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.

ST TAMMANY PARISH HOSPITAL 1202 S TYLER STREET COVINGTON, LA 70433 June 24, 2011
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the hospital failed to ensure compliance with the rights of a patient (Patient #2) who presented to the hospital's ED (Emergency Department) in need of services by failing to ensure personal privacy as glasses were placed on the face of Patient #2 while he (Patient #2) was unresponsive in the ED and a picture of Patient #2's face was seen on a cellular phone with the glasses on his (Patient #2) face. The glasses were in a drawer in the ED prior to Patient #2's arrival to St. Tammany Parish Hospital and were not his (Patient #2) glasses. Findings:

The medical record of Patient #2 was reviewed. This review revealed that Patient #2 presented to St. Tammany Parish Hospital's Emergency Department on 5/02/10 and was triaged by S10 (ED registered nurse) on 5/02/10 at 7:10 p.m. The ED (Emergency Department) Triage Assessment documents the "Chief Complaint" as "pt reports taking 22 Lortab 10 & Klonopin unknown amt @ 1000 this a.m. Pt's cousin states he took more than that approx 130 tablets. Pt very drowsy, but answers questions appropriately. Pt stated he's depressed & going through a divorce". Review of the "Patient Care Notes" revealed an entry by S9 (ED registered nurse) indicating that Patient #2 was taken to "C-1" on 5/02/10 at 7:04 p.m. and was lethargic with slurred speech. Further review revealed an entry by S7 (ED registered nurse) indicating that a 32 French OG (Oral-Gastric) tube was inserted and Patient #2 was medicated with 125 grams of charcoal at 8:15 p.m. Further review revealed an entry by S7 (ED registered nurse) indicating that Patient #2 vomited a large amount of charcoal & possibly aspirated and S18 (ED physician) was at the bedside at 8:30 p.m. Further review revealed an entry by S7 (ED registered nurse) indicating that Patient #2 was intubated by S17 (ED physician) with a 7.0 ETT (Endotracheal Tube) and placed on ventilator support at 9:04 p.m. Further review revealed an entry by S7 (ED registered nurse) indicating that Patient #2 was transported to the Intensive Care Unit via stretcher at 10:05 p.m. The "Emergency Department Nursing Record" documents that 0.4mg of Narcan was administered intravenously on 5/02/10 at 8:17 p.m. and 2mg of Narcan was administered intravenously on 5/02/10 at 8:30 p.m. Review of the "History and Physical" dated 5/02/10 revealed that Patient #2's diagnoses included drug overdose, mental status change, respiratory acidosis, elevated thyroid stimulating hormone, and hyperglycemia. Review of the "Discharge Summary" revealed Patient #2 was discharged from St. Tammany Parish hospital on [DATE] and transferred to an inpatient psychiatric facility for admission and treatment.

S4 (Emergency Care Services Department Head) was interviewed on 6/22/11 at 2:30 p.m. S4 reviewed the medical record of Patient #2. S4 reported that he was attending an educational conference in Grapevine, Texas at the time of Patient #2 hospitalization in May of 2010. S4 reported that he received a call from either S21 (DON) or S2 (CNO) on either Wednesday (5/05/10) or Thursday (5/06/10) and was informed of an event that took place in the ED earlier in the week. S4 reported that he returned back to the hospital on Friday (5/07/10). S4 indicated that S21 and S2 had initiated an internal investigation relating to a reported incident involving Patient #2 prior to his return to the hospital. S4 indicated that one of the ED technicians (S15) reported that some of the ED nurses had taken pictures of Patient #2 after placing glasses on him and drawing lines on his face while he was unresponsive in the ED. S4 indicated that he participated with S21 in the interview of S12 (ED registered nurse) and S11 (ED registered nurse) sometime after his return to the hospital. S4 reported that he could not remember the date or time of the meetings. When asked if he maintained any notes or documentation relating to the interviews with S12 and S11 to include the date, time and/or investigatory findings, S4 reported that he did not have any documentation of the investigatory findings. S4 reported that S21 asked S12 about the event and that S12 denied witnessing the event and denied having anything to do with the event involving Patient #2. S4 reported that S11initially denied having knowledge of the event involving Patient #2 in her interview, but submitted a letter to S21 soon after the interview indicating that she (S11) was not completely honest during her interview as she did have knowledge that someone had put glasses on Patient #2 and that S10 took a picture of Patient #2 with the glasses on. S4 reported that he was not present for any other interviews. S4 reported that S21 and S2 conducted the internal investigation and that indicated that he was told of the outcome by S21 and S2. S4 reported that S10 (ED registered nurse) had taken a picture with a cell phone of Patient #2 with glasses on that had been left in the ED by a former patient. S4 indicated that S10 resigned from employment with St. Tammany Parish hospital on [DATE] instead of being discharged . S4 indicated that S11 received a "decision making leave day" for withholding information during the interview. When asked how long the glasses that were placed on Patient #2's face had been in the ED, S4 reported that the glasses had been left in the ED years ago.

S9 (ED registered nurse) was interviewed on 6/23/11 at 11:00 a.m. S9 reported that she works as a registered nurse in the ED. S9 reviewed the medical record of Patient #2. S9 indicated that her first contact with Patient #2 was on 5/02/10 at 7:04 p.m. at which time a cardiac monitor, blood pressure cuff, and pulse oximeter were placed on the patient. S9 reported that S10 was the triage nurse and S7 was the primary nurse. S9 reported that she was in and out of Patient #2's room and would assist S7 as needed. S9 indicated that there were several nurses assisting with Patient #2's care while in the ED. When asked if eyeglasses were placed on Patient #2 and/or if a picture had been taken of Patient #2, S9 reported that S10 handed her a cell phone that had a picture of Patient #2 with glasses on his face and with lines drawn under both eyes. S9 reported that the lines were well defined, black, and appeared to be charcoal. When asked if the lines appeared to be from the patient vomiting or appeared to be smeared on the patients face as a result of wiping, S9 indicated the lines did not appear to be a result of vomiting or smearing. S9 reported that Patient #2 was still in the ED when she saw the picture on the cell phone. S9 reported that she did not know who the cell phone belonged to. S9 reported that S10, S11, S7, S15, S16, and S12 were in the room when she saw the picture of Patient #2 and that she heard laughter in the room. S9 reported that she told S10 and S11 they "needed to stop". S9 reported she overheard from S12, S10, and S11 that this (glasses placed on patients and pictures taken) has happened before and that S10, S11, and S12 were going to compare the pictures to determine which one was the best. When asked if she had been interviewed by anyone from the hospital prior to this interview, S9 indicated that she discussed this incident with S21 (Director of Nursing) not long after the incident occurred but was not sure of the date.

S21 (Director of Nursing) was interviewed on 6/24/11 at 10:00 a.m. When asked about the steps taken by hospital administration after being made aware of the 5/02/10 incident involving Patient #2, S21 reported she created a grid of information obtained from the different employees she interviewed for the 5/02/10 incident involving Patient #2. Review of the grid created by S21 revealed the names of personnel interviewed but no date and/or time of the interviews. Documentation on this grid created by S21 that included information relating to the hospital's internal investigation revealed the following:

S7 (ED registered nurse) indicated "Eye glasses were placed on patient while he was pushing charcoal thru the OGT but he does not know who put them on patient" and "a picture was taken of the patient but he does not know who took the picture".

S9 (ED registered nurse) indicated "Eye glasses were on patient when she walked into C1. She didn't see who put them on patient. (S12) was at the head of the bed" and "A picture was taken and (S9) saw the picture on a cell phone. The phone was in (S10)'s hand. She knows that another patient had the glasses on and a picture was taken. She doesn't remember what patient".

S12 (ED registered nurse) indicated "Eye glasses were on patient-she didn't see who put them on. Has never placed glasses on a patient and does not know of any other patient they were placed on" and "(S10) took a picture of the patient with the glasses on".
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the hospital failed to ensure compliance with the rights of a patient (Patient #2) who presented to the hospital's ED (Emergency Department) in need of services as evidenced by failing to ensure Patient #2 was free from all forms of abuse or harassment while receiving services in the hospital and failing to assure that any incidents of abuse or harassment were reported in accordance with applicable State law. The Staff to Patient Abuse included glasses being placed on the face of Patient #2 while he (Patient #2) was unresponsive in the ED and a picture of Patient #2's face being seen on a cellular phone with the glasses on his (Patient #2) face. The glasses were in a drawer in the ED prior to Patient #2's arrival to St. Tammany Parish Hospital and were not his (Patient #2) glasses. Findings.

The medical record of Patient #2 was reviewed. This review revealed that Patient #2 presented to St. Tammany Parish Hospital's Emergency Department on 5/02/10 and was triaged by S10 (ED registered nurse) on 5/02/10 at 7:10 p.m. The ED (Emergency Department) Triage Assessment documents the "Chief Complaint" as "pt reports taking 22 Lortab 10 & Klonopin unknown amt @ 1000 this a.m. Pt's cousin states he took more than that approx 130 tablets. Pt very drowsy, but answers questions appropriately. Pt stated he's depressed & going through a divorce". Review of the "Patient Care Notes" revealed an entry by S9 (ED registered nurse) indicating that Patient #2 was taken to "C-1" on 5/02/10 at 7:04 p.m. and was lethargic with slurred speech. Further review revealed an entry by S7 (ED registered nurse) indicating that a 32 French OG (Oral-Gastric) tube was inserted and Patient #2 was medicated with 125 grams of charcoal at 8:15 p.m. Further review revealed an entry by S7 (ED registered nurse) indicating that Patient #2 vomited a large amount of charcoal & possibly aspirated and S18 (ED physician) was at the bedside at 8:30 p.m. Further review revealed an entry by S7 (ED registered nurse) indicating that Patient #2 was intubated by S17 (ED physician) with a 7.0 ETT (Endotracheal Tube) and placed on ventilator support at 9:04 p.m. Further review revealed an entry by S7 (ED registered nurse) indicating that Patient #2 was transported to the Intensive Care Unit via stretcher at 10:05 p.m. The "Emergency Department Nursing Record" documents that 0.4mg of Narcan was administered intravenously on 5/02/10 at 8:17 p.m. and 2mg of Narcan was administered intravenously on 5/02/10 at 8:30 p.m. Review of the "History and Physical" dated 5/02/10 revealed that Patient #2's diagnoses included drug overdose, mental status change, respiratory acidosis, elevated thyroid stimulating hormone, and hyperglycemia. Review of the "Discharge Summary" revealed Patient #2 was discharged from St. Tammany Parish hospital on [DATE] and transferred to an inpatient psychiatric facility for admission and treatment.

S4 (Emergency Care Services Department Head) was interviewed on 6/22/11 at 2:30 p.m. S4 reviewed the medical record of Patient #2. S4 reported that he was attending an educational conference in Grapevine, Texas at the time of Patient #2 hospitalization in May of 2010. S4 reported that he received a call from either S21 (DON) or S2 (CNO) on either Wednesday (5/05/10) or Thursday (5/06/10) and was informed of an event that took place in the ED earlier in the week. S4 reported that he returned back to the hospital on Friday (5/07/10). S4 indicated that S21 and S2 had initiated an internal investigation relating to a reported incident involving Patient #2 prior to his return to the hospital. S4 indicated that one of the ED technicians (S15) reported that some of the ED nurses had taken pictures of Patient #2 after placing glasses on him and drawing lines on his face while he was unresponsive in the ED. S4 indicated that he participated with S21 in the interview of S12 (ED registered nurse) and S11 (ED registered nurse) sometime after his return to the hospital. S4 reported that he could not remember the date or time of the meetings. When asked if he maintained any notes or documentation relating to the interviews with S12 and S11 to include the date, time and/or investigatory findings, S4 reported that he did not have any documentation of the investigatory findings. S4 reported that S21 asked S12 about the event and that S12 denied witnessing the event and denied having anything to do with the event involving Patient #2. S4 reported that S 11 initially denied having knowledge of the event involving Patient #2 in her interview, but submitted a letter to S21 soon after the interview indicating that she (S11) was not completely honest during her interview as she did have knowledge that someone had put glasses on Patient #2 and that S10 took a picture of Patient #2 with the glasses on. S4 reported that he was not present for any other interviews. S4 reported that S21 and S2 conducted the internal investigation and that indicated that he was told of the outcome by S21 and S2. S4 reported that S10 (ED registered nurse) had taken a picture with a cell phone of Patient #2 with glasses on that had been left in the ED by a former patient. S4 indicated that S10 resigned from employment with St. Tammany Parish hospital on [DATE] instead of being discharged . S4 indicated that S11 received a "decision making leave day" for withholding information during the interview. When asked how long the glasses that were placed on Patient #2's face had been in the ED, S4 reported that the glasses had been left in the ED years ago. When asked if he felt that putting glasses on an unresponsive or comatose patient and then taking a picture of the patient with the glasses on was patient abuse, S4 stated "absolutely".

The daily staffing report for the date of 5/02/10 was reviewed. This review revealed the following staff members were working in the ED at St. Tammany Parish Hospital during the time of Patient #2's treatment in the ED: S7 (ED registered nurse), S10 (ED registered nurse), S13 (ED registered nurse), S12 (ED registered nurse), S8 (ED registered nurse), S9 (ED registered nurse), S11 (ED registered nurse), S14 (ED technician), S15 (ED technician), and S16 (ED technician).

S5 (Vice President of Human Resources) was interviewed on 6/22/11 at 3:00 p.m. and on 6/23/11 at 10:40 a.m. When asked about the current employment status of the S7 (ED registered nurse), S10 (ED registered nurse), S13 (ED registered nurse), S12 (ED registered nurse), S8 (ED registered nurse), S9 (ED registered nurse), S11 (ED registered nurse), S14 (ED technician), S15 (ED technician), and S16 (ED technician), S5 indicated that S7, S8, S9, S13, and S14 are still employed with St. Tammany Parish Hospital and that S10, S11, S12, S15, and S16 are no longer employed at St. Tammany Parish Hospital.

? S5 reported S10 resigned on 5/13/10. S5 indicated that S10 would have been discharged from employment as a result of the incident involving Patient #2 had she not voluntarily resigned.
? S5 reported that S11's separation date was 6/03/11. S5 indicated that S11 walked into the Human Resources Department and turned in her letter of resignation.
? S5 reported that S12 had received a one day " Decision Making Leave " disciplinary action on 5/13/10 relating to the incident involving Patient #2 and was placed on " Administrative Leave " on 6/02/11 relating to " unit operational concerns " secondary to increased public awareness of the incident involving Patient #2 in May of 2010. S5 indicated that the May of 2010 incident involving Patient #2 recently hit the news media and that an investigative report was aired on one of the local news channel on May 25th of 2011. S5 indicated that this media attention resulted in unit operational concerns in the ED and that S12 was then placed on " Administrative Leave " and will not be returning to work at St. Tammany Parish Hospital.
? S5 reported that S15 was discharged from employment on 8/03/10 as a result of " unacceptable rude behavior and failing to follow care standards " . S5 indicated that S15 ' s discharge was not relating to the incident involving Patient #2 in May of 2010.
? S5 reported that S16 was discharged from employment on 6/01/11 as a result of not calling and not showing up for work 3 days. S5 indicated that S16 ' s discharge was not relating to the incident involving Patient #2 in May of 2010.

During interview with S5, a request was made for all hospital approved policies/procedures that relate to abuse and/or neglect, patient rights, and cellular phone usage. The following policies/procedures were presented: 1. Policy/Procedure titled "Abuse, Neglect and Abandonment" with an adoption date of 3/98 and revision date of 10/09; 2. Policy/Procedure titled "Code of Ethical and Professional Behavior" with an adoption date of 5/95 and revision date of 8/06; 3. Policy/Procedure titled "Patient Rights and Responsibilities" with an adoption date of 10/89 and revision date of 5/10; 4. Policy/Procedure titled "Cellular Phone Usage" with adoption date of 1/10 and no revision date.

1. Policy/Procedure titled "Abuse, Neglect and Abandonment" (adoption date of 3/98 and revision date of 10/09) documents under the section of "Policy" that "Actual or suspected victims of abuse or physical, sexual or psychological neglect or abandonment are to be identified, assessed and referred to the appropriate Hospital department. Cases of abuse, neglect, abandonment or exploitation are to be reported to appropriate agencies according to this policy and procedure and state laws and regulations". The policy/procedure documents under guidelines "Any actual or suspected abuse, neglect or abandonment is to be reported to the Hospital's Case Management Department by any Hospital employee as soon as possible".
2. Policy/Procedure titled "Code of Ethical and Professional Behavior" (adoption date of 5/95 and revision date of 8/06) documents one of the purposes of the policy/procedure is "To ensure that the Hospital conducts its business and patient care practices in an honest, decent, and proper manner and in a manner which takes into account the needs and values of patients, their families, other caregivers and employees, and the community as a whole" and "Patient Relations. All patients and their families are treated with courtesy, respect, and in a manner which demonstrates the Hospital's commitment to providing timely and effective attention to their needs".
3. Policy/Procedure titled "Patient Rights and Responsibilities" (adoption date of 10/89 and revision date of 5/10) documents under the section of "Patient Rights" that patients have the right to "receive considerate and respectful care in a clean and safe environment, with respect for their privacy and individuality" and "be free from all forms of abuse or harassment and the right to be free from restraints that are not medically necessary".
4. Policy/Procedure titled "Cellular Phone Usage" (adoption date of 1/10 and no revision date) documents under the section of "Cellular Phones with Photograpy (sic) Capability" that "St. Tammany Parish Hospital prohibits the use of personal cameras in the workplace, including cameras which are incorporated into any cellular telephone. Any employee who uses a cell phone camera to photograph a co-worker, patient, or any aspect of Hospital business is subject to the Human Resources Positive Discipline policy and may in fact, be subject to the termination of his/her employment".

When asked if there were any additional hospital approved policies/procedures relating to patient abuse and/or cellular phone usage, S5 reported that the policies presented (as documented above) were the only policies relating to patient abuse, and/or cellular phone usage. S3 (Director of Critical Care) confirmed in an interview on 6/24/11 at 9:00 a.m. that the policies presented (as documented above) were the only policies relating to patient abuse, and/or cellular phone usage.

S6 (Director of Case Management) was interviewed on 6/22/11 at 3:45 p.m. S6 reviewed the hospital's policy/procedure titled "Abuse, Neglect and Abandonment" and confirmed the policy/procedure documents that "any actual or suspected abuse, neglect or abandonment is to be reported to the Hospital's Case Management Department by any Hospital employee as soon as possible". When asked if the hospital's Case Management Department was notified of the 5/02/10 incident involving Patient #2, S6 reported that the Case Management Department was not notified of the allegations or the incident until it was broadcasted on the local news within the last month (approximately one year after the 5/02/10 incident occurred).

S7 (ED registered nurse) was interviewed on 6/23/11 at 9:00 a.m. S7 reported that he works as a registered nurse in the ED. S7 reviewed the medical record of Patient #2. S7 reported that his first contact with Patient #2 was on 5/02/10 at 7:04 p.m. S7 reported that he was the primary nurse assigned to provide care for Patient #2 while in the ED on 5/02/10. S7 indicated that Patient #2 was rolled straight back to ED room C-1 after his arrival to the hospital. S7 reported that S10 (ED registered nurse) performed the triage assessment on Patient #2. S7 reported that S9 (ED registered nurse) started an IV on the patient and he (S7) catheterized the patient. S7 reported that S10 had contacted poison control and their recommendation was for the administration of charcoal. S7 indicated that S18 was the attending physician and that an OG tube was inserted into the patient ' s mouth and charcoal was administered as ordered after verifying placement of the OG tube. S7 reported the charcoal was administered on 5/02/10 at 8:15 p.m. and that Patient #2 was lethargic at the time of charcoal administration. S7 reported that Patient #2 vomited and aspirated about 15 minutes after the charcoal was administered. S7 indicated that suction was initiated and the head of bed was elevated. S7 reported that Narcan was administered to Patient #2 at 8:17 p.m. and 8:30 p.m. S7 indicated that S17 (ED physician) successfully intubated Patient #2 at 9:04 p.m. S7 reported that Patient #2 was unresponsive at the time of intubation. S7 reported that Patient #2 remained intubated on ventilator support during the remainder of his stay in the ED. S7 reported that Patient #2 was transported to the ICU on 5/02/10 at 10:05 p.m. When asked if eyeglasses were placed on Patient #2, S7 indicated that he was charting with his back turned to Patient #2 when he heard laughter in the room and reported when he turned around he saw eyeglasses on Patient #2's face. S7 indicated that Patient #2 was unresponsive at this time and would not have been able to put the eyeglasses on himself. S7 reported that he did not know who put the eyeglasses on Patient #2's face. When asked if a picture had been taken of Patient #2, S7 reported that he heard a clicking noise that sounded like a camera does when taking a picture. S7 reported that he did not see any pictures of Patient #2. When asked if he could identify the time he heard laughter in the room, and heard the clicking sound and saw the glasses on Patient #2's face, S7 reported that it was sometime after the charcoal was administered to Patient #2 but before being intubated. When asked about charcoal on the patient's face, S7 reported that charcoal was everywhere including on Patient #2's face after he vomited but he did not recall seeing charcoal lines drawn on Patient #2's face. When asked if he had been interviewed by anyone from the hospital prior to this interview, S7 reported that he was first interviewed by telephone by S21 (Director of Nursing) on 5/06/10. S7 indicated that he had a second meeting with S21 (Director of Nursing) and S2 (CNO) to discuss the incident but was unsure of the date of this second meeting. S7 reported the second meeting was within 3 weeks of the phone interview on 5/06/10. When asked for the names of all people in the ED room at the time he heard the laughter and saw the glasses on Patient #2's face, S7 reported that he was "pretty sure" that S10 (ED registered nurse), S12 (ED registered nurse), and S11 (ED registered nurse) were in the room at the time. When asked if he considered what happened to Patient #2 to be patient abuse, S7 replied "No I don't". S7 reported that he considered it to be "poor judgment and bad behavior by nurses".

S9 (ED registered nurse) was interviewed on 6/23/11 at 11:00 a.m. S9 reported that she works as a registered nurse in the ED. S9 reviewed the medical record of Patient #2. S9 indicated that her first contact with Patient #2 was on 5/02/10 at 7:04 p.m. at which time a cardiac monitor, blood pressure cuff, and pulse oximeter were placed on the patient. S9 reported that S10 was the triage nurse and S7 was the primary nurse. S9 reported that she was in and out of Patient #2's room and would assist S7 as needed. S9 indicated that there were several nurses assisting with Patient #2's care while in the ED. When asked if eyeglasses were placed on Patient #2 and/or if a picture had been taken of Patient #2, S9 reported that S10 handed her a cell phone that had a picture of Patient #2 with glasses on his face and with lines drawn under both eyes. S9 reported that the lines were well defined, black, and appeared to be charcoal. When asked if the lines appeared to be from the patient vomiting or appeared to be smeared on the patients face as a result of wiping, S9 indicated the lines did not appear to be a result of vomiting or smearing. S9 reported that Patient #2 was still in the ED when she saw the picture on the cell phone. S9 reported that she did not know who the cell phone belonged to. S9 reported that S10, S11, S7, S15, S16, and S12 were in the room when she saw the picture of Patient #2 and that she heard laughter in the room. S9 reported that she told S10 and S11 they "needed to stop". S9 reported she overheard from S12, S10, and S11 that this (glasses placed on patients and pictures taken) has happened before and that S10, S11, and S12 were going to compare the pictures to determine which one was the best. When asked if she had been interviewed by anyone from the hospital prior to this interview, S9 indicated that she discussed this incident with S21 (Director of Nursing) not long after the incident occurred but was not sure of the date.

S18 (ED physician) was interviewed on 6/24/11 at 12:15 p.m. S18 reported he was the emergency room Physician providing care for Patient #2. With review of the Clinical Record, S18 reported Patient #2 was seen in the ED (Emergency Department) for an overdose of Lortab and depression with the intent to hurt himself. S18 confirmed he took care of Patient #2 in room C-1 in the ED at St. Tammany Parish hospital on [DATE]. S18 indicated that he was interviewed over a year ago by S2 (CNO) and at that time he learned of the allegations of someone placing glasses on Patient #2 and taking a picture of the patient. S18 stated he was shocked the incident occurred, but he did not witness or overhear anything about the incident. A hypothetical question was asked of S18; if a patient was unresponsive and glasses were placed on his face and a picture was taken would he consider it to be patient abuse. S18 answered "yes" indicating he would consider it to be patient abuse.

S21 (Director of Nursing) was interviewed on 6/24/11 at 10:00 a.m. S21 reported that she has been a Director of Nursing at St. Tammany Parish Hospital for 12 years and she (S21) reports directly to S2 (Chief Nursing Officer). S21 reported the Department Head of Emergency Care Services reported to her up until January of 2011. When asked about the hospital ' s current reporting and organization structure in relation to the Emergency Department, S21 reported that S3 (Director of Critical Care) is currently the Director over the Emergency Department. S21 reported the organizational structure of the hospital changed in January of 2011. When asked if the organizational structure change had anything to do with the 5/02/10 incident involving Patient #2, S21 reported the change was not related to the 5/02/10 incident involving Patient #2. When asked about the steps taken by hospital administration after being made aware of the 5/02/10 incident involving Patient #2, S21 reported she created a grid of information obtained from the different employees she interviewed for the 5/02/10 incident involving Patient #2. Review of the grid created by S21 revealed the names of personnel interviewed but no date and/or time of the interviews. When asked for the names of the personnel interviewed and the dates and times of the interviews, S21 reported that she did not know the exact date and time of the interviews. When asked to present all documentation relating to her investigatory findings to include fact finding notes and dates and times of interviews, S21 reported she did not have any notes or documentation to indicate the date and/or time of the interviews. When asked if she normally maintains documentation relating to investigatory findings or fact findings, S21 indicated that she typically maintains fact finding notes in her office and the notes typically contain the name of the person interviewed with the date and time the interview took place and the information discussed. S21 repeated that she created a grid of information obtained from the different employees she interviewed for the 5/02/10 incident and that she did not have the dates and times documented on the grid of the interviews and the only other documentation she maintained was a printed email from S12RN. When asked if she recorded any additional notes during the interviews with personnel relating to the 5/02/10 incident involving Patient #2, S21 indicated that she did record additional notes. When asked what she did with these additional notes, S21 stated that she "shredded the notes". S21 reported that she was not sure of the date or time she shredded the notes. When asked about the time she first became aware of any allegations relating to the 5/02/10 incident involving Patient #2, S21 reported that S2 (CNO) notified her sometime during the work day on May 6th of 2010. S21 reported that S2 informed her that she had met with S15 (ED Technician) and there was an incident in the emergency room with a patient who overdosed. S21 reported that S2 told her a patient had overdosed and there was an incident with eye glasses being placed on the patient and charcoal being placed under the patient's eyes. S21 reported that was all S2 told her at that time and she then started to review the staffing sheet to investigate who was working at the time of the incident. S21 indicated that S7 (ED registered nurse), S9 (ED registered nurse), S10 (ED registered nurse), S11 (ED registered nurse), S12 (ED registered nurse), S13 (ED registered nurse), and S16 (ED technician) were interviewed and the grid was developed with the information obtained during the interviews. S21 stated her conclusion of the investigation was something happened on May 2, 2010, in the emergency room , but was not sure what happened. The conclusion of the investigation was that bad behavior of nurses did occur. S21 indicated the 5/02/10 incident had been reported to the State Board of Nursing but was unsure of the date of reporting the incident to the State Board of Nursing. S21 reported that she (S21) and S2 had met with a representative from the State Board of Nursing, but did not maintain any notes relating to this meeting and did not know the date of this meeting. S21 reported the State Board of Nursing requested information from the hospital and indicated that the hospital provided the information when the information was subpoenaed, not when the State Board of Nursing initially requested the information. S21 was asked again to provide information relating to the dates and times of any and all interviews relating to the 5/02/10 incident involving Patient #2 including interviews with hospital personnel and outside agencies to include the State Board of Nursing so that a timeline of events could be established. S21 indicated that she needed to go see if there was any additional documentation that would include the dates and times of interviews. S21 then left the conference room that the interview was being conducted in. Approximately 15 minutes later, S21 returned to the conference room with S2 (CNO).

S2 joined the interview with S21 on 6/24/11 at 10:55 a.m. S2 presented a document that outlined a timeline of events. Review of this document revealed the following:
1. Sunday, May 2, 2010. Care provided to (Patient #2) between 7:04 p.m. and 10:05 p.m. in the STPH Emergency Department.
2. Thursday, May 6, 2010. (S2) interviewed (S15) in response to an email request from (S15). (S2) spoke with (S18), an ED physician on duty at the time of the alleged incident. (S15) confirmed that he did not observe any inappropriate behavior.
3. Thursday, May 6, 2010. (S2) reviewed the patient ' s medical record.
4. Friday, May 7, 2010. (S21) interviewed (S10), ED Charge RN, at 0730. (S21) interviewed (S7), ED Staff RN, via telephone. (S21) interviewed (S9), ED Staff RN, via telephone.
5. Monday, May 10, 2010. (S21) interviewed ED nursing personnel (S23) and (S13). (S21) and (S4) met with (S12) and (S11). Both nurses denied the behaviors as reported by (S15).
6. Wednesday, May 12, 2010. (S2) followed up with a telephone interview of (S15) to obtain additional information.
7. Thursday, May 13, 2010. (S10) RN submitted a letter of resignation.
8. Thursday, May 13, 2010. (S21) and (S4) met with (S12) to counsel/discuss disciplinary action.
9. Friday, May 14, 2010. (S21) and (S4) met with (S11) to counsel/discuss (S11) ' s disciplinary action, a written reminder.
10. Wednesday, May 19, 2010. (S4) held ED staff meetings at 7 am and 7pm to review the Administrative Policy " Cellular Phone Usage " and other expectations regarding behavior standards with ED staff.
11. The last week of May 2010. (S2) and (S21) talked with (S22), Louisiana State Board of Nursing.
12. June 17, 2010. (S21) received a call from (S22), LSBN, regarding probable investigation of (S12).
13. Tuesday, July 6, 2010. (S2) and (S21) met personally with (S22), LSBN.
14. Friday, July 9, 2010. (S2) and (S21) met with (S15) again in an effort to further understand the nature of the alleged incident.
15. Tuesday, August 3, 2010. (S15) was discharged from employment by STPH for misconduct. She was terminated for continued unacceptable rude behavior to patients and a failure to follow the Hospital ' s customer service standards after earning a Written Reminder and Decision Making Leave Day for identical behaviors on 8/12/09 and 3/01/10. These behaviors were unrelated to the allegations previously made by (S15).
16. Thursday, June 2, 2011. (S2) and (S3), Director/Critical Care Services, meet with (S12) and place her on Administrative Leave.
17. Friday, June 3, 2011. (S11) submits a letter of resignation prior to being placed on administrative leave.

Review of the grid created by S21 that included information relating to the hospital's internal investigation revealed the following:
S7 (ED registered nurse) indicated "Eye glasses were placed on patient while he was pushing charcoal thru the OGT but he does not know who put them on patient" and "a picture was taken of the patient but he does not know who took the picture".
S9 (ED registered nurse) indicated "Eye glasses were on patient when she walked into C1. She didn't see who put them on patient. (S12) was at the head of the bed" and "A picture was taken and (S9) saw the picture on a cell phone. The phone was in (S10)'s hand. She knows that another patient had the glasses on and a picture was taken. She doesn't remember what patient".
S12 (ED registered nurse) indicated "Eye glasses were on patient-she didn't see who put them on. Has never placed glasses on a patient and does not know of any other patient they were placed on" and "(S10) took a picture of the patient with the glasses on".

When asked if any policies/procedures had been revised as a result of the findings of the hospital's internal investigation, S2 indicated that there were no revisions made to any of the hospital's policies and procedures as a result of the 5/02/10 incident involving Patient #2. When asked if the 5/02/10 incident involving Patient #2 was reported to the Department of Health and Hospitals as Patient Abuse, S2 reported that the hospital did not consider it to be Patient Abuse. S2 indicated that the hospital considered it to be bad nursing behavior and poor judgment which was more of a State Board of Nursing issue. When told that the survey team was substantiating the allegation of Patient Abuse in relation to the events that occurred in the ED with Patient #2, S2 reported that she did not consider it to be Patient Abuse.


Louisiana Revised Statutes; Title 40. Public Health and Safety; Chapter 11. State Department of Health and Hospitals; ?2009.20. Duty to make complaints; penalty; immunity documents:

(1) " Abuse " is the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including but not limited to sexual abuse, or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered.

B. (1) Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, licensed practical nurse, nurse's aide, home- and community-based service provider employee or worker, personal care attendant, respite worker, physician's assistant, physical therapist, or any other direct caregiver having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report.

According to the St. Tammany Parish Clerk of Courts office, Patient #2 is listed as a plaintiff in a lawsuit against St. Tammany Parish Hospital relating to the events that occurred while in the Emergency Department on 5/02/10. This indicates that Patient #2 is aware of the 5/02/10 incident.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the hospital failed to ensure the hospital's QAPI (Quality Assurance Performance Improvement) program was aware of an adverse patient event (Staff to Patient Abuse) that occurred in the hospital's ED (Emergency Department) on 5/02/10 and failed to ensure the implementation of a quality indicator and/or quality indicators relating to an adverse patient event (Staff to Patient Abuse) that occurred in the hospital's ED (Emergency Department) on 5/02/10. The Staff to Patient Abuse included glasses being placed on the face of Patient #2 while he (Patient #2) was unresponsive in the ED and a picture of Patient #2's face being seen on a cellular phone with the glasses on his (Patient #2) face. The glasses were in a drawer in the ED prior to Patient #2's arrival to St. Tammany Parish Hospital and were not his (Patient #2) glasses. Findings:

The medical record of Patient #2 was reviewed. This review revealed that Patient #2 presented to St. Tammany Parish Hospital's Emergency Department on 5/02/10 and was triaged by S10 (ED registered nurse) on 5/02/10 at 7:10 p.m. The ED (Emergency Department) Triage Assessment documents the "Chief Complaint" as "pt reports taking 22 Lortab 10 & Klonopin unknown amt @ 1000 this a.m. Pt's cousin states he took more than that approx 130 tablets. Pt very drowsy, but answers questions appropriately. Pt stated he's depressed & going through a divorce". Review of the "Patient Care Notes" revealed an entry by S9 (ED registered nurse) indicating that Patient #2 was taken to "C-1" on 5/02/10 at 7:04 p.m. and was lethargic with slurred speech. Further review revealed an entry by S7 (ED registered nurse) indicating that a 32 French OG (Oral-Gastric) tube was inserted and Patient #2 was medicated with 125 grams of charcoal at 8:15 p.m. Further review revealed an entry by S7 (ED registered nurse) indicating that Patient #2 vomited a large amount of charcoal & possibly aspirated and S18 (ED physician) was at the bedside at 8:30 p.m. Further review revealed an entry by S7 (ED registered nurse) indicating that Patient #2 was intubated by S17 (ED physician) with a 7.0 ETT (Endotracheal Tube) and placed on ventilator support at 9:04 p.m. Further review revealed an entry by S7 (ED registered nurse) indicating that Patient #2 was transported to the Intensive Care Unit via stretcher at 10:05 p.m. The "Emergency Department Nursing Record" documents that 0.4mg of Narcan was administered intravenously on 5/02/10 at 8:17 p.m. and 2mg of Narcan was administered intravenously on 5/02/10 at 8:30 p.m. Review of the "History and Physical" dated 5/02/10 revealed that Patient #2's diagnoses included drug overdose, mental status change, respiratory acidosis, elevated thyroid stimulating hormone, and hyperglycemia. Review of the "Discharge Summary" revealed Patient #2 was discharged from St. Tammany Parish hospital on [DATE] and transferred to an inpatient psychiatric facility for admission and treatment.

S4 (Emergency Care Services Department Head) was interviewed on 6/22/11 at 2:30 p.m. S4 reviewed the medical record of Patient #2. S4 reported that he was attending an educational conference in Grapevine, Texas at the time of Patient #2 hospitalization in May of 2010. S4 reported that he received a call from either S21 (DON) or S2 (CNO) on either Wednesday (5/05/10) or Thursday (5/06/10) and was informed of an event that took place in the ED earlier in the week. S4 reported that he returned back to the hospital on Friday (5/07/10). S4 indicated that S21 and S2 had initiated an internal investigation relating to a reported incident involving Patient #2 prior to his return to the hospital. S4 indicated that one of the ED technicians (S15) reported that some of the ED nurses had taken pictures of Patient #2 after placing glasses on him and drawing lines on his face while he was unresponsive in the ED. S4 indicated that he participated with S21 in the interview of S12 (ED registered nurse) and S11 (ED registered nurse) sometime after his return to the hospital. S4 reported that he could not remember the date or time of the meetings. When asked if he maintained any notes or documentation relating to the interviews with S12 and S11 to include the date, time and/or investigatory findings, S4 reported that he did not have any documentation of the investigatory findings. S4 reported that S21 asked S12 about the event and that S12 denied witnessing the event and denied having anything to do with the event involving Patient #2. S4 reported that S 11 initially denied having knowledge of the event involving Patient #2 in her interview, but submitted a letter to S21 soon after the interview indicating that she (S11) was not completely honest during her interview as she did have knowledge that someone had put glasses on Patient #2 and that S10 took a picture of Patient #2 with the glasses on. S4 reported that he was not present for any other interviews. S4 reported that S21 and S2 conducted the internal investigation and that indicated that he was told of the outcome by S21 and S2. S4 reported that S10 (ED registered nurse) had taken a picture with a cell phone of Patient #2 with glasses on that had been left in the ED by a former patient. S4 indicated that S10 resigned from employment with St. Tammany Parish hospital on [DATE] instead of being discharged . S4 indicated that S11 received a "decision making leave day" for withholding information during the interview. When asked how long the glasses that were placed on Patient #2's face had been in the ED, S4 reported that the glasses had been left in the ED years ago. When asked if he felt that putting glasses on an unresponsive or comatose patient and then taking a picture of the patient with the glasses on was patient abuse, S4 stated "absolutely".

S7 (ED registered nurse) was interviewed on 6/23/11 at 9:00 a.m. S7 reported that he works as a registered nurse in the ED. S7 reviewed the medical record of Patient #2. S7 reported that his first contact with Patient #2 was on 5/02/10 at 7:04 p.m. S7 reported that he was the primary nurse assigned to provide care for Patient #2 while in the ED on 5/02/10. S7 indicated that Patient #2 was rolled straight back to ED room C-1 after his arrival to the hospital. S7 reported that S10 (ED registered nurse) performed the triage assessment on Patient #2. S7 reported that S9 (ED registered nurse) started an IV on the patient and he (S7) catheterized the patient. S7 reported that S10 had contacted poison control and their recommendation was for the administration of charcoal. S7 indicated that S18 was the attending physician and that an OG tube was inserted into the patient ' s mouth and charcoal was administered as ordered after verifying placement of the OG tube. S7 reported the charcoal was administered on 5/02/10 at 8:15 p.m. and that Patient #2 was lethargic at the time of charcoal administration. S7 reported that Patient #2 vomited and aspirated about 15 minutes after the charcoal was administered. S7 indicated that suction was initiated and the head of bed was elevated. S7 reported that Narcan was administered to Patient #2 at 8:17 p.m. and 8:30 p.m. S7 indicated that S17 (ED physician) successfully intubated Patient #2 at 9:04 p.m. S7 reported that Patient #2 was unresponsive at the time of intubation. S7 reported that Patient #2 remained intubated on ventilator support during the remainder of his stay in the ED. S7 reported that Patient #2 was transported to the ICU on 5/02/10 at 10:05 p.m. When asked if eyeglasses were placed on Patient #2, S7 indicated that he was charting with his back turned to Patient #2 when he heard laughter in the room and reported when he turned around he saw eyeglasses on Patient #2's face. S7 indicated that Patient #2 was unresponsive at this time and would not have been able to put the eyeglasses on himself. S7 reported that he did not know who put the eyeglasses on Patient #2's face. When asked if a picture had been taken of Patient #2, S7 reported that he heard a clicking noise that sounded like a camera does when taking a picture. S7 reported that he did not see any pictures of Patient #2. When asked if he could identify the time he heard laughter in the room, and heard the clicking sound and saw the glasses on Patient #2's face, S7 reported that it was sometime after the charcoal was administered to Patient #2 but before being intubated. When asked about charcoal on the patient's face, S7 reported that charcoal was everywhere including on Patient #2's face after he vomited but he did not recall seeing charcoal lines drawn on Patient #2's face. When asked if he had been interviewed by anyone from the hospital prior to this interview, S7 reported that he was first interviewed by telephone by S21 (Director of Nursing) on 5/06/10. S7 indicated that he had a second meeting with S21 (Director of Nursing) and S2 (CNO) to discuss the incident but was unsure of the date of this second meeting. S7 reported the second meeting was within 3 weeks of the phone interview on 5/06/10. When asked for the names of all people in the ED room at the time he heard the laughter and saw the glasses on Patient #2's face, S7 reported that he was "pretty sure" that S10 (ED registered nurse), S12 (ED registered nurse), and S11 (ED registered nurse) were in the room at the time. When asked if he considered what happened to Patient #2 to be patient abuse, S7 replied "No I don't". S7 reported that he considered it to be "poor judgment and bad behavior by nurses".

S9 (ED registered nurse) was interviewed on 6/23/11 at 11:00 a.m. S9 reported that she works as a registered nurse in the ED. S9 reviewed the medical record of Patient #2. S9 indicated that her first contact with Patient #2 was on 5/02/10 at 7:04 p.m. at which time a cardiac monitor, blood pressure cuff, and pulse oximeter were placed on the patient. S9 reported that S10 was the triage nurse and S7 was the primary nurse. S9 reported that she was in and out of Patient #2's room and would assist S7 as needed. S9 indicated that there were several nurses assisting with Patient #2's care while in the ED. When asked if eyeglasses were placed on Patient #2 and/or if a picture had been taken of Patient #2, S9 reported that S10 handed her a cell phone that had a picture of Patient #2 with glasses on his face and with lines drawn under both eyes. S9 reported that the lines were well defined, black, and appeared to be charcoal. When asked if the lines appeared to be from the patient vomiting or appeared to be smeared on the patients face as a result of wiping, S9 indicated the lines did not appear to be a result of vomiting or smearing. S9 reported that Patient #2 was still in the ED when she saw the picture on the cell phone. S9 reported that she did not know who the cell phone belonged to. S9 reported that S10, S11, S7, S15, S16, and S12 were in the room when she saw the picture of Patient #2 and that she heard laughter in the room. S9 reported that she told S10 and S11 they "needed to stop". S9 reported she overheard from S12, S10, and S11 that this (glasses placed on patients and pictures taken) has happened before and that S10, S11, and S12 were going to compare the pictures to determine which one was the best. When asked if she had been interviewed by anyone from the hospital prior to this interview, S9 indicated that she discussed this incident with S21 (Director of Nursing) not long after the incident occurred but was not sure of the date.

S18 (ED physician) was interviewed on 6/24/11 at 12:15 p.m. S18 reported he was the emergency room Physician providing care for Patient #2. With review of the Clinical Record, S18 reported Patient #2 was seen in the ED (Emergency Department) for an overdose of Lortab and depression with the intent to hurt himself. S18 confirmed he took care of Patient #2 in room C-1 in the ED at St. Tammany Parish hospital on [DATE]. S18 indicated that he was interviewed over a year ago by S2 (CNO) and at that time he learned of the allegations of someone placing glasses on Patient #2 and taking a picture of the patient. S18 stated he was shocked the incident occurred, but he did not witness or overhear anything about the incident. A hypothetical question was asked of S18; if a patient was unresponsive and glasses were placed on his face and a picture was taken would he consider it to be patient abuse. S18 answered "yes" indicating he would consider it to be patient abuse.

The administrative policy/procedure titled "Performance Improvement Plan-2011" was reviewed. The policy/procedure documents "The hospital collects data on performance improvement priorities identified by leadership, operative or other procedures that place patients at risk of disability or death, significant discrepancies between preoperative and postoperative diagnoses, adverse events related to using moderate or deep sedation or anesthesia, the use of blood and blood components, all reported and confirmed transfusion reactions, the results of resuscitation, behavior management and treatment, significant medication errors, significant adverse drug reactions, patient perception of the safety and quality of care, staff opinions and needs, staff perceptions of risk to individuals, staff suggestions for improving patient safety, staff willingness to report adverse events, the effectiveness of fall reduction activities and the effectiveness of its response to change or deterioration in a patient's condition". The policy/procedure also documents "Additional components of the performance improvement process will include the assessment and improvement of the quality and safety of patient care and the clinical performance of individuals with clinical privileges. This occurs through the monitoring of physician and staff competencies and analysis of staffing effectiveness throughout the organization".

S3 (Director of Critical Care) was interviewed on 6/23/11 at 2:35 p.m. When asked who the Director of the hospital's Quality Assurance Performance Improvement program was, S3 reported that S19 was the Department Head of Decision Support which deals with hospital quality issues.

S19 (Department Head of Decision Support) was interviewed on 6/23/11 at 2:45 p.m. S19 was asked about the hospital's QAPI program. S19 indicated that Decision Support is the department that addresses Quality issues within the hospital. S19 reported that the Quality Council meets monthly. When asked about the time she first became aware of the 5/02/10 incident involving Patient #2, S19 reported that she first became aware of the incident through one of the local news channels last month. S19 reported that she had no knowledge of the 5/02/10 incident involving Patient #2 prior to hearing about it being in the news media recently. When asked who the Director of the hospital's Quality Assurance Performance Improvement program was, S19 reported that S20 is the Director.

The "Quality Committee Minutes" for the meetings conducted from 5/13/10 through 5/12/11 were reviewed. This review revealed no evidence to indicate the hospital's QAPI (Quality Assurance Performance Improvement) program had ensured the development of quality indicators relating to the 5/02/10 incident that occurred in the hospital's Emergency Department involving Patient #2. It was determined (by written statements and/or staff interviews) that glasses were placed on an unresponsive patient (Patient #2) while in the Emergency Department and a picture was seen on a cell phone of Patient #2 with the glasses on his face.

S20 (Chief Medical Officer) was interviewed on 6/24/11 at 9:35 a.m. S20 reported he has been in the role of Chief Medical Officer at St. Tammany Parish Hospital for ten years and was the Chief Medical Officer at the time of the 5/10/10 incident involving Patient #2. S20 also reported he was the Chairman of the Quality Committee in the Hospital. When asked about the time he first became aware of the 5/02/10 incident involving Patient #2, S20 indicated that he first became aware of the incident in the last 2 months when the malpractice lawsuit was reviewed. S20 indicated that prior to the malpractice lawsuit, he had heard something was going on in nursing, but had no knowledge of the incident. When asked if the 5/02/10 incident involving Patient #2 had been addressed in the hospital's Quality Assurance Performance Improvement program, S20 reported this event was not addressed in the Quality Committee because it wasn't a patient issue, it was an employee issue. S20 indicated that the 5/02/10 incident may have been addressed in another committee but was not addressed in the Quality Committee. S20 indicated that it is his opinion that the allegations relating to the 5/02/10 incident involving Patient #2 are still disputed because he has not seen a picture. S20 indicated that he felt the 5/02/10 incident was inappropriate employee behavior and not patient abuse.

In an interview on 6/24/11 at 11:10 a.m., S2 (Chief Nursing Officer) confirmed that there were no quality indicators developed, monitored, or tracked relating to the adverse event that occurred with Patient #2 while in the hospital's ED on 5/02/10.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the hospital failed to ensure the hospital's QAPI (Quality Assurance Performance Improvement) program was aware of an adverse patient event (Staff to Patient Abuse) that occurred in the hospital's ED (Emergency Department) on 5/02/10 and failed to ensure the implementation of a quality indicator and/or quality indicators relating to an adverse patient event (Staff to Patient Abuse) that occurred in the hospital's ED (Emergency Department) on 5/02/10. The Staff to Patient Abuse included glasses being placed on the face of Patient #2 while he (Patient #2) was unresponsive in the ED and a picture of Patient #2's face being seen on a cellular phone with the glasses on his (Patient #2) face. The glasses were in a drawer in the ED prior to Patient #2's arrival to St. Tammany Parish Hospital and were not his (Patient #2) glasses. Findings:

The medical record of Patient #2 was reviewed. This review revealed that Patient #2 presented to St. Tammany Parish Hospital's Emergency Department on 5/02/10 and was triaged by S10 (ED registered nurse) on 5/02/10 at 7:10 p.m. The ED (Emergency Department) Triage Assessment documents the "Chief Complaint" as "pt reports taking 22 Lortab 10 & Klonopin unknown amt @ 1000 this a.m. Pt's cousin states he took more than that approx 130 tablets. Pt very drowsy, but answers questions appropriately. Pt stated he's depressed & going through a divorce". Review of the "Patient Care Notes" revealed an entry by S9 (ED registered nurse) indicating that Patient #2 was taken to "C-1" on 5/02/10 at 7:04 p.m. and was lethargic with slurred speech. Further review revealed an entry by S7 (ED registered nurse) indicating that a 32 French OG (Oral-Gastric) tube was inserted and Patient #2 was medicated with 125 grams of charcoal at 8:15 p.m. Further review revealed an entry by S7 (ED registered nurse) indicating that Patient #2 vomited a large amount of charcoal & possibly aspirated and S18 (ED physician) was at the bedside at 8:30 p.m. Further review revealed an entry by S7 (ED registered nurse) indicating that Patient #2 was intubated by S17 (ED physician) with a 7.0 ETT (Endotracheal Tube) and placed on ventilator support at 9:04 p.m. Further review revealed an entry by S7 (ED registered nurse) indicating that Patient #2 was transported to the Intensive Care Unit via stretcher at 10:05 p.m. The "Emergency Department Nursing Record" documents that 0.4mg of Narcan was administered intravenously on 5/02/10 at 8:17 p.m. and 2mg of Narcan was administered intravenously on 5/02/10 at 8:30 p.m. Review of the "History and Physical" dated 5/02/10 revealed that Patient #2's diagnoses included drug overdose, mental status change, respiratory acidosis, elevated thyroid stimulating hormone, and hyperglycemia. Review of the "Discharge Summary" revealed Patient #2 was discharged from St. Tammany Parish hospital on [DATE] and transferred to an inpatient psychiatric facility for admission and treatment.

S4 (Emergency Care Services Department Head) was interviewed on 6/22/11 at 2:30 p.m. S4 reviewed the medical record of Patient #2. S4 reported that he was attending an educational conference in Grapevine, Texas at the time of Patient #2 hospitalization in May of 2010. S4 reported that he received a call from either S21 (DON) or S2 (CNO) on either Wednesday (5/05/10) or Thursday (5/06/10) and was informed of an event that took place in the ED earlier in the week. S4 reported that he returned back to the hospital on Friday (5/07/10). S4 indicated that S21 and S2 had initiated an internal investigation relating to a reported incident involving Patient #2 prior to his return to the hospital. S4 indicated that one of the ED technicians (S15) reported that some of the ED nurses had taken pictures of Patient #2 after placing glasses on him and drawing lines on his face while he was unresponsive in the ED. S4 indicated that he participated with S21 in the interview of S12 (ED registered nurse) and S11 (ED registered nurse) sometime after his return to the hospital. S4 reported that he could not remember the date or time of the meetings. When asked if he maintained any notes or documentation relating to the interviews with S12 and S11 to include the date, time and/or investigatory findings, S4 reported that he did not have any documentation of the investigatory findings. S4 reported that S21 asked S12 about the event and that S12 denied witnessing the event and denied having anything to do with the event involving Patient #2. S4 reported that S 11 initially denied having knowledge of the event involving Patient #2 in her interview, but submitted a letter to S21 soon after the interview indicating that she (S11) was not completely honest during her interview as she did have knowledge that someone had put glasses on Patient #2 and that S10 took a picture of Patient #2 with the glasses on. S4 reported that he was not present for any other interviews. S4 reported that S21 and S2 conducted the internal investigation and that indicated that he was told of the outcome by S21 and S2. S4 reported that S10 (ED registered nurse) had taken a picture with a cell phone of Patient #2 with glasses on that had been left in the ED by a former patient. S4 indicated that S10 resigned from employment with St. Tammany Parish hospital on [DATE] instead of being discharged . S4 indicated that S11 received a "decision making leave day" for withholding information during the interview. When asked how long the glasses that were placed on Patient #2's face had been in the ED, S4 reported that the glasses had been left in the ED years ago. When asked if he felt that putting glasses on an unresponsive or comatose patient and then taking a picture of the patient with the glasses on was patient abuse, S4 stated "absolutely".

S7 (ED registered nurse) was interviewed on 6/23/11 at 9:00 a.m. S7 reported that he works as a registered nurse in the ED. S7 reviewed the medical record of Patient #2. S7 reported that his first contact with Patient #2 was on 5/02/10 at 7:04 p.m. S7 reported that he was the primary nurse assigned to provide care for Patient #2 while in the ED on 5/02/10. S7 indicated that Patient #2 was rolled straight back to ED room C-1 after his arrival to the hospital. S7 reported that S10 (ED registered nurse) performed the triage assessment on Patient #2. S7 reported that S9 (ED registered nurse) started an IV on the patient and he (S7) catheterized the patient. S7 reported that S10 had contacted poison control and their recommendation was for the administration of charcoal. S7 indicated that S18 was the attending physician and that an OG tube was inserted into the patient ' s mouth and charcoal was administered as ordered after verifying placement of the OG tube. S7 reported the charcoal was administered on 5/02/10 at 8:15 p.m. and that Patient #2 was lethargic at the time of charcoal administration. S7 reported that Patient #2 vomited and aspirated about 15 minutes after the charcoal was administered. S7 indicated that suction was initiated and the head of bed was elevated. S7 reported that Narcan was administered to Patient #2 at 8:17 p.m. and 8:30 p.m. S7 indicated that S17 (ED physician) successfully intubated Patient #2 at 9:04 p.m. S7 reported that Patient #2 was unresponsive at the time of intubation. S7 reported that Patient #2 remained intubated on ventilator support during the remainder of his stay in the ED. S7 reported that Patient #2 was transported to the ICU on 5/02/10 at 10:05 p.m. When asked if eyeglasses were placed on Patient #2, S7 indicated that he was charting with his back turned to Patient #2 when he heard laughter in the room and reported when he turned around he saw eyeglasses on Patient #2's face. S7 indicated that Patient #2 was unresponsive at this time and would not have been able to put the eyeglasses on himself. S7 reported that he did not know who put the eyeglasses on Patient #2's face. When asked if a picture had been taken of Patient #2, S7 reported that he heard a clicking noise that sounded like a camera does when taking a picture. S7 reported that he did not see any pictures of Patient #2. When asked if he could identify the time he heard laughter in the room, and heard the clicking sound and saw the glasses on Patient #2's face, S7 reported that it was sometime after the charcoal was administered to Patient #2 but before being intubated. When asked about charcoal on the patient's face, S7 reported that charcoal was everywhere including on Patient #2's face after he vomited but he did not recall seeing charcoal lines drawn on Patient #2's face. When asked if he had been interviewed by anyone from the hospital prior to this interview, S7 reported that he was first interviewed by telephone by S21 (Director of Nursing) on 5/06/10. S7 indicated that he had a second meeting with S21 (Director of Nursing) and S2 (CNO) to discuss the incident but was unsure of the date of this second meeting. S7 reported the second meeting was within 3 weeks of the phone interview on 5/06/10. When asked for the names of all people in the ED room at the time he heard the laughter and saw the glasses on Patient #2's face, S7 reported that he was "pretty sure" that S10 (ED registered nurse), S12 (ED registered nurse), and S11 (ED registered nurse) were in the room at the time. When asked if he considered what happened to Patient #2 to be patient abuse, S7 replied "No I don't". S7 reported that he considered it to be "poor judgment and bad behavior by nurses".

S9 (ED registered nurse) was interviewed on 6/23/11 at 11:00 a.m. S9 reported that she works as a registered nurse in the ED. S9 reviewed the medical record of Patient #2. S9 indicated that her first contact with Patient #2 was on 5/02/10 at 7:04 p.m. at which time a cardiac monitor, blood pressure cuff, and pulse oximeter were placed on the patient. S9 reported that S10 was the triage nurse and S7 was the primary nurse. S9 reported that she was in and out of Patient #2's room and would assist S7 as needed. S9 indicated that there were several nurses assisting with Patient #2's care while in the ED. When asked if eyeglasses were placed on Patient #2 and/or if a picture had been taken of Patient #2, S9 reported that S10 handed her a cell phone that had a picture of Patient #2 with glasses on his face and with lines drawn under both eyes. S9 reported that the lines were well defined, black, and appeared to be charcoal. When asked if the lines appeared to be from the patient vomiting or appeared to be smeared on the patients face as a result of wiping, S9 indicated the lines did not appear to be a result of vomiting or smearing. S9 reported that Patient #2 was still in the ED when she saw the picture on the cell phone. S9 reported that she did not know who the cell phone belonged to. S9 reported that S10, S11, S7, S15, S16, and S12 were in the room when she saw the picture of Patient #2 and that she heard laughter in the room. S9 reported that she told S10 and S11 they "needed to stop". S9 reported she overheard from S12, S10, and S11 that this (glasses placed on patients and pictures taken) has happened before and that S10, S11, and S12 were going to compare the pictures to determine which one was the best. When asked if she had been interviewed by anyone from the hospital prior to this interview, S9 indicated that she discussed this incident with S21 (Director of Nursing) not long after the incident occurred but was not sure of the date.

S18 (ED physician) was interviewed on 6/24/11 at 12:15 p.m. S18 reported he was the emergency room Physician providing care for Patient #2. With review of the Clinical Record, S18 reported Patient #2 was seen in the ED (Emergency Department) for an overdose of Lortab and depression with the intent to hurt himself. S18 confirmed he took care of Patient #2 in room C-1 in the ED at St. Tammany Parish hospital on [DATE]. S18 indicated that he was interviewed over a year ago by S2 (CNO) and at that time he learned of the allegations of someone placing glasses on Patient #2 and taking a picture of the patient. S18 stated he was shocked the incident occurred, but he did not witness or overhear anything about the incident. A hypothetical question was asked of S18; if a patient was unresponsive and glasses were placed on his face and a picture was taken would he consider it to be patient abuse. S18 answered "yes" indicating he would consider it to be patient abuse.

The administrative policy/procedure titled "Performance Improvement Plan-2011" was reviewed. The policy/procedure documents "The hospital collects data on performance improvement priorities identified by leadership, operative or other procedures that place patients at risk of disability or death, significant discrepancies between preoperative and postoperative diagnoses, adverse events related to using moderate or deep sedation or anesthesia, the use of blood and blood components, all reported and confirmed transfusion reactions, the results of resuscitation, behavior management and treatment, significant medication errors, significant adverse drug reactions, patient perception of the safety and quality of care, staff opinions and needs, staff perceptions of risk to individuals, staff suggestions for improving patient safety, staff willingness to report adverse events, the effectiveness of fall reduction activities and the effectiveness of its response to change or deterioration in a patient's condition". The policy/procedure also documents "Additional components of the performance improvement process will include the assessment and improvement of the quality and safety of patient care and the clinical performance of individuals with clinical privileges. This occurs through the monitoring of physician and staff competencies and analysis of staffing effectiveness throughout the organization".

S3 (Director of Critical Care) was interviewed on 6/23/11 at 2:35 p.m. When asked who the Director of the hospital's Quality Assurance Performance Improvement program was, S3 reported that S19 was the Department Head of Decision Support which deals with hospital quality issues.

S19 (Department Head of Decision Support) was interviewed on 6/23/11 at 2:45 p.m. S19 was asked about the hospital's QAPI program. S19 indicated that Decision Support is the department that addresses Quality issues within the hospital. S19 reported that the Quality Council meets monthly. When asked about the time she first became aware of the 5/02/10 incident involving Patient #2, S19 reported that she first became aware of the incident through one of the local news channels last month. S19 reported that she had no knowledge of the 5/02/10 incident involving Patient #2 prior to hearing about it being in the news media recently. When asked who the Director of the hospital's Quality Assurance Performance Improvement program was, S19 reported that S20 is the Director.

The "Quality Committee Minutes" for the meetings conducted from 5/13/10 through 5/12/11 were reviewed. This review revealed no evidence to indicate the hospital's QAPI (Quality Assurance Performance Improvement) program had ensured the development of quality indicators relating to the 5/02/10 incident that occurred in the hospital's Emergency Department involving Patient #2. It was determined (by written statements and/or staff interviews) that glasses were placed on an unresponsive patient (Patient #2) while in the Emergency Department and a picture was seen on a cell phone of Patient #2 with the glasses on his face.

S20 (Chief Medical Officer) was interviewed on 6/24/11 at 9:35 a.m. S20 reported he has been in the role of Chief Medical Officer at St. Tammany Parish Hospital for ten years and was the Chief Medical Officer at the time of the 5/10/10 incident involving Patient #2. S20 also reported he was the Chairman of the Quality Committee in the Hospital. When asked about the time he first became aware of the 5/02/10 incident involving Patient #2, S20 indicated that he first became aware of the incident in the last 2 months when the malpractice lawsuit was reviewed. S20 indicated that prior to the malpractice lawsuit, he had heard something was going on in nursing, but had no knowledge of the incident. When asked if the 5/02/10 incident involving Patient #2 had been addressed in the hospital's Quality Assurance Performance Improvement program, S20 reported this event was not addressed in the Quality Committee because it wasn't a patient issue, it was an employee issue. S20 indicated that the 5/02/10 incident may have been addressed in another committee but was not addressed in the Quality Committee. S20 indicated that it is his opinion that the allegations relating to the 5/02/10 incident involving Patient #2 are still disputed because he has not seen a picture. S20 indicated that he felt the 5/02/10 incident was inappropriate employee behavior and not patient abuse.

In an interview on 6/24/11 at 11:10 a.m., S2 (Chief Nursing Officer) confirmed that there were no quality indicators developed, monitored, or tracked relating to the adverse event that occurred with Patient #2 while in the hospital's ED on 5/02/10.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the registered nurse failed to ensure the supervision and evaluation of care provided to a patient (Patient #2) who presented to the hospital's ED (Emergency Department) in need of services as evidenced by failing to ensure Patient #2 was free from all forms of abuse or harassment while receiving services in the hospital. The Staff to Patient Abuse included glasses being placed on the face of Patient #2 while he (Patient #2) was unresponsive in the ED and a picture of Patient #2's face being seen on a cellular phone with the glasses on his (Patient #2) face. The glasses were in a drawer in the ED prior to Patient #2's arrival to St. Tammany Parish Hospital and were not his (Patient #2) glasses. Findings.

The medical record of Patient #2 was reviewed. This review revealed that Patient #2 presented to St. Tammany Parish Hospital's Emergency Department on 5/02/10 and was triaged by S10 (ED registered nurse) on 5/02/10 at 7:10 p.m. The ED (Emergency Department) Triage Assessment documents the "Chief Complaint" as "pt reports taking 22 Lortab 10 & Klonopin unknown amt @ 1000 this a.m. Pt's cousin states he took more than that approx 130 tablets. Pt very drowsy, but answers questions appropriately. Pt stated he's depressed & going through a divorce". Review of the "Patient Care Notes" revealed an entry by S9 (ED registered nurse) indicating that Patient #2 was taken to "C-1" on 5/02/10 at 7:04 p.m. and was lethargic with slurred speech. Further review revealed an entry by S7 (ED registered nurse) indicating that a 32 French OG (Oral-Gastric) tube was inserted and Patient #2 was medicated with 125 grams of charcoal at 8:15 p.m. Further review revealed an entry by S7 (ED registered nurse) indicating that Patient #2 vomited a large amount of charcoal & possibly aspirated and S18 (ED physician) was at the bedside at 8:30 p.m. Further review revealed an entry by S7 (ED registered nurse) indicating that Patient #2 was intubated by S17 (ED physician) with a 7.0 ETT (Endotracheal Tube) and placed on ventilator support at 9:04 p.m. Further review revealed an entry by S7 (ED registered nurse) indicating that Patient #2 was transported to the Intensive Care Unit via stretcher at 10:05 p.m. The "Emergency Department Nursing Record" documents that 0.4mg of Narcan was administered intravenously on 5/02/10 at 8:17 p.m. and 2mg of Narcan was administered intravenously on 5/02/10 at 8:30 p.m. Review of the "History and Physical" dated 5/02/10 revealed that Patient #2's diagnoses included drug overdose, mental status change, respiratory acidosis, elevated thyroid stimulating hormone, and hyperglycemia. Review of the "Discharge Summary" revealed Patient #2 was discharged from St. Tammany Parish hospital on [DATE] and transferred to an inpatient psychiatric facility for admission and treatment.

S4 (Emergency Care Services Department Head) was interviewed on 6/22/11 at 2:30 p.m. S4 reviewed the medical record of Patient #2. S4 reported that he was attending an educational conference in Grapevine, Texas at the time of Patient #2 hospitalization in May of 2010. S4 reported that he received a call from either S21 (DON) or S2 (CNO) on either Wednesday (5/05/10) or Thursday (5/06/10) and was informed of an event that took place in the ED earlier in the week. S4 reported that he returned back to the hospital on Friday (5/07/10). S4 indicated that S21 and S2 had initiated an internal investigation relating to a reported incident involving Patient #2 prior to his return to the hospital. S4 indicated that one of the ED technicians (S15) reported that some of the ED nurses had taken pictures of Patient #2 after placing glasses on him and drawing lines on his face while he was unresponsive in the ED. S4 indicated that he participated with S21 in the interview of S12 (ED registered nurse) and S11 (ED registered nurse) sometime after his return to the hospital. S4 reported that he could not remember the date or time of the meetings. When asked if he maintained any notes or documentation relating to the interviews with S12 and S11 to include the date, time and/or investigatory findings, S4 reported that he did not have any documentation of the investigatory findings. S4 reported that S21 asked S12 about the event and that S12 denied witnessing the event and denied having anything to do with the event involving Patient #2. S4 reported that S 11 initially denied having knowledge of the event involving Patient #2 in her interview, but submitted a letter to S21 soon after the interview indicating that she (S11) was not completely honest during her interview as she did have knowledge that someone had put glasses on Patient #2 and that S10 took a picture of Patient #2 with the glasses on. S4 reported that he was not present for any other interviews. S4 reported that S21 and S2 conducted the internal investigation and that indicated that he was told of the outcome by S21 and S2. S4 reported that S10 (ED registered nurse) had taken a picture with a cell phone of Patient #2 with glasses on that had been left in the ED by a former patient. S4 indicated that S10 resigned from employment with St. Tammany Parish hospital on [DATE] instead of being discharged . S4 indicated that S11 received a "decision making leave day" for withholding information during the interview. When asked how long the glasses that were placed on Patient #2's face had been in the ED, S4 reported that the glasses had been left in the ED years ago. When asked if he felt that putting glasses on an unresponsive or comatose patient and then taking a picture of the patient with the glasses on was patient abuse, S4 stated "absolutely".

The daily staffing report for the date of 5/02/10 was reviewed. This review revealed the following staff members were working in the ED at St. Tammany Parish Hospital during the time of Patient #2's treatment in the ED: S7 (ED registered nurse), S10 (ED registered nurse), S13 (ED registered nurse), S12 (ED registered nurse), S8 (ED registered nurse), S9 (ED registered nurse), S11 (ED registered nurse), S14 (ED technician), S15 (ED technician), and S16 (ED technician).

S5 (Vice President of Human Resources) was interviewed on 6/22/11 at 3:00 p.m. and on 6/23/11 at 10:40 a.m. When asked about the current employment status of the S7 (ED registered nurse), S10 (ED registered nurse), S13 (ED registered nurse), S12 (ED registered nurse), S8 (ED registered nurse), S9 (ED registered nurse), S11 (ED registered nurse), S14 (ED technician), S15 (ED technician), and S16 (ED technician), S5 indicated that S7, S8, S9, S13, and S14 are still employed with St. Tammany Parish Hospital and that S10, S11, S12, S15, and S16 are no longer employed at St. Tammany Parish Hospital.

? S5 reported S10 resigned on 5/13/10. S5 indicated that S10 would have been discharged from employment as a result of the incident involving Patient #2 had she not voluntarily resigned.
? S5 reported that S11's separation date was 6/03/11. S5 indicated that S11 walked into the Human Resources Department and turned in her letter of resignation.
? S5 reported that S12 had received a one day " Decision Making Leave " disciplinary action on 5/13/10 relating to the incident involving Patient #2 and was placed on " Administrative Leave " on 6/02/11 relating to " unit operational concerns " secondary to increased public awareness of the incident involving Patient #2 in May of 2010. S5 indicated that the May of 2010 incident involving Patient #2 recently hit the news media and that an investigative report was aired on one of the local news channel on May 25th of 2011. S5 indicated that this media attention resulted in unit operational concerns in the ED and that S12 was then placed on " Administrative Leave " and will not be returning to work at St. Tammany Parish Hospital.
? S5 reported that S15 was discharged from employment on 8/03/10 as a result of " unacceptable rude behavior and failing to follow care standards " . S5 indicated that S15 ' s discharge was not relating to the incident involving Patient #2 in May of 2010.
? S5 reported that S16 was discharged from employment on 6/01/11 as a result of not calling and not showing up for work 3 days. S5 indicated that S16 ' s discharge was not relating to the incident involving Patient #2 in May of 2010.

During interview with S5, a request was made for all hospital approved policies/procedures that relate to abuse and/or neglect, patient rights, and cellular phone usage. The following policies/procedures were presented: 1. Policy/Procedure titled "Abuse, Neglect and Abandonment" with an adoption date of 3/98 and revision date of 10/09; 2. Policy/Procedure titled "Code of Ethical and Professional Behavior" with an adoption date of 5/95 and revision date of 8/06; 3. Policy/Procedure titled "Patient Rights and Responsibilities" with an adoption date of 10/89 and revision date of 5/10; 4. Policy/Procedure titled "Cellular Phone Usage" with adoption date of 1/10 and no revision date.

1. Policy/Procedure titled "Abuse, Neglect and Abandonment" (adoption date of 3/98 and revision date of 10/09) documents under the section of "Policy" that "Actual or suspected victims of abuse or physical, sexual or psychological neglect or abandonment are to be identified, assessed and referred to the appropriate Hospital department. Cases of abuse, neglect, abandonment or exploitation are to be reported to appropriate agencies according to this policy and procedure and state laws and regulations". The policy/procedure documents under guidelines "Any actual or suspected abuse, neglect or abandonment is to be reported to the Hospital's Case Management Department by any Hospital employee as soon as possible".
2. Policy/Procedure titled "Code of Ethical and Professional Behavior" (adoption date of 5/95 and revision date of 8/06) documents one of the purposes of the policy/procedure is "To ensure that the Hospital conducts its business and patient care practices in an honest, decent, and proper manner and in a manner which takes into account the needs and values of patients, their families, other caregivers and employees, and the community as a whole" and "Patient Relations. All patients and their families are treated with courtesy, respect, and in a manner which demonstrates the Hospital's commitment to providing timely and effective attention to their needs".
3. Policy/Procedure titled "Patient Rights and Responsibilities" (adoption date of 10/89 and revision date of 5/10) documents under the section of "Patient Rights" that patients have the right to "receive considerate and respectful care in a clean and safe environment, with respect for their privacy and individuality" and "be free from all forms of abuse or harassment and the right to be free from restraints that are not medically necessary".
4. Policy/Procedure titled "Cellular Phone Usage" (adoption date of 1/10 and no revision date) documents under the section of "Cellular Phones with Photograpy (sic) Capability" that "St. Tammany Parish Hospital prohibits the use of personal cameras in the workplace, including cameras which are incorporated into any cellular telephone. Any employee who uses a cell phone camera to photograph a co-worker, patient, or any aspect of Hospital business is subject to the Human Resources Positive Discipline policy and may in fact, be subject to the termination of his/her employment".

S7 (ED registered nurse) was interviewed on 6/23/11 at 9:00 a.m. S7 reported that he works as a registered nurse in the ED. S7 reviewed the medical record of Patient #2. S7 reported that his first contact with Patient #2 was on 5/02/10 at 7:04 p.m. S7 reported that he was the primary nurse assigned to provide care for Patient #2 while in the ED on 5/02/10. S7 indicated that Patient #2 was rolled straight back to ED room C-1 after his arrival to the hospital. S7 reported that S10 (ED registered nurse) performed the triage assessment on Patient #2. S7 reported that S9 (ED registered nurse) started an IV on the patient and he (S7) catheterized the patient. S7 reported that S10 had contacted poison control and their recommendation was for the administration of charcoal. S7 indicated that S18 was the attending physician and that an OG tube was inserted into the patient ' s mouth and charcoal was administered as ordered after verifying placement of the OG tube. S7 reported the charcoal was administered on 5/02/10 at 8:15 p.m. and that Patient #2 was lethargic at the time of charcoal administration. S7 reported that Patient #2 vomited and aspirated about 15 minutes after the charcoal was administered. S7 indicated that suction was initiated and the head of bed was elevated. S7 reported that Narcan was administered to Patient #2 at 8:17 p.m. and 8:30 p.m. S7 indicated that S17 (ED physician) successfully intubated Patient #2 at 9:04 p.m. S7 reported that Patient #2 was unresponsive at the time of intubation. S7 reported that Patient #2 remained intubated on ventilator support during the remainder of his stay in the ED. S7 reported that Patient #2 was transported to the ICU on 5/02/10 at 10:05 p.m. When asked if eyeglasses were placed on Patient #2, S7 indicated that he was charting with his back turned to Patient #2 when he heard laughter in the room and reported when he turned around he saw eyeglasses on Patient #2's face. S7 indicated that Patient #2 was unresponsive at this time and would not have been able to put the eyeglasses on himself. S7 reported that he did not know who put the eyeglasses on Patient #2's face. When asked if a picture had been taken of Patient #2, S7 reported that he heard a clicking noise that sounded like a camera does when taking a picture. S7 reported that he did not see any pictures of Patient #2. When asked if he could identify the time he heard laughter in the room, and heard the clicking sound and saw the glasses on Patient #2's face, S7 reported that it was sometime after the charcoal was administered to Patient #2 but before being intubated. When asked about charcoal on the patient's face, S7 reported that charcoal was everywhere including on Patient #2's face after he vomited but he did not recall seeing charcoal lines drawn on Patient #2's face. When asked if he had been interviewed by anyone from the hospital prior to this interview, S7 reported that he was first interviewed by telephone by S21 (Director of Nursing) on 5/06/10. S7 indicated that he had a second meeting with S21 (Director of Nursing) and S2 (CNO) to discuss the incident but was unsure of the date of this second meeting. S7 reported the second meeting was within 3 weeks of the phone interview on 5/06/10. When asked for the names of all people in the ED room at the time he heard the laughter and saw the glasses on Patient #2's face, S7 reported that he was "pretty sure" that S10 (ED registered nurse), S12 (ED registered nurse), and S11 (ED registered nurse) were in the room at the time. When asked if he considered what happened to Patient #2 to be patient abuse, S7 replied "No I don't". S7 reported that he considered it to be "poor judgment and bad behavior by nurses".

S9 (ED registered nurse) was interviewed on 6/23/11 at 11:00 a.m. S9 reported that she works as a registered nurse in the ED. S9 reviewed the medical record of Patient #2. S9 indicated that her first contact with Patient #2 was on 5/02/10 at 7:04 p.m. at which time a cardiac monitor, blood pressure cuff, and pulse oximeter were placed on the patient. S9 reported that S10 was the triage nurse and S7 was the primary nurse. S9 reported that she was in and out of Patient #2's room and would assist S7 as needed. S9 indicated that there were several nurses assisting with Patient #2's care while in the ED. When asked if eyeglasses were placed on Patient #2 and/or if a picture had been taken of Patient #2, S9 reported that S10 handed her a cell phone that had a picture of Patient #2 with glasses on his face and with lines drawn under both eyes. S9 reported that the lines were well defined, black, and appeared to be charcoal. When asked if the lines appeared to be from the patient vomiting or appeared to be smeared on the patients face as a result of wiping, S9 indicated the lines did not appear to be a result of vomiting or smearing. S9 reported that Patient #2 was still in the ED when she saw the picture on the cell phone. S9 reported that she did not know who the cell phone belonged to. S9 reported that S10, S11, S7, S15, S16, and S12 were in the room when she saw the picture of Patient #2 and that she heard laughter in the room. S9 reported that she told S10 and S11 they "needed to stop". S9 reported she overheard from S12, S10, and S11 that this (glasses placed on patients and pictures taken) has happened before and that S10, S11, and S12 were going to compare the pictures to determine which one was the best. When asked if she had been interviewed by anyone from the hospital prior to this interview, S9 indicated that she discussed this incident with S21 (Director of Nursing) not long after the incident occurred but was not sure of the date.

S21 (Director of Nursing) was interviewed on 6/24/11 at 10:00 a.m. S21 reported that she has been a Director of Nursing at St. Tammany Parish Hospital for 12 years and she (S21) reports directly to S2 (Chief Nursing Officer). S21 reported the Department Head of Emergency Care Services reported to her up until January of 2011. When asked about the hospital ' s current reporting and organization structure in relation to the Emergency Department, S21 reported that S3 (Director of Critical Care) is currently the Director over the Emergency Department. S21 reported the organizational structure of the hospital changed in January of 2011. When asked if the organizational structure change had anything to do with the 5/02/10 incident involving Patient #2, S21 reported the change was not related to the 5/02/10 incident involving Patient #2. When asked about the steps taken by hospital administration after being made aware of the 5/02/10 incident involving Patient #2, S21 reported she created a grid of information obtained from the different employees she interviewed for the 5/02/10 incident involving Patient #2. Review of the grid created by S21 revealed the names of personnel interviewed but no date and/or time of the interviews. When asked for the names of the personnel interviewed and the dates and times of the interviews, S21 reported that she did not know the exact date and time of the interviews. When asked to present all documentation relating to her investigatory findings to include fact finding notes and dates and times of interviews, S21 reported she did not have any notes or documentation to indicate the date and/or time of the interviews. When asked if she normally maintains documentation relating to investigatory findings or fact findings, S21 indicated that she typically maintains fact finding notes in her office and the notes typically contain the name of the person interviewed with the date and time the interview took place and the information discussed. S21 repeated that she created a grid of information obtained from the different employees she interviewed for the 5/02/10 incident and that she did not have the dates and times documented on the grid of the interviews and the only other documentation she maintained was a printed email from S12RN. When asked if she recorded any additional notes during the interviews with personnel relating to the 5/02/10 incident involving Patient #2, S21 indicated that she did record additional notes. When asked what she did with these additional notes, S21 stated that she "shredded the notes". S21 reported that she was not sure of the date or time she shredded the notes. When asked about the time she first became aware of any allegations relating to the 5/02/10 incident involving Patient #2, S21 reported that S2 (CNO) notified her sometime during the work day on May 6th of 2010. S21 reported that S2 informed her that she had met with S15 (ED Technician) and there was an incident in the emergency room with a patient who overdosed. S21 reported that S2 told her a patient had overdosed and there was an incident with eye glasses being placed on the patient and charcoal being placed under the patient's eyes. S21 reported that was all S2 told her at that time and she then started to review the staffing sheet to investigate who was working at the time of the incident. S21 indicated that S7 (ED registered nurse), S9 (ED registered nurse), S10 (ED registered nurse), S11 (ED registered nurse), S12 (ED registered nurse), S13 (ED registered nurse), and S16 (ED technician) were interviewed and the grid was developed with the information obtained during the interviews. S21 stated her conclusion of the investigation was something happened on May 2, 2010, in the emergency room , but was not sure what happened. The conclusion of the investigation was that bad behavior of nurses did occur. S21 indicated the 5/02/10 incident had been reported to the State Board of Nursing but was unsure of the date of reporting the incident to the State Board of Nursing. S21 reported that she (S21) and S2 had met with a representative from the State Board of Nursing, but did not maintain any notes relating to this meeting and did not know the date of this meeting. S21 reported the State Board of Nursing requested information from the hospital and indicated that the hospital provided the information when the information was subpoenaed, not when the State Board of Nursing initially requested the information. S21 was asked again to provide information relating to the dates and times of any and all interviews relating to the 5/02/10 incident involving Patient #2 including interviews with hospital personnel and outside agencies to include the State Board of Nursing so that a timeline of events could be established. S21 indicated that she needed to go see if there was any additional documentation that would include the dates and times of interviews. S21 then left the conference room that the interview was being conducted in. Approximately 15 minutes later, S21 returned to the conference room with S2 (CNO).

S2 joined the interview with S21 on 6/24/11 at 10:55 a.m. S2 presented a document that outlined a timeline of events. Review of this document revealed the following:
1. Sunday, May 2, 2010. Care provided to (Patient #2) between 7:04 p.m. and 10:05 p.m. in the STPH Emergency Department.
2. Thursday, May 6, 2010. (S2) interviewed (S15) in response to an email request from (S15). (S2) spoke with (S18), an ED physician on duty at the time of the alleged incident. (S15) confirmed that he did not observe any inappropriate behavior.
3. Thursday, May 6, 2010. (S2) reviewed the patient ' s medical record.
4. Friday, May 7, 2010. (S21) interviewed (S10), ED Charge RN, at 0730. (S21) interviewed (S7), ED Staff RN, via telephone. (S21) interviewed (S9), ED Staff RN, via telephone.
5. Monday, May 10, 2010. (S21) interviewed ED nursing personnel (S23) and (S13). (S21) and (S4) met with (S12) and (S11). Both nurses denied the behaviors as reported by (S15).
6. Wednesday, May 12, 2010. (S2) followed up with a telephone interview of (S15) to obtain additional information.
7. Thursday, May 13, 2010. (S10) RN submitted a letter of resignation.
8. Thursday, May 13, 2010. (S21) and (S4) met with (S12) to counsel/discuss disciplinary action.
9. Friday, May 14, 2010. (S21) and (S4) met with (S11) to counsel/discuss (S11) ' s disciplinary action, a written reminder.
10. Wednesday, May 19, 2010. (S4) held ED staff meetings at 7 am and 7pm to review the Administrative Policy " Cellular Phone Usage " and other expectations regarding behavior standards with ED staff.
11. The last week of May 2010. (S2) and (S21) talked with (S22), Louisiana State Board of Nursing.
12. June 17, 2010. (S21) received a call from (S22), LSBN, regarding probable investigation of (S12).
13. Tuesday, July 6, 2010. (S2) and (S21) met personally with (S22), LSBN.
14. Friday, July 9, 2010. (S2) and (S21) met with (S15) again in an effort to further understand the nature of the alleged incident.
15. Tuesday, August 3, 2010. (S15) was discharged from employment by STPH for misconduct. She was terminated for continued unacceptable rude behavior to patients and a failure to follow the Hospital ' s customer service standards after earning a Written Reminder and Decision Making Leave Day for identical behaviors on 8/12/09 and 3/01/10. These behaviors were unrelated to the allegations previously made by (S15).
16. Thursday, June 2, 2011. (S2) and (S3), Director/Critical Care Services, meet with (S12) and place her on Administrative Leave.
17. Friday, June 3, 2011. (S11) submits a letter of resignation prior to being placed on administrative leave.

Review of the grid created by S21 that included information relating to the hospital's internal investigation revealed the following:
S7 (ED registered nurse) indicated "Eye glasses were placed on patient while he was pushing charcoal thru the OGT but he does not know who put them on patient" and "a picture was taken of the patient but he does not know who took the picture".
S9 (ED registered nurse) indicated "Eye glasses were on patient when she walked into C1. She didn't see who put them on patient. (S12) was at the head of the bed" and "A picture was taken and (S9) saw the picture on a cell phone. The phone was in (S10)'s hand. She knows that another patient had the glasses on and a picture was taken. She doesn't remember what patient".
S12 (ED registered nurse) indicated "Eye glasses were on patient-she didn't see who put them on. Has never placed glasses on a patient and does not know of any other patient they were placed on" and "(S10) took a picture of the patient with the glasses on".