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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) Observation of the hospital's Glucometer Quality Control Log failed to reveal any documentation for quality controls;
2) Observations and interviews revealing and verifying in 34 patient rooms 'g' through 'nn' and 2 seclusion rooms 'd' and 'e' revealed unsecured toilet seats presenting ligature risks;
3) Observations revealed air conditioner covers presenting ligature risk in patient rooms 'g-n', 'r', 'w', 'mm', 'y', 'cc', 'dd' and 'ff';
4) Observation revealed an unsecured doorway leading from the patient care unit into the adjacent nursing home;
5) An observation of the outside enclosed courtyard area revealed multiple safety risks for patient elopement;
6) Observations revealed the hospital used plastic bags inside of waste receptacles in patient care areas;
7) Observation of bathroom window in Room 'z' revealed broken Plexiglas with sharp edges creating a patient safety issue;
8) Observations in three patient's rooms 'bb', 'ee' and 'kk' revealed plastic cutlery sets enclosed in plastic coverings, a door that would not properly latch, exposed screws and jagged Plexiglas; and
9) Observation of three patient rooms 'k', 'dd', and 'bb' revealed the zipper on the patient's mattresses could be unzipped creating a hiding place for contraband. (See all findings in A-0144)


40548

Based on record review and interview the hospital failed to inform the patients or patients' representative of the patients' rights in advance of providing patient care for 3 (Pt.#1, Pt.#4, and Pt.#5) of 5 (Pt.#1, Pt.#2, Pt.#3, Pt.#4, and Pt.#5) patients sampled.
Findings:

A review of hospital policy titled, "NS (Nursing Service). Subject: "Nursing Admission Assessment", revealed, in part, in addition to conducting the assessment, the registered nurse will obtain signatures from the patient (or the patient's representative) on the documents required for admission. NOTE: If the patient is unable or unwilling to sign any of the documents, the registered nurse will note the refusal;

Patient #1
Review of medical records on 02/07/2023 at 11:30 a.m., revealed no documented evidence of a signed acknowledgment of Patient Rights.

In an interview on 02/07/2023 at 11:50 a.m., S7HIM confirmed there was no evidence of a signed acknowledgment of Patient Rights in the medical record.

Patient #4
Review of medical records on 02/07/2023 at 3:00 p.m., revealed no documented evidence of a signed acknowledgment of Patient Rights.

In an interview on 02/07/2023 at 3:00 p.m., S7HIM confirmed there was no evidence of a signed acknowledgment of Patient Rights in the medical record.

Patient #5
Review of medical records on 02/07/2023 at 3:50 p.m., revealed no documented evidence of a signed acknowledgment of Patient Rights.

In an interview on 2/7/2023 at 3:50 p.m., S7HIM confirmed there was no evidence of a signed acknowledgment of Patient Rights in the medical record.

40548




44763


Based on observations and interviews, the hospital failed to ensure patients received care in a safe setting when:
1) Observation of the hospital's Glucometer Quality Control Log failed to reveal any documentation for quality controls;
2) Observations and interviews revealing and verifying in 34 patient rooms 'g' through 'nn' and 2 seclusion rooms 'd' and 'e' revealed unsecured toilet seats presenting ligature risks;
3) Observations revealed air conditioner covers presenting ligature risk in patient rooms 'g-n', 'r', 'w', 'mm', 'y', 'cc', 'dd' and 'ff';
4) Observation revealed an unsecured doorway leading from the patient care unit into the adjacent nursing home;
5) An observation of the outside enclosed courtyard area revealed multiple safety risks for patient elopement;
6) Observations revealed the hospital used plastic bags inside of waste receptacles in patient care areas;
7) Observation of bathroom window in Room 'z' revealed broken Plexiglas with sharp edges creating a patient safety issue;
8) Observations in three patient's rooms 'bb', 'ee' and 'kk' revealed plastic cutlery sets enclosed in plastic coverings, a door that would not properly latch, exposed screws and jagged Plexiglas; and
9) Observation of three patient rooms 'k', 'dd', and 'bb' revealed the zipper on the patient's mattresses could be unzipped creating a hiding place for contraband.
Findings:

Review of the policy and procedure titled, "Patient Rights" revealed, in part, every patient has the right to 19. Receive care in a safe setting.

1) Observation of the hospital's Glucometer Quality Control Log failed to reveal any documentation for quality controls.

On 02/08/2023 at 12:50 p.m. a review of the hospital's Glucometer Quality Control Log failed to reveal any documentation for quality controls.

In an interview on 02/08/2023 at 12:50 p.m., S2RN and S20LPN verified the hospital did not have any quality control documentation for the two glucometers the nursing staff were using.

2) Observations and interviews revealing and verifying in 34 patient rooms 'g' through 'nn' and 2 seclusion rooms 'd' and 'e' unsecured toilet seats presenting ligature risks.

An observation on 02/06/2023 at 11:28 a.m. revealed a toilet seat in room 'd' with a toilet seat not secured to the base of the toilet presenting a ligature risk.

In an interview on 02/06/2023 at 11:28 a.m., S8Adm verified that no toilet seats in the hospital had been secured and verified this presented ligature risks.

In an interview on 02/06/2023 at 3:08 p.m., S2RN indicated there were 34 patient rooms with toilets and 2 seclusion rooms with toilets.

3) Observations revealed air conditioner covers presenting ligature risk in patient rooms g-n, r, w, mm, y, cc, dd and ff.

On 02/08/2023 a tour of the hospital revealed metal air condition units in patient rooms with potential ligature points that could be utilized for patient harm. This deficient practice was evidenced by patient rooms g-n, p , r, w, mm, y, cc, dd, and ff air conditioner metal covers having open and unsecured metal doors to the controls and or vent area creating a ligature point.

In an interview on 02/-8/2023 at 2:50 p.m. S15MHT verified the aforementioned ligature points.

4) Observation and interview revealed an unsecured doorway leading from the patient care unit into the adjacent nursing home.

On 02/08/2022 an observation of the doorway connecting the adjacent nursing home from a patient room hallway was noted to be unsecured.

In an interview on 02/08/2022 at 9:00 a.m. S16RecTh verified the door from the patient room hallway to the adjacent nursing home was unsecured and should remain secured at all time. She also verified there was the potential for patient elopement.


5) An observation of the outside enclosed courtyard area revealed multiple safety risks for patient elopement.
An observation of the outside, enclosed courtyard area revealed multiple safety risks for patient elopement. The wooden fenced area was noted to be falling down and the gate was not secured. Within the fenced area the fence was noted to have bracing that would have allowed patient access to the roof for elopement. Further observation of the enclosed area revealed an unsecured door to an unused area of the building. This open door could have allowed patients to elope, hide, and possibly utilize one of the many ligature points throughout the unused area.

In an interview on 02/08/2023 at 9:30 a.m., S8Adm verified the safety risks identified within the courtyard area as noted above.

6) Observations revealed the hospital used plastic bags inside of waste receptacles in patient care areas,

An observation on 02/06/2023 at 11:18 a.m. revealed in room 'c' a plastic bag in a waste receptacle presenting a potential danger to patients.

An observation on 02/07/2023 at 8:45 a.m. revealed, in room 'c', plastic bags in two waste receptacles presenting a potential danger to patients.

In an interview on 02/07/2023 at 8:45 a.m., S12AT indicated she used the trash cans to throw away garbage from her lunch and supplies from the area. S12AT indicated she was aware the plastic liners could be a danger to patients.

An observation on 02/06/2023 at 11:28 a.m. revealed in room 'd' a plastic bag in a waste receptacle.

An observation on 02/07/2023 at 8:45 a.m. revealed S1RN in room 'd' with a newly admitted patient. Further observation revealed a trash receptacle with a plastic bag in the can within reach of the patient.

In an interview on 02/07/2023 at 12:02 p.m., S8Adm indicated there should be no plastic bags in the receptacle bins of the hospital.

7) Observation of the bathroom window in Room 'z' revealed broken Plexiglas with sharp edges creating a patient safety issue.

An observation on 02/06/2023 at 12:40 p.m. of the window in Room 'z' revealed Plexiglas broken in half, creating a sharp edge noted to left and right corners of the broken Plexiglas.

In an interview on 02/06/2023 at 12:44 p.m., S8Adm confirmed the presence of broken Plexiglas and stated it needed to be removed due to it being a patient safety issue.

8) Observations in patient rooms 'bb', 'ee', and 'kk' revealed plastic cutlery sets enclosed in plastic coverings, a door that would not properly latch, exposed screws and jagged Plexiglas.

An observation on 02/06/2023 at 12:05 p.m. revealed utensils in a plastic bag in patient's room 'ee'.

In an interview on 02/06/2023 at 12:06 p.m., S8Adm verified there should be no plastic utensil holders in the patient's rooms.

An observation on 02/07/2023 at 10:15 a.m. revealed in patient room 'kk' a plastic utensil holder with plastic covering, and a piece of Plexiglas with jagged edge approximately 1" by 0.5". Further observation revealed the door would not latch properly and had 2 exposed non-tamper resistant screws in the door handle.

In an interview on 02/07/2023 at 10:22 a.m., S8Adm verified there should be no plastic utensil holders with plastic coverings in patient rooms, the Plexiglas with jagged edges should be removed, the door would not close properly to allow for patient safety and privacy, and the exposed non-tamper resistant screws in the door handle should be removed.

An observation on 02/08/2023 at 9:09 a.m. - 10:00 a.m. revealed utensils in a plastic bag in patient room 'bb'.

In an interview during this observation, S8Adm verified there should be no plastic utensils in patient rooms.



9) Observations of three patient rooms 'k', 'dd', and 'bb' revealed the zipper on the patient's mattresses could be unzipped creating a hiding place for contraband.

An observation on 02/08/2023 at 9:09 a.m. - 10:00 a.m. of patient rooms 'k', 'dd', and 'bb', revealed the zipper on the patient's mattresses could be unzipped creating a hiding place for contraband.

In an interview during the observation, S8Adm stated the zipper tag was removed and was JB welded closed so that the zipper could not be unzipped. In the presence of S8Adm, the surveyor was able to unzip the patient's mattresses. S8Adm verified the zipper could be unzipped on the patient's mattresses.

Based on record review and interview, the hospital failed to ensure initial reports of allegations of patient abuse/neglect of care were reported to Louisiana Department of Health within 24 hours of awareness of the allegation, as required by LDH-HSS, for 4 (R16-19) of 4 (R16-19) eloped patients reviewed for self-reports of incidents of alleged neglect of care to LDH-HSS.
Findings

Review of the State law R.S. 40:2009.20 revealed "Any person who is engaged in the practice of medicine, social service, facility administration, psychological services or any RN, LPN, nurses' aide, personal care attendant, respite worker, physician's assistant, physical therapist, or any other healthcare giver having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within 24 hours, submit a report to the department or local law enforcement agency of such abuse or neglect."

A review of the Unusual Occurrence/ Incident Reports revealed the following:
On 02/12/2022 at 6:05 p.m. R17 eloped through a metal fence in hall C day room. Patient was not found.

On 07/14/2022 at 6:20 p.m. R16 eloped through a door left open. Further review failed to reveal if Patient was located and returned.

On 09/30/2022 at 6:00 p.m. staff discovered R18 was not in the building. A full search of the building was conducted. Janine was not located.

On 10/18/2023 at 11:30 a.m. R19 eloped from the outside area. R19 was located and returned to the hospital without injury.

In an interview on 02/08/20223 at 10:55 a.m. S8Adm verified the hospital has not reported any patient elopements to LDH-HSS for possible neglect.

Based on record review and interview the hospital failed to ensure all clinical nursing staff were current with certification in Cardiopulmonary Resuscitation as evidenced by 2 (S1RN and S3LPN) of 2 licensed Nurses not having evidence of Cardiopulmonary Resuscitation Certification.
Findings:

S1RN
Review of personnel files on 02/07/2023 at 10:35 a.m., revealed no evidence of certification in Cardiopulmonary Resuscitation.

In an interview at on 02/08/2023 at 12:30 p.m., S2RN stated that there was no evidence of certification in Cardiopulmonary Resuscitation for S1RN.

S3LPN
Review of personnel files on 02/07/2023 at 10:45 a.m., revealed no evidence of certification in Cardiopulmonary Resuscitation.

In an interview at 02/08/2023 at 12:30 p.m., S2RN stated that there was no evidence of certification in Cardiopulmonary Resuscitation for S3LPN.

Based on record review and interview the hospital failed to ensure documentation in the personnel files for all clinical staff indicating successful completion and competency regarding patient rights and restraint education for 1 (S1RN) of 2 (S1RN and S3LPN) clinical nursing staff reviewed for training.
Findings:

Review of S1RN's personnel files on 02/07/2023 at 10:58 a.m. revealed no evidence indicating successful completion and competency regarding patient rights and restraint education.

In an interview at 12:30 p.m. on 02/08/2023, S2RN confirmed there was no evidence indicating successful completion and competency regarding patient rights and restraint education for S1RN.

Based on record review and interview the facility failed to periodically conduct appraisals of the medical staff. This deficiency is evidenced by the omission of peer evaluations for 2 (S17MD and S18MD) of 2 (S17MD and S18MD)members of the medical and psychiatric staff reviewed.
Findings:

S17MD
Review of personnel records on 02/07/2023 at 1:01 p.m., revealed no evidence of peer reviews completed upon hire or every 24 months thereafter.

S18MD
Review of personnel records on 02/07/2023 at 2:05 p.m., revealed no evidence of peer reviews completed upon hire or every 24 months thereafter.

In an interview on 02/07/2023 at 3:18 p.m., S8Adm confirmed there were no peer reviews for S17MD and S18MD.

Based on record review and interview, the hospital failed to assure that personnel meet
applicable standards (such as continuing education, certification or training) required by State or local law as evidenced by the absence of the charge nurse's resume and application in the personnel files.

Record review on 02/08/2023 at 10:30 a.m. revealed no evidence of an application or resume for S1RN.

In an interview on 02/08/2023 at 11:00 a.m., S2RN stated that the S1RN's application or resume is unavailable per administration.

Based on record review and interview the registered nurse failed to ensure the proper execution of physician orders. This deficient practice is evidenced by failure of the nursing staff to document observations every 15 minutes as ordered in 7 (Pt.#1, Pt.#2, Pt.#3, Pt.#4, Pt.#5, Pt.#8, Pt.#9) of 7 (Pt.#1, Pt.#2, Pt.#3, Pt.#4, Pt.#5, Pt.#8, Pt.#9) records reviewed for observations.
Findings:

Review of the hospital's policy titled "Levels of Observation" revealed, in part, the hospital recognizes three levels of observation, which may be tailored to meet the specific needs of the individual patient. Either an electronic record or an observation sheet is maintained.
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 observed the patient to determine: Signs of life, location, activity (may include behavior and/or affect). Immediately after (or while) observing the patient, the staff member documents or electronically enters, the patient's location and activity.
Line of sight is defined as maintaining visual observation of a patient at all times. The staff member assigned to line of sight is continuously observing for: Signs of life, location, activity, to include any activity regarding the reason for line of sight. Although visualization is continuous, the staff member documents or electronically enters the patient's location and general activity at least every 15 minutes.
One-to-One observation (1:1) is maintained when a patient is considered at high risk and requires observation by a staff member dedicated only to that patient. The staff member assigned to One-to-One observation is continuously observing for: signs of life, location, activity, to include any activity regarding the reason for 1:1. Although visualization is continuous, the staff member documents or enters the patient's location and general activity at least every 15 minutes.

Patient #1
A review of the physician orders dated 02/02/2023 at 9:22 p.m., revealed, in part:
Observation Q 15 Minutes Daily, Request Type: Now, Comments: Monitor patient every 15 minutes until discontinued by physician.
A review of Patient #1's medical records titled, "Behavioral Health-Observation Sheet" dated 02/07/2023 at 10:10 a.m., revealed, in part:
The intervals between observations was greater than 15 minutes on the following dates:

02/02/2023 between the times of 12:02 a.m.- 11:59 p.m.:
Interval between observations greater than 15 minutes occurred (23) times. Further review revealed, between the time of 9:24 p.m. and 9:33 p.m., a "flag LOS (line of sight) removed". The patient location was unknown.
02/03/2023 between the times of 12:38 a.m. - 11:42 p.m.:
Interval between observations greater than 15 minutes occurred (28) times.
Further review revealed no documented observation between the times of 3:55 a.m.- 5:04 a.m. (1 hour and 9 minutes).
02/04/2023 between the times of 12:14 a.m.-11:57 p.m.:
Interval between observations greater than 15 minutes occurred (34) times.
Further review revealed no documented observation between the times of 7:58 a.m.-8:57 a.m. (59 minutes).
02/05/2023 between the times of 12:21 a.m.-11:53 p.m.:
Interval between observations greater than 15 minutes occurred (34) times. Further review revealed no documented observation between the times of 12:44 a.m.-3:18 a.m. (2 hours and 34 minutes); 1:58 p.m.-2:47 p.m.(49 minutes); 5:09 p.m.-6:46 p.m. (1 hour and 37 minutes); 6:46 p.m.-7:49 p.m. (1 hour and 3 minutes).
02/06/2023 between the times of 12:09 a.m.-11:43 p.m.:
Interval between observations greater than 15 minutes occurred (25) times.
Further review revealed no documented observation between the times of 3:37 a.m.-4:31 a.m. (54 minutes); 07:46-09:21 (1 hour 34 minutes); 21:00-22:02 (1 hour and 2 minutes).

In an interview on 02/07/2023 at 10:15 a.m., S7HIM confirmed observations were not occurring every 15 minutes as ordered by the physician.
S7HIM further stated that the patient's location was unknown on 02/02/2023 between 9:24 p.m. and 9:33 p.m..

Patient #2
A review of the physician's orders dated 01/30/2023 at 1:03 p.m., revealed, in part:
Observation Q 15 Minutes Daily, Request Type: Now, Comments: Monitor patient every 15 minutes until discontinued by physician.
A review of patient's medical records titled, "Behavioral Health-Observation Sheet" on 02/07/2023 at 11:15 a.m., revealed, in part:
The interval between observations was greater than 15 minutes on the following dates:

01/30/2023 between the times of 5:23 a.m.-11:39 p.m.:
Interval between observations greater than 15 minutes occurred (11) times.
01/31/2023 between the times of 12:05 a.m.-11:32 p.m.:
Interval between observations greater than 15 minutes occurred (23) times.
Further review revealed no documented observation between the times of 7:52 p.m.-9:34 p.m. (1 hour and 42 minutes).
02/01/2023 between the times of 12:01 a.m.:
Interval between observations greater than 15 minutes occurred (1) time.
Further review revealed no additional documented observations until 02/02/2023 at 12:02 a.m.
02/02/2023 between the times of 12:02 a.m.-11:59 p.m.:
Interval between observations greater than 15 minutes occurred (25) times.
02/03/2023 between the times of 12:38 a.m.-11:42 p.m.:
Interval between observations greater than 15 minutes occurred (27) times.
Further review revealed no documented observation between the times of 3:55 a.m.-4:59 a.m. (1 hour and 4 minutes) and between the times of 3:01 p.m.-3:44 p.m. (43 minutes).
02/04/2023 between the times of 12:13 a.m.-11:56 p.m.:
Interval between observations greater than 15 minutes occurred (34) times.
Further review revealed no documented observation between the times of 9:31 p.m.-10:15 p.m. (44 minutes).
02/05/2023 between the times of 12:21 a.m.-11:53 p.m.:
Interval between observations greater than 15 minutes occurred (36) times.
Further review revealed no documented observation between the times of 12:44 a.m.-3:18 a.m. (2 hours and 34 minutes); 1:58 p.m.-2:47 p.m.(49 minutes); 5:09 p.m.-6:46 p.m. (1 hour and 37 minutes); and 6:46 p.m.-7:49 p.m. (1 hour and 3 minutes).
02/06/2023 between the times of 12:09 a.m.-11:42 p.m.:
Interval between observations greater than 15 minutes occurred (26) times.
Further review revealed no documented observation between the times of 3:35 a.m.-4:31 a.m. (56 minutes); 7:50 a.m.-9:21 a.m. (1 hour and 31 minutes); 9:00 p.m.-10:00 p.m. (1 hour).

In an interview on 2/7/2023 at 11:15 a.m., S7HIM confirmed observations were not occurring every 15 minutes as ordered by the physician.

Patient #3
A review of the physician's orders dated 02/01/2023 at 12:36 p.m., revealed, in part:
Observation Status: Line of Site.

A review of patient's medical records titled, "Behavioral Health-Observation Sheet" on 2/7/2023 at 2:10 p.m., revealed, in part:
The interval between observations within "Line of Sight" were greater than 15 minutes on the following dates:

02/02/2023 between the times of 12:04 a.m.-11:02 p.m.:
Interval between observations within "Line of Sight" were greater than 15 minutes (23) times.
02/03/2023 between the times of 12:02 a.m.-11:45 p.m.:
Interval between observations within "Line of Sight" were greater than 15 minutes (34) times.
Further review revealed no documented observations between the times of 3:52 a.m.-4:55 a.m. (1 hour and 3 minutes) and between the times of 2:59 p.m.-3:43 p.m. (44 minutes).
02/04/2023 between the times of 12:17 a.m.-11:59 p.m.;
Interval between observations within "Line of Sight" were greater than 15 minutes (34) times.
Further review revealed no documented observations between the times of 12:59 p.m.-1:59 p.m. (1 hour).
02/05/2023 between the times of 12:23 a.m.-11:50 p.m.:
Interval between observations within "Line of Sight" were greater than 15 minutes (27) times.
Further review revealed no documented observations between the times of 12:49 a.m.-3:15 a.m. (1 hour and 28 minutes); 1:47 p.m.-2:49 p.m. (52 minutes); 4:41 p.m.-6:46 p.m. (2 hours and 5 minutes); 6:46 p.m.-7:56 p.m. (1 hour and 10 minutes).
02/06/2023 between the times of 12:07 a.m.-3:35 p.m.:
Interval between observations within "Line of Sight" were greater than 15 minutes (21) times.
Further review revealed no documented observations between the times of 3:32 a.m.-4:34 a.m. (58 minutes); 7:49 a.m.-9:43 a.m. (1 hour and 54 minutes).

In an interview on 2/7/2023 at 2:22 p.m., S7HIM confirmed observations were not occurring every 15 minutes as ordered by the physician.

Patient #4
A review of the physician's orders undated revealed, in part:
Observation Q 15 Minutes Daily, Request Type: Now, Comments: Monitor patient every 15 minutes until discontinued by physician.
A review of patient's medical records titled, "Behavioral Health-Observation Sheet" on 02/07/2023 at 3:15 p.m., revealed, in part:
The interval between observations was greater than 15 minutes on the following dates:

10/18/2022 between the times of 3:13 p.m.-11:47 p.m.: Interval between observations greater than 15 minutes occurred (8) times.
10/19/2022 between the times of 12:15 a.m.-11:48 p.m.: Interval between observations greater than 15 minutes occurred (21) times. Further review revealed no documented observations between the times of 12:31 a.m.-1:29 a.m. (58 minutes); 6:45 a.m.-7:30 a.m. (45 minutes); and 8:24 a.m. -10:49 a.m. (2 hours and 25 minutes).
Further review revealed patient had a fall at 11:55 a.m.
10/20/2022 between the times of 12:00 a.m.-11:51 p.m.: Interval between observations greater than 15 minutes occurred (24) times.
10/21/2022 between the times of 12:05 a.m.-11:50: p.m. Interval between observations greater than 15 minutes occurred (31) times.
10/22/2022 between the times of 12:05 a.m.-11:46 p.m.: Interval between observations greater than 15 minutes occurred (29) times. Further review revealed no documented observations between the times of 1:33 a.m.-3:04 a.m. (1 hour and 31 minutes); 8:36 a.m.-9:40 a.m. (1 hour and 4 minutes); 14:02-14:48 (46 minutes); 2:48 p.m.-3:41 p.m. (53 minutes) and 17:16-18:28 (1 hour and 12 minutes).
10/23/2022 between the times of 12:11 a.m.-11:45 p.m.: Interval between observations greater than 15 minutes occurred (31) times. Further review revealed no documented observations between the times of 1:06 p.m.-2:03 p.m. (57 minutes).
10/24/2022 between the times of 12:00 a.m.-11:35 p.m. Interval between observations greater than 15 minutes occurred (16) times. Further review revealed no documented observations between the times of 4:01 a.m.-4:45 a.m. (44 minutes).
In an interview on 02/07/2023 at 3:22 p.m., S7HIM confirmed the observations were not occurring every 15 minutes as ordered by the physician.

Patient #5
A review of the physician's orders undated revealed, in part:
Observation Q 15 Minutes Daily, Request Type: Now, Comments: Monitor patient every 15 minutes until discontinued by physician.

A review of patient's medical records titled, "Behavioral Health-Observation Sheet" on 2/7/2023 at 15:30 p.m., revealed, in part:
The interval between observations was greater than 15 minutes on the following dates:

02/03/2023 between the times of 4:54 a.m.-11:44 p.m.: Interval between observations greater than 15 minutes occurred (30) times.
Further review revealed no documented observations between the times of 12:50 p.m.-1:51 p.m. (1 hour and 1 minute); 2:10 p.m.-2:59 p.m. (49 minutes); and 2:59 p.m.-3:43 p.m. (44 minutes).
02/04/2023 between the times of 12:15 a.m.-11:48 p.m.: Interval between observations greater than 15 minutes occurred (32) times. Further review revealed no documented observations between the times of 7:24 a.m.-8:57 a.m. (1 hour and 33 minutes); and 12:58-2:04 p.m. (1 hour and 6 minutes).
02/05/2023 between the times of 12:24 a.m.-11:58 p.m.: Interval between observations greater than 15 minutes occurred (32) times. Further review revealed no documented observations between the times of 12:46 a.m.-3:17 a.m. (2 hours and 31 minutes); and 5:11 p.m.-6:46 p.m. (1 hour and 35 minutes) and 6:46 p.m.-7:49 p.m. (1 hour and 3 minutes).
02/06/2023 between the times of 12:05 a.m.-11:41 p.m.: Interval between observations greater than 15 minutes occurred (25) times. Further review revealed no documented observations between the times of 3:46 a.m.-4:31 a.m. (45 minutes); and 7:45 a.m.-9:21 a.m. (1 hour and 36 minutes).

In an interview on 02/07/2023 at 3:52 p.m., S7HIM confirmed observations were not occurring every 15 minutes as ordered by the physician.

Patient #8
Review of Patient #8's medical record revealed an admission date of 01/05/2023 with a diagnosis of bi-polar disorder, manic severe with psychosis. Review of the physician's order dated 01/05/2023 revealed 1:1 observation daily, request type: now, rationale for 1:1: patient at risk for harm to others.

Review of Patient #8's observation sheets revealed the following:
01/05/2023 between the times 1:50 a.m. - 11:59 p.m.:
Interval between observations greater than 15 minutes occurred (13) times.
01/06/2023 between the times 12:15 a.m. - 11:59 p.m.:
Interval between observations greater than 15 minutes occurred (22) times. Further review revealed no documented observation between the times of 5:57 p.m. and 8:10 p.m.
01/07/2023 between the times 12:18 a.m. - 11:47 p.m.:
Interval between observations greater than 15 minutes occurred (26) times.
01/08/2023 between the times 12:02 a.m. - 11:49 p.m.
Interval between observations greater than 15 minutes occurred (21) times. Further review revealed no documented observation between the times of 9:25 p.m. and 11:17 p.m.
01/09/2023 between the times 12:00 a.m. - 11:48 p.m.:
Interval between observations greater than 15 minutes occurred (27) times.
01/10/2023 between the times 12:07 a.m. - 11:57 p.m.:
Interval between observations greater than 15 minutes occurred (27) times.
01/11/2023 between the times 12:20 a.m. - 11:01 a.m.:
Interval between observations greater than 15 minutes occurred (12) times.

Patient #9
Review of Patient #9's medical record revealed an admission date of 12/05/2022 with a diagnosis of schizoaffective disorder, bi-polar type. Review of the physician's order dated 12/05/2022 revealed observation Q15 (every 15) minutes: daily, request type: now, comments: monitor patient every 15 minutes until discontinued by physician. Further review revealed another physician's order dated 12/07/2022 1:1 observation: daily, request type: now, rationale for 1:1: patient at risk for harm to others, comments: 1:1 monitoring until discontinued by physician.

Review of Patient #9's observation sheets revealed the following:
12/07/2022 between the times 12:01 a.m. - 11:51 p.m.
Interval between observations greater than 15 minutes occurred (26) times.
12/08/2022 between the times 12:01 a.m. - 11:45 p.m.:
Interval between observations greater than 15 minutes occurred (28) times.
12/09/2022 between the times 12:01 a.m. - 11:57 p.m.:
Interval between observations greater than 15 minutes occurred (26) times.
12/10/2022 between the times 12:07 a.m. - 11:59 p.m.:
Interval between observations greater than 15 minutes occurred (29) times. Further review revealed no documented observation between the times of 10:57 a.m. and 1:46 p.m.
12/11/2022 between the times 12:10 a.m. - 11:51 p.m.:
Interval between observations greater than 15 minutes occurred (20) times.
12/12/2022 between the times 12:03 a.m. - 12:48 p.m.:
Interval between observations greater than 15 minutes occurred (17) times.

In an interview on 02/07/2023 at 4:10 p.m. S10TG verified >15m on observation sheet is not within 15 minutes.

Based on observation, record review and interview, the hospital failed to ensure drugs were administered as per the order of the practitioner for 3 (Pt. #1, R11 and R12) of 3 (Pt. #1, R11 and R12) sampled patients whose medication had not been administered timely as per the physician's orders.
Findings:

Review of hospital policy titled, "NS (Nursing Service)"
Subject: "Medication and Treatment Administration", revealed, in part:
Any parameters considered standard with a medication or ordered by a prescriber will be upheld by the nurse. The nurse will ensure that the patient's condition is properly assessed to determine the patient's status in relation to such parameters. In the event that the nurse refrains from administering the medication or treatment as ordered, the nurse is required to indicate in the Mediation Administration Record (MAR) the intentional omission. The nurse is then required to notify the treating prescriber as soon as possible and document the reason for not administering the medication/treatment, the notification details, the response of the prescriber and any orders obtained, in the patient's medical record.

Patient #1

Review of nurse practitioner orders dated 02/01/2023 revealed, in part:
Clonidine HCL 0.1 mg by mouth every six hours PRN for systolic pressure >160 diastolic >100 Indication: Hypertension.

Review of Patient #1's medical records on 02/07/2023 at 11:10 a.m. revealed, in part:
Blood Pressures:
02/01/2023 at 3:39 p.m.: 162/83
02/03/2023 at 9:55 a.m.: 175/81
02/03/2023 at 9:48 p.m.: 172/90
02/04/2023 at 10:00 p.m.: 163/82
Review of patient Medication Administration Record dated 02/01/2023 to 02/07/2023 revealed, in part:
No documentation Clonidine was administered and no documentation for the reason it was not administered.

In an interview on 02/07/2023 at 11:53 a.m., S7HIM confirmed there was no documentation Clonidine was administered and no documentation as to the reason why.

Random Patient #11

Review of the medical record revealed R11 was admitted on 02/02/23 with a diagnosis of Bipolar Disorder, Manic Severe with Psychotic Features. Review of the medical record revealed a practitioner's order for Gabapentin (Neurontin) 400 mg. by mouth three times daily. Gabapentin is an anticonvulsant

An observation on 02/07/2023 at 10:25 a.m. revealed a plastic cup standing upright on a table with R11's name on the cup. Further observation revealed 400mg. dose of Gabapentin in the cup.

In an interview on 02/07/2023 at 10:25 a.m., S3LPN indicated medication orders prescribed as three times per day are given at 9:00 a.m., 3:00 p.m., and 9:00 p.m. S3LPN further indicated R11 should have received the morning dose of Gabapentin 400 mg. between 8:30 a.m. and 9:30 a.m. S3LPN indicated she enters the time she pulls the medication in the medication administration record, not when the medication is actually administered. S3LPN verified that R11 had not been administered his medication timely.

Random Patient #12

Review of the medical record revealed R12 was admitted on 02/02/23 with a diagnosis of Bipolar Disorder, Current Episode Severe with Psychotic Features. Further review revealed a practitioner's order for Risperdone (Risperdal) 1mg. by mouth twice daily. Rsiperdone is an antipsychotic.

An observation on 02/07/2023 at 10:25 a.m. revealed a plastic cup standing upright on a table with R12's name on the cup. Further observation revealed 1mg. of Risperdal in the cup.

In an interview on 02/07/2023 at 10:25 a.m., S3LPN indicated medication orders prescribed as two times per day are given at 9:00 a.m. and 9:00 p.m. S3LPN further indicated R12 should have received the morning dose of Risperdal between 8:00 a.m. and 9:30 a.m. S3LPN indicated she enters the time she pulls the medication in the medication administration record, not when the medication is actually administered. S3LPN verified that R12 had not been administered his medication timely.

Based on record review and interview, the hospital failed to ensure medical records included a properly executed informed consent for procedures and treatments. This deficient practice was evidenced by informed consents that were not completed per hospital policy for 3 ( Pt.#1, Pt.#4, and Pt.#5) out of 5 (Pt.#1 - Pt.#5) medical records reviewed.
Findings:

A review of hospital policy titled, "NS (Nursing Service). Subject: "Nursing Admission Assessment", revealed, in part: In addition to conducting the assessment, the registered nurse will obtain signatures from the patient (or the patient's representative) on the documents required for admission. NOTE: If the patient is unable or unwilling to sign any of the documents, the registered nurse will note the refusal;


Patient #1
Review of medical record on 02/07/2023 at 10:30 a.m., revealed no documented evidence of a signed Consent for Treatment.

In an interview on 02/07/2023 at 11:00 a.m., S7HIM confirmed there was no evidence of a signed consent for treatment form in the medical records.

Patient #4
Review of medical records on 02/07/2023 at 2:45 p.m., revealed no documented evidence of a signed Consent for Treatment.

In an interview on 02/07/2023 at 2:58 p.m., S7HIM confirmed there was no evidence of a signed consent for treatment form in the medical records.

Patient #5
Review of medical records on 02/07/2023 at 3:30 p.m., revealed no documented evidence of a signed Consent for Treatment.

In an interview on 02/07/2023 at 3:51 p.m., S7HIM confirmed there was no evidence of a signed consent for treatment form in the medical records.

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

Review of the hospital's policy titled "Discontinued, Expired, and Unusable Drugs" revealed, in part, as per state law, all discontinued patient medications; expired, contaminated, improperly stored drugs; and containers with worn, illegible or missing labels shall be returned to the pharmacy for proper disposal.

An observation on 02/06/2023 at 12:30 p.m. of the medication room revealed the following expired medications:
1 vial of Novolin 70/30 Inj. 100 units/mL with an expiration date of 01/2023;
1 bottle of Aspirin USP 81mg with an expiration date of 12/2022.

In an interview during this observation, S3LPN verified the above stated medications were expired and should not be available for patient use.

Based on observation, record review and interview, the facility failed to ensure periodic inspections of equipment on the Emergency Cart.
Findings:

Review of facility policy titled "NS (Nursing Service). Subject: Emergency Carts", revealed, in part:
A log is completed daily or when emergency equipment and /or supplies are used. The log indicates:
The date/time the inspection was made;
The presence and operational status of each item (or a comment);
The name and credentials of the nurse performing the inspection.

Observations in Room 'b' on 02/06/2023 at 12:55 p.m., revealed the Emergency Cart Logbook. Review of the Emergency Cart Logbook revealed last AED and O2 tank check was performed on 02/02/2023.
Further review revealed no evidence of suction pump and emergency eye flush check for the year 2022 and January and February of 2023.

In an interview on 02/06/2023 at 1:05 p.m., S1RN confirmed the Code Cart log was not completed daily as per policy.

Based on record review and interview the hospital failed to provide for the nutritional needs of the individual patient in accordance with recognized dietary practices. This deficiency is evidenced by the failure of the hospital to provide a special diet for 1 (R13) of 2 (R13 and R15) patients reviewed with orders for a special diet.
Findings:

Review of the hospital's policy titled "Food and Dietetic Services" revealed, in part, patients' nutritional needs will be met based on orders issued by authorized licensed prescribers and will consider any allergies noted.

Review of R13's medical record revealed an admission date of 02/01/2023 with a diagnosis of major depressive disorder, single episode, mild; suicidal ideations; anemia; and thrombocytosis. Review of R13's psychiatric evaluation also revealed the patient had a history of DM (diabetes mellitus) and HTN (hypertension). Further review revealed a physician's order dated 02/01/2023 Diet: Heart Healthy - 1800 ADA.

Review of the dietary sheet dated 02/08/2023 revealed R13's diet as regular.

In an interview on 02/08/2023 at 12:05 p.m. S5MHT stated each patient's diet is on the dietary sheet including special diets. S5MHT stated the contracted food provider uses the dietary sheet to provide each patient with the correct diet.

In an interview on 02/08/2023 at 2:08 p.m. S14RN stated the night charge nurse completed the dietary sheet. S14RN verified R13 received the wrong diet.

Based on document review and interview, the hospital failed to implement an effective utilization review plan including two or more practitioners who are doctors of medicine or osteopathy present during utilization review committee meetings.
Findings:

Review of the policy and procedure titled, "Leadership - Utilization Management Plan" revealed, in part, the hospital plan's objective is to provide both quality patient care and effective utilization of available health facilities and services. There must be effective cooperation between the hospital administration and the medical staff to assure that this goal is achieved.

In an interview on 02/08/2023 at 10:10 a.m., S11UR indicated there were no physician participants in the utilization review committee.

Based on observations and interviews the hospital failed to ensure the hospital environment was maintained in sanitary condition and to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by:
1.) failing to ensure expired supplies were not available for patient use;
2.) failing to dispose of open, unused supplies; and
3.) failing to ensure the hospital environment was maintained in a sanitary condition.
Findings:

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

An observation on 02/06/2023 at 12:30 p.m. of the medication room revealed 12 of 12 Mepore Film 10 x 12cm / 4 x 4.8 in with the expiration date of 11/2017.

In an interview during the observation, S3LPN verified the above stated supplies were expired.

Observation of Room 'a' at 12:41 p.m. on 02/06/2023, revealed (7) COVID-19, Celltrim Diatrust Rapid tests labeled with the expiration date of 11/24/2022.

In an interview on 02/06/2023 at 12:43 p.m., S3LPN confirmed the COVID tests were expired and available for patient use.

Observation of Room 'b' revealed an eye flush station containing eye flush labeled with an expiration of 1/2023.

In an interview on 02/06/2023 at 1:03 p.m., S3LPN confirmed the expiration date of the eye flus and its availability for use.

2.) Failing to dispose of open, unused supplies.

An observation on 02/06/2023 at 12:30 p.m. of the medication room revealed the following open, unused supplies:
1-medium non-stick pads with adhesive tabs
1-dermapore dressing

In an interview during the observation, S3LPN verified the above stated supplies were opened and stored with other supplies available for patient use.

3.) Failing to ensure the hospital environment was maintained in a sanitary condition.

An observation on 02/08/2023 at 9:09 a.m. - 10:00 a.m. of the hospital revealed the following:

Multiple floor tiles were missing and 2 vent plates had numerous rust spots in room 'oo'.
4 vent plates had numerous rust spots and the wall had multiple areas of peeling paint in room 'pp'.

In an interview during the observation, S8Adm verified the above stated findings.

Based on observations, interviews, and record reviews, the hospital failed to meet the conditions of participation related to infection control by failing to implement effective policies, procedures and protocols for the prevention of infectious diseases as evidenced by:

1) Failure to ensure the glucometer was appropriately cleaned between patient use and;
2) Failure to implement policy and procedure related to meeting the Covid-19 vaccination rates for hospital personnel resulting in 17% of staff being unvaccinated (see all findings in A-0749).

Based on record review and interview, the hospital failed to demonstrate the staff member assigned to the infection prevention and control program was an individual qualified through education, training, experience or certification.
Findings:

Review of the policy and procedure titled, "Infection Prevention and Control Prgram" revealed, in part, the designated Infection Control Officer maintains ongoing membership in the Association for Professionals in Infection Control and Epidemiology (APIC) and maintains awareness of current changes to, guidelines for infection control and prevention provided by APIC.

Review of human resource file for S2RN assigned as the infection prevention and control professional revealed no evidence of certification or training regarding Infection Control to demonstrate competency.

In an interview on 02/07/2023 at 12:00 p.m., S8Adm indicated S2RN had no certification or training in infection prevention and control.

Based on observation, interview and record review, the hospital failed to employ methods for preventing and controlling the transmission of infections. This deficient practice was evidenced by:
1) Failure to ensure the glucometer was appropriately cleaned between patient use;
2) Failure to implement policy and procedure related to meeting the Covid-19 vaccination rates for hospital personnel; and,
3) Failure to ensure staff and patients were protected from infectious disease as evidenced by failure to ensure all staff were screened for Tuberculosis and were provided annual educational information explaining the health concerns, signs, symptoms, and risks of Tuberculosis. This deficient practice was evidenced by failure to ensure each employee's personnel file had documented evidence they were free of TB (tuberculosis) in a communicable state, as required per Louisiana Public Health Sanitary Code, Title 51, Part II., for 2 (S1RN and S3LPN) of 5 (S1RN, S3LPN, S18MD, S19MD and S5MHT) personnel records reviewed.
Findings:

1.) Failure to ensure the glucometer was appropriately cleaned between patient use.

Review of the True Metrix glucometer's owner's booklet revealed, in part, cleaning and disinfecting the lancing device and the meter destroys most, but not necessarily all, blood borne pathogens. Further review revealed to clean and disinfect immediately after getting any blood on the meter or if meter is dirty. Clean and disinfect meter at least once a week for up to 5 years. To clean make sure meter is off and a test strip is not inserted. With ONLY PDI Super Sani Cloth Wipes, rub the entire outside of the meter using 3 circular wiping motions with moderate pressure on the front, back left side, right side, top and bottom of the meter. Discard used wipes.

In interview on 02/06/2023 at 1:35 p.m., S3LPN indicated the nursing staff used alcohol wipes to clean the glucometer in between patient use.

In an interview on 02/06/2023 at 3:15 p.m. S2RN indicated there were 4 patients on accuchecks including Pt. #2, R14, R15 and R16.

In an interview on 02/07/2023 at 9:13 a.m. S8Adm indicated the hospital did not have the manufacturer's guidelines related to the care of the glucometer because he was ensuring the correct manufacturer was being researched.

In interview on 02/07/2023 at 1:25 p.m., S2RN verified the cleaning instructions for the glucometer included using PDI wipes which were not immediately available in the hospital.

In interview on 02/08/2023 at 3:00p.m. S20LPN verified the 2 glucometers were cleaned with the appropriate PDI wipes. She showed this surveyor the wipes and demonstrated the cleaning process.

2) Failure to implement policy and procedure related to meeting the Covid-19 vaccination rates for hospital personnel.

Review of the Covid - 19 vaccination surveillance log revealed the hospital had no explanations regarding 17% of the staff not being vaccinated against Covid - 19.

In an interview on 02/08/23 at 3:10 p.m., S2RN indicated there was no record or explanation regarding non-compliance with the Covid-19 vaccination rates.

3) Failure to ensure staff and patients were protected from infectious disease as evidenced by failure to ensure all staff were screened for Tuberculosis and were provided annual educational information explaining the health concerns, signs, symptoms, and risks of Tuberculosis.

Review of the Louisiana Public Health Sanitary Code, Title 51, Part II. The Control of Diseases - Health Examinations for Employees, Volunteers and Patients at Certain Medical Facilities, Section 503, Mandatory Tuberculosis Testing, revealed in part: A. [formerly paragraph 2:022] All persons, including employees, students or volunteers, having no history of latent tuberculosis infection or tuberculosis disease, prior to or at the time of employment, beginning clinical rotations in the healthcare profession, or volunteering at any hospital or nursing home (as defined in Parts XIX and XX of the Sanitary Code, respectively, herein, and including intermediate care facilities for the developmentally disabled) requiring licensing by the Louisiana Department of Health or at any Louisiana Department of Health, Office of Public Health (LDH-OPH) parish health unit or an LDH-OPH outpatient health care facility, whose duties include direct patient care, shall be free of tuberculosis in a communicable state as evidenced by either:
1. a negative purified protein derivative skin test for tuberculosis, 5 tuberculin unit strength, given by the Mantoux method or a blood assay for Mycobacterium tuberculosis approved by the United States Food and Drug Administration;
2. a normal chest X-ray, if the skin test or a blood assay for Mycobacterium tuberculosis approved by the United States Food and Drug Administration is positive; or
3. All initial screening test results and all follow-up screening test results shall be kept in each employee's, Student's, or volunteer's health record or facility's personnel record.
D. Annually, but no sooner than 6 months since last receiving tuberculosis educational information (more fully described at the end of this sentence) or symptom screening, all employees, students in the healthcare professions, or volunteers at any medical or 24-hour residential facility requiring licensing by LDH or at any hospital or nursing home (as defined in Parts XIX and XX of the Sanitary Code, respectively, herein, and including intermediate care
facilities for the developmentally disabled) requiring licensing by the LDH or at any LDH-OPH parish health unit or and LDH-OPH out-patient health care facility shall receive, at a minimum, educational information explaining the health concerns, signs, symptoms, and risks of tuberculosis.

Review of the personnel record of S1RN revealed no documentation of TB screening or evidence of annual educational information explaining the health concerns, signs, symptoms, and risks of tuberculosis.

Review of the personnel record of S3LPN revealed TB screening on 12/20/2019. Further review revealed no evidence of annual educational information explaining the health concerns, signs, symptoms, and risks of tuberculosis.

In an interview on 02/08/2023 at 9:19 a.m., S2RN confirmed there was no evidence of initial TB screening for S1RN and no evidence of annual educational information explaining the health concerns, signs, symptoms, and risks of tuberculosis for S1RN and S3LPN.

Based on observation, interview and record review, the hospital failed to maintain a clean and sanitary environment to avoid sources and transmission of infection when:
1) An observation in room 'c' revealed a chair with a torn covering not allowing for effective sanitizing;
2) An observation in room 'kk' with a mattress on the floor;
3.) having multiple dead frogs in the light fixture in room 'f'.

Findings:

1) An observation in room 'c' revealed a chair with a torn covering not allowing for effective sanitizing.

An observation on 02/06/2023 at 11:18 a.m. revealed a chair in room 'c' with a torn covering not allowing for effective sanitizing.

2) An observation in room 'kk' with a mattress on the floor.

An observation on 02/07/2023 at 10:15 a.m. revealed a mattress on the floor of room 'kk', an occupied patient room.

In an interview on 02/07/2023 at 10:22 a.m., S8Adm verified the mattress should not be on the floor.

3.) Having multiple dead frogs in the light fixture in room 'f'.

An observation on 02/08/2022 at 9:09 a.m. - 10:00 a.m. of room 'f' revealed multiple dead frogs in the light fixture.

In an interview during the observation, S8Adm verified the above stated findings.

Based on observations and interviews, the hospital Director of Nursing failed to provide in-service and continuing education for nursing personnel in the areas of laboratory specimen collection, storage and labeling as evidence by failure to properly collect and label a specimen container with an approprite physician order.
Findings:

Review of facility policy titled "AS (Ancillary Services). Subject: Laboratory Services", revealed, part:
Procedure:
1. The authorized licensed prescriber issues an order for laboratory testing. The order will specify:
a. The name of the test
b. The type of specimen to be tested
c. The date and time to be obtained, if appropriate
4. The healthcare professional obtaining the specimen:
a. Reviews the laboratory requisition against the prescriber's order
e. Labels any specimen tubes or containers with:
i. Patient Name
ii. Patient's Date of Birth
iii. Date and Time Specimen Obtained.

Review of document titled "Business Associate Agreement", revealed, in part:
Test Orders: Client will ensure that all specimen testing is ordered by a person authorized by Client pursuant to applicable law.

Observation on 02/06/2023 at 12:50 p.m. of refrigerator in Room 'b' revealed an unlabeled specimen container of yellowish liquid.

In an interview on 02/06/2023 at 1:00 p.m., S3LPN stated the liquid was a urine sample obtained from a patient the day before. S3LPN further stated there was no label indicating the patient's name, contents or date the sample was obtained because the patient was not admitted and that the urine was collected before knowing the patient had been sent to the wrong facility. S3LPN stated she kept the urine sample in case the intended admit facility requested the sample.