HospitalInspections.org

Based on observations and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by:
1) Failing to ensure the physical environment and patient gowns at the main campus were free of ligature and suffocation risks as observed on 05/21/19 from 8:55 a.m. to 10:15 a.m.
2) Failing to ensure the physical environment and patient gowns at the offsite campus located in Gretna were free of ligature and suffocation risks as observed on 05/22/19 from 10:55 a.m. to 11:20 a.m.
Findings:

1) Failing to ensure the physical environment and patient gowns at the main campus were free of ligature and suffocation risks:
Observations during a tour of the main campus on 05/21/19 from 8:55 a.m. to 10:15 a.m. with S1ADM and S2DON present revealed the following ligature and suffocation risks:
Patient gowns on linen carts have ties at the neck and sides that can be used as a ligature when tied together;
Room "a" bathroom has an approximate 1 ½ inch space between the sink and wall that can be used as a ligature point; the mattress in the bed near the door has a zipper on the base that can be a risk for suffocation;
Room "b" - this patient room uses the same bathroom as Room "a";
Room "c" - the bed near the window had a zippered mattress; the bathroom had the toilet plumbing containment detached from the wall leaving the plumbing exposed and becoming a ligature point;
Room "d" - the wall across from both beds had spackled, unpainted sheetrock which if peeled off and ingested could be a health risk;
Room "e" - the toilet has an approximate 2 inch space behind the toilet and the wall that can be used to attach a ligature;
Room "f" - the shelf next to the bed near the window had slippers with a leather cord laced around each slipper that could be used as a ligature;
Room "g" - the toilet had a hole at the wood plumbing containment that opened around the underside from one side of the toilet to the other side to which a ligature could be attached;
Room "h" - the bed near the window had a zippered mattress that could be a risk for suffocation; patient belongings on the shelf next to the bed near the door were in a paper bag that had 2 paper cord-type handles could be a ligature risk of removed and joined together;
Seclusion Room vestibule entrance door had hinges with spaces between them as well as the seclusion room entrance door; the toilet in the seclusion bathroom had an approximate 3 to 4 inch space between the wall and around the base of the toilet that could be a ligature risk (S1ADM indicated staff would stand outside the bathroom door with a 1 inch crack in the door and would not have eyes on the patient while the patient was using the bathroom and further indicated "we can't watch them when they're using the bathroom");
Shower Room had a door with open spaces between each hinge; the toilet plumbing was not contained; there were holes around the sink plumbing that could be a site for hiding contraband; there were 3 shower chairs in the bathroom (2 in shower stalls) that had multiple ligature points (S1ADM indicated a patient was allowed in the shower with the curtain closed with the MHT standing outside the shower curtain and not having eyes on the patient while the patient was showering); there was a toilet lift seat that had ligature points; an unlocked cabinet in one of the shower stalls had an unlabeled bottle of body wash and a pail with dried paint in it; the cabinets in the shower stalls and the cabinets along the entrance wall in the bathroom had a total of 11 handles with open spaces in the handle around which a ligature could be tied.
All above observations were confirmed by S2DON.

In an interview on 05/21/19 at 8:55 a.m., S2DON Judy indicated all their patient gowns have ties at the neck and sides. She further indicated the gowns with snaps only come in medium size.

In an interview on 05/21/19 at 9:35 a.m., S2DON indicated S4EOC was the EOC staff who checked for ligature risks, and the nursing staff should be checking on rounds every shift. She further indicated the patient belongings on the shelf in Room "h" should not have been left in the room. She indicated the patient had been admitted the previous night, and the belongings should have been removed at that time.

2) Failing to ensure the physical environment and patient gowns at the offsite campus located in Gretna were free of ligature and suffocation risks:
Observation at the offsite campus located in Gretna on 05/22/19 from 10:55 a.m. to 11:20 a.m. with s2DON present revealed the following ligature and suffocation risks:
Male Shower Room had a shower chair in the shower stall that had multiple ligature points; Female Shower Room had the toilet with an open space behind it and the wall around which a ligature could be placed; the shower had an approximate ½ inch space between the metal handrail and the shower to the back of the handrail that presented an opportunity to hide contraband and was a safety risk for cutting oneself; there was a shower chair in the stall that had multiple ligature points;
Seclusion hall entrance door and entrance door into the seclusion room had hinges with open spaces between each hinge; the baseboard was separated from the wall and lying on the floor approximately 3 feet;
Room "i" - the bed near the window had a zippered mattress that could be a suffocation risk;
Room "j" - the bathroom door in the room was partially open with a patient lying in bed (S2DON indicated the bathroom door should remain locked);
Room "k" - there was unpainted spackled sheetrock on the wall across from the bed near the door that if scratched off and ingested could be a health risk; the bed near the door had a wedge pillow at the foot of the bed that had a zipper that could be risk for suffocation;
Room "l" - the bed near the door had a zippered mattress;
Clean Linen Closet - had gowns with ties at the neck and sides that could be a ligature when tied together.

In an interview on 05/22/19 at 11:20 a.m., S2DON confirmed the above observations of ligature and suffocation risks.

Based on record reviews and interview, the hospital failed to ensure restraints were only used when less restrictive interventions had been determined to be ineffective to protect the patient, a staff member, or others from harm as evidenced by having a patient administered a chemical restraint without documented evidence that a less restrictive intervention had been attempted and determined to be ineffective for 1 (#1) of 1 patient record reviewed where a chemical restraint had been administered from a sample of 5 patient records reviewed for restraints.
Findings:
Review of the policy titled "Seclusion and Restraints", presented as a current policy by S2DON, revealed a chemical restraint was defined as a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. Further review revealed the use of restraint will be used only after assessment and when less restrictive measures have failed. The nursing progress note includes the behavior prior to initiation of the restraint, justification for the continuation throughout the course of the restraint, justification for release from restraint, and the patient's condition upon release. Chemical restraint implies the patient is under the restraint for no less than one hour. The procedure for every 15 minute assessment and vital signs apply and the one hour RN assessment. Every 15 minutes the patient status is documented on the flow sheet, and the RN assessment is documented hourly.

Review of Patient #1's physician orders revealed an order on 01/19/19 at 12:00 p.m. to start Zyprexa 5 mg by mouth every HS, and if the patient refuses the by mouth dose, give the Zyprexa IM. Further review revealed there was no documented evidence of an order to administer Zyprexa on 01/23/19 at 4:20 a.m. and 9:00 a.m.

Review of Patient #1's "Multi-Disciplinary Note" documented on 01/23/19 at 4:20 a.m. by S15LPN revealed "Patient severely agitated screaming "(name of son) bring my ladder!" crying, threatening staff. Zyprexa IM 5 mg given to R (right) gluteal will continue to monitor." Further review revealed an entry on 01/23/19 at 5:30 a.m. by S15LPN that included "Patient calmer, yelling less. Still crying and yelling for son intermittently. Respirations even and unlabored No complications. Will continue to monitor." There was no documented evidence that a physician's order was obtained for the chemical restraint, that less restrictive measures were attempted and had failed to be effective, and that a RN assessed Patient #1 prior to S15LPN administering the chemical restraint.

Review of Patient #1's "Multi-Disciplinary Note" documented on 01/23/19 at 8:40 a.m. by S11LPN revealed "Pt. refusing AM medications. Pt. is refusing p.o. fluids or food. Pt. very aggressive & cursing staff & other patients. Attempting to remove all clothing. At dining room table - lifted up table & proceeded to drop table on 2 others." Further review revealed an entry on 1/23/19 at 9:00 a.m. by S11LPN of "Zyprexa 5 mg IM given R (right) deltoid as ordered." There was no documented evidence that a physician's order was obtained for the chemical restraint, that less restrictive measures were attempted and had failed to be effective, and that a RN assessed Patient #1 prior to S11LPN administering the chemical restraint.

In an interview on 05/22/19 at 10:15 a.m., S2DON, after reviewing Patient #1's medical record, confirmed that Zyprexa was ordered to be given HS only, and the doses administered on 01/23/19 at 4:20 a.m. and 9:00 a.m. were administered without a physician's order. She confirmed it was a chemical restraint, because it wasn't given for delusion or psychotic behavior. She confirmed the requirements for chemical restraint assessment and documentation were not met.

Based on record reviews and interview, the hospital failed to ensure there was a written modification to the patient's plan of care when a chemical restraint was used as evidenced by failure to have Patient #1's plan of care modified when he was administered a chemical restraint on 01/23/19 at 4:20 a.m. and 9:00 a.m. This deficient practice was evident in 1 (#1) of 1 patient record reviewed where a chemical restraint had been administered from a sample of 5 patient records reviewed for restraints.
Findings:

Review of the policy titled "Seclusion and Restraints", presented as a current policy by S2DON, revealed the treatment team will review the occurrence and use of a chemical restraint and modify the patient's plan of care as needed.

Review of Patient #1's "Multi-Disciplinary Note" documented on 01/23/19 at 4:20 a.m. by S15LPN revealed "Patient severely agitated screaming "(name of son) bring my ladder!" crying, threatening staff. Zyprexa IM 5 mg given to R (right) gluteal will continue to monitor." Further review revealed an entry on 01/23/19 at 5:30 a.m. by S15LPN that included "Patient calmer, yelling less. Still crying and yelling for son intermittently. Respirations even and unlabored No complications. Will continue to monitor."

Review of Patient #1's "Multi-Disciplinary Note" documented on 01/23/19 at 8:40 a.m. by S11LPN revealed "Pt. refusing AM medications. Pt. is refusing p.o. fluids or food. Pt. very aggressive & cursing staff & other patients. Attempting to remove all clothing. At dining room table - lifted up table & proceeded to drop table on 2 others." Further review revealed an entry on 1/23/19 at 9:00 a.m. by S11LPN of "Zyprexa 5 mg IM given R (right) deltoid as ordered."

Review of Patient #1's "Multi-Disciplinary Integrated Treatment Plan Problem List", the "Multi-Disciplinary Integrated Treatment Plan", and "Treatment Plan Review and update with Physician Certification" revealed the treatment plan was not modified after the use of chemical restraints on 01/23/19.

In an interview on 05/22/19 at 10:15 a.m., S2DON, after reviewing Patient #1's medical record, confirmed that Zyprexa was ordered to be given HS only, and the doses administered on 01/23/19 at 4:20 a.m. and 9:00 a.m. were administered without a physician's order. She confirmed it was a chemical restraint, because it wasn't given for delusion or psychotic behavior. She confirmed the requirement that the treatment plan be modified with the use of chemical restraints was not met.

Based on record reviews and interview, the hospital failed to ensure the use of chemical restraint was in accordance with the order of a physician or other licensed independent practitioner who was responsible for the care of the patient as evidenced by failure to have a physician's/licensed independent practitioner's order to administer chemical restraints on 01/23/19 at 4:20 a.m. and 9:00 a.m. for 1 (#1) of 1 patient record reviewed where a chemical restraint had been administered from a sample of 5 patient records reviewed for restraints.
Findings:

Review of the policy titled "Seclusion and Restraints", presented as a current policy by S2DON, revealed restraints are used upon the written or verbal order of a physician.

Review of Patient #1's "Multi-Disciplinary Note" documented on 01/23/19 at 4:20 a.m. by S15LPN revealed "Patient severely agitated screaming "(name of son) bring my ladder!" crying, threatening staff. Zyprexa IM 5 mg given to R (right) gluteal will continue to monitor." Further review revealed an entry on 01/23/19 at 5:30 a.m. by S15LPN that included "Patient calmer, yelling less. Still crying and yelling for son intermittently. Respirations even and unlabored No complications. Will continue to monitor." There was no documented evidence that a physician's order was obtained for the chemical restraint.

Review of Patient #1's "Multi-Disciplinary Note" documented on 01/23/19 at 8:40 a.m. by S11LPN revealed "Pt. refusing AM medications. Pt. is refusing p.o. fluids or food. Pt. very aggressive & cursing staff & other patients. Attempting to remove all clothing. At dining room table - lifted up table & proceeded to drop table on 2 others." Further review revealed an entry on 1/23/19 at 9:00 a.m. by S11LPN of "Zyprexa 5 mg IM given R (right) deltoid as ordered." There was no documented evidence that a physician's order was obtained for the chemical restraint.

In an interview on 05/22/19 at 10:15 a.m., S2DON, after reviewing Patient #1's medical record, confirmed that Zyprexa was ordered to be given HS only, and the doses administered on 01/23/19 at 4:20 a.m. and 9:00 a.m. were administered without a physician's order. She confirmed it was a chemical restraint, because it wasn't given for delusion or psychotic behavior. She confirmed the requirements for chemical restraint assessment and documentation were not met.

Based on record reviews and interview, the hospital failed to ensure that when restraint was used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient was seen face-to-face within 1 hour after the initiation of the intervention by a physician or other licensed practitioner or RN who had been trained in performing the one hour face-to-face assessment for 1 (#1) of 1 patient record reviewed where a chemical restraint had been administered from a sample of 5 patient records reviewed for restraints.
Findings:

Review of the policy titled "Seclusion and Restraints", presented as a current policy by S2DON, revealed a physician/licensed independent practitioner must see and evaluate the need for restraint within 1 hour after initiation of the intervention. In lieu of the physician/licensed independent practitioner, a trained RN or physician's assistant may perform the one hour face-to-face assessment.

Review of Patient #1's "Multi-Disciplinary Note" documented on 01/23/19 at 4:20 a.m. by S15LPN revealed "Patient severely agitated screaming "(name of son) bring my ladder!" crying, threatening staff. Zyprexa IM 5 mg given to R (right) gluteal will continue to monitor." Further review revealed an entry on 01/23/19 at 5:30 a.m. by S15LPN that included "Patient calmer, yelling less. Still crying and yelling for son intermittently. Respirations even and unlabored No complications. Will continue to monitor." There was no documented evidence that a RN assessed Patient #1 prior to S15LPN administering the chemical restraint, and there was no documented evidence that the physician/licensed independent practitioner or a trained RN performed the one hour face-to-face assessment within 1 hour after initiation of the chemical restraint.

Review of Patient #1's "Multi-Disciplinary Note" documented on 01/23/19 at 8:40 a.m. by S11LPN revealed "Pt. refusing AM medications. Pt. is refusing p.o. fluids or food. Pt. very aggressive & cursing staff & other patients. Attempting to remove all clothing. At dining room table - lifted up table & proceeded to drop table on 2 others." Further review revealed an entry on 1/23/19 at 9:00 a.m. by S11LPN of "Zyprexa 5 mg IM given R (right) deltoid as ordered." There was no documented evidence that a RN assessed Patient #1 prior to S11LPN administering the chemical restraint, and there was no documented evidence that the physician/licensed independent practitioner or a trained RN performed the one hour face-to-face assessment within 1 hour after initiation of the chemical restraint.

In an interview on 05/22/19 at 10:15 a.m., S2DON, after reviewing Patient #1's medical record, confirmed that Zyprexa was ordered to be given HS only, and the doses administered on 01/23/19 at 4:20 a.m. and 9:00 a.m. were administered without a physician's order. She confirmed it was a chemical restraint, because it wasn't given for delusion or psychotic behavior. She confirmed the requirements for the one hour face-to-face assessment by the physician/licensed independent practitioner or a trained RN were not met.

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:
1) Failing to ensure assessments of skin, wounds, alcohol screening, suicide risk, and change in condition were conducted and documented accurately for 3 (#1, #2, #3) of 5 (#1 - #5) patient records reviewed for RN assessment from a sample of 5 patients; and
2) Failing to ensure a patient was assessed after a fall in accordance with the hospital's policy for 1 (#4) of 1 patient record reviewed with a fall from a sample of 5 patients;
Findings:

1) Failing to ensure assessments of skin, wounds, alcohol screening, suicide risk, and change in condition were conducted and documented accurately:
Skin assessment/wounds:
Review of the policy titled "Skin/Wound Care", presented as a current policy by S2DON, revealed a skin assessment is completed by the RN on all patients at admission, weekly, after a fall/injury, upon new findings, and at discharge. Description of abnormalities should be documented according to assessed findings including the initiation of the impaired skin integrity treatment plan. A Braden Scale Risk Assessment is completed by the RN on all patients upon admission, weekly, and as needed in addition to the skin assessment process. If the Braden score is less than 18, the wound care prevention/protocol will be implemented as applicable and as ordered. An impaired skin integrity treatment plan will be initiated or updated according to the patients' assessed results. The wound care procedure included the following: If a patient is identified to have a wound, a picture is taken, and documentation of the wound is completed on the hospital skin assessment wound care documentation form. The RN opens a skin integrity treatment plan. The RN places the picture of the wound in the patient's medical record. Pictures will be retaken at a minimum of every 3 days. The picture is placed on the skin assessment wound care documentation form in the medical record. Wound care interventions included the following: relieve pressure by keeping off of reddened area as much as possible, turning at least every 2 hours, and administer wound care per physician orders. Wound prevention interventions included the following: pressure relief is the most important prevention/intervention. Immobility is the most significant risk factor for pressure injury development. Chair-bound patients should be repositioned at least every hour, shift weight every 30 minutes if able, and foam, gel, or air cushions should be used to relieve pressure.

Patient #1
Review of Patient #1's medical record revealed she was admitted on 01/18/19 at 4:16 p.m. with an admit diagnosis of Suicidal Ideations and Major Depressive Disorder, single episode, unspecified. She was discharged on 02/01/19 at 5:30 p.m.

Review of Patient #1's Braden Scale revealed it was scored a 15 on 01/18/19 (at admit) and on 01/26/19. There was no documented evidence that a care plan for impaired skin integrity was developed in accordance with the hospital's policy for a Braden Scale score of less than 18. There was no documented evidence that wound prevention interventions were implemented that included relieving pressure by keeping the patient off of reddened area as much as possible, turning at least every 2 hours, repositioning at least every hour while chair-bound, shifting weight every 30 minutes if able, and using a foam, gel, or air cushion to relieve pressure.

Review of the multi-disciplinary notes documented on 01/30/19 at 3:00 p.m. by S13RN revealed she observed a Stage 2 pressure ulcer to the sacrum and 2 more open areas in between the top buttock folds. There was no documented evidence of an assessment of the appearance and measurement of any of 3 wounds.

In an interview on 05/21/19 at 4:08 p.m., S13RN confirmed she didn't document an assessment and the wound measurements on 01/30/19. She questioned the surveyor about whether she was supposed to document another assessment when the nurse had done so on 01/29/19. When told by the surveyor that her documentation revealed 2 new wounds had been identified, S13RN answered "Oh."

In an interview on 05/22/19 at 10:15 a.m., S2DON confirmed the wound care protocol and initiation of an impaired skin integrity care plan was not done based on the Braden Scale of 15 and should have been done. She confirmed there was no documented evidence that wound prevention interventions had been implemented during Patient #1's hospital stay.

Patient #3
Review of Patient #3's medical record revealed she was admitted on 02/20/19 and discharged on 02/28/19. Review of her Braden Scale score documented on 02/20/19 (at admit) revealed a score of 14 and a score of 11 on 02/24/19 with no documented evidence that a treatment plan was developed for impaired skin integrity. There was no documented evidence wound prevention interventions had been implemented during Patient #3's hospital stay.

In an interview on 05/22/19 at 1:54 p.m., S2DON confirmed no treatment plan was developed for impaired skin integrity but should have been done upon admit.

Alcohol screening:
Patient #1
Review of Patient #1's alcohol screening tool documented on 01/18/19 at 5:00 p.m. by S12RN revealed the response to the questions were as follows: "How often do you have a drink containing alcohol" was checked as "4 or more times a week (4); "How many drinks containing alcohol do you have on a typical day when you are drinking was checked as "3 or 4 (1); "How often do you have six or more drinks on one occasion was checked as "less than monthly (1). The score was totaled as "2" when it should have been scored at "6." Review of the scoring revealed in women, a score of 3 or more is considered positive.

In an interview on 05/21/19 at 3:45 p.m., S2DON confirmed the alcohol screening score was incorrect.

Suicide risk assessment:
Review of the policy titled "Suicide/Homicide Risk Assessment", presented as a current policy by S2DON, revealed the hospital will assess and identify safety risks in the facility's client population and identify those clients of high-risk potential for suicide/homicide. Suicide/homicide assessments are conducted at first contact and with any subsequent suicidal/homicidal behavior, increased ideation, or pertinent clinical change. The "Suicide Assessment Five-Step Evaluation and triage" process included identifying risk factors, identifying protective factors, conducting a suicide inquiry, determining the risk level/intervention, and documenting the process. High suicide risk was defined as potentially lethal suicide attempt or persistent ideation with strong intent or suicide rehearsal. Action included calling the physician, reviewing date gathered, receiving orders, and developing a crisis safety plan as indicated. Moderate suicide risk was defined as suicidal ideation with plan but no intent or behavior. Action included utilizing suicide precautions as indicated and always to provide suicide hotline numbers, and develop a crisis safety plan as indicated.

Patient #1
Review of Patient #1's medical record revealed she was admitted on 01/18/19 at 4:16 p.m. with an admit diagnosis of Suicidal Ideations and Major Depressive Disorder, single episode, unspecified. She was discharged on 02/01/19 at 5:30 p.m. Further review revealed she was PEC'd on 01/17/19 at 12:30 a.m. due to telling her son she was suicidal. Her mental condition was documented as belligerent, hostile, refusing care, and threatening to kill herself. She assessed as currently suicidal, dangerous to self, and gravely disabled. Further review revealed she was CEC'd on 01/17/19 at 12:18 p.m. as being dangerous to self and gravely disabled.

Review of Patient #1's suicide risk level screen documented by S12RN on 01/18/19 at 5:00 p.m. revealed the following risk factors were checked: single, widowed, divorced, or separated; greater than 65 years old; alcohol or heavy drug use. No protective factors were identified by S12RN. S12RN assessed Patient #1 as her suicide risk not being a clinical issue when the risk tool revealed that multiple risk factors with no modifiable risk was a moderate risk and having no protective factors a high risk.

In an interview on 05/21/19 at 3:45 p.m., S2DON confirmed Patient #1 should have scored as a high risk for suicide, and the physician should have been called but was not. She indicated S12RN is currently on leave and not available for interview.

Patient #2
Review of Patient #2's medical record revealed she was admitted on 02/05/19 with an admit diagnosis of Unspecified Dementia with behavioral disturbance. Further review revealed she was discharged on 02/13/19 with discharge diagnoses of Major Depressive Disorder, recurrent, severe, recent suicide attempt, and Major Neurocognitive Disorder due to Huntington's disease.

Review of Patient #2's "Admit Nursing assessment" documented on 02/05/19 at 4:35 p.m. revealed she had attempted suicide by wrapping her roommate's oxygen tubing around her neck. Review of her "Suicide Risk level Screen" revealed the risk factors of single, widowed, divorced, or separated, current or past diagnosis of mood disorder or psychosis disorder, and past attempt/rehearsals were checked. Further review revealed the protective factors checked were absence of psychosis and social support. Review of the risk level scoring revealed moderate risk included multiple risk factors with no modifiable risk, 1 or 2 protective factors, suicidal ideation with no plan or constant intent. Low risk scoring revealed less than 2 risks and risks are modifiable, 3 or more protective factors, and thoughts of dying with no plan or behaviors. The suicidality risk level for high risk, potentially lethal suicide attempt, was not checked (patient had attempted suicide prior to admission). The RN scored the suicide risk as low risk rather than moderate risk in accordance with the assessment tool.

In an interview on 05/22/19 at 1:48 p.m., S2DON confirmed the suicide risk score should have been moderate based on the RN's documented assessment.

Patient #3
Review of Patient #3's medical record revealed she was admitted on 02/20/19 and discharged on 02/28/19.

Suicide risk assessment scored as not a clinical issue but has one risk checked. Intake has current symptoms of sleep disturbance, hallucinations but not checked on risk assessment.
Review of Patient #3's Intake Assessment" documented by S12RN on 02/20/19 at 4:30 p.m. revealed she was gravely disabled, had hallucinations, and sleep disturbance.

Review of Patient #3's suicide risk level screen documented by S12RN on 02/20/10 at 4:30 p.m. revealed the only risk factor checked was greater than 65 years old. The risk factor "have at least 2 key symptoms of anhedonia, hopelessness, anxiety, panic, insomnia, command hallucinations, impulsivity, or rapid mood shifts was not checked, but S12RN had documented on the intake assessment that she was having hallucinations and had sleep disturbance. There no protective factors identified by S12RN who scored Patient #3's suicide risk as not a clinical issue. Having multiple risk factors was a moderate risk, and having no protective factors was a high risk.

In an interview on 05/22/19 at 1:54 p.m., S2DON confirmed the suicide risk assessment was not accurate, and it should have been assessed as a low risk.

Change in condition:
Review of the policy titled "Early Response intervention To Deteriorating Patient Condition/Change in Condition", presented as a current policy by S2DON when a policy related to the RN's assessment of a patient with a change in condition was requested, revealed the facility identifies situations in which an individual's psychological health is deteriorating and they are becoming a threat to themselves or others, respiratory/cardiopulmonary arrest, and response to abnormal changes/fluctuations in a patient's status, such as intake and output, capillary blood glucose levels, vital signs, and such. There was no documented evidence the policy addressed the required RN assessment for changes in patient condition that were not as severe as listed above, such as respiratory wheezing.

Review of Patient #4's multi-disciplinary notes revealed the following documentation by S10LPN:
05/13/19 at 4:30 a.m. - wheezing with productive cough; nebulizer treatment given Albuterol; 05/17/19 at 6:30 a.m. - patient wheezing 3 cc Proventil given via nebulizer treatment.
There was no documented evidence a RN assessed Patient #4 who experienced a change in condition and required a respiratory treatment for wheezing.

In an interview on 05/22/19 at 2:04 p.m., S2DON confirmed there was no RN assessment when Patient #4 experienced a change in condition (wheezing, productive cough).

2) Failing to ensure a patient was assessed after a fall in accordance with the hospital's policy:
Review of the policy titled "Fall Assessment/Re-Assessment and Precautions", presented as a current policy by S2DON, revealed all patients will be assessed and identified for the potential of being at risk for falls within the first 8 hours of admission at the time of their initial nursing assessment, immediately after a fall, and every 7 days if identified as moderate or high risk. In the event of a fall occurrence, patients will be re-assessed and moved to a higher fall risk. And secondary fall prevention interventions will be implemented. Further review revealed the RN post fall assessment should include the following: nursing note with a brief summary of the event; how the patient was found; what was the patient able to tell about the fall in quotes; has the patient fallen before; was the patient on anticoagulants, new antipsychotics or blood pressure medications; was there adequate fluid intake over the last 48 hours; include an assessment note with the following information: nursing physical assessment of vital signs, neurological signs, patient behavior, pain or tenderness; check the skin for pallor, trauma, circulation, abrasion, bruising, and sensation; signs of fracture, bleeding, range of motion assessment with all extremities; level of consciousness; inform physician, family, and document notifications and if new orders were received.

Patient #4
Review of Patient #4's medical record revealed he was admitted on 05/10/19 at 10:55 p.m. with an admitting diagnosis of Major Depressive Disorder, single episode, unspecified.

Review of the multi-disciplinary note documented by S18RN on 05/21/19 at 2:00 a.m. revealed she was notified by a peer that Patient #4 was on floor. Further review revealed he was found in front of the bathroom sink and he stated he was trying to go to bathroom. He was assisted back into the wheelchair and assessed. S18RN documented he demonstrated active range of motion to all 4 extremities but complained of right shoulder pain. There was no documented evidence of an assessment after a fall that included the above-listed information.

Review of Patient #4's nursing care plan for falls revealed no documented evidence he was re-assessed and his fall risk was increased to a higher level. There was no documented evidence secondary fall prevention interventions were implemented after the fall.

In an interview on 05/22/19 at 2:04 p.m., S2DON indicated a full assessment should have been done after the fall including vital signs and assessment of neurological status. She confirmed the nursing care plan was not revised and secondary fall prevention interventions were not implemented after the fall in accordance with hospital policy.

Based on observations, record reviews, and interviews, the hospital failed to ensure:
1) Medication and nourishment products that had expired were not available for use as evidenced by having Sterile Normal Saline and liquid protein nourishments that had expired still on the shelf in the medication room available for use as observed at the offsite campus located in Gretna on 05/22/19 at 11:05 a.m.
2) Physician orders for medications included the indication for use as evidenced by failing to have the medication's indication for use included in the order with no clarification order received by the nurse for 2 (#4, #5) of 5 (#1 - #5) patient records reviewed for medication orders from a sample of 5 patients.
Findings:


1) Medication and nourishment products that had expired were available for use:
Observation in the medication room at the offsite campus located in Gretna on 05/22/19 at 11:05 a.m. revealed the following medications and nourishments had expired:
500 ml Sterile Normal Saline expired May 2018;
2 containers of 30 fluid ounces Pro-Start Sugar Free Liquid Protein Citrus Splash expired 06/14/18;
6 containers of 30 fluid ounces Pro-Start Sugar Free Liquid Protein Wild Cherry Punch expired 12/27/18.
Further observation revealed a carton with multiple unopened packs of cigarettes was stored in the medication cabinet.

Review of the policy titled "Medications", presented as a current policy by S2DON, revealed expired or unused medications will be destroyed at the hospital according to their classification.

In an interview on 05/22/19 at 11:05 a.m., S11LPN indicated medications in the medication room were checked by the medication nurse monthly. She offered no explanation for the above-listed medications and nourishments being expired and remaining available for use.

2) Physician orders for medications included the indication for use:
Review of the policy titled "Medications", presented as a current policy by S2DON, revealed each medication order has to include the medication indication. Medication indication is required for all admit medication orders, new medication orders initiated during the course of treatment, and on all discharge medication orders.

Patient #4
Review of Patient #4's physician orders revealed the order for Zyprexa 2.5 mg po HS documented on 05/22/19 at 11:57 a.m. did not include the indication for use.

Patient #5
Review of Patient #5's physician's orders revealed the following medication orders did not include the indication for use:
05/16/19 at 12:00 a.m. - Colace 100 mg po daily and Dulcolax 2 tablets po daily prn;
05/16/19 at 6:00 p.m. - Folic Acid 1 mg po daily and Vitamin B6 25 mg po daily;
05/18/19 at 7:30 p.m. - Trazadone 150 mg po Q HS and Vistaril 50 mg po now.

In an interview on 05/22/19 at 2:01 p.m. and 2:08 p.m., S2DON confirmed the medications listed above for Patients #4 and #5 did not include the indication for use.

Based on observations, record reviews, and interviews, the hospital failed to ensure the infection control officer implemented a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel as evidenced by:
1) Failing to ensure hand hygiene practice was implemented in accordance with the CDC's guidelines as evidenced by multiple breaches in hand hygiene observed during medication administration on 05/21/19 at 9:40 a.m. at the main campus.
2) Failing to ensure specimen refrigerator temperatures at the main campus were monitored daily as evidenced by failure to have a documented refrigerator temperature for 7 days from 05/10/19 through 05/20/19.
3) Failing to ensure dirty linens were stored in a covered container in the dirty linen room as evidenced by having a bedspread, sheet, and towels stored on top of the covered dirty linen container rather than inside the container as observed on 05/21/19 at 9:50 a.m. at the main campus.
4) Having the questionnaire used for screening personnel annually for TB not inclusive of all required questions in accordance with the OPH's requirements for 4 (S12RN, S13RN, S14RN, S15LPN) of 4 personnel files reviewed with TB questionnaires from a sample of 5 (S10LPN, S12RN, S13RN, S14RN, S15LPN) personnel files reviewed.
Findings:

1) Failing to ensure hand hygiene practice was implemented in accordance with the CDC's guidelines:
Observation in the day room at the main campus during a medication pass on 05/21/19 at 9:40 a.m. revealed S5LPN reached with gloved hands to pick a napkin off the floor. With the same gloved hands she poured water in a cup and handed the cup to a patient. With same gloved, contaminated hands, S5LPN opened a container of eye drops and instilled a drop in each eye of a patient. Continuous observation revealed a hole in the index tip of her left hand. S5LPN removed her gloves and regloved without performing hand hygiene. With an ungloved hand, S5LPN touched a patient's hair to turn her head. After gloving without performing hand hygiene after patient contact, she again touched the patient's hair. With the same contaminated, gloved hands, Janice handed a patient a cup of water, opened peel packs of pills, and placed them in a plastic cup. S5LPN then removed her gloves and didn't perform hand hygiene. She wrote on the medication administration record and got medication out the drawer. She donned gloves without hand hygiene, opened pill packs and placed the pills in a container. Continuous observation revealed S6MHT cut bracelets off 3 different patients without performing hand hygiene between patient contact. S5LPN was observed to pick a medication peel pack off the floor with gloved hands and took the scissors used by S6MHT and placed the contaminated scissors in the medication drawer with contaminated, gloved hands. S5LPN took an opened Lidocaine patch that she touched with gloved hands and placed it in the medication drawer. She removed her gloves and redonned gloves without performing hand hygiene.

Review of the CDC's "Guideline for Hand hygiene in Health-Care Settings" revealed indications for handwashing and hand antisepsis were as follows: 1) when hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water; 2) if hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations; 3) decontaminate hands before having direct contact with patients; 4) decontaminate hands before donning sterile gloves when inserting a central intravascular catheter; 5) decontaminate hands before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure; 6) decontaminate hands after contact with a patient's intact skin (such as taking a pulse or blood pressure, and lifting a patient); 7) decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled; 8) decontaminate hands if moving from a contaminated body site to a clean body site during patient care; 9) decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; 10) decontaminate after removing gloves; 11) before eating and after using a restroom, wash hands with a non-antimicrobial soap and water or with an antimicrobial soap and water.

In an interview on 05/21/19 at 10:05 a.m. with S2DON present, S5LPN was informed of the observations made of breaches in infection control. She indicated they had hand sanitizer on the cart but ran out. She indicated she uses the one on the wall, but it's the only one they have, and it's in the nursing station (not near the day room). She confirmed there is a sink and soap in the day room that could be used for hand hygiene.

2) Failing to ensure specimen refrigerator temperatures at the main campus were monitored daily:
Review of the specimen refrigerator temperatures at the main campus revealed no documented evidence that the temperature had been checked on 05/10/19, 05/11/19, 05/12/19, 05/13/19, 05/15/19, 05/16/19, and 05/20/19.

In an interview on 05/21/19 at 9:03 a.m., S2DON indicated temperatures were to be checked every day.

3) Failing to ensure dirty linens were stored in a covered container in the dirty linen room:
Observation in the soiled holding room at the main campus on 05/21/19 at 9:50 a.m. revealed a bedspread, sheet, and towels were placed on top the covered dirty linen bin rather than inside the bin.

In an interview on 05/21/19 at 9:50 a.m., S2DON indicated the soiled linen should have been placed in the bin.

4) Having the questionnaire used for screening personnel annually for TB not inclusive of all required questions in accordance with the OPH's requirements:
Review of the policy titled "Tuberculosis Exposure Control Plan-Risk Assessment", presented as a current policy by S16QD, revealed in addition to baseline TB testing upon hire, hospitals that are classified as a low risk for TB will require all hospital employees to complete a Tuberculosis Symptom Screen annually.

Review of the Louisiana Administrative Code, "Chapter 5. Health Examinations for Employees, Volunteers and Patients at Certain Medical and Residential Facilities" revealed all persons prior to or at the time of employment at any medical or 24-hour residential facility requiring licensing by the Louisiana Department of Health shall be free of tuberculosis in a communicable state as evidenced by either: 1) a negative PPD skin test given by the Mantoux method or a blood assay for Mycobacterium tuberculosis; 2) a normal chest x-ray if the skin test or blood assay is positive; or 3) a statement from a licensed physician certifying the individual is non-infectious if the x-ray is other than normal. In order to remain employed, the individual shall be rescreened annually by one of the following methods: purified protein derivative skin test for TB given by the Mantoux method or a blood assay for Mycobacterium tuberculosis approved by the United States Food and Drug Administration remains negative, or a completed questionnaire asking of the person pertinent questions related to active TB symptoms, including, but not limited to: do you have productive cough that has lasted at least 3 weeks, are you coughing up blood, have you had an unexplained weight loss recently, have you had fever, chills, or night sweats for 3 or more days. Any employee converting from a negative to a positive skin test for TB or a blood assay or having indicated symptoms of active TB revealed by the completed questionnaire shall be referred to a physician and followed as indicated.

Review of the personnel files of S12RN, S13RN, S14RN, and S15LPN revealed the TB questionnaire included the question do you have night sweats but didn't include the required OPH question of have you had fever, chills, or night sweats for 3 or more days.

In a telephone interview with S17ICO on conference call with S16QD present, S17ICO confirmed the questionnaire didn't include the question whether the employee had fever, chills, or night sweats lasting 3 or more days.

Based on record reviews and interview, the hospital failed to ensure each patient received a psychiatric evaluation that estimated the intellectual and memory functioning and orientation as evidenced by failure of the practitioner to describe the appearance and behavior, emotional response, verbalization, thought content, and cognition of the patient as reported by the patient and observed by the examiner at the time of the examination for 1 (#4) of 5 (#1 - #5) patient records reviewed for estimation of intellectual and memory functioning and orientation from a sample of 5 patients.
Findings:

Review of Patient #4's Psychiatric Evaluation documented by S7MD on 05/17/19 revealed "his memory was intact." There was no documented evidence that his intellectual functioning, memory (recent and remote) functioning, and orientation were evaluated and included a description of the appearance and behavior, emotional response, verbalization, thought content, and cognition of the patient as reported by Patient #4 and observed by S7MD at the time of the examination.

In an interview on 05/22/19 at 2:04 p.m., S2DON confirmed the psychiatric evaluation didn't include the required documentation related to intellectual and memory functioning and orientation. She further indicated S7MD was not available for interview during the survey.

Based on record reviews and interview, the hospital failed to ensure each patient had a written nursing treatment plan that included short-term and long range goals that were stated as expected behavioral outcomes for the patient and written as observable, measurable patient behaviors to be achieved as evidenced by failure to have documented evidence that patient goals were stated as expected behavioral outcomes for the patient and written as observable, measurable patient behaviors to be achieved for 4 (#1, #2, #4, #5) of 5 (#1 - #5) patient records reviewed for measurable goals from a sample of 5 patients.
Findings:

Patient #1
Review of Patient #1's nursing treatment plan revealed the following goals that were not stated as expected behavioral outcomes for the patient and written as observable, measurable patient behaviors to be achieved:
Safely withdraw from alcohol and drugs with minimal physical complications;
Comply with prescribed detox regime;
Establish a balance of rest, sleep, and activity;
Maintain adequate nutrition, hydration, and elimination.

Patient #2
Review of Patient #2's nursing treatment plan revealed the following goals that were not stated as expected behavioral outcomes for the patient and written as observable, measurable patient behaviors to be achieved:
Demonstrate increased ability to maintain nutrition, hydration, and elimination;
Patient will be compliant with medications and activities of daily living in 10 days.

Patient #4
Review of Patient #4's nursing treatment plan revealed the following goals that were not stated as expected behavioral outcomes for the patient and written as observable, measurable patient behaviors to be achieved:
Consistently comply with activities that decrease risk for falls;
Demonstrate an understanding of treatment regime to maintain medical condition at optimal level within 2 weeks;
Remain free of signs and symptoms of elevated blood pressure difficulties for 3 consecutive days;
Patient will comply with prescribed diet and medications to manage medical conditions.

Patient #5
Review of Patient #5's nursing treatment plan revealed the following goals that were not stated as expected behavioral outcomes for the patient and written as observable, measurable patient behaviors to be achieved:
Demonstrate an understanding of treatment regime to maintain medical condition at optimal level;
Identify alternative techniques to manage stress within 7 days;
Consistently comply with activities that decrease risk of falls.

In an interview on 05/22/19 at 1:48 p.m., S2DON indicated she had noticed that treatment goals are not always stated in measurable terms.