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Based on record review and interviews, the hospital failed to implement its policy related to informing each patient whom to contact to file a grievance as evidenced by 1 (#2) of 3 current inpatients and 1(R1) random inpatient indicating in interview that they had not been informed of the hospital's grievance process since their admission to the hospital.

Findings:

Review of the hospital policy titled "Grievance Procedure Patient And Family Louisiana," presented as a current policy by S1ADM, revealed that at the time of admission, a "Grievance Consent" is presented to the patient and/or family in which they are informed of whom to contact a grievance, as well as external remedies for grievance resolution.

Review of the "Complaint/Grievance Process Patient Representative/Advocacy Program" form that explains the hospital's grievance process revealed that Patient #2 and patient R1 had signed the form at the time of their admission.

In an interview on 08/09/17 at 10:30 a.m., Patient #2 indicated no staff member had explained the process for reporting a complaint or grievance to her. She further indicated she had not read any information contained in the patient handbook.

In an interview on 08/09/17 at 10:40 a.m., Patient R1 indicated he had not had the hospital's grievance process explained to him.

Based on record reviews and interviews, the hospital failed to review, investigate, and resolve each patient's grievance within a reasonable time frame and provide a response to the patient at the completion of the investigation as evidenced by failure to have documented evidence that a patient's report of an allegation of assault by a MHT was handled as a grievance for 1 (#3) of 1 report of an allegation of assault made to hospital staff.


Findings:

Review of the hospital policy titled "Grievance Procedure Patient And Family Louisiana", presented as a current policy by S1ADM, revealed that a patient or family member may at any time file a grievance allegation of violation of a patient's rights or concern regarding quality of care. Depending on the nature of the complaint, the staff will offer resolution at the time the complaint is made and if resolved, report the encounter to the Administrator. The complaint with resolution will be logged on the "Complaint/Grievance Log." If no resolution is made at the time of the complaint, the Administrator is notified, and the grievance process is initiated. The Administrator logs the grievance allegation onto the "Complaint/Grievance Log: and contacts the patient and/or family and opens an investigation to determine validity of the grievance allegation within 48 hours of notification or receipt of the grievance allegation. The Administrator completes the investigation and the "Grievance Report" within 10 days of the the date of notification or receipt of the grievance allegation. The Administrator issues a written determination that contains the name of the hospital contact person, steps taken on behalf of the patient to investigate the grievance allegation, the results of the grievance process, the resolution of the grievance, and the date of completion that is sent to the grievant on the 10th day following notification or receipt of the grievance allegation.

In an interview on 08/07/17 at 12:45 p.m., S1ADM indicated they had not had any grievances since the hospital opened in January 2017.

In a telephone interview on 08/08/17 at 8:30 a.m. with S8LPC while S11LCSW was present, S8LPC indicated a charge nurse had reported in the morning report with staff that Patient #3 had reported that a MHT went into the bathroom and took something out of her hand that she wasn't supposed to have. S8LPC indicated the charge nurse reported that Patient #3 had claimed that the MHT had assaulted her in some way. S8LPC indicated she couldn't remember which charge nurse had reported this information to her. She further indicated she didn't know if the charge nurse was told this or if she had observed the alleged incident. S8LPC was asked by the surveyor if she was supposed to report this information to the Administrator. She indicated that S9RN, the former ADON, was in the meeting at the time, and she didn't know if he followed up to see if it had happened or if Patient #3 was delusional. S8LPC confirmed she didn't report the allegation of assault to the Administrator.

In an interview on 08/08/17 at 8:50 a.m., S1ADM indicated she had never been made aware of a report of an allegation of assault/abuse as documented above. She confirmed that no investigation had been conducted related to the allegation of assault and that Patient #3 had not received a response to her grievance that was reported to S8LPC.

In an interview on 08/09/17 at 8:25 a.m., S13MHT indicated when she came to work on the morning after the alleged incident had occurred, Patient #3 told her (S13MHT) what had happened. S13MHT further indicated Patient #3 said she wasn't going to worry about it, because she (Patient #3) was going to handle it with the charge nurse and DON. S13MHT indicated she saw Patient #3 talking with the charge nurse after her conversation with Patient #3, but she (S13MHT) didn't remember who the charge nurse was. S13MHT indicated she heard Patient #3 tell the charge nurse to call the DON if the charge nurse couldn't handle the situation, and she (Patient #3) "wanted something to be done now." S13MHT indicated she observed Patient #3's hand to be swollen. When S13MHT was asked by the surveyor what specifically had been reported to her by Patient #3, S13MHT indicated Patient #3 said "the boy came into the room and pulled something out her hand."

Based on observations and interview, the hospital failed to ensure patients received care in a safe setting as evidenced by having multiple risks for the potential of hanging, suffocation, and danger to self injury.

Findings:

Observation of the hospital physical environment on 08/07/17 at 10:45 a.m. and 11:45 a.m. revealed the following ligature risks and risks for suffocation and injury to self:

1) Room "a" revealed a wall air conditioner unit with an approximate 5 to 6 foot electrical cord attached. The unit had 32 slats with a space between and below each slat that would allow a string or cord to passed and tied that presented a ligature risk. Further observation revealed a wall-mounted television with a Linksys modum placed on the floor below the television. The modum had 2 cords connected to it, one plugged into the electrical outlet and one plugged into the wall telephone jack, that were each approximately 3 feet long. There were 4 uncontained electrical outlets in the room. The 4 electrical outlets and the 2 telephone jacks in the room had non-tamper-resistant screws. The light switch at the entrance of the room had non-tamper-resistant screws. The entrance door had hinges with spaces between each hinge that presented a ligature risk, and the screws were non-tamper-resistant. The attached bathroom (entered from within Room "a") door had hinges with spaces between each hinge that presented a ligature risk, and the screws were non-tamper-resistant. The sink and toilet plumbing was not contained.

2) Room "b" - entrance door has hinges with spaces between hinge that presents a ligature risk, and the screws are non-tamper-resistant. The entrance door lock has non-tamper-resistant screws. The window covering inside Room "b" has a screw protruding approximately ¼ inch that presents a risk for self-injury. The entrance door glass to Room "b" has non-tamper-resistant screws. The hall entrance door has locks with non-tamper-resistant screws.

3) The hall electrical outlet outside Room "b" has non-tamper-resistant screws as well as 1 wall button keypad and 1 keyed keypad at the exit door across from Room "p".

4) The two wall electrical outlets, silver panel, and 1 phone jack on the wall outside the nursing station had non-tamper-resistant screws. The fire alarm panel at the exit door to the outside area had non-tamper-resistant screws.

5) Outside area - a 6 feet plastic fence separating the hospital's outside area from the parking lot and public street had 4 trees with protruding limbs planted next to the fence that provided a means for elopement (admission criteria age was patients aged 30 to 50 years, male and female). The garbage can had a plastic liner. The corner of the outdoor area (building is L-shaped) isn't in full view when a staff member is in the seating area of the gazebo. Air conditioner units accessible to patients in the outdoor area have exposed pipes that present a ligature risk. The wooden bench in the gazebo has 2 open slats of wood as the back of the bench that present a ligature risk. The ceiling over the seating area has exposed beams and pipe covers that present a ligature risk. Fans hung in the gazebo have approximate 12 inch chains hanging from the fan. 3-4 feet of plastic wiring extends from an electrical outlet and a protruding water faucet that are on the outside wall to the right when exiting the building to the outdoor area from the door next to Room "c".

6) Interior wall next to the Room "c" has a button keypad and a keyed keypad with non-tamper-resistant screws.

7) Wall electrical outlet next to Room "d" has non-tamper-resistant screws.

8) Each patient's room (Rooms "e", "f", "g", "h", "i", "j", "k", "l") has an air conditioner unit that has an open plastic grill with enough space to pass a cord/string that presents a ligature risk. Each bed (2 beds in each room) has a bedside cabinet that is not attached to the wall that can be thrown as a weapon, and each bedside cabinet has removable drawers that can be removed and thrown. Each bedroom has a bathroom with a slanted top to the door and an approximate 5-6 inch space between the floor and the bottom of the door. This space allows tied sheets to be attached to the bathroom door and used as a ligature. During the observation S3QD indicated that patients are allowed in their rooms without supervision with the hall door closed. Each patient's room had a bed alarm attached to the wall outside the room that was removable by lifting it up, and the 2 screws holding it in place were non-tamper-resistant.

9) Room "m" had a radio with an approximate 6 feet cord and a phone charging with an approximate 3 feet cord, both presenting ligature risks. 2 electrical outlets on the wall below the cabinets had non-tamper-resistant screws. An unlocked cabinet above the sink had 7 plastic bags with condiments or utensils in them (risk for suffocation). Another unlocked cabinet above the sink had more than 4 plastic bags. The exit door from Room "m" to the outdoor area had 2 keyed keypads and 1 button key pad with non-tamper-resistant screws. The electrical outlet on the wall below the TV screen had non-tamper-resistant screws. The plexi-glass covering the TV had 10 non-tamper-resistant screws. The sink at the counter in Room "m" had a goose neck faucet with regular knobs which were a ligature risk.

10) Room "n" - door hinges had spaces between each hinge that presented a ligature risk. The hinges had non-tamper-resistant screws. The lock and door panel had non-tamper-resistant screws. The hall from Room "n" leading to the nursing home entrance had 2 electrical outlets with non-tamper-resistant screws. The 2 air conditioner units had open grills as described above related to the patient bedrooms that presented a ligature risk. The door fire alarm had non-tamper-resistant screws, and the key button pad and keyed pad at the entrance door to the nursing home had non-tamper-resistant screws. There was 1 fire alarm pad, 1 keyed keypad, and 1 button keypad at the exit door to the outdoor area with non-tamper-resistant screws.

11) Room "o" had 2 wall switches with non-tamper-resistant screws. The blind cords were hanging approximately 6-7 feet which presented a ligature risk. The air conditioner unit had open vents as described above.


In an interview during the above observations on 08/07/17 at 10:45 a.m., and 11:45 a.m., S3QD confirmed the above findings.

Based on record reviews and interview, the hospital failed to respond to and report to LDH's HHS a patient's allegation of abuse in accordance with Louisiana R.S. 40:2009.20 as evidenced by failure of the hospital to investigate a patient's allegation of assault and report the allegation to LDH's HSS within 24 hours of knowledge of the allegation for 1 (#3) of 1 report of an allegation of assault made to hospital staff.

Findings:

Review of the policy titled "Assessment and Reporting of abuse, Neglect, Exploitation, and/or Extortion of Youth and adults", presented as a current policy by S1ADM, revealed that clinical staff are to notify the Administrator/DON if abuse is suspected, and the Administrator/DON will call the regional Coordinator and inform of alleged abuse. Further review revealed the Administrator will notify the Chief Operating Officer prior to reporting. The facility must self-report internal allegations of abuse/neglect to maintain compliance with Louisiana R.S. 40:2009.20 which calls for reporting of knowledge of potential abuse incidents within 24 hours to either law enforcement or LDH. A final investigative report should incorporate a copy of the investigation conducted by the hospital which includes the following: a summary of the initial report; transcripts of interviews conducted with staff, patients, and other relevant witnesses; interview transcript with alleged perpetrator; copies of documents that provide evidence of the validity or lack thereof of the allegation; a report indicating the type and numbers of staff on duty for the unit at which the event allegedly occurred; conclusions reached by the administration (valid, invalid, unable to determine); a description of actions taken by the facility.

Review of Louisiana R.S. 2009.20 revealed that any person engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services, or any RN, licensed practical nurse, nurse's aide, 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 24 hours, submit a report to LDH or inform the local law enforcement agency of such abuse or neglect.

Review of LDH's "Hospital Abuse/Neglect Initial Report Instructions for Completing and Submitting Form HSS-HO-41" revealed that in accordance with Louisiana R.S. 40:2009.20, a health care facility must notify the LDH or the local law enforcement agency of any allegation of abuse or neglect occurring within the facility, within 24 hours of knowledge of the allegation.

In a telephone interview on 08/08/17 at 8:30 a.m. with S8LPC while S11LCSW was present, S8LPC indicated a charge nurse had reported in a morning report with staff that Patient #3 had reported that a MHT went into the bathroom and took something out of her hand that she wasn't supposed to have. S8LPC indicated the charge nurse reported that Patient #3 had claimed that the MHT had assaulted her in some way. S8LPC indicated she couldn't remember which charge nurse had reported this information to her. She further indicated she didn't know if the charge nurse was told this or if she had observed the alleged incident. S8LPC was asked by the surveyor if she was supposed to report this information to the Administrator. She indicated that S9RN, the former ADON, was in the meeting at the time, and she didn't know if he followed up to see if it had happened or if Patient #3 was delusional. S8LPC confirmed she didn't report the allegation of assault to the Administrator.

In an interview on 08/08/17 at 8:50 a.m., S1ADM indicated she had never been made aware of a report of an allegation of assault/abuse as documented above. She confirmed that no investigation had been conducted related to the allegation of assault. She confirmed that a report of the allegation of abuse had not been submitted to HSS in accordance with R.S. 2009.20 within 24 hours of knowledge by S8LPC.

In an interview on 08/09/17 at 8:25 a.m., S13MHT indicated when she came to work on the morning after the alleged incident had occurred, Patient #3 told her (S13MHT) what had happened. S13MHT further indicated Patient #3 said she wasn't going to worry about it, because she (Patient #3) was going to handle it with the charge nurse and DON. S13MHT indicated she saw Patient #3 talking with the charge nurse after her conversation with Patient #3, but she (S13MHT) didn't remember who the charge nurse was. S13MHT indicated she heard Patient #3 tell the charge nurse to call the DON if the charge nurse couldn't handle the situation, and she (Patient #3) "wanted something to be done now." S13MHT indicated she observed Patient #3's hand to be swollen. When S13MHT was asked by the surveyor what specifically had been reported to her by Patient #3, S13MHT indicated Patient #3 said "the boy came into the room and pulled something out her hand." S13MHT confirmed that she did not report Patient #3's allegation of abuse to the Administrator.

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

1) Failing to have a DON who was a licensed RN and responsible for the operation of nursing services, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. The hospital did not have a DON and ADON at the time of entrance for the survey conducted on 08/07/17 at 10:35 a.m.

See findings in tag A0386.

2) Failing to ensure the RN supervised and evaluated the nursing care for each patient as evidenced by:

a) The RN failing to accurately assess each patient's suicide risk for 4 (#1, #3, #4, #5) of 5 sampled patient records reviewed for RN assessment of suicide risk.

b) The RN failing to document an assessment of a patient with complaints of chest pain prior to transfer to an acute hospital's emergency department for 1 (#3) of 1 patient record reviewed with complaints of chest pain requiring transfer from a total sample of 5 patients.

c) The RN failing to document neuro checks as ordered by the physician for a patient who fell for 1 (#2) of 1 patient record reviewed with falls from a total sample of 5 patients.

d) The RN failing to assess and document a complete pain assessment during the initial admit assessment for 1 (#3) of 5 sampled patient records reviewed for pain assessment at the time of admission.

e) The RN failed to implement physician orders for lab work for 1 (#3) of 5 patient records reviewed for implementation of physician orders for labs from a total sample of 5 patients.

f) The RN failing to ensure the MHT observation sheets were complete and accurate for 3 (#2, #3, #5) of 5 sampled patient records reviewed for completion of accurate MHT observation records

See findings in tag A0395.

Based on interviews, the hospital failed to have a DON who was a licensed RN and responsible for the operation of nursing services, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. The hospital did not have a DON and ADON at the time of entrance for the survey conducted on 08/07/17 at 10:35 a.m.

Findings:

In an interview on 08/07/17, at 10:35 a.m., during the entrance conference, S2RN indicated she was the charge nurse at the Crowley campus (off-site) on this day, but she usually works as a charge nurse at Hospital A (main campus). She further indicated S9RN, who was the ADON at the Crowley campus, had "walked out last week," and currently there was no DON for Hospital A and the Crowley campus. S2RN indicated S3QD is the Acting ADON who is covering both campuses.

In an interview on 08/07/17 at 11:08 a.m., S3QD indicated she is the QD for both Hospital A and the Crowley campus. She further indicated she is not the Acting ADON, because she is a licensed practical nurse and not a RN.

In an interview on 08/07/17 at 12:45 p.m., S1ADM indicated S9RN, who was the ADON in Crowley, left last week. She further indicated the DON's last week to work was the previous week (week of July 31st), and the new DON isn't starting work for about 2 weeks. S1ADM indicated she had not notified LDH's HSS that the hospital did not have a DON or ADON in place at this time.

In an interview on 08/07/17 at 4:10 p.m. with S1ADM and S5RDCS present, S1ADM indicated S9RN turned in his resignation as ADON on 07/27/17 and "walked out" on 07/28/17. She further indicated the DON had turned in her resignation officially on 08/01/17, but she had been aware of her (DON) wanting to leave since 04/01/17. S1ADM indicated the DON agreed to stay on as DON until the hospital had their triannual recertification survey but stayed beyond that time until 08/01/17. S1ADM confirmed the hospital did not have a DON or ADON in place as of the time of this interview.

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care for each patient as evidenced by:

1) failing to accurately assess each patient's suicide risk for 4 (#1, #3, #4, #5) of 5 sampled patient records reviewed for RN assessment of suicide risk.

2) failing to document an assessment of a patient with complaints of chest pain prior to transfer to an acute hospital's emergency department for 1 (#3) of 1 patient record reviewed with complaints of chest pain requiring transfer from a total sample of 5 patients.

3) failing to document neuro checks as ordered by the physician for a patient who fell for 1 (#2) of 1 patient record reviewed with falls from a total sample of 5 patients.

4) failing to assess and document a complete pain assessment during the initial admit assessment for 1 (#3) of 5 sampled patient records reviewed for pain assessment at the time of admission.

5) failing to implement physician orders for lab work for 1 (#3) of 5 patient records reviewed for implementation of physician orders for labs from a total sample of 5 patients.

6) failing to ensure the MHT observation sheets were complete and accurate for 3 (#2, #3, #5) of 5 sampled patient records reviewed for completion of accurate MHT observation records.


Findings:

1) The RN failing to accurately assess each patient's suicide risk:

Review of the policy titled "Suicide/Homicide Risk Assessment", presented as a current policy by S1ADM, revealed that safety/homicide assessments are conducted at first contact with any subsequent suicidal/homicidal behavior, increased ideation, or pertinent clinical change. The nurse/therapist assesses risks and protective factors as indicated in the "Five Step evaluation and triage" or the "Homicide Assessment Five Step evaluation and triage. Further review revealed the chart "is intended to represent a range of risk levels and interventions, not actual determinations. One must always utilize clinical judgments. Categories are not intended to be final." The chart revealed the following:

Risk level:

High - multiple risk factors; psychiatric diagnosis with severe symptoms; acute precipitating event; with no protective factors; suicidality as potentially lethal suicide attempt made or persistent suicidal ideation with rehearsals. Notify psychiatrist of high risk level for further clarification.

Moderate - multiple risk factors with no modifiable risk; 1 or 2 protective factors; suicidal ideation with no plan or constant intent. Implement every 15 minute observation; monitor for changes in status.

Low - less than 2 risk factors and risks are modifiable; 3 or more protective factors; thoughts of dying with no plan or behaviors. Implement every 15 minute observation.

Not a clinical issue - frustration/stress; no significant clinical indication; more needed for suicidality. Not a clinical issue: implement every 15 minute observation.


Patient #1

Review of Patient #1's "Admit Nursing Assessment" documented on 07/25/17 at 12:15 p.m. revealed the reason for admission was gravely disabled, increased anxiety, decreased appetite, poor focus, feelings of hopelessness, helplessness, and worthlessness, and poor attention to hygiene and grooming. Review of her suicide risk level screen at admission revealed 5 risk factors were selected with 5 protective factors selected. Review of the suicide risk chart revealed the RN checked "not a clinical issue: implement every 15 minute observation." The RN's completion of the chart revealed no documented evidence whether the identified risk factors were modifiable. There was no clarification of the determination of "not a clinical issue" when the RN assessed Patient #1 to have multiple risk factors and 3 or more protective factors.

In an interview on 08/09/17 at 11:55 a.m. with S1ADM and S5RDCS present, S5RDCS confirmed the above findings.


Patient #3

Review of Patient #3's medical record revealed she was "Admit Nursing Assessment" documented on 03/21/17 at 5:07 a.m. revealed her reason for admission was delusions and paranoia. Review of the suicide risk and homicide/violence risk level screen completed at the time of admission revealed that no risk factors and protective factors were checked. The only check mark made by the RN on the form for both suicide and homicide sections was "not a clinical issue: implement every 15 minute observation." Review of Patient #3's medical record revealed the following risk factors could have been checked: widowed; current or past diagnosis of mood disorder or psychotic disorder (had diagnosis of Bipolar Disorder); chronic pain; and have at least 2 key symptoms of anxiety and insomnia (currently sleeps 2 hours).

In an interview on 08/08/17 at 7:35 a.m., S7RN confirmed her assessment of Patient #3's suicide risk was not accurate.

In an interview on 08/08/17 at 4:35 p.m., S5RDCS indicated the risk factors weren't accurately assessed by the RN at the time of admission. She confirmed no protective factors identified by the RN, and the RN didn't document supporting factors for the assessment level to be not a clinical issue.


Patient #4

Review of Patient #4's medical record revealed he was admitted on 03/13/17 with diagnoses of Bipolar Disorder, Depressed, severe with Psychosis, and Cocaine and Cannabis Abuse. Further review revealed he was PEC'd on 03/12/17 at 3:30 p.m. due to hearing persecutory voices, having suicidal and homicidal ideations, pulling a gun on his brother, and being dangerous to self and others. He was CEC'd on 03/14/17 at 5:55 p.m. due to being dangerous to others and gravely disabled.

Review of Patient #4's "Admit Nursing Assessment" completed on 03/13/17 at 4:20 p.m. revealed the reason for admission was the hospital reported he had command voices to harm himself and others, he was depressed, and he recently pulled a gun on his brother. Review of his suicide risk level screen revealed 3 risk factors were checked: single, widowed, divorced, or separated; history of suicide in immediate family; alcohol or heavy drug use. There was no documented evidence that the risk factors of current or past diagnosis of mood disorder or psychotic disorder and access to weapons were checked. Further review revealed no protective factors were checked. The RN scored Patient #4's suicide risk level as low risk, while the chart revealed multiple risk factors with a psychiatric diagnosis with severe symptoms and an acute precipitating event, no protective factors, and persistent suicidal ideation which would place a patient in the high risk category. Review of the homicide/violence risk level screen revealed 3 risk factors were checked with no documented evidence whether the risks were modifiable, no deterrent factors were checked, and the RN scored his homicide risk as low risk. Review of the chart revealed low risk had modifiable risk factors with 3 or more deterrent factors present and thoughts of anger and violence with no plan or behavior. The selections checked by the RN did not meet this criteria.

In an interview on 08/08/17 at 4:30 p.m., S5RDCS indicated she would have assessed Patient #4 as a moderate risk, because he had a plan but no intent. She further indicated the assessment didn't capture the protective factors.


Patient #5

Review of Patient #5's "Admit Nursing Assessment" completed on 07/28/17 revealed the RN assessed her suicide risk to be a moderate risk. Further review revealed the RN checked 4 risk factors with no documented evidence whether the risks were modifiable and no protective factors. Review of the moderate risk criteria revealed it included multiple risk factors with no modifiable risk, 1 or 2 protective factors, and suicide ideation with no plan or constant intent. There was no documented evidence that Patient #5 met the criteria of moderate risk, as no protective factors had been identified.

In an interview on 08/09/17 at 12:15 p.m. with S1ADM and S5RDCS present, S5RDCS confirmed the above findings.


2) The RN failing to document an assessment of a patient with complaints of chest pain prior to transfer to an acute hospital's emergency department:

Review of the policy titled "Early Response Intervention To Deteriorating Patient Condition/Change In Condition", presented as a current policy by S1ADM, revealed that an RN is immediately available as needed to provide bed side care and to conduct an assessment that enables the RN to recognize the fact that the patient may need emergency care and/or assistance.

Review of Patient #3's "Multi-Disciplinary Note" revealed an entry on 03/23/17 at 11:10 p.m. by S9RN that Patient #3 was complaining of burning chest pain. Further review revealed S12NP was notified, and transfer orders were given. There was no documented evidence of an assessment by S9RN that included vital signs during the 20 minutes prior to the arrival of the ambulance attendants.

Review of Patient #3's physician orders revealed a telephone order on 03/23/17 at 11:10 p.m. received by S9RN from S12NP to transfer Patient #3 to the acute care hospital by ambulance for evaluation of chest pain.

In an interview on 08/08/17 at 7:35 a.m., S7RN reviewed Patient #3's medical record and confirmed there was no documentation of an assessment by a RN at the time Patient #3 complained of chest pain and had to be transferred for evaluation.

S9RN, the RN who provided care during Patient #3's complaints of chest pain, was no longer employed and unable to be interviewed.


3) The RN failing to document neuro checks as ordered by the physician for a patient who fell:

Review of the policy titled "Fall Assessment/Re-Assessment And Precautions", presented as a current policy by S1ADM, revealed that 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 charge or primary RN will implement secondary fall prevention interventions and update the Fall Treatment Plan after a fall. He/she will contact the licensed independent practitioner for additional precautions which may include one-to-one observation in special cases or range of motion exercises for balancing and strengthening as applicable.

Review of Patient #2's multi-disciplinary notes revealed the following entries:

07/28/17 at 12:45 p.m. by S6RN - patient fell when coming out of her room; fell on her right knee when her right ankle gave out; patient suffered a mild abrasion to her tight knee; no other injuries noted. There was no documented evidence that vital signs were assessed and the abrasion was measured.

07/28/17 at 1:00 p.m. by S6RN - S4NP was notified with no new orders received.

07/30/17 at 11:20 a.m. by S6RN - patient called out from room and MHT found her on the floor; patient stated her right foot gave out, and she fell on her right side; no injuries noted; patient denies hitting head; S4NP notified and ordered neuro checks for 6 hours.

08/03/17 at 9:00 a.m. by S6RN - patient's room mate told staff that Patient #2 told her (room mate) that she (Patient #2) had fallen in the bathroom; patient was assessed and vitals were taken to make sure patient had no injuries. There was no documented evidence of vital sign results.

Review of Patient #2's physician orders revealed no documented evidence that a telephone order was documented when S4NP gave orders to do neuro checks for 6 hours on 07/30/17 at 11:20 a.m. There was no documented evidence that neuro checks were assessed at the time of the fall and for 6 hours after the fall. There was no documented evidence that an assessment of Patient #2's right foot/ankle was conducted after having 2 falls as a result of her right ankle/foot giving out.

Review of Patient #2's care for "High Risk For Falls" revealed no documented evidence that the care plan was revised with each fall and that additional interventions were put in place to prevent further falls.

In an interview on 08/09/17 at 12:00 p.m. with S1ADM and S5RDCS present, S5RDCS confirmed there was no documentation that the RN revised Patient #2's care plan after each fall and added interventions to prevent further falls.


4) The RN failing to assess and document a complete pain assessment during the initial admit assessment:

Review of the policy titled "Assessment Process", presented as a current policy by S1ADM, revealed that the admit nursing assessment includes a physical review of systems. Further review revealed the list of patient assessments to be included did not contain an assessment of pain.

Review of Patient #3's "Admit Nursing Assessment" completed by S7RN on 03/21/17 at 5:07 a.m. revealed an assessment of chronic pain. There was no documented evidence of a complete pain assessment that included a numeric or face scale score, the location of pain, the description of pain, the frequency of pain, and pain relief measures that were used (all included in the section under pain).

In an interview on 08/08/17 at 7:35 a.m., S7RN confirmed that her pain assessment for Patient #3 was incomplete.


5) The RN failed to implement physician orders for lab work:

Review of Patient #3's physician orders revealed an order on 03/21/17 at 2:30 p.m. to obtain a BMP in the morning. Review of the lab results revealed no documented evidence of results of a BMP that was ordered to be done on 03/22/17. Further review revealed a physician's order on 03/22/17 at 2:20 p.m. to do a BMP in the morning.

In an interview on 08/08/17 at 7:35 a.m., S7RN reviewed Patient #3's medical record and confirmed there was no evidence that a BMP had been drawn on 03/22/17 as ordered.


6) The RN failing to ensure the MHT observation sheets were complete and accurate:

Patient #2
Review of Patient #2's "Close Observation Check Sheet" documented by the MHTs on 07/31/17 revealed no documented evidence that it included the patient's location and the staff's initials from 3:00 p.m. through 3:45 p.m.

Patient #3
Review of Patient #3's "Close Observation Check Sheet" documented by the MHTs on 03/21/17 revealed no documented evidence that it included the patient's location and the staff's initials from 6:00 a.m. through 7:15 a.m. on 03/22/17.

Patient #5
Review of Patient #5's "Close Observation Check Sheet" documented by the MHTs on 07/31/17 revealed no documented evidence that it included the patient's location and the staff's initials from 3:00 p.m. through 3:45 p.m.

In an interview on 08/09/17 at 12:15 p.m. with s1ADM and S5RDCS present, S5RDCS indicated the patient's close observation sheets are supposed to have documentation for all times and be initialed by the person who is assigned to observe the patient.

Based on record reviews and interviews, the hospital failed to ensure drugs and biologicals were administered in accordance with the orders of the practitioner for 2 (#3, #4) of 5 patient records reviewed for medication administration from a total sample of 5 patients.

Findings:

Patient #3

Review of Patient #3's physician orders revealed a physician order on 03/23/17 at 1:30 p.m. to give an additional dose of K+ 40 meq now and 40 meq on 03/24/17 at 8:00 a.m. Further review revealed a clarification order documented on 03/23/17 at 2:45 p.m. to continue K+ 10 meq po BID with additional K+ 40 meq today and 40 meq on 03/24/17 at 8:00 a.m.

Review of Patient #3's MAR for 03/23/17 revealed no documented evidence that K+ 40 meq was administered on 03/23/17 at 1:30 p.m. as ordered to be given "now."

Review of Patient #3's nurses' notes revealed an entry on 03/23/17 at 11:10 p.m. by S9RN that Patient #3 was complaining of burning chest pain. Further review revealed S12NP was notified, and transfer orders were given.

Review of Patient #3's medical record revealed no documented evidence of documentation from the acute care hospital's emergency department visit.

Review of documentation from the acute care hospital's emergency department visit, requested during the survey by the surveyor, revealed Patient #3 was seen by the physician on 03/24/17 at 1:12 a.m. Her diagnosis was Atypical Chest Pain. Her K+ level was 3.7, and she was discharged with orders for Imdur 30 mg po, extended release, 1 tablet every morning.

Review of Patient #3's medical record revealed no documented evidence that S14MD, S4NP, or S12NP were notified of the order for Imdur from the emergency department physician.

In an interview on 08/09/17 at 9:50 a.m., S12NP indicated she had reviewed Patient #3's medical record and the emergency physician's note with her collaborating physician. She further indicated they determined Patient #3's K+ level of 3.7 would not have caused her symptoms of chest pain. S12NP confirmed the K+ 40 meq should have been given as ordered on 03/23/17 at 1:30 p.m., and there was no follow-up for the Imdur to be given as ordered by the emergency department physician.


Patient #4

Review of Patient #4's physician orders revealed an order on 03/13/17 at 2:30 p.m. to give Lisinopril 20 mg po every morning at 8:00 a.m.

Review of patient #4's MAR for 03/19/17 revealed no documented evidence that Lisinopril was administered as ordered at 8:00 a.m.

In an interview on 08/09/17 at 12:10 p.m. with s1ADM and S5RDCS present, S5RDCS confirmed there was no documented evidence that Lisinopril was administered as ordered on 03/19/17 at 8:00 a.m.

Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of Participation for 482.23 Nursing Services as evidenced by:

1) Failing to have a DON who was a licensed RN and responsible for the operation of nursing services, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. The hospital did not have a DON and ADON at the time of entrance for the survey conducted on 08/07/17 at 10:35 a.m. (see findings in tag A0386).


2) Failing to ensure the RN supervised and evaluated the nursing care for each patient as evidenced by:

a) The RN failing to accurately assess each patient's suicide risk for 4 (#1, #3, #4, #5) of 5 sampled patient records reviewed for RN assessment of suicide risk.

b) The RN failing to document an assessment of a patient with complaints of chest pain prior to transfer to an acute hospital's emergency department for 1 (#3) of 1 patient record reviewed with complaints of chest pain requiring transfer from a total sample of 5 patients.

c) The RN failing to document neuro checks as ordered by the physician for a patient who fell for 1 (#2) of 1 patient record reviewed with falls from a total sample of 5 patients.

d) The RN failing to assess and document a complete pain assessment during the initial admit assessment for 1 (#3) of 5 sampled patient records reviewed for pain assessment at the time of admission.

e) The RN failed to implement physician orders for lab work for 1 (#3) of 5 patient records reviewed for implementation of physician orders for labs from a total sample of 5 patients.

f) The RN failing to ensure the MHT observation sheets were complete and accurate for 3 (#2, #3, #5) of 5 sampled patient records reviewed for completion of accurate MHT observation records (see findings in tag A0395).

Based on record reviews and interview, the hospital failed to ensure each patient receive a psychiatric evaluation that contained a record of mental status that described 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 as evidenced by having no documented evidence that the patient's evaluation of mental status by the examiner included both a report by the patient and the observations of the examiner for 5 (#1, #2, #3, #4, #5) of 5 patients' psychiatric evaluations reviewed for documentation of mental status from a total sample of 5 patients.

Findings:

Review of the hospital "Psychiatric Evaluation" document revealed the mental status examination included the following choices to be checked by the examiner with no line/space for narrative documentation:

Appearance - choice of well-groomed, disheveled, inappropriate, physical impairment, bizarre;

Attitude - choice of cooperative, guarded, suspicious, uncooperative, belligerent;

Motor Activity - choice of calm, hyperactive, agitated, tremors/tics, lethargic;

Affect - choice of appropriate, labile, expansive, constricted, blunted, flat, sad, worrisome, apathetic;

Mood - choice of normal, depressed, anxious, euphoric, irascible;

Speech - choice of normal, delayed, soft, loud, slurred, excessive, pressured, incoherent, persevering;

Thought process - choice of intact, circumstantial, tangential, flight of ideas, loose associations.


Review of the Psychiatric Evaluation conducted for Patients #1, #2, #3, and #5 revealed the evaluation was conducted by S4NP. Review of Patient #4's Psychiatric Evaluation revealed it was conducted by S14MD. Review of all patients' Psychiatric Evaluations revealed no documented evidence that mental status assessment included the patient's report of mental status.

In an interview on 08/08/17 at 3:55 p.m., S4NP reviewed the above-listed psychiatric evaluations and confirmed the evaluations did not include an assessment as reported by the patients. She also confirmed that the evaluation didn't include what means were used to assess each patient's attitude, affect, mood, and thought process.

Based on record reviews and interview, the hospital failed to ensure each patient receive a psychiatric evaluation that contained an estimate of intellectual functioning, memory functioning, and orientation as evidenced by having no documented evidence of the means used by the examiner to determine the patient's intellectual and memory functioning and orientation for 5 (#1, #2, #3, #4, #5) of 5 patients' psychiatric evaluations reviewed for documentation of intellectual and memory functioning and orientation from a total sample of 5 patients.

Findings:

Review of the hospital "Psychiatric Evaluation" document revealed the choices to be selected by the examiner for orientation, intellectual functioning, and memory functioning were as follows:

Orientation - time, place, person, situation;

Memory - Immediate: intact, impaired; Recent: intact, impaired; Remote: intact, impaired;

General Fund Of Knowledge - intact, impaired;

Gross Estimate Of Intelligence - below average, average, above average.


Review of the Psychiatric Evaluation conducted for Patients #1, #2, #3, and #5 revealed the evaluation was conducted by S4NP. Review of Patient #4's Psychiatric Evaluation revealed it was conducted by S14MD. Review of all patients' Psychiatric Evaluations revealed no documented evidence of the means used by the examiner to determine the selected choices for orientation, intellectual functioning, and memory functioning.

In an interview on 08/08/17 at 3:55 p.m., S4NP reviewed the above-listed psychiatric evaluations and confirmed the evaluations did not include a description of how memory, orientation, and intelligence were determined.

Based on record reviews and interview, the hospital failed to ensure each patient receive a psychiatric evaluation that included an inventory of the patient's assets in descriptive, not interpretive fashion as evidenced by having check boxes to be selected for the patient's assets that were used for all patients that were not descriptive terms for 5 (#1, #2, #3, #4, #5) of 5 patients' psychiatric evaluations reviewed for documentation of patient assets from a total sample of 5 patients.

Findings:

Review of the hospital "Psychiatric Evaluation" document revealed the choices to be selected by the examiner for patient assets included the following: capable of individual living; motivated for treatment; intelligence; educated; marital support; community support; employment; family support; stable physical health; adequate finances; and 4 lines with "other" next to the line.

Review of the Psychiatric Evaluation conducted for Patients #1, #2, #3, and #5 revealed the evaluation was conducted by S4NP. Review of Patient #4's Psychiatric Evaluation revealed it was conducted by S14MD.

Review of the psychiatric evaluations of Patients #1, #2, and #5 revealed S4NP checked "motivated for treatment" as the only patient asset. There was no documented evidence that each patient's assets were documented in descriptive terms.

Review of Patient #3's psychiatric evaluation revealed S4NP checked "family support" as the only patient asset. There was no documented evidence that Patient #3's asset was documented in descriptive terms.

Review of Patient #4's psychiatric evaluation revealed that S14MD checked "capable of individual living" and "family support" as his assets. There was no documented evidence that the assets were documented in descriptive fashion.

In an interview on 08/08/17 at 3:55 p.m., S4NP confirmed that there above patients' assets were not stated in descriptive terms in the psychiatric evaluation.


In an interview on 08/08/17 at 3:55 p.m., S4NP reviewed the above-listed psychiatric evaluations and confirmed the evaluations did not include a description of how memory, orientation, and intelligence were determined.

Based on record reviews and interviews, the hospital failed to ensure that the written treatment for each patient included short-term and long range goals that are written as observable, measurable patient behaviors to be achieved as evidenced by having no documented evidence that short-term and/or long range goals were written as observable, measurable patient behaviors to be achieved for 5 (#1, #2, #3, #4, #5) of 5 patient records reviewed for treatment plan goals from a total sample of 5 patients.

Findings:

Review of the policy titled "Treatment Planning; Integrated/Multidisciplinary", presented as a current policy by S1ADM, revealed that the treatment plan includes defined problems and needs, measurable goals and objectives based on assessed needs, strengths and limits, frequency of care, treatment and services, facilitating factors and barriers, and transition criteria to lower levels of care. There was no documented evidence that policy addressed that the goals had to be written as observable, measurable patient behaviors to be achieved.

Patient #1
Review of Patient #1's treatment plan for Alteration In Health Maintenance revealed the LTG was written as "demonstrate an understanding of treatment regime to maintain medical condition at optimal level." The STG was written as patient "will maintain normal homeostasis ... throughout stay in hospital." There was no documented evidence that these goals were written as observable, measurable patient behaviors to be achieved.

Patient #2
Review of Patient #2's treatment plan for High Risk For Falls revealed the LTG was written as "consistently comply with activities that decrease risk." Review of the treatment plan for Alteration In Health Maintenance revealed the LTG was written as "demonstrate an understanding of treatment regime to maintain medical condition at optimal level." There was no documented evidence that these goals were written as observable, measurable patient behaviors to be achieved.

Patient #3
Review of Patient #3's treatment plan for nursing for Alteration Thought Process - Psychosis revealed the LTG was written as "have an improvement in thought processes within 14 days." Review of the treatment plan for nursing for Alteration In Health Maintenance revealed the LTG was written as "demonstrate an understanding of treatment regime to maintain medical condition at optimal level." Review of the treatment plan for nursing for High Risk For Falls revealed the LTG was written as "consistently comply with activities that decrease risk." Review of the treatment plan for recreational therapy services for Alteration Thought Process - Psychosis revealed the LTG was written as "increase ability to modify symptomatology of psychosis by increasing self-control, self-esteem, and/or functional ability within 14 days. There was no documented evidence that these goals were written as observable, measurable patient behaviors to be achieved.

Patient #4
Review of Patient #4's treatment plans revealed the following documentation of goals:
Potential For Self Harm: nursing LTG written as "be free from self-harm risk within 14 days; social services LTG written as "demonstrate an increased ability to manage issues related to risk for self-harm within 14 days"; recreational therapy services LTG written as "increase ability to modify symptomatology of self-harm by increasing self-control, self-esteem, and/or functional ability within 14 days";

Alteration Thought Processes - Psychosis: nursing LTG written as "have an improvement in thought processes within 14 days"; recreational therapy services LTG written as "increase ability to modify symptomatology of psychosis by increasing self-control, self-esteem, and/or functional ability within 14 days";

Alteration In Mood: Depression: recreational therapy services LTG written as "increase ability to modify symptomatology of depression by increasing self-control, self-esteem, and/or functional ability within 14 days";

Alteration In Health Maintenance: nursing LTG was written as "demonstrate an understanding of treatment regime to maintain medical condition at optimal level within 2 weeks";

High Risk For Falls: nursing LTG was written as "consistently comply with activities that decrease risk within 14 days."

There was no documented evidence that the above-listed goals were written as observable, measurable patient behaviors to be achieved.

Patient #5
Review of Patient #5's nursing treatment plan for Alteration In Health Maintenance revealed the LTG was written as "demonstrate an understanding of treatment regime to maintain medical condition at optimal level within 2 weeks." Review of the nursing treatment plan for High Risk For Falls revealed the LTG was written as "consistently comply with activities that decrease risk within 14 days." There was no documented evidence that the above-listed goals were written as observable, measurable patient behaviors to be achieved.

In an interview on 08/09/17 at 12:20 p.m. with S1ADM and S5RDCS present, S5RDCS confirmed the patient goals in the treatment plans were not being written as observable, measurable patient behaviors to be achieved.

Based on record reviews and interview, the hospital failed to ensure each discharged patient's medical record contained a discharge summary documented in accordance with the discharge time frames established by the hospital's policies and medical staff rules and regulations as evidenced by having discharge summaries completed more than 30 days after discharge for 2 (#3, #4) of 2 closed records reviewed for discharge summaries from a total sample of 5 patients.

Findings:

Review of the policy titled "Patients' Discharge Summary", presented as a current policy by S1ADM, revealed that the facility documents the patient's discharge information and formulates an authenticated Discharge Summary within 30 days following discharge.

Review of the Medical Staff Rules and regulations, presented as the current rules and regulations by S1ADM, revealed that a discharge summary shall be written or dictated on all medical records of patients hospitalized within 30 days of discharge.

Patient #3
Review of Patient #3's medical record revealed she discharged on 03/24/17. Review of her discharge summary documented by S14MD revealed the discharge summary was dictated on 06/21/17, transcribed on 06/22/17, and signed by S14MD on 06/23/17. The summary was signed 3 months after Patient #3 was discharged.

In an interview on 08/09/17 at 12:20 p.m. with S1ADM and S5RDCS present, S1ADM confirmed Patient #3's discharge summary wasn't completed within 30 days after discharge.

Patient #4
Review of Patient #4's medical record revealed he was discharged on 03/20/17. review of his discharge summary revealed it was dictated on 04/09/17, transcribed on 04/10/17, and signed by S14MD on 06/14/17, 86 days after discharge.

In an interview on 08/08/17 at 8:12 a.m., S1ADM confirmed Patient #4's discharge summary was not completed within 30 days after discharge.

Based on interviews, the hospital failed to ensure it had a qualified director of psychiatric nursing services as evidenced by not having a DON and ADON at the time of the entrance conference for the survey conducted on 08/07/17 at 10:35 a.m.

Findings:


In an interview on 08/07/17 at 10:35 a.m. during the entrance conference, S2RN indicated she was the charge nurse at the Crowley campus (off-site) on this day, but she usually works as a charge nurse at Hospital A (main campus). She further indicated S9RN, who was the ADON at the Crowley campus, had "walked out last week," and currently there was no DON for Hospital A and the Crowley campus. S2RN indicated S3QD is the Acting ADON who is covering both campuses.

In an interview on 08/07/17 at 11:08 a.m., S3QD indicated she is the QD for both Hospital A and the Crowley campus. She further indicated she is not the Acting ADON, because she is a licensed practical nurse and not a RN.

In an interview on 08/07/17 at 12:45 p.m., S1ADM indicated S9RN, who was the ADON in Crowley, left last week. She further indicated the DON's last week to work was the previous week (week of July 31st), and the new DON isn't starting work for about 2 weeks. S1ADM indicated she had not notified LDH's HSS that the hospital did not have a DON or ADON in place at this time.

In an interview on 08/07/17 at 4:10 p.m. with S1ADM and S5RDCS present, S1ADM indicated S9RN turned in his resignation as ADON on 07/27/17 and "walked out" on 07/28/17. She further indicated the DON had turned in her resignation officially on 08/01/17, but she had been aware of her (DON) wanting to leave since 04/01/17. S1ADM indicated the DON agreed to stay on as DON until the hospital had their triannual recertification survey but stayed beyond that time until 08/01/17. S1ADM confirmed the hospital did not have a DON or ADON in place as of the time of this interview.

Based on interview, the hospital failed to have available psychological services to meet the needs of the patients as evidenced by failing to have a psychologist on staff or contracted to provide psychological services when needed.

Findings:

In an interview on 08/09/17 at 9:30 a.m., S5RDCS indicated the hospital does not currently have a psychologist employed or contracted to provide psychological services when needed.