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.

LAKE CHARLES MEMORIAL HOSPITAL 1701 OAK PARK BLVD LAKE CHARLES, LA 70601 Feb. 19, 2014
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on observation, interview and record review, the hospital failed to ensure there was a Registered Nurse (RN) assigned for each unit as evidenced by no RN scheduled on the adolescent psychiatric Emergency Department extension on 10 shifts from 2/2/14 until 2/15/14 while patients were present.

Findings:

An observation on 2/18/14 at 4:00 a.m. of the conference room in the adolescent psychiatric unit on the 4th floor of the hospital revealed three recliners which were used for Emergency Department adolescent psychiatric patients awaiting placement.

In an interview on 2/18/14 at 4:00 a.m. with S8RN, she said adolescent psychiatric hold patients were transferred from the Emergency Department (ED) and housed in the conference room in the adolescent psychiatric unit on the 4th floor until an inpatient bed became available or placement was found at another facility. S8RN said the conference room was considered an ED extension and a separate unit from the adolescent psychiatric unit. S8RN also said when she had patients in the ED extension while she was working, she was the Registered Nurse (RN) responsible for the ED extension patients and for the inpatient adolescent psychiatric unit patients.

In an interview on 2/18/14 at 9:20 a.m. with S14DirNursingPsych, she said there had been times when the RN had been shared between the ED extension unit and the inpatient adolescent psychiatric unit.

Review of the staffing sheets from 2/2/14 through 2/15/14 for the ED extension on the 4th floor revealed the following:

2/2/14- 0 RNs assigned entire day, 1 patient in the unit

2/3/14- 0 RN on day and evening shift, 2 patients in the unit

2/6/14- 0 RN on evening shift, 2 patients in the unit

2/10/14- 0 RN on night shift, 2 patients in the unit

2/14/14- 0 RNs assigned entire day, 2 patients in the unit


In an interview on 2/19/14 at 10:15 a.m. with S3DirPsychServices, she said the ED extension on the 4th floor did not have a Registered Nurse assigned at all times when patients were in the unit. S3DirPsychServices said sometimes the Registered Nurse from the Adolescent Psychiatric unit would be over both units.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and record reviews the hospital failed to ensure a registered nurse evaluated the care of each patient as evidenced by delegating the performance of Mental Health Screening Evaluations, which included assessments of suicidal intent, presence of Hallucinations/Delusions and mental status, to unlicensed personnel (Mental Health Specialists) for 4 (#1, #2, #4,#6) of 4 (#1,#2,#4,#6) patients reviewed for Mental Health Screening out of a total of 10 (#1-#10) patients reviewed.

Findings:

Review of the hospital job description entitled Mental Health Specialist; Department: Psychiatric Services, revealed the following, in part:

Description/Purpose of Position:

The ER (emergency room ) Mental Health Specialist (MHS) assists the Emergency Department personnel in providing/and or coordinating emergency psychiatric care for persons experiencing acute symptoms of mental illness or emotional distress. Assists the professional and technical nursing staff from the Psych (Psychiatric) and ER departments by performing any delegated duties, specialized procedures, assessment and disposition recommendations, and assists with care of seriously ill patients. The ER MHS will act as a leader for the Psych ER Team.

Minimum Qualifications:

Education: Bachelor ' s degree, in Social Service field preferred, Nursing licensure, and/or Experience of 3-5 years.

Experience: Minimum of 3-5 years experience working with mentally ill and /or addictions

Review of the emergency room Mental Health Specialist Initial and Annual Competency Assessment/ Skills Validation Tool revealed the following, in part:

Skills:
3. Utilizes effective interviewing/assessment techniques
4. Utilizes effective crisis intervention techniques and suicidal risk assessing.

Review of the Mental Health Screening Form revealed the following areas of assessment, in part:

I.Suicidal Risk Factors: (Any one of these factors meets inpatient criteria- hospitalization should be strongly considered):

Not suicidal risk at this time; Current risk of suicide/self- injury: Risk of suicide by self report or report by others: Describe; Suicidal attempt in the past 48 hours: Describe; Suicidal Intent/Plan: Current suicidal ideation with well formulated plan; Imminent intent to act & available means that is severe & dangerous with minimal expressed ambivalence or significant barriers to doing so: Describe: Frequency; Intensity; Duration; Plan.

II. Extreme Risk Factors:

Hallucinations and/or delusions: Command/threatening hallucinations within the past 48 hours that override usual impulse control & likely to result in harm to self or others; Suspicious/paranoid behaviors that other are after him/her: Auditory, Visual, Olfactory, Tactile, Gustatory

Extreme Recklessness:
Current risk of homicide/danger to others
Homicidal Attempt: Serious homicide attempt indicated by degree of lethal intent within the last 48 hours; history of serious past attempts.

Homicidal Intent/Plan:
Mental Status Screening:

Appearance: possible choices: Clean, Neat, Appropriate dress, Unkempt, Inappropriate dress

Gait: possible choices: WNL (within normal limits) checked, Shuffled, Unsteady, Limping, Assistive Device

Neuromuscular: possible choices: WNL, Tics, Rigidity, Tremors, Posturing

Behavior: possible choices: Friendly, Withdrawn, Angry, Dramatic, Combative, Bizarre, Intrusive

Affect: possible choices: Appropriate: checked, Flat, Worried, Sad, Angry, labile, Irritable.

Mood: possible choices: Appropriate, Depressed, Anxious, Euphoric, Labile, Irritable

Speech: possible choices: Clear, Coherent, Soft, Slurred, Loud, Hyper-verbal, Rapid, Pressured, Impoverished, Incoherent, Tangential, Mute

Thoughts: possible choices: Organized, Disorganized, Racing, FOI (flight of ideas), Obsessive, Ideas of Reference.

Patient#1:

Review of Patient #1 ' s ER record revealed an admission date of [DATE], date of birth: 8/4/1956, and diagnoses including the following: Anxiety, Depression, Suicidal Thoughts and Auditory Hallucinations.

Further review of Patient #1 ' s medical record revealed the patient ' s Mental Health Screening, dated 2/17/14, was performed by a Mental Health Specialist.


Patient #2

Review of Patient #2 ' s ER record revealed an admission date of [DATE], date of birth: 10/23/1987, and diagnoses including the following: Depression and Suicidal Thoughts.

Further review of Patient #2 ' s medical record revealed the patient ' s Mental Health Screening, dated 2/17/14, was performed by a Mental Health Specialist.


Patient #4

Review of Patient #4 ' s ED record revealed an admission date of [DATE], date of birth: 9/15/2000, and diagnoses including the following: depression and suicidal thoughts, and bipolar disorder.

Further review of Patient #4 ' s medical record revealed the patient ' s Mental Health Screening, dated 1/8/14, was performed by S18MHS.


Patient#6

Review of Patient #6 ' s ED record revealed an admission date of [DATE], date of birth: 5/15/1997, and diagnoses including the following: depression and suicidal thoughts ( told mother she would kill herself).

Further review of Patient #6 ' s medical record revealed the following Mental Health Screening, dated 1/8/14, was performed by S18MHS.


Review of S16MHS Job Performance Evaluation, dated 10/21/13, performed by S3DirPsychServices, revealed the following, in part:

Utilizes effective interviewing/assessment techniques: Comments/Goals/Action Plan: significant improvements noted, however, effective communication is a vital role of this position
Communicates abnormal variances of emotional &/or cognitive data (tearful/hallucinating, etc.{etcetera}) to appropriate staff.

Reviews and validates physician's orders, reports progress and unusual occurrences on patients. Continues to have forms come to unit that are either incorrect or incomplete- it is very important to ensure accuracy of all admission paperwork from ER.
Maintains appropriate records and thorough documentation: Comments/Goals/Action Plan: Multiple discussions regarding completing the entire assessment- no blanks left empty.

Review of S18MHS Job Performance Evaluation, dated 10/21/13, performed by S3DirPsychServices, revealed the following, in part:

Communicates abnormal variances of physical data (vital signs, pain, etc{etcetera}) to appropriate staff: Comments/Goals/Action Plan: Various complaints from co-workers on weak patient hand off communication.

Communicates abnormal variances of emotional &/or cognitive data (tearful/hallucinating, etc.{etcetera}) to appropriate staff: Comments/Goals/Action Plan: Various complaints from co-workers on weak patient hand off communication.

Overall Comments: S18MHS is hard working and provides quality assessment of patient needs; remember to stay paced with the ever changing needs of the ER & inpatient units; remember to be liaison for ER and Psych processes & staff- focus on complete and thorough assessments.


In an interview on 2/18/14 at 10:42 a.m. with S3DirPsychServices , she was asked if Mental Health Specialists were Nurse Practitioners or Physician Assistants and she replied, "No" . S3DirPsychServices explained Mental Health Specialists were former Mental Health Technicians who had received additional training. She said they obtained information from the patient and the information they obtained was used to identify mental health issues.

In an interview 2/18/14 at 12:50 p.m. with S3DirPsychServices, she said the hospital had no policies regarding completion and scoring of the Mental Health Screening Form. She was asked who completed the screening form and she replied the Mental Health Specialists was responsible for completion of the Mental Health Screening.

In an interview on 2/18/14 at 1:20 p.m. with S16MHS he said he was a CNA with a 12 year background of working in a psychiatric (Psych) setting. He explained his qualification for the job of Mental Health Specialist was his Psych experience. S16MHS was asked what type of additional training he had received when he became a Mental Health Specialist and he said he had been trained by another Mental Health Specialist. S16MHS was also asked how he obtained the information documented on the Mental Health Screening Tool. He explained information was obtained from the patient, the patient's family, Emergency Medical Technicians, and Law Enforcement Officers. He said he also reviewed triage information obtained by the nurses. S16MHS was asked to explain how he evaluated suicide risk/intensity. He said he asked the patient if they thought about suicide and how often they had those thoughts. S16MHS said the frequency of the thoughts determined the suicide risk score. He explained there was no suicide risk scoring system in place to assist in determining suicide risk. S16MHS was asked how he evaluated patients for hallucinations/delusions and he said he asked the patient if they had heard things and/or had seen shadows out of the corner of their eye while alone in a room. He further explained he observed the patient to assess the criteria listed in the mental status assessment. He said he shared his findings with the nurses and with the doctor when they came to see the patient. He explained the Mental Health Specialists filled in the doctor and nurses name on the bottom of the screening tool after reviewing the information with them. S16MHS agreed portions of the Mental Health Screening tool involved assessment on his part and it was not just simple data collection.

In an interview on 2/18/14 at 1:30 p.m. with S5AsstDirPsychServices, she agreed portions of the Mental Health Screening tool involved assessment of the patient by the Mental Health Specialist. She also agreed obtaining the information contained in the Mental Health Screening was not just simple data collection. S5AsstDirPsychServices said she could see how the assessment portions of the tool were outside the scope of practice for unlicensed personnel.

In an interview on 2/19/14 at 3:00 p.m., with S3DirPsychServices she said the Mental Health Specialists were part of a team and performing Mental Health Screening assessments was the expected function of the Mental Health Specialists. S3DirPsychServices said the doctor either agreed or disagreed with the Mental Health Specialists' assessment of the patients. She further explained the Mental Health Specialists reported to her and she was responsible for their evaluations. S3DirPsychServices said her supervisor was S6SpecialtyServices.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, record reviews, and interviews, the hospital failed to meet the requirements for the Condition of Participation for Patient Rights as evidenced by:

1. Placing ED (Emergency Department) adolescent psychiatric patients in an area of the hospital that had not been approved by the Louisiana Department of Health & Hospitals as a patient care area. In addition, multiple environmental safety hazards (including a crash cart with only a plastic break away lock, coffee pot, electric cords, plastic garbage can liner, and reclining chairs not spaced in a manner to allow for safe staff intervention) were identified in this unapproved area used by the hospital to hold ED adolescent psychiatric patients (see findings cited A0144);

2. Failing to provide direct observation at all times of adult psychiatric patients in the 10th floor ED psychiatric holding area for 2 (#1, #2) of 2 (#1, #2) patients observed (see findings cited A0144);

3. Failing to ensure there was a Registered Nurse (RN) assigned for each unit as evidenced by no RN scheduled on the adolescent psychiatric Emergency Department extension on 10 shifts from 2/2/14 until 2/15/14 while patients were present (see findings cited A0144);

4. Failing to provide direct visualization of ED adolescent psychiatric patients while behind a closed door in a restroom with non-secured ceiling tiles (see findings cited A0144).
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on observation and interview, the hospital failed to ensure patients in the adult psychiatric Emergency Department (ED) extension on the 10th floor of the hospital had personal privacy for 4 of the 5 stretchers by failing to provide curtains between all of the stretchers.
Findings:
An observation of the adult psychiatric ED extension on the 10th floor revealed 5 beds located along 1 wall. 2 curtains partitioned the beds into two groups of 2 and 1 single bed. There were no curtains to separate all of the beds. Further observation revealed the beds were approximately 2 feet apart.

In an interview on 2/18/14 at 9:00 a.m. with S3DirPsychServices, she said the 10th floor ED extension was approved for 4 beds, but they have had up to 6 people in the unit because it is an ED so they can't turn people away. S3DirPsychServices said they had moved an extra bed into the unit to have 5 beds and have even had 6 beds in the unit at times. S3DirPsychServices verified there were no curtains between all of the beds for privacy.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, interview and record review, the hospital failed to ensure psychiatric emergency room patients received care in a safe setting as evidenced by:

1. Placing ED (Emergency Department) adolescent psychiatric patients in an area of the hospital that had not been approved by the Louisiana Department of Health & Hospitals as a patient care area. In addition, multiple environmental safety hazards (including a crash cart with only a plastic break away lock, coffee pot, electric cords, plastic garbage can liner, and reclining chairs not spaced in a manner to allow for safe staff intervention) were identified in this unapproved area used by the hospital to hold ED adolescent psychiatric patients;
2. Failing to provide direct observation at all times of adult psychiatric patients in the 10th floor ED psychiatric holding area for 2 (#1, #2) of 2 (#1, #2) patients observed.
3. Failing to ensure there was a Registered Nurse (RN) assigned for each unit as evidenced by no RN scheduled on the adolescent psychiatric Emergency Department extension on 10 shifts from 2/2/14 until 2/15/14 while patients were present;
4. Failing to provide direct visualization of ED adolescent psychiatric patients while behind a closed door in a restroom with non-secured ceiling tiles;

Findings:

1) Placing ED (Emergency Department) adolescent psychiatric patients in an area of the hospital that had not been approved by the Louisiana Department of Health & Hospitals as a patient care area. In addition, multiple environmental safety hazards (including a crash cart with only a plastic break away lock, coffee pot, electric cords, plastic garbage can liner, and reclining chairs not spaced in a manner to allow for safe staff intervention) were identified in this unapproved area used by the hospital to hold ED adolescent psychiatric patients.

An observation on 2/18/14 at 4:00 a.m. of the "conference room" in the adolescent psychiatric unit on the 4th floor revealed the room contained a desk, a table with chairs, 2 television sets with multiple removable cords hanging from the side of the television cart, a blood pressure machine with a removable cord, an adult unit crash cart with a plastic break away lock, a trash can with a plastic garbage bag and 3 recliners against a wall with less than a foot between them. A coffee maker was also observed in the unit on a shelf approximately three feet from the recliners. Further observation revealed the coffee maker had a glass pot half full of coffee.

In an interview on 2/18/14 at 4:00 a.m. with S8RN, she said adolescent psychiatric patients were transferred from the ED and housed in the conference room on the adolescent psychiatric unit until an inpatient bed became available or placement was found at another facility. S8RN said this holding area in the conference room was considered an ED extension. S8RN said she has had 3-4 patients at one time in the room waiting placement. S8RN also said coffee was made in the coffee pot while patients were in the room. S8RN verified there were several cords in the room on the television, blood pressure machine, and computers that could be removed. S8RN said there was usually 1 Mental Health Technician (MHT) in the room to watch 3 patients. S8RN also said a crash cart was kept in the room at night from another unit. S8RN said the room was not safe for adolescent psychiatric patients.

In an interview on 2/18/14 at 4:30 a.m. with S9MHT, she said she did not feel like the conference room on the 4th floor adolescent psychiatric unit was safe for adolescent psychiatric ED patients because it had loose cords, medications in the crash cart and hot coffee on a shelf.

Record review revealed no evidence to indicate the conference room on the adolescent psychiatric unit used as an ED extension unit to hold adolescent psychiatric patients had ever been approved by the Louisiana Department of Health & Hospitals as a patient care area.

In an interview on 2/19/14 at 10:00 a.m., S6SpecialtyServices reported that he was unable to provide documentation of approval from the Louisiana Department of Health & Hospitals for the ED extension on the 4th floor.

2) Failing to provide direct observation at all times of adult psychiatric patients in the 10th floor ED psychiatric holding area.

Review of the Hospital Policy and Procedure titled Emergency Psychiatric Services, Reviewed 1/14, revealed in part:
5. PS (psychiatric Services) techs (technicians)/ staff will monitor patients- close observation- to ensure they are safe during the Emergency stay.
Review of the Hospital Policy and Procedure titled Safety Observations, Reviewed 1/14, revealed in part:
Close Observations: Continuous, visual monitoring of patients by staff.

Review of the Emergency Department Safety Observation Flow Sheets dated 2/17/14 and 2/18/14 for Patient #2 revealed observations were initialed as having been done every 15 minutes. Review of the observation level options at the top of the documents revealed the choices " Close Observation " , " 1:1 " or " Other " . On 2/17/14, Patient #2 ' s Observation Flow sheet had " Other " selected as the observation level with 015 (every 15 minutes) written next to the choice. On 2/18/14, no level of observation had been chosen on the flow sheet.

In an observation on 2/18/14 at 8:30 a.m. on the 10th floor ED holding area, S19RN and S13MHT were outside of the holding room in the seclusion room. Further observation revealed Patient #1 was in his bed behind a curtain with no direct observation being performed. Approximately 1 minute after S19RN and S13MHT reentered the room, Patient #2 entered the room from the seclusion room.
In an interview on 2/18/14 at 8:35 a.m. with S13MHT, he said Patient #2 was out of the holding room because she was in the restroom. S13MHT said the seclusion room was used as a hallway to access the restroom. S13MHT also said all patients in the psychiatric holding areas were supposed to be in line of sight at all times. He verified his observation level sheets did not have an observation level specified and were only initialed every 15 minutes

On 2/18/14 at 9:15 a.m. an observation was made of S15MHT who had accompanied Patient #2 to the bathroom. Patient #2 was on close observation status at the time of the observation due to suicide risk. The door to the bathroom was closed and S15MHT was standing outside the door. S15MHT was asked if she had accompanied a patient #2 and she replied yes. She was asked if she should have the patient in her line of sight and she replied," Yes". She was asked if she could visualize the patient with the door closed and she replied," No, it should be open a little so the patient can be seen."

In an observation on 2/18/14 at 9:20 a.m. of the 10th floor, no staff member was in the adult ED psychiatric holding area while Patient #1 and Patient #2 were in their beds unsupervised.

3) Failing to ensure there was a Registered Nurse (RN) assigned for each unit as evidenced by no RN scheduled on the adolescent psychiatric Emergency Department extension on 10 shifts from 2/2/14 until 2/15/14 while patients were present.

An observation on 2/18/14 at 4:00 a.m. of the conference room in the adolescent psychiatric unit on the 4th floor of the hospital revealed three recliners which were used for Emergency Department adolescent psychiatric patients awaiting placement.

In an interview on 2/18/14 at 4:00 a.m. with S8RN, she said adolescent psychiatric hold patients were transferred from the Emergency Department (ED) and housed in the conference room in the adolescent psychiatric unit on the 4th floor until an inpatient bed became available or placement was found at another facility. S8RN said the conference room was considered an ED extension and a separate unit from the adolescent psychiatric unit. S8RN also said when she had patients in the ED extension while she was working, she was the Registered Nurse (RN) responsible for the ED extension patients and for the inpatient adolescent psychiatric unit patients.

In an interview on 2/18/14 at 9:20 a.m. with S14DirNursingPsych, she said there had been times when the RN had been shared between the ED extension unit and the inpatient adolescent psychiatric unit.

Review of the staffing sheets from 2/2/14 through 2/15/14 for the ED extension on the 4th floor revealed the following:
2/2/14- 0 RNs assigned entire day, 1 patient in the unit
2/3/14- 0 RN on day and evening shift, 2 patients in the unit
2/6/14- 0 RN on evening shift, 2 patients in the unit
2/10/14- 0 RN on night shift, 2 patients in the unit
2/14/14- 0 RNs assigned entire day, 2 patients in the unit

In an interview on 2/19/14 at 10:15 a.m. with S3DirPsychServices, she said the ED extension on the 4th floor did not have a Registered Nurse assigned at all times when patients were in the unit. S3DirPsychServices said sometimes the Registered Nurse from the Adolescent Psychiatric unit would be over both units.


4) Failing to provide direct visualization of ED adolescent psychiatric patients while behind a closed door in a restroom with non-secured ceiling tiles.

Review of the Hospital Policy and Procedure titled Emergency Psychiatric Services, Reviewed 1/14, revealed in part:
5. PS (psychiatric Services) techs (technicians)/ staff will monitor patients- close observation- to ensure they are safe during the Emergency stay.

Review of the Hospital Policy and Procedure titled Safety Observations, Reviewed 1/14, revealed in part:
Close Observations: Continuous, visual monitoring of patients by staff. This level of observation is implemented for all patients 8 years and old or under, but may also be implemented on any patient regardless of age.

Review of the Hospital Policy titled Emergency Department, Mental Health Patients, Management of, reviewed 2/13 revealed in part:
4. Patients being assessed for admission to the psychiatric unit will be asked to undress (including underclothes and socks) searched, and placed in a gown or paper scrubs.
11. Patients who pose a harm to self will be offered the bed pan or accompanied to the restroom and remain under direct visualization from the ED staff.

Review of a patient list provided by S3DirPsychServices for the adolescent psychiatric ED extension from 2/2/14 through 2/14/14 revealed the unit had held 6 suicidal patients and 3 depressed patients.

An observation on 2/18/14 at 4:00 a.m. of the " conference room " in the adolescent psychiatric unit on the 4th floor revealed the room contained two restrooms, both with acoustical tile ceilings that were not secured. Removal of the ceiling tiles exposed metal strips which posed a safety risk for a suicidal patient because they could be used to secure an item for hanging.

In an interview on 2/18/14 at 4:00 a.m. with S8RN, she said the adolescent psychiatric patients in the ED extension (conference room in the adolescent unit on the 4th floor) were allowed leave their clothes on instead of changing into a hospital gown until admitted or transferred, including their shoestrings and belts. S8RN said the patients could go to restrooms in the conference room unattended, even if they were suicidal. S8RN verified the ceiling tiles in the restrooms were not secured.

In an interview on 2/18/14 at 4:30 a.m. with S9MHT, she the adolescent psychiatric patients in the 4th floor ED extension were not placed into gowns unless they were going to be admitted . S9MHT said if small children went to the restroom, they would help them if needed or leave the door cracked, but if the kids were older, they could go to the restroom by themselves unsupervised.

In an interview on 2/18/14 at 5:00 a.m. with S11MHT, she said she worked on all of the psychiatric units at the hospital. S11MHT stated she did not feel like the conference room on the 4th floor was a safe place to hold psychiatric patients. S11MHT said the 3 recliners in the room were there for sleeping, but the kids were free to walk around the room. S11MHT said nobody accompanied the children to the restroom. S11MHT said several staff members had complained to S3DirPsychServices that the room was not safe, but she would just reply that they were working on it.

In an interview on 2/18/14 at 9:20 a.m. with S14DirNursingPsych, she said they have had 3-4 ED adolescent psychiatric patients being housed at a time in the conference room on the 4th floor. S14DirNursingPsych said there was 1 technician to watch all of the patients. S14DirNursingPsych verified that when a patient went to the restroom, staff would not be able to visualize them because they allowed the patients to close the door. S14DirNursingPsych said the patients were searched when they arrived on the unit, but their shoestrings and belts were not removed even if they were suicidal.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, record reviews, and interviews, the hospital failed to meet the requirements for the Condition of Participation for Nursing Services as evidenced by failing to ensure there was a Registered Nurse (RN) assigned for each unit as evidenced by no RN scheduled on the adolescent psychiatric Emergency Department extension on 10 shifts from 2/2/14 until 2/15/14 while patients were present on the unit.
(see findings in tag A-0392).
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on observation, interview and record review, the hospital failed to ensure there was a clear chain of command in regards to nursing services for staff members working on the psychiatric ED extension units (which is part of the hospital's Emergency Department) on the 4th floor and 10th floor and failing to ensure all licensed registered nurses had the required training for nursing staff working in the ED (Emergency Department).

Findings:

An observation on 2/18/14 at 4:00 a.m. of the "Conference Room" in the adolescent psychiatric unit on the 4th floor revealed the room contained 3 recliners against a wall. In an interview with S8RN, she said adolescent psychiatric hold patients were transferred from the Emergency Department (ED) and housed in the conference room in the adolescent psychiatric unit on the 4th floor until an inpatient bed became available or placement was found at another facility.

An observation of a locked unit within the adult inpatient psychiatric unit on the 10th floor revealed 5 stretchers located along 1 wall. The room contained 2 Emergency Department (ED) patients on hold for psychiatric bed placement.

In an interview on 2/18/14 at 9:00 a.m. with S3DirPsychServices, she said the ED psychiatric holding areas on the 10th floor had been there since 2006 or 2007 and on the 4th floor since 1/6/14. S3DirPsychServices verified the two rooms on the 4th and 10th floors were ED extensions.

In an interview on 2/19/14 at 12:30 p.m. with S4DirED, she said she was the nursing director of the ED. S4DirED said the Director of Psychiatric Services (S3DirPsychServices) staffed the 10th floor and 4th floor ED extension units. S4DirED said when the psychiatric holding rooms were in the main ED, they were staffed with ED nurses. She said the ED extension units on the 4th and 10th floors have always been staffed by psychiatric nurses rather than ED nurses. S4DirED said she evaluates her employees that work in the main ED, but does not evaluate the employees that work on the ED extension units which are part of the Emergency Department. When asked about the policies/procedures used on the ED extension units, S4DirED indicated the staff members working on the ED extension units were using a combination of policies from both the ED and the inpatient psychiatric units. When asked if the psychiatric holding units on the 4th and 10th floors were an extension of the ED, S4DirED replied yes. When asked if she did all of the evaluations and supervision for the employees of the ED extension that she did for the employees in the main ED on the 1st floor, S4DirED replied no. S4DirED said the reason why the ED extensions were not treated the same as the main ED was because when the extensions were opened, they were assigned to psychiatric services.

In an interview on 2/19/14 at 1:06 p.m. with S22RiskMgr, she said if she received an incident report, she would send it to the unit manager where the incident occurred for investigation. S22RiskMgr said if she received a complaint from the ED extension on the 4th floor or the 10th floor, she would send it to the psychiatric inpatient nursing director, not the ED nursing director.

In an interview on 2/19/14 at 1:10 p.m. with S23DirQuality, he said Quality Assurance (QA) was organized by each department and they reported to him quarterly. S23DirQuality said the reports were brought to the council and to the board. He said indicators were initiated by the managers, or by patient satisfaction surveys, or by the QA department. If a service is added, indicators are usually added by the specific department manager. S23DirQuality said he considered S3DirPsychServices to be the director of the 4th and 10th floor psychiatric ED extensions, not S4DirED.

Review of the Louisiana State Hospital Licensing Regulations for provision of Emergency Services Section 9327E.1. Personnel, revealed in part, the following: There shall be a registered nurse and other nursing service personnel qualified in emergency care to meet written emergency procedures and needs anticipated by the hospital. All registered nurses working in Emergency Services shall be trained in pediatric advanced life support (PALS) and Advanced Cardiac Life Support (ACLS).

In an interview on 2/19/14 at 1:44 p.m. with S24HRManager, she said the Nurses in the Emergency Department were required to have Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS). S24HRManager said the nurses working in the ED extensions were not required to have ACLS. Further review of the personnel files for S10RN and S14DirNursingPsych revealed they were not certified in ACLS or PALS. Review of the personnel record for S8RN revealed she did not have certification in PALS.

In an interview on 2/19/14 at 3:45 p.m. with S3DirPsychServices, she stated the main ED department and the psychiatric ED extensions on the 4th floor and the 10th floors were disconnected. S3DirPsychServices said the units on the 4th and 10th floors were managed by her instead of S4DirED.

Review of the hospital organizational chart revealed Psychiatric Services, 4 tower and 10 tower triage (adult and adolescent psychiatric units on the 4th and 10th floors) were under the direction of S6SpecialtyServices. The ED was listed under the direction of S2CNO.
VIOLATION: EMERGENCY SERVICES PERSONNEL Tag No: A1110
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the hospital failed to ensure all emergency services personnel requirements were met by failing to ensure registered nurses in the Emergency Department (ED) Extension units were trained in:

1) Pediatric Advanced Life Support (PALS) for 3 (S8RN, S10RN, S14DirNursingPsych) of 3 (S8RN, S10RN, S14DirNursingPsych) ED Extension registered nurses' personnel records reviewed for PALS certification.

2) Advanced Cardiac Life Support (ACLS) for 2 (S10RN,14DirNursingPsych) of 3(S8RN, S10RN, S14DirNursingPsych) ED Extension registered nurses' personnel records reviewed for ACLS certification. as set forth in the Louisiana State Hospital Licensing Regulations for provision of Emergency Services Section 9327E.1. Personnel.

Findings:

Review of the Louisiana State Hospital Licensing Regulations for provision of Emergency Services Section 9327E.1. Personnel, revealed in part, the following: There shall be a registered nurse and other nursing service personnel qualified in emergency care to meet written emergency procedures and needs anticipated by the hospital. All registered nurses working in Emergency Services shall be trained in pediatric advanced life support (PALS) and Advanced Cardiac Life Support (ACLS).

Review of the hospital job description entitled : Registered Nurse, Department: Nursing revealed the following:

Description/Purpose of Position:

Provides professional nursing care for patients within an assigned unit of a hospital, in support of medical care as directed by medical staff and pursuant to objectives and policies of the hospital. The registered nurse is responsible for total nursing care for all patients assigned to him/her by the Nurse manager and/or Charge Nurse.

Department Specific Requirements:

Current unit specific Cardiopulmonary Resuscitation (CPR) requirements: Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS), Neonatal Resuscitation Program (NRP).

1) Failing to ensure all emergency room nurses were trained in PALS as set forth in the Louisiana State Hospital Licensing Regulations for provision of Emergency Services Section 9327E.1. Personnel.

Review of Patient #3's medical record revealed an admission date of [DATE], date of birth 5/2/09 (4 years old) and diagnoses including the following: [DIAGNOSES REDACTED], Oppositional Defiant Disorder, Sociopathic Type Behavior. Further review revealed she was transferred to the ED Extension unit while awaiting admission to the Adolescent Psychiatric unit.

Review of the personnel record for S8RN revealed she was a registered nurse assigned to work in the ED Extension unit. Further review of her personnel record revealed she had no PALS certification.

Review of the personnel record for S10RN revealed she was a registered nurse assigned to work in the ED Extension unit. Further review of her personnel record revealed she had no PALS certification.
Review of the personnel record for S14DirNursingPsych revealed she was a registered nurse who was the Nursing director for Psychiatric services. She also worked in the ED Extension unit. Further review of her personnel record revealed she had no PALS certification.

2) Failing to ensure all ED Extension unit nurses were trained in ACLS as set forth in the Louisiana State Hospital Licensing Regulations for provision of Emergency Services Section 9327E.1. Personnel:

Review of the personnel record for S10RN revealed was a registered nurse assigned to work in the ED Extension unit. Further review of her personnel record revealed she had no ACLS certification.

Review of the personnel record for S14DirNursingPsych revealed she was a registered nurse who was the Nursing Director of Psychiatric Services. She also worked in the ED Extension unit. Further review of her personnel record revealed she had no ACLS certification.
In an interview on 2/19/14 at 1:44 p.m. with S24HRManager, she said the nurses in the ED were required to have ACLS certification.
In an interview on 2/19/14 at 3:00 p.m. with S3DirPsychServices she said the staff of the ED extension was not trained like nursing staff in the ED because the focus of care in the ED Extension unit was mental health. She also said the patients had medical clearance prior to coming to the ED extension unit. S3DirPsychServices said only one of her nurses had ACLS certification (S8RN) and none of the nurses in the ED Extension units had PALS certification.