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.

GREENBRIER BEHAVIORAL HEALTH 201 GREENBRIAR BLVD COVINGTON, LA 70433 Aug. 10, 2016
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the hospital failed to ensure the grievance process was implemented as evidenced by failing to identify, investigate, and document a patient's grievance for 1 out of 1(Patient #2) patient's documentation of a grievance reviewed out of a sample of 5.
Findings:

Review of the hospital's policy for Patient Complaints and Grievances revealed in part, III Procedure: A "Patient Grievance" is defined as a formal, written, or verbal allegation or source of dissatisfaction that is filed by a patient or patient's representative that requires and investigation.

Review of Patient #2's medical record revealed he was admitted on [DATE] by a PEC (Physician Emergency Certificate) for Suicidal ideation with a plan.

An interview was conducted with S4LMSW on 8/9/16 at 10:30 a.m. She reported she was the case manager for Patient #2 while he was hospitalized from [DATE] to 7/19/16. She reported she received a phone call from Patient #2 on the evening of his discharge (7/19/16), he reported to her the shelter didn't have a bed for him and he couldn't get one of his medications.

An interview was conducted with S5Risk Manager with 8/9/16 at 1:45 p.m. S5Risk Manager reported she was the person responsible for the grievances and complaints at the hospital. She further reported she was not aware of a grievance called in on the phone by Patient #2 after his discharge and there was no documentation of the grievance and investigation. She also reported the phone call should have been handled as a grievance.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0196
Based on record review and interview, the hospital failed to ensure all direct care staff were competent in the application of restraints as evidenced by failing to ensure competencies for 2 (S7MHT and S8RN) out of 3 direct care staff (S7MHT, S8RN and S9MHT) personnel records reviewed. Findings:

Review of the hospital's policy on Staff Competency, Policy Number HR.012, revealed in part, Purpose to provide a method of evaluating staff's level of competency within an assigned department and job description. III. Procedure Method of assuring staff competency....3. Skills Check List, department, and/or population specific.

Review of the personnel record for S7MHT revealed her date of hire was 5/04/16. With further review of her personnel records revealed no documentation of her being competent in the application or monitoring of restraints.

Review of the personnel record for S8RN revealed her date of hire was 07/06/16. With further review of her personnel record revealed no documentation of her being competent in the application or monitoring of restraints.

An interview was conducted with S2DON on 8/10/16 at 1:00 p.m. She reported she did not have documentation of S7MHT and S8RN skill competencies.
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview, the hospital failed to ensure the patient's discharge plan was implemented by the Social Worker in accordance with hospital policy as evidenced by the Social Worker failing to meet with the patient to discuss the planning needs, and failing to send patient information to the post hospital care provider for 1 (#5) of 5 (#1-#5) sampled patients.
Findings:

Review of the hospital policy titled, Discharge Planning Process, Policy #PM 024 revealed in part the following: The therapist is responsible for completing the psychosocial aftercare plan with the patient prior to discharge....The social service staff is responsible for coordinating the discharge plan....Aftercare Plan: Tasks to be accomplished: Finalize arrangements for patient and family to enter continuing care program....

Patient #5
Review of the medical record for Patient #5 revealed the patient was a [AGE] year old admitted on [DATE] with diagnoses of Schizoaffective Disorder, Bipolar Type and Poly-Substance Use. The record revealed the patient was discharged on [DATE] at 10:50 a.m.
Review of the Discharge Care Plan and Home Medications form revealed an aftercare appointment was made with a mental health clinic. Further review of the Discharge Care Plan revealed the section titled Continuing Care Coordination revealed the section was left blank. This section of the form revealed, "*Must be transmitted within 24 hours of discharge and fax confirmation page must be retained in the medical record. The discharge plan was transmitted and shared with the following providers:" Further review of the Discharge Plan revealed the section titled, "Other Important Contact Information" was left blank. This section included space for documentation of the name and number of a Support Person, Insurance Customer Service, Crisis Team, Support Group for self, Support Group for family, and other resources. The Discharge Plan was signed only by the RN.
Review of the Interdisciplinary Progress Note dated 07/05/16 at 10:50 a.m. revealed the social worker documented the patient's mother confirmed the patient had a home to return to and there were no weapons in the patient's home. There was no documented evidence of any other discharge instructions, planning or coordination with aftercare providers.

In an interview on 08/10/16 at 10:40 am S3Clinical Director reviewed the medical record for Patient #5 and stated, "It looks like social services was not involved in this discharge." S3Clinical Director stated it may have not been done because the social worker was not available when the patient was discharged . After reviewing a calendar, she stated social services were not working the day the patient was discharged . S3Clinical Director stated, "It's not good, but that's the reason." S3Clinical Director stated the aftercare appointment was made prior to the date of discharge and confirmed patient information was not sent to the aftercare provider as required. She confirmed the social worker should have faxed patient information to the provider and documented that in the Continuing Care Coordination section. S3Clinical Director confirmed the Important Contact Information should have been completed by the social worker at the time of discharge. S3Clinical Director stated the social worker should have signed the Discharge Care Plan and Home Medications form on the day of discharge.