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 Aug. 17, 2012
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on observation and interview, the hospital failed to ensure the patients' right to privacy was maintained in the emergency department as evidenced by displaying patients' full names with their diagnosis on computerized screens in full view of patients, visitors, and hospital staff. Findings:

On 08/16/12 at 10:45 a.m. an observation was made of the emergency department with the Director of Critical Care (S1). 2 "Flat screen" computerized panels approximately 30 inches high by 48 inches wide were observed mounted to the walls. One screen was observed adjacent to the trauma room and across from the emergency department nurse's station. The other screen was observed on the wall between rooms #3 and #4. Displayed on both screens were the first and last names of the all patients currently being treated in the emergency department. Adjacent to the patients' names were the patients' diagnoses. The patient information was visible from at least five feet away from the screens. Patient #2 was observed to have a diagnosis displayed as "Overdose". Patient #1 was observed to have a diagnosis displayed as "Altered Mental". Random patient #R1 was observed to have a diagnosis displayed as "Blood in Stool". At this time patient family members, visitors, emergency medical technicians, and other hospital staff were observed in the emergency department with full view of the patients' names and diagnoses. S1 verified the patient names and diagnoses were displayed and were in full view of patients, family members, and other staff in the emergency department. S1 stated the screens were intended for staff use, but confirmed there were family members present and it was possible they could read the patient information on the screens. S1 verified Patient #1's diagnosis was displayed as "Altered Mental" and Patient #2's diagnosis was displayed as "Overdose". S1 further stated the emergency department had a policy of "Open Visiting" and patients were allowed one visitor at the bedside.

Review of the hospital's policy titled, "Patient Rights and Responsibilities" adopted 10/89 and revised 07/12, provided by S6 Administrative Assistant as current, revealed in part the following: IV. Patient Rights - All patients (or the patient's representative when appropriate) have the right to: receive considerate and respectful care in a clean and safe environment, with respect for their privacy and individuality....
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review, and staff interview, the hospital failed to ensure PEC (Physician Emergency Certificate) patients received care in a safe setting when being held in the Emergency Department as evidenced by: 1) failing to ensure the PEC patient was observed at all times, according to hospital policy for 1 of 1 (#1) current sampled PEC patients out of a total sample of 13, 2) failing to ensure the PEC patient's environment was free of potentially harmful objects such as power cords, disposable gloves, hand sanitizer, and plastic trash can liners, and 3) failing to ensure supervision/observation of the PEC patient was documented in the Emergency Department for 7 of 7 (#1, #3, #4, #5, #8, #9, #12) sampled PEC patients out of a total sample of 13. This deficient practice had the potential to affect an average of 38 PEC patients per month (Average number of PEC patients seen in ED over last 7 months). Findings:

1) failing to ensure PEC patients were observed at all times

On 08/16/12 at 10:30 a.m., an observation was made in the Emergency Department with the Director of Critical Care (S1). S1 stated PEC patients were placed in room "a" until bed placement can be obtained. S1 stated a Security Officer was assigned to the PEC patients. S1 stated if room "a" was occupied, they also used room "c". S1 confirmed that Patient #1 was under a PEC and awaiting bed placement in a psychiatric facility. S1 stated Patient #1 was in room "a". The door to room "a" was observed to be partially opened. The Security Officer, S3 was observed seated in a chair in front of room "b", near the juncture of the hall leading to room "a" and the hall leading to the nurse's station. S3 was observed to have his back to room "a" and to be facing the direction of the nurse's station. S3 was unable to visually observe Patient #1 from his position in the hall.

Review of the Emergency Department record for Patient #1 revealed the patient was a [AGE] year old male admitted to the ED by ambulance at 12:32 a.m. on 08/16/12 with a chief complaint of, "I've got bugs in me". Review of the record revealed the patient was PEC'd by the emergency department physician on 08/16/12 at 0123 (1:23 a.m.) due to, "Gravely disabled and Unwilling to seek voluntary admission". Review of the record revealed a CEC (Coroner's Emergency Certificate) was documented on 08/16/12 at 1135 (11:35 a.m.) due to, "Dangerous to self, Gravely disabled, and Unable to seek voluntary admission".

Review of the nurse's notes revealed the PEC was signed at 0120 (1:20 a.m.) and security was notified. The nurse's notes revealed at 0230 (2:30 a.m.) security was "at door". The nurse's notes revealed the patient's vital signs were documented at 4:30 a.m., 6:45 a.m., and 12:45 p.m. There was no other documented evidence of any monitoring, supervision, or observation of Patient #1. The patient was transferred to an inpatient psychiatric facility at 2:50 p.m. on 08/16/12.

On 08/16/12 at 3:20 p.m. in a face-to-face interview, S10RN indicated he was assigned to the ED and had been on duty all day. S10 stated they use room "a" for PEC patients after the patient is medically cleared. S10 stated Security sits outside in a chair and stated they don't usually have anyone in the room with the PEC patient. S10 stated he had never seen 1 on 1 supervision of PEC patients. S10 stated if room "a" is in use and they have another PEC patient they use room "c". S10 stated they have only 1 security officer to monitor all PEC patients no matter how many they have.

On 08/17/12 at 9:15 a.m., a face-to-face interview was conducted with S3 Security Officer. S3 stated his job was to make sure patients are safe, don't hurt themselves or others, and don't leave. S3 verified he was assigned to Patient #1 yesterday (08/16/12). S3 stated he usually sits beside the door of room "a" outside the room, but yesterday there were 2 other issues going on in the ED, so he sat toward the hall to monitor those issues too.

Review of the hospital's policy titled, "Psychiatric and Substance Abuse Emergencies", adopted 01/86, revised 12/06 and provided by S6Administrative Assistant as current policy revealed in part the following: I. Policy......The hospital will provide a safe environment for these patients while attempting to provide an appropriate level of care for the patient or while facilitating a transfer. V. Principles of Care [Adopted from Emergency Department Nursing Structure Standards] A. In the event a patient is acutely mentally ill or suffering from an exacerbation of substance abuse, nursing staff and other hospital personnel should: 1. Attempt to minimize the stimuli in the patient's room and remove any persons from the room who are not essential to the patient's care; ....3. place the Hospital's Security Officer on notice of the patient's location and request he/she make frequent rounds to the area; 4. notify the Nursing Supervisor of the patient's presence and advise him/her of special needs for the patient, e.g., a nursing assistant to remain in the patient's room 1:1, assistance with coroner notification;...

Review of the hospital's policy titled, "Psychological/Substance Abuse Disorders, Management of Patient With", adopted 09/93, revised 03/12 and provided by S6Administrative Assistant as current policy revealed in part the following: Nursing Interventions: 1. In the event a patient is ordered a Physician's Emergency Certificate (PEC) or Coroner's Emergency Certificate (CEC) or is a danger to self or others, nursing staff and other hospital personnel will do the following: A. Keep a staff member or attendant present with the patient at all times.......D. Security: Provide patient attendant with a two-way radio, Educate attendant on the appropriate use of the two-way radio, Make frequent rounds on the patient.....F. Patient Attendant: Patient attendant will assist the nurse in maintaining the safety of the patient by performing the following: Observe patient at all times......

On 08/17/12 at 2:15 p.m., the Director of Critical Care (S1) and the ED Supervisor (S5) were interviewed. S1 confirmed she had observed the Security Officer (S3) seated near the hall on 08/16/12 while Patient #1 was in the ED. S1 confirmed the Security Office had his back to the patient's room and did not have visual observation of the patient while in room "a". S5 stated this ED used security officers to monitor PEC patients and confirmed the security officers do not document any monitoring/observation of PEC patients. After reviewing the above policies, S1 stated the Patient Attendant refers to the sitters used on the inpatient units when a PEC patient was admitted to the hospital. S1 verified the policies were not specific to the ED. S1 verified there was no specific time frame for the "frequent rounds" the Security Officer was to make on PEC patients. S1 verified the Security Officers only keep a log of time spent watching PEC patients and stated the log was not part of the patient's medical record. S1 and S5 confirmed there was no documentation of the monitoring/supervision of PEC patients.


2)failing to ensure the PEC patient's environment was free of potentially harmful objects

On 08/17/12 at 10:15 a.m., and observation was made of room "a" with S4RN, ED charge nurse. 2 Stretchers were observed in the room with a privacy curtain between the stretchers suspended from the ceiling with one end of the curtain track noted to not be attached to the ceiling. A television was observed to be mounted to the wall with the electrical cord coiled up, but hanging from the bottom of the television. 2 dispensers of hand sanitizer were observed mounted on the wall adjacent to the sink in the room and 2 more hand sanitizer dispensers were observed on the wall by the sink in the bathroom of room "a". 2 boxes of disposable plastic gloves were observed mounted on the wall across from the sink. 2 garbage cans in the room were observed to have plastic can liners. S4RN confirmed the above observations and verified they could be a hazard to a patient who wanted to harm himself. S4RN stated she would take the privacy curtain down if the patient was suicidal. S4RN stated the security officer usually sits at the end of the hall when there was a PEC patient in room "a". At 10:30 a.m. the Director of Critical Care (S1) was interviewed in room "a", and the above findings were verified by S1 and she confirmed they could be dangerous to patients who wanted to harm themselves. S1 verified she had observed the Security Officer (S3) seated near the hall on 08/16/12 while Patient #1 was in the ED. S1 confirmed the Security Office had his back to the patient's room and did not have visual observation of the patient while in room "a".


3) failing to ensure supervision/observation of the PEC patient was documented in the Emergency Department

Patient #1
Review of the Emergency Department record for Patient #1 revealed the patient was a [AGE] year old male admitted to the ED by ambulance at 12:32 a.m. on 08/16/12 with a chief complaint of, "I've got bugs in me". Review of the record revealed the patient was PEC'd by the emergency department physician on 08/16/12 at 0123 (1:23 a.m.) due to, "Gravely disabled and Unwilling to seek voluntary admission". Review of the record revealed a CEC (Coroner's Emergency Certificate) was documented on 08/16/12 at 1135 (11:35 a.m.) due to, "Dangerous to self, Gravely disabled, and Unable to seek voluntary admission".

Review of the nurse's notes revealed the PEC was signed at 0120 (1:20 a.m.) and security was notified. The nurse's notes revealed at 0230 (2:30 a.m.) security was "at door". The nurse's notes revealed the patient's vital signs were documented at 4:30 a.m., 6:45 a.m., and 12:45 p.m. There was no other documented evidence of any monitoring, supervision, or observation of Patient #1. The patient was transferred to an inpatient psychiatric facility at 2:50 p.m. on 08/16/12.

Review of the, "Emergency Department Routine PEC Orders" revealed no documented evidence of any order for supervision or monitoring of the patient.

Patient #3
Review of the Emergency Department Record for Patient #3 revealed the patient was a [AGE] year old female admitted on [DATE] at 22:21 (10:21 p.m.) with chief complaints of suicidal thoughts, suicide attempt, and intentional drug overdose. Review of the record revealed the patient was PEC'd by the emergency department physician on 07/27/12 at 22:50 (10:50 p.m.) due to "Dangerous to self and unwilling to seek voluntary admission".

Review of the nurse's notes revealed the patient was placed in trauma room 1 on arrival and moved to the room "c" at 9:45 a.m. on 07/28/12. Review of the nurse's notes revealed the following entry at 1210 (12:10 p.m.) on 07/28/12: Pt. (Patient) still very upset and crying, beginning to get drowsy. Wants to use phone but pt. too drowsy to walk at this time, explained to pt.
There was no documentation of the patient's status or any monitoring or supervision of the patient. The next entry in the nurse's notes was documented at 2200 (10:00 p.m.) on 07/28/12, 10 hours after the last entry. Further review of the nurse's notes revealed the nurse documented the patient's status at the following dates/times: 07/28/12 at 23:30 (11:30 p.m.), 07/29/12 at 0100 (1:00 a.m.), 07/29/12 at 0400 (4:00 a.m.), 07/29/12 at 0700 (7:00 a.m.). The next nursing entry revealed the following: 07/29/12 at 1255 (12:55 p.m.) Pt. attempting to run - Security restrain pt. Pt. fighting with Security - have epistaxis right nares.

There was no documented evidence that a Security Officer was monitoring the patient or providing observation of the patient until 07/29/12 at 12:55 p.m. when the patient attempted to elope from the ED. There was no documented evidence that any other staff member was monitoring or observing the patient. There was no documented evidence that visual observation of the patient was provided while the patient was placed in the room "c" or in room "a".


Patient #4
Review of the Emergency Department record for Patient #4 revealed the patient was a [AGE] year old female admitted to the ED by ambulatory at 17:03 (5:03 p.m.) on 06/01/12 with a chief complaint of feeling depressed and has been thinking about cutting her wrist or taking an overdose. Review of the record revealed the patient was PEC'd by the emergency department physician on 06/01/12 at 1913 (7:13 p.m.) due to, "Dangerous to self and Unwilling to seek voluntary admission". Review of the record revealed a CEC was documented on 06/02/12 at 1450 (2:50 p.m.) due to, "Dangerous to self, and Unable to seek voluntary admission".

Review of the nurse's notes revealed the patient was placed in room "a" at 6:25 p.m. on 06/01/12. The nurse's notes revealed the patient was PEC'd at 6:55 p.m. and "Security at door". Nursing entries at 2200 (10:00 p.m.) and 2330 (11:30 p.m.) on 06/01/12 revealed Security was at the door or bedside. There was no documented evidence from 06/01/12 at 11:30 p.m. to 06/02/12 at 4:10 p.m. that security or any other staff had provided observation or monitoring of the patient. The record revealed the patient was transferred to an inpatient psychiatric facility at 4:10 p.m. on 06/02/12.


Patient #6
Review of the Emergency Department record for Patient #6 revealed the patient was a [AGE] year old male admitted to the ED by ambulance at 4:25 a.m. on 07/21/12 with a chief complaint of self injury and agitated. Review of the record revealed the patient was PEC'd by the emergency department physician on 07/21/12 at 5:30 a.m. due to, "Dangerous to self and others, Gravely disabled and Unwilling to seek voluntary admission".

Review of the nurse's notes revealed the following: 07/21/12 at 0500 (5:00 a.m.) Pt. moved to room "c" with security at bedside. 0509 (5:09 a.m.) pt. pulled his own IV out, catheter in hand, pressure dressing applied. 0615 (6:15 a.m.) Pt. to CT (computerized tomography). Security remains at side. 0700 (7:00 a.m.) Assumed care....Security with in view.
Further review of the nurse's notes revealed no entries from 9:00 a.m. to 3:05 p.m. There was no documented evidence that the patient was observed or monitored by security or any other staff from 9:00 a.m. to 3:06 p.m. when the patient was transferred to an inpatient psychiatric facility.


Patient #8
Review of the Emergency Department record for Patient #8 revealed the patient was a [AGE] year old female admitted to the ED by ambulance at 11:33 a.m. on 08/14/12 with a chief complaint of decreased mental status, overdose and depression. Review of the record revealed the patient was PEC'd by the emergency department physician on 08/14/12 at 5:30 p.m. due to, "Dangerous to self, Gravely disabled and Unwilling/Unable to seek voluntary admission". Review of the record revealed the physician had documented the patient was stable at 4:00 p.m.

Review of the Emergency Department Nursing Record revealed the patient was moved to "overflow" at 1645 (4:45 p.m.). The next entry was documented at 1800 (6:00 p.m.) indicating the patient was awaiting placement. The next entry at 2035 (8:35 p.m.) revealed the patient received Ativan 2 mg. IM for increased heart rate and agitation. There was no documented evidence on the record that security or any other staff were providing observation of the patient.

Patient #9
Review of the Emergency Department record for Patient #9 revealed the patient was a [AGE] year old female admitted to the ED by wheelchair at 21:48 (9:48 p.m.) on 08/13/12 with a chief complaint of depression. Review of the record revealed the patient was PEC'd by the emergency department physician on 08/13/12 at 10:35 p.m. due to, "Dangerous to self, Gravely disabled and Unwilling/Unable to seek voluntary admission".

Review of the Emergency Department Nursing Record revealed no documented evidence that Security or any other staff provided observation or monitoring of the PEC patient. The record revealed the patient was transferred to an inpatient psychiatric facility on 08/14/12 at 0520 (5:20 a.m.)

Patient #12
Review of the Emergency Department record for Patient #12 revealed the patient was a [AGE] year old male admitted to the ED ambulatory with police at 1:26 a.m. on 08/03/12 with a chief complaint of suicide attempt and intentional overdose. Review of the record revealed the patient was PEC'd by the emergency department physician on 08/03/12 at 5:00 a.m. due to, "Dangerous to self, Gravely disabled and Unwilling/Unable to seek voluntary admission". Review of the triage record revealed the patient was placed in room "c".

Review of the Emergency Department Nursing Record revealed no documented evidence that Security or any other staff provided observation or monitoring of the PEC patient. The record revealed the patient was transferred to an inpatient psychiatric facility on 08/03/12 at 1650 (4:50 p.m.)


On 08/17/12 at 2:15 p.m., the Director of Critical Care (S1) and the ED Supervisor (S5) were interviewed. S1 confirmed she had observed the Security Officer (S3) seated near the hall on 08/16/12 while Patient #1 was in the ED. S1 confirmed the Security Office had his back to the patient's room and did not have visual observation of the patient while in room "a". S1 confirmed there were electrical cords, plastic gloves and trash can liners, hand sanitizers in both room "a" and room "c". S5 stated this ED used security officers to monitor PEC patients and confirmed the security officers do not document any monitoring/observation of PEC patients. After reviewing the above ED patient records, S1 and S5 confirmed there was no documentation of the monitoring/supervision of PEC patients.
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 that allegations of abuse were investigated and reported to the Department of Health and Hospitals, Health Standards Section within 24 hours of knowledge of the allegation for 1 of 1 (#3) sampled patients with an allegation of abuse out of a total sample of 13. Findings:

Review of the Emergency Department Record for Patient #3 revealed the patient was a [AGE] year old female admitted on [DATE] at 22:21 (10:21 p.m.) with chief complaints of suicidal thoughts, suicide attempt, and intentional drug overdose. Review of the record revealed the patient was PEC'd by the emergency department physician on 07/27/12 at 22:50 (10:50 p.m.) due to "Dangerous to self and unwilling to seek voluntary admission".

Review of the nurse's notes revealed the patient was placed in trauma room 1 on arrival and moved to the room "c" at 9:45 a.m. on 07/28/12. Review of the nurse's notes revealed the following: 07/29/12 at 1255 (12:55 p.m.) Pt. attempting to run - Security restrain pt. Pt. fighting with Security - have epistaxis right nares. Further review of the nurse's notes revealed the patient was transferred by ambulance to an inpatient psychiatric facility (Hospital "A") at 11:40 a.m. on 07/29/12.

On 08/16/12 at 1:30 p.m., S1 Director of Critical Care provided documentation of an incident with Patient #3 documented by the Security Department. Review of the Security Department Incident or Irregularity Report dated/timed 07/29/12 at 1105 (11:05 a.m.) revealed the following: Subject: PEC Altercation Personnel involved: S13 Security Officer, S3 Security Officer, S10RN, S11ED Technician.
Information: At approximately 1105 (11:05 a.m.) hours Sunday July 29, 2012 while relieving ____ (S3 Security Officer) for a lunch break _____ (S13 Security Officer) was involved in an altercation with P.E.C. ____ (Patient #3). Patient #3 had exited the E.R. holding room appearing very agitated and began walking towards the E.R. main entrance without speaking. S13 Security Officer attempted multiple times to speak with Patient #3 who would not respond and began walking faster as S13 Security Officer approached. S13 Security Officer then stepped in front of Patient #3 who picked up pace and continued to push past. When Patient #3 reached the area near E.R. triage-2, S13 Security Officer was forced to grab hold of the patient's arm and detain her. Patient #3 attempted to scratch and pull away, falling forward, at which point S13 Security Officer was able to slowly lower Patient #3 to the ground and restrain her until assistance arrived. S3 Security Officer arrived soon afterwards and assisted with getting Patient #3 up and back to her bed where officers stood by as S10RN administered injections to help calm her down. Once the situation deescalated S3 Security Officer monitored Patient #3 while S13 Security Officer left to wash his hands and arms which had minor scratches. Upon returning minutes later, Patient #3 walked to the door of her room to show officers that her nose was bleeding. No blood could be seen on the patient's face during or after the altercation up until this time. S3 Security Officer advised that he had been watching Patient #3; however, she had gone into the bathroom for a short period of time. Officers advised S10RN, who then helped the patient clean up and was able to quickly stop the bleeding. At approximately 1140 hours (11:40 a.m.) Patient #3 was transferred to Hospital "A" with no further problems. It should be noted that S11ED Technician had been in triage-2 when Patient #3 attempted to leave and witnessed the entire incident. Nothing further to report. Signed by S13 Security Officer.

On 08/16/12 at 3:20 p.m. in a face-to-face interview, S10RN indicated he was assigned Patient #3 on 07/29/12 when the patient attempted to elope from the ED. S10 stated he did not know how the patient got out of the room, but he saw her walk in the hall. S10 stated, "When she took off, she was booking it". S10 stated he did not see the Security Officer, "take the patient down". S10 stated when Security returned the patient to room "a", he saw the patient there because her nose was bleeding.

On 08/16/12 at 4:00 p.m. in a face-to-face interview with S11 ED Technician she confirmed she recalled the incident with Patient #3 on 07/29/12. S11 stated she heard a "commotion" while she was at triage. S11 stated Patient #3 walked out as S13 Security Officer tried to talk to her and tell her she couldn't leave. S11 stated Patient #3 pushed the security officer and S13 Security Officer grabbed the patient's arm. S11 stated, "It was the gentlest take down I ever saw". S11 stated the patient never was all the way on the floor, "I think she was on her knees". S11 stated she never saw any blood until the patient walked to the door of her room and pointed at her nose. S11 stated the security officer grabbed the patient's left arm, not even behind her, and the patient just sat down. S11 stated she never saw the officer's knee or foot touch the patient. S11 was asked if anyone had asked her what she had witnessed during this incident, she stated no. S11 confirmed she was not asked to document what she had witnessed.

On 08/16/12 at 4:30 p.m. S13 Security Officer was interviewed and verified the events as documented in the Security Department Incident or Irregularity Report dated/timed 07/29/12 at 1105 (11:05 a.m.). S13 stated he documented the incident report because the patient scratched him and she had a bloody nose.

On 08/17/12 at 9:15 a.m. in a face-to-face interview,S3 Security Officer confirmed the events as documented in the Security Department Incident or Irregularity Report dated/timed 07/29/12 at 1105 (11:05 a.m.).

Review of the Emergency Department Complaint/Grievance Log August 2012 report revealed on 08/03/12 a care concern with security was received from Hospital "A" regarding a patient complaint that security staff was "rough" with the patient in the Emergency Department on 07/27/12.

Review of the supporting documentation for the grievance reported on 08/03/12 regarding security in the ED (Emergency Department) revealed the, "Patient Complaint/Grievance Form" was dated received on 08/03/12 by phone and the complainant was S9 Social Services Supervisor from Hospital "A". The patient was identified as Patient #3 and the date of service was 07/27/12. The form revealed the complaint was received by S8 Guest Services Interpreter. The Complaint Details were listed as follows: "08/03/12 _____ (S9) called Guest Services to let us know the Spanish speaking patient wanted to file a formal complaint. Patient claims security was rough with her during her ED visit on 07/27/12...She claims her arm and stomach were bruised by Security."
Further review of the Patient Complaint/Grievance Form revealed a section titled, "Documentation of Investigation and Resolution". This section revealed the person responsible for Investigation was S7 Patient Advocate. The following subtitles under "Documentation of Investigation and Resolution" were left blank: "Steps Taken on Behalf of Patient to Investigate Grievance, Results of Review, Complaint Resolution". Attached to the "Patient Complaint/Grievance Form" were 2 letters, both addressed to Patient #3. One letter was in English and had "DRAFT" stamped across the document, and the other letter was in Spanish. Review of the "Draft" letter to Patient #3 revealed in part the following: As I understand, you reported to _____ (S9 Social Service Supervisor at Hospital "A") that you were "treated rough by security" in our E.D. I assure you that your care has been carefully reviewed in preparation of this response. I looked at pertinent portions of your medical record and spoke with individual staff members who were directly involved with your E.D. care....At no time was physical force used on you by any employee of St. Tammany Parish Hospital or by any other person....

There was no documented evidence of any specific information provided by Patient #3 regarding how she received the bruises. There was no documented evidence of any statements from the staff involved in the patient's care.

On 08/17/12 at 12:50 a.m., a telephone interview was conducted with S8 Guest Services Interpreter. S8 confirmed she recalled taking a complaint from Patient #3 and they spoke in Spanish. S8 stated that S9 Social Services Supervisor at Hospital "A" prompted the patient to tell her why they had called. S8 stated Patient #3 told her she wanted to make a telephone call and they wouldn't let her. S8 stated Patient #3 told her when she tried to get out he (Security Officer) held her down and put his foot on her stomach. S8 stated that later she was told the patient had fallen in the rest room and that was how she got the bruises. S8 stated she turned the complaint over to S7 Patient Advocate.

On 08/17/12 at 1:10 p.m. in a face-to-face interview S12 Vice President of Legal Affairs indicated S7Patient Advocate was unavailable for interview. S12 stated she was the supervisor of S7. S12 stated she had spoken to S7 about the investigation of the complaint/grievance received from Patient #3. S12 stated S7 had determined there was no abuse by the staff to the patient. S12 stated S7 had talked to the staff involved. S12 verified there was no documentation of any interviews with the staff involved, staff managers, or the ED Technician that had witnessed the incident. S12 verified this allegation of abuse was not reported to the Department of Health & Hospitals Health Standard Section. S12 stated any substantiated abuse would be reported. After reviewing the hospital's policy titled "Abuse and Neglect - Recognizing and Reporting by Hospital Personnel", S12 confirmed the policy included reporting of confirmed events to external agencies only and did not include reporting allegations of abuse/neglect to the Department of Health & Hospitals Health Standard Section within 24 hours of knowledge of an allegation.

On 08/17/12 at 4:15 p.m., during the exit conference, the Chief Nursing Officer (S2) and the Chief Operating Officer (S17) stated the hospital was not required to report allegations of abuse, only substantiated abuse to the Department of Health & Hospitals. S2 further stated, " JCAHO requires only substantiated abuse has to be reported " .

Review of the hospital policy titled, "Abuse and Neglect - Recognizing and Reporting by Hospital Personnel", adopted 03/98 and revised 08/2011, provided as current policy by S6 Administrative Assistant revealed in part the following: V. Actual or suspected events occurring within the hospital - D. All instances of suspected abuse, neglect or harassment will be investigated under the direction of the Hospital's Executive Team. E. Appropriate remedial measures and actions will be taken. Such actions may include reporting confirmed events to the Hospital's Board of Commissioners and external agencies as warranted by a particular situation.

Review of LA R.S. 40.?2009.2 revealed:
Louisiana Revised Statutes Title 40. Public Health and Safety Chapter 11. State Department of Health and Hospitals ?2009.2. Definitions (Excerpt) (3) "Department" shall mean the Department of Health and Hospitals...?2009.20. Duty to make complaints; penalty; immunity. A. As used in this Section, the following terms shall mean: (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. (2) "Neglect" is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer's well-being. 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. For the purposes of this Paragraph, the chief law enforcement agency of Orleans Parish shall be the New Orleans Police Department. (2) Any person who knowingly or willfully violates the provisions of this Section shall be fined not more than five hundred dollars or imprisoned for not more than two months, or both. C. Any person, other than the person alleged to be responsible for the abuse or neglect, reporting pursuant to this Section in good faith shall have immunity from any civil liability that otherwise might be incurred or imposed because of such report. Such immunity shall extend to participation in any judicial proceeding resulting from such report. D. All hospitals shall permanently display in a prominent location in their emergency room s a copy of R.S. 40:2009.20.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews, the hospital failed to ensure all drugs and biologicals were administered according to physician orders and acceptable standards of practice for 5 of 13 sampled patients (#1, #3, #4, #7, #10). This resulted in 7 medication errors noted during chart reviews that were not identified by the hospital for the 5 patients. Findings:

Patient #1
Review of the medical record for Patient #1 revealed the patient was a [AGE] year old male admitted on [DATE] at 00:32 (12:32 a.m.) with a chief complaint of bizarre behavior. Review of the record revealed the patient was PEC'd at 0123 (1:23 a.m.) on 08/16/12 due to, "Gravely disabled and Unwilling to seek voluntary admission".

Review of the physician's orders dated 08/16/12 (No time documented) revealed the following medication orders: Risperdal 0.5 mg. PO TID (by mouth, 3 times a day) - 1st dose now. Benadryl 25 mg. PO BID (by mouth, 2 times a day) - 1st dose now.

Review of the patient's record revealed no documented evidence that the Risperdal or the Benadryl were administered to the patient.

On 08/17/12 at 2:15 p.m., a face-to-face interview was conducted with the ED (Emergency Department) Supervisor (S5), and S4 ED Charge nurse. After reviewing the medical record for Patient #1, they verified the Risperdal and the Benadryl were not administered as ordered by the physician.

Patient #3
Review of the Emergency Department Record for Patient #3 revealed the patient was a [AGE] year old female admitted on [DATE] at 22:21 (10:21 p.m.) with chief complaints of suicidal thoughts, suicide attempt, and intentional drug overdose. Review of the record revealed the patient was PEC'd by the emergency department physician on 07/27/12 at 22:50 (10:50 p.m.) due to "Dangerous to self and unwilling to seek voluntary admission".

Review of the physician's orders dated/timed 07/28/12 at 5:45 (no documentation of a.m. or p.m.) revealed the following order: Haldol 5 mg. IM (Intramuscular injection) every 6 hours PRN (As needed) for agitation, irrational behavior.

Review of the Emergency Department Nursing Record revealed Haldol 5 mg. IM was administered on 07/28/12 at 2250 (10:50 p.m.) and again on 07/29/12 at 0130 (1:30 a.m.), 2 hours and 40 minutes after the first dose. There was no documented evidence of any other physician's orders for Haldol.

On 08/16/12 at 3:20 p.m., in a face-to-face interview, S10RN reviewed the patient's record and confirmed the Haldol injection was administered within 2 hours and 40 minutes of the last dose, and confirmed the medication was ordered by the physician to be administered every 6 hours as needed. S10RN verified there were no other physician's orders for Haldol on the patient's record.

Patient #4
Review of the Emergency Department Record for Patient #4 revealed the patient was a [AGE] year old female admitted on [DATE] at 17:03 (5:03 p.m.) with chief complaints of depression and suicidal thoughts. Review of the record revealed the patient was PEC'd by the emergency department physician on 06/01/12 at 1913 (7:13 p.m.) due to "Dangerous to self and unwilling to seek voluntary admission".

Review of the physician's orders dated/timed 06/01/12 at 1855 (6:55 p.m.) revealed the following order: Ativan 2 mg. PO/IM (By mouth or Intramuscular injection) every 6 hours PRN agitation.

Review of the Emergency Department Nursing Record revealed on 06/01/12 at 2045 (8:45 p.m.) Ativan 2 mg. was administered IV (Intravenous injection). There was no documented evidence of a physician's order to administer the Ativan by the IV route.

On 08/17/12 at 2:15 p.m., a face-to-face interview was conducted with the ED (Emergency Department) Supervisor (S5), and S4 ED Charge nurse. After reviewing the medical record for Patient #4, they verified the Ativan was not administered as ordered by the physician.

Patient #7
Review of the medical record for Patient #7 revealed the patient was an [AGE] year old male admitted on [DATE] at 08:51 (8:51 a.m.). The triage record revealed the patient arrived by wheelchair with a chief complaint of shortness of breath with mild-moderate respiratory distress.

Review of the Emergency Department Physician Orders (no date and no time documented) revealed an order for Rocephin 1 gram IVPB (Intravenous Piggy Back).

Review of the Emergency Department Nursing Record revealed no documented evidence that the Rocephin was administered. Review of the nursing documentation revealed other prescribed medications were administered at 9:35 a.m. and 10:20 a.m. on 08/01/12. Further review of the nursing documentation revealed the patient was transferred to the CCU (Cardiac Care Unit) at 12:00 p.m. on 08/01/12.

On 08/17/12 at 2:35 p.m. the Director of Critical Care (S1), and S4RN ED Charge Nurse were interviewed. S1 indicated she had reviewed the ED record and the CCU record and stated the Rocephin was not administered to the patient until 08/03/12. S4RN stated the order for the Rocephin was written on the ED physician orders on 08/01/12, and the Rocephin should have been administered in the ED.

Patient #10
Review of the medical record for Patient #10 revealed the patient was a [AGE] year old female admitted on [DATE] at 20:42 (8:42 p.m.) with a chief complaint of suicide attempt and intentional drug overdose.

Review of the Emergency Department Physician Orders dated/timed 08/11/12 at 8:45 p.m. revealed the following medication orders:
Charcoal 50 gm. PO (By mouth)
Ativan 1 mg. per Dr. ____ (S15)
Ativan 1 mg. IV
Ativan 2 mg. IV
Ativan 2 mg. IV
Haldol 5 mg. IM
Zofran 4 mg. IV
There was no documented evidence of a time written by each medication order, and there was no documented evidence of any other medication orders in the patient's record.

Review of the Emergency Department Nursing Record revealed the following medications were administered:
2055 (8:55 p.m.) - GI Cocktail PO
2100 (9:00 p.m.) - Charcoal PO
2110 (9:10 p.m.) - Zofran 4 mg. IV
2255 (10:55 p.m.) - Ativan 1 mg. IV
2320 (11:20 p.m.) - Ativan 1 mg. IV
2340 (11:40 p.m.) - Ativan 2 mg. IV
0005 (12:05 a.m.) - Ativan 2 mg. IV
0030 (12:30 a.m.) - Ativan 2 mg. IV
0042 (12:42 a.m.) - Haldol 5 mg. IM

There was no documented evidence of a physician's order for the GI Cocktail, or the third dose of Ativan administered at 12:30 a.m.

On 08/17/12 at 2:15 p.m., a face-to-face interview was conducted with the ED (Emergency Department) Supervisor (S5), and S4 ED Charge nurse. After reviewing the medical record for Patient #10, they verified there were no physician's orders for the GI Cocktail and the third dose of Ativan.

Review of the hospital's policy titled, "Addendum W Responsibilities Generic for Staff RN, LPN Staff, and Non-Licensed Personnel", adopted 1991, revised 1/2011 and provided by S6Administrative Assistant as current policy revealed in part the following: 1. Registered Nurse c. Carries out physician orders. g. Administers a variety of treatments and medications as directed in a safe and effective manner...

Review of the hospital's policy titled, "Addendum P documentation of Nursing Care", adopted July/1991, revised 1/2012 and provided by S6Administrative Assistant as current policy revealed in part the following: 8. Document complete information about medication. A. For each medication administered, document the date, time, route, site for parenteral injections and initials, or use the electronic medication administration system if appropriate. B. Document why a medication was omitted and subsequent steps that were taken in the nurse's notes.....
VIOLATION: WRITTEN MEDICAL ODERS FOR DRUGS Tag No: A0406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure a physician's order was documented for medications administered for 3 of 13 sampled patients (#1,#3, #10). The hospital failed to ensure all physician orders for medications included the exact dose and route for 5 of 13 sampled patients (#1, #4, #6, #8, #9). Findings:

1) Physician's order documented for medications administered:

Patient #1
On 08/17/12 the medical record for Patient #1 was reviewed and revealed the patient was a [AGE] year old male admitted on [DATE] at 00:32 (12:32 a.m.) with a chief complaint of bizarre behavior. Review of the record revealed the patient was PEC'd at 0123 (1:23 a.m.) on 08/16/12 due to, "Gravely disabled and Unwilling to seek voluntary admission". The record revealed the patient was transferred to an inpatient psychiatric facility on 08/16/12 at 14:50 (2:50 p.m.).

Review of the Emergency Department Nursing Record revealed Maalox 30 cc PO (by mouth) was administered to Patient #1 on 08/16/12 at 1435 (2:35 p.m.). Review of the Emergency Department Physician Orders dated 08/16/12 (no time), the Physician Orders dated 08/16/12 (no time), and the Emergency Department Routing PEC Orders dated/timed 08/16/12 at 0105 (1:05 a.m.), revealed no documented evidence of a physician's order for Maalox. There was no documented evidence of any other physician orders on the patient's record.

Patient #3
Review of the Emergency Department Record for Patient #3 revealed the patient was a [AGE] year old female admitted on [DATE] at 22:21 (10:21 p.m.) with chief complaints of suicidal thoughts, suicide attempt, and intentional drug overdose. Review of the record revealed the patient was PEC'd by the emergency department physician on 07/27/12 at 22:50 (10:50 p.m.) due to "Dangerous to self and unwilling to seek voluntary admission".

Review of the physician's orders dated/timed 07/28/12 at 5:45 (no documentation of a.m. or p.m.) revealed the following order: Haldol 5 mg. IM (Intramuscular injection) every 6 hours PRN (As needed) for agitation, irrational behavior.

Review of the Emergency Department Nursing Record revealed Haldol 5 mg. IM was administered on 07/28/12 at 2250 (10:50 p.m.) and again on 07/29/12 at 0130 (1:30 a.m.), 2 hours and 40 minutes after the first dose. There was no documented evidence of any other physician's orders for Haldol.

On 08/16/12 at 3:20 p.m., in a face-to-face interview, S10RN reviewed the patient's record and confirmed the Haldol injection was administered within 2 hours and 40 minutes of the last dose, and confirmed the medication was ordered by the physician to be administered every 6 hours as needed. S10RN verified there were no other physician's orders for Haldol on the patient's record.

Patient #10
Review of the medical record for Patient #10 revealed the patient was a [AGE] year old female admitted on [DATE] at 20:42 (8:42 p.m.) with a chief complaint of suicide attempt and intentional drug overdose.

Review of the Emergency Department Physician Orders dated/timed 08/11/12 at 8:45 p.m. revealed the following medication orders:
Charcoal 50 gm. PO (By mouth)
Ativan 1 mg. per Dr. ____ (S15)
Ativan 1 mg. IV
Ativan 2 mg. IV
Ativan 2 mg. IV
Haldol 5 mg. IM
Zofran 4 mg. IV
There was no documented evidence of any other medication orders in the patient's record.

Review of the Emergency Department Nursing Record revealed the following medications were administered:
2055 (8:55 p.m.) - GI Cocktail PO
2100 (9:00 p.m.) - Charcoal PO
2110 (9:10 p.m.) - Zofran 4 mg. IV
2255 (10:55 p.m.) - Ativan 1 mg. IV
2320 (11:20 p.m.) - Ativan 1 mg. IV
2340 (11:40 p.m.) - Ativan 2 mg. IV
0005 (12:05 a.m.) - Ativan 2 mg. IV
0030 (12:30 a.m.) - Ativan 2 mg. IV
0042 (12:42 a.m.) - Haldol 5 mg. IM

There was no documented evidence of a physician's order for the GI Cocktail, or the third dose of Ativan administered at 12:30 a.m.

On 08/17/12 at 2:15 p.m., a face-to-face interview was conducted with the ED (Emergency Department) Supervisor (S5), and S4 ED Charge nurse. After reviewing the medical record for Patient #10, they verified there were no physician's orders for the GI Cocktail and the third dose of Ativan.


2) Medication orders included exact dose and route:

Patient #1
Review of the medical record for Patient #1 revealed the patient was a [AGE] year old male admitted on [DATE] at 00:32 (12:32 a.m.) with a chief complaint of bizarre behavior. Review of the record revealed the patient was PEC'd at 0123 (1:23 a.m.) on 08/16/12 due to, "Gravely disabled and Unwilling to seek voluntary admission".

Review of the physician's orders dated/timed 08/16/12 at 0105 (1:05 a.m.) revealed the following medication orders:
Ativan (lorazepam) 1-2 mg. every 6 hours PRN (as needed) agitation (No route specified)
Benadryl (diphenhydramine) 25-50 mg. PO, IM (by mouth, intramuscular injection) Q4H PRN (every 4 hours as needed) itching or sleep.
There was no documented evidence of a clarification order received by the nurse for the specific route of administration or the specific dose.

Patient #4
Review of the Emergency Department Record for Patient #4 revealed the patient was a [AGE] year old female admitted on [DATE] at 17:03 (5:03 p.m.) with chief complaints of depression and suicidal thoughts. Review of the record revealed the patient was PEC'd by the emergency department physician on 06/01/12 at 1913 (7:13 p.m.) due to "Dangerous to self and unwilling to seek voluntary admission".

Review of the physician's orders dated/timed 06/01/12 at 1855 (6:55 p.m.) revealed the following order: Ativan 2 mg. PO/IM (By mouth or Intramuscular injection) every 6 hours PRN agitation.

Review of the Emergency Department Nursing Record revealed on 06/01/12 at 2045 (8:45 p.m.) Ativan 2 mg. was administered IV (Intravenous injection). There was no documented evidence of a physician's order to administer the Ativan by the IV route, nor was there any evidence of a clarification order received by the nurse for the specific route of administration.

Patient #6
Review of the Emergency Department record for Patient #6 revealed the patient was a [AGE] year old male admitted to the ED by ambulance at 4:25 a.m. on 07/21/12 with a chief complaint of self injury and agitated. Review of the record revealed the patient was PEC'd by the emergency department physician on 07/21/12 at 5:30 a.m. due to, "Dangerous to self and others, Gravely disabled and Unwilling to seek voluntary admission".

Review of the Emergency Department Routine PEC Orders dated/timed 07/22/12 at 5:00 a.m. revealed the following order:
Ativan (lorazepam) 1 mg. every 4-6 hours PRN agitation IV, PO, IM.
There was no documented evidence of a clarification order received by the nurse for the specific route of administration.

Patient #8
Review of the Emergency Department record for Patient #8 revealed the patient was a [AGE] year old female admitted to the ED by ambulance at 11:33 a.m. on 08/14/12 with a chief complaint of decreased mental status, overdose and depression. Review of the record revealed the patient was PEC'd by the emergency department physician on 08/14/12 at 5:30 p.m. due to, "Dangerous to self, Gravely disabled and Unwilling/Unable to seek voluntary admission".

Review of the Emergency Department Routine PEC Orders dated/timed 08/14/12 at 6:35 p.m. revealed the following orders:
Ativan (lorazepam) 2 mg. every 2 hours PRN agitation IV, PO, IM
Benadryl (diphenhydramine) 25 mg. IV, PO, IM Q4H PRN itching or sleep.
There was no documented evidence of a clarification order received by the nurse for the specific route of administration.

Review of the Emergency Department Nursing Record revealed Ativan 2 mg. PO was administered on 08/14/12 at 1849 (6:49 p.m.) and Ativan 2 mg. IM was administered on 08/14/12 at 2035 (8:35 p.m.)

Patient #9
Review of the Emergency Department record for Patient #9 revealed the patient was a [AGE] year old female admitted to the ED by wheelchair at 21:48 (9:48 p.m.) on 08/13/12 with a chief complaint of depression. Review of the record revealed the patient was PEC'd by the emergency department physician on 08/13/12 at 10:35 p.m. due to, "Dangerous to self, Gravely disabled and Unwilling/Unable to seek voluntary admission".

Review of the Emergency Department Routine PEC Orders dated/timed 08/13/12 at 18:30 (6:30 p.m.) revealed the following:
Ativan (lorazepam) 2 mg. every 4 hours PRN agitation PO, IM
Benadryl (diphenhydramine) 50 mg. PO, IM Q4H PRN itching or sleep.
There was no documented evidence of a clarification order received by the nurse for the specific route of administration.

On 08/17/12 at 2:15 p.m., in a face-to-face interview with the Director of Critical Care (S1), the ED Supervisor (S5), and S4RN ED Charge Nurse, the above ED patient records were reviewed. S5 and S4 verified the PEC Routine Orders were written by the physician with ranges of dosages and multiple administration routes. S1, S5, and S4 indicated they were unaware that ranges could not be used in physician orders. S4 verified there were no clarification orders obtained by the nursing staff.

On 08/17/12 at 3:20 p.m. in a face-to-face interview with the ED Medical Director (S16) the above ED patient records were reviewed. S16 verified the orders for Ativan and Benadryl were written with a range of the dose and multiple routes of administration. S16 stated the hospital policy was they could order a range of doses for medications for a specific reason. S16 stated he had written orders with multiple routes of administration to allow the nurse to administer the medication however the patient could tolerate it.

Review of the "Range Orders" policy from the "Pharmacy Policy & Procedure Manual" adopted on 10/03 and revised on 10/11, approved by the Department Head of Pharmacy and provided by the Director of Critical Care (S1) as current policy, revealed in part the following:
1. Range Orders are defined as "orders where the dose is expressed as a range"....
2. Initiate therapy with the lowest dose.....
D. If the management of symptoms is not adequate an additional dose may be given provided that the total of the initial dose and additional dose does not exceed the higher dose in the range....
E. If an order is written with a range for the frequency, the medication may be administered at the shortest time interval.
(There was no documentation in the policy regarding medication orders with multiple routes of administration).
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview, the hospital failed to ensure physician's orders were dated and timed for 10 of 13 sampled records (#1, #2, #3, #5, #7, #8, #9, #10, #11, #12). Findings:

Patient #1
Review of the medical record for Patient #1 revealed the patient was a [AGE] year old male admitted on [DATE] at 00:32 (12:32 a.m.) with a chief complaint of bizarre behavior. Review of the record revealed the patient was PEC'd at 0123 (1:23 a.m.) on 08/16/12 due to, "Gravely disabled and Unwilling to seek voluntary admission".

Review of the Emergency Department Physician Orders dated 08/16/12 revealed an order for Psych Profile (Laboratory tests). There was no documented evidence of the time the order was written. Further review of the patient's record revealed a Physician Orders form dated 08/16/12 for the following orders: 1. Risperdal 0.5 mg. PO TID (by mouth, 3 times a day) - 1st dose now. 2. Benadryl 25 mg. PO BID (by mouth, 2 times a day) - 1st dose now. 3. Consult Social Services.... There was no documented evidence of a time on the Physician Orders.

Patient #2
Review of the medical record for Patient #2 revealed the patient was a [AGE] year old male admitted on [DATE] at 08:53 (8:53 a.m.) with a chief complaint of found unresponsive, possible overdose. Review of the record revealed the patient was PEC'd at 0123 (1:23 a.m.) on 08/16/12 due to, "Gravely disabled and Unwilling to seek voluntary admission".

Review of the Emergency Department Physician Orders dated 08/16/12 revealed an order for Social Services for out patient resources. There was no documented evidence of the time the order was written.

Patient #3
Review of the Emergency Department Record for Patient #3 revealed the patient was a [AGE] year old female admitted on [DATE] at 22:21 (10:21 p.m.) with chief complaints of suicidal thoughts, suicide attempt, and intentional drug overdose. Review of the record revealed the patient was PEC'd by the emergency department physician on 07/27/12 at 22:50 (10:50 p.m.) due to "Dangerous to self and unwilling to seek voluntary admission".

Review of the Emergency Department Physician Orders form revealed no documented evidence of a date or time. The Emergency Department Physician Orders revealed the following orders: Saline Lock, Charcoal 50 gm with Sorbitol PO or NG (by mouth or naso gastric tube), Zofran 4 mg. IV, Psych Profile, UA (Urinalysis). Further review of the patient's record revealed a Physician Orders form with orders for medications, consults, and elopement precautions, dated 07/28/12 and timed, "5:45". There was no way to determine if the orders were written at 5:45 a.m. or 5:45 p.m.

Patient #5
Review of the medical record for Patient #5 revealed the patient was a [AGE] year old male admitted on [DATE] at 11:32 (11:32 a.m.) with a chief complaint of suicidal thoughts and hallucinating.

Review of the Emergency Department Physician Orders dated 07/17/12 revealed an order for Psych Profile, Ativan 1 mg. IV, EKG (Electrocardiogram). There was no documented evidence of the time the order was written.

Patient #7
Review of the medical record for Patient #7 revealed the patient was an [AGE] year old male admitted on [DATE] at 08:51 (8:51 a.m.). The triage record revealed the patient arrived by wheelchair with a chief complaint of shortness of breath with mild-moderate respiratory distress.

Review of the Emergency Department Physician Orders form revealed no documented evidence of a date or time. The Emergency Department Physician Orders revealed the following orders: Xopenex Aerosol, ASA (Aspirin) 325 mg., Lasix 40 mg. IV, NTG (Nitroglycerin) Paste 1/2 inch to chest wall, Rocephin 1 gram IVPB (Intravenous Piggy Back), K-lyte 50 mEq. PO, Cardiac Profile, B Type Natriuretic Pep, Pro, D-Dimer, UA (Urinalysis), Chest x-ray, EKG, and CT scan of chest.

Patient #8
Review of the Emergency Department record for Patient #8 revealed the patient was a [AGE] year old female admitted to the ED by ambulance at 11:33 a.m. on 08/14/12 with a chief complaint of decreased mental status, overdose and depression. Review of the record revealed the patient was PEC'd by the emergency department physician on 08/14/12 at 5:30 p.m. due to, "Dangerous to self, Gravely disabled and Unwilling/Unable to seek voluntary admission".

Review of the Emergency Department Physician Orders dated 08/14/12 revealed an order for Narcan 0.2 mg. IV and Flumazenil 0.2 mg. IV, Saline Lock, and Normal Saline 1 liter bolus. There was no documented evidence of the time the orders were written.

Patient #9
Review of the Emergency Department record for Patient #9 revealed the patient was a [AGE] year old female admitted to the ED by wheelchair at 21:48 (9:48 p.m.) on 08/13/12 with a chief complaint of depression. Review of the record revealed the patient was PEC'd by the emergency department physician on 08/13/12 at 10:35 p.m. due to, "Dangerous to self, Gravely disabled and Unwilling/Unable to seek voluntary admission".

Review of the Emergency Department Physician Orders revealed an order for Psych Profile. There was no documented evidence of the date or time on the order.

Patient #10
Review of the medical record for Patient #10 revealed the patient was a [AGE] year old female admitted on [DATE] at 20:42 (8:42 p.m.) with a chief complaint of suicide attempt and intentional drug overdose.

Review of the Emergency Department Physician Orders dated/timed 08/11/12 at 8:45 p.m.(Time and date next to physician's signature) revealed the following medication orders:
Charcoal 50 gm. PO (By mouth)
Ativan 1 mg. per Dr. ____ (S15)
Ativan 1 mg. IV
Ativan 2 mg. IV
Ativan 2 mg. IV
Haldol 5 mg. IM
Zofran 4 mg. IV
There was no documented evidence of a time written by each medication order, and there was no documented evidence of any other medication orders in the patient's record.

Patient #11
Review of the medical record for Patient #11 revealed the patient was an [AGE] year old female admitted on [DATE] at 17:51 (5:51 p.m.). The triage record revealed the patient arrived ambulatory with a chief complaint of chills after receiving her first chemotherapy treatment.

Review of the Emergency Department Physician Orders form revealed no documented evidence of a date or time. The Emergency Department Physician Orders revealed the following orders: CBC (Complete Blood Count), CMP (Complete Metabolic Profile), UA (Urinalysis), Rapid Strep, Blood Culture, and Chest x-ray.

Patient #12
Review of the medical record for Patient #12 revealed the patient was a [AGE] year old male admitted on [DATE] at 01:26 (1:26 a.m.) with a chief complaint of suicide attempt and intentional drug overdose.

Review of the Emergency Department Physician Orders dated 08/03/12 revealed an order for Charcoal 50 gm per NGT (Naso gastric tube), Saline Lock, Normal Saline 1 liter bolus. There was no documented evidence of the time the orders were written.

On 08/17/12 at 2:15 p.m., a face-to-face interview was conducted with the Director of Critical Care (S1), the ED Supervisor (S5), and S4RN ED Charge Nurse. After reviewing the above patient records, S5 confirmed the physician orders were not dated or timed. S4RN stated the times written to the right of the orders indicated the time the orders were entered into the computer and not the time of the order.

On 08/17/12 at 3:20 p.m. in a face-to-face interview, the ED Medical Director (S16) stated the ED physicians were under the same requirements as the hospital physicians were regarding the date and time of orders and assessments. After reviewing the sampled patient ED records, S16 verified there was no date and/or time on the physician orders. S16 stated the date and time should be documented on the physician orders.

Review of the "Policy and Procedure Manual of the Medical Staff" approved by the Board of Commissioners on 11/22/2004, revised 10/21/09, and provided as current Medical Staff bylaws by S6 Administrative Assistant, revealed in part the following: 1.1 General A. Content....All patient medical records entries must be dated, timed and authenticated....
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital's Emergency Department failed to ensure policies and procedures were developed/implemented regarding safety of psychiatric patients that were suicidal, gravely disabled, under a PEC (Physician's Emergency Certificate), or CEC (Coroner's Emergency Certificate) to include specific procedures for observation and monitoring of these patients in the ED while awaiting bed placement in a psychiatric facility. This practice effected 7 of 7 sampled PEC patients out of a total sample of 13 (#1, #3, #4, #6, #8, #9, #12). Findings:

On 08/16/12 at 10:30 a.m., an observation was made in the Emergency Department with the Director of Critical Care (S1). S1 stated PEC patients were placed in room "a" until bed placement can be obtained. S1 stated a Security Officer was assigned to the PEC patients. S1 stated if room "a" was occupied, they also used room "c". S1 confirmed that Patient #1 was under a PEC and awaiting bed placement in a psychiatric facility. S1 stated Patient #1 was in room "a". The door to room "a" was observed to be partially opened. The Security Officer, S3 was observed seated in a chair in front of room "b", near the juncture of the hall leading to room "a" and the hall leading to the nurse's station. S3 was observed to have his back to room "a" and to be facing the direction of the nurse's station. S3 was unable to visually observe Patient #1 from his position in the hall.

Review of the Emergency Department record for Patient #1 revealed the patient was admitted to the ED by ambulance at 12:32 a.m. on 08/16/12 with a chief complaint of, "I've got bugs in me". Review of the record revealed the patient was PEC'd by the emergency department physician on 08/16/12 at 0123 (1:23 a.m.) due to, "Gravely disabled and Unwilling to seek voluntary admission". Review of the record revealed a CEC (Coroner's Emergency Certificate) was documented on 08/16/12 at 1135 (11:35 a.m.) due to, "Dangerous to self, Gravely disabled, and Unable to seek voluntary admission".

Review of the nurse's notes revealed the PEC was signed at 0120 (1:20 a.m.) and security was notified. The nurse's notes revealed at 0230 (2:30 a.m.) security was "at door". The nurse's notes revealed the patient's vital signs were documented at 4:30 a.m., 6:45 a.m., and 12:45 p.m. There was no other documented evidence of any monitoring, supervision, or observation of Patient #1. The patient was transferred to an inpatient psychiatric facility at 2:50 p.m. on 08/16/12.

On 08/17/12 at 9:15 a.m., a face-to-face interview was conducted with S3 Security Officer. S3 stated his job was to make sure patients are safe, don't hurt themselves or others, and don't leave. S3 verified he was assigned to Patient #1 yesterday (08/16/12). S3 stated he usually sits beside the door of room "a" outside the room, but yesterday there were 2 other issues going on in the ED, so he sat toward the hall to monitor those issues too.

Review of the hospital's policy titled, "Psychiatric and Substance Abuse Emergencies", adopted 01/86, revised 12/06 and provided by S6 Administrative Assistant as current policy revealed in part the following: I. Policy......The hospital will provide a safe environment for these patients while attempting to provide an appropriate level of care for the patient or while facilitating a transfer. V. Principles of Care [Adopted from Emergency Department Nursing Structure Standards] A. In the event a patient is acutely mentally ill or suffering from an exacerbation of substance abuse, nursing staff and other hospital personnel should: 1. Attempt to minimize the stimuli in the patient's room and remove any persons from the room who are not essential to the patient's care; ....3. place the Hospital's Security Officer on notice of the patient's location and request he/she make frequent rounds to the area; 4. notify the Nursing Supervisor of the patient's presence and advise him/her of special needs for the patient, e.g., a nursing assistant to remain in the patient's room 1:1, assistance with coroner notification;...

Review of the hospital's policy titled, "Psychological/Substance Abuse Disorders, Management of Patient With", adopted 09/93, revised 03/12 and provided by S6 Administrative Assistant as current policy revealed in part the following: Nursing Interventions: 1. In the event a patient is ordered a Physician's Emergency Certificate (PEC) or Coroner's Emergency Certificate (CEC) or is a danger to self or others, nursing staff and other hospital personnel will do the following: A. Keep a staff member or attendant present with the patient at all times.......D. Security: Provide patient attendant with a two-way radio, Educate attendant on the appropriate use of the two-way radio, Make frequent rounds on the patient.....F. Patient Attendant: Patient attendant will assist the nurse in maintaining the safety of the patient by performing the following: Observe patient at all times......

On 08/17/12 at 2:15 p.m., the Director of Critical Care (S1) and the ED Supervisor (S5) were interviewed. S1 confirmed she had observed the Security Officer (S3) seated near the hall on 08/16/12 while Patient #1 was in the ED. S1 confirmed the Security Office had his back to the patient's room and did not have visual observation of the patient while in room "a". S5 stated this ED used security officers to monitor PEC patients and confirmed the security officers do not document any monitoring/observation of PEC patients. After reviewing the above policies, S1 stated the Patient Attendant refers to the sitters used on the inpatient units when a PEC patient was admitted to the hospital. S1 verified the policies were not specific to the ED. S1 verified there was no specific time frame for the "frequent rounds" the Security Officer was to make on PEC patients. S1 verified the Security Officers only keep a log of time spent watching PEC patients and stated the log was not part of the patient's medical record. S1 and S5 confirmed there was no documentation of the monitoring/supervision of PEC patients.

On 08/17/12 at 10:15 a.m., and observation was made of room "a" with S4RN, ED charge nurse. 2 Stretchers were observed in the room with a privacy curtain between the stretchers suspended from the ceiling with one end of the curtain track noted to not be attached to the ceiling. A television was observed to be mounted to the wall with the electrical cord coiled up, but hanging from the bottom of the television. 2 dispensers of hand sanitizer were observed mounted on the wall adjacent to the sink in the room and 2 more hand sanitizer dispensers were observed on the wall by the sink in the bathroom of room "a". 2 boxes of disposable plastic gloves were observed mounted on the wall across from the sink. 2 garbage cans in the room were observed to have plastic can liners. S4RN confirmed the above observations and verified they could be a hazard to a patient who wanted to harm himself. S4RN stated she would take the privacy curtain down if the patient was suicidal. S4RN stated the security officer usually sits at the end of the hall when there was a PEC patient in room "a". At 10:30 a.m. the Director of Critical Care (S1) was interviewed in room "a", and the above findings were verified by S1 and she confirmed they could be dangerous to patients who wanted to harm themselves. S1 verified she had observed the Security Officer (S3) seated near the hall on 08/16/12 while Patient #1 was in the ED. S1 confirmed the Security Office had his back to the patient's room and did not have visual observation of the patient while in room "a".

Patient #3
Review of the Emergency Department Record for Patient #3 revealed the patient was [AGE] year old female admitted on [DATE] at 22:21 (10:21 p.m.) with chief complaints of suicidal thoughts, suicide attempt, and intentional drug overdose. Review of the record revealed the patient was PEC'd by the emergency department physician on 07/27/12 at 22:50 (10:50 p.m.) due to "Dangerous to self and unwilling to seek voluntary admission".

Review of the nurse's notes revealed the patient was placed in trauma room 1 on arrival and moved to the room "c" at 9:45 a.m. on 07/28/12. Review of the nurse's notes revealed the following entry at 1210 (12:10 p.m.) on 07/28/12: Pt. (Patient) still very upset and crying, beginning to get drowsy. Wants to use phone but pt. too drowsy to walk at this time, explained to pt.
There was no documentation of the patient's status or any monitoring or supervision of the patient. The next entry in the nurse's notes was documented at 2200 (10:00 p.m.) on 07/28/12, 10 hours after the last entry. Further review of the nurse's notes revealed the nurse documented the patient's status at the following dates/times: 07/28/12 at 23:30 (11:30 p.m.), 07/29/12 at 0100 (1:00 a.m.), 07/29/12 at 0400 (4:00 a.m.), 07/29/12 at 0700 (7:00 a.m.). The next nursing entry revealed the following: 07/29/12 at 1255 (12:55 p.m.) Pt. attempting to run - Security restrain pt. Pt. fighting with Security - have epistaxis right nares.

There was no documented evidence that a Security Officer was monitoring the patient or providing observation of the patient until 07/29/12 at 12:55 p.m. when the patient attempted to elope from the ED. There was no documented evidence that any other staff member was monitoring or observing the patient. There was no documented evidence that visual observation of the patient was provided while the patient was placed in the room "c" or in room "a".


Patient #4
Review of the Emergency Department record for Patient #4 revealed the patient was a [AGE] year old female admitted to the ED by ambulatory at 17:03 (5:03 p.m.) on 06/01/12 with a chief complaint of feeling depressed and has been thinking about cutting her wrist or taking an overdose. Review of the record revealed the patient was PEC'd by the emergency department physician on 06/01/12 at 1913 (7:13 p.m.) due to, "Dangerous to self and Unwilling to seek voluntary admission". Review of the record revealed a CEC was documented on 06/02/12 at 1450 (2:50 p.m.) due to, "Dangerous to self, and Unable to seek voluntary admission".

Review of the nurse's notes revealed the patient was placed in room "a" at 6:25 p.m. on 06/01/12. The nurse's notes revealed the patient was PEC'd at 6:55 p.m. and "Security at door". Nursing entries at 2200 (10:00 p.m.) and 2330 (11:30 p.m.) on 06/01/12 revealed Security was at the door or bedside. There was no documented evidence from 06/01/12 at 11:30 p.m. to 06/02/12 at 4:10 p.m. that security or any other staff had provided observation or monitoring of the patient. The record revealed the patient was transferred to an inpatient psychiatric facility at 4:10 p.m. on 06/02/12.


Patient #6
Review of the Emergency Department record for Patient #6 revealed the patient was a [AGE] year old male admitted to the ED by ambulance at 4:25 a.m. on 07/21/12 with a chief complaint of self injury and agitated. Review of the record revealed the patient was PEC'd by the emergency department physician on 07/21/12 at 5:30 a.m. due to, "Dangerous to self and others, Gravely disabled and Unwilling to seek voluntary admission".

Review of the nurse's notes revealed the following: 07/21/12 at 0500 (5:00 a.m.) Pt. moved to room "c" with security at bedside. 0509 (5:09 a.m.) pt. pulled his own IV out, catheter in hand, pressure dressing applied. 0615 (6:15 a.m.) Pt. to CT (computerized tomography). Security remains at side. 0700 (7:00 a.m.) Assumed care....Security with in view.
Further review of the nurse's notes revealed no entries from 9:00 a.m. to 3:05 p.m. There was no documented evidence that the patient was observed or monitored by security or any other staff from 9:00 a.m. to 3:06 p.m. when the patient was transferred to an inpatient psychiatric facility.


Patient #8
Review of the Emergency Department record for Patient #8 revealed the patient was a [AGE] year old female admitted to the ED by ambulance at 11:33 a.m. on 08/14/12 with a chief complaint of decreased mental status, overdose and depression. Review of the record revealed the patient was PEC'd by the emergency department physician on 08/14/12 at 5:30 p.m. due to, "Dangerous to self, Gravely disabled and Unwilling/Unable to seek voluntary admission". Review of the record revealed the physician had documented the patient was stable at 4:00 p.m.

Review of the Emergency Department Nursing Record revealed the patient was moved to "overflow" at 1645 (4:45 p.m.). The next entry was documented at 1800 (6:00 p.m.) indicating the patient was awaiting placement. The next entry at 2035 (8:35 p.m.) revealed the patient received Ativan 2 mg. IM for increased heart rate and agitation. There was no documented evidence on the record that security or any other staff were providing observation of the patient.

Patient #9
Review of the Emergency Department record for Patient #9 revealed the patient was a [AGE] year old female admitted to the ED by wheelchair at 21:48 (9:48 p.m.) on 08/13/12 with a chief complaint of depression. Review of the record revealed the patient was PEC'd by the emergency department physician on 08/13/12 at 10:35 p.m. due to, "Dangerous to self, Gravely disabled and Unwilling/Unable to seek voluntary admission".

Review of the Emergency Department Nursing Record revealed no documented evidence that Security or any other staff provided observation or monitoring of the PEC patient. The record revealed the patient was transferred to an inpatient psychiatric facility on 08/14/12 at 0520 (5:20 a.m.).

Patient #12
Review of the Emergency Department record for Patient #12 revealed the patient was a [AGE] year old male admitted to the ED ambulatory with police at 1:26 a.m. on 08/03/12 with a chief complaint of suicide attempt and intentional overdose. Review of the record revealed the patient was PEC'd by the emergency department physician on 08/03/12 at 5:00 a.m. due to, "Dangerous to self, Gravely disabled and Unwilling/Unable to seek voluntary admission". Review of the triage record revealed the patient was placed in room "c".

Review of the Emergency Department Nursing Record revealed no documented evidence that Security or any other staff provided observation or monitoring of the PEC patient. The record revealed the patient was transferred to an inpatient psychiatric facility on 08/03/12 at 1650 (4:50 p.m.)