HospitalInspections.org

Based on observation and interview, the facility failed to ensure the patients right to care in a safe setting as evidenced by:
1) Failure to ensure unsecured rooms in the patient care area were locked and not accessible to patients; and
2) Failure to ensure the packaged thermal air conditioner (PTAC) in Rooms "a" - "z" was secured by a ligature free enclosure that would prevent a patient from accessing the interior components of the PTAC which could potentially cause injury or self-harm.
Findings:

1) Failure to ensure unsecured rooms in the patient care area were locked and not accessible to patients

Observations during a walk - through of the facility on 12/09/2025 from 3:15 p.m. to 4:30 p.m. revealed Room "yy" unlocked and containing the following items:
--Janitorial cart which was unlocked with some of its contents being multiple plastic trash liners;
-- a wooden mop handle;
-- a metal mop handle;
--2, 5-gallon buckets of iSHine Floor Finisher; and
--1, 5-gallon bucket of Shineline Emulsifier.
All of the above-mentioned items could potentially be used by a patient for self-harm/injury or injury to other patients. This placed current Patients #R2 - #R14 at risk for harm and/or injury.

In an interview on 12/11/2025 and present during the walk-through, S2AAdm and S3HM confirmed the above-mentioned findings and confirmed Room "yy" should be locked and secured.

2) Failure to ensure the packaged thermal air conditioner (PTAC) in Rooms "a" - "xx" were secured by a ligature free enclosure that would prevent a patient from accessing the interior components of the PTAC which could potentially cause injury or self-harm

Observations during a walk - through of the facility on 12/09/2025 from 3:15 p.m. to 4:30 p.m. revealed Patients #R9, #R11, #R15 and #R16 rooms having a PTAC that was not secured by a ligature free enclosure. Without a secured ligature free enclosure, a patient would have the potential to remove the plastic front panel of the PTAC and access the mechanical components and parts of the PTAC. This had the potential for all current patients and future patients to create an environment in which self-injurious/harmful behaviors could exist and/or harm to other patients.

In an interview on 12/09/2025 and present during the walk-through, S2AADM and S3HM confirmed the above-mentioned findings and further confirmed patient rooms "a" - "vv" and seclusion rooms "ww" - "xx" had a PTAC and further confirmed each of these PTACs were not enclosed by a ligature free enclosure.

Based on record review and interview, the governing body, medical staff and administrative officials failed to ensure all departments of the hospital were measuring, tracking, and analyzing the effectiveness and safety of services and quality of care.
Findings:

A review of the facility's document titled, "QUALITY/PERFORMANCE IMPROVEMENT PLAN 2025," revealed in part: "Purpose On an annual basis the Quality/Performance Improvement Plan is reviewed and update to reflect priorities in providing quality care in a safe environment to all patients. The purpose of the Physicians Behavioral Hospital's (PBH) Quality/Performance Improvement Plan is to provide framework for a collaboratively planned, systematic and organization-wide approach to improving patient care and organization performance. It is designed to provide an integrated and comprehensive program that will monitor, assess, and improve the quality of patient care delivered at this facility."

The purpose of this plan indicated an organization -wide approach, however this Quality/Performance Improvement Plan failed to reveal quality improvement indicators for 2025 that were related to the services or functions provided by the Outpatient Services department of the facility.

A review of the Medical Executive Committee Meeting Minutes from 02/18/2025, 06/24/2025, and 09/17/2025 failed to reveal discussion of Quality Assurance Performance Improvement (QAPI) data related to the Outpatient Services of the facility. Further, the QAPI data that was presented to committee failed to reveal date related to the Outpatient Services of the facility.

A review of the Committee of the Whole Meeting Minutes from 02/17/2025, 06/24/2025, and 09/16/2025 failed to reveal discussion of QAPI data related to the Outpatient Services of the facility. Further, the QAPI data that was presented to committee failed to reveal date related to the Outpatient Services of the facility.

In an interview on 12/10/2025 at 2:28 p.m. S4UR confirmed the above-mentioned data and confirmed the data that is being collected for Outpatient Services was not presented to these committee members.

Based on record review and interview, the facility failed to ensure the discharge summary included all requirements of the facility policy and all requirements set forth in the behavioral health service (BHS) provider state regulations for an Intensive Outpatient Program (IOP) at La R.S. 48:5649E in 2 (#1, #2) of 3 sampled patients medical records.
Findings:

A review of facility policy, "Discharge Summary," policy number HIM006, with an approval in 2008 (month and day not available) and last revised in 2025 (month and day not available), revealed in part:
"PROCEDURE The Discharge Summary shall include the following:
A. Identifying information
1. Name of Physician
2. Date
3. Patient's name, age, and sex
4. Date of admission
5. Date of discharge
B. Initial assessment and Diagnosis
1. Reason for admission (to include mental and legal status)
2. Pertinent history and physical findings
3. Admitting diagnosis and Discharge Diagnosis
C. Findings
1. Pertinent negative and positive laboratory
2. Pertinent negative and positive x-ray findings
D. Hospital Course
1. Course and progress of patient by each problem number
2. Special procedures and treatment of patients by each problem
3. Identify any known complications such as fractures, seizures, infections, adverse medication effects, suicide attempts, cardiac arrest
4. Consultation findings and recommendations
E. Condition on discharge
1. Patient's ability to function at the time of discharge
2. Patient's behavior at the time of discharge (include useful approaches; and problems and issues yet to be worked on after discharge)
3. Prognosis
F. Post Hospital Care Plans
1. Include prescribed medications and dosage (include knowledge and attitude toward medication)
2. Aftercare plans (include recommended modality of therapy and frequency, as well as name of who will provide aftercare, when, and where)
3. Dietary and/or restrictions
G. Final Diagnosis
H. Signature of Physician"

A review of behavioral health service (BHS) provider state regulations at La R.S. 48:5649E revealed in part:
"Discharge Summary. The BHS provider shall ensure that each client record contains a written discharge summary that includes:
1. the client's presenting needs and issues identified at the time of admission;
2. the services provided to the client;
3. the provider's assessment of the client's progress towards goals;
4. the discharge disposition; and
5. the continuity of care recommended following discharge, supporting documentation and referral or transfer information."

A review of medical records revealed the following:
A review of Patient #1's discharge summary failed to reveal the patient's presenting needs and issues identified at the time of admission, a discharge and final diagnosis, the services provided to patient over their admissions, the course and progress of the patient towards their goals, and the patient's condition at time of discharge, including the patient's ability to function at the time of discharge and problems and issues yet to be worked on after discharge.

A review of Patient #2's discharge summary failed to reveal a discharge and final diagnosis, the services provided to patient over their admissions, the course and progress of the patient towards their goals, and the patient's condition at time of discharge, including the patient's ability to function at the time of discharge and problems and issues yet to be worked on after discharge.

In an interview on 12/10/2025 at 2:00 p.m. S3DOTS confirmed the above-mentioned findings.

In an interview on12/10/2025 at 2:30 p.m. S1AADM confirmed the above-mentioned Discharge Summary policy would refer to inpatient and outpatient discharges.

Based on observation and interview, the facility failed to ensure clean linen was stored in a clean and sanitary to avoid sources and transmission of infection.
Findings:

Observations during a walk - through of the facility on 12/09/2025 from 3:15 p.m. to 4:30 p.m. revealed clean linen stacked in Rooms "zz" and "aaa." Room "zz" had a shelving unit with multiple face towels and bath towels being stored uncovered. The towels in Room "zz" were being exposed to multiple staff members walking through this room and to following items: 1 clothes washer, 1 clothes dryer, 3 brown bags of patient belongings (confirmed by S2HM as needing to be laundered), a vending machine, a mop bucket and mop, a dust mop, and 3-5-gallon containers of Kentwood Water (sealed). Room "aaa" had shelving with multiple stacks of clean linen (face towels, bath towels, bed linens, and blankets) being stored. The clean linen in these 2 rooms was not covered and protected from exposure to the environmental elements of each room.

In an interview on 12/09/2025 and present during the walk-through, S2AADM and S3HM confirmed the above-mentioned findings and S3HM further confirmed the clean towels should not be stored in Room "zz" and all clean linen should be covered.