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.

OCEANS BEHAVIORAL HOSPITAL OF KENTWOOD 921 AVENUE G KENTWOOD, LA Feb. 1, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to meet the requirement of the Condition of Participation of Patient Rights as evidenced by failing to ensure:

1) Each patient was free from all forms of abuse/neglect as evidenced by Patient #3 being discharged on [DATE], transported by S7TD, and left by S7TD outside a locked residence. Patient #3 remained outside during the cold night of 12/28/18 (temperatures between 35-44 degrees) until she was discovered in the parking lot of a business on 12/29/18 as reported by S10APS.
2) An incident of neglect was reported and analyzed and remedial or disciplinary action occurred in accordance with Louisiana Revised Statute 40:2009.20. The above incident of neglect of Patient #3 was not reported within 24 hours to the LDH or the local law enforcement agency.
(see findings in tag A0145)
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews the hospital failed to ensure:
1) Each patient was free from all forms of abuse/neglect as evidenced by Patient #3 being discharged on [DATE], transported by S7TD, and left by S7TD outside a locked residence. Patient #3 remained outside during the cold night of 12/28/18 (temperature between 33 and 45 degrees) until she was discovered in the parking lot of a business on 12/29/18 as reported by S10APS.
2) An incident of neglect was reported and analyzed and remedial or disciplinary action occurred in accordance with Louisiana Revised Statute 40:2009.20. The above incident of neglect of Patient #3 was not reported within 24 hours to the LDH or the local law enforcement agency.
Findings:

1) Each patient was free from all forms of abuse/neglect:
Review of the policy titled "Assessment And Reporting Of Abuse, Neglect, Exploitation, And/Or Extortion Of Youth And Adults", presented as a current policy by S1ADM, revealed that the hospital's policy was to protect children, adults, and elderly from harm by identifying, evaluating all allegations, observations, and suspected cases of neglect, exploitation, and abuse external to the organizatiuon and that which could occur while the patient is receiving care, treatment and services. There was no documented evidence that the policy defined abuse or neglect.

Review of Patient #3's medical record revealed she was admitted on [DATE] and discharged on [DATE]. Review of her nurse's note documented by S8RN on 12/28/17 at 2:15 p.m. revealed Patient #3 was escorted off the unit by staff in the hospital's wheelchair and transported via the hospital's transport van.

Review of Patient #3's "Psychiatric Evaluation": dictated by S5NP on 12/20/17 revealed documentation as follows: "she was most recently living with her son. I do not know for how long, but now she does not want to live there and she wants to get her apartment back. She said she has talked to her landlord and she can pay $150 and get back to her Hammond apartment where her furniture is still at."

Review of Patient #3's "Transportation Request Sheet", documented on 12/28/17 and signed by S4LMSW and S8RN, revealed she was transported home to the address documented on her "Record Of Admission." Further review revealed the start time of the transportation was 2:15 p.m., and the end time was 3:45 p.m. There was no documented evidence of the name of the driver assigned to transport Patient #3, and there was no documented evidence of the signature of the driver.

In a telephone interview on 02/01/18 at 7:45 a.m., S10APS confirmed she called S4LMSW at the hospital on [DATE] to notify him that Patient #3 had been left at her locked home by the hospital's driver on 01/28/17, and Patient #3 had remained outside all night. She indicated that the person at a business in Hammond called her (S10APS) to report that Patient #3 was in the back parking lot of her business "panhandling." S10APS indicated S4LMSW indicated he would check with the driver. She confirmed that she did not hear from the hospital after her report was made on 01/29/18.

In an interview on 02/01/18 at 10:55 a.m., S7TD confirmed that she did drive Patient #3 home at the time of her discharge. She indicated Patient #3 wanted her to stop to get some prescriptions filled, but she (Patient #3) didn't have money, so she (S7TD) didn't stop. When the surveyor asked S7TD to explain the process for transporting patients at the time of discharge, S7TD indicated she usually transports patients from the the intensive outpatient program, but sometimes she transports inpatients if the inpatient being discharged is going in the direction she (S7TD) is traveling. S7TD indicated she had another inpatient to take to New Orleans and 5 intensive outpatient program patients to transport at the time of Patient #3's transport. She further indicated someone calls her to tell her they need her to transport a patient. S7TD indicated S8RN called her to request that she transport Patient #3. S7TD indicated she comes inside the hospital to get the patient, and a mental health technician assists with bringing the patient to the van. She further indicated the nurse gives her a transportation sheet with the address on it. S7TD indicated she brought Patient #3 to the address documented on the face sheet. She further indicated when she got to the home, she helped Patient #3 to get out the van. Patient #3 wanted her to go to the door to see if the door was open, because the landlord was supposed to come to unlock the door. S7TD indicated the door was locked. After she told Patient #3 that the landlord had not unlocked the door, Patient #3 sat down in a chair at the corner of a trailer on the same lot as her duplex apartment. Patient #3 knocked on the side of the trailer, and no one came to the door. S7TD indicated she told Patient #3 that she was going to check at the door of the trailer, but Patient #3 told S7TD not to go, because the brown pit bull that was tied to the tree didn't know her (S7TD). S7TD confirmed she didn't go to the trailer to knock. S7TD indicated she asked Patient #3 what she was going to do, and Patient #3 indicated she would sit there, because her landlord should be coming. S7TD indicated she left Patient #3 outside her locked apartment. She further indicated she didn't notify anyone at the hospital that she left Patient #3 outside her home and unable to get inside her residence. S7TD indicated she was never educated on what to do if she brought someone home, and they couldn't get in their home.

In an interview on 02/01/18 at 11:25 a.m., S8RN indicated the discharge coordinator tells her the disposition of the patient (where the person is going) at discharge. She then sees which van is available. She indicated S7TD had intensive outpatient program patients to take to Hammond, so Patient #3 was put on that van to be taken home. S8RN indicated when she goes over the discharge papers, she asks the patient for the address; she also sees the transportation sheet prepared by S4LMSW which is given to the van driver. She indicated she goes by the transportation sheet for the discharge address and doesn't review the record to check for an address. S8RN indicated the morning before she left, Patient #3 asked her (S8RN) to use the phone to call her landlord. She further indicated before discharge, they talked with Patient #3 about her going to a group home, but Patient #3 said she didn't want to go to a group home. S8RN indicated she wasn't made aware that Patient #3 did not have access to her home when S7TD left her with the door to her apartment locked. S8RN indicated the next day (01/29/17) after Patient #3 was discharged ,S4LMSW was in the nursing station talking with the APS worker and was told that the landlord had Patient #3 locked out of her apartment.

In an interview on 02/01/18 at 12:38 p.m., S4LMSW indicated before Patient #3 came to hospital, she was residing with her son, even though she had her own apartment. When it came time for discharge planning, they discussed intensive outpatient programs, and Patient #3 provided him with her address in Hammond. he indicated Patient #3 was discharged to her address in Hammond that was listed on her "Record Of Admission." S4LMSW indicated after Patient #3's plan for discharge was discussed with her, she asked to use the phone to call her landlord to ask him to come unlock the door for her. He further indicated the next day (12/29/17) about 4:30 p.m. S10APS called him and reported that Patient #3 called her and said she had to sleep outside the night that she was discharged (12/28/17), because she had an argument with her landlord, and he would not give her a key to the apartment. S4LMSW indicated he discussed the phone call with S8RN, and he "can't believe I wouldn't have discussed it with someone else, because that's not the norm." When the surveyor asked S4LMSW what neglect is on the part of hospital, S4LMSW indicated it means "not fulfilling someone's needs by not properly conducting discharge planning or making sure a patient had a safe environment to go to." When asked by the surveyor if incident involving Patient #3's discharge was an instance of neglect, he answered "unfortunately I do believe so." At the conclusion of the interview, S4LMSW indicated he remembered this time of the event being when the area had a cold spell, and it was "very cold" during the night of 12/28/17.

2) An incident of neglect was reported and analyzed and remedial or disciplinary action occurred in accordance with Louisiana R.S. 40:2009.20:
Review of the policy titled "Assessment And Reporting Of Abuse, Neglect, Exploitation, And/Or Extortion Of Youth And Adults", presented as a current policy by S1ADM, revealed that the hospital's policy was to report abuse in accordance with assessment/reporting standards set by the LDH. Further review revealed clinical staff were to notify the Administrator/DON if abuse was suspected, and the Administrator/DON was to call the Regional Coordinator and inform of alleged abuse. Further review revealed the Administrator/DON must self-report internal allegations of abuse/neglect within 24 hours of knowledge of the allegation to maintain compliance with Louisiana R.S. 40:2009.20. There was no documented evidence that the policy defined abuse or neglect.

Review of Louisiana R.S. 40:2009.20 "Duty to make complaints; penalty; immunity" revealed neglect was defined as the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer's well-being. Further review revealed 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, home- and community-based service provider employee or worker, personal care attendant, respite worker, physician's assistant, physical therapist, or any other direct caregiver having knowledge that a consumer's physical or mental health or welfare has been or may be 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.

See information related to Patient #3 above under #1.

In an interview on 02/01/18 at 12:38 p.m., S4LMSW confirmed the issue of Patient #3 being left at her locked residence and unable to get inside that resulted in her having to spend the night outside on the cold night of 12/28/17 should have been reported to LDH as neglect. He said to his knowledge nothing had changed related to transportation of discharged patients since this event. He indicated he tried to discuss the event with S7TD who was assigned to transport Patient #3 at discharge, but he was never able to reach her due to her being out on transportations.

In an interview on 02/01/18 at 1:10 p.m. with S2DON and S1ADM present, S2DON indicated she was never made aware of the event of Patient #3 being left at her locked residence by S7TD on 12/28/17 which resulted in Patient #3 remaining outside during the cold night of 12/28/17. She confirmed this issue of patient neglect was not reported to LDH in accordance with Louisiana R.S. 40:2009.20. S1ADM indicated he was not employed at the time of this incident and had no further information to present related to it.
VIOLATION: DISCHARGE PLANNING Tag No: A0799
Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of Participation of Discharge Planning as evidenced by:

1) Failing to ensure each patient's discharge planning evaluation included an evaluation of the likelihood of a patient needing post-hospital services and of the availability of the services and an evaluation of the likelihood of a patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he or she entered the hospital. This was evident in the medical record of 4 (#1, #3, #4, #5) of 5 patient records reviewed for completion of the discharge planning evaluation from a sample of 5 patients. (see findings in tag A0806)

2) Failing to ensure a registered nurse, social worker, or other appropriately qualified personnel developed, or supervised the development of, the discharge planning evaluation as evidenced by S4LMSW self-assessing himself as having moderate experience in the principles of the discharge planning process and familiarity with available discharge planning and his supervisor's evaluation revealing he needed additional training/supervision in familiarity with available discharge planning with no documented evidence that further training and/or supervision had been provided for 1 (S4LMSW) of 1 discharge planning staff personnel file reviewed. (see findings in tag A0807)
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure each patient's discharge planning evaluation included an evaluation of the likelihood of a patient needing post-hospital services and of the availability of the services and an evaluation of the likelihood of a patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he or she entered the hospital. This was evident in the medical record of 4 (#1, #3, #4, #5) of 5 patient records reviewed for completion of the discharge planning evaluation from a sample of 5 patients.
Findings:

Review of the policy titled "Discharge Planning: Transition Record", presented by S1ADM as the hospital's discharge planning policy, revealed that discharge planning commences upon admission, and tentative discharge plans are established, reviewed, and modified throughout treatment. Further review revealed the intake staff initiates the patient's discharge plan during the time of admission. The treatment team members updates/reviews post discharge plans during weekly treatment team meetings or more frequently to determine if the discharge plan meets treatment needs of the patient. Discharge planning should encompass the following areas: review of precipitating events and stressors which led to current treatment and what resources the patient will need to deal with these events/stressors post-discharge; review of any daily living changes the patient may need to decrease relapse potential; family's needs post discharge; patient's/family's continued education needs; Social Services participates/facilitates discharge planning and develops mechanisms for exchanging information with services outside the facility, coordinates transportation arrangements, and notifies the patient and family of the date discharge will occur. Social Services conducts a discharge conference with the patient/family prior to discharge to finalize living arrangements and post-treatment care plans to meet ongoing needs for care and services.

Patient #1
Review of Patient #1's medical record revealed she was admitted on [DATE] after having a Physician's Emergency Certificate completed on 01/24/18 due to her being violent (confused and psychotic), a danger to herself, and gravely disabled. Further review revealed Patient #1 lived alone in an apartment, and her family support was her nephew.

Review of Patient #1's "Psychosocial Assessment And Multi Treatment Integration", documented by S2LMSW on 01/27/18 at 7:30 p.m., revealed no documented evidence whether her family support base was able or not able to provide adequate support/care for the patient. There was no documented evidence of an evaluation of the likelihood of Patient #1 needing post-hospital services and of the availability of the services and an evaluation of the likelihood of her capacity for self-care or of the possibility of her being cared for in the environment from which she entered the hospital.

In an interview on 02/01/18 at 12:08 p.m., S4LMSW indicated the patient's discharge planning evaluation is documented in the psychosocial assessment done by the social worker. He further indicated the evaluation of the likelihood of a patient needing post-hospital services and of the availability of the services and an evaluation of the likelihood of a patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he or she entered the hospital is discussed in treatment team, but there is no documentation of this discussion in Patient #1's medical record.

Patient #3
Review of Patient #3's medical record revealed she was admitted on [DATE] and discharged on [DATE]. Review of her "Psychosocial Assessment And Multi Treatment Integration", documented on 12/21/17 at 6:55 p.m. revealed that Patient #3 lived in a house with a friend. There was no documented evidence whether her family support base was able or not able to provide adequate support/care for the patient after discharge.

Review of Patient #3's Psychiatric Evaluation conducted by S5NP on 12/20/17 revealed "she was most recently living with her son. I do not know for how long, but now she does not want to live there and she wants to get her apartment back. She said she has talked to her landlord and she can pay $150 and get back to her Hammond apartment where her furniture is still at."

Review of Patient #3's discharge documentation revealed she was discharged on [DATE] and delivered by S7TD to the locked residence documented on her "Record of Admission" and left outside the locked residence (remained outside through the night of 12/28/17 until found on 12/29/17). There was no documented evidence that follow-up to S5NP's documentation that Patient #3 had been most recently living with her son had been done to clarify where Patient #3 was to be discharged . There was no documented evidence in Patient #3's medical record of an evaluation of the likelihood of Patient #3 needing post-hospital services and of the availability of the services and an evaluation of the likelihood of her capacity for self-care or of the possibility of her being cared for in the environment from which she entered the hospital.

In an interview on 02/01/18 at 12:38 p.m., S4LMSW confirmed the hospital staff did not follow-up to determine if Patient #3 was being discharged to her brother's home or whether she would be going back to her apartment. He further indicated when patient #3 gave her address to the apartment, she was brought there, and this resulted in her being left outside a locked residence by S7TD where she remained throughout the night of 12/28/17.

Patient #4
Review of Patient #4's medical record revealed she was admitted on [DATE] and discharged home on 01/02/18. Review of her "Psychosocial Assessment And Multi Treatment Integration", documented on 12/25/17 at 3:20 p.m. by S3LMSW, revealed that she lived at home with her son. There was no clear documentation whether her family support base was able or not able to provide adequate support/care for her after discharge.

Review of Patient #4's Psychiatric Evaluation revealed S9MD documented that she had sitters at home, and her son was not reliable and refused nursing home placement for his mother. There was no documented evidence in Patient #4's medical record of an evaluation of the likelihood of Patient #4 needing post-hospital services and of the availability of the services and an evaluation of the likelihood of her capacity for self-care or of the possibility of her being cared for in the environment from which she entered the hospital. There was no documented evidence of follow-up by hospital staff with the sitters who had been providing care prior to Patient #4's hospitalization .

In an interview on 02/01/18 at 12:08 p.m., S4LMSW indicated the evaluation of the likelihood of a patient needing post-hospital services and of the availability of the services and an evaluation of the likelihood of a patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he or she entered the hospital is discussed in treatment team, but there is no documentation of this discussion in Patient #4's medical record.

Patient #5
Review of patient #5's medical record revealed she was admitted on [DATE] and discharged on [DATE]. Review of her "Psychosocial Assessment And Multi Treatment Integration", documented on 12/05/17 at 3:30 p.m. by S4LMSW, revealed she lived with relatives. There was no documented evidence whether her family support was able or not able to provide adequate support/care for her after discharge. There was no documented evidence in Patient #5's medical record of an evaluation of the likelihood of Patient #5 needing post-hospital services and of the availability of the services and an evaluation of the likelihood of her capacity for self-care or of the possibility of her being cared for in the environment from which she entered the hospital.

In an interview on 02/01/18 at 12:08 p.m., S4LMSW indicated the evaluation of the likelihood of a patient needing post-hospital services and of the availability of the services and an evaluation of the likelihood of a patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he or she entered the hospital is discussed in treatment team, but there is no documentation of this discussion in Patient #5's medical record.
VIOLATION: QUALIFIED DISCHARGE PLANNING PERSONNEL Tag No: A0807
Based on record review and interview, the hospital failed to ensure a registered nurse, social worker, or other appropriately qualified personnel developed, or supervised the development of, the discharge planning evaluation as evidenced by S4LMSW self-assessing himself as having moderate experience in the principles of the discharge planning process and familiarity with available discharge planning and his supervisor's evaluation revealing he needed additional training/supervision in familiarity with available discharge planning with no documented evidence that further training and/or supervision had been provided for 1 (S4LMSW) of 1 discharge planning staff personnel file reviewed.
Finding:

Review of the employee list presented by S1ADM as the list of current staff employed at the hospital revealed no documented evidence that a position of discharge planner was included.

Review of the policy titled "Discharge Planning: Transition Record", presented by S1ADM as the hospital's discharge planning policy, revealed that discharge planning commences upon admission, and tentative discharge plans are established, reviewed, and modified throughout treatment. Further review revealed the intake staff initiates the patient's discharge plan during the time of admission. The treatment team members updates/reviews post discharge plans during weekly treatment team meetings or more frequently to determine if the discharge plan meets treatment needs of the patient. Social Services participates/facilitates discharge planning and develops mechanisms for exchanging information with services outside the facility, coordinates transportation arrangements, and notifies the patient and family of the date discharge will occur. Social Services conducts a discharge conference with the patient/family prior to discharge to finalize living arrangements and post-treatment care plans to meet ongoing needs for care and services.

Review of S4LMSW's personnel file revealed he was hired on 02/01/17. Review of his "Competency Skill Checklist", signed by S4LMSW and his supervisor on 02/13/17, revealed S4LMSW self-assessed that he had moderate experience in the principles of the discharge planning process and familiarity with available discharge planning. He did not self-assess himself as being proficient/competent. Further review revealed S4LMSW's supervisor evaluated him as being in need of additional training/supervision in familiarity with available discharge planning. His supervisor's remediation plan included that the Clinical Director will continue to assess and provide training on becoming more familiar with discharge planning with re-review in 60 days. There was no documented evidence presented of further education provided to S4LMSW related to discharge planning and a re-review /re-assessment of competency related to discharge planning.

In an interview on 02/01/18 at 12:38 p.m., S4LMSW confirmed that he is responsible for discharge planning. He indicated he has a lot to learn about discharge planning and probably wasn't adequately trained.

In an interview on 02/01/18 at 3:05 p.m., S1ADM indicated more education would have to be provided to S4LMSW if S4LMSW didn't think he received adequate training for discharge planning.
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
Based on record reviews and interview, the hospital failed to ensure that the patient and family members were counseled to prepare them for post-hospital care as evidenced by failing to ensure that patients and family members were informed of and provided a list of all medications the patient should be taking after discharge that included clear indication of changes from the patient's pre-admission medications for 3 (#3, #4, #5) of 3 patient discharged records reviewed from a total sample of 5 patients.
Findings:

Review of the policy titled "Discharge Planning: Transition Record", presented by S1ADM as the hospital's discharge planning policy, revealed that nursing would review the patient's medication regimen and educate on medications at discharge. Further review revealed the therapist and/or nurse would provide the discharge medication list to other service providers when the patient was transferred or discharged . There was no documented evidence that the policy required the hospital to provide a list of medications that included a clear indication of changes from the patient's pre-admission medications.

Review of the medical record of Patients #3, #4, and #5 revealed they had each been admitted and discharged from the hospital. Further review revealed each patient's discharge medication list did not include a clear indication of the changes in the medications prescribed at discharge from the medications the patients were taking prior to admission.

In an interview on 02/01/18 at 1:10 p.m., S2DON confirmed the hospital didn't have a process in place for the nursing staff to include giving patients a list of medications at discharge that included a clear indication of changes in the discharge medications from those that were being taken prior to admission.
VIOLATION: LIST OF HOME HEALTH AGENCIES Tag No: A0823
Based on interview, the hospital failed to ensure a list of HHAs or SNFs was presented to patients for whom home health care or post-hospital extended care services were indicated and appropriate as determined by the discharge planning evaluation. The hospital did not have list of HHAs and SNFs to present for surveyor review.
Findings:

In an interview on 02/01/18 at 12:08 p.m., S4LMSW indicated he didn't have a list of HHAs and SNFs to present to patients when a patient is being referred for either service. He further indicated he has a "hodgepodge" list of HHAs that includes business cards, and he chooses an agency located in the area where the patient resides.