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Based on record review and interview, the psychiatric hospital failed to provide care in a safe setting. The deficient practice is evidenced by failure to initiate seizure precautions for 1 (#3) of 1 reviewed patients with suspected seizures from a total of 3 reviewed patient records.
Findings:

Review of the medical record for Patient #3 revealed the patient was taken to an acute care hospital on 12/22/2024 after exhibiting seizure-like activity. The patient was discharged back to the psychiatric hospital on 12/23/2024.

Review of the "After Visit Summary" provided at discharge revealed instructions for neurology follow up and seizure precautions.

Review of the "Physician's Orders" and 'Behavioral Health Observation Sheets" revealed Patient #3 was not started on seizure precautions until 01/05/2025, after a second visit to the emergency department for seizure-like activity.

In interview on 01/09/2025 at 1:05 PM, S3QD verified Patient #3 was not placed on seizure precautions as per the discharge instructions after the first visit to the emergency department.

Based on record review and interview, the facility failed to ensure all incidents of possible abuse and/or neglect were reported to the Louisiana Department of Health within 24 hours of becoming aware of the incident. The deficient practice is evidenced by failure of the facility to report a fight that occurred at the facility.
Findings:

Review of LA R.S. 40:2009.20 revealed, in part, "facilities/health care workers shall report these allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Louisiana Department of Health (LDH) (or the Medicaid Fraud Unit as applicable). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence."


Review of video was performed on 01/06/2025 between 11:00 AM and 2:45 PM. Video from 01/04/2025 revealed Patient #3 was attached by several girls at 4:50 PM. The video revealed the mental health technicians (MHTs) reacted quickly, but Patient #3 was knocked to the floor and kicked and hit repeatedly by the girls for approximately thirty seconds.

Review of the incident reports revealed an incident report for the occurence was filled out for the fight on 01/04/2024, but review of the self-reports of possible abuse sent to Louisiana Department of Health revealed the incident was not reported.

Interview on 01/08/2025 at 1:20 PM, S3QD verified the psychiatric hospital did not report the abuse of Patient #3 by the other patients to Louisiana Department of Health as required.

Based on record review, video review, and interview the governing body failed to provide clear and written guidance for the safe initiation of a new Bluetooth enabled observation system. The deficient practice is evidenced by failure of the governing body to establish policies with clear guidance for proper use of the observation system and failure to establish procedures to monitor for proper use and to effectively implement corrective actions related to quality of care in a timely manner.
Findings:

Tour of the facility on 01/08/2024 at 10:00 AM revealed the hospital was using a new Bluetooth enabled system to document patient observations. The system allowed the behavioral health technician (BHT) to document the ordered observations electronically when the patient was in Bluetooth range. If the patient was observed by BHT but not within range of the Bluetooth system, the BHT could manually enter the observation in the system, which was called a "forced" entry.

In interview on 01/08/2024 at 11:25 AM, S3QD was asked about the distance range on the system and if it was possible to have the patient in Bluetooth range but not visible to the BHT. S3QD stated the manufacturer set the ranges and they were still adjusting them, S3QD explained the range was not established by distance but by frequency. S3QD verified it was possible that occasionally a patient might be detected when not visable on the other side of a wall.

On 01/08/2025 between 1:22 PM and 1:51 PM, S3QD navigated the review of video of an incident that occurred on 01/04/2025. The video revealed Patient #3 was in her room between 1:04 PM and 2:21 PM and was not in the view of the assigned MHT for more than an hour and yet the observations were documented at least every 15 minutes as ordered. Further investigation revealed that the system had documented the entries as "forced" or manual entries.

On 01/08/2025 at 3:40 P.M., a demonstration of the range of the system was performed with S2DON. The demonstration verified that the Bluetooth range was variable and noted to be longer if a patient was moving out of range and shorter when coming into the range. The demonstration also verified that a patient might be considered in range although not visible while positioned more than 10 feet away in an adjacent room.

In interview on 01/08/2025 at 3:07 PM, S3QD verified there were no policies developed to guide the use of the system which had been in use for three weeks and the facility continued to follow Policy CS-23, "Level of Observations," last revised 03/01/23. S3QD verified reports with data, like the one that showed a MHT had "forced" a significant number of observations consecutively in a short period of time, were sent to S1ADM via email daily. S3QD verified the reports were collected and reviewed at the weekly meeting about the system. S3QD verified the nurses did not have real time access to review the documented care provided by the MHTs during the shift, and no one was assigned to review the data collected and analyze the quality of care provided by the MHTs immediately after the shift, or daily as the reports were recieved.

Based on video, record review, and interview the registered nurse failed to supervise the care provided to the patients by the mental health technicians (MHTs). The deficient practice is evidenced by failure of the registered nurse to ensure the direct care staff to performed direct observation every 15 minutes as ordered for 1(#3) of 1 patient for whom video was reviewed from a total sample of 3 (#1-#3) patients.
Findings:

Review of the policy "Levels of Observations," last revised 03/01/2023, revealed in part, "Observation Levels: Every 15 minutes- the staff member will visually observe the patient every 15 minutes to moniter their location and activity, with an demphasis on any noticable behaviors of escalation, aggression and unsafe activities."
On 01/08/2024 between 1:22 PM and 1:51 PM, S3QD reviewed the video from the hall outside the room of Patient #3 with the surveyor. The video revealed on 01/04/2025 between 1:04 PM and 2:21 PM, Patient #3 was in the bedroom and no mental health technician performed observation rounds outside the bedroom during that time.

Review of the "Behavioral Health- Patient Observation Sheet" revealed Patient #3 had orders for observations to be performed every fifteen minutes from 0:16 AM through 6:44 PM on 01/04/2025. Patient #3 was also on precautions for elopement, self-harm and violent behavior. Further review revealed S6MHT documented observation at 1:06 PM in the hall, and S5MHT documented observations at 1:17 PM, 1:31 PM, 1:37 PM, 1:48 PM, and 2:00 PM in the bedroom.

After reviewing the video and observation sheets on 01/08/2024 at 3:07 PM, S3QD verified Patient #3 was not directly observed by the mental health technicians as documented in the patient record. S3QD also verified the electronic documentation did show S5MHT had "forced" the electronic observation because the patient was not in range and there was another patient with two forced observations by S5MHT during that time for whom video was not reviewed. S3QD verified the nursing staff did not have real time access to review the observations made by the mental health technicians during the shift. When asked how the nursing staff monitored the MHTs to ensure they were performing the observations as ordered, S3QD stated, "The nurses do their own rounds every 2 hours." S3QD verified the facility had no policy for the use of the newly initiated electronic monitoring and no policy that addressed the review of data provided by the system.

Based on observation, record review, and interview the psychiatric hospital failed to ensure all activities were therapeutic and age appropriate. The deficient practice is evidenced by the viewing of a movie with a Motion Picture Association of America (MPAA) rating of Restricted (R) by the adolescent patients.
Findings:

Review of the "Inpatient Adolescent Program Handbook," dated 09/01/2023, revealed in part, "Television sets are provided in patient lounges. Television can be a hindrance to the recovery process; however, there are designated times for watching the news and viewing television during free time. Television viewing is not to interfere with any scheduled activity or take place of completing assigned work. The choice of programs to be watched shall be governed by the democratic process as long as they are appropriate to the therapeutic process."

Review of the patient census for 01/08/2024 revealed the admitted patients ranged in age from 10 to 17 years old.

A tour of the facility was conducted on 01/08/2025 between 10:00 AM and 10:25 AM. While in Room A, direct observation revealed a movie playing on the television that was extremely violent and contained profanity. The movie was identified as a rated R movie. The rating was assigned for violence throughout, pervasive language, and some nudity.

In interview at the time of discovery, S4QA verified the movie was not appropriate. When asked how the movie was selected, S5MHT stated "One of the boy's requested it."

In interview on 01/08/2025 at 10:55 AM, S3QD verified the movie was not appropriate.