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Based on record reviews, observations, and interviews, the hospital failed to meet the Condition of Participation for Patient Rights as evidenced by:

1) failing to ensure care in a safe setting by failing to implement and maintain strict adherence to the observational status of patients as per physician's orders for 1 of 9 sampled patients, (#6). This resulted in patient #6 being found deceased on 05/02/10 at 6:25 a.m. after a 55 minute period when the patient was not monitored every 15 minutes per physician's order. .(See findings at A0144)

2) failing to ensure physician's orders were implemented and carried out for 1 of 9 sampled patients, (#9). as evidenced by patient #9 not being monitored on Line-of-Sight observation from 11/02/10 at 12:30 p.m. when the physician (S13MD) increased patient #9's observational status until 11/10/10 at about 5:00 p.m. (over 8 days) when surveyor's notified S1 Admin of the patient not being monitored on the physician ordered observational status.(See findings at A0144);

An Immediate Jeopardy situation was identified on 11/12/10 at 12:40 p.m. and was reported to the Administrator, (S1). The Immediate Jeopardy situation was a result of:

The hospital failed to ensure the nursing staff implemented and maintained strict adherence to the observational status of patients per physician's orders. On 11/02/10 at 12:30 p.m., the physician increased patient #9's observational status from being checked every 15 minutes to constant visual observation ("line of sight") due to suicidal ideations. The nursing staff failed to implement the physician's order for "line of sight" from 11/02/10 at 12:30 p.m. through 11/10/10 at approximately 5:00 p.m. when the surveyor brought it to the administrator's attention. Surveyors made observations on 11/09/10 and 11/10/10 during the survey that patient #9 was not being monitored on "line of sight" as ordered by the physician. Surveyors determined a prior occurrence through review of a death record dated 05/02/10 in which patient #6 was not being monitored every 15 minutes as ordered by the physician. This patient was found to be deceased and the documentation revealed this patient had not been checked for 55 minutes. The facility failed to investigate or implement corrective action after patient #6 was found deceased. Failure of the hospital to maintain strict adherence to the observational levels of patients was not identified by the quality assurance/performance improvement program in May of 2010 and therefore not corrected at the time of this survey.

A Plan of Removal was submitted by S1 Admin on 11/16/10 at 9:00 a.m. and the Immediate Jeopardy situation was lifted on 11/16/10 at 10:10 a.m. The deficient practice remains at the condition level. The corrective action plan included the following:

"Oceans will do immediate In-Servicing, of all nursing staff prior to working with patients, on the responsibilities/documentation of Q-15 minute and 1:1 observation per policy. Competency will be determined through observation and testing within 1 hour. No nursing staff will be allowed to work until In-Service is complete and all staff will be In-Serviced by 11/24/10.

To ensure the strict adherence of the ordered observation status of patients is being maintained and, effective immediately, the RN in charge will randomly observe/monitor MHTs a minimum of, 4 times per shift and sign off on the Q15 minute sheet. This will be done for both Q-15 and 1:1 observation.

To assure nursing staff implement all physicians' orders, when an LPN signs off an order, the RN on duty will co-sign the order, within 1 hour, to assure proper transcription and communication to the oncoming shift. The oncoming RN will review and sign off on all orders, within 1 hour.

A committee of review consisting of the DON and a physician on staff will review all deaths beginning immediately and the review and Root Cause Analysis shall be completed in 72 hours. Upon completion, the results of the review will be sent to the Medical Director within 1 hour. At any point during the review there are any findings indicative of abuse or neglect, the Medical Director, DHH and the Joint Commission shall be notified within 1 hour of the findings. Results of all reviews will be submitted to the PI Committee and Med Exec on the next scheduled meeting. All deaths, currently not reviewed will be reviewed within the next 7 days."

Based on record reviews, observations, and interviews, the hospital failed to ensure the Registered Nurse (RN) supervised and evaluated the care of each patient by:

1) failing to ensure care in a safe setting by failing to implement and maintain strict adherence to the observational status of patients as per physician's orders for 1 of 9 sampled patients, (#6). This resulted in patient #6 being found deceased on 05/02/10 at 6:25 a.m. after a 55 minute period when the patient was not monitored every 15 minutes per physician's order.

2) failing to ensure physician's orders were implemented and carried out for 1 of 9 sampled patients, (#9). as evidenced by patient #9 not being monitored on Line-of-Sight observation from 11/02/10 at 12:30 p.m. when the physician (S13MD) increased patient #9's observational status until 11/10/10 at about 5:00 p.m. (over 8 days) when surveyor's notified S1 Admin of the patient not being monitored on the physician ordered observational status

3) failing to conduct daily skin assessments per hospital policy. This resulted in the failure to identify a bruise to the Right axilla/upper chest of Patient #4. This bruise was photographed upon arrival at the emergency room 24 minutes after departing the hospital. Findings:

1)

Patient #6:
Review of the medical record of Patient #6 revealed she was admitted to Ocean's Behavioral Hospital on 05/01/10 at 2300 (11:00 p.m.). Further review of the medical record revealed S13, MD admitted Patient #6 with an admitting diagnosis of Schizoaffective D/O (Disorder).
Review of the Admission orders for Patient #6 revealed the Admission orders were taken as a verbal order by S7, RN from S13, MD. The orders included the following: "5) Vital Signs: Geriatric TID (three times daily); 8) Precautions: Assault, Falls; 9) Close Observation Q-15 (every 15 minutes); 18) Initial Treatment Plan Problems: Gravely disabled R/T (related to) psychosis)."
Review of the Initial Nursing Assessment dated/timed 05/01/10 at 2230 (11:30 p.m.) revealed under "Physical Illnesses/Disabilities" the following "Hx. (history) Thyroid CA (cancer), hypothyroid, Valvular Heart Disease (pt. needs replacement of 2 valves but is not sx. (surgery) candidate, CHF (congestive heart failure), Emphysema, Parkinson's, long psych. (psychiatric) history."
Review of the nursing narrative notes dated/timed 05/01/10 at 2300 (11:00 p.m.) revealed in part: "63 y/o (year old) female admitted to the services of (S13, MD). Dx. Schizoaffective D/O. Pt. unable to sign consents..."
Review of the nursing notes dated/timed 05/02/10 at 0200 (2:00 a.m.) read: "Pt taken to room and placed in bed. Bed alarm on bed and functioning properly. TB (tuberculosis) skin test administered to RFA (forearm), inner aspect...Will monitor closely." The nursing note is signed by S7RN.
Review of the Graphic/ I & O (intake and output) sheet revealed Patient #6's vital signs were documented at 11:00 p.m. as follows: "Blood Pressure 145/79, Pulse rate 98, Respiratory rate 20 and Temperature 97.5 (no indication of where taken)."
Review of the Observation Check Sheet revealed the documentation indicated that Patient #6 was "2 - 1" (Pt. room (lying down)/Sleeping (eyes closed)) from 2:00 a.m. until 5:30 a.m. Further review of the Observation Check Sheet revealed no documentation for 5:45 a.m., 6:00 a.m. and 6:15 a.m. The 6:15 a.m. documentation slot has the time marked out and the time of 6:25 a.m. written in it's place. Documentation for 6:25 a.m. reads: "31" (Pt. found unresponsive."
Review of the nursing documentation revealed there was no documentation from 2:00 a.m. until 0625 (6:25 a.m.) on 05/02/10.
Review of the nursing notes for 05/02/10 at 0625 (6:25 a.m.) revealed: "Pt. found in bed by MHT (mental health technician) unresponsive. No signs of life evident. Pt. not breathing. No pulse palpable. CPR (cardiopulmonary resuscitation) started immediately...Call placed to 911 at 0634 (9 minutes after Patient #4 was found unresponsive)..." Review of the nursing documentation for 0639 (6:39 a.m.) revealed "(ambulance service "a") paramedics arrived. CPR stopped. Heart rhythm analyzed by paramedics. Indicated Asystole..."
Review of the ambulance service "a" record revealed: "Dispatch Time: 6:34 a.m.; On Scene: 6:39 a.m.; History of Present Illness:..This morning nurse went to check on pt at 5:30 (a.m.) and stated she was asleep. Nurses were giving pt more time to sleep since she had not gone to bed until 2 a.m. At approx. 630 (6:30 a.m.) nurse went in to get vitals and pt was face down on the bed and blue. CPR was initiated and 911 was called at 6:34 a.m....Observation and exam: Head: cyanotic, cold to touch; Face: Pupils dilated, cyanotic, pupils fixed and dilated, lividity noted;...Thorax: asystole on monitor, pt not breathing;...Upper Extremities: cyanosis noted to right hand, rigor mortis to extremities;...Lower extremities: cyanosis noted to right leg, rigor mortis to extremities...CPR discontinued due to obvious signs of death. Response to Treatment:..Response and other narrative: code called due to obvious signs of death and rigor mortis..."
Review of the nursing notes for 05/02/10 at 0730 (7:30 a.m.) read in part: "Pt. daughter (name) notified of pt's expiration." (56 minutes after Patient #6 was found unresponsive, not breathing and without a pulse)
In a telephone interview on 11/09/10 at 4:15 p.m. with S7RN she stated the MHT was responsible for checking on Patient #6 every 15 minutes per the physician's order. She stated that she instructed the MHT to allow Patient #6 to sleep late but did not instruct the MHT to not follow the physician ordered checks every 15 minutes. S7RN stated she became aware that Patient #6 was not checked on every 15 minutes after the patient had died. S7RN stated she "could not remember if an incident report was filled out. S7RN was asked if an incident report should have been filled out per hospital policy and she stated "I guess so." S7RN further stated that when patients are sleeping the MHT should "put on the bathroom light and note rise and fall of the patients chest as part of the every 15 minute check." S7RN stated that when she attempted to roll Patient #6 over to assess for breathing the patient "was stiff." S7RN was asked if Patient #6 had rigor mortis and replied "I suppose it was rigor, it was hard to roll her." S7RN stated she asked S11MHT why the 15 minute checks were not documented and the MHT responded "we were busy getting everyone else up."
In an interview on 11/10/10 at 7:50 a.m. S7RN stated she was the Registered Nurse (RN)responsible for the care of Patient #6 on the night shift of 05/01/10 - 05/02/10 from admission until 7:00 a.m. on 05/02/10. S7RN stated that the RN signs the Observation sheets at the end of the shift. S7RN stated she questioned the MHT about the documentation that revealed that Patient #6 was not checked on from 5:30 a.m. until she was found unresponsive at 6:25 a.m. S7RN stated that S11MHT (no longer employed at the hospital) told her that "she was busy with other patients." S7RN stated she does not remember if she notified the Administrator or DON of this information. S7RN further indicated she is not aware of any policy that requires the RN to check on patients.
In an interview on 11/09/10 at 3:55 p.m. with S1Administrator he stated there was no investigation into the death of Patient #6 conducted by Ocean's Behavioral Hospital of Opelousas. S1Administrator reviewed the documentation by ambulance service "a" and stated he was not aware of the documentation of rigor mortis and lividity. S1Administrator stated that documentation on the Observation sheet revealed that Patient #6 was not checked every 15 minutes per the physician's order and the documentation indicated Patient #6 was not checked on for 55 minutes prior to being found face down, unresponsive, not breathing and without a pulse. S1Administrator confirmed there is no documentation of the nurse checking on Patient #6 from 2:00 a.m. until 6:25 a.m.
In an interview on 11/18/10 at 10:50 with S13MD, admitting psychiatrist and Medical Director, stated the hospital had no Mortality Policy, that he "glanced" through the chart, and could not remember if he was aware that the 15 minute checks he ordered were done.
Review of an incident report filled out by S7RN dated/timed 05/02/10 at 0625 (6:25 a.m.) revealed no documentation of the time lapse between checks on Patient #6 or the RN's knowledge that the patient was not checked on for 55 minutes prior to her being found unresponsive, not breathing and without a pulse.
2)
Patient #9:
Review of the "Psychiatric Evaluation" dictated on 11/01/10 (no time indicated) revealed the patient (#9) was evaluated by the Psychiatrist (S14MD). Further review of the "Psychiatric Evaluation" by S14MD revealed there was no date/time that the physician authenticated the patient's evaluation. The "Psychiatric Evaluation" of #9 read, "suicidal thoughts with increased thoughts of wanting to die, suicidal thoughts including a plan to use her 38-caliber pistol or to take all of her medications at once. She appears fragile, withdrawn, sad, and tearful during examination".
Review of the medical record for patient #9 revealed an order that read: "(line of sight) LOS observations. D/C (discontinue) /q (every) 15 minute" was written by S13MD at 12:30 p.m. on 11/02/10.
On 11/09/10, random observations of the dining room area revealed Patient #9 was observed sitting at the back of the room at 11:14 a.m. on a couch. At 5:40 p.m., the patient (#9) was observed sitting at a table in the room. During both dining room observations at 11:14 a.m. and 5:40 p.m., there were no MHT observed assigned to monitor the patient.
In an interview on 11/09/10 at 11:20 a.m., S23MHT indicated there was only one patient (#7) on 1:1 observation for today, 11/09/10.
In an interview on 11/09/10 at 11:21 a.m., S19MHT Staff Coordinator stated patient #7 is the only patient on 1:1 observation as of today, 11/09/10.
In an interview on 11/09/10 at 12:12 p.m., S4RN reported there were no patients with "LOS" and/or 1:1 observation orders for today, (11/9/10).
An observation of the dining room was conducted from 7:30 a.m. to 8:32 a.m. on 11/10/10. This observation revealed Patient #9 was sitting at the back of the room on a couch in the dining room at 7:30 a.m. Patient #9 was observed at 8:10 a.m. and 8:32 a.m. sitting at a table in the front of the dining room area. During these observations at 7:30 a.m., 8:10 a.m. and 8:32 a.m., there was no MHT observed monitoring the patient.
Review of the daily "Observation Check Sheets" revealed there was no documentation of an MHT assigned to supervise the "LOS" and/or 1:1 observation orders for patient #9 from 11/02/10 to 11/10/10.

The "Daily Staffing Schedule" for the MHTs was reviewed. Further review revealed there was no documentation Patient #9 was assigned a MHT to directly supervise the patient ' s (#9's) " LOS " and 1:1 observation orders for about 8 days.

Review of the daily "Nursing Psychiatric Assessment" notes for patient #9 revealed there was no documentation the "LOS" and 1:1 observation orders were supervised and evaluated by the nursing staff from 11/02/10 at 12:30 p.m. through 11/10/10 at 5:00 p.m. for about 8 days.

In an interview on 11/15/10 at 12:25 p.m., S19MHT, Staff Coordinator indicated there was no documentation the patient (#9) was assigned to an MHT for the "LOS" and/or 1:1 observation orders from 11/2/10 to 11/10/10. S19MHT stated all patients assigned "LOS" and/or 1:1 observation orders are assigned an MHT. She reported the "LOS" and/or 1:1 observation orders are recorded on the daily MHTs ' staffing schedules under the section titled, "1:1 Special Assignments". S19MHT (MHT, Staff Coordinator ) verified there was no documentation the patient (#9) was assigned an MHT for the "LOS" and/or 1:1 observation orders on the MHT's " Daily Staffing Schedule" from 11/02/10 through 11/10/10.

During interviews on 11/10/10 from 4:15 p.m. to 4:45 p.m. and 11/15/10 at 2:00 p.m., S1Administrator indicated there was no documentation a MHT was assigned to supervise the "LOS" or 1:1 observation orders for the patient (#9) from 11/02/10 through 11/10/10. The Administrator (S1) reported there was no documented evidence the nursing staff followed the physician's orders and assigned a designated MHT to directly supervise the patient as ordered "LOS" from 11/02/10 to 11/10/10. S1Administrator indicated there was no documentation in #9's record that the "LOS" or 1:1 observation orders were supervised/evaluated by the nursing staff from 11/02/10 through 11/10/10.

In face-to-face interviews held on 11/10/10 at 4:25 p.m., S21MHT and S5RN were not aware patient #9 had a "LOS" or 1:1 observation order since 11/02/10.
A telephone interview was conducted at 4:45 p.m. on 11/10/10 with the Psychiatrist/Medical Director (S13MD). S13MD recalled increasing the patients' observation status because the patient (#9) had a suicidal ideation with a plan. He stated he had changed the patient's observation status from Q15M to "LOS" after he had reviewed the "Psychiatric Evaluation" by S24, MD/Psychiatrist on 11/02/10. S13MD indicated the patient needed more observation than Q15M because the patient's plan included the patient's gun/pistol to harm herself. S13MD stated he did not know that the nursing staff was not following the "LOS" orders written on 11/02/10. S13MD indicated that he expected all nursing staff to follow the "LOS" orders written because the patient (#9) needed more observation than Q15M.
During another interview on 11/10/10 at 4:50 p.m., the S1, Administrator verified S14MD, Psychiatrist indicated the patient (#9) was evaluated on 11/01/10 with "thoughts of wanting to die, including plan to use her pistol or take all medications at once". The Administrator stated S13MD, (Psychiatrist/Medical Director) reviewed S14MD's evaluation of the patient on 11/01/10 and wrote the "LOS" order to increase patient #9's observation level.
Another interview was held with the S1Administrator at 11:50 a.m. on 11/17/10. The Administrator indicated the hospital did not have a line of sight policy. S1 stated the "LOS " order written by the physician (S13MD) should have been a 1:1 observation order for the patient (#9) since 11/2/10.
The policy titled, "Suicide Precautions/Close Observations", Policy #TX-SPEC. 05, Adoption date of March of 2008, with no revised or reviewed dates, presented as the hospitals current "Observation Levels" on 11/9/10 at 3:00 p.m. was reviewed. The policy indicated there were two (2) observation levels, (1:1 Observation and Close Observation every 15 minutes) used to provide inpatients with direct supervision that are a high suicidal risk and verbalizing suicide.
3)

Patient #4

Review of an Oceans Behavioral Hospital of Opelousas Progress Note for patient complaint or follow up (a communication tool written by nursing staff and placed in the physician progress note area of the medical record for the physician to address) dated/timed 09/17/10 at 1830 (6:30 p.m.) read in part: "Nurse's Report: 4 blisters & dark purple areas noted Lt (left) foot & 1 blister with dark purple area noted on Rt (right) foot. Pls (please) eval. (evaluate). Heel protectors put on pt. Please give orders if needed. "This was the first documentation of any skin problems for Patient #4 since his admission on 08/25/10.

Review of a physician's order dated/timed 09/17/10 at 2000 (8:00 p.m.) taken as a verbal order by S7RN from S15MD that read as follows:
- Eucerin lotion to both feet q day.

Review of the Skin assessment for 09/17/10 revealed "Wound Care, Other: Blisters, Heel protectors in place " for the 7:00 a.m. - 7:00 p.m. shift and "Bruises, Wound Care, Other - PEG " documented with no documentation of where on the skin of Patient #4 the bruises were located for the 7:00 p.m. - 7:00 a.m. shift.

Review of the Skin assessment for 09/18/10 revealed "Wound Care, Other: Blisters to (arrow down) lower ext. (extremities), Heel protectors in place" for the 7:00 a.m. - 7:00 p.m. shift and "Bruises, Wound Care - PEG tube" documented with no documentation of where on the skin of Patient #4 the wound care was performed on the skin of Patient #4 for the 7:00 p.m. - 7:00 a.m. shift.

Review of the Skin assessment for 09/19/10 revealed "Wound Care, Other: Blisters to (arrow down) lower ext. (extremities), Heel protectors in place" for the 7:00 a.m. - 7:00 p.m. shift and further review of the medical record revealed there was no nursing documentation for the 7:00 p.m. - 7:00 a.m. shift. This was confirmed by S1Administrator at 10:30 a.m. on 11/17/10.

Patient #4 was discharged to the Emergency Room of hospital "a" at 10:00 a.m. Review of the Skin assessment for 09/20/10 revealed " Other - flaky, cyanotic feet."

In an interview on 11/16/10 at 12:45 p.m. with S1Administrator and S2DON confirmed that there was no comprehensive skin assessment documented in the medical record after the Initial Nursing Assessment dated 08/25/10. S1Administrator and S2DON confirmed that there was no documentation of the Right axilla/upper chest bruise on Patient #4 which was photographed/documented 24 minutes later after discharge in the emergency room.

Review of a hospital policy titled "Skin/Wound Care Protocol", policy number NSG-40, adopted March 2008, no date of last revision, reads in part: "Policy:..Skin assessments will be performed daily on Geriatric patients and documented...Purpose: To provide guidelines and protocol for the prevention, assessment and treatment of wounds...Procedure: RN...Wound description documentation will include location, type, where acquired, stage, length, width, depth, wound bed description, drainage, odor, surrounding skin and pain. Wound description will be documented on the Wound Evaluation Form when wound care is performed. Wound length, width and depth will be measured in centimeters weekly and documented on the wound Evaluation Form..."

Based on record review and interview the hospital failed to analyze and track adverse patient events as evidenced by the failure to investigate the death of a patient, analyze the events surrounding the event, and/or implement any process changes or monitor quality indicators related to the failure of staff to monitor a patient in accordance with the orders of the physician responsible for the care of the patient. Findings:

In an interview on 11/18/10 at 10:50 with S13MD, admitting psychiatrist and Medical Director, he stated the hospital had no Mortality Policy, that he "glanced" through the chart, and could not remember if he was aware that the 15 minute checks he ordered were done.
Review of an incident report filled out by S7RN dated/timed 05/02/10 at 0625 (6:25 a.m.) revealed no documentation of the time lapse between checks on Patient #6 or the RN's knowledge that the patient was not checked on for 55 minutes prior to her being found unresponsive, not breathing and without a pulse.
In an interview on 11/09/10 at 3:55 p.m. with S1Administrator he stated there was no investigation into the death of Patient #6 conducted by Ocean's Behavioral Hospital of Opelousas. S1 Administrator reviewed the documentation by ambulance service "a" and stated he was not aware of the documentation of rigor mortis and lividity. S1Administrator stated that documentation on the Observation sheet revealed that Patient #6 was not checked every 15 minutes per the physician's order and the documentation indicated Patient #6 was not checked on for 55 minutes prior to being found face down, unresponsive, not breathing and without a pulse. S1Administrator confirmed there is no documentation of the nurse checking on Patient #6 from 2:00 a.m. until 6:25 a.m.

Based on record reviews, observations, and interviews, the hospital failed to meet the Condition of Participation for Nursing Services as evidenced by:

1) failing to ensure care in a safe setting by failing to implement and ensure strict adherence to the observational status of patients as per physician's orders for 1 of 9 sampled patients, (#6). This resulted in patient #6 being found deceased on 05/02/10 at 6:25 a.m. after a 55 minute period when the patient was not monitored every 15 minutes per physician's order. (See findings at A0395);

2) failing to ensure physician's orders were implemented and carried out for 1 of 9 sampled patients, (#9). as evidenced by patient #9 not being monitored on Line-of-Sight observation from 11/02/10 at 12:30 p.m. when the physician (S13MD) increased patient #9's observational status until 11/10/10 at about 5:00 p.m. (over 8 days) when surveyor's notified S1 Admin of the patient not being monitored on the physician ordered observational status. (See findings at A0395);

An immediate jeopardy situation was identified on 11/12/10 at 12:40 p.m. and was reported to S1, Administrator. The immediate jeopardy situation was a result of:

The hospital failed to ensure the nursing staff implemented and maintained strict adherence to the observational status of patients per physician's orders. On 11/02/10 at 12:30 p.m., the physician increased patient #9's observational status from being checked every 15 minutes to constant visual observation ("line of sight") due to suicidal ideations. The nursing staff failed to implement the physician's order for "line of sight" from the date ordered (11/02/10 at 12:30 p.m.) through 11/10/10 at approximately 5:00 p.m. when the surveyor brought it to the administrator's attention. Surveyors made observations during the survey that patient #9 was not being monitored on "line of sight" as ordered by the physician. Surveyors determined a prior occurrence on 05/02/10 in which patient #6 was not being monitored every 15 minutes as ordered by the physician. This patient was found to be deceased and the documentation revealed this patient had not been checked for 55 minutes. The facility failed to investigate or implement corrective action regarding patient #6. Failure of the hospital to maintain strict adherence to the observational levels of patients was not identified by the quality assurance/performance improvement program in May of 2010 and therefore not corrected at the time of this survey.

A plan of removal was submitted by S1Administrator on 11/16/10 at 9:00 a.m. and the immediate jeopardy situation was lifted on 11/16/10 at 10:10 a.m..The deficient practice remains at the Condition level. The corrective action plan included the following:

"Oceans will do immediate In-Servicing, of all nursing staff prior to working with patients, on the responsibilities/documentation of Q-15 minute and 1:1 observation per policy. Competency will be determined through observation and testing within 1 hour. No nursing staff will be allowed to work until In-Service is complete and all staff will be In-Serviced by 11/24/10.

To ensure the strict adherence of the ordered observation status of patients is being maintained and, effective immediately, the RN in charge will randomly observe/monitor MHTs a minimum of, 4 times per shift and sign off on the Q15 minute sheet. This will be done for both Q-15 and 1:1 observation.

To assure nursing staff implement all physicians' orders, when an LPN signs off an order, the RN on duty will co-sign the order, within 1 hour, to assure proper transcription and communication to the oncoming shift. The oncoming RN will review and sign off on all orders, within 1 hour.

A committee of review consisting of the DON and a physician on staff will review all deaths beginning immediately and the review and Root Cause Analysis shall be completed in 72 hours. Upon completion, the results of the review will be sent to the Medical Director within 1 hour. At any point during the review there are any findings indicative of abuse or neglect, the Medical Director, DHH and the Joint Commission shall be notified within 1 hour of the findings. Results of all reviews will be submitted to the PI Committee and Med Exec on the next scheduled meeting. All deaths, currently not reviewed will be reviewed within the next 7 days."

2) failing to conduct daily skin assessments per hospital policy. This resulted in the failure to identify a bruise (injury of unknown origin) to the Right axilla/upper chest of Patient #4. This bruise was photographed upon arrival at the emergency room 24 minutes after departing the hospital. (see findings at A0395)

3) failing to identify the initial assessment findings of "decreased appetite, not eating, requiring care with ADL's (activities of daily living) and assistance" and "refusing to eat at times" as an ongoing problem for Patient #4 as evidenced by failing to notify the physician or Registered Dietician (RD) of fluid intake being below the RD's recommended daily intake for 27 of 27 days Patient #4 was an inpatient. (see findings at A0395)

4) failing to follow physicians order for "VS (vital signs) TID (three times a day) with Apical pulses and record. Notify MD of abnormalities/bradycardia." (#4) (see findings at A0395)

5) failing to ensure that the nursing care plan was based on assessment of the patient's nursing care needs and that the Multidisciplinary Treatment Team developed appropriate nursing interventions in response to those needs by failing to include assessment findings related to dysphagia and decreased intake of food and fluids in the care plan for 1 of 9 sampled patients. (#4) (see findings at A0396)

6) failing to ensure medications were administered in accordance with hospital policy/accepted standards of practice by administering Digoxin without checking an Apical Pulse for 1 of 9 sampled patients. (#4) (see findings at A0404)

Based on record reviews, observations, and interviews, the hospital failed to ensure the Registered Nurse (RN) supervised and evaluated the care of each patient by:

1) failing to ensure care in a safe setting by failing to implement and ensure strict adherence to the observational status of patients as per physician's orders for 1 of 9 sampled patients, (#6). This resulted in patient #6 being found deceased on 05/02/10 at 6:25 a.m. after a 55 minute period when the patient was not monitored every 15 minutes per physician's order.

2) failing to ensure physician's orders were implemented and carried out for 1 of 9 sampled patients, (#9). as evidenced by patient #9 not being monitored on Line-of-Sight observation from 11/02/10 at 12:30 p.m. when the physician (S13MD) increased patient #9's observational status until 11/10/10 at about 5:00 p.m. (over 8 days) when surveyor's notified S1 Admin of the patient not being monitored on the physician ordered observational status.

3) failing to conduct daily skin assessments per hospital policy. This resulted in the failure to identify a bruise to the Right axilla/upper chest of Patient #4. This bruise was photographed upon arrival at the emergency room 24 minutes after departing the hospital.

4) failing to identify the initial assessment findings of "decreased appetite, not eating, requiring care with ADL's (activities of daily living) and assistance" and "refusing to eat at times" as an ongoing problem for Patient #4 as evidenced by failing to notify the physician or Registered Dietician (RD) of fluid intake being below the RD's recommended daily intake for 27 of 27 days Patient #4 was an inpatient.

5) failing to follow physicians order for "VS (vital signs) TID (three times a day) with Apical pulses and record. Notify MD of abnormalities/bradycardia. " (#4) Findings:

1)
Patient #6:
Review of the medical record of Patient #6 revealed she was admitted to Ocean's Behavioral Hospital on 05/01/10 at 2300 (11:00 p.m.). Further review of the medical record revealed S13MD admitted Patient #6 with an admitting diagnosis of Schizoaffective D/O (Disorder).
Review of the Admission orders for Patient #6 revealed the Admission orders were taken as a verbal order by S7RN from S13MD. The orders included the following: "5) Vital Signs: Geriatric TID (three times daily); 8) Precautions: Assault, Falls; 9) Close Observation Q-15 (every 15 minutes); 18) Initial Treatment Plan Problems: Gravely disabled R/T (related to) psychosis)."
Review of the Initial Nursing Assessment dated/timed 05/01/10 at 2230 (11:30 p.m.) revealed under "Physical Illnesses/Disabilities" the following "Hx. (history) Thyroid CA (cancer), hypothyroid, Valvular Heart Disease (pt. needs replacement of 2 valves but is not sx. (surgery) candidate, CHF (congestive heart failure), Emphysema, Parkinson's, long psyc. (psychiatric) history."
Review of the nursing narrative notes dated/timed 05/01/10 at 2300 (11:00 p.m.) revealed in part: "63 y/o (year old) female admitted to the services of (S13MD). Dx. Schizoaffective D/O. Pt. unable to sign consents..."
Review of the nursing notes dated/timed 05/02/10 at 0200 (2:00 a.m.) read: "Pt taken to room and placed in bed. Bed alarm on bed and functioning properly. TB (tuberculosis) skin test administered to RFA (forearm), inner aspect...Will monitor closely." The nursing note is signed by S7RN.
Review of the Graphic/ I & O (intake and output) sheet revealed Patient #6's vital signs were documented at 11:00 p.m. as follows: "Blood Pressure 145/79, Pulse rate 98, Respiratory rate 20 and Temperature 97.5 (no indication of where taken)."
Review of the Observation Check Sheet revealed the documentation indicated that Patient #6 was "2 - 1" (Pt. room (lying down)/Sleeping (eyes closed)) from 2:00 a.m. until 5:30 a.m. Further review of the Observation Check Sheet revealed no documentation for 5:45 a.m., 6:00 a.m. and 6:15 a.m. The 6:15 a.m. documentation slot has the time marked out and the time of 6:25 a.m. written in it's place. Documentation for 6:25 a.m. reads: "31" (Pt. found unresponsive."
Review of the nursing documentation revealed there was no documentation from 2:00 a.m. until 0625 (6:25 a.m.) on 05/02/10.
Review of the nursing notes for 05/02/10 at 0625 (6:25 a.m.) revealed: "Pt. found in bed by MHT (mental health technician) unresponsive. No signs of life evident. Pt. not breathing. No pulse palpable. CPR (cardiopulmonary resuscitation) started immediately...Call placed to 911 at 0634 (9 minutes after Patient #4 was found unresponsive)..." Review of the nursing documentation for 0639 (6:39 a.m.) revealed "(ambulance service "a") paramedics arrived. CPR stopped. Heart rhythm analyzed by paramedics. Indicated Asystole..."
Review of the ambulance service "a" record revealed: "Dispatch Time: 6:34 a.m.; On Scene: 6:39 a.m.; History of Present Illness:..This morning nurse went to check on pt at 5:30 (a.m.) and stated she was asleep. Nurses were giving pt more time to sleep since she had not gone to bed until 2 a.m. At approx. 630 (6:30 a.m.) nurse went in to get vitals and pt was face down on the bed and blue. CPR was initiated and 911 was called at 6:34 a.m....Observation and exam: Head: cyanotic, cold to touch; Face: Pupils dilated, cyanotic, pupils fixed and dilated, lividity noted;...Thorax: asystole on monitor, pt not breathing;...Upper Extremities: cyanosis noted to right hand, rigor mortis to extremities;...Lower extremities: cyanosis noted to right leg, rigor mortis to extremities...CPR discontinued due to obvious signs of death. Response to Treatment:..Response and other narrative: code called due to obvious signs of death and rigor mortis..."
Review of the nursing notes for 05/02/10 at 0730 (7:30 a.m.) read in part: "Pt. daughter (name) notified of pt's expiration." (56 minutes after Patient #6 was found unresponsive, not breathing and without a pulse)
In a telephone interview on 11/09/10 at 4:15 p.m. with S7RN she stated the MHT was responsible for checking on Patient #6 every 15 minutes per the physician's order. She stated that she instructed the MHT to allow Patient #6 to sleep late but did not instruct the MHT to not follow the physician ordered checks every 15 minutes. S7RN stated she became aware that Patient #6 was not checked on every 15 minutes after the patient had died. S7RN stated she "could not remember if an incident report was filled out. S7RN was asked if an incident report should have been filled out per hospital policy and she stated "I guess so." S7RN further stated that when patients are sleeping the MHT should "put on the bathroom light and note rise and fall of the patients chest as part of the every 15 minute check." S7RN stated that when she attempted to roll Patient #6 over to assess for breathing the patient "was stiff." S7RN was asked if Patient #6 had rigor mortis and replied "I suppose it was rigor, it was hard to roll her." S7RN stated she asked S11MHT why the 15 minute checks were not documented and the MHT responded "we were busy getting everyone else up."
In an interview on 11/10/10 at 7:50 a.m. S7RN stated she was the Registered Nurse (RN)responsible for the care of Patient #6 on the night shift of 05/01/10 - 05/02/10 from admission until 7:00 a.m. on 05/02/10. S7RN stated that the RN signs the Observation sheets at the end of the shift. S7RN stated she questioned the MHT about the documentation that revealed that Patient #6 was not checked on from 5:30 a.m. until she was found unresponsive at 6:25 a.m. S7RN stated that S11MHT (no longer employed at the hospital) told her that "she was busy with other patients." S7RN stated she does not remember if she notified the Administrator or DON of this information. S7RN further indicated she is not aware of any policy that requires the RN to check on patients.
In an interview on 11/09/10 at 3:55 p.m. with S1Administrator he stated there was no investigation into the death of Patient #6 conducted by Ocean's Behavioral Hospital of Opelousas. S1Admin reviewed the documentation by ambulance service "a" and stated he was not aware of the documentation of rigor mortis and lividity. S1Administrator stated that documentation on the Observation sheet revealed that Patient #6 was not checked every 15 minutes per the physician's order and the documentation indicated Patient #6 was not checked on for 55 minutes prior to being found face down, unresponsive, not breathing and without a pulse. S1Administrator confirmed there is no documentation of the nurse checking on Patient #6 from 2:00 a.m. until 6:25 a.m.
In an interview on 11/18/10 at 10:50 with S13MD, admitting psychiatrist and Medical Director, he stated the hospital had no Mortality Policy, that he "glanced" through the chart, and could not remember if he was aware that the 15 minute checks he ordered were done.
Review of an incident report filled out by S7RN dated/timed 05/02/10 at 0625 (6:25 a.m.) revealed no documentation of the time lapse between checks on Patient #6 or the RN's knowledge that the patient was not checked on for 55 minutes prior to her being found unresponsive, not breathing and without a pulse.
2)
Patient #9:
Review of the "Psychiatric Evaluation" dictated on 11/01/10 (no time indicated) revealed the patient (#9) was evaluated by the Psychiatrist (S14MD). Further review of the "Psychiatric Evaluation" by S14MD revealed there was no date/time that the physician authenticated the patient's evaluation. The "Psychiatric Evaluation" of #9 read, "suicidal thoughts with increased thoughts of wanting to die, suicidal thoughts including a plan to use her 38-caliber pistol or to take all of her medications at once. She appears fragile, withdrawn, sad, and tearful during examination".
Review of the medical record for #9 revealed an order by S13MD that read: "LOS observations-D/C (discontinue) /q (every) 15 minute" at 12:30 p.m. on 11/02/10.
On 11/09/10, random observations of the dining room area revealed Patient #9 was observed sitting at the back of the room at 11:14 a.m. on a couch. At 5:40 p.m., the patient (#9) was observed sitting at a table in the room. During both dining room observations at 11:14 a.m. and 5:40 p.m., there were no MHT observed assigned to monitor the patient.
In an interview on 11/09/10 at 11:20 a.m., S23MHT indicated there was only one patient (#7) on 1:1 observation for today, 11/09/10.
In an interview on 11/09/10 at 11:21 a.m., S19MHT Staff Coordinator stated patient #7 is the only patient on 1:1 observation as of today, 11/09/10.
In an interview on 11/09/10 At 12:12 p.m., S4RN reported there were no patients with "LOS" and/or 1:1 observation orders for today, (11/9/10).
An observation of the dining room was conducted from 7:30 a.m. to 8:32 a.m. on 11/10/10. This observation revealed Patient #9 was sitting at the back of the room on a couch in the dining room at 7:30 a.m. Patient #9 was observed at 8:10 a.m. and 8:32 a.m. sitting at a table in the front of the dining room area. During these observations at 7:30 a.m., 8:10 a.m. and 8:32 a.m., there was no MHT observed monitoring the patient.
Review of the daily "Observation Check Sheets" revealed there was no documentation of an MHT assigned to supervise the "LOS" and/or 1:1 observation orders for patient #9 from 11/02/10 to 11/10/10.

The "Daily Staffing Schedule" for the MHTs was reviewed. Further review revealed there was no documentation Patient #9 was assigned an MHT to directly supervise the patient ' s (#9 ' s) " LOS " and/or 1:1 observation orders for about 8 days.

Review of the daily "Nursing Psychiatric Assessment" notes revealed there was no documentation the "LOS" and/or 1:1 observation orders were supervised and evaluated by the nursing staff from 11/02/10 at 12:30 p.m. through 11/10/10 at 5:00 p.m. for about 8 days.

In an interview on 11/15/10 at 12:25 p.m., S19MHT, Staff Coordinator indicated there was no documentation the patient (#9) was assigned to an MHT for the "LOS" and/or 1:1 observation orders from 11/2/10 to 11/10/10. S19 stated all patients assigned "LOS" and/or 1:1 observation orders are assigned an MHT. She reported the "LOS" and/or 1:1 observation orders are recorded on the daily MHTs ' staffing schedules under the section titled, "1:1 Special Assignments". S19 (MHT, Staff Coordinator ) verified there was no documentation the patient (#9) was assigned an MHT for the "LOS" and/or 1:1 observation orders on the MHT's " Daily Staffing Schedule" from 11/02/10 through 11/10/10.

During interviews on 11/10/10 from 4:15 p.m. to 4:45 p.m. and 11/15/10 at 2:00 p.m., S1Admin indicated there was no documentation an MHT was assigned to supervise the "LOS" or 1:1 observation orders for the patient (#9) from 11/02/10 through 11/10/10. The Administrator (S1) reported there was no documented evidence the nursing staff followed the physician's orders and assigned a designated MHT to directly supervise the patient as ordered " LOS" from 11/02/10 to 11/10/10. S1, Administrator indicated there was no documentation in #9's record that the "LOS" or 1:1 observation orders were supervised/evaluated by the nursing staff from 11/02/10 through 11/10/10.

In face-to-face interviews held on 11/10/10 at 4:25 p.m., S21MHT and S5RN were not aware patient #9 had a "LOS" and/or 1:1 observation order since 11/02/10.
A telephone interview was conducted at 4:45 p.m. on 11/10/10 with the Psychiatrist/Medical Director (S13, MD). S13MD recalled increasing the patients' observation status because the patient (#9) had a suicidal ideation with a plan. He stated he had changed the patient ' s observation status from Q15M to " LOS " after he had reviewed the "Psychiatric Evaluation" by S24, MD/Psychiatrist on 11/02/10. S13MD indicated the patient needed more observation than Q15M because the patient's plan included the patient ' s gun/pistol to harm herself. S13MD stated he did not know that the nursing staff was not following the "LOS" orders written on 11/02/10. S13MD indicated that he expected all nursing staff to follow the "LOS" orders written because the patient (#9) needed more observation than Q15M.
During another interview on 11/10/10 at 4:50 p.m., the Administrator (S1) verified S14MD, Psychiatrist indicated the patient (#9) was evaluated on 11/01/10 with "thoughts of wanting to die, including plan to use her pistol or take all medications at once". The Administrator stated S13MD, (Psychiatrist/Medical Director) reviewed S14MD's evaluation of the patient on 11/01/10 and wrote the "LOS" order to increase patient #9's observation level.
Another interview was held with the Administrator (S1) at 11:50 a.m. on 11/17/10. The Administrator indicated the hospital did not have a line of sight policy. S1 stated the "LOS " order written by the physician (S13MD) should have been a 1:1 observation order since 11/2/10 for the patient (#9).
The policy titled, "Suicide Precautions/Close Observations", Policy #TX-SPEC. 05, Adoption date of March of 2008, with no revised or reviewed dates, presented as the hospitals current "Observation Levels " on 11/9/10 at 3:00 p.m. was reviewed. The policy indicated there were two (2) observation levels, (1:1 Observation and Close Observation every 15 minutes) used to provide inpatients with direct supervision that are a high suicidal risk and verbalizing suicide.
3)

Patient #4

Review of an Oceans Behavioral Hospital of Opelousas Progress Note for patient complaint or follow up (a communication tool written by nursing staff and placed in the physician progress note area of the medical record for the physician to address) dated/timed 09/17/10 at 1830 (6:30 p.m.) read in part: " Nurse's Report: 4 blisters & dark purple areas noted Lt (left) foot & 1 blister with dark purple area noted on Rt (right) foot. Pls (please) eval. (evaluate). Heel protectors put on pt. Please give orders if needed. " This was the first documentation of any skin problems for Patient #4 since admission on 08/25/10.

Review of a physician's order dated/timed 09/17/10 at 2000 (8:00 p.m.) taken as a verbal order by S7RN from S15MD that read as follows:
- Eucerin lotion to both feet q day.
-
Review of the Skin assessment for 09/17/10 revealed " Wound Care, Other: Blisters, Heel protectors in place " for the 7:00 a.m. - 7:00 p.m. shift and " Bruises, Wound Care, Other - PEG " documented with no documentation of where on the skin of Patient #4 the bruises were located for the 7:00 p.m. - 7:00 a.m. shift.

Review of the Skin assessment for 09/18/10 revealed "Wound Care, Other: Blisters to (arrow down) lower ext. (extremities), Heel protectors in place" for the 7:00 a.m. - 7:00 p.m. shift and "Bruises, Wound Care - PEG tube" documented with no documentation of where on the skin of Patient #4 the wound care was performed on the skin of Patient #4 for the 7:00 p.m. - 7:00 a.m. shift.

Review of the Skin assessment for 09/19/10 revealed "Wound Care, Other: Blisters to (arrow down) lower ext. (extremities), Heel protectors in place " for the 7:00 a.m. - 7:00 p.m. shift and further review of the medical record revealed there was no nursing documentation for the 7:00 p.m. - 7:00 a.m. shift. This was confirmed by S1Administrator at 10:30 a.m. on 11/17/10.

Patient #4 was discharged to the Emergency Room of hospital "a" at 10:00 a.m. Review of the Skin assessment for 09/20/10 revealed "Other - flaky, cyanotic feet."

In an interview on 11/16/10 at 12:45 p.m. with S1Administrator and S2DON confirmed that there was no comprehensive skin assessment documented in the medical record after the Initial Nursing Assessment dated 08/25/10. S1Administrator and S2DON confirmed that there was no documentation of the Right axilla/upper chest bruise on Patient #4 which was photographed/documented 24 minutes later after discharge in the emergency room.

Review of a hospital policy titled "Skin/Wound Care Protocol", policy number NSG-40, adopted March 2008, no date of last revision, reads in part: "Policy:..Skin assessments will be performed daily on Geriatric patients and documented...Purpose: To provide guidelines and protocol for the prevention, assessment and treatment of wounds...Procedure: RN...Wound description documentation will include location, type, where acquired, stage, length, width, depth, wound bed description, drainage, odor, surrounding skin and pain. Wound description will be documented on the Wound Evaluation Form when wound care is performed. Wound length, width and depth will be measured in centimeters weekly and documented on the wound Evaluation Form..."

4)
Patient #4
In an interview on 11/16/10 at 5:50 p.m. with S18RD she stated she performed the initial Nutritional Assessment on Patient #4 on 08/27/10. S18RD confirmed the documentation on the nutritional assessment that Patient #4 had "Chew/Swallow Difficulties." She further confirmed that under "Nutritional Risk Assessment" Patient #4 was documented as a
"Severe Risk. " Further review of the documentation on the Nutritional Risk Assessment revealed Patient #4 required 3000 cc of fluid intake daily. S18RD also documented the following: "He (Patient #4) needs assistance with all intake ...He gets 810 cc flush so 8 cups of fluid are needed orally. "S18RD reviewed the nursing documentation and confirmed that Patient #4 received the recommended amount of total fluid intake on 0 of 27 days he was at inpatient at Oceans Behavioral Hospital of Opelousas.

In an interview on 11/17/10 at 8:45 a.m. with S4RN confirmed he was the RN in charge of the care of Patient #4 on the 7:00 a.m. - 7:00 p.m. shift for 08/30/10, 08/31/10, 09/03/10, 09/04/10, 09/08/10, 09/09/10, 09/13/10, 09/14/10, 09/17/10, 09/18/10 and 09/19/10.

S4RN reviewed the Comprehensive Interdisciplinary Assessment and confirmed the assessment identified that Patient #4 was assessed to have "decreased appetite, not eating, requiring care with ADL's (activities of daily living) and assistance" and "refusing to eat at times."

S4RN reviewed the I & O (intake and output) documentation sheet for Patient #4. He confirmed that Patient #4 received the 3000 cc of fluid recommended by the Registered Dietician (RD) on 0 of 11 days he was responsible for the care of Patient #4. S4RN further stated that neither the physician nor the RD were notified.

S4RN reviewed the Multidisciplinary Plan of Care. S4RN confirmed that no part of the Multidisciplinary Plan of Care addressed the food or fluid intake problems documented in the Comprehensive Interdisciplinary Assessment or the Nutritional Assessment.

In an interview on 11/17/10 at 8:10 a.m. with S7, RN she confirmed she was the RN responsible for the care of Patient #4 on 08/30/10, 09/03/10, 09/04/10, 09/05/10, 09/08/10, 09/09/10, 09/13/10, 09/14/10, 09/17/10, and 09/18/10 on the 7:00 p.m. - 7:00 a.m. shift.

S7RN reviewed the Comprehensive Interdisciplinary Assessment and confirmed the assessment identified that Patient #4 was assessed to have "decreased appetite, not eating, requiring care with ADL's (activities of daily living) and assistance " and "refusing to eat at times. "

S7RN reviewed the I & O (intake and output) documentation sheet for Patient #4. She confirmed that Patient #4 did not receive receive the 3000 cc of fluid recommended by the Registered Dietician (RD) on 0 of 11 days she was responsible for the care of Patient #4. S7RN further stated that neither the physician nor the RD were notified.

Review of the Nursing Psychiatric Assessments revealed S7RN documented that Patient #4 had " inadequate " Nutrition/Fluids for her 7:00 p.m. - 7:00 a.m. shift on 09/03/10, 09/08/10, and 09/14/10. S7RN confirmed there was no documented evidence of notification of the physician or Registered Dietician of the " inadequate " intake of patient #4.

S7RN reviewed the Multidisciplinary Plan of Care. S7RN confirmed that no part of the Multidisciplinary Plan of Care addressed the food or fluid intake problems documented in the Comprehensive Interdisciplinary Assessment or the Nutritional Assessment.

In an interview on 11/16/10 at 12:30 p.m. with S1Administrator and S2DON both reviewed the Comprehensive Interdisciplinary Assessment and confirmed the assessment identified that Patient #4 was assessed to have "decreased appetite, not eating, requiring care with ADL's (activities of daily living) and assistance" and "refusing to eat at times." S1Administrator and S2DON confirmed that this was not addressed in the Multidisciplinary Plan of Care for Patient #4.

Review of an Oceans Behavioral Hospital policy, titled "Fluid Hydration", policy number TX-Diet-07, adopted March 2008, reads in part: "Policy: Nursing Service will offer fluids frequently to patients...Purpose: To ensure proper fluid consumption by patients while in treatment for proper hydration...Procedure: Nursing Staff:..Have elderly patients consume fluids frequently throughout the day as the sensation of thirst diminishes with age...A minimum of 4 - 8 oz. (ounces) fluid in the AM and PM is recommended...Water is to be taken with all meds...A minimum of 4 - 8 oz. fluid is recommended. Give water with all meals in addition to beverages."

5)

Patient #4

Review of a physician ' s order dated/timed 08/29/10 at 1730 (5:30 p.m.) revealed a verbal order taken by S5RN from S15MD that read: " Geriatric VS (vital signs) TID with Apical pulses and record. Notify MD of abnormalities/bradycardia. "

Review of the MAR revealed no documentation on the MAR for 08/29/10 that the Apical pulse check ordered by S15MD was done for 08/29/10.

Review of the Graphics sheet for 08/30/10 revealed that for the 0600 (6:00 a.m.) vital signs Patient #4 had a heart rate of 44. Review of the nursing notes for 08/30/10 revealed no notification of the physician of the heart rate of 44 per the physician ' s order dated/timed 08/29/10 at 1730 (5:30 p.m.) that read: " Geriatric VS (vital signs) TID with Apical pulses and record. Notify MD of abnormalities/bradycardia. "

Review of the MAR for 08/30/10 revealed the physician ordered Apical pulses were documented as done for 1400 (2:00 p.m.) and 2000 (8:00 p.m.) but no heart rates were documented per the physicians order.

Review of the MAR for 08/31/10 revealed no documentation that the physician ordered Apical pulse check for 0800 (8:00 a.m.) and 1400 (2:00 p.m.) were performed.

Review of the Graphics sheet for 09/01/10 revealed Patient #4 had a documented heart rate of 52 at 12:00 p.m. with no indication of how the heart rate was obtained. Review of the nursing notes for 09/1/10 revealed no documentation of notification of the physician of the heart rate of Patient #4 for the 12:00 p.m. vitals per the physician ' s order dated/timed 08/29/10 at 1730 (5:30 p.m.) that read: " Geriatric VS (vital signs) TID with Apical pulses and record. Notify MD of abnormalities/bradycardia. "

Review of the MAR for 09/1/10 revealed documentation that read: " Geriatric vitals TID with Apical pulse. " Further review of the MAR for 09/01/10 revealed no documented Apical pulse checks for Patient #4 at the hospital scheduled times of 0800 (8:00 a.m.), 1400 (2:00 p.m.) or 2000 (8:00 p.m.).

Review of the Medication Administration Record (MAR) for 09/01/10 revealed the following note from the RpH (Registered Pharmacist): " RpH Note: Record Apical pulse on MAR, hold if
Review of the Medication Administration Record (MAR) for 09/02/10 revealed the following note from the RpH (Registered Pharmacist): " RpH Note: Record Apical pulse on MAR, hold if
Review of the Graphics sheet for 09/02/10 revealed there was one documented Apical pulse check at 12:00 p.m. for 09/02/10. Review of the MAR and Graphics sheet revealed no documentation of the physician ordered Apical pulses for 0800 (8:00 a.m.) or 2000 (8:00 p.m.).

Review of the MAR for 09/04/10 revealed documentation on the MAR that read: " Geriatric vital with apical pulse. " Further review revealed the Apical pulse checks were documented as done for 0800 (8:00 a.m.), 1400 (2:00 p.m.) and 2000 (8:00 p.m.) and no pulse rates were documented on the MAR.

Review of the Graphics sheet for 09/05/10 revealed the documented heart rate for Patient #4 at 6:00 a.m. was 54. Review of the nursing notes for 09/05/10 revealed no documented notification of the physician of the heart rate of Patient #4 per the physician ' s order dated/timed 08/29/10 at 1730 (5:30 p.m.) that read: " Geriatric VS (vital signs) TID with Apical pulses and record. Notify MD of abnormalities/bradycardia. "

Review of the MAR for 09/05/10 revealed documentation on the MAR that read: " Geriatric vital with apical pulse. " Further review revealed no documentation that the physician ordered Apical pulse checks were done.

Review of the Medication Administration Record (MAR) for 09/05/10 revealed the following note from the RpH (Registered Pharmacist): " RpH Note: Record Apical pulse on MAR, hold if

Review of the MAR for 09/06/10 revealed documentation on the MAR that read: " Geriatric vital with apical pulse. " Further review revealed no documentation that the physician ordered Apical pulse checks were done.

Review of the Medication Administration Record (MAR) for 09/06/10 revealed the following note from the RpH (Registered Pharmacist): " RpH Note: Record Apical pulse on MAR, hold if
Review of the MAR for 09/07/10 revealed documentation on the MAR that read: " Geriatric vital with apical pulse. " Further review revealed no documentation that the physician ordered Apical pulse checks were done.

Review of the Medication Administration Record (MAR) for 09/07/10 revealed the following note from the RpH (Registered Pharmacist): " RpH Note: Record Apical pulse on MAR, hold if
Review of the MAR for 09/08/10 revealed documentation on the MAR that read: " Geriatric vital with apical pulse. " Further review revealed no documentation that the physician ordered Apical pulse checks were done.

Review of the MAR for 09/09/10 revealed documentation on the MAR that read: " Geriatric vital with apical pulse. " Further review revealed no documentation that the physician ordered Apical pulse checks were done.

Review of the Medication Administration Record (MAR) for 09/09/10 revealed the following note from the RpH (Registered Pharmacist): " RpH Note: Record Apical pulse on MAR, hold if
Review of the MAR for 09/10/10 revealed documentation on the MAR that read: " Geriatric vital with apical pulse. " Review of the Graphics sheet revealed one Apical pulse was documented at 12:00 p.m. Further review revealed no documentation that the physician ordered Apical pulse checks TID were done for 8:00 a.m. or 8:00 p.m.

Review of the Medication Administration Record (MAR) for 09/10/10 revealed the following note from the RpH (Registered Pharmacist): " RpH Note: Record Apical pulse on MAR, hold if
Review of a physician ' s order dated/timed 09/11/10 at 1500 (3:00 p.m.) revealed a verbal order taken by S5RN from S17MD that read as follows:
- D/C Apical pulse checks
- (arrow down) decrease flush rate to PEG/G tube
- Observe for functionality
- Bactroban and Boudreaux ' s to PEG site with cover dressing

Review of the MAR for 09/11/10 revealed documentation on the MAR that read: " Geriatric vital with apical pulse. " Review of the Graphics sheet revealed one Apical pulse was documented at 12:00 p.m. Further review revealed no documentation that the physician ordered Apical pulse checks TID were done for 8:00 a.m. or 2:00 p.m. which was prior to the 3:00 p.m. order to D/C Apical pulse checks.

In an interview on 11/16/10 at 10:10 a.m. with S1Admin and S2DON the above findings were confirmed.

Review of an Oceans Behavioral Hospital policy titled "Vital Signs Monitoring", policy number NSG-32-A, adopted March 2008, no date of last revision, read in part: "Policy: It is the policy to effectively communicate all vital signs that fall outside of the "within normal limits" parameters. Purpose: To ensure that abnormal vital signs readings are reported to all licensed and independent practitioners in a timely manner and to establish a guide for nursing staff. Procedure: Director of Nursing: Works in conjunction with the physicians to establish parameters for reporting of vital signs...Pulse = 22 degrees [as typed on policy] outside of the normal 80 above or below...Staff obtaining vitals will notify RN of any abnormal vital signs reading...RN assesses the patient status...retakes vital signs to validate accuracy. Notify the Licensed Independent Practitioner of vital signs..."

Based on record review and interview the hospital failed to ensure that the nursing care plan was based on assessment of the patient's nursing care needs and that the Multidisciplinary Treatment Team developed appropriate nursing interventions in response to those needs by failing to include assessment findings related to dysphagia and decreased intake of food and fluids in the care plan for 1 of 9 sampled patients. (#4) Findings:

Review of the Nursing Initial Assessment for Patient #4 revealed the following: "Alteration in health maintenance related to :...Dysphagia...Needs Education on: Nutrition/Diet."

Review of the Comprehensive Interdisciplinary Assessment for Patient #4 revealed: "...(arrow down) decreased appetite, not eating, and refusing to eat at times."

Review of the Nutritional Assessment for Patient #4 revealed the following: "Chew/Swallow Difficulty, Dysphagia, Aspiration precautions, He needs assistance with all intake, Estimated needs:...Fluid: 3000 cc every day..."

Review of the Multidisciplinary Treatment Team's Plan of Care for Patient #4 revealed the assessment findings related to Patient #4's dysphagia, decreased intake of food and fluids and need for assistance with intake of food and fluids were not addressed in the Plan of Care.

In an interview on 11/16/10 at 12:30 with S1Administrator and S2DON both confirmed the findings on the Nursing Initial Assessment, Comprehensive Interdisciplinary Assessment and Nutritional Assessment were not addressed in the Multidisciplinary Integrated Team Care Plan or updates to the Multidisciplinary Integrated Team Care Plan.

Based on record review and interview the hospital failed to ensure medications were administered in accordance with hospital policy/accepted standards of practice by administering Digoxin without checking an Apical Pulse for 1 of 9 sampled patients. (Patient #4) Findings:

Review of the medical record of Patient #4 revealed the admitting physician ordered Digoxin (Lanoxin) 0.125 mcg (micrograms) to be administered to Patient #4 once daily.

Review of the vital signs documented for 08/26/10 at 6:00 a.m. revealed Patient #4 had a heart rate of 55 bpm (beats per minute). Review of the MAR revealed the following note from the RpH (Registered Pharmacist): " RpH Note: Record Apical pulse on MAR, hold if
Review of the Graphics sheet for 08/27/10 revealed the vital signs documented for 6:00 a.m. were "refused" by Patient #4. Review of the MAR revealed the following note from the RpH (Registered Pharmacist): "RpH Note: Record Apical pulse on MAR, hold if
Review of the Medication Administration Record (MAR) for 08/28/10 revealed the following note from the RpH (Registered Pharmacist): "RpH Note: Record Apical pulse on MAR, hold if
Review of a physician's order dated/timed 08/29/10 at 1640 (4:40 p.m.) revealed a verbal order taken by S5RN from S15, MD that read: "OK to hold Dig (digoxin) this AM." Review of the Medication Administration Record for 08/29/10 revealed the medication was due for 8:00 a.m. (8 hours and 40 minutes before notification of the physician) and documentation revealed it was not administered due to Patient #4's heart rate being 53.

Review of the Medication Administration Record (MAR) for 09/01/10 revealed the following note from the RpH (Registered Pharmacist): "RpH Note: Record Apical pulse on MAR, hold if
Review of the Medication Administration Record (MAR) for 09/02/10 revealed the following note from the RpH (Registered Pharmacist): "RpH Note: Record Apical pulse on MAR, hold if
Review of the Medication Administration Record (MAR) for 09/05/10 revealed the following note from the RpH (Registered Pharmacist): "RpH Note: Record Apical pulse on MAR, hold if
Review of the Medication Administration Record (MAR) for 09/06/10 revealed the following note from the RpH (Registered Pharmacist): "RpH Note: Record Apical pulse on MAR, hold if
Review of the Medication Administration Record (MAR) for 09/07/10 revealed the following note from the RpH (Registered Pharmacist): " RpH Note: Record Apical pulse on MAR, hold if
Review of the Medication Administration Record (MAR) for 09/09/10 revealed the following note from the RpH (Registered Pharmacist): " RpH Note: Record Apical pulse on MAR, hold if
Review of the Medication Administration Record (MAR) for 09/10/10 revealed the following note from the RpH (Registered Pharmacist): "RpH Note: Record Apical pulse on MAR, hold if
Review of the Medication Administration Record (MAR) for 09/11/10 revealed the following note from the RpH (Registered Pharmacist): "RpH Note: Record Apical pulse on MAR, hold if
Review of the Medication Administration Record (MAR) for 09/12/10 revealed the following note from the RpH (Registered Pharmacist): "RpH Note: Record Apical pulse on MAR, hold if
Review of the Medication Administration Record (MAR) for 09/13/10 revealed the following note from the RpH (Registered Pharmacist): "RpH Note: Record Apical pulse on MAR, hold if
Review of the Medication Administration Record (MAR) for 09/14/10 revealed the following note from the RpH (Registered Pharmacist): "RpH Note: Record Apical pulse on MAR, hold if
Review of the Medication Administration Record (MAR) for 09/16/10 revealed the following note from the RpH (Registered Pharmacist): "RpH Note: Record Apical pulse on MAR, hold if
Review of the Medication Administration Record (MAR) for 09/18/10 revealed the following note from the RpH (Registered Pharmacist): "RpH Note: Record Apical pulse on MAR, hold if
Review of the Medication Administration Record (MAR) for 09/19/10 revealed the following note from the RpH (Registered Pharmacist): "RpH Note: Record Apical pulse on MAR, hold if
Review of the Medication Administration Record (MAR) for 09/20/10 revealed the following note from the RpH (Registered Pharmacist): "RpH Note: Record Apical pulse on MAR, hold if
In an interview on 11/16/10 at 10;10 a.m. with S1Administrator and S2DON they confirmed that the Digoxin was being administered to Patient #6 without Apical pulses being checked.

Review of a hospital policy titled "Principles of Medication Administration", policy number NSG-24, adopted March 2008, no date of last revision, reads in part: "Policy: The patient will receive the correct drug and dose at the correct time without injury. Purpose: To define basic safety factors in preparing and administering medications and to avoid patient injury due to drug errors. Procedure:..Guidelines for preparing Various forms of Medication:..Separate drugs requiring pre-assessment data, such as vital signs..."

Based on record review and interview the hospital failed to ensure all entries in the medical record were legible. Findings:

Review of the medical record of patient #4 on 11/16/10 revealed physician progress notes that were illegible.

In an interview on 11/16/10 at 3:30 p.m. S1Administrator and S2DON confirmed the following medical record entries were illegible:

Physician progress notes dated/timed:

09/18/10 at 1600 (4:00 p.m.)
09/16/10 at 11:40 a.m.
09/14/10 at 11:30 a.m.
09/13/10 at 11:30 a.m.
09/09/10 at 1:00 p.m.
09/07/10 at 11:30 a.m.
09/02/10 at 7:30 a.m.
08/31/10 at 11:00 a.m.
08/30/10 at 12:35 p.m.
08/29/10 at 12:00 p.m.
08/27/10 at 1700 (5:00 p.m.)
08/26/10 at (no time documented)

Based on record review and interview the hospital failed to ensure that verbal orders were authenticated within 10 days as required by State Law by failing to ensure the practitioner dated/timed when the telephone or verbal order was authenticated. Findings:

Review of the medical record for Patient #4 on 11/16/10 revealed the discharge date was 09/20/10.

In an interview on 11/16/10 at 3:30 p.m. with S1Administrator and S2DON the following orders were confirmed to have authentication without documentation of the date/time the physician authenticated the order in the medical record of Patient #4:

08/26/10 at 1715 (5:15 p.m.) by S17MD.
08/26/10 at 1720 (5:20 p.m.) by S17MD.
08/28/10 at 12:30 p.m. by S15MD.
08/28/10 at 12:40 p.m. by S13MD.
08/29/10 at 1640 (4:40 p.m.) by S15MD.
08/29/10 at 1730 (5:30 p.m.) by S15MD.
09/04/10 at 1120 (11:20 a.m.) by S16MD.
09/06/10 at 1250 (12:50 p.m.) by S16MD.
09/07/10 at 0700 (7:00 a.m.) by S16MD.
09/07/10 at 1610 (4:10 p.m.) by S29MD.
09/09/10 at 1050 (10:50 a.m.) by S15MD.
09/11/10 at 1500 (3:00 p.m.) by S17MD.
09/15/10 at 1510 (3:10 p.m.) by S29MD.
09/15/10 at 1600 (4:00 p.m.) by S13MD.
09/16/10 at 0820 (8:20 a.m.) by S17MD.
09/17/10 at 2000 (8:00 p.m.) by S15MD.
09/18/10 at 1645 (4:45 p.m.) by S15MD.

Review of the Oceans Behavioral Hospital Medical and Professional Staff Organization By Laws, presented as the current Medical Staff By Laws, read in part: "Article VII. Clinical Responsibilities. Section 4:..A. Medical Records. Practitioner's must complete their patients's medical records within 30 days of each patients discharge..."

Based on observations, interviews and record reviews, the hospital failed to ensure the contracted dietary director was responsible for the daily management of the food and dietetic services as evidenced by not having a policy for safe practices to test the temperatures of food prior to serving the hot food at temperatures of less than 120 degrees Fahrenheit and not following the licensure requirement S9383C for hot food to be maintained at 120 degrees Fahrenheit (120-F) or above. Findings:

Review of the Food/Dietetic Sanitary Condition requirement S9383C. reads in part as follows: "C. Hot foods shall leave the kitchen or steam table at or above 140-F.,...In-room delivery temperatures shall be maintained at 120-F or above for hot foods...Food shall be transported to the patients' in a manner that protects it from contamination, while maintaining required temperatures."

On 11/9/10 from 12:30 p.m. through 12:40 p.m., the temperatures of the food on the test tray was performed by S23, MHT. Further observation revealed there was a slice of roast, a serving of zucchini casserole and a serving of black-eyed peas on the test tray provided by the contracted dietary service. The temperature of the slice of roast read 80 degrees Fahrenheit. The zucchini serving registered a temperature of 80 degrees Fahrenheit. The serving of black-eyed peas read a temperature of 40 degrees Fahrenheit. At this time, S23MHT indicated all hot food served should be at 120 degrees Fahrenheit or greater. S23MHT verified the slice of roast, serving of zucchini and serving of black-eyed peas were less than 120 degrees Fahrenheit. S23MHT was unaware of what to do with the hot food temperatures that were less than 120 degrees Fahrenheit. S23MHT indicated food temperatures are checked one time a week.
Review of the daily "Dietary Services Food Temperature Checks" logs from March 2010 through November of 2010 revealed there was no documentation the food temperatures were done with each meal served at the hospital.
During an interview on 11/9/10 from 12:40 p.m. to 12:50 p.m., S19MHT Staffing Coordinator indicated all hot food is served at 120 degrees Fahrenheit or greater. S19MHT Staffing Coordinator verified the food temperatures for the slice of roast, serving of zucchini, and serving of black-eyed peas was less than 120 degrees Fahrenheit. S19MHT Staffing Coordinator denied knowledge of a policy to address what the temperature ranges are for the hot food to be served at the hospital. S19MHT Staffing Coordinator indicated the hot food (roast, zucchini, and black-eyed peas) temperatures were less than 120 degrees Fahrenheit. S19MHT Staffing Coordinator reported a test tray was provided by dietary every week to test the temperatures of the food. S19MHT Staffing Coordinator indicated the test trays are sent randomly during the scheduled meal times. S19MHT Staffing Coordinator stated there was no policy indicating how often the temperatures of the food should be performed. At 12:50 p.m. on the same day, S19MHT Staffing Coordinator reviewed the random weekly "Dietary Services Food Temperature Checks" sheets from March to November of 2010. S19MHT Staffing Coordinator indicated there was no documented evidence the food temperatures were performed three times a day with each meal served at the hospital from March through November of 2010.
In a face-to-face interview on 11/9/10 at 12:45 p.m., S1Administrator indicated all hot food should be served at a temperature of 120 degrees Fahrenheit or greater as per policy. S1Administrator verified the roast, zucchini casserole, and black-eyed peas were less than 120 degrees Fahrenheit as per policy. S1Administrator denied knowledge that the dietary staff were only testing the food temperatures once a week. S1Administrator indicated all food temperatures should be performed with each meal served at the hospital.

In another interview on 11/9/10 at 1:20 p.m., S1Administrator verified there was no documented evidence the food temperatures were tested three times a day with each meal served at the hospital from March 2010 through November of 2010. S1Administrator stated food temperatures should be conducted with every meal served at the facility to ensure the hot food served follows the policy to be 120 degrees Fahrenheit or greater.
Review of the "Food Temperature Checks" from the kitchen dated 11/10/10 for breakfast revealed the eggs were 165 degrees Fahrenheit. Further review of the "Food Temperature Checks" revealed there was no temperature recorded for the (banana nut) muffin or biscuit.

A second check of the food on the test tray was done on 11/10/10 from 7:45 a.m. through 8:00 a.m. with S22MHT. Further observation revealed the test tray had a serving of scrambled eggs and a banana nut muffin. An observation of random patient #1 (R1) had a plain biscuit noted in her plate of food. There was no biscuit noted in the test tray presented by the contracted kitchen service. Further observation revealed the egg was 107.2 degrees Fahrenheit and banana nut muffin was 92.6 degrees Fahrenheit. S22MHT agreed the scrambled eggs and banana nut muffin temperatures were less than 120 degrees Fahrenheit. S22MHT at this time touched the eggs and muffin in the test tray. S22MHT indicated the eggs and muffin are cold. The surveyor touched the food in the test tray. The eggs and muffin were cold to touch. S22MHT did not know what to do with the hot food temperatures that were less than 120 degrees Fahrenheit.

Another interview was held on 11/10/10 at 8:00 a.m. with S1Administrator. S1Administrator verified there was no documentation of the "Food Temperature Checks" from March of 2010 through November of 2010 that the dietary staff performed food temperature checks with each meal served at the hospital.

Review of the "Dietary Services Food Temperature Checks" log dated 11/16/10 revealed there was no documentation of what the potato salad temperature was when it was checked by the contracted kitchen.

A third food temperature check was conducted on 11/16/10 from 11:50 a.m. to 11:55 a.m. with S22MHT. Further observation revealed the potato salad temperature was 90.6 degrees Fahrenheit. During this same observation, S22MHT indicated the potato salad is a hot food item that should be at 120 degrees Fahrenheit. S22MHT stated the potato salad was less than 120 degrees Fahrenheit as per policy. S22MHT confirmed there was no recorded temperature for the potato salad by the contracted kitchen. S22MHT stated the kitchen temperature would let me know whether or not the potato salad was to be served as hot or cold food. S22MHT indicated the cold temperature for food to be served is at 78 degrees Fahrenheit or greater. S22MHT reported the potato salad was less than 78 degrees Fahrenheit. S22MHT indicated the potato salad was not within the temperature ranges for hot food or cold food to be served. S22MHT did not know what to do with the potato salad with a temperature of 90.6 degrees Fahrenheit.

In another interview on 11/16/10 at 12:00 p.m., S1Administrator, confirmed the potato salad did not have a temperature documented when it left the contracted kitchen. S1Administrator stated the potato salad temperature of 90.6 degrees Fahrenheit was not the appropriate temperature for hot or cold food to be served.

During a face-to-face interview held on 11/9/10 from 6:00 p.m. to 6:03 p.m., S18RD indicated test trays are sent to the hospital for the food temperatures to be checked once a week. S18RD stated the food temperatures are not performed everyday with all meals served to the hospital. S18RD reported that the food temperatures are performed and recorded by the contracted kitchen service prior to sending the hospital the test trays. S18RD indicated all hot food temperatures should be at 120 degrees Fahrenheit or greater. S18RD stated all cold food temperatures should be at 50 degrees Fahrenheit or less. S18RD indicated she expected the food temperatures to drop between 15 to 20 degrees when transported from the contracted kitchen service to the hospital. S18RD agreed the slice of roast and zucchini was 80 degrees Fahrenheit. S18RD verified the black-eyed peas temperature was 40 degrees Fahrenheit. S18RD indicated the roast, zucchini and black-eyed peas were not as per policy for all hot food temperatures to be served at 120 degrees Fahrenheit or greater. S18RD was unaware of any prior hot food temperatures of less than 120 degrees Fahrenheit was reported by the dietary staff as of today.

Review of the policy titled, "TX-Patient Food Service", Adopted Date: August of 2006, with no policy number, with no effective, revised or reviewed dates, page 1 of 4, page 2 of 4, page 3 of 4, presented on 11/9/10 at 4:50 p.m. as the hospital's current "Dietary Services" policy revealed its purpose was to establish guidelines for the delivery of patient's meals. The policy indicated the Registered Dietitian ensures that all safety/sanitation practices are observed in accordance with local, state, and federal regulations.

Further review of the "Dietary Services" policy revealed there was no documentation of what the temperature ranges was for the hot food to be served at the facility. There was no documented evidence of how often the dietary staff was to test the food temperatures.

Based on observation, record review, and interview, the hospital failed to meet the Condition of Participation of Special Provisions Applying to Psychiatric Hospitals by:

1) failing to be in compliance with the hospital Conditions of Participation specified in ?482.1 through ?482.23 by failing to meet the CoP of Patient Rights at ?482.13 and the CoP of Nursing Services at ?482.23. (cross reference findings at A0115 and A0385)

Based on observation, record review, and interview, the Psychiatric hospital failed to meet the Conditions of Participation specified in ?482.1 through ?482.23 by failing to be in compliance with the Hospital's Condition of Participation requirements for Patient Rights at ?482.13 and Nursing Services at ?482.23.

Based on record review and interview the hospital failed to ensure periodic review of patient #4's response and progress toward meeting planned goals. Patient #4's lack of progress was documented in his medical record. The review failed to justify continuing with the current goals and approaches. Findings:


Review of the Multidisciplinary Group/Progress Notes revealed the following:

08/26/10 10:30 a.m. - 11:30 a.m. Title: none listed ...no participation ...
08/26/10 3:00 p.m. - 3:45 p.m. Title: GP (group) ...Response: poor ...no participation ...
08/27/10 10:00 a.m. - 11:00 a.m. Title: Group Psychotherapy ...Response: poor ...participated ...
08/27/10 2:00 p.m. - 3:00 p.m. Title: Leisure Skills ...Response: poor ...no participation ...
08/30/10 10:00 a.m. - 11:00 a.m. Title: TR (Recreational Therapy) ...Response: poor ...no participation ...
08/30/10 3:15 p.m. - 4:00 p.m. Title: GP ...Response: poor ...no participation ...
08/31/10 2:00 p.m. - 3:00 p.m. Title: TR (Recreational Therapy) ...Response: poor ...participation unrelated to topic ...
09/01/10 3:00 p.m. - 4:00 p.m. Title: GP ...Response: poor ...no participation ...
09/02/10 11:00 a.m. - 12:00 p.m. Title: GP ...Response: poor ...no participation ...
09/03/10 10:30 a.m. - 11:30 a.m. Title: GP ...Response: poor ...no participation ...
09/07/10 3:00 p.m. - 4:00 p.m. Title: GP ...Response: poor ...no participation ...
09/08/10 11:15 a.m. - 12:00 p.m. Title: GP ...Response: poor ...no participation ...
09/09/10 10:30 a.m. - 11:30 a.m. Title: TR ...Response: poor ...no participation ...
09/10/10 10:00 a.m. - 10:45 a.m. Title: TR ...Response: no documentation ...no participation ...
09/10/10 3:00 p.m. - 4:00 p.m. Title: GP ...Response: poor ...pt refused to attend ...
09/13/10 10:00 a.m. - 11:00 a.m. Title: TR ...Response: poor ...no participation ...
09/13/10 3:00 p.m. - 4:00 p.m. Title: GP ...Response: poor ...no participation ...
09/14/10 10:00 a.m. - 11:00 a.m. Title: TR ...Response: poor ...no participation ...
09/14/10 3:00 p.m. - 4:00 p.m. Title: GP ...Response: poor ...no participation ...
09/15/10 2:00 p.m. - 3:00 p.m. Title: TR ...Response: poor ...pt attended, unable to participate ... (arrow up) increased drowsiness ...
09/15/10 3:00 p.m. - 4:00 p.m. Title: GP ...Response: poor ...no participation ...09/14/10 10:00 a.m. - 11:00 a.m. Title: TR ...Response: poor ...no participation ...
09/16/10 10:30 a.m. - 11:15 a.m. Title: TR ...Response: poor ...no participation ...
09/16/10 3:00 p.m. - 4:00 p.m. Title: GP ...Response: poor ...no participation ...
09/17/10 10:00 a.m. - 11:00 a.m. Title: GP ...Response: poor ...no participation ...
09/17/10 3:00 p.m. - 4:00 p.m. Title: TR ...Response: poor ...no participation ...

Further review revealed no further therapy sessions for Patient #4 prior to his discharge to the emergency room on 09/20/10 at 10:00 a.m.

Review of the Multidisciplinary Integrated Team Care Plan for Patient #4 revealed the goal was "Pt. will demonstrate a significant improvement in overall functioning prior to D/C." The care plan is not individualized based on the assets and strengths of Patient #4.

In an interview on 11/16/10 at 12:10 p.m. with S25GSW she confirmed the documentation of "no participation" in therapy for patient #4. She further stated that the therapy was of "very limited value because of his (Patient #4's) inability to participate." She further stated that she is responsible for the plan, but did not change the plan.

In an interview with S13MD, attending psychiatrist and Medical Director, he stated that they "try to make group fit all" of the patients.

Based on record review and interview the hospital failed to ensure the Therapy program was appropriate to the individualized needs of 1 of 9 sampled patients. (#4) The patient participated in the therapy on 1 of 25 days of inpatient treatment. Findings:

Review of the initial Multidisciplinary Integrated Care Plan dated 08/28/10 revealed the Therapeutic Recreation goals were: "Patient will attend to task at hand 70% of the time within 14 days."

Review of the " Walk Program " documentation for Patient #4 revealed:

08/25/10 Admit. (no therapy)
08/26/10 Response: refused
08/27/10 W/C (wheelchair) Response: Active.
08/29/10 Response: Unable
08/30/10 Response: Refused
08/31/10 Response: Unable
09/01/10 Response: Refused
09/02/10 Response: Unable
09/03/10 Response: Refused
09/04/10 Response: Unable
09/05/10 Response: Unable
09/06/10 Response: Unable
09/08/10 Response: Unable
09/09/10 Response: Unable
09/10/10 Response: Unable
09/13/10 Response: Unable
09/14/10 Response: Unable
09/15/10 Response: Unable
09/16/10 Response: Unable
09/17/10 Response: Unable

Further review revealed no further therapy sessions for Patient #4 prior to his discharge to the emergency room on 09/20/10 at 10:00 a.m.

In an interview on 11/16/10 at 12:10 p.m.with S30 ,Recreational Therapy, she confirmed that Patient #4 participated on 1 of 25 days while an inpatient at Oceans Behavioral Hospital of Opelousas. (the 25 days excludes the date of admission and discharge)

Review of the "Walk Program" policy, policy number NSG-35, adopted August 2007, no date revised reads in part: "Programs/Services(s): Geriatric Program. Policy: It is the policy of Ocean's Behavioral Hospital that all patients admitted to the geriatric program will participate in the established guidelines for the walk program. Purpose: To ensure the highest physical functioning of each of our geriatric clients. Procedure: Walk Program Guidelines. Each patient participates at least once on a daily basis unless otherwise requested by physician ...MHT staff will assist and encourage patients as needed ...Deterioration must be explained for each patient and reported to the charge nurse. One lap is the equivalent of a complete walk of the hallway from double doors to end of hall back and forth. Objectives:..Wheelchair Mobile Patients. Patients will participate in modified mobility exercises 1-2 times daily ..."