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23515 HIGHWAY 190

MANDEVILLE, LA 70448

PATIENT RIGHTS: NOTICE OF RIGHTS

Tag No.: A0117

Based on record review and interview the psychiatric hospital failed to inform the patients or patients' representative of the patients' rights in advance as evidenced by failure to explain in a language or manner Patient #2 could understand.
Findings:

Review of psychiatric hospital policy titled "Communication with Persons of Limited English", last reviewed on 06/17/2023, revealed, in part: Policy: It is the policy of the hospital to provide for communication with persons with Limited English Proficiency (LEP), including current and prospective patients and families/significant others. Purpose, in part: ...the policy also provides for communication of information contained in vital documents, including but not limited to waivers of rights, consent to treatment forms, financial and insurance benefit forms, etc. All interpreters, translators and other aids needed to comply with this policy shall be provided without cost to the person being served, and patients and their families will be informed of the availability of such assistance free of charge. Language assistance will be provided through use of competent bilingual staff, staff interpreters, contracts or formal arrangements with local organizations providing interpretation or translation services, or technology/assistive and telephonic interpretation services. Applicability: All staff will be provided notice of this policy and procedure, and staff that may have direct contact with LEP individuals will be trained in effective communication techniques, including the effective use of an interpreter/access to contract services the services patients with limited English proficiency. Procedures. In part: 1. Obtaining a Qualified Interpreter, in part: The treatment team leader, Nurse Supervisor, or unit charge nurse is responsible for obtaining an interpreter, with the approval of the Director of Nursing/Director of Clinical Services ....In emergency situation, the hospital may opt to utilize an unqualified interpreter in order to quickly resolve the emergency. 3. Accessing Services, in part: a. The Admissions RN Supervisor or designee will be responsible for initiating arrangements for translator services beginning with the evaluations. Admission process. The hospital contracts with Multi Language Solutions. MLS can be reached ...24 hours per day. b. The use of an interpreter must be documented on the Consent for Interpreter Services form, as well as the completion of the required HIPAA documentation. e. for day-to-day communication between direct care staff and the patient, an electronic translator program can be accessed via computer.

Review of psychiatric hospital policy titled "Patient Rights, Responsibilities, Advocacy, last reviewed 06/01/2023, revealed, in part: Policy: It is the policy of the hospital to protect the rights of each patient. Purpose: To assure that patients and staff are knowledgeable of patient's rights ...Procedure, in part: G. Acknowledgement of Rights/Responsibilities. Upon receipt and review of information at admission to any program, the patient is given forms to sign acknowledging receipt and understanding of the information presented by the admission staff.

Review of the psychiatric hospital document titled, "Patient Rights & Responsibilities, Patient Bill of Rights", revealed in part: Every patient, or his/her designated representative, shall whenever possible, be informed of the patient's rights and responsibilities in advance of furnishing or discontinuing patient care. ...The right to receive, as soon as possible, the services of a translator or interpreter to facilitated communication between the patient and the he hospitals' health care personnel ...

Review of Patient #2's medical record revealed patient #2 was admitted on 10/26/2023 with a diagnosis of psychosis, mood disorder and THC use disorder. Further review revealed a document titled hospital "Consent for Treatment". Continued review revealed Patient #2 acknowledged the need for an interpreter on 10/26/2023 at 10:34 a.m.

Review of Patient #2's medical record revealed Patient #2 was a self-pay patient whose preferred language was Spanish, Castilian. Continued review failed to reveal evidence of the use of an interpreter documented on the "Consent for Interpreter Services" form, as well as on the completion of the required HIPAA documentation as per hospital policy.

Review of Patient #2's medical record revealed a document dated 10/26/2023 at 10:37 a.m., acknowledging the receipt of Notice of Privacy Practices, Patient Rights and Responsibilities, Receipt of Video and Audio Surveillance Protocol and Receipt of Grievance Procedure. Further review failed to reveal the use of an interpreter documented on the acknowledgement. Continued review failed to reveal staff signature.

Review of Patient #2's medical record revealed a document titled "Acknowledgment of Receipt Advance Directive/Organ Donor Information". Further review failed to reveal the use of an interpreter documented on the acknowledgement.

Review of Patient #2's medical record revealed a document titled "Financial Agreement" and "Release of Protected Health Care Information Via Telephone to Answering Machine or Voice Mail". Further review failed to reveal the use of an interpreter documented on the "Financial Agreement" and "Release of Protected Health Care Information Via Telephone to Answering Machine or Voice Mail" authorization.

In an interview on 12/04/2023 at 2:35 p.m., S11RM reported that the staff should have used an interpreter when communicating with Patient #2 and should have used an interpreter when completing assessments. S11RM stated she was not aware of the Interpreter Consent form as described in the Interpreter policy. S11RM confirmed that there is no evidence of Interpreter consent form documented in Patient #2's chart.

In an interview on 12/05/2023 at 10:45 a.m., S11RM and S9ADON confirmed that there was no evidence of the use of an interpreter documented on the Consent for Interpreter Services form, as well as the completion of the required HIPAA documentation, Patient Rights forms, Advance Directive, and Organ donor form, Financial Agreement forms Release of Protected Information form, as per hospital policy.

PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING

Tag No.: A0130

Based on record review and interview, the psychiatric hospital failed to ensure the patient /patient representative's right to participate in the development and implementation of his or her plan of care was met. This deficient practice was evidenced by failure to ensure Spanish speaking Patient #2 had a translator to assist with the development and implementation of the patient's plan of care.
Findings:

Review of psychiatric hospital policy titled "Communication with Persons of Limited English", last reviewed on 06/17/2023, revealed, in part: Purpose: To ensure persons with Limited English Proficiency have an equal opportunity to participate in the facility's services, activities, programs and benefits. The policy of the hospital is to ensure meaningful communication with LEP patients and their authorized representatives involving their medical conditions and treatment. Procedures, in part: ...when records are kept of past interactions with patients or family members, the language used to communicate with the LEP person will be included as part of the record.

Review of psychiatric hospital policy titled "Treatment Planning" last reviewed on 06/10/2023, revealed, in part: 4. The patient ...is included in treatment planning team reviews in order to: a. involve them in the decision making process; b. solicit their views/preferences; and c. develop conclusion/recommendations for care which consider their preferences. Participation must be documented ...

Review of the psychiatric hospital document titled, "Patient Rights & Responsibilities, Patient Bill of Rights", revealed in part: The right to participate in the development and implementation of his/her plan of care. Every patient...has the right to make informed decisions regarding his or her care.

Review of Patient #2's medical record revealed a document titled "Multidisciplinary Master Treatment Plan" dated 10/26/2023 at 3:37 p.m. Further review failed to reveal the language used to communicate with Patient #2. Continued review failed to reveal evidence that Patient #2 was provided a translator or interpreter during the care plan meetings in order to ensure that Patient #2 was able to fully participate in: 1) the decision making process of his treatment plan; 2) the provision of his views and preferences; and 3) the consideration of his preferences.

In an interview on 12/05/2023 at 10:45 a.m. S11RM and S9ADON confirmed the treatment plan failed to reveal the language used to communicate with Patient #2 and failed to reveal evidence that Patient #2 was provided a translator or interpreter during the care plan meetings

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

Based on observation and interview the hospital failed to ensure each patient's right to care in a safe setting. This deficient practice is evidenced by failing to ensure that enough staff were available for the safe monitoring of patients.
Findings:

Review of psychiatric hospital policy titled Nursing Staffing Plan, last reviewed on 03/31/2023, revealed, in part: Purpose: to provide adequate coverage to meet the patient care needs while maintaining safety for patients and staff. Procedure, in part: 2. Basic coverage provides resources for: b. Maintenance of routine observation, Q-15, SP1, Limited VC and Precautions. 3. Staffing Mix-Direct care staffing mix is comprised of RN/LPN/MHT. 4. Acuity factors that require adjusted staffing include: b. Precautions-SP (2.3), EP, Multiple VC and 1:1.

Review of psychiatric hospital policy titled "Level of Observation and Precaution", last reviewed 03/10/2023, revealed in part: Policy: It is the policy of the hospital to appropriately assess patients for high risk behaviors and to order and maintain special precautions to protect the welfare of the patient. Purpose, in part: To reduce the risk of patient harm to self or others as needed for patient condition, using active supervision. Active Supervision, in part: a. Maintaining the patient level of observation /precaution at all time. b. maintaining staff and patient safety through conscious and deliberate observation ...Types of Observations, in part: Visual Contact (VC)-This level of observation requires that the patient is kept within an area with unobstructed views such that staff has the ability to obtain and maintain eyesight readily and the patient is accessible at all times. Types of Precautions: 2) Elopement Precautions (EP)-to prevent possible runaway of a patient considered at risk of leaving the hospital. Procedures: 3. Visual Contact (VC)-Medically compromised or an suicide precaution, extremely confused or disoriented assaultive behaviors and constant elopement risk. E. Interventions, in part: 1. Visual Contact, in part: ii. Immediately assign a staff person to the level of observation. iii. Maintain therapeutic interaction and engage in activity. iv. Hand-off to next staff assignment (including breaks). G. Assignment: 3. VC can be maintained by one staff person who can still be responsible for multiple patients as long as the patient remains in line of sight. Failure to properly maintain assignment can result in harm to the patient, other patients and staff and may result in disciplinary action against the employee for neglect.

Review of Unit A Census dated 10/30/2023 at 6:45 p.m. through 7:15 a.m., revealed 18 patients plus 1 incoming admission and 2 visual contact precautions and 1 elopement precautions.

Review of staffing schedule of Unit A on 10/30/2023 at 6:45 p.m. through 7:15 a.m., revealed 1 Registered Nurse, and 3 Mental Health Technicians (MHT) and 1 shadowing MHT in orientation.

Review of document titled "Hospital Abuse/Neglect Initial Report" dated 11/02/2023 revealed an incident involving Patient #2 on 10/31/2023 at 1:07 a.m. The report revealed all three MHTs were involved in the incident with Patient #2 while the nurse was getting an injection.

In an interview on 12/04/2023 at 3:25 p.m., S9ADON confirmed the hospital failed to ensure that enough staff were available for the safe monitoring of patients. Based on the acquity level, Unit A should have had at least 4 MHTs, not including a shadowing MHT. S9ADON reported Unit A was short-staffed on the night of 10/30/2023 due to having to pull staff over to another unit.

PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT

Tag No.: A0145

Based on interview and record review, the hospital failed to provide an environment free from abuse/neglect and failed to implement effective interventions to prevent future occurrences of abuse/neglect. This deficient practice was evidenced by 1(#2) of 3 (#1 - #3) patient records reviewed who was the victim of physical abuse by S3MHT and verbal abuse by S1MHT and S2MHT of which the allegation was substantiated by the hospital.
Findings:

Review of the psychiatric hospital policy titled, "Abuse / Neglect of Patients/Reporting Allegations" revealed, in part, Statutory Definition of Abuse from 42CFR 51.2 (Protection & Advocacy for the Mentally Ill) definition of abuse: Abuse means any act (or failure to act) done knowingly, recklessly, or intentionally, including an act, which caused or could have caused major physical injury to an individual with mental illness, and includes but is not limited to acts such as: rape or sexual assault; striking; the use of excessive force when placing an individual with mental illness in bodily restrains; the use of excessive force when placing an individual with mental illness in bodily restraints; the use of bodily or chemical restraints which is not in compliance with Federal and State laws and regulations; verbal, nonverbal, mental and emotional harassment; and any other practice which is likely to cause immediate physical or psychological harm or result in long-term harm if such practices continue. Neglect means a negligent act or omission by an individual responsible for providing services in a facility rendering care or treatment which caused or may have caused injury or death to an individual with mental illness or which placed an individual with mental illness at risk of injury or an appropriated individual program or treatment plan ...and the failure to provide a safe environment which also includes failure to maintain adequate numbers of appropriately trained staff ...Examples of Neglect, c. Failure to provide a safe environment. IV. Duty to Report Abuse, in part: A. Timeline for notifications: Adults-Allegations will be reported to the Unit Nurse Immediately.

Review of the psychiatric hospital document titled, "Patient Rights & Responsibilities, Patient Bill of Rights", revealed in part: The right to be free from all forms of abuse and harassment. The right to receive care in a safe setting.

Review of the incident report log for October 2023 revealed, in part, on 10/31/2023 at 1:07 a.m. the type of incident as "Staff to Patient".

Review of the hospital's self-report revealed, in part, on 10/31/2023 at 1:07, Patient #2 with diagnoses psychosis and known language barrier, would not stay dressed. S1MHT, S2MHT and S3MHT began to tell the patient to go sit down when S3MHT grabbed the patient and tried to forcibly make him sit down. Patient #2 jumped up again and appeared to elbow S3MHT in the stomach area. S3MHT proceeded to put his hands around the patient's neck and put him down on the dining room chair in a supine position. S2MHT grabbed the patient's wrist and attempted to tell the patient he was not being compliant in Spanish. S3MHT let go of the patient's neck and grabbed his other wrist as well. S2MHT proceeded to tell the patient "If you want drugs just say that. You are going to be here for a while chasing drugs." And started calling the patient "El Drugo". S1MHT then stated "If S3MHT grabs you S3MHT is tired. It takes a lot for S3MHT to put his hands on yall." S3MHT stated, "I am not helping him anymore." Patient #2 tried to stand up again and S3MHT forcibly placed him in the chair again while yelling at him with his finger in the patient's face to sit down. Furthermore, the techs began having another conversation amongst themselves that the patient liked the feeling from the shots because he falls asleep while standing up, and liked being high. The patient got out of his seat and S3MHT grabbed his arm to put him back in the seat. The patient elbowed him to try to get away. S3MHT then tried to grab Patient #2 around his neck again and the patient hit him. S3MHT tried to grab Patient #2 to gain control over him but the patient fought back which caused him to rip out of his shirt and start running down the hall into his bedroom. All of the staff ran behind him into his bedroom. Witness statements state that the patient ran into the bedroom and jumped on top of his peer's bed at the headboard. The staff tried to redirect the patient for disturbing the unit but were unsuccessful so an injection was given to the patient. The conclusion revealed the allegation of physical and verbal abuse was substantiated for S3MHT and he was immediately terminated. The allegation of verbal abuse against S1MHT and S2MHT was substantiated. Both of these employees were to attend abuse and neglect retraining before being allowed to return to the floor and placed on a 90-day Performance Improvement Plan (P.I.P) to be monitored by their direct supervisor.

Review of physican orders dated 10/31/2023 at 10:00 a.m. revealed "Notify Risk Manager. Patient has scratches on neck (make incidence report).

Review of S1MHTs Employee Performance Improvement Plan dated 11/03/2023 revealed S1MHT was scheduled to attend Abuse and Neglect training on 11/06/2023.

Review of S2MHTs Employee Performance Improvement Plan 11/03/2023 revealed S2MHT was scheduled to attend Abuse and Neglect training on 11/06/2023.

Review of S2MHTs Disciplinary Action Form dated 11/02/2023 revealed that on 10/31/2023 S2MHT violated hospital Abuse/Neglect policy by failing to report abuse/neglect when the incident occurred. Due to the abundance of infractions, S2MHT would receive a disciplinary action and a 90 day PIP due to the policy violation. Future policy violations would result in further disciplinary action and up to separation of employment.

Review of staff schedule for Unit A, dated 11/02/2023 and 11/03/2023 from 6:45 p.m. through 7:15 a.m. revealed both S1MHT and S2MHT were on the schedule.

In an interview on 12/05/2023 at 10:20 a.m., S9ADON and S11RM confirmed that S1MHT and S2MHT were back working on Unit A before undergoing the retraining as per the P.I.P's. S9ADON and S11RM both stated that S1MHT and S2MHT should not have been working again until they underwent the training scheduled for 11/06/2023 in order to prevent abuse from re-occurring.

USE OF RESTRAINT OR SECLUSION

Tag No.: A0154

Based on record reviews and interview, the hospital failed to ensure patients in the psychiatric hospital were informed of their right to be free from physical or mental abuse, and corporal punishment and to be free from restraint or seclusion of any form imposed as a means of coercion, discipline, convenience, or retaliation by staff. This is evidenced by failing to have documented evidence that a translator was utilized to inform Spanish speaking Patient #2 of the reasons for the use of restraint/seclusion and to confirm his understanding before he was placed in seclusion.
Findings:

Review of the psychiatric hospital document titled, "Patient Rights & Responsibilities, Patient Bill of Rights", revealed in part: The right to be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff. You may not be placed in restraints or in seclusion except in an emergency to protect you or others from physical injury.

Review of Patient #2's medical record revealed hospital document titled "Philosophy and Practice for Seclusion and Restraint Use" dated 10/26/2023. Further review failed to reveal evidence of documentation that a translator or an interpreter was utilized to confirm Patient #2's understanding of the following: 1) the hospital philosophy regarding seclusion and restraint use; 2) the definition of seclusion and restraint and when they are used; 3) the alternatives tried before using seclusion or restraint; 4) the behaviors that will result in release from restraint; and 5) how the hospital staff can help with triggered behaviors that can lead to seclusion or restraint.

Review of Patient #2's medical record revealed a Restraint/Seclusion document dated 10/29/2023 at 2:15 p.m. Further review revealed Patient #2 was placed in locked seclusion on 10/29/2023 at 2:15 p.m. for taking of clothes and banging on nurses station doors when he was told he could not go outside because of Elopement Precautions. Noted "unable to verbally direct". Continued review failed to reveal a translator was utilized to inform Spanish speaking Patient #2 of the reasons for the use of seclusion and to confirm his understanding before he was placed in seclusion.

In an interview on 12/05/2023 at 10:45 a.m., S11RM and S9ADON confirmed that Restraint/Seclusion document failed to reveal evidence that a interpreter/translator was utilized to inform Spanish speaking Patient #2 of the reasons for the use of seclusion and to confirm his understanding before he was placed in seclusion.

In an interveiw on 12/04/2023 at 10:25 a.m., S12MHT stated if there is a language barrier then the MHT relies on the RN to obtain an individual translator or interperter to assist with communication. If the situation becomes volatile, the RN is responsible for determining how to overcome the language barrier.