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Based on record reviews, observations and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by 1) failure 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; and 2) failure to ensure the entire seclusion room was able to be visualized.
Findings:

1) Failure 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.

Review of the hospital's policy titled, Safety Management Plan revealed in part that it is the goal of the safety plan to assure a safe environment within the hospital and on the grounds for the employees, patients, and visitors and that the hospital does not create a physical or biological hazard in the community.

On 06/06/22 at 10:45 a.m., observations of patient rooms at the main campus revealed the following:
The toilets in the bathrooms of rooms a and b had a toilet seat that lifted up, creating a ligature point at the hinge where there was an opening. The toilet base was open underneath and at the rear, creating a ligature point.

An interview at this time with S7MHT confirmed that all toilets in patient rooms were of the same design.

The following observations of safety and ligature risks were observed on 06/07/22 at 10:12 a.m. - 11:24 a.m. at the off-site location, accompanied by S6NurseMgr.

9 of 18 total patient beds were hospital type and had numerous anchoring points. These beds were located in rooms c, d, e, f, g, h, i, j and k.

4 of 18 total patient beds were sleigh bed type which had an opening from the bottom of the bed to the floor making the bed an anchoring point. These beds were located in rooms l, m, n and o.

In an interview during the observation, S6NurseMgr verified the above findings.

2) Failure to ensure the entire seclusion room was able to be visualized.

An observation on 06/07/22 at 10:12 a.m. - 11:24 a.m. revealed the seclusion room had a blind spot in the left corner closest to the door. S6NurseMgr stated when a patient is in the seclusion room, a MHT would be stationed outside of the door observing the patient through the window in the door. S6NurseMgr verified when the surveyor stood in the left corner closest to the door inside the seclusion room, S6NurseMgr verified she could not visualize the surveyor.




20310

Based on record review and interview, the hospital failed to ensure that all patients have the right to be free from restraints or seclusion as evidenced by documenting that a patient was in seclusion without a physician order or any documentation related to the reason for seclusion for 2 (Patient # 7, Patient # 9) of 2 patients whose records were reviewed for restraint use in a total sample of 9.
Findings:

Review of the policy titled, Restraints and Seclusion Use, revealed in part that orders for the use of seclusion must be given by an MD or NP prior to their use. Seclusion should be used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others.

Patient #7
Review of the closed medical record for Patient #7 revealed an admit date of 03/21/22 at 11:15 a.m. with diagnoses including schizophrenia and hallucinations.

Review of the Patient Observation Record revealed documentation that the patient was in seclusion on the following dates:
03/23/22 from 2:15 a.m. until 11:45 p.m.
03/24/22 from 12:15 a.m. until 2:45 p.m. and from 9:45 p.m. until 11:45 p.m.
03/25/22 from 12:00 a.m. until 6:00 a.m.

Patient #9
Review of the closed medical record for Patient #9 revealed an admit date of 05/03/2022 at 7:00 a.m. with diagnoses including auditory hallucinations, history of schizophrenia, and history of bipolar disorder.

Review of the Patient Observation Record revealed documentation that the patient was in seclusion on the following dates:
05/04/2022 from 6:45 p.m. until 11:45 p.m.
05/05/2022 from 12:00 a.m. until 7:00 a.m.
from 8:00 a.m. until 11:00 a.m.
from11:30 a.m. until 11:45 a.m.
from 12:15 pm. until 2:30 p.m.
from 3:00 p.m. until 4:15 p.m.
from 5:00 p.m. until 5:15 p.m.
from 5:45 p.m. until 8:45 p.m.
from 9:15 p.m. until 11:45 p.m.
05/06/2022 from 12:00 a.m. until 6:15 a.m.
05/14/2022 from 8:00 a.m. until 11:00 a.m.
from 12:00 p.m. until 12:45 p.m.

Review of the medical record, provided as complete by S1DON, revealed no physician order for seclusion or documented evidence related to the reason for the patient's seclusion.

On 06/08/22 at 1:30 p.m., interview with S1DON confirmed that she was unable to provide any documentation related to a physician order for seclusion or any notes related to the reason for seclusion.

In an interview on 06/08/2022 at 2:47 p.m. S7MHT stated patients are not allowed to use the BCR (seclusion) room as a quiet room. He stated patients are not allowed to sleep in the BCR room. He stated the BCR room is always locked when there are no patients ordered for seclusion or restraints. He stated patients are not allowed in this room unless the physician specifies.

20310

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient. This deficient practice was evidenced by the registered nurse failing to perform a complete initial nursing assessment upon admit for 4 (#1, 2, 5, 6) of 4 patient medical records reviewed for initial assessments in a total sample of 9.
Findings:

Review of the hospital's policy titled, Initial Nursing Assessment, revealed in part that it shall be the responsibility of a registered nurse to perform an initial assessment within eight hours of admission.

Review of the medical records for Patients #1, 2, 5 and 6 revealed no documented evidence of a complete nursing assessment upon admit. The records revealed the only phyical assessments conducted were skin assessments.

In an interview on 06/07/22 at 11:30 a.m., S8RN stated that the nurses do not complete a complete nursing assessment on the patients at admit because the physicians do that with their History and Physicals.

In an interview on 06/08/22 at 10:30 a.m. with S1DON confirmed the RNs were not conducting a complete nursing assessment upon admit for all patients, but should be doing one.

Based on observation, record review and interview, the hospital failed to maintain medical records on each patient as evidenced by failing to ensure that patient medical records were completed within 30 days
Findings:

Review of the Medical Staff Rules and Regulations revealed in part that each medical record shall be completed within 30 days of discharge of the patient or the record becomes delinquent. The physician who has any delinquent charts shall be so notified by phone. If the records are still incomplete two weeks after being notified, he/she shall automatically suffer suspension of admitting privileges.

On 06/07/22 at 2:05 p.m., interview with S4RHIA revealed that she worked in the hospital's corporate office and was over the medical records department. When asked if there were any delinquent medical records at the hospital, over 30 days, she stated yes. When asked for the delinquency rate or number of delinquent records, she stated she was unsure of that number. When asked if any physicians had been suspended due to delinquent medical records, she stated no.

On 06/08/22 at 10:10 a.m., interview with S1DON revealed that she was unsure of the number of delinquent medical records. At that time, she led the surveyor to an office that held multiple discharged medical records that were incomplete. She stated that they are held at the hospital for approximately two weeks after discharge in order for the record to be completed before they are sent to the corporate office to be scanned into electronic medical record. Review of some of the incomplete records revealed that 20 of the records had discharge dates back to February 2022. Further interview with S1DON at that time revealed that the medical records were lacking a discharge summary. When asked why the physicians were not performing discharge summaries on their discharged patients, S1DON stated that the nurses on the floor complete the discharge summaries because the physicians will not do it. S1DON stated that the nurses had been too busy lately to do the discharge summaries.

Based on record review and interview, the hospital failed to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed (review for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications).
Findings:

Review of the Louisiana Administrative Code, Title 46 Professional and Occupational Standards, Part LIII Pharmacist, Chapter 15 Hospital Pharmacy, Section: 1511: Prescription Drug Orders, Item A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial dose of medication, except in cases of emergency.

Review of the hospital policy titled, Preventing and Detecting Adverse Consequences/Pharmacy, revealed in part that the interdisciplinary team will review the patient's medication regimen for efficacy and actual or potential medication related problems when a patient receives a new medication. The policy did not mention a first dose review by a pharmacist.

Review of the list of medication overrides (from the electronic medication dispensing system) provided by S1DON for the past month revealed hundreds of overrides for medications.

On 06/06/22 at 10:30 a.m., observations of the hospital revealed it did not contain an in-house pharmacy. Further observations in the nurses station revealed that the nurses used an electronic medication dispense system (Pyxis) to obtain medications.

On 06/06/22 at 10:50 a.m., interview with S3LPN was asked the process for obtaining medication after a new physician order was written. S3LPN stated that the order would be faxed to the pharmacy and after it was reviewed by a pharmacist, the medication would be profiled under the patients name in the Pyxis. S3LPN stated that the contracted pharmacy is not open 24/7, but the nurses are able to "override" the medication in the Pyxis in order to obtain the first dose of the medication prior to pharmacy review.

On 06/08/22 at 1:40 p.m., interview with S5Pharmacist revealed that the hospital contracts with a pharmacy to provide and stock medications in the Pyxis. S5Pharmacist stated that this pharmacy is only open Monday-Friday from 8:00 a.m. until 5:00 p.m. When asked the process for performing first dose reviews after pharmacy hours, he stated that there is a pharmacist on-call to provide those services. When asked is there was any log or documentation indicating first dose reviews were performed after pharmacy hours, he stated no. S5Pharmacist stated there was much staff turnover at the hospital and the new or agency staff may not know the process for first dose reviews.

On 06/08/22 at 2:12 p.m., interview with S1DON and S2DON revealed that if a new medication is ordered after pharmacy hours or on the weekends, the on-call pharmacist is only notified if the medication is not stocked in the Pyxis machine, in order for it to be delivered to the hospital. They further stated that the nurses will "override" the newly ordered medications (after pharmacy hours) in order to administer first doses of medications that are stocked in the Pyxis.

Based on observation and interview, the hospital failed to develop and implement an effective system in controlling infections and communicable diseases of patients as evidenced by 1) failing to ensure that appropriate infection control practices were implemented during blood glucose checks for 1 of 1 nurse observed performing glucometer checks (S3LPN) and 2) failing to maintain a sanitary environment.
Findings:

1) Failing to ensure that appropriate infection control practices were implemented during blood glucose checks for 1 of 1 nurse observed performing glucometer checks (S3LPN)

On 06/06/22 at 11:05 a.m., observation revealed S3LPN walked out of the nurses station wearing gloves and holding a plastic basket containing a glucometer, stips and alcohol swab. Further observations revealed S3LPN approached Patient #5 while the patient was sitting a table with other patients in the dining room. Further observations revealed S3LPN placed the basket on the dining room table, checked the patient's glucose with the glucometer and exited the dining room, still wearing the gloves. S3LPN was observed to re-enter the nurses station and place the glucometer and strips into the drawer on the medication cart, without first disinfecting them. S3LPN was then observed to remove her gloves, hand the patient a snack and then went back to her desk. S3LPN was not observed to perform any hand hygiene.

On 06/08/22 at 2:30 p.m., interview with S1DON revealed that the glucometer should be disinfected after each use with "Purple Top" wipes. S1DON further revealed that she was unable to locate a hospital policy and procedure that addressed proper disinfection of the glucometer. S1DON further stated that staff should perform hand hygiene prior to and after patient contact.

2) Failing to maintain a sanitary environment

On 06/06/22 at 11:10 a.m., observation of the EKG machine in the nurses station revealed it was coated with a thick build-up of dust and had brown splatters on it. Interview with S1DON at that time confirmed the EKG machine was in need of cleaning.

On 06/06/22 at 11:15 a.m., observation of the hand rails on the hall ways revealed they were coated in dust and debris.

Observations were conducted on tour on 06/07/2022 at 10:12 a.m. - 11:24 a.m. at the offsite location, accompanied by S6NurseMgr.

All door frames located in the shower room had multiple areas of rust that could not be disinfected.

The door frame to Room o had multiple areas of rust that could not be disinfected.

In the equipment storage room there was a blue wedge sitting on the floor that the zipper was broken and had multiple tears at the seams exposing the inside cushion that could not be disinfected.

In an interview during the observation, S6NurseMgr verified the above stated findings.


44763

Based on record review and interview, the physician failed to complete a neurological examination at the time of the admission physical examination for 5 of 9 (Patient #1, 2, 3, 4, 9) patients reviewed for neurological exams in a total sample of 9 patients.
Findings:

Review of the medical record for Patient #1 revealed he was admitted on 06/02/22. Review of the History and Physical examination dated 06/02/22 at 12:20pm revealed there was no documented assessment of the cranial nerves.

Review of the medical record for Patient #2 revealed he was admitted on 05/25/22. Review of the History and Physical examination dated 05/24/22 at 3:30pm revealed there was no documented assessment of the cranial nerves.

Review of the medical record for Patient #3 revealed she was admitted on 05/31/2022. Review of the History and Physical examination dated 05/31/2022 at 3:00 p.m. revealed there was no documented evidence as to how the physician assessed Patient #3's cranial nerves.

Review of the medical record for Patient #4 revealed he was admitted on 05/28/2022. Review of the History and Physical examination dated 05/29/2022 at 11:00 a.m. revealed there was no documented evidence as to how the physician assessed Patient #4's cranial nerves.

Review of the medical record for Patient #9 revealed he was admitted on 05/03/2022. Review of the History and Physical examination dated 05/03/2022 at 11:15 a.m. revealed there was no documented assessment of the cranial nerves.

In an interview on 06/07/2022 at 1:00 p.m. S6NurseMgr verified the cranial nerves were documented WNL (within normal limits) and there was no documentation as to how the physician assessed the cranial nerves for Patient #3 and Patient #4.

On 06/08/22 at 2:00 p.m., an interview with S1DON confirmed the History and Physical assessments did not include an assessment of the cranial nerves.