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Based on record review and interview, the hospital failed to ensure the use of restraints was in accordance with the order of a physician or licensed independent practitioner who is responsible for the care of the patient. This was noted in the medical record of 1 of 5 patients (Patient #12) whose medical record was reviewed for restraint use out of a total sample of 12 patients. Findings:

Patient #12: Medical record review revealed that Patient #12 presented to Lake Charles Memorial Hospital on 1/02/11. Documentation on the Emergency Department Triage Report revealed that the arrival time was 5:43 a.m. Documentation on the triage record revealed an entry that was entered into the medical record on 1/02/11 at 7:25 a.m. which read "pt tossed into triage booth by another individual who then fled, pt combative in triage SI/HI, threatening staff, ran out of triage into waiting room, (S18) psych brought pt to P4, ERMD notified of arrival, "government trying to kill me, ima kill them, i have been walking in traffic all night and can't get killed". Documentation on the Emergency Room Nursing Record dated 1/02/11 at 6:00 a.m. revealed that the patient was combative, hostile, and yelling that he wanted to kill someone in triage. Documentation on the Emergency Room Nursing Record revealed that the patient was placed in restraints on 1/02/11 at 6:05 a.m. The documentation failed to indicate the type of restraint used at the time of application. Documentation on the Emergency Room Nursing Record revealed that the right wrist restraint was removed on 1/02/11 at 7:05 a.m. Documentation on the Emergency Room Nursing Record revealed an entry dated 1/02/11 at 8:45 a.m. that read "Pt now released from 4 point Restraints, Pt sleeping calmly in bed". Review of the medical record revealed no documentation to indicate that the use of restraints on Patient #12 was ordered by a physician or a qualified LIP (Licensed Independent Practitioner).

The hospital's policy/procedure titled "Restraints" was reviewed. The policy/procedure documents "The use of restraint or seclusion requires a written or verbal order from a physician of Licensed Independent Practitioner (LIP). The use of physical restraints can be implemented by a trained registered nurse in an emergency situation" and "Orders for restraint must include 1) Date and time restraint was initiated. 2) Type of restraint (i.e. vest, mittens, limb holder, belt...). 3) Length of time restraint will be utilized. 4) Reason or clinical justification for seclusion-restraint".

The ED (Emergency Department) Director (S15) was interviewed on 4/21/11 at 10:50 a.m. S15 reviewed the medical record of Patient #12. S15 reported the documentation indicated that Patient #12 was placed in restraints on 1/02/11 at 6:05 a.m. and remained in restraints until 1/02/11 at 8:45 a.m. S15 reported that she was unable to find an order by a physician or licensed independent practitioner to place Patient #12 in restraints on 1/02/11.

Based on record review and interview, the hospital failed to ensure the condition of a patient placed in restraints was monitored by a physician, other licensed independent practitioner or trained staff at an interval determined by hospital policy. This was noted in the medical record of 1 of 5 patients (Patient #12) whose medical record was reviewed for restraint use out of a total sample of 12 patients. Findings:

Patient #12: Medical record review revealed that Patient #12 presented to Lake Charles Memorial Hospital on 1/02/11. Documentation on the Emergency Department Triage Report revealed that the arrival time was 5:43 a.m. Documentation on the triage record revealed an entry that was entered into the medical record on 1/02/11 at 7:25 a.m. which read "pt tossed into triage booth by another individual who then fled, pt combative in triage SI/HI, threatening staff, ran out of triage into waiting room, (S18) psych brought pt to P4, ERMD notified of arrival, "government trying to kill me, ima kill them, i have been walking in traffic all night and can't get killed". Documentation on the Emergency Room Nursing Record dated 1/02/11 at 6:00 a.m. revealed that the patient was combative, hostile, and yelling that he wanted to kill someone in triage. Documentation on the Emergency Room Nursing Record revealed that the patient was placed in restraints on 1/02/11 at 6:05 a.m. The documentation failed to indicate the type of restraint used at the time of application. Documentation on the Emergency Room Nursing Record revealed that the right wrist restraint was removed on 1/02/11 at 7:05 a.m. Documentation on the Emergency Room Nursing Record revealed an entry dated 1/02/11 at 8:45 a.m. that read "Pt now released from 4 point Restraints, Pt sleeping calmly in bed". Review of the medical record revealed no documentation to indicate that Patient #12 was under constant visual observation for the first hour of being placed in restraints and no documentation to indicate that the patient was assessed every 15 minutes as documented in the hospital's policy/procedure titled "Restraints".

The hospital's policy/procedure titled "Restraints" was reviewed. The policy/procedure documents under "Care of the Patient in Behavioral Seclusion-Restraint" that "The patient in restraints will be monitored via continuous in-person observation for the first hour" and "Q:15 minute documentation/assessment of patients in seclusion-restraints by authorized staff may include 1) Range of motion and circulation checks. 2) Skin Integrity. 3) Respiration. 4) Nutrition-Hydration. 5) Elimination. 6) Behavior Observation. 7) Readiness for release". The policy/procedure further documents under "Staff Competencies and Staff Education" that "Direct care staff members and other staff who may be required to apply restraining devices or monitor a patient in seclusion or restraints will receive ongoing training and demonstrate competence in minimizing the use of seclusion-restraint and their safe use before they participate in any use of seclusion-restraint".

The ED (Emergency Department) Director (S15) was interviewed on 4/21/11 at 10:50 a.m. S15 reviewed the medical record of Patient #12. S15 reported the documentation indicated that Patient #12 was placed in restraints on 1/02/11 at 6:05 a.m. and remained in restraints until 1/02/11 at 8:45 a.m. S15 reported that she was unable to find documentation indicating that Patient #12 was under constant visual observation for the first hour of being placed in restraints and no documentation to indicate that the patient was assessed every 15 minutes as documented in the hospital's policy/procedure titled "Restraints".

Based on record review and interview, the hospital failed to provide evidence to indicate that a registered nurse (S16) assigned to work in the hospital's ED (Emergency Department) had received training and was determined to be competent in the application of restraints and the provision of care for patients who are placed in restraints and/or seclusion. This was noted in the personnel record of 1 of 9 employees whose personnel records were reviewed. Findings:

Patient #12: Medical record review revealed that Patient #12 presented to Lake Charles Memorial Hospital on 1/02/11. Documentation on the Emergency Department Triage Report revealed that the arrival time was 5:43 a.m. Documentation on the triage record revealed an entry that was entered into the medical record on 1/02/11 at 7:25 a.m. which read "pt tossed into triage booth by another individual who then fled, pt combative in triage SI/HI, threatening staff, ran out of triage into waiting room, (S18) psych brought pt to P4, ERMD notified of arrival, "government trying to kill me, ima kill them, i have been walking in traffic all night and can't get killed". Documentation on the Emergency Room Nursing Record dated 1/02/11 at 6:00 a.m. revealed that the patient was combative, hostile, and yelling that he wanted to kill someone in triage. Documentation on the Emergency Room Nursing Record revealed that the patient was placed in restraints on 1/02/11 at 6:05 a.m. The documentation failed to indicate the type of restraint used at the time of application. Documentation on the Emergency Room Nursing Record revealed that the right wrist restraint was removed on 1/02/11 at 7:05 a.m. Documentation on the Emergency Room Nursing Record revealed an entry dated 1/02/11 at 8:45 a.m. that read "Pt now released from 4 point Restraints, Pt sleeping calmly in bed". Review of the medical record revealed no documentation to indicate that Patient #12 was under constant visual observation for the first hour of being placed in restraints and no documentation to indicate that the patient was assessed every 15 minutes as documented in the hospital's policy/procedure titled "Restraints". Documentation revealed that S16 (Registered Nurse) provided care to Patient #12.

The ED (Emergency Department) Director (S15) was interviewed on 4/21/11 at 10:50 a.m. S15 reviewed the medical record of Patient #12. S15 reported the documentation indicated that Patient #12 was placed in restraints on 1/02/11 at 6:05 a.m. and remained in restraints until 1/02/11 at 8:45 a.m. S15 reported that she was unable to find documentation indicating that Patient #12 was under constant visual observation for the first hour of being placed in restraints and no documentation to indicate that the patient was assessed every 15 minutes as documented in the hospital's policy/procedure titled "Restraints".

The personnel record of S16 (Registered Nurse) was reviewed. Review of the education/training/competency records revealed a 3 page document titled "Orientation & Annual Competency Restraint Application". There was no documentation on this 3 page document to indicate the date the document was completed or the name of the employee that the document was completed on. The section for Employee Name was blank. The section for the date was blank.

Based on record review and interview, the hospital failed to provide evidence to indicate that a registered nurse (S16) assigned to work in the hospital's ED (Emergency Department) had received training and demonstrated knowledge relating to the use of nonphysical intervention skills. This was noted in the personnel record of 1 of 9 employees whose personnel records were reviewed. Findings:

Patient #12: Medical record review revealed that Patient #12 presented to Lake Charles Memorial Hospital on 1/02/11. Documentation on the Emergency Department Triage Report revealed that the arrival time was 5:43 a.m. Documentation on the triage record revealed an entry that was entered into the medical record on 1/02/11 at 7:25 a.m. which read "pt tossed into triage booth by another individual who then fled, pt combative in triage SI/HI, threatening staff, ran out of triage into waiting room, (S18) psych brought pt to P4, ERMD notified of arrival, "government trying to kill me, ima kill them, i have been walking in traffic all night and can't get killed". Documentation on the Emergency Room Nursing Record dated 1/02/11 at 6:00 a.m. revealed that the patient was combative, hostile, and yelling that he wanted to kill someone in triage. Documentation on the Emergency Room Nursing Record revealed that the patient was placed in restraints on 1/02/11 at 6:05 a.m. The documentation failed to indicate the type of restraint used at the time of application. Documentation on the Emergency Room Nursing Record revealed that the right wrist restraint was removed on 1/02/11 at 7:05 a.m. Documentation on the Emergency Room Nursing Record revealed an entry dated 1/02/11 at 8:45 a.m. that read "Pt now released from 4 point Restraints, Pt sleeping calmly in bed". Review of the medical record revealed no documentation to indicate that Patient #12 was under constant visual observation for the first hour of being placed in restraints and no documentation to indicate that the patient was assessed every 15 minutes as documented in the hospital's policy/procedure titled "Restraints". Documentation revealed that S16 (Registered Nurse) provided care to Patient #12.

The ED (Emergency Department) Director (S15) was interviewed on 4/21/11 at 10:50 a.m. S15 reviewed the medical record of Patient #12. S15 reported the documentation indicated that Patient #12 was placed in restraints on 1/02/11 at 6:05 a.m. and remained in restraints until 1/02/11 at 8:45 a.m. S15 reported that she was unable to find documentation indicating that Patient #12 was under constant visual observation for the first hour of being placed in restraints and no documentation to indicate that the patient was assessed every 15 minutes as documented in the hospital's policy/procedure titled "Restraints".

The personnel record of S16 (Registered Nurse) was reviewed. Review of the education/training/competency records revealed no documentation to indicate that S16 had received training and demonstrated knowledge in the use of nonphysical intervention skills.

Based on record review and interview, the hospital failed to ensure that all drugs and biologicals were administered in accordance with Federal and State laws and accepted standards of practice. This was noted for 1 of 12 sampled patients (Patient #12) and evidenced by documentation indicating that a 20mg injection of Geodon was administered by a registered nurse (S17) when the injection was actually administered by a mental health specialist (S18). The mental health specialist was not authorized to administer medications and this intervention was outside the scope of practice for this employee. Findings:

Patient #12: Medical record review revealed that Patient #12 presented to Lake Charles Memorial Hospital on 1/02/11. Documentation on the Emergency Room Nursing Record dated 1/02/11 at 6:00 a.m. revealed that the patient was combative, hostile, and yelling that he wanted to kill someone in triage. Documentation on the Emergency Room Nursing Record revealed that the patient was placed in restraints on 1/02/11 at 6:05 a.m. The documentation failed to indicate the type of restraint used at the time of application. Documentation on the Emergency Room Nursing Record revealed that the right wrist restraint was removed on 1/02/11 at 7:05 a.m. Documentation on the Emergency Room Nursing Record revealed an entry dated 1/02/11 at 8:45 a.m. that read "Pt now released from 4 point Restraints, Pt sleeping calmly in bed". Further documentation on the Emergency Room Nursing Record revealed that a 20mg injection of Geodon was administered intramuscularly by S17 RN.

The hospital's policy/procedure titled "Medication Administration". The policy/procedure documents "Medication may only be administered by licensed personnel in accordance with Louisiana State Board of Nursing requirements. L.R.S. 37:913 (13) and L.R.S. 37:913 (14) (f) selected nursing functions approved by the board my be delegated to licensed or unlicensed personnel".

Review of an Incident Report dated 1/02/11 revealed that the 20mg injection of Geodon was administered by a mental health specialist (S18) who was not licensed and not authorized to administer medications.

Documentation presented by the hospital revealed that disciplinary action was taken in regards to the employees who were involved in this incident. However, there was no documentation to indicate that the administration of this medication by an unauthorized employee was included in the hospital's medication occurrence reporting data.

The Chief Nursing Officer (S3) was interviewed on 4/21/11 at 2:00 p.m. When asked if the administration of the Geodon by an unauthorized employee was included in the hospital's data relating to medication occurrences or if a medication occurrence report had been filled out relating to this occurrence, S3 indicated that a medication occurrence report was not filled out and indicated that the administration of this medication by an unauthorized person would not be included in the hospital's data relating to medication occurrences.

Based on record review and interview, the hospital failed to ensure the medical record was accurately written for 1 of 12 sampled patients (Patient #12). This was evidenced by documentation indicating that a 20mg injection of Geodon was administered by a registered nurse (S17) when the injection was actually administered by a mental health specialist (S18). The mental health specialist was not authorized to administer medications and this intervention was outside the scope of practice for this employee. Findings:

Patient #12: Medical record review revealed that Patient #12 presented to Lake Charles Memorial Hospital on 1/02/11. Documentation on the Emergency Department Triage Report revealed that the arrival time was 5:43 a.m. Documentation on the Emergency Room Nursing Record revealed that a 20mg injection of Geodon was administered intramuscularly by S17 RN.

Review of an Incident Report dated 1/02/11 revealed that the 20mg injection of Geodon was administered by a mental health specialist (S18) who was not licensed and not authorized to administer medications.

The ED (Emergency Department) Director (S15) was interviewed on 4/21/11 at 10:50 a.m. S15 reviewed the medical record of Patient #12 and the Incident Report dated 1/02/11. S15 confirmed that the documentation in the medical record indicated that the 20mg injection of Geodon was administered by S17 (Registered Nurse). S15 confirmed that the Incident Report indicated that 20mg injection of Geodon was administered by S18 (Mental Health Specialist).

The Director of Psychiatric Services (S4) was interviewed on 4/21/11 at 10:30 a.m. S4 confirmed that S18 (mental health specialist) administered a 20mg injection of Geodon to Patient #12 on 1/02/12. S4 reported that S18 was not licensed and/or authorized to administer medications. S4 reported that the 20mg injection of Geodon was administered by S18 as documented on the Incident Report. S4 indicated that the documentation entered into the medical record relating to the administration of Geodon was not accurate.

Based on record review and interview the hospital failed to ensure all entries in the medical record are dated and timed as evidenced by 1) no date and time of the order for patient #5 to be placed in restraints and 2) no date and time of the authentication of the order for patient #5 to be placed in restraints by the physician who gave the order for 1 of 5 patients ordered seclusion and/or restraint in a total sample of 12. (#5) Findings:

1)

Review of the "Behavior Management Seclusion/Restraint Order/Flowsheet" revealed an order sheet dated 02/10/1. Review of box #4 revealed an order for patient #5 to be placed in seclusion and restraints. Further review revealed the verbal order was taken by S9RN from S7MD. Review of the verbal order revealed no documented evidence of what time the order was taken.

In an interview on 04/21/11 at 2:00 p.m. with S3DON and S4Program Manager both confirmed the documentation did not indicate the time the order was given by the physician responsible for the care of patient #5.

2) Review of the "Behavior Management Seclusion/Restraint Order/Flowsheet" revealed an order sheet dated 02/10/1. Review of box #4 revealed an order for patient #5 to be placed in seclusion and restraints. Further review revealed the verbal order was taken by S9RN from S7MD. The verbal order was authenticated by S7MD with no documented evidence of the date and time the order was authenticated.

In an interview on 04/21/11 at 2:00 p.m. with S3DON and S4Program Manager both confirmed the documentation did not indicate the time the order was authenticated by the physician (S7MD) responsible for the care of patient #5.

Review of a hospital policy titled " Documentation " , last revised and reviewed 04/2011, reads in part: " ...3. All entries must be legibly signed, dated, and timed ...Key Points: 1. Date, time, sign all entries ... "

Based on record review and interview the hospital failed to ensure the implementation of infection control measures included all physicians by failing to have documentation of a chest x-ray for a physician with a positive PPD (purified protein derivative) (TB) skin test per hospital policy for 1 of 2 physician credentialing files reviewed. Findings:

Review of the credentialing file for S8MD file revealed the physician filled out the "Tuberculosis Screening Form" on 09/01/09. (initial appointment 01/21/10 There is no documentation on the line which reads "I tested positive_______ (Approximate Date/Year)." The signs/symptoms experienced for more than 3 weeks in the last year which include fever, prolonged cough that raised secretions or bloody sputum, night sweats, loss of weight, and chronic fatigue" or not checked either "Yes" or "No".

In an interview on 04/25/11 at 1345 (1:45 p.m.) with S28Medical Staff Credentialing she stated that S8MD had previously reported that she had a positive PPD (TB) skin test in the past. S28Medical Staff Credentialing confirmed her documentation on the bottom of the "Tuberculosis Screening Form" that read "(S8MD) did not provide us with a chest x-ray."

Review of a hospital policy titled "Employee Health Program", effective date April 12, 2006, revealed in part: "...I-39.2.2 Employees with a previous positive PPD will complete a signs and symptoms form annually. Annual chest x-rays are not needed unless signs and symptoms arise. New hires will have to present documentation of the past positive, complete the signs and symptoms form, and receive a chest x-ray if cannot show results of one completed within the last 6 months."