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.

BATON ROUGE GENERAL MEDICAL CENTER 3600 FLORIDA BLVD BATON ROUGE, LA 70806 Aug. 30, 2011
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on record review and interview the hospital failed to ensure the written response to a grievance contained the results of the investigation as required by hospital policy as evidenced by the hospital not responding to a grievance filed on 01/31/11 until 04/06/11 and failing to include the steps taken on behalf of the patient to investigate the grievance and results of the grievance process. Findings:

Review of an e-mail dated 02/07/11 from S13Grievance Coordinator indicated the hospital was in receipt of the grievance. Review of an e-mail from S35VP, HR, revealed the following: "...On the hospital end we should handle as a grievance and have our documentation in order in case she goes to DHH (Department of Health and Hospitals) or any other regulatory body with allegations."

Review of the response letter sent to the patient representative in response to the grievance filed on 01/31/11 revealed it was dated April 6, 2011. Further review revealed the only result listed in the response regarding the results of the investigation were "As a result of our investigation, the medical care provided by the medical staff was deemed to be appropriate."

Review of 2 (two) forms titled "Baton Rouge General Formal Counseling Agreements" revealed the Registered Nurse (S8RN) was counseled regarding Professionalism, Safety, and Accountability in regards to the care provided to patient on 01/09/11. S5RN, Unit Manager documented under "Description of Problem or Situation" the following: "Failure to document in EMR (electronic medical record) on patient (timeframe 07:30 - 11:15a), poor and inconsistent charting noted, No vital signs. Failure to ensure 15 minute checks were maintained and documented by MHT (Mental Health Technician)." This document was signed by S5RN and S8RN on 02/14/11.

Review of the second form titled "Baton Rouge General Formal Counseling Agreements" revealed the MHT (S9MHT) was counseled regarding Professionalism, Safety, and Accountability in regards to the care provided to patient on 01/09/11. S5RN, Unit Manager documented under "Description of Problem or Situation" the following: "Failure to complete q (every) 15 minute checks on patient charting from 08:00 - 11:15 am." This document was signed by S5RN and S9MHT on 02/14/11.

In an interview on 08/29/11 at 10:01 a.m. with S13Grievance Coordinator (during the 01/11 time frame) she stated that, in regards to the response letter to the patient representative of patient #5, she "felt it best not to disclose all results of the investigation because we could open ourselves up to legal issues." She further stated she "did not state the part about staff not following policy."

Review of a hospital policy titled "Grievance Process", Policy Number A-110, effective 09/97, last reviewed 06/11, last revised 10/10, presented as current hospital policy, reads in part: "Purpose: To provide/maintain a timely, reasonable and consistent grievance process in which prompt resolution to patient/patient representative grievances is achieved. Definitions: 1. According to CMS (Center for Medicare/Medicaid Services), a patient grievance is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoP's)...Policy:..4. BRGMC (Baton Rouge General Medical Center) will review, investigate, and resolve each grievance within a reasonable time frame. Grievances regarding situations that endanger the patient, such as neglect, or abuse are addressed immediately. (See PE-102, Abuse/Neglect: Patient Rights). 5. A written response is sent to the patient/patient representative within 7 - 10 days from the time the Grievance Manager is notified of the grievance. Should the grievance require extensive investigation, the patient/patient representative will receive a letter acknowledging receipt of the grievance and ongoing investigative review. A second letter will be issued containing all of the requirements as noted below. 6. Each written response includes the following:..b. Steps taken on behalf of the patient. c. Results of the investigation of grievance."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure the patient's plan of care was updated when restraints were implemented for 3 of 4 patients reviewed with restraints from a total of 9 sampled patients ( #6, #7, #9). Findings:

Patient #6
Review of the discharge summary for Patient #6 revealed she was admitted to the hospital on 05/24/11 for evaluation and therapy of altered mental status secondary to acute [DIAGNOSES REDACTED] secondary to clinical sepsis and a urinary tract infection.

Review of the Doctor's Order Sheet for 24 Hour/Daily Seclusion/Restraint Order and Communication Record (Violent and/or Self-Destructive Behavior) dated 05/24/11 and timed 1330 revealed she was physically aggressive toward others. Review of the Doctor's Order Sheet for Initial Restraint Order and Communication Record (Non-Violent Behavior)) dated 05/24/11 and timed 1900 revealed Patient #6 demonstrated activity that posed high risk for re-injury. Review of the Doctor's Order Sheet for 24-Hour Restraint Order form (Non-violent Behavior) revealed restraint day #2, 05/25/11, was for disruptive of acute medical/post procedure care, attempting to remove essential medical equipment, and activity that poses high risk for re-injury. Review of the Doctor's Order Sheet for 24-Hour Restraint Order form (Non-violent Behavior) revealed restraint day #3, 05/27/11, was for disruptive of acute medical/post procedure care, attempting to remove essential medical equipment, IV(intravenous), and activity that poses high risk for re-injury. Review of the Doctor's Order Sheet for 24-Hour Restraint Order form (Non-violent Behavior) revealed restraint day #4, 05/28/11, was for disruptive of acute medical/post procedure care, attempting to remove essential medical equipment, IV (intravenous), and activity that poses high risk for re-injury.
Review of the Doctor's Order Sheet for 24-Hour Restraint Order form (Non-violent Behavior) revealed restraint day #5, 05/29/11, was for disruptive of acute medical/post procedure care, and attempting to remove essential medical equipment, IV (intravenous).

Review of the documentation labeled Flowsheet, which was the care plan, dated 05/27/11 and timed 12:35 (12:35 p.m.) revealed Alt (Altered) Skin Integrity related to abrasion, indwelling cathr (catheter), invasive line,and pressure ulcer. Priority/Timelin (timeline) was listed as hospitalization . Eval (evaluation) of Progress was listed as initiated. Goals/Outcome were adeq(adequate )nutrition, maint (maintain) skin integt (integrity), s/s (signs/symptoms) wd (wound) healing, wound size, edema, adq (adequate) skin turgor. Under Plan and Intervention the following were listed: topical meds, monitor nutrition, position change, pressure mgmt (management) pressure ulcer prev (prevention), skin care tx (treatment), skin surveillance, wound care, turn q (every) 2 hours, foam wedge, and float heels.

An interview was conducted with S25Director of Quality/Patient Safety and S2VP of Patient Care on 08/25/2011 at 10:45 a.m. They verified there was no Plan of Care for Patient #6 related to the use of restraints on her from 05/24/2011 to 05/29/11. The only Plan of Care for the patient was initiated on 05/27/11 and was related to Altered Skin Integrity.

Patient #7
Review of the medical record for Patient #7 revealed he was admitted on [DATE] at 23:57 (11: 57 p.m.) from the nursing home related to a fall in the nursing home. His diagnoses for admission to the hospital was recurrent falls and subdural hematoma. He was admitted on [DATE] at 3:16 a.m.

Review of a progress note by S32MD dated 07/04/11 and timed 1643 (4:43 p.m.) revealed, "The patient became agitated and threatened to leave because he wanted to smoke. I saw the pt (patient) and tried to calm him verbally. The pt continued to argue and swear. The pt began to stand up and was obviously unstable. I tried to steady the patient and direct him back to the bed. The patient became combative, grabbed me forcefully, shoved me, and tried to hit me. Security was called. The pt. was appropriately restrained...An order of psych consult, PEC (Physician Emergency Confinement) was done and the patient was transferred to the med psych for further management of his agitation and Dilantin toxicity...."

Review of the Doctor's Order Sheet dated 07/04/11 Initial Restraint Order and Communication Record (Non-violet Behavior) revealed the justification for restraint was disruption of acute medical/post procedure care, and attempting to remove essential medical equipment (IV). Review of the electronic Order Confirmation Report revealed on 07/04/11 at 12:11 p.m. there was orders to remove the restraints. On 07/04/11 at 16:54 (4:54 p.m.) there was an electronic order to start restraint (violent) 18 yrs. (years) and older. Justification was combative, physical aggression to others, self-injurious behavior. Review of the Doctor's Order Sheet for 24-Hour/Daily Restraint Order form (non-violent behavior) dated 07/05/11 at 8 a.m., Day 2, revealed he was disruptive of acute medical/post procedure care by attempting to remove essential medical equipment, IV and demonstrating activity that poses high risk for re-injury. Also documented was he was combative and confused. Review of the Doctor's Order Sheet for 24-Hour/Daily Restraint Order form (non-violent behavior) dated 07/06/11 at 8 a.m., Day 3, revealed he was disruptive of acute medical/post procedure care by attempting to remove essential medical equipment, IV and demonstrating activity that poses high risk for re-injury. Also documented was he was confused. Review of the Doctor's Order Sheet for 24-Hour/Daily Restraint Order form (non-violent behavior) dated 07/07/11 at 8 a.m., Day 4, revealed he was disruptive of acute medical/post procedure care by attempting to remove essential medical equipment, IV and demonstrating activity that poses high risk for re-injury. Also documented was he was confused and aggression.

Review of the Interdisciplinary Plan of Care revealed a plan of care for Risk for Injury for 07/08/11 at 1634(4:34 p.m.), 07/07/11 at 17:56 (5:56 p.m.), 07/05/11 at 19:55 (7:55 p.m.). A plan of care for Imprd ( Impairment) of Mobility was documented on 07/08/11 at 16:34 (4:34 p.m.), 07/07/11 at 17:56 (5:56 p.m.), 07/07/11 at 9:05 a.m., 07/05/11 at 19:57 (7:57 p.m.) , and 07/05/2011 at 9:35 a.m. The restraint plan of care was not started until the problem was resolved on 07/08/11 when the restraints were discontinued on the 4th day of use. Review of the plan of care of restraints revealed on 07/08/11 16:39 (4:39 p.m.), evaluation of progress was documented as the plan of care was met and resolved.

An interview was conducted with S24Director of Quality/Patient Safety and S2VP of Patient Care on 08/29/11 at 9:10 a.m. They confirmed Patients #7's plan of care for restraints should had been initiated when the restraint were started not on discontinuing the restraint..

Patient #9
Review of Patient #9's medical record revealed she was admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED].

Review of Patient #11's "Plan of Care Flowsheet" revealed the patient problems identified were impaired mobility, altered cognition, and infection. Further review revealed no documented evidence that the plan of care was updated upon implementation of restraints.

In a face-to-face interview on 08/29/11 at 12:40 pm, Director of Quality and Patient Safety S25 confirmed Patient #9's care plan was not updated when restraints were initiated.

Review of the hospital policy titled "Restraint and Seclusion", policy number TX-510 revised 10/10 and submitted by Director of Quality and Patient Safety S25 as the current hospital policy for restraints, revealed, in part, "... 8. Plan of Care-Violent and Non-Violent Restraint/Seclusion use A. The patient's Plan of Care will be modified when restraints/seclusion is initiated. Use of the restraints/seclusion interventions should reflect in patient's plan of care or treatment plan based on an evaluation of the patient. B. The patient's Plan of Care or treatment plan will be reviewed and updated accordingly...".
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews the hospital failed to ensure a physician's order was obtained for continuation of a medical restraint and/or behavioral restraint for 2 of 4 patients reviewed for restraints out of a total sample of 9 ( #6, #7). Findings:

Patient #6
Review of the discharge summary for Patient #6 revealed she was admitted to the hospital on 05/24/11 for evaluation and therapy of altered mental status secondary to acute [DIAGNOSES REDACTED] secondary to clinical sepsis and a urinary tract infection.

Review of the entire medical record revealed no physician's orders for restraints on 05/26/2011.

Review of the EMR (electronic medical record) for Restraint Documentation every 2 hours by the RN on 05/26/11 revealed documentation of the nonviolent restraints being secured on the patient. On 05/26/11 the following times were documented that the patient's wrist and ankle restraints and 4 siderails were secured: 03:35 (3:35 a.m.), 08:47 (8:47 a.m.), 10:22 (10:22 a.m.), 12:20 (12:20 p.m.), 14:14 (2:14 p.m.), 16:20 (4:20 p.m.), 18:50 (6:50 p.m.), 19:37 (7:37 p.m.), and 23:37 (11:37 p.m.).

An interview was conducted with S25Director of Quality/Patient Safety and S2VP of Patient Care on 08/25/2011 at 10:45 a.m. They confirmed there was no physician orders on 05/26/2011 for the patient to be in restraints on that day.

Patient #7
Review of the medical record for Patient #7 revealed he was admitted on [DATE] at 23:57 (11: 57 p.m.) from the nursing home related to a fall in the nursing home. His diagnoses for admission to the hospital was recurrent falls and subdural hematoma. He was admitted on [DATE] at 3:16 a.m.

Review of a progress note by S32MD dated 07/04/11 and timed 1643 (4:43 p.m.) revealed, "The patient became agitated and threatened to leave because he wanted to smoke. I saw the pt (patient) and tried to calm him verbally. The pt continued to argue and swear. The pt began to stand up and was obviously unstable. I tried to steady the patient and direct him back to the bed. The patient became combative, grabbed me forcefully, shoved me, and tried to hit me. Security was called. The pt. was appropriately restrained, given Ativan 2 mg IV, and placed in wrist restraints. An order of psych consult, PEC (Physician Emergency Certificate) was done and the patient was transferred to the med psych for further management of his agitation and Dilantin toxicity...."

Review of the PEC dated 07/04/11 at 4:45 p.m. revealed the patient was admitted for dilantin toxicity and acute/subacute subdural hematoma. Increase (arrow going upwards) falls at nursing home. Patient with h/o (history of) seizures, HIV, AIDS dementia. Oriented to place. Pt threatening to hit housestaff. Violent resisting medical advise. Wants to go out and smoke. However very unstable on feet. Under the section "Is patient currently?" violent was checked. Under the section, "I am of the opinion that the above person named is in need of immediate psychiatric treatment in a treatment facility because he/she is seriously mentally ill or suffering form substance abuse so that he/she is.." Both dangerous to self and dangerous to others were checked.

Review of the Doctor's Order Sheet dated 07/04/11 Initial Restraint Order and Communication Record (Non-violet Behavior) revealed the justification for restraint was disruption of acute medical/post procedure care, and attempting to remove essential medical equipment (IV). Review of the electronic Order Confirmation Report revealed on 07/04/11 at 12:11 p.m. there was orders to remove the restraints. On 07/04/11 at 16:54 (4:54 p.m.) there was an electronic order to start restraint (violent) 18 yrs. (years) and older. Justification was combative, physical aggression to others, self-injurious behavior. Review of the Doctor's Order Sheet for 24-Hour/Daily Restraint Order form (non-violent behavior) dated 07/05/11 at 8 a.m., Day 2, revealed he was disruptive of acute medical/post procedure care by attempting to remove essential medical equipment, IV and demonstrating activity that poses high risk for re-injury. Also documented was he was combative and confused. Review of the Doctor's Order Sheet for 24-Hour/Daily Restraint Order form (non-violent behavior) dated 07/06/11 at 8 a.m., Day 3, revealed he was disruptive of acute medical/post procedure care by attempting to remove essential medical equipment, IV and demonstrating activity that poses high risk for re-injury. Also documented was he was confused. Review of the Doctor's Order Sheet for 24-Hour/Daily Restraint Order form (non-violent behavior) dated 07/07/11 at 8 a.m., Day 4, revealed he was disruptive of acute medical/post procedure care by attempting to remove essential medical equipment, IV and demonstrating activity that poses high risk for re-injury. Also documented was he was confused and had aggression.

An interview was conducted with S12Charge Nurse on 08/30/11 at 8:55 a.m. He stated he was the charge nurse on the medical psych floor when the Code White was called on the telemetry unit on the night of 07/04/11. He went on to state a Code White was when a patient posed a security risk for his/her self and others. He stated when he got to Patient #7's room he was yelling and trying to push a doctor out of the room. It took two nurses to maintain him in standing position and they put soft restraints on the patient and the patient was given Ativan IVP. The patient was transferred to the medical psych floor. When the patient transfers to another floor all the orders transfers with him so the violent restraint order transferred with him. He went on to state after 4 hours he did not get another violent restraint order from the physician because in his head he thought it was a nonviolent/medical restraint. He confirmed the patient should had another violent restraint order 4 hours after the first, which would have been at 20:54 (8:54 p.m.). The next restraint order was a nonviolent restraint on 07/05/11 at 8 a.m. The patient went without a restraint order for approximately 11 hours.

An interview was conducted with S25Director of Quality/Pt Safety on 08/30/11 at 8:20 a.m. She stated the 07/05/11 restraint order should had been an initial non-violet behavior restraint order or a violet restraint reorder. She did confirm the patient went about 11 hours without a restraint order.

Review of the hospital's current policy on Restraint and Seclusion, Number TX-510 revealed in part..." 5. Non-Violet Restraint. B. Documentation and Forms: ....C. Primary Documentation: 1) Initial Restraint Order and Communication Record: This order form is to be completed by the RN that initiates the use of restraints and is available for physician signature. 2) 24 Hours/Daily Restraint Order Form: This order form is available for physician signature when reordering restraints and is to be completed by the RN and available for physician signature. 3) 24 Hour Restraint/Seclusion Flow Sheet: When EMR (electronic medical record) is unavailable or not in use in a department, this record will be used during every restraint episode to document ongoing monitoring, and RN reevaluation of all patients in restraints...6. Violent Restraint Violent and/or Self-Destructive Behavior A. Physician Orders 1) Upon determination of the need to initiate restraints or seclusion, the nurse will consult with the physician concerning the patient's physician and psychological status and to obtain an order for the use of restraints/seclusion, or immediately thereafter. 2) The attending physician must be consulted as soon as possible after restraint application/patient seclusion of the attending physician did not order the restraint(i.e. the attending was not on call)....4) Physician orders for violet and/or self destructive behavior must include:
a. Patient behavior demonstrating an immediate risk of physical harm to self or others related to an emotional or behavioral disorder.
b. Type of restraint and/or seclusion.
c. The 24-Hour/Daily Restraint/Seclusion Order Form, based on patient age, is required every 24 hours. At the same time, also based on patient's age, the seclusion/Restraint Renewal Orders are required with the time limit not to exceed 24 hours:
4 hours for patients 18 years and older.
2 hours for patients 9 years to [AGE] years old.
1 hour for patients under 9 years..."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
**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 for the use of restraints to manage the violent behavior of a patient was renewed within 4 hours as evidenced by the patient remaining in restraints for 11 hours without a renewal order from the physician for 1 out 4 patients reviewed for restraints out of a total sample of 9 (#7) Finding:

Patient #7
Review of the medical record for Patient #7 revealed he was admitted on [DATE] at 23:57 (11: 57 p.m.) from the nursing home related to a fall in the nursing home.

Review of a progress note by S32MD dated 07/04/11 and timed 1643 (4:43 p.m.) revealed, "The patient became agitated and threatened to leave because he wanted to smoke. I saw the pt (patient) and tried to calm him verbally. The pt continued to argue and swear. The pt began to stand up and was obviously unstable. I tried to steady the patient and direct him back to the bed. The patient became combative, grabbed me forcefully, shoved me, and tried to hit me. Security was called. The pt. was appropriately restrained, given Ativan 2 mg IV, and placed in wrist restraints. An order of psych consult, PEC (Physician Emergency Certificate) was done and the patient was transferred to the med psych for further management of his agitation and Dilantin toxicity...."

Review of the PEC dated 07/04/11 and timed 4:45 p.m. revealed the patient was admitted for dilantin toxicity and acute/subacute subdural hematoma. Increase (arrow going upwards) falls at nursing home. Patient with h/o (history of) seizures, HIV, AIDS dementia. Oriented to place. Pt threatening to hit housestaff. Violent resisting medical advise. Wants to go out and smoke. However very unstable on feet. Under the section "Is patient currently?" violent was checked. Under the section, "I am of the opinion that the above person named is in need of immediate psychiatric treatment in a treatment facility because he/she is seriously mentally ill or suffering form substance abuse so that he/she is.." Both dangerous to self and dangerous to others were checked.

Review of the Doctor's Order Sheet dated 07/04/11 Initial Restraint Order and Communication Record (Non-violet Behavior) revealed the justification for restraint was disruption of acute medical/post procedure care, and attempting to remove essential medical equipment (IV). Review of the electronic Order Confirmation Report revealed on 07/04/11 at 12:11 p.m. there was orders to remove the restraints. On 07/04/11 at 16:54 (4:54 p.m.) there was an electronic order to start restraint (violent) 18 yrs. (years) and older. Justification was combative, physical aggression to others, self-injurious behavior. Review of the Doctor's Order Sheet for 24-Hour/Daily Restraint Order form (non-violent behavior) dated 07/05/11 at 8 a.m., Day 2, revealed he was disruptive of acute medical/post procedure care by attempting to remove essential medical equipment, IV and demonstrating activity that poses high risk for re-injury. Also documented was he was combative and confused.

Review of the entire medical record revealed there was no order for restraints from 8:54 p.m. on 07/04/11 when the violet restraint order expired after 4 hours and the non-violet behavior restraint was ordered on [DATE] at 8 a.m.

An interview was conducted with S12Charge Nurse on 08/30/11 at 8:55 a.m. He stated he was the charge nurse on the medical psych floor when the Code White was called on the telemetry unit on the night of 07/04/11. He went on to state a Code White was when a patient posed a security risk for his/her self and others. He stated when he got to Patient #7's room he was yelling and trying to push a doctor out of the room. It took two nurses to maintain him in standing position and they put soft restraints on the patient and the patient was given Ativan IVP. The patient was transferred to the medical psych floor. When the patient transfers to another floor all the orders transfers with him so the violent restraint order transferred with him. He went on to state after 4 hours he did not get another violent restraint order from the physician because in his head he thought it was a nonviolent/medical restraint. He confirmed the patient should had another violent restraint order 4 hours after the first, which would have been at 20:54 (8:54 p.m.). The next restraint order was a nonviolent restraint on 07/05/11 at 8 a.m. The patient went without a restraint order for approximately 11 hours. S12Charge Nurse stated the next shift he took care of the patient was on 07/06/11.

An interview was conducted with S25Director of Quality/Pt Safety on 08/30/11 at 8:20 a.m. She stated the 07/05/11 restraint order should had been an initial non-violet behavior restraint order or a violet restraint reorder. She did confirm the patient went about 11 hours without a restraint order.

Review of the hospital's current policy on Restraint and Seclusion, Number TX-510 revealed in part..." 5. Non-Violet Restraint. B. Documentation and Forms: ...B. Medical record documentation will be electronic and/or handwritten based on the department's current documentation system in use at that time...C. Primary Documentation: 1) Initial Restraint Order and Communication Record: This order form is to be completed by the RN that initiates the use of restraints and is available for physician signature. 2) 24 Hours/Daily Restraint Order Form: This order form is available for physician signature when reordering restraints and is to be completed by the RN and available for physician signature..Violent Restraint Violent and/or Self-Destructive Behavior A. Physician Orders...(.4) Physician orders for violet and/or self destructive behavior must include:
a. Patient behavior demonstrating an immediate risk of physical harm to self or others related to an emotional or behavioral disorder.
b. Type of restraint and/or seclusion.
c. The 24-Hour/Daily Restraint/Seclusion Order Form, based on patient age, is required every 24 hours. At the same time, also based on patient's age, the seclusion/Restraint Renewal Orders are required with the time limit not to exceed 24 hours:
4 hours for patients 18 years and older.
2 hours for patients 9 years to [AGE] years old.
1 hour for patients under 9 years..."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews the hospital failed to ensure the condition of the patient placed in restraints was monitored by a physician, other licensed independent practitioner, or trained staff at the intervals determined by the hospital for 2 out of 4 patients reviewed for restraints out of a total sample of 9 patients ( #6, #7) Findings:

Patient #6
Review of the discharge summary for Patient #6 revealed she was admitted to the hospital on 05/24/11 for evaluation and therapy of altered mental status secondary to acute [DIAGNOSES REDACTED] secondary to clinical sepsis and a urinary tract infection.

Review of the Doctor's Order Sheet for 24 Hour/Daily Seclusion/Restraint Order and Communication Record (Violent and/or Self-Destructive Behavior) dated 05/24/11 and timed 1330 revealed she was physically aggressive toward others. Review of the Doctor's Order Sheet for Initial Restraint Order and Communication Record (Non-Violent Behavior)) dated 05/24/11 and timed 1990 revealed Patient #6 demonstrated activity that posed high risk for re-injury. Review of the Doctor's Order Sheet for 24-Hour Restraint Order form (Non-violent Behavior) revealed restraint day #2, 05/25/11, was for disruption of acute medical/post procedure care, attempting to remove essential medical equipment, and activity that poses high risk for re-injury. Review of the Doctor's Order Sheet for 24-Hour Restraint Order form (Non-violent Behavior) revealed restraint day #3, 05/27/11, was for disruption of acute medical/post procedure care, attempting to remove essential medical equipment, IV(intravenous), and activity that poses high risk for re-injury. Review of the Doctor's Order Sheet for 24-Hour Restraint Order form (Non-violent Behavior) revealed restraint day #4, 05/28/11, was for disruption of acute medical/post procedure care, attempting to remove essential medical equipment, IV (intravenous), and activity that poses high risk for re-injury.
Review of the Doctor's Order Sheet for 24-Hour Restraint Order form (Non-violent Behavior) revealed restraint day #5, 05/29/11, was for disruption of acute medical/post procedure care, and attempting to remove essential medical equipment, IV (intravenous).

Review of the EMR (electronic medical record) for restraint documentation of the RN/LPN monitoring and assisting by a RN/LPN revealed the patient was not monitored every 2 hours as required by the hospital policy. She was monitored on 05/25/11 at 23:34 (11:34 p.m.) and the patient was not monitored until 3:35 a.m. on 05/26/11. On 05/26/11 the patient was monitored at 3:35 a.m. and not monitored again until 8:47 a.m. On 05/26/11 the patient was monitored at 19:37 (7:37 p.m.) and was not monitored again until 23:37 (11:37 p.m.) On 5/27/11 the patient was monitored at 10:17 a.m. and was not monitored again until 13:30 (1:30 p.m.).

An interview was conducted with S33Director of Nursing Services on 08/25/11 at 2:30 p.m. and with a review of the EMR confirmed that assisting and monitoring Patient #6 every 2 hours while the patient was in restraints did not always occur every 2 hours.

Patient #7
Review of the medical record for Patient #7 revealed he was admitted on [DATE] at 23:57 (11: 57 p.m.) from the nursing home related to a fall in the nursing home. His diagnoses for admission to the hospital was recurrent falls and subdural hematoma. He was admitted on [DATE] at 3:16 a.m.

Review of a progress note by S32MD dated 07/04/11 and timed 1643 (4:43 p.m.) revealed, "The patient became agitated and threatened to leave because he wanted to smoke. I saw the pt (patient) and tried to calm him verbally. The pt continued to argue and swear. The pt began to stand up and was obviously unstable. I tried to steady the patient and direct him back to the bed. The patient became combative, grabbed me forcefully, shoved me, and tried to hit me. Security was called. The pt. was appropriately restrained, given Ativan 2 mg IV, and placed in wrist restraints. An order of psych consult, PEC (Physician Emergency Certificate) was done and the patient was transferred to the med psych for further management of his agitation and Dilantin toxicity...."

Review of the PEC dated 07/04/11 at 4:45 p.m. revealed the patient was admitted for Dilantin toxicity and acute/subacute subdural hematoma. Increase (arrow going upwards) falls at nursing home. Patient with h/o (history of) seizures, HIV, AIDS dementia. Oriented to place. Pt threatening to hit housestaff. Violent resisting medical advise. Wants to go out and smoke. However very unstable on feet. Under the section "Is patient currently?" violent was checked. Under the section, "I am of the opinion that the above person named is in need of immediate psychiatric treatment in a treatment facility because he/she is seriously mentally ill or suffering form substance abuse so that he/she is.." Both dangerous to self and dangerous to others were checked.

Review of the Doctor's Order Sheet dated 07/04/11 Initial Restraint Order and Communication Record (Non-violet Behavior) revealed the justification for restraint was disruption of acute medical/post procedure care, and attempting to remove essential medical equipment (IV). Review of the electronic order confirmation report revealed on 07/04/11 at 12:11 p.m. there was orders to remove the restraints. On 07/04/11 at 16:54 (4:54 p.m.) there was an electronic order to start restraint (violent) 18 yrs. (years) and older. Justification was combative, physical aggression to others, self-injurious behavior. Review of the Doctor's Order Sheet for 24-Hour/Daily Restraint Order form (non-violent behavior) dated 07/05/11 at 8 a.m., Day 2, revealed he was disruptive of acute medical/post procedure care by attempting to remove essential medical equipment, IV and demonstrating activity that poses high risk for re-injury. Also documented was he was combative and confused. Review of the Doctor's Order Sheet for 24-Hour/Daily Restraint Order form (non-violent behavior) dated 07/06/11 at 8 a.m., Day 3, revealed he was disruptive of acute medical/post procedure care by attempting to remove essential medical equipment, IV and demonstrating activity that poses high risk for re-injury. Also documented was he was confused. Review of the Doctor's Order Sheet for 24-Hour/Daily Restraint Order form (non-violent behavior) dated 07/07/11 at 8 a.m., Day 4, revealed he was disruptive of acute medical/post procedure care by attempting to remove essential medical equipment, IV and demonstrating activity that poses high risk for re-injury. Also documented was he was confused and had aggression.

Review of the EMR restraint documentation for every 2 hour monitoring by an RN/LPN to assist and monitor a patient while in restraints revealed on 07/06/11, Patient #7's 2 hour check was performed at 5:58 a.m. and then the next 2 hour check was performed at 9:05 a.m. Also on 07/06/11 after the 9:05 a.m. check another 2 hour check was not documented until 19:55 (7:55 p.m.) of the same day. On 07/08/11 at 3:25 a.m. the 2 hour checked was performed and the next check was documented at 7:00 a.m. Documentation of the restraints being discontinued was on 07/08/11 at 9:00 a.m.

An interview was conducted with S25Director of Quality/Pt. Safety and S2VP of Patient Care on 08/29/11 at 9:10 a.m. They confirmed there were times where there was no documentation of a RN or LPN performing the every 2 hour checks of assisting/monitoring the patient while in restraints.

Review of the hospital's policy for Restraint and Seclusion, Number TX-510, presented to the surveyors as the hospital current policy revealed in part, "...5. Non-Violent Restraint:..C. Monitoring and Assisting
The monitoring and assisting of a restrained patient is performed by assigned staff competent and trained to ensure that the physical and emotional well-being, rights, dignity,and safety of the patient are maintained. Patient monitoring and assisting is required every 2 hours by their RN/LPN...
6. Violent Restraint:...C. Monitoring and Assisting
The monitoring and assisting of a restrained or secluded patient is performed by assigned staff competent and trained to ensure that the physical and emotional well-being, right, dignity, and safety of the patient are maintained. 1) Patient monitoring and assisting is required every 2 hours by the RN...
2) Supplemental monitoring is required at a minimum of every 15 minutes by the RN, LPN or MHT and will include:
a. Patient location
b. Patient actions/behavior..."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0202
Based on observations, educational video review, review of the hospital current restraint/ seclusion policy, and interviews the hospital failed to ensure hospital staff were trained in a safe application of wrist restraints as evidence by the hospital staff failing to use the appropriate techniques for securing wrist restraints to the bed. This resulted in patients being capable of removing the secured wrist restraint form the bed. . Findings:

An interview was conducted with S12Charge Nurse of the Med Psych on 08/30/11 at 8:40 a.m. He stated the current beds the Med Psych unit have on the unit; even if a nurse applied the restraints appropriately, the patient can still get out of the restraints. He went on to state the location on the bed where the restraints are tied to the bedframe are easy for the patient to reach if the patient is able to manipulate their bodies towards the foot of the bed and the side of the bed. He further stated he was the person the hospital video taped for their online educational program for restraints, which is the primary training for all new hires.

An observation was made of S12Charge Nurse securing a staff member to a bed on the Med Psych unit with wrist restraints on 08/30/11 at 9:30 a.m. S12Charge Nurse pointed out how a patient was able to reach the quick release knot where the restraints had to be secured on the bedframe and release himself/herself from the restraint.

Review of the educational inservices video on restraints revealed S12Charge Nurse did the demonstration of the application of restraints with the same technique and with the restraint being secured to the same location on the bedframe demonstrated to the surveyors in the demonstration. With this specific technique of application of the restraint to the bedframe, allowed patients to be able to reach the restraint and untie the restraint from the bedframe and remove their restraints.

An interview was conducted with S23Manager of Clinical Education and S24Staff Developer on 08/30/11 at 11 a.m. They stated the educational inservice video was the primary training for all new staff hires since 10/01/10. They also confirmed S12 Charge Nurse was the staff member taped for the video demonstration of the proper application of restraints.

Review of the hospital's policy on Restraint and Seclusion, number TX-510, presented to the surveyors as the current policy in use, revealed in part,"...4. Application of Restraint or Seclusion-Violent and Non-Violent Restraint/Seclusion use. A. Application of restrain or seclusion is always a last resort. Application is performed by trained staff competent in restraint or seclusion and application and release. B. Chose the correct restraint or seclusion implementation, based on patient's age, body size, and behavior. C. Use a quick- release knot. D. Secure restraint straps to bed frame at the level of the patient's waist, out of patient's reach..."
VIOLATION: PATIENT RIGHTS: SECLUSION OR RESTRAINT Tag No: A0214
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the hospital failed to report the death of a patient in restraints as evidenced by the CMS (Center for Medicare/Medicaid Services) having no documented evidence of a report of the death of a patient in restraints (#3) on 01/06/11 at Baton Rouge General Medical Center and documentation produced by the hospital of a "Hospital Restraint/Seclusion Death Report Worksheet" revealed documentation that the patient (#3) had died "Within 24 hours of Removal of Restraint, Seclusion or Both." Findings:

Review of a Baton Rouge General "Record of Death" document in the medical record of patient #3 revealed that patient #3 had a date of death of [DATE]. Further review of the form under "Restraint/Seclusion" revealed "Patient was in Restraint/Seclusion: at time of death."

Review of the "Hospital Restraint/Seclusion Death Report Worksheet" revealed documentation that the patient (#3) had died "Within 24 hours of Removal of Restraint, Seclusion or Both."

In an interview on 08/25/11 at 2:00 p.m. with S26Compliance he stated that he reviewed the medical record of patient #3 and noted the nursing note timed at 8:08 a.m. on 01/06/11 where the nurse explained the criteria for release and "assumed" there were no restraints on patient #3 due to no further documentation of restraints before the death of patient #3. S26Compliance confirmed there was no order to remove the restraints from patient #3. S26Compliance further confirmed that the Record of Death for patient #3 clearly indicates patient #3 was in restraints at the time of death.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on record review and interview the hospital failed to perform an investigation to identify the cause of the failure of staff to document and/or perform physician ordered 15 minute checks on patient #5 as evidenced by the patient (#5) being found in cardiac arrest in her room. Documentation of the 15 minute checks was absent from 8:00 a.m. through the time the patient was discovered unresponsive in her room at 10:55 a.m. (patient #5) Findings:

In an interview on 08/25/11 at 10:40 with S25Director of Quality/Patient Safety she stated there was no Root Cause Analysis done to allow the hospital to analyze the adverse patient event that occurred on 01/09/11 in regards to patient #5.

In an interview on 08/30/11 with S25Director of Quality/Patient Safety she stated that no new QA/PI indicators were developed/monitored to allow the hospital to analyze the adverse patient event that occurred on 01/09/11 in regards to patient #5.
VIOLATION: NURSING SERVICES Tag No: A0385
The Hospital failed to meet the Condition of Participation as evidenced by:

1) failing to ensure patients were monitored per hospital policy as evidenced by patient #5 being found in cardiac arrest at 10:55 a.m. with the last documented evidence of the patient being checked at 8:00 a.m. for 1 of 9 sampled patients (patient #5) (see findings at A0395)

2) failed to supervise and evaluate the care provided to a patient by failing to ensure a patient with a a subdural hematoma had their physician orders for neuro checks every 4 hours and head of the bed at 45 degrees implemented for 1 out of a total of 9 sample patients (#7) (see findings at A0395)

3) failing to ensure the Director of Nursing and the Registered Nurse assigned the care of each patient based on the needs of the patient as evidenced by assigning one MHT the care of two patients who required an increased level of monitoring. Patient # 4 was in restraints with a subsequent 1:1 order due to the patient's increased agitation and patient #5 with every 15 minute checks due to the patient being admitted under a PEC (physician emergency certificate). This resulted in the patient (#5) not being checked on from 8:00 a.m. until the time she was found in cardiac arrest at 10:55 a.m. (see findings at A0397)

4) failing to ensure the RN (registered nurse) assigned the nursing care of each patient to MHTs (mental health techs) who had been evaluated for competency for 2 of 7 MHT's personnel files reviewed from a total of 48 employed MHT's on the medical-psych unit (S11, S20). (see findings at A0397)



On 08/25/11 at 3:39 p.m. the Hospital was notified of an Immediate Jeopardy.

The Immediate Jeopardy Situation was: The hospital failed to ensure the Registered Nurse made patient assignments on 01/09/11 based on patient acuity/needs as evidenced by one (1) MHT (S9MHT) being assigned a patient requiring increased observation and in restraints (#4) and another patient (#5) with physician ordered q (every) 15 minute checks. The q 15 minute checks by the Mental Health Technician were not documented as done from 8:00 a.m. on 01/09/11 through 10:55 a.m. when patient #5 was found unresponsive, pulseless, and apneic. The Registered Nurse (S8RN) failed to document q 2 hours rounds on the patient (#5) on 01/09/11 from 0730 (7:30 a.m.) through the time (10:55 a.m.) patient #5 was found unresponsive, pulseless, and apneic. The Immediate Jeopardy for patient # 5 began on 01/09/11 at 8:00 a.m. (last documentation of patient #5 being checked) and ended when the Code Blue was called at 10:55 a.m., the next documentation that patient #5 was observed.

The Hospital submitted a Plan of Removal for the Immediate Jeopardy on 08/26/11 at 1:15 p.m. that included the following:

1. Patient #5 has been discharged . Registered Nurse S8 was counseled on February 14, 2011 on the expectations of documentation of patient care. Mental Health Technician S9 was counseled on February 14, 2011 on expectations of completion and documentation of the patient 15 minute checks.

2. a. The charge nurse tool, Shift Management Report (Attachment A) completed by the off-going charge nurse was revised. This report provides information for the oncoming charge nurse to evaluate the unit status at a glance. The tool includes:

i. Skill mix
ii. Census
iii. Restraints
iv. 1:1
v. PEC (Physicians Emergency Certificate), CEC (Coroners Emergency Certificate)
vi. Fall Risk

b. Policy NPP-C-100 Nursing Assignment: Patient Care (Attachment B) was reviewed and revised to provide guidelines and expectations for the nursing staff regarding making assignments.

c. A Standard Operating Procedure (Attachment C) Escalation Guidelines for Unit Staffing was developed as an attachment to policy NPP-C-100 Nursing Assignment: Patient Care: to provide escalation guidelines for the Charge Nurses to follow when the charge nurse on the unit deems the patient acuity to be higher than the staff currently present on the unit. The charge nurse will notify the Unit Nurse Manager during normal working hours or the House Supervisor during off-shifts that he/she has determined that the current staffing on the unit requires additional staff based on the current patient acuity. The Nurse Manager/House Supervisor will immediately go to the unit and conduct an in-person assessment of the situation. The Nurse Manager/House Supervisor in collaboration with the charge nurse determine the appropriate staff needs based on the current situation. The Nurse Manager/House Supervisor will arrange appropriate staffing for the unit by either staffing on the unit to assist, re-directing in-house resources or call in additional resources from outside the hospital. The Nurse Manager/House Supervisor will not leave the unit until it is determined that it is safe to do so.

d. The documentation for "every 15 minute observations" was reviewed and deemed to be an extremely difficult workflow for the staff to provide and document. The documentation was revised so that the staff will now document on a non-electronic paper form, MR-NS-1649 Observation Flow Sheet (Attachment D) during the shift. At the end of the shift, the staff conducting and documenting the observations will document in the electronic medical record that the "15 minute observations have been completed for the day [e.g. day,evening or night] shift." Then the Registered Nurse will document a verification of the delegated duty in the electronic medical record. Policy PE-130 Addressing Behavioral Health Needs and Identifying Suicide Risk Patients (Attachment E) to reflect the changed process and expectations.

3. a. Staff will be educated (Attachment F) on:

New Shift Management Report: Target Audience: House Supervisors, Nurse Manager 4NW, Charge Nurses 4NW.

Revised Policy NPP-C-100 Nursing Assignment: Patient Care. Target Audience: House Supervisors, Nurse Manager 4NW, Charge Nurses 4NW.

New Standard Operating Procedure: Escalation Guidelines for Staffing. Target Audience: House Supervisors, Nurse Manager 4NW, Charge Nurses 4NW.

Revised documentation of 15 minute observations. Target Audience: House Supervisors, Nurse Manager 4NW, Charge Nurses 4NW, Registered Nurses 4NW, Licensed Practical Nurses 4NW, Mental Health Technicians 4NW.

b. Education will begin immediately. Education as outlined above will be completed for 100% of the staff to include PRN (as needed) staff by Monday August 26, 2011. Staffs that have not completed the education will not be allowed to accept a patient care assignment until the education is completed.

4. Auditing and monitoring of the corrective action plan will be coordinated by the 4NW Nurse Manager using the 4NW Corrective Action Plan Audit Tool (Attachment G) to include the following:

a. Beginning August 26, 2011 daily until 100%compliance has been achieved for two weeks, the 4NW Nurse Manager, or designee (e.g. House Supervisor), will conduct an audit of the previous 24 hours for the completion and accuracy of the 4NW Shift Management Report. Immediate corrective actions will be taken for any deficient practice. Once 100% compliance has been achieved for two weeks, weekly random audits will be conducted by the Nurse Manager, or designee until 100% compliance has been achieved for four months.

b. Beginning August 26, 2011 daily until 100% compliance has been achieved for two weeks, the 4NW Nurse Manager, or designee (e.g. Unit Educator) will conduct an audit of the medical record documentation of the 15 minute observation checks on the MR-NS-1649 Observation Flow Sheet and electronic medical record documentation of 15 minute observations and registered nurse verification. Immediate corrective actions will be taken for any deficient practice. Once 100% compliance has been achieved for two weeks, weekly random audits will be conducted by the 4NW Nurse Manager, or designee until 100% compliance has been achieved for 4 months.

The Immediate Jeopardy was lifted on 08/26/11 at 2:00 p.m. Deficient practice remains at the condition level.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interviews the registered nurse 1) failing to ensure patients were monitored per hospital policy as evidenced by patient #5 being found in cardiac arrest at 10:55 a.m. with the last documented evidence of the patient being checked at 8:00 a.m. for 1 of 9 sampled patients (patient #5) and 2) failed to supervise and evaluate the care provided to a patient by failing to ensure a patient with a subdural hematoma had ordered neuro checks done every 4 hours and the head of the bed at 45 degrees maintained for 1 out of a total of 9 sample patients (#7) Findings:

1)

Review of the medical record of patient #5 revealed she was admitted to the Baton Rouge General Medical Center Med-Psyc Unit (4 East) on 01/08/11 at 2236 (10:36 p.m.). Review of the physician ' s admission orders, with no time indicated, revealed: "1. Continue Home Medications. 2. ? normal saline at mc (unknown abbreviation/fluids are delivered in cc's (cubic centimeters) or ml (milliliters) per hour)." A second physician's order dated 01/08/11, no time, revealed: "Admit to Med/Psyc/ Dr. (S15MD). Full Code. Renal ADH Diet. Accu-check AC (before meals)/HS (hour of sleep). Condition Stable. Rt. (routine) V/S (vital signs)." Past medical History included: Psychiatric, Hypertension, Congestive Heart Failure, Pneumonia, Diabetes, [DIAGNOSES REDACTED], Gastroesophageal Reflux Disease, Mild [DIAGNOSES REDACTED], Renal Failure, Cholecystectomy, and bilateral AV shunts (arterio-venous shunts for dialysis).

Review of a Hospital Policy titled "Assessment/Reassessment", policy number PE-110, effective 06/94, last reviewed 05/97, last revised 06/11, presented as current hospital policy reads in part: "...Reassessment:...2. Nursing: ...C. Timeframes and scopes for reassessment: Area ...4E...Vital Signs: Every 8 hours..."

Further review of the medical record of patient #5 revealed she was under a Physician Emergency Certificate (PEC) dated/timed 01/07/11 at 1800 (6:00 p.m.). The PEC was done at hospital "a", the sending hospital. Review of the PEC revealed patient #5 was "suicidal, unable to seek voluntary admission and Gravely Disabled."

Review of a Hospital Policy titled "Assessing Behavioral Needs and Identifying Suicide Risk Patients", policy number PE-130, effective 04/07, last revised 10/09, presented as current hospital policy, reads in part: "...Procedure...5. Monitoring Guidelines used for those patients identified as "at risk" or a danger to themselves or others...B. This documentation will be completed at a minimum of 15 minutes ..."

Review of the "Home Medication Re-Order Form" revealed the following medications, in part, were ordered for patient #5 via telephone order by S31MD with no documented date or time the telephone order was taken: Amlodopine Besylate (Amlodopine) 2.5 mg (milligrams) 1 tablet oral once a day, Aspirin 81 mg 1 chew oral once a day, Accu-check with Insulin Regular (Novolin R) sliding scale AC/HS (before meals and at hour of sleep), Levothyroxine Sodium (Synthroid) 0.088 mg 1 tab oral once a day, Lorazepam (Ativan) 1 mg 1 tab oral twice a day, Metoprolol Tartrate (Lopressor) 100 mg by mouth 2 times per day, Sevelamer Carbonate (Renvela) 800 mg 1 tab oral 3 times a day with meals, and Valsartan (Diovan) 160 mg 1 tab oral twice a day."

Review of the Medication Administration Report (MAR) for 01/09/11 revealed the following: "Amlodopine was documented as "held - BP (blood pressure) low at 8:26 a.m. by S8RN, the Accu-check for AC (breakfast) was not documented as completed, Aspirin was documented as administered by S8RN at 8:30 a.m., Synthroid was documented as administered at 8:26 by S8RN, Ativan was documented as administered at 8:59 a.m., Lopressor was documented as "held - BP low" at 8:26 a.m. by S8RN, Renvela was documented as administered at 8:26 a.m. by S8RN, and Diovan was documented as "held - BP low" at 8:30 a.m. by S8RN. Further review of the MAR for patient #5 for 01/09/11 revealed no documented evidence the physician was notified of the held medications or the blood pressure of patient #5. Review of the entire medical record of patient #5 revealed no documented vital signs for the day shift of 01/09/11.

Review of the medical record for patient #5 revealed the routine vital signs order was entered into the computer as Nursing Order #6, frequency every shift, priority routine, start 01/09 at 6:00 a.m. Further review revealed no documented blood pressure for patient #5 for 01/09/11. The physician order for an Accu-check (blood glucose check) written upon admission was on the MAR (medication administration record) with a start date/time of 01/09/11 at 18:00 (6:00 p.m.). Review of the Intake/Output documentation and nursing notes revealed there was no documentation of patient #5 having an IV (intravenous) site or receiving the physician ordered fluids that were ordered on admission. S29MD, ER, confirmed the lack of an IV in his Code note (see Code note below). The "Code Blue Resuscitation Progress Note", documented as dictated by S27MD for S28MD, also documents the lack of an IV. Review of the Intake and Output Sheet for 01/09/11 revealed no documentation of IV fluids administered to patient #5.

Review of a document titled "Cardiopulmonary Resuscitation Record (CPR)" dated 01/09/11 revealed the following: "Time of Arrest: 1055 (10:55 a.m.). Time Code Blue Activated: 1100 (11:00 a.m.). Time CPR initiated: 1105 (11:05 a.m.)...1055 (10:55 a.m.) Monitor Pattern: Asystole...Accu-check 53 (mg/dl)...1103 (11:03 a.m.) CPR initiated ...1111 (11:11 a.m.) Medications: 2 Epi (epinephrine), 2 Atropine per ETT (endotracheal tube)...1114 (11:14 a.m.) V-Tach ([DIAGNOSES REDACTED])...Defib (defibrillation) 360 J (joules)...1120 (11:20 a.m.) ST (sinus tachycardia)...1130 (11:30 a.m.) Tx (transfer) to ICU..."

In an interview on 08/24/11 at 1:00 p.m. with S9MHT she stated she worked the day shift on 01/09/11 and was the only MHT assigned to the 13 room locked portion of 4E. S9MHT confirmed she was assigned the 15 minute observations on patient #5. S9MHT confirmed that S7MHT was not on duty as indicated on the RN assignment sheet for the day shift on 01/09/11. S9MHT stated that "staffing is an issue here a lot" and that "staffing is fixed and not acuity based." S9MHT stated she was responsible for patient #5 and that patient #4 was almost directly across the hall (off by one room) and he (#4) was keeping her "too busy to chart " on patient #5. (patient #4 had physician orders dated 01/09/11 at 0848 (8:48 a.m.) for 1:1 observation) S9MHT stated "I checked on her (#5) when I first got to work." (documentation timed at 8:00 a.m.) S9MHT stated she "does not recall if patient #5 was seen at all from the initial visit until the time she found patient #5 unresponsive." S9MHT stated "she entered the room of patient #5 around 11:00 a.m. and found #5 lying face up, across the bed with her lower back down off the left side of the bed." S9MHT stated she approached patient #5 and noted that she was "sweating profusely, was cool and clammy and mumbled something" when she lifted #5's legs to attempt to get her back on the bed. S9MHT stated it "was not a word" that came out of patient #5 and that she was lifting the legs of patient #5 at the time. S9MHT stated an attempt was made by her to get a Blood Pressure with the machine but she was unable. S9MHT stated she notified S8RN who came into the room of Patient #5 and stated "she is not breathing." Per S9MHT, S8RN instructed her to go get the CBG (capillary blood glucose) machine. Then S8RN instructed her (S9MHT) to "don't worry about that, call a Code." S9MHT stated that as she went up the hall towards the Nursing Station outside the locked unit the door was opening or closing (it was open so she did not have to go all the way to it) and she told S17RN Charge Nurse to "call a Code." S9MHT stated she was unsure if CPR was initiated prior to the "Code" team arriving. S9MHT stated there was about 6 minutes from the time she found patient #5 unresponsive to CPR being initiated by the Code team. S9MHT further stated that the locked Med-Psyc unit was short staffed on the day shift of 01/09/11. S9MHT stated that S8RN had stated more than once that day that "we need more help." S9MHT confirmed there was no 15 minute observation documentation on patient #5 from 8:00 a.m. until she was found unresponsive.

In an interview on 08/23/11 at 10:30 a.m. with S8RN she stated she worked the locked Med-Psyc unit on the day shift on 01/09/11. S8RN stated that staff assigned to the locked unit on the day shift on 01/09/11 were herself (S8RN) and S9MHT. S8RN stated that S17RN was the RN Charge Nurse on 01/09/11 and that she was at the Nursing Station on the outside of the locked doors. S8RN stated she was responsible for 6 patients in the locked unit. S8RN stated patient #5 was talking on the morning of 01/09/11. S8RN stated that after she got report, which begins at 6:45 a.m. and lasts about 45 minutes, that she saw patient #5 seated at the bedside with her breakfast. S8RN confirmed there is no assessment/re-assessment documentation by her from 8:00 a.m. until the "Code Blue" at 10:56 a.m. S8RN stated there was "a big male patient in restraints trying to get out of bed." (patient #4 who had physician orders dated 01/09/11 at 0848 (8:48 a.m.) for 1:1 observation and was in restraints) Review of the MAR indicates S8RN administered Ativan to patient #5 at 8:59 a.m. S8RN stated that just prior to the Code that S9MHT told her that patient #5 was "sedated." S8RN stated that when she entered the room of patient #5 that she (S8RN) touched patient #5 and she (patient #5) was "unresponsive and cool" and she (S8RN) was unable to get vital signs. S8RN stated "I probably checked for a pulse, don't remember if she was breathing." S8RN stated she sent S9MHT to call a Code and get the crash cart. S8RN stated they were short staffed as patient #4 was requiring a lot of attention. S8RN stated she did not remember if she notified Administration of the need for help. S8RN stated she has called "numerous times in the past for additional staff." S8RN stated that she did not recall if she told S17RN Charge Nurse she needed help on 01/09/11. S8RN stated she often felt "helpless" on this unit. S8RN stated that when she called for help in the past, Administration would tell them to "make do with what you have." S8RN confirmed that S7MHT was not on duty that day as indicated on the staffing sheet.

Review of the medical record for patient #5 revealed documentation by S9MHT for 01/09/11 at 8:00 a.m. that read: "Resting in bed, resp (respirations) even, resp unlabored, eyes closed; Safety Precautions: call light near, bed/low position, side rails up X2, door opened." S8RN confirmed there was no assessment\re-assessment documentation by her from 8:00 a.m. to the time the Code was called.

In an interview on 08/24/11 at 9:45 a.m. with S17RN she stated she was the 4E RN Charge Nurse on 01/09/11. S17RN stated the Med-Psyc Unit is staffed based on numbers of patients. S17RN stated staffing is as follows: 1 - 6 patients = 1 RN, 1 MHT and 1 Unit Clerk (UC); 7 - 11 patients = 2 RN, 1 MHT and 1 UC; 12 and above patients = 2 RN, 2 MHT, and 1 UC. S17RN stated "we don't get extra help according to acuity." She further stated "we are short handed to this day."

In an interview on 08/24/11 at 9:10 a.m. with S14MHT she stated she was called in on 01/09/11 and arrived at 10:44 a.m. S14MHT stated she was assigned patient #4. Review of the medical record of patient #4 revealed physician's orders dated 01/09/11 at 0848 (8:48 a.m.) for 1:1 (observation) to prevent fall. S14MHT stated that patient #4 was restrained when she arrived. S14MHT stated S9MHT was with patient #4 and that S9MHT gave her (S14MHT) report. S14MHT stated the 15 minute observation documentation was not current. S14MHT stated that after she took patient #4 that S9MHT was unable to obtain a blood pressure on patient #5. S14MHT stated that S9MHT tried for 6 - 7 minutes to obtain a blood pressure. S14MHT stated S9MHT told S17RN Charge Nurse "come check out (patient #5), she seems sedated, she's not responding, come check her out, she's not waking up." S14MHT stated S17RN came to the room of patient #5 and after 6-7 minutes said to "call MRT (Medical Response Team)." S14MHT stated she did not remember a "Code Blue" being called.

Review of the documentation dictated by S29MD on 01/09/11 at 1410 (2:10 p.m.) revealed the following: "This is a patient of (S15MD) that was admitted to the med-psyc unit last night by (hospitalist). The patient was in the med-psyc unit and suffered a cardiopulmonary arrest. I was called to the bedside where CPR (cardiopulmonary resuscitation) was in process. The patient had suffered a cardiac arrest. Blood sugar in the 50's had been noted. Efforts were being made to address the blood sugar, however, IV access was not available. We were able to start an intraosseous line on the patient and ultimately starting a central line on the patient..."

Review of a Progress Note titled " Code Blue Resuscitation Progress Note, date and time of note January 9, 2011 at 11:00 a.m. " , revealed: " History: A [AGE]-year-old African-American female patient with past medical history of [DIAGNOSES REDACTED]. CPR continues throughout code. No IV (intravenous) access available at initiation of code..." (The dictation was documented as dictated by S27MD for S28MD)

Review of a Neurology consult revealed in part: "...sustained a cardiac arrest 2 days ago. The patient was reported to have been found unresponsive with a very low blood sugar of 53 and also in asystole...The patient has remained unresponsive since this event and there is concern about anoxic brain injury...Impression: 1. Severe anoxic brain injury, status post cardiac arrest ..." The documentation has a date/time dictated of 01/11/11 at 1903 (7:03 p.m.) by S30MD.

Review of a Baton Rouge General Formal Counseling Agreement dated 02/14/11, signed by S8RN and S5RN, Unit Manager, revealed under " Description of Problem or Situation " in part: "Failure to document in EMR (electronic medical record) on patient (Timeframe 7:30 - 11:15a), poor and inconsistent charting noted, no vital signs. Failure to ensure 15 minute checks were maintained and documented by MHT..."

Review of a Baton Rouge General Formal Counseling Agreement dated 02/14/11, signed by S9MHT and S5RN, Unit Manager, revealed under "Description of Problem or Situation" in part: "Failure to complete q (every) 15 minute checks on patient. (No) Charting from 8:00 - 11:15 am ..."

Review of a hospital policy titled "BHS (behavioral health services), policy number: BHS TX NSG 11, no effective date, last reviewed 10/09, last revised 6/06, presented as current policy for the Med-Psyc Unit, reads in part: "Purpose: To maintain the safety and security of patients in the therapeutic milieu. Policy: 1. All BHU patients are monitored at least every 15 minutes..."

2)
Patient #7
Review of the medical record for Patient #7 revealed he was admitted on [DATE] at 23:57 (11: 57 p.m.) from the nursing home related to a fall in the nursing home. His diagnoses for admission to the hospital was recurrent falls and subdural hematoma. He was admitted on [DATE] at 3:16 a.m.

Review of the EMR (electronic medical record) Order Confirmation Report revealed a physician order for elevate head of the bed 45 degrees. The physician order's frequency was on going and the priority was listed as routine. The start date for the order was 07/04 at 03:04 and the stop time was indefinite. Neuro checks, monitor for pupils reactivity and symmetricity was ordered every 4 hours. The order's priority was listed as routine and the start date was 7/04 at 04:00. The stop time was listed as indefinite.

Review EMR for the neuro check for pupil reactivity and symmetricity every 4 hours revealed the patient's neuro checks were not performed through out his stay every 4 hours from 07/04/11 at 4:00 a.m., when the order was written until his discharge on 07/11/11. The following times were when his pupils were checked for reactivity and symmetricity:
07/04/11 19:45 (7:45 p.m.)
07/05/11 07:00 (7:00 a.m.)
12:00 (12:00 p.m.)
15:00 ( 3:00 p.m.)
16:00 ( 4:00 p.m.)
19:15 ( 7:15 p.m.)
07/06/11 03:18 ( 3:18 a.m.)
19:55 (7:55 p.m.)
23:32 (11:32 p.m.)
07/07/11 03:30 (3:30 a.m.)
07:00 (7:00 a.m.)
15:00 (3:00 p.m.)
19:58 (7:58 p.m.)
23:30 (11:30 p.m.)
07/08/11 03:25 (3:25 a.m.)
07:00 (7:00 a.m.)
16:35 (4:35 p.m.)
07/09/11 08:31 (8:31 a.m.)
15:31 (3:31 p.m.)
07/10/11 19:30 (7:30 p.m.)
21:30 (9:30 p.m.)
23:30 (11:30 p.m.)
07/11/11 01:30(1:30 a.m.)
03:30(3:30 a.m.)
05:30(5:30 a.m.)
11:29(11:29 a.m.)
11:55 (11:55 a.m.)

Review of the EMR revealed no documentation that the patient's head of bed was raised 45 degrees as ordered by the physician.

An interview was conducted with S12Charge Nurse on 08/30/11 at 8:55 a.m. He stated he took care of the patient on 07/04/11 when Patient #7 was first admitted on [DATE], on the day shift, 7 a.m. to 7 p.m. He stated he was not aware the patient had an order to have his head of bed elevated at 45 degrees. He went on to state he did not check the patient's reactivity and symmetricity every 4 hours as ordered by the physician.

An interview was conducted with S25Director of Quality/Pt Safety and S2VP of Patient Care on 08/29/2011 at 9:10 a.m. They confirmed there was numerous times neuro checks for pupil reactivity and symmetricity were not performed every 4 hours as ordered by the physician. They also confirmed on their review of the EMR, they could not find documentation the patient's head of the bed was at 45 degrees as ordered by the physician due to the risk of increase intracranial pressure from the subdural hematoma.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the hospital failed to 1) ensure the Director of Nursing and the Registered Nurse assigned the care of each patient based on the needs of the patient as evidenced by assigning one MHT the care of two patients who required an increased level of monitoring. Patient # 4 was in restraints with a subsequent 1:1 order due to the patient's increased agitation and patient #5 with every 15 minute checks due to the patient being admitted under a PEC (physician emergency certificate). This resulted in the patient (#5) not being checked on from 8:00 a.m. until the time she was found in cardiac arrest at 10:55 a.m. and 2) ensure the RN (registered nurse) assigned the nursing care of each patient to MHTs (mental health techs) who had been evaluated for competency by failing to ensure the hospital competency checklist was completed and in the employee file for 2 of 7 MHT's personnel files reviewed from a total of 48 employed MHT's on the medical-psych unit (S11, S20). Findings:

1)

Review of the medical record of patient #5 revealed she was admitted to the Baton Rouge General Medical Center Med-Psyc Unit (4 East) on 01/08/11 at 2236 (10:36 p.m.). Review of the physician ' s admission orders, with no time indicated, revealed: "1. Continue Home Medications. 2. ? normal saline at mc (unknown abbreviation/fluids are delivered in cc's (cubic centimeters) or ml (milliliters) per hour)." A second physician's order dated 01/08/11, no time, revealed: "Admit to Med/Psyc/ Dr. (S15MD). Full Code. Renal ADH Diet. Accu-check AC (before meals)/HS (hour of sleep). Condition Stable. Rt. (routine) V/S (vital signs)." Past medical History included: Psychiatric, Hypertension, Congestive Heart Failure, Pneumonia, Diabetes, [DIAGNOSES REDACTED], Gastroesophageal Reflux Disease, Mild [DIAGNOSES REDACTED], Renal Failure, Cholecystectomy, and bilateral AV shunts (arterio-venous shunts for dialysis).

Review of a Hospital Policy titled "Assessment/Reassessment", policy number PE-110, effective 06/94, last reviewed 05/97, last revised 06/11, presented as current hospital policy reads in part: "...Reassessment:...2. Nursing: ...C. Timeframes and scopes for reassessment: Area ...4E...Vital Signs: Every 8 hours..."

Further review of the medical record of patient #5 revealed she was under a Physician Emergency Certificate (PEC) dated/timed 01/07/11 at 1800 (6:00 p.m.). The PEC was done at hospital "a", the sending hospital. Review of the PEC revealed patient #5 was "suicidal, unable to seek voluntary admission and Gravely Disabled."

Review of a Hospital Policy titled "Assessing Behavioral Needs and Identifying Suicide Risk Patients", policy number PE-130, effective 04/07, last revised 10/09, presented as current hospital policy, reads in part: "...Procedure...5. Monitoring Guidelines used for those patients identified as "at risk" or a danger to themselves or others...B. This documentation will be completed at a minimum of 15 minutes ..."

Review of the medical record for patient #5 revealed the routine vital signs order was entered into the computer as Nursing Order #6, frequency every shift, priority routine, start 01/09 at 6:00 a.m. Further review revealed no documented blood pressure for patient #5 for 01/09/11. The physician order for an Accu-check (blood glucose check) written upon admission was on the MAR (medication administration record) with a start date/time of 01/09/11 at 18:00 (6:00 p.m.). Review of the Intake/Output documentation and nursing notes revealed there was no documentation of patient #5 having an IV (intravenous) site or receiving the physician ordered fluids that were ordered on admission. S29MD, ER, confirmed the lack of an IV in his Code note (see Code note below). The "Code Blue Resuscitation Progress Note", documented as dictated by S27MD for S28MD, also documents the lack of an IV. Review of the Intake and Output Sheet for 01/09/11 revealed no documentation of IV fluids administered to patient #5.

In an interview on 08/24/11 at 1:00 p.m. with S9MHT she stated she worked the day shift on 01/09/11 and was the only MHT assigned to the 13 room locked portion of 4E. S9MHT confirmed she was assigned the 15 minute observations on patient #5. S9MHT confirmed that S7MHT was not on duty as indicated on the RN assignment sheet for the day shift on 01/09/11. S9MHT stated that "staffing is an issue here a lot" and that "staffing is fixed and not acuity based." S9MHT stated she was responsible for patient #5 and that patient #4 was almost directly across the hall (off by one room) and he (#4) was keeping her "too busy to chart " on patient #5. (patient #4 had physician orders dated 01/09/11 at 0848 (8:48 a.m.) for 1:1 observation) S9MHT stated "I checked on her (#5) when I first got to work." (documentation timed at 8:00 a.m.) S9MHT stated she "does not recall if patient #5 was seen at all from the initial visit until the time she found patient #5 unresponsive." S9MHT stated "she entered the room of patient #5 around 11:00 a.m. and found #5 lying face up, across the bed with her lower back down off the left side of the bed." S9MHT stated she approached patient #5 and noted that she was "sweating profusely, was cool and clammy and mumbled something" when she lifted #5's legs to attempt to get her back on the bed. S9MHT stated it "was not a word" that came out of patient #5 and that she was lifting the legs of patient #5 at the time. S9MHT stated an attempt was made by her to get a Blood Pressure with the machine but she was unable. S9MHT stated she notified S8RN who came into the room of Patient #5 and stated "she is not breathing." Per S9MHT, S8RN instructed her to go get the CBG (capillary blood glucose) machine. Then S8RN instructed her (S9MHT) to "don't worry about that, call a Code." S9MHT stated that as she went up the hall towards the Nursing Station outside the locked unit the door was opening or closing (it was open so she did not have to go all the way to it) and she told S17RN Charge Nurse to "call a Code." S9MHT stated she was unsure if CPR was initiated prior to the "Code" team arriving. S9MHT stated there was about 6 minutes from the time she found patient #5 unresponsive to CPR being initiated by the Code team. S9MHT further stated that the locked Med-Psyc unit was short staffed on the day shift of 01/09/11. S9MHT stated that S8RN had stated more than once that day that "we need more help." S9MHT confirmed there was no 15 minute observation documentation on patient #5 from 8:00 a.m. until she was found unresponsive.

In an interview on 08/23/11 at 10:30 a.m. with S8RN she stated she worked the locked Med-Psyc unit on the day shift on 01/09/11. S8RN stated that staff assigned to the locked unit on the day shift on 01/09/11 were herself (S8RN) and S9MHT. S8RN stated that S17RN was the RN Charge Nurse on 01/09/11 and that she was at the Nursing Station on the outside of the locked doors. S8RN stated she was responsible for 6 patients in the locked unit. S8RN stated patient #5 was talking on the morning of 01/09/11. S8RN stated that after she got report, which begins at 6:45 a.m. and lasts about 45 minutes, that she saw patient #5 seated at the bedside with her breakfast. S8RN confirmed there is no assessment/re-assessment documentation by her from 8:00 a.m. until the "Code Blue" at 10:56 a.m. S8RN stated there was "a big male patient in restraints trying to get out of bed." (patient #4 who had physician orders dated 01/09/11 at 0848 (8:48 a.m.) for 1:1 observation and was in restraints) Review of the MAR indicates S8RN administered Ativan to patient #5 at 8:59 a.m. S8RN stated that just prior to the Code that S9MHT told her that patient #5 was "sedated." S8RN stated that when she entered the room of patient #5 that she (S8RN) touched patient #5 and she (patient #5) was "unresponsive and cool" and she (S8RN) was unable to get vital signs. S8RN stated "I probably checked for a pulse, don't remember if she was breathing." S8RN stated she sent S9MHT to call a Code and get the crash cart. S8RN stated they were short staffed as patient #4 was requiring a lot of attention. S8RN stated she did not remember if she notified Administration of the need for help. S8RN stated she has called "numerous times in the past for additional staff." S8RN stated that she did not recall if she told S17RN Charge Nurse she needed help on 01/09/11. S8RN stated she often felt "helpless" on this unit. S8RN stated that when she called for help in the past, Administration would tell them to "make do with what you have." S8RN confirmed that S7MHT was not on duty that day as indicated on the staffing sheet.

Review of the medical record for patient #5 revealed documentation by S9MHT for 01/09/11 at 8:00 a.m. that read: "Resting in bed, resp (respirations) even, resp unlabored, eyes closed; Safety Precautions: call light near, bed/low position, side rails up X2, door opened." S8RN confirmed there was no assessment\re-assessment documentation by her from 8:00 a.m. to the time the Code was called.

In an interview on 08/24/11 at 9:45 a.m. with S17RN she stated she was the 4E RN Charge Nurse on 01/09/11. S17RN stated the Med-Psyc Unit is staffed based on numbers of patients. S17RN stated staffing is as follows: 1 - 6 patients = 1 RN, 1 MHT and 1 Unit Clerk (UC); 7 - 11 patients = 2 RN, 1 MHT and 1 UC; 12 and above patients = 2 RN, 2 MHT, and 1 UC. S17RN stated "we don't get extra help according to acuity." She further stated "we are short handed to this day."

In an interview on 08/24/11 at 9:10 a.m. with S14MHT she stated she was called in on 01/09/11 and arrived at 10:44 a.m. S14MHT stated she was assigned patient #4. Review of the medical record of patient #4 revealed physician's orders dated 01/09/11 at 0848 (8:48 a.m.) for 1:1 (observation) to prevent fall. S14MHT stated that patient #4 was restrained when she arrived. S14MHT stated S9MHT was with patient #4 and that S9MHT gave her (S14MHT) report. S14MHT stated the 15 minute observation documentation was not current. S14MHT stated that after she took patient #4 that S9MHT was unable to obtain a blood pressure on patient #5. S14MHT stated that S9MHT tried for 6 - 7 minutes to obtain a blood pressure. S14MHT stated S9MHT told S17RN Charge Nurse "come check out (patient #5), she seems sedated, she's not responding, come check her out, she's not waking up." S14MHT stated S17RN came to the room of patient #5 and after 6-7 minutes said to "call MRT (Medical Response Team)." S14MHT stated she did not remember a "Code Blue" being called.

Review of a Baton Rouge General Formal Counseling Agreement dated 02/14/11, signed by S8RN and S5RN, Unit Manager, revealed under " Description of Problem or Situation " in part: "Failure to document in EMR (electronic medical record) on patient (Timeframe 7:30 - 11:15a), poor and inconsistent charting noted, no vital signs. Failure to ensure 15 minute checks were maintained and documented by MHT..."

Review of a Baton Rouge General Formal Counseling Agreement dated 02/14/11, signed by S9MHT and S5RN, Unit Manager, revealed under "Description of Problem or Situation" in part: "Failure to complete q (every) 15minute checks on patient. (No) Charting from 8:00 - 11:15 am ..."

Review of a hospital policy titled "BHS (behavioral health services), policy number: BHS TX NSG 11, no effective date, last reviewed 10/09, last revised 6/06, presented as current policy for the Med-Psyc Unit, reads in part: "Purpose: To maintain the safety and security of patients in the therapeutic milieu. Policy: 1. All BHU patients are monitored at least every 15 minutes..."

2)

Review of the "BRGMC (Baton Rouge General Medical Center) - Unit Based Orientation / Initial Competency Inventory Mental Health Technician/Patient Care Associate (Behavioral Health Services)" revealed the following directions: "...1) Evaluation Method Column - Preceptor initials are entered under the appropriate key letter to indicate type of evaluation method used for each task listed. [R = Review of Policy/Procedure and/or Process; S = Simulated performance of task; C = Clinical performance of task; D = Verified complete and accurate documentation of task] Note: A variety of evaluation methods should be used to evaluate competency. [i.e. - Restraint documentation = R - Review policy, S - Simulate a pt. (patient) care scenario, C - observe competent clinical performance of actual care, D - verify that documentation is complete and accurate in the Medical Record.] ...". Further review revealed the acknowledgement statement signed by the employee included the statement "After release from unit orientation, any task not available as a clinical performance should be performed in the presence of a BRGMC experienced peer for compliance with established policies/procedures and competency evaluation".

MHT S11
Review of MHT S11's personnel file revealed he was hired on 02/07/11. Review of MHT S11's "BRGMC - Unit Based Orientation / Initial Competency Inventory Mental Health Technician/Patient Care Associate (Behavioral Health Services)" revealed no documented evidence of the date range for the orientation period. Further review revealed no documented evidence of clinical performance of the following tasks and verification of complete and accurate documentation of the tasks: demonstrates awareness of the individual rights of the patient; follows unit procedure by using code number and consent forms when allowing visitors on the unit; identifies situations that require an incident report; demonstrates how to use the Incident Reporting System; demonstrates proper use of PPE (personal protective equipment); demonstrates knowledge of appropriate actions to be taken for Isolation Precautions; demonstrates process for calling and responding to a Code White; verbalizes understanding of MHT's Role during a Code White; demonstrates ability to conduct belongings and room searches/checks; identifies restricted items/contraband and appropriate procedure for disposition; participates in ensuring that broken equipment is processed according to policy and immediately removed from patient care setting and transferred to biomed; identify safety risks inherent in the organization's patient population; improve recognition and response to changes in patient's condition; performs a patient search according to department policy; performs a luggage search according to department policy; labels luggage, clothing according to policy; secures patient valuables according to hospital/department policy; demonstrates appropriate department procedure and completes appropriate paperwork when finding sharps, weapons, and/or contraband; participates in scheduled toileting as assigned; monitors, records, and reports changes in GU (genitourinary) output; monitors, records, and reports changes in the bowel movement status of the patient; verbalizes specimen collection technique and disposition as requested; works in partnership with team members to collect specimens; demonstrates process for calling a code blue; identifies location of crash cart and age specific respiratory box on unit; identifies Code Blue procedure and role of Tech; and assists with cleaning, preparing and transporting the body to the morgue or for discharge to the funeral home.

Review of MHT S11's "BRGMC Competency - Therapeutic use of Restraints / Seclusion Techs & (and) PCAs (personal care attendants) - Nursing Unit" and "BRGMC Competency - Blood Glucose Levels (POCT) PCA's and Tech's" revealed S11's competency was evaluated by simulation by MHT S20. Review of MHT S20's personnel file revealed S20 had not been assessed for competency since her transfer to the behavioral health unit on 01/03/10.

MHT S20
Review of MHT S20's personnel file revealed she was hired on 03/10/08 and transferred to the behavioral health unit on 01/03/10. Review of MHT S20's "BRGMC - Unit Based Orientation / Initial Competency Inventory Mental Health Technician/Patient Care Associate (Behavioral Health Services)" revealed no documented evidence that the clinical performance of the tasks had been completed for all tasks with the exception of knocks before entering rooms; demonstrates catheter care; performs or assists with bladder training as directed by the nurse; verbalizes specimen collection technique and disposition; and works in partnership with team members to collect specimens. Further review revealed no documented evidence that any tasks had been documented as complete and performed accurately.

In a face-to-face interview on 08/29/11 at 1:35 pm, Director of Quality and Patient Safety S25 indicated the MHT performed simulated tasks in education, and then the preceptor worked with the MHT on the unit. S25 further indicated the hospital policy did not require performance evaluations by the supervisor at the completion of the three month probationary period.

In a face-to-face interview on 08/29/11 at 2:35 pm, Vice President of Patient Care S2 indicated, when asked by the surveyor about the probationary period policy that stated the supervisor would observe the performance of the new employee, that MHT S11 was ranked on the "Baton Rouge General Front Line Talent Management Assessment" as "highly valued contributor". S2 further indicated the third quarter ranking (which was the period in which MHT S11 was listed) was completed during the second week of July 2011. This assessment was performed 5 months after S11 had been hired.

In a face-to-face interview on 08/30/11 at 8:45 am, Director of Quality and Patient Safety S25 confirmed, after review of MHT S11's and MHT S20's personnel file, that S11's and S20's competency assessments were incomplete.

Review of the hospital policy titled "Probationary Period", policy number HR 02-11 reviewed 01/01/09 and submitted as the current policy for probationary period for new employees, revealed, in part, "...New employees are hired for a probationary period of three months. ... (1) The probationary period is a trial period during which the supervisor carefully observes performance of the new employee, and a period for both employee and employer to determine suitability and interest in the position...".

Review of the hospital policy titled "Competency Validation, Employee", policy number HR-100 revised 07/11 and submitted as the current policy for competency assessments, revealed, in part, "...D. Unit Department Orientation is the responsibility of the Department Manager... and includes: ... d. Initial competency assessment based on job description ... g. Completion of competency-based unit orientation h. Department manager, preceptor, and the employee are responsible for completion and documentation of initial competency at the department level...".
VIOLATION: CONTENT OF RECORD Tag No: A0458
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the hospital failed to ensure the History and Physical was on the patients chart within 24 hours of admission as evidenced by patient #5 being admitted on [DATE] and the History and Physical not being dictated until 01/10/11 for 1 of 9 sampled patients (#5). Findings:

Review of the medical record of patient #5 revealed she was admitted on [DATE] at 10:36 p.m. Review of the History and Physical revealed it was dictated on 01/10/11 at 12:50 p.m. and typed on 01/10/11 at 1728 (5:28 p.m.), 55 hours and 52 minutes after admission.

Review of the Medical Staff By-Laws, Article V - Medical Records Section D. 1. reads as follows: "History and Physical...within 24 hours."
VIOLATION: CONTENT OF RECORD - DIAGNOSIS Tag No: A0463
Based on record review and interview the hospital failed to ensure the medical record contained an admission diagnosis as evidenced by the medical record of patient #5 having no documented admission diagnosis. Findings:

Review of the medical record of patient #5 revealed no admission diagnosis.

In an interview on 08/29/11 at 9:40 a.m. with S25Director of Quality/Patient Safety, S2VP Patient Care, and S4Director 4W it was confirmed there was no admission diagnosis in the medical record of patient #5.

Review of the Medical Staff By-Laws, Article V - Medical Records Section C. 3. reads as follows: "Contents of Medical Record. A complete medical record shall include:...3. Reason for admission and treatment..."
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observations and interviews the hospital failed to ensure the Behavioral Health Unit was maintained in a a matter to provide a safe setting for patients with homicidal and suicidal ideation's. Findings:

A tour was made on 08/23/11 at 9:25 a.m. of the Behavioral Health Unit with S3Service Line Administrator for Geri Psych, S4Director of 4W/Geri Psych, and S5Unit Manager 4West/Geri Psych. S5 stated 75% of the patients in the Behavioral Health Unit are admitted on a Physician Emergency Certificate (PEC).

The following environmental safety issues were observed and verified with S3, S4, and S5.

In the open Nutrition Room Nook:
A 4 foot electrically cord to a refrigerator.
A coffee pot with two burners, one on the top of the coffee pot and one on the bottom, with recently brewed hot coffee in the bottom coffee pot.
Numerous loose plastic bags under the sink and in unlocked drawers.
In an unlocked drawer- a heavy stiff plastic pointed pie server.
3 foot electrical cord to the microwave.
Large trash can with numerous clear plastic bags layered on top of each other lining the trash can.
On one hallway 2 computers on rolling stands were plugged into an electrical outlet with the electrical cord being approximately 4 feet long and the scanner cord on the computer being approximately 3 feet long. On another hallway 5 computers on rolling stands were plugged into an electrical outlets with the electrical cords being approximately 4 feet long and the scanner cord on the computer being approximately 3 feet long.

2 cordless phone electrical cords, 2 oxygen concentrator electrical cords, and 1 radio with an electrical cord. All the electrical cords were approximately 3 feet long. These items were located in the dayroom.

On another hallway was a unlocked staff bathroom with handicap rails on both sides of the toilet with a fully stocked unsecured linen cart down the hall with sheets, blankets, towels, and patient gowns on the cart.

An unlocked housekeeping cart was on the hallway with furniture polish, bathroom cleanser and Windex on the cart. An interview was conducted with S34Housekeeper on 08/23/11 at 10:35 a.m. She stated the lock on housekeeping cart has been broken for a couple of days. The housekeeper was observed going in patients' rooms and cleaning and leaving the cart in the hallway.

An unlocked medication cart was found on the hallway with the following medications in the unlocked patients' drawers:
Resperidine 1 mg (milligrams)
Benztropine mesylate 2 mg
Famotidine 20 mg
Lithium 300 mg
Lopressor 50 mg
Lasix 40 mg
Senekot 8.6 mg
K-Dur (potassium) 10 meq (milliequivalents)
Mirtazapine 15 mg
Flomax 0.4 mg

Room "a" had a speciality bed in the room with an 8 foot electrically cord and a 6 foot call light cord.

In the anteroom to room "b" a soiled linen holder had large plastic bag in the holder with numerous replacement plastic bags in a container on the back side of the linen holder.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on record review and interview the hospital failed to ensure staff had annual TB (Tuberculosis) surveillance in accordance with CDC (Centers for Disease Control) as evidenced by 4 of 4 records reviewed having no documented evidence TB skin tests were read within the 48 - 72 hour guideline from the CDC (S7MHT, S8RN, S9MHT, S11MHT). Findings:

Review of the Baton Rouge PPD (purified protein derivative) Skin Test Record for S7MHT revealed documentation the "Date Injected" was 02/01/10 at 10:55 a.m. Documentation indicated the TB Skin test was read on 02/04/11 at 1315 (1:15 p.m.). Review of the time from injection to result revealed it was 73 hours and 20 minutes. This is outside of the 72 hour time frame recommended by the CDC.

Review of the Baton Rouge PPD (purified protein derivative) Skin Test Record for S8RN revealed documentation the "Date Injected" was 09/29/10 with no time documented. Documentation indicated the TB Skin test was read on 10/02/10 with no time documented. Due to no documented times it cannot be determined if the test was read within the time frame recommended by the CDC.

Review of the Baton Rouge PPD (purified protein derivative) Skin Test Record for S9MHT revealed documentation the "Date Injected" was 01/03/10 at 10:15 a.m. Documentation indicated the TB Skin test was read on 01/05/10 at 0730 (7:30 a.m.). Review of the time from injection to result revealed it was 45 hours and 15 minutes. This is outside of the 48 - 72 hour time frame recommended by the CDC.

Review of the personnel record for S11MHT revealed she had previously converted to positive TB skin tests. The hospital could provide no documented evidence of a negative chest x-ray for S11MHT.

In an interview on 08/30/11 at 8:45 a.m. with S25Director of Quality/Patient Safety the above findings were confirmed.