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Based on observation, record review, and interview, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to protect and promote each patient's rights as evidenced by:
1) failure of the hospital to provide continuous line of sight supervision as ordered by the physician for 1 (#2) of 4 (#1-#4) psychiatric patients observed with potential ligature risk (See findings under A-0144);
2) failure to notify psychiatric physician following an incident of self-injurious behavior in Patient #1 potentially leading to a 2nd self-injurious behavior incident (See findings under A-0144);
3) failure to ensure psychiatric patients did not have access to items and contraband considered potential risks for self-harm or harm to others (See findings under A-0144);
4) failure to ensure each patient was accurately identified per psychiatric hospital policy in 2 (#R5 and #R23) of 2 (#R5 and #R23) patients observed (See findings under A-0144);
5) failure to ensure observation check sheets with precautions were implemented per policy in 12 (#R11-#R22) of 29 (#2, #R1-#R28) Patient Observation Sheets reviewed (See findings under A-0145).
6) failure to have the patient/patient representative/nurse sign the statement of Patient Acknowledgment of rights in 1 (#4) of 4 (#1-#4) patients sampled (See findings under A-0116);
7) failure to ensure the patient /patient representative was included in the development and implementation of the patient's plan of care for 1 (#4) of 4 (#1- #4) patients sampled (See findings under A-0130); and
8) failure to ensure each patient or patient representative was provided information about his/her health status, diagnosis, and prognosis in order to make "informed" decisions regarding his/her care. This deficient practice is evidenced by the lack of a signed informed consent form for 1 (#4) of 4 (#1-#4) patients sampled (See findings under A-0131).

Based on record review and interview the psychiatric hospital failed to ensure that the medical record contained documented evidence of patient notification of their rights. This is evidenced by failing to have the patient/patient representative/nurse sign the statement of Patient Acknowledgment of rights in 1 (#4) of 4 (#1-#4) patients sampled.
Findings:

Review of the psychiatric hospital's policy #: RTS-01, titled. "Patient Rights Louisiana", Revised: 09/01/2023, revealed in part: Policy: ...Every patient shall receive a written copy of their rights ...and shall sign an acknowledgement that they are aware of their rights. The written copy shall include all applicable state and federal rights protections afforded to the patient. Procedure: ...4. If the patient is cognitively and/or physical unable to sign and comprehend this information about their rights, the patient's guardian or a family member will be so informed and will sign for them as legally appropriate.

Continued review of the psychiatric hospital's policy #: RTS-01, titled. "Patient Rights Louisiana", Revised: 09/01/2023, failed to reveal the patient had the right to receive care in a safe setting.

Review of Patient #4's medical record revealed an admission date of 10/31/2024 under a Formal Voluntary Admission that was later changed by spouse to Non-Contested Admission. Continued review failed to reveal evidence Patient #4 or her spouse were given the opportunity to acknowledge that they were aware of all patient rights.

In an interview on 11/07/2024 at 10:40 a.m., S4QD verified the psychiatric hospital policy did not include the patient right for care in a safe setting.

In an interview on 11/07/2024 at 4:05 p.m., S4QD confirmed the medical record failed to reveal evidence Patient #4 or her spouse were given the opportunity to acknowledge that they were aware of all patient rights.

Based on record review and interview, the psychiatric hospital failed to ensure the patient /patient representative's right to participate in the development and implementation of his or her plan of care was met. This deficient practice was evidenced by failure to ensure the patient /patient representative was included in the development and implementation of the patient's plan of care for 1 (#4) of 4 (#1- #4) patients sampled.
Findings:

Review of the psychiatric hospital's policy #: RTS-01, titled. "Patient Rights Louisiana", Revised: 09/01/2023, revealed in part: ...Exhibit A: Rights of Persons Suffering from Mental Illness and Substance Abuse Summarized in Layman Terms. You are guaranteed certain rights by the Constitution. Through state and federal law, you are guaranteed additional rights as follows ....Treatment ...You have a right to be involved in making decisions regarding the nature of care, treatment, and services that you will receive and to make decisions about your care. If you are unable to make decisions about the care, treatment, and services, the rights of involvement of family/surrogate decisions maker instated on the patient's behalf will be respected in accordance law and regulations.

Review of Patient #4's medical record revealed an admission date of 10/31/2024 with diagnosis of Major Depressive Disorder and Anxiety.

Review of Patient #4's medical document titled "Treatment Plan" dated 10/31/2024 failed to reveal evidence Patient #4 or her spouse participated in her plan of care.

In an interview on 11/07/2024 at 4:08 p.m., S4QD confirmed the medical record failed to reveal evidence Patient #4 or her spouse participated in her plan of care.

Based on record review and interview the hospital failed to ensure each patient or patient representative was provided information about his/her health status, diagnosis, and prognosis in order to make "informed" decisions regarding his/her care. This deficient practice is evidenced by the lack of a signed informed consent form for 1 (#4) of 4 (#1-#4) patients sampled.
Findings:

Review of psychiatric hospital's policy titled "Informed Consent, Care Decisions, and Conflicts Resolution", revised 12/01/2024, revealed in part: ...Policy: The facility recognizes the benefit and the need to involve patients and significant others, when appropriate in care treatment and services decisions, conflict resolution and to ensure that appropriate informed consent is obtained as outlined by the State, Federal and other regulatory bodies. Procedure: Informed Consent 1. The Governing Body/Administration dictates that informed consent is mandatory on those procedures, care, treatment, and services normally requiring informed consent and mandates that all staff responsible for the delivery of care, treatment and services educate patients/patient's family/representative to allow for informed decision making as to participate in the care, treatment, and services being delivered. 3. The facility will, during the admission process, obtain signature on informed consent forms. If the patient is unable to sign due to physical impairments, verbal consent can be obtained and documented with two witnesses. In the case of involuntary commitment, the facility will follow the policies of the organization related to involuntary admission. 4. Specific informed consent is required in the following circumstances: Facility treatment programming/admission.

Review of Patient #4's medical record revealed an admission date of 10/31/2024 under a Formal Voluntary Admission that was later changed by spouse to Non-Contested Admission. Continued review failed to reveal evidence Patient #4 or her spouse signed an informed consent form acknowledging that they were provided information about Patient #4's health status, diagnosis, and prognosis in order to make "informed" decisions regarding her care.

In an interview on 11/07/2024 at 4:05 p.m., S4QD confirmed the medical record failed to reveal evidence Patient #4 or her spouse signed an informed consent form.

Based on observation, record review, and interview, the psychiatric hospital failed to ensure patients received care in a safe setting as evidenced by:
1) failure of the hospital to provide continuous line of sight supervision as ordered by the physician for 1 (#2) of 4 (#1-#4) psychiatric patients observed with potential ligature risk;
2) failure to notify psychiatric physician following an incident of self-injurious behavior in Patient #1 potentially leading to a 2nd self-injurious behavior incident;
3) failure to ensure psychiatric patients did not have access to items and contraband considered potential risks for self-harm or harm to others;
4) failure to ensure each patient was accurately identified per psychiatric hospital policy in 2 (#R5 and #R23) of 2 (#R5 and #R23) patients observed;
5) failure to conduct a contraband search of each patient per psychiatric hospital policy in 4 (#1-#4) of 4 (#1-#4) patients reviewed; and
Findings:

1) Failure of the hospital to provide continuous line of sight supervision as ordered by the physician for 1 (#2) of 4 (#1-#4) psychiatric patients observed with potential ligature risk.
Review of psychiatric hospital's policy #: CS-23 titled "Level of Observations" revealed in part ...Observation Levels: ...Line of Sight (Constant Observation)-the staff member will ensure the patient is visually within sight at all times ...

Review of Patient #2's medical record revealed an admission date of 11/04/2024 at 8:35 p.m. with a diagnosis of Psychosis, visual hallucinations, paranoia, impulsivity, violence, COPD on oxygen therapy, UTI, hypertension, diabetes, and atrial fibrillation.

Review of Patient #2's physician orders dated 11/05/2024 at 9:00 a.m. revealed observation level, continuous line of sight due to oxygen tubing required with oxygen therapy.

Review of Patient #2's observation sheet dated 11/05/2024 from 7:00 a.m. until 6:45 a.m. on 11/06/2024 revealed observation level indicated every 15 minutes observation.

On 11/06/2024 from 10:22 a.m.-11:45 a.m. a review of video footage was navigated by S4QD for the location 'A', on 11/05/2024 from 7:00 p.m. through 11/06/2024 at 8:51 a.m. The review failed to reveal Patient #2 was continuously in line of sight of nursing staff from 7:00 p.m. until 8:50 a.m. At 8:51 a.m. on 11/06/2024, the video revealed an MHT pulling up a chair to Patient #2's doorway for continuous line of sight observation.

In an interview on 11/06/2024 at 12:17 p.m., S4QD confirmed the above findings as observed on video. S4QD verified the observation sheet dated 11/05/2024 failed to indicate that Patient #2 was on continuous line of site observations as ordered by the physician.

In an interview on 11/06/2024 at 3:05 p.m., S4QD verified that Patient #2 had physician orders for continuous, line of sight observations due to the tubing required for oxygen therapy and patient diagnoses of Psychosis, visual hallucinations, paranoia, impulsivity, and violence.

2) Failure to notify physician following an incident of self-injurious behavior in Patient #1 potentially leading to a 2nd self-injurious behavior incident.
Review of psychiatric hospital's policy #: AS-19 titled, "Suicide/Homicide Risk Assessment", revised 11/01/2013, revealed in part: Procedure: Inpatient: ...3 ....Report and document any suicidal/homicidal/violence ideation/plan to the ...physician immediately ...

Review of psychiatric hospital's policy #: NSG-02 titled, "Documentation", revised on 01/01/2023 revealed in part: ...Routine: 1. RN and/or LPN documents ...any notifications or issues reported to the physician or non-physician practitioner ...

Review of Patient #1's medical record revealed a date of birth of 10/16/2009 with an admission to the Kentwood location on 09/04/2024 with a diagnoses of Major Depressive Disorder and Homicidal Ideations.

Review of Patient #1's Psychiatric evaluation dated 09/04/2024 revealed patient with history of self-injurious behavior and suicidal ideation.

Review of physician orders dated 09/26/2024 at 8:00 p.m. revealed Suicide/Self Harm Precautions Continuous.

Review of self-report dated 10/21/2024 at 5:47 p.m. revealed Patient #1 went into bathroom and broke off a piece of plastic and then went into the hallway and began scratching his neck, causing superficial cuts. Then proceeded to the boys' dayroom, where his injury was noted by social worker and nurse. Further review failed to reveal Patient #1's psychiatrist, S12PMD or delegate was notified of the self-injurious behavior.

Review of nursing note dated 10/21/2024 at 5:30 p.m. failed to reveal S12PMD or psychiatric delegate was notified of the self-injurious behavior.

Review of Self-Report dated 10/29/2024 at 4:09 p.m. revealed Patient #1 was let into the bathroom, where he broke off a piece of plastic, then went into a hallway and made scratches to left wrist. Further review revealed S12PMD was notified of this incident.

Review of physician orders dated 10/29/2024 at 8:00 p.m. revealed Line of Sight- continuous observation.

In an interview on 11/07/2024 at 11:36 a.m., S4QD confirmed S12PMD or psychiatric delegate should have been notified of the self-injurious behavior on 10/21/2024, especially in light of the patient history of self-injurious and suicidal behaviors stated in the psychiatric evaluation on admission.

3) Failure to ensure psychiatric patients did not have access to items and contraband considered potential risks for self-harm or harm to others.
Review of psychiatric hospital's policy #: EOC-28 titled, "Safety Inspection of all Areas", revised on 08/01/2024 revealed in part: Purpose: To monitor the physical environment to ensure patient safety and compliance with regulatory standards. Policy: areas of the facility shall be inspected to ensure that safety standards are being met, that when deficiencies are found corrective action is taken. Procedure ...2. The nursing department completes a safety walk through patient care areas every shift to assess the environment for potential unsafe conditions...Day shift safety and security rounds to be done at the beginning of every shift ...

Review of psychiatric hospital's policy #: NSG-222 titled, "Body and Belongings Search", revised on 07/01/2024 revealed in part: Procedure ...7. Contraband items include the following ...Substances containing alcohol (such as mouthwashes ...) ...Any substance or object flet to be potentially injurious to the patient or that may be used as a weapon.

Observations during tour of location 'A' on 11/06/2024 from 8:25 a.m.-9:30 a.m. guided by S9QA revealed the following in part:

8:26 a.m. area 'a': observed a box of Styrofoam cups in a large plastic bag next to garbage can lined with plastic bag next to the 2 scales where patients are weighed on intake.
8:27 a.m. area 'b': observed 2 garbage cans lined with empty plastic bags next to storage container with urine cups and paper bags.
8:47 a.m. area 'c': observed a large garbage can lined with large plastic bag and 2 bottles of shaving cream.
8:50 a.m. patient room 'd': observed water-like substance noted to bedroom floor leading from bed into bathroom. Continued observation revealed 2 wet bath towels laying in water covering the bathroom floor.
8:58 a.m. patient room 'e': observed wet bathroom floor with unattended shower chair made of pvc-type pipe. A toothbrush on floor with bottle of body wash.
9:03 a.m. patient room 'f': observed bathroom with toothbrush on sink with toothpaste cap.
9:11 a.m. room 'g': observed plastic cup holder with large vice-like mounting screw that twists out of the cup holder.
9:13 a.m. room 'h': observed with paper bag containing 4 bottles of shampoo, deodorant, bottle of mouthwash, and a bottle of shaving cream. In an interview on 11/06/2024 at 9:13 a.m., The Patient #R19 stated, "they gave it to me."
9:22 a.m. room 'i': observed shampoo and deodorant on sink. Unattended shower chair made of pvc-type pipe. Shampoo in crevice of handrail.

In an interview on 11/06/2024 at 9:25 a.m., S9QA confirmed the above findings as contraband and items considered potential risks for self-harm or harm to others. S9QA stated the items should be removed immediately.

Observations during tour of location 'B' on 11/07/2024 from 9:23 a.m.-9:55 a.m. guided by S1DON and S9QA revealed the following:
9:31 a.m. room 'j': observed panel on the ceiling with 3-Phillip's head-type screws.
In an interview on 11/07/2024 at 9:31 a.m., S1DON and S9QA confirmed the 3-Phillip's head-type screws were a safety risk and need to be removed immediately.
9:46 a.m. room 'k': observed toothbrush contained in a plastic cylinder noted to bedside shelf.

In an interview on 11/07/2024 at 9:46 a.m., S1DON and S9QA confirmed the toothbrush and the plastic cylinder were considered contraband and should be removed immediately.

4) Failure to ensure each patient was accurately identified per psychiatric hospital policy in 2 (#R5 and R23) of 2 (#R5 and R23) patients observed.
Review of psychiatric hospital's policy #: EOC-103 titled, "Hospital Armbands", Effective 04/01/2020 revealed in part: Purpose: A clearly defined and consistently implemented practice for identifying patients and communicating patient risk factors, precautions, or special needs by standardizing the use of color-coded bands to support optimal safe care ...Policy ...All patients will be accurately identified prior to receiving any care, treatment or services consistently in all inpatient settings. To establish guidelines to ensure patient safety ...utilizing preprinted color-coded alert wristbands ...Procedure for Identification ...5. All inpatients will have an ID band placed before treatment is initiated ...Patient Care Provider at Point of Care will ...2. Prior to care, treatment, or procedure, the patient is to be identified ...Procedure For Arm Band Placement/Removal/Refusal: 1. When patient's identity cannot be verified because the imprinted band is ...missing, no services will be performed until the patient ID band is properly replaced. 2. ...missing bands shall be replaced immediately with a new band ...3. A multidisciplinary note will be completed when a patient ID band is found to be missing ...4. If a patient refuses to wear the ID band they must have the ID band in their possession and present it to the department for testing/treatment/procedure ...

Review of psychiatric hospital's policy #: NSG-25 titled, "Principles of Medication Administration", revised on 02/01/2024 revealed in part: Purpose: To establish guidelines to promote the safety of patients ...Procedure ...5. When utilizing an e-Mar through the Electronic Medical record (EMR) the nurse will identify the patient via scanning the barcode located on the patient's identification armband ...

Observations during tour of location 'A' on 11/06/2024 from 8:25 a.m.-9:30 a.m. guided by S9QA revealed the following in part:
9:07 a.m. room 'l': observed armband laying on bedside table with Patient #R5's name. In an interview on 11/06/2024 at 9:07 a.m., Patient #R5 stated the arm band fell off of his arm "a couple of days ago".
9:18 a.m. room 'm': observed armband laying on bedside table with Patient #R23's name.

In an interview on 11/06/2024 at 9:26 a.m., S9QA confirmed the above findings and stated the armbands should be immediately replaced with new armbands for both patients.

On 11/06/2024 from 10:22 a.m.-11:45 a.m. a review of video footage navigated by S4QD for location 'A' on 11/05/2024 from 7:00 p.m. through 11/06/2024 at 8:51 a.m. 10:06 p.m. revealed the following:
10:06 p.m.: Patient #R5 at nurses' station window speaking with nurse. Observation failed to reveal an armband on Patient #R5's right or left wrist.

In an interview on 11/06/2024 at 10:40 a.m., S4DQ confirmed the above observation.

5) Failure to conduct a contraband search of each patient per psychiatric hospital policy in 4 (#1-#4) of 4 (#1-#4) patients reviewed.
Review of psychiatric hospital's policy #: NSG-02 titled, "Documentation", revised on 01/01/2023 revealed in part: Admission: 1. The nurse records a notation of the admission information in the medical record which can include the following information ...Patient searched/Belongings Searched ...

Review of psychiatric hospital's policy #: NSG-22 titled, "Body & Belongings Search", revised on 07/01/2024 revealed in part: ...Inpatient ...1. Nursing staff are responsible for conducting the admission body and belongings search ...8. The licensed nurse will document in the patient's medical record that a body search was conducted, rationale for body search, persons present at the time of the search disposition of contraband found and patients response to the search.

A review of Patients' #1-#4 medical records failed to reveal evidence a contraband search was conducted or documented per hospital policy.

In an interview on 11/06/2024 at 3:26 p.m., S4QD verified that Patients' #1-#4 medical records failed to reveal evidence a contraband search was conducted or documented per hospital policy.

Based on record review, and interview the hospital failed to provide an environment free from neglect. This deficient practice is evidenced by failure to ensure observation check sheets with precautions were implemented per policy in 12 (#R11-#R22) of 29 (#2, #R1-#R28) Patient Observation Sheets reviewed.
Findings:
Review of psychiatric hospital's policy #: RTS-10 titled, "Abuse and/or Neglect of Patients by Staff Members, Students, Interns", revised on 01/11/2016 revealed in part: ...Policy ...Neglect is the failure to provide the proper or necessary medical care ...for a consumer's well-being ...Examples of actions/inactions which could be considered mistreatment/abuse include: ...Failing to or refusing to attend to the necessary care and treatment ...Implementing actions contrary to the prescribed treatment of the program.

Review of psychiatric hospital's policy #: CS-23 titled "Level of Observations" revised 03/01/2023, revealed in part ...Procedure ...3. Staff members utilize the close observation checklist form (Q15 check sheet) to document the ongoing observation and location of the patient. Additional information regarding activities are included on the form when relevant ...The observing staff initials the 15-minute increments on the form to indicate the patient was observed. This form ...will also be utilized for 1:1 monitoring when a stricter level of monitoring is ordered and will be notated as such on top of form ....

On 11/06/2024 at 8:41 a.m., observation sheets were provided by S12RN as the observation sheets to be utilized by the day shift staff on 11/06/2024 starting at 7:00 a.m. A review of the observation sheets revealed 12 (#R11-#R22) of 29 (#2, #R1-#R28) observation sheets that were blank except for the date, 11/06/2024, the initials of S12RN indicating the nurse had validated MHT rounds, and S12RN's signature at the bottom of the page. Additionally, the 12 observation sheets were on the nurses' unit desk and not with the MHTs for use. The 12 sheets failed to reveal observation levels for each patient. Further review failed to reveal MHT initials on the 12 observation sheets indicating rounds were conducted from 7:00 a.m. until 8:41 a.m.

In an interview on 11/06/2024 at 8:45 a.m., S9QA verified the above findings.

In an interview on 11/06/2024 at 9:50 a.m., S4QD verified the above findings.

Based on record review and interview the psychiatric hospital failed to ensure a registered nurse assigned the nursing care of each patient to other nursing personnel in accordance with Hospital policy and the patient's needs. This deficiency is evidenced by failing to ensure a Registered Nurse completed patient care assignments at the beginning of shift for 29 (#2, #R1-#R28) of 29 (#2, #R1-#R28) patients on the census
Findings:

Review of psychiatric hospital's policy #: NSG-05 titled "Nursing Assignments", revised 06/01/2023, revealed, in part: ...Policy: It is the charge nurse's responsibility to complete the nursing assignment sheet at the onset of every shift.

On 11/06/2024 at 8:39 a.m. a review of psychiatric hospital document titled "7A-7P Assignment Sheet", dated 11/06/2024 failed to reveal assignments made for 29 (#2, #R1-#R28) of 29 (#2, #R1-#R28) patients on the census for 11/06/2024.

In an interview on 11/06/2024 at 8:39 a.m., S12RN and S9QA verified the assignment sheet was not completed.

In an interview on 11/06/2024 at 10:05 a.m., S2DQ verified the nursing shift began at 7:00 a.m. and the assignment sheet should have been completed.