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.

COMPASS SENIOR CARE HOSPITAL 1 HOSPITAL DRIVE, SUITE 201 JENNINGS, LA 70546 March 24, 2011
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the hospital failed to ensure the patient received care in a safe setting as evidenced by 1) failing to monitor hallways at all times per hospital policy which allowed a male patient to enter a female patient's room undetected for 1 of 11 sampled patients and the potential to affect all patients (#5), 2) failing to arrange appropriate therapeutic transport with adequate, properly trained staff by transporting a patient under a Physician's Emergency Certificate in a transport van with only a driver aboard for 1 of 1 patients transported from the outpatient clinic to the inpatient hospital in a total sample of 11. (#5), and 3) failing to assess a patient with suicidal ideation prior to being discharged from the outpatient facility for 1 of 3 sampled records reviewed focused for suicidal ideation out of a total of 11 sampled records reviewed, (#10). Findings:

1)

In a telephone interview on 03/23/11 at 2:00 p.m. with S17LPN, she stated she worked the night shift on Friday 01/28/11, Saturday 01/29/11 and Sunday 01/30/11. S17LPN stated that on one of these nights (could not remember which one) she was walking past the room of patient #5 and heard a male and female talking. S17LPN stated there were no male MHT's on duty that night so she entered the room of patient #5. S17LPN stated there was a male patient speaking to patient #5 and she (S17 LPN) made him leave the room. S17LPN stated it was a patient who was being moved because his roommate snored loudly and he entered the wrong room. S17LPN further stated that both female MHT' s on duty were in another patient room changing a patient's diaper. S17LPN confirmed patient #4 would not have been able to enter the room un-noticed if the hospital' s policy that the hall should never be left unattended were followed.

Review of the staffing sheets for 01/28/11 - 01/30/11 revealed three different MHT' s had worked that weekend. S18MHT, S19MHT, and S20MHT. (Administration was unable to secure either a telephone or face to face interview with S20MHT as she attends college during the day and has no cell phone)

In an interview on 03/24/11 at 9:10 a.m. with S18MHT she stated she did not remember both MHT' s being in a room and a male patient being in the hall unattended and entering the room of a female patient. She further stated the LPN would be asked to watch the hall if the MHT' s needed to both be in a room at the same time.

In an interview on 03/24/11 at 9:13 a.m. with S19MHT she stated she did not remember both MHT's being in a room and a male patient being in the hall unattended and entering the room of a female patient. She further stated the MHT's do diaper checks every two hours and the LPN watches the hallway while this is done.

In an interview on 03/23/11 at 2:10 p.m. with S2DON she confirmed there was no documentation in the medical record of patient #5 or patient #4 and no incident report regarding the patient #4 being in the room of patient #5.

Review of a policy titled "Night Shift MHT duties" revealed " ** ALERT: Hall cannot be left unattended.***"

In an interview on 03/23/11 at 2:10 p.m. with S2DON she confirmed it would be a violation of hospital to leave the hall unattended. She could offer no explanation of how patient #4 could enter the room of patient #5 if the hall were monitored per policy.

2)

Review of the medical record of patient #5 revealed nursing notes from Bridgeway Outpatient Clinic dated/timed 01/28/11 at 12:00 revealed: " Dr. (S4MD) here. Psych Eval done. Discussed with pt the need for hospitalization due to reports from (nursing home " a " ) where pt lives. Pt very resistant to hospitalization and refuses, but (S4MD) instructed her she is gravely disabled and needs hospitalization .

Review of the nursing notes dated/timed 01/28/11 at 12:15 p.m. revealed: "PEC completed by (S4MD). PEC' d to Jennings Senior Care. Discussed PEC with pt. She's agreeable to go to hospital voluntarily."

In an interview on 03/22/11 at 10:15 a.m. with S12RN, Administrator of Bridgeway Outpatient Clinic, she stated that patient #5 was under a PEC and was subsequently transported to Jennings Senior Care by the transport van from Jennings Senior Care.

In an interview on 03/23/11 at 9:10 a.m. with S1Admin and S2DON confirmed there was no hospital policy for transporting patients under PEC from the offsite Bridgeway Outpatient Clinic. They further confirmed that Bridgeway Outpatient Clinic calls the SO to transport patients that are PEC' d at the clinic, regardless of whether or not the patient meets Jennings Senior Care hospital admission criteria, to a hospital emergency room . S1Admin and S2DON stated the Jennings Senior Care transport van typically does not transport PEC' d patients. Both confirmed the van, with only a driver (S21MHT) aboard, transported patient #5 on 01/28/11.

3)

Review of the "Psychotherapy" note dated/timed 1/31/11 from 10:45 a.m. to 11:30 a.m. revealed Patient #10 attended group therapy with S22LCSW. Further review revealed the patient was "manipulative and attention seeking. Slowed thought process and speech. Intermittently alert and attentive with intermittent participation when prompted. Patient expressed understanding of topic. Will continue to monitor and assess for mood disorder and altered thoughts " .
Review of the "Interdisciplinary Progress Notes" dated/timed 1/31/11 at 1152 (11:52 a.m.) read, "met /c (with) pt (patient), another SWR (social worker) stated pt is ... having thoughts of suicide on a questionnaire. Pt states when asked why the other SWR asked for clinician to meet /c her pt began to discuss how people at church are saying that she is sleeping with different men. Pt stated these rumors are being started by her sister and her friend. Pt stated she does not want to stay /c her mtr (mother). SWR stated pt would need to return home until she found another living arrangements. Pt voiced understanding " was recorded by S22LSW. Further review of the "Interdisciplinary Progress Notes" recorded by S22LSW revealed no documentation the patient' s thoughts of suicide were assessed and evaluated to determine whether or not the patient had a plan to commit suicide prior to being discharged from the hospital.
Review of the "Interdisciplinary Progress Notes" dated/timed 2/1/11 at 1030 (10:30 a.m.) read, "Report by staff pt verbally stating she wanted to kill herself, loud, disruptive, & necessary to remove from group. To S22LSW (LSW named) for individual therapy" was documented by S13RN.
Review of the "Interdisciplinary Progress Notes" dated/timed 2/1/11 at 1030 (10:30 a.m.) revealed S22LSW "met with patient by request of another SWRs request see above" -see the above review of the "Interdisciplinary Progress Notes" recorded by an RN, (S13RN). Further review revealed "pt fearful and paranoid. Pt stated she was going to kill herself but she was going to run away. Pt claims her family was spreading rumors at church that she was sleeping with men. Pt was difficult to calm. Brought her to be assessed by S14PMHNP (NP named)."
Review of the "Interdisciplinary Progress Notes" dated/timed 2/1/11 at 1040 (10:40 a.m.) read, "notified S24MD pt /c SI (suicidal ideation) /c intent. PEC (Physician Emergency Certificate) eval (evaluation) being done by S14PMHNP & (and) pt will be transported to a (local emergency room hospital named) "was recorded by S13RN. Further review revealed the patient was "manipulative and attention seeking. Slowed thought process and speech. Intermittently alert and attentive with intermittent participation when prompted. Patient expressed understanding of topic. Will continue to monitor and assess for mood disorder and altered thoughts. "
The Physician Emergency Certificate (PEC) dated/timed 2/1/11 at 1045 (10:45 a.m.) for Patient #10 revealed the patient was "in the need of immediate psychiatric treatment in a treatment facility because he/she is seriously mentally ill so that he/she is "dangerous to self and others and unwilling to seek voluntary admission. "
During interview on 3/22/11 at 12:05 p.m., S21LCSW verified Patient #10 was in group therapy session from 10:45 a.m. to 11:30 a.m. on 1/31/11. S21 indicated there was no documented evidence in her "Psychotherapy" notes the patient had thoughts of suicide. S21 recalled the patient completed a questionnaire in regards to the group topic of the day, "Feelings." S21 continued the patient stated on the questionnaire that she was having thoughts of suicide, so she referred to patient to another S22LSW. S21 confirmed there was no documented evidence in the patient' s medical record of the questionnaire completed by the patient during group therapy. S21 stated the hospital' s suicide protocol is for the patient's thoughts of suicide are to be addressed by the Registered Nurse, (S13 named) and S12.
In interview on 3/22/11 at 11:30 a.m., S22LSW reviewed her "Interdisciplinary Progress Notes" dated/timed 1/31/11 at 1152 (11:52 a.m.). At this time, S22 translated her notes written as indicated above. S22 indicated there was no documented evidence Patient #10 ' s thoughts of suicide were assessed prior to discharging the patient from the hospital on [DATE] at 11:52 a.m... S22 reported patients with suicidal ideation and/or thoughts of suicide should be assessed by a qualified licensed staff member like the Registered Nurse and/or Director, (S12). S22 continued the Nurse Practitioner is notified of the patient ' s suicidal ideation. The Nurse Practitioner then assesses the patient' s suicidal ideation. S22 indicated the Nurse Practitioner was not in-house at the hospital on [DATE]. S22 stated the physician should be contacted. S22 verified there was no documented evidence in Patient #10' s medical record the Registered Nurse, Nurse Practitioner and/or attending physician were notified of the patient ' s suicidal ideation reported on the questionnaire form on 1/31/11. S22 indicated there was no documented evidence in her progress notes the patient' s suicidal ideation was assessed as per standard protocol prior to the patient leaving the hospital on [DATE]. S22 verified the patient returned the following morning approximately 23 hours later stating she wanted to kill herself.
During face-to-face interviews on 3/22/11 at 10:20 a.m., at 12:00 p.m., at 12:15 p.m., S12RN (IOP) indicated the patient had "thoughts of suicide" during the group session conducted by S21LCSW from 10:45 a.m. to 11:30 a.m. on 1/31/11. S21 conducted the group therapy session that morning with the topic of "feelings." The LCSW (S21) used a "Questionaire" form for the patients to complete regarding their feelings during the group session. The patient (#10) stated on the form that she was "having thoughts of suicide" . S12 verified there was no documented evidence in the patient' s medical record of the "Questionaire" form completed by the patient during the group session conducted on 1/31/11. S12RN indicated all patients with "thoughts of suicide" are assessed by the social worker to determine whether or not the patients have a passive and/or active suicidal ideation plan. The Social Worker will determine whether or not the patient has the means to carry out the active suicidal ideation plan at home by calling and speaking with the family member. If the patients have an active suicidal plan, the Social Worker then contacts the Registered Nurse , Director (S12), Nurse Practitioner, and Physician to have the patient assessed by a licensed personnel of the hospital. If the Nurse Practitioner and/or Physician are not available then an Order Protective Custody (OPC) would be obtained from the Sheriff ' s Department. An OPC is the only way to take care of a patient if no Nurse Practitioner and/or Physician are available to admit a patient. S12 confirmed the Nurse Practitioner was not available on 1/31/11. S12 confirmed there was no documented evidence the Social Worker (S22) followed the policy/protocol to notify the Registered Nurse, Director (S12), Nurse Practitioner, and Physician that the patient was having suicidal thoughts on 1/31/11. S12, IOP verified the patient was PEC on 2/1/11 about 23 hours later with a plan to kill herself.
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
Based on record review and interview the hospital 1) failed to ensure the patient participated in the development and implementation of her care plan as evidenced by failing to present the plan of care to the patient for over 60 hours after admission for 1 of 11 sampled patients (#5) and 2) failing to allow the family to participate in the development and implementation of the care plan and discharge planning as evidenced by not responding to a family request for a meeting and not inviting the family to the Treatment team meeting per hospital policy for 1 of 11 sampled patients. (#5) Findings:

1)

Review of the Multidisciplinary Treatment Plan revealed it was initiated on 01/28/11 by S15RN. Further review revealed patient #5 refused to sign it on 01/31/11 when presented by the administrator.

In a telephone interview on 03/23/11 at 11:35 a.m. with S5RN he stated he does not remember the patient specifically. He further stated the Care Plan was prepared at night and does not specifically remember discussing it with the patient.

In an interview on 03/23/11 at 10:50 a.m. with S2DON, she confirmed patient #5 refused to sign the Multidisciplinary Treatment Plan on the morning of 01/31/11 because she did not agree she needed to be in an inpatient facility.

Review of a document titled " Treatment Plan Review " revealed patient #5 had signed the form after Treatment Team was held with the patient present on 01/31/11.

In an interview on 03/23/11 at 11:15 with S8RN, she stated the Treatment Team was held on 01/31/11 and the patient was present. S8RN stated patient #5 signed the form after S3MD informed her (patient #5) she would be discharged the next day.

Review of a hospital policy titled " Treatment Plans " , no date effective, reviewed, or last revised, reads in part: " Subject: Treatment Plans ...Procedure ...9) The patient has the right to participate in the development and modification of treatment plans and discharge plans ... "

2)

Review of a document titled "Contact Log" revealed a family member of patient #5 requested a family conference with S8RN on 01/31/11 at 11:30 a.m.

In an interview on 03/23/11 at 11:15 a.m. with S8RN, she stated she reported the request to S9LCSW.

Review of a hospital policy titled " Psychotherapy " , no effective date, no date of review or last revision, read in part: " Purpose: To describe the various psychotherapeutic approaches provided to patients by the Hospital psychiatric program ...Procedure: The following approaches to psychotherapy are available to the patients ...4) FAMILY CONFERENCE - a family meeting initiated for the purpose of directing the patient's course of treatment, family's view of the patient's progress, and discharge plans. "

Review of a hospital policy titled " Treatment Team Coordinator " , no effective date, no date of last review or revision, read in part: " Subject: Treatment Team Coordinator. Policy: Master Treatment Planning is coordinated by the Treatment Team Coordinator (TC). Procedure: The Treatment Team Coordinator is the social worker ... "

In an interview on 03/23/11 with S9LCSW, she stated she did the psychosocial assessment on Friday 01/28/11 and was aware the family and patient #5 were " upset " about the inpatient admission. S9LCSW stated after patient #5 was advised of her plan of care and discharge plans on 01/31/11, there was no further contact with the family. S9LCSW confirmed the family of patient #5 was not advised of or invited to attend the Team meeting on 01/31/11.
VIOLATION: INTEGRATION OF OUTPATIENT SERVICES Tag No: A1077
Based on record review and interview the hospital failed to ensure the outpatient clinic and inpatient hospital had policies and procedures to assure continuity of care as evidenced by the failure to develop and implement policy and procedure to address continuity of care between the outpatient clinic and the inpatient hospital when the patient who presents at the outpatient clinic requires services of the inpatient hospital. This has the potential to affect all patients seen at the outpatient clinic who require inpatient services. Findings:

Review of the medical record of patient #5 revealed nursing notes from Bridgeway Outpatient Clinic dated/timed 01/28/11 at 12:00 revealed: " Dr. (S4MD) here. Psych Eval done. Discussed with pt the need for hospitalization due to reports from (nursing home "a" ) where pt lives. Pt very resistant to hospitalization and refuses, but (S4MD) instructed her she is gravely disabled and needs hospitalization . Her 2 options are to sign in Formal Voluntary admission or PEC. Pt. very angry and irritable. Pt. to group with staff monitoring her to prevent elopement or harm to self or others, although pt. denies SI/HI (suicidal or homicidal ideations). "

Review of the nursing notes dated/timed 01/28/11 at 12:15 p.m. revealed: "PEC completed by (S4MD). PEC' d to Jennings Senior Care. Discussed PEC with pt. She' s agreeable to go to hospital voluntarily."

In an interview on 03/22/11 at 10:15 a.m. with S12RN, Administrator of Bridgeway Outpatient Clinic, she stated that patient #5 was told " if she did not sign a voluntary admission that the Sheriff 's Office (SO) would pick her up and taken to the nearest emergency room and she could end up at any hospital. If she signed a voluntary admission she could go to Jennings Senior Care. " In the same interview S12RN stated that patient #5 was under a PEC and was subsequently transported to Jennings Senior Care by the transport van from Jennings Senior Care. S12RN further stated that patient #5 had indicated she wanted to be seen by S3MD and that S3MD sees patients at Jennings Senior Care.

In an interview on 03/22/11 at 10:30 with S13RN, Bridgeway Outpatient Clinic, she stated that patient #5 was not initially agreeable to hospitalization . She stated S4MD placed patient #5 under a PEC. S13RN stated patient #5 then agreed to go "voluntarily." She further stated that Sheriff's Office (SO) would only take patients to a hospital in Calcasieu Parish and Jennings Senior Care is not in Calcasieu Parish. S13RN stated a patient must be a FVA (formal voluntary admission) to go to Jennings Senior Care.

Review of the entire medical record for patient #5 at Bridgeway Outpatient Clinic revealed no FVA signed by patient #5. This finding was confirmed by S12RN and S13RN.

In an interview on 03/23/11 at 9:10 a.m. with S1Admin and S2DON, both confirmed there was no hospital policy for transporting patients under PEC from the offsite Bridgeway Outpatient Clinic. They further confirmed that Bridgeway Outpatient Clinic calls the SO to transport patients that are PEC 'd at the clinic, regardless of whether or not the patient meets Jennings Senior Care hospital admission criteria, to a hospital emergency room . S1Admin and S2DON stated the Jennings Senior Care transport van typically does not transport PEC'd patients. Both confirmed the van, with only a driver (S21MHT) aboard, transported patient #5 on 01/28/11.

In a telephone interview on 03/24/11 with PD1 he stated SO will transport patients to any facility if the hospital has a contract (i.e. must pay for services rendered). If the hospital has no contract, the SO only transports to the nearest emergency room .
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
Based on record review and interview the hospital failed to have documented evidence of family involvement in discharge planning as evidenced by failing to respond to the family's request for a meeting and/or failing to invite family to the Treatment team meeting so they could be informed of the progress of the patient and discharge planning for 1 of 11 sampled patients. (#5) Findings:

Review of a document titled "Contact Log" revealed a family member of patient #5 requested a family conference with S8 RN on 01/31/11 at 11:30 a.m.

In an interview on 03/23/11 at 11:15 a.m. with S8RN, she stated she reported the request to S9LCSW.

Review of a hospital policy titled "Psychotherapy" , no effective date, no date of review or last revision, read in part: "Purpose: To describe the various psychotherapeutic approaches provided to patients by the Hospital psychiatric program ...Procedure: The following approaches to psychotherapy are available to the patients ...4) FAMILY CONFERENCE - a family meeting initiated for the purpose of directing the patient's course of treatment, family's view of the patient's progress, and discharge plans."

Review of a hospital policy titled "Treatment Team Coordinator" , no effective date, no date of last review or revision, read in part: "Subject: Treatment Team Coordinator. Policy: Master Treatment Planning is coordinated by the Treatment Team Coordinator (TC). Procedure: The Treatment Team Coordinator is the social worker ..."

In an interview on 03/23/11 with S9LCSW, she stated she did the psychosocial assessment on Friday 01/28/11 and was aware the family and patient #5 were " upset " about the inpatient admission. S9LCSW stated that after patient #5 was advised of her plan of care and discharge plans on 01/31/11 there was no further contact with the family. S9LCSW confirmed the family of patient #5 was not advised of or invited to attend the Team meeting on 01/31/11.