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Based on record review and interview the facility failed to ensure a patient had the capacity to make informed decisions related to his care. This deficiency is evidenced by failure of the multidisciplinary team to ensure 1 (Patient #2) of 1 patient with a developmental disability understood consents related to privacy and was capable of making decisions and/or had a representative to assist in the decisions related to his care plan.
Findings:

Record review revealed Patient #2 was an involuntary admitted on 06/07/2022 with a diagnosis of psychosis, autism spectrum disorder, and intellectual disability. It was documented that he lived in a group home. On 06/16/2022 Patient #2 fell backwards out of a wheelchair and was transported to an acute care hospital for evaluation. Neither his care giver nor his mother were notified of the fall or his transfer to an acute care facility because on admission Patient #2 had not indicated he wanted his status shared with anyone.

Review of the admission assessment revealed S9RN noted "unable to sign" on consents related to HIPPA, Acknowledgement of Patient Rights, and Authorization to Release Information to Family Members and/ or Friends. On the Patient Pneumococcal and Influenza Vaccine consent S9RN wrote, "UTA patient not understanding."

Review of the psychosocial assessment revealed S14SW attempted to perform the evaluation and noted "could not complete" on each page. Review of the social work notes revealed the group home was contacted on 06/15/2022 for placement after discharge. There was no documentation questions were asked related to completing the psychosocial assessment or about a power of attorney, judgement of interdiction or continuing tutorship.

Review of the Daily Nursing Notes filled out each shift while in the hospital revealed Patient #2 was only oriented to person most days.

Review of the Progress Notes- Psychiatric Attending on 06/11/2022 S15NP noted Patient #2 had poor judgement, poor concentration, impaired attention and " inappropriate at times with peers. Client with minimal verbal interaction."

In interview on 07/13/2022 at 12:57 p.m. S9RN was asked to clarify her statement "unable to sign." She said he could not sign his name and she did not think he could put an "x" on the line. She also said she could not tell if he understood the consents and he did not give a name when he was asked if there was someone he wanted to receive updates on his medical status. .

In interview on 07/13/2022 at 10:40 a.m. S3DON agreed there were questions about the capacity of Patient #2 related to informed consent. She agreed that the record contained no indication the multidisciplinary team tried to clarify if he was capable of informed consent without his supportive network.

Based on record review and interview the facility failed to include facility operations in the quality assessment and improvement program. This deficiency is evidenced by the failure of the facility to document sewerage backups in the facility occurrence reports.
Findings:

Review of the facility policy "Environmental Services; Environmental Care" reveals in part, " Occurrence Report shall be completed for all major spills."

In interview on 07/12/2022 at 8:15 a.m. S1CEO verified there had been several occurrences of sewerage backing up into the facility related to patients flushing large non-biodegradable objects in the toilets.

Review of the occurrence reports revealed no documentation of the sewerage backups into the building.

In interview on 07/13/2022 at 11:40 a.m. S3DON and S4QA verified occurrence reports were not filled out for the sewerage backups and it was not included in the quality assessment and improvement program.

Based on record review and interview the registered nurse failed to ensure the proper execution of physician orders. This deficiency is evidenced by: 1) failure of the nursing staff to document observations every 15 minutes as ordered in 1 (Pt. #1) of 5 (Pt #1, Pt. #2, Pt. #3, Pt. #4, Pt. #5) records reviewed; 2) failure of the nursing staff to assess vital signs twice a day as ordered in 4 (Pt, #2, Pt. #3, Pt. #4, Pt. #5) of 5 (Pt #1, Pt. #2, Pt. #3, Pt. #4, Pt. #5) records reviewed; 3) failure to notify the attending physician of elevated blood pressure as ordered in 3(Pt. #2, Pt. #3, and Pt. #4) of 5(Pt #1, Pt. #2, Pt. #3, Pt. #4, Pt. #5) records reviewed; and 5) failure of the nursing staff to verify home medications as ordered in 1(Pt. #1) of 5(Pt #1, Pt. #2, Pt. #3, Pt. #4, Pt. #5) records reviewed.
Findings:

1)Failure of the nursing staff to document observations every 15 minutes.

Patient #1
Review of the medical record for Patient #1 revealed admission on 07/09/2022 with a diagnosis of psychosis, bipolar disease, and depression with suicidal ideation. Review of the orders for Patient #1 placed on 07/09/2022 at 12:00 p.m. revealed "Observation Level II- Q15."

Review of the observation sheets revealed on 07/09/2022 the patient was not observed at 6:00 p.m. and 6:15 p.m.

Further review of the medical record revealed there was no observation sheet for 07/10/2022.

On 07/11/2022 at 3:10 p.m. S3DON verified the observations were not done as ordered and observations were missing for an entire day.

2) Failure of the nursing staff to assess vital signs twice a day.

Review of hospital policy 3.23, "Vital Signs," revealed in part, "2. Vital signs are taken BID (2 times a day) unless otherwise specified by the physician."

Patient #2
Review of the orders for Patient #2 from admission on 06/07/2022 at 1:05 p.m. revealed, "Vital signs BID."
Review of the vital signs revealed assessment on 06/08/2022 at 6:55 p.m., 06/09/2022 at 6:37 p.m., 06/11/2022 at 6:00 a.m., 06/15/2022 at 6:00 p.m. Vitals signs were not assessed on 06/16/2022.

In interview on 07/13/2022 at 10:25 a.m. S3DON verified the missing vital sign assessments.

Patient #3
Review of the orders for Patient #3 from admission on 06/14/2022 at 10:30 a.m. revealed "Vital Signs BID."

Review of the vital signs revealed assessments on 06/16/2022 at 6:00 p.m. and on 06/19/2022 at 7:03 a.m.

In interview on 07/13/2022 at 10:45 a.m. S3DON verified the missing vital sign assessments.

Patient #4
Review of the orders for Patient #4 from admission on 06/13/2022 at 8:30 p.m. revealed. "Vital Signs BID."

Review of the vital signs revealed assessments on 06/20/2022 at 6:30 p.m., on 6/24/2022 there are no recorded vital signs, and vital signs were assessed on 06/25/2022 at 6:15 a.m.

In interview on 07/13/2022 at 11:10 a.m. S3DON verified the missing vital sign assessments.

Patient #5
Review of the orders for Patient #5 from admission on 06/09/2022 at 1:23 p.m. revealed, "Vital Signs BID."

Review of the vital signs revealed assessments on 06/10/ 2022 at 6:29 a.m., 06/12/2022 at 6:00 a.m., and 06/ 19/2022 at 7:21 p.m.

In interview on 07/13/2022 at 10:57 a.m. S3DON verified the missing vital sign assessments.

3) Failure to notify the attending physician of elevated blood pressure as ordered.
Review of the hospital policy 3.13, "Calling Physicians After Office Hours- Care of the Patient," revealed in part, "Procedure- 1) Contact the physician/ LIP via cell phone or at home. Telephone numbers are listed in the Physician and LIP call sheet in the nurse's station. 2) Document the time the call was placed, name of Physician and the response."

Patient #2
Review of the orders from admission on 06/07/2022 at 1:05 p.m. revealed "Vital Signs BID - call M.D. for systolic B/P greater than 160 or less than 100, diastolic B/P greater than 90 or less than 60, pulse greater than 110 or less than 60, respirations greater than 22 or less than 12, temperature greater the 99.5,"

Review of the medical record for Patient #2 revealed the following:

On 06/09/2022 vital signs were assessed once at 6:37 p.m. and the blood pressure was 163/106. The physician was not notified of the elevated blood pressure.

On 06/11/2022 vital signs were assessed at 6:00 a.m. and the blood pressure was 159/ 107. The physician was not notified of the elevated blood pressure.

On 6/14/2022 at vital signs were assessed at 6:00 p.m. and the blood pressure was 154/ 93. The physician was not notified of the elevated blood pressure.

On 06/15/2022 vital signs were assessed at 6:00 p.m. and blood pressure was 168/96. The physician was not notified of the elevated blood pressure.

On 07/13/2022 between 10:20 a.m. and 10:26 a.m. S3DON verified the physician was not notified of the elevated blood pressures.

Patient #3
Review of the orders from admission on 06/14/2022 at 10:30 a.m. revealed "Vital Signs BID - call M.D. for systolic B/P greater than 160 or less than 100, diastolic B/P greater than 90 or less than 60, pulse greater than 110 or less than 60, respirations greater than 22 or less than 12, temperature greater the 99.5."

Review of the medical record for Patient #3 revealed vital signs were assessed on 06/20/2022 at 6:25 p.m. and the blood pressure was 139/ 93. The physician was not notified of the elevated blood pressure.

In interview on 07/13/2022 at 10:45 a.m. S3DON verified the physician was not called for the elevated blood pressure.

Patient #4
Review of the orders from admission on 06/13/2022 at 8:30 p.m. revealed "Vital Signs BID - call M.D. for systolic B/P greater than 160 or less than 100, diastolic B/P greater than 90 or less than 60, pulse greater than 110 or less than 60, respirations greater than 22 or less than 12, temperature greater the 99.5."

Review of the medical record for Patient #4 revealed the following:

On 06/17/2022 there was an untimed set of vitals with a blood pressure of 139/93. The physician was not notified of the elevated blood pressure.

On 06/19/2022 vitals were assessed at 6:41 a.m. and the blood pressure was 131/97. The vital signs were repeated at 7:12 a.m. and the blood pressure was 162/104. The physician was not notified of the elevated blood pressure.

On 06/20/2022 vitals were assessed at 6:30 p.m. The blood pressure was 134/ 94. The physician was not notified of the elevated blood pressure.

In interview on 07/13/2022 at 11:10 a.m. S3DON verified the physician was not called for the elevated blood pressures.

5) Failure of the nursing staff to verify home medications as ordered.

Review of the orders for Patient #1 revealed on 06/10/2022 at 12:40 a.m. an order, "Please call Walgreens in Houma for meds."

Review of the Medication Reconciliation Sheet on 07/11/2022 at 3:00 p.m. revealed it had not been not filled out. There was no evidence the pharmacy was called.

On 07/11/2022 3:00 p.m. S3DON verified the medications were not reconciled with the pharmacy.

Based on record review and interview the charge nurse failed to document staff assignments. This deficiency is evidenced by failure of the nursing staff to document complete staff assignments on 20 of 24 shifts reviewed.
Findings:

Review of hospital policy 8.08, "Observation Precautions, Care of Patient," revealed in part, "The Charge RN is responsible for assigning the staff members to perform designated special observation status for each patient on his/her assigned unit. The patient care assignments cannot be delegated. The Charge RN will enter the patient's name and name of staff member assigned to monitor special observation on the MHT Team Assignment Form."

Review of the Unit Assignments from 07/04/2022 through 07/10/2022 revealed the charge RN had completed the assignments for Unit 1 on 07/04/2022 for the a.m.shift, 07/04/2022 for the p.m. shift , and 07/06/2022 for the a.m. shift The charge RN completed assignments for Unit 2 on 07/07/2022 for the a.m. shift.

In interview on 07/13/2022 at 8:35 a.m. S1CEO verified the missing Unit Assignments.

Based on record review and interview the director of nursing failed to ensure all nurses adhered to the policies and procedures of the hospital. This deficiency is evidenced by: 1) failure of the nursing staff to document notes twice per shift in the multidisciplinary notes in 5 (Pt. #1, Pt. #2, Pt, #3, Pt, #4, Pt. #5) of 5 (Pt. #1, Pt. #2, Pt, #3, Pt, #4, Pt. #5)records reviewed; and 2) failure of the nursing staff to recognize improper medication orders in 1 (Pt. #2) of 5 (Pt. #1, Pt. #2, Pt, #3, Pt, #4, Pt. #5) records reviewed.
Findings:

1) Failure of the nursing staff to document notes twice per shift.

Review of hospital policy 3.12, "Progress Notes- Care of the Patient," revealed in part, "5.The frequency of Interdisciplinary Progress Note entries will be as follows: b. Nursing: A minimum of two (2) entries per shift around the clock."

Patient #1
Review of the medical record for Patient #1 revealed on 07/09/2022 one Multidisciplinary Note for the p.m. shift and on 07/10/2022 one Multidisciplinary Note for the p.m. shift.

In interview on 07/11/2022 at 3:03 p.m. S3DON verified there were not two notes per shift.

Patient #2
Review of the medical record for Patient #2 revealed one Multidisciplinary Note per shift on 06/08/2022, 06/10/2022, 06/11/2022, 06/12/2022, 06/14/2022, and 06/15/2022.

In interview on 07/13/2022 at 10:19 a.m. S3DON verified there were not two notes per shift.

Patient #3
Review of the medical record for Patient #3 revealed one Multidisciplinary Note per shift on 06/17/2022 and 06/18/2022.

In interview on 07/13/2022 at 10:40 a.m. S3DON verified there were not two notes per shift.

Patient #4
Review of the medical record for Patient #4 revealed one Multidisciplinary Note on 06/16/2022 for the p.m. shift, one Multidisciplinary Note on 06/18/2022 for the p.m. shift, one Multidisciplinary Note on 06/25/2022 for the a.m. shift and one Multidisciplinary Note on 06/26/2022 for the a.m. and p.m. shift.

In interview on 07/13/2022 at 11:05 a.m. S3DON verified there were not two notes per shift.

Patient #5
Review of the medical record for Patient #5 revealed one Multidisciplinary Note per shift on 06/15/2022, one Multidisciplinary Note per shift on 06/16/2022, and one Multidisciplinary Note per shift on 06/17/2022.

In interview on 07/13/2022 at 10:55 a.m. S3DON verified there were not two notes per shift.

2) Failure of the nursing staff to recognize improper medication orders.

Review of hospital policy 12.19, "Verbal and Written Orders- General," revealed in part, " All orders for medications should include the date and time of the order, the name of the drug, the dosage, the route, the frequency of administration, age, known allergies, is ordered for the patient and the name of the prescriber."

Patient #2
Review of the orders for Patient #2 revealed a telephone order placed by S16MD on 06/07/2022 at 7:54 p.m., "B52 I.M. and p.o. prn."

Further review revealed a second order placed on 06/15/2022 at 7:50 a.m., "Benadryl 50 mg I.M. prn extreme agitation, Ativan 2 mg I.M. prn extreme agitation, Haldol 5 mg I.M. prn extreme agitation." The order had no odering physician.

Review of the Medication Administration Record revealed on 06/13/2022 at 11:00 p.m. Patient #2 was administered Benadryl 50 mg I.M. , Ativan 2 mg I.M. , and Haldol 5 mg I.M.

In interview on 07/13/2022 at 10:35 a.m. DON verified the orders given on 06/07/2022 and 06/15/2022 should not have been active and should have been clarified. S3DON also verified the medication was administered on 06/13/2022 at 11:00 p.m. was done without a valid order.

Based on record review and interview the hospital failed to provide regular re-evaluation of the patient's condition to identify changes that required modification of the discharge plan. This deficiency is evidenced by failure of the hospital staff to notify the receiving facility of a delay in discharge in 1 (Pt. #2) of 2 (Pt. #2 and Pt. #5) patients discharged to a another facility.
Findings:

Patient #2
Review of the medical record for Patient #2 revealed the discharge plan was to return to his previous group home. The patient was scheduled to be discharged on 06/16/2022 and the group home had been contacted for placement. The pateint suffered a fall on 06/16/2022 and was transferred to an acute care hospital for evaluation and his discharge was delayed until 06/17/2022. Further review of the medical record revealed the group home was not notified of the delay in discharge.

In interview on 07/13/2022 at 10:15 a.m. S3DON verified there was no documentation the group home was notified of the delay in discharge.

Based on record review and interview the facility failed to ensure social service records included all interviews with patients, family members and others, assessment of home plans, family attitudes, and community resource contacts as well as a social history. This deficiency is evidenced by: 1) failure of social services to complete the psychosocial assessment for 2 (Pt. 2 and Pt.5) of 5 (Pt.1, Pt.2, Pt.3, Pt.4, and Pt.5) patient records reviewed; and 2) failure to document all conversations related to patient care.
Findings:

1) Failure of social services to complete the psychosocial assessment.

Review of hospital policy 5.24, titled "Social Work Plan and Services- Continuum of Care," revealed in part, "1. Psychosocial assessments will be completed and documented within the patient's medical record within seventy-two (72) hours of admission."

Patient #2
Review of the medical record for Patient #2 revealed admission on 06/07/2022. Further review revealed a partially completed psychosocial evaluation dated 06/09/2022 with "unable to complete" on each page.

In interview on 07/13/2022 at 10:15 a.m. S3DON verified the psychosocial assessment was not complete.

Patient #5
Review of the medical record for Patient #5 revealed admission on 06/09/2022 with a diagnosis of psychosis and seasonal affective disorder- bipolar type. Further review revealed a psychosocial assessment that was performed in the outpatient clinic on 06/01/2022. There was no documented psychosocial assessment done during the admission.

In interview on 07/13/2022 at 11:01 a.m. S3DON an S4QA verified the hospital policy and verified the psychosocial assessment was not performed as indicated in the policy.

2) Failure to document all conversations related to patient care.

Patient #5
Review of the medical record for Patient #5 revealed admission on 06/09/2022 with a diagnosis of psychosis and seasonal affective disorder- bipolar type. His discharge plan was to return to the group home where he had lived prior to admission. There was no documentation social services contacted the home to verify his placement after discharge.

In interview on 07/13/2022 at 10:58 a.m. S3DON verified there was no documentation from social services that the group home had been contacted to verify Patient #5 would be allowed to return.