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 Dec. 28, 2018
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation and interviews, the hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety for patients admitted to the inpatient psychiatric hospital for being a danger to themselves and/or others.

Findings:

Willow Unit
An observation of Willow Unit on 12/27/18 between 9:45 a.m. and 09:58 a.m., in the presence of S3StaffCoord and
S2RN, revealed the following:

Non-tamper proof screws were noted on the windows in patient rooms, securing the artwork (in the commons area), and on the book/belongings shelves in patient rooms. S3StaffCoord and S2RN verified the identified safety risks during the observation.

A deficiency was cited on a previous survey (8/1/18) regarding the hospital units having non-tamper proof screws in the patient care environment.


Cypress Unit
An observation of Cypress Unit on 12/27/18 between 10:00 a.m. and 10:15 a.m., in the presence of S3StaffCoord, revealed the following:

a. Non-tamper proof screws were noted in the windows and book/belonging shelves throughout the unit (including but not limited to patient rooms and activity room). The observed safety risks were confirmed by S3StaffCoord during the observation.

b. Patient beds in Rooms 204 and 205 (8 beds total- 4 beds per room ) had non-tamper proof screws in the frames. The observed safety risks were confirmed by S3StaffCoord during the observation.

c. Seclusion room failed to have a bubble mirror resulting in a blind spot in the room where patients in seclusion could not be visualized by staff. S3StaffCoord confirmed, during the observation, that there should have been a bubble mirror in place to provide an unobstructed staff view of patients in seclusion.

On 12/28/18 at 11:00 a.m. in an interview with S1DON, she verified the above safety risks. S1DON confirmed there should have been a bubble mirror in place to provide an unobstructed staff view of patients in seclusion. S1DON indicated the seclusion room bubble mirror on Cypress Unit had probably been broken by one of the adolescent boys while in seclusion and it had not been replaced (as of 12/27/18).
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on record review and interview, the hospital failed to ensure all patient medical record entries were legible and completed, in written or electronic form, by the person responsible for providing or evaluating the service provided. This deficient practice was evidenced by failure of the hospital to ensure patients' medical records had documentation of incidents of inappropriate contact and notification of the physician for 2 (#4, #5) of 6 medical records reviewed for incidents (#1,#2,#3,#4,#5, #R1) from a total patient sample of 9 (#1-#6, #R1,#R2,#R3).

Findings:

Patient #4
Review of self-report to LDH revealed on 11/2/18 Patient #3 and Patient #4 were involved in an unwitnessed incident of inappropriate contact which resulted in Patient #4 receiving a mark on her neck ("hickey") from Patient #3.

Review of Patient #4's medical record revealed a Body Audit Report,completed by S2RN on 11/3/18, which documented an "abrasion/hickey" on the left neck of Patient #4.

Further review of Patient #4's medical record revealed no description of the incident had been documented in the medical record. Additional review revealed the record failed to have documentation of physician notification of the event (no physician name).

On 12/28/18 at 10:00 a.m. in an interview with S2RN, she revealed she remembered the incident but could not recall if she had documented the incident in her nursing notes. S2RN confirmed the hospital's expectation was for the incident to have been documented in the patient's medical record.

Patient #5
Review of a self-report to LDH revealed on 11/01/18 Patient #5 and Patient #R1 were involved in inappropriate touching.

Review of Patient #5's medical record revealed no documented description of the incident and no documentation of physician notification in the patient's record.

On 12/28/18 at 11:00 a.m. in an interview with S1DON, she verified a summary of incidents and notification of the physician should have been documented in the patient's medical records when an incident occurred.