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Based on observations and interviews, the hospital failed to ensure that patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for psychiatric patients admitted for being a danger to self or others.
Findings:

Observations on 01/03/2024 beginning 9:42 a.m. revealed the toilets used by patients in rooms a, b, (shared) d, e (shared) f (single use), g (single use), h, i, (shared) k, l, (shared) m (single use), n (single use), o, p (shared), r, s (shared), t (single use), and u (single use) with unsecured seats presenting ligature risks.

Continued observations revealed the toilets available to patients at locations v, w, x, y, z, aa, and ee with unsecured seats presenting ligature risks.

In an interview on 01/03/2024 at 11:10 a.m., S10DON verified the findings of the observations.

Based on interview and record review, the hospital failed to submit critical incident reports to the Louisiana Department of Health regarding the elopement of patients R2, R3, R4, R5 and R6. This deficient practice had the potential to affect the safety of any patients admitted to the hospital who have eloped.
Findings:

Review of document titled, "Louisiana Department of Health, Health Standards Section Self-Reporting Process for Hospitals - Abuse/Neglect", (Revised 12/01/2021) revealed the following, in part: Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report (abuse/neglect) within 24 hours of receiving knowledge of the (incident) to either the local law enforcement agency or the Louisiana Department of Health (LDH) (or the Medicaid Fraud Unit as applicable).

Review of the hospital incident log revealed 5 elopements occurring on the dates 07/11/2023, 07/20/2023, 07/23/2023, 09/16/2023 and 11/18/2023.

Review of incident report dated 07/11/2023 revealed R2 was outside in the smoking area at 4:30 p.m. and while the MHT was watching R2 jumped over the fence and eloped. S10Admin and S12DON were notified. Review of hospital documents failed to reveal a critical incident report submitted to the Louisiana Department of Health.

Review of incident report dated 07/20/2023 revealed R3 was outside in the smoking area at 8:55 p.m. and walked out the cafeteria into the lobby and out the front door. Staff called after R3 but to no avail. S12DON was notified. Review of hospital documents failed to reveal a critical incident report submitted to the Louisiana Department of Health.

Review of incident report dated 07/23/2023 revealed R4 was outside in the smoking area at 6:15 p.m. and R4 climbed the fence and ran. Several people thought they saw him get it a car after he jumped the fence. S6MHT was outside with patient and stated he was lighting other patients' cigarettes and his back was turned away from R4. The second MHT was inside the cafeteria when the event occurred. S10Admin and S12DON were notified. Review of hospital documents failed to reveal a critical incident report submitted to the Louisiana Department of Health.

Review of incident report dated 09/16/2023 revealed R5 went down for breakfast at 9:00 a.m. with S6MHT and ran out the front door. M6MHT reported the door in cafeteria (patio door) was unlocked. S12DON was notified. Police were called. Review of hospital documents failed to reveal a critical incident report submitted to the Louisiana Department of Health.

Review of incident report dated 11/18/2023 revealed R6 ran from staff after breakfast. R6 exited building through main door and staff pursued him but were not able to catch R6. Review of hospital documents failed to reveal a critical incident report submitted to the Louisiana Department of Health.

In an interview on 01/04/2024 at 12:30 p.m., S11Admin and S12DON indicated the hospital did not submit self-reports to the Louisiana Department of Health regarding the elopements as per state rules and regulations.

Based on record review and interviews, the hospital failed to ensure staff personnel records contained documentation that demonstrated Patient Rights competencies had been successfully completed during orientation upon hire for 3 (S4NP, S5PMHNP, and S13PA) of 3 (S4NP, S5PMHNP, and S13PA) hospital midlevel providers reviewed for Orientation with Patient Rights training.
Findings:

Review of hospital policy titled "HR Policies and Procedures, Orientation Program 8.8", revealed, in part: Policy Statement: An orientation program shall be conducted for all newly hired employees that will assess the competency of the employee as it relates to his or her job performance upon hire and at least every three years thereafter. Procedure, in part: 1. All newly hired personnel must attend an orientation program within their first five (5) days of employment. Then every three years thereafter. d. An introduction to our administrative structure, which includes, in part: (4) A review of resident rights. (5) A review of abuse reporting procedures.

Review of S4NP's personnel record revealed hire date of 03/27/2021. Further review failed to reveal Patient Rights training and competency was successfully completed during orientation upon hire.

Review of S5PMHNP's personnel record revealed hire date of 05/25/2021. Further review failed to reveal Patient Rights training and competency was successfully completed during orientation upon hire.

Review of S13PA's personnel record revealed hire date of 07/13/2022. Further review failed to reveal Patient Rights training and competency was successfully completed during orientation upon hire.

In an interview on 01/04/2024 at 9:20 a.m., S14HR confirmed that S4NP, S5PMHNP, and S13PA did not go through hospital employee orientation and Patient Rights training upon hire.

Based on observations and interviews, the hospital failed to ensure schedule IV medications were locked within a secure area. This deficient practice was evidenced by failure to ensure vials of Lorazepam were stored securely under double lock.
Findings:

Review of hospital policy titled "Narcotic Count and Documentation" dated January 2023, revealed, in part: Policy Statement, in part: Narcotic medication (referred to as narcotics) is located in the locked narcotic box and in the locked medication refrigerator in each medication room on each unit.

On 01/03/2024 at 9:24 a.m., an observation with S10DON was conducted of the Nurses' Station Medication Refrigerator located on floor ff. During the observation, 39 vials of 2mg/ml Lorazepam were noted to be located in an unsecured cardboard box in an unlocked refrigerator.

In an interview on 01/03/2024 at 9:25 a.m., S10DON verified 39 vials of 2mg/ml Lorazepam were stored in an unsecured cardboard box in an unlocked refrigerator on floor ff.

Based on observation and interview the hospital failed to have an approved therapeutic diet manual with a publication or revision date of not more than 5 years old.
Findings:

Review of hospital therapeutic diet manual titled, "Adult Nutrition Care Manual (NCM)", revealed the manual was published in 2018.

In an interview on 01/04/2024 at 11:13 a.m., S15DM verified the hospital therapeutic diet manual titled, "Adult Nutrition Care Manual (NCM)" was published in 2018 and was more than 5 years old.

Based on observations and interviews, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors. This deficient practice was evidenced by failure to maintain the physical plant in good repair and failure to maintain a safe patient care environment.
Findings:

Review of hospital policy titled "Environmental Services Policy & Procedure, Environmental Safety", dated January 2023, revealed, in part: Policy Statement. It is the policy to operate and maintain a safe environment, which minimizes risk and promotes safety.

Review of hospital policy titled "Environmental Services Policy & Procedure, Maintenance Rounding", dated January 2023, revealed, in part: Purpose: to ensure thoroughness and consistency in providing a safe and functional environment, the Environmental Services department will conduct environmental tours to maintain compliance. Procedure, in part: Maintenance Rounding checklist ...of the following items, in part: Shower/bath cleanliness and functionality; Patient bed cleanliness and functionality.

Review of hospital policy titled "Environmental Services Policy & Procedure, Scope of Services", dated January 2023, revealed, in part: Policy Statement, in part: The Environmental Services Department ...will provide housekeeping services, seven days per week 24 hours a day.

Observations on 01/03/2024 beginning 9:42 a.m. with S10DON the following was observed:

Unit C:
Temperature on Unit C was noted to be markedly cold at 9:45 a.m. Observation of temperature gauge read 66 degrees. Patients were observed to be in sweaters, jackets and wrapped in blankets.

In an interview on 01/03/2024 at 10:21 a.m. Patient R1, who was wrapped in a blanket stated, "It is freezing in here".

In an interview on 01/03/2024 at 9:50 a.m., S10DON confirmed the temperature on Unit C was 66 degrees.

Observation of bathroom aa noted to have approximately 2-3 inches of white cloudy water on shower floor. Water was noted puddled on the floor near the sink.

In an interview on 01/03/2024 at 10:15 a.m., S10DON and S9EVS confirmed white cloudy water collected on the shower floor and the puddles of water on the floor near the sink of bathroom aa and agreed the condition of bathroom aa was not sanitary.

Observation bathroom z noted to have strips of dirty paper wrinkled up on shower floor. Continued observation revealed used wet wash clothes tucked into crevices of the shower. Hairbrush with hair in it stuck in shower crevice. Clothes and paper cups in chair in bathroom z. No soap by sink for patients to wash hands.

In an interview on 01/03/2024 at 10:23 a.m., S10DON and S9EVS confirmed the condition of the bathroom z was not sanitary.

Observation of room u revealed ripped and torn mattress creating unsanitary conditions.

In an interview on 1/03/2024 at 10:27 a.m., S12DON confirmed the torn mattress in room u and agreed this was not sanitary.

Unit B:
Observation of the shower in bathroom y revealed the water was cold. After letting the water run for approximately 20 mintues, the water rose to barely luke-warm.

In an interview on 01/03/2024 at 10:55 a.m. S10DON reported the temperature of the water in the shower of bathroom y was barely luke-warm because of the pipes.

Observation of room j noted to have 2 ripped mattresses creating unsanitary conditions.

In an interview on 1/03/2024 at 10:36 a.m., S10DON and S9EVS confirmed the torn mattresses in room j and agreed this was not sanitary.

Unit A:
Observation of room e noted to have ripped mattress with food wrappers located under the mattress creating unsanitary conditions.

In an interview on 1/03/2024 at 11:00 a.m., S10DON and S9EVS confirmed the torn mattresses and food wrappers under the mattress of room e and agreed this was unsanitary.

Observation of room c revealed the bed under the mattress with brown, dried, fluid-like substance and food crumbs noted.

In an interview on 1/03/2024 at 11:06 a.m., S10DON and S9EVS confirmed that under the mattress of the bed in room c there contained a brown, dried, fluid-like substance and food crumbs. Both agreed this was unsanitary. S10DON stated that the hospital policy is to clean every bed at discharge and on admit.

Based on record review and interview, the hospital failed to ensure the Psychiatric Evaluation described the information necessary to justify the diagnosis and treatment of each patient. This is evidenced by failure to include the physician certification for admission, the estimated length of stay, the treatment goals, criteria for discharge and the required signature of the evaluating licensed practitioner on Psychiatric Evaluation for 1 (#3) of 3 (#1-#3) psychiatric evaluations reviewed.
Findings:

Review of Patient #3's medical record revealed an admit date of 12/03/2023 and date of birth 07/22/1954. Further review revealed a document titled "Psychiatric Evaluation" dated 12/03/2023. Continued review failed to reveal the provider, S16PMHNP, completed the "Physician Certification for Admission", "Estimated Length of Stay", "Treatment Goals", and the "Criteria for Discharge". Further review failed to reveal S16PMHNP's signature.

In an interview on 01/03/2024 at 3:30 p.m., S10DON confirmed that Patient #3's Psychiatric Evaluation did not reveal documentation containing the "Physician Certification for Admission", the "Estimated Length of Stay", the "Treatment Goals", the "Criteria for Discharge" and the evaluating licensed practitioner's signature.

Based on record review and interview, the hospital failed to ensure a complete medical history was documented on the Psychiatric Evaluation for each patient admitted to the psychiatric hospital. This deficiency is evidenced by failure to obtain a complete medical history for 1 (#1) of 3 (#1-#3) reviewed records.
Findings:

Review of the History and Physical completed by S4NP on 11/17/2023 for Patient #1, revealed in part, Medical History: "Autism", "Drug Addiction", "Mixed Hyperlipidemia", and "Hypertension".

Review of the Psychiatric Evaluation completed by S16PMHNP on 11/18/2023 for Patient #1, revealed in part, Medical History: "0"; Disease/Illness: "0"; Surgical history: "0"; PCP: "0"; Last Appointment: "NA".

In interview on 01/03/2024 at 3:40 p.m., S10DON verified the evaluating licensed psychiatric practitioner did not document an accurate nor complete medical history on the Psychiatric Evaluation.

Based on record review and interview, the hospital failed to ensure each patient had an individualized, comprehensive treatment plan for 1 (#3) of 3 (#1-#3) patients. This deficiency is evidenced by failure to include all medical and nursing diagnoses as part of an individualized, comprehensive treatment plan.
Findings:

A review of hospital document titled "Patient Rights", revealed, in part: All patients have the right to ...in part: Individualized treatment plans ...

A review of hospital document titled "Master Treatment Plan/Weekly Update Treatment Plan", revealed, in part: Purpose, in part: To provide comprehensive, individualized plan of treatment for each patient ...Procedure, in part: B. Treatment plans will be individualized to address patient specific problems, identified through clinical assessments ...

A review of Patient #3's list of psychiatric diagnoses included Major Depressive Disorder.

Review of incident report dated 12/15/2023 revealed Patient #3 had a fall when she got up to use the restroom. She had no socks or shoes on. She fell and landed on her bottom. Patient reported pain to the right upper posterior arm.

Review of Patient #3's medical record revealed a document titled "Treatment Plan". Further review failed to reveal evidence of the following: 1) Identified diagnoses (the diagnosis section was blank). 2) Updated physical problems that included pain to the right upper posterior arm. 3) Target dates for short-term goals (this section was blank). 4) The specific therapies Patient #3 would attend (this section was blank). 5) Discharge or Transition plan (this section was blank). 6) A signature that indicated the Treatment plan had been reviewed and approved (this section was blank).7) A signature the treatment plan was given to patient/family or declined by the patient/family (this section was blank).

In an interview on 01/03/2024 at 4:02 p.m., S10DON confirmed the Treatment Plan failed to reveal evidence that the treatment plan was individualized, comprehensive and complete.

Based on record review and interview, the hospital failed to ensure all patients treatments were within compliance of particular aspects of the patients' individualized treatment program as evidenced by failure to have documentation that a treatment team conference was held since patient's admission in 1 (#2) of 3 (#1-#3) patient records reviewed.

Review of hospital policy titled "Master Treatment Plan/Weekly Update Treatment Plan", dated January 2023, revealed, in part: Policy Statement: It is the policy of this hospital to utilize a multi-disciplinary approach in the development and implementation of an individualized Master Treatment Plan and Weekly Treatment Plan for each patient. Procedure, in part: A. The multi-disciplinary team is headed by the physician and consists of Nursing, Social Services, and Activity/Recreational Therapy and other health professionals as indicted. 5. The Master Treatment Plan will be developed in the first team meeting ...

Review of Patient #2's medical record revealed an admission date of 12/16/2023. Further review failed to reveal documented evidence of a treatment team conference held since admission.

In an interview on 01/03/2024 at 4:20 p.m., S10DON verified that there was evidence that a treatment team conference was held for patient #2 since admission on 12/16/2023.

Based on record review and interviews, the hospital failed to ensure each patient who had been discharged had a discharge summary that included a recapitulation of the patient's hospitalization. This deficiency is evidenced by failure to have a documented discharge summary in 1 (#1) of 3 (#1-#3) patient records reviewed.
Findings:

Review of hospital policy titled "Discharge Summary" revealed, in part: Discharge Summary. A. A discharge summary shall be recorded at the time of discharge ...3 ....the Discharge Summary must be completed within thirty (30) days of discharge.

Review of Patient #1's medical record revealed an admission date of 11/17/2023 and a discharge date of 11/24/2023. Further review failed to reveal a discharge summary.

In an interview on 01/03/2024 at 3:15 p.m., S10DON confirmed that the medical record revealed no evidence of a discharge summary and that the discharge summary should have been completed within 30 days of discharge.