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Based on record review and interviews, the Governing Body failed to ensure that all services provided by contract and agreement were evaluated to identify quality and performance problems and/or implement appropriate corrective or improvement activities to ensure the monitoring and sustainability of those contracted services. This failed practice was evidenced by no documented evidence of quality indicators developed for contracted services, inclusion of contracted services in the Quality meeting minutes, and confirmation by interview that no quality indicators for each contracted service had been developed or initiated for the evaluation of services provided by contract or agreement.
Findings:

Review of the Quality Assurance quarterly performace plans dated 04/22/2021 and 08/09/23021 failed to reveal documentation of quality indicators for services provided by contract or agreement. No documentation of evaluations of services provided by contract or agreement was provided.

In an interview 10/18/2021 at 2:30 p.m. S1Compliance acknowledged the contracted services were not evaluated.

Based on record review and interview, the hospital failed to ensure an effective grievance process was in place. This deficient practice is evidenced by the facility failing to thoroughly investigate a patient's grievance for 2 of 2 patients with grievances in the past year (Patient #3 and #8).
Findings:

Review of the hospital policy titled, Patient Complaint/Grievance Policy, revealed in part that the patient advocate will respond and interview the patient within 72 hours of submission of a grievance. The patient advocate will collect any investigative information to document on the patient grievance form.

Patient #3
Review of the Complaint/Grievance binder revealed a handwritten note dated 09/02/21 that stated in part that, since Patient #3's admission, a behavioral health tech has made sexual comments to her alluding to her body. Further review of the note revealed that "The fact that I made this known and he was still allowed to show up today disturbs me greatly."

Review of the patient's medical record revealed a note written by the therapist on 9/3/21 at 2:49 p.m. The note stated that the therapist spoke with the client about her grievance and the patient stated "I don't feel safe here." The note further stated that the therapist informed the patient that her physician will be notified and the therapist will meet with her after speaking to the physician. There were no further notes in the patient's record regarding the grievance.

Review of the investigation provided to the survey team regarding the grievance revealed minutes from the hospital grievance committee meeting and a statement from the accused tech.
Review of minutes from the hospital grievance committee meeting dated 09/23/21 regarding the patient's grievance revealed that the tech diligently refuted the comments in the Patient #3's complaint. The minutes further revealed that the client eloped during her third day of inpatient treatment and did not return. The minutes stated that the committee ruled 3-0 that the complaint drafted by client was frivolous. Review of the tech's statement revealed that he denied the accusations. There were no other documented interviews or further investigation of the grievance.

On 10/18/21 at 10:35 a.m., interview with S1Compliance confirmed that there was no further documented investigation of the patient's grievance. She confirmed no other staff or clients were interviewed.

Patient #8
Review of the Complaint/Grievance binder revealed documentation that on 08/03/21, the patient stated "my grievance is S7Staff is prejudiced against some of us." Further review revealed no documented investigation of the grievance.

On 10/15/21 at 3:00 p.m., interview with S1Compliance revealed that she was unable to locate any documentation related to the outcome or investigation of this grievance.

Based on record review and interview, the hospital failed to ensure that in its resolution of a grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for 1 of 1 grievance documented in the grievance committee meeting minutes (Patient #3).
Findings:

Review of the Complaint/Grievance binder revealed a handwritten note from Patient #3 dated 09/02/21 that stated in part that a behavioral health tech made sexual comments to her alluding to her body since she arrived at the hospital. Further review of the note revealed that "The fact that I made this known and he was still allowed to show up today disturbs me greatly."

Review of minutes from the hospital grievance committee meeting dated 09/23/21 regarding the patient's grievance revealed that the tech diligently refuted the comments in the patient's complaint. The minutes further revealed that the client eloped during her third day of inpatient treatment and did not return. The minutes stated that the committee ruled 3-0 that the complaint drafted by client was frivolous.

On 10/18/21 at 10:35 a.m., interview with S1Compliance revealed that there was no written notice sent to the patient regarding its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion. Further interview with S1Complaince confirmed that the hospital did not follow its grievance procedures.

Based on observation and interview, the hospital failed to ensure patients had the right to personal privacy. This deficient practice is evidenced by the facility failing to provide window coverings for 3 of 24 patient rooms.
Findings:

Observation on 10/14/2021 at 9:00 a.m. revealed the following:

Room "a" had no window curtains or blinds, which allowed visual exposure into the room from outside the facility.
Room "c" had no window curtains or blinds, which allowed visual exposure into the room from outside the facility.
Room "d" had no window curtains or blinds, which allowed visual exposure into the room from outside the facility.

On 10/18/2021 at 9:00 a.m., S2DON acknowledged the window coverings in rooms "a", "b" and "c" failed to provide privacy by allowing visual exposure into the rooms from outside the facility.

Based on observation and interviews, the hospital failed to ensure patients requiring acute inpatient psychiatric care, who have been admitted for being a danger to self and others, received care in a safe setting. This deficient practice was evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients for ligature risks and safety risks.
Findings:

On 10/14/21 at 9:20 a.m., tour of the "Brown Hall" of the hospital revealed the following:
-An unlocked mechanical room containing an old piece of equipment with several exposed pipes which posed ligature risks; the hinges on the doors of the mechanical room had gaps which posed a ligature risk;
- The nurses station at the far end of the hall was unlocked and accessible to anyone passing by;
- The hinges on the door of the patient bathroom, behind the front nurse's station, had gaps which posed ligature risk

On 10/14/21 at 10:10 a.m., interview with S1Compliance confirmed the above ligature points and stated that these areas were accessible to all patients.

Based on record review, observation, and interview, the hospital failed to ensure the hospital wide Quality Assurance and Performance Improvement (QAPI) program set priorities aimed at performance improvement activities that focused on high-risk, high-volume, or problem-prone areas that affected health outcomes, patient safety, and quality of care. This deficient practice was evidenced by failure of the hospital's QAPI program to identify and address the following survey identified issues: investigation of grievances, ligature risks, first dose reviews of medication by the pharmacist and infection control issues regarding sanitary environment.
Findings:

Grievances - Review of the patient grievance records for Patient #3 and #8 revealed the hospital failed to ensure an effective grievance process was in place by failing to thoroughly investigate the patients' grievances.

Ligature Risks - The hospital failed to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients for ligature risks and safety risks.

Medication - The hospital failed to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed and administered.

Infection Control - The hospital failed to maintain a sanitary environment, including adequate pest control. Rodent droppings and a live mouse were observed during the survey. Review of the current infection control program revealed the only documentation for the hospital's infection control program was of antibiotic use. There was no documented evidence of an active surveillance program.

In an interview on 10/18/2021 at 2:30 p.m., S1Compliance confirmed the above referenced, survey identified, problems had not been identified as opportunities for improvement to be addressed through the hospital wide QAPI program.

Based on record review and interview, the registered nurse responsible for supervision and evaluation of the nursing care of patients failed to ensure that care was provided in accordance with hospital policy relative to documentation of patient observations . This deficient practice was evidenced by the mental health technician failing to document every 15 minute observations for 3 of 3 patients whose observation flow sheets were reviewed (Patient #7, R1, R2).
Findings:

Review of the hospital policy titled, Levels of Observation, revealed in part that routine observations will be maintained at a minimum on all patients indicating that the patient will be checked every 15 minutes to determine location and describe behavior. Documentation regarding the patient's location and behavior is to be made every 15 minutes on the Flow Sheet. Mental health technicians must document on the observation Flow Sheet.

On 10/14/21 at 9:20 a.m. during the initial tour, observation revealed S3Tech was standing in the hallway holding a clipboard. At that time, the surveyor requested the patient observation flowsheets. Review of the flowsheets for Patient #7, R1 and R2 revealed the last documented observation time was at 8:30 a.m. Interview with S3Tech at that time revealed that the patients' were probably in their rooms, and S3Tech pointed down the hall to indicate the patient's possible locations. Further interview with S3Tech revealed that they were supposed to observe and document on their assigned patients every 15 minutes, but review of S3Tech's documents revealed patients #7, R1 and R2 observations for were overdue by 50 minutes.

Based on record review and interview, the hospital failed to ensure that all orders were timed by the ordering practitioner for 3 of 3 records reviewed for timing orders (Patient #1, 2, 4).
Findings:

Review of the medical staff bylaws revealed in part that all medical record entries must be legible, complete, dated, timed and authenticated by the ordering practitioner.

Review of the medical record for Patient #1 revealed a physician order dated 10/07/21 and a telephone order dated 10/12/21 that were not timed.

Review of the medical record for Patient #2 revealed two physician orders dated 10/08/21 with no time documented.

Review of the medical record for Patient #4 revealed a physician order dated 10/17/21 with no time documented.

On 10/18/21 at 10:35 a.m., interview with S1Compliance revealed that all practitioner orders must be timed, but confirmed the above orders were not.

Based on record review and interview, the hospital failed to ensure all information needed to provide appropriate care was contained in patients' medical records. This deficient practice was evidenced by failing to ensure a completed restraint/seclusion order and a completed patient observation form for 1 (#5) of 10 medical records reviewed.
Findings:

Review of the hospital's Medical Staff and Regulations revealed in part: 27. All medical record entries must be legible, complete, dated, timed and authenticated by the ordering practitioner or another practitioner who is responsible for the care of the patient and authorized to write orders.

Review of Patient #5's medical record revealed a restraint/seclusion order dated 09/17/2021 at 7:45 a.m. and a patient observation form which were not labeled with the patient's name or date of birth to identify who the orders were for and which patient was under observation.

In an interview on 10/18/2021 at 10:45 a.m., S1Compliance acknowledged the restraint/seclusion order and the observation form were not labeled with the patient's name and date of birth.

Based on record review and interview, the hospital failed to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed (review for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications).
Findings:

Review of the Louisiana Administrative Code, Title 46 Professional and Occupational Standards, Part LIII Pharmacist, Chapter 15 Hospital Pharmacy, Section: 1511: Prescription Drug Orders, Item A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial dose of medication, except in cases of emergency.

On 10/14/21 at 9:50 a.m., observation of the medication room with S2DON and S5LPN revealed the hospital utilized an automated medication delivery system (Omnicell). They stated that when a new medication order is obtained, the order is faxed to the pharmacy for review and then profiled by the pharmacist under the patient's name in the Omnicell. When asked if their is a process for administering a medication that had not been profiled by the pharmacist into the Omnicell, they stated that the nurse can perform an override with another staff member witnessing. S2DON and S5LPN confirmed that staff are able to administer (non-emergency) medications prior to a pharmacist first dose review.

Review of the Daily Medication Override Report dated 10/07/21 revealed the following medications were overridden by the nurse at 11:19 a.m. and administered to Patient #1 prior to a pharmacist first dose review: Risperdal 0.5 mg and Depakote ER 250 mg.

Review of the Daily Medication Override Report dated 09/28/21 revealed the following medication was overridden by the nurse at 10:43 p.m. and administered to Patient #2 prior to a pharmacist first dose review: Melatonin 5 mg.

On 10/15/21 at 1:25 p.m., interview with S2DON revealed that she was aware that staff were overriding for medications in the Omnicell prior to a first dose review by the pharmacist. She stated that the nurses get impatient while waiting for the pharmacist to profile the new medications in the Omnicell. S2DON further stated that she gets a daily override report from the pharmacy. She stated that she reviews it and if she sees the same nurse doing multiple overrides daily, she will in-service them. When asked if she had any documentation of in-services, she stated no. Further interview with S2DON revealed that she was unable to locate a policy for first-dose reviews of medications.

Based on observation and interview, the hospital failed to ensure all drugs and biologicals were kept in a secure area and locked to prevent unauthorized access as evidenced by failing to ensure the medication room door was locked at all times when not in use.
Findings:

On 10/14/21 at 9:30 a.m., observation of the medication room, next to the seclusion room on the back hall, revealed the medication door was unlocked and unsupervised by any staff. Further observations revealed patients were ambulating down the hall in front of the medication room. The survey team was able to enter the medication room without any staff aware.

On 10/14/21 at 9:40 a.m., the survey notified S1Compliance and S2DON of the unlocked medication room. They stated that the room should be locked at all times when not in use.

Based on record review, observation and interview, the hospital failed to ensure that outdated or otherwise unusable drugs and biologicals were not available for patient use as evidenced by having expired medications and/or unusable medications and biologicals available for patient use.
Findings:

Review of the hospital policy, titled multi-dose injectables, revealed in part that multi-dose injectables (including insulin) and liquids may be used after first use, unless the literature indicated a certain length of stability after opening-or the date of expiration is reached. The policy did not indicate a specific time frame for the use of opened multi-dose vials of medications.

On 10/14/21 at 9:30 a.m., observation of the back nurses medication room revealed an opened vial of Semglee insulin, with the date of 08/28/21 handwritten on the vial. At that time, interview with S2DON stated she was unsure how long multi-dose vials can be used after opening.

On 10/14/21 at 9:50 a.m., observation of the front nurses medication room revealed the following expired medications:
- 2 containers of Triamcinalone cream, expired 07/2021 and other 08/2021
- Emergency medication box contained Nitroglycerin sublingual tablets, expired 09/2021
- The medication refrigerator contained a multi-dose vial of Tubersol which had an open date of 08/16/21. The label stated that the medication would expire 30 days after opened.

On 10/14/21 at 3:10 p.m., interview with S1Compliance revealed that multi-dose vials are good for 28 days after the first puncture date. She confirmed that the above multi-dose vials and expired medications should not have been available for patient use.

Based on observations and interviews, the infection control officer failed to ensure the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented in accordance with hospital policy and acceptable standards of practice. This deficient practice is evidenced by the hospital failing to maintain a sanitary environment, including adequate pest control.
Findings:

On 10/14/21 at 9:05 a.m., observation of the patient refrigerator/freezer on the front hall revealed brown debris and grime in its interior. The ice chest that contained ice for the patients had red splatters, pen marks and dirt and grime on the insides. At that time, S2DON observed the ice chest and stated that she would not want to eat any ice from the ice chest. S2DON stated the refrigerator/freezer and ice chest was in need of cleaning.

On 10/14/21 at 9:20 a.m., observation of the patient bathroom, behind the front nurses station, revealed multiple hairs in the floor of the dry tub. At that time, interview with S3Tech revealed that the bathtub should be cleaned after each use.

On 10/14/21 at 9:30 a.m., observation of the back medication room, next to the seclusion room, revealed multiple mice droppings in the drawers containing patient supplies and on the floor. Upon opening a lower cabinet, a live mouse was observed. The crash cart in the medication room was coated with a thick build-up of dust. Further observations in the nurses station revealed the over head vent was coated in a thick build-up of dust and a build-up of dirt and grime was observed in all corners of the nurses station.

On 10/14/21 at 9:40 a.m., S1Compliance and S2DON observed the above nurses station and medication room and confirmed it was in need of cleaning and disinfecting. They further stated that they were not aware of a pest problem.

Based on record review and interview, the hospital failed to ensure that all psychiatric patients had an individualized, comprehensive treatment plan for 3 of 3 patients reviewed for treatment plans (Patient #1, 7, 9).
Findings:

Review of the hospital policy titled, Multidisciplinary Treatment Planning, revealed in part that the master treatment plan is formalized no later than three days after admission. It includes the following: achievable long term goals of treatment, measurable short term goals, therapeutic approaches (interventions) used by each discipline, the individual or discipline accountable for assisting the patient with therapeutic approaches and patient progress in meeting the treatment plan goals.

Patient #1
Review of the medical record revealed an admit date of 10/06/21 with diagnoses including schizoaffective disorder and bipolar.

Review of the document titled, Inpatient Multidisciplinary Integrated Treatment Plan, revealed that problems of delusions, depressed mood and medication non-compliance were identified but there were no goals, interventions or projected achievement dates documented.

Patient #7
Review of the medical record revealed an admit date of 10/12/21 with diagnoses including schizoaffective disorder and bipolar.

Review of the document titled, Inpatient Multidisciplinary Integrated Treatment Plan, revealed that problems of delusions, depressed mood and medication non-compliance were identified but there were no goals, interventions or projected achievement dates documented.

Patient #9
Review of the medical record revealed an admit date of 10/11/21 with diagnoses including schizoaffective disorder. Further review of the record revealed no treatment plan was developed.

On 10/18/21 at 1:50 p.m., S1Compliance confirmed that she was unable to locate a treatment plan for the patient. S1Compliance also confirmed that each patient should have a complete, individualized and comprehensive treatment plan no later than three days after admission which included goals and interventions.

Based on record review and interview, the hospital failed to conduct an annual exercise to test the emergency plan by failing to participate in a community-based drill, a facility-based staff drill, or a tabletop exercise during the past 12 months.
Findings:

Review of the hospital's Emergency Preparedness Binder failed to reveal and evacuation drill or an influx drill had been conducted in the past 12 months.

In an interview on 10/18/2021 at 2:40 p.m., S2 Compliance acknowledged the hospital had not conducted an evacuation drill or an influx drill in the last 12 months.