HospitalInspections.org

Based on record review and interviews, the hospital failed to meet the Conditions of Participation (CoP) of Patient Rights. This deficient practice was evidenced by:
1) Failure to ensure a patient complaint of alleged staff to patient physical abuse was recognized as a grievance (See Findings Tag A0118);
2) Failure to ensure a patient was provided with written notice of its decision following its resolution of its grievance investigation process (See Findings Tag A0123);
3) Failure to ensure a patient received care in a safe setting by properly monitoring a high fall risk patient which resulted in a fall with head injury (See Findings Tag A0144);
4) Failure to thoroughly investigate and report allegations of abuse within 24 hours to the Department of Health and Hospitals or law enforcement (See Findings Tag A0145); and
5) Failure to thoroughly investigate and report allegations of elopement within 24 hours to the Department of Health and Hospitals or law enforcement (See Finding Tag A0145).

Based on record review and interviews, the hospital failed to ensure a patient complaint of alleged staff to patient physical abuse was recognized as a grievance. This deficient practice was evidenced by failing to correctly identify a patient grievance for 1 (#3) of 3 (#1 - #3) total sample patients reviewed for complaints/grievances.
Findings:

Review of the hospital's policy number RTS-04 titled "Patient Grievance Process" last revised on 09/01/2024 indicated the following in part:
"Purpose:
To provide an internal process that establishes guidelines for:
-Submission of a patient and/or family's grievance allegation to the facility
-Timely review and investigation of the allegation
-Provision of a response
-Timely referral to the appropriate external agency as deemed necessary
Policy:
This facility has adopted an internal grievance process in accordance with Title 42 CFR, §482.13 which provides for prompt resolution of patient and/or patient representative concern regarding violation of a patient's rights, quality of care, and other complaints involving the patient's treatment stay.
Definitions
Grievance: A formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, and/or patient's rights.
Procedure:
Grievance Submission
2. Depending on the nature of the complaint, the staff will offer resolution at the time the complaint is made, and if resolved, report the encounter to the Patient Advocate. The complaint with resolution will be logged on the "Complaint/Grievance Log" with no additional action.
3. If no resolution is made by staff present at the time of the complaint, the Patient Advocate is notified, and the grievance process is initiated. If the patient and/or family file a grievance allegation as defined above, the grievance process is initiated immediately.
Grievance Procedures
1. The Patient Advocate logs the grievance allegation onto the "Complaint/Grievance Log" and contacts the patient, or patient representative, and opens an investigation to determine the validity of the grievance allegation within 48 hours of notification or receipt of the grievance allegation. If the grievance is regarding an allegation of abuse or neglect, the appropriate state mandatory guidelines for reporting will be followed.
2. The Patient Advocate completes the investigation using the "Grievance Report" within 7 calendar days of the date of the notification or receipt of the grievance allegation.
Role of the Patient Advocate:
1. Maintains a complete "Complaint/Grievance Log" along with files and results of all grievances including a signed copy of the letter sent to the grievant and dated documentation of the method of delivery.
2. Complete a thorough investigation of all grievances representing the expressed desires of the individuals served ad advocating for the resolution of their grievances.
3. Responsible for reporting all grievance investigation findings and resolutions to QAPI committee hierarchy.
Roles of the Administrator:
1. Ensure appropriate policies and procedures are followed for grievances alleging abuse and neglect of patients."

Review of the hospital's Complaint and Grievance Log for September - November 2024 revealed no documented complaints or grievances for Patient #3.

On 12/02/2024 at 3:15 p.m., a telephone interview was conducted with S9NP. He stated the bruising to Patient #3's left eye/temporal region and face were new to him when he saw her on the afternoon of 11/05/2024 and she did not have that bruising when he made rounds on her on 11/04/2024. He confirmed Patient #3 verbally reported to him on 11/05/2024 staff had "beat her up" on the prior shift.

On 12/02/2024 at 4:04 p.m., an interview was conducted with S11RN. She stated Patient #3 had reported to her prior to 11/05/2024 that night shift staff had assaulted her. S11RN stated she had completed a hand written report and gave it to S10FADON. S11RN stated she could not recall the exact date of when Patient #3 reported the assault to her, but stated it was around the time of when the 11/05/2024 incident with the generalized bruising had occurred but was prior to that event. S11RN stated she had "started to become suspicious" of the increased bruising on Patient #3. S11RN stated she had never personally seen any other staff members be physical or assault Patient #3. S11RN stated when Patient #3 reported the assault to her, she asked Patient #3 if she could tell her who the person or persons were who assaulted her and she stated Patient #3 could not provide her with a name of a staff member, but she did describe them which was what she included in her report. S11RN stated she put in her report word for word what Patient #3 said regardless of what she stated if it was appropriate or not. S11RN stated once she completed the report, she gave it to her superior, which at the time was S10FADON. S11RN stated she did not know if it was reported to and investigated by the Patient Advocate.

On 12/03/2024 at 10:15 AM, an interview was conducted with S1DON. She reviewed the facility provided hospital "Complaint and Grievance Log" for September - November 2024. She confirmed per hospital policy a reported allegation of abuse to a staff member would be considered a complaint and/or grievance and should be reported to the Patient Advocate for review and investigation. She confirmed there were no documented complaints and/or grievances associated with Patient #3 listed on the log.

Based on record review and an interview, the hospital failed to ensure a patient was provided with written notice of its decision following its resolution of its grievance investigation process for 1 (#3) of 3 (#1 - #3) patients reviewed for grievances.
Findings:

Review of the hospital's policy number RTS-04 titled "Patient Grievance Process" last revised on 09/01/2024 indicated the following in part:
"Purpose:
To provide an internal process that establishes guidelines for:
-Provision of a response
Policy:
This facility has adopted an internal grievance process in accordance with Title 42 CFR, §482.13 which provides for prompt resolution of patient and/or patient representative concern regarding violation of a patient's rights, quality of care, and other complaints involving the patient's treatment stay.
Definitions
Grievance: A formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, and/or patient's rights.
Grievance Procedures
1. The Patient Advocate logs the grievance allegation onto the "Complaint/Grievance Log" and contacts the patient, or patient representative, and opens an investigation to determine the validity of the grievance allegation within 48 hours of notification or receipt of the grievance allegation. If the grievance is regarding an allegation of abuse or neglect, the appropriate state mandatory guidelines for reporting will be followed.
2. The Patient Advocate completes the investigation using the "Grievance Report" within 7 calendar days of the date of the notification or receipt of the grievance allegation.
3. If the investigation is ongoing on the 7th day, an extension letter should be sent to the grievant with documentation confirming date of issuance. The extension letter should include the date the expected resolution will be completed and sent.
4. The Patient Advocate issues a final written response to the grievant by the 7th day, or no later than the date referenced on the extension letter, from the date of the grievance allegation, and will include:
a. The name of the facility contact person
b. The steps taken on behalf of the person reporting to investigating the grievance
c. The results of the grievance process
d. The facility's decision
e. The date of completion
f. The contact information to appeal the offered resolution."

Review of the hospital's Complaint and Grievance Log for September - November 2024 revealed no documented complaints or grievances for Patient #3.

Review of Patient #3's Nursing Notes dated 11/05/2024 revealed the following note:
11/05/2024 at 1:38 PM - Patient #3's daughter-in-law notified that patient had bruising of unknown source. Family informed they will be provided with developing findings. Signed by: S11RN

On 12/02/2024 at 4:04 PM, an interview was conducted with S11RN. She stated she had not provided Patient #3's family with any additional follow-up regarding the investigation into the bruising of unknown source Patient #3 sustained on or around 11/05/2024. She stated she was unaware if any other facility staff provided the family with an update either. S11RN stated she only reported the allegation of suspected staff abuse to Patient #3 to S10FADON who was her direct superior at the time. She stated she did not report it to the Patient Advocate and was unsure if S10FADON reported it to the Patient Advocate or the DON for further investigation.

On 12/03/2024 at 10:15 AM, an interview was conducted with S1DON. She reviewed the facility provided hospital "Complaint and Grievance Log" for September - November 2024. She confirmed per hospital policy a reported allegation of abuse to a staff member would be considered a complaint and/or grievance and should be reported to the Patient Advocate for review and investigation. She confirmed since no documented complaints and/or grievances associated with Patient #3 were listed on the log, no notice of grievance decision report letters would have been sent and/or provided to Patient #3.

Based on record review and interviews, the hospital failed to ensure patients received care in a safe setting by failing to properly monitor high fall risk patient patients which resulted in a fall with head injury for 1 (#3) of 3 (#1-#3) patient reviewed for falls.
Findings:

Review of the hospital policy number AS-12 titled "Fall Assessment/Re-Assessment and Precautions" last revised on 11/16/2022, indicated the following, in part:
"Purpose:
To screen patient's potential for falling and decrease the risk of injury.
Policy:
Inpatient
1. All patients will be assess and identified for the potential of being at risk for falls at the time of initial nursing assessment, immediately after a fall, or change in mobility status, and/or every 7 days if identified as "at risk for falls".
2. In the event of a fall occurrence, patients will be re-assessed and additional fall prevention interventions will be implemented.
3. The RN will assess/re-assess and determine the risk of all patients with regard to falls and implement fall precautions if so indicated.
Procedure:
Inpatient
5. Interventions shall include:
-Additional fall precautions - (must select at least 2 additional interventions from below that are appropriate to the patient's individual needs)
-Line of Sight observation level
-1:1 observation level
-Reclining chair
-Assist with ADLs"

Review of the hospital's policy number CS-23 titled, "Level of Observations" last revised on 03/01/2023, indicated the following, in part:
"Purpose:
To provide staff with a framework for monitoring patients to ensure safety. Observation should be both safe and therapeutic. Respect should be shown for the patient's need for autonomy while ensuring safety.
Policy:
The level of observation is determined by the individual needs of the patient and treatment team recommendation and ultimately requires a physician order
Observation Levels:
Line of Sight (Constant Observation) - the staff member will ensure the patient is visually within sight at all times
Procedure:
Line of Sight Observation
-Patient is under constant observation and within line of sight at all times.
-Line of Sight observation level may be required for the patient assessed as high or increased risk in the context of their illness and their environment.
-The designated staff (MHT) is assigned to perform line of sight observation and can observe multiple patients, but must remain in the area with the patients such that if a patient needs immediate intervention, the staff member can intervene and call for assistance.
-In some instances, it may be clinically identified that the assigned observer is to remain in the same room as the patient at all times. This can include assigning one observer to a shared room with two patients, if appropriate. This must be clearly documented on the inpatient observation record.
-Line of Sight observation level includes constant observation in the bathroom and toilet areas, unless the door is able to be left ajar and the observer is able to access the room immediately."

Review of Patient #3's Provider Orders from Admission (10/08/2024) to Discharge (11/09/2024) revealed the following in part:
On 10/08/2024 at 3:00 PM Fall Precautions were ordered by S7MD.
On 11/08/2024 at 8:00 PM Line of Sight Observation were ordered by S7MD.
On 11/09/2024 at 9:00 AM Transfer Patient - Send to ER for further eval and treat of fall with head injury was ordered by S9NP. Furthermore, Patient #3 did not return to the facility and was officially discharged from the system on 11/10/2024 at 10:00 AM.

Review of Patient #3's Nursing Notes on 11/08/2024 between 11:00 PM and 11:36 PM by S12RN staff reported to her around 11:00 PM Patient #3 had fallen and hit her head. Upon her assessment of Patient #3, S12RN had found a "gulf ball sized area" to the back of her head with a smear of blood and no other new notable injuries visible on patient's skin. Patient #3 denied any pain to her at that time and Patient #3's mental status remained unchanged. S12RN notified S9NP who gave an order to send Patient #3 to the local emergency department of further evaluation and treatment. S12RN documented vital signs and neuro checks and notified S1DON of the incident. The local ambulance transport company was contact to set up transport for Patient #3 to the local emergency room and Patient #3's family was notified of the incident. Patient #3 was left the facility and was transferred to local emergency room at 11:36 PM.

Review of the facility's Incident Report dated 11/08/2024 for Patient #3 revealed the following in part:
Date/Time of Incident: 11/08/2024 at 11:00 PM
Occurrence: Incident
Category: Fall
Location: Patient Room
Notifications:
Nurse Practitioner - S9NP - 11/08/2024 - 11:02 PM
Director of Nursing - S1DON - 11/08/2024 - 11:03 PM
Administrator on Call - 11/08/2024 - 11:05 PM
Family Contact - 11/08/2024 - 11:10 PM
Brief Description of Incident: 11:00 PM - Reported by staff pt with fall and hit her head. Upon assessment, gulf side area to back of head noted with smear of blood noted. No other new injuries observed on pt skin. Patient denies any pain at present. Mental status remains unchanged. S9NP notified, order received to send out to ED for further eval and treatment. Neuro checks initiated per facility protocol. BP 164/57, p 79, t 97.8, r 18, sat 100% on RA.
Related Causes & Factors: Confused/disoriented; Policy/procedure not followed; other - patient LOS no one watching at time of call
Actions Taken Post-Incident: MD notified; appropriate authorities notified; Family notified; Neuro checks ordered, initiated; Education provided to patient; Education provided to Employee
Follow Up/Resolution (DON): Unwitnessed fall with head injury. Pt was transferred to ED and subsequently admitted to HLOC, did not return to facility. Pt was on line of sight observation status at time of injury - staff member was not maintaining appropriate observations, removed from schedule. Corrective action to follow. Patient was on fall precautions at time of event with care plan in place. Neuro checks were initiated per protocol. Orders obtained for transfer. Family notified.
Incident Report Electronically Signed by: S12RN at 11/09/2024 at 1:12 AM and S1DON at 11/11/2024 at 7:27 PM
Patient Fall Report -
Was the fall assisted or unassisted? Unassisted
Was the fall observed? No
Did the patient sustain an injury as a result of the fall? Yes
What type of injury was sustained? Abrasion/scrape; Other (explain) - gulf size area to back of head noted with smear of blood, no other new injuries observed on pt skin, pt denies any pain at present, mental status remains unchanged
Prior to the fall, what was the patient doing or trying to do? Unknown
Were there any identifiable causes or factors that contributed to the patient's fall? Confused/disoriented; Intentional act of patient
Prior to the fall, was the patient assessed for fall risk? Yes
Was the patient determined to be at risk for a fall? Yes
What protocols/interventions were in place, or being used, to prevent falls for this patient? Fall alert; Non-slip footwear; other (specify) - LOS
At time of the fall, was the patient on medication known to increase the risk for a fall? Yes
Was the medication considered to have contributed to the fall? Yes
Actions Taken Post-Fall: MD notified; Supervisor notified; Family notified; Care plan initiated/updated; Incident & intervention documented in patient's record; Neuro checks ordered, initiated; Teaching to patient provided, as appropriate; Transferred to higher level of care; Other (specify) - Sent out to local hospital for further eval and treat
Patient Fall Report Electronically Signed: S12RN on 11/09/2024 at 1:16 AM and S1DON 11/11/2024 at 7:57 PM

Review of the Observation Check Sheet/Graphic Flowsheet dated 11/08/2024 for Patient #3 revealed her observation level was Line of Sight. S20MHT documented at 10:45 PM Patient #3 was sitting in her room. At 11:00 PM, S20MHT documented Patient #3 had fallen and was offsite.

On 12/02/2024 at 3:00 PM an interview was conducted with S1DON. She stated she was made aware of the incident with Patient #3 on the night shift of 11/08/2024 when she fell and hit her head. S1DON confirmed Patient #3 was on LOS observation at the time of the fall, but S20MHT was not properly observing her at the time of the fall. S1DON confirmed there were 2 MHTs on staff working on 11/08/2024 and the staff matrix called for 3 MHTs.

48537

Based on record review and interviews, the hospital failed to ensure patients were free from abuse and neglect and ensure all incidents of abuse and neglect were reported and analyzed to ensure the hospital was in compliance with applicable local, State, and Federal Laws and Regulations. This deficient practice was evidenced by:
1) failure to thoroughly investigate and report allegations of abuse within 24 hours to the Department of Health and Hospitals or law enforcement for 1 (#3) of 3 (#1-#3) patients reviewed for abuse; and
2) failure to thoroughly investigate and report allegations of elopement within 24 hours to the Department of Health and Hospitals or law enforcement for 1 (#1) of 3 (#1-#3) patients reviewed for elopement.
Findings:

Review of the Louisiana Revised Statutes, Title 40. Public Health and Safety, Chapter 11, State Department of Health and Hospitals indicated the following "Department" shall mean the Department of Health and Hospitals. "Unit" means the Medicaid fraud control unit created within the office of criminal law of the Department of Justice and which is certified by the secretary of the United States Department of Health, Education and Welfare. Regarding §2009.20. Duty to make complaints; penalty; immunity, "Abuse" is the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including but not limited to sexual abuse, or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered. "Neglect" is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer's well-being. Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, ... having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report.

Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report abuse/neglect allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Louisiana Department of Health (LDH). 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 the hospital's policy number RTS-10 titled "Abuse and/or Neglect of Patients by Staff Members, Students, and Interns" effective 01/11/2016, indicated the following in part:
"Purpose:
To prevent and rectify misconduct in a just and constructive manner to reduce likelihood of recurrence and to protect patients from abuse.
Policy:
Patients have the right to be free from neglect, exploitations, and verbal, mental, physical and sexual abuse. This facility supports and conforms to all state and federal guidelines for protection of patients' rights.
Definitions:
Abuse is the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including but not limited to sexual abuse, or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered.
Neglect is the failure to provide the proper or necessary medical, nutrition, or other care necessary for a consumer's well-being.
No employee or student will mistreat and/or neglect a patient. Examples of actions/inactions which could be considered mistreatment/abuse include:
- Causing pain or suffering;
- Direct physical aggressive behavior toward a patient;
- Failing to or refusing to attend to the necessary care and treatment;
- Implementing actions contrary to the prescribed treatment of the program;
- Unauthorized restriction of patients' rights;
- Failing to intervene to protect a patient from abuse and/or mistreatment.
Any staff or student suspected of any of the above infractions will be investigated under this policy. If it is determined that the staff member physically, sexually, or verbally abused the patient in question or willfully neglected the patient(s), disciplinary actions will be enacted against him/her, up to and including termination of employment. Employees are educated on this policy.
Procedure:
Refer to Assessment and Reporting of Abuse, Neglect, Exploitation and/or Extortion of Youth and Adults Policy for report procedures."

Review of the hospital's policy number AS-18 titled "Assessment and Reporting of Abuse, Neglect, Exploitation" last revised on 10/01/2024 indicated the following, in part:
"Purpose:
To protect patients from harm and meet compliance standards set by state and federal guidelines and other regulatory or accreditation bodies, or contractual obligations regarding the assessment and reporting of suspected cases of abuse, neglect, and exploitation.
Policy:
The facilities prohibit abuse, neglect, and exploitation of patients/clients and/or participants. The facilities shall promptly and properly respond to allegations of abuse, neglect or exploitation and shall comply with all reporting obligations, including, but not limited to those set by the following:
Federal:
- CMS (Centers for Medicare & Medicaid Services)
Accreditation:
- The Joint Commission
Louisiana:
- Area police/sheriff's department
- The Louisiana Department of Health
- Adult Protective Services of the Louisiana Department of Health
- Office of Community Services of the State of Louisiana
- The Governor's Office of Elderly Affairs/Elderly Protective Services
- Professional Licensing Boards
Procedure:
Procedure to Respond to Alleged of Suspected Abuse, Neglect, Exploitation by Facility Staff (employed or contracted) or by another patient:
1. Should a staff member identify, or be notified of, a suspected case or of abuse, neglect, and exploitation, he/she will notify his/her immediate supervisor and the Administrator/Administrator-on-Call and the Director of Nurses (DON) immediately.
2. If the allegation involves another patient or an employed or contracted staff member of the facility, the Administrator/Administrator-on-Call are responsible to ensure a thorough investigation is performed and will respond immediately to address any clinical assessments and ensure the provision of any clinical interventions necessitated by the circumstances and perform an investigation to determine if the allegations are substantiated. The Administrator/Administrator-on-Call shall take, or ensure that the following actions are taken, by appropriate staff members:
- Contacts attending physician to relay events
- Immediately contacts family to inform family of allegations and actions takes and arranges a session. If the patient is an adult, must obtain patient's consent prior to contacting family
- The findings of investigation will be reviewed with patient/family members/authorized representative as required/permitted by law.
- If required, obtain consent for further referral, assessment, evaluation, treatment, intervention as pertinent to specific situation as needed will be obtained.
- Immediately notify the Regional Director of Clinical Services
- Prepare and submit any required Self Report documentation per the following:
Louisiana
Louisiana Department of Health (LDH)
The Facility shall send the Self-Report on the Hospital Abuse and Neglect Self-Reporting Form Louisiana to the email listed above. The Facility may also report to the local law enforcement or the Louisiana Medicaid Fraud Unit, as applicable.
Initial reporting must be submitted within 24 hours of a staff member or contract worker becoming aware that an incident of abuse or neglect has been alleged, witnessed or is suspected.
Final Investigative Report within five (5) working days of submitting the initial report."

1) Failure to thoroughly investigate and report allegations of abuse within 24 hours to the Department of Health and Hospitals or law enforcement for 1 (#3) of 3 (#1-#3) patients reviewed for abuse.

Review of Patient #3's Provider Orders for October 2024 revealed the following orders:
10/09/2024 9:00 AM Aspirin 81mg 1 tablet by mouth daily Indication: myocardial infarction prevention. Ordered by S9NP on 10/17/2024 at 9:09 AM
10/09/2024 9:00 AM Clopidogrel Bisulfate 75mg 1 tablet by mouth daily Indication: thrombosis prevention after percutaneous coronary intervention. Ordered by S9NP on 10/17/2024 at 9:09 AM

Review of Patient #3's Provider Orders for November 2024 revealed the following orders:
11/05/2024 2:01 PM Transfer Patient - Send patient to ER for further evaluation and treatment of bruising to facial/temporal area and chest area, pt on Plavix and aspirin. Ordered by S9NP on 11/08/2024 at 7:41 AM

Review of Patient #3's Medical Progress Notes dated 11/04/2024 by S9NP revealed the following in part:
On 11/04/2024, Patient #3 stated to S9NP, "I want to see my doctor." Patient in room with MHT at bedside. Patient denies acute medical complaints. Currently calm although labile mood. Physical exam revealed skin documentation of "Other: chronic ecchymosis and skin tears to arms, no active bleeding, bandages noted on forearms." Electronically signed by S9NP on 11/04/2024 at 4:35 PM

Review of Patient #3's Skin and Wound Care Assessment for 11/05/2024 revealed the following:
Date: 11/05/2024
Site: Face
Etiology: Bruise
Origin: Not present on admission
Comment: Left eye bruising

Date: 11/05/2024
Site: Right Upper Extremity
Etiology: Bruise
Origin: Not present on admission
Comment: Right breast bruising

Date: 11/05/2024
Site: Right lower extremity
Etiology: Bruise
Origin: Not present on admission
Comment: Outer right leg bruising

Date: 11/05/2024
Site: Left Lower Extremity
Etiology: Bruise
Origin: Not present on admission
Comment: Left thigh bruising

Date: 11/05/2024
Site: Face
Etiology: Bruise
Origin: Not present on admission
Comment: Eye/mouth bruising

Date: 11/05/2024
Site: Right Knee
Etiology: Bruise
Origin: Not present on admission
Comment: Right inner knee bruising

Date: 11/05/2024
Site: Left Upper Extremity
Etiology: Bruise
Origin: Not present on admission
Comment: Left breast bruising

Review of Patient #3's Nursing Notes dated 11/05/2024 revealed the following note:
11/05/2024 at 7:20 AM - It was reported to me at shift change on the evening of 11/04/2024, by S11RN day shift, that bruises were observed by her on the patient in question. Also, S11RN informed me that the S10FADON and Medical MD was notified. On 11/05/2024 at 7:20 a.m. after report was given to day nurse S11RN. I was called into the shower room by S18LPN to observe the patient's skin. While standing at the distance I was, I clearly saw that the patient bilateral breast was bruised, left side of her face bruised and her bilateral lower legs had some discolored blue-black streaks. I notified S10FADON. Electronically signed by: S12RN on 11/06/2024 at 4:49 a.m.

11/05/2024 at 1:38 PM - Patient #3's daughter-in-law notified that patient had bruising of unknown source. Family informed they will be provided with developing findings. Signed by: S11RN

Review of Patient #3's Medical Progress Notes dated 11/05/2024 by S9NP revealed the following in part:
On 11/05/2024, Patient #3 stated to S9NP, "I was beat up last night." Patient has multiple bruises throughout body. Patient states staff twisted her breast and hit her in the head. Patient has bruising to bilateral breast. RN took pics of wounds. Patient also has bruising to left orbit, and temple. Patient has multiple bruising to extremities and toes. Wounds do appear to be from assault differential causes, unreported fall. Patient to be sent to ER for evaluation of wounds and have radiographs done since she is on Plavix. Physical exam revealed skin documentation of "Other: chronic ecchymosis and skin tears to arms, no active bleeding, bandages noted on forearms, bruising to bilateral breast. RN took pics of wounds. Patient also has bruising to left orbit, and temple. Patient has multiple bruising to extremities and toes. Assessment: 16. Bruising/multiple wounds: most likely from assault. Patient sent to ER for evaluation. Electronically signed by S9NP on 11/05/2024 at 3:13 PM

Review of the facility Grievance Logs for October and November 2024 revealed no documented grievances for Patient #3 related to allegations of abuse.

Review of the facility Incident Logs for October and November 2024 revealed no documented incidents involving staff to patient abuse for Patient #3. An incident report was completed on 11/05/2024 at 2:01 PM Patient #3 for a change in condition related to bruising of unknown source with "area of concern per Provider due to patient being on a daily regimen of Plavix and Aspirin" and no mention of suspected assault as mentioned in S9NP's progress note.

On 12/02/2024 at 3:15 p.m., a telephone interview was conducted with S9NP. He stated he was notified by S11RN who was caring for the Patient #3 when he made rounds at the facility on the morning of 11/05/2024 of new generalized bruising to Patient #3. He stated he went into Patient #3's room to assess her and S11RN and S10FADON were taking pictures of the bruising. He stated Patient #3's bruising was new to what he had seen the day prior (11/04/2024) when he had made rounds on her at the facility, however, he stated he does not usually do a full skin assessment on every patient daily unless the nurse notifies him of a new wound or reason to perform a skin assessment on a patient. He agreed the skin areas commonly visible on patients he would see during routine exams would be a patient's face, lower arms or legs if they were wearing a short-sleeved shirt or gown, he would be able to visualize any newly bruised areas. He stated the bruising to Patient #3's left eye/temporal region and face were new to him when he saw her on the afternoon of 11/05/2024 and she did not have that bruising when he made rounds on her on 11/04/2024. He confirmed Patient #3 verbally reported to him on 11/05/2024 staff had "beat her up" on the prior shift, but did not hold much weight to it because she was "demented". He stated she had been exhibiting aggressive behaviors towards staff and self-harm towards herself recently and took daily Plavix and Aspirin so his main concern was her increased risk for bleeding. He stated he included that in his progress note as well as the potential allegation the patient had made of assault and sent her out for further evaluation to the local emergency department for further evaluation and treatment. He stated he did not further report the allegation of assault to anyone else because the S11RN and S10FADON were in the room with him and heard the patient report the allegation as well.

On 12/02/2024 at 4:04 p.m., an interview was conducted with S11RN. She stated Patient #3 had reported to her prior to 11/05/2024 that night shift staff had assaulted her. S11RN stated she had completed a hand written report and gave it to S10FADON. S11RN stated she could not recall the exact date of when Patient #3 reported the assault to her, but stated it was around the time of when the 11/05/2024 incident with the generalized bruising had occurred but was prior to that event. S11RN stated she had "started to become suspicious" of the increased bruising on Patient #3, but was aware Patient #3 was on Plavix and a daily aspirin which increased her risk for bleeding and knew it was why she was on bleeding precautions. S11RN stated she had never personally seen any other staff members be physical or assault Patient #3. S11RN stated when Patient #3 reported the assault to her, she asked Patient #3 if she could tell her who the person or persons were who assaulted her and she stated Patient #3 could not provide her with a name of a staff member, but she did describe them which was what she included in her report. S11RN stated she put in her report word for word what Patient #3 said regardless of what she stated if it was appropriate or not. S11RN stated once she completed the report, she gave it to her superior, which at the time was S10FADON. S11RN stated she was never contacted about the incident after that from anyone so she was unsure if S10FADON escalated the issue to anyone above her. S11RN stated when she arrived to work on the morning of 11/05/2024, she went to assess Patient #3 and found multiple new bruises to Patient #3's left eye/temporal region, bilateral breasts, right outer leg, left thigh, right inner knee and facial bruising. S11RN stated as soon as she observed the new bruising to Patient #3, she notified S9NP who was at the facility making rounds on patients at that time, and requested he come to assess Patient #3's skin with her and S10FADON. She stated while S9NP assessed Patient #3, S10FADON and herself photographed the new bruises for her medical record. S11RN stated she voiced her concerns to S9NP regarding the bruises being suspicious in nature and not having received any reported falls in shift report. She stated S9NP placed an order for Patient #3 to be transferred to the local emergency department for further evaluation and treatment.

On 12/03/2024 at 10:15 AM, an interview was conducted with S1DON. She stated she was unaware of the allegation of assault Patient #3 had made to S11RN which she had reported to S10FADON in a handwritten report. She confirmed if an allegation of assault and/or abuse towards a patient was made and/or witnessed, it should be reported immediately to be investigated.

2) Failure to thoroughly investigate and report allegations of elopement within 24 hours to the Department of Health and Hospitals or law enforcement for 1 (#1) of 3 (#1-#3) patients reviewed for elopement.

Review of Patient #1's Nursing Progess Notes dated 09/30/2024 9:20 a.m. revealed in part: Patient #1 lingering at exit door with clothes packed. Patient unable/unwilling to follow directive to remove self from exit door. Patient later removed herself from the exit door and sat in the hall seated in the middle of the floor with her legs folded. Patient #1 witnessed running behind a nurse as she exited the unit, Patient #1 reported catching exit door and pushing it open. Patient #1 reached outside ramp where charge nurse was standing. Patient returned to unit without further episodes.

An interview on on 12/03/2024 at 10:05 a.m., S1DON verified neither the local law enforcement agency or the Louisiana Department of Health (LDH) was notified of Patient #1 elopement.

Based on record review and interviews, the hospital failed to recognize opportunities for improvement and initiate changes to ensure compliance. The deficient practice was evidenced by:
1) failure of the hospital to self-report and investigate allegations of staff physical abuse to a patient after being reported to nursing staff and medical provider; and
2) failure of the hospital to self-report and investigate an elopement attempt made by patient.
Findings:

Review of the QAPI Meeting Minutes provided were from January 31, 2024; July 24, 2024; and October 16, 2024. No further QAPI Meetings were held after the above incidents.

1) Failure of the hospital to self-report and investigate allegations of staff physical abuse to a patient after being reported to nursing staff and medical provider.

Review of the hospital's current QAPI projects for 4th quarter 2024 revealed no open projects related to abuse and/or abuse reporting.

On 12/03/2024 at 12:45 PM, an interview was conducted with S3DQ. She confirmed there were no open QAPI projects currently related to abuse, self-reporting or investigating allegations.

2) Failure of the hospital to self-report and investigate an elopement attempt made by patient.

Review of the hospital's current QAPI projects for 4th quarter 2024 revealed no open projects related to elopements.

On 12/03/2024 at 12:45 PM, an interview was conducted with S3DQ. She confirmed there were no open QAPI projects currently related to elopements, self-reporting or investigating elopements.

Based on record review and interviews, the hospital failed to ensure an adequate number of licensed nursing and other personnel were scheduled to provide nursing care to all patients. This deficient practice was evidenced by the inadequate number of MHT's scheduled to work on the 7:00 PM - 7:00 AM shift on 11/01/2024.

Review of the hospital's policy number NSG-06 titled "Staffing Plan" last revised on 09/01/2022, indicated the following, in part:
"Purpose:
To establish criteria that provides guidelines for meeting anticipated needs of the nursing staff and to provide for safe deliver of care to the patients in a fiscally responsible manner.
Policy:
The Governing Body has adopted, implemented and enforces a written Nurse Staffing policy to ensure that an adequate number and skill mix of nurses are available to meet the level of patient car needed. The Director of Nursing, or designee plans a master schedule for each discipline within the nursing department. The master schedule is adjusted as needed to provide for patient needs and ensure positive patient outcomes. The charge nurse or nursing supervisor, in the absence of the DON, makes necessary changes to staffing units to meet unit needs."

Review of the hospital's staffing matrix revealed the following in part:
13 patients on 7:00 PM - 7:00 AM 3 MHTs

Review of the hospital's policy number CS-23 titled, "Level of Observations" last revised on 03/01/2023, revealed the following in part:
Purpose:
To provide staff with a framework for monitoring patients to ensure safety. Observation should be both safe and therapeutic. Respect should be shown for the patient's need for autonomy while ensuring safety.
Policy:
Three levels of observation are utilized: every 15-minute (Q15 minute) observation; Line of Sight (Constant Observation); and one-to-one observation. The level of observation is determined by the individual needs of the patient and treatment team recommendation and ultimately requires a physician order
Observation Levels:
Line of Sight (Constant Observation) - the staff member will ensure the patient is visually within sight at all times
One-to-one observation - The staff will ensure the patient is visually within sight and within arm's reach of a staff member at all times and in all circumstances.
Procedure:
Line of Sight Observation
-Patient is under constant observation and within line of sight at all times.
-Line of Sight observation level may be required for the patient assessed as high or increased risk in the context of their illness and their environment.
-The designated staff (MHT) is assigned to perform line of sight observation and can observe multiple patients, but must remain in the area with the patients such that if a patient needs immediate intervention, the staff member can intervene and call for assistance.
-In some instances, it may be clinically identified that the assigned observer is to remain in the same room as the patient at all times. This can include assigning one observer to a shared room with two patients, if appropriate. This must be clearly documented on the inpatient observation record.
-Line of Sight observation level includes constant observation in the bathroom and toilet areas, unless the door is able to be left ajar and the observer is able to access the room immediately.
One-to-one Observation
Physician/NPP
-Provides order for -one-to-one observation based on assessed risk and individual needs.
-The physician/NPP must give the order to discontinue a one-to-one level of observation once it is begun.
Charge Nurse
-Assesses patient's condition regarding danger to self, others, fall risk, psychological factors, elopement and psychosis which places the patient at risk.
-Reassesses patient status, at a minimum of every 4 hours for continued risk and need for the one-to-one level of care. The rationale for the continued one-to-one will be documented in the multidisciplinary progress notes every 4 hours. If the patient is assessed and it is found that the patient no longer needs the one-to-one level of care, then the physician/NPP MUST be notified and an order received to discontinue the one-to-one.

Review of the hospital census for 11/01/2024 revealed a total of 13 patients, 6 males and 7 females. Review of the nursing assignment sheet for 11/01/2024 for the night shift (7:00 PM - 7:00 AM) revealed a starting census of 13 patients with a total of 3 admissions during the shift, a total of 4 staff members - 1 charge RN, 1 medication LPN and 2 MHTs. Based on the nursing assignment sheet there were two patients on 1:1/LOS observation, but it did not differentiate which observation status they were on.

Review of the Observation Check Sheet/Graphic Flowsheet for 11/01/2024 for the 7:00 PM to 7:00 AM shift revealed the following:
Observational Level MHT who initialed direct observation of patient
Patient #3 LOS S23MHT
#R1 Q15 S23MHT
#R2 Q15 S23MHT
#R3 Q15 S23MHT
#R4 Q15 S23MHT
#R5 Q15 S23MHT
#R6 Q15 S23MHT

On 12/02/2024 at 3:00 PM an interview was conducted with S1DON. S1DON confirmed there were 2 MHTs on staff working on 11/01/2024 7:00 PM - 7:00 AM shift and the staff matrix called for 3 MHTs.

Based on record review and an interview, the hospital failed to ensure the RN received a provider's order to modify an observation level for 1 (#3) of 3 (#1-#3) patients reviewed for observation statuses.
Findings:

Review of the hospital's policy number CS-23 titled, "Level of Observations" last revised on 03/01/2023, indicated the following, in part:
"Purpose:
To provide staff with a framework for monitoring patients to ensure safety. Observation should be both safe and therapeutic. Respect should be shown for the patient's need for autonomy while ensuring safety.
Policy:
The level of observation is determined by the individual needs of the patient and treatment team recommendation and ultimately requires a physician order
Observation Levels:
Line of Sight (Constant Observation) - the staff member will ensure the patient is visually within sight at all times
One-to-one observation - The staff will ensure the patient is visually within sight and within arm's reach of a staff member at all times and in all circumstances.
Procedure:
Line of Sight Observation
-Patient is under constant observation and within line of sight at all times.
One-to-one Observation
Physician/NPP
-Provides order for -one-to-one observation based on assessed risk and individual needs.
-The physician/NPP must give the order to discontinue a one-to-one level of observation once it is begun.
Charge Nurse
-Assesses patient's condition regarding danger to self, others, fall risk, psychological factors, elopement and psychosis which places the patient at risk.
-Reassesses patient status, at a minimum of every 4 hours for continued risk and need for the one-to-one level of care. The rationale for the continued one-to-one will be documented in the multidisciplinary progress notes every 4 hours. If the patient is assessed and it is found that the patient no longer needs the one-to-one level of care, then the physician/NPP MUST be notified and an order received to discontinue the one-to-one."

Review of Patient #3's Providers Orders from admission on 10/08/2024 to 11/08/2024 revealed the following, in part:
10/26/2024 at 9:00 AM - 1:1 Observation Continuous Rationale: Danger to others, Comments: Psychotic Behavior, High Fall Risk, Aggressive towards others. Ordered by S8NP (Order was discontinued on 11/08/2024 at 9:37 PM)

Review of Patient #3's Observation Check Sheet/Graphic Flowsheet dated 11/01/2024 revealed a documented observation level of "Line of Sight".

On 12/03/2024 at 12:15 p.m., an interview was conducted with S1DON. She reviewed Patient #3's Observation Check Sheet/Graphic Flowsheet dated 11/01/2024. She confirmed the observation level checked on the paper was "Line of Sight". She reviewed Patient #3's Providers' Orders for 11/01/2024 and confirmed Patient #3 had an order for 1:1 Observation Continuous on 11/01/2024 and no order for Line of Sight observation.

Based on record review and interview, the hospital failed to ensure the nursing staff developed, and kept current, an individualized nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs. This deficient practice is evidenced by the failure to update the nursing care plans on 1 (#1) of 3 (#1-#3) sampled patients reviewed for completed and updated nursing care plans.
Findings:

A review of facility policy number CS-02 titled, "Treatment Planning; Integrated/Multidisciplinary" revealed in part, under the section "Purpose: To document and implement treatment objectives/interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of patient's treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided. POLICY: The treatment plan shall be initiated as a component of the admissions process with continual development and formulation by attending physician and multi-disciplinary treatment team, with the patient's involvement, throughout the course of treatment. PROCEDURE: 2.The admitting nurse is responsible for the following: implementing immediate treatment interventions for safety and stabilization of the patient. Revising and developing nursing and medical components of the treatment plan based on additional findings from patient assessments, problems, needs, strengths, and limitations, and physician's orders. Revising the plan based on changes in condition and physician's orders. All physician orders will be incorporated into the Treatment Plan".

A medical record review on 12/03/2024 at 10:00 a.m. revealed Patient #1 had a diagnosis of Diabetes during nursing assessments completed during hospitalizations dated 09/20/2024 and 10/07/204 by RNs. There was no documentation indicating Patient #2's nursing care plans had initiated or been updated to include this medical diagnosis or treatment interventions.

In an interview on 12/03/2024 at 10:40 a.m. S1DON confirmed there had been no initiation intervention related to the Patient #1's diagnosis of Diabetes or updates to the nursing care plan.

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 number NSG-06 last revised date 09/10/2022 titled, "Staffing Plan," revealed in part: "PURPOSE: To establish criteria that provides guidelines for meeting anticipated needs of the nursing staff and to provide for safe delivery of care to the patients in a fiscally responsible manner. PROCEDURE: Inpatient: Factors considered in determining staffing needs: Patient census and staffing matrix are used to determine staffing needs. A registered nurse plans, assigns, supervises, and evaluates the nursing care of each patient daily. A registered nurse is responsible for supervising all License Practical/Vocational Nurses (LPN/LVN), Mental Health Techs (MHT) and Certified Nursing Assistants (CNA)".

A review of the following staff assignments failed to reveal that all patient assignments were made by the RN for each shift:
10/26/2024 Day Shift (07:00- 19:00) Patient census 15
10/26/2024 Night Shift (19:00- 07:00) Patient census 16
11/02/2024 Day Shift (07:00- 19:00) Patient census 15
11/02/2024 Night Shift (19:00- 07:00) Patient census 17
11/06/2024 Day Shift (07:00- 19:00) Patient census 17
11/06/2024 Night Shift (19:00- 07:00) Patient census 17
11/07/2024 Day Shift (07:00- 19:00) Patient census 17
11/07/2024 Night Shift (19:00- 07:00) Patient census 15
11/09/2024 Day Shift (07:00- 19:00) Patient census 17
11/10/2024 Day Shift (07:00- 19:00) Patient census 16
11/11/2024 Day Shift (07:00- 19:00) Patient census 17
11/11/2024 Night Shift (19:00- 07:00) Patient census 18
11/12/2024 Day Shift (07:00- 19:00) Patient census 18
11/12/2024 Night Shift (19:00- 07:00) Patient census 16
11/13/2024 Day Shift (07:00- 19:00) Patient census 16
11/13/2024 Night Shift (19:00- 07:00) Patient census 14
11/14/2024 Day Shift (07:00- 19:00) Patient census 15
11/14/2024 Night Shift (19:00- 07:00) Patient census 14
11/15/2024 Day Shift (07:00- 19:00) Patient census 13
11/15/2024 Night Shift (19:00- 07:00) Patient census 13
11/16/2024 Day Shift (07:00- 19:00) Patient census 15
11/17/2024 Day Shift (07:00- 19:00) Patient census 16
11/18/2024 Day Shift (07:00- 19:00) Patient census 18


In an interview on 12/03/2024 at 1:30 p.m., S3DQ confirmed RN makes patient assignments for the MHTs for all patients on the unit. S3DQ verified that the above assignment sheets did not have all patients assigned to MHTs. S1DON also confirmed that the hospital policy states the RN on each shift is responsible for delegating patient care assignments.

Based on record review and an interview, the hospital failed to ensure the medical record contained information to describe the patient's response and effectiveness of PRN (as needed) medications for 1 (#3) of 3 (#1 - #3) sample patients reviewed for PRN medications.
Findings:

A review of the hospital policy #MM-01 titled "Medications" last revised on 12/01/2024, indicated the following, in part:
"Purpose:
To establish protocols for inpatient medications related to:
-Documentation
Policy:
The hospital will ensure that all medications related to the patient' inpatient stay are documented in the medical record in accordance with Federal and State Law and industry best practice.
Procedure:
Documentation
RN/LVN/LPN
5. Documents on the patient's MAR any PRN and STAT medications administered, with cause and effect noted.
7. Documents PRN medication effectiveness of any new medication prescribed by physician."

A review of the Provider Orders for Patient #3 from 10/23/2024 to 11/08/2024 revealed the following orders:
10/23/2024 7:38 PM Zyprexa 10mg IM one time only - Do not give at the same time or within 2 hours of Ativan eSignature: S7MD on 10/26/2024 at 5:39 AM
10/25/2024 4:20 PM Ativan 2mg/mL, 1mg(0.5mL) Im one time only - Medication joined with Haldol 2.5mg IM injection Indication: psychotic disorder eSignature: S8NP on 10/29/2024 on 10:47 AM
10/25/2024 4:20 PM Haldol 5mg/mL, 2.5mg (0.5mL) IM one time only - Medication joined with Ativan 1mg IM Indication: psychotic disorder eSignature: S8NP on 10/29/2024 on 10:47 AM
10/26/2024 3:20 AM Ativan 2mg/mL, 2mg (1mL) IM one time only Indication: psychotic disorder eSignature: S7MD on 10/26/2024 on 5:39 AM
10/26/2024 3:20 AM Haldol 5mg/mL, 5mg (1mL) IM one time only Indication: psychotic disorder eSignature: S7MD on 10/26/2024 on 5:39 AM
10/27/2024 12:53 PM Ativan 2mg/mL, 2mg (0.5mL) IM one time only - Medication joined with Haldol 2.5mg Indication: agitation and aggression eSignature: S7MD on 10/26/2024 on 5:39 AM
10/27/2024 12:53 PM Haldol 5mg/mL, 5mg (0.5mL) IM one time only - Medication joined with Ativan 1mg Indication: agitation and aggression eSignature: S7MD on 10/26/2024 on 5:39 AM
11/03/2024 9:00 AM Ativan 2mg/mL, 2mg (1mL) IM one time only Indication: agitation eSignature: Mohammad Anwar on 11/04/2024 on 6:15 PM
11/04/2024 4:04 PM Ativan 2mg/mL, 2mg (1mL) IM one time only Indication: preoperative anxiety eSignature: S8NP on 11/06/2024 on 10:32 AM
11/05/2024 9:04 AM Ativan 2mg/mL, 2mg (1mL) IM one time only Indication: physical aggression eSignature: S8NP on 11/06/2024 on 10:32 AM
11/06/2024 2:12 AM Ativan 2mg/mL, 2mg (1mL) IM one time only Indication: agitation eSignature: S7MD on 11/06/2024 on 1:54 PM

A review of the of MAR for Patient #3 from 10/23/2024 to 11/08/2024 revealed the following PRN medications given with no documented effectiveness after receiving the medication:
Zyprexa 10mg IM:
10/23/2024 at 7:38 PM given by S15LPN; no effectiveness follow-up documented

Ativan 0.5mg IM:
10/25/2024 at 4:30 PM given by S16LPN; no effectiveness follow-up documented

Haldol 2.5mg IM:
10/25/2024 at 4:30 PM given by S16LPN; no effectiveness follow-up documented
10/27/2024 at 12:55 PM given by S16LPN; no effectiveness follow-up documented

Ativan 1mg IM:
10/26/2024 at 3:15 AM given by S17LPN; no effectiveness follow-up documented
10/27/2024 at 12:55 PM given by S16LPN; no effectiveness follow-up documented

Haldol 5mg IM:
10/26/2024 at 3:15 AM given by S17LPN; no effectiveness follow-up documented

Ativan 2mg IM:
11/03/2024 at 9:15 AM given by S19LPN; no effectiveness follow-up documented
11/04/2024 at 4:04 PM given by S16LPN; no effectiveness follow-up documented
11/05/2024 at 9:05 AM given by S16LPN; no effectiveness follow-up documented
11/06/2024 at 2:12 AM given by S18LPN; no effectiveness follow-up documented

On 12/02/2024 at 1:24 PM, an interview was conducted with S3DQ. While reviewing the MAR for Patient #3 for PRN medication administration, it was discovered none of the PRN medications administered to Patient #3 had been evaluated for effectiveness after being administered to Patient #3. S3DQ stated the charting system used by the nursing staff "prompted staff with a reminder to document effectiveness when a PRN medication is administered to a patient." S3DQ confirmed none of the PRN medications listed above between 10/23-11/06/2024 administered to Patient #3 had a documented effectiveness and should have.