HospitalInspections.org

Based on record review and interview, the hospital failed to assure that personnel completed criminal background checks by an authorized agent of the Louisiana State Police in the manner required by R.S. 15:587.1 et seq. prior to hire or employment for all unlicensed personnel providing care for adults and for all staff providing care to children. This deficient practice was evidence by 10 (S5DD, S8PLPC, S11LPN, S12MHT, S13MM, S14RN, S15MHT, S16RN, S17RN, S18ES) of 10 (S5DD, S8PLPC, S11LPN, S12MHT, S13MM, S14RN, S15MHT, S16RN, S17RN, S18ES) personnel records reviewed regarding criminal background checks.
Findings:

Review of S5DD's human resource filed revealed a hire date of 11/02/2020. Further review revealed a criminal background check completed by PreCheck which is an unauthorized agency;
Review of S8PLPC's human resource filed revealed a hire date of 03/16/2017. Further review revealed a criminal background check completed by PreCheck which is an unauthorized agency;
Review of S11LPN's human resource filed revealed a hire date of 03/06/2023. Further review revealed a criminal background check completed by PreCheck which is an unauthorized agency;
Review of S12MHT's human resource filed revealed a hire date of 11/07/2022. Further review revealed a criminal background check completed by PreCheck which is an unauthorized agency;
Review of S13MM's human resource filed revealed a hire date of 09/09/2019. Further review revealed a criminal background check completed by PreCheck which is an unauthorized agency;
Review of S14RN's human resource filed revealed a hire date of 03/01/2021. Further review revealed a criminal background check completed by PreCheck which is an unauthorized agency;
Review of S15MHT's human resource filed revealed a hire date of 02/06/2023. Further review revealed a criminal background check completed by PreCheck which is an unauthorized agency;
Review of S16RN's human resource filed revealed a hire date of 09/04/2018. Further review revealed a criminal background check completed by PreCheck which is an unauthorized agency;
Review of S17RN's human resource filed revealed a hire date of 03/06/2023. Further review revealed a criminal background check completed by PreCheck which is an unauthorized agency;
Review of S18ES's human resource filed revealed a hire date of 12/05/2017. Further review revealed a criminal background check completed by PreCheck which is an unauthorized agency;

In an interview on 04/12/2023 at 10:00 a.m., S3RN and S7HR verified the hospital used PreCheck for all employee background checks.

44495

Based on observation and interview the hospital failed to ensure each patient's right to care in a safe setting. This deficient practice is evidenced by 1) failure to provide a seclusion room on 2 (a, b) of 5 (a, b, f, g, h) buildings with inpatient units; 2) presence of unlocked base cabinets in 1 (a) of 5 (a, b, f, g, h) buildings with inpatient units 3) phones accessible to patients with cords over 3 feet long; 4) slotted screws used in cover plates; 5) presence of forks in plastic bags accessible to patients in 1 (a) of 5 (a ,b , f, g, h) buildings used by inpatients; 6) plastic film peeling off of the windows in patient care areas; and, 7) 2 sharp pencils in Room k; and 8) a large plastic bag with a styrofoam container in the bag placed in the large trash can in the unit h's dayroom presenting a danger to patients.
Findings:

1) Failure to provide a seclusion room;

Tour of the hospital on 04/10/2023 between 10:00 a.m. and 12:50 p.m. revealed no seclusion or restraint room in buildings a and b.

In interview on 04/10/2023 at 10:37 a.m. during the tour, S2RN verified there was no seclusion room in building b and stated the facility rarely used the seclusion rooms.

In interview on 04/10/2023 at 2:56 p.m., S3RN verified there were no seclusion or restraint rooms in buildings/ units a and b at the hospital. S3RN also verified the hospital had no restraint equipment. S3RN stated only physical holds or chemical restraints were used to prevent patients from injuring themselves or others on the unit when de-escalation did not work.

2) Presence of unlocked base cabinets in 1 (a) of 5 (a, b, f, g, h) buildings with inpatient units;

Tour of the hospital on 04/10/2023 between 10:00 a.m. and 12:50 p.m. revealed 2 unlocked base cabinets in the common area of unit a. The cabinets were noted to have activity supplies stored in them.

In interview at 10:17 a.m., S1CEO verified the cabinets were unlocked.

In interview at 10:20 a.m., S4DES verified the cabinets were placed on the unit before locks were installed.

3) Phones accessible to patients with cords over 3 feet long;

Limited inspection of the hospital on 04/10/2023 at 8:45 a.m., revealed 2 phones in area i. One phone was on the wall and was noted to have a short cord. The second phone was sitting on an end table. It was plugged into a jack on the wall with a long cord and had a spiral cord attached to the receiver which extended over 3 feet.

Throughout the survey as surveyors walked through area i, patients were noted to be waiting in this area for admission.

In interview on 04/11/2023 at 10:40 a.m., S1CEO verified the corded phone was used because the phone on the wall was not working and had been removed.

In interview on 04/11/2023 at 12:41 a.m., S2RN verified it was not uncommon for patients to wait several hours in i for evaluation for admission because it was part of an emergency department.

4) Slotted screws used in cover plates;

Tour of building f on 04/10/2023 at 11: 55 a.m. revealed a slotted screw in an outlet cover plate in the common area.

Tour of building h on 04/10/2023 at 12:27 p.m. revealed a slotted screw in a light switch cover plate in a hallway.

S3RN verified the slotted screws at the time of discovery.

5) Presence of forks in plastic bags accessible to patients;

Tour of building a on 04/10/2023 at 10:17 a.m. revealed a bin of plastic forks in individual plastic packages on a counter in the refreshment area.

At the time of discovery, S1CEO verified the utensils should not be unattended on the unit and there should not be plastic bags on the unit.

6) plastic film peeling off of the windows in patient care areas;

Tour of the hospital between 10:00 a.m. and 12:50 p.m. revealed the following units with sheets of plastic peeling off of the windows - units b and f.

In interview on 04/10/2023 at 10:30 a.m., S4DES verified there was a problem with the plastic peeling away from the windows in patient care areas.

7) 2 sharp pencils on the nightstand of Room k; and,

In interview on 04/10/2023 at 10:55 a.m., S1CEO verified the presence of 2 sharp pencils in room k and indicated the sharp pencils should not be in the patient's room.

8) a large plastic bag with a styrofoam container in the bag placed in the large trash can in the unit h's dayroom presenting a danger to patients.

In interview on 04/10/2023 at 11:50 a.m., S3RN verified that the plastic bag was in the trash can and that plastic bags should not be in patient care areas.

Based on record review and interview, the hospital failed to ensure all incidents of abuse, neglect, and/or harassment were reported and analyzed, and the hospital was in compliance with applicable local, State, and Federal Laws and Regulations. This deficient practice was evidenced by the hospital's failure to report abuse within 24 hours to the Department of Health and Hospitals or law enforcement for 2 (#2, R1) of 2 (#2, R1) patients reviewed for mandatory reporting.
Findings:

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

Patient #2
Review of the report for an incident that occurred on 03/24/2023 in building/ unit f at 2:00 p.m. revealed, ""@1400 R9 was watching TV and was told by RN to start turning off the TV to get ready for group. R10 grabbed the remote from his hands and R9 landed a punch with his left hand to the left side of R10's face. @1401 while the nurse was distracted, R11 and R12 jumped out of their seats to punch Patient #2 in a pre-planned attack. Patient #2 was knocked to the ground, drug on the floor by her hair, and punched on her face and on body. Staff intercepted, as well as numerous peers jumped into "help." @ 14:10 "Patient #2 was removed from the bottom of a human pile on the floor and sequestered to the Quiet Room for her safety. Glasses smashed and pt c/o pain to right eye & face."

Further review of the incident report reveals no documentation of why it took 9 minutes to resolve the fight.

Review of the incident report for R12 for the same incident on 03/24/2023 at 2:00 p.m. further revealed, "@1520, S12MHT was hurt and had to go to Urgent Care."

In interview on 04/11/2023 at 1:46 p.m., S3RN verified the incident was not reported to local law enforcement or Louisiana Department of Health as required. S3RN verified she did not report patient to patient abuse as required if the investigation determined there was no neglect on the part of the staff.

Patient R1
Review of medical record revealed Patient R1 eloped from the hospital on 02/08/2023 at 6:00 p.m. with no documentation of the incident being reported to the state or law enforcement.

In an interview on 04/11/2023 at 12:23 p.m., S3RN verified there was no documentation in the medical record regarding Patient R1's elopement or notification to law enforcement; S3RN also verified there was no documentation of a seventy-two hour written notice of discharge in the medical record.


48050

Based on record review and interview the hospital failed to ensure the use of seclusion was performed according to hospital policy. This deficiencydeficient practice is evidenced by failure to notify the Department of Children and Family Services (DCFS) representative in 2 (Pt.1 and Pt.2) of 2 (Pt. 1-2) reviewed patient records where notification was required.
Findings:

Review of the hospital policy titled "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion" revealed, in part, "With any of restraints/seclusion episode for a patient that is under 16 years of age, unless they are an emancipated minor, shall require notification of the patient, guardian, family member, or conservator will be notified. . . . Restraint/seclusion be used with patients over the age of 16 or emancipated minors shall require notification if the patient and a family member had consented to release of information. The form, Authorization for Release of Protected Health Information, must be signed by the patient prior to contacting the family."

Review of the letter from DCFS provided to the hospital after a child under their custody is admitted states, "This correspondence will constitute a Letter of Expectation between the Department of Children and Family Services and the hospital. . . . The Department of Children and Family Services shall be notified immediately of restraint or seclusion and informed of the minor patient's status."


Patient #1
Review of the medical record for Patient #1 revealed the patient was admitted on 02/06/2023 and was in DCFS custody. The letter of expectation was attached in the front of the medical record.

Review of the UHS Restraint/ Seclusion Order/ Documentation Form revealed on 03/18/2023 at 6:55 p.m. chemical restraint was used. Further review of the form revealed documentation in the box for notifications, "Pt in DCFS office closed."

In an interview on 04/12/2023 at 4:05 p.m., S3RN verified there was no documentation that DCFS was immediately notified. There was no documentation a message was left with the office and the next documented contact with the office was several days later by a social worker and does not mention the chemical restraint.

Patient #2
Review of the medical record for Patient #2 revealed the patient was admitted on 03/02/2023 and was in DCFS custody. The letter of expectation was attached in the front of the medical record.

Review of the UHS Restraint/ Seclusion Order/ Documentation Form revealed on 03/11/2023 at 9:40 a.m. physical restraint was used. Further review of the form revealed documentation in the box for notifications, "Called father. No answer. No VM to leave message."

In interview on 04/12/2023 at 12:30 p.m., S3RN verified there was no documentation for release of information to the father and there was no evidence DCFS was notified.

Based on record review and interview the hospital failed to identify opportunities for improvement and document a plan which included a process to evaluate the effectiveness of changes implemented. This deficient practice is evidenced by failure of hospital staff to complete the Patient's Personal Property Checklist in 7 (1, 5, R3, R5, R6, R7, R8) of 8 (1, 5, R3- R8) records reviewed for completion of the form.
Findings:

Review of the policy titled "River Oaks Hospital Quality Assurance and Performance Improvement" revealed in part, "The QAPI program is designed to provide a coordinated, objective and systematic approach to organization-wide performance improvement activities. The program is based upon an integrated and collaborative approach to increase the probability of desired patient outcomes by assessing and improving those governance, managerial, clinical and support processes that most effect patient outcomes. The plan is used as a guide to design, measure, assess and improve organizational performance; identify, minimize and prevent organizational risks and ensure delivery of state patient care."

Review of the Patient Relations Details Report supplied to the survey team for the review of grievances revealed 12 grievances and 3 complaints submitted between 12/1/2022 and 03/14/2023. Review of the 12 grievances revealed 6 (R3-R8) involved missing personal items and 5 (R3, R4, R5, R7, and R8) were reimbursed for their losses.

Review of the hospital policy titled "Admission to Discharge: Personal Belongings, Valuables, Safety/Skin, & Contraband Searches" reveals in part, "1. Once the patient has been admitted/searched the Admissions PC will bring the patient's belongings and valuables to the Inventory Room. 2. Document all valuable items on the "Personal Belongings and Valuables Inventory List." Be specific as possible (i.e. name each credit card, amount of money, brand name items, etc.). Place all valuables in the "Patient Valuables Envelope Bag" with the patient's label on the front of the bag. At a minimum, the bad should indicate the patient's first name, last name, date of admission and unit. If there is more than one bag, Staff and will label each bag. . . . The patient, admissions PC, and witness will sign the "Personal Belongings & Valuables Inventory List" form attesting that everything they brought in has been recorded and inventoried." Instruction for discharge included, "at this time the patient will be able to go through their belongings and attest that they have received everything that they came with. . . . The patient and admissions PC will sign the "Personal Belongings & Valuables Inventory List Form."

Patient 1
Review of the medical record for Patient 1 revealed admission on 02/06/2023 and discharge on 04/03/2023.

Review of the Personal Belongings & Valuables Inventory List revealed a list of clothing the patient had on admission. The form was not signed by the patient or a witness. The form was signed and dated by one member of the staff. The inventory form was not completed at the time of discharge.

In interview on 04/11/2023 at 4:00 p.m.. S3RN verified the form was not properly filled out.

Patient 5
Review of the medical record for Patient 5 revealed admission on 04/04/2023. Patient 5 was still admitted in the facility at the time of the survey.

Review of the Personal Belongings & Valuables Inventory List revealed six envelopes were filled at admission but the form was not filled out with an itemized list of the items and the form was not signed by the patient, witnessed, or any of the staff.

In interview on 04/11/2023 at 9:33 a.m. S3RN verified the form was not properly filled out.

Patient R3
Review of the medical record for R3 revealed admission on 11/22/2022 and discharge on 11/30/2022.

Review of the Personal Belongings & Valuables Inventory List revealed R3 was admitted with one envelope and the form contained a list of items held in the envelope. There was no witness signature on the form. The form was signed and dated by the patient and one member of the staff at the time of admit. The form was not completed at the time of discharge.

Patient R5
Review of the medical record for R5 revealed admission on 11/26/2022 and discharge on 11/30/2022.

Review of the Personal Belongings & Valuables Inventory List revealed the inventory was done on 11/28/2022 and was not signed by the patient or a witness. The form was signed and dated by one staff member. At the time of discharge the form was signed by the patient and a member of staff and dated 11/30/2022.

Patient R6
Review of the medical record for R6 revealed admission on 12/09/2022 and discharge on 12/14/2022.

Review of the Personal Belongings & Valuables Inventory List revealed the patient was admitted with cash but there is no number for the envelope where it was supposed to be stored. There was no witness signature on the form. The form was signed by the patient and a member of the staff on admission. At the time of discharge the form was not signed by the patient. The discharge part was signed and not dated by a member of the staff.

Patient R7
Review of the medical record for R7 revealed admission on 02/24/2023 and discharge on 02/27/2023.

Review of the medical record revealed there was no Personal Belongings & Valuables Inventory List.


Patient R8
Review of the medical record for R8 revealed admission on 02/06/2023 and discharge on 03/20/2023.

Review of the Personal Belongings & Valuables Inventory List revealed on admission the patient's possessions were listed and placed in a numbered envelope. The form was not signed by a member of staff or a witness, but it was signed by the patient. At the time of discharge the form was signed and dated by the patient and a member of the staff on 03/20/2023 at 10:15 a.m.

In interview on 04/12/2023 at 1:22 p.m., S3RN verified the forms for R3, R5, R6, R7, and R8 were not properly filled out.

In interview on 04/11/2023 at 2:35 p.m., S2RN presented an agenda for a recent meeting where the personal inventory form was discussed and a copy of the sign in roll for that meeting.

In interview on 04/12/2023 at 12:45 p.m., S3RN discussed the education that had been performed with the staff and the plan that was formulated but not written for the lost personal items and the incomplete inventory forms.

During the exit conference, S3RN expressed that she thought the hospital had properly addressed the incomplete inventory forms. The sample reviewed included one admission from one week prior to survey entry (Patient 5) and the form was not properly filled out in that record.

During the exit conference, S1CEO questioned whether it was reasonable to expect the hospital to do a complete inventory of the possessions brought in by their homeless patients. The sample only contained 3 homeless patients.

Based on record review and interview the psychiatric hospital failed to ensure drugs and biologicals were administered as ordered by the licensed practitioner and according to standard of care. This deficient practice is evidenced by 1) failure to administer prn medication as ordered in 1(#5) of 5 (#1-#5) records reviewed for medication administration; 2) failure to follow up for response to prn pain medication in 1 (#5) of 5 (#1-#5) records reviewed for medication administration.

Findings:

Review of the medical record for Patient #5 revealed admission on 04/04/2023 for opioid abuse with withdrawal.

Review of the orders from admission revealed an order placed on 04/04/2023 at 3:00 p.m. for "buprenorphine tablet 4 mg; Sublingual every 4 hours prn; To give 4 mg use 2 of 2 mg for opiate withdrawal with a COWS (Clinical Opiate Withdrawal Scale) score >/= 12; max daily doses: 6."

Review of the medication administration record revealed the buprenorphine was given 04/04/2023 at 5:09 p.m., 04/06/2023 at 10:58 a.m., and 04/06/2023 at 5:08 p.m.


Review of the Observation log revealed the Clinical Opiate Withdrawal Scale (COWS) was not entered for 04/04/2023. Further review revealed COWS assessments on 04/06/2023 at 1:58 a.m. with a total score of 4, 7:05 a.m. with a total score of 4, 9:40 a.m. with a total score of 5, 3:11 p.m. with a total score of 5, 4:23 p.m. with a total score of 4 and 11:10 p.m. with a total score of 8.

In interview on 04/11/2023 at 1:16 p.m. S2RN and S3RN verified the medication was not administered as ordered. S2RN and S3RN verified there was no recorded COWS score for 04/04/2023 and the highest recorded COWs score for 04/06/2023 was 8.

2)Failure to follow up for response to prn pain medication in 1 (#5) of 5 (#1-#5) records reviewed for medication administration.

Review of the orders from admission revealed an order placed 04/04/2023 at 2:00 p.m. for "acetaminophen tablet 1,000 mg; Oral every 6 hours prn; To give 1,000 mg use 2 of 500 mg for pain scale 6-10."

Review of the medication administration record revealed the acetaminophen was given on 04/07/2023 at 7:46 p.m. Follow up for efficacy was done on 04/08/2023 at 1:53 a.m.

In interview on 04/11/2023 at 1:15 p.m., S2RN verified the standard of care is to follow up on the efficacy of prn pain medication around 1 hour after administration.

Based on observation and interview the hospital failed to ensure dietary services were organized to ensure the patients' nutritional needs were met in accordance with acceptable standards of practice. This deficient practice is evidenced by 1) Expired consumables; 2) Opened consumbales with no label to indicate the date of opening or expiration; and, 3) Unopened consumables in storage bins with no label to indicate the expiration date.
Findings:

Review of the hospital policy "Infection Control for Dietary Employees" revealed in part, "Flour sugar, rice etc. are kept in covered bins on wheels. The bin and cover are both labeled."

A tour of area e guided by S5DD on 04/10/ 2023 between 11:30 a.m. and 11:45 a.m. revealed the following:

1) Expired consumables:
a. Cheese crackers with peanut butter filling with expiration date of 01/17/2023
b. 2-2quart jars of honey parmesan wing sauce with expiration 09/05/2022

2) Opened consumables with no label to indicate the date of opening or expiration:
a. Open spaghetti wrapped in plastic wrap
b. Open cooking oil with no date of opening and no expiration date
c. Open flour in an unlabeled plastic bin
d. Open rice in an unlabeled plastic bin

3) Unopened consumables in storage bins with no label to indicate the expiration date.
a. Crispy rice treats
b. Single serve graham crackers
c. Single serve saltine crackers

At the time of discovery during the tour between 11:30 a.m. and 11:45 a.m., S5DD verified the above items were either expired or not properly labeled and stored.

Based on observation and interview the hospital failed to ensure proper handling and disposal of trash in durable, easily cleanable, insect and rodent proof containers. This deficient practice is evidenced by paper bags of trash left outside and unattended.
Findings:

Tour of the facility on 04/10/2023 at 11:25 a.m. revealed 5 large unsealed paper bags with visible trash lining the sidewalk in area j.

At the time of discovery S4DES verified the trash in the paper bags was placed there to be pick up later by maintenance staff.

Based on observation and interview, the hospital failed to maintain an effective infection prevention and control program including the prevention of the transmission of infection when 2 (S9LPN and S10RN) licensed nurses failed to identify the proper method to clean the glucometer to prevent the spread of infection and as per the hospital's procedure.
Findings:

An observation on 04/10/2023 at 10:15 a.m. of the glucometer cleaning instructions on unit a revealed a picture showing the nursing staff to use Super Sani-Cloth Germicidal disposable wipes to clean the glucometer in between patient use. The wipes were observed as being available to the staff.

In an interview on 04/10/2023 at 10:35 a.m., S9LPN assigned to unit b indicated she worked at the hospital for 6 months, failed to properly identify the method to clean the glucometer when she indicated she cleaned the glucometer in between patient use using an alcohol pad. S9LPN also indicated there was 1 (Pt. #5) patient who was getting accu-checks on unit b.

In an interview on 04/10/2023 at 11:05 a.m., S10RN assigned to unit b indicated he worked at the hospital for 3 years, failed to properly identify the method to clean the glucometer when he indicated he used some warm soapy water and a tissue to clean the glucometer in between patient use. S10RN further indicated he was assigned to administer medications on some shifts and there was 1 (Pt. #5) patient who was getting accu-checks on unit b.

In an interview on 04/10/2023 at 1:38 p.m., S3RM indicated the staff have been trained to use the Super Sani-Cloth Germicidal disposable wipes to clean the glucometer in between patient use and verified the methods verbalized by S9LPN and S10RN were not as per hospital policy.

Review of a report validated that Patient #5, who was a patient on unit b, was ordered insulin and accu-checks were used to assess blood glucose. Review of the orders for Patient #5 revealed the nursing staff was to perform tests for blood glucose monitoring before meals and at bedtime. Further review revealed physician's orders for regular humulin insulin subcutaneous before meals and at bedtime as needed for CBG of 0-60 give orange juice; for CBG 61-150 mL zero units; for CBG of 151-200mL give 5 units; for CBG of 201-250mL give 10 units; for CBG of 251-300mL give 15 units; for CBG 301-350mL give 20 units; for CBG of 301-350mL give 20 units; for CBG of 351-400mL give 25 units; for CBG > 400 call MD.

Based on observation and interview the hospital failed ensure adherence to infection prevention and control policies and procedures by hospital staff. This deficient practice is evidenced by 1) soiled linen found overflowing out of bins and on the floor of the soiled linen closet; 2) pink substance on the shower curtains and sticky adhesive on the shower walls throughout the facility; 3) no sink or basin for handwashing in the room designated for patient intake and physical examinations; and 4) patio l with a black coating on the patio, cigarette butts on the patio and hundreds of cigarette butts on the outer portion of the patio.
Findings:

1) Soiled linen found overflowing out of bins and on the floor of the soiled linen closet.

Review of the policy titled "Hazard Waste Disposal," reviewed 12/2023, revealed in part, " When hospital linens are soiled they must be placed into a blue soiled linen liner provided by the housekeeping department. Then it is to be placed into a soiled linen cabinet located on the unit."

Tour of building/unit f on 04/10/2023 at 12:20 p.m. revealed linen in the dirty linen closet overflowing from the bin and piled on the floor.

S2RN, S3RN and S4DES verified the above finding at the time of discovery.

Tour of building/unit h on 04/10/2023 at 12:32 p.m. revealed linen in the dirty linen closet overflowing form the bin and piled on the floor.

S3RN and S4DES verified the above finding at the time of discovery.

2) Pink substance on the shower curtains and sticky adhesive on the shower walls throughout the facility.

Tour of the facility between 10:00 a.m. and 12:50 p.m. revealed pink staining of the seam and lower section of the shower curtain in showers in buildings/units b and f and adhesive residue on shower walls in buildings/units a,b, and f.

At the time of discovery during the tour S2RN and S3RN verified the above findings.

3) No sink or basin for handwashing in the room designated for patient intake and physical examinations; and,

Tour if the intake area on 04/10/2023 at 12:36 p.m. revealed the intake/examination room had an examination bed but no sink

In interview at the time of discovery, S3RN verified there was no sink in the examination room. The room with the sink that had previously been the examination room had been converted into an office.

4) Patio l with a black coating on the patio, cigarette butts on the patio and hundreds of cigarette butts on the outer portion of the patio.

On 04/10/2022 at 10:15 a.m., a tour of unit a patio l revealed a black substance covering the concrete of the patio with cigarette butts surrounding the receptacle for cigarette butts. Further observation revealed hundreds of cigarette butts in the grass area lining the patio, 5 empty cigarette boxes and weeds growing over 2 feet high in the grass.

In interview at the time of discovery, S4DES verified the presence of the dirty patio and hundreds of cigarette butts in the grass, but indicated the patio is not on a schedule to be power washed and the lawn company cannot fit their riding lawn mower in the space to cut the grass.

Based on record review and interview, the hospital failed to maintain clinical records related to completion of the Formal Voluntary Admission (FVA) form for 1 (Pt. 4) of 5 (Pt. 1 - 5) sample records reviewed for completion of the legal status form.
Findings:

Review of the policy and procedure titled, "Legal Status - Patient Admission Status - Function: Rights" revealed, in part, it is the policy of the hospital for all admitted patients to have a recognized legal status. Further review revealed, Formal Voluntary Admissions include any individual who meets specified admission criteria may request admission to the hospital and will be asked to sign a request for formal voluntary admission and agrees to abide by the rules and regulation of the facility. Individuals requesting formal voluntary admission will be informed of the provisions of R.S. 28:171 governing voluntary admissions in Louisiana. Should this individual desire to be discharged from the facility, he/she will be asked to sign the Request for Release Form.

Review of Patient 4's medical record revealed an admit date of 04/05/2023 via a Formal Voluntary Admission. Review of the FVA form revealed the patient's signature with no documentation of the date, time, date of birth or address. Further review of the form revealed the physician's signature agreed that Patient 4 was suitable for a Voluntary Admission, however, the physician did not date or time the signature line making the form incomplete.

In an interview on 04/11/2023 at 2:37 p.m., S3RM verified the Formal Voluntary Form was incomplete.

Based on observation, interview and record review, the hospital failed to ensure it 1) Employed qualified professional personnel; and 2) Ensured that active treatment measures were furnished in accordance with accepted standards of professional practice providing the patient assistance with resolving or ameliorating the problems or circumstances that led to the hospitalization for 5 (R1, Pt.3, R6, R7, R13) of the 5 (R1, Pt. 3, R6, R7, R13) sampled medical records reviewed for active treatment.
Findings:

1) Employed qualified professional personnel; and,

Review of the job description/performance evaluation titled "Milieu Manager" revealed, in part, Education: Bachelor's degree in Psychology or related field, or two (2) years of college and commensurate experience required.. Further review revealed S13MM did not meet the minimum requirements listed in the hospital's job description for the position occupied since S13MM had no bachelor's degree and only two semesters of college, Fall 2020 and Spring 2021.

In an interview on 04/12/2023 at 1:20 p.m., S7HR verified that S13MM did not meet the minimum requirements of the job and had only two semesters of college classes.

Review of the job description/performance evaluation titled "Clinical Services Director" revealed, in part, requirements including a licensure/certification: Louisiana licensed Mental Health Professional (LPC, LCSW) or Registered Nurse (RN).

Review of S8PLPC's human resource file revealed she did not meet the minimum requirements listed in the hospital's job description for the position occupied. Review of S8PLPCs human resource file revealed she had a provisional LPC license.

In an interview on 04/12/2023 at 1:30 p.m., S7HR indicated S8PLPC, who was appointed as the Interim Director of Clinical Services, did not meet the minimum requirements listed in the hospital's job description.

2) Ensured that active treatment measures were furnished in accordance with accepted standards of professional practice providing the patient assistance with resolving or ameliorating the problems or circumstances that led the hospitalization.

Random Patient 1
Review of the medical record for Random Patient 1 revealed an admit date of 02/04/2023 via a Formal Voluntary legal status to unit b with diagnoses including Opiate Use Disorder Severe, Alcohol Use Disorder and Sedative Use Disorder. Further review revealed an interdisciplinary master treatment plan that included the following goals and interventions, in part: Random Patient 1 will demonstrate the use of 3 distress tolerance skills daily for 3 consecutive days prior to discharge and will have improved symptoms at discharge with interventions including Social Services groups 3 times daily for 60 minutes and Activity therapy group daily. Review of the clinical services group notes revealed the following:
Dated 02/03/2023 for 1:30p.m. - 2:30 p.m., Social Services group, revealed R1 did not attend the group and the patient's progress towards treatment goals was not documented; Further review revealed no supervisor's name, signature, date or time documented on the group note of the provisionally licensed LPC;
Dated 02/05/2023 for 11:30 a.m. - 12:30 p.m., Social Services group, revealed RPt.1 did not attend the group and the patient's progress towards treatment goals was not documented;
Dated 02/05/2023 for 3:30 p.m. - 4:30 p.m., Social Services group, revealed RPt.1 did not attend the group and the patient's progress towards treatment goals was not documented;
Dated 02/06/2023 for 3:00 p.m. - 4:00 p.m., Social Services group, revealed R1 did not attend the group and the patient's progress towards treatment goals was not documented;
Dated 02/05/2023 for 11:30 a.m. - 12:30 p.m., Social Services group, revealed no supervisor's name, signature, date or time documented on the group note of the provisionally licensed LPC;
Dated 02/05/2023 for 3:30 p.m. - 4:30 p.m., Social Services group, revealed no supervisor's name, signature, date or time documented on the group note of the provisionally licensed LPC;
Dated 02/08/2023 for 1:30 p.m. - 2:30 p.m., Social Services group, revealed no supervisor's name, signature, date or time documented on the group note of the provisionally licensed LPC;
R1 eloped from the hospital (See findings in A-286).

Patient 3
Review of the medical record for Pt. 3 revealed an admit date of 04/07/2023 via an Involuntary legal status to unit b with diagnoses including Bipolar Disorder and Alcohol Use Disorder. Further review revealed an interdisciplinary master treatment plan that included the following goal and interventions, in part: Patient 3 will be observed using DBT/CBT skills of distress tolerance, emotional regulation and mindfulness for 3 consecutive days prior to discharge with interventions including Social Services group therapy 2 times daily for 60 minutes and Activity therapy group daily. Review of the clinical services group notes revealed the following:
Dated 04/11/2023 for 3:00 p.m. - 4:00 p.m., Nursing group, revealed Pt. 3 did not attend the group and the patient's progress towards treatment goals was not documented;
Dated 04/09/2023 for 10:00 a.m. - 11:00 a.m., Activity Therapy group, revealed Pt. 3 did not attend and the patient's progress towards treatment goals was not documented;
Dated 04/09/2023 for 11:00 a.m. - 12:00 p.m., Social Services group, revealed Pt. 3 did not attend and the patient's progress towards treatment goals was documented as N/A;
Dated 04/08/2023 for 1:30 p.m. - 3:00 p.m., Social Services group, revealed Pt. 3 did not attend and the patient's progress towards treatment goals was documented as N/A;
Dated 04/08/2023 for 10:00 a.m. - 11:00 a.m., Activity Therapy group, revealed Pt. 3 did not attend and the patient's progress towards treatment goals was not documented.

Random Patient 6
Review of the medical record for R6 revealed an admit date of 02/13/2023 via FVA to unit a with diagnoses including Alcohol Use Disorder, Severe; Schizoeffective Disorder, Bipolar Type; Post Traumatic Stress Disorder, Chromic.. Further review revealed an interdisciplinary master treatment plan that included the following interventions, in part: R6 will develop competency in recognizing warning signs for relapse and practice 3 distress tolerance skills in a group setting, 3 times daily for 50 minutes by a PLPC; and, Assist R6 in identifying relapse triggers to increase awareness and crate chemical free alternatives to avoid relapse through creative arts and recreation intervention in a group setting, daily by an Activity Therapist. Review of the clinical services group notes revealed the following:
Dated 02/14/2023 for 3:00 p.m. - 4:00 p.m., Social Services group, revealed R6 did not attend the group and the patient's progress towards treatment goals was not documented; Further review revealed no supervisor's name, signature, date or time on the group note of the provisionally licensed LPC;
Dated 02/14/2023 for 8:30 a.m. - 9:30 a.m., Activity group, revealed R6 did not attend group and the patient's progress towards treatment goals was not documented; Further review revealed no supervisor's name, signature, date or time on the group note of the provisionally certified activity therapist;
Dated 02/15/2023 for 3:00 p.m. - 4:00 p.m., Social Services group, revealed R6 did not attend group and the patient's progress towards treatment goals was not documented;
Dated 02/15/2023 for 10:45 a.m. - 11:45 a.m., Social Services group, revealed R6 did not attend group and the patient's progress towards treatment goals was not documented;
Dated 02/15/2023 for 8:30 a.m. - 9:30 a.m., Activity Therapy group, revealed R6 did not attend group and the progress towards treatment goals was not documented;
Dated 02/16/2023 for 8:30 a.m. - 9:30 a.m., Activity Therapy group, revealed R6 did not attend and the patient's progress towards treatment goals was not documented;
Dated 02/18/2023 for 8:30 a.m. - 9:30 a.m., Activity Therapy group, revealed R6 did not attend and the patient's progress towards treatment goals was not documented;
Dated 02/18/2023 for 10:45 a.m. - 11:45 a.m., Social Services group, revealed R6 did not attend and the patient's progress towards treatment goals was not documented; Further review revealed no supervisor's name, signature, date or time on the group note of the provisionally licensed LPC;
Dated 02/18/2023 for 3:00 p.m. - 4:00 p.m., Social Services group, revealed no supervisor's name, signature, date or time on the group note of the provisionally licensed LPC;
Dated 02/18/2023 for 1:00 p.m. - 2:00 p.m., Social Services group, revealed no supervisor's name, signature, date or time on the group note of the provisionally licensed LPC.


Random Patient 7
Review of the medical record for R7 revealed an admit date of 02/24/2023 via FVA to unit a with diagnoses including Opioid Use Disorder, Alcohol Use Disorder, and Sedative Hypnotic Use Disorder. Further review revealed an interdisciplinary master treatment plan that included the following interventions, in part: R7 will demonstrate the use of emotional regulation 2 times daily for three consecutive days to address impulsivity. Specific intervention focus included group 3 times daily for 60 minutes by an LCSW; and, Assist R7 to facilitate insight into relapse warning signs while developing stress management and emotional regulation in a group setting, daily by an Activity Therapist. Review of the clinical services group notes revealed the following:
Dated 02/24/2023 for 8:30 a.m. - 9:30 a.m., Activity Therapy group, revealed R7 did not attend the group and the patient's progress towards treatment goals was not documented;
Dated 02/25/2023 for 10:45 a.m. - 11:45 a.m., Social Services group, revealed R7 did not attend group and the patient's progress towards treatment goals was documented as N/A;
Dated 02/25/2023 for 1:00 p.m. - 2:00 p.m., Social Services group, revealed R7 did not attend group and the patient's progress towards treatment goals was documented as N/A;
Dated 02/25/2023 for 3:00 p.m. - 4:00 p.m., Social Services group, revealed R7 did not attend group and the patient's progress towards treatment goals was documented as N/A;
Dated 02/25/2023 for 8:30 a.m. - 9:30 a.m., Activity Therapy group, revealed R7 did not attend group and the patient's progress towards treatment goals was not documented;
Dated 02/26/2023 for 10:45 a.m. - 11:45 a.m., Social Services group, revealed R7 did not attend group and the patient's progress towards treatment goals was documented as N/A;
Dated 02/26/2023 for 1:00 p.m. - 2:00 p.m., Social Services group, revealed R7 did not attend group and the patient's progress towards treatment goals was documented as N/A;
Dated 02/26/2023 for 3:00 p.m. - 4:00 p.m., Social Services group, revealed R7 did not attend group and the patient's progress towards treatment goals was documented as N/A;

Random Patient 13
Review of the medical record for Random Patient 13 revealed an admit date of 01/09/2023 via FVA to unit a with diagnoses of Opiate Use Disorder; Alcohol Use Disorder and Schizoaffective Disorder. Further review revealed an interdisciplinary master treatment plan that included the following interventions, in part: R13 will demonstrate the use of 3 distress tolerance skills daily for 3 consecutive days prior to discharge through the following interventions, in part: Group Therapy 3 times per day for 60 minutes by a provisionally licensed LPC and Activity therapy group once daily. Review of the clinical services group notes revealed the following:
Dated 01/10/2023 for 3:00 p.m. - 3:50 p.m. a Social Services group revealed, R13 did not attend group and the patient's progress towards treatment goals was not documented;
Dated 01/10/2023 for 1:00 p.m. - 2:00 p.m. a Social Services group revealed, R13 did not attend group and the patient's progress towards treatment goals was not documented;
Dated 01/10/23 for 8:30 a.m. - 9:30 a.m. an Activity Therapy group revealed, R13 did not attend group and the patient's progress towards treatment goals was not documented;
Dated 01/11/2023 for 3:00 p.m. - 4:00 p.m. a Social Services group revealed, R13 did not attend group and the patient's progress towards treatment goals was not documented; Further review revealed no supervisor's name, signature, date or time documented on the group note of the provisionally licensed LPC;
Dated 01/13/2023 for 3:00 p.m. - 4:00 p.m., a Social Services group revealed, no supervisor's name, signature, date or time documented on the group note of the provisionally licensed LPC.

In an interview on 04/12/2023 at 1:35 p.m. S8PLPC reviewed clinical services group notes and indicated those notes completed by an unlicensed or provisonionally licensed counselor should be signed by a supervisor.

Based on record review and interview, the hospital failed to provide adequate numbers of nurses and mental health workers to provide the nursing care necessary under each patient's active treatment program for 2 (3/18/2023, 3/26/2023) of the 8 (02/03/2023, 02/12/2023, 02/15/2023, 02/25/2023, 03/08/2023, 03/10/2023, 03/18/2023, 03/26/2023) days of nursing staffing schedule sheets reviewed.
Findings:

Review of the policy and procedure titled, "Staffing Standards" last reviewed in July 2018 and last revised in May 2021 revealed, in part, it shall be the policy of the hospital's Department of Nursing to provide adequate nursing staff to meet the defined needs of patients.

Review of the policy and procedure titled, "Patient Rights" last reviewed January 2023 and last revised in October 2018 revealed, in part, 4. Patient is provided reasonable access to care, in a safe environment.

Review of the job description of the Chief Nursing Officer revealed, in part, the Chief Nursing Officer serves as a key member of leadership on the senior management team. Directs and coordinates nursing/direct care patient services in an around-the-clock inpatient environment. Monitors subordinate daily staffing analysis. Provides guidance in allocation of adequate competent staff. Reviews staff schedules for adequacy. Assists in monitoring staff productive and non-productive hours. Takes action to assure patient care is proper, least restrictive and respectful.

Review of the daily staffing report for 03/18/2023 day shift revealed on the DDU 6 unit b there were a total of 23 patients including a patient on a 1:1 status. Review of the staffing grid revealed with a total census of 23 patients the required staffing for the day shift required 24 hours of RN/LPN, 24 hours of PC and 12 hours of PC from 7:00 a.m. - 11:00 p.m. Review of the daily staffing report for 03/18/2023 day shift revealed 2 RNs (24 hours) and 3 MHTs (36 hours), however, 1 MHT was assigned to the 1:1 staffing. Therefore, according to the official staffing grid, the unit was short by 1 MHT.

In interview on 04/11/2023 at 12:14 p.m., S2RN verified the census of 23 patients on unit b.

Review of the official census report for unit b revealed on midnight of 03/25/2023 a total census of 17 patients. Review of the official census report for midnight on 03/26/2023 for the Adult Unit revealed a total census of 18 patients.

Review of the staffing grid revealed with a total census of 18 patients the number of staff for the night shift required 24 hours of RN/LPN and 24 hours of PC. Review of the daily staffing report for 03/26/2023 night shift revealed 12 hours of RN, 24 hours of PC and S11LPN in orientation. Therefore, because S11LPN was in orientation, and did not count towards the staffing grid, the unit was short 12 hours of RN/LPN staffing.

In an interview on 04/12/2023 at 9:35 a.m., S2RN indicated staff in orientation are not considered part of the grid.