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Based on record review and interview, the hospital failed to ensure the patient /patient representative's right to participate in the development and implementation of his or her plan of care was met. This deficient practice was evidenced by failure to ensure the patient's representative was included in the development and implementation of the patient's plan of care for 1 (#2) of 5 (#1- #5) sampled patient records reviewed.

Findings:

Review of the hospital's policy titled, "Patient Rights", revealed the following in part: Policy: Beacon Behavioral Hospital is committed to upholding the rights of the patient, as enumerated by State and Federal Regulations and Laws. In accordance with Louisiana Licensing Regulations for Hospitals Section 9319 every patient has the right to: 7. Participate in the development and implementation of his/her plan of care. 8. Make informed decisions regarding his/her care. 10. Be informed of his/her health status, be involved in care planning and treatment, and be able to request or refuse treatment.

Review of Patient #2's medical record revealed the patient was admitted on 09/24/2021 with an admission diagnosis of Alzheimer's Dementia. Further review revealed the patient was confused and unable to make decisions. Additional review revealed the patient's daughter was listed as her power of attorney.

Review of S3SW's notes revealed the following entry: 09/29/2021 11:30 a.m. SW telephone to nurse at Facility "A". Nurse expressed the family's concerns regarding this Beacon Psychiatric Hospital. When the patient arrived, the family requested to be consulted before any medication changes and that did not happen. The family would like to come to get the patient as soon as possible. Please contact the patient's daughter (name and phone number documented).

In an interview on 11/08/2021 at 2:30 p.m. with S3SW, she indicated she remembered Patient #2. She confirmed she had never spoken directly to the family and communicated through the nurse at Facility "A". She further confirmed she had not spoken directly to Patient #2's family regarding their desire to be notified of changes made in Patient #2's medications and their wishes to have the patient discharged as soon as possible.

In an interview on 11/09/2021 at 11:33 a.m. with S4Psych, he confirmed he remembered Patient #2. S4Psych reported he communicates about patients with staff first and tries not to venture out into speaking with family because he must verify if there an issue with release of information. S4Psych further confirmed patient's family members were not routinely included in treatment team meetings.

In an interview on 11/09/2021 at 2:30 p.m. with S2DON, she confirmed staff had not followed up with the family's request, taken by S3SW, to be called to discuss the patient's medication regimen and their desire to have the patient discharged as soon as possible. S2DON further confirmed patient's families were not routinely offered an opportunity to be included in the patient's treatment team meetings.

Based on observation, record review, and interview, the hospital failed to ensure the registered nurse supervised and evaluated the care of each patient. This deficient practice was evidenced by:
1. failure to ensure skin assessments were accurate and updated post incident with injury skin tear for 2 (#2, #4) of 5 (#1-#5) sampled patients.;
2. failure to ensure a patient incident report was completed, as per hospital policy, for an incident between staff and a patient resulting in skin tears (#2) and for an incident involving a patient (#2) biting a staff member for 1 (#2) of 3 (#2, #5, #R1) sampled patients reviewed for incidents from a total patient sample of 5 (#1-#5).; and
3. failure to notify a patient's family of an incident resulting in the patient having post blood exposure lab work drawn after the patient bit a staff member, breaking the skin, for 1 (#2) of 2 (#2, #5) sampled patients reviewed for incident reports resulting in injury from a total patient sample of 5 (#1-#5) .

Findings:

1.Failure to ensure skin assessments were accurate and updated post incident with injury.

Patient #4
On 11/08/2021 at 11:00 a.m. an observation was made of Patient #4's skin. A large purplish-red oval shaped bruise was noted on the inside of the patient's forearm. Another quarter sized purplish-red bruise was noted on the bony prominence of the patients elbow. Patient #4 reported the large bruise on her forearm happened in the hospital prior to her admission and the smaller bruise had occurred from hitting her elbow on the wheelchair while in this hospital. Patient #4 also had a large number of various sized moles on her chest and back.

Review of Patient #4's medical record revealed an admission date of 11/05/2021 with admission diagnoses of Major Depressive Disorder, Unspecified Mood Affective Disorder, and Tertiary Anxiety Disorder.

Review of Patient #4's skin assessments revealed the following entries:
11/05/2021 - Admission Skin Assessment: Bilateral skin tags and chest has a mole. Further review revealed no bruising had been documented and the large number of various sized moles on the patient's chest and back had also not been documented.

11/07/2021- Nursing Note Skin Assessment: Review revealed the patient's bruising had not been documented. The large number of various sized moles on the patient's chest and back had also not been documented.

S2DON, present during the observation of Patient #4's skin and assisting the surveyor with electronic medical record review, verified the patient's skin assessments failed to include documentation describing the large purplish-red oval shaped bruise on the inside of the patient's forearm and the quarter sized purplish-red bruise on the bony prominence of the patients elbow. She further verified the large number of various sized moles on the patient's chest and back had also not been documented.

Patient #2
Review of Patient #2's medical record revealed Patient #2 was admitted on 09/24/2021.

Review of Patient #2's Nursing Notes revealed the following entry, in part: 09/25/2021 7:00 a.m. shift: Patient fought with night staff and got a skin tear on her upper right arm at some point after admission last evening.

Review of Patient #2's medical record revealed no documented evidence that an updated skin assessment had been performed immediately after the patient sustained a skin tear on her right upper arm during a combative episode with the night shift staff on 09/24/2021.

In an interview on 11/09/2021 at 2:30 p.m. with S2DON, she confirmed an updated skin assessment had not been documented immediately post incident when the patient sustained a skin tear on her upper right arm. She further confirmed S8RN had not documented a description of the incident in the patient's record on the night shift of 09/24/2021.

In an interview on 11/09/2021 at 8:10 p.m. with S8RN, he confirmed he had been working on the night shift of 09/24/2021. When asked how Patient #2 had sustained the skin tear on her arm, he explained staff members had been waking the patients up and Patient #2 had gotten up swinging at staff, had spun around, lost her balance and one of the staff members had to grab her to keep her from falling. He indicated the patient had sustained a skin tear on her arm at that time.

2. Failure to ensure a patient incident report was completed, as per hospital policy, for two incidents involving Patient #2 and staff members.

Review of the hospital policy titled, "Incident/Accident Reporting", revealed the following, in part: Policy: All incidents/accidents must be reported as well as any other occurrences presenting risks to company personnel.
Definitions: Incident: defined as an unusual event involving company personnel. The event is considered unusual if the result was unintended, undesirable, and/or unexpected. An incident is also any happening which is not consistent with the routine operation of the company or the routine care/service of a patient.

Review of the hospital policy titled, "Disclosure of Unanticipated Outcome", revealed the following, in part: Procedure: 2. The nurse will transcribe, note, and implement any orders received regarding patient care and other items specified. 4. The nurse will complete and submit an Incident Report regarding the event and enter detailed information in the patient's medical record.

Review of Patient #2's medical record revealed was the patient was admitted on 09/24/2021.

Review of Patient #2's nursing notes revealed the following entry: 09/25/2021 7:00 a.m. shift: Patient fought with night staff and got a skin tear on her upper right arm at some point after admission last evening.

Review of Patient #2's skin assessment, documented on 09/25/2021 at 10:53 a.m. by S10RN, revealed the following: 3 inch skin tear on right upper arm. Cleaned, dressed and dry.

In an interview on 11/08/2021 at 2:30 p.m. with S2DON, she confirmed an incident report should have been written by S8RN when the patient sustained a skin tear on her right upper arm when she was combative with staff. S2DON also confirmed an incident report had not been written by S8RN and an account of the event had not been documented in the patient's record by S8RN.

In an interview on 11/09/2021 at 8:10 p.m. with S8RN, he explained the staff had been waking the patient's up and Patient #2 had gotten up swinging at staff, had spun around, lost her balance and one of the staff members had to grab her to keep her from falling. He indicated the patient had sustained a skin tear on her arm at that time.

Review of the hospital's incident reports for 09/2021 - 11/2021 revealed no documented evidence that an incident report had been generated for the above referenced incident on the nightshift of 09/24/2021 when the patient sustained a skin tear on her upper right arm while being combative with staff.

Further review of the hospital's incident reports from 09/2021 - 11/2021 revealed the following incident on 09/26/2021: Patient bit a staff member (S9MHT) on the finger. Patient was being escorted out of the hygiene room when she reached over and bit staff member on the right hand on her first knuckle. Upon further review of the details of the incident with S2DON, it was determined the patient who had bitten S9MHT was Patient #2.

In an interview on 11/09/2021 at 10:30 a.m. with S11RN, she confirmed an unexpected event should be documented in the patient record and in an incident report.

On 11/09/2021 at 1:30 p.m., S2DON confirmed an incident report had not been generated for Patient #2 when she bit S9MHT. S2DON agreed an incident report should have also been generated for Patient #2 since the patient had bitten S9MHT, broken the skin, and had to have blood exposure labs drawn for Hepatitis C, RPR (rapid plasma reagin for Syphilis), RIBA (Recombinant Immunoblot Assay for Hepatitis C antibodies), and HIV (Human Immunodeficiency Virus). S2DON also confirmed an account of the event had not been documented in Patient #2's medical record.

3.Failure to notify a patient's family of an incident resulting in the patient having to have post-blood exposure lab work drawn after the patient bit a staff member, breaking the skin.

Review of the hospital policy titled, "Disclosure of Unanticipated Outcome", revealed the following, in part: Policy: Beacon Behavioral Hospital supports full disclosure and transparency in issues involving unanticipated outcomes, regardless of contributing factors and/or causes. Any unanticipated outcome that involves the patient shall be disclosed to the patient, and as permitted by the patient and by law, a designated family member, significant other, or representative. Procedure: 6. The treating physician will promptly and openly discuss the event with the patient, family representative, and/or medical power of attorney. This discussion may occur in-person or via telephone (or a combination of the two).

Review of an incident report dated 09/26/2021 revealed S9MHT had been bitten on the knuckle by a patient (Patient #2).

Review of Patient #2's medical record revealed the following labs had been ordered on 09/26/2021: Hepatitis C, RPR (rapid plasma reagin for Syphilis), RIBA (Recombinant Immunoblot Assay for Hepatitis C antibodies), and HIV (Human Immunodeficiency Virus).

Review of Patient #2's electronic medical record, navigated by S2DON, revealed no documented evidence the patient's family had been notified about the incident and the post blood exposure labs being drawn. S2DON confirmed there was no documentation regarding notification of the patient's family in the patient's record. S2DON further confirmed the family should have been notified about the incident and informed the patient was having post-blood exposure lab work drawn.

In an interview on 11/09/2021 at 10:30 a.m. with S11RN, she confirmed an unexpected event should be documented in the patient record, in an incident report, and the family should have been notified as well. S11RN reported if family had been notified the patient had bitten a staff member it would have been documented in the record.

In an interview on 11/09/2021 at 10:45 a.m. with S7NP, she confirmed Patient #2 had bitten a staff member and the patient had to have post-blood exposure lab work drawn. S7NP indicated she wasn't sure if the patient's family had been notified. S7NP further indicated Patient #2's family should have been notified, especially since blood work was drawn due to the patient biting S9MHT hard enough to draw blood. S7NP reported she had assumed the hospital's post-blood exposure protocol included notification of the family.

Based on record review and interview, the hospital failed to ensure patient medical records were were accurate. This deficient practice was evidenced by failure to ensure a patient's medical record had an accurate history and reason for admission documented for 1 (#2) of 5 (#1-#5) sampled records reviewed.

Findings:

Review of the hospital policy titled,"Medical Records", revealed the following, in part: Beacon Behavioral Hospital ensures that each patient shall have an individualized medical record that accurately reflects the patient's condition and the provision of care. Content: in addition to the components required of the medical records of hospitalized patients, in general, this hospital ensures the medical records of its patients reflect, at least: The need for admission, the need for treatment, the patient's legal status, and admitting or provisional diagnoses that include primary psychiatric condition and co-morbidity ( that impacts the primary psychiatric condition or is significant).

Review of Patient #2's medical record revealed the patient was admitted on 09/24/2021 with an admission diagnosis of Alzheimer's Dementia. Further review revealed the patient's suicide risk assessment scores had consistently been scored at 0 risk which was verified by S2DON during medical record review.

Review of Patient #2's PEC, dated 09/24/2021, and CEC, dated 09/25/2021, revealed the patient was currently violent at the time of the assessments. Further review revealed the choice for the patient being suicidal had not been indicated on the PEC nor on the CEC.

Review of Patient #2's pre-admission assessment documentation, completed by central intake, revealed the following presenting problem: Patient is an 83 year-old female on a PEC. Patient presents to ER as gravely disabled. Patient here with EMS for violent behavior. Patient has a history of Alzheimer's Dementia, becoming violent with staff, swinging at them at Facility "A". Facility "A" states they cannot care for patient and she needs to be evaluated by Geri Psych. Patient #2 was sent here for Geri Psych placement. There was no documentation indicating the patient was having suicidal ideations.

Review of Patient #2's Initial Psychiatric Evaluation, dated 09/25/2021, revealed the following: History of Present Illness: Patient is an 83 year-old female on a PEC. Patient presents to ER as gravely disabled. Patient here with EMS for violent behavior. Patient has a history of Alzheimer's Dementia, becoming violent with staff, swinging at them at Facility "A". Facility "A" states they cannot care for patient and she needs to be evaluated by Geri Psych. Patient #2 was sent here for Geri Psych placement. There was no documentation indicating the patient was having suicidal ideations as part of the history of present illness.

Further review of the Initial Psychiatric Evaluation revealed the justification for admission was listed as patient presents as gravely disabled with Suicidal Ideations and requires at least 24 hour skilled psychiatric monitoring services at this time, expected to improve in condition with treatment.

Review of Patient #2's Psychosocial Evaluation, completed by S6LPC, dated 09/24/2021, revealed in part: Clinical Summary: Patient is an 83 year-old female on a PEC. Patient presents to ER as gravely disabled. Patient here with EMS for violent behavior. Patient has a history of Alzheimer's Dementia, becoming violent with staff, swinging at them at Facility "A". Facility "A" states they cannot care for patient and she needs to be evaluated by Geri Psych. Patient #2 was sent here for Geri Psych placement.

Review of S6LPC's contact note, dated 09/25/2021, revealed the following: Spoke to patient's daughter (POA) to help with completing Psychosocial Assessment and Audit. During the conversation learned patient is not at Facility "A" as reported from ED, but is in Facility "B" 's Memory Center. Daughter believes patient will be able to return there upon discharge.

In an interview on 11/09/2021 at 9:16 a.m. with S5PNP, she confirmed she had completed Patient #2's Initial Psychiatric Evaluation. S5PNP indicated Patient # 2 had been threatening and aggressive where she had been residing. S5PNP further indicated Patient #2 was exhibiting homicidal ideations, not suicidal ideations, and she had mistakenly documented suicidal ideations in the patient's Initial Psychiatric Evaluation.

In an interview on 11/09/2021 at 2:30 p.m. with S2DON, she explained the presenting problem is obtained from the PEC, documented on the pre-admission assessment, and from there it is promulgated throughout the chart. She verified, after review of the above referenced documents, that the patient's medical record was not accurate. S2DON agreed the incorrect entries in Patient #2's medical record should have been corrected.