical diagnoses included the following: Diabetes Mellitus.

A review of Patient #9's Multidisciplinary Integrated Treatment Plan failed to reveal evidence Diabetes Mellitus was identified as a problem for the patient.

In an interview on 04/17/2023 at 2:44 p.m., S15RN, Director of Quality confirmed the treatment plan should have included Diabetes Mellitus.

Patient #8:

A review of Patient #8's list of medical diagnoses included the following: Diabetes Mellitus.

A review of Patient #8's Multidisciplinary Integrated Treatment Plan failed to reveal evidence Diabetes Mellitus was identified as a problem for the patient.

In an interview on 04/20/2023 at 9:57 a.m., S6DCS confirmed the treatment plan should have included Diabetes Mellitus.



47397

47397

Based on record reviews and interviews, hospital b failed to ensure patient rights were being addressed and protected for 2 (#6, #8) of 5 (#6 - #10) sampled patients. This deficient practice is evidenced by the failure of hospital b to allow Patient #6 to verify the document containing a written list of his possessions and by the failure of hospital b to have evidenced Patient #8's possessions were returned when discharged.
Findings:

A review of hospital b's policy titled "Patient Rights Louisiana" revealed, in part:
Policy: Every client shall receive a written copy of the Patient Rights and sign the "Acknowledgment of Rights" form stating they reviewed and understand their rights. Authorization and Informed Consent Form, in part: Valuables, in part: I acknowledge that Oceans Behavioral Hospital respects the right of an individual to keep in their possession certain valuables (such as money, credit cards, jewelry, etc). However, we encourage all patients to send valuables home or allow us to lock them in the safe.

Patient #6:

Review of Patient #6's medical records revealed a document titled "Inventory of Patient Possessions" labeled with the first name and first initial of Patient #6's last name on the document. Continued review revealed written statements "See 2nd sheet for meds" and "See 3rd sheet for wallet, etc". Review of medical record failed to reveal evidence of the "2nd sheet" and the "3rd sheet". Further review failed to reveal that Patient #6 confirmed and verified the "Inventory of Patient Possessions" document with his signature. Review of medical records failed to reveal a reason as to why the document was not signed.

In an interview on 04/19/2023 at 1:30 p.m., S6DCS confirmed the document containing a list of Patient #6's possessions failed to reveal Patient#6 confirmed and verified the Inventory of Patient Possessions. S6DCS confirmed that she could not locate the "2nd sheet" and the "3rd sheet" in the medical record.

Patient #8:

Review of Patient #8's medical records revealed a discharge date of 04/08/2023.

Review of Patient #8's medical records revealed a document titled "Inventory of Patient Possessions. Continued review revealed a description of belongings that included, in part, silver rings, black sports watch, shirts, pants, socks, and shoes. Further review failed to reveal that Patient #8's items and possessions were returned when discharged.

In an interview on 04/20/2023 at 9:59 a.m., S6DCS confirmed there was no evidence Patient #8's possessions were returned since discharged.

Based on record review and interview, hospital b failed to provide adequate staffing as evidenced by not hiring nursing personnel with education, experience and/or training in psychiatric care.
Findings:

A review of S14RN's personnel file revealed a date of hire, 03/28/2023. Further review of S14RN's resume failed to reveal education, experience and/or training in psychiatric care.

In an interview on 04/19/2023 at 6:20 p.m., S9RHRD confirmed that S14RN had no psychiatric experience, Training or education.