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.

LIBERTY HEALTHCARE SYSTEMS, LLC 4673 EUGENE WARE ROAD BASTROP, LA Dec. 20, 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. This deficient practice was evidenced by:

1) failure of the RN to perform and document an assessment of a patient complaining of arm pain and failure to notify the physician of a change in condition for 1 (#2) of 5 (#1-#5) patients sampled; and

2) failure of the RN to assess and document the assessment of a patient after a physical altercation with another patient and after being hit in the eye with a basketball for 1 (#2) of 5 (#1-#5) patients sampled.

Findings:

Review of Patient #2's medical record revealed he was a 9 year old that had been admitted on [DATE] with diagnosis including Attention Deficit Disorder, Disruptive Mood Disregulation Disorder, and rule out Conduct Disorder. Further review revealed he had also been suicidal.

1) Failure of the RN to perform and document an assessment of a patient complaining of arm pain and failure to notify the physician of a change in condition.

Review of Patient #2's admission history and physical dated 12/6/18 revealed no documentation of any arm injury, deformity or pain.

Review of a document about Patient #2 titled Hospital Abuse/Neglect Initial Report revealed the type of incident was listed as Alleged Physical Abuse. Patient #2's discharge date was written as 12/14/18 and the alleged incident was written as the following: While the patients parents were at the facility for discharge, patients parents complained that they noticed swelling to the patient's right arm. Patient stated arm was hurting but did not know what happened. Swelling to the right arm was noted by S4LPN.

Review of Patient #2's medication administration record dated 12/14/18 at 4:49 p.m. revealed he was given an Ibuprofen 400 milligrams by S4LPN for complaints of pain to his right forearm. No pain scale was documented.

Review of Patient #2's Daily Nursing Note revealed the following entry on 12/14/18 at 4:01 p.m.:"Patients parents here for discharge. Parents complained of swelling to patient's arm in which he told he sustained it several days ago. Nurses were not informed to any injury to patient. Additionally, the patient had been to nursing station several times the same day and did not complain of any pain to right wrist. Upon further examination, slight swelling was noted to right wrist. Standing order as needed Ibuprofen 400 milligrams administered. Administration notified of incident." Further review of Patient #2's medical record revealed no entry by a RN, physician or nurse practitioner of an examination or notification of Patient #2's right arm pain.

In an interview on 12/19/18 at 4:22 p.m. with S5RN, she said she did not know anything about Patient #2's arm being hurt until he was discharged . She said S4LPN notified her that Patient #4's arm was hurt. She said she did not examine the patient. S5RN said she did not assess Patient #2 because S4LPN was very competent. S5RN also verified she did not notify the nurse practitioner or the doctor about the injury.

In an interview on 12/20/18 at 8:07 a.m. with Patient #2's mother, she said when she went to pick her son up from the hospital she noticed his right arm was swollen. The mother said she asked the LPN (she could not recall the LPN's name) what happened to her son's arm, but LPN told her they were not aware of the injury. She subsequently said when she got home Patient #2 kept complaining that his arm hurt so she took him to the doctor and his arm was broken. When asked, Patient #2's mother said neither the RN nor the doctor examined Patient #2's arm after it was discovered he had an injury.

In an interview on 12/20/18 at 8:51 a.m. with S4LPN, she said she discharged Patient #2. She said when Patient #2's mom looked at his arm she said something was wrong. She said Patient #2 said he did not know what was wrong with his arm. S4LPN said Patient #2's mom said Patient #2's arm was broken. S4LPN said she assessed both of his arms and Patient #2 had a little grimace when the mom was touching his arm. S4LPN said she gave Patient #2 some Ibuprofen. She said she told S5RN and a therapist about Patient #2's injured arm. She said the RN did not assess the arm. S4LPN also verified she did not call the medical practitioner because she thought the therapist was going to call her.

In an interview on 12/20/18 at 10:04 a.m. with S2CNO, she verified the RN working on the unit when Patient #2 was discovered to have an arm injury should have assessed Patient #2 since he had a change in condition. She also verified S4LPN or S5RN should have notiifed the medical practitioner.

2) Failure of the RN to assess and document the assessment of a patient after physical altercations with other patients and after being hit in the eye with a basketball.

Review of Patient #2's medical record revealed documentation on his Close Observation Sheet dated 12/5/18 (not timed) that stated Patient #2 was getting water when another patient started hitting him.

Review of Patient #2's nurse's notes dated 12/5/18 revealed no documentation of an assessment of Patient #2 after another patient hit him.

Review of Patient #2's medical record revealed documentation on his Close Observation Sheet dated 12/12/18 that stated he had gotten into a fight in the gym and got hit on the head (entry did not have a time). There was also an entry that said Patient #2 had been asked what happened to his eye and he said he had been hit in the eye with a basketball (entry not timed).

Review of Patient #2's nurse's notes dated 12/12/18 revealed at 12:43 p.m. he had been given 2.5 mg Zyprexa for agitation and trying to fight a peer. Further review revealed there was no documentation of an assessment of Patient #2 after he had been hit in the head during an altercation or after he had been hit in the eye with a basketball.

In an interview on 12/20/18 at 10:04 a.m. with S2CNO, she verified a nurse should have assessed a patient for injuries after a physical fight.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on record review, hospital policy and staff interviews, the hospital failed to ensure an effective grievance process was in place. The deficient practice is evidenced by the facility failing to identify and investigate an adolescent patient's gardians' grievance for 1(#2) of 5 sampled patients.

Findings:

Review of the hospital policy titled Patient Complaint and Grievance Resolution revealed in part: A complaint is a patient grievance if it cannot be resolved at the time of the complaint by staff or manager present; Is postponed for later resolution; Requires investigation and /or requires further action for resolution.
Further review revealed the policy did not include sending a letter to the complainant about the results of the investigation.

Review of Patient #2's social worker's notes revealed the following entries:
12/6/18- From 9:08 a.m. until 9:39 a.m. with Patient's dad: Dad complained to CNO about situation where his son was restrained on 12/5/18.

12/7/18- Dad called to follow up on complaint he made yesterday and had a new complaint about his son being taken out of art class for drawing an inappropriate picture.

12/8/18- Mom complained that she was the only one that should be making decisions about the patient, not the father.

Review of the hospital's complaint/grievance log revealed no grievances had been initiated for the above mentioned complaints that could not be resolved immediately upon notification without further investigation.

In an interview on 12/19/18 at 3:50 p.m. with S3Compliance, she verified when parents called and complained about incidents that needed to be investigated it should have been logged as a grievance.

In an interview on 12/20/18 at 10:04 a.m. with S2CNO, she verified the grievance process should have been initiated if Patient #2's guardian's complaints could not have been resolved immediately.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on record review and interview, the hospital failed to ensure any incident of abuse, neglect, and/or harassment was reported and the hospital was in compliance with applicable local, State, and Federal Laws and Regulations. This deficient practice was evidenced by the hospital's failure to report potential neglect within 24 hours to the Louisiana Department of Health for 2 (#2,#5) of 5 (#1-#5) sampled patients.

Findings:

Review of the State law R.S. 40:2009.20 revealed any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, licensed practical nurse, nurse's aide, home-and community-based service provider employee or worker, personal care attendant, respite worker, physician's assistant, physical therapist, or any other direct caregiver having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department (LDH) or inform the unit or local law enforcement agency of such abuse or neglect. Further review revealed "Neglect" was defined as the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer's well-being.

Patient #2
Review of a document titled Hospital Abuse/Neglect Initial Report revealed the type of incident was listed as Alleged Physical Abuse. Patient #2's discharge date was written as 12/14/18 and the alleged incident was written as the following: While the patients parents were at the facility for discharge, patients parents complained that they noticed swelling to the patient's right arm. Patient stated arm was hurting but did not know what happened. Swelling to the right arm was noted by S4LPN. Further review revealed the date of discovery was listed as 12/14/18 and the report to the Louisiana Department of Health was written as 12/17/18 (3 days after being made aware of the incident).

Patient #5
Review of a document titled Hospital Abuse/Neglect Initial Report revealed Patient #5 had alleged physical abuse against a staff member on 9/6/18. The date of discovery by the staff was listed as 9/7/18.

Review of a letter from the Louisiana Department of Health revealed the self report of an allegation of abuse by Patient #5 was not made until 9/10/18 (3 days after discovery).

In an interview on 12/20/18 at 9:30 a.m. with S3Compliance, she verified notification of an allegation of abuse or neglect should have been sent to the Louisiana Department of Health within 24 hours of discovery.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on record review and interview, the hospital failed to ensure the use of restraints was in accordance with a written modification to the patient's plan of care for 1 (#2) of 1 patient reviewed for restraints out of a total patient sample of 5.

Findings:

Review of the hospital policy titled Seclusion and Restraint revealed in part: The use of restraint or seclusion must be in accordance with the order of a physician or other licensed independent practitioner permitted by the state and hospital to order restraint or seclusion. The orders must be in accordance with a written modification to the patient's plan of care.

Review of a behavioral health technician's close observation sheet for Patient #2 revealed an entry dated 12/5/18 (not timed) that Patient #2 was restrained by 2 technicians for acting out in the dayroom.

Review of Patient #2's nurse's notes dated 12/6/18 at 11:52 a.m. revealed he had refused to calm down and had been placed in a CPI hold by two staff members.

Review of Patient #2's nurse's notes dated 12/7/18 at 11:15 a.m. revealed he had pulled another patient's hair and had been placed in a CPI hold by a behavioral health technician for 2 minutes and 54 seconds.

Review of Patient #2's treatment plan revealed no modifications had been made for the use of a physical hold as restraints.

In an interview on 12/20/18 at 10:04 a.m. with S2CNO, she said Patient #2's treatment plan (plan of care) should have been updated with the use of physical holds because it was a form of restraint.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on record review and interview, the hospital failed to ensure the use of restraint was in accordance with the order of a physician or other licensed independent practitioner who was responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This deficient practice is evidenced by 1 (#2) of 1 psychiatric patient sampled being placed in a physical hold as a restraint on 3 occasions with no physician's order.

Findings:
Review of the hospital policy titled Seclusion and Restraint revealed in part: The use of restraint or seclusion must be in accordance with the order of a physician or other licensed independent practitioner permitted by the state and hospital to order restraint or seclusion.

Review of a behavioral health technician's close observation sheet for Patient #2 revealed an entry dated 12/5/18 (not timed) that Patient #2 was restrained by 2 technicians for acting out in the dayroom.

Review of Patient #2's nurse's notes dated 12/6/18 at 11:52 a.m. revealed he had refused to calm down and had been placed in a CPI hold by two staff members.

Review of Patient #2's nurse's notes dated 12/7/18 at 11:15 a.m. revealed he had pulled another patient's hair and had been placed in a CPI hold by a behavioral health technician for 2 minutes and 54 seconds.

In an interview on 12/20/18 at 10:04 a.m. with S2CNO, she verified the use of physically holding a patient against thier will is a form of restraint. She also verified an order by the physician or nurse practitioner is needed for the use of restraints.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services as evidenced by the hospital failing to ensure the RN supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by failure of the RN to perform and document an assessment of a patient complaining of arm pain and failure to notify the physician of a change in condition for 1 (#2) of 5 (#1-#5) patients sampled (see tag 395).
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record reviews and interview, the hospital failed to ensure the nursing staff developed, and kept current, a nursing care plan (treatment plan). This deficient practice is evidenced by failing to ensure interventions and goals were developed by each member of the treatment team for 2 (#2,#5) of 5 (#1-#5) patients sampled.

Findings:

Review of the hospital's policy titled Treatment Planning-Protocol for Interdisciplinary Individualized Master treatment Plans Policy revealed in part:
Each discipline will be responsible for identifying objectives (short term goals) that the department will address and identify the person responsible for addressing that objective (short term goal).

Review of care plans used by the facility revealed for each identified problem there was a preprinted form with various interventions to be selected as appropriate by the nursing staff, the social worker and the activity therapist.

Patient #2
Review of Patient #2's medical record revealed he was a 9 year old that had been admitted on [DATE] with diagnosis including Attention Deficit Disorder, Disruptive Mood Disregulation Disorder, and rule out Conduct Disorder. Further review revealed he had also been suicidal.

Review of Patient #2's care plan revealed the activity therapist was the only one that selected interventions for the identified problems of Aggressive Behavior and Suicidal Ideation. There were no nursing or social worker interventions or goals listed.

Patient #5
Review of Patient #5's medical record revealed she was an [AGE] year old admitted on [DATE] with diagnosis that included Oppositional Defiant Disorder, Anxiety, Depression, Attention Deficit Hyperactivity Disorder, Aspergers and Suicidal Ideation.

Review of Patient #5's care plan revealed the social worker had not selected any interventions or goals for the identified problems of Depressed Mood and Suicidal Ideations.

In an interview on 12/20/18 at 9:30 a.m. with S3Compliance, she verified all members of the treatment team should complete their section of the treatment plan (care plan).

In an interview on 12/20/18 at 10:04 a.m. with S2CNO, she said patient's treatment plan should have been initiated by the nurse and should have been completed by all disciplines.