HospitalInspections.org

Based on record review and interview, the hospital failed to meet the Condition of Participation for Patient Rights by failing to ensure that measures were put in place to ensure the safety of 1 of 1 patients (#7) who was fearful of his roommate (#5) as documented on 11/04/2010 and 11/07/2010. (Patient #5 had been admitted to the hospital for gyrating on a peer's bed and on a Nursing Home employee.) Patient #7 indicated Patient #5 had stood near his bed rubbing himself (private parts) on 11/09/2010 at 2:10 p.m. See findings cited at A0144.

An immediate jeopardy situation was identified on 11/10/2010 at 1620 (4:20 p.m.) and reported to the hospital's Administrator and Director of Nursing (S3). The immediate jeopardy was a result of the hospital's failure to ensure that measures were put in place to ensure the safety of Patient #7 who was fearful of his roommate. This was evident after Patient #7 reported to the staff he was fearful of his roommate Patient #5 due to the continued attempts by Patient #5 to get in bed with him (#7) on 11/04/2010. This failure to implement safety measures resulted in the ongoing fear of Patient #7 as he had reported to the staff on 11/04/2010 and again on 11/07/2010. Patient #5 was admitted to the hospital from the nursing home where he resided, for being found in other patient's rooms gyrating and also gyrating on nursing home staff. Patients #5 and #7 remained in the same room on 15 minute observations from 11/01/2010 through 11/09/2010. During an interview on 11/09/2010 at 2:10 p.m. (5 days after #7 complained about #5 trying to get in bed with him causing him to be fearful) Patient #7 indicated that Patient #5 had been near his bed (#7) on 2 - 3 occasions while rubbing himself (penis/private parts). Patient #7 stated he did not like what had happened and would prefer to be in a different room. On 11/10/2010 Patient #7 made up and down hand gestures to illustrate what Patient #5 had done while in his room.

As a result of a corrective action plan submitted by the hospital on 11/12/2010 at 9:25 a.m., the Immediate Jeopardy was lifted and remained at a Condition Level. Review of this corrective action plan revealed the hospital's implementation of a process titled, "Speak Up! Don't Be Afraid" which included an assessment of all patients upon admission into the hospital and daily to identify fearful stimuli and implement measures to protect the patient from the feared incident. Further the process included modifying the Comprehensive Interdisciplinary Assessment to include sexual inappropriateness and prompts to avoid assigning the patient a roommate until a psychiatric assessment was performed and/or the Physician approved a roommate assignment. Education was provided to nursing staff on 11/10/2010 regarding implementation of the Process titled, "Speak Up! Don't Be Afraid!" The corrective action plan included Performance Improvement Monitoring with quality indictors to ensure ongoing improvement with protecting patients from source of fear with a plan to monitor 100 % of open charts for 4 weeks and then 25% of the medical records until 90 to 100 % compliance is achieved.

Based on record review and interview, the hospital failed to ensure the effective implementation of the grievance process by failing to provide the complainant with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This was noted for 1 of 7 sampled patients (Patient #2). Findings:

The medical record of Patient #2 was reviewed. This review revealed that Patient #2 is an 86 year old male who was admitted to Oceans Behavioral Hospital on 9/01/10 and was discharged from Oceans Behavioral Hospital on 9/04/10. Review of the Discharge Summary revealed that Patient #2 was discharged from Oceans Behavioral Hospital of Baton Rouge on 9/04/10. Documentation under the heading of Hospital Course was "Initial Mental Status Exam: level of consciousness-alert, gait/posture-small steps with unsteady balancing, needs max assist, appearance-appears younger than stated age, disheveled, facial expression-blunted, mouth held agape, psychomotor activity-slow, methodical, behavior/attitude-hesitant but does redirect or follow, speech-very poor articulation in soft whisper, level of cooperation-moderate, thought process-incoherent due to language barriers, thought content-difficult to assess, lack of facial animation, affect-blunted to flat, mood-varies but currently anxious, orientation-X2, memory-unable to assess due to communication problems, concentration-unable to assess due to communication problems, abstraction-unable to assess due to communication problems, insight and judgment-impaired. 9/2 confused, depressed, and very anxious. Affect labile. 9/3 concerned about roommate but too hard to understand fully. He will grab your hand to pull you closer and whisper in your ear. At times he attempts to touch other places. Possibly depressed. Affect flat. No obvious suicidal or homicidal ideations. 9/4 while patient being transferred to couch from wheelchair he was standing and favoring his left side. LPN and RN assessed and noted that weight bearing difficult and unsteady. Pelvic x-ray ordered-fractured neck of proximal right femur. X-ray results called to (name), NP, and patient transferred to (Hospital A) ER via (name of ambulance provider) for evaluation and treatment of fracture".

S1 (Administrator) was interviewed on 11/10/10 at 1:00 p.m. S1 reported that the family of Patient #2 had reported concerns relating to the care and services provided to Patient #2 during his hospitalization in September of 2010. S1 reported that the family was indicating that they felt that Patient #2 was not adequately supervised which resulted in his sustaining a fracture while in the hospital. S1 reported that he conducted a thorough internal investigation into the care provided to Patient #2. S1 reported that he concluded that Patient #2's fracture was not due to a fall as all staff members denied that Patient #2 had fallen while at Oceans Behavioral Hospital of Baton Rouge. When asked if he had provided the complainant with written notification that included the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion, S1 reported that no written notice was provided to the complainant.

Based on record review and interview, the hospital failed to ensure that the patient's representative was afforded the opportunity to participate in the development and implementation of the plan of care by failing to comply with family members request to inform the attending psychiatrist/practitioner of their wishes to have the dosage of Seroquel re-evaluated as they (family) were reporting that the patient was doing well on a lower dose than what was being administered during his hospitalization at Oceans Behavioral Hospital of Baton Rouge. This was noted for 1 of 7 sampled patients (Patient #2). Findings:

The medical record of Patient #2 was reviewed. Review of the treatment plan revealed that the treatment plan was initiated on 9/01/10 which was the day of Patient #2 ' s admission to the hospital. Problem #1 indicated that Patient #2 was " gravely disabled " related to Senile Dementia and frustration relating to his inability to communicate. Goals and/or Objectives under Problem #1 included " Patient will identify and utilize 1-3 alternative actions/activities when experiencing depression within 14 days " ; " Pt will have overall improvement in mood within 10 days " ; " Patient will appropriately interact with peers and staff within 10 days " ; and " Patient will display a 50% decrease in agitative behavior within 10 days " . Interventions under Problem #1 included check marks next to boxes that included interventions relating to medication therapy, interventions relating to assessments, interventions relating to the provision of a safe environment, interventions relating observational levels, and interventions relating to coping strategies.

Review of the physician orders revealed orders dated 9/01/10 (orders were not signed by the ordering practitioner) for 100mg of Seroquel to be administered by mouth three times daily. Documentation in the medical record revealed a note addressed to the psychiatrist that was placed on the record and signed by S22 (RN) which indicated that the patient ' s son wanted the psychiatrist to know that Patient #2 was taking 225mg of Seroquel at home and was doing good on that dose. There was no documentation to indicate that the psychiatrist and/or practitioner reviewed this note or was made aware of this request.

S9 was interviewed on 11/10/10 at 9:50 a.m. S9 reported that she works as a Registered Nurse on the day shift which she reported was from 7:00 a.m. till 7:00 p.m. S9 reviewed the medical record of Patient #2 and reported that she did remember the patient. S9 reported that she was the registered nurse who admitted Patient #2 to Oceans Behavioral Hospital of Baton Rouge on 9/01/10 at 1:00 p.m. S9 confirmed that the orders were for 100mg of Seroquel to be administered by mouth three times daily. S9 reported that she had no knowledge of the family reporting that they wanted the patient to be on a lower dose of Seroquel.

S3 (RN) was interviewed on 11/12/10 at 9:45 a.m. S3 reported that she was aware of the families request to inform the psychiatrist that they (family) were giving Patient #2 less Seroquel than he was getting while hospitalized at Oceans Behavioral Hospital of Baton Rouge. S3 reported that the family had met with her and informed her that they had already discussed this with another nurse and that they wanted the psychiatrist to be informed of this information. S3 indicated that she informed S22 (RN) who was providing direct care to Patient #2 of the need to inform the psychiatrist that the family was concerned about Patient #2 being on 300mg of Seroquel daily. S3 reported that she did not follow up to ensure that the psychiatrist or the practitioner was made aware of the family ' s request.

S22 (RN) was not available for interview as this nurse is no longer employed at this hospital.

In interviews with S15 (PA) on 11/12/10 at 9:50 a.m. and with S23 (Psychiatrist) on 11/12/10 at 10:20 a.m., both reported that they were not made aware by staff of the family's concern about the dosage of Seroquel ordered for Patient #2.

Based on record review and interview the hospital failed to ensure that measures were put in place to ensure the safety of 1 of 1 patients (#7) who was fearful of his room mate (#5) as documented on 11/04/2010 and 11/07/2010 out of a total sample of 7. (Patient #5 had been admitted to the hospital for gyrating on a peer's bed and on a Nursing Home employee.) Patient #7 indicated Patient #5 had stood near his bed rubbing himself (private parts) on 11/09/2010 at 2:10 p.m. Findings:

Patient #5 (Admit date 10/26/2010) :
Review of Patient #5's Psychiatric Evaluation dated 10/27/2010 revealed in part, "History of Present Illness: This is a 66 year old African American male with a history of depressive disorder and Alzheimer dementia. He has been admitted to Oceans Behavioral Hospital from (name of Nursing Home) by a non-contested admission. The account of the events leading up to the transfer from (Nursing Home) to Oceans indicates that the patient has been increasingly agitated and sexually inappropriate with staff and peers. The patient was found to be gyrating against another peer's bed, as well as attempting to gyrate against staff at the nursing home. The patient is nonverbal and has been so for approximately one and a half years. . . Admission Diagnosis: Depressive disorder. . Hypertension, Hyperlipidemia, Alzheimer dementia. . . " Patient #5 was admitted to the hospital on 10/26/2010.

Review of Patient #5's Multidisciplinary Treatment Plan revealed Sexually Inappropriate Behavior was identified as a problem on 10/26/2010 by Social Services, 11/01/2010 by nursing Services, on 11/02/2010 by Therapeutic Recreation Services. Further review revealed the following interventions: Nursing will: 1) provide safe, structured environment daily for the duration of treatment per stay. 2) All staff (will) notify MD (Medical Doctor) of patient status as ordered and prn (as needed), 3) Assess mood, behavior, and effectiveness of intervention daily for duration of treatment RN/LPN (Registered Nurse/ Licensed Practical Nurse), Implement observations as ordered daily. 4) Educate on medication regimen daily and prn. Social Services will: gather history and assess level of functioning, develop multidisciplinary treatment integration, engage patient's family/significant others in continued support and participation of treatment. Therapeutic Recreation will prompt and encourage as needed. Reduce environmental stimuli as needed.

Patient #7 (Admit Date 10/20/2010):
Review of Patient #7's Psychiatric Evaluation dated 10/21/2010 revealed in part, "History of Present Illness: According to the information, the patient is acting very bizarre, sexually preoccupied grabbing the female patient to his room and started kissing her, and uncontrollable behavior, and at times he is agitated, restless, and combative. The patient says he likes women and he is missing sex and he said his wife died years ago and the patient said he is very depressed, not sleeping at night, unable to do the things he was doing before. . . Provisional/Admitting Diagnosis: Alzheimer's dementia with depression and psychosis, Hypertension, CVA (Cerebral Vascular Accident), Gout, CHF (Congestive Heart Failure). . ."

Review of Patient #7's Multidisciplinary Treatment Plan revealed Sexually Inappropriate Behavior was identified as a problem on 10/20/2010 by Social Services, 10/21/2010 by Nursing Services, on 10/20/2010 by Therapeutic Recreation Services. Further review revealed the following interventions: Nursing will: 1) provide safe, structured environment daily for the duration of treatment per prn. 2) All staff (will) notify MD (Medical Doctor) of patient status as ordered and prn (as needed), 3) Assess mood, behavior, and effectiveness of intervention daily for duration of treatment RN/LPN (Registered Nurse/ Licensed Practical Nurse), Implement observations as ordered daily. 4) Educate on medication regimen daily and prn. Social Services will: gather history and assess level of functioning, develop multidisciplinary treatment integration, and encourage sharing feelings in order to clarify/gain insight as to causes of depression. Therapeutic Recreation will provide supervised structured activities. Encourage peer interactions, prompt , encourage, and redirect as needed.

Review of the medical records for patients #5 and #7 (located in double occupancy Room "A"/ roommates) as documented below are presented in time line order:

Review of Patient #7's Psychiatric Progress Notes dated 10/30/2010 (no documented time) revealed in part, "The patient (#7) has been a bit more restless at night. Today, his roommate (#5) is getting up several times at night. . ."

Review of Patient #5's nursing notes dated 10/30/2010 (no documented time) revealed in part, "He (#5) was seen gyrating the sofa in the day room. . . quite difficult to redirect. . ."

Review of Patient #5's nursing notes dated 11/01/2010 (no documented time) revealed in part, "wanders into other's rooms places self on stomach of bed, couch, grinds against bed or couch. Difficult to redirect. Redirection attempted all usually unsuccessful - Meds (medications) given. Refuses redirection, continues to grind self against stationary objects, wanders. . . continue to monitor , redirect as per need - provide safe therapeutic environment."

Review of Patient #7's nursing notes dated 11/04/2010 at 3:15 a.m. revealed in part, "C/O (complained of) fearful of roommate (#5) D/T (due to) continued attempts by room mate (#5) to get in bed (with) client (#7). . . to monitor q15 (every 15) mins. (minutes) for safe environment."

Review of Patient #7's Psychiatric Progress Notes dated 11/05/2010 (no documented time) revealed in part, "Little change except for his (#7) reaction to his roommate (#5). Patient (#7) was lying on his (#7) bed wide awake during the interview. (Roommate Patient #5) wandered in. Patient (#7) got up and out of bed, got his walker and strolled quickly out of the room. He (#7) would not say what bothered him nor did he say anything bad about his roommate (#5). . . Staff filled me in on what is getting him (#7) (upset) about his roommate (#5). His room (mate) (#5's first name), is very sexually inappropriate and tries to get in bed with him (#7) several times a night. We will try to get his roommate (#5) something for this. . . Possible paranoid ideation and some suspicious, but may be reasons to be. . ."

Review of Patient #5's Psychiatric Progress notes dated 11/05/2010 (no documented time) revealed in part, "Patient (#5) has been and continues to be sexually inappropriate. Whenever he (#5) goes to get down or lie down, he (#5) gets on his stomach and reproduces sexual movements. Difficult to redirect him (#5) on this. He (#5) has tried to get in bed with is roommate (#7), which is very upsetting to his roommate (#7). . . "

Review of Patient #7's Psychiatric Progress notes dated November 6, 2010 (no documented time) revealed in part, "Pt (#7) in bed, just getting up for the morning. I noticed that he (#7) had positioned his (#7) walker in front of his (#7) bed instead of on the side. Staff said that his roommate (#5) always tries to get into bed with him (#7) from the front. When I asked patient if this was the reason why he (#7) pushed the walker like that, he (#7) said, "Yes.", but made no eye contact and got up quickly saying he (#7) had to go to the bathroom. . . With regards to his (#7) thought content, he (#7) remains a bit suspicious. It is questionable whether it is to the degree of paranoia. The suspiciousness is about his roommate (#5), but no cause for paranoia. . ."

Review of Patient #5's Psychiatric Progress notes dated November 6, 2010 (no documented date) revealed in part, " Still making sexual thrusts when he (#5) lies down. FYI (For your information)- patient (#5) only does this on the sofa in the second TV (Television room) and not the first. Possibly more evidence of an OCD (Obsessive Compulsive Disorder) component. Still trying to get in bed with his roommate (#7). "

Review of Patient #5's 7:00 a.m. - 7:00 p.m. nursing notes dated 11/07/2010 (no documented time) revealed in part, "Quietly wandering unit in p.m. (afternoon), odd gait, back arched, required distraction to keep out of other rooms. In am (morning) (after) b'fast (breakfast). . . found in roommates (#7's) bed, pelvic thrusting - roommate (#7) upset. removed pt. from other's bed. . . late entry (0100/ 1:00 a.m.) Pt (patient) (#5) found in room attempting to climb in roommate's bed (#7). Pt. (#5) redirected to his bed but refused to sit down. Pt. (#5) then walked to another pt's bed that was empty. Pt.(#5) layed down in bed and started thrusting his pelvis forward in a hypersexual way. Removed pt. from room and brought to the dayroom. Closely monitored pt. - pt. began pacing the halls."

Review of Patient #7's nursing notes dated 11/07/2010 at no documented time revealed in part, "Pt. (Patient #7) verbalizes paranoia about roommates (#5's) behavior. Very anxious. No aggression or hypersexual behavior noted. Very confused. Administer meds (medications), listen to pt (patient) concerns, provide a safe, environment, ensure pt. is safe and feels comfortable in environment. . . 0030 (12:30 a.m.) Pt. very anxious sitting in dining area on edge of seat. Ativan 0.5 mg (milligrams) po (by mouth) prn (as needed) administered for anxiety. . . 0130 (1:30 a.m.) Pt. unable to sleep. Restoril 7.5 mg (milligrams) po (by mouth) prn (as needed) administered for insomnia. . . 0200 (2:00 a.m.) Pt. resting quietly (with) eyes closed sleeping. Medications effective".

Review of Patient #7's Psychiatric Progress notes dated November 7, 2010 (no documented time) revealed in part, "Patient (#7) is very upset and anxious this evening. He (#7) does not want to go to bed because of his fear of (first name of Patient #5) trying to get in his (#7's) bed. Patient (#7) was given Ativan, but it was not efficacious. Will give Restoril prn (as needed) to help with his (#7) fear of going back to sleep. . ."

Review of Patient #5 ' s Psychiatric Progress notes dated November 7, 2010 (no documented date) revealed in part, " Staff reported another night of poor sleep, waking several times, and attempted to get in bed with his roommate (#7). He (#5) is restless at night and now rocking back and forth. . . Speech is improving slowly, but he (#5) remains slightly sexually preoccupied and very difficult to redirect. "

During a face to face interview on 11/09/2010 at 2:10 p.m. (5 days after Patient #7 complained of being fearful of his roommate (#5) on 11/04/2010 documented at 3:15 a.m.), Patient #7 indicated that his roommate (#5) had been near his (#7's) bed on 2 to 3 occasions (verbalized and gestured with his hand, by Patient #7, by holding up 2 then 3 fingers) while rubbing himself (private part/penis). Patient #7 further indicated he did not like what had happened and would prefer to be in another room.

During a face to face interview on 11/10/2010 at 1:45 p.m., Patient #7 was interviewed by Registered Nurse S3 in the presence of surveyors. Patient #7 indicated he had seen Patient #5's penis and demonstrated with up and down motions of his hand (#7) to illustrate how Patient #5 had manipulated himself.

During a face to face interview on 11/09/2010 at 2:25 p.m., Registered Nurse S15 indicated she was the nurse that provided care to Patient # 5 and #7 on the night that patient #7 had to be medicated for sleep due to complaints of his roommate (#5) getting too close to him (note Psychiatric progress notes indicate Patient #7 was medicated with Ativan and then Restoril for fear of going back to sleep.). S15 indicated Patient #5 was extremely restless that night and she had placed him in the Day Room. S15 indicated she had planned on placing Patient #5 in a different room if he became sleepy that night; however, he never slept. S15 indicated she did not change the room assignment. Further (after reviewing the medical records of both patients, #5 and #7) S15 indicated that both patients located in Room "A" were placed on Q15 minutes (every 15 minute) observations on the date of 10/29/2010 (6 days before the first complaint by Patient #7 regarding fear of Patient #5). S15 indicated that prior to that date one or the other of the patients had been on "Line of Sight".

During a face to face interview on 11/09/2010 at 9:15 a.m., LPN S16 indicated she was on duty one night when there were complaints from Patient #7 about fear of his roommate, Patient #5. S16 indicated she thought the night the incident occurred would have been the 7:00 p.m. - 7:00 a.m. shift from 11/07/2010 through 11/08/2010. S16 indicated staff heard Patient #7 calling out and went to his room in response. S16 did not recall which staff responded with her; however, she indicated that Patient #7 told them that Patient #5 had been trying to get in bed with him and he was uneasy. S16 indicated that she did not think the incident had been witnessed by any staff. S16 indicated the Nurse Practitioner had been informed of the incident. S16 indicated Patient #5 had been removed from the room and she thought it was the same night that staff had found Patient #5 in an empty room humping on a bed. S16 indicated Patient #7 was medicated for sleep that night and Patient #5 was placed in the Day Room. S16 confirmed there was no change in bed assignment for either Patient #5 or Patient #7.

During a face to face interview on 11/10/2010 at 9:50 a.m., Registered Nurse S6 indicated he interviewed Patient #7 on 11/04/2010 regarding his interaction with Roommate, Patient #5, because he (S6) had been told in report at the change of shift that Patient #7 was complaining that Patient #5 had been trying to get in bed with him. S6 indicated Patient #7 confirmed his fear of Roommate, Patient #5, and confirmed that it was a result of Patient #5 trying to get in bed with him (#7). S6 indicated he had never witnessed Patient #5 trying to get in the bed with Patient #7; however, the reason that Patient #5 had been admitted to the hospital, from the nursing home where he (#5) resided, was for incidents of gyrating against a peer's bed and gyrating against staff. S6 indicated he was able to see Patient #7 when he was sitting at the nursing station because the opening to the door of Room "A" made Patient #7's bed visible from the nursing station. S6 indicated there had been no change in observation status on the night of the 4th, that both Patient #5 and Patient #7 remained on Q15 (every fifteen) minute observations. S6 confirmed there had been no change in room assignment for either Patient #5 or #7. S6 indicated that he had witnessed Patient #5 making squirming pelvic movements on the sofa in the group room on the morning of 11/10/2010. After reviewing the medical records of Patient #5 and Patient #7, S6 indicated the two patients should have been moved into separate rooms and there should have been better communication between shifts.

During a face to face interview on 11/10/2010 at 10:40 a.m., Registered Nurse S9 indicated she had witnessed Patient #5 going into empty rooms and pressing his pelvis against the bed in a thrusting movement which seemed to comfort him in a primitive manner. S9 indicated she had placed Patient #5 on Line of Sight for her shift because of Patient #7's fear of Patient #5. S9 indicated that Patient #5 was marked on the medical record as Q15 minute observations; however, she knew that she had him on Line of Sight on 11/07/2010. S9 further indicated she had informed the oncoming shift of the problem with sexual inappropriateness of the two patients. S9 confirmed there had been no changes made to either Patient #5 or Patient #7's treatment plans in response to Patient #7's verbalized fear of Patient #5. S9 indicated she would have moved the two patients; however, there had not been another room available on 11/05/2010 and 11/07/2010. S9 indicated the hospital's practice had been to move bed assignments to separate patients that did not get along.

Review of a hand written document presented by Director of Nursing S3 revealed the following census for the 20 bed hospital:
10/29/2010 = Census 12, 10/30/2010 = Census 12, 10/31/2010 = Census 11, 11/01/2010 = Census 11, 11/02/2010 = Census 11, 11/03/2010 = Census 13, 11/04/2010 = Census 11, 11/05/2010 = Census 11, 11/06/2010 = Census 15, 11/07/2010 = Census 15, 11/08/2010 = Census 15, and 11/09/2010 = Census 11.

During a face to face interview on 11/10/2010 at 1:10 p.m., Mental Health Technician S13 indicated he had witnessed Patient #5 masturbating in his bed a few times (unsure of dates); however, had never seen #5 being sexually inappropriate with another patient or staff. S13 further indicated he had found Patient #5 humping on a bed in empty rooms on a few occasions.

During a face to face interview on 11/10/2010 at 3:20 p.m., Advanced Practice Nurse S15 confirmed she had known that Patient #7 had complained of his roommate (Patient #5) trying to get into bed with him since first documented in her progress notes on
11/05/2010. S15 further indicated that she had made no changes in the Treatment Plans for either Patient #5 or #7 that addressed the sexually inappropriate interaction other than adding sleep medications. S15 indicated that although Patient #7 had complained of being fearful of Patient #5, he did not look fearful. S15 further indicated that she had a difficult time believing that Patient #5 could perform the actions that Patient #7 had described because Patient #5 had difficulty with his motor skills and she could not imagine that he would be capable of disrobing (Record review of Initial Registered Nurse assessment dated 10/26/2010 at 1700 (5:00 p.m.) revealed "unsteady gait." Observations on 11/10/2010 at 2:00 p.m. revealed Patient #5 to be walking at moderate pace with a pattern of ambulating with one long stride followed by one short stride. Further observations revealed Patient #5 to be staring forward with no apparent focus.).

Review of the entire Multidisciplinary Treatment Plan revealed no documented evidence of Patient #5's or Patient #7's treatment plan revisions after their initial treatment plans proved to be ineffective in providing for the safety of Patient #5 who was fearful of his roommate, Patient #7.

Based on record review and interview, the hospital failed to ensure the effective implementation of the nursing care plan for 1 of 7 sampled patients (Patient #2) by failing to ensure that the mattress was on the floor during Patient #2's hospitalization as documented as an intervention in the nursing care plan; by failing to ensure that objectives and interventions were developed relating to a toileting schedule and/or relating to incontinence; and by failing to ensure that interventions included the need to assist the patient with a bath/shower during the first 2 days of his hospitalization. Findings:

The medical record of Patient #2 was reviewed. This review revealed that Patient #2 is an 86 year old male who was admitted to Oceans Behavioral Hospital on 9/01/10 and was discharged from Oceans Behavioral Hospital on 9/04/10.

Review of the Psychiatric Evaluation (dated 9/02/10 completed by S15, PA) revealed that Patient #2's admitting diagnoses included Behavior Changes, Mood Instability & Aggressive & Sexually Aggressive Behavior in concurrence with Senile Dementia; Diabetes Mellitus; Hypertension; Prostate Issues; Dysphasia; Hard of Hearing; and possible Coronary Artery Disease. Documentation on the Psychiatric Evaluation revealed that Patient #2 was gravely disabled and potentially or actively dangerous to self, others, or property with need for controlled environment. Documentation on the Psychiatric Evaluation revealed that Patient #2 required maximum assistance to walk and that he (Patient #2) had impaired judgement and impaired insight.

Review of the admission assessment (dated 9/01/10 completed by S9, RN) revealed nursing documentation indicating that Patient #2 ambulates with a walker/cane and/or wheelchair and that Patient #2 is at risk for falls. Documentation on the fall risk assessment tool revealed that Patient #2 was assessed to be at a high risk for falls.

Review of the Discharge Summary revealed that Patient #2 was discharged from Oceans Behavioral Hospital of Baton Rouge on 9/04/10. Documentation under the heading of Hospital Course was "Initial Mental Status Exam: level of consciousness-alert, gait/posture-small steps with unsteady balancing, needs max assist, appearance-appears younger than stated age, disheveled, facial expression-blunted, mouth held agape, psychomotor activity-slow, methodical, behavior/attitude-hesitant but does redirect or follow, speech-very poor articulation in soft whisper, level of cooperation-moderate, thought process-incoherent due to language barriers, thought content-difficult to assess, lack of facial animation, affect-blunted to flat, mood-varies but currently anxious, orientation-X2, memory-unable to assess due to communication problems, concentration-unable to assess due to communication problems, abstraction-unable to assess due to communication problems, insight and judgment-impaired. 9/2 confused, depressed, and very anxious. Affect labile. 9/3 concerned about roommate but too hard to understand fully. He will grab your hand to pull you closer and whisper in your ear. At times he attempts to touch other places. Possibly depressed. Affect flat. No obvious suicidal or homicidal ideations. 9/4 while patient being transferred to couch from wheelchair he was standing and favoring his left side. LPN and RN assessed and noted that weight bearing difficult and unsteady. Pelvic x-ray ordered-fractured neck of proximal right femur. X-ray results called to (name), NP, and patient transferred to (Hospital A) ER via (name of ambulance provider) for evaluation and treatment of fracture".

Review of the treatment plan revealed that the treatment plan was initiated on 9/01/10 which was the day of Patient #2's admission to the hospital. Problem #2 indicated that Patient #2 was at "High risk for falls" related to limited mobility, shuffling gait, or unsteady gait; poor balance or motor function; poor judgment and impulse; and rolls out of bed at home. Objectives under Problem #2 included "Pt will demonstrate proper transfer techniques from bed to chair, chair to walker within 5 days"; and "Will remain free of injuries (secondary) to fall from bed during stay also (secondary) to dementia after attempts to walk (without) assistance". Interventions under Problem #2 included measures to promote a safe environment including the use of a "Chair Alarm" and "Mattress on floor". Review of the treatment plan revealed no documentation to indicate that objectives and interventions were developed relating to a toileting schedule and/or relating to incontinence. Documentation in the medical record revealed no evidence to indicate that Patient #2 was bathed and/or assisted with a bath on 9/01/10 or 9/02/10. Review of the Observation Check Sheet revealed the first documented bath/shower was on 9/03/10 at 9:15 p.m.

S6 (RN) was interviewed on 11/10/10 at 8:20 a.m. S6 reported that he works as a Registered Nurse on the night shift which he reported was from 7:00 p.m. till 7:00 a.m. S6 reviewed the medical record of Patient #2 and reported that he did remember the patient. S6 reported that Patient #2 was confused and had a flat affect. S6 reported that Patient #2 was in a wheelchair, had an unsteady gait, and was a high risk for falls. S6 reported that Patient #2 required assistance for all transfers. S6 reported that fall precautions included clearing the environment of obstacles, implementing fall precautions on the problem list of the treatment plan, placing signage on the chart and near the door of the patients room, and placing a yellow arm band on the patient as the yellow arm band indicates fall risk. S6 reported that he worked the night shift that began on 9/03/10 and 9/04/10 and stated that Patient #2 ' s mattress was on the bed-frame on both these dates and not on the floor as documented in the treatment plan. S6 reported that he was told by the day shift RN (S7) after his arrival at approximately 7:00 p.m. on 9/04/10 that Patient #2 was complaining of pain and had reported that he (Patient #2) had fell the night before (night of 9/03/10). S6 reported that he was not aware of any falls involving Patient #2 during his hospitalization. S6 reported that interviewed all staff members who worked on the night of 9/03/10 and that all informed him that they were not aware of Patient #2 falling during the night. S6 reported that he did not feel that Patient #2 could have fallen without staff knowing because he was being checked every 15 minutes and he would have remained on the floor had he fell as he was too weak to get back in bed or in a chair independently. S6 reported that X-rays obtained on Patient #2 revealed a fracture of the neck of the right femur and that Patient #2 was transferred to Hospital A by ambulance on 9/04/10 at 11:15 p.m. S6 confirmed that the treatment plan was not followed in this area as the mattress was not on the floor for Patient #2.

S9 was interviewed on 11/10/10 at 9:50 a.m. S9 reported that she works as a Registered Nurse on the day shift which she reported was from 7:00 a.m. till 7:00 p.m. S9 reviewed the medical record of Patient #2 and reported that she did remember the patient. S9 reported that she was the registered nurse who admitted Patient #2 to Oceans Behavioral Hospital of Baton Rouge on 9/01/10 at 1:00 p.m. S9 reported that she also worked with Patient #2 on 9/02/10. S9 reported that Patient #2 was hard of hearing, confused and oriented to person only. S9 reported that Patient #2 was in a wheelchair, was weak and unsteady, and required assistance with transfers. S9 reported that Patient #2 was assessed to be a high risk for falls. S9 reported that fall precautions for patients assessed to be at a high risk of falls included placing the mattress on the floor as there were no handrails on the beds. S9 reported that she had heard that an x-ray was done on Patient #2 which revealed a fracture but was not aware of Patient #2 falling at any point during his hospitalization. S9 confirmed that the treatment plan was not followed in that Patient #2's mattress was not on the floor during his hospitalization as documented on the treatment plan. S9 indicated that dependant patients are to be bathed and/or assisted with their bath daily. S9 confirmed that there was no documentation in the medical record to indicate that Patient # had been bathed and/or assisted with a bath on 9/01/10 or 9/02/10.

25452


Based on record review and interview the hospital failed to 1) ensure that insulin was administered per sliding scale as ordered by the attending physician for 1 of 7sampled patients (Patient #4); 2) ensure nursing staff monitor patients receiving Metoprolol as indicated in the hospital's Drug Reference Book titled, "Nursing 2008, Drug Handbook" for 1 of 1 patients reviewed on the medication Metoprolol out of a total sample of 7 patients (Patient #3). Findings:

1) Review of physicians orders dated 9/01/2010 for Patient #4 revealed:
Accucheck AC (before meals) and HS (at bedtime) per sliding scale with Regular Insulin.
BG (blood glucose) <150= 0 units
BG 150-200=2 units
BG 201- 250 = 4 units
BG 251 -300 = 6 units
BG 301 -350 = 8 units
BG 351 - 400 = 12 units
BG > 400= 14 units and recheck in 2 hours

Review of Patient #4's Insulin Flow Sheet revealed the following:
09/06/2010: 2100- Blood Sugar 157- Insulin type and Amount Given, None
09/08/2010: 2100- Blood Sugar 152- Insulin type and Amount Given, None
09/10/2010: 2100- Blood Sugar 166- Insulin type and Amount Given, None
09/12/2010: 1630- Blood Sugar 150- Insulin type and Amount Given, None

An interview was held with S2 RN DON on 11/10/2010 at 2:35 PM. After review of the Insulin Flow Sheet and the medical record for Patient #4, she confirmed there were missing opportunities where the sliding scale insulin had not been administered to the patient as ordered by the physician.

2) Review of the hospital's Drug Reference Book titled, "Nursing 2008 Drug Reference" page 312 regarding the Medication Metoprolol revealed in part, "Nursing considerations: Always check patient's apical pulse rate before giving drug. If it's slower than 60 beats/minute, withhold drug and call prescriber immediately. .. Monitor blood pressure frequently; drug masks common signs and symptoms of shock."

Review of Patient #3's Physician's orders dated 11/03/2010 at 1630 (4:30 p.m.) revealed an order for Metoprolol Tartrate 100 milligrams by mouth two times per day. Review of Patient #3's entire medical record revealed no documented evidence that the patient's apical pulse had ever been taken. Further review revealed Patient #3's graphics sheet to indicated blood pressure, pulse, and respirations were taken every AM (morning) and PM (evening) with no documented time as to when the vital signs were taken.

During a face to face interview on 11/09/2010 at 1:10 p.m., Director of Nursing S3 confirmed there was no documented evidence of apical pulses being performed on Patient #3 who was receiving Metoprolol. S3 confirmed there were no times documented on the graphics sheet to indicate when vital signs had been taken. S3 indicated there was no hospital policy for the administration of Metoprolol; however, the hospital used a Drug Reference Book which she provided to the surveyors, titled, "Nursing 2008 Drug Reference". S3 indicated the vital signs recorded on the graphic sheet were most likely taken with an automated machine that measured blood pressure and pulse.

Based on record review and interview, the hospital failed to ensure that all orders were signed and/or timed by the ordering practitioner. This was found in the medical record of 1 of 1 patient (Patient #2) whose medical record was reviewed for the signing and/or timing of orders out of a total sample of 7 patients. Findings:

The medical record of Patient #2 was reviewed. This review revealed that Patient #2 is an 86 year old male who was admitted to Oceans Behavioral Hospital on 9/01/10 and was discharged from Oceans Behavioral Hospital on 9/04/10.

Review of the physician orders on 11/12/10 revealed orders dated 9/01/10 and 9/04/10 that were not signed or timed by the ordering practitioner.

S2 (RN) was interviewed on 11/12/10 at 9:30 a.m. S2 confirmed that the orders were not signed or timed by the ordering practitioner.

Based on record review and interview the hospital failed to ensure quality control monitoring of the hospital's accucheck machine was implemented as per hospital policy for 1 of 1 accheck machine reviewed for quality controls in the hospital. Findings

Review of the hospital policy titled, "Glucometer Method for Obtaining Capillary Blood Glucose Levels, NSG-26, adopted August 2006" presented by the hospital as their current policy revealed in part, "Confirm system performance/Control Test: A control test confirms that the system is functioning properly. Control tests are to be done every 24 hours of patient use and anytime there is a question about the blood glucose tests results."

Review of the hospital's "Assure 3 Blood Glucose Monitoring System Daily Quality Control Record" revealed no documented evidence control testing was performed on 10/4, 10/05, 10/08, 10/09, 10/10, 10/13, 10/14, 10/18, 10/19, 10/22, 10/23, 10/24, 10/27, 10/28, 11/01, 11/02, 11/06, 11/06, and 11/07/ 2010. This finding was confirmed by Director of Nursing S3 on 11/09/2010 at 1:10 p.m. who further indicated that the nurse that had been assigned to control testing of the machine for the missing days was no longer working at the hospital and the task should have been assigned to someone else.

Based on record review and interview, the hospital failed to ensure patients had individualized comprehensive treatment plans that were updated with the patients change in condition and/or behavior for 2 of 7 sampled patients (#5, #7). Findings:

Patient #5 (Admit date 10/26/2010) :
Review of Patient #5's Psychiatric Evaluation dated 10/27/2010 revealed in part, "History of Present Illness: This is a 66 year old African American male with a history of depressive disorder and Alzheimer dementia. He has been admitted to Oceans Behavioral Hospital from (name of Nursing Home) by a non-contested admission. The account of the events leading up to the transfer from (Nursing Home) to Oceans indicates that the patient has been increasingly agitated and sexually inappropriate with staff and peers. The patient was found to be gyrating against another peer's bed, as well as attempting to gyrate against staff at the nursing home. The patient is nonverbal and has been so for approximately one and a half years. . . Admission Diagnosis: Depressive disorder. . Hypertension, Hyperlipidemia, Alzheimer dementia. . . " Patient #5 was admitted to the hospital on 10/26/2010.

Review of Patient #5's Multidisciplinary Treatment Plan revealed Sexually Inappropriate Behavior was identified as a problem on 10/26/2010 by Social Services, 11/01/2010 by nursing Services, on 11/02/2010 by Therapeutic Recreation Services. Further review revealed the following interventions: Nursing will: 1) provide safe, structured environment daily for the duration of treatment per stay. 2) All staff (will) notify MD (Medical Doctor) of patient status as ordered and prn (as needed), 3) Assess mood, behavior, and effectiveness of intervention daily for duration of treatment RN/LPN (Registered Nurse/ Licensed Practical Nurse), Implement observations as ordered daily. 4) Educate on medication regimen daily and prn. Social Services will: gather history and assess level of functioning, develop multidisciplinary treatment integration, engage patient's family/significant others in continued support and participation of treatment. Therapeutic Recreation will prompt and encourage as needed. Reduce environmental stimuli as needed.

Review of Patient #5's medical record revealed the patient was found gyrating on the sofa in the day room on 10/30/2010, found grinding on the couch and sofa on 11/01/2010, documented as reproducing sexual movements and trying to get in his roommates bed on 11/05/2010, making sexual thrusts on sofa in TV room on 11/06/2010, pelvic thrusting in his roommates bed on 11/07/2010, and trying to get into his roommate's bed on the same date (11/07/2010).(See findings cited at A0144)

Further review of Patient #5's entire medical record revealed no documented change in the patient's multidisciplinary treatment plan when the initial treatment plan failed to be effective. This findings was confirmed by Director of Nursing S3 on 11/10/2010 at 10:40 a.m.

Patient #7 (Admit Date 10/20/2010):
Review of Patient #7's Psychiatric Evaluation dated 10/21/2010 revealed in part, "History of Present Illness: According to the information, the patient is acting very bizarre, sexually preoccupied grabbing the female patient to his room and started kissing her, and uncontrollable behavior, and at times he is agitated, restless, and combative. The patient says he likes women and he is missing sex and he said his wife died years ago and the patient said he is very depressed, not sleeping at night, unable to do the things he was doing before. . . Provisional/Admitting Diagnosis: Alzheimer's dementia with depression and psychosis, Hypertension, CVA (Cerebral Vascular Accident), Gout, CHF (Congestive Heart Failure). . ."

Review of Patient #7's Multidisciplinary Treatment Plan revealed Sexually Inappropriate Behavior was identified as a problem on 10/20/2010 by Social Services, 10/21/2010 by Nursing Services, on 10/20/2010 by Therapeutic Recreation Services. Further review revealed the following interventions: Nursing will: 1) provide safe, structured environment daily for the duration of treatment per prn. 2) All staff (will) notify MD (Medical Doctor) of patient status as ordered and prn (as needed), 3) Assess mood, behavior, and effectiveness of intervention daily for duration of treatment RN/LPN (Registered Nurse/ Licensed Practical Nurse), Implement observations as ordered daily. 4) Educate on medication regimen daily and prn. Social Services will: gather history and assess level of functioning, develop multidisciplinary treatment integration, and encourage sharing feelings in order to clarify/gain insight as to causes of depression. Therapeutic Recreation will provide supervised structured activities. Encourage peer interactions, prompt , encourage, and redirect as needed.

Review of Patient #7's medical record revealed the patient (#7) complained of being fearful of his room mate (#5) due to continued attempts by roommate (#5) to get in his bed on 11/04/2010, was upset with his roommate's (#5) attempt to get in his (#7) bed on 11/05/2010, placing his (#7) walker at an angle near his (#7) bed to prevent his roommate (#5) from trying to get in bed with him (#7) on 11/06/2010, and being upset/anxious regarding his roommates (#5) attempts to get in his (#7) bed on 11/07/2010 (See findings cited at A0144).

During a face to face interview on 11/09/2010 at 2:10 p.m. (5 days after Patient #7 complained of being fearful of his roommate (#5) on 11/04/2010 documented at 3:15 a.m.), Patient #7 indicated that his roommate (#5) had been near his (#7's) bed on 2 to 3 occasions (verbalized and gestured with his hand, by Patient #7, by holding up 2 then 3 fingers) while rubbing himself (private part/penis). Patient #7 further indicated he did not like what had happened and would prefer to be in another room.

During a face to face interview on 11/10/2010 at 1:45 p.m., Patient #7 was interviewed by Registered Nurse S3 in the presence of surveyors. Patient #7 indicated he had seen Patient #5's penis and demonstrated with up and down motions of his hand (#7) to illustrate how Patient #5 had manipulated himself.

Further review of Patient #7's entire medical record revealed no documented change in the patient's multidisciplinary treatment plan when the initial treatment plan failed to be effective in providing safety for Patient #7. This findings was confirmed by Director of Nursing S3 on 11/10/2010 at 10:40 a.m.