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.

EASTERN LA MENTAL HEALTH SYSTEM 4502 HIGHWAY 951 JACKSON, LA Feb. 22, 2011
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on record review and interview, the hospital failed to set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem prone areas. This was evidenced by the hospital's failure to identify the need to incorporate quality indicators in an effort to assist in safeguarding patients from a patient (Patient #5) who had exhibited a pattern of physically assaulting other hospitalized patients (7 physical assaults in 7 months-July of 2010 thru January of 2011). Findings:

The incident reports for July of 2010 thru January of 2011 were reviewed. This review revealed the following in regards to Patient #5:

? July 3, 2010- Patient #5 physically assaulted Patient #7 at 7:30 p.m.
? August 28, 2010- Patient #5 physically assaulted a Psych Aide (S22) at 9:20 p.m.
? October 9, 2010- Patient #5 physically assaulted Patient #8 at 5:50 p.m.
? October 17, 2010- Patient #5 physically assaulted Patient #7 at 6:05 p.m.
? November 10, 2010- Patient #5 physically assaulted Patient #3 at 6:07 p.m.
? November 23, 2010- Patient #5 physically assaulted Patient #4 at 1:50 p.m.
? January 19, 2011- Patient #5 physically assaulted Patient #6 at 12:50 p.m.

The Quality Management Director (S21) was interviewed on 2/22/11 at 12:45 p.m. When asked if the hospital's QAPI program had a system in place to track incidents that occur in the hospital and to track allegations of abuse, S21 reported that the QAPI program does have a system in place to track incidents and allegations of abuse. When asked if the QAPI program had identified the repeated assaultive outburst exhibited by Patient #5, S21 indicated that information relating to Patient #5's assaultive outburst were included in the QAPI data and presented in a cumulative report in the "ELMHS Clinical Department Heads Meeting". S21 explained that the QAPI program identifies all incidents that occur in the hospital which includes assaultive behavioral outbursts. S21 reported that the QAPI program failed to make the connection to identify that Patient #5 was involved in multiple patient assaults and failed to identity the need to determine what measures had been implemented to address Patient #5's repeated physical assaults on other hospitalized patients. S21 presented the meeting minutes for the most recent two meetings held by the "ELMHS Clinical Department Heads Meeting".

The "ELMHS Clinical Department Heads Meeting" minutes for the most recent two meetings were reviewed. This review revealed the most recent 2 meetings were held in November 29, 2010 and January 25, 2011. Review of the meeting minutes revealed no documentation to indicate that the hospital had identified the pattern of assaultive behavior exhibited by Patient #5 (7 physical assaults in 7 months-July of 2010 thru January of 2011) in the QAPI program. This review also revealed no documentation to indicate that the hospital's QAPI program had identified the need to determine what measures had been implemented to address Patient #5's repeated physical assaults on other hospitalized patients.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the registered nurse failed to ensure the supervision and evaluation of care provided to patients on the psychiatric unit by failing to ensure that the attending psychiatrist (leader of the treatment team) was immediately notified of the status of patients immediately following instances of physical aggression. This was noted for both the victims of the physical aggression (Patient #3, #4, #7 & #8) and the perpetrator of the physical aggression (Patient #5). Findings:

Review of incident reports (July of 2010 thru January of 2011) revealed the following:

? July 3, 2010- Patient #5 physically assaulted Patient #7 at 7:30 p.m. in the Dayroom of the B Hall on Cedarview.
? August 28, 2010- Patient #5 physically assaulted a Psych Aide (S22) at 9:20 p.m. in the Living room of Gabriel House.
? October 9, 2010- Patient #5 physically assaulted Patient #8 at 5:50 p.m. on the B-Side on Gabriel House.
? October 17, 2010- Patient #5 physically assaulted Patient #7 at 6:05 p.m. in the Treatment Room of Evangeline 3.
? November 10, 2010- Patient #5 physically assaulted Patient #3 at 6:07 p.m. in the Living room of Evangeline 3.
? November 23, 2010- Patient #5 physically assaulted Patient #4 at 1:50 p.m. in the Recreation Hall of Evangeline 3.

Review of the above incident reports revealed no documentation to indicate that Patient #5's psychiatrist was immediately notified of his (Patient #5) assaultive behavior and no documentation to indicate the attending psychiatrist of the patients who were assaulted by Patient #5 had been immediately notified.

This was confirmed in an interview with the Quality Management Director (S21) and the Director of Nursing (S2) on 2/22/11 at 12:45 p.m. as both reported that there was no documentation to indicate that the attending psychiatrist was immediately notified of the physical assaults involving the above patients.

The medical record of Patient #5 was reviewed on 2/18/11. This review revealed that Patient #5 was admitted to East Louisiana State hospital on [DATE]. This review revealed that Patient #5 is currently being held on a Judicial Commitment. This review revealed that Patient #5 was initially admitted on [DATE] where he remained until his transfer to the Cedarview Building on 1/28/10 where he remained until his transfer to the Gabriel House on 3/17/10 where is remained until his transfer to the Evangeline House on 10/15/10. Patient #5 has remained hospitalized on the Evangeline House from 10/15/10 through the time of this record review (2/18/11). Documentation on the psychiatric evaluation dated 5/11/09 revealed that Patient #5 was a [AGE] year old male who was committed by the First District Court of Caddo Parish after being found incompetent to proceed on the charge of Possession of Marijuana Second Offense that occurred on 2/22/08. Documentation revealed that Patient #5 has a history of aggression as evidenced by his past arrest on his RAP sheet and by Victim/Witness reports. Documentation revealed "The victim reportedly was punched out of the blue while in a store and (Patient #5) then appeared to walk out calmly". Documentation on the psychiatric evaluation revealed that Patient #5's Axis I diagnosis was "Psychosis, Not Otherwise Specified, Rule Out Schizophrenia, Undifferentiated Type". Review of the Plan of Care revealed that Aggressive Behavior was documented as one of the identified problems. Documentation under this problem revealed the goal as "(Patient #5) will refrain from aggressive behavior. This objective has NOT BEEN met." Documented interventions included administering medications as ordered, monitor the effects, notify the physician of changes, place patient on close visual observation at 15 feet for random violent behavior, attempt to calm patient by asking questions regarding what is upsetting him and what will be beneficial in calming him, listen to patient and attempt to problem solve prior to using more restrictive interventions and to assess and treat as indicated. Review of the incident reports, progress notes and orders revealed the following in regards to the observation level that Patient #5 was on at the time of the documented physical assaults:

-July 3, 2010- Patient #5 physically assaulted Patient #7 at 7:30 p.m. Documentation indicated that Patient #5 was on a "Routine Observation" level at the time of assaulting Patient #7. Documentation indicated that Patient #5 was placed on a 48 hour Ward Restriction following the physical assault of Patient #7. No documentation was found to indicate that Patient #5's or Patient #7's attending psychiatrist had been immediately notified of the physical assault.
-August 28, 2010- Patient #5 physically assaulted a Psych Aide (S22) at 9:20 p.m. Documentation indicated that Patient #5 was on a "Routine Observation" level at the time of assaulting S22. Documentation indicated that Patient #5 was immediately taken to the time out room and administered 2mg of Ativan ordered by the internal medicine physician. Documentation revealed that Patient #5 was placed on a 48 hour Ward Restriction following the physical assault of S22. No documentation was found to indicate that Patient #5's attending psychiatrist had been immediately notified of the physical assault.
-October 9, 2010- Patient #5 physically assaulted Patient #8 at 5:50 p.m. Documentation indicated that Patient #5 was on a "Routine Observation" level at the time of assaulting Patient #8. Documentation indicated that Patient #5 was placed on a 48 hour Ward Restriction following the physical assault of Patient #8. No documentation was found to indicate that Patient #5's or Patient #8's attending psychiatrist had been immediately notified of the physical assault.
-October 17, 2010- Patient #5 physically assaulted Patient #7 at 6:05 p.m. Documentation indicated that Patient #5 was on a "Routine Observation" level at the time of assaulting Patient #7. Documentation indicated that Patient #5 was placed on a 48 hour Ward Restriction following the physical assault of Patient #7. No documentation was found to indicate that Patient #5's or Patient #7's attending psychiatrist had been immediately notified of the physical assault.
-November 10, 2010- Patient #5 physically assaulted Patient #3 at 6:07 p.m. Documentation indicated that Patient #5 was on a "Routine Observation" level at the time of assaulting Patient #3. Documentation indicated that Patient #5 was placed on a 48 hour Ward Restriction following the physical assault of Patient #3 and then placed on a "Continuous Visual Observation at 15 Feet in Length" and ordered to sleep in the observation room at night beginning on 11/12/10 as this was the date of the treatment team meeting that followed the assault on Patient #3. No documentation was found to indicate that Patient #5's or Patient #3's attending psychiatrist had been immediately notified of the physical assault.
-November 23, 2010- Patient #5 physically assaulted Patient #4 at 1:50 p.m. Documentation indicated that Patient #5 was on a "Continuous Visual Observation at 15 Feet in Length" level at the time of assaulting Patient #4. Documentation indicated that Patient #5 remained on a "Continuous Visual Observation at 15 Feet in Length" level following the physical assault of Patient #4. No documentation was found to indicate that Patient #5's or Patient #4's attending psychiatrist had been immediately notified of the physical assault.

In an interview with the Director of Nursing (S2) on 2/22/11 at 12:55 p.m., the Director of Nursing reported that there was no documentation in the medical record to indicate that the attending psychiatrist was immediately notified of the physical assaults involving the above patients.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on record review and interview, the hospital failed to ensure there was adequate numbers of nursing personnel to meet the needs of the patients by:
1) failing to ensure adequate numbers of nursing personnel were provided during the change of shift for 1 of 4 units (Evangeline 4) on 1 of 22 days reviewed (1/12/2011) by having no Registered Nurse on the unit and having 2 Psych Aides (S6 and S8) provide care for 26 patients during the change of shift. Two patients (#1, #2) became involved in an altercation during the change of shift on 1/12/2011.
2) failing to ensure adequate numbers of Psych Aides were provided as per the hospital's staffing grid for 1 of 22 days reviewed (10/09/2010). Findings:

1)
Review of a hospital "Client Incident, Injury and Data Reporting Form" dated 1/12/2011 revealed in part, "pt. (patient/ #2) stated she (#2) was in the shower room when pt. (#1) came in and bumped her (#2) and then started attacking her (#2) for no reason. (W)when staff entered the bathroom both pts (#1 and #2) were physically fighting and had to be separated using verbal redirection." This form was signed by Psych Aide S6.

Review of Patient #1's Progress Notes dated 1/12/2011 at 1805 (6:05 p.m./ start of the 6:00 p.m. - 6:00 a.m. shift) revealed in part, "pt (patient/#1) came to nurse's station, stating that pt (#2) kept bothering her (#1) in the shower. Staff instructed pt (#1) to have a seat in the dayroom until pt. (#2) was finished but she (#1) went to the shower anyway. Pt. (#1) came out and told staff that pt (#2) bump her (#1), pt. (#1) was told to wait, that staff was coming to see what the problem was between (as written), before staff could get to the shower room pt. (#1) was physically fighting with pt (#2). . . the nurse was notified." This documentation was signed by Psych Aide S6.

Review of Patient #2's Progress Notes dated 1/12/2011 at 1805 (6:05 p.m.) revealed in part, "Pt (Patient #2) stated she (#2) was in the shower room when pt (#1) came in and bumped her (#2) and then started attacking her (#2) for no reason. (W)when staff entered the bathroom both pts (#1 and #2) were physically fighting and had to be separated. . . the nurse was notified." This documentation was signed by Psych Aide S6.

Review of staffing for the female unit of the hospital (Evangeline 4) on the date of 1/12/2011 revealed the census was 26 with no patients on special precautions. Further review revealed 1 Registered Nurse and 3 Psych Aides were scheduled for the unit for day and night shift (12 hour shifts).

During a telephone interview on 2/21/2011 at 10:05 a.m., Psych Aide S4 indicated she (S4) had been scheduled to work on 1/12/2011 from 6:00 p.m. until 6:00 a.m. S4 indicated that a truck had overturned on the highway and she (S4) had not been able to get to work at the scheduled time. S4 indicated that by the time she (S4) arrived; on 1/12/2011, the altercation between Patient #1 and Patient #2 had already occurred.

During a telephone interview on 2/21/2011 at 11:00 a.m., Psych Aide S6 indicated she (S6)had been one of the two Psych Aides staffing the unit (Evangeline 4) where Patient #1 and Patient #2 were involved in an altercation at 1805 (6:05 p.m.) on 1/12/2011. Psych Aide S6 indicated that the unit (Evangeline 4) had been short staffed, at the time, due to the Registered Nurse and Psych Aide Supervisor being off the unit for report (Hand off communication). S6 indicated she (S6) and one other Nurse Aide (S8) were the only staff on the unit. S6 indicated that the normal procedure during "shower time" was for one Psych Aide to directly monitor the shower room and the other two Psych aides were to monitor the patients that remained on the unit. S6 indicated that she (S6) stood near the shower on the date of 1/12/2011 at 6:00 p.m. and attempted to observe shower room activity and also observe patients on the unit, since there had only been 2 Psych Aides on the unit at the time. S6 indicated she (S2) had been aware of conflict between Patient #1 and #2 regarding the use of the shower. S6 indicated Patient #1 had been instructed to stay out of the shower until Patient #2 had finished; however, Patient #1 had managed to get into the shower room after being instructed to wait. S6 indicated she had not seen Patient #1's entrance into the shower room although she(S6) had attempted to monitor shower room activity. S6 indicated when she (S6) became aware that a fight had started between Patient #1 and #2 in the shower room, she (S6) had called out for help. S6 indicated the two patients (#1 and #2) had stopped fighting when she (S6) had verbally redirected them. S6 indicated there had been no need for physical intervention.

Unsuccessful attempts were made to reach Psych Aide S8 for an interview on 2/21/2011 at 11:45 a.m., 11:50 a.m., 1:10 p.m., and 1:15 p.m.

During a telephone interview on 2/21/2011 at 11:35 a.m., Registered Nurse S7 indicated he (S7) had been the House Supervisor and the Registered Nurse covering Evangeline 4 on the 6:00 p.m. - 6:00 a.m. shift for the date of 1/12/2011. S7 indicated the practice at the hospital had been for all Registered Nurses; to include oncoming and offgoing, to meet in the Conference Room located in the center of the Building (Evangeline) for Report (Hand off communication) and counting of narcotics at the change of shift. S7 confirmed that all Patient Care Units (Evangeline 1, 2, 3, and 4) were left without RN coverage during "Report" which averaged anywhere from 15 to 30 minutes. S7 indicated that Narcotic Count would also been performed during this time frame. S7 indicated 2 Psych Aides to provide care for 26 patients would not be adequate coverage.

During a face to face interview on 2/22/2011 at 9:55 a.m., Director of Nursing S2 indicated all Nursing Staff had been educated regarding the need to have at least one Registered Nurse on every clinical care unit during Code Blue calls (confirmed with record review). S2 indicated he had not been aware that Registered Nurses had left the clinical units without Registered Nurse coverage during Hand Off Communication at the change of shift. S2 further indicated that he would think Registered Nurses would know if they could not leave clinical units unattended by a Registered Nurse during a Code Blue that it would not be acceptable to leave the unit without RN coverage during change of shift.

Review of the hospital policy titled, "Staffing Variances" presented by the hospital as their current policy revealed in part, "The nurse assesses the cumulative needs for patient care and determines the staffing needs based on professional judgment, experience, and an acquired sense of the relative care needs of patients. This is accomplished without forms or tools, using a combination of professional judgment and knowledge of current care models and staffing practices. Psychiatric mental health head nurses supervises and direct patient care and therefore, possess a critical front-line perspective of nursing practice problems, i.e. patient care, staffing, and organizational management concerns. Professional care is directed toward healing the patient, preparing the patient for return to normalcy, or managing the patient's personal challenges or family issues. . ."

Review of the hospital policy titled, "Hand Off, effective March 15, 2006" presented by the hospital as their current policy revealed in part, "Hand off communications shall take place whenever there is a change in the patient's/client's/resident's caregivers. caregivers shall include all clinical staff and physicians. . . "

2)
Review of Staffing for the date of 10/09/2010 revealed the 6:00 p.m. to 6:00 a.m. shift on Evangeline 4 to be staffed with one Registered Nurse and two Psych Aides. Further review revealed the census for Evangeline 4 on the date of 10/09/2011 was 25.

Review of the hospital's "Nursing Staff Variance Sheet" presented by the hospital as current revealed in part, Evangeline 4's required staffing for Day Shift (6:00 a.m. - 6:00 p.m.) was 1 Registered Nurse and 3 Psych Aides. Further review revealed the required staffing for Night Shift (6:00 p.m. - 6:00 a.m.) was 1 Registered Nurse and 3 Psych Aides.

During a face to face interview on 2/21/2011 at 9:55 a.m., Director of Nursing S2 indicated there had been a call in on the date of 10/09/2010 which had left Evangeline 4 understaffed. S2 further indicated there had been no staff that could have been pulled from other units at the time. S2 indicated one Psych Aide would have had to observe 12 patients and the other 13 patients. S2 confirmed the staffing of Evangeline 4 on the night shift of 10/09/2010 had been understaffed and it would be difficult for 1 Psych Aide to properly monitor 12 to 13 patients assigned to her care.