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.

GENESIS BEHAVIORAL HOSPITAL 606 LATIOLAIS ROAD BREAUX BRIDGE, LA March 21, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights as evidenced by:

1) Failing to ensure a patient was free from neglect for 1 (#3) of 5 patient records reviewed for neglect from a sample of 5 patients. Patient #3, after having an incident of diarrhea on 02/19/18 and having no clean clothing to replace the soiled clothing, was placed in a garbage bag with no clothes from the waist down, was allowed to continue a group session in the company of males and females while wearing the garbage bag, and was transported home while wearing the garbage bag with other clients present in the van. (see findings in tag A0145)

2) Failing to ensure a patient was provided privacy, including respect, dignity, and comfort, when the patient had an incident of diarrhea, had no clean clothing to replace the soiled clothing, was placed in a garbage bag with no clothes from the waist down, and allowed to continue a group session in the company of males and females for 1 (#3) of 5 records reviewed for right to privacy from a sample of 5 patients. (see findings in tag A0143)
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on record reviews and interviews, the hospital failed to ensure its grievance process required complaints that could not be resolved by staff present to be handled as a grievance as evidenced by having a policy that allowed a complaint that was referred by the charge nurse to the Administrator to be considered a complaint if discussion between the Administrator and the patient resulted in resolution of the problem expressed. This deficient practice resulted in failure of the hospital to identify 2 complaints (R1, Nursing Home A) as a grievance and to document and investigate a grievance presented by a patient's (#3) representative.
Findings:

Review of the policy titled "Patient Complaints and Grievances", presented as a current policy by S1COO, revealed a patient grievance was defined as a formal, written, or verbal allegation or source of dissatisfaction that is filed by a patient or patient's representative that requires an investigation. Patient care complaints that cannot be resolved by staff present at the time which require further investigation and/or actions for resolution will be treated as a grievance. The patient and Administrator or designee will discuss the patient's verbal or written request in order to clarify the patient's concerns and formulate a statement of grievance. Should the Administrator or designee and the patient come to a resolution of the problem expressed, no further action will be necessary. If the problem or concern is not resolved at this stage, the Corporate Compliance Coordinator or designee is responsible for facilitating the grievance process. The first step of the grievance process will be for the Administrator or designee to investigate the allegations contained in the grievance and conduct a meeting of the grievance committee to present all known information within five working days. There was no documented evidence that the policy required a complaint that had to be referred by the charge nurse to the Administrator to be considered a grievance.

Review of the "Grievance Complaint Log" revealed 2 complaints had been received related to the PHP from 11/01/17 to 03/20/18.

Patient R1
Review of the "Grievance Complaint Log" revealed a complaint was received as follows: date 11/14/17; complaint made by Patient R1; nature of grievance/complaint: privacy; immediate resolution provided: compliance coordinator met with patient and addressed concerns; patient/family satisfied: yes; investigation completed: yes; forwarded to compliance officer/grievance committee: no (immediate resolution revealed the compliance coordinator met with the patient to address concerns); outcome: substantiated; corrective action taken: staff education.

Review of the "Complaint/Grievance Form" documented by S2CC on 11/14/17 revealed Patient R1 made a complaint by phone on 11/14/17. Description of the nature of the complaint revealed Patient R1 was upset that during his one-to-one session with his counselor other staff members entered the office and did not respect his privacy. Documentation of the "immediate resolution/corrective action provided" included an in-service will be provided to staff on privacy, and an "in session" sign will be made to hang on the door during one-to-one sessions. S2CC documented that Patient R1 was satisfied, and no further action was needed. There was no documented evidence that the allegation made by Patient R1 was investigated with documentation of the investigation presented.

Nursing Home A
Review of the "Complaint/Grievance Form" documented by S2CC on 12/06/17 revealed an employee of Nursing Home A phoned a complaint on 12/05/17 and stated that a PHP employee arrived at Nursing Home A on 12/04/17 to pick up a patient for the program. Further review revealed the employee of Nursing Home A reported that the PHP employee overheard the nursing home staff tell a PHP patient that she (client) was out of her insulin. The PHP employee questioned the nursing home staff asking what they (nursing home staff) were going to do about the patient being out of insulin. The nursing home employee reported that the PHP employee approached the desk when he returned from the PHP with the patient and rudely demanded to know about her insulin. Further review of the documentation revealed the PHP employee's route was reassigned, and a meeting was to be held with the employee on 12/06/17. There was no documented evidence of an investigation conducted prior to a disciplinary action form being documented on 12/06/17.

In an interview on 03/21/18 at 8:20 a.m., S2CC indicated she spoke with Patient R1 by phone and apologized and told him they would put something in place to correct the problem. She further indicated she spoke with the counselor who conducted the one-to-one session with Patien R1 when other staff entered the room. S2CC indicated she thought the concern expressed was a complaint, so she didn't follow through with an investigation. Regarding the complaint from Nursing Home A, S2CC indicated she received the call from the staff at Nursing Home A. She further indicated she spoke with driver, reassigned his route, and documented a disciplinary action with the PHP employee involved. She indicated she thought this was a complaint, so she didn't document her discussion with the employee and her investigation of the event.

Patient #3
Review of a multi-disciplinary progress note documented by S3LPC on 02/19/18 at 1:30 p.m. revealed Patient #3 had diarrhea and needed to have clothes brought with her every day in case she urinated or defecated on herself again.

There was no documented evidence of a grievance submitted by the sister of Patient #3.

In an interview on 03/21/18 at 8:40 a.m., S4PD indicated she met with Patient #3's sister when the sister came to the facility to express her (Patient #3's sister) concern for Patient #3 being placed in a garbage bag without clothing from the waist down after having a diarrhea episode while at the PHP. She further indicated Patient #3's sister's concern was why she had not been called and to find out the facility's protocol when such an event occurred. S4PD indicated she didn't see this complaint voiced by Patient #3's sister as a complaint or grievance and did not document it as such. When the definition of a grievance as stated in the hospital's policy was reviewed with S4PD, S4PD offered no explanation for not documenting Patient #3's sister's concerns as a grievance.

In an interview on 03/21/18 at 9:25 a.m., S1COO indicated she didn't view the complaint made by Patient #3's sister as a complaint or a grievance, because Patient #3's sister was not Patient #3's representative. When informed that review of Patient #3's medical record revealed her sister was designated as her next of kin, S1COO indicated the group home staff was Patient #3's representative. S1COO confirmed the grievance voiced by Patient #3's sister was not documented as a grievance, an investigation was not documented, and a written resolution letter was not provided to Patient #3 or her sister.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on record reviews and interviews, the hospital failed to ensure, in its resolution of a grievance, the patient was provided 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 as evidenced by failure to have documented evidence that a resolution letter was sent to the complainant for 3 (R1, Nursing home A, #3) of 3 grievances received by the hospital related to its PHP.
Findings:

Review of the policy titled "Patient Complaints and Grievances", presented as a current policy by S1COO, revealed within 2 working days of the Grievance Committee Meeting, a written response will be provided to the patient or his/her legal representative that includes 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.

Review of the "Grievance Complaint Log" revealed 2 complaints had been received related to the PHP from 11/01/17 to 03/20/18.

Patient R1
Review of the "Grievance Complaint Log" revealed a complaint was received as follows: date 11/14/17; complaint made by Patient R1; nature of grievance/complaint: privacy; immediate resolution provided: compliance coordinator met with patient and addressed concerns; patient/family satisfied: yes; investigation completed: yes; forwarded to compliance officer/grievance committee: no (immediate resolution revealed the compliance coordinator met with the patient to address concerns); outcome: substantiated; corrective action taken: staff education.

Review of the "Complaint/Grievance Form" documented by S2CC on 11/14/17 revealed Patient R1 made a complaint by phone on 11/14/17. Description of the nature of the complaint revealed Patient R1 was upset that during his one-to-one session with his counselor other staff members entered the office and did not respect his privacy. Documentation of the "immediate resolution/corrective action provided" included an in-service will be provided to staff on privacy, and an "in session" sign will be made to hang on the door during one-to-one sessions. S2CC documented that Patient R1 was satisfied, and no further action was needed. There was no documented evidence that the grievance made by Patient R1 was investigated with documentation of the investigation presented, and no written resolution was provided to Patient R1.

Nursing Home A
Review of the "Complaint/Grievance Form" documented by S2CC on 12/06/17 revealed an employee of Nursing Home A phoned a complaint on 12/05/17 and stated that a PHP employee arrived at Nursing Home A on 12/04/17 to pick up a patient for the program. Further review revealed the employee of nursing Home A reported that the PHP employee overheard the nursing home staff tell a PHP patient that she (patient) was out of her insulin. The PHP employee questioned the nursing home staff asking what they (nursing home staff) were going to do about the patient being out of insulin. The nursing home employee reported that the PHP employee approached the desk when he returned from the PHP with the patient and rudely demanded to know about her insulin. Further review of the documentation revealed the PHP employee's route was reassigned, and a meeting was to be held with the employee on 12/06/17. There was no documented evidence that a written resolution letter was provided to Nursing Home A regarding the submitted grievance.

In an interview on 03/21/18 at 8:20 a.m., S2CC indicated she spoke with Patientt R1 by phone and apologized and told him they would put something in place to correct the problem. She further indicated she thought the concern expressed was a complaint, so she didn't follow through with an investigation and provision of a written resolution letter. Regarding the complaint from Nursing Home A, S2CC indicated she received the call from the staff at Nursing Home A. She further indicated she thought this was a complaint, so she didn't provide a written resolution letter to Nursing Home A.

Patient #3
Review of a multi-disciplinary progress note documented by S3LPC on 02/19/18 at 1:30 p.m. revealed Patient #3 had diarrhea and needed to have clothes brought with her every day in case she urinated or defecated on herself again.

There was no documented evidence of a grievance submitted by the sister of Patientt #3.

In an interview on 03/21/18 at 9:25 a.m., S1COO indicated she didn't view the complaint made by Patient #3's sister as a complaint or a grievance, because Patient #3's sister was not Patient #3's representative. When informed that review of Patient #3's medical record revealed her sister as her next of kin, S1COO indicated the group home staff was Patient #3's representative. S1COO confirmed the grievance voiced by Patient #3's sister was not documented as a grievance, an investigation was not documented, and a written resolution letter was not provided to Patient #3 or her sister.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on observations, record reviews, and interview, the hospital failed to ensure patients in the PHP were informed of their right to personal privacy which includes the right to respect, dignity, and comfort as evidenced by:
1) Failing to ensure a patient was provided privacy, including respect, dignity, and comfort, when the patient had an incident of diarrhea, had no clean clothing to replace the soiled clothing, was placed in a garbage bag with no clothes from the waist down, and allowed to continue a group session in the company of males and females for 1 (#3) of 5 records reviewed for right to privacy from a sample of 5 patients.
2) Failing to have documented evidence that the list of patient rights contained in the "Client Handbook", presented as the patient's notification of patient rights, included the patient's right to personal privacy and failure to maintain patient privacy during group therapy sessions conducted on 03/20/18 at 10:00 a.m. and 11:05 a.m..
Findings:

1) Failing to ensure a patient was provided privacy, including respect, dignity, and comfort, when the patient had an incident of diarrhea, had no clean clothing to replace the soiled clothing, was placed in a garbage bag with no clothes from the waist down, and allowed to continue a group session in the company of males and females:
Review of a multi-disciplinary progress note documented by S3LPC on 02/19/18 at 1:30 p.m. revealed Patient #3 had diarrhea and needed to have clothes brought with her every day in case she urinated or defecated on herself again.

In an interview on 03/20/18 at 12:10 p.m., Patient #4 indicated a garbage bag was placed on Patient #3 on the day she soiled herself and had no clothing available. She confirmed Patient #3 remained with the garbage bag in place during the group session. Patient #4 indicated it would have bothered her if that had happened to her.

In an interview on 03/20/18 at 12:15 p.m., Patient #2 indicated staff put Patient #3 in a garbage bag after she had diarrhea and had no clean clothes to change into. She further indicated Patient #3 remained in group while wearing the garbage bag, and there were males and females in group at the time. She further indicated Patient #3 had to go home in the facility van with other clients present while wearing the garbage bag. Patient #2 indicated Patient #3 "seemed a little bit bothered, embarrassed... it's not like they couldn't call someone or take her home." Patient #2 indicated it would have bothered her (Patient #2) to remain in group in mixed company wearing a garbage bag. She further indicated "I would have been embarrassed."

In a telephone interview on 03/21/18 at 10:05 a.m., S7Conf indicated Patient #3 told her she (Patient #3) was embarrassed to be in group with a garbage bag on and no clothing from the waist down, but she (Patient #3) didn't want to leave group.

In an interview on 03/21/18 at 10:30 a.m., S5MHT indicated she helped to clean Patient #3 after she had an episode of diarrhea. She further indicated they had no clothing to put on Patient #3, so they decided to try a trash bag. She further indicated Patient #3 remained in group with the garbage bag in place until it was time to leave. She confirmed Patient #3 was in group in mixed company with a garbage bag on as clothing. She indicated she was embarrassed for Patient #3.

2) Failing to have documented evidence that the list of patient rights contained in the "Client Handbook", presented as the patient's notification of patient rights, included the patient's right to personal privacy:
Observation during group sessions conducted on 03/20/18 at 10:00 a.m. and 11:05 a.m. revealed Patients #1, #2, #3, #4, and #5 were present during each group therapy session. Further observation revealed the room where the two group sessions were conducted had to be entered and passed through to enter another group room, where group therapy was being conducted at the same time. Further observation revealed the group therapy room (where group therapy was observed) had to be entered for patients to access the two bathrooms. Continuous observations on 03/20/18 from 10:00 a.m. through 11:55 a.m. revealed multiple occasions of patients and staff entering the group therapy room (where observations were being conducted) to access the other group therapy room or the bathroom or to exit through the room to get to the kitchen/dining area.

Review of the "Client Handbook:, presented as the current patient handbook presented to patients at the time of admission to the PHP by S1COO, revealed no documented evidence the list of patient rights included the right to personal privacy which includes the right to respect, dignity, and comfort.

Review of the hospital's consent for admission, signed by patients at the time of admission, revealed the statement "The undersigned acknowledges the receipt of the Genesis Client Handbook, he/she is responsible for reading and understanding of the information contained within it, including patients' rights, rules, and responsibilities..."

In an interview on 03/21/18 at 9:25 a.m., S1COO confirmed the list of patient rights contained in the "Client Handbook" did not include the patient's right to personal privacy which includes the right to respect, dignity, and comfort. She confirmed each patien receives a copy of the Client Handbook at admission, and this is the manner used to inform patients of their rights. S1COO confirmed the group therapy room where the surveyor made observations had to be accessed by patients and staff to get to the bathroom or the other group therapy room. She confirmed this was a breach in patient privacy during group sessions.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on record reviews and interview, the hospital failed to ensure patients in the PHP were informed of their right to receive care in a safe setting as evidenced by failing to have documented evidence that the list of patient rights contained in the "Client Handbook", presented as the patient's notification of patient rights, included the patient's right to receive care in a safe setting.
Findings:

Review of the "Client Handbook:, presented as the current patient handbook presented to patients at the time of admission to the PHP by S1COO, revealed no documented evidence the list of patient rights included the right to receive care in a safe setting.

Review of the hospital's consent for admission, signed by patients at the time of admission, revealed the statement "The undersigned acknowledges the receipt of the Genesis Client Handbook, he/she is responsible for reading and understanding of the information contained within it, including patients' rights, rules, and responsibilities..."

In an interview on 03/21/18 at 9:25 a.m., S1COO confirmed the list of patient rights contained in the "Client Handbook" did not include the patient's right to receive care in a safe setting. She confirmed each patient receives a copy of the Client Handbook at admission, and this is the manner used to inform patients of their rights.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on record reviews and interview, the hospital failed to ensure patients in the PHP were free from all forms of abuse (neglect as a form of abuse) and harassment and were informed of their right to be free from abuse and harassment as evidenced by:
1) Failing to ensure a patient was fee from neglect for 1 (#3) of 5 patient records reviewed for neglect from a sample of 5 patients. Patient #3, after having an incident of diarrhea on 02/19/18 and having no clean clothing to replace the soiled clothing, was placed in a garbage bag with no clothes from the waist down, was allowed to continue a group session in the company of males and females while wearing the garbage bag, and was transported home while wearing the garbage bag with other patients present in the van.
2) Failing to have documented evidence that the list of patient rights contained in the "Client Handbook", presented as the patient's notification of patient rights, included the patient's right to free from all forms of abuse and harassment.
Findings:

1) Failing to ensure a patient was free from neglect:
Review of a multi-disciplinary progress note documented by S3LPC on 02/19/18 at 1:30 p.m. revealed Patient #3 had diarrhea and needed to have clothes brought with her every day in case she urinated or defecated on herself again.

Review of the policy titled "Patient Abuse and/or Neglect", presented as a current policy by S1COO, revealed neglect was defined as a form of abuse in which there is failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.

In an interview on 03/21/18 at 10:30 a.m., S5MHT indicated she helped to clean Patient #3 after she had an episode of diarrhea. She further indicated they had no clothing to put on Patient #3, so they decided to try a trash bag. She further indicated Patient #3 remained in group with the garbage bag in place until it was time to leave. She confirmed Patient #3 was in group in mixed company with a garbage bag on as clothing from the wasit down. S5MHT indicated she was embarrassed for Patient #3. She further indicated "we didn't know what to do with that situation, because we had nothing here to cover her with."

In an interview on 03/21/18 at 12:15 p.m., S1COO reviewed the hospital's abuse policy and the definition of neglect in the presence of the surveyor. S1COO indicated she had not viewed the incident of Patient #3 being placed in a garbage bag with no clothing from the waist down and allowed to sit in a group session in mixed company as neglect.

2) Failing to have documented evidence that the list of patient rights contained in the "Client Handbook", presented as the patient's notification of patient rights, included the patient's right to free from all forms of abuse and harassment:
Review of the "Client Handbook:, presented as the current patient handbook presented to patients at the time of admission to the PHP by S1COO, revealed no documented evidence the list of patient rights included the right to be free from all forms of abuse and harassment.

Review of the hospital's consent for admission, signed by patients at the time of admission, revealed the statement "The undersigned acknowledges the receipt of the Genesis Client Handbook, he/she is responsible for reading and understanding of the information contained within it, including patients' rights, rules, and responsibilities..."

In an interview on 03/21/18 at 9:25 a.m., S1COO confirmed the list of patient rights contained in the "Client Handbook" did not include the patient's right to to be free from all forms of abuse and harassment. She confirmed each patient receives a copy of the Client Handbook at admission, and this is the manner used to inform patients of their rights.
VIOLATION: PATIENT RIGHTS: ACCESS TO MEDICAL RECORD Tag No: A0148
Based on record reviews and interview, the hospital failed to ensure patients in the PHP were informed of their right to access information contained in his or her clinical record within a reasonable time frame as evidenced by failing to have documented evidence that the list of patient rights contained in the "Client Handbook", presented as the patient's notification of patient rights, included the patient's right to access information contained in his or her clinical record within a reasonable time frame.
Findings:

Review of the "Client Handbook:, presented as the current patient handbook presented to patients at the time of admission to the PHP by S1COO, revealed no documented evidence the list of patient rights included the right to access information contained in his or her clinical record within a reasonable time frame.

Review of the hospital's consent for admission, signed by patients at the time of admission, revealed the statement "The undersigned acknowledges the receipt of the Genesis Client Handbook, he/she is responsible for reading and understanding of the information contained within it, including patients' rights, rules, and responsibilities..."

In an interview on 03/21/18 at 9:25 a.m., S1COO confirmed the list of patient rights contained in the "Client Handbook" did not include the patient's right to access information contained in his or her clinical record within a reasonable time frame. She confirmed each patient receives a copy of the Client Handbook at admission, and this is the manner used to inform patients of their rights.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on record reviews and interview, the hospital failed to ensure patients in the PHP were informed of their right to be free from physical or mental abuse, and corporal punishment and to be free from restraint or seclusion of any form imposed as a means of coercion, discipline, convenience, or retaliation by staff as evidenced by failing to have documented evidence that the list of patient rights contained in the "Client Handbook", presented as the patient's notification of patient rights, included these rights.
Findings:

Review of the "Client Handbook:, presented as the current patient handbook presented to patients at the time of admission to the PHP by S1COO, revealed no documented evidence the list of patient rights included the right to be free from physical or mental abuse, and corporal punishment and to be free from restraint or seclusion of any form imposed as a means of coercion, discipline, convenience, or retaliation by staff.

Review of the hospital's consent for admission, signed by patients at the time of admission, revealed the statement "The undersigned acknowledges the receipt of the Genesis Client Handbook, he/she is responsible for reading and understanding of the information contained within it, including patients' rights, rules, and responsibilities..."

In an interview on 03/21/18 at 9:25 a.m., S1COO confirmed the list of patient rights contained in the "Client Handbook" did not include the above-listed rights. She confirmed each patient receives a copy of the Client Handbook at admission, and this is the manner used to inform patients of their rights.