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Based on record review and interview, the facility failed to properly notify the complainant in writing of the grievance decision by the facility. The deficient practice is evidenced by failure to include the steps taken on behalf of the patient to investigate the grievance and the results of the investigation in 2 (Pt. #1 and Pt. #2) of 2 reviewed letters of grievance resolution.

Findings:

Patient #1
Review of the medical record for Patient #1 revealed admission on 08/31/2023 for major depression with suicidal ideations. Patient #1 was admitted with suicide precautions and one on one observations were ordered on 09/01/2023 after the patient said she would kill herself in the shower. On 09/02/2023 the patient was transferred to an acute care hospital of observation after possible ingestion of an unknown amount of a Schedule II narcotic.

Review of the self-report filed with Louisiana Department of Health (LDH) on 09/08/2023 for the incident involving Patient #1 and Patient #2 revealed in part, "K. Investigation Results- The allegation of neglect was substantiated due to patient having access to home medication secondary to communication and process failures in the search process."

Review of the Grievance Resolution Form revealed the grievance was taken by phone on 09/02/2023 and stated, "On 09/02/2023 staff delivered patient's belongings to the patient after being told that the belongings were searched in admissions. The patient's medication was still in patient's bag. Patient Advocate spoke to patient's mother on 09/03/2023. Mom stated that didn't do a good job at making sure the medication was out of the patient's belongings. Mom stated that staff didn't communicate with abat (? Misspelled) patient return to the facility. Mom would like to press charges if possible. Just wants to make sure this doesn't happen to anyone else."

Review of the letter sent to the patient and her guardian to notify them of the grievance decision revealed:

"Steps taken to resolve:
1.Patient Advocate spoke with the Physician, Medical Director, Chief Nursing Officer, and Chief Executive Officer about your concerns to ensure that quality care is provided.
2.Corrective action and coaching of nursing staff.

Results/Resolution:
Thank you for reporting your concerns to the facility. Our Physician, Medical Director, and Chief executive Officer have been made aware of and addressed your concerns. Our goal is to provide a safe and therapeutic environment for our patients. For this reason, we maintain Policies and Procedures related to the medication management, personal belongings, contraband, and patient care. We regret any inconvenience related to treatment and medication management. It is my understanding at the time of our meeting you felt as though your safety was being maintained."

The letter did not mention if an investigation was performed to find out how the Schedule II drug ended up on the psychiatric unit in the possession of minors on suicide precautions. The letter did not disclose the results of the investigation as reported to LDH.

Patient #2
Review of the medical record for Patient #2 revealed admission on 08/19/2023 with a diagnosis of major depressive disorder with psychosis and suicidal ideation. On 09/02/2023 the patient admitted to taking a large amount of another patient's Schedule II medication and was noted to have tachycardia and had difficulty walking. Patient #2 was transferred to an acute care hospital for evaluation. The patient was admitted to the acute care hospital and never returned to the facility.

Review of the self-report filed with Louisiana Department of Health (LDH) on 09/08/2023 for the incident involving Patient #1 and Patient #2 revealed in part, "K. Investigation Results- The allegation of neglect was substantiated due to patient having access to home medication secondary to communication and process failures in the search process."

Review of the Grievance Resolution Form revealed the grievance was taken by phone on 09/02/2023 and documented, "On 09/02/2023 patient was sent out to the ER due to possibly overdosing on another patient medication that they found on the unit. Patient was admitted into the hospital to monitor her heart rate and to have EKG. Patient Advocate spoke with the patient's mother. Mom stated that the patient is still in the hospital. Mom stated that the patient told her she found the pills and took 27 of them. Mom stated that she is very upset about what happen to her daughter. Corrective action and coaching is taking place with staff."

Review of the letter sent to Patient #2 and her guardian to notify them of the grievance decision revealed were sent the exact same letter as Patient #1. The letter did not mention if an investigation was performed to find out how the Schedule II drug ended up on the psychiatric unit in the possession of minors on suicide precautions. The letter did not disclose the results of the investigation as reported to LDH.

In interview on 09/20/2023 at 3:10 p.m., S2DRM was asked about the contents of the grievance letter and why the letter did not contain an explanation of the investigation and the results of the investigation. S2DRM stated there was no proof that Patient #1 or Patient #2 actually ingested any of the medication. S2DRM did verify the bottle of medication should not have been in the children's possession on the secured unit and that someone had been negligent in their search of the patient's possessions.

In interview on 09/20/2023 at 4:45 p.m., S2DRM stated the resolution or result was that they had closed the investigation.

Based on record review and interview, the facility failed to ensure patients were treated in a manner that maintained dignity. The deficient practice is evidenced by restricting the diet of 1 (#2) of 2 (#1 and #2) patients on suicide precautions with one-to-one observation to finger foods only.

Findings:

Review of the medical record for Patient #2 revealed a physician's note on 08/20/2023 at 8:49 a.m. which documented, "patient attempted to self-harm with a broken fork yesterday patient on one-to-one and a room search performed and states that she is still suicidal and seeing visual hallucinations today."

Review of the nursing notes and other documents in the medical record failed to reveal evidence of the incident and the documented room search.

Review of the orders revealed an order for finger foods only with a start date of 08/20/2023 at 9:00 a.m. and a stop time of 9:09 a.m. Further review revealed second order for finger foods only with a start date 08/21/2023 at 9:00 a.m. and no stop date or time. The comments documented, "no utensils pt attempted to harm herself and verbalized SI."

In interview on 09/25/2023 at 11:37 a.m., S2DRM verified two of the staff physicians occasionally ordered finger foods if they felt it was necessary. S2DRM verified limiting the diet to finger foods restricted the patient's choice of food, might be seen as a punishment, and could be viewed as forcing her to eat in an undignified manner. S2DRM was unable to answer questions about the type of food or nutritional content provided by the diet.

Based on observation, record review, and interview the facility failed to ensure care in a safe setting. The deficient practice is evidenced by: 1) failure to document q 15 minute observation for 1 (#2) of 8 (#1-#8) reviewed observation records; 2) failure to remove monitored items from patient rooms; 3) failure to ensure fences were maintained in patient care areas; 4) failure to ensure cabinets on the unit were secured and did not provide a place for hiding; 5) failure to ensure contracted workers maintained the security of the facility perimeter.

Findings:

1) Failure to document q 15 minute observations.

Review of the medical record for Patient #2 revealed admission on 08/19/2023 with a diagnosis of major depressive disorder with psychosis and suicidal ideation. On 09/02/2023 the patient admitted to taking a large amount of another patient's Schedule II medication and was noted to have tachycardia and had difficulty walking. At the time of the incident the patient was on suicide precautions and Q15 minute observations. Patient #2 was transferred to an acute care hospital for evaluation.

Review of the Q 15 minute observation sheets revealed the sheet for 09/02/2023 was missing.
In interview on 09/19/2023 at 3:30 p.m., S2DRM verified the observation sheet was missing.

2) Failure to remove monitored items from patient rooms.

Review of the policy "Admission to Discharge: Personal Belongings, Valuables, Safety/Skin, & Contraband Searches" revealed in part, "Staff can take cigarettes to the unit where they will be monitored and stored by unit staff. Open cigarette packs will be searched & stored in patient designated lockers in the unit, only to be accesses by unit staff."

Review of the "Attestation for All Facility Staff MHT" revealed in part, " Utensils cannot be accessible to patients when not in use. Utensils cannot be left in patient care areas or patient bedrooms."

Tour of the facility on 09/25/2023 between 9:30 a.m. and 10:30 a.m. revealed the following contraband:
Room "a" -a bottle of shampoo/ body wash
Room "b" - a plastic spoon
Room "c" -hygiene bucket with shampoo/ body wash, deodorant, and toothbrush
Room "d" - cigarettes, hygiene bucket with shampoo/ body wash
Room "e" - hygiene bucket with shampoo/body wash, deodorant, and toothbrush
Room "f" - Hygiene bucket with toothbrush, toothpaste.
Room "g" - several packages of cigarettes, and shampoo/ body wash
Room "h" -plastic spoon, toothpaste and toothbrush

At the time of discovery on 09/25/2023 between 9:15 a.m. and 10:30 a.m., S2DRM verified the above findings. S2DRM verified the hygiene products and utensils are monitored items and should be picked up by staff after use.

3) Failure of the facility to ensure fences were maintained to prevent elopement, injury, or entry of contraband.

Review of the policy "Environmental Rounds" reveals in part, "As part of an ongoing environment of care program, the Safety Officer shall coordinate the environmental tours of the facility to identify and evaluate information concerning safety, security, fire safety, hazardous conditions, exposure to hazardous materials and waste, medical equipment, utilities, and staff knowledge."

Review of the provided documents revealed the walk through inspections were performed each week on one unit. Each unit was inspected approximately every 6 weeks. Unit "C" was last inspected on 08/13/2023 and Unit "D" was inspected 08/20/2023. The fences were not included in the Environmental Rounds checklist.

Tour of the facility on 09/25/2023 between 9:30 a.m. and 10:30 a.m. revealed compromised fences in the following areas:

The wooden fence for the patio area on Unit "C" had one fence board completely transected approximately 10 inches above the ground with mobility of the two ends which would allow passage of a hand and could be easily broken with pressure. A second fence board with a long linear crack that allowed the board to be separated and grasped in the separation.

At the time of discovery, S2DRM verified the findings and verified patients were allowed in the area and the broken areas of fence could easily be grasped and ripped open.

Inspection of the chain link fence for the smoking area of Unit "D" revealed the metal had been recently been cut in 3 areas and the open areas were re-approximated with smaller chains woven through the opening and secured with pad locks. The metal was cut at the top and bottom and the piece of metal in between the cuts spiraled out. In two of the repaired areas there were protruding sharp ends of the fence which could pierce the skin.

Further inspection of the Unit "D" patio revealed a wooden fence approximately 24 inches beyond the chain link fence providing privacy from the street. Direct observation revealed there was no lock on the wooden gate latch.

At the time of discovery, S2DRM verified the findings and verified the wooden fence was not locked because of the fire code.

The wooden fence on the west side of Area "F" was noted to have a broken board on the gate. The board was broken at the top and the bottom. There had been an attempt to repair the area at the top, but the board was mobile and not secure.

At the time of discovery S2DRM verified the findings and verified patients were allowed in the area. S2DRM verified the gate on the west side of Area "F" was broken in an elopement in July.

On 09/26/2023 at 12:00 p.m. while passing by the facility on the busy boulevard on the west side of the complex, a green object was observed crossing the gate to Area "F." Closer inspection of the public side of the gate revealed a green tow strap with a ratchet spanning between the metal posts holding the gate to Area "F."

Inspection of the wooden fence enclosing the patio of Unit "D" revealed it was not locked providing access to the chain link fence surrounding the smoking patio of Unit "D." The surveyor opened the gate, walked in and lingered in the area and was never approached by staff.

On 09/26/2023 between 1:00 p.m. and 1:22 p.m., an interview was conducted with S2DRM and S4DPO. S4DPO verified the fences were not on the list of items inspected during Safety Rounds. S4DPO verified if the tow strap was removed from the gate in Area "F", the gate would not latch properly. S4DPO verified no one monitored the gate to ensure the strap was not removed. S4DPO verified the wooden gate outside the chain link fence smoking patio of Unit "D" was not locked because there can only be two locks in a designated fire escape route. S2DRM and S4DPO verified this is a potential area for introduction of contraband to the unit. They also verified that someone could cut the chain link fence from the street side. S2DRM also verified Unit "D" is the unit with the most contraband.

4) Failure of the facility to ensure cabinets on the unit were secured and did not provide a place for hiding.

Review of the "Attestation for All Facility Staff MHT" revealed in part, " all cabinets ( to include base cabinets or any other cabinets) in patient care areasmust be secured shut and locked."

Tour of the facility on 09/25/2023 at 2:30 p.m. revealed the base cabinet with activity supplies on Unit "A" was open providing a potential place for patients to hide.

At the time of discovery on 09/25/2023 at 2:30 p.m., S2DRM verified the cabinet was supposed to be locked.

5) Failure of the facility to ensure contracted workers maintained the security of the facility perimeter.

Tour of the facility on 09/25/2023 at 2:47 p.m., revealed an unlocked open door into Area "G." A warning posted on the door indicated the area was used for oxygen cylinder storage. Further observation revealed the building was also open on the other side of the building and there were workers unloading material from trucks.

S2DRM verified the door was supposed to be locked. S2DRM closed the door and contacted S4DPO to secure the area. The contracted worker was noted to open the door again prior to the arrival of S4DPO.

Based on observation,record review and interview, the facility failed to properly investigate and report all incidents of possible neglect. The deficient practice is evidenced by failure to investigate and report possible abuse or neglect as required by R.S. 40:2009.20 in 6 (#5- #8, R1, R2) of 6 documented elopements.

Findings:

Review of LA R.S. 40:2009.20 revealed in part, "Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, licensed practical nurse, nurse's aide, home- and community-based service provider employee or worker, personal care attendant, respite worker, physician's assistant, physical therapist, or any other direct caregiver having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect."

Review of the provided list of Louisiana Department of Health (LDH) Self-Reports between the dates of 07/1/2023 and 09/19/2023 revealed there were no elopements reported.

Review of the incident reports provided revealed 6 elopements from the facility between 07/09/2023 and 09/03/2023.

In interview on 09/20/2023 at 1:35 p.m., S2DRM stated the elopements were all reported to the local police because the regulation allowed either a report to the police or report to LDH. When asked if the reports to the police were reports of possible neglect, S2DRM stated she did not think any of the elopements involved possible neglect.

In interview on 09/25/2023 at 4:37 p.m., the surveyor read the excerpt from LA R.S. 40:2009.20 listed above to S2DRM and asked if the reports filed were for possible neglect or abuse. S2DRM replied that the police determined what was put on the report. S2DRM stated in some cases she was given a blue slip from the police with the complaint in code and the report number, but they did not always give the facility the blue slip.

Review of the blue complaint slips provide by law enforcement revealed none of the reports were for possible neglect or abuse. The elopements were recorded as complaint, missing person, 22M, or 21.

The local sheriff's office was contacted on 09/27/2023 at 9:00 a.m. and the surveyor was informed 22M was a missing person report and 21 was a civil complaint.

Review of the elopements revealed at least 3 (#6, #7, #8) of 6 (#5-#8, R1, R2) elopements involved neglect.

Patient #6
Review of the policy "Smoking Policy- Function: Environmental Care" revealed in part, "Patients on special precautions, 1-1, may smoke only upon staff discretion and if staff are available to accompany them to the designated smoke patio."

Review of the incident report for Patient #6 revealed the elopement occurred 08/04/2023 at 1:00 p.m. from the smoking patio on Unit "C." Patient #6 was on one to one observation and the MHT assigned to the observation was re-educated after the event.

Review of the blue complaint slips provided by law enforcement revealed there was no complaint slip for this date.

Review of the medical record for Patient #6 revealed the patient had been in a physical altercation on 08/03/2023, had received a chemical restraint twice on 08/03/2023, and was transferred to another unit on 08/03/2023 because of "paranoia and psychosis."

Review of the "Post Event Note" revealed "Pt had stated he was going to elope. MHT let on patio during smoke break while on 1:1. Pt jumped over fence at 1 p.m." Police were notified at 1:10 p.m. and the complaint number was listed.

In interview on 09/27/2023 at 10:20 a.m., S2DRM verified Patient #6 was on one to one observation and the MHT did go outside with the patient. S2DRM stated the MHT was afraid of the patient, did not intervene and did receive disciplinary action. S2DRM verified patients on one to one observation are taken out on smoke breaks at the discretion of the staff.

Patient #7
Review of the incident report for Patient #7 revealed the patient eloped on 09/03/2023 at 5:15 p.m. from the smoking patio of Unit "D." The incident report documented, "During the 17:00 smoke break the patient was able to pull apart the fence on the smoke patio and left through the gate. Pt refused to come back into the hospital. She was informed that the police would be called and made known that she was a patient on our unit. Police called by staff, house supervisor, MD on call and ADON made aware of patient elopement." An addendum dated 09/05/2023 revealed "Pt made a hole in the smoking patio fence while using other patients to block staff view, seconds after the patient went through the hole, staff responded but were unable to have pat. Return. Patient safety confirmed."

Review of the blue complaint slip provided by law enforcement and revealed the incident was reported as a missing person.

Review of the form "Patient Observation/ Round Precaution" revealed on 09/02/2023 Patient #7 was allowed to stay on the smoking patio for at least one hour between 2:00 p.m. and 3:00 p.m. On 09/03/2023 Patient #7 was on the smoking patio for 2 observation periods at 3:00 p.m. and 3:15 p.m.

In interview on 09/20/2023 at 2:05 p.m., S2DRM stated that the patient had opened the fence with her fingers by working the wire behind her back while sitting on the concrete to obscure what she was doing. S2DRM denied the fence was cut or broken prior to the event. S2DRM verified smoking breaks were 10 minutes.

Tour of the facility on 09/25/2023 between 9:30 a.m. and 10:30 a.m. revealed the smoking patio fence on Unit "D" was a chain link fence. Inspection of the chain link fence revealed three areas where it appeared the fence had been patched with additional chain and padlocks. The lower cut edge of the fence was secured by looping the wire. Some of the loops were noted to be slightly open and would allow for potential unraveling of the chain link fence. Direct visualization revealed the wooden fence, surrounding the chain link fence, obscuring the area from the street, did not have a lock on the gate latch.

At the time of discovery S2DRM verified the gate was not locked because of the fire code.

Tour of the outside of the fence on 09/26/2023 between 12:00 p.m. and 12:30 p.m. revealed the gate was unlocked and the surveyor was able to enter the area between the wooden fence and the chain link fence. The area was noted to contain cigarette packages, cigarettes and trash. The surveyor had not yet entered the building that day and no one came out to inquire why someone was in between the fences.

In interview on 09/26/2023 between 1:00 p.m. and 1:22 p.m., S4DPO verified the wooden fence outside the chain link fence did not have a lock on the gate because it was part of the designated fire escape route. S2DRM and S4DPO verified the area was not secure and also a potential source of entry for contraband through the chain link fence.

In interview on 09/27/2023 at 11:20 a.m. S2DRM verified the facility did review the video of the event. S2DRM verified the MHT performing the Q15 observations was inside the building "in a blind spot" and could not be seen at the observation window for the smoking patio. S2DRM verified the patients stood in front of the window during the break and blocked the view of the camera and the MHT inside. S2DRM verified smoking breaks were 10 minutes and Patient #7 was on the smoking patio longer than 10 minutes on 09/02/2023 and 09/03/2023.

Patient #8
Review of the incident report for Patient #8 revealed the patient eloped on 07/09/2023 at 4:30 a.m. from Area "H". The patient was found by police and returned to the facility 07/10/2023. The door latch was repaired after the event.

Review of the blue complaint slip provided by law enforcement and revealed the incident was reported as a missing person.

Review of the medical record revealed Patient #8 was placed under a Physician's Emergency Certificate (PEC) on 07/08/2023 at 7:50 p.m. His history was notable for polysubstance abuse, personality disorder, incomplete quadriplegia, and recent rhabdomyolysis. The evaluating physicians documented "Muscle spasticity due to spinal cord injury," and "left sided weakness with frequent falls, incomplete quadriplegia C1-C6 fx with left hand flexion contracture but he can walk- chronic pain."

In interview on 09/27/2023 at 12:41 p.m., S2DRM verified she reviewed the video of the elopement and all she could see was the patient walked out of the door. S2DRM verified the door is supposed to be locked to prevent elopement. S2DRM stated she was not sure if there was a problem with the latch before the elopement.

Based on record review and interview, the hospital failed to ensure orders for restraints were executed in accord with hospital policy. The deficient practice is evidenced by failure of the physician to authenticate restraint orders within 24 hours of initiation.

Findings:

Review of the hospital policy, Telephone/Verbal Orders, revealed in part, "Orders for seclusion/restraint must be authenticated within 24 hours."

Review of the medical record for Patient #2 revealed the patient was placed in a physical restraint on 08/31/2023 at 8:52 p.m. Review of the form titled Restrain and Seclusion Order revealed Patient #2 "stood up from table she was sitting at and attacked another female peer unprovoked."

Futher review of the form revealed the orders were given over the telephone on 08/31/2023 at 9:05 p.m. The registered nurse did not indicate that the orders were read back. The physician signed the orders on 09/02/2023 at 10:00 a.m.

In interview on 09/20/2023 at 2:57 p.m., S2DRM verified the orders were not signed within 24 hours as per hospital policy.

Based on record review and interview, the facility failed to identify opportunities for improvement. The deficient practice is evidenced by failure to identify neglect.

Findings:

Review of the preliminary incident self-report submitted to Louisiana Department of Health on 09/17/2023 revealed Patient #3 was admitted to the facility on 9/15/2023 with diagnosis of schizophrenia and polysubstance abuse . On 09/16/2023 Patient #3 was found vomiting in his bed and a bottle of cleaner containing bleach was found in the patient room. The patient denied drinking the cleaner, but stated he did drink some water. The patient was sent to a local acute care hospital for evaluation.

In telephone interview on 09/20/2023 at 3:59 p.m., S6RN admitted to the surveyor and S2DRM that she had brought the cleaner into the room after the patient had an episode of incontinence. S6RN stated she remember picking up the spray bottle but put it aside because she did not feel the bottle contained enough cleaner to complete the job. S6RN stated there was only about 3 sprays left in the bottle. S6RN stated she did not think Patient #3 could have taken the top off but admitted that the bottle stilled sprayed if the trigger was activated.

In interview on 09/18/2023 at 3:45 p.m., the surveyor asked S2DRM if she felt the allegation of neglect was substantiated because the nurse had admitted to leaving the bottle with bleach in Patient #3's room. S2DRM said she had no evidence of neglect and there was no evidence the patient consumed any of the cleaner.

In the finalized report dated 09/22/2023, S2DRM concluded, "The allegation was unable to be substantiated due to lack of evidence."

Based on record review and interview, the facility failed to track all adverse patient events. The deficient practice is evidenced by failure to complete an incident report for a documented self-harm event in 1 (#2) of 8 (#1-#8) reviewed medical records.

Findings:

Review of the policy "IR/ Incident Reporting" revised 09/2023 revealed in part, "Incident: an event, outcome, or situation that is not consistent with routine care of patients and/ or the desired operations of the facility and results in or could have resulted in (near miss) unexpected medical intervention, unexpected intensity of care, or unexpected physical or mental impairment."

Review of the medical record for Patient #2 revealed a physician's note on 08/20/2023 at 8:49 a.m. which documented, "patient attempted to self-harm with a broken fork yesterday patient on one-to-one and a room search performed and states that she is still suicidal and seeing visual hallucinations today."

Review of the nursing notes and other documents in the medical record failed to reveal evidence of the incident and the resulting room search.

Review of the list of incident reports provided failed to reveal an incident report for the incident.

In interview on 09/25/2023 at 11:40 a.m., S2DRM verified she did not see a nursing note about the incident in the medical record and there was no incident report for Patient #2 on 08/19/2023 or 08/20/2023.

Based on observation, record review, and interview the registered nurse failed to supervise the care provided by the mental health techs (MHT). The deficient practice is evidenced by failure of the MHT to monitor all patients Q15 minutes as ordered for patients on Unit "C." Findings:

Tour of the facility was performed on 09/25/2023 between 9:30 a.m. and 10:30 a.m. During the tour of Unit "C" the surveyor noted only one patient on the unit.

Interview with S8MHT on Unit "C" on 09/25/2023 at 9:45 a.m. revealed there were 12 patients on the unit and all 12 patients were on Q15 minute observation. All the observations sheets were up to date. S8MHT verified she was performing all the observations and the majority of patients admitted to the unit were in Area "F". Staffing for the unit during the shift was 1 Registered Nurse and 2 MHTs.

After inspection of the unit, the surveyor accompanied by S2DRM stepped into Area "F" and noted only 4 patients and one counselor in the area. S2DRM walked over to the counselor and verified the rest of the patients had gone inside another building with a counselor. The surveyor and S2DRM stood outside and waited for S8MHT to appear for the 10:00 a.m. observations. S8MHT did not appear outside. At 10:03 a.m. the surveyor noted the group of patients had returned to Area "F" and were in route to Unit "C." The surveyor and S2DRM entered the unit ahead of the group and checked the observation sheet. All 12 were filled out for 10:00 a.m.

In interview on 09/23/2023 at 10:05 a.m., S8MHT stated that she had stepped outside to complete the evaluations. S2DRM verified S8MHT was not observed outside, not all the patients were in the courtyard and the windows on the unit were frosted so she could not have seen the patients from the inside.

Based on record review and interview, the director of nursing services failed to ensure nursing care was provided according to hospital policy. The deficient practice is evidenced by failure to follow hospital policy for 1(#3) of 8 (#1-#8) reviewed intake assessments.

Findings:

Review of the policy 'Admission to discharge: Personal Belongings, Valuables, Safety/Skin, and Contraband Searches" revealed in part, "Safety Search shall be performed by a minimum of 2 qualified staff members."

Review of the form "Nursing Admission Assessment" for Patient #3 revealed the assessment/ search was signed by Staff #1 but there was no signature in the blank for Staff #2.

In interview on 09/20/2023 at 11:20 a.m., S2DRM verified the search was to be performed by two staff members and only one staff member signed the form.

Based on record review and interview, the facility failed to ensure verbal orders were immediately transcribed and read back according to standard of care. The deficient practice is evidenced by failure to document verbal orders were read back in 2 (#2,#6) of 8(#1-#8) medical records reviewed for use of verbal of orders.

Findings:

Review of the policy titled "Telephone/Verbal Orders" revealed in part, "It is the policy of River Oaks Psychiatric Hospital to minimize the use of verbal and telephone medication orders. In the event that a verbal or telephonic order is absolutely necessary, only licensed nurses or for medication orders only, a registered pharmacist may accept telephone or verbal orders from physicians. Procedure: 1) the licensed nurse receiving the verbal/telephone order shall promptly enter the order into the electronic medical record, indicating the order in the following manner: . . . The licensed nurse receiving the verbal/telephone order will repeat the order back to the physician to ensure accuracy of the order."

Patient #2
Medical Record review for Patient #2 revealed the patient was placed in a physical hold on 08/31/2023 at 8:52 p.m.

Review of the form "River Oaks Restraint and Seclusion Order" revealed the patient stood up from the table and attacked another peer unprovoked. The patient was placed in a physical hold and escorted to her room and released.

Review of the order for the restraint revealed the telephone order was obtained from the physician 08/31/2023 at 9:05 p.m. The nurse did not check the box in front of the statement "Read Back Completed."

In interview on 09/26/2023 3:20 p.m., S2DRM verified the restraint orders for Patient #2 were not checked off as read back.

Patient #6

Medical record review for Patient #6 revealed the patient was administered a chemical restraint on 07/30/2023 and on 08/03/2023.

Review of the form "River Oaks Restraint and Seclusion Order" completed on 07/30/2023 revealed the patient was threatening to "shank" his roommate.

Review of the order for the restraint revealed the telephone order was obtained from the physician on 07/30/2023 at 12:00 p.m. The nurse did not check the box in front of the statement "Read Back Completed."

Review of the form "River Oaks Restraint and Seclusion Order" completed on 08/03/2023 at 12:00 p.m. revealed the patient was threatening to physically injure the nursing staff.

Review of the order for the restraint revealed the telephone order was obtained from the physician on 08/02/2023 at 12:00 p.m. The nurse did not check the box in front of the statement "Read Back Completed."

In interview on 09/27/2023 at 11:35 a.m., S2DRM verified the restraint orders for Patient #6 were not checked off as read back.

Based on record review and interview, the facility failed to ensure the psychosocial evaluation contained requisite information. The deficient practice is evidenced by failure to include family history, dynamics, and patient's relationship with family and significant others in the report in 1(#1) of 8 (#1- #8) reviewed psychosocial evaluations.

Findings:

Review of the medical record for Patient #1 revealed the parents of the patient were divorced. The surveyor and S2DRM referred to the psychosocial evaluation for further explanation of the family dynamics.

Review of the psychosocial evaluation revealed that both parents were alive, the patient had four siblings, and she lived with her family.

Review of the Discharge Summary revealed the patient lived with her biological dad and stepmother. The patient endorsed "missing her mom with whom she 'cannot have contact,'" and "Per guardian mother does not have legal custody but in the past they allowed visitation every other weekend."

In interview on 09/20/2023 at 2:55 p.m., S2DRM verified the information should have been in the psychosocial evaluation and the page where it would have been documented was left blank.