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.

BEACON BEHAVIORAL HOSPITAL - NORTHSHORE, INC 64026 HWY 434, SUITE 300 (3RD FLOOR) LACOMBE, LA May 16, 2018
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure documented evidence was maintained to indicate a grievance regarding patient care was thoroughly investigated and documented evidence to indicate a written response had been sent to the complainant at the conclusion of the investigation for 1 (#2) of 1 patients reviewed for grievances.

Findings:

Review of the hospital policy titled, "Patient Rights - Complaint and Grievance Processes" revealed in part: All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements are considered grievances for the purposes of this policy and must be handled through the grievance process .....7. The grievance committee: b. Initiates an investigation c. Investigation may include, but not limited to: i. Interviews with complainant and patient involved ii. Interviews with staff members on duty at the time of the occurrence of the alleged event. iii. Review of patient's medical record. iv. Review of policies/procedures. v. Review of video surveillance .....10. When the grievance has been resolved, the Administrator will send a written response to the complainant that includes: a.The determination of the grievance committee and any general actions taken to resolve the issue. b. The date of completion of the process. c. Steps taken on behalf of the patient/complainant to investigate the grievance. d. The name and contact information of the Administrator (who should be identified as the individual that the complainant should contact in the event that further concerns and/or questions are to be expressed).

Review of Patient #2's medical record revealed an admission date of [DATE] and discharge date of [DATE].

Review of the hospital's complaints and grievances from 1/1/2018-5/14/2018 revealed no documented evidence of an investigation of a grievance related to the care Patient #2 had received during her hospitalization .

In an interview on 5/14/18 at 4:20 p.m. with S1Adm, she reported she remembered a discussion with S9FormerAdm related to a complaint regarding the quality of care Patient #2 had received during her hospitalization . S1Adm confirmed Patient #2 had basically been total care. S1Adm confirmed she could find no documented evidence of an investigation into the grievance referenced above. S1Adm reported she had reached out to S9FormerAdm regarding the grievance and had received no response.

In an interview on 5/16/18 at 12:00 p.m. with S2DON, she confirmed S9FormerAdm had spoken with Patient #2's family regarding the above referenced grievance. S2DON reported she was not sure whether a written response had been sent to the patient's family regarding the grievance.

In an interview on 5/16/18 at 12:05 p.m. with S1Adm, she indicated she was doubtful that a written response had been sent to Patient #2's family even though the hospital's practice was to send a written response to the complainant upon conclusion of a grievance investigation. S1Adm confirmed she could not produce documented evidence that a written response had been sent to the complainant.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on record review, observation, and interview, the hospital failed to ensure geriatric psychiatric patients admitted to the inpatient geriatric psychiatric hospital were provided care in a safe setting. This deficient practice is evidenced by:
1. failing to ensure geriatric psychiatric patients who were admitted to the inpatient geriatric psychiatric hospital for being a harm to themselves or others were observed by MHTs as ordered by the physician for 2 (#3, #R4) of 9 patients with every 15 minute observations ordered and 1 (#R3) of 2 (#R2, #R3) patients with line of sight at all times ordered on the night shift of 5/11/18 and 2 (#R1,#R3) of 3 (#R1, #R2, #R3) patients on ordered line of sight on the day shift of 5/14/18; and
2. failing to ensure staffing assignments were made that allowed staff members to maintain observation levels for 5 (#3,#R4,#R5,#R6,#R7) of 9 patients with every 15 minute observations ordered and 1 (#R3) of 2 (#R2, #R3) patients on ordered line of sight on the night shift of 5/11/18 and for 2 (#4, #R3) of 4 (#4, #R1,#R2,#R3) patients on ordered line of sight on the night shift of 5/13/18.

Findings:

1. Failing to ensure patients who were admitted for being a harm to themselves or others were observed by MHTs as ordered by the physician.

Review of the hospital policy titled,"Levels of Observation", revealed in part: This hospital recognizes that many risks may be decreased by providing an appropriate level of observation to meet the patient's individual needs.
Close Observation: The routine level of observation applied to patients that are not considered at risk and in need of increased supervision. At least every 15 minutes, a staff member directly visually observes the patient to determine: signs of life, location, and activity (may include behavior and/or effect). Immediately after (or while) observing the patient, the staff member documents the patient's location and activity on the observation sheet.

Line of Sight: Defined as maintinaing visual observation of a patient at all times. A staff member may be assigned to maintain line of sight on up to 3 patients (though this number may be increased if the line of sight patients are involved in a group activity). It is always the staff member's responsibility to maintain visual contact with the patient. If assigned more than one line of sight patient and at least one patient needs to use the bathroom, shower, or leave the group for another reason, the staff member must enlist the assistance of another staff member to ensure that all patients on line of sight are maintained within visual range of staff. At night, patients on line of sight may be roomed together or in close proximity eneough to allow a staff member to maintain visual contact at all times ( including ability to confirm signs of life). In the event that a staff member providing line of sight observation must leave his/her spot, compromising visualization of any line of sight patients assigned, the staff member must obtain relief and/or assistance from another staff member.

Observation of a hospital-provided video recording on 5/14/18 at 1:30 p.m. of the night shift of 5/11/18 from 1:00 a.m. to 4:00 a.m. (a total of 3 hours) revealed no hospital staff was observed performing 15 minute observations as ordered for Patient's #3 and #R4: 1:00 a.m. - 1:59 a.m. (59 minutes with no observation); 2:01 a.m. - 3:00 a.m.(59 minutes without observation); 3:03 a.m. - 3:49 a.m. (46 minutes with no observations). Review of S4MHT's observation sheets (the MHT who had been assigned Patients #3 and #R4) revealed the MHT had documented every 15 minute observations on the referenced patients' observation sheets although she was not observed on the video making the ordered observations. Patient #3 had precautions including elopement, fall, seizure, suicide, aggression, and swallowing and Patient #R4 had precautions including fall, suicide, and alcohol withdrawal.

Further review of the above referenced hospital - provided video recording of the night shift of 5/11/18 from 1:00 a.m. to 4:00 a.m. revealed S5MHT, who had been assigned to monitor Patient #R3 line of sight, walked down the hall at 1:07 a.m., away from the patient's room, in an area where the patient could not be directly visualized. Patient #R3 was observed leaving the room at 1:10 a.m., unattended by staff, and returning to his room at 1:11 a.m. unattended by staff. S5MHT was observed returning at 1:13 a.m. (Patient #R3 had been out of line of sight by staff for 6 minutes). Additional review revealed S5MHT sat in a chair in the hall out side of Patient #R3's room, facing forward, without the patient in her line of sight. S5MHT had a cell phone in her hand and appeared to be looking at and touching the screen on the phone. Patient #R3 was observed at 1:42 a.m. going into the bathroom again, unattended by staff (not in direct line of staff) and going back into his room at 1:43 a.m. S5MHT was seated outside of the door to the patient's room, looking at a computer screen for the duration of the time the patient had gone into the bathroom and had returned to his room. Patient #R3 had been ordered to be on constant line of sight observation with every 15 minute documentation because he had precautions including suicide, aggression, seizure, and fall precautions.

S2DON was present on 5/14/18 at 1:30 p.m., during the review of the video recordings referenced above, and verified the lapses in patient supervision noted by the surveyors.

On 5/14/18 at 12:48 p.m. an observation was made of 2 patients (#R1 and #R2) who were on ordered line of sight observation in the dining room during meal time. Patient #R2 was seated at a table at the far end of the room and Patient #R1 was laying on a sofa (also located in the far side of the room) covered with a blanket with the back of the sofa facing where S13MHT was located. S13MHT, the only staff member in the room at the time of the observation, was observed passing out meals. Patients #R1 (Suicide, Seizure and Withdrawal Precautions) and #R2 (Fall Precautions) were observed to be out of direct staff line of sight for 7 minutes total. S2DON confirmed Patients #R1 and #R2 were currently on ordered line of sight observation level.

In an interview on 5/15/18 at 9:30 a.m. with S7LPN, she confirmed patients who were on ordered line of sight should have been within the direct line of sight of staff at all times.


2.Failing to ensure staffing assignments were made that allowed staff members to maintain observation levels.

On the night shift of 5/11/18, S4MHT was assigned 5 patients (Patients #3, #R4, #R5, #R6, #R7) who were located on both the male and female halls with 15 minute observations ordered. S4MHT also observed Patient #R3 line of sight for 32 minutes (1:21 a.m. - 1:53 a.m.). S4MHT's 5 assigned patients were in different rooms and unable to be visualized from where she was seated outside of Patient #R3's door. Review of Patients #3, #R4, #R5, #R6, and #R7's observation sheets revealed S4MHT had documented every 15 minute observations on the referenced patients observation sheets although she was not observed on the hospital- provided video making the ordered observations.

In an interview 5/16/18 at 9:59 a.m. with S4MHT, she confirmed she had worked on the night shift of 5/11/18. S4MHT confirmed she had been assigned patients on the male and female halls, located on opposite sides of the hospital. S4MHT further confirmed she could not see all of the every 15 minute observation patients that had been assigned to her when she was observing Patient #R3 line of sight. S4MHT reported there wasn't anyone extra to watch her other patients on the night shift of 5/11/18.


Review of S3MHT's assignment sheets for the night shift of 5/13/18 revealed S3MHT had been assigned 2 patients (#4 and #R3) in two separate rooms with ordered line of sight observation, but the patients could not be observed from the same location making the assignment impossible to perform by one MHT.

In an interview on 5/15/18 at 9:30 a.m. with S7LPN, she confirmed the above referenced line of sight patient assignment would not have been possible due to the locations of Patient #4 and Patient #R3's rooms and location of the patient beds within the rooms.

In an interview on 5/16/18 at 9:29 a.m. with S3MHT, she confirmed she had been assigned 2 patients on line of sight (Patients #4 and #R3) on the night shift of 5/13/18. S3MHT reported when the patients were in their rooms she would not have been able to fully visualize their faces and entire bodies when seated in the hall outside of their bedrooms.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the hospital failed to report an allegation of neglect to LDH-HSS (Louisiana Department of Health - Health Standards Section) or a local law enforcement agency within 24 hours of receipt of the allegation for 1 (#2) of 1 sampled patients reviewed for allegations of neglect.

Findings:

Review of the State law R.S. 40:2009.20 revealed "Any person who is engaged in the practice of medicine, social service, facility administration, psychological services or any RN, LPN, nurses' aide, personal care attendant, respite worker, physician's assistant, physical therapist, or any other healthcare giver 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 24 hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect."

Review of Patient #2's medical record revealed an admission date of [DATE] and discharge date of [DATE]. Further review revealed the patient had a diagnosis of Dementia, had required staff assistance for meal and fluid intake and was dependent on staff for activities of daily living.

In an interview on 5/14/18 at 4:20 p.m. with S1Adm, she reported she remembered a discussion with S9FormerAdm related to a complaint regarding the care Patient #2 had received and the patient's family member reporting the patient had not received adequate nutrition during her hospitalization . S1Adm confirmed Patient #2 had basically been total care.

Review of the hospital's self-reports of allegations of abuse/neglect submitted to LDH-HSS from 1/1/2018-5/14/2018 revealed no documented evidence of a self-report regarding an allegation of neglect of Patient #2 during the patient's hospitalization .

In an interview on 5/16/18 at 12:05 p.m. with S1Adm, she confirmed the hospital had not self-reported the above-referenced allegations to LDH-HSS within 24 hours of discovery.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews, observations and interviews, the hospital failed to ensure the registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by:

1) failure of the RN to ensure MHT staff performed and accurately documented every 15 minute checks at night, as ordered by the physician, for 5 (#3,#R4,#R5,#R6,#R7) of 9 patients with every 15 minute observations ordered who were observed on a hospital provided video recording of the night shift of 5/11/18 from 1:00 a.m. - 4:00 a.m.( a total of 3 hours).

2) failure of the RN to ensure the treating provider had been notified of a trigger (decline in meal intake) for further nutritional evaluation (dietary consult) for a patient (#2) who was dependent on staff for consumption of meals, fluids, and snacks with a documented decline in meal intake for 1 (#2) of 3 (#2, #3,#5) patients reviewed for special dietary needs/dietary consults from a total patient sample of 5 (#1-#5).

Findings:

1) Failure of the RN to ensure MHT staff performed and accurately documented every 15 minute checks at night, as ordered.

Review of the hospital policy titled,"Levels of Observation", revealed in part: This hospital recognizes that many risks may be decreased by providing an appropriate level of observation to meet the patient's individual needs.

Close Observation: The routine level of observation applied to patients that are not considered at risk and in need of increased supervision. At least every 15 minutes, a staff member directly visually observes the patient to determine: signs of life, location, and activity (may include behavior and/or effect). Immediately after (or while) observing the patient, the staff member documents the patient's location and activity on the observation sheet.

Line of Sight: Defined as maintinaing visual observation of a patient at all times. A staff member may be assigned to maintain line of sight on up to 3 patients (though this number may be increased if the line of sight patients are involved in a group activity). It is always the staff member's responsibility to maintain visual onctact with the patient. If assigned more than one line of sight patient and at least one patient needs to use the bathroom, shower, or leave the group for another reason, the staff member must enlist the assistance of another staff member to ensure that all patients on line of sight are maintained within visual range of staff. At night, patients on line of sight may be roomed together or in close proximity eneough to allow a staff member to maintain visual contact at all times ( including ability to confirm signs of life). In the event that a staff member providing line of sightobservation must leave his/her spot, compromising visualization of any line of sight patients assigned, the staff member must obtain relief and/or assistance from another staff member.

Observation of a hospital-provided video recording on 5/14/18 at 1:30 p.m. of the night shift of 5/11/18 from 1:00 a.m. to 4:00 a.m. (a total of 3 hours) revealed no hospital staff was observed performing 15 minute observations as ordered for Patient's #3 and #R4: 1:00 a.m. - 1:59 a.m. (59 minutes with no observation); 2:01 a.m. - 3:00 a.m.(59 minutes without observation); 3:03 a.m. - 3:49 a.m. (46 minutes with no observations). Review of S4MHT's observation sheets (the MHT who had been assigned Patients #3 and #R4) revealed the MHT had documented every 15 minute observations on the referenced patients' observation sheets although she was not observed on the video making the ordered observations. Patient #3 had precautions including elopement, fall, seizure, suicide, aggression, and swallowing and Patient #R4 had precautions including fall, suicide, and alcohol withdrawal.

Further observation of the video revealed S4MHT had been assigned 5 patients (Patients #3, #R4, #R5, #R6, #R7) with ordered every 15 minute observations who were located on both the male and female halls. S4MHT also observed Patient #R3 line of sight for 32 minutes (1:21 a.m. - 1:53 a.m.). S4MHT's 5 assigned patients were in different rooms and unable to be visualized from where she was seated outside of Patient #R3's door. Review of Patients #3, #R4, #R5, #R6, and #R7's observation sheets revealed S4MHT had documented every 15 minute observations on the referenced patients' observation sheets although she was not observed on the hospital- provided video making the ordered observations.

S2DON was present on 5/14/18 at 1:30 p.m., during the review of the video recordings referenced above, and verified the lapses in patient supervision noted by the surveyors.

Interview on 5/15/18 at 9:30a.m. with S7LPN, she confirmed she had worked the night shift of 5/11/18 and 5/13/18. S7LPN reported she had not been aware that the every 15 minute patient observations had not been done on the night shift of 5/11/18, but were being charted as being done.

In an interview 5/16/18 at 9:59 a.m. with S4MHT, she confirmed she had worked on the night shift of 5/11/18. S4MHT confirmed she had been assigned patients on the male and female halls, located on opposite sides of the hospital. S4MHT further confirmed she could not see all of the every 15 minute observation patients that had been assigned to her when she was observing Patient #R3 line of sight. S4MHT reported there wasn't anyone extra to watch her other patients on the night shift of 5/11/18.


2) Failure of the RN to ensure the treating provider had been notified of a trigger for
further nutritional evaluation (dietary consult) for a patient (#2) who was dependent on staff for consumption of meals, fluids, and snacks with a documented decline in meal intake.


Review of the hospital policy titled,"Nutritional Consult", revealed in part: This hospital ensures that a comprehensive nutritional consult is completed by the registered dietician and a plan of care for nutrition needs is developed and implemented for any inpatient determined by the treating prescriber to be at risk. Procedure: 1. The need for nutritional consult with a registered dietician may be triggered by any of the following: b. Notations regarding intake in the nurses progress notes and/or daily flowsheet. 2. As soon as practicable, the nurse will notify the treating provider that there is a trigger for further nutritional evaluation, if the precipitating information is not part of the results routinely and/or frequently monitored by the presciber (such as nurses notes, etcetera).

Review of Patient #2's medical record revealed an admission date of [DATE] and discharge date of [DATE]. Further review revealed the patient had a diagnosis of Dementia, had required staff assistance for meal and fluid intake and was dependent on staff for activities of daily living.

Review of Patient #2's medical record revealed the following nurses' note entries regarding patient meal intake, patient mental status, and level of assistance with meal intake:

2/2/2018 at 11:55 a.m.: 20 % breakfast; 0 % lunch; 30% dinner.
Patient disoriented, confused, illogical, conversations with self, lays in geri-chair;
Eats with assist, sleeps frequently, eyes closed majority of time, will continue to monitor.

2/3/2018 6:00 p.m.: 30% breakfast; 30 % lunch; 0 % dinner and 0% for snacks. Patient resting with eyes closed in geri chair in dayroom, rambling incoherent word salad. Patient total assist for ADLs (activities of daily living) and needs to be fed meals and snacks.

2/4/2018: 70 % breakfast; 0% lunch; 0% dinner; and 0% snack.
Patient observed to be sitting in dayroom, not interacting with staff or other patients only alert to self mumbles rambles to self-illogical in conversation. Visual hallucinations, picking at invisible items in the air.

Further review of Patient #2's entire electronic medical record revealed no documented evidence that the treating prescriber had been notified of Patient #2's decline in intake resulting in a trigger for further nutritional evaluation by a dietician. Additional review of the prescribers orders revealed no documented evidence of an order for a nutritional consult.

The above referenced findings were verified by S12Quality, electronic medical record navigator, during Patient #2's medical record review on 5/14/18 at 2:30 p.m.

In an interview on 5/16/18 at 9:29 a.m. with S3MHT, she reported Patient #2 had a diagnosis of Alzheimer's disease and had been total care. S3MHT reported the staff had to feed Patient #2. S3MHT further reported the patient had been dependent on staff for consumption of all of her meals, snacks and fluids.

In an interview on 5/16/18 at 11:00 a.m. with S10Dietician, she confirmed Patient #2 should have triggered a dietary consult due having had a tapering off of her intake.
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 the nursing staff developed, and kept current, a nursing care plan for each patient. This deficient practice was evidenced by failure of the nursing staff to address a patient's total dependence on staff for nutritional intake and decreased oral intake of meals as identified problems on the patient's plan of care for 1 (#2) of 4 (#2 - #5) sampled patient records comprehensively reviewed.

Findings:

Review of the hospital policy titled," Multidisciplinary Treatment Plan" revealed in part: The Multidisciplinary Treatment Plan includes a list of identified problems (of any nature: psychiatric, medical, social, legal, etcetera); Short-term and Long-range goals...... 9. As changes in the patient's needs and/or condition changes or as interventions not already listed in the Multidisciplinary Treatment Plan are implemented, the Multidisciplinary Treatment Plan is revised and updated.


Review of Patient #2's medical record revealed an admission date of [DATE] and discharge date of [DATE]. Further review revealed the patient had a diagnosis of Dementia, had required staff assistance for meal and fluid intake and was dependent on staff for activities of daily living. The patient was bedbound/chairbound, had been unable to stand and was a 2-3 person assist for tranfers requiring the use of a hoyer lift.

Review of Patient #2's medical record revealed the following nurses' note entries regarding patient meal intake, patient mental status, and level of assistance with meal intake:

2/2/2018 at 11:55 a.m.: 20 % breakfast; 0 % lunch; 30% dinner.
Patient disoriented, confused, illogical, conversations with self, lays in geri-chair;
Eats with assist, sleeps frequently, eyes closed majority of time, will continue to monitor.

2/3/2018 6:00 p.m.: 30% breakfast; 30 % lunch; 0 % dinner and 0% for snacks. Patient resting with eyes closed in geri chair in dayroom, rambling incoherent word salad, intermittent productive cough observed, lung fields clear bilaterally. Afebrile, patient total assist for ADLs (activities of daily living) and needs to be fed meals and snacks.

2/4/2018: 70 % breakfast; 0% lunch; 0% dinner; and 0% snack.
Patient observed to be sitting in dayroom, not interacting with staff or other patients only alert to self mumbles rambles to self-illogical in conversation. Visual hallucinations, picking at invisible items in the air.

Above referenced findings verified by S12Quality,electronic medical record navigator, during Patient #2's medical record review on 5/14/18 at 2:30 p.m.

Review of Patient #2's comprehensive treatment plan revealed Patient #2's total dependence on staff for nutritional intake and decreased oral intake of meals had not been identified as problems on the patient's plan of care.

In an interview on 5/14/18 at 4:20 p.m. with S1Adm, she confirmed Patient #2 had basically been total care.

In an interview on 5/16/18 at 9:29 a.m. with S3MHT, she reported Patient #2 had a diagnosis of Alzheimer's disease and had been total care. S3MHT reported the staff had to feed Patient #2. S3MHT further reported the patient had been dependent on staff for consumption of all of her meals, snacks and fluids.

In an interview on 5/16/18 at 12:00 p.m. with S2DON, she confirmed the patient's dependence on staff for consumption of all of her meals, snacks, and fluids and decreased meal intake should have been addressed on the patient's comprehensive treatment plan as an identified problem.
VIOLATION: THERAPEUTIC DIETS Tag No: A0629
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure individual patient nutritional needs were met in accordance with recognized dietary practices. The deficient practice was evidenced by failure of the hospital to ensure a patient (#2) with a documented decline in meal intake had been referred to the dietician for assessment due to being at risk for nutritional deficiencies associated with a decline in nutritional intake for 1 (#2) of 3 (#2, #3,#5) patients reviewed for special dietary needs/dietary consults from a total patient sample of 5 (#1-#5).

Findings:

Review of the hospital policy titled,"Nutritional Consult", revealed in part: This hospital ensures that a comprehensive nutritional consult is completed by the registered dietician and a plan of care for nutrition needs is developed and implemented for any inpatient determined by the treating prescriber to be at risk. Procedure: 1. The need for nutritional consult with a registered dietician may be triggered by any of the following: b. Notations regarding intake in the nurses progress notes and/or daily flowsheet.

Review of Patient #2's medical record revealed an admission date of [DATE] and discharge date of [DATE]. Further review revealed the patient had a diagnosis of Dementia, had required staff assistance for meal and fluid intake and was dependent on staff for activities of daily living.

Review of Patient #2's medical record revealed the following nurses' note entries, in part, regarding patient meal intake percentage, patient mental status, and level of assistance with meal intake:

2/2/2018 at 11:55 a.m.: 20 % breakfast; 0 % lunch; 30% dinner.
Patient disoriented, confused, illogical, conversations with self, lays in geri-chair;
Eats with assist, sleeps frequently, eyes closed majority of time, will continue to monitor.

2/3/2018 6:00 p.m.: 30% breakfast; 30 % lunch; 0 % dinner and 0% for snacks. Patient resting with eyes closed in geri chair in dayroom, rambling incoherent word salad. Patient total assist for ADLs (activities of daily living) and needs to be fed meals and snacks.

2/4/2018: 70 % breakfast; 0% lunch; 0% dinner; and 0% snack.
Patient observed to be sitting in dayroom, not interacting with staff or other patients only alert to self mumbles rambles to self-illogical in conversation. Visual hallucinations, picking at invisible items in the air.

Further review of Patient #2's entire electronic medical record revealed no documented evidence that the treating prescriber had been notified of Patient #2's decline in intake which resulted in a trigger for further nutritional evaluation by a dietician. Additional review of the prescribers orders revealed no documented evidence of an order for a nutritional consult. There was also no documented evidence of a nutritional assessment in the special assessment section of the patient's electronic medical record.

The above referenced findings were verified by S12Quality, electronic medical record navigator, during Patient #2's medical record review on 5/14/18 at 2:30 p.m.

In an interview on 5/16/18 at 9:29 a.m. with S3MHT, she reported Patient #2 had a diagnosis of Alzheimer's disease and had been total care. S3MHT reported the staff had to feed Patient #2. S3MHT further reported the patient had been dependent on staff for consumption of all of her meals, snacks and fluids.

In an interview on 5/16/18 at 11:00 a.m. with S10Dietician, she confirmed she was a registered dietician and was contracted with the hospital. S10Dietician indicated in the past she had performed a nutritional assessment on all of the new patients, but had only performed patient nutritional assessments per consult for the last year or so. S10Dietician reported she entered her dietary assessment as part of the special assessments section in the electronic medical record. S10Dietician reported Patient #2 should have triggered a dietary consult due to having had a tapering off of her intake. S10Dietican indicated she could have assessed Patient #2's labs, chewing and swallowing ability, and dentition. S10Dietician reported she could have made recommendations for appetite stimulation, supplements, modified consistency diets, protein supplements, and would have monitored the patient for dehydration.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to ensure geriatric psychiatric patients received care in a safe setting as evidenced by:

1. failing to ensure geriatric psychiatric patients who were admitted to the inpatient geriatric psychiatric hospital for being a harm to themselves or others were observed by MHTs as ordered by the physician for 2 (#3, #R4) of 9 patients with every 15 minute observations ordered and 1 (#R3) of 2 (#R2, #R3) patients with line of sight at all times ordered on the nightshift of 5/11/18 and 2 (#R1,#R3) of 3 (#R1, #R2, #R3) patients on ordered line of sight on the day shift of 5/14/18 (See findings under tag A-0144); and

2. failing to ensure staffing assignments were made that allowed staff members to maintain observation levels for 5 (#3,#R4,#R5,#R6,#R7) of 9 patients with every 15 minute observations ordered and 1 (#R3) of 2 (#R2, #R3) patients on ordered line of sight on the night shift of 5/11/18 and for 2 (#4, #R3) of 4 (#4, #R1,#R2,#R3) patients on ordered line of sight on the night shift of 5/13/18 (See findings under tag A-0144).


An Immediate Jeopardy situation was identified on 5/15/18 at 3:32 p.m. and reported to S1Adm, S2DON and S12Quality. The Immediate Jeopardy situation was a result of the hospital failing to have a system in place to ensure staff observed patients in the Geri Psychiatric Hospital admitted for being a danger to themselves or others as ordered per physician's order.

On 5/16/18 at 8:30 a.m. S1Adm presented the 1st plan for lifting the immediacy of the IJ situation and the plan included the following:

1. Staff members assigned line of sight patients would not be assigned any other task and would not be allowed a computer on wheels or any other item likely to provide a distraction.

2. Whenever staff members assigned to line of sight patients are in common areas with other patients present (for example the day room) another staff member will be stationed in that area to monitor/meet the needs of other patients (those patients not on 1:1 or line of sight).

3. Approximately 2 hours before the end of each shift, the charge nurse will be required to examine the census, the acuity of the unit and its patients, and the levels of observation to determine the need for additional staff members, so as to allow calling in additional staff as needed. The analysis will include number of patients, number of staff members scheduled, level of functioning of patients, number of patients on line of sight, 1:1 observation, genders of patients on higher levels of observation (as patient must be accompanied to shower, bathroom), activities scheduled, room assignments of patients on line of sight. Staffing must be sufficient to provide staff members to station themselves in position to observe every patient on line of sight ( if patients are in distant rooms, staffing may constitute 1:1 coverage for each line of sight patient). The charge nurse will document the analysis on the staffing evaluation form and, in the event that additional staff members are required, the charge nurse will notify the administrator on call and additional staff will be summoned.

4. The nurses will make rounds a minimum of every 2 hours, on a random schedule, to ensure staff members are following all policies and procedures. Nurses will ensure that staff members are conducting and documenting observations per prescriber's orders.

5. Staff members assigned line of sight and 1:1 patients will be relieved at least every 2 hours for a minimum of 30 minutes. The charge nurse must be aware of the identity of staff members relieving assigned staff. The charge nurse will assign staff to relieve staff assigned line of sight and 1:1 patients for his/her breaks.

6. Staff members assigned line of sight and 1:1 observation shall be issued two-way radios to facilitate communication with the charge nurse or designee to enable the staff member to continue his/her patient observations while asking to be relieved.

7. Staff education was provided regarding a. policies and procedures for levels of observation including the need to provide observations as ordered, document direct visual observation every 15 minutes, maintain constant visual observation on patients on line of sight and 1:1 observation, staff members assigned line of sight and 1:1 may never leave their patients unobserved and must confirm relief or assistance by another staff member before leaving the patient. b. use of two way radios, c. hand off communications- it was re-iterated observation sheets must be handed off with any patients being observed by a different staff member, d. it is the responsibility of the charge nurse to supervise LPNs and MHTs to ensure that tasks are completed per policy and procedures. RNs were advised to make random rounds at least every 2 hours to ensure compliance. Any staff members unable to attend educational sessions on 5/14/18 and 5/15/18 were required to meet with the administrator or designee to receive education listed above in order to continue to work with patients.

On 5/16/18 at 9:00 a.m. S1Adm was informed the 1st plan for lifting needed information regarding how the hospital was going to evaluate/measure compliance such as video review and/or direct observation, and the time frames to evaluate and maintain compliance.

On 5/16/18 at 10:45 a.m. the 2nd revised plan for lifting was presented by S1Adm. The revised plan included video monitoring 3 times a week and administrative spot checks on the night shift. S1Adm was advised the plan for monitoring for continued compliance needed more detail.

On 5/16/18 at 11:54 a.m. the 3rd revised plan for lifting was presented by S1Adm and was revised to include video monitoring 4 times per week to view 3 hours of footage to evaluate staff supervision of patients, as ordered per the patients' physicians. Administrative staff was also to do random 7 p.m. shift observations once per week. Video monitoring had begun, effective immediately. Footage was to be monitored until evidence was obtained that there was 100 % staff compliance with supervision of patients as ordered for 3 consecutive months. After establishing compliance administrative staff was to continue to do random checks of video footage to ensure staff compliance with monitoring of patients as ordered. This plan of correction had been added to the hospital's quality assurance plan.

On 5/16/18 at 9:30 a.m. observations of staff supervision of patients were conducted in the patient care unit. All patients were being monitored as ordered. The MHT and nursing staff were interviewed during the observation regarding re-education on patient observation and precaution levels. The staff was able to define/describe patient observation levels and precaution levels.

On 5/16/18 at 10:30 a.m. a review was conducted of hospital provided video recordings of staff supervision of patients for the night shift of 5/15/18-5/16/18 from 1:28 a.m. - 3:05 a.m. (a total of 1 hour and 37 minutes). Staff was observed monitoring patients as ordered and performing/documenting every 15 minute checks as ordered.

Documentation of staff education and sign in sheets were presented to the survey team. The staff education focused on patient supervision/levels of observation, use of two way radio communication, and importance of maintaining patient supervision as ordered. The staff education sign-in sheets were reviewed and all staff, currently working, had been in-serviced. Provisions were put into the plan indicating staff would not be allowed to work until they had been re-educated as referenced in the plan for lifting.

The Immediacy was lifted on 5/16/18 at 12:01 p.m. at survey team exit. However, there was not enough evidence to determine sustainability of Compliance for the Condition of Patient Rights to be cleared. Noncompliance remains at the Condition Level.