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 Feb. 14, 2019
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on record review and interview, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by the Patient Observation and Locator form not completed by the MHTs for 5 (#3, #4, #R4, #R5, #R6) of 8 (#1, #3, #4, #5, #6, #R4, #R5, #R6) patients reviewed for complete and accurate documentation for observation.


Findings:


Patient #3

On 2/14/19 at 12/25 p.m. a review of Patient #3's medical record revealed completed Patient Observation and Locator forms dated 12/15/18 and 12/19/18. Further review revealed 3 Patient Observation and Locator forms located in the medical record between these dates of 12/15/18 an 12/19/18 that failed to contain a date, precautions identified, intervention identified or a reason identified.


Patient #4

Review of Patient #R4's medical record revealed the Patient Observation and Locator Form dated 2/8/19 did not have the type of precaution, intervention, or reason sections of the form completed.


Patient #R4

Review of Patient #R4's medical record revealed the Patient Observation and Locator Form dated 2/8/19 did not have the type of precaution, intervention, or reason sections of the form completed.


Patient #R5

Review of Patient #R5's medical record revealed the Patient Observation and Locator Form dated 2/8/19 did not have the type of precaution, intervention, or reason sections of the form completed.


Patient #R6

Review of Patient #R6's medical record revealed the Patient Observation and Locator Form dated 2/8/19 did not have the type of precaution, intervention, or reason sections of the form completed.


In an interview on 2/14/19 at 12:41 p.m. S5DON confirmed the Patient Observation and Locator forms failed to contain the above required documentation.
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, #3) of 7 (#1-#7) patients comprehensively reviewed from a total patient sample of 13 (#1-#7 and #R1-#R6).


Findings:


Review of the policy titled Treatment Planning presented as current policy revealed, in part, the treatment plan must be updated to reflect change in patient condition; the following requires modification of the treatment plan prior to scheduled update:
...b. A restraint or seclusion
...d. Precautions added for violence, suicide, elopement ...


Patient #2

Review of Patient #2's medical record revealed, a [AGE] year old male admitted on [DATE] with a Juvenile Court Order for transportation to Northlake Hospital for inpatient treatment related to charges of Simple Battery; Aggravated Battery with Dangerous Weapon; Simple Criminal Damage to Property; and Simple Assault.

Review of incident report revealed, on 02/11/19 Patient #2 was on 1:1 observation. While on 1:1 observation, Patient #2 displayed aggressive behavior requiring a "Code Green".

Review of the medical record of Patient #2 revealed, on 02/11/19 at 7:00 a.m. an order stating, "continue 1:1 observation secondary to UPB (Unwanted Pursuit Behaviors) and aggressive violent behavior.

Review of Patient #2's treatment plan revealed no documented evidence of an update after the patient's incident on 02/11/19.

On 02/14/19 at 3:00 p.m. S5DON verified Patient #2's treatment plan was not updated after the incident on 02/11/19.



Patient #3

A review of Patient #3's medical record revealed, a [AGE]-year-old male admitted [DATE] with a Physician's Emergency Certificate and then a Formal Voluntary after suicidal thoughts after a fight with his foster parent.

A review of an incident report dated 12/13/18 at approximately 6:30 p.m. in Cypress unit; at 6:35 p.m. Resident #3 threatened to physically harm peers and staff, broke property and punched staff. Patient #3 was administered Haldol 5mg and Benadryl 50 mg IM and was placed on seclusion from 7:07 p.m. to 8:22 p.m. and 1:1 observation.

Review of Patient #3's treatment plan revealed no documented evidence of an update after the patient's incident on 12/13/18.

On 02/14/19 at 1:45 p.m. S5DON verified Patient #3's treatment plan was not updated after the incident 12/13/18.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the hospital failed to ensure that drugs were administered in accordance with physician orders as evidenced by
1) failing to administer Haldol and Benadryl as ordered by the physician for 1 (#3) of 5 (#1, #3, #4, #5, and #6) patients reviewed for medication administration; and
2) failing to have medication orders that contained the dose, route and/or specific instructions for use on the physician's order sheet for 1 (#R2) of 2 (R1, R2) patient records reviewed for topical medication administration.

Findings:

1) Failing to administer Haldol and Benadryl as ordered by the physician as evidenced by:

Patient #3
Review of the medical record for Patient #3 revealed he was a [AGE] year old admitted on [DATE] by PEC with a diagnosis of Major Depressive Disorder.

Review of Patient #3's physician's order dated 11/10/18 at 6:40 p.m. revealed an order for Haldol 5 mg PO Q 6 hours PRN extreme agitation. Benadryl 50 mg PO Q 6 hours PRN extreme agitation. If refuses PO give Haldol 5 mg PO Q 6 hours PRN extreme agitation, Benadryl 50 mg PO Q 6 hours PRN extreme agitation. TORB.

Further review of the medical record revealed:
A One Hour Face- to Face Evaluation completed on 12/13/18 at 8:10 p.m. revealed Haldol 5 mg and Benadryl 50 mg IM was administered at 6:35 p.m.
A Medication Administration Record for 12/10/18 through 12/16/18 revealed Haldol 5 mg and Benadryl 50 mg was administered IM on 12/13/18 at 6:35 p.m. and on 12/14/18 at 1:18 p.m.
Further review of the Medical Record failed to reveal an order clarification for the Haldol and Benadryl order dated 11/10/18 at 6:40 p.m.

In an interview on 02/14/19 at 12:41 p.m. S5DON reviewed Patient #3's medical record and confirmed the medical record did not contain a physician order for the Haldol 5mg/ Benadryl 50 mg IM that was administered on 12/13/18 at 18:35 p.m. and 12/14/18 at 1:18 p.m.

2) Failing to have medication orders that contained the dose, route and/or specific instructions for use on the physician's order sheet as evidenced by:

Review of the Medical Staff Rules and Regulations presented as current revealed in part, PRN medication orders must contain medication dosage, frequency, and reason.

Patient #R2
Review of the medical record for Patient #R2 revealed she was a [AGE] year old female admitted on [DATE] by PEC with diagnosis of Bipolar and Schizophrenia.

Review of Patient R2's physician's order dated 12/03/18 at 9:40 a.m. revealed "lice treatment x 1 today"

Review of the MAR dated 12/03/18 revealed handwritten medication "lice treatment" without a time of administration documented.

In an interview on 02/14/19 with S5DON verified no clarification order for "lice treatment". Further review revealed no documented time for the administration of "lice treatment".
VIOLATION: LICENSURE OF PERSONNEL Tag No: A0023
Based on record review and interview the hospital failed follow their policy when they failed to ensure the CEO (Chief Executive Officer) was provided by an individual with a Master's Degree in Psychology or Health Care Administration or equivalent master's degree in a recognized mental health field. Findings:

Review of the CEO's job description signed by S1CEO on 02/04/19. Further review of the CEO's job description states the minimum education qualifications is a Master's Degree in Psychology or Health Care Administration or equivalent master's degree in a recognized mental health field.

Review of the Organizational chart revealed S1CEO and S2ADM are Interim CEO's.

On 02/13/19 at 11:15 a.m. in an interview with S1CEO, S2ADM, S5DON, S8HR, and S9DBO it was revealed S1CEO and S2ADM are Interim CEO's.

On 02/13/19 at 11:30 a.m. in an interview with S2ADM revealed S1CEO has a bachelor's degree.

On 02/14/19 at 12:45 p.m. in an interview with S2ADM revealed S1CEO and S2ADM share the job as CEO.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review and interview, the hospital failed to meet the requirements of the Condition of Participation for Patient Rights as evidenced by the hospital failing to ensure psychiatric patients were provided care in a safe setting. This deficient practice is evidenced by failing to ensure patients assigned to S4MHT that had been determined to have been a harm to themselves or others were observed as ordered by the physician for 1 (#4) of 1 patient ordered to be within eyesight at all times for self-injury behaviors and 3 (#R4, #R5, #R6) of 3 patients ordered to be observed every 10 minutes (see findings tag 0144).
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on observation, record review, and interview, the hospital failed to ensure psychiatric patients were provided care in a safe setting. This deficient practice is evidenced by failing to ensure patients determined to have been a harm to themselves or others that were assigned to S4MHT were observed as ordered by the physician for 1 (#4) of 1 patient ordered to be within eyesight at all times for self-injury behaviors and 3 (#R4, #R5, #R6) of 3 patients ordered to be observed every 10 minutes .


Findings:


Review of Patient #4's medical record revealed, he had been admitted on [DATE] with diagnosis including depression and intentional self-harm with a sharp object. Further review revealed an order, dated 2/2/19, to send to Med Clinic for evaluation and treatment related to new lacerations on bilateral forearms and wrist from a piece of plastic. Initiate visual contact precautions due to new self-injury behaviors.


Review of Patient #R4's medical record revealed, he had been admitted with the chief problem of being suicidal. He was ordered to be observed every 10 minutes for safety.


Review of Patient #R6's medical record revealed, he had been admitted with a diagnosis of unspecified mood disorder for stating that he wanted to see his father dead. He was ordered to be observed every 10 minutes for safety.


Review of video footage was made with S2ADM and S7SDC. The video footage began at 1:00 a.m. on 2/9/19 of a patient hallway on the Cypress unit. Review revealed no staff went down the hall to check on the patients until 2:00 a.m. (1 hour). At that time, S4MHT walked down the hall looking into the rooms and then left again and returned at 2:23 p.m. (23 minutes). She then left the hall way one minute later. The next staff member observed making observations of the patients in the hallway was S6RN at 3:26 a.m. (1 hour and 2 minutes).


Review of observation sheets for Patient #R4, #R5, and #R6 revealed S4MHT documented she had observed them sleeping at 10 minute intervals and direct observation of Patient #4 from 1:00 a.m. until 1:50 a.m. although she was not viewed on the hall near their rooms on the video. S4MHT also documented she had visualized Patients #R4, #R5 and #R6 in 10 minute intervals and Patient #4 in direct line of sight from 2:30 a.m. until 3:20 a.m., but did not return on the video as of 3:26 a.m.


In an interview on 2/14/19 at 10:30 a.m. with S2ADM, she verified the staff should have making rounds more frequently than was seen on the above mentioned video. She also verified Patient #4 was supposed to be in line of sight of a staff member at all times.


In an interview on 2/14/19 at 3:05 p.m. with S6RN, he said he was the charge nurse on the Cypress unit on the 2/08/19 night shift. He said he made sure the MHT's watched their patients as ordered. When told of the observations on the video, he said he was not aware the MHT's were not watching their patients.


In an interview on 2/14/19 at 3:10 p.m. with S4MHT, she said she worked the night shift on 2/08/19. She said Patient #4 was in line of sight by her all night and she made 10 minute rounds on her other patients. When told of the observations on the video, she had no explanation why she documented that she had observed the patients but had not done so.