HospitalInspections.org

Based on record review and staff interview the Governing Body failed to ensure the Medical Staff had written policies and procedure to address situations in which a person's emergency needs may exceed the capabilities of the off-campus department as evidenced by the hospital policy relying on 9-1-1 for its emergency response capabilties. Findings:

Review of the Outpatient Policy titled, Suicidal/Homicidal/Gravely Disabled Patient, Policy #OP-311, revised July 2016, provided by SF3PD as the plan of correction for PHP deficiencies cited during the previous survey dated 06/16/16 revealed the following:
When a partial hospitalization or intensive outpatient patient is identified, through clinical assessment, as being suicidal, homicidal, and/or gravely disabled and requiring inpatient hospitalization, the following procedure must be followed:
1. A staff member must remain with the patient at all times.
2. The patient is to be immediately placed on one-to-one observation with a staff member. The patient must not leave the program alone.
3. The attending physician is notified of the patient's status and necessary orders are obtained.
4. If the patient is unwilling to seek voluntary admission to inpatient treatment, staff is to contact 9-1-1 for emergency assistance or accompany the patient to the nearest emergency room.
5. The patient's information is sent to the Intake Department so that transfer of the patient to an inpatient unit can be arranged according to intake processes and procedures....

Further review of the policy revealed no provision that if an outpatient at the offsite campus required inpatient hospitalization, the offsite campus would be required to send the patient to the main campus if the main campus had beds available. Review of the policy revealed no provisions for apprasials of patients with emergencies.

In an interview on 07/26/16 at 9:00 a.m., SF3PD stated the corporate entity has a central intake for all their facilities when a psychiatric inpatient bed is needed in a non-crisis situation. SF3PD stated if a physician was onsite in the PHP when a patient decompensates, that physician can PEC the patient, and then the patient could go to the main campus hospital. SF3PD stated if a physician is not onsite in the PHP, then the patient (decompensated in a crisis situation) would go to the emergency room at the closest hospital. SF3PD stated the main campus was 45 minutes away from the PHP. SF3PD stated the closest hospital was Hospital "FC". She stated SF7Physician requests his patients go to Hospital "FB."

In an interview on 07/26/16 at 1:45 p.m., SF1ADM confirmed the above policy was the only policy the hospital had for transfer of PHP patients who experience psychiatric decompensation. He confirmed the policy did not include a provision that the offsite campus was required to send the patient to the main campus. SF1ADM stated it was difficult getting patients transferred across parish lines and the ambulance staff want to take the patient to the nearest facility. SF1ADM stated if they could get the patient to the main campus, they have physicians available to see the patient and PEC the patient if needed. SF1ADM confirmed the procedure for transfer of decompensated patients in crisis from the PHP was to call 9-1-1 and transfer to the emergency room.

Based on observations, interviews, and record review, the hospital failed to ensure that patients received care in a safe setting by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for geriatric psychiatric patients as evidenced by the presence of ligature risks.

Findings:

An observation of the inpatient unit was conducted on 07/25/16 at 12:50 p.m. with SF1ADM. There were 8 double occupancy patient rooms. All rooms were located down a single hallway in view of the nurse's station. All rooms had a bathroom within the room with a toilet and a sink. All rooms had an outside window view and all rooms opened to the main hallway. The census on 07/25/16 was 11 patients.

The following ligature risk and safety risk observations were made in all the patient rooms including Room "Fa" that was designated for suicidal patients:
1) Interior bathroom doors with open-ended door hinges (x3 on each door) that could be used as ligature points, and;
2) Exposed plumbing/pipes below the toilet plumbing encasement that could be used as a ligature point.

An interview was conducted with SF1ADM at the time of the observations. He confirmed Room "Fa" was designated as the room to modify for the ligature risks identified in the last survey. He stated the two (2) patients that were currently in this room were not suicidal. SF1ADM stated the hospital population ages were 50 and above. After observing the bathroom in Room "Fa" and the other 7 patient rooms, he confirmed the separate door hinges on the interior bathroom doors could be used as a ligature point. He also confirmed the space below the toilet encasement allowed enough space to be used as a low ligature point around the exposed plumbing pipe.


On 07/26/16 at 1:45 p.m., further observations were made of the beds in Room "Fa" with SF1ADM. Observation of the bed without the mattress in place revealed 4 separate square metal hooks (2 on each side of the bed frame) attached to the metal frame and extended up from the bed frame that could be used as low ligature points. Also observed on the bed was a wooden headboard attached to the bed frame with two (2) metal rods with spacing between the head board and the bed frame, providing a potential low ligature point. SF1ADM was present for the observations and confirmed the metal hooks and the rods between the head board and the bed frame could be used as possible ligature points.








31206

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by failing to ensure a RN assessed each patient at the time of admission as required by the LSBN's practice act for 2 of 2 (#F5, #F6) PHP patient records reviewed for RN assessment from a total sample of 6 patients.
Findings:

Review of the hospital's policy titled "Admission Procedures", effective 07/02/12 and presented as a current policy by SF3PD, revealed that that the nursing staff performs the nursing assessment to include evaluation of the following: physical health, identification of relevant medical conditions, infectious diseases, and allergies. The Nursing Care Plan/Preliminary Treatment Plan is completed within one day, and presenting problems are listed on the master problem list. There was no documented evidence that the hospital policy required the admission nursing assessment of each patient to the PHP to be conducted by a RN.

Review of LSBN's "Chapter 39. Legal Standards of Nursing Practice 3901. Legal Standards" revealed that the Louisiana State Board of Nursing recognizes that assessment, planning, intervention, evaluation, teaching, and supervision are the major responsibilities of the RN in the practice of nursing. The standards of nursing practice provides a means of determining the quality of care which an individual receives regardless of whether the intervention is provided solely by a RN or by a RN in conjunction with other licensed or unlicensed personnel.

Review of LSBN's "Chapter 37. Nursing Practice 3701. Duties of the Board Directly Related to Nursing Practice as cited in R.S. (revised statute) 37:918" revealed that assessing health status was defined as gathering information relative to physiologic, behavioral, sociologic, spiritual, and environmental impairments and strengths of an individual by means of the nursing history, physical examination, and observation, in accordance with the board's Legal Standards of Nursing Practice. Delegating nursing interventions was defined as entrusting the performance of selected nursing tasks by the RN to other competent nursing personnel in selected situations. The RN shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. The assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required.

Review of Patient #F5's and Patient #F6's medical record revealed both patients were admitted to the PHP on 07/25/16 and the initial nursing assessment was performed by an LPN. There was no documented evidence that a RN assessed each patient to determine which tasks may be delegated to a LPN and the amount of supervision which will be required.

Review of the plan of correction dated 07/21/16 revealed the corrective actions for failure to ensure an RN assessed the patient at the time of admission was to consult the LPN board for the LPN's scope of practice. Review of the Scope of Practice obtained from the LSBPNE revealed the following: A licensed practical nurse must practice under the direction of one of the following: licensed physician, optometrist, dentist, psychologist, or registered nurse.

In an interview on 07/26/16 at 9:00 a.m., SF3PD confirmed the above PHP patients were assessed only by the LPN and there was no RN assessments done on either patient. SF3PD stated she had contacted the Practical Nursing Board (LSBPNE) and was told the LPN could do head to toe assessments under the supervision of the RN or the physician. SF3PD confirmed they have not changed the staffing of the PHP and have continued to have initial nursing assessments conducted by the LPN.




25065

Based on record reviews and interviews, the hospital failed to ensure its policy and procedure for conducting an updated examination of the patient when a medical H&P examination was completed within 30 days before admission was specific for outpatient services as evidenced by having the psychiatric evaluation modified to include H&P requirements with no policy developed to reflect the changes made. This resulted in 2 (#F5, #F6) of 3 (#F4, #F5, #F6) PHP Patient records with "Traditional Out Patient Psychiatric Evaluation Update" not including whether there were changes in the patient's medical condition since the previous H&P had been done out of a total sample of 6 (#F1-#F6).
Findings:

Review of the hospital policy titled "History and Physical Examination", presented as a current policy by SF3PD, revealed that every patient has a H&P examination performed and included as part of their medical record within 24 hours of admission in order to establish medical necessity for partial hospitalization services. If the patient has had a H&P within the past 30 days, that, with appropriate update, is acceptable. Further review revealed the "1997 E/M (evaluation and management) Documentation Guidelines" define a problem-focused physical exam as including 1 to 5 bullets (guidelines below indicated at least 10 organ systems must be reviewed) from one or more of the following organ systems: constitutional; eyes; ears, nose, mouth and throat; neck; respiratory; cardiovascular, chest (breasts), gastrointestinal; genitourinary; lymphatic; musculoskeletal; skin; neurologic; psychiatric. The procedure included that the physician will perform a H&P examination (as defined by the 1997 E/M Documentation Guidelines indicated above) within 24 hours of admission or a copy of a recent (within past 30 days) H&P will be placed on the chart within 24 hours. The admitting physician will review all H&P examinations. Review of the entire policy revealed no documented evidence that the psychiatric evaluation could be used as the H&P or the H&P update.

Review of the "Psychiatric Evaluation Update" form provided by SF3PD as the form revised since the last survey as part of the plan of correction, revealed a section titled, "System Review" and "Previous H&P obtained for record" were included on the form.

Patient #F5
Review of the PHP record for Patient #F5 revealed the patient was a 62 year old admitted to the PHP program on 07/25/16 at 9:00 a.m. with a diagnosis of Bipolar Disorder with Psychosis. Review of the record revealed the "Traditional Out Patient Psychiatric Evaluation Update" was documented by SF6MD on 07/25/16 at 1:30 p.m. The Evaluation Update revealed the following statement had a check mark in the box located on the form before the statement: "I have reviewed the patient's most recent psychiatric evaluation." There was no documented evidence that a physical examination was performed and whether there was any change in Patient #F5's medical condition since the previous "Physician's Admit Note/Psychiatric Evaluation" was done on 07/01/16.

In an interview on 07/26/16 at 12:05 p.m., SF3PD stated SF6MD did not use the new form and confirmed there was no documented evidence of a physical examination on the update to the H&P. SF3PD stated it was the nurse's responsibility to get the appropriate paperwork together for the physician. SF3PD stated SF6MD was familiar with the new form. SF3PD confirmed the revised form for the H&P update was part of the plan of correction and should have been used for this patient.


Patient #F6
Review of the PHP record for Patient #F6 revealed the patient was a 56 year old admitted to the PHP program on 07/25/16 at 9:00 a.m. with a diagnosis of Schizoaffective Disorder. Review of the record revealed the "Traditional Out Patient Psychiatric Evaluation Update" was documented by SF6MD on 07/25/16 at 1:30 p.m. The Evaluation Update revealed the following statement had a check mark in the box located on the form before the statement: "I have reviewed the patient's most recent psychiatric evaluation." There was no documented evidence that a physical examination was performed and whether there was any change in Patient #F6's medical condition since the previous "Psychiatric Evaluation" was done on 07/11/16.

In an interview on 07/26/16 at 12:50 p.m., SF3PD confirmed there was no documented evidence of a physical examination or review of systems on the Psychiatric Evaluation Update. She stated the physician used the incorrect form to document the updated H&P.




25065

Based on interviews, the hospital failed to ensure outpatient services were organized and integrated with inpatient services as evidenced by failing to ensure the hospital developed a policy that addressed that if an outpatient at the offsite campus required inpatient hospitalization, the offsite campus would be required to send the patient to the main campus if the main campus had beds available.
Findings:

Review of the Outpatient Policy titled, Suicidal/Homicidal/Gravely Disabled Patient, Policy #OP-311, revised July 2016, provided by SF3PD as the plan of correction for PHP deficiencies cited during the previous survey dated 06/16/16 revealed the following:
When a partial hospitalization or intensive outpatient patient is identified, through clinical assessment, as being suicidal, homicidal, and/or gravely disabled and requiring inpatient hospitalization, the following procedure must be followed:
1. A staff member must remain with the patient at all times.
2. The patient is to be immediately placed on one-to-one observation with a staff member. The patient must not leave the program alone.
3. The attending physician is notified of the patient's status and necessary orders are obtained.
4. If the patient is unwilling to seek voluntary admission to inpatient treatment, staff is to contact 9-1-1 for emergency assistance or accompany the patient to the nearest emergency room.
5. The patient's information is sent to the Intake Department so that transfer of the patient to an inpatient unit can be arranged according to intake processes and procedures....

Further review of the policy revealed no provision that if an outpatient at the offsite campus required inpatient hospitalization, the offsite campus would be required to send the patient to the main campus if the main campus had beds available.

In an interview on 07/26/16 at 9:00 a.m., SF3PD stated the corporate entity has a central intake for all their facilities when a psychiatric inpatient bed is needed in a non-crisis situation. SF3PD stated if a physician was onsite in the PHP when a patient decompensates, that physician can PEC the patient, and then the patient could go to the main campus hospital. SF3PD stated if a physician is not onsite in the PHP, then the patient (decompensated in a crisis situation) would go to the emergency room at the closest hospital. SF3PD stated the main campus was 45 minutes away from the PHP. SF3PD stated the closest hospital was Hospital "FC". She stated SF7Physician requests his patients go to Hospital "FB."

In an interview on 07/26/16 at 1:45 p.m., SF1ADM confirmed the above policy was the only policy the hospital had for transfer of PHP patients who experience psychiatric decompensation. He confirmed the policy did not include a provision that the offsite campus was required to send the patient to the main campus. SF1ADM stated it was difficult getting patients transferred across parish lines and the ambulance staff want to take the patient to the nearest facility. SF1ADM stated if they could get the patient to the main campus, they have physicians available to see the patient and PEC the patient if needed. SF1ADM confirmed the procedure for transfer of decompensated patients in crisis from the PHP was to call 9-1-1 and transfer to the emergency room.





25065