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.

SEASIDE BEHAVIORAL CENTER 4201 WOODLAND DRIVE NEW ORLEANS, LA Sept. 12, 2011
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, record review, and interviews the hospital failed to meet the Condition of Participation for Nursing Services by failing to ensure a Registered Nurse supervised and evaluated the care for each patient by failing to:
1a) accurately assess patients' skin daily which resulted in identification of wounds/skin tears by the surveyors for 4 of 5 patients observed for skin integrity (#1, #3, R1, R2)
1b) assess and stage wounds upon admit and weekly thereafter according to hospital protocol for 1 of 5 patients with wounds from a total sample of 7 patients and 2 random patients (#3, #R1, #R2)
1c) identify a Stage I pressure ulcer for 2 of 2 patients reviewed that had been transferred to an emergency department (#5 transferred to Hospital B) and (#6 transferred to Hospital A) from a total sample of 7 patients.
1d) to perform the admission nursing assessment of 1 of 7 sampled patients (#3) (See findings cited at A0395)
2a) ensure skin assessments were provided to geriatric patients at risk for developing skin integrity problems by nursing staff that were evaluated and deemed competent in the assessment of wounds for 19 of 19 Registered Nurses working at the hospital (entire Registered Nurse staff employed by the hospital)
2b) ensure wound care was provided by nursing staff that were evaluated and deemed competent in wound care for 19 of 19 Registered Nurses and 9 of 9 Licensed Practical Nurses working at the hospital (entire Registered Nurse and Licensed Practical Nurse staff employed by the hospital)
2c) ensure Nursing Staff did not delegate the responsibility for identifying skin integrity problems to Mental Health Technicians who were not licensed for assessing patients for 3 of 5 nursing staff interviewed about daily shift skin assessments (Registered Nurse S7, Licensed Practical Nurse S25, and Licensed Practical Nurse S18).
2d) ensure Registered Nurses did not delegate assessment of wounds to Licensed Practical Nurses as per Louisiana State Board of Nursing Declaratory Statement of Practice for Registered Nurses-Wound Care Management (see findings cited at A0397)
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**






Based on observation, record review, and interviews, the hospital failed to ensure the RN (registered nurse) supervised and evaluated the nursing care for each patient as evidenced by: 1) failure to accurately assess patients' skin daily which resulted in identification of wounds/skin tears by the surveyors of 4 of 5 patients observed for skin integrity (#1, #3, R1, R2) and identification of a Stage I pressure ulcer of 2 patients transferred to the emergency department (#5 transferred to Hospital B) and (#6 transferred to Hospital A); 2) failure to assess and stage wounds upon admit and weekly thereafter according to hospital protocol for 1 of 5 patients with wounds from a total sample of 7 patients and 2 random patients (#3, #R1, #R2); 3) failure to perform the admission nursing assessment of 1 of 7 sampled patients (#3); and 4) failure to assess and report abnormal vital signs to the physician for 2 of 7 sampled patients (#5, #6) : elevated blood pressure for 1 of 1 patient with a noted elevation of blood pressure from a sample of 7 patients (#5), low pulse rate for 1 of 1 patient with a noted low pulse rate from a sample of 7 patients (#6). Findings:

1) Failure to accurately assess patients' skin daily which resulted in identification of wounds/skin tears by the surveyors and identification of a Stage I pressure ulcer of 1 patient transferred to the emergency department of Hospital B (#1) and 1 patient transferred to the emergency department of Hospital A (#6) :

Patient #1
Review of Patient #1's record revealed the patient was admitted on [DATE] with diagnoses that included [DIAGNOSES REDACTED]

Review of Patient #1's "Wound Document Progress Sheet" dated 8/09/2011 (day of admission) 12:15 p.m. revealed "few minor scrapes, no significant tears". Further review revealed no documented evidence as to the location of the few minor scrapes".

Review of Patient #1's Daily Nursing note dated Tuesday 9/06/2011 (no documented time/ Tuesday is day designated for weekly wound assessments) revealed in part, "(Check marks indicating) skin Color normal, temperature warm dry, elastic." Further review revealed no check marks by excoriated, rash, skin tear, wound, or bruises."

Observations were made of Registered Nurse S5 performing skin assessments on 9/09/2011 at 1355 (1:55 p.m.) with Mental Health Technician S26 assisting. S5 identified a small open area on Patient #1's right inner buttock. S5 used a camera and took a picture of the wound. S5 was asked what the measurements of the wound were. S5 was located at the bedside of Patient #1. The photo had just been taken and the patient (#1) remained undressed. The tape measure used to take the photo, was within reach of the Registered Nurse (S5). S5 picked up the camera and reviewed the digital photo in an attempt to determine the measurements of the wound rather than measure the wound itself. It was not until surveyors requested she (S5) measure the actual wound, rather than use the photo for measurements, that S5 used tape and measured the actual wound (skin tear measuring 1/2 centimeter by 1 centimeter). S5 confirmed in a face to face interview on 9/09/2011 at 1355 (1:55 p.m.) that there had been no documented evidence of identification of Patient #1's skin tear to buttock prior to the current assessment.

During a face to face interview on 9/09/2011 at 1355 (1:55 p.m.), Registered Nurse S5 indicated there had been no documentation to indicate Patient #1 had previously been identified as having a wound to the patient's right inner buttock. S5 indicated she had not been aware of a wound to Patient #1's buttock prior to the assessment.

Patient #3
Review of Patient #3's medical record revealed she was admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]

Review of Patient #3's "Wound Document Progress Sheet" completed by LPN S18 on 08/29/11 revealed Patient #3 had a wound to the right outer heel that was healing, a Stage II 3cm by 2 cm pressure ulcer to the right outer/inner buttock, and a Stage I pressure ulcer 1cm by 0.5cm to the left outer buttock. Further review of Patient #3's medical record revealed no documented evidence a reassessment of Patient #3's wounds had been performed since admit (11 days).

Observation on 09/09/11 at 2:40pm of RN S7 performing a skin assessment of Patient #3 revealed the following wounds:
Skin tears to anus 1.0cm by 0.5cm with scant amount serosanguineous drainage, surrounding skin normal for ethnic group, tissue normal - these skin tears had not been previously identified by hospital staff prior to the skin assessment performed with the surveyors present;
Right hip Stage I pressure ulcer 1.5cm by 1.5cm , wound base callused, no odor, wound edges rolled and dry, surrounding skin normal for ethnic group, tissue scaly - this pressure ulcer had not been previously identified by hospital staff prior to the skin assessment performed with the surveyors present;
Left buttocks Stage II pressure ulcer 2.0cm by 0.5cm with reddened wound base, no odor, wound edges dry, surrounding skin normal for ethnic group, tissue normal;
Right heel Stage II pressure ulcer 2.25cm by 1cm with callused wound base, wound edges pink, rolled, and dry, surrounding skin normal for ethnic group, tissue dry and scaly;
Left heel Stage II pressure ulcer 1.0cm by 1.5cm with wound edges indurated, rolled, and dry, surrounding skin tissue hard (indurated), dry, scaly - this pressure ulcer had not been previously identified by hospital staff prior to the skin assessment performed with the surveyors present;
Left foot second toe Stage I pressure ulcer 1cm by 0.75cm with callused wound edges, tissue edematous (boggy) - this pressure ulcer had not been previously identified by hospital staff prior to the skin assessment performed with the surveyors present;
Right foot: second toe 1cm by 1cm; third toe 0.5cm by 0.5cm; little toe 1cm by 2cm; all areas of callous dry wound edges with little toe with reddened area - this pressure ulcer had not been previously identified by hospital staff prior to the skin assessment performed with the surveyors present.

In a face-to-face interview on 09/12/11 at 1:45pm, DON (Director of Nursing) S2, after reviewing Patient #3's medical record and the wound assessments performed on 09/09/11, confirmed the initial skin assessment did not include wounds to the anus, right hip, left heel, left foot, and the toes of the right foot. S2 indicated that based on the observations of 09/09/11, accurate skin assessments were not being performed. S2 indicated "people are being lazy and not looking at all the skin".

Patient R1
Review of Patient R1's medical record revealed she was admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]

Review of Patient R1's "Wound Document Progress Sheet" dated 09/07/11 at 2040 (8:40pm) by RN S30 revealed she (R1) had a bruise on the left forearm, healed areas on the front of both legs, and a PEG (percutaneous gastric tube) tube to the right abdomen.

Observation on 09/09/11 at 3:40pm of RN S7 performing a skin assessment of Patient R1 revealed the following wounds:
Right lower leg 8cm by 4cm bruise above the knee with no skin breakdown;
Bilateral lower extremities with mottled skin;
Right leg skin tear 1cm by 0.5cm with scant serosanguineous drainage, no odor, wound edges pink - not previously identified by hospital staff prior to the skin assessment performed with the surveyors present;
PEG tube to abdomen with scant amount brownish-red drainage with no odor; surrounding skin normal for ethnic group;
Under left breast pink area - not previously identified by hospital staff prior to the skin assessment performed with the surveyors present.

In a face-to-face interview on 09/09/11 at 4:15pm, DON S2, after reviewing Patient R1's medical record, confirmed the right leg skin tear and pink area under the left breast had not been identified on the initial skin assessment 09/07/11 and during any daily assessment performed since admit.

Patient R2
Review of Patient R2's medical record revealed she was admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]

Review of Patient R2's "Wound Document Progress Sheet" dated 09/07/11 at 1540 (3:40pm) by LPN S18 revealed she (R2) had no wounds at admit.

Observation on 09/09/11 at 3:15pm of RN S7 performing a skin assessment of Patient R2 revealed the following wounds:
Right buttock excoriation 5.5cm by 1cm - not previously identified by hospital staff prior to the skin assessment performed with the surveyors present;
Left inner thigh with reddened area - not previously identified by hospital staff prior to the skin assessment performed with the surveyors present;
Left buttock excoriation 1.5cm by 0.5cm - not previously identified by hospital staff prior to the skin assessment performed with the surveyors present.

Review of the "Wound Document Progress Sheet" completed by RN S7 on 09/09/11 and reviewed by surveyors on 09/12/11 revealed the following wounds:
Left buttocks Stage I pressure ulcer 5.5cm by 1.0cm with reddened wound base, dry wound edges, surrounding skin normal for ethnic group, tissue dry (observed by surveyors to be the wound to the right buttocks);
Right buttocks Stage II pressure ulcer 1.5cm by 0.5cm with reddened wound base, no odor, dry wound edges, surrounding skin normal for ethnic group, tissue dry and scaly (observed by surveyors to be the wound to the left buttock);Left inner thigh with reddened wound base, wound edges intact, and normal tissue;
Left heel with dry callused wound edges, no odor, surrounding skin tissue hard (indurated), dry, scaly.

In a face-to-face interview on 09/09/11 at 4:15pm, DON S2, after reviewing Patient R2's medical record, could offer no explanation for not having identification and subsequent assessment by the RN of the 3 wounds identified during the skin assessment performed with the surveyors present that were not present on admit on 09/07/11.

Patient #5
Review of Patient #5's medical record revealed she was admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]

Review of the "Daily Treatment Plan Update and Team Progress Note" dated 06/11/11 at 2015 (8:15pm) revealed Patient #5 was transferred to the emergency room at the request of her daughter and the order from Physician S16 via Nurse Practitioner S8. Review of the "Nurses Notes" for 06/11/11 revealed no documented evidence that Patient #5 had skin tears, wounds, or bruises.

Review of the "History and Physical Examination" documented by Physician S32 at Hospital B revealed "she has a circular area of nonblanching [DIAGNOSES REDACTED] directly over the sacrum measuring 3-4 cm in diameter but no skin breakdown, consistent with a stage I pressure ulcer on the sacrum.

In a face-to-face interview on 09/12/11 at 10:40am, Physician S16, when informed of the wounds identified during the surveyors' observation of skin assessments on 09/09/11, indicated the RN should do the initial skin assessments at admit, but since they're so busy, the RNs have to rely on the CNAs' (certified nursing assistant) report of abnormalities.

In a face-to-face interview on 09/12/11 at 1:45pm, DON S2 indicated a wound/skin assessment, Braden Scale assessment, and a photograph of any wounds was done on admission and every Tuesday thereafter. S2 further indicated that "based on observations by you all, it's not being done, people are being lazy and not looking at all the skin".

Review of the hospital policy titled, "Wound Assessment and Documentation, # NS-026" presented by the hospital as current, revealed in part, " Policy: All wounds will be assessed on admission and with each dressing change. Overview: Assessment is a continuous process that serves to provide data/information about the wound status, it ' s etiology and the efficacy of the interventions. It is very important to make the observations as measurable as possible." Review of the entire policy revealed no documented evidence that a reassessment of wounds was required every week, and the policy did not address that the wound assessment and staging had to be performed by a RN.

Patient #6:
Patient #6 was admitted on [DATE] with diagnoses that included [DIAGNOSES REDACTED]

Review of Patient #6's medical record revealed the following:
Daily Nursing Assessment: 3/01/2011 7p - 7a, Skin Condition (no documented check marks)
Daily Nursing Assessment: 3/02/2011 7a - 7p and 7p - 7a, Skin Condition (no documented check marks)
Daily Nursing Assessment: 3/03/2011 7a - 7p , Skin Condition (no documented check mark) and 7 p - 7 a, Skin Condition (check mark) Skin Tears/Wound
Photo: 3/03/2011 photo with no documented time and no documentation revealing what appears to be superficial laceration to the bend of an extremity, difficult to determine if it is knee or elbow,
Daily Nursing Assessment: 3/04/2011 7a - 7p, Skin Condition (check mark) Bruises, 7p - 7a, Skin Condition (check mark) Skin Tears, Wound, Bruises
Daily Nursing Assessment: 3/05/2011 7a - 7p, Skin condition (check mark) Skin Tears, Wound, Bruises, 7p - 7a (no documented check marks)
Daily Nursing Assessment: 3/06/2011 7a - 7p and 7p - 7a Skin Condition (check mark) Skin Tears, Wound, Bruises
Daily Nursing Assessment: 3/07/2011 7a - 7p and 7p - 7a Skin Condition (check mark) Skin Tears, Wound
Daily Nursing Assessment: 3/08/2011 7a - 7p and 7p - 7a Skin Condition (check mark) Skin Tears, Wound, Bruises
Daily Nursing Assessment: 3/09/2011 7a - 7p and 7p - 7a Skin Condition (check mark) Skin Tears, Wound, Bruises
Daily Nursing Assessment: 3/10/2011 7a - 7p and 7p - 7a Skin Condition (no documented check marks)
Daily Nursing Assessment: 3/11/2011 7a - 7p and 7p - 7a (check mark) Skin Tears, Wound
Daily Nursing Assessment: 3/12/2011 Skin Condition 7a - 7p no documented check marks
Daily Treatment Plan Update and Team Progress Note: (Registered Nurse S29) " multiple bruises l (left) leg , l (left) shoulder
Discharge Summary/dictated 4/14/2011 (no documented time): " On 3/12/2011, later in the day, the nursing staff noted that the patient had become increasingly confused, disorganized. He had some bruises noted on his legs and left shoulder. . . "

Review of Patient #6's entire medical record revealed no documented descriptive notes regarding assessment of Skin Tears, Wounds, or Bruises for Patient #6 to include location and size. Check marks documented on Daily Nursing Assessment next to "Skin Tears/Wound" revealed no documented evidence as to whether the patient had skin tears or wounds or both.

Review of the Medical Record and Incident/Occurrence Report for Patient #6 at Hospital A (Hospital where Patient #6 was transferred on 3/12/2011 from Seaside Behavioral Center) revealed in part, "Occurrence Date: 3/12/2011, time 1940 (7:40 p.m.) Location of ulcer on patient : Sacrum. Ulcer Stage: Stage 1, Where Ulcer acquired? Present on Admission. Unblanchable redness to sacral area with a purple center." Review of Medical record revealed Patient #6's skin assessments as follows:
3/12/2011 at 1803: [DIAGNOSES REDACTED] and warmth noted to a large area of the upper right calf, no knee joint involvement.
3/12/2011 at 1807: No Abuse/Neglect suspected.
3/12/2011 at 19:20: Wound evaluation: Patient presents with an abrasion located on the right calf. The wound appears to have redness to be swelling. Redness is circumferential from knee to distal calf. Calf is warm to touch, pedal pulses palpated to bilat (bilateral) LE (lower extremity). Patient also has a history of gangrene to right foot 3rd digit, today has redness, minimal swelling and bloody discharge from around the nail bed. 2 small abrasions noted to forehead with swelling on the left side of the forehead. Patient daughter at the bedside, states these wounds were not present yesterday when she visited him at Seaside.
3/12/2011 at 19:41: On assessment, patient was rolled over to left side to have back and sacrum assessed. Bruising noted to left flank. Patient's daughter states that was present for last few days.
3/12/2011 at 20:25: He does have a new area of Cellulitis on his right lower leg, and this could possible be responsible for his mental status change. . .
3/12/2011 at 22:50: Ecchymosis back, L (left) lateral side, bil (bilateral) arms, Skin Tear Right leg, Knot to L (left) forehead. Cellulitis right knee, Pressure Ulcer, Sacral, Stage I, Non blanchable, red, partial thickness tissue loss.

During a face to face interview on 9/09/2011 at 1620 (4:20 p.m.), Director of Nursing S2 indicated she had reviewed the Medical Record for Patient #6. S2 indicated she had found multiple instances where nursing staff (Registered Nurses and Licensed Practical Nurses) had checked off bruises, skin tears, and wounds for Patient #6. S2 indicted she was not able to find any documented evidence of skin assessments for the wounds, skin tears, and bruises that were identified with check marks. S2 indicated the only documentation regarding location of bruises that she found was on 3/12/2011 when Registered Nurse S29 documented bruises to left leg and left shoulder. S2 indicated there would be no way to determine the number, location, size, or any other characteristics of the skin integrity issues for Patient #6 without properly documented assessments. S2 confirmed there had been no documented evidence that Patient #6 had a sacral wound during his entire hospital stay.


2) Failure to assess and stage wounds upon admit and weekly thereafter according to hospital policy:
Patient #3
Review of Patient #3's medical record revealed she was admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]

Review of Patient #3's "Wound Document Progress Sheet" completed by LPN (licensed practical nurse) S18 on 08/29/11 ( 2 of 3 sheets were not dated and 1 of 3 sheets had no evidence of the nurse's signature who performed the assessment) revealed the following documentation of wounds:
Wound 1 of 3: right outer heel, healing, wound edges intact, surrounding skin normal for ethnic group, and tissue was dry, scaly; there was no documented evidence of a measurement, appearance of the wound base, presence or absence of odor, and presence or absence of undermining and/or tunneling which were areas required on the assessment form;
Wound 2 of 3: right outer/inner buttock Stage II 3 cm (centimeters) length by 2 cm width with no odor, macerated wound edges, and surrounding skin was normal for ethnic group and tissue was normal; there was no documented evidence of appearance of the wound base and presence or absence of undermining and/or tunneling which were areas required on the assessment form;
Wound 3 of 3: left outer buttock Stage I 1 cm length by 0.5 cm width with no odor, wound edges intact and dry, and surrounding skin normal for ethnic group and tissue normal; there was no documented evidence of appearance of the wound base and presence or absence of undermining and/or tunneling which were areas required on the assessment form.
Review of Patient #3's "Braden Risk Assessment" revealed it was performed on 08/29/11 at 1700 (5:00pm) by LPN S18.
Review of Patient #3's entire medical record revealed no documented evidence that a RN assessed and staged her (#3) wounds upon admit. Further review of the record on 09/09/11 revealed no documented evidence Patient #3's wounds had been reassessed since admit which was eleven days prior to the record review.

In a face-to-face interview on 09/09/11 at 4:15pm, DON (director of nursing) S2 indicated a thorough head-to-toe skin assessment was to be done upon admission and weekly on Tuesday after that for any patient identified with wounds. S2 further indicated her expectation was that the nurses were to perform a head-to-toe skin assessment every day. After reviewing Patient #3's medical record, S2 confirmed another wound assessment had not been performed since admit, which was eleven days ago. S2 could offer no explanation for the hospital policy not addressing the need for a wound reassessment every week and that the assessment and staging needed to be performed by a RN.

In a face-to-face interview on 09/12/11 at 9:30am, LPN S18 confirmed he performed the wound assessment and staging of Patient #3's wounds upon admit. S18 further confirmed there was no RN signature on the "Wound Document Progress Sheet" completed by him on 08/29/11.

Review of the hospital policy titled, "Wound Assessment and Documentation, # NS-026" presented by the hospital as current, revealed in part, " Policy: All wounds will be assessed on admission and with each dressing change. Overview: Assessment is a continuous process that serves to provide data/information about the wound status, it's etiology and the efficacy of the interventions. It is very important to make the observations as measurable as possible." Review of the entire policy revealed no documented evidence that a reassessment of wounds was required every week, and the policy did not address that the wound assessment and staging had to be performed by a RN.

Review of the Louisiana State Board of Nursing "Declaratory Statement Scope of Practice for Registered Nurses-Wound Care Management" revealed in part, "The Registered Nurse initiates appropriate wound preventative measures, stages wounds and collaborates with the wound care team (physician, other registered nurses, dietician, physical therapist, occupational therapist, social workers, and orthotist) in the implementation and evaluation of nursing interventions as prescribed by an authorized prescriber. Delegation- In accord with the Law Governing the Practice of Nursing the registered nurse may delegate select nursing interventions to qualified nursing personnel as set forth in the board's rules on delegation. The Registered Nurse retains the accountability for the total nursing care of the individual. The Registered Nurse may delegate to a Licensed Practical Nurse wound care interventions in any situation when the Registered Nurse has deemed (through assessment) the patient's status is stable, the intervention is based on a relatively fixed and limited body of scientific knowledge, can be performed by following a defined nursing procedure with minimal alteration, responses of the individual to the nursing care are predictable and changes in the patient's clinical condition are predictable. Further more, the patient's medical and nursing orders are not subject to continuous change or complex modification, appropriate RN (Registered Nurse) supervision is available, and provided that the LPN (Licensed Practical Nurse) has been adequately trained and demonstrates competency is documented in the LPN's file."


3) Failure to perform the admission nursing assessment:
Patient #3
Review of Patient #3's medical record revealed she was admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]

Review of the "Admit Nursing Assessment Form" dated 08/29/11 at 1615 (4:15pm) revealed LPN S18's signature in the blank labeled "RN Signature/Date". Further review revealed RN S17's signature at the bottom of the page with the date of 08/29/11. Further review revealed no documented evidence of a time for the signatures of LPN S18 and RN S17.

In a face-to-face interview on 09/12/11 at 8:40am, RN S17, when asked by the surveyor to explain the admit process for Patient #3, indicated "LPN S18 admitted her and we assessed her together".

In a face-to-face interview on 09/12/11 at 9:00am (interview had to be interrupted for a moment), RN S17 indicated LPN S18 did the physical assessment of Patient #3 at admission, and she (RN S17) was in the room at the same time.

In a face-to-face interview on 09/12/11 at 9:30am, LPN S18 indicated he auscultated Patient #3's breath sounds, apical pulse, and bowel sounds. S18 further indicated if he found an abnormality when he performed the physical assessment of lung sounds, apical heart rate, and bowel sounds, the RN would reassess behind him, but if not, the RN trusts his ability. LPN S18 confirmed RN S17 did not auscultate the lungs, apical heart rate, and abdominal bowel sounds of Patient #3.

Review of the hospital policy titled "Assessments", policy number PP-013 reviewed 02/13/09, revealed, in part, "...Nursing assessments shall be completed by a Registered Nurse during the admission process within 8 (eight) hours of admission. The Nursing assessment shall include a nutritional screening. A Registered Nurse will assess each patient at least every 24 hours; as soon as there is a change in a patient's condition; and upon a patient's return from receipt of Emergency Services...".

4) Failure to assess and report abnormal vital signs:
Patient #5
Review of Patient #5's medical record revealed she was admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]

Review of Patient #5's "Admit Nursing Assessment Form" completed on 05/31/11 at 2150 (9:50pm) by RN S30 revealed her blood pressure was 185/103. Review of the "Treatment Team Progress Notes" dated 05/31/11 at 2150 revealed RN S30 documented "B/P (blood pressure) 197/116 - rechecked manually 185/103..." Further review revealed no documented evidence Patient #5's blood pressure was reported to a physician. There was no documented evidence the blood pressure was rechecked until the vital signs were taken on 06/01/11 at 8:00am.

In a face-to-face interview on 09/12/11 at 12:30pm, Medical Director S13 indicated Patient #5's blood pressure of 185/103 should have been reported to him or the medical doctor.

Review of the hospital policy titled "Assessments", policy number PP-013 reviewed 02/13/09, revealed, in part, "...A Registered Nurse will assess each patient at least every 24 hours; as soon as there is a change in a patient's condition ...". Further review revealed no documented evidence that the assessment should result in notification of the patient's physician of the change in condition.

Patient #6:
Patient #6 was admitted on [DATE] with diagnoses that included [DIAGNOSES REDACTED].m. Review of Patient #6's entire medical record revealed no documented evidence of an RN (Registered Nurse) assessment of the low pulse rate and no documented evidence that Patient #6's physician had been notified.

During a face to face interview on 9/09/2011 at 9:30 a.m., Registered Nurse S7 indicated she was the nurse assigned to the care of Patient #6 on 3/11/2011. S7 indicated her normal practice was to review the vital sign sheet on all patients as recorded by Mental Health Technicians (MHT). S7 indicated her normal practice included documented re-assessment of any abnormal vital signs taken by MHT which would include an apical pulse if there was an abnormal pulse reading by a MHT. S7 indicated her normal practice would be to notify the patient's physician if her assessment confirmed the abnormal readings obtained by a MHT. S7 indicated she must not have seen Patient #6's pulse rate of 49 or she would have documented a re-assessment of the vital sign and any action taken. S7 indicated a pulse rate of 49 was very low in a patient with no prior history of low heart rates.

During a face to face interview on 9/12/2011 at 12:40 p.m., Physician S13 indicated he had never been informed of a pulse rate of 49 for Patient #6. S13 further indicated he would have wanted to be informed of any heart rate/pulse that was less than 55.

Review of the hospital policy titled, "Routine Vital Signs, NS-003" presented by the hospital as current revealed in part, "Significant changes in Vital (signs) should also be documented in the nurses' notes and called to the physician."
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure: 1) nursing staff developed a nursing care plan for patients who were admitted to the hospital for aggressive behavior that included interventions to ensure the safety of the patient and peers that might be exposed to the aggressive behavior of the patient for 4 of 4 sampled patients with documented history of aggressive behaviors out of a total sample of 7 (#3, #5, #6, #7); and 2) the nursing staff implemented the physician's plan of care for weights, nutritional supplements, and wound care for 2 of 7 sampled patients (#3, #6). Findings:

1) Nursing staff developed a nursing care plan for patients who were admitted to the hospital for aggressive behavior that included interventions to ensure the safety of the patient and peers that might be exposed to the aggressive behavior of the patient:

Patient #3
Review of Patient #3's medical record revealed she was admitted on [DATE] with diagnoses of Dementia with Behavioral Disturbance, Anemia, Diabetes Mellitus Type I, Hypertension, Renal Insufficiency, Osteoarthritis, Gastrointestinal Bleed, and Acute Diverticulitis.

Review of "Progress Notes" dictated by Physicians S12 and S13 revealed the following reports:
08/31/11 - "the staff reports that the patient has been quite agitated and hits staff";
09/02/11 - "she was fighting, spitting the last couple of days";
09/05/11 - "was hitting visitors there (at nursing home), hit a nurse here yesterday";
09/06/11 - "patient is very agitated, angry, and upset. She bit one of the staff members earlier when she was trying to help the patient. She gets very aggressive. She has been abusive towards the staff";
09/07/11 - "she has been hitting and scratching staff when they attempt to assist her".

Review of Patient #3's "Master Treatment Plan", developed 08/29/11, revealed, in part, "...Problem #1 combative, aggressive manifested by hit staff numerous times - different staff members... Interventions: MD - Pharm (pharmaceutical)/medical management, RN/LPN (Registered Nurse/ Licensed Practical Nurse) - Administer medication & (and) report response. Monitor mood/behavior. Redirect as needed. Provide calm environment. ... AT (activity therapy) - group therapy. ... SW (social worker) - group therapy...". Review of the "Treatment Plan Review" documented on 09/06/11 revealed, in part, "...Problem #1 Combative, aggressive Progress: Pt (patient) continues to demonstrate both physical and verbal aggressive behavior. Pt hit staff nurse on 09/04/11. Changes in Goals or Interventions ... Continue with current Tx (treatment) plan and develop better coping skills...". Review of Patient #3's entire Medical Record revealed no documented evidence of any safety interventions to ensure Patient #3 was protected from injuring herself and others during behavioral outbursts.

Patient #5
Review of Patient #5's medical record revealed she was admitted on [DATE] with diagnoses of Dementia with Behavioral Disturbance, Hypertension, history of Atrial Fibrillation, Congestive Heat Failure, and Parkinson's Disease. Further review revealed he was admitted by "Physician Emergency Certificate" due to agitation and aggressive behavior (patient struck another resident). Review of Patient #5's "Master Treatment Plan" developed on 08/29/11 revealed, in part, "...Problem #1 Physically aggressive manifested by hit another resident at the nursing home... Interventions: MD - Med (medication)/pharm management... RN/LPN - Provide a safe environment. Redirect as needed. Administer meds as needed. Monitor for pain, V.S. (vital signs), physically assessment... AT - Group therapy ... SW - Group therapy...". Review of Patient #5's entire Medical Record revealed no documented evidence of any safety interventions to ensure Patient #5 was protected from injuring himself and others during behavioral outbursts.

Patient #6:
Review of Patient #6's Medical Record revealed the patient was admitted on [DATE] with diagnoses that included Dementia with Behavioral Disturbance. Further review of Patient #6's Psychiatric Evaluation dictated 3/02/2011 revealed in part, "The patient was having increased combativeness and had hit several staff members." Review of Patient #6's "Master Treatment Plan" revealed in part, "Problem #1 Dementia (with) Behavioral Disturbances manifested by kicking aide (with) aggressive behaviors at staff. Interventions: MD: Pharm/Medical management, RN/LPN: Monitor for improved behavior toward staff (and) peers/ encourage group participation to develop coping mechanism. . AT: Grp (group) therapy. . SW: Grp. therapy. . . Review of Patient #6's entire Medical Record revealed no documented evidence of any safety interventions to ensure Patient #6 was protected from injuring himself and others during behavioral outbursts.

Patient #7:
Review of Patient #7's Medical Record revealed the patient was admitted on [DATE] with diagnoses that included Alzheimer's dementia with behavioral disturbance. Further review of Patient #7's "Admit Nursing Assessment Form" dated 8/16/2011 at 1610 (4:10 p.m.) revealed in part, "Reason for admission: flipping over tables and chairs at nursing home, hitting staff, grabbing and shaking other residents". Review of Patient #7's "Master Treatment Plan" revealed in part, "Primary Problems are: 1. Aggressive and Combative Behavior. Interventions: MD (Medical Doctor) Med-pharm management (Medical Pharmaceutical management), RN/LPN: (no documented evidence of any interventions), AT (Activity Therapy): Group Therapy. . . SW (Social Worker): Group Therapy." Review of Patient #7's entire Medical Record revealed no documented evidence of any safety interventions to ensure Patient #7 was protected from injuring himself and others during behavioral outbursts.

Review of the hospital's entire policy and procedure manual revealed no documented evidence of a policy to address safety interventions for patients that had exhibited behavioral disturbances that included acts of aggression towards self, staff, and peers.

During a face to face interview on 9/09/2011 at 1620 (4:20 p.m.), Director of Nursing S2 indicated the hospital had previously had a policy which addressed violence/aggressive precautions; however, it had been deleted with a previous administration change. S2 indicated the hospital did not have any current policy regarding behavioral interventions for patients with aggressive behavior to ensure the safety of the patient, staff, and peers. S2 confirmed the Master Treatment Plans for Patients #3, #5, #6, and #7 failed to include interventions to ensure the safety of the patient, staff, and peers from aggressive behaviors of the patients.

Review of the hospital policy titled, "Treatment Planning, Effective 5/01/2011" presented by the hospital as their current policy revealed in part, "Interventions, Responsible Staff, and Frequency: A. The intervention strategies are the actions and approaches to be taken by the staff in assisting the patient in resolving the identified problem and reaching the discharge goal. . . Intervention strategies must be very specific."

2) Nursing staff implemented the physician's plan of care for weights, nutritional supplements, and wound care:
Patient #3
Review of Patient #3's medical record revealed she was admitted on [DATE] with diagnoses of Dementia with Behavioral Disturbance, Anemia, Diabetes Mellitus Type I, Hypertension, Renal Insufficiency, Osteoarthritis, Gastrointestinal Bleed, and Acute Diverticulitis.

Review of Patient #3's "Physician Orders" dated 08/29/11 at 1615 (3:15pm) revealed the following orders: weigh on admit and weekly on Thursday; Glucerna 1 can TID (three times a day) with meals; and Stage 2 ulcer left buttock clean with normal saline, apply duoderm, and change every three days.

Review of the "Admit Nursing Assessment Form" of 08/29/11 at 1615 (4:15pm) revealed a note by LPN (licensed practical nurse) S18 that Patient #3 was combative and refused her height and weight to be taken. Review of the "Graphic Sheet" and the "Nurses Notes" revealed no documented evidence an attempt was made to weigh and assess the height of Patient #3 until 09/01/11, three days after she was admitted .

Review of Patient #3's MAR for 08/31/11 and 09/03/11 revealed no documented evidence Glucerna was served at 12:00pm and 5:00pm at meal time as ordered. Further review revealed no documented evidence wound care was performed on 09/08/11 as ordered.

In a face-to-face interview on 09/12/11 at 1:45pm, DON (director of nursing) S2 could offer no explanation for the nursing staff not following the physician's orders for Patient #3.

Patient #6:
Review of Patient #6's medical record revealed the patient was admitted on [DATE] with Diagnoses that included Dementia with Behavioral Disturbance. Further review revealed physician's orders dated 3/01/2011 at 2100 (9:00 p.m.) for "Med Pass 2.0 2 oz (ounces) bid (twice per day)."

Review of Patient #6's Medication Administration Record revealed Patient #6 failed to receive the Nutritional Supplement, Med Pass, on 3/01/2011 at 9:00 p.m., 3/07/2011 at 9:00 a.m. and 9:00 p.m., and 3/10/2011 at 9:00 a.m.. Further review revealed Patient #6 was administered Ensure (no amount documented) on 3/11/2011 at 9:00 a.m. and 9:00 p.m. with no physician's order.

Review of Nutrition Facts for Med Pass revealed serving size to be 2 ounces with calories per serving to be 480 and Protein 20 grams.

Review of Nutrition facts for Ensure revealed serving size to be 8 ounces with calories 250 and protein 9 grams.

Review of the hospital policy titled, "Food and Nutritional Services, NS-055" presented by the hospital as current, revealed in part, "The Dietary coordinator/Quality Manager shall: e. Ensure the procurement of all items necessary for nutritional service provision within the program."

During a face to face interview on 9/12/2011 at 1430 (2:30 p.m.), Director of Nursing S2 indicated the hospital's Dietary Manager was out and not available for interview. S2 further indicated Patient #6 should have received Supplements as ordered by the patient's physician. S2 further indicated if the Supplement ordered by the patient's physician was not available the nurse responsible for the care of the patient should have called the physician to determine if he/she wished to order a different supplement for the patient.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review, and interview the hospital failed to ensure:
1) assessment of skin was provided to geriatric patients at risk for developing skin integrity problems by nursing staff that were evaluated and deemed competent in the assessment of wounds for 19 of 19 Registered Nurses working at the hospital (entire Registered Nurse staff employed by the hospital)
2) wound care was provided by nursing staff that were evaluated and deemed competent in wound care for 19 of 19 Registered Nurses and 9 of 9 Licensed Practical Nurses working at the hospital (entire Registered Nurse and Licensed Practical Nurse staff employed by the hospital)
3) Nursing Staff did not delegate the responsibility for identifying skin integrity problems to Mental Health Technicians who were not licensed for assessing patients for 3 of 5 nursing staff interviewed about daily shift skin assessments (Registered Nurse S7, Licensed Practical Nurse S25, and Licensed Practical Nurse S18).
4) Registered Nurses did not delegate assessment of wounds to Licensed Practical Nurses as per Louisiana State Board of Nursing Declaratory Statement of Practice for Registered Nurses-Wound Care Management.
Findings:

1)
Director of Nursing S2 provided surveyors a list of all Nursing Staff employed by the hospital. Review of the list revealed there were 19 Registered Nurses (RN) on staff at the hospital.

Review of the hospital's "Admission Criteria" presented by the hospital as current revealed in part, "As a gero-psychiatric service, patients will typically be [AGE] or over, or those individuals under 55 who have "end of life" issues."

During a face to face interview on 9/09/2011 at 1620 (4:20 p.m.), Director of Nursing S2 indicated due to serving Geriatric Psychiatric patients, many of the patients had medical issues as well as psychiatric issues. S2 further indicated many of the patients admitted to the hospital were at moderate to high risk for developing pressure ulcers and/or skin tears. S2 indicated none of the 19 Registered Nurses working at the hospital had been evaluated for competency in assessment of wounds.

Observations were made of Registered Nurse S5 performing skin assessments on 9/09/2011 at 1355 (1:55 p.m.) with Mental Health Technician S26 assisting. S5 identified a small open area on Patient #1's right inner buttock. S5 used a camera and took a picture of the wound. S5 was asked what the measurements of the wound were. S5 was located at the bedside of Patient #1. The photo had just been taken and the patient (#1) remained undressed. The tape measure used to take the photo, was within reach of the Registered Nurse (S5). S5 picked up the camera and reviewed the digital photo in an attempt to determine the measurements of the wound rather than measure the wound itself. It was not until surveyors requested she (S5) measure the actual wound, rather than use the photo for measurements, that S5 used tape and measured the actual wound (skin tear measuring 1/2 centimeter by 1 centimeter).

During a face to face interview on 9/12/2011 at 8:50 a.m., Registered Nurse S17 indicated she (S17) had been told by someone; although she (S17) could not recall whether it had been someone at the hospital or someone from nursing school, that the only staff qualified to perform staging of wounds were wound care nurses. S17 confirmed there were no wound care nurses at the hospital. S17 indicated she (S17) would use the sending facility's assessment to document pre-existing pressure wounds.

During a face to face interview on 9/09/2011, Advanced Practice Nurse S8 (collaborative practice with Medical Internist S16) indicated she only assessed the skin for areas of the body that she could see easily such as exposed areas of the patients arms and legs. S8 further indicated she would look at exposed areas of the patient's chest and back when she assessed the patient's lungs and heart.

During a face to face interview on 9/09/2011 at 1640 (4:40 p.m.), Director of Nursing S2 indicated all nursing staff (Registered Nurse and Licensed Practical Nurses) were expected to do head to toe skin assessments every shift (12 hour shift). S2 indicated the Registered Nurse or Licensed Practical Nurse assigned to the patient's care was responsible for these assessments. S2 indicated a photo should never be used for measurements of a wound. S2 indicated the wound should be measured directly.

2)
Director of Nursing S2 provided surveyors a list of all Nursing Staff employed by the hospital. Review of the list revealed there were 19 Registered Nurses (RN) and 9 Licensed Practical Nurses (LPN) on staff at the hospital.

During a face to face interview on 9/09/2011 at 1620 (4:20 p.m.), Director of Nursing S2 indicated due to serving Geriatric Psychiatric patients, many of the patients had medical issues as well as psychiatric issues. S2 further indicated many of the patients admitted to the hospital were at moderate to high risk for developing pressure ulcers and/or skin tears. S2 indicated none of the 19 Registered Nurses or 9 Licensed Practical Nurses working at the hospital had been evaluated for competency in providing wound care.

During a face to face interview on 9/12/2011 at 9:40 a.m., Licensed Practical Nurse S18 indicated he (S18) and other LPNs at the hospital provided wound care to patients with wounds that were assigned to their care. S18 indicated he had had no formal training at the hospital regarding wound care and no formal competency evaluation of his ability to perform wound care.

3)
During a face to face interview on 9/09/2011 at 9:30 a.m., Registered Nurse S7 indicated she (S7) depended on Mental Health Technicians (MHT) to inform her (S7) if there were any abnormalities of the skin that they (MHT) noticed when they (MHT) were performing incontinence care or hygiene to patients. S7 indicated she would perform some assessments of patient's skin when they (patients) were sitting in a chair and parts of their arms and legs were exposed. S7 further indicated that she (S7) would do a more in depth skin assessment when a Mental Health Technician would inform her (S7) that a patient had a problem with their skin.

During a face to face interview on 9/12/2011 at 9:40 a.m., Licensed Practical Nurse S18 indicated (S18) he would trust the Mental Health Technicians at the hospital to notify him if they found any skin abnormalities during their care of patients during showers or diaper changes. S18 indicated he would assess the patient's skin abnormality after being told by a Mental Health Technician that the patient had a problem with skin integrity. S18 indicated it had not been his practice to do Daily Head to Toe skin assessments of patients assigned to his care.

During a face to face interview on 9/12/2011 at 8:05 a.m., Licensed Practical Nurse S25 indicated she had never performed Daily Head to Toe skin assessments of patients assigned to her care on night shift. S25 indicated Mental Health Technicians would inform her if they found any abnormal skin problems with patients.

During a face to face interview on 9/09/2011 at 1640 (4:40 p.m.), Director of Nursing S2 indicated all nursing staff were expected to do head to toe skin assessments every shift (12 hour shift). S2 indicated the Registered Nurse or Licensed Practical Nurse assigned to the patient's care was responsible for these assessments. S2 indicated she (S2) had not been aware that Nursing Staff had failed to provide daily Head-to-Toe skin assessments as expected and had been depending upon Mental Health Technicians to inform them of problems identified with skin before the Nurse would assess the patient's skin.

4)
During a face to face interview on 9/12/2011 at 9:40 a.m., Licensed Practical Nurse S18 indicated as a Licensed Practical Nurse he (S18) was not able to do initial admission assessments without Registered Nurse supervision; however, Licensed Practical Nurses were able to do wound assessments alone. S18 indicated he had performed wound assessments for patients at the hospital that were assigned to his care.

During a face to face interview on 9/09/2011 at 1640 (4:40 p.m.), Director of Nursing S2 indicated she (S2) had not been aware that Registered Nurses could not delegate assessment of wounds to a Licensed Practical Nurse.

Review of the hospital policy titled, "Assessments PP-013" presented by the hospital as their current policy revealed in part, "Nursing assessments shall be completed by a Registered Nurse during the admission process within 8 hours of admission. . . A Registered Nurse will assess each patient at least every 24 hours; as soon as there is a change in a patient's condition; and upon a patient's return from receipt of Emergency Services."

Review of the hospital policy titled, "Wound Assessment and Documentation, NS-026" presented by the hospital as current revealed in part, "Assessment is a continuous process that serves to provide data/information about the wound status, it's etiology and the efficacy of the interventions. It is very important to make the observations as measurable as possible. . . Length and width can be measured with a disposable guide/ruler, or wound can be traced with clear plastic sheet or bag. . ."

Review of the Louisiana State Board of Nursing "Declaratory Statement Scope of Practice for Registered Nurses-Wound Care Management" revealed in part, "The Registered Nurse initiate appropriate wound preventative measures, stages wounds and collaborates with the wound care team (physician, other registered nurses, dietician, physical therapist, occupational therapist, social workers, and orthotist) in the implementation and evaluation of nursing interventions as prescribed by an authorized prescriber. Delegation- In accord with the Law Governing the Practice of Nursing the registered nurse may delegate select nursing interventions to qualified nursing personnel as set forth in the board's rules on delegation. The Registered Nurse retains the accountability for the total nursing care of the individual. The Registered Nurse may delegate to a Licensed Practical Nurse wound care interventions in any situation when the Registered Nurse has deemed (through assessment) the patient's status is stable, the intervention is based on a relatively fixed and limited body of scientific knowledge, can be performed by following a defined nursing procedure with minimal alteration, responses of the individual to the nursing care are predictable and changes in the patient's clinical condition are predictable. Further more, the patient's medical and nursing orders are not subject to continuous change or complex modification, appropriate RN (Registered Nurse) supervision is available, and provided that the LPN (Licensed Practical Nurse) has been adequately trained and demonstrates competency is documented in the LPN's file."
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure in it's resolution of a grievance the hospital provided the patient/representative with a written notice of it's decision that contained the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for 2 of 3 grievances reviewed (#5, #7). Findings:

Patient #5
Review of Patient #5's medical record revealed she was admitted on [DATE] with diagnoses of Dementia with Behavioral Disturbance, Hypertension, history of Atrial Fibrillation, Congestive Heat Failure, and Parkinson's Disease.

Review of a typed report titled "Informal Complaint", with no documented evidence of the author of the report, revealed on 06/14/11 someone spoke with the daughter of Patient #5 who expressed "several concerns regarding her mother's care". Further review revealed the concerns were "why we allowed her mother to have a stroke on the unit and did not do anything about it ... concerns about her mother's clothing ... reported her mother was covered with bed sores...". Further review revealed Patient #5's daughter "went on to say ...she would never allow her mother to return to our facility". Review revealed no documented evidence of an investigation into the complaints voiced by Patient #5's daughter nor a response letter sent to the complainant after the investigation had been completed.

In a face-to-face interview on 09/09/11 at 4:15pm, DON (director of nursing) S2 confirmed that she documented the "Informal Complaint". When asked by the surveyor about an informal complaint versus a grievance, S2 indicated "in my mind a formal complaint was a written complaint". S2 indicated that she now knows differently as the result of a discussion with former CEO (chief executive officer) S33. S2 indicated she spoke with staff members about the complaints, but the only documentation was a note written by RN S7. S2 confirmed no response letter regarding the investigation and outcome of the investigation had been sent to Patient #5's daughter.

Patient #7
Review of Patient #7's medical record revealed the patient was admitted on [DATE] with diagnoses that included Alzheimer's Dementia with Behavioral Disturbance.

Review of a "Complaint Form" dated 8/21/2011 (no documented time)" for Patient #7 revealed in part, "Patient's wife verbalized concern to (Registered Nurse S7) concerning her husband. She (#7's wife) reported he (#7) had fecal matter around his (#7) anus, he(#7) was in pajamas, he (#7) was not shaved, and he (#7) did not have his (#7) glasses on. . ."

Review of the Response Letter sent to Patient #7's wife dated 8/29/2011 revealed in part, "In response to your concerns, an investigation was conducted to explore possible areas we can improve upon. We take all feedback from our clients very seriously and use the information to explore opportunities to better serve our population. It is our goal to provide the highest standards of care to all of our patients and their families. I am available if you have any further questions or concerns you would like to discuss. . . (Signature of Board President S14)." Review of the entire Grievance Response letter revealed no documented evidence of the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion of the investigation.

During a face to face interview on 9/09/2011 at 1620 (4:20 p.m.), Director of Nursing S2 confirmed the above findings. S2 indicated the Response letter to Patient #7's wife failed to contain documented evidence of the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion of the investigation.

Review of the hospital policy titled, "Complaints/Grievances PP-79, Developed 5/01/2011" presented by the hospital as current revealed in part, "A grievance is any written or verbal, complaint by a patient, relative, or any other representative relating to patient care or the quality of services provided. . . Responses and appropriate resolutions to all complaints will be made within 48 hours. In it's resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion."
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure a patient's consents were signed by a family member/Power of Attorney when the patient's mental status prevented comprehension by the patient for 1 of 7 sampled patients (#6). Findings:

Review of the following consents dated 3/01/2011 revealed a notation of "unable to sign 2 (secondary) Dementia".
2100 (9:00 p.m.): An important Message from Medicare about your Rights. Your Medicare Discharge Rights.
(no documented time): Acknowledgement of Receipt of Notice of Privacy Practices
(no documented time): Conditions of Admission.
2100: Advance Directive Evaluation.
(no documented time): Release of Information/ Consent to engage in verbal discussions.

Review of Patient #6's "Treatment Plan Update and Team Progress Note (no documented date) 2100 (9:00 p.m.)" revealed in part, "Orient to Unit (admitted [DATE]). . . Accompanied on unit by daughter who I got collateral information from because client is a poor historian. . ."

Review of all consents as listed above revealed no documented evidence of review or signatures by Patient #6's responsible party (his daughter) that accompanied him to the unit at the time of his admission.

Review of the hospital policy titled, "Patient Rights" presented by the hospital as current, revealed in part, "If the patient is cognitively and/or physically unable to sign and comprehend this information about their rights, the patient's guardian or a family member will be so informed and will sign for them as legally appropriate".

Review of the "Acute Care Hospital Patient Rights and Privacy Listing" located in Patient #6's Medical Record revealed in part, "Every patient or his or her representative has the right to make informed (educated, knowledgeable, based on possession of information) decisions regarding his or her care."

These findings were confirmed in a face to face interview with Director of Nursing S2 on 9/12/2011 at 1430 (2:30 p.m.). S2 indicated staff should ensure consents are signed by available family and/or Power of Attorny when patients are not capable of signing the consents.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on record review and interview the hospital failed to ensure a policy was developed that directed staff/management to follow Louisiana Revised Statute Title 40. Chapter 11. 2009.20 regarding reporting of allegations of abuse/neglect to the Department of Health and Hospitals within 24 hours. Findings:

Review of Louisiana Revised Statute Title 40. Chapter 11. 2009.20 revealed in part, "Department shall mean the Department of Health and Hospitals. . .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. . ."

Review of a Hospital Memo addressed to "All Licensed Hospitals" from the "Department of Health and Hospitals, Health Standards Section, Hospitals Program Desk" dated October 27, 2010 regarding "Reporting Allegations of Abuse/Neglect" revealed in part "The purpose of this memorandum is to clarify the process to be used by hospitals when self-reporting allegations of abuse and/or neglect so that the information submitted may be processed in an efficient and timely manner by the Hospitals Program Desk. Effective immediately, all hospital self-reports allegations of abuse and/or neglect submitted to the Department of Health and Hospitals Health Standards Section must be faxed to (phone number) within 24 hours of the facility having knowledge of the allegations. The facility is free to determine which of its personnel will be responsible for initial notification, but it must be sent via facsimile. The preliminary report must contain all of the information required in the Abuse/Neglect Initial Report form, including, but not limited to: 1. Name and DOB 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, licensing board, protective services, etc.)".

Review of the hospital policy titled, "Suspected Abuse and Neglect #83" presented by the hospital as their current policy revealed in part, "Within 72 hours of the initiation of an investigation a decision and the corresponding report will be completed. Any offending staff members will be terminated, reported to the appropriate state agency, and all those directly involved will be contacted regarding the findings and resulting actions taken." Review of the entire policy revealed no documented evidence regarding the procedure for following Louisiana Revised Statute Title 40. Chapter 11. 2009.20.

During a face to face interview on 9/12/2011 at 1430 (2:30 p.m.), Director of Nursing S2 confirmed the above findings. S2 indicated she (S2) had not been aware that the Department of Health and Hospitals needed to be informed of any allegations of facility abuse/neglect within 24 hours nor was she (S2) aware of the law regarding Louisiana Revised Statute Title 40. Chapter 11. 2009.20.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review, and interview the hospital failed to ensure a patient was not placed in a restraint without a physician's order for 1 of 1 patients observed in a restraint out of a total sample of 7 (Patient #1). Findings:

Review of Patient #1's medical record revealed the patient was admitted on [DATE] with diagnoses that included Dementia with Behavioral Disturbance. Further review revealed Daily Treatment Plan update and Team Progress Note dated 9/06/2011 at 1500 (3:00 p.m.) indicating "pt (patient) trying to get out of chair, gait unsteady, staff attempt to walk pt (at) 1400 (2:00 p.m.), pt. ambulated (with) staff down hallway. no incidents (with) unsteady gait. 1555 (3:55 p.m.). Pt attempted to get out of chair again, when redirected, pt. became combative with staff, very agitated, cursing, Ativan 1 mg (milligram) given IM (intramuscularly) LUA (left upper arm)." Further review revealed documentation by Music Therapist S6 dated 9/06/2011 at 1631 (4:31 p.m.), "Pt (Patient) was sitting in gerichair- very restless. Pt (patient) pulled his legs on top of tray. Pt was placed (with) nurses to keep full monitor. Pt (patient) too confused to engage in arts (and crafts activity." Review of Patient #1's entire medical record revealed no documented evidence of a physician's order for a Lap Tray Restraint.

Observations on 9/07/2011 at 11:30 a.m. revealed Patient #1 to be located in the Activity Room during the time that was designated on the Activity Schedule as Nursing Education Group. There was no nurse observed as present in the group (Activity Room) at the time observations began at 11:30 a.m.. Further observations revealed Patient #1 to be seated in a Geri Chair with the Lap Tray locked in place.

During a face to face interview on 9/08/2011 at 12:00 noon, Mental Health Technician S3 indicated the locks to release the Lap Tray located on the Geri Chair for Patient #1 were located underneath the tray towards the front of the arm rests. S3 illustrated how to unlock and release the tray. S3 indicated Patient #3 would not have been able to release the Lap Tray himself. Observations revealed no meals being eaten at the time of observation/interview and no craft like activities involving the need for a table/tray.

During a face to face interview on 9/08/2011 at 10:30 a.m., Music Therapist S6 indicated she (S6) did not know why Patient #1 had a Lap Tray attached to his Geri Chair on 9/07/2011. S6 indicated Patient #1 had been observed by her (S6) to be located in a GeriChair with a Lap Tray in place off and on throughout his current admission.

During a face to face interview on 9/09/2011 at 9:30 a.m., Registered Nurse S7 indicated it would be inappropriate for Patient #1 to have a Lap Tray attached to his Geri Chair outside of Meals because it would be considered a restraint. S7 confirmed there was no physician's order for a restraint for Patient #1. S7 indicated there should never be a restraint applied without a physician's order and an evaluation to determine that it was needed and least restrictive.

During a face to face interview on 9/12/2011 at 12:40 p.m., Physician S13 indicated any patient that was placed in a Geri Chair with a Lap Tray would be considered to be in a restraint. S13 indicated less restrictive interventions should be tried first. S13 indicated in the event that less restrictive measures were not effective the nurse providing care to the patient should call the physician to receive an order for the restraint. S13 indicated no one had ever called him for an order for Lap Tray Restraint for Patient #1. S13 indicated there were times when Patient #1 was out of control and he would have agreed to ordering a Lap Tray as a restraint; however, there had never been any request from staff for an order.

Review of the hospital policy titled, "Restraint and Seclusion #50" presented by the hospital as current revealed in part, "Seclusion/restraint usage is limited to those situation in which all less restrictive measures have been unsuccessful to prevent injury to the patient, other patients and/or staff or to deescalate serious disruption to the milieu. . . The choice of a safe, effective, and least restrictive method determined by the patient's assessed needs and the effective or ineffective methods previously used on the patient. The least restrictive methods are used and discontinued as soon as possible. . . When emergency use is initiated a licensed practitioner is called within one hour and sees the patient within that timeframe. Continues use depends on authorization by that practitioner. . . It is expected that only on rare occasions will physical restraint be necessary. More often it will be necessary to use posey vests and waists belts (soft restraints) or gerichairs for agitated patients who do not have the cognition or physical acument to function without such intervention. It is necessary and expected that physician approval and order be provided for each episode of restraint."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0200
Based on record review and interview the hospital failed to ensure all clinical staff were training in non-physical intervention skills for intervening with aggressive patients 3 of 8 staff reviewed for non-physical intervention skills training (Registered Nurse S28, Registered Nurse S29, Mental Health Tech S24). Findings:

Review of Personnel Records revealed the following employees failed to have any documented evidence of training in non-physical intervention behavioral skills: Registered Nurse S28, Registered Nurse S29, Mental Health Tech S24 to Include Crisis Prevention Intervention (CPI).

During a face to face interview on 9/12/2011 at 1430 (2:30 p.m.), Director of Nursing S2 indicated the hospital used training titled, "Crisis Prevention Intervention (CPI)" to educate staff on non-physical interventions skills for behavioral outburst by patients. S2 confirmed she (S2) had no documentation to indicate Registered Nurse S28, Registered Nurse S29, Mental Health Tech S24 had been trained in CPI and had no knowledge of the three clinical staff being current with CPI certification.
VIOLATION: MEDICAL STAFF PRIVILEGING Tag No: A0355
Based on record review and interviews, the hospital failed to ensure physicians and allied health professionals were privileged according to medical staff bylaws as evidenced by failure to have privileges requested and approved prior to approval for temporary privileges and/or recommendation by the medical staff for approval by the governing body for 1 physician's file reviewed from a total of 9 active physicians (S15) and 1 of 2 allied health professionals' files reviewed from a total of 7 allied health professionals (S20). Findings:

Physician S15
Review of Physician S15's credentialing file revealed an application was completed by S15 on 04/17/11. Further review revealed a request for temporary privileges was signed by Physician S15, former CEO (chief executive officer) S33, and Medical Director S13 on 05/09/11. Further review revealed no documented evidence of a list of privileges being requested by Physician S15. Review of Physician S15's "Medical Staff Committee of the Whole and Governing Board Approval Form" revealed he was approved by the medical staff and governing board on 07/14/11. Review of the "Delineation of Privileges Internal Medicine" revealed it was signed by Physician S15 and Medical Director S13 on 08/12/11, 29 days after S15 had been approved for active staff membership.

Psychologist S20
Review of Psychologist S20's credentialing file revealed an application was completed on 04/04/11. Further review revealed a "Request For Temporary Privileges" was signed by former CEO S33, Psychologist S20, and Medical Director S13 on 04/23/11. Review of the "Medical Staff Committee of the Whole and Governing Board Approval Form" revealed appointment of Psychologist S20 was approved by the medical staff and governing body on 07/14/11. Further review revealed a "Delineation of Privileges Psychologist" was included in the file with no documented evidence of the date S20 and Medical Director S13 signed the privileges. There was no manner of determining whether the privileges were requested at the time temporary privileges were requested or at the time active membership was being approved.

In a face-to-face interview on 09/12/11 at 10:10am, Human Resource (HR) Manager S19 indicated she was responsible for the credentialing process. S19 further indicated the hospital had contracted with a credentialing company in May 2011, but no credentialing file had been completed by the company yet. S19 confirmed she prepared the file and checked the contents for Physician S15. S19 confirmed there was no request for privileges at the time temporary privileges were granted for S15. S19 indicated she became responsible for the credentialing process about 1-2 months ago and did not have prior experience with credentialing in a hospital setting. S19 indicated she "was given the Medical Staff manual by former CEO S33 and that's about it". S19 confirmed she had no training for the credentialing process.

Review of the "Medical Staff Bylaws", presented by DON S2 as their current medical staff bylaws, revealed, in part, "...Article 6 Clinical Privileges ...Each application for appointment and reappointment to the Medical Staff must contain a request for the specific Clinical Privileges desired by the applicant. ...".
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on record review and interview the hospital failed to ensure the problem prone area regarding assessment, treatment, and competency in providing assessments and interventions for patients with skin integrity problems had been identified by the hospital for the purpose of designing and implementing corrective action to improve patient Quality of Care. Findings:

Review of the hospital's Indicators/Benchmarks Summary 2011 regarding Infection Control/Wounds revealed in part, "Total number of wounds with documentation per P & P (Policy and Procedure) 2, Number of patients that develop new nosocomial pressure wounds, 0". The same data was present for April, May, and June 2011. There was no documented evidence of any wounds that had occurred or been reviewed for July and August 2011.

During a face to face interview on 9/12/2011 at 1430 (2:30 p.m.), Director of Nursing S2 indicated the Quality Control Director was out on leave and not available for interview. S2 further indicated that she (S2) had been working as a team with the Quality Director in tracking, trending, and analyzing Quality Data. S2 indicated from review of hospital data, there had been no problems identified in the assessment of skin integrity or the provision of wound treatment at the hospital. S2 indicated problems identified within the current survey (9/08/2011 through 9/12/2011) such as 1) nursing staff depending on Mental Health Techs (MHT) to notify them of skin abnormalities rather than doing daily head to toe skin assessments as expected, 2) RN (Registered Nurses) delegating to LPN (Licensed Practical Nurses) the responsibility for Wound Assessments that was outside their scope of practice, 3) No RN on staff having been evaluated and deemed competent in assessment of wounds, 4) No RN or LPN having been evaluated and deemed competent in treatment of wounds, and 5) failing to identify Stage I pressure ulcers for patients that were found to have Stage I pressure ulcers at receiving facilities (Refer to findings cited at A0395 and A0397). S2 further indicated the Quality Assessment Performance Improvement program should have identified problems with Skin Integrity Assessment, Competency, and implementation of Proper Assessment/Intervention.

Review of the hospital policy titled, "Wound Care, Quality Management, ICR-03-002" presented by the hospital as their current policy revealed in part, "The Quality Manager or designee will review wounds reported by the nursing staff and patient records. The Wound Care Log will be presented bi-monthly at the professional activities meeting. The committee's recommendations, actions, resolution/follow up will be monitored by the medical staff committee of the whole and presented to the governing body."
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure adverse patient events were documented on an incident report as indicated in hospital policy to ensure the Quality Assurance Performance Improvement Department analyzed the cause and reviewed for opportunities to improve Quality of Care for 1 of 1 Incidents reviewed in the medical records of sampled patients (Patient # 1). Findings:

Review of Patient #1's medical record revealed the patient was admitted on [DATE] with diagnoses that included Dementia with Behavioral Disturbances. Review of Patient #1's "Daily Treatment Plan Update and Team Progress Note" dated 8/25/2011 at 11:42 a.m. revealed in part, "Pt (patient) stated he (#1) had picked up a pencil and was putting it in peer's chair- at which time peer (no medical record number to identify the peer) hit pt (#1) for touching him. Pts (patients/ #1 and unidentified patient) were separated and then settled down." Review of Patient #1's entire medical record revealed no documented nursing assessment to ensure no injuries were received during the altercation.

During a face to face interview on 9/08/2011 at 10:30 a.m., Music Therapist S6 indicated she was the staff member that documented in the Medical Record of Patient #1 regarding an altercation between Patient #1 and a peer on 8/25/2011. S6 indicated she witnessed the altercation. S6 confirmed there was physical contact made. S6 indicated it appeared to be a slap rather than full blow. S6 indicated the strike appeared to startle Patient #1. S6 indicated she (S6) saw no bruise or cut and therefore had not completed an incident report. S6 indicated she (S6) had informed a nurse but had not documented and had no recall of which nurse she (S6) may have reported the incident to.

During a face to face interview on 9/09/2011 at 1620 (4:20 p.m.), Director of Nursing S2 indicated there should be an incident report made for any aggressive physical contact made between patients.

Review of the hospital policy titled, "Adverse Event/Incident Reporting #68, Effective 5/01/2011" presented by the hospital as current policy revealed in part, "It is the policy of the Psychiatric service to assure the reporting of all significant events/occurrences in order to maintain a safe environment for all clients, staff and visitors. The information reported is used to evaluate and identify risk areas so as to assure resolution and prevention of potential problem areas. Whenever there is a significant occurrence the staff member involved in identifying the event will complete an Incident Report form. The Program Nurse will be notified of any physical mishap to assess the appropriate action to be taken and disposition. Any incident involving a patient/client will be documented in the progress notes of that individual including ; patient condition and the action taken. The quality Manager will assist the program in investigating the incident, trending similar incidents and problem correction."
VIOLATION: MEDICAL STAFF CREDENTIALING Tag No: A0341
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews, the hospital failed to ensure physicians and allied health professionals were credentialed according to medical staff bylaws as evidenced by failure to have all required elements of the credentialing file prior to recommendation by the medical staff for approval by the governing body and/or failure to have evidence of approval for continuation of temporary privileges after 30 days as required by the bylaws and hospital policy for 1 physician's file reviewed from a total of 9 active physicians (S15) and 2 allied health professionals' files reviewed from a total of 7 allied health professionals (S20, S21). Findings:

Physician S15
Review of Physician S15's credentialing file revealed an application was completed by S15 on 04/17/11. Further review revealed a request for privileges was signed by Physician S15, former CEO (chief executive officer) S33, and Medical Director S13 on 05/09/11. Further review revealed no documented evidence of a list of privileges being requested by Physician S15. Further review revealed no documented evidence Physician S15's temporary privileges had been extended after the initial 30 days and 30 days thereafter as required by the medical staff bylaws. Review of Physician S15's "Medical Staff Committee of the Whole and Governing Board Approval Form" revealed he was approved by the medical staff and governing board on 07/14/11. Review of the "Delineation of Privileges Internal Medicine" revealed it was signed by Physician S15 and Medical Director S13 on 08/12/11, 29 days after S15 had been approved for active staff membership.

Psychologist S20
Review of Psychologist S20's credentialing file revealed an application was completed on 04/04/11. Further review revealed a "Request For Temporary Privileges" was signed by former CEO S33, Psychologist S20, and Medical Director S13 on 04/23/11. Further review revealed no documented evidence Psychologist S20's temporary privileges had been extended after the initial 30 days, not to exceed two separate 30-day intervals as required by the medical staff bylaws. Review of the "Medical Staff Committee of the Whole and Governing Board Approval Form" revealed appointment of Psychologist S20 was approved by the medical staff and governing body on 07/14/11. Further review revealed a "Delineation of Privileges Psychologist" was included in the file with no documented evidence of the date S20 and Medical Director S13 signed the privileges. Review of S20's credentialing file revealed the liability insurance expired on [DATE].

Psychologist S21
Review of Psychologist S21's credentialing file revealed an application was completed on 04/27/11. Further review revealed no documented evidence Psychologist S21's temporary privileges had been extended after the initial 30 days, not to exceed two separate 30-day intervals as required by the medical staff bylaws. Review of the "Medical Staff Committee of the Whole and Governing Board Approval Form" revealed appointment of Psychologist S21 was approved by the medical staff and governing body on 07/14/11. Review of the entire credentialing file revealed no documented evidence of current licensure to practice psychology, as the license in the file had expired on [DATE].

In a face-to-face interview on 09/12/11 at 10:10am, Human Resource (HR) Manager S19 indicated she was responsible for the credentialing process. S19 further indicated the hospital had contracted with a credentialing company in May 2011, but no credentialing file had been completed by the company yet. S19 confirmed she prepared the file and checked the contents for Physician S15. S19 confirmed there was no request for privileges at the time temporary privileges were granted. S19 indicated she became responsible for the credentialing process about 1-2 months ago and did not have prior experience with credentialing in a hospital setting. S19 indicated she "was given the Medical Staff manual by former CEO S33 and that's about it". S19 confirmed she had no training for the credentialing process.

In a face-to-face interview on 09/12/11 at 12:30pm, Medical Director S13 indicated the hospital should not have to approve temporary privileges every 30 days. He offered no explanation for this requirement being part of the medical staff bylaws and it not being followed in practice.

Review of the hospital policy titled "Appointment to the Medical Staff", presented by DON (director of nursing) S2 when the medical staff bylaws were requested, revealed, in part, "...Only physicians and psychologists who satisfy the following conditions shall be eligible for appointment to the Medical Staff: (1) have a current unrestricted license to practice in the State of Louisiana; ... (4) possess current, valid professional liability insurance coverage in such form and in amounts satisfactory to the Board ... Applications for initial appointment and reappointment shall contain a request for specific clinical privileges desired by the individual and shall require detailed information concerning the individual's professional qualifications...".

Review of the "Medical Staff Bylaws", presented by DON S2 as their current medical staff bylaws, revealed, in part, "...The applicant shall deliver a completed application to the Chief Executive Officer. The application and all supporting materials then available shall be transmitted to the Medical Director. ... When collection and verification is complete, all such information shall be transmitted to the "Committee of the Whole" (MS-COW). ... At its next regular meeting after receipt of the Medical Director's report and recommendations, or as soon thereafter as is practicable, the "Committee of the Whole" (MS-COW) shall consider the report and any other relevant information. ... Within 60 days after receipt of the completed application ... the "Committee of the Whole" (MS_COW) shall forward to the Chief Executive Officer for prompt transmittal to the Governing Board. ... Within sixty (60) days of receiving the application and recommendation of the "Committee of the Whole" (MS-COW) the Governing Board may accept, modify, or reject the recommendation... Article 6 Clinical Privileges ...Each application for appointment and reappointment to the Medical Staff must contain a request for the specific Clinical Privileges desired by the applicant. ... Temporary Clinical Privileges are granted by the Chief Executive Officer upon recommendation of the Medical Director or designee for the care of patients to a practitioner who is an applicant for membership... The applicant shall provide a current State license, current DEA (drug enforcement administration) registration and evidence of the required professional liability insurance. The Temporary Privileges may be granted for a period of time not to exceed 30 days. Temporary Privileges may be extended for two separate 30-day intervals upon approval of the Governing Board...".
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**






Based on record review and interview, the hospital failed to ensure medications were administered according to the physician's order for 3 of 7 sampled patients (#2, #4, #5). Findings:

Patient #2:
Review of Patient #2's medical record revealed she was admitted on [DATE] with diagnoses of Schizoaffective Disorder.

Review of the "Physician Orders" dated 8/19/2011 revealed an order for Trihexyphen 5 milligrams by mouth two times daily.

Review of Patient #2's MAR (medication administration record) for 8/20/2011 revealed no documented evidence Trihexyphen 5 milligrams was administered at 9:00 a.m. as ordered.


Patient #4
Review of Patient #4's medical record revealed he was admitted on [DATE] with diagnoses of Dementia with Behavioral Disturbance, history of Brain Injury, Hypertension, Schizophrenia, Epilepsy, and Dementia.

Review of the "Physician Orders" dated 08/29/11 at 1952 (7:52pm) revealed an order for Gabapentin 600 mg (milligrams) by mouth TID (three times a day) and Ativan 2 mg by mouth TID.

Review of Patient #4's MAR (medication administration record) for 08/29/11 revealed Ativan 1 mg was given at 2100 (9:00pm) rather than 2 mg as ordered. Review of the MAR for 09/01/11 revealed no documented evidence Gabapentin 600 mg was administered at 1300 (1:00pm) as ordered.

Patient #5
Review of Patient #5's medical record revealed she was admitted on [DATE] with diagnoses of Dementia with Behavioral Disturbance, Hypertension, history of Atrial Fibrillation, Congestive Heart Failure, and Parkinson's Disease.

Review of the medications ordered for Patient #5 revealed an order for Metoprolol 25 mg by mouth BID (twice a day).

Review of the MAR for 06/06/11 revealed the blood pressure and apical pulse were to be checked prior to administering Metoprolol and the dose held if the heart rate was below 60 beats per minute. Further review of the MAR revealed no documented evidence Patient #5's apical pulse was checked prior to administering the Metoprolol.

In a face-to-face interview on 09/12/11 at 1:45pm, DON (director of nursing) S2 could offer no explanation when informed of the medication errors found by the surveyors during chart review.

Review of the hospital policy titled, "Administration of Medications Using the MAR System, NS-035" presented by the hospital as their current policy revealed in part, "The Medication Administration Record is referred to as the MAR. Charting is done immediately after the medication is given by drawing one line through the time and initialing it. There are several reasons for putting a note regarding medications into the nurses notes. some include: Medication refusal, Medication omission, PRN (as needed) medication. If the medication is refused or omitted for any reason, circle the times and place the appropriate code in the space."

Review of the hospital policy titled, "Medication General Policies, NS-034" presented by the hospital as current revealed in part, "Medication Errors should be reported to the physician and the charge nurse and/or director immediately."
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital: 1) failed to ensure medical records were stored in a manner that protected them from water should the sprinkler system be activated and 2) failed to ensure medical records were complete and accurate for 6 of 7 sampled patients (#1, #2, #3, #4, #6, #7). Findings:

1)
Medical Records Protection from water:
Observations on 9/09/2011 at 9:15 a.m. revealed 47 medical records to be lying on table tops in the Medical Records department. Further observation revealed a sprinkler to be located on the ceiling of the room and no visible mechanism to prevent water damage to the 47 medical records, stored on table tops, should the sprinkler system accidentally be triggered.

This finding was confirmed in a face to face interview with Health Information Management Director S4 on 9/09/2011 at 9:15 a.m. S4 indicated the hospital had plans to secure new filing cabinets; however, at the time of the survey, there were no secure cabinets in which the 47 Medical Records stored on table tops in the Medical Records Storage room could be filed to protect them from water damage should the sprinklers be triggered.

2)
Conflicting Documentation:
Patient #1: Review of Patient #1's medical record revealed the patient was admitted on [DATE] with diagnoses that included Schizoaffective Disorder. Further review of Nursing Documentation for Patient #1 located on "Treatment Team Progress Notes" on 8/20/2011 at 11:00 a.m. revealed in part, "Pt (patient) refused lunch." Review of Patient #1's Daily Assessment for 8/20/2011 revealed a check list indicating "Lunch, 1/2".

During a face to face interview on 9/09/2011 at 9:30 a.m., Registered Nurse S7 indicated she (S7) had been the nurse assigned to the care and documenting for Patient #1 on 8/20/2011. S7 further indicated she was unsure why there was conflicting information documented in the medical record of Patient #1 regarding dietary intake on 8/20/2011. S7 indicated it could be that she documented in the wrong section or documented lunch when she meant to document breakfast; however, she could not be sure.

Patient #6: Review of Patient #6's medical record revealed the patient was admitted on [DATE] with diagnoses that included Dementia with Behavioral Disturbance. Further review revealed the initial Registered Nurse assessment dated [DATE] at 2100 (9:00 p.m.) to indicate "height 6'6" (6 feet 6 inches), Weight estimate 219". Review of Patient #6's entire medical record revealed the only documented actual weight taken on Patient #6 was dated 3/10/2011 and documented as 172 pounds.

Review of Patient #6's Medical Nutritional Therapy form as documented by Registered Dietician S10 on 3/03/2011 (no documented time) revealed in part, "Height 67" (67 inches/ 5 feet 5 inches)", Weight 219 (pounds)." Further review revealed calculations regarding nutritional requirements for Patient #6 by Registered Dietician S10 to be calculated based on the wrong height (#6's actual height was 6 feet 6 inches) and weight (no actual weight obtained prior to 3/10/2011).

This finding was confirmed in a face to face interview with Registered Dietician S10 on 9/09/2011 at 1250 (12:50 p.m.). S10 had no explanation as to why she made Nutritional needs calculations based on a height of 5 feet 5 inches for a man (Patient #6) that was actually 6 feet 6 inches.

Blanks in Dictation:
Review of the following medical records revealed blanks in dictated notes that had been signed by the practitioner without correcting the areas of dictation that were left blank:

Patient #1:
Review of Patient #1's Psychiatric Evaluation revealed it was dictated on 8/10/2011 (no documented time), transcribed 8/11/2011 (no documented time), and signed by the physician (S12) on 8/12/2011 at 1420 (2:20 p.m.). Further review revealed a blank that remained in the content of the Psychiatric Evaluation for Patient #1 that had not been corrected by Physician S12 at the time the physician signed agreement with the transcribed Psychiatric Evaluation as follows, "The patient had been loud, argumentative, and not taking medications at ____ group home."

Patient #2:
Review of Patient #2's Progress Note dated 8/30/2011 revealed it was dictated on 8/30/2011 at 12:33 p.m., transcribed on 8/31/2011 at 5:27 a.m., and signed by the physician (S13) on 9/01/2011. Further review revealed a blank that remained in the content of the dictation for Patient #2 that had not been corrected by Physician S13 at the time the physician signed agreement with the transcribed Progress Notes as follows, "She has been on ____, which will be discontinued and I will put her on small dose of Cogentin."

Patient #3
Review of Patient #3's medical record revealed she was admitted on [DATE] with diagnoses of Dementia with Behavioral Disturbance, Anemia, Diabetes Mellitus Type I, Hypertension, Renal Insufficiency, Osteoarthritis, Gastrointestinal Bleed, and Acute Diverticulitis.

Review of the "Progress Note" dictated 08/31/11 and signed by Physician S12 on 09/02/11 at 12:30pm and the "Progress Note" dictated 09/02/11 and signed by Physician S12 on 09/07/11 revealed blanks left by the transcriptionist that remained blank after S12 had signed the notes.

Patient #4
Review of Patient #4's medical record revealed he was admitted on [DATE] with diagnoses of Dementia with Behavioral Disturbance, history of Brain Injury, Hypertension, Schizophrenia, Epilepsy, and Dementia.

Review of the "Psychiatric Evaluation" dictated on 08/30/11 and signed on 09/01/11 by Medical Director S13 revealed two blanks left by the transcriptionist had not been filled by when signed by S13.

Patient #6:
Review of Patient #6's Psychiatric Evaluation revealed it was dictated on 3/02/2011 (no documented time), transcribed on 3/03/2011 (no documented time), and signed by the physician (S12) with no documented date/time of signature. Further review revealed a blank that remained in the content of the dictation for Patient #6 that had not been corrected by Physician S12 at the time the physician signed agreement with the transcribed Psychiatric Evaluation as follows, "Current Medications: ____ Plus one twice daily. . . ."

Further review of Patient #6's medical record revealed Progress Notes dictated on 3/08/2011 (no documented time), transcribed 3/09/2011 (no documented time), and signed by the physician (S12) on 3/10/2011 at 1430 (2:30 p.m.). Further review revealed a blank that remained in the content of the dictation for Patient #6 that had not been corrected by Physician S12 at the time the physician signed agreement with the transcribed Progress Note as follows, "He talks today about today being his granddaughter's wedding and is concerned about a ____ fish."

Patient #7:
Review of Patient #7's Psychiatric Evaluation revealed it was dictated on 8/17/2011 at 1513 (3:13 p.m.), transcribed on 8/18/2011 at 1710 (5:10 p.m.), and signed by the physician (S12) on 8/19/2011 at 1325 (1:25 p.m.). Further review revealed a blank that remained in the content of the dictation for Patient #7 that had not been corrected by Physician S12 at the time the physician signed agreement with the transcribed Psychiatric Evaluation as follows, "He says he is out of Gum School, but now he is in Derry or Fox School, which he says builds you automatic aesthetic ____. He says that there are "Spiry Edisons, punchy leg buildings hitting on data" he says that a ____ was sucked down this hole but that it would not stop humans, he says something about Castlevania and this is where it is. When asked where he is, he says he doesn't not have a checkbook, but he has ____ blue and says that it gives more radical cities. . . When asked to do serial subtractions of 3 from 25, he starts off with 33 and goes to 32, 25, 35, then says 10 staple 2 ____ house."

These findings were confirmed by Health Information Management Director S4 on 9/09/2011 at 9:00 a.m. in a face to face interview. S4 indicated he had not been monitoring the Medical Records of patients to ensure that physicians were completing any dictation that contained blanks in the content of the dictation.
VIOLATION: DIETS Tag No: A0630
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital's Registered Dietician failed to ensure nutritional needs for a patient were accurately calculated for 2 of 7 sampled patients (#3, #6). Findings:

Patient #3
Review of Patient #3's medical record revealed she was admitted on [DATE] with diagnoses of Dementia with Behavioral Disturbance, Anemia, Diabetes Mellitus Type I, Hypertension, Renal Insufficiency, Osteoarthritis, Gastrointestinal Bleed, and Acute Diverticulitis.

Review of Patient #3's "Physicians' Admit Orders & (and) Preliminary Treatment Plan" dated 08/29/11 at 1615 (4:15pm) revealed an order for a nutritional assessment.

Review of Patient #3's "Medical Nutrition Therapy" signed by Registered Dietitian (RD) S10 on 08/30/11 revealed no documented evidence of a height or weight. Further observation revealed a note of "will monitor for ht (height) & wt (weight) when less combative (noted pt refused on admit)...". Review of the "Medical Nutrition Therapy Progress Notes" revealed the next documented assessment by RD S10 was on 09/05/11, 7 days after the order was received for a nutritional assessment.

In a face-to-face interview on 09/09/11 at 12:45pm, RD S10 indicated she came to the hospital one time a week. She further indicated she usually completes and faxes the top portion of the "Medical Nutrition Therapy" (by using information she gathers from the nurse's admission assessment that is faxed to her by the nurse) to the hospital if she won't be coming to the hospital within 24 hours. S10 indicated this was her way of assuring the nutritional assessment is completed within 24 hours of receipt of the order. Regarding Patient #3, RD S10 indicated she was at the hospital on [DATE] and completed the "Medical Nutrition Therapy", but she did not have the patient's weight and height. S10 confirmed the assessment she completed for Patient #3 was not a complete assessment without having the weight and height to compute nutritional needs. When asked by the surveyor if waiting 7 days to complete a nutritional assessment was appropriate, RD S10 indicated "I didn't see a problem".

Patient #6
Review of Patient #6's medical record revealed the patient was admitted on [DATE] with diagnoses that included Dementia with Behavioral Disturbance. Further review revealed the initial Registered Nurse assessment dated [DATE] at 2100 (9:00 p.m.) to indicate "height 6'6" (6 feet 6 inches), Weight estimate 219". Review of Patient #6's entire medical record revealed the only documented actual weight taken on Patient #6 was dated 3/10/2011 and documented as 172 pounds.

Review of Patient #6's Medical Nutritional Therapy form as documented by Registered Dietician S10 on 3/03/2011 (no documented time) revealed in part, "Height 67" (67 inches/ 5 feet 5 inches)", Weight 219 (pounds)." Further review revealed calculations regarding nutritional requirements for Patient #6 by Registered Dietician S10 to be calculated based on the wrong height (#6's actual height was 6 feet 6 inches) and weight (no actual weight obtained prior to 3/10/2011).

Review of Patient #6's Medical Record for intake of food and Med Pass revealed the following:
3/03/2011: no documented evidence of the amount of food intake for Breakfast, Lunch, or Dinner.
3/08/2011: documented as having eaten 1/2 Breakfast, 1/2 Lunch, 3/4 Dinner.
3/09/2011: documented as having eaten 1/2 Breakfast, 3/4 Lunch, 1/2 Dinner.
3/10/2011: documented as having been administered only 1 of the 2 Med Pass supplements ordered for the day.
3/11/2011: documented as having eaten 1/4 Breakfast, 3/4 Lunch, Refusal of Dinner.
3/12/2011: documented as having eaten 1/4 Breakfast, 1/4 Lunch.

This finding was confirmed in a face to face interview with Registered Dietician S10 on 9/09/2011 at 1250 (12:50 p.m.). S10 had no explanation as to why she (S10) made Nutritional needs calculations based on a height of 5 feet 5 inches for a man (#6) that was actually 6 feet 6 inches. S10 indicated based on a height of 6 feet 6 inches and 172 pounds, Patient #6's nutritional needs should have been calculated as 2400 - 2500 calories and 77 - 97 Grams of protein. S10 indicated Patient #6 had been receiving 2545 calories and 106 Grams of Protein with the physician's ordered diet of Regular-Mechanical soft with Chopped Meat plus 2 ounces of Med Pass twice per day, if the patient consumed 100% of the meal and the supplement.

Review of the hospital policy titled, "Nutritional Assessment, #NS-056" presented by the hospital as current revealed in part, "Nursing staff, and when indicated in collaboration with the dietitian, will collect the data necessary to plan the nutritional care of the patient. This information may be obtained from physician and nursing history and physical data, social history and family contact, laboratory findings, evaluation of weight changes, factors influencing selection and consumption of food including dentition and Dysphagia, and food allergies or intolerance."

Review of the hospital policy titled, "Food and Nutritional Services, # NS-055" presented by the hospital as current revealed in part, "The Registered Licensed Dietitian will provide the Seaside Behavioral Center with the following services: Physician referrals for nutrition consult within 24 hours of order, Assessment of patients at nutritional risk or otherwise identified through Nursing Assessment, H&P (History and Physical), or other evaluation, Nutrient intake analysis, and Medical Record documentation of nutritional status and response to therapeutic diet as needed."

Review of the hospital policy titled, "Comprehensive Nutrition Consult/ Assessment, NS-057" presented by the hospital as current revealed in part, "The Dietitian will assess the nutritional status of the patient using the patient's medical record (diagnosis, lab values, height, weight, and medical history) and diet history."
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, record review, and interviews, the infection control officer failed to ensure: 1) an active TB (tuberculosis) surveillance was implemented according to CDC (Centers for Disease Control) guidelines as evidenced by failure to have documented TB results for 1 of 1 physician's file reviewed from a total of 9 active physicians (S15) and 1 of 2 allied health professionals' files reviewed from a total of 7 allied health professionals (S20) and 2) active surveillance of random handwashing by staff (who were unaware the observation was being done) was conducted which resulted in observation of multiple breaches in infection control on 09/09/11 for 4 of 4 patients observed (#1, #3, #R1, #R2). Findings:

1) Active TB surveillance was implemented according to CDC guidelines:
Review of the credentialing files of Physician S15 and Psychologist S20 revealed no documented evidence of the administration and results of TB testing.

In a face-to-face interview on 09/12/11 at 10:10am, Human Resource Manager S19 indicated they began requiring TB testing of all physicians and allied health professionals after the last survey conducted at the hospital. S19 indicated if the test results were not in the credentialing files, she could not say they were done.

Review of the " Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005 " published by the CDC (Centers for Disease Control) revealed, in part, " ...HCWs (health-care workers) refer to all paid and unpaid persons working in health-care settings who have the potential for exposure to M. tuberculosis through air space shared with persons with infectious TB disease. Part time, temporary, contract, and full-time HCWs should be included in TB screening programs. All HCWs who have duties that involve face-to-face contact with patients with suspected or confirmed TB disease (including transport staff) should be included in a TB screening program. The following are HCWs who should be included in a TB screening program: Administrators or managers ...Nurses ...Physicians (assistant, attending, fell ow, resident, or intern) ... " .
2) Active surveillance of random handwashing by staff (who were unaware the observation was being done) was conducted which resulted in observation of multiple breaches in infection control on 09/09/11:

Observation of a skin assessment of Patient #1 by RN (registered nurse) S5 on 09/09/11 at 1:50pm revealed RN S5 took photographs of Patient #1's skin, removed her gloves, then placed the camera on Patient #1's bed linens. Further observation revealed RN S5 did not wash her hands or use hand gel after removing her gloves.

Observation of a skin assessment of Patient #3 by RN S7 on 09/09/11 at 2:40pm revealed RN S7 donned gloves without first washing her hands, took photographs of Patient #3's wounds to the buttocks and anus, placed the camera on the bed linens in the area that Patient #3 had been lying prior to being turned, and used a disposable tape measure to measure the wounds to the buttocks and anus. After measuring the wounds, without removing her gloves, RN S7 used her pen to document the measurements. Wearing the same gloves used used to measure Patient #3's buttocks and anus, S7 measured wounds to the toes and feet. Observation revealed S7 continually pushing her hair from her face with her gloved hands. Observation revealed MHT (mental health tech) S36 removed her gloves and reapplied gloves without washing her hands between the use of gloves. During the assessment RN S7's lanyard (cord hanging from her neck that contained her identification) hung across and touched the bed linens. RN S7 assisted Patient #3 into a wheelchair, removed her gloves, rolled Patient #3 to the group room, went into the nursing station, opened a drawer, removed paper, went to the copier to make copies, all of which was done without washing her hands or using hand gel after having removed her gloves.

Observation on 09/09/11 at 3:10pm revealed RN S7 placed the disposable tape measure used to measure the wounds of Patient #3 on the nursing station desk top. This was confirmed by RN S7 on 09/09/11 at 3:10pm.

Observation of the skin assessment of Patient R2 by RN S7, with the assistance of MHT S36, on 09/09/11 at 3:15pm revealed MHT S36 removed the camera from her uniform pocket with gloved hands. Further observation revealed RN S7 measured wounds to the right and left buttocks and left inner thigh. Further observation revealed RN S7 removed her gloves, reapplied gloves without washing her hands or using hand gel, and measured wounds to the left heel. RN S7 then removed her gloves and did not wash her hands after removing the gloves.

Observation on 09/09/11 at 3:35pm revealed RN S7 washed her hands at the nursing station and then placed the contaminated camera on the nursing station desk top.

Observation of the skin assessment of Patient R1 by RN S7 on 09/09/11 at 3:40pm revealed RN S7 applied gloves and took a photograph of Patient R1's skin under her breast. Further observation revealed the camera cord was allowed to hang and touch Patient R1's skin at the draining PEG (percutaneous gastrostomy tube) site. After applying tegaderm to the right ankle, RN S7 removed her gloves and reapplied gloves to perform care to the PEG site without washing her hands or using hand gel.

Observation revealed the same camera was used to photograph Patients #1, #3, R1, and R2 without being cleaned between patients. The camera was placed in staff members' pockets, placed on patients' bed linens, and used by staff who were not observed to wash their hands after removing gloves used to position patients and measure wounds.

In a face-to-face interview on 09/12/11 at 1:45pm, after review of the observations made by the surveyors on 09/09/11 during skin assessments, DON (director of nursing) S2 confirmed these were breaches in infection control practice. S2 indicated RN S28, the infection control nurse, had done handwashing surveillance, but it was not random and nursing staff was aware they were being observed. S2 confirmed there had been no observation of handwashing practices of the staff without them being aware of the observation.

Review of the hospital policy titled "Wound Assessment and Documentation", policy number NS-026 developed 05/01/11 and submitted by DON S2 as their current wound assessment policy, revealed, in part, "...1. Wash hands. Explain the procedure to the patient. 2. Assemble supplies and equipment... 3. Drape the patient for comfort and privacy. 4. Put on gloves. 5. Remove and discard dressing and gloves. Wash hands and put on fresh new gloves...".