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.

OCHSNER MEDICAL CENTER 1516 JEFFERSON HWY NEW ORLEANS, LA 70121 June 27, 2012
VIOLATION: QUALIFIED EMERGENCY SERVICES PERSONNEL Tag No: A1112
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure a registered nurse (RN) assigned the nursing care of each patient to other nursing personnel according to the needs of the patient and the qualifications and competence of the available nursing staff as evidenced by the RN delegating the one-to-one observation of patients under a physician's emergency commitment (PEC) to Emergency Department Technicians who had not received training and had not been assessed for competency in crisis prevention and interventions for 1 of 1 sampled Emergency Department Technician personnel file reviewed from a total of 11 Emergency Department Technicians employed (S28). Findings:

Review of the emergency room record for Patient #4 revealed the patient arrived at the emergency room on [DATE] at 1810 (6:10 p.m.) with a chief complaint of suicide attempt. The record revealed the patient had a physician emergency commitment at 7:15 p.m.
Review of the physician's orders dated/timed 06/24/12 at 1924 (7:24 p.m.) revealed Direct Psychiatric Observation was ordered.
Review of the Precautionary Measures Guide to Risk Sitting Flowsheet revealed that S28 documented direct visual contact for Patient #4 from 7:15 p.m. to 2245 (10:45 p.m.).

Review of the personnel record for S28 revealed S28 was employed as an Emergency Department Technician on 04/09/12. Review of the clinical job duties revealed no documented evidence that S28 had received training or a competency assessment for crisis prevention or crisis intervention. There was no documented evidence of any training or competency evaluation for dealing with psychiatric patients requiring direct observation, or crisis intervention/prevention.

On 06/27/12 at 1:40 p.m., the Assistant Vice President of Nursing, S5, was interviewed. After reviewing the personnel record for S28, she confirmed there was no documentation of any training or competency assessment for crisis prevention/intervention. S5 stated S28 was employed in April and had 6 months to complete the CPI (Crisis Prevention Intervention)training.

On 06/27/12 at 1:45 p.m., the Emergency Department Director, S3 was interviewed. After reviewing the emergency department record for Patient #4, S3 confirmed that S28 had provided direct psychiatric observation for Patient #4, who was under a PEC for a suicide attempt. S3 confirmed S28 had been assigned direct psychiatric observation prior to completion of crisis prevention/intervention training and competency assessment.
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to: 1) develop and implement a system to ensure that patients who were treated in the emergency department (E.D.) could designate a representative to exercise the patient's rights in developing and implementing the patient's plan of care. This resulted in a patient being transferred from the E.D. to another inpatient facility approximately 7 hours' drive away without the patient's family being notified prior to transfer for 1 of 3 patients' records reviewed who were transferred to another inpatient facility from a total of 12 sampled patients (#2) and 2) follow the hospital policy for notifying a patient's family member when a patient on the psychiatric unit was discharged to the E.D. for treatment for 1 of 2 patients' records reviewed who were transferred/discharged to another unit for treatment from a total sample of 12 patients (#2). Findings:

1) Develop and implement a system to ensure that patients who were treated in the E.D. could designate a representative to exercise the patient's rights in developing and implementing the patient's plan of care:
Review of Patient #2's medical record revealed he was a [AGE] year old male who presented to the E.D. on 07/19/11 at 9:58am from the hospital's psychiatric unit for treatment. Review the E.D.'s "History Of Present Illness" revealed he presented for evaluation of a single episode of vomiting with a systolic blood pressure of 95 mm Hg (millimeters mercury).

Review of Patient #2's medical record revealed a Physician Emergency Certificate (PEC) was completed on 07/19/11 at 1930 (7:30pm) due to Patient #2 being dangerous to self and gravely disabled.

Review of the E.D. "Nursing Notes" and the "Medication Record" revealed the following documentation:
07/19/11 at 1826 (6:26pm) - psychiatry in patient's room with family members and sitter at doorway;
07/19/11 at 2020 (8:20pm) - resting quietly with sitter at bedside;
07/19/11 at 2211 (10:11pm) - resting quietly with sitter at bedside;
07/19/11 at 2230 (10:30pm) - Risperdal 1 mg (milligrams) administered orally;
07/20/11 at 0000 (12:00am) - patient calm, resting comfortably in bed with the sitter at bedside and security outside room;
07/20/11 at 0005 (12:05am) - Ativan 2 mg administered orally for anxiety;
07/20/11 at 0214 (2:14am) - patient sleeping, calm, sitter at bedside, security at room, awaiting transport to new facility.
Review of the entire E.D. record revealed no documented evidence that Patient #2's family was present after 6:26pm on 07/19/11.

Review of Patient #2's "Disposition" revealed the nurse documented on 07/20/11 at 1:27am that Patient #2 was transferred to Hospital A. Further review revealed that Patient #2's valuables were with the patient, the risks, benefits, and alternatives of the transfer were explained to the patient (who had been given Ativan 1 hour and 22 minutes prior to this time), and informed consent was obtained (Ativan is used to treat anxiety and can cause sedation, drowsiness, amnesia, and disorientation).

Review of Patient #2's "Patient Transfer Documentation" revealed no documented evidence that Patient #2 or his family member had signed acknowledgement of, consent to, or refusal of transfer as evidenced by the line labeled "Signature of patient or legally responsible individual signing on patient's behalf" being void of writing.

Review of the entire medical record revealed no documented evidence that Patient #2's family was notified of his transfer to Hospital A which was located about 7 hours by car from the transferring hospital.

In a face-to-face interview on 06/25/12 at 10:45am, Director of E.D. S3 indicated a report prior to transferring a minor patient was given to a family member, but no report was given to an adult patient's family member. She further indicated that the E.D. did not have a process in place or a document in the E.D. for a patient to sign giving consent to discuss their care with a patient's family member. S3 indicated if a patient requested a telephone to call their family member, the patient's request would be granted, but the E.D. did not ask patients if they wanted to notify family members of their transfer. She further indicated that, since Patient #2 did not request a telephone to contact a family member, Patient #2's family member was not notified of his transfer.

In a face-to-face interview on 06/27/12 at 9:50am, Director of E.D. S3 indicated if a patient's (who was PEC'd or CEC'd -Coroner's Emergency Certificate) family member was present at the time of transfer, the family member could sign the transfer consent. She further indicated that she didn't think the physician would approach the patient who was PEC'd or CEC'd to get a transfer consent signed. S3 indicated it was not hospital practice to notify a patient's family member when a patient was transferred to another facility if they were not present at the hospital. She further indicated that this practice was based on the patient's right to privacy and HIPAA (Health Insurance Portability and Accountability Act). During the interview S3 indicated the PEC had documentation that read "The director of the treatment facility shall notify the patient's nearest relative, if known, or designated responsible party, if any, in writing, of the patient's admission by emergency certificate as soon as reasonably possible".

Review of the hospital's policy titled "Patient Rights and Responsibilities", number OMC.PTREL.001, issued 06/11, and presented by Performance Improvement (PI) Manager S1 as a current policy, revealed, in part, "...4. The patient has the right to understandable information on his / her health status, treatment and progress in order to make decisions. ... 7. The patient has a right within legal guidelines to have a guardian, next-of-kin or legal designee exercise patient rights when unable to do so...".

2) Follow the hospital policy for notifying a patient's family member when a patient on the psychiatric unit was discharged to the E.D. for treatment:
Review of Patient #2's medical record revealed he was a [AGE] year old male admitted from the E.D. to the inpatient psychiatric unit on 07/18/11 at 8:15pm with the diagnosis of Psychosis. Further review revealed a PEC was signed on 07/17/11 at 5:45pm due to Patient #2 being questionably homicidal and violent, dangerous to self and others, and gravely disabled. Further review revealed a CEC was signed on 07/18/11 at 2:33pm due to Patient #2 being dangerous to others and gravely disabled. Further review of the CEC revealed next to the section for suicidal, homicidal, and violent the word "potentially" was written.

Review of Patient #2's "Nursing Notes" revealed an entry by RN (registered nurse) S8, with no documented evidence of the date (should be 07/19/11), of "7-3P (3:00pm) approx. (approximately) 9 AM or so pt (patient) started to "feel weak" & (and) needed assistance. CORE Team called as pt became orthostatic. He was assisted to bed. pt went to BR (bathroom) (with) as. (assistance). pt is in bed, drinking fluids. pt to be discharged to ER (emergency room ) for further treatment & care".

Review of Patient #2's "Physician Order Form" dated 07/19/11 revealed an order was written by Physician S20 on 07/19/11 at 9:40am to discharge Patient #2 to the E.D. with a sitter, continue the PEC, and to consult psychiatry for disposition when his condition was stabilized. Further review revealed his condition was guarded and fluid depleted.

Review of the entire medical record revealed no documented evidence that Patient #2's family was notified of his discharge from the inpatient psychiatric unit and admission as an outpatient to the E.D.

In a face-to-face interview on 06/27/12 at 10:25am, Vice-President of Nursing and Operations S21 indicated Physician S20 was no longer at the hospital and was unable to be reached for an interview. She further indicated that it was hospital policy that the physician notify a patient's family member when the patient was transferred or discharged from an inpatient unit and sent to the E.D. for treatment.

Review of the hospital policy titled "Admission/Discharge", number 6340-E02, revised 03/11, and presented by PI Manager S1 as the current policy, revealed, in part, "...II. Transfers / Discharges A. In-house Transfers: 1. APU (acute psychiatric unit) staff will transfer patients to other medical services when necessary to provide individualized treatment. Patients may be transferred to other services as medical condition warrants, in order to receive more aggressive medical management of illness. . 3. The nursing staff will notify Admit of patient's discharge from Psychiatry service and admit to the medical or surgical service. ... 4. The patient's family or significant other is notified of the transfer by the APU physician...".
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, record reviews, and interview, the hospital failed to ensure patients received care in a safe setting. Observation of the psychiatric unit day room on 06/25/12 revealed a boom box with approximately a six (6) foot cord attached that could be used as a means of strangulation in the day room with a patient present with no staff member present. Observation of the psychiatric unit's patient dining area on 06/25/12 revealed an unlocked drawer that contained plastic knives, spoons, and straws that could be used to injure oneself or another patient. These safety issues had the opportunity to affect the 11 inpatients admitted on [DATE]. Findings:

Observation on 06/25/12 at 11:10am revealed Patient #6 seated in the psychiatric unit's dayroom with no staff member present. Further observation revealed a boom box with an approximately 6 foot cord was on the table in the dayroom.

In a face-to-face interview on 06/25/12 at 11:15am, RN (registered nurse) Psychiatric Unit Director S4 indicated a relaxation group therapy had just concluded in the dayroom. She further indicated the boom box with the electrical cord could be a means of strangulation and should not have been left unattended by staff in the dayroom.

Observation of the inpatient psychiatric unit's patient dining area on 06/25/12 at 11:25am revealed the door was locked with Patient #6 in the room unattended by staff. Patient #6 was attempting to heat coffee in the microwave. Further observation revealed a drawer to the far right of the cabinet was unlocked and contained 8 disposable packets of plastic utensils, each containing a plastic knife, a plastic spoon, and a plastic straw. Further observation revealed numerous loose plastic straws in the same drawer.

In a face-to-face interview on 06/25/12 at 11:25am, RN Psychiatric Unit Director S4 indicated patients were allowed in the dining area at meal time unattended by staff. She further indicated the dining area was constantly monitored by camera monitor by a staff member seated in the nursing station.

Observation of the monitor screen in the psychiatric unit's nursing station on 06/25/12 at 11:35am revealed the area of the unlocked drawer in the dining area that contained plastic forks, spoons, and straws was not visible on the camera screen. This observation was confirmed by RN Psychiatric Unit Director S4.

Review of the hospital policy titled "Safety Precautions", number 6340-E14, revised 03/11, and presented by Performance Improvement Manager S1 as a current policy, revealed, in part, "...Sharp objects and objects that can be used as weapons are restricted from patient use on the Acute Psychiatric nit (APU) to ensure the safety of all persons living and working on the unit...".
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to investigate a patient's allegation #18) of possible sexual abuse by his room mate (#1) for 1 of 1 allegation of abuse from a total sample of 12 patients. Findings:

Patient #1
Review of Patient #1's medical record revealed he was an [AGE] year old male admitted on [DATE] with the chief complaint of aggressive behavior. Patient #1 was PEC'd (Physician Emergency Certificate) on 06/19/12 at 3:30pm due to being violent and dangerous to others. Patient #1 was CEC'd (Coroner's Emergency Certificate) on 06/20/12 at 10:50am due to being dangerous to others and gravely disabled. Review of his "Psychiatry Hospital Consult" dated 06/19/12 at 2200 (10:00pm) revealed Patient #1 had a previous diagnosis of Mild Alzheimer's and developed hyper-sexual/aggressive behavior towards his wife. Further review revealed he sexually assaulted her "out of the blue", and Patient #1 said he would probably do it again.

Review of Patient #1's "Notes & (and) Consultant's Reports" revealed the following documentation:
06/21/12 at 10:39am by Physician S31 - "pt (patient) noted by staff to be hypersexual last night (with) M (male) roommate propositioning oral sex";
06/21/12 at 10:58am by Physician S33 - "Family Meeting... Risks of wandering & sexual disinhibition were discussed. Pt. propositioned male roommate last night";
06/23/12 at 11:00am by Physician S32 - "Nursing reports patient propositioned roommate a couple days ago for oral sex. Still hypersexual. Wanders halls".

Review of Patient #1's "Nursing Plan Of Care" and "Nursing Flow Sheet" from 06/20/12 at 8:00am through 06/25/12 at 9:45am revealed no documented evidence of any hypersexual behavior or of Patient #1 propositioning his roommate for oral sex. Review of his "Plan Of Care" revealed RN (registered nurse) S23 documented altered thought process as evidenced by "hypersexual", and the intervention was to "monitor boundaries (with) peers". Further review revealed on 06/22/12 at 5:10pm RN S35 documented altered thought process as evidenced by "hypersexual @ (at) times".

Review of Patient #1's "Observation/Restraint Checklist" revealed Mental Health Associate (MHA) S22 documented that Patient #1 was asleep from 7:15pm on 06/20/12 through 6:15am on 06/21/12.

Patient #18
Review of Patient #18's medical record revealed he was an [AGE] year old male admitted on [DATE] with the chief complaint of Depression, Alcohol Dependence, Sedative Hypnotic Abuse, Robitussin Intoxication, Perceptual Change, and Mood Disorder. Patient #18 was PEC'd on 06/19/12 at 1:42 p.m. due to dangerous to self and others and unable to seek voluntary admission. Patient #18 was CEC'd on 06/20/12 at 10:29 a.m. due to being dangerous to self, unwilling, and gravely disabled.

Review of his "Psychiatry Hospital Consult" dated 06/19/12 at 1900 (7:00 p.m.) revealed Patient #18 had a previous diagnosis of Depression. Further review revealed he had a history of sexual/physical abuse from his father.
Review of the section titled, Abnormal/psychotic thoughts, revealed illusions and delusions were marked "no".
Maladaptive or problem behaviors: drugs/alcohol abuse.
Review of the section titled, Staff Comments, revealed the following documented by S33:
Impression: Alcohol and Benzo Dependence..
Recommendation: Detox in safe environment. Inpatient drug rehab will be sought for discharge.
There was no documented evidence that the patient was delusional.

Review of Patient #18's "Notes & (and) Consultant's Reports" revealed the following documentation:
06/21/12 at 9:50 a.m. by Physician S31 - "pt (patient) reports fell ing "ok" with full affect. Pt. had trouble sleeping last night secondary to roommate being hypersexual...."
06/21/12 at 9:57 a.m. by Physician S33 - "Staff Note - Pt. interviewed in treatment team. He slept poorly due to intrusive roommate. That will be changed......"
There was no documented evidence that the patient was delusional.

Review of Patient #18's "Nursing Plan Of Care" and "Nursing Flow Sheet" from 06/20/12 at 8:00 a.m. through 06/24/12 at 8:00 a.m. revealed no documented evidence of any report form Patient #18 that he had been propositioned for oral sex by his roommate (Patient #1).

Review of Patient #1's "Observation/Restraint Checklist" revealed Mental Health Associate (MHA) S22 documented that Patient #18 was calm/compliant from 7:15 p.m. on 06/20/12 through 2:30 a.m. on 06/21/12, and asleep from 2:45 a.m. to 6:00 a.m. on 06/22/12.

The hospital could provide no documented evidence of an investigation of Patient #18's allegation of being propositioned by Patient #1 for oral sex to determine if sexual abuse had occurred.

In a face-to-face interview on 06/25/12 at 3:05pm, RN Psychiatric Unit Director S4 confirmed that there was no documentation by the nurse related to hypersexual activity reported by the nursing staff to the physicians. She indicated that the nursing care plan was adjusted to remove Patient #1 from his room, but there was no documented evidence of the time he was moved or the reason for moving him. She further indicated there was no plan for protecting the other patients on the unit while Patient #1 remained on modified visual contact observation and was noted to be wandering the halls.

In a face-to-face interview on 06/26/12 at 3:35pm, RN S7 indicated she began her shift on the acute psychiatric unit on 06/21/12 at 3:00am. She further indicated both Patient #1 and Patient #18 were sleeping. S7 indicated that Patient #18, who was delusional, came into the nursing station at the change of shift the morning of 06/21/12 and reported that Patient #1 told him "you want me to suck your dick". S7 indicated that she reported this comment to Physician S33 on rounds. When asked why she didn't document Patient #18's allegation of sexual abuse, S7 indicated "I didn't want to document anything false and hurt either patient". She further indicated that Patient #1 denied that the event occurred.

In a face-to-face interview on 06/26/12 at 3:45pm, RN S8 indicated that she worked on the acute psychiatric unit on 06/20/12 from 3:00pm until 3:00am on 06/21/12. She further indicated that she didn't know anything about the allegation of sexual abuse from Patient #18 until after the allegation was made. S8 indicated neither Patient #1 nor Patient #18 reported anything to her. She further indicated the patient doors remain open at night, and she makes observations by use of the camera monitor at the nursing station that showed each patient's room and the beds in each room. She further indicated that she checked to see that the patients were in bed at 11:00pm. S8 indicated Patient #18 got up during the night and was administered Benadryl for a cough. She further indicated that Patient #1 never got up that night, and she "didn't see him at all".

In a face-to-face interview on 06/27/12 at 8:05am, MHA (mental health associate) S22 indicated she worked on the acute psychiatric unit on the night of 06/20/12 through the morning of 06/21/12. She further indicated Patient #1 was asleep in bed from 7:30pm on 06/20/12 through 6:15am on 06/21/12. S22 indicated that she spoke with RN S7 after Patient #18 reported the allegation to S7. S22 indicated until speaking during this interview, no one had questioned her regarding her observations of Patients #1 and #18 on the night of 06/20/12.

In a face-to-face interview on 06/27/12 at 3:20pm, RN Psychiatric Unit Director S4 indicated that she was not aware of Patient #18's allegation of sexual abuse until she was questioned on 06/25/12 by the surveyors. She further indicated the allegation was not reported to her by the RN who received the allegation. S4 confirmed that an incident report had not been completed related to the allegation of sexual abuse, and there had not been any investigation to determine if sexual abuse had occurred.

Review of the hospital policy titled "Patient Rights and Responsibilities", number OMC.PTREL.001, issued 06/11, and presented by Performance Improvement (PI) Manager S1 as a current policy, revealed, in part, "...13. The patient has a right to personal safety (free from mental, physical, sexual and verbal abuse, or humiliation, neglect and exploitation)...".

Re view of the hospital policy titled "Safety on Site Occurrence Reporting System", number OMC.PI.006, issued 06/10, and presented by PI Manager S1 as a current policy, revealed, in part, "...Occurrence Reporting is the formal process to facilitate investigation, analysis, follow-up and documentation of incidents. ... Employees are encouraged to report occurrences as the organization relies on staff as an important source of improvement opportunities. ... An occurrence includes any unforeseen event that harmfully affects or could have affected (near miss) a patient, visitor and/or employee. Types of occurrences include, but are not limited to: ... (no documented evidence that sexual abuse was listed)... Red Flag Occurrences are a subset of occurrences in which significant harm has occurred as a result of the event. Red Flag occurrences should be immediately reported to the Performance Improvement department for immediate investigation. ... Examples of "Red Flag Occurrences" include, but are not limited to: ...Rape or Sexual Assault of any patient... It is the Department Director's responsibility to ensure timely follow up to investigations, queries, action items that result for occurrence reporting...".
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on record reviews and interviews, the hospital failed to develop quality indicators for the acute psychiatry unit that assessed processes of care related to patient assignments. This resulted in the RN delegating initial admit assessments to MHAs (Mental Health Associates) and Licensed Practical Nurses (LPNs) on the acute psychiatric inpatient unit for 8 of 12 sampled patients (#1,#2, #4, #5, #6, #16, #17, #19) and patient's daily reassessments on the acute psychiatry unit to MHAs for 7 of 12 sampled patients (#1, #5, #6, #16, #17, #18, #19) The delegation did not meet the RN's scope of practice for delegation by the Louisiana State Board of Nursing's nurse practice act. Findings:

Review of the "OMC (Ochsner Medical Center) Nursing Monthly Operating Reviews" presented by Assistant Vice-President of Performance Improvement S9 revealed the acute psychiatry unit collected data on stability, labor, people, cost containment initiatives, loyalty, quality (medication errors, care planning, falls with injury, pain assessment/reassessment, restraints), and pharmacy metrics.

Review of the "Sweep Sheet Documentation Review", the documentation tool used by the acute psychiatry unit and presented by Assistant Vice-President of Performance Improvement S9, revealed the reviews related to assessments included the following:
Initial nursing assessment completed within 24 hours of admit;
Contents of the initial nursing assessment;
Pain assessed/reassessed as per policy/standards;
Plan of Care individualized to patient and reviewed/updated daily and as needed;
Medication reconciliation completed on admission and discharge.
There was no documented evidence that the documentation audit addressed which discipline had completed the nursing admission assessments and daily reassessments.

Review of the medical records of Patients #1,#2, #4, #5, #6, #16, #17, and #19 revealed that parts of the initial nursing assessment was performed by the LPN or MHA without documented evidence that the RN had assessed the patients to determine what part of their care could be provided by the LPN or MHA (see findings in tag A0395).

Review of the medical records of Patients #1, #5, #6, #16, #17, #18, and #19 revealed the nursing assessments each shift were performed by the MHA. Patient assessment was not a task that could be delegated to an unlicensed person according to the RN nurse practice act with the Louisiana State Board of Nursing (see findings in tag A0395 and A0397).

In a face-to-face interview on 06/27/12 at 1:10pm, Assistant Vice-President of Performance Improvement S9 indicated that she did not see patient assessments not being assessed by the RN as a problem that should have been identified through QAPI (quality assessment and performance improvement), because their interpretation of the delegation process was that the collection of data for the admit assessment was a task that could be delegated to the LPN and the MHA.

Review of the hospital policy titled "Quality Improvement Plan", number OMC.PI.002, revised 04/11, and presented by Assistant Vice-President of Performance Improvement S9 as the current policy, revealed, in part, "...The plan will focus on clinical processes, operational systems and minimization of individual blame or retribution for involvement in a medical/healthcare occurrence. ... The organization will measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital service and operations... OMC will maintain an environment compliant with regulatory standards/requirements...".
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on record reviews and interviews, the hospital failed to develop quality indicators for the acute psychiatry unit that assessed processes of care related to patient assignments. This resulted in the RN delegating initial admit assessments to MHAs (Mental Health Associates) and Licensed Practical Nurses (LPNs) on the acute psychiatric inpatient unit for 8 of 12 sampled patients (#1,#2, #4, #5, #6, #16, #17, #19) and patient's daily reassessments on the acute psychiatry unit to MHAs for 7 of 12 sampled patients (#1, #5, #6, #16, #17, #18, #19) The delegation did not meet the RN's scope of practice for delegation by the Louisiana State Board of Nursing's nurse practice act. Findings:

Review of the "OMC (Ochsner Medical Center) Nursing Monthly Operating Reviews" presented by Assistant Vice-President of Performance Improvement S9 revealed the acute psychiatry unit collected data on stability, labor, people, cost containment initiatives, loyalty, quality (medication errors, care planning, falls with injury, pain assessment/reassessment, restraints), and pharmacy metrics.

Review of the "Sweep Sheet Documentation Review", the documentation tool used by the acute psychiatry unit and presented by Assistant Vice-President of Performance Improvement S9, revealed the reviews related to assessments included the following:
Initial nursing assessment completed within 24 hours of admit;
Contents of the initial nursing assessment;
Pain assessed/reassessed as per policy/standards;
Plan of Care individualized to patient and reviewed/updated daily and as needed;
Medication reconciliation completed on admission and discharge.
There was no documented evidence that the documentation audit addressed which discipline had completed the nursing admission assessments and daily reassessments.

Review of the medical records of Patients #1,#2, #4, #5, #6, #16, #17, and #19 revealed that parts of the initial nursing assessment was performed by the LPN or MHA without documented evidence that the RN had assessed the patients to determine what part of their care could be provided by the LPN or MHA (see findings in tag A0395).

Review of the medical records of Patients #1, #5, #6, #16, #17, #18, and #19 revealed the nursing assessments each shift were performed by the MHA. Patient assessment was not a task that could be delegated to an unlicensed person according to the RN nurse practice act with the Louisiana State Board of Nursing (see findings in tag A0395 and A0397).

In a face-to-face interview on 06/27/12 at 1:10pm, Assistant Vice-President of Performance Improvement S9 indicated that she did not see patient assessments not being assessed by the RN as a problem that should have been identified through QAPI (quality assessment and performance improvement), because their interpretation of the delegation process was that the collection of data for the admit assessment was a task that could be delegated to the LPN and the MHA.

Review of the hospital policy titled "Quality Improvement Plan", number OMC.PI.002, revised 04/11, and presented by Assistant Vice-President of Performance Improvement S9 as the current policy, revealed, in part, "...The plan will focus on clinical processes, operational systems and minimization of individual blame or retribution for involvement in a medical/healthcare occurrence. ... The organization will measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital service and operations... OMC will maintain an environment compliant with regulatory standards/requirements...".
VIOLATION: NURSING SERVICES Tag No: A0385
Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Nursing Services as evidenced by:

1) Failing to ensure the RN (registered nurse) supervised and evaluated the nursing care of each patient.
a) The RN delegated initial admit assessments to MHAs (Mental Health Associates) and Licensed Practical Nurses (LPNs) on the acute psychiatric inpatient unit for 8 of 12 sampled patients on the acute psychiatric unit (#1,#2, #4, #5, #6, #16, #17, #19).
b) The RN failed to assess the patients on the acute psychiatric unit to determine which patients' care could be delegated to licensed and unlicensed staff according to the Louisiana State Board of Registered Nurse's nurse practice act (Administrative Rules Defining RN Practice LAC46:XLVII) for 7 of 12 sampled patients on the acute psychiatric unit (#1, #5, #6, #16, #17, #18, #19).
c) The RN failed to assess a patient's change in condition related to elevated blood pressure for 2 of 2 patients with elevated blood pressure from a total of 12 sampled patients (#4, #16) and orthostatic hypotension that resulted in the patient being discharged to the emergency department (E.D.) for treatment for 1 of 1 patient with orthostatic hypotension from a total of 12 sampled patients (#2).
d) The RN failed to report and investigate an allegation of inappropriate sexual behavior between patients for 1 of 1 patient with a report of inappropriate sexual behavior from a total of 12 sampled patients on the acute psychiatric unit (#1) (see findings in tag A0395).

2) Failing to ensure a RN assigned the nursing care of each patient to other nursing personnel according to the needs of the patient and the qualifications and competence of the available nursing staff.
a) The RN delegated the patient assessments on the acute psychiatry unit to unlicensed nursing staff by having the MHAs (mental health associates) perform daily nursing assessments for 7 of 12 sampled patients (#1, #5, #6, #16, #17, #18, #19).
b) The RN delegated the one-to-one observation of patients under a physician's emergency certificate (PEC) to Emergency Department Technicians who had not received training and had not been assessed for competency in crisis prevention and interventions for 1 of 1 sampled Emergency Department Technician personnel files reviewed from a total of 11 Emergency Department Technicians employed (S28);
c) The RN delegated the assessment of the patient's vital signs in the inpatient psychiatric unit to MHA who had not received training and had not been assessed for competency in the assessment of vital signs for 4 of 4 sampled MHA personnel files reviewed from a total of 6 MHAs employed (S22, S24, S29, S30) (see findings in tag A0397).
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews, the hospital failed to ensure the RN (registered nurse) supervised and evaluated the nursing care of each patient.
1) The RN delegated initial admit assessments to MHAs (Mental Health Associates) and Licensed Practical Nurses (LPNs) on the acute psychiatric inpatient unit for 8 of 12 sampled patients on the acute psychiatric unit (#1,#2, #4, #5, #6, #16, #17, #19).
2) The RN failed to assess the patients on the acute psychiatric unit to determine which patients' care could be delegated to licensed and unlicensed staff according to the Louisiana State Board of Registered Nurse's nurse practice act (Administrative Rules Defining RN Practice LAC46:XLVII) for 7 of 12 sampled patients on the acute psychiatric unit (#1, #5, #6, #16, #17, #18, #19).
3) The RN failed to assess a patient's change in condition related to elevated blood pressure for 2 of 2 patients with elevated blood pressure from a total of 12 sampled patients (#4, #16) and orthostatic hypotension that resulted in the patient being discharged to the emergency department (E.D.) for treatment for 1 of 1 patient with orthostatic hypotension from a total of 12 sampled patients (#2).
4) The RN failed to report and investigate an allegation of inappropriate sexual behavior between patients for 1 of 1 patient with a report of inappropriate sexual behavior from a total of 12 sampled patients on the acute psychiatric unit (#1). Findings:

1) The RN delegated initial admit assessments to MHAs and LPNs on the acute psychiatric inpatient unit:
Patient #1
Review of Patient #1's medical record revealed he was an [AGE] year old male admitted on [DATE] with the chief complaint of aggressive behavior. Patient #1 was PEC'd (Physician Emergency Certificate) on 06/19/12 at 3:30pm due to being violent and dangerous to others. Patient #1 was CEC'd (Coroner's Emergency Certificate) on 06/20/12 at 10:50am due to being dangerous to others and gravely disabled.

Review of Patient #1's "Nursing Admit Assessment" revealed MHA S30 assessed Patient #1's height, temperature, pulse, respirations, and sitting and standing blood pressure on 06/19/12 at 2346 (11:46pm). Further review revealed Patient #1's pulse was 45, and there was no documented evidence that S30 reported the finding to the RN for assessment. Further review of the "Nursing Admit Assessment" revealed RN S8 assessed Patient #1 on 06/20/12 at 1:30pm (12 hours and 44 minutes after he had arrived on the unit). The assessment included the following: medication and food allergies; patient care needs including whether eyeglasses were needed for reading, any difficulty hearing, presence of pain, whether he had fallen recently, was experiencing weakness, dizziness, forgetfulness, wandering, confusion, or difficulty sleeping, whether he was on a special diet, had lost weight recently, or had difficulty chewing or swallowing foods; psychosocial factors related to abuse (elder, negligence, sexual, physical, psychological); skin assessment (for lacerations, abrasions, bruises, scar, burn, mole, birthmark, tattoos) by asking patient as evidenced by documentation of "denies all"; report of history of violence and whether currently reporting suicidal and/or homicidal ideation and auditory/visual hallucinations; self care needs including feeding, grooming, bathing, dressing, toileting, moving from bed to chair, and energy level; environmental factors including special equipment or services used at home prior to admission; physical assessment including appearance, appetite, oral mucosa; current living arrangements; community resources used; history of substance abuse; whether he had ever experienced symptoms of withdrawal from alcohol or drugs; previous medical history including a review of systems. There was no documented evidence that RN S8 assessed Patient #1 upon admission to the unit as required by hospital policy. There was no documented evidence that RN S8 assessed Patient #1's vital signs or rechecked his heart rate that was documented by MHA S30 as 45.

Patient #2
Review of Patient #2's medical record revealed he was a [AGE] year old male admitted from the E.D. to the inpatient psychiatric unit on 07/18/11 at 8:15pm with the diagnosis of Psychosis. Further review revealed a PEC was signed on 07/17/11 at 5:45pm due to Patient 32 being questionably homicidal and violent, dangerous to self and others, and gravely disabled. Further review revealed a CEC was signed on 07/18/11 at 2:33pm due to Patient #2 being dangerous to others and gravely disabled. Further review of the CEC revealed next to the section for suicidal, homicidal, and violent the word "potentially" was written.

Review of Patient #2's "Psychiatric Nursing Admit Assessment" revealed the assessment of the following information was performed by MHA S29 on 07/18/11 at 8:15pm: height, weight, vital signs; medication and food allergies; patient care needs; diet and whether he had problems with weight loss and chewing or swallowing food; psychosocial factors; skin condition; history of violence and whether suicidal, homicidal, or having auditory/visual hallucinations; self care; special equipment or services used at home prior to admission, physical assessment including general appearance, appetite, oral mucosa; current living arrangements; community resources used by the patient; history of substance abuse; whether patient ever experienced symptoms of withdrawal from alcohol or drugs; previous medical history with a review of systems. Further review revealed the line labeled "completed by ___ date/time___) was signed by MHA S29 on 07/18/12 with no documented evidence of a time (beginning of assessment was timed by S29 at 8:15pm). Further review revealed RN S26 signed the form on 07/18/11 at 9:24pm.

Review of Patient #2's "Nursing Notes" revealed an entry written in the same handwriting of and signed by MHA S29 of "(date & Hour) 7/18/11 Admit Pt (patient) is a 38 y/o (year old) male admitted from the ED (with) a h/o (history of) depression. Pt oriented to unit/signed & (and) agreed to rules & regulations all sharps removed. Pt currently denies SI (suicidal ideation). Will continue to monitor". Further review revealed RN S26 signed next to MHA S29's signature. There was no documented evidence that a RN assessed Patient #2 to determine if any part of his admit assessment could be delegated to an unlicensed staff member.

In a face-to-face interview on 06/26/12 at 1:00pm, Acute Psychiatric Unit Director S4 indicated MHA S29 completed Patient #2's admit assessment and took his vital signs at 8:15pm on 07/18/11.

Patient #4
Review of the patient's medical record revealed the patient was a [AGE] year old female admitted on [DATE] at 1435 (2:35 p.m.) from the Emergency Department with diagnoses of suicide attempt and Depression. Patient #4 was PEC'd on 06/24/12 at 7:15 p.m. due to dangerous to self.

Review of Patient #4's "Nursing Admit Assessment" revealed PCT (Patient Care Technician) S38 assessed Patient #4's height, temperature, pulse, respirations, and sitting and standing blood pressure on 06/25/12 at 1435 (2:35 p.m.). Further review revealed Patient #4's Blood Pressure was 139/109, and there was no documented evidence that S38 reported the finding to the RN for assessment. Further review of the "Nursing Admit Assessment" revealed RN S7 assessed Patient #4 on 06/25/12 at 4:00 p.m. (1 hour and 25 minutes after she had arrived on the unit). The assessment documented by PCT S38 included the following: medication and food allergies; patient care needs including whether eyeglasses were needed for reading, any difficulty hearing, presence of pain, whether she had fallen recently, was experiencing weakness, dizziness, forgetfulness, wandering, confusion, or difficulty sleeping, whether she was on a special diet, had lost weight recently, or had difficulty chewing or swallowing foods; psychosocial factors related to abuse (elder, negligence, sexual, physical, psychological); skin assessment (for lacerations, abrasions, bruises, scar, burn, mole, birthmark, tattoos) by asking patient as evidenced by documentation of "denies all"; report of history of violence and whether currently reporting suicidal and/or homicidal ideation and auditory/visual hallucinations; self care needs including feeding, grooming, bathing, dressing, toileting, moving from bed to chair, and energy level; environmental factors including special equipment or services used at home prior to admission. RN S7 documented the section titled, "Physical Assessment", that included appearance, appetite, oral mucosa; current living arrangements; community resources used; history of substance abuse; whether she had ever experienced symptoms of withdrawal from alcohol or drugs; previous medical history including a review of systems. There was no documented evidence that RN S7 assessed Patient #4 upon admission to the unit as required by hospital policy. There was no documented evidence that RN S7 assessed Patient #4's vital signs or rechecked her Blood Pressure that was documented by PCT S38 as 139/109. There was no documented evidence that a RN assessed Patient #4 to determine if any part of her admit assessment could be delegated to an unlicensed staff member.

On 06/27/12 at 8:25 a.m., in a face-to-face interview with S23 RN, she was asked how she completed the admit assessment. S23 stated she reviewed what the MHA had documented and she completed page 3 and page 4. She stated, "Anyone can fill out the sections above the Physical Assessment section." She stated she asked the patient to verify what she received in report. S23 stated she talked to the patient and asked them what happened-why they were here. S23 stated she had been employed in the acute psychiatric unit for 7 years and worked the 7 p.m. to 7 a.m. shift.

Patient #5
Review of the patient's medical record revealed the patient was admitted on [DATE] at 2210 (10:10 p.m.) from the Emergency Department with diagnoses of Psychosis, Rule Out Substance Induced Psychosis. Patient #5 was PEC'd on 06/21/12 at 4:10 p.m. due to paranoid behavior and dangerous to others.

Review of Patient #5's "Psychiatric Nursing Admit Assessment" revealed the assessment of the following information was performed by MHA S24 on 06/21/12 at 10:10 p.m.: height, weight, vital signs; medication and food allergies; patient care needs; diet and whether he had problems with weight loss and chewing or swallowing food; psychosocial factors; skin condition; history of violence and whether suicidal, homicidal, or having auditory/visual hallucinations; self care; special equipment or services used at home prior to admission. Review of the section titled, "Physical Assessment", revealed the section was documented by S7RN and included the following: general appearance, appetite, oral mucosa; current living arrangements; community resources used by the patient; history of substance abuse; whether patient ever experienced symptoms of withdrawal from alcohol or drugs; previous medical history with a review of systems. Further review revealed RN S23 signed the form on 06/22/12 at 12:45 a.m. (2 hours and 35 minutes after patient's arrival on unit).

Review of Patient #5's "Nursing Notes" revealed an entry written in the same handwriting of and signed by MHA S24 of "06/21/12 2230 (10:30 p.m.) Admit note: Patient is a 32 y/o (year old) female admitted from _____ (Local Hospital) for paranoid behavior. OPC'd by father then PEC'd. No psych history. Patient was cooperative upon admit, but restless. Denies SI (suicidal ideation) and HI (Homicidal Ideations). Will continue to monitor behavior. Patient checked for sharps, oriented to unit and valuables were placed in patient belongings closet". Further review revealed RN S23 signed next to MHA S24's signature. There was no documented evidence that a RN assessed Patient #5 to determine if any part of his admit assessment could be delegated to an unlicensed staff member.

Patient #6
Review of the patient's medical record revealed the patient was a [AGE] year old male admitted on [DATE] at 3:43 a.m. from the Emergency Department with diagnoses of Depression, ETOH (Alcohol) Dependency, and Opiate Dependence. Patient #6 was PEC'd on 06/15/12 in the Emergency Department due to dangerous to self. The patient was CEC's on 06/18/12 due to dangerous to self.

Review of Patient #6's "Psychiatric Nursing Admit Assessment" revealed the assessment of the following information was performed by MHA S44 on 06/16/12 at 3:43 a.m.: height, weight, vital signs; medication and food allergies; patient care needs; diet and whether he had problems with weight loss and chewing or swallowing food; psychosocial factors; skin condition; history of violence and whether suicidal, homicidal, or having auditory/visual hallucinations; self care; special equipment or services used at home prior to admission. The section titled, "Physical Assessment", documented by RN S45, included general appearance, appetite, oral mucosa; current living arrangements; community resources used by the patient; history of substance abuse; whether patient ever experienced symptoms of withdrawal from alcohol or drugs; previous medical history with a review of systems. Further review revealed RN S45 signed the form on 06/16/12 at 3:55 a.m.

Review of Patient #6's "Nursing Notes" revealed an entry written in the same handwriting of and signed by MHA S44 of "0400 (4:00 a.m.) 06/16/12 Pt. is a 61 y/o (year old) male admitted with depression and history of substance abuse. Recent relapse. Disheveled appearance, appropriate behavior, cooperative and pleasant. Complained of leg and back pains. PEC and placed on MVC. Asleep after assessment when observed." Further review revealed RN S45 signed next to MHA S44's signature. There was no documented evidence that a RN assessed Patient #6 to determine if any part of his admit assessment could be delegated to an unlicensed staff member.

Patient #16
Review of Patient #16's medical record revealed she was a [AGE] year old female admitted on [DATE] with diagnoses of Psychosis and Bipolar Disorder by history.

Review of Patient #16's "Acute Psychiatric Unit Nursing Admit Assessment" documented by LPN S40 on 06/25/12 at 3:35pm revealed the following patient information was assessed by LPN S40: vital signs; orientation to the environment; medication and food allergies; patient care needs; diet and whether she had problems with weight loss and chewing or swallowing food; psychosocial factors; skin condition; history of violence and whether suicidal, homicidal, or having auditory/visual hallucinations; self care; special equipment or services used at home prior to admission; and whether any medical conditions or disability/limitations exist that would place her at greater risk during restraint use. Further review revealed the physical assessment including general appearance, appetite, and oral mucosa, current living arrangements, community resources used by the patient, assessment of substance abuse and whether she ever experienced any symptoms of withdrawal from alcohol or drugs, and her previous medical history including a review of systems was completed by RN S23 on 06/25/12 at 9:09pm (5 hours and 34 minutes after she had been assessed by LPN S40). There was no documented evidence that Patient #16 was assessed by a RN to determine if any part of the admit assessment could be delegated to a LPN.

Review of Patient #16's "Nursing Notes" revealed an entry on 06/25/12 at 3:40pm by LPN S40 that Patient #16 was unable to finish answering questions for the admit packet, because she began to cry. Review of the Acute Psychiatric Unit Nursing Admit Assessment" documented by LPN S40 on 06/25/12 at 3:35pm revealed no documented evidence of the time LPN S40 completed the admit assessment.

Patient #17
Review of Patient #17's medical record revealed he was a [AGE] year old male admitted on [DATE] with the diagnosis of Depression.

Review of Patient #17's "Nursing Admit Assessment" revealed LPN S37 completed the following assessments on 06/24/12 at 3:45pm:
General Information including height, weight, vital signs;
Medication and food allergies;
Patient care needs including assessment of sight, if difficulty hearing, pain, falls recently, weakness or dizziness, forgetfulness, wandering or confusion, difficulty sleeping, special diet, recent weight loss, and difficulty chewing or swallowing foods;
Psychosocial factors including evidence of abuse or history of abuse;
Body identification marks;
Medical conditions or disability/limitations that would place him at greater risk if placed in restraints and whether he'd been restrained or secluded before;
History of violent behavior;
Whether currently reporting suicidal ideation, homicidal ideation, auditory/visual hallucinations;
Self care needs;
Environmental factors including special equipment or services used at home prior to admission.
Further review revealed RN S8 completed the physical assessment on 06/24/12 at 4:00pm which included Patient #17's general appearance, appetite, oral mucosa, current living arrangements, community resources used by the patient, substance abuse history, whether he had ever experienced symptoms of withdrawal from alcohol or drugs, previous medical history, and a review of systems. There was no documented evidence that RN S8 reviewed the information collected from LPN S37's assessment of Patient #17. There was no documented evidence that RN S8 had assessed Patient #17 to determine if any part of his assessment could be delegated to a LPN.

Patient #19
Review of the patient's medical record revealed the patient was a [AGE] year old male admitted on [DATE] at 2210 (10:10 p.m.) from the Emergency Department with diagnoses of Depression and Poor Impulse Control with Laceration to Left Wrist. Patient #19 was PEC'd on 06/25/12 at 9:05 p.m. due to Dangerous to self and unwilling.

Review of Patient #19's "Psychiatric Nursing Admit Assessment" revealed the assessment of the following information was performed by LPN S40 on 06/25/12 at 10:10 p.m.: height, no weight, vital signs; medication and food allergies; patient care needs; diet and whether he had problems with weight loss and chewing or swallowing food; psychosocial factors; skin condition; history of violence and whether suicidal, homicidal, or having auditory/visual hallucinations; self care; special equipment or services used at home prior to admission. Review of the section titled, "Physical Assessment", documented by RN #23 included general appearance, appetite, oral mucosa; current living arrangements; community resources used by the patient; history of substance abuse; whether patient ever experienced symptoms of withdrawal from alcohol or drugs; previous medical history with a review of systems. Further review revealed RN S23 signed the form on 06/25/12 at 11:45 p.m.

Review of Patient #19's "Nursing Notes" revealed an entry written in the same handwriting of and signed by LPN S40 of "06/25/12 2210 (10:10 p.m.) Admit note: Pt. received to unit on PEC from ER (emergency room ). Affect flat. Pt. stated "I don't know why I'm here. They think I tried to kill myself." Pt. has not eaten since Friday. Pt. C/O (Complained of) left laceration on proximal wrist. Laceration is packed with Aquacel and covered with gauze and kerlex. Also pt. has bruises to bilateral elbows. Pt. denies SI and HI. Pt. felt nauseous after admitted . I helped to bathroom to vomit. Pt. did not vomit. Oriented pt. to unit. Pt. expressed understanding of teaching.
There was no documented evidence that a RN assessed Patient #19 to determine if any part of his admit assessment could be delegated to an unlicensed staff member.

Review of the MHA "Job Description", presented as the current job description by Performance Improvement Manager S1, revealed, in part, "...Essential Job Duties: ...20% (per cent) 2. Conducts Admit Patient Assessment...".

Review of the LPN "Job Performance Standards", presented as current by Performance Improvement Manager S1, revealed, in part, "...Essential Job Duty: ... 1. Demonstrates effective use of the Nursing Process in the delivery of patient care. a. Assessment b. Planning c. Evaluation In collaboration with the RN, utilizes clinical skills and knowledge in the assessment of client's health status (physiologic, psychosocial, emotional, cultural and spiritual). In consultation with the RN, integrates patient data in the development of an individualized plan of care utilizing appropriate reference material...".

Review of the MHA's "Job Performance Standards", presented as the current standards by Performance Improvement Manager S1, revealed, in part, "...II. Conducts Admit Assessment Under the directions of the RN, conducts admit assessment within 8 hours of admit, including biopsychosocial, environmental, self care, educational needs, discharge planning needs, and input from patient/family/significant other...".

In a face-to-face interview on 06/25/12 at 3:45pm, Assistant Vice-President of Nursing S5 indicated the hospital allowed ancillary staff to collect data within their scope including height, weight, and vital signs, and the RN completed the physical assessment portion of the admit assessment. When informed that a patient's height, weight, and vital signs were part of a physical assessment, S5 indicated they allow ancillary staff to collect data "on their skill set and they're trained to take vital signs and the RN reviews their data".

In a face-to-face interview on 06/26/12 at 3:00pm, Assistant Vice-President of Nursing S5 indicated she had done a lot of research and had determined that the LPN could perform psychosocial assessments and collect data for the admit assessment. She further indicated that LPNs throughout the hospital did psychosocial assessments. She further indicated the MHAs had degrees but were not licensed, and she confirmed that MHAs on the Acute Psychiatry Unit did perform parts of the initial admit assessment. When asked if the Louisiana State Board of Registered Nurses (LSBN) (Administrative Rules Defining RN Practice LAC46:XLVII) would view MHAs as unlicensed personnel, S5 shook her head indicating yes.

In a face-to-face interview on 06/27/12 at 8:25am, RN S23 indicated her assessment of the patient on admit included her talking to the patient and asking what happened that brought them into the hospital. She further indicated that if a patient had a wound or any medical issue, she would check it herself. S23 indicated the MHA completed the couple pages of the admit assessment form. She further indicated that she reviewed what the MHA documented on the first 2 pages, but she liked to question the patient about what the MHA documented on the ADLs (activities of daily living) and medications. S23 indicated she completes the physical assessment portion of the admit assessment form.

In a face-to-face interview on 06/27/12 at 12:40pm, Assistant Vice-President of Nursing S5 indicated she used the LSBN nurse practice act (Administrative Rules Defining RN Practice LAC46:XLVII) as a resource regarding nursing assessments. She further indicated she looked at the part stating RNs could delegate predictable tasks to unlicensed staff, unlicensed staff could gather data, and the RN could make decisions based on the data collected. She further indicated patient blood pressures were performed with the use of a Dinamap and not taken manually. When asked how a RN could know which patient could be delegated to LPNs or unlicensed staff (MHA) when the RN had not yet assessed the patient, S5 could offer no explanation.

In a face-to-face interview on 06/27/12 at 3:45pm, RN S26 indicated the MHA performs the vital signs, addresses patient valuables and sharps, and checks patient allergies when the patient presents to the unit for admission. She further indicated she usually completed the remainder of the admit assessment. S26 indicated if the MHA had completed the nursing assessment form up to the physical assessment (which she does as the RN), she would go back and ask the patient the same information to verify what the MHA had documented.

In a face-to-face interview on 06/27/12 at 4:05pm, RN S27 indicated her role for patient admit assessments was to complete the fall assessment, the suicide assessment, and go behind and check the medical history and orders that were done by the MHA and check any abnormal findings. She further indicated that she did this by taking the chart in the patient's room and asked the patient the same questions to make sure that what the MHA or LPN documented was accurate. She further indicated she only reassessed the vital signs if they were abnormally high or low.

In a face-to-face interview on 06/27/12 at 4:15pm, Assistant Vice-President of Nursing S5 indicated, when asked why the acute psychiatric unit would hold the admit assessment of patients to a lower standard than other areas of the hospital (psychiatric unit did not specify that nursing assessments had to be performed by a RN), S5 indicated they allow MHAs to collect data.

Review of the hospital policy titled "Assessment and Reassessment (hospitalized Patients)", number OHS.NURS.017, revised 12/10, and presented as a current policy by Performance Improvement Manager S1, revealed, in part, "...A. Upon admission to the unit, a registered nurse will assess each patient to collect data, determine any immediate needs and make appropriate care assignments. 1. Specific elements of data collection may be delegated based upon the patient's condition and defined competencies of the patient care personnel according to the rules of delegation by the LA State Board of Nursing. B. The admission assessment must be completed by a Registered Nurse within 24 hours of admission to the unit. Essential elements of this assessment include: 1. Patient History 2. Physical systems review 3. Biopsychosocial systems review 4. Environmental concerns 5. Cultural, spiritual, developmental and educational needs assessment 6. Sensory, functional, abuse/neglect, nutritional, fall risk and pain 7. Assessment of potential discharge needs...".

Review of the hospital policy titled "Acute Psychiatry Unit Operational Standards Admission/Discharge", policy number 6340-EO2, revised 03/11, and presented as a current policy by Performance Improvement Manager S1, revealed, in part, "...I. Admission To The Unit: ...B. Nursing Responsibilities: 1. The nursing staff initiates a biopsychosocial assessment, utilizing the Acute Psychiatry Admission Assessment form and the Nursing Assessment Form upon admission to APU (Acute Psychiatry Unit). 2. The admission assessment forms must be completed within 24 hours of admission to the unit. ... 3. The Mental Health Associate (MHA) or Recreation Therapist may initiate the bio-psychosocial assessment of the patient, but the RN must review information, verify completeness and accuracy of the information and initiate the Interdisciplinary Treatment Plan...".

2) The RN failed to assess the patients on the acute psychiatric unit to determine which patients' care could be delegated to licensed and unlicensed staff according to the Louisiana State Board of Registered Nurse's nurse practice act (Administrative Rules Defining RN Practice LAC46:XLVII):
Review of the "Acute Psychiatry Nursing Flow Sheet" revealed the following patient assessments were included to be documented for each shift:
Nutrition/appetite - good, adequate, fair, poor, improving, overeating, special diet, purging, binging;
Suicidal - verbalizes ideation, self harm behavior, hopelessness, intermitted ideation, denies;
Homicidal - ideation, threat, denies;
Thought process - grandiose, self depreciative, flight of ideas, delusions, loose associations, ideas of reference, hallucinations, phobias, illogical, rambling, tangential, coherent, clear, poor, concentration;
Appearance - un-kept, unclean, well groomed, fair, ADL's (activities of daily living) completed, yes/no;
Attitude/mood - stable, sad, euphoric, labile, irritable, guilty, fearful, apathetic, depressed, anxious, guarded;
Affect - flat, blunted, tearful, appropriate to mood, fearful, consistent;
Behavior - appropriate, agitated, impulsive, avoids eye contact, anxious, psychomotor retarded, threatening, paranoid, physically aggressive, using denial, somatic, oppositional, pushing limits, combative, tics, participating in treatment, withdrawn, hyper, intrusive, short attention span, negative;
Withdrawal - tremors, VS (vital signs) unstable, cramping, N/V (nausea/vomiting), craving, VS WNL (vital signs within normal limits), bone pain, diarrhea, med seeking, diaphoresis;
Memory - recent impaired, recent intact, oriented, disoriented, confused.

Patient #1
Review of Patient #1's medical record revealed he was an [AGE] year old male admitted on [DATE] with the chief complaint of aggressive behavior. Patient #1 was PEC'd on 06/19/12 at 3:30pm due to being violent and dangerous to others. Patient #1 was CEC'd on 06/20/12 at 10:50am due to being dangerous to others and gravely disabled.

Review of Patient #1's "Acute Psychiatry Nursing Flow Sheet" revealed the assessments were performed as follows:
06/20/12 at 3:00pm by RN S8;
06/21/12 at 6:00am by MHA S22 - only documentation was that the patient slept the entire shift;
06/22/12 at 2:00pm by Recreation Therapist S25;
06/22/12 at 9:20pm by MHA S24;
06/23/12 at 6:03am by MHA S22 - only documentation was that the patient slept the entire shift;
06/23/12 at 4:20pm by MHA S36;
06/23/12 at 11:00pm by MHA S30;
06/24/12 at 5:55am by MHA S30;
06/24/12 at 2:20pm by MHA S24;
06/24/12 at 8:30pm by LPN S37;
06/25/12 at 5:42am by MHA S22 - only documentation was that the patient slept the entire shift.
There was no documented evidence that Patient #1 was assessed by a RN on 06/21/12, 06/22/12, 06/23/12, 06/24/12, and 06/25/12 to determine if his care could be delegated to a LPN or an unlicensed staff member.

Patient #5
Review of the patient's medical record revealed the patient was admitted on [DATE] at 2210 (10:10 p.m.) from the Emergency Department with diagnoses of Psychosis, Rule Out Substance Induced Psychosis. Patient #5 was PEC'd on 06/21/12 at 4:10 p.m. due to paranoid behavior and dangerous to others.

Review of the Nursing Flow Sheets revealed the assessments were performed as follows:
06/21/12 at 10:30 p.m. by MHA S24
06/22/12 at 6:25 a.m. by MHA S22, only documentation was patient sleeping entire shift.
06/22/12 at 2:00 p.m. by MHA S25
06/22/12 at 9:20 p.m. by MHA S24
06/23/12 at 6:01 a.m. by MHA S22, only documentation was patient sleeping entire shift.
06/23/12 at 5:20 p.m. by MHA S36
06/23/12 at 11:00 p.m. by MHA S30
06/24/12 at 5:48 a.m. by MHA S30, only documentation was patient sleeping entire shift.
06/24/12 at 2:10 p.m. by MHA S24
06/24/12 at 8:30 p.m. by LPN S37
06/25/12 at 5:40 a.m. by MHA S22, only documentation was patient sleeping entire shift.
There was no documented evidence of an assessment of the patient by the RN on 06/22/12, 06/23/12, and 06/24/12 to determine if the patient's care could be delegated to an LPN or an unlicensed staff member.

Patient #6
Review of the patient's medical record revealed the patient was a [AGE] year old male admitted on [DATE] at 3:43 a.m. from the Emergency Department with diagnoses of Depression, ETOH (Alcohol) Dependency, and Opiate Dependence. Patient #6 was PEC'd on 06/15/12 in the Emergency Department due to dangerous to self. The patient was CEC's on 06/18/12 due to dangerous to self.

Review of the Nursing Flow Sheets revealed the assessments were performed as follows:
06/16/12 at 6:15 a.m. by MHA S44, only documentation was patient sleeping entire shift.
06/17/12 at 5:55 a.m. by MHA S22, only documentation was patient sleeping entire shift.
06/17/12 at 5:30 p.m. by MHA S36
06/18/12 at 5:18 a.m. by MHA S22, only documentation was patient sleeping entire shift.
06/18/12 at 1:00 p.m. by MHA S25
06/18/12 at 8:30 p.m. by LPN S37
06/21/12 at 6:00 a.m. by MHA S22, only documentation was patient sleeping entire shift.,
06/21/12 at 7:00 p.m. by MHA S25
06/21/12 at 8:55 p.m. by MHA S24
06/22/12 at 6:24 a.m. by MHA S22, only documentation was patient sleeping entire shift.
06/22/12 at 2:00 p.m. by MHA S25
06/22/12 at 9:2
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure a registered nurse (RN) assigned the nursing care of each patient to other nursing personnel according to the needs of the patient and the qualifications and competence of the available nursing staff.
1) The RN delegated the patient assessments on the acute psychiatry unit to unlicensed nursing staff by having the MHAs (mental health associates) perform parts of the initial admit assessments for 8 of 12 sampled patients on the acute psychiatric unit (#1,#2, #4, #5, #6, #16, #17, #19) and the daily nursing assessments for 7 of 12 sampled patients (#1, #5, #6, #16, #17, #18, #19).
2) The RN delegated the one-to-one observation of patients under a physician's emergency certificate (PEC) to Emergency Department Technicians who had not received training and had not been assessed for competency in crisis prevention and interventions for 1 of 1 sampled Emergency Department Technician personnel files reviewed from a total of 11 Emergency Department Technicians employed (S28);
3) The RN delegated the assessment of the patient's vital signs in the inpatient psychiatric unit to MHA who had not received training and had not been assessed for competency in the assessment of vital signs for 4 of 4 sampled MHA personnel files reviewed from a total of 6 MHAs employed (S22, S24, S29, S30). Findings:

1) The RN delegated the patient assessments on the acute psychiatry unit to unlicensed nursing staff by having the MHAs perform parts of the initial admit assessments and the daily nursing assessments:
Initial nursing assessment:
Patient #1
Review of Patient #1's medical record revealed he was an [AGE] year old male admitted on [DATE] with the chief complaint of aggressive behavior. Patient #1 was PEC'd (Physician Emergency Certificate) on 06/19/12 at 3:30pm due to being violent and dangerous to others. Patient #1 was CEC'd (Coroner's Emergency Certificate) on 06/20/12 at 10:50am due to being dangerous to others and gravely disabled.

Review of Patient #1's "Nursing Admit Assessment" revealed MHA S30 assessed Patient #1's height, temperature, pulse, respirations, and sitting and standing blood pressure on 06/19/12 at 2346 (11:46pm). Further review revealed Patient #1's pulse was 45, and there was no documented evidence that S30 reported the finding to the RN for assessment. Further review of the "Nursing Admit Assessment" revealed RN S8 assessed Patient #1 on 06/20/12 at 1:30pm (12 hours and 44 minutes after he had arrived on the unit). There was no documented evidence that RN S8 assessed Patient #1 upon admission to the unit as required by hospital policy. There was no documented evidence that RN S8 assessed Patient #1's vital signs or rechecked his heart rate that was documented by MHA S30 as 45.

Patient #2
Review of Patient #2's medical record revealed he was a [AGE] year old male admitted from the E.D. to the inpatient psychiatric unit on 07/18/11 at 8:15pm with the diagnosis of Psychosis. Further review revealed a PEC was signed on 07/17/11 at 5:45pm due to Patient 32 being questionably homicidal and violent, dangerous to self and others, and gravely disabled. Further review revealed a CEC was signed on 07/18/11 at 2:33pm due to Patient #2 being dangerous to others and gravely disabled. Further review of the CEC revealed next to the section for suicidal, homicidal, and violent the word "potentially" was written.

Review of Patient #2's "Psychiatric Nursing Admit Assessment" revealed the assessment of the following information was performed by MHA S29 on 07/18/11 at 8:15pm: height, weight, vital signs; medication and food allergies; patient care needs; diet and whether he had problems with weight loss and chewing or swallowing food; psychosocial factors; skin condition; history of violence and whether suicidal, homicidal, or having auditory/visual hallucinations; self care; special equipment or services used at home prior to admission, physical assessment including general appearance, appetite, oral mucosa; current living arrangements; community resources used by the patient; history of substance abuse; whether patient ever experienced symptoms of withdrawal from alcohol or drugs; previous medical history with a review of systems. Further review revealed the line labeled "completed by ___ date/time___) was signed by MHA S29 on 07/18/12 with no documented evidence of a time (beginning of assessment was timed by S29 at 8:15pm). Further review revealed RN S26 signed the form on 07/18/11 at 9:24pm.

Review of Patient #2's "Nursing Notes" revealed an entry written in the same handwriting of and signed by MHA S29 of "(date & Hour) 7/18/11 Admit Pt (patient) is a 38 y/o (year old) male admitted from the ED (with) a h/o (history of) depression. Pt oriented to unit/signed & (and) agreed to rules & regulations all sharps removed. Pt currently denies SI (suicidal ideation). Will continue to monitor". Further review revealed RN S26 signed next to MHA S29's signature. There was no documented evidence that a RN assessed Patient #2 to determine if any part of his admit assessment could be delegated to an unlicensed staff member.

In a face-to-face interview on 06/26/12 at 1:00pm, Acute Psychiatric Unit Director S4 indicated MHA S29 completed Patient #2's admit assessment and took his vital signs at 8:15pm on 07/18/11.

Patient #4
Review of the patient's medical record revealed the patient was a [AGE] year old female admitted on [DATE] at 1435 (2:35 p.m.) from the Emergency Department with diagnoses of suicide attempt and Depression. Patient #4 was PEC'd on 06/24/12 at 7:15 p.m. due to dangerous to self.

Review of Patient #4's "Nursing Admit Assessment" revealed PCT (Patient Care Technician) S38 assessed Patient #4's height, temperature, pulse, respirations, and sitting and standing blood pressure on 06/25/12 at 1435 (2:35 p.m.). Further review revealed Patient #4's Blood Pressure was 139/109, and there was no documented evidence that S38 reported the finding to the RN for assessment. Further review of the "Nursing Admit Assessment" revealed RN S7 assessed Patient #4 on 06/25/12 at 4:00 p.m. (1 hour and 25 minutes after she had arrived on the unit). The assessment documented by PCT S38 included the following: medication and food allergies; patient care needs including whether eyeglasses were needed for reading, any difficulty hearing, presence of pain, whether she had fallen recently, was experiencing weakness, dizziness, forgetfulness, wandering, confusion, or difficulty sleeping, whether she was on a special diet, had lost weight recently, or had difficulty chewing or swallowing foods; psychosocial factors related to abuse (elder, negligence, sexual, physical, psychological); skin assessment (for lacerations, abrasions, bruises, scar, burn, mole, birthmark, tattoos) by asking patient as evidenced by documentation of "denies all"; report of history of violence and whether currently reporting suicidal and/or homicidal ideation and auditory/visual hallucinations; self care needs including feeding, grooming, bathing, dressing, toileting, moving from bed to chair, and energy level; environmental factors including special equipment or services used at home prior to admission. RN S7 documented the section titled, "Physical Assessment", that included appearance, appetite, oral mucosa; current living arrangements; community resources used; history of substance abuse; whether she had ever experienced symptoms of withdrawal from alcohol or drugs; previous medical history including a review of systems. There was no documented evidence that RN S7 assessed Patient #4 upon admission to the unit as required by hospital policy. There was no documented evidence that RN S7 assessed Patient #4's vital signs or rechecked her Blood Pressure that was documented by PCT S38 as 139/109. There was no documented evidence that a RN assessed Patient #4 to determine if any part of her admit assessment could be delegated to an unlicensed staff member.

On 06/27/12 at 8:25 a.m., in a face-to-face interview with S23 RN, she was asked how she completed the admit assessment. S23 stated she reviewed what the MHA had documented and she completed page 3 and page 4. She stated, "Anyone can fill out the sections above the Physical Assessment section." She stated she asked the patient to verify what she received in report. S23 stated she talked to the patient and asked them what happened-why they were here. S23 stated she had been employed in the acute psychiatric unit for 7 years and worked the 7 p.m. to 7 a.m. shift.

Patient #5
Review of the patient's medical record revealed the patient was admitted on [DATE] at 2210 (10:10 p.m.) from the Emergency Department with diagnoses of Psychosis, Rule Out Substance Induced Psychosis. Patient #5 was PEC'd on 06/21/12 at 4:10 p.m. due to paranoid behavior and dangerous to others.

Review of Patient #5's "Psychiatric Nursing Admit Assessment" revealed the assessment of the following information was performed by MHA S24 on 06/21/12 at 10:10 p.m.: height, weight, vital signs; medication and food allergies; patient care needs; diet and whether he had problems with weight loss and chewing or swallowing food; psychosocial factors; skin condition; history of violence and whether suicidal, homicidal, or having auditory/visual hallucinations; self care; special equipment or services used at home prior to admission. Review of the section titled, "Physical Assessment", revealed the section was documented by S7RN and included the following: general appearance, appetite, oral mucosa; current living arrangements; community resources used by the patient; history of substance abuse; whether patient ever experienced symptoms of withdrawal from alcohol or drugs; previous medical history with a review of systems. Further review revealed RN S23 signed the form on 06/22/12 at 12:45 a.m. (2 hours and 35 minutes after patient's arrival on unit).

Review of Patient #5's "Nursing Notes" revealed an entry written in the same handwriting of and signed by MHA S24 of "06/21/12 2230 (10:30 p.m.) Admit note: Patient is a 32 y/o (year old) female admitted from _____ (Local Hospital) for paranoid behavior. OPC'd by father then PEC'd. No psych history. Patient was cooperative upon admit, but restless. Denies SI (suicidal ideation) and HI (Homicidal Ideations). Will continue to monitor behavior. Patient checked for sharps, oriented to unit and valuables were placed in patient belongings closet". Further review revealed RN S23 signed next to MHA S24's signature. There was no documented evidence that a RN assessed Patient #5 to determine if any part of his admit assessment could be delegated to an unlicensed staff member.

Patient #6
Review of the patient's medical record revealed the patient was a [AGE] year old male admitted on [DATE] at 3:43 a.m. from the Emergency Department with diagnoses of Depression, ETOH (Alcohol) Dependency, and Opiate Dependence. Patient #6 was PEC'd on 06/15/12 in the Emergency Department due to dangerous to self. The patient was CEC's on 06/18/12 due to dangerous to self.

Review of Patient #6's "Psychiatric Nursing Admit Assessment" revealed the assessment of the following information was performed by MHA S44 on 06/16/12 at 3:43 a.m.: height, weight, vital signs; medication and food allergies; patient care needs; diet and whether he had problems with weight loss and chewing or swallowing food; psychosocial factors; skin condition; history of violence and whether suicidal, homicidal, or having auditory/visual hallucinations; self care; special equipment or services used at home prior to admission. The section titled, "Physical Assessment", documented by RN S45, included general appearance, appetite, oral mucosa; current living arrangements; community resources used by the patient; history of substance abuse; whether patient ever experienced symptoms of withdrawal from alcohol or drugs; previous medical history with a review of systems. Further review revealed RN S45 signed the form on 06/16/12 at 3:55 a.m.

Review of Patient #6's "Nursing Notes" revealed an entry written in the same handwriting of and signed by MHA S44 of "0400 (4:00 a.m.) 06/16/12 Pt. is a 61 y/o (year old) male admitted with depression and history of substance abuse. Recent relapse. Disheveled appearance, appropriate behavior, cooperative and pleasant. Complained of leg and back pains. PEC and placed on MVC. Asleep after assessment when observed." Further review revealed RN S45 signed next to MHA S44's signature. There was no documented evidence that a RN assessed Patient #6 to determine if any part of his admit assessment could be delegated to an unlicensed staff member.

Patient #16
Review of Patient #16's medical record revealed she was a [AGE] year old female admitted on [DATE] with diagnoses of Psychosis and Bipolar Disorder by history.

Review of Patient #16's "Acute Psychiatric Unit Nursing Admit Assessment" documented by LPN S40 on 06/25/12 at 3:35pm revealed the following patient information was assessed by LPN S40: vital signs; orientation to the environment; medication and food allergies; patient care needs; diet and whether she had problems with weight loss and chewing or swallowing food; psychosocial factors; skin condition; history of violence and whether suicidal, homicidal, or having auditory/visual hallucinations; self care; special equipment or services used at home prior to admission; and whether any medical conditions or disability/limitations exist that would place her at greater risk during restraint use. Further review revealed the physical assessment including general appearance, appetite, and oral mucosa, current living arrangements, community resources used by the patient, assessment of substance abuse and whether she ever experienced any symptoms of withdrawal from alcohol or drugs, and her previous medical history including a review of systems was completed by RN S23 on 06/25/12 at 9:09pm (5 hours and 34 minutes after she had been assessed by LPN S40). There was no documented evidence that Patient #16 was assessed by a RN to determine if any part of the admit assessment could be delegated to a LPN.

Review of Patient #16's "Nursing Notes" revealed an entry on 06/25/12 at 3:40pm by LPN S40 that Patient #16 was unable to finish answering questions for the admit packet, because she began to cry. Review of the Acute Psychiatric Unit Nursing Admit Assessment" documented by LPN S40 on 06/25/12 at 3:35pm revealed no documented evidence of the time LPN S40 completed the admit assessment.

Patient #17
Review of Patient #17's medical record revealed he was a [AGE] year old male admitted on [DATE] with the diagnosis of Depression.

Review of Patient #17's "Nursing Admit Assessment" revealed LPN S37 completed the following assessments on 06/24/12 at 3:45pm:
General Information including height, weight, vital signs;
Medication and food allergies;
Patient care needs including assessment of sight, if difficulty hearing, pain, falls recently, weakness or dizziness, forgetfulness, wandering or confusion, difficulty sleeping, special diet, recent weight loss, and difficulty chewing or swallowing foods;
Psychosocial factors including evidence of abuse or history of abuse;
Body identification marks;
Medical conditions or disability/limitations that would place him at greater risk if placed in restraints and whether he'd been restrained or secluded before;
History of violent behavior;
Whether currently reporting suicidal ideation, homicidal ideation, auditory/visual hallucinations;
Self care needs;
Environmental factors including special equipment or services used at home prior to admission.
Further review revealed RN S8 completed the physical assessment on 06/24/12 at 4:00pm which included Patient #17's general appearance, appetite, oral mucosa, current living arrangements, community resources used by the patient, substance abuse history, whether he had ever experienced symptoms of withdrawal from alcohol or drugs, previous medical history, and a review of systems. There was no documented evidence that RN S8 reviewed the information collected from LPN S37's assessment of Patient #17. There was no documented evidence that RN S8 had assessed Patient #17 to determine if any part of his assessment could be delegated to a LPN.

Patient #19
Review of the patient's medical record revealed the patient was a [AGE] year old male admitted on [DATE] at 2210 (10:10 p.m.) from the Emergency Department with diagnoses of Depression and Poor Impulse Control with Laceration to Left Wrist. Patient #19 was PEC'd on 06/25/12 at 9:05 p.m. due to Dangerous to self and unwilling.

Review of Patient #19's "Psychiatric Nursing Admit Assessment" revealed the assessment of the following information was performed by LPN S40 on 06/25/12 at 10:10 p.m.: height, no weight, vital signs; medication and food allergies; patient care needs; diet and whether he had problems with weight loss and chewing or swallowing food; psychosocial factors; skin condition; history of violence and whether suicidal, homicidal, or having auditory/visual hallucinations; self care; special equipment or services used at home prior to admission. Review of the section titled, "Physical Assessment", documented by RN #23 included general appearance, appetite, oral mucosa; current living arrangements; community resources used by the patient; history of substance abuse; whether patient ever experienced symptoms of withdrawal from alcohol or drugs; previous medical history with a review of systems. Further review revealed RN S23 signed the form on 06/25/12 at 11:45 p.m.

Review of Patient #19's "Nursing Notes" revealed an entry written in the same handwriting of and signed by LPN S40 of "06/25/12 2210 (10:10 p.m.) Admit note: Pt. received to unit on PEC from ER (emergency room ). Affect flat. Pt. stated "I don't know why I'm here. They think I tried to kill myself." Pt. has not eaten since Friday. Pt. C/O (Complained of) left laceration on proximal wrist. Laceration is packed with Aquacel and covered with gauze and kerlex. Also pt. has bruises to bilateral elbows. Pt. denies SI and HI. Pt. felt nauseous after admitted . I helped to bathroom to vomit. Pt. did not vomit. Oriented pt. to unit. Pt. expressed understanding of teaching.
There was no documented evidence that a RN assessed Patient #19 to determine if any part of his admit assessment could be delegated to an unlicensed staff member.

Review of the MHA "Job Description", presented as the current job description by Performance Improvement Manager S1, revealed, in part, "...Essential Job Duties: ...20% (per cent) 2. Conducts Admit Patient Assessment...".

Review of the LPN "Job Performance Standards", presented as current by Performance Improvement Manager S1, revealed, in part, "...Essential Job Duty: ... 1. Demonstrates effective use of the Nursing Process in the delivery of patient care. a. Assessment b. Planning c. Evaluation In collaboration with the RN, utilizes clinical skills and knowledge in the assessment of client's health status (physiologic, psychosocial, emotional, cultural and spiritual). In consultation with the RN, integrates patient data in the development of an individualized plan of care utilizing appropriate reference material...".

Review of the MHA's "Job Performance Standards", presented as the current standards by Performance Improvement Manager S1, revealed, in part, "...II. Conducts Admit Assessment Under the directions of the RN, conducts admit assessment within 8 hours of admit, including biopsychosocial, environmental, self care, educational needs, discharge planning needs, and input from patient/family/significant other...".

In a face-to-face interview on 06/25/12 at 3:45pm, Assistant Vice-President of Nursing S5 indicated the hospital allowed ancillary staff to collect data within their scope including height, weight, and vital signs, and the RN completed the physical assessment portion of the admit assessment. When informed that a patient's height, weight, and vital signs were part of a physical assessment, S5 indicated they allow ancillary staff to collect data "on their skill set and they're trained to take vital signs and the RN reviews their data".

In a face-to-face interview on 06/26/12 at 3:00pm, Assistant Vice-President of Nursing S5 indicated she had done a lot of research and had determined that the LPN could perform psychosocial assessments and collect data for the admit assessment. She further indicated that LPNs throughout the hospital did psychosocial assessments. She further indicated the MHAs had degrees but were not licensed. When asked if the Louisiana State Board of Registered Nurses (LSBN) would view MHAs as unlicensed personnel, S5 shook her head indicating yes.

In a face-to-face interview on 06/27/12 at 8:25am, RN S23 indicated her assessment of the patient on admit included her talking to the patient and asking what happened that brought them into the hospital. She further indicated that if a patient had a wound or any medical issue, she would check it herself. S23 indicated the MHA completed the couple pages of the admit assessment form. She further indicated that she reviewed what the MHA documented on the first 2 pages, but she liked to question the patient about what the MHA documented on the ADLs (activities of daily living) and medications. S23 indicated she completes the physical assessment portion of the admit assessment form.

In a face-to-face interview on 06/27/12 at 12:40pm, Assistant Vice-President of Nursing S5 indicated she used the LSBN nurse practice act as a resource regarding nursing assessments. She further indicated she looked at the part stating RNs could delegate predictable tasks to unlicensed staff, unlicensed staff could gather data, and the RN could make decisions based on the data collected. She further indicated patient blood pressures were performed with the use of a Dinamap and not taken manually. When asked how a RN could know which patient could be delegated to LPNs or unlicensed staff (MHA) when the RN had not yet assessed the patient, S5 could offer no explanation.

In a face-to-face interview on 06/27/12 at 3:45pm, RN S26 indicated the MHA performs the vital signs, addresses patient valuables and sharps, and checks patient allergies when the patient presents to the unit for admission. She further indicated she usually completed the remainder of the admit assessment. S26 indicated if the MHA had completed the nursing assessment form up to the physical assessment (which she does as the RN), she would go back and ask the patient the same information to verify what the MHA had documented.

In a face-to-face interview on 06/27/12 at 4:05pm, RN S27 indicated her role for patient admit assessments was to complete the fall assessment, the suicide assessment, and go behind and check the medical history and orders that were done by the MHA and check any abnormal findings. She further indicated that she did this by taking the chart in the patient's room and asked the patient the same questions to make sure that what the MHA or LPN documented was accurate. She further indicated she only reassessed the vital signs if they were abnormally high or low.

In a face-to-face interview on 06/27/12 at 4:15pm, Assistant Vice-President of Nursing S5 indicated, when asked why the acute psychiatric unit would hold the admit assessment of patients to a lower standard than other areas of the hospital (psychiatric unit did not specify that nursing assessments had to be performed by a RN), S5 indicated they allow MHAs to collect data.

Review of the hospital policy titled "Assessment and Reassessment (hospitalized Patients)", number OHS.NURS.017, revised 12/10, and presented as a current policy by Performance Improvement Manager S1, revealed, in part, "...A. Upon admission to the unit, a registered nurse will assess each patient to collect data, determine any immediate needs and make appropriate care assignments. 1. Specific elements of data collection may be delegated based upon the patient's condition and defined competencies of the patient care personnel according to the rules of delegation by the LA State Board of Nursing. B. The admission assessment must be completed by a Registered Nurse within 24 hours of admission to the unit. Essential elements of this assessment include: 1. Patient History 2. Physical systems review 3. Biopsychosocial systems review 4. Environmental concerns 5. Cultural, spiritual, developmental and educational needs assessment 6. Sensory, functional, abuse/neglect, nutritional, fall risk and pain 7. Assessment of potential discharge needs...".

Review of the hospital policy titled "Acute Psychiatry Unit Operational Standards Admission/Discharge", policy number 6340-EO2, revised 03/11, and presented as a current policy by Performance Improvement Manager S1, revealed, in part, "...I. Admission To The Unit: ...B. Nursing Responsibilities: 1. The nursing staff initiates a biopsychosocial assessment, utilizing the Acute Psychiatry Admission Assessment form and the Nursing Assessment Form upon admission to APU (Acute Psychiatry Unit). 2. The admission assessment forms must be completed within 24 hours of admission to the unit. ... 3. The Mental Health Associate (MHA) or Recreation Therapist may initiate the bio-psychosocial assessment of the patient, but the RN must review information, verify completeness and accuracy of the information and initiate the Interdisciplinary Treatment Plan...".

Daily nursing assessments:
Review of the "Acute Psychiatry Nursing Flow Sheet" revealed the following patient assessments were included to be documented for each shift:
Nutrition/appetite - good, adequate, fair, poor, improving, overeating, special diet, purging, binging;
Suicidal - verbalizes ideation, self harm behavior, hopelessness, intermitted ideation, denies;
Homicidal - ideation, threat, denies;
Thought process - grandiose, self depreciative, flight of ideas, delusions, loose associations, ideas of reference, hallucinations, phobias, illogical, rambling, tangential, coherent, clear, poor, concentration;
Appearance - un-kept, unclean, well groomed, fair, ADL's (activities of daily living) completed, yes/no;
Attitude/mood - stable, sad, euphoric, labile, irritable, guilty, fearful, apathetic, depressed, anxious, guarded;
Affect - flat, blunted, tearful, appropriate to mood, fearful, consistent;
Behavior - appropriate, agitated, impulsive, avoids eye contact, anxious, psychomotor retarded, threatening, paranoid, physically aggressive, using denial, somatic, oppositional, pushing limits, combative, tics, participating in treatment, withdrawn, hyper, intrusive, short attention span, negative;
Withdrawal - tremors, VS (vital signs) unstable, cramping, N/V (nausea/vomiting), craving, VS WNL (vital signs within normal limits), bone pain, diarrhea, med seeking, diaphoresis;
Memory - recent impaired, recent intact, oriented, disoriented, confused.

Patient #1
Review of Patient #1's medical record revealed he was an [AGE] year old male admitted on [DATE] with the chief complaint of aggressive behavior. Patient #1 was PEC'd on 06/19/12 at 3:30pm due to being violent and dangerous to others. Patient #1 was CEC'd on 06/20/12 at 10:50am due to being dangerous to others and gravely disabled.

Review of Patient #1's "Acute Psychiatry Nursing Flow Sheet" revealed the assessments were performed as follows:
06/20/12 at 3:00pm by RN S8;
06/21/12 at 6:00am by MHA S22 - only documentation was that the patient slept the entire shift;
06/22/12 at 2:00pm by Recreation Therapist S25;
06/22/12 at 9:20pm by MHA S24;
06/23/12 at 6:03am by MHA S22 - only documentation was that the patient slept the entire shift;
06/23/12 at 4:20pm by MHA S36;
06/23/12 at 11:00pm by MHA S30;
06/24/12 at 5:55am by MHA S30;
06/24/12 at 2:20pm by MHA S24;
06/24/12 at 8:30pm by LPN S37;
06/25/12 at 5:42am by MHA S22 - only documentation was that the patient slept the entire shift.
There was no documented evidence that Patient #1 was assessed by a RN on 06/21/12, 06/22/12, 06/23/12, 06/24/12, and 06/25/12 to determine if his care could be delegated to a LPN or an unlicensed staff member.

Patient #5
Review of the patient's medical record revealed the patient was admitted on [DATE] at 2210 (10:10 p.m.) from the Emergency Department with diagnoses of Psychosis, Rule Out Substance Induced Psychosis. Patient #5 was PEC'd on 06/21/12 at 4:10 p.m. due to paranoid behavior and dangerous to others.

Review of the Nursing Flow Sheets revealed the assessments were performed as follows:
06/21/12 at 10:30 p.m. by MHA S24
06/22/12 at 6:25 a.m. by MHA S22, only documentation was patient sleeping entire shift.
06/22/12 at 2:00 p.m. by MHA S25
06/22/12 at 9:20 p.m. by MHA S24
06/23/12 at 6:01 a.m. by MHA S22, only documentation was patient sleeping entire shift.
06/23/12 at 5:20 p.m. by MHA S36
06/23/12 at 11:00 p.m. by MHA S30
06/24/12 at 5:48 a.m. by MHA S30, only documentation was patient sleeping entire shift.
06/24/12 at 2:10 p.m. by MHA S24
06/24/12 at 8:30 p.m. by LPN S37
06/25/12 at 5:40 a.m. by MHA S22, only documentation was patient sleeping entire shift.
There was no documented evidence of an assessment of the patient by the RN on 06/22/12, 06/23/12, and 06/24/12 to determine if the patient's care could be delegated to an LPN or an unlicensed staff member.

Patient #6
Review of the patient's medical record revealed the patient was a [AGE] year old male admitted on [DATE] at 3:43 a.m. from the Emergency Department with diagnoses of Depression, ETOH (Alcohol) Dependency, and Opiate Dependence. Patient #6 was PEC'd on 06/15/12 in the Emergency Department due to dangerous to self. The patient was CEC's on 06/18/12 due to dangerous to self.

Review of the Nursing Flow Sheets revealed the assessments were performed as follows:
06/16/12 at 6:15 a.m. by MHA S44, only documentation was patient sleeping entire shift.
06/17/12 at 5:55 a.m. by MHA S22, only documentation was patient sleeping entire shift.
06/17/12 at 5:30 p.m. by MHA S36
06/18/12 at 5:18 a.m. by MHA S22, only documentation was patient sleeping entire shift.
06/18/12 at 1:00 p.m. by MHA S25
06/18/12 at 8:30 p.m. by LPN S37
06/21/12 at 6:00 a.m. by MHA S22, only documentation was patient sleeping entire shift.,
06/21/12 at 7:00 p.m. by MHA S25
06/21/12 at 8:55 p.m. by MHA S24
06/22/12 at 6:24 a.m. by MHA S22, only documentation was patient sleeping entire shift.
06/22/12 at 2:00 p.m. by MHA S25
06/22/12 at 9:20 p.m. by MHA S24
06/23/12 at 6:01 a.m. by MHA S22, only documentation was patient sleeping entire shift.
06/23/12 at 3:20 p.m. by MHA S36
06/23/12 at 11:00 p.m. by MHA S30
06/24/12 at 5:42 a.m. by MHA S30, only documentation was patient sleeping entire shift.
06/24/12 at 2:10 p.m. by MHA S24
06/24/12 at 8:30 p.m. by LPN S37
There was no documented evidence of an assessment of the patient by the RN on 06/17/12, 06/18/12, 06/21/12, 06/23/12, and 06/24/12 to determine if the patient's care could be delegated to an LPN or an unlicensed staff member.

Patient #16
Review of Patient #16's medical record revealed she was a [AGE] year old female admitted on [DATE] with diagnoses of Psychosis and Bipolar Disorder by history.

Review of Patient #16's "Nursing Flow Sheet" revealed MHA S22 documented on 06/26/12 at 5:00am that she slept the entire shift. Review of the "Nursing Plan of Care" revealed RN S23 documented on 06/25/12 at 7:00pm that there was no change noted for the 3:00pm to 11:00pm shift. There was no documented evidence that a RN assessed Patient #16 on the 11:00pm to 7:00am shift of 06/25/12 as evidenced by the "Nursing Plan of Care" being blank.

Patient #17
Review of Patient #17's medical record revealed he was a [AGE] year old male admitted on [DATE] with the diagnosis of Depression.

Review of Patient #17's "Acute Psychiatry Nursing Flow Sheet" revealed the assessments were performed as follows:
06/24/12 at 3:45pm by LPN S37;
06/25/12 at 5:43am by MHA S22;
06/25/12 at 2:00pm by Recreation Therapist S25;
06/25/12 at 11:51pm by LPN S40;
06/26/12 at 5:00am by MHA S22;
06/26/12 at 10:45am by RN S27.
There was no documented evidence that Patient #17 was assessed by a RN on 06/25/12 and 06/26/12 prior to 10:4
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and record reviews, the hospital failed to ensure a patient's family member was provided with discharge paperwork to prepare them for post-hospital care for 1 of 7 (#10) patients reviewed for discharge planning. Findings:
Review of the medical record revealed Patient #10 was an [AGE] year old female admitted on [DATE] with the chief complaint of altered mental status. Further review revealed Patient #10's past medical history included hypertension (high blood pressure), diabetes (blood sugar problems), CVA (stroke), and Depression. Patient #10 was discharged to home with home health on 5/26/12 at 14:07 (2:07 p.m.).
Review of the nurse's notes for 5/26/12 revealed no entries had been made except Plan of care reviewed with patient/family to validate identified problems/needs. In an interview on 6/27/12 at 1:15 p.m. with RN Assistant Vice President of Nursing S5, she indicated this was a computer generated response and was very misleading. After review of Patient #10's nursing notes, she indicated this response was written approximately every 12 hours and was computer generated. S5 indicated there was no way the staff spoke with the family every twelve hours, and the patient was unable to speak because she was unresponsive.
In an interview on 6/26/12 at 2:25 p.m. with S14 Registered Nurse (RN), she indicated if formalized teaching had been done with a patient, the corresponding form would have been printed and placed on the patient's medical record. If the teaching with the patient was not formalized, S14 indicated she would have written what teaching she had completed in her nurse's notes. RN S14 indicated the nurse who discharged a patient was ultimately responsible for ensuring the discharge teaching had been completed for the patient. S 14 also indicated the RN performing the patient's discharge was responsible for providing the discharge paperwork to the patient or families. S14 indicated a copy of the "medication instruction sheet" should have been sent to the home health agency and another copy given to the family or patient on discharge. S14 indicated for Patient #10, the discharge instruction sheet had been signed by her, but she had not done the teaching to the family or patient. S14 stated Physician S19 said she had done the discharge teaching to the family. When asked if the physician had completed all of the teaching for medications, appointments, treatments, and feedings, she indicated yes. There was no documentation in Patient #10 ' s medical record that Physician S19 had completed any discharge teaching for Patient #10. S14 indicated Physician S19 indicated the family had been well informed and S14 did not need to do additional teaching to the family. S14 indicated she had given discharge instructions on the telephone to a nurse who she thought worked for the home health agency. S14 stated she did not remember giving the discharge packet to the ambulance driver transporting patient #10 to her home, but would be unlikely that she did not give the packet to the ambulance driver. S14 verified that she had not documented in the medical record that the discharge documents had been given to the family or to the ambulance driver. S14 also indicated that she had not documented Physician S19 telling her to not give discharge instructions to the family, and had not signed off the physician ' s order dated 6/26/12 at 11:42 a.m. to D/C (discharge) the patient, and had not written any nurse's notes on 6/26/12. S14 said the only note was that the plan of care was reviewed with the patient/family to validate identified problems/needs, but that was just a note about care plans that was generated by the computer. She said the plan of care was not discussed every 12 hours with the patient or family.
In an interview on 6/27/12 at 1:15 p.m. with S5 RN Assistant Vice President of Nursing, she indicated she could not locate any nurse's notes for Patient #10 on 5/26/12. S5 said she would have expected a note from S14 RN about discharge teaching being completed, and discharge paperwork having been given to the ambulance driver transporting Patient #10 home, and documentation of the time Patient #10 had been discharged .
In an interview on 6/27/12 at 2:00 p.m. with Patient #10's son, he indicated his mother had been sent home from the hospital on [DATE] with an allergy band on her arm, but no other discharge documentation had been sent from the hospital. Patient #10 ' s son said he and the private home nurse called the hospital several times to obtain discharge instructions and medication orders, but did not receive discharge papers until two weeks after discharge.
In an interview on 6/27/12 at 3:05 p.m. with Patient #10's private home nurse, she indicated she had gotten a "sketchy report" from S14 RN on 5/26/12. The private home nurse said S14RN only gave her a brief history of Patient #10's past history and what medications Patient #10 had already received earlier in the day. The private home nurse also indicated when Patient #10 arrived home, there were no discharge instructions with Patient #10. The private home nurse asked the paramedic if he had any paperwork from the hospital, and the paramedic indicated he had not been given any paperwork from the hospital. The private home nurse stated that she had called back to the hospital and S14 RN told her the social worker had the discharge paperwork. The private home nurse left several messages with the social worker, but never received a return call.
A review was done of the hospital's Policy titled "Discharge Planning, Nursing", Policy OHS.NURS.039, Date of issue January 2011. The Policy stated in part:
B. Upon receiving discharge orders, the nurse will complete home care instructions and review information regarding medications (reconciliation) and any other pertinent information with the patient.
C. A list of home medications will be given to the patient (if applicable) along with additional instructions.
V. Enforcement and Exceptions
A. Failure to follow this standard can result in failure to provide appropriate patient care and can result in disciplinary action for the employee.