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.

BRENTWOOD HOSPITAL 1006 HIGHLAND AVENUE SHREVEPORT, LA April 11, 2014
VIOLATION: ADEQUATE RESPIRATORY CARE STAFFING Tag No: A1154
Based on record reviews and interviews, the hospital failed to:
1) have Respiratory Therapy Technician/s employee/s or contract employee/s to administer respiratory therapy services to patients should they require these services; and
2) have qualifications specified by the Medical Staff. Findings:

Review of the Medical Staff Bylaws revealed they failed to include approval of the scope of diagnostic and/or therapeutic respiratory services and to define in writing the specific respiratory services provided by the hospital.

Review of the Governing Body Bylaws/meeting minutes revealed the Respiratory Therapy services were not defined in writing and approved as evidenced by failure of the Governing Body to designate Respiratory Services as one of the clinical services provided by the hospital.

Interview, 04/10/14 at 1:30pm, with S48 Director Human Resources confirmed the hospital did not have respiratory therapists as employees; nor did the hospital have respiratory therapists on contract.
VIOLATION: DIRECTOR OF RESPIRATORY SERVICES Tag No: A1153
Based on record reviews and interview the hospital failed to appoint a director of respiratory care services to supervise the service and ensure respiratory care was properly administered. Findings:

Review of the credential files for physicians (S49, S50 both Family Practice Physicians; and Psychiatrists S31, S32, S43, S51), on the medical staff revealed there failed to be documented evidence a physician was appointed to be the director of respiratory care services.

Review of the Governing Body and Medical Staff meeting minutes revealed the Medical Staff failed to nominate a physician to serve as the Medical Director of Respiratory Services and the Governing Body failed to ensure there was a Medical Director of Respiratory Services.

Review of Medical Staff Bylaws revealed there failed to be documented evidence a Medical Director of Respiratory Services was required.

Interview, 04/09/14 at 10:50am, with S1 Administrator revealed if a patient required respiratory therapy services they would be transferred to Hospital A (a local acute care hospital which served as the receiving hospital per transfer agreement).
VIOLATION: CONTRACTED SERVICES Tag No: A0083
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure Radiology Services were provided according to the contracted agreement for 2 (#32, #35) of 2 patients reviewed for X-ray services as evidenced by:
I) a patient (#32) who had injured his right arm (04/0714 at 3:00 p.m.) and did not receive an X-ray until 6:50 p.m., then was transferred (at 9:30pm) and examined/treated at Hospital A's Emergency Department (local acute care) for a fractured wrist;
II) a patient (#35) sustained a head injury and did not receive a X-ray that had been ordered STAT (now) for 4 hours and 45 minutes.
Findings:

Review of the contract agreement with Radiology Contract A revealed it was dated 08/01/2011 and was reviewed by Administrative personnel again on 10/22/2013. Further review of Radiology Contract A revealed STAT (now) x-rays would be completed within 3 hours, ASAP (as soon as possible) x-rays would be done "as soon as the schedule" permitted; however, there failed to be a designated time frame for "routine" x-rays.

I) A patient (#32) who had injured his right arm, 04/07/14 at 3:00pm, and did not receive an X-ray until 6:50pm, and was examined and treated at Hospital A's Emergency Department (local acute care) for a fractured wrist.

Review of patient #32's medical record revealed the following documentation on "Interdisciplinary Notes", dated 04/07/2014: 3:00pm Patient #32 on floor of room screaming...states 'my arm got slammed in the door'; patient #32 holding his right forearm/wrist area, edema noted, bruising noted at right lower forearm, arm immobilized on pillow for support; 3:15pm S58 psychiatrist notified, and X-ray ordered; 6:50pm X-ray performed...7:45pm S58 psychiatrist notified of X-ray results and orders to transfer patient to Hospital A obtained; 9:30pm patient #32 transported to Hospital A for treatment.

Review of Physician's Orders, dated 04/07/14, 3:10pm, revealed "X-Ray (R) [right] Forearm today"...04/07/14, 7:45pm, "Transfer" to Hospital A "for evaluation of" right arm.

Review of Radiology report from Radiology Contract A revealed the "Findings" indicated "Impacted buckle type deformity distal radius about wrist" and the "Impression" was "Distal radial fracture". Continued review of the report from Radiology Contract A revealed the date of the report was 04/07/14 however there failed to be a time documented.


II) A patient (#35) sustained a head injury and did not receive a X-ray ordered STAT (now) for 4 hours and 45 minutes.

Review of the medical record for Patient #35 revealed she was a [AGE] year old female admitted on [DATE] with diagnosis which included Scizoaffective Disorder. Review of a Progress Note dated 2/18/14 at 4:00 p.m. revealed the patient fell on the floor and hit her head.

Review of a Physician's Orders sheet for Patient #35 dated 2/18/14 at 5:00 p.m. revealed an order in part: X ray of the head STAT (now).

Review of the X ray report revealed for Patient #35 revealed an x ray had been taken on 2/18/14 but no time was on the report.

Review of the observation sheet for Patient #35 dated 2/18/14 revealed "x ray" was written at 9:45 p.m.

In an interview on 4/10/14 at 4:47 p.m. with S2DON, she verified 4 hours and 45 minutes was too long for Patient #35 to obtain a STAT X ray after a head injury.
VIOLATION: CONTRACTED SERVICES Tag No: A0084
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interview, the governing body failed to ensure all services provided under contract were provided in a safe and effective manner as evidenced by:
1) failing to obtain radiology testing until 4 hours and 45 minutes after a STAT (now) X-ray had been ordered on a patient (#35) who sustained a head injury; and
2) failing to ensure the contracted radiology service (Radiology Contract A) performed the ordered testing as indicated by agreement.
Findings:

1) Failing to obtain radiology testing until 4 hours and 45 minutes after a STAT X-ray had been ordered on a patient who sustained a head injury.

Review of the medical record for Patient #35 revealed she was a [AGE] year old female admitted on [DATE] with diagnosis which included Scizoaffective Disorder. Review of a Progress Note dated 2/18/14 at 4:00 p.m. revealed the patient fell on the floor and hit her head.

Review of a Physician's Orders sheet for Patient #35 dated 2/18/14 at 5:00 p.m. revealed an order in part: X ray of the head STAT.

Review of the X ray report revealed for Patient #35 revealed an x ray had been taken on 2/18/14 but no time was on the report.

Review of the observation sheet for Patient #35 dated 2/18/14 revealed "x ray" was written at 9:45 p.m.

In an interview on 4/10/14 at 4:47 p.m. with S2DON, she verified 4 hours and 45 minutes was too long for Patient #35 to obtain a STAT X ray after a head injury.

2) Failing to ensure the contracted radiology service (Radiology Contract A) performed the ordered testing as indicated by agreement.

Review of the Radiology Contract A agreement revealed it was dated 08/01/2011 and was reviewed by Administrative personnel again on 10/22/2013. Further review of Radiology Contract A revealed STAT (now) x-rays would be completed within 3 hours, ASAP (as soon as possible) x-rays would be done "as soon as the schedule" permitted; however, there failed to be a designated time frame for "routine" x-rays.
VIOLATION: PATIENT RIGHTS: EXERCISE OF RIGHTS Tag No: A0129
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based upon record reviews and interviews the hospital failed to ensure each patient's rights were protected as evidenced by a patient (#18) being denied the right to contact the Mental Health Advocacy Service. Findings

Review of Patient #18's medical record revealed a physician's order for the patient to be allowed to use the telephone to contact the Mental Health Advocacy Service (MHAS). Continued review of the physician's orders, dated 04/08/14, revealed S32 Psychiatrist documented another order to allow Patient #18 to use the telephone to contact the MHAS.

Interview, 04/07/14 at 10:40am, with Patient #18 revealed she was admitted on [DATE] for Homicidal Ideation (HI). Patient #18 stated she had a knife in her bedroom to protect herself from her stepfather after being sexually molested by him.

Interview, 04/09/14 at 9:30am, with S32 Psychiatrist confirmed he had documented orders, on 2 separate dates, for Patient #18 to use the telephone to contact MHAS.

Patient #18 was allowed to contact MHAS on 04/10/14 after surveyors with the State of Louisiana Department of Health and Hospitals--Health Standards Section interceded on Patient #18 behalf.

Interview, 04/09/14 at 10:40am, with S2 Director of Nursing (DON), revealed patients could use the telephone to call the MHAS, all they had to do "was ask to use the phone".

Continued interview with Patient #18 confirmed she had asked 2 different staff members (she identified S29 Licensed Practical Nurse as one of the staff members, the other she could not recall), if she could use the telephone to call the MHAS.
VIOLATION: QAPI PERFORMANCE IMPROVEMENT PROJECTS Tag No: A0297
Based on record review and staff interview, the hospital failed to ensure the quality improvement projects included measurable quality indicators for the project and the measurable progress achieved for 1 of 1 (Restraint/Seclusion) performance improvement project reviewed. Findings:

Review of the hospital policy titled Performance Improvement Plan, number PI.001, current date of 11/12, and presented as current, revealed the objective of the Performance Improvement Program was to ensure all patients received appropriate and timely services in a safe environment. There was no documented evidence in the Performance Improvement Plan of a provision for performance improvement projects.

Review of the Quality Management Committee report dated 02/20/14 and 03/20/14 revealed the number of total restrain/seclusion cases were reported as 49 for January and 62 for February. Review of the reports revealed the actions to address the restraint/seclusion were related to activities and rewards. The follow up was documented on both reports as data collected monthly and presented to Quality Management Committee, PI team, and Medical Staff. There was no documented evidence that restraint/seclusion was a performance improvement project.

In an interview on 04/11/14 at 8:20 a.m., S3Performance Improvement/Risk Manager/Patient Advocate stated the hospital's performance improvement project was restraint/seclusion and stated it was reported in the Quality Management Committee meeting. Documentation of the Restraint/Seclusion performance improvement project was requested for review.

In an interview on 04/11/14 at 9:00 a.m., S3Performance Improvement/Risk Manager/Patient Advocate provided a folder of her documentation of the Restraint/Seclusion performance improvement project. There was no documented evidence of any quality indicators identified for the project and there were no measurable goals identified for the project. Review of the documentation revealed PI meetings dated 11/07/13, 11/15/13, 12/10/13, 02/07/14, 02/14/14, and 02/19/14 revealed only documentation of activities related to rewards and activities for the patients. The folder also included a spread sheet of statistical data related to restraints/seclusion that included unit, type of restraint, multiple episodes, total minutes, shift, day of week, sex, diagnosis per age group, and staff names. S3Performance Improvement/Risk Manager/Patient Advocate stated they wanted to decrease restraint/seclusion use by 10%. S3Performance Improvement/Risk Manager/Patient Advocate stated they had made improvement in restraint use, but not in the use of seclusion. S3Performance Improvement/Risk Manager/Patient Advocate verified there were no documented quality indicators for the project and no documented goals for the project.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to set priorities for high-risk, high volume and problem-prone areas as evidenced by:
1) implementing preventive actions to address sexually inappropriate behavior between patients;
2) failing to monitor the hospital process for compliance with the Pharmacist review of the patient's medication profile prior to the first dose of a new medication, and;
3) compliance with staffing levels and the prescribed observation precautions.

Findings:

1) Failed to implement preventive actions to address sexually inappropriate behavior between patients:

Patient#10
Review of Patient#10's medical record revealed he was a [AGE] year old male who had been admitted on [DATE] with diagnoses including the following: Attention Deficit Hyperactivity Disorder (ADHD), Depression/Psychosis: Severe; Mild Intellectual Disability, and Conduct Disturbance. Further review revealed the patient's legal status was PEC (Physician's Emergency Certificate) 2/3/14 at 12:45 p.m. with reason for admission listed as potential danger to self, unable to seek voluntary admission.

Review of the Hospital ' s incident reports for the last three months revealed the following incidents involving Patient #10:

2/17/14: Patient loud, disruptive, yelling and cursing staff, took an aggressive stance and threatened to " beat up staff " .
2/18/14: Physical altercation with peer.
2/28/14: agitated, threatening and cursing peers, fighting staff.
3/3/14: Patient #10 attempted to attack staff.
3/10/14: alleged touching of female peer ' s breast. Patient denies touching female peer.
3/18/14: Patient denies touching female peer.

Review of the hospital's grievance log for the last three months revealed the following complaints related to allegations of inappropriate sexual conduct against Patient #10:

Complaint #1: Date submitted: 3/12/14, Date to Patient Advocate: 3/12/14, Complainant: Patient #11: Date resolved: 3/18/14; Program involved: Nursing; Complaint Issue: Accused male peer (Patient #10) of touching.
Complaint #2: Date submitted: 3/16/14, Date to Patient Advocate: 3/19/14, Complainant: Patient #12: Date resolved: 3/20/14; Program involved: Nursing, Social Services; Complaint Issue: Accused male peer (Patient #10) of touching.

Review of Patient#10's medical record revealed a seclusion/restraint order/record dated 2/28/14 at 6:55 a.m. The explanation given for the order was as follows: Patient agitated yelling at females on unit stating, "One of you B (expletive) gonna suck my (penis) today". Fighting staff when redirected and asked to stop and go to time out.
Review of Patient#10's medical record revealed no MD orders for increased supervision or SAP precautions following the first incident of inappropriate sexual behavior on 3/10/14 (reported 3/12/14).
Review of Patient#10's Master Treatment Plan revealed sexually inappropriate behavior/language was not identified as a problem on the treatment plan after the first incident which occurred on 3/10/14. A second incident of inappropriate sexual behavior by Patient#10, almost identical to first incident, was reported by another female on 3/16/14.
Review of Patient#10's medical record revealed the following entries, in part:
Interdisciplinary Notes, dated 3/10/14, 8:00 p.m.: Hypersexual most of shift. Telling female peers, "You want to sit on it" as well as hugging another female peer who didn't complain, however was redirected yet again not to touch any peers. When redirected by charge nurse to go to room as everyone else did he said, "F (expletive) you ho." Told a peer I need another hug, can I touch your body.

Nursing Progress Notes, dated 3/10/14, 10:00 p.m., 3-11 shift: Patient#10 presents with labile affect, pushing limits, refusing to redirect at times. Female peer accused Patient#10 of touching her breast, patient stated, "I was gonna touch her but I didn't."
Review of Patient#10's Rounds Sheets revealed the patient remained on Suicide Precautions with an Observation Status of every 15 minute checks from 3/6/14 until he was placed on CVO (Constant Visual Contact) with SAP (Sexually Acting Out) perpetrator precautions on 3/18/14 at 12:30 p.m. after the occurrence of the second incident.

In an interview on 4/10/14 at 1:44 pm with S4RNQualityAssessment she said she had investigated the allegation made by Patient#12 against Patient#10 (second allegation) on 3/16/14. She was asked why Patient#10 was placed on CVO and SAP precautions after the incident on 3/16/14 and not after the incident on 3/10/14. She replied it was because it was a second allegation against Patient#10 and because the second patient (#12) had requested the police. S4RNQualityAssement was asked if she was aware Patient#10 had been placed in seclusion on 2/28/14 for being physically aggressive, fighting staff, and screaming. "All you B (expletive) are gonna suck my (penis)". She said she had not been aware of this incident and she agreed Patient#10's sexually inappropriate behavior toward the two complainants had appeared to be an escalation from the incident on 2/28/14.

In an interview on 4/10/14 at 2:12 p.m. with S12YouthServicesManager she was asked if she remembered the incident on 3/10/14 involving Patient#11 and Patient#10 and she replied, "Yes". She said Patient#11 was being discharged the day she filed the grievance against Patient#10. S12YouthServicesManager reviewed the incident report documentation and confirmed the space for notification of MD was marked no. She reviewed Patient#10's chart (MD orders, both MD and Nurse progress notes) and confirmed there was no documentation of notification of the MD of the incident nor were there any orders related to increasing supervision. S12YouthServicesManager explained it was the duty of the nurse on the unit where the incident occurred to inform the MD so he could have made a decision regarding supervision level changes for Patient#10. She explained increased supervision required an MD order and she didn't understand why the MD wasn't called. She agreed perhaps it was because Patient#11 was discharged the day she filed the grievance against Patient#10. S12YouthServicesManager also agreed, based upon Patient#10's escalation of behavior, he should have been placed on a higher level of supervision after the first incident. She explained increasing Patient#10's supervision level to CVO with SAP precautions would have resulted in the patient's placement in a private room and he would have been in constant line of sight of staff at all times. She further explained the staff would have also monitored Patient#10 for sexually inappropriate behaviors.

2) Failing to monitor the hospital process for compliance with the Pharmacist review of the patient's medication profile prior to the first dose of a new medication:
Review of the Hospital Policy titled After Hours Medication Supplies, Revised 3/14, revealed in part:
A pharmacist review of medication orders is required prior to the first dose being administered. Licensed Nurses (RN or LPN) are determined qualified to review the medication order in the absence of the pharmacist.

In an interview on 4/10/14 at 9:32 a.m. with S14RN, she said the nurses did not have to wait for the pharmacist to review new medications before they were administered to patients. S14RN said when she received the order for a new medication she pulled the medication from the Pyxis (Automated Medication Dispensing Machine) and administered it to the patient.

In an interview on 4/10/14 at 11:13 a.m. with S12RN, she said she did not have the Pharmacist review medications before she administered the first dose.

In an interview on 4/10/14 at 8:45 a.m. with S22Pharmacist, he said he was the director of pharmacy and the only pharmacist on staff at the hospital. S22Pharmacist said the pharmacy hours were 8:00 a.m. until 2:30 p.m. during the weekdays. S22Pharmacist said he came back to the pharmacy at 8:00 p.m. to check for more orders that had been written during the week. He said on the weekend, he came in to the pharmacy at 2:00 p.m. to catch the orders that were written in the morning. S22Pharmacist said the nurses did not have to have the first dose of a medication reviewed before it was administered. S22Pharmacist also said when a medication was ordered after pharmacy hours, the doses were not reviewed until the next time he came to the pharmacy. He verified when he reviewed those medications the first dose had been given already by the nursing staff. S22Pharmacist said the nurses used drug references to check doses of medications. S22Pharmacist said he knew failing to perform first dose review was a problem because the hospital's accreditation organization had pointed it out to him as a problem last year. S22Pharmacist said reviewing medications had always been a struggle because there was no 24 hour pharmacist at the hospital.

3) Compliance with staffing levels and the prescribed observation precautions:
Staffing Patient #5
Review of the medical record for Patient #5 revealed she was a [AGE] year old female admitted on [DATE] with diagnosis which included Paranoid Schizophrenia.

Review of the medical record for Patient #4 revealed he was a [AGE] year old male admitted on [DATE] with diagnosis which included Schizoaffective Disorder. Further review revealed Patient #4 had a PEC dated 2/18/14 which listed him as gravely disabled and a CEC dated 2/19/14 which listed him as acutely psychotic. Review of the Hospital hand off communication sheet for Patient #4 dated 2/20/14 at 10:30 a.m. revealed his reason for admission was, "Danger to self and others, paranoid" and his risk factors included violence, "hit another patient."

A review of the medical record for Patient #5 revealed an interdisciplinary note dated 2/23/14 at 11:50 a.m. Review of the note revealed in part: "Patient #5 was attacked by a male peer while she was standing at nurse's station speaking with nurse. A male peer walked up behind her, placed his hands on her head in a crushing like motion. He then put his arm with elbow around her neck in a head back type motion. He released her neck and shoved her to the floor and she was kicked by him 2-3 times. Patient was on the floor, on her right side and was kicked on her left side lower rib and hip area. Staff assisted Patient to shelter in the ladies shower room. Patient was crying and emotionally shaken. Her body was examined for injury. No broken skin, bleeding or bruising noted. Patient did complain of pain to her right hip area. She was able to walk and move all extremities well. She stated, " He beat me and I want the police. "Shreveport Police notified by nursing supervisors. Officer responded and collected information. Ultimately a summons was issued to the male peer and he was charged with simple battery. S43MD notified regarding patient being beat up. S43MD called Hospital A and spoke with ER MD. Patient to be taken there for evaluation."

Review of the medical record for Patient #5 revealed a Physician's Order dated 2/23/14 at 12:45 p.m. which read in part: "Send pt (patient) to Hospital A ER (emergency room ) for evaluation. Pt was physically assaulted by a male peer/ choked/ hit and thrown to the floor, kicked repeatedly when shoved to the floor."

Review of the Interdisciplinary Notes for Patient # 5 revealed an entry on 2/23/14 at 7:47 p.m. which stated in part: "To Hospital A ER via ambulance transport for physical evaluation. Patient #5 is complaining of R (right) side pain between breast and hip. She rates 10/10 at this time." Further review of the Notes and Physician's Orders revealed no documentation that the Physician had been notified that Patient #5 was not going to be sent to the ER for over 7 hours.

In an interview on 4/8/14 at 2:30 p.m. with S22RN, he said he was a nursing supervisor on the weekends at the hospital. S22RN said on 2/23/14 he wanted 5 staff for the Adult Enhanced Unit (AEU) but could only find 4 staff to work. S22RN said the AEU was 1 person short on staffing because the unit had 2 patients that were 1:1 observations. S22RN said on 2/23/14 he remembered when the ADU called a Code Green, he went to the unit and Patient #4 was already in the dining room with staff. S22RN said he talked to Patient #5 and she was complaining of pain to her abdomen where she had been kicked by Patient #4. He said the physician ordered Patient #5 to go to the emergency room to be examined at 12:45 p.m., but another patient from another unit was medically unstable and had to be sent to the hospital. S22RN said at the time if he would have sent 2 staff members to the hospital with patients the hospital would have been too short staffed. S22RN said he was not aware if the physician was notified of the delay in treatment. After review of the medical record for Patient #5, he verified there was no documentation of physician notification for the delay in sending Patient #5 to the hospital until 7:47 p.m. (7 Hours and 2 minutes after the Physician's Order). S22RN also verified after Patient #4 was made a 1:1, there were 3 patients on 1:1 for 3 staff members and 11 other patients on the AEU for 1 staff member. S22RN said the unit was definitely short staffed on 2/23/14. S22RN also said the hospital was short at least 4 staff members on various units for the 7-3 shift on 2/23/14.

Review of the Daily Staffing Worksheet for 7am-3pm on 2/23/14 revealed the beginning census on the AEU was 13 and the ending census was 14. The 1:1 patients were listed as 2 females. "3 + 2" was written above the staff ' s names. In an interview on 4/8/14 at 2:30 p.m. with S22RN he said he filled out the staffing sheets for the units on 2/23/14. He said the "3" above the staff's names was what staff he had available and the "+ 2" was how many more staff he needed for the shift. He said he needed 5 people for the shift on the AEU, but had 4 available. He also verified by the end of the shift, 3 of the 14 patients were 1:1 observation patients with only 4 staff members. He said being 1:1 required the staff member to be within arm's length of the patients at all times.

In an interview on 4/9/14 at 1:16 p.m. with S24RN, she said she worked on the AEU and was in the nurses' station when the altercation happened between Patient #4 and Patient #5 on 2/23/14. S24RN said the doctor was not notified until 25-30 minutes after the incident because she was examining Patient #5 and calming her down. S24RN said she was the first one to call the doctor and he ordered Patient #4 to be on a 1:1 observation, made some medication changes for Patient #4 and ordered Patient #5 to be sent to the Emergency Department for evaluation. S24RN said she called the nursing supervisor for more help during the shift, but he could not get anybody. S24RN also said she notified the supervisor about Patient #4 needing to go to the ED, but she did not go until about 8:00 at night. S24RN said she called back a couple of times to get Patient #4 sent to the ED, but she assumed the patient did not go until later because of staffing. S24RN said none of the phone calls were documented. S24RN was unable to locate documentation that Patient #5 was reassessed by a nurse after the initial assessment at 11:50 a.m. until she was transferred to the hospital at 7:47 p.m.

In an interview on 4/9/14 2:05 p.m. with S9RN, she said she was working on 2/23/14 on the Adult Enhanced Unit (AEU). S9RN said the two 1:1 patients she and S25MHT had were not actually being watched 1:1 because of staffing. S9RN said Patient #5 did not go to the hospital for several hours after the attack because the supervisor (S22RN) and S24RN told her there was not enough staff to bring her to the ED. S9RN said to her knowledge the physician was never notified about Patient #5 not going to the ED immediately. S9RN said she knows the AEU was short staffed on 2/23/14. S9RN said the Adult Enhanced Unit is short staffed a lot because of the high acuity of the patients.

Review of the hospital Document titled Staffing Ratios by Unit and Census Level (staffing grid) revealed in part:
Adult Enhanced Unit (AEU): 14 bed unit. 3 staff on days (7:00 a.m. - 3:00 p.m.) for 5-12 patients.
Further review revealed no staffing grid for a census over 12 patients.

In an interview on 4/10/14 at 2:50 p.m. with S2DON, she verified the staffing needed to be increased on the unit for 2/23/14 and the staffing for the 7:00 a.m. to 3:00 p.m. did not meet the hospital staffing grid requirements. S2DON said the 2 of 4 staff assigned to 1:1 patients should have not been included in the grid. S2DON said for 12 patients other than the 1:1 patients on 2/23/14, the unit required 3 staff members per the staffing grid but only had 2. She said from 3:00 p.m. until 11:00 p.m., the AEU had 5 staff but 3 patients on 1:1 which still left the unit short one staff member.

Staffing Patient #32:
Review of patient #32's medical record revealed the following documentation on "Interdisciplinary Notes", dated 04/07/2014: 3:00pm Patient #32 on floor of room screaming...states 'my arm got slammed in the door'; patient #32 holding his right forearm/wrist area, edema noted, bruising noted at right lower forearm, arm immobilized on pillow for support; 3:15pm S58 psychiatrist notified, and X-ray ordered; 6:50pm X-ray performed...7:45pm S58 psychiatrist notified of X-ray results and orders to transfer patient to Hospital A obtained; 9:30pm patient #32 transported to Hospital A for treatment.

Review of Physician's Orders, dated 04/07/14, 3:10pm, revealed "X-Ray (R) [right] Forearm today"...04/07/14, 7:45pm, "Transfer" to Hospital A "for evaluation of" right arm.

Interview, 04/09/14 at 3:00pm, with S2 Director of Nursing revealed the reason for the delay for transferring Patient #32 was as a result of not having enough personnel on staff to transport this patient. S2 DON stated Patient #32 waited because a staff member had to be called in to transport Patient #32.

Monitoring Patients as Ordered:
Review of the Hospital Policy titled Acuity Staffing Plan, Last Review/Revision Date: 3/14, Policy Number NR 003, revealed in part:
2. Constant Visual Observation:
-The patient must be maintained within the visual contact of the staff at all times.
3. One- to - One Order Criteria:
Patient Care Elements
-The patient must be maintained within the visual contact/arm's reach of the staff at all times.
-The patient is not able to leave the unit.
- At any given time, the staff assigned to provide contact/arm's reach must insure that another staff member will assume this responsibility if he/she must leave the presence of the patient (i.e. lunch breaks, etc.)
- This visual contact/arm's reach extends to a requirement for complete supervision of the patient in routine daily care, including accompaniment of patient to the bathroom.
- The Patient Observation Record is used to document the level of supervision using the every 15 minute format of this form.

Review of the Patient Assignment Sheet for the AEU dated 3/23/14 from 7:00 a.m. - 3:00 p.m. revealed the following assignments:
S24RN-Medications, Orders, Glucose Checks, a.m. group, Admit.
S9RN- Patient #34 1:1, Nurses' Notes.
S26MHT- Trays, 11 close observation patients
S25RN- Patient #35 1:1

Review of the Medical record for Patient #4 revealed an order dated 2/23/14 at 1:00 p.m. for 1:1 staffing at all times for safety. The order was not changed to Constant Visual until 2/24/14 at 9:05 a.m.
Review of the documents titled "Rounds Sheets" and "Precaution Logs" for the Adult Enhanced Unit for 2/23/14 revealed the following documentation:
S25MHT:
On 26 occasions S25MHT documented every 15 minutes she was observing both Patient #34 and Patient #35 on a 1:1 observation level. (From 7:00 a.m. until 8:00 a.m., 9:30 a.m., 10:30 a.m. - 11:00 a.m., 12:00 p.m., 12:15 p.m., 12:45 p.m. - 2:00 p.m., 4:00 p.m., 4:45 p.m., 5:00 p.m., 8:15 p.m., 8:45 p.m. - 10:00 p.m.)
At 8:15 a.m., S25MHT documented she made every 15 minute rounds on Patient #4 in his room while observing the other two 1:1 patients in the dayroom.
At 8:15-9:30, S25MHT documented she was observing 3 patients every 15 minutes in the day room and the cafeteria while watching Patient #35 on 1:1.
At 9:30 a.m., S25MHT documented watching 1 patient 1:1, one patient every 15 minutes on the patio and three patients in group in the day room.
At 12:00 p.m.-12:15 p.m. S25MHT documented she watched two patients 1:1 in addition to 4 patients every 15 minutes in the day room, 1 patient in the hall and 1 patient at the nurses ' station.
At 4:45 p.m. and 5:00 p.m. S25MHT documented she was observing Patient #4 on a 1:1 basis in addition to the other two 1:1 patients she was observing.
S9RN:
On 17 occasions S9RN documented every 15 minutes she was observing both Patient #34 and Patient #35 on a constant 1:1observation level (At 10:00 a.m., 10:15 a.m., 12:30 p.m., 2:15 p.m., 2:30 p.m., 2:45 p.m., 3:00 p.m., 3:15 p.m., 3:30 p.m., 4:15 p.m., 4:30 p.m., 5:15 p.m., 5:30 p.m., 5:45 p.m., 6:00 p.m., 6:15 p.m., 8:30 p.m.)
At 2:30 p.m. S9RN documented performing every 15 minute checks on all 11 patients and 3 patients on 1:1 observation. Patient #4 was on 1:1 in the time out room while the other two 1:1 patients were in the dayroom. The other 11 patients were documented as 7 in the dayroom, 1 in the hall, 1 in the bathroom and 2 in their rooms.
S53MHT:
At 11:00 p.m. S53 MHT documented he was 1:1 with Patient #4 and Patient #35 in two separate bedrooms. He also documented he was making 15 minute observations at 11:00 p.m. on 5 other patients in 4 separate rooms.
At 11:30 p.m. S53MHT documented he was 1:1 with Patient #4 while observing 11 other patients every 15 minutes.
At 11:45 p.m. S53MHT documented he was 1:1 with Patient #4 and Patient #35 and every 15 minute rounds on 11 other patients.

Review of the hospital Document titled Staffing Ratios by Unit and Census Level (staffing grid) revealed in part:
Adult Enhanced Unit (AEU): 14 bed unit. 3 staff on days (7:00 a.m. - 3:00 p.m.) for 5-12 patients.
Further review revealed no staffing grid for a census over 12 patients.

In an interview on 4/10/14 at 2:50 p.m. with S2DON, she reviewed the 1:1 observation sheets on the AEU dated 2/23/14 for Patient #34, Patient #35 and Patient #4. She also reviewed the staffing sheets for the other patients on the AEU on 4/10/14. S2DON verified based on the observation sheets, the patients could not have been observed at the frequency or levels ordered by the physician. S2DON also verified the staffing needed to be increased on the unit for 2/23/14 and the staffing for the 7:00 a.m. to 3:00 p.m. did not meet the hospital staffing grid requirements. S2DON said the 2 of 4 staff assigned to 1:1 patients in the beginning of the 7:00 a.m. to 3:00 p.m. should have not been included in the grid. S2DON said for 12 patients other than the 1:1 patients on 2/23/14, the unit required 3 staff members per the staffing grid but only had 2. She said from 3:00 p.m. until 11:00 p.m., the AEU had 5 staff but 3 patients on 1:1 which still left the unit short one staff member.

In an interview on 04/10/14 at 5:00 p.m., S3Performance Improvement/Risk Manager/Patient Advocate verified the hospital's Quality Improvement program did not include any quality indicators for first dose medication review by the pharmacist, sexually inappropriate behavior between patients, nor were there quality indicators for staffing or observation/precaution levels. S3Performance Improvement/Risk Manager/Patient Advocate further indicated she was not aware of problems in these areas.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview, the hospital failed to ensure the QAPI program included an analysis of medication errors and adverse events and implemented preventative actions. The QAPI program failed to include:
1) Activities to analyze the causes of patient elopements and implement preventative actions as evidence by patient elopements on 03/10/14 and 03/20/14 with no analysis of how the patients were able to elope, resulting in 4 patient elopements on 03/21/14, and;
2) Activities to analyze the causes of medication errors and implement preventative actions as evidenced by no documented evidence of an analysis of the causative factors of medication errors other than staff error, and no documented evidence of any preventative actions other than counseling of the staff involved.

Findings:

Review of the hospital policy titled Performance Improvement Plan, number PI.001, current date of 11/12, and presented as current, revealed the objective of the Performance Improvement Program was to ensure all patients received appropriate and timely services in a safe environment. The policy revealed the Performance Improvement Program Director was responsible to for assisting in the planning, implementing and monitoring of the performance improvement program and would supervise and support QAPI activities on a daily basis and take action as needed.

1) Activities to analyze the causes of patient elopements and implement preventative actions:

Review of the Incident Report Log for February-March 2014 revealed Patient #30 eloped from the adolescent unit on 03/10/14 and Patient #26 eloped from the adolescent unit on 03/20/14. Further review of the Incident Report Log revealed Patients #16, #17, #26 and #33 eloped from the adolescent unit on 03/21/14.

Review of the Incident Report for Patient #30 dated 03/10/14, revealed the patient was a [AGE] year old male that ran down the hall, broke through the magnetic locked door, ran down the stairs and out of an opened basement door and eloped from the facility at 11:50 a.m. There was no documented evidence of any further investigation into the circumstances of the elopement.

Review of the Incident Report for Patient #26 dated 03/20/14, revealed the patient was a [AGE] year old male that was agitated, busted through the double door on the Youth Enhanced Unit, kicked the stair will doors open all the way to the exit and eloped from the facility at 7:45 p.m. The incident report revealed the staff pursued the patient but were unable to catch him and the police were notified. There was no documented evidence of any further investigation into the circumstances of the elopement.

In a telephone interview on 04/10/14 at 3:15 p.m., S3Performance Improvement/Risk Manager/Patient Advocate verified there was no investigation into the circumstances of the elopements by Patient #30 and #26 and stated all she did was documented on the incident reports.


2) Activities to analyze the causes of medication errors and implement preventative actions

Review of the February 2014 Quality Management Committee meeting report dated 02/20/14, revealed 11 medication variances were reported for the month and the wrong medication administered was the most prominent variance. The action was documented as, "Medication variances are tracked by nurse responsible, shift, and reason for occurrence. The Education Coordinator reviews the medication administration policy with the responsible nurse and observed 3 medication passes."

Review of the March 2014 Quality Management Committee meeting report dated 03/20/14, revealed 14 medication variances were reported for the month and the wrong medication administered was the most prominent variance. The action was documented as, "Medication variances are tracked by nurse responsible, shift, and reason for occurrence. The Education Coordinator reviews the medication administration policy with the responsible nurse and observed 3 medication passes."

In an interview on 04/10/14 at 5:00 p.m., S3Performance Improvement/Risk Manager/Patient Advocate stated S2DON (Director of Nursing) reported the medication variance information and stated the nurse responsible for the variance was inserviced and the nurse had to be observed 3 times before being released. S3Director QAPI/Risk Manager/Patient Advocate verified there was no other analysis of medication variances conducted and there were no other corrective/preventative actions taken.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview, the hospital failed to develop quality indicators that could be used to measure, analyze, and track performance to assess processes of care as evidenced by failing to accurately collect data regarding radiology services resulting in the performance improvement program failing to identify delays in obtaining radiological tests and reports. Findings:

Patient #32
Review of patient #32's medical record revealed the following documentation on "Interdisciplinary Notes", dated 04/07/2014: 3:00pm Patient #32 on floor of room screaming...states 'my arm got slammed in the door'; patient #32 holding his right forearm/wrist area, edema noted, bruising noted at right lower forearm, arm immobilized on pillow for support; 3:15pm S? psychiatrist notified, and X-ray ordered; 6:50pm X-ray performed...7:45pm S? psychiatrist notified of X-ray results and orders to transfer patient to Hospital A obtained; 9:30pm patient #32 transported to Hospital A for treatment.

Review of Physician's Orders, dated 04/07/14, 3:10pm, revealed "X-Ray (R) [right] Forearm today"...04/07/14, 7:45pm, "Transfer" to Hospital A "for evaluation of" right arm.

Review of Radiology report from Radiology Contract A revealed the "Findings" indicated "Impacted buckle type deformity distal radius about wrist" and the "Impression" was "Distal radial fracture". Continued review of the report from Radiology Contract A revealed the date of the report was 04/07/14 however there failed to be a time documented.

Patient #35
Review of the medical record for Patient #35 revealed she was a [AGE] year old female admitted on [DATE] with diagnosis which included Scizoaffective Disorder. Review of a Progress Note dated 2/18/14 at 4:00 p.m. revealed Patient #35 fell on the floor and hit her head.

Review of a Physician's Orders sheet for Patient #35 dated 2/18/14 at 5:00 p.m. revealed an order in part: X ray of the head STAT (without delay; immediately).

Review of the X ray report revealed for Patient #35 revealed an x ray had been taken on 2/18/14 but no time was on the report.

Review of the observation sheet for Patient #35 dated 2/18/14 revealed "x ray" was written at 9:45 p.m.

In an interview on 4/10/14 at 4:47 p.m. with S2DON, she verified 4 hours and 45 minutes was too long for Patient #35 to obtain a STAT X ray after a head injury.

Review of the Quality Management Committee reports dated 02/20/14 and 03/20/14 revealed the following report for Radiology Services:
02/20/14 - Total time for x-ray services decreased slightly over the previous month. There were no complaints regarding x-ray services in January.
03/20/14 - Total time for x-ray services was unchanged over the previous month. There were no complaints regarding x-ray services in February.

In an interview on 04/10/14 at 5:00 p.m., S3Performance Improvement/Risk Manager/Patient Advocate stated she was not aware of any problems with radiology services and was not aware of any delays in getting X-rays done. S3Performance Improvement/Risk Manager/Patient Advocate stated S52Director of Clinical Services was responsible for radiology.

In an interview on 04/10/14 at 5:10 p.m., S52Director of Clinical Services was asked how he evaluated radiology services. He stated the radiology contractor sends him a report and he based his evaluation of the services on the report. S52Director of Clinical Services the report was an average of times the tests were obtained by month. He verified the report did not reflect stat orders and times completed. S52Director of Clinical Services verified he did not collect any data from within the hospital and relied solely on the report from the radiology contractor.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based upon observations, record reviews and interviews, the hospital failed to ensure patient rooms and equipment were provided in a safe setting. This was evidenced by:
I) the use of rooms (Room #s 244 and 246) to sleep patients on the Adolescent Open Unit when they were short of beds on the unit. The rooms had ceiling tiles present in these rooms and in the bathrooms that could allow patients to escape or harm themselves, i.e. ligature hazard;
II) failing to transfer a patient to a local emergency room for evaluation and treatment after an attack by another patient for 7 hours and 2 minutes after the Physician's Order had been written; delay of transporting a patient with a wrist/arm fracture; and failing to transport a patient who sustained a head injury for treatment due to lack of staffing for 3(#5, #32, #35) of 3 (#5, #32, #35) patients reviewed for response to injury;
III) failing to investigate the causative factors of patient elopements and ensure adequate supervision of patients to prevent patient elopements for 5 of 5 (#16, #17, #26, #30, #33) sampled patients reviewed for elopement;
IV) failing to implement a safety plan for the use of patient beds that had cranks and side rails; shower room #2 on the Youth Enhanced Unit had ceiling tiles (non-monolithic ceilings) and fluorescent light bulbs that were easily accessible; also found in the ceiling was a 19 inch rigid wire rod, telephone cords, and pipes large enough to provide a ligature risk.
Findings:

I) Observations conducted, 04/08/14 5:25am through 5:45am, (on the Female Adolescent Unit), revealed 5 patients (#s 2, 3, 19, 20, 21), were sleeping in the dayroom on roll-away beds. There were no males noted to be sleeping in the dayroom on the Adolescent Male Unit. Observation made of rooms 244 and 246 revealed these 2 rooms were not being utilized on this morning's observations as "sleeping rooms". However, when rooms 244 and 246 were utilized for patients, the hospital did not take steps to ensure patient safety related to the non-monolithic ceilings located in the rooms and bathrooms. Any patient who utilized room 244 or 246 could remove the ceiling tiles and either make attempts at escape, injury or hang themselves.

Interview, on 4/8/14 at 2:30pm with S22 RN House Supervisor, revealed he stated the Adolescent unit was a 42 bed unit, but they adjusted the rooms to sleep 4 more people on the unit. S22 RN House Supervisor stated the chairs and desks were removed from 2 rooms (identified as Room #s 244, 246 that were used as Consultation offices) and put roll away beds in the rooms for the patients to sleep.

II) Failing to transfer a patient to a local emergency room for evaluation and treatment after an attack by another patient for 7 hours and 2 minutes after the Physician's Order had been written due to lack of staffing.

Review of the medical record for Patient #5 revealed she was a [AGE] year old female admitted on [DATE] with diagnosis which included Paranoid Schizophrenia.

Review of the medical record for Patient #4 revealed he was a [AGE] year old male admitted on [DATE] with diagnosis which included Schizoaffective Disorder. Further review revealed Patient #4 had a PEC (Physician Emergency Certificate) dated 2/18/14 which listed him as gravely disabled and a CEC (Coroner Emergency Certificate) dated 2/19/14 which listed him as acutely psychotic. Review of the Hospital hand off communication sheet for Patient #4 dated 2/20/14 at 10:30 a.m. revealed his reason for admission was, "Danger to self and others, paranoid" and his risk factors included violence, "hit another patient."

A review of the medical record for Patient #5 revealed an interdisciplinary note dated 2/23/14 at 11:50 a.m. Review of the note revealed in part: " Patient #5 was attacked by a male peer while she was standing at nurse's station speaking with nurse. A male peer walked up behind her, placed his hands on her head in a crushing like motion. He then put his arm with elbow around her neck in a head back type motion. He released her neck and shoved her to the floor and she was kicked by him 2-3 times. Patient was on the floor, on her right side and was kicked on her left side lower rib and hip area. Staff assisted Patient to shelter in the ladies shower room. Patient was crying and emotionally shaken. Her body was examined for injury. No broken skin, bleeding or bruising noted. Patient did complain of pain to her right hip area. She was able to walk and move all extremities well. She stated, " He beat me and I want the police. " Shreveport Police notified by nursing supervisors. Officer responded and collected information. Ultimately a summons was issued to the male peer and he was charged with simple battery. S43MD notified regarding patient being beat up. S43MD called Hospital A and spoke with ER MD. Patient to be taken there for evaluation."

Review of the medical record for Patient #5 revealed a Physician's Order dated 2/23/14 at 12:45 p.m. which read in part: "Send pt (patient) to Hospital A ER (emergency room ) for evaluation. Pt was physically assaulted by a male peer/ choked/ hit and thrown to the floor, kicked repeatedly when shoved to the floor."

Review of the Interdisciplinary Notes for Patient # 5 revealed an entry on 2/23/14 at 7:47 p.m. which stated in part: "To Hospital A ER via ambulance transport for physical evaluation. Patient #5 is complaining of R (right) side pain between breast and hip. She rates 10/10 at this time." Further review of the Notes and Physician's Orders revealed no documentation that the Physician had been notified that Patient #5 was not going to be sent to the ER for over 7 hours.

In an interview on 4/8/14 at 2:30 p.m. with S22RN, he said he was a nursing supervisor on the weekends at the hospital. S22RN said on 2/23/14 he wanted 5 staff for the Adult Enhanced Unit (AEU) but could only find 4 staff to work. S22RN said the AEU was 1 person short on staffing because the unit had 2 patients that were 1:1 observations. S22RN said on 2/23/14 he remembered when the ADU called a Code Green, he went to the unit and Patient #4 was already in the dining room with staff. S22RN said he talked to Patient #5 and she was complaining of pain to her abdomen where she had been kicked by Patient #4. He said the physician ordered Patient #5 to go to the emergency room to be examined at 12:45 p.m., but another patient from another unit was medically unstable and had to be sent to the hospital. S22RN said at the time if he would have sent 2 staff members to the hospital with patients the hospital would have been too short staffed. S22RN said he was not aware if the physician was notified of the delay in treatment. After review of the medical record for Patient #5, he verified there was no documentation of physician notification for the delay in sending Patient #5 to the hospital until 7:47 p.m. (7 Hours and 2 minutes after the Physician ' s Order). S22RN also verified after Patient #4 was made a 1:1, there were 3 patients for 3 staff members on 1:1 and 11 other patients on the AEU for 1 staff member. S22RN said the unit was definitely short staffed on 2/23/14. S22RN also said the hospital was short at least 4 staff members on various units for the 7-3 shift on 2/23/14.

Review of the Daily Staffing Worksheet for 7am-3pm on 2/23/14 revealed the beginning census on the AEU was 13 and the ending census was 14. The 1:1 patients were listed as 2 females. "3 + 2" was written above the staff ' s names. In an interview on 4/8/14 at 2:30 p.m. with S22RN he said he filled out the staffing sheets for the units on 2/23/14. He said the " 3 " above the staff ' s names was what staff he had available and the "+ 2" was how many more staff he needed for the shift. He said he needed 5 people for the shift on the AEU, but had 4 available. He also verified by the end of the shift, 3 of the 14 patients were 1:1 observation patients with only 4 staff members. He said being 1:1 required the staff member to be within arm' s length of the patients at all times.

In an interview on 4/9/14 at 1:16 p.m. with S24RN, she said she worked on the AEU and was in the nurses' station when the altercation happened between Patient #4 and Patient #5 on 2/23/14. S24RN said the doctor was not notified until 25-30 minutes after the incident because she was examining Patient #5 and calming her down. S24RN said she was the first one to call the doctor and he ordered Patient #4 to be on a 1:1 observation, made some medication changes for Patient #4 and ordered Patient #5 to be sent to the Emergency Department for evaluation. S24RN said she called the nursing supervisor for more help during the shift, but he could not get anybody. S24RN also said she notified the supervisor about Patient #4 needing to go to the ED, but she did not go until about 8:00 at night. S24RN said she called back a couple of times to get Patient #4 sent to the ED, but she assumed the patient did not go until later because of staffing. S24RN said none of the phone calls were documented. S24RN was unable to locate documentation that Patient #5 was reassessed by a nurse after the initial assessment at 11:50 a.m. until she was transferred to the hospital at 7:47 p.m.

In an interview on 4/9/14 2:05 p.m. with S9RN, she said she was working on 2/23/14 on the Adult Enhanced Unit (AEU). S9RN said the two 1:1 patients she and S25MHT had were not actually being watched 1:1 because of staffing. S9RN said Patient #5 did not go to the hospital for several hours after the attack because the supervisor (S22RN) and S24RN told her there was not enough staff to bring her to the ED. S9RN said to her knowledge the physician was never notified about Patient #5 not going to the ED immediately. S9RN said she knows the AEU was short staffed on 2/23/14. S9RN said the Adult Enhanced Unit is short staffed a lot because of the high acuity of the patients.

Review of the hospital Document titled Staffing Ratios by Unit and Census Level (staffing grid) revealed in part:
Adult Enhanced Unit (AEU): 14 bed unit. 3 staff on days (7:00 a.m. - 3:00 p.m.) for 5-12 patients.
Further review revealed no staffing grid for a census over 12 patients.

In an interview on 4/10/14 at 2:50 p.m. with S2DON, she verified the staffing needed to be increased on the unit for 2/23/14 and the staffing for the 7:00 a.m. to 3:00 p.m. did not meet the hospital staffing grid requirements. S2DON said the 2 of 4 staff assigned to 1:1 patients should have not been included in the grid. S2DON said for 12 patients other than the 1:1 patients on 2/23/14, the unit required 3 staff members per the staffing grid but only had 2. She said from 3:00 p.m. until 11:00 p.m., the AEU had 5 staff but 3 patients on 1:1 which still left the unit short one staff member. S2DON also verified she could not locate a nursing or physician assessment of Patient #5 after the initial assessment at 11:50 a.m. until she was transferred to the hospital at 7:47 p.m.

Review of Patient #32's medical record revealed: "Interdisciplinary Notes", dated 04/07/2014: 3:00pm Patient #32 on floor of room screaming...states 'my arm got slammed in the door'; patient #32 holding his right forearm/wrist area, edema noted, bruising noted at right lower forearm, arm immobilized on pillow for support; 3:15pm S58 psychiatrist notified, and X-ray ordered; 6:50pm X-ray performed...7:45pm S58 psychiatrist notified of X-ray results and orders to transfer patient to Hospital A obtained; 9:30pm patient #32 transported to Hospital A for treatment.

Review of the medical record for Patient #35 revealed she was a [AGE] year old female admitted on [DATE] with diagnosis which included Scizoaffective Disorder. Review of a Progress Note dated 2/18/14 at 4:00 p.m. revealed the patient fell on the floor and hit her head.

Review of a Physician's Orders sheet for Patient #35 dated 2/18/14 at 5:00 p.m. revealed an order in part: X ray of the head STAT.

Review of the X ray report revealed for Patient #35 revealed an x ray had been taken on 2/18/14 but no time was on the report.

Review of the observation sheet for Patient #35 dated 2/18/14 revealed "x ray" was written at 9:45 p.m.

In an interview on 4/10/14 at 4:47 p.m. with S2DON, she verified 4 hours and 45 minutes was too long for Patient #35 to obtain a STAT X ray after a head injury.




III) Failing to investigate the causative factors of patient elopements and ensure adequate supervision of patients to prevent patient elopements for 5 of 5 (#16, #17, #26, #30, #33) sampled patients reviewed for elopement:

Review of the hospital policy titled Elopement Procedure, number TX.003, current date of 02/14, presented as current, revealed in part the following: Policy: It is the policy of [hospital] to prevent patient elopements whenever possible and to provide consistent methods of follow-up in the event that they do occur. Procedure: Elopement Precautions: All patients deemed as elopement risks should be placed on Elopement Precautions according to the severity of the risk of elopement....Clear assignment must be made of a staff member responsible for precautions implementation and monitoring. High-risk patients should be clearly identified to all staff and elopement precautions related in shift report on a shift by shift basis....When not involved in program activities, staff will keep the patient in common areas for easy observation and monitoring....Staff shall maintain heightened alert during times of potential chaos or confusion (i.e.: medication times, shift change times, emergency code situations, loud combative or belligerent patients who may be serving as a diversion, etc.)...

Review of the Incident Report for Patient #26 dated 03/20/14, revealed the patient was a [AGE] year old male that was agitated, busted through the double door on the Youth Enhanced Unit, kicked the stair well doors open all the way to the exit and eloped from the facility at 7:45 p.m. The incident report revealed the staff pursued the patient but were unable to catch him and the police were notified. There was no documented evidence of any further investigation into the circumstances of the elopement.

In a telephone interview on 04/10/14 at 3:15 p.m., S3Performance Improvement/Risk Manager/Patient Advocate verified there was no investigation into the circumstances of the elopements by Patient #26 and stated all she did was documented on the incident reports.

Patient #30
Review of the clinical record for Patient #30 revealed the patient was a [AGE] year old male admitted on [DATE] under a PEC (Physician Emergency Certificate) for suicidal, dangerous to self, and unable to seek voluntary admission. The patient's diagnosis included Mood Disorder, Impulse Control Disorder, Attention Deficit Hyperactivity Disorder, Conduct Disorder, and Relationship Problems. The patient was also in the custody of DCFS (Department of Child and Family Services).

Review of the physician orders dated 02/27/14 revealed Suicidal, Self-Mutilation/Injury, and Elopement Precautions were ordered.

Review of the Nursing Progress Note dated 03/10/14 revealed at 11:50 a.m., Patient #30 eloped from the building after he kicked the exit door of the unit open and ran down the stair well to the basement and out of the building. The Nursing Progress Notes revealed the patient returned to the hospital at 12:15 p.m. and was brought back on the unit. Upon returning to the unit, Patient #30 kicked the door open again, but returned on his own. The note revealed the patient attempted to kick the door open a third time, but was redirected and then transferred to a more secure unit.

Review of the Incident Report dated 03/10/14 at 11:50 a.m. revealed Patient #30 ran down the hall breaking through the magnetic locked door and ran down the stairs and out of an open basement door. There was no documented evidence of any investigation of the incident or how the patient was able to kick open the locked doors.

Review of the Nursing Progress Noted dated 03/21/14 revealed at 7:40 a.m. Patient #30 was anxious, irritated and yelling at S19RN. The patient was unable to be redirected or calmed down. S19RN documented the patient room doors were unlocked at 7:46 a.m. in an attempt to re-establish order on the unit. At 7:50 a.m., S19RN documented a search of the unit was made and Patient #30 was not located in his room. The unit was searched again and Patient #30 was not located.

Review of the Assignment Sheet and Daily Staffing Worksheet for the Adolescent Unit on 03/21/14 revealed a census of 40 patients with 3 MHTs (Mental Health Technicians), 1 LPN, and 3 RNs. The assignment sheet revealed the LPN and 1 RN were assigned to the desk/Medications, leaving 3 MHTs and 1RN and 1RN charge nurse to monitor 40 patients. The assignment sheet revealed 3 patients were on CVO (Constant Visual Observation). There was no designation on the assignment sheet of patients on Elopement Precautions.

Review of the Hospital Abuse/Neglect Initial Report (HSS-HO-41) dated 03/21/14 revealed Patient #30 pushed through the adolescent hallway exterior door, with other peers following him. (Patient #16, #17, and #33). Patient #16 and #17 were returned by police at 10:37 a.m. Patient #30 and #33 were returned by police at 11:24 a.m. Review of the investigation of the elopement revealed the following: The adolescent male patients were going to their rooms in effort to separate the group and allow for them to deescalate due to tension among the group While the nurse and MHT were unlocking the patient rooms the male patients were gathered in the hallway and that is when 4 male patients walked to the stairwell door and were able to push it open, ran down the stairs to the ground floor, out the door and ran from the facility....On the morning of the incident, prior to the elopement, the Fire Alarm System was being tested . During that time the magnetic doors were released for safety reasons to allow for evacuation in case of fire. Once the testing of the alarm system is completed the magnetic doors are supposed to re-engage. However the doors did not re-engage that day as patients were able to elope through the door. The problem with the door was discovered after the elopement and repaired promptly.

Patient #16
Review of the clinical record for Patient #16 revealed the patient was a [AGE] year old male admitted on [DATE] under a PEC for suicidal, violent, dangerous to self and unwilling/unable to seek voluntary admission. Review of the record revealed a CEC (Coroner's Emergency Certificate) dated 03/20/14 for dangerous to self and unable to seek voluntary admission. Review of the physician's admission orders revealed the patient was ordered to be on Elopement and Suicidal Precautions. Further review of the record revealed Patient #16 was placed on CVO (Constant Visual Observation) on 03/20/14 due to active suicidal ideation's. Review of the Nursing Progress Note dated 03/21/14 at 7:40 a.m. revealed the patient was anxious and irritable, and at 7:50 a.m., was unable to be found after a search of the unit was conducted. Further review of the note revealed the patient was returned to the hospital by the police at 10:50 a.m. Further review of the Assignment Sheet revealed no documented evidence that Patient #16 was on CVO. There was no designation on the assignment sheet of patients on Elopement Precautions.

In an interview on 04/09/14 at 4:20 p.m., S3Performance Improvement/Risk Manager/Patient Advocate stated she was not sure if the patients busted the door open or if the doors were not engaged. She stated the fire alarm tests were done by the hospital.

In an interview on 04/10/14 at 9:40 a.m., S27RN stated on 03/21/14 she was assigned to the Youth Enhanced Unit but went to the adolescent unit after 4 patients had eloped. S27RN stated there was an elopement the night before (on 03/20/14) and the magnetic doors were working as they had maintenance check the doors. S27RN stated Patient #26 stated he did not think the doors were locked and was able to push through the doors. S27RN stated the patient reported the exit from the basement was harder to open. S27RN stated Patient #26 returned to the hospital before midnight because he got cold. S27RN stated the fire drill was in the afternoon after the 4 patients had eloped. S27RN stated Patient #30 was on elopement precautions and was aware Patient #26 had eloped the night before. S27RN stated on 03/21/14 they did not have as many male MHTs as they normally have and the patients take advantage of that. When asked what was done for patients on Elopement Precautions, she stated, "just watch closer." S27RN stated if the patient has made threats or attempts, they put them on CVO.

In an interview on 04/10/14 at 10:35 a.m., S19RN verified she was the charge nurse on the adolescent unit on the 7:00 a.m. to 3:00 p.m. shift on 03/21/14 when the 4 patients eloped. S19RN stated Patient #30 was the "ring leader" and told the other patients the staff were lying to them about unit restrictions that were imposed the night before. She stated Patient #30 got Patient #36 agitated and the staff were trying to remove the other patients away from Patient #36. S19RN stated S38MHT unlocked the patients' room doors and she sent the patients to their rooms to quiet down and regain order on the unit. She stated she got her patient census and started checking for all patients. S19RN stated, "That's when I couldn't locate Patients #16. #17, #30, and #33. She stated Patient #30's room was at the end of the hall by the exit and Patient #26 eloped from that exit door the night before. S19RN stated she called S12 Youth Services Manager to look at the video tape and that is when they saw the 4 patients leave the exit door at the end of the hall. S19RN stated she recalled the fire alarm was being checked but she was not sure when. S19RN stated Patient #30 and #33 were returned to the hospital by the police around 11:00 a.m. to 11:30 a.m.

In an interview on 04/10/14 at 2:50 p.m., S5Plant Operations stated there was an incidental alarm on 03/18/14 resulting in a gray period from 03/1814 to 03/21/14 where they do not know if the magnetic doors were locked. He stated there was a reset button on the main fire alarm panel and maintenance or Nursing Supervisors can reset the panel to lock the doors. He stated no one routinely checks the doors to ensure they are locked and there are no alarms when the doors are opened. S5Plant Operations stated they did not realized there was a problem until the door company came out (03/21/14), checked the doors and found the doors were not locking due to the fire system was not reset. He stated the Fire Alarm company came out and determined the fire alarm panel was not reset properly. S5Plant Operations stated maintenance had not correctly reset the fire alarm panel. S5Plant Operations provided the "final report" of the investigation regarding the elopements on 03/21/14. Review of the email, "final report", dated 04/02/14 revealed the following: The hospital was conducting maintenance tests, sprinkler system enhancements and maintenance staff training the week of March 17, we are unable to specifically determine which action left the magnetic locks disengaged. However, all maintenance staff members were educated on how to reactivate the magnetic locks as well as the importance of validating this step was completed.

IV) Observations on 4/7/14 at 9:45 a.m. revealed Shower Room #2 on the Youth Enhanced Unit had ceiling tiles (non-monolithic ceilings) and fluorescent light bulbs that were easily accessible. Also found in the ceiling was a 19 inch rigid wire rod, telephone cords, and pipes large enough to provide a ligature risk.

In an interview on 4/7/14 at 9:55 a.m. with S2DON, she agreed the non-monolithic tiles in the shower room could have provided access to the potential ligature fixtures that were noted within the ceiling tiles (large pipes and telephone cords). She also agreed the 19 inch rigid wire rod was a potential hazard. She acknowledged that the fluorescent light bulbs were accessible and could also be hazardous.

In an interview on 4/10/14 at 9:11 a.m. with S27RN (Youth Enhanced Unit), she said she has found sharp objects inside ceiling tiles that have been shifted/moved. She also said if ceiling tiles were noted to have been hanging down or moved maintenance should have been called to fix them because the patient's hide stuff in there.

Further observations on 4/7/14 revealed the beds in rooms 333, 361, 367, 369, 381, 387, and 389 had cranks located at the end of the beds along with upper side rails. Interview with S2 RN/DON on 4/8/14 at 1:30 p.m. revealed the hospital did not have a policy and procedure related to the use of crank beds and side rails in the patient rooms to ensure patient safety.
VIOLATION: RESPIRATORY CARE SERVICES Tag No: A1151
Based on record reviews and interviews the hospital failed to met the Condition of Participation for Respiratory Care Services as evidenced by:

1) failing to appoint a director of respiratory care services to supervise the service and ensure respiratory care was properly administered (A1153);

2) failing to have Respiratory Therapy Technician/s employee/s or contract employee/s to administer respiratory therapy services to patients should they require these services and have their qualifications specified by the Medical Staff. (A1154);

3) failing to ensure the respiratory therapy services were delivered according to written directives made by the Medical Staff (A1160); and

4) failing to ensure policies/procedures specifically addressing qualifications and the amount of supervision required to perform specific respiratory therapy procedures were designated in writing (A1161).
VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
Based on record reviews and interview, the governing body failed to ensure that the hospital's Performance Improvement Plan reflected the hospital's organization and services as evidenced by not having all hospital departments and services including those services furnished under contract involved in the Performance Improvement Plan.
Findings:

Review of the hospital policy titled Performance Improvement Plan, number PI.001, current date of 11/12, and presented as current, revealed the purpose of the Performance Improvement Program was to continually monitor and evaluate the full extent of services provided by all practitioners in the organization, including contracted services.

Review of the Quality Management Committee reports dated 02/20/14 and 03/20/14 revealed no documented evidence that respiratory services, laundry/linen services, bio-hazardous waste disposal services, and housekeeping services were included in the quality improvement program.

Review of the hospital contracts, policies and procedures, medical staff appointments and credentialing files, and current personnel records revealed the hospital did not have policies and procedures to address all areas of respiratory therapy, the hospital did not have a Medical Director over Respiratory Services, and the hospital did not have a Respiratory Therapist on staff/contact. On 04/11/14 at 11:40am, S2 Director of Nursing confirmed the nursing staff performed respiratory services in the hospital should a patient require this service.

In an interview on 04/10/14 at 5:00 p.m., S3Performance Improvement/Risk Manager/Patient Advocate verified respiratory services, laundry/linen services, bio-hazardous waste disposal services, and housekeeping services were not included in the performance improvement program.
VIOLATION: RESPIRATORY CARE SERVICES POLICIES Tag No: A1160
Based on record reviews and interviews, the hospital failed to ensure respiratory services were delivered in accordance with written Medical Staff directives. Findings:

Review of policies/procedures for respiratory therapy included:
A. Policy Number TX.056 titled Respiratory Therapy: Hand Held Nebulizer Therapy...I. POLICY To provide instruction for hand held nebulizer treatments II. PROCEDURE All ...treatments...are administered by Respiratory Therapy Services or Nursing staff...

B. Policy Number TX.059 titled Respiratory Therapy: Oxygen Therapy and Humidity...I. POLICY Bubble humidifiers are used on all patients with supplemental oxygen...II. PROCEDURE...

C. Policy Number TX.060 titled Respiratory Therapy: Nasal CPAP...I. POLICY To provide direction for the set up, monitoring, and discontinuing of nasal CPAP...a collaborative effort between nursing and respiratory therapy for the best possible outcome for the patient...

D. Policy Number TX.061 titled Respiratory Therapy: Pulse Oximetry...I. POLICY To provide information to Nursing staff as to why and how pulse oximeters are monitored...

Continued review of the Respiratory Services policies/procedures revealed the above (A through D) were the only respiratory therapy service policies given to the surveyor for review.

Review of the above policies/procedures revealed there failed to be documentation in the policies related to: Safety practices, including infection control measures for equipment, sterile supplies, biohazardous waste, posting of signs, and gas line identification;
o Handling, storage, and dispensing of therapeutic gases to both inpatients and outpatients;
o Cardiopulmonary resuscitation;
o Procedures to follow in the advent of adverse reactions to treatments or interventions;
o Pulmonary function testing;
o Therapeutic percussion and vibration;
o Bronchopulmonary drainage;
o Mechanical ventilatory and oxygenation support;
o Aerosol, humidification, and therapeutic gas administration;
o Storage, access, control, administration of medications and medication errors; and
o Procedures for obtaining and analyzing blood samples (e.g., arterial blood gases).

Interview, 04/11/14 at 11:40am, with S2 Director of Nursing confirmed the nursing staff performed respiratory services in the hospital should a patient require this service.

Review of personnel files for Registered Nurses (RN) and Licensed Practical Nurses (LPN) revealed there failed to be documented evidence they had received training specific to the administration of respiratory therapy services (RNs--S6, S12, S14, S15, S19, S24, S28, S33, S40, S41, S55; LPNs-- S7, S29, S54, S56).
VIOLATION: RESPIRATORY CARE PERSONNEL POLICIES Tag No: A1161
Based on record reviews and interview, the hospital failed to ensure the personnel qualified to perform specific respiratory therapy services and the amount of supervision required for personnel to carry out the specific respiratory therapy procedures were designated in writing. Findings:

Review of policies/procedures for respiratory therapy included:
A. Policy Number TX.056 titled Respiratory Therapy: Hand Held Nebulizer Therapy...I. POLICY To provide instruction for hand held nebulizer treatments II. PROCEDURE All ...treatments...are administered by Respiratory Therapy Services or Nursing staff...

B. Policy Number TX.059 titled Respiratory Therapy: Oxygen Therapy and Humidity...I. POLICY Bubble humidifiers are used on all patients with supplemental oxygen...II. PROCEDURE...

C. Policy Number TX.060 titled Respiratory Therapy: Nasal CPAP...I. POLICY To provide direction for the set up, monitoring, and discontinuing of nasal CPAP...a collaborative effort between nursing and respiratory therapy for the best possible outcome for the patient...

D. Policy Number TX.061 titled Respiratory Therapy: Pulse Oximetry...I. POLICY To provide information to Nursing staff as to why and how pulse oximeters are monitored...

Continued review of the Respiratory Services policies/procedures revealed the above (A through D) were the only respiratory therapy service policies given to the surveyor for review.

Review of the Medical Staff Bylaws revealed they failed to include approval of the scope of diagnostic and/or therapeutic respiratory services and to define in writing the specific respiratory services provided by the hospital.

Review of the Governing Body Bylaws/meeting minutes revealed the Respiratory Therapy services were not defined in writing and approved as evidenced by failure of the Governing Body to designate Respiratory Services as one of the clinical services provided by the hospital.

Interview, 04/10/14 at 1:30pm, with S48 Director Human Resources confirmed the hospital did not have respiratory therapists as employees; nor did the hospital have respiratory therapists on contract.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review, the hospital failed to ensure the nursing service had adequate numbers of licensed registered nurses, licensed practical nurses, and mental health technicians to provide nursing care to all patients as needed. This deficient practice is evidenced by:
1) failing to transfer a patient to a local emergency room for evaluation and treatment after an attack by another patient for 7 hours and 2 minutes after the Physician's Order had been written due to lack of staffing for 1 (#5) of 3 (#5, #32, #35) patients reviewed for response to injury.
2) failing to transfer an adolescent patient with a broken wrist to the emergency room for treatment for 1 hour and 45 minutes after the order had been written for 1 (#32) of 3 (#5, #32, #35) patients reviewed for response to injury.
Findings:

1) Failing to transfer a patient to a local emergency room for evaluation and treatment after an attack by another patient for 7 hours and 2 minutes after the Physician's Order had been written due to lack of staffing.
Review of the medical record for Patient #5 revealed she was a [AGE] year old female admitted on [DATE] with diagnosis which included Paranoid Schizophrenia.

Review of the medical record for Patient #4 revealed he was a [AGE] year old male admitted on [DATE] with diagnosis which included Schizoaffective Disorder. Further review revealed Patient #4 had a PEC dated 2/18/14 which listed him as gravely disabled and a CEC dated 2/19/14 which listed him as acutely psychotic. Review of the Hospital hand off communication sheet for Patient #4 dated 2/20/14 at 10:30 a.m. revealed his reason for admission was, "Danger to self and others, paranoid" and his risk factors included violence, "hit another patient."

A review of the medical record for Patient #5 revealed an interdisciplinary note dated 2/23/14 at 11:50 a.m. Review of the note revealed in part: " Patient #5 was attacked by a male peer while she was standing at nurse's station speaking with nurse. A male peer walked up behind her, placed his hands on her head in a crushing like motion. He then put his arm with elbow around her neck in a head back type motion. He released her neck and shoved her to the floor and she was kicked by him 2-3 times. Patient was on the floor, on her right side and was kicked on her left side lower rib and hip area. Staff assisted Patient to shelter in the ladies shower room. Patient was crying and emotionally shaken. Her body was examined for injury. No broken skin, bleeding or bruising noted. Patient did complain of pain to her right hip area. She was able to walk and move all extremities well. She stated, " He beat me and I want the police. " Shreveport Police notified by nursing supervisors. Officer responded and collected information. Ultimately a summons was issued to the male peer and he was charged with simple battery. S43MD notified regarding patient being beat up. S43MD called Hospital A and spoke with ER MD. Patient to be taken there for evaluation. "

Review of the medical record for Patient #5 revealed a Physician's Order dated 2/23/14 at 12:45 p.m. which read in part: "Send pt (patient) to Hospital A ER (emergency room ) for evaluation. Pt was physically assaulted by a male peer/ choked/ hit and thrown to the floor, kicked repeatedly when shoved to the floor."

Review of the Interdisciplinary Notes for Patient # 5 revealed an entry on 2/23/14 at 7:47 p.m. which stated in part: "To Hospital A ER via ambulance transport for physical evaluation. Patient #5 is complaining of R (right) side pain between breast and hip. She rates 10/10 at this time." Further review of the Notes and Physician's Orders revealed no documentation that the Physician had been notified that Patient #5 was not going to be sent to the ER for over 7 hours.

In an interview on 4/8/14 at 2:30 p.m. with S22RN, he said he was a nursing supervisor on the weekends at the hospital. S22RN said on 2/23/14 he wanted 5 staff for the Adult Enhanced Unit (AEU) but could only find 4 staff to work. S22RN said the AEU was 1 person short on staffing because the unit had 2 patients that were 1:1 observations. S22RN said on 2/23/14 he remembered when the ADU called a Code Green, he went to the unit and Patient #4 was already in the dining room with staff. S22RN said he talked to Patient #5 and she was complaining of pain to her abdomen where she had been kicked by Patient #4. He said the physician ordered Patient #5 to go to the emergency room to be examined at 12:45 p.m., but another patient from another unit was medically unstable and had to be sent to the hospital. S22RN said at the time if he would have sent 2 staff members to the hospital with patients the hospital would have been too short staffed. S22RN said he was not aware if the physician was notified of the delay in treatment. After review of the medical record for Patient #5, he verified there was no documentation of physician notification for the delay in sending Patient #5 to the hospital until 7:47 p.m. (7 Hours and 2 minutes after the Physician ' s Order).S22RN also verified after Patient #4 was made a 1:1, there were 3 patients on 1:1 for 3 staff members and 11 other patients on the AEU for 1 staff member. S22RN said the unit was definitely short staffed on 2/23/14. S22RN also said the hospital was short at least 4 staff members on various units for the 7-3 shift on 2/23/14.

Review of the Daily Staffing Worksheet for 7am-3pm on 2/23/14 revealed the beginning census on the AEU was 13 and the ending census was 14. The 1:1 patients were listed as 2 females. " 3 + 2 " was written above the staff ' s names. In an interview on 4/8/14 at 2:30 p.m. with S22RN he said he filled out the staffing sheets for the units on 2/23/14. He said the " 3 " above the staff ' s names was what staff he had available and the " + 2 " was how many more staff he needed for the shift. He said he needed 5 people for the shift on the AEU, but had 4 available. He also verified by the end of the shift, 3 of the 14 patients were 1:1 observation patients with only 4 staff members. He said being 1:1 required the staff member to be within arm' s length of the patients at all times.

In an interview on 4/9/14 at 1:16 p.m. with S24RN, she said she worked on the AEU and was in the nurses' station when the altercation happened between Patient #4 and Patient #5 on 2/23/14. S24RN said the doctor was not notified until 25-30 minutes after the incident because she was examining Patient #5 and calming her down. S24RN said she was the first one to call the doctor and he ordered Patient #4 to be on a 1:1 observation, made some medication changes for Patient #4 and ordered Patient #5 to be sent to the Emergency Department for evaluation. S24RN said she called the nursing supervisor for more help during the shift, but he could not get anybody. S24RN also said she notified the supervisor about Patient #4 needing to go to the ED, but she did not go until about 8:00 at night. S24RN said she called back a couple of times to get Patient #4 sent to the ED, but she assumed the patient did not go until later because of staffing. S24RN said none of the phone calls were documented. S24RN was unable to locate documentation that Patient #5 was reassessed by a nurse after the initial assessment at 11:50 a.m. until she was transferred to the hospital at 7:47 p.m.

In an interview on 4/9/14 2:05 p.m. with S9RN, she said she was working on 2/23/14 on the Adult Enhanced Unit (AEU). S9RN said the two 1:1 patients she and S25MHT had were not actually being watched 1:1 because of staffing. S9RN said Patient #5 did not go to the hospital for several hours after the attack because the supervisor (S22RN) and S24RN told her there was not enough staff to bring her to the ED. S9RN said to her knowledge the physician was never notified about Patient #5 not going to the ED immediately. S9RN said she knows the AEU was short staffed on 2/23/14. S9RN said the Adult Enhanced Unit is short staffed a lot because of the high acuity of the patients.

Review of the hospital Document titled Staffing Ratios by Unit and Census Level (staffing grid) revealed in part:
Adult Enhanced Unit (AEU): 14 bed unit. 3 staff on days (7:00 a.m. - 3:00 p.m.) for 5-12 patients.
Further review revealed no staffing grid for a census over 12 patients.
In an interview on 4/10/14 at 2:50 p.m. with S2DON, she verified the staffing needed to be increased on the unit for 2/23/14 and the staffing for the 7:00 a.m. to 3:00 p.m. did not meet the hospital staffing grid requirements. S2DON said the 2 of 4 staff assigned to 1:1 patients should have not been included in the grid. S2DON said for 12 patients other than the 1:1 patients on 2/23/14, the unit required 3 staff members per the staffing grid but only had 2. She said from 3:00 p.m. until 11:00 p.m., the AEU had 5 staff but 3 patients on 1:1 which still left the unit short one staff member. S2DON also verified she could not locate a nursing or physician assessment of Patient #5 after the initial assessment at 11:50 a.m. until she was transferred to the hospital at 7:47 p.m.
2) Failing to transfer an adolescent patient with a broken wrist to the emergency room for treatment for 1 hour and 45 minutes after the order had been written

Review of patient #32's medical record revealed the following documentation on "Interdisciplinary Notes", dated 04/07/2014: 3:00pm Patient #32 on floor of room screaming...states 'my arm got slammed in the door'; patient #32 holding his right forearm/wrist area, edema noted, bruising noted at right lower forearm, arm immobilized on pillow for support; 3:15pm S58 psychiatrist notified, and X-ray ordered; 6:50pm X-ray performed...7:45pm S58 psychiatrist notified of X-ray results and orders to transfer patient to Hospital A obtained; 9:30pm patient #32 transported to Hospital A for treatment.

Review of Physician's Orders, dated 04/07/14, 3:10pm, revealed "X-Ray (R) [right] Forearm today"...04/07/14, 7:45pm, "Transfer" to Hospital A "for evaluation of" right arm.

Interview, 04/09/14 at 3:00pm, with S2 Director of Nursing revealed the reason for the delay for transferring Patient #32 was as a result of not having enough personnel on staff to transport this patient. S2 DON stated Patient #32 waited because a staff member had to be called in to transport Patient #32.
VIOLATION: DELIVERY OF DRUGS Tag No: A0500
Based on interview and record review, the hospital failed to ensure drugs and biologicals were controlled and distributed by acceptable standards of practice as evidenced by the pharmacist failing to review all first dose medications for appropriateness, duplication, interactions, allergies, sensitivities or other contraindications before the dose was dispensed and administered to patients.

Findings:

Review of the Hospital Policy titled After Hours Medication Supplies, Revised 3/14, revealed in part:
A pharmacist review of medication orders is required prior to the first dose being administered. Licensed Nurses (RN or LPN) are determined qualified to review the medication order in the absence of the pharmacist.

In an interview on 4/10/14 at 9:32 a.m. with S14RN, she said the nurses did not have to wait for the pharmacist to review new medications before they were administered to patients. S14RN said when she received the order for a new medication she pulled the medication from the Pyxis (Automated Medication Dispensing Machine) and administered it to the patient.

In an interview on 4/10/14 at 11:13 a.m. with S12RN, she said she did not have the Pharmacist review medications before she administered the first dose.

In an interview on 4/10/14 at 8:45 a.m. with S22Pharmacist, he said he was the director of pharmacy and the only pharmacist on staff at the hospital. S22Pharmacist said the pharmacy hours were 8:00 a.m. until 2:30 p.m. during the weekdays. S22Pharmacist said he came back to the pharmacy at 8:00 p.m. to check for more orders that had been written during the week. He said on the weekend, he came in to the pharmacy at 2:00 p.m. to catch the orders that were written in the morning. S22Pharmacist said the nurses did not have to have the first dose of a medication reviewed before it was administered. S22Pharmacist also said when a medication was ordered after pharmacy hours, the doses were not reviewed until the next time he came to the pharmacy. He verified when he reviewed those medications the first dose had been given already by the nursing staff. S22Pharmacist said the nurses used drug references to check doses of medications. S22Pharmacist said he knew failing to perform first dose review was a problem because the hospital's accreditation organization had pointed it out to him as a problem last year. S22Pharmacist said reviewing medications had always been a struggle because there was no 24 hour pharmacist at the hospital.
VIOLATION: RADIOLOGIST RESPONSIBIITIES Tag No: A0546
Based on interview and record review, the hospital failed to ensure a full-time, part-time or consulting radiologist was appointed as the Director of Radiological Services.
Findings:

Review of the Credentialing file for S 20 MD revealed he had been approved for reappointment to the consulting medical staff as a radiologist, but had not been appointed as the medical director of radiology at the hospital.

In an interview on 4/9/14 at 8:30 a.m. with S1CEO, he said the hospital had radiologists credentialed at the hospital, but he did not have a medical director appointed for radiology
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the hospital failed to ensure the nurse supervised and evaluated the nursing care for each patient as evidenced by:
1) Failing to transfer a patient to a local emergency room for evaluation and treatment of an injury sustained from another patient, and failing to reassess the patient for 7 hours and 2 minutes after the Physician's Order had been written for 1 (#5) of 3 (#5, #32, #35) patients reviewed for staff response to an injury, and
2) Failing to notify the physician of a patient's sexually inappropriate behavior for 1 of 1
(#10) patients reviewed for sexually inappropriate behavior and ensure the physician ordered level of observation/precautions was provided for 1 of 1 (#30) sampled adolescent patients on 1:1 precautions.

Findings:

1) Failing to transfer a patient to a local emergency room for evaluation and treatment of an injury sustained from another patient and failing to reassess the patient for 7 hours and 2 minutes after the Physician's Order had been written.

Review of the medical record for Patient #5 revealed she was a [AGE] year old female admitted on [DATE] with diagnosis which included Paranoid Schizophrenia.

Review of the medical record for Patient #4 revealed he was a [AGE] year old male admitted on [DATE] with diagnosis which included Schizoaffective Disorder. Further review revealed Patient #4 had a PEC dated 2/18/14 which listed him as gravely disabled and a CEC dated 2/19/14 which listed him as acutely psychotic. Review of the Hospital hand off communication sheet for Patient #4 dated 2/20/14 at 10:30 a.m. revealed his reason for admission was, "Danger to self and others, paranoid" and his risk factors included violence, "hit another patient."

A review of the medical record for Patient #5 revealed an interdisciplinary note dated 2/23/14 at 11:50 a.m. Review of the note revealed in part: "Patient #5 was attacked by a male peer while she was standing at nurse's station speaking with nurse. A male peer walked up behind her, placed his hands on her head in a crushing like motion. He then put his arm with elbow around her neck in a head back type motion. He released her neck and shoved her to the floor and she was kicked by him 2-3 times. Patient was on the floor, on her right side and was kicked on her left side lower rib and hip area. Staff assisted Patient to shelter in the ladies shower room. Patient was crying and emotionally shaken. Her body was examined for injury. No broken skin, bleeding or bruising noted. Patient did complain of pain to her right hip area. She was able to walk and move all extremities well. She stated, "He beat me and I want the police." Shreveport Police notified by nursing supervisors. Officer responded and collected information. Ultimately a summons was issued to the male peer and he was charged with simple battery. S43MD notified regarding patient being beat up. S43MD called Hospital A and spoke with ER MD. Patient to be taken there for evaluation."

Review of the medical record for Patient #5 revealed a Physician's Order dated 2/23/14 at 12:45 p.m. which read in part "Send pt (patient) to Hospital A ER (emergency room ) for evaluation. Pt was physically assaulted by a male peer/ choked/ hit and thrown to the floor, kicked repeatedly when shoved to the floor."

Review of the Interdisciplinary Notes for Patient # 5 revealed an entry on 2/23/14 at 7:47 p.m. which stated in part: "To Hospital A ER via ambulance transport for physical evaluation. Patient #5 is complaining of R (right) side pain between breast and hip. She rates 10/10 at this time." Further review of the Notes and Physician's Orders revealed no documentation that the Physician had been notified that Patient #5 was not going to be sent to the ER for over 7 hours. Review of the nurse's notes revealed no assessment on Patient #5 after the initial assessment until she was being transferred to the hospital.

In an interview on 4/8/14 at 2:30 p.m. with S22RN, he said he was a nursing supervisor on the weekends at the hospital. S22RN said on 2/23/14 he wanted 5 staff for the Adult Enhanced Unit (AEU) but could only find 4 staff to work. S22RN said the AEU was 1 person short on staffing because the unit had 2 patients that were 1:1 observations. S22RN said on 2/23/14 he remembered when the ADU called a Code Green, he went to the unit and Patient #4 was already in the dining room with staff. S22RN said he talked to Patient #5 and she was complaining of pain to her abdomen where she had been kicked by Patient #4. He said the physician ordered Patient #5 to go to the emergency room to be examined at 12:45 p.m., but another patient from another unit was medically unstable and had to be sent to the hospital. S22RN said at the time if he would have sent 2 staff members to the hospital with patients the hospital would have been too short staffed. S22RN said he was not aware if the physician was notified of the delay in treatment. After review of the medical record for Patient #5, he verified there was no documentation of physician notification for the delay in sending Patient #5 to the hospital until 7:47 p.m. (7 Hours and 2 minutes after the Physician's Order). S22RN also verified after Patient #4 was made a 1:1, there were 3 patients on 1:1 for 3 staff members and 11 other patients on the AEU for 1 staff member. S22RN said the unit was definitely short staffed on 2/23/14. S22RN also said the hospital was short at least 4 staff members on various units for the 7-3 shift on 2/23/14.

Review of the Daily Staffing Worksheet for 7am-3pm on 2/23/14 revealed the beginning census on the AEU was 13 and the ending census was 14. The 1:1 patients were listed as 2 females. "3 + 2" was written above the staff's names. In an interview on 4/8/14 at 2:30 p.m. with S22RN he said he filled out the staffing sheets for the units on 2/23/14. He said the "3" above the staff's names was what staff he had available and the "+2" was how many more staff he needed for the shift. He said he needed 5 people for the shift on the AEU, but had 4 available. He also verified by the end of the shift, 3 of the 14 patients were 1:1 observation patients with only 4 staff members. He said being 1:1 required the staff member to be within arm's length of the patients at all times.

In an interview on 4/9/14 at 1:16 p.m. with S24RN, she said she worked on the AEU and was in the nurses' station when the altercation happened between Patient #4 and Patient #5 on 2/23/14. S24RN said the doctor was not notified until 25-30 minutes after the incident because she was examining Patient #5 and calming her down. S24RN said she was the first one to call the doctor and he ordered Patient #4 to be on a 1:1 observation, made some medication changes for Patient #4 and ordered Patient #5 to be sent to the Emergency Department for evaluation. S24RN said she called the nursing supervisor for more help during the shift, but he could not get anybody. S24RN also said she notified the supervisor about Patient #4 needing to go to the ED, but she did not go until about 8:00 at night. S24RN said she called back a couple of times to get Patient #4 sent to the ED, but she assumed the patient did not go until later because of staffing. S24RN said none of the phone calls were documented. S24RN was unable to locate documentation that Patient #5 was reassessed by a nurse after the initial assessment at 11:50 a.m. until she was transferred to the hospital at 7:47 p.m.

In an interview on 4/9/14 2:05 p.m. with S9RN, she said she was working on 2/23/14 on the Adult Enhanced Unit (AEU). S9RN said the two 1:1 patients she and S25MHT had were not actually being watched 1:1 because of staffing. S9RN said Patient #5 did not go to the hospital for several hours after the attack because the supervisor (S22RN) and S24RN told her there was not enough staff to bring her to the ED. S9RN said to her knowledge the physician was never notified about Patient #5 not going to the ED immediately. S9RN said she knows the AEU was short staffed on 2/23/14. S9RN said the Adult Enhanced Unit is short staffed a lot because of the high acuity of the patients.

Review of the hospital Document titled Staffing Ratios by Unit and Census Level (staffing grid) revealed in part:
Adult Enhanced Unit (AEU): 14 bed unit. 3 staff on days (7:00 a.m. - 3:00 p.m.) for 5-12 patients.
Further review revealed no staffing grid for a census over 12 patients.

In an interview on 4/10/14 at 2:50 p.m. with S2DON, she verified the staffing needed to be increased on the unit for 2/23/14 and the staffing for the 7:00 a.m. to 3:00 p.m. did not meet the hospital staffing grid requirements. S2DON said the 2 of 4 staff assigned to 1:1 patients should have not been included in the grid. S2DON said for 12 patients other than the 1:1 patients on 2/23/14, the unit required 3 staff members per the staffing grid but only had 2. She said from 3:00 p.m. until 11:00 p.m., the AEU had 5 staff but 3 patients on 1:1 which still left the unit short one staff member. S2DON could not locate a nursing or physician assessment of Patient #5 after the initial assessment at 11:50 a.m. until she was transferred to the hospital at 7:47 p.m. S2DON also verified she could not locate a nursing or physician assessment of Patient #5 after the initial assessment at 11:50 a.m. until she was transferred to the hospital at 7:47 p.m.


2) Failing to notify the physician of a patient's sexually inappropriate behavior for 1 of 1
(#10) patients reviewed for sexually inappropriate behavior and ensure the physician ordered level of observation/precautions was provided for 1 of 1 (#30) sampled adolescent patients on 1:1 precautions.

Patient #10
Review of Patient #10's medical record revealed he was a [AGE] year old male who had been admitted on [DATE] with diagnoses including the following: Attention Deficit Hyperactivity Disorder (ADHD), Depression/Psychosis: Severe; Mild Intellectual Disability, and Conduct Disturbance. Further review revealed the patient's legal status was PEC (Physician's Emergency Certificate) 2/3/14 at 12:45 p.m. with reason for admission listed as potential danger to self, unable to seek voluntary admission.

Review of the Hospital ' s incident reports for the last three months revealed the following incidents involving Patient #10:

2/17/14: Patient loud, disruptive, yelling and cursing staff, took an aggressive stance and threatened to " beat up staff " .
2/18/14: Physical altercation with peer.
2/28/14: agitated, threatening and cursing peers, fighting staff.
3/3/14: Patient #10 attempted to attack staff.
3/10/14: alleged touching of female peer ' s breast. Patient denies touching female peer.
3/18/14: Patient denies touching female peer.

Review of the hospital's grievance log for the last three months revealed the following complaints related to allegations of inappropriate sexual conduct against Patient #10:

Complaint #1: Date submitted: 3/12/14, Date to Patient Advocate: 3/12/14, Complainant: Patient #11: Date resolved: 3/18/14; Program involved: Nursing; Complaint Issue: Accused male peer (Patient #10) of touching.
Complaint #2: Date submitted: 3/16/14, Date to Patient Advocate: 3/19/14, Complainant: Patient #12: Date resolved: 3/20/14; Program involved: Nursing, Social Services; Complaint Issue: Accused male peer (Patient #10) of touching.

Review of Patient #10's medical record revealed a seclusion/restraint order/record dated 2/28/14 at 6:55 a.m. The explanation given for the order was as follows: Patient agitated yelling at females on unit stating, "One of you B (expletive) gonna suck my (penis) today". Fighting staff when redirected and asked to stop and go to time out.
Review of Patient #10's medical record revealed no MD orders for increased supervision or SAP precautions following the first incident of inappropriate sexual behavior on 3/10/14 (reported 3/12/14).
Review of Patient #10's Master Treatment Plan revealed sexually inappropriate behavior/language was not identified as a problem on the treatment plan after the first incident which occurred on 3/10/14. A second incident of inappropriate sexual behavior by Patient #10, almost identical to first incident, was reported by another female on 3/16/14.
Review of Patient #10's medical record revealed the following entries, in part:
Interdisciplinary Notes, dated 3/10/14, 8:00 p.m.: Hypersexual most of shift. Telling female peers, "You want to sit on it" as well as hugging another female peer who didn't complain, however was redirected yet again not to touch any peers. When redirected by charge nurse to go to room as everyone else did he said, "F (expletive) you ho." Told a peer I need another hug, can I touch your body.

Nursing Progress Notes, dated 3/10/14, 10:00 p.m., 3-11 shift: Patient #10 presents with labile affect, pushing limits, refusing to redirect at times. Female peer accused Patient #10 of touching her breast, patient stated, "I was gonna touch her but I didn't." Female peer responded that is a lie.
Review of Patient #10's Rounds Sheets revealed the patient remained on Suicide Precautions with an Observation Status of every 15 minute checks from 3/6/14 until he was placed on CVO (Constant Visual Contact) with SAP (Sexually Acting Out) perpetrator precautions on 3/18/14 at 12:30 p.m. after the occurrence of the second incident.

In an interview on 4/10/14 at 2:12 p.m. with S12YouthServicesManager she was asked if she remembered the incident on 3/10/14 involving Patient #11 and Patient #10 and she replied, "Yes". She said Patient #11 was being discharged the day she filed the grievance against Patient #10. S12YouthServicesManager reviewed the incident report documentation and confirmed the space for notification of MD was marked no. She reviewed Patient #10's chart (MD orders, both MD and Nurse Progress Notes) and confirmed there was no documentation of notification of the MD of the incident nor were there any orders related to increasing supervision. S12YouthServicesManager explained it was the duty of the nurse on the unit where the incident had occurred to inform the MD so he could have made a decision regarding supervision level changes for Patient #10. She explained increased supervision required an MD order and she didn't understand why the MD wasn't called. She agreed perhaps it was because Patient #11 was discharged the day she had filed the grievance against Patient #10. S12YouthServicesManager also agreed, based upon Patient #10's escalation of behavior, he should have been placed on a higher level of supervision after the first incident. She explained increasing Patient #10's supervision level to CVO with SAP precautions would have resulted in the patient's placement in a private room and he would have been in constant line of sight of staff at all times. She further explained the staff would have also monitored Patient #10 for sexually inappropriate behaviors.





Patient #30
Review of the Hospital Policy titled Acuity Staffing Plan, Last Review/Revision Date: 3/14, Policy Number NR 003, revealed in part:
2. Constant Visual Observation:
-The patient must be maintained within the visual contact of the staff at all times.
3. One- to - One Order Criteria:
Patient Care Elements
-The patient must be maintained within the visual contact/arm's reach of the staff at all times.
-The patient is not able to leave the unit.
- At any given time, the staff assigned to provide contact/arm's reach must insure that another staff member will assume this responsibility if he/she must leave the presence of the patient (i.e. lunch breaks, etc.)
- This visual contact/arm's reach extends to a requirement for complete supervision of the patient in routine daily care, including accompaniment of patient to the bathroom.
- The Patient Observation Record is used to document the level of supervision using the every 15 minute format of this form.

Patient #30: Review of the clinical record for Patient #30 revealed the patient was a [AGE] year old male admitted on [DATE] under a PEC (Physician Emergency Certificate) for suicidal, dangerous to self, and unable to seek voluntary admission. The patient's diagnosis included Mood Disorder, Impulse Control Disorder, Attention Deficit Hyperactivity Disorder, Conduct Disorder, and Relationship Problems. The patient was also in the custody of DCFS (Department of Child and Family Services).

Review of the physician orders dated 02/27/14 revealed Suicidal, Self-Mutilation/Injury, and Elopement Precautions were ordered.

Review of the Nursing Progress Noted dated 03/21/14 revealed at 7:40 a.m. Patient #30 was anxious, irritated and yelling at S19RN. The patient was unable to be redirected or calmed down. S19RN documented the patient room doors were unlocked at 7:46 a.m. in an attempt to re-establish order on the unit. At 7:50 a.m., S19RN documented a search of the unit was made and Patient #30 was not located in his room. The unit was searched again and Patient #30 was not located.

Review of the Hospital Abuse/Neglect Initial Report (HSS-HO-41) dated 03/21/14 revealed Patient #30 pushed through the adolescent hallway exterior door, with other peers following him. (Patient #16, #17, and #33). Patient #16 and #17 were returned by police at 10:37 a.m. Patient #30 and #33 were returned by police at 11:24 a.m.

Review of the physician orders dated 03/21/14 at 11:45 a.m., revealed an order for "1 on 1 all times" and Elopement Precautions. Review of the Precaution Sheets for 03/21/14 revealed 1 on 1 precautions were not implemented until 11:00 p.m. on 03/21/14.

In an interview on 04/10/14 at 4:20 p.m., S2Director of Nursing reviewed the record for Patient #30 and verified the physician had ordered 1 on 1 precautions for Patient #30 at 11:45 a.m. on 03/21/14, and there was no documented evidence the 1:1 precautions were implemented until 11:00 p.m.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observation and interview, the hospital failed to ensure the overall hospital environment was developed and maintained in such a manner that the safety and well-being of patients are assured as evidenced by:
1) failing to ensure electrical receptacles in the patient rooms were of the safety type or protected by 5-milliampere ground-fault-interrupters.
2) failing to ensure all rooms where psychiatric patients slept had tamper proof or monolithic ceilings.
3) failing to ensure there were no plastic bag trash liners present in the common areas on the Adult Psychiatric Unit, the Adult Enhanced Unit, the Geriatric Unit, the Child Psychiatric Unit, and the Child Enhanced Unit.
4) failing to ensure the shower room on the Youth Enhanced Unit did not have safety risks including non-monolithic ceilings, accessible fluorescent light bulbs, and ligature risks.
5) failing to ensure the shower room on the Geriatric Psychiatric Unit did not have a shower wand with a hose that posed a ligature risk.
6) failing to ensure showers were clean on the Youth Enhanced Unit (YEU); other safety issues; and contraband found on YEU.
7) failing to ensure seclusion rooms on the Adolescent Open Unit did not have a dirty wax build up along the baseboards; and the Youth Enhanced Unit's seclusion room was missing layers of "chalkboard" wall covering in a couple of areas.
8) failing to ensure hinges on patient room doors and patient bathroom doors were of the anti-ligature type.
Findings:

1) Failing to ensure electrical receptacles in the patient rooms were of the safety type or protected by 5-milliampere ground-fault-interrupters. Findings:

Observations made during the environmental tour on 4/8/14 at 2:30 p.m. revealed the electrical receptacles in all patient care areas were not of the safety type or protected by 5-milliampere ground-fault-interrupters.

Interview with S5 Plants Operation on 4/7/14 at 2:30 p.m. confirmed the electrical outlets were not of the safety type. When asked if the electrical breaker box contained any type of ground fault, S5 replied "no".

2) Failing to ensure all rooms where psychiatric patients slept had tamper proof or monolithic ceilings.

Interview, on 4/8/14 at 2:30pm with S22 RN House Supervisor, revealed he stated the Adolescent unit was a 42 bed unit, but they adjusted the rooms to sleep 4 more people on the unit. S22 RN House Supervisor stated the chairs and desks were removed from 2 rooms (identified as Room #s 244, 246 with signage they were Consultation offices) and put roll away beds in the rooms for the patients to sleep.

Observations, 04/09/14 at 2:00pm, on the Adolescent Open Unit revealed rooms 244 and 246 were utilized as Consultation Rooms; however, the ceilings in the rooms and the bathrooms were ceiling tiles. The ceiling tiles were noted to be removable and the bathrooms in each room did not have the commode pipes covered, nor were the sink pipes covered.

3) Failing to ensure there were no plastic bag trash liners present in the common areas on the Adult Psychiatric Unit, the Adult Enhanced Unit, the Geriatric Unit, the Child Psychiatric Unit, and the Child Enhanced Unit.

Observations made during the environmental tour on 4/7/14 at 9:45 a.m. revealed the following:
A) On the Adult Psychiatric Unit there was a plastic liner in the large trash can located in the laundry room. Interview with S57 RN revealed patients were allowed in the laundry without supervision.
B) In the dining room area on the Adult Psychiatric Unit there were two plastic garbage bags full of trash and the trash can had a plastic liner.
C) On the Geriatric Unit there was a trash can with a plastic liner located in the hall near the bathroom.
D)On the Children's Unit there was a trash can with a plastic liner located in the common area.
E) On the Children's Enhanced unit there was a trash can with a plastic liner located in the shower room.

4) Failing to ensure the shower room on the Youth Enhanced Unit did not have safety risks including non-monolithic ceilings, accessible fluorescent light bulbs, and ligature risks.
Observations on 4/7/14 at 9:45 a.m. revealed Shower Room #2 on the Youth Enhanced Unit had ceiling tiles (non-monolithic ceilings) and fluorescent light bulbs that were easily accessible. Also found in the ceiling was a 19 inch rigid wire rod, telephone cords, and pipes large enough to provide a ligature risk. Exposed plumbing beneath the sinks was also noted in the bathrooms.

In an interview on 4/7/14 at 9:55 a.m. with S2DON, she agreed the non-monolithic tiles in the shower room could have provided access to the potential ligature fixtures that were noted within the ceiling tiles (large pipes and telephone cords). She also agreed the 19 inch rigid wire rod was a potential hazard. She acknowledged that the fluorescent light bulbs were accessible and could also be hazardous.

In an interview on 4/10/14 at 9:11 a.m. with S27RN (Youth Enhanced Unit), she said she has found sharp objects inside ceiling tiles that have been shifted/moved. She also said if ceiling tiles were noted to have been hanging down or moved maintenance should have been called to fix them because the patient's hide stuff in there.

5) Failing to ensure the shower room on the Geriatric Psychiatric Unit did not have a shower wand with a hose that posed a ligature risk.
Review of one of the two shower rooms at the end of the hall on the Geriatric Unit revealed a hand held shower wand with rubber tubing approximately 5 feet long.
In an interview on 4/07/14 at 10:35 a.m. with S57RN, she said at night psychiatric women that were not geriatric patients were housed on the unit. S57RN said the women used the shower room with the wand and hose unattended.

6) Failing to ensure showers were clean on the YEU, other safety issues, and contraband item.

Observations, 04/07/14 at 10:00am, on the Youth Enhanced Unit(YEU) revealed the following:
Shower room#1: Black substance on both walls, dank, musty smell
Shower room#2: Non-monolithic ceiling tiles (possible elopement/ligature risk), easily accessible fluorescent light bulbs, leaking shower head with a puddle of water on floor; Found within the ceiling: 19 inch rigid wire rod, telephone cords, pipes large enough to provide possible ligature.
Exposed plumbing beneath the sink in bathrooms
Rooms #209 and #211: flat head screws (not tamper resistant)
Room #210B: Corded sweatpants found in drawer under patient bed, missed during contraband room search (patient could use the draw string as ligature device).
7) Failing to ensure seclusion rooms on the Adolescent Open Unit did not have a dirty wax build up along the baseboards; and the Youth Enhanced Unit's seclusion room was missing layers of "chalkboard" wall covering in a couple of areas.
8) Failing to ensure hinges on patient room doors and patient bathroom doors were of the anti-ligature type.
Observations, 04/08/14 at 10:40am, revealed: Adolescent Open Unit room #s 265, 267, 268, 269, and 271 bathrooms had 3 hinges on the bathroom doors. The top hinge could be utilized by patients to hang ligature devices thus causing harm.
VIOLATION: QAPI Tag No: A0263
Based upon review of the Quality Assurance/Performance Improvement Program Plan and activities, record review and interviews, the hospital failed to meet the Condition of Participation related to Quality Assurance/Performance Improvement. This was evidenced by:

I) Failure to develop quality indicators to measure, analyze, and track performance to assess processes of care related to radiological services. This resulted in the performance improvement program failing to identify delays in obtaining radiological tests and reports (A273);

II) Failure of the Quality Assurance/Performance Improvement Program to include:
1) an analysis of the causes of patient elopements and implement preventative actions related to patient elopements on 03/10/14 and 03/20/14 and 4 patient elopements on 03/21/14.
2) an analysis of medication errors and adverse events and implementation of preventative actions related to the causative factors other than staff error.
(A286);

III) Failure to ensure the quality improvement projects included measurable quality indicators for the project and the measurable progress achieved for 1 of 1 (Restraint/Seclusion) performance improvement project reviewed (A297);

IV) Failure of the Governing Body to ensure the hospital's Performance Improvement Plan reflected the hospital's organization and services, including services furnished under contract were involved in the Performance Improvement Program (A308)..
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based upon observations, record reviews, policy and procedure reviews, and staff and patient interviews, the hospital failed to meet the Condition of Participation for Patient Rights. This was evidenced by the Hospital's failure to:

I) Ensure patient care was provided in a safe setting relative to:
1) allowing patients on the Adolescent Open Unit to sleep in Rooms #244 and #246 when they were short of beds on the unit. These rooms, including the bathrooms, had ceiling tiles present that could allow patients to escape/elope or harm themselves, i.e. ligature hazard;
2) having crank beds and side rails available on the Adult Psychiatric Unit which posed a ligature hazard;
3) investigate the causative factors of patient elopements and ensure adequate supervision of patients to prevent patient elopements for 5 of 5 (#16, #17, #26, #30, #33) sampled patients reviewed for elopement;
4) transfer a patient to a local emergency room for evaluation and treatment after an attack by another patient for 7 hours and 2 minutes after the Physician's Order had been written due to lack of staffing for 1 (#5) of 3 (#5, #32, #35) patients reviewed for response to injury,
5) have a policy and procedure in place for crank beds and side rails that were available on the Adult Psychiatric Unit which posed a ligature hazard (A144);

II) Ensure each patient's rights were protected related to patient #18 being denied the right to contact the Mental Health Advocacy Services (A129);
VIOLATION: NURSING SERVICES Tag No: A0385
Based on record reviews and interview the hospital failed to be in compliance with the Condition of Participation for Nursing Services as evidenced by:

I) Failure to ensure the nurse supervised and evaluated the nursing care for each patient by:
A) Failing to transfer a patient to a local emergency room for evaluation and treatment of an injury sustained from another patient, and failing to reassess the patient for 7 hours and 2 minutes after the Physician's Order had been written for 1 (#5) of 3 (#5, #32, #35) patients reviewed for staff response to an injury, and
B) Failing to notify the physician of a patient's sexully inappropriate behavior for 1 of 1
(#10) patients reviewed for sexually inappropriate behavior and ensure the physician ordered level of observation/precautions was provided for 1 of 1 (#30) sampled adolescent patients on 1:1 precautions (A0395);

II) Failure to ensure the nursing service had adequate numbers of licensed registered nurses, licensed practical nurses, and mental health technicians to provide nursing care to all patients as needed as evidenced by:
A) failing to transfer a patient to a local emergency room for evaluation and treatment after an attack by another patient for 7 hours and 2 minutes after the Physician's Order had been written due to lack of staffing for 1 (#5) of 3 (#5, #32, #35) patients reviewed for response to injury.
B) failing to transfer an adolescent patient with a broken wrist to the emergency room for treatment for 1 hour and 45 minutes after the order had been written for 1 (#32) of 3 (#5, #32, #35) patients reviewed for response to injury. (A0392)