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 received care in a safe setting by preventing a patient to enter a toilet stall with a toothbrush unsupervised while on 2:1 direct observation (See Findings Tag A0144); and
2) Failure to ensure a patient received care in a safe setting by having a medical provider assess a patient or placed an order for diagnostic assessment for a patient following an alleged self-insertion of a toothbrush into his anus (See Findings Tag A0144).

Based on record review and interviews, the hospital failed to ensure it provided patient care in a safe setting. This deficient practice was evidenced by:
1) failure to prevent Patient #1 from entering the toilet stall with a toothbrush unsupervised while on 2:1 direct observation; and
2) failure of the medical provider to assess Patient #1 or place an order for diagnostic assessment of Patient #1 following an alleged self-insertion of a toothbrush into his anus.
Findings:

Review of the hospital policy number Nursing-2004-504, PC-NUR-12 titled "Observations and precautions" last revised on 09/27/2024 revealed in part:
"I. Definitions: B. Two-To-One (2:1) Direct Observation: two staff members shall observe and monitor a client at not more than eight (8) feet in distance with a physicians' order. The client must be visualized at all times.
II. Purpose: The purpose of this policy is to ensure behavior management techniques that provide the least restrictive management possible, uphold ethical standards of care, and protect the client's rights. Precautions are instituted for situations where a client's condition and/or behavior presents as a clear and present risk to himself, others or the environment. The client's needs are such that vigilant observation is necessary to provide a safe and protective level of care.
IV. Policy: It is the policy of the Hospital 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.
V. Procedure: B. Nursing Care for Clients on Precautions - i. One-to-One (1:1) Direct of Two-to-One (2:1) Direct Observation - b. Staff assigned to a client on a one-to-one or two-to-one direct observation shall remain within eight (8) feet of the client and the client must remain in sight at all times. c. Reasonable privacy may be given for a patient who is on one-to-one or two-to-one direct observation. While the client is toileting, a Staff Member may stand just outside of the toilet stall door. However, staff must remain vigilant for any signs/behaviors that would indicate possible harm to the client. x. Employees assigned to any client on one-to-one or two-to-one direct shall ensure that the client receives assistance and supervision to provide for the client's: a. Personal safety and safety of others; b. Hygiene needs; c. Nutrition, hydrations and elimination needs."

Review of the hospital's Medical Staff Rules and Regulations, Section XVII titled "Rules Regarding Documentation and the Clinical Record", last reviewed January 2020, revealed in part:
"B. Progress Notes: The progress notes will be written with sufficient frequency to cover all major events, complications, and responses to treatments. While anecdotal information is desirable, of greater importance is the inclusion on information containing the following elements: 1. The condition of the patient from his own perspective; 2. The condition of the patient in descriptive terms; 3. The physician's interpretation or assessment of the patient's status; and 4. The plan for further intervention to aid the patient's care and treatment. It is expected that progress notes will be tied into the documented treatment plan so that the hospital course of the patient can be clearly identified. A progress note, in any case, must be written when there is a material change in the patient's progress."

1) Failure to prevent Patient #1 from entering the toilet stall with a toothbrush unsupervised while on 2:1 direct observation.

Review of medical record for Patient #1 revealed he was admitted to the hospital on 02/25/2025 with diagnoses which included Unspecified Mood Disorder, Generalized Anxiety Disorder, PICA, Antisocial Trait Disorder, Impulse Control Disorder and Mild Intellectual Disability.

Review of Patient #1's Provider Orders revealed in part the following:
1:1 Direct Observation at not more than 8FT for self-injurious behavior; must be observed on toilet as well, need male RPM. TORB S6MD / S11RN on 02/25/2025 at 12:11 PM (This order was discontinued on 03/22/2025 at 5:20 PM).

2:1 Direct Observation at no more than 8 feet - Males only for Danger to others. TORB S7MD / S10RN on 03/22/2025 at 5:20 PM.

Place Patient #1 in waist-wrist restraints. If in 72 hours there have been no violent acts against self or others or verbal threats/gestures against self or others, one wrist may be released at time. If another 72 hours passes without violent acts or threats/gestures against self or others, his other wrist may be released. If he makes violent threats/gestures/acts towards himself or others the waist wrist restraint is to be reapplied and restarted. Signed by S6MD on 03/24/2025 at 3:10 PM.

A helmet with bite guard should be used while in waist-wrist restraints related to attempts to continue to bite self. Signed by S6MD on 03/24/2025 at 3:54 PM.

Waist-wrist restraints are being applied primarily for reduction of severe self-injury. Vital signs to be obtained on patient Q6H. TORB S6MD / S12RN on 03/24/2025 at 4:39 PM.

May remove 1 arm from restraint for 15 minutes for grooming and hygiene. Remove other arm after hygiene and grooming and clean arm where restraints are with soap and water. Ensure that where restraints are reapplied CMS checks are done. If at any time during the 15 minutes Patient attempts any type of self-injurious behavior, place restraint back to arm ASAP. TORB S6MD / S12RN on 03/28/2025 at 1:45 PM.

Place in wrist-waist restraints x72 hours. S6MD on 04/07/2025 at 7:39 PM.

Right hand to be free from restraints and remain free unless patient is verbally/physically aggressive. T.O. S6MD / RBTO S13RN on 04/17/2025 at 5:30 PM.

1. Client is 2:1 Direct Observation at 8 ft. self-injury, danger to others; 2. Client to be observed at all times, including when using the restroom; and 3. Not eligible to have arm out of restraint until 04/25/2025 at 6:00 AM (Release the arm without the bandage first - Right arm). T.O. S6MD / RBTO S14LPN on 04/24/2025 at 12:00 PM.

Review of the facility Incident Report for 04/19/2025 for Patient #1 revealed the following:
Date/Time of Incident: 04/19/2025 at 3:00 PM
Location of Incident: Hallway
Description of Incident: While standing on B Hall, Patient #1 was told by CGT that he could not be on that hall. When told he had to be on A Hall, Patient #1 got aggressive and banged the Plexiglass on monitor room. He then asked the nurse for a toothbrush because his mouth hurt and he wanted to brush his teeth. He later alleged that he stuck the toothbrush up his anus.
Treating Psychiatrist: S8MD / S9MD
RN: S10RN
Assigned Staff: S15CGT & S16CGT
Witnesses: S17CGT
Signed: S10RN on 04/19/2025
Supervisor's Review: Patient #1 remains on 2:1 Direct Observation at 8 ft. S15CGT and S16CGT were reassigned away from Patient #1.
What Was Client's Role? Aggressor
Was Client Under Restrictive Patient Management? Yes, 8ft. direct with waist to wrist restraint
Was Client Referred for Injury Review? No
When Did You First Observe the Client For Injury? Date: 04/19/2025 Time: 3:00 PM
Describe the Injury: No visible injury
What Was the Probable Cause of the Injury: No Injury
Describe What You Did to Address the Injury: N/A
What Action Did You Take: Return to Program
Seriousness and Level of Injury: How Serious Was the Injury - No Apparent Injury, Alleged that he stuck a toothbrush up his rectum.
Signed: S10RN on 04/19/2025

Review of Patient #1's Nursing Security Notes revealed in part the following:
On 04/19/2025 at 3:00 PM - Patient #1 was standing on B Hall and was told by staff he needed to come to his hall on the ward, A Hall. Patient #1 went to his room upset. Patient #1 then came back to the monitor station and requested a toothbrush and toothpaste to brush his teeth. When he came banging on the Plexiglass and stated he shoved the toothbrush up his a**. Restraint will be replaced to right arm. Signed by: S10RN

On 04/19/2025 at 3:00 PM - Patient #1 requested a toothbrush and toothpaste from the nurse, went into restroom and brushed his teeth in the toilet stall, flushed the toilet, and returned to room, then told myself and the other CGT that "I am going to get y'all under investigation. I just shoved a toothbrush up my a**." This CGT did not see the patient insert anything. He then went to the nurses' station and started to hit his head and first against the glass. Patient #1 was escorted back to his room. The Lt. on duty and medical notified. Signed by: S15CGT

Review of the Restrictive Management Observation & Precaution Sheet (0600-1800), ELMHS #99-107a dated 04/19/2025 from 12:00 PM to 6:00 PM revealed Patient #1 was on 2:1 Direct Observation. During the time period of 1:23 PM to 3:46 PM, S16CGT and S15CGT were assigned to Patient #1. From 3:15 PM to 3:45 PM, it was documented Patient #1's behaviors to be awake, aggressive, verbally and physically threatening.

Review of Patient #1's Psychiatric Progress Note dated 04/24/2025 at 10:53 AM revealed in part the following:
Patient #1 was seen for his routine weekly staffing. Apparently on Sunday, he reported to staff that he had taken a toothbrush and inserted it into his anus. In speaking with him today about it, he stated "I lied. I didn't do nothing with it." When asked where the toothbrush went he stated "I flushed it down the toilet." Treatment Plan: Problem 1. Impulsive and Inappropriate Behaviors - Patient #1 had an episode where he reported inserting a toothbrush into his anus. In speaking with him today, he stated that he lied about it. No medication adjustments will be made this week. Signed by: S6MD

On 04/24/2025 at 11:40 AM, during an interview with S6MD he confirmed on 04/19/2025 prior to the incident taking place, Patient #1 no longer had an order for direct supervision while on the toilet, however he did have an order for 2:1 direct observation of 8 feet. S6MD also confirmed Patient #1 did have a history of ingesting and inserting items into his body which was one of the reasons he was on 2:1 direct observation due to his self-injurious behaviors.

2) Failure of the medical provider to assess Patient #1 or place an order for diagnostic assessment of Patient #1 following an alleged self-insertion of a toothbrush into his anus.

Review of the Progressive Behavior Evaluation and Management, ELMHS #99-105 completed on 04/19/2025 for Patient #1 revealed the following:

A. Indications of Emergent Behaviors:
Approximate Time: 3:00 PM
Behavior Cues: Muscle tension, Raised voice, Loss of personal boundaries.
Staff Interventions: Referred to nursing staff.
Comments: Patient #1 became difficult to redirect. Patient #1 alleges that he shoved a toothbrush up his rectum.

B. Indications of Increasing Anxiety, Irritability or Psychotic Behaviors
Approximate Time: 3:15 PM
Behavior Cues: Refusing to listen ("No" to both verbal and nonverbal communication), Becoming verbally aggressive (Belligerent, sarcastic, starts yelling), and Intimidating staff (Shakes fist, verbal threats).
Staff Interventions: Used a directive approach, Set limits (clear, concise, enforceable limits, i.e. "Please go to your room").
Comments: S8MD notified. New orders noted for Thorazine 100mg IM. S9MD notified. S9MD states no need for action to be taken for toothbrush in the rectum at this time as patient will defecate.

C. Indications of Imminent Danger to Self or Others
Approximate Time: 3:21 PM
Behavior Cues: Hitting, Yelling.
Staff Interventions: Medication given.
Comments: Patient #1 received Thorazine bilaterally in buttocks. Tolerated well.
Staff Impression of Triggering Incident: Patient #1 became difficult to redirect. Client alleged he shoved a toothbrush into his rectum. S8MD notified. New orders for Thorazine noted. S9MD notified. S9MD stated no action needed at the time for toothbrush as client will defecate. Signed by: S10RN at 3:00 PM.

Reassessment of Patient
Approximate Time: 4:21 PM

Behavior Cues: Decreased muscle tone

Staff Interventions: Patient Reassessment
Comments: Lying in bed resting. No signs or symptoms of distress. Signed by: S10RN at 4:21 PM.

Review of Medical Provider Progress Notes for Patient #1 from 04/19/2025 to 04/24/2025 revealed no documented visits and/or assessments related to the incident involving the toothbrush on 04/19/2025.

Review of the Psychiatric Provider Progress Notes for Patient #1 on 04/24/2025 revealed Patient #1 was seen by S6MD at 10:53 AM for his weekly staffing meeting and was asked about the incident on 04/19/2025.

On 04/24/2025 at 11:40 AM, during an interview with S6MD, he stated because of the size of the toothbrushes (approximately 3-4" in length) the hospital was supplied with for patient use which would have been what Patient #1 was given by the nurse on 04/19/2025, the concern for Patient #1 to have done damage to his rectum and/or even his sigmoid colon if he were to have inserted the toothbrush that far was minimal. S6MD stated the patient had a tendency of attention-seeking behavior that would result in him being transported off hospital grounds to received diagnostic testing and/or treatment at another facility, also resulting in him getting to eat at off-site fast food places. S6MD did not want to "reward" bad behavior by allowing him a trip off the grounds for a diagnostic assessment. S6MD stated to his knowledge he was unaware if medical had come to physical assess Patient #1 after the incident. S6MD confirmed the first time he had seen Patient #1 since the incident on 04/19/2025 was on 04/24/2025 when he made rounds and saw the patient during the weekly staffing meeting.

Based on record review and interview the facility failed to thoroughly analyze all adverse patient events and implement preventive actions. The deficient practice was evident by the hospital's failure to ensure the safety of Patient #1 by implementing preventative measures to protect him from future self-injurious behaviors.
Findings:

Review of medical record for Patient #1 revealed he was admitted to the hospital on 02/25/2025 with diagnoses which included Unspecified Mood Disorder, Generalized Anxiety Disorder, PICA, Antisocial Trait Disorder, Impulse Control Disorder and Mild Intellectual Disability.

Review of Patient #1's Provider Orders revealed in part the following:

1:1 Direct Observation at not more than 8FT for self-injurious behavior; must be observed on toilet as well, need male RPM. TORB S6MD / S11RN on 02/25/2025 at 12:11 PM (This order was discontinued on 03/22/2025 at 5:20 PM).

2:1 Direct Observation at no more than 8 feet - Males only for Danger to others. TORB S7MD / S10RN on 03/22/2025 at 5:20 PM.

1. Client is 2:1 Direct Observation at 8 ft. self-injury, danger to others; 2. Client to be observed at all times, including when using the restroom; T.O. S6MD / RBTO S14LPN on 04/24/2025 at 12:00 PM.

Review of the facility Incident Report for 04/19/2025 for Patient #1 revealed the following:
Date/Time of Incident: 04/19/2025 at 3:00 PM
Location of Incident: Hallway
Description of Incident: While standing on B Hall, Patient #1 was told by CGT that he could not be on that hall. When told he had to be on A Hall, Patient #1 got aggressive and banged the Plexiglass on monitor room. He then asked the nurse for a toothbrush because his mouth hurt and he wanted to brush his teeth. He later alleged that he stuck the toothbrush up his anus.
Treating Psychiatrist: S8MD / S9MD
RN: S10RN
Assigned Staff: S15CGT & S16CGT
Witnesses: S17CGT
Signed: S10RN on 04/19/2025
Supervisor's Review: Patient #1 remains on 2:1 Direct Observation at 8 ft. S15CGT and S16CGT were reassigned away from Patient #1.
What Was Client's Role? Aggressor
Was Client Under Restrictive Patient Management? Yes, 8ft. direct with waist to wrist restraint
Review of the Restrictive Management Observation & Precaution Sheet (0600-1800), ELMHS #99-107a dated 04/19/2025 from 12:00 PM to 6:00 PM revealed Patient #1 was on 2:1 Direct Observation. During the time period of 1:23 PM to 3:46 PM, S16CGT and S15CGT were assigned to Patient #1. From 3:15 PM to 3:45 PM, it was documented Patient #1's behaviors to be awake, aggressive, verbally and physically threatening.

Review of Patient #1's Psychiatric Progress Note dated 04/24/2025 at 10:53 AM revealed in part the following:
Patient #1 was seen for his routine weekly staffing. Apparently on Sunday, he reported to staff that he had taken a toothbrush and inserted it into his anus. In speaking with him today about it, he stated "I lied. I didn't do nothing with it." When asked where the toothbrush went he stated "I flushed it down the toilet." Treatment Plan: Problem 1. Impulsive and Inappropriate Behaviors - Patient #1 had an episode where he reported inserting a toothbrush into his anus. In speaking with him today, he stated that he lied about it. No medication adjustments will be made this week. Signed by: S6MD

On 04/24/2025 at 8:35 AM, during morning conference for the day with S2EDON, S4ADON and S5TQM, they confirmed there was not open QAPI review for the 04/19/2025 incident that had taken place with Patient #1 inserting a toothbrush into in anus in the toilet stall.

On 04/24/2025 at 11:40 AM, during an interview with S6MD, he confirmed on 04/19/2025 prior to the incident taking place, Patient #1 no longer had an order for direct supervision while on the toilet, however he did have an order for 2:1 direct observation of 8 feet. He stated he had tried to give Patient #1 some freedom and privacy because of his other protective measures in place. S6MD confirmed Patient #1 did have a history of ingesting and inserting items into his body which was one of the reasons he was on 2:1 direct observation due to his self-injurious behaviors. S6MD confirmed Patient #1 did not have orders at the time of the interview in place for direct observation while on the toilet, but would order them as soon as the interview was over.

Based on record review and interviews, the hospital failed to ensure the shift observation records were signed and dated accurately for 1 (#1) of 2 (#1 & #2) patients reviewed for shift observation records. This was evidenced by failure of the CGT to initial every 15 minutes while assigned 2:1 direct observation of Patient #1.
Findings:

Review of the hospital policy number Nursing-2004-504, PC-NUR-12 titled "Observations and precautions" last revised on 09/27/2024 revealed in part:
"I. Definitions: B. Two-To-One (2:1) Direct Observation: two staff members shall observe and monitor a client at not more than eight (8) feet in distance with a physicians' order. The client must be visualized at all times.
II. Purpose: The purpose of this policy is to ensure behavior management techniques that provide the least restrictive management possible, uphold ethical standards of care, and protect the client's rights. Precautions are instituted for situations where a client's condition and/or behavior presents as a clear and present risk to himself, others or the environment. The client's needs are such that vigilant observation is necessary to provide a safe and protective level of care.
IV. Policy: It is the policy of the Hospital 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.
V. Procedure: C. Documentation for Clients on Precautions - ii. The Restrictive Management Observation and Precaution Sheet (ELMHS #99-107a) shall be maintained per client, with entries noted every fifteen (15) minutes according to Nursing Charting Guidelines. Staff shall initial and sign all observational client records. iii. Staff shall document behaviors of the assigned client, nursing care provided, whether contraband was found, and other pertinent data. Documentation completion is required prior to the end of the assigned employee's shift. F. Continuation of the Restrictive Management Observation and Precaution Sheet for Successive Shifts - iii. Nursing-Security Staff Member (CGTT, CGT, CLT) or PA Responsibilities b. Document on the RPM flow sheet at a minimum of every fifteen (15) minutes to include: 3. Initials of the person documenting every fifteen (15) minutes."

Review of Patient #1's Provider Orders revealed in part the following:
2:1 Direct Observation at no more than 8 feet - Males only for Danger to others. TORB S7MD / S10RN on 03/22/2025 at 5:20 PM.

Review of the Restrictive Management Observation & Precaution Sheet (0600-1800), ELMHS #99-107a dated 04/19/2025 from 12:00 PM to 6:00 PM revealed Patient #1 was on 2:1 Direct Observation. During the time period of 1:23 PM to 3:46 PM, S16CGT and S15CGT were assigned to Patient #1. From 2:00 PM to 3:30 PM, only one CGT's initials were documented on the sheet.

On 04/24/2025 at 2:50 PM, during an interview with S5TQM, she reviewed the Restrictive Management Observation & Precaution Sheet (0600-1800), ELMHS #99-107a dated 04/19/2025 from 12:00 PM to 6:00 PM and confirmed there was no initials from a second CGT from 2:00 PM to 3:30 PM for Patient #1 and there should have been.