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Based on observation, record review, and interview the facility failed to meet the requirements for the Condition of Participation (CoP) for Patients' Rights. The deficient practice is evidenced by:
1. Failure to have inpatient room doors that allow easy access to patients related to proper use of locks and/or if the keyhole had been tampered with by a patient. Staff having to use a key to access the patient room could allow the patient the ability to tamper with the lock and/or insert an object into the key hole, which could prevent or delay the staff obtaining access to the patient (see findings under Tag A0144);
2. Failure to ensure 15 minute observations of adolescent psychiatric patients were performed as ordered (see findings under Tag A0144);
3. Failure to provide privacy during personal bathing (shower) by having no shower curtains for the shower stalls (see findings under Tag A0143);
4. Failure to ensure each patient has the right to personal privacy by failing to provide window coverings to obscure the view from the outside into 10 of 10 patient rooms observed (see findings under Tag 0143).

An Immediate Jeopardy (IJ) was identified on 06/05/2024 at 3:45 p.m. and reported to S1QD and S2RADM.

The Immediate Jeopardy (IJ) situation was the result of the hospital's failure to ensure patient safety. A second Immediate Jeopardy (IJ) situation was the result of the hospital's failure to easily access patients due to improper lock usage. The hospital's failure to maintain adequate supervision of patients created the potential for serious harm/injury.

On 06/06/2024 S1QD and S2RADM presented the plan for lifting the immediacy of the IJ. The plan included re-education in regards to monitoring compliance with observation, rounding and reviewing camera footage and re-education regarding proper use of locks in patient care areas.

On 06/06/2024 at 11:00 a.m. the Immediate Jeopardy was removed and remains at a Condition level.

Based on observation and interview, the hospital failed to ensure each patient has the right to personal privacy. This deficient practice had the potential to impact any of the 12 adolescent patients that were on the unit during the time of the survey and is evidenced by:
1. Failure to provide privacy during personal bathing (shower) by having no shower curtains for the shower stalls;
2. Failure to ensure each patient has the right to personal privacy by failing to provide window coverings to obscure the view from the outside into 10 of 10 patient rooms observed.
Findings:

A review of hospital policy, "Patient Rights Louisiana," last revised 09/01/2023, revealed in part: Purpose: To ensure that all patients are aware of their rights while being treated at this facility and to provide guidance to the program staff regarding the method for ensuring patient rights are respected and the method for restricting a patient's rights if deemed necessary. Treatment: You have the right to treatment that recognizing and respects your personal dignity, confidentiality, privacy and security. Rights of Minors: A. Each minor patient has a right to care provided in a dignified and humane manner, and to such privacy as is possible consistent with the minor's treatment plan.

1. Failure to provide privacy during personal bathing (shower) by having no shower curtains for the shower stalls.

Observations during a tour on 06/03/2024 from 1:10 p.m. to 2:05 p.m. revealed 4 shower stalls in the bathroom with no shower curtains to allow for privacy while performing hygiene. The patients are able to be visualized by staff unclothed while showering. During patient shower time, staff remain outside of room (cc) unless performing q15 minute observations of patient.

In an interview during the tour on 06/03/2024, S1QD indicated that there are no shower curtains due to the patients pulling them down.

2. Failure to ensure each patient has the right to personal privacy by failing to provide window coverings to obscure the view from the outside into 10 of 10 patient rooms observed.

Observations during a tour on 06/03/2024 from 1:10 p.m. to 2:05 p.m. revealed 10 of 10 rooms lacked any covering over the windows in the bedrooms to provide privacy from passersby on the outside of the building.

In an interview during the tour on 06/03/2024, S1QD and S4ADON confirmed that people on the outside of the building would be able to see into the rooms, and personal privacy was not provided.

Based on observation and interview, the hospital failed to ensure patients requiring inpatient psychiatric care received care in a safe setting. This deficient practice was evidenced by:
1. Failure to have inpatient room doors that allow easy access to patients related to proper use of locks and/or if the keyhole had been tampered with by a pateint;
2. Failure to ensure 15 minute observations of adolescent psychiatric patients were performed as ordered;
3. Failure to follow MD order by failing to maintain LOS;
4. Failure to provide the order level of observation for a patient in seclusion.
Findings:

Review of facility policy, "Level of Observations," last revised 03/01/2023, revealed in part: Three levels of observation are utilized: every 15-minutes (Q15 minutes) observation; Line of Sight (Constant Observation); and one-to-one observation ... Every 15-minutes - the staff member will visually observe the patient every 15 minutes to monitor their location and activity, with an emphasis on any noticeable behaviors of escalation, aggression, and unsafe activities. Line of Sight (Constant Observation) - the staff member will ensure the patient is visually within sight at all times. One-to-one observation - the staff will ensure the patient is visually within sight and within arms-reach of a staff member at all times and in all circumstances. Procedure 3 ... The observing staff initials the 15-minute increments on the form to indicate the patient was observed. Line of Sight Observations: The designated staff (MHT) is assigned to perform line of sight observation and can observe multiple patients, but must remain in the area with the patients such that if a patient needs immediate intervention, the staff member can intervene and call for assistance. Line of sight observation level includes constant observation in the bathroom and toilet areas, unless the door is able to be left ajar and the observer is able to access the room immediately. One-to-one Observation: is defined as: Keeping the patient under direct observation within one arm's reach of the patient at all times. This includes use of bathroom and bathing.

1. Failure to have inpatient room doors that allow easy access to patients related to proper use of locks and/or if the keyhole had been tampered with by a pateint.

An observation during a tour revealed that each inpatient room door locks from the outside upon closing. In order to open a closed door, the patient must either open it from the inside or a staff member must use a key to open the door from the outside within the main hall. Staff having to use a key to access the patient room could allow the patient the ability to tamper with the lock and/or insert an object into the key hole, which could prevent or delay the staff obtaining acess to the patient.

On 06/05/2024 from 12:45 p.m. - 1:50 p.m., during a review of video footage dated 06/05/2024 from 7:00 a.m. - 11:00 a.m., revealed main hallway. S12MHT was assigned to perform q15 minute observations on patient #16. Review of footage revealed the following:
-10:13 a.m. S12MHT rounds on patient #16 in his room.
-10:27 a.m. S12MHT goes to round on patient #16 in room (m). Video footage shows S12MHT knock on patient door. S12MHT then gets her key and unlocks patient door from main hallway to access patient. Unable to view how long patient door had been closed.

During an interview on 06/05/2024 at 1:15 p.m. S1QD confirmed findings above.

2. Failure to ensure 15 minute observations of adolescent psychiatric patients were performed as ordered.

In an interview on 06/05/2024 at 1:40 p.m., S1QD confirmed the following 3 patients on the night shift of 06/04/2024 were assigned to rooms (i-p):
-Patient #17 in room (j)
-Patient #16 in room (m)
-Patient #18 in room (p)

On 06/05/2024 from 12:45 p.m. - 1:50 p.m., a review of video footage dated 06/04/2024 from 10:00 p.m. - 5:00 a.m., revealed main hallway. S11MHT observing rooms 105, 107, and 108 is viewed slumped forward with her head on the table and not moving to make observations of patients she was assigned to. No direct observations made for room (i-p) during the following periods:
1:30 a.m. - 2:59 a.m.
3:30 a.m. - 4:58 a.m.

In an interview on 06/05/2024 during review of video footage S1QD confirmed findings above.

In an interview on 06/05/2024 at 2:00 p.m. S1QD confirmed S11MHT signed observation sheets but did not actually round per video footage during the times above.

In an interview on 06/05/2024 at 9:40 a.m., S1QD confirmed the following patient on the day shift of 06/05/2024 was assigned to room (m):
- Patient #16 in room (m)

On 06/05/2024 from 12:45 p.m. - 1:50 p.m., a review of video footage dated 06/05/2024 from 7:00 a.m. - 11:00 a.m., revealed main hallway. S12MHT was assigned to perform q15 minute observations on patient #16. No direct observations made on patient #16 during the following periods:
7:03 a.m. - 7:45 a.m.
8:52 a.m. - 9:44 a.m.

In an interview on 06/05/2024 during review of video footage S1QD confirmed findings above.

In an interview on 06/05/2024 at 2:00 p.m. S1QD confirmed S12MHT signed observation sheets but did not actually round per video footage during the times above.

3. Failure to follow MD order by failing to maintain LOS.

Review of a self-report incident that occurred on 05/16/2024 at 6:19 a.m. revealed that patient #1 was on LOS observation when he was involved in an altercation with another patient. S13MHT was assigned to maintain LOS on Patient #1, reported that he did not witness incident.

In an interview on 06/06/2024 at 10:00 a.m. S3DON confirmed that S13MHT did not maintain LOS as per MD order on patient.

Based on record review and interview, the hospital failed to ensure patients were free from abuse and failed to ensure all incidents of abuse, neglect, and/or harassment were reported and analyzed, and the hospital was in compliance with applicable local, State, and Federal Laws and Regulations. This deficient practice was evidenced by the hospital's failure to thoroughly investigate all reported cases of possible abuse or neglect in 1of 11 reviewed incidents that was reported to Louisiana Department of Health.

Findings:

Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report abuse/neglect allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Louisiana Department of Health (LDH). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence.

Review of hospital policy revised 11/01/2023 titled "Assessment and Reporting of Abuse, Neglect" revealed in part: PROCEDURE: Procedure to Respond to Alleged or Suspected Abuse, Neglect, Exploitation by Facility staff or by another patient. 2. If the allegations involves another patient or a staff member of the facility, the Administrator/Administrator-on-Call are responsible to ensure a thorough investigation is performed and will respond immediately to address any clinical assessments and ensure the provision of any clinical interventions necessitated by the circumstances and perform an investigation to determine if the allegations are substantiated.

Review of hospital policy revised 09/01/2023 titled "Patient Rights Louisiana" revealed in part: Abuse, Neglect, Exploitation, Harassment: You have the right to be free from mental, physical, and verbal abuse; neglect; exploitation; and/or harassment.

Review of hospital policy revised on 03/01/2023 titled, "Level of Observations" revealed in part: Observation Levels: Line of Sight (Constant Observation)- the staff member will ensure the patient is visually within sight at all times.

Review of Self-Reports for April and May 2024 revealed, in part, "11 incidents involving patient altercations." One incident investigated involving an altercation between Patients #1, #8, #18. The Self-Report reviewed indicated that the facility investigated incident and found allegations unsubstantiated. Further review revealed Patient #1 was on a line of sight observation which S13MHT was assigned during time of incident. S13MHT reported not witnessing the event therefore not following MD order.

In an interview on 06/06/2024 at 10:17 a.m. S4ADON indicated performing the investigation regarding the altercation involving Patients #1, #8, and #18, but failed to substantiated incident not recognizing S13MHT was not following MD orders for line of sight observation on Patient #1. S4ADON verified that hospital policies/procedures for level of observations were not followed.

Based on record review and interview the hospital failed to analyze and track all adverse patient events. The deficient practice is evidenced by failure of hospital staff to initiate an incident reports after a patient exhibited self-harm behavior.
Findings:

Review of hospital policy effective date 02/01/2024 titled, "Incident Reporting" revealed in part: PURPOSE: to document any potential or adverse incidents within the facility or on the facility grounds/property/vehicle, with the facts available at the time, recorded by persons involved, either in the incident or in the discovery of the incident. DEFINITIONS: Patient incident- anything that is out of the expected norm for the patient. Incident Severity: Mild harm: minimal symptoms or loss of function, or injury limited to additional treatment, monitoring, and/or increased length of stay. No harm: Event reached the patient, but no harm was evident.

On 06/04/2024 medical record review revealed that Patient #4 had punched a wall on 04/25/2024 and 04/29/2024. Furthermore neither incidents were reported per hospital policy/procedures.

On 06/04/2024 review of Incident Reporting Log did not reveal entries for Patient #4 punching a wall on 04/25/2024 or 04/29/2024.

In an interview on 06/04/2024 at 11:20 a.m. S1QD verified no incident report was entered for Patient #4 punching a wall on 04/25/2024 and/or 04/29/2024.

Based on record review and interview the hospital failed to ensure the Registered Nurse evaluated the care of each patient on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy. This deficiency is evidenced by failure of the Registered Nurse to perform neurovascular checks for Patient #8 per NPP order.
Findings:

Review of hospital policy revised 01/01/2023, titled "Documentation" reveal in part: PURPOSE: To maintain a comprehensive and chronologically continuous account of treatment delivered to a patient by nursing staff. ROUTINE: 3. Documents the implementation and execution of physician and NPP orders.

Review of Patient #8's medical record revealed a NPP ordered neurovascular checks every 4 hours ordered 05/16/2024 7:28 p.m. to start at 9:00 p.m. and ordered to continue neurovascular checks every 4 hours on 05/17/2024 at 8:06 p.m. Review of nursing documentation revealed neurovascular checks done on 05/16/2024 at 9:00 p.m., and on 05/17/2024 at 1:00 a.m., 5:00 a.m., 9:00 a.m., 1:00 p.m., 3:20 p.m., and on 05/18/2024 at 1:00 a.m., 5:00 a.m., 1:00 p.m. The nurse missed the neurovascular assessments on 05/18/2024 at 9:00 a.m. and 7:30 p.m.

In an interview on 06/05/2024 at 10:28 a.m. S1QD verified that there were no nursing neurovascular assessments for Patient #8 on 05/18/2024 at 9:00 a.m. and 7:30 p.m.

Based on record review and interviews the hospital failed to ensure a registered nurse assigned the nursing care of each patient to other nursing personnel in accordance with the patient's needs for 6 (#8, #17, #19-#22) of 14 (#8-#9, #16-#27) patients on the unit.

Findings:

Review of facility policy titled, "Seclusion and Restraints - LA/MS/OK," last revised on 05/01/2024, revealed in part: Definition: Seclusion: The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for management of violent or self-destructive behavior. 3. Utilization of Seclusion: *Assign a trained/competent staff member to provide one-to-one observation of the patient for continuous monitoring while in seclusion.

Review of facility policy, "Level of Observations," last revised 03/01/2023, revealed in part: Three levels of observation are utilized: every 15-minutes (Q15 minutes) observation; Line of Sight (Constant Observation); and one-to-one observation ... Every 15-minutes - the staff member will visually observe the patient every 15 minutes to monitor their location and activity, with an emphasis on any noticeable behaviors of escalation, aggression, and unsafe activities. Line of Sight (Constant Observation) - the staff member will ensure the patient is visually within sight at all times. One-to-one observation - the staff will ensure the patient is visually within sight and within arms-reach of a staff member at all times and in all circumstances. Procedure 3 ... The observing staff initials the 15-minute increments on the form to indicate the patient was observed. Line of Sight Observations: The designated staff (MHT) is assigned to perform line of sight observation and can observe multiple patients, but must remain in the area with the patients such that if a patient needs immediate intervention, the staff member can intervene and call for assistance. Line of sight observation level includes constant observation in the bathroom and toilet areas, unless the door is able to be left ajar and the observer is able to access the room immediately. One-to-one Observation: is defined as: Keeping the patient under direct observation within one arm's reach of the patient at all times. This includes use of bathroom and bathing.

On 06/05/2024, Medical Record Review of patient #17 revealed that patient #17 was put in seclusion with 1:1 observation on 05/25/2024 from 12:18 p.m. - 12:50 p.m. Further review of observation documentation during seclusion revealed S14MHT documented q15 minute checks on the observation flowsheet for patient #17 who was on a 1:1 level of observation, while also documenting q15 minute checks on 5 other patients (#8, #19-#22).

On 06/05/2024 at 12:10 p.m., S1QD confirmed the findings above.

Based on observations and interviews, the hospital failed to ensure the condition of the physical plant and overall hospital environment were maintained in such a manner that the safety and well-being of patients were assured. This deficient practice was evidenced by failing to maintain the physical plant in good repair.
Findings:

Observations during a tour on 06/03/2024 from 1:10 p.m. to 2:05 p.m. and on 06/04/2024 from 10:11 a.m. - 10:22 a.m. revealed the following:
1. The mirror bubble in top right corner of the ceiling was broken and the trim was missing from bottom left side of room (u). Restraint chair dirty with rust colored areas noted.
2. Plastic Reference board sign on the wall of (v) was damaged to right bottom corner.
3. Toilet seats were broken in 3 (w, x, and y) out of the 7 (z-cc) bathrooms.
4. Cover not secured covering pipes under the sink was loose and hanging in room (x).
5. There were 4 card board boxes stacked on floor between carts in the room (dd).
6. Missing floor tiles noted in 2 (p, t) out of 20 (a-o, q-s) patient rooms.

In an interview on 06/03/2024, S1QD confirmed the above mentioned findings during the facility tour.

Based on observation, record review, and interview, the facility failed to ensure facilities, supplies and equipment, were maintained to an acceptable level of safety and/or quality. This deficient practice is evidenced by:
1. Failure to ensure expired supplies were not available for patient use;
2. Failure to ensure the emergency cart is inspected daily.
Findings:

Review of policy, "Emergency Cart," last revised 05/01/2021, revealed in part: Procedure: 6. The emergency cart is inspected daily by the designated nursing staff on the designated shift. This inspection includes the following: a. Inspection, stock, and clean cart as needed. b. Identify, remove, and replace expired items. c. Document the completed emergency cart check on the provided checklist. d. Notify the Director of Nursing of any needed supplies that are not readily available for restocking.

1. Failure to ensure expired supplies were not available for patient use.

Observations during a tour on 06/03/2024 from 1:10 p.m. to 2:05 p.m. revealed 1 box of Med Gel Adult Resting Tab ECG Electrodes, quantity of 4, with an expiration date of 11/04/2022.

In an interview on 06/03/2024, S1QD confirmed the above mentioned findings during the facility tour.

2. Failure to ensure emergency cart is inspected daily.

Observations during a tour on 06/03/2024 from 1:10 p.m. to 2:05 p.m. revealed the Emergency Cart Checklist Log for May revealed missing code cart checks for 05/21/2024, 05/22/2024, and 05/31/2024.

In an interview on 06/03/2024, S1QD confirmed the above mentioned findings during the facility tour.

Reviewed copy of Emergency Cart Checklist Log provided. Further review revealed original missing dates discovered during tour were no longer blank. S1QD re-confirmed that dates 05/21/2024, 05/22/2024, and 05/31/2024 were blank during the tour.

In an interview, on 06/03/2024 at 2:25 p.m. S3DON confirmed that she altered the Emergency Cart Checklist Log and falsified documentation for 05/21/2024, 05/22/2024, and 05/31/2024 on the original log.

Based on observation, record review and interview, the facility failed to maintain an infection prevention and control program which includes surveillance, prevention, and control of HAIs, and maintains a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities. This deficient practice was evidenced by:
1. Failing to maintain the temperature log for the patient nourishment refrigerator/freezer;
2. Failing to prevent storage of previously consumed items in the patient nourishment refrigerator;
3. Failing to maintain patient rooms in a sanitary condition.

Findings:

A review of facility policy, "Care and Monitoring of Refrigerators and Freezers," last revised on 11/01/2023, revealed in part: Medications, food and nutrition products, and laboratory specimens will be stored under proper conditions of sanitation, temperature, light, moisture, ventilation, and security to maintain product stability. All refrigerator/freezer temperatures shall be maintained within acceptable standards to inhibit microbial growth and reduce the risk of infection. Refrigerator/Freezer Use: FOOD 2. Nutritional supplements and snacks for patients shall be stored in a refrigerator designated for patients only. 3. Food for employees shall be stored in a refrigerator designated for employees only. 4. Food stored in refrigerators should be discarded on a regular weekly schedule and/or when the food is past the printed expiration date. Temperature 1. Options for monitoring temperatures in refrigerators and freezers: Option 1: The temperature of any refrigerator or freezer that contains drugs, patient food, lab specimens, or blood will be checked and recorded in degrees Fahrenheit (*F) on a log ... The log shall contain acceptable temperature ranges for the storage unit, date of reading, temperature observed, and signature of person reading, along with any corrective measures taken. 2. If temperatures register above or below the appropriate range adjust thermostat and re-check temperature in 30 minutes. If temperature continues to be above or below the appropriate range, all stored items shall be removed, the viability of the items stored shall be determined and non-viable items shall be discarded. 3. Environment of Care (EOC) personnel must be notified immediately for an out-of-range temperature finding.

1. Failing to maintain the temperature log for the patient nourishment refrigerator/freezer.

Observations during a tour on 06/03/2024 from 1:10 p.m. to 2:05 p.m. revealed a Patient Nourishment Refrigerator Temperature Log for May 2024 and June 2024 had documented dates with a normal range for Patient Nourishment Refrigerator of 32F-40F and Patient Nourishment Freezer of <0F. The following dates the Patient Nourishment Refrigerator was not within normal range (32F-40F) 05/01/2024-05/04/2024, 05/06/2024, 05/09/2024, 05/13/2024, 05/17/2024, 05/21/2024-05/23/2024, and 06/01/2024-06/02/2024. The following dates the Patient Nourishment Freezer was not within normal range (<0F) 05/06/2024-05/07/2024 and 05/23/2024. There was no comment or follow up regarding temperatures out of normal range.

In an interview on 06/03/2024, S1QD confirmed the above mentioned findings during the facility tour.

2. Failing to prevent storage of previously consumed items in the patient nourishment refrigerator.

Observations during a tour on 06/03/2024 from 1:10 p.m. to 2:05 p.m. revealed unlabeled personal staff items stored in the refrigerator. Chinese takeout container, takeout container containing Mexican food, red bull, glass starbucks coffee container, and bag with fruit noted in refrigerator. Freezer noted to have a bottle of frozen mountain dew not assigned or labeled to a patient.

In an interview on 06/03/2024, S1QD confirmed the above mentioned findings during the facility tour.

3. Failing to maintain patient rooms in a sanitary condition.

Observations during a tour on 06/03/2024 from 1:10 p.m. to 2:05 p.m. revealed the following:
a) Room (a) had a clear liquid on panel covering overhead ceiling lights above first bed.

In an interview on 06/03/2024, S1QD and S4DON confirmed the above mentioned findings during the facility tour.

b) Room (cc) had wet dirty towels in a pile in the corner of the room.

In an interview on 06/03/2024, S1QD confirmed the above mentioned findings during the facility tour.

Based on record review and interview the hospital failed to document an appropriate discharge plan for each patient including discussion with the patient and the patient's representative. This deficiency is evidenced by failure to provide an appropriate discharge plan in 3 (#4, #6, #10) of 7 (#5, #6, #7, #10, #11, #12, #4) discharged patients reviewed.
Findings:

Review of hospital policy PC-18, "Discharge Planning: Transition Record," revised 02/01/2021 revealed in part," PURPOSE: To establish for assisting patients to the appropriate level of psychosocial/physical care, treatment and services for post-treatment placement, follow-up, and/or transfer. PROCEDURE: 3. Discharge planning should encompass the following areas: Orders for continuing care to meet physical and psychosocial needs for discharge or transfer.

Medical record review revealed Patient #4 was sustained a right hand injury on 04/30/2024 by punching a wall and NPP ordered a hand x-ray to be performed on 05/01/2024. Patient #4 was discharged on 04/30/2024 with no x-ray being performed or follow-up provided on the Transition Record related to right hand injury.

In an interview on 06/04/2024 at 1:30 p.m. S1QD verified Patient #4 did not have right hand x-ray ordered completed or follow-up provided regarding right hand injury on his Transition Record.

Medical record review of Patient #6 revealed the last medical NPP progress note on 04/30/2024 documented that patient needed further laboratory test and special diet. Patient was discharged on 04/30/2024 with no follow-up provided on the Transition Record related to laboratory testing and/or special diet.

In an interview on 06/04/2024 at 1:40 p.m. S1QD verified Patient #6 did not have follow-up for laboratory tests or special diet on transition record.

Medical record review revealed Patient #10 was sustained a bilateral hand injuries on 04/30/2024 by punching a wall and NPP ordered a bilateral hand x-rays to be performed on 05/01/2024. Patient #10 was discharged on 04/30/2024 with no x-rays being performed or follow-up provided on the Transition Record related to bilateral hand injuries.

In an interview on 06/04/2024 at 1:45 p.m. S1QD verified that Patient #10 did not have bilateral hands x-ray completed or follow-up care provided regarding bilateral hand injuries on the Transition Record.

Based on record review and interview, the hospital failed to revise a multidisciplinary treatment plan following a change in a patient's status. This deficient practice was evidenced by:
1. Failure to update the multidisciplinary treatment plan following an incident of seclusion for 1 (#17) out of 18 (#1-#16, #18) patient records;
2. Failure to update treatment plan based on changes in patient condition on 6 (#2, #8, #9, #14, #15, and #17) out of 18 (#1, #3-#7, #10-#13, #16, and #18).
Findings:

Review of facility policy titled, "Seclusion and Restraints - LA/MS/OK," last revised on 05/01/2024, revealed in part: Documentation: Treatment Plan: The use of restraint or seclusion must be in accordance with a documented modification to the patient's treatment plan. The treatment plan must be reviewed and updated at the time of the debriefing or within 24 hours from the seclusion/restraint episode. Treatment Team: 1. The Treatment Team will review the occurrence and use of seclusion/restraints and modify the patient's plan of care as needed. 2. The Treatment Team must explore whether alternative treatment strategies for the future should be considered when restraint or seclusion is used.

Review of facility Policy titled, "Treatment Planning; Integrated/Multidisciplinary," last revised on 04/01/2021, revealed in part: Purpose: To document and implement treatment objectives/interventions ... throughout the course of patient's treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided ... Revising the plan based on changes in condition and physician's orders. All physician orders will be incorporated into the Treatment Plan.

1. Failure to update the multidisciplinary treatment plan following an incident of seclusion for 1 (#17) out of 18 (#1-#16, #18) patient records.

Review of patient #17 medical record revealed on 05/25/2024 at 12:18 p.m. the patient was put in seclusion following an incident with another patient. The patient was taken out of seclusion at 12:50 p.m. Further review of patient #17 multidisciplinary treatment plan revealed no revision to include the patient's change in status, interventions implemented, including the use of seclusion, and revision of the treatment goals.

In an interview on 06/05/2024 at 12:14 p.m. S1QD confirmed that the treatment plan had not been revised following Patient #17 change in condition resulting in the use of seclusion.

2. Failure to update treatment plan based on changes in patient condition on 6 (#2, #8, #9, #14, #15, and #17) out of 18 (#1, #3-#7, #10-#13, #16, and #18).

Review of medical records for 6 6 (#2, #8, #9, #14, #15, and #17) out of 18 (#1, #3-#7, #10-#13, #16, and #18) revealed that the Care Plans were not updated and had no added interventions following the incidents involving patients.

In an interview on 06/05/2024 at 12:21 p.m. S1QD confirmed the findings above.