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.

NORTHLAKE BEHAVIORAL HEALTH SYSTEM 23515 HIGHWAY 190 MANDEVILLE, LA 70448 April 17, 2018
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:
1) The RN failed to ensure patient admit assessments and suicide and homicide risk assessments were completed in accordance with hospital policy for 3 (#1, #2, #3) of 5 patient records reviewed for nursing assessments from a sample of 5 patients.
2) The RN failed to ensure lab work that was ordered by the physician was resulted timely, placed on the patient's medical record, and reported to the physician when applicable for 3 (#1, #3) of 5 patient records reviewed for timely results of lab work from a sample of 5 patients.
Findings:

1) The RN failed to ensure patient admit assessments and suicide and homicide risk assessments were completed in accordance with hospital policy:
Review of the policy titled "Assessments", presented as a current policy by S2COO, revealed the RN Assessment is conducted within 8 hours of admission and contains questions to screen for pain, nutrition, and functional status.

Review of the policy titled "Suicide Plan, Hospital-Wide", presented as the current policy for suicide precautions by S2COO, revealed patients at risk for suicide and/or self-destructive behavior require intensive support, close observation, frequent re-assessment, and indicated protective measures for their emotional and physical well-being at all times. Further review revealed re-assessment of suicidality will occur at least every 24 hours for any patient on suicide precautions and as needed for any patient who exhibits a sudden or significant change in mental status.

Review of the "RN Progress Note - 7:00 AM to 7:00 PM shift" revealed the suicide re-assessment was to be completed by the first shift RN prior to the end of the shift for all patients that are on any type of suicide precautions or heightened observations for self-injurious behaviors, those whose clinical presentation has changed to warrant a re-assessment for suicide risk, and once a day as well as prior to discharge for all patients.

Patient #1
Review of Patient #1's medical record revealed he was admitted on [DATE] and had an order from S11MD on 03/09/18 at 12:20 a.m. for Suicide precautions. Further review revealed an order on 03/12/18 at 8:00 a.m. from S6NP to discontinue Suicide Precautions.

Review of Patient #1's medical record revealed no documented evidence the RN assessed his suicide risk in accordance with policy on the day shift of 03/10/18.

In an interview on 04/17/18 at 1:55 p.m., S3IDON confirmed the suicide risk assessment was not documented on the day shift on 03/10/18.

Patient #2
Review of Patient #2's "Integrated RN Assessment" documented on 04/11/18 at 6:00 p.m. S12RN revealed no documented evidence Patient #2's present problem was documented as follows: according to the patient, according to the chart/others, the reliability of the informants' information, the family history of similar problems, the patient's opinion of the outcome of previous hospitalization s and use of the mental health system, and the patient's expectation from this hospitalization . Further review revealed no documented evidence the following emotional/mental status and physical/medical assessment was documented: affect; suicidal thoughts; memory; thought content; insight; neurological; gastro-intestinal; bowel/bladder elimination; oral health; sexual assessment. Further review revealed no documented evidence Patient #1's sleep/rest and mobility/activity were assessed by S12RN.

Review of patient #2's "RN Admission Progress Note" revealed no documented evidence of the signature of the RN who performed the assessment and the date and time the assessment was performed.

In an interview on 04/17/18 at 2:00 p.m., S3IDON confirmed the above-listed assessments were incomplete and/or were not dated, timed, and signed by the RN.

Patient #3
Review of Patient #3's "Integrated Nursing Assessment" documented on 04/10/18 at 3:45 p.m. revealed no documented evidence his assaultive/homicidal ideation/risk of violence was assessed as evidenced by having no check marks present in any available blocks, one of which was "has past history." Review of his "Initial Care Orders" dated 04/10/18 at 11:30 a.m. revealed Patient #3's reason for admission was aggression/violence.

In an interview on 04/17/18 at 2:15 p.m., S3IDON confirmed the history of homicide was not assessed by the nurse conducting the integrated nursing assessment.

2) The RN failed to ensure lab work that was ordered by the physician was resulted timely, placed on the patient's medical record, and reported to the physician when applicable:
Review of the policy titled "Assessments", presented as a current policy by S2COO, revealed laboratory/diagnostic tests are performed and test results of the UA, CBC, RPR, CMP, TSH, and UDS are available within 24 hours.

Patient #1
Review of Patient #1's "Initial Care Orders" received by telephone from S11MD revealed an order was given to obtain a CBC, CMP, UDS, UA, RPR, TSH, HgbA1c, Full Lipid Panel, and Lead Level. Review of his closed medical record revealed no documented evidence of a Lead level result, and there was no documented evidence S11MD was notified.

In an interview on 04/17/18 at 1:55 p.m., S3IDON confirmed Patient #1's medical record did not have a Lead Level result documented.

Patient #3
Review of Patient #3's "Initial Care Orders" received by telephone from S13MD revealed an order was given to obtain a CBC, CMP, UDS, UA, RPR, TSH, HgbA1c, Full Lipid Panel, and Lead Level. Review of his medical record on 04/16/18 (6 days after the order was received) revealed no documented evidence of lab results in his record.

In an interview on 04/16/18 at 12:50 p.m., S3IDON confirmed the lab results had not been reviewed and placed in the medical record by the RN. She indicated the HgbA1c, RPR, TSH, CBC, and CMP results were available by email on 04/11/18, and the UA and UDS results were available by email on 04/12/18.

In an interview on 04/16/18 at 1:00 p.m., S10RN indicated the unit secretary was supposed to check for lab results each day. She further indicated if labs were drawn on 04/11/18 and 04/12/18 and results weren't in the patients' medical records yet, it meant the unit secretary had not checked the email for lab results.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on record reviews and interviews, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan for each patient as evidenced by failure of the RN to develop and/or keep current a nursing care that included a plan for conditions for which the patient was being treated for 3 (#1, #2, #3) of 5 patient records reviewed for a current nursing care plan from a sample of 5 patients.
Findings:

Review of the policy titled "Treatment Planning", presented as a current policy by S2COO, revealed the nurse in charge on the acute units is responsible for the completion of the treatment plan. Axis III (consists of general medical conditions) diagnoses must be addressed in the treatment plan. If it is an active problem (receiving current treatment) then a plan of care with objectives and interventions is required. The treatment plan must be updated to reflect a change in the patient's condition.

Patient #1
Review of Patient #1's medical record revealed a nursing care plan was developed on 03/09/18 for depressed mood and risk of self-harm/suicidal gestures. There was no documented evidence that the nursing care plan was revised to include a plan for sexually inappropriate behavior/discussion.

In an interview on 04/17/18 at 8:44 a.m., S8MHT indicated she worked the day shift and spent a lot of time with Patient #1 during his hospital stay. She further indicated he initiated discussions with his peers about porn and said he was "addicted to it like people are addicted to drugs." She indicated she reported the discussions to the a therapist and a nurse on 03/11/18.

In an interview on 04/17/18 at 1:55 p.m., S3IDON confirmed the sexually inappropriate behavior/discussion should have resulted in Patient #1's nursing care plan being revised to include interventions and goals to address the behavior.

Patient #2
Review of Patient #2's medical record revealed a nursing care plan was developed on 04/11/18 for aggression, hyperactivity, and poor impulse control. There was no documented evidence the nursing care plan was developed for or revised for Hypotension.

Review of Patient #2's "Vital Statistics Record" revealed the following BPs:
04/14/18 - 96/70 at 8:00 a.m.; 98/66 at 8:00 p.m.;
04/15/18 - 81/53 at 8:00 a.m.; 89/59 at 8:00 p.m.;
04/16/18 - 89/62 at 8:00 a.m.

In an interview on 04/17/18 at 2:00 p.m., S3IDON confirmed Patient #2's nursing care plan was not revised to include nursing interventions and goals for Hypotension. She also confirmed there was no documented evidence the physician or NP was notified of the Hypotension.

Patient #3
Review of Patient #3's Psychiatric Evaluation conducted on 04/11/18 at 11:00 a.m. by S6NP revealed a medical diagnosis of Asthma. Review of his "Doctor's Order Sheet" revealed an order on 04/11/18 at 12:35 p.m. for Singulair (used to treat asthma and allergy symptoms) 10 mg po daily for allergies.

Review of Patient #3's nursing care plan revealed a plan was developed on 04/11/18 for aggression, persistent violation of rights of others/homicidal ideations, and argumentative/defiant behavior. There was no documented evidence a nursing care plan was developed for Asthma/allergies for which Patient #3 was receiving treatment.

In an interview on 04/17/18 at 2:15 p.m., S3IDON confirmed a nursing care plan was not developed for Asthma/allergies for Patient #3.
VIOLATION: SUPERVISION OF CONTRACT STAFF Tag No: A0398
Based on record reviews and interview, the DON failed to ensure non-employee licensed nurses' clinical activities were evaluated by an appropriately qualified hospital-employed RN. S7RN, who was contracted through Agency A and worked as the charge nurse on the Boys' Adolescent Unit on the night shift (7:00 p.m. to 7:00 a.m.) of 03/11/18, had no documented evidence in her personnel file of a current RN license and a competency evaluation performed by an appropriately qualified hospital-employed RN.
Findings:

Review of S7RN's personnel file revealed she was contracted RN with Agency A. Further review revealed documentation of her RN license verification revealed an expiration date of 01/31/18. Further review revealed a "Handbook Receipt And Acknowledgment" statement signed by S7RN on 11/23/16 that included the statement "I have received a copy of the Northlake Behavioral Health System Employee Handbook. I understand that it is my responsibility to review the Manual and to familiarize myself with the policies and procedures contained within..."

Review of the "Agency Nurse Agenda" contained in S7RN's personnel file revealed no documented evidence of the signature of the person who provided education. Further review of the personnel file revealed no documented evidence of an evaluation of S7RN's clinical activities that was conducted by an appropriately qualified hospital-employed RN.

In an interview on 04/17/18 at 12:55 p.m., S4HRM confirmed the license verification in S7RN's personnel file revealed the license was expired. She confirmed she didn't have evidence of current licensure for S7RN. She further indicated the contract agency director is provided education by the hospital on policies and procedures, and the agency person educates the agency staff used by the hospital. She confirmed the hospital RN doesn't evaluate the competency of the agency RNs, and the hospital uses the competency evaluation done by the agency.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interview, the hospital failed to ensure drugs were administered as ordered by the physician/NP as evidenced by failure of the RN to ensure medications were administered as ordered for 2 (#3, #5) of 5 records reviewed for medication administration from a sample of 5 patients.
Findings:

Patient #3
Review of Patient #3's "Doctor's Order Sheet" revealed the following orders:
04/11/18 at 11:00 a.m. - after consent for medications start Lexapro 5 mg po daily and Abilify 2.5 mg po daily;
04/11/18 at 12:35 p.m. - Singulair 10 mg po daily for allergies;
04/11/18 - verbal consent from mother at 2:50 p.m.

Review of Patient #3's medical record revealed no documented evidence Lexapro, Abilify, and Singulair were administered on 04/11/18 after consent was received from his mother. The first dose of each was administered on 04/12/18. There was no documented evidence of a clarification order received by the nurse to hold the first dose until 04/12/18.

In an interview on 04/17/18 at 2:58 p.m., S3IDON confirmed the Lexapro, Abilify, and Singulair were not administered as ordered on [DATE].

Patient #5
Review of Patient #5's "Doctor's Order Sheet" revealed an order on 03/13/18 at 11:50 a.m. for Fluoxetine 10 mg po daily after parent consent. Further review revealed the mother gave consent on 03/13/18 at 1:20 p.m.

Review of Patient #5's MAR revealed the first dose of Fluoxetine was administered at 8:00 a.m. on 03/14/18. There was no documented evidence of a clarification order received that addressed whether the first dose was to be held until 03/14/18 or whether it was to be given immediately after parental consent was obtained on 03/13/18.

In an interview on 04/17/18 at 2:58 p.m., S3IDON confirmed the Fluoxetine was not administered on 03/13/18, and there was no clarification order in the record.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on record reviews and interview, the hospital failed to ensure its infection control program was maintained as evidenced by failing to have documented evidence that all individuals providing direct patient care were free of tuberculosis in accordance with the Louisiana Administrative Code for 2 (S6NP, S7RN) of 4 personnel/credentialing files reviewed for current TB test results.
Findings:

Review of the Louisiana Administrative Code, "Chapter 5. Health Examinations for Employees, Volunteers and Patients at Certain Medical and Residential Facilities" revealed all persons prior to or at the time of employment at any medical or 24-hour residential facility requiring licensing by the Louisiana Department of Health shall be free of tuberculosis in a communicable state as evidenced by either: 1) a negative PPD skin test given by the Mantoux method or a blood assay for Mycobacterium tuberculosis; 2) a normal chest x-ray if the skin test or blood assay is positive; or 3) a statement from a licensed physician certifying the individual is non-infectious if the x-ray is other than normal. In order to remain employed, the individual shall be tested annually as long as the test remains negative.

Review of the policy titled "Employee health", presented as a current policy by S4HRM, revealed employees will be tested for TB annually. Annual TB clearance is mandatory.

S4NP
Review of S4NP's credentialing file revealed no documented evidence of a current TB test result.

S7RN
Review of S7RN's personnel file revealed she had a TB test administered on 04/17/18. Further review revealed her last TB test result was read on 04/10/17, more than one year prior to having her TB test administered.

In an interview on 04/17/18 at 12:55 p.m., S4HRM confirmed S7RN's TB test was administered more than one year after her previous TB test result was obtained. She indicated the physicians and NPs turn in a health statement but were not required to have a TB test as required by the Louisiana Administrative Code.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on record reviews and interviews, the hospital failed to ensure its grievance policy included the process for investigating patient/family grievances. There was no documented evidence a patient representative's grievance was thoroughly investigated as evidenced by failure to have documentation that interviews were conducted to determine if allegations brought forth were substantiated for 1 (#1) of 2 (#1, R1) grievances reviewed from a total of 3 grievances received from 02/01/18 through 04/16/18.
Findings:

Review of the policy titled "Patient Comments/Complaints", presented as a current policy by S2COO, revealed if the complaint is not solved at the initial level, staff will forward it to the Program Coordinator for resolution. If resolution cannot be achieved at this level, the complaint shall be referred to the Patient rights Officer. Further review of the policy revealed no documented evidence the policy addressed the manner in which grievances would be investigated.

Review of the "Grievance Summary March 2018", presented as the list of grievances received from 02/01/18 through 04/16/18 by S5RM, revealed a grievance was filed by Patient #1's mother on 03/11/18 and resolved on 03/12/18. Further review revealed the description of the grievance included the following: requested transfer to another facility, Patient #1 called his mother and stated "its horrible here and they do nothing but watch movies and play in the gym or sit and when he is sitting he thinks sad bad things." She stated the kids are a bad influence to him, and all they talk about is porn. Review of the resolution revealed the following: Patient #1's mother was able to speak with administrative staff to assist with concerns and was assisted with reaching out to the facility the mother had requested for transfer, but no beds were available. "Initiated review of patient stay; he reported that he voluntarily gave his food away last 2 nights and other boys was speaking of porn and felt this would trigger bad thought sin in his head. S7RN verified was on unit with age appropriate peers and she offered him a sandwich upon offering his food to peers. S7RN admits boys were not acting out and no sexualized conversation."

Review of the "Investigation Report" documented by S5RM on 03/13/18 revealed an email was received on 03/11/18 at 6:41 p.m. from Patient #1's mother with the subject of "moving my child." Further review revealed the email included the report by Patient #1's mother that Patient #1 reported "it's horrible there. He said they are doling nothing at all to help him get better all he does is watch movies and play in the gym or sit there and he said when he sits around he is thinking sad bad things. He also stated that the kids are a bad influence to him and all they talk about is porn... Please help me get him out... Please contact me ... about this situation." Results of the investigation were the grievance was unsubstantiated. Findings of the investigation included the following: Patient #1's mother had sent an email on 03/09/18 (date Patient #1 was admitted ) to the insurance carrier expressing concern that no one called her, and she needed to speak with the doctor. She was particularly concerned that she had read "35 very negative reviews ... and was very concerned about her son's safety." Further review revealed the corporate governmental affairs liaison spoke with patient #1's mother, and S2COO spoke with the mother afterwards. S2COO activated everyone to call Patient #1's mother on 03/09/18 as they did their evaluations. "The treatment team spoke with her." Further review revealed during treatment team on 03/12/18 staff shared that patient #1 is the one saying he is addicted to porn, and he is the one bringing it up to his peers.

Review of the documentation presented by S5RM revealed no documented evidence of interviews conducted with staff who provided care during Patient #1's hospital stay and the interview conducted with Patient #1's mother by the corporate governmental affairs liaison.

Review of Patient #1's MHT observation records revealed the following:
03/09/18 - watching television from 2:00 p.m. to 2:45 p.m.; in the gym from 3:30 p.m. to 4:30 p.m.; watching television from 4:45 p.m. to 6:15 p.m.;
03/10/18 (Saturday) - watching television from 8:30 a.m. to 9:00 a.m.; outside from 10:45 a.m. to 11:45 a.m.; watching movies from 3:00 p.m. to 4:45 p.m.;
03/11/18 (Sunday) - activities from 9:45 a.m. to 11:45 a.m.; outside/gym from 1:15 p.m. to 2:45 p.m.; watching movies from 3:00 p.m. to 4:30 p.m.; watching TV from 5:15 p.m. to 6:30 p.m.

Review of the activity schedule for the Boys' Adolescent Unit, presented as the current activity schedule by S2COO, revealed health education led by the RN was scheduled from 9:30 a.m. to 10:00 a.m., music therapy was scheduled from 1:00 p.m. to 2:00 p.m., and Group Therapy was scheduled from 3:30 p.m. to 4:30 p.m. on 03/09/18 (Friday). Further review revealed on Saturday, Sunday, and Holidays health education led by the RN is scheduled from 2:00 p.m. to 2:30 p.m. There was no documented evidence group therapy and music therapy was conducted on these days. Further review revealed these days consisted of morning personal care and room cleaning, breakfast, review of schedule and expectations led by MHTs, mindfulness led by MHTs, indoor free time, outside time, lunch, gym/recreation room, dinner, cared games/coloring led by MHTs, thinking games/trivia led by MHTs, free time, snack time, daily wrap-up led by MHTs, and lights out at 9:00 p.m.

In an interview on 04/17/18 at 10:20 a.m., S5RM indicated the investigation of patient #1's mother's grievance was started over the weekend, and S2COO assisted and "headed it up."

In an interview on 04/17/18 at 10:37 a.m., S2COO indicated she reviewed Patient #1's medical record but didn't interview any staff related to the grievance. She further indicated the investigation should have included interviews to determine the facts related to the allegations presented by Patient #1's mother.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on record reviews and interview, the hospital failed to ensure it implemented its grievance policy related to the written notice of its decision in its resolution of the grievance as evidenced by failure to have the resolution letter to include 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 (#1, R1) of 2 grievances reviewed from a total of 3 grievances received from 02/01/18 through 04/16/18.
Findings:

Review of the policy titled "Patient Comments/Complaints", presented as the current grievance policy by S2COO, revealed all patient grievances must be responded to in writing as soon as possible. Further review revealed the written response must include the substance of the grievance, the steps taken to investigate the grievance, the results of the investigation, and the date of completion.

Review of the resolution letters sent to Patient #1's mother and Patient R1's mother by S5RM revealed no documented evidence the letters included 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 grievance process.

In an interview on 04/17/18 at 10:20 a.m., S5RM indicated has a template she uses to construct the resolution letter. She further indicated it's a "basic letter", and she "just plugs in" the situation/allegations that have been presented by the complainant. S5RM confirmed the resolution letters sent to the mothers of Patient #1 and Patient R1 didn't include 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 grievance process.
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
Based on record reviews and interview, the hospital failed to ensure that the patient and family members were counseled to prepare them for post-hospital care as evidenced by failing to ensure that patients and family members were informed of and provided a list of all medications the patient should be taking after discharge that included clear indication of changes from the patient's pre-admission medications for 2 (#1, #2) of 4 (#1, #2, #4, #5) patients' discharged records reviewed from a sample of 5 patients.
Findings:

Review of the policy titled "Discharge Planning and Process", presented as a current policy by S2COO, revealed it was the hospital's policy to begin discharge planning at the time of admission, develop appropriate discharge plans prior to discharge, and provide discharge instructions and continuity of care information for aftercare to all patients prior to their departure from the hospital. Further review revealed the discharge order form will be used to write orders that contain discharge medications (medication, dose, route, time, special instructions) that have been reconciled with current medications, and the physician shall review these with the patient prior to discharge.

Patient #1
Review of Patient #1's medication reconciliation form dated 03/09/18 revealed prior to hospitalization s he was taking the following medications: Vistaril 25 mg po Q HS, Vyvanse 20 mg po daily, Zoloft 100 mg po Q HS ( also listed as Q a.m. and not clarified).

Review of Patient #1's "Doctor's Discharge Order Sheet" dated 03/12/18 at 11:00 a.m. revealed his discharge medications included Prozac 10 mg po daily, Vistaril 25 mg po Q HS, and Vyvanse 30 mg po daily. There was no documented evidence of a clear indication of the changes in Patient #1's discharge medications from his pre-admission medications. The "Doctor's Discharge Order Sheet" did not address Zoloft which he was taking pre-admission, that Prozac was added since his admission, and that his Vyvanse dose had been increased from 20 mg to 30 mg daily.

Patient #2
Review of Patient #2's medication reconciliation form dated 04/11/18 revealed prior to hospitalization he was taking the following medications: Clonidine 0.1 mg po Q p.m., Adderall 15 mg po daily, Vyvanse 50 mg po Q a.m.

Review of Patient #2's "Doctor's Discharge Order Sheet" dated 04/16/18 at 11:00 a.m. revealed his discharge medications included Adderall 10 mg po Q a.m. There was no documented evidence of a clear indication of the changes in Patient #2's discharge medications from his pre-admission medications. The "Doctor's Discharge Order Sheet" did not address Clonidine and Vyvanse which he was taking pre-admission. It also did not address the decrease in the dose of Adderall from 15 mg to 10 mg.

In an interview on 04/17/18 at 1:40 p.m., S2COO confirmed the physicians and NPs are not documenting changes in the patients' discharge medications from those the patients were taking prior to hospitalization .