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Based on observation and interviews, the hospital failed to ensure patients requiring acute inpatient psychiatric care, who have been admitted for being a danger to self and others, received care in a safe setting. This deficient practice was evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients for ligature risks and safety risks.

Findings:

A tour of the hospital between 9:15 a.m. and 9:45 a.m. with S4Quality revealed:

Patient rooms a and d contained oxygen concentrators with electrical cords and nasal cannula tubing attached, which could be used for strangulation. Both rooms were unsecured and accessible to all patients.

Patient room b A bedside table missing the top exposing cross bars, which could be used as a ligature point.

In an interview on 10/04/2021 at 9:45 a.m., S4Quality verified the above findings.

Based on record review and interview, the hospital failed to ensure the RN who performed the face-to-face evaluation after the initiation of restraints or seclusion consulted with the attending physician as soon as possible after the evaluation for 1 (#4) of 1 patient records reviewed for restraints or seclusion.

Findings:

Review of policy titled "Seclusion and Restraints" revealed in part:
If the RN performs the one-hour face-to-face assessment, conduct post face-to-face evaluation review of findings with physician. Document contact/review.

Review of Patient #4's medical record revealed he had been placed in seclusion on 07/22/2021 at 9:50 a.m. for imminent and serious danger to others.

Review of Patient #4's medical record revealed an one hour evaluation had been completed by S5RN on 07/22/2021 at 11:30 a.m. Further review revealed no documentation of physician notification of the findings of the one hour face to face evaluation.

In an interview on 10/05/2021 at 3:40 p.m. S2DON confirmed there was no documentation of physician notification about the RN's one hour face to face evaluation.

Based on record review and interview, the facility failed to assure the registered nurse provided supervision of nursing care for each patient. This deficiency is evidenced by failure of the registered nurse to complete every two hour checks of mental health technician direct observations in 5 (#2, #4, #6, #7 and #8) of 10 (#1-#10) patient records reviewed.
Findings:

Review of hospital policy NSG-06 titled, "Staffing Policy reveals in part, "A registered nurse is responsible to supervise all licensed practical/ vocational nurses (LPN/ LVN), Mental Health Techs (MHT) and Certified Nursing Assistants (CNA).

Review of the Observation Check Sheet/ Graphic Flowsheet reveals the patient is to be observed and the location and clinical status noted by the mental health technician every fifteen minutes. The sheet is to be signed by the mental technician every fifteen minutes and the registered nurse every two hours.

Patient #2
Review of the Observation Check Sheet/ Graphic Flowsheet for Patient #2 revealed the registered nurse failed to sign the flowsheet on 08/21/2021 between 7:00 p.m. and 7:00 a.m., 08/26/2021 at 3:00 p.m. and 5:00 p.m., and on 9/4/2021 at 7:00 p.m.

Patient #4
Review of the Observation Check Sheet/Graphic Flowsheet for Patient #4 revealed the registered nurse failed to sign the flowsheet on 07/20/2021 between 5:00 p.m. and 11:00 p.m.; 07/21/2021 between 1:00 a.m. and 5:00 a.m.; 07/22/2021 between 7:00 a.m. and 5:00 p.m.; 07/23/2021 at 3:00 a.m. and 5:00 a.m.; 07/27/2021 between 7:00 a.m. and 5:00 p.m.

Patient #6
Review of the Observation Check Sheet/ Graphic Flowsheet for Patient #6 revealed the registered nurse failed to sign the flowsheet on 07/23/2021. The shift began at 7:00 a.m. and at 3:00 p.m., the mental health technician noted the patient was deceased.

Patient #7
Review of the Observation Check Sheet/Graphic Flowsheet for Patient #7 revealed the mental health technician failed to record every fifteen-minute checks on 08/27/2021 between 4:00 a.m. and 6:45 a.m.; 08/27/2021 between 3:00 p.m. and 6:45 p.m.
Review of the Observation Check Sheet/Graphic Flowsheet for Patient #7 revealed the registered nurse failed to sign the flowsheet on 08/27/2021 between 7:00 a.m. and 5:00 p.m.

Patient #8
Review of the Observation Check Sheet/ Graphic Flowsheet for Patient #8 revealed the mental health technician failed to record every fifteen-minute checks between 9:00 p.m. and 9:45 p.m. and the registered nurse failed to sign the flowsheet at 7:00 p.m. and 9:00 p.m.

Review of the Multi-Disciplinary Note for Patient #8 revealed that at 9:40 p.m. the patient was unresponsive to verbal/ tactile stimuli. The coroner later pronounced the patient dead.

Interview with S2DON on 10/05/2021 at 2:40 p.m., S2DON verified the patients were supposed to be monitored every fifteen minutes by the mental health technician and every 2 hours by the assigned nurse. She verified the nurse failed to supervise the mental health technician.


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Based on observations and interviews, the infection control officer failed to ensure the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented in accordance with acceptable standards. This deficient practice was evidenced by having a patient's mattress that was torn and unable to be disinfected and failing to ensure clean linen, towels and paper scrubs were covered to prevent contamination.

Findings:

A tour of the hospital between 9:15 a.m. and 9:45 a.m. with S4Quality revealed:

Patient room c A mattress was torn and there was a hole in the sheetrock behind the door.

The clean utility room was noted to have 2 small-uncovered carts with clean towels, sheets and paper scrubs uncovered.

The clean linen storage room was noted to have a large uncovered cart and open shelf with clean folded towels.

In an interview on 10/04/2021 at 9:45 a.m., S4Quality verified the above findings.

Based on record review and interview the facility failed to assure the nursing staff was educated on policies and procedures related to notification of LOPA after the death of a patient. This deficiency is evidenced by the failure of the registered nurse to notify LOPA of the patient's death in two (#7 and #8) of three (#6, #7 and #8) death records reviewed.
Findings:

Review of hospital policy NSG-30 titled, "Post Mortem Care," revised 09/011/2019, reveals in part, "The Registered Nurse will call the state specific organ procurement agency and document notification in the medical record."

Review of hospital policy NSG-60 titled, "Organ Donation Louisiana," revised 02/21/2021, "Upon the Imminent Death of a patient or in the event pf an unexpected death of a patient, including patients who have donated their remains to the Louisiana Anatomical Board, the facility shall timely notify LOPA." Further review of the policy reveals, "Timely Referral: a telephone call to LOPA at 1(800) 833-3666 by Facility staff within two (2) hours (ideally one hour) of when the Facility identifies a patient meets the clinical triggers for organ donation."

Patient #7
Review of the medical record of Patient #7 revealed the patient was admitted on 08/06/2021. Patient #7 died on 09/03/2021 at the facility. Further review of the medical record revealed a note by S2DON that LOPA was not notified after the patient's death.

Patient #8
Review of the medical record of Patient #8 revealed the patient was admitted 06/03/2021. Patient #8 died on 06/05/2021 at the facility. Further review of the medical record revealed no documentation of LOPA notification.

Interview with S2DON on 10/05/2021 at 3:50 p.m., S2DON verified nursing staff did not notify LOPA of the death of Patient #7 or Patient #8. S2DON stated she placed the note in the record of Patient #7 because she was at the facility after the death of Patient #7 but she arrived after the two-hour window to notify LOPA.