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.

NORTHLAKE BEHAVIORAL HEALTH SYSTEM 23515 HIGHWAY 190 MANDEVILLE, LA 70448 May 30, 2014
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, record reviews, and interviews, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care for each patient as evidenced by:

1) Failing to ensure the RN received a physician's order to change a patient's level of observation as required by hospital policy for 2 (#F5, #FR10) of 6 (#F5, #F6, #FR9, #FR10, #FR11, #FR12) current patients' records reviewed on Esplanade I Unit (acute adult unit) for physician orders to change the observation status from a total of 16 current patients on Esplanade I Unit and
2) Failing to ensure the MHTs (Mental Health Technicians) observed patients according to Physician's Orders and hospital policy for:
-3 (#F5, #FR9, #FR10) of 3 current patients on Suicide Precautions, 1 (#FR11) of 7 current patients on Close Staff Sight, and 1 (#FR12) of 9 current patients on Routine Observation from a total of 16 current patients on Esplanade I Unit (acute adult unit).
-2 (Patient #F3 and Patient #F15) out of 2 current patients on visual contact (V.C.) on Esplanade II Unit;
-1 (#F10) of 4 ( #FR7, #FR8, #F10, #F12) current patients on Visual Contact Precautions on out of a total of 6 active patients on the Live Oak Unit (Adolescent Unit).
Findings:
1) Failing to ensure the RN received a physician's order to change a patient's level of observation as required by hospital policy:

Review of the hospital policy titled "Level of Observation and Precaution", policy number TX7-1001, revised 03/20/14, and presented as the current policy by SF1Director of Clinical Services, revealed that the types of observations were Routine Observation (every 15 minutes direct observation of the location and activity of the patient is documented), Close Staff Sight (CSS) (every 10 minutes direct observation of the location and activity of the patient is documented), Visual Contact (VC) (maintain visual contact of the patient at all times), and One-to-one (1:1) (one staff member assigned within 3 to 6 feet of visual contact of the patient at all times during waking hours; during sleeping hours the staff member assigned will monitor the client from the bedroom doorway). Further review revealed the types of precautions include Suicide Precautions, Elopement Precautions, Fall Precautions, Seizure Precautions, and Withdrawal Precautions. At admission all patients will be placed on Routine Observation, and the level of observation can be adjusted when a patient poses a risk of harm to self, others, or property at the time of admission or in response to the Initial Nursing Assessment results. An order must be written to change a level of observation/precaution outside the initial placement of Routine Observation upon admission. The order must be written by a physician. If an order is written to discontinue a level of observation/precaution, the patient will revert back to Routine Observation, unless otherwise indicated in the physician's order.

Patient #F5

Review of Patient #F5's medical record revealed his admission orders were signed on 05/28/14 at 6:15 p.m. by SF16Medical Director. Review of his "RN Assessment of Risk/Initial Care Needs" revealed he arrived on Esplanade I Unit on 05/29/14 with no documented evidence of the time of arrival. Review of his "RN Assessment" revealed SF15RN completed her admit assessment on 05/29/14 at 1:30 a.m. Further review of Patient #F5's medical record revealed he was PEC'd (Physician's Emergency Certificate) on 05/28/14 at 2:00 p.m. after being found by police standing in the middle of the road telling passing drivers that he wanted to kill himself. Further review revealed he was PEC'd as being suicidal, dangerous to himself, and gravely disabled.

Review of Patient #F5's "Initial Care Orders" signed by SF16Medical Director on 05/28/14 at 6:15 p.m. revealed he was ordered to be on VC with no documented evidence of the type of precautions that were to be followed. His preliminary psychiatric diagnosis was Mood Disorder with a history of Asthma. Review of Patient #F5's "Doctor's Order Sheet" revealed an order written on 05/29/14 at 1:20 a.m. by SF15RN to change his precautions from VS (should be VC) to Routine Observation with Suicide Precautions. There was no documented evidence that the order was received from verbally or by telephone with read-back verification from a physician as required by hospital policy.

Review of Patient #F5's "Suicide Risk Assessment" included in his "RN Assessment of Risk/Initial Care Needs" and completed by SF15RN revealed Patient #F5's suicide risk was scored as a "4" by SF15RN (the factors checked totaled 5 rather than 4) with a score of 1 next to gender, Depression,use of alcohol within 72 hours, diagnosed or perceived chronic medical condition, and support system lacking. A note above the assessment on the form stated "if starred factors or three or more factors circled, then consider visual contact or 1:1." There was no documented evidence that SF15RN had reviewed her assessment with a physician as evidenced by the section for the time reviewed and the name of the physician being blank.

In an interview on 05/29/14 at 2:45 p.m., SF19DON indicated that she had done one-to-one education with the nurses about needing a physician's order to change a patient's observation level, but she had not gotten to SF15RN yet.

In a telephone interview on 05/30/14 at 8:30 a.m., SF15RN indicated "I'm new at the company and just do what the other nurses told me to do... can use our discretion" when asked if she had a physician's order to decrease the level of observation for Patient #F5. She confirmed that she did not get a physician's order to change Patient #F5's observation from VC to Routine Observation. SF15RN indicated that they do not have enough staff for everyone to be on VC, but if it's necessary, "I'd keep them on VC." She indicated that after she assessed Patient #F5, he told her that he was upset because his girlfriend had cheated on him. She further indicated that he was anxious to get to sleep and was placed on the side of the unit where a MHT was seated near his room most of the night. When asked if she was aware that he had been found in traffic telling drivers passing by that he wanted to kill himself, SF15RN answered, "he said he was trying to get to his daughter's house and never wanted to commit suicide." SF15RN indicated that she read Patient #F5's PEC. When the surveyor read what was written as stated above (about being found in traffic), she answered, "I read the PEC but sometimes I can't read the writing... I can't actually remember reading what you read to me." When asked if it was common practice for the nurses to change the patient's level of observation without obtaining a physician's order, SF15RN answered, "I'm not clear on it, but I'm going on what I'm trained on and wouldn't do what I haven't been trained on." She indicated that in the middle of the night "I don't have access to SF16Medical Director."

In an interview on 05/30/14 at 10:05 a.m., SF1Director of Clinical Services indicated that Patient #F5 remained on Routine Observation with Suicide Precautions. She confirmed that after administration was notified on 05/29/14 that there was no documented evidence that the order written by SF15RN to change Patient #F5's level of observation had been given by a physician, there had been no assessment made and a new order other than VC written by a physician as required by hospital policy.

Patient #FR10

Review of Patient #FR10's medical record revealed he was admitted on [DATE] at 12:00 p.m. with a diagnosis of Mood Disorder and arrived on the unit at 6:20 p.m. He was PEC'd on 05/27/14 at 6:15 p.m. due to being suicidal and dangerous to self. He was CEC'd on 05/28/14 at 12:00 p.m. as being suicidal and dangerous to self.

Review of Patient #FR10's admission orders signed by SF16Medical Director revealed an order for VC with no documented evidence of special precautions. Review of his "Doctor's Order Sheet" revealed a telephone order was received from SF17NP (Nurse Practitioner) to change from VC to CSS with Suicide Precautions. Further review revealed an order was written by SF15RN on 05/28/14 at 9:00 p.m. to change Patient #FR10's level of observation from CSS to Routine Observation with Suicide Precautions. There was no documented evidence that the order was received from verbally or by telephone with read-back verification from a physician as required by hospital policy.

In a telephone interview on 05/30/14 at 8:30 a.m., SF15RN indicated she did not receive a physician's order to change Patient #FR10 from CSS to Routine Observation as required by hospital policy.

In an interview on 05/30/14 at 10:15 a.m., SF20Director of Risk Management indicated that Patient #FR10 was currently being observed as Routine Observation. When shown the order that was written by SF15RN and confirmed in the earlier interview that she did not receive the order from a physician, he confirmed that Patient #FR10 should have continued to be observed as CSS.

In an interview on 05/30/14 at 2:15 p.m. with SF16Medical Director, SF1Directorof Clinical Services, SF20Director of Risk Management, SF21Chief Executive Officer (CEO), and SF19Director of Nursing (DON) present, SF19DON indicated that because the RN has to evaluate a patient's suicide risk, SF15RN may have understood that she could change the level of observation. When told that SF15RN confirmed that she did not get a physician's order to change Patient #F5's observation level, and it was common practice for the nurses to change the observation levels without obtaining a physician's order, SF19DON offered no explanation. SF16Medical Director indicated that he did not remember getting a phone call from SF15RN requesting an order to change Patient #F5's level of observation. He further indicated that all patients on Esplanade I Unit were re-evaluated today and confirmed that this was not done on 05/29/14 when it was brought to the attention of administration.

2) Failing to ensure the MHTs observed patients according to Physician's Orders and hospital policy:
See the hospital policy titled "Level of Observation and Precaution", policy number TX7-1001, revised 03/20/14, and presented as the current policy by SF1Director of Clinical Services as written above under part 1. Review of the entire policy revealed no documented evidence of the procedure to follow when a patient on Suicide Precautions is in the bathroom to shower or perform hygiene activities.

Esplanade I Unit

During a tour of Esplanade I Unit on 05/29/14 at 10:20 a.m., SF10MHT was observed in the male's patient bathroom with the door ajar. Running water could be heard from the doorway. Further observation revealed upon entering the bathroom, the lavatories were located on the right wall, the toilet stalls were straight down the hall to the left, and around the corner (u-shaped bathroom) were 2 shower stalls with vinyl curtains hanging on rods that hung to the floor (could not see into the shower when the curtain was closed).

In an interview during the observation of SF10MHT in the male bathroom doorway on 05/29/14 at 10:20 a.m., SF10MHT asked the surveyor if she was supposed to leave Patient #F5 who was Routine Observation with Suicide Precautions in the shower while she went to make her every 10 minute rounds on Patient #FR9 who was on CSS with Suicide Precautions and Patient #FR11 who was on CSS with Withdrawal Precautions and her every 15 minute rounds on Patient #FR10 who was Routine Observation with Suicide Precautions and Patient #FR12 who was on Routine Precautions. SF10MHT indicated she just started going into the bathroom with Suicide Precautions today, but she had been going into the bathroom with patients who were on every 10 minutes observation and 1:1. She further indicated that she had never had anyone explain to her how to handle other patients assigned to her when she was observing a patient in the shower. SF10MHT confirmed that she could not see Patient #F5 while he was in the shower, because the shower was around the corner from where she was standing in the doorway.

Review of the staff assignment sheet for 05/29/14 for the Esplanade I Unit presented by SF8Charge RN (Registered Nurse) revealed SF10MHT was assigned to observe Patients #FR9 (listed as CSS observation with Suicide Precautions), #FR10 (listed as Routine Observation with Suicide Precautions), #F5 (listed as Routine Observation with Suicide Precautions), #FR12 (listed as Routine Observation), and #FR11 (listed as CSS observation with Withdrawal Precautions).

Patient #F5

Review of Patient #F5's medical record revealed his admission orders were signed on 05/28/14 at 6:15 p.m. by SF16Medical Director. Review of his "RN Assessment of Risk/Initial Care Needs" revealed he arrived on Esplanade I Unit on 05/29/14 with no documented evidence of the time of arrival. Review of his "RN Assessment" revealed SF15RN completed her admit assessment on 05/29/14 at 1:30 a.m. Further review of Patient #F5's medical record revealed he was PEC'd (Physician's Emergency Certificate) on 05/28/14 at 2:00 p.m. after being found by police standing in the middle of the road telling passing drivers that he wanted to kill himself. Further review revealed he was PEC'd as being suicidal, dangerous to himself, and gravely disabled.

Review of Patient #F5's "Initial Care Orders" signed by SF16Medical Director on 05/28/14 at 6:15 p.m. revealed he was ordered to be on VC with no documented evidence of the type of precautions that were to be followed. His preliminary psychiatric diagnosis was Mood Disorder with a history of Asthma. Review of Patient #F5's "Doctor's Order Sheet" revealed an order written on 05/29/14 at 1:20 a.m. by SF15RN to change his precautions from VS (should be VC) to Routine Observation with Suicide Precautions. There was no documented evidence that the order was received from verbally or by telephone with read-back verification from a physician as required by hospital policy.

Review of Patient #F5's "Suicide Risk Assessment" included in his "RN Assessment of Risk/Initial Care Needs" and completed by SF15RN revealed Patient #F5's suicide risk was scored as a "4" by SF15RN (the factors checked totaled 5 rather than 4) with a score of 1 next to gender, Depression,use of alcohol within 72 hours, diagnosed or perceived chronic medical condition, and support system lacking. A note above the assessment on the form stated "if starred factors or three or more factors circled, then consider visual contact or 1:1." There was no documented evidence that SF15RN had reviewed her assessment with a physician as evidenced by the section for the time reviewed and the name of the physician being blank.

Review of Patient #F5's "Patient Observation & (and) Locator Form-Side 1" revealed he was placed on Routine Observation with Suicide Precautions on 05/28/14 at 10:45 p.m. when he was admitted . Review of his observation record for 05/29/14 and 05/30/14 revealed he was on Suicide Precautions with no documented evidence of the level of observation that was ordered and for which he was being observed. Patient #F5 was not being observed by VC from his time of admission through 05/30/14 at 10:05 a.m. as ordered by SF16Medical Director.

In a telephone interview on 05/30/14 at 8:30 a.m., SF15RN confirmed that she did not receive a physician's order to change Patient #F5's observation status from VC to Routine Observation.

Patient #FR9

Review of Patient #FR9's medical record revealed he was admitted on [DATE] at 8:00 a.m. with a diagnosis of Mood Disorder and arrived on the unit at 3:00 p.m. Further review revealed Patient #FR9 was PEC'd on 05/27/14 at 11:31 p.m. due to being suicidal, homicidal, and a danger to self and others. He was CEC'd (Coroner's Emergency Certificate) on 05/29/14 at 10:57 a.m. due to being a danger to himself. Review of his physician admit orders revealed SF16Medical Director ordered Patient #FR9 to be on VC with no special precautions. Review of his "Doctor's Order Sheet" revealed an order received by telephone from SF16Medical Director on 05/28/14 at 1:20 p.m. to change him to CSS with Suicide Precautions.

Review of Patient #FR9's "Patient Observation & Locator Form-Side 1" during the interview with SF10MHT on 05/29/14 at 10:20 a.m. revealed Patient #FR9's 10:15 a.m. observation had not been made as evidenced by the space for the 10:15 a.m. location, behavior, and staff initials being blank. Review of the same record on 05/30/14 revealed that the 10:15 a.m. space had been completed by SF10MHT showing that he was in the dayroom watching television.

In an interview during the observation of SF10MHT in the male bathroom doorway on 05/29/14 at 10:20 a.m., SF10MHT confirmed that she had not made the 10:15 a.m. observation of Patient #FR9.

Patient #FR10

Review of Patient #FR10's medical record revealed he was admitted on [DATE] at 12:00 p.m. with a diagnosis of Mood Disorder and arrived on the unit at 6:20 p.m. He was PEC'd on 05/27/14 at 6:15 p.m. due to being suicidal and dangerous to self. He was CEC'd on 05/28/14 at 12:00 p.m. as being suicidal and dangerous to self.

Review of Patient #FR10's admission orders signed by SF16Medical Director revealed an order for VC with no documented evidence of special precautions. Review of his "Doctor's Order Sheet" revealed a telephone order was received from SF17NP (Nurse Practitioner) to change from VC to CSS with Suicide Precautions. Further review revealed an order was written by SF15RN on 05/28/14 at 9:00 p.m. to change Patient #FR10's level of observation from CSS to Routine Observation with Suicide Precautions. There was no documented evidence that the order was received from verbally or by telephone with read-back verification from a physician as required by hospital policy.

Review of Patient #FR10's "Patient Observation & Locator Form-Side 1" for 05/29/14 and 05/30/14 revealed he was on Suicide Precautions with no documented evidence of the level of observation that was ordered. Review of the form for 05/28/14 revealed no documented evidence of the level of observation or the type of precaution that was ordered.

Review of Patient #FR10's "Patient Observation & Locator Form-Side 1" during the interview with SF10MHT on 05/29/14 at 10:20 a.m. revealed Patient #FR10's 10:15 a.m. observation had not been made as evidenced by the space for the 10:15 a.m. location, behavior, and staff initials being blank. Review of the same record on 05/30/14 revealed that the 10:15 a.m. space had been completed by SF10MHT showing that he was in the dayroom watching television.

In an interview during the observation of SF10MHT in the male bathroom doorway on 05/29/14 at 10:20 a.m., SF10MHT confirmed that she had not made the 10:15 a.m. observation of Patient #FR10.

In a telephone interview on 05/30/14 at 8:30 a.m., SF15RN confirmed that she did not receive a physician's order to change Patient #FR10's observation status from CSS to Routine Observation.

Patient #FR11

Review of Patient #FR11's medical record revealed she was admitted on [DATE] at 3:55 p.m. with a diagnosis of Mood Disorder and arrived on the unit at 3:45 p.m. Further review revealed she was PEC'd on 05/25/14 at 2:55 p.m. due to being gravely disabled and CEC'd on 05/27/14 at 11:09 a.m. due to being gravely disabled. Review of her physician admit orders revealed Patient #FR11 was ordered to be on VC. There was a telephone order received from SF16Medical Director on 05/26/14 at 5:30 p.m. to change her observation status to CSS.

Review of Patient #FR11's "Patient Observation & Locator Form-Side 1" during the interview with SF10MHT on 05/29/14 at 10:20 a.m. revealed Patient #FR11's 10:20 a.m. observation had not been made as evidenced by the space for the 10:20 a.m. location, behavior, and staff initials being blank. Review of the same record on 05/30/14 revealed that the 10:20 a.m. space had been completed by SF10MHT showing that Patient #FR11 was outside talking with peers.

In an interview during the observation of SF10MHT in the male bathroom doorway on 05/29/14 at 10:20 a.m., SF10MHT confirmed that she had not made the 10:20 a.m. observation of Patient #FR11.

Patient #FR12

Review of Patient #FR12's medical record revealed she was admitted on [DATE] at 8:53 p.m. with a diagnosis of Paranoid Schizophrenia and a history of Crohn's Disease. Further review revealed she was ordered to be on CSS. Review of the physician's orders revealed a telephone order was received from SF16Medical Director on 05/10/14 at 5:10 p.m. for Routine Observation.

Review of Patient #FR12's "Patient Observation & Locator Form-Side 1" during the interview with SF10MHT on 05/29/14 at 10:20 a.m. revealed Patient #FR12's 10:15 a.m. observation had not been made as evidenced by the space for the 10:15 a.m. location, behavior, and staff initials being blank. Review of the same record on 05/30/14 revealed that the 10:15 a.m. space had been completed by SF10MHT showing that Patient #FR12 was outside walking or pacing.

In an interview during the observation of SF10MHT in the male bathroom doorway on 05/29/14 at 10:20 a.m., SF10MHT confirmed that she had not made the 10:15 a.m. observation of Patient #FR12.

In an interview on 05/29/14 at 2:35 p.m., SF19DON indicated that she had done individual training with MHTs on the observation policy and precaution policy. She further indicated that SF10MHT had told her that she was nervous when she spoke with the surveyor on 05/29/14 and really knew how the observation was to be done. When the surveyor informed SF19DON that SF10MHT had approached the surveyor during the tour and asked how she was to observe her other 4 patients and maintain observation of Patient #F5 during his shower, SF19DON had no comment to offer.

Esplanade II Unit
Patient #F3
Record review revealed Patient #F3 was admitted to the facility on [DATE] at 1443 with the diagnoses of Paranoid Schizophrenia. Review of his physician order dated 5/28/14 at 1200 revealed an order for V.C. (Visual Contact). Review of the RN Assessment of Risk/Initial Care Needs dated 5/28/14 and timed as completed at 1536 revealed he was scored a 2 on the Suicide Risk Assessment. One point was because he was a male and the second point was scored because he had impaired judgment, increased confusion, and unable to see a solution. Visual Contact Observation was checked off as the precaution.
Patient #F15
Record review revealed Patient#F15 was admitted to the facility on [DATE] on 1500 with diagnosis of Bipolar Disorder. Review of the Physician Orders dated 5/28/14 at 1200 revealed an order for a level of observations of V.C. Review of Patient #F15's RN Assessment Risk/Initial Care Needs form dated 5/28/14 and timed as completed at 1702 revealed the patient had a score of 2 with 1 starred item on the suicide risk assessment. The instructions for the Suicide Risk Assessment form stated if starred or three or more factors circled, then consider visual contact or 1:1. The items circled were that he was a male, which was 1 point, and he had impaired judgment, increase confusion, and unable to see solution, which was 1 point. The starred item was he had two (2) previous suicide attempts, 1 attempt was 4 months ago when he cut his own throat. Also listed was he had a past history of assaultive/homicidal ideation, he also had paranoia and command hallucinations. His presenting problem was listed as he was at his parent ' s house yelling and screaming at them because they were the devil. His parents called the police and then the patient started yelling at the police.
An interview was conducted with SF4MHT at 5/29/14 at 10:30 a.m. She reported she was in charge of 2 patients (Patient #F3 and Patient # F15) who were on visual contact observation. When questioned what visual contact means, she reported it meant she must have visual contact with the patients at all times. When asked her to point out her patients, she reported one patient (F15) was outside with another MHT and she was able to located Patient F15 outside and point him out to the surveyor. When she went to locate her other patient (F3), she reported she thought he was outside with the other MHT, but she was unable to locate him at that time. SF4MHT located Patient #F3 a few minutes later sitting in a chair in the dayroom unattended by staff. SF4MHT reported the treatment team must have taken the patient into meet with them and placed him in the day room in a chair after assessing him. SF4MHT then proceeded to ask the surveyor how she was supposed to observe one patient that is inside the building and one patient that is outside building at the same time.
An interview was conducted with SF1DirClinical Services on 5/30/14 at 2:50 p.m. She reported she spoke to SF4MHT and she confirmed she had not handed over her observation level forms to another MHT to do visual contact observations on Patient #F3 and #F15. SF1DirClinical Service reported the appropriate procedure for when the MHTs switched which patients they were observing was for the MHTs to also switch observation forms.
Live Oak Unit (Adolescent Unit).
Patient #F10
Review of the medical record for Patient #F10 revealed he was a [AGE] year old male admitted to the hospital on 2/11/14 for diagnosis which included Depression, ADHD ( Attention Deficit Hyperactivity Disorder) and obesity.
Review of the Document titled "Patient Observation and Locator Form", dated 5/29/14, revealed Patient #F10 was ordered to be on Visual Contact precautions for EP (elopement precautions).

Review of the document entitled Unit Census, Room Assignment and Legal Status ,dated 5/29/14 for Live Oak Unit revealed the following: Level of Observation and Precaution: Patient #F10: EP/VC (Elopement Precautions/Visual Contact).

In an interview on 5/29/14 at 9:55 a.m., with SF13ChargeRN (Charge Nurse-Live Oak Unit), she said the following patients were on Visual Contact level of observation: #FR7-Visual Contact -unpredictable behavior, #FR8- Visual Contact -unpredictable behavior, #F10- Visual Contact- elopement precautions, #F12-Visual Contact- unpredictable behavior.

On 5/29/14 at 10:00 a.m. an observation was made of S14MHT monitoring 3 Visual Contact patients ( Patient #FR8- unpredictable behavior, Patient #F10-elopement precautions, and Patient #F12- unpredictable behavior) in the commons area. Patient #F10 was observed going into his room unattended twice during this observation period. Patient #F10 was not within direct line of sight of S14MHT on the two occasions when he was allowed to be in his room unattended by staff. An interview was conducted with S14MHT at the time of the observation and she confirmed she had not maintained direct visual contact with Patient #F10 on the two occasions when he went to his room unattended.

In an interview on 5/29/14 at 2:08 p.m. with SF2RNHouseSupv she confirmed one person should not be responsible for 3 visual contact patients. She said, " You can ' t keep your eyes on all 3 patients at all times". She said no more than 2 visual contact patients should have been assigned to one staff member. SF2RNHouseSupv explained if more than patients were assigned to one staff member that staff member should have called for additional help.