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Based on observation, record review, and interview, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to protect and promote each patient's rights as evidenced by:
1) failure to provide patient observations as per hospital policy (See findings in A0145);
2) Failure to maintain a patient care environment free of ligature risk related to square top bathroom doors (See findings in A0144);
3) failure to provide a focused assessment following a claim of sexual assault (See findings in A0145);
4) failure to complete nursing rounds per hospital policy (See findings in A0145); and
5) Failure to maintain a patient care environment free of items that could potentially be self-injurious to patients (See findings in A0144).

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Based on observation, policy review and interview, the hospital failed to ensure the patient's right to receive care in a safe setting. This deficient practice is evidenced by:
1) Failure to maintain a patient care environment free of ligature risk related to square top bathroom doors in 12 (e - h, m - t) of 16 (a - t) patient rooms; and
2) Failure to maintain a patient care environment free of items that could potentially be self-injurious to patients.
Findings:

A review of hospital policy, "PR (Patient Rights)," with an effective date of 09/01/2011 and last revision 03/21/2018, revealed in part: "19. Receive care in a safe setting. The Hospital is committed to providing a safe, secure, therapeutic environment. As part of this endeavor, clinical staff have identified items that are considered a risk to safety and/or are counter-therapeutic. Such items are considered "contraband." The Hospital utilizes a number of methods for controlling the existence of Contraband, including, but not limited to: Checking patient rooms daily. Maintaining a safe environment is the responsibility of all staff members. Contraband: 2. Prohibited Items: This category includes any items that a patient will not be permitted to access at any time while on the unit. b. Sharp Objects: Nails and screws."

1) Failure to maintain a patient care environment free of ligature risk related to square top bathroom doors in 12 of 16 patient rooms

Observations during a walk-through of the hospital's offsite location at 4201 Woodland Drive, Suite 400, New Orleans, LA 70131 on 12/23/2024 from 1:20 PM to 2:00 PM revealed wooden, square-top style restroom doors in 12 (e - h, m - t) of 16 (a - t) patient bedrooms. This wooden, square-top style door would create a ligature risk with the potential for self-injurious behavior by a patient.

In an interview on 12/23/2024 and present during the hospital walk-through, S4MHT confirmed the above mention findings.

2) Failure to maintain a patient care environment free of items that could potentially be self-injurious to patients

Observations during a walk-through of the hospital's offsite location at 4201 Woodland Drive, Suite 400, New Orleans, LA 70131 on 12/23/2024 from 1:20 PM to 2:00 PM revealed a crosshead screw protruding from the restroom wall of Room "t." It appeared this was the location of a prior paper towel dispenser that was removed and the screw was not removed. The screw was loosely fastened in its wall anchor and could be removed by hand. This crosshead screw had the potential for self-injurious behavior by a patient.

In an interview on 12/23/2024 and present during the hospital walk-through, S4MHT confirmed the above mention findings.

Based on observation, record review and interview, the hospital failed to ensure all patients were free from all forms of abuse or neglect. This deficiency is evidenced by:
1) failure to provide patient observations as ordered by the physician for 2 (#3 and #R20) of 2 (#3 and #R20) psychiatric patients observed on hospital video; and
2) failure to provide a focused assessment on Patient #2 following a sexual assault; and
3) failure to complete nursing rounds per hospital policy.
Findings:

Review of psychiatric hospital's policy titled "Patient Rights", approved 01/25/2014, revealed in part: "Policy [in part]: In accordance with Louisiana Licensing Regulations for Hospitals §9319 every patient has the right to [in part]: 18. Be free from all forms of abuse and harassment."

1) Failure to provide patient observations per hospital policy for 2 (#3 and #R20) of 2 (#3 and #R20) psychiatric patients observed on hospital video.
Review of psychiatric hospital's policy titled "Levels of Observation", approved 01/25/2024, revealed in part: "Policy [in part]: In the inpatient setting, the levels of observation for any patient, must be directly observed, in-person, according to prescriber orders. Procedure [in part]: Close Observation is the routine level of observation applied to patients that are not considered at risk and in need of increased supervision. At least every 15 minutes, a staff member directly visually observes the patient".

A review of psychiatric hospital document titled "Louisiana Department of Health Hospital/Licensed Provider Abuse/Neglect Initial Report" dated 12/16/2024-12/17/2024 at 7:00 AM and submitted on 12/18/2024, revealed in part: "Alleged incident: Patient #3 woke up yelling around the halls asking to see the cameras. "I need to see the cameras because I feel like someone came into my room and put their fingers in my ass!" Further review of the report revealed video surveillance was reviewed: "Camera footage shows observations q 15 minute rounds being completed by mental health techs and q 2 hour rounds by nursing staff."

Review of hospital assignment sheet dated 12/16/2024 PM revealed S5MHT was assigned Patient #3 and Patient #R20. Patient #3 was on aggression precautions and every 15-minute observations and was assigned to room 'u'.
Patient #R20 was on suicide, aggression and detoxification precautions, and every 15-minute observations and was assigned to room 'v'.

A review of Patient #3's Patient Observation Sheet dated 12/17/2024 between 12:01 AM-7:06 AM revealed documentation that Patient #3 was observed by the following:
S14MHT from 12:01 AM until 1:00 AM approximately every 15 minutes.
S13MHT from 1:14 AM until 2:29 AM approximately every 15 minutes.
S6MHT from 2:41 AM until 4:01 AM approximately every 15 minutes.
S5MHT from 4:16 AM until 5:29 AM approximately every 15 minutes.
S14MHT from 5:40 AM until 6:53 AM approximately every 15 minutes.

On 12/26/2024 from 1:57 PM until 2:25 PM, a review of video from 12/17/2024 at 12:01 AM through 6:58 AM was navigated by S2DON with S3ADON present. The video, with camera focus on rooms 'u' and 'v', revealed the following:
12:01 AM until 1:10 AM: S5MHT with tablet in hand walked down the middle of the hall, aimed the tablet towards the closed doors of rooms 'u' and 'v'. The video failed to reveal S5MHT opened the doors to rooms 'u' and 'v' to observe Patients #3 and #R20.
1:10 AM until 1:55 AM: S14MHT observed Patients #3 and #R20 approximately every 15 minutes.
1:55 AM until 3:51 AM: S13MHT with tablet in hand walked down the middle of the hall, aimed the tablet towards the closed doors of rooms 'u' and 'v'. The video failed to reveal S13MHT opened the doors to rooms 'u' and 'v' to observe Patients #3 and #R20.
3:51 AM: S6MHT went into room 'u' but not room 'v'.
4:12 AM: S6MHT went into room 'u' but not room 'v'.
4:38 AM: S6MHT went into room 'u' but not room 'v'.
5:00 AM: difficult to ascertain if S6MHT opened the door to room 'u', S2DON reports she did peek in the room through a crack but did not go into room 'v'.
5:09 AM until 6:58 AM: S5MHT with tablet in hand walked down the middle of the hall, aimed the tablet towards the closed doors of rooms 'u' and 'v'. The video failed to reveal S5MHT opened the doors to rooms 'u' and 'v' to observe Patients #3 and #R20.

During an interview on 12/26/2024 at 2:30 PM, S2DON and S3ADON confirmed the above video findings. S2DON confirmed the observation sheets did not correlate with the video findings. S2DON did not comment on the self report and video finds not correlating. S2DON reported she had already addressed the failure of the MHTs to observe patients per hospital policy. S2DON stated she would provide documentation the issue had been addressed. At 5:30 PM, when exit conference was held, the documentation still had not been provided to the surveyor.

2) Failure to provide a focused assessment on Patient #2 following a sexual assault.
Review of psychiatric hospital's policy titled "Ongoing Nursing Assessments", approved on 01/25/2024, revealed in part: "Policy [in part]: In addition to the comprehensive assessment conducted on each shift, the registered nurse will conduct focused assessments in response to the patient, in part: Demonstrating or verbalizing indications that the patient has been assaulted or has engaged in high-risk behavior during hospitalization."

Review of Patient #2's medical record revealed an admission date of 12/16/2024 with admitting diagnoses of bipolar disorder, stimulant use disorder, sedative, hypnotic or anxiolytic use. Patient with recent history aggressive behaviors and abuse by her husband.

A review of psychiatric hospital document titled "Louisiana Department of Health Hospital/Licensed Provider Abuse/Neglect Initial Report" dated 12/18/2024 at 1:48 AM and submitted on (date written as "9/17/2024"), revealed in part: On 12/18/2024 at 1:48 AM, Patient #1 was found attempting to hide on the side of Patient #2's bed with no pants on naked from the waist down. On further observation, Patient #2 was discovered to be not wearing any bottoms, also naked from the waist down.

Review of statement taken from Patient #2 on 12/19/2024 revealed the following: "Mood stabilizer-I did not want to take it but she made me take it to sleep. 'Just take it, so you can go to sleep.' Wrong answer. I was knocked out. I came to and he was on top of me. He was already having intercourse with me. He said, 'the door is locked.' I then could hear the nurse's voice yelling. I don't know what staff was in there, it was a lot, but I heard the night nurse's voice. Next thing I knew, I felt her hand grab the blanket off of me and I was exposed. I could tell because when I woke up the next morning, my pants were stuck around my ankles. Did they come back to check on me? I don't even think they came back to check on me! Please pull the tapes to check if they came back and check on me. I haven't even taken a shower since it happened! Please don't let me see him get arrested, let me be in my room. This should not have happened in any situation. No one should have been in anyone's room."

A review of social worker note dated 12/19/2024 at 4:26 PM revealed the social worker typed up Patient #2's statement regarding her disclosure of sexual assault by another patient on 12/18/2024 at 2 AM. The social worker emailed statement to DON, ADON, administrator and provider. Social worker filed incident report of patient's disclosure.

Review of Patient #2's medical record failed to reveal a focused assessment in response to the patient demonstrating and verbalizing indications that she had been assaulted during her hospitalization.

During an interview on 12/26/2024 at 3:15 PM, S2DON confirmed the medical record failed to reveal a focused assessment in response to Patient #2 demonstrating and verbalizing indications that she had been assaulted during her hospitalization.

3) Failure to complete nursing rounds per hospital policy.
Review of psychiatric hospital's policy titled "Ongoing Nursing Assessments", approved on 01/25/2024, revealed in part: "Policy [in part]: The registered nurse is required to make rounds on and observe each patient at least every two hours."

On 12/26/2024 from 3:58 PM until 4:45 PM, a review of video from 12/17/2024 at 7:00 PM through 12/18/2024 at 12:07 AM was navigated by S2DON with S3ADON present.
The video, with camera focused on nurses' station located at offsite location, 4201 Woodland Drive, Suite 400, New Orleans, LA 70131, revealed the following:
7:00 PM: S15RN in nurses' station on computer.
8:00 PM: S15RN had not left nurses'station.
9:00 PM: S15RN had not left nurses'station.
9:54 PM: S15RN walked out of nurses' station into admission room.
10:11 PM: S15RN back in nurses'station.
11:11 PM: S15RN left for hydration and back in nurses' station at 11:12 PM
11:15 PM: S15RN went to lunch.
12:00 AM: S15RN back in nurses' station in restroom.
12:07 AM: S15RN in hallway rounding on patients.

During an interview on 12/26/2024 at 4:45 PM, S2DON and S3ADON confirmed the above video findings. S2DON verified S15RN failed to make nursing rounds every 2 hours as required per hospital policy.

Based on observation, record review and interview, the hospital failed to recognize patient safety issues through the Quality Assurance and Performance Improvement (QAPI) review process. The deficient practice is evidenced by the hospital failing to implement an action plan for locking housekeeping carts.
Findings:

Observations during a walk-through of the hospital's offsite location at 4201 Woodland Drive, Suite 400, New Orleans, LA 70131 on 12/23/2024 from 1:20 PM to 2:00 PM revealed an open housekeeping cart being pushed by housekeeping in the patient care area with cleaning products and accessories within arms-reach of the patients.

A review of hospital document titled, "Committee of Whole Meeting Minutes and Agenda," revealed the minutes of the meetings taking place on 10/16/2024, 11/20/2024 and 12/18/2024. Each of these meetings minutes for the Topic: Annual EOC Risk Assessment for West (4201 Woodland Drive, Suite 400, New Orleans, LA 70131) included, "Housekeeping care(t) are not lockable." The Action Plan included, "Locked Housekeeping carts ordered for replacement."

In an interview on 12/23/2024 and present during the hospital walk-through, S4MHT confirmed the housekeeping cart was in the patient care area and the housekeeping supplies were not secured.

In an interview on 12/23/2024 at 3:10 PM, S3ADON confirmed the above mention findings and further indicated the hospital had not received lockable housekeeping carts.

Based on observation, record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by failure to ensure patient precautions were accurately communicated to the Mental Health Technician (MHT) assigned to monitor the entire census.
Findings:

Review of the psychiatric hospital policy titled "NS (Nursing Services), Precautions", last approved 01/25/2024, revealed in part: "Precautions [in part]: All direct care staff members (i.e. nurses, mental health technicians, counselors, etc.) are fully trained on the components of all precautions. The following are components of suicide precautions: unit restriction, sharps restriction. The following are components of aggression/violent behavior precautions: unit restriction, shoe restriction, signage, and 10-foot door parameter. The following are components of sexual acting out precautions: 10-foot parameter, line of sight while with peers, and restriction from room." Further review failed to reveal policy pertaining to alcohol/detoxification precautions.

Review of psychiatric hospital document titled "Daily Nursing Assignment Sheet" dated 12/26/2024, presented as correct per S2DON at 9:56 AM revealed a census of 20. 2 patients on 1:1 observation with 1 pending admission. Further review revealed R1 was on 1:1 observation with suicide precautions. R2 was on aggression precautions, R3 was on ETOH precautions and R4 was on 1:1 observation with aggression precautions. The following assignments were documented:
S12MHT assigned to R5, R6, R7, R8, R9, and R10. Tablet time from 7 AM - 9 AM and 3 PM-5 PM.
S9MHT assigned to R1. Tablet time from 9 AM-11 AM and 5 PM-7 PM.
S10MHT assigned to R1 (when S9MHT is on Tablet time), R2, R3, R11, R12, R13, and R14. Tablet time 11 AM- 1 PM.
S11MHT assigned to R4. Tablet time 1 PM- 3 PM.
S4MHT assigned to (R4 when S11MHT on Tablet time), #2, R15, R16, R17, R18 and R19. No assigned tablet time.

On 12/26/2024 at 10:04 AM, observation revealed S10MHT was observing R1 while S9MHT was on Tablet time.

During an interview on 12/26/2024 at 10:04 AM, S10MHT reported R1 was on 1:1 observation because she banged her head on the wall. When asked, S10MHT stated R1 was not on suicide precautions.

On 12/26/2024 at 10:10 AM observation, revealed S9MHT was walking with an electronic tablet down each hallway. She was attempting to locate a patient stating that sometimes tablet time was difficult because she could not always find the patients since they move around the unit. When asked, S9MHT indicated R2 was not on any precautions. S9MHT was surprised when she learned R2 was on aggression precautions. "it doesn't say that in the tablet". She reported the tablet showed R3 was on fall, seizure, suicide and ETOH precautions and was surprised when she learned the assignment sheet showed R3 was on only on ETOH precautions.

During an interview on 12/26/2024 at 3:42 PM, S2DON and S3ADON reported the hospital does not have a policy outlining the procedure for the one MHT observing the entire census every 15 minutes. The MHTs were taught that one MHT should observe all the patients on the census every 15 minutes while the other MHTs tended to needs of the patients and performed tasks such as showers, redirection, laundry, taking patients on smoke breaks, etc. S2DON indicated that when S4MHT was on 1:1 observation with R4, the other MHTs and S11MHT observed his assigned patients. When S10MHT was on 1:1 with R1 the other MHTs and S9MHT observed his assigned patients.

During an interview on 12/26/2024 at 3:42 PM, S2DON and S3ADON verified that the hospital does not have a policy on this procedure. Also during the interview S2DON verified the tablet is not always updated to reflect the precautions shown on the assignment sheet.

Based on record review and interview, the hospital failed to ensure the nursing staff developed an individualized nursing care plan for each patient. This deficient practice was evidenced by failure of the nursing staff to include medical diagnoses and condition changes in the plan of care for 2 (#2 and #3) of 2 (#2 and #3) sampled patients with medical diagnoses and condition changes.
Findings:

Review of the psychiatric hospital policy titled "Multidisciplinary Treatment Plan", last approved 01/25/2024, revealed in part: "Policy [in part]: The Multidisciplinary Treatment Plan includes: b. Medical problems that require intervention during hospitalization. 9. As changes in the patient's needs and/or condition changes or as interventions not already listed in the Multidisciplinary Treatment Plan are implemented, the multidisciplinary Treatment Plan is revised and updated."

Patient #2
Review of Patient #2's medical record revealed an admission date of 12/16/2024 with admitting diagnoses of bipolar disorder, stimulant use disorder, Sedative, hypnotic or anxiolytic use, with withdrawal and hypokalemia requiring potassium chloride administration.

A review of psychiatric hospital document titled "Louisiana Department of Health Hospital/Licensed Provider Abuse/Neglect Initial Report" dated 12/18/2024 at 1:48 AM and submitted on (date written as "9/17/2024"), revealed in part: On 12/18/2024 at 1:48 AM, Patient #1 was found attempting to hide on the side of Patient #2's bed with no pants on naked from the waist down. On further observation, Patient #2 was discovered to not be wearing any bottoms, also naked from the waist down.

Review of statement taken from Patient #2 on 12/19/2024 revealed the following: "Mood stabilizer-I did not want to take it but she made me take it to sleep. "Just take it, so you can go to sleep." Wrong answer. I was knocked out. I came to and he was on top of me. He was already having intercourse with me. He said, "the door is locked." I then could hear the nurse's voice yelling. I don't know what staff was in there, it was a lot, but I heard the night nurse's voice. Next thing I knew, I felt her hand grab the blanket off of me and I was exposed. I could tell because when I woke up the next morning, my pants were stuck around my ankles. Did they come back to check on me? I don't even think they came back to check on me! Please pull the tapes to check if they came back and check on me. I haven't even taken a shower since it happened! Please don't let me see him get arrested, let me be in my room. This should not have happened in any situation. No one should have been in anyone's room."

A review of Master Treatment Plan last updated on 12/19/2024 at 4:03 PM, failed to reveal active problems pertaining to events involving sexual assault occurring on 12/18/2024. Continued review failed to reveal active problems pertaining to hypokalemia, a medical problem requiring intervention.

During an interview on 12/26/2024 at 1:49 PM, S2DON and S3ADON verified Patient #2's Master Treatment Plan was last updated on 12/19/2024 and failed to reveal active problems pertaining to hypokalemia. S2DON and S3ADON confirmed the treatment plan had not been revised and updated following the events of sexual assault occuring on 12/18/2024.

Patient #3
Review of Patient #3's medical record revealed an admission date of 12/10/2024 with admitting diagnosis of brief psychotic disorder. Further review revealed Patient #1 had nicotine dependency, emesis, hypoglycemia, and low TSH.

A review of psychiatric hospital document titled "Louisiana Department of Health Hospital/Licensed Provider Abuse/Neglect Initial Report" dated 12/17/2024 and submitted on 12/18/2024, revealed in part: Patient #3 woke up yelling, "Someone came into my room and put their fingers in my ass!" The patient was sent to the ER for evaluation. A physician from ER called the psychiatric hospital and stated that due to the patient's current psychiatric mentality, the patient cannot give consent for a forensic evaluation. He did state that his lab results showed an acute kidney injury and that they will hydrate patient and return the patient to the psychiatric hospital."

A review of Master Treatment Plan last updated on 12/12/2024 failed to reveal active problems pertaining to events occurring on 12/17/2024. Continued review failed to reveal active problems pertaining to acute kidney injury, nicotine dependency, emesis, hypoglycemia, and low TSH, all medical problems requiring intervention.

During an interview on 12/26/2024 at 1:12 PM, S2DON and S3ADON verified Patient #3's Master Treatment Plan was last updated on 12/12/2024 and failed to reveal active problems pertaining to acute kidney injury, nicotine dependency, emesis, hypoglycemia, and low TSH. S2DON and S3ADON confirmed the treatment plan had not been revised and updated following the events of 12/17/2024.

Based on observation and interview, the hospital failed to ensure the condition of the physical plant and the overall hospital environment was developed and maintained in such a manner that the safety and well-being of patients were assured. This deficient practice is evidenced by failure to ensure the surfaces of the ventilation vents and the interior door frame of Room "u" were free of brown, rough and irregular surfaces creating an infection control issue.
Findings:

Observations during a walk-through of the hospital's offsite location at 4201 Woodland Drive, Suite 400, New Orleans, LA 70131 on 12/23/2024 from 1:20 PM to 2:00 PM revealed Room "u" with ventilation vents and the interior door frame containing brown, rough and irregular surfaces resembling rust which created an infection control issue.

In an interview on 12/23/2024 and present during the hospital walk-through, S4MHT confirmed the above mentioned findings.

Based on observation and interview, the hospital failed to ensure there was proper ventilation in all appropriate areas. This deficient practice was evidenced by the hospital failing to ensure Room "u" was properly ventilated.
Findings:

Observations during a walk-through of the hospital's offsite location at 4201 Woodland Drive, Suite 400, New Orleans, LA 70131 on 12/23/2024 from 1:20 PM to 2:00 PM revealed Room "u" with a damp floor, water beading on the exterior windows, a pungent smell, and a warm, humid feel. Observation failed to reveal indication of air circulating as felt by hand or movement of paper next to the vents and no obvious noise of an exhaust ventilation system functioning within this room.

In an interview on 12/23/2024 and present during the hospital walk-through, S4MHT confirmed the above mention findings.

Based on observation and interview, the hospital failed to have an effective infection prevention and control program as evidenced by failing to have a clean and sanitary environment.
Findings:

Observations during a walk-through of the hospital's offsite location at 4201 Woodland Drive, Suite 400, New Orleans, LA 70131 on 12/23/2024 from 1:20 PM to 2:00 PM revealed Room "u" with an adhesive medical bandage stuck to the wall of shower stall #1 and saturated toilet paper around the rim of the toilet.

In an interview on 12/23/2024 and present during the hospital walk-through, S4MHT confirmed the above mentioned findings.