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 Oct. 10, 2014
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on record review and interview the hospital failed to ensure a written response to grievances was provided in a reasonable time frame for 2 patients (Patient # R7 and Patient # R8) with grievances out of a total 3 written grievance responses reviewed.
Findings:
Review of the hospital policy titled, "Patient Grievance Procedures", policy number RI.012, reviewed/revised date of 03/14 revealed in part the following: ....All complaints of abuse or neglect will be considered a grievance. When a report of sexual or physical abuse or neglect, whether directly or by referral is received the Department of Health and Hospitals will be notified within 24 hours from the time the facility was notified of the complaint.....The Patient Advocate will continue with the investigation of the grievance until a resolution is achieved.....5.0 All allegations of abuse or neglect are considered grievances and cannot be resolved at the unit level. Investigation should be initiated immediately as directed by the nursing supervisor or previously outlined administrative representatives.....7.0 When a prompt resolution is possible, the hospital will provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. 8.0 If a prompt resolution is not possible, a written response will be forwarded to the person filing the grievance within seven days of receipt stating that the issue is being investigated. A second/final response will be sent when the investigation is completed, indicating the hospital's decision, the name of the hospitals contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion. This notice will be sent after the investigation is completed....
Patient #R7
Review of the Hospital Abuse/Neglect Initial Report revealed on 9/25/14 Patient #R7 stated S17Social Worker hit him. Patient #R7 reported that S17Social Worker hit him in the hand because he accidentally touched S17Social Worker on the buttock. Patient #R7 reported he had nerve damage in his hand and he was in pain.
The first written response to the grievance was dated on October 9, 2014 (15 days after the grievance was filed). The findings were confirmed by S4Patient Advocate on 10/10/14 at 8:45 a.m.

Patient #R8
Review of the Hospital Abuse/Neglect Initial Report revealed Patient #R8 reported to a staff member on 9/25/14 that her roommate Patient #R9 had performed oral sex on her while she was asleep.
Review of the response to the grievance revealed the letter was dated 10/10/14 (16 days after the grievance was reported). The findings were confirmed by S4Patient Advocate on 10/10/14 at 8:45 a.m.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interviews, the hospital failed to ensure that a patient who filed a grievance was provided a written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. The hospital failed to provide a written response to the patient for 2 (Patient #3 and Patient #R5) patients' grievances from a total of 5 grievances reviewed.
Findings:

Review of the hospital policy titled, "Patient Grievance Procedures", policy number RI.012, reviewed/revised date of 03/14 revealed in part the following: ....All complaints of abuse or neglect will be considered a grievance. When a report of sexual or physical abuse or neglect, whether directly or by referral is received the Department of Health and Hospitals will be notified within 24 hours from the time the facility was notified of the complaint.....The Patient Advocate will continue with the investigation of the grievance until a resolution is achieved.....5.0 All allegations of abuse or neglect are considered grievances and cannot be resolved at the unit level. Investigation should be initiated immediately as directed by the nursing supervisor or previously outlined administrative representatives.....7.0 When a prompt resolution is possible, the hospital will provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. 8.0 If a prompt resolution is not possible, a written response will be forwarded to the person filing the grievance within seven days of receipt stating that the issue is being investigated. A second/final response will be sent when the investigation is completed, indicating the hospital's decision, the name of the hospitals contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion. This notice will be sent after the investigation is completed....

Patient #2 and #3 incident:
Review of the medical record for Patient #2 revealed the patient was a [AGE] year old female admitted on [DATE] on a PEC (Physician Emergency Certificate) secondary to Suicidal Ideation with a plan and increased depression. Her Psychiatric Evaluation listed her diagnosis as Bipolar with a history of psychosis. Her observation status was Line of Sight (CVO) with Suicide Ideations and Sexually Predator Precaution on 9/22/14.

Review of the medical record for Patient #3 revealed he was a [AGE] year old male admitted on a PEC on 9/20/14 for fighting with mother and threatening to kill her and having a gun. His psychiatric evaluation on 9/21/14 revealed diagnoses of Bipolar Disorder, Cannabis Dependence and Conduct Disorder. Review of his admission orders revealed he was placed on Elopement, Behavioral, Suicidal and Violence/Assaultive Precautions and his observation level was every 15 minutes on 9/22/14.
Review of the Hospital Abuse/Neglect Initial Report submitted to Department of Health and Hospitals revealed in part: "... On video at 1910 on 9/22/14 in Patient #2 and Patient #3 were in the dayroom with other patients. Patient #2 was crawling on the floor, and appeared to be seeking attention from peers. Patient #2 put her hand in Patient #3's lap. Another patient pulled Patient #2 away, while Patient #3 guarded his lap. Patient #2 attempted to touch Patient #3 again, Patient #3 got up and walked around room. Patient #2 walked over to the other side of the room, and sat down. S15LPN was standing in nursing station doorway, and appeared to be giving out medications at the time..."
An observation was made on 10/9/14 at 4 p.m. of the video on 9/22/14 at 1910. Numerous patients were in the dayroom running around the dayroom. Patient #2 was crawling on the floor in front of Patient #3 while he was sitting in a chair. Patient #2 did attempt to grab Patient #3's groin area, but it was unclear if Patient #2 actually touched Patient #3.

Review of the Interdisciplinary Notes dated 9/22/14 revealed the following in part: "...1940 Patient #3 reports that a female peer grabbed his butt and tried to grab the front of his groin; female peer became loud and defiant, cursing staff and escorted to dayroom away from Patient #3. 1955- Nursing Supervisor notified of situation. 2015- Spoke with M (Mother) of situation, understanding..."

An interview was conducted with S4Patient Advocate on 10/10/14 at 9 a.m. She reported a letter notifying the mother and the patient of the results of the investigation was not sent to the family.

Incident with R5 and R6

Review of the Alleged Sexual Abuse and Alleged Physical Abuse submitted to Department of Health and Hospitals revealed in part, "....Date of Discovery 8/17/14 at 15:30, Patient R5 stated Patient R6, her roommate threatened to choke her if she didn't have sex with her. Patient R5 stated Patient R6 took Patient R5's hand and place in R6's crotch. Patient R5 stated R6 was only wearing a shirt and wasn't wearing any underwear. Patient R5 stated a staff member walked in and R6 let go of her hand and asked "what is going on?" Patient R5 stated they both said nothing. R5 waited until R6 was discharged before reporting it to staff. R5 stated "I was scared to report it sooner because R6 was bigger than me." Patient R5 stated "I don't want to press charges; I just wanted the staff to know."

An interview was conducted with S4Patient Advocate on 10/10/14 at 9 a.m. When questioned if a letter was provided to Patient R5 when the investigation was completed, she reported she wasn't the Patient Advocate at that time, but she was unable to locate a letter to Patient R5.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review, and staff interview, the hospital failed to ensure patients received care in a safe setting as evidenced by:
1) failing to ensure patients on the Youth Enhanced Unit (YEU) with the patient census consisting of patients on Aggressive/Assaultive/Violent precautions were not allowed to possess contraband as evidenced by Patient #7 having a hair pick in his hair during group therapy; and
2) failing to ensure the environment of care was free of ligature risks and safety hazards as evidenced by A) the presence of loose vent covers (measuring approximately 2 foot X 2 foot) on the ceiling in the patient care rooms and B) failing to ensure patients on the Tweens Units were free of ligature risks and safety hazards as evidenced by 2 rotating black fans mounted half way up the wall in the Tween's day room with the approximately 5 feet length of electrical cords plugged into the electrical outlets at the bottom of the wall and a metal vent with sharp edges only secured in 2 corners in the hall shower room, which could easily be removed from the wall.

Findings:

1) Contraband on YEU:

Review of the hospital's policy titled, "Valuable - Patient's Personal Belongings/Contraband", policy number TXOP.012, current date of 03/14 revealed in part the following: Policy: ....Contraband is not permitted in the patient area at any time....Contraband is strictly prohibited in the program. Contraband is defined as such items as: knives, weapons of any kind, drugs (prescription or non-prescription), alcohol or any item that can pose a threat of physical harm to the patient or another person in the program.

Review of the hospital's policy titled, "Contraband", policy number TX.002, current date of 03/14 revealed in part the following: Policy: To provide a safe and therapeutic environment for patients and staff, contraband is defined and procedures regarding contraband found are delineated. Procedure: When contraband is brought onto any unit, it will be confiscated from the patient or visitors by the unit staff....The DON (Director of Nursing)/Supervisor will be informed of the presence of contraband....Specific items considered contraband: ....Hair picks or rakes....

On 10/08/14 at 9:25 a.m., an observation was made of group therapy on the YEU. Patient #7 was observed sitting in the group of patients with a hard, plastic hair pick protruding from his hair. S16RN who was present at the time of the observation confirmed the patient should not have the hair pick in his hair during the group session, and stated the pick should have been locked up after the patient's shower.

Review of the medical record for Patient #7 revealed the patient was a [AGE] year old male admitted on [DATE] under a PEC (Physician Emergency Certificate) for suicidal ideations. Review of the record revealed the patient had a history of self-injurious behaviors.






2. Ligature Risk and Safety Hazards

A) Observations on 10/08/14 between 9:10 a.m. and 10:30 a.m. revealed the presence of loose vent covers (measuring approximately 2 foot X 2 foot) on the ceiling in the patient care rooms. The vent covers in several Patient Rooms (including but not limited to Patient Room #336, #367, and #369) were noted to be unsecured and/or loose. The vent covers could have been removed from the ceiling by a patient with minimal to moderate force resulting in the patient having access to the sections of the hospital immediately above the ceiling. The Director of Nursing was present at the time of these observations. The Director of Nursing verified that the vent covers were unsecured and/or loose and could pose a safety hazard should they be removed by a patient.

B) A tour was made of the Tween Dayroom on 10/8/14 at 9:30 a.m. Two black rotating fans were observed secured half way up the wall with approximately 5 feet of electrical cords hanging underneath the fan and plugged into an electrical outlet at the bottom of the wall. S6Intake Coordinator confirmed the observation.

An observation was made at 9:35 a.m. on 10/8/14 of the hall shower room at the end Tween unit of a metal vent on the wall (at about 5 feet up the wall). The metal vent had sharp edges and was only secured on two corners. The vent was easily pulled out from the wall. S6Intake Coordinator confirmed the observation.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on record review and staff interview, the hospital failed to ensure the QAPI program included an evaluation of the preventative actions for adverse events for 3 of 3 adverse events reviewed. Findings:

On 10/09/14 at 4:00 p.m., S3Risk Management provided a Root Cause Analysis Report of an adverse event dated 06/08/14 related to a patient's death after the patient was transferred to an acute care hospital. Review of the Root Cause Analysis revealed an investigation of the incident with Risk Reduction Actions Taken and Prevention Strategies documented. The Root Cause Analysis revealed no documented evidence of any evaluation of the impact of the preventative actions implemented by the hospital.

On 10/10/14 at 8:50 a.m., S3Risk Management provided two more Root Cause Analysis Reports of an adverse event involving inappropriate sexual behavior between 2 patients on 06/25/14. Review of the Root Cause Analysis revealed an investigation of the incident with Risk Reduction Actions Taken and Prevention Strategies documented. The Root Cause Analysis revealed no documented evidence of any evaluation of the impact of the preventative actions implemented by the hospital.

In an interview on 10/10/14 at 8:50 a.m., S3Risk Management reviewed the above 3 Root Cause Analyses and confirmed there was no evaluation done of the preventative actions that were implemented by the hospital for these 3 adverse events, other than the absence of any further incidents.