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Based on observation, record review and interview, the hospital failed to ensure the patient right to be free from all forms of abuse/neglect. This deficient practice is evidenced by the failure to ensure Continuous Visual Observation (CVO) at 15 feet distance was being appropriately performed on 1 (#2) of 3 (#1 - #3) patients reviewed.
Findings:

A review of hospital policy, "Observation and Precautions," Policy Number: Nursing-2005-504, PC-NUR-12, effective 03/3005, last revised 05/19/2025 and approved 05/20/2025, revealed in part: "I. DEFINITIONS C. Continuous Visual Observation (CVO) at Fifteen (15) Feet: the client is continuously visually observed from a distance of not more that fifteen (15) feet from the assigned staff member. A physician's order is required for CVO at fifteen (15) feet in distance. The registered nurse (RN) shall confer with the physician to determine the exact type of observation required for the client (1:1, 2:1). A staff member may observe no more than (3) clients on CVO. E. Precaution Observation: level of observation for clients with risk factors that present as potential for or as danger to self. Risk factors requiring elevated observation may include, but are not limited to, suicidal ideations, gestures, elopement and falls. Precautionary observation requires a physician's order. IV. POLICY It is the policy of ELMHS to provide professionally supervised care consistent with the Louisiana Office of Behavioral Health (OBH) policy and regulatory accrediting agencies ensuring the utilization of preventative strategies, non-physical interventions and the provision of a safe therapeutic environment of care. PROCEDURE B. Nursing Care for Clients on Precautions: ii. Continuous Visual Observation (CVO) at Fifteen (15) Feet in Distance a. PAs or Nursing-Security staff shall be assigned to clients on continuous visual observation at fifteen (15) feet. b. Staff assigned to a client on continuous visual observation shall remain within fifteen (15) feet of the client and the client must remain in sight at all times."

A review of hospital policy, "Client Abuse and Neglect Policy and Procedure," Policy Number: LD-25, effective 05/16/2024 and approved 05/28/2024, revealed in part: I. POLICY: Eastern Louisiana Mental Health System (ELMHS) is committed to preserving the right of each person receiving services to be free of abuse and neglect. All forms of abuse/neglect of client by employees of ELMHS and its affiliates are prohibited. V. STATUTORY DEFINITIONS AND EXAMPLES B. Louisiana R.S. 15:1503. i. Abuse: the infliction of physical or mental injury, or action which may reasonably be expected to inflict physical injury, on an adult by other patties including, but not limited to, such means as sexual abuse, abandonment, isolation, exploitation, or extortion of funds or other things of value. Neglect: failure, by a caregiver responsible for an adult's care, or by other parties, to provide the proper or necessary support or medical, surgical, or any other care necessary for the adult's well-being. No adult who is being provided treatment in accordance with a recognized religious method of healing in lieu of medical treatment shall for that reason alone be considered to be neglected or abused. C. Louisiana R.S. 40:2009.20. These definitions apply to any person residing in a facility or receiving services from a provider licensed by HSS of the LDH Office of the Secretary. This includes, but is not limited to, clients residing in a licensed hospital and other licensed health facilities as defined by this statute. i. Abuse: the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including, but no 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. ii. Neglect: the failure to provide the proper or necessary medical care, nutrition, or other care necessary for the consumer's well-being. D. 42 CFR 482.13(c)(3). These definitions contained in the Code of Federal Regulations (CFR) apply to hospitals participating in the Medicaid and /or Medicare programs. i. Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. ii. Neglect: the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. H. Listed below are examples of the types of conduct that constitute abuse and neglect. vi. Neglect: a. Acts or omissions by a person responsible for providing care or treatment which caused harm to, or placed a client at risk of harm, or which deprived a client of sufficient or appropriate services, treatment, or basic care. b. Failure to provide or withhold appropriate services, nutrition, clothing, treatment, or care by gross errors in judgement, inattentions, or ignoring may also be considered a form of neglect. c. Failure to establish and carry out an appropriate program or treatment plane. d. Failure to provide a safe environment. e. Failure to provide and obtain needed medical treatment. f. Failure to supervise a client such that the client is placed in danger."

A review of the form, "State of Louisiana Department of Health & Hospitals - Office of Mental Health Client Incident, Injury, and Data Reporting Form," revealed in part, an incident involving Patient #2 taking place on 06/29/2025 at 7:30 AM. The S16RN's description of the incident in Section B of the report: "Pt acquired a piece of bacon from the floor, shoved it in his mouth and began choking. Pt fell from sitting position in chair to floor. While choking, code blue was called by S17CGT. Pt was able to cough up the bacon. Pt didn't lose consciousness or stop breathing. S18MD notified."

A review of the "APS Facility Investigation Report," Investigation ID: 12859, investigation by S19APSI, revealed an interview with Patient #2 on 07/01/2025 at 3:25 PM, conducted by S19APSI. Patient #2 revealed in part, "He was eating bacon and eggs and oatmeal. Client stated, The food got caught in his throat and wouldn't come out." This report revealed an interview with S12CGT on 07/02/2025 at 1:35 PM conducted by S19APSI. S12CGT revealed in part, "I was assigned to two CVO's. During breakfast feeding (730) I was assisting one of the CVO's while the other was eating his breakfast tray. In the process, The CVO that was eating [Patient #2], began to choke ...at no time did I leave either patient unattended. I [S12CGT] feel one CGT shouldn't be assigned to two patient at the same time, because no two patients are alike and I as a CGT can't be in two places at one time." A second interview with S12CGT on 07/03/2025 at 12:25 PM and conducted by S19APSI revealed in part, S20CGT's location during the before mentioned choking incident on 06/29/2025. S12CGT replied, "I was present at the time and never left the unit. I was currently assisting the other CVO [Random #1] ...the nurse did the report and it stated patient [Patient #2] had picked a piece of bacon off the floor, which in my defense is incorrect [Patient #2] tray had chopped bacon on it and his tray had been verified by the nurse. Also in my defense, the lineup of that day is incorrect. I was on two CVO's both [Patient #2] and [Random #1]." This report revealed an interview with S13CGT on 07/08/2025 at 10:31 AM conducted by S19APSI. S13CGT revealed in part, "[Patient #2] was a CVO and assigned to S12CGT. However S12CGT was also assigned [Random #1]. S12CGT was in the sleeping area with [Random #1] at the time of the incident."

A request was initiated on 07/29/2025 at 11:30 AM with S3TQMPC to interview S12CGT. However, S12CGT was not on duty on this day and was unavailable via telephone.

Observations during a walk-through of the hospital on 07/28/2025 from 9:10 AM to 9:55 AM revealed Patient #2 ambulating the unit of Building A. Patient #2 was hunched over at the waist at an approximate 80 - 90 degree angle with his head/face towards the ground. His upper body, from waist up was almost parallel with the floor. He was hastily ambulating unassisted. His general body appearance or posture did not afford a physically easy way to swallow food or allow food to easily pass down his esophagus. His upper body, from waist up was almost parallel with the floor.

In an interview on 07/28/2025 and present on the walk-through of Building A, S21RNBM and S22CGT confirmed the identity of Patient #2. They further confirmed Patient #2 body configuration and indicated that was his normal appearance. S22CGT confirmed if a patient was on CVO at 15 Feet, then the CGT assigned to the patient would remain in the dining day room with the patient as he was eating.

Observations on 07/28/2025 of recorded video from camera W4DayRm SW EH-135 on 06/29/2025 from 7:25 AM to 7:25 AM, with S20PM navigating the computer and S3TQMPC present, revealed Patient #2 during this time frame ambulating between the main day room and the dining day room. The recorded video failed to reveal S12CGT, the assigned CGT within 15 feet of Patient #2 until the patient had been assisted up from the floor.

In an interview on 07/28/2025 and present during the observation of recorded video, S20PM confirmed the above mention findings on the recorded video.

A review of Patient #2's medical record revealed a provider order on 04/28/2025 at 2:10 PM for CVO at not more than 15 feet for medical observation/choke precautions and a diet order on 04/16/2025 for Dysphagia Level 2 Mechanical Altered Supervision order: Close Visual Observation (CVO): At all times, including meals. A review of the form, "Restrictive Management Observation & Precaution Sheet (0600 - 1800) dated 06/29/2025 revealed in part, S12CGT's initials as the performer of observations checks from 6:30 AM to 11:00 AM.

A review of Random Patient #1's medical record and the form, "Restrictive Management Observation & Precaution Sheet (0600 - 1800) dated 06/29/2025 revealed in part, S12CGT's initials as the performer of observations checks from 6:30 AM to 11:00 AM.

After review of the above mentioned findings, S12CGT was unable to be in 2 locations at one time and maintain CVO at fifteen (15) feet in distance on 2 patients while these patients were in different locations at one time.

In an interview on 07/29/2025 at 1:30 PM, S3TQMPC confirmed the above mentioned findings.

Based on observation, record review and interview, the hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice is evidenced by the failure to fully investigate and identify the source and the potential cause of Patient #2's choking event and the observation of Patient #2 while eating.
Findings:

A review of hospital policy, "Observation and Precautions," Policy Number: Nursing-2005-504, PC-NUR-12, effective 03/3005, last revised 05/19/2025 and approved 05/20/2025, revealed in part: "I. DEFINITIONS C. Continuous Visual Observation (CVO) at Fifteen (15) Feet: the client is continuously visually observed from a distance of not more that fifteen (15) feet from the assigned staff member. A physician's order is required for CVO at fifteen (15) feet in distance. The registered nurse (RN) shall confer with the physician to determine the exact type of observation required for the client (1:1, 2:1). A staff member may observe no more than (3) clients on CVO. E. Precaution Observation: level of observation for clients with risk factors that present as potential for or as danger to self. Risk factors requiring elevated observation may include, but are not limited to, suicidal ideations, gestures, elopement and falls. Precautionary observation requires a physician's order. IV. POLICY It is the policy of ELMHS to provide professionally supervised care consistent with the Louisiana Office of Behavioral Health (OBH) policy and regulatory accrediting agencies ensuring the utilization of preventative strategies, non-physical interventions and the provision of a safe therapeutic environment of care. PROCEDURE B. Nursing Care for Clients on Precautions: ii. Continuous Visual Observation (CVO) at Fifteen (15) Feet in Distance a. PAs or Nursing-Security staff shall be assigned to clients on continuous visual observation at fifteen (15) feet. b. Staff assigned to a client on continuous visual observation shall remain within fifteen (15) feet of the client and the client must remain in sight at all times."

A review of the, "Diet Manuel Nutritional Services Department Easter Louisiana Mental Health System 2022," approved 10/10/2022, revealed in part: "Texture Modified Diets and Thickened Liquids: ELMHS Dysphagia Level 2-Ground: Minced, soft and moist foods, can be scooped and shaped; easily by fork. No mixed consistency. Foods that are minced, soft and moist and can be scooped and shaped (e.g., into a ball shape) should have a particle size four millimeters by 4 millimeters for adults. ELMHS Order: Dysphagia Level 2: Food Group: Protein Foods; Foods Recommended: Prepared, Moistened, tender fresh or frozen red meat, including beef, pork, or lamb finely mashed into pieces no larger than 4 mm lump size."

A review of hospital policy, "Prevention of Choking," Policy Number: MS-13, approved and effective 08/15/2017, revealed in part: "DEFINITIONS 1. Choking: identified as a blockage, obstruction or compression in the larynx or trachea causing occlusion of the airway, resulting in the failure of air exchange. 2. Choking precautions: Observations and interventions by staff utilized to provide a safe environment for clients that are at risk of for choking. 3. Modified Texture Diet: Blending, chopping, grinding, or mashing foods easier to chew or swallow. In some cases only meats are altered in texture. In other cases, all foods must be altered. 4. Dysphagia: difficulty swallowing which can cause medical and/or feeding issues. IV. POLICY It is the policy of Eastern Louisiana Mental Health System that clients will be provided with a sage and therapeutic environment. This will include ongoing assessment of the individual client's ability to chew and swallow safely, provisions of treatment such as environmental modifications, behavioral interventions, and dietary modifications that are based on individual needs of each client. V. CHOKING RISK FACTORS A. Clients with cognitive and/or behavioral problems may have an increased risk for choking. Listed below are several barriers staff should be aware of that can increase a client's risk of choking: 1. Eating too fast 2. Not chewing food well 3. Overfilling mouth 4. Eating too large portions 5. Talking while eating 6. Having a poor posture while eating 7. Hoarding/Stealing Food. VI. PORCEDURES B. Placement of Clients on Special Diets and Supervision 3. For clients at risk for choking, the initial Choking Precautions Order Protocol shall be: b. Ward Mealtime Supervision: ii. Clients shall sit at the same table as other clients at risk for choking. iii. Close Visual Observation (CVO) during meal time."

A review of the form, "State of Louisiana Department of Health & Hospitals - Office of Mental Health Client Incident, Injury, and Data Reporting Form," revealed in part, an incident involving Patient #2 taking place on 06/29/2025 at 7:30 AM. The S16RN's description of the incident in Section B of the report: "Pt acquired a piece of bacon from the floor, shoved it in his mouth and began choking. Pt fell from sitting position in chair to floor. While choking code blue was called by S17CGT. Pt was able to cough up the bacon. Pt didn't lose consciousness or stop breathing. S18MD notified."

A review of the "APS Facility Investigation Report," Investigation ID: 12859, investigation by S19APSI, revealed an interview with Patient #2 on 07/01/2025 at 3:25 PM, conducted by S19APSI. Patient #2 revealed in part, "He was eating bacon and eggs and oatmeal. Client stated, The food got caught in his throat and wouldn't come out." This report revealed an interview with S12CGT on 07/02/2025 at 1:35 PM conducted by S19APSI. S12CGT revealed in part, "I was assigned to two CVO's. During breakfast feeding (730) I was assisting one of the CVO's while the other was eating his breakfast tray. In the process, The CVO that was eating [Patient #2], began to choke ...at no time did I leave either patient unattended. I S12CGT feel one CGT shouldn't be assigned to two patient at the same time, because no two patients are alike and I as a CGT can't be in two places at one time." A second interview with S12CGT on 07/03/2025 at 12:25 PM and conducted by S19APSI revealed in part, S20CGT's location during the before mentioned choking incident on 06/29/2025. S12CGT replied, "I was present at the time and never left the unit. I was currently assisting the other CVO [Random #1] ...the nurse did the report and it stated patient [Patient #2] had picked a piece of bacon off the floor, which in my defense is incorrect [Patient #2] tray had chopped bacon on it and his tray had been verified by the nurse. Also in my defense, the lineup of that day is incorrect. I was on two CVO's both [Patient #2] and [Random #1]." This report revealed an interview with S13CGT on 07/08/2025 at 10:31 AM conducted by S19APSI. S13CGT revealed in part, "[Patient #2] was a CVO and assigned to S12CGT. However S12CGT was also assigned [Random #1]. S12CGT was in the sleeping area with [Random #1] at the time of the incident."

A request was initiated on 07/29/2025 at 11:30 AM with S3TQMPC to interview S12CGT. However, S12CGT was not on duty on this day and was unavailable via telephone.

Observations on 07/28/2025 of recorded video from camera W4DayRm SW EH-135 on 06/29/2025 from 7:25 AM to 7:25 AM, with S20PM navigating the computer and S3TQMPC present, revealed Patient #2 eating his breakfast tray in the main day room. Patient #2's food tray was sat on a chair in the middle of the main day room. Patient #2 was in his standing position, which placed him leaned over his food tray. Patient #2's upper body was bent over at the waist and at times, his head was lower than his waist. Patient #2 appeared to be chewing, however, Patient #2 was also ambulating between the main day room and the dining day room. At no point was a CGT following him as he was walking between these rooms. The dining day room was not visible to camera video. While Patient #2 was in the dining day room, it appeared another patient summoned Patient #2 to return to the main day room. During this process, Patient #2 appeared to be chewing and hastily ambulating to get to his tray. As he approaches the chair with his tray, a substance appears to come from his mouth. After reaching his chair, he grabs the chair with both hands and as he leans forward over the chair, more substance appeared to fall from his mouth and he appeared to be coughing at that point. He then stands and motions towards a CGT (which was not assigned to him) who assists him and them assists him to floor. During the review of video, when Patient #2 was in view of the camera, it was never observed that he retrieved anything from the floor.

In an interview on 07/28/2025 and present during the observation of recorded video, S20PM confirmed the above mention findings on the recorded video.

A review of the document, "Jackson and Forensic Campuses House Managers' Report," dated 06/29/2025 with an entry under the heading: Incidents/PRNs: "[Patient #2]-CVO at 15ft. for patient safety/choking/fall precautions being watched by S12CGT was sitting in the dayroom eating Breakfast when he fell onto the floor coughing from choking on a small piece of beacon."

After the review of the above mentioned finding, a full investigation of this incident did not take into account all aspects related to observations of the client, limited activity while eating, a review of the food tray for findings of bacon being on this tray and not retrieved from the floor, and initiatives to limit Patient #2's activity while eating. Per video review, Patient #2 was not siting while he was eating, he was not being appropriately observed and monitored and it was reported he had chopped bacon on his food tray.

In an interview on 07/29/2025 at 1:30 PM S3TQMPC confirmed the above mentioned findings.

Based on observation, record review and interview, the hospital failed to assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualification and competence of the nursing staff available. This deficient practice was evidenced by the failure to appropriately monitor 1 (#2) of 3 (#1 - #3) patients according to the provider order and precaution level.
Findings:

A review of hospital policy, "Observation and Precautions," Policy Number: Nursing-2005-504, PC-NUR-12, effective 03/2005, last revised 05/19/2025 and approved 05/20/2025, revealed in part: "I. DEFINITIONS C. Continuous Visual Observation (CVO) at Fifteen (15) Feet: the client is continuously visually observed from a distance of not more that fifteen (15) feet from the assigned staff member. A physician's order is required for CVO at fifteen (15) feet in distance. The registered nurse (RN) shall confer with the physician to determine the exact type of observation required for the client (1:1, 2:1). A staff member may observe no more than (3) clients on CVO. E. Precaution Observation: level of observation for clients with risk factors that present as potential for or as danger to self. Risk factors requiring elevated observation may include, but are not limited to, suicidal ideations, gestures, elopement and falls. Precautionary observation requires a physician's order. IV. POLICY It is the policy of ELMHS to provide professionally supervised care consistent with the Louisiana Office of Behavioral Health (OBH) policy and regulatory accrediting agencies ensuring the utilization of preventative strategies, non-physical interventions and the provision of a safe therapeutic environment of care. PROCEDURE B. Nursing Care for Clients on Precautions: ii. Continuous Visual Observation (CVO) at Fifteen (15) Feet in Distance a. PAs or Nursing-Security staff shall be assigned to clients on continuous visual observation at fifteen (15) feet. b. Staff assigned to a client on continuous visual observation shall remain within fifteen (15) feet of the client and the client must remain in sight at all times."

A review of the, "Diet Manuel Nutritional Services Department Easter Louisiana Mental Health System 2022," approved 10/10/2022, revealed in part: "Texture Modified Diets and Thickened Liquids: ELMHS Dysphagia Level 2-Ground: Minced, soft and moist foods, can be scooped and shaped; easily by fork. No mixed consistency. Foods that are minced, soft and moist and can be scooped and shaped (e.g., into a ball shape) should have a particle size four millimeters by 4 millimeters for adults. ELMHS Order: Dysphagia Level 2: Food Group: Protein Foods; Foods Recommended: Prepared, Moistened, tender fresh or frozen red meat, including beef, pork, or lamb finely mashed into pieces no larger than 4 mm lump size."

A review of hospital policy, "Prevention of Choking," Policy Number: MS-13, approved and effective 08/15/2017, revealed in part: "DEFINITIONS 1. Choking: identified as a blockage, obstruction or compression in the larynx or trachea causing occlusion of the airway, resulting in the failure of air exchange. 2. Choking precautions: Observations and interventions by staff utilized to provide a safe environment for clients that are at risk of for choking. 3. Modified Texture Diet: Blending, chopping, grinding, or mashing foods easier to chew or swallow. In some cases only meats are altered in texture. In other cases, all foods must be altered. 4. Dysphagia: difficulty swallowing which can cause medical and/or feeding issues. IV. POLICY It is the policy of Eastern Louisiana Mental Health System that clients will be provided with a sage and therapeutic environment. This will include ongoing assessment of the individual client's ability to chew and swallow safely, provisions of treatment such as environmental modifications, behavioral interventions, and dietary modifications that are based on individual needs of each client. V. CHOKING RISK FACTORS A. Clients with cognitive and/or behavioral problems may have an increased risk for choking. Listed below are several barriers staff should be aware of that can increase a client's risk of choking: 1. Eating too fast 2. Not chewing food well 3. Overfilling mouth 4. Eating too large portions 5. Talking while eating 6. Having a poor posture while eating 7. Hoarding/Stealing Food. VI. PORCEDURES B. Placement of Clients on Special Diets and Supervision 3. For clients at risk for choking, the initial Choking Precautions Order Protocol shall be: b. Ward Mealtime Supervision: ii. Clients shall sit at the same table as other clients at risk for choking. iii. Close Visual Observation (CVO) during meal time."

A review of the form, "State of Louisiana Department of Health & Hospitals - Office of Mental Health Client Incident, Injury, and Data Reporting Form," revealed in part, an incident involving Patient #2 taking place on 06/29/2025 at 7:30 AM. The S16RN's description of the incident in Section B of the report: "Pt acquired a piece of bacon from the floor, shoved it in his mouth and began choking. Pt fell from sitting position from chair to floor. While choking code blue was called by S17CGT. Pt was able to cough up the bacon. Pt didn't lose consciousness or stop breathing. S18MD notified."

A review of the "APS Facility Investigation Report," Investigation ID: 12859, investigation by S19APSI, revealed an interview with Patient #2 on 07/01/2025 at 3:25 PM, conducted by S19APSI. Patient #2 revealed in part, "He was eating bacon and eggs and oatmeal. Client stated, The food got caught in his throat and wouldn't come out." This report revealed an interview with S12CGT on 07/02/2025 at 1:35 PM conducted by S19APSI. S12CGT revealed in part, "I was assigned to two CVO's. During breakfast feeding (730) I was assisting one of the CVO's while the other was eating his breakfast tray. In the process, The CVO that was eating [Patient #2], began to choke ...at no time did I leave either patient unattended. I S12CGT feel one CGT shouldn't be assigned to two patient at the same time, because no two patients are alike and I as a CGT can't be in two places at one time." A second interview with S12CGT on 07/03/2025 at 12:25 PM and conducted by S19APSI revealed in part, S20CGT's location during the before mentioned choking incident on 06/29/2025. S12CGT replied, "I was present at the time and never left the unit. I was currently assisting the other CVO [Random #1] ...the nurse did the report and it stated patient [Patient #2] had picked a piece of bacon off the floor, which in my defense is incorrect [Patient #2] tray had chopped bacon on it and his tray had been verified by the nurse. Also in my defense, the lineup of that is incorrect. I was on two CVO's both [Patient #2] and [Random #1]." This report revealed an interview with S13CGT on 07/08/2025 at 10:31 AM conducted by S19APSI. S13CGT revealed in part, "[Patient #2] was a CVO and assigned to S12CGT. However S12CGT was also assigned [Random #1]. S12CGT was in the sleeping area with [Random Patient#1] at the time of the incident."

A request was initiated on 07/29/2025 at 11:30 AM with S3TQMPC to interview S12CGT. However, S12CGT was not on duty on this day and was unavailable via telephone.

Observations on 07/28/2025 of recorded video from camera W4DayRm SW EH-135 on 06/29/2025 from 7:25 AM to 7:25 AM, with S20PM navigating the computer and S3TQMPC present, revealed Patient #2 during this time frame ambulating between the main day room and the dining day room. The recorded video failed to reveal S12CGT, the assigned CGT within 15 feet of Patient #2.

In an interview on 07/28/2025 and present during the observation of recorded video, S20PM confirmed the above mention findings on the recorded video.

A review of Patient #2's medical record revealed a provider order on 04/28/2025 at 2:10 PM for CVO at not more than 15 feet for medical observation/choke precautions and a diet order on 04/16/2025 for Dysphagia Level 2 Mechanical Altered Supervision order: Close Visual Observation (CVO): At all times, including meals. A review of the form, "Restrictive Management Observation & Precaution Sheet (0600 - 1800) dated 06/29/2025 revealed in part, S12CGT's initials as the performer of observations checks from 6:30 AM to 11:00 AM.

A review of Random Patient #1's medical record and the form, "Restrictive Management Observation & Precaution Sheet (0600 - 1800) dated 06/29/2025 revealed in part, S12CGT's initials as the performer of observations checks from 6:30 AM to 11:00 AM.

After review of the above mentioned findings, S12CGT was unable to be in 2 locations at one time and keep a CVO on 2 patients at one time.

In an interview on 07/29/2025 at 1:30 PM, S3TQMPC confirmed the above mentioned findings.

Based on record review and interview, the hospital failed to ensure all licensed nurses adhered to the policies and procedure of the hospital. This deficient practice is evidenced by:
1) Failure to ensure the timely notification of a provider of a fall with head injury in 1 (#3) of 3 (#1 - #3) patients reviewed;
2) Failure to ensure written documentation was performed and maintained during a code blue that accurately reflected the status of the patient, the interventions being performed, the patient response to those interventions, a timed log of the interventions and events as they occur and team member role and participation; and
3) Failure to ensure written documentation of active members of the Code Blue were included in the Code Blue Multi-Disciplinary.
Findings:

1) Failure to ensure the timely notification of a provider of a fall with head injury in 1 (#3) of 3 (#1 - #3) patients reviewed

A review of hospital policy, "ELMHS Post Altercation Medical Evaluation Protocol," Policy #: MS-14, with an effective date 11/15/2020, last revised 08/2021 and approved 04/23/2021, revealed in part, "I. DEFINITIONS A. Client: a term used to refer to a client, patient or resident. C. Fall: The event in which a client loses their footing and falls to the floor or against a wall or object. D. Post-Altercation or Post Fall: The period of time immediately following an altercation or a fall. E. Head and/or Neck Trauma: any blow to the head or neck from an altercation, fall or self-inflected trauma. There is no need for any positive physical finding to be present for a head trauma to have occurred. E. Head and/or Neck Injury: physical findings on examination including but not limited to contusions edema, lacerations, or deformities of the areas of the scalp, face, jaws, neck, temporal, parietal, occipital or other areas of the anatomical areas about the head or neck. G. Blunt Trauma: shall mean a trauma with a closed fist (punching), any object, or a fall in which the head hit a surface such as a floor, wall or piece of furniture. H. Glasgow Coma Scale: shall mean the standard systematic system used to evaluate level of consciousness. I. Neuro Checks: shall mean a systematic evaluation of the client's neurological status done by the appropriate personnel and recorded on the Neurological Assessment Flow Sheet. V. PROCEDURE A. Procedure for post-altercation nursing evaluation and medical and administrative staff notifications. 1. During the post altercation period, assigned staff, including but not limited to CGT's, RSS's, or PA's are to assess the clients for any evidenced of trauma with particular attention to head and neck injuries. Assigned nurses will complete a Nursing Physical Assessment evaluation and form. If any head or neck injuries are noted the nurse is to notify the following of the altercation by telephone: =Building Medical Physician or on call physician (MOD) =The building Nurse Practitioner if the NP is on duty = Client's Psychiatrist or on call Psychiatrist = Medical Director; AOD, APS as indicated by AOD =The division DON 2. Follow the ELMHS Incident Reporting Process. 4. Nursing/Security Staff are to ensure that the Post Altercation Protocol has been implemented and documented in the client's medical record. 6. Staff shall utilized the Post Altercation Flow Sheet (Appendix A) to evaluate the client to determine if a head or neck trauma has occurred. B. Procedure for post-altercation medical evaluation and notifications 1. If an altercation occurs and the nurses report no trauma or if the medical provider feels that the description of the injuries constitute a minor injury then the notified PHYSICIAN or NP shall specifically ask the reporting nurse if the client was punched, fell or otherwise has had any blunt trauma on or about the head or neck, has had any loss of consciousness (LOC), nausea, vomiting. a. Neuro Checks every 2 hours times six checks shall be ordered on all clients who have had a head trauma. The Neurological Assessment Flow Sheet shall be utilized to do and document Neuro Checks. Unless otherwise ordered by the examining medical care provider the neuro checks shall be discontinued after the above 12 hour period. APPENDIX A: HEAD INJURY DECISION CHART (attached) **Medical Services Director or Designee must be notified of all head injuries."

A review of the form, "State of Louisiana Department of Health & Hospitals - Office of Mental Health Client Incident, Injury, and Data Reporting Form," revealed in part, an incident involving Patient #3 taking place on 07/16/2025 with an unknown time and being discovered on 07/16/2025 at 9:00 PM. The S7RN's description of the incident in Section B of the report: "PT. OBSERVED WITH A RED MARK ON THE LEFT SIDE OF FACE. WHEN INITIALLY QUERIED AS TO THE ORIGIN HE REFUSED TO RESPOND. EVENTUALLY ON AROUND 2100 ON 7/16/25 HE STATED THAT HE SLIPPED AND HIT HIS FACE O HIS LOCKER AS HE WAS TRYING TO GET HIS SHOES. NURSE MANAGER NOTIFIED. NP NOTIFIED AT 0743." Signed by S7RN on 07/17/2025. Supervisors review revealed: "Informed of incident 7/17/25. Pt. assess by RN on unit. Referred to FNP for evaluation. Pt. placed on neuro checks. Referred to S14RNS supervisor for further information regarding the incident."

A review of the form, "Injury Review Form," revealed the section: "DESCRIBE WHAT YOU DID TO ADDRESS THE INJURY: PT ASSESSED, WAITED FOR THE DAYSHIFT AND REFERRED TO NP." Signed by S7RN on 07/17/2025. The section, "TO BE COMPLETED BY PHYSICIAN ONLY" revealed the physician being notified on 07/17/2025 at 7:43 AM and the time of first treatment by the physician on 07/17/2025 at 7:45 AM. S15FNP reported no suspicion of abuse or neglect and further documented: "No Client hit left side of face/cheek bone/head on door frame - he report he was walking out of his room and caught walker on door frame, he fell and hit face on frame. No LOC, No problem getting up and walking to dayroom. Abrasion to left cheek ~0.5 x 0.1 cm, no bleeding at this time. Keep open to air. Neuro checks." Signed by S15FNP on 07/17/2025.

A review of the form, "Nursing Physical Assessment," dated 07/16/2025 at 9:00 PM and signed by S7RN revealed, "P - WILL REPORT TO ON COMING SHIFT FOR FOLLOW-UP WITH NURSE PRACTIONER."

A review of a progress note by S15FNP on 07/17/2025 at 7:45 AM revealed in part, "Staff reported to me at 743 am that [Patient #3] fell on 07/16/2025 around 3pm and it wasn't reported until night nurse reported it this morning."

The above mentioned policy and procedure was not followed upon the discovery of Patient #3's fall and resulting head injury. This delay in the notification of the provider could have had negative implications in the timely delivery of medical treatment and care.

In an interview on 07/29/2025 at 11:30 AM, S3TQMPC confirmed the above mentioned findings.

2) Failure to ensure written documentation was performed and maintained during a code blue that accurately reflected the status of the patient, the interventions being performed, the patient response to those interventions, a timed log of the interventions and events as they occur and team member role and participation

A review of hospital policy, "Code Blue Policy and Procedures," Policy Number: MS-03, effective 08/29/2006, last revised 04/24/2019 and approved 09/04/2019, revealed in part: "I. DEFINTIONS B. Code Blue: A medical condition that requires Advance Cardia Life Support (ACLS), Basic Life Support (BLS), use of the Heimlich Maneuver, or any other medical emergency which requires the restoration of respiration and/or circulation. Additional medical emergencies may be designated by the Medical Doctor as needed. D. Code Blue Documentation Packet: Documents must be completed in the event of a Code Blue. 1. CODE BLUE RECORD - completed during the code event. G. Code Blue Record: The official medical emergency record of the response, interventions and patient condition during the code event. V. PROCEDURE C. Code Team Roles/Responsibilities 1. Code Leader: a. The most qualified medical personnel to arrive first at the scene (e.g.: RN Manager, RN Supervisor, MOD-Physician) shall be the Code Leader and will assign a designated staff person to be the code recorder. 2. Code Recorder: a. The code recorder shall be responsible for documenting the detail of the action taken as they occur during the code. b. He/she documents on the official CODE BLUE RECORD form throughout the complete code event. If the patient is being transferred by ambulance, documentation shall continue until the patient is transferred to the ambulance's stretcher ready for loading. c. Appropriate RN handoff shall be recorded. Documented Hand-off shall include date, time , accepting facility name, accepting facility department name, and name of the RN that hand-off is provided to (e.g.: 11/12/08 1435 Report [hand-off] provide to Jane Smith, RN, BRGMC-ER). d. The Code Recorder should ideally be an RN/LPN. e. The Code Recorder ensures that staff participating are identified utilizing first and last name, job title, and if applicable, his/her code assignment (e.g.: recorder, compressions, rescue breathing).

A review of Patient #1's medical record revealed a CODE BLUE Record dated 06/19/2025, revealed in part the following team members with their role: S23MD-MD, S15FNP-NP, S10RNA-RN, S24RN-RNSA, and S25RN-RN. The section for vital signs revealed no documentation of time and for each: "BP - unable to obtain; HR - unable to obtain; RESP. - unable to obtain; TEMP. - unable to obtain; SAT. - unable to obtain." The record of events section revealed in part:
"6/19/2025, 1214 Code blue called. S15FNP came in CPR started;
1216 Ambulance called by S26[illegible], unable to obtain vital signs;
1217 Vital signs, suction and AED placed, nasopharyngeal airway placed per S15NP, bag and mask with oxygen started;
1217 S23MD arrived; 1228, ambulance called 2nd time;
1238 Ambulance called, CPR continuously don, no pulse CPR, bag and mask, suction are continuously provided. Blood sugar - 230 mg/dil; and
1254 Provider A on DD, took over, CPR continued, IO place per Provider A. Provider A pushed code drugs and CPR continued. No pulse at all during this time. Provider A continue code measures and still no pulse, they called time of death at 1335 (Provider A gave [illegible] doses of Epi and 2 doses of Amiodarone)."

The Code Blue form failed to reveal a time logged of the events taken place, the code team including the role of each, staff performing chest compressions, staff performing ventilations, attempted interventions and at what time (e.g.: attempts at IV, AED placement, AED instructions, suctioning, airway management, chest compressions, medications administered), and patient response to any interventions. The Code Blue form failed to reveal the staff performing the recording of events or a signature after each entry as to whom was recording. The Code Blue form's record of events was also found in the nursing progress notes as a typed entry by S10RNA. It did not appear the Code Blue form was completed as the sequence of events occurred during the code.

In an interview on 07/29/2025 at 1:30 PM, S3TQMPC and S4TQMM confirmed the above mentioned findings.

3) Failure to ensure written documentation of active members of the Code Blue were included in the Code Blue Multi-Disciplinary.

A review of hospital policy, "Code Blue Policy and Procedures," Policy Number: MS-03, effective 08/29/2006, last revised 04/24/2019 and approved 09/04/2019, revealed in part: "I. DEFINTIONS B. Code Blue: A medical condition that requires Advance Cardia Life Support (ACLS), Basic Life Support (BLS), use of the Heimlich Maneuver, or any other medical emergency which requires the restoration of respiration and/or circulation. Additional medical emergencies may be designated by the Medical Doctor as needed. D. Code Blue Documentation Packet: Documents must be completed in the event of a Code Blue. 1. CODE BLUE RECORD - completed during the code event. F. Code Blue Multi-Disciplinary Review: The post-code analysis that includes all active members of the code event. The Code Blue Multi-Disciplinary Review Form is completed and sent to the Medical Director. G. Code Blue Record: The official medical emergency record of the response, interventions and patient condition during the code event. V. PROCEDURE E. Code Resolution/Review 1. The Medical Director and Registered Nurse shall assure: a. Completion and appropriate distribution of the documents as indicated on the Code Blue Multi-Disciplinary Review document. b. All Code Blue participants shall remain to review and analyze the Code Blue events. The Team Leader may designate those participant which need to remain for review.

A review of the documents titled, "CODE BLUE Multi-Disciplinary Review," failed to reveal documentation of all the participants and the review and analysis of the Code Blue event. This form appeared to be a post code check list of what actions and events that needed to be completed post Code Blue event. This form appeared to be completed by one team member, S10RNA, staff nurse assigned to Patient #1. This form did not reveal the review and analysis of the actual events of the CODE BLUE.

In an interview on 07/29/2025 at 1:30 PM, S3TQMPC and S4TQMM confirmed the above mentioned findings.