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.

UNIVERSITY HEALTH CONWAY 4864 JACKSON STREET MONROE, LA 71202 Feb. 3, 2016
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0200
Based on record review and interview, the hospital failed to ensure all direct care staff received and remained current in training based on the use of nonphysical intervention skills for 3 (S5BHT, S16BHT, S17BHT) of 5 (S5BHT, S16BHT, S17BHT, S18BHT, S19BHT) direct care staff personnel records reviewed for crisis prevention intervention training. Findings:
Review of the personnel files for the following BHTs employed on the psychiatric unit revealed no documented evidence of current CPI (Crisis Prevention Intervention) training. CPI was the program of choice for this hospital.
S5BHT, CPI training certificate expired 05/02/15.
S16BHT, CPI training certificate expired 08/31/15.
S17BHT, CPI training certificate expired 10/31/15.
In an interview on 02/01/16 at 4:00 p.m. with S5BHT, he revealed on 01/18/16, he had to use CPI techniques to restrain patient #1. Further interview with S5BHT revealed he had taken CPI training in the past, but his certification had expired.
In an interview on 02/02/16 at 9:00 a.m. with S1Manager, she confirmed that all staff working on the psychiatric unit should have current CPI training. She reviewed the personnel file for S5BHT and confirmed he did not have current CPI training. She stated she was unaware of this and S15BHT Supervisor was responsible for ensuring that all BHTs have current CPI training.
In an interview on 02/03/16 at 1:30 p.m. with S15BHT Supervisor, he revealed he was responsible for ensuring all BHTs had current CPI training. He confirmed S5BHT did not have current CPI training. He further confirmed there were other BHT staff who had expired CPI training. When asked why the staff did not have current CPI training, he stated they must have missed the training classes.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on record review and interview, the hospital failed to provide the patient with a written notice of its decision regarding grievances that contains the steps taken on behalf of the patient to investigate the grievance and the results of the grievance process for 1 of 1 (Patient #1) grievances reviewed.
Findings:

Review of the hospital policy titled Patient Grievance/Complaint Policy and Procedure (review date of 10/17/14) revealed a written response will be provided after the grievance is resolved and will include steps taken to investigate and the results of the investigation.

Review of a report titled Complaint/Grievance Detail revealed that on 01/19/16, patient #1's aunt called S7Patient Advocate and stated that three orderlies jumped on the patient last night (01/18/16) and beat him up. The patient thought his shoulder was broken. The report further stated that the patient's aunt was very concerned and would like this looked into.

On 02/02/16 at 10:30 a.m., interview with S1Manager revealed that on 01/20/16, she notified University Police of the abuse allegation regarding patient #1. S1Manager stated that she did not interview the staff involved or the patient regarding the incident, but was leaving it to the police to investigate. When asked what the police's investigation determined, she stated that she has not heard back from them.

On 02/02/16 at 12:00 p.m., interview with S7Patient Advocate revealed that she received a verbal grievance from patient #1's aunt on 01/19/16. She stated that when she receives a grievance, she emails the director of the unit involved and they are responsible for performing the investigation. She further revealed that she emailed S1Manager on 01/19/16 regarding the allegation of abuse with patient #1. She stated that she mails the response letter to the patient/family member after she receives an email from the unit manager indicating the investigation is complete.

S7Patient Advocate provided copies of the final response letters mailed to patient #1 and his family member who filed the grievance. She confirmed that the written response letter did not indicate the steps taken to investigate the grievance or the results of the grievance process. Further review of the response letter revealed it stated that the investigation was completed on 01/22/16. At that time, interview with S7Patient Advocate revealed that she did not realize that University Police was conducting this investigation and that it had not been completed as of the date of the response letter.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation and interview, the hospital failed to ensure that patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for patients admitted to the acute care psychiatric unit. There were currently 25 patients receiving treatment at the time of the observations. Findings:

On 02/01/16 at 1:20 p.m., the following observations of patient rooms were made on the acute care psychiatric unit:

a. Room entry door and inside bathroom doors with 3 hinges with an area between the hinges that were a ligature risk.
b. Room entry door and inside bathroom doors with rigid fixed paddle handles pointing downward that were (non-anti-ligature).
c. The toilet in room (g) had an exposed flush valve that was a ligature risk.
d. All bathroom sinks had paddle lavatory faucet handles (non-anti-ligature).
e. All bathrooms had showers that had a single control knob that was (non-anti-ligature).
f. Rooms (a, b, c, d, e, e, f, g, h, i, and j) had two uncovered exposed red emergency outlets on the wall by the head of each bed. Rooms (k, l, m, n, o, and p) had one uncovered exposed red emergency outlets on the wall by the head of each bed that were a safety threat of electrical shock.

Interview on 02/01/16 at 1:25 p.m. with S12BHT confirmed there were 8 patients currently on close observations. When surveyor asked S12BHT how he was monitoring the patients on close observation who were at the time lying in their rooms, in their beds with the room door closed, S12BHT stated that he looks into the room through the (approximately 8 inch by 8 inch) window in the door. S12BHT verified with this surveyor that you could only observe the lower extremities of the patient lying in bed.

An interview was conducted with S1Manager on 02/01/16 at 1:45 p.m. S1Manager confirmed the above observations were safety risks for the patients in the psychiatric unit.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure all allegations of abuse were immediately investigated and timely reported to the appropriate state agency, Department of Health and Hospitals, for 1 (Patient #1) of 1 patients' records reviewed with an allegation of abuse from a total sample of 8.
Findings:

Review of the hospital policy titled, Self-Reporting Process for Allegations of Abuse/Neglect Involving Employees (no policy number), revealed in part: All allegations of abuse and/or neglect made by a patient or visitor while at this hospital shall be immediately reported by the staff member who is made aware of the allegation to the hospital administrator/administrator on call. The hospital administrator (or designee) shall immediately take action to ensure the safety of the individual whom is suspected to be abused or neglected and all other patients in the immediate area. The hospital administrator (or designee) shall report the allegation of abuse/neglect to the Department of Health and Hospitals Health Standards Section; the DHH Hospital Abuse/Neglect Initial Report form shall be completed and faxed with 24 hours of the facility having knowledge of the allegation. Investigation, including interviewing of individual(s) making the allegation, staff involved, witnesses or any other persons of interest shall be conducted by the administrator (or designee). University police may be contacted for assistance. Note: the facility has knowledge of the allegation when the first staff member becomes aware of the potential abuse or neglect.

Review of the medical record for patient #1 revealed he was admitted on [DATE] with diagnoses including unspecified psychosis and alcohol use disorder. Review of the nurses notes dated 01/18/16 at 5:44 p.m. revealed patient uncooperative, cursing staff, being aggressive- hitting and kicking, and unwilling to be directed. Staff used CPI techniques. Review of the nurses notes dated 01/18/16 6:10 p.m. revealed patient at medication window complaining of discomfort to left shoulder. He thinks it is broken. Paged physician.

Review of an Occurrence Report dated 01/19/16 at 11:01 p.m., completed by S10RN, revealed on 01/17/16 at 5:44 p.m., patient #1 was in an altercation with BHT staff members who used CPI techniques. Patient complained that his left shoulder was broken about 30 minutes after the altercation.
Review of a report titled Complaint/Grievance Detail revealed that on 01/19/16, patient #1's aunt called S7Patient Advocate and stated that three orderlies jumped on the patient last night (01/18/16) and beat him up. The patient thought his shoulder was broken. The report further stated that the patient's aunt was very concerned and would like this looked into.

Review of the Hospital Abuse/Neglect Initial Report submitted to DHH, dated 01/20/16, revealed that patient #1 became agitated and violent towards staff. Staff reported using CPI techniques during an altercation with the patient, the patient's aunt reported that the staff beat her nephew up. The allegations have been reported to local law enforcement and in the process of being investigated. Patient claimed shoulder was broken.

On 02/02/16 at 10:30 a.m., interview with S1Manager revealed that she received an email from S7Patient Advocate on 01/19/16 regarding patient #1's aunt stating that the patient was beat up by three orderlies the night of 01/18/16. S1Manager stated that she talked to the nurse (S10RN), who worked the evening shift of 01/18/16, and she stated that the BHTs used CPI techniques to calm patient #1 down. S1Manager stated that she discussed with S10RN that an occurrence report should have been completed the night of the incident. She further stated that an occurrence report was completed on 01/19/16.

Further interview with S1Manager at that time revealed that on 01/20/16, she notified University Police of the abuse allegation regarding patient #1. S1Manager stated that she did not interview the staff involved or the patient regarding the incident, but was leaving it to the police to investigate. When asked what the police's investigation determined, she stated that she has not heard back from them.

On 02/02/16 at 12:00 p.m., interview with S7Patient Advocate revealed that she received a verbal grievance from patient #1's aunt on 01/19/16. She stated that when she receives a grievance, she emails the director of the unit involved and they are responsible for performing the investigation. She further revealed that she emailed S1Manager on 01/19/16 regarding the allegation of abuse with patient #1.

On 02/02/16 at 12:50 p.m., interview with S8Compliance Officer revealed that she also received an email from S7Patient Advocate on 01/19/16 regarding patient #1's aunt complaint that the patient was beat up by three orderlies. She stated she read the email, but it didn't register that it was an abuse allegation. S8Compliance Officer stated on 01/20/16, their sister hospital called to ask if the Hospital Abuse/Neglect Initial Report had been completed and submitted to DHH because they also receive copies of the occurrence reports and had seen the occurrence report regarding patient #1. S8Compliance Officer stated at that time, they realized it was an allegation of abuse and notified University Police to conduct an investigation. She stated that the hospital does not conduct their own investigations regarding abuse/neglect. S8Compliance Officer further stated that the Hospital Abuse/Neglect Initial Report was not initiated until 1/20/16, because that is when the hospital first realized that it was an allegation of abuse.

On 02/02/16 at 3:40 p.m., interview with S10RN revealed that she was working the evening shift on 01/18/16. She stated that patient #1 did not want to follow the rules of the unit and fell to the floor in his door way. She stated that she told two BHTs to get the patient off of the floor and bring him to the dayroom. At that time, the patient began kicking and hitting and three BHTs had to use CPI techniques to calm the patient down. S10RN stated that about 30 minutes later, the patient came to the nurses station stating that the staff broke his shoulder. S10RN notified the physician, who ordered x-rays. S10RN further stated that later that night, the patient's family member called stating that the BHTs had beat up the patient. S10RN stated that she did not report this allegation of abuse to anyone. She further stated that she did not complete an occurrence report the night of the incident, because she did not know she was supposed to do that.

On 02/03/16 at 4:40 p.m., interview with S20Administrator confirmed that an investigation of the incident with patient #1 was not immediately initiated and DHH was not notified within 24 hours after the allegation.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the hospital failed to ensure the registered nurse supervised and evaluated the care provided to patients on the acute care psychiatric unit as evidenced by:

1. The Registered Nurse failing to ensure visual contact was maintained as ordered and per hospital policy for 6 (Patient #2, Patient #4, Patient #R1, Patient #R2, Patient #R3, Patient #R4) of 8 sampled patients who were admitted to the hospital's acute care psychiatric unit and ordered to be on a "close observation" observational status.

2. The Registered Nurse failing to ensure patients on close observation levels were not required to spend most of their time in the day room for staff convenience.

Findings:

1. Failing to ensure visual contact was maintained as ordered for patients (Patient #2, Patient #4, Patient #R1, Patient #R2, Patient #R3, Patient #R4) who were admitted to the hospital's acute care psychiatric unit and ordered to be on a "close observation" observational status.

Review of the hospital policy titled Observation Levels, revised 11/15, revealed in part: 3) Close Observation. a) The patient is maintained within the visual contact of the staff at all times except while in bed during the sleeping hours. During this time close observation may be accomplished by a staff member continually rotating between not more than four contiguous rooms unless otherwise specifically by physician order or as determined by the RN.

Observation on 02/01/16 at 1:20 p.m. revealed Patient #2, Patient #4, Patient #R1, Patient #R2, Patient #R3, and Patient #R4, lying in their beds in their rooms with the door to the patients room closed. The patients were unsupervised and not within visual contact of staff at the time of this observation. There were also multiple ligature and safety risks in the patient rooms that were not visible through the window in the door.

Interview on 02/01/16 at 1:25 p.m. with S12BHT confirmed there were 8 patients currently on close observations. When surveyor asked S12BHT how he was monitoring the patients on close observation who were at the time lying in their rooms, in their beds with the room door closed, S12BHT stated that he looks into the room through the (approximately 8 inch by 8 inch) window in the door. S12BHT verified with this surveyor that you could only observe the lower extremities of the patient lying in bed.

S12BHT further stated that the staff tries to get all the patients to the day room, but some patients refuse and remain in their rooms. S12BHT also stated that there is usually 2 staff assigned to each hall. One staff member will be assigned to the hall and the other staff member will monitor the close observation patients.

Review of the clinical record on 02/02/16 for Patient #2 revealed the patient was admitted on [DATE] with a diagnosis of Bipolar Disorder. Review of the physicians orders dated 01/29/16 revealed an order for close observation.

Review of the clinical record on 02/02/16 for Patient #4 revealed the patient was admitted on [DATE] with a diagnosis of Schizoaffective Disorder. Review of the physicians orders dated 01/28/16 revealed an order for close observation.

Review of the clinical record on 02/02/16 for Patient #R1 revealed the patient was admitted on [DATE] with a diagnosis of Major Depressive Disorder. Review of the physicians orders dated 01/30/16 revealed an order for close observation.

Review of the clinical record on 02/02/16 for Patient #R2 revealed the patient was admitted on [DATE] with a diagnosis of Unspecified Psychosis disorder. Review of the physicians orders dated 01/31/16 revealed an order for close observation.

Review of the clinical record on 02/02/16 for Patient #R3 revealed the patient was admitted on [DATE] with a diagnosis of Acute Stress Disorder. Review of the physicians orders dated 01/31/16 revealed an order for close observation.

Review of the clinical record on 02/02/16 for Patient #R4 revealed the patient was admitted on [DATE] with a diagnosis of Unspecified Psychosis Disorder. Review of the physicians orders dated 01/31/16 revealed an order for close observation.

Interview on 02/03/16 at 11:50 a.m. with S14Physician revealed that everyone admitted to the psychiatric unit is placed on close observation level. The patients are to be seen by the physician every day and re-evaluated for their observation level. S14Physician further stated that close observation meant direct visual contact in line of sight of staff outside of quiet time, but he was unaware of the specifics of the hospitals policy.


2. Failing to ensure patients on close observation levels were not required to spend most of their time in the day room for staff convenience.

Observations on 02/01/16 at 9:45 a.m. and 2:30 p.m. revealed all patients on the psychiatric unit who had physician orders for close observation levels were in the day room.

On 02/01/16 at 2:00 p.m., interview with S1Manager revealed that around 2:30 p.m. every day, the BHTs bring all patients who are on close observation levels to the day room. She stated that they are all put in one location so it is easier for staff to monitor them.

On 02/01/16 at 3:15 p.m., interview with S4BHT revealed that staff brings all of the patients who are on close observation levels to the day room at shift change every day, around 2:30 p.m. She stated it is easier for staff to watch them during the shift change. When asked what staff does if patients want to remain in their rooms, she stated "we make them come".

On 02/01/16 at 4:00 p.m., interview with S5BHT revealed that the unit rules are that all patients on close observations go to the day room from 2:30 p.m. until 6:15 p.m. every day so they can be watched. He further revealed that the patients are allowed to go back to their rooms until 8:00 p.m., then they come back to the day room and stay until 9:30 p.m. S5BHT stated that the patients are in the day room so late that they are falling asleep at the tables in the day room and asking to go back to their rooms. He stated that they cannot let the patients go back to their rooms because there is not enough staff to watch them.

Further interview with S5BHT at that time revealed that he was involved in an incident where CPI techniques had to be utilized on Patient #1. He stated that the staff was trying to get Patient #1 (who was on close observation level) to the day room on the evening of 01/18/16. The patient did not want to go to the day room and he began kicking and hitting at the staff, at which time the staff had to physically restrain the patient.

On 02/02/16 at 10:00 a.m., interview with S6BHT revealed that patients on close observation levels are forced to stay in the day room for most of the day. He stated that at times, he has had six to eight patients on close observation status that he has to watch. S6BHT stated that he takes them as a group to the restroom. Each patient uses their own restroom and he stands on the hall waiting for them to exit their rooms to go back to the day room. S6BHT stated that the patients complain stating "What did I do?" and "Why can't I go to my room like the other patients do?", referring to the patients on routine (every 15 minute) observations who are allowed to freely ambulate on the unit.

On 02/02/16 at 3:00 p.m., interview with S9BHT revealed that the patients on close observation levels are required to spend most of their time in the day room because there is not enough staff to watch them if they go to their rooms. S9BHT further revealed that he was involved in an incident with Patient #1 in which CPI techniques were used on the patient. He stated that he was working the evening shift on 01/18/16 and the patient walked out of the day room to his room. He stated that the patient was on close observation status so he had to stay in the day room to be watched by staff. The patient stated that he did not want to go to the day room and then the patient began to kick and hit at staff. He indicated that CPI techniques were used and the patient was returned to the day room.

On 02/03/16 at 2:30 p.m., interview with S13Social Worker revealed that he was aware of the incident that occurred with patient #1 on 01/18/16 in which CPI techniques were used on the patient. He stated that the patient did not like to get into big groups or go into the day room. He further stated that it was not therapeutic for staff to force him to spend most of his days in the day room, but due to limited staff, that had to occur.

Review of Patient #1's nurses notes dated 01/21/16 at 4:01 p.m. revealed patient refusing to come to dayroom or hall way. Insistent on remaining in his room out of the view of staff. Continues to be undirectable. Escorted to day room with BHTs under each arm. Patient yelling, cursing, kicking, hitting at staff. Will give PRN (as needed) medication.