HospitalInspections.org

Based on record review and interview, the psychiatric hospital failed to ensure each patient was informed of their right to have a family member or representative of his or her own choice and his or her own physician notified promptly of his or her admission to the hospital as evidenced by failure to include the Patient's Right for admission status notification included in the list of patient rights provided to the patient.
Findings:

Review of psychiatric hospital document titled "Client Handbook" last reviewed 06/2024, revealed in part: "A summary of your rights are available in this Handbook." Further review of section titled "Civil and Treatment Rights", failed to reveal the right to admission status notification."

Review of psychiatric hospital document titled "Civil and Treatment Rights, Policy review" presented by S20ED as current, failed to reveal the right to admission status notification as part of the staff policy review.

During an interview on 09/17/205 at 2:40 PM, S18SW stated the hospital did not have a policy in place to make the admission notification phone call; therefore the calls were not made.

During an interview on 09/18/205 at 11:12 AM, S19PRS stated each patient is given a copy of the "Client Handbook" which contained their patient rights. S19PRS and S3TQM confirmed the right to admission status notification was not included.

Based on record review and interview, the psychiatric facility failed to ensure each patients' right to have a family member or representative of his or her own choice and his or her own physician notified promptly of his or her admission to the hospital as evidenced by failure to document family notification of admission in 4 (#1 and #4) of 4 (#1-#4) patient medical records reviewed.
Findings:

Patient #1
Review of Patient #1's medical record revealed an admission date 09/02/2025. Continued review failed to reveal that a family member or representative of Patient #1 was notified promptly of his psychiatric hospital admission.

During an interview on 09/17/205 at 2:40 PM, S18SW and S3TQM confirmed there was no evidence of Patient #1's family or caregiver having been notified of Patient #1's admission.

Patient #2
Review of Patient #2's medical record revealed an admission date 07/22/2025. Continued review failed to reveal that a family member or representative of Patient #2 was notified promptly of his psychiatric hospital admission.

During an interview on 09/17/205 at 12:23 PM, S3TQM confirmed there was no evidence of Patient #2's family or caregiver having been notified of Patient #2's admission.

Patient #3
Review of Patient #3's medical record revealed an admission date 05/28/2025. Continued review failed to reveal that a family member or representative of Patient #3 was notified promptly of his psychiatric hospital admission.

During an interview on 09/17/205 at 12:45 PM, S3TQM confirmed there was no evidence of Patient #3's family or caregiver having been notified of Patient #3's admission.

Patient #4
Review of Patient #4's medical record revealed an admission date 07/01/2025. Continued review failed to reveal that a family member or representative of Patient #4 was notified promptly of his psychiatric hospital admission.

During an interview on 09/17/205 at 2:23 PM, S3TQM confirmed there was no evidence of Patient #4's family or caregiver having been notified of Patient #4's admission.

On 09/17/205 at 2:40 PM, S18SW stated the hospital did not have a policy in place to make the notification call, therefore the calls were not made.

Based on record review and interview, the psychiatric hospital failed to ensure care in a safe setting as evidenced by failure to ensure 1 (S11CGT) of 10 (S6CGT, S8CGT-S15CGT) unlicensed staff personnel files reviewed contained a complete criminal background report.
Findings:

Pursuant to La. R.S. 40:1203.1-5, licensed health care providers shall request that a criminal history and security check be conducted on the non-licensed person, prior to any employer making an offer to employ or to contract with a non-licensed person or any licensed ambulance personnel to provide nursing care, health-related services, medic services, or supportive assistance to any individual.

Pursuant to La. R.S. 40:2179 and 2179.1, in part: "Non-licensed person" means any person who provides for compensation nursing care or other health-related services directly related to patient care to patients of a hospital.

The Louisiana Office of State Police, Bureau of Criminal Identification and Information (Bureau), is the State's designated repository for criminal history information pursuant to the laws cited in La. R.S. 15:575 et seq. Any criminal event that is documented by the submission of fingerprints to the State is stored in the Louisiana Computerized Criminal History (LACCH) database. The Bureau is authorized to release criminal history information stored in LACCH to those employers and Authorized Agencies defined in La. R.S. 40:1203.1 as required by La. R.S. 40:1203.2 Employers may request criminal history information stored in LACCH in one of three ways: (1) use of the Bureau's Internet Background Check (IBC) website (https://ibc.dps.louisiana.gov/), (2) via Authorized Agents, and (3) submission of applicants fingerprints.

Review of S11CGT's personnel file revealed a non-licensed person hired 01/17/2023. Continued review revealed a Background Report furnished by Screening Company 'A' dated 07/08/2022. Further review revealed the Sex Offender Registry as "Incomplete", the Nationwide Criminal Registry as "Incomplete, The Statewide Criminal Registry as incomplete, and the county criminal registry as incomplete.

During an interview on 09/18/2025 at 10:26 AM, S5DONHR confirmed S11CGT''s personnel file did not reveal evidence of a completed Louisiana Office of State Police approved criminal background check.

Based on record review and interview, the hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice was evidenced by failure to adhere to hospital policy and ensure video surveillance was available 24 hours a day, 7 days a week to protect the safety of the of the clients, staff, visitors and Eastern Louisiana Mental Health System (ELMHS) property.
Findings:

Review of psychiatric hospital's document titled "Client Handbook", revised 06/2024, revealed in part: "Video Surveillance, in part: ELMHS uses Video Surveillance 24 hours a day 7 days a week to protect the safety of the clients, staff, visitors and ELMHS Property".

Review of psychiatric hospital's policy #LD-26 titled "Incident Reporting Policy and Procedure", last reviewed 09/30/2024, revealed in part: "I. Definitions: 17. Incident-Generally, an incident is defined as any event, condition or situation, which impacts the systems and operation of the worksites. 18. Incident Reporting-An incident report is a tool that documents any event that may or may not have caused injuries to a person or damage to an ELMHS' asset. It is used to capture injuries and accidents, near misses, property and equipment damage, health and safety issues, security breaches and misconduct in the worksite. (Other than abuse and neglect reporting). IV. Policy: 3. Continuous Improvement of Processes: An Incident Report provides a clear picture of what ELMHS should focus on resolving, changing, improving, or eliminating. This also helps Management implement new policies to determine the efficacy of these changes for safety and quality. V. Procedures: A. Types of Incidents: 2. Near Misses-these are situations where the people involved had no injuries but could have been potentially harmed by the risks detected.

Observations on 09/16/2025 between 1:37 PM and 2:00 PM, guided by S1TQM, R2RNC, and S3TQM of Room 'b' and Room 'c' revealed each room contained a large black box attached to the wall with an electrical cord dangling from the bottom plugged into an electrical outlet located over a desk. Two electrical panels noted near the large box, no pad locks and open in Room 'c'. Pad lock noted to one of the two electrical panels in Room'd'.

Review of Patient #3's progress notes dated 09/08/2025 at 8:10 AM, revealed patient punched the TV stand and snatched the temperature gauge off the seclusion room doors. Staff immediately intervened and escorted this patient to the seclusion room.

Review of Patient #3's medical record revealed patient was placed in restraint chair located in Room 'a' on 09/08/2025 from 10:05 AM until 2:00 PM.

Review of Patient #3's Progress Notes dated 09/08/2025 at 10:15 AM, revealed patient was in restraint chair in seclusion room, uncooperative, shaking chair, forcing it backwards. No obvious injuries noted.

Review of video surveillance on 09/16/2025 at 2:22 PM navigated by S16PM of Room 'a' on 09/08/2025 failed to reveal video images between the times of 6:33:31 AM and 2:49 PM.

Review of video surveillance on 09/17/2025 at 10:22 AM navigated by S16PM and S17IT of Room 'b' revealed at 5:38 AM the breaker was flipped per staff, the battery took over power for approximately one hour and the video was no longer functioning from 6:33:31 AM until 2:49 PM when IT was on the scene.

During an interview on 09/16/2025 at 1:51 PM, S20IT confirmed the large box contained Video System 'B' that was plugged into the wall above the security officers' desk. If the system became unplugged, video surveillance would run on battery for approximately 1 hour then video would no longer be available unless the system was attached to the generator power.

During an interview on 09/16/2025 at 2:35 PM, S16PM stated he was investigating an incident that occurred on 09/05/2025 and noticed the video of the seclusion room was not available. S16PM reported he sent an email to S17IT and discovered that on 09/08/2025 at 2:49 PM the video was turned back on per S17IT.

During an interview on 09/17/2025 at 11:05 AM, S17IT reported he installed new cameras approximately 2 weeks ago and noticed the breaker was off on the 09/08/2025 around 2:30 PM. The cameras in Rooms 'a' and 'b', and the sleep area did not have power and were not functioning. S17IT turned the breaker back on at 2:49 PM. Since then he has installed light switches so staff will not need to use the breakers for turning of the lights. He also padlocked the electrical panels. He stated he had plans to place a conduit around the plug so that it cannot be unplugged.

During an interview on 09/18/2025 at 3:07 PM, S1TQM and S3TQM stated they were not sure if staff had been educated on the proper procedure to turn lights off so as not to accidentally turn of the camera system. S3TQM reported she had a sign placed above the light switches and padlocks placed on the electrical panels with hopes to have all units with the new camera system updated with the light fixtures and conduits by the following Friday.

During an interview on 09/18/2025 at 3:40 PM, S3TQM verified the psychiatric hospital did not submit an incident report or a self-report related to the cameras having been shut off by staff that provided a clear picture of what the hospital should resolve, change, improve, or eliminate.

Based on record review and interview, the psychiatric hospital failed to ensure 2 (#2 and #3) of 4 (#1-#4) client medical records reviewed had an updated, individualized treatment plan.
Findings:

Review of psychiatric hospital's document titled "Client Handbook", revised 06/2024, revealed in part: "Civil and Treatment Rights", in part: S. The right to an individualized treatment plan.

Review of psychiatric hospital's policy titled "Components and Guidelines for Treatment Planning Process", last revised on 07/08/2025, revealed in part: "I. Definitions: E. Planning of Care: Individualized planning and provision of care, treatment and services that addresses the needs, safety and well-being of the client. Policy: It is the policy of ELMHS that each client shall have an integrated plan of care that is specific, individualized, comprehensive, dynamic, unique and appropriate to the client's identified needs for treatment."

Patient #2
Review of Patient #2's medical record revealed an admission date 07/22/2025 with diagnoses psychiatric diagnosis of psychosis, substance use disorder, incompetency to stand trial, involuntary hospitalization. Medical diagnosis of tobacco use disorder, tinea pedis, and overweight.

Review of Patient #2's "Master Problem List" dated 08/01/2025 revealed the following problems related to: Psychosis, Substance Use Disorder, Incompetency, Involuntary Hospitalization, Overweight, and Tobacco Use Disorder.

Review of Patient #2's "Master Problem List" dated 08/31/2025 revealed the following problems related to: Psychosis, Substance Use Disorder, Incompetency, Involuntary Hospitalization, Overweight, Chronic Hepatitis C, and Tobacco Use Disorder.

Review of Patient #2's Progressive Behavior Evaluation and Management Form dated 08/27/2025 revealed patient was attempting to hit staff and was administered Vistaril 50 mg by mouth for anxiety at 11:30 AM which was ineffective. Thorazine 100 mg intramuscularly was administered at 11:37 AM. Further review revealed Patient #2 was administered another injection of Thorazine 100 mg intramuscularly at 11:37 AM. At 11:52 AM patient was in open seclusion crying and asking for his mother, stating he was bitten by a black widow spider. No bite marks noted. Patient was unable to be redirected and became physically and verbally aggressive towards staff. Client was in restraint chair with muscle tension still present. 1:32 PM patient was released from restraint chair.

Review of Patient #2's treatment plan failed to reveal evidence a change in patient status was noted on treatment plan related to the incidents on 08/27/2025.

Review of Patient #2's Progressive Behavior Evaluation and Management Form dated 08/31/2025 revealed patient was eating food out of the trash and yelling at staff for attempting to re-direct him. He was administered Thorazine 50 mg intramuscularly at 9:35 AM.

Review of Patient #2's treatment plan failed to reveal evidence a change in patient status was noted on treatment plan related to the incident on 08/31/2025.

Review of Patient #2's Progress notes dated 09/06/2025 revealed that during rounds the patient exposed himself to multiple staff members. He reports issues with his private area. Staff notified medical. Nursing noted no obvious injuries to private area when patient exposed himself in the hallway.

Review of Patient #2's treatment plan failed to reveal evidence a change in patient status was noted on treatment plan related to the incident on 09/06/2025.

Review of Patient #2's Progress notes dated 09/12/2025 at 3:55 PM revealed that during rounds Patient #2 walked out of the same bathroom stall with another patient. Staff immediately intervened and escorted both patients away from each other. Patient #2 was placed on 1:1 for protection of others at 4:40 PM.

Review of Patient #2's treatment plan failed to reveal evidence a change in patient status was noted on treatment plan related to the incident on 09/12/2025.

Patient #3
Review of Patient #3's Progress note dated 09/07/2025 at 8:05 PM revealed Patient #3 received two shots for breakthrough psychosis. 8:12 PM patient #3 was placed on time out for twenty-nine (29) minutes in seclusion room. While in seclusion room patient picked up the mattress off bed and threw it on the floor. Patient started screaming toward staff making verbal threats saying he will break their jaw and mess them up.

Review of Patient #3's treatment plan failed to reveal evidence a change in patient status was noted on treatment plan related to the incidents on 09/07/2025.

Review of Patient #3's Progress note dated 09/13/2025 at 8:20 AM revealed Patient #3 was on administrative review and escorted from the dayroom area to seclusion room to receive a shot for refusing his morning medications. Patient was placed in a manual hold to receive the shot.

Review of Patient #3's treatment plan failed to reveal evidence a change in patient status was noted on treatment plan related to the incidents on 09/13/2025.

Review of incident report dated 09/14/2025 at 8:21 AM revealed Patient #3 wason administrative review and escorted from dayroom to seclusion room for refusing morning medications. Patient was placed into manual hold to receive his shot.

Review of Patient #3's treatment plan failed to reveal evidence a change in patient status was noted on treatment plan related to the incidents on 09/14/2025.

Review of Patient #3's Progress note dated 09/17/2025 at 8:10 PM revealed Patient #3 wa placed in a manual hold from 8:10 PM to 8:11 PM due to becoming aggressive when attempting to administer his scheduled medication injection. Once Patient #3 was released from the hold, client continued to be aggressive and began kicking the cubical wall, staff redirected.

During an interview on 09/18/2025 at 3:24 PM, S3TQM confirmed the above 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 failure of licensed nurse to document rounds and vital signs per policy on 1 (#2) of 4 (#1-#4) patient medical records reviewed.
Findings:

Review of psychiatric hospital policy titled "Nursing-2005-604, PC-NUR-00" last reviewed 05/19/2025, revealed in part: "V. Procedure: D. Documentation: ii. The RN shall assess the client and document the client's status every two hours on the Restrictive Management Seclusion & Restraint Sheet. iii. Documentation may include, but is not limited to the following: b. Vital signs every fifteen minutes with the RN taking vital signs every thirty minutes."

Patient #2
Review of Patient #2's medical record revealed Restrictive Management, Seclusion & Restraint Sheet dated 09/02/2025 and ordered at 8:35 AM due to patient attempting to attack staff while being redirected. He was placed in manual hold and escorted to seclusion room. Behaviors continued to elevate and patient was placed in restraint chair at 8:40 AM. Patient was released from restraint chair at 11:55 PM.

Review of the observation portion of the Restrictive Management, Seclusion & Restraint Sheet dated 09/02/2025 and ordered at 8:35 AM failed to reveal the registered nurse documented a patient assessment and status between 8:40 AM and 11:45 AM as required per hospital policy. Continued review failed to reveal the nurse documented vital signs between the hours of 10:55 AM and 11:55 AM.

During an interview on 09/18/2025 at 12:30 PM, S3TQM confirmed the above findings.