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Based on observation and interview, the psychiatric hospital failed to ensure the patient right to receive care in a safe setting. This deficient practice is evidenced by:
1) Failure to ensure the patient care area was free of ligature risk; and
2) Failure to ensure the patient care area was free of items that could potentially cause harm or injury.
Findings:

1) Failure to ensure the patient care area was free of ligature risk

Observations during a hospital walk-through on 08/28/2025 from 12:05 PM to 12:30 PM revealed patient toilets being a potential ligature risk. There was a space of approximately 1.5 inches to 3 inches between the wall and the lower portion of the tank and top of the underlying toilet pedestal. This surveyor was able to place his hands in this space on each side approximately 5 inches. The patient toilets were as follows:
-Room "e": 2 inch space on either side;
-Room "j": 2.5 inch space on either side;
-Room "l": 2.5 inch space on either side; and
-Room "n": 2 inch space on either side.

In an interview on 08/28/2025 and present during this hospital walk-through, S1ADM confirmed the above mentioned findings.

2) Failure to ensure the patient care area was free of items that could potentially cause harm or injury

Observations during a hospital walk-through on 08/28/2025 from 12:05 PM to 12:30 PM revealed the following:
a) Missing call light covers above the entry doors of Rooms "l", "m", and "o". The missing covers exposed the following potential hazards in the patient care area:
Room "l": 2 glass bulbs were exposed;
Room "m": 2 electrical sockets (glass bulbs were missing) were exposed; and
Room "o": 1 glass bulb and 1 electrical socket (glass bulb was missing) were exposed.
Of note, this surveyor (height 59 inches) was able to extend arm/hand and be within approximately 2-3 inches of these bulbs and electrical sockets.

b) Packaged Terminal Air Conditioners (PTACs) in Rooms "b" - "n". Although each PTAC had the manufactured plastic cover installed and attached, these plastic covers were not tamper resistant. Without a tamper resistant covering, these PTACs could expose the patient to potential injury and/or harm if access were gained to the electrical and mechanical parts of the inner PTAC.

In an interview on 08/28/2025 and present during this hospital walk-through, S1ADM confirmed the above mentioned findings.

Based on observation and interview, the psychiatric hospital failed to ensure the condition of the physical plant the overall hospital environment was maintained in such a manner that the safety and well-being of patients are assured. This deficient practice was evidenced by towels being placed under Room "k's" and "m's" restroom doors.
Findings:

Observations during a hospital walk-through on 08/28/2025 from 12:05 PM to 12:30 PM revealed the restrooms of Rooms "k" and "m" having 2 entries/doorways. The restroom entries/doorways not being utilized by Rooms "k" and "m" had brown, stained towels which appeared to be wedged under each restroom door. From these towels' placements and their brown, stained appearances, it appeared these towels were purposely placed to block the space under each doorway and seemed to be positioned in these doorways for more than a day.

In an interview on 08/28/2025 and present during this hospital walk-through, S1ADM confirmed the above mentioned findings and indicated the towels should not be used for the purpose of blocking the space under each of these doors.

Based on observation, record review and interview the psychiatric hospital failed to maintain facilities, supplies and equipment to ensure an acceptable level of safety and quality. This deficient practice was evidenced by the failure to perform daily refrigerator temperature checks on the lab specimen refrigerator.
Findings:

A review of hospital policy, "INFECTION PREVENTION AND CONTROL PROGRAM," policy number unavailable, being effective 09/01/2011, last revised 01/11/2021 and Governing Body approval 01/24/2023, revealed in part: "PROCEDURE Responsibilities of Hospital Personnel: The responsibilities for implementing and maintaining an effective Infection Control and Prevention Plan are not limited to nursing. A variety of departments are required to perform certain activities to make the program effective. On an ongoing basis: =All hospital refrigerator contain thermometers and temperature logs to ensure that the proper temperature are maintained. To ensure preventive measures are in place, the hospital provides refrigerator: Specifically, for the temporary storage of laboratory specimens of blood or body fluids will be labeled for specimens only. Laboratory specimen refrigerators are separate from refrigerator used to store medications and food, respectively. Authorized personnel shall have access. *A temperature log will be maintained for each refrigerator. Documentation on the log will be daily in inpatient settings and on days of operation in outpatient settings. A staff member will record the temperature readings and, if outside the acceptable range (as indicated by LAC51), will immediately notify a supervisor. The supervisor is responsible to: Schedule repairs; Arrange for interim safe placement of the contents elsewhere; Place a notice on the refrigerator that it is not to be used; Notify personnel and removed the notice when the refrigerator has returned to normal functioning; and Ensure that the temperature log contains documentation that reflects all actions."

Observations during a hospital walk-through on 08/27/2025 from 2:35 PM to 3:30 PM revealed the lab specimen refrigerator in Room "a" and the associated cleaning and temperature document titled, "REFRIGERATOR/FREEZER CLEANING & TEMPERATURE LOG," A review of this document dated 08/2025 failed to reveal temperature checks being performed on 08/04/2025, 08/05/2025, 08/08/2025 - 08/10/2025, 08/13/2025, 08/14/2025, 08/18/2025, 08/19/2025, and 08/22/2025 - 08/24/2025. Further review of this document revealed the instructions: "3. Temperature Checks a. The temperature of the refrigerator and freezer will be checked and recorded for each day that the unit/office/department is occupied, i.e., the temperatures do not have to be checked on weekends and holidays if the department is not open on those days.

A review of the hospital's admissions and discharges did not reveal any of the above mentioned dates as not having patients or the unit not being occupied.

In an interview on 08/27/2025 and accompanied on hospital walk-through, S1ADM and S2URLPN confirmed the above mentioned findings and agreed these checks should be performed daily.

Based on record review and interview, the psychiatric hospital failed to ensure social service staff participating in discharge planning, arranging for follow-up care, and exchanging appropriate information with sources outside the hospital communicated the patient's entire hospitalization from admission to discharge. This deficient practice was evidenced by:
1) Failure to update the Discharge Instructions to reflect the discharge date and the signatures of staff and patient at the actual discharge date in 1 (#1) of 3 (#1 - #3) medical records reviewed;
2) Failure to reveal the documentation of the pharmacy being utilized on the Discharge Instructions in 1 (#1) of 3 (#1 - #3) medical records reviewed;
3) Failure to reveal the documentation of a 30-day supply of discharge medications as being provided in the Discharge Instructions in 1 (#1) of 3 (#1 - #3) medical records reviewed;
4) Failure to reveal the documentation of provider notification that a patient admitted for inpatient behavioral health services pursuant to an emergency certificate was being referred to for follow-up behavioral health services within twenty-four hours of discharge in 1 (#1) of 3 (#1 - #3) medical records reviewed; and
5) Failure to reveal the documentation of a patient admitted for inpatient behavioral health services pursuant to an emergency certificate, received patient educational documents published by the Louisiana Department of Health prior to or at the time of discharge in 1 (#1) of 3 (#1 - #3) medical records reviewed.
Findings:

A review of hospital policy, "Discharge of the Patient," policy number unavailable, being effective 09/01/2011, last revised 03/21/2018 and Governing Body approval 01/25/2024, revealed in part: "POLICY Beacon Behavioral Hospital supports the need for accurate and adequate Discharge Instructions that enable the patient to transition to a different level of care as seamlessly as possible. Discharge Instructions represent a summary of the Discharge Plan that instructs the patient on the treatment regime to be maintained after leaving the program. Discharge Instructions are reviewed with the patient by the discharging nurse or other clinician. PROCEDURE 3.A nurse transcribes the orders and initiates the Discharge Instructions form and Discharge Medications list. 5. The counselor provides information to be included in the Discharge Instructions with regard to follow-up and aftercare. The information includes, but is not necessarily limited to: a. Name of the Provider (for follow-up or aftercare) b. Address and Phone Number of Provider c. Date and time of appointment with Provider (if able to schedule) d. Instructions to contact Provider for appointment (if unable to schedule) 6. At a minimum, the completed Discharge Instructions include: b. Admission and Discharge Dates g. Confirmation of 30-day Prescriptions sent to a discharging inpatient's Pharmacy (including Name, Address, and Phone Number for Pharmacy) 8. Shortly prior to leaving the hospital, the patient is provided with a copy of the Discharge Instructions and a list of Discharge Medications, at which time the nurse or discharging clinician reviews both documents with the patient (and possible family member or caregiver), ensuring that the patient understands the instructions. 9. The patient is asked to sign the Discharge Instructions to indicate that the instructions were reviewed with, and that a copy was received by, the patient. 10. The nurse or clinician that reviewed the instructions and gave a copy to the patient also signs the document. 13. A copy of the Discharge Instructions is entered into the Medical Record and the nurse or clinician completes a note that includes, at a minimum: f. Prescriptions for Discharge Meds sent to patient's pharmacy (inpatients)."

1) Failure to update the Discharge Instructions to reflect the discharge date and the signatures of staff and patient at the actual discharge date in 1 (#1) of 3 (#1 - #3) medical records reviewed

A review of Patient #1's medical record revealed the patient being discharge on 08/25/2025 at 9:53 AM. A review of the document titled, "Form: Discharge Instructions," revealed in part: "Date of Discharge: 08/22/2025; Discharge information Reviewed with: Patient, 08/21/2025 8:19 AM; Copy of Instructions provided to patient/caregiver: yes, 08/22/2025 8:12 AM; Patient Choice Information & Signatures: Patient signature: [Patient #1] 08/19/2025 5:02 PM; Social Worker/therapist signature: S5CSW 08/19/2025 5:03 PM; Nursing Signature: S4RN 08/21/2025 8:21 AM." The before mentioned dates do not correspond with Patient #1's actual discharge date. Further, Patient #1 and S5CSW signatures reflected the signing taking place 6 days prior to the actual discharge date - 08/25/2025. S4RN signature corresponded to the time of the discharge information being reviewed with Patient #1 - 08/21/2025, however, this information was reviewed 4 days prior to the actual discharge date - 08/25/2025.

In an interview on 08/28/2025 at 11:30 AM, S2URLPN confirmed the above mentioned findings and indicated Patient #1's discharge date was pushed back, however the Discharge Instructions did not reflect the updates related to these changes or accurately reflect the correct discharge date.

2) Failure to reveal the documentation of the pharmacy being utilized on the Discharge Instructions in 1 (#1) of 3 (#1 - #3) medical records reviewed

A review of Patient #1's medical record revealed the document titled, "Form: Discharge Instructions," and this form revealed in part: "Medications: Needs assistance with obtaining medications (Describe) [no information on this form to describe this assistance]; Medical Follow Up: 30 day supply of medication sent to patient's pharmacy." The Discharge Instruction failed to reveal the pharmacy being utilized for discharge medications or the assistance needed to obtain medications.

In an interview on 08/28/2025 at 11:30 AM, S2URLPN confirmed the above mentioned findings and a pharmacy should appear on the discharge instructions. S2URLPN further confirmed Patient #1 was provided a 30-day supply of medications upon discharge and this information was not on the Discharge Instructions.

3) Failure to reveal the documentation of a 30-day supply of discharge medications as being provided in the Discharge Instructions in 1 (#1) of 3 (#1 - #3) medical records reviewed

A review of Patient #1's medical record revealed the document titled, "Form: Discharge Instructions," and this form failed to reveal the documentation of a 30-day supply of discharge medications being provided to Patient #1 upon discharge.

In an interview on 08/28/2025 at 11:30 AM, S2URLPN confirmed the above mentioned findings and Patient #1 was provided with a 30-day supply of medications upon discharge.

4) Failure to reveal the documentation of provider notification that a patient admitted for inpatient behavioral health services pursuant to an emergency certificate was being referred to for follow-up behavioral health services within twenty-four hours of discharge in 1 (#1) of 3 (#1 - #3) medical records reviewed

Pursuant La R. S. 28:53:1 (2024 Regular Legislative Session (Act 737) Matthew Samuel Milam Act) Discharge plan; healthcare provider notification requirements:
If a patient is admitted for inpatient behavioral healthcare services pursuant to an emergency certificate issued in accordance with R.S. 28:53, the individual who is responsible for discharge planning at the healthcare facility where the patient has been admitted shall make a reasonable effort to do all of the following:
(1) Provide written or telephonic notification to any healthcare professional that is currently providing behavioral health services to the patient, if known, of the date and time the patient is scheduled to be discharged unless the patient objects to that information being communicated.
(2) Provide written or telephonic notification within twenty-four hours of discharge to any healthcare professional that the patient is being referred to for follow-up behavioral health services. The healthcare professional that the patient is being referred to shall be provided with a summary of the patient's medical history and any current mental health conditions the patient is suffering from at the time of discharge. The summary shall be transmitted no later than the date the patient has been scheduled for follow-up behavioral services.
(3) Provide to the patient educational documents published by the Louisiana Department of Health prior to or at the time of discharge.

A review of Patient #1's medical record revealed the patient being discharge on 08/25/2025 at 9:53 AM. A review of the document provided by S6DCP revealed a "Fax Message Transmission Result to +1 (337) 4621354 - Sent" which indicated it had been sent on 08/19/2025 at 11:57 AM and consisted of a 68 page file named [Patient #1.pdf]. This fax transmittal would have taken place 6 days prior to Patient #1's discharge and would not have reflected all of Patient #1's medical care, therapy, treatments and current mental health condition at the time of discharge.

In an interview on 08/28/2025 at 11:25 AM, S6DCP confirmed the above mentioned information and Provider A was not sent Patient #1's last 6 days of admissions.

In an interview on 08/28/2025 at 11:30 AM, S2URLPN confirmed the above mentioned findings and the medical record failed to reveal documentation related to Provider A being notified.

5) Failure to reveal the documentation of a patient admitted for inpatient behavioral health services pursuant to an emergency certificate, received patient educational documents published by the Louisiana Department of Health prior to or at the time of discharge in 1 (#1) of 3 (#1 - #3) medical records reviewed

Pursuant La R. S. 28:53:1 (2024 Regular Legislative Session (Act 737) Matthew Samuel Milam Act) Discharge plan; healthcare provider notification requirements:
If a patient is admitted for inpatient behavioral healthcare services pursuant to an emergency certificate issued in accordance with R.S. 28:53, the individual who is responsible for discharge planning at the healthcare facility where the patient has been admitted shall make a reasonable effort to do all of the following:
(1) Provide written or telephonic notification to any healthcare professional that is currently providing behavioral health services to the patient, if known, of the date and time the patient is scheduled to be discharged unless the patient objects to that information being communicated.
(2) Provide written or telephonic notification within twenty-four hours of discharge to any healthcare professional that the patient is being referred to for follow-up behavioral health services. The healthcare professional that the patient is being referred to shall be provided with a summary of the patient's medical history and any current mental health conditions the patient is suffering from at the time of discharge. The summary shall be transmitted no later than the date the patient has been scheduled for follow-up behavioral services.
(3) Provide to the patient educational documents published by the Louisiana Department of Health prior to or at the time of discharge.

A review of Patient #1 medical record revealed the patient being admitted on 08/13/2025 under a Physician's Emergency Certificate (PEC) for suicidal ideations with a plan, homicidal ideations and auditory hallucinations. Patient #1 was subsequently placed under a Coroner's Emergency Certificate (CEC). The medical record's Discharge Instructions failed to reveal the patient educational documents published by the Louisiana Department of Health and to be given upon discharge relate to La R. S, 28:53:1.

In an interview on 08/28/2025 at 11:30 AM, S1ADM and S2URLPN confirmed the above mentioned findings.

Based on record review and interview, the psychiatric hospital failed to ensure the medical record of each patient who has been discharged has a discharge summary that includes a recapitulation of the patient's hospitalization. This deficient practice was evidenced by the failure to have a discharge summary on the 1 (#3) of 3 (#1 - #3) medical records reviewed for discharge summaries.
Findings:

A review of hospital policy, "Timely Documentation in Medical Record," policy number unavailable, being effective 09/01/2011, last revised 03/21/2018 and Governing Body approval 01/25/2024, revealed in part: "POLICY Beacon Behavioral Hospital requires that Medical Records are complete within 30 days, per federal regulation."

A review of Patient #3's medical record on 08/28/2025 revealed a discharge date of 07/25/2025 at 12:23 PM. The medical record failed to reveal a discharge summary as of the day of this review and this review was completed approximately 34 days post discharge.

In an interview on 08/28/2025 and present for the medical record review, S2URLPN confirmed the above mentioned findings.