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 July 21, 2017
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on record review, video recording review, and staff interviews, the Hospital failed to ensure the patient's right to receive care in a safe setting was maintained as evidenced by the Hospital staff removing the patient's bed frame and placing the mattress on the floor for the patient to sleep on for the acute adolescent male unit (Unit "a").

Findings:

Review of the Hospital's policy titled Patient Rights, Responsibilities, Advocacy and the Patient Bill or Rights revealed patients in all treatment settings are afforded rights in accordance to Mental Health Code, The Joint Commission and HIPAA, CMS, and Bureau of Health Standards. The Patient Bill of Rights included the right to receive care in a safe setting.

Review of the Incident Report log revealed the following:
06/17/17 - Patient #3 - 7:00 p.m. Property Damage: Dayroom - Damaged shelf, bed frames hitting walls with boards/screws. No injury.

Review of the medical record for Patient #3 revealed the RN progress note dated 06/17/17 for the 7:00 p.m. to 7:00 a.m. shift revealed the following: "Patient destroying shelves and bed frames and using broken boards with screws and nails sticking out as a weapon to threaten staff and to beat on windows, doors, fire alarms, etc. De-escalated with PRN med, safety maintained at all times. No injuries to self or other during incident."

Review of the video recording of Unit "a" revealed the following:
On 07/09/17 at 12:00 a.m., the video recording revealed 3 patients lying on mattresses on the floor in the day room (3 patients was the current census of the unit at that time - Patients #1, #2, #3). There were no chairs or tables visible in the room.
On 07/10/17 at 12:00 a.m., the video recording revealed 3 patients lying on mattresses on the floor in the day room. There was one staff member observed seated in a chair in the dayroom.

Observation of Unit "a" on 07/20/17 at 10:45 a.m. with S5QC revealed adult female patients were currently housed on this unit. S5QC stated the male adolescent patients were moved to Unit "b" after the patients destroyed the beds, table, and chairs. S5QC confirmed the adolescent boys were housed on the left side of the unit and the adolescent girls were housed on the right side. S5QC stated the adolescent male patients were moved to Unit "b" last week. When asked about the patient beds, S5QC stated there is a lip on the platform beds to prevent the mattress from sliding off the platform. S5QC stated the patients hit and kick the lip until it breaks off. She stated the wooden lip broken off had nail/screws in it. S5QC stated Patient #1 got the broken wood and threatened the staff with it. S5QC stated Patient #1 had it and he would throw it to Patient #3 when staff tried to take it from them. S5QC stated the staff had to administer injections, chemical restraints, to get the wooden pieces of the bed from them. S5QC stated she thought the mattress was moved out of rooms into the day room and the beds were not removed immediately after they were damaged. She stated when they damaged the beds in one room; they would close/lock that room off and move the patients to another room. She stated after the second room beds were damaged, the beds were removed and the mattresses placed on the floor.

In an interview on 07/20/17 at 11:45 a.m., S1COO stated the boys tore the beds apart and they moved the mattress to the floor for them to sleep on. She stated the move of the mattress to the floor was deliberate. S1COO for staff safety and as an incentive to the patients they moved the mattresses to the floor of the day room. She stated the boys were wielding the wood torn from the bed as a weapon and stated the wood had nails/screws in it. She confirmed the boys slept on the floor for several nights.

In an interview on 07/20/17 at 3:20 p.m. S8MHT confirmed she worked from 7:00 a.m. to 11:00 p.m. on 07/08/17 in Unit "a". S8MHT stated Patient #3 and Patient #1 would jump on the platform beds until they could bet a board loose. S8MHT stated Patient #1 had swung a board at her. She stated the board from the bed had nail/screws hanging from it. S8MHT confirmed Unit "a" did not have platform beds on 07/08/17 and the patients on that unit did not have platform beds until they moved to Unit "b" last week.

In an interview on 07/21/17 at 10:10 a.m., S1COO stated this was the first time the staff had removed patient beds and placed mattresses on the floor for the patients to sleep on. S1COO confirmed the hospital has a Behavior Management policy and it does not include putting patient mattresses on the floor. When asked if the hospital had additional beds they could have replaced the damaged beds with, she stated yes. S1COO stated it was intentional for the safety of the staff to place the mattresses on the floor in the day room. S1COO stated it was not safe for the staff to be in the bedrooms with these 3 patients (#1, #2, #3). S1COO stated the 3 patients were threatening the staff. S1COO stated these 3 patients had verbally and physically threatened the staff repeatedly.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on record review and patient and staff interview, the Hospital failed to ensure patients were free from all forms of abuse or harassment as evidenced by staff calling a patient by an inappropriate, derogatory name, and staff failing to document and report the incident to administrative staff for 1 (#3) of 5 sampled patients (#1-#5).

Findings:

Review of the Hospital policy titled, Abuse/Neglect of Patients/Reporting Allegations, Policy #RI-0800, revealed in part the following: Examples of Abuse: Verbal conduct may be abusive because of either the manner of communication or the content of the communication. Examples include yelling, cursing, ridiculing, harassment, coercion, threats, intimidation and other communication which is derogatory or disrespectful.....
Any employee or an affiliate who has knowledge of possible abuse of a patient, or who receives a complaint of abuse from a patient or any other person, shall report in accordance with the provisions of this policy and procedure....
Responsibilities of the Unit Nurse: Ensure patient safety, Notify RN Supervisor, Documents assessment of patient and instructs all witnesses to document: Incident report; Serious Occurrence Form and Progress Noted.
Timeframe: Immediate (all should be completed in 1 hour).
Further review of the policy revealed the RN Supervisor would re-assign the staff member and contact the on-call administrator within 1 hour of the initial report.

In an interview on 07/20/17 at 10:40 a.m., Patient #3 was asked if the staff had cursed at him or called him names, Patient #3 stated S10MHT had called him a "p---y".

In an interview on 07/20/17 at 3:20 p.m., S8MHT was asked if she had heard any staff member curse or call a patient a name. S8MHT stated yes, and then stated S10MHT had called Patient #3 a "p---y" on 07/08/17. S8MHT stated she reported the incident to the RN on the unit and S10MHT was removed from the unit. S8MHT stated she did not know what happened after the MHT was removed from the unit.

Review of the incident log from 02/03/17 to 07/19/17 revealed no documented evidence of an incident related to the above allegation.

In an interview on 07/21/17 at 12:20 p.m., S3DON confirmed S8MHT reported to her that she reported to S7RN that S10MHT had called Patient #3 a "p---y" on 07/08/17. S3DON confirmed the RN removed S10MHT from the unit but did not document the incident or notify anyone above him (RN Supervisor) of the incident. S3DON confirmed there was no incident report completed and stated there should have been. S3DON confirmed the patient's allegation of being called a derogatory name by S10MHT did occur.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the hospital failed to ensure the use of restraints and seclusion was in accordance with a written modification to the patient's plan of care for 2 of 2 (#1, #3) sampled patients reviewed for the use of restraints out of a total sample of 5 (#1-#5) patients.

Findings:

Review of the Hospital policy titled, Restraint/Seclusion, Policy # TX.7-0102, revealed a physical hold was defined as a restraint. The policy revealed the following: Treatment Planning: the prevention of restraint/seclusion use is a treatment team responsibility therefore, strategies for prevention of restraint/seclusion use will be incorporated into the Plan of Care. At the time of master treatment plan development: High risk behaviors will be identified as problem title or symptom of condition, Behavioral objectives will be developed to address target behavior, Staff interventions for the management of the behaviors, including medications that are going to be used as standard treatment (routine and PRN), will be identified.
There was no documented evidence of a provision to update the patient's treatment plan after the use of restraints and seclusion.


Patient #1
Review of the record for Patient #1 revealed the patient was a [AGE] year old admitted on [DATE] with diagnoses of Major Depressive Disorder, Oppositional Defiant Disorder, and Conduct Disorder. The record revealed the patient was court ordered to the hospital for competency restoration. The record also revealed the patient was housed in a juvenile detention center prior to hospital admission.

Review of the restraint/seclusion orders revealed the following:
06/01/17 at 7:45 p.m. Locked seclusion for destroying unit property and threatening staff.
06/06/17 at 10:50 a.m. Locked seclusion and chemical restraint for aggressive, threatening behavior toward RN and staff. Physically trying to attack RN. Destruction of property....
06/19/17 at 1:00 p.m. Locked seclusion for yelling, threating, shouting profanity, throwing food, swinging at staff and throwing furniture. Threatening to harm staff.
06/27/17 at 11:00 a.m. Locked seclusion for swinging at staff, pushing staff, threatening staff. Tells nurse: "I'm going to break her jaw."
06/27/17 at 11:20 a.m. Locked seclusion for destroying property, tore down electronic fire sign over turned furniture, pulling down furniture (table). Refuses to follow directions. Attempting to hit staff-swinging & pushing.


Review of the Master Treatment Plan revealed the patient's identified problems were Depressed Mood, Poor Impulse Control, and Oppositional Defiant. There was no documented evidence of any specific interventions to address the patient's behaviors. There was no documented evidence of any interventions related to the use of any type of restraints or seclusion. There was no documented evidence the treatment plan was updated with the use of restraints/seclusion.

In an interview on 07/21/17 at 2:14 p.m., S5QC reviewed the medical record for Patient #1 and confirmed there was no documentation of the use of restraints/seclusion in the treatment plan and stated they should have initiated the care plan for "risk for violence" and updated the treatment plan with restraint use. S5QC confirmed restraint and seclusion had been used for Patient #1 multiple times during his hospital stay.


Patient #3
Review of the record for Patient #3 revealed the patient was a [AGE] year old male admitted on [DATE] with diagnoses of Major Depressive Disorder, Bipolar Disorder, Impulse Control Disorder, Oppositional Defiant Disorder, and Conduct Disorder. The record revealed the patient was court ordered to the hospital for competency restoration. The record also revealed the patient was housed in a juvenile detention center prior to hospital admission.

Review of the restraint/seclusion orders revealed the following:
06/19/17 at 1:39 p.m. - Physical Restraint (Manual Hold) for Swinging at staff, attempting to hit staff. Placed in a manual hold and escorted to the unit.
07/09/17 at 4:40 p.m. - Physical Restraint (Manual Hold) from 4:18 p.m. to 4:30 p.m. Hit staff, kicked staff, spit on staff.
07/19/17 at 4:40 p.m. - Locked seclusion for punching glass, broke through unit door screaming and threatening staff. Destruction of property.
07/20/17 at 11:50 p.m. - Physical Restraint (Manual Hold) for patient threatening staff and physically advancing upon staff, as well as dangerous/destructive behavior.

Review of the Master Treatment Plan dated 06/13/17 revealed the patient's identified problems were Suicidal Ideation, Conduct Disorder/Delinquency, Poor Impulse Control, Oppositional Defiant, and Anger Management. There was no documented evidence of any specific interventions to address the patient's behaviors. There was no documented evidence of any interventions related to the use of any type of restraints or seclusion. There was no documented evidence the treatment plan was updated with the use of restraints/seclusion.

In an interview on 07/21/17 at 2:25 p.m. S5QC reviewed the treatment plan for Patient #3 and the restraint documentation and confirmed there was no documentation of restraints in the plan of care.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observation, record review and staff interview, the Hospital failed to ensure the facilities and equipment was maintained to ensure an acceptable level of safety and quality as evidenced by failing to ensure necessary equipment was provided to meet the needs of the patient by failing to provide bed frames, tables and chairs for patient use on the adolescent boys unit.

Findings:

Review of the Hospital policy titled, "Medical Equipment/Equipment Management Plan", Policy # EC-0151/Facility Wide, revealed in part the following: Purpose: To assess and manage the clinical and physical risks of equipment used for resident care, diagnosis and treatment through regular inspections, testing and maintenance and by providing education to users on equipment use and emergency procedures. Objective: To institute a program which ensures that selected medical equipment/equipment is inventoried, evaluated, tested , and maintained to perform properly and safely....

Review of the Incident Report log revealed the following:
06/17/17 - Patient #3 - 7:00 p.m. Property Damage: Dayroom - Damaged shelf, bed frames hitting walls with boards/screws. No injury.
06/21/17 - Patient #3 - 9:15 a.m. Property Damage: Dayroom - Broke plexiglass at Nursing station, kicking doors, tables.
06/21/17 - Patient #1 - 9:15 a.m. Property Damage: Dayroom - Broke plexiglass at Nursing station, kicking doors, tables.
06/21/17 - Patient #2 - 9:15 a.m. Property Damage: Dayroom - Broke plexiglass at Nursing station, kicking doors, tables.
07/04/17 - Patient #2 - 8:30 p.m. Property Damage: Dayroom - Damaged ("cracked") chair (sand filled chair), also attempted to take staff keys, resulting in jammed lock to conference room door.

Review of the medical record for Patient #3 revealed the RN progress note dated 06/17/17 for the 7:00 p.m. to 7:00 a.m. shift revealed the following: "Patient destroying shelves and bed frames and using broken boards with screws and nails sticking out as a weapon to threaten staff and to beat on windows, doors, fire alarms, etc. De-escalated with PRN med, safety maintained at all times. No injuries to self or other during incident."

Review of the video recording of Unit "a" on 07/08/17 at 9:30 p.m. staff was seen moving the "sand chairs" from the day room off the unit.
On 07/08/17 at 12:00 a.m., the video recording revealed there were 3 chairs in the day room and there was no table.
On 07/09/17 at 12:00 a.m., the video recording revealed 3 patients lying on mattresses on the floor in the day room (3 patients was the current census of the unit at that time). There were no chairs or tables visible in the room.
On 07/10/17 at 12:00 a.m., the video recording revealed 3 patients lying on mattresses on the floor in the day room. There was one staff member observed seated in a chair in the dayroom.

Observation of Unit "a" on 07/20/17 at 10:45 a.m. with S5QC revealed adult female patients were currently housed on this unit. S5QC stated the male adolescent patients were moved to Unit "b" after the patients destroyed the beds, table, and chairs. S5QC confirmed the adolescent boys were housed on the left side of the unit and the adolescent girls were housed on the right side. There was no table observed on the left side day room. S5QC stated the table that was on the left side was broken by the boys and used as a battering ram when they were on the unit. S5QC stated the boys (and girls) were moved to Unit "b" after the door between the units was broken. S5QC stated the patients were moved to Unit "b" last week. When asked about the patient beds, S5QC stated there is a lip on the platform beds to prevent the mattress from sliding off the platform. S5QC stated the patients hit and kick the lip until it breaks off. She stated the wooden lip broken off had nail/screws in it. S5QC stated Patient #1 got the broken wood and threatened the staff with it. S5QC stated Patient #1 had it and he would throw it to Patient #3 when staff tried to take it from them. S5QC stated the staff had to administer injections, chemical restraints, to get the wooden pieces of the bed from them. S5QC stated she thought the mattress was moved out of rooms into the day room and the beds were not removed immediately after they were damaged. She stated when they damaged the beds in one room, they would close/lock that room off and move the patients to another room. She stated after the second room beds were damaged, the beds were removed and the mattress placed on the floor.

In an interview on 07/20/17 at 11:45 a.m., S1COO stated the boys tore the beds apart and they moved the mattress to the floor for them to sleep on. She stated the move of the mattress to the floor was deliberate. S1COO for staff safety and as an incentive to the patients they moved the mattresses to the floor of the day room. She stated the boys were wielding the wood torn from the bed as a weapon and stated the wood had nails/screws in it. She confirmed the boys slept on the floor for several nights and confirmed they had to move the furniture out of the day room. S1COO stated the patients had slit open the sides of the sand chairs and let the sand out then broke pieces of the chairs off and used that as weapons to threaten the staff. S1COO confirmed they had removed the table after the patients damaged it.

In a telephone interview on 07/20/17 at 1:45 p.m., S7RN confirmed he worked 7:00 a.m. to 7:00 p.m. on 07/08/17 in Unit "a". S7RN confirmed the patients did not have chairs that day. When asked where the patient ate if they did not have tables or chairs, he stated he did not remember, but did remember the patients sitting down to eat.

In an interview on 07/20/17 at 3:20 p.m. S8MHT confirmed she worked from 7:00 a.m. to 11:00 p.m. on 07/08/17 in Unit "a". S8MHT stated Patient #3 and Patient #1 would jump on the platform beds until they could bet a board loose. S8MHT stated she had also removed a damaged dresser from a patient room. S8MHT stated they pulled the dresser out for maintenance to determine if it could be repaired. S8MHT confirmed Unit "a" did not have platform beds on 07/08/17 and the patients on that unit did not have platform beds until they moved to Unit "b" last week.