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.

LAKEVIEW REGIONAL MEDICAL CENTER 95 JUDGE TANNER BOULEVARD COVINGTON, LA 70433 March 15, 2011
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on record review and interview the hospital failed to ensure all patients and/or authorized representatives were advised of patient rights on admit as evidenced by no documented evidence the hospital had attempted to contact and inform the authorized representative of a patient assessed as too confused and paranoid upon admit of patient rights for 1 of 5 sampled patients (#1). Findings:

Review of the "Rights of Mental Health Patients" form (provided to all patients upon admit) for Patient #1 dated 01/06/11 revealed in the space provided for the patient's signature, "Patient too paranoid and increased confusion to sign". Further review of the medical record revealed no documented evidence the patient had received information concerning her patient rights at any time during her admission.

In a face to face interview on 03/15/11 at 11:05am RN S7 Clinical Manager for the hospital indicated if the patient is unable to sign at the time of admit, the staff does not go back and review the information presented at the time of admit. Further S7 indicated the PEC (Physician's Emergency Certificate) was interpreted as her consent for treatment and acceptance of rights.

In a face to face interview on 03/15/11 at 11:30am S3 Director of Risk Management indicated the hospital does not have a separate policy addressing patients with behavioral/psychiatric diagnosis and the information on rights should have been given to the patient's POA (Power of Attorney) or next of kin.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on record review and interview the hospital failed to ensure a patient's family member thathad filed a grievance was provided with a letter that outlined the steps taken on behalf of the patient to investigate the grievance or the results of the findings regarding all the components of the grievance for 1 of 7 sampled patients (Patient #3). Findings:

Review of a typed grievance dated January 31, 2011 by Patient #3's wife revealed in part, "I did speak with social workers. . . regarding my husband's discharge plans to fulfill the 15 day PEC (Physicians Emergency Certificate) which was to expire on 9/14/2010. Since we have private (Insurance Company) insurance, we do not have coverage for mental/nervous problems and from the night my husband was admitted I informed everyone involved in his care that we had no coverage for this, including (Psychiatrist S 13), the two social workers, and (Cardiologist S15), and his nurse. I had asked that if possible he be transferred to the state facility to fulfill whatever days were left on his PEC, although my hope was that he would stay on the Cardiac Unit long enough to fulfill the time left. . ."

Review of the Grievance Response letter from Lakeview Regional Medical Center to Patient #3's wife dated 2/01/2011 revealed in part, "During our investigation, we found that (Psychiatrist S13) did see (Patient #3) while he was at our medical facility. (Psychiatrist S13) and (Physician S15) did not rescind the Physician's Emergency Certificate (PEC) because they both felt that your husband was in need of further treatment. At the time of his discharge from Lakeview Regional medical Center, Senior Behavioral Health was not the place to provide a therapeutic milieu in meeting your husband's needs. While we appreciate your concerns regarding your husband, any further discussion will have to occur between us and him (Patient #3). This is to maintain confidentiality of information pertaining to his treatment. . ." Review of the entire grievance response letter revealed no documented evidence of what steps the hospital had taken on behalf of the patient (#3) to investigate the grievance or of any investigation results regarding Patient #3's wife's complaint that the hospital had not honored her request for State Hospital placement due to issues with mental health insurance coverage for her husband, Patient #3.

This finding was confirmed in a face to face interview with Director of Quality and Risk, S3 on 3/15/2011 at 1:15 p.m. S3 further indicated she (S3) had thought Patient #3's wife's primary concern was a desire to have Lakeview Regional pay for the patient's ambulance transfer bill and she (S3) had focused on that part of the complaint (Patient #3's need for psychiatric treatment that could not be provided by Lakeview Regional thus triggering the need to transfer the patient to an appropriate hospital with an available bed). S3 indicated there had been no beds available at state facilities; however, she (S3) had not included that information in the response letter to Patient #3's wife nor had she (S3) informed the complainant of the steps taken on behalf of the patient (#3) to investigate the grievance.

Review of the hospital policy titled, "Patient Grievance and Complaint Management Policy, #001.26, last reviewed 7/10" presented by the hospital as their current policy revealed in part, "In resolution of the grievance, a written notice of the decision must be provided to the complainant that contains the name of the facility contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion."
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on record review and interview the hospital failed to ensure effectiveness of their grievance process as evidenced by failure to have documented evidence that all allegations listed in the grievance were thoroughly investigated for 1 of 7 sampled patients (Patient #3). Findings:

Review of a typed grievance dated January 31, 2011 by Patient #3's wife revealed in part, "I did speak with social workers. . . regarding my husband's discharge plans to fulfill the 15 day PEC (Physicians Emergency Certificate) which was to expire on 9/14/2010. Since we have private (Insurance Company) insurance, we do not have coverage for mental/nervous problems and from the night my husband was admitted I informed everyone involved in his care that we had no coverage for this, including (Psychiatrist S 13), the two social workers, and (Cardiologist S15), and his nurse. I had asked that if possible he be transferred to the state facility to fulfill whatever days were left on his PEC, although my hope was that he would stay on the Cardiac Unit long enough to fulfill the time left. . ."

Review of the hospital's electronic record regarding the investigation of Patient #3's wife's complaint revealed no documented evidence of an investigation regarding the hospital's attempt to honor the request for placement in a state facility due to Patient #3 having no mental health insurance. This finding was confirmed by Director of Quality and Risk, S3.

During a face to face interview on 3/15/2011 at 1:15 p.m., Director of Quality and Risk, S3 indicated she(S3) had written a summary of her findings in the electronic grievance record for Patient #3. S3 further indicated she (S3) had not record detailed information regarding the interviews and/or investigation of Patient #3's wife's grievance. S3 indicated she had identified the primary concern; listed in the grievance letter, as a desire by Patient #3's wife to have the hospital pay for the ambulance transfer of Patient #3 from Lakeview Regional Medical Center to the recipient hospital in Shreveport, Louisiana and had made that her (S3) primary focus of the investigation. S3 indicated she (S3) had spoken with social workers about their attempts to locate a state facility but had no documentation to verify the interviews.

Review of the hospital policy titled, "Patient Grievance and Complaint Management Policy, #001.26, last reviewed 7/10" presented by the hospital as their current policy revealed in part, "Upon receipt of a grievance, the Risk Manager (or designee of the organization) shall confer with the appropriate department manger to review, investigate and resolve with the patient and/or patient representative within seven days of receipt of the grievance. . . Regardless of the nature of the grievance, the substance of each grievance must be addressed while identifying, investigating, and resolving any deeper, systemic problems indicated by the grievance."
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the Registered Nurse failed to supervise and evaluate the nursing care for each patient as evidenced by failing to have documented evidence of immediate and ongoing assessments of a patient that fell in the hospital and sustained an orbital fracture for 1 of 7 sampled patients (#5). Findings:

Patient #5 was admitted on [DATE] with diagnoses that included Diabetes Type 2, Dementia with Behavioral Disturbance, and Debility. Review of Patient #5's "Interdisciplinary Treatment Team Update Worksheet and Signature Form" revealed in part, "12/24/2010, Labile-aggressive (with) staff and other pts (patients). Resisting to care- fell - went to ER (emergency room )- Ativan 1106 (11:06 a.m.) for aggressive behavior (with) pt. (patient) (and) kicking at staff." Review of Patient #5's "Daily Progress Note" dated 12/24/2010 at 7:00 p.m. revealed in part, "Pt (patient) easily agitated, impulsive, and verbally aggressive. Pt. did fall today, MD (physician) (and) fly (family) notified (right) orbital fx (fracture)." Review of the entire medical record revealed no documented evidence of a Registered Nurse assessment immediately post fall or ongoing post- fall assessments upon return to the Geriatric Psychiatric Unit post evaluation and treatment at the hospital's Emergency Department located at the Main Campus. This finding was confirmed by Director of Quality and Risk S3 and Geriatric Psych Clinic Manager S7 on 3/15/2011 at 10:50 a.m.

Review of physician's orders dated 12/26/2010 at 10:00 a.m. (2 days after patient #5 fell ) revealed in part, "Monitor Neuro Status closely- notify for any changes. Ice/Cool Paks to right eye/face qid (four times per day) if pt. (patient) allows x 48 hours."

During a telephone interview on 3/15/2011 at 10:30 a.m., Registered Nurse S8; the Geriatric Psych Nurse assigned to the care of Patient #5 on the date of the patient's (#5) fall (12/24/2010) resulting in an orbital fracture, indicated she (S8) had no recall of Patient #5's fall or what type of assessment she (S8) performed post fall and/or post return from the Emergency Department. S8 indicated she typically takes a patient's vital signs after any type of trauma or change in condition. Further S8 indicated she (S8) typically looks for any medical needs that a patient might need post incident/accident such as x-rays. S8 indicated she (S8) did not know what had occurred with Patient #5 and apparently she (S8) had forgotten to chart.

During a face to face interview on 3/15/2011 at 10:50 a.m., Geriatric Psych Clinical Manager S7 indicated she (S8) would have expected the Registered Nurse that provided care to Patient #5 on the date of 12/24/2010 to have performed and documented an assessment of the patient's range of motion, neuro-status, and vital signs immediately post fall and then performed neurochecks at regular intervals post fall. S7 confirmed there had been no documented evidence of any Registered Nurse Assessment in the Medical Record of Patient #5 immediately post fall and following the patient's return from the Emergency Department when the patient had been diagnosed with an orbital fracture.

Review of the hospital policy titled, "Neurological Vital Signs" presented by the hospital as their current policy revealed in part, "Neurological vital signs are specified for evaluating a patient's neurological status. The items listed below should be tested and the results entered in the Meditech Nursing assessment and reassessment. Check pupil for size and briskness reaction. Check blood pressure. Check pulse. Check respirations for quality, rate, and rhythm. Test strength of extremities. Evaluate level of consciousness and orientation. Evaluate speech".

Review of the hospital policy titled, "Fall Preventions Program, # 002.07" presented by the hospital as their current policy revealed in part, "In the event of a patient fall: Prior to moving a patient that has fallen, an RN (Registered Nurse) should assess for injury. If the patient does not respond appropriately or exhibits pain with movement, he/she should be examined by a physician prior to movement. In the absence of the attending MD (medical doctor), this will be the Emergency MD. For patients at Senior Behavioral Health. . .: If the patient does not respond appropriately or exhibits pain with movement, call 911. Emergency personnel will determine the patient's ability to move. Notify the attending physician of the fall.. . Record the details of the patient's fall in the record including: any injuries or complaint of pain, notification of MD and orders received. action taken, patient's response, reassessment of patient status within 4 hours.. ."
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on record review and interview the hospital failed to ensure a nursing care plan was individualized and kept current regarding a fall that occurred in the hospital for 1 of 7 sampled patients (#5). Findings:

Review of an electronic "Patient Event Information" form for Patient #5 revealed the patient fell "Event Date 12/24/2010, Time 1130 (11:30 a.m.), Day Shift". Further review revealed "Objective Description of Event View" as "Pt. (patient) disruptive this am (morning) to milieu- hollering and aggressive other patients and staff- medicated with Ativan at 1106 (11:06 a.m.) 1 mg (milligram) IM (intramuscularly)- removed from group setting continued to holler while staff on phone at nurses station - tech wheeled pt. in visiting lounge hoping quiet and Christmas tree would settle her down but pt in wheel chair with tech standing within a few feet of her- impulsively threw herself to floor before tech could catch her- hitting r (right) side of face resulting in contusion to r (right) eye- complained of pain to r (right) arm- tech hollered for help- pt (patient) assist with (equipment) back to sitting position. VS (vital sign) taken 167/78 (blood pressure) 80 (heart rate) 22 (respirations) 97.9 (temperature). . . spoke with (responsible party) listed on face sheet- states she (Patient #5) was doing this at NH (nursing home)." Further review; to include review of Patient #5's medical record, revealed no documented assessment of the patient's neurological or neurovascular status immediately post fall.

Review of Patient #5's medical record revealed no documented evidence that the patient's treatment plan for fall precautions had been updated and individualized post fall on 12/24/2010 regarding an established pattern of "impulsively" throwing self from wheelchair to the floor when agitated. This finding was confirmed in an interview with Geriatric Psych Clinical Manager S7 and Director of Quality and Risk S3 on 3/15/2011 at 10:50 a.m. During this interview, S3 and S7 indicated standard fall precautions would not address behavior patterns where a patient responded to frustration by impulsively throwing herself out of a wheelchair. Further S3 and S7 indicated Patient #5's treatment plan should have been updated to include behavioral interventions to prevent falls as a result of Patient #5 impulsively throwing self from wheelchair when frustrated/agitated.

Review of the hospital policy titled, "Falls Prevention Program, last reviewed 8/10, # 002.07" presented by the hospital as their current policy revealed in part, "Purpose: To assess and appropriately identify those patients who are risk for possible falls while hospitalized , therefore preventing patient falls through a comprehensive program of staff awareness, family and patient education , and patient protection. Fall: A fall is defined as a sudden, uncontrolled, unintentional, downward displacement of the body to the ground or other object, excluding falls resulting in violent blows or purposeful action. . . The following Falls Prevention Interventions must be implemented as appropriate for individual patients identified as being high risk for falls. A yellow dot will be placed on the patient's name plate and chart. . . Intensified observation by staff; safety rounds every 2 hours, Patient located near nursing station, when possible, Offer frequent bathroom assistance by making toileting rounds, Educate the patient and family . . . Provide non skid footwear. . Remind patients not to get up without assistance, Patient will not be left unattended in bathroom or on bedside commode, 24 hour family member attendance when possible, family will be instructed on fall precautions. sitter as ordered by physician. . ."
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure accurate discharge instructions were provided to the patient, patient's care giver, or recipient hospital at the time of transfer and/or discharge from the hospital for 2 of 7 sampled patients (Patients #3 and #5). Findings:

Patient #3:
Patient #3 was admitted on [DATE] and discharged on [DATE] with diagnoses that included Major Depressive episode, Hypertension, Alcohol Abuse with Withdrawal, and newly diagnosed Atrial fib, hypertension and hypokalemia.

Review of Patient #3's physician's orders dated 9/10/2010 with no documented time revealed an order to increase the patient's (#3's) Lopressor (Metoprolol) to 50 milligrams by mouth every 12 hours.

Review of Patient #3's Discharge Instructions (Occurred Date: 9/11/2010) revealed "Patient's Home Medication List" to include "Metoprolol Tartrate (Lopressor) 25 mg (milligrams) oral twice a day (25 milligrams per dosage less than what had been ordered by the patient's physician)". This finding was confirmed in an interview by Director of Quality and Risk S3 on 3/15/2011 at 1:15 p.m. S3 further indicated the patient should have received discharge instructions that accurately reflected the orders of the physician. S3 indicated Patient #3's discharge instructions should have included Metoprolol (Lopressor) 50 milligrams every 12 hours as ordered by the physician on 9/10/2010.

During a telephone interview on 3/15/2011 at 12:40 p.m., Physician S15 indicated he wanted Patient #3 to take Lopressor (Metoprolol) 50 milligrams every 12 hours as written on 9/10/2010. Physician S15 indicated it must have been an oversight that Patient #3's Discharge instructions had 25 milligrams rather than 50 milligrams.

Patient # 5:
Patient #5 was admitted on [DATE] with diagnoses that included Diabetes Type 2, Dementia with Behavioral Disturbance, and Debility. Review of Patient #5's "Interdisciplinary Treatment Team Update Worksheet and Signature Form" revealed in part, "12/24/2010, Labile-aggressive (with) staff and other pts (patients). Resisting to care- fell - went to ER (emergency room )- Ativan 1106 (11:06 a.m.) for aggressive behavior (with) pt. (patient) (and) kicking at staff." Review of Patient #5's "Daily Progress Note" dated 12/24/2010 at 7:00 p.m. revealed in part, "Pt (patient) easily agitated, impulsive, and verbally aggressive. Pt. did fall today, MD (physician) (and) fly (family) notified (right) orbital fx (fracture)." Review of the entire medical record revealed no documented evidence of discharge instructions being provided from the hospital's Emergency Department, where the patient (#5) had been transferred for evaluation post fall, to the Geriatric Psychiatric Unit where the patient (#5) returned post evaluation of a fall with a diagnosis of orbital fracture. This finding was confirmed by Director of Quality and Risk S3 and Geriatric Psych Clinic Manager S7 on 3/15/2011 at 10:50 a.m.

Review of physician's orders dated 12/26/2010 at 10:00 a.m. (2 days after patient #5 fell ) revealed in part, "Monitor Neuro Status closely- notify for any changes. Ice/Cool Paks to right eye/face qid (four times per day) if pt. (patient) allows x 48 hours."

During a telephone interview on 3/15/2011 at 10:30 a.m., Registered Nurse S8; the Geriatric Psych Nurse assigned to the care of Patient #5 on the date of the patient's (#5) fall (12/24/2010) resulting in an orbital fracture, indicated she (S8) had no recall of Patient #5's fall or discharge instructions from the Emergency Department post fall.

During a face to face interview on 3/15/2011 at 10:50 a.m., Director of Quality and Risk S3 indicated discharge instructions should have been sent to the Geriatric Psych Unit after the fall with orbital fracture for Patient #5. S3 confirmed there were no discharge instructions in the entire medical record for Patient #5 regarding care of the patient's orbital fracture from the Emergency Department. S3 indicated the nurse on the unit should have called the Emergency Department for clarification. S3 indicated she (S3) was able print a copy of the Discharge Instructions for Patient #5 from the Emergency Department electronic file but had no explanation as to how Patient #5 had been returned to the Geriatric Psychiatric Unit without a copy of the instructions. S3 indicated the instructions could have been misplaced on the Geri-Psych Unit; however, there was no documented evidence of post fall care being provided to Patient #5 on the unit as was indicated in the Emergency Department Record (elevate head on two pillows, ice pack, neurochecks). Note physician's orders for ice pack and monitoring of neuro status were not written until 2 days after the patient had returned from the emergency department.

Review of Emergency Department Discharge Instructions for Patient #5; printed 3/15/2011 at 11:27 a.m. and provided by S3 for surveyor review, revealed in part, "Facial Fracture: A blow to the face forceful enough to cause a fracture may also cause a concussion or more serious brain injury. Therefore, watch for the warning signs below. Home Care: Apply an ice pack over the injured area for 20 minutes every 1-2 hours the first day. Continue with ice packs 3 - 4 times a day for the next two days, then as needed for the relief of pain and swelling. . . Sleep with your head elevated on 2 or more pillows to reduce swelling. If you have facial pain when eating, avoid crunchy or chewy foods. A softer diet will be more comfortable for the first 2 - 3 weeks. . . If your nose bleeds, sit up and lean forward while pinching the nostrils together for five minutes. If bleeding is not controlled, continue to pinch and call your doctor or return to this facility. Do not blow your nose for 12 hours after the bleeding stops. . . Get prompt medical attention if any of the following occur: Increasing facial swelling or pain, Redness, warmth or pus from the injured area, Fever over 100.0 F (Fahrenheit), Double vision, Repeated vomiting, Severe or worsening headache or dizziness, Unusual drowsiness, or unable to awaken as usual, Confusion or change in behavior or speech, Convulsion. . ." Note: There was no documented evidence of these discharge instructions anywhere in the Geriatric Psychiatric Record for Patient #5.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure consent for treatment had been obtained for all patients as evidenced by failing to obtain a consent for treatment on a patient assessed as too confused and paranoid but who had a Power of Attorney and a son who acted as a caregiver for 1 of 5 sampled patients (Patient #1). Findings:

Review of the medical record for Patient #1 revealed a [AGE] year old female admitted from home to the hospital accompanied by her son on 01/06/11 with paranoid delusions, poor nutrition, anxiety, increased confusion and non-compliance with medication. Further review revealed a history of Myocardial Infarction (MI), Hypertension (HTN) and [DIAGNOSES REDACTED].

Review of the "Conditions of Admissions" form dated 01/06/11 which contained a consent to treatment, wireless phone calls, release of information and notice of privacy practices for Patient #2 revealed in the space provided for the signature of the patient or authorized representative "Patient paranoid/confused. Unable to sign". Further review revealed no documented evidence a family member or authorized representative had signed the consent for admission and treatment.

Review of the Discharge Summary for Patient #1 dated 01/12/11 revealed she was discharged from the hospitals's offsite behavioral unit and admitted to the acute care unit on the main campus of the hospital for further evaluation of dysphasia.

Review of the "Conditions of Admissions" form dated 01/12/11 which contained a consent to treatment, wireless phone calls, release of information and notice of privacy practices for Patient #2 revealed in the space provided for the signature of the patient or authorized representative "Patient paranoid/confused. Unable to sign". Further review revealed no documented evidence a family member or authorized representative had been contacted to consent for admission and treatment.

In a face to face interview on 03/15/11 at 11:05am RN S7 Clinical Manager for the hospital indicated if the patient is unable to sign at the time of admit, the staff does not go back and review the information presented at the time of admit. Further S7 indicated the PEC (Physician's Emergency Certificate) was interpreted as her consent for treatment.

In a face to face interview on 03/15/11 at 11:30am S3 Director of Risk Management indicated the hospital does not have a separate policy addressing patients with behavioral/psychiatric diagnosis and the information on rights should have been given to the patient's POA (Power of Attorney) or next of kin.

Review of Policy No. 001.08 titled "Consent, Informed, last revised 07/10 and submitted as the one currently in use, revealed ..... 1. All patients undergoing medical treatments, invasive procedure must give their informed consent to such procedure...".