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EARL K LONG MEDICAL CENTER 5825 AIRLINE HIGHWAY BATON ROUGE, LA April 29, 2011
VIOLATION: PATIENT RIGHTS: EXERCISE OF RIGHTS Tag No: A0129
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to develop and implement a policy to ensure patients had the right to use a telephone while waiting in the MHERE (Mental Health emergency room Extension) Unit for placement into a psychiatric facility or discharge to home as evidenced by phone privileges of each patient determined at the discretion of the charge nurse for 1 of 1 patients complaining of not being able to access the phone out of a total of 11 sampled patients (#1). Findings:

Review of the medical record for Patient #1 a [AGE] year old female who was brought to the hospital's Emergency Department by the Emergency Medical Services (EMS) on 01/26/11 at 0931 (9:31am) with paranoid delusions believing her parents and ex-husband were trying to poison her with Robinul. Patient #1 was PEC ' d (Physician's Emergency Certificate) for severe psychotic cannibas abuse features and bipolar disorder with manic episodes and was transferred to the MHERE unit on 01/26/11 at 1156 (11:56am).

Review of the Nurses' Notes dated/timed 01/26/11 at 1328 (1:28pm) for Patient #1 revealed the patient was on the phone and her behavior began to escalate and her speech became pressured. 1409 (2:09pm) Patient wanted to call 911 and her privileges were taken away. Further review of the chart revealed no documented evidence #1 requested to use the phone until 01/27/11 at 2010 (8:10pm) when she wanted to speak to the Mental Health Advocacy Attorney. According to the nurses' notes the number was dialed and the phone handed to the patient. Documentation of the conversation indicated #1 informed the advocate she was being held against her will because she was the star witness regarding street poisonings. At 2248 (10:48pm), Patient #1 requested pen and paper to make a list for her lawsuit; however the nurse offered to write the list which satisfied the patient and a list was made. Review of the remainder of the nurses' notes until discharge on 01/18/11 at 1235 (12:35pm) revealed no documented evidence further requests for phone use or paper/pen were made by Patient #1.

Review of the booklet titled "Patient Rights, Responsibilities and Patient Safety" given to every patient admitted to the facility revealed .... "Communication: The patient has the right of access to people outside the hospital by means of visitors and by verbal and written communication".

Review of a document submitted to the survey team on 04/27/11 titled "Procedures" with a revision date 3/23/11 revealed ... Telephone Usage: This will always be at the discretion of the charge nurse. If we choose to let a patient have telephone privileges, we will limit the phone call to five minutes .... The cut off time for regular night use will be 2200 (11:00pm). Patients will always be allowed to contact the Mental Health Advocacy Line ...".

In a face to face interview on 04/ 29/11 at 9:00 am RN S1 RN Supervisor of the MHERE indicated the charge nurse makes the decision whether or not to revoke phone privileges. She added that the patient does not have the right to use the phone if the patient becomes agitated or begins to use the phone as a weapon. Further S1 indicated there are no written behavioral guidelines for determining when phone privileges are to be revoked or for how long.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0162
Based on observation, record review and interview the hospital failed ensure patients were not placed in involuntary confinement as evidenced by placing patients in locked observation rooms in which they cannot leave for the management of violent behavior for 2 of 2 patients out of a total of 11 sampled patients. Findings:

Observation on 04/26/11 at 4:00pm of the MHERE Unit (Mental Health emergency room Extension) located in a trailer across the parking lot from the Emergency Department revealed 4 rooms located by the nursing station designated as observation rooms. Further review revealed a large window, a seclusion bed and a door that when closed locked from the inside preventing exiting from the inside. The door has a small rectangular glass pane for viewing which requires a staff member performing 1:1 observation to stand at the door in order to visualize the patient in the observation room.

Review of the Nurses' Notes for Patient #1 dated 01/28/11 at 0205 (2:05am) revealed.... "Continued to yell and scream,; cursing and threatening lawsuits then removed both arms and right leg restraint and urinated on floor by bed.....".

Review of the Nurses' Notes for Patient #8 dated 03/27/11 at 0140 (1:40am) revealed.... "Patient in observation window, opened door to speak with patient". Further review revealed after the nurse explained the reason the patient had been placed in the observation room, "closed door, will continue to monitor".

In a face to face interview on 04/28/11 at 7:15am CNA S11 indicated she was assigned 1:1 observation of Patient #1 when she (#1) was placed in the observation room during the early morning hours of 01/28/11. Further S11 indicated the door was closed to the observation room until around 3:00am when the door was opened.

In a face to face interview on 04/28/11 at 1:30pm RN S indicated the door to the observation room can be closed during 1:1 observations. Further he indicated the nurse who has the patient can determine whether the door remains open or closed.

In a face to face interview on 04/29/11 at 9:25am RN S1 Supervisor of the MHERE Unit verified the MHERE Unit does not have any seclusion rooms. When asked by the surveyor if a patient was placed in an observation room on the MHERE Unit with the door closed, would this be considered seclusion since the when the door to the room closes the patient is unable to exit. S1 indicated that it would be considered seclusion.

Review of Policy Number: 06-13-005 titled "Restraint Use, Policy for" last revised 10/10 revealed ........ C. Seclusion - According to CMC Conditions of Participation, seclusion is the involuntary confinement of a patient in a room or an area from which the patient is physically prevented from leaving.... (Note: This is not practiced at Earl K. Long Medical Center....)".
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on record review and interview the hospital failed to set priorities on performance improvement activities to include possible problem prone areas as evidenced by no documented evidence of indicators monitoring restraint usage with the use of new beds in the MHERE Unit resulting in 2 (#1, #3) of 9 (#2, #5, #6, #7, #8, #9, #11) patients able to remove his/her restraints out of a total of 11 sampled patients. Findings:

Patient #1
Review of the "Restraint Assessment and Physician Order Set dated 1/28/11 at 0100 (1:00am) revealed an order for 4-point soft limb restraints after least restrictive devices of adjusting the light in the room, calming techniques, reduction of outside stimuli, active listening, and frequent observations failed. Further review revealed Patient #1 attempted to attack staff and was placed in 4-point restraints at 0040 (12:40am). Further review of the form revealed Patient #1 removed the bilateral arm restraints at 0050 (12:50am) at which time the restraints were replaced. At 0140 (1:40am) Patient #1 removed the right lag restraint and the bilateral arm restraints which were immediately replaced. At 0205 (2:05am) 3 of the 4 restraints were removed by patient #1 and the restrained were re-applied.

Patient #3
Review of the Restraint Assessment and Physician Order Set for Patient #3 dated 03/30/11 revealed an order for 4 -point soft limb restraints after least restrictive devices of decreased stimuli, reorientation, frequent observation, calming techniques and re-location of the patient closer to the nurses' station failed. Further review revealed Patient #3 continued aggressive behavior towards the staff which included spitting, yelling and threatening continued and #3 was placed in restraints at 2020 (8:20pm) with a sitter at the bedside. At 2100 (8:00pm) Patient #3 had removed all four restraints and was found standing at his bedside requesting a drink of water.

In a face to face interview on 04/28/11 at 7:15am CNA S11 indicated she has observed a patient removing restraints.

In a face to face interview on 04/28/11 at 8:15am RN S4 indicated patients can get out of restraints all the time because the restraints have Velcro to secure the ends.

In a face to face interview on 04/28/11 at 8:45am CNA S8 indicated patients are able to get out of the restraints by twisting to loosen up the restraints.

In a face to face interview on 04/28/11 at 11:14am RN S10 indicated a patient can get out of restraints because the soft Posey type is used on the unit.

In a face to face interview on 04/28/11 at 1:30pm RN S9 indicated the restraints used in the MHERE Unit are such that the patients can untie themselves.

Review of the Quality Assurance Nursing Specific Indicators: Restraints ER (Emergency Department) for January 2010 through March 2011 revealed no documented evidence appropriate application of restraints was being monitored even though the equipment (beds in the MHERE Unit) was new.

In a face to face interview on 04/29/11 at S1 the Director of Quality Management indicated application of restraints with the use of new beds on the MHERE unit should have been monitored. Further S1 indicated the staff of the MHERE unit had not reported any problems with the patients being able to remove the restraints.