HospitalInspections.org

Bringing transparency to federal inspections

23515 HIGHWAY 190

MANDEVILLE, LA 70448

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

39791

Based on observation and interviews, the hospital failed to ensure patients 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 for patients admitted to the inpatient psychiatric hospital for being a danger to themselves and/or others.

Findings:

Willow Unit
An observation of Willow Unit on 12/27/18 between 9:45 a.m. and 09:58 a.m., in the presence of S3StaffCoord and
S2RN, revealed the following:

Non-tamper proof screws were noted on the windows in patient rooms, securing the artwork (in the commons area), and on the book/belongings shelves in patient rooms. S3StaffCoord and S2RN verified the identified safety risks during the observation.

A deficiency was cited on a previous survey (8/1/18) regarding the hospital units having non-tamper proof screws in the patient care environment.


Cypress Unit
An observation of Cypress Unit on 12/27/18 between 10:00 a.m. and 10:15 a.m., in the presence of S3StaffCoord, revealed the following:

a. Non-tamper proof screws were noted in the windows and book/belonging shelves throughout the unit (including but not limited to patient rooms and activity room). The observed safety risks were confirmed by S3StaffCoord during the observation.

b. Patient beds in Rooms 204 and 205 (8 beds total- 4 beds per room ) had non-tamper proof screws in the frames. The observed safety risks were confirmed by S3StaffCoord during the observation.

c. Seclusion room failed to have a bubble mirror resulting in a blind spot in the room where patients in seclusion could not be visualized by staff. S3StaffCoord confirmed, during the observation, that there should have been a bubble mirror in place to provide an unobstructed staff view of patients in seclusion.

On 12/28/18 at 11:00 a.m. in an interview with S1DON, she verified the above safety risks. S1DON confirmed there should have been a bubble mirror in place to provide an unobstructed staff view of patients in seclusion. S1DON indicated the seclusion room bubble mirror on Cypress Unit had probably been broken by one of the adolescent boys while in seclusion and it had not been replaced (as of 12/27/18).

MEDICAL RECORD SERVICES

Tag No.: A0450

Based on record review and interview, the hospital failed to ensure all patient medical record entries were legible and completed, in written or electronic form, by the person responsible for providing or evaluating the service provided. This deficient practice was evidenced by failure of the hospital to ensure patients' medical records had documentation of incidents of inappropriate contact and notification of the physician for 2 (#4, #5) of 6 medical records reviewed for incidents (#1,#2,#3,#4,#5, #R1) from a total patient sample of 9 (#1-#6, #R1,#R2,#R3).

Findings:

Patient #4
Review of self-report to LDH revealed on 11/2/18 Patient #3 and Patient #4 were involved in an unwitnessed incident of inappropriate contact which resulted in Patient #4 receiving a mark on her neck ("hickey") from Patient #3.

Review of Patient #4's medical record revealed a Body Audit Report,completed by S2RN on 11/3/18, which documented an "abrasion/hickey" on the left neck of Patient #4.

Further review of Patient #4's medical record revealed no description of the incident had been documented in the medical record. Additional review revealed the record failed to have documentation of physician notification of the event (no physician name).

On 12/28/18 at 10:00 a.m. in an interview with S2RN, she revealed she remembered the incident but could not recall if she had documented the incident in her nursing notes. S2RN confirmed the hospital's expectation was for the incident to have been documented in the patient's medical record.

Patient #5
Review of a self-report to LDH revealed on 11/01/18 Patient #5 and Patient #R1 were involved in inappropriate touching.

Review of Patient #5's medical record revealed no documented description of the incident and no documentation of physician notification in the patient's record.

On 12/28/18 at 11:00 a.m. in an interview with S1DON, she verified a summary of incidents and notification of the physician should have been documented in the patient's medical records when an incident occurred.

INDIVIDUAL COMPREHENSIVE TREATMENT PLAN

Tag No.: B0118

Based on 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 changes in patient level of observation and room changes for safety, after an incident involving inappropriate touching, for 2 (#1,#2) of 6 (#1-#5, #R1) patients reviewed for incidents involving inappropriate contact out of a total patient sample of 9 (#1-#6, #R1,#R2,#R3).

Findings:

Review of the hospital policy titled,"Treatment Planning", Policy number: TX.1-0200, revealed in part: Purpose: To assure the patient/family/guardian and all members of the treatment team have the opportunity to provide input into treatment planning and to assure developement of a comprehensive and complete plan of care that serves as a guide for providing individualized treatment. F. Updating the Treatment Plan: The treatment plan must be updated to reflect a change in the patient's condition.

Review of a self-report to LDH regarding an incident of Alleged Neglect, dated 11/16/18 (date of incident discovery 12/15/18), revealed an allegation of inappropriate contact (Patient #1 inappropriately touching his roommate - Patient #2). Further review revealed Patient #1 had been observed, by staff, running back to his bed, when staff had gone to investigate after Patient #2 had yelled/screamed. S5RN had interviewed Patient #2 after the incident and had documented Patient #2 had answered "yes" to both questions when asked if he was afraid of Patient #1 and if Patient #1 had touched him.

Patient #1
Review of Patient #1's medical record revealed an admission date of 11/6/18 with admission diagnoses of unspecified Depressive Disorder and Suicidal thoughts/actions (Patient had stabbed himself in the neck with a pencil at school). Further review revealed the patient's legal status had ben PEC due to suicidal ideations.

Review of Patient #1's Admit Physician's Orders, dated 11/6/18, revealed the patient's level of observation was Close staff sight with documentation of patient activity/location every 10 minutes with Suicide precautions- Reason: unpredictable behavior and self-harm.

Review of Patient #1's Observation and Locator form, dated 11/12/18 (time interval -7:10 a.m. - 2:20 a.m.), revealed a hand written notation indicating the patient's level of observation had been changed from close staff sight to 1:1 at 2:30 a.m. on 11/13/18.

Review of Patient #1's RN Progress Notes, dated 11/12/18 (7:00 p.m.- 7:00 a.m. shift), revealed the following entry: Pt. attempted to touch peer (Patient #2) inappropriately and peer screamed and staff moved peer (Patient #2)
out of room, peer (Patient #2) voiced he is afraid of Patient #1. Physician notified and Pt. #1 made 1:1 for safety of unit.

Review of Patient #1's Physician Progress Notes, dated 11/13/18, revealed the patient had been placed on 1:1 level of observation due to alleged sexually inappropriate touching of roommate.

Review of Patient #1's treatment plan revealed the incident of alleged sexually inappropriate touching which had resulted in moving Patient #2 (patient's roommate) out of the room and a change in Patient #1's level of observation to 1:1 status had not been identified as a patient change to be addressed/updated on the patient's treatment plan.

Patient #2
Review of Patient #2's medical record revealed an admission date of 11/4/18 with admission diagnoses of Depression and Suicidal Ideation. Further review revealed the patient had moderate cognitive impairment/intellectual disability. Additional review revealed the patient's legal status had been PEC due to violent outbursts and suicidal ideations.

Review of Patient #2's Admit Physician's Orders, dated 11/4/18, revealed the patient's level of observation was Close staff sight with documentation of patient activity/location every 10 minutes with Suicide precautions- Reason: Aggression/Violence and unpredictable behavior.

Review of Patient #2's RN Progress Notes, dated 11/12/18 (7:00 p.m. - 7:00 a.m. shift), revealed the following entry: Pt. noted screaming in room. Pt. #1 attempted to touch Pt. #2 inappropriately. Pt. unable to verbally express details but states he is afraid of Patient #1. Pt. moved to another room to ensure safety.

Review of Patient #2's Observation and Locator form, dated 11/13/18 (time interval -7:10 a.m. - 7:00 a.m.), revealed the patient's level of observation had been changed to close staff sight (patient had been routine, every 15 minute observation level prior to the incident).

Review of Patient #2's treatment plan revealed the incident of alleged sexually inappropriate touching which had resulted in moving Patient #2 out of the room for his safety due to expressed fear of Patient #1 and placing the patient back on close staff sight observation level had not been identified as a patient change to be addressed/updated on the patient's treatment plan.

In an interview on 12/28/18 at 9:23 a.m. with S5RN, she reported she remembered the incident, referenced above, involving Patient #1 and Patient #2. S5RN confirmed Patient #2 had expressed he was afraid of Patient #1 and had not felt safe in the room with him when he was interviewed about the incident. S5RN confirmed Patient #2 had been moved to another room for safety and Patient #1 had been changed to 1:1 level of observation. S5RN also confirmed Patient #1 and Patient #2's treatment plans should have been updated to address the incident and to indicate actions taken such as room assignment changes for patient safety and precaution level changes for patient safety.

In an interview on 12/28/18 at 11:07 a.m. with S1DON, she confirmed the above referenced incident of alleged sexually inappropriate behavior requiring a level of observation change to 1:1 (Patient #1), removal of the patient's roommate (Patient #2) for safety, and placing Patient #2 back on close staff sight after the incident (Pt. had previously been on every 15 minute routine observation) should have been identified as patient changes and their treatment plans should have been updated to reflect these changes.