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Based on record review and interview, the hospital failed to ensure a patient's consent for treatment was obtained and signed according to hospital policy by failing to obtain a patient's signed consent prior to treatment in the emergency department for 1 of 7 sampled patients' records reviewed (#6). Findings:

Review of the "Emergency Department Record" for Patient #6 revealed she presented to the ED (emergency department) on 10/1, with no documented evidence of the year, at 2345 (11:45pm). Further review revealed the section "Authorization for treatment: I hereby agree to the performance of such procedures, treatment, anesthetics, and operations that, in the opinion of the attending physician are deemed necessary on the patient" was blank with no documented evidence of a signature by the patient or relative. Review of the entire medical record revealed 2 forms titled "General Consent for Medical Treatment" with no documented evidence of the signature of the patient and/or relative and a witness.

In a face-to-face interview on 01/06/10 at 9:30am, S10 Registered Nurse (RN) confirmed there was no consent for treatment on the chart of Patient #6. She indicated it was the admit clerk's job to get the consent signed. She further indicated sometimes a patient's consent wasn't signed until a patient was ready for discharge. S10 RN indicated she remembered Patient #6 came by ambulance (no documented evidence of the mode of transport upon arrival), and she was previously told (could not remember who told her this) that if a patient came by ambulance, that it was assumed that the patient was giving informed consent.

Review of the hospital policy titled "Consent/Informed Consent", presented by the hospital as their current policy on consents and last revised 04/17/09, revealed, in part, "... All patients at (name of hospital system) hospitals must have a valid consent prior to receiving treatment. ... Definitions and Notes: General Consent for Medical Treatment: Signed when a patient presents to the facility for emergency services or is admitted to the facility ...".

Based on record review and interview, the hospital failed to ensure registered nurses (RN) evaluated the nursing care of patients by failing to: 1) reassess the vital signs of patients who presented to the emergency department (ED) with complaints of chest pain for 2 of 2 patients reviewed with chest pain from a total of 7 sampled patients (#3, #4) and 2) assess the need for suicidal observation of a patient presenting with psychiatric symptoms for 2 of 5 patients reviewed with psychiatric symptoms from a total of 7 sampled patients (#2, #5). Findings:

1) Assessment of patients with chest pain:
Patient #3
Review of Patient #3's "Emergency Department Record" revealed he arrived on 08/03/09 at 1416 (2:16pm) with complaints of left-sided chest pain after having been tazered 2 days previously. Further review revealed his vital signs taken at 1437 (2:37pm) by S19 RN was blood pressure 149/79, pulse 78, respirations 20, temperature 98.5 degrees Fahrenheit (F), and oxygen saturation 99% (per cent). Review of the entire ED record revealed the only documented vital signs were those taken at 2:37pm. Review of the "Initial Nurse Assessment" revealed an entry at 1830 by S12 RN that Patient #3 had eloped.
In a face-to-face interview on 01/06/10 at 10:00am, S12 RN indicated Patient #3 eloped at some time between 1629 (4:29pm) and 1830 (6:30pm). She further indicated she did not remember if more vital signs were taken by the nursing assistant. RN S12 indicated the nursing assistants usually take vital signs every 2 hours, and it's the nurse's responsibility to transfer the vital signs to the nursing record. She confirmed there were no documented vital signs other than those taken by the triage nurse, and she should have reassessed Patient #3's vital signs.

Patient #4
Review of Patient #4's "Emergency Department Record" revealed he was a 10 year old male who arrived to the ED with an attendant on 09/01/09 at 0030 (12:30am). Further review revealed his chief complaint was "woke up with c/o (complaints of) chest pain. Has had it before. Was dx (diagnosed) as "growing pains" get SOB (short of breath) when it occurs. Balls up in a knot-comes & (and) goes". Further review revealed his vital signs taken by RN S19 at 0040 (12:40am) were blood pressure 127/44, pulse 66, respirations 20, temperature 97.3 orally, and oxygen saturation 100%. Review of the "Initial Nurse Assessment" completed by RN S9 at 0315 (3:15am) revealed the only notation documented was "DC (discharge) instructions given. Pt (patient) mother verbalized understanding". Further review revealed the documented vital signs were those taken in triage at 12:40am.
In a face-to-face interview on 01/06/10 at 9:00am, RN S9 indicated the nursing assistant usually took vital signs every 2 hours. She confirmed Patient #4 should have had his vital signs taken prior to him being discharged.

Review of the hospital's policy titled "Assessment of the ED Patient", submitted by the hospital as their current policy on ED patient assessment and reassessment and last revised in 2009, revealed, in part, "...All patients admitted to the Emergency Department will have the following documentation: Chief Complaint, Assessment of psychological status, Initial vital signs, Additional vital signs shall be obtained depending on patient's condition, Allergies, Medications and OTC (over the counter) medications, herbal supplements, Medical history ...". Further review revealed no documented evidence of the parameters that would warrant repeating the vital signs and the frequency at which they were to be done.

In a face-to-face interview on 01/05/10 at 1:55pm, S2 Director of Nursing (DON) indicated the hospital did not have a policy that addressed what would determine if vital signs would need to be reassessed in the ED. She further indicated their policy revealed the vital signs being reassessed would be dependent upon the patient's condition.

2) Assessment for suicidal observation
Patient #2
Review of Patient #2's "Emergency Department Record" revealed she presented to the ED on 11/09/09 at 1810 (6:10pm) with complaints documented by RN S9 of "in per transport service from Mental Health with PEC (physician emergency certification) stating pt (patient) has recovering SI (suicidal ideation) with plan to OD (overdose). Pt. presently denies SI/HI (suicidal ideation/homicidal ideation) (0 with line through indicating no) A/V (auditory/visual) hallucinations". Review of the "Suicide Lethality Screen Addendum To Nursing Assessments" revealed the entire form was blank.
In a face-to-face interview on 01/06/10 at 9:00am, RN S9 indicated she usually completes the suicide screening form when the patient arrives in the ED room. She confirmed it was her responsibility to have completed the assessment, and it was not done.

Patient #5
Review of the "Suicide Lethality Screen Addendum To Nursing Assessments" revealed there was no documented evidence of the level of suicidal precautions on which Patient #5 was placed and that the physician was notified and an order was obtained.

In a face-to-face interview on 01/06/10 at 9:30am, RN S10 confirmed there was no documented evidence that the physician was notified of the suicide screening assessment. She indicated she did not know that the physician had to order the level of observation.

Review of the hospital policy titled "Psychiatric Patients, Care of", last revised 05/09 and submitted by the hospital as their current policy for care of the psychiatric patient in the ED, revealed, in part, "... Definitions: ... c. Sitters/Observers: Hospital personnel with Nursing Services who have documented training and competency to provide continuous observation of the patient ... Guidelines for Care and Monitoring Patients with Behavioral Health Diagnosis: ...b. The medical staff or designee will implement special observation procedures by a written or verbal order as soon as possible. The nurse may initiate any precaution level, notifying the attending physician or designee as soon as possible. This action may be validated by a physician's order. ... Documentation: a. Suicide Screening will be documented for all patients on the initial triage form or admit assessment form and throughout the patient's stay when additional 'triggers' are identified. Any hospital personnel identifying such triggers or other indication of persons at risk will report these findings to a licensed care provider immediately for further evaluation ... b. If a patient is classified at risk for suicide, a Suicide Lethality Screen Nursing Assessment Form will be completed by the primary nurse in consultation with the physician ... c. A physician will order 1:1 observation if indicated ...".

Based on record review and interview, the hospital failed to ensure the emergency department (ED) nursing staff followed the patient's plan of care by failing to obtain physician orders for observation and suicide precautions for 3 of 5 sampled patients with psychiatric complaints in the ED from a total of 7 sampled patients (#2, #5, #6). Findings:

Patient #2
Review of Patient #2's "Emergency Department Record" revealed she presented to the ED on 11/09/09 at 1810 (6:10pm) with complaints documented by RN S9 of "in per transport service from Mental Health with PEC (physician emergency certification) stating pt (patient) has recovering SI (suicidal ideation) with plan to OD (overdose). Pt. presently denies SI/HI (suicidal ideation/homicidal ideation) (0 with line through indicating no) A/V (auditory/visual) hallucinations". Review of the "Suicide Lethality Screen Addendum To Nursing Assessments" revealed the entire form was blank.
In a face-to-face interview on 01/06/10 at 9:00am, RN S9 indicated she usually completes the suicide screening form when the patient arrives in the ED room. She confirmed it was her responsibility to have completed the assessment, and it was not done. She also confirmed she did not obtain an order from the physician for the level of observation.

Patient #5
Review of the "Suicide Lethality Screen Addendum To Nursing Assessments" revealed there was no documented evidence of the level of suicidal precautions on which Patient #5 was placed and that the physician was notified and an order was obtained.

In a face-to-face interview on 01/06/10 at 9:30am, RN S10 confirmed there was no documented evidence that the physician was notified of the suicide screening assessment. She indicated she did not know that the physician had to order the level of observation.

Patient #6
Review of the "Suicide Lethality Screen Add" completed by S10 RN on 10/01/09 at 2355 (11:55pm) revealed Patient #6 was placed on suicidal precautions at Level I, which was constant observation, due to a "yes" answer to the following questions included in the screening: are there statements of intent to self-harm; is the patient unwilling and unable to contract not to harm oneself; and is the patient experiencing auditory hallucinations that command self-harm. Further review revealed no documented evidence the physician was notified of the screening and had signed the observation level or a verbal or telephone order had been obtained for the level of observation.

In a face-to-face interview on 01/06/10 at 9:30am, S10 RN, when asked if the physician had given her orders for the type of observation required for Patient #6, RN S10 indicated no, " we just automatically use constant observation if the patient was suicidal or homicidal".

Review of the hospital policy titled "Psychiatric Patients, Care of", last revised 05/09 and submitted by the hospital as their current policy for care of the psychiatric patient in the ED, revealed, in part, "...Guidelines for Care and Monitoring Patients with Behavioral Health Diagnosis: ... b. The medical staff or designee will implement special observation procedures by a written or verbal order as soon as possible. The nurse may initiate any precaution level, notifying the attending physician or designee as soon as possible. This action may be validated by a physician ' s order. ... Documentation: a. Suicide Screening will be documented for all patients on the initial triage form or admit assessment form and throughout the patient's stay when additional 'triggers' are identified. Any hospital personnel identifying such triggers or other indication of persons at risk will report these findings to a licensed care provider immediately for further evaluation ... b. If a patient is classified at risk for suicide, a Suicide Lethality Screen Nursing Assessment Form will be completed by the primary nurse in consultation with the physician ...c. A physician will order 1:1 observation if indicated ...".

Based on observation, record review, and interview, the hospital failed to ensure the nursing care of the emergency department (ED) patients was provided by nursing staff who had specialized education required by hospital standard and/or state licensing regulations by failing to have ED nursing staff with current CPR (cardiopulmonary resuscitation), ACLS (advanced cardiac life support), PALS (pediatric advanced life support), and/or IMAB (intervention and management of aggressive behavior) certifications for 6 of 7 nurses from a total of 7 sampled nurses' files reviewed (S8, S9, S10, S12, S20, S21), 1 of 1 sampled administrative coordinator (S11), and 1 of 1 sampled nursing assistant (S15). Findings:

Observation on 01/05/10 at 9:55am revealed S15 Nursing Assistant (NA) seated at a desk outside Room "a" with clear vision of a psychiatric patient in Room "a".
In a face-to-face interview on 01/05/10 at 9:55am, when asked by the surveyor if she had training in CPI (crisis prevention intervention, or IMAB as used by the hospital), S15 NA answered "yes".

Review of RN S8's personnel file revealed her CPR certification had expired 12/31/09. Further review revealed no documented evidence of a current CPR certification.

Review of RN S9's personnel file revealed her CPR certification had expired 12/31/09. Further review revealed she was scheduled to be recertified 01/25/10, and she was currently working as a staff nurse in the ED.

Review of RN S10's personnel file revealed no documented evidence of a current CPR card. In a face-to-face interview on 01/06/10 at 11:20am, S12 ED Charge Nurse confirmed she did not have a CPR card for RN S10. Further review revealed no documented evidence of completion of the IMAB training, and RN S10 was currently employed as an ED staff nurse. In a face-to-face interview on 01/06/10 at 10:55am, S14 RN Manager indicated RN S10 attended day 1 of the IMAB training on 11/29/09 and was scheduled for the second part on 01/22/10.

Review of S11 Administrative Coordinator's personnel file revealed IMAB certification had expired on 09/18/08. Review of her job description revealed no documented evidence that her job duties included providing psychiatric patient observations in the ED.
In a face-to-face interview on 01/06/09 at 10:55am, S14 RN Manager could offer no explanation for the job description not including psychiatric patient observations other than it was probably included in the "any other duties required by the supervisor".

Review of S12 ED RN Charge Nurse's personnel file revealed her CPR certification expired on 12/31/09. Further review revealed she did not recertify her CPR until 01/06/10, the day after her personnel file had been requested by the surveyor.

Review of NA S15's personnel file revealed her hire date was 12/28/09. Further review of the "Competency Assessment for Observer/Sitter for Patients Identified at Risk for Suicide" revealed it was signed by NA S15 on 12/30/09. Further review revealed it included the following: receipt of a copy of the policy regarding care of the psychiatric patients, receipt of instructions on completing the "Nursing Observation Log", receipt of a copy of the "Guidelines for Continuous Observation of a patient", and acknowledgement of completion of the inservice "How is Your Patient Today? Assessing for Suicide Risk". Further review of the entire personnel file revealed no documented evidence of an assessment of NA S15's competency by a qualified preceptor or supervisor prior to her providing constant observation of psychiatric patients at risk for suicide. There was no documented evidence of attendance at the IMAB training as required by hospital standards.

Review of RN S20's personnel file revealed no documented evidence of current ACLS and PALS certification.
In a face-to-face interview on 01/06/10 at 10:55am, RN Manager S14 confirmed they did not have a copy of RN S20's ACLS and PALS cards.

Review of RN S21's personnel file revealed her CPR certification had expired 12/31/09.

In a face-to-face interview on 01/06/10 at 10:55am, S14 RN Manager confirmed the above expired CPR certifications and the lack of IMAB training. She further indicated it was the responsibility of the DON to keep these requirements updated and current.

Review of the hospital ' s policies and procedures revealed no documented evidence of a policy for employee training on IMAB. Review of a memo, dated 08/01/07 to all hospital administrators from the Acting Deputy CEO (chief executive officer) S18, submitted by DON S2 revealed, in part, "...The requirements are that these instructors must continue to teach IMAB to all current staff, to all new hires who have direct patient contact, and that instructors must continue their own training to the level of Master Instructors ...".

Review of the hospital policy titled "American Heart Association Emergency Cardiovascular Care (ECC) Course", submitted by the hospital as their current policy on CPR requirements for personnel and last revised 06/09, revealed, in part, "...BLS (basic life support) shall be mandatory every two years for personnel who provide direct patient care.... Advanced Cardiovascular Life Support (ACLS) and Pediatric Advanced Life Support (PALS) shall be offered to ... employees quarterly as indicated on the Education Calendar. a. ACLS and PALS courses are open to physicians and extenders, licensed nurses...".

Review of the "Performance Planning And Review (PPR) Form" for the RN revealed, in part, "...will ensure that ACLS, PALS ... is kept up to date...".

Review of the Louisiana Hospital State Regulations for Emergency Services 9327-E.1-2 revealed, in part, "...All registered nurses working in emergency services shall be trained in advanced cardiac life support, pediatric trauma and pediatric advanced life support...".

Based on record review and interview, the hospital failed to ensure that all medical record entries were complete, dated, timed, and signed by failing to have forms completed, signed, dated, and/or timed for 6 of 7 sampled patient records (#2, #3, #4, #5, #6, #7). Findings:

Patient #2
Review of Patient #2's "Suicide Lethality Screen Addendum To Nursing Assessments" revealed the entire form was blank. Review of the "Emergency Department Discharge Instructions" revealed no documented evidence of the completion of activities, diet, medication, aftercare instructions, and prescriptions given. Further review revealed the physician did not date and time when he signed the instructions. Review of the "Emergency Department General Evaluation" revealed no documented evidence of the time of the examination, and no documented evidence of the date and time the physician signed the evaluation.
In a face-to-face interview on 01/06/10 at 9:00am, RN S9 indicated she usually completes the suicide screening form when the patient arrives in the ED room. She confirmed it was her responsibility to have completed the assessment, and it was not done.

Patient #3
Review of Patient #3's "Emergency Department Discharge Instructions" revealed no documented evidence of the completion of activities, diet, medication, aftercare instructions, and prescriptions given. There was no documented evidence of the signature of Patient #3 and the time and date the physician signed the instructions.

Patient #4
Review of Patient #4's "Emergency Department Record" revealed no documented evidence of the time and date when RN S9 discharged Patient #4. Further review revealed no documented evidence of the time Patient #4 was seen by the ED physician, and the physician did not date and time when he signed the form.

Patient #5
Review of Patient #5's "Nursing Observation Log" revealed no documented evidence of the signature of S11 Administrative Coordinator. Review of the "Suicide Lethality Screen Addendum To Nursing Assessments" revealed there was no documented evidence of the level of suicidal precautions on which Patient #5 was placed and that the physician was notified and an order was obtained.
In a face-to-face interview on 01/06/10 at 9:30am, RN S10 indicated she should have had the physician sign the form, but she was not aware the physician needed to give an order for the level of observation.

Patient #6
Review of Patient #6's "Emergency Department Record" revealed the date documented as 10/1, with no documented evidence of the year. Further review revealed no documented evidence of the date and time the physician signed the record.
Review of the "Emergency Department General Evaluation" revealed no documented evidence of the time of the physician's exam, as well as the date and time the physician signed the form.
Review of the "Code Documentation Record" revealed no documented evidence of the date and time the physician signed the form. Further review revealed no documented evidence the RN Supervisor of House Supervisor reviewed the form as evidenced by a blank for his/her signature.
In a face-to-face interview on 01/06/10 at 7:35am, Physician S5 indicated he usually times and dates his signatures and confirmed the above forms did not include a date and time when he signed them.
Review of the"Suicide Lethality Screen Add" completed by S10 RN on 10/01/09 at 2355 (11:55pm) revealed Patient #6 was placed on suicidal precautions at Level I. Further review revealed no documented evidence the physician was notified of the screening and had signed the observation level or a verbal or telephone order had been obtained for the level of observation.
In a face-to-face interview on 01/06/10 at 9:30am, RN S10 confirmed the suicide screening form did not have the signature of the physician. She indicated the nursing staff automatically uses constant observation if a patient was suicidal or homicidal.

Patient #7
Review of Patient #7's "Emergency Department General Evaluation" revealed no documented evidence of the time of the physician's exam, as well as the date and time the physician signed the form.
Review of Patient #7's "Emergency Department Record" revealed no documented evidence of the date and time Physician S4 and RN S8 signed the record.
In a face-to-face interview on 01/06/10 at 8:10am, S8 RN indicated she was aware that medical record entries needed to be dated and timed and confirmed she did not do this on the record of Patient #7.

Review of the hospital policy titled "Accuracy and timeliness of Record Completion", submitted by the hospital as their policy requirements for medical record entries and last revised 02/02/09, revealed, in part, "... 4. All entries are timed and dated, the author identified and authenticated, either by written or electronic signature...".

Review of the hospital's "Medical Staff Bylaws and Rules and Regulations", last revised September 2009, revealed, in part, "...Entries in the medical record may be made by a medical, nursing, or other allied health student ... House Staff and medical Staff members, licensed nurses ... All medical record entries are dated, timed and authenticated and their authors are identified ...".