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Based on record review, observation, and interview, the hospital failed to meet the requirements of the Condition of Participation for Patient Rights by failing to ensure patients received care in a safe setting by failing to mitigate a known elopement risk. This deficient practice is evidenced by having a patient elope by jumping a fence surrounding an exterior patient area for 1 (#2) of 1 patient reviewed for elopements. Deficient practice was previously cited on a complaint survey at the hospital on 12/19/17 for 7 patient elopements since 1/24/17 resulting from patients jumping exterior fences (see findings tag A-0144).

Based on observation, record review, and interview, the hospital failed to ensure patients received care in a safe setting by failing to mitigate a known elopement risk. This deficient practice is evidenced by having a patient elope by jumping a fence surrounding an exterior patient area for 1 (#2) of 1 patient reviewed for elopements. Deficient practice was previously cited on a complaint survey at the hospital on 12/19/17 for 7 psychiatric patient elopements since 1/24/17 resulting from patients jumping exterior fences.

Findings:

Observations beginning on 1/29/18 at 10:00 a.m. of the exterior patient areas of the hospital's 3 units revealed the following:
Unit A: The outside area was surrounded by a 6-foot wooden fence on 3 sides and a chain link fence on 1 side. A brick ledge which could act as a stepping point protruded from the exterior of the building near the corner of the wooden fence.
Unit B: The outside area was surrounded by a 6-foot wooden fence on 1 side and chain link fence on the other 3 sides. The chain link section had 2 gates with bars across the middle which could facilitate climbing. A brick ledge which could act as a stepping point protruded from the exterior of the building near the corner of the fence.
Unit C: The outside area was surrounded by a 6-foot wooden fence on 3 sides and a chain link fence on the 1 side. A brick ledge which could act as a stepping point protruded from the exterior of the building near the corner of the wooden fence and the chain link fence.

Review of Patient #2's medical record revealed he was admitted to the locked psychiatric unit on 1/22/18 with a dignosis of Substance Induced Mood Disorder , Intravenous Opioid Use Disorder and Cocaine Use Disorder. Patient #2 had reported intermittant low mood, anergia, guilt and hopelessness that is due to his daily Heroin and cocaine use. Further review of Patient #2's Psychiatric Evaluation revealed a history of Schizophrenia and Bipolar Disorder on a chart review by the physician.

Review of an incident report for Patient #2 dated 1/24/18 at 3:30 p.m. revealed he was located outside of Unit B of the psychiatric hospital in the smoking section and eloped by jumping over a perimeter fence.

In an interview on 1/29/18 at 10:05 p.m. with S3RN, he said he was the charge nurse on Unit B. He said he was working on the unit on 1/24/18 when Patient #2 eloped. S3RN said Patient #2 was outside smoking with 1 staff member S4MHT and other patients when he eloped. When asked if he had any recent specialized training from the hospital on elopements, he said, "No". S3RN said if there were less than 10 patients outside smoking, only 1 technician was required to be with the patients.

In an interview on 1/29/18 at 10:13 p.m. with S4MHT, she said usually 2 staff members went outside with the patients to smoke. When asked what she meant by "usually", she said if someone was at lunch then only 1 MHT would go out with the patients. S4MHT said she was outside alone on 1/24/18 at 3:30 p.m. with Patient #2 and other patients. She said Patient #2 was not a known elopement risk. S4MHT said Patient #2 eloped by jumping the fence. S4MHT said she knew there was supposed to be 2 people outside with the patients but the other technician was at lunch.

In an interview on 1/29/18 at 12:15 p.m. with S5RiskMgr, she was asked what the hospital had put in place since the last survey by the Louisiana Department of Health on 12/19/17 to mitigate elopement risks after a deficiency was written for 7 of 9 elopements occurring by patients jumping exterior fences. S5RiskMgr said after Patient #2 eloped on 1/24/18, the administration of the hospital determined 2 staff members should be outside of the locked units at all times when patients were smoking. When asked if all of the staff had been educated on this new rule of having 2 staff members outside with patients she replied, "No". S5RiskMgr said the hospital was adopting an elopement risk screening tool to begin using 2/16/18 but had not completely finished the tool, educated staff, or started using the tool as of yet. S5RiskMgr verified S3RN, who was in charge of Unit B today had also been in charge of Unit B on 1/24/18. S5RiskMgr confirmed S3RN had not been educated as of yet. S5RiskMgr said they did not have an updated policy for staffing requirements while the patients were smoking or a sign in sheet indicating which staff had been educated on new elopement training and which staff had not been educated. S5RiskMgr said the plan was to hire a "float" MHT to help with observations but no additional float MHT staff had been hired as of yet. S5RiskMgr also verified the identified elopement risk associated with exterior fences and other areas identified as presenting an elopement risk on the previous survey had not been mitigated.

Based on record reviews and interviews, the hospital failed to ensure adverse events were analyzed for cause and preventive actions were implemented and reevaluated. This deficient practice is evidenced by the hospital's failure to measure, analyze, track and trend adverse patient events involving psychiatric male and female patients being undetected in patient's rooms together for 6 (#R1, #R2, #R3, #R4, #1, #3) of 6 patients having sexual intercourse and 2 (#4, #5) of 2 patients hiding in a patient's shower stall.

Findings:

On 1/30/18 at 10:30 a.m. review of the Patient Handbook revealed in-part, only room occupants and staff are allowed in patient's rooms. No visitors are allowed in rooms.

Review of medical records and Alleged Incident Reports since March of 2017 revealed the following adverse events:
March 17, 2017
Review of Patient #R1's incident report revealed she had been admitted to the psychiatric hospital on 3/16/17 with Bipolar II Disorder and Borderline Personality Disorder.

Review of Patient #R2's incident report revealed he had been admitted to the psychiatric hospital on 3/17/17 with diagnosis including Major Depressive Disorder, Generalized Anxiety Disorder and Impulse Control.

Review of the Alleged Incident Investigation Report for incident dated 3/17/2017 read in part: Friday, March 17, 2017 at approximately 9:40 p.m., Patient #R1 and Patient #R2 were caught having sexual intercourse in Patient #R1's room. S6MHT caught them. Once caught, both patients stated "I got caught." Further review revealed Patient #1 said the sex was not consentual and the local police were notified.

March 24, 2017
Review of Patient #R3's incident report revealed she had been admitted to the psychiatric hospital on 3/18/17 with diagnosis including Major Depressive Disorder.

Review of Patient #R4's incident report revealed he had been admitted to the psychiatric hospital on 3/21/17 with diagnosis including Schizoaffective Disorder.

Review of the Alleged Incident Investigation Report for incident dated 3/ 24/ 2017 reads in part: On Friday, March 24, 2017 at approximately 7:46 p.m., Patient #R3 and Patient #R4 had sexual intercourse in Patient #R3's room. S7MHT saw Patient #R4 exiting Patient #R3's room. Both patients admitted to having sex.

December 26, 2017
Review of Patient #4's medical record revealed he had been admitted to the psychiatric hospital on 12/20/17 with diagnosis including Suicidal Ideation and Paranoid Schizophrenia.

Review of Patient #5's medical record revealed she had been admitted to the psychiatric hospital on 12/25/17 with diagnosis including Schizoaffective Disorder, Bipolar type.

Review of the Alleged Incident Investigation Report for incident dated 12/26/2017 read in part: Patients involved were Patient #4 and Patient #5. Patient #4 was observed on the unit at 8:05 p.m. Sometime between 8:05 p.m. and 8:08 p.m. both patients went into Patient #5's bathroom. At 8:08 p.m., S8RN entered Patient #5's room looking for the patients. The patient door was wide open but the bathroom door was closed. S8RN asked Patient #5 if she was in the bathroom. Patient #5 responded that she was in the shower then turned the water on. At that time, the other staff members reported that Patient #4 wasn't found in his room. S8RN entered the bathroom after a verbal warning that she was entering. Both patients were standing in the shower fully clothed. Both denied physical contact. Denied any sexually inappropriate behavior.

January 20, 2018
Review of Patient #1's medical record revealed he had been admitted on 1/16/18 with a Physician's Emergency Certificate for being homicidal.

Review of Patient #3's medical record revealed she had been admitted on 1/19/18 with diagnosis of Axis II Traits and Manipulation.

Review of Patient #1's Daily Nursing Note revealed the following entry dated 1/20/18 at 9:20 p.m.: Patient (Patient #1) found in bathroom of room "A". A female patient was also in room "A" sitting on bed "A" topless. Patient denies anything happened. Female patient (Patient #3) states they had sexual intercourse.

Review of the hospital's quality data revealed the following documented in the 4/19/17 meeting minutes: There were 2 significant events in March, both related to sexual allegations. The first allegation has been reported to the state as appropriate and the case has been closed. Authorities are still investigating the second allegation. In the meantime, S5RiskMgr conducted a root cause analysis with frontline staff to review the incidents. An additional MHT has been added to unit B. (Unknown Name) is reeducating her staff on the importance of observation rounding as appropriate. S1Adm instituted leadership rounding during the night shift once per week by Administrator on Call for that week.
Further review revealed no documentation of the hospital following-up to determine if the measures put in place on 4/19/17 for alleviating the identified problem were successful and no documentation of tracking and trending of future similar adverse events.

In an interview on 1/31/18 at 10:00 a.m. with S5RiskMgr, she said there were 2 sexual encounters between male and female patients in March of 2017 which was discussed in April of 2017 at the Quality meeting. She said they instituted that administration on call would make an appearance on the evening shift once a week to ensure observations were being done as ordered by staff, but the weekly observations did not last very long. She also said they added a MHT to Unit B but for only a short time. In the May Quality meeting, she verified it had not been discussed if the measures put in place had been successful. She verified there was no documentation in the hospital's Quality meeting minutes analyzing, tracking, trending, or putting measures in place to prevent these adverse patient events since May of 2017 but said there should have been. She said she did not identify these encounters as a problem until the last incident this month. S5RiskMgr also verified psychiatric patients could not consent to sex while being held in a psychiatric hospital.

In an interview on 1/31/18 at 10:20 a.m. with S2DON, she said she participated in Quality Assurance at the hospital. She said she was not aware of the above mentioned male and female encounters except for the one on 1/20/18. S2DON said it certainly should have been reviewed by the hospitals Quality committee. S2DON verified as of now nothing has been implemented at the hospital, to her knowledge, to correct the problem of males and females going undetected into patients' rooms other than every 15 minute observations.

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Based on observation, record reviews and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient as evidenced by:

1. failing to ensure male and female patients were not allowed to enter patients' rooms undetected for 6 (#R1, #R2, #R3, #R4, #1, #3) of 6 patient's having sexual intercourse and 2 (#4, #5) of 2 patients hiding in a patient's shower stall; and

2. failing to maintain ordered observation levels for 1 (#R5) of 1 patient ordered to be maintained in direct line of sight during waking hours; and

3. failing to maintain patient to staff ratios per hospital policy for 14 (#4, #5, #R6, #R7, #R8, #R9, #R10, #R11, #R12, #R13, #R14, #R15, #R16) of 14 patients; and

4. failing to ensure on the patients' Observation Log that patient observation levels were accurate for 4 (#1, #3, #4, #5) of 4 (#1, #3, #4, #5) patients on increased observation precautions.

Findings:

1. Failing to ensure male and female patients were not allowed to enter patients' rooms undetected.

On 1/30/18 at 10:30 a.m. review of the Patient Handbook revealed in-part, only room occupants and staff are allowed in patient's rooms. No visitors are allowed in rooms.

March 17, 2017
Review of Patient #R1's incident report revealed she had been admitted to the psychiatric hospital on 3/16/17 with Bipolar II Disorder and Borderline Personality Disorder.

Review of Patient #R2's incident report revealed he had been admitted to the psychiatric hospital on 3/17/17 with diagnosis including Major Depressive Disorder, Generalized Anxiety Disorder and Impulse Control.

Review of the Alleged Incident Investigation Report for incident dated 3/17/2017 revealed in part: Friday, March 17, 2017 at approximately 9:40 p.m., patient #R1 and patient #R2 were caught having sexual intercourse in patient #R1's room. S6MHT caught them. Once caught, both patients stated "I got caught." Further review revealed Patient #1 said the sex was not consentual and the local police were notified.

March 24, 2017
Review of Patient #R3's incident report revealed she had been admitted to the psychiatric hospital on 3/18/17 with diagnosis including Major Depressive Disorder.

Review of Patient #R4's incident report revealed he had been admitted to the psychiatric hospital on 3/21/17 with diagnosis including Schizoaffective Disorder.

Review of the Alleged Incident Investigation Report for incident dated 3/24/ 2017 revealed in part: On Friday, March 24, 2017 at approximately 7:46 p.m., Patient #R3 and Patient #R4 had sexual intercourse in Patient #R3's room. S7MHT saw Patient #R4 exiting Patient #R3's room. Both patients admitted to having consensual sex.

December 26, 2017
Review of Patient #4's medical record revealed he had been admitted to the psychiatric hospital on 12/20/17 with diagnosis including Suicidal Ideation and Paranoid Schizophrenia.

Review of Patient #5's medical record revealed she had been admitted to the psychiatric hospital on 12/25/17 with diagnosis including Schizoaffective Disorder, Bipolar type.

Review of the Alleged Incident Investigation Report for an incident dated 12/26/2017 revealed in part: Patients involved were Patient #4 and Patient #5. Patient #4 was observed on the unit at 8:05 p.m. Sometime between 8:05 p.m. and 8:08 p.m. both patients went into Patient #5's bathroom. At 8:08 p.m., S8RN entered Patient #5's room looking for the patients. The patient door was wide open but the bathroom door was closed. S8RN asked Patient #5 if she is in the bathroom. Patient #5 responded that she was in the shower then turned the water on. At that time, the other staff members reported that Patient #4 wasn't found in his room. S8RN entered the bathroom after a verbal warning that she was entering. Both patients were standing in the shower fully clothed. Both denied physical contact. Denied any sexually inappropriate behavior.

January 20, 2018
Review of Patient #1's medical record revealed he had been admitted on 1/16/18 with a Physician's Emergency Certificate for being homicidal.

Review of Patient #3's medical record revealed she had been admitted on 1/19/18 with diagnosis of Axis II Traits and Manipulation.

Review of Patient #1's Daily Nursing Note revealed the following entry dated 1/20/18 at 9:20 p.m.: Patient (Patient #1) found in bathroom of room "A". A female patient was also in room "A" sitting on bed A topless. Patient denies anything happened. Female patient (Patient #3) states they had sexual intercourse that was consensual.

In an interview on 1/31/18 at 10:00 a.m. with S5RiskMgr, she said there were 2 sexual encounters by male and female patients in March of 2017 which was discussed in April of 2017 at the Quality meeting. She said they instituted that administration on call would make an appearance on the evening shift once a week to ensure observations were being done as ordered by staff, but it did not last very long. She also said they added a MHT to Unit B but for only a short time and education had been done. In the May meeting, it was not discussed in the Quality meeting if the measures put in place had been successful. S5RiskMgr verified there was no documentation in the hospital's Quality meeting minutes analyzing, tracking, trending, or putting measures in place to prevent these adverse patient events since May of 2017 but said there should have been. S5RiskMgr said she did not identify these patients' encounters as a problem until the incident this month.

In an interview on 1/31/18 at 10:20 a.m. with S2DON, she said she was not aware of the above mentioned male and female encounters except for the one on 1/20/18. S2DON verified as of now nothing has been implemented at the hospital, to her knowledge, to correct the problem of males and females going undetected into patients' rooms except every 15 minute observations.


2. Failing to maintain a ordered observation levels for 1 (#R5) patients ordered to be maintained in direct line of sight during waking hours.

Review of Policy Number NU 432, Level of Observation- Therapeutic Safety Measures revealed in part: Level 2- line of sight observation during waking hours: Line of sight means staff visually observing assigned patient(s) by scanning the patient care area. A staff member may observe more than one patient at a time but the patient must remain in the assigned staff member's visual eye sight at all times. Level 2 patients cannot be in patient bed rooms during waking hours and must be monitored and have door ajar when using bathrooms.

Review of Patient #2's medical record revealed she had been admitted on 1/18/18 with the diagmnosis of Psychosis.

On 1/30/18 at 11:00 a.m. an observation on Unit A revealed Patient #R5 was in her bed in her bedroom with no staff member directly observing her. S9MHT was the only MHT observed on the unit.

In an interview on 1/30/18 at 11:05 a.m. with S9MHT, she verified she was not able to maintain line of sight on Patient #R5 while conducting her 15 minute checks on the other 15 patients. S9MHT said she was the only technician on the unit.

In an interview on 1/30/18 at 11:15 a.m. with S10RN, she verified S9MHT could not watch Patient #R5 in her line of sight and monitor the other 15 patients on the unit every 15 minutes. S10RN stated said Patient #R5 wanders into other patient's rooms on the unit and was up all night and was now sleeping.


On 1/31/18 at 10:00a.m. S2DON reviewed the hospital policy and verified a patient on level 2 observation should not be allowed to sleep in their room during waking hours and should be in line of sight at all times.

3. Failing to maintain patient to staff ratios per hospital policy.

A review of Policy Number NU 432 last revision date revealed in part:
B. Level 2- Line of sight Observation During Wakin Hours.
During hours of sleep, staff members will be strategically placed outside assigned patient rooms to ensure that patients are monitored and a one (1) to six (6) staff to patient ratio is maintained at all times.

On 1/30/18 a review of the assignment sheet and Observation Logs for 12/26/18 7:00 p.m - 7:00 a.m revealed 1 RN, 1 LPN and 1 MHT were scheduled and working. At 7:00 p.m. S12MHT was assigned to make observations of 14 patients with the following acuity levels: 12 (#4, #5, #R6, #R7, #R8, #R9, #R11, #R12, #R13, #R14, #R16) patients were level 1 (15 minute observations) and 2 (#R10, #R15) patients were level 2 (line of sight). At 8:20 p.m. Patient #4's and Patient #5's levels were changed from level 1 to level 2, because they were caught hiding in a shower together, which gave S12MHT an assignment of 4 line of sight patients and 10 patients with every 15 min checks from 8:20 p.m. to 7:00 a.m. A review the Observation log sheets for the 14 patients on the unit revealed S12MHT had signed off on all 14 patients every 15 minutes except for a 30 minute break from 2:45 a.m. through 3:15 a.m.

On 1/3/2018 at 9:40 a.m. an interview was conducted with S2DON who reviewed the staffing policy and stated each staff member could monitor up to 6 patients if any were a level 2 or up to 6 level 2 patients. S2DON also verified only one MHT was monitoring 14 patients on the 7:00 p.m. to 7:00 a.m. shift beginning on 12/26/18.


4. Failing to ensure documentation on the patients' Observation Logs was accurate for patients on increased observation precautions.

Patient #1
Review of Patient #1's medical record revealed a physician's order dated 1/20/18 at 10:45 to place Patient #1 on sexual precautions.

Review of Patient #1's observation sheets dated 1/20/18 and 1/21/18 revealed no documentation he was placed on sexual precautions.

Patient #2
Review of Patient #2's medical record revealed a physician's order dated 1/20/18 at 10:45 to place Patient #2 placed on sexual precautions.

Review of Patient #2's observation sheets dated 1/21/18 revealed no documentation she was placed on sexual precautions.

Patient #4
Review of Patient #4's medical record revealed a physician's order dated 12/26/17 at 8:20 p.m. to increase Patient #4 from level 1 to level 2 precautions.

Review of Patient #4's observation sheets dated 12/26/17 revealed no documentation of increased observation levels.

Patient #5
Review of Patient #5's medical record revealed a physician's order dated 12/26/17 at 8:20 p.m. to icrease Patient #5 from level 1 to level 2 precautions.

Review of Patient #5's observation sheets dated 12/26/17 revealed no documentation of increased observation levels.

On 1/31/18 at 9:40 a.m. an interview was conducted with S2DON who verified the above mentioned patients did not have documentation of their increased observation levels on their Observation Logs.

Based on policy review, record review and interview, the hospital failed to ensure each patient had a comprehensive treatment plan. This deficient practice is evidenced by failing to update the treatment plan with a change in status for 4 (#1, #3, #4, #5) of 5 (#1, #2, #3, #4, #5) patients sampled.

Findings:

Review of policy number NU453, Interdisciplinary Treatment Planning- Overview last revision 7/12/17 revealed in part, the treatment planning process is continuous, beginning at the time of admission and continues through discharge.

Patient #1
Review of Patient #1's Daily Nursing Note dated 1/20/18 at 9:20 p.m. revealed the following entry: Patient found in bathroom of room "A". A female patient was also in room "A" sitting on bed A topless. Patient denies anything happened. Female patient states they had sexual intercourse that was consensual.

Review of Patient #1's medical record revealed a physician's order dated 1/20/18 at 10:45 to place Patient #1 on sexual precautions.

Review of Patient #1's medical record revealed no update in the treatment plan for ordered sexual precautions.

Patient #3
Review of Patient #3's Daily Nursing Note dated 1/20/18 at 9:20 p.m. revealed the following entry: Patient found by staff (this writer) in room "A" bed "A". She was sitting in the bed topless and was putting her shirt back on. A male patient was in the bathroom of room "A". Patient #3 states that they had sexual intercourse that was consensual. She was smiling and stated, "I'm just impulsive I guess".

Review of Patient #3's medical record revealed a physician's order dated 1/20/18 at 10:45 p.m. to place Patient #3 on sexual precautions.

Review of Patient #3's medical record revealed no update in the treatment plan for ordered sexual precautions.

Patient #4
Review of Patient #4's Daily Nursing Note dated 12/26/17 at 8:05 p.m. revealed the following entry: Pt observed walking on unit talking with female patient. Sometime between 8:05 p.m. and 8:08 p.m. both female patient and male patient go unseen into female patient's room's bathroom. Both patients standing in the shower fully dressed. Both patients denied any physical contact.

Review of Patient #4's medical record revealed a physician's order dated 12/26/17 at 8:20 p.m. to place the patient on level 2 aggression precautions - keep aggression precautions.

Review of Patient #4's medical record revealed no update in the treatment plan for the ordered level change.

Patient #5
Review of Patient's Daily Nursing Note dated 12/26/17 at 8:05 p.m. revealed the following entry: Pt observed walking on unit talking with male patient. Sometime between 8:05 p.m. and 8:08 p.m. both Patient #5 and male patient go unseen into patient's room's bathroom. Both patients standing in the shower fully dressed. Both patients denied any physical contact.

Review of Patient #5's medical record revealed a physician order dated 12/26/18 at 8:20 p.m. to change the patient's observation level to 2.

Review of Patient #5's medical record revealed no update in the treatment plan for the ordered level change.

In an interview on 1/31/18 at 9:40 a.m. with S2DON, she verified if observation levels changed or precautions were put in place then the patients' treatment plans should have been updated. S2DON also verified Patient #1 and Patient #3 did not have an updated treatment plan when sexual precautions were initiated on 1/20/18 but should have. Also, she verified Patient #4 and Patient #5 had orders to change the observation levels from 1 to level 2; however, the treatment plans were not updated to reflect this change.








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