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 Nov. 17, 2014
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on interviews and records review, the hospital failed to ensure that a patient's allegation of sexual abuse was considered a grievance. This failed practice was evident by no documentation on the Grievance Log for 1of 1 patient's (Patient #3) allegation of sexual abuse out of 5 sampled patients (#1, #2, #3, #4, #5) reviewed out of a total of 12 incidents on the hospital's abuse log for sexual abuse/sexual familiarity of peers.


Findings:


A review of the hospital's "Complaint/Grievance Log," provided by S3RM/QA as the most current, revealed no reported grievances from August 2014 to present.


A review of the hospital's "Abuse/Neglect Log," provided by S3RM/QA as the most current, revealed 12 reported incidents of sexual abuse/sexual peer to peer familiarity from August 2014 to present. A further review of the "Abuse/Neglect Log" revealed no evidence that any of the reported sexual abuse/sexual familiarity incidents had been considered a grievance.


In an interview on 11/12/14, at 3:30 p.m., with S3RM/QA, he indicated that he was responsible for the hospital's Risk Management Program and that he was the Patient Safety Officer.


S3RM/QA was asked about the "Complaint/Grievance Log" and the "Abuse/Neglect Log." S3RM/QA indicated that the hospital had no reported grievances from August 2014 to present.


S3RM/QA indicated that most of the incidents reported on the "Abuse/Neglect Log" from August 2014 to present were incidents reported by staff and/or other patients of patient inappropriate sexual behavior or sexual peer to peer familiarity.


S3RM/QA indicated that Patient #3's reported sexual abuse allegation, as documented on the "Abuse/Neglect Log" and dated 10/11/14, was reported by her family on 10/14/14. The family alleged that Patient #3 was sexually abused by a staff member on 10/11/14.


S3RM/QA further indicated that he did not consider that a grievance and handled it according to the hospital's Abuse/Neglect Policy. S3RM/QA further indicated that abuse allegations were not considered grievances.


S3RM/QA was asked about the hospital's policy/definition of complaints and grievances. S3RM/QA indicated that a complaint "can be in any format" and a grievance was "more formal and written and required further investigation and a resolution."


S3RM/QA was asked if Patient #3's allegation required further investigation and a resolution. S3RM/QA indicated that the incident probably should have been considered a grievance and the hospital's Grievance Policy should have been followed.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on records review and staff interviews, the hospital failed to ensure the patient was free from all forms of abuse, neglect, or harassment as evidenced by failure of staff to conduct a timely, thorough, objective investigation of allegations of sexual abuse and inappropriate sexual behavior was conducted for 5 of 5 (#1- #5) sampled patients reviewed with allegations of sexual abuse or inappropriate sexual behavior.


Findings:


Review of the hospital policy titled, Abuse/Neglect of Patients/Reporting Allegations, Policy Number RI-0800, reviewed date of 02/12/14, revealed in part the following:


Procedure:

A. Time line for notifications: Adults
Allegations will be reported to the Unit Nurse Immediately


Responsibilities of the Unit Nurse:

1. Ensure patient safety

2. Notify RN Supervisor

3. Documents assessment of patient and instructs all witness to document: Incident Report (completed by initial reporter); Serious Occurrence Form and Progress Noted (by unit nurse).

Timeframe: Immediate (all should be completed in 1 hour)


Responsibilities of RN Supervisor:

1. Ensure that any patient(s) involved has been removed from any hazard or danger and has received appropriate care and/or medical treatment.

2. Contact the CEO (Chief Executive Officer) or On-Call Administrator to determine whether to suspend/re-assign staff member involved, based on witnesses or obvious signs of abuse, neglect or exploitation. Arranges coverage per decision. Telephone notification of reassignment is made to the DON (Director of Nursing), CEO, RN Supervisors whose units may be affected and Patient Rights Officer. To preserve the integrity of the investigation, no information concerning the allegation will be communicated to staff.

3. After reassigning/suspending the staff member, ensure proper coverage of the unit according to established staffing ratios.

4. Ensure that any relevant evidence is safeguarded and preserved.

5. Gather completed statements from all staff on duty. Patient statement will be attained by Patient Rights Officer.

6. The RN Supervisor will contact the Patient Rights Officer by telephone. The original MH-03 form and witness statements shall be confidentially forwarded to the Patient Rights Officer following the notification by telephone.

7. Complete the Alleged Abuse and Neglect form to provide an electronic tracking document to ensure that all Authorities are notified within the specified time frames. This document is utilized as electronic notification to the CEO, DON, program coordinator, and attending physician.

Timeframe: Steps 1-7 should be completed within 1 hour of initial report.

8. Notify DHH Health Standards section of all allegations, no matter how irrational the allegation may be, within 24 hours....


Responsibilities of the Patient Rights Officer

The Rights Officer will conduct objective investigations of allegations of abuse and neglect in a timely and thorough manner. Specific responsibilities and timeline include:

1. The Patient Rights Officer will view the videotape (if surveillance footage is available) within 24 hours of the initial report.

2. Collect witness statements, interview patient(s).

3. Completes full report for CEO's review within 72 hours of the initial allegation. If extenuating circumstances delay the completion of the report past 72 hours, the Patient Rights Officer must report those circumstances to the CEO and the CEO may authorize an extended timeframe.

Immediately upon completion of the investigation, the Patient Rights Officer will report the findings of the investigation to the patient (if the patient made the allegation).


Responsibilities of the CEO

The CEO or designee will notify local law enforcement if the incident may involve a criminal act. Specific responsibilities and timelines include:

1. Reviews the investigation. Makes decision regarding employment status of employee.

2. Ensure report is comprehensive and shared with applicable agencies.

3. Develops corrective action plan if needed....


Additional notification required for youth 17 years or younger involved in an incident:

RN Supervisor will:

1. Complete the directions for Adults, and

2. Verbally notify the Department of Children and Family Services (DCFS) by calling the state intake line immediately....


For allegations of sexual abuse/contact:....

2. Consensual - ....Note: Patient/patient consensual sexual activity should not be categorized as "Abuse." The question being investigated is whether the facility failed to take action to prevent the occurrence. As a result, these incidents should be considered alleged "Neglect."


Patient #3 Investigation:

A review of the medical record for Patient #3 revealed that the patient was a [AGE] year old female, admitted on [DATE], with diagnoses of Bipolar Disorder, Schizophrenia, Substance Abuse, Bizarre Behaviors, and Verbal Aggression with loud outbursts, and Manic Episodes. The patient was PEC'ed (Physician Emergency Certificate) prior to her admit and was CEC'ed (Coroner's Emergency Certificate) on 10/08/14.


A review of the RN Progress Notes on 10/11/14, documented that Patient #3 had episodes of crying and screaming on the evening shift. A review of the MHT Progress Notes on 10/11/14, at 10:50 p.m., revealed that Patient #3 became verbally abusive to staff when she was unable to exit her room after "lights out." The MHT Progress Notes further revealed that Patient #3 started screaming that she was being raped.


A review of RN Progress Notes on 10/14/14, revealed that Patient #3 called 911 stating she was raped by staff. The police arrived at the hospital and the patient was interviewed by the police.


Review of the Louisiana Department of Health and Hospitals Hospital Abuse/Neglect Initial Report (HSS-HO-41 form) revealed the following:

Date of Incident: 10/11/14

Time of Incident: 22:50 (10:50 p.m.)

Shift of Incident: Evening

Date of Discovery: 10/15/14

Specific Location of Incident: Adult Unit- Patient Room

Patients Involved: Patient #3

Video Surveillance at Incident site: Yes

Video revealed: 10/11/14, at 21:00-23:00 (9:00 p.m. -11:00 p.m.). Patient in constant 1:1 observation. When she enters her room, a staff member is present and is seated outside in the hallway. Staff " hands off " to other staff member during this time. Patient remains under 1:1 observation. At several points patient is seen in the doorway. Staff remain in view, either sitting or standing in the hall performing 1:1 observations.

How was incident discovered: Patient reported

Did the initial Reporter claim to witness the Incident : Yes No (both checked)

Name and Title of first employee aware of Allegation: S27RNS

Describe alleged incident: Patient alleges that on 10/11/14, a staff member named "Tyrese", but whose real name is Robert, pushed her on her bed and fondled her genitals. (There were no staff members identified by that name). Client has a bruise on her left abdomen attributed to an event on the previous day on 10/10/14, in which she climbed on top of the railing (in the bathroom) between the stalls and broke the railing. Client is on 1:1 precautions, and she was on 1:1 precautions on 10/11/14.

Initial Actions Taken:

Client is on 1:1 precautions

Investigation ongoing
No staff members have been identified, fitting the patient's allegation; Video Review does not support the allegations. Staff members on duty at the time of the allegation will be interviewed as part of the investigation.

No Additional Information was noted.


Review of the, "Investigation Report" provided, as the hospital's investigation of the incident alleged by Patient #3 on 10/11/14 revealed the following:

Patient Names: Patient #3

Date of Event: 10/11/14

Date of Discovery: 10/14/14

Type of Event: Allegation of Abuse

Summary of Event: Patient alleged that on 10/11/14 at approximately or prior to 22:50 (10:50 p.m.) a person by the name of "Tyrese", but whose real name is Robert, pushed her on her bed and fondled her genitals.

Results of Investigation: The allegations are not substantiated

1. Key Individuals - Patient #3 and S26MHT. Witnesses: S17MHT

2. Video Review: Patient is in 1:1 observation by staff member, S26MHT. The patient is observed entering her room. S26MHT is present and seated outside in the hallway. S26MHT hands off to S17MHT briefly during the shift. At times both S26MHT and S17MHT are present together at the patient's doorway. Patient remains under 1:1 observation. The patient appears briefly at the open bedroom doorway. S26MHT and S17MHT remain in view, either sitting or standing in the hall performing 1:1 observations. At change of shift, S26MHT hands off the 1:1 assignment to the 11-7 shift staff member S18MHT. There is no visual observation that any staff member entered into the patient's room, they remained in view of the camera.

3. Chronology of Events:
10/11/14 at 21:00-23:00 (9:00 p.m. - 11:00 p.m.)- the date and approximate time the alleged event occurred.

10/14/14 at 20:00 -21:00 (8:00 p.m. - 9:00 p.m.). Patient calls family using the unit patient phone, a call to 911 is made. Sheriff department responds, officer comes to hospital and interviews the patient, at which time she makes her allegations, as reported by S27RNS, that on 10/11/14 some time prior to 22:50 (10:50 p.m.) a person by the name of "Tyrese", but whose real name is Robert, pushed her on her bed and fondled her genitals.

10/16/14 at 11:00 a.m. Patient #3 interviewed by a Detective from the Sheriff Department. S3RM/QA present. Patient #3 states "MHT tackled her" and touched her titties and vagina and pushed her on the bed and bruised her left side of abdomen. Described person as a black male.

10/16/14 S3RM/QA interviewed S17MHT who worked the evening shift on 10/11/14, the date of the alleged event. S17MHT states that the patient was constantly yelling "rape" over and over. S17MHT stated she tried to reassure patient that she was not being raped. S17MHT affirmed that S26MHT remained outside the room performing the 1:1 observations. S17MHT denies the patient's allegations.

10/17/14 at 9:00 a.m. interviewed S26MHT, a black male, the MHT that was assigned 1:1 observations of the patient on the evening shift of 10/11/14. S26MHT states that the patient was acting bizarre all evening. S26MHT said he observed the patient urinating on the floor, and that she was yelling most of the evening. S26MHT stated that the patient said she was raped by a man named Tyree, when she was a little girl. S26MHT denies the patient's allegation.

10/17/14 at 9:30 a.m. S18MHT interviewed, a white male, was the MHT that took over 1:1 observation of the patient from S26MHT for the night shift on 10/11/14 from 11:00 p.m. to 7:00 a.m. S18MHT states that he did not see S26MHT enter the patient's room. S18MHT also commented that the patient continued to be vocal during the night. S18MHT stated that the patient said the "the ambulance driver raped me". Later that night, S18MHT stated that the patient said "I lied, I made it up" and later made the remark that a man called Tyree did it (raped her).

4. Additional Information: The previous day on 10/10/14 she (Patient #3) had an incident in the bathroom, in which she pulled the bathroom railing and the shower curtains off the wall. Per the patient's medical record, it (medical record) reflects that she has a Bipolar/Schizophrenic Diagnosis, and was exhibiting delusional behavior.

5. Changes/Actions: The patient continues on 1:1 observation, she is assigned to female MHT's for 1:1 observations, as a further precaution.

The findings of the investigation: The allegations made by the patient are not substantiated.


A further review of the hospital's investigative report revealed no written statements by the MHT's on duty on 10/11/14, for the 3-11 p.m. shift, nor any documentation that Patient #3 was interviewed.


In an interview on 11/13/14, at 3:35 p.m., with S17MHT, she indicated that she was one of the MHTs working on the 3-11 pm shift on 10/11/14.


S17MHT indicated that she remembered Patient #3. S17MHT indicated that S26MHT was assigned to Patient #3, who had been on 1:1 observation since 10/10/14. S17MHT indicated that she relieved S26MHT for 30 minutes that evening from 10:00 p.m. to 10:30 p.m.


S17MHT indicated that around 10:50 p.m. on 10/11/14 she heard Patient #3 screaming "rape". S17MHT indicated that she was at the nurse's station and looked toward Patient #3's room and saw S26MHT sitting in a chair in the patient's doorway. She indicated she went into the patient's room to try to calm the patient and find out what was going on. S17MHT indicated that Patient #3 had taken her pants off and she (S17MHT) told the patient to put her pants back on.


S17MHT indicated that she did not mention this incident to the charge nurse and that it was 3 days later when she was told the patient alleged that a staff member had raped her on 10/11/14.


S17MHT indicated she was interviewed by S3RM/QA and asked by S3RM/QA to write a detailed account of the events on 10/11/14. S17MHT further indicated that S3RM/QA never came back to the unit to obtain her written statement. She indicated that she still had her written statement and that she turned it in today (11/13/14) at 3:00 p.m. S17MHT reviewed the hospital's investigative report from S3RM/QA and indicated that she never said to S3RM/QA that Patient #3 was screaming "rape" over and over that evening (10/11/14), only that one time at 10:50 p.m. and that was how she documented it in her written statement.


In an interview on 11/13/14, at 4:10 p.m., with S18MHT he indicated that he was one of the MHTs working on the 11-7 am (night) shift on 10/11/14.


S18MHT indicated that he remembered Patient #3. S18MHT further indicated that he relieved S26MHT, who had been assigned to Patient #3 who was on 1:1 observation. S18MHT indicated that S26MHT reported that Patient #3 had episodes of screaming and yelling during the 3-11 pm shift.


S18MHT indicated that he had heard later on that week that Patient #3 alleged that she had been raped by a staff member on 10/11/14. S18MHT indicated that he was asked by S3RM/QA to write a detailed account of the events on 10/11/14. S17MHT further indicated that S3RM/QA never came back to the unit to obtain his written statement, so he eventually gave the written statement to S27RNS (7pm -7am RN Supervisor).


S18MHT reviewed the hospital's investigative report from S3RM/QA and he (S18MHT) indicated that he did not say to S3RM/QA that Patient #3 said she was raped by an ambulance driver. He indicated that the patient told him that she lied about being raped by the MHT whom he relieved that night. S18MHT indicated that the investigative report contained inaccurate information regarding his interview and that the correct information was detailed in his written statement that he gave to S27RNS.


In an interview on 11/14/14, at 10:45 a.m., with S26MHT he indicated that he was the MHT assigned to Patient #3 on the 3-11 pm shift on 10/11/14 and that he was relieved by S18MHT at 11:00 p.m.


S26MHT indicated that Patient #3 was on 1:1 observation. S18MHT was asked about Patient #3 screaming " rape " on 10/11/14 at 10:50 p.m. He indicated that Patient #3 wanted to leave her room after "lights out" and when she could not, she screamed "rape" and S17MHT came down to the room and redirected the patient to put her clothes back on.


S26MHT indicated that he reported the incident to the charge RN that night, S21RN. S26MHT indicated that later on that week he was informed that Patient #3 alleged she was raped on 10/11/14 on the 3-11 pm shift. S26MHT indicated that he was interviewed by S3RM/QA, but was never asked by anyone to provide a written statement about the events on 10/11/14 regarding Patient #3.


In a phone interview on 11/13/14, at 12:15 p.m., with S21RN she indicated that she remembered Patient #3 and was somewhat familiar with the alleged rape allegation made by Patient #3 on 10/11/14. S21RN indicated that she was the charge RN on the 7 pm - 7 am shift on 10/11/14. S21RN further indicated that S26MHT reported the incident to her that night, but she did not report the incident to S30RNS, the RN Supervisor that night. S21RN indicated that Patient #3 was frequently loud at times and she told S26MHT to document the incident on the MHT Progress Note.


In an interview on 11/14/14, at 4:00 p.m., with S3RM/QA he indicated that he was the Risk Manager and was the Patient Right's Officer for the hospital.


S3RM/QA indicated that he was in charge of investigating Patient #3's allegation of sexual abuse. S3RM/QA indicated that the report, as provided, contained the complete report of Patient #3's allegation of sexual abuse.


S3RM/QA indicated that the patient alleged that she was raped by a member of the staff on 10/11/14. S3RM/QA further indicated that the hospital was made aware of the abuse allegation on 10/14/14, when the police arrived at the hospital after Patient #3 called her family and the patient's family called 911 to report that Patient #3 indicated that she was raped by a staff member.


The investigative report submitted by S3RM/QA was reviewed with S3RM/QA. S3RM/QA was asked for the staff 's written statements and the interview with Patient #3. S3RM/QA indicated that he interviewed S26MHT, S17MHT and S18MHT and included their verbal interviews in his investigative report. S3RM/QA indicated that he did not obtain the staff 's written statements for his investigative report. S3RM/QA further indicated that he did not interview Patient #3 because he did not "feel the need to interview her again after the police spoke to her."


S3RM/QA was unable to produce any written statements from staff and indicated that he only included his notes from the staff's verbal interviews in his investigative reports. S3RM/QA was made aware of the staff 's interviews above and that the staff indicated that some of the information that he (S3RM/QA) obtained from them in their verbal interviews was inaccurate. S3RM/QA had no response. The hospital's Abuse/Neglect Policy was reviewed with S3RM/QA and he indicated that the hospital's Abuse/Neglect Policy had not been followed.


In an interview on 11/17/14, at 2:10 p.m., with S1ADM, he indicated that he was responsible for reviewing the abuse allegation investigative reports before they were submitted to DHH. A review of Patient #3's abuse allegation investigation report was reviewed with S1ADM. S1ADM indicated that the hospital's Abuse/Neglect Policy was not followed regarding obtaining statements from the staff or interviewing patients. S1ADM indicated that if a video review was definitive, the hospital did not feel the need to ask anyone else about alleged incidents.


Patient #1 and Patient #2 Investigation:

Review of the medical record for Patient #1 revealed that the patient was a [AGE] year old female, admitted to the female adolescent unit of the hospital on [DATE] with diagnoses of Impulse Control Disorder, Mild Mental Retardation, Major Depressive Disorder, and Attention Deficit Hyperactivity Disorder. Review of the RN Progress Notes dated 10/21/14, revealed at 3:00 p.m. the patient accused a peer of inappropriate sexual behavior.


Review of the medical record for Patient #2 revealed that the patient was a [AGE] year old female, admitted to the female adolescent unit of the hospital on [DATE], with diagnoses of Major Depressive Disorder with psychotic factors, Rule/Out Bipolar, and Moderate Mental Retardation. Review of the RN Progress Notes dated 10/21/14, revealed that at 4:00 p.m., the patient was accused by a peer of inappropriate behavior and the client denied such allegations.


Review of the Louisiana Department of Health and Hospitals Hospital Abuse/Neglect Initial Report (HSS-HO-41 form) revealed the following:

Date of Incident: 10/20/14

Time of Incident: Unknown

Shift of Incident: Evening

Date of Discovery: 10/21/14

Specific Location of Incident: Female Adolescent Unit- Patient Room

Patients Involved: Patient #1, Patient #2

Video Surveillance at Incident site: No

How was incident discovered: Patient reported
Describe alleged incident: Per S19RN on 10/21/14, 1500, Patient #1 alleged that Patient #2 and herself "kissed, touched each other and humped" at an unspecified time last evening around bath time. Patient #2 was questioned and denies any inappropriate behavior between the two.

Additional information: S3RM/QA (Risk Manager/Quality Assurance) 1550 10/21/14 interviewed S20MHT (Mental Health Technician), she worked on the unit on the evening shift on 10/20/14. S20MHT stated that clients were not allowed to be alone together, at any time, during the shift. Investigation ongoing.


Review of the, "Investigation Report" provided as the hospital's investigation of the incident alleged by Patient #1 on 10/20/14 revealed the following:

Patient Names: Patient #1 and Patient #2

Date of Event: 10/20/14 time unknown

Date of Discovery: 10/21/14

Type of Event: Sexual Familiarity between peers

Summary of Event: Patient #1 alleged that Patient #2 and herself "kissed, touched each other and humped" at an unspecified time last evening around bath time.

Results of Investigation: The allegations are not substantiated

1. Key Individuals - Patient: Patient #1 and Patient #2. Witnesses: None.

2. Video Review: 10/20/14 (Patient sleep rooms are not under video surveillance). 1900-0700: Video of Day room area, and hallways outside of patient rooms were reviewed. Staff are seen in hallways and Dayroom areas with patients. Staff are performing q15 (every 15 minute) observations. No activity supporting allegations is seen.

3. Chronology of Events:

10/21/14: Patient #1 alleged that Patient #2 and herself "kissed, touched each other and humped" at an unspecified time last evening around bath time. Patient #2 was questioned and denies any inappropriate behavior between the two.

10/21/14 1550 - Risk Management: Interviewed S20MHT, she worked on the unit on the evening shift on 10/20/14. S20MHT stated that clients were not allowed to be alone together, at any time, during the shift.

4. Additional Information: none

5. Changes/Actions: Patient maintained at a safe distance 1:1 observations by staff. Both patients were assessed with full body audits, no signs or evidence of injuries.
Report completed by S3RM/QA 10/28/14.

There was no documented evidence in either report of the approximate time of the alleged occurrence or the location of the alleged event.


In an interview on 11/13/14, at 3:00 p.m., S15RNS (RN Supervisor) confirmed that she was the RN Supervisor on 10/21/14 and she was aware of the allegation of inappropriate sexual behavior between Patient #1 and Patient #2.


S15RNS stated other clients on the unit told her about the incident of sexual behavior between Patient #1 and Patient #2.


S15RNS stated she talked to Patient #1 and Patient #2 separately and both denied the incident of sexually inappropriate behavior. S15RNS stated she set limits with both clients and confirmed Patient #1 and Patient #2 shared a room.


S15RNS stated Patient #1 and Patient #2 told her the incident was a rumor coming from other peers. S15RNS stated she found out about the allegation after the clients returned from school on 10/21/14 (school ends at 2:45 p.m.) when she made rounds on the adolescent unit. S15RNS stated S19RN told her she had heard the rumor also.


S15RNS was asked if she had documented the interviews she had conducted with Patient #1 and #2 and she stated no. When asked what actions were taken after she had received the allegation, S15RNS stated she talked to S19RN and asked her to follow up with the social worker or staff who were there the day before. S15RNS stated she, "Felt like the clients needed support and needed to find out what caused the peers to say that."


S15RNS confirmed she did not notify the Patient Rights Officer and stated she asked S19RN to follow up with the previous shift to see what happened. S15RNS stated, "The girls will make up stories on the unit." S15RNS confirmed she was not interviewed by the Patient Rights Officer and she did not document a statement of her knowledge of the allegation. S15RNS stated if she had knowledge that something had happened, she would have followed through with S3RM/QA (Patient Rights Officer).


In an interview on 11/13/14, at 3:30 p.m., S20MHT confirmed she was assigned to Patient #1 and Patient #2 on 10/20/14 on the 3 p.m. to 11 p.m. shift.


S20MHT stated that when she reported to work on 10/21/14 for the 3:00 p.m. shift, Patient #1 ran up to her and apologized, stating she had lied. S20MHT stated she did not know what Patient #1 was referring to. S20MHT stated S19RN asked her about the allegation of inappropriate sexual behavior between Patient #1 and Patient #2 on 10/20/14. S20MHT stated she was assigned to Patient #1, Patient #2, and Patient #R6 and only these 3 patients on 10/20/14.


S20MHT stated Patient #R6 was on VC (Visual Contact) and Patient #1 and #2 were on Q 15 minute observation. She stated Patient #1 and Patient #2 were never alone in the bath room or in the bedroom. S20MHT stated patients are not allowed in the bathroom at the same time. S20MHT stated the patient bath time starts after the clients return from dinner (around 5:45 p.m.). S20MHT stated all 3 had to go to bed at the same time (9:00 p.m.) because of the patient on VC. S20MHT stated she sat at the doorway of the bedroom to maintain VC for Patient #R6 (All three patients in same room). S20MHT stated she was able to see all 3 patients in the bedroom from where she was sitting. S20MHT stated she was not asked to write a statement related to this allegation.


In an interview on 11/13/14, at 4:15 p.m., S19RN confirmed she was the RN assigned to the female adolescent unit on 10/21/14 7:00 a.m. to 7:00 p.m. shift.


S19RN stated Patient #1 reported, "in passing" of the incident the day before of inappropriate sexual behavior with Patient #2. S19RN stated that she notified the physician of the patient's allegation and the physician ordered VC for 48 hours for Patient #2.


S19RN stated that she notified S15RNS of the allegation and she instructed her to complete the incident report and notify the physician. When asked if she notified S3RM/QA, S19RN stated she doesn't normally notify S3RM/QA, just the RN Supervisor.


S19RN stated that she spoke with S20MHT and S22RN about the patient's allegation, but confirmed she did not document the conversations. S19RN stated that she talked to Patient #1 and, "something happened." S19RN stated she asked probing questions to both Patient #1 and Patient #2 and both admitted to touching breasts. S19RN stated the patients reported it happened in the bed room around bath time. S19RN denied hearing reports of inappropriate behavior from other peers. S19RN confirmed she had not been asked to document a statement related to this allegation and she had not been interviewed by S3RM/QA.


In a telephone interview on 11/14/14, at 10:00 a.m., S22RN confirmed that she was assigned to the female adolescent unit on 10/20/14 7:00 a.m. to 7:00 p.m. shift. S22RN confirmed no one from the hospital had asked her about the allegation of inappropriate sexual behavior between Patient #1 and Patient #2 on 10/20/14. S22RN stated she had, "heard about it through the grapevine", and stated she wasn't concerned because she knew the MHTs did not leave the patients alone.


In a telephone interview on 11/14/14, at 11:25 a.m., S23MHT confirmed that she had talked to Patient #1 and Patient #2 on 10/21/14 about the allegation of inappropriate sexual behavior. S23MHT stated both patients told her that they were not telling the truth. S23MHT stated both patients confessed to lying about the allegation and she stated she took both the clients to S19RN and had them talk to her. S23MHT confirmed she had not been asked to write a statement about her conversation with Patient #1 and Patient #2 and also confirmed no one from the hospital had talked to her about the allegation.


In an interview on 11/14/14, at 3:30 p.m., S24MHT confirmed that she was assigned to the female adolescent unit on 10/20/14 for the 3 p.m. to 11 p.m. shift.


S24MHT stated Patient #2 reported to her on 10/22/14, that Patient #2 and Patient #1 had "humped" in the same bed. S24MHT stated she told Patient #2 that was not possible since Patient #R6 was on VC. S24MHT stated she also talked to Patient #1 and she said she and Patient #2 made it up. S24MHT stated no one from the hospital asked her about the allegation and she stated she did not report what the clients told her.


In an interview on 11/14/14, at 3:40 p.m., S3RM/QA confirmed he was also the Patient Rights Officer. S3RM/QA confirmed that his investigation consisted of interviewing S20MHT and reviewing the video. S3RM/QA confirmed patient sleep rooms were not under video surveillance. S3RM/QA confirmed there were no witness/staff statements obtained and he did not interview the clients. After reviewing the hospital's policy for Abuse/Neglect of Patients/Reporting Allegations, S3RM/QA was asked if he agreed that the policy had not been followed related to obtaining witness statements and interviewing patients. S3RM/QA stated, "I understand what you are saying, the bottom line is to do due diligence to verify what happened."


Patient #4 and Patient #5 Investigation:

Review of the medical record for Patient #4 revealed that the patient was a [AGE] year old male, admitted to the hospital's male adolescent unit on 9/18/14 with diagnoses of Mood Disorder, History of Anxiety, Attention Deficit Hyperactivity Disorder, Depression, Learning Disability, and Asthma.


Review of the RN Progress note dated 10/19/14, revealed the following: 0925, Patient #R7 reports/alleged walking past peers bedroom and seeing Patient #4 and Patient #5 engaged in oral sex Patient #4 denied, but stated Patient #5 approached him and began to fondle him. Patient #4 was placed in another room for his safety. The RN Supervisor, Patient #4's physician and mother were notified.


Review of the MHT Progress Note dated 10/19/14, revealed the following: Client #R7 reported to staff that when he walked in peer Patient #4 and Patient #5 room he saw them fondling each other private area and engaging in oral sex. When staff came to room both clients were in their own separate beds and Patient #4 was found in his boxers. Patient #4 was removed from room, immediately separated with room change following. Upon interview Patient #5 admitted to fondling with the private area of Patient #4 but didn't engage in oral sex. RN Supervisor was notified.


Review of the medical record for Patient #5 revealed that the patient was a [AGE] year old male, admitted to the hospital's male adolescent unit with diagnoses of Mood Disorder, Oppositional Defiant Disorder, Attention Deficit Hyperactivity Disorder, Pervasive Developmental Disorder, Moderate Mental Retardation, and Asperger's Syndrome.


Review of the RN Progress note dated 10/19/14, revealed the following: 0925, Patient was accused of approaching Patient #4 and asking to fondle him and have oral sex. Patient denied above and stated that Patient #4 approached him. Patient #R7 reports/alleged walking past peers bedroom and seeing both engaged in oral sex.


Review of the MHT Progress Note dated 10/19/14, revealed the following: Client #R7 reported to staff that when he walked in peer Patient #4 and Patient #5 room he saw them fondling each other private area and engaging in oral sex. When staff came to room both clients were in their own separate beds and Patient #4 was found in his boxers. Patient #4 was removed from room, immediately separated with room change following. Upon interview Patient #5 admitted to fondling with the private area of Patient #4 but didn't engage in oral sex.


Review of the Louisiana Department of Health and Hospitals Hospital Abuse/Neglect Initial Report (HSS-HO-41 form) revealed the following:

Date of Incident: 10/19/14

Time of Incident: 0925

Shift of Incident: Day

Date of Discovery: 10/19/14

Specific Location of Incident: Unit adolescent-male - Patient Room

Patients Involved: Patient #4, Patient #5, Patient #R7

Video Surveillance at Incident site: No

How was incident discovered: Patient reported

Describe alleged incident: Per S27RNS (RN Sup
VIOLATION: QAPI Tag No: A0263
Based on records review and interviews, the hospital failed to meet the requirements of the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) as evidenced by:


1) Failing to ensure that the QAPI program included an ongoing program that shows measurable improvement in indicators that improve health outcomes, analyzed quality indicators and other aspects of performance that assess processes of care, hospital service, and operations, and had the frequency and detail of data collection specified by the hospital's governing body (see findings in tag A0273);


2) Failing to ensure that data collected was used to identify opportunities for improvement and changes that will lead to improvement, set its priorities for its performance improvement activities on high-risk, high-volume, or problem-prone areas, and take actions aimed at performance improvement, measure success with the actions, and track performance to ensure that improvements are sustained (see findings in tag A0283);


3) Failing to ensure that adverse patient events were measured, tracked, analyzed for cause, and preventive actions were implemented with mechanisms in place for feedback and learning throughout the hospital (see findings in tag A0286);


4) Failing to ensure distinct performance improvement projects were conducted with documentation of the measurable progress achieved on each project as evidenced by failure to have the number of distinct performance improvement projects conducted proportional to the scope and complexity of the hospital's services and operations (see findings in tag A0297);


5) Failing to ensure that its QAPI program reflected the complexity of the hospital's organization and services as evidenced by failure of the hospital to include all hospital departments and clinical care services provided by contract or arrangement in its QAPI monitoring (see findings in tag A0308); and


6) Failing to ensure that the governing body, medical staff, and administrative officials assured that the quality assessment and performance improvement (QAPI) program was implemented and maintained. The governing body failed to ensure that all improvement activities were evaluated, failed to determine the number of distinct quality improvement projects to be conducted annually, and failed to conduct and document an annual review of the effectiveness of the QAPI program as required by hospital policy (see findings in tag A0309).
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on records review and interviews, the hospital failed to ensure that the quality assessment and performance improvement (QAPI) program included an ongoing program that shows measurable improvement in indicators that improve health outcomes, analyzed quality indicators and other aspects of performance that assess processes of care, hospital service, and operations, and had the frequency and detail of data collection specified by the hospital's governing body.


Findings:


Review of the hospital policy titled "Quality Improvement Plan/Performance Improvement," reviewed 10/27/14 and presented as the current policy by S3RM/QA revealed that the hospital is dedicated to providing quality care and services through continuous and systematic measurement, assessment, and improvement of its systems and processes. The Performance Improvement Committee assures that intensive assessment is initiated when statistical analysis indicates undesirable variations in performance. The Director of RM/PI (performance improvement) is the committee chairperson, and the committee shall meet at a minimum monthly. The Medical Executive Committee is responsible to ensure resolution and follow-up of identified problems and is to conduct and document an annual review of the effectiveness of the QAPI program. Further review revealed that data is collected for measurement and assessment of processes and outcomes, particularly those high risk, high volume, and problem prone processes, based upon a comprehensive set of performance measures. The findings are analyzed to identify significant variances and/or opportunities to improve patient care outcomes.


Review of the "Risk Management and Performance Improvement Quarterly Report to Governing Body 1st Quarter 2013" revealed the following key indicators for the year:

1) physical restraint rate/1000 patient days;

2) seclusion rate/1000 patient days;

3) aggression rate/1000 patient days;

4) sexual familiarity rate/1000 patient days; 5) total incident rate/1000 patient days.


Review of the "Governing Board Report" for the 4th quarter of 2013 and the 1st and 2nd quarter for 2014 revealed that the 1st quarter report included the Executive Management Team's performance improvement goals for 2014.

The goals included the following:

1) 95% (per cent) compliance for completion of treatment plans and assessments;

2) 95% compliance of door-to-doctor-to-door patient experience (includes monitoring for completion of all documentation from admission to discharge);

3) 20% reduction of physical aggression incidents;

4) overall patient satisfaction scores greater than 80.

There was no documented evidence provided by the hospital that showed that the governing body specified the frequency and detail of data collection. There was no documented evidence of the measurement or comparison to be used in determining a 20% reduction of physical aggression incidents.


Review of the hospital's QAPI goals listed above revealed no evidence that the quality indicators selected were related to improving health outcomes.


Review of the QAPI meeting minutes included the following information related to quality indicators for 2013 and 2014:

11/26/13 - property destruction has increased; 74 incidents in October as compared to 54 in November thus far; most aggression to peer and property destruction attributed to 1 patient. Review of "conclusions/recommendation" revealed "need to look at negative staffing trends. Nurses need to be empowered to redirect patients and staff during incidents to change outcomes." There was no documented evidence of action to be taken to address the identified problem;

12/17/13 - at 50% aggression continues to be the highest-occurring incident hospital wide; the rate of aggression on the Adolescent Unit of 67% continued at about the same pace as in November; discussion was held with no documented evidence of action taken to address the identified problem.

04/22/14 - treatment plans "are looking better-the documentation is there"; "conclusions/recommendations" revealed "quality is an issue and audits will now move toward addressing that." There was no documented evidence that an action plan was implemented to address how the quality of the treatment plans would be addressed.

Hospital-wide 26% of incidents related to physical aggression, down from the previous month (unable to confirm as the monthly report reveals number of incidents of aggression, not % of aggression incidents); highest % of incidents is contraband at 21%. There was a significant decrease in incidents between February (74) and March (53). There was increase in medication errors on the Adult Unit. There was no documented evidence of an action plan implemented to address the identified problems of physical aggression, contraband, and medication errors.

10/31/14 - treatment plan corrective action: new nursing service quality management registered nurse plans to revamp the audit form; "conclusions/recommendations"; numbers and flow charts and specifics of what will be measured on Treatment Plans will be available by the next meeting. There was no documented evidence that an action plan was implemented to address the treatment plans that was a quality indicator established 6 months prior to this meeting. Physical confrontations and harm to peers accounted to 40% of the 96 incidents that occurred in September. Physical aggression: August 2013 = (equals) 13.5% and August 2014 = 25.88%. There was no documented evidence that action plans were implemented to address the identified problem of physical confrontations and harm to peers.



Review of the "Executive Management Team" meeting minutes revealed the following information:

06/10/14 - overall from the beginning of the year, treatment plans have improved; focus has recently been on quality; "conclusions/recommendation" included "improvement is noted, monitoring will continue." There was no documented evidence of an action plan. Majority of incidents were related to physical aggression followed by property destruction.

Physical aggression rate per 1000 patient days: January 9.8; February 10.8; March 6.07; April 13.6; May 11.2. Treatment Plan % of compliance: January 80%; February 85%; March 86%; April 88%. There was no documented evidence of an action plan implemented related to physical aggression and treatment plans.

07/15/14 - Treatment Plan Corrective Action Update: training is in place and samples are ready to roll. There was no documented evidence of a specific action plan to address this quality indicator that had been in place since April 2014. "there needs to be a clearer picture of where the facility is going. Some days it seems like all we do is put out fires." "Conclusions/recommendations" included "it was agreed that formal strategic planning is needed and that a focused meeting needs to be held... to put together the framework for the plan."

08/12/14 - "Treatment Plan Corrective Action Update": S1ADM reported that he and S3RM/QA (Risk manager/Quality Assessment) have met and completion of this project will be S3RM/QA's primary focus at this time; "conclusions/recommendations" included that S3RM/QA, S4ClinDir, and S5DON (Director of Nursing) will meet this week and devise a plan for monitoring which will be turned in to S1ADM by 08/15/14; S1ADM reported that the formal strategic planning meeting "is in the works."

09/05/14 - "Treatment Plan Corrective Action": 24 and 72 hour admission audits and weekly audits are being conducted. There was no documented evidence that the quality of the completed treatment plan was being evaluated but rather than the treatment plan was completed. Hospital-wide highest % of incidents was physical confrontation with others at 20% and harm to staff at 15%. Incidents were up significantly from 136 in July as opposed to 29 in June primarily due to the inclusion of data from the PRTF (psychiatric residential treatment facility). The action was that data for the PRTF would be reported separately from the hospital data. There was no documented evidence of any action planned to address the increase in the hospital data (aggression incidents in June were 13 as compared to 31 incidents in July). August data revealed that incidents were up significantly from 136 in July to 199 in August. There was no documented evidence of action plans to address this increase in incidents.


In an interview on 11/13/14, at 10:55 a.m., S3RM/QA indicated that he had been at the hospital in his present role since August 2014. He further indicated that each morning the management team meets to discuss problems that have occurred since the previous day, but there is no documentation of these meetings related to what is discussed each day. He indicated that currently audits are being conducted 24 hours after admission, 72 hours after admission, and weekly. S3RM/QA indicated the audits began this month (November 2014).


In an interview on 11/13/14, at 2:00 p.m., S4ClinDir indicated the first data for chart audits had been collected in November 2014. She further indicated that prior to that, they were only tracking treatment plan completion but data wasn't being aggregated.


In an interview on 11/13/14, at 3:05 p.m., S3RM/QA confirmed that the data on the risk management reports and the performance improvement reports were not the same. He indicated that one report showed physical aggression per 250 patient days and one reports it per 1000 patient days. He confirmed that there is no written action plan for physical aggression in the QAPI meeting minutes. S3RM/QA confirmed that there was no documented evidence of the measurement to be used in determining a 20% reduction in physical aggression incidents. He indicated that it was meant to be a 20% reduction from the previous year.


In an interview on 11/14/14, at 8:20 a.m., S1ADM, when the findings of the review of the QAPI meeting minutes was discussed, indicated that he feels there's a lot of analysis of data, but the problem is with the lack of documentation. When explained that documentation doesn't show evidence that the data was analyzed and that corrective action plans were implemented, S1ADM indicated that "it (documentation) could be better."


In an interview on 11/14/14, at 9:35 a.m., S4ClinDir reviewed the QAPI data collection and meeting minutes and confirmed there was no evidence of data analysis and corrective actions implemented and revisions to the action plan when needed.


In an interview on 11/14/14, at 10:45 a.m., S3RM/QA indicated that he thought an incomplete treatment plan would be considered a measurement to show improvement or lack of improvement in health outcomes. He confirmed that there could be an improvement in the documentation of the analysis. S3RM/QA confirmed that the strategic planning meeting identified as a need in July 2014 had not occurred or been scheduled as of the date of this interview.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on records review and interviews, the hospital failed to ensure that data collected was used to identify opportunities for improvement and changes that will lead to improvement, set its priorities for its performance improvement activities on high-risk, high-volume, or problem-prone areas, and take actions aimed at performance improvement, measure success with the actions, and track performance to ensure that improvements are sustained.


Findings:


Review of the hospital policy titled "Quality Improvement Plan/Performance Improvement," reviewed 10/27/14, and presented as the current policy by S3RM/QA, revealed that the hospital is dedicated to providing quality care and services through continuous and systematic measurement, assessment, and improvement of its systems and processes.


Further review revealed that data is collected for measurement and assessment of processes and outcomes, particularly those high risk, high volume, and problem prone processes, based upon a comprehensive set of performance measures. The findings are analyzed to identify significant variances and/or opportunities to improve patient care outcomes. The process improvement strategy included the following: plan the improvement; do the improvement, data collection, and analysis; check and study the results; act to hold the gain and continue to improve the process.


Review of the "Governing Board Report" for the 4th quarter of 2013 and the 1st and 2nd quarter for 2014 revealed that the 1st quarter report included the Executive Management Team's performance improvement goals for 2014.


The goals included the following:

1) 95% (per cent) compliance for completion of treatment plans and assessments;

2) 95% compliance of door-to-doctor-to-door patient experience (includes monitoring for completion of all documentation from admission to discharge);

3) 20% reduction of physical aggression incidents; 4) overall patient satisfaction scores greater than 80.


Review of the hospital's QAPI goals listed above revealed no evidence that the quality indicators selected were based on high-volume, high-risk, and problem-prone areas and related to improving health outcomes.


Review of the QAPI meeting minutes included the following information related to quality indicators for 2014:

04/22/14 - treatment plans "are looking better-the documentation is there"; "conclusions/recommendations" revealed "quality is an issue and audits will now move toward addressing that." There was no documented evidence that an action plan was implemented to address how the quality of the treatment plans would be addressed. Hospital-wide 26% of incidents related to physical aggression, down from the previous month (unable to confirm as the monthly report reveals number of incidents of aggression, not % of aggression incidents). Highest % of incidents is contraband at 21%. There was a significant decrease in incidents between February (74) and March (53). There was increase in medication errors on the Adult Unit. there was no documented evidence of an action plan implemented to address the identified problem of physical aggression and the newly identified problem with contraband and medication errors.

10/31/14 - treatment plan corrective action: new nursing service quality management registered nurse plans to revamp the audit form; "conclusions/recommendations"; numbers and flow charts and specifics of what will be measured on Treatment Plans will be available by the next meeting. There was no documented evidence that an action plan was implemented to address the treatment plans that was a quality indicator established 6 months prior to this meeting. Physical confrontations and harm to peers accounted to 40% of the 96 incidents that occurred in September. Physical aggression: August 2013 = (equals) 13.5% and August 2014 = 25.88%. There was no documented evidence that action plans were implemented to address the identified problem of physical confrontations and harm to peers and the type and frequency of monitoring to be done.


Review of the "Executive Management Team" meeting minutes revealed the following information:

06/10/14 - overall from the beginning of the year, treatment plans have improved; focus has recently been on quality; "conclusions/recommendation" included "improvement is noted, monitoring will continue." There was no documented evidence of an action plan. Majority of incidents were related to physical aggression followed by property destruction. Physical aggression rate per 1000 patient days: January 9.8; February 10.8; March 6.07; April 13.6; May 11.2; Treatment Plan % of compliance: January 80%; February 85%; March 86%; April 88%. There was no documented evidence of an action plan implemented related to physical aggression and treatment plans.

07/15/14 - Treatment Plan Corrective Action Update: training is in place and samples are ready to roll. There was no documented evidence of a specific action plan to address this quality indicator that had been in place since April 2014.

08/12/14 - "Treatment Plan Corrective Action Update": S1ADM reported that he and S3RM/QA (Risk manager/Quality Assessment) have met and completion of this project will be S3RM/QA's primary focus at this time; "conclusions/recommendations" included that S3RM/QA, S4ClinDir, and S5DON (Director of Nursing) will meet this week and devise a plan for monitoring which will be turned in to S1ADM by 08/15/14.

09/05/14 - "Treatment Plan Corrective Action": 24 and 72 hour admission audits and weekly audits are being conducted. There was no documented evidence that the quality of the completed treatment plan was being evaluated but rather than the treatment plan was completed. Hospital-wide highest % of incidents was physical confrontation with others at 20% and harm to staff at 15%; incidents were up significantly from 136 in July as opposed to 29 in June primarily due to the inclusion of data from the PRTF (psychiatric residential treatment facility). The action was that data for the PRTF would be reported separately from the hospital data. There was no documented evidence of any action planned to address the increase in the hospital data (aggression incidents in June were 13 as compared to 31 incidents in July). August data revealed that incidents were up significantly from 136 in July to 199 in August. There was no documented evidence of action plans and subsequent monitoring to address this increase in incidents.


Review of a "Root Cause Analysis" presented by S3RM/QA revealed on 08/11/14 (4 months after contraband had been identified as an increasing problem) that a [AGE] year old male patient, admitted on [DATE], at 9:20 a.m., was found at 6:00 p.m. (after contraband search had been performed) with "over 200 Xanax and Skoal".


Review of the incident report log presented by S3RM/QA revealed from 07/01/14 to 10/31/14, there were 76 occurrences of harm to staff, harm to peer, and physical confrontation with harm to staff and/or peer, 43 occurrences of physical confrontation with others, and 7 occurrences of sexual familiarity.


In an interview on 11/13/14, at 10:55 a.m., S3RM/QA indicated that he had been at the hospital in his present role since August 2014. He further indicated that each morning the management team meets to discuss problems that have occurred since the previous day. There is no documentation of these meetings related to what is discussed each day. He indicated that currently audits are being conducted 24 hours after admission, 72 hours after admission, and weekly. S3RM/QA indicated the audits began this month (November 2014).


In an interview on 11/13/14, at 2:00 p.m., S4ClinDir indicated the first data for chart audits had been collected in November 2014. She further indicated that prior to that, they were only tracking treatment plan completion but data wasn't being aggregated.


In an interview on 11/13/14, at 3:05 p.m., S3RM/QA confirmed that the data on the risk management reports and the performance improvement reports were not the same. He indicated that one report showed physical aggression per 250 patient days and one reports it per 1000 patient days. He confirmed that there is no written action plan for physical aggression in the QAPI meeting minutes.


In an interview on 11/14/14, at 8:20 a.m., S1ADM, when the findings of the review of the QAPI meeting minutes was discussed, indicated that he feels there's a lot of analysis of data, but the problem is with the lack of documentation. When explained that documentation doesn't show evidence that the data was analyzed and that corrective action plans were implemented, S1ADM indicated that "it (documentation) could be better."


In an interview on 11/14/14, at 9:35 a.m., S4ClinDir reviewed the QAPI data collection and meeting minutes and confirmed that there was no evidence of data analysis and corrective actions implemented and revisions to the action plan when needed.


In an interview on 11/14/14, at 10:45 a.m., S3RM/QA indicated that he thought an incomplete treatment plan would be considered a measurement to show improvement or lack of improvement in health outcomes. He confirmed that there could be an improvement in the documentation of the analysis. S3RM/QA confirmed that an action plan was not implemented in April 2014 when contraband was identified as the highest cause of incident reports and medication errors had increased on the Adult Unit (high-risk, problem-prone area).
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on records review and interviews, the hospital failed to ensure that adverse patient events were measured, tracked, analyzed for cause, and preventive actions were implemented with mechanisms in place for feedback and learning throughout the hospital.


1) The hospital provided no documented evidence of tracking of significant adverse patient events other than through a review of incident reports, an analysis of significant adverse patient events for cause, and preventive actions implemented as a result of the significant adverse patient event and analysis for 3 ( R3, R4, R5) of 4 significant adverse patient events reviewed.


2) The hospital failed to document an adverse patient event (physical altercation of peer to peer) that resulted in Patient R2 having his teeth loosened after being hit in the mouth by Patient R1, and there was no documented evidence that an incident report had been completed as required by hospital policy.


Findings:


1) The hospital provided no documented evidence of tracking of significant adverse patient events other than through a review of incident reports, an analysis of significant adverse patient events for cause, and preventive actions implemented as a result of the significant adverse patient event and analysis:


Review of the hospital policy titled "Serious Occurrence (Critical Incidents/Adverse Event) Reporting", revised May 2016 (incorrect year) and presented as a current policy by S3RM/QA (Risk Manager/Quality Assessment), revealed that the hospital's policy was to define serious occurrences and develop a mechanism for reporting incidents to external agencies and internal departments for follow-up on serious occurrences.

Serious occurrences are defined as those incidents falling into one of 14 categories that includes attempted suicide by a client, absence without leave (elopement off premises), and an incident that requires off-site emergency medical treatment for injuries or complications from any treatment or medication intervention.

The procedure was that, whenever an event occurred which fell into one of the named categories, the staff member closest to the event was to initiate a Serious Occurrence report and Risk Management Incident Report immediately. The report was to give a clear description of the events leading to the behavioral situation, staff intervention into the behavioral situation, and the outcome and necessary follow-up to the behavioral situation.

After the report was reviewed for accuracy and details by the therapist, supervisor, and RN (registered Nurse) Supervisor on duty, the report was to be given to the Executive Director of the Program or Risk Manager for review. If the event occurred after hours, the Administrator On-call, Risk Manager, and Executive Director shall notified within one hour of the event.

The Executive Director, Program Director, Clinical Manager, DON (Director of Nursing), and Risk Manager or designee will review the Serious Occurrence Report and determine the appropriate follow-up action(s) needed and conduct further investigation and corrective action. A copy of the Serious Occurrence report shall be kept in a location in administration where it is readily available for review by staff of the monitoring entities. The Executive Director or designee shall maintain a serious occurrence log detailing serious occurrences.


In an interview on 11/14/14, at 8:20 a.m., S1ADM indicated that he didn't recall a significant adverse patient event other than the most recent event in August 2014. He confirmed that he did not and was not aware of any staff member who maintained a log of serious occurrences. He indicated that he would have to look at the hospital's incident report log to see if any of the incidents refreshed his memory regarding serious occurrences.


Patient R3

Review of an incident report dated 10/07/14, revealed that on 10/07/14, at 11:20 a.m., Patient R3, a [AGE] year old male, admitted on [DATE], had pulled his T-shirt off and was tying it around his neck in a suicide gesture while witnessed by staff. Further review revealed Patient R3 punched doors, walls, and windows, cut his fingers, and hit his head repeatedly against the wall while yelling "I'm killing self and everyone tonight."


Review of the "Serious Occurrence Report," completed by the S15RNS (RN Supervisor) and provided by S3RM/QA, revealed notification of the administrative team began at 8:00 a.m., on 10/08/14, 20 hours and 40 minutes after the event had occurred.

Further review revealed that the report had no signatures of the Clinical Reviewer and Administrative Reviewer as evidenced by blank lines in the space provided for their signature, title, and date. Attached to the report was an e-mail sent to the administrative team on 10/08/14, at 8:17 a.m., by S15RNS notifying the team that the event had been reported through an incident report received the morning of 10/08/14.

Further review of the "Serious Occurrence Report" revealed the precipitating factor that may have contributed to the incident was that the client was noted to have unpredictable behavior. The description of follow-up actions taken included "client assessed by unit nurse... not to have any injury to fingers or head, provided with 1:1 (one-to-one) therapeutic intervention and close monitoring visual contact maintained." There was no documented evidence of an analysis of the event and preventive actions implemented as a result of the significant adverse patient event after the report was reviewed by S3RM/QA.


Patient R4

Review of a "Serious Occurrence Report", completed by S15RNS and provided by S3RM/QA, revealed Patient R4, a [AGE] year old male, admitted on [DATE], reportedly plotted with a peer to elope as a team.

Further review revealed that while the peer attempted to jump the fence and distract staff, Patient R4 was able to jump the fence on 10/12/14, at 2:30 p.m., and escape into the wooded area near the hospital. The precipitating factor contributing to the incident was identified as a past history of elopement. The follow-up actions taken included staff following Patient R4 to a skateboard area, picking him up in the hospital van, and returning him to the hospital. Patient R4 was placed on unit restrictions with elopement precautions and phone restrictions.

Further review revealed the report had no signatures of the Clinical Reviewer and Administrative Reviewer as evidenced by blank lines in the space provided for their signature, title, and date. Review of a second copy of the "Serious Occurrence Report", presented at 5:00 p.m. on 11/14/14, by S3RM/QA, revealed the signature of S3RM/QA with the typed date of 10/13/14. There was no documented evidence of an analysis of the event and preventive actions implemented as a result of the significant adverse patient event after the report was reviewed by S3RM/QA.


Patient R5

Review of a "Serious Occurrence Report" completed by S15RNS on 11/04/14, revealed that Patient R5, a [AGE] year old female, required off-site emergency medical treatment on 11/04/14, at 10:15 a.m., secondary to having a rash on the upper part of her back that spread to other parts of her body with face swelling also noted. The precipitating factor to the event was "unknown." The follow-up was documented as Patient R5 was evaluated in the acute care hospital's Emergency department as having had a reaction to Clozaril. It was recommended to discontinue the Clozaril and to take Prednisone 10 mg (milligrams) orally daily for 6 days and Benadryl 25 mg orally every 6 hours as needed.

Further review revealed "current orders to include change of Clozaril to 100 mg po BID (by mouth twice a day), along with Prednisone and Benadryl as recommended. There was no documented evidence of a signature and date of the Clinical reviewer, and S3RM/QA typed his signature on 11/05/14. There was no documented evidence of an analysis of the event and preventive actions implemented as a result of the significant adverse patient event after the report was reviewed by S3RM/QA.


Review of the "Adverse Drug Reaction Reporting Form" for Patient R5 revealed a verbal order from S16MD, Medical Director with his signature on 11/07/14, of the following: "I ___ agree ___ disagree that client displayed suspected signs and symptoms of an adverse drug reaction." The blank next to "disagree" had a check mark. Review of Patient R5's physician orders revealed a telephone order was received from S16MD, Medical Director on 11/04/14 at 2:10 p.m. to decrease Clozaril to 100 mg orally twice a day.


Review of a "Serious Occurrence Report" completed by S15RNS on 11/04/14, and signed by S3RM/QA on 11/05/14, revealed Patient R5 had the Heimlich Maneuver administered for an episode of choking on 11/04/14, at 5:15 p.m., at which time a piece of chicken was evacuated. The precipitating factor was "unknown." There was no documented evidence of an analysis of the event and preventive actions implemented as a result of the significant adverse patient event after the report was reviewed by S3RM/QA. There was no documented evidence that an investigation occurred to assure that the choking incident was not related to the earlier adverse drug reaction evaluated by the Emergency Department physician with the subsequent denial that it was an adverse drug reaction by Patient R5's physician with orders to continue a decreased dose of Clozaril.


In an interview on 11/14/14, at 3:30 p.m., S3RM/QA indicated that if they had not been providing more than first aid to a patient, they had not been considering patient altercations as serious occurrences. He further indicated that he had looked for an incident report on the elopement of Patient R4 but had not been able to find it. He further indicated that an elopement is considered "an incident not a serious occurrence." He indicated that he did not investigate the elopement event. Regarding Patient R5's event of the rash, S3RM/QA indicated he did not speak with S16MD, Medical Director when he wrote orders stating he did not consider it an adverse drug reaction and subsequently reordered a lower dose of Clozaril. He further indicated that he did not investigate the subsequent choking event and the possible relation of it to the earlier drug reaction. S3RM/QA indicated that at the Pharmacy and Therapeutics Committee meeting on 11/07/14, it was determined to be an adverse drug reaction.


2) The hospital failed to document an adverse patient event (physical altercation of peer to peer) that resulted in Patient R2 having his teeth loosened after being hit in the mouth by Patient R1, and there was no documented evidence that an incident report had been completed as required by hospital policy:

See the "Serious Occurrence (Critical Incidents/Adverse Event) Reporting" policy information contained in part 1 above.


In an interview on 11/14/14, at 2:45 p.m., S4ClinDir indicated there had been an altercation between 2 adolescent males, Patients R1 and R2, that was handled on the unit level rather than as a serious occurrence. She further indicated that Patient R2 was being transferred to another facility, and Patient R1 was upset about it and punched Patient R2 in the mouth causing his teeth to become loosened. She indicated that Patient R2 was examined by the medical clinic onsite, and an incident report was not completed. She indicated that she thought an incident report was not documented, because since one of the patients was leaving, there would be no need to take any action, such as separating the 2 patients from one another.


In an interview on 11/14/14, at 3:30 p.m., S3RM/QA indicated that anything outside the norm on the unit should be documented on an incident report, and the incident with Patients R1 and R2 should have been followed with an incident report. He indicated that, because the medical treatment provided to Patient R2 was done onsite and he didn't have to be sent off-site for treatment, the event did not rise to a serious occurrence even though Patient R2 had loose teeth as a result of the incident.
VIOLATION: QAPI PERFORMANCE IMPROVEMENT PROJECTS Tag No: A0297
Based on records review and interviews, the hospital failed to ensure distinct performance improvement projects were conducted with documentation of the measurable progress achieved on each project as evidenced by failure to have the number of distinct performance improvement projects conducted proportional to the scope and complexity of the hospital's services and operations. The hospital failed to provide documented evidence of distinct performance projects conducted from 10/03/13 to 08/11/14, and the measurable progress achieved on each project that was conducted in February 2013, March 2013, April 2013, October 2013, and August 2014.


Findings:


Review of the hospital policy titled "Quality Improvement Plan/Performance Improvement", reviewed 10/27/14, and presented as the current policy by S3RM/QA, revealed that each process improvement team is responsible to analyze the process selected using various statistical tools and techniques and to present its recommendation for improvement. Documentation should include a brief statement about the process and any issues that led to its selection, including the significance to the customer, a summary of data and methods of statistical analysis related to the status of the process or any problems that occurred at the beginning of the project, and a summary of the final conclusions, recommendations, and actions and resulting improvements.


Review of the distinct quality improvement projects presented by S1ADM and S3RM/QA revealed no projects had been conducted from 10/03/13 to 08/11/14. Review of the projects conducted in February 2013, March 2013, April 2013, October 2013, and August 2014 revealed no documented evidence of measurable progress achieved on each project and a summary of the outcome of the project.


In an interview on 11/13/14, at 3:15 p.m., S3RM/QA confirmed that the hospital did not have an ongoing distinct quality improvement project in place at the time of the survey.


In an interview on 11/14/14, at 8:20 a.m., S1ADM presented 2 distinct quality improvement projects that had been completed for review. He could provide no explanation for the 2 projects not having documented measurable progress achieved and the summary of the outcome of the project.


In an interview on 11/14/14, at 10:45 a.m., S3RM/QA indicated that at the completion of the project (related to contraband found on a patient after he had been searched) a memo was placed in the communication book for staff as a form of education on changes in policy. He further indicated that it's the expectation that staff are to read the communication book, but he doesn't know if the staff are required to initial the communication book when they review it. S3RM/QA indicated that he had no documented evidence of staff education of the policy changes related to the distinct quality improvement project on contraband searches. After asking more than once if monitoring was being done to assess for re-occurrence and the assurance that staff was following the revised policies and if documented evidence was available of such was available for review, S3RM/QA would not answer the question. When informed that no documented evidence was noted of measurable progress and summaries of outcomes of the distinct quality improvement projects, S3RM/QA indicated "I can't disagree."
VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
Based on records review and interviews, the hospital failed to ensure that its quality assessment and performance improvement (QAPI) program reflected the complexity of the hospital's organization and services as evidenced by failure of the hospital to include all hospital departments and clinical care services provided by contract or arrangement in its QAPI monitoring.


Findings:


Review of the hospital policy titled "Quality Improvement Plan/Performance Improvement", reviewed 10/27/14, and presented as the current policy by S3RM/QA, revealed that organization-wide QAPI activities include utilization management, management of information, infection control, medication use, safety, risk management, and quality control activities. Further review revealed that all departments and programs participate in the QAPI process. There was no documented evidence that the hospital's policy addressed the inclusion of clinical care services provided by contract or agreement in its monitoring.


Review of the QAPI meeting minutes for 11/26/13, 04/22/14, and 10/31/14 revealed no documented evidence that all hospital departments and clinical care services provided by contract or arrangement was included in its monitoring. There was no documented evidence of reports related to utilization management, management of information, infection control, medication use, safety, and risk management, as well as dietary, laundry, lab, and biohazardous waste.


Review of the "Safety/Risk Management Meeting" minutes for 01/23/14 and 04/24/14, revealed safety management, infection control, hazardous waste management, emergency management, life safety management, medical equipment management, environmental rounds, and risk management was discussed.


In an interview on 11/13/14, at 3:15 p.m., S3RM/QA indicated that infection control "is part of the umbrella of performance improvement." He indicated that infection control is addressed at the Safety Committee meetings, and he attends both meetings. S3RM/QA could offer no explanation as to how utilization management, management of information, infection control, medication use, safety, and risk management, as well as dietary, laundry, lab, and biohazardous waste were integrated into the hospital's QAPI program when these items were discussed at the safety meeting which was held after the QAPI meeting was conducted.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
Based on records review and interviews, the hospital failed to ensure that the governing body, medical staff, and administrative officials assured that the quality assessment and performance improvement (QAPI) program was implemented and maintained.


The governing body failed to ensure that all improvement activities were evaluated, determined the number of distinct quality improvement projects to be conducted annually, and conducted and documented an annual review of the effectiveness of the QAPI program as required by hospital policy.


Findings:


Review of the hospital policy titled "Quality Improvement Plan/Performance Improvement", reviewed 10/27/14, and presented as the current policy by S3RM/QA, revealed that the governing body had the ultimate responsibility and authority to establish, maintain, and support an effective QAPI program.

Further review revealed that hospital management provided the resources, equipment, personnel, staff training, information systems, data management processes, and other support necessary to maintain, an ongoing, comprehensive QAPI program. A quality management function of the Medical Executive Committee is to conduct and document an annual review of the effectiveness of the QAPI program. The Director of Risk Management/Performance Improvement is assigned to the program to assist the leadership, medical staff, and the QAPI Committee in designing, planning, implementing, and overseeing a comprehensive and integrated management program. The Director of Risk Management/Performance Improvement is evaluate QAPI activities and coordinate reports of findings to the Committee, Medical Executive Committee, and the governing body. He/she is also to maintain a record of all completed reviews, evaluations, and process improvement team activities.


Review of the "Governing Board Report" for the 4th quarter of 2013 and the 1st and 2nd quarter for 2014 revealed the 1st quarter report included the Executive Management Team's performance improvement goals for 2014.

The goals included the following:

1) 95% (per cent) compliance for completion of treatment plans and assessments;

2) 95% compliance of door-to-doctor-to-door patient experience (includes monitoring for completion of all documentation from admission to discharge);

3) 20% reduction of physical aggression incidents; 4) overall patient satisfaction scores greater than 80. There was no documented evidence provided by the hospital that showed that the governing body specified the frequency and detail of data collection.

There was no documented evidence of the measurement or comparison to be used in determining a 20% reduction of physical aggression incidents.


Review of the hospital's QAPI goals listed above revealed no evidence that the quality indicators selected were related to improving health outcomes.


Review of the QAPI meeting minutes for 11/26/13, 04/22/14, and 10/31/14 revealed no documented evidence of action to be taken to address the identified problems and opportunities for improvement.


The hospital could provide no documented evidence that the governing body determined the number of distinct quality improvement projects to be conducted annually and that it had conducted and documented an annual review of the effectiveness of the QAPI program as required by hospital policy.


In an interview on 11/13/14, at 2:00 p.m., S4ClinDir the first data for chart audits had been collected in November 2014. She further indicated that prior to that, they were only tracking treatment plan completion but data wasn't being aggregated.


In an interview on 11/13/14, at 3:05 p.m., S3RM/QA confirmed that there is no written action plan for physical aggression in the QAPI meeting minutes. S3RM/QA confirmed that there was no documented evidence of the measurement to be used in determining a 20% reduction in physical aggression incidents. He indicated that it was meant to be a 20% reduction from the previous year.


In an interview on 11/14/14, at 8:20 a.m., S1ADM, when the findings of the review of the QAPI meeting minutes was discussed, indicated that he feels there's a lot of analysis of data, but the problem is with the lack of documentation. When explained that documentation doesn't show evidence that the data was analyzed and that corrective action plans were implemented, S1ADM indicated that "it (documentation) could be better."


In an interview on 11/14/14, at 9:35 a.m., S4ClinDir reviewed the QAPI data collection and meeting minutes and confirmed there was no evidence of data analysis and corrective actions implemented and revisions to the action plan when needed.


In an interview on 11/14/14, at 10:45 a.m., S3RM/QA indicated that he thought an incomplete treatment plan would be considered a measurement to show improvement or lack of improvement in health outcomes. He confirmed that there could be an improvement in the documentation of the analysis.


In an interview on 11/14/14, at 2:45 p.m., S1ADM indicated that he could not find documented evidence that an annual QAPI program evaluation had been conducted and reviewed by the governing body.