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.

RIVER PLACE BEHAVIORAL HEALTH 500 RUE DE SANTE LA PLACE, LA 70068 May 15, 2019
VIOLATION: INSTITUTIONAL PLAN AND BUDGET Tag No: A0073
Based on record review and interview, the hospital failed to ensure the institutional plan provided for capital expenditures for at least a 3-year period, including the year in which the operating budget was applicable, as evidenced by failure to have documented evidence that a 3-year capital expenditure plan had been developed for the hospital.
Findings:

Review of the "Capital Expenditure Budget ... For year Ending 12/31/19", presented by S1CEO as the current 3-year capital expenditure plan, revealed no documented evidence that plan had been developed for a 3-year period.

In an interview on 05/14/19 at 3:10 p.m., S1CEO confirmed the capital expenditure budget was not developed for a 3-year period.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on observation and interview, the hospital failed to ensure medical records were properly filed and retained as evidenced by failure to ensure 20 patient medical records waiting to be scanned into the electronic medical record system were protected from potential water damage if the hospital's sprinkler system became activated as observed on 05/14/19 at 10:50 a.m.
Findings:

Observation in medical record room on 05/14/19 at 10:50 a.m. revealed 20 patient records that had not been scanned were stored on the table to the right of the entrance door. Further observation revealed there was no protection of these medical records from potential water damage if the sprinkler system became activated.

In an interview on 05/14/19 at 10:50 a.m. during the above observation, S3HIMD confirmed the 20 medical records had no protection from potential water damage.
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital's governing body failed to ensure that the medical staff was accountable to the governing body for the quality of care provided to the patients. This deficient practice was evidenced by:
1) Failure to ensure patient levels of observation were not ordered by the physician (prior to the patient's arrival at the hospital) based on reported patient status information received from the referring hospitals and prior to having had the patient's suicide risk assessed for 4 (#2, #4, #5, #11) of 8 (#1 - #8) patient records reviewed for ordered levels of observation from a sample of 11 patients and
2) Failure to ensure the pronouncement of a patient's (#2) death, by a physician or the Coroner, was documented in the patient's medical record for 1 (#2) of 2 ( #2, #R2) sampled patient death records reviewed from a sample of 11 patients.
Findings:

1) Failure to ensure patient levels of observation were not ordered by the physician (prior to the patient's arrival at the hospital) based on reported patient status information received from the referring hospitals and prior to having had the patient's suicide risk assessed:

Review of the policy titled" Suicide risk Assessment", presented as a current policy by S1CEO, revealed SRAs are completed for all patients and include assessment of specific factors and features that may increase or decrease risk for suicide. The admitting staff will complete the initial SRA during the initial admission (intake) process. If any SRA renders information that has potential to immediately affect patient safety and/or results in a score of Moderate, High, or Severe, the psychiatrist and Director of Nursing/House Supervisor shall be contacted immediately. This applies to the initial and all subsequent SRAs. The psychiatrist shall order the appropriate level of observation based on results of the SRA and additional patient specific information based on previous knowledge of the patient or as reported by staff. Documentation of consult and subsequent physician orders are noted by the nurse in the patient chart.

Review of the policy titled "Observations, Patient", presented as a current policy by S1CEO, revealed level of observation can be increased by the RN any time there is a concern but only a psychiatric practitioner may decrease the level. If an RN implements or increases a level of observation, they must also contact the attending psychiatric provider for an order as soon as is reasonably possible. Documentation of the observation is to be completed once the patient has been observed. It is not permissible to complete in advance and or to back fill time frames that were not completed in a timely manner. All patients with a "Severe" rating on the most recent SRA must be on one-to-one observation.

Patient #2
Review of Patient #2's hospital record revealed the patient had been PEC'd on 05/07/19 at 6:58 p.m. due to being suicidal, violent, dangerous to self, and unable to seek voluntary admission. Further review revealed the patient's history of present illness on the PEC indicated the patient was violent, angry, with suicidal ideation. Additional review revealed the physical findings were Bipolar, Depression, Substance Abuse, and the patient's mental condition was described as patient is crying and threatened suicide yesterday.

Further review of Patient #2's electronic medical record revealed the following ED nursing note entries:
05/07/19 at 8:04 p.m.: Pt. states to Charge RN, "I don't care how much treatment I get, I have been through this for 6 years, why don't people understand I just want to die."
05/07/19 at 8:30 p.m.: Pt. significant other arrived to check on patient.... He reports patient has a previous history of 8 overdoses in the past and had been admitted to psych facility before in Baton Rouge. He reports she has an ongoing history of depression.

Review of Patient #2's admission orders revealed the orders had been obtained on 05/07/19 at 11:37 p.m., 1 hour and 48 minutes prior to the patient's arrival. Further review revealed the patient had been placed on check every 15 minute psych observation (routine level of observation) with suicide precautions. The orders had been obtained by S22RN (intake staff) from S4Psych.

Review of Patient #2's transport trip sheet documentation revealed Patient #2 had arrived at the hospital on [DATE] at 01:25 a.m.

Further review of Patient #2's electronic medical record revealed the patient's SRA had been performed on 05/08/19 at 02:05 a.m., and S7RN (nurse who received the patient on the unit) had received notification on 05/08/19 at 02:20 a.m. that the patient had a medium suicide risk (score of 27).

Patient #4
Review of Patient #4's medical record revealed he was admitted on [DATE] at 9:20 p.m. with a diagnosis of Suicidal Ideation. Further review revealed he was PEC'd on 05/09/19 at 3:28 p.m. due to threatening to kill hospital staff and himself, being intoxicated, being assessed as + for SI and HI, being dangerous to self and others, and being gravely disabled. He was CEC'd on 05/10/19 at 6:20 a.m. due to being suicidal and homicidal, dangerous to self and others, and gravely disabled.

Review of Patient #4's physician orders revealed an order to admit signed by S30NP on 05/10/19 at 6:18 p.m., 3 hours 2 minutes prior to his arrival at the hospital. Further review revealed his SRA was conducted on 05/10/19 at 9:43 p.m. by S22RN who notified S27Psych of a SRA score of 38. There was no documented evidence that Patient #4's admission was based on an assessment performed at the admitting hospital and not by information received from the transferring hospital.

Patient #5
Review of Patient #5's medical record revealed he was admitted on [DATE] at 5:38 p.m. with a diagnosis of Depression with SI.

Review of Patient #5's physician orders revealed an order to admit by S27Psych on 05/12/19 at 3:28 p.m., 2 hours 58 minutes prior to his arrival at the hospital. Further review revealed his SRA was conducted on 05/12/19 at 6:26 p.m. by S10ID and was scored as 28 (medium) and reported to the Nurse Supervisor at 6:21 p.m. There was no documented evidence the physician was notified as required by hospital policy. There was no documented evidence that Patient #5's admission was based on an assessment performed at the admitting hospital and not by information received from the transferring hospital.

Patient #11
Review of Patient #11's admission orders revealed they had been written on 05/13/19 at 11:42 p.m. by S30NP with an admitting diagnosis of Depression. Further review revealed the SRA was not completed until 05/14/19 at 1:06 a.m. (1 hour 11 minutes after the patient arrived at the hospital) with a score of 39 (medium risk). Review revealed current symptoms and complaints were documented at 1:25 a.m. and the admission vital signs were documented at 1:41 a.m.

In an interview on 05/14/19 at 08:40 a.m. with S10ID, she reported patient packets from referring hospitals were reviewed for criteria, and intake staff would then call the referring facility/ED to accept the patient. S10ID further reported intake staff reviewed the referral information while waiting for new patients to arrive. S10ID confirmed physicians were ordering levels of observation, as well as other admission orders, prior to patient arrival.

In an interview on 05/14/19 at 09:35 a.m. with S1CEO, he verified the admission orders should have been based on the assessment of staff at this hospital.

In an interview on 05/15/19 at 06:10 a.m. with S6LPN, she confirmed patient admit orders had been obtained prior to the patient arriving. S6LPN indicated at that point (prior to patient arrival), the level of observation was based upon information from the referring hospital because the patient had not arrived and had not had a SRA at that time.

In an interview on 05/15/19 at 12:45 p.m., S22RN indicated she didn't remember Patient #4. She indicated sometimes the patient may be accepted on the day shift, and the NP orders the admit. She further indicated on the night shift they call the doctor with a report of what's reported from the transferring hospital and what's been faxed, and they then call the doctor after the suicide risk assessment is done to get orders for the observation level.

In an interview on 05/15/19 at 1:35 p.m. with S4Psych, he confirmed he was called for patient admission orders prior to the patient's arrival. S4Psych reported generally intake personnel received a patient referral packet, called the provider on call, and presented them with enough information to determine if the patient could be accepted. He reported at that point basic admission orders were given, prior to patient arrival. S4Psych indicated basic admit orders included admit to unit, PRNs for extreme agitation, and routine every 15 minute monitoring. S4Psych reported the understanding is that the patient's level of observation can be changed by the nurse, and his expectation is that they call him, as well, if the patient's level of observation needs to be changed. He reported intake only told him what Patient #2's PEC documentation had indicated, and he said he was told the patient was angry. S4Psych further reported when he saw the individual nurses' notes indicating Patient #2 was telling the ED staff she wanted to die, he indicated that certainly would have led to a need for a higher level of observation and a need for more staff supervision.

2) Failure to ensure pronouncement of a patient's (#2) death, by a physician, was documented in the patient's medical record:
Review of La. R.S. 9:111. Definition of death revealed, in part, "... A. A person will be considered dead if in the announced opinion of a physician, duly licensed in the state of Louisiana based on ordinary standards of approved medical practice, the person has experienced an irreversible cessation of spontaneous respiratory and circulatory functions...". Added by Acts 1976, No. 233, 1; Acts 2001, No. 317, 1; Acts 2010, No. 937, 1, eff. July 1, 2010.

Review of the hospital policy titled,"Death of a Patient", revealed in part: Procedure: 2.0 The attending physician/designee or Coroner pronounces the patient dead. 5.0 Document recorded time of death, doctor/Coroner pronouncing death, disposition of body.

Review of the hospital's Medical Staff Bylaws, presented as current by S1CEO, revealed the following, in part; 19.0 Patient Death and Autopsy: In the event of a patient's death, the County Coroner will be notified by hospital staff. Completion of death certificates shall be governed by the applicable State regulations and reporting requirements. The attending physician, in collaboration with the coroner, shall request an autopsy in all cases of unusual deaths.
Further review of the Medical Staff Bylaws revealed no documented evidence that the hospital's Medical Staff had set forth guidelines indicating who could pronounce death.

Review of Patient #2's electronic medical record revealed the following nurses' note entry dated 5/8/19:
06:05 a.m. Tech came to nursing station to report that patient was hanging from the door. I went to patient's room, removed the sheet from around the top of the door. I pulled the sheet from around patient's neck. Patient didn't respond. I laid patient down on the floor and began CPR, utilized crash cart that was brought by staff. CPR was continued until EMS arrived and took over.
06:14 a.m.: EMS and police arrived. EMS took over CPR.
06:51 a.m.: EMS pronounced death.

Additional review of Patient #2's electronic medical record revealed no documented evidence that a physician, or the Coroner, had pronounced the patient's death. S3HIMD reported the Coroner pronounces patients' deaths and there should have been documentation from the Coroner in the patient's medical record. S3HIMD, assisting with medical record navigation, confirmed, after review of the patient's entire electronic medical record on 05/14/19 at 3:09 p.m., that there was no documentation indicating a physician or the Coroner had pronounced Patient #2's death.

In an interview on 05/15/19 at 04:05 a.m. with S7RN, she reported she had been working the night Patient #2 had expired and indicated she had performed CPR. S7RN was asked if the Coroner had pronounced Patient #2 and she replied, "No, I think EMS pronounced Patient #2."
VIOLATION: CARE OF PATIENTS - PRACTITIONERS Tag No: A0066
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the governing body failed to ensure policies and by-laws were established that allowed NPs to admit patients as evidenced by having a NP's collaborative agreement allowing the NP to admit patients but not including the admission of patients in the NP's delineation of privileges for 1 (S30NP) of 2 (S24NP, S30NP) NP credentialing files reviewed for privilege to admit patients. Patient #4 was admitted on [DATE] at 6:18 p.m. by S30NP, and Patient #11 was admitted on [DATE] at 11:42 p.m., when S30NP didn't have privileges to admit patients.
Findings:

Review of S30NP's credentialing file, presented for review by S13AA, revealed her collaborative practice agreement with S29Psych stated that she would collaborate with the physician in continuing to provide care for patients admitted by herself.

Review of S30NP's "Allied Staff Delineation of Privileges", presented for review by S13AA, revealed she was privileged to evaluate, treat, manage medication, and write orders within her scope of license to patients 13 years and above. There was no documented evidence that privilege to admit patients to the hospital had been requested by S30NP and approved by the governing body on 11/02/18.

In an interview on 05/14/19 at 1:00 p.m., S13AA confirmed S30NP's delineation of privileges did not include the privilege to admit patients.

In an interview on 05/15/19 at 11:00 a.m., S30NP indicated she is a psychiatric mental health nurse practitioner. She indicated she didn't realize she couldn't admit patients. She further indicated she usually writes the order, and the psychiatrist co-signs it when they do the psych evaluation. She offered no explanation for the privilege to admit patients not being requested.
VIOLATION: CONTRACTED SERVICES Tag No: A0084
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the governing body failed to ensure services performed under a contract were provided in a safe and effective manner as evidenced by failure of the hospital to evaluate the contracted services to assure they were being provided in a safe and effective manner.
Findings:

Review of the list of "Contracts/Agreements 2018 - 2019", presented as the current list of hospital contracts by S1CEO, revealed the hospital had 32 contracts.

Review of the Certificate of Liability Insurance for Company A, the provider of contracted x-ray services, revealed the coverage had expired on [DATE].

Review of the contract with Company B, the company contracted to provide one-way transportation for PEC'd or CEC'd patients, revealed the provider would maintain automobile liability insurance, worker's compensation, and general liability insurance coverage. Further review revealed no documented evidence of current coverage for automobile liability insurance, worker's compensation, and general liability insurance.

No documented evidence of an evaluation of contracted services was presented for review during the survey.

In an interview on 05/15/19 at 3:35 p.m. with S1CEO and S2CNO present, S1CEO confirmed they had not been evaluating contracted services.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on record review and interview, the hospital failed to ensure the hospital wide QAPI program set priorities aimed at performance improvement activities that focused on high-risk, high-volume, or problem-prone areas that affected health outcomes, patient safety, and quality of care, and failed to ensure actions were measured, tracked and sustained. This deficient practice was evidenced by failure of the hospital wide QAPI program to have QAPI data for November 2018 to February 2019.
Findings:

Review of the hospital's QAPI plan, presented as current, revealed no QAPI data for for November 2018 to February 2019.

In an interview on 05/15/19 at 3:35 p.m. with S1CEO and S2CNO, they reported the hospital had not had a staff member to serve as QAPI Director for several months. S1CEO indicated when the former QAPI Director left there was no way to access any QAPI data from for November 2018 to February 2019. S1CEO reported none of the incident reports had been entered into the system electronically, and files had been wiped from the system. S1CEO reported they were having to rebuild the QAPI program and had started that process in March 2019.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observations, record reviews, and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by having personal hygiene items and an unidentifiable, unlabeled container with a creamy substance in it in the patient rooms that were considered contraband as observed during a tour of patient units on 05/13/19 from 9:05 a.m. through 10:25 a.m.
Findings:

Observations during a tour of the patient units on 05/13/19 from 9:05 a.m. through 10:25 a.m. with S18BOD present revealed the following contraband items in patient rooms:
Room "c" - a comb on the shelf next to the bed nearest the door;
Room "a" - an unidentifiable, unlabeled plastic medicine cup at the bedside with a whitish substance (cream) in it;
Room "b" - tray of toiletries in the bathroom on the sink ledge;
Room "d" - bottle of body wash on the shower floor;
Room "e" - toothbrush and deodorant on the shelf next to the bed nearest the door; the bathroom had a toiletry bin on the floor; 2 combs and toothpaste were on the sink ledge;
Room "g" - body wash on the toilet edge;
Room "h" - body wash on the bathroom floor and deodorant on the shelf in the patient's room;
Room "j" - body lotion on the bedside table.
The above observations were confirmed by S18BOD at the time of the observation.

Review of the policy titled "Contraband", presented as a current policy by S1CEO, revealed upon admission, a thorough search will be made of the patient, purses, pockets, luggage, and belongings. Staff will consider the following to be contraband: any item deemed unsafe by any staff member, cosmetic containers, mouthwash/gel toothpaste containing alcohol, aerosols, and grooming equipment. There was no documented evidence that the policy addressed at what time a room search should be done for the presence of contraband.

Review of the "MHT Environmental Rounds" for Unit 2000, presented by S16MHTS, revealed the form had the heading of "This completed form must be submitted DAILY to the MHT Supervisor." Further review revealed the form was dated 05/13/19 and had a signature on the line following "P.M. Shift" and "Nurse." The form included a check for the following: patient rooms are free of clutter and harmful objects (perform room search) ... no contraband in room, all personal item baskets out of room if not activities of daily living time, bathrooms clean and plumbing is working, unit free of common items that may be used to harm self or others... There was no documented evidence of a signature by staff for the A.M. Shift, and there were no check marks in the column labeled as "7 AM" indicating that a room search had not been conducted or had not been documented.

Review of the "MHT Environmental Rounds" for the Dual Unit, presented by S19MHT, revealed the form had the heading of "This completed form must be submitted DAILY to the MHT Supervisor." Further review revealed the form was not dated, had check marks in the column labeled "7 AM" indicating that the rounds had been conducted, and had a signature by a MHT for the A.M. Shift, a MHT for the P.M. Shift, and a RN.

In an interview on 05/13/19 at 10:25 a.m., S21RN (on Unit 2000) indicated I "have nothing to do with environmental rounds" for contraband. She indicated MHTs are assigned, and she signs after the rounds were done. She further indicated if the MHTs don't bring the round form to her by lunch time, she'd ask about it. She indicated the checks were usually done by about 9:00 a.m.

In an interview on 05/13/19 at 9:26 a.m., S18BOD indicated S2CNO told her she (S2CNO) didn't know what the substance was in the unlabeled cup in Room "a", but looking at the medications the patient in that room is on and talking to the nurse, she (S2CNO) thinks it's Bactroban ointment. S15LPN indicated the only ointment the patient is on is Bactroban, and she saw the patient apply it to her arm at the medication window, and she (S15LPN) didn't give the patient a cup with ointment. S15LPN further indicated she didn't know who gave the cup to the patient, but it shouldn't be in the room

In an interview on 05/13/19 at 9:39 a.m., S18BOD asked S2CNO about the toiletries found in Room "b", and S2CNO told S18BOD the toiletries shouldn't be in patients' rooms. During the interview S16MHTS indicated when the MHTs do room checks, they check for contraband. He indicated they do the check during shift change and after lunch. He indicated the rooms should have been checked during shift change this a.m. He further indicated patients take showers between 6:00 a.m. to 6:45 a.m., so no kits with toiletry items should still be in patient rooms.

In an interview on 05/13/19 at 9:45 a.m., S16MHTS presented the contraband log for Unit 2000 that had no checks documented. During the interview S17SC indicated the staff told him the room checks had not been done as of the time of this interview, because they had a few patients who woke up late. S16MHTS indicated he wasn't made aware that the checks had not been done until the time of this interview. He further indicated staff told S17SC, and S17SC didn't tell him (S16MHTS). S16MHTS indicated patients shouldn't have a comb in the room.

In an interview on 05/13/19 at 10:05 a.m., S19MHT indicated she did environmental rounds with the night shift MHT on the Dual Unit, and there were no toiletry items in any rooms. She further indicated after breakfast a toothbrush and toothpaste may be in the room. She indicated they had 2 patients "cutting up" this a.m., and that "throws them off to check rooms." She indicated another MHT did the environmental check with her but didn't sign the sheet. S19MHT confirmed she didn't sign the rounds sheet yet.

In an interview on 05/13/19 at 10:10 a.m., S20RN,Charge Nurse, when asked about her role as charge nurse with MHTs doing contraband checks, indicated the MHTs usually do the room checks after lunch, and they bring any concerns to her attention at that time. She further indicated the morning rounds are with the 2 MHTs, but she doesn't sign off until the end of her shift in the evening. She confirmed she doesn't check to assure that contraband checks were done and indicated "that's the tech's job."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on record review and interview, the hospital failed to ensure the use of restraints was in accordance with a written modification to the patient's plan of care for 2 (#R4, #R6) of 2 patients sampled for restraint/manual holds out of a total patient sample of 11.
Findings:

Review of the hospital policy titled, "Restraint" revealed in part: Restraint may only be used for the management of violent or self-destructive behavior that jeopardizes the immediate safety of the patient, a staff member, or others after less restrictive interventions are ineffective or ruled out. Definitions: Physical Restraint: Physical restraint includes manual measures approved by CPI to limit or restrict body movement. Holding a patient who is not cooperative with receiving a medication through injection and/or approved CPI holds is considered a physical restraint. Procedure: 12. The treatment plan shall be reviewed and revised following the first episode of restraint to include measures to prevent recurrence. Additional review of the treatment plan, with revisions as indicated, will occur if the patient is restrained on more than one occasion.

Patient #R4
Review of Patient #R4's electronic medical record revealed on 04/24/19 the patient had been placed in a restraint hold and administered an IM PRN after the patient had attempted to attack staff in the hallway.

Further review revealed the following entry: 04/24/19 6:58 p.m.: Pt. threw shoes off when MHTs directed her to her room. Pt. then jumped to attack MHT. CPI enforced, pt. placed in physical hold.

Additional review of Patient #R4's electronic medical record, assisted by navigator S3HIMD, revealed no documented evidence that the patient's treatment plan had been revised after the above referenced physical holds. S3HIMD verified there were no treatment plan revisions for the above referenced physical holds during the treatment plan review on 05/14/19 at 3:05 p.m.

Patient #R6
Review of Patient #R6's electronic medical record revealed the following entry:
04/27/19 7:30 p.m.: Patient pacing hallway. He became verbally aggressive stating someone ran into him on purpose. Multiple attempts to redirect him failed. Threatening staff, yelling at them. Placed in physical hold to administer IM injection and released after injection.

Additional review of Patient #R4's electronic medical record, assisted by navigator S3HIMD, revealed no documented evidence that the patient's treatment plan had been revised after the above referenced physical holds. S3HIMD verified there were no treatment plan revisions for the above referenced physical holds during the treatment plan review on 05/14/19 at 3:18 p.m.

In an interview on 05/14/19 at 3:55 p.m. with S2CNO, she confirmed staff manual holds were physical restraints and the treatment plans should have been revised after use of the holds.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on record review and interview, the hospital failed to ensure the use of restraint was in accordance with the order of a physician or other licensed independent practitioner who was responsible for the care of the patient and authorized to order restraint or seclusion, by hospital policy, in accordance with State law. This deficient practice is evidenced by psychiatric patients (#R4,#R6) being placed in physical holds without a physician/LIP order for 2 (#R4, #R6) of 2 patients sampled for restraint/manual holds out of a total patient sample of 11.
Findings:

Review of the hospital's Medical Staff Bylaws, presented as current by S1CEO, revealed the following, in part: 9.2: Restraints or Seclusion used for Emergency Behavior Management Reasons: Orders: A practitioner must order restraint or seclusion , the use of which is limited to emergency situations. If a practitioner is not immediately available, a specifically trained registered nurse may initiate restraints or seclusion based on an appropriate assessment of the patient. A practitioner will be notified as soon as possible thereafter to obtain an order.

Review of the hospital policy titled, "Restraint" revealed in part: Policy: Restraint may only be used for the management of violent or self-destructive behavior that jeopardizes the immediate safety of the patient, a staff member, or others after less restrictive interventions are ineffective or ruled out. Restraint may only be ordered by the attending physician or covering practitioner. Definitions: Physical Restraint: Physical restraint includes manual measures approved by CPI to limit or restrict body movement. Holding a patient who is not cooperative with receiving a medication through injection and/or approved CPI holds is considered a physical restraint.

Patient #R4
Review of Patient #R4's electronic medical record revealed on 04/24/19 the patient had been placed in a restraint hold and administered an IM PRN after the patient had attempted to attack staff in the hallway.

Further review revealed the following entry:
04/24/19 6:58 p.m.: Pt. threw shoes off when MHTs directed her to her room. Pt. then jumped to attack MHT. CPI enforced, pt. placed in physical hold.

Additional review of Patient #R4's electronic medical record, assisted by navigator S3HIMD, revealed no documented evidence of physician/LIP orders for the above referenced physical holds. S3HIMD verified there were no physician/LIP orders for the above referenced physical holds during the record review on 05/14/19 at 3:05 p.m.

Patient #R6
Review of Patient #R6's electronic medical record revealed the following entry:
04/27/19 7:30 p.m.: Patient pacing hallway. He became verbally aggressive stating someone ran into him on purpose. Multiple attempts to redirect him failed. Threatening staff, yelling at them. Placed in physical hold to administer IM injection and released after injection.

Further review of Patient #R6's electronic medical record, assisted by navigator S3HIMD, revealed no documented evidence of physician/LIP orders for the above referenced physical hold. S3HIMD verified there were no physician/LIP orders for the above referenced physical holds during the record review on 05/14/19 at 3:18 p.m.

In an interview on 05/14/19 at 3:55 p.m. with S2CNO, she confirmed staff manual holds were physical restraints and further confirmed a physician/LIP order should have been obtained for the holds.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
Based on record review and interview, the hospital failed to ensure a 1 hour face-to-face medical and behavioral evaluation was performed by a physician, licensed independent practitioner, or a trained registered nurse for a patient placed in restraints for the management of violent or self-destructive behavior for 2 (#R4, #R6) of 2 patients sampled for restraint/manual holds out of a total patient sample of 11.
Findings:

Review of the hospital policy titled "Restraint", revealed in part: Restraint may only be used for the management of violent or self-destructive behavior that jeopardizes the immediate safety of the patient, a staff member, or others after less restrictive interventions are ineffective or ruled out. Definitions: Physical Restraint: Physical restraint includes manual measures approved by CPI to limit or restrict body movement. Holding a patient who is not cooperative with receiving a medication through injection and/or approved CPI holds is considered a physical restraint. Procedure: 8. A practitioner or trained nurse shall conduct an in-person evaluation of the patient within 1 hour of initiation of restraint to assess physical and psychological status. The in-person evaluation includes the patient's immediate situation, reaction to the intervention, medical and behavioral condition, and the need to continue or terminate the intervention. The evaluation must be completed even if the physical restraint has been discontinued prior to the in-person evaluation.

Patient #R4
Review of Patient #R4's electronic medical record revealed on 04/24/19 the patient had been placed in a restraint hold and administered an IM PRN after the patient had attempted to attack staff in the hallway.

Further review revealed the following entry:
04/24/19 6:58 p.m.: Pt. threw shoes off when MHTs directed her to her room. Pt. then jumped to attack MHT. CPI enforced, pt. placed in physical hold.

Additional review of Patient #R4's electronic medical record, assisted by navigator S3HIMD, revealed no documented evidence of one hour in-person face to face evaluations of the patient after the above referenced physical holds. S3HIMD verified there were no documented one hour in-person face to face evaluations of the patient after the above referenced physical holds during the record review on 05/14/19 at 3:05 p.m.

Patient #R6
Review of Patient #R6's electronic medical record revealed the following entry:
04/27/19 7:30 p.m.: Patient pacing hallway. He became verbally aggressive stating someone ran into him on purpose. Multiple attempts to redirect him failed. Threatening staff, yelling at them. Placed in physical hold to administer IM injection and released after injection.

Additional review of Patient #R6's electronic medical record, assisted by navigator S3HIMD, revealed no documented evidence of a one hour in-person face to face evaluation of the patient after the above referenced physical hold. S3HIMD verified there were no documented one hour in-person face to face evaluations of the patient after the above referenced physical hold during the record review on 05/14/19 at 3:18 p.m.

In an interview on 05/14/19 at 3:55 p.m. with S2CNO, she confirmed staff manual holds were physical restraints. S2CNO further confirmed one hour in-person face to face evaluations of the patients should have been performed and documented after the above referenced physical holds.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure the QAPI program established indicators, time-frames for compliance, and tracked performance to ensure that improvements were sustained when addressing adverse patient events that impacted patient safety and quality of care. This deficient practice was evidenced by failure of the hospital to establish performance indicators, time-frames for compliance, and methods for tracking/ analyzing staff compliance/maintenance of continued compliance with preventive actions that were implemented after a patient's (#2) death by suicide in the hospital.
Findings:

Review of a Root Cause Analysis investigation, conducted by the hospital to investigate Patient #2's suicide by hanging which occurred within 4 hours of the patient's admission to the hospital on [DATE] revealed the following: d. The role played by QA in tracking and trending such events: i. Through analysis of the event, we identified several areas for improvement and implemented training or actions to correct. We plan to implement PI monitors for full completion of the SRA, admission orders occurring after the results of the intake assessment are shared with the physician, and continue increased frequency of leadership rounds to monitor proper patient observations. ii. Improve ability to use data from leadership observation monitoring of all patients according to their ordered level of observations. iii. Due to the inherent risk of our patient population this is an ongoing initiative and includes training on all new policies and completing competencies at new hire orientation, annually, and as needed, with compliance measured and reported as a monthly percentage.

Review of the hospital's QAPI plan revealed no documented evidence that performance indicators, with time-frames for measurement of staff compliance with preventive actions taken to address identified areas in need of improvement related to Patient #2's suicide, had been established in the hospital wide QAPI plan.

In an interview on 05/15/19 at 3:35 p.m. with S1CEO and S2CNO, they verified the hospital's QAPI plan had no established performance indicators with time-frames for measurement of staff compliance with preventive actions put into place to address identified areas in need of improvement related to Patient #2's suicide. S2CNO confirmed there had been no assimilation of data as of yet.
VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
Based on record reviews and interviews, the governing body failed to ensure services performed under a contract were included in its QAPI program as evidenced by failure to have documented evidence that quality indicators had been developed, were being tracked and analyzed, and incorporated into the hospital's QAPI program for all contracted services provided by the hospital.
Findings:

Review of the list of "Contracts/Agreements 2018 - 2019", presented as the current list of hospital contracts by S1CEO, revealed the hospital had 32 contracts.

There was no documented evidence presented that revealed that quality indicators had been developed for the contracted services of lab, radiology, dietary, linen, hazardous waste, organ, eye, and tissue procurement, and ambulance service.

In an interview on 05/15/19 at 3:35 p.m. with S1CEO and S2CNO present, S1CEO confirmed they had not been evaluating contracted services, and they had not developed quality indicators for above contracted services to be included in the hospital's QAPI program.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on record reviews, interviews, and observations, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services as evidenced by:

1) Failure of the RN to supervised the nursing care to ensure a patient admitted with thoughts of self-harm, with a reported suicide attempt by overdose prior to admission, who subsequently committed suicide in the hospital approximately 4 hours after admission, had been observed at the ordered level of observation for 1 (#2) of 1 sampled patient reviewed for a self-report to LDH- HSS of suicide (in the hospital) from a total patient sample of 11 (#1-#11) and a random patient sample of 12 (#R1-#R12). (See findings in tag A-0395);

2) Failure of the RN to supervise the nursing care to ensure MHTs documented observations of patients, as ordered, for 5 current inpatients (#3, #4, #R10, #R11, #R12) who were on every 15 minute observations and for 1 current inpatient (#R9) who was on every 5 minute observations (due to a SRA of 35), from a total patient sample of 11 (#1-#11) and a random patient sample of 12 (#R1-#R12). (See findings in tag A-0395);

3) Failure of the RN to ensure patients had been assessed by the RN to determine if they met the criteria for delegation of performing newly admitted patients' SRAs to the LPN according to the LSBN's "Administrative Rules Defining RN Practice LAC46: XLVII 3703. Definition of Terms Applying to Nursing Practice." for 1 (#2) of 6 (#1-#5, #11) sampled patients reviewed for SRA from a total patient sample of 11 (#1-#11). (See findings in tag A-0395);

4) Failure of the RN to ensure the Physician/LIP, CNO, and house supervisor were notified of patients' medium/moderate, high, or severe suicide risk scores on the hospital's SRA as indicated on the hospital's SRA policy for 2 (#2, #5) of 6 (#1 - #5, #11) sampled patients reviewed for SRA from a total patient sample of 11 (#1-#11). (See findings in tag A-0395);

5) Failure of the RN to ensure a patient's suicide risk was assessed accurately on the SRA tool for 1 (#2) of 6 (#1 - #5, #11) sampled patients' records reviewed for SRA from a total patient sample of 11 (#1-#11). (See findings in tag A-0395); and

6) Failure of the RN to ensure patients' admission orders were based on observation and assessment of the patient upon arrival at the hospital and not based on reported information received from the referring hospital for 3 (#2, #5, #11) out of 6 (#1 - #5, #11) patient records reviewed for admission orders from a sample of 11 patients. (See findings in tag A-0395).
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 interview, 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 supervise the nursing care to ensure a patient admitted with thoughts of self-harm, with a reported suicide attempt by overdose prior to admission, who subsequently committed suicide in the hospital approximately 4 hours after admission, had been observed at the ordered level of observation for 1 (#2) of 1 sampled patient reviewed for a self-report to LDH- HSS of suicide (in the hospital) from a total patient sample of 11 (#1-#11) and a random patient sample of 12 (#R1-#R12).

2) Failure of the RN to supervise the nursing care to ensure MHTs documented observations of patients, as ordered, for 5 current inpatients (#3, #4, #R10, #R11, #R12) who were on every 15 minute observations and for 1 current inpatient (#R9) who was on every 5 minute observations (due to a SRA of 35), from a total patient sample of 11 (#1-#11) and a random patient sample of 12 (#R1-#R12).;

3) Failure of the RN to ensure patients had been assessed by the RN to determine if they met the criteria for delegation of performing newly admitted patients' SRAs to the LPN according to the LSBN's "Administrative Rules Defining RN Practice LAC46: XLVII 3703. Definition of Terms Applying to Nursing Practice." for 1 (#2) of 6 (#1-#5, #11) sampled patients reviewed for SRA from a total patient sample of 11 (#1-#11).;

4) Failure of the RN to ensure the Physician/LIP, CNO, and house supervisor were notified of patients' medium/moderate, high, or severe suicide risk scores on the hospital's SRA as indicated on the hospital's SRA policy for 2 (#2, #5) of 6 (#1 - #5, #11) sampled patients reviewed for SRA from a total patient sample of 11 (#1-#11).;

5) Failure of the RN to ensure patients' suicide risk was assessed accurately on the SRA tool for 1 (#2) of 6 (#1 - #5, #11) sampled patients' records reviewed for SRA from a total patient sample of 11 (#1-#11).;

6) Failure of the RN to ensure patients' admission orders were based on observation and assessment of the patient upon arrival at the hospital and not based on reported information received from the referring hospital for 3 (#2, #5, #11) 6 (#1 - #5, #11) patient records reviewed for admission orders from a sample of 11 patients.; and

7) Failure of the RN to notify the physician of an abnormal respiratory assessment of a patient for 1 (#3) of 1 patient record reviewed with an abnormal respiratory assessment from a sample of 11 patients.

Findings:

1) Failure of the RN to ensure a patient admitted with thoughts of self-harm, with a reported suicide attempt by overdose prior to admission, who subsequently committed suicide in the hospital approximately 4 hours after admission, had been observed at the ordered level of observation:

Review of Patient #2's electronic medical record revealed an admission date of [DATE] at 02:05 a.m. with admission diagnoses of Bipolar Disorder Type 1, Suicidal Ideation, and Depression. Further review revealed Patient #2 had committed suicide, by hanging, in her room. The patient was found by staff during 06:00 a.m. rounds on 05/08/19.

Review of Patient #2's admission legal status revealed the patient was PEC'd on 05/07/19 at 6:58 p.m. due to being suicidal, violent, dangerous to self, and unable to seek voluntary admission. Additional review of the PEC revealed the patient's history of present illness had been documented as violent and angry with suicidal ideation. The patient's mental condition was documented as follows: Pt. is crying and threatened suicide yesterday.

Review of Patient #2's electronic medical record revealed the following ED nurses' note entry from Hospital B: 05/07/19 8:04 p.m.: Pt. states to charge RN, "I don't care how much treatment I get, I have been through this for 6 years, why don't people understand I just want to die."

Review of Patient #2's initial SRA was completed on 05/08/19 at 02:09 a.m. (obtained by S6LPN in the hospital's intake department) revealed a suicide risk score of 27 (Score of 25-41- Medium Risk of Suicide).

Review of Patient #2's admission orders, dated 05/07/19 at 11:37 p.m. revealed the patient was ordered to have documented observations every 15 minutes and was on suicide precautions.

Review of Patient #2's observation record, dated 05/18/19, revealed the last entry was documented at 05:00 a.m. Further review revealed the patient was documented as being in her room, calm, and appears asleep with chest rising/falling. The entry was completed by S5MHT. Additional review revealed no co-signature of S7RN, who was the nurse responsible for co-signature, on the observation record.

Review of the Initial Self-report, submitted to LDH-HSS, regarding Patient #2's suicide, revealed the following description of the incident: During 06:00 a.m. rounds, staff (S5MHT) found patient hanging inside of her patient room door and immediately notified the charge nurse, S7RN. The charge nurse initiated CPR at 06:05 a.m. and emergency services was called. Emergency services arrived at 6:14 a.m. and began CPR. CPR continuing until 6:51 a.m.

Review of the RCA (Root Cause Analysis) of Patient #2's suicide, performed by administrative staff, presented to survey team on 05/15/19, revealed the following, in part:
1) S5MHT could not verify that she had completed all of her checks after 05:00 a.m. as required. S5MHT indicated that during rounds after 05:00 a.m. she would look and listen from the doorway for sounds, but not do checks every 15 minutes.
2) S7RN and S5MHT reported they were not aware of the seriousness of the patient's suicidal ideation. Content of ED notes from Hospital B was not passed during the hand-off from intake to RN though hand-off did include history of suicide attempts including recent overdose on 05/07/19.


In an interview on 05/15/19 at 05:05 a.m. with S7RN, she confirmed she had been working on 05/08/19 (night shift of 05/07/19). S7RN indicated she had admitted Patient #2 to the 4000 Unit at around 02:00 a.m. and reported the patient had been irritable in intake. S7RN reported the SRA score was obtained by intake (S6LPN) and the SRA was not repeated when the patient was admitted to the floor. S7RN reported Patient #2 had denied thoughts of self-harm and had been on every 15 minute observations with suicide precautions. S7RN confirmed intake had notified her of Patient #2's medium suicide risk assessment score of 27 and she had signed documentation of notification by intake staff. S7RN confirmed she had not called the physician about the medium suicide risk score because at that time they were not required to notify the physician. S7RN reported there was no house supervisor on duty on 05/08/19. S7RN indicated S5MHT had gone to wake the patients up at around 06:00 a.m. and had discovered Patient #2 had hung herself on the back of her room door, using a fitted sheet. S7RN reported they now have to review patient observation records every 2 hours must initial them.

In an interview on 05/15/19 at 09:40 a.m. with S2CNO, she confirmed nursing staff should have been reviewing MHTs' patient observation records to ensure they had been completed in real-time. S2CNO acknowledged nursing staff was also responsible for providing patient observations and should also have been assuming hand offs from MHTs if the MHTs were performing other duties.

In an interview on 05/15/19 at 10:09 a.m. with S5MHT, she reported she had worked at the hospital for almost 8 months and worked mostly nights. S5MHT indicated she would usually be assigned 6 or 7 every 15 minute observation patients. S5MHT explained she would round on the patients whenever they went to bed at around 10:00 p.m. and she would round again at around 10:30 p.m. after everybody had a chance to settle down.
S5MHT indicated she had been assigned Patient #2 on 05/08/19. She reported she had gone to intake with S7RN to do Patient #2's admit skin assessment and the patient had been agitated. S5MHT reported Patient #2 had come to the unit at around 2:20 a.m. and she had told her she just wanted to go to bed. S5MHT explained on her first every 15 minute round she had stood at the door, using a flashlight to see if the patients were breathing and/or moving. S5MHT further explained on her second 15 minute rounds she made sure all patient doors had a crack in them and she would walk around and listen at the doors to see if the patients were snoring, and if not, she would peep her head in to see if the patient was alright. S5MHT indicated the last time she had checked on Patient #2 was at 05:02 a.m. She said she had checked on her, she was in bed, she could hear her breathing, but she wasn't sure if she was sleeping because the covers were over her head. S5MHT explained at 05:45 a.m. one of the other techs had handed her papers to her and said she was leaving early. S5MHT further explained at that time she then had 13 patients to observe. S5MHT reported the MHTs also had other duties besides patient observation which included cleaning up during their shift and doing laundry. S5MHT said she was responsible for laundry on 05/08/19, as well as "wiping down stuff", and pulling trash. S5MHT reported a lot was going on around 05:00 a.m. and she indicated the MHTs usually did their last patient rounds between 05:00 a.m. - 05:30 a.m. S5MHT further reported on 05/08/19 she never had a chance to "fill-in" her patient observation records because she had found Patient #2 between 06:06 a.m. - 06:07 a.m. S5MHT reported Patient #2 was the last room on her rounds and she had awakened patients in 5 other rooms before she got to Patient #2's room. S5MHT indicated S8MHT had seen Patient #2 in her doorway at about 5:45 a.m. S5MHT reported she had noticed Patient #2's door had been heavy when she tried to push open the door to wake the patient up at 06:06 a.m. S5MHT reported she was trying to open the door just enough to get her head around the door to peek in. S5MHT explained Patient #2 was sitting down with the sheet around her neck behind the door of her room. She said the patient had used the fitted sheet and had made a tight knot on the fitted corner and hooked the tied knot where the door opens. She said the patient had tied the other part of the sheet around her neck and sat down, leaning forward. S5MHT reported she had gone to tell S7RN about Patient #2 and S7RN had taken the patient down and started CPR.

In an interview on 05/15/19 at 2:25 p.m. with S1CEO, he reported once they debriefed the staff after Patient #2's death, S5MHT had been suspended because she had admitted she had not done the patient's observations every 15 minutes, as ordered. He said S5MHT had made up her own way of rounding and was doing rounds in the room every other time and had peeped into patients' rooms, not shining the flashlight on the patients and not looking for rise/fall of the patients' chest. S1CEO also acknowledged nursing staff had not provided adequate supervision of MHT staff to ensure monitoring of patients according to observation level.

2) Failing to ensure MHTs documented observations of patients, as ordered:

Review of the hospital policy titled "Observations, Patient", presented as a current policy by S1CEO, revealed the following, in part: Documentation of the observation is to be completed once the patient has been observed. It is not permissible to complete in advance and or to back fill time frames that were not completed in a timely manner. All patients with a "Severe" rating on the most recent SRA must be on one-to-one observation.

Review of the 4000 Unit census, verified as current by S7RN, revealed the following:
Patient #3's primary problem was listed as Schizoaffective Disorder, Depressive type;
Patient #4's primary problem was listed as Suicidal Ideation;
Patient #R9's primary problem was listed as Depression with Suicidal Ideation;
Patient #R10's primary problem was listed as Schizophrenia;
Patient #R11's primary problem was listed as Psychosis;
Patient #R12's primary problem was listed as Schizophrenia.

On 05/15/19 at 04:30 a.m. an observation was made on Unit 4000. During the observation S9MHT's clipboard with her assigned patient observation records (Patients #3, #4, #R10, #R11, and #R12) was noted to be standing on end against the arm of a chair in the hallway. S9MHT was observed collecting linens and carrying them in the hallway. S7RN was observed in the nursing station during the observation.

Review of the observation records for Patients #3, #4, #R10, #R11, and #R12, at 04:30 a.m. on 05/15/19, revealed the last documented entry on all 5 patients' observation records had been at 03:45 a.m. (no observations documented for 45 minutes). Further review of the patients' observation records revealed Patients #3, #4, #R10, #R11, and #R12 were marked as being on every 15 minute level of observation. Additional review revealed the patients' activity/behavior and location should have been documented every 15 minutes. The columns on the patients' observation records for RN/LPN co-signature also had no signatures for the above referenced time interval, at the time the record was reviewed on 05/15/19.

On 05/15/19 at 04:35 a.m. Patient #R9's observation record was reviewed. Patient #R9 was on every 5 minute observations due to a SRA score of 35 (Medium Risk- Score of 25- 41). Further review of the observation record revealed there was an entry at 04:00 a.m., no entries for 04:05 a.m. and 04:10 a.m., and the next entry documented was at 04:15 a.m. (15 minutes without a documented observation). S38MHT was assigned to Patient #R9.

In an interview on 05/15/19 at 04:45 a.m. with S9MHT, she reported she had been collecting linen during the intervals that were not documented for Patients #3, #4, #R10, #R11, and #R12. S9MHT reported she had checked on the patients and indicated she had not caught up on her documentation of her observations. She indicated she had told the nurses she was going off the unit. S9MHT confirmed she had not handed off her patients to the nurses or to any other staff.

In an interview on 05/15/19 at 04:53 a.m. with S38MHT, he reported he had handed off his assignment to S11MHT when he was pulling trash. S38MHT indicated he wasn't sure why S11MHT had not done his "q's" (every 5 minute checks).

In an interview on 05/15/19 at 05:05 a.m. with S7RN, she confirmed she was the charge nurse for Unit 4000. She reported the patients' observation records should have been kept up-to-date. S7RN confirmed S9MHT had not handed off her patient assignment when she was pulling linens. S7RN confirmed the nurses on the inpatient units were to review the MHTs' patient observation records for accuracy and were to initial them every 2 hours.

In an interview on 05/15/19 at 09:40 a.m. with S2CNO, she confirmed patient observation records should have been completed in real-time. S2CNO further confirmed MHTs' assigned patients should have been handed off to another staff member if the MHTs were performing other duties. S2CNO indicated the nursing staff was to have been reviewing MHTs' observation records every 2 hours and should have been signing off on them. S2CNO reported S38MHT had told her he had handed off Patient #R9 to S11MHT when he was pulling trash. S2CNO indicated she had spoken to S11MHT about not documenting Patient #R9's q 5 minute observations at 04:05 a.m. and 04:10 a.m. and she said S11MHT had told her, "she had forgotten to do Patient #R9's observations."

In an interview on 05/15/19 at 2:25 p.m. with S1CEO, he indicated the reported surveyor observations regarding staff failing to document patient observations as ordered this morning, on Unit 4000, was disappointing, especially since the hospital staff knew surveyors were in the building. S1CEO reported S7RN, of all people, should have been supervising the MHTs and ensuring patients were being observed, since she had just had a death, by suicide, on her unit.

3) Failure of the RN to ensure patients' initial SRAs were not delegated to LPN staff:

Review of the LSBN's "Administrative Rules Defining RN Practice LAC46: XLVII 3703. Definition of Terms Applying to Nursing Practice" revealed that the RN retains the accountability for the total nursing care of the individual and is responsible for and accountable to each consumer of nursing care for the quality of nursing care he or she receives, regardless of whether the care is provided solely by the RN or by the RN in conjunction with other licensed or unlicensed assistive personnel. The RN shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. This assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required. Any situation where tasks are delegated should meet the following criteria:
a) the person has been adequately trained for the task;
b) the person has demonstrated that the task has been learned;
c) the person can perform the task safely in the given nursing situation;
d) the patient's status is safe for the person to carry out the task;
e) appropriate supervision is available during the task implementation;
f) the task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all.
Further review revealed the RN may delegate to LPNs the major part of the nursing care needed by individuals in stable nursing situations, i.e., when the following three conditions prevail at the same time in a given situation:
a) nursing care ordered and directed by the RN or physician requires abilities based on a
relatively fixed and limited body of scientific fact and can be performed by following a
defined nursing procedure with minimal alteration, and responses of the individual to the
nursing care are predictable; and
b) change in the patient's clinical conditions is predictable; and
c) medical and nursing orders are not subject to continuous change or complex modification.

Patient #2
Review of Patient #2's electronic medical record revealed an admission date of [DATE] at 02:05 a.m. with admission diagnoses of Bipolar Disorder Type 1, Suicidal Ideation, and Depression.

Review of Patient #2's initial SRA revealed the assessment had been performed by S6LPN on 05/08/19 at 02:09 a.m. Further review revealed Patient #2 had a suicide risk score of 27 (Score of 25-41- Medium Risk of Suicide).

Additional review of Patient #2's electronic medical record, assisted by S3HIMD, revealed no documentation that a scored SRA had been performed by S7RN when the patient was admitted to the unit. S3HIMD verified there was only one scored SRA (the one obtained by S6LPN in intake) in the patient's electronic medical record.

In an interview on 05/13/19 at 3:10 p.m. with S2CNO, she confirmed S6LPN had been performing initial SRAs in the hospital's intake department. She reported she had not been aware the SRA could not be delegated to LPNs for performance. S2CNO indicated the scored SRA was not performed again unless a patient expressed suicidal thoughts or exhibited suicidal behaviors.

In an interview on 05/14/19 at 08:40 a.m. with S10ID, she reported anybody in the intake department, including S6LPN, could perform the initial suicide risk assessment. S10ID indicated the person performing the assessment would input the information into the computer. S10ID explained if the suicide risk assessment was high, then the staff was to do a high risk notification form. S10ID further explained the doctor or the NP should be contacted if the patient's suicide risk was assessed as medium-severe and the notification should have been documented in the notes section.

In an interview on 05/15/19 at 5:05 a.m. with S7RN, she indicated the hospital's intake department saw new admits first. S7RN further indicated intake assessed the patient and performed the SRA. S7RN reported patients were asked if they were having thoughts of self-harm when they arrived on the unit. S7RN reported the scored SRA was not repeated by nursing staff unless the patient expressed suicidal thoughts or had suicidal behaviors. S7RN further confirmed she had not performed a scored SRA on Patient #2 when she had admitted the patient on 05/08/19.


4) Failure of the RN to ensure the Physician/LIP, CNO, and house supervisor were notified of patients' medium/moderate, high, or severe suicide risk scores on the hospital's SRA as indicated in the hospital's SRA policy:

Review of the policy titled" Suicide Risk Assessment", presented as a current policy by S1CEO, revealed SRAs are completed for all patients and include assessment of specific factors and features that may increase or decrease risk for suicide. The admitting staff will complete the initial SRA during the initial admission (intake) process. If any SRA renders information that has potential to immediately affect patient safety and/or results in a score of Moderate, High, or Severe, the psychiatrist and Director of Nursing/House Supervisor shall be contacted immediately. This applies to the initial and all subsequent SRAs. The psychiatrist shall order the appropriate level of observation based on results of the SRA and additional patient specific information based on previous knowledge of the patient or as reported by staff. Documentation of consult and subsequent physician orders are noted by the nurse in the patient chart. Further review of the policy revealed Patients at Moderate risk-Implement suicide precautions for all patients who are at medium or highter risk for suicide. Suicide Precautions include but not limited to: Placing patient in a room that is as close to the nurse station as possible. Placing patient in a room with a roommate if possible and if otherwise clinically appropriate. Monitoring Red Flags (changes in mood, affect or behavior that can include increase isolation, quickly changing from depressed or sad to cheerful, denying any suicidal thoughts despite recent suicidal thought or attempts, excessive trips to the restroom, patient monitoring staff rounding patterns, patient attempting to closed door, etc.). Ensure patient room door is closed and locked at all times when patient is not present. Ensure patient room door is open at all times when patient is present.

Patient #2
Review of Patient #2's electronic medical record revealed an admission date of [DATE] at 02:05 a.m.
Review of Patient #2's initial SRA performed on 05/08/19 at 02:09 a.m. revealed Patient #2 had a suicide risk score of 27 (Score of 25-41- Medium Risk of Suicide).

Additional review of Patient #2's electronic medical record, assisted by S3HIMD, revealed no documentation that the physician /LIP, CNO or house supervisor had been notified of the patient's medium risk score on the initial SRA. S3HIMD verified, during the medical record review, there was no documented evidence of physician/LIP/CNO/house supervisor notification of in the patient's electronic medical record.

Patient #5
Review of Patient #5's medical record revealed he was admitted on [DATE] at 5:38 p.m. with a diagnosis of Depression with SI.

Review of Patient #5's physician orders revealed an order to admit by S27Psych on 05/12/19 at 3:28 p.m., 2 hours 58 minutes prior to his arrival at the hospital. Further review revealed his SRA was conducted on 05/12/19 at 6:26 p.m. by S10ID and was scored as 28 (medium) and reported to the Nurse Supervisor at 6:21 p.m. There was no documented evidence the physician was notified as required by hospital policy.

In an interview on 05/13/19 at 3:10 p.m. with S2CNO, she confirmed the physician/LIP should have been informed of medium/moderate, severe, and high risk patient scores on the SRA and the notification should have been documented in the patient's record.

In an interview on 05/14/19 at 08:40 a.m. with S10ID, she confirmed the doctor or the NP should be contacted if the patient's suicide risk was assessed as medium-severe and the notification should have been documented in the notes section.

In an interview on 05/15/19 at 05:05 a.m. with S7RN, she indicated the hospital's intake department had notified her that Patient #2's SRA risk assessment score had been moderate/medium risk with a score of 27. S7RN confirmed she had not called the physician/LIP nor had she called S2CNO on 05/08/19 to inform them of the patient's SRA score. S7RN reported there was no house supervisor on duty on 05/08/19.

In an interview on 05/15/19 at 1:35 p.m. with S4Psych, he reported he remembered Patient #2. S4Psych indicated intake had only reported the contents of Patient #2's PEC documentation. S4Psych confirmed he had not been called about Patient #2's moderate/medium suicide risk score of 27 on the SRA. S4Psych reported he had given basic admit orders for Patient #2, but once staff had seen the patient they should have called him in order to update the patient's orders, if needed.

5) Failure of the RN to ensure patients' suicide risk was assessed accurately on the SRA tool:

Review of Patient #2's hospital record revealed the patient had been PEC'd on 05/07/19 at 6:58 p.m. due to being suicidal, violent, dangerous to self, and unable to seek voluntary admission. Further review revealed the patient's history of present illness on the PEC indicated the patient was violent, angry, with suicidal ideation. Additional review revealed the physical findings were Bipolar, Depression, Substance Abuse, and the patient's mental condition was described as patient is crying and threatened suicide yesterday.

Review of Patient #2's electronic medical record revealed the following ED nursing note entries:
05/07/19 at 8:04 p.m.: Pt. states to Charge RN, "I don't care how much treatment I get, I have been through this for 6 years, why don't people understand I just want to die."
05/07/19 at 8:30 p.m.: Pt. significant other arrived to check on patient.... He reports patient has a previous history of 8 overdoses in the past and had been admitted to psych facility before in Baton Rouge. He reports she has an ongoing history of depression.

Review of Patient #2's ED Psych Evaluation, dated 05/07/19, revealed in part: Pt. to ED per EMS states family called reporting pt.'s son stated pt. took "pills". EMS reports pt. best friend reported pt. told her she "didn't want to deal with this anymore and was on the levee". Pt found at home per area police, aroused by officers. EMS reports finding empty Baclofen 10 milligram bottle and empty Clonazepam 1 milligram bottle (filled yesterday, 05/06/19, with #60 (count of 60). 52 y/o female who has a history of suicide attempts or at least threats comes with threat of suicide earlier in the day, apparently patient was going to take 60 Klonopin pills, but the patient does not appear to have overdosed, she is talking, awake, slightly agitated.

Review of Patient #2's SRA performed on 05/08/19 at 02:05 a.m. revealed the patient had been scored a "0" for having a suicide plan (patient had reportedly attempted suicide by overdose 8 times in the past and had an attempted overdose within 24 hours of admission) and a "3" for lethality (level of dangerousness) of the plan. Additional review revealed the patient had a medium/moderate suicide risk (score of 27).

In an interview on 05/13/19 at 3:10 p.m. with S2CNO, she confirmed, after review of Patient #2's SRA scores, that the patient's history of previous suicide attempts, especially within the last 72 hours prior to admission, should have been taken into consideration when scoring whether the patient had a plan or not. S2CNO indicated she could not explain how the patient had been scored a "3" for lethality of plan when the patient had been scored a "0" for having a plan. S2CNO agreed Patient #2's SRA had been scored inaccurately.

In an interview on 05/15/19 at 06:10 a.m. with S6LPN, she confirmed she works in the hospital's intake department and performs newly admitted patient's SRAs. S6LPN explained the information used for assessing a patient's suicide risk was based upon the patient's current answers at the time of admission. S6LPN confirmed the patient's prior history of suicide attempts had not previously been taken into consideration when assessing whether the patient had a plan.

6) Failure of the RN to ensure patients' admission orders were based on observation and assessment of the patient upon arrival at the hospital and not based on reported information received from the referring hospital:

Patient #2
Review of Patient #2's electronic medical record revealed the patient had been PEC'd on 05/07/19 at 6:58 p.m. due to being suicidal, violent, dangerous to self, and unable to seek voluntary admission. Further review revealed the patient had been admitted on 05/08/19 with an admission diagnosis of Bipolar Disorder, Type 1, Depression, and Suicidal Ideation.

Review of Patient #2's admission orders revealed an order to admit by S4Psych on 05/07/19 at 11:37 p.m., 1 hour and 48 minutes prior to the patient's arrival (the patient had arrived on 05/08/19 at 1:25 a.m.). Further review revealed the patient had been placed on check every 15 minute psych observation (routine level of observation) with suicide precautions. The orders had been obtained by S22RN (intake staff) from S4Psych.

Additional review revealed the patient's SRA was conducted on 05/08/19 at 02:05 a.m. by S6LPN and was scored as 27 (medium). There was no documented evidence that Patient #2's admission was based on an assessment performed at the admitting hospital and not by information received from the transferring hospital.

Patient #5
Review of Patient #5's medical record revealed he was admitted on [DATE] at 5:38 p.m. with a diagnosis of Depression with SI.

Review of Patient #5's physician orders revealed an order to admit by S27Psych on 05/12/19 at 3:28 p.m., 2 hours 58 minutes prior to his arrival at the hospital. Further review revealed his SRA was conducted on 05/12/19 at 6:26 p.m. by S10ID and was scored as 28 (medium) and reported to the Nurse Supervisor at 6:21 p.m. There was no documented evidence that Patient #5's admission was based on an assessment performed at the admitting hospital and not by information received from the transferring hospital.

Patient #11
Review of Patient #11's admission orders revealed they had been written on 05/13/19 at 11:42 p.m. by S30NP with an admitting diagnosis of Depression. Further review revealed the SRA was not completed until 05/14/19 at 1:06 a.m. (1 hour 11 minutes after the patient arrived at the hospital) with a score of 39 (medium risk). Review revealed current symptoms and complaints were documented at 1:25 a.m. and the admission vital signs were documented at 1:41 a.m.

In an interview on 05/14/19 at 08:40 a.m. with S10ID, she reported patient packets from referring hospitals were reviewed for criteria, and intake staff would then call the referring facility/ED to accept the patient. S10ID further reported intake staff reviewed the referral information while waiting for new patients to arrive. S10ID confirmed physicians were ordering levels of observation, as well as other admission orders, prior to patient arrival.

In an interview on 05/14/19 at 09:35 a.m. with S1CEO, he verified the admission orders should have been based on the assessment of staff at this hospital.

7) Failure of the Registered Nurse to notify the physician of a patient's abnormal respiratory assessment:

Review of the hospital policy titled "Assessment/Reassessment", presented as a current policy, revealed in part, all patients admitted to the hospital will receive a thorough assessment and evaluation. Results of assessments are reviewed and integrated by the multidisciplinary team to prioritize identified problems within the Interdisciplinary Treatment Plan.

Review of the hospital policy titled "Early Response to Change in Condition" revealed in part, the procedure is for a Registered Nurse to provide assessment data to the medical practitioner who will then give orders for treatment or additional assessment.

Review of the medical record for Patient #3 revealed he was a [AGE] year old admitted on [DATE] at 11:58 p.m. with an admission diagnosis of Depression with suicidal ideation under a Physician's Emergency Certificate. Further review revealed a history of Chronic Obstructive Pulmonary Disease.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered in accordance with the physician's orders for 1 (R7) of 2 (R7, R8) random patients sampled for medication variances from a sample of 11 patients (#1 - #11) and a sample of 12 (#R1 - #R12) random patients.

Review of the hospital policy titled "Medication Errors/Adverse Drug Events", presented as current policy, revealed in part: 4.0 Procedure: Notify the licensed practitioner immediately. Notify patient and/or representative of error unless instructed by licensed practitioner. Document evidence of same. Record the medication error in the progress note.

Review of Patient R7's medical record revealed an order dated 07/13/18 at 5:40 p.m. for Clozapine 200 milligrams by mouth nightly.

Review of Patient R7's Medication Administration Record revealed Clozapine 200 milligrams was documented as having not been given on 07/13/18 by S37LPN and on 07/14/18 by S33LPN. Further review revealed notations by the nurse that the medication was not available. There was no documentation of physician notification that the medicines were not given.

In an interview on 05/15/19 at 11:00 a.m. with S2CNO, she verified there was no documentation in the medical record the physician was notified Clozapine was not given.
VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY Tag No: A0468
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure all patient records included documentation of outcomes of hospitalization , disposition of care, and provisions for follow-up care. This deficient practice was evidenced by failure of the hospital to ensure a completed discharge summary was on all patient records within 30 days of discharge for 1 (#9) of 2 (#9, #10) sampled patient records reviewed for discharge summaries.

Findings:

Review of the hospital's Medical Staff Rules and Regulations revealed the following, in part: 7. Completion of the Medical Records - All discharge summaries and other medical record documentation shall be completed within thirty (30) days following the patient's discharge. Incomplete records exceeding thirty (30) days following discharge will be considered delinquent.

Review of Patient #9's electronic medical record navigated by S3HIMD revealed an admission date of [DATE] and a discharge date of [DATE]. Further review of the patient's medical record revealed that as of 05/14/19 (date of the record review) there was no discharge summary in the patient's medical record.

In an interview on 05/14/19 at 1:15 p.m. with S3HIMD, she verified there was no discharge summary in the medical record of Patient #9.
VIOLATION: SAFETY POLICY AND PROCEDURES Tag No: A0535
Based on record review and interview, the hospital failed to ensure policies and procedures were developed that addressed proper safety precautions against radiation hazards to provide for the safety of patients and staff during radiological procedures performed by the hospital's contracted mobile x-ray service.
Findings:

Review of a list of contracted services, provided as current by S1CEO, revealed the hospital's radiological services were provided via a contracted mobile x-ray service.

Review of the hospital's radiological policy, presented as current by S2CNO, revealed no documented evidence that the policy addressed proper safety precautions for protection of patients and staff against radiation hazards during radiological procedures performed by the hospital's contracted mobile x-ray service.

In an interview on 05/15/19 at 2:00 p.m. with S2CNO, she confirmed the above-referenced radiology policy was the hospital's only radiology policy. S2CNO acknowledged the policy did not address proper safety precautions for protection of patients and staff against radiation hazards during radiological procedures performed by the hospital's contracted mobile x-ray service.
VIOLATION: RADIOLOGIST RESPONSIBIITIES Tag No: A0546
Based on record review and interview, the hospital failed to ensure a qualified full-time, part-time, or consulting radiologist supervised the radiology services of the hospital as evidenced by failure to have a radiologist appointed and privileged to supervise the radiology services provided by the hospital.
Findings:

Review of the credentialing file of S28MD revealed he was a radiologist who was appointed by the governing body on 01/05/18. Further review revealed he requested and was approved for the following privileges: diagnostic radiological interpretation x-ray via tele-radiography; diagnostic radiological interpretation ultrasound via tele-radiography; diagnostic radiological interpretation EKG (electrocardiogram) via tele-radiography. There was no documented evidence S28MD requested to be privileged as the supervisor of the hospital's radiological services. There was no documented evidence that the governing body had appointed and privileged S28MD as the supervisor of the hospital's radiological services.

In an interview on 05/14/19 at 1:00 p.m., S13AA confirmed S28MD's privileges didn't include director of radiology services.
VIOLATION: UTILIZATION REVIEW COMMITTEE Tag No: A0654
Based on record review and interview, the hospital failed to ensure the UR committee consisted of 2 physicians who did not have a direct financial interest in the hospital or was professionally involved in the care of the patient whose case was being reviewed as evidenced by having either S4Psych, S27Psych, or S29Psych, (physicians who provided patient care in the hospital) as members of the UR committee. Findings:

Review of the policy titled "Utilization Management Plan", presented as a current policy by S31UD, revealed the Medical Director (S29Psych) or designated physician provides consulting oversight to the utilization management staff for referrals, medical record reviews, and other utilization management issues, and is a member of the utilization Management Committee. This committee is established as a standing committee of the medical staff, and has as its responsibilities to review and evaluate documentation and services related to medical necessity, over and under-utilization of services, delays in services, quality of care, quality of medical record documentation, lengths of stay, professional services, and obstacles to discharges. No member of this committee may participate in reviewing a case in which he/she participated in the patient's care.

In an interview on 05/15/19 at 7:52 a.m., S31UD indicated S29Psych and the attending physicians, either S4Psych or S27Psych were the UR committee members. She further indicated S29Psych does see patients in the hospital as well as S4Psych and S27Psych. She confirmed the three physicians on the committee are all involved with patient care at the hospital.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observations and interview, the hospital failed to ensure the condition of the physical plant and the overall hospital environment was maintained in such a manner that the safety and well-being of patients was assured as evidenced by having walls with unpainted sheetrock spackle in 3 patient rooms as observed during a tour on 05/13/19 from 9:05 a.m. through 10:10 a.m.
Findings:

Observation on 05/13/19 from 9:05 a.m. through 10:10 a.m. with S18BOD present revealed the following observations:
Room "f" with the wall to the right of the entrance behind the door with sheetrock spackle unpainted;
Room "i" with the wall to the right of the entrance behind the door with sheetrock spackle unpainted approximately 14 inches by 14 inches;
Room "k" with the wall to the right of the entrance behind the door had sheetrock spackle unpainted approximately 2 feet (vertical) by 14 inches (horizontal).

In an interview on 05/13/19 during the above observations from 9:05 a.m. through 10:10 a.m., S18BOD confirmed the observations.
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on record review and interview, the hospital failed to ensure a person qualified by education and experience and competency in infection control practices was designated as the infection control officer as evidenced by failure to have documented evidence of education, prior experience, and competency in infection control practices for S2CNO who was designated as the infection control officer.
Findings:

Review of the personnel file for S2CNO revealed no documented evidence of education, prior work experience, and competency in infection control practices.

In an interview on 05/15/19 at 1:10 p.m. with S2CNO, she indicated she had no prior work experience in infection control and had not completed infection control education related to developing and implementing an effective infection control program.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observations, record review, and interviews, the infection control officer failed to ensure the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented in accordance with hospital policy and acceptable standards of practice as evidenced by:

1) Failure to ensure surveillance and training were adequate to ensure staff compliance with hand hygiene and PPE use practices. An observation of a breach in hand hygiene was observed on 05/14/19 at 3:25 p.m.

2) Failure to maintain a sanitary environment in the hospital as evidenced by observations of practices performed not in accordance with acceptable infection control practice/policy during a hospital tour on 05/13/19 at 1:32 p.m.
Findings:

1) Hand hygiene breech by staff:
An observation on 05/14/19 at 3:25 p.m. of S39HK on Unit 1 revealed she had gloves on both hands, a brown bag in her right hand, and she was noted to exit the unit pushing on the door handle with her gloved left hand.

Review of the CDC's "Guideline for Hand hygiene in Health-Care Settings" revealed indications for handwashing and hand antisepsis are as follows: 1) when hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water; 2) if hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations; 3) decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; 4) decontaminate after removing gloves.

An interview on 05/14/19 at 3:45 with S2CNO verified the above findings.

2) Failure to maintain a sanitary environment in the hospital:
An observation on 05/13/19 at 1:32 p.m. of Unit 4's laundry room with S16MHTS revealed brown paper bags with patient names on them. Observation further revealed the clean clothes were placed in the same brown paper bag the dirty clothes had been in.

An interview on 05/14/19 at 3:45 with S2CNO verified the above findings.
VIOLATION: OPO AGREEMENT Tag No: A0886
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure their contracted OPO was notified, in a timely manner, of all individuals whose who had died in the hospital in order for the OPO to determine medical suitability for organ donation. This deficient practice was evidenced by failure of the hospital to notify the OPO of patient deaths for 2 (#2,#R2) of 2 sampled patient records reviewed for death from a total patient sample of 11.

Findings:

Review of the hospital's contracted services, presented as current by S1CEO, revealed the hospital had contractual agreements with an organ procurent agency and an eye bank.

Review of the hospital's policy titled," Organ , Tissue, and Eye Procurement", revealed in part: Procedure: Notification criteria to the OPO by the hospital would include: Death or Imminent Death ( DNR with decreasing levels of consciousness). The staff nurse caring for the patient notifies the Donor Referral Line within 1 hour , after the patient dies or meets criteria for imminent death stated above.

Patient #2
Review of Patient #2's electronic medical record revealed a nurses' note entry dated 5/8/19 indicating CPR had been initated at 6:05 a.m. and emergency services arrived at 6:14 a.m. and took over CPR. CPR continued until 6:51 a.m. at which time there was no return of cardiac activity and CPR was discontinued by emergency services. The patient was deceased .

Additional review of Patient #2's electronic medical record revealed no documented evidence that the hospital's OPO had been notified of the patient's death. S3HIMD confirmed, after review of the patient's entire electronic medical record, that there was no documentation indicating the hospital's OPO had been notified of Patient #2's death.

Additional review of Patient #2's electronic medical record revealed no documented evidence that the hospital's OPO had been notified of the patient's death. S3HIMD confirmed, after review of the patient's entire electronic medical record, that there was no documentation indicating the hospital's OPO had been notified of Patient #2's death.


In an interview on 5/15/19 at 5:05 a.m. with S7RN, she was asked if she had notified the hospital's OPO about Patient #2's death and she replied,"What is that?" The surveyor explained what the name of the OPO meant and S7RN confirmed she had not called to report Patient #2's death to the OPO.


Patient #R2
Review of Patient #R2's electronic medical record revealed the patient was admitted on [DATE]. Further review revealed a nurses' note entry dated 02/14/19 at 10:24 a.m. indicating the Coroner's office representative was in the hospital to pronounce the patient.

Additional review of Patient #R2's electronic medical record revealed no documented evidence that the hospital's OPO had been notified of the patient's death. S3HIMD confirmed, after review of the patient's entire electronic medical record, that there was no documentation indicating the hospital's OPO had been notified of Patient #R2's death.

In an interview on 05/15/19 at 12;45 p.m. with S2CNO, she reported she didn't think the hospital's staff had been trained to notify the contracted OPO of all patient deaths.
VIOLATION: STAFF EDUCATION Tag No: A0891
Based on record reviews and interview, the hospital failed to ensure it worked cooperatively with the designated organ procurement organization, tissue bank, and eye bank in educating staff on donation issues as evidenced by failure to have documented evidence of staff education related to donation issues for 18 (S2CNO, S3HIMD, S5MHT, S6LPN, S7RN, S8MHT, S10ID, S16MHTS, S17SC, S19MHT, S20RN, S21RN, S22RN, S23RN, S32MHT, S33LPN, S34RN, S35DCS) of 18 employee files reviewed for donation issues education.
Findings:

Review of the personnel files of S2CNO, S3HIMD, S5MHT, S6LPN, S7RN, S8MHT, S10ID, S16MHTS, S17SC, S19MHT, S20RN, S21RN, S22RN, S23RN, S32MHT, S33LPN, S34RN, and S35DCS revealed no documented evidence each employee had received education related to organ, tissue, and eye donation.

In an interview on 05/14/19 at 3:40 p.m., S2CNO indicated staff were not trained on organ, tissue, and eye donation and the procedure for contacting the organ procurement organization.
VIOLATION: DIRECTOR OF RESPIRATORY SERVICES Tag No: A1153
Based on record review and interview, the hospital failed to ensure a respiratory care services director was appointed and privileged to supervise and administer the service properly as evidenced by failure to have a doctor of medicine or osteopathy with the knowledge, experience, and capabilities appointed and privileged to supervise and administer the respiratory care services on either a full-time or part-time basis.
Findings:

Review of S29Psych's credentialing file revealed he was appointed by the governing body on 09/26/17 with privileges including admit, evaluate, and diagnose and treat patients presenting with psychiatric and/or substance abuse disorders and to assess, stabilize, and determine the disposition of patients with emergent conditions consistent with facility policy and Medical Staff By-laws regarding emergency and consultative call services. There was no documented evidence that S29Psych, the hospital's Medical Director, had been appointed and privileged as the Director of respiratory care services.

In an interview on 05/14/19 at 1:00 p.m., S13AA confirmed S29Psych wasn't credentialed as Director of Respiratory Services.
VIOLATION: ADEQUATE RESPIRATORY CARE STAFFING Tag No: A1154
Based on record reviews and interview, the hospital failed to ensure the nursing staff were trained and determined to be competent to administer multi-dose respiratory inhalers as evidenced by failure to have documented evidence that education and evaluation of competency had been conducted for 9 (S2CNO, S6LPN, S7RN, S20RN, S21RN, S22RN, S23RN, S33LPN, S34RN) of 9 nurses' employee files reviewed for education and competency to administer multi-dose respiratory inhalers.
Findings:

Review of the personnel files of S2CNO, S6LPN, S7RN, S20RN, S21RN, S22RN, S23RN, S33LPN, and S34RN revealed no documented evidence that each nurse had received education and been evaluated for competency in administering multi-dose respiratory inhalers.

In an interview on 05/15/19 at 11:00 a.m., S2CNO indicated there was no policy regarding multi-dose inhalers related to respiratory training for the nursing staff.
VIOLATION: RESPIRATORY CARE SERVICES POLICIES Tag No: A1160
Based on record review and interview, the hospital failed to ensure there were appropriate written policies for the delivery of respiratory care services that were developed and approved by the medical staff as evidenced by having documented evidence of a respiratory care services policy for the administration of multi-dose inhalers.
Findings:

Review of the Respiratory Therapy policies and procedures, presented by S2CNO as current, failed to reveal a policy for multi-dose inhalers.

In an interview on 05/15/19 at 8:05 a.m. with S40RPh, she indicated multi-dose inhalers are ordered and dispensed at the hospital.

In an interview on 05/15/19 at 11:00 a.m. with S2CNO, she indicated there is no policy for multi-dose inhalers.