HospitalInspections.org

50453

Based on observation and interview, the hospital failed to ensure patients requiring inpatient psychiatric care received care in a safe setting. This deficient practice was evidenced by:
1) Observation of the plastic liners in trash cans and unlocked cabinets containing personal care items in patient care areas; and
2) Observation of a non-functioning nurse call button in a patient bathroom.
Findings:

1) Observation of the plastic liners in trash cans and unlocked cabinets containing personal care items in patient care areas

A facility policy regarding the personal care items allowed to be in a patient care area and in the possession of a patient was not available.

An observation during a tour of the North campus on 04/24/2024 from 7:20 a.m. to 9:15 a.m. revealed the following:
a) Plastic garbage bags in the following patient care areas: Room #a and Room #b; and
b) A storage cabinet in the Room #c was not locked and secured which would allow patient access to personal care items not allowed on the unit without supervision.

In an interview on 04/24/2024 during the tour, S2DON and S3QD confirmed the above mentioned findings and further confirmed a patient is not allowed to have access to personal care items without supervision.

2) Observation of a non-functioning nurse call button in a patient bathroom

An observation during a tour of the North campus on 04/24/2024 from 7:20 a.m. to 9:15 a.m. revealed Room #f bathroom's nurse call button in non-functioning condition.

In an interview on 04/24/2024, S2DON and S3QD confirmed the above mentioned findings during the facility tour.

Based on record review and interview, the hospital failed to ensure reports of potential patient abuse/neglect of care were reported to Louisiana Department of Health - Health Standards Section (LDH-HSS) within 24 hours of awareness of the allegation, as required by LDH-HSS. This deficient practice is evidenced by the facility failing to report to LDH-HSS an incident of potential neglect related to a psychiatric patient who was attending the hospital's IOP (Intensive Outpatient Program), climbing on to the roof of the facility.
Findings:

Review of the Louisiana Revised Statutes, Title 40. Public Health and Safety, Chapter 11, State Department of Health and Hospitals revealed "Department" shall mean the Department of Health and Hospitals. "Unit" means the Medicaid fraud control unit created within the office of criminal law of the Department of Justice and which is certified by the secretary of the United States Department of Health, Education and Welfare. Regarding §2009.20. Duty to make complaints; penalty; immunity, "Abuse" is the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including but not limited to sexual abuse, or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered. "Neglect" is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer's well-being. Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, ... having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report.

Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report these allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Department of Health and Hospitals (LDH) (or the Medicaid Fraud Unit as applicable). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence.

A review of medical record revealed Patient #2 recently admitted under a Physician Emergency Certificate (PEC) for suicidal ideations. The patient was attending IOP at this facility prior to admission. On 04/23/2024, the patient arrived at IOP via facility bus transportation and attended group session #1 with S9T as the group leader. A Multidisciplinary Progress Note from 04/23/2024 at 1:00 p.m. and signed by S9T on 04/24/2024 at 4:11 p.m. revealed in part, upon the initiation of group session #2, S9T noticed Patient #2 was not in the group session and notified his supervisor who begin to search for the patient. The patient was unable to be located, S9T contacted the patient's mother. The mother pinged the patient's phone via location services and it revealed the patient's phone was currently located at this facility. S9T contacted the patient by phone with the patient revealing his location as being on the facility's roof. S9T was able to talk the patient down off of the roof and once on the ground safely, S9T noted, "Therapist processed with patient after being on ground, patient was anxious, delusional, suicidal, and constantly reported, 'I don't want another failed suicide attempt.'" The patient was admitted to the facility's inpatient program under a PEC. Inpatient Psychiatric Evaluation on 04/24/2024 at 12:22 revealed, "Patient with suicide attempt yesterday during break at IOP. Found on roof of building contemplating jumping. Has HX (history) of medically and psychiatrically significant suicide attempts in the past including attempting to hang self while admitted." Further the evaluation noted in part, the patient had a history of suicidal ideations with an attempt at hanging self during a hospitalization in 12/2023. The patient had been admitted to inpatient psychiatric care 6 times since 12/2023. The History and Physical on 04/24/2024 at 10:33 a.m. revealed, "Patient admitted from IOP due to attempted suicide when he was trying to jump off of the top of the hospital." Initial Nursing Assessment from 04/23/2023 at 3:01 p.m. noted Reason for Admission: "increased depression with an attempt to jump off the roof of IOP today." Further, the Initial Nursing Assessment noted in part, the Suicidal Risk Stratification on admission: High Suicidal Risk: Suicidal Ideation with intent or intent with a plan in the past month. The Initial Nursing Assessment summarization included, "current SI (suicidal ideation) with attempt today." Psychosocial Assessment from 04/25/2024 at 2:30 p.m. revealed the Presenting Problem, "I climbed the roof of a building, because I was feeling overwhelmed." Stressors included, "In the IOP, I was depressed about a heartbreak." Patient reported SI, "to be honest, but I wasn't going to jump because I didn't want to break both my legs."

Contact with state office on 04/24/2024 at 4:00 p.m. revealed the facility had not self-reported to LDH-HSS the above mentioned event.

In an interview on 04/25/2024 at 7:45 a.m. S5RVP and S1Adm confirmed the above mentioned findings.


50453

Based on observation, record review and interview, the hospital failed to ensure there were current and accurate records kept on the receipt and disposition of all scheduled drugs. This deficient practice is evidenced by:
1) Failing to log and verify a narcotics count every shift by two nurses; and
2) Failing to destroy medication not returned to a patient at discharge.
Findings:

Review of the hospital policy revised 06/01/2022 titled Medications: Medication Management revealed in part, STANDARD: Special Considerations: 5. Destruction of Medications: Expired or unused medications, including those not returned to the patient at discharge will be destroyed at the hospital according to their classification. All controlled substances such as patient-specific narcotics, expired institutionally owned narcotics, and patient specific narcotics that patients bring from home not returned at discharge will be destroyed using the drug dispose all containers in which the medications will be dropped into a chemical solution that destroys the drugs rendering them non retrievable. Individual patient specific narcotics will be counted and verified every shift by two nurses until the patient is discharged on the patient's individual narcotic count sheet. Once the patient is discharged and the final count is documented, the drugs are to be destroyed utilizing the drug dispose all containers in the presence of two nurses signing off on the final count.

1) Failure to log and verify a narcotics count every shift by two nurses

An observation of Room #g on 04/25/2024 at 8:20 a.m. revealed Patient #4's home medication Clonazepam 0.5mg was being held in the locked narcotics box. Patient #4 was discharged on 02/22/2024. A review of Patient #4's Individual Narcotic Count Sheet revealed the last narcotic count being completed on 02/05/2024 at 4:57 p.m. Patient #4's home narcotic medication was not accounted for on 17 days of his admission and since his discharge of 02/22/2024.

In an interview on 04/24/2024 at 8:20 a.m. S2DON and S3QD confirmed the above mentioned findings.

An observation of Room #i on 04/25/2024 at 9:00 a.m. revealed Patient #3's home medication Percocet 5mg/325mg was being held in the locked narcotics box. A review Patient #3's Individual Narcotic Count Sheet revealed counts being completed on 04/22/24 at 7:00 a.m., 04/23/2024 at 10:00 a.m. and 04/24/2024 at 6:57 a.m. This would reflect the narcotics being counted and verified once per 24 hour period and not per policy of once every shift.

In an interview on 04/24/2024 at 9:02 a.m. S3QD confirmed the above mentioned findings.

2) Failure to destroy medication not returned to patient at discharge

An observation of Room #g on 04/25/2024 at 8:20 a.m. revealed Patient #4's home medication Clonazepam 0.5mg was being held in the locked narcotics box. A review of Patient #4's Individual Narcotic Count Sheet revealed the last narcotic count being completed on 02/05/2024 at 4:57 p.m. with a total count of 108 tablets. Patient #4 was discharged on 02/22/2024. Per policy, the medication was not properly disposed of after patient discharge.

In an interview on 04/24/2024 at 8:20 a.m. S2DON and S3QD confirmed the above mentioned findings.



50453

Based on observations, record review and interviews, the hospital failed to ensure the condition of the physical plant and overall hospital environment were maintained in such a manner that the safety and well-being of patients were assured. This deficient practice was evidenced by failing to maintain the physical plant in good repair.
Findings:

Observations during a tour of the South campus on 04/23/2024 from 2:25 p.m. to 3:45 p.m. revealed the following:
1) There was wood in disrepair and within arms-reach of a patient. This wood could serve as a source of self-injury or injury to others.
a) The plywood paneling covering the walls of the Room #d had a 1 inch by 2 inch rectangular piece of layering, on its top edge, peeling away and splintering and exposing the underlying wood; and
b) The wood paneling and trim in the corner of the exterior recreation area to the left of the dining room windows had water damaged which has resulted in peeling, flaking and splintering wood pieces.

2) Stained ceiling tile noted outside the entrance to room #e.

In an interview on 04/23/2024, S2DON and S3QD confirmed the above mentioned findings during the facility tour.


50453

Based on observation, record review, and interview, the facility failed to ensure facilities, supplies and equipment, were maintained to an acceptable level of safety and/or quality. This deficient practice is evidenced by:
1) Observation of current glucose meter controls and test strips had no open date recorded;
2) Failing to perform control testing on the glucometer per facility policy;
3) Failing to ensure expired supplies were not available for patient use;
4) Failing to maintain exhaust vents for optimal performance; and
5) Failing to maintain the patient clothes dryer in a safe operating condition.
Findings:

1) Observation of current glucose meter controls and test strips had no open date recorded

A review of facility policy, "Glucometer Method for Obtaining CBGs," with an effective date of 01/11/2016 and last revised on 07/01/2022, revealed in part, Care of Meter and Strips: Test strips and control solutions must be labeled with the open and discard dates according to the manufacturer's guidelines.

A review of the facility's Glucose Control Log Sheet revealed a note at the top of the sheet, "All opened control solution bottles MUST have "open date" and 90 day expire Date." Also, a note on the bottom of the sheet revealed in part, Test strip bottles must be labeled with open date and 6 month discard date.

A review of the Medline EVENCARE G3 Blood Glucose Monitoring System User Guide revealed in part, notes regarding control solutions and test strips. Record the date on the bottle when opening a new bottle of control solution, discard any unused control solution 3 months after the opening date, and control solutions are good for 3 months after opening or until the expiration date on the bottle, whichever comes first. Record the date on the vial test strips when opening a new bottle and discard any unused test strips 6 months after opening. Vial test strips are good for 6 months after opening or until the expiration date on the bottle, whichever comes first.

An observation on 04/23/2024 at 3:25 p.m. of the Medline EVENCARE G3 Glucose Control Solutions (Level 1 bottle and Level 3 bottle) and Test Strips currently being used at the South campus were not properly labeled with an open date.

In an interview on 04/23/2024 at 3:26 p.m. S2DON and S3QD confirmed the above mentioned findings.

2) Failing to perform control testing on the glucometer per facility policy

A review of facility policy, "Glucometer Method for Obtaining CBGs," with an effective date of 01/11/2016 and last revised on 07/01/2022, revealed in part, Confirm System Performance/Control Test: A control test confirms that the system is functioning properly. Control tests are to be performed every 24 hours of patient use and anytime there is a question about the blood glucose test results.

An observation on 04/23/2024 at 3:25 p.m. of the South campus' Glucose Control Log Sheet revealed control testing not being performed on 04/18/2024 and 04/19/2024.

In an interview on 04/23/2024 at 3:26 p.m. S2DON and S3QD confirmed the above mentioned findings.

3) Failing to ensure expired supplies were not available for patient use

Observations during a tour of the South campus on 04/23/2024 from 2:25 p.m. to 3:45 p.m. revealed the following expired supplies available for patient use:
a) Medline Medgel Adult Resting Tab Electrode 500 count per box, Quantity 5 unopened boxes, expired on 04/28/2023; and
b) Hudson RCI STAR Lumen Oxygen Tubing, 25 feet, Quantity 3, expired on 05/30/2022.

In an interview on 04/23/2024, S2DON and S3QD confirmed the above mentioned findings during the facility tour.

Observations during a tour of the North campus on 04/24/2024 from 7:20 a.m. to 9:15 a.m. revealed the following expired supplies available for patient use:
a) BD Vacutainer Urine C & S Preservation Tubes in the Clean Supply Room - 33 tubes expired 12/31/2023, 4 tubes expired 10/31/2023, and 9 tubes expired 01/31/2024;
b) Ecolab Hand Sanitizer, 2 - 1 gallon containers, expired 09/2021, located in Room #g and Room #h; and
c) Room #i contained a blue bin of single use packets of Lubricating Jelly, expired 10/28/2023 and a blue bin of single use Sureprep Protective Wipes, expired 11/2023.

In an interview on 04/24/2024, S2DON and S3QD confirmed the above mentioned findings during the facility tour.

4) Failing to maintain exhaust vents for optimal performance

Observations during a tour of the South campus on 04/23/2024 from 2:25 p.m. to 3:45 p.m. revealed greyish fuzzy substances on the exhaust vent coverings located in Rooms #j, #k, and #l.

In an interview on 04/23/2024, S2DON and S3QD confirmed the above mentioned findings during the facility tour.

5) Failing to maintain the patient clothes dryer in a safe operating condition

A review of facility policy, "Laundry and Linen Service," Policy Number: EOC-76, with an effective date of 01/11/2016 revealed in part, Purpose: to ensure the patient's personal laundry are properly cleaned. Procedure: Patient's Personal Clothes: The following process will be followed when laundering the patient's personal clothes: Washing machine and dryer: The lint filter on the dryer will be cleaned with each use by the hospital staff.

An observation of the patient laundry room revealed the dryer lint filter was completely full with lint to the extent that when the filter was removed, a second section of lint, the size of the lint filter, was attached to the bottom of the filter. The Laundry Usage and Sanitizing Log was last completed on 04/16/2024. This log is used to indicate the washer had been sanitized and lint had been removed from the dryer lint filter after each use.

In an interview on 04/23/2024, S2DON and S3QD confirmed the above mentioned findings during the facility tour.


50453

Based on observation and interview, the facility failed to ensure proper ventilation was maintained to an acceptable level of safety and quality in the patient care areas. This deficient practice is evidenced by a non-functioning exhaust vent in the male shower stall area.
Findings:

An observation on 04/23/2024 at 3:07 p.m. of male shower stall #2 revealed a non-functioning exhaust vent, with its covering pulled away from the ceiling exposing the inner mechanical parts, wiring and fan blade.

In an interview on 04/23/2024 at 3:07 p.m. S2DON confirmed the above mentioned findings.


50453

Based on observation, record review and interview, the facility failed to maintain an infection prevention and control program which includes surveillance, prevention, and control of HAIs, and maintains a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities. This deficient practice was evidenced by:
1) Failing to maintain the temperature log for the patient nourishment refrigerator/freezer;
2) Failing to prevent storage of previously consumed items in the patient nourishment refrigerator;
3) Failing to maintain the patient washing machine in sanitary condition;
4) Failing to maintain patient rooms in a sanitary condition; and
5) Failing to store patient nutritional supplies in a sanitary condition.

Findings:

A review of facility policy, "Infection Control Plan," Policy Number IC-01.03, with an effective date of 01/11/2016 and last revised 09/01/2024, revealed in part, Purpose: The Infection Control Plan is implemented for the purpose of preventing and controlling the acquisition and transmission of infectious agents throughout the hospital. Systems are implemented to communicate with physicians and other independent practitioners, staff, patients, visitors and families. Priorities Areas and Strategic Goals: The Hospital establishes goals to reflect the current trends and environmental factors. At a minimum, the following goals are established: Maintain a clean and sanitary environment to avoid sources and transmission of infection.

1) Failing to maintain the temperature log for the patient nourishment refrigerator/freezer

Observations during a tour of the South campus on 04/23/2024 from 2:25 p.m. to 3:45 p.m. revealed the temperature log for the patient nourishment refrigerator/freezer was not checked on 04/01/2024, 04/02/2024, 04/07/2024, 04/08/2024, and 04/21/2024.

In an interview on 04/23/2024, S2DON confirmed the above mentioned findings during the facility tour.

2) Failing to prevent storage of previously consumed items in the patient nourishment refrigerator

Observations during a tour of the North campus on 04/24/2024 from 7:20 a.m. to 9:15 a.m. revealed a McDonald's bag and an opened bottle of Coke stored in the refrigerator and not assigned or labeled to a patient.

In an interview on 04/24/2024, S2DON and S3QD confirmed the above mentioned findings during the facility tour.

3) Failing to maintain the patient washing machine in sanitary condition

A review of facility policy, "Laundry and Linen Service," Policy Number: EOC-76, with an effective date of 01/11/2016 revealed in part, Purpose: to ensure the patient's personal laundry are properly cleaned. Procedure: Patient's Personal Clothes: The following process will be followed when laundering the patient's personal clothes: Washing machine and dryer: The lint filter on the dryer will be cleaned with each use by the hospital staff. The washer will be cleaned between washing each patient's cloths by making sure all solids are removed from the basket and utilizing an EPA - registered disinfectant around the lip of the basket and the inside of the basket. The lid is opened to wipe off any excess dirt or soap.

Observations during a tour of the South campus on 04/23/2024 from 2:25 p.m. to 3:45 p.m. revealed the patient washing machine log incomplete. The last recorded date on the Laundry Usage and Sanitizing Log clipboard located in the laundry room was 04/16/2024. The log included a date, MHT name and a room number. This log did not indicate what this information reflected.

A review of the Laundry Usage and Sanitizing Log utilized for this documentation revealed the log for the MHT to complete. The columns headings include patient room, wash (yes), sanitized (yes), lint removed (yes), MHT signature and date. This form was not being used.

In an interview on 04/23/2024, S2DON and S3QD confirmed the above mentioned findings during the facility tour.

4) Failing to maintain patient rooms in a sanitary condition

Observations during a tour of the North campus on 04/24/2024 from 7:20 a.m. to 9:15 a.m. revealed the following:
a) Room #b's mattress and bed platform contained a dry, brown substance along the side and under the mattress. This substance also appeared on the bed platform.

In an interview on 04/24/2024, S2DON and S3QD confirmed the above mentioned findings during the facility tour and confirmed the room had been cleaned and was ready for patient use.

b)Room #n bed platform contained a puddle of liquid under the mattress. Also, a reddish/brown substance was smeared on the window and the window seal.

In an interview on 04/24/2024, S2DON and S3QD confirmed the above mentioned findings during the facility tour and confirmed this room was currently occupied.

c) Room #m had 5 blankets stacked on the floor between the chairs.

In an interview on 04/24/2024, S2DON and S3QD confirmed the above mentioned findings during the facility tour.

d) Room #o's bathroom shower was covered in a yellow and foul smelling fluid.

In an interview on 04/24/2024, S2DON and S3QD confirmed the above mentioned findings during the facility tour.

e) Failing to store patient nutritional supplies in a sanitary condition

Observations during a tour of the North campus on 04/24/2024 from 7:20 a.m. to 9:15 a.m. revealed paper plates and napkins, being stored in a cabinet of Room #p which contained an open, sewer drainage line from the ice machine.

In an interview on 04/24/2024, S2DON and S3QD confirmed the above mentioned findings during the facility tour.


50453