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.

COMPASS BEHAVIORAL CENTER OF HOUMA, LLC 4701 WEST PARK AVENUE HOUMA, LA 70364 June 18, 2019
VIOLATION: NURSING SERVICES Tag No: A0385
Based on record reviews, observations, and interviews, the hospital failed to ensure the requirements of the Condition of Participation of Nursing Services were met as evidenced by:

1) Failure of the RN to assess a patient after a fall that included a total body assessment for 2 (#3, #5) of 4 (#1, #3, #4, #5) patient records reviewed for falls from a sample of 5 (#1 - #5) patients (see findings in tag A0395).

2) Failure of the RN to ensure post fall risk assessments, neurological checks post fall (including unwitnessed falls), and fall risk re-assessments were initiated/completed post fall for 4 ( #1, #3, #4, #5) of 5 (#1 - #5) patient records reviewed for falls from a sample of 5 patients (see findings in tag A0395).

3) Failure of the RN to ensure the physician was notified of abnormal (high) blood glucose results, as per hospital policy, for 1 (#1) of 3 (#1, #3, #4) diabetic patient records reviewed for diabetic treatment from a sample of 5 patients (#1 - #5) (see findings in tag A0395).

4) Failure of the RN to ensure patients' admit orders had been obtained from a LIP/MD for 2 (#1, #5) of 5 (#1 - #5) sampled patient and 2 (R1, R2) of 2 random patient records reviewed for admission orders from a sample of 5 patients and 2 random patients (see findings in tag A0395).

5) Failure of the RN to ensure patients' level of observation was ordered on admission orders for 4 (#1, #2, #3, #5) of 5 (#1-#5) patient records reviewed for ordered observation level from a sample of 5 patients (see findings in tag A0395).

6) Failure of the RN to ensure the nursing care of each patient was assigned to nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the available nursing staff as evidenced by failure to have documented evidence that direct care staff had received orientation and competency evaluation in providing observations as ordered with appropriate documentation (MHTs) and/or annual competency assessment of performing suicide assessments (nurses) for 10 (S2DON, S3MHT, S4MHT, S5RN, S6LPN, S11RN, S13MHT, S14MHT, S16MHT, S21RN) of 13 (S1ADM, S2DON, S3MHT, S4MHT, S5RN, S6LPN, S11RN, S13MHT, S14MHT, S15LPN, S16MHT, S17MHT, S21RN) personnel files reviewed for orientation and competency evaluations required upon hire and annually (see findings in tag A0397).
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**






Based on record reviews, observation, and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:

1) Failure of the RN to assess a patient after a fall that included a total body assessment for 2 (#3, #5) of 4 ( #1, #3, #4, #5) patient records reviewed for falls from a sample of 5 (#1 - #5) patients.

2) Failure of the RN to ensure the physician was notified of abnormal (high) blood glucose results, as per hospital policy, for 1 (#1) of 3 (#1, #3, #4) diabetic patient records reviewed for diabetic treatment from a sample of 5 patients (#1 - #5).

3) Failure of the RN to ensure post fall risk assessments, neurological checks post fall (including unwitnessed falls), and fall risk re-assessments were initiated/completed post fall for 4 ( #1, #3, #4, #5) of 5 (#1 - #5) patient records reviewed for falls from a sample of 5 patients.

4) Failure of the RN to ensure patients' admit orders had been obtained from a LIP/MD for 2 (#1, #5) of 5 (#1 - #5) sampled patient and 2 (R1, R2) of 2 random patient records reviewed for admission orders from a sample of 5 patients and 2 random patients.

5) Failure of the RN to ensure a LIP/MD was contacted for orders after patients returned from hospitalization or an ER visit for 2 (#3, #5) of 4 (#1, #3, #4, #5) patient records reviewed for falls from a sample of 5 patients.

6) Failure of the RN to ensure patients' observation records were accurate and complete, including ordered precautions and levels of observation, for 3 (#1, #3, #4) of 5 (#1-#5) patient records reviewed for falls from a sample of 5 patients.

7) Failure of the RN to ensure patients' level of observation was ordered on admission orders for 4 (#1, #2, #3, #5) of 5 (#1-#5) patient records reviewed for ordered observation level from a sample of 5 patients.

Findings:

1) Failure of the RN to assess a patient after a fall that included a total body assessment:
Review of the policy titled "Patient Falls", presented as a current policy by S2DON, revealed no documented evidence that the policy addressed the assessment of the patient after a fall.

Patient #3
Review of Patient #3's medical record revealed he was admitted on [DATE] at 3:00 p.m. with diagnoses of [DIAGNOSES REDACTED]

Review of Patient #3's Multi-Disciplinary Note documented by S5RN on 04/25/19 at 1:55 a.m. revealed on 04/25/19 at 12:55 a.m. the MHT reported Patient #3 fell in his room. He was found at the bedside on his right side with blood noted on the right side of his forehead and nose with a "1.5 avulsion noted to right side of nose." Further review revealed documentation included that the bleeding was controlled by direct pressure, the patient was awake, alert, and oriented to self with no note of loss of consciousness. Further review revealed the MHT had just left the room on rounds when Patient #3 rolled out of bed. His blood pressure was 134/80, he was afebrile, his pulse was 75, his respirations were 18, and his oxygen saturation was 93 per cent on room air. There was no documented evidence S5RN documented a full assessment for injury as evidenced by failure to have documentation of an assessment of the patient's body other than the face.

In an interview on 06/18/18 at 8:57 a.m., S5RN, when told by the surveyor that the chart review revealed there was no evidence of an assessment for injury other than the head area, he indicated he did a head to toe assessment. When told there was no documentation in the chart, he indicated "we chart by exception."

Patient #5
Review of Patient #5's medical record revealed he was admitted on [DATE] at 3:10 with diagnoses of [DIAGNOSES REDACTED]

Review of Patient #5's Multi-Disciplinary Note documented on 06/09/19 at 1:50 p.m. revealed Patient #5 fell at 6:35 a.m. while ambulating from the hallway to the dayroom. Further review revealed patient was "assessed, and vital signs taken ... when assisting pt to stand up to sit in chair, pt began making a gurgling noise. Pt not answering as he was being talked to. Pt appeared to have a seizure then vomited." Further review revealed S19Psych was notified at 6:40 a.m. and gave an order to send him to the ER for evaluation. Further review revealed the ambulance arrived and transferred Patient #5 at 7:00 a.m. There was no documented evidence of the patient assessment that was documented as having been done.

In an interview on 06/17/19 at 4:15 p.m. during a telephone interview, S20RN indicated she remembered Patient #5. She indicated he was walking into the dayroom, and the MHT who witnessed it reported it to her. He was on the floor right outside the dayroom laying down on the floor. She further indicated he didn't appear that he hit his head, and she asked him if he had hit his head. S20RN indicated he seemed to be staring, and it looked like he was having a seizure. She indicated she didn't remember the name of the MHT who witnessed the fall. She indicated she filled out an incident report and put the name of the MHT on the report. She indicated other staff took the vital signs. She confirmed she doesn't know if he hit his head, because she didn't witness the fall. She indicated when she went to assess him is when she witnessed the gurgling, and he appeared to have a seizure and vomited.

In an interview on 06/17/19 at 4:35 p.m., S2DON indicated she didn't have an incident report related to Patient #5's fall that was completed by S20RN.

2) Failure of the RN to ensure the physician was notified of abnormal (high) blood glucose results, as per hospital policy:
Review of the hospital policy titled, "Scope of Services - Nursing". Policy Number: PC-105, revealed in part: 5. Glucose testing: Notify physician if glucose level is below 60 mg/dL or above 350 mg/dL.

Review of Patient #1's EMR revealed the patient was admitted on [DATE] with a co-morbid admission diagnosis of [DIAGNOSES REDACTED]

Review of Patient #1's physician's orders, dated 04/30/19, revealed the following Accu-check and insulin orders: Accu-checks (capillary blood glucose testing) before meals TID (3 times a day), with sliding scale insulin and Accu-check at hour of sleep (no sliding scale insulin ordered for hour of sleep).

Review of Patient #1's Diabetic Flow Record revealed Patient #1's blood sugar was greater than 350 mg/dL 4 times from 04/30/19 - 05/04/19 on the following dates:
04/30/19 8:00 p.m. 534 mg/dL
05/01/19 8:00 p.m.: 354 mg/dL
05/02/19 8:00 p.m.: 392 mg/dL
05/04/19 8:00 p.m.: 413 mg/dL

Further review of Patient #1's EMR revealed no documented evidence of physician notification of the above referenced capillary blood glucose readings that were above 350 mg/dL. S2DON, who navigated Patient #1's EMR, confirmed during the record review on 06/13/19 that there was no documentation of notification of the physician of the above referenced elevated glucose readings. S2DON confirmed, based upon the above referenced policy, that the physician should have been notified of the elevated capillary blood glucose results.

In an interview on 06/18/19 at 8:58 a.m. with S5RN, he reported the LPN nursing staff administered medications. S5RN indicated the physician should be notified of capillary blood glucose readings below 60 mg/dL or above 300 mg/dL or 350 mg/dL depending upon facility because that was routine nursing knowledge.

3) Failure of the RN to ensure post fall risk assessments, neurological checks post fall (including unwitnessed falls), and fall risk re-assessments were initiated/completed post fall:
Review of the policy titled "Patient Falls", presented as a current policy by S2DON, revealed upon admission a fall risk assessment will be completed to identify patients at high risk for falls. Patients identified to be at high risk for falls will have a fall risk treatment plan implemented. Following a fall, the physician will be notified, and the post fall assessment form will be completed to insure identification of appropriate interventions for safety. Any fall with blunt force to the head and any unwitnessed fall require 24 hour neurological checks according to the following schedule: every 15 minutes for 1 hour; every 30 minutes for 2 hours; every 1 hour for 4 hours; every 4 hours for 16 hours.

Patient #1
Review of Patient #1's EMR revealed the patient was a [AGE] year old female with an admission date of [DATE] with admission diagnoses including Depression with suicidal ideation, Type 1 Diabetes, history of Cocaine abuse, and Chronic Kidney Disease.

Review of the hospital's incident reports for the last 6 months (01/2019 - 06/2019) revealed a report indicating on 05/07/19 at 01:20 a.m. Patient #1 had an unwitnessed fall and had been found sitting on the floor, beside the bed, after having "rolled out of bed". Further review revealed S5RN had documented a quick head to assessment noting no apparent trauma.

Review of Patient #1's EMR revealed no documented evidence that neurological checks had been initiated, as per hospital policy, for unwitnessed falls and no documented evidence the physician had been notified of the patient's fall.

Review of a Root Cause Analysis conducted to review Patient #1's death revealed the following, in part: Details of event: 05/07/19 01:20 a.m.: Patient "rolled out of bed", between the bed and the bedside table. She was awake, alert, and oriented. Patient denied hitting her head but complained of mild, dull pain to lower back. Head to toe assessment completed and patient assisted back to bed.

In an interview on 06/18/19 at 08:58 a.m. with S5RN, he confirmed he had been working on 05/07/19 at 01:20 a.m. and had completed the incident report for Patient #1's fall. S5RN confirmed he had seen Patient #1 sitting upright on the floor in her room, but had not called the physician to notify him of Patient #1's fall because he had not considered it a fall. He indicated he had completed an incident report after the fact because S2DON told him he had to complete a report. He confirmed he had not checked Patient #1's blood sugar as part of his assessment of the patient post-fall and also confirmed he had not begun neuro-checks post fall (as indicated per policy in an unwitnessed fall) nor had he completed the hospital's post-fall assessment form, reassessed the patient's fall risk, or update the patient's treatment plan post-fall.

In an interview on 06/18/19 at 3:16 p.m. with S13MHT, she confirmed she had been assigned Patient #1 on 05/07/19. She confirmed techs from the off going shift had told her the patient had fallen, she said they pushed the bed against the wall so she wouldn't fall out again.

Patient #3
Review of Patient #3's medical record revealed he was admitted on [DATE] at 3:00 p.m. with diagnoses of [DIAGNOSES REDACTED]

Review of Patient #3's Multi-Disciplinary Note documented by S5RN on 04/25/19 at 1:55 a.m. revealed on 04/25/19 at 12:55 a.m. the MHT reported Patient #3 fell in his room. He was found at the bedside on his right side with blood noted on the right side of his forehead and nose with a "1.5 avulsion noted to right side of nose." Further review revealed documentation included that the bleeding was controlled by direct pressure, the patient was awake, alert, and oriented to self with no note of loss of consciousness. There was no documented evidence S5RN documented a full assessment for injury as evidenced by failure to have documentation of an assessment of the patient's body other than the face. Patient #3 was transferred to the ER for evaluation on 04/25/19 at 1:55 a.m. and returned on 04/25/19 at 7:17 a.m.

Review of Patient #3's medical record revealed no documented evidence that a post fall risk assessment, neurological checks post fall in accordance with hospital policy, and a fall risk re-assessment were initiated/completed post fall.

In an interview on 06/18/18 at 8:57 a.m., S5RN, when told by the surveyor there was no documentation in the chart of assessment of neuro status, he indicated the documentation of neuro status was done in the past, but it didn't apply in every case, because they rely on the doctor's instructions when they return from the ER. He indicated he doesn't see it done routinely. He indicated he could see it being done if the doctor didn't send him out and wanted neuro checks done. When told neuro checks is a hospital policy; he indicated he's never seen that policy. He indicated they don't have the policy and procedure manual in the nursing station ... it's kept in the DON's office. He indicated the manual was not online. He indicated when there's a fall there should be a fall risk assessment done and the care plan should be revised.

In a telephone interview on 06/18/19 at 4:00 p.m., S11RN indicated he didn't think there was a specific form to document neuro assessments, and if there had been one, he would have documented it. He confirmed he didn't do a post fall risk assessment or neuro assessments in accordance with the hospital's policy.

Patient #4
Review of Patient #4's EMR revealed an admission date of [DATE] with admission diagnoses including Bipolar Depression.

Review of the hospital's incident reports for the last 6 months (01/2019 - 06/2019) revealed a report indicating on 06/13/19 Patient #4 had fallen while showering and had lacerated her eyelid. The patient was sent to an area ER and her lid injury had been repaired with "glue."
Further review of Patient #4's EMR revealed no documented evidence that neurological checks had been initiated, as per hospital policy, no post fall risk had been re-assessed, and the treatment plan had not been updated post fall.

Patient #4 was observed on 06/18/19 at 7:30 a.m. and the patient was noted to have a purplish-red bruised area encircling her left eye top and bottom, forming a ring.

In an interview on 06/17/19 at 12:15 p.m. with S2DON, she confirmed Patient #4 had fallen on 06/13/19 and had sustained an eye injury in the fall requiring evaluation and treatment at an area ER. S2DON confirmed staff had not performed a post fall risk re-assessment. S2DON also confirmed staff had not completed the hospital's post fall assessment form and had not initiated neuro-checks.

Patient #5
Review of Patient #5's medical record revealed he was admitted on [DATE] at 3:10 with diagnoses of [DIAGNOSES REDACTED]

Review of Patient #5's Multi-Disciplinary Note documented on 06/09/19 at 1:50 p.m. revealed Patient #5 fell at 6:35 a.m. while ambulating from the hallway to the dayroom. Further review revealed patient was "assessed, and vital signs taken ... when assisting pt to stand up to sit in chair, pt began making a gurgling noise. Pt not answering as he was being talked to. Pt appeared to have a seizure then vomited." Further review revealed S19Psych was notified at 6:40 a.m. and gave an order to send him to the ER for evaluation. Further review revealed the ambulance arrived and transferred Patient #5 at 7:00 a.m. There was no documented evidence of the patient assessment that was documented as having been done.

Review of Patient #5's medical record revealed he returned from the hospital admission on 06/10/19 at 2:45 p.m. Further review revealed no documented evidence that a post fall risk assessment was conducted as well as a fall risk re-assessment.

In an interview on 06/18/19 at 3:35 p.m., S21RN confirmed a post fall risk assessment and a fall risk re-assessment were not done following Patient #5's fall.

4) Failure of the RN to ensure patients' admit orders had been obtained from a LIP/MD:
Review of the "Bylaws, Rules and Regulations" revealed standing orders shall be formulated by conference between the Medical Staff and the Administrator. They can be changed only by mutual consent of the Medical Staff and the Administrator. These orders shall be signed by a physician with Medical Staff Privileges. After final approval, standing orders shall be followed insofar as proper treatment of the patient will allow.

No documented evidence of a standing order for admission signed by S19Psych was presented during the survey.

Patient #1
Review of Patient #1's admission orders revealed an admission date of [DATE].
Further review revealed diagnostic data: labs, therapies to be utilized, vital sign frequency (routine), diet (regular diet was chosen- Patient #1 was Type 1 Diabetic and receiving insulin), and special precautions (fall and suicide) were checked off/handwritten on the admit orders. Additional review revealed the orders were written as VO/TO per S19Psych by the nurse who had written the order. The physician signed the order on 05/3/19.

Patient #5
Review of Patient #5's "Admission orders" dated 06/03/19 at 12:08 p.m. revealed a provisional diagnosis of [DIAGNOSES REDACTED].m. S19Psych signed the orders on 06/05/19 at 12:00 p.m.

Patient R1
Review of Patient R1's "Admission Orders" dated 06/11/19 at 1:45 p.m. revealed a provisional diagnosis of [DIAGNOSES REDACTED].m. S19Psych signed the orders on 06/12/19 at 12:00 p.m.

Patient R2
Review of Patient R2's "Admission Orders" dated 06/12/19 at 12:57 p.m. revealed a provisional diagnosis of [DIAGNOSES REDACTED].m., and S19Psych signed the orders on 06/12/19 at 2:00 p.m.

In an interview on 06/18/19 at 2:43 p.m. with S18RN, she reported she writes the new patient admit orders. S18RN indicated the hospital's admit orders are standing orders, and the hospital has a protocol in place. S18RN confirmed the admit orders were written as VO/TO orders even though the physician is not called to review what orders the new patient should have. S18RN confirmed the physician is not called when a patient is admitted , unless the admitting nurse has a question about something in the patient's referral packet that is not addressed on the hospital's admit standing orders. S18RN further confirmed newly admitted patients' admit orders are filled out based on information from the referral packet. S18RN reported the physician signed the orders at a later time.

In an interview on 06/18/19 at 3:13 p.m. with S2DON, she reported the intake department located in an offsite location reviews patient referral information and accepts patients to be admitted to the hospital. S2DON confirmed staff who were admitting the patients were not calling the physician and reviewing the orders, even though the admit orders were documented as verbal/telephone orders. S2DON reported the nursing staff was accepting the admission for the physician.

5) Failure of the RN to ensure a LIP/MD was contacted for orders after patients returned from hospitalization or an ER visit:
Review of the policy titled "Patient Falls", presented as a current policy by S2DON, revealed no documented evidence that the policy addressed the procedure for contacting the physician upon the patient's return to the hospital following an acute care hospitalization of a visit to the ER.

Patient #3
Review of Patient #3's medical record revealed he was admitted on [DATE] at 3:00 p.m. with diagnoses of [DIAGNOSES REDACTED]

Review of Patient #3's Multi-Disciplinary Note documented by S5RN on 04/25/19 at 1:55 a.m. revealed on 04/25/19 at 12:55 a.m. the MHT reported Patient #3 fell in his room.

Review of Patient #3's physician orders revealed an order on 04/25/19 at 1:00 a.m. received from S19Psych by telephone to S5RN to send Patient #3 to the ER for evaluation post fall.

Review of Patient #3's Multi-Disciplinary Note documented on 04/25/19 at 7:17 a.m. by S11RN revealed Patient #3 returned from the acute care hospital in stable condition and was alert and oriented. There was no documented evidence that S11RN contacted S19Psych to notify him of Patient #3's return from the ER and to obtain orders for treatment.

In a telephone interview on 06/18/19 at 4:00 p.m., S11RN indicated he didn't remember there being anything that warranted him to notify the physician upon the patient's return from the hospital. He confirmed he didn't notify S19Psych of Patient #3's return from the ER to obtain orders for further treatment.

Patient #5
Review of Patient #5's medical record revealed he was admitted on [DATE] at 3:10 with diagnoses of [DIAGNOSES REDACTED]

Review of Patient #5's Multi-Disciplinary Note documented on 06/09/19 at 1:50 p.m. revealed Patient #5 fell at 6:35 a.m. while ambulating from the hallway to the dayroom.

Review of Patient #5's physician orders revealed an order received from S19Psych by S20RN on 06/09/19 at 6:40 a.m. to send Patient #5 to the acute care hospital for evaluation after a fall due to vomiting and disorientation.

Review of Patient #5's Multi-Disciplinary Note documented by S21RN on 06/10/19 at 4:29 p.m. revealed Patient #5 returned from the hospital at 2:45 p.m. and seemed slightly sedated. Further review revealed he was interacting with staff and peers. There was no documented evidence that S21RN contacted S19Psych to notify him of Patient #5's return from the acute care hospitalization and to obtain orders for treatment.

In an interview on 06/18/19 at 10:40 a.m., S2DON indicated she doesn't know if there's a policy for what's supposed to happen when the patient returns from the ER regarding getting orders from the physician.

In an interview on 06/18/19 at 3:35 p.m., S21RN indicated he assumed there's documentation in the record received from the treating hospital when the patient is sent out. He indicated it's not been a standard of practice that the nurse calls the doctor to obtain orders for treatment following an ER or hospital admission visit.

6) Failure of the RN to ensure patients' observation records were accurate and complete, including ordered precautions and levels of observation:
Patient #1
Review of Patient #1's admission orders revealed an admission date of [DATE]. Further review revealed the patient was on every 15 minute level of observation with suicide precautions.

Review of Patient #1's observation record, dated 05/07/19, revealed suicide precautions were not checked off on the observation record.

Patient #3
Review of Patient #3's "Patient Observation Record" during his entire hospital stay from 04/18/19 through 05/02/19 revealed no documented evidence fall precautions were checked to assure the MHT knew fall was a precaution for which Patient #3 was to be observed.

Patient #4
Review of Patient #4's admission orders, dated 06/11/19 at 10:50 p.m., revealed the patient was on seizure precautions, fall precautions, and safety precautions.

Further review revealed the patient was on every 15 minute level of observation starting on 06/11/19 until 06/13/19 when she was changed to Line of Sight observation level status post a fall with injury on 06/13/19.

Review of Patient #4's observation records revealed none of the patient's precautions were documented on the following dates: 06/15/19, 06/16/19, 06/17/19, and 06/18/19.

Further review revealed safety and seizure precautions were not documented on the patient observation records on 06/13/19 and 06/14/19.

Additional review revealed the frequency of checks, every 15 minutes, was left blank on 06/16/19 and 06/17/19, and the patient's line of sight observation level was also not documented on the observation records for 06/16/19, 06/17/19, and 06/18/19.

In an interview on 6/17/19 at 11:14 a.m. with S2DON, she confirmed the above-referenced patient observation records failed to have documentation of ordered precautions and/or ordered levels of observation. S2DON confirmed the observation records were incomplete and verified all ordered precautions and levels of observation should have been documented on the records.

7) Failure of the RN to ensure patients' level of observation was ordered on admission orders:
Patient #1
Review of Patient #1's EMR revealed an admission date of [DATE] with an admission diagnosis of [DIAGNOSES REDACTED]

Review of Patient #1's admission orders, dated 04/30/19 at 8:00 p.m., revealed no level of observation had been ordered.

Patient #2
Review of Patient #2's EMR revealed an admission date of [DATE] with an admission diagnosis of [DIAGNOSES REDACTED]

Review of Patient #2's admission orders, dated 05/01/19 at 8:45 p.m., revealed no level of observation had been ordered.

Patient #3
Review of Patient #3's EMR revealed an admission date of [DATE] with an admitting diagnosis of [DIAGNOSES REDACTED]

Review of Patient #3's admission orders, dated 04/18/19 at 1:56 p.m. revealed no level of observation had been ordered.

Patient #5
Review of Patient #5's EMR revealed he was admitted on [DATE].

Review of Patient #5's admission orders, dated 06/03/19 at 12:08 p.m. revealed no level of observation had been ordered.

In an interview on 06/17/19 at 4:23 p.m. with S2DON, she confirmed patient observation levels should have been ordered on admit and should have been documented in the section where special precautions were ordered. S2DON reported all patients were automatically placed on every 15 minute observation levels on admit. S2DON agreed staff can't just automatically the assume a patient is on every 15 minute observation levels if there was no order documented in admit orders, because the patient may have required a higher level of observation, and it may not have been ordered.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**






Based on record reviews and interviews, the hospital failed to ensure the nursing staff developed, and kept current, an individualized nursing care plan for each patient as evidenced by failure of the nursing staff to include all identified patient problems for which the patient was being treated in the nursing care plan for 5 (#1, #2, #3, #4, #5) of 5 (#1 - #5) patient records reviewed for nursing care plans from a sample of 5 patients.
Findings:

Review of the policy titled "Treatment Plans", presented as a current policy by S2DON, revealed the comprehensive treatment plan was initiated upon admission following assessments by the various disciplines and would reflect the patient's clinical needs, condition, functional strengths, and limitations. The plan would be revised throughout the patient's hospitalization to reflect progress toward treatment goals. Each problem of the treatment plan was to be addressed, updated, revised or resolved, and documented weekly during treatment team. All newly identified patient problems or diagnoses will be incorporated into the plan of care, and the treatment plan will be modified to reflect these changes.

Patient #1
Review of Patient #1's admission orders revealed an admission date of [DATE]. Further review revealed Patient #1 was Type 1 Diabetic and receiving insulin and the patient was on special precautions - fall and suicide.

Review of Patient #1's treatment plan revealed the plan had not been updated after patient's the fall on 05/07/19.

Patient #2
Review of Patient #2's admission orders revealed an admission date of [DATE]. Further review revealed Patient #2 was legally blind.

Review of Patient #2's treatment plan revealed visual impairment and the patient's eye treatments (eye drops and eye ointment) had not been addressed on the patient's plan of care.

Patient #3
Review of Patient #3's EMR revealed he was admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]

Review of Patient #3's Treatment Plan revealed the identified problems that were addressed included dementia, at high risk for altered thought process, and risk for fall.

Review of the multi-disciplinary notes documented by the nursing staff revealed Patient #3 fell on [DATE]. There was no documented evidence his nursing care plan was revised after his fall to ensure appropriate interventions were in place to prevent another fall.

In an interview on 06/18/19 at 8:57 a.m., S5RN indicated when there's a fall there should be a fall risk assessment done, and the care plan should be revised.

Patient #4
Review of Patient #4's admission orders revealed an admission date of [DATE] at 10:50 p.m.
Further review revealed the patient was Diabetic and was receiving insulin. Additional review revealed the patient was on fall, seizure, and safety precautions. Additional review revealed the patient had to wear a helmet for safety.

Review of Patient #4's treatment plan revealed Diabetes and Seizure Risk had not been addressed on the patient's plan of care. Additional review revealed the treatment plan had not been updated after patient's the fall with injury (eyelid laceration requiring "glued" for repair) on 06/13/19.

Patient #5
Review of Patient #5's medical record revealed he was admitted on [DATE] at 3:10 with diagnoses of [DIAGNOSES REDACTED]

Review of Patient #5's Treatment Plan revealed the identified that were addressed included dementia and risk for falls.

Review of S19Psych's progress note dated 06/05/19 at 2:28 p.m. revealed Patient #5 hit the nursing home staff, asked for a gun to shoot himself, and was hypersexual with residents going into other residents' rooms and tried to rape a resident prior to his admission.

Review of Patient #5's multi-disciplinary noted dated 06/09/19 at 1:50 p.m. revealed S20RN documented he fell while ambulating from the hall to the dayroom and appeared to have a seizure.

Review of S19Psych's progress noted dated 06/10/19 revealed Patient #5 went to the ER for a seizure.

Review of a multi-disciplinary note dated 06/13/19 at 9:40 a.m. revealed S11RN documented that Patient #5 was up and about in the dayroom, remained confused and disoriented, and was "taking clothes off."

There was no documented evidence Patient #5's nursing care plan was revised after his fall to ensure appropriate interventions were in place to prevent another fall. There was no documented evidence it was revised to include the documented identified problems of seizures, potential for hypersexual behavior, and suicidal ideations.

In an interview on 06/18/19 at 2:15 p.m., S8CCN indicated she does quarterly chart reviews based on certain quality indicators that have been developed. She further indicated one of the indicators is related to treatment plans being individualized, and this indicator has scored low on at least 6 months of chart reviews.

In an interview on 06/18/19 at 3:35 p.m., S21RN confirmed Patient #5 didn't have hypersexual behavior, suicidal ideations, and seizure precautions added to his care plan but the problems should have been added to the nursing care plan.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on record reviews and interviews, the RN failed to ensure the nursing care of each patient was assigned to nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the available nursing staff as evidenced by failure to have documented evidence that direct care staff had received orientation and competency evaluation in providing observations as ordered with appropriate documentation (MHTs) and/or annual competency assessment of performing suicide assessments (nurses) for 10 (S2DON, S3MHT, S4MHT, S5RN, S6LPN, S11RN, S13MHT, S14MHT, S16MHT, S21RN) of 13 (S1ADM, S2DON, S3MHT, S4MHT, S5RN, S6LPN, S11RN, S13MHT, S14MHT, S15LPN, S16MHT, S17MHT, S21RN) personnel files reviewed for orientation and competency evaluations required upon hire and annually.
Findings:

Review of the "2019 Staff Development Plan", presented as the hospital's current plan by S22HRC, revealed employees will receive a comprehensive orientation at the onset of employment in order to determine basic competency as a basis for further skill development and the provision of quality services. This shall include a minimum of facility-wide and department-based orientations. Clinical competency shall be determined by the clinical supervisor of the employee. All staff will be oriented to the unit/department to which they have been assigned as evidenced by the completion of the Unit-Specific Orientation Checklist. Inpatient staff will complete a suicide assessment competency skills checklist within 30 days of hire and annually.

Review of the "MHT Competency Skills Checklist" revealed "close observation" was listed as a skill to be evaluated. There was no documented evidence that the competency checklist included observation of the MHT performing levels of patient observation as ordered (such as q 15 minutes, LOS, and 1:1) and the evaluation of the MHT's ability to accurately document the patient's observation record. This was evident in the personnel files of S3MHT, S4MHT, S13MHT, S14MHT, and S16MHT.

Review of S2DON's "Competency - Suicidal Assessment and precautions (RNs) revealed it was done on 06/01/18. There was no documented evidence it was performed annually.

Review of S3MHT's personnel file revealed his "MHT Competency Skills Checklist" was not dated when signed by S3MHT and S2DON. Further review revealed his "Inpatient Unit Orientation Checklist" was not signed and dated by the trainer, the mentor, and the supervisor, and S3MHT did not date his signature. Review of the "Competency - Therapeutic use of Restraints/Seclusion Mental Health Technicians" revealed no documented evidence of the date S3MHT and S2DON signed the form. Review of the "MHT Test" revealed no documented evidence that date was taken by S3MHT and that the test had been scored as evidenced by a score (70 per cent and above was a passing score) not being documented.

Review of the personnel files of S5RN, S11RN, S18RN, and S21RN revealed no documented evidence each had received a suicide assessment competency conducted and a skills checklist completed within 30 days of hire and annually.

In an interview on 06/18/19 at 4:40 p.m., S22HRC confirmed the above-listed MHTs did not have documentation of competency performing levels of patient observation as ordered and an evaluation of the MHT's ability to accurately document the patient's observation record. She also confirmed the above-listed RNs did not have evidence of a suicide assessment competency, and it was required within 30 days of hire and annually thereafter. She confirmed the above-listed RNs had been employed for more than a year.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**






Based on record reviews and interviews, the hospital failed to ensure drugs and biologicals must be prepared and administered in accordance with Federal and State laws and regulations, the orders of the practitioner or practitioners responsible for the patient's care, and in accordance with the approved medical staff policies and procedures as evidenced by:

1) Failure to ensure drugs and biologicals were administered in accordance with the physician's orders for 1 (#1) of 5 (#1-#5) patient records reviewed for medication administration from a sample of 5 patients.

2) Failure to ensure the physician's order for medications included the specific instruction (indication) for use for 2 (#3, #5) of 5 (#1 - #5) patient records reviewed for medication's indication for use from a sample of 5 patients.

Findings:

1) Failure to ensure drugs and biologicals were administered in accordance with the physician's orders:
Review of the hospital policy titled, "Administration of Medication", Policy Number: Pharm-102, revealed in part: 4.All medications will be individually ordered for each patient by his/her physician and will be given only to the patient for which it is ordered. 6. Drugs to be administered are checked against the physician's orders. 7. Observe the five rights in giving medications: the right patient, right time, right medication, right dose, and the right method of administration.

Review of the hospital policy titled," Medication Administration-Error", Policy Number: Pharm-107, revealed in part: Policy: Medication errors are defined as any medication that is not given with the correct drug, dose, and route of administration, condition, or time to the correct patient. This includes: Medication not given as ordered or given without a physician's order.

Review of Patient #1's EMR revealed an admission date of [DATE] with admission diagnoses including Chronic Kidney Disease and Type I Diabetes.

Review of Patient #1's physician's orders, dated 04/30/19, revealed the following Accu-check and insulin orders:
Accu-checks (capillary blood glucose testing) before meals TID (3 times a day), with sliding scale insulin and Accu-check at hour of sleep (no sliding scale insulin ordered for hour of sleep).

Levermir (long - acting insulin) 30 units sub q (subcutaneous injection) at hour of sleep.

Novolin R (short- acting insulin) 5 units, 3 times a day before meals.

Insulin Sliding Scale:
200 mg/dL- 250 mg/dL: 3 units
251 mg/dL- 300 mg/dL: 5 units
301 mg/dL - 350 mg/dL: 7 units
351 mg/dL - 400 mg/dL: 10 units
401 mg/dL and above: 12 units.

Review of Patient #1's Diabetic Flow Record (Accu-check and Insulin Administration Record) revealed the following:

05/04/19 8:00 p.m.: Accu-check reading: 413 mg/dL; Action taken: Levemir 30 units and Novolog 12 units;

05/05/19 8:00 p.m.: Accu-check reading: 225 mg/dL; Action taken: Levemir (no dose documented) /Novolog (no dose documented);

05/06/19 8:00 p.m.: Accu-check reading 294 mg/dL; Action taken: Levemir 30 units and Novolog 7 units.
In an in interview on 06/17/19 at 10:38 a.m. with S2DON she confirmed, after review of the patient's orders, that the staff should have been obtaining an Accu-check at hour of sleep and should have been administering Levemir insulin at hour of sleep with no sliding scale insulin coverage. S2DON indicated the nursing staff should have clarified the insulin order to verify whether or not sliding scale insulin was to be administered in addition to Levemir insulin at hour of sleep.

In an interview on 06/17/19 at 3:02 p.m. with S8CCN, she confirmed the above referenced insulin administration errors.

2) Failure to ensure the physician's order for medications included the specific instruction (indication) for use:

Review of the EMR of Patient #3 and Patient #5 revealed the "Medication Reconciliation/MD Order" did not include the specific instructions or indication for use of each prescribed medication.

In an interview on 06/18/19 at 1:10 p.m., S2DON indicated the medication's indication for use was documented on the "pink paper" which is the order that is returned by the contracted pharmacy company. She confirmed this form ("pink paper") was not signed by the physician.
VIOLATION: REPORTING ADVERSE EVENTS Tag No: A0508
Based on record review and interview, the hospital failed to ensure identified medication variances were documented in the patient's record for 1 (#1) of 5 (#1-#5) patient records reviewed for medication errors from a sample of 5 patients.
Findings:

Review of the hospital policy titled, "Administration of Medication", Policy Number: Pharm-102, revealed in part: 15. Report an error in medication immediately to the nurse in charge, fill out an incident report, and forward to DON.

Review of Patient #1's EMR revealed an admitted 04/30/19 with admission diagnosis including Type I Diabetes.

Review of Patient #1's physician's orders, dated 04/30/19, revealed the following Accu-check and insulin orders:
Accu-checks (capillary blood glucose testing) before meals TID with sliding scale insulin and Accu-check at hour of sleep (no sliding scale insulin ordered for hour of sleep).

Levermir (long - acting insulin) 30 units sub q at hour of sleep.

Novolin R (short- acting insulin) 5 units 3 times a day before meals.

Insulin Sliding Scale:
200 mg/dL- 250 mg/dL: 3 units
251 mg/dL- 300 mg/dL: 5 units
301 mg/dL - 350 mg/dL: 7 units
351 mg/dL - 400 mg/dL: 10 units
401 mg/dL and above: 12 units.

Review of Patient #1's Diabetic Flow Record (Accu-check and Insulin Administration Record) revealed Patient #1 had received sliding scale insulin in addition to the ordered Levemir 30 units sub q at hour of sleep on the following dates:

05/04/19 8:00 p.m.: Accu-check reading: 413 mg/dL; Action taken: Levemir 30 units and Novolog 12 units;

05/05/19 8:00 p.m.: Accu-check reading: 225 mg/dL; Action taken: Levemir (no dose documented) /Novolog (no dose documented);

05/06/19 8:00 p.m.: Accu-check reading 294 mg/dL; Action taken: Levemir 30 units and Novolog 7 units.

In an interview on 06/17/19 at 3:02 p.m. with S8CCN, she confirmed the above referenced insulin administration errors. S8CCN further confirmed no medication variance reports had been completed in regard to the above referenced medication errors and verified the medication variances had not been documented in the patient's medical record.
VIOLATION: CONTENT OF RECORD Tag No: A0458
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interview, the hospital failed to ensure each patient had a medical H&P examination completed and documented no more than 30 days before or 24 hours after admission as evidenced by having H&Ps performed more than 24 hours after admission for 2 (#3, #5) of 5 (#1 - #5) patient records reviewed for H&Ps from a sample of 5 patients.
Findings:

Review of the Medical Staff By-laws and Rules and Regulations revealed a complete admission H&P examination shall be recorded by an MD or Nurse Practitioner within 24 hours of the patient's admission.

Review of Patient #3's EMR revealed he was admitted on [DATE] at 3:00 p.m.

Review of Patient #3's H&P revealed it was performed by S9MD on 04/20/19 at 6:00 p.m. (51 hours after admit).

Patient #5
Review of Patient #5's EMR revealed he was admitted on [DATE] at 3:10 p.m.

Review of Patient #5's H&P revealed it was performed by S9MD on 06/05/19 at 3:40 p.m. (48 hours and 30 minutes after admission).

In a telephone interview on 06/18/19 at 11:25 a.m., S19Psych indicated the medical staff talked about H&Ps not being done and documented in 24 hours monthly at Medical Staff meetings, but it wasn't missed more than a few hours. He offered no explanation when the surveyor informed him that EMR review revealed some were not done within 48 hours of admission.
VIOLATION: GOVERNING BODY Tag No: A0043
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**






Based on record reviews, interviews, and observations, the hospital failed to ensure it's Governing Body was effective in ensuring the hospital was compliant with the Condition of Participation for Governing Body as evidenced by:

1) Failure of the Governing Body to ensure the Medical Staff was accountable for the quality of care provided to patients as evidenced by failing to ensure a patient death review had been completed timely for a patient who had been found unresponsive and later pronounced deceased on [DATE] (no death review had been completed as of 06/18/19 over 6 weeks after Patient #1's death) for 1 (#1) of 1 death records reviewed from a total patient sample of 5 (See findings in tag A-0049).

2) Failure of the Governing Body to ensure the requirements of the Condition of Participation of Patient's Rights was met as evidenced by failing to ensure patients received care in a safe setting due to:

a) Failure to ensure a patient on ordered every 15 minute level of observation, who had been found unresponsive and had been declared deceased , had been directly observed by MHT staff, at the bedside, at the ordered level of observation prior to being found unresponsive for 1 (#1) of 1 sampled patient reviewed for death from a total patient sample of 5 (#1-#5). (See findings in tag A-144);

b) Failure to ensure MHTs observed a patient (#4) on ordered LOS level of observation, as ordered, for 1 (#4) of 1 inpatient who was on ordered LOS observation due to falls from a total patient sample of 5 ( #1-#5) (see findings in tag A-0144); and

3) Failure to ensure the requirements of the Condition of Participation of Nursing Services was met as evidenced by:
a) Failure of the RN to assess a patient after a fall that included a total body assessment for 2 (#3, #5) of 4 (#1, #3, #4, #5) patient records reviewed for falls from a sample of 5 (#1 - #5) patients (see findings in tag A0395).

b) Failure of the RN to ensure post fall risk assessments, neurological checks post fall (including unwitnessed falls), and fall risk re-assessments were initiated/completed post fall for 4 ( #1, #3, #4, #5) of 5 (#1 - #5) patient records reviewed for falls from a sample of 5 patients (see findings in tag A0395).

c) Failure of the RN to ensure the physician was notified of abnormal (high) blood glucose results, as per hospital policy, for 1 (#1) of 3 (#1, #3, #4) diabetic patient records reviewed for diabetic treatment from a sample of 5 patients (#1 - #5) (see findings in tag A0395).

d) Failure of the RN to ensure patients' admit orders had been obtained from a LIP/MD for 2 (#1, #5) of 5 (#1 - #5) sampled patient and 2 (R1, R2) of 2 random patient records reviewed for admission orders from a sample of 5 patients and 2 random patients (see findings in tag A0395).

e) Failure of the RN to ensure patients' level of observation was ordered on admission orders for 4 (#1, #2, #3, #5) of 5 (#1-#5) patient records reviewed for ordered observation level from a sample of 5 patients (see findings in tag A0395).

f) Failure of the RN to ensure the nursing care of each patient was assigned to nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the available nursing staff as evidenced by failure to have documented evidence that direct care staff had received orientation and competency evaluation in providing observations as ordered with appropriate documentation (MHTs) and/or annual competency assessment of performing suicide assessments (nurses) for 10 (S2DON, S3MHT, S4MHT, S5RN, S6LPN, S11RN, S13MHT, S14MHT, S16MHT, S21RN) of 13 (S1ADM, S2DON, S3MHT, S4MHT, S5RN, S6LPN, S11RN, S13MHT, S14MHT, S15LPN, S16MHT, S17MHT, S21RN) personnel files reviewed for orientation and competency evaluations required upon hire and annually (see findings in tag A0397).
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews, observations, and interviews, the Governing Body failed to ensure the Medical Staff was accountable for the quality of care provided to patients as evidenced by:
1) Failure of the Medical Staff to ensure a patient death review had been completed timely for a patient who had been found unresponsive and later pronounced deceased on [DATE] (no death review had been completed as of 06/18/19 over 6 weeks after Patient #1's death) in order to identify and address any potential contributing factors related to the patient's death for 1 (#1) of 1 death record reviewed from sample of 5 patients;

2) Failure of the Medical Staff to ensure a patient (#4) on ordered LOS observations due to fall risk and being status post a fall with injury was being observed as ordered for 1 (#4) of 1 current patient on ordered LOS observation level from a sample of 5 patients; and

3) Failure of the Medical Staff to ensure patients' history and physicals were on the chart within 24 hours of admission for 2 (#3, #5) of 5 (#1 - #5) patient records reviewed for H&Ps from a sample of 5 patients.
Findings:

1) Medical Staff failed to ensure a patient death review had been completed timely.

Review of Patient #1's EMR revealed the patient was a [AGE] year old female with an admission date of [DATE] with admission diagnoses including Depression with suicidal ideation, Type 1 Diabetes, and a history of cocaine abuse. Further review revealed the patient had been found unresponsive in her bed on 05/07/19 at 06:51 a.m. and had been pronounced dead on 05/07/19 at 07:30 a.m.

Review of a Root Cause Analysis conducted to review Patient #1's death revealed the following, in part: Details of event: On 04/30/19 Patient #1 was admitted due to Depression with Suicidal Ideation.

05/07/19 01:20 a.m.: Patient #1 "rolled out of bed", between the bed and the bedside table. She was awake, alert, and oriented. Patient denied hitting her head but complained of mild, dull pain to lower back. Head to toe assessment completed and patient assisted back to bed.
06:51 a.m.: nurses' note: MHT called for nurse to come to patient's room. Upon arrival to room, the patient was noted to be lying face-down on the bed and appeared to be sleeping. The nurse attempted to wake the patient up, but the patient did not respond. She documented extremities felt cold. She checked for a pulse, but no pulse could be felt. No breath sounds. No vital signs were registering on the machine.
07:01 First responders arrived and took over CPR from staff.
07:34 a.m.: Ambulance personnel notified physician by phone to update on patient's condition. Time of death called at 07:30 a.m.

Human factors relevant to outcome: 1. S13MHT stated she opened the door to the patient's room at 06:00 a.m., 06:15 a.m., 06:30 a.m., and 06:45 a.m. but did not go into the patient's room and up to the bed to check on the patient. She stated she thought the patient was sleeping.
3. Medication reconciliation/MD order completed on 04/30/19 indicated to continue Novolin R insulin 5 units 3 times a day before meals with a sliding scale. The sliding scale did not have documented parameters to alert nursing staff when to notify the physician of elevated blood glucose levels. MD was not notified of any blood glucose results. MD order was not followed for hour of sleep blood glucose check. Staff administered sliding scale insulin at hour of sleep on 05/04/19, 05/05/19, and 05/06/19 along with Levemir. Order was for blood glucose check at hour of sleep and administration of Levemir.

In an interview on 06/18/19 at 11:25 a.m. with S19Psych (Medical Director), he reported the last full medical staff meeting had been in April 2019. He indicated there had been an abbreviated medical staff meeting in May 2019, but they had a function to attend, and the meeting had consisted mostly of hand-outs being given out. S19Psych reported a medical staff meeting had been scheduled for 06/18/19, and it had been rescheduled due to surveyors being onsite. S19Psych indicated the governing body had discussed reviewing the record of Patient #1's death 3 weeks ago at the meeting and confirmed the patient's death had not been reviewed by medical staff as of 06/18/19. S19Psych indicated he had not been informed of anything that may have contributed to the patient's death, and they were waiting on the autopsy results to come back. S19Psych reported he had no discussions related to potential issues with orders for sliding scale insulin, blood glucose parameters and physician notification, and capillary blood glucose monitoring.

2) Medical staff failed to ensure a patient (#4) on ordered Line of Sight observations due to fall risk and being status post a fall with injury was being observed as ordered.

Review of Patient #4's EMR revealed an admission date of [DATE] with admission diagnoses including Bipolar Depression.

Review of Patient #4's physician's orders revealed the patient had been placed on LOS observation level for fall risk when she returned from the ER on 06/13/19. Further review of Patient #4's orders revealed the patient remained on LOS at the time of the record review on 06/18/19.

Patient #4 was observed on 06/18/19 at 7:30 a.m., and the patient was noted to have a purplish-red bruised area encircling her left eye top and bottom, forming a ring. Patient #4 was observed in her room, alone, with no staff member maintaining her in their direct LOS.

On 06/18/19 at 7:45 a.m. an observation was made of S17MHT in a patient room, changing bed linens. S17MHT had her assignment clipboard with her assigned patients' observation sheets with her in the room. S17MHT was observed filling in Patient #4's observation sheet indicating the patient was in the dayroom. S17MHT had not been observed in the dayroom when surveyors were conducting observations of Patient #4 in the dayroom.
S17MHT was interviewed during the observation, and she verified she had just "filled in" the patient's observation sheets and acknowledged that she had not visualized the patient prior to filling in the observation sheet at 7:45 a.m. S17MHT indicated she had not known Patient #4 was on LOS level of observation and had not been observing her LOS. S17MHT's assignment sheet indicated she was assigned Patient #4 (LOS) and 3 other patients - Patient R3, Patient R4, and Patient R5 who were on q 15 minute levels of observation.

On 06/18/19 at 8:20 a.m. S13MHT was observed in the dayroom with Patient #4. S13MHT had her back turned to the patient. No other staff member was observed maintaining the patient in their constant LOS.

In an interview on 06/18/19 at 07:48 a.m. with S14MHT, she indicated all current patients were on every 15 minute observation levels and none of the patients were on LOS or 1:1 levels of observation. S14MHT was asked if Patient #4 was still on LOS observation level for safety due to falls, and she reported she didn't think so, because it wasn't "on the board" and had not been passed on by off-going staff. S14MHT asked the surveyors to "let the techs know if they found out the patient was still on LOS."

In an interview on 06/18/19 at 08:05 a.m. with S15LPN (who was working during the observation), she reported she had not known Patient #4 was still on LOS observation level.

In an interview on 06/18/19 at 08:08 a.m. with S18RN (who was working during the observation), she confirmed she had not known Patient #4 was still on LOS observation level.

In an interview on 06/18/19 at 8:31 a.m. with S4MHT, she confirmed she had worked the night shift of 06/17/19. S4MHT reported she works Monday - Friday 10:00 p.m. - 6:00 a.m. shift. S4MHT reported she had been unaware Patient #4 was still on LOS observation, because it wasn't "on the board" anymore, and that is where patient precautions and levels of observation are documented. S4MHT further reported the off-going MHTs had not reported Patient #4 was on LOS either.

In an interview on 06/18/19 at 8:58 a.m. with S5RN, he confirmed he had worked the night shift of 06/17/19. S5RN reported he had not known Patient #4 was on LOS level of observation.

In an interview on 6/18/19 at 10:04 a.m. with S6LPN, she indicated she had worked on Thursday night (06/13/19) and Friday night (06/14/19). S6LPN confirmed she had also worked on Sunday night (06/16/19). S6LPN explained she had heard Patient #4 had been placed on LOS level of observation when she came back from the hospital on [DATE]. S6LPN indicated she had not known Patient #4 had remained on LOS on Sunday night (06/16/19) when she had worked that night. S6LPN confirmed she had done a chart check on Patient #4's orders last night (06/17/19). S6LPN was asked if she had called the physician to clarify the order on Patient #4's chart that she couldn't read she replied, "No", due to the fact that she does chart checks around midnight. S6LPN indicated she typically only calls the physician for emergent issues.

In an interview on 06/18/19 at 10:44 a.m. with S2DON, she confirmed she was not aware Patient #4 was on LOS level of observation yesterday and today. S2DON indicated she generally knew all of the patients' levels of observation, because she reviewed the patient information board on the patient care unit. S2DON reviewed Patient #4's physician's orders and confirmed the LOS order was obvious in the patient's record.

Interview on 06/18/19 at 11:25 a.m. with S19Psych, he confirmed Patient #4 had been placed on LOS observation level status post fall with injury for safety. S19Psych confirmed Patient #4 was still on LOS observation level on 06/18/19 and continued to need the increased level of supervision due to cognitive disabilities and continued risk for falls. S19Psych confirmed he had not been aware that Patient #4 was not being observed LOS, as ordered. S19Psych indicated Patient #4 should remain on LOS observation level as long as the patient was at risk for falling. He indicated he felt Patient #4 was an intermediate fall risk level.

Observation on 06/18/19 at 11:48 a.m. revealed the patient care board in the nursing station did not have Patient #4 listed as being on LOS (board had not been corrected after it had been brought to the attention of the nursing staff and administration that Patient #4 had not been being observed LOS as ordered since 06/13/19).

In an interview on 06/18/19 at 1:18 p.m., when the survey findings were presented to S1ADM, he indicated it's "kind of shocking with what's taking place." He further indicated he didn't realize the magnitude of what's taking place related to the observations made by the surveyors and the record reviews conducted by the surveyors during the survey.

3) Failure of the Medical Staff to ensure patients' history and physicals were on the chart within 24 hours of admission:
Review of Patient #3's EMT revealed he was admitted on [DATE] at 3:00 p.m.

Review of Patient #3's H&P revealed it was performed by S9MD on 04/20/19 at 6:00 p.m. (51 hours after admit).

Patient #5
Review of Patient #5's EMR revealed he was admitted on [DATE] at 3:10 p.m.

Review of Patient #5's H&P revealed it was performed by S9MD on 06/05/19 at 3:40 p.m. (48 hours and 30 minutes after admission).

In a telephone interview on 06/18/19 at 11:25 a.m., S19Psych indicated the medical staff talked about H&Ps not being done and documented in 24 hours monthly at Medical Staff meetings, but it wasn't missed more than a few hours. He offered no explanation when the surveyor informed him that EMR review revealed some were not done within 48 hours of admission.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record reviews, observations, and interviews, the hospital failed to meet the requirements of the Condition of Participation for Patient's Rights as evidenced by:

1) Failure to ensure psychiatric patients were provided care in a safe setting as evidenced by:

a) Failure to ensure a patient on ordered every 15 minute level of observation, who had been found unresponsive and had been declared deceased , had been directly observed by MHT staff, at the bedside, at the ordered level of observation prior to being found unresponsive for 1 (#1) of 1 sampled patient record reviewed for death from a total patient sample of 5 (#1-#5) (see findings in tag A-0144).

b) Failure to ensure MHTs observed a patient (#4) on ordered LOS level of observation, as ordered, for 1 (#4) of 1 inpatient who was on ordered LOS observation due to falls from a total patient sample of 5 ( #1-#5) (see findings in tag A-0144).

c) Failure to ensure appropriate corrective action was taken to address incidents of neglect as evidenced by failure to timely complete staff education regarding identified lapses in patient care for 2 (#1, #3) of 2 patient records reviewed for abuse/neglect from a total patient sample of 5 ( #1-#5) (see findings in tag A-0145).

2) Failure to ensure the use of restraint was in accordance with a written modification to the patient's plan of care as evidenced by failure of the nursing staff to identify a physical hold of a patient as a restraint and to revise the patient's plan of care to include the use of restraint for 1 (#3) of 2 (#3, #5) patient records reviewed for restraint from a sample of 5 patients (see findings in tag A0166).
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on observation, record review, and interview, the hospital failed to ensure each patient's right to personal privacy during personal hygiene activities. This deficient practice was evidenced by failure to provide privacy in the shower or whirlpool tub stall during hygiene activities (showering/bathing). This deficient practice had the potential to affect all 18 current inpatients receiving care in the hospital at the time of the observation.
Findings:

On 06/13/19 from 10:55 a.m. to 11:20 a.m. an observation was conducted of the patient care unit which included an observation of the patient shower room. Three deep, recessed tiled shower stalls/bays and 1 room with a whirlpool tub were noted in the shower room. Two of the shower stalls/bays were side by side and one shower stall/bay was located across from the 2 side by side shower stalls/bays. The whirlpool tub room was located to the left of the shower room entry door. Further observation revealed there were no means in place to protect the patients' privacy while showering/bathing in the shower stalls/bays and whirlpool room.

S2DON, present during the observation on 06/13/19 from 10:55 a.m. to 11:20 a.m., explained the patients could not see each other while showering, but a staff member was standing outside of the shower bays and visualized both patients at the same time during showering. She reported there is always a MHT in the bathroom when patients are showering for safety reasons, especially due to having the whirlpool tub in the shower room. S2DON confirmed constant visual monitoring with "eyes on the patients at all times" was conducted on all patients, including patients on every 15 minute observations who did not require constant visual contact like a patient who was on line of sight or on 1:1 observation levels.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews, observation, and interview, the hospital failed to ensure patients at risk for harm to self or others were provided care in a safe setting as evidenced by:

1) Failure to ensure observation levels of psychiatric patients were maintained by the MHTs as ordered by the physician for 1 (#1) of 5 (#1-#5) sampled patients.

2) Failure to ensure MHTs observed a patient (#4) on ordered LOS level of observation, as ordered, for 1 current inpatient who was on LOS observations due to falls from a total patient sample of 5 ( #1-#5).

3) Failure to ensure the patients' physical environment was free of safety risks and did not afford opportunities for self -injury/harm to others.
Findings:

1) Failure to ensure observation levels of psychiatric patients were maintained by the MHTs as ordered by the physician.

Review of Patient #1's EMR revealed the patient was a [AGE] year old female with an admission date of [DATE] with admission diagnoses including Depression with suicidal ideation, Type 1 Diabetes, history of Cocaine abuse, and Chronic Kidney Disease. Further review revealed the patient had been found unresponsive in her bed on 05/07/19 at 06:51 a.m. and had been pronounced dead on 05/07/19 at 07:30 a.m.

Review of Patient #1's physician's orders, dated 04/30/19, revealed the patient's level of observation was routine - every 15 minute observations. Further review revealed the patient had been PEC'd for suicidal ideations and was on suicide precautions.

Review of Patient #1's observation record for the day shift of 05/07/19 revealed the following entries:
06:00 a.m.: patient in room sleeping
06:15 a.m.: patient in room sleeping
06:30 a.m.: patient in room, awake
06:45 a.m.: patient in room, quiet
07:00 a.m.: patient in room with ambulance personnel
07:15 a.m.: patient in room with ambulance personnel
07:30 a.m.: patient in room with ambulance personnel

Review of nurses' note dated 05/07/19 6:51 a.m. revealed the following: MHT called for nurse to come to Patient #1's room. Upon arrival to room, patient was noted to be lying face down on the bed and appeared to be sleeping. The nurse attempted to wake the patient up, but the patient did not respond. Extremities felt cold. Checked for pulse, no pulse could be felt. No breath sounds. No vital signs were registering on vital sign machine.
06:53 a.m.: charge nurse attempted to get blood pressure reading manually but was unsuccessful.
06:54 a.m.: CPR initiated by charge nurse. MHT called 911 and LPN went to get emergency cart.
07:01 First responders arrived and took over CPR from staff.
07:34 a.m.: Ambulance personnel notified physician by phone to update on patient's condition. Time of death called at 07:30 a.m.

Review of the Root Cause Analysis of Patient #1's death revealed the following: Human factors relevant to outcome: 1. S13MHT stated she opened the door to the patient's room at 06:00 a.m., 06:15 a.m., 06:30 a.m., and 06:45 a.m. but did not go into the patient's room and up to the bed to check on the patient. She stated she thought the patient was sleeping.

In an interview on 06/18/19 at 1:25 p.m. with S1ADM, he confirmed S13MHT had not observed Patient #1 as ordered and had failed to directly observe the patient at the patient's bedside. He reported S13MHT had observed the patient from the door and had assumed she was asleep.

In an interview on 06/18/19 at 2:43 p.m. with S18RN, she confirmed she had been on duty on 05/07/19 for the 06:00 a.m. - 2:00 p.m. shift. S18RN indicated before she could make out assignments, S17MHT came and told her S14MHT couldn't wake up Patient #1 and was unable to get any vital sign readings on the patient. S18RN reported she ran to the patient's room and could not get the patient to respond, not even to a sternal rub. She reported Patient #1's extremities were cold, and she was unable to get a pulse or a manual blood pressure. She reported CPR was started and 911 was called. The patient failed to respond to resuscitation efforts and was pronounced at 07:30 a.m. S18RN reported the nursing staff would review MHTs' patient observation sheets at the end of the shift and sign off on them.

In an interview on 06/18/19 at 3:16 p.m. with S13MHT, she confirmed she had been assigned Patient #1 on 05/07/19. S13MHT indicated she had done her every 15 minute rounds starting at 06:00 a.m. S13MHT reported she had gone in at 6:00 a.m. to wake Patient #1's room-mate up. She reported she thought Patient #1 was on her side, but she was covered up and her head was towards the window. She said at 06:15 a.m. the patient was in the same position she had been in at 06:00 a.m. S13MHT reported she never saw the patient awake from 06:00 a.m. - 06:51 a.m. S13 MHT reported she had not gone into the room and had only stood at the doorway when performing her every 15 minute rounds. S13MHT verified she had found Patient #1 unresponsive when she had gone in to take vital signs.


2) Failure to ensure MHTs observed a patient (#4) on ordered LOS level of observation, as ordered.

Review of Patient #4's EMR revealed an admission date of [DATE] with admission diagnoses including Bipolar Depression.

Review of the hospital's incident reports for the last 6 months (01/2019 - 06/2019) revealed a report indicating on 06/13/19 Patient #4 had fallen while showering and had lacerated her eyelid. The patient was sent to an area ER and her lid injury had been repaired with "glue."

Review of Patient #4's physician's orders revealed the patient had been placed LOS observation level for fall risk when she returned from the ER on 06/13/19. Further review of Patient #4's orders revealed the patient remained on LOS at the time of the record review on 06/18/19.

Patient #4 was observed on 06/18/19 at 7:30 a.m., and the patient was noted to have a purplish-red bruised area encircling her left eye top and bottom, forming a ring. Patient #4 was observed in her room, alone, with no staff member maintaining her in their direct LOS.

On 06/18/19 at 7:45 a.m. an observation was made of S17MHT in a patient room, changing bed linens. S17MHT had her assignment clipboard with her assigned patients' observation sheets with her in the room. S17MHT was observed filling in Patient #4's observation sheet indicating the patient was in the dayroom. S17MHT had not been observed in the dayroom when surveyors were conducting observations of Patient #4 in the dayroom.

S17MHT was interviewed during the observation on 06/18/19 at 7:45 a.m., and she verified she had just "filled in" the patient's observation sheets and acknowledged that she had not visualized the patient prior to filling in the observation sheet at 7:45 a.m. S17MHT indicated she had not known Patient #4 was on LOS level of observation and had not been observing her LOS. S17MHT's assignment sheet indicated she was assigned Patient #4 ( LOS) and 3 other patients - Patient R3, Patient R4, and Patient R5 who were on q 15 minute levels of observation.

On 06/18/19 at 7:50 a.m. an observation was made of the patient information dry erase board which included all patients' levels of observation. Patient #4 was not listed as being on LOS level of observation on the board.

On 06/18/19 at 8:20 a.m. S13MHT was observed in the dayroom with Patient #4. S13MHT had her back turned to the patient. No other staff member was observed maintaining the patient in their constant LOS.

In an interview on 06/18/19 at 07:48 a.m. with S14MHT, she indicated all current patients were on every 15 minute observation levels, and none of the patients were on LOS or 1:1 levels of observation. S14MHT was asked if Patient #4 was still on LOS observation level for safety due to falls, and she reported she didn't think so, because it wasn't "on the board" and had not been passed on by off-going staff. S14MHT asked the surveyors to "let the techs know if they found out the patient was still on LOS." S14MHT indicated, after review of her assignment (given to her at 8:00 a.m. after having been observing patients since 6:00 a.m.), that the patients she was currently observing were not the patients she had been assigned on the assignment sheet. She reported when the techs came on at the start of the shift they grabbed their specific clipboard with patient observation sheets already on them and began performing observations of those patients. S14MHT indicated the techs now needed to review all of their patient observation sheets on their clipboards and would have to divide them up in order to match their assignments.

In an interview on 06/18/19 at 08:05 a.m. with S15LPN, she reported she had not known Patient #4 was still on LOS observation level.

In an interview on 06/18/19 at 08:08 a.m. with S18RN, she confirmed she had not known Patient #4 was still on LOS observation level. She indicated the night nurse performed patient chart checks and should have passed on that Patient #4 was still on LOS observation level. S18RN also indicated the patient's LOS status should have been written "on the board" and confirmed it was not written there. S18RN confirmed she made out MHT assignments and acknowledged the MHTs came in for their shift and took their clipboards with patient observation records already on them and began making patient observations. S18RN further confirmed she had not passed out the MHTs assignments until 8:00 a.m. (2 hours after the shift began at 6:00 a.m.).

In an interview on 06/18/19 at 8:31 a.m. with S4MHT, she confirmed she had worked the night shift of 06/17/19. S4MHT reported she works Monday - Friday 10:00 p.m. - 6:00 a.m. shift. S4MHT reported she had been unaware Patient #4 was still on LOS observation, because it wasn't "on the board" anymore and that is where patient precautions and levels of observation are documented. S4MHT further reported the off-going MHTs had not reported Patient #4 was on LOS either. S4MHT indicated one MHT usually observes all patients, and they all take turns watching patients. S4MHT indicated the MHTs don't really go by the patient assignments completed by the charge nurse. S4MHT explained they just divide the patients amongst themselves and hand off the patients while performing other tasks such as taking patient vitals, doing the laundry, changing linens, performing patient changes, offering water, pulling trash, mopping and wiping down surfaces in the commons area. S4MHT indicated two techs performed other duties/chores while the third tech watches all of the patients, on the hall, when the patients are asleep.

In an interview on 06/18/19 at 8:58 a.m. with S5RN, he confirmed he had worked the night shift of 06/17/19. S5RN reported he had not known Patient #4 was on LOS level of observation. S5RN indicated he had been told Patient #4 was on fall precautions. S5RN reported he had not done a chart check on Patient #4's medical record. S5RN indicated S6LPN, who had worked the weekend, had told him she had read the patient's orders and had not reported the patient was on LOS. S5RN was presented with a copy of the order fomr Patient #4's medical record and after review of the order, confirmed the patient had been placed on LOS on 06/13/19 and the order had not been discontinued. S5RN further confirmed the psychiatric nurse practitioner had written the order.

In an interview on 6/18/19 at 10:04 a.m. with S6LPN, she indicated she had worked on Thursday night (06/13/19) and Friday night (06/14/19). S6LPN confirmed she had also worked on Sunday night (06/16/19). S6LPN explained she had heard Patient #4 had been placed on LOS level of observation when she came back from the hospital on [DATE]. S6LPN indicated she had not known Patient #4 had remained on LOS on Sunday night (06/16/19) when she had worked that night. S6LPN indicated she had asked the charge nurse on Sunday night to help her with an order she had difficulty reading (the order for LOS and fall precautions) and she indicated the charge nurse had said the patient was not LOS. S6LPN reported she does chart checks every night, typically after 12:00 a.m., and follows-up when any questions come up regarding patient orders, usually by passing on the information in need of clarification to the day shift. S6LPN confirmed she had done a chart check on Patient #4's orders last night (06/17/19). S6LPN was asked if she had called the physician to clarify the order on Patient #4's chart that she couldn't read, and she replied, "No", due to the fact that she does chart checks around midnight. S6LPN indicated she typically only calls the physician for emergent issues.

In an interview on 06/18/19 at 10:44 a.m. with S2DON, she confirmed she was not aware Patient #4 was on LOS level of observation yesterday and today. S2DON indicated she generally knew all of the patients' levels of observation, because she reviewed the patient information board on the patient care unit. S2DON reviewed Patient #4's physician's orders and confirmed the LOS order was obvious in the patient's record. She further confirmed 24 hour chart checks had been performed daily (on the night shift) since 06/13/19, and the staff had failed to catch the LOS order to update the patient care board. S2DON acknowledged there was a nursing report communication issue if patient care staff did not know patients were on LOS level of observation. S2DON confirmed if an order is difficult to read, of if there is any question regarding an order, then the staff member reading the order should clarify the order. S2DON indicated clarifying a patient's order for level of observation, such as LOS, should be considered an emergent reason to call the physician for clarification.

In an interview on 06/18/19 at 11:25 a.m. with S19Psych, he confirmed Patient #4 had been placed on LOS observation level status post fall with injury for safety. S19Psych confirmed Patient #4 was still on LOS observation level on 06/18/19 and continued to need the increased level of supervision due to cognitive disabilities and continued risk for falls. S19Psych confirmed he had not been aware that Patient #4 was not being observed LOS, as ordered. S19Psych indicated Patient #4 should remain on LOS observation level as long as the patient was at risk for falling. He indicated he felt Patient #4 was an intermediate fall risk level.

Observation on 06/18/19 at 11:48 a.m. revealed the patient care board in the nursing station did not have Patient #4 listed as being on LOS (board had not been corrected after it had been brought to the attention of the nursing staff and administration that Patient #4 had not been being observed LOS as ordered since 06/13/19).

In an interview on 06/18/19 at 3:16 p.m. with S13MHT, she confirmed no one on the day shift had any idea Patient #4 was on LOS level of observation this morning (06/18/19).

3) Failure to ensure the patients' environment was free of safety risks and did not afford opportunities for self -injury/harm to others.


On 06/13/19 at 1:50 p.m. an observation was conducted of the patient care unit.
The following safety risks were observed during the observation:

1. Non-tamper resistant screws were noted in the metal plates of the patient doors and in the door handles which could be used for harm of self or others.

2. A silver "school type" desk top bell that had been taken apart, with the silver dome covering having been removed leaving the sharp metal parts inside the bell exposed, was noted on a patient bedside table.

In an interview on 06/13/19 at 1:50 p.m., during the observation, S2DON confirmed the screws were not tamper resistant and could pose a safety risk for patients. S2DON further confirmed the exposed metal parts of the bell could also pose a safety risk to patients.

On 06/18/19 at 7:40 a.m. an observation was made of a silver "school-type" desk type bell that had the silver part of the bell coming apart from the bottom of the bell that was secured to the bedside table. Further observation revealed sharp metal parts contained within the bell could be felt when the surveyor touched the exposed part of the bell. S2DON, present during the observation, confirmed the sharp parts of the bell could pose a safety risk to patients.
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 ensure patients were free from abuse and neglect as evidenced by:
1) Failure to ensure neglect of care was reported to LDH-HSS or a local law enforcement agency within 24 hours of the incident for 1 (#1) of 2 (#1, #3) sampled patients reviewed for abuse/neglect.; and
2) Failure to ensure appropriate corrective action was taken to address incidents of neglect as evidenced by failure to timely complete staff education regarding identified lapses in patient care for 2 (#1, #3) of 2 patient records reviewed for abuse/neglect from a total patient sample of 5 ( #1-#5).
Findings:


1) Failure to ensure neglect of care was reported to LDH-HSS or a local law enforcement agency within 24 hours of the incident:

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 the policy titled "Patient Falls", presented as a current policy by S2DON, revealed upon admission a fall risk assessment will be completed to identify patients at high risk for falls. Patients identified to be at high risk for falls will have a fall risk treatment plan implemented. Following a fall, the physician will be notified, and the post fall assessment form will be completed to insure identification of appropriate interventions for safety. Any fall with blunt force to the head and any unwitnessed fall require 24 hour neurological checks according to the following schedule: every 15 minutes for 1 hour; every 30 minutes for 2 hours; every 1 hour for 4 hours; every 4 hours for 16 hours.

Review of the hospital's admissions and discharges for the last 3 months (04/2019 - 06/2019) revealed Patient #1 had expired on [DATE].

Review of Patient #1's EMR revealed the patient was a [AGE] year old female with an admission date of [DATE] with admission diagnoses including Depression with suicidal ideation, Type 1 Diabetes, history of Cocaine abuse, and Chronic Kidney Disease. Further review revealed the patient had been found unresponsive in her bed on 05/07/19 at 06:51 a.m. and had been pronounced dead on 05/07/19 at 07:30 a.m.

Review of Patient #1's physician's orders, dated 04/30/19, revealed the following Accu-check and insulin orders: Accu-checks (capillary blood glucose testing) before meals TID (3 times a day), with sliding scale insulin and Accu-check at hour of sleep (no sliding scale insulin ordered for hour of sleep).
Levermir (long - acting insulin) 30 units sub q at hour of sleep.

Review of Patient #1's Diabetic Flow Record (Accu-check and Insulin Administration Record) revealed on 05/06/19 8:00 p.m.: Accucheck reading 294 mg/dL; Action taken: Levemir 30 units and Novolog 7 units was administered.

Review of the hospital's incident reports for the last 6 months (01/2019 - 06/2019) revealed a report indicating on 05/07/19 at 01:20 a.m. Patient #1 had an unwitnessed fall and had been found sitting on the floor, beside the bed, after having "rolled out of bed". Further review revealed S5RN had documented a quick head to toe assessment noting no apparent trauma. Additional review revealed no documented evidence that neurological checks had been initiated, as per hospital policy, for unwitnessed falls and no documented evidence the physician had been notified of the patient's fall.

Review of a Root Cause Analysis conducted to review Patient #1's death revealed the following, in part: Details of event: On 04/30/19 Patient #1 was admitted due to Depression with Suicidal Ideation.

05/07/19 01:20 a.m.: Patient "rolled out of bed", between the bed and the bedside table. She was awake, alert, and oriented. Patient denied hitting her head but complained of mild, dull pain to lower back. Head to toe assessment completed and patient assisted back to bed.

06:51 a.m.: nurses' note: MHT called for nurse to come to patient's room. Upon arrival to room, the patient was noted to be lying face-down on the bed and appeared to be sleeping. The nurse attempted to wake the patient up but the patient did not respond. She documented extremities felt cold. She checked for a pulse, but no pulse could be felt. No breath sounds. No vital signs were registering on the machine.

06:53 a.m.: charge nurse attempted to get blood pressure reading manually but was unsuccessful.

06:54 a.m.: CPR initiated by charge nurse. MHT called 911 and LPN went to get emergency cart.
07:01 First responders arrived and took over CPR from staff.

07:34 a.m.: Ambulance personnel notified physician by phone to update on patient's condition. Time of death called at 07:30 a.m.

Review of the hospital' s self-reports for 06/2018 - 06/2019 revealed no documented evidence that Patient #1's death on 05/07/19 at 07:30 a.m. had been reported to LDH-HSS as a death related to neglect of care.

In an interview on 06/17/19 at 10:38 a.m. with S2DON, she confirmed, after review of the patient's orders, that the staff should have been obtaining an Accu-check at hour of sleep and should have been administering Levemir insulin at hour of sleep with no sliding scale insulin coverage. S2DON indicated the nursing staff should have clarified the insulin order to verify whether or not sliding scale insulin was to be administered in addition to Levemir insulin at hour of sleep.

In an interview on 06/18/19 at 08:58 a.m. with S5RN, he confirmed he had been working on 05/07/19 at 01:20 a.m. and had completed the incident report for Patient #1's fall. S5RN confirmed he had seen Patient #1 sitting upright on the floor in her room, but had not called the physician to notify him of Patient #1's fall because he had not considered it a fall. He indicated he had completed an incident report after the fact, because S2DON told him he had to complete a report. He confirmed he had not checked Patient #1's blood sugar as part of his assessment of the patient post-fall and also confirmed he had not begun neuro-checks post fall (as indicated per policy in an unwitnessed fall) nor had he completed the hospital's post-fall assessment form or re-assessed the patient's fall risk.

In an interview on 06/18/19 at 1:25 p.m. with S1ADM, he confirmed he had not self-reported Patient #1's death to LDH-HSS. He indicated he had not realized the death should be reported. When the above-referenced events were described to him in order of occurrence, up to Patient #1's time of death, he acknowledged the patient's death should have been reported.

In an interview on 06/18/19 at 3:16 p.m. with S13MHT, she confirmed she had been assigned Patient #1 on 05/07/19. S13MHT indicated she had done her every 15 minute rounds starting at 06:00 a.m. S13MHT reported she had gone in at 6:00 a.m. to wake up Patient #1's room-mate. She reported she thought Patient #1 was on her side, but she was covered up, and her head was towards the window. She said at 06:15 a.m. the patient was in the same position she had been in at 06:00 a.m. S13MHT reported she never saw the patient awake from 06:00 a.m. - 06:51 a.m. S13 MHT reported she had not gone into the room and had only stood at the doorway when performing her every 15 minute rounds. S13MHT verified Patient #1 had been found unresponsive when it was time to take vital signs. She confirmed MHTs from the off-going shift had told her the patient had fallen and she said they pushed the bed against the wall so she wouldn't fall out of bed again.

2) Failure to ensure appropriate corrective action was taken to address incidents of neglect as evidenced by failure to timely complete staff education regarding identified lapses in patient care.

Patient #1
Review of the Root Cause Analysis conducted to review Patient #1's death revealed the following, in part:
Human factors relevant to outcome: 1. S13MHT stated she opened the door to the patient's room at 06:00 a.m., 06:15 a.m., 06:30 a.m., and 06:45 a.m. but did not go into the patient's room and up to the bed to check on the patient. She stated she thought the patient was sleeping.

Medication reconciliation/MD order completed on 04/30/19 indicated to continue Novolin R insulin 5 units 3 times a day before meals with a sliding scale. The sliding scale did not have documented parameters to alert nursing staff when to notify the physician of elevated blood glucose levels. MD was not notified of any blood glucose results. MD order was not followed for hour of sleep blood glucose check. Staff administered sliding scale insulin at hour of sleep on 05/04/19, 05/05/19, and 05/06/19 along with Levemir. Order was for blood glucose check at hour of sleep and administration of Levemir.

Review of staff training, presented as the current staff training regarding issues identified in the Root Cause Analysis for Patient #1, revealed all staff had not been trained as of 06/18/19 (over six weeks after the patient's death).

In an interview on 06/18/19 at 1:25 p.m. with S1ADM, he confirmed some, but not all hospital staff had been trained regarding lapses in Patient #1's care that were identified when the Root Cause Analysis had been done to review the patient's death. S1ADM confirmed video recordings of the shift when Patient #1 expired had not been reviewed as part of the Root Cause Analysis. He reported staff had been traumatized after the patient's death and many of them had taken off, not returning to work for 2-3 days. S1ADM reported staff education had begun around 05/30/19 when staff came in to pick-up their checks. S1ADM indicated he had not known the magnitude of the issues with patient monitoring and with issues related to insulin administration. S1ADM reported video monitoring was being conducted for 1 hour one time a month as part of the corrective action being taken by the hospital related to Patient #1's death.

In an interview on 06/18/19 at 2:18 p.m. with S8CCN, she confirmed she had done the Root Cause Analysis to evaluate Patient #1's death. S8CCN reported Patient #1 had expired on [DATE], and she indicated she had probably started the Root Cause Analysis the following week. S8CCN indicated she had completed analysis last week in order to review the findings at the Medical Staff meeting scheduled for 06/18/19.

Patient #3
Review of the hospital's self-report to LDH - HSS revealed an alleged physical abuse was reported by S1ADM of an incident on the night shift of 05/02/19 with a discovery date of 05/07/19. The incident was that after discharge from the hospital the patient complained of pain to the arm when he returned to the nursing home. Upon review of x-rays it was determined he had a fracture to his arm. The hospital's final report revealed that it was determined that no physical abuse had occurred at the hospital by any member of the night shift team. However, it was determined that due to the patient's combative incident with staff and the transferring of the patient from the bed to the mat on the floor, it was possible that the fracture occurred at this time. Due to the hospital's increasing geriatric population, it was determined that mandatory education regarding proper transfers and positioning of geriatric patients will be held at the hospital to help eliminate incidents such as this.

Review of the education provided to staff on 05/30/19 that included proper transfer of patients, proper communication of patients, Q 15 monitoring, medication errors and proper reporting to leadership revealed no documented evidence of the name and credentials of the person who provided the training and no documented evidence that the RN, LPN, and MHTs involved in the transfer of the patient from the bed to the mattress on the floor attended the in-service. This was confirmed by S2DON on 06/17/19 at 2:10 p.m. who also confirmed that S21RN, a staff RN, provided the training.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on record review and interview, the hospital failed to ensure the use of restraint was in accordance with a written modification to the patient's plan of care as evidenced by failure of the nursing staff to identify a physical hold of a patient as a restraint and to revise the patient's plan of care to include the use of restraint for 1 (#3) of 2 (#3, #5) patient records reviewed for restraint from a sample of 5 patients.
Findings:

Review of the policy titled "Restraints and Seclusion Use", presented as a current policy by S2DON, revealed restraint was defined as any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. A Physical Hold is considered a restraint and requires adherence to the restraint policy and procedure. When restraint or seclusion is used, there must be documentation in the patient's medical record of revisions to the plan of care.

Review of the hospital's restraint and seclusion log for April 2019 and May 2019 revealed no documented evidence that any patient had been placed in restraint or seclusion.

Review of a hospital self-report to LDH - HSS, submitted by S1ADM, revealed the hospital was notified on 05/07/19 that after discharge from the facility on 05/02/19 Patient #3 complained of pain to the arm when he returned to the nursing home. Further review revealed upon review of x-rays it was determined he had a fracture to his arm. Further review revealed S1ADM obtained written statements from S3MHT, S4MHT, S5RN, S6LPN, and S7MHT (staff who worked the night shift of the incident of combative behavior and the need to transfer Patient #3 from the bed to a mat on the floor).

Review of the written statement documented by S3MHT on 05/08/19 revealed the following: while doing a 15 minute check, Patient #3 was in need of incontinent care. S4MHT and S3MHT gathered supplies and changed the patient. Patient #3 attempted to get out of bed again. We didn't want to see him fall, so we moved his wheelchair and placed a mattress on the floor next to his bed. Patient #3 became violent and began to swing his right arm and kick at S4MHT and S3MHT. S4MHT caught his right wrist when he swung and got control and put it by his side. I took control of the legs as Patient #3 continued to try to swing and kick. He began screaming which brought S5RN and S6LPN into the room. S5RN took control of the right wrist from S4MHT and began to talk with the patient.

Review of Patient #3's EMR revealed no documented evidence that the incident described above was included in Patient #3's medical record. There was no documented evidence that his nursing care plan was revised to include the use of restraint.

In an interview on 06/18/19 at 8:30 a.m., S4MHT indicated Patient #3 couldn't do anything with his left arm and left leg due to "brain injury." When Patient #3 grabbed her wrist, she "grabbed his right wrist and removed his hold on her and placed his hand on the bed. She indicated she just held his wrist (demonstrated with her hand wrapped around her wrist). She didn't think they taught about holds in their crisis prevention education. She confirmed when she held his wrist down, she was keeping him from moving. When asked by the surveyor if she's holding someone to keep them from moving, is that a means of a restraint. She answered "yes." She indicated they do a yearly training on restraints and seclusion.

In an interview on 06/18/19 at 8:57 a.m., S5RN indicated holding Patient #3 down was a physical hold, but it wasn't for a length of time. He indicated it "doesn't say one way or the other" whether a hold for a short period of time was a restraint. He indicated being held could be a physical hold, but it's "a matter of interpretation isn't it?" When told there was no documentation of the move of the patient and the need to hold in Patient #3's EMR, he indicated it was a routine safety issue, and he didn't document it.

In an interview on 06/18/19 at 9:57 a.m., S3MHT indicated he would refer to the statement he wrote, and any further questions he would rather refer to his lawyer.

In an interview on 06/18/19 at 10:04 a.m., S6LPN indicated S3MHT, S5RN, and S4MHT were in the room a while before S6LPN went to check, once she heard loud talking. When she entered the room she saw S3MHT and S5RN trying to talk to Patient #3 to try to reorient him; she didn't observe them holding the patient. While she was in the room, she indicated she didn't observe anyone holding the patient.

In an interview on 06/18/19 at 10:24 a.m., S7MHT indicated she was in the hall with a patient. When she went to Patient #3's door, the staff were trying to help him, and he started yelling and cursing. She indicated she couldn't say if staff were holding him.

In an interview on 06/18/19 at 10:40 a.m., S2DON confirmed holding wrists and legs is a physical hold, and it's a restraint. She offered no comment or explanation when informed there was no documentation in Patient #3's EMR of restraint use, an order for a physical hold, and the care plan was not revised for restraint use.

In an interview on 06/18/19 at 1:10 p.m., S2DON indicated on the day of discharge Patient #3 said his arm didn't feel well. She further indicated when she asked if he wanted to go the hospital, he said no, he wanted to go to the nursing home. She indicated she was never told the patient was restrained.

In an interview on 06/18/19 at 1:18 p.m., S1ADM indicated he didn't know when staff held a patient to keep from moving that it was considered a restraint.

In an interview on 06/18/19 at 2:15 p.m., S8CCN confirmed there was no analysis done of the chart of the patient who had a fracture upon discharge.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on record review and interviews, the hospital failed to ensure the use of restraint was in accordance with the order of a physician or other LIP who was responsible for the care of the patient as evidenced by having no documented evidence of a physician's order for a physical hold (restraint) used to restrain Patient #3 on 05/02/19 for 1 (#3) of 2 (#3, #5) patient records reviewed for use of restraint from a sample of 5 patients.
Findings:

Review of the policy titled "Restraints and Seclusion Use", presented as a current policy by S2DON, revealed orders for the use of restraint or seclusion must be given by an MD or Nurse Practitioner prior to their use. In an Emergency Situation, an RN can initiate the use of restraint or seclusion, but the attending physician must be consulted as soon as possible (within a few minutes).

Review of a hospital self-report to LDH - HSS, submitted by S1ADM, revealed the hospital was notified on 05/07/19 that after discharge from the facility on 05/02/19 Patient #3 complained of pain to the arm when he returned to the nursing home. Further review revealed upon review of x-rays it was determined he had a fracture to his arm. Further review revealed S1ADM obtained written statements from S3MHT, S4MHT, S5RN, S6LPN, and S7MHT (staff who worked the night shift of the incident of combative behavior and the need to transfer Patient #3 from the bed to a mat on the floor).

Review of the written statement documented by S3MHT on 05/08/19 revealed the following: while doing a 15 minute check, Patient #3 was in need of incontinent care. S4MHT and S3MHT gathered supplies and changed the patient. Patient #3 attempted to get out of bed again. We didn't want to see him fall, so we moved his wheelchair and placed a mattress on the floor next to his bed. Patient #3 became violent and began to swing his right arm and kick at S4MHT and S3MHT. S4MHT caught his right wrist when he swung and got control and put it by his side. I took control of the legs as Patient #3 continued to try to swing and kick. He began screaming which brought S5RN and S6LPN into the room. S5RN took control of the right wrist from S4MHT and began to talk with the patient.

In an interview on 06/18/19 at 10:40 a.m., S2DON confirmed holding wrists and legs is a physical hold, and it's a restraint. She offered no comment or explanation when informed there was no documentation in Patient #3's EMR of restraint use and an order for a physical hold.