HospitalInspections.org

Based on interview and record reviews, the hospital's Governing Body failed to ensure the medical staff had written policies and procedures for appraisal of emergencies, initial treatment, and referral when appropriate, that was hospital-wide for hospitals that did not have a dedicated Emergency Department.
Findings:

A review of the hospital's Policy and Procedure titled, "Life Threatening Emergencies", provided by S3RN/IC/QA, as the most current, revealed a policy pertaining to the assessment of patients in emergency situations. A further review of the policy revealed no documented evidence for a procedure for the appraisal of emergencies, initial treatment, and transfer as appropriate for emergency situations pertaining to staff, visitors, or walk-in persons entering the hospital with an emergency.

A review of the hospital's Policy and Procedure titled, "Code Blue", provided by S3RN/IC/QA, as the most current, revealed guidelines to be followed in the event of a life threatening situation to assure prompt and skilled cardiopulmonary resuscitation of a patient while on the premises of the hospital campus. A further review of the policy revealed no procedure for the appraisal of emergencies, initial treatment, and transfer as appropriate for any emergency in the hospital, other than hospital patients.

In an interview 8/05/15 at 3:45 p.m. with S1CEO, she indicated that she was a member of the Governing Body. S1CEO was asked about the hospital's policies on Emergency Services. S1CEO indicated that the hospital did not have a dedicated Emergency Room. She indicated that the hospital had a policy for the appraisal for emergencies, initial treatment, and referral when appropriate, for emergency situations. On review of the hospital policy, S1CEO indicated that the policy only addressed emergency situations that involved a hospital patient and that the policy did not address emergency situations involving staff, visitors, or walk-in persons entering the hospital with an emergency. S1CEO indicated that the Medical Staff had no other policy in place that addressed a hospital-wide policy for emergency situations involving any other emergency situations, other than patient emergencies.

Based on observations, interviews and record reviews, the hospital failed to meet the requirements for the Condition of Participation of Patient's Rights as evidenced by:
1) Failing to ensure patients with physician orders for suicide precautions were being monitored at the observation level set forth per hospital policy and
2) Failing to ensure the physical environment at the main campus did not afford patients who had been identified as at risk for injury to themselves or others opportunities for injury to themselves or others. (See findings in tag A-0144).

An Immediate Jeopardy Situation was identified on 8/6/15 at 5:00 p.m. due to the hospital:
1) Failing to ensure patients with physician orders for suicide precautions were being monitored at the observation level set forth per hospital policy;
2) Failing to ensure the physical environment at the main campus did not afford patients who had been identified as at risk for injury to themselves or others opportunities for injury to themselves or others. (See findings in tag A-0144).

1) Failing to ensure patients with physician orders for suicide precautions were being monitored at the observation level set forth per hospital policy.
Review of the hospital policy titled "Suicide", effective 05/01/11, revised 06/01/15, and presented on 08/04/15 as a current policy by S3RN/IC/QA (registered nurse/infection control/quality assessment), revealed that a patient who is assessed at the time of admission by staff as suicidal will have suicide precautions initiated by the nursing staff or therapist. The nursing staff will then call the physician for an order. Further review revealed that the patient must at least be in the sight of staff at all times, and patients who are actively suicidal will be placed on a 1:1 (one-to-one) observation level. The assigned staff member must document the patient's behavior, emotional status, activity level, and significant verbalization in the progress notes. Review of the entire policy revealed no documented evidence whether the suicide risk assessment had to be performed by a RN or a LPN (licensed practical nurse).
Review of the hospital policy titled "Suicidal Behavior-SBC/Metairie (Seaside Behavioral Center/Metairie)", effective 05/01/11, revised 03/24/14, and presented as a current policy on 08/07/15 at 11:50 a.m. by S3RN/IC/QA, revealed that within 8 hours of admission and every shift thereafter, a suicide risk assessment will be completed on every patient as a part of the Nursing Assessment. A patient assessed as suicidal will have suicide precautions initiated by the nursing staff or therapist. The nursing staff will then call the physician for an order. If the patient is a potential risk for suicide, he/she will be placed on a higher level of observation to ensure safety of the patient. The assigned staff member documents the patient's behavior, emotional status, activity level, and significant verbalization in the progress notes. Patients who are actively suicidal will be placed on an observation level of 1:1, and the attending physician will be notified. The suicidal behavior is listed as a problem in the treatment plan with all of the expected objectives and staff interventions documented. The RN progress note will include daily assessment of suicidal potential. The RN discharge note will include assessment of suicidal potential, and the patient will be offered a safety contract to sign.

Main Campus:
Patient #2
On 8/6/15 at 10:00 a.m., Patient #2 was observed to be in his room with the door closed. Review of the patient's medical record revealed the patient had orders for suicide precautions. He was not in line of sight of staff at that time as required by hospital policy. Review of the staff patient assignment sheet revealed S25MHT was assigned to observe the patient. S25MHT was interviewed and asked if she was assigned to Patient #2 and she replied, "I think so." She also replied that she had not known the patient was on suicide precautions. She was asked to show the surveyor her observation sheets at that time and they were observed to be blank from 7am-10 am. She indicated she had not had time to fill out the sheets. She also indicated she was assigned to observe 6 other patients. 2 of the 7 patients she was observing were on line of sight precautions for suicide. She was asked what type of supervision was required per hospital policy for patients on suicide precautions and she replied, "1:1 observation".
Review of the day shift assignment sheet for 8/6/15 revealed the patient assignments contained only the first name of the patients and had no documented evidence of the type of precaution or the observation level of each patient.
In an interview on 8/6/15 at 11:15 am. with S3RN/IC/QA (Assistant Administrator), he was informed of the above referenced observations and he indicated S25MHT was in need of further training.
On 8/6/15 at 1:05 p.m. S25MHT was observed (after S3RN/IC/QA-Assistant Administrator had indicated S25MHT required further training) seated outside of the dayroom, observing patients who had not gone outside for a smoke break. Review of the 7 patients' observation logs revealed no documented observations from 12:45 p.m. -1:15 p.m. The 7 patients referenced above were on every 15 minute observations. 1 of the patients was on suicide precautions.

Patient #8
In an observation on 8/4/15 at 10:20 a.m., Patient # 8, (a new admission admitted on 8/4/15 who had attempted suicide) with physician orders for suicide precautions, was observed pacing the hallway. He was not in direct line of sight of any of the staff members.
In an observation on 8/4/15 at 10:30 a.m. Patient # 8 was observed at the far end of the hall, at the door. He was not in direct line of sight of any of the staff members.
In an observation on 8/4/15 at 11:30 a.m. Patient # 8 was observed seated in the hall. He was not in direct line of sight of any of the staff members.
Patient #7
In an observation on 8/4/15 at 1:45 p.m. revealed Patient #7 (a new admission admitted on 8/4/15 who had attempted suicide) with physician orders for suicide precautions, seated in a chair in the hall, outside the dayroom, with the MHTs back facing Patient #7. Patient #7 was not in the line of sight of any staff member.

Off-site campus:
In an interview on 8/5/15 at 10:55 a.m. S22MHT indicated Patient #13 (who had physician orders for suicide precautions and was to be on line of sight observation) was allowed to be in his room unobserved when he did not attend group therapy. He further indicated that patients on line of sight were allowed in the bathroom with the door closed without a staff member present.
S22MHT indicated that he was assigned to observe patients who were using the phone. During that time he had not documented observations on Patient #13. He indicated during the interview that he thought all patients were on routine (every 15 minute) precautions. He said he was not told Patient #13 was on suicide precautions that morning in report.
Review of the observation sheet on 8/5/15 at 10:55 a.m. by the surveyor for Patient #13 revealed the last observation documented was at 9:30 a.m. on 8/5/15.

2) Failing to ensure the physical environment at the main campus did not afford patients who had been identified as at risk for injury to themselves or others opportunities for injury to themselves or others.
Observations on 8/3/15 from 11:50 a.m. - 1:15 p.m. on the main campus (24 bed, locked in-patient psychiatric unit) with S6Dir HR/HIM revealed the following risks to safety:
A.1.Bathrooms in all patient rooms were not directly visualized from the hallway enabling patients the opportunity to be in an area unobserved by staff;
The toilets in all rooms, except room #2, was noted to have exposed plumbing- pipe flush valves with flanged handle- potential ligature risk;
Exposed plumbing under the sink was observed in patient rooms, except for room #2, -potential ligature risks;
Sink with elongated faucet and flanged handles - potential ligature risk;
Patient grab bar open widely enough to facilitate ligature risk.
B.1.Entry door and bathroom door secured with 3 hinges on each door, separated widely enough to facilitate potential ligature points;
2. Door handle on bathroom positioned in a sideways fashion, facilitating potential ligature risk;
3. Room entry door handle positioned, on the back side of the door in a downward fashion, facilitating ligature risk.
C. Free standing clothing closet with 2 doors noted to have 6 interior hinges (3 per door) -potential ligature risk, 2 drawer pulls (non-flush, metal handles): potential ligature risk or potential weapon if removed.
D. 6 of 19 total patient units, which contained potential ligature risks, were separated into 2 separate rooms with interior doors that could not be directly visualized from the hallway.
During the interview on 8/5/15 at 11:15 a. m. with S3RN/IC/QA (Assistant Administrator), he indicated there was a lack of staff training by the prior DON that was identified after she left 2 weeks ago. He further indicated that an action plan had been developed, but not implemented, to train staff.

1st Corrective Action Plan for Lifting of IJ
S3RN/IC/QA (Assistant Administrator) and S6DirHR/HIM presented the first corrective action plan to lift the Immediate Jeopardy Situation on 8/7/15 at 9:20 a.m. The plan was reviewed by the survey team and was rejected due to the plan not addressing mitigation of risk to patients until all of the identified physical environment safety risks had been removed and observations made, by the survey team, of failed compliance of the staff with supervision of patients and maintenance of patient levels of observation. The survey team's concerns were addressed during the meeting with S3RN/IC/QA and S6DirHR/HIM. The concerns discussed with S3RN/IC/QA and S6Dir HR/HIM are referenced below:
In an interview on 8/07/15 at 9:20 a.m. with S3RN/IC/QA and S6Dir HR/HIM, after the 1st attempt to lift the IJ was presented to the team, they indicated that that all staff were in-serviced on the suicide and precaution policies on 8/07/15 prior to their shifts and that all staff signed the attendance sheet and a sheet indicating that they understood the policies. S3RN/IC/QA and S6DirHR/HIM were told that the team, through further staff interviews and observations, had concerns regarding staff understanding of the policies on suicide and precautions since staff interviewed were still not understanding the content of the in-service. They were also told that the patients who were identified as being on suicide precautions were still unclear and that the team would need further clarification. S3RN/IC/QA and S6DirHR/HIM were informed that a plan for mitigation of patient safety risk needed to be devised to protect patients until all environmental safety risks had been corrected.
In an interview on 8/7/15 at 10:00 a.m. with S3RN/IC/QA (Assistant Administrator) he indicated the hospital had attempted to re-educate S25MHT on precaution levels, suicide precautions and the importance of accurate and timely documentation on patient observation logs. He said S25MHT told Administrative staff attempting to re-educate her that patient care was her priority and not paperwork. S3RN/IC/QA told the survey team S25MHT had been terminated.
Documentation of staff in-services, titled: " Suicidal /Homicidal Precautions " was presented by S3RN/IC/QA and it was reviewed by the team. The in- services provided in depth information related to assessment of suicidal/homicidal risk on admission, members of the treatment team who can initiate suicidal/homicidal precautions and the need for obtaining a physician ' s order for the precautions after being notified of the patient ' s new status. The staff education also covered hand-off report of patient levels of observation, accurate documentation on observation sheets regarding precaution type and level of observation, and staff responsibilities for preparation of observation sheets. Staff was instructed to keep patients on suicidal/homicidal precautions in line of sight at all times. They were instructed that patients on suicidal/homicidal precautions were not allowed to go to the bathroom unattended and were not allowed to go to their rooms with the door closed, unless attended by staff. Nursing staff was instructed that only a RN can assess patients for suicidal/homicidal precautions on a daily basis and the RN staff is the only staff that can document the daily assessments in the patient ' s record. Hospital staff was also instructed that the RN Charge Nurse was responsible for accurate documentation, on the daily assignment sheet, of patient precautions (listed by the patient ' s name). Staff was also instructed to place actively suicidal patients on 1:1 observation level. Each staff member was given a copy of the policy with an attestation indicating they had been given a copy of the Policy and Procedures for Suicide Precautions, Homicide Precautions and Special Precautions. The attestation indicated that the staff member understood that any violation of the policy/procedures referenced above was grounds for immediate termination. Each box referencing parts of the policy was initialed by staff and the attestations were signed and dated by the staff members.
The corresponding staff sign in sheets from both campuses (main and offsite) were also reviewed.
Review of Patient #8's medical record on 08/07/15 revealed a physician's order was obtained on 08/06/15 at 9:00 p.m. to discontinue Suicide precautions. There was no documented evidence that a RN had performed the suicide risk assessment prior to calling to discontinue the orders. Patient #8 complained of being suicidal at 10:00 p.m. and had to be placed on Suicide precautions again.
In an interview on 08/07/15 at 9:05 a.m., S3RN/IC/QA confirmed the suicide risk assessment on 08/06/15 for Patient #8 was performed by a LPN and not a RN.
In an interview on 08/07/15 at 10:10 a.m., S28MHT indicated he was never assigned to observe Patient #8 who was on Suicide Precautions and thus had to be in a staff member's sight at all times. Review of S28MHT's "Observation Log" at 10:10 a.m. for the 6 patients he was observing revealed he had not documented since 8:15 a.m.
In an interview on 08/07/15 at 11:00 a.m., S29MHT indicated he had no patients assigned to him for observations.
Observation on 08/07/15 at 11:15 a.m. in the day room revealed Patient #8, who was supposed to be within sight of staff at all times, was blocked from view of S28MHT by someone sitting on the arm of the sofa. This observation was confirmed by S28MHT.
On 08/07/15 at 1:32 p.m. observations/interviews/record reviews were conducted at the offsite location of the hospital in an attempt to lift the Immediate Jeopardy Situation. The census on the offsite campus was 16. None of the 16 patients were on any type of special precautions. All 16 patients were being observed every 15 minutes.
Did you have any type of post-test/competency testing after the training? Yes, post-test given, S4DON has the test and results. (Reviewed-all staff given post-test and passed).
In an interview on 08/07/15 at 1:32 p.m., S4DON indicated the unit had 16 patients and all of the patients were on every 15 minutes checks. S4DON indicated staff had been given a post test after being re-educated on the suicide, homicide and special precautions policies. He also indicated all staff had achieved a passing score on the test.
The staff tests were reviewed by the surveyor conducting the site visit and all staff had achieved a passing score.
Staff interviews/observations were conducted at the offsite campus on 8/7/15 from 1:32 p.m. to 2:30 p.m. Staff was observed performing q (every) 15 minute checks. Observational logs were reviewed and were noted to be completed. Staff (S40RN, S41LPN, S22MHT, S42MHT, and S43MHT) who were working 8/7/15 were interviewed regarding suicide, homicide, special precautions policies, observation levels and accuracy of patient information documented on observation logs. No concerns to keep IJ in place at the Off-site.
The Suicide Precautions Competency Test provided to staff currently working was reviewed and all staff passed the test. Test date 8/7/15.
2nd Corrective Action Plan for Lifting of the IJ:
S3RN/IC/QA (Assistant Administrator) and S6DirHR/HIM presented the second corrective action plan to lift the Immediate Jeopardy situation on 8/7/15 at 3:20 p.m. The plan was reviewed by the survey team and was rejected due to concerns with the issues referenced below. The team's concerns were discussed with S3RN/IC/QA and S6Dir HR/HIM during the meeting:
In an interview on 08/07/15 at 2:10 p.m., S30MHT indicated she had training yesterday at the off-site campus. She further indicated she received no further training since she arrived at the main campus this morning. She indicated she went to take a test a short while ago, but she didn't have any training before taking the test.
In an interview on 08/07/15 at 2:12 p.m., S44MHT indicated he received training on suicide precautions yesterday and had a review this morning before the surveyors arrived. He further indicated he had not had any further training since the review done at the beginning of his shift this morning.
In an interview on 8/07/15 at 3:20 p.m. with S3RN/IC/QA and S6Dir HR/HIM, after the 2nd attempt to lift the IJ was presented to the team, they indicated that that all staff were rein-serviced on the suicide and precaution policies again and that the staff was given a post-test to demonstrate understanding of the suicide and precaution policies. S3RN/IC/QA and S6Dir HR/HIM were told that the team, again through further staff interviews and observations, had concerns regarding staff understanding of the policies on suicide and precaution policies since staff interviewed were still not understanding the content of the in-service. S3RN/IC/QA and S6DirHR/HIM were also told that the team had concerns regarding the hospital's plan to monitor continued compliance of the suicide and precaution policies and concerns with the mitigation of the identified environmental suicide ligature risks that had not been modified at this time.
3rd Corrective Action Plan for lifting of the IJ
S3RN/IC/QA (Assistant Administrator) and S6DirHR/HIM presented a third corrective action plan to lift the Immediate Jeopardy Situation on 8/7/15 at 4:20 p.m. The plan was reviewed by the survey team and was rejected due to concerns with the following issues referenced below. The team ' s concerns were discussed with S3RN/IC/QA and S6DirHR/HIM during the meeting:
In an interview on 8/07/15 at 4:20 p.m. with S3RN/IC/QA and S6Dir HR/HIM, after the 3rd attempt to lift the IJ was presented to the team, they indicated that the identified staff (staff the team had concerns with regarding understanding of levels of observation and types of precautions) were again re-inserviced and the staff indicated they had misunderstood the surveyors questions. S3RN/IC/QA and S6Dir HR/HIM were told that the team still had concerns regarding the hospital ' s plan to monitor continued compliance at 90%-100% compliance for the suicide and precaution policies. S3RN/IC/QA indicated that 90%-100% was the hospital's benchmark criteria and S3RN/IC/QA indicated that he would adjust the benchmark criteria to be 100% until compliance was met.

4th Corrective Action Plan for Lifting of the IJ:
As a result of the fourth plan for lifting the Immediate Jeopardy, presented on 8/7/15 at 5:05 p.m. by S3RN/IC/QA (Assistant Administrator) and S6DirHR/HIM, the Immediate Jeopardy Situation was removed on 8/7/15 at 5:25 p.m. The fourth corrective action plan, instituted by the hospital, is outlined below:
1. Failing to ensure patients with physician's orders for suicide precautions were being monitored at the observation level set forth per hospital policy:
Corrective Actions:
All staff at both facilities will be re-educated regarding suicide, homicide, and special precautions immediately. A meeting was held with the staff at 6:45 p.m. on 8/6/15 and 7:00 a.m. on 8/7/15. Policies were explained to staff, employees signed off acknowledging that they understood the policies, and copies of the policies were given to each staff member. Only RN ' s can conduct suicide risk assessments. We will continue educating staff on each shift until 100% of the staff have been re-educated. No employees will be allowed to work until they have been in-serviced.
Administrator, DON, and/or ADON will be responsible for monitoring on a daily basis all patients that are required to have suicidal or homicidal precautions. This will be conducted on 100% of the patient records. A tool will be created immediately that will address who is immediately at risk, who is assigned to the suicidal patient for visual contact, who the lead mental health technician/floater is, and was presented to the Governing Board for approval to do these daily checks. Daily audits on observation sheets and environmental rounds will be conducted at 100% of all records and any issues that are identified, staff member will be disciplined accordingly. The identified issues will be presented in in-services with staff to resolve any safety issues.
This will be added to the Quality Assurance and Performance Improvement Program and be monitored on a daily basis utilizing the Administrative Suicide Prevention Monitoring Tool, and will be presented in our monthly QA/PI meeting for three months. At the end of the three month period, we will re-assess compliance with all suicidal precautions, observation sheets and environmental rounds. If success was accomplished, we will begin conducting audits twice a week on open patient charts, utilizing the Administrative Suicide Prevention Monitoring Tool. As long as no problem is found, this will continue on an ongoing basis indefinitely to ensure continued compliance. If compliance is not maintained at 100%, reassessment of procedures and monitoring will occur and any new implementation to continued success will be implemented and monitored. The process will be the same as above and monitored in QA/PI for continued success.
A second education was given to all staff that were present on the unit, allowing them to ask any questions and respond to their questions. They were also given a competency Test to ensure that they understood the policy and our expectations regarding Suicidal precautions. Target date for all staff to be trained on Suicide Precautions Policies and procedures: 8/14/15. Responsible Party: S3RN/IC/QA, S4DON and S36RN.
2. Failing to ensure the physical environment at the main campus did not afford patients who had been identified as at risk for injury to themselves or others opportunities for injury to themselves or others.
Corrective Actions:
The CEO (Chief Executive Officer) of the hospital has notified the following people with corporate office: CEO, CFO (Chief Financial Officer), and the Vice President of the Corporation. Financial approval has been given to begin repairs immediately. The bid process has been waived due to the emergent situation. Repairs will begin immediately.
All plumbing pipe-flush valves with flanged handles will be covered.
Exposed plumbing under the sink will be covered.
Sink faucets will be changed to anti-ligature faucets.
Patient grab bars in patient rooms will be changed to anti-ligature.
Door handles will be changed to anti-ligature door handles.
Doors and hinges will be removed from patient clothing closet. Also drawer pulls will be changed to flush drawer pulls.
All door hinges in the entire unit need to be anti-ligature and will be changed.
Bathtub in patient ' s room needs to be removed or covered with a wooden box. Plumbing has already been disengaged.
All vents will be replaced with screen vents.
All pull handles on windows in patient rooms will be removed.
Repairs will begin immediately. Maintenance man is in the process of removing cabinet doors, hinges, and drawer pulls on all armoires in patients ' rooms. This will be completed today, 8/7/15.
Our goal is to mitigate with respect to the unrepaired environmental issues. As part of environmental rounds, each shift will be assessing all potential ligature risk and points to prevent any suicide attempts and to ensure patient safety.
We will be increasing staffing to have extra MHT classified as Lead Tech (LT) to be floating throughout the unit to monitor patient rooms that have ligature points to ensure patient safety. This assignment for the floating lead MHT is within the scope of his/her job description. The lead MHT will also be required to assist with relief of other MHTs for lunch/breaks, will also be required to retrieve lunch and serve food for patients, and to assist the other MHTs with patient care, including bathroom assistance. If at any point all MHTs are assisting clients or staff, the lead MHT will notify charge RN for assistance in monitoring patients. The Charge RN will adjust assignments accordingly, allowing nurses and techs to work as a team to monitor patient safety. If assistance is needed beyond the present staff, the charge nurse will notify the administrative team for administrative support in monitoring for patient safety.
To ensure the safety of all of our clients until the above items have been fixed the following will be done:
Anyone on suicide precautions will be placed on visual contact. At night, the patients will be placed in split rooms/semi-private rooms with a tech in place to have visual line of sight on both patients. This staff member will only be assigned to these two individuals. If a patient has to use the restroom, the tech monitoring will contact the lead MHT to monitor the other patient while attending the patient in the restroom.
Target date for completion: 9/7/15, Responsible parties: S1CEO, S3RN/IC/QA and S6DirHR/HIM.
There will be an emergency Board meeting today at 12:00 noon for the Board to review and approve any necessary policy changes or forms needed to lift Immediate Jeopardy status. The Board members present at the teleconference meeting will be as follows: CEO, President of the Board, CEO of the Hospital (Corporate level), COO (Chief Operating Officer), CFO (Chief Financial Officer). Information presented by S3RN/IC/QA and S6DirHR/HIM.
On 8/7/15 at 2:00 p.m. a tour was conducted at the main campus (no environmental safety risk issues identified at the offsite location) to observe the hospital 's actions to initiate removal of environmental safety/ligature risks at the main campus. The cabinet doors, hinges, and drawer pulls on all armoires in patients ' rooms and the window handles were removed in half of the patient rooms at the time of the tour. The hospital had increased staffing by adding a fourth MHT (mental health technician) and the lead MHT was conducting environmental rounds every 15 minutes.

The immediacy had been lifted though there was not enough evidence to determine sustainability of Compliance for the Condition of Patient Rights to be cleared. Non-compliance remains at the Condition level. (See findings in tag A-0144).

Based on record reviews and interview, the hospital failed to ensure patients were provided written notice that there was no doctor of medicine or osteopathy present in the hospital 24 hours per day, seven days per week, in accordance with 42CFR 489.20(w). This deficient practice was evident in 19 (#1 - #19) of 19 patient records reviewed and could affect all future inpatients admitted to the hospital.
Findings:

No policy that addressed informing inpatients in writing that the hospital did not have a doctor of medicine or osteopathy present in the hospital 24 hours per day, seven days per week, was presented as of the conclusion of the survey on 08/07/15.

Review of the medical records of Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19 revealed no documented evidence that any of the patients had been informed in writing that the hospital did not have a doctor of medicine or osteopathy present in the hospital 24 hours per day, seven days per week.

In an interview on 08/04/15 at 10:50 a.m., S3RN/IC/QA (registered nurse/infection control/quality assessment) confirmed the hospital did not have a process in place or a policy developed that addressed informing inpatients in writing that the hospital did not have a doctor of medicine or osteopathy present in the hospital 24 hours per day, seven days per week.

Based on record reviews and interviews, the hospital failed to ensure the staff implemented its advance directive policy for 2 (#4, #10) of 7 (#1, #2, #3, #4, #10, #12, #13) patient records reviewed for advance directives from a total sample of 19 patients as evidenced by failure to obtain a copy of Patient #10's advance directive and failure to develop a policy that addressed "do not resuscitate" (DNR) orders written for Patient #4.
Findings:

Review of the hospital policy titled "Advance Directives", presented as a current policy by S3RN/IC/QA (registered nurse/infection control/quality assessment), revealed that if the patient has a Living Will, the information will be placed in the patient's chart and made known to all who are involved in the patient's care and treatment. If the patient does not have the Living Will with him/her at the time of admission, they either must provide a copy within 24 hours or choose to execute a new/duplicate directive.

Review of the policy titled "Death of a Patient", presented as the only policy that addressed DNR by S3RN/IC/QA, revealed no documented evidence that the policy addressed the procedure for making a patient a DNR and addressed the pronouncement of death of a patient with a DNR order.

Administrative staff of the hospital presented no policy regarding DNR by the completion of the survey on 08/07/15.

Patient #4
Review of Patient #4's medical record revealed he was a 72 year old male admitted on 07/27/15 with diagnoses of Chronic Paranoid Schizophrenia, GERD (Gastroesophageal Reflux Disease), Epilepsy, Hypertension, and COPD (Chronic Obstructive Pulmonary Disease).

Review of Patient #4's "Advance Directive Evaluation", witnessed by S33RN on 07/27/15 at 5:00 p.m., revealed a hand-written note at the top of the form of "pt. (patient) is DNR - need paperwork." Further review revealed Patient #4 did not have an advanced directive, and a check was placed in the "Yes" box for CPR (cardiopulmonary resuscitation), respirator, tube feeding, kidney dialysis, hospice care, and pain medication. Further review revealed "refused to sign" was written on the "Patient Signature" line.

Review of Patient #4's "Physician's Admit Orders & (and) Admit Note" dated 07/27/15 revealed "DNR" was checked.

Review of Patient #4's medical record revealed no documented evidence of a clarification of Patient #4's status regarding resuscitation.

In an interview on 08/07/15 at 1:50 p.m., S19MedDir (Medical Director) reviewed Patient #4's medical record and confirmed he didn't document a discussion with Patient #4 or his family members regarding Patient #4 being a DNR. He indicated sometimes the medical doctor may discuss DNR. After further review of the chart, S19MedDir confirmed no physician had documented a discussion regarding DNR with Patient #4 or his family.

Patient #10
Review of Patient #10's medical record revealed he was a 41 year old male admitted on 07/28/15 with a diagnosis of Dementia with Behavioral Disturbance. Review of Patient #10's "Advance Directive Evaluation", witnessed by S34RN on 07/28/15 at 10:00 p.m., revealed he had an advance directive for health care, but it was not on the chart.

Review of Patient #10's "Physician's Admit Orders & Admit Note" dated 07/28/15 at 6:00 p.m. revealed an order for "Full Code."

Review of Patient #10's medical record revealed no documented evidence that his advance directive for health care had been obtained for the chart or that a new/duplicate directive had been executed within 24 hours of admission as required by hospital policy.

In an interview on 08/05/15 at 3:30 p.m. with S11LPN (licensed practical nurse) and S4DON (Director of Nursing) present, S11LPN indicated Patient #10 was a "full code". S4DON indicated he couldn't say Patient #10 was a "full code" without having the advance directive for health care to review. S4DON confirmed there was a discrepancy regarding Patient #4's code status. S11LPN indicated she was Patient #4's nurse on the day of this interview, and she wasn't aware Patient #4 had a physician's order for DNR.

Based on record reviews, observations and interviews, the hospital failed to ensure patients identified at risk for harm to self or others were provided care in a safe setting as evidenced by:
1) failing to ensure patients with physician orders for suicide precautions were being monitored at the observation level set forth per hospital policy (main campus and offsite campus) for 4 (#2, #7,#8,#13) of 4 psychiatric patients reviewed out of a total sample of 19.
2) failing to ensure the physical environment at the main campus did not afford patients who had been identified as at risk for injury to themselves or others opportunities for injury to themselves or others. This deficient practice had the potential to affect all 23 current psychiatric patients on the main campus out of a total capacity for 24 psychiatric patients.
3) failing to ensure a confused (oriented only to self), elderly patient with a diagnosis of Dementia was not placed in a room (main campus) with a bathtub, facilitating a potential risk for drowning, ligature and falls for 1 (#9) of 1 psychiatric patients reviewed out of a total sample of 19.
4) failing to ensure an unsecured, open, wide mouth sharps container containing razors and needles was not within reach of patients admitted to the psychiatric unit.
5) failing to ensure a psychiatric patient (offsite campus) was not in possession of any contraband items (drawstring waist scrub pants) for 1 (#15 ) of 1 patient out of 21 total patients observed on the offsite campus.
Findings:
1) failing to ensure patients with physician orders for suicide precautions were being monitored at the observation level set forth per hospital policy (main campus and offsite campus) for 4 (#2, #7,#8,#13) of 4 psychiatric patients reviewed out of a total sample of 19
Review of the hospital policy titled "Suicide", effective 05/01/11, revised 06/01/15, and presented on 08/04/15 as a current policy by S3RN/IC/QA (registered nurse/infection control/quality assessment), revealed that a patient who is assessed at the time of admission by staff as suicidal will have suicide precautions initiated by the nursing staff or therapist. The nursing staff will then call the physician for an order. Further review revealed that the patient must at least be in the sight of staff at all times, and patients who are actively suicidal will be placed on a 1:1 (one-to-one) observation level. The assigned staff member must document the patient's behavior, emotional status, activity level, and significant verbalization in the progress notes. Review of the entire policy revealed no documented evidence whether the suicide risk assessment had to be performed by a RN or a LPN (licensed practical nurse).
Review of the hospital policy titled "Suicidal Behavior-SBC/Metairie (Seaside Behavioral Center/Metairie)", effective 05/01/11, revised 03/24/14, and presented as a current policy on 08/07/15 at 11:50 a.m. by S3RN/IC/QA, revealed that within 8 hours of admission and every shift thereafter, a suicide risk assessment will be completed on every patient as a part of the Nursing Assessment. A patient assessed as suicidal will have suicide precautions initiated by the nursing staff or therapist. The nursing staff will then call the physician for an order. If the patient is a potential risk for suicide, he/she will be placed on a higher level of observation to ensure safety of the patient. The assigned staff member documents the patient's behavior, emotional status, activity level, and significant verbalization in the progress notes. Patients who are actively suicidal will be placed on an observation level of 1:1, and the attending physician will be notified. The suicidal behavior is listed as a problem in the treatment plan with all of the expected objectives and staff interventions documented. The RN progress note will include daily assessment of suicidal potential. The RN discharge note will include assessment of suicidal potential, and the patient will be offered a safety contract to sign.
In an interview on 08/07/15 at 11:50 a.m., S3RN/IC/QA indicated the suicide policy he had presented on 08/04/15 had not been approved by the Governing Body. He further indicated the policy titled "Suicidal Behavior-SBC/Metairie" should have been the policy presented as the current policy to be implemented by the staff.
Patient #2 Review of Patient #2 ' s medical record revealed he was a 55 year old male, admitted on 7/24/15. His legal status was PEC (physician emergency certificate) with an admission diagnosis of depression and suicidal ideation. Further review revealed he was placed on suicide precautions with a level of observation of q (every) 15 minutes.
Review of Patient #2 ' s Psychiatric Evaluation, dated 7/24/15, revealed the following mental status examination, in part: The patient is a depressed, sad, rather weak looking white male. He is talkative. He wanders in his conversation. He is generally depressed, sad, expresses his ideas of hopelessness and helplessness. He says, " I got here before I could do anything to kill myself, I don ' t want to go to that point, but if I didn't ' t come over here, I will be making some plans to kill myself " . The patient says he feels hopeless, helpless, and worthless. He does not feel like his life is going anywhere. He cannot deal with the stress, which he has been going through and the grief, which he is going through.
On 8/6/15 at 10:00 a.m., Patient #2 was observed to be in his room with the door closed. Review of the patient ' s medical record revealed the patient had orders for suicide precautions. He was not in line of sight of staff at that time as required by hospital policy. Review of the staff patient assignment sheet revealed S25MHT was assigned to observe the patient. S25MHT was asked if she was assigned to Patient #2 and she replied, " I think so. " She also replied that she had not known the patient was on suicide precautions. She was asked to show the surveyor her observation sheets at that time and they were observed to be blank from 7am-10 am. She indicated she had not had time to fill out the sheets. She also indicated she was assigned to observe 6 other patients. 2 (Patient #2 and Patient # R2) of the 7 patients she was observing were on line of sight precautions for suicide. She was asked what type of supervision was required per hospital policy for patients on suicide precautions and she replied, " 1:1 observation " .
Review of the day shift assignment sheet for 8/6/15 revealed the patient assignments contained only the first name of the patients and had no documented evidence of the type of precaution or the observation level of each patient.
In an interview on 8/6/15 at 10:35 a.m. with S3RN/IC/QA (Assistant Administrator), he indicated patients on suicide precautions were not to be allowed to go to their rooms unattended and certainly they should not be in their rooms with the door closed. He also indicated the patients were not allowed to go to the bathroom unattended. He indicated the night shift lead MHT (mental health technician) prepared the observation sheets for each patient with level of observation and precautions filled in for the oncoming day shift. He said the techs reported off to each other. He confirmed the MHTs were not in report with the nurses. He indicated patient ' s status/type of precautions was on the census board. He confirmed the MHT assignment sheets, at this time, did not have information indicating level of observation or precautions.
In an interview on 8/6/15 at 11:15 a.m. with S3RN/IC/QA (Assistant Administrator), he was informed of the above referenced observations and he indicated S25MHT was in need of further training.
On 8/6/15 at 1:05 p.m. S25MHT was observed (after S3RN/IC/QA-Assistant Administrator had indicated S25MHT required further training) seated outside of the dayroom, observing patients who had not gone outside for a smoke break. Review of the 7 patients ' observation logs revealed no documented observations from 12:45 p.m. -1:15 p.m. The 7 patients referenced above were on every 15 minute observations. 1 of the patients was on suicide precautions.
Patient #8 Review of Patient #8's medical record revealed he was a 37 year old male admitted on 08/04/15 with with a diagnosis of Suicidal Ideation with Depression.
In an observation on 8/4/15 at 10:20 a.m. Patient # 8, (a new admission admitted on 8/4/15 who had attempted suicide) with physician orders for suicide precautions, was observed pacing the hallway. He was not in direct line of sight of any of the staff members.
In an observation on 8/4/15 at 10:30 a.m. Patient # 8 was observed at the far end of the hall, at the door. He was not in direct line of sight of any of the staff members.
In an observation on 8/4/15 at 11:30 a.m. Patient # 8 was observed seated in the hall. He was not in direct line of sight of any of the staff members.
Patient #7 Review of Patient #7's medical record revealed she was a 35 year old female admitted on 08/04/15 with diagnoses of Suicidal Ideation and Bipolar Disorder.
In an observation on 8/4/15 at 1:45 p.m. revealed Patient #7 (a new admission admitted on 8/4/15 who had attempted suicide) with physician orders for suicide precautions, seated in a chair in the hall, outside the dayroom, with the MHTs back facing Patient #7. Patient #7 was not in the line of sight of any staff member.
In an interview on 8/4/15 at 4:16 p.m. with S32MHT, she confirmed she had been assigned to observe Patient #7 and Patient #8. She also confirmed Patients #7 and #8 were on suicide precautions. She explained patients on suicide precautions were to remain in direct line of sight of the staff assigned to observe them at all times. She indicated she was currently monitoring 12 patients total, including the 2 patients (#7 and #8) who were on suicide precautions.
Off-site campus:
In an interview on 8/5/15 at 10:55 a.m. S22MHT indicated Patient #13 (who had physician orders for suicide precautions and was to be on line of sight observation) was allowed to be in his room unobserved when he did not attend group therapy. He further indicated that patients on line of sight were allowed in the bathroom with the door closed without a staff member present. S22MHT indicated that he was assigned to observe patients who were using the phone. During that time he had not documented observations on Patient #13. He indicated during the interview that he thought all patients were on routine (every 15 minute) precautions. He said he was not told Patient #13 was on suicide precautions that morning in report.
Review of the observation sheet on 8/5/15 at 10:55 a.m. by the surveyor, for Patient #13 revealed the last observation documented was at 9:30 a.m. on 8/5/15.
In an interview on 08/05/15 at 12:10 p.m., S20RN indicated patients with orders for suicide precautions were allowed to be in their room without staff present and to use the bathroom with the door closed. He further indicated these patients were not required to be on 1:1 observation. When asked how the patient was maintained in the sight of staff in these instances, S20RN indicated "the door may be ajar."
In an interview on 08/05/15 at 12:35 p.m., S4DON indicated the hospital's suicide precaution policy wasn't too clear.
2) failing to ensure the physical environment at the main campus did not afford patients who had been identified as at risk for injury to themselves or others opportunities for injury to themselves or others. This deficient practice had the potential to affect all 23 current psychiatric patients on the main campus out of a total capacity for 24 psychiatric patients
Observations on 8/3/15 from 11:50 a.m. - 1:15 p.m. on the main campus (24 bed, locked in-patient psychiatric unit) with S6DirHR/HIM revealed the following risks to safety:
A. Bathrooms in all patient rooms were not directly visualized from the hallway enabling patients the opportunity to be in an area unobserved by staff.
The toilets in all rooms, except room #2, were noted to have exposed plumbing- pipe flush valves with flanged handle- potential ligature risk.
Exposed plumbing under the sink was observed in patient rooms, except for room #2, -potential ligature risks.
Sink with elongated faucet and flanged handles - potential ligature risk.
Patient grab bar open widely enough to facilitate ligature risk
B. Entry door and bathroom door secured with 3 hinges on each door, separated widely enough to facilitate potential ligature. The bathroom door could not be visualized directly from the hallway. Door handle on bathroom positioned in a sideways fashion, facilitating potential ligature risk. Room entry door handle positioned, on the back side of the door in a downward fashion, facilitating ligature risk.
C. Free standing clothing closet with 2 doors noted to have 6 interior hinges (3 per door) -potential ligature risk, 2 drawer pulls (non-flush, metal handles): potential ligature risk or potential weapon if removed.
In an interview on 8/4/15 at 8:45 a.m. with S3RN/IC/QA (Assistant Administrator), he confirmed, after review of the above referenced observations, that the physical environment findings posed ligature risks and safety risks for the patient population receiving psychiatric treatment at the hospital. He confirmed the patients were allowed to go to their rooms at times during the day. He said staff monitored the patients every 15 minutes, both nights and days, unless they were on visual contact (line of sight) or 1:1 observation levels.
3) failing to ensure a confused (oriented only to self), elderly patient with a diagnosis of Dementia was not placed in a room (main campus) with a bathtub, facilitating a potential risk for drowning, ligature and falls for 1 (#9) of 1 psychiatric patients reviewed out of a total sample of 19.
Review of Patient #9 ' s medical record revealed he was admitted on 7/10/15 with an admission diagnosis of psychosis. Further review revealed the patient also had a diagnosis of Alzheimer 's Dementia. Patient #9 was discharged on 8/4/15.
Review of Patient #9's Preliminary Treatment Plan, dated 7/9/15, revealed the following regarding special precautions: assess for fall precautions, aggression precautions. Further review revealed the patient met the following inpatient admission criteria: Potential danger to self, others, property; active delusions or hallucinations that affect ability to function; Inability to maintain ordinary habits of living; Bizarre, inappropriate or socially disruptive; Need for skilled 24 hour psychiatric observation/interventions.
Review of Patient #9 ' s admission nurses assessment, dated 7/10/15, revealed the following in part: Reason for hospitalization: Confused; Patient care considerations: Needs help with ADLs (activities of daily living)-bathing, feeding, dressing, grooming and oral hygiene. Maximal assistance required. Further review revealed the patient ' s fall risk assessment score was 16 (5+=High Risk). Review of the supplemental admission nurses' assessment notes titled, "additional nursing notes", dated 7/10/15, revealed the following in part: Pt. (patient) very confused requiring constant redirection. Thinks wife is here. Unsteady gait.
Review of Patient #9 ' s daily physical assessments for 7/30/15-8/4/15 revealed the patient was confused and disoriented. The patient ' s remote memory and recent remote memory were both documented as , " no " (not intact). Further review revealed the patient was described as confused, requiring prompts and redirection, oriented to self only. Additional review revealed the following narrative entry on 7/29/15: Ambulatory on unit. Continues to require constant supervision with redirections secondary to Dementia. Wanders about unit-requiring constant supervision.
Review of Patient #9 ' s observation sheets revealed he was on every 15 minute observations. Further review revealed he was not on line of sight or 1:1 supervision.
On 8/3/15 at 1:00 p.m. an observation was made of room #12 (main campus). A bathtub with faucets was noted in room- potential ligature, fall and drowning risk for an elderly confused patient assessed to be at risk for falls. S6DirHR/HIM confirmed Patient #9 had been assigned to this room.
On 8/4/15 at 10:35 a.m. Patient #9 was observed coming out of another patient ' s room and entering a second patient ' s room. He was not being redirected by staff at the time of the observation.
In an interview on 8/4/15 at 8:45 a.m. with S3RN/IC/QA (Assistant Administrator), he confirmed placement of an elderly, confused patient at risk for falls (Patient #9) in a room with a bathtub posed a potential risk for drowning, ligature and falls. He said the patient should never have been placed in the room with the tub without being placed on increased supervision.
In an interview on 8/5/15 at 12:34 p.m. with S4DON, he indicated placing a confused, disoriented, elderly patient (Patient #9) at risk for falls, in a room with a bathtub posed a potential risk for drowning, ligature and falls.
4) failing to ensure an unsecured, open, wide mouth sharps container containing razors and needles was not within reach of patients admitted to the psychiatric unit.
On 8/3/15 at 1:00 p.m. an observation was made of the patient examination room at the main campus. An unsecured, open, wide mouth (large enough to reach into) sharps container was noted on top of a small refrigerator. The refrigerator was located directly beside the patient examination table. It was within easy reach of patients that were seated on the examination table. The sharps container was noted to contain 4 used disposable razors and 2 large used needles.
Observation on 08/05/15 at 3:09 p.m. in the exam room revealed a sharps container on the counter where Patient R1 was seated. The sharps container had an open lid that allowed enough space to place one's hands inside the container. The sharps container had 2 razors with blades in the bottom of the container.
In an interview on 8/4/15 at 3:07 p.m. with S3RN/IC/QA (Assistant Administrator), he confirmed the location of the above referenced sharps container was a safety risk. He agreed the needle box containing 4 used disposable razors and 2 used needles was readily accessible to patients and posed a safety risk for both patients and staff.
5) failing to ensure a psychiatric patient (offsite campus) was not in possession of any contraband items (drawstring waist scrub pants) for 1 (#15 ) of 1 patient out of 21 total patients observed on the offsite campus
Patient #15
Review of Patient #15 ' s medical record revealed an admission date of 7/29/15 with admission diagnoses including the following: Bipolar disorder, Schizophrenia and PTSD (post- traumatic stress disorder). Further review revealed his legal status was PEC. Additional review of patient #15 ' s PEC revealed the patient was assessed as gravely disabled, dangerous to others, unable to seek voluntary admission. His mental condition assessment revealed the patient had pressured speech, was grandiose, delusional, bizarre, had not slept for 8 days, and indicated the patient said he was a killer.
On 8/5/15 at 11:25 a.m. an observation was made on Patient #15 (offsite campus). He was wearing scrub pants with a drawstring. The drawstring was untied with both ends hanging loosely.
In an interview on 8/5/15 at 12:10 p.m. with S20RN (RN at offsite campus), he indicated the drawstring scrub pants worn by Patient #15 were prohibited. He confirmed drawstrings were considered contraband and the drawstring from the scrubs should have been removed.
In an interview on 8/5/15 at 12:34 p.m. with S4DON, he indicated drawstrings on clothing was prohibited and was considered contraband. He said the drawstring on Patient #15 ' s scrub pants should have been confiscated by staff during contraband search.


25065




30172

Based on record reviews and interviews, the Governing Body failed to ensure the hospital's QAPI (Quality Assessment Performance Improvement) program reflected the hospital's organization and services by not having all the hospital's departments and services, including those services furnished under contract, included in the QAPI Plan. This failed practice was evidenced by no QAPI quality assurance indicators for 3 contracted services (Linen, Bio-Medical, and Maintenance) out of 19 patient care oriented Contract Services (Ambulance Services x2, Nursing Placement Agency, Utilization Review Services, Dietary Services, Pharmacy Services, Bio-Medical Services, Organ Procurement Agency x2, Maintenance Services, Interpreter Services, Transfer Agreement x2, Respiratory Services, Waste Management, Therapy Services, Laboratory Services, Linen Services, Radiology Services) out of a total of 28 Contracted Services listed.

Findings:
A review of the hospital's QAPI documentation revealed no documented evidence that 3 of the Contract Services (Linen, Bio-Medical, and Maintenance) out of 19 patient care oriented Contract Services listed had been included in the QAPI Plan.

In an interview on 8/07/15 at 11:45 a.m. with S3RN/IC/QA, he indicated that he was the Quality Assurance officer for the hospital. He was asked about the QAPI's quality assurance indicators for the hospital's Contract Services. The QAPI indicators for the hospital were reviewed with S3RN/IC/QA. S3RN/IC/QA indicated that there were no QAPI quality assurance indicators developed for 3 of the hospital's Contract Services (Linen, Bio-Medical, and Maintenance) out of the 19 patient care oriented Contract Services listed. S3RN/IC/QA further indicated that he was not aware that all the hospital's Contract Services had to be incorporated into the hospital's QAPI plan.

Based on record reviews and interview, the hospital failed to ensure the medical staff examined the credentials of eligible candidates for medical staff membership and made recommendations to the governing body on the appointment as evidenced by S19MedDir (Medical Director) reviewing and approving his own credentialing packet and request for privileges. This was evident for 1 (S19) of 4 (S19, S37, S38, S39) credentialing files reviewed.
Findings:

Review of the Medical Staff By-laws, presented as the current by-laws by S3RN/IC/QA (registered nurse/infection control/quality assessment), revealed that within 60 days after receipt of the completed application and all supporting information, the "Committee of the Whole" shall forward to the Chief Executive Officer for prompt transmittal to the Governing Board, a written report and recommendation as to Medical Staff appointment, and, if appointment is recommended, as to membership category, Clinical Privileges to be granted, and any special conditions to be attached to the appointment.

Review of S19MedDir's credentialing file revealed S19MedDir reviewed and approved his own credentialing information and requested privileges.

In an interview on 08/05/15 at 9:00 a.m., S6DirHR/HIM (Director of Human Resources/Health Information Management) indicated she was responsible for the credentialing process. She confirmed that S19MedDir had reviewed and approved his own credentialing packet and privileges. She indicated she didn't know he couldn't approve his own privileges and appointment.

Based on record reviews, observations, and interviews, the hospital failed to meet the requirements for the Condition of Participation of Nursing Services as evidenced by:

1) Failing to ensure the RN (registered nurse) assessed each patient upon admit, every shift, and with each change in condition as required by hospital policy for 5 (#4,#6, #9, #13, #15) of 12 (#1, #2, #3, #4, #6, #8, #9, #10, #12, #13, #15, #R1) patient records reviewed for RN assessments from a total sample of 19 patient records and observation of 1 (R1) patient being admitted (see findings in tag A0395).

2) Failing to ensure the RN supervised the observations of patients by the MHTs (mental health technician) as evidenced by failure to have documented evidence that each patient ordered to be on suicide precautions was in the sight of staff at all times as required by hospital policy for 7 (#2, #3, #4, #6, #9, #12, #13) of 10 (#1, #2, #3, #4, #6, #8, #9, #10, #12, #13) patient records reviewed for observation of patients on suicide precautions from a total sample of 19 patient records. The RN failed to ensure each patient's observation record contained the type of precaution for which the patient was to be monitored, such as suicide and aggression (see findings in tag A0395).

25065

Based on record reviews, observations, and interviews, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care for each patient as evidenced by:
1) Failing to ensure the RN assessed each patient upon admit, every shift, and with each change in condition as required by hospital policy for 5 (#4, #6, #9, #13, #15) of 12 (#1, #2, #3, #4, #6, #8, #9, #10, #12, #13, #15, #R1) patient records reviewed for RN assessments from a total sample of 19 patient records and observation of 1 (R1) patient being admitted.

2) Failing to ensure the RN supervised the observations of patients by the MHTs (mental health tech) as evidenced by failure to have documented evidence that each patient ordered to be on suicide precautions was in the sight of staff at all times as required by hospital policy for 7 (#2, #3, #4, #6, #9, #12, #13) of 10 (#1, #2, #3, #4, #6, #8, #9, #10, #12, #13) patient records reviewed for observation of patients on suicide precautions from a total sample of 19 patient records. The RN failed to ensure each patient's observation record contained the type of precaution for which the patient was to be monitored, such as suicide and aggression.

3) Failing to ensure lab specimens were drawn in accordance with physician orders and lab results were received timely for 2 (#4, #10) of 10 (#1, #2, #3, #4, #6, #8, #9, #10, #12, #13) patient records reviewed for labs done and reported timely from a total sample of 19 patient records.

4) Failing to ensure physician orders for Accuchecks included directions for when to notify the physician for 1 (4) of 3 (#4, #10, #11) patient records reviewed with orders for Accuchecks from a total sample of 19 patient records.

Findings:

1) Failing to ensure the RN assessed each patient upon admit, every shift, and with each change in condition as required by hospital policy:
Review of the hospital policy titled "Assessments", presented as a current policy by S3RN/IC/QA (registered nurse/infection control/quality assessment), revealed that nursing assessments shall be completed by a RN during the admission process within 8 hours of admission. A RN will assess each patient at least every shift, as soon as there is a change in a patient's condition, and upon a patient's return from receipt of Emergency Services.

Review of the hospital policy titled "Change of Condition", presented as a current policy by S3RN/IC/QA, revealed it was the policy of the hospital that a RN assesses any patient who has a change of condition and documents his/her findings in the interdisciplinary notes. Further review revealed the physician must be notified, and the treatment plan must be updated.

Patient #4
Review of Patient #4's medical record revealed he was a 72 year old male admitted on 07/27/15 with diagnoses of Chronic Paranoid Schizophrenia, GERD (Gastroesophageal Reflux Disease), Epilepsy, Hypertension, and COPD (Chronic Obstructive Pulmonary Disease).

Review of Patient #4's "Daily Physical Assessment" from 07/27/15 through 08/03/15 revealed no documented evidence of an assessment performed by a RN each shift.

Patient #6 Review of Patient #6's medical record revealed she was a 47 year old female, admitted on 8/1/15 with an admission diagnosis of Depression with SI (suicidal ideation). Further review revealed her legal status on admission was PEC (physician's emergency certificate) due to a suicide attempt- overdose of Mobic. Additional review revealed a CEC (coroner's emergency certificate) dated 8/3/15, indicating the patient was dangerous to self, and unwilling to seek voluntary admission. The patient was on suicide precautions.
Review of Patient #6's "Daily Physical Assessment" from 8/3/15 - 8/5/15 revealed no documented evidence of an assessment performed by a RN each shift.

Patient #9 Review of Patient #9's medical record revealed he was admitted on 7/10/15 with an admission diagnosis of psychosis. Further review revealed the patient also had a diagnosis of Alzheimer's Dementia. Patient #9 was discharged on 8/4/15.
Review of Patient #9's Preliminary Treatment Plan, dated 7/9/15, revealed the following regarding special precautions: assess for fall precautions, aggression precautions. Further review revealed the patient met the following inpatient admission criteria: Potential danger to self, others, property; active delusions or hallucinations that affect ability to function; Inability to maintain ordinary habits of living; Bizarre, inappropriate or socially disruptive; Need for skilled 24 hour psychiatric observation/interventions.

Review of Patient #9's "Daily Physical Assessments" for 7/27/15-7/30/15, 8/2/15 and 8/3/15 revealed no documented evidence of an assessment of Patient #9 performed by a RN each shift.

Patient #13
Review of Patient #13's medical record revealed he was a 35 year old male admitted on 07/16/15 with diagnoses of Chronic Paranoid Schizophrenia with Acute Exacerbation and Bronchitis secondary to cigar smoking.

Review of Patient #13's "Physician Progress Notes" of 07/20/15, 07/21/15, and 07/22/15 revealed entries by the physician of sexually inappropriate behavior being reported by the nursing staff.

Review of Patient #13's "Additional Nursing Notes" dated 07/20/15 revealed an entry by S35LPN (Licensed Practical Nurse) at 10:45 p.m. that she had notified the psychiatrist that Patient #13 was exhibiting inappropriate behavior and taking off his clothes in the room with his roommate present. There was no documented evidence that a RN assessed Patient #13's behavior and notified the physician.

Review of Patient #13's "Master Treatment Plan" revealed problems of altered thoughts and depressed mood were identified with a treatment plan initiated on 07/16/15. There was no documented evidence that Patient #13's nursing care plan was revised when he began to exhibit sexually inappropriate behaviors on 07/20/15.

In an interview on 08/05/15 at 12:10 p.m., S20RN indicated he was working on Patient #13's discharge paperwork currently, because Patient #13 was discharged on the day of this interview. He further indicated he had not worked previously before this day since Patient #13 was admitted, and he (S20RN) had not been informed in report that Patient #13 had exhibited sexually inappropriate behavior. After reviewing Patient #13's nursing care plan, S20RN confirmed a nursing care plan had not been developed for sexually inappropriate behavior.

In an interview on 08/05/15 at 12:35 p.m., S4DON (Director of Nursing) indicated a RN should have assessed Patient #13 when he began to exhibit sexually inappropriate behavior and developed a nursing care plan at that time to address this problem. Regarding RN assessments every shift, S4DON indicated the LPN usually assesses the patient with the RN signing the assessment form. He indicated the RN's signature doesn't "prove" that the RN actually performed an assessment.


Patient #15
Review of Patient #15's medical record revealed he was a 40 year old male admitted to the offsite campus on 07/29/15 with a Diagnosis of Bipolar Disorder - Manic with Psychosis.

Review of Patient #15's "Daily Physical Assessments" for 7/30/15-8/4/15 revealed no documented evidence of an assessment of Patient #15 performed by a RN each shift.


Patient R1
Observation on 08/05/15 from 3:05 p.m. to 3:24 p.m. revealed S26MHT performing an EKG (electrocardiogram) on Patient R1 as part of her admission process.

Observation on 08/05/15 at 3:28 p.m. revealed S27LPN entered the exam room to perform a skin assessment for Patient R1. S27LPN assessed Patient R1's legs, back, and buttocks and took photos of wounds to her legs and a mole on her right breast (photo documented as left breast).

Review of Patient R1's "Nursing Admission Assessment" dated 08/05/15 at 2:51 p.m. revealed the entire documentation of the assessment and admit nursing note was documented by S27LPN. There was a RN's signature dated 08/05/15 with no documented evidence of the time the RN signed the form, and there was no documented evidence of an assessment at admit by a RN.

In an interview on 08/07/15 at 3:08 p.m., S27LPN indicated she had documented the assessment of Patient R1 and handed her notes afterward to S5ADON (Assistant Director of Nursing). S27LPN indicated she didn't know if S5ADON reassessed Patient R1.

In an interview on 08/07/15 at 3:15 p.m., S3RN/IC/QA confirmed there was no evidence in Patient R1's medical record that she was assessed by a RN at the time of admit as required by hospital policy.


2) Failing to ensure the RN supervised the observations of patients by the MHTs: Review of the hospital policy titled "Suicide", effective 05/01/11, revised 06/01/15, and presented on 08/04/15 as a current policy by S3RN/IC/QA (registered nurse/infection control/quality assessment), revealed that a patient who is assessed at the time of admission by staff as suicidal will have suicide precautions initiated by the nursing staff or therapist. The nursing staff will then call the physician for an order. Further review revealed that the patient must at least be in the sight of staff at all times, and patients who are actively suicidal will be placed on a 1:1 (one-to-one) observation level. The assigned staff member must document the patient's behavior, emotional status, activity level, and significant verbalization in the progress notes. Review of the entire policy revealed no documented evidence whether the suicide risk assessment had to be performed by a RN or a LPN (licensed practical nurse).
Review of the hospital policy titled "Suicidal Behavior-SBC/Metairie (Seaside Behavioral Center/Metairie)", effective 05/01/11, revised 03/24/14, and presented as a current policy on 08/07/15 at 11:50 a.m. by S3RN/IC/QA, revealed that within 8 hours of admission and every shift thereafter, a suicide risk assessment will be completed on every patient as a part of the Nursing Assessment. A patient assessed as suicidal will have suicide precautions initiated by the nursing staff or therapist. The nursing staff will then call the physician for an order. If the patient is a potential risk for suicide, he/she will be placed on a higher level of observation to ensure safety of the patient. The assigned staff member documents the patient's behavior, emotional status, activity level, and significant verbalization in the progress notes. Patients who are actively suicidal will be placed on an observation level of 1:1, and the attending physician will be notified. The suicidal behavior is listed as a problem in the treatment plan with all of the expected objectives and staff interventions documented. The RN progress note will include daily assessment of suicidal potential. The RN discharge note will include assessment of suicidal potential, and the patient will be offered a safety contract to sign. There was documented evidence that the policy addressed what specific higher level of observation would be implemented if the patient was a potential risk for suicide.
In an interview on 08/07/15 at 11:50 a.m., S3RN/IC/QA indicated the suicide policy he had presented on 08/04/15 had not been approved by the Governing Body. He further indicated the policy titled "Suicidal Behavior-SBC/Metairie" should have been the policy presented as the current policy to be implemented by the staff.
Review of the hospital policy titled "Violence/Aggression Policy", presented as a current policy by S3RN/IC/QA, revealed close observation and monitoring the patient every 15 minutes is the minimum requirement for patients of this nature. The charge nurse can obtain an order from the physician for 1:1 observation if necessary. Further review revealed staff is to approach the client calmly from the front or side rather than from behind to avoid startling the client. Adequate staff-to-client distance should be maintained during all interactions. Arms-length apart is recommended.
Patient #2 Review of Patient #2's medical record revealed he was a 55 year old male, admitted on 7/24/15. His legal status was PEC (physician emergency certificate) with an admission diagnosis of depression and suicidal ideation. Further review revealed he was placed on suicide precautions with a level of observation of q (every) 15 minutes.
Review of Patient #2's Psychiatric Evaluation, dated 7/24/15, revealed the following mental status examination, in part: The patient is a depressed, sad, rather weak looking white male. He is talkative. He wanders in his conversation. He is generally depressed, sad, expresses his ideas of hopelessness and helplessness. He says, " I got here before I could do anything to kill myself, I don't want to go to that point, but if I didn't come over here, I will be making some plans to kill myself " . The patient says he feels hopeless, helpless, and worthless. He does not feel like his life is going anywhere. He cannot deal with the stress, which he has been going through and the grief, which he is going through.
Review of Patient #2's observation logs from 7/24/15-8/4/15, revealed the type of precaution was left blank. The patient was on suicide precautions.
On 8/6/15 at 10:00 a.m., Patient #2 was observed to be in his room with the door closed. Review of the patient's medical record revealed the patient had orders for suicide precautions. He was not in line of sight of staff at that time as required by hospital policy. Review of the staff patient assignment sheet revealed S25MHT was assigned to observe the patient. S25MHT was asked if she was assigned to Patient #2 and she replied, "I think so." She also replied that she had not known the patient was on suicide precautions. She was asked to show the surveyor her observation sheets at that time and they were observed to be blank from 7am-10 am. She indicated she had not had time to fill out the sheets. She also indicated she was assigned to observe 6 other patients. 2 (Patient #2 and Patient # R2) of the 7 patients she was observing were on line of sight precautions for suicide. She was asked what type of supervision was required per hospital policy for patients on suicide precautions and she replied, "1:1 observation".

Patient #3:
Review of the medical record revealed the patient was a 71 year old female admitted to the hospital on 07/31/15 with the diagnoses of depressive disorder, hypertension, hypothyroidism, and chronic obstructive pulmonary disease.

Review of the admit Physician Orders revealed a diagnosis of depression with suicide attempt. Further review revealed the physician ordered the patient to be on suicide and fall precautions.

Review of the Observation Logs dated 08/01/15, 08/02/15, and 08/03/15 revealed the type of precautions (suicide and fall) the patient was to be monitored for were not identified on the observation logs.

Patient #4
Review of Patient #4's medical record revealed he was a 72 year old male admitted on 07/27/15 with diagnoses of Chronic Paranoid Schizophrenia, GERD (Gastroesophageal Reflux Disease), Epilepsy, Hypertension, and COPD (Chronic Obstructive Pulmonary Disease).

Review of Patient #4's physician orders revealed an order for Aggression Precautions.

Review of Patient #4's "Observation Log" (form used by MHTs to document patient's behavior, location, and activity every 15 minutes) from the time of admit on 07/27/15 through 08/03/15 revealed no documented evidence that Aggression Precautions was checked to inform the MHT that Patient #4 had to be observed for aggression.
Patient #6 Review of Patient #6's medical record revealed she was a 47 year old female, admitted on 8/1/15 with an admission diagnosis of Depression with SI (suicidal ideation). Further review revealed her legal status on admission was PEC (physician's emergency certificate) due to a suicide attempt- overdose of Mobic. Additional review revealed a CEC (coroner's emergency certificate) dated 8/3/15, indicating the patient was dangerous to self, and unwilling to seek voluntary admission. The patient was on suicide precautions.
Review of the Daily Physical Assessment sheets for 8/1/15 and 8/3/15 revealed Patient #6's precaution type was suicide.
Review of the observation logs dated 8/2/15 and 8/3/15 revealed the precaution type was left blank.
Patient #9 Review of Patient #9's medical record revealed he was admitted on 7/10/15 with an admission diagnosis of psychosis. Further review revealed the patient also had a diagnosis of Alzheimer's Dementia. Patient #9 was discharged on 8/4/15.
Review of patient #9's Preliminary Treatment Plan, dated 7/9/15, revealed the following regarding special precautions: assess for fall precautions, aggression precautions. Further review revealed the patient met the following inpatient admission criteria: Potential danger to self, others, property; Active delusions or hallucinations that affect ability to function; Inability to maintain ordinary habits of living; Bizarre, inappropriate or socially disruptive; Need for skilled 24 hour psychiatric observation/interventions.
Review of Patient #9's admission nurses' assessment, dated 7/10/15, revealed the following in part: Reason for hospitalization: Confused; Patient care considerations: Needs help with ADLs (activities of daily living)-bathing, feeding, dressing, grooming and oral hygiene. Maximal assistance required. Further review revealed the patient 's fall risk assessment score was 16 (5+=High Risk) and he was on fall precautions. Review of the supplemental admission nurses' assessment notes titled, "additional nursing notes", dated 7/10/15, revealed the following in part: Pt. (patient) very confused requiring constant redirection. Thinks wife is here. Unsteady gait.
Review of Patient #9's daily physical assessments for 7/30/15-8/4/15 revealed the patient was confused and disoriented. The patient 's remote memory and recent remote memory were both documented as, "no" (not intact). Further review revealed the patient was described as confused, requiring prompts and redirection, oriented to self only. Additional review revealed the following narrative entry on 7/29/15: Ambulatory on unit. Continues to require constant supervision with redirections secondary to Dementia. Wanders about unit-requiring constant supervision. The patient's precaution types were listed as fall and aggression on the daily physical assessment notes.
Review of Patient #9's observation logs from 7/10/15 (admission) - 8/4/15 (discharged) revealed he was on every 15 minute observations. Further review revealed the type of precaution was left blank on all of the patient's observation logs throughout his stay in the Psychiatric hospital.

Patient #12
The patient was admitted to the hospital on 8/01/15 with an admit diagnoses of Bipolar Disorder and Depression.

A review of the History and Physical dated 8/02/15 revealed that Patient #12 was PEC (Physician Emergency Certificate) at the transferring hospital for bizarre behavior and aggression, prior to her admit at the psychiatric hospital.

A review of the Physician order dated 8/01/15 revealed that Patient #12 was to be placed on "Aggression Precautions".

A review of Patient #12's Observation Log sheets that were completed by the MHTs (mental health technician) dated 8/01/15, 8/02/15 and 8/03/15 revealed that the type of precautions (aggression) that was ordered for the patient was not identified on the observation log sheet as a precaution for the MHTs to monitor/observe.

In an interview on 08/06/15 at 9:48 a.m., S3RN/IC/QA indicated the type of precautions the patient was monitored for should be identified on the observation logs.

Patient #13
Review of Patient #13's medical record revealed he was a 35 year old male admitted on 07/16/15 with diagnoses of Chronic Paranoid Schizophrenia with Acute Exacerbation and Bronchitis secondary to cigar smoking.

Review of Patient #13's physician orders dated 07/16/15 revealed an order for Suicide Precautions. Review of the entire physician orders revealed no documented evidence of a physician order to discontinue Suicide Precautions.

Review of Patient #13's "Observation Log" from 07/16/15 through 08/04/15 revealed no documented evidence that Suicide Precautions was checked to inform the MHT that Patient #13 had to be observed for suicide and maintained with his/her (MHT) sight at all times.

In an interview on 08/05/15 at 10:55 a.m., S22MHT indicated he was assigned to observe Patient #13 today. He further indicated he had no patients on any type of precautions today. S22MHT indicated the charge nurse tells him which patients are on precautions, and the MHTs report off to one another. He further indicated he wasn't told this morning that Patient #13 was on Suicide Precautions. After reviewing the "Observation Log" since admit, S22MHT confirmed no log had "Suicide" checked that would have indicated that Patient #13 was on Suicide Precautions.

In an interview on 08/05/15 at 12:35 p.m., S4DON indicated the suicide precaution policy wasn't too clear. He indicated that any type of precautions, such as suicide and aggression, needs a physician's order to initiate and to discontinue.


3) Failing to ensure lab specimens were drawn in accordance with physician orders and lab results were received timely:
Review of the hospital policy titled "Clinical Laboratory Tests", presented as a current policy by S3RN/IC/QA, revealed clinical laboratory tests will be done by an accredited facility, and all lab work will be recorded in an accurate and consistent manner. Lab work will be documented in the patient chart. There was no documented evidence that the policy addressed the timeframe at which lab results were to be reported to the hospital by he lab and the process for assuring that lab results were received timely.

Patient #4
Review of Patient #4's medical record revealed he was a 72 year old male admitted on 07/27/15 with diagnoses of Chronic Paranoid Schizophrenia, GERD (Gastroesophageal Reflux Disease), Epilepsy, Hypertension, and COPD (Chronic Obstructive Pulmonary Disease).

Review of Patient #4's physician orders dated 07/27/15 revealed an order for a Urinalysis and Urine Drug Screen. Review of his lab results revealed the urine specimen was not collected until 07/29/15, 2 days after the order, with no documented evidence of the reason for the delay in obtaining the specimen.

Patient #10
Review of Patient #10's medical record revealed he was a 41 year old male admitted on 07/28/15 with a diagnosis of Dementia with Behavioral Disturbance.

Review of Patient #10's admit orders dated 07/28/15 revealed orders for the following labs: Complete Blood Count with Differential with Platelets, Comprehensive Metabolic Profile, Thyroid Stimulating Hormone, Urinalysis, Rapid Plasma Reagin, Vitamin B12, Folate, and Urine Drug Screen.

Review of Patient #10's medical record on 08/04/15 (7 days after admit) revealed no documented evidence of lab results for the Complete Blood Count with Differential with Platelets, Urinalysis, and Urine Drug Screen.

In an interview on 08/05/15 at 12:35 p.m., S4DON indicated the nurse is supposed to check that patients' lab results are on the chart timely. He offered no explanation for the delay in Patient #4's urine specimen being collected for the ordered tests.


4) Failing to ensure physician orders for Accuchecks included directions for when to notify the physician:
Review of Patient #4's medical record revealed he was a 72 year old male admitted on 07/27/15 with diagnoses of Chronic Paranoid Schizophrenia, GERD (Gastroesophageal Reflux Disease), Epilepsy, Hypertension, and COPD (Chronic Obstructive Pulmonary Disease).

Review of Patient #4's "Admission Medication List" dated 07/27/15 revealed an order for Accuchecks every morning. There was no documented evidence of directions for when the physician was to be notified of abnormal values.

In an interview on 08/05/15 at 12:35 p.m., S4DON (Director of Nursing) indicated if a physician has an order for Accuchecks, the order should have parameters when the physician wants to be notified.


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Based on record reviews and interviews, the hospital failed to ensure that the nursing staff developed and kept current a nursing care plan for each patient as evidenced by failure to include medical problems for which the patient was receiving treatment in the nursing care plan and stating goals in objective, measurable terms as required by hospital policy for 6 (#1, #2, #3, #4, #12, #13) of 10 (#1, #2, #3, #4, #6, #8, #9, #10, #12, #13) patient records reviewed for the nursing care plan from a total of 19 sampled patient records.
Findings:

Review of the hospital policy titled "Treatment Planning", presented as a current policy by S3RN/IC/QA (registered nurse/infection control/quality assessment), revealed that a multidisciplinary approach was to be used in the development and implementation of the Master Treatment Plan for each patient to ensure continuity of care from admission to the discharge of the patient's stay. Preliminary Treatment Plans are completed within 24 hours of admission by the physician and the admitting nurse. The Master Treatment Plan was to be completed by the fifth day of admission. The Master Treatment Plan will contain behavioral objectives written in measurable terms and include target dates as well as active medical issues for which the patient is currently being treated.

Patient #1
The patient was admitted to the hospital on 07/31/15 with admit diagnoses of Schizoaffective Disorder and Bipolar Disorder.

A review of the History and Physical dated 08/01/15 revealed that Patient #1 had HTN (hypertension) and GERD (gastroesophageal reflux disease).

A review of the Physician order dated 07/31/15 revealed in part: Regular diet with NAS (no added salt) and to notify physician if the patient's blood pressure was higher than 160/100.

A review of the initial Nursing Admission Assessment dated 07/31/15 revealed documentation under the Health Problems section that Patient #1 had Mental Health Problems, HTN and GERD.

A review of the patient's Interdisciplinary Treatment Plan revealed that Patient #1 was care planned for Altered Thoughts, Depression, and Poor Impulse Control. There was no documented evidence that the patient was care planned for HTN or GERD.

Patient #2
The patient was admitted to the hospital on 07/24/15 with admit diagnoses of Suicidal Ideation and Depression.

A review of the History and Physical dated 07/25/15 revealed Patient #2 had HTN, CAD (Coronary Artery Disease) and Hyperlipidemia. Patient #2 was also on anticoagulant therapy.

A review of the patient's Interdisciplinary Treatment Plan revealed that Patient #2 was care planned for High risk to harm self or others, Depressed Mood related to history of mental illness as evidenced by: SI (suicidal ideation)/gestures and Altered Thoughts/Psychosis related to history of mental illness as evidenced by: Depression and SI. Further review revealed HTN, CAD, hypercholesterolemia and anticoagulant therapy were not addressed in the patient ' s current plan of care.

Patient #3:
Review of the medical record revealed the patient was a 71 year old female admitted to the hospital on 07/31/15 with the diagnoses of Depressive Disorder, Hypertension, Hypothyroidism, and Chronic Obstructive Pulmonary Disease.

Review of the medication orders revealed, in part: Metoprolol Tartrate (Hypertension) 50 mg (milligrams) by mouth twice a day, Lisinopril 30 mg daily (Hypertension), Synthroid (Hypothyroidism) 50 mcg (micrograms) by mouth every morning, and Ventolin inhalation (Chronic Obstructive Pulmonary Disease) two puffs every 6 hours as needed for shortness of breath.

Review of the Interdisciplinary Treatment Plan revealed no documented evidence that care plans were developed for Hypertension, Hypothyroidism, and Chronic Obstructive Pulmonary Disease.

In an interview on 08/06/15 at 9:44 a.m., S3RN/IC/QA confirmed that Patient #3's interdisciplinary treatment plan did not address the patient's medical conditions.

Patient #4
Review of Patient #4's medical record revealed he was a 72 year old male admitted on 07/27/15 with diagnoses of Chronic Paranoid Schizophrenia, GERD (Gastroesophageal Reflux Disease), Epilepsy, Hypertension, and COPD (Chronic Obstructive Pulmonary Disease).

Review of Patient #4's "Master Treatment Plan" revealed problems identified with a treatment plan initiated on 07/27/15 included high risk to harm others, anxiety, and Diabetes Mellitus Type 2. Risk for infection related to UTI (Urinary Tract Infection) was added on 08/01/15. There was no documented evidence that Patient #4's nursing care was developed for GERD, Epilepsy, Hypertension, and COPD.

Patient #12
The patient was admitted to the hospital on 08/01/15 with admit diagnoses of Bipolar Disorder and Depression.

A review of the History and Physical dated 08/02/15 revealed that Patient #12 had Type 2 Diabetes.

A review of the Physician order dated 08/02/15 revealed in part: Accu-check before each meal and before bedtime.

A review of the initial Nursing Admission Assessment dated 08/01/15 revealed documentation under the Health Problems section that Patient #12 had Mental Health Problems and Diabetes

A review of the patient's Interdisciplinary Treatment Plan revealed that Patient #12 was care planned for Altered Thoughts, Depression, and Poor Impulse Control. There was no documented evidence that the patient was care planned for Diabetes.

Patient #13
Review of Patient #13's medical record revealed he was a 35 year old male admitted on 07/16/15 with diagnoses of Chronic Paranoid Schizophrenia with Acute Exacerbation and Bronchitis secondary to cigar smoking.

Review of Patient #13's "Physician Progress Notes" of 07/20/15, 07/21/15, and 07/22/15 revealed entries by the physician of sexually inappropriate behavior being reported by the nursing staff.

Review of Patient #13's "Additional Nursing Notes" dated 07/20/15 revealed an entry by S35LPN (Licensed Practical Nurse) at 10:45 p.m. that she had notified the psychiatrist that Patient #13 was exhibiting inappropriate behavior and taking off his clothes in the room with his roommate present.

Review of Patient #13's "Master Treatment Plan" revealed problems of altered thoughts and depressed mood were identified with a treatment plan initiated on 07/16/15. There was no documented evidence that a nursing care plan was developed for Bronchitis. There was no documented evidence that Patient #13's nursing care plan was revised when he began to exhibit sexually inappropriate behaviors on 07/20/15.

In an interview on 08/05/15 at 12:10 p.m., S20RN indicated he was working on Patient #13's discharge paperwork currently, because Patient #13 was discharged on the day of this interview. He further indicated he had not worked previously before this day since Patient #13 was admitted, and he (S20RN) had not been informed in report that Patient #13 had exhibited sexually inappropriate behavior. After reviewing Patient #13's nursing care plan, S20RN confirmed a nursing care plan had not been developed for sexually inappropriate behavior.

In an interview on 08/05/15 at 12:35 p.m., S4DON (Director of Nursing) indicated a RN should have assessed Patient #13 when began to exhibit sexually inappropriate behavior and developed a nursing care plan at that time to address this problem.

In an interview on 8/03/15 at 3:15 p.m. with S16RN, she was asked if the nursing care plans were based on assessing all the patient's nursing care needs, as well as, the care needs relating to the admitting diagnoses. S16RN indicated that nurses usually care planned patients for a couple of the patient's medical problems and a couple of the patient's mental health problems. S16RN indicated that she was not sure if the hospital's care plan policy addressed how many medical care problems and how many mental care problems the nurses were required to include in a patient's care plan. S16RN indicated that she usually care planned for the patient's most outstanding medical care needs, like Diabetes.




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Based on record reviews and interviews, the hospital failed to ensure:
1) Drugs and biologicals were administered in accordance with physician orders for 2 (#4, #10) of 10 (#1, #2, #3, #4, #6, #8, #9, #10, #12, #13) patient records reviewed for medication administration from a total sample of 19 patient records.
2) All physician orders for the administration of drugs and biologicals included at least the exact strength and specific instructions for use as evidenced by failure to define anxiety/agitation and severe anxiety/agitation to determine when to administer oral or intramuscular (IM) Ativan for 10 (#1, #2, #3, #4, #6, #8, #9, #10, #12, #13) of 10 patient records reviewed for medication administration from a total sample of 19 patient records.

Findings:

1) Drugs and biologicals were administered in accordance with physician orders:
Patient #4
Review of Patient #4's medical record revealed he was a 72 year old male admitted on 07/27/15 with diagnoses of Chronic Paranoid Schizophrenia, GERD (Gastroesophageal Reflux Disease), Epilepsy, Hypertension, and COPD (Chronic Obstructive Pulmonary Disease).

Review of Patient #4's "Admission Medication List", received by telephone order on 07/27/15 at 5:00 p.m. by S33RN (registered nurse), revealed orders for Seroquel 150 mg (milligrams) by mouth at bedtime, Norvasc 5 mg by mouth daily, Aspirin 325 mg by mouth daily, and Multivitamin one tablet by mouth daily.

Review of Patient #4's "Physician Orders" revealed an order on 07/29/15 at 10:50 a.m. to increase Seroquel to 25 mg every morning (no route of administration ordered) and 150 mg at bedtime (no route of administration ordered). Further review revealed an order on 07/30/15 at 11:00 a.m. to increase Seroquel to 50 mg every morning by mouth and 150 mg at bedtime (no route of administration ordered), hold if sedated.

Review of Patient #4's MARS (medication administration records) revealed no documented evidence that he received Norvasc 5 mg orally, Aspirin 325 mg orally, and Multivitamin orally on 07/28/15 at 9:00 a.m. Further review revealed no documented evidence Patient #4 received Seroquel 25 mg on 07/30/15 as ordered on 07/29/15 at 10:50 a.m.

Patient #10
Review of Patient #10's medical record revealed he was a 41 year old male admitted on 07/28/15 with a diagnosis of Dementia with Behavioral Disturbance.

Review of Patient #10's physician orders revealed an order on 07/29/15 at 9:28 a.m. for Accuchecks (capillary blood glucose monitoring) before meals and at bedtime with Sliding Scale Humalog Insulin for blood glucose levels from 176 to 425. Further review revealed "Physician Orders Sliding Insulin Scale" on 07/29/15 at 1:00 p.m. for Accuchecks before meals and at bedtime with Novolog or Humalog Insulin for blood glucose levels between 151 and 400. There was no documented evidence of a clarification order by the nurse to determine if Novolog or Humalog Insulin was to be administered for a blood glucose level out of range according to the physician orders. Further review revealed an order written on 07/29/15 at 12:30 p.m. to "use facility sliding scale." There was no documented evidence of what the facility's sliding scale protocol was.

Review of Patient #10's "Diabetic Record" revealed his Accuchecks were 158 on 08/01/15 at 6:00 a.m., 172 on 08/01/15 at 9:00 p.m., 153 on 08/02/15 at 6:00 a.m., and 156 on 08/03/15 at 6:00 a.m. These results all required administration of Sliding Scale Insulin according to physician orders, and there was no documented evidence that Insulin was administered.

In an interview on 08/05/15 at 12:35 p.m., S4DON (Director of Nursing) indicated sliding scale insulin orders should state the specific type of insulin to be used. He further indicated if the order wasn't specific, the nurse should have clarified the order with the physician. He confirmed the above listed medication administration errors.

2) All physician orders for the administration of drugs and biologicals included at least the exact strength and specific instructions for use:
Review of the hospital's standing "Physician Orders" for Patients #1, #2, #3, #4, #6, #8, #9, #10, #12, and #13 revealed an order for Ativan 1 mg (milligram) by mouth every 6 hours as needed for anxiety/agitation and Ativan 1 mg IM every 6 hours as needed for severe anxiety/agitation. There was no parameter given to define the difference between anxiety/agitation and severe anxiety/agitation.

In an interview on 08/05/15 at 12:35 p.m., S4DON indicated physician orders for Ativan to be used PRN (as needed) should include parameters to measure anxiety/agitation versus severe anxiety/agitation, so the nurse can determine when the oral medication versus the IM medication is to be used.

Based on record reviews and interview, the hospital failed to ensure nutritional assessments by the Registered Dietitian were performed within 24 hours of a physician's order as required by hospital policy for 2 (#4, #10) of 10 (#1, #2, #3, #4, #6, #8, #9, #10, #12, #13) patient records reviewed for timely nutritional assessments from a total sample of 19 patients.

Findings:

Review of the hospital policy titled "Assessments", presented as a current policy by S3RN/IC/QA (registered nurse/infection control/quality assessment), revealed that dietary/nutritional assessments shall be completed within 24 hours of a physician's order.


Patient #4
Review of Patient #4's medical record revealed he was a 72 year old male admitted on 07/27/15 with diagnoses of Chronic Paranoid Schizophrenia, GERD (Gastroesophageal Reflux Disease), Epilepsy, Hypertension, and COPD (Chronic Obstructive Pulmonary Disease).

Review of Patient #4's "Physician's Admit Orders & (and) Admit Note", dated 07/27/15, revealed an order for a nutritional assessment.

Review of Patient #4's "Nutrition Screen/Assessment" revealed the registered dietitian performed the assessment on 07/31/15, 4 days after the physician had ordered the nutritional assessment.

Patient #10
Review of Patient #10's medical record revealed he was a 41 year old male admitted on 07/28/15 with a diagnosis of Dementia with Behavioral Disturbance.

Review of Patient #4's "Physician's Admit Orders & Admit Note", dated 07/28/15, revealed an order for a nutritional assessment.

Review of Patient #10's "Nutrition Screen/Assessment" revealed the registered dietitian performed the assessment on 07/31/15, 3 days after the physician had ordered the nutritional assessment.

In an interview on 08/04/15 at 10:50 a.m., S3RN/IC/QA indicated a request for a nutritional assessment is faxed to the registered dietitian. He further indicated the dietitian has to do the assessment within 24 hours when it is ordered by the physician. After review of the medical records of Patients #4 and #10, S3RN/IC/QA confirmed the registered dietitian did not perform each patient's nutritional assessment within 24 hours of the physician's order.

Based on observation, interview and record review, the hospital failed to ensure the infection control officer developed a system for controlling infections and communicable diseases of patients and personnel. This deficient practice is evidenced by:
1) Failing to ensure hand hygiene and accepted standards of practice for infection control were followed during blood glucose monitoring for 3 (#10, #11, #12) of 3 patients observed on the main campus. This deficient practice is evidenced by failure of staff to perform proper hand hygiene and failing to disinfect a glucose meter per hospital policy and manufacturer's recommendations,
2) Failing to ensure hand hygiene and acceptable standards of practice for infection control were implemented during observations in the performance of an EKG (electrocardiogram) as evidenced by failure of staff to perform proper hand hygiene and failing to disinfect the EKG machine and thermometer for 1 (R1) of 1 patient observed having an EKG performed and her temperature assessed on the main campus , and

3) Failing to ensure that the hospital ' s hand hygiene monitoring tool included monitoring the compliance of acceptable hand hygiene infection control practices for all hospital staff, including contract staff and physicians,
Findings:
Review of the hospital policy titled, " Hand Hygiene ", Policy Number: ICP 01-009, developed date: 3/11/11, revealed the following, in part:
Purpose: To render the hands as free from microorganisms as possible. To prevent the spread of infection to patients, visitors, or personnel.
Policy: Use of cleansing agent with sufficient friction to cleanse the hands or the use of an alcohol hand product. Hands will be washed with soap and water after any patient contact, even if gloves are worn.
The hands are the most common carriers of microorganisms. Hand hygiene should be performed after every contact with patients or contaminated surfaces, even if gloves have been used.
Review of the policy titled, " Intermediate and Low- level Disinfection of Patient Care Equipment " , Policy No.: ICP 01-012, Developed date: 3/11/11, revealed the following, in part: 3)The equipment manufacturer 's instructions shall be followed for cleaning and disinfection of non-critical items; 4) Only EPA (environmental protection agency) approved hospital level disinfectants with or without a claim for tuberculocidal activity shall be used for disinfection of non-critical surfaces. For disinfection, hard non-porous surfaces should remain wet as indicated by the manufacturer of the disinfectant.
Review of the manufacturer's user's guide for the hospital's glucose meter revealed the following, in part: Cleaning and disinfecting procedures for the meter: The glucose meter should be cleaned and disinfected between each patient. The following products have been approved for cleaning and disinfecting the meter: Dispatch Hospital Cleaner Disinfectant Towels with bleach, Clorox Healthcare Bleach Germicidal and Disinfectant wipes, Microkill Bleach Germicidal Bleach wipes.
Note: Glucose meters used in a clinical setting for testing multiple persons must be cleaned and disinfected between patients. Used gloves should be removed and hands washed before proceeding to the next patient.
1) Failing to ensure hand hygiene and accepted standards of practice for infection control were followed during blood glucose monitoring for 3 (#10, #11, #12) of 3 patients observed on the main campus. This deficient practice is evidenced by failure of staff to perform proper hand hygiene and failing to disinfect a glucose meter per hospital policy and manufacturer's recommendations,
On 8/4/15 at 11:45 a.m. the following observations were made of S11LPN performing finger stick blood glucose monitoring on Patients #12, #11 and #10. Patients #12, #11, and #10 were lined up one after the other and she performed their finger stick blood glucose monitoring in that order.
S11LPN obtained Patient #12 ' s blood sample, per finger stick, and applied it to the test strip. She retrieved a pen from her pocket, wrote down the result, took off her gloves and removed a bottle of alcohol hand sanitizer from her pocket. She performed hand hygiene after retrieving the bottle from the pocket of her scrubs. She failed to clean the glucose meter after obtaining Patient #12 ' s capillary blood glucose sample.
S11LPN then moved on to Patient # 11, obtaining the patient ' s blood sample, applying it to the test strip. She retrieved a pen from her pocket, wrote down the result, took off her gloves and again removed a bottle of alcohol hand sanitizer from her pocket. She performed hand hygiene after retrieving the bottle from the pocket of her scrubs. She failed to clean the glucose meter after obtaining Patient #11 ' s capillary blood glucose sample.
S11LPN then moved on to Patient #10. She obtained Patient #10 ' s blood sample, per finger stick, and applied it to the test strip. She retrieved a pen from her pocket, wrote down the result, took off her gloves and removed a bottle of alcohol hand sanitizer from her pocket. She performed hand hygiene after retrieving the bottle from the pocket of her scrubs. She cleaned the glucose meter with an alcohol wipe after obtaining Patient #10 ' s capillary blood glucose sample.
In an interview on 8/4/15 at 11: 59 a.m. with S11LPN, she confirmed she had wiped the blood glucose meter with an alcohol wipe after completing all of the blood glucose readings on Patients #12, #11 and #10. She indicated she had not wiped down the glucose meter in-between the patients. S11LPN said she had been taught to use an alcohol wipe to clean the meter and that was the way she had always cleaned it.
In an interview on 8/4/15 at 3:07 p.m. with S3RN/IC/QA (Assistant Administrator), he confirmed the blood glucose meter should have been cleaned prior to, in between, and after each patient use with a disinfectant wipe. He also confirmed alcohol was not appropriate to disinfect the glucose meter. S3RN/IC/QA (Assistant Administrator) indicated hand hygiene should have been performed prior to donning gloves and immediately after removal of gloves. He further indicated staff removing gloves and retrieving alcohol based hand sanitizer out of their pocket was not appropriate and confirmed it was a breach in infection control practice. He said it was his expectation that the staff use the wall mounted hand sanitizer, in the examination room, due to the potential for transfer of potentially infectious materials to the pockets of their scrubs when retrieving hand sanitizer from their pockets.
2) Failing to ensure hand hygiene and acceptable standards of practice for infection control were implemented during observations in the performance of an EKG (electrocardiogram) as evidenced by failure of staff to perform proper hand hygiene and failing to disinfect the EKG machine and thermometer for 1 (R1) of 1 patient observed having an EKG performed and her temperature assessed on the main campus , and

Observation at the nursing station on 08/05/15 at 3:06 p.m. revealed S26MHT (Mental Health Tech) checking Patient R1's temperature with a digital thermometer. Further observation revealed S26MHT placed the thermometer in the wire basket attached to the rolling blood pressure machine without disinfecting the thermometer after it was used for Patient R1. S26MHT removed her gloves, did not perform hand hygiene, placed Patient R1's identification band on Patient R1's arm with ungloved hands, and did not perform hand hygiene after contacting Patient R1's skin.

Observation in the exam room on 08/05/15 at 3:09 p.m. revealed S26MHT donned gloves taken from her uniform pocket without performing hand hygiene. Further observation revealed a sharps container on the counter beside where Patient R1 was seated that had the lid opened large enough that one's hand could reach into the container. There were 2 razors with the blades attached in the bottom of the opened sharps container. Continuous observation revealed S26MHT placed EKG (electrocardiogram) electrodes on Patient R1 with the lead connector and wires lying on Patient R1's pants. While wearing gloves that were contaminated from attaching EKG electrodes to Patient R1, S26MHT touched the EKG machine's dials to set it to print (date on strip printed of Patient R1's EKG on 08/05/15 was 07/06/15).

Observation in the exam room on 08/05/15 at 3:19 p.m. revealed S26MHT donned gloves and removed the EKG electrodes from Patient R1, placed the electrodes and wires on the cart next to the EKG machine, removed her gloves, removed the electrode pads from Patient R1's skin without wearing gloves, and touched the door handle to open it without performing hand hygiene.

Observation on 08/05/15 at 3:24 p.m. revealed S26MHT picked something off the floor in the exam room, removed the glove used to pick the item off the floor, and redonned a glove without performing hand hygiene.

Observation on 08/05/15 at 3:28 p.m. in the exam room revealed S27LPN (Licensed Practical Nurse) donned gloves and assessed Patient R1's skin (legs, back, buttocks), removed her gloves, and left the room without performing hand hygiene.

Observation on 08/05/15 at 3:32 p.m. revealed no observation of any staff member disinfecting the EKG machine after use to perform Patient R1's EKG. S26MHT indicated at this time that she was "finished with everything."

In an interview on 08/05/15 at 3:45 p.m., S26MHT confirmed she didn't disinfect the thermometer after using it for Patient R1. She further indicated she wiped the EKG electrodes after the surveyor left the room, but she didn't disinfect the wires or the EKG machine itself. S26MHT confirmed the above-listed breaches in hand hygiene.

3) Failing to ensure that the hospital ' s hand hygiene monitoring tool included monitoring the compliance of acceptable hand hygiene infection control practices for all hospital staff, including contract staff and physicians
A review of the hospital ' s hand hygiene monitoring tool revealed in part: hand hygiene monitoring was performed monthly on random hospital staff (RN, LPN, MHT) with no documented evidence of hand hygiene monitoring being performed on contract staff or physicians.
In an interview on 8/07/15 at 12:45 p.m. with S3RN/IC/QA, he indicated that he was the Infection Control officer for the hospital. S3RN/IC/QA was asked about the monitoring of hand hygiene for acceptable infection control practices. S3RN/IC/QA indicated that he performed random monitoring of staff (RN, LPN, MHT) for compliance for acceptable hand hygiene practices. S3RN/IC/QA indicated that he was not monitoring contract staff or physicians for hand hygiene compliance for acceptable infection control practices.



30172





30984

Based on observations, record reviews, and interviews, the hospital failed to meet all special provisions applying to psychiatric hospitals as evidenced by:

1) Failing to meet the requirements for the Condition of Participation for Nursing Services and Patient Rights (see findings in tag B-0100).

2) Failing to meet the requirements for the Condition of Participation of Special Staff Requirements for Psychiatric Hospitals (see findings in tag B-0136).

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation for:

1) Patient Rights as evidenced by:
a) Failing to ensure patients with physician orders for suicide precautions were being monitored at the observation level set forth per hospital policy and
b) Failing to ensure the physical environment at the main campus did not afford patients who had been identified as at risk for injury to themselves or others opportunities for injury to themselves or others. (See findings in tag A-0144).
An Immediate Jeopardy Situation was identified on 08/06/15 at 5:00 p.m. due to the hospital:
a)Failing to ensure patients with physician orders for suicide precautions were being monitored at the observation level set forth per hospital policy;
b)Failing to ensure the physical environment at the main campus did not afford patients who had been identified as at risk for injury to themselves or others opportunities for injury to themselves or others. (See findings in tag A-0144).
2) Nursing Services as evidenced by:
a) Failing to ensure the RN (registered nurse) assessed each patient upon admit, every shift, and with each change in condition as required by hospital policy for 5 (#4,#6, #9, #13, #15) of 12 (#1, #2, #3, #4, #6, #8, #9, #10, #12, #13, #15, #R1) patient records reviewed for RN assessments from a total sample of 19 patient records and observation of 1 (R1) patient being admitted (see findings in tag A0395).

b) Failing to ensure the RN supervised the observations of patients by the MHTs (mental health tech) as evidenced by failure to have documented evidence that each patient ordered to be on suicide precautions was in the sight of staff at all times as required by hospital policy for 7 (#2, #3, #4, #6, #9, #12, #13) of 10 (#1, #2, #3, #4, #6, #8, #9, #10, #12, #13) patient records reviewed for observation of patients on suicide precautions from a total sample of 19 patient records. The RN failed to ensure each patient's observation record contained the type of precaution for which the patient was to be monitored, such as suicide and aggression (see findings in tag A0395).

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Special Medical Record Requirements For Psychiatric Hospitals as evidenced by:

1) Failing to ensure each patient's psychiatric evaluation included an inventory of the patient's assets in descriptive, not interpretive, fashion for 2 (#4,#15) of 12 (#1, #2, #3, #4, #5, #6, #9, #10, #12, #13, #14, #15) patient records reviewed for a complete psychiatric evaluation from a total of 19 sampled patients (see findings in tag B-0117).

2) Failing to ensure that each patient had an individualized, comprehensive treatment plan as evidenced by failure to include identified medical problems for which the patient is being treated, failure to individualize the interventions planned for each patient to address the patient's identified problems, and failure to revise the patient's treatment plan with changes in the patient's condition for 6 (#1, #2, #3, #4, #12, #13) of 10 (#1, #2, #3, #4, #6, #8, #9, #10, #12, #13) patient records reviewed for the treatment plan from a total of 19 sampled patient records (see findings in tag B-0118).

3) Failing to ensure that the written treatment plan for each patient included short-term and long-range goals that are stated as expected behavioral outcomes for the patient for 2 (#4, #13) of 10 (#1, #2, #3, #4, #6, #8, #9, #10, #12, #13) patient records reviewed for the treatment plan goals from a total of 19 sampled patient records (see findings in tag B-0121).

4) Failing to ensure the written treatment plan included the specific treatment modalities utilized as evidenced by failure to have specific interventions identified for each patient for 4 (#4, #6, #13,#15) of 11 (#1, #2, #3, #4, #6, #8, #9, #10, #12, #13, #15) patient records reviewed for the treatment plan interventions from a total of 19 sampled patient records (see findings in tag B-0122).

Based on record reviews and interviews, the hospital failed to ensure each patient's psychiatric evaluation included an inventory of the patient's assets in descriptive, not interpretive, fashion for 2 (#4, #15) of 12 (#1, #2, #3, #4, #5, #6, #9, #10, #12, #13, #14, #15) patient records reviewed for a complete psychiatric evaluation from a total of 19 sampled patients.
Findings:

Review of the hospital policy titled "Assessments", presented as a current policy by S3RN/IC/QA (registered nurse/infection control/quality assessment), revealed that the psychiatric evaluation was to be completed within 24 hours of admission. There was no documented evidence of the components to be included in the psychiatric evaluation.

No hospital policy related to the components of the psychiatric evaluation was presented for review as of the completion of the survey on 08/07/15.

Patient #4

Review of Patient #4's medical record revealed he was a 72 year old male admitted on 07/27/15 with diagnoses of Chronic Paranoid Schizophrenia, GERD (Gastroesophageal Reflux Disease), Epilepsy, Hypertension, and COPD (Chronic Obstructive Pulmonary Disease).

Review of Patient #4's "Psychiatric Evaluation" performed on 07/29/15 (not within 24 hours as per hospital policy) revealed no documented evidence that Patient #4's assets had been assessed and identified.

Patient #15

Review of Patient #15's medical record revealed he was a 40 year old male admitted on 07/29/15 with a diagnosis of Bipolar Disorder with Psychotic features.

Review of Patient #15's "Psychiatric Evaluation" performed on 07/29/15 revealed no documented evidence that Patient #15's assets had been assessed and identified.

In an interview on 08/07/15 at 1:50 p.m., S19MedDir confirmed Patient #4's and Patient #15's Psychiatric Evaluations didn't include assets. He further indicated the evaluations were performed by his partner, but as Medical Director, he (S19MedDir) is responsible for the medical staff's actions.

Based on record reviews and interviews, the hospital failed to ensure that each patient had an individualized, comprehensive treatment plan as evidenced by failure to include identified medical problems for which the patient is being treated, failure to individualize the interventions planned for each patient to address the patient's identified problems, and failure to revise the patient's treatment plan with changes in the patient's condition for 6 (#1, #2, #3, #4, #12, #13) of 10 (#1, #2, #3, #4, #6, #8, #9, #10, #12, #13) patient records reviewed for the treatment plan from a total of 19 sampled patient records.
Findings:

Review of the hospital policy titled "Treatment Planning", presented as a current policy by S3RN/IC/QA (registered nurse/infection control/quality assessment), revealed that a multidisciplinary approach was to be used in the development and implementation of the Master Treatment Plan for each patient to ensure continuity of care from admission to the discharge of the patient's stay. Preliminary Treatment Plans are completed within 24 hours of admission by the physician and the admitting nurse. The Master Treatment Plan is to be completed by the fifth day of admission. The intervention strategies are the actions and approaches to be taken by the staff in assisting the patient in resolving the identified problem and reaching the discharge goal. Intervention strategies must be very specific. The name and/or discipline of the party responsible for overseeing the intervention strategy is also documented. Further review revealed active medical issues that the patient is currently being treated for is to be included.

Patient #1
The patient was admitted to the hospital on 07/31/15 with admit diagnoses of Schizoaffective Disorder and Bipolar Disorder.

A review of the History and Physical dated 08/01/15 revealed that Patient #1 had HTN (hypertension) and GERD (gastroesophageal reflux disease).

A review of the Physician order dated 07/31/15 revealed in part: Regular diet with NAS (no added salt) and to notify physician if the patient's blood pressure was higher than 160/100.

A review of the initial Nursing Admission Assessment dated 07/31/15 revealed documentation under the Health Problems section that Patient #1 had Mental Health Problems, HTN and GERD.

A review of the patient's Interdisciplinary Treatment Plan revealed that Patient #1 was care planned for Altered Thoughts, Depression, and Poor Impulse Control. There was no documented evidence that the patient was care planned for HTN or GERD.

Patient #2
The patient was admitted to the hospital on 07/24/15 with admit diagnoses of Suicidal Ideation and Depression.

A review of the History and Physical dated 07/25/15 revealed Patient #2 had HTN, CAD (Coronary Artery Disease) and Hyperlipidemia. Patient #2 was also on anticoagulant therapy.

A review of the patient's Interdisciplinary Treatment Plan revealed that Patient #2 was care planned for High risk to harm self or others, Depressed Mood related to history of mental illness as evidenced by: SI (suicidal ideation)/gestures and Altered Thoughts/Psychosis related to history of mental illness as evidenced by: Depression and SI. Further review revealed HTN, CAD, hypercholesterolemia and anticoagulant therapy were not addressed in the patient ' s current plan of care.

Patient #3:
Review of the medical record revealed the patient was a 71 year old female admitted to the hospital on 07/31/15 with the diagnoses of Depressive Disorder, Hypertension, Hypothyroidism, and Chronic Obstructive Pulmonary Disease.

Review of the medication orders revealed, in part: Metoprolol Tartrate (Hypertension) 50 mg (milligrams) by mouth twice a day, Lisinopril 30 mg daily (Hypertension), Synthroid (Hypothyroidism) 50 mcg (micrograms) by mouth every morning, and Ventolin inhalation (Chronic Obstructive Pulmonary Disease) two puffs every 6 hours as needed for shortness of breath.

Review of the Interdisciplinary Treatment Plan revealed no documented evidence that care plans were developed for Hypertension, Hypothyroidism, and Chronic Obstructive Pulmonary Disease.

In an interview on 08/06/15 at 9:44 a.m., S3RN/IC/QA confirmed that Patient #3's interdisciplinary treatment plan did not address the patient's medical conditions.

Patient #4
Review of Patient #4's medical record revealed he was a 72 year old male admitted on 07/27/15 with diagnoses of Chronic Paranoid Schizophrenia, GERD (Gastroesophageal Reflux Disease), Epilepsy, Hypertension, and COPD (Chronic Obstructive Pulmonary Disease).

Review of Patient #4's "Master Treatment Plan" revealed problems identified with a treatment plan initiated on 07/27/15 included high risk to harm others, anxiety, and Diabetes Mellitus Type 2. Risk for infection related to UTI (Urinary Tract Infection) was added on 08/01/15. There was no documented evidence that Patient #4's nursing care was developed for GERD, Epilepsy, Hypertension, and COPD. Review of his physician orders at admit revealed an order for group therapy and individual therapy.

Review of Patient #4's medical record on 08/04/15 revealed no documented evidence he had received individual therapy since he was admitted.

Review of Patient #4's interventions for "High Risk To Harm self Or Others" revealed the following:
Group psychotherapy 1 time a day, 1 to 4 days per week, for one hour each by counseling staff: there was no documented evidence of the specific frequency at which the group would be held, the specific topic to be discussed in the group setting, and the name of the counseling staff responsible for the group;
Psych-education group 1 time a day, 1 to 4 days per week, for one hour each by the counseling staff: there was no documented evidence of the specific frequency at which the group would be held, the specific topic to be discussed in the group setting, and the name of the counseling staff responsible for the group;
Nursing education on assessed needs: there was no documented evidence of the specific patient needs related to education and the name of the nursing staff responsible for the education.
All selected interventions (9 total interventions circled) had no documented evidence of the specific patient intervention, approach, and frequency to be implemented.

Review of Patient #4's treatment plans implemented for anxiety, Diabetes, and risk for infection had no documented evidence of the specific focus of interventions, the name of the staff person responsible for the intervention, and the frequency at which the intervention would be done specifically for Patient #4.

Patient #12
The patient was admitted to the hospital on 08/01/15 with admit diagnoses of Bipolar Disorder and Depression.

A review of the History and Physical dated 08/02/15 revealed that Patient #12 had Type 2 Diabetes.

A review of the Physician order dated 08/02/15 revealed in part: Accu-check before each meal and before bedtime.

A review of the initial Nursing Admission Assessment dated 08/01/15 revealed documentation under the Health Problems section that Patient #12 had Mental Health Problems and Diabetes

A review of the patient's Interdisciplinary Treatment Plan revealed that Patient #12 was care planned for Altered Thoughts, Depression, and Poor Impulse Control. There was no documented evidence that the patient was care planned for Diabetes.

Patient #13
Review of Patient #13's medical record revealed he was a 35 year old male admitted on 07/16/15 with diagnoses of Chronic Paranoid Schizophrenia with Acute Exacerbation and Bronchitis secondary to cigar smoking. Review of his physician orders revealed an order at admit for group therapy and individual therapy.

Review of Patient #13's medical record on 08/05/15 revealed no documented evidence that he had received individual therapy since admit.

Review of Patient #13's "Physician Progress Notes" of 07/20/15, 07/21/15, and 07/22/15 revealed entries by the physician of sexually inappropriate behavior being reported by the nursing staff.

Review of Patient #13's "Additional Nursing Notes" dated 07/20/15 revealed an entry by S35LPN (Licensed Practical Nurse) at 10:45 p.m. that she had notified the psychiatrist that Patient #13 was exhibiting inappropriate behavior and taking off his clothes in the room with his roommate present.

Review of Patient #13's "Master Treatment Plan" revealed problems of altered thoughts and depressed mood were identified with a treatment plan initiated on 07/16/15. There was no documented evidence that a nursing care plan was developed for Bronchitis. There was no documented evidence that Patient #13's nursing care plan was revised when he began to exhibit sexually inappropriate behaviors on 07/20/15. Further review revealed the established treatment plans for depressed mood and altered thoughts had no interventions selected as evidenced by the space for frequency being blanks and no intervention circled indicating that it had been selected as an intervention.

In an interview on 08/05/15 at 12:10 p.m., S20RN indicated he was working on Patient #13's discharge paperwork currently, because Patient #13 was discharged on the day of this interview. He further indicated he had not worked previously before this day since Patient #13 was admitted, and he (S20RN) had not been informed in report that Patient #13 had exhibited sexually inappropriate behavior. After reviewing Patient #13's nursing care plan, S20RN confirmed a nursing care plan had not been developed for sexually inappropriate behavior.

In an interview on 08/05/15 at 12:35 p.m., S4DON (Director of Nursing) indicated a RN should have assessed Patient #13 when began to exhibit sexually inappropriate behavior and developed a nursing care plan at that time to address this problem. S4DON indicated that medical problems should be addressed in the patient's care plan, and if the patient is receiving medication to treat a medical condition, the medical condition should be care planned.

In an interview on 8/03/15 at 3:15 p.m. with S16RN, she was asked if the nursing care plans were based on assessing all the patient's nursing care needs, as well as, the care needs relating to the admitting diagnoses. S16RN indicated that nurses usually care planned patients for a couple of the patient's medical problems and a couple of the patient's mental health problems. S16RN indicated that she was not sure if the hospital's care plan policy addressed how many medical care problems and how many mental care problems the nurses were required to include in a patient's care plan. S16RN indicated that she usually care planned for the patient's most outstanding medical care needs, like Diabetes.

In an interview on 08/05/15 at 11:35 a.m., S24LMSW (Licensed Medical Social Worker) indicated she sometimes does individual therapy with patients, but she doesn't document when she does it. She further indicated she would do individual therapy if it was ordered by the physician, but she doesn't look at the pre-printed admit orders where individual therapy is ordered for Patient #13. S24LMSW indicated since the hospital is a "short term facility", most of the therapy provided is in the group setting.

In an interview on 08/06/15 at 3:20 p.m., S7SW (social worker) indicated the pre-printed physician orders are a "checklist". She further indicated if the physician wanted individual therapy, the physician would write an order. She confirmed that she doesn't look at the "Physician's Admit Orders & (and) Admit Note" (where orders were written for individual therapy). After review of the patients' treatments plans, S7SW confirmed the frequency and focus of groups was not individualized for each patient.









30172

Based on record reviews and interviews, the hospital failed to ensure that the written treatment plan for each patient included short-term and long-range goals that are stated as expected behavioral outcomes for the patient for 2 (#4, #13) of 10 (#1, #2, #3, #4, #6, #8, #9, #10, #12, #13) patient records reviewed for the treatment plan goals from a total of 19 sampled patient records.
Findings:

Review of the hospital policy titled "Treatment Planning", presented as a current policy by S3RN/IC/QA (registered nurse/infection control/quality assessment), revealed that a multidisciplinary approach was to be used in the development and implementation of the Master Treatment Plan for each patient to ensure continuity of care from admission to the discharge of the patient's stay. Preliminary Treatment Plans are completed within 24 hours of admission by the physician and the admitting nurse. The Master Treatment Plan is to be completed by the fifth day of admission. Further review revealed the plan will contain behavioral objectives written in measurable terms and include target dates as well as active medical issues that the patient is currently being treated for.

Patient #4
Review of Patient #4's medical record revealed he was a 72 year old male admitted on 07/27/15 with diagnoses of Chronic Paranoid Schizophrenia, GERD (Gastroesophageal Reflux Disease), Epilepsy, Hypertension, and COPD (Chronic Obstructive Pulmonary Disease).

Review of Patient #4's "Master Treatment Plan" revealed problems identified with a treatment plan initiated on 07/27/15 included high risk to harm others, anxiety, and Diabetes Mellitus Type 2. Risk for infection related to UTI (Urinary Tract Infection) was added on 08/01/15.

Review of Patient #4's long-range goal for "High Risk To Harm Self Or Others" revealed no documented evidence that it was stated in measurable terms as evidenced by it stating "patient will verbalize support systems available after discharge." Review of the short-term goals revealed no documented evidence they were stated in measurable terms as written: "patient will state he/she no longer has thoughts of harming self or others" and "patient will comply with prescribed medication regimen daily and report any side effects". Review of the stated long-range goal for anxiety, "patient will acknowledge the core conflict that is the source of the anxiety and able to verbalize his/her support system", revealed no means of how this goal could be measured to determine when the goal was met.

Patient #13
Review of Patient #13's medical record revealed he was a 35 year old male admitted on 07/16/15 with diagnoses of Chronic Paranoid Schizophrenia with Acute Exacerbation and Bronchitis secondary to cigar smoking.

Review of Patient #13's "Master Treatment Plan" revealed problems of altered thoughts and depressed mood were identified with a treatment plan initiated on 07/16/15. Review of the short-term goals for depressed mood revealed no documented evidence that they goals were stated in measurable terms: "patient will demonstrate an increase in energy level" and "patient will report improved sleep patterns for 2 consecutive nights."

In an interview on 08/05/15 at 12:35 p.m., S4DON (Director of Nursing) reviewed patients' treatment plans and indicated the goals were not stated in measurable terms and observable behaviors.

Based on record reviews and interviews, the hospital failed to ensure the written treatment plan included the specific treatment modalities utilized as evidenced by failure to have specific interventions identified for each patient for 4 (#4,#6, #13,#15) of 11 (#1, #2, #3, #4, #6, #8, #9, #10, #12, #13, #15) patient records reviewed for the treatment plan interventions from a total of 19 sampled patient records.
Findings:

Review of the hospital policy titled "Treatment Planning", presented as a current policy by S3RN/IC/QA (registered nurse/infection control/quality assessment), revealed that a multidisciplinary approach was to be used in the development and implementation of the Master Treatment Plan for each patient to ensure continuity of care from admission to the discharge of the patient's stay. Preliminary Treatment Plans are completed within 24 hours of admission by the physician and the admitting nurse. The Master Treatment Plan is to be completed by the fifth day of admission. The intervention strategies are the actions and approaches to be taken by the staff in assisting the patient in resolving the identified problem and reaching the discharge goal. Intervention strategies must be very specific.

Patient #4
Review of Patient #4's medical record revealed he was a 72 year old male admitted on 07/27/15 with diagnoses of Chronic Paranoid Schizophrenia, GERD (Gastroesophageal Reflux Disease), Epilepsy, Hypertension, and COPD (Chronic Obstructive Pulmonary Disease).

Review of Patient #4's "Master Treatment Plan" revealed problems identified with a treatment plan initiated on 07/27/15 included high risk to harm others, anxiety, and Diabetes Mellitus Type 2. Risk for infection related to UTI (Urinary Tract Infection) was added on 08/01/15.

Review of Patient #4's interventions for "High Risk To Harm self Or Others" revealed the following:
Group psychotherapy 1 time a day, 1 to 4 days per week, for one hour each by counseling staff: there was no documented evidence of the specific frequency at which the group would be held, the specific topic to be discussed in the group setting, and the name of the counseling staff responsible for the group;
Psych-education group 1 time a day, 1 to 4 days per week, for one hour each by the counseling staff: there was no documented evidence of the specific frequency at which the group would be held, the specific topic to be discussed in the group setting, and the name of the counseling staff responsible for the group;
Nursing education on assessed needs: there was no documented evidence of the specific patient needs related to education and the name of the nursing staff responsible for the education.
All selected interventions (9 total interventions circled) had no documented evidence of the specific patient intervention, approach, and frequency to be implemented.

Review of Patient #4's treatment plans implemented for anxiety, Diabetes, and risk for infection had no documented evidence of the specific focus of interventions, the name of the staff person responsible for the intervention, and the frequency at which the intervention would be done specifically for Patient #4.

Patient #6
Review of Patient #6's medical record revealed she was a 47 year old female admitted on 08/1/15 with diagnoses of Depression and Suicidal Ideation and Hypertension. The patient was also started on antibiotics, on admit, due to mild dysuria.
Review of Patient #6's "Master Treatment Plan" revealed problems identified with a treatment plan initiated on 08/1/15 included depressed mood, high risk to harm others, ineffective coping and Genitourinary.
Review of Patient #6's interventions for "Depressed Mood" revealed the following:
Group psychotherapy 1 time a day, 1 to 5 days per week, for one hour each by counseling staff: there was no documented evidence of the specific frequency at which the group would be held, the specific topic to be discussed in the group setting, and the name of the counseling staff responsible for the group;
Psycho-education group 1 time a day, 1 to 5 days per week, for one hour each by the counseling staff: there was no documented evidence of the specific frequency at which the group would be held, the specific topic to be discussed in the group setting, and the name of the counseling staff responsible for the group;
Nursing education on assessed needs: there was no documented evidence of the specific patient needs related to education and the name of the nursing staff responsible for the education.
All selected interventions (8 total interventions circled) had no documented evidence of the specific patient intervention, approach, and frequency to be implemented.
Review of Patient #6's treatment plans implemented for high risk to harm others and ineffective coping had no documented evidence of the specific focus of interventions, the name of the staff person responsible for the intervention, and the frequency at which the intervention would be done specifically for Patient #6.
Patient #13
Review of Patient #13's medical record revealed he was a 35 year old male admitted on 07/16/15 with diagnoses of Chronic Paranoid Schizophrenia with Acute Exacerbation and Bronchitis secondary to cigar smoking.

Review of Patient #13's "Physician Progress Notes" of 07/20/15, 07/21/15, and 07/22/15 revealed entries by the physician of sexually inappropriate behavior being reported by the nursing staff.

Review of Patient #13's "Additional Nursing Notes" dated 07/20/15 revealed an entry by S35LPN (Licensed Practical Nurse) at 10:45 p.m. that she had notified the psychiatrist that Patient #13 was exhibiting inappropriate behavior and taking off his clothes in the room with his roommate present.

Review of Patient #13's "Master Treatment Plan" revealed problems of altered thoughts and depressed mood were identified with a treatment plan initiated on 07/16/15. There was no documented evidence that Patient #13's nursing care plan was revised when he began to exhibit sexually inappropriate behaviors on 07/20/15. Further review revealed the established treatment plans for depressed mood and altered thoughts had no interventions selected as evidenced by the space for frequency being blanks and no intervention circled indicating that it had been selected as an intervention.


Patient #15
Review of Patient #15's medical record revealed she was a 23 year old female admitted on 07/30/15 with an admit diagnosis of Schizophrenia and a history of seizures.
Review of Patient #15's "Master Treatment Plan" revealed problems identified with a treatment plan initiated on 08/1/15 included altered thoughts, depressed mood,medication non-compliance and Neurosystem related to seizures.
Review of Patient #15's interventions for "altered thoughts" revealed the following:
Group psychotherapy 1 time a day, 1 to 5 days per week, for one hour each by counseling staff: there was no documented evidence of the specific frequency at which the group would be held, the specific topic to be discussed in the group setting, and the name of the counseling staff responsible for the group;
All selected interventions (7 total interventions circled) had no documented evidence of the specific patient intervention, approach, and frequency to be implemented.
Review of Patient #15's treatment plans implemented for depressed mood and medication non-compliance had no documented evidence of the specific focus of interventions, the name of the staff person responsible for the intervention, and the frequency at which the intervention would be done specifically for Patient #15.

In an interview on 08/05/15 at 12:10 p.m., S20RN confirmed a nursing care plan had not been developed for sexually inappropriate behavior for Patient #13.

In an interview on 08/05/15 at 12:35 p.m., S4DON (Director of Nursing) indicated a RN should have assessed Patient #13 when began to exhibit sexually inappropriate behavior and developed a nursing care plan at that time to address this problem. S4DON indicated that medical problems should be addressed in the patient's care plan, and if the patient is receiving medication to treat a medical condition, the medical condition should be care planned.

In an interview on 08/06/15 at 3:20 p.m., S7SW (social worker) indicated, after review of the patients' treatments plans, that the frequency and focus of groups was not individualized for each patient.

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Special Staff Requirements for Psychiatric Hospital as evidenced by:

1) Failing to ensure S4DON (Director of Nursing) met the qualifications required by the Louisiana State Licensing Regulations for Hospitals for the psychiatric DON (see findings in B-0146).

2) Failing to ensure the recreational therapists were qualified to provide comprehensive therapeutic activities consistent with each patient's active treatment plan as evidenced by failure to have documented evidence that the therapist had been evaluated for competency to perform his/her duties for 2 (S12, S13) of 2 recreational therapists employed and whose personnel files were reviewed for competency (see findings in tag B-0158).

Based on record review and interview, the hospital failed to ensure that S4DON (Director of Nursing) met the qualifications required by the Louisiana Licensing Regulations as evidenced by failure to have 5 years of nursing experience.
Findings:

Review of the Louisiana State Licensing Regulations for Hospitals revealed the Director of Nursing in a psychiatric hospital must meet one of the following requirements:
1) Master's Degree in psychiatric or mental health nursing;
2) Master's degree in a related field, such as psychology or nursing education, and 5 years nursing experience and 3 years providing nursing care to the mentally ill;
3) Bachelor's Degree, Associate's Degree, or Diploma in nursing with documented evidence of education; programs focused on treating psychiatric patients and at least 5 years nursing experience, 3 of which were providing nursing care to the mentally ill or receive regular, documented supervision/consultation from a master's-prepared psychiatric nurse.

Review of S4DON's personnel file revealed he was hired on 08/03/15 as the DON. Further review revealed he was initially licensed as a RN on 04/15/11 (did not have 5 years nursing experience).

In an interview on 08/06/15 at 9:30 a.m., S6DirHR/HIM (Director of Human Resources and Health Information Management) indicated she thought the DON had to have 3 years of psychiatric nursing experience and didn't know that S4DON had to have been licensed as a RN for 5 years..

Based on record reviews and interview, the hospital failed to ensure the recreational therapists were qualified to provide comprehensive therapeutic activities consistent with each patient's active treatment plan as evidenced by failure to have documented evidence that the therapist had been evaluated for competency to perform his/her duties for 2 (S12, S13) of 2 recreational therapists employed and whose personnel files were reviewed for competency. Findings:

Review of S12ActTher's (Activity Therapist) personnel file revealed she was hired on 05/20/14. Further review revealed no documented evidence that she had been evaluated for competency to perform the duties of Activity Therapist.

Review of S13RecTher's (Recreational Therapist) personnel file revealed she was hired on 05/01/14. Further review revealed no documented evidence that she had been evaluated for competency to perform the duties of Recreational Therapist.

In an interview on 08/06/15 at 9:30 a.m., S6DirHR/HIM (Director of Human Resources/Health Information Management) confirmed the personnel files of S12ActTher and S13RecTher had no evidence that they had been evaluated for competency.