HospitalInspections.org

Based on record review and interview, the hospital failed to meet the requirements of the Condition of Participation for Patients Rights as evidenced by:

Failing to have a system in place to ensure the safety of patients admitted with homicidal or suicidal ideations before a suicide risk assessment has been completed. This deficient practice was evidenced by assigning an observation level of every 15 minutes on admission before an assessment by a RN or psychiatrist had been completed to determine if a higher level of observation was necessary for 10 (#1, #2, #3, #4, #6, #7, #8, #9, #13, #16) of 16 patients sampled. The hospital also failed to report a score of high risk on a suicide or homicide assessment by the LPC to the psychiatrist as per policy for 7 (#1, #2, #3, #7, #8, #9, #16) of 16 patients sampled. (see findings tag A-0144).

Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services as evidenced by:
1) The RN failed to assess/evaluate the mental status and possible need for increased supervision and report to the physician when a patient expressed suicidal thoughts for 1 (#16) of 12 (#1 - #9, #11, #15, #16) patient records reviewed for assessment for increased supervision from a total sample of 16 patients. Patient #16 attempted suicide 9 hours after expressing suicidal thoughts by wrapping scrub pants around her neck and hanging on the door until the pants broke loose (see findings tag A-0395); and
2) The RN failing to obtain specific orders form a Physician or Licensed Independent Practitioner before completing an admission order sheet for 1 (#R3) of 1 random patient sampled for the process of obtaining admission orders. (see findings tag A-0395).

25065



Based on record review and interview, the hospital failed to provide care in a safe setting as evidenced by:
1) failing to have a system in place to ensure the safety of patients admitted with homicidal or suicidal ideations before a suicide risk assessment has been completed. This deficient practice is evidenced by assigning an observation level of every 15 minutes on admission before an assessment by a RN or psychiatrist had been completed to determine if a higher level of observation was necessary for 10 (#1, #2, #3, #4, #6, #7, #8, #9, #13, #16) of 16 patients sampled. The hospital also failed to report a score of high risk on a suicide or homicide assessment by the LPC to the psychiatrist as per policy for 7 (#1, #2, #3, #7, #8, #9, #16) of 16 patients sampled; and

2) failing to ensure the patient unit environment was maintained in a safe manner and was free of hazards as evidenced by an unlocked housekeeping cart left unattended with chemicals, plastic bags, and keys to the unit accessible to patients.

3) failing to assess/evaluate the mental status and possible need for increased supervision and report to the physician when a patient expressed suicidal thoughts for 1 (#16) of 12 (#1 - #9, #11, #15, #16) patient records reviewed for assessment for increased supervision from a total sample of 16 patients. Patient #16 attempted suicide 9 hours after expressing suicidal thoughts by wrapping scrub pants around her neck and hanging on the door until the pants broke loose.

Findings:

1) failing to have a system in place to ensure the safety of patients admitted with homicidal or suicidal ideations before a suicide risk assessment has been completed and a high risk score was reported to the psychiatrist:

Review of the hospital policy titled Care, Treatment and Services, Suicide Risk Assessment, No: CTS-089, revealed in part: The admitting staff will complete the initial Suicide Risk Assessment (SRA form) during the initial admission (intake) process....If any suicide risk assessment renders information that has potential to immediately affect patient safety and/or results in a score of High or Severe, the psychiatrist shall be contacted immediately. There was no documented evidence of any provisions in the policy to ensure patients were observed at a level to ensure their safety until a suicide risk assessment had been completed to determine if an increased observation level was needed for safety.

Patient #1
Review of Patient #1's medical record revealed he had a Physician Emergency Certificate dated 05/07/17 at 9:08 p.m. Further review revealed the History of Present Illness was listed as the patient presents with severe depression and with thoughts of suicide.

Review of Patient #1's Physician's order for 15 minutes observations revealed it had been completed on 05/08/17 at 3:36 p.m. (39 minutes before arrival to the hospital and an assessment by the nurse). Patient #1 remained on a 15 minute observation level throughout the hospitalization.

Review of Patient #1's Nursing Assessment dated 05/08/17 at 4:15 p.m. revealed the nurse scored him as a medium suicide risk. There was no documentation the physician had been notified of the medium risk identified.

Review of Patient #1's Integrated Assessment by the LPC on 05/09/17 at 9:43 a.m. revealed Patient #1 was determined to be a high risk for suicide because of intense ideation, imminent action, lethal plan, means available, and prior attempt(s) within last 5 months. There was no documentation the physician had been notified of the high risk score.

Patient #2
Review of Patient #2's medical record revealed the patient was admitted on 05/08/17 at 5:10 p.m. Further review revealed the patient had been PEC'd on 05/06/17 and CEC'd on 05/07/17 for suicidal ideation and suicide attempt with an overdose with pills. The patient was documented as dangerous to self and unable to seek voluntary admission on both the PEC and CEC.

Review of Patient #2's medical record revealed an admission order dated 05/08/17 at 5:10 p.m. for an observation level of q 15 minute checks with no special precautions (1 hour and 5 minutes before the patient was assessed by the RN). Review of Patient #2's observation records revealed the patient remained on a 15 minute observation level through 05/15/17 (date of record review).

Review of the Initial Nursing Assessment, completed on 05/08/17 at 6:15 p.m., revealed the patient's scores on the Safety Assessment for Suicide Risk and Aggressive Behaviors were documented as Medium Risk.

Review of the Adult Integrated Assessment, completed by a LPC on 05/09/17 at 11:09 a.m. revealed the Patient #2's Homicidal and Suicidal Risk scores fell into the High Risk category. Further review revealed no documented evidence that a physician had been notified of the high scores and no evidence that observation levels had been increased.

Additional review revealed no documented evidence that a Suicide Risk Assessment had been performed by a RN as of 05/15/17 (date of chart review).

Review of Patient #2's Psychiatric Evaluation revealed he had not been assessed by the psychiatrist until 05/09/17 at 07:08 a.m.

Patient #3
Review of Patient #3's medical record revealed he was PEC'd on 05/10/17 for SI and HI when he was sent to the ED on an OPC that stated he is threatening to kill his grandmother and himself and is dangerous to himself and others.

Review of Patient #3's "Integrated Assessment - Part One" documented by S4LPC on 05/11/17 at 8:57 a.m. revealed documentation that Patient #3 reported active SI after his grandmother hit him and that he got a hose and chair to hang himself. Further documentation by S4LPC revealed that Patient #3 had suicidal gestures and a suicide plan and was rated as a high risk for self-harm. Review of the homicide risk revealed Patient #3 reported he told his grandmother that he would "break her neck" and had thoughts and threats to kill or break his classmates' neck when he gets angry. S4LPC rated him as a high homicide risk.

Review of Patient #3's "Nursing Assessment - Part Two" documented by S3RN on 05/10/17 at 11:20 p.m. revealed she scored Patient #3 as a low risk for suicide and aggressive behaviors.

Review of Patient #3's admit orders received by telephone order from S5PNP on 05/10/17 at 8:50 p.m., received prior to Patient #3 being assessed for suicide and homicide risk, revealed an order for suicide, self-harm, and aggressive behavior precautions and special observation to include q15 minute checks.

Review of the medical record revealed no documented evidence of specific, non-contradictory assessments of risk for suicide, homicide, and aggression.

Patient #4
Review of Patient #4's medical record revealed she was PEC'd on 05/09/17 at 7:30 p.m. as dangerous to self and others and gravely disabled.

Review of Patient #4's "Integrated Assessment - Part One" documented by S4LPC on 05/10/17 at 9:25 a.m. revealed he was assessed as a low risk for suicide and a medium risk for homicide. Review of Patient #4's "Nursing Assessment - Part Two" documented by S6RN on 05/10/17 at 3:00 a.m. revealed patient "is refusing to talk or move out of chair" and "unable to complete nursing assessment" on 05/10/17 at 2:35 a.m. and on 05/10/17 at 7:45 p.m. There was no documented evidence that the "Suicide Risk Assessment" had been completed as of the time the record was reviewed on 05/15/17 at 1:50 p.m.

Review of Patient #4's physician admit orders revealed orders were received by telephone order from S8Psych on 05/10/17 at 2:15 a.m. at which time Patient #4 was ordered to be on fall and aggressive behavior/assault precautions and observed q15 minutes (prior to the suicide risk assessment being conducted).

Patient #6
Review of Patient #6's medical record revealed the patient was admitted on 05/12/17 at 11:25 a.m. Further review revealed the patient had been PEC'd on 05/11/17 and CEC'd on 05/13/17 for suicidal ideations and depression. The patient was documented as dangerous to self and unable to seek voluntary admission on both the PEC and CEC. The documented reason, on the Psychosocial Assessment, for the patient's admission was as follows: "I tried to commit suicide, I jumped out of the truck twice going 40. I have people in my head tells me to do stuff like that."

Review of Patient #6's medical record revealed an admission order dated 05/12/17 at 11:25 a.m. for an observation level of q 15 minute checks with suicide/self-harm precautions. The patient arrived on the unit at 4:10 p.m. Further review revealed a blank Suicide Risk Assessment in the patient's chart. Additional review revealed no documented evidence that a Suicide Risk Assessment had been performed on Patient #6 as of 05/15/17 (date of chart review).

Review of the Initial Nursing Assessment, completed on 05/12/17 at 4:20 p.m., revealed the patient's scores on the Safety Assessment for Suicide Risk and Aggressive Behaviors were documented as Low Risk.

Review of the Adult Integrated Assessment, completed by an LPC on 05/12/17 at 1:00 p.m., revealed the following, in part: Level of Care Determination: Inpatient Acute Care: Presentation consistent with at least one of the following (last 72 hours): Suicide/Self Injury (Attempt, Intent/Plan, Self-Mutilation, Hallucinations and/or delusions): box checked and Gravely Disabled: box checked. Additional review revealed Patient #6's Homicidal Risk score fell into the Low Risk Category and his Suicidal Risk scores fell into the Medium Risk category.

Patient #7
Review of Patient #7's medical record revealed she had a Physician Emergency Certificate dated 05/11/17 at 12:17 a.m. Further review revealed the History of Present Illness was listed as a 26 year old with suicidal ideations. She was also classified as being dangerous to herself and gravely disabled. Patient #7 was admitted to the hospital at 8:05 a.m. on 05/11/17.

Review of Patient #7's medical record revealed an admission order dated 05/11/17 at 8:05 a.m. for an observation level of q 15 min checks (3 hours and 10 minutes before being assessed by a staff member for suicidal risk).

Review of Patient #7's Adult Integrated Assessment by the LPC dated 05/11/17 at 10:25 a.m. revealed the suicidal risk was not scored and the homicidal risk was scored as being high. There was no documented evidence the physician had been notified of the high score or that observation levels were increased.

Review of Patient #7's Psychiatric Evaluation revealed she had not been assessed by the psychiatrist until 05/11/17 at 11:15 a.m.

Patient #8
Review of Patient #8's medical record revealed the patient was admitted on 05/11/17 at 4:10 p.m. Further review revealed the patient had been PEC'd on 05/11/17 and CEC'd on 05/11/17 for suicidal ideation and suicide attempt by trying to jump out of a car twice last week and once today (05/11/17). The patient was documented as dangerous to self and unable to seek voluntary admission on both the PEC and CEC. The patient's reason for admission on the Psychosocial Assessment was documented as follows: "I tried to commit suicide, I jumped out of the truck twice going 40. I have people in my head tells me to do stuff like that."

Review of Patient #8's medical record revealed an admission order dated 05/11/17 at 11:15 a.m. for an observation level of q 15 minute checks with suicide/self-harm precautions. The patient arrived on the unit at 4:10 p.m. The patient was on the unit, without a risk assessment by a RN, for 1 hour and 20 minutes.

Review of the Initial Nursing Assessment, completed on 05/11/17 at 5:30 p.m., revealed the patient's scores on the Safety Assessment for Suicide Risk and Aggressive Behaviors were documented as Low Risk.

Review of the Adult Integrated Assessment, completed by a LPC on 05/12/17 at 9:18 a.m. revealed Patient #8's Homicidal risk score fell into the Medium Risk Category and her Suicidal Risk scores fell into the High Risk category. Further review revealed no documented evidence that a physician had been notified of the high scores and no evidence that observation levels had been increased.

Additional review revealed a Suicide Risk Assessment had been performed by a RN on 05/11/17 at 5:10 p.m. scoring the patient as 19 (17-24 is low risk).

Review of Patient #8's Psychiatric Evaluation revealed he had not been assessed by the psychiatrist until 05/12/17 at 10:41 a.m.

Patient #9
Review of Patient #9's medical record revealed she admitted on 05/04/17 and signed a formal voluntary admission on 05/04/17 at 7:15 p.m.

Review of Patient #9's "Nursing Assessment - Part Two" documented on 05/05/17 at 9:19 a.m. revealed S4LPC reported active and passive SI and reported thoughts to overdose on pills and had thoughts to hang herself. S4LPC scored Patient #9 as a high suicide risk. There was no documented evidence that S4LPC documented an assessment of homicide risk.

Review of Patient #9's "Nursing Assessment - Part Two" documented by S3RN revealed she assessed Patient #9's suicide risk as medium and her aggressive behavior risk as low. Review of her "Suicide Risk Assessment" documented by S3RN on 05/05/17 at 1:25 a.m. revealed Patient #9 was assessed as a medium risk for suicide.

Review of Patient #9's physician admit orders received by telephone order by S9Psych on 05/04/17 at 7:15 p.m. revealed orders for suicide/self-harm precautions and observation q15 minute checks (prior to the suicide risk assessment being conducted).

Patient #13
Review of Patient #13's medical record revealed he had been admitted on 01/08/17 at 12:53 p.m. He had a Physician Emergency Certificate dated 01/08/17 which listed him as having a history of schizophrenia and substance abuse. Further review revealed he had been placed in a manual hold and then 4 point restraints on 01/08/17 at 1:25 p.m. for violent behavior and released at 2:00 p.m.

Review of Patient #13's admission orders revealed he was ordered to be on 15 minute observations on 01/08/17 at 12:53 p.m. (no risk assessment had been completed for 6 hours and 27 minutes).

Review of Patient #13's 15 Minute Observation Sheets revealed he remained on 15 minute observations during his hospitalization except when he was in restraints. Before a suicide risk assessment had been completed, he was documented as being in his room.

Review of Patient #13 Integrated Assessment dated 01/08/17 at 8:25 p.m. revealed the suicide and homicide risk assessment had not been completed.

Review of Patient #13's Suicide Risk Assessment dated 01/08/17 at 7:20 p.m. revealed he was scored as a medium risk. There was no documentation the physician was made aware of the increased risk or that observation levels were increased.

Review of Patient #13's medical record revealed he had not been assessed by the psychiatrist until 01/09/17 at 8:45 a.m.


Patient #16
Review of Patient #16's medical record revealed she was admitted on 04/24/17. Review of her "Adult Integrated Assessment" documented on 04/25/17 at 9:55 a.m. revealed Patient #16 reported she "want to kill myself" and reports two plans, one of which is to cut her arm with an exacto knife and one was to go to a gun range and shoot herself in the heart. S4LPC assessed Patient #16 as a high risk for suicide and a low risk for homicide.

Review of Patient #16's "Nursing Assessment - Part Two" documented by S6RN on 04/25/17 at 12:55 a.m. revealed 6RN assessed Patient #16 as low risk for suicide and aggressive behaviors. Review of the medical record by the surveyor on 05/16/17 revealed no documented evidence that the suicide risk assessment had been conducted.

Review of Patient #16's physician admit orders received by telephone order on 04/24/17 at 9:55 p.m. (prior to the suicide risk assessments being conducted) revealed an order for suicide/self-harm precautions and observations q15 minutes.

In an interview on 05/16/17 at 3:06 p.m. with S2DON, he said the suicide risk assessment is completed by the nurse on admission and a separate safety assessment is done by the nurse also. He said the nursing staff had 8 hours to complete the assessment. He said if the suicide risk assessment score is greater than the safety risk score it held more weight than the other assessment. S2DON said if a patient is scored as a high or medium risk for suicide or homicide by the nurse the physician should have been notified. He said with the admission orders the physician orders an observation level. S2DON verified the observation levels were being ordered before the patient was assessed for being a suicide or aggression risk. S2DON also verified the hospital did not have any policies in place to assure patients were observed at a level to ensure their safety until a suicide risk assessment had been completed to determine if an increased observation level was needed for safety.

In an interview on 05/16/17 at 4:35 p.m., S1Adm indicated when an assessment score of high risk for suicide or homicide is determined, any practitioner conducting the assessment should notify the physician or NP and should document the contact in the respective notes. She further indicated the suicide risk assessment (long form) done by the nurse at admission is the score that's "really looked at." S1Adm indicated the assessment done by the LPC should be documented on the hand-off from the LPC to the nurse, and anything "outstanding should be reported to the charge nurse who reports to the psychiatrist or NP."

2) failing to ensure the patient unit environment was maintained in a safe manner and was free of hazards as evidenced by an unlocked housekeeping cart left unattended with chemicals, plastic bags and keys to the unit accessible to patients:

On 05/16/17 at 1:15 p.m., an observation was made on the adult in-patient psychiatric unit. An unlocked housekeeping cart was observed outside the nurse's station in the hallway that was accessible to patients. The housekeeping cart was observed to have multiple bottles of spray disinfectant cleaners, multiple rolls of plastic garbage bags and 2 key rings with multiple keys. Observation of the cart and the proximity to the nurse's station revealed the cart was not visible from the nurse's station.

On 05/16/17 at 1:18 p.m., S10Housekeeping was observed leaving the activity room where the patients were participating in a recreational activity.

On 05/16/17 at 1:20 p.m. S10Housekeeping was observed to return to the housekeeping cart. S10Housekeeping was interviewed at this time and stated she does not usually leave the cart unattended. S10Housekeeping stated, "We are not supposed to leave it." S10Housekeeping stated she had to put linen up and stated she was supposed to lock the housekeeping cart in the closet at the end of the hall. S10Housekeeping confirmed there were disinfectants, plastic bags and 2 sets of keys left unlocked in the cart that were accessible to the patients.

3) failing to assess/evaluate the mental status and possible need for increased supervision and report to the physician when a patient expressed suicidal thoughts:
Review of Patient #16's nurses' note for 04/25/17 at 1:55 p.m. revealed documentation that Patient #16 "stated she has thoughts of suicide at times." There was no additional documentation to indicate the nurse further assessed/evaluated Patient #16's mental status relative to her thoughts of suicide. There was no documented evidence that the psychiatrist was notified, and the observation level was not increased.

Review of Patient #16's "Multidisciplinary Notes Nursing" revealed documentation by S6RN at 11:p.m. on 04/25/17 that Patient #16 had torn a scrub outfit into large shreds and made a noose which she placed around her neck. Further review revealed the noose was taken away from Patient #16, she was placed in the quiet room, and S8Psych was notified. S8Psych ordered her to be on line of sight around the clock on 04/25/17 at 11:00 p.m. (after the incident) and then 1:1 on 04/26/17 at 12:20 p.m.

Review of the incident report documented on 04/25/17 at 10:55 p.m. revealed that Patient #16 had "wrapped scrub pants around neck and hung on the door until the pants broke."

In an interview on 05/16/17 at 3:05 p.m., S2DON offered no explanation for the psychiatrist not being notified of Patient #16's expressed thoughts of suicide.






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30984

Based on record review and interview, the hospital failed to ensure when restraints were used for the management of violent behavior, the patient was seen face-to-face within 1 hour after the initiation of the intervention and evaluated for the patient's immediate situation, reaction to the intervention, medical and behavioral condition, and the need to continue or terminate the restraints for 1 (#13) of 1 patient record reviewed for restraints.

Findings:

Review of Patient #13's medical record revealed he had been admitted to the hospital on 01/08/17 at 12:53 p.m. and had a Physician Emergency Certificate dated 01/08/17 which listed him as having a history of Schizophrenia and Substance Abuse. Further review revealed he had been placed in a manual hold and then 4 point restraints on 01/08/17 at 1:25 p.m. for violent behavior and released at 2:00 p.m.

Review of a document in Patient #13's medical record titled One Hour Face to Face revealed two pages of assessment criteria including if the restraint was less than 15 minutes, the reason for the hold, the assessment of the immediate situation, the patient's response to the intervention, the mental status/behavioral assessment, the behavioral criteria for discontinuation of seclusion or restraint, the summary and communication and MD notification. The document had been dated 01/08/17 at 1:40 p.m. but none of the assessment had been documented.

In an interview on 05/16/17 at 3:00 p.m. with S2DON, he verified a face to face evaluation should have been completed within 1 hour of a patient being placed into restraints and should have been documented in the patient's medical record.

25065

Based on record reviews and interview, the hospital failed to ensure performance improvement activities analyzed adverse patient events as evidenced by failure to have documented evidence of an investigation of an incident that involved 2 patients (#11, #15) from a review of 3 incidents.
Findings:

Review of the Hospital's policy titled, Incident Reporting-Risk Management Program, Policy number RM 02 revealed in part the following: Any facility staff member who witnesses, discovers, or has direct knowledge of an incident must complete an Incident Report before the end of the shift/work day....If the incident involves a patient, staff must chart relevant information in the patient's medical record. When documenting incidents in the medical records, staff will chart precisely what happened without making reference to an "error" or that an Incident Report was completed....The Shift Supervisor or Facility Designated Individual will conduct a preliminary incident review. Risk Manager will further investigate if deemed necessary and/or will document the investigation under Level "I" and "II"....Risk Manager must review and sign all Incident Reports. Recommendations and/or outcomes should be noted on the Incident Report.

Review of an incident report and subsequent documentation by the MHT on 04/03/17 who witnessed the event revealed that Patient #11 was found in Patient #15's bathroom at 3:15 p.m. after Patient #15 was observed to have exited her bathroom. Further documentation revealed that the MHT saw Patient #11 in the hall, and when he walked by a few seconds later, he (MHT) didn't see Patient #11 anywhere. The MHT passed by Patient #15's room (because "I was told him and [Patient #15] were getting close") and saw her door closed. The MHT knocked on Patient #15's door and got no answer, so she knocked on her bathroom door, when Patient #15 said she was using the bathroom. After Patient #15 got down the hall, the MHT walked into Patient #15's bathroom where she found Patient #11 standing in the bathroom of Patient #15.

No documented evidence of an investigation of the incident was provided to the surveyor during the survey.

In an interview on 05/17/17 at 8:45 a.m., S1Adm indicated the incident report was signed by S14PI and S2DON. She further indicated she remembered discussing the situation, but "it didn't seem to be a concern because of the timing in the bathroom."

In an interview on 05/17/17 at 8:51 a.m., S14PI indicated he reviewed the q15 minute records, and they were consistent with what the staff had reported and "it was seconds" that the two patients were in the bathroom together. He indicated he took verbal statements from the charge nurse and the MHTs who were present and the specific MHT who wrote the report. He further indicated S2DON also spoke with the MHT who documented the incident. S14PI confirmed he had no documentation of the interviews that were conducted to present as an investigation into the incident.

Based on record review and interview, the hospital's governing body failed to ensure that the program reflected the complexity of the hospital's organization and services. This deficient practice was evidenced by the hospital's failure to include all contracted services and Dietary Services in the hospital's QAPI program.
Findings:

Review of the hospital Quality Assurance and Performance Improvement documentation revealed there was no data collected, tracked and trended for dietary or contracted services.

In an interview on 05/17/17 at 10:00 a.m. with S14PI, he said he was over the QAPI program for the hospital. S14PI verified the contracted services and dietary were not included in the quality data.

25065

Based on record reviews and interview, the hospital failed to ensure physicians' credentials were examined and recommendations made to the governing body on the reappointment in accordance with the Medical Staff By-laws as evidenced by failure to have documented evidence that the reappointment process was implemented for 1 (S19MD) of 7 medical staff credentialing files reviewed for reappointment. The hospital failed to ensure the physician's credentials were current in accordance with Medical Staff By-laws as evidenced by failing to have current malpractice liability insurance for 1 (S8Psych) of 7 medical staff credentialing files reviewed.
Findings:

Review of the Medical Staff By-laws provided by S1Adm as the hospital's current Medical Staff By-laws revealed in part the following:
6.1 The Medical Staff, through its committees and officers, shall investigate and consider each complete application for appointment or reappointment....
6.6 Reappointment process.
6.6.1 Reappointment form....Within thirty (30) days after service of the application, each such person who desires reappointment shall send the completed Reappointment/Recredentialing application form to the CEO. Failure to return the form timely shall be deemed a voluntary resignation from appointment status and voluntary relinquishment of Clinical Privileges....When the application for reappointment is complete, the CEO shall transmit the Reappointment/Recredentialing application form and related materials to the MEC.
6.6.6 MEC Review. After the MEC has completed its review, it shall forward to the Governing Board the application....
Further review of the Medical Staff By-laws revealed the applicant carried at least $1,000,000/$3,000,000 of professional liability insurance coverage.

Review of S19MD's credentialing file revealed his appointment was from 07/24/13 to 07/14/15. Further review revealed a request for consulting privileges was signed by S19MD and approved by the Medical Director, Medical Executive Committee, and the Board of Trustees on 03/02/15. There was no documented evidence that S19MD was reappointed in accordance with the Medical Staff By-laws as evidenced by failure to have a completed application, as outlined in the Medical Staff By-laws, Article 6.6.

In an interview on 05/17/17 at 9:05 a.m., S20HIM confirmed that S19MD was not re-credentialed in 2015. She indicated his privileges were approved without having a complete re-application packet as required by the Medical Staff By-laws.


Review of the credentialing file for S8Psych revealed the professional liability insurance coverage expired on 04/01/17. There was no documented evidence of current professional liability insurance coverage.

In an interview on 05/17/17 at 10:30 a.m., S20HIM reviewed the credentialing file for S8Psych and confirmed the professional liability insurance had expired and she was unable to provide any verification of current coverage.

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:
1) The RN failed to assess/evaluate the mental status and possible need for increased supervision and report to the physician when a patient expressed suicidal thoughts for 1 (#16) of 12 (#1 - #9, #11, #15, #16) patient records reviewed for assessment for increased supervision from a total sample of 16 patients. Patient #16 attempted suicide 9 hours after expressing suicidal thoughts by wrapping scrub pants around her neck and hanging on the door until the pants broke loose; and
2) The RN failing to obtain specific orders form a Physician or Licensed Independent Practitioner before completing an admission order sheet for 1 (#R3) of 1 random patient sampled for the process of obtaining admission orders; and
3) The RN failed to ensure physician orders were implemented for labs for 3 (#3, #4, #9) of 9 (#1 - #9) patient records reviewed for implementation of physician orders from a total sample of 16 patients; and
4) The RN failed to ensure unclear physician orders were clarified for 1 (#4) of 9 (#1 - #9) patient records reviewed for clarification orders from a total sample of 16 patients; and
5) The RN failed to ensure the MHT's observation records were complete and reflected the appropriate precautions and/or observation level for 7 (#3, #4, #6, #8, #9, #11, #15) of 11 (#1 - #9, #11, #15) patient records reviewed for observation documentation from a total sample of 16 patients.

Findings:

1) The RN failed to assess/evaluate the mental status and possible need for increased supervision and report to the physician when a patient expressed suicidal thoughts.

Review of Patient #16's nurses' note for 04/25/17 at 1:55 p.m. revealed documentation that Patient #16 "stated she has thoughts of suicide at times." There was no additional documentation to indicate the nurse further assessed/evaluated Patient #16's mental status relative to her thoughts of suicide. There was no documented evidence that the psychiatrist was notified, and the observation level was not increased.

Review of Patient #16's "Multidisciplinary Notes Nursing" revealed documentation by S6RN at 11:p.m. on 04/25/17 that Patient #16 had torn a scrub outfit into large shreds and made a noose which she placed around her neck. Further review revealed the noose was taken away from Patient #16, she was placed in the quiet room, and S8Psych was notified. S8Psych ordered her to be on line of sight around the clock on 04/25/17 at 11:00 p.m. (after the incident) and then 1:1 on 04/26/17 at 12:20 p.m.

Review of the incident report documented on 04/25/17 at 10:55 p.m. revealed that Patient #16 had "wrapped scrub pants around neck and hung on the door until the pants broke."

In an interview on 05/16/17 at 3:05 p.m., S2DON offered no explanation for the psychiatrist not being notified of Patient #16's expressed thoughts of suicide.

2) The RN failing to obtain specific orders form a Physician or Licensed Independent Practitioner before completing an admission order sheet.

Review of the preprinted document titled Adult Standing Order revealed orders were chosen from multiple choices by a check mark being placed in a box next to the order selected. Orders that had multiple boxes to select included: Activity level, groups, Laboratory tests, Drug levels, Capillary blood glucoses, vital signs, Special observations, Nutritional services, Precautions, Limited Precautions, PRN pain medications, PRN GI medicines, PRN insomnia medication, PRN anxiety medications, PRN agitation and/or psychosis medications.

Review of Patient #R3's medical record revealed his admission orders had been documented as a telephone order by the physician taken by S15RN.

In an interview on 05/16/17 at 2:55 p.m. with S15RN, she said when she took admission orders from the psychiatrist he would usually just tell her "routine orders" and she selected the orders from the preprinted order set based on a protocol. S15RN said that is what she did for Patient #R3's admission orders. S15RN said for example if the patient had some labs recently at another hospital she would not check those labs to be drawn. She also said if the patient was diabetic she would check the box for sliding scale insulin and blood glucoses before meals and at bedtime. She said she did not read each line of the orders she selected to the physician for approval. S15RN said the physician would usually come in and sign the orders the next day.

In an interview on 05/16/17 at 3:05 p.m. with S15RN, she said she did not have a protocol for deciding which boxes to check on the order sheet. S15RN said she had worked at the hospital a long time and just knew what the doctor wanted. S15RN verified it was not within her scope of practice as a nurse to write physician's admission orders.

In an interview on 05/16/17 at 3:50 p.m. with S2DON, he verified S15RN could not select orders on the admission order sheet without going over each order with the physician.



3) The RN failed to ensure physician orders were implemented for labs, medications, and/or vital signs:
Patient #3
Labs:
Review of Patient #3's "Adult Standing Orders" received by telephone order from S5PNP on 05/10/17 at 8:50 p.m. revealed an order for RPR, TSH, and Lipid Profile and do not repeat if readmitted within 30 days. There was no documented evidence that Patient #3 was a readmit within 30 days.

Review of Patient #3's medical record revealed no documented evidence of TSH and Lipid Profile results.

Patient #4
Review of Patient #4's "Adult Standing Orders" received by telephone order from S8Psych on 05/10/17 at 2:15 a.m. revealed an order for RPR, TSH, and Lipid Profile and do not repeat if readmitted within 30 days. There was no documented evidence that Patient #4 was a readmit within 30 days.

Review of Patient #4's medical record revealed no documented evidence of a RPR result. No RPR result was presented for review as of the end of the survey on 05/17/17.

Patient #9
Review of Patient #9's physician orders revealed an order on 05/05/17 at 7:10 a.m. for an ANC (Absolute neutrophil count) level this morning stat.

Review of Patient #9's lab results revealed no documented evidence of an ANC result for lab drawn on 05/05/17. There was an ANC result on 05/12/17 with no documented evidence of an order for the lab draw.

In an interview on 05/16/17 at 3:05 p.m., S2DON offered no explanation for the lab results not being on the chart. He was asked by the surveyor to review the record and present any documentation of the above lab results.

As of the end of the survey on 05/17/17, no documentation of the above-listed lab results for Patients #3, #4, and #9 were presented to the surveyor.

In an interview on 05/17/17 at 9:20 a.m., S2DON indicated "some of the things we discussed yesterday, I have no answers or corrections for."

4) The RN failed to ensure unclear physician orders were clarified:
Patient #4
Review of Patient #4's medical record revealed a NP's order on 05/12/17 ( no time documented when the order was received by telephone; the order was signed off by the nurse at 6:00 p.m.) to give Haldol 5 mg IM with Ativan 2 mg IM and Benadryl 50 mg IM per patient refusal of medications. There was no documented evidence that the order was written as a PRN order, and there was no documented evidence that the order was clarified by the nurse.

Review of Patient #4's MARs revealed she received the above injections on 05/12/17 at 6:02 p.m., 05/13/17 at 10:30 p.m., and 05/14/17 at 10:00 a.m.

In an interview on 05/16/17 at 3:05 p.m., S2DON offered no explanation for the above order not being written as a PRN order and not being clarified. He was offered to submit any further documentation he may have related to this finding in the morning of 05/17/17.

In an interview on 05/17/17 at 9:20 a.m., S2DON indicated "some of the things we discussed yesterday, I have no answers or corrections for."

5) The RN failed to ensure the MHT's observation records were complete and reflected the appropriate precautions and/or observation level:

Review of the hospital's policy titled, Nursing Rounds-Safety/Q 15 Minute Checks, Policy number CTS-045 revealed in part the following: Patient rounds are recorded on the Q 15 sheet every 15 minutes by assigned staff to indicate patient's activity, behavior, and/or locations according to the key code. Documentation is to be done timely and accurately, never in advance....Staff shall update the sheets during each shift to reflect any changes in observation level, precautions, restrictions, room, or bed changes.

Patient #3
Review of Patient #3's physician orders received on 05/10/17 at 8:50 p.m. revealed he was to be placed on self-harm and aggressive behavior precautions. Review of his "q15 Minute Observation Check Sheet" documented by the MHTs revealed no documented evidence that self-harm and aggressive behavior precautions were checked on the day of admit, self-harm and elopement were checked on 05/13/17, rather than self-harm and aggressive behavior.

Patient #4
Review of patient #4's physician orders received on 05/10/17 at 2:15 a.m. revealed aggressive behavior/assault precautions was ordered. Review of her "q15 Minute Observation Check Sheet" documented by MHTs revealed no documented evidence that the aggression precaution was checked on 05/09/17, and self-harm was checked on 05/10/17.

Patient #6
Review of Patient #6's physician orders received on 05/12/17 at 11:25 a.m. revealed suicide/self-harm precautions and special observation: q 15 minute checks were ordered. Review of the patient's "q15 Minute Observation Check Sheets" documented by MHTs revealed no documented evidence that the suicide/self-harm precaution was checked on 05/12/17 (day of admit).

Patient #8
Review of Patient #8's physician orders received on 05/11/17 at 11:15 a.m. revealed suicide/self-harm precautions and special observation: q 15 minute checks were ordered. Review of the patient's "q15 Minute Observation Check Sheets" documented by MHTs revealed no documented evidence that the suicide/self-harm precaution was checked on 05/11/17 (day of admit). Further review revealed precaution type was marked "none" on 5/13/17.

Patient #9
Review of Patient #9's physician orders received on 05/04/17 at 7:15 p.m. revealed an order for self-harm precautions. Review of her "q15 Minute Observation Check Sheet" documented by MHTs revealed no documented evidence that self-harm precaution was checked on 05/04/17 and 05/12/17.

Patient #11
Review of Patient #11's physician orders revealed an order on 03/31/17 at 3:35 p.m. to place him on hypersexual precautions. Further review revealed an order on 04/03/17 at 4:30 p.m. for unit restriction and to remain 15 feet away from female patients.

Review of Patient #11's "q15 Minute Observation Check Sheet" documented by MHTs revealed no documented evidence that hypersexual precaution was checked on 04/01/17. Further review revealed no documented evidence on the observation sheets of 04/04/17 and 04/05/17 that he was to remain 15 feet away from female patients.

Patient #15
Review of Patient #15's physician orders revealed an order was received on 04/03/17 at 4:30 p.m. for unit restriction and to keep her 15 feet away from male patients.

Review of Patient #15's "q15 Minute Observation Check Sheet" documented by MHTs revealed no documented evidence that the observation sheet included that she was to be be kept 15 feet away from male patients on 04/03/17 and 04/04/17.

In an interview on 05/16/17 at 3:05 p.m., S2DON was informed of the above findings. When asked if the nurse has any responsibility for the MHT's observations and documentation of observations, S2DON indicated the nurses have a board in the nursing station that has colored stickers on it for each type of precaution that the patient is on. He further indicated the nurse has to assure that the observation sheet coincides with the board in the nursing station. S2DON indicated the night MHT prepares the observation sheets for the next day. He further indicated the hospital has no policy that requires the nurse to review the MHT's observation sheets for completeness and accuracy.





30984

25065

Based on record reviews and interview, the hospital failed to ensure that the nursing staff developed and kept current a nursing care plan for each patient as evidenced by failure to have nursing care plans that included medical diagnoses for which the patient was being treated, goals that were measurable, and/or were revised with changes in condition or situations for 4 (#4, #11, #15, #16) of 12 (#1 - #9, #11, #15, #16) patient records reviewed for nursing care plans from a total sample of 16 patients.
Findings:

Review of the hospital policy titled Record of Care, Treatment and Services, No: RC-017, revealed in part:
The treatment plan shall be initiated as a component of the admissions process with continual development and formulation by the attending physician/LIP and multidisciplinary treatment team. The treatment team is patient-specific, individualized and includes defined problems and needs, strengths and limits/weakness, frequency of care, treatment of services, facilitating factors and barriers, and transition criteria to lower levels of care.
2. Admitting RN
a. Formulates the treatment plan based on physician/LIP's orders/initial plan and findings and conclusions from the Assessment and Referral assessment, Nursing assessment, and family/significant other information within (8) hours of admission or sooner if the patients' needs warrant immediate action/intervention.

Patient #4
Review of patient #4's "Initial Treatment Plan" documented on 05/10/17 revealed problems of depressed mood and anger/aggression. Review of the treatment plan for "Disturbed Thought" revealed the long term goal was documented as "display and increase in judgement, mood stability, and goal directed behavior on a daily basis, by the time of discharge with no documented evidence how this goal would be measured to determine when it was met. Further review revealed no documented evidence of nursing interventions. There was no documented evidence of a care plan developed for anger/aggression.

Patient #11
Review of Patient #11's medical record revealed he was admitted on 03/28/17 and his diagnoses included Hepatitis C.

Review of his physician orders revealed on 03/31/17 at 3:35 p.m. he was placed on hypersexual precautions.

Review of Patient #11's "Initial Treatment Plan" documented on 03/28/17 revealed his problems included disturbed thought, substance use, GERD (gastroesophageal reflux disease), Neuropathy, Weight Loss, and Back Pain. Further review revealed deferred problems included elevated blood pressure, deferred due to no current signs/symptoms/complaints, and Hepatitis C, deferred due to no special monitoring or treatment.

Review of Patient #11's "Disturbed Thought" care plan revealed the long term goal was documented as "display and increase in judgement, mood stability, and goal directed behavior on a daily basis, by the time of discharge with no documented evidence how this goal would be measured to determine when it was met. Further review revealed no documented evidence the care plan was revised to include hypersexual precautions on 03/31/17.

Patient #15
Review of Patient #15's medical record revealed her diagnoses included Hepatitis and Cirrhosis. Further review revealed physician orders were received on 04/03/17 at 4:30 p.m. to place her on unit restrictions and to keep her 15 feet away from male patients.

Review of Patient #15's "Initial Treatment Plan" documented on 03/29/17 revealed her problems included depressed mood, anxiety, and substance use. Deferred problems included Hepatitis C and Cirrhosis. Review of the care plan for depressed mood included a long term goal of "will verbalize healthier cognitive patterns and beliefs about self and others by the time of discharge with no documented evidence how this goal would be measured to determine when it was met. Review of the care plan for anxiety revealed a long term goal of "achieve daily, reduced level, frequency, and intensity of anxiety, so that functioning is not impaired, by the time of discharge." There was no documented evidence how this goal would be measured to determine when it was met.

There was no documented evidence that Patient #15's care plan was revised to include the unit restriction and maintaining 15 feet away from male patients.

Patient #16
Review of Patient #16's medical record revealed a "Multidisciplinary Notes Nursing" with documentation by S6RN at 11:00 p.m. on 04/25/17 that Patient #16 had torn a scrub outfit into large shreds and made a noose which she placed around her neck.

Review of an incident report documented on 04/26/17 revealed that Patient #16 had "wrapped scrub pants around neck and hung on the door until the pants broke."

Review of Patient #16's master treatment plan revealed her problems included depressed mood without psychosis, substance abuse, anxiety, and anorexia.

Review of the care plan for depressed mood revealed a long term goal of "will verbalize healthier cognitive patterns and beliefs about self and others by the time of discharge with no documented evidence how this goal would be measured to determine when it was met. Review of the care plan for anxiety revealed a long term goal of "achieve daily, reduced level, frequency, and intensity of anxiety, so that functioning is not impaired, by the time of discharge." There was no documented evidence how this goal would be measured to determine when it was met. Review of the care plan for anorexia revealed the long term goal was that Patient #16 "will not experience any exacerbations related to poor appetite while hospitalized with no documented evidence how this goal would be measured to determine when it was met.

Review of the nursing care plan revealed no documented evidence that the plan was revised on 04/26/17 after Patient #16 experienced a suicide attempt.

In an interview on 05/16/17 at 3:05 p.m., S2DON indicated care plans are new, and they have extensive training. He further indicated they've been instructed to wait until the physician's history and physical is complete before care planning medical problems. He offered no comments when informed that review of the nursing care plans revealed no documented evidence that goals were written in measurable terms, medical diagnoses were included in the care plan, and that care plans were revised for hypersexual activity and suicide attempts.

In an interview on 05/17/17 at 9:20 a.m., S2DON indicated they defer Hepatitis C on the care plan unless it's active.





30364

Based on record review and interview, the hospital failed to ensure that drugs and biologicals were administered in accordance with the orders of the practitioner responsible for the patient's care. This deficient practice was evidenced by nursing staff failing to administer ordered insulin on 3 occasions for 1 (#14) of 3 patients reviewed with sliding scale insulin orders.
Findings:

Review of Patient #14's Regular Insulin per Sliding Scale ordered on 04/04/17 at 10:20 p.m. revealed the following:
If the blood glucose is 201-250 = administer 4 units subcutaneously
If the blood glucose is 251-300 = administer 6 units subcutaneously

Review of Patient #14's MAR and the diabetic flow sheet revealed the following blood glucoses documented:
04/05/17 at 6:30 a.m. - 238; no insulin documented as having been administered.
04/07/17 at 1630 - 271; no insulin documented as having been administered.
04/08/17 at 6:30 a.m. - 284; no insulin documented as having been administered.

In an interview on 05/16/17 at 1:37 p.m. with S16LPN, she said 4 units of regular insulin should have been administered to Patient #14 on 04/05/17 at 6:30 a.m., on 04/07/17 at 4:30 p.m. 6 units should have been administered and on 04/08/17 at 6:30 a.m. there should have been 6 units administered. S16LPN said she did not find documentation of the insulin being administered.

In an interview on 05/16/17 at 2:00 p.m. with S2DON, he verified the above mentioned insulin was not documented as having been given as ordered.

25065

Based on record reviews and interview, the hospital failed to ensure a medical record was maintained on each patient that was accurately written as evidenced by failure to have documentation of an incident in the medical record that occurred on 04/03/17 that involved Patient #11 and Patient #15 for 1 of 3 incident reports reviewed for documentation of the event in the medical record.
Findings:

Review of the Hospital's policy titled, Incident Reporting-Risk Management Program, Policy number RM 02 revealed in part the following: Any facility staff member who witnesses, discovers, or has direct knowledge of an incident must complete an Incident Report before the end of the shift/work day....If the incident involves a patient, staff must chart relevant information in the patient's medical record. When documenting incidents in the medical records, staff will chart precisely what happened without making reference to an "error" or that an Incident Report was completed.

Review of an incident report and subsequent documentation by the MHT on 04/03/17 who witnessed the event revealed that Patient #11 was found in Patient #15's bathroom at 3:15 p.m. after Patient #15 was observed to have exited her bathroom.

Review of the medical records of Patient #11 and Patient #15 revealed no documented evidence that the above incident was documented in either medical record.

In an interview on 05/17/17 at 9:20 a.m., S2DON indicated Patient #11 was on hypersexual precautions (defined by S2DON as a heightened awareness of hypersexual activity) from admit to discharge except on 03/29/17. He confirmed there was no documentation in Patient #11's and patient #15's medical records of the event that occurred on 04/03/17.

25065

Based on record reviews and interview, the hospital failed to ensure discharge summaries were documented by the physician or qualified practitioner with admitting privileges or delegated to other qualified health care personnel such as NPs or physician assistants as evidenced by having the discharge summaries dictated by a LPN for 4 (#10, #11, #12, #15) of 4 patient records reviewed for discharge summaries from a total sample of 16 patients.
Findings:

Review of the Medical Staff By-laws, Rules & Regulations provided by S1ADM as current, revealed in part the following: Medical Records and Orders: A discharge summary shall be written or dictated on all medical records of all patients within thirty (30) days of discharge....All summaries shall be signed by the attending medical staff member. If AHP signs the Discharge Summary, the Supervising Attending Medical Staff Member is required to cosign. Dictation responsibilities for the discharge summary may be delegated to qualified staff - APRN, RN or LPN, but completion of the medical record is ultimately the responsibility of the attending practitioner.

Review of the Hospital's policy titled, Discharge Summary, Policy number RC-011 revealed in part the following: 1.0 The attending physician/Licensed Independent Practitioner (LIP) is responsible for the completion of the Discharge Summary. There was no documented evidence of any provisions in the policy for delegation of the discharge summary to the RN or LPN.


Patient #10
Review of Patient #10's discharge summary revealed it was dictated by S22LPN on 12/24/16 for S23NP.

Patient #11
Review of Patient #11's discharge summary revealed it was dictated by S22LPN on 04/18/17 for S5PNP.

Patient #12
Review of Patient #12's discharge summary revealed it was dictated by S22LPN on 02/27/17 for S23NP.

Patient #15
Review of patient #15's discharge summary revealed it was dictated by S22LPN on 04/10/17 for S5PNP.

In an interview on 05/17/17 at 11:10 a.m., S1Adm was informed of the contradiction between the hospital's policy for discharge summaries and the Medical Staff By-laws and that the discharge summaries were being dictated by an LPN which was not in accordance with the federal regulations. She confirmed that the LPN had been dictating the discharge summaries.

Based on record review and interview, the hospital failed to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed (review for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications).
Findings:

Review of the Louisiana Administrative Code, Title 46 Professional and Occupational Standards, Part LIII Pharmacist, Chapter 15 Hospital Pharmacy, Section: 1511: Prescription Drug Orders, Item A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial dose of medication, except in cases of emergency.

In an interview on 05/16/17 at 2:24 p.m. S15Pharm said the pharmacy was open Monday through Friday from 8:00 a.m. until 9:00 p.m. and from 9:00 a.m. until 3:00 p.m. on the weekends. S15Pharm said the pharmacy did not do first dose reviews on medications ordered after scheduled pharmacy hours. S15Pharm verified the medications would be reviewed the next day as a retrospective review after the first dose had already been given. She said the pharmacy realized this and were trying to work on a solution.

Based on record reviews and interview, the hospital failed to ensure a qualified full-time, part-time, or consulting radiologist was appointed to supervise the ionizing radiology services as evidenced by failing to have documented evidence that S21MD was granted privileges to supervise the radiology services provided at the hospital.
Findings:

Review of S21MD's credentialing file revealed his appointment was from 07/24/13 to 07/14/15. Further review revealed a request for consulting privileges was signed by S21MD and approved by the Medical Director, Medical Executive Committee, and the Board of Trustees on 03/02/15. There was no documented evidence that S21MD was granted privileges to supervise the radiology services provided at the hospital.

Review of the Governing Board Meeting minutes dated 09/27/16 revealed S21MD was granted clinical privileges. There was no documented evidence in the meeting minutes that S21MD was appointed as Director of Radiology.

In an interview on 05/17/17 at 9:05 a.m., S20HIM confirmed that S21MD was not appointed as Director of Radiology.

Based on UR (Utilization Review) Committee policy review and interview, the hospital failed to ensure at least two of the members of the UR Committee were doctors of medicine or osteopathy.
Findings:

Review of the hospital policy titled," Utilization Review Committee", Policy Number: 10, effective date: 5/20/15, revealed in part: Procedures: 2. The UR Committee shall be comprised of at least 2 physicians who do not have a direct financial interest in the hospital.

In an interview on 05/17/17 at 9:50 a.m. with S13UR, she confirmed S11MedDir was the only physician currently on the hospital's UR Committee. She also confirmed S11MedDir, who is a Psychiatrist, was actively involved in treatment of the hospital's patients.

Based on record review and staff interview, the hospital failed to ensure the infection control officer assured the system for controlling infections and communicable diseases of patients and personnel was implemented according to hospital policy and acceptable standards of infection control practices as evidenced by failure to ensure all hospital staff were free of TB in a communicable state. This deficient practice was evidenced by 2 (S11MedDir, S21MD) of 7 (S8Psych, S11MedDir, S19MD, S21MD, S23NP, S24NP, S25MD) credentialed/privileged staff files and 1 (S6RN) of 9 (S6RN, S7MHT, S10Housekeeping, S16LPN, S17RN, S18LPN, S20HIM, S26CTRS, S27MHT) personnel files reviewed with no documented evidence of current TB screening.
Findings:

Review of the Louisiana Public Health Sanitary Code, Title 51, Part II. The Control of Diseases - Health Examinations for Employees, Volunteers and Patients at Certain Medical Facilities, Section 503, Mandatory Tuberculosis Testing, revealed in part: All persons prior to or at the time of employment, involved in providing direct patient care, shall be free of tuberculosis in a communicable state as evidenced by either 1. A negative purified protein derivative skin test for TB, 2. A normal chest x-ray, if the skin or a blood assay for TB is positive, or 3. A statement from a licensed physician certifying that the individual is non-infectious if the x-ray is other than normal....C. Any employee or volunteer at any medical or 24-hour residential facility requiring licensing by the Department of Health and Hospitals....in order to remain employed or continue work as a volunteer shall be rescreened annually.


Review of the hospital policy titled, Tuberculosis Guidelines, policy number IC-09 revealed all applicants for employment shall be screened for presence of infection with M. Tuberculosis using the PPD skin test. The policy revealed baseline testing for TB will be performed upon hire and following potential exposure for all healthcare workers. The need for annual screening will be determined at the time of the annual risk assessment. Further review of the policy revealed in the case of previous positive PPD test, a negative chest x-ray report within the past 5 years will be substituted and a TB screening questionnaire will be filled out to screen for symptomatology.

S11MedDir
Review of the credentialing file for S11MedDir revealed an application for appointment dated 05/19/16 and an initial appointment to the hospital medical staff dated 06/06/16. Review of the credentialing file revealed the only documented evidence of a TB screening was a PPD test dated 08/17/15.

In an interview on 05/17/17 at 11:00 A.M., S20HIM confirmed she was responsible for credentialing files for the medical staff. After reviewing the credentialing file for S11MedDir, she confirmed there was no documentation of a TB screening for S11MedDir since 08/17/15. S10HIM confirmed she was aware the TB screening was not up to date and stated she had been unable to obtain a TB screening for S11MedDir.


S21MD
Review of S21MD's credentialing file revealed no documented evidence of a current TB test result.

In an interview on 05/17/17 at 9:05 a.m., S20HIM indicated the hospital requires annual TB testing for physicians and allied health professionals. She confirmed that S21MD did not have a current TB test result.


S6RN
Review of the personnel record for S6RN revealed a date of hire of 02/15/10. Review of the record revealed S6RN had a positive TB test in the past. Review of the record revealed a chest x-ray dated 02/03/16 and a screening of symptoms dated 04/26/16. There was no documented evidence of a current screening of symptoms for S6RN.

In an interview on 05/17/17 at 2:15 p.m., S12HR reviewed the personnel record for S6RN and confirmed there was no documented evidence of a current TB screening for S6RN. S12HR confirmed the last documented TB screening for 04/26/16.








25065

Based on record reviews and interview, the hospital failed to ensure that the patient and family members were counseled to prepare them for post-hospital care that included a list of all medications the patient should be taking after discharge with a clear indication of changes from the patient's pre-admission medications as evidenced by failure to provide a clear indication of the changes in the discharge medications from the pre-admission medications for 3 (#11, #12, #15) of 3 patient records reviewed for implementation of the discharge plan from a total of 16 sampled patients.
Findings:

Review of the policy titled "Discharge Planning", presented as a current policy by S2DON, revealed that the RN, therapist, or discharge planner documents the final discharge plans on the Discharge Instruction Form that includes medications to be taken post-discharge. There was no documented evidence that the policy addressed that there needed to be a clear indication of changes from the patient's pre-admission medications.

Patient #11
Review of Patient #11's discharge medication list and his home medication list documented on the day of his admission revealed the discharge medication list did not indicate the change in dose of Depakote ER from 500 mg po every morning (pre-admission) to 750 mg po by mouth every morning at discharge.

Patient #12
Review of Patient #12's discharge medication list and her home medication list revealed the discharge medication list did not indicate the change in dose of Seroquel from 100 mg po at bedtime (pre-admission) to 300 mg po at bedtime at discharge.

Patient #15
Review of Patient #15's discharge medication list and her home medication list revealed the discharge medication list did not indicate the change in dose of Lexapro from 10 mg po q day (pre-admission) to 20 mg po every morning at discharge.

In an interview on 05/17/17 at 10:10 a.m., S2DON indicated the back of the discharge instruction sheet has a place to document the medications the patient is no longer supposed to take from the medications taken pre-admission. He confirmed there is no documentation of changes in dose of medications from what was taken pre-admission from what is being ordered at discharge.

Based on record review and staff interview, the Hospital failed to ensure that hospital policies were adhered to that incorporated the OPO (Organ Procurement Organization) and the hospital's definition of Clinical Triggers and Imminent Death and Timely Notification in order to identify potential donors as agreed upon by the hospital's OPO contract and in accordance with the Louisiana Uniform Anatomical Gift Act. Findings:


A review of the hospital's OPO signed contract, dated 01/21/10, provided by S1Adm, as the current contract, revealed in part: By entering into this agreement, the Donor Hospital verifies that it will meet all obligations set forth in CMS 42CFR part 482.45. The contract revealed the Donor Hospital would be in compliance with the Louisiana Uniform Anatomical Gift Act. The contract revealed timely referral was defined as within 1 hour of when a Donor Hospital identifies a patient that meets the Donor Hospital's definition of "Clinical Triggers" for organ donation. The contract also revealed Imminent Death is defined as a Donor Hospital patient who meets the criteria for medically established "Clinical Triggers" for organ donor evaluation.

A review of the hospital policy titled, "Organ Donation", provided by S14PI as the most current, revealed the hospital had chosen to participate in the eye, organ, and tissue program as required. Review of the procedure revealed the following: Medical suitability for donation is to be determined on every death with the assistance of local donor programs, documentation of organ donation intent and if appropriate family involvement. Call the donor program as soon as possible after an individual has died.
Review of the policy revealed no documented evidence of the hospital's definition of clinical triggers, imminent death, or timely notification. There was no provision in the policy for notification to the OPO within 1 hour of patient death as directed in the written agreement with the OPO.

In an interview on 05/17/17 at 3:40 p.m., S14PI confirmed the hospital's policy for organ donation did not define clinical triggers, imminent death, or timely notification as outlined in the contract with LOPA.

30984

Based on record review and interview, the hospital failed to maintain documented evidence of training of nursing personnel assigned to perform specific respiratory procedures. This deficient practice was evidenced by failure of the hospital to maintain documented evidence of annual respiratory service training for 3 of 3 (S6RN, S17RN, S18LPN) nursing personnel records reviewed.
Findings:

Review of the personnel record for S6RN revealed a date of hire of 02/15/10. Review of the record revealed no documented evidence of annual respiratory service training since 07/15/15.

In an interview on 05/17/17 at 1:45 p.m., S12HR confirmed there was no annual respiratory service training provided since 2015.


Review of S17RN's personnel record revealed no documented evidence of annual respiratory service training since 07/15/15.

Review of S18LPN's personnel record revealed no documented evidence of annual respiratory service training since 06/24/14.

In an interview on 05/17/17 at 1:27 p.m. with S14PI, he confirmed the hospital's nursing staff performed all of hospital's respiratory care services. S14PI indicated respiratory services training was conducted upon hire and annually. S14PI confirmed documentation of nursing staff respiratory service training should have been maintained in the nursing staff personnel files.

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of 482.13 (Patient Rights) and 482.23 (Nursing Services) as evidenced by:

1) Failing to meet the requirements of the Condition of Participation for Patient Rights as evidenced by
1) failing to have a system in place to ensure the safety of patients admitted with homicidal or suicidal ideations before a suicide risk assessment had been completed. This deficient practice was evidenced by assigning an observation level of every 15 minutes on admission before an assessment by a RN or psychiatrist had been completed to determine if a higher level of observation was necessary for 10 (#1, #2, #3, #4, #6, #7, #8, #9, #13, #16) of 16 patients sampled. The hospital also failed to report a score of high risk on a suicide or homicide assessment by the LPC to the psychiatrist as per policy for 7 (#1, #2, #3, #7, #8, #9, #16) of 16 patients sampled. (see findings tag A-0144).

2) Failing to meet the requirements of the Condition of Participation for Nursing services as evidenced by:

1) The RN failed to report to the physician for possible increased supervision when a patient expressed suicidal thoughts for 1 (#16) of 12 (#1 - #9, #11, #15, #16) patient records reviewed for assessment for increased supervision from a total sample of 16 patients. Patient #16 attempted suicide 9 hours after expressing suicidal thoughts by wrapping scrub pants around her neck and hanging on the door until the pants broke loose (see findings tag A-0395); and

2) The RN failing to obtain specific orders from a Physician or Licensed Independent Practitioner before completing an admission order sheet for 1 (#R3) of 1 random patient sampled for the process of obtaining admission orders. (see findings tag A-0395).