HospitalInspections.org

Based on observation, record review, and interview, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to protect and promote each patient's rights as evidenced by:
1) failure of the hospital to have a process in place to ensure criminal background checks are being performed, and applicants are being screened for convictions that bar employment (See findings in A0144);

An Immediate Jeopardy situation was identified on 10/31/2024 at 4:13 p.m. and reported to S1ADM and S3CEO. The Immediate Jeopardy situation was a result of the hospital failing to ensure criminal background checks were performed and applicants were appropriately screened for convictions that bar employment.

On 11/01/2024 at 10:50 a.m. S1ADM and S3CEO presented the 1st plan for lifting the immediacy of the IJ situation and the plan included the following:
1. All 48 active unlicensed employee files were audited on 10/31/2024. Out of the 48, 2 were found to have convictions listed on the stature. Both employees say they provided the documents stating their charges were dropped and not charge. Supporting documents not in the HR file. Both employees were suspended immediately and were given 5 business days to provide documentation to prove the charges were dropped. If documentation not provided within 5 business days, they will term those employees.
2. Ongoing Corrective Action Plan: Educated HR Staff on the Regulation not to hire unlicensed persons that have criminal background convictions listed in the Louisiana revised Statute 40:1203.3. Provided that statue to HR staff.

The Immediacy was lifted on 11/01/2024 at 11:20 a.m. by the survey team. Noncompliance remains at the Condition Level.

2) failure to ensure 15 minute observation rounds were performed by Mental Health Technicians as ordered by the physician on 10 (R1-R10) of 10 (R1-R10) psychiatric patients observed (See findings in A0144);

An Immediate Jeopardy situation was identified on 11/04/2024 at 5:06 p.m. and reported to S3CEO. The Immediate Jeopardy situation was a result of the hospital failing to ensure 15 minute observation rounds were performed as ordered by the physician.

On 11/06/2024 at 8:40 a.m. S2ADM presented the 1st plan for lifting the immediacy of the IJ situation and the plan included the following:
1. On 11/04/2024 S1DON started the education/inservice on how to do the Q15 checks with the 7p-7a shift. S1DON is educating all Nurses on all shifts that they need to supervise the MHTs to make sure that the MHTs are doing the Q15 checks and other tasks assigned to them to ensure the patient safety and provide good care.
2. On 11/05/2024 S3CEO met with S1DON and S2ADM and came up with the following corrective action plan:
a. Shift nurses need to tag along with MHT to perform Q15 observation rounds twice every 2 hours and review MHT Q15 round sheets to make sure they are documenting accurately.
b.S1DON, Nurse Manager and S2ADM each one of them needs to tag along with MHT and make at least one Q15 round with MHT in a day and review MHT Q15s documenting accuracy.
c. S1DON, Nurse Manager and S2ADM or their designee to spot check cameras daily 6 times (Example: 9:00 a.m., 1:00 p.m., 4:00 p.m., 8:00 p.m., 2:00 a.m., 6:00 a.m.) to make sure MHTs are doing Q15 checks as ordered.
d. Educate MHTs, Nurses on the importance of patient safety and Q15 rounds and discipline them if they violate the policy. We are including this training in town hall meeting scheduled on 11/06/2024 at 3:00 p.m. and 11/08/2024 at 3:00 p.m.
3. Ongoing Corrective Action plan: We are going to report the Nurses Q15 tag along MHT rounds audits and Q15 video audits by administration to the monthly QAPI team and governing body for 4 months. The goal is 100% in compliance.

Documentation of staff training content and the accompanying sign in sheets was given to the survey team as part of the process for lifting the IJ. The training content was as referenced in the plan for lifting when it was reviewed on 11/06/2024.

On 11/06/2024 at 12:55 p.m., video footage was reviewed with S2ADM for the night of 11/05/2024 through 11/06/2024. Observations of video footage revealed Q15 rounds were not completed between 6:15 a.m. and 7:15 a.m.

In an interview on 11/06/2024, S2ADM confirmed that they have not started spot checking cameras since IJ called, but will start today.

Due to the continued failure to ensure 15 minute observation rounds were performed as ordered by the physician, the IJ remained in place on 11/06/2024 pending further observations and completions of camera audits.

On 11/07/2024 at 8:45 a.m., updated education list requested from S1DON.

On 11/07/2024 from 8:58 a.m. - 9:38 a.m. observations were conducted on the unit. Observations revealed Q15 minute observation rounds being performed by staff. S15MHT confirmed she had received education regarding Q15 rounds during this time.

On 11/07/2024 at 10:48 a.m. S1DON was educating the staff currently working about Q15 rounds on the unit.

On 11/07/2024 at 11:06 a.m. S2ADM provided updated documentation of staff education. All staff who worked 11/06/2024 and who are scheduled to work 11/07/2024 have signed that they received education on Q15 rounds.

On 11/07/2024 at 11:11 a.m., video footage was reviewed with S2ADM for the night of 11/06/2024 through 11/07/2024. Review of video footage revealed Q15 rounds being performed and revealed nursing staff rounding with MHT's every 2 hours on patients.

The Immediacy was lifted on 11/07/2024 at 11:42 a.m. However, there was not enough evidence to determine sustainability of compliance for the Condition of Patient Rights to be cleared. Noncompliance remains at the Condition Level.


3) failure to ensure the immediate safety of a patient being sexually assaulted was implemented (See findings in A0145);
4) failure of the staff who witnessed the sexual abuse to immediately report the incident (See findings in A0145); and
5) failure to ensure the staff member accused of patient abuse was immediately removed from patient care (See findings in A0145).

Based on record review and interview the hospital failed to ensure the psychiatric patients received care in a safe setting. This deficient practice is evidenced by:
1) failure of the hospital to have a process in place to ensure criminal background checks are being performed, and applicants are being screened for convictions that bar employment;
2) failure to ensure 15 minute observation rounds were performed by Mental Health Technicians as ordered by the physician on 10 (R1-R10) of 10 (R1-R10) psychiatric patients observed.
Findings:

1) Failure of the hospital to have a process in place to ensure criminal background checks are being performed, and applicants are being screened for convictions that bar employment.

Review of the hospital policy titled "Selection and Hiring of Personnel" with last revision/approval date of 01/2024 revealed in part: PURPOSE: To outline the requirements for and process of selection and hiring of hospital personnel as well as the process for promotion, demotion, and transfer within the company. DEFINITION: Personnel: The hospital defines "personnel" as any individual, whether the person is employed by the hospital or contracted who provides service on behalf of the hospital, and who is subject to and governed by all of the policies and procedures of the hospital as well as all appropriate federal and state regulations governing the hospital and the practices of its personnel. POLICY: 5. The hospital prohibits any personnel from engaging in unlawful practices or any form of harassment involving patients, families, or co-workers. HIRING: 10. In accordance with appropriate state and federal law and regulation, the hospital may require criminal background checks on employees who are to have direct contact with a consumer in the hospital such as a patient and his/her significant others such as family and friends in an effort to facilitate patient safety. Information obtained during the background check will be submitted to the Administrator and/or designee.

A review of hospital policy titled "Patient Abuse and/or Neglect," last revised January 2024, revealed in part: Procedure: 1. Screening. All potential employees undergo a criminal background check as a part of their pre-employment screening. Persons with a record of abuse or neglect are not hired or retained as employees.

Review of S8MHT's personnel record revealed a criminal background check dated 08/26/2024 which had R.S. 14:67 Felony Theft and R. S. 14:44.1 Second Degree Kidnapping among the findings. S8MHT date of hire was 09/11/2024 even though the criminal background had convictions that bar employment. Furthermore S8MHT's personnel record revealed a document that S3CEO reviewed the criminal background investigation and recommended hiring.
Review of a Self-Report dated 10/29/2024 revealed S8MHT was caught sexually abusing a schizo-affective disorder, intellectually disabled female patient.

Review of S11MHT's personnel record revealed a criminal background check dated 10/16/2024 which had R.S. 14:89 Crime Against Nature. S11MHT date of hire was 11/21/2018 even though the criminal background had a conviction that bar employment. Furthermore S11MHT's personnel record revealed a document that S3CEO reviewed the criminal background investigation and recommended hiring.

2) Failure to ensure 15 minute observation rounds were performed by Mental Health Technicians as ordered by the physician on 10 (R1-R10) of 10 (R1-R10) psychiatric patients observed.

A review of hospital policy titled, "Patient Observation Levels," last revised January 2024, revealed in part: POLICY: It is the policy of the Hospital to provide observation categories to carry out the physician's order for patient observation. PURPOSE: Provide clear directions for staff to carry out observations of patients hospitalized at Hospital as ordered by the patient's physician. PROCEDURE: Standard q 15-minute Observations: The assigned staff observes the patient's whereabouts on the unit every 15 minutes. The patient's whereabouts are recorded on the MHT Observation Record at 15-minute intervals and this document becomes part of the permanent record. The RN will review and initial the MHT's Observation Record every 4 hours.

On 11/04/2024 at 12:45 p.m., review of video footage navigated by S2ADM of hall "k"on 11/04/2024 within the timeframe of 12:05 a.m. - 7:30 a.m. revealed the MHT's failed to round between:
12:07 a.m. - 7:21 a.m. (7 hours and 14 minutes) that there were no every 15 minute observations performed by a Mental Health Technician.

Review of patient records for hall "k" revealed all 10 patients had physician orders for every 15 minute observations.

Review of the MHT Observation Check Sheet for 11/04/2024 revealed that the MHT initialed that completed rounds on the patients every 15 minutes from 12:07 a.m. - 7:21 a.m.

In an interview on 11/04/2024 at 2:30 p.m. S2ADM confirmed that no Mental Health Technician rounds were performed as per physician order and hospital policy on patients R1-R10. S2ADM also confirmed that MHT Observation Check Sheets should not have been initialed by the MHT since video review proved that the rounds were not performed. S2ADM agreed this placed all 10 patients at risk for serious injury, serious harm, serious impairment or death.


50453

50453

Based on record review, video observation and interview, the facility failed to ensure all patients were protected and free from abuse and/or neglect. This deficient practice is evidenced by:
1) failure to ensure the immediate safety of a patient being sexually assaulted was implemented;
2) failure of the staff who witnessed the sexual abuse to immediately report the incident;
3) failure to ensure the staff member accused of patient abuse was immediately removed from patient care.
Findings:

A review of hospital policy titled "Patient Abuse and/or Neglect," last revised January 2024, revealed in part: Procedure: 1. Screening. All potential employees undergo a criminal background check as a part of their pre-employment screening. Persons with a record of abuse or neglect are not hired or retained as employees. 2. Training. a. Each employee will be educated on abuse and neglect during general orientation ... prior to coming into direct contact with patients. b. Acknowledgement of this instruction shall be signed by the employee and filed in his/her personnel file. (A) Abuse: 1. Class 1 abuse means any act (or failure to act) done knowingly, recklessly, or intentionally, including an act, which caused or could have caused a major physical injury to a patient ... any sexual activity between an employee, employee of an affiliated, or agent and a patient will be considered to be a Class 1 abuse. (B) Neglect: Neglect is the act or series of acts or omission of any employee, affiliated, or agent which causes or may have caused any physical or emotional injury to patient. Examples of neglect shall include ... failure to provide a safe environment. 3. Prevention: a. The hospital will provide reasonable prevention of abuse and neglect. 4. Identify, Protect: a. When an incident arises that constitutes possible neglect and/or abuse during any course of the patient's care, the following procedure is to be followed: [1] A staff person witnessing or suspecting patient abuse or neglect must report the incident to their immediate supervisor as soon as they are aware of the incident. Failure to do so is grounds for immediate termination. [3] The employee documents all information concerning the incident on the Incident Report form, being as descriptive and factual as possible. [4] The RN will assume care of the patient. [5] the safety of the patient will be ensured immediately. If a staff member is accused of abuse or neglect, they will be removed from the care of the alleged victim. [6] Once the patient is safe, the Director of Nursing, Administrator, and patient's physician will be notified. 6. Report, Respond: d. Appropriate protective agencies and licensing agencies will be notified in accordance with State and Federal laws individualized to the situation. e. All patients involved in abuse and neglect incidents will have their treatment plans reviewed for any needs and be adjusted appropriately.

A review of hospital policy titled, "Rights of All Patients (Voluntary and Involuntary Admits)," last revised January 2024, revealed in part: Purpose: To provide education and understanding to hospital employees on informing and upholding the patient's rights. Procedure: 5. Rights and Responsibilities - Respect, Dignity and Comfort: You have the right to considerate, respectful care at all times with recognition of your personal dignity and comfort, cultural, psychosocial, spiritual, and personal values, beliefs and preferences. You have the right to be protected from mental, physical, sexual and verbal abuse, neglect, harassment or exploitation.

1) Failure to ensure the immediate safety of a patient being sexually assaulted was implemented.
Review of Patient #1's medical record revealed she was admitted with Suicidal Ideation, and had a diagnosis of schizo-affective disorder and an intellectual disability.

Review of incident report involving Patient #1 revealed the following:
Date of Incident: 10/29/2024, time: 11:00 a.m., Type of occurrence: Sexual Offense
Describe the facts of the occurrence: S9LPN was asked by S11MHT to see what S8MHT was doing in Room a because S11MHT said he went in there twice and closed the door. S9LPN then just opened the door and seen patient laying on the bed with clothes off, legs spread apart, and S8MHT head was down in between Patient #1's legs. S9LPN told S8MHT to stop that he has to quit it and he said you see what I've got going on here (that was said when S9LPN 1st opened the door.) S9LPN then went to nursing station and told S10RN, charge nurse.
DON/Adminstrative Review: This report is currently under investigation. S8MHT sent home, badge confiscated, and police informed.
Person reporting: S9LPN 10/29/2024 at 11:00 a.m.
DON signed 10/29/2024 at 2:00 p.m.
Risk Management signed 10/29/2024 at 2:20 p.m.
BRPD - Report time and date: 10/29/2024 (no time documented by BRPD). Incident type: Sexual Offense

On 10/31/2024 at 10:50 a.m., video footage was reviewed for the incident involving Patient #1 that occurred on 10/29/2024 navigated by S2ADM. Review of the video footage revealed the following:
10:51:56 a.m. - Patient #1 goes in her room, room a.
10:52:20 a.m. - Patient #1 is standing with S8MHT in doorway of Room a.
10:52:41 a.m. - S8MHT walks away.
10:53:37 a.m. - S8MHT enters room a and closes the door.
10:55:34 a.m. - S8MHT exits room a and closes the door.
10:56 a.m. - S8MHT outside room a.
11:03:32 a.m. - S8MHT enters room a and partially closes door.
11:03:57 a.m. - S8MHT exits room a and stands outside door way.
11:15:49 a.m. - S8MHT enters room a partially closes door.
11:16:08 a.m. - S8MHT exits room a.
11:24:37 a.m. - S8MHT enters room a and closes door all the way.
11:29:16 a.m. - S8MHT exits room a and closes the door. (S8MHT was in room a with Patient #1 for 5 minutes with the door closed at this point)
11:31:30 a.m. - S8MHT enters room a and closes door.
11:34:04 a.m. - S9LPN opens room a. (S8MHT has been in room a with Patient #1 for 3 minutes with the door closed at this point)
11:34:13 a.m. - S9LPN closes door to room a leaving Patient #1 and S8MHT in the room together while she stands outside Room a. S9LPN is viewed talking with other patients.
11:34:40 a.m. - S9LPN walks away from room a, and out of camera view. S8MHT is still in room a with Patient #1.
11:34:50 a.m. - S8MHT exits room a.
11:38 a.m. - S9LPN walks by room a, door still closed.
11:46 a.m. - S9LPN walks by room a, door still closed.
11:49:05 a.m. - S24MNP opens door to room a, and then closes door.
11:51:30 a.m. - Patient #1 at door way of room a in sleeveless shirt and shorts.
11:53:09 a.m. - Patient #1 talking with S24MNP at doorway to room a. S24MNP places stethoscope on patient in doorway to room a.
11:54:10 a.m. - S24MNP walks away, Patient #1 in room a, door is open.
11:55:34 a.m. - S8MHT walks to room a and stands in doorway.
11:55:42 a.m. - S8MHT walks away and shuts door to room a.
11:59:57 a.m. - S8MHT outside of room a sitting in chair.
12:06:40 a.m. - S11MHT walks into room a, door remains open. S8MHT is still in chair outside room a.
12:06:55 a.m. - S11MHT exits room a.
12:07:19 p.m. - Patient #1 walks out of room a and is brought by S11MHT to room d to speak with S23PNP. This is when Patient #1 informs S23PNP about the sexual assault involving S8MHT.
12:08:59 p.m. - S8MHT goes to bathroom and then around hallway s which contains room d.
12:10:25 p.m. - S8MHT walks down hallway s again, door to room d is closed.
12:12:48 p.m. - Patient #1 exits room d and returns to the unit.
12:15:20 p.m. - S10RN exits room d.
12:15:56 p.m. - S10RN walks into room e and told S1DON about incident.
12:19:26 p.m. - S2ADM walked into room e.
12:19:48 p.m. - S8MHT walked into room e.
12:23:05 p.m. - S8MHT sent home after S2ADM collects employee badge and keys.

In an interview on 10/31/2024 at 11:13 a.m., S2ADM confirmed that the nurse closed the door to room a, and left Patient #1 alone with S8MHT while she was being sexually assaulted. S2ADM also stated he questioned why S9LPN turned away and closed the door when she discovered the incident. Per S2ADM, S9LPN stated to him that she (S9LPN) was traumatized by what she saw.

In an interview on 10/31/2024 at 12:13 p.m., S2ADM confirmed that from the time the incident was discovered by S9LPN on 10/29/2024 at 11:34 a.m., the next time a nurse saw Patient #1 was when the nurse practitioner was rounding on the unit at 11:53 a.m. S2ADM verified that when the nurse practitioner was making her rounds at this time, she was not aware of the sexual assault. S2ADM confirmed during this time that S8MHT remained on the unit approximately 44 minutes following discovery of sexual assault until S8MHT called off the unit by S1DON. S2ADM also confirmed that S8MHT continued to perform patient care during this time, including rounding on Patient #1.

In an interview on 10/31/2024 at 1:00 p.m., S1DON confirmed that S9LPN should not have left Patient #1 alone with S8MHT when she discovered the sexual assault. S1DON confirmed that prior to this incident, S9LPN had received education regarding abuse/neglect. At this time, S1DON stated he has not educated S9LPN in regards to abandoning Patient #1 while the perpetrator was still in the room with Patient #1.

In an interview on 10/31/2024 at 1:10 p.m. both S1DON and S2ADM confirmed that the staff failed to ensure the immediate safety of Patient #1 was implemented after discovering she was being sexually assaulted. S1DON and S2ADM also confirmed that all 3 nurses working at time of incident failed to go immediately assess the patient following the sexual assault.

2) Failure of the staff who witnessed the sexual abuse to immediately report the incident.
On 10/31/2024 from 10:50 a.m. - 1:15 p.m., video footage was reviewed for the incident involving Patient #1 that occurred on 10/29/2024 navigated by S2ADM. Review of the video footage revealed the following:
10/31/2024
11:34:04 a.m. - S9LPN opens room a. (S8MHT has been in room a with Patient #1 for 3 minutes with the door closed at this point)
11:34:13 a.m. - S9LPN closes door to room a leaving Patient #1 and S8MHT in the room together while she stands outside room a. S9LPN is viewed talking with other patients.
11:34:40 a.m. - S9LPN walks away from room a, and out of camera view. S8MHT is still in room a with Patient #1.
11:34:50 a.m. - S8MHT exits room a.
11:38 a.m. - S9LPN walks by room a, door still closed.
11:44:39 a.m. - S9LPN walks into room b. Charge Nurse, S10RN is at desk eating, and S12RN is also at the desk.
11:46:03 a.m. - S9LPN walks out room b and walks by room a. Door to room a is closed.
11:46:49 a.m. - S9LPN walks back to room b and puts head on desk.
11:50:20 a.m. - All nurses still in room b.
11:51:39 a.m. - S12RN is laughing in room b.
11:56:30 a.m. - S9LPN is laughing in room b.
12:00:00 p.m. - All nurses still in room b.
12:00:41 p.m. - S10RN goes into room c.
12:01:45 p.m. - S10RN exits room c.
12:04:00 p.m. - S11MHT sitting in chair outside room c.
12:05:15 p.m. - S10RN talking with S11MHT in room c.
12:07:00 p.m. - S10RN exits room c and goes into room d next door.
12:07:19 p.m. - Patient #1 walks out of room a and is brought by S11MHT to room d to speak with S23PNP. This is when Patient #1 informs S23PNP about the sexual assault involving S8MHT.

Review of Patient #1's medical record revealed the following note on 10/29/2024 at 12:07 p.m. by the nurse practitioner regarding the incident:
Immediately prior to patient being brought to exam room for eval, S10RN spoke with provider and requested that provider speak with the patient due to an "incident with male staff member that went in her room with door closed and was sexually inappropriate." Patient evaluated with S10RN present. She reports feeling great and denies any current depression or anxiety. Patient states mood has been good since hospital admission. She is without any overt delusions. She is fully oriented, cooperative and reports looking forward to being discharged home tomorrow and following up with outpatient.
After evaluating patient mental status, the patient was asked if a male staff member entered her room. Patient became very guarded and appeared anxious, with poor eye contact and reported "I was just trying to sleep." Patient initially had difficulty disclosing the incident, but then reported the male staff member brought her a candy bar, which she reported is in bathroom trashcan. Unprompted but with much apparent anxiety, the patient described behaviors from the male staff member that were, incredibly inappropriate. Emotional support was provided and hospital administration notified immediately after patient encounter. Exact events of the S8MHT's misconduct were then confirmed by staff S9LPN, who initially witnessed the behaviors of the male staff member upon entering the patient's room to check on the patient and had notified S10RN. At 12:41 p.m. provider returned to unit and asked patient if she would like to speak with the police to press charges against the male staff member. Patient stated while nodding, "Yes. I want to talk to the police."

Review of Patient # 1's medical record failed to reveal documentation by S9LPN who witnessed the sexual assault, what steps she took to resolve the incident, or when she notified someone of the incident. Further review of Patient #1's medical record revealed the only nursing note entered about the sexual assault was entered at 6:37 p.m. on 10/29/2024 by S10RN. This note stated, Patient #1 brought in to speak to S23PNP about reported incident. Patient #1 admitted to us that S8MHT came into room with a snickers bar and started licking her neck, breast and between legs. Administration notified. Accused employee taken off of unit. Date/time of this nursing note was back dated as occurring on- 10/26/2024 at 11:30 a.m.

In an interview on 10/31/2024 at 11:13 a.m., S2ADM confirmed that the nurse who witnessed the sexual abuse did not report the incident as soon as she was aware of the incident as per hospital policy. S2ADM also confirmed that he is unsure of the exact time S9LPN reported the incident to the charge nurse, but verified that the sexual assault was reported when S9LPN was in room b with S10RN and S12RN between 11:44 a.m. - 12:00 p.m. on 10/29/2024.

In an interview on 10/31/2024 at 4:00 p.m., S9LPN confirmed that she opened Patient #1's door to her room and found Patient #1 lying on bed naked with S8MHT's head in between Patient #1's legs. S9LPN reported that she told S8MHT to stop and to get out. S9LPN admits to leaving Patient #1's room and closing the door while S8MHT and Patient #1 remained in the room. S9LPN reports that she stood outside Patient #1's room for a minute then walked away before S8MHT left Patient #1's room. S9LPN states that she didn't tell the charge nurse about incident immediately, and that she didn't check on Patient #1 intiially. When asked why she delayed in reporting the incident, S9LPN replied that she was processing the events. S9LPN states later that day she asked Patient #1 if she was ok and Patient #1 stated she wanted to notify police of incident.

In an interview on 11/04/2024 at 11:00 a.m., S1DON confirmed there is no documentation in Patient #1's medical record by S9LPN of the time she reported the incident or to whom it was reported to.

3) Failure to ensure the staff member accused of patient abuse was immediately removed from patient care.
On 10/31/2024 at 10:50 a.m. - 1:15 p.m., video footage was reviewed for the incident involving Patient #1 that occurred on 10/29/2024 navigated by S2ADM. Review of the video footage revealed the following:
11:34:04 a.m. - S9LPN opens room a and discovers Patient #1 is being sexually assaulted by S8MHT.
11:34:50 a.m. -12:19:48 p.m. S8MHT continued to make patient rounds on the unit, including rounds on Patient #1.
12:19:48 p.m. - S8MHT in room e with S1DON and S2ADM.
12:23:05 p.m. - S8MHT sent home after S2ADM collects employee badge and keys.

In an interview on 10/31/2024 at 12:20 p.m., S2ADM confirmed that S8MHT remained on the unit approximately 44 minutes following discovery of sexual assault. S2ADM also confirmed that S8MHT was not immediately removed from the care of the alleged victim as per hospital policy.

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation (CoP) for Nursing Services. The deficient practice was evidenced by:

1) failure to verify each RN's nursing license to be valid and current for 1 (S10RN) of 3 (S10RN, S12RN, S14RN) RN personnel records reviewed (See findings in A0394);
2) failure to document Patient #1's condition following sexual assault incident (See findings in A0395);
3) failure of nursing staff to document vital signs as ordered by the physician for 1 (#2) or 3 (#1-#3) patient medical records reviewed (See findings in A0395);
4) failure of the RN to document an assessment each shift for 2 (#2, #3) of 3 (#1-#3) patient medical records reviewed (See findings in A0395);
5) failure to update the care plan on 2 (#1, #2) of 3 (#1-#3) patients reviewed (See findings in A0396);
6) failure to ensure a Registered Nurse made all patient care assignments (See findings in A0397);
7) failure of the nursing staff to administer medications per policy in 1 (#2) of 3 (#1-#3) patient records reviewed (See findings in A0398);
8) failure of the nursing staff to monitor the therapeutic effect of PRN medications in 3 (#1-#3) of 3 (#1-#3) patients reviewed (See findings in A0405); and
9) having electronic standing admission order sheet with options for ordering medications which were being completed by a Registered Nurse instead of the practitioner for 3 (#1-#3) of 3 (#1-#3) records reviewed for medication orders (See findings in A0406).

Based on record review and interview, the hospital failed to ensure each RN's nursing license was verified to be valid and current. This deficient practice was evidenced by failing to verify each RN's nursing license to be valid and current for 1 (S10RN) of 3 (S10RN, S12RN, S14RN) RN personnel records reviewed.

Findings:

Review of the hospital policy titled "Selection and Hiring of Personnel" with last revision/approval date of 01/2024 revealed in part: PURPOSE: To outline the requirements for and process of selection and hiring of hospital personnel as well as the process for promotion, demotion, and transfer within the company. DEFINITION: Personnel: The hospital defines "personnel" as any individual, whether the person is employed by the hospital or contracted who provides service on behalf of the hospital, and who is subject to and governed by all of the policies and procedures of the hospital as well as all appropriate federal and state regulations governing the hospital and the practices of its personnel. POLICY: 5. The hospital prohibits any personnel from engaging in unlawful practices or any form of harassment involving patients, families, or co-workers. HIRING: 4. Professional licensure/certification will be confirmed through visualization of the actual license/certificate. The appropriate governing board for the applicant's area of practice will be contacted for licensure verification as well. All personnel of the hospital who are required to be licensed, registered, certified, or otherwise approved in accordance with federal and state regulations in order to perform the duties of their position within the hospital must present evidence of said licensure, registration, certification, or other approval prior to hire, and annually thereafter prior to expiration date. Proof of current, valid licensure in the form of a verification of the license/certification/registration will be maintained in appropriate personnel files.

Review of S10RN's personnel record revealed a date of hire of 09/25/2023 and RN license verification documentation dated 09/25/2023 had blanks for license, active, license status, license original issue date, license expiration date, and compact status. Furthermore it was documented on the RN license verification document: Primary source Boards of Nursing message & notification history: 05/25/2023- This alert is provided by the Louisiana RN Board of Nursing: Please fax a written request to the Louisiana State Board of Nursing at (225) 755- 7582 as the information about this license is not available.

In an interview on 11/07/2024 at 10:50 a.m. S2ADM verified the license verification documentation that was included in S10RN's personnel record was missing the following information: license, active, license status, license original issue date, license expiration date, and compact status. Furthermore S2ADM verified that the Louisiana State Board of Nursing had not been emailed until 11/06/2024 at 3:13 p.m. or faxed until 11/07/2024 at 9:36 a.m. with no response.



50453

50453


Based on record review and interview, the hospital failed to have a Registered Nurse supervise and evaluate the nursing care for each patient. The deficient practice is evidenced by:
1) failure to document Patient #1's condition following sexual assault incident;
2) failure of nursing staff to document vital signs as ordered by the physician for 1 (#2) or 3 (#1-#3) patient medical records reviewed.;
3) failure of the RN to document an assessment each shift for 2 (#2, #3) of 3 (#1-#3) patient medical records reviewed.
Findings:

1) Failure to document Patient #1's condition following sexual assault incident.
Review of Patient #1's medical record failed to reveal documentation of an assessment of the Patient #1's condition from a nurse following the sexual assault incident that occurred on 10/29/2024. Further review of Patient #1's medical record revealed following documentation by the primary nurse:
10/29/2024 at 12:00 p.m. - Patient at lunch in dinging hall. NADN (No Acute Distress Noted). Will continue to monitor.
10/29/2024 at 4:00 p.m. - Patient in dayroom watching tv. NADN. Will continue to monitor. Medical Problems this shift: None at this time.

In an interview on 11/04/2024 at 11:00 a.m., S1DON confirmed that video footage revealed that at 12:00 p.m. on 10/29/2024 S12RN was in room b, and she did not go assess her patient once she was informed of the sexual assault. S1DON also confirmed at this time that on 10/29/2024 at 12:00 p.m., Patient #1 was in room a prior to being brought to the provider. S1DON further confirmed that S12RN failed to assess Patient #1 after the sexual assault and document the assessment in Patient #1's medical record.

2) Failure of nursing staff to document vital signs as ordered by the physician for 1 (#2) or 3 (#1-#3) patient medical records reviewed.
A review of hospital policy titled "Vital Signs General," last revised January 2024, revealed in part: PROCEDURE: 1. Vital Signs are defined as blood pressure, temperature, pulse, respirations, and pulse oximetry. 2. Vital signs for all patients admitted to the hospital will be obtained on admission then twice a day thereafter unless otherwise ordered by the attending psychiatrist or medical physician. 5. The nurse will recheck abnormal vital signs and document findings. 6. The attending psychiatrist and/or medical physician will be notified immediately when there is either a significant change in the patient's vital signs or when directed by physician order. 7. Vital signs are to be recorded on the patient's medical record according to Hospital policy.

Patient #2
A review of Patient #2's medical record revealed an admit diagnosis on 10/18/2024 of Schizoaffective disorder and bipolar with a history of Hypertension. Further review of Patient #2's medical record revealed on 10/25/2024 at 4:28 p.m. an order was entered by S4NM for the provider to obtain Vital signs every 4 hours for 3 days, starting 10/25/2024 at 4:15 p.m. and ending 10/28/2024. Per MAR for Patient #2, vital signs were to be obtained at the following times per order: 12:15 a.m., 4:15 a.m., 8:15 a.m., 12:15 p.m., 4:15 p.m., and 8:15 p.m.
Review of Patient #2's vital signs revealed that vital signs were only obtained the following times:
10/25/2024: 9:53 a.m. and 9:17 p.m.
10/26/2024: 7:00 a.m., 4:09 p.m., and 9:44 p.m.
10/27/2024: 7:00 a.m., 12:24 p.m., and 10:17 p.m.
10/28/2024: 10:08 a.m. and 9:02 p.m.
Review of scheduled vital sign times listed on the MAR revealed that the nurse documented n/a. Patient #2's medical record failed to reveal documentation for not completing the order for scheduled vital signs. There was also no order from the provider to discontinue obtaining vital signs every 4 hours. Further review failed to reveal that vital signs were obtained every 4 hours from 4:15 p.m. on 10/25/2024 through 10/28/2024 per provider order.

In an interview on 11/07/2024 at 2:24 p.m., S1DON confirmed that vital signs were not obtained on Patient #2 as per provider order. S1DON also confirmed that the nurse should not have documented "n/a" without documenting a comment and provider notification about why they were not obtained.

3) Failure of the RN to document an assessment each shift for 2 (#2, #3) of 3 (#1-#3) patient medical records reviewed.

Patient #2
A review of Patient #2's medical record revealed that Patient #2 was admitted on 10/17/2024 at 10:15 a.m. and discharged on 10/29/2024 at 11:25 a.m. Further review of the nursing assessments in Patient #2's medical record revealed the following:
10/17/2024: no documented 7p-7a nursing assessment.
10/19/2024: no documented 7p-7a nursing assessment. On 10/19/2024 at 9:06 p.m. a Multidisciplinary Nursing Note was entered stating, Patient wouldn't allow me to assess him. Patient wouldn't talk to me at all.
10/20/2024: 7a-7p nursing assessment entered by S10RN on 10/22/2024 at 5:52 p.m. (entered 2 days later)
10/21/2024: There are 2 different 7a-7p nursing assessments entered by S10RN on 10/22/2024 at 7:49 a.m. and 7:58 a.m.
10/22/2024: no documented 7a-7p nursing assessment.
10/24/2024: no documented 7a-7p nursing assessment.

In an interview on 11/06/2024 at 12:55 p.m., S1DON confirmed that a nursing assessment is to be completed for each shift on each patient. S1DON verified the Multidisciplinary Nursing Note entered on 10/19/2024 at 9:06 p.m. is not a nursing shift assessment. S1DON also confirmed that this note does not contain required fields that are included in the nursing shift assessment.

In an interview on 11/07/2024 at 2:17 p.m., S1DON confirmed that Patient #2's medical record failed to reveal a nursing assessment for each shift on 10/17/2024, 10/19/2024, 10/22/2024, and 10/24/2024. At this time S1DON confirmed the note entered for 7a-7p on 10/20/2024 was entered 2 days late, and verified that documentation should be completed within 24 hours when backcharting. S1DON also confirmed that there were multiple notes entered for 10/21/2024 at different times and is unable to verify which assessment is the correct shift assessment.

Patient #3
A review of Patient #3's medical record revealed that Patient #3 was admitted on 10/25/2024 at 4:00 a.m. and discharged on 10/31/2024 at 9:20 a.m. Further review of the nursing assessments in Patient #2's medical record revealed the following:
10/28/2024: no documented 7a-7p nursing assessment.
10/28/2024: no documented 7a-7p nursing assessment.

In an interview on 11/07/2024 at 3:00 p.m., S1DON confirmed that Patient #3's medical record failed to reveal a nursing assessment for each nursing shift on 10/28/2024 7a-7p and 7p-7a.

Based on record review and interview, the nursing staff to develop and update an individualized plan of care for each patient. This deficient practice was evidenced by failing to update the care plan on 2 (#1, #2) of 3 (#1-#3) patients reviewed.
Findings:

A review of hospital policy titled "Multidisciplinary Treatment Plan," last revised January 2024, revealed in part: PROCEDURE: 1. An initial Care Plan/Problem List is developed within 8 hours of admission by the registered nurse that completes the Nursing Admission Assessment. This is considered the beginning of the MTP. 2. The Initial Care Plan should address the presenting problem and any high-risk behaviors at a minimum. 3. It is important for the registered nurse to include physical issues that require intervention during hospitalization, even if the problem is adequately managed (if the patient has hypertension, this should be addressed in the Initial Care Plan, even if medication keeps the pressure manageable). 10. The MTP will be updated as needed during hospitalization, to reflect such interventions as seclusion, a new medical illness, etc.

A review of hospital policy titled "Patient Abuse and/or Neglect," last revised January 2024, revealed in part: 6. Report, Respond: e. All patients involved in abuse and neglect incidents will have their treatment plans reviewed for any needs and be adjusted appropriately.

Patient #1
Review of incident report involving Patient #1 revealed the following:
Date of Incident: 10/29/2024, time: 11:00 a.m., Type of occurrence: Sexual Offense

Review of Patient #1's medical record failed to reveal evidence that Patient #1's care plan was updated after being sexually assaulted on 10/29/2024.

In an interview on 11/07/2024 at 12:35 p.m., S1DON confirmed that Patient #1's care plan was not updated following the sexual assault incident or per policy after being involved in an abuse incident.

Patient #2
Review of Patient #2's medical record revealed he was admitted on 10/17/2024 at 10:15 a.m. with psychosis. Upon arrival the nurse documented Patient #2 was trying to elope off unit during admission. Further review revealed the Patient #2 had a history of Hypertension.

Review of Patient #2's medical record failed to reveal Hypertension or risk for elopement documented on Patient #2's care plan.

In an interview on 11/07/2024 at 1:56 p.m., S1DON confirmed that the care plan for Patient #2 should have included Hypertension and risk for elopement.

Based on record review and interviews the hospital failed to ensure a registered nurse assigned the nursing care of each patient to other nursing personnel in accordance with the patient's needs. This deficiency is evidenced by failing to ensure a Registered Nurse made all patient care assignments.
Findings:

A review of hospital policy titled, "Scope of Services- Staffing Grid," last revised January 2024, revealed in part: The RN on each shift is responsible for delegating LPN and MHT assignments on each shift.

A review of the staff assignments for 11/03/2024 failed to reveal that patient assignments were made by the RN for each shift.

A review of the staff assignments for 11/04/2024 revealed hand written patient assignments by S1DON.

In an interview on 11/04/2024 at 3:12 p.m., S1DON confirmed that the staff decide amongst themselves what the patient assignments will be and verified the staff assignments are not being made by the RN. S1DON also confirmed that the hospital policy states the RN on each shift is responsible for delegating patient care assignments.

In an interview on 11/07/2024 at 8:45 a.m., S1DON confirmed that he did not have patient care assignment sheets for 11/05/2024 7p-7a or 11/06/2024 7a-7p.

Based on record review and interview, the Director of Nursing failed to ensure all nursing staff adhered to the policies and procedures of the hospital. This deficient practice is evidenced by failure of the nursing staff to administer medications per policy in 1 (#2) of 3 (#1-#3) patient records reviewed.
Findings:


A review of hospital policy, titled "Medication Errors," last revised January 2024, revealed in part: DEFINITIONS: Types of medication errors include: 1. Ordering 2. Transcribing including unordered dose 3. Dispensing: wrong patient, dose, route, or time 4. Omission (not administered before next schedule dose due) 5. Procurement 6. Other Medication Errors 7. Adverse Drug Reaction PROCEDURE: When a medication error occurs, the following should occur in this order: 1. Notify the physician and evaluate the patient. 2. Perform any necessary clinical interventions, within the patient care provider's scope of practice to reduce the negative effects of the identified error. 3. Record the medication as given in the medical record. 4. Record the observed and assessed outcome of the patient in the medical record. 5. Record notification of physician in the medical record with any resultant orders. 6. Record any actions and clinical interventions take and the patient's response to same. 7. Report the error in detail on an occurrence report.

A review of hospital policy, titled "Medication Administration," last revised January 2024, revealed in part: PRINCIPLES OF MEDICATION ADMINISTRATION: A. No medication should be given without a doctor's order. B. Each dose of medicine to be administered must be considered as offering an opportunity for a potential medication error. C. Never give a medicine about which you have a shadow of a doubt. E. Observe the "six rights" in giving medications: The right patient, the right medicine, the right time, the right dose, the right method of administration, and document. M. Medications are to be given and charted using the MAR System by the nurse who gives them. N. Phone orders for medications may be taken by an RN or an LPN and countersigned by a doctor. The nurse taking the phone orders must read the complete order back to the doctor and document, R.B.V.O.

Review of Patient #2's medical record revealed Patient #2 was a FVA on 10/17/2024, with an admit diagnosis of Psychosis. Patient #2 was discharged on 10/29/2024. Review of the hospital incident reports revealed Patient #2 had a medication error that was discovered on 10/24/2024.

Review of incident report involving Patient #2 revealed in part the following:
On October 21, 2024 S26MD, Psychiatrist ordered Invega Sustenna 234mg IM for Patient #2. The hospital had samples of this medication in house therefore S9LPN administered the 234mg IM injection using one of the samples. The pharmacy shipped the Invega Sustenna 234mg injection to the hospital the evening of 10/21/2024. On 10/23/2024 the medication shipped by the pharmacy was noticed by S16RN. The medication was then reordered and discontinued by S23PNP. Charge nurse S10RN spoke with S27NP on 10/23/2024 and states she was told by S27NP to do a verbal order for Invega Sustenna 234mg IM for Wednesday. S10RN entered the medication as an order and S16RN administered the injection. S10RN did not apply an end date to the order which made it appear again on 10/24/2024 resulting in the patient receiving a 3rd injection from S14RN on 10/24/2024 of Invega Sustenna 234mg as we had another sample package available, for a total of 3 injections in 4 days. S9LPN informed me of this error on 10/24/2024 at about 5:15 p.m. I (S1DON) instructed her to call the NP on call, S28NP and advise him of the error and to call S26MD, our Medical Director to advise him of the medication error. S26MD ordered a discontinuation of all Psych meds for this patient. S1DON called the pharmacy and advised them of the medication error. S1DON spoke with Pharmacist who called the manufacturer for Invega Sustenna to find out ramifications of this dosage. Pharmacist informed S1DON that testing has been done with this amount of medication and no ramifications were reported per the manufacturer. Instructed staff to monitor patient for any side effects or unusual response to the medication. The patient was assessed by S26MD on 10/25/2024 and advised by the doctor of the medication error. I (S1DON) spoke with S27NP about this medication error which she stated she told S10RN to order the injection only if the patient had not received it yet. S9LPN, S10RN, S14RN, and S16RN will all receive counseling on this error and verbal written warnings for medication adherence. S1DON advised S10RN to ask providers to put in their orders when they are present in the hospital.


Review of Patient #2's medication orders revealed the following orders:
10/21/2024 at 11:44 a.m. entered by S26MD
Invega Sustenna 234mg/1.5ml, Intramuscular, Syringe, Frequency: Once (first, loading dose) Start date: 10/21/2024 11:30 a.m., End date: 10/22/2024 11:29 a.m.

10/23/2024 at 1:05 p.m. entered by S27NP
Invega Sustenna 234mg/1.5ml, Intramuscular, Syringe, Frequency: Once Start date: 10/23/2024 1:00 p.m., End date: 10/24/2024 12:59 p.m. - This order was discontinued by S10RN on 10/23/2024 at 1:28 p.m.

10/23/2024 at 1:28 p.m. entered by S10RN as a verbal, read back order from S23PNP
Invega Sustenna 156mg/1.5ml, Intramuscular, Syringe, Frequency: at a specific time for 1 day. Start date: 10/25/2024 2:00 p.m., End date: 10/26/2024 1:59 p.m. - This order was discontinued by S28NP on 10/25/2024 at 10:52 a.m.

10/23/2024 at 2:08 p.m. entered by S10RN as a verbal, read back order from S27NP
Invega Sustenna 234mg/1.5ml, Intramuscular, Syringe, Frequency: at a specific time until further notice Start date: 10/23/2024 2:00 p.m., End date: No end date in order - This order was discontinued by S28NP on 10/25/2024 at 10:52 a.m.

10/23/2024 at 2:08 p.m. entered by S10RN as a verbal, read back order from S27NP
Invega Sustenna 156mg/1.5ml, Intramuscular, Syringe, Frequency: at a specific time until further notice Start date: 10/27/2024 2:00 p.m., End date: No end date in order - This order was discontinued by S28NP on 10/25/2024 at 10:52 a.m.

Review of Patient #2's Medication Administration Record revealed the following:
10/21/2024 Invega Sustenna 234mg/1.5ml, Intramuscular scheduled for 11:30 a.m. This medication was administered by S9LPN. The MAR reflects that this injection was administered on 10/24/2024 at 5:01 p.m. with a note from S9LPN stating 234mg IM injection was administered. Med did come up on the MAR the next day and S1DON was informed.

10/23/2024 Invega Sustenna 234mg/1.5ml, Intramuscular scheduled for 3:00 p.m. This medication was administered by S16RN at 2:59 p.m. on 10/23/2024 - Further review of this MAR entry revealed a Note entered by S16RN stating patient did not receive dose as stated 10/21/2024.

10/24/2024 Invega Sustenna 234mg/1.5ml, Intramuscular scheduled for 3:00 p.m. This medication was administered by S14RN at 2:35 p.m. on 10/24/2024 - Further review of this MAR entry revealed a Note entered by S9LPN on 10/24/2024 at 6:23 p.m. stating don't administer any psych meds per S26MD.

Review of Patient #2's medical record failed to reveal an assessment of the patient for the day shift on the date the incident was discovered, 10/24/2024. There are also no additional notes documented by nursing staff regarding the medication error, or notification to provider. Patient #2 had a total of 5 orders entered for the Invega Sustenna, with 3 of the orders entered by S10RN. Further review revealed Patient #2 received 3 doses of Invega Sustenna 234mg/1.5ml over a 3 day period, totaling 702mg administered IM. Review of provider notes for Patient #2 failed to reveal documentation regarding the medication error or that a provider was aware of the incident.

In an interview on 11/07/2024 at 2:35 p.m., S1DON confirmed that the nursing staff failed to administer medications per hospital policy. S1DON also confirmed that S10RN and S16RN did not look back far enough in the MAR to verify that the first dose was given, which led to Patient #2 receiving a 2nd dose of Invega Sustenna. S1DON verified that S10RN discontinued the provider order for Invega Sustenna entered on 10/23/2024 at 1:05 p.m. entered by S27NP, and confirmed that S10RN re-entered the order incorrectly without an end date. Per S1DON, this error led to Patient #2 receiving a 3rd dose of Invega Sustenna. S1DON confirmed that nurses should have the provider enter their own patient care orders. S1DON provided counseling for S10RN and S14RN, at this time S9LPN and S16RN had not been counseled on this medication error.

50453

Based on record review and interview, nursing staff failed to administer PRN medications in accordance with accepted standards of practice. This deficiency is evidenced by failure of the nursing staff to monitor the therapeutic effect of PRN medications in 3 (#1-#3) of 3 (#1-#3) patients reviewed.
Findings:

Patient #1
Review of Patient #1's medication administration record revealed the following PRN medications were administered:
10/28/2024 at 11:17 a.m. - Pepto-Bismol 262mg/15ml, 15ml oral suspension every 4 hours, PRN for Gastric Upset or Diarrhea
10/30/2024 at 10:23 a.m. - Claritin 10mg oral tablet, 1 tablet daily, PRN for Nasal Congestion
Further review of Patient #1's medical record and medication administration record failed to reveal a re-evaluation of the effectiveness of the medications listed above.

In an interview on 11/07/2024 at 1:23 p.m., S1DON confirmed the above mentioned findings and verified that there was no documented re-evaluation of effectiveness. S1DON also confirmed that all PRN medications and interventions should be re-evaluated by the nurse.

Patient #2
Review of Patient #2's medication administration record revealed the following PRN medications were administered:
10/21/2024 at 9:07 a.m. - Ativan 2mg oral tablet, 1 tablet every 4 hours, PRN for Anxiety
10/21/2024 at 9:07 a.m. - Haldol 5mg tablet, PO, 1 tablet every 4 hours, PRN for Psychosis; Agitation
10/22/2024 at 9:02 a.m. - Ativan 2mg oral tablet, 1 tablet every 4 hours, PRN for Anxiety
10/22/2024 at 9:02 a.m. - Haldol 5mg tablet, PO, 1 tablet every 4 hours, PRN for Psychosis; Agitation
Further review of Patient #2's medical record and medication administration record failed to reveal a re-evaluation of the effectiveness of the medications listed above.

In an interview on 11/07/2024 at 2:30 p.m., S1DON confirmed the above mentioned findings and verified that there was no documented re-evaluation of effectiveness. S1DON also confirmed that all PRN medications and interventions should be re-evaluated by the nurse.

Patient #3
Review of Patient #3's medication administration record revealed the following PRN medications were administered:
10/25/2024 at 8:35 a.m.- Ativan 2mg tablet oral, 1 tablet every 8 hours, PRN for Anxiety
10/25/2024 at 8:35 a.m.- Ibuprofen 400mg tablet, 1 tablet every 6 hours, PRN for Pain
10/25/2024 at 1:49 p.m- Ativan 2mg tablet oral, 1 tablet every 8 hours, PRN for Anxiety
10/26/2024 at 7:56 p.m.- Ibuprofen 400mg tablet, 1 tablet every 6 hours, PRN for Pain
10/26/2024 at 1:35 p.m.- Ativan 2mg tablet oral, 1 tablet every 8 hours, PRN for Anxiety
10/26/2024 at 5:24 p.m.- Tylenol 650mg, 1 tablet oral every 8 hours, PRN for Pain
10/26/2024 at 8:42 p.m.- Ativan 2mg tablet oral, 1 tablet every 8 hours, PRN for Anxiety
10/26/2024 at 8:44 p.m- Trazodone 50mg tablet, 1 tablet every once a day PRN for Insomnia
10/27/2024 at 9:29 a.m.- Ativan 2mg tablet oral, 1 tablet every 8 hours, PRN for Anxiety
10/27/2024 at 9:29 a.m.- Antacid (Magnesium hydroxide/aluminum hydroxide/simethicone) 200-200-20mg/ 5ml, oral suspension, every 6 hours PRN for Gastric Distress
10/27/2024 at 5:02 p.m.- Haldol 5mg tablet PO, 1 tablet every 4 hours, PRN for Psychosis; Agitation
10/27/2024 at 9:45 p.m.- Trazodone 50mg tablet, 1 tablet every once a day PRN for Insomnia
10/28/2024 at 8:39 a.m.- Ativan 2mg tablet oral, 1 tablet every 8 hours, PRN for Anxiety
10/29/2024 at 3:47 p.m.- Ativan 2mg tablet oral, 1 tablet every 8 hours, PRN for Anxiety
10/29/2024 at 5:12 p.m.- Pepto-Bismol 262mg/15ml, 15ml oral suspension every 4 hours, PRN for Gastric Upset or Diarrhea
10/30/2024 at 8:07 a.m.- Trazodone 50mg tablet, 1 tablet every once a day PRN for Insomnia
10/30/2024 at 8:32 a.m.- Ibuprofen 400mg tablet, 1 tablet every 6 hours, PRN for Pain

In an interview on 11/07/2024 at 2:55 p.m., S1DON confirmed the above mentioned findings and verified that there was no documented re-evaluation of effectiveness. S1DON also confirmed that all PRN medications and interventions should be re-evaluated by the nurse.

Based on interview and record review the hospital failed to have orders for drugs and biologicals documented and signed by a practitioner who is authorized to write orders according to the hospital policy. This deficient practice is evidenced by having electronic standing admission order sheet with options for ordering medications which were being completed by a Registered Nurse instead of the practitioner for 3 (#1-#3) of 3 (#1-#3) records reviewed for medication orders.
Findings:

A review of hospital policy, titled "Physician Orders/Plans of Care," last revised January 2024, revealed in part: POLICY: All diagnostic and therapeutic orders will be written according to facility policy, law and regulation. PROCEDURE: A. Only licensed professional may take an order from a physician. B. Diagnostic and therapeutic orders, including verbal orders, will be signed, dated and timed noted by the physician.

A review of hospital policy, titled "Medication Administration," last revised January 2024, revealed in part: PRINCIPLES OF MEDICATION ADMINISTRATION: A. No medication should be given without a doctor's order. B. Each dose of medicine to be administered must be considered as offering an opportunity for a potential medication error. C. Never give a medicine about which you have a shadow of a doubt. N. Phone orders for medications may be taken by an RN or an LPN and countersigned by a doctor. The nurse taking the phone orders must read the complete order back to the doctor and document, R.B.V.O.

A medical record review of Patient #1, Patient #2, and Patient #3 revealed an admission order set titled ABHH IPF Physician's Admit Orders & Problem List completed by the nurse on admit. Under the Medication section, 9 choices of medications that had the option to be ordered including: Multivitamin, Haldol, Geodon, Zyprexa, Benadryl, Ativan PO, Ativan IM, Trazodone, and Cogentin. Each medication has the option for the nurse to select yes or no to initiate the order. This order set is signed by the nurse, documentation failed to reveal that the orders were received by a physician.
Further medical record review of Patient #1, Patient #2, and Patient #3 revealed a second admission order set titled ABHH IPF Physician's Standing Orders - Medical, completed by the nurse on admit. Under this order set is a list of 12 choices of medications that had the option to be ordered including: Clonidine, Ibuprofen, Tylenol, Throat Lozenges, Milk of Magnesia, Imodium, Antacid, Pepto Bismul, Orajel Ointment, Glucose Tablet, Claritin, and Insulin Regular Sliding Scale. Each medication has the option for the nurse to select yes or no to initiate the order. This order set is signed by the nurse, documentation failed to reveal that the orders were received by a physician.

In an interview on 11/07/2023 at 1:02 p.m. S1DON confirmed when a patient is admitted, the admission nurse completes both order sets on admission by selecting yes or no for each medication down the page. S1DON confirmed these orders are selected by the admitting nurse without reviewing each medication with the admitting physician or licensed practitioner. S1DON confirmed both order sets are used for each patient on admission. S1DON confirmed that when the nurse selects yes for a medication the medication is automatically uploaded to the patient medication administration record. S1DON also confirmed that these medications will appear on the MAR prior to being signed off by the provider. S1DON confirmed that documentation for Patient #1, Patient #2, and Patient #3 failed to reveal that medication orders on admission were received by a physician.



50453

Based on record review and interview the hospital failed to ensure all hospital orders were signed, dated, and timed by the physician or licensed practitioner. This deficient practice was evident for 1 (Patient #3) of 3 (Patient #1, #2, #3) medical records reviewed.

Findings:

Review of the hospital's Medical Staff Bylaws with last review of 01/2024 revealed in part, 2. All orders for treatment shall be in writing. The responsible practitioner shall authenticate such orders within 10 calendar days, and failure to do so shall be brought to the attention of the Executive Committee for appropriate action.

Review of Patient #3's medical record with S1DON revealed an admission date of 10/25/2024. Review of Patient #3's orders revealed standing admit orders were not signed by the physician or licensed practitioner. Further review revealed that S29RN initiated standing admit orders for Patient #3 on 10/25/2024 at 5:30 a.m. and there is no physician or licensed practitioner's signature to authenticate the standing orders.

In an interview on 11/07/2024 at 2:50 p.m. S1DON verified the above stated standing admit orders were not signed by the practitioner.

Based on record review and interview the hospital failed to demonstrate orders and protocols are consistent with nationally recognized evidenced based guidelines. This deficient practice is evidenced by 3 (#1-#3) of 3 (#1-#3) patient medical records reviewed having admission order sets being completed by the registered nurse.
Findings:

A review of hospital policy, titled "Physician Orders/Plans of Care," last revised January 2024, revealed in part: POLICY: All diagnostic and therapeutic orders will be written according to facility policy, law and regulation. PROCEDURE: A. Only licensed professional may take an order from a physician. B. Diagnostic and therapeutic orders, including verbal orders, will be signed, dated and timed noted by the physician.

A medical record review of Patient #1, Patient #2, and Patient #3 revealed an admission order set titled ABHH IPF Physician's Admit Orders & Problem List completed by the nurse on admit. The order set has the option for the nurse to select yes or no to initiate the orders listed. The options in this order set include the following: Standard observation (Q15 minute), Visual Observation, 1:1 arm's length observation, Diet, Consults, UPT, Clozaril level, Dilantin Level, Depakote Level, Lithium Level/Renal Function/TSH, Admit Accucheck, Alcohol Detox Protocol, and Opioid Detox Protocol. Review of Patient #1, Patient #2, and Patient #3 revealed each patient had this order set which was signed by the nurse, documentation failed to reveal that the orders were received by a physician.

Further medical record review of Patient #1, Patient #2, and Patient #3 revealed a second admission order set titled ABHH IPF Physician's Standing Orders - Medical, completed by the nurse on admit. The order set has the option for the nurse to select yes or no to initiate the orders listed. The options in this order set include the following: Routine admit labs CMP, CBC, UDS, TSH, PT/INR on admit if on anticoagulant therapy, Keppra Level (if patient currently on medication), Blood Glucose AC/HS, Dietary: Continue previous home diet, EKG for patients 50 years old and above, Check RPR required on every patient, Lipid Panel, and Urinalysis with culture if indicated. Review of Patient #1, Patient #2, and Patient #3 revealed each had this order set which was signed by the nurse, documentation failed to reveal that the orders were received by a physician.

In an interview on 11/07/2023 at 1:02 p.m. S1DON confirmed the admission nurse completes both order sets on admission by selecting yes or no for each item listed down the page. S1DON confirmed these orders are checked off by the admitting nurse without reviewing each item with the admitting physician or licensed practitioner. S1DON confirmed that documentation for Patient #1, Patient #2, and Patient #3 failed to reveal that admission orders were received by a physician.

Based on record review and interview, the hospital failed to ensure a medical history and physical was documented within 24 hours after admission for 1 (#2) of 3 (#1-#3) patients reviewed.
Findings:

A review of hospital policy titled "Documentation Timeliness Guidelines," last revised January 2024, revealed in part: The H & P should be documented within 24 hours by the physician.

Patient #2 was admitted on 10/17/2024 at 10:15 a.m. The History and Physical Exam was initiated on 10/17/2024 at 9:34 a.m. with a note stating unable to close HP due to incomplete assessment. Patient refuses to answer any questions. Patient is a FVA. Admit lab pending. Further review revealed the following sections were incomplete: Medical History, Surgical History, Social History, Family History, Review of Systems, Physical Exam, Examination of Cranial Nerves, Nutritional Screen, and Pain Assessment. The end time of this history and physical was 10/17/2024 at 9:39 a.m. Further review failed to reveal a provider signature with a date/time stamp on this history and physical exam.
Review of Patient #2's medical progress note on 10/18/2024 at 12:29 p.m. revealed documentation in the plan, unable to close HP due to incomplete assessment. Patient refuses to answer any questions. This note was signed by provider on 10/18/2024 at 7:32 p.m.
Further review of Patient #2's medical record failed to reveal a completed history and physical exam or any additional provider notes regarding the delay or inability to complete the history and physical exam.

In an interview on 11/07/2024 at 1:44 p.m., S1DON confirmed that a medical history and physical was not documented within 24 hours from the time of admission on Patient #2. S1DON also verified that the medical history and physical for Patient #2 had multiple sections that were incomplete.

Based on record review and interview the hospital failed to ensure drugs and biologicals are dispensed by a licensed pharmacist and stored in accordance with hospital policy. This deficient practice is evidenced by having sample medications available for patient use in the acute care hospital setting.
Findings:

A review of hospital policy, titled "Storage and Care of Medications," last revised January 2024, revealed in part: GENERAL RULES: 1. No sample drugs shall be permitted in the cabinet. Apollo Behavior Health Hospital does not administer sample drugs in the acute care hospital setting.

Review of Patient #2's medical record and incident report revealed that S9LPN and S14RN both administered separate injections of Invega Sustenna to Patient #2. Both administrations were given using samples of the Invega Sustenna found by S9LPN and S14RN on the counter.

In an interview on 11/07/2024 at 2:35 p.m., S1DON confirmed that staff should not be administering sample medications, and verified that the staff failed to follow hospital policy. S1DON also confirmed that the sample medications that were administered contained no patient identifications on the samples. S1DON verified that all medications ordered by the provider should be dispensed by pharmacy with the appropriate medication/patient label identifiers.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable standards of practice, consistent with state law and hospital policy. This deficient practice was evidenced by failing to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications.

Findings:

Review of the Louisiana Administrative Code, Professional and Occupational Standards,
Title 46: LIII, Pharmacist, Chapter 15, Hospital Pharmacy, §1511. Revealed in part:
Prescription Drug Orders: A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial dose of medication, except in cases of emergency.

Review of hospital policies/procedures did not reveal any information regarding a pharmacist shall review the practitioner's medical order prior to dispensing the initial dose of medication, except in cases of emergency.

Review of the hospital titled "Dispensing Machine: Pharmacy Services After Hours and Overrides" effective date 01/2024 revealed in part: In the event that a new medication order requires a medication that is not normally stocked in the AMS unit, the hospital's pharmacy will initiate the First Dose Process. This First Dose Process entails the pharmacy receiving the faxed or e-mailed order from the facility and calling in the order, as a transfer, to an approved local contracted retail pharmacy. The hospital's pharmacy will also coordinate the delivery of the medication from the contracted retail pharmacy to the facility, via a contracted courier service.

A review of Patient #1, Patient #2, and Patient #3's medical record failed to reveal any documentation related to the first medication dose being reviewed by a pharmacist before the first dose was dispensed for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications.

A review of all medication documentation as provided by S1DON failed to reveal the first dose review for Patient #1, Patient #2, and Patient #5.

In an interview on 11/04/2024 at 1:40 p.m., S1DON confirmed that there was no first dose review completed by the pharmacy before Patient #1, Patient #2, and Patient #3 received any of their medications. S1DON stated the pharmacist doesn't do a first dose review, but when medications are ordered in the electronic medical record it automatically goes on the medication administration record.

Based on observation and interview, the facility failed to ensure facilities, supplies and equipment, were maintained to an acceptable level of safety and/or quality. This deficient practice is evidenced by:
1) failure to ensure expired supplies were not available for patient use;
2) failure to ensure the glucometer control testing was performed;
3) failure to ensure the emergency cart was inspected daily.
Findings:

1) Failure to ensure expired supplies were not available for patient use.

A review of hospital policy titled "Sterile Supplies and Equipment," last revised January 2024, revealed in part: Procedure: 3. The Director of Nursing will ensure compliance with Hospital regulations regarding the following: c. monitoring and inventory control of shelf life and expiration date of supplies, as well as the removal from use of expired supplies.

A review of the Medline EVENCARE G3 Blood Glucose Monitoring System User Guide revealed in part, notes regarding control solutions and test strips. Record the date on the bottle when opening a new bottle of control solution, discard any unused control solution 3 months after the opening date, and control solutions are good for 3 months after opening or until the expiration date on the bottle, whichever comes first.

Observations during a tour on 11/07/2024 from 8:58 a.m. - 9:38 a.m. revealed Even Care G3 Glucose controls, Lot# 16823013101/201, with an open date of 06/01/2024 on the Glucose control vials.

In an interview on 11/07/2024 at 9:27 a.m. S14RN verified the open date on the vials was 06/01/2024 and confirmed that the glucose controls were expired.

2) Failure to ensure the glucometer control testing was performed.

Observations during a tour on 11/07/2024 from 8:58 a.m. - 9:38 a.m. revealed a log titled Quality control for Blood Glucose for November 2024. Further review of the Quality Control for Blood Glucose log failed to reveal that daily quality controls were completed for the glucometer on 11/01/2024, 11/02/2024, 11/03/2024, and 11/04/2024.

In an interview on 11/07/2024 at 9:23 a.m., S3CEO confirmed the findings above.

In an interview on 11/07/2024 at 9:25 a.m., S13RN confirmed that glucometer quality controls should be done daily.

3) Failure to ensure the emergency cart was inspected daily.

A review of hospital policy titled "Emergency Cart and Oxygen Tanks Monitoring," last revised January 2024, revealed in part: Procedure: 1. Open the AED box cover and check the battery status, if low order new battery. 2. Check expiry dates of AED pads. 3. Check each oxygen control device for proper functioning. 5. Check emergency cart to be sure flowmeters, cannulas, treatment nebulizers, aerosol masks, oxygen masks, ambu bags, and respiratory aerosolized medications are present. 6. Check power suction machine if it is powering up. Maintenance of Oxygen Cylinder, AED Machine and Supplies 2. Nurse checks level of oxygen and condition of apparatus daily during night shift. 3. Nurse to check AED battery levels daily at night. 4. Nurse to check AED pads and other supplies daily at night. 6. Maintain log of AED machine battery good condition.

Observations during a tour on 11/07/2024 from 8:58 a.m. - 9:38 a.m. of the Emergency Cart log failed to reveal that daily checks were performed on 10/09/2024, 10/18/2024, and 11/06/2024.

In an interview on 11/07/2024 at 9:30 a.m., S3CEO and S1DON confirmed the findings above.

Based on record review and interview, the hospital failed to ensure a complete neurological examination was recorded at the time of the admission physical examination. This deficient practice was evidenced by failing to ensure the Cranial Nerve Assessment was documented on 1 (#2) of 3 (#1-#3) patients reviewed.
Findings:

Review of Patient #2's medical record revealed he was admitted on 10/17/2024 at 10:15 a.m. Further review of the history and physical examination initiated on 10/17/2024 at 9:34 a.m. revealed an incomplete neurological assessment with no documentation of a completed cranial nerve assessment for Patient #2.

In an interview on 11/07/2024 at 1:44 p.m., S1DON confirmed the above mentioned findings.