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Based on record reviews and interview, the hospital failed to ensure it maintained compliance with State law as evidenced by having a patient admitted for treatment by emergency certificate for greater than 15 days for 1 (#5) of 5 (#1 - #5) patient records reviewed for implementation of State law from a sample of 5 patients.
Findings:

Review of "2011 Louisiana Laws Revised statutes Title 28 - Mental Health RS 28:53 - Admission by emergency certificate; extension" revealed a mentally ill person or a person suffering from substance abuse may be admitted and detained at a treatment facility for observation, diagnosis, and treatment for a period not to exceed fifteen days under an emergency certificate. Within seventy-two hours of admission, the person shall be independently examined by the coroner or his deputy who shall execute an emergency certificate which shall be a necessary precondition to the person's continued confinement.

Review of the roster of discharged patients in April 2018 revealed Patient #5 was admitted on 04/16/18 and discharged on 05/01/18 with a diagnosis of Paranoid schizophrenia.

Review of Patient #5's medical record revealed he was PEC'd on 04/16/18 at 2:20 a.m. and CEC'd on 04/16/18 at 2:30 p.m. Further review revealed he was discharged on 05/01/18 at 10:30 a.m., 8 hours 10 minutes after his PEC confinement had ended. There was no documented evidence in the record that a formal voluntary admission had been signed by Patient #5.

In an interview on 05/08/18 at 12:00 p.m., S3RVP indicated Patient #5's PEC/CEC time limit of 15 days "ran out" on 05/01/18 at 2:20 a.m. She confirmed a formal voluntary admission had not been signed by Patient #5 prior to his PEC expiring.

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to ensure patients received care in a safe setting as evidenced by:

1) Failing to ensure patients were observed by MHTs in accordance with physician orders.
a) Observation of a hospital-provided video recording on 05/08/18 at 3:00 p.m. of 05/07/18 from 1:57 a.m. to 4:07 a.m. revealed S6MHT, assigned to observe Patient R8 who was on LOS observations and on aggression precautions, failed to maintain Patient R8 in his LOS from 2:02 a.m. to 2:28 a.m. (26 minutes), from 2:39 a.m. to 2:50 a.m. (11 minutes), and from 3:42 a.m. to 4:07 a.m. (25 minutes). There was no observation of Patient R10, who was ordered to be on every 15 minutes observations and on suicide precautions, on 05/07/18 from 1:57 a.m. to 4:07 a.m. (2 hours 10 minutes).
b) Observation of a hospital-provided video recording on 05/09/18 at 9:35 a.m. of 05/09/18 from 12:58 a.m. to 2:58 a.m. revealed Patient R11, who was ordered to be on LOS observation and was on suicide and homicide precautions, was not in the LOS of a MHT from 1:59 a.m. to 2:01 a.m. (2 minutes) and from 2:32 a.m. to 2:34 a.m. (2 minutes).
(See findings in tag A0144)

2) Having hospital gowns with approximate 8 to 10 inch ties at the neck and side openings, that presented a risk for strangulation, worn by Patients #1, R11, R13, and R14 who were on suicide precautions.
(See findings in tag A0144)

3) Failing to ensure that the patient's basic right to respect, dignity, and comfort while in the hospital were met as evidenced by failing to have a sufficient quantity of towels available for bathing, pillows covered with pillow cases, and having no pillow available for use for each patient as observed and/or reported on 05/07/18 from 9:10 a.m. to 11:05 a.m. and observed on 05/08/18 at 9:40 a.m. (see findings in tag A0143)

Based on observations, interviews, and record reviews, the hospital failed to ensure that patient's basic right to respect, dignity, and comfort while in the hospital were met as evidenced by failing to have a sufficient quantity of towels available for bathing, pillows covered with pillow cases, and no pillow available for use for each patient as observed and/or reported on 05/07/18 from 9:10 a.m. to 11:05 a.m. and observed on 05/08/18 at 9:40 a.m.
Findings:
The underlying principle of this requirement is the patient's basic right to respect, dignity, and comfort while in the hospital.
Observation during the tour of the hospital on 05/07/18 from 9:10 a.m. to 11:05 a.m. revealed the following rooms had no pillow case covering the pillow being used by patients:
Room j - no pillow case on pillow
Rooms p, q, and s - no pillow case on pillow
Room r - 2 pillows without a pillow case
Rooms a, b, c, d, e, f, and g - pillow with no pillow case.

Observation during the tour of the hospital on 05/08/18 at 9:40 a.m. revealed the following rooms had no pillow available for use by the patients in each room:
Room c - no pillow
Room i - no pillow for each of 2 patients admitted to the room
Room t - no pillow
Rooms n and s - no pillow.

In an interview on 05/07/18 at 9:30 a.m., Patient R12 indicated she was admitted on 05/05/05/18 and had to take a shower with a sock as her hand towel and use a sheet to dry off. She further indicated staff told her they "don't have anything else." She further indicated she was given a sheet to cover her pillows.

In an interview on 05/08/18 at 9:40 a.m., Patient R11 indicated she was admitted on 05/02/18 and had not had a pillow since she was admitted. She further indicated was used to sleeping with a pillow and was not comfortable without one.

In an interview on 05/07/18 at 10:35 a.m., S4HK, with S3RVP present, indicated he came in on 05/04/18 and 05/06/18, and there was linen available. He further indicated he did not come to the hospital on 05/05/18. S3RVP indicated the hospital ordered mattresses and pillows last week.

In an interview on 05/08/18 at 8:55 a.m., S5MHT indicated he worked Saturday 05/05/18 from 7:00 p.m. to 7:00 a.m. on Sunday. He further indicated patients take their bath/shower on the night shift. He indicated they usually have enough towels for the first 10 or 12 patients only, because when they bring their linen to the nursing home who is contracted to provide linen, the nursing home doesn't return all their linen. He indicated they were short face towels and bath towels on 05/05/18. He further indicated the patients used a bath towel that had been cut into face towel size to use as a face towel and used blankets to dry. He further indicated it's been a problem with shortage of towels for about a month or so.

In an interview on 05/08/18 at 10:00 a.m., S7MHT indicated she worked Friday, Saturday, and Sunday this past weekend (05/04/18 to 05/07/18 at 7:00 a.m.). She indicated she was assigned one of the three nights to do showers. She indicated they ran out of face towels after the third person, so they used big towels.

In an interview on 05/08/18 at 11:15 a.m., S9RN indicated she was the charge nurse this past Saturday and Sunday night (05/05/18 and 05/06/18). She indicated she'd been employed for about a year, and they've had problems with linens off and on for about a year. She further indicated when they don't have towels, she has cut up bath towels to make wash cloths. She further indicated when they don't have bath towels, the patients have to use a sheet to dry after the bath.

Review of an invoice dated 04/18/18 at 12:31 p.m., presented by S1ADM, revealed 12 pillows had been ordered. There was no documented evidence presented that revealed the shipment and receipt of the pillows.

Based on observations, record reviews, and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by:
1) Failing to ensure patients were observed by MHTs in accordance with physician orders. Observation of a hospital-provided video recording on 05/08/18 at 3:00 p.m. of 05/07/18 from 1:57 a.m. to 4:07 a.m. revealed S6MHT, assigned to observe Patient R8 who was on LOS observations and on aggression precautions, failed to maintain Patient R8 in his LOS from 2:02 a.m. to 2:28 a.m. (26 minutes), from 2:39 a.m. to 2:50 a.m. (11 minutes), and from 3:42 a.m. to 4:07 a.m. (25 minutes). There was no observation of Patient R10, who was ordered to be on every 15 minutes observations and on suicide precautions, from 1:57 a.m. to 4:07 a.m. (2 hours 10 minutes). Observation of a hospital-provided video recording on 05/09/18 at 9:35 a.m. of 05/09/18 from 12:58 a.m. to 2:58 a.m. revealed Patient R11, who was ordered to be on LOS observation and was on suicide and homicide precautions, was not in the LOS of a MHT from 1:59 a.m. to 2:01 a.m. (2 minutes) and from 2:32 a.m. to 2:34 a.m. (2 minutes).
2) Having a large comb and ink pen (a safety risk for patients who were suicidal or aggressive) under the mattress in Room r on 05/07/18 at 1:30 p.m. Patient #4 who was admitted to Room r was on suicide and aggression precautions.
3) Having hospital gowns with approximate 8 to 10 inch ties at the neck and side openings, that presented a risk for strangulation, worn by Patients #1, R11, R13, and R14 who were on suicide precautions.
4) Having rough, splintered edges on a panel of wood mounted on the wall in Room f that presented a safety risk for Patient R5 who was on suicide precautions.
Findings:

1) Failing to ensure patients were observed by MHTs in accordance with physician orders:
Observation of a hospital-provided video recording on 05/08/18 at 3:00 p.m., with S2DON navigating the video, of 05/07/18 from 1:57 a.m. to 4:07 a.m. revealed S6MHT, assigned to observe Patient R8 who was on LOS observations and on aggression precautions, failed to maintain Patient R8 in his LOS from 2:02 a.m. to 2:28 a.m. (26 minutes), from 2:39 a.m. to 2:50 a.m. (11 minutes), and from 3:42 a.m. to 4:07 a.m. (25 minutes). There was no observation that S6MHT was replaced by another MHT before leaving Patient R8 unobserved. There was no observation of Patient R10, who was ordered to be on every 15 minutes observations and on suicide precautions, from 1:57 a.m. to 4:07 a.m. (2 hours 10 minutes).

Observation of a hospital-provided video recording on 05/09/18 at 9:35 a.m., with S1ADM navigating the video, of 05/09/18 from 12:58 a.m. to 2:58 a.m. revealed Patient R11, who was ordered to be on LOS observation and was on suicide and homicide precautions, was not in the LOS of a MHT from 1:59 a.m. to 2:01 a.m. (2 minutes) and from 2:32 a.m. to 2:34 a.m. (2 minutes).

Review of the staff assignment sheet for the night shift (7:00 p.m. on 05/06/18 to 7:00 a.m. 05/07/18) of 05/06/18 revealed S6MHT was assigned to observe Patient R8 on LOS and Patient R10 every 15 minutes.

Review of the staff assignment sheet for the night shift of 05/08/18 (7:00 p.m. on 05/08/18 to 7:00 a.m. on 05/09/18) revealed S11MHT was assigned to observe Patient R11 on LOS.

Review of the policy titled "Levels Of Observation", presented as a current policy by S1ADM, revealed 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 observes the patient to determine signs of life, location, and activity. Line of sight is defined as maintaining visual observation of a patient at all times. A staff member may be assigned to maintain LOS on up to three patients. Although visualization is continuous, the staff member documents the patient's location and general activity at least every 15 minutes. At night, patients on LOS may be roomed together or in close enough proximity to allow a staff member visual contact at all times. In the event that a staff member providing LOS observation must leave his/her spot, compromising visualization of any LOS patients assigned, the staff member must obtain relief and/or assistance from another staff member.

Patient R8
Review of Patient R8's medical record revealed he was admitted on 05/06/18 with a diagnosis of Schizoaffective Disorder, Depressive Type. Review of his physician orders revealed an order on 05/06/18 at 5:50 p.m. for LOS observation and aggression precautions. Review of patient R8's close observation form revealed he was on "Level III - Close Observation - every 15 min." There was no documented evidence the form used by S6MHT revealed Patient R8 was to be observed on LOS. Further observation revealed S6MHT documented he observed Patient R8 every 15 minutes from 2:00 a.m. to 4:00 a.m. on 05/07/18, and Patient R8 in his room sleeping in his bed.

Patient R10
Review of Patient R10's medical record revealed she was admitted on 05/02/18 with diagnoses of Bipolar Disorder, unspecified and Major Depressive Disorder, single episode, unspecified. Review of her physician orders revealed an order on 05/02/18 at 7:10 a.m. for suicide precautions and an order on 05/02/18 at 7:47 a.m. for every 15 minutes observations. Review of her MHT observation record revealed S6MHT documented she was in her room sleeping in her bed from 2:00 a.m. to 4:00 a.m. on 05/07/18.

Patient R11
Review of Patient R11's medical record revealed she was admitted on 05/02/18 with a diagnosis of Major depressive Disorder, single episode, unspecified. Review of her physician orders revealed an order on 05/07/18 at 6:00 p.m. for LOS observation. Review of her MHT observation record revealed S11MHT documented Patient R11 was in her room sleeping in her bed from 2:00 a.m. to 3:00 a.m. on 05/09/18.

In an interview on 05/08/18 at 3:00 p.m., S2DON confirmed the hospital video revealed no observation that S6MHT was replaced by another MHT before leaving Patient R8 unobserved for 3 separate times of 26 minutes, 11 minutes, and 25 minutes on 05/07/18 from 1:57 a.m. to 4:07 a.m. He confirmed there was no observation of Patient R10 being observed for 2 hours 10 minutes from 1:57 a.m. to 4:07 a.m. on 05/07/18.

In an interview on 05/09/18 at 9:35 a.m., S1ADM confirmed Patient R11 was not in the LOS of a MHT from 1:59 a.m. to 2:01 a.m. (2 minutes) and from 2:32 a.m. to 2:34 a.m. (2 minutes) on 05/09/18.

2) Having a large comb and ink pen (a safety risk for patients who were suicidal or aggressive) under the mattress in Room r on 05/07/18 at 1:30 p.m.:
Observation during a tour of the hospital on 05/07/18 at 1:30 p.m., with S3RVP present, revealed a large comb and an ink pen were under the mattress in Room r.

Review of the staff assignment sheet for 05/07/18 revealed Patient #4 was admitted to Room r.

Review of Patient #4's medical record revealed physician orders on 05/01/18 at 8:45 a.m. for aggression precautions and on 05/01/18 at 10:00 a.m. for suicide precautions.

Review of the policy titled "Precautions", presented as a current policy by S1ADM, revealed suicide precautions are utilized when a patient demonstrates or verbalizes an indication that he/she represents a danger to himself/herself or is contemplating self-injurious behavior. Aggression/violent behavior precautions are ordered when a patient, by behavior, verbalization, history, or by report presents a risk of violence towards others, regardless of the specific type of risk. Both precautions prohibit staff members from providing those sharp items typically allowed for patient use with supervision and/or with time restrictions. The patient may not have access to items identified as "sharps" at any time. Further review revealed the only "sharps" item noted was razors. There was no documented evidence that policy identified what would be considered "sharps."

In an interview on 05/07/18 at 1:30 p.m. during the observation, S3RVP indicated the ink pen should not be in the patient's room. She further indicated the MHT was supposed to make safety rounds every shift.

3) Having hospital gowns with approximate 8 to 10 inch ties at the neck and side openings, that presented a risk for strangulation, worn by Patients #1, R11, R13, and R14 who were on suicide precautions:
Observation outdoors during the patients' smoke break on 05/07/18 at 11:02 a.m. revealed Patients #1, R11, R13, and R14 had hospital gowns on with an approximate 8 to 10 inch tie at the neck and side openings that presented a ligature risk for patients on suicide precautions.

Review of the medical records of Patients #1 and R13 revealed each had physician orders for suicide precautions.

Review of the medical records of patients R11 and R14 revealed each had physician orders for suicide and aggression precautions.

In an interview on 05/07/18 at 11:02 a.m. during the above observation, S1ADM confirmed Patients #1, R11, R13, and R14 were wearing hospital gowns with ties at the neck and sides. he confirmed the ties were a ligature risk for patients on suicide precautions.

4) Having rough, splintered edges on a panel of wood mounted on the wall in Room f that presented a safety risk for Patient R5 who was on suicide precautions:
Observation in Room f on 05/07/18 at 10:42 a.m., with S1ADM and S2DON present, revealed a wood panel screwed on the wall that had rough, splintered edges at the bottom of the wood panel that presented a safety risk for scratches and injury to patients.

In an interview on 05/07/18 at 10:42 during the above observation, S1ADM confirmed the rough, splintered edges of the wood panel in Room f.

Based on record reviews and interview, the hospital failed to ensure the RN assigned the nursing care of each patient to MHTs in accordance with the specialized qualifications and competence of the available MHTs as evidenced by having MHTs assigned to patient care who did not meet the qualifications specified in the MHT job description and/or who had not been evaluated for competency for 3 (S5MHT, S6MHT, S10MHT) of 3 MHT personnel files reviewed for qualifications and competence.
Findings:

Review of the MHT job description revealed qualifications included two years experience in a mental health care setting was required.

Review of the policy titled "Competency Of staff", presented as a current policy by S1ADM, revealed the methods of assessing competency may include written exam, return demonstration, use of simulations, interview, direct observation by a qualified supervisor or preceptor, and/or successful completion of a skills checklist.

Review of the personnel files of S5MHT, S6MHT, and S10MHT revealed no documented evidence that each MHT had any prior experience working in a mental health care setting.

Review of S5MHT's unit orientation documented on 01/08/18 revealed no documented evidence that he was evaluated for competency for the MHT duties listed on page 3 and 4 of the form.

In an interview on 05/08/18 at 1:25 p.m., S1ADM confirmed the above findings.

Based on observations, record reviews, and interviews, the hospital failed to ensure the physical plant and the overall hospital environment was maintained in such a manner that the safety and well-being of patients was assured as evidenced by having a hole in the wall in Room u, splintered edges on the bottom of the Seclusion Room door, having a toilet that wouldn't flush in Room i, having several packets of sugar on the window sill in the Day Room with an accumulation of ants crawling on the window sill, and having dead termites on bedspreads, window sills, under mattresses, and on the floor throughout the hospital, all observed during the hospital tour on 05/07/18 at 9:10 a.m. through 11:05 a.m. and on 05/08/18 at 9:40 a.m.
Findings:

Hole in the wall:
Observation on 05/07/18 at 9:10 a.m. revealed a hole in the wall at the baseboard and at the edge where the tile starts on the wall in Room u. This observation was confirmed during the tour by S1ADM and S2DON.

Seclusion Room door:
Observation on 05/07/18 at 9:10 a.m. during a tour of the hospital revealed the bottom edge of the Seclusion Room door had a rough, splintered edge. This observation was confirmed by S2DON.

Toilet not flushing:
Observation on 05/08/18 at 9:40 a.m., with S2DON present, revealed the toilet in Room i was filled with toilet tissue.

In an interview on 05/08/18 at 9:40 a.m., Patient R11 indicated had not been flushing since 05/07/18. She further indicated she had been using the toilet and had reported it "to some lady who said it's not her job."

In an interview on 05/08/18 at 9:40 a.m., S2DON indicated he would have to notify someone to fix the toilet.

Sugar on window sill with accumulation of ants:
Observation in the Day Room on 05/07/18 at 10:42 a.m., with S1ADM and S3RVP present, revealed several opened packets of sugar on the window sill with an accumulation of crawling ants on the window sill. S1ADM and S3RVP confirmed the presence of ants surrounding the opened sugar packets.

Dead termites throughout the hospital:
Observation during the tour of the hospital on 05/07/18 from 9:10 a.m. to 11:05 a.m. revealed the presence of dead termites in the following locations: on the bedspread of Patient R12; the window sill in Rooms l, o, p, r, g, e, c, a; on the floor on each side of the entrance door to the building.

Review of the policy titled "Proper Cleaning Of patient Rooms - Inpatient", presented as a current policy by S1ADM, revealed the environmental services department was to clean each occupied patient room daily. Further review revealed routine cleaning included damp dusting all window sills, mopping/cleaning floors, and wiping down the bed, starting from the top of the mattress and working down to the bottom including the sides and underneath the mattress.

In an interview on 05/07/18 at 9:45 a.m., S2DON confirmed the presence of dead termites throughout the building during the tour. He further indicated he was aware that termites swarming outside the building entered the building when the entrance door was opened at night.

Based on observations, record reviews, and interviews, the hospital failed to implement its system for controlling infections and communicable diseases of patients.
1) The hospital failed to maintain a sanitary physical environment as evidenced by a) having no soiled linen cart in the Soiled Utility Room that resulted in having soiled linen uncontained on top of the biohazard bin; b) having torn,shredded pillows that presented no means for disinfection between patient use in Rooms q, w, o, h, e, f, c, d, and a; c) having a mattress in Room x with an approximate 1/8 inch hole and an approximate 4 inch tear that provided no means of disinfection between patient use.
2) The hospital failed to have evidence of infection risk mitigation measures as evidenced by failure to have documented evidence of hand hygiene surveillance.
3) The hospital failed to practice safe injection practices as evidenced by having an opened vial of Humulin R U-100 injection opened on 03/19/18 and an opened vial of Novolog 100 ml per injection opened on 03/26/18 in the medication refrigerator available for use. Observation revealed the medication refrigerator had a thick block of ice in the back of the refrigerator.
Findings:

1) The hospital failed to maintain a sanitary physical environment:
a) Soiled linen:
Observation on 05/07/18 at 9:10 a.m. revealed the Soiled Utility Room did not have a soiled linen cart in the room. Further observation revealed soiled linen was not bagged and placed on top the biohazard bin.

In an interview on 05/07/18 at 9:10 a.m., S2DON indicated the soiled linen should be bagged and placed in the soiled linen cart which should be in the room.

b) Torn, shredded pillows:
Observation on 05/07/18 from 9:10 a.m. through 11:05 a.m. during the tour of the hospital revealed the beds in Rooms q, w, o, h, e, f, c, d, and a had pillows that torn or shredded.

In an interview on 05/07/18 at 10:00 a.m., S1ADM and S2DON indicated the staff should be reporting to them the condition of the pillows. S2DON indicated he was the Infection Control Officer for the hospital. He further indicated he didn't include inspections of pillows and mattresses when he did his weekly environmental and hand hygiene rounds.

c) Mattress:
Observation on 05/07/18 at 9:10 a.m. revealed the mattress in Room x had an approximate 1/8 inch hole and an approximate 4 inch tear.

In an interview on 05/07/18 at 9:10 a.m., S2DON confirmed the tears in the mattress prevented the mattress to be appropriately disinfected between patient use.

2) The hospital failed to have evidence of infection risk mitigation measures as evidenced by failure to have documented evidence of hand hygiene surveillance:
In an interview on 05/09/18 at 2:35 p.m., S1ADM indicated he could not locate the hand hygiene surveillance that S2DON had conducted for infection control.

3) The hospital failed to practice safe injection practices:
Observation on 05/07/18 at 10:25 a.m. in the Medication Room revealed an opened vial of Humulin R U-100 injection opened on 03/19/18 and an opened vial of Novolog 100 ml per injection opened on 03/26/18 in the medication refrigerator available for use. Further observation revealed the medication refrigerator had a thick block of ice in the back of the refrigerator.

Review of the policy titled "Infection Prevention And control Program", presented as a current policy by S1ADM, revealed the section related to safe injection practices did not address the timeframe for discarding opened vials of medications.

Review of the CDC's guidelines for safe injection practices revealed multi-dose vials that have been opened and accessed should be dated and discarded within 28 days unless the manufacturer specifies a different date.

In an interview on 05/07/18 at 10:25 a.m., S2DON confirmed the two vials of medication mentioned above should have been discarded and not available for use.