HospitalInspections.org

Based on record reviews and interview, the hospital failed to ensure personnel met applicable standards required by State regulations for hospital personnel as evidenced by failure to have documented evidence of a check of the Louisiana NA/DSW Registry every 6 months after hire for 1 (S18MHT) of 1 MHT personnel file reviewed from a sample of 7 (S1DON, S3DQ, S9HIMD, S12RN, S13RN, S16CTRS, S18MHT) personnel files reviewed.
Findings:

Review of the "New Louisiana Department of Health and Hospitals Adverse Actions Web Search" revealed providers that employ CNAs and DSWs are required to check the NA/DSW registry upon hire and every 6 months thereafter.

Review of S18MHT's personnel file revealed the NA/DSW registry was checked as part of her background check on 06/11/18 after her hire date of 06/06/18. Further review revealed no documented evidence the registry was checked 6 months after she was hired.

In an interview on 01/09/19 at 10:45 a.m., S4DHR confirmed the initial NA/DSW registry check was done after S18MHT was hired. She indicated she didn't know that it needed to be checked every 6 months after hire.

Based on record review and interview, the hospital failed to ensure the members of the medical staff were accountable to the Governing Body for quality of care provided to patients as evidenced by the medical staff not documenting the assessment and pronouncement of death for 1 (#4) of 2 (#4, #5) sampled patient records reviewed for pronouncement of death by a medical staff member from a total sample of 9 patients.
Findings:

Review of the hospital's policy titled :Death of a Patient" revealed in part: The pronouncement of the patient's death, date and time of death, and the name and title of the individual pronouncing the death must be documented in the patient's medical record.

Review of Patient #4's Discharge Summary by S7MD revealed he expired on 09/19/18 at 3:40 a.m. Further review revealed the patient (nurse?) was called in by tech, reported the patient with no obvious signs of life, no pulse, no respiration. Time of death was 3:45 a.m. Staff was informed. I was informed as well.

Review of Patient #4's medical record revealed no documentation of which physician pronounced the death.

In an interview on 01/08/19 at 12:46 with S6MD, he said he could not remember if he came out to the hospital or not to pronounce Patient #4. He said death happens so seldom there must be a protocol, but he was not sure. When asked if he should come out to the hospital to pronounce the death of a patient, he said he was not sure of the protocol.

Based on record reviews and interview, the governing body failed to ensure services performed under a contract were provided in a safe and effective manner as evidenced by failure to have documented evidence of an evaluation of the services provided by contract with Company A, B, G, H, I, K, L, M, N, and O.
Findings:

Review of the "Written Evaluation of Contracted Services", presented as the most recent evaluations of contracted services by S2DCC, revealed no documented evidence that the services provided by Company A, B, G, H, I, K, L, M, N, and O had been evaluated to determine that the services were being provided in a safe and effective manner.

In an interview on 01/08/19 at 3:15 p.m., S2DCC confirmed the above-listed contracts had not been evaluated.

Based on record reviews and interview, the hospital failed to maintain a list of all contracted services, including the scope and nature of the services provided, as evidenced by failure to have all contracted services listed and failure to remove contracted services that were no longer in effect from the list.
Findings:

Review of the "Contract List", presented as the current list of hospital contracts by S2DCC, revealed Company A, B, and C were listed. Further review revealed Company D, E, and F were not included in the list of contracts.

Review of the "Written Evaluation of Contracted Services" revealed the service provided by Company D, E, and F was evaluated on 01/31/18.

In an interview on 01/08/19 at 3:15 p.m., S2DCC indicated she had given the contract list hurriedly, and that's why some of the agencies listed weren't in effect.

Review of the second list of contracts presented by S2DCC after the above interview revealed Company A, B, and C were on the list, and Company D, E, and F were not listed.

Based on record reviews, observation, and interviews, the hospital failed to ensure each patient or representative was informed in advance of furnishing or discontinuing care as evidenced by:
1) Failure to have documented evidence in each inpatient's medical record that the patient or representative was provided the standardized notice, "An Important Message from Medicare" within 2 days of admission and presented a signed copy of the message in advance of the patient's discharge, but no more than 2 calendar days before the patient's discharge for 3 (#2, #3, #6) of 3 inpatient records reviewed for the presence of the signed "An Important Message from Medicare" and for 1 (#7) of 1 closed medical record reviewed for the signed "An Important Message from Medicare" at discharge from a sample of 9 patients; and
2) Failure to follow hospital policy that required a written copy of Patient Rights be provided to all patients (or their representatives) on admission to the hospital, prior to furnishing patient care, for 3 (#2, #3, #6) of 3 patient records reviewed for patient rights from a sample of 9 patients and failure to have the Patient Rights posted in the patient treatment area. This deficient practice was evidenced by staff interview reporting that Patient Rights were not provided in writing to patients or their representatives, and observations of patient rights not posted in the patient treatment areas.
Findings:

1) Failure to have documented evidence in each inpatient's medical record that the patient or representative was provided the standardized notice, "An Important Message from Medicare" within 2 days of admission and presented a signed copy of the message in advance of the patient's discharge, but no more than 2 calendar days before the patient's discharge for 3 (#2, #3, #6) of 3 inpatient records reviewed for the presence of the signed "An Important Message from Medicare" and for 1 (#7) of 1 closed medical record reviewed for the signed "An Important Message from Medicare" at discharge from a sample of 9 patients.
Patient #2
Review of the medical record of Patients #2, #3, and #6 revealed no documented evidence that each patient was provided "An Important Message from Medicare" within 2 days of admission.

Review of Patient #7's medical record revealed he was admitted on 10/18/18 and discharged on 11/05/18. Further review revealed no documented evidence that a signed copy of the "An Important Message from Medicare" had been provided within 2 days of discharge.

Review of the "An Important Message from Medicare" forms presented by S9HIMD on 01/09/19 at 8:30 a.m. revealed the following:
Patient #2's form was signed as "Patient #2's daughter/S9HIMD" on 01/02/19 (admitted on 12/28/18).
Patient #3's form was signed as "Patient #3's daughter/S9HIMD" on 01/02/19 (admitted on 12/28/18).
Patient #6's form was signed as "Patient #6's daughter/S9HIMD" on 01/07/19 (admitted on 01/03/19).

In an interview on 01/09/19 at 8:30 a.m., S9HIMD indicated she gets the Important Message forms signed when she does the insurance verification, so it may not always be done within 2 days of admission. She further indicated she doesn't place them in the patient's medical record. She further indicated the forms for Patients #2, #3, and #6 were reviewed by telephone with the patients' daughters, but she did not provide each daughter or patient with a written notice. She indicated she signed the name of each daughter. She confirmed the forms are not signed again at discharge.

The surveyor requested the hospital's policy related to the "An Important Message from Medicare" form. As of the conclusion of the survey on 01/09/19 at 12:50 p.m., this policy was not presented.

2) Failure to follow hospital policy that required a written copy of Patient Rights be provided to all patients (or their representatives) on admission to the hospital, prior to furnishing patient care, and failure to have the Patient Rights posted in the patient treatment area:


Review of hospital policy #RTS-01 titled "Patient Rights Louisiana", provided by S2DCC as current, revealed in part the following: "Every client shall receive a written copy of the Patient Rights and sign the 'Acknowledgement of Rights' form stating they reviewed and understand their rights. If applicable, the patient's family/significant other shall also receive a copy of the Patient Rights and their responsibilities and the program rules. Procedure: Admission Staff/Nurse shall provide all patients and family(if applicable) with a written copy of the Patient Rights... Nursing Staff/Social Services Staff: If a patient is disoriented or in a state that impairs cognition at the time of entry, he/she is informed of his/her rights at an appropriate time during care, treatment, and services...Administrator shall post at least one copy of the Patient Rights in the patient treatment area..."

An observation of the hospital on 01/07/19 at 12:45 p.m. revealed a large poster in the hallway of the Patient Care Unit which included the Mental Health Patient Bill of Rights, the Grievance Process with contact information for the hospital, LDH/HSS, and Mental Health Advocate. Further observation revealed the Patient Rights were not posted on this poster or in any other area of the hospital. S1DON, present for the observation, verified the Patient's Rights were not posted in the hospital.

Review of a 42 page document titled "Oceans Behavioral Hospital DeRidder Patient Handbook", provided by S12RN as current, revealed the following contents: Mission Statement, "You are Important", Letter to Family Members, Initial Program Guidelines, Respect and Dignity, Guidelines for Personal Property, Program Outline, Patient Guidelines and Responsibilities, HIPPA Privacy Practice (HIPAA), LOPA, Rights of Mentally Ill Patients Summarized in Layman's Terms, Message for Medicare, Mental Health Advocacy, Suicide Hotline Contact Information, Patient/Family Grievance, Patient Rights, Advanced Directives, Physician Availability, and Civil Rights/Non-Discrimination.

Patient #2
Review of Patient #2's "Authorization and Informed Consent Form" revealed a statement acknowledging that he had received a copy of the Patient Handbook and "received in writing or an explanation and understand" the rights listed in Revised statute 28:171. Further review revealed the form was signed by S13RN on 12/28/18 at 8:30 p.m. and witnessed by a second staff member with a note that Patient #2's daughter/power of attorney was spoken to at the same time and date and was in agreement with the consent.

Patient #3
Review of the medical record for Patient #3 revealed a document titled "Authorization and Informed Consent Form" with boxes checked for Notice of Patient Handbook/Patient Rights "Acknowledgement and Notification of Rights", Acknowledgement of Mental Health Louisiana Revised Statute 28:183. Further review of the consent form revealed the first box checked (by hand) read "I acknowledge that I have received a copy of the Patient Handbook. I have receive in writing or an explanation/, and do understand: 1) The Rights listed in Revised Statue 28:171, 2) The availability of counsel, 3) Information about the Mental Health Advocacy Service, DHH, The Joint Commission and QIO Services, 4) The rules and regulations applicable to or concerning my conduct while a patient in the facility. This includes not bringing any contraband items (sharp objects, razors, knives, glass items, scissors, etc.) on the premises. Purses need to be stored in the nurse's station. Patients will take full responsibility for items kept in their possession, 5) All information & Acknowledgment concerning any patient of this facility is held to be confidential. There are exceptions to confidentiality that are legally mandated. Proper authority & relevant others, will be informed.
The second box checked was "Acknowledgment of Mental Health Law Revised Statute (R.S.) 28:183, and read, "I hereby acknowledge Mental Health Law R.S. 28:183 which states: Any person who knowingly makes available any dangerous instrument or weapon to any patient of any mental institution shall be fined not more than $500.00 or imprisoned not more than two (2) year(s) or both. All parties involved in providing dangerous instruments, weapons, and/or drugs to any patient will be banned from visitation and a report will be provided to Law Enforcement."
Other boxes checked included Community Agreement, Authorization to Disclosure Consent/Patient Identification Number, Authorization of Treatment Interventions (authorization for restraints and/or seclusion), Valuables, Authorization for Clergy Involvement, Consultation Consent (for providers not on staff at Oceans Behavioral Hospital at the patient's own expense,) Photograph Authorization, Transportation Consent, and authorization for Primary Physician Involvement. Review of page 2 of this authorization and consent document revealed the patient had not signed it, but the name of her daughter (power of attorney) was filled in under "Spoke to" via phone, dated and timed 12/2818 at 3:20 p.m. with two staff witnesses. Further review revealed no documentation the patient or her power of attorney refused or declined the written Handbook, or any patient rights.

Patient #6
Review of Patient #6's "Authorization and Informed Consent Form" revealed a statement acknowledging that he had received a copy of the Patient Handbook and "received in writing or an explanation and understand" the rights listed in Revised statute 28:171. Further review revealed the form was signed and witnessed by two staff members on 01/03/19 at 8:35 p.m. with a note that Patient #6's sister was spoken to at the same time and date and was in agreement with the consent.

In an interview in the nursing station on 01/08/19 at 1:20 p.m., S12RN reported that the nurses admit the patients and go over information which included patient rights, advances directives, rules for patients on the unit, and other information found in the patient handbook. She reported the nurses would have them(the patients) sign the consent form (with check boxes for items covered), if they were cognitively able to understand. She advised that there was a copy of the Patient Handbook in the nurses' station if they asked to see it. She confirmed that patients were not provided with the Patient Handbook unless they asked for it. S12RN reported they only had that one copy, but could print another copy. She reported if the patient was not cognitively able to understand or sign the consents and acknowledgements, the nurse would call the patient's power of attorney or representative and get the consents over the phone, with a 2nd witness. S14WC, present for the interview, reported they would speak to the patient's power of attorney/representative and go over forms with them, but did not email or mail the representative (giving phone consent) any written documents related to Patient Rights, notifications, Advances Directives, The Medicare Important Notice (if they had Medicare) or any other written/printed information. S14WC reported they did not provide a copy of the Patient Handbook to them (representatives giving phone consent for treatment). S13RN, also present for the interview, confirmed the information provided by S12RN and S14WC.

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30420

Based on record reviews and interview, the hospital failed to ensure its grievance process was implemented as evidenced by failure to identify complaints as grievances and to conduct a thorough investigation in accordance with hospital policy for 5 (R1, R2, R3, R4, R5) of 6 patient complaints/grievances reviewed.
Findings:

Review of the Hospital Policy #RTS-05 titled "Grievance Procedure Patient and Family Louisiana", provided by
S2DCC as current, revealed in part that the complaint resolution process responsibility was designated, by the Governing Body, to the hospital Administrator. Further review revealed a COMPLAINT was defined as an expression of the the standard of service, actions or lack of action by staff or regarding the facility and is resolved by staff at the time the complaint is made requiring no further resolution. A GRIEVANCE was defined as an allegation, however made, of a violation of a patient's rights, quality of care, premature discharge, and/or a complaint that is not resolved at the time the complaint is made and requires further action for resolution. Under " Time Frames for Review/Investigation, the policy stated the "Administrator:* logs the grievance allegation onto the "Complaint/Grievance Log" and contact the patient and/or family and opens an investigation to determine validity of the grievance allegation within 48 hours of notification or receipt of the grievance allegation. *Complete the investigation and the "Grievance Report" within 10 days of the date of notification or receipt of the grievance allegation." Under Provision of a Response, "Administrator:* Issue a written determination. A copy of the "Grievance Report" containing the name of the hospital contact person, step taken on behalf of the patient to investigate the grievance allegation, the results of the grievance process, the resolution of the grievance, and the date of completion is sent to the grievant on the 10th day following notification or receipt of the grievance allegation. Further review revealed the Administrator would maintain the "Complaint/Grievance Log", along with files and records of the facility of all resolved complaints and grievance investigations.

Review of copies of the hospital Grievance Log, provided by S2DCC revealed, in part, the following:
March 2018 Log:
Patient: R1, Date (of complaint/grievance): 03/23/18 Nature: Missing clothes complaint , Complaint resolution: "Bought replacement step son picked up from S22LPN, Date of pt/family contact & start of investigation: none documented, Date investigation complete: none documented, Mail Date of Grievance report/letter to pt/family: none documented. A hand written note across the last 3 entry boxes read, "son verbalized he was satisfied." Review of documentation related to this grievance (noted as a complaint) revealed an "Inventory of Patient Possessions" from the patient's medical record dated 03/09/18 which included itemized clothing articles, a suitcase, two pocket knives, a leather wallet, and a specified amount of cash. It was signed by a staff member, but not the patient or a representative. The patient signature line was blank (for acknowledgement reading, " Discharge: All of the above items have been returned to me." The staff signature was signed and dated 03/20/18 by two staff members. On the back of this patient possession inventory were handwritten notes as follows, "(2) wrangler jeans 32/34, (1) LS Shirt size 16 Blue, (1) Hooded sweat shirt zip up color doesn't matter Large.
03/23/18 12:45 p.m. Spoke with patients son (name) The patient's son agreed to give us 1 week- 03/30/18 to find the items. If the items are not found they will be replaced. This was signed by a previous Quality Director.
No other documentation was provided. No grievance resolution letter was provided.

April 2018 Log:
Patient: R2, Date (received): none documented. Nature of Complaint: none documented: none documented. Complaint resolution: none documented Date of Patient/Family Contact and Start of Investigation: none documented Date Investigation Complete: none documented Mail Date of Copy of Grievance Report/Letter to Patient/Family: "N/A". No documentation related to this complaint/grievance. S2DCC, present for the review confirmed there was no information available to determine what this complaint was about, when it occurred, what, if any, investigation was done, if it was substantiated or not, or if a resolution letter should have been sent.
Patient R3, Date (received): 04/21/18. Nature of Complaint: "treatment" Complaint resolution: "resolved" Date of Patient/Family Contact and Start of Investigation: none documented Date Investigation Complete: none documented. Mail Date of Copy of Grievance Report/Letter to Patient/Family: N/A. S2DCC, present during the review, verified their was no documentation related to this complaint/grievance, if it was a complaint or grievance, if there was an investigation, what a resolution may have been, if required time lines were met, and if a resolution letter should have been provided.

October 2018 Log:
Pt R4: Date (received): 10/22/18, Nature of Complaint: "Complaint" Complaint resolution: "Complaint resolved". Date of Patient/Family Contact and Start of Investigation: 10/22/18. Date Investigation Complete: 10/22/18. Mail Date of Copy of Grievance Report/Letter to Patient/Family: "N/A" Review of documentation related to this patient complaint revealed the "complaint" was documented on a Multi-Disciplinary Note dated 10/22/18 at 9:00 a.m. by nursing regarding "Patient Complaint' that revealed, "Spoke with patient in a one to one session in patient's room about the events earlier that morning when patient was assisted with getting up by staff. The patient was concerned because the staff was in a hurry and rude when getting her up and assisting her with getting dressed. The patient stated she was moved quickly when rolled side to side while the MHT was performing incontinence care. She also stated that the MHT tossed the clothing to her that she was going to wear for the day. The patient verbalized that she understood they were busy and had many tasks to perform that morning, but the staff still needed to calm down and slow down when assisting her. She also felt that it was rude to have her clothing tossed to her. The patient was given time (continued on next page)" No continued page was included, and no signature was noted on this page. The documentation included individual statements from 3 MHTs that described the patient's behavior and verbiage, but did not speak to the allegations of staff rudeness or their care provided. A nursing note (10/02/18) documented the patient , while in the day room wanted to speak to the nurse regarding MHT staff being rude and "ugly" to her last night. The patient told the nurse she was "humiliated as staff came into her room with masks and gowns on (for infectious patient). Then she states that she asked for techs to turn the heat on but they refused....the techs threw her dress in her face and demanded she put it on without help...this incident was reported to Director of Nursing.."
In an interview after a review of the grievance documentation, S2DCC confirmed not all of the patient's allegations were addressed in the investigation, and this, by definition, should have been handled as a grievance with a resolution letter.

November 2018 Log:
Pt. R5: Date (received): 11/02/18. Nature of Complaint: "PC" (patient care) Complaint resolution: "complaint resolved". Date of Patient/Family Contact and Start of Investigation: 11/02/18 Date Investigation Complete: 11/02/18. Mail Date of Copy of Grievance Report/Letter to Patient/Family: "N/A"

In an interview on 01/09/19 at 10:30 a.m., after the complaint logs were reviewed, S2DCC verified there was no documentation regarding this complaint (or grievance) to determine if it was a complaint or grievance, an investigation, findings, a resolution, or if a resolution letter should have been provided to the patient. S2DCC verified the administrator was not available for further interview. S2DCC verified no one was able to identify the author's handwriting of the Complainant and Grievance Log, but that someone had said that they may have been recopied for the purpose of a recent survey by an accreditation agency. S2DCC confirmed the hospital's complaint and grievance process had not been followed.

Based on record reviews and interview, the hospital failed to ensure its grievance process was implemented as evidenced by failure to identify complaints as grievances, and provide a written notice of its decision that contained 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, in accordance with hospital policy for 5 (R1, R2, R3, R4, R5) of 6 patient complaints/grievances reviewed.
Findings:


Review of the Hospital Policy #RTS-05 titled "Grievance Procedure Patient and Family Louisiana", provided by
S2DCC as current, revealed in part that the complaint resolution process responsibility was designated, by the Governing Body, to the hospital Administrator. Further review revealed a COMPLAINT was defined as an expression of the the standard of service, actions or lack of action by staff or regarding the facility and is resolved by staff at the time the complaint is made requiring no further resolution. A GRIEVANCE was defined as a allegation, however made, of a violation of a patient's rights, quality of care, premature discharge, and/or a complaint that is not resolved at the time of the complaint is made and requires further action for resolution. Under Provision of a Response, "Administrator:* Issue a written determination. A copy of the "Grievance Report" containing the name of the hospital contact person, step taken on behalf of the patient to investigate the grievance allegation, the results of the grievance process, the resolution of the grievance, and the date of completion is sent to the grievant on the 10th day following notification or receipt of the grievance allegation. Further review revealed the Administrator would maintain the "Complaint/Grievance Log", along with files and records of the facility of all resolved complaints and grievance investigations.

Review of copies of the hospital Grievance Log revealed, in part, the following:
March 2018 Log:
Patient: R1, Date (of complaint/grievance): 03/23/18 Nature: Missing clothes complaint , Complaint resolution: "Bought replacement step son picked up from S22LPN, Date of pt/family contact & start of investigation: none documented, Date investigation complete: none documented, Mail Date of Grievance report/letter to pt/family: none documented.
A hand written note across the last 3 entry boxes read, "son verbalized he was satisfied." Review of documentation related to this grievance (noted as a complaint) revealed a "Inventory of Patient Possessions" from the patient's medical record dated 03/09/18 which included itemized clothing articles, a suitcase, to pocket knives, a leather wallet and a specified amount of cash. It was signed by a staff member, but not the patient or a representative. The patient signature line was blank (for acknowledgement reading, " Discharge: All of the above items have been returned to me." . The staff signature was signed and dated 03/20/18 by two staff members (patient's date of discharge). On the back of this patient possession inventory were handwritten notes as follows, " (2) wrangler jeans 32/34, (1) LS Shirt size 16 Blue, (1) Hooded sweat shirt zip up color doesn't matter Large.
03/23/18 12:45 p.m. Spoke with patients son (name) The patient's son agreed to give us 1 week, 03/30/18, to find the items. If the items are not found they will be replaced. This was signed by a previous Quality Director.
No other documentation was provided. No grievance resolution letter was provided.

October 2018 Log:
Pt R4: Date (received): 10/22/18, Nature of Complaint: "Complaint" Complaint resolution: "Complaint resolved". Date of Patient/Family Contact and Start of Investigation: 10/22/18. Date Investigation Complete: 10/22/18. Mail Date of Copy of Grievance Report/Letter to Patient/Family: "N/A" Review of documentation related to this patient complaint revealed the "complaint" was documented on a Multi-Disciplinary Note dated 10/22/18 at 9:00 a.m. by nursing regarding "Patient Complaint' revealed, "Spoke with patient in a one to one session in patient's room about the events earlier that morning when patient was assisted with getting up by staff. The patient was concerned because the staff was in a hurry and rude when getting her up and assisting her with getting dressed. The patient stated she was moved quickly when rolled side to side while the MHT staff was performing incontinence care. She also stated that the MHT tossed the clothing to her that she was going to wear for the day. The patient verbalized that she understood they were busy and had many tasks to perform that morning but he staff still needed to calm down and slow down when assisting her. She also felt that it was rude to have her clothing tossed to her. The patient was given time (continued on next page)" No continued page was included, and no signature was noted on this page. The documentation included individual statements from 3 MHTs that described the patient's behavior and verbiage, but did not speak to the allegations of staff rudeness or their care provided. A nursing note (10/02/18) documented the patient , while in the day room wanted to speak to the nurse regarding MHT staff being rude and "ugly" to her last night. The patient told the nurse she was "humiliated as staff came into her room with masks and downs on (for infectious patient). Then she states that she asked for techs to turn the heat on but the refused....the techs threw her dress in her face and demanded she put it on without help...this incident was reported to Director of Nursing.."
In an interview on 01/09/19 at 10:30 a.m. after a review of the grievance documentation, S2DCC confirmed not all of the patient's allegations were addressed in the investigation, and this, by definition, should have been handled as a grievance with a resolution letter.

April 2018 Log:
Patient: R2, Date (received): none documented. Nature of Complaint: none documented: none documented. Complaint resolution: none documented Date of Patient/Family Contact and Start of Investigation: none documented Date Investigation Complete: none documented Mail Date of Copy of Grievance Report/Letter to Patient/Family: "N/A".- No documentation related to this complaint/grievance. S2DCC, present for the review confirmed there was not information available to determine if this was a complaint or grievance, what this complaint was about, when it occurred, what, if any, investigation was done, if it was substantiated or not, or if a resolution letter should have been sent.
Patient R3, Date (received): 04/21/18. Nature of Complaint: "treatment" Complaint resolution: "resolved" Date of Patient/Family Contact and Start of Investigation: none documented Date Investigation Complete: none documented Mail Date of Copy of Grievance Report/Letter to Patient/Family: N/A. S2DCC, present during the review, verified their was no documentation related to this complaint/grievance, if it was a complaint or grievance, if there was an investigation, what a resolution may have been, if required time lines were met, and if a resolution letter should have been provided.

November 2018 Log:
Pt. R5: Date (received): 11/02/18. Nature of Complaint: "PC" (patient care) Complaint resolution: "complaint resolved". Date of Patient/Family Contact and Start of Investigation: 11/02/18 Date Investigation Complete: 11/02/18. Mail Date of Copy of Grievance Report/Letter to Patient/Family: "N/A" No documentation related to this complaint/grievance was provided to determine if this was a complaint or a grievance, the investigation, resolution, or if a written notification should have been sent to the complainant.

In an interview 01/09/19 at 10:30 a.m., after the complaint logs were reviewed, S2DCC verified there was no documentation regarding complaints (or grievances) for Patients R3, R4, or R5 to determine if it was a complaint or grievance, an investigation, findings, a resolution, or if a resolution letter should have been provided to the patient. S2DCC confirmed logged complaints for Patients R1 and R4 should ,by definition have been documented and treated as grievances and a written letter provided to the complainants. S2DCC verified the administrator was not available for further interview. S2DCC confirmed the hospital's complaint and grievance process had not been followed and written notification provided as per the hospital policy and procedure.

30420

Based on record reviews, observation, and interviews, the hospital failed to ensure the patient or his/her representative had the right to make informed decisions regarding his/her care as evidenced by failing to have documented evidence of a discussion with a patient, his/her primary care physician, and/or his/her family regarding the DNR order and the decision to have the DNR order written in accordance with hospital policy for 3 (#2, #3, #8) of 4 (#2, #3, #6, #8) patient records reviewed with an order for DNR or documented patient/power of attorney request for a DNR from a sample of 9 patients.
Findings:

Review of hospital policy #RTS-03, titled, "Advance Directives/Psychiatric Advance Directives", provided by S1DON as current, revealed in part, "orders to resuscitate are standing orders at this facility UNLESS there is is a collaborative decision made by the physician, patient or Power of Attorney(POA), and/or family followed by documentation in the record of the decision and a written order signed by the physician to the contrary based on patient's advised directives (refer to 'Do Not Resuscitate-DNR' policy and procedures)... Procedure..Admit nurse notifies attending physician of any Advance Directives/Psychiatric Advance Directive executed by the patient. Attending Physician: discusses with patient and patient representative, any Advance Directives executed.., All Employees: Upon becoming aware that patient has executed or revoked an Advance Directive, shall immediately notify attending physician. Employee should not be involved as witnessing an executed advanced directive."

Review of the policy titled "Do Not resuscitate - Louisiana", presented as a current policy by S9HIMD, revealed the physician discusses the DNR request with patient/Personal Healthcare Representative and/or family as indicated or as desired by the patient. If the DNR is determined to be appropriate, the physician will document the discussion and decision in the record and write a DNR order. A verbal order cannot be accepted.

Patient #2
Review of Patient #2's medical record revealed he was admitted on 12/28/18 with a diagnosis of Dementia with behavioral disturbance. Review of his physician orders revealed an order on 01/03/19 at 10:00 a.m. by S6MD written as "DNR per daughter (daughter's first name). Further review of his medical record revealed a DNR order signed by a physician for a Texas facility. Further review revealed a CPR Consent that revealed no CPR, no respirator/ventilator, and no feeding tube administration that was signed on 12/19/18 (prior to Patient #2's admission to the hospital) by a daughter with a different first name as that written in S6MD's DNR order.

Review of the entire medical record revealed no documented evidence of a discussion by S6MD with the daughter named in the order explaining what DNR means and agreement by the daughter for the DNR order for her father.

Patient #3
Review of the medical record for Patient #3 revealed she was admitted 12/28/18 as an inpatient and had legal documents for her family member as her POA. Further review revealed a copy of a document titled, "OUT OF HOSPITAL DO-NOT-Resuscitate (PPJ-DNR)Order" from the state from which the patient resided (different from this facility in Louisiana ) for Patient #3 which instructed under Section C, no cardiopulmonary resuscitation (CPR), defibrillation, advanced airway management, or artificial ventilation was to be were to be initiated and was signed by Patient #3's POA and dated 12/03/18, and signed by the patient's attending physician. Further review revealed a document titled, "Oceans Behavioral Hospital ADVANCE DIRECTIVE ACKNOWLEDGMENT" that documented, by check marks in the designated boxes, the patient was an organ donor, had executed a DNR previously, and requested the MD to evaluate and implement an Advance Directive. Also checked were boxes by the following: "I HAVE NOT executed an Advance Directive.", and "I HAVE NOT executed a Psychiatric Advance Directive." The form had the name of the patient's POA and relationship entered into the line for whom was spoken, witnessed as documented by two staff members, and dated 12/28/18 at 3:20 p.m. Review of the physician's orders revealed no order for a DNR status, or any documentation of a discussion with the patient and/or her POA.

Review of physician's orders for Patient #3, as of 01/09/18 at 8:00 a.m., revealed no physician's orders for DNR, or documentation of a physician's evaluation or discussion with the patient or her POA regarding her resuscitation status, and previously documented DNR request.

An observation 01/09/18 at 8:30 a.m. revealed the patient information board in the nursing station had documentation by Patient #3's name denoting "needs DNR orders". In an interview at the time of the observation, S12RN verified that the note of a need for DNR orders had just been added to the patient information board, and it was to remind them to have the physician write DNR orders.

Patient #8
Review of Patient #8's medical record revealed he was admitted on 12/26/18 with a diagnosis of Psychosis. Review of his "Advance Directive Acknowledgement" signed and witnessed by 2 staff members on 12/26/18 at 7:00 p.m. revealed by phone that Patient #8's daughter indicated he had executed a DNR previously. Further review revealed an order by S6MD on 01/09/19 at 12:00 p.m. (written after an interview regarding DNR was conducted on 01/08/18 at 12:40 p.m.) for "DNR per daughter (first name of daughter)."

Review of the entire medical record revealed no documented evidence of a discussion by S6MD with the daughter named in the order explaining what DNR means and agreement by the daughter for the DNR order for her father.

In an interview on 01/08/19 at 12:40 p.m., S6MD indicated someone got Patient #2's daughter on the phone for him, and he asked if she wanted to make her father a DNR, and she said yes. He indicated he didn't remember if he went into what DNR meant, but normally "these people have them & I don't always go into that if the family member doesn't have questions." He indicated even if he has to explain, he typically wouldn't put anything more in the chart than what is there, meaning the order for Patients #2 and #8.

Based on record reviews and interview, the hospital failed to ensure its QAPI program included measurement, analysis, and tracking of quality indicators and other aspects of performance to assess processes of care and hospital services and operations as evidenced by failure to have quality indicators developed, measured, analyzed, and tracked for the contracted services of radiology, linen services, ambulance services, pharmacy, medical record storage, biomedical services, and housekeeping services.
Findings:

Review of the policy titled "Quality Assessment And Performance Improvement Plan", presented as the current policy by S3DQ, revealed the QAPI plan strived to provide for a facility-wide program that ensures the facility designs processes well and systematically measures, assesses, analyzes, and improves its performance to achieve optimal patient health outcomes in a collaborative and interdisciplinary approach. The hospital ensures the process is organization-wide, monitors, assesses, and evaluates the quality and appropriateness of patient care and clinical performance to identify changes that will lead to improved performance and risk of sentinel events.

Review of the "Quality Compass", provided as the current quality indicators by S21CDQ, revealed no documented evidence that quality indicators had been developed and were being measured, analyzed, and tracked for the above-listed contracted services.

In a telephone conference with S21CDQ with S3DQ in attendance, S21CDQ confirmed quality indicators had not been developed and were not being measured, analyzed, and tracked for the contracted services of radiology, linen services, ambulance services, pharmacy, medical record storage, biomedical services, and housekeeping services.

Based on record reviews and interviews, the hospital failed to ensure it had an ongoing performance improvement project as evidenced by presenting no documented evidence that a distinct improvement project had been selected with the reasons for conducting the project and measurable progress achieved thus far on the project since the last project was completed.
Findings:

Review of the policy titled "Quality Assessment And Performance Improvement Plan", presented as the current policy by S3DQ, revealed the QAPI program conducts annual performance improvement projects, the number and scope of which are proportional to the range and complexity of the facility's services and operations. There was no documented evidence that the policy addressed how many improvement projects were expected to be done annually.

Review of the Governing Body By-laws, presented as the current by-laws by S2DCC, revealed no documented evidence that governing body had determined how many improvement projects were expected to be done annually.

No documented evidence was presented by the hospital as of the time of exit on 01/09/19 at 12:50 p.m. of an ongoing improvement project that included the reasons for conducting the project and any measurable progress achieved thus far.

In a telephone interview on 01/09/19 at 9:00 a.m. with S21CDQ with S3DQ in attendance, S21CDQ indicated S1DON would have documentation of the quality improvement project selected for 2019.

In an interview on 01/09/19 at 10:20 a.m. with S1DON and S3DQ in attendance, S1DON indicated he did not have a quality improvement project developed for 2019 yet.

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the care of each patient. This deficient practice is evidenced by:
1) The RN completing sections of a pre-printed admission order based on information received from the referring hospital instead of obtaining all of the orders from the admitting physician for 1 (#3) of 1 patient reviewed for admission order completion from a sample of 9 patients.
2) Failing to ensure the RN assessed a patient upon the patient's return from an emergency visit for evaluation after a fall as evidenced by failure to have documented evidence that a RN assessed the VS and neuro status of Patient #2 upon his return from the emergency department for 1 (#2) of 1 patient record reviewed for assessment after a fall from a sample of 9 patients.
3) Failing to ensure the RN implemented physician orders for labs, EKGs, and CT scans as evidenced by failing to schedule/obtain ordered labs, EKGs, and CT scans when ordered for 3 (#2, #3, #6) of 3 patient records reviewed for implementation of physician orders from a sample of 9 patients.
4) Failing to ensure the RN included the patient's special precautions and observation level on the MHT observation records as evidenced by failing to have documented evidence that Patient #2 was on violence and choking precautions and was to be observed 1:1 for 1 (#2) of 3 (#2, #3, #6) patient records reviewed for completion and documentation of the MHT observation record from a sample of 9 patients.
Findings:

1) The RN completing sections of a pre-printed admission order based on information received from the referring hospital instead of obtaining all of the orders from the admitting physician:
Review of the "Medical Staff Rules and Regulations", presented as the current rules and regulations by S2DCC, revealed patients may be admitted and discharged only on an order of a credentialed and privileged licensed independent practitioner. Further review revealed all orders for treatment must be in writing. An order will be considered to be in writing if it is dictated to authorized personnel. Orders dictated by telephone shall be signed by the person to whom the order was dictated with the name of the ordering medical staff member and then signed by the person to whom it was dictated.

Review of the pre-printed form titled Admit Orders/Initial Plan of Care, admit orders completed for all patients admitted to the hospital, revealed the following items were included: height; weight; allergies; admit to the care of ___ (physician's name); patient's social security number; AIMS (abnormal involuntary movement scale) Test upon initiation of antipsychotic and weekly thereafter; legal status; admitting diagnosis; vital signs; weight on admit then 3 times weekly; diet; dietary consult; precautions (choice of suicide, elopement, seizure, assault, falls, infection control/wound, bleeding, choking); observation level (choice of close observation every 15 minutes, one-to-one observation, routine on admit, other); therapeutic recreation to assess/evaluate and implement recreational groups per patient assessment; activity; social services for psychosocial assessment/individual therapy and group psychotherapy as needed; education groups per schedule; medical consult for physical examination/for any medical conditions; lab and diagnostics (choice of 29 blanks/labs/tests to check); levels of medications to test; medications upon admit reconciled with physician on Admission Medication Reconciliation Order; initial treatment plan problems; space for nurse receiving orders with read back verification of order to sign; date/time; space for physician signature, date, and time.

Review of Patient #3's medical record revealed the selections on the pre-printed order sheet included the following:
Vital signs: every shift
Weights: Every Tuesday
Diet: Special Diet, No added Sodium
Dietary Consult: Not selected
Precautions: Elopement, Assault
Medication Levels: None selected
Initial Treatment Plan Problem: Alteration in mood
Observation Level: Every 15 minutes
Activity: As tolerated

In an interview on 01/08/19 at 4:10 p.m. with S12RN, she indicated she had completed Patient #3's admission order form. She said she did not have to go over every order on the sheet with the doctor. S12RN said some of the selections were made by her based on what she knew the doctor wanted, and some of them were selected from the paperwork the patients were admitted with. S12RN said she did not have to discuss with the physician when obtaining a verbal order the following items: vital sign frequency, frequency of weights, diet, dietary consult, precautions (suicide, elopement, seizure, assault, falls, IC wounds, bleeding, choking), drug levels, treatment plan, observation levels, and activity levels. She verified she wrote the orders as a read back verbal order from S8MD, although she did not go over every order with him. S12RN said that was how all admissions were done by everybody.

In an interview on 01/09/18 at 10:18 a.m. with S7MD, he said he had complained about RNs not completely going over all orders with him to S1DON a couple of months ago. S7MD said there were a couple of nurses that would assume certain things that he would order. S7MD said it is a must that the nurses go over all of the orders with him.

2) Failing to ensure the RN assessed a patient upon the patient's return from an emergency visit for evaluation after a fall:
Review of Patient #2's medical record revealed an order on 12/30/18 at 3:05 p.m. to send him to Hospital A's emergency room to evaluate and treat status/post fall with head injury received by S13RN from S6MD.

Review of the "Multi-Disciplinary Note" documented by S11RN on 12/30/18 at 9:15 p.m. revealed Patient #2 returned from the hospital following a CT of the head that showed no significant finding, had a laceration to the back of the head which was bandaged with a hematoma noted. Further review revealed Patient #2 was administered Tylenol 650 mg orally for pain. There was no documented evidence that Patient #2's VS and neurological status was assessed by S11RN.

Review of Patient #2's "Daily Nurse Note" documented by S11RN on 12/20/18 at 7:00 p.m. (documented while Patient #2 was at Hospital A) revealed Patient #2 was very difficult to follow directions and was very defensive when interacting with others. Further review revealed neurological status was documented as "other: fall / hit head." There was no documented evidence that Patient #2's VS and neurological status was assessed by S11RN upon his return from Hospital A.

In an interview on 01/08/19 at 8:10 a.m., S1DON confirmed S11RN didn't document an assessment that included VS and neuro assessment upon Patient #2's return from the ED, and this should have been done.

3) Failing to ensure the RN implemented physician orders for labs, EKGs, and CT scans:
Patient #2
Review of Patient #2's "Admit Orders/Initial Plan of Care" received by verbal order from S8MD by S13RN on 12/28/18 at 9:30 p.m. (Friday) revealed the following orders: CBC on admit and Q Monday and Friday; UA with C&S after antibiotic therapy; CMP; TSH; LFT on admit and Q Monday and Friday.

Review of Patient #2's physician orders revealed an order by S6MD on 12/29/18 at 10:00 a.m. for a CT brain scan without contrast secondary to a fall. The order was noted by S12RN on 12/29/18 at 10:20 a.m.

Review of Patient #2's lab reports revealed the CBC, CMP, TSH, and LFT were drawn on 01/02/19 (Wednesday). There was no documented evidence that labs were collected as ordered on admit and on Monday (12/31/18).

Review of Patient #2's medical record revealed his CT of the brain was done on 12/30/18.

In an interview on 01/08/19 at 8:10 a.m., S1DON indicated the admit labs were done on 01/02/18. He indicated they contract with Hospital A, and they typically come Monday through Friday, and on holidays they don't come for routine labs (would come for stat labs). He confirmed there was no clarification order documented by the RN from S8MD and S6MD regarding changing the dates for the ordered labs or for not having the CT scheduled when the order was received. He confirmed the brain scan was not done until the next day (12/30/18) after it was ordered. S1DON confirmed the labs ordered at admit were not done until 01/02/19, 5 days after admit, and there was no lab drawn on 12/31/19 as ordered (Monday) .

In an interview on 01/08/19 at 9:00 a.m., S12RN indicated Patient #2 had a fall prior to admit at the nursing home and had swelling on the head. She indicated after the order was written, the ward clerk schedules the CT scan with Hospital A. She further indicated if the CT scan is not ordered as "now", they try to get it scheduled as soon as possible.

In an interview on 01/08/19 at 9:30 a.m., S14WC indicated when the CT scan was ordered on a Saturday (12/29/19), there's no ward clerk staffed. Since the patient fell on Sunday (12/30/19), the nurse requested it be done when the patient was sent to the ED for evaluation of the fall that occurred on 12/30/19. S14WC indicated had it not been done when Patient #2 went to the ED on 12/30/18, she would have scheduled it on Monday when she returned to work. She further indicated if the order was stat, the RN would call for the CT and send the patient over.

In an interview on 01/08/19 at 12:40 p.m., when told of the above procedure for scheduling CT scans (per interview with S14WC), S6MD indicated he "would have assumed the RN would have got it scheduled on Saturday, and if that's not the way it's done, it's what we should be doing."

Patient #3
Review of Patient #3's medical record 1/7/19 revealed she was admitted 12/28/18 at 1:30 p.m. Further review revealed her admission orders included an order for an RPR blood test and and EKG. Further review 1/7/19 at 3:00 p.m. revealed no documentation of a blood draw for an RPR or that an EKG had been performed. No results of either test were found in the patient's record, and a request to S1DON was made for location of the test results.

Review of an EKG for Patient #3, provided 1/8/19 at 12:45 p.m. by S1DON, revealed the EKG had been performed 1/8/19 at 12:15 p.m., 11 days after it was ordered. Review of a clinical laboratory request for Patient #3 revealed an RPR had been collected 1/9/19 at 7:20 a.m., 12 days after it was ordered.

In an interview 1/8/19 at 12:45 p.m. S1DON verified the EKG for Patient #3 was not performed until the day after surveyors asked him to locate the results for her ordered EKG, 11 days after ordered as part of her admission orders. The DON also verified the RPR ordered on Patient #3's admission was not drawn and sent to the lab until 1/9/19, 12 days after her admission and after results were requested by surveyors. S1DON verified these ordered test should have been done when the patient was admitted. S1DON, when asked if the hospital had a process for ensuring provider orders for tests and treatments were initiated or implemented, reported that the nurses did "chart checks" at night, which should have identified the omitted orders. S1DON agreed that the current process had not been effective in ensuring the Patient's ordered tests were performed.

Patient #6
Review of Patient #6's "Admit Orders/Initial Plan of Care" received by verbal order from S7MD on 01/03/19 revealed an order for an EKG.

Review of Patient #6's physician's orders revealed an order on 01/05/19 at 5:25 p.m. to obtain a head CT without contrast if not done recently. There was no documented evidence of the timeframe related to "recently."

Review of Patient #6's medical record on 01/08/19 at 10:30 a.m. revealed no documented evidence that the EKG had been done as evidenced by having no documented evidence of a copy of the EKG in the medical record.

In an interview on 01/08/19 at 12:35 p.m., S1DON indicated the EKG ordered on 01/03/19 at admit for Patient #6 wasn't done until today (01/08/19). He confirmed there was no documentation in the record of the reason why it wasn't done when ordered.

In an interview on 01/08/19 at 1:25 p.m., S12RN indicated if a CT wasn't done within 3 months of the order, she would get another one (related to Patient #6). She confirmed his CT on the record was done in May 2018, and there was no clarification order whether to obtain another scan.

In an interview 1/9/19 at 10:18 a.m. S7MD, Medical Director reported he was not aware that labs and diagnostics, ordered on admission, were not being done in a timely manner. He advised that was a problem if the orders were not being implemented when ordered.

4) Failing to ensure the RN included the patient's special precautions and observation level on the MHT observation records:
Review of Patient #2's "Admit Orders/Initial Plan of Care" received by verbal order from S8MD by S13RN on 12/28/18 at 9:30 p.m. revealed an order for assault, falls, and choking precautions and close observation Q 15 minutes.

Review of Patient #2's physician orders revealed an order on 12/31/18 at 9:15 a.m. received by verbal order from S7MD to place him on 1:1 observation for safety.

Review of Patient #2's "Observation Check Sheet/Graphic/Flowsheet" from admit on 12/28/18 through 01/06/19 revealed the choice of violence/homicide and choking precautions was not checked as ordered by the physician. Further review revealed no documented evidence on 12/31/18 that Patient #2 was changed to 1:1 observation. Further rev review revealed his observation level was documented as Q 15 minutes rather than 1:1 on 01/01/19, 01/02/19, 01/04/19, and 01/05/19.

In an interview on 01/08/19 at 8:10 a.m., S1DON indicated the charge nurse prepares the MHT observation records. He confirmed the MHT records for Patient #2 were not completed with proper observation level and all precautions that were ordered.

In an interview on 01/09/19 at 8:52 a.m., S10MHT indicated she has to refer to the precautions listed on the patient's observation sheet or ask the charge nurse to know what precautions the patients she was assigned to observe were on. She further indicated she wouldn't know the patient was on a certain precaution unless it was listed on the observation sheet.




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30420

Based on record reviews and interview, the hospital failed to ensure it had an agreement or contract with the acute care hospital to provide radiological services that could not be provided onsite as evidenced by failure to have a contract with a hospital to provide CT services ordered for 1 (##2) of 1 patient record reviewed with physician orders for a CT from a sample of 9 patients.
Findings:

Review of the contracts presented by S2DCC revealed no documented evidence that a contract had been obtained for Hospital A to perform radiological services that could not be performed onsite.

Review of Patient #2's medical record revealed a physician's order on 12/29/18 at 10:00 a.m. from S6MD to obtain a CT of the brain without contrast secondary to a fall. Further review revealed the CT of the brain was performed on 12/30/18 at Hospital A.

In an interview on 01/08/19 at 2:25 p.m., S2DCC indicated the hospital didn't have a contract with Hospital A to provide radiological services, such as a CT.

Based on record review and staff interview, the hospital failed to ensure there was a Radiologist appointed by the Governing Body to supervise the Radiology Services on either a full-time, part-time, or consulting basis as evidenced by having no documentation indicating the hospital had a Director of Radiology for the hospital.
Findings:

Review of a list of privileged physicians practicing at the hospital revealed no physician had been appointed as the medical director of Radiologic Services.

Review of governing body meeting minutes revealed no physician had been appointed as the medical director of Radiologic Services.

In an interview on 01/08/19 at 12:15 p.m. with S2DCC, she verified there had been no physician appointed as the director of Radiologic Services.

Based on record review and interview, the hospital failed to ensure the Utilization Review committee consisted of at least two doctors of medicine or osteopathy who do not have a direct financial interest in the hospital or was professionally involved in the care of the patient whose case was being reviewed. The hospital did not have two such physicians designated as physicians on the Utilization Review committee.
Findings:

Review of the UR Committee meeting minutes for 2018 revealed two physicians were listed as participating on the committee. The two physicians were S6MD and S7MD.

Review of a list of credentialed physicians at the hospital revealed S7MD was the psychiatrist and S6MD was a medical doctor.

In an interview on 01/08/19 at 2:00 p.m. with S2DCC, she verified there was not a physician on the UR committee who was not professionally involved in the care of the patients at the hospital.

Based on record review and interview, the hospital failed to ensure an infection control officer, qualified through education, training, experience, or certification, was designated to implement and monitor the infection control program for compliance and policies governing control of infections and communicable diseases. This deficient practice was evidenced when the infection control officer designated by the Governing Body was no longer in the position (S22LPN), and no new officer was designated. The hospital hired a new employee (S3DQ) to fulfill the role of Infection Preventionist who had no prior experience or training in Infection Control and also was hired for the positions of Quality Assurance Director and Dietary Manager, for which the employee required training. S3DQ was the only staff member onsite for the monitoring of infection prevention activities in the hospital by the hospital staff.
Findings:

Review of the Governing Board Meeting Minutes dated 01/29/18 (provided by S2DCC as the Governing Body Meeting Minutes for the last year) revealed S22LPN was appointed under "Leadership" as the "Director of Quality. As part of the Director of Quality, S22LPN is identified as the individual responsible for the Infection Control Program..."

Review of a current list of employees, provided by S9HIMD as current, revealed S3DQ's position was listed as "Director of Quality." Further review revealed S22LPN's position was listed as "Licensed Practical Nurse Full Time". S23PICO was not listed on the employee list. No listed employee was documented with the position related to Infection Control.

Review of the personnel file for S3DQ revealed no prior experience or specialized training in Infection Control.

In an interview on 01/09/19 at 11:35 a.m., S3DQ reported she had been working at the hospital in her current positions of Infection Control Director, Quality Director, and Dietary Manager since 12/17/18. S3DQ reported she did not have prior experience in overseeing an Infection Control Program or specialized training in infection control. S3DQ reported she was also having to train about Quality Assurance, Employee Health, and Dietary Manager positions and responsibilities, as she did not have prior experience or specialized training in any of the these areas. S3DQ reported she had just received an email from S24CICO on 01/04/19 with an education plan for S3DQ. S3DQ reported that S23PICO had come to the hospital a couple of times for a few hours, and she (S3DQ) had gone to another hospital in their health system for a day to work with that hospital's Quality Director/Infection Control Officer/Dietary Manager. S3DQ reported that while she was at the "sister" hospital, most of what she was shown was related to quality. S3DQ reported she could not estimate how much time she spent on infection control, as she was trying to learn and perform duties in quality and dietary management also. S3DQ reported she could call S24ICO, the Infection Preventionist at the Corporate level, if she (S3DQ) had questions or needed help. She said she could also call S23PICO as a resource. S3DQ reported she was, at this time, keeping current with patients on antibiotics, but had not started any surveillance of hand hygiene, PPE use, equipment and environmental cleaning, or any other infection prevention practices. During the interview, when asked for a report of infection control indicators used for quality assurance, S3DQ reported she would have to get help to locate these on a program "dashboard". During this time in the interview, S3DQ attempted to call S24CICO, but was unable to make contact. S3DQ also attempted to call S23PICO,but was unable to make contact. S3DQ verified she was still in training and orientation, but did not have a preceptor onsite regularly while she was in training and orientation for her role in infection control, as well has her other roles of Quality Director and Dietary Manager.

Review of an email to S3DQ, from S24CICO dated 01/04/19 at 2:36 p.m. and provided by S3DQ, revealed the orientation plan would include time with a preceptor (to be coordinated with the Administrator) as well as on-line education.

Based on record reviews and interview, the hospital failed to ensure its policy related to organ procurement was implemented as evidenced by not providing each patient or patient representative upon admission printed information regarding Tissue Donations or Anatomical Gift. The information was included in the Patient Handbook which was not routinely provided to patients upon admission. This deficient practice had the potential to affect the current 15 inpatients and future patients admitted to the hospital.
Findings:

Review of the policy titled "Organ Donation Louisiana", presented as a current policy by S9HIMD, revealed it was the policy of the hospital to provide information regarding Organ Tissue Donation and/or Anatomical Gifts to all patients admitted to the hospital and to assure that all patients and/or families of potential donors were made aware of their options to donate organs or tissues and that Company P was properly notified of the impending death or death of a patient. Further review revealed upon admission of a patient, staff would present printed information regarding Advance Directives and Tissue Donations or Anatomical Gift and obtain the patient's or family member's signature of the Advance Directive Acknowledgment Form indicating that he/she received the information. Review of the entire policy revealed it addressed organ and tissue donation only and did not include information regarding eye donation.

Review of the contract with Company P revealed the hospital was responsible for assuring that families of potential donors were made aware of the option of organ, tissue, and/or eye donation.

Review of the "Patient Handbook", presented as the current Patient Handbook by S9HIMD, revealed page 25 included information on Company P related to organ and tissue donation.

Review of the "Advance Directive Acknowledgment" form revealed "Please read the following statement and sign below. ... 8. I have been given written information regarding organ Tissue Donation and/or Anatomical Gifts."

In an interview on 01/08/19 at 9:03 a.m., S13RN indicated she asked Patient #2's daughter if the patient was an organ donor but didn't address information about tissue donation and anatomical gifts. She confirmed she wasn't aware of the policy but confirmed the advance directive form states they have received written information.

In an interview on 01/08/19 at 1:20 p.m. in the nursing station with S12RN and S14WC, S12RN indicated that the nurses admit the patients and go over information which included patient rights, advances directives, rules for patients on the unit, and other information found in the patient handbook. She reported the nurses would have the patient sign the consent form (with check boxes for items covered) and sign it, if they were cognitively able to understand. She further indicated that there was a copy of the Patient Handbook in the nurses' station if they wanted to see it. She confirmed that patients were not provided with the Patient Handbook unless they asked for it. S12RN indicated they didn't have very many copies of the Patient Handbook, but another copy could be printed if needed. She indicated if the patient was not cognitively able to understand or sign the consents and acknowledgements, staff would call the patient's power of attorney or representative and get the consents over the phone, with a 2nd witness. S14WC indicated they would speak to the patient's power of attorney/representative and go over forms with them, but forms related to Patient Rights, notifications, and Advance Directives were not emailed or mailed to the representative (giving phone consent). S14WC confirmed they did not provide a copy of the Patient Handbook to patient representative giving phone consent. S13RN, who was also present during the interview with S12RN and S14WC, confirmed the information provided by S12RN and S14WC.

Based on record reviews and interview, the hospital failed to ensure each patient had a psychiatric evaluation completed within 60 hours of admission as evidenced by failure to have the psychiatric evaluation completed within 60 hours of admission for 1 (#2) of 5 (#2, #3, #6, #8, #9) patient records reviewed for completion of the psychiatric evaluation within 60 hours of admission from a sample of 9 patients.
Findings:

Review of the policy titled "Psychiatric Evaluation", presented as a current policy by S9HIMD, revealed the psychiatrist documents a complete psychiatric evaluation including Axis I-V, prognosis, recommended treatment interventions, and assessment findings on the psychiatric evaluation form or dictated in appropriate format within 60 hours.

Review of Patient #2's medical record revealed he was admitted on 12/28/18 with a diagnosis of Dementia with behavioral disturbance. Review of his psychiatric evaluation documented and performed by S7MD revealed it was done on 01/02/19, 5 days after admit and not within 60 hours of admit.

In an interview on 01/08/19 at 8:10 a.m., S1DON confirmed the psychiatric evaluation for Patient #2 was done within 60 hours of admission.

Based on record review and interview, the hospital failed to ensure the mental status examination on the psychiatric evaluation included supportive information used to determine level of function, insight, and judgement. This deficient practice was evidenced by failure to include supportive information on the psychiatric evaluation that was utilized for assessment of insight and judgement for 3 ( #3, #6, #8) of 5 (#2, #3, #6, #8, #9) patient records reviewed for psychiatric evaluations from a total sample of 9 patients.
Findings:.

Review of the policy titled "Psychiatric Evaluation", presented as a current policy by S9HIMD, revealed the psychiatrist documents a complete psychiatric evaluation including Axis I-V, prognosis, recommended treatment interventions, and assessment findings on the psychiatric evaluation form or dictated in appropriate format within 60 hours. Further review revealed no documented evidence of the means to be used to determine insight and judgment.


Patient #3
Review of Patient #3's medical record revealed an admission date of 12/28/18 with an admission diagnosis of Delusional Disorder, Rule out Delirium, Anxiety, and Depression.. The patient's legal status: non-contested admission, and Patient #3 had a POA..

Review of Patient #3's Psychiatric Evaluation, dated 12/20/18, revealed the patient's insight and judgement were both documented as gravely impaired. Further review of the patient's psychiatric evaluation revealed no supportive information/methodology utilized for determining the patient's insight and judgement.

In an interview 1/9/19 at 8:15 a.m. S1DON reviewed Patient #3's Psychiatric Evaluation done 12/30/18 at 4:40 p.m. and verified there was no documentation of the methodology used for determining the patient's insight and judgement.

Patient #6
Review of Patient #6's medical record revealed he was admitted on 01/03/19 with a diagnosis of Major Depressive Disorder. Review of his psychiatric evaluation documented on 01/04/19 revealed insight and judgement were assessed as "poor" with no documented evidence of the means used to make this determination. Further review revealed the space after "as evidenced by" for insight and judgement were blank.

Patient #8
Review of Patient #8's medical record revealed he was admitted on 12/26/18 with a diagnosis of Psychosis. Review of his psychiatric evaluation documented on 12/27/18 at 5:00 p.m. by S15PMHNP revealed insight and judgement were assessed as "gravely impaired" with no documented evidence of the means used to make this determination. Further review revealed the space after "as evidenced by" for insight and judgement were blank.

In an interview on 01/09/19 at 11:00 a.m., S7MD indicated he was very familiar with what was required to be documented related to the psychiatric evaluation. He further indicated he emphasized with the medical staff the importance of documenting how judgment and insight were determined.

Based on record reviews and interviews, the hospital failed to ensure the psychiatric evaluation included an estimate of intellectual functioning, memory functioning, and orientation by description of appearance and behavior, emotional response, verbalization, thought and content, and cognition of the patient as reported by the patient and observed by the examiner at the time of the examination. This deficient practice was evidenced by failure to have the method used to determine each patient's estimate of intellectual functioning, memory functioning, and orientation for 2 (#8, #9) of 5 (#2, #3, #6, #8, #9) patients' psychiatric evaluations reviewed from a sample of 9 patients.
Findings:

Review of the policy titled "Psychiatric Evaluation", presented as a current policy by S9HIMD, revealed the psychiatrist documents a complete psychiatric evaluation including Axis I-V, prognosis, recommended treatment interventions, and assessment findings on the psychiatric evaluation form or dictated in appropriate format within 60 hours. Further review revealed the psychiatrist performs a systematic mental status examination emphasizing immediate recall and recent and remote memory appropriate to age. He/she documents an assessment of cognitive functioning, memory, and estimated intellectual functioning in a sufficient manner to establish a diagnosis and an objective baseline.

Patient #8
Review of Patient #8's medical record revealed he was admitted on 12/26/18 with a diagnosis of Psychosis. Review of his psychiatric evaluation conducted by S15PMHNP on 12/27/18 revealed he was oriented to time, place, and person. Further review revealed his recent memory was impaired, and his remote memory was intact, his attention and concentration was impaired with notation of "easily distracted." There was no documented evidence of the means used to determine memory as evidenced by the blank following "as evidenced by" under the heading "sensorium and cognition" being blank.

Patient #9
Review of Patient #9's medical record revealed she was admitted on 12/31/18 with a diagnosis of dementia. Review of her psychiatric evaluation documented by S7MD on 01/02/19 revealed no documented evidence of the means used to determine recent and remote memory which were both assessed as "impaired. Further review revealed the blank after the words "as evidenced by" for memory was blank. Further review revealed attention and concentration was assessed as "impaired" with "poor" written next to the choices of digit span, serial subtractions, spell 5 letter word backward and forward, and other.

In an interview on 01/09/19 at 11:00 a.m., S7MD indicated he was very familiar with what was required to be documented related to the psychiatric evaluation. He further indicated he emphasized with the medical staff the importance of documenting how judgment, intellectual functioning, memory functioning, and orientation were determined.

Based on record reviews and interviews, the hospital failed to ensure the psychiatric evaluation included an inventory of the patient's assets in descriptive, not interpretive fashion, as evidenced by failure to have the patients' assets described in descriptive fashion for 3 (#6, #8, #9) of 5 (#2, #3, #6, #8, #9) patients' psychiatric evaluations reviewed from a sample of 9 patients.
Findings:

Review of the policy titled "Psychiatric Evaluation", presented as a current policy by S9HIMD, revealed the psychiatrist documents a complete psychiatric evaluation including Axis I-V, prognosis, recommended treatment interventions, and assessment findings on the psychiatric evaluation form or dictated in appropriate format within 60 hours. Further review revealed the psychiatrist identifies specific patient strengths and assets to enable the multi-disciplinary treatment team to choose treatment modalities that best utilize these strengths and assets in the patients' treatment.

Review of the "Inpatient Psychiatric Evaluation" form revealed the pre-printed choices listed under the heading "Strengths and Assets" included insight, education, motivated for treatment, supportive family/friends, capable of independent living, insight into problem, employment, articulate, adequate finances, community support, stable physical health, and other.

Patient #6
Review of Patient #6's psychiatric evaluation documented on 01/04/19 revealed his strengths and assets were documented as motivated for treatment, supportive family/friends, and community support. There was no documented evidence his strengths and assets were documented in a descriptive fashion that would enable the multi-disciplinary treatment team to choose treatment modalities that best utilize his strengths and assets in his treatment.

Patient #8
Review of Patient #8's psychiatric evaluation conducted by S15PMHNP on 12/27/18 revealed his strength and asset was documented as supportive family/friends. There was no documented evidence his strength and asset was documented in a descriptive fashion that would enable the multi-disciplinary treatment team to choose treatment modalities that best utilize his strengths and assets in his treatment.

Patient #9
Review of Patient #9's psychiatric evaluation documented by S7MD on 01/02/19 revealed her strength and asset was documented as supportive family/friends. There was no documented evidence her strength and asset was documented in a descriptive fashion that would enable the multi-disciplinary treatment team to choose treatment modalities that best utilize her strengths and assets in his treatment.

In an interview on 01/09/19 at 11:00 a.m., S7MD indicated he was very familiar with what was required to be documented related to the psychiatric evaluation. He further indicated he emphasized with the medical staff the importance of documenting how judgment, intellectual functioning, memory functioning, and orientation were determined. he further indicated he was aware that strengths and assets should be documented in a descriptive fashion.

Based on record reviews and interview, the hospital failed to ensure each patient had a comprehensive individualized treatment plan which addressed all psychiatric and medical diagnoses for 3 (#1, #3, #4) of 7 (#1, #2, #3, #4, #5, #6, #7) patient records reviewed for a comprehensive individualized treatment plan from a sample of 9 patients.
Findings:

Review of the hospital policy titled, "Treatment Planning; Integrated/Multidisciplinary", Policy Number CS-02, revised 05/01/2017, revealed in part: Policy: The multidisciplinary treatment team, under the direction and supervision of the attending physician, shall develop an integrated, written, comprehensive treatment plan with specific goals and objectives necessary to address deficits identified in the assessment process. The treatment plan shall be initiated as a component of the admission process with continual development and formulation by the attending physician and multidisciplinary treatment team, with the patient's involvement, throughout the course of treatment. The treatment plan includes defined problems and needs, measurable goals and objectives based on assessed needs, strengths and limits, frequency of care, treatment and services, facilitating factors and barriers, and transition criteria to lower levels of care.
Procedure: 2. The admitting nurse is responsible for the following: *Revising and developing nursing and medical components of the treatment plan based on additional findings from patient assessments, problems, needs, strengths, limitations, and physician's orders. Revising the plan based on changes in condition and physician's orders received. All physician's orders will be added to the treatment plan.

Patient #1
Review of Patient #1's medical record revealed he had been admitted on 01/04/19 at 11:00 p.m. with diagnoses including Bipolar Disorder, Impaired mobility with a history of falls, Laceration right forehead (from recent fall), and dysphagia. Patient #1's Skin Assessment and Wound Care documentation dated 01/04/19 identified a healing stage 4 wound to the coccyx measuring 3cm x 1cm with a depth of less than 1cm.

Review of Patient #1's Integrated Treatment Plan Problem List revealed problems identified for High Risk For Falls, Recent Fall, and High Risk for Elopement. Further review revealed no goals or interventions listed for the identified problems. There was no problem identified for the wound to the coccyx.

Patient #3
Review of Patient #4's medical record revealed she was admitted 12/28/18 with diagnoses that included Delusional Disorder, Depression, rule out Delirium, Hypothyroidism, GERD, and COPD. Review of her History and Physical revealed her assessment included continued problems of HLD, hypothyroidism, GERD, Constipation, as well as anorexia, with a plan to start her on Periactin and MVI. Review of her Care Plans revealed no care plan for her diagnosis of Thyroidism, Anorexia, or GERD.

Patient #4
Review of Patient #4's medical record revealed he had been admitted on 08/30/18 with a diagnosis of Dementia. Further review of Patient #4's medical record revealed a Skin Assessment and Wound Care assessment indicating he had a skin tear to his right elbow.

Review of Patient #4's Integrated Treatment Plan Problem List revealed no problem had been identified for the wound to his right elbow.

In an interview 01/10//19 at 9:20 a.m., S1DON verified all patients' identified problems, including medical diagnoses for which the patient was being treated, should have been included in his/her treatment/care plan.





30420

Based on record reviews and interview, the hospital failed to ensure each patient's written treatment plan included short-term and long range goals that were stated as expected behavioral outcomes for the patient and written as observable, measurable patient behaviors to be achieved. This deficient practice was evidenced by short-term and long range goals not being written as observable, measurable patient behaviors for 2 (#2, #6) of 7 (#1, #2, #3, #4, #5, #6, #7) patient treatment plans reviewed for measurable goals from a sample of 9 patients.
Findings:


Review of the hospital policy titled, "Treatment Planning; Integrated/Multidisciplinary", presented as a current policy by S9HIMD, revealed the multidisciplinary treatment team, under the direction and supervision of the attending physician, shall develop an integrated, written, comprehensive treatment plan with specific goals and objectives necessary to address deficits identified in the assessment process. The treatment plan includes defined problems and needs, measurable goals and objectives based on assessed needs, strengths and limits, frequency of care, treatment and services, facilitating factors and barriers, and transition criteria to lower levels of care.

Patient #2
Review of Patient #2's treatment plan revealed the following short-term and/or long range goals that were not written as observable, measurable patient behaviors as evidenced by failure to include the specific manner by which the goal could be measured to determine when it was met:
Risk for violence (nursing): Patient #2 will experience control of behaviors with assistance from others as evidenced by a decrease in agitation/aggressive behaviors (no measurement to determine how a decrease would be determined); demonstrate improved cooperation with activities of daily living assistance by staff within 8 days (no measurement to determine how improvement would be determined);
Risk for violence (recreational therapist): Patient will demonstrate an increase in ability to functionally participate in activities involving peer integration within 15 days (no measurement to determine how an increase would be determined); demonstrate relaxed/socially appropriate behavior during tasks daily within 10 days (no measurement to determine when this goal would be met);
Alteration in perception (nursing): have improved responses to situations as evidenced by clearer responses to topic when asked direct questions (no measurement to determine when this goal would be met); decrease aggressive/agitated behavior for 4 consecutive days within 14 days (no measurement to determine how a decrease would be determined); demonstrate a decrease in restless/wandering behaviors within 10 days (no measurement to determine how a decrease would be determined);
Alteration in perception (social services): establish increase in functioning and trust with others within 10 days "(no combativeness or urinating in undesignated areas)" (no measurement to determine how trust would be determined);
Alteration in perception (recreational therapist): demonstrate relaxed/socially appropriate behavior during tasks daily within 10 days (no measurement to determine when this goal would be met);
Alteration in health maintenance (nursing): demonstrate an understanding of treatment regime to maintain medical condition at optimal level within 2 weeks (no measurement to determine when this goal would be met);
High risk for falls (nursing): consistently comply with activities that decrease risk within 15 days (no documentation of specific activities and no measurement to determine how a decrease would be determined); demonstrate a decrease in restless/wandering behaviors within 10 days (no measurement to determine how a decrease would be determined);
Risk for choking (nursing): demonstrate increased ability to utilize "postural" adaptations to reduce the risk of choking within 6 days (specific adaptations to be assessed and no measurement to determine a reduction).

Patient #6
Review of Patient #6's treatment plan revealed the following short-term and/or long range goals that were not written as observable, measurable patient behaviors as evidenced by failure to include the specific manner by which the goal could be measured to determine when it was met:
Alteration in mood (nursing): demonstrate stabilized mood as evidenced by overall improvement in mood (no description of how stabilization would be determined and no measurement to determine when improvement would be met); patient will demonstrate a positive attitude for 10 days (no description of how a positive attitude would be determined);
Alteration in mood (recreational therapist): have an increase in social skills with improved functioning within 15 days (no description of social skills to be evaluation and no measurement to determine when an increase would be met); be motivated to participate in activities within 10 days (no measurement to determine when the goal would be met);
Risk for violence (nursing): Patient #6 will experience control of behaviors with assistance from others as evidenced by improved interaction with others within 21 days (no measurement to determine how an improvement would be determined);
Risk for violence (recreational therapist): Patient will demonstrate an increase in ability to functionally participate in activities involving peer integration within 15 days (no measurement to determine how an increase would be determined); demonstrate relaxed/socially appropriate behavior during tasks daily within 10 days (no measurement to determine when this goal would be met);
Alteration in health maintenance (nursing): demonstrate an understanding of treatment regime to maintain medical condition at optimal level within 2 weeks (no measurement to determine when this goal would be met);
High risk for falls (nursing): consistently comply with activities that decrease risk within 15 days (no documentation of specific activities and no measurement to determine how a decrease would be determined); demonstrate a decrease in restless/wandering behaviors within 5 days (no measurement to determine how a decrease would be determined).

In an interview on 01/09/19 at 7:45 a.m., S1DON confirmed the nursing goals in the patient treatment plans were not stated in behavioral, measurable terms.

In an interview on 01/09/19 at 8:05 a.m., S20LCSW indicated there could be more specificity in the way the goals were stated in the above patients' treatment plans.

In an interview on 01/09/19 at 8:10 a.m., S16CTRS confirmed the treatment goals for Patients #2 and #6 were not written in observable, measurable terms.

Based on observation, record review, and interview, the hospital failed to ensure all treatment received by the patient was documented in such a way that all active active therapeutic efforts were included as evidenced by observation on 01/ at of the scheduled recreational therapy group activity not being conducted. There was no documented evidence that treatment was provided in accordance with the patient's treatment plan for 3 (#2, #3, #6) of patient records reviewed for treatment plan intervention from a sample of 9 patients.
Findings:

Observation on the patient care unit on 01/08/19 at 3:00 p.m. revealed patients were either in their beds, moving in the hallways, or sitting in the dayroom with MHTs. Further observation revealed no art activities were being facilitated with any of the patients. No patient was observed to be participating in any activity other than sitting, talking to staff, walking in the hallways, or resting in bed.

Review of the patient schedule, posted in the patient hallway near the nursing station and dayroom, revealed Art Activity was the scheduled activity from 2:30 p.m. to 4:00 p.m. for 01/08/19.

Patient #2
Review of Patient #2's treatment plan revealed recreational therapy group was to be conducted 45 to 60 minutes a day for 5 days a week for 2 weeks, and social service group groups were to be conducted 45 to 60 minutes per day 4 to 5 times a week for 1 to 2 weeks.

Review of Patient #2's inpatient group documentation revealed S20LCSW documented a social service group for 1 hour on 12/31/18, 1 hour on 01/02/19, and 1 hour on 01/03/19. There was no documented evidence that a social service group was conducted 4 to 5 times a week for the week of 12/31/18 in accordance with Patient #2's treatment plan. Further review revealed S16CTRS documented a recreational therapy group for 1 hour on 12/31/18, 1 hour on 01/02/19, 1 hour on 01/03/19, and 1 hour on 01/04/19. There was no documented evidence that a recreational therapy group was conducted 5 days a week for the week of 12/31/18 in accordance with Patient #2's treatment plan. Further review revealed no documented evidence that any recreational therapy group had been conducted in the afternoon.

Patient #3
Review of Patient #3's medical record revealed no documented evidence that any recreational therapy group had been conducted in the afternoon.

Patient #6
Review of Patient #6's (admitted on 01/03/19 at 7:30 p.m.) treatment plan revealed recreational therapy group was to be conducted 45 to 60 minutes a day for 5 days a week for 2 weeks, and social service group groups were to be conducted 45 to 60 minutes per day 4 to 5 times a week for 1 to 2 weeks.

Review of Patient #6's inpatient group documentation revealed S20LCSW documented that Patient #6 did not attend group on 01/05/19 and 01/06/19, and there was no documented evidence of alternative therapy attempted. There was no documented evidence that a social service group was conducted in accordance with Patient #2's treatment plan (could have had 2 groups the first week of admission). Further review revealed S16 CTRS documented a recreational therapy group for 1 hour on 01/04/19 (could have had 2 groups the first week of admission). There was no documented evidence that a recreational therapy group was conducted in accordance with Patient #6's treatment plan. Further review revealed no documented evidence that any recreational therapy group had been conducted in the afternoon.

In an interview on 010/8/19 at 3:10 p.m., S16CTRS indicated she did not understand when the surveyor asked if the patient schedule had been changed today. When it was pointed out by the surveyor that the posted schedule (in the patient hallway) revealed the current activity listed was Art Therapy, she indicated that she had played some music earlier. When asked about the Art Therapy activity slot being at 2:30 -4:00 p.m., she indicated that that entire time was not for art therapy. She reported that she did not document participation of patients in any afternoon therapy, she only documented participation in the morning activities. When asked why the afternoon therapies were not documented, she gave no answer.

In an interview on 01/08/19 at 3:20 p.m., S1DON , after a request for a copy of the activity schedule was made, reported that patient participation in afternoon activities was not usually documented, but participation in the morning activities was documented. He did not provide a rationale for there being no documentation of participation in afternoon activities. He reported he thought the Activity Therapist had maybe had to switch times for activities.

In an interview on 01/08/19 at 3: 50 p.m., S18MHT reported she was in the process of getting patients who had taken naps up and ready for dinner that was served around 4:45 p.m. She reported she had just turned on music.

In an interview on 01/08/19 at 4:20 p.m., S16CTRS indicated she is a CTRS and had been at this hospital about 4 months. She indicated in the morning they have a group for 1 hour, one for high function (A) & one for lower function patients (B) alternating with S20LCSW. She indicated she does the 9:00 a.m. to 10:00 a.m. group for lower function patients while S20LCSW does the high function social service group, then they switch from 10:00 a.m. to 11:00 a.m. S16CTRS indicated around 2:00 p.m. they do a walk program with the MHTs assisting her to walk the patients. She indicated they don't document the afternoon group. She makes sure everything is available like paints and colored pencils for the afternoon group, but she doesn't document the group that is conducted in the afternoon. She indicated she facilitates the afternoon group. She confirmed again the afternoon group therapy isn't documented for the patient's record. She indicated if a patient doesn't attend morning group, she does a 1:1 session with the patient. S16CTRS confirmed the recreation therapy groups for Patients #2 and #6 were no conducted in accordance with each patient's treatment plan.

In an interview on 01/09/19 at 8:05 a.m., S20LCSW indicated he didn't know there was a group missing on the weekend of Patient #2's admission. He indicated sometimes they can't get patients to group, and they try to engage them when this happens. He confirmed the social services groups were not conducted in accordance with the treatment plan for Patients #2 and #6.