The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

LAFAYETTE GENERAL MEDICAL CENTER 1214 COOLIDGE AVENUE LAFAYETTE, LA 70503 Nov. 19, 2015
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on record review and interview, the hospital's governing body failed to ensure the prompt resolution of patient gievances and effective operation of the grievance process. This deficient practice was evidenced by failing to ensure a patient's allegation of abuse was promptly investigated and written notice provided to the complainant for 1 (#2) of 1 patient reviewed for grievances.

Findings:

Review of the hospital policy titled Patient Complaint and Grievance Policy, Policy Number: II-U, revealed in part:
I. Purpose: To establish a process for timely referral, prompt review, investigation and resolution of patient's complaints or grievances.
D. A Verbal Complaint: If a grievance cannot be resolved at the time of the complaint by staff present, if it is postponed for later resolution, if it is referred to other staff for later resolution, if it requires investigation, and/or if it requires further action for resolution.
C. Grievance Resolution Process
2. Upon receipt of a grievance, the Patient Representative shall confer with the patient and or patient representative within seven days of receipt of the grievance with the exception of complaints that endanger the patient (i.e., abuse or neglect). These abuse or neglect grievances shall be reviewed immediately given the seriousness of the allegations and the potential for harm to the patient.
3. Occasionally, a grievance is complicated and may require an extensive investigation. If the grievance will not be resolved within seven days of the receipt, or of the investigation is not or will not be completed within the initial seven days, the complainant should be informed that the facility is still working to resolve the grievance and that the facility will follow-up with a written response within 21 business days.

Review of the Hospital's Emergency Department notes for Patient #2 dated 10/21/15 revealed in part:
MD note: The patient presents following alleged sexual assault. The onset was 4 days ago. The location where the incident occurred was while involuntarily admitted to the psych facility. Circumstance: 3 assailant(s). Penetration: unknown. Type of injury: none. The character of symptoms is none. Additional History: Pt states that she was admitted involuntarily to LBHU. On the night of 10/17 she asked the staff for medication to help her rest. Upon awakening the next morning, she states she overheard 3 gentlemen (patients) hinting that they had had intercourse with her during the night. She states that when she confronted them, they became silent. She did not alert the staff, but states,"they were in on it too." She was released yesterday AM and went to her PMD today, who called authorities.

Review of a list of grievances provided by the hospital revealed there had been no grievances for 2015.

In an interview on 11/18/15 at 10:14 a.m. with S2RiskManager, she said Patient #2 was allegedly abused on 10/17/15 and she was made aware on 10/21/15. S2RiskManager said she was going to consider the incident as a grievance but the October quality assurance meeting had not been done yet because of a joint commission survey, but she would include the complaint. S2RiskManager said she had not spoken with Patient #2 about the incident. S2RiskManager said the incident was not counted as a grievance as of yet because she had not completed the investigation. S2RiskManager verified she had not sent the patient a letter within 7 days of the complaint as per the hospital policy. S2RiskManager said she had not followed the hospital ' s grievance policy.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on interview, observations and record review, the hospital failed to ensure patients identified at risk for harm to self or others were provided care in a safe setting as evidenced by:
1) failing to ensure staff did not lock patient's doors to their rooms while the patients were sleeping inside the locked room; and
2) failing to ensure the physical environment did not afford patients who had been identified as at risk for injury to themselves or others the opportunities for injury to themselves or others. This deficient practice had the potential to affect all 24 current psychiatric patients out of a total capacity for 24 psychiatric patients.

Findings:
1) failing to ensure staff did not lock patient's doors to their rooms while patients were sleeping inside the locked room.

In an interview on 11/18/15 at 10:14 a.m. with S2RiskManager, she said Patient #2's door to her room was locked from the outside that night of 10/17/15 as reported by the staff. She said the patients could open their doors from the inside. She said they lock the doors for the female patients sometimes because there were male patients on the units. She said it was not documented in the patients' charts when the doors were locked. She also said there was no policy for locking the patient's doors.

In an interview on 11/18/15 at 10:37 a.m. with S1Director, she said Patient #2 requested her door to her bedroom to be locked from the outside. S1Director said if a patient requested their door to be locked, the staff would lock the door but the patient was free to leave at any time. She said all of the doors could be opened from the inside when locked. She verified there was no policy for locking patients' doors. S1Director agreed if the patients wedged an object into the exterior key hole after the doors were locked the staff would not be able to unlock the doors from the outside.

In an interview on 11/18/15 at 3:30 p.m. with S9RN, he said when there were female patients on the hall with male patients the staff would sometimes lock the female patients' doors with a key to ensure the male patients could not enter.

In an interview on 11/19/15 at 5:21 a.m. with S6MHT, he said the staff locked the female patients' doors (from the outside with a key) at night so male patients could not walk into female patients' rooms.

2) Failing to ensure the physical environment did not afford patients who had been identified as at risk for injury to themselves or others opportunities for injury to themselves or others.

Observations on 11/18/15 from 8:55 a.m.-9:15 a.m. of the hospital's in-patient psychiatric unit revealed the following risks to safety:
1. Sink with elongated faucet and knob shaped protruding handles presented a potential ligature anchor point;
2. Room entry doors secured with 3 hinges separated widely enough to facilitate a potential ligature anchor point;
3. Hinges on room entry doors were fastened with screws that were not tamper resistant;
4. Base of faucet handle in the patient ' s in-room shower protruded presenting a potential ligature anchor point.

In an interview on 11/18/15 at 9:15 a.m. with S1Director, she confirmed all 12 patient rooms (2 beds in each room) were constructed with the same layout and equipped/furnished with the same fixtures, doors and hardware.

In an interview on 11/19/15 at 9:30 a.m. with S1Director she confirmed the physical environment findings referenced above potentially posed safety risks for the patient population receiving psychiatric treatment at the hospital. She confirmed the hospital's staff observed the patients every 15 minutes on both nights and days unless they were on increased levels of supervision.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on record review and interview, the hospital failed to report suspected abuse within 24 hours to the Louisiana Department of Health and Hospitals for 1 (#2) of 1 (#2) patients reviewed with allegations of abuse.

Findings:
A review was made of the hospital document titled Hospital Abuse/Neglect Initial Report. The top of the form had a statement to fax (fax number listed) the completed form to the Louisiana Department of Health and Hospitals within 24 hours of Awareness of Allegation.

Review of the Hospital's Emergency Department notes for Patient #2 dated 10/21/15 revealed in part:
MD note: The patient presents following alleged sexual assault. The onset was 4 days ago. The location where the incident occurred was while involuntarily admitted to the psychiatric facility. Circumstance: 3 assailant(s). Penetration: unknown. Type of injury: none. The character of symptoms is none. Additional History: Pt. states that she was admitted involuntarily to LBHU. On the night of 10/17/15 she asked the staff for medication to help her rest. Upon awakening the next morning, she states she overheard 3 gentlemen (patients) hinting that they had had intercourse with her during the night. She states that when she confronted them, they became silent. She did not alert the staff, but states,"they were in on it too." She was released yesterday AM and went to her PMD today, who called authorities.

In an interview on 11/18/15 at 10:14 a.m. with S2RiskManager, she said Patient #2 was allegedly abused on 10/17/15 on the psychiatric unit and she was made aware of the potential abuse on 10/21/15. S2RiskManager said she was aware the initial report should have been submitted to the state within 24 hours. S2RiskManager said the suspected abuse was not submitted to the state until 10/25/15.

In an interview on 11/19/15 at 7:48 a.m. with S1Director, she said when the hospital became aware of any allegations of abuse it was to be reported to the state within 24 hours.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on record review and interview, the hospital failed to ensure the use of restraints was used in accordance with a written modification to the patient's plan of care for 1 (#1) of 1 (#1) patients reviewed for restraints.

Findings:

Review of the hospital policy titled Medical/Surgical/Behavioral Seclusion revealed in part:
Care Plan modified to include change in condition and d/c of restraint or seclusion.

Review of the medical record for Patient #1 revealed he had been placed in restraints on 5/31/15 for aggressive behavior. Further review revealed Patient #1's care plan had not been updated to include the use of restraints.

In an interview on 11/19/15 at 9:15 a.m. with S1Director, she verified Patient #1 should have had a modification in his care plan to include the use of restraints.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record reviews, observations and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient as evidenced by:

1) the Registered Nurse failing to ensure mental health technicians were performing/documenting safety observation rounds in real time as evidenced by MHTs pre-populating the Safety Observation Rounds sheet 3 hours in advance for 14 (#4, #5, #R8, #R9, #R10, #R11, #R12, #R13, #R14, #R21, #R22, #R23, #R24, #R25) of 21 patients; not documenting safety rounds for 9 hours for 4 (#3, #R17, #R18, #R19) of 21 patients; and not documenting safety rounds for 5 hours and 15 minutes for 1 (#R16) of 21 patients; and

2) the RN failing to increase the level of supervision for a patient who had developed a new behavior of head banging and failing to document this new behavior in the patient's medical record for 1(Patient #5) of 3 (#3,#4,#5) current patient records reviewed; and

3) the RN failing to assess and document patient rounds every 2 hours on 5 (#R1, #R2, #R3, #R4, #R6) of 12 records reviewed for nursing assessments; and

4) The RN failing to review MHT documentation to ensure the patients' observation records documented the level of observation for 13 (#4, #R8, #R9, #R10, #R11, #R12, #R13, #R14, #R15, #R16, #R17, #R20 and #R25) of 21 current patients' records reviewed for documentation of levels of observation.

Findings:
1) The Registered Nurse failing to ensure mental health technicians were performing/documenting safety observation rounds in real time.
Review of the hospital policy titled Patient Rounding, Policy Number: V-A, revealed in part:
Rounds are to be made on the unit on all patients by the assigned nursing staff at a frequency of approximately every 15 minutes or more frequently as ordered for each 24 hour period.

In an observation on 11/19/15 at 4:30 a.m., S3RN, S8RN, S6MHT and S7MHT were working in the psychiatric hospital. Review of the documents titled Safety Observation Rounds revealed there were spaces to place initials of staff every 15 minutes to indicate the safety, location and activities of the patients. The observation times on the Safety Observation Rounds sheets began on 11/18/15 at 7:30 a.m. and continued until 11/19/15 at 7:15 a.m. Further review on 11/19/15 at 4:30 a.m. revealed the Safety Observation Rounds sheets were filled out through 7:15 a.m. (11/19/15) for 14 of the patients (#4, #5, #R8, #R9, #R10, #R11, #R12, #R13, #R14, #R21, #R22, #R23, #R24, #R25); 4 patients (#3, #R17, #R18, #R19) did not have any documented 15 minute checks since 7:00 p.m. the day before (11/18/15); and 1 patient (#R16) had not had a 15 minute check documented since 11:15 p.m. the night before (11/18/15).

In an interview on 11/19/15 at 5:05 a.m. with S8RN, he said he was the charge nurse on the night shift. He said he did not know that S6MHT and S7MHT were filling out the Safety Observation Rounds sheets for the whole shift ahead of time. S8RN said the 15 minute safety checks should have been documented as they were done, not later or ahead of time.

In an interview on 11/19/15 at 5:20 a.m. with S6MHT, he said the MHT's did safety rounds every 15 minutes. He said he filled out the 15 minutes checks on his patients ahead of time and placed them in the patients' charts because they were busy at the end of the shift.

In an interview on 11/19/15 at 5:44 a.m. with S7MHT, he said he had filled out the 15 minute sheets at 4:15 a.m. through 7:15 a.m. He said he had completed the observation sheets ahead of time because he needed to file it and he had other tasks to do.

In an interview on 11/19/15 at 7:48 a.m. with S1Director, she said the 15 minute rounds were to be charted in real time and not pre-charted or charted at the end of the shift. S1Director said charting ahead of time or several hours later were unacceptable.

2) The RN failing to increase the level of supervision for a patient who had developed a new behavior of head banging and failing to document this new behavior in the patient's medical record for 1(Patient #5) of 3 (#3,#4,#5) current patient records reviewed.

Review of Patient #5's medical record revealed an admission date of [DATE] and admission diagnoses of psychosis and depression. Further review revealed an admission order, dated 11/16/15 at 5:23 p.m. for placing the patient on suicide precautions for 72 hours with every 15 minute checks. Additional review revealed a Suicide Risk Assessment, dated 11/17/15 at 11:08 a.m. documenting that the Pt. had reported having thoughts of suicide due to his inability to cope with depression.


In an interview on 11/18/15 at 3:30 p.m. with S4Security, he indicated he had one patient (Patient #5) that he was "keeping close to him " because the patient was banging his head.

In an interview on 11/19/15 at 5:00 a.m. with S3RN, she indicated Patient #5 had begun banging his head yesterday (day shift of 11/18/15). She said one of the other patients had told her to check on Patient #5 because he was banging his head. She said she had observed the patient and he did have a reddened area on his forehead. S3RN indicated the patient had been on suicide precautions for the last 72 hours and the order had just expired. She confirmed he was not on enhanced supervision precautions such as 1:1 or line of sight observation. She said the patient has remained on every 15 minute observations since his admission on 11/16/15.

In an interview on 11/19/15 at 9:20 a.m. with S1Director, she indicated it was not the security personnel's duty to observe Patient #5. She said the MHTs were responsible for supervision of the patients and security personnel's duty was to maintain order.

In an interview on 11/19/15 at 8:05 a.m. with S1Director, she confirmed Patient #5 was not on enhanced supervision. S1Director indicated Patient #5 was a patient who would benefit from enhanced precautions/special observations due to the head banging behavior he was exhibiting.

In an interview on 11/19/15 at 8:15 a.m. with S1Director, she indicated the patient began head banging in group on 11/18/15 at around 3 p.m. She said direct care staff had been aware of the patient's head banging behavior.

An observation was made of Patient #5 on 11/19/15 at 7:40 a.m. He was noted to have a reddened area on his forehead. A staff member was overheard telling Patient #5 that he had to stop banging his head. This conversation was overheard during the above referenced observation.

Review of Patient #5's nursing entries revealed no evidence of documentation of the patient's new behavior of head banging that began on 11/18/15 during group therapy. Further review revealed no documented evidence of nursing staff increasing Patient #5's level of supervision/observation related to the patient's head banging behavior. Additional review revealed no documentation that the patient's physician had been notified of the above referenced new behavior.

Review of Patient #5's Safety Observation Round sheet for 11/18/15 at 7:30 a.m. -11/19/15 at 7:15 a.m. revealed the patient had remained on a Q 15 minute observation level and had not been increased to line of sight or 1:1 supervision.

In an interview on 11/19/15 at 9:44 p.m. with S2RiskManager, she confirmed there was no documentation in Patient #5's electronic medical record or in the paper portion of the patient's medical record of the patient's new behavior of head banging.

3) The RN failing to assess and document patient rounds every 2 hours on 5 (#R1, #R2,#R3,#R4,#R6) of 12 records reviewed for nursing assessments.

Review of the hospital policy titled Daily Documentation/Progress Record Documentation, Policy Number: V-J, revealed in part:
C. Q2H nursing rounds are documented in the nursing round section of Power Chart.

Patient #R1
Review of Patient #R1's medical record revealed an admission date of [DATE]. Further review revealed no documentation of nurses' rounding from 3:00 p.m. on 10/17/15 until 8:00 p.m. on 10/18/15.

Patient #R2
Review of Patient #R2's medical record revealed an admission date of [DATE]. Further review revealed no documentation of nurses' rounding from 5:00 p.m. on 10/17/15 until 7:00 a.m. on 10/18/15.

Patient #R3
Review of Patient #R3's medical record revealed an admission date of [DATE]. Further review revealed no documentation of nurses' rounding from 5:00 p.m. on 10/17/15 through 7:00 a.m. on 10/18/15.

Patient #R4
Review of Patient #R4's medical record revealed an admission date of [DATE]. Further review revealed no documentation of nurses rounding from 5:00 p.m. on 10/17/15 through 7:00 a.m. on 10/18/15.

Patient #R6
Review of Patient #R6's medical record revealed an admission date of [DATE]. Further review revealed no documentation of nurses rounding from 7:00 p.m. on 10/17/15 through 7:00 a.m. on 10/18/15.

In an interview on 11/18/15 at 12:20 p.m. with S1Director, she indicated nurses rounded and documented on pt's. Q 2 hours.
In an interview on 11/18/15 at 2:33 p.m. with S2RiskManager, she confirmed there was no Q 2 hour nurses rounding notes documented in the electronic medical records for Patients #R1, #R2,#R3,#R4 and #R6 for the dates referenced above.
In an interview on 11/19/15 at 5:30 a.m. with S3RN, she indicated the staff nurses rounded on patients every 2 hours and documented their rounds in the patients' medical records.

4) The RN failing to review MHT documentation to ensure the patient's observation records documented the level of observation.
Review of the hospital policy titled, "Precautions Levels and Record", Policy Number: V-E. revealed in part: I. Purpose: A precautionary measure and/or level that determines the minimum frequency of nursing observation and degree of independent activity within the behavioral milieu will be ordered for each patient. Nursing staff may increase the frequency of observation in response to changes in the patient's condition while waiting to discuss this with the physician. The minimum level of observation of all patients is every 15 minutes.
2. A precaution record will be documented on all patients who are placed on precautions for suicide, homicide, elopement, withdrawal or other reasons. Assessments will be made per physician's order or hospital policy: a. Each time a patient is placed on a precaution for suicide, homicide, elopement or other reasons, a Precautions record will be initiated by the licensed nursing staff in charge of the unit. b. Assessment of the patient will start at the time the order is initiated and continued until the order is discontinued. c. All staff documenting on the precautions record will sign and initial in the designated area. d. The precautions record covers a 24 hour period and a new form must be initiated daily, as needed. e. The staff member assigned to the patient must document all criteria which apply to the patient's location and status as applicable to the patient's level of precautions.
Review of the Hospital's Safety Observation Rounds Sheet revealed three choices for the level of patient supervision were listed at the top of the page. The correct level was to be circled by staff to indicate how frequently the patients were to be observed. The three choices were Q15 minutes, line of sight or 1:1.
Review of the Safety Observation Rounds sheets dated 11/18/15 for Patients #4, #R8, #R9, #R10, #R11, #R12, #R13, #R14, #R15, #R16, #R17, #R20 and #R25 did not have a level of observation selected to indicate how ofter they were being observed by the staff.
In an interview on 11/19/15 at 9:15 a.m. with S2RiskManager, she indicated level of observation should have been circled on the above referenced observation records. She confirmed the above referenced patient observation sheets were incomplete because the level of observation had been left blank.