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.

ST JAMES BEHAVIORAL HEALTH HOSPITAL, INC 3136 SOUTH ST LANDRY ROAD GONZALES, LA Aug. 12, 2011
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on record review and interview the hospital failed to ensure their grievance policy was implemented to ensure patients filing grievances received a 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 for 1 of 2 patients reviewed for hospital response to grievances out of a total sample of 20 (Random Sampled Patient #R1). Findings:

Review of a grievance completed by Patient #R1 on 5/30/2011 at 1:00 p.m. regarding allegations of abuse by having his arm squeezed by the Director of Nursing S2 and withholding of medically indicated sunglasses revealed no documented evidence of a follow up letter to the patient.

Review of the hospital policy titled, "Patient Complaint/Grievance #1.24" presented by the hospital as their current policy revealed in part, "Once the Committee and the Corporate Director of Quality/Risk Management make a final decision, a written response will be provided the complainant within 5 working days. The written response will include the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigative process, as appropriate, and the date of completion. The response will not exceed 30 days from the original receipt of the grievance.

During a face to face interview on 8/12/2011 at 1450 (2:50 p.m.), Clinical Coordinator S3 indicated she had been the administrative staff that had investigated Patient #R1's grievance regarding medically necessary use of sunglasses; however, she had no documented evidence of investigating the patient's allegations of abuse. S3 further indicated she (S3) had failed to provide Patient #R1 with a follow up letter within 30 days of the original grievance that contained the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigative process, as appropriate, and the date of completion. S3 indicated she had never provided Patient #R1 with a follow up letter.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0194
Based on record review and interview the hospital failed to conduct staff training in Restraint/Seclusion for 35 of 38 Mental Health Technicians (MHT) as evidenced by review of 38 of 38 MHT personnel records (S6MHT, S9MHT, S10MHT, S11MHT, S13MHT, S20MHT, S21MHT, S25MHT, S27MHT, S34MHT, S37MHT, S41MHT, S43MHT, S44MHT, S45MHT, S46MHT, S47MHT, S48MHT, S50MHT, S51MHT, S52MHT, S53MHT, S54MHT, S55MHT, S56MHT, S57MHT, S58MHT, S59MHT, S60MHT, S61MHT, S62MHT, S63MHT, S64MHT, S65MHT, S66MHT). This has the potential to place all staff and patients at risk. Findings:

Review of a sample of the personnel records of MHT's employed by the hospital revealed a lack of training in Restraint/Seclusion. The sample of MHT's was expanded to include all MHT's employed by the facility and data was extracted from all files.

Review of the data from all 38 MHT personnel records revealed 35 of 38 MHT's employed by St. James Behavioral Health Hospital had no documented evidence of any Restraint/Seclusion.

In an interview on 08/09/11 at 9:10 a.m. S2DON confirmed the hospital has not conducted Restraint/Seclusion training for employees.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0196
Based on record review and interview the hospital failed to ensure staff was trained in and able to perform return demonstration in the safe use of Restraint/Seclusion as evidenced by 35 of 38 MHT's employed by the hospital having no documented evidence of Restraint/Seclusion training at any time during their employment (S6MHT, S9MHT, S10MHT, S11MHT, S13MHT, S20MHT, S21MHT, S25MHT, S27MHT, S34MHT, S37MHT, S41MHT, S43MHT, S44MHT, S45MHT, S46MHT, S47MHT, S48MHT, S50MHT, S51MHT, S52MHT, S53MHT, S54MHT, S55MHT, S56MHT, S57MHT, S58MHT, S59MHT, S60MHT, S61MHT, S62MHT, S63MHT, S64MHT, S65MHT, S66MHT). This has the potential to affect all staff and patients. Findings:

Review of a sample of the personnel records of MHT's employed by the hospital revealed a lack of training in Restraint/Seclusion. The sample of MHT's was expanded to include all MHT's employed by the facility and data was extracted from all files.

Review of the data from all 38 MHT personnel records revealed 35 of 38 MHT's employed by St. James Behavioral Health Hospital had no documented evidence of any Restraint/Seclusion training.

In an interview on 08/09/11 at 9:10 a.m. S2DON confirmed the hospital has not conducted Restraint/Seclusion training for employees.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0200
Based on record review and interview the hospital failed to ensure the development and implementation of a training program which complied with regulatory requirements as evidenced by 30 of 38 MHT's employed by the hospital not being trained in the use of nonphysical intervention skills (S9MHT, S10MHT, S13MHT, S20MHT, S25MHT, S27MHT, S32MHT, S34MHT, S37MHT, S41MHT, S42MHT, S43MHT, S44MHT, S45MHT, S46MHT, S47MHT, S48MHT, S50MHT, S51MHT, S52MHT, S53MHT, S54MHT, S55MHT, S58MHT, S60MHT, S61MHT, S62MHT, S63MHT, S64MHT, S66MHT) . This has the potential to affect all staff and patients. Findings:

Review of a sample of the personnel records of MHT's employed by the hospital revealed a lack of training in nonphysical intervention skills. The sample of MHT's was expanded to include all MHT's employed by the facility and data was extracted from all files.

Review of the data from all 38 MHT personnel records revealed 30 of 38 MHT's employed by St. James Behavioral Health Hospital had no documented evidence of any training in nonphysical intervention skills.

In an interview on 08/09/11 at 9:10 a.m. S2DON confirmed the hospital has not conducted training in nonphysical intervention skills for 30 of 38 MHT employees.
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the Hospital failed to meet the requirements for the Condition of Participation for Patient Rights as evidenced by:

1) failing to ensure measures were in place to protect psychiatric patients from harm by self inflicted acts or harmful acts committed by peers, staff, and/or visitors for 3 of 20 sampled patients. (Patient #5, #17, #10) (see findings at A0144)

2) failing to ensure patients were monitored as per physician's orders for 6 of 20 sampled patients (#3, #7, #11,#12, #17, #4) and while located in the Laundry Room/Linen Room on the night of 7/19/2011. (see findings at A0144)

3) failing to ensure all patients were free from abuse and neglect as evidenced by a patient admitted by Physician's Emergency Certificate and Coroner's Emergency Certificate with suicidal ideations was not under close observation every 15 minutes as ordered by the physician for 1 1/2 hours which resulted in the patient's elopement and the police and the facility being unable to locate the patient (Patient #7) (see findings at A0145)

4) failing to ensure the hospital had and enforced an effective abuse prohibition policy as evidenced by failing to ensure appropriate screening of employees by not conducting criminal history background checks on 7 of 38 Mental Health Technicians (MHT's) (S6MHT, S13MHT, S20MHT, S41MHT, S44MHT, S49MHT, S50MHT) (see findings at A0144)

5) failing to ensure that allegations of abuse were reported to the Department of Health and Hospitals' Health Standards Section within 24 hours of knowledge of the allegation for 1 of 1 sampled patient (#5) (see findings at A0145)

6) failing to ensure measures were in place to educate and train all clinical employees in regards to abuse/neglect for 35 of 38 Mental Health Techs reviewed. This has the potential to affect all patients and staff. (S9MHT, S10MHT, S11MHT, S13MHT, S20MHT, S21MHT, S25MHT, S27MHT, S32MHT, S34MHT, S37MHT,S41MHT, S42MHT, S43MHT, S44MHT, S45MHT, S46MHT, S47MHT, S48MHT, S49MHT, S50MHT, S51MHT, S53MHT, S54MHT, S55MHT, S56MHT, S57MHT, S58MHT, S59MHT, S60MHT, S61MHT, S62MHT, S63MHT, S64MHT, S65MHT) (see findings at A0145)

7) failing to ensure MHT's received training in the use of Restraint/Seclusion as evidenced by failing to ensure 35 of 38 MHT's had documented training and return demonstration in the safe application/use of Restraint/Seclusion. (S6MHT, S9MHT, S10MHT, S11MHT, S13MHT, S20MHT, S21MHT, S25MHT, S27MHT, S34MHT, S37MHT, S41MHT, S43MHT, S44MHT, S45MHT, S46MHT, S47MHT, S48MHT, S50MHT, S51MHT, S52MHT, S53MHT, S54MHT, S55MHT, S56MHT, S57MHT, S58MHT, S59MHT, S60MHT, S61MHT, S62MHT, S63MHT, S64MHT, S65MHT, S66MHT) (see findings at A0144)

8) failing to ensure MHT's received training in nonphysical intervention skills as evidenced by failing to have documented evidence of training for 30 of 38 MHT's. (S9MHT, S10MHT, S13MHT, S20MHT, S25MHT, S27MHT, S32MHT, S34MHT, S37MHT, S41MHT, S42MHT, S43MHT, S44MHT, S45MHT, S46MHT, S47MHT, S48MHT, S50MHT, S51MHT, S52MHT, S53MHT, S54MHT, S55MHT, S58MHT, S60MHT, S61MHT, S62MHT, S63MHT, S64MHT, S66MHT) (see findings at A0144)

9) failing to provide security for patient belongings brought into the hospital as evidenced by items documented as being placed in the hospital's safe not being there upon discharge of the patient. (patient #8). (see findings at A0144)

10) failing to ensure their grievance policy was implemented to ensure patients filing grievances received a 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 for 1 of 2 patients reviewed for hospital response to grievances out of a total sample of 20 (Random Sampled Patient #R1). (see findings at A0123)

On 08/11/11 at 12:10 p.m. S1Administrator, S2DON, and S3Clinical Coordinator were notified of an Immediate Jeopardy. The Immediate Jeopardy situation was:

The hospital failed to ensure patients received care in a Safe Setting by 1) failing to ensure measures were in place to protect psychiatric patients from harm by self inflicted acts or harmful acts committed by peers, staff, and/or visitors; 2) failing to ensure the hospital had and enforced an effective abuse prohibition policy; 3) failing to ensure a complete investigation was conducted to identify the Root Cause of incidents to facilitate development and implementation of corrective measures and; 4) failing to ensure the environment of care was safe as evidenced by having 70" X 62" (wide) windows that open 6" at waist height on the ground level allowing the potential introduction of contraband into the hospital as evidenced by:

Patient #5

Patient #5 complained to a Registered Nurse on 7/24/2011 at 9:30 a.m. that she (#5) had been sexually violated with vaginal penetration and ejaculation by a black male Mental Health Technician (unidentified at that time) in the shower room a few days prior to voicing the complaint (unsure of the date that alleged rape occurred). Review of nursing documentation dated 7/24/2011 at 9:30 a.m. revealed the hospital Administrator (S1) was notified. The hospital has a video surveillance system with views of patient care hallways, common areas, and two acute patient care rooms. Administration failed to review the video tapes until the morning of 7/25/2011 (Confirmed by Administrator S1). Video tape review revealed Mental Health Tech S9 had been alone in the shower room with Patient #5 on two occasions the date of 7/19/2011. S9 had worked 7:00 p.m. until 7:00 a.m. on 7/24/2011 and was assigned to the care of three female patients. Physician's Assistant S38 indicated she (S38) had made rounds on the evening of 7/24/2011 and someone on duty (identity not recalled) had informed her that Mental Health Technician S9 had been accused of raping Patient #5. S38 indicated she was also told that Administration was handling the situation. S38 indicated that she thought it was "odd" that Mental Health Technician S9 was allowed to continue working while an investigation of alleged rape was being conducted.

Patient #17

Patient #11(male) and Patient #17 (female): Review of Patient #11's nursing notes dated 7/17/2011 at 1930 (7:30 p.m.) revealed "pt (patient) went into the female's shower room and took his (#11) shower, been making sexual remarks about one of the female pt's, he (#11) heard her (female patient) say she (female patient) was going to shower but one of the other pt's walked in on him." Review of Patient #17's Physician Assistant notes dated 7/17/2011 (no documented time) revealed in part, "Pt (patient) is a little worried, a male peer is obsessed (with) her (Patient #17) and has been watching her (#17) closely". During a face to face interview on 8/10/2011 at 8:00 a.m., Registered Nurse S18 indicated she (S18) was the nurse on duty when Patient #11 entered the female shower room on 7/17/2011 in attempt to encounter Patient #17. S18 indicated Patient #11 had been "interested" in Patient #17. S18 indicated Patient #11 had overheard Patient #17 make plans to shower and had entered the female shower room and disrobed/showered awaiting the arrival of Patient #17. S18 indicated she (S18) had not updated Patient #11's treatment plan to ensure interventions were carried out across all shifts to protect Patient #17 from Patient #11. S18 further indicated that she (S18) had not completed an incident report and had not reported the incident to the patient's physician or to administration.

Patient #10

Patient #10 was admitted to the hospital after a self inflicted cut to his wrist as a suicide attempt on 7/22/2011. Patient #10 was placed on suicide precautions with observations every 15 minutes. Review of Patient #10's Nursing Notes dated 7/23/2011 at 15:50 revealed in part, "summoned to patient's room and found pt sitting on bed bleeding from lt (left) wrist wound. Noted he (#10) was holding pressure to wound (with) a blue cloth. Noted a large amount of blood droplets on floor (with) spray of blood on wall, attempted to approach pt. (#10) to provide care but unable to do so as pt (#10) growled "don't come near me", 911 called. . .1815 pt. (#10) received back on the unit and escorted to an observation room by (Director of Nursing S2)." Patient #10 remained on 15 minute observations after an active attempt at self harm in the hospital. Physician Assistant S36 indicated any patient with an active suicide attempt in the hospital should have been placed on 1:1 monitoring.

Patient #7

Patient #7 was admitted on [DATE] under a PEC/CEC for Suicidal Ideations. The physician responsible for the care of Patient #7 ordered q (every) 15 minute checks on Patient #7. On 07/24/11 at 7:00 p.m. S9MHT was assigned the q 15 minute checks for Patient #7. Review of the nursing documentation revealed Patient #7 was noted to be missing from the hospital at 8:30 p.m. on 07/24/11. Review of the observation flowsheet revealed documentation that S9MHT had checked on the patient (#7) every 30 minutes throughout the shift (7:15 p.m. - 6:45 a.m.). Documentation of examination of the room of Patient #7 revealed that the window next to the patient's bed had been broken. Review of a document titled "Environmental Safety Report" created by the Administrator dated July 25, 2011 revealed contraband in the form of a "short black screwdriver" was found in the room of Patient #7 on 07/24/11 when Patient #7 was noted to be missing from the hospital. Review of the nurse's notes revealed the Police Department was called, S31MD, S36PA, S38PA, and S39MD were notified. Further review of the incident report revealed Patient #7 was never found.

The Hospital failed to ensure patients received Care in a Safe Setting as evidenced by failing to ensure the hospital had and enforced an effective abuse prohibition policy by failing to obtain Criminal History Background checks on 7 of 38 Mental Health Technicians (MHT) (S6MHT, S13MHT, S20MHT, S41MHT, S44MHT, S49MHT, S50MHT), failing to have 30 of 38 MHT's certified in Crisis Prevention Intervention (CPI) (S9MHT, S10MHT, S13MHT, S20MHT, S25MHT, S27MHT, S32MHT, S34MHT, S37MHT, S41MHT, S42MHT, S43MHT, S44MHT, S45MHT, S46MHT, S47MHT, S48MHT, S50MHT, S51MHT, S52MHT, S53MHT, S54MHT, S55MHT, S58MHT, S60MHT, S61MHT, S62MHT, S63MHT, S64MHT, S66MHT) , failed to ensure 35 of 38 MHT's received any training in Abuse/Neglect (S9MHT, S10MHT, S11MHT, S13MHT, S20MHT, S21MHT, S25MHT, S27MHT, S32MHT, S34MHT, S37MHT,S41MHT, S42MHT, S43MHT, S44MHT, S45MHT, S46MHT, S47MHT, S48MHT, S49MHT, S50MHT, S51MHT, S53MHT, S54MHT, S55MHT, S56MHT, S57MHT, S58MHT, S59MHT, S60MHT, S61MHT, S62MHT, S63MHT, S64MHT, S65MHT), failing to ensure 34 of 38 MHT's had documented evidence of Restraint training (S6MHT, S9MHT, S10MHT, S11MHT, S13MHT, S20MHT, S21MHT, S25MHT, S27MHT, S34MHT, S37MHT, S41MHT, S43MHT, S44MHT, S45MHT, S46MHT, S47MHT, S48MHT, S50MHT, S51MHT, S52MHT, S53MHT, S54MHT, S55MHT, S56MHT, S57MHT, S58MHT, S59MHT, S60MHT, S61MHT, S62MHT, S63MHT, S64MHT, S65MHT, S66MHT), failed to ensure 32 of 38 MHT's had documented evidence of orientation to their job duties (S9MHT, S10MHT, S11MHT, S13MHT, S20MHT, S21MHT, S25MHT, S27MHT, S32MHT, S34MHT, S37MHT, S41MHT, S43MHT, S44MHT, S45MHT, S47MHT, S48MHT, S49MHT, S50MHT, S51MHT, S52MHT, S53MHT, S54MHT, S55MHT, S56MHT, S57MHT, S58MHT, S59MHT, S61MHT, S62MHT, S63MHT, S66MHT) and failed to ensure 27 of 38 MHT's had documentation of skills competency (S9MHT, S10MHT, S11MHT, S13MHT, S20MHT, S21MHT, S25MHT, S27MHT, S32MHT, S34MHT, S41MHT, S42MHT, S43MHT, S44MHT, S45MHT, S46MHT, S47MHT, S48MHT, S49MHT, S50MHT, S53MHT, S55MHT, S56MHT, S58MHT, S60MHT, S62MHT, S63MHT).

The hospital failed to ensure a complete investigation was conducted to identify the Root Cause of these incidents to facilitate development and implementation of corrective measures.

On 08/12/11 at 3:15 p.m. the hospital submitted a Plan of Removal for the Immediate Jeopardy. The Plan included the following:

Abuse Prohibition:

1. The 7 of 38 Mental Health Technicians (MHT) found to have no verification of Criminal History Background checks have been identified and criminal history backgrounds verified.

2. An effective Abuse Prohibition Policy has been created in conjunction with the facility's contracted Human Resource service provider Contracted Service " a ". Please see attached policy.

3. Employees will not be allowed to work in the facility until background check and other Abuse Prohibition measures are completed and verified.

Crisis Prevention Intervention:

1. The 8 of 38 MHT's certified in Crisis Prevention Intervention (CPI) have been identified and assigned to the schedule to ensure immediate minimum of 2 CPI certified clinical staff per shift.

2. CPI training will be conducted for 23 staff identified without training and certification Friday, August 12, 2011 by Contracted Service " b ", a DHH and LDOL certified company.

3. Additional CPI training will be conducted for staff on Tuesday August 16, 2011 at 7:30 am and 3:30 pm.

4. A confidence date for 100% of MHT's to be CPI trained and certified is Thursday August 18, 2011.

5. New clinical employees will be trained and certified in CPI within 90 days of hire in conjunction with a comprehensive orientation, training and continuing education staff development program.

Abuse and Neglect Training:

1. Training in Abuse & Neglect policy and procedures will be conducted for the AM & PM shifts on Thursday August 11, 2011 to ensure immediate safety and benefit. The training will continue daily per AM & PM shifts until the 35 of 38 MHT's without education receive training and verification.

2. A confidence date of Wednesday August 17, 2011 is set for 100% of MHT's to have documentation of training in abuse/neglect policy & procedure.

3. A minimum of 2 clinical staff with Abuse and Neglect education per shift will be ensured until all 38 current MHT's are trained and verified.

4. Training will include abuse/neglect policy & procedure review and comprehensive testing with benchmark of greater than 85% passing score. Abuse and neglect policy & procedure has been revised on to include testing and benchmark percentage. Please see attached policy & procedure.

5. Compliance with Abuse and Neglect policies and procedures will be ensured by all new employees being oriented and by annual re-education of abuse & neglect policies and procedures. Each occurring event of abuse & neglect will be reported and investigated through our root cause analysis process.

Seclusion and Restraint Training:

1. Training in Seclusion/Restraint Policy & Procedure and skills competencies will be conducted for the AM & PM shifts on Thursday August 11, 2011 to ensure immediate patient safety and benefit. The training will continue daily per AM & PM shifts until all 38 MHT's training is verified.

2. A minimum of 2 clinical staff with Seclusion and Restraint education per shift will be ensured immediately until all 38 MHT's are trained and verified.

3. A confidence date for 100% of MHT's to be trained and documented in seclusion restraint policy & procedure and competencies is Wednesday August 17, 2011.

4. Training will include seclusion/restraint policy policy & procedures review and acknowledgement. Training and competencies will include CMS guidelines for restraint training.

5. Compliance with Seclusion and Restraint policies and procedures will be ensured by a full audit of every restraint and/or seclusion. Seclusion & restraint policy and procedure has been revised to include skills competencies. Please see attached policy & procedure.

Orientation to Job Duties:

1. Orientation to Job Duties will be conducted for the AM & PM shifts on Thursday August 11, 2011 to ensure immediate patient safety. The training will continue daily per AM & PM shifts until all 38 MHT's are documented as oriented as oriented to duties.

2. A minimum of 2 MHT's with documented orientation to duties per shift will be ensured until all 38 current MHT's are oriented.

3. A confidence date for 100% of MHT's to be trained and documented in orientation to job duties is Wednesday August 17, 2011.

4. Training will include written description of performance of duties and comprehension acknowledgement.

5. Compliance with job duties policies and procedures will be ensured by all current employees receiving re-training, all new employees having documentation of orientation and training and annual re-training.

Documentation of Skills Competencies:

1. Documentation of observation skills competency will be completed for the AM & PM shifts on Thursday August 11, 2011 to ensure immediate patient safety. Competency demonstration and documentation will continue daily per AM & PM shifts until all 38 current MHT's have competency documentation.

2. A minimum of 2 clinical staff with documented skill competencies per shift will be ensured until all 38 current MHT's have documentation of orientation.

3. A confidence date for 100% of MHT's to be trained and documented is Wednesday August 17, 2011.

4. Training will include written description of performance of duties and comprehension acknowledgement as well as skills competencies.

5. Compliance with Seclusion and Restraint policies and procedures will be ensured by all current employees receiving re-training, all new employees having documentation of orientation and training and annual re-training.

Root cause analysis & development/implementation of corrective measures:

The facility will ensure and maintain a safe setting for patient care by immediately implementing and enforcing the following process for incident/grievance reporting and response:

Incident/Grievance

1. Immediate & appropriate care intervention
Physical/Medical/Psychological/Emotional Interventions
Create immediate safety setting
Identify staff allegedly involved and send home or re-assign
Report to physician, administration, and appropriate patient related party

2. Incident/Grievance report

3. Supporting statements & documentation

4. Communication of incident/grievance to appropriate parties
Business hours - Clinical Administration
After Hours - Administration on Call (AOC)
Communication to be made immediately

5. Administrative Video Surveillance & documentation
Video surveillance is conducted immediately by Administration when surveillance is available & relevant to investigation
Video Surveillance is documented:
- Surveyor (s)
- Time/Date of Surveillance
- Incident/Grievance
- Parties surveyed
- Video evidence and video timeline
- Summary of findings

6. Documentation of incident/grievance into patient treatment plan (information to influence individual patient care and supporting unit interventions)

7. Administrative Investigation & analysis of root causes of incident/grievance
- Investigation to be conducted by Administrator, DON, ADON, RN Clinical Coordinator & HR
Staffing patterns
Video surveillance
Interview staff and witnesses
Review of treatment plan interventions
Review of Treatment staff notes
Review of relevant documentation any correlated incidents
Search for relevant triggers
Review of safety policies and staff performance
Written Notification to Medical Director
Investigation incorporated into QA/QI

8. Administrative corrective measures and resolution

9. Report to higher authority (DHH/CMS/Police) if appropriate

10. Incorporation of incident/grievance & corrective measures documentation into QA/QI

Video Surveillance:

Video surveillance will be monitored by administrative staff for patient safety and quality assurance purposes. Surveillance of staff policy & procedure adherence, employee performance and other unit activity will be monitored on a daily basis. Surveillance of incidents, grievances, patient/staff allegations and other occurrences will be conducted as necessary. Administrative staff video surveillance will be documented in a surveillance binder and include surveyor, surveillance purpose, date, time, observation, observation timelines and determinations. Daily monitoring will be recorded for quality assurance and incident/grievance reporting will be recorded in the investigation file. Surveillance file will be created electronically and stored for reference and review. The facility administrator, clinical coordinator, DON, and human resource liaison will be trained in and authorized for surveillance.

Environment of Care Safety:

The facility will ensure a safe environment by immediately applying safety & tamper-proof screws to the 70" X 62" (wide) windows in each patient room to prevent them from opening. This measure will ensure the safety of the patient care environment by preventing introduction of contraband into the hospital. Confidence date for this action to be completed is Thursday August 11, 2011.

08/12/11, Friday

St. James Behavioral Health Hospital

Emergency MEC Governing Board Quorum

Agenda - Policies Approved
1. Observations Precautions - Policy 8.21A
2. Occurrence Report - Policy 8.6
3. Seclusion & Restraint for Behavioral Management - Policy 3.1
4. Patient Abuse and/or Neglect - Policy 2.3
5. Selection and Hiring of Personnel - Policy 9.2
6. MHT Responsibilities, Guidelines, Policies
7. MHT Competency Checklist


On 08/12/11 at 4:05 p.m. S1Administrator, S2DON, and S3Clinical Coordinator were notified that the Immediate Jeopardy was lifted. Condition level non-compliance remains for the Condition of Participation for Patient Rights.
VIOLATION: NURSING SERVICES Tag No: A0385
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the Hospital failed to meet the requirements for the Condition of Participation for Nursing Services as evidenced by:

1) failing to ensure the bath/shower room was monitored to ensure the safety of all psychiatric patients admitted to the hospital for 2 of 20 sampled patients (#11, #17). (see findings at A0395)

2) failing to ensure psychiatric patients were observed as per hospital protocol and/or orders by the patients' physician for 6 of 20 sampled patients (#3, #4, #7, #11, #12, #17), 6 random sampled patients (R5, R12, R13, R14, R15, R16) and two unidentified patients in the Laundry/Linen Room. (see findings at A0395)

3) failing to ensure a Registered Nurse performed an assessment on patients every 24 hours as per hospital policy for 2 of 12 days reviewed for Patient #5 (7/19/2011 and 7/22/2011).
(see findings at A0395)

4) failing to ensure patient's plan of care was kept current for 7 of 20 sampled patients (#1, #2, #5, #10, #11, #12, #13). (see findings at A0396)

5) failing to have a registered nurse assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs as evidenced by the 7 p.m. to 7 a.m. shift on 04/06/11, (1) Mental Health Tech was assigned 12 patients and (1) Mental Health Tech was assigned 13 patients with the patients either on every 30 minutes or every 15 minutes observations. The census on the shift was 27. The two (2) remaining MHTs had two(2) 1:1 supervised patients after the physician ordered Patient #4 to be 1:1 supervision on 04/06/11 at 1830 (6:30 p.m.). (see findings at A0397)
6) failing to have a registered nurse assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs as evidenced by a female patient (Patient #4) on 1:1 close observation at arm length was left alone in the bathroom for 5 minutes by a male MHT, a female MHT was not available to assist Patient #4 to the bathroom. (see findings at A0397)
7) failing to have a registered nurse assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs as evidenced by a female patient (#3) ordered 1:1 visual contact with no MHT assigned/designated to monitor the patient during the night shift from 06/26/11 from 7:30 pm (1930) to 10:10 pm (2210) for about 2 hours and 40 minutes or from 3:00 am (0300) through 7:00 am (0700) for about 4 hours as ordered by the physician at 7:30 pm (1930) on 06/26/11. (see findings at A0397)
8) failing to ensure all medications were administered according to physician's orders as per policy as evidenced by medication not administered as ordered by the physician for 2 of 20 sampled records reviewed, (#13, #20). (see findings at A0397)

On 08/11/11 at 12:10 p.m. S1Administrator, S2DON, and S3Clinical Coordinator were notified of an Immediate Jeopardy. The Immediate Jeopardy situation was:

The hospital failed to ensure patients received care in a Safe Setting by 1) failing to ensure measures were in place to protect psychiatric patients from harm by self inflicted acts or harmful acts committed by peers, staff, and/or visitors; 2) failing to ensure the hospital had and enforced an effective abuse prohibition policy; 3) failing to ensure a complete investigation was conducted to identify the Root Cause of incidents to facilitate development and implementation of corrective measures and; 4) failing to ensure the environment of care was safe as evidenced by having 70" X 62" (wide) windows that open 6" at waist height on the ground level allowing the potential introduction of contraband into the hospital as evidenced by:

Patient #5

Patient #5 complained to a Registered Nurse on 7/24/2011 at 9:30 a.m. that she (#5) had been sexually violated with vaginal penetration and ejaculation by a black male Mental Health Technician (unidentified at that time) in the shower room a few days prior to voicing the complaint (unsure of the date that alleged rape occurred). Review of nursing documentation dated 7/24/2011 at 9:30 a.m. revealed the hospital Administrator (S1) was notified. The hospital has a video surveillance system with views of patient care hallways, common areas, and two acute patient care rooms. Administration failed to review the video tapes until the morning of 7/25/2011 (Confirmed by Administrator S1). Video tape review revealed Mental Health Tech S9 had been alone in the shower room with Patient #5 on two occasions the date of 7/19/2011. S9 had worked 7:00 p.m. until 7:00 a.m. on 7/24/2011 and was assigned to the care of three female patients. Physician ' s Assistant S38 indicated she (S38) had made rounds on the evening of 7/24/2011 and someone on duty (identity not recalled) had informed her that Mental Health Technician S9 had been accused of raping Patient #5. S38 indicated she was also told that Administration was handling the situation. S38 indicated that she thought it was "odd" that Mental Health Technician S9 was allowed to continue working while an investigation of alleged rape was being conducted.

Patient #11 and Patient #17

Patient #11(male) and Patient #17 (female): Review of Patient #11's nursing notes dated 7/17/2011 at 1930 (7:30 p.m.) revealed " pt (patient) went into the female's shower room and took his (#11) shower, been making sexual remarks about one of the female pt's, he (#11) heard her (female patient) say she (female patient) was going to shower but one of the other pt's walked in on him." Review of Patient #17's Physician Assistant notes dated 7/17/2011 (no documented time) revealed in part, "Pt (patient) is a little worried, a male peer is obsessed (with) her (Patient #17) and has been watching her (#17) closely". During a face to face interview on 8/10/2011 at 8:00 a.m., Registered Nurse S18 indicated she (S18) was the nurse on duty when Patient #11 entered the female shower room on 7/17/2011 in attempt to encounter Patient #17. S18 indicated Patient #11 had been "interested" in Patient #17. S18 indicated Patient #11 had overheard Patient #17 make plans to shower and had entered the female shower room and disrobed/showered awaiting the arrival of Patient #17. S18 indicated she (S18) had not updated Patient #11's treatment plan to ensure interventions were carried out across all shifts to protect Patient #17 from Patient #11. S18 further indicated that she (S18) had not completed an incident report and had not reported the incident to the patient's physician or to administration.

Patient #10

Patient #10 was admitted to the hospital after a self inflicted cut to his wrist as a suicide attempt on 7/22/2011. Patient #10 was placed on suicide precautions with observations every 15 minutes. Review of Patient #10's Nursing Notes dated 7/23/2011 at 15:50 revealed in part, "summoned to patient's room and found pt sitting on bed bleeding from lt (left) wrist wound. Noted he (#10) was holding pressure to wound (with) a blue cloth. Noted a large amount of blood droplets on floor (with) spray of blood on wall, attempted to approach pt. (#10) to provide care but unable to do so as pt (#10) growled "don't come near me" , 911 called. . .1815 pt. (#10) received back on the unit and escorted to an observation room by (Director of Nursing S2)." Patient #10 remained on 15 minute observations after an active attempt at self harm in the hospital. Physician Assistant S36 indicated any patient with an active suicide attempt in the hospital should have been placed on 1:1.

Patient #7

Patient #7 was admitted on [DATE] under a PEC/CEC for Suicidal Ideations. The physician responsible for the care of Patient #7 ordered q (every) 15 minute checks on Patient #7. On 07/24/11 at 7:00 p.m. S9MHT was assigned the q 15 minute checks for Patient #7. Review of the nursing documentation revealed Patient #7 was noted to be missing from the hospital at 8:30 p.m. on 07/24/11. Review of the observation flowsheet revealed documentation that S9MHT had checked on the patient (#7) every 30 minutes throughout the shift (7:15 p.m. - 6:45 a.m.). Documentation of examination of the room of Patient #7 revealed that the window next to the patient's bed had been broken. Review of a document titled "Environmental Safety Report" created by the Administrator, dated July 25, 2011, revealed contraband in the form of a "short black screwdriver" was found in the room of Patient #7 on 07/24/11 when Patient #7 was noted to be missing from the hospital. Review of the nurse's notes revealed the Police Department was called, S31MD, S36PA, S38PA, and S39MD were notified. Further review of the incident report revealed Patient #7 was never found.

The Hospital failed to ensure patients received Care in a Safe Setting as evidenced by failing to ensure the hospital had and enforced an effective abuse prohibition policy by failing to obtain Criminal History Background checks on 7 of 38 Mental Health Technicians (MHT) (S6MHT, S13MHT, S20MHT, S41MHT, S44MHT, S49MHT, S50MHT), failing to have 30 of 38 MHT's certified in Crisis Prevention Intervention (CPI) (S9MHT, S10MHT, S13MHT, S20MHT, S25MHT, S27MHT, S32MHT, S34MHT, S37MHT, S41MHT, S42MHT, S43MHT, S44MHT, S45MHT, S46MHT, S47MHT, S48MHT, S50MHT, S51MHT, S52MHT, S53MHT, S54MHT, S55MHT, S58MHT, S60MHT, S61MHT, S62MHT, S63MHT, S64MHT, S66MHT) , failed to ensure 35 of 38 MHT's received any training in Abuse/Neglect (S9MHT, S10MHT, S11MHT, S13MHT, S20MHT, S21MHT, S25MHT, S27MHT, S32MHT, S34MHT, S37MHT,S41MHT, S42MHT, S43MHT, S44MHT, S45MHT, S46MHT, S47MHT, S48MHT, S49MHT, S50MHT, S51MHT, S53MHT, S54MHT, S55MHT, S56MHT, S57MHT, S58MHT, S59MHT, S60MHT, S61MHT, S62MHT, S63MHT, S64MHT, S65MHT), failing to ensure 34 of 38 MHT's had documented evidence of Restraint training (S6MHT, S9MHT, S10MHT, S11MHT, S13MHT, S20MHT, S21MHT, S25MHT, S27MHT, S34MHT, S37MHT, S41MHT, S43MHT, S44MHT, S45MHT, S46MHT, S47MHT, S48MHT, S50MHT, S51MHT, S52MHT, S53MHT, S54MHT, S55MHT, S56MHT, S57MHT, S58MHT, S59MHT, S60MHT, S61MHT, S62MHT, S63MHT, S64MHT, S65MHT, S66MHT), failed to ensure 32 of 38 MHT's had documented evidence of orientation to their job duties (S9MHT, S10MHT, S11MHT, S13MHT, S20MHT, S21MHT, S25MHT, S27MHT, S32MHT, S34MHT, S37MHT, S41MHT, S43MHT, S44MHT, S45MHT, S47MHT, S48MHT, S49MHT, S50MHT, S51MHT, S52MHT, S53MHT, S54MHT, S55MHT, S56MHT, S57MHT, S58MHT, S59MHT, S61MHT, S62MHT, S63MHT, S66MHT) and failed to ensure 27 of 38 MHT's had documentation of skills competency (S9MHT, S10MHT, S11MHT, S13MHT, S20MHT, S21MHT, S25MHT, S27MHT, S32MHT, S34MHT, S41MHT, S42MHT, S43MHT, S44MHT, S45MHT, S46MHT, S47MHT, S48MHT, S49MHT, S50MHT, S53MHT, S55MHT, S56MHT, S58MHT, S60MHT, S62MHT, S63MHT).

The hospital failed to ensure a complete investigation was conducted to identify the Root Cause of these incidents to facilitate development and implementation of corrective measures.

On 08/12/11 at 3:15 p.m. the hospital submitted a Plan of Removal for the Immediate Jeopardy. The Plan included the following:

Abuse Prohibition:

1. The 7 of 38 Mental Health Technicians (MHT) found to have no verification of Criminal History Background checks have been identified and criminal history backgrounds verified.

2. An effective Abuse Prohibition Policy has been created in conjunction with the facility's contracted Human Resource service provider HR Solutions. Please see attached policy.

3. Employees will not be allowed to work in the facility until background check and other Abuse Prohibition measures are completed and verified.

Crisis Prevention Intervention:

1. The 8 of 38 MHT's certified in Crisis Prevention Intervention (CPI) have been identified and assigned to the schedule to ensure immediate minimum of 2 CPI certified clinical staff per shift.

2. CPI training will be conducted for 23 staff identified without training and certification Friday, August 12, 2011 by Training Solutions, L.L.C., a DHH and LDOL certified company.

3. Additional CPI training will be conducted for staff on Tuesday August 16, 2011 at 7:30 am and 3:30 pm.

4. A confidence date for 100% of MHT's to be CPI trained and certified is Thursday August 18, 2011.

5. New clinical employees will be trained and certified in CPI within 90 days of hire in conjunction with a comprehensive orientation, training, and continuing education staff development program.

Abuse and Neglect Training:

1. Training in Abuse & Neglect policy and procedures will be conducted for the AM & PM shifts on Thursday, August 11, 2011 to ensure immediate safety and benefit. The training will continue daily per AM & PM shifts until the 35 of 38 MHT's without education receive training and verification.

2. A confidence date of Wednesday, August 17, 2011 is set for 100% of MHT's to have documentation of training in abuse/neglect policy & procedure.

3. A minimum of 2 clinical staff with Abuse and Neglect education per shift will be ensured until all 38 current MHT's are trained and verified.

4. Training will include abuse/neglect policy & procedure review and comprehensive testing with benchmark of greater than 85% passing score. Abuse and neglect policy & procedure has been revised on to include testing and benchmark percentage. Please see attached policy & procedure.

5. Compliance with Abuse and Neglect policies and procedures will be ensured by all new employees being oriented and by annual re-education of abuse & neglect policies and procedures. Each occurring event of abuse & neglect will be reported and investigated through our root cause analysis process.

Seclusion and Restraint Training:

1. Training in Seclusion/Restraint Policy & Procedure and skills competencies will be conducted for the AM & PM shifts on Thursday, August 11, 2011 to ensure immediate patient safety and benefit. The training will continue daily per AM & PM shifts until all 38 MHT's training is verified.

2. A minimum of 2 clinical staff with Seclusion and Restraint education per shift will be ensured immediately until all 38 MHT's are trained and verified.

3. A confidence date for 100% of MHT's to be trained and documented in seclusion restraint policy & procedure and competencies is Wednesday, August 17, 2011.

4. Training will include seclusion/restraint policy policy & procedures review and acknowledgement. Training and competencies will include CMS guidelines for restraint training.

5. Compliance with Seclusion and Restraint policies and procedures will be ensured by a full audit of every restraint and/or seclusion. Seclusion & restraint policy and procedure has been revised to include skills competencies. Please see attached policy & procedure.

Orientation to Job Duties:

1. Orientation to Job Duties will be conducted for the AM & PM shifts on Thursday, August 11, 2011 to ensure immediate patient safety. The training will continue daily per AM & PM shifts until all 38 MHT's are documented as oriented as oriented to duties.

2. A minimum of 2 MHT's with documented orientation to duties per shift will be ensured until all 38 current MHT's are oriented.

3. A confidence date for 100% of MHT's to be trained and documented in orientation to job duties is Wednesday, August 17, 2011.

4. Training will include written description of performance of duties and comprehension acknowledgement.

5. Compliance with job duties policies and procedures will be ensured by all current employees receiving re-training, all new employees having documentation of orientation and training and annual re-training.

Documentation of Skills Competencies:

1. Documentation of observation skills competency will be completed for the AM & PM shifts on Thursday August 11, 2011 to ensure immediate patient safety. Competency demonstration and documentation will continue daily per AM & PM shifts until all 38 current MHT's have competency documentation.

2. A minimum of 2 clinical staff with documented skill competencies per shift will be ensured until all 38 current MHT's have documentation of orientation.

3. A confidence date for 100% of MHT's to be trained and documented is Wednesday, August 17, 2011.

4. Training will include written description of performance of duties and comprehension acknowledgement as well as skills competencies.

5. Compliance with Seclusion and Restraint policies and procedures will be ensured by all current employees receiving re-training, all new employees having documentation of orientation and training and annual re-training.

Root cause analysis & development/implementation of corrective measures:

The facility will ensure and maintain a safe setting for patient care by immediately implementing and enforcing the following process for incident/grievance reporting and response:

Incident/Grievance

1. Immediate & appropriate care intervention
Physical/Medical/Psychological/Emotional Interventions
Create immediate safety setting
Identify staff allegedly involved and send home or re-assign
Report to physician, administration, and appropriate patient related party

2. Incident/Grievance report

3. Supporting statements & documentation

4. Communication of incident/grievance to appropriate parties
Business hours - Clinical Administration
After Hours - Administration on Call (AOC)
Communication to be made immediately

5. Administrative Video Surveillance & documentation
Video surveillance is conducted immediately by Administration when surveillance is available & relevant to investigation
Video Surveillance is documented:
- Surveyor (s)
- Time/Date of Surveillance
- Incident/Grievance
- Parties surveyed
- Video evidence and video timeline
- Summary of findings

6. Documentation of incident/grievance into patient treatment plan (information to influence individual patient care and supporting unit interventions)

7. Administrative Investigation & analysis of root causes of incident/grievance
- Investigation to be conducted by Administrator, DON, ADON, RN Clinical Coordinator & HR
Staffing patterns
Video surveillance
Interview staff and witnesses
Review of treatment plan interventions
Review of Treatment staff notes
Review of relevant documentation any correlated incidents
Search for relevant triggers
Review of safety policies and staff performance
Written Notification to Medical Director
Investigation incorporated into QA/QI

8. Administrative corrective measures and resolution

9. Report to higher authority (DHH/CMS/Police) if appropriate

10. Incorporation of incident/grievance & corrective measures documentation into QA/QI

Video Surveillance:

Video surveillance will be monitored by administrative staff for patient safety and quality assurance purposes. Surveillance of staff policy & procedure adherence, employee performance and other unit activity will be monitored on a daily basis. Surveillance of incidents, grievances, patient/staff allegations and other occurrences will be conducted as necessary. Administrative staff video surveillance will be documented in a surveillance binder and include surveyor, surveillance purpose, date, time, observation, observation timelines and determinations. Daily monitoring will be recorded for quality assurance and incident/grievance reporting will be recorded in the investigation file. Surveillance file will be created electronically and stored for reference and review. The facility administrator, clinical coordinator, DON, and human resource liaison will be trained in and authorized for surveillance.

Environment of Care Safety:

The facility will ensure a safe environment by immediately applying safety & tamper-proof screws to the 70" X 62" (wide) windows in each patient room to prevent them from opening. This measure will ensure the safety of the patient care environment by preventing introduction of contraband into the hospital. Confidence date for this action to be completed is Thursday, August 11, 2011.

08/12/11, Friday

St. James Behavioral Health Hospital

Emergency MEC Governing Board Quorum

Agenda - Policies Approved
1. Observations Precautions - Policy 8.21A
2. Occurrence Report - Policy 8.6
3. Seclusion & Restraint for Behavioral Management - Policy 3.1
4. Patient Abuse and/or Neglect - Policy 2.3
5. Selection and Hiring of Personnel - Policy 9.2
6. MHT Responsibilities, Guidelines, Policies
7. MHT Competency Checklist

On 08/12/11 at 4:05 p.m. S1Administrator, S2DON, and S3Clinical Coordinator were notified that the Immediate Jeopardy was lifted. Condition level non-compliance remains for the Condition of Participation for Nursing Services.
VIOLATION: REASSESSMENT OF DISCHARGE PLANNING PROCESS Tag No: A0843
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the hospital failed to ensure patients' discharge planning was reviewed to ensure follow up for abnormal labs was addressed with the patient at the time of discharge for 1 of 20 sampled patients (#5). Findings:

Review of Patient #5's medical record revealed a Syphilis Screening Test result of Non-reactive on 7/17/2011. A Syphilis Screening Test- RPR titer was repeated on 7/26/2011 after Patient #5 indicated she (#5) had been raped by a hospital employee. The results of the 7/26/2011 RPR Titer was "Reactive 1:1".

Review of Physician S31 Progress Notes for Patient #5 dated 7/28/2011 (no documented time) revealed in part, "Abnormal RPR. In reviewing her chart, her previous RPR have (had) been nonreactive. . . There is some question as to whether this is a false positive. We are going to repeat her test and further intervention will depend on the result." Further review revealed a physician's order dated 7/28/2011 for "RPR now". Review of Patient #5's entire medical record revealed no documented evidence that the RPR ordered "now" on 7/28/2011 had been drawn and no lab results for a RPR dated 7/28/2011 were in the medical record.

Patient #5 was discharged from the hospital on [DATE] at 9:30 a.m.. Record review revealed no documented evidence of instructions to the patient regarding follow up for the repeat RPR ordered for 7/28/2011 after a positive result on 7/26/2011.

During a telephone interview on 8/09/2011, Physician Assistant S33 indicated he (S33) had written the progress notes for Patient #5 on 7/28/2011 under the name of Physician S31. S33 indicated he (S33) had spoken with Physician S31 on the telephone to discuss the results of the RPR. S33 indicated he (S33) had also spoken with the patient (#5) but had failed to document the conversation. S33 indicated Patient #5 had been told that the results of her RPR were positive but the results were questionable. S33 indicated that although the repeat RPR had been drawn, he (S33) was unsure of the results. Physician S31 was present when the telephone interview with Physician Assistant S33 was conducted. Physician S31 reviewed the Medical Record and confirmed there were no results of Patient #5's RPR from 7/28/2011 in the record. Physician Assistant S33 indicated he (S33) had not reviewed the medical record of Patient #5 for results of the 7/28/2011 RPR. Physician Assistant S33 indicated there had been no follow up with Patient #5 regarding the results of the RPR. S33 reviewed electronic data from the contracted lab where Patient #5's RPR had been performed and indicated the results were negative. S33 confirmed that follow up should have been done regarding the results of Patient #5's RPR.

Review of the hospital policy titled, "Discharge Planning, Policy 3.11, Originated June 2006" presented by the hospital as their current policy revealed in part, "The discharge plan will address the individual needs of the patient, be realistic and achievable, and include, but not limited to, the following: Aftercare, Disposition, and Education/Teaching Needs."
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 ensure high risk problem prone incidents were documented on an incident report or reported to the Administration/Quality Department and thoroughly investigated by Quality/Administration for 5 of 5 incidents reviewed (Incident Date 5/30/2011 involving Random Sampled Patient #R1, Incident Date 7/17/2011 involving Patient #11 and #17, Incident date 7/19/2011 involving Patient #5, Incident Date 7/23/2011 involving Patient #10, and Incident date of 07/24/11 involving Patient #7. Findings:

Incident Date 5/30/2011: Involving Patient #R1
Review of Patient #R1's "Patient/Family complaint form" dated 5/30/2011 with no documented time and no signature of the administrative staff reviewing the Grievance revealed in part, "While standing in hall wafting (waiting) for a smoke brake (break) (Director of Nursing S2) approach me asking for my glasses (sun glasses). The glasses I been having on for 70 plus hours. He (S2) said I (R1) would have to hand them over. The (S2) grabbed (grabbed) my arm. Then, he squeezed the arm. I consider at the a least a threat. He is a big big man. My eyes were damage (d) with OC (over counter) pepper spray. I am on antibiotics. What action/resolution does the person making the complaint want? The glasses-sunglasses back in my possession. and full disciplinary action be taken immediately so (S2) can never hurt any body again."

Review of documentation dated 5/30/2011 with no signature or time, revealed in part, "R (right) eye redness noted. Bil (bilateral) pupil not dilated. APN (Advanced Practice Nurse) S33 paged to get medical necessity for sunglasses. NP (Nurse Practitioner) gave order for sunglasses. Sunglasses returned to patient." Review of the entire document revealed no documented evidence of an investigation into the allegation of abuse by Random Sampled Patient #R1.

During a face to face interview on 8/12/2011 at 1450 (2:50 p.m.), Clinical Coordinator S3 indicated she (S3) had been the administrative staff that had investigated the incident involving Patient #R1 that allegedly occurred on 5/30/2011. S3 indicated she (S3) had failed to review video surveillance and/or investigate allegations of abuse by Patient #R1. S3 indicated she (S3) had assessed Patient #R1's arm but had failed to document it on the form. S3 indicated she (S3) had seen no evidence of injury to R1's arm. S3 indicated the focus of her (S3) investigation had been the Patient's medical need for sunglasses.

Incident Date 7/17/2011: Involving Patient #11/Patient #17:
Review of Patient #11's medical record revealed the patient (#11) was admitted on [DATE] with diagnoses that included Schizoaffective Disorder by history. Review of Patient #11's Physician Emergency Certificate (from the sending hospital) dated 7/15/2011 at 7:00 a.m. revealed in part, "Findings of Examination: 27 y/o (year old) male presents to ED (Emergency Department) C/O (complains of) homicidal ideation. states he (#11) has gun and will shoot (name of intended victim) who he (#11) believes killed his younger brother. Review of Patient #11's Nursing documentation dated 7/17/2011 at 1930 (7:30 p.m.) revealed "pt (patient) went into the females shower room (and) took his shower, been making sexual remarks about one of the female pts (patients/no ID (identification) number for the female patient ), he (#11) heard her (no ID number for the female patient) say she (no ID number for the female patient) was going to shower but one of the other pts (patients/no ID number for this patient) walked in on him."

During a face to face interview on 8/10/2011 at 8:00 a.m., Registered Nurse S18 indicated Patient #11 had gone into the female shower room with plans to encounter a young female patient (#17) that he (#11) had been "interested" in. S18 indicated S11 had heard the female patient (#17) state that she (#17) was about to shower. S11 indicated another female patient (didn't recall name of this patient) had opened the door to the shower and screamed when she (didn't recall name of this patient) saw a male in the shower room. S11 indicated the shower rooms should have been locked where no patient had access unless there had been a Mental Health Tech monitoring shower activity. S11 indicated she (S11) did not know how Patient #11 had managed to enter the female's shower and it should not have been possible if staff had been performing their duties properly. S11 indicated Patient #11 was a rather large man (6 feet 2 inches and 287 pounds/ [AGE]) and Patient #17 (intended victim) had been a small girl (5 feet 5 inches and 123 pounds/ [AGE]). S11 indicated she (S11) had not completed an Incident/Occurrence form, had not informed the patients' physician, and had not informed administration of the incident. S11 indicated the patients (#11 and #17) were moved to rooms at opposite ends of the hall. S11 indicated she (S11) had not updated to two patients' (#11, #17) treatment plans to ensure safety interventions were put in place across all shifts by all staff to protect Patient #17 from Patient #11. S11 indicated she (S11) should have completed an Incident/Occurrence form after the incident occurred.

Review of Patient #17's (intended victim) medical record revealed the patient was admitted on [DATE] with diagnoses that included Major Depressive Disorder. Review of Patient #17's Physician Assistant orders dated 7/17/2011 at 11:00 (p.m.) revealed in part, "Pt (patient) is a little worried, a male peer is obsessed (with) her (and) has been watching her closely."

During a face to face interview on 8/09/2011 at 1300 (1:00 p.m.), Administrator S1, Director of Nursing S2, and Clinical Coordinator S3 indicated they had no knowledge of the incident that had occurred when Patient #11 had executed a plan to encounter Patient #17 in the female shower room. S1, S2, and S3 indicated the incident had never been investigated.
S3 indicated there had never been a review of video surveillance recordings after the incident to determine if the patients (#11 and #17) had been properly monitored. or to determine which staff had unlocked the shower door and left it unattended. S1, S2, and S3 indicated the nurse that discovered the incident should have reported the incident to administration and should have completed an Incident/Occurrence Report.

Incident Date 7/19/2011 regarding Patient #5:
Review of Patient #5's medical record revealed the patient was admitted on [DATE] with diagnoses that included Bipolar Disorder. Review of a handwritten letter by Patient #5 dated 7/24/2011 with no documented time revealed in part, "I (Patient #5) am reporting on about July 19 or 20th during the evening shower, I had asking for a razor. The tech told me she did not have time because she needing to stay in while I shave, I told her that was no problem, she gave me my towels . I waited about 10 minute, and decided to go ahead and shower. The Tech was a short white female, very sweet to all patient, she was just really busy. I understood. While I was in the shower, I was washing my hair a face, had my eyes closed due to the soap, after washing out the soap, when I opened my eyes, There was a dark skin black male with a slim trimmed Beard was standing with one hand out with a razor (and) cream, the other was holding his private part, he told me to touch it. I turned and said get out of here. when I turned, he grabbed me from behind, put his hand over my face and mouth and put his private in my vagina from behind. I couldn't over power him so he continued until his climax. I would like a blood test ASAP (as soon as possible) to check for possible STD (Sexually Transmitted Diseases). When he got through he quickie (as written) got to the door and said you better not tell, I will kill you. I've been afraid to tell and I've held in it and I can't keep in bottle up any longer. I will take polygraph test what ever it take."

Review of Patient #5's Nursing Documentation dated 7/24/2011 at 0930 (9:30 a.m.) revealed "observed pt (patient) crying in the hall (and) both (Licensed Practical Nurse S30) and I (Registered Nurse S26) approached her to find out why. She (#5) said she (#5) held back telling the whole truth when she had reported a male MHT (Mental Health Tech) had come in while she was showering to bring her a razor. She (#5) reported he (unidentified Mental Health Tech) had a razor in one had (and) he (unidentified MHT) was masturbating (with) the other hand. She (#5) said he (unidentified MHT) bent her (#5) over (and) put his hand over her (#5) mouth so she couldn't scream. She (#5) said he (unidentified MHT) then penetrated her vaginally (and) actually climaxed inside her vagina. She said she did not tell anyone because he (unidentified MHT) told her he would kill her and she (#5) said she felt ashamed because of wearing too tight jeans. She (#5) reported she is not sure of the dates (19th, 20th, or 21st). I (RNS26) instructed her (#5) that I (S26) would notify the doctors and administration and perform an investigation (Physician S31, Physician S39, and Administrator S1) notified. Investigation begun."

Review of a typed attached document to a "Patient/Family Complaint (signed by Clinical Coordinator S3 on 7/25/2011 at 8:30 a.m. regarding Patient #5)" form revealed in part, "On 7/25/2011, St. James was notified by (PD/ Local Police Department) of the alleged rape of (Patient #5). Our administrative staff cooperated fully with detective assigned. On July 26, 2011, I (S3) spoke with (patient #5) about accusations of a staff member making threats to kill her. She (#5) stated that a male patient had overheard two black male(s) talking in hall and one made threats to kill her. The one that made the threat was the brother in law to (MHT/Mental Health Tech S9) With more questioning, she (#5) states she heard the male staff member make the threat. . . She (#5) stated with the alleged rape happening she (#5) felt she could not get better in this facility. I (S3) told her (#5) that transferring her (#5) to another facility is an option she (#5) could request. She (#5) immediately said "no, that would be like starting over...I (S3) reassured her (#5) that her psychiatrist would be meeting with her (#5) later this afternoon. On 7/26/11, education started with MHT regarding patient shower policy and procedure. . .On 8/01/2011, S28 (Recreational Therapist and mother to MHT S9/accused perpetrator) handed me (S3) a statement from patient (Random Sampled Patient #R12), saying that (patient #5) admitted to her accounts about the alleged rape were not true. . ."

Review of Mental Health Technician (MHT) S9's personnel file revealed a "Employee Reprimand/Disciplinary Report" dated 7/26/11 (2 days after Patient #5 reported alleged rape and 1 day after video review by administration revealed MHT S9 was alone with Patient #5 in the shower on 7/19/2011 from 21;02:30 - 21:02:37 and again from 21:05:05 - 21:06:36) with no documented time indicating, "Date of Violation 7/19/2011. Time of Violation: 9:00 p.m., Nature of Violation Policy Violation, Conduct, Explanation: Allegation of Sexual impropriety. Suspend until investigation is complete."

During a face to face interview on 8/09/2011 at 1300 (1:00 p.m.), Administrator S1 indicated he (S1) had no documentation regarding the phone call he (S1) had received on 7/24/2011. S1 indicated his memory of the call from the hospital regarding an allegation of inappropriate behavior with conflicting vague details by Patient #5 was that the phone call had occurred in the evening rather than 9:30 a.m. as the nursing documentation indicated. S1 further indicated he (S1) had never been informed of the graphic details described in Patient #5's nursing notes. S1 indicated he (S1) was told that the patient had alternating stories that were conflicting regarding a male in the shower. S1 indicated he (S1) had asked staff to write statements regarding the allegations and asked if the MHT (Mental Health Tech) had been identified. S1 indicated no one had informed him (S1) that an identity of the alleged perpetrator had been established. S1 indicated he (S1) had not reviewed video surveillance recordings until the morning of the 5th (one day after the allegation had been made by Patient #5 that a MHT had entered the female bathroom when she (#5) had been showering and had masturbated, bent her (#5) over, put his hand over her mouth, penetrated her (#5) vaginally, climaxed, and threatened to kill her (#5) if she told). S1 indicated if he (S1) had received the report as it was written in Nursing Documentation on 7/24/2011 at 9:30 a.m. he (S1) would have come immediately to the hospital and started an investigation to include review of video surveillance rather that until the following morning (7/25/2011). S1 indicated an allegation of that magnitude warranted immediate involvement and investigation by Administration but had not been informed of the graphic details of the allegation made by Patient #5.

Incident Date 7/23/2011/Patient #10 :
Review of Patient #10's medical record revealed the patient (#10) was admitted on [DATE] with diagnoses that included Chronic Paranoid Schizophrenia with Acute Exacerbation and Lacerated wound on the left wrist. Review of Patient #10's Physician Emergency Certificate dated 7/22/2011 at 5:20 a.m. revealed in part, "Findings of Examination: presents (after) suicidal attempt of trying to cut wrist. . .+ AH (positive auditory hallucinations), L (left) wrist (with) superficial laceration 4 cm (centimeters)". Review of Patient #10's Nursing Documentation dated 7/23/2011 at 1550 (3:50 p.m.) revealed in part, "summoned to patient's room (and) found pt. sitting on bed bleeding form Lt. Wrist wound. Noted he was holding pressure to wound (with) a blue cloth. Noted a large amount of blood droplets on floor (with) a spray of blood on wall. attempted to approach pt. to provide care but unable to do so as pt growled "don't come near me." 911 called (ambulance and police). (Physician's Assistant S36, Administrator S1, and Director of Nursing S2) notified. . .It needs to be noted pt. apparently used wrist band (name tag) to re-open the previous laceration he had sustained prior to admit here).

During a face to face interview on 8/09/2011 at 7:30 a.m., Director of Nursing S2 and Clinical Coordinator S3 indicated administration had never received an incident/occurrence report regarding Patient #10's self inflicted opening of a wrist wound on Day # 2 of his admission to the hospital post suicide attempt by cutting of his wrist. S2 and S3 indicated there should have been an incident report written. S2 and S3 indicated they both were aware of the incident but had no formal written investigation of the incident and no identified problems that needed corrective action. S3 indicated there had never been a review of video surveillance recordings after the incident to determine if the patient had been properly monitored. S3 further indicated Patient #10 had been located in the observation room where video cameras were located; however, the hospital had no policy or procedure for monitoring of the camera screens that were located in the nursing station.

Face to face interviews were conducted with Physician Assistant S36 on 8/10/2011 at 7:10 a.m. and Director of Nursing S2 and Clinical Coordinator S3 8/10/2011 at 9:25 a.m. S36, S2, and S3 indicated any patient that had an active attempt at self harm while admitted to the hospital should have been placed on 1:1. S2 confirmed that Patient #10 had never been placed on 1:1 after using his arm band to open a wrist wound that had required sutures. S2 and S3 indicated they had never identified the failure of hospital staff to place Patient #10 on 1:1 after an attempt at self harm at the hospital as a problem needing correction.

Review of the hospital policy titled, "Occurrence Reports, #8.6, Originated June 2006" presented by the hospital as their current policy revealed in part, "Occurrences for which an HOR (Hospital Occurrence Report) should be completed include but are not limited to the following: a. Patient Injuries, b. Patient Deaths, c. Physical Health Episodes, d. Medication Errors, e. Contraband Possession or Contraband Found on Unit, f. Relations Issues. . . h. Interdepartmental incidents, i. Serious breach of policy, j. Property damaged, k. Lost or stolen property, l. Internal disasters. . .When an unusual event occurs staff will take appropriate action and then complete the HOR. . .Construct a report that is both factual and objective. Report interventions that occurred following the incident, Report patient status twenty four hours after the incident, Record the occurrence in the patient's medical chart as well as on the Hospital Occurrence Report form. . . In the event of a serious incident (e.g. fractures, attempted suicides, death of a patient, medical problems resulting in transfer of a patient to another Hospital, serious breach of policy, situations involving sexual contact), the Administrator will be notified immediately, who will then call the corporate office and will complete the confidential Critical Incident Reporting Record. Notification of risk management will be determined when reviewing the incident. . ."

Review of the hospital plan titled, "Quality Assurance Plan (no documented date of adoption)" revealed in part, "The Monitoring and Evaluation Process will include the following activities: Clinical Outcomes Reviews. . .Risk Management/Patient Safety. . .Sentinel Events Occurrences (Root Cause Analysis). . .Through the use of a high risk process grid, the corporation has identified key indicators for monitoring based upon data availability, volume, patient population, problem prone, and clinical significance. These identified key indicators include: Incident reporting..."

Incident #5 Elopement of Patient #7 on 07/24/11
Review of the medical record for Patient #7 revealed that the patient was admitted to the facility on [DATE] by a PEC/CEC(Physician Emergency Certificate/Coroner's Emergency Certificate) for polysubstance abuse, suicidal ideations, and he had a history of Schizophrenia. Review of the Initial Psychiatric Evaluation dated 07/20/11 revealed in part ... "This is a [AGE] year old married Caucasian male with a history of mood disorder and polysubstance abuse, has been admitted after he threatened to jump out of a moving a car while he was with this wife. The patient's wife reports the patient was agitated, because he has been out of his Lortab and he also has been drinking. The patient was taken to the emergency room by EMS and then sent here now to St. James Hospital for further treatment. The patient admits to a long history of polysubstance abuse. He has a history of intravenous drug administration as well. He reports he has been to various emergency room s in order to get treated in the emergency room for his pain medication. He has admitted to burning himself on the arm in order to get treated in the emergency room for his pain medications. He has also cut himself with a fishing line and shot himself with a nail gun all in hopes of getting pain medication."

Review of the St. James Behavioral Health Hospital-Patient/Visitor/Staff/Medication Error Form dated 07/24/11 revealed under the section labeled Incident, "Patient Escaped from Hospital. "Under the section labeled Description of Event revealed, "Pt (patient) noticed missing tonight out of his room by S10MHT. Window next to pat's bed has been broken open. Staff searches for patient. Pt was nowhere to found. He was seen between the hours of 3-4:30 p.m. during visiting hours with a white female. S38PA says not to alert the family @ this time." Under the section labeled Assessment/Outcome and or Follow-up of incident/Error revealed, "The window in the patient's room had been broken open. PD called and Sgt (Sergeant) came. Copies of a picture of the pt. along with his face sheet was given to Sgt. He says the department will contact the family. Police report number was given by officer."

Review of the PD-Case Report dated and timed 07/24/11 9:57:59 revealed under the narrative section of the report, "On 07/24/11 I Sgt. responded to St. James Behavioral Hospital located at 3136 S. St. Landry Road for a 911 hang up. Upon my arrival dispatch advised they were unable to make contact with anyone at the hospital. I then hit the call button at the front door and was met by S24RN who advised they had a patient escape. S24RN advised they went to check on a patient and discovered the window in his room has been broken with an unknown type of object and the subject had escaped. S24RN advised the patient was last seen at 20:30 hours and advised his name was Patient #7 w/m (white/male) 06/14/83 (date of birth). She advised that Patient #7 was transported to the facility on [DATE] as a transfer from hosp."b". He is a described as a paranoid schizophrenia, suicidal, and substance abuser. S24RN advised that Patient #7 did have a female visitor during visiting hours and she left at 19:00. She advised that Patient #7 as provided an address in Addis, Louisiana and they were going to call his family and let them know he had left. I then noticed the window had a plastic plexi glass type security feature that only allows the window to go up about 4" and locks in place after that. The plastic plexi glass security feature was broken by an unknown object and the window was able to be forced up and opened all the way allowing him to make his escape. I then advised other units to B.O.L.O(be on the lookout) for Patient #7. I also had dispatch put out A B.O.L.O (be on the lookout) to APSO (Parish Sheriff Office) units. I advised S24RN to contact the police department if Patient #7 showed back up. I then left and checked the area and was unable to locate Patient #7. He was entered into N.C.I.C. (National Crime Information Computer) as a missing person and his home town Police Department was contacted to go by the residence. They advised they would check the residence as B.O.L.O. for Patient #7. They were unable to locate him."

Review of the St James Behavioral Health Hospital Multi-Disciplinary Progress Note dated 07/24/11 at 2030 revealed, "Pt noticed missing tonight out of his room. The window next to his bed had been broken open. Staff searched for patient inside and outside the hospital. Patient nowhere to be found. He was last seen by S32MHT after supper around 5:30 p.m. going to his room to lie down. He was seen during visiting hours with a white female between the hours of 3 p.m.-4:30 p.m." The next entry was timed 2100- "PD called to notify them that patient had escaped. S31MD and S38PA on the unit made aware of pt's escape. S39MD and S36PA notified. S38PA says not to alert the family at this time." The next entry on the progress note was timed 2130- "Sgt. from PD came. He was given a copy of a picture of the patient along with a face sheet. Sgt. Says his department will contact the family."

Review of the St James Behavioral Health Hospital Physician Admit Orders & Problem List dated 07/20/11 revealed an order for CO q 15" (close observation every 15 minutes).

Review of the Patient 15" &/or 30" Observation Form AM Shift dated 07/24/11 revealed he was observed every 15 minutes from 0715 to 1900. From 5:30 p.m. to 7:00 p.m. S32MHT documented he was being monitored, and he was awake and cooperative. Review of the Patient 15" &/or 30" Observation Form PM Shift dated 07/24/11, S9MHT documented every 30 minutes Patient #7 was monitored and awake until 9:45 p.m. and then was monitored and asleep from 10:15 p.m. until 5:45 a.m. At 6:15 a.m. on 07/25/11 Patient #7 was awake and monitored and fluids were offered and at 6:45 a.m. he was offered a meal/snack and he was awake and monitored. According to the nursing notes and the police report the patient was reported missing at 8:30 p.m. the evening of 07/24/2011.

Review of the Environmental Safety Report dated 07/25/11 revealed, "An environmental safety inspection of patient room #8 was conducted by hospital staff immediately upon discovering the elopement of the patient assigned to bed 8b on the evening of July 24, 2011 and again by the hospital administrator and maintenance supervisor on the morning of July 25, 2011. A short black screw driver was found under the mattress in the patient's room. The screwdriver was examined and found not to be a tool from the facility maintenance collection. The patient either snuck in the tool or had someone deliver it from the outside. It appeared that the patient planned to unscrew the framework of the plexi-glass protective covering of the window in order to open the window enough to pass his body through to the outside. Because the screwdriver was unable to turn the safety, tamper pro screws it appears that the patient was able to loosen the cover instead by pushing and pulling the frame from the bottom over a period of time. A corrective action plan was immediately initiated. Maintenance repaired the window framework and install new plexi-glass. This action was completed on the afternoon of 1." The Environmental Safety Report was signed by S1Administrator.

An interview was conducted with S24RN on 08/08/11 at 1 p.m. She stated she was the registered nurse working on the night that Patient #7 was discovered missing. Patient #7 was on every 15 minute observations. She went on to state at 8:30 p.m. S31MD was in the facility making rounds. S10MHT went to get Patient #7 for the physician to examine and he could not find the patient. S9MHT was assigned to the patient for the p.m. shift (7 p.m. to 7 a.m.) to do the every 15 minutes observations. S24RN stated she asked S9MHT if he had located all his assigned patients when he started his shift at 7 p.m. At first he stated he did, and then he changed his story. He went on to say he must have gotten the patient confused with someone else and he had not seen the patient since he came on his shift. She went on to state on 07/24/11 the day RN, S26RN was still in the facility and called S32MHT at home (the MHT who was assigned to perform the every 15 minutes observation on the a.m. shift). S32MHT stated she saw him last at 5:30 p.m. after supper and she saw him with a white female visitor earlier that afternoon. The staff started searching for Patient #7 inside and outside the facility. When the patient was not found and the window was found broken in his room, the police, the physician, and the administrator was called. When the police came to the facility to investigate, they stated they would notify the family. An incident report was completed. S24RN went on to say the patient was not volatile, but he was a danger to himself.

An interview was conducted on 08/09/11 at 2:10 p.m. with S32MHT. She stated she worked from 7a.m. to 7 p.m. on 07/24/11 and was assigned to conduct every 15 minutes observations on Patient #7. She stated she checked on him up until the end of her shift at 7 p.m. When asked why the Incident Report stated the last time she saw the patient was 5:30 p.m., S32 MHT stated she was called at home of the night of 07/24/11 at 10:30 p.m. after she had fallen asleep by the day RN, S26RN. S26RN asked her the last time she saw Patient #7. She was half asleep and "foggy" at the time the nurse questioned her, but her documentation on the Patient 15" and/& 30" Observation Form AM Shift was correct. She monitored him up to the end of her shift, 7 p.m., and he was in his room until she left her shift. S32MHT stated after dinner he went to his room and did not go out and smoke like he typically did. Earlier in the afternoon from 3 p.m. to 4:30 p.m. he had a female visitor and another MHT watched him during the visitation time. S9MHT then picked up the observation of every 15 minutes from 7p.m. to 7a.m. When questioned if anyone in Administration ever interviewed her about when and where she last saw the patient, she stated no.

An interview was conducted with Detectives PD1 and PD2 on 08/05/11 at 1 p.m. They stated the PD was called to St James Behavioral Health hospital on [DATE] at 9:57 p.m. when Patient #7 had eloped. They further stated they made rounds in the hospital and found that Patient #7's window was busted out. The police searched for him and was unable to find him. They notified his hometown police department to be on the lookout for him. He still has not been found.

On 08/09/11 at 9:50 a.m. S35Maintenance Tech was interviewed. He stated on 07/24/11 Patient #7 broke the plexi glass in his room, raised the window and left. On examination of the window, he stated he had to take the whole window down and repair the plexi glass and the frame for the plexi glass. He replaced the window as it was prior to the elopement of Patient #7; no alterations were made to the window and plexi glass in the window.

An interview was conducted with S38PA on 08/10/11 at 2:30 p.m. She stated she arrived at the hospital on [DATE] between 8:30 p.m. and 9:30 p.m. with the hospital in chaos. She went on to state an employee met her at the door of the facility stating, "I think someone is gone." The employees proceeded to search the hospital and found that Patient #7's window was busted out. She went on to state she has always been concerned that contraband could be introduced into the facility through the window since it was capable of being opened some. When questioned why she told the staff not to call the family immediately and tell them he was missing, she stated she was told his wife had visited him earlier during the day and she didn't want to alert the family in case the family had picked him and was taking him to his home. That way the police would have time to go to his house first before alerting the family the police were on their way. The police said they would tell the family he had eloped after driving by his home.

On 08/09/11 at 2:45 p.m. an interview was conducted with S1Administrator, S2DON, and S3 Clinical Coordinator. They stated that Patient #7 was on every 15 minutes observations the entire time he was admitted to the facility. They confirmed on the 7p.m. to 7a.m. shift on 07/24/11, the night of the elopement, S9MHT documented every 30 minutes observations from 7 p.m. until the next morning (7/25/11) at 7 a.m., even though the patient was discovered missing on 07/24/11 at 8:30 p.m. S3Clinical Coordinator stated when she reviewed Patient #7's chart she saw where S9MHT had documented the patient was in the hospital even though he had been reported missing already. She went on to state she could not speak to S9MHT because he was under investigation for another allegation in the facility. S3Clinical Coordinator stated she did not interview S32MHT, who last saw the patient at 5:30 p.m. on 07/24/11. When questioned if she reviewed the video tapes in the hospital to assist with her investigation of the elopement, she stated she had not. She further stated they were not sure how the patient obtained the screwdriver that was found in his room after he eloped.

Review of the hospital's policy, Absence Without Authorization, Policy #2.4, given to the surveyor as the current one in use, revealed in part, "It is the policy of the Hospital to designate a patient as absent with authorization (AWOL) in the following situations: Absence fro the hospital without a physician's order....A. Identification of AWOL 1. The occurrence of a patient unaccounted for during hourly or more frequent observation will be brought to the attention of all staff. 2. Exploration of patient's whereabouts will ensure, including a search of the Hospital. Should this prove unsuccessful, the following procedures are to be implemented:
a. Hospital security is notified of patient's absence and placed on alert;
b. The nurse notifies the attending psychiatrist ...
c. The Administrator and Director of Nursing are notified.
d. A search of the Hospital ensues, if determined necessary by the nurse and with the assistance of security;
e. The search will not occur outside the confines of the Hospital by staff, unless the patient is determined to be of danger to self or others;
f. Notification of family/significant others is to occur when judged appropriate by nurse and psychiatrists; and
g. If the patient is determined to be of danger to self or others, the police department will be notified; this intervention will be ordered by the attending psychiatrist after consultation with the staff...
C. AWOL of Involuntary Patients
10. Initiating AWOL procedures
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**







Based on record reviews and staff interviews, the hospital failed to have a registered nurse assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs as evidence by:
1) On the 7 p.m. to 7 a.m. shift on 04/06/11,(1) Mental Health Tech was assigned 12 patients and (1) Mental Health Tech was assigned 13 patients with the patients either on every 30 minutes or every 15 minutes observations. The census on the shift was 27 The (2) remaining MHTs had (2) 1:1 supervised patients after the physician ordered Patient #4 to be 1:1 supervision on 04/06/11 at 1830,
2) A female patient (Patient #4) on 1:1 close observation at arm length was left alone in the bathroom for 5 minutes by a male MHT, a female MHT was not available to assist Patient #4 to the bathroom, and
3) A female patient (#3) ordered 1:1 visual contact with no MHT assigned/designated to monitor the patient during the night shift from 06/26/11 from 7:30 pm (1930) to 10:10 pm (2210) for about 2 hours and 40 minutes or from 3:00 am (0300) through 7:00 am (0700) for about 4 hours as ordered by the physician at 7:30 pm (1930) on 06/26/11. Findings:
1)
Patient #4:
Review of the medical record for Patient #4 revealed she was a [AGE] year old female admitted on a PEC (Physician's Emergency Certificate) and a CEC (Coroner's Emergency Certificate) on 04/06/11. She had sudden onset of auditory and visional hallucinations and "talking out of her head" with no previous history of these symptoms according to the family. Review of the Physician Admit Orders and Problem List dated 04/06/11 revealed her reasons for admission/problem list was as follows:
1. Potential danger to self, others, property.
2. Need for cont. (continued) skilled observation or therapeutic milieu.
3. Impaired social, familial, occupational functioning.
4. Impaired Reality Testing accompanied by disordered behavior.
5. Acute disturbance of affect, behavior or thinking.
Review of the Physician's orders on admission revealed an order for close observation every 15 minutes x (time) 24 hours. Review of the Physician's Orders dated 04/06/11 at 1830 (6:30 p.m.) revealed an order to place the patient on 1:1 Supervision for safety/FP (fall precautions). Review of the Multi-Disciplinary Progress Note from 04/06/11 and timed 1800 (6:00 p.m.), 1815 (6:15 p.m.), and 1830 (6:30 p.m.) revealed, "1800-Pt is noncompliant with assessment. She is confused and walks off. It is noticed she gets weak in legs and knees and "goes down" as though going to fall. Each time staff has caught her. Placed in gerichair for safety but she climbed out. 1815 - Call placed to S39MD to request med for anxiety and combativeness as pt refusing to stay in gerichair. 1830- S39MD returned call and given update/report on new patient. Orders received of Zyprexa Zydis 5 mg po (by mouth) given per med nurse. Pt. to be placed 1:1 AL (arm length) supervision and to be kept in gerichair for safety."
Review of the St. James Behavioral Health Hospital-Patient/Visitor/Staff/Medication Error Form dated 04/06/11 at 1830 revealed under the section labeled Patient Name, Patient #4 was listed. Under the section of description of event revealed, "d/t (due to) confused, non-compliant, combative behavior, S39MD ordered 1:1 supervision but we were unable to staff for it." Under the section labeled Assessment/Outcome of incident/error revealed, "There was a floater MHT (mental health tech) that was not assigned patients that could have been used for 1:1 from 1830 (6:30 p.m.) - 2100 (9:00 p.m.). The extra night MHT." The person filling out report was S26RN and the compliance coordinator was S3RN.
Review of the Daily Schedule and Assignment sheet dated April 6, 2011; 7 a.m. to 7 p.m. shift revealed there was one patient with 1 to 1 supervision. The staff on the shift were: 1 RN from 7a.m. to 7p.m., 1 Medication Nurse-LPN from 7 a.m. to 7 p.m., 1 Float LPN 9 a.m. to 9 p.m., 5 MHT (Mental Health Techs) from 7 a.m. to 7 p.m., and 1 MHT floater from 9 a.m. to 9 p.m.
Review of the Daily Schedule and Assignments sheet dated 04/06/11 at 7 p.m. to 7 a.m. revealed there were: (1) 7 p.m. to 7 a.m. RN, 1 Medication Nurse from 7 p.m. to 7a.m., 1 Float LPN until 9 p.m., 4 MHT with 1 of the 4 MHT assigned to 1 patient for 1:1 supervision.
Review of the Nurses' Daily Shift Report for 7 p.m. to 7 a.m. revealed the beginning census was 27 and ending census was 27 patients. Two (2) of the MHTs were assigned to 2 patients on 1:1 supervision. In the Commitment Changes section of the form, there was a handwritten documentation note that stated, "short-handed; had 2 pt. 1:1. Could not get anyone to come in."
An interview was conducted on 08/09/11 at 2:45 p.m. with S1Administrator, S2DON, and S3Clinical Coordinator to review of the staffing for the 7p.m. to 7 a.m. shift on 04/06/11. They stated on the 7 p.m. and 7 a.m. 2 MHT had 1:1 supervision patients, which left 2 MHTs with 25 patients. They stated they were not staffed approximately and the typically ratio of MHT to patients are 1 to 9. With the 25 patients left to observe out of the census of 27; 1 MHT would have 12 patients and 1 MHT would have 13 patients. S3Clinical Coordinator stated when she investigated the incident, she thought there was only 1 patient with 1:1 supervision, not two patients. S2DON further stated when the hospital gets an order for a new patient to be added to 1:1 supervision; it usually means they need to add staff to the schedule. The RN and/or the LPN will start calling the prn (as needed) staff. If the nurses can't find staff, the nurses then call the Administrator on call and that person would attempt to get help. They confirmed they were short one MHT on 04/06/11 on the 7 p.m. to 7 a.m. shift.
2)
Patient #4:
Review of the St. James Behavioral Health Hospital-Patient/Visitor/Staff/Medication Error Form dated 04/07/2011 and timed 2220 revealed in part under the section labeled Patient Name revealed the incident report was also on Patient #4. Under the section labeled Description of event, "Patient requested to use the bathroom so her 1:1 S9MHT and S10MHT assisted her. S10MHT stated he placed her on the toilet, gave her privacy went back she had voided and when he pulled her brief up she fell back against the toilet. She couldn't stand so he picked her up and placed her in the gerichair. M9MHT came and MHT10 ran to the nurse's station to get the nurses. S18RN assessed patient ...called 911 and necessary information given ..."
Review of the Patient q 15" &/or 30 " Observation Form PM Shift dated 04/07/11 at 1915 to 2015 (8:15 p.m.) revealed Patient #4 was monitored, watching TV, awake and cooperative. At 2030 (8:30 p.m.) fluids were offered, meal or snack offered, she was monitored and awake and cooperative, and the fluids were taken and the snack eaten. At 2230 (10:30 p.m.) the toilet was offered.
An interview was conducted with S10MHT on 08/08/11 at 3:30 p.m. S10MHT stated Patient #4 was not his patient, but he assisted her to the bathroom and back to the gerichair on the 04/07/11. S9MHT was assigned the 1:1 close observation at arm length for Patient #4, but he was unable to be interviewed due to incarceration. During S10MHT's interview he stated S9MHT and himself brought the patient from the TV room to her room to use the bathroom. He assisted her to the toilet and gave her privacy. He stated he left her for approximately 5 minutes. At this time S9MHT had left the room and he stated he was not sure where he went. Prior to being placed on the toilet, he stated she was alert and talking, but when he went to get her off the toilet she sporadically moved back against the wall, then jerked, and went limp. When questioned on what her observation level was, S10MHT stated he was not sure. When questioned on what the observation level 1:1 at arm's length meant, he stated you have to be at arm's length from the patient at all times. He went on to state it depended on the patient if you give them privacy when they go to bathroom or not when they are listed as 1:1 at arm's length. When questioned why a female MHT wasn't assigned to Patient #4, he stated it depended on staffing, if they had a female MHT or not and if she was available to assist the patient.
An interview was conducted on 08/09/11 at 12:55 p.m. with S1Administrator, S2DON, and S3 Clinical Coordinator. They confirmed 1:1 observation at arm's length meant not leaving the patient on the toilet without being in the room. They went on to state, they usually try to assign female MHT with female patients that are 1:1 at arm's length, but there was no policy on a male MHTs trying to get a female MHT's to take a female patient on close observation at arm's length to the bathroom.
3)
Patient #3:
Review of the medical record revealed the patient (#3) was admitted on [DATE] at 1715 (5:15 pm) with the diagnosis of Schizophrenia, BiPolar and other medical diagnosis and was discharged on [DATE] at 10:00 am. Further review revealed "Physicians Orders" dated/timed 06/26/11 at 1930 (7:30 pm) read in part, "...1:1 visual contact /c (with) a female MHT (mental health tech) ...".
Review of the "Incident Log" for June 2011 read, "...1:1 ordered (with no staff on) 06/26/11 ..." for Patient #3. Further review revealed a "Patient Incident/Injury" form for Patient #3 dated 06/26/11 with no documented time, read in part, "...order received (See attached) to place pt (patient) on 1:1 visual contact (VC) /c (with) a female MHT (mental health tech). But unable to staff...".
There were no "Staffing Assignment Sheets" presented for the night shift (7:00 pm through 7:00 am) on 06/26/11 presented during the survey conducted on 08/04/11 through 08/12/11.
Review of medical record copied by S16Medical Record Clerk on 08/05/11 at 11:40 am and on 08/08/11 at 11:15 am revealed no documented evidence an MHT was assigned/designated to monitor Patient #3 during the night shift on 06/26/11 from 7:30 pm (1930) to 10:10 pm (2210) for about 2 hours and 40 minutes or from 3:00 am (0300) through 7:00 am (0700) for about 4 hours as ordered by the physician at 7:30 pm (1930).
Further review of Patient #3's medical record revealed a "Patient Observation Form PM Shift" form was copied from the medical record by the surveyor on 08/12/11 at 9:00 am. The "Patient Observation Form PM Shift" form had a handwritten date of 6/26/11 written over the original date of 6/24/11 noted on the form. The number "6" was handwritten over the number "4" on the form indicating Patient #3 was monitored by S20MHT on 06/26/11 from 7:30 pm (1930) to 10:10 pm (2210) for about 2 hours and 40 minutes and from 3:00 am (0300) through 7:00 am (0700) for about 4 hours. Further review revealed S20MHT documented the patient (#3) was at another hospital from 10:00 pm (2200) through 2:45 am (0245). S20MHT further documented the patient (#3) maintained 1:1 continued visual sight less than 15 feet from the MHT from 7:30 pm (1930) to 10:10 pm (2210) for about 2 hours and 40 minutes and from 3:00 am (0300) through 7:00 am (0700) for about 4 hours. There was no documented evidence the patient (#3) slept during S20MHT's night shift on 06/26/11. Further review revealed there was no documentation the patient (#3) was in the "Time Out" room as ordered at 6:00 pm (1800) by the administration on call/S2DON documented by S20MHT during the night shift on 06/26/11.
Review of the "Nursing Assessment" dated/timed 06/26/11 at 1615 (4:15 pm) for Patient #3 read in part, "...Orders received to place pt on 1:1 visual contact (VC) /c a female MHT...Attempted to call in staff ...1:1 VC but was unsuccessful ...". At 1800 (6:00 pm), "...I (S26RN)...was not able to staff for 1:1 VC & he (S2DON) stated to have pt sleep in time out room /c door open (it is near nurses station) ...". Further review revealed there was no documented evidence in the medical record that the patient (#3) was monitored by an Registered Nurse from 10:30 pm (2230) through 7:00 am (0700) on 06/26/11 for approximately 8 hours and 30 minutes. There was no documentation the patient (#3) was monitored 1:1 visual contact by a designated MHT during the night shift from 7:30 pm (1930) to 10:10 pm (2210) for about 2 hours and 40 minutes and/or from 3:00 am (0300) through 700 am (0700) for about 4 hours as ordered by the physician on 06/26/11 at 7:30 pm (1930).
During a face-to-face interview on 08/08/11 at 4:25 pm, S2DON verified there was no documented evidence in the medical record that Patient #3 was monitored 1:1 visual contact during the night shift from 7:30 pm (1930) through 7:00 am (0700) on 06/26/11 as ordered by the physician at 7:30 pm (1930). In another face-to-face interview on 08/12/11 at 9:25 am, S2DON verified the "Patient Observation Form PM Shift" had the date changed from 6/24/11 to 6/26/11 for Patient #3 from 7:15 pm through 7:00 am. S2 confirmed there was no documented evidence Patient #3 was monitored by the night shift Registered Nurse every two (2) hours as per policy. S2DON reported there was no documentation of the "Staffing Assignment Sheets" for the 06/26/11 night shift from 7:00 pm through 7:00 am. S2 stated there was no documentation in the patient's (#3's) medical record and/or staffing assignment sheets the patient was assigned/designated an MHT to monitor the patient's 1:1 visual contact as ordered by the physician during the night shift on 06/26/11 and as per policy.
During an interview on 08/09/11 at 8:45 am, S26RN verified there was no documented evidence in the medical record of Patient #3 that an MHT monitored the patient 1:1 visual contact during the night shift from 7:30 pm (1930) to 10:10 pm (2210) for about 2 hours and 40 minutes and/or from 3:00 am (0300) through 700 am (0700) for about 4 hours as ordered by the physician at 7:30 pm (1930). S26 confirmed there was no documentation that a Registered Nurse supervised and evaluated the patient (#3) that same night (06/26/11) from 10:30 pm (2230) through 7:00 am (0700) as per policy.
Review of the hospital's policy Close Observation, Policy #8.21, which was given to the surveyor as the current policy in use, revealed in part, "It is the policy of the hospital to provide and initiate close observation for patients exhibiting behavior warranting increased staff supervision and external control.
Procedure 1. Identify patients of special concern and document specific behavior validating need of increase supervision and control. 2. Inform the attending psychiatrist or their designee and secure an order for close observation. 3. If behavior indicates a safety risk to patient and/or others, immediately institute close observation procedures and then secure an order. 4. Specify type and frequency of observation. A. Type of Close Observation includes but is not limited to:
1. Suicide precautions
2. Behavioral precautions
3. Falls precautions
4. AWOL (away without leave) precautions
5. Physical assessment precautions
B. Frequency ....
8. 1:1 Constant Observation: Twenty-four (24) hour constant observation of the identified patient within arm's length of the specified staff member...".
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the hospital 1) failed to ensure that allegations of abuse were reported to the Department of Health and Hospitals' Health Standards Section within 24 hours of knowledge of the allegation for 1 of 1 sampled patient (#5) 2) failed to ensure all patients were free from abuse and neglect as evidenced by a patient admitted by Physician's Emergency Certificate and Coroner's Emergency Certificate with suicidal ideations was under close observation every 15 minutes as ordered by the physician for 1 1/2 hours which resulted in the patient's elopement and the police and the facility being unable to locate the patient (Patient #7) and 3) failed to ensure measures were in place to educate and train all clinical employees in regards to abuse/neglect for 35 of 38 Mental Health Techs reviewed. This has the potential to affect all patients and staff. Findings:

1) Incident Date 7/19/2011 regarding Patient #5:
Review of Patient #5's medical record revealed the patient was admitted on [DATE] with diagnoses that included Bipolar Disorder. Review of a handwritten letter by Patient #5 dated 7/24/2011 with no documented time revealed in part, "I (Patient #5) am reporting on about July 19 or 20th during the evening shower, I had asking for a razor. The tech told me she did not have time because she needing to stay in while I shave, I told her that was no problem, she gave me my towels . I waited about 10 minute, and decided to go ahead and shower. The Tech was a short white female, very sweet to all patient, she was just really busy. I understood. While I was in the shower, I was washing my hair a face, had my eyes closed due to the soap, after washing out the soap, when I opened my eyes, There was a dark skin black male with a slim trimmed Beard was standing with one hand out with a razor (and) cream, the other was holding his private part, he told me to touch it. I turned and said get out of here. when I turned, he grabbed me from behind, put his hand over my face and mouth and put his private in my vagina from behind. I couldn't over power him so he continued until his climax. I would like a blood test ASAP (as soon as possible) to check for possible STD (Sexually Transmitted Diseases). When he got through he quickie (as written) got to the door and said you better not tell, I will kill you. I've been afraid to tell and I've held in it and I can't keep in bottle up any longer. I will take polygraph test what ever it take."

Review of Patient #5's Nursing Documentation dated 7/24/2011 at 0930 (9:30 a.m.) revealed "observed pt (patient) crying in the hall (and) both (Licensed Practical Nurse S30) and I (Registered Nurse S26) approached her to find out why. She (#5) said she (#5) held back telling the whole truth when she had reported a male MHT (Mental Health Tech) had come in while she was showering to bring her a razor. She (#5) reported he (unidentified Mental Health Tech) had a razor in one had (and) he (unidentified MHT) was masturbating (with) the other hand. She (#5) said he (unidentified MHT) bent her (#5) over (and) put his hand over her (#5) mouth so she couldn't scream. She (#5) said he (unidentified MHT) then penetrated her vaginally (and) actually climaxed inside her vagina. She said she did not tell anyone because he (unidentified MHT) told her he would kill her and she (#5) said she felt ashamed because of wearing too tight jeans. She (#5) reported she is not sure of the dates (19th, 20th, or 21st). I (RNS26) instructed her (#5) that I (S26) would notify the doctors and administration and perform an investigation (Physician S31, Physician S39, and Administrator S1) notified. Investigation begun."

Review of a typed attached document to a "Patient/Family Complaint (signed by Clinical Coordinator S3 on 7/25/2011 at 8:30 a.m. regarding Patient #5)" form revealed no documented evidence that the Louisiana Department of Health and Hospitals' Health Standards Section had ever been notified of an allegation of sexual abuse made by Patient #5 that allegedly occurred in the hospital on [DATE].

During a face to face interview on 8/09/2011 at 1300 (1:00 p.m.), Administrator S1 indicated he (S1) had never made a report to the Louisiana Department of Health and Hospitals regarding Patient #5's allegation of sexual abuse. S1 indicated the report had been received by him on the evening 7/24/2011 and further investigated on 7/25/2011. S1 indicated he (S1) knew he had 24 hours to investigate the allegation prior to contacting the Department. S1 indicated the investigation showed that Mental Health Technician S9 had entered the female shower room while a female patient (#5) had been located there. S1 indicated he (S1) was unable to prove that any sexual contact had occurred. S1 indicated the Police had already become involved on 7/25/2011. S1 indicated that he (S1) felt the situation did not require reporting to the Department of Health and Hospitals.

Review of a Hospital Memorandum from the State of Louisiana Department of Health and Hospitals dated 10/27/2010 presented by the hospital as current revealed in part, "Effective immediately, all hospital self reports allegations of abuse a and/or neglect submitted to the Department of Health and Hospitals Health Standards Section must be faxed. . .within 24 hours of the facility having knowledge of the allegations. . . it must contain all of the information required in the preliminary report, including but not limited to: 1. Name and DOB (date of birth) of the patient. 2. The patient's admission and discharge date s 3. Patient's admitting and pertinent diagnoses 4. Nature and specific description of the alleged event, including any details available 5. Date, time, and specific location of the alleged event 6. How and when the incident was discovered 7. Whether patient sustained injuries or adverse effects 8. Name and title of the alleged perpetrator 9. Alleged perpetrator's professional license number or social security number if unlicensed 10. Alleged perpetrator's date of hire 11. Whether or not there is video surveillance of the location involved. 12. If video surveillance existed is it the type that records? If so, how long does it maintain the recording? 13. Was the video reviewed relative to the incident? If so, by whom; what were the findings: 14. Date and time facility administration became aware of the allegation. 15. Name and title of administrative personnel first notified 16. Actions taken by the facility to safeguard the patient (s) 17. To whom the facility has reported the incident (including physician, family member, police dept (department), licensing board, protective services, etc.)."

Review of Louisiana Revised Statute 40.2009.20 Duty to make complaints. . . revealed in part, "Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, licensed practical nurse, nurse's aide, . . . or any other direct caregiver having knowledge that a consumer's physical or mental health or welfare has been or may further adversely affected by abuse, neglect, or exploitation, shall, within twenty four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect..."

2) Review of the medical record for Patient #7 revealed that the patient was admitted to the facility on [DATE] by a PEC/CEC(Physician Emergency Certificate/Coroner's Emergency Certificate) for polysubstance abuse, suicidal ideations, and he had a history of Schizophrenia. Review of the Initial Psychiatric Evaluation dated 07/20/11 revealed in part ... "This is a [AGE] year old married Caucasian male with a history of mood disorder and polysubstance abuse, has been admitted after he threatened to jump out of a moving a car while he was with this wife. The patient's wife reports the patient was agitated, because he has been out of his Lortab and he also has been drinking. The patient was taken to the emergency room by EMS and then sent here now to St. James Hospital for further treatment. The patient admits to a long history of polysubstance abuse. He has a history of intravenous drug administration as well. He reports he has been to various emergency room s in order to get treated in the emergency room for his pain medication. He has admitted to burning himself on the arm in order to get treated in the emergency room for his pain medications. He has also cut himself with a fishing line and shot himself with a nail gun all in hopes of getting pain medication."

Review of the St. James Behavioral Health Hospital-Patient/Visitor/Staff/Medication Error Form dated 07/24/11 revealed under the section labeled Incident, "Patient Escaped from Hospital."Under the section labeled Description of Event revealed, "Pt (patient) noticed missing tonight out of his room by S10MHT. Window next to pat's bed has been broken open. Staff searches for patient. Pt was nowhere to be found. He was seen between the hours of 3-4:30 p.m. during visiting hours with a white female. S38PA says not to alert the family @ this time." Under the section labeled Assessment/Outcome and or Follow-up of incident/Error revealed, "The window in the patient's room had been broken open. PD called and Sgt (Sergeant) came. Copies of a picture of the pt. along with his face sheet was given to Sgt. He says the department will contact the family. Police report number was given by officer."

Review of the PD-Case Report dated and timed 07/24/11 9:57:59 revealed under the narrative section of the report, "On 07/24/11 I Sgt. responded to St. James Behavioral Hospital located at 3136 S. St. Landry Road for a 911 hang up. Upon my arrival dispatch advised they were unable to make contact with anyone at the hospital. I then hit the call button at the front door and was met by (S24RN) who advised they had a patient escape. (S24RN) advised they went to check on a patient and discovered the window in his room has been broken with an unknown type of object and the subject had escaped. (S24RN) advised the patient was last seen at 20:30 hours and advised his name was (Patient #7) w/m (white/male) 06/14/83 (date of birth). She advised that (Patient #7) was transported to the facility on [DATE] as a transfer from hosp."b" . He is a described as a paranoid schizophrenia, suicidal, and substance abuser. (S24RN) advised that (Patient #7) did have a female visitor during visiting hours and she left at 19:00. She advised that (Patient #7) as provided an address in Addis, Louisiana and they were going to call his family and let them know he had left. I then noticed the window had a plastic plexi glass type security feature that only allows the window to go up about 4" and locks in place after that. The plastic plexi glass security feature was broken by an unknown object and the window was able to be forced up and opened all the way allowing him to make his escape. I then advised other units to B.O.L.O (be on the lookout) for (Patient #7). I also had dispatch put out a B.O.L.O (be on the lookout) to APSO (Parish Sheriff Office) units. I advised (S24RN) to contact the police department if (Patient #7) showed back up. I then left and checked the area and was unable to locate (Patient #7). He was entered into N.C.I.C. (National Crime Information Computer) as a missing person and his home town Police Department was contacted to go by the residence. They advised they would check the residence as B.O.L.O. for (Patient #7). They were unable to locate him."

Review of the St James Behavioral Health Hospital Multi-Disciplinary Progress Note dated 07/24/11 at 2030 revealed, "Pt noticed missing tonight out of his room. The window next to his bed had been broken open. Staff searched for patient inside and outside the hospital. Patient nowhere to be found. He was last seen by S32MHT after supper around 5:30 p.m. going to his room to lie down. He was seen during visiting hours with a white female between the hours of 3 p.m.-4:30 p.m." The next entry was timed 2100 - "PD called to notify them that patient had escaped. S31MD and S38PA on the unit made aware of pt's escape. S39MD and S36PA notified. S38PA says not to alert the family at this time." The next entry on the progress note was timed 2130 - "Sgt. from PD came. He was given a copy of a picture of the patient along with a face sheet. Sgt. Says his department will contact the family."

Review of the St James Behavioral Health Hospital Physician Admit Orders & Problem List dated 07/20/11 revealed an order for CO q 15" (close observation every 15 minutes).

Review of the Patient 15" &/or 30" Observation" Form AM Shift dated 07/24/11 revealed he (#7) was observed every 15 minutes from 0715 (7:15 a.m.) to 1900 (7:00 p.m.). From 5:30 p.m. to 7:00 p.m. S32MHT documented patient #7 was being monitored, and he (#7) was awake and cooperative. Review of the Patient 15" &/or 30" Observation Form PM Shift dated 07/24/11, S9MHT documented every 30 minutes Patient #7 was monitored and awake until 9:45 p.m. and then was monitored and asleep from 10:15 p.m. until 5:45 a.m. At 6:15 a.m. on 07/25/11 Patient #7 was awake and monitored and fluids were offered and at 6:45 a.m. he was offered a meal/snack and he was awake and monitored. According to the nursing notes and the police report the patient was reported missing at 8:30 p.m. the evening of 07/24/2011.

Review of the Environmental Safety Report dated 07/25/11 revealed, "An environmental safety inspection of patient room #8 was conducted by hospital staff immediately upon discovering the elopement of the patient assigned to bed 8b on the evening of July 24, 2011 and again by the hospital administrator and maintenance supervisor on the morning of July 25, 2011. A short black screw driver was found under the mattress in the patient's room. The screwdriver was examined and found not to be a tool from the facility maintenance collection. The patient either snuck in the tool or had someone deliver it from the outside. It appeared that the patient planned to unscrew the framework of the plexi-glass protective covering of the window in order to open the window enough to pass his body through to the outside. Because the screwdriver was unable to turn the safety, tamper pro screws it appears that the patient was able to loosen the cover instead by pushing and pulling the frame from the bottom over a period of time. A corrective action plan was immediately initiated. Maintenance repaired the window framework and install new plexi-glass. This action was completed on the afternoon of 1." The Environmental Safety Report was signed by S1Administrator.

An interview was conducted with S24RN on 08/08/11 at 1 p.m. She stated she was the registered nurse working on the night that Patient #7 was discovered missing. Patient #7 was on every 15 minute observations. She went on to state at 8:30 p.m. S31MD was in the facility making rounds. S10MHT went to get Patient #7 for the physician to examine and he could not find the patient. S9MHT was assigned to the patient for the p.m. shift (7 p.m. to 7 a.m.) to do the every 15 minutes observations. S24RN stated she asked S9MHT if he had located all his assigned patients when he started his shift at 7 p.m. At first he stated he did, and then he changed his story. He went on to say he must have gotten the patient confused with someone else and he had not seen the patient since he came on his shift. She went on to state on 07/24/11 the day RN, S26RN was still in the facility and called S32MHT at home (the MHT who was assigned to perform the every 15 minutes observation on the a.m. shift). S32MHT stated she saw him last at 5:30 p.m. after supper and she saw him with a white female visitor earlier that afternoon. The staff started searching for Patient #7 inside and outside the facility. When the patient was not found and the window was found broken in his room, the police, the physician, and the administrator was called. When the police came to the facility to investigate, they stated they would notify the family. An incident report was completed. S24RN went on to say the patient was not volatile, but he was a danger to himself.

An interview was conducted on 08/09/11 at 2:10 with S32MHT. She stated she worked from 7a.m .to 7 p.m. on 07/24/11 and was assigned to conduct every 15 minutes observations on Patient #7. She stated she checked on him up until the end of her shift at 7 p.m. When asked why the Incident Report stated the last time she saw the patient was 5:30 p.m., S32MHT stated she was called at home of the night of 07/24/11 at 10:30 p.m. after she had fallen asleep by the day RN, S26RN. S26RN asked her the last time she saw Patient #7. She was half asleep and "foggy" at the time the nurse questioned her, but her documentation on the Patient 15" and/& 30" Observation Form AM Shift was correct. She monitored him up to the end of her shift, 7 p.m., and he was in his room until she left her shift. S32MHT stated after dinner he went to his room and did not go out and smoke like he typically did. Earlier in the afternoon from 3 p.m. to 4:30 p.m. he had a female visitor and another MHT watched him during the visitation time. S9MHT then picked up the observation of every 15 minutes from 7 p.m. to 7a.m. When questioned if anyone in Administration ever interviewed her about when and where she last saw the patient, she stated "no".

An interview was conducted with Detectives PD1 and PD2 on 08/05/11 at 1 p.m. They stated the PD was called to St. James Behavioral Health hospital on [DATE] at 9:57 p.m. when Patient #7 had eloped. They further stated they made rounds in the hospital and found that Patient #7's window was busted out. The police searched for him and was unable to find him then they notified his hometown police department to be on the lookout for him. He still has not been found.

On 08/09/11 at 9:50 a.m. S35Maintenance Tech was interviewed. He stated on 07/24/11 Patient #7 broke the plexi glass in his room, raised the window and left. On examination of the window, he stated he had to take the whole window down and repair the plexi glass and frame for the plexi glass. He replaced the window as it was prior to the elopement of Patient #7; no alterations were made to the window and plexi glass in the window.

An interview was conducted with S38PA on 08/10/11 at 2:30 p.m. She stated she arrived at the hospital on [DATE] between 8:30 p.m. and 9:30 p.m. with the hospital in chaos. She went on to state an employee met her at the door of the facility stating, "I think someone is gone." The employees proceeded to search the hospital and found that Patient #7's window was busted out. She went on to state she has always been concerned that contraband could be introduced into the facility through the window since it was capable of being opened some. When questioned why she told the staff not to call the family immediately and tell them he was missing, she stated she was told his wife had visited him earlier during the day and she didn't want to alert the family in case the family had picked him and was taking him to his home. That way the police would have time to go to his house first before alerting the family the police were on their way. The police said they would tell the family he had eloped after driving by his home.

On 08/09/11 at 2:45 p.m. an interview was conducted with S1Administrator, S2DON, and S3 Clinical Coordinator. They stated that Patient #7 was on every 15 minutes observations the whole time he was admitted to the facility. They confirmed on the 7p.m. to 7a.m. shift on 07/24/11, the night of the elopement, S9MHT documented every 30 minutes observations from 7 p.m. until the next morning at 7 a.m. on 07/25/11, even though the patient was discovered missing on 07/24/11 at 8:30 p.m. S3Clinical Coordinator stated when she reviewed Patient #7's chart she saw where S9MHT had documented the patient was in the hospital even though he had been reported missing already. She went on to state she could not speak to S9MHT because he was under investigation for another allegation in the facility. S3Clinical Coordinator stated she did not interview S32MHT, who last saw the patient at 5:30 p.m. on 07/24/11. When questioned if she reviewed the video tapes in the hospital to assist with her investigation of the elopement, she stated she had not. She further stated they were not sure how the patient obtained the screwdriver that was found in his room after he eloped.

Review of the hospital's policy on Suicide Precaution, Policy # 8.33, given to the surveyor
as the current policy in use, revealed in part, "...2. All patients admitted following a suicide attempt will considered at high risk. For these patients, suicide precautions will be initiated upon arrival to the hospital...A. Level I: Close Observation ...3. Nursing Interventions: a. check patient every fifteen (15) minutes; b. frequent verbal contact during waking hours; c. 1:1 staff accompaniment for any necessary out of the hospital activity (test and procedures); d. routine confiscations of sharps..."

Review of the hospital's policy on Absence Without Authorization, Policy 2.4, given to the
surveyor as the current one in use, revealed in part, "It is the policy of the Hospital to designate a patient as absent with authorization (AWOL) in the following situations: Absence from the hospital without a physician's order....A. Identification of AWOL 1. The occurrence of a patient unaccounted for during hourly or more frequent observation will be brought to the attention of all staff. 2. Exploration of patient's whereabouts will ensue, including a search of the Hospital. Should this prove unsuccessful, the following procedures are to be implemented:
a. Hospital security is notified of patient's absence and placed on alert;
b. The nurse notifies the attending psychiatrist ...
c. The Administrator and Director of Nursing are notified.
d. A search of the Hospital ensues, if determined necessary by the nurse and with the assistance of security;
e. The search will not occur outside the confines of the Hospital by staff, unless the patient is determined to be of danger to self or others;
f. Notification of family/significant others is to occur when judged appropriate by nurse and psychiatrists; and
g. If the patient is determined to be of danger to self or others, the police department will be notified; this intervention will be ordered by the attending psychiatrist after consultation with the staff...
C. AWOL of Involuntary Patients
10. Initiating AWOL procedures for involuntary patients remains the same as those described for voluntary patients with the following exceptions:
a. searches are to include the Hospital facility, Hospital grounds, and immediate environment; and
b. local and, if appropriate, state police will be notified.
11. If the patient has not been returned to the hospital within twenty-four (24) hours, the attending psychiatrist or their designee must notify, in writing, the court of jurisdiction as outlined by state specific regulations...
D. Documentation
14. Time of incident, intervention, staff action, notification(s), and patient status will be clearly described and entered in the patient's clinical record.
15. A Hospital Occurrence Report (HOR) will be completed for every (AWOL):
a. the Administrator and Director of Nurses will review and evaluate each incident; and
b. a copy of the report will be forwarded to corporate with monthly HORS. In the vent that circumstances are of critical nature, the Senior Vice President of Behavioral Health will be notified immediately."

An interview was conducted with the S3Clinical Coordinator on 08/10/11 at 8:45 a.m. The Absence Without Authorization policy was reviewed with her. She stated the hospital did not have security, no written documentation was done after the patient was gone for 24 hours, and there was no corporate office to forward the monthly HORS.

3) Review of 38 of 38 Mental Health Technicians (MHT) records for training in Abuse/Neglect revealed 35 of 38 MHT's had no documented evidence of training in Abuse/Neglect.

In an interview on 08/09/11 at 9:10 a.m. S2DON confirmed the personnel records for the 35 MHT's did not have documented evidence of training in Abuse/Neglect.

Review of a hospital policy titled "Staff Orientation", Policy 4.2, originated June 2006, reviewed January 2010, presented as current hospital policy reads in part: "Policy. It is the policy of the Hospital that all staff be fully and properly oriented to the Hospital prior to assuming full work responsibilities...Purpose. To outline expectations for staff orientation. Procedure. 1. At the time of hire, each employee will be informed of the orientation process of the Hospital operations. 2. The employee's direct supervisor will assume responsibility for orientation activities (i.e.: Director of Nursing, Administrator). 3. Orientation of all full-time and part-time staff will include, but not be limited to items outlined on the "Staff Skills Checklist"..."
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**












Based on record reviews and interviews the hospital failed to ensure patients received care in a safe setting by:

1. The hospital's failure to ensure measures were in place to protect psychiatric patients from harm by self inflicted acts or harmful acts committed by peers, staff, and/or visitors for 3 of 20 sampled patients (Patient #5, #17, #10),

2. The hospital's failure to a) ensure it had and enforced an effective abuse prohibition policy as evidenced by failing to ensure appropriate screening of employees by not conducting background checks on 7 of 38 Mental Health Technicians (MHT) (S6MHT, S13MHT, S20MHT, S41MHT, S44MHT, S49MHT, S50MHT) b) ensure MHT's received training in the use of Restraint/Seclusion as evidenced by failing to ensure 34 of 38 MHT's had documented training and return demonstration in the safe application/use of Restraint/Seclusion (S6MHT, S9MHT, S10MHT, S11MHT, S13MHT, S20MHT, S21MHT, S25MHT, S27MHT, S34MHT, S37MHT, S41MHT, S43MHT, S44MHT, S45MHT, S46MHT, S47MHT, S48MHT, S50MHT, S51MHT, S52MHT, S53MHT, S54MHT, S55MHT, S56MHT, S57MHT, S58MHT, S59MHT, S60MHT, S61MHT, S62MHT, S63MHT, S64MHT, S65MHT, S66MHT) and c) ensure MHT's received training in nonphysical intervention skills as evidenced by failing to have documented evidence of training for 30 of 38 MHT's (S9MHT, S10MHT, S13MHT, S20MHT, S25MHT, S27MHT, S32MHT, S34MHT, S37MHT, S41MHT, S42MHT, S43MHT, S44MHT, S45MHT, S46MHT, S47MHT, S48MHT, S50MHT, S51MHT, S52MHT, S53MHT, S54MHT, S55MHT, S58MHT, S60MHT, S61MHT, S62MHT, S63MHT, S64MHT, S66MHT),

3. The hospital's failure to ensure patients were monitored as per physician's orders for 6 of 20 sampled patients (#3, #7, #11,#12, #17, #4) and failed to ensure two unidentified patients as per video surveillance were monitored by any staff while located in the Laundry Room/Linen Room on the night of 7/19/2011. The failure to monitor per physician's orders resulted in an elopement of a patient (#7) on 07/24/11 after 1 1/2 hours without observations done every 15 minutes as ordered. (Patient #7),

4. The hospital's failure to provide security for patient belongings brought into the hospital as evidenced by items documented as being placed in the hospital's safe not being there upon discharge of the patient. (Patient #8). Findings:


1)
Protection of Patients while taking showers (#5, #11, #17):

On 8/05/11 at 8:30 a.m. an observation was made with S1Administrator that the Female shower room door was not closed and locked, allowing access to the empty female shower room. Further observations revealed the hospital had two bathroom/shower rooms: One male bath/shower room in the hallway on one side of the nursing station and One female bath/shower room on the opposite hallway from the nurisng station.

Patient #5:
Review of Patient #5's medical record revealed the patient was admitted on [DATE] with diagnoses that included Bipolar Disorder.

The hospital had video surveillance with views of patient care hallways, common areas, and two acute patient care rooms.

Video Surveillance for the evening of 7/19/2011 was reviewed. Observations of video surveillance revealed Patient #5 entered the female shower room at 2101 (9:01 p.m.) and exited at 2127 (9:27 p.m.). Review further revealed MHT (Mental Health Tech) S9 entered the female shower room two times on 7/19/2011 from 21:02:30 (9:02:30 p.m.) - 21:02:37 (9:02:37 p.m.) and again from 21:05:05 (9:05:05 p.m.) - 21:06:36 (9:06:36 p.m.) while Patient #5 was in the female shower/bathroom. Review of video surveillance revealed Mental Health Tech S25 (assigned to the care of Patient #5) was seen repeatedly entering and exiting the Laundry Room with Laundry baskets in hand from 7/19/2011 at 2053 (8:53 p.m.) until 2118 (9:18 p.m.).

Review of Patient #5's Observation Form dated 7/19/2011 completed by Mental Health Tech (MHT) S25 revealed Patient #5 was documented as receiving medication at 2109, as located in the TV room at 2115 (9:15 p.m.), and smoking at 2130 (9:30 p.m.) when video surveillance revealed Patient #5 was in the female shower room from 9:01 p.m. until 9:27 p.m.

During a face to face interview on 8/08/2011 at 1520 (3:20 p.m.), S25 confirmed she (S25) had been assigned to the care of Patient #5 on the 7 p.m. - 7 a.m. shift for 7/19/2011. S25 indicated that any date/time that she entered information on the Observation Form for a patient indicated that she had visually observed the patient. S25 had no explanation as to how she had entered visualizing Patient #5 in the TV room when video surveillance indicated the patient had been in the female shower room on the night of 7/19/2011.

Review of Patient #5's Progress notes dated 7/22/2011 at 1530 (3:30 p.m.) by Physician Assistant S36 revealed in part, "reports tech (male) came into shower while she (#5) was there. Administration investigating."

Review of Patient #5's Activity Group Notes by Activity Therapist S28 dated 7/22/2011 (no documented time) revealed in part, "Pt (patient) went on today that a male tech brought her some shampoo in the shower. . ."

Graduate Social Worker S23 was interviewed on 8/08/2011 at 1410 (2:10 p.m.) and again on 8/12/2011 at 8:30 a.m. S23 initially stated that she (S23) had been informed by Patient #5 on 7/20/2011 (time unknown) that she (#5) was upset because a black Mental Health Tech (no known identity) had handed her a razor while she (#5) was in the shower. S23 later indicated the date of the report by Patient #5 had been 7/22/2011 (time unknown). S23 indicated she (#5) had not documented the conversation but had verbally reported it to Charge Nurse S26 and Clinical Coordinator S3. S23 indicated she (S23) was certain the date of the report was 7/22/2011 because it was the day after visitation when Patient #5 had received some scrubs from a visitor and had been instructed that she (#5) could not wear them because she (#5) might be confused with staff.

During a face to face interview on 8/12/2011 at 8:30 a.m., Clinical Coordinator S3 indicated that she (S3) had heard someone mention in passing on 7/22/2011 that Patient #5 had complained that a male staff (identity unknown) had entered the female shower room and handed her a razor. S3 indicated she(S3) had never documented or investigated the complaint made on 7/22/2011.

Review of Patient #5's entire medical record revealed no documented evidence of any Nursing Assessment and/or Nursing Notes for the dates of 7/19/2011 (date of alleged rape) or 7/22/2011 (date of report by Patient #5 to Activity Therapist S28 and Physician Assistant S36 that a male had entered the female bathroom while she had been showering).

This finding was confirmed during a face to face interview by Clinical Coordinator S3 and Medical Records Manager S16 on 8/12/2011 at 11:55 a.m. S3 and S16 indicated they had no explanation as to how or why there was no nursing documentation for the dates of 7/19/2011 or 7/22/2011.

Review of a handwritten letter by Patient #5 dated 7/24/2011 with no documented time revealed in part, "I (Patient #5) am reporting on about July 19 or 20th during the evening shower, I had asking for a razor. The tech told me she did not have time because she needing to stay in while I shave, I told her that was no problem, she gave me my towels. I waited about 10 minute, and decided to go ahead and shower. The Tech was a short white female, very sweet to all patient, she was just really busy. I understood. While I was in the shower, I was washing my hair a face, had my eyes closed due to the soap, after washing out the soap, when I opened my eyes, There was a dark skin black male with a slim trimmed Beard was standing with one hand out with a razor (and) cream, the other was holding his private part, he told me to touch it. I turned and said get out of here. when I turned, he grabbed me from behind, put his hand over my face and mouth and put his private in my vagina from behind. I couldn't over power him so he continued until his climax. I would like a blood test ASAP (as soon as possible) to check for possible STD (Sexually Transmitted Diseases). When he got through he quickie (as written) got to the door and said you better not tell, I will kill you. I've been afraid to tell and I've held in it and I can't keep in bottle up any longer. I will take polygraph test what ever it take."

Review of Patient #5's Nursing Documentation dated 7/24/2011 at 0930 (9:30 a.m.) revealed "observed pt (patient) crying in the hall (and) both (Licensed Practical Nurse S30) and I (Registered Nurse S26) approached her (#5) to find out why. She (#5) said she (#5) held back telling the whole truth when she had reported a male MHT (Mental Health Tech) had come in while she was showering to bring her a razor. She (#5) reported the (unidentified Mental Health Tech) had a razor in one had (and) he (unidentified MHT) was masturbating (with) the other hand. She (#5) said he (unidentified MHT) bent her (#5) over (and) put his hand over her (#5) mouth so she couldn't scream. She (#5) said he (unidentified MHT) then penetrated her vaginally (and) actually climaxed inside her vagina. She said she did not tell anyone because he (unidentified MHT) told her he would kill her and she (#5) said she felt ashamed because of wearing too tight jeans. She (#5) reported she is not sure of the dates (19th, 20th, or 21st). I (RNS26) instructed her (#5) that I (S26) would notify the doctors and administration and perform an investigation (Physician S31, Physician S39, and Administrator S1) notified. Investigation begun."

Review of Nursing Note documentation for Patient #5 dated 7/24/2011 at 2100 (9:00 p.m.) revealed in part, "She (#5) also told MD (Medical Doctor) that she was sexually assault (ed) by one of the MHT (Mental Health Techs/no identification of the male tech) on the unit. MHT will monitor the opposite hall from this pt (patient). will monitor during the night (documented by Registered Nurse S24)."

Observations on 8/05/2011 at 8:30 a.m. revealed the hospital was comprised with one Patient Care Unit with the capability of housing 28 patients. Two hall ways; where patient rooms were contained, were separated by a Dining Room, a Group Room, and a Nursing Station. The Dining Room, Group Room and Nursing Stations all had doors opening to both sides of the hallway and community activities involving all patients were conducted in the rooms.

Review of Staff Assignment Sheets revealed Mental Health Technician S9 worked 7 p.m. until 7:00 a.m. on 7/24/2011 and was assigned to the care of three female patients

Review of Physician S31's Progress notes dated 7/24/2011 (no documented time) revealed in part, "She is also alleging that she was sexually assaulted three days ago. . . Alleged Sexual Assault. I have instructed nursing staff to discuss the issue with the administration for proper inquiry. The patient currently denies any complaints related to her alleged attempt."

During a face to face interview on 8/09/2011 at 8:00 a.m., Registered Nurse S26 indicated she (S26) was the RN on duty when Patient #5 complained of sexual assault by a Mental Health Tech (identity unknown). S26 indicated she (S26) had searched the unit for a Policy Manual to guide her on how to handle the situation (alleged abuse) but there had been no Manual available. S26 indicated it had been a reoccurring problem- that the Policy Manual would be locked in someone's office for administrative reviews. S26 indicated she (S26) had informed the Hospital Administrator (S1), Physician S39, and Physician S31 of the allegation made by Patient #5. S26 indicated she (S26) had informed night shift to avoid assigning male staff to Patient #5. S26 indicated she (S26) had not revised Patient #5's treatment plan to reflect the need to avoid assigning Patient #5 to male staff. S26 indicated Patient #5 had never identified the alleged perpetrator.

During a face to face interview on 8/10/2011 at 1420 (2:20 p.m.) Physician's Assistant S38 indicated she (S38) remembered being told by staff (although she (S38) could not remember the identity of the staff) on 7/24/2011 around 11:00 p.m. during rounds that Patient #5 had accused Mental Health Tech S9 of sexually assaulting her (#5) in the bathroom. S38 indicated she (S38) had thought it unusual that MHT S9 was working after being accused of rape. S38 indicated she (S38) was unaware that MHT S9 had been assigned to three female patients that night. S38 indicated she (S38) had been told by staff (identity not recalled) that Administration was handling the situation. S38 indicated that she (S38) was unsure why Patient #5 had not been sent out for a rape exam but she (S38) had been told that administration was handling the case and therefore she (S38) did not get involved. (Note during a face to face interview on 8/09/2011 at 4:30 p.m., Physician S31 indicated a rape exam would not have been beneficial because it had been over 72 hours and there would be no live sperm present plus the patient had had multiple baths and there would be no DNA obtainable).

Review of Patient #5's Observation Form dated 7/25/2011 from 7:15 a.m. until 9:00 a.m. revealed Patient #5 was observed every 15 minutes by a male Mental Health Tech (S21).

Review of Patient #5's Physician's orders dated 7/25/2011 at 11:50 a.m. revealed an order for "pt (patient) not to be alone (with) male staff or peers."

During a face to face interview on 8/10/2011 at 7:10 a.m., Advance Practice Nurse S36 indicated she (S36) had informed staff on 7/24/2011 (time unknown); in the form of a verbal order, that Patient #5 was not to be alone with any males. S36 indicated she (S36) wrote the order for "pt. not to be alone with male staff or peers" on 7/25/2011 at 11:50 a.m. because she (S36) had noticed that the verbal order that she (S36) had given the night before had not been documented. S36 indicated she (S36) had not been aware that a male MHT had been providing q15 minute (every 15 minute) observations of Patient #5 on 7/25/2011 from 7:15 a.m. until 9:00 a.m.

Review of Mental Health Technician (MHT) S9's personnel file revealed a "Employee Reprimand/Disciplinary Report" dated 7/26/11 (2 days after Patient #5 reported alleged rape and 1 day after video review by administration revealed MHT S9 was alone with Patient #5 in the shower on 7/19/2011 from 21;02:30 - 21:02:37 and again from 21:05:05 - 21:06:36) with no documented time indicating, "Date of Violation 7/19/2011. Time of Violation: 9:00 p.m., Nature of Violation Policy Violation, Conduct, Explanation: Allegation of Sexual impropriety. Suspend until investigation is complete."

During a face to face interview on 8/09/2011 at 1300 (1:00 p.m.), Administrator S1 indicated he (S1) had no documentation regarding the phone call he (S1) had received on 7/24/2011. S1 indicated his memory of the call from the hospital regarding an allegation of inappropriate behavior with conflicting vague details by Patient #5 was that the phone call had occurred in the evening rather than 9:30 a.m. as the nursing documentation indicated. S1 further indicated he (S1) had never been informed of the graphic details described in Patient #5's nursing notes. S1 indicated he (S1) was told that the patient had alternating stories that were conflicting regarding a male in the shower. S1 indicated he (S1) had asked staff to write statements regarding the allegations and asked if the MHT (Mental Health Tech) had been identified. S1 indicated no one had informed him (S1) that an identity of the alleged perpetrator had been established. S1 indicated he (S1) had not reviewed video surveillance recordings until the morning of the 25th (one day after the allegation had been made by Patient #5 that a MHT had entered the female bathroom when she (#5) had been showering and had masturbated, bent her (#5) over, put his hand over her mouth, penetrated her (#5) vaginally, climaxed, and threatened to kill her (#5) if she told). S1 indicated if he (S1) had received the report as it was written in Nursing Documentation on 7/24/2011 at 9:30 a.m. he (S1) would have come immediately to the hospital and started an investigation to include review of video surveillance rather than wait until the following morning (7/25/2011). S1 indicated an allegation of that magnitude warranted immediate involvement and investigation by Administration with safety measures established to protect the patient. S1 indicated the failure of nursing staff to provide him with details of the event resulted in a delay in the investigation and resolution.

Patient #17:
Review of Patient #11's medical record revealed the patient (#11) was admitted on [DATE] with diagnoses that included Schizoaffective Disorder by history. Review of Patient #11's Physician Emergency Certificate (from the sending hospital) dated 7/15/2011 at 7:00 a.m. revealed in part, "Findings of Examination: 27 y/o (year old) male presents to ED (Emergency Department) C/O (complains of) homicidal ideation. states he (#11) has gun and will shoot (name of intended victim) who he (#11) believes killed his younger brother. Review of Patient #11's Nursing documentation dated 7/17/2011 at 1930 (7:30 p.m.) revealed "pt (patient) went into the females shower room (and) took his shower, been making sexual remarks about one of the female pts (patients/no ID (identification) number for the female patient ), he (#11) heard her (no ID number for the female patient) say she (no ID number for the female patient) was going to shower but one of the other pts (patients/no ID number for this patient) walked in on him."

During a face to face interview on 8/10/2011 at 8:00 a.m., Registered Nurse S18 indicated Patient #11 had gone into the female shower room with plans to encounter a young female patient (#17) that he (#11) had been "interested" in. S18 indicated S11 had heard the female patient (#17) state that she (#17) was about to shower. S11 indicated another female patient (didn't recall name of this patient) had opened the door to the shower and screamed when she (didn't recall name of this patient) saw a male in the shower room. S11 indicated the shower rooms should have been locked where no patient had access unless there had been a Mental Health Tech monitoring shower activity. S11 indicated she (S11) did not know how Patient #11 had managed to enter the female's shower and it should not have been possible if staff had been performing their duties properly. S11 indicated Patient #11 was a rather large man (6 feet 2 inches and 287 pounds/ [AGE]) and Patient #17 (intended victim) had been a small girl (5 feet 5 inches and 123 pounds/ [AGE]). S11 indicated she (S11) had not completed an Incident/Occurrence form, had not informed the patients' physician, and had not informed administration of the incident. S11 indicated the patients (#11 and #17) were moved to rooms at opposite ends of the hall. S11 indicated she (S11) had not updated to two patients' (#11, #17) treatment plans to ensure safety interventions were put in place across all shifts by all staff to protect Patient #17 from Patient #11. S11 indicated she (S11) should have completed an Incident/Occurrence form after the incident occurred.

Review of Patient #17's (intended victim) medical record revealed the patient was admitted on [DATE] with diagnoses that included Major Depressive Disorder. Review of Patient #17's Physician Assistant orders dated 7/17/2011 at 11:00 (p.m.) revealed in part, "Pt (patient) is a little worried, a male peer is obsessed (with) her (and) has been watching her closely."

During a face to face interview on 8/09/2011 at 1300 (1:00 p.m.), Administrator S1, Director of Nursing S2, and Clinical Coordinator S3 indicated they (S1, S2, S3) had no knowledge of the incident that had occurred when Patient #11 had executed a plan to encounter Patient #17 in the female shower room. S1, S2, and S3 indicated the incident had never been investigated. S3 indicated there had never been a review of video surveillance recordings after the incident to determine if the patients (#11 and #17) had been properly monitored or to determine which staff had unlocked the shower door and left it unattended. S1, S2, and S3 indicated the nurse that discovered the incident should have reported the incident to administration and should have completed an Incident/Occurrence Report. S1, S2, and S3 indicated there should never have been an opportunity for Patient #11 to enter the female shower room in an attempt to make contact with Patient #17 had the showers been properly monitored.

June 2006 Policy titled Patient Hygiene Showers/Baths 3.15 was reviewed. Review revealed " Policy: The shower room is located on the unit and contains one shower and one bath tub. . . Patients (male/female) are scheduled for showers/baths. Assisted showers/baths are a requirement of the facility. The MHT (Mental Health Tech) will unlock the shower room door and accompany the patient until the shower is completed and the patient is back in his/her room. The door to the shower area will remain locked at all times when the patients are not using the area. Under no circumstances are patients allowed to be unattended in the shower area."

Review of Patient #10's medical record revealed the patient (#10) was admitted on [DATE] with diagnoses that included Chronic Paranoid Schizophrenia with Acute Exacerbation and Lacerated wound on the left wrist. Review of Patient #10's Physician Emergency Certificate dated 7/22/2011 at 5:20 a.m. revealed in part, "Findings of Examination: presents (after) suicidal attempt of trying to cut wrist. . . + AH (positive auditory hallucinations), L (left) wrist (with) superficial laceration 4 cm (centimeters)".

Review of Patient #10's Nursing Documentation dated 7/23/2011 at 1550 (3:50 p.m.) revealed in part, "summoned to patient's room (and) found pt. sitting on bed bleeding form Lt. Wrist wound. Noted he was holding pressure to wound (with) a blue cloth. Noted a large amount of blood droplets on floor (with) a spray of blood on wall. attempted to approach pt. to provide care but unable to do so as pt growled "don't come near me." 911 called (ambulance and police). (Physician's Assistant S36, Administrator S1, and Director of Nursing S2) notified. . . . It needs to be noted pt. apparently used wrist band (name tag) to re-open the previous laceration he had sustained prior to admit here)."

Face to face interviews were conducted with Physician Assistant S36 on 8/10/2011 at 7:10 a.m. and Director of Nursing S2 and Clinical Coordinator S3 8/10/2011 at 9:25 a.m. S36, S2, and S3 indicated any patient that had an active attempt at self harm while admitted to the hospital should have been placed on 1:1. S2 confirmed that Patient #10 had never been placed on 1:1 after using his arm band to open a wrist wound that had required sutures.

2)

a) the hospital failed to ensure it had and enforced an effective abuse prohibition policy as evidenced by failing to ensure appropriate screening of employees by not conducting criminal background checks on 7 of 38 Mental Health Technicians (MHT's) (S6MHT, S13MHT, S20MHT, S41MHT, S44MHT, S49MHT, S50MHT). Findings:

Review of a sample of the personnel records of MHT's employed by the hospital revealed a lack of screening of employees by not conducting criminal background checks . The employment applications used by the Hospital read in part: "...employment is contingent upon the following...a clear criminal record from the (state police agency)..." The sample of MHT's was expanded to include all MHT's employed by the facility and data was extracted from all files.

Review of the data from all 38 MHT personnel records revealed 7 of 38 MHT's employed by St. James Behavioral Health Hospital had no documented evidence of any criminal background checks .

In an interview on 08/09/11 at 9:10 a.m. S2DON confirmed the hospital had not conducted criminal background checks for 7 of 38 MHT's employed by St. James Behavioral Health Hospital.

b) the hospital failed to ensure staff was trained in and able to perform return demonstration in the safe use of Restraint/Seclusion as evidenced by 35 of 38 MHT's employed by the hospital having no documented evidence of Restraint/Seclusion training at any time during their employment. (S6MHT, S9MHT, S10MHT, S11MHT, S13MHT, S20MHT, S21MHT, S25MHT, S27MHT, S34MHT, S37MHT, S41MHT, S43MHT, S44MHT, S45MHT, S46MHT, S47MHT, S48MHT, S50MHT, S51MHT, S52MHT, S53MHT, S54MHT, S55MHT, S56MHT, S57MHT, S58MHT, S59MHT, S60MHT, S61MHT, S62MHT, S63MHT, S64MHT, S65MHT, S66MHT) This has the potential to affect all staff and patients. Findings:

Review of a sample of the personnel records of MHT's employed by the hospital revealed a lack of training in Restraint/Seclusion. The sample of MHT's was expanded to include all MHT's employed by the facility and data was extracted from all files.

Review of the data from all 38 MHT personnel records revealed 35 of 38 MHT's employed by St. James Behavioral Health Hospital had no documented evidence of any Restraint/Seclusion training.

In an interview on 08/09/11 at 9:10 a.m. S2DON confirmed the hospital has not conducted Restraint/Seclusion training for employees.

c) the hospital failed to ensure the development and implementation of a training program which complied with regulatory requirements as evidenced by 30 of 38 MHT's employed by the hospital not being trained in the use of nonphysical intervention skills. (S9MHT, S10MHT, S13MHT, S20MHT, S25MHT, S27MHT, S32MHT, S34MHT, S37MHT, S41MHT, S42MHT, S43MHT, S44MHT, S45MHT, S46MHT, S47MHT, S48MHT, S50MHT, S51MHT, S52MHT, S53MHT, S54MHT, S55MHT, S58MHT, S60MHT, S61MHT, S62MHT, S63MHT, S64MHT, S66MHT) This has the potential to affect all staff and patients. Findings:

Review of a sample of the personnel records of MHT's employed by the hospital revealed a lack of training in nonphysical intervention skills. The sample of MHT's was expanded to include all MHT's employed by the facility and data was extracted from all files.

Review of the data from all 38 MHT personnel records revealed 30 of 38 MHT's employed by St. James Behavioral Health Hospital had no documented evidence of any training in nonphysical intervention skills.

In an interview on 08/09/11 at 9:10 a.m. S2DON confirmed the hospital has not conducted training in nonphysical intervention skills for 30 of 38 MHT employees.

3)

Patient #3:
Review of the "Incident Log" for June 2011 read, "...1:1 ordered (with no staff on) 06/26/11 ..." for Patient #3.
Review of the medical record revealed the patient (#3) was admitted on [DATE] at 1715 (5:15 pm) with the diagnosis of Schizophrenia, BiPolar and other medical diagnosis. Further review revealed Patient #3 was discharged on [DATE] at 10:00 am. Review of the "Physicians Orders" read back telephone order (RBTO) dated/timed 06/26/11 at 1930 (7:30 pm) read in part, "...1:1 visual contact /c (with) a female MHT (mental health tech) ...".
Review of medical record for Patient #3 revealed no documented evidence an MHT was assigned to monitor the patient (#3) 1:1 visual contact during the night shift on 06/26/11 from 7:30 pm (1930) to 10:10 pm (2210) for about 2 hours and 40 minutes and/or from 3:00 am (0300) through 7:00 am (0700) for about 4 hours as ordered by the physician at 7:30 pm (1930).
The "Patient Incident/Injury" form for Patient #3 dated 06/26/11 with no documented time, read in part, "...order received (See attached) to place pt (patient) on 1:1 visual contact (VC) /c (with) a female MHT (mental health tech). But unable to staff. S2DON (named) administration notified /c (with) instructions given to allow pt to sleep in Time Out room in front of nurses station /c door kept open. Instructions passed on to oncoming charge nurse...". Further review revealed there was Physicians Orders attached to the "Patient Incident/Injury" form that read, "Patient #3 to be placed on 1:1 visual contact /c (with) a female MHT" dated/timed 06/26/11 at 1930 (7:30 pm).
Review of the "Nursing Assessment" dated/timed 06/26/11 for Patient #3 read in part, "...at 1545 (3:45 pm), a call was placed to S5MD, Medical Director's cell. At 1615 (4:15 pm), "...No answer from S5MD, Medical Director (not on call) so call placed to S36PA (named) to inform her (S36) of circumstances. Orders received to place pt on 1:1 visual contact (VC) /c (with) a female MHT. I (S26RN) called S2DON (named) to let him (S2) know as S36 (named) had stated/requested to get administration involved if staffing was an issue. Attempted to call in staff ... 1:1 VC but was unsuccessful ...". At 1800 (6:00 pm), "...I (S26RN) notified S2DON (named) I (S26) was not able to staff for 1:1 VC & he (S2DON) stated to have pt sleep in time out room /c door open (it is near nurses station) ...". Further review revealed there was no documented evidence in Patient #3's medical record that the patient was monitored by an Registered Nurse from 10:30 pm (2230) through 7:00 am (0700) on 06/26/11 for approximately 8 hours and 30 minutes.
During face-to-face interviews on 08/08/11 at 4:25 pm and on 08/09/11 at 10:00 am., S2DON verified there was no documented evidence in the medical record that Patient #3 was monitored "1:1 visual contact" by a designated MHT during the night shift from 7:30 pm (1930) through 7:00 am (0700) on 06/26/11 as ordered by the physician. S2DON indicated the Patient Observation Form used to observe patients is a true picture of what the assigned MHT observed the patient doing during that shift. S2 reported there was no Observation Form documented by an assigned MHT for Patient #3 on the night of 06/26/11 as per policy. S2DON confirmed there was no documented evidence the patient (#3) was monitored by the night shift Registered Nurse every two (2) hours as per policy. The DON reported there was no documentation of the "Staffing Assignment Sheets" for the night shift of 06/26/11 from 7:00 pm through 7:00 am of the nurse and/or MHT assigned to the patient (#3). S2DON indicated there was no documented evidence in the medical record and/or staffing assignment sheets that Patient #3 was monitored 1:1 visual contact as ordered by the physician and as per policy during the night shift of 06/26/11.
In an interview on 08/09/11 at 8:45 am, S26RN verified there was no documented evidence in the medical record of Patient #3 that an MHT monitored the patient 1:1 visual contact during the night shift from 7:00 pm to 7:00 am on 06/26/11 as ordered by the physician. S26 confirmed there was no documentation that a Registered Nurse supervised and evaluated the patient (#3) that same night (06/26/11) from 10:30 pm through 7:00 am. S26RN indicated there was no documented evidence Patient #3 was monitored 1:1 visual contact as ordered by the physician from 7:30 pm (1930) to 10:10 pm (2210) for about 2 hours and 40 minutes and/or from 3:00 am (0300) through 7:00 am (0700) for about 4 hours as ordered by the physician at 7:30 pm (1930).
Review of the policy titled, "Close Observation", Policy 8.21, Originated on June of 2006, with no revised and/or reviewed date(s) indicated Visual Contact is twenty-four (24) constant observation of the identified patient within visual sight of the staff member. 1:1 Constant Observation is 24 hour constant observation of the identified patient within arm's length of the specified staff member. Document close observation procedures in the medical record that describe the patient's behavior and status, note the level of observation and frequency of staff contact, identify patient's response, and maintenance of observation protocol until discontinued by the attending psychiatrist or their designee. The close observation orders will be evaluated daily by the RN and documented. Observation status changes require a new order from the attending psychiatrist. The Close Observation Documentation Form will be completed for the duration of the close observation period and become a part of the patient's permanent medical record.
The policy titled, "Patient Observation"; Policy 8.8; Originated date of June 2006; Reviewed date(s) of July, 2007, June 2008; Revised date(s) of [DATE], March 2011; was reviewed. The policy indicated it was hospital policy to continually monitor patients of the unit ensuring consistent and continuous surveillance of all patients routinely. The patients in the hospital are observed by staff every thirty minutes with documentation recorded on the Patient Observation Flowsheet. The "checking" task is to be assign
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**







Based on record review and interview the hospital failed to have complete and accurate documentation in the patients' medical record for 3 of 20 sampled patients (#5, #7, #10) as evidence by :

1. A patient (#7) under close observation every 15 minutes was discovered missing on 07/24/11 at 8:30 p.m. and Mental Health Tech (MHT) documented he was observed every 30 minutes on 07/24/11 from 8:30 p.m. to 7 a.m. on 07/25/11, when he was not in the hospital.
2. A patient (#5) who made allegations of sexual abuse that reportedly occurred in the hospital failed to have any documented evidence of nursing notes for the dates of 7/19/2011 (date of alleged incident) or 7/22/2011 (one of the dates of alleged reporting of incident) (Patient #5)
3. A patient (#10) had a written verbal order documented by Director of Nursing S2 on 7/23/2011 at 1745 (5:45 p.m.) for 1:1 (one to one) if RN (Registered Nurse) deems needed" as taken from Advanced Practice Nurse S36 who indicated she (S36) had never given the order as written in the patient's (#10) medical record.

Findings:

Patient #7
Review of the medical record for Patient #7 revealed that the patient was admitted to the facility on [DATE] by a PEC/CEC(Physician Emergency Certificate/Coroner's Emergency Certificate) for polysubstance abuse, suicidal ideations, and he had a history of Schizophrenia. Review of the Initial Psychiatric Evaluation dated 07/20/11 revealed in part ... "This is a [AGE] year old married Caucasian male with a history of mood disorder and polysubstance abuse, has been admitted after he threatened to jump out of a moving a car while he was with this wife. The patient's wife reports the patient was agitated, because he has been out of his Lortab and he also has been drinking. The patient was taken to the emergency room by EMS and then sent here now to St. James Hospital for further treatment. The patient admits to a long history of polysubstance abuse. He has a history of intravenous drug administration as well. He reports he has been to various emergency room s in order to get treated in the emergency room for his pain medication. He has admitted to burning himself on the arm in order to get treated in the emergency room for his pain medications. He has also cut himself with a fishing line and shot himself with a nail gun all in hopes of getting pain medication."

Review of the St. James Behavioral Health Hospital-Patient/Visitor/Staff/Medication Error Form dated 07/24/11 revealed under the section labeled Incident, "Patient Escaped from Hospital." Under the section labeled Description of Event revealed, "Pt (patient) noticed missing tonight out of his room by S10MHT. Window next to pat's bed has been broken open. Staff searches for patient. Pt was nowhere around. He was seen between the hours of 3-4:30 p.m. during visiting hours with a white female. S38PA says not to alert the family @ this time." Under the section labeled Assessment/Outcome and or Follow-up of incident/Error revealed, "The window in the patient's room had been broken open. PD called and Sgt (Sergeant) came. Copies of a picture of the pt. along with his face sheet was given to Sgt. He says the department will contact the family. Police report number was given by officer."

Review of the PD-Case Report dated and timed 07/24/11 9:57:59 revealed under the narrative section of the report, "On 07/24/11 I Sgt. responded to St. James Behavioral Hospital located at 3136 S. St. Landry Road for a 911 hang up. Upon my arrival dispatch advised they were unable to make contact with anyone at the hospital. I then hit the call button at the front door and was met by S24RN who advised they had a patient escape. S24RN advised they went to check on a patient and discovered the window in his room has been broken with an unknown type of object and the subject had escaped. S24RN advised the patient was last seen at 20:30 hours and advised his name was Patient #7 w/m (white/male) 06/14/83 (date of birth). She advised that Patient #7 was transported to the facility on [DATE] as a transfer from hosp."b". He is a described as a paranoid schizophrenia, suicidal, and substance abuser. S24RN advised that Patient #7 did have a female visitor during visiting hours and she left at 19:00. She advised that Patient #7 as provided an address in Addis, Louisiana and they were going to call his family and let them know he had left. I then noticed the window had a plastic plexi glass type security feature that only allows the window to go up about 4" and locks in place after that. The plastic plexi glass security feature was broken by an unknown object and the window was able to be forced up and opened all the way allowing him to make his escape. I then advised other units to B.O.L.O(be on the lookout) for Patient #7. I also had dispatch put out A B.O.L.O (be on the lookout) to APSO (Ascension Parish Sheriff Office) units. I advised S24RN to contact the police department if Patient #7 showed back up. I then left and checked the area and was unable to locate Patient #7. He was entered into N.C.I.C. (National Crime Information Computer) as a missing person and his home town Police Department was contacted to go by the residence. They advised they would check the residence as B.O.L.O. for Patient #7. They were unable to locate him."

Review of the St James Behavioral Health Hospital Multi-Disciplinary Progress Note dated 07/24/11 at 2030 revealed, "Pt noticed missing tonight out of his room. The window next to his bed had been broken open. Staff searched for patient inside and outside the hospital. Patient nowhere to be found. He was last seen by S32MHT after supper around 5:30 p.m. going to his room to lie down. He was seen during visiting hours with a white female between the hours of 3 p.m. -4:30 p.m." The next entry was timed 2100- "PD called to notify them that patient had escaped. S31MD and S38PA on the unit made aware of pt's escape. S39MD and S36PA notified. S38PA says not to alert the family at this time." The next entry on the progress note was timed 2130- "Sgt. from PD came. He was given a copy of a picture of the patient along with a face sheet. Sgt. Says his department will contact the family."

Review of the St James Behavioral Health Hospital Physician Admit Orders & Problem List dated 07/20/11 revealed an order for CO q 15" (close observation every 15 minutes).

Review of the Patient 15" &/or 30" Observation Form AM Shift dated 07/24/11 revealed he was observed every 15 minutes from 0715 to 1900. From 5:30 p.m. to 7:00 p.m. S32MHT documented he was being monitored, and he was awake and cooperative. Review of the Patient 15" &/or 30" Observation Form PM Shift dated 07/24/11, S9MHT documented every 30 minutes Patient #7 was monitored and awake until 9:45 p.m. and then was monitored and asleep from 10:15 p.m. until 5:45 a.m. At 6:15 a.m. on 07/25/11 Patient #7 was awake and monitored and fluids were offered and at 6:45 a.m. he was offered a meal/snack and he was awake and monitored. According to the nursing notes and the police report the patient was reported missing at 8:30 p.m. the evening of 07/24/2011.

An interview was conducted with S24RN on 08/08/11 at 1 p.m. She stated she was the registered nurse working on the night that Patient #7 was discovered missing. Patient #7 was on every 15 minute observations. She went on to state at 8:30 p.m. S31MD was in the facility making rounds. S10MHT went to get Patient #7 for the physician to examine and he could not find the patient. S9MHT was assigned to the patient for the p.m. shift (7 p.m. to 7 a.m.) to do the every 15 minutes observations. S24RN stated she asked S9MHT if he had located all his assigned patients when he started his shift at 7 p.m. At first he stated he did, and then he changed his story. He went on to say he must have gotten the patient confused with someone else and he had not seen the patient since he came on his shift. She went on to state on 07/24/11 the day RN, S26RN was still in the facility. S26RN called S32MHT at home (the MHT who was assigned to perform the every 15 minutes observation on the a.m. shift). S32MHT stated she saw him last at 5:30 p.m. after supper and she saw him with a white female visitor earlier that afternoon. The staff started searching for Patient #7 inside and outside the facility. When the patient was not found and the window was found broken in his room, the police, the physician, and the administrator was called. When the police came to the facility to investigate, they stated they would notify the family. An incident report was completed. S24RN went on to say the patient was not volatile, but he was a danger to himself.

An interview was conducted on 08/09/11 at 2:10 p.m. with S32MHT. She stated she worked from 7a.m. to 7 p.m.on 07/24/11 and was assigned to conduct every 15 minutes observations on Patient #7. She stated she checked on him up until the end of her shift at 7 p.m. When asked why the Incident Report stated the last time she saw the patient was 5:30 p.m., S32 MHT stated she was called at home of the night of 07/24/11 at 10:30 p.m. after she had fallen asleep by the day RN, S26RN. S26RN asked her the last time she saw Patient #7. She was half asleep and "foggy" at the time the nurse questioned her, but her documentation on the Patient 15" and/& 30 " Observation Form AM Shift was correct. She monitored him up to the end of her shift, 7 p.m., and he was in his room until she left her shift. S32MHT stated after dinner he went to his room and did not go out and smoke like he typically did. Earlier in the afternoon from 3 p.m. to 4:30 p.m., he had a female visitor and another MHT watched him during the visitation time. S9MHT then picked up the observation of every 15 minutes from 7p.m. to 7a.m. When questioned if anyone in Administration ever interviewed her about when and where she last saw the patient, she stated no.

On 08/09/11 at 2:45 p.m. an interview was conducted with S1Administrator, S2DON, and S3 Clinical Coordinator. They stated that Patient #7 was on every 15 minutes observations the entire time he was admitted to the facility. They confirmed on the 7p.m. to 7a.m. shift on 07/24/11, the night of the elopement, S9MHT documented every 30 minutes observations from 7 p.m. until the next morning (07/25/11) at 7 a.m., even though the patient was discovered missing on 07/24/11 at 8:30 p.m. S3Clinical Coordinator stated when she reviewed Patient #7's chart she saw where S9MHT had documented the patient was in the hospital even though he had been reported missing already. She went on to state she could not speak to S9MHT because he was under investigation for another allegation in the facility. S3Clinical Coordinator stated she did not interview S32MHT, who stated she last saw the patient at 5:30 p.m. on 07/24/11 in the incident report, but told the surveyor she last saw the patient at 7:00 p.m.

Review of the hospital's policy on Suicide Precaution, Policy # 8.33, given to the surveyor as the current policy in use, revealed in part, "...2. All patients admitted following a suicide attempt will considered at high risk. For these patients, suicide precautions will be initiated upon arrival to the hospital...A. Level I: Close Observation ....3. Nursing Interventions: a. check patient every fifteen (15) minutes; b. frequent verbal contact during waking hours; c. 1:1 staff accompaniment for any necessary out of the hospital activity (test and procedures); d. routine confiscations of sharps..."

2.
Patient #5:
Review of Patient #5's medical record revealed the patient was admitted on [DATE] with diagnoses that included Bipolar Disorder.

Review of Patient #5 s Progress notes dated 7/22/2011 at 1530 (3:30 p.m.) by Physician Assistant S36 revealed in part, "reports tech (male) came into shower while she was there. Administration investigating." Review of Patient #5's Activity Group Notes by Activity Therapist S28 dated 7/22/2011 (no documented time) revealed in part, "Pt (patient) went on today that a male tech brought her some shampoo in the shower. . . "

Video Surveillance for the evening of 7/19/2011 was reviewed. Observations of video surveillance revealed Patient #5 entered the female shower room at 2101 (9:01 p.m.) and exited at 2127 (9:27 p.m.). Review further revealed MHT S9 entered the female shower room two times on 7/19/2011 from 21:02:30 (9:02:30 p.m.) - 21:02:37 (9:02:37 p.m.) and again from 21:05:05 (9:05:05 p.m.) - 21:06:36 (9:06:36 p.m.) while Patient #5 was in the female shower/bathroom.

Review of Patient #5's Observation Form dated 7/19/2011 completed by Mental Health Tech (MHT) S25 revealed Patient #5 was documented as receiving medication at 2109, as located in the TV room at 2115 (9:15 p.m.), and smoking at 2130 (9:30 p.m.) when video surveillance revealed Patient #5 was in the female shower room from 9:01 p.m. until 9:27 p.m.

During a face to face interview on 8/08/2011 at 1520 (3:20 p.m.), S25 confirmed she (S25) had been assigned to the care of Patient #5 on the 7 p.m. - 7 a.m. shift for 7/19/2011. S25 indicated that any date/time that she entered information on the Observation Form for a patient indicated that she had visually observed the patient. S25 had no explanation as to how she had entered visualizing Patient #5 in the TV room when video surveillance indicated the patient had been in the female shower room on the night of 7/19/2011.

Review of Patient #5's entire medical record revealed no documented evidence of any Nursing Assessment and/or Nursing Notes for the dates of 7/19/2011 (date of alleged rape) or 7/22/2011 (date of report by Patient #5 to Activity Therapist S28 and Physician Assistant S36 that a male had entered the female bathroom while she had been showering).

This finding was confirmed during a face to face interview by Clinical Coordinator S3 and Medical Records Manager S16 on 8/12/2011 at 11:55 a.m. S3 and S16 indicated they had no explanation as to how or why there was no documented nursing documentation for the dates of 7/19/2011 or 7/22/2011.

3.
Patient #10: Review of Patient #10's medical record revealed the patient (#10) was admitted on [DATE] with diagnoses that included Chronic Paranoid Schizophrenia and Lacerated Wound to left wrist (self inflicted). Further review revealed Patient #10 was found on 7/23/2011 bleeding from his wrist, where he (#10) had used his arm band to re-open the wound on his left arm (self inflicted wound). Review of Patient #10's Physician Order sheet dated 7/23/2011 at 1745 (5:45 p.m.) revealed "pt (patient) may sleep in TO (time out/observation) RM (room) for safety and close observation. 1:1 if RN (Registered Nurse) deems needed. RBTO (read back telephone order)/ (Director of Nursing S2)."

During a face to face interview on 8/10/2011 at 7:10 a.m., Physician Assistant S36 indicated she (S36) would never give an order for 1:1 if RN (Registered Nurse) deems necessary. S36 indicated when she (S36) determines the level of observation for a patient it is determined firmly by her (S36). S36 indicated if she (S36) ordered 1:1, it would be a definite 1:1. S36 indicated she would not be able to recall the details of any conversation with Director of Nursing S2 on 7/23/2011; however, any patient with an active suicide attempt in the hospital should be placed on 1:1.

During a face to face interview on 8/10/2011 at 9:15 a.m., Director of Nursing S2 indicated initially that he (S2) had received the verbal order from Physicians' Assistant S36 face to face on 7/23/2011 regarding Patient #10's level of observation. When asked why he (S2) would have written RBTO (read back telephone order) if the order had been given face to face rather than by telephone, S2 indicated it must have been by telephone or he (S2) would not have written RBTO. S2 indicated he (S2) would have written what he (S2) was told; however, as Director of Nursing, he (S2) would expect a patient that had an active attempt at self harm in the hospital to be placed on 1:1.
VIOLATION: COMPLEXITY OF FACILITIES Tag No: A0725
Based on observation and interview the hospital failed to ensure that the physical facilities were appropriate for psychiatric patients as evidenced by having windows that allowed a 5 1/2 inch opening at waist level in 14 of 14 ground level patient rooms allowing the potential for the introduction of contraband into the hospital. This had the potential to affect all patients in the hospital. Findings:

In an observation made on 08/05/11 at 11:05 a.m. with S1Administrator present it was noted that the windows were approximately 5 feet wide. The width was divided into two separate windows which opened from the bottom. On the interior of the windows was a frame that covered the entire width of the windows with a center frame that matched the middle divide of the windows. The height of the interior frame began from the top of the window but ended 5 1/2 inches above the bottom of the exterior window. The interior frame had plexi-glass installed and was screwed to the exterior frame. This allowed the exterior window to be opened 5 1/2 inches from inside the patient room allowing direct access to the outside of the hospital. There were no screens or other physical barrier to the outside. S1Administrator stated "this was what they came up with to meet the regulations for fresh air" and questioned the surveyor about "whether the windows met regulations."

In an observation and interview on 08/11/11 at 8:10 a.m. with S2DON and S35, Maintenance, the windows were measured to be 70" X 62" with the interior plexi-glass and frame 5 1/2" shorter than the exterior window, with the opening being at the bottom. Both S2DON and S35, Maintenance, confirmed this allowed access through which contraband could be introduced into the hospital.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0202
Based on record review and interview the hospital failed to ensure staff was trained in and able to perform return demonstration in the safe use of Restraint/Seclusion as evidenced by 35 of 38 MHT's employed by the hospital having no documented evidence of Restraint/Seclusion training at any time during their employment (S6MHT, S9MHT, S10MHT, S11MHT, S13MHT, S20MHT, S21MHT, S25MHT, S27MHT, S34MHT, S37MHT, S41MHT, S43MHT, S44MHT, S45MHT, S46MHT, S47MHT, S48MHT, S50MHT, S51MHT, S52MHT, S53MHT, S54MHT, S55MHT, S56MHT, S57MHT, S58MHT, S59MHT, S60MHT, S61MHT, S62MHT, S63MHT, S64MHT, S65MHT, S66MHT). This has the potential to affect all staff and patients. Findings:

Review of a sample of the personnel records of MHT's employed by the hospital revealed a lack of training in Restraint/Seclusion. The sample of MHT's was expanded to include all MHT's employed by the facility and data was extracted from all files.

Review of the data from all 38 MHT personnel records revealed 35 of 38 MHT's employed by St. James Behavioral Health Hospital had no documented evidence of any Restraint/Seclusion training.

In an interview on 08/09/11 at 9:10 a.m. S2DON confirmed the hospital has not conducted Restraint/Seclusion training for employees.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0208
Based on record review and interview the hospital failed to ensure staff was trained in and able to perform return demonstration in the safe use of Restraint/Seclusion as evidenced by 35 of 38 MHT's employed by the hospital having no documented evidence of Restraint/Seclusion training at any time during their employment (S6MHT, S9MHT, S10MHT, S11MHT, S13MHT, S20MHT, S21MHT, S25MHT, S27MHT, S34MHT, S37MHT, S41MHT, S43MHT, S44MHT, S45MHT, S46MHT, S47MHT, S48MHT, S50MHT, S51MHT, S52MHT, S53MHT, S54MHT, S55MHT, S56MHT, S57MHT, S58MHT, S59MHT, S60MHT, S61MHT, S62MHT, S63MHT, S64MHT, S65MHT, S66MHT). This has the potential to affect all staff and patients. Findings:

Review of a sample of the personnel records of MHT's employed by the hospital revealed a lack of training in Restraint/Seclusion. The sample of MHT's was expanded to include all MHT's employed by the facility and data was extracted from all files.

Review of the data from all 38 MHT personnel records revealed 35 of 38 MHT's employed by St. James Behavioral Health Hospital had no documented evidence of any Restraint/Seclusion training.

In an interview on 08/09/11 at 9:10 a.m. S2DON confirmed the hospital has not conducted Restraint/Seclusion training for employees.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record reviews and staff interviews the hospital failed to ensure patient's plan of care was kept current for 7 of 20 sampled patients (#1, #2, #5, #10, #11, #12, #13). Findings:

Patient #1:
The medical record for #1 was reviewed. Further review revealed the patient was admitted on [DATE] with diagnoses that included Depressive Disorder.

Review of the "Incident Log" for June of 2011 revealed Patient #1 had inappropriate behavior with Patient #2 on 02/04/11. Further review revealed the "Patient/Visitor Incident Report Form" dated 02/4/11 at 7:50 am (0750) read, "...at 0750 (7:50 am) S32MHT (named) reported to me (S26RN) that she was checking all the rooms to make sure all the patients were out & (and) ready to start group. She opened the door to Patient #2's (named) room & saw #2 (named) standing at the side of the bed & he (#2) was facing the door. She said Patient #1 (named) was on the bed & had her legs up on his (Patient #2 ' s) shoulders ..." .

Review of the Treatment Plan for Patient #1 revealed no documented evidence the Plan of Care addressed the patient's inappropriate behavior with Patient #2 on 02/04/11 as per policy.

In a face-to-face interview held on 08/09/11 at 2:30 pm, S2DON verified Patient #1's treatment plan should have been revised/updated with the patient ' s inappropriate behavior with Patient #2 on 02/04/11 as per policy.

Patient #2:
The medical record for #2 was reviewed. Further review revealed the patient was admitted on [DATE] with diagnoses that included Depressive Disorder.

Review of the "Progress Notes" revealed the patient had a toothache with gingivitis documented on the dictated on 02/03/11 and 02/04/11. Further review revealed the "Progress Notes" dated 02/05/11 read, " ...Tooth abscess ...".

The "Nursing Progress Notes" dated 02/03/11 at 9:00 pm (2100) read in part, "...continues to c/o (complain of) pain in ? (right) tooth ...". On 02/04/11 at 9:00 pm, the Nursing Progress Notes read, "c/o toothache".

The "Incident Log" for June of 2011 revealed documentation on 02/04/11 Patient #2 had inappropriate behavior with Patient #1. Further review revealed the "Patient/Visitor Incident Report Form" dated 02/4/11 at 7:50 am (0750) read, "...at 0750 (7:50 am) S32MHT (named) reported to me (S26RN) that she was checking all the rooms to make sure all the patients were out & (and) ready to start group. She opened the door to Patient #2's (named) room & saw #2 (named) standing at the side of the bed & he (#2) was facing the door. She said Patient #1 (named) was on the bed & had her legs up on his (Patient #2's) shoulders...".

Review of the Treatment Plan for the patient (#2) revealed no documented evidence the Plan of Care addressed the patient's toothache with gingivitis documented on 02/03/11 and 02/04/11 or tooth abscess on 02/05/11 as per policy. Further review revealed there was no documented evidence the patient's (#2's) Plan of Care was revised/updated with #2's inappropriate behavior with Patient #1 on 02/04/11 as per policy.

In a face-to-face interview held on 08/10/11 at 10:30 am, S2DON verified Patient #2's treatment plan should have included the patient ' s toothache with gingivitis on 02/03/11 and 02/04/11 and tooth abscess on 02/05/11 as per policy. The DON confirmed there was no documented evidence the patient's (#2's) Plan of Care was revised/updated with #2's inappropriate behavior with Patient #1 on 02/04/11 as per policy.

Patient #5:
The medical record for Patient #5 was reviewed. Review revealed the patient was admitted on [DATE] with diagnoses that included Bipolar Disorder. Further review of Patient #5's Nursing documentation dated 7/24/2011 at 9:30 a.m. revealed in part, "she (#5) said she (#5) held back telling the whole truth when she (#5) had reported male MHT (Mental Health Tech/no identity revealed) had come in while she (#5) was showering to bring her (#5) a razor. She (#5) reported he (unidentified black male Mental Health Tech) had a razor in one hand and he was masturbating (with) the other hand. She (#5) said he (MHT) bent her over (and) put his (MHT) hand over her mouth so she (#5) couldn't scream. She (#5) said he (MHT) then penetrated her (#5) vaginally (and) actually climaxed inside her (#5) vagina. She (#5) said she (#5) did not tell anyone because he (MHT) told her (#5) he (MHT) would kill her (#5) and she (#5) said she felt ashamed..." Review of Patient #5's Treatment Plan revealed no documented revisions to to the Plan of Care that addressed the safety needs of Patient #5 who alleged being raped in the hospital by hospital staff.

This finding was confirmed by Clinical Coordinator S3 on 8/09/2011 at 1300 (1:00 p.m.) who indicated Patient #5's treatment plan should have included safety interventions after an alleged rape.

Patient #10:
The medical record for Patient #10 was reviewed. Review revealed the patient was admitted on [DATE] with diagnoses that included Chronic Paranoid Schizophrenia with acute exacerbation. Review of Patient #10's Physician's Emergency Certificate dated 7/22/2011 at 0520 (5:20 a.m.) revealed "40 y/o (year old) wm (white male) (with) hs (history) of bipolar schizophrenia presents (after) suicidal attempt of trying to cut wrist. Pt. also (with) substance abuse problems. . . +AH (auditory hallucinations), L (left) wrist )(with) superficial laceration 4 cm (centimeters). . ." Further review of Patient #10's Psychiatric Evaluation dated 7/23/2011 (no documented time) revealed in part, "Chief Complaint: 'I am very depressed, I want to hurt myself'.'" Review of Patient #10's admission orders dated 7/22/2011 at 1950 (7:50 p.m.) revealed in part, "Suicide Precautions". Review of Patient #10's Initial RN (Registered Nurse) assessment dated [DATE] at 1950 (7:50 p.m.) revealed in part, "Skin: Lt. (left) wrist sutures from cutting". Review of Patient #10's nursing documentation dated 7/23/2011 at 1550 (3:50 p.m.) revealed in part, "summoned to patient's room and found pt. (patient) sitting on bed bleeding from Lt. (left) wrist wound. Noted he was holding pressure to wound (with) a blue cloth. noted a large amount of blood droplets on floor (with) a blue cloth. Noted a large amount of blood droplets on floor (with) a spray of blood on wall. attempted to approach pt. to provide care but unable to do so as pt. growled "don't come near me. 911 called (ambulance and police). . . 1815 (6:15 p.m.) pt received back on the unit (and) escorted to an observation room by (Director of Nursing S2)."

Review of Patient #10's Multidisciplinary Integrated Treatment Plan revealed no documented evidence of identifying the patient's wrist wound as a problem. Treatment Plan review revealed no documented goals, objectives, interventions, responsible party, or frequency of interventions regarding Patient #10's wrist wound. Further review revealed no documented evidence that Patient #10's Treatment Plan was updated after an active attempt in the hospital at self harm on 7/23/2011.

During a face to face interview on 8/09/2011 at 8:00 a.m., Registered Nurse (RN) S26 indicated that she (S26) had not updated Patient #10's Treatment Plan after the patient (S26) had actively reopened a cut to his wrist on 7/23/2011. RN S26 confirmed there was no documentation in the entire Treatment Plan regarding a wound to the patient's wrist as a problem.

During a face to face interview on 8/11/2011 at 9:10 a.m., Medical Director S5 indicated he would have liked to have seen that a higher level of observation had been implemented for Patient #10 after he exhibited behavior that resulted in self harm in the hospital. S5 indicated the treatment plan for Patient #10 should have been revised.

Patient #11:
Review of Patient #11's medical record revealed the patient was admitted to the hospital with diagnoses that included Schizoaffective Disorder under a Physician Emergency Certificate dated 7/15/2011 at 7:00 a.m. with findings which included "presents to ED (emergency department) c/o (complaining of) homicidal ideation. states he has gun and will shoot (name of intended victim) whom he believes killed his younger brother. . ." Further review revealed Nursing documentation dated 7/17/2011 at 1930 (7:30 p.m.) "pt (patient) went into the female's shower room (and) took his shower, been making sexual remarks about one of the female pts (patients), he heard her say she was going to shower but one of the other pts walked in on him (no ID # of female patient listed)"

Patient #17: Review of Patient #17's medical record revealed the patient was admitted on [DATE] with diagnoses that included Major Depressive Disorder. Review of Physician Assistant (S38) documentation dated 7/25/2011 at 1100 (p.m.) revealed in part, "Pt (patient) is a little worried, a male peer is obsessed (with) her (and) has been watching her closely".

In a face to face interview on 8/10/2011 at 8:00 a.m., Registered Nurse S18 indicated she had been present of the night that Patient #11 had been found in the female shower room. S18 indicated Patient #11 had been "interested" in Patient #17. S18 indicated Patient #11 had overheard Patient #17 saying that she was going to shower. S18 indicated Patient #11 had sneaked into the female shower room and disrobed awaiting the arrival of Patient #17. S18 indicated another female patient opened the door to the shower, saw Patient #11 and then screamed out. S18 indicated Patient #11 was removed from the shower. S18 indicated patient #11 and #17 had been located in rooms next to one another prior to the shower incident and after the incident their room assignments had been changed to keep them on opposite sides of the hall. S18 indicated she (S18) had not revised either of the patients' treatment plan to ensure interventions were put in place to ensure the safety of Patient #17 from Patient #11.

During a face to face interview on 8/11/2011 at 9:10 a.m., Medical Director S5 indicated he had never been informed of the incident in the shower room with Patient #11 who had planned an uninvited encounter with Patient #17. S5 indicated there should have been a plan put in place to ensure all staff across all shifts implemented measures to protect Patient #17 from Patient #11.

Patient #12:
The medical record for #12 was reviewed. Further review revealed the patient was admitted on [DATE] with diagnoses that included Depressive Disorder and Suicidal Attempts. Review of Physician's orders dated 08/03/11 at 2020 8:20 pm) revealed, "Precautions: SP (suicidal precaution)". Review of the Treatment Plan for the patient (#12) revealed no documented evidence the Plan of Care addressed the patient ' s admission diagnosis of depressive disorder and/or suicidal attempts. Further review revealed there was no documented evidence the patient's (#12's) Plan of Care was revised/updated with the interventions implemented by the staff to follow the physician's order for suicidal precaution monitoring every 15 minutes upon admission.

This finding was confirmed by S2DON on 08/09/2011 from 4:30 pm to 4:45 pm, who indicated Patient #12's treatment plan should have included the admitting diagnosis of depressive disorder and suicidal attempt with interventions implemented by the staff to monitor the patient's suicidal precaution every 15 minutes.

Patient #13:
The medical record for the patient (#13) was reviewed. Further review revealed the patient was admitted on [DATE] with diagnoses that included Major Depressive Disorder, NIDDM (non-insulin-dependent diabetes mellitus), Hypertension, Gastrointestinal reflux, Seizure Disorder, and Chronic Kidney Disease. Review of Physician's admission orders dated 08/09/11 at 5:15 pm (1715) revealed, "Precautions: SP (suicidal precaution), CO X 24 hrs then Obs q 30 (close observation for 24 hours then observe every 30 minutes)". Review of the Treatment Plan for Patient #13 revealed no documented evidence the Plan of Care addressed the patient's admission diagnosis of Major Depressive Disorder, NIDDM, Hypertension, Gastrointestinal reflux, Seizure Disorder, and/or Chronic Kidney Disease. Further review revealed there was no documented evidence the patient's (#13's) Plan of Care was revised/updated with the interventions implemented by the staff to follow for monitoring the patient's Major Depressive Disorder, NIDDM, Hypertension, Gastrointestinal reflux, Seizure Disorder, Chronic Kidney Disease, and/or suicidal precaution monitoring upon admission.

During interviews held on 08/10/11 at 8:25 am and on 08/10/11 at 8:45 am, at 8:55 am, and at 11:05 am, S2DON verified the patient's (#13's) treatment plan should have included the admitting diagnosis of Major Depressive Disorder, NIDDM, Hypertension, Gastrointestinal reflux, Seizure Disorder, and Chronic Kidney Disease with interventions to monitor these diagnosis as per policy.

Review of the hospital policy titled, "Treatment Plans, #1.37, Originated June 2006" revealed in part, "An initial Care Plan/Problem List is developed within 24 hours of admission. Appropriate therapeutic efforts shall begin based on Initial Care Plan/Problem List. The Initial Care Plan/Problem List will establish goals and interventions that address problems noted on the referral information and admission interviews. The Master Treatment Plan will be developed by the seventh day of treatment by the multi-disciplinary treatment team. . . The Master Treatment Plan shall be clearly linked to the assessment process. . . The Master Treatment Plan shall be clearly linked to the assessment process. It shall c. Include a problem list which reflects the patient's weakness clinical needs f. Include measurable objectives which are related to the goals and describe specific behaviors or results to be achieved g. Include interventions which are services, activities and programs addressing the patient's problems, h. Specify the frequency of treatment procedures and staff assigned to perform them l. Consider specific treatment needs as related to age and disability o. Include any test results, medical conditions, medical treatment, rehabilitative service, diet limitations, significant lab findings and medications. . ."
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on record review and interview the hospital failed to ensure staff had annual TB (Tuberculosis) surveillance in accordance with CDC (Centers for Disease Control) as evidenced by 7 of 7 records reviewed having no documented evidence TB skin tests were read within the 48 - 72 hour guideline from the CDC (S2DON, S11MHT, S12LPN, S14RN, S17LPN, S19LPN and S13MHT). Findings:

Review of a "St. James Psychiatric Hospital Tuberculosis Screening Program" document for S11MHT, S2DON, S14RN, and S12LPN revealed there were no documented time of administration or time read for the TB skin test.

Review of a "St. James Psychiatric Hospital Tuberculosis Screening Program" document for S17LPN revealed the TB skin test was placed on 03/10/11 at 0200 (2:00 a.m.) and read on 03/11/11 at 1000 (10:00 a.m.). The TB skin test is documented as being read 32 hours after administration.

Review of a document presented for S19LPN revealed the document was from another hospital and had no indication of when the TB skin test was administered and/or read.

The hospital could provide no documented evidence of a TB skin test for S13MHT.

In an interview on 08/11/11 at 12:10 p.m. with S3Clinical Coordinator and ICP (Infection Control Practitioner) she confirmed that 7 of 7 TB skin tests were not in compliance with CDC guidelines.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record reviews and staff interviews, the hospital failed to ensure all medications were administered according to physician's orders as per policy as evidenced by medication not administered as ordered by the physician for 2 of 20 sampled records reviewed, (#13, #20). Findings:

Patient #13:
The medical record for the patient (#13) was reviewed. Further review revealed the patient was admitted on [DATE] with diagnoses that included Major Depressive Disorder, NIDDM (non-insulin-dependent diabetes mellitus), Hypertension, Gastrointestinal reflux, Seizure Disorder, and Chronic Kidney Disease. Review of Physician's admission orders dated 08/09/11 at 5:15pm (1715) revealed, Amitriptyline anxiety 25mg (milligrams) hs (at night), Dilantin seizure 100mg tid (three times a day) was ordered on the " Medication Reconcilitation " list.

Review of the Medication Administration Records (MAR) revealed the medication administration time of 8:00pm (2100) was left blank for the Amitriptyline and Dilantin medication administration times on 08/09/11.

During an interview on 08/10/11 at 8:25am, S2DON verified Patient #13 was not administered the Amitriptyline or Dilantin medications as ordered on [DATE] at 9:00pm. S2 indicated Patient #13 had two (2) missed medication administrations/medication errors for Amitriptyline and Dilantin. Further S2DON indicated there were no incident reports for Patient #13 ' s two (2) missed medication administrations/medication errors on 08/09/11. S2DON stated there should be 2 incident reports completed prior to the nurse departing the night shift on 08/09/11 for the missed medication administrations/medication errors for Patient #13 ' s Amitriptyline and Dilantin as per policy.

In an interview on 08/10/11 at 9:50am, S4LPN indicated she picked up all incident reports (medication variance reports) from the locked box located in the nurses station at about 8:30am this morning. S4LPN stated that as of today, 08/10/11 there were no medication variance (incident) reports received for the 2 missed medication administrations/medication errors for Patient #13 on 08/09/11. S4LPN indicated the medication variance reports (incident report) must be completed for all medication errors as soon as possible as per policy.
Patient #20:
Review of the medical record for #20 revealed she was admitted on [DATE] at 8:15pm (2015) with the admitting diagnosis of bipolar disorder. Further review revealed the "Admission Orders" dated/timed 08/05/11 at 8:15pm revealed a " Medication Reconciliation " List read,
" ...Elavil (at night) antidepressant 50mg (milligrams) (at night) daily,
Hydrocodone-APAP QID (four times a day) back pain 500/10mgs PRN (as needed and)
Lorazepam anxiety 1mg daily ... " .
Review of the Medication Administration Records (MAR) read in part, " ...Elavil 50mg PO (oral) daily (,) Lorazepam 1mg po BID (two times a day)(, and) Hydrocodone-APAP 10/500mg PO QID PRN pain ... " . Further review revealed the MAR dated 08/05/11 revealed the administration time of 9:00pm (2100) was left blank for the Elavil medication indicating Patient #20 was not administered the medication as ordered by the physician. S24RN transcribed the physician ' s medication order for Elavil medication to be administered to the patient (#20) daily instead of at night on the MARs dated 08/06/11 through 08/10/11. The Elavil medication was administered to Patient #20 in the morning (at 9:00am) instead of as ordered by the physician at night five (5) doses from 08/06/11 to 08/10/11. Patient #20 had six (6) missed medication administrations/medication errors of Elavil. Further review revealed the Lorazepam medication was transcribed on the MAR by S24RN to be administered BID (two times a day) on Patient #20 ' s MAR dated 08/05/11. The Lorazepam medication administration time was left blank at 9:00pm (2100) on 08/05/11. Patient #20 had one (1) missed medication administration or medication error of Lorazepam pain medication. Further review revealed the Hydrocodone-APAP medication was transcribed by S24RN as QID PRN pain on Patient #20 ' s MARs from 08/05/11 through 08/10/11. The Hydrocodone medication was ordered for Patient #20 to be administered the pain medication QID (four times a day) and prn (as needed). Patient #20 had seventeen (17) missed medication administrations/medication errors of the pain medciation, Hydrocodone-APAP.
Patient #20 had a total of twenty-four (24) missed medication administrations/medication errors from 08/05/11 through 08/10/11.
During a face-to-face interview on 08/10/11 at 10:20am and at 10:45am, S2DON confirmed Patient #20 had a total of 6 missed medication administrations/medication errors of Elavil, 1 missed medication administration/medication error of Lorazepam, and 17 missed medication administrations/medication errors of Hydrocodone-APAP. The DON verified Patient #20 had a total of 24 missed medication administrations/medication errors from 08/05/11 through 08/10/11. S2DON indicated there was no medication variance reports (incident reports) completed for the 24 missed medication administrations/medication errors for Patient #20 from 08/05/11 to 08/1011 as per policy. S2 stated all missed medication administrations/medication errors must have an incident report filled out and put in the locked box in the nurses station prior to leaving that shift.
In an interview held on 08/10/11 at 9:50am, S4LPN indicated she picked up all incident reports (medication variance reports) from the locked box located in the nurses station at about 8:30am every morning except for the weekends, she picks up the reports that following Monday morning. S4LPN stated that as of today, 08/10/11 there were no medication variance (incident) reports received for the 24 missed medication administrations/medication errors for Patient #20 from 08/05/11 through 08/10/11. S4LPN indicated the medication variance reports (incident report) must b as per policy.
Review of the policy titled, " Occurrence Reports " , Policy 8.6, Originated date of June of 2006, with no revised or reviewed date(s), presented as the hospital ' s current " Incident Report " policy, indicated it was the policy of the hospital to document on a Hospital Occurrence Report (HOR) the occurrence of any unusual or extraordinary event. The purpose of the policy was to maintain a record of unusual occurrences and provide a mechanism for monitoring and minimizing risk in the Hospital. Occurrences for which a HOR should be completed include, but are not limited to, the following (if doubt remains, the HOR should be completed): Medication Error omissions, wrong medication administered, incorrect dose administered, or transcription error.
Review of the policy titled, "Medication Administration", Policy 12.14, Originated date of June 2006, Reviewed date of October 2010, with no revised date, presented to the surveyors as the current " Medication Administration " policy revealed in part, "...The nurse administering the medications must understand the drug, usage, action, method of administration and danger involved. A nurse should never allow herself to give a drug when in doubt ...A. No medication should be given without the doctor ' s order ...B. Each dose of medicine to be administered must be considered as offering an opportunity for a potential medication error ...C. Never give a medication about which you have a shadow of a doubt ...E. Observe the " five rights " in giving medications: The right patient, the right medicine, the right time, the right dose, and the right method of administration...N. Medications are to be given and charted using the Medex System by the nurse ...T. Information on the Medex is to include:
1. Patient ' s name and room number
2. Name and dosage of medications to be administered
3. Modes of administration
4. Frequency
5. Hours of administration
6. Date and nurses ' initial on back of card ...
Steps in Clarifying an Order ...
1. Call the doctor who wrote the order when in doubt about any of the order.
2. Do not try to interpret:
a. Illegible handwriting
b. Incomplete orders
3. Do not consult another doctor.
4. Do not give any medication ...until an order is understood ...
6. If it is necessary to take an order over the telephone, read back the complete order back to the
Doctor... " .
The policy titled, "Administration of Medications Using the MAR System", Policy 12.2, Originated date of June 2006, Reviewed date of January 2010, Revised date of January 2011, presented to the surveyors as the current one in use, revealed in part, "...1. The Medication Record is referred to as the MAR ...2. It is divided into 4 sections: Routine orders, PRN orders, One time order section (and) Nurse signature record ...3. Charting is done immediately after the medication is given by initialing the appropriate square on the MAR ...5. The unit secretary may complete the top portion and bottom portion of the MAR with the patient information. The nurse is to complete the other sections of the form ...6. Complete the bottom and top of the form when the patient is admitted . The diagnosis is placed in the lower left hand corner ...7. Transcribing Orders: Schedule medications are listed in the routine medication column. Print the medication ordered in black ink ...Steps in Transcribing Orders:
a. Insert the order date in the left hand column.
b. Enter the date and time of expiration in the expiration date column.
c. Fill in the medication column as necessary. All medication entries must be legible.
d. In the hour column, vertically list the hours the medication is to be given ...
e. Predate the MAR for the total number of days ...
9. After medications are given, the nurse initials the square across from the hour and below the date ...10. If the medication is omitted for any reason, the nurse should circle the time the medication should have been given. The nurse must document the reason medication was not given on the back of the MAR ...11. If the medication is changed in any way, draw a line thru the medication order and write " D/C " , the date and your initials. Color over it with a yellow highlighter. Do not use the highlighter alone, as it is not permanent. All medications are to be discontinued in the same manner. Transcribing errors are to be treated the same as discontinued medications but instead of writing " D/C " print " void " or " error " , the date and initials ...14. When medication is ordered in a specific number of doses, the transcriber numbers the squares for each dose and place a X in the squares following the last dose due. It is important to remember that the nurse who administers the last dose of medication is responsible for canceling the order ...15. Any drug ordered on a daily basis ...may be recorded in the routine order section, ...18. PRN Medications:
a. The PRN section is located on the PRN med sheet. All PRN medications are to be recorded in this section.
b. Enter the order date and your initials in the first column. Enter the expiration date and time in the next column. Then, ...transcribe the medication, dosage frequency of administration. Comments for the reason for the PRN should be written ...ex. Pain, ...etc.).
c. Record the date, time, site and your initials next to the medication in the 4 vertical lines provided when a medication is given ...22. To ensure complete accuracy, once every 24 hours the MAR should be checked against the doctor ' s orders ...25. Blank spaces on the MAR indicate a medication error; therefore, each nurse should check the forms before going off duty to make sure all squares are properly initialed ...26. No blanks are to be left when transcribing orders ...27. Remember to record all medication ...omissions, and PRNs in the nurses ' notes as well as the MAR ...28. Remember to document the effectiveness of the PRN medications in the nurses ' notes and on the back of the MAR ... " .

The policy titled, " National Pharmacy Acquisition, LLC " , Attachment(s) NPA Incident/Occurrence Investigative Report, Policy: 3.18, Issued date of 4/16/07, Revised date(s): 08/18/08, 01/09/09, 08/21/09, 09/21/10, with no reviewed date, presented as the hospital ' s current " Medication Error " policy for Pharmacy, was reviewed. The purpose of the policy indicated was to identify, monitor, and improve medication errors which could cause potential risks for facilities and patients through a planned systemic process. All actual or potential medication errors will be reported in writing to the Pharmacy Manager or Pharmacist in Charge for a complete review, investigation, adverse outcome, and plan of action response. Quarterly reviews are conducted for trends and outcomes. Any potential medication errors will be reported per phone immediately and in writing to the Pharmacy Manager or Pharmacist in Charge within 48 hours. The following information will be required:
1. Date of error
2. Time of error
3. Name of Patient
4. Medication Error specifics:
a. wrong medication
b. wrong dose
c. wrong time
d. wrong route
e. wrong patient
5. Patient response to medication error
6. Patient physician contacted (immediately on discovery of error)
7. Description of medication error (narrative of the medication error)
8. Person(s) involved
9. Person completing report
10. Condition of patient
11. A complete Investigative report/outcome assessment/plan of action response/and follow will
be completed by Compliance Officer
12. Medication Error / Incident Reports will be reviewed quarterly for trends and cause analysis
will be done quarterly by provider Pharmacy
13. Provider will implement improvements in the process to prevent or reduce medication errors
in the future
14. Continual review processes to reduce and/or detect potential errors will be monitored.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review, video review, and interview the Registered Nurse (RN) failed to supervise the care of each patient as evidence by:

1) failing to ensure the bath/shower room was monitored to ensure the safety of all psychiatric patients admitted to the hospital for 2 of 20 sampled patients (#5, #17)

2) failing to ensure psychiatric patients were observed as per hospital protocol and/or orders by the patients physician for 6 of 20 sampled patients (#3, #4, #7, #11, #12, #17), 6 random sampled patients (R5, R12, R13, R14, R15,R16) and two unidentified patients in the Laundry/Linen Room.

3) failing to ensure a Registered Nurse performed an assessment on patients every 24 hours as per hospital policy for 2 of 12 days reviewed for Patient #5 (7/19/2011 and 7/22/2011).
Findings:


1)
On 8/05/11 at 8:30 a.m. an observation was made with S1Administrator that the Female shower room door was not closed and locked, allowing access to the empty female shower room.

Face to face interviews were conducted with RN S24 on 8/08/2011 at 1450 (2:50 p.m.), Mental Health Tech (MHT) S25 on 8/08/2011 at 1520 (3:20 p.m.) , Licensed Practical Nurse (LPN) S30 on 8/09/2011 at 1230 (12:30 p.m.), Administrator S1, Director of Nursing S2, and Clinical Coordinator S3 on 8/09/2011 at 1300 (1:00 p.m.). All interviewed indicated the bath/shower room was to be locked at all times unless staff were monitoring patients during bath/shower time.

Patient #5:
Review of Patient #5's medical record revealed the patient was admitted on [DATE] with diagnoses that included Bipolar Disorder.

Review of Patient #5's Progress notes dated 7/22/2011 at 1530 (3:30 p.m.) by Physician Assistant S36 revealed in part, "reports tech (male) came into shower while she (#5) was there. Administration investigating."

Review of a handwritten letter by Patient #5 dated 7/24/2011 with no documented time revealed in part, "I (Patient #5) am reporting on about July 19 or 20th during the evening shower, I had asking for a razor. The tech told me she did not have time because she needing to stay in while I shave, I told her that was no problem, she gave me my towels. I waited about 10 minute, and decided to go ahead and shower. The Tech was a short white female, very sweet to all patient, she was just really busy. I understood. While I was in the shower, I was washing my hair a face, had my eyes closed due to the soap, after washing out the soap, when I opened my eyes, There was a dark skin black male with a slim trimmed Beard was standing with one hand out with a razor (and) cream, the other was holding his private part, he told me to touch it. I turned and said get out of here. when I turned, he grabbed me from behind, put his hand over my face and mouth and put his private in my vagina from behind. I couldn't over power him so he continued until his climax. I would like a blood test ASAP (as soon as possible) to check for possible STD (Sexually Transmitted Diseases). When he got through he quickie (as written) got to the door and said you better not tell, I will kill you. I've been afraid to tell and I've held in it and I can't keep in bottle up any longer. I will take polygraph test what ever it take."

Review of Patient #5's Nursing Documentation dated 7/24/2011 at 0930 (9:30 a.m.) revealed "observed pt (patient) crying in the hall (and) both (Licensed Practical Nurse S30) and I (Registered Nurse S26) approached her (#5) to find out why. She (#5) said she (#5) held back telling the whole truth when she had reported a male MHT (Mental Health Tech) had come in while she was showering to bring her a razor. She (#5) reported the (unidentified Mental Health Tech) had a razor in one had (and) he (unidentified MHT) was masturbating (with) the other hand. She (#5) said he (unidentified MHT) bent her (#5) over (and) put his hand over her (#5) mouth so she couldn't scream. She (#5) said he (unidentified MHT) then penetrated her vaginally (and) actually climaxed inside her vagina. She said she did not tell anyone because he (unidentified MHT) told her he would kill her and she (#5) said she felt ashamed because of wearing too tight jeans. She (#5) reported she is not sure of the dates (19th, 20th, or 21st). I (RNS26) instructed her (#5) that I (S26) would notify the doctors and administration and perform an investigation (Physician S31, Physician S39, and Administrator S1) notified. Investigation begun."

The hospital had video surveillance with views of patient care hallways, common areas, and two acute patient care rooms.

Video Surveillance for the evening of 7/19/2011 was reviewed. Observations of video surveillance revealed Patient #5 entered the female shower room at 2101 (9:01 p.m.) and exited at 2127 (9:27 p.m.). Review further revealed MHT (Mental Health Tech) S9 entered the female shower room two times on 7/19/2011 from 21:02:30 (9:02:30 p.m.) - 21:02:37 (9:02:37 p.m.) and again from 21:05:05 (9:05:05 p.m.) - 21:06:36 (9:06:36 p.m.) while Patient #5 was in the female shower/bathroom. Review of video surveillance revealed Mental Health Tech S25 (assigned to the care of Patient #5) was seen repeatedly entering and exiting the Laundry Room with Laundry baskets in hand from 7/19/2011 at 2053 (8:53 p.m.) until 2118 (9:18 p.m.).

During a face to face interview on 8/08/2011 at 1520 (3:20 p.m.), S25 confirmed she (S25) had been assigned to the care of Patient #5 on the 7 p.m. - 7 a.m. shift for 7/19/2011. S25 indicated that any date/time that she entered information on the Observation Form for a patient indicated that she had visually observed the patient. S25 had no explanation as to how she had entered visualizing Patient #5 in the TV room when video surveillance indicated the patient had been in the female shower room on the night of 7/19/2011.

Review of Patient #5's Observation Form dated 7/19/2011 completed by Mental Health Tech (MHT) S25 revealed Patient #5 was documented as receiving medication at 2109, as located in the TV room at 2115 (9:15 p.m.), and smoking at 2130 (9:30 p.m.) when video surveillance revealed Patient #5 was in the female shower room from 9:01 p.m. until 9:27 p.m.

During a face to face interview on 8/09/2011 at 8:00 a.m., Registered Nurse S26 indicated male staff were to observe/assist male patients in the shower room when using a razor and female staff were to observe/assist female patients in the shower room when using a razor. S26 indicated there should never be a time when opposite gender staff entered the bathroom to monitor opposite gender patients shave.

Patient #17:
Review of Patient #11's medical record revealed the patient (#11) was admitted on [DATE] with diagnoses that included Schizoaffective Disorder by history. Review of Patient #11's Physician Emergency Certificate (from the sending hospital) dated 7/15/2011 at 7:00 a.m. revealed in part, "Findings of Examination: 27 y/o (year old) male presents to ED (Emergency Department) C/O (complains of) homicidal ideation. states he (#11) has gun and will shoot (name of intended victim) who he (#11) believes killed his younger brother. Review of Patient #11's Nursing documentation dated 7/17/2011 at 1930 (7:30 p.m.) revealed "pt (patient) went into the females shower room (and) took his shower, been making sexual remarks about one of the female pts (patients/no ID (identification) number for the female patient ), he (#11) heard her (no ID number for the female patient) say she (no ID number for the female patient) was going to shower but one of the other pts (patients/no ID number for this patient) walked in on him."

During a face to face interview on 8/10/2011 at 8:00 a.m., Registered Nurse S18 indicated Patient #11 had gone into the female shower room with plans to encounter a young female patient (#17) that he (#11) had been "interested" in. S18 indicated S11 had heard the female patient (#17) state that she (#17) was about to shower. S11 indicated another female patient (didn't recall name of this patient) had opened the door to the shower and screamed when she (didn't recall name of this patient) saw a male in the shower room. S11 indicated the shower rooms should have been locked where no patient had access unless there had been a Mental Health Tech monitoring shower activity. S11 indicated she (S11) did not know how Patient #11 had managed to enter the female's shower and it should not have been possible if staff had been performing their duties properly. S11 indicated Patient #11 was a rather large man (6 feet 2 inches and 287 pounds/ [AGE]) and Patient #17 (intended victim) had been a small girl (5 feet 5 inches and 123 pounds/ [AGE]). S11 indicated she (S11) had not completed an Incident/Occurrence form, had not informed the patients' physician, and had not informed administration of the incident. S11 indicated the patients (#11 and #17) were moved to rooms at opposite ends of the hall. S11 indicated she (S11) had not updated to two patients' (#11, #17) treatment plans to ensure safety interventions were put in place across all shifts by all staff to protect Patient #17 from Patient #11. S11 indicated she (S11) should have completed an Incident/Occurrence form after the incident occurred.

Review of Patient #17's (intended victim) medical record revealed the patient was admitted on [DATE] with diagnoses that included Major Depressive Disorder. Review of Patient #17's Physician Assistant orders dated 7/17/2011 at 11:00 (p.m.) revealed in part, "Pt (patient) is a little worried, a male peer is obsessed (with) her (and) has been watching her closely."

June 2006 Policy titled Patient Hygiene Showers/Baths 3.15 was reviewed. Review revealed "Policy: The shower room is located on the unit and contains one shower and one bath tub. . . Patients (male/female) are scheduled for showers/baths. Assisted showers/baths are a requirement of the facility. The MHT (Mental Health Tech) will unlock the shower room door and accompany the patient until the shower is completed and the patient is back in his/her room. The door to the shower area will remain locked at all times when the patients are not using the area. Under no circumstances are patients allowed to be unattended in the shower area."

During a face to face interview on 8/09/2011 at 1300 (1:00 p.m.), Administrator S1, Director of Nursing S2, and Clinical Coordinator S3 indicated they (S1, S2, S3) had no knowledge of the incident that had occurred when Patient #11 had executed a plan to encounter Patient #17 in the female shower room. S1, S2, and S3 indicated there should never have been an opportunity for Patient #11 to enter the female shower room in an attempt to make contact with Patient #17 had the showers been properly monitored.

2)

Patient #3:
The "Incident Log" for June 2011 read, "...1:1 ordered (with no staff on) 06/26/11 ..." for Patient #3.
Review of the medical record revealed the patient (#3) was admitted on [DATE] at 1715 (5:15 pm) with the diagnosis of Schizophrenia, BiPolar and other medical diagnosis. Further review revealed Patient #3 was discharged on [DATE] at 10:00 am. Review of the "Physicians Orders" read back telephone order (RBTO) dated/timed 06/26/11 at 1930 (7:30 pm) read in part, "...1:1 visual contact /c (with) a female MHT (mental health tech) ...".
Review of medical record for Patient #3 revealed no documented evidence an MHT was assigned to monitor the patient (#3) 1:1 visual contact during the night shift on 06/26/11 from 7:30 pm (1930) to 10:10 pm (2210) for about 2 hours and 40 minutes and/or from 3:00 am (0300) through 7:00 am (0700) for about 4 hours as ordered by the physician at 7:30 pm (1930).
The "Patient Incident/Injury" form for Patient #3 dated 06/26/11 with no documented time, read in part, "...order received (See attached) to place pt (patient) on 1:1 visual contact (VC) /c (with) a female MHT (mental health tech). But unable to staff. S2DON (named) administration notified /c (with) instructions given to allow pt to sleep in Time Out room in front of nurses station /c door kept open. Instructions passed on to oncoming charge nurse...". Further review revealed there was Physicians Orders attached to the "Patient Incident/Injury" form that read, "Patient #3 to be placed on 1:1 visual contact /c (with) a female MHT" dated/timed 06/26/11 at 1930 (7:30 pm).
Review of the "Nursing Assessment" dated/timed 06/26/11 for Patient #3 read in part, "...at 1545 (3:45 pm), a call was placed to S5MD, Medical Director's cell. At 1615 (4:15 pm), "...No answer from S5MD, Medical Director (not on call) so call placed to S36PA (named) to inform her (S36) of circumstances. Orders received to place pt on 1:1 visual contact (VC) /c (with) a female MHT. I (S26RN) called S2DON (named) to let him (S2) know as S36 (named) had stated/requested to get administration involved if staffing was an issue. Attempted to call in staff ... 1:1 VC but was unsuccessful ...". At 1800 (6:00 pm), "...I (S26RN) notified S2DON (named) I (S26) was not able to staff for 1:1 VC & he (S2DON) stated to have pt sleep in time out room /c door open (it is near nurses station) ...". Further review revealed there was no documented evidence in Patient #3's medical record that the patient was monitored by an Registered Nurse from 10:30 pm (2230) through 7:00 am (0700) on 06/26/11 for approximately 8 hours and 30 minutes.
During face-to-face interviews on 08/08/11 at 4:25 pm and on 08/09/11 at 10:00 am., S2DON verified there was no documented evidence in the medical record that Patient #3 was monitored "1:1 visual contact" by a designated MHT during the night shift from 7:30 pm (1930) through 7:00 am (0700) on 06/26/11 as ordered by the physician. S2DON indicated the Patient Observation Form used to observe patients is a true picture of what the assigned MHT observed the patient doing during that shift. S2 reported there was no Observation Form documented by an assigned MHT for Patient #3 on the night of 06/26/11 as per policy. S2DON confirmed there was no documented evidence the patient (#3) was monitored by the night shift Registered Nurse every two (2) hours as per policy. The DON reported there was no documentation of the "Staffing Assignment Sheets" for the night shift of 06/26/11 from 7:00 pm through 7:00 am of the nurse and/or MHT assigned to the patient (#3). S2DON indicated there was no documented evidence in the medical record and/or staffing assignment sheets that Patient #3 was monitored 1:1 visual contact as ordered by the physician and as per policy during the night shift of 06/26/11.
In an interview on 08/09/11 at 8:45 am, S26RN verified there was no documented evidence in the medical record of Patient #3 that an MHT monitored the patient 1:1 visual contact during the night shift from 7:00pm to 7:00am on 06/26/11 as ordered by the physician. S26 confirmed there was no documentation that a Registered Nurse supervised and evaluated the patient (#3) that same night (06/26/11) from 10:30pm through 7:00am. S26RN indicated there was no documented evidence Patient #3 was monitored 1:1 visual contact as ordered by the physician from 7:30 pm (1930) to 10:10 pm (2210) for about 2 hours and 40 minutes and/or from 3:00 am (0300) through 7:00 am (0700) for about 4 hours as ordered by the physician at 7:30 pm (1930).
Review of the policy titled, "Close Observation", Policy 8.21, Originated on June of 2006, with no revised and/or reviewed date(s) indicated Visual Contact is twenty-four (24) constant observation of the identified patient within visual sight of the staff member. 1:1 Constant Observation is 24 hour constant observation of the identified patient within arm's length of the specified staff member. Document close observation procedures in the medical record that describe the patient's behavior and status, note the level of observation and frequency of staff contact, identify patient's response, and maintenance of observation protocol until discontinued by the attending psychiatrist or their designee. The close observation orders will be evaluated daily by the RN and documented. Observation status changes require a new order from the attending psychiatrist. The Close Observation Documentation Form will be completed for the duration of the close observation period and become a part of the patient's permanent medical record.
The policy titled, "Patient Observation"; Policy 8.8; Originated date of June 2006; Reviewed date(s) of July, 2007, June 2008; Revised date(s) of [DATE], March 2011; was reviewed. The policy indicated it was hospital policy to continually monitor patients of the unit ensuring consistent and continuous surveillance of all patients routinely. The patients in the hospital are observed by staff every thirty minutes with documentation recorded on the Patient Observation Flowsheet. The "checking" task is to be assigned to a specific staff member for a given period of time; this task may be performed by all nursing staff members, but may be delegated according to unit needs.

Patient #7
Review of the medical record for Patient #7 revealed that the patient was admitted to the facility on [DATE] by a PEC/CEC(Physician Emergency Certificate/Coroner's Emergency Certificate) for polysubstance abuse, suicidal ideations, and he had a history of Schizophrenia. Review of the Initial Psychiatric Evaluation dated 07/20/11 revealed in part ... "This is a [AGE] year old married Caucasian male with a history of mood disorder and polysubstance abuse, has been admitted after he threatened to jump out of a moving a car while he was with this wife. The patient's wife reports the patient was agitated, because he has been out of his Lortab and he also has been drinking. The patient was taken to the emergency room by EMS and then sent here now to St. James Hospital for further treatment. The patient admits to a long history of polysubstance abuse. He has a history of intravenous drug administration as well. He reports he has been to various emergency room s in order to get treated in the emergency room for his pain medication. He has admitted to burning himself on the arm in order to get treated in the emergency room for his pain medications. He has also cut himself with a fishing line and shot himself with a nail gun all in hopes of getting pain medication."

Review of the St. James Behavioral Health Hospital-Patient/Visitor/Staff/Medication Error Form dated 07/24/11 revealed under the section labeled Incident, "Patient Escaped from Hospital. "Under the section labeled Description of Event revealed, "Pt (patient) noticed missing tonight out of his room by S10MHT. Window next to pt's bed has been broken open. Staff searches for patient. Pt was nowhere to be found. He was seen between the hours of 3-4:30 p.m. during visiting hours with a white female. S38PA says not to alert the family @ this time." Under the section labeled Assessment/Outcome and or Follow-up of incident/Error revealed, "The window in the patient's room had been broken open. PD called and Sgt (Sergeant) came. Copies of a picture of the pt. along with his face sheet was given to Sgt. He says the department will contact the family. Police report number was given by officer."

Review of the PD-Case Report dated and timed 07/24/11 9:57:59 revealed under the narrative section of the report, "On 07/24/11 I Sgt. responded to St. James Behavioral Hospital located at 3136 S. St. Landry Road for a 911 hang up. Upon my arrival dispatch advised they were unable to make contact with anyone at the hospital. I then hit the call button at the front door and was met by S24RN who advised they had a patient escape. S24RN advised they went to check on a patient and discovered the window in his room has been broken with an unknown type of object and the subject had escaped. S24RN advised the patient was last seen at 20:30 (8:30 p.m.) hours and advised his name was Patient #7 w/m (white/male) 06/14/83 (date of birth). She advised that Patient #7 was transported to the facility on [DATE] as a transfer from hosp."b". He is a described as a paranoid schizophrenia, suicidal, and substance abuser. S24RN advised that Patient #7 did have a female visitor during visiting hours and she left at 19:00. She advised that Patient #7 as provided an address in Addis, Louisiana and they were going to call his family and let them know he had left. I then noticed the window had a plastic plexi glass type security feature that only allows the window to go up about 4" and locks in place after that. The plastic plexi glass security feature was broken by an unknown object and the window was able to be forced up and opened all the way allowing him to make his escape. I then advised other units to B.O.L.O (be on the lookout) for Patient #7. I also had dispatch put out A B.O.L.O (be on the lookout) to APSO (Parish Sheriff Office) units. I advised S24RN to contact the police department if Patient #7 showed back up. I then left and checked the area and was unable to locate Patient #7. He was entered into N.C.I.C. (National Crime Information Computer) as a missing person and his home town Police Department was contacted to go by the residence. They advised they would check the residence as B.O.L.O. for Patient #7. They were unable to locate him."

Review of the St James Behavioral Health Hospital Multi-Disciplinary Progress Note dated 07/24/11 at 2030 revealed, "Pt noticed missing tonight out of his room. The window next to his bed had been broken open. Staff searched for patient inside and outside the hospital. Patient nowhere to be found. He was last seen by S32MHT after supper around 5:30 p.m. going to his room to lie down. He was seen during visiting hours with a white female between the hours of 3 p.m. -4:30 p.m." The next entry was timed 2100- "PD called to notify them that patient had escaped. S31MD and S38PA on the unit made aware of pt's escape. S39MD and S36PA notified. S38PA says not to alert the family at this time." The next entry on the progress note was timed 2130- "Sgt. from PD came. He was given a copy of a picture of the patient along with a face sheet. Sgt. Says his department will contact the family."

Review of the St James Behavioral Health Hospital Physician Admit Orders & Problem List dated 07/20/11 revealed an order for CO q 15" (close observation every 15 minutes).

Review of the Patient 15" &/or 30" Observation Form AM Shift dated 07/24/11 revealed he was observed every 15 minutes from 0715 to 1900. From 5:30 p.m. to 7:00 p.m. S32MHT documented he was being monitored, and he was awake and cooperative. Review of the Patient 15" &/or 30" Observation Form PM Shift dated 07/24/11, S9MHT documented every 30 minutes Patient #7 was monitored and awake until 9:45 p.m. and then was monitored and asleep from 10:15 p.m. until 5:45 a.m. At 6:15 a.m. on 07/25/11 Patient #7 was awake and monitored and fluids were offered and at 6:45 a.m. he was offered a meal/snack and he was awake and monitored. According to the nursing notes and the police report the patient was reported missing at 8:30 p.m. the evening of 07/24/2011.

Review of the Environmental Safety Report dated 07/25/11 revealed, "An environmental safety inspection of patient room #8 was conducted by hospital staff immediately upon discovering the elopement of the patient assigned to bed 8b on the evening of July 24, 2011 and again by the hospital administrator and maintenance supervisor on the morning of July 25, 2011. A short black screw driver was found under the mattress in the patient's room. The screwdriver was examined and found not to be a tool from the facility maintenance collection. The patient either snuck in the tool or had someone deliver it from the outside. It appeared that the patient planned to unscrew the framework of the plexi-glass protective covering of the window in order to open the window enough to pass his body through to the outside. Because the screwdriver was unable to turn the safety, tamper pro screws it appears that the patient was able to loosen the cover instead by pushing and pulling the frame from the bottom over a period of time. A corrective action plan was immediately initiated. Maintenance repaired the window framework and install new plexi-glass. This action was completed on the afternoon of 1." The Environmental Safety Report was signed by S1Administrator.

An interview was conducted with S24RN on 08/08/11 at 1 p.m. She stated she was the registered nurse working on the night that Patient #7 was discovered missing. Patient #7 was on every 15 minute observations. She went on to state at 8:30 p.m. S31MD was in the facility making rounds. S10MHT went to get Patient #7 for the physician to examine and he could not find the patient. S9MHT was assigned to the patient for the p.m. shift (7 p.m. to 7 a.m.) to do the every 15 minutes observations. S24RN stated she asked S9MHT if he had located all his assigned patients when he started his shift at 7 p.m. At first he stated he did, and then he changed his story. He went on to say he must have gotten the patient confused with someone else and he had not seen the patient since he came on his shift. She went on to state on 07/24/11 the day RN, S26RN was still in the facility and called S32MHT at home (the MHT who was assigned to perform the every 15 minutes observation on the a.m. shift). S32MHT stated she saw him last at 5:30 p.m. after supper and she saw him with a white female visitor earlier that afternoon. The staff started searching for Patient #7 inside and outside the facility. When the patient was not found and the window was found broken in his room, the police, the physician, and the administrator was called. When the police came to the facility to investigate, they stated they would notify the family. An incident report was completed. S24RN went on to say the patient was not volatile, but he was a danger to himself.

An interview was conducted on 08/09/11 at 2:10 p.m. with S32MHT. She stated she worked from 7a.m. to 7 p.m. on 07/24/11 and was assigned to conduct every 15 minutes observations on Patient #7. She stated she checked on him up until the end of her shift at 7 p.m. When asked why the Incident Report stated the last time she saw the patient was 5:30 p.m., S32 MHT stated she was called at home of the night of 07/24/11 at 10:30 p.m. after she had fallen asleep by the day RN, S26RN. S26RN asked her the last time she saw Patient #7. She was half asleep and "foggy" at the time the nurse questioned her, but her documentation on the Patient 15" and/& 30" Observation Form AM Shift was correct. She monitored him up to the end of her shift, 7 p.m., and he was in his room until she left her shift. S32MHT stated after dinner he went to his room and did not go out and smoke like he typically did. Earlier in the afternoon from 3 p.m. to 4:30 p.m. he had a female visitor and another MHT watched him during the visitation time. S9MHT then picked up the observation of every 15 minutes from 7 p.m. to 7a.m. When questioned if anyone in Administration ever interviewed her about when and where she last saw the patient, she stated no.

An interview was conducted with Detectives PD1 and PD2 on 08/05/11 at 1 p.m. They stated the PD was called to St. James Behavioral Health hospital on [DATE] at 9:57 p.m. when Patient #7 had eloped. They further stated they made rounds in the hospital and found that Patient #7's window was busted out. The police searched for him and was unable to find him. They notified his hometown police department to be on the lookout for him. He still has not been found.

On 08/09/11 at 9:50 a.m. S35Maintenance Tech was interviewed. He stated on 07/24/11 Patient #7 broke the plexi glass in his room, raised the window and left. On examination of the window, he stated he had to take the whole window down and repair the plexi glass and the frame for the plexi glass. He replaced the window as it was prior to the elopement of Patient #7; no alterations were made to the window and plexi glass in the window.

An interview was conducted with S38PA on 08/10/11 at 2:30 p.m. She stated she arrived at the hospital on [DATE] between 8:30 p.m. and 9:30 p.m. with the hospital in chaos. She went on to state an employee met her at the door of the facility stating, "I think someone is gone." The employees proceeded to search the hospital and found that Patient #7's window was busted out. She went on to state she has always been concerned that contraband could be introduced into the facility through the window since it was capable of being opened some. When questioned why she told the staff not to call the family immediately and tell them he was missing, she stated she was told his wife had visited him earlier during the day and she didn't want to alert the family in case the family had picked him and was taking him to his home. That way the police would have time to go to his house first before alerting the family the police were on their way. The police said they would tell the family he had eloped after driving by his home.

On 08/09/11 at 2:45 p.m. an interview was conducted with S1Administrator, S2DON, and S3 Clinical Coordinator. They stated that Patient #7 was on every 15 minutes observations the entire time he was admitted to the facility. They confirmed on the 7 p.m. to 7a.m. shift on 07/24/11, the night of the elopement, S9MHT documented every 30 minutes observations from 7 p.m. until the next morning (7/25/11) at 7 a.m., even though the patient was discovered missing on 07/24/11 at 8:30 p.m. S3Clinical Coordinator stated when she reviewed Patient #7's chart she saw where S9MHT had documented the patient was in the hospital even though he had been reported missing already. She went on to state she could not speak to S9MHT because he was under investigation for another allegation in the facility. S3Clinical Coordinator stated she did not interview S32MHT, who last saw the patient at 5:30 p.m. on 07/24/11. When questioned if she reviewed the video tapes in the hospital to assist with her investigation of the elopement, she stated she had not. She further stated they were not sure how the patient obtained the screwdriver that was found in his room after he eloped.

Review of the hospital's policy on Suicide Precaution, Policy # 8.33, given to the surveyor
as the current policy in use, revealed in part, "...2. All patients admitted following a suicide attempt will considered at high risk. For these patients, suicide precautions will be initiated upon arrival to the hospital...A. Level I: Close Observation ....3. Nursing Interventions: a. check patient every fifteen (15) minutes; b. frequent verbal contact during waking hours; c. 1:1 staff accompaniment for any necessary out of the hospital activity (test and procedures); d. routine confiscations of sharps..."

Review of the hospital's policy on Absence Without Authorization, Policy 2.4 given to the
surveyor as the current one in use, revealed in part, "It is the policy of the Hospital to designate a patient as absent with authorization (AWOL) in the following situations: Absence from the hospital without a physician's order....A. Identification of AWOL 1. The occurrence of a patient unaccounted for during hourly or more frequent observation will be brought to the attention of all staff. 2. Exploration of patient's whereabouts will ensue, including a search of the Hospital. Should this prove unsuccessful, the following procedures are to be implemented:
a. Hospital security is notified of patient's absence and placed on alert;
b. The nurse notifies the attending psychiatrist ...
c. The Administrator and Director of Nursing are notified.
d. A search of the Hospital ensues, if determined necessary by the nurse and with the assistance of security;
e. The search will not occur outside the confines of the Hospital by staff, unless the patient is determined to be of danger to self or others;
f. Notification of family/significant others is to occur when judged appropriate by nurse and psychiatrists; and
g. If the patient is determined to be of danger to self or others, the police department will be notified; this intervention will be ordered by the attending psychiatrist after consultation with the staff...
C. AWOL of Involuntary Patients
10. Initiating AWOL procedures for involuntary patients remains the same as those described for voluntary patients with the following exceptions:
a. searches are to include the Hospital facility, Hospital grounds, and immediate environment; and
b. local and, if a
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the hospital failed to ensure high risk incidents were thoroughly investigated and reported to Administration/Quality Department and Governing Body for 5 of 5 incidents reviewed (Incident Date 5/30/2011 involving Random Sampled Patient #R1, Incident Date 7/17/2011 involving Patient #11 and #17, Incident date 7/19/2011 involving Patient #5, Incident Date 7/23/2011 involving Patient #10, and Incident date of 07/24/11 involving Patient #7). Findings:

Review of the Hospital's Governing Body Bylaws revealed in part, "The Governing Body retains ultimate authority for the quality of patient care rendered in the Hospital and shall periodically examine the goals, policies, purposes and current programs of the Hospital and receive periodic reports from the Medical Staff concerning monitoring and evaluation of patient care, and will be responsible for the implementation of the mechanisms that provide for systematic review of the quantity and the quality of the services provided by the hospital..."

Incident Date 5/30/2011: Involving Patient #R1
Review of Patient #R1's "Patient/Family complaint form" dated 5/30/2011 with no documented time and no signature of the administrative staff reviewing the Grievance revealed in part, "While standing in hall wafting (waiting) for a smoke brake (break) (Director of Nursing S2) approach me asking for my glasses (sun glasses). The glasses I been having on for 70 plus hours. He (S2) said I (R1) would have to hand them over. The (S2) grabbed (grabbed) my arm. Then, he squeezed the arm. I consider at the a least a threat. He is a big big man. My eyes were damage (d) with OC (over counter) pepper spray. I am on antibiotics. What action/resolution does the person making the complaint want? The glasses-sunglasses back in my possession. and full disciplinary action be taken immediately so (S2) can never hurt any body again."

Review of documentation dated 5/30/2011 with no signature or time, revealed in part, "R (right) eye redness noted. Bil (bilateral) pupil not dilated. APN (Advanced Practice Nurse) S33 paged to get medical necessity for sunglasses. NP (Nurse Practitioner) gave order for sunglasses. Sunglasses returned to patient." Review of the entire document revealed no documented evidence of an investigation into the allegation of abuse by Random Sampled Patient #R1.

During a face to face interview on 8/12/2011 at 1450 (2:50 p.m.), Clinical Coordinator S3 indicated she (S3) had been the administrative staff that had investigated the incident involving Patient #R1 that allegedly occurred on 5/30/2011. S3 indicated she (S3) had failed to review video surveillance and/or investigate allegations of abuse by Patient #R1. S3 indicated she (S3) had assessed Patient #R1's arm but had failed to document it on the form. S3 indicated she (S3) had seen no evidence of injury to R1's arm. S3 indicated the focus of her (S3) investigation had been the Patient's medical need for sunglasses.

Incident Date 7/17/2011: Involving Patient #11/Patient #17:
Review of Patient #11's medical record revealed the patient (#11) was admitted on [DATE] with diagnoses that included Schizoaffective Disorder by history. Review of Patient #11's Physician Emergency Certificate (from the sending hospital) dated 7/15/2011 at 7:00 a.m. revealed in part, "Findings of Examination: 27 y/o (year old) male presents to ED (Emergency Department) C/O (complains of) homicidal ideation. states he (#11) has gun and will shoot (name of intended victim) who he (#11) believes killed his younger brother. Review of Patient #11's Nursing documentation dated 7/17/2011 at 1930 (7:30 p.m.) revealed "pt (patient) went into the females shower room (and) took his shower, been making sexual remarks about one of the female pts (patients/no ID (identification) number for the female patient ), he (#11) heard her (no ID number for the female patient) say she (no ID number for the female patient) was going to shower but one of the other pts (patients/no ID number for this patient) walked in on him."

During a face to face interview on 8/10/2011 at 8:00 a.m., Registered Nurse S18 indicated Patient #11 had gone into the female shower room with plans to encounter a young female patient (#17) that he (#11) had been "interested" in. S18 indicated S11 had heard the female patient (#17) state that she (#17) was about to shower. S11 indicated another female patient (didn't recall name of this patient) had opened the door to the shower and screamed when she (didn't recall name of this patient) saw a male in the shower room. S11 indicated the shower rooms should have been locked where no patient had access unless there had been a Mental Health Tech monitoring shower activity. S11 indicated she (S11) did not know how Patient #11 had managed to enter the female's shower and it should not have been possible if staff had been performing their duties properly. S11 indicated Patient #11 was a rather large man (6 feet 2 inches and 287 pounds/ [AGE]) and Patient #17 (intended victim) had been a small girl (5 feet 5 inches and 123 pounds/ [AGE]). S11 indicated she (S11) had not completed an Incident/Occurrence form, had not informed the patients' physician, and had not informed administration of the incident. S11 indicated the patients (#11 and #17) were moved to rooms at opposite ends of the hall. S11 indicated she (S11) had not updated to two patients' (#11, #17) treatment plans to ensure safety interventions were put in place across all shifts by all staff to protect Patient #17 from Patient #11. S11 indicated she (S11) should have completed an Incident/Occurrence form after the incident occurred.

Review of Patient #17's (intended victim) medical record revealed the patient was admitted on [DATE] with diagnoses that included Major Depressive Disorder. Review of Patient #17's Physician Assistant orders dated 7/17/2011 at 11:00 (p.m.) revealed in part, "Pt (patient) is a little worried, a male peer is obsessed (with) her (and) has been watching her closely."

During a face to face interview on 8/09/2011 at 1300 (1:00 p.m.), Administrator S1, Director of Nursing S2, and Clinical Coordinator S3 indicated they had no knowledge of the incident that had occurred when Patient #11 had executed a plan to encounter Patient #17 in the female shower room. S1, S2, and S3 indicated the incident had never been investigated.
S3 indicated there had never been a review of video surveillance recordings after the incident to determine if the patients (#11 and #17) had been properly monitored. or to determine which staff had unlocked the shower door and left it unattended. S1, S2, and S3 indicated the nurse that discovered the incident should have reported the incident to administration and should have completed an Incident/Occurrence Report.

Incident Date 7/19/2011 regarding Patient #5:
Review of Patient #5's medical record revealed the patient was admitted on [DATE] with diagnoses that included Bipolar Disorder. Review of a handwritten letter by Patient #5 dated 7/24/2011 with no documented time revealed in part, "I (Patient #5) am reporting on about July 19 or 20th during the evening shower, I had asking for a razor. The tech told me she did not have time because she needing to stay in while I shave, I told her that was no problem, she gave me my towels . I waited about 10 minute, and decided to go ahead and shower. The Tech was a short white female, very sweet to all patient, she was just really busy. I understood. While I was in the shower, I was washing my hair a face, had my eyes closed due to the soap, after washing out the soap, when I opened my eyes, There was a dark skin black male with a slim trimmed Beard was standing with one hand out with a razor (and) cream, the other was holding his private part, he told me to touch it. I turned and said get out of here. when I turned, he grabbed me from behind, put his hand over my face and mouth and put his private in my vagina from behind. I couldn't over power him so he continued until his climax. I would like a blood test ASAP (as soon as possible) to check for possible STD (Sexually Transmitted Diseases). When he got through he quickie (as written) got to the door and said you better not tell, I will kill you. I've been afraid to tell and I've held in it and I can't keep in bottle up any longer. I will take polygraph test what ever it take."

Review of Patient #5's Nursing Documentation dated 7/24/2011 at 0930 (9:30 a.m.) revealed "observed pt (patient) crying in the hall (and) both (Licensed Practical Nurse S30) and I (Registered Nurse S26) approached her to find out why. She (#5) said she (#5) held back telling the whole truth when she had reported a male MHT (Mental Health Tech) had come in while she was showering to bring her a razor. She (#5) reported he (unidentified Mental Health Tech) had a razor in one had (and) he (unidentified MHT) was masturbating (with) the other hand. She (#5) said he (unidentified MHT) bent her (#5) over (and) put his hand over her (#5) mouth so she couldn't scream. She (#5) said he (unidentified MHT) then penetrated her vaginally (and) actually climaxed inside her vagina. She said she did not tell anyone because he (unidentified MHT) told her he would kill her and she (#5) said she felt ashamed because of wearing too tight jeans. She (#5) reported she is not sure of the dates (19th, 20th, or 21st). I (RNS26) instructed her (#5) that I (S26) would notify the doctors and administration and perform an investigation (Physician S31, Physician S39, and Administrator S1) notified. Investigation begun."

Review of a typed attached document to a "Patient/Family Complaint (signed by Clinical Coordinator S3 on 7/25/2011 at 8:30 a.m. regarding Patient #5)" form revealed in part, "On 7/25/2011, St. James was notified by (PD/ Local Police Department) of the alleged rape of (Patient #5). Our administrative staff cooperated fully with detective assigned. On July 26, 2011, I (S3) spoke with (patient #5) about accusations of a staff member making threats to kill her. She (#5) stated that a male patient had overheard two black male(s) talking in hall and one made threats to kill her. The one that made the threat was the brother in law to (MHT/Mental Health Tech S9) With more questioning, she (#5) states she heard the male staff member make the threat. . . She (#5) stated with the alleged rape happening she (#5) felt she could not get better in this facility. I (S3) told her (#5) that transferring her (#5) to another facility is an option she (#5) could request. She (#5) immediately said "no, that would be like starting over...I (S3) reassured her (#5) that her psychiatrist would be meeting with her (#5) later this afternoon. On 7/26/11, education started with MHT regarding patient shower policy and procedure. . .On 8/01/2011, S28 (Recreational Therapist and mother to MHT S9/accused perpetrator) handed me (S3) a statement from patient (Random Sampled Patient #R12), saying that (patient #5) admitted to her accounts about the alleged rape were not true. . ."

Review of Mental Health Technician (MHT) S9's personnel file revealed a "Employee Reprimand/Disciplinary Report" dated 7/26/11 (2 days after Patient #5 reported alleged rape and 1 day after video review by administration revealed MHT S9 was alone with Patient #5 in the shower on 7/19/2011 from 21;02:30 - 21:02:37 and again from 21:05:05 - 21:06:36) with no documented time indicating, "Date of Violation 7/19/2011. Time of Violation: 9:00 p.m., Nature of Violation Policy Violation, Conduct, Explanation: Allegation of Sexual impropriety. Suspend until investigation is complete."

During a face to face interview on 8/09/2011 at 1300 (1:00 p.m.), Administrator S1 indicated he (S1) had no documentation regarding the phone call he (S1) had received on 7/24/2011. S1 indicated his memory of the call from the hospital regarding an allegation of inappropriate behavior with conflicting vague details by Patient #5 was that the phone call had occurred in the evening rather than 9:30 a.m. as the nursing documentation indicated. S1 further indicated he (S1) had never been informed of the graphic details described in Patient #5's nursing notes. S1 indicated he (S1) was told that the patient had alternating stories that were conflicting regarding a male in the shower. S1 indicated he (S1) had asked staff to write statements regarding the allegations and asked if the MHT (Mental Health Tech) had been identified. S1 indicated no one had informed him (S1) that an identity of the alleged perpetrator had been established. S1 indicated he (S1) had not reviewed video surveillance recordings until the morning of the 5th (one day after the allegation had been made by Patient #5 that a MHT had entered the female bathroom when she (#5) had been showering and had masturbated, bent her (#5) over, put his hand over her mouth, penetrated her (#5) vaginally, climaxed, and threatened to kill her (#5) if she told). S1 indicated if he (S1) had received the report as it was written in Nursing Documentation on 7/24/2011 at 9:30 a.m. he (S1) would have come immediately to the hospital and started an investigation to include review of video surveillance rather that until the following morning (7/25/2011). S1 indicated an allegation of that magnitude warranted immediate involvement and investigation by Administration but had not been informed of the graphic details of the allegation made by Patient #5.

Incident Date 7/23/2011/Patient #10 :
Review of Patient #10's medical record revealed the patient (#10) was admitted on [DATE] with diagnoses that included Chronic Paranoid Schizophrenia with Acute Exacerbation and Lacerated wound on the left wrist. Review of Patient #10's Physician Emergency Certificate dated 7/22/2011 at 5:20 a.m. revealed in part, "Findings of Examination: presents (after) suicidal attempt of trying to cut wrist. . .+ AH (positive auditory hallucinations), L (left) wrist (with) superficial laceration 4 cm (centimeters)". Review of Patient #10's Nursing Documentation dated 7/23/2011 at 1550 (3:50 p.m.) revealed in part, "summoned to patient's room (and) found pt. sitting on bed bleeding form Lt. Wrist wound. Noted he was holding pressure to wound (with) a blue cloth. Noted a large amount of blood droplets on floor (with) a spray of blood on wall. attempted to approach pt. to provide care but unable to do so as pt growled "don't come near me." 911 called (ambulance and police). (Physician's Assistant S36, Administrator S1, and Director of Nursing S2) notified. . .It needs to be noted pt. apparently used wrist band (name tag) to re-open the previous laceration he had sustained prior to admit here).

During a face to face interview on 8/09/2011 at 7:30 a.m., Director of Nursing S2 and Clinical Coordinator S3 indicated administration had never received an incident/occurrence report regarding Patient #10's self inflicted opening of a wrist wound on Day # 2 of his admission to the hospital post suicide attempt by cutting of his wrist. S2 and S3 indicated there should have been an incident report written. S2 and S3 indicated they both were aware of the incident but had no formal written investigation of the incident and no identified problems that needed corrective action. S3 indicated there had never been a review of video surveillance recordings after the incident to determine if the patient had been properly monitored. S3 further indicated Patient #10 had been located in the observation room where video cameras were located; however, the hospital had no policy or procedure for monitoring of the camera screens that were located in the nursing station.

Face to face interviews were conducted with Physician Assistant S36 on 8/10/2011 at 7:10 a.m. and Director of Nursing S2 and Clinical Coordinator S3 8/10/2011 at 9:25 a.m. S36, S2, and S3 indicated any patient that had an active attempt at self harm while admitted to the hospital should have been placed on 1:1. S2 confirmed that Patient #10 had never been placed on 1:1 after using his arm band to open a wrist wound that had required sutures. S2 and S3 indicated they had never identified the failure of hospital staff to place Patient #10 on 1:1 after an attempt at self harm at the hospital as a problem needing correction.

Review of the hospital policy titled, "Occurrence Reports, #8.6, Originated June 2006" presented by the hospital as their current policy revealed in part, "Occurrences for which an HOR (Hospital Occurrence Report) should be completed include but are not limited to the following: a. Patient Injuries, b. Patient Deaths, c. Physical Health Episodes, d. Medication Errors, e. Contraband Possession or Contraband Found on Unit, f. Relations Issues. . . h. Interdepartmental incidents, i. Serious breach of policy, j. Property damaged, k. Lost or stolen property, l. Internal disasters. . .When an unusual event occurs staff will take appropriate action and then complete the HOR. . .Construct a report that is both factual and objective. Report interventions that occurred following the incident, Report patient status twenty four hours after the incident, Record the occurrence in the patient's medical chart as well as on the Hospital Occurrence Report form. . . In the event of a serious incident (e.g. fractures, attempted suicides, death of a patient, medical problems resulting in transfer of a patient to another Hospital, serious breach of policy, situations involving sexual contact), the Administrator will be notified immediately, who will then call the corporate office and will complete the confidential Critical Incident Reporting Record. Notification of risk management will be determined when reviewing the incident. . ."

Review of the hospital plan titled, "Quality Assurance Plan (no documented date of adoption)" revealed in part, "The Monitoring and Evaluation Process will include the following activities: Clinical Outcomes Reviews. . .Risk Management/Patient Safety. . .Sentinel Events Occurrences (Root Cause Analysis). . .Through the use of a high risk process grid, the corporation has identified key indicators for monitoring based upon data availability, volume, patient population, problem prone, and clinical significance. These identified key indicators include: Incident reporting..."

Incident #5 Elopement of Patient #7 on 07/24/11
Review of the medical record for Patient #7 revealed that the patient was admitted to the facility on [DATE] by a PEC/CEC(Physician Emergency Certificate/Coroner's Emergency Certificate) for polysubstance abuse, suicidal ideations, and he had a history of Schizophrenia. Review of the Initial Psychiatric Evaluation dated 07/20/11 revealed in part ... "This is a [AGE] year old married Caucasian male with a history of mood disorder and polysubstance abuse, has been admitted after he threatened to jump out of a moving a car while he was with this wife. The patient's wife reports the patient was agitated, because he has been out of his Lortab and he also has been drinking. The patient was taken to the emergency room by EMS and then sent here now to St. James Hospital for further treatment. The patient admits to a long history of polysubstance abuse. He has a history of intravenous drug administration as well. He reports he has been to various emergency room s in order to get treated in the emergency room for his pain medication. He has admitted to burning himself on the arm in order to get treated in the emergency room for his pain medications. He has also cut himself with a fishing line and shot himself with a nail gun all in hopes of getting pain medication."

Review of the St. James Behavioral Health Hospital-Patient/Visitor/Staff/Medication Error Form dated 07/24/11 revealed under the section labeled Incident, "Patient Escaped from Hospital. "Under the section labeled Description of Event revealed, "Pt (patient) noticed missing tonight out of his room by S10MHT. Window next to pat's bed has been broken open. Staff searches for patient. Pt was nowhere to found. He was seen between the hours of 3-4:30 p.m. during visiting hours with a white female. S38PA says not to alert the family @ this time." Under the section labeled Assessment/Outcome and or Follow-up of incident/Error revealed, "The window in the patient's room had been broken open. PD called and Sgt (Sergeant) came. Copies of a picture of the pt. along with his face sheet was given to Sgt. He says the department will contact the family. Police report number was given by officer."

Review of the PD-Case Report dated and timed 07/24/11 9:57:59 revealed under the narrative section of the report, "On 07/24/11 I Sgt. responded to St. James Behavioral Hospital located at 3136 S. St. Landry Road for a 911 hang up. Upon my arrival dispatch advised they were unable to make contact with anyone at the hospital. I then hit the call button at the front door and was met by S24RN who advised they had a patient escape. S24RN advised they went to check on a patient and discovered the window in his room has been broken with an unknown type of object and the subject had escaped. S24RN advised the patient was last seen at 20:30 hours and advised his name was Patient #7 w/m (white/male) 06/14/83 (date of birth). She advised that Patient #7 was transported to the facility on [DATE] as a transfer from hosp."b". He is a described as a paranoid schizophrenia, suicidal, and substance abuser. S24RN advised that Patient #7 did have a female visitor during visiting hours and she left at 19:00. She advised that Patient #7 as provided an address in Addis, Louisiana and they were going to call his family and let them know he had left. I then noticed the window had a plastic plexi glass type security feature that only allows the window to go up about 4" and locks in place after that. The plastic plexi glass security feature was broken by an unknown object and the window was able to be forced up and opened all the way allowing him to make his escape. I then advised other units to B.O.L.O(be on the lookout) for Patient #7. I also had dispatch put out A B.O.L.O (be on the lookout) to APSO (Parish Sheriff Office) units. I advised S24RN to contact the police department if Patient #7 showed back up. I then left and checked the area and was unable to locate Patient #7. He was entered into N.C.I.C. (National Crime Information Computer) as a missing person and his home town Police Department was contacted to go by the residence. They advised they would check the residence as B.O.L.O. for Patient #7. They were unable to locate him."

Review of the St James Behavioral Health Hospital Multi-Disciplinary Progress Note dated 07/24/11 at 2030 revealed, "Pt noticed missing tonight out of his room. The window next to his bed had been broken open. Staff searched for patient inside and outside the hospital. Patient nowhere to be found. He was last seen by S32MHT after supper around 5:30 p.m. going to his room to lie down. He was seen during visiting hours with a white female between the hours of 3 p.m.-4:30 p.m." The next entry was timed 2100- "PD called to notify them that patient had escaped. S31MD and S38PA on the unit made aware of pt's escape. S39MD and S36PA notified. S38PA says not to alert the family at this time." The next entry on the progress note was timed 2130- "Sgt. from PD came. He was given a copy of a picture of the patient along with a face sheet. Sgt. Says his department will contact the family."

Review of the St James Behavioral Health Hospital Physician Admit Orders & Problem List dated 07/20/11 revealed an order for CO q 15" (close observation every 15 minutes).

Review of the Patient 15" &/or 30" Observation Form AM Shift dated 07/24/11 revealed he was observed every 15 minutes from 0715 to 1900. From 5:30 p.m. to 7:00 p.m. S32MHT documented he was being monitored, and he was awake and cooperative. Review of the Patient 15" &/or 30" Observation Form PM Shift dated 07/24/11, S9MHT documented every 30 minutes Patient #7 was monitored and awake until 9:45 p.m. and then was monitored and asleep from 10:15 p.m. until 5:45 a.m. At 6:15 a.m. on 07/25/11 Patient #7 was awake and monitored and fluids were offered and at 6:45 a.m. he was offered a meal/snack and he was awake and monitored. According to the nursing notes and the police report the patient was reported missing at 8:30 p.m. the evening of 07/24/2011.

Review of the Environmental Safety Report dated 07/25/11 revealed, "An environmental safety inspection of patient room #8 was conducted by hospital staff immediately upon discovering the elopement of the patient assigned to bed 8b on the evening of July 24, 2011 and again by the hospital administrator and maintenance supervisor on the morning of July 25, 2011. A short black screw driver was found under the mattress in the patient's room. The screwdriver was examined and found not to be a tool from the facility maintenance collection. The patient either snuck in the tool or had someone deliver it from the outside. It appeared that the patient planned to unscrew the framework of the plexi-glass protective covering of the window in order to open the window enough to pass his body through to the outside. Because the screwdriver was unable to turn the safety, tamper pro screws it appears that the patient was able to loosen the cover instead by pushing and pulling the frame from the bottom over a period of time. A corrective action plan was immediately initiated. Maintenance repaired the window framework and install new plexi-glass. This action was completed on the afternoon of 1." The Environmental Safety Report was signed by S1Administrator.

An interview was conducted with S24RN on 08/08/11 at 1 p.m. She stated she was the registered nurse working on the night that Patient #7 was discovered missing. Patient #7 was on every 15 minute observations. She went on to state at 8:30 p.m. S31MD was in the facility making rounds. S10MHT went to get Patient #7 for the physician to examine and he could not find the patient. S9MHT was assigned to the patient for the p.m. shift (7 p.m. to 7 a.m.) to do the every 15 minutes observations. S24RN stated she asked S9MHT if he had located all his assigned patients when he started his shift at 7 p.m. At first he stated he did, and then he changed his story. He went on to say he must have gotten the patient confused with someone else and he had not seen the patient since he came on his shift. She went on to state on 07/24/11 the day RN, S26RN was still in the facility and called S32MHT at home (the MHT who was assigned to perform the every 15 minutes observation on the a.m. shift). S32MHT stated she saw him last at 5:30 p.m. after supper and she saw him with a white female visitor earlier that afternoon. The staff started searching for Patient #7 inside and outside the facility. When the patient was not found and the window was found broken in his room, the police, the physician, and the administrator was called. When the police came to the facility to investigate, they stated they would notify the family. An incident report was completed. S24RN went on to say the patient was not volatile, but he was a danger to himself.

An interview was conducted on 08/09/11 at 2:10 p.m. with S32MHT. She stated she worked from 7a.m. to 7 p.m. on 07/24/11 and was assigned to conduct every 15 minutes observations on Patient #7. She stated she checked on him up until the end of her shift at 7 p.m. When asked why the Incident Report stated the last time she saw the patient was 5:30 p.m., S32 MHT stated she was called at home of the night of 07/24/11 at 10:30 p.m. after she had fallen asleep by the day RN, S26RN. S26RN asked her the last time she saw Patient #7. She was half asleep and "foggy" at the time the nurse questioned her, but her documentation on the Patient 15" and/& 30" Observation Form AM Shift was correct. She monitored him up to the end of her shift, 7 p.m., and he was in his room until she left her shift. S32MHT stated after dinner he went to his room and did not go out and smoke like he typically did. Earlier in the afternoon from 3 p.m. to 4:30 p.m. he had a female visitor and another MHT watched him during the visitation time. S9MHT then picked up the observation of every 15 minutes from 7p.m. to 7a.m. When questioned if anyone in Administration ever interviewed her about when and where she last saw the patient, she stated no.

An interview was conducted with Detectives PD1 and PD2 on 08/05/11 at 1 p.m. They stated the PD was called to St James Behavioral Health hospital on [DATE] at 9:57 p.m. when Patient #7 had eloped. They further stated they made rounds in the hospital and found that Patient #7's window was busted out. The police searched for him and was unable to find him. They notified his hometown police department to be on the lookout for him. He still has not been found.

On 08/09/11 at 9:50 a.m. S35Maintenance Tech was interviewed. He stated on 07/24/11 Patient #7 broke the plexi glass in his room, raised the window and left. On examination of the window, he stated he had to take the whole window down and repair the plexi glass and the frame for the plexi glass. He replaced the window as it was prior to the elopement of Patient #7; no alterations were made to the window and plexi glass in the window.

An interview was conducted with S38PA on 08/10/11 at 2:30 p.m. She stated she arrived at the hospital on [DATE] between 8:30 p.m. and 9:30 p.m. with the hospital in chaos. She went on to state an employee met her at the door of the facility stating, "I think someone is gone." The employees proceeded to search the hospital and found that Patient #7's window was busted out. She went on to state she has always been concerned that contraband could be introduced into the facility through the window since it was capable of being opened some. When questioned why she told the staff not to call the family immediately and tell them he was missing, she stated she was told his wife had visited him earlier during the day and she didn't want to alert the family in case the family had picked him and was taking him to his home. That way the police would have time to go to his house first before alerting the family the police were on their way. The police said they would tell the family he had eloped after driving by his home.

On 08/09/11 at 2:45 p.m. an interview was conducted with S1Administrator, S2DON, and S3 Clinical Coordinator. They stated that Patient #7 was on every 15 minutes observations the entire time he was admitted to the facility. They confirmed on the 7p.m. to 7a.m. shift on 07/24/11, the night of the elopement, S9MHT documented every 30 minutes observations from 7 p.m. until the next morning (7/25/11) at 7 a.m., even though the patient was discovered missing on 07/24/11 at 8:30 p.m. S3Clinical Coordinator stated when she reviewed Patient #7's chart she saw where S9MHT had documented the patient was in the hospital even though he had been reported missing already. She went on to state she could not speak to S9MHT because he was under investigation for another allegation in the facility. S3Clinical Coordinator stated she did not interview S32MHT, who last saw the patient at 5:30 p.m. on 07/24/11. When questioned if she reviewed the video tapes in the hospital to assist with her investigation of the elopement, she stated she had not. She further stated they were not sure how the patient obtained the screwdriver that was found in his room after he eloped.

Review of the hospital's policy, Absence Without Authorization, Policy #2.4, given to the surveyor as the current one in use, revealed in part, "It is the policy of the Hospital to designate a patient as absent with authorization (AWOL) in the following situations: Absence fro the hospital without a physician's order....A. Identification of AWOL 1. The occurrence of a patient unaccounted for during hourly or more frequent observation will be brought to the attention of all staff. 2. Exploration of patient's whereabouts will ensure, including a search of the Hospital. Should this prove unsuccessful, the following procedures are to be implemented:
a. Hospital security is notified of patient's absence and placed on alert;
b. The nurse notifies the attending psychiatrist ...
c. The Administrator and Director of Nursing are notified.
d. A search of the Hospital ensues, if determined necessary by the nurse and with the assistance of security;
e. The search will not occur outside the confines of the