r PRINTED: 06/26/201 FORM APPROVEI 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 0411112014 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG A 000 INITIAL COMMENTS A000 A full certification survey was conducted due to the loSS of deemed Status 04/07/14 through 04/11/14. and complaints LA0003801 5/14YHO3801 5, LA00038010/14YH038010, LA00037982J1 4YH037982, LA00038127/14PH038127 A083 482.12(e) CONTRACTED SERVICES A083 PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) P (XSI COMPLETIDN DATE The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the I hospital to Comply with all applicable conditions of participation and standards for the contracted services. This STANDARD is not met as evidenced by: Based on record reviews and interviews, the hospital failed to ensure Radiology Services were provided according to the contracted agreement for 2 (#32, #35) of 2 patients reviewed for X-ray services as evidenced by: I) a patient (#32) who had injured his right arm (04/0714 at 3:00 p.m.) and did not receive an X-ray until 6:50 p.m., then was transferred (at 9:30pm) and examined/treated at Hospital A’s Emergency Department (local acute care) for a fractured wrist; II) a patient (#35) sustained a head injury and did not receive a X-ray that had been ordered STAT (now) for 4 hours and 45 minutes. Findings: Review of the contract agreement with Radiology LABORATORY DIRECTORS OR PROVIDER/SUPPLIER REPRESENTATIvES SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction Is requisite to continued program participation. FORM cMS-2567(O299) Previous versions Obsolete Event lD:v3D211 FaciCty ID: H00001 728 If continuation sheet Page 1 of 108 PRINTED: 06/26/201 FORM APPROVE 0MB NO. 0938-039’ CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 194020 B. WING 0411112014 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTW000 HOSPITAL (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A083 Continued From page 1 ContractA revealed it was dated 08/01/2011 and was reviewed by Administrative personnel again on 10/22/2013. Further review of Radiology Contract A revealed STAT (now) X-rays would be completed within 3 hours, ASAP (as soon as possible) x-rays would be done “as soon as the schedule” permitted; however, there failed to be a designated time frame for “routine” x-rays. ID PREFIX TAG PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5I COMPLETION DATE A083 I) A patient (#32) who had injured his right arm, 04/07/14 at 3:00pm, and did not receive an X-ray until 6:50pm, and was examined and treated at Hospital As Emergency Department (local acute care) for a fractured wrist. Review of patient #32’s medical record revealed the following documentation on ‘Interdisciplinary Notes”, dated 04/07/2014: 3:00pm Patient #32 on floor of room screaming...states ‘my arm got slammed in the door’; patient #32 holding his right forearm/wrist area, edema noted, bruising noted at right lowerforearm, arm immobilized on pillow for support; 3:1 5pm S58 psychiatrist notified, and X-ray ordered; 6:50pm X-ray performed...7:45pm S58 psychiatrist notified of X-ray results and orders to transfer patient to Hospital A obtained; 9:30pm patient #32 transported to Hospital A for treatment. Review of Physician’s Orders, dated 04/07/14, 3:10pm, revealed “X-Ray(R) [right] Forearm today”..04/07/14, 7:45pm, “Transfer” to Hospital A”for evaluation of’ right arm. Review of Radiology report from Radiology Contract A revealed the “Findings” indicated “Impacted buckle type deformity distal radius about wrist” and the “Impression” was “Distal radial fracture”. Continued review of the report FORM CM5-2567(02-99) Previous versions Obsolete Event ID:V3D2II Facility ID: H00001728 If continuation sheet Page 2 of 10€ PRINTED: 06/26/201 FORM APPROVEF 0MB NO. 0938-039: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 194020 C 04/1112014 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 083 Continued From page 2 from Radiology Contract A revealed the date of the report was 04/07/14 however there failed to be a time documented. PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XSI COMPLETION DATE A 083 II) A patient (#35) sustained a head injury and did not receive a X-ray ordered STAT (now) for 4 hours and 45 minutes. Review of the medical record for Patient #35 revealed She was a 59 year old female admitted on 2/12/14 with diagnosis which included Scizoaffective Disorder. Review of a Progress Note dated 2/18/14 at 4:00 p.m. revealed the patient fell on the floor and hit her head. Review of a Physician’s Orders sheet for Patient #35 dated 2/18/14 at 5:00 p.m. revealed an order in part: X ray of the head STAT (now). Review of the X ray report revealed for Patient #35 revealed an x ray had been taken on 2)18/14 but no time was on the report. Review of the observation sheet for Patient #35 dated 2/18/14 revealed “x ray” was written at 9:45 p.m. In an interview on 4/10/14 at 4:47 p.m. with S2DON, she verified 4 hours and 45 minutes was too long for Patient #35 to obtain a STAT X ray after a head injury. A084 482.12(e)(1) CONTRACTED SERVICES A084 The governing body must ensure that the services performed under a contract are provided in a safe and effective manner FORM CMS-2567(02-99) Previous Versions Obsclele Event ID:VDD211 Facility ID: H00001728 If continuation sheet Page 3 of 1 0 PRINTED: 06/26/201 FORMAPPROVEI 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER’SUPPLIER’CLIA IDENTIFICATION NUMBER: 194020 A. BUILDING C 04111/2014 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 084 Continued From page 3 This STANDARD is not met as evidenced by: Based on record reviews and interview, the governing body failed to ensure all services provided under contract were provided in a safe and effective manner as evidenced by: 1) failing to obtain radiology testing until 4 hours and 45 minutes after a STAT (now) X-ray had been ordered on a patient (#35) who sustained a head injury; and 2) failing to ensure the contracted radiology service (Radiology Contract A) performed the ordered testing as indicated by agreement. Findings: PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG COMPLETION DATE A 084 1) Failing to obtain radiology testing until 4 hours and 45 minutes after a STAT X-ray had been ordered on a patient who sustained a head injury. Review of the medical record for Patient #35 revealed she was a 59 year old female admitted on 2/12/14 with diagnosis which included Scizoaffective Disorder. Review of a Progress Note dated 2/18/14 at 4:00 p.m. revealed the patient fell on the floor and hit her head. Review of a Physician’s Orders sheet for Patient #35 dated 2/18/14 at 5:00 p.m. revealed an order in part: X ray of the head STAT. Review of the X ray report revealed for Patient #35 revealed an x ray had been taken on 2/18/14 but no time was on the report. Review of the observation sheet for Patient #35 dated 2/18/14 revealed “x ray” was written at 9:45 p.m. In an interview on 4/10/14 at 4:47 p.m. with S2DON, she Verified 4 hours and 45 minutes was FORM cMs-2567(02-9g) Previous Versions Obsolete Event ID:V3D211 Facility ID: H0000I72B If Conlinuation sheet Page 4 of 10 PRINTED: 06/26/201’ FORM APPROVE[ 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PR0vIDERI5UPPLIER/cLIA IDENTIFICATION NUMBER: 194020 (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A BUILDING C 0411112014 B. WING NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HOSPITAL 1006 HIGHLAND AVENUE SHREVEPORT, LA 71106 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MU5T BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULO BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG A 084 Continued From page 4 too long for Patient #35 to obtain a STAT X ray after a head injury. (X5} COMPLETION DATE A084 2) Failing to ensure the contracted radiology service (Radiology Contract A) performed the ordered testing as indicated by agreement. Review of the Radiology Contract A agreement revealed it was dated 08/01/2011 and was reviewed by Administrative personnel again on 10/22/2013. Further review of Radiology Contract1 A revealed STAT (now) x-rays would be completed within 3 hours, ASAP (as soon as possible) x-rays would be done “as soon as the schedule” permitted; however, there failed I be a designated time frame for “routine” x-rays. A115 482.13 PATIENT RIGHTS A115 A hospital must protect and promote each patient’s rights. This CONDITION is not met as evidenced by. Based upon observations, record reviews, policy I and procedure reviews, and staff and patient interviews, the hospital failed to meet the Condition of Participation for Patient Rights. This was evidenced by the Hospital’s failure to: I) Ensure patient care was provided in a safe selling relative to: 1) allowing patients on the Adolescent Open Unit to sleep in Rooms #244 and #246 when they were short of beds on the unit. These rooms, including the bathrooms, had ceiling tiles present that could allow patients to escape/elope or harm themselves, i.e. ligature hazard; 2) having crank beds and side rails available on the Adult Psychiatric Unit which posed a ligature FORM cMs-2567(02-99) Previous versions Obsolete Event ID: vaD2ll Facility ID: H00001728 If continuation sheet Page 5cr 101 AF U PRINTED: 06/26/201 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PRO VIDER/SUPPLIECLIA IDENTIFICATION NUMBER: 194020 FORM APPROVE[ 0MB NO. 0938-039 (X2) MULTIPLE CONSTRUCTION C 0411112014 SWING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A115 Continued From page 5 hazard; 3) inveStigate the causative faCtors of patient elopements and ensure adequate supervision of patients to prevent patient elopements for 5 of 5 (#16, #17, #26, #30, #33) Sampled patients reviewed for elopement; 4) transfer a patient to a local emergency room for evaluation and treatment after an attack by another patient for 7 hours and 2 minutes after the Physician’s Order had been written due to lack of Staffing for 1 (#5) of 3 (#5, #32, #35) patients reviewed for response to injury, 5) have a policy and procedure in place for crank beds and side rails that were available on the Adult Psychiatric Unit which posed a ligature hazard (A144); II) Ensure each patient’s rights were protected related to patient #18 being denied the right to contact the Mental Health Advocacy Services (A129); A 129 482.13(b) PATIENT RIGHTS: EXERCISE OF RIGHTS PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG 1X5) COMPLETION DATE A115 A 129 Patient Rights: Exercise of Rights This STANDARD is not met as evidenced by: Based upon record reviews and interviews the hospital failed to ensure each patient’s rights were protected as evidenced by a patient (#18) being denied the right to contact the Mental Health Advocacy Service. Findings Review of Patient #18’s medical record revealed a physician’s order for the patient to be allowed to use the telephone to contact the Mental Health Advocacy Service (MHAS). Continued review of the physician’s orders, dated 04/08/1 4, revealed FORM CM5-2567(D2-99) Previous versions Obsolete Event ID:v3D2ll Facility ID: H00001728 If Continuation sheet Page 6 of 10E PRINTED: 06/26/201’ FDRM APPRDVE[ 0MB NO. 0938-039’ DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION C 0411112014 B. WING NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A129 Continued From page 6 S32 Psychiatrist documented another order to allow Patient #18 to use the telephone to contact the MHAS. ID PREFIX TAG PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) IXS) COMPLETION DATE A129 Interview, 04/07/14 at 10:40am, with Patient #18 revealed she was admitted on 04/01/14 for Homicidal Ideation (HI). Patient #18 stated she had a knife in her bedroom to protect herself from her stepfather after being sexually molested by him. Interview, 04/09/14 at 9:30am, with S32 Psychiatrist confirmed he had documented orders, on 2 separate dates, for Patient #18 to use the telephone to contact MHAS. Patient #18 was allowed to contact MHAS on 04/10/14 after surveyors with the State of Louisiana Department of Health and Hospitals--Health Standards Section interceded on Patient #18 behalf. Interview, 04/09/14 at 10:40am, with S2 Director of Nursing (DON), revealed patients could use the telephone to call the MHAS, all they had to do “was ask to use the phone”. Continued interview with Patient #18 confirmed she had asked 2 different staff members (she identified S29 Licensed Practical Nurse as one of the staff members, the other she could not recall), if she could use the telephone to call the MHAS. A 144 482.1 3(c)(2) PATIENT RIGHTS: CARE IN SAFE S EVil N G A 144 The patient has the right to receive care in a safe setting. FORM CMS-2567(02-99) PrevIous Versions Obsolete Event ID:V3D211 Facility ID: H00001728 If continuation sheet Page 7 of bE PRINTED: 06/26/201 FORM APPROVE[ 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PRO VIDER’SUPPLIECLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION C 0411112014 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTW000 HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 144 Continued From page 7 This STANDARD is not met as evidenced by: Based upon observations, record reviews and interviews, the hospital failed to ensure patient rooms and equipment were provided in a safe setting. This was evidenced by: I) the use of rooms (Room #s 244 and 246) to sleep patients on the Adolescent Open Unit when they were short of beds on the unit. The rooms had ceiling tiles present in these rooms and in the bathrooms that could allow patients to escape or harm themselves, i.e. ligature hazard; II) failing to transfer a patient to a local emergency room for evaluation and treatment after an attack by another patient for 7 hours and 2 minutes after the Physician’s Order had been written; delay of transporting a patient with a wrist/arm fracture; and failing to transport a patient who sustained a head injury for treatment due to lack of staffing for 3(#5, #32, #35) of 3 (#5, #32, #35) patients reviewed for response to injury; Ill) failing to investigate the causative factors of patient elopements and ensure adequate supervision of patients to prevent patient elopements for 5 of 5 (#16, #17, #26, #30, #33) sampled patients reviewed for elopement; IV) failing to implement a safety plan for the use of patient beds that had cranks and side rails; shower room #2 on the Youth Enhanced Unit had ceiling tiles (non-monolithic ceilings) and fluorescent light bulbs that were easily accessible; also found in the ceiling was a 19 inch rigid wire rod, telephone cords, and pipes large enough to provide a ligature risk. Findings: PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (1<5) COMPLETION DATE A 144 I) Observations conducted, 04/08/14 5:25am through 5:45am, (on the Female Adolescent Unit), revealed 5 patients (#s 2,3, 19, 20, 21), FORM cM5-2567(02-99) Previous Versions Obsolete Event ID:v3D2ll Facility ID: H0000172B If Continuation sheet Page 8 of 10 PRINTED: 06/26/201 FORM APPROVEI 0MB NO. 0938-039 I(X3) DATE SURVEY DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION I (Xl) PROVIDER’SUPPLIER’CLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION COMPLETED C 04/11/2014 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG I I A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 144 Continued From page 8 were sleeping in the dayroom on roll-away beds. There were no males noted to be sleeping in the dayroom on the Adolescent Male Unit. Observation made of rooms 244 and 246 revealed these 2 rooms were not being Utilized on this morning’s observations as “sleeping rooms”. However, when rooms 244 and 246 were Utilized for patients, the hospital did not take steps to ensure patient safety related to the non-monolithic ceilings located in the rooms and bathrooms. Any patient who utilized room 244 or 246 could remove the ceiling tiles and either make attempts at escape, injury or hang themselves. PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X51 COMPLETION DATE A 144 Interview, on 4/8/14 at 2:30pm with 622 RN House Supervisor, revealed he stated the Adolescent unit was a 42 bed unit, but they adjusted the rooms to sleep 4 more people on the unit. S22 RN House Supervisor stated the chairs and desks were removed from 2 rooms (identified as Room #s 244, 246 that were used as Consultation offices) and put roll away beds in the rooms for the patients to sleep. II) Failing to transfer a patient to a local emergency room for evaluation and treatment after an attack by another patient for 7 hours and 2 minutes after the Physician’s Order had been written due to lack of staffing. Review of the medical record for Patient #5 revealed she was a 57 year old female admitted to the hospital on 2/1 9/14 with diagnosis which included Paranoid Schizophrenia. Review of the medical record for Patient #4 revealed he was a 23 year old male admitted to the hospital on 2/20/14 with diagnosis which FORM CM5-2567(02-99) Previous Versions Obsolete Event ID:v3D2l1 Facility ID: H00001728 If continuation sheet Page 9of 1O PRINTED: 06/26/201 FORM APPROVE 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 194020 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG 0411112014 SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 144 Continued From pageD included SchizoaffectiVe Disorder. Further review revealed Patient #4 had a PEC (Physician Emergency Certificate) dated 2/18/14 which listed him as gravely disabled and a CEC (Coroner Emergency Certificate) dated 2/19/14 which listed him as acutely psychotic. Review of the Hospital hand off communication sheet for Patient #4 dated 2/20/14 at 10:30 a.m. revealed his reason for admission was, “Danger to self and others, paranoid” and his risk factors included violence, “hit another patient.” PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) CDMPLETI0 DATE A 144 A review of the medical record for Patient #5 revealed an interdisciplinary note dated 2/23/14 at 11:50 am. Review of the note revealed in part: Patient #5 was attacked by a male peer while she was standing at nurse’s station speaking with nurse. A male peer walked up behind her, placed his hands on her head in a crushing like motion. He then put his arm with elbow around her neck in a head back type motion. He released her neck and shoved her to the floor and she was kicked by him 2-3 times. Patient was on the floor, on her right side and was kicked on her left side lower rib and hip area. Staff assisted Patient to shelter in the ladies shower room. Patient was Crying and emotionally shaken. Her body was examined for injury. No broken skin, bleeding or bruising noted. Patient did complain of pain to her right hip area. She was able to walk and move all extremities well. She stated, “ He beat me and I want the police.” Shreveport Police notified by nursing supervisors. Officer responded and collected information. Ultimately a summons was issued to the male peer and he was charged with simple battery. S43MD notified regarding patient being beat up. S43MD called Hospital A and spoke with ER MD. Patient to be taken there for evaluation.” FORM CMS-2567(02-99) Previous versions Obsolete Event ID:v3D21l Facility ID: H0000172B If continuation sheet Page 10 of 10 PRINTED: 06/26/201 FORM APPROVEI 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SER\ICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A BUILDING C 194020 B. WING NAME OF PROVIDER OR SUPPLIER STREETADDRESS. CITY. STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTW000 HOSPITAL SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY CR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG A144 Continued From page 10 Review of the medical record for Patient #5 revealed a Physicians Order dated 2/23/14 at 12:45 p.m. which read in part: “Send pt(patient) to Hospital A ER (Emergency Room) for evaluation. Pt was physically assaulted by a male peer? choked/ hit and thrown to the floor, kicked repeatedly when shoved to the floor.” I 04/1112014 PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A144 Review of the Interdisciplinary Notes for Patient # 5 revealed an entry on 2123/14 at 7:47 p.m. which stated in part: ‘To Hospital A ER via ambulance transport for physical evaluation. Patient #5 is complaining of R (right) side pain between breast and hip. She rates 10/10 at this time.” Further review of the Notes and Physician’s Orders revealed no documentation that the Physician had been notified that Patient #5 was not going to be sent to the ER for over 7 hours. In an interview on 4/8/14 at 2:30 p.m. with S22RN, he said he was a nursing supervisor on the weekends at the hospital. 522RN said on 2/23/14 he wanted 5 staff for the Adult Enhanced Unit (AEU) but Could only find 4 staff to work. S22RN said the AEU was 1 person short on staffing because the unit had 2 patients that were 1:1 observations. S22RN said on 2/23/14 he remembered when the ADU called a Code Green, he went to the unit and Patient #4 was already in the dining room with staff. 522RN said he talked to Patient #5 and she was complaining of pain to her abdomen where she had been kicked by Patient #4. He said the physician ordered Patient #5 to go to the Emergency Room to be examined at 12:45 p.m., but another patient from another unit was medically unstable and had to be sent to the hospital. S22RN said at the time if he would have sent 2 staff members to the hospital with patients the hospital would have been too short FORM cM52567(O2-99) Previous versions Obsolete Event ID:v3D2ll Facility ID: H00001T2R If continuation sheet Page 11 of 101 PRINTED: 06/26/201 FORM APPROVEr 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 194020 A BUILDING C 04/1112014 B. WING NAME OF PROVIDER OR SUPPLIER STREETADDRESS. CITY. STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTW000 HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A144 Continued From page 11 staffed. S22RN said he was not aware if the physician was notified of the delay in treatment. After review of the medical record for Patient #5, he verified there was no documentation of physician notification for the delay in sending Patient #5 to the hospital until 7:47 p.m. (7 Hours and 2 minutes after the Physician s Order). S22RN also verified after Patient #4 was made a 1:1, there were 3 patients for 3 staff members on 1:1 and 11 other patients on theAEU for I staff member. S22RN said the unit was definitely short staffed on 2/23/1 4. S22RN also said the hospital was short at least 4 staff members on various units for the 7-3 shift on 2/23/14. PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG {X5) COMPLETION DATE A144 Review of the Daily Staffing Worksheet for 7am-3pm on 2/23/14 revealed the beginning census on theAEU was 13 and the ending census was 14. The 1:1 patients were listed as 2 females. “3 + 2” Was written above the staff’ s names. In an interview on 4/8/14 at 2:30 p.m. with. S22RN he said he filled out the staffing sheets for the units on 2/23/14. He said the “3” above the staff’ a names was what staff he had available and the “+ 2’ was how many more staff he needed for the shift. He said he needed 5 people for the shift on the AEU, but had 4 available. He also verified by the end of the shift, 3 of the 14 patients were 1:1 observation patients with only 4 staff members. He said being 1:1 required the staff member to be within arm’s length of the patients at all times. In an interview on 4/9/14 at 1:16p.m. with S24RN, she said she worked on the AEU and was in the nurses’ station when the altercation happened between Patient #4 and Patient #5 on 2/23/14. S24RN said the doctor was not notified until 25-30 minutes after the incident because she FORM CM52567(02-99) Previous versions Obsolete Event ID:v3D21I Facility ID: H00001728 If Continuation sheet Page 12 of 10 PRINTED: 06/26/2O1 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PRO VIDER’SUPPLIER’CLIA IDENTIFICATION NUMBER: FORM APPROVEE 0MB NO. 0938-039 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 194020 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG 0411112014 RELAfli 06 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORrvtATION) A 144 Continued From page 12 was examining Patient #5 and Calming her down. S24RN said she was the first one to call the doctor and he ordered Patient #4 to be on a 1:1 observation, made some medication changes for Patient #4 and ordered Patient #5 to be sent to the Emergency Department for evaluation. 524RN said she called the nursing supervisor for more help during the shift, but he could not get anybody. S24RN also Said She notified the supervisor about Patient #4 needing to go to the ED, but She did not go until about 8:00 at night. S24RN said she called back a couple of times to get Patient #4 sent to the ED, but she assumed the patient did not go until later because of staffing. S24RN Said none of the phone calls were documented. S24RN was unable to locate documentation that Patient #5 was reassessed by a nurse after the initial assessment at 11:50 a.m. until she was transferred to the hospital at 7:47 PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS’REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A 144 p.m. In an interview on 4/9/14 2:05 p.m. with S9RN, she said she was working on 2/23/14 on the Adult Enhanced Unit (AEU). S9RN said the two 1:1 patients she and S25MHT had were not actually being watched 1:1 because of staffing. S9RN said Patient #5 did not go to the hospital for several hours after the attack because the supervisor (S22RN) and S24RN told her there was not enough staff to bring her to the ED. S9RN said to her knowledge the physician was never notified about Patient #5 not going to the ED immediately. S9RN said she knows the AEU was short staffed on 2/23/1 4. S9RN said the Adult Enhanced Unit is short staffed a lot because of the high acuity of the patients. Review of the hospital Document titled Staffing Ratios by Unit and Census Level (staffing grid) FORM cMs-2567(02-99) Previous versions Obsolete Event ID:v3D2ll Facilily ID: H00001728 If Continuation sheet Page 13 of ICE PRINTED: 06/26/201 FORM APPROVEr 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION C 04/1112014 B. WING I NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A144 Continued From page 13 revealed in part: Adult Enhanced Unit (AEU): 14 bed unit. 3 staff on days (7:00 am. 3:00 p.m.) for 5-12 patients. Further review revealed no Staffing grid for a census over 12 patients. ID PREFIX TAG PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XC) COMPLETION DATE P.144 - In an interview on 4/10/14 at 2:50 p.m. with S2DON, she Verified the staffing needed to be increased on the unit for 2/23/14 and the staffing for the 7:00 am. to 3:00 p.m. did not meet the hospital staffing grid requirements. S2DON Said the 2 of 4 staff assigned to 1:1 patients should have not been included in the grid. S2DON said for 12 patients other than the 1:1 patients on 2123/14, the unit required 3 staff members per the staffing grid but only had 2. She said from 3:00 p.m. until 11:00 p.m., theAEU had 5 staff but 3 patients on 1:1 which still left the unit short one staff member. S2DON also Verified she could not locale a nursing or physician assessment of Patient #5 after the initial assessment at 11:50 a.m. until she was transferred to the hospital at 7:47 p.m. Review of Patient #32’s medical record revealed: ‘Interdisciplinary Notes”, dated 04/07/2014: 3:00pm Patient #32 on floor of room screaming...states ‘my arm got slammed in the door’; patient #32 holding his right forearm/wrist area, edema noted, bruising noted at right lower forearm, arm immobilized on pillow for support; 3:15pm S58 psychiatrist notified, and X-ray ordered; 6:50pm X-ray performed...7:45pm S58 psychiatrist notified of X-ray results and orders to transfer patient to Hospital A obtained; 9:30pm patient #32 transported to Hospital A for treatment. Review of the medical record for Patient #35 FORM CM5-2567(02-99) Previous versions Obsolete Event ID: V3D211 Facility ID: H0000172B If continuation sheet Page 14 of 10€ PRINTED: 06/26/201 FORM APPR0VE 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION I (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION C 04/1112014 B. WING I NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTW000 HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 144 Continued From page 14 revealed she was a 59 year old female admitted on 2/12/14 with diagnosis which included PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X51 COMPLETION DATE A 144 Scizoaffective Disorder. Review of a Progress Note dated 2/18/14 at 4:00 p.m. revealed the patient fell on the floor and hit her head. Review of a Physician’s Orders sheet for Patient #35 dated 2/18/14 at 5:00 p.m. revealed an order in part: X ray of the head STAT. Review of the X ray report revealed for Patient #35 revealed an x ray had been taken on 2/18/14 but no time was on the report. Review of the observation sheet for Patient #35 dated 2/18/14 revealed Mx ray” was written at 9:45 p.m. In an interview on 4/10/14 at 4:47 p.m. with S2DON, she verified 4 hours and 45 minutes was too long for Patient #35 to obtain a STAT X ray after a head injury. Ill) Failing to investigate the causative factors of patient elopements and ensure adequate supervision of patients to prevent patient elopements for 5 of 5 (#16. #17, #26, #30, #33) sampled patients reviewed for elopement: Review of the hospital policy titled Elopement Procedure, number TX.003, current date of 02/14, presented as current, revealed in part the following: Policy: It is the policy of [hospital] to prevent patient elopements whenever possible and to provide consistent methods of follow-up in the event that they do occur. Procedure: Elopement Precautions: All patients deemed as elopement risks should be placed on Elopement Precautions according to the severity of the risk of elopement....Clear assignment must be made FORM cMS-2567(02-99) Previous Versions Obsolete Event ID:v3D2l I Facility ID: H00001728 If Continuation sheet Page 15 of 1DI PRINTED: 06/26/201 FORM APPROVE 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER!CLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION C 04/1112014 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 144 Continued From page 15 of a staff member responsible for precautions implementation and monitoring. High-risk patients should be clearly identified to all staff and elopement precautions related in shift report on a shift by shift basis....When not involved in program activities, staff will keep the patient in common areas for easy observation and monitoring....Staff shall maintain heightened alert during times of potential chaos or confusion (i.e.: medication times, shift change times, emergency code situations, loud combative or belligerent patients Who may be serving as a diversion, etc.)... PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A 144 Review of the Incident Report for Patient #26 dated 03/20/14, revealed the patient was a 17 year old male that was agitated, busted through the double door on the Youth Enhanced Unit, kicked the stair well doors open all the way to the exit and eloped from the facility at 7:45 p.m. The incident report revealed the staff pursued the patient but were unable to catch him and the police were notified. There was no documented evidence of any further investigation into the circumstances of the elopement. In a telephone interview on 04/10/14 at 3:15 p.m., S3Performance Improvement/Risk Manager/Patient Advocate verified there was no investigation into the circumstances of the elopements by Patient #26 and stated all she did was documented on the incident reports. Patient #30 Review of the clinical record for Patient #30 revealed the patient was a 16 year old male admitted to the hospital on 02/27/14 under a PEC (Physician Emergency Certificate) for suicidal, dangerous to self, and unable to seek voluntary FORM cM5-2567(02-99) Previous versions Obsolete Event ID:v3D2ll FaCUity ID: H00001728 If continuation sheet Page 16 of 10 PRINTED: 06/26/201 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PRO VIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: FORM APPROVEL 0MB NO. 0938-039 (X2) MULTIPLE CONSTRUCTION A. BUILDING C 04/1112014 SWING 194020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BREN1WOOD HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A144 Continued From page 16 admission. The patient’s diagnosis included Mood Disorder, Impulse Control Disorder, I Attention Deficit Hyperactivity Disorder, Conduct Disorder, and Relationship Problems. The patient was also in the custody of DCFS (Department of Child and Family Services). PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A144 Review of the physician orders dated 02/27/14 revealed Suicidal, Self-Mutilation/Injury, and Elopement Precautions were ordered. Review of the Nursing Progress Note dated 03/10/14 revealed at 11:50 a.m., Patient #30 eloped from the building after he kicked the exit door of the unit open and ran down the stair well to the basement and out of the building. The Nursing Progress Notes revealed the patient returned to the hospital at 12:15 p.m. and was brought back on the unit. Upon returning to the unit, Patient #30 kicked the door open again, but returned on his own. The note revealed the patient attempted to kick the door open a third time, but was redirected and then transferred to a more secure unit. Review of the Incident Report dated 03/10/14 at 11:50 a.m. revealed Patient #30 ran down the hail breaking through the magnetic locked door and ran down the stairs and out of an open basement door. There was no documented evidence of any investigation of the incident or how the patient was able to kick open the locked doors. Review of the Nursing Progress Noted dated 03/21/14 revealed at 7:40 a.m. Patient #30 was anxious, irritated and yelling at S19RN. The patient was unable to be redirected or calmed down. S19RN documented the patient room doors were unlocked at 7:46 a.m. in an attempt to FORM CM5-2567(02-99) Previous versions Obsolete Event ID:V3D211 Facility ID: H0000l728 If continuation sheet Page 17 of 101 PRINTED: 06/26/201 FORM APPROVEE 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PRO VIDERJSUPPLIER’CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION C 04/1112014 B. WING 194020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING PROViDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG I A 144 Continued From page 17 re-establish order on the unit. At 7:50 am., S19RN documented a search of the unit was made and Patient #30 was not located in his room. The unit was searched again and Patient #30 was not located. (X5) CDMP..ETION DATE A 144 Review of the Assignment Sheet and Daily Staffing Worksheet for the Adolescent Unit on 03/21/14 revealed a census of 40 patients with 3 MHTs (Mental Health Technicians), I LPN, and 3 RNs. The assignment sheet revealed the LPN and 1 RN were assigned to the desk/Medications, leaving 3 MHTs and 1RN and IRN charge nurse to monitor 40 patients. The assignment sheet revealed 3 patients were on CVO (Constant Visual Observation). There was no designation on the assignment sheet of patients on Elopement Precautions. Review of the Hospital Abuse/Neglect Initial Report (HSS-HO-41) dated 03/21/14 revealed Patient #30 pushed through the adolescent hallway exterior door, with other peers following him. (Patient #16, #17, and #33). Patient #16 and #17 were returned by police at 10:37 a.m. Patient #30 and #33 were returned by police at 11:24 a.m. Review of the investigation of the elopement revealed the following: The adolescent male patients were going to their rooms in effort to separate the group and allow for them to deescalate due to tension among the group While the nurse and MHT were unlocking the patient rooms the male patients were gathered in the hallway and that is when 4 male patients walked to the stairwell door and were able to push it open, ran down the stairs to the ground floor, out the door and ran from the facility....On the morning of the incident, prior to the elopement, the Fire Alarm FORM CMS-2557(02•99) Previous versions Obsolete System was being Event ID:v3D2l1 Facility ID: H0000172B If continuation sheet Page 18 of 10 PRINTED: 06/26/201’ FORM APPROVE 0MB NO. 0938-039’ DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION I (Xl) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: II (X3) DATE SURVEY (X2) MULTIPLE CONSTRUCTION A. BUILDING I COMPLETED C B. WING 194020 I NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG 04111/2014 SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 144 Continued From page 18 tested. During that time the magnetic doors were released for safety reasons to allow for evacuation in case of fire. Once the testing of the alarm system is completed the magnetic doors are supposed to re-engage. However the doors did not re-engage that day as patients were able to elope through the door. The problem with the door was discovered after the elopement and repaired promptly. PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG I I (X5) COMPLETION DATE A 144 Patient #16 Review of the clinical record for Patient #16 revealed the patient was a 14 year old male admitted to the hospital on 03/18/14 under a PEC for suicidal, violent, dangerous to self and unwilling/unable to seek voluntary admission. Review of the record revealed a CEC (Coroner’s Emergency Certificate) dated 03/20/14 for dangerous to self and unable to seek voluntary admission. Review of the physician’s admission orders revealed the patient was ordered to be on Elopement and Suicidal Precautions. Further review of the record revealed Patient #16 was placed on CVO (Constant Visual Observation) on 03/20/14 due to active suicidal ideation’s. Review of the Nursing Progress Note dated 03/21/14 at 7:40 a.m. revealed the patient was anxious and irritable, and at 7:50 a.m., was unable to be found after a search of the unit was conducted. Further review of the note revealed the patient was returned to the hospital by the police at 10:50 a.m. Further review of the Assignment Sheet revealed no documented evidence that Patient #16 was on CVO. There was no designation on the assignment sheet of patients on Elopement Precautions. In an interview on 04/09/14 at 4:20 p.m., S3Performance Improvement/Risk FORM CM5-2567(02-99) Previous versions Obsolete Event ID:v3D2l1 Facility ID: H00001 728 If continuation sheet Page 19 of iCE PRINTED: 06/26/20 1 FORM APPROVEC 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 194020 B. WING NAME OF PROVIDER OR SUPPLIER 0411112014 STREET ADDRESS, CITY, STATE, ZIP CODE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 144 Continued From page 19 Manager/Patient Advocate stated she was not sure if the patients busted the door open or if the doors were not engaged. She stated the fire alarm tests were done by the hospital. PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A 144 In an interview on 04/10/14 at 9:40 am., S27RN stated on 03/21/14 she was assigned to the Youth Enhanced Unit but went to the adolescent unit after 4 patients had eloped. S27RN Stated there was an elopement the night before (on 03/20/1 4) and the magnetic doors were working as they had maintenance check the doors. S27RN stated Patient #26 stated he did not think the doors were locked and was able to push through the doors. S27RN stated the patient reported the exit from the basement was harder to open. S27RN stated Patient #26 returned to the hospital before midnight because he got cold. S27RN stated the fire drill was in the afternoon after the 4 patients had eloped. S27RN stated Patient #30 was on elopement precautions and was aware Patient #26 had eloped the night before. 527RN stated on 03/21/14 they did not have as many male MHTs as they normally have and the patients take advantage of that. When asked what was done for patients on Elopement Precautions, she stated, ‘just watch closer.” S27RN stated if the patient has made threats or attempts, they put them on CVO. In an interview on 04/10/14 at 10:35 am., S19RN verified she was the charge nurse on the adolescent unit on the 7:00 a.m. to 3:00 p.m. shift on 03/21/14 when the 4 patients eloped. S19RN stated Patient #30 was the ring leader” and told the other patients the staff were lying to them about unit restrictions that were imposed the night before. She stated Patient #30 got Patient #36 agitated and the staff were trying to remove the FORM cM5-2567(02-99) Previous Versions Obsolete Event ID: v3D2ll Facility ID: [100001728 If continuation sheet Page 20 of 101 PRINTED: 06/26/201 FORM APPROVE 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (x2) MULTIPLE CONSTRUCTION C 04/1112014 B. WING 194020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 71106 SUMr.tARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 144 Continued From page 20 other patients away from Patient #36. Si 9RN stated S38MHT unlocked the patients’ room doors and she sent the patients to their rooms to quiet down and regain order on the unit. She stated she got her patient census and started checking for all patients. S19RN stated, Thats when I couldn’t locate Patients #16. #17, #30, and #33. She stated Patient #30’s room was at the end of the hail by the exit and Patient #26 eloped from that exit door the night before. S19RN stated she called S12 Youth Services Manager to look at the video tape and that is when they saw the 4 patients leave the exit door at the end of the hall. 51 9RN stated she recalled the fire alarm was being checked but she was not sure when. S19RN stated Patient #30 and #33 were returned to the hospital by the police around 11:00 a.m. to 11:30 a.m. PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG 1X5) COMPLETION DATE A 144 In an interview on 04/10/14 at 2:50 p.m., S5Plant Operations stated there was an incidental alarm on 03/i 8/14 resulting in a gray period from 03/1814 to 03/21/14 where they do not know if the magnetic doors were locked. He stated there was a reset button on the main fire alarm panel and maintenance or Nursing Supervisors can reset the panel to lock the doors. He stated no one routinely checks the doors to ensure they are locked and there are no alarms when the doors are opened. S5PIant Operations stated they did not realized there was a problem until the door company came out (03/21/1 4), checked the doors and found the doors were not locking due to the fire system was not reset. He stated the Fire Alarm company came out and determined the fire alarm panel was not reset properly. SSPlant Operations stated maintenance had not correctly reset the fire alarm panel. S5PIant Operations provided the final report” of the FORM CMS-2567(O2-99) Previous Versions Obsolete Event ID:V3D211 Facility ID: H00001728 If continuation sheet Page 21 of 10; . ,t t,, I t PRINTED: 06/26/201 FORM APPROVE 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDESUPPLIECLIA IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 194020 B. WING 0411112014 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTW000 HOSPITAL SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG ID PREFIX TAG , i , A 144 Continued From page 21 investigation regarding the elopements on 03/21/14. Review of the email, “final report’, dated 04/02/14 revealed the following: The hospital was conducting maintenance tests, sprinkler system enhancements and maintenance staff training the week of March 17, we are unable to specifically determine which action left the magnetic locks disengaged. However, all maintenance staff members were educated on how to reactivate the magnetic locks as well as the importance of validating this step was completed. PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ‘ (X5) COMPLETION DATE I A 144 IV) Observations on 4/7/14 at 9:45 a.m. revealed Shower Room #2 on the Youth Enhanced Unit had ceiling tiles (non-monolithic ceilings) and fluorescent light bulbs that were easily accessible. Also found in the ceiling was a 19 inch rigid wire rod, telephone cords, and pipes large enough to provide a ligature risk. In an interview on 4/7/14 at 9:55 am. with S2DON, she agreed the non-monolithic tiles in the shower room could have provided access to I the potential ligature fixtures that were noted within the ceiling tiles (large pipes and telephone cords). She also agreed the 19 inch rigid wire rod was a potential hazard. She acknowledged that the fluorescent light bulbs were accessible and could also be hazardous. In an interview on 4/10/14 at 9:11 am. with 527RN (Youth Enhanced Unit), she said she has found sharp objects inside ceiling tiles that have been shifted/moved. She also said if ceiling tiles were noted to have been hanging down or moved maintenance should have been called to fix them because the patient’s hide stuff in there. FORM CMS-2567(02-99) Previous versions Obsolete Event Io:v3D211 Facility ID: H00001728 If continuation sheet Page 22 or 101 PRINTED: 06/26/201 FORM APPROVE 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION C 0411112014 SWING NAME OF PRDVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST SE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 144 Continued From page 22 Further observations on 4/7/14 revealed the beds in rooms 333, 361, 367, 369, 381, 387, and 389 had Cranks located at the end of the beds along with upper side rails. Interview with 52 RN/DON on 4/8/14 at 1:30 p.m. revealed the hospital did not have a policy and procedure related to the use of crank beds and Side rails in the patient rooms to ensure patient safety. A 263 482.21 QAPI PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD SE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG X5) CDMPLETION DATE A 144 A 263 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This CONDITION is not met as evidenced by: Based upon review of the Quality Assurance/Performance Improvement Program Plan and activities, record review and interviews, the hospital failed to meet the Condition of Participation related to Quality Assurance/Performance Improvement. This was evidenced by: I) Failure to develop quality indicators to measure, FORM cM5-2567(02-9g) Previous Versions Obsolete Event ID:v3D2ll Facilily ID: H00001728 If continuation sheet Page 23 of 101 r PRINTED: 06/26/201 FORM APPROVEr 0MB NO, 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDERISUPPLIER’CLIA IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 194020 aWING 0411112014 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE. ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 263 Continued From page 23 analyze, and track performance to assess processes of care related to radiological services. This resulted in the performance improvement program failing to identify delays in obtaining radiological tests and reports (A273); ID PREFIX TAG PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5I COMPLETION DATE A 263: II) Failure of the Quality Assurance/Performance Improvement Program to include: 1) an analysis of the causes of patient elopements and implement preventative actions related to patient elopements on 03/10/14 and 03/20/14 and 4 patient elopements on 03/21/1 4. 2) an analysis of medication errors and adverse events and implementation of preventative actions related to the causative factors other than staff error, (A286); Ill) Failure to ensure the quality improvement projects included measurable quality indicators for the project and the measurable progress achieved for 1 of I (Restraint/Seclusion) performance improvement project reviewed (A297); IV) Failure of the Governing Body to ensure the hospital’s Performance Improvement Plan reflected the hospital’s organization and services, including services furnished under contract were involved in the Performance Improvement Program (A308).. A273 482.21(a), (b)(1),(b)(2)(i), (b)(3)DATA COLLECTION & ANALYSIS A273 (a) Program Scope (1)The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is FORM cM5-2557(02-99) Previous versions Obsolete Event ID:v3D211 C. Facwty ID: H00001728 If conlinuation sheet Page 24 of 1OE PRINTED: 06/26/201’ FORM APPROVEr 0MB NO. 0938-039’ DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION C 04/1112014 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTW000 HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 273 Continued From page 24 evidence that it Will improve health outcomes (2) The hospital must measure, analyze, and track quality indicators and other aspects of performance that assess processes of care, hospital service and operations. PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG IX5) COMPLETION DATE A 273 ... (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data, for example, information submitted to, or received from, the hospital’s Quality Improvement Organization. (2) The hospital must use the data collected to(i) Monitor the effectiveness and safety of services and quality of care; and (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This STANDARD is not met as evidenced by: Based on record review and staff interview, the hospital failed to develop quality indicators that could be used to measure, analyze, and track performance to assess processes of care as evidenced by failing to accurately collect data regarding radiology services resulting in the performance improvement program failing to identify delays in obtaining radiological tests and reports. Findings: Patient #32 Review of patient #32’s medical record revealed the following documentation on “Interdisciplinary Notes”, dated 04/07/2014: 3:00pm Patient #32 on floor of room screaming...states ‘my arm got FORM CM5-2567(02-99) Previous versions Obsolete Event ID:v3D2ll Facilily ID: H00001728 If continuation sheet Page 25 of bE PRINTED: 06/26/201 FORM APPROVEE 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDE5UPPLIER’CLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION C 0411112014 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTW000 HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORNtATION) A 273 Continued From page 25 slammed in the door’; patient #32 holding his right forearm/wrist area, edema noted, bruising noted at right lower forearm, arm immobilized on pillow for support; 3:15pm 5? psychiatrist notified, and X-ray ordered; 6:50pm X-ray performed...7:45pm S? psychiatrist notified of X-ray results and orders to transfer patient to Hospital A obtained; 9:30pm patient #32 transported to Hospital Afor treatment. PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (Xe) COMPLETION DATE A 273 Review of Physician’s Orders, dated 04/07/14, 3:10pm, revealed “X-Ray (R) [rightj Forearm today”...04/07/14, 7:45pm, “Transfer” to Hospital A “for evaluation of’ right arm. Review of Radiology report from Radiology ContractA revealed the “Findings” indicated “Impacted buckle type deformity distal radius about wrist” and the “Impression” was “Distal radial fracture”. Continued review of the report from Radiology Contract A revealed the date of the report was 04/07/14 however there failed to be a time documented. Patient #35 Review of the medical record for Patient #35 i revealed she was a 59 year old female admitted on 2/12/14 with diagnosis which included Scizoaffective Disorder. Review of a Progress Note dated 2/18/14 at 4:00 p.m. revealed Patient #35 fell on the floor and hit her head. Review of a Physician’s Orders sheet for Patient #35 dated 2/18/14 at 5:00 p.m. revealed an order in part: X ray of the head STAT (without delay; immediately). Review of the X ray report revealed for Patient #35 revealed an x ray had been taken on 2/18/14 FORM CMS-2567(02-99) Previous versions Obsolete Event ID:v3D2l1 FaciliIy ID: H0000l 728 If continuation sheet Page 26 of iDE PRINTED: 06/26/201 FORM APPROVE! 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDESUPPLIER’CLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION C 0411112014 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 273 Continued From page 26 but no time was on the report. PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A 273 Review of the observation sheet for Patient #35 dated 2/18/14 revealed “x ray’ was written at 9:45 p.m. In an interview on 4/10/14 at 4:47 p.m. with S2DON, she verified 4 hours and 45 minutes was too long for Patient #35 to obtain a STAT X ray after a head injury. Review of the Quality Management Committee reports dated 02/20/14 and 03/20/14 revealed the following report for Radiology Services: 02/20/14 Total time for x-ray services decreased slightly over the previous month. There were no Complaints regarding x-ray services in January. 03/20/14 Total time for x-ray services was unchanged over the previous month. There were no Complaints regarding x-ray services in February. - - In an interview on 04/10/14 at 5:00 p.m., S3Performance Improvement/Risk Manager/Patient Advocate stated she was not aware of any problems with radiology services and was not aware of any delays in getting X-rays done. S3Performance Improvement/Risk Manager/Patient Advocate stated S52Director of Clinical Services was responsible for radiology. In an interview on 04/10/14 at 5:10 p.m., S52Director of Clinical Services was asked how he evaluated radiology services. He stated the radiology contractor sends him a report and he based his evaluation of the services on the report. S52Director of Clinical Services the report was an average of times the tests were obtained by month. He verified the report did not reflect stat FORM CM5-2567(02-99) Previous versions Obsolete Event ID:v3D2ll FacIlity ID: H0000172B If continuation sheet Page 27 of 10; PRINTED: 06/26/201 FORM APPROVE 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION I (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION I(X3) DATE SURVEY COMPLETED I A. BUILDING C 194020 B. WING I NAME OF PROVIDER OR SUPPLIER 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG 04/11/2014 STREETADDRESS. CITY. STATE, ZIP CODE SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 273 Continued From page 27 orders and times completed. S52Director of Clinical Services verified he did not collect any data from within the hospital and relied solely on the report from the radiology contractor. A 263 482.21 (b)(2)(U), (c)(1), (c)(3) QUALITY IMPROVEMENT ACTIVITIES (b) Program Data (2) [the hospital must Use the data collected to PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS.REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A 273 A 283 - (U) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that— (i) Focus on high-risk, high-volume, or problem-prone areas; (U) Consider the incidence, prevalence, and severity of problems in those areas; and (Hi) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This STANDARD is not met as evidenced by: Based on record review and interview the hospital failed to set priorities for high-risk, high volume and problem-prone areas as evidenced by: 1) implementing preventive actions to address sexually inappropriate behavior between patients; FORM CMS-2567(O2-99) Previous versions Obsolete Event ID: V3D21I Facility ID: H0000l 728 If continuation sheet Page 28 of 101 PRINTED: 06/26/201 FORM APPROVEF 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 194020 B. WING NAME OF PROVIDER OR SUPPLIER 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG 04/11/2014 STREET ADDRESS. CITY. STATE, ZIP CODE SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 283 Continued From page 28 2) failing to monitor the hospital process for compliance with the Pharmacist review of the patient’s medication profile prior to the first dose of a new medication, and; 3) compliance with staffing levels and the prescribed observation precautions. PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A 263 Findings: 1) Failed to implement preventive actions to address sexually inappropriate behavior between patients: Patient#10 Review of Patient#10’s medical record revealed he was a 13 year old male who had been admitted to the Hospital on 2/3/14 with diagnoses including the following: Attention Deficit Hyperactivity Disorder (ADHD), Depression/Psychosis: Severe; Mild Intellectual Disability, and Conduct Disturbance. Further review revealed the patient’s legal status was PEC (Physician’s Emergency Certificate) 2/3/14 at 12:45 p.m. with reason for admission listed as I potential danger to self, unable to seek voluntary admission. Review of the Hospital ‘ s incident reports for the last three months revealed the following incidents involving Patient #10: 2/17/14: Patient loud, disruptive, yelling and cursing staff, took an aggressive stance and threatened to “ beat up staff” 2/1 8/1 4: Physical altercation with peer. 2/28/14: agitated, threatening and cursing peers, fighting staff. 3/3/14: Patient #10 attempted to attack staff. 3/10/14: alleged touching of female peer’s FORM cM5-2567(02-99) Previous versions Obsotete Event ID:V3D211 Facility ID: H00001728 If continuation sheet Page 29 of 1O PRINTED: 06/26/201 FORM APPROVE[ 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 194020 B. WING I NAME OF PROVIDER OR SUPPLIER 1006 HIGHLAND AVENUE BRENTW000 HOSPITAL SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG 0411112014 STREET ADDRESS. 01W, STATE. ZIP CODE A 283 Continued From page 29 breast. Patient denies touching female peer. 3/18/14: Patient denies touching female peer. PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A 283 Review of the hospital’s grievance log for the last three months revealed the following complaints related to allegations of inappropriate sexual conduct against Patient #10: Complaint #1: Date submitted: 3/12114, Date to Patient Advocate: 3/12/14, Complainant: Patient I #11: Date resolved: 3/1 8/1 4; Program involved: I Nursing; Complaint Issue: Accused male peer (Patient #10) of touching. Complaint #2: Date submitted: 3/16/14, Date to Patient Advocate: 3/19/14, Complainant: Patient #12: Date resolved: 3/20/1 4; Program involved: Nursing, Social Services; Complaint Issue: Accused male peer (Patient #10) of touching. I Review of Patient#1 0’s medical record revealed a seclusion/restraint order/record dated 2/28/14 at 6:55 am. The explanation given for the order was as follows: Patient agitated yelling at females on unit stating, “One of you B (expletive) gonna suck my (penis) today”. Fighting staff when redirected and asked to stop and go to time out. Review of Patient#10’s medical record revealed no MD orders for increased supervision or SAP precautions following the first incident of inappropriate sexual behavior on 3/10/14 (reported 3/1 2/1 4). Review of Patient#1 0’s Master Treatment Plan revealed sexually inappropriate behavior/language was not identified as a problem on the treatment plan after the first incident which occurred on 3/10/14. A second incident of inappropriate sexual behavior by Patient#10, almost identical to first incident, was reported by another female on 3/16/14. FORM cMs-2567(o2-99) Previous VersIons Obsolete Event ID:v3D2ll Facility ID: H0000172B If continuation sheet Page 30 of bE PRINTED: 06/26/201’ FORM APPROVEL 0MB NO. 0938-039’ DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION I (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION I(X3) DATE SURVEY I COMPLETED I A. BUILDING C 194020 B. WING 04111/2014 I NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG I SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 283 Continued From page 30 Review of Patient#1O’s medical record revealed the following entries, in part: Interdisciplinary Notes, dated 3/1 0/1 4, 8:00 p.m.: Hypersexual most of shift. Telling female peers, “YOU want to sit on it” as well as hugging another female peer who didn’t complain, however was redirected yet again not to touch any peers. When redirected by Charge nurse to go to room as everyone else did he said, “F (expletive) you ho.” Told a peer I need another hug, can I touch your body. ID PREFIX TAG PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE A 283 Nursing Progress Notes, dated 3/10/14, 10:00 p.m., 3-11 shift: Patient#10 presents with labile affect, pushing limits, refusing to redirect at times. Female peer accused Patient#1 0 of touching her breast, patient stated, “I was gonna touch her but I didn’t.” Review of Patient#10’s Rounds Sheets revealed the patient remained on Suicide Precautions with an Observation Status of every 15 minute checks from 3)6/14 until he was placed on CVO (Constant Visual Contact) with SAP (Sexually Acting Out) perpetrator precautions on 3/18/14 at 12:30 p.m. after the occurrence of the second incident. In an interview on 4/10/14 at 1:44 pm with S4RNQualityAssessment she said she had investigated the allegation made by Patient#12 against Patient#1 0 (second allegation) on 3/16/14. She was asked why Patient#10 was placed on CVO and SAP precautions after the incident on 3/16/14 and not after the incident on 3/10/14. She replied it was because it was a second allegation against Patient#10 and because the second patient (#12) had requested the police. S4RNoualityAssement was asked if she was aware Patient#10 had been placed in FORM CMS-2567(D2-99) Previous Versions Obsolete Event ID: V3D211 Facility ID: H0000l 728 If continuation sheet Page 31 of 108 PRINTED: 06/26/201 FORM APPROVEI 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PRO VIDER’sUPPLIER’CLIA IDENTIFICATION NUMBER 194020 (X2) MULTIPLE CONSTRUCTION C 04111/2014 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CDDE 1006 HIGHLAND AVENUE BRENTW000 HOSPITAL (X4) ID PREFIX TAG I ‘ (X3) DATE SURVEY COMPLETED A BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 283 Continued From page 31 seclusion on 2128/14 for being physically aggressive, fighting staff, and screaming. AlI you B (expletive) are gonna suck my (penis). She said she had not been aware of this incident and she agreed Patient#10’s sexually inappropriate behavior toward the two complainants had appeared to be an escalation from the incident on 2/28/14. ID PREFIX TAG PROVIDERS PUN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) I (X5 COMPLET:ON DATE A 283’ In an interview on 4/10/14 at 2:12 p.m. with Sl2YouthServicesManager she was asked if she remembered the incident on 3/10/14 involving Patient#11 and Patient#10 and she replied, “Yes”. She said Patient#11 was being discharged the day she filed the grievance against Patient#1 0. Sl2YouthServicesManager reviewed the incident report documentation and confirmed the space for notification of MD was marked no. She reviewed Patient#10’s chart (MD orders, both MD and Nurse progress notes) and confirmed there was no documentation of notification of the MD of the incident nor were there any orders related to increasing supervision. Sl2YouthServicesManager explained it was the duty of the nurse on the unit where the incident occurred to inform the MD so he could have made a decision regarding supervision level changes for Patient#10. She explained increased supervision required an MD order and she didn’t understand why the MD wasn’t called. She agreed perhaps it was because Patient#11 was discharged the day she filed the grievance against Patient#10. Sl2YouthServicesManager also agreed, based upon Patient#10’s escalation of behavior, he should have been placed on a higher level of supervision after the first incident. She explained increasing Patient#1 0’s supervision level to CVQ with SAP precautions would have resulted in the patient’s placement in FORM cMS-2567(02-99) Previous Versrons Obsolete Event ID:v3D211 Facility ID: H00001728 If continuation sheet Page 32 of 1D PRINTED: 06/26/201 FORM APPR0VE 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 194020 B. WING NAME OF PROVIDER OR SUPPLIER 04/11/2014 STREETADDRESS. CITY, STATE, ZIP CODE BREN1W000 HOSPITAL (X4) ID PREFIX TAG 06 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG ! A 283 Continued From page 32 a private room and he would have been in constant line of sight of staff at all times. She further explained the staff would have also monitored Patient#10 for sexually inappropriate behaviors. PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE A 283 2) Failing to monitor the hospital process for compliance with the Pharmacist review of the patient’s medication profile prior to the first dose of a new medication: Review of the Hospital Policy titled After Hours Medication Supplies, Revised 3/14, revealed in part: A pharmacist review of medication orders is required prior to the first dose being administered. Licensed Nurses (RN or LPN) are determined I qualified to review the medication order in the absence of the pharmacist. In an interview on 4/10/14 at 9:32 a.m. with S14RN, she said the nurses did not have to wait for the pharmacist to review new medications before they were administered to patients. said when she received the order fora S14RN new medication she pulled the medication from the Pyxis (Automated Medication Dispensing Machine) and administered it to the patient. In an interview on 4/10/14 at 11:13 a.m. with S12RN, she said she did not have the Pharmacist review medications before she administered the first dose. In an interview on 4/10/14 at 8:45 a.m. with S22Pharmacist, he said he was the director of pharmacy and the only pharmacist on staff at the hospital. S22Pharmacist said the pharmacy hours were 8:00 a.m. until 2:30 p.m. during the weekdays. S22Pharmacist said he came back to FORM cMs-2567(o2-gg) Previous versions Obsolete Event ID:v3D2ll Facility ID: 1-100001728 If Continuation sheet Page 33 of 101 PRINTED: 06/26/201 FORM APPROVE 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 194020 B. WING 04/11/2014 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 283 Continued From page 33 the pharmacy at 8:00 p.m. to check for more orders that had been written during the week. He said on the weekend, he came in to the pharmacy at 2:00 p.m. to catch the orders that were written in the morning. S22Pharmacist said the nurses did not have to have the first dose of a medication reviewed before it was administered. S22Pharmacist also said when a medication was ordered after pharmacy hours, the doses were not reviewed until the next time he came to the pharmacy. He Verified when he reviewed those medications the first dose had been given already by the nursing staff. S22Pharmacist said the nurses used drug references to check doses of medications. S22Pharmacist said he knew failing to perform first dose review was a problem because the hospital’s accreditation organization had pointed it out to him as a problem last year. S22Pharmacist said reviewing medications had always been a struggle because there was no 24 hour pharmacist at the hospital. ID PREFIX TAG PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 1X5) COMPLETION DATE A 283 3) Compliance with staffing levels and the prescribed observation precautions: Staff ng Patient #5 Review of the medical record for Patient #5 revealed she was a 57 year old female admitted to the hospital on 2/19/14 with diagnosis which included Paranoid Schizophrenia. Review of the medical record for Patient #4 revealed he was a 23 year old male admitted to the hospital on 2/20/14 with diagnosis which included Schizoaffective Disorder. Further review revealed Patient #4 had a PEC dated 2/18/14 which listed him as gravely disabled and a CEC dated 2/19/14 which listed him as acutely psychotic. Review of the Hospital hand off communication sheet for Patient #4 dated FORM CM5-2567(02-99) PrevIous versions Obsolete Event ID: v3D211 Facility ID: H0000l 728 If continuation sheet Page 34 of lOi PRINTED: 06/26/201 FORM APPROVEL 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION NAME OF PROVIDER OR SUPPLIER (X4) ID PREFIX TAG C 0411112014 B. WING 194020 BRENTWOOD (X3) DATE SURVEY COMPLETED A. BUILDING STREET ADDRESS, CITY, STATE, ZIP CODE HOSPITAL SHREVEPORT,LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 283 Continued From page 34 2/20/14 at 10:30 am. revealed his reason for admission was, “Danger to self and others, paranoid” and his risk factors included violence, “hit another patient.” PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A 283 A review of the medical record for Patient #5 revealed an interdisciplinary note dated 2/23/14 at 11:50 a.m. Review of the note revealed in part: “Patient #5 was attacked by a male peer while she was standing at nurse’s station speaking with nurse. A male peer walked up behind her, placed his hands on her head in a crushing like motion. He then put his arm with elbow around her neck in a head back type motion. He released her neck and shoved her to the floor and she was kicked by him 2-3 times. Patient was on the floor, on her right side and was kicked on her left side lower rib and hip area. Staff assisted Patient to shelter in the ladies shower room. Patient was crying and emotionally shaken. Her body was examined for injury. No broken skin, bleeding or bruising noted. Patient did complain of pain to her right hip area. She was able to walk and move all extremities well. She stated, “He beat me and I want the police. “Shreveport Police notified by nursing supervisors. Officer responded and collected information. Ultimately a summons was issued to the male peer and he was charged with simple battery. S43MD notified regarding patient being beat up. 543MD called Hospital A and spoke with ER MD. Patient to be taken there for evaluation.” Review of the medical record for Patient #5 revealed a Physician’s Order dated 2/23/14 at 12:45 p.m. which read in part: “Send pt (patient) to Hospital A ER (Emergency Room) for evaluation. Pt was physically assaulted by a male peer/ choked/ hit and thrown to the floor, kicked repeatedly when shoved to the floor.” FORM cM5-2567(02-99) Previous Versions Obsolete Event ID:v3D211 Facility ID: H00001728 If continuation sheet Page 35 of 10 PRINTED: 06/26/201 FORM APPROVE[ 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PRO VIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 194020 B. WING 0411112014 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 283 Continued From page 35 ID PREFIX TAG PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE A 283 Review of the Interdisciplinary Notes for Patient # 5 revealed an entry on 2)23/14 at 7:47 p.m. which stated in part: ‘To Hospital A ER via ambulance transport for physical evaluation. Patient #5 is complaining of R (right) side pain between breast and hip. She rates 10/10 at this time.” Further review of the Notes and Physician’s Orders revealed no documentation that the Physician had been notified that Patient #5 was not going to be sent to the ER for over 7 hours. In an interview on 4/8/14 at 2:30 p.m. with S22RN, he said he was a nursing supervisor on the weekends at the hospital. 522RN said on 2)23/14 he wanted 5 staff for the Adult Enhanced Unit (AEU) but could only find 4 staff to work. S22RN said the AEU was 1 person short on staffing because the unit had 2 patients that were 1:1 observations. S22RN said on 2/23/14 he remembered when the ADU called a Code Green, he went to the unit and Patient #4 was already in the dining room with staff. 522RN said he talked to Patient #5 and she was Complaining of pain to her abdomen where she had been kicked by Patient #4. He said the physician ordered Patient #5 to go to the Emergency Room to be examined at 12:45 p.m., but another patient from another unit was medically unstable and had to be sent to the hospital. S22RN said at the time if he would have sent 2 staff members to the hospital with patients the hospital would have been too short staffed. S22RN said he was not aware if the physician was notified of the delay in treatment. After review of the medical record for Patient #5, he verified there was no documentation of physician notification for the delay in sending Patient #5 to the hospital until 7:47 p.m. (7 Hours and 2 minutes after the Physician’s Order). FORM cMS2567(o2-99) Previous Versions Obsolete Event ID:V3D211 C Facility ID: H00001T2S If continuation sheet Page 36 of 1OE PRINTED: 06/26/2O1 FORM APPROVEE 0MB NO. 0938-039’ DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 194020 B. WING NAME OF PROVIDER OR SUPPLIER 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG 04111/2014 STREET ADDRESS. CITY, STATE, ZIP CODE SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 283 Continued From page 36 522RN also Verified after Patient #4 was made a 1:1, there were 3 patients on 1:1 for 3 Staff members and 11 other patients on the AEU for 1 Staff member. S22RN said the unit was definitely short staffed on 2/23/1 4. 522RN also said the hospital was short at least 4 staff members on various units for the 7-3 shift on 2/23/1 4. PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A 283 Review of the Daily Staffing Worksheet for 7am-3pm on 2/23/14 revealed the beginning census on the AEU was 13 and the ending census was 14. The 1:1 patients were listed as 2 females. “3 + 2” was written above the staff’ s names. In an interview on 4/8/14 at 2:30 p.m. with S22RN he said he filled out the staffing sheets for the units on 2/23/14. He said the “3” above the staffs names was what staff he had available and the “+ 2” was how many more staff he needed for the shift. He said he needed 5 people for the shift on the AEU, but had 4 available. He also verified by the end of the shift, 3 of the 14 patients were 1:1 observation patients with only 4 staff members. He said being 1:1 required the staff member to be within arm’s length of the patients at all times. In an interview on 4/9/14 at 1:16p.m. with S24RN, she said she worked on the AEU and was in the nurses’ station when the altercation happened between Patient #4 and Patient #5 on 2/23/1 4. 524RN said the doctor was not notified until 25-30 minutes after the incident because she was examining Patient #5 and calming her down. 524RN said she was the first one to call the doctor and he ordered Patient #4 to be on a 1:1 observation, made some medication changes for Patient #4 and ordered Patient #5 to be sent to the Emergency Department for evaluation. 524RN said she called the nursing supervisor for FORM cMS-2557(02-99) Previous versions Obsolete Event ID:V3D21I Facility ID: H00001728 If continuation sheet Page 37 of bE PRINTED: 06/26/201 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES I (Xl) STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION I 37 the shift, but he could STREET ADDRESS, CITY. STATE, ZIP CODE PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A 283 Continued From page help during anybody. S24RN C 04/11/2014 SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) more COMPLETED 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL A 283 I I A. BUILDING B. WING NAME OF PROVIDER OR SUPPLIER (X4) ID PREFIX TAG FORM APPROVEI 0MB NO. 0938-039 I(X3) DATE SURVEY not get also said she notified the Supervisor about Patient #4 needing to go to the ED, but she did not go until about 8:00 at night. 524RN said She called back a couple of times to get Patient #4 sent to the ED, but she assumed the patient did not go until later because of staffing. S24RN said none of the phone calls were documented. S24RN was unable to locate documentation that Patient #5 was reassessed by a nurse after the initial assessment at 11:50 am. until she was transferred to the hospital at 7:47 pm. In an interview on 4/9/14 2:05 p.m. with S9RN, she said she was working on 2/23/14 on the Adult Enhanced Unit (AEU). S9RN said the two 1:1 patients she and S25MHT had were not actually being watched 1:1 because of staffing. S9RN said Patient #5 did not go to the hospital for several hours after the attack because the supervisor (S22RN) and S24RN told her there was not enough staff to bring her to the ED. S9RN said to her knowledge the physician was never notified about Patient #5 not going to the ED immediately. S9RN said she knows theAEU was short staffed on 2/23/14. S9RN said the Adult Enhanced Unit is short staffed a lot because of the high acuity of the patients. Review of the hospital Document titled Staffing Ratios by Unit and Census Level (staffing grid) revealed in part: Adult Enhanced Unit (AEU): 14 bed unit. 3 staff on days (7:00 a.m. 3:00 p.m.) for 5-12 patients. Further review revealed no staffing grid for a census over 12 patients. - In an interview on 4/10/14 at 2:50 p.m. with FORM cM5-2567(02-99) Previous Versions Obsolete Event ID:v3D2l1 FaCility ID: H00001728 If continuation sheet Page 38 of 101 PRINTED: 06/261201 FORM APPROVE 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 194020 C 0411112014 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 283 Continued From page 38 S2DON, she verified the staffing needed to be increased on the unit for 2/23/14 and the staffing for the 7:00 am. to 3:00 p.m. did not meet the hospital staffing grid requirements. S2DON said the 2 of 4 staff assigned to 1:1 patients should have not been included in the grid. S2DON said for 12 patients other than the 1:1 patients on 2/23/1 4, the unit required 3 staff members per the staffing grid but only had 2. She said from 3:00 p.m. until 11:00 p.m., the AEU had 5 staff but 3 patients on 1:1 which still left the unit short one staff member. PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG 1X5) COMPLETION DATE A 283 P Staffing Patient #32: Review of patient #32’s medical record revealed the following documentation on “Interdisciplinary Notes”, dated 04/07/2014: 3:00pm Patient #32 on floor of room scream ing...states ‘my arm got slammed in the door’; patient #32 holding his right forearm/wrist area, edema noted, bruising noted at right lower forearm, arm immobilized on pillow for support; 3:15pm S58 psychiatrist notified, and X-ray ordered; 6:50pm X-ray performed...7:45pm S58 psychiatrist notified of X-ray results and orders to transfer patient to Hospital A obtained; 9:30pm patient #32 transported to Hospital Afor I treatment. Review of Physician’s Orders, dated 04/07/14, 3:10pm, revealed “X-Ray (R) [right] Forearm today”...04/07/14, 7:45pm, “Transfer” to Hospital A “for evaluation of’ right arm. Interview, 04/09/14 at 3:00pm, with S2 Director of Nursing revealed the reason for the delay for transferring Patient #32 was as a result of not having enough personnel on staff to transport this patient. S2 DON stated Patient #32 waited because a staff member had to be called in to FORM CMS-2567(02-99) Previous versions Obsolete Evenl ID;V3D211 Facility ID: HOODO1T2B If continuation sheet Page 39 of 10 PRINTED: 06/26/201 FORM APPROVE 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER. 194020 (X2) MULTIPLE CONSTRUCTION C 04/11/2014 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING A 283 Continued From page 39 transport Patient #32. PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG 1X5) COMPLETION DATE A 283 Monitoring Patients as Ordered: Review of the Hospital Policy tiued Acuity Staffing Plan, Last Review/Revision Date: 3/14, Policy Number NR 003, revealed in part: 2. Constant Visual Observation: -The patient must be maintained within the visual contact of the Staff at all times. 3. One- to One Order Criteria: Patient Care Elements -The patient must be maintained within the visual contact/arm’s reach of the Staff at all times. -The patient is not able to leave the unit. At any given time, the staff assigned to provide contact/arm’s reach must insure that another staff member will assume this responsibility if he/she must leave the presence of the patient (i.e. lunch breaks, etc.) This visual contact/arm’s reach extends to a requirement for complete supervision of the patient in routine daily care, including accompaniment of patient to the bathroom. The Patient Observation Record is used to document the level of supervision using the every 15 minute format of this form. - - - - Review of the Patient Assignment Sheet for the AEU dated 3/23/14 from 7:00 a.m. 3:00 p.m. revealed the following assignments: 524RN-Medications, Orders, Glucose Checks, a.m. group, Admit. S9RN- Patient #34 1:1, Nurses’ Notes. S26MHT- Trays, 11 close observation patients S25RN- Patient #35 1:1 - Review of the Medical record for Patient #4 revealed an order dated 2/23/14 at 1:00 p.m. for 1:1 staffing at all times for safety. The order was FORM cMS-2567(O2-99) Previous versions Obsolete Event Io:V3D211 Facility ID: H0000172B If continuation sheet Page 40 of 10 PRINTED: 06/26/201 FORM APPROVE[ 0MB NO. 0938-039’ DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FQR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 194020 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG 0411112014 SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG A 283] Continued From page 40 not Changed to Constant Visual Until 2/24/14 at 9:05 a.m. Review of the documents titled “Rounds Sheets” and “Precaution Logs” for the Adult Enhanced Unit for 2/23/14 revealed the following documentation: S25MHT: On 26 occasions S25MHT documented every 15 minutes she was observing both Patient #34 and Patient #35 on a 1:1 observation level. (From 7:00 a.m. until 8:00 am., 9:30 am., 10:30 a.m. 11:00 a.m., 12:00 p.m., 12:15 p.m., 12:45 p.m. 2:00 p.m., 4:00 p.m., 4:45 p.m., 5:00 p.m., 8:15 p.m., 8:45 p.m. 10:00 p.m.) At 8:15 am., S25MHT documented She made every 15 minute rounds on Patient #4 in his room while observing the other two 1:1 patients in the dayroom. At 8:1 5-9:30, S25MHT documented she was observing 3 patients every 15 minutes in the day room and the cafeteria while watching Patient #SSonl:1. At 9 30 a m , S25MHT documented watching 1 patient 1 1, one patient every 15 minutes on the patio and three patients in group in the day room. At 1200 p m -12 15 pm S25MHT documented she watched two patients 1:1 in addition to 4 patients every 15 minutes in the day room 1 patient in the hall and 1 patient at the nurses’ station. At 4:45 p.m. and 5:00 p.m. S25MHT documented she was observing Patient #4 on a 1:1 basis in addition to the other two 1:1 patients she was observing. S9RN: On 17 occasions S9RN documented every 15 minutes she was observing both Patient #34 and Patient #35 on a Constant 1:lobservation level (At (X5) COMPLETION DATE A 283 - - - 10:00 a.m., 10:15 am., 12:30 FORM CM5-2567(02-99) Previous versions Obsoleie p.m., 2:15 p.m., Event ID: V3D211 Facility ID: H00001 728 if continuation sheet Page 41 of 1 0€ PRINTED: 06/26/201 FORM APPROVE[ 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 194020 C 04/1112014 B. WING NAME OF PROVIDER OR SUPPLIER STREETADDRESS. CITY, STATE. 21P CODE 1006 HIGHLAND AVENUE BRENTW000 HOSPITAL SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) o PREFIX TAG PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG I A283 From page 41 2:45 p.m., 3:00 p.m., 3:15 p.m., 3:30 I p.m., 4:15 p.m., 4:30 p.m., 5:15 p.m., 5:30 p.m., 5:45 p.m., 6:00 p.m., 6:15 p.m., 8:30 p.m.) At 2:30 p.m. S9RN documented performing every 15 minute checks on all 11 patients and 3 patients on 1:1 observation. Patient #4 was on 1:1 in the time out room while the other two 1:1 patients were in the dayroom. The other 11 patients were documented as 7 in the dayroom, 1 in the hall, 1 in the bathroom and 2 in their rooms. i S53MHT: At 11:00 p.m. S53 MHT documented he was 1:1 with Patient #4 and Patient #35 in two separate bedrooms. He also documented he was making 15 minute observations at 11:00 p.m. on 5 other patients in 4 separate rooms. At 11:30 p.m. S53MHT documented he was 1:1 with Patient #4 while observing 11 other patients every 15 minutes. At 11:45 p.m. S53MHT documented he was 1:1 with Patient #4 and Patient #35 and every 15 minute rounds on 11 other patients. Continued 2:30 I (X3) DATE SURVEY COMPLETED A. BUILDING 1X5) COMPLETION DATE A283 p.m., Review of the hospital Document titled Staffing Ratios by Unit and Census Level (staffing grid) revealed in part: Adult Enhanced Unit (AEU): 14 bed unit. 3 staff on days (7:00 a.m. 3:00 p.m.) for 5-12 patients. Further review revealed no staffing grid for a census over 12 patients. - In an interview on 4/10/14 at 2:50 p.m. with S2DON, she reviewed the 1:1 observation sheets on the AEU dated 2/23/14 for Patient #34, Patient #35 and Patient #4. She also reviewed the staffing sheets for the other patients on the AEU on 4/1 0/1 4. S2DON verified based on the observation sheets, the patients could not have been observed at the frequency or levels ordered FORM CM5-2567(O2-99) Previous Versions Obsolele Event ID: v3D2ll Facility ID: [100001728 If continuation sheet Page 42 of 1 CE PRINTED: 06/26/201’ FORM APPROVE[ 0MB NO. 0938-030’ DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 194020 B. WING NAME OF PROVIDER OR SUPPLIER 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG 04/1112014 STREET ADDRESS, CITY, STATE, ZIP CODE SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A283 Continued From page 42 by the physician. S2DON also verified the staffing needed to be increased on the unit for 2/23/14 and the staffing for the 7:00 am. to 3:00 p.m. did not meet the hospital staffing grid requirements. S2DON said the 2 of 4 staff assigned to 1:1 patients in the beginning of the 7:00 a.m. to 3:00 p.m. should have not been included in the grid. S2DON said for 12 patients other than the 1:1 patients on 2/23/14, the unit required 3 staff members per the staffing grid but only had 2. She said from 3:00 p.m. until 11:00 p.m., the AEU had 5 staff but 3 patients on 1:1 which still left the unit short one staff member. In an interview on 04/10/14 at 5:00 p.m., S3Performance Improvement/Risk Manager/Patient Advocate verified the hospital’s Quality Improvement program did not include any quality indicators for first dose medication review by the pharmacist, sexually inappropriate behavior between patients, nor were there quality indicators for staffing or observation/precaution levels. S3Performance Improvement/Risk Manager/Patient Advocate further indicated she was not aware of problems in these areas. A 286 482.21(a), (c)(2), (e)(3) PATIENT SAFETY PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG ‘ {X51 COMPLETION DATE A283 A 286 (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will identify and reduce medical errors. (2) The hospital must measure, analyze, and track .adverse patient events .. .. (c) Program Activities (2) Performance improvement activities must FORM CMS-2567(02-99) Previous versions Obsolete Event ID:V3D211 Facility ID: H00001728 If continuation sheet Page 43 of 10 - PRINTED: 06/26/201 FORM APPROVEE 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION C 04111/2014 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 286 Continued From page 43 track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. ID PREFIX TAG PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETiON DATE A 286 (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: (3) That clear expectations for safety are established. This STANDARD is not met as evidenced by: Based on record review and staff interview, the hospital failed to ensure the QAPI program included an analysis of medication errors and adverse events and implemented preventative actions. The QAPI program failed to include: 1) Activities to analyze the causes of patient elopements and implement preventative actions as evidence by patient elopements on 03/10/14 and 03/20)14 with no analysis of how the patients were able to elope, resulting in 4 patient elopements on 03/21/1 4, and; 2) Activities to analyze the causes of medication errors and implement preventative actions as evidenced by no documented evidence of an analysis of the causative factors of medication errors other than staff error, and no documented evidence of any preventative actions other than counseling of the staff involved. Findings: FORM CM5-2567(02-99) Previous versions Obsolete Event ID:v3D2ll Facilily ID: H00001728 If conthiuation sheet Page 44 of 1 0 PRINTED: 06/26/201 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PRO VIDER’SUPPLIER’CLIA IDENTIFICATION NUMBER: FORMAPPROVE 0MB NO. 0938-039 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 5. WING 194020 0411112014 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE. ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG A 2861 SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 44 ID PREFIX TAG PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) IXS) COM?LETCN DATE I__________ A 286 Review of the hospital policy titled Performance Improvement Plan, number P1.001, current date of 11112, and presented as current, revealed the objective of the Performance Improvement Program was to ensure all patients received appropriate and timely services in a safe environment. The policy revealed the Performance Improvement Program Director was responsible to for assisting in the planning, implementing and monitoring of the performance improvement program and would supervise and support QAPI activities on a daily basis and take action as needed. 1) Activities to analyze the causes of patient elopements and implement preventative actions: Review of the Incident Report Log for February-March 2014 revealed Patient #30 eloped from the adolescent unit on 03/10/14 and Patient #26 eloped from the adolescent unit on 03/20/14. Further review of the Incident Report Log revealed Patients #16, #17, #26 and #33 eloped from the adolescent unit on 03/21/14. Review of the Incident Report for Patient #30 dated 03/10/14, revealed the patient was a 16 year old male that ran down the hall, broke through the magnetic locked door, ran down the stairs and out of an opened basement door and eloped from the facility at 11:50a.m. There was no documented evidence of any further investigation into the circumstances of the elopement. Review of the Incident Report for Patient #26 dated 03/20/14, revealed the patient was a 17 year old male that was agitated, busted through the double door on the Youth Enhanced Unit, FORM CM5-2567(02-99) Previous Versions Obsolete Event ID:v30211 Facihty ID: H00001728 If conilnuation sheet Page 45 of 101 PRINTED: 06/26/201 FORM APPROVE 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION C 04111/2014 BWING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTW000 HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 286 Continued From page 45 PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG 1X5) COMPLETION DATE A 286 kicked the stair will doors open all the way to the exit and eloped from the facility at 7:45 p.m. The incident report revealed the staff pursued the • patient but were unable to catch him and the police were notified. There was no documented • evidence of any further investigation into the circumstances of the elopement. In a telephone interview on 04/10/14 at 3:15 p.m., S3Performance Improvement/Risk Manager/Patient Advocate verified there was no investigation into the Circumstances of the elopements by Patient #30 and #26 and stated all she did was documented on the incident reports. 2) Activities to analyze the causes of medication errors and implement preventative actions Reviewof the February2Ol4Quality Management Committee meeting report dated 02120/14, revealed 11 medication variances were reported for the month and the wrong medication administered was the most prominent variance. The action was documented as, “Medication variances are tracked by nurse responsible, shift, and reason for occurrence. The Education Coordinator reviews the medication administration policy with the responsible nurse and observed 3 medication passes.” Review of the March 2014 Quality Management Committee meeting report dated 03/20/1 4, revealed 14 medication variances were reported for the month and the wrong medication administered was the most prominent variance. The action was documented as, “Medication variances are tracked by nurse responsible, shift, and reason for occurrence. The Education FORM CM5-2567(02-99) Previous Versions Obsolete Event ID:V3D211 Facility ID: H0000172B If continuation sheet Page 46 of 10; PRINTED: 06/26/201 FORM APPROVE[ 0MB NO. 0938-039’ DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION I (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 194020 I COMPLETED C 04/1112014 B. WING I NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG II (X3) DATE SURVEY (X2) MULTIPLE CONSTRUCTION A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 286 Continued From page 46 Coordinator reviews the medication administration policy with the responsible nurse and observed 3 medication passes.” In an interview on 04/10/14 at 5:00 p.m., S3Performance Improvement/Risk Manager/Patient Advocate stated S2DON (Director of Nursing) reported the medication Variance information and stated the nurse responsible for the variance was inserviced and the nurse had to be observed 3 times before being released. S3Director QAPI/Risk Manager/Patient Advocate verified there was no other analysis of medication variances conducted and there were no other corrective/preventative actions taken. A 297 482.21(d) QAPI PERFORMANCE IMPROVEMENT PROJECTS PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG 0<51 COMPLETION DATE A 286 A 297 As part of its quality assessment and performance improvement program, the hospital must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must be proportional to the scope and complexity of the hospital’s services and operations. (2) A hospital may, as one of its projects, develop and implement an information technology system explicitly designed to improve patient safety and quality of care. This project, in its initial stage of development, does not need to demonstrate measurable improvement in indicators related to health outcomes. (3) The hospital must document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. FORM CM5-2567(02-99) Previous Versions Obsolete Event ID:V3D211 Facility ID: H00001728 If continuation sheet Page 47 of 1O PRINTED: 06/26/201 FORM APPROVE[ 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xi) PROVIDERISUPPLIER!CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 194020 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG 0411112014 A 297 Continued From page 47 (4) A hospital is not required to participate in a QlO cooperative project, but its own projects are required to be of comparable effort. PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETIDN DATE A 297 This STANDARD is not met as evidenced by: Based on record review and staff interview, the hospital failed to ensure the quality improvement I projects included measurable quality indicators for the project and the measurable progress achieved for 1 of 1 (Restraint/Seclusion) performance improvement project reviewed. Findings: i Review of the hospital policy titled Performance Improvement Plan, number P1.001, current date of 11/12, and presented as current, revealed the objective of the Performance Improvement Program was to ensure all patients received appropriate and timely services in a safe environment. There was no documented evidence in the Performance Improvement Plan of a provision for performance improvement projects. Review of the Quality Management Committee report dated 02/20/14 and 03/20/14 revealed the number of total restrain/seclusion cases were reported as 49 for January and 62 for February. Review of the reports revealed the actions to address the restraint/seclusion were related to activities and rewards. The follow up was documented on both reports as data collected monthly and presented to Quality Management Committee, P1 team, and Medical Staff. There was no documented evidence that restraint/seclusion was a performance improvement project. FORM cMs-2567(02-99) Previous versions Obsolete Event ID: v3D211 Facility ID: H00001728 If continuation sheet Page 48 of 1 DE PRINTED: 06/26/201’ FORM APPROVEE 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERISUPPLIER’CLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION C 04111/2014 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 297 ContinUed From page 48 ID PREFIX TAG PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPI.ETION DATE A 297: In an interview on 04/11/14 at 8:20 am., S3Performance Improvement/Risk Manager/Patient Ad vocate stated the hospital’s performance improvement project was restraint/seclusion and stated it was reported in the Quality Management Committee meeting. Documentation of the Restraint/Seclusion performance improvement project was requested for review. In an interview on 04/11/14 at 9:00 am., S3Performance Improvement/Risk Manager/Patient Advocate provided a folder of her documentation of the Restraint/Seclusion performanCe improvement project. There was no documented evidence of any quality indicators identified for the project and there were no measurable goals identified for the project. Review of the documentation revealed P1 meetings dated 11/07/13, 11/15/13, 12/10/13, 02/07/14, 02/1 4/1 4, and 02/19/14 revealed only documentation of activities related to rewards and activities for the patients. The folder also I included spread sheet of statistical data related a to restraints/seclusion that included unit, type of restraint, multiple episodes, total minutes, shift, day of week, sex, diagnosis per age group, and staff names. S3Performance Improvement/Risk Manager/Patient Advocate stated they wanted to decrease restraint/seclusion use by 10%. SsPerformance Improvement/Risk Manager/Patient Advocate stated they had made improvement in restraint use, but not in the use of seclusion. S3Performance Improvement/Risk Manager/Patient Advocate verified there were no documented quality indicators for the project and no documented goals for the project. FORM CMS-2557(02-99) Previous Versions Obsolete Event lD:V3D211 Facility ID: H0000l728 If continuation sheet Page 49 of 108 PRINTED: 06/26/201 FORM APPROVEI 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERISUPPLIECLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 194020 B. WING NAME OF PROVIDER OR SUPPLIER BRENTWOOD HOSPITAL (X4) ID PREFIX TAG 04/11/2014 STREET ADDRESS. CITY. STATE, ZIP CODE SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 308 Continued From page 49 A308 482.21 QAPI GOVERNING BODY. STANDARD TAG PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD SE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG COMPLETION DATE A 308 A30& The hospital’s governing body must ensure that the program reflects the Complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement) The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. ... This STANDARD is not met as evidenced by: Based on record reviews and interview, the governing body failed to ensure that the hospital’s Performance Improvement Plan reflected the hospital’s organization and services as evidenced by not having all hospital departments and Services including those services furnished under contract involved in the Performance Improvement Plan. Findings: Review of the hospital policy titled Performance Improvement Plan, number P1.001, current date of 11/1 2, and presented as current, revealed the purpose of the Performance Improvement Program was to continually monitor and evaluate the full extent of services provided by all practitioners in the organization, including contracted services. Review of the Quality Management Committee reports dated 02/20/14 and 03/20/14 revealed no documented evidence that respiratory services, laundry/linen services, bio-hazardous waste disposal services, and housekeeping services were included in the quality improvement program. FORM cMs-2567(02-99) Previous versions Obsolele Event ID:v3D2l1 Facility ID: H00001728 If continuation sheet Page 50 of 101 PRINTED: 06/26/201 FORM APPROVEI 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PRO VIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION C 04/1112014 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTW000 HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 308 Continued From page 50 PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A 308 Review of the hospital contracts, policies and procedures, medical staff appointments and credentialing files, and current personnel records revealed the hospital did not have policies and procedures to address all areas of respiratory therapy, the hospital did not have a Medical Director over Respiratory Services, and the hospital did not have a Respiratory Therapist on staff/contact. On 04/11/14 at 11:40am, S2 Director of Nursing confirmed the nursing staff performed respiratory services in the hospital should a patient require this service. In an interview on 04/10/14 at 5:00 p.m., S3Performance Improvement/Risk Manager/Patient Advocate verified respiratory services, laundry/linen services, bio-hazardous waste disposal services, and housekeeping services were not included in the performance improvement program. A 385 482.23 NURSING SERVICES A 385 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This CONDITION is not met as evidenced by: Based on record reviews and interview the hospital failed to be in compliance with the Condition of Participation for Nursing Services as evidenced by: I) Failure to ensure the nurse supervised and evaluated the nursing care for each patient by: A) Failing to transfer a patient to a local emergency room for evaluation and treatment of FORM CMS•2567(02-99) Previous Versions Obsolete Event ID:v3D211 Facility ID: H00001728 If continuation sheet Page 51 of 101 PRINTED; 06/261201 FORM APPROVE 0MB NO. 0938-03 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PRO VIDERSUPPLIER’CLIA IDENTIFICATION NUMBER 194020 (X2) MULTIPLE CONSTRUCTION C 04111/2014 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE. ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORWJION) A 385 Continued From page 51 an injury sustained from another patient, and failing to reassess the patient for 7 hours and 2 minutes after the Physician’s Order had been written for 1 (#5) of 3 (#5, #32, #35) patients reviewed for staff response to an injury, and B) Failing to notify the physician of a patient’s sexully inappropriate behavior for 1 of 1 (#10) patients reviewed for sexually inappropriate behavior and ensure the physician ordered level of observation/precautions was provided for 1 of 1 (#30) sampled adolescent patients on 1:1 precautions (A0395); ID PREFIX TAG PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5I C0MPLETIO DATE A 385 II) Failure to ensure the nursing service had adequate numbers of licensed registered nurses, licensed practical nurses, and mental health technicians to provide nursing care to all patients as needed as evidenced by: A) failing to transfer a patient to a local emergency room for evaluation and treatment after an attack by another patient for 7 hours and 2 minutes after the Physician’s Order had been written due to lack of staff ng for 1 (#5) of 3 (#5, #32, #35) patients reviewed for response to injury. B) failing to transfer an adolescent patient with a broken wrist to the emergency room for treatment for 1 hour and 45 minutes after the order had been written for 1 (#32) of 3 (#5, #32, #35) patients reviewed for response to injury. (A0392) A 392 482.23(b) STAFFING AND DELIVERY OF CARE A 392 The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when FORM CM5-2567(02-99) Previous Ver5on, Obsoele Event ID:V3D211 Faciily ID: H0000l 728 If continuation sheet Page 52 of 10. PRINTED: 06/26/201 FORM APPROVEI 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 194020 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTW000 HOSPITAL SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG A 392 Continued From page 52 needed, the immediate availability of a registered nurse for bedside care of any patient. p 04111/2014 PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG XS) COMPLETION DATE A392 This STANDARD is not met as evidenced by: Based on interview and record review, the hospital failed to ensure the nursing Service had adequate numbers of licensed registered nurses, licensed practical nurses, and mental health technicians to provide nursing care to all patients as needed. This deficient practice is evidenced by: 1) failing to transfer a patient to a local emergency room for evaluation and treatment after an attack by another patient for 7 hours and 2 minutes after the Physician’s Order had been written due to lack of staffing for 1 (#5) of 3 (#5, #32, #35) patients reviewed for response to injury. 2) failing to transfer an adolescent patient with a broken wrist to the emergency room for treatment for 1 hour and 45 minutes after the order had been written for 1 (#32) of 3 (#5, #32, #35) patients reviewed for response to injury. Findings: 1) Failing to transfer a patient to a local emergency room for evaluation and treatment after an attack by another patient forT hours and 2 minutes after the Physician’s Order had been written due to lack of staffing. Review of the medical record for Patient #5 revealed she was a 57 year old female admitted to the hospital on 2/19/14 with diagnosis which included Paranoid Schizophrenia. Review of the medical record for Patient #4 revealed he was a 23 year old male admitted to the hospital on 2/20/14 with diagnosis which included Schizoaffective Disorder. Further review FORM cMs-2567(02-99) Previous Versions Obsolete Event ID:V3D2II Facility ID: H0000172S If continuaUon sheet Page 53 of 1O DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 06/26/201 FORM APPROVEL CENTERS FOR MEDICARE & MEDICAID SERVICES 0MB NO. 0938-039 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION I (Xl) PROVIDER/5UPPLIECLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION I(X3) DATE SURVEY A. BUILDING I C 0411112014 B. WING I NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTW000 HOSPITAL (X4) ID PREFIX TAG I COMPLETED SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 392, Continued From page 53 revealed Patient #4 had a PEC dated 2)18/14 which listed him as gravely disabled and a CEC dated 2/19/14 which listed him as acutely ID PREFIX TAG PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD SE CROSS.REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5} COMPLETION DATE A 392 psychotic. Review of the Hospital hand off communication sheet for Patient #4 dated 2/20/14 at 10:30 a.m. revealed his reason for admission was, “Danger to self and others, paranoid” and his risk factors included violence, “hit another patient.” A review of the medical record for Patient #5 revealed an interdisciplinary note dated 2/23/14 at; 11:50 am. Review of the note revealed in part: Patient #5 was attacked by a male peer while she was standing at nurse’s station speaking with nurse. A male peer walked up behind her, placed his hands on her head in a crushing like motion. He then put his arm with elbow around her neck in a head back type motion. He released her neck I and shoved her to the floor and she was kicked by him 2-3 times. Patient was on the floor, on her right side and was kicked on her left side lower rib’ and hip area. Staff assisted Patient to shelter in the ladies shower room. Patient was crying and emotionally shaken. Her body was examined for injury. No broken skin, bleeding or bruising noted. Patient did comp)ain of pain to her right hip area. She was able to walk and move all extremities well. She stated, “He beat me and I want the police. Shreveport Police notified by nursing supervisors. Officer responded and collected information. Ultimately a summons was issued to the male peer and he was charged with simple battery. S43MD notified regarding patient being beat up. 543MD called Hospital A and spoke with ER MD. Patient to be taken there for evaluation. “ Review of the medical record for Patient #5 revealed a Physician’s Order dated 2/23/14 at FORM CM5-2567(O2-99) Previous versions Obsolete Event lD:v3D2ll Facility ID: H00001728 If continuation sheet Page 54 of bE PRINTED: 06/26/201 FORM APPROVEE 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A BUILDING C 194020 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTW000 HOSPITAL (X4) ID PREFIX TAG 04/11/2014 SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 392 Continued From page 54 12:45 p.m. which read in part: ‘Send pt (patient) to Hospital A ER (Emergency Room) for I evaluation. Pt was physically assaulted by a male peer! choked/ hit and thrown to the floor, kiCked repeatedly when shoved to the floor.’ PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A 392 Review of the Interdisciplinary Notes for Patient # 5 revealed an entry on 2/23/14 at 7:47 p.m. which stated in part: ‘To Hospital A ER via ambulance transport for physical evaluation. Patient #5 is i complaining of R (right) side pain between breast I and hip. She rates 10/10 at this time.” Further review of the Notes and Physician’s Orders revealed no documentation that the Physician had been notified that Patient #5 was not going to be sent to the ER for over 7 hours. In an interview on 4/8/14 at 2:30 p.m. with S22RN, he said he was a nursing supervisor on the weekends at the hospital. S22RN said on 2/23/14 he wanted 5 staff for the Adult Enhanced Unit (AEU) but could only find 4 staff to work. S22RN said the AEU was 1 person short on staffing because the unit had 2 patients that were 1:1 observations. S22RN said on 2)23/14 he remembered when theADU called a Code Green, he went to the unit and Patient #4 was already in the dining room with staff. S22RN said he talked to Patient #5 and she was complaining of pain to her abdomen where she had been kicked by Patient #4. He said the physician ordered Patient #5 to go to the Emergency Room to be examined at 12:45 p.m., but another patient from another unit was medically unstable and had to be sent to the hospital. 522RN said at the time if he would have sent 2 staff members to the hospital with patients the hospital would have been too short staffed. 522RN said he was not aware if the physician was notified of the delay in treatment. FORM CM5-2567(02-99) Previous versions Obsolele Event ID:V3D211 FaciIiIy ID: H00001728 If continuation sheet Page 55 of iDE PRINTED: 06/26/201 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PRO VIDER’SUPPLIER’CLIA IDENTIFICATION NUMBER; 194020 FORM APPROVEI 0MB NO. 0938-039 (X2) MULTIPLE CONSTRUCTION C 04/1112014 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE. ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 392 Continued From page 55 After review of the medical record for Patient #5, he verified there was no documentation of physician notification for the delay in sending Patient #5 to the hospital until 7:47 p.m. (7 Hours and 2 minutes after the Physician s Order).522RN also verified after Patient #4 was made a 1:1, there were 3 patients on 1:1 for 3 staff members and 11 other patients on the AEU for 1 staff member. S22RN Said the Unit was definitely short staffed on 2/23/14. 522RN also said the hospital was short at least 4 staff members on various units for the 7-3 shift on ID PREFIX TAG PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) j (X3 COMPLETION DATE A 392 2/23/14. Review of the Daily Staffing Worksheet for 7am-Spm on 2/23/14 revealed the beginning census on the AEU was 13 and the ending census was 14. The 1:1 patients were listed as 2 females. “3 + 2” was written above the staff’s names. In an interview on 4/8/14 at 2:30 p.m. with S22RN he said he filled out the staffing sheets for the units on 2/23/14. He said the “3 “ above the staff’ s names was what staff he had available and the “+ 2” was how many more staff he needed for the shift, He said he needed 5 people for the shift on the AEU, but had 4 available, He also verified by the end of the shift, 3 of the 14 patients were 1:1 observation patients with only 4 staff members. He said being 1:1 required the staff member to be within arm’ s length of the patients at all times. In an interview on 4/9/14 at 1:16 p.m. with S24RN, she said she worked on the AEU and was in the nurses’ station when the altercation happened between Patient #4 and Patient #5 on 2/23/14. S24RN said the doctor was not notified until 25-30 minutes after the incident because she was examining Patient #5 and calming her down. FORM CMS’2567(O2-99) Previous Versions Obsolete Event lD:v3D21l Facility ID: H00001728 If continuation sheel Page 56 of bE PRINTED: 06/26/201 FORM APPROVE! 0MB NO, 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER’SUPPLIERCLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION C 04111/2014 SWING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BREN1W000 HOSPITAL (X4) 0 PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 392 Continued From page 56 524RN said she was the first one to Call the doctor and he ordered Patient #4 to be on a 1:1 observation, made some medication changes for Patient #4 and ordered Patient #5 to be sent to the Emergency Department for evaluation. S24RN Said she called the nursing supervisor for more help during the shift, but he could not get anybody. S24RN also said she notified the supervisor about Patient #4 needing to go to the ED, but she did not go until about 8:00 at night. S24RN said she called back a couple of times to get Patient #4 sent to the ED, but she assumed [the patient did not go until later because of staffing. S24RN said none of the phone calls were documented. S24RN was unable to locate documentation that Patient #5 was reassessed by a nurse after the initial assessment at 11:50 am. until she was transferred to the hospital at 7:47 p.m. ID PREFIX TAG PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X53 CDMPI.ETION DATE A 392 In an interview on 4/9/14 2:05 p.m. with S9RN, she said she was working on 2/23/14 on the Adult Enhanced Unit (AEU). S9RN said the two 1:1 patients she and S25MHT had were not actually being watched 1:1 because of staffing. S9RN said Patient #5 did not go to the hospital for several hours after the attack because the supervisor (S22RN) and 524RN told her there was not enough staff to bring her to the ED. S9RN said to her knowledge the physician was never notified about Patient #5 not going to the ED immediately. S9RN said she knows theAEU was short staffed on 2)23/14. S9RN said the Adult Enhanced Unit is short staffed a lot because of the high acuity of the patients. Review of the hospital Document titled Staffing Ratios by Unit and Census Level (staffing grid) revealed in part: FORM CMS’2567(02-99) Previous versions Obsolete Event ID: v3D21l Facility ID: H000D1728 If continuation sheet Page 57 of 101 PRINTED: 06/26/201 FORM APPROVE 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER’SUPPLIER’CLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION C 0411112014 B. WING NAME OF PROVIDER OR SUPPLIER STREETADDRESS. CITY. STATE. ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 392 Continued From page 57 Adult Enhanced Unit (AEU): 14 bed Unit. 3 Staff on days (7:00 a.m. 3:00 p.m.) for 5-12 patients. Further review revealed no staffing grid for a census over 12 patients. In an interview on 4/10/14 at 2:50 p.m. with S2DON, she verified the staffing needed to be increased on the unit for 2/23/14 and the staffing for the 7:00 a.m. to 3:00 p.m. did not meet the hospital staffing grid requirements. S2DDN said the 2 of 4 staff assigned to 1:1 patients should have not been included in the grid. S2DON said for 12 patients other than the 1:1 patients on 2/23/14, the unit required 3 staff members per the staffing grid but only had 2. She said from 3:00 p.m. until 11:00 p.m., theAEU had Sstaffbut3 patients on 1:1 which still left the unit short one staff member. S2DON also verified she could not locate a nursing or physician assessment of Patient #5 after the initial assessment at 11:50 a.m. until she was transferred to the hospital at 7:47 p.m. 2) Failing to transfer an adolescent patient with a broken wrist to the emergency room for treatment for 1 hour and 45 minutes after the order had been written ID PREFIX TAG PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETlOt DATE A 392 - Review of patient #32’s medical record revealed the following documentation on “Interdisciplinary Notes”, dated 04/07/2014: 3:00pm Patient #32 on floor of room screaming...states ‘my arm got slammed in the door’; patient #32 holding his right forearm/wrist area, edema noted, bruising noted at right lower forearm, arm immobilized on pillow for support: 3:15pm 558 psychiatrist notified, and X-ray ordered: 6:50pm X-ray performed...7:45pm S58 psychiatrist notified of X-ray results and orders to transfer patient to Hospital A obtained: 9:30pm patient #32 transported to Hospital A for treatment. FORM cMS-2567(02-99) Previous Versions Obsolete -4 Event ID:v3D211 Facility ID: H00001728 If continuation sheet Page 58 of 101 PRINTED: 06/26/201 FORM APPROVEE 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) OATE SURVEY COMPLETED A. BUILDING C 194020 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG 0411112014 SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 392 Continued From page 58 PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5I COMPLETIDN DATE A 392 Review of Physician’s Orders, dated 04/07/1 4, 3:10pm, revealed “X-Ray (R) [right] Forearm today”...04/07/14, 7:45pm, “Transfer” to Hospital A “for evaluation of’ right arm. Interview, 04/09/14 at 3:00pm, with S2 Director of Nursing revealed the reason for the delay for transferring Patient #32 was as a result of not having enough personnel on staff to transport this patient. S2 DON stated Patient #32 waited because a staff member had to be called in to transport Patient #32. A 395 482.23(b)(3) RN SUPERVISION OF NURSING CARE A 395 A registered nurse must supervise and evaluate the nursing care for each patient. This STANDARD is not met as evidenced by: Based on interview and record review the hospital failed to ensure the nurse supervised and evaluated the nursing care for each patient as evidenced by: 1) Failing to transfer a patient to a local emergency room for evaluation and treatment of an injury sustained from another patient, and failing to reassess the patient for 7 hours and 2 minutes after the Physician’s Order had been written for 1 (#5) of 3 (#5, #32, #35) patients reviewed for staff response to an injury, and 2) Failing to notify the physician of a patient’s sexually inappropriate behavior for 1 of 1 (#10) patients reviewed for sexually inappropriate behavior and ensure the physician ordered level of observation/precautions was provided for 1 of 1 (#30) sampled adolescent patients on 1:1 precautions. FORM CMS-2567(02-99) Previous versions Obsolete Event ID:v3D211 Facility ID: H00001728 If continuation sheet Page 59 of 101 PRINTED: 06/26/201 FORM APPROVE 0MB NO. 0938-039 O) DATE SURVEY DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER’CLIA IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION A. BUILDING COMPLETED B. WING 04/1112014 C 194020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG SHREVEPORT, LA 71106 SUMMRY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE ! A 395 Continued From page 59 A 395 Findings: 1) Failing to transfer a patient to a local emergency room for evaluation and treatment of an injury sustained from another patient and failing to reassess the patient for 7 hours and 2 minutes after the Physician’s Order had been written. Review of the medical record for Patient #5 revealed she was a 57 year old female admitted to the hospital on 2/19/14 with diagnosis which included Paranoid Schizophrenia. Review of the medical record for Patient #4 revealed he was a 23 year old male admitted to the hospital on 2/20/14 with diagnosis which included Schizoaffective Disorder. Further review revealed Patient #4 had a PEC dated 2/18/14 which listed him as gravely disabled and a CEC dated 2/19/14 which listed him as acutely psychotic. Review of the Hospital hand off communication sheet for Patient #4 dated 2/20/14 at 10:30 am, revealed his reason for admission was, “Danger to self and others, paranoid” and his risk factors included violence, “hit another patient.” A review of the medical record for Patient #5 revealed an interdisciplinary note dated 2/23/14 at 111:50 a.m. Review of the note revealed in part: “Patient #5 was attacked by a male peer while she was standing at nurse’s station speaking with nurse. A male peer walked up behind her, placed his hands on her head in a crushing like motion. He then put his arm with elbow around her neck in a head back type motion. He released her neck and shoved her to the floor and she was kicked FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:v3D211 Facility ID: H00001728 If continuation sheet Page 60 of iDE PRINTED: 06/26/201s FORM APPROVE[ 0MB FiO. 0938-039’ DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEQICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER’SUPPLIER’CLIA IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION 194020 C 04/11/2014 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG , (X3) DATE SURVEY COMPLETED A BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 395 Continued From page 60 by him 2-3 times. Patient was on the floor, on her right side and was kicked on her left side lower rib and hip area. Staff assisted Patient to shelter in the ladies shower room. Patient was crying and emotionally shaken. Her body was examined for injury. No broken skin, bleeding or bruising noted. Patient did complain of pain to her right hip area. She was able to walk and move all extremities well. She stated, ‘He beat me and I want the police.” Shreveport Police notified by nursing supervisors. Officer responded and Collected information. Ultimately a summons was issued to the male peer and he was charged with Simple battery. S43MD notified regarding patient being beat up. S43MD called Hospital A and spoke with ER MD. Patient to be taken there for evaluation.” ID PREFIX TAG ‘ PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) IXE) COPLETION DATE A 395 Review of the medical record for Patient #5 revealed a Physician’s Order dated 2/23/14 at 12:45 p.m. which read in part “Send pt (patient) to Hospital A ER (Emergency Room) for evaluation. Pt was physically assaulted by a male peer/ choked/ hit and thrown to the floor, kicked repeatedly when shoved to the floor.” Review of the Interdisciplinary Notes for Patient # 5 revealed an entry on 2/23/14 at 7:47 p.m. which stated in part: ‘To Hospital A ER via ambulance transport for physical evaluation. Patient #5 is complaining of R (right) side pain between breast and hip. She rates 10/10 at this time.” Further review of the Notes and Physicians Orders revealed no documentation that the Physician had been notified that Patient #5 was not going to be sent to the ER for over 7 hours. Review of the nurse’s notes revealed no assessment on Patient #5 after the initial assessment until she was being transferred to the hospital. FORM CM5-2567(02-99) Previous Versions Obsolete Event ID: V3D211 Facility ID: H0000l 726 If continuation sheet Page 61 of 108 PRINTED: 06/26/201 FORM APPROVEI 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER’SUPPLIER’CLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION C 0411112014 B. WING NAME OF PROVIDER DR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTW000 HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 396 Continued From page 61 In an interview on 4/8/14 at 2:30 p.m. with S22RN, he said he was a nursing supervisor on the weekends at the hospital. S22RN said on 2/23/14 he wanted 5 staff for the Adult Enhanced Unit (AEU) but could only find 4 staff to work. S22RN said the AEU was 1 person Short on staffing because the unit had 2 patients that were 1:1 observations. S22RN said on 2/23/14 he remembered when theADU called a Code Green, he went to the unit and Patient #4 was already in the dining room with staff. 522RN said he talked to Patient #5 and she was Complaining of pain to her abdomen where she had been kicked by Patient #4. He said the physician ordered Patient #5 to go to the Emergency Room to be examined at 12:45 p.m., but another patient from another unit was medically unstable and had to be sent to the hospital. S22RN said at the time if he would have sent 2 staff members to the hospital with patients the hospital would have been too short staffed. S22RN said he was not aware if the physician was notified of the delay in treatment. After review of the medical record for Patient #5, he Verified there was no documentation of physician notification for the delay in sending Patient #5 to the hospital until 7:47 p.m. (7 Hours and 2 minutes after the Physician’s Order). 522RN also verified after Patient #4 was made a 1:1, there were 3 patients on 1:1 for 3 staff members and 11 other patients on theAEU for 1 staff member. S22RN said the unit was definitely short staffed on 2/23/14. S22RN also said the hospital was short at least 4 staff members on various units for the 7-3 Shift on 2/23/14. ID PREFIX TAG PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XE) COMPLETION DATE A 395 Review of the Daily Staffing Worksheet for 7am-3pm on 2/23/14 revealed the beginning census on the AEU was 13 and the ending census was 14. The 1:1 patients were listed as 2 FORM CM5-2567(O299) Previous Versions Obsolete Event ID:V3D211 Facility ID: H00001728 If continuation sheet Page 62 of 1O PRINTED: 06/26/201 FORM APPROVEI 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERSUPPLIER/CLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION C 04/1112014 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTW000 HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 395 Continued From page 62 females. “3 + 2” was written above the staffs names. In an interview on 4/8/14 at 2:30 p.m. with S22RN he said he filled out the staffing sheets for the units on 2123/14. He said the above the staffs names was what staff he had available and the “+2” was how many more staff he needed for the shift. He said he needed 5 people for the shift on the AEU, but had 4 available. He also verified I by the end of the shift, 3 of the 14 patients were 1:1 observation patients with only 4 staff members. He said being 1:1 required the staff member to be within arm’s length of the patients at all times. PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG {X5) COMPLETION DATE A 395 I•3fl In an interview on 4/9/14 at 1:16 p.m. with S24RN, she said she worked on the AEU and was in the nurses’ station when the altercation happened between Patient #4 and Patient #5 on 2/23/14. 524RN said the doctor was not notified until 25-30 minutes after the incident because she was examining Patient #5 and calming her down. S24RN said she was the first one to call the doctor and he ordered Patient #4 to be on a 1:1 observation, made some medication changes for Patient #4 and ordered Patient #5 to be sent to the Emergency Department for evaluation. S24RN said she called the nursing supervisor for more help during the shift, but he could not get anybody. S24RN also said she notified the supervisor about Patient #4 needing to go to the ED, but she did not go until about 8:00 at night. S24RN said she called back a couple of times to get Patient #4 sent to the ED, but she assumed the patient did not go until later because of staffing. S24RN said none of the phone calls were documented. S24RN was unable to locate documentation that Patient #5 was reassessed by a nurse after the initial assessment at 11:50 am. until she was transferred to the hospital at 7:47 FORM cM5-2567(02-99) Previous Versions Obsolete Event ID:v3D211 Facility ID: H0000172S If continuation sheet Page 63 of 101 I ••‘, &&ait PRINTED: 06/26/201 FORM APPROVE 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION I (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION I(X3) DATE SURVEY A. BUILDING I COMPLETED C 194020 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG 0411112014 SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 395 Continued From page 63 p.m. PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5I COMPLETlOt DATE A 395 In an interview on 4/9/14 2:05 p.m. with S9RN, she said she was working on 2/23/14 on the Adult Enhanced Unit (AEU). S9RN said the two 1:1 patients she and S25MHT had were not actually being watched 1:1 because of Staffing. S9RN said Patient #5 did not go to the hospital for several hours after the attack because the supervisor (S22RN) and 524RN told her there was not enough staff to bring her to the ED. S9RN said to her knowledge the physician was never notified about Patient #5 not going to the ED immediately. S9RN said she knows theAEU was short staffed on 2/23/14. S9RN said the Adult Enhanced Unit is short staffed a lot because of the high acuity of the patients. Review of the hospital Document titled Staffing Ratios by Unit and Census Level (staffing grid) revealed in part: Adult Enhanced Unit (AEU): 14 bed unit. 3 staff on days (7:00 am. 3:00 p.m.) for 5-12 patients. Further review revealed no staffing grid for a I I Census over 12 patients. - In an interview on 4/10/14 at 2:50 p.m. with S2DON, she verified the staffing needed to be increased on the unit for 2/23/14 and the staffing for the 7:00 am. to 3:00 p.m. did not meet the hospital staffing grid requirements. S2DON said the 2 of 4 staff assigned to 1:1 patients should have not been included in the grid. S2DON said for 12 patients other than the 1:1 patients on 2/23/14, the unit required 3 staff members per the staffing grid but only had 2. She said from 3:00 p.m. until 11:00 p.m., theAEU had 5staffbut3 patients on 1:1 which still left the unit short one staff member. S200N could not locate a nursing FORM CMS-2567(02-99) Previous versions Obsolete Event ID:v3D211 Facility ID: H0DOO1T2B If continuation sheet Page 64 of 10 PRINTED: 06/26/201 FORM APPROVEI 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED C 194020 B. WING 0411112014 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 395 Continued From page 64 ID PREFIX TAG PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {XSI COMPLETION DATE A 395 or physician assessment of Patient #5 after the initial assessment at 11:50a.m. Until she was transferred to the hospital at 7:47 p.m. S2DON also verified she could not locate a nUrsing or physician assessment of Patient #5 after the initial assessment at 11:50 a.m. until she was transferred to the hospital at 7:47 p.m. 2) Failing to notify the physician of a patient’s sexually inappropriate behavior for 1 of 1 (#10) patients reviewed for sexually inappropriate behavior and ensure the physician ordered level of observation/precautions was provided for 1 of 1 (#30) sampled adolescent patients on 1:1 precautions. Patient #10 Review of Patient #10’s medical record revealed he was a 13 year old male who had been admitted to the Hospital on 2/3/14 with diagnoses including the following: Attention Deficit Hyperactivity Disorder (ADHD), Depression/Psychosis: Severe; Mild Intellectual Disability, and Conduct Disturbance. Further review revealed the patient’s legal status was PEC (Physician’s Emergency Certificate) 2/3/14 at 12:45 p.m. with reason for admission listed as potential danger to self, unable to seek voluntary admission. Review of the Hospital ‘ s incident reports for the last three months revealed the following incidents involving Patient #10: 2/17/14: Patient loud, disruptive, yelling and cursing staff, took an aggressive stance and threatened to “beat up staff”, 2/1 8/1 4: Physical altercation with peer. FORM CM5’2567(02-99) Previous VersIons Obso’ete Event ID:v3D21l Facility ID: H00001728 If continuation sheet Page 65 of 10 PRINTED: 06/26/201 FORM APPROVEr 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERJSUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 194020 B. WING a411112o14 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG 06 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG A 395 Continued From page 65 2/28/1 4: agitated, threatening and cursing peers. fighting staff. 3/3/14: Patient #10 attempted to attack staff. 3/10/14: alleged touching of female peer’s breast. Patient denies touching female peer. 3/18/14: Patient denies touching female peer. PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) IX5) COMPLETION DATE A 395 Review of the hospital’s grievance log for the last three months revealed the following Complaints related to allegations of inappropriate sexual conduct against Patient #10: Complaint #1: Date submitted: 3/1 2/1 4, Date to Patient Advocate: 3/1 2/1 4, Complainant: Patient #11: Date resolved: 3/18/14; Program involved: Nursing; Complaint Issue: Accused male peer • (Patient #10) of touching. Complaint #2: Date submitted: 3/16/14, Date to • Patient Ad ‘iocate: 3/19/14, Complainant: Patient #12: Date resolved: 3/20/1 4; Program involved: Nursing, Social Services; Complaint Issue: Accused male peer (Patient #10) of touching. Review of Patient #10’s medical record revealed a seClusion/restraint order/record dated 2)28/14 at 6:55 a.m. The explanation given for the order was as follows: Patient agitated yelling at females on unit stating, ‘One of you B (expletive) gonna suck my (penis) today”. Fighting staff when redirected and asked to stop and go to time out. Review of Patient #10’s medical record revealed no MD orders for increased supervision or SAP precautions following the first incident of inappropriate sexual behavior on 3/10/14 (reported 3/1 2/1 4). Review of Patient #10’s Master Treatment Plan revealed sexually inappropriate behavior/language was not identified as a problem on the treatment plan after the first FORM CMS-2567(02-99) Previous versions Obsolete Event ID:V3D211 I Facility ID: H0000l728 If continuation sheet Page 66 of lOf PRINTED: 06/26/201’ FORM APPROVE[ 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PRO VIDER’SUPPLIER(CLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION C 04111/2014 6. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG A 395 66 inCident which occurred on 3/10/14. Asecond incident of inappropriate sexual behavior by Patient #10. almost identical to first incident, was reported by another female on 3/16/14. Review of Patient #10’s medical record revealed the following entries, in part: Interdisciplinary Notes, dated 3/1 0/1 4, 8:00 p.m.: Hypersexual most of shift. Telling female peers, “You want to sit on it” as well as hugging another female peer who didn’t complain, however was redirected yet again not to touch any peers. When redirected by charge nurse to go to room as everyone else did he said, “F (expletive) you ho.” Told a peer I need another hug, can I touch your body. Continued From page I (X3) DATE SURVEY COMPLETED A. BUILDING ID PREFIX TAG PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XE) COMPLETION DATE A 395 Nursing Progress Notes, dated 3/1 0/1 4, 10:00 p.m., 3-11 shift: Patient #10 presents with labile affect, pushing limits, refusing to redirect at times. Female peer accused Patient #10 of touching her breast, patient stated, “I was gonna touch her but I didn’t.” Female peer responded that is a lie. Review of Patient #10’s Rounds Sheets revealed the patient remained on Suicide Precautions with an Observation Status of every 15 minute checks from 3/6/14 until he was placed on CVO (Constant Visual Contact) with SAP (Sexually Acting Out) perpetrator precautions on 3/18/14 at 12:30 p.m. after the occurrence of the second incident. In an interview on 4/10/14 at 2:12 p.m. with Si 2YouthServicesManager she was asked if she remembered the incident on 3/10/14 involving Patient #11 and Patient #10 and she replied, “Yes”. She said Patient #11 was being discharged the day she filed the grievance against Patient #10. Sl2YouthServicesManager reviewed the incident report documentation and confirmed the FORM CMS-2557(02-99) Previous Versions Obsolete Event ID:V30211 Facility ID: H00001725 L If continuatiDn sheet Page 67 of 108 PRINTED: 06/26/201 FORM APPROVEI 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER’CLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION C 0411112014 B. WING NAME OF PROVIDER ORSUPPLIER STREETADDRESS. CITY. STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG A 395 (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 67 space for notification of MD was marked no. She reviewed Patient #10’s chart (MD orders, both MD and Nurse Progress Notes) and confirmed there was no documentation of notification of the MD of the incident nor were there any orders related to increasing supervision. Si 2YouthServicesManager explained it was the duty of the nurse on the unit where the incident had occurred to inform the MD so he could have made a decision regarding supervision level changes for Patient #10. She explained increased supervision required an MD order and she didn’t understand why the MD wasn’t called. She agreed perhaps it was because Patient #11 was discharged the day she had filed the grievance against Patient #10. Sl2YouthServicesManager also agreed, based upon Patient #10’s escalation of behavior, he should have been placed on a higher level of supervision after the first incident. She explained increasing Patient #10’s supervision level to CVO with SAP precautions would have resulted in the patient’s placement in a private room and he would have been in constant line of sight of staff at all times. She further explained the staff would have also monitored Patient #10 for sexually inappropriate behaviors. Continued From page ID PREFIX TAG PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE A 395’ Patient #30 Review of the Hospital Policy titled Acuity Staffing Plan, Last Review/Revision Date: 3/14, Policy Number NA 003, revealed in part: 2. Constant Visual Observation: -The patient must be maintained within the visual contact of the staff at all times. 3. One- to One Order Criteria: Patient Care Elements -The patient must be maintained within the visual contactlarm’s reach of the staff at all times. - FORM cMs-2567(02-99) Previous versions Obsolete Event ID:v3D211 FaCility ID: H00001728 If Continuation sheet Page 68 of 10 PRINTED: 06/26/201 FORM APPROVEI DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER’SUPPLIER’CLIA IDENTIFICATION NUMBER. 194020 0MB NO. 0938-039 (X2) MULTIPLE CONSTRUCTION C 0411112014 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING ID PREFIX TAG : A 395 Continued From page 68 -The patient is not able to leave the unit. At any given time, the staff assigned to provide contact/arm’s reach must insure that another staff member will assume this responsibility if he/She must leave the presence of the patient (i.e. lunch breaks, etc.) This visual contact/arm’s reach extends to a requirement for complete supervision of the patient in routine daily care, including accompaniment of patient to the bathroom. The Patient Observation Record is used to document the level of supervision using the every 15 minute format of this form. PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) . (X5) COMPLETION DATE A 395 - - - Patient #30: Review of the clinical record for Patient #30 revealed the patient was a 16 year old male admitted to the hospital on 02/27/14 under a PEC (Physician Emergency Certificate) for suicidal, dangerous to self, and unable to seek voluntary admission. The patient’s diagnosis included Mood Disorder, Impulse Control Disorder, Attention Deficit Hyperactivity Disorder, Conduct Disorder, and Relationship Problems. The patient was also in the custody of DCFS (Department of Child and Family Services). Review of the physician orders dated 02/27/14 revealed Suicidal, Self-Mutilation/Injury, and Elopement Precautions were ordered. Review of the Nursing Progress Noted dated 03/21/14 revealed at 7:40 a.m. Patient #30 was anxious, irritated and yelling at S19RN. The patient was unable to be redirected or calmed down. S19RN documented the patient room doors were unlocked at 7:46 a.m. in an attempt to re-establish order on the unit. At 7:50 am., S19RN documented a search of the unit was made and Patient #30 was not located in his FORM cMS-2567(D2-99) Previous Versions Obsolete Event ID:V3D21l Facility ID: H00001728 II conlinualion sheet Page 69 of 101 PRINTED: 06/26/201 FORM APPROVE 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERISUPPLIER’CLIA IDENTIFICATION NUMBER 194020 (X2) MULTIPLE CONSTRUCTION C 0411112014 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTW000 HOSPITAL (X4) ID PREFIX TAG A 395 . (X3) DATE SURVEY COMPLETED A BUILDING SHREVEPORT, LA 71106 SUNI?iARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 69 room. The unit was Searched again and Patient #30 was not located. Continued From page ID PREFIX TAG PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5 COMPLETIOb DATE A 395 Review of the Hospital Abuse/Neglect Initial Report (HSS-HO-41) dated 03/21/14 revealed Patient #30 pushed through the adolescent hallway exterior door, with other peers following him. (Patient #16, #17, and #33). Patient #16 and #17 were returned by police at 10:37 am. Patient #30 and #33 were returned by police at 11:24 am. Review of the physician orders dated 03/21/14 at 11:45a.m., revealed an order for “1 on 1 all times” and Elopement Precautions. Review of the Precaution Sheets for 03/21/14 revealed 1 on 1 precautions were not implemented until 11:00 p.m. on 03/21)1 4. In an interview on 04/10/14 at 4:20 p.m., S2Director of Nursing reviewed the record for Patient #30 and Verified the physician had ordered 1 on 1 precautions for Patient #30 at 11:45 am. on 03/21/14, and there was no documented evidence the 1:1 precautions were implemented until 11:00 pm. A 500 482.25(b) DELIVERY OF DRUGS A 500 In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This STANDARD is not met as evidenced by: Based on interview and record review, the hospital failed to ensure drugs and biologicals were controlled and distributed by acceptable standards of practice as evidenced by the FORM CMS-2567(02-99) PreviDus VersIons Obsolete Event ID: v3D2ll Facility ID: H00001728 If continuation sheet Page 70 of 10 PRINTED: 06/26/201 FORM APPROVEI 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION C 0411112014 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE BRENTW000 HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 500 Continued From page 70 pharmacist failing to review all first dose medications for appropriateness, duplication, interactions, allergies, sensitivities or other contraindications before the dose was dispensed and administered to patients. PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG 1X5} COMPLETION DATE A 500 Findings: Review of the Hospital Policy titled After Hours Medication Supplies, Revised 3/14, revealed in part: A pharmacist review of medication orders is required prior to the first dose being administered. Licensed Nurses (RN or LPN) are determined qualified to review the medication order in the absence of the pharmacist. In an interview on 4/10/14 at 9:32 a.m. with S14RN, she said the nurses did not have to wait for the pharmacist to review new medications before they were administered to patients. S14RN said when she received the order fora new medication she pulled the medication from the Pyxis (Automated Medication Dispensing Machine) and administered it to the patient. In an interview on 4/10/14 at 11:13 am. with SI2RN, she said she did not have the Pharmacist review medications before she administered the first dose. In an interview on 4/10/14 at 8:45 a.m. with S22Pharmacist, he said he was the director of pharmacy and the only pharmacist on staff at the hospital. S22Pharmacist said the pharmacy hours were 8:00 a.m. until 2:30 p.m. during the weekdays. S22Pharmacist said he came back to the pharmacy at 8:00 p.m. to check for more orders that had been written during the week. He FORM cMs-2567(o2-9g) Previous versions Obsolete Event ID:V3D211 Facility ID: H00001728 If continuation sheet Page 71 of 1 0( PRINTED: 06/26/201 FORM APPROVEI 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER’CLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION C 0411112014 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL SHREVEPORT, LA 71106 5UMF&ARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING ID PREFIX TAG PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE ! A 500 Continued From page 71 said on the weekend, he came in to the pharmacy at 2:00 p-rn. to catch the orders that were written in the morning. S22Pharmacist said the nurses did not have to have the first dose of a medication reviewed before it was administered. S22Pharmacist also said when a medication was ordered after pharmacy hours, the doses were not reviewed Until the next time he came to the pharmacy. He verified when he reviewed those medications the first dose had been given already by the nursing staff. S22Pharmacist said the nurses used drug references to check doses of medications. S22Pharmacist said he knew failing to perform first dose review was a problem because the hospital’s accreditation organization had pointed it out to him as a problem last year. S22Pharmacist said reviewing medications had always been a struggle because there was no 24 hour pharmacist at the hospital. A 546 482.26(c)(1) RADIOLOGIST RESPONSIBILITIES - I - A 500 A 546 A qualified full-time, part-time, or consulting radiologist must supervise the ionizing radiology services and must interpret only those radiological tests that are determined by the medical staff to require a radiologist’s specialized knowledge. For purposes of this section, a radiologist is a doctor of medicine or osteopathy who is qualified by education and experience in radiology. This STANDARD is not met as evidenced by: Based on interview and record review, the hospital failed to ensure a full-time, part-time or consulting radiologist was appointed as the Director of Radiological Services. Findings: FORM CM5-2567(O299) Previous Versions Obsolete Event ID:V3D211 Facihtylo: H00001728 If continuation sheet Page 72 of 10€ PRINTED: 06/26/201 FORM APPROVEr 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDESUPPLIECLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION C 0411112014 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTW000 HOSPITAL (X4) ID PREFIX TAG A 546 A701 I (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 72 Review of the Credentialing file for S 20 MD revealed he had been approved for reappointment to the consulting medical staff as a radiologist, but had not been appointed as the medical director of radiology at the hospital. Continued From page In an interview on 4/9/14 at 8:30 am. with Si CEO, he said the hospital had radiologists credentialed at the hospital, but he did not have a medical director appointed for radiology 482.41(a) MAINTENANCE OF PHYSICAL PLANT ID PREFIX TAG PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 1X5} CONLETION DATE A 546 A701 The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This STANDARD is not met as evidenced by: Based on observation and interview, the hospital failed to ensure the overall hospital environment was developed and maintained in such a manner that the safety and well-being of patients are assured as evidenced by: 1) failing to ensure electrical receptacles in the patient rooms were of the safety type or protected by 5-milliampere ground-fault-interrupters. 2) failing to ensure all rooms where psychiatric patients slept had tamper proof or monolithic ceilings. 3) failing to ensure there were no plastic bag trash liners present in the common areas on the Adult Psychiatric Unit, the Adult Enhanced Unit, the Geriatric Unit, the Child Psychiatric Unit, and the Child Enhanced Unit. 4) failing to ensure the Shower room on the Youth Enhanced Unit did not have safety risks including non-monolithic ceilings, accessible fluorescent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:V3D211 Facitty ID: H0000l728 If continuation sheet Page 73 of bE PRINTED: 06/26/201 FORM APPROVEL 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION C 0411112014 B. WING 194020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG A701 (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 73 light bulbs, and ligature risks. 5) failing to ensure the shower room on the Geriatric Psychiatric Unit did not have a shower wand with a hose that posed a ligature risk. 6) failing to ensure showers were clean on the Youth Enhanced Unit (YEU); other safety issues; and contraband found on YEU. 7) failing to ensure seclusion rooms on the Adolescent Open Unit did not have a dirty wax build up along the baseboards; and the Youth Enhanced Unit’s seclusion room was missing layers of “Chalkboard” wall covering in a couple of areas. 8) failing to ensure hinges on patient room doors and patient bathroom doors were of the anti-ligature type. Findings: ID PREFIX TAG PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 1X5) COPaSTION DATE A701 1) Failing to ensure electrical receptacles in the patient rooms were of the safety type or protected by 5-milliampere ground-fault-interrupters. Findings: Observations made during the environmental tour on 415114 at 2:30 p.m. revealed the electrical receptacles in all patient care areas were not of the safety type or protected by 5-milliampere ground-fau It-interrupters. Interview with S5 Plants Operation on 4/7/14 at 2:30 p.m. confirmed the electrical outlets were not of the safety type. When asked if the electrical breaker box contained any type of ground fault, 55 replied “no”. 2) Failing to ensure all rooms where psychiatric patients slept had tamper proof or monolithic ceilings. FORM CM5-2567(02-99) Previous versions Obsolete Event ID:V3D211 Facility ID: H00001728 If continuation sheet Page 74 of bE PRTEE106/26/20i DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION 0MB NO. 0938-039 (Xl) PROVIDER/SUPPLIER’CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION k BUILDING (X3) DATE SURVEY COMPLETED C B. WING 194020 04111/2014 NAME OF PROVIDER OR SUPPLIER BRENTW000 (X4) ID PREFIX TAG A 701 STREET ADDRESS, CITY. STATE. ZIP CODE 1006 HIGHLAND AVENUE HOSPITAL SHREVEPORT, LA 71106 SUMRY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 74 I ID PREFIX TAG ‘ PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE A 701 Interview, On 4/8/14 at 2:30pm with S22 RN House Supervisor, revealed he Stated the Adolescent Unit was a 42 bed Unit, but they adjusted the rooms to sleep 4 more people on the Unit. S22 RN House Supervisor stated the chairs and desks were removed from 2 rooms (identified as Room #s 244, 246 with signage they were Consultation offices) and put roll away beds in the rooms for the patients to sleep. Observations, 04/09/14 at 2:00pm, on the Adolescent Open Unit revealed rooms 244 and 246 were utilized as Consultation Rooms; however, the ceilings in the rooms and the bathrooms were ceiling tiles. The ceiling tiles were noted to be removable and the bathrooms in each room did not have the commode pipes covered, nor were the sink pipes covered. 3) Failing to ensure there were no plastic bag trash liners present in the common areas on the Adult Psychiatric Unit, the Adult Enhanced Unit, the Geriatric Unit, the Child Psychiatric Unit, and the Child Enhanced Unit. Observations made during the environmental tour on 4/7/14 at 9:45 am. revealed the following: A) On the Adult Psychiatric Unit there was a I plastic liner in the large trash can located in the laundry room. Interview with S57 RN revealed patients were allowed in the laundry without supervision. B) In the dining room area on the Adult Psychiatric Unit there were two plastic garbage bags full of trash and the trash can had a plastic liner. C) On the Geriatric Unit there was a trash can with a plastic liner located in the hall near the bathroom. FORM CM5-2567(O2’99) Previous Versions Obsolete Event ID:v3D21l Facility ID: H0000I728 If continualion sheet Page 75 of 101 PRINTED: 06/26/201 FORM APPROVE 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PRO VIDER’SUPPLIER’CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) OATE SURVEY COMPLETED A. BUILDING C 194020 8. WING 0411112014 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE. ZIP CODE 1006 HIGHLAND AVENUE BRENTW000 HOSPITAL (X4) ID PREFIX TAG A 701 I SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 75 I D)On the Children’s Unit there was a trash can with a plastic liner located in the common area, E) On the Children’s Enhanced unit there was a trash can with a plastic liner located in the shower room. ID PREFIX TAG PROViDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 1X5) CDMPLETIO DATE A 701 4) Failing to ensure the shower room on the Youth Enhanced Unit did not have safety risks including non-monolithic ceilings, accessible fluorescent light bulbs, and ligature risks. Observations on 4/7/14 at 9:45 am. revealed Shower Room #2 on the Youth Enhanced Unit had ceiling tiles (non-monolithic ceilings) and fluorescent light bulbs that were easily accessible. Also found in the ceiling was a 19 inch rigid wire rod, telephone cords, and pipes large enough to provide a ligature risk. Exposed plumbing beneath the sinks was also noted in the bathrooms. In an interview on 4/7/14 at 9:55 am. with S2DON, she agreed the non-monolithic tiles in the shower room could have provided access to the potential ligature fixtures that were noted within the ceiling tiles (large pipes and telephone cords). She also agreed the 19 inch rigid wire rod was a potential hazard. She acknowledged that the fluorescent light bulbs were accessible and could also be hazardous. In an interview on 4/10/14 at 9:11 am. with 527RN (Youth Enhanced Unit), she said she has found sharp objects inside ceiling tiles that have been shifted/moved. She also said if ceiling tiles were noted to have been hanging down or moved maintenance should have been called to fix them because the patient’s hide stuff in there. 5) Failing to ensure the shower room on the FORM CM5-2567(02-99) Previous Versions Obsolete Event ID:v3D211 Facility ID: H00001728 If continuation sheet Pago 76 of 101 PRINTED: 06/26/201 FORM APPRDVEI 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERJSUPPLIER’CLIA IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C B. WING 194020 0411112014 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTW000 HOSPITAL (X4) ID PREFIX TAG A 701 SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 76 Geriatric Psychiatric Unit did not have a shower wand with a hose that posed a ligature risk. Review of one of the two shower rooms at the end of the hall on the Geriatric Unit revealed a hand held shower wand with rubber tubing approximately 5 feet long. In an interview on 4/07/14 at 10:35 a.m. with S5TRN, she said at night psychiatric women that were not geriatric patients were housed on the unit. S57RN Said the women used the shower room with the wand and hose unattended. ‘ ID PREFIX TAG ‘ PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) X5I CCMPIZrION DATE A 701 6) Failing to ensure showers were clean on the YEU, other safety issues, and contraband item. Observations, 04/07/14 at 10:00am, on the Youth Enhanced Unit(YEU) revealed the following: Shower room#1: Black substance on both walls, dank, musty smell Shower room#2: Non-monolithic ceihng tiles (possible elopement/ligature risk), easily accessible fluorescent light bulbs, leaking shower head with a puddle of water on floor; Found within the ceiling: 19 inch rigid wire rod, telephone cords, pipes large enough to provide possible ligature. Exposed plumbing beneath the sink in bathrooms Rooms #209 and #211: flat head screws (not tamper resistant) Room #21 OS: Corded sweatpants found in drawer under patient bed, missed during I contraband room search (patient could use the l draw string as ligature device). 7) Failing to ensure seclusion rooms on the Adolescent Open Unit did not have a dirty wax build up along the baseboards; and the Youth Enhanced Unit’s seclusion room was missing layers of “chalkboard” wall covering in a couple of areas. FORM CM5-2567(02-99) PrevIous Versions Obsolete Event ID:v3D211 Faculty ID: H00001728 If ContinUation sheet Page 77 or io PRINTED: 06/26/201 FORM APPROVEI 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PRO VIDER/SUPPLIECLIA IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 8. WING 194020 04/11/2014 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 77 8) Failing to ensure hinges on patient room doors and patient bathroom doors were of the anti-ligature type. Observations, 04/08/14 at 10:40am, revealed: Adolescent Open Unit room #s 265, 267, 265, 269, and 271 bathrooms had 3 hinges on the bathroom doors. The top hinge could be utilized by patients to hang ligature devices thus causing harm. A1151 482.57 RESPIRATORY CARE SERVICES A 701 ‘ PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5I COPLETION DATE A 701 I I A1151 The hospital must meet the needs of the patients in accordance with acceptable standards of practice. The following requirements apply if the hospital provides respiratory care services. This CONDITION is not met as evidenced by: Based on record reviews and interviews the hospital failed to met the Condition of Participation for Respiratory Care Services as evidenced by: 1) failing to appoint a director of respiratory care services to supervise the Service and ensure respiratory care was properly administered (A1153); 2) failing to have Respiratory Therapy Technician/s employee/s or contract employee/s to administer respiratory therapy services to patients should they require these services and have their qualifications specified by the Medical Staff. (A1154); 3) failing to ensure the respiratory therapy services were delivered according to written directives made by the Medical Staff (A1160); and FORM CM5-2567(o299) Previous versions Obsolete Event ID:v3D21l Facility ID: H00001728 If continuation sheet Page 78 of 10 PRINTED: O6/26/201 FORM APPROVE[ 0MB NO. 0938-039’ DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION I (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 194020 B. WING 04/11/2014 I NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG A1151 SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 78 PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5I COMPLETION DATE A1151 4) failing to ensure policieslprocedures specifically addressing qualifications and the amount of supervision required to perform specific respiratory therapy procedures were designated in writing (A1161). A1153 482.57(a)(1) DIRECTOR OF RESPIRATORY SERVICES A1153 There must be a director of respiratory care services who is a doctor of medicine or osteopathy with the knowledge, experience and capabilities to supervise and administer the service properly. The director may serve on either a full-time or part-time basis. This STANDARD is not met as evidenced by: Based on record reviews and interview the hospital failed to appoint a director of respiratory care services to supervise the service and ensure respiratory care was properly administered. Findings: Review of the credential files for physicians (S49, S50 both Family Practice Physicians; and Psychiatrists 531, 532, S43, S51), on the medical staff revealed there failed to be documented evidence a physician was appointed to be the director of respiratory care services. Review of the Governing Body and Medical Staff meeting minutes revealed the Medical Staff failed to nominate a physician to serve as the Medical Director of Respiratory Services and the Governing Body failed to ensure there was a Medical Director of Respiratory Services. Review of Medical Staff Bylaws revealed there failed to be documented evidence a Medical FORM CM5-2S67(O299) Previous versions Obsolete Event ID:v3D21I Facility ID: H00001728 If continuation sheet Page 79 of ioe PRINTED; 06/26/201 FORM APPROVEI 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION I (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION I STREET ADDRESS, CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A1153 C 0411112014 B. WING NAME OF PROVIDER OR SUPPLIER (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING 79 Director of Respiratory Services was required. Continued From page PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) CDMPLEtON DATE A1153 Interview, 04/09/14 at 10:50am, with Si Administrator revealed if a patient required respiratory therapy services they would be transferred to Hospital A (a local acute care hospital which served as the receiving hospital per transfer agreement). A1154 482.57(a)(2)ADEQUATE RESPIRATORY CARE STAFFING A1154 ,There must be adequate numbers of respiratory therapists, respiratory therapy technicians, and other personnel who meet the qualifications specified by the medical staff, consistent with State law. I This STANDARD is not met as evidenced by: Based on record reviews and interviews, the hospital failed to: 1) have Respiratory Therapy Technician/s employee/s or contract employee/s to administer respiratory therapy services to patients should they require these services; and 2) have qualifications specified by the Medical Staff. Findings: Review of the Medical Staff Bylaws revealed they failed to include approval of the scope of diagnostic and/or therapeutic respiratory services and to define in writing the specific respiratory services provided by the hospital. Review of the Governing Body Bylaws/meeting minutes revealed the Respiratory Therapy services were not defined in writing and approved as evidenced by failure of the Governing Body to designate Respiratory Services as one of the FORM cMs-2s67(02-gg) Previous versions Obsolete Event ID:v3D2ll Facility ID: H00001728 If continuation sheet Page ao of 101 PRINTEIThOG/26/201 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: 194020 0MB NO. 0938-039 (X2) MULTIPLE CONSTRUCTION C 04/1112014 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 1006 HIGHLAND AVENUE BREN1WOOD HOSPITAL (X4) ID PREFIX TAG Al 1541 SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMR,ETION DATE Al 154i ContinUed From page 80 clinical services (X3) DATE SURVEY COMPLETED A BUILDING provided by the hospital. Interview, 04/10/14 at 1:30pm, with S48 Director Human Resources confirmed the hospital did not have respiratory therapists as employees; nor did the hospital have respiratory therapists on contract. A1160 482.57(b) RESPIRATORY CARE SERVICES POLICIES A1160 Services must be delivered in accordanCe with medical staff directives. This STANDARD is not met as evidenced by: Based on record reviews and interviews, the hospital failed to ensure respiratory services were delivered in accordance with written Medical Staff directives. Findings: Review of policies/procedures for respiratory therapy included: A. Policy Number TX.056 titled Respiratory Therapy: Hand Held NebulizerTherapy...I. POLICY To provide instruction for hand held nebulizer treatments II. PROCEDURE All ...treatments...are administered by Respiratory Therapy Services or Nursing staff... B. Policy Number TX.059 titled Respiratory Therapy: Oxygen Therapy and Hum idity...l. POLICY Bubble humidifiers are used on all patients with supplemental oxygen...Il. PROCEDURE... C. Policy Number TX,060 titled Respiratory Therapy: Nasal CPAP...I. POLICY To provide direction for the set up, monitoring, and discontinuing of nasal CPAP...a collaborative FORM CM5-2567(02-99) Previous versions Obsolete Event ID: v3D211 Facwty ID: H00001728 If continuatiDn sheet Page 81 of 1 D PRINTED: 06/26/201 FORM APPROVE 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION I (Xl) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: I(X3) DATE SURVEY I (X2) MULTIPLE CONSTRUCTION I A. BUILDING COMPLETED C 194020 B. WING I NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE. ZIP CODE 1006 HIGHLAND AVENUE BRENTW000 HOSPITAL (X4) ID PREFIX TAG 0411112014 SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A1160 Continued From page 81 effort between nursing and respiratory therapy for the best possible outcome for the patient... PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 10 PREFIX TAG (X51 COMPLETION DATE A1160 D. Policy Number TX.061 titled Respiratory Therapy: Pulse Oximetry...I. POLICY To provide information to Nursing staff as to why and how pulse oximeters are monitored... Continued review of the Respiratory Services policies/procedures revealed the above (A through D) were the only respiratory therapy service policies given to the surveyor for review. Review of the above policies/procedures revealed there failed to be documentation in the policies related to: Safety practices, including infection control measures for equipment, sterile supplies, biohazardous waste, posting of signs, and gas line identification; o Handling, storage, and dispensing of therapeutic gases to both inpatients and outpatients; o Cardiopulmonary resuscitation; o Procedures to follow in the advent of adverse reactions to treatments or interventions; o Pulmonary function testing; o Therapeutic percussion and vibration; o Bronchopulmonary drainage; o Mechanical ventilatory and oxygenation support; oAerosol, humidification, and therapeutic gas administration; o Storage, access, control, administration of medications and medication errors; and o Procedures for obtaining and analyzing blood samples (e.g., arterial blood gases). Interview, 04/11/14 at 11:40am, with S2 Director of Nursing confirmed the nursing staff performed FORM CMS-2567(02-99) Previous versions Obsolete Event ID:v3D2ll Facility ID: H00001T2B If continuation sheet Page 82 of 101 PRINTED: 06/26/201 FORM APPROVE 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER’SUPPLIERICLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING C 194020 B. WING 0411112014 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 1006 HIGHLAND AVENUE BRENTW000 HOSPITAL (X4) ID PREFIX TAG SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORFTION) A1160 Continued From page 82 respiratory services in the hospital should a patient require this service. Al 161 Review of personnel files for Registered Nurses (RN) and Licensed Practical Nurses (LPN) revealed there failed to be documented evidence they had received training specific to the administration of respiratory therapy services (RNs—56, S12, S14, S15, S19, 524, 528, S33, S40, S41, S55; LPNs— 57, S29, S54, S56). 482.57(b)(1) RESPIRATORY CARE PERSONNEL POLICIES PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG IXS) COMPLETION DATE A1160 All 61 Personnel qualified to perform specific procedures and the amount of supervision required for personnel to carry out specific procedures must be designated in writing. This STANDARD is not met as evidenced by: Based on record reviews and interview, the hospital failed to ensure the personnel qualified to perform specific respiratory therapy services and the amount of supervision required for personnel to carry out the specific respiratory therapy procedures were designated in writing. Findings: Review of policies/procedures for respiratory therapy included: A. Policy Number TX.056 titled Respiratory Therapy: Hand Held NebulizerTherapy...l. POLICY To provide instruction for hand held nebulizer treatments II, PROCEDURE All ...treatments...are administered by Respiratory Therapy Services or Nursing staff... B. Policy Number TX.059 titled Respiratory Therapy: Oxygen Therapy and Humidity...I. POLICY Bubble humidifiers are used on all FORM cMS-2567(o299) Previous versions Obsolete Event ID:v3D21l FaciliIy ID: H0000I72B If continuation sheet Page 83 of 10 PRINTED: 06/26/201 FORM APPROVEI 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDE5UPPLIECLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 194020 B. WING 0411112014 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTW000 HOSPITAL SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG A1161 I Continued From page 83 patients with supplemental oxygen...lI. PROCEDURE... PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A1161 C. Policy Number TX.060 titled Respiratory Therapy: Nasal CPAP...I. POLICY To provide direction for the set up, monitoring, and discontinuing of nasal CPAP...a collaborative effort between nursing and respiratory therapy for the best possible outcome for the patient... D. Policy Number TX.061 tiued Respiratory Therapy: Pulse OXimetry...l. POLICY To provide information to Nursing staff as to why and how pulse oximeters are monitored... Continued review of the Respiratory Services policies/procedures revealed the above (A through D) were the only respiratory therapy service policies given to the surveyor for review. Review of the Medical Staff Bylaws revealed they failed to include approval of the scope of diagnostic and/or therapeutic respiratory services and to define in writing the specific respiratory services provided by the hospital. Review of the Governing Body Bylaws/meeting minutes revealed the Respiratory Therapy services were not defined in writing and approved as evidenced by failure of the Governing Body to designate Respiratory Services as one of the clinical services provided by the hospital. Interview, 04/10/14 at 1:30pm, with S48 Director Human Resources confirmed the hospital did not have respiratory therapists as employees; nor did the hospital have respiratory therapists on contract. FORM cM5-2567(O2-99) Previous Versions Obsolete Event ID:v3D21l Facility ID: H00001728 If continuation sheet Page 84 of 101 PRINTED: 06/26/20I FORM APPROVEE 0MB NO. 0938-039’ DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PRO VIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 194020 8. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE. ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG 0411112014 SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 113 ContinUed From page 84 B 113 482.61(b)(3) PSYCHIATRIC EVALUATION PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG 1X5) COMPLETION DATE B 113 B 113 Each patient must receive a psychiatric evaluation that must contain a record of mental status. This STANDARD is not met as evidenced by: Based on record reviews and interview, the psychiatrist failed to ensure the patients psychiatric evaluation contained a documentation of their mental status for 2 of 12 patient psychiatric evaluations (#4, #24). Findings: Review of Patient #4’s psychiatric evaluation, dated 02/21/14, revealed 549 Family Practice Physician documented, ‘The patients mental status examination is deferred to the attending psychiatrist”. Further review of the psychiatric evaluation revealed S43 Psychiatrist failed to document a mental status evaluation. Review of Patient #24’s psychiatric evaluation, dated 03/28/14, revealed S51 Psychiatrist documented, “Mental Status Exam...Orientation to time, place, person: left blank...Memory (Recent & Remote [include how determined])...Fund of knowledge? Estimate of Intelligence: left blank...” Interview, 04/10/14 at 2:40pm, with S32 Psychiatrist confirmed the patient’s mental status evaluation must be documented in the psychiatric evaluation. B 117 482.61(b)(7) PSYCHIATRIC EVALUATION B 117 Each patient must receive a psychiatric evaluation that must include an inventory of the FORM cMS-2567(02-99) Previous Versions Obsolete Event ID:v3D2l1 Facility ID: H00001728 If Continuation sheet Page 85 of 1O PRINTED: 06/26/201 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION I (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION I I A. BUILDING COMPLETED C 04/1112014 B. WING I NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTW000 HOSPITAL (X4) ID PREFIX TAG FORM APPROVEI 0MB NO. 0938-039 I(X3) DATE SURVEY SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 117 Continued From page 85 patient’s assets in descriptive, not interpretive fashion. ID PREFIX TAG ] I PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD SE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) IX5) COMPLE11ON DATE B 117 This STANDARD is not met as evidenced by: Based on record reviews and interview, the psychiatrist failed to document patient assets in descriptive and not interpretive terms as evidenced by 9 of 12 patients’ (#s2, 3, 4, 8, 9, 11, 16, 18, 30) assets documented as “likes to play video games, read, play . Findings: Review of Patient #2’s psychiatric evaluation, dated 04/04/1 4, revealed S51 Psychiatrist documented, “ASSETS: The patient likes to paint, dance, and play tennis.” Review of Patient #3’s psychiatric evaluation, dated 03/21/14, revealed S32 Psychiatrist documented, “ASSETS: Include attractiveness... Review of Patient #4’s psychiatric evaluation, dated 02121/14, revealed S43 Psychiatrist documented, ASSETS Not available”. Review of Patient #8’s psychiatric evaluation, dated 04/01/14, revealed S51 Psychiatrist documented, “ASSETS:” left blank, no documentation. Review of Patient #9’s psychiatric evaluation, dated 04/04/14, revealed S31 Psychiatrist documented, “ASSETS: Draw, play video games.” Review of Patient #11’s psychiatric evaluation, dated 02/22/14, revealed 631 Psychiatrist documented, “ASSETS: The patient likes to sing and draw.” FORM CM5-2567(02-99) Previous Versions Obsolete Event ID:V3D211 Facility ID: H00001728 If continuation sheet Page 86 of 1O PRINTED: 06/26/201 FORM APPROVE 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PRO VIDER/SUPPLIER’CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 194020 B. WING 04/1112014 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE. ZIP CODE BRENTW000 HOSPITAL (X4) ID PREFIX TAG 06 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 117 Continued From page 86 Review of Patient #16’s psychiatric evaluation, dated 03/19/14, revealed S51 Psychiatrist documented, ASSETS: The patient likes baseball and listens to music.” PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG I (X5) COMPLETION DATE 8117 Review of Patient #18’s psychiatric evaluation, dated 04/02/14, revealed S32 Psychiatrist documented, “ASSETS: Include attractiveness, good enough IQ, reasonable health.” Review of Patient #30’s psychiatric evaluation, dated 02/28/1 4, revealed S51 Psychiatrist documented, “ASSETS: The patient likes to read and play video games.” Whereas the ability to draw can be considered an asset/strength, the playing of video games, baseball, liking to singing, attractiveness, and listening to music were not considered assets that helped the patients according to their respective treatment plans. Interview, 04/11/14 at 11:50am, with S59 Health Information Management Director confirmed there were issues with the psychiatrists using descriptive terms when documenting patient psychiatric evaluations and they were in the process of”teaching” terms. B 118 482.61(c)(1) TREATMENT PLAN B 118 Each patient must have an individual comprehensive treatment plan. This STANDARD is not met as evidenced by: Based on interview and record review the hospital failed to have an individualized comprehensive treatment plan as evidenced by: FORM CM5-2567(02-99) Previous Versions Obsolete Event ID:v3D211 FacuitylD: H00001728 If continuation sheet Page 87 of 1O PRINTED: 06/26/201 FORM APPROVEI 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERISUPPLIER!CLIA IDENTIFICATION NUMBER: 194020 C 04/1112014 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 118 Continued From page 87 I) failing to ensure a patient s sexually inappropriate behavior/language was identified as a problem on the Master Treatment Plan prior to 3/18/14 for 1 (Patient #10) of 1 patients reviewed for sexually inappropriate behavior/language treatment plans; II) failing to ensure each patient with Suicidal ideation reCeived individualized treatment plans instead of using generic printed treatment plans without adding individualized treatment goals and interventions for 15 of 15 patients reviewed with suicidal ideation (Patient #s 1,2, 3, 6, 9, 10, 11, 15, 20, 21, 22, 23, 25, 27, 30); and Ill) failing to identify interventions to redirect patient #7’s aggressive behaviors. Findings: I) Review of the Hospital ‘ s incident reports for the last three months revealed the following incidents involving Patient #10: PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG X5) COMPLETION DATE B 118 2/1 7/1 4: Patient loud, disruptive, yelling and cursing staff, took an aggressive stance and threatened to “beat up staff”. 2/1 8/1 4: Physical altercation with peer. 2/28/1 4: agitated, threatening and cursing peers, fighting staff. 3/3/14: Patient #10 attempted to attack staff. 3/10/14: alleged touching of female peer’s breast. Patient denies touching female peer. 3/18/14: Patient denies touching female peer. Review of the hospital s grievance log for the last three months revealed the following complaints related to allegations of inappropriate sexual conduct against Patient #10: Complaint #1: Date submitted: 3/1 2/1 4, Date to Patient Advocate: 3/12/14, Complainant: Patient #11: Date resolved: 3/18/14; Program involved: Nursing; Complaint Issue: Accused male peer (Patient #10) of touching. FORM cMS-2567(02-99) Previous versions Obsolete Event ID:v3D2ll FacUity ID: H00001 728 If continuation sheet Page 88 of 1 0 I PRINTED: 06/26/201 FORM APPROVEI 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER’SUPPLIER/CLIA IDENTIFICATION NUMBER: 194020 STREET ADDRESS, CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 118 Continued From page 88 Complaint #2: Date submitted: 3/16/14, Date to Patient Ad voCate: 3/1 9/1 4, Complainant: Patient #12: Date resolved: 3/20/1 4; Program involved: Nursing, Social Services; Complaint Issue: Accused male peer (Patient #10) of touching. I C 0411112014 B. WING NAME OF PROVIDER OR SUPPLIER (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XSI COMPLETION DATE B 118 Review of Patient #10’s medical record revealed he was a 13 year old male who had been admitted to the Hospital on 2/3/14 with diagnoses including the following: Attention Deficit Hyperactivity Disorder (ADHD), Depression/PsyChosis: Severe; Mild Intellectual Disability, and Conduct Disturbance. Further review revealed the patient’ s legal status was PEC (Physician’s Emergency Certificate) 2/3/14 at 12:45 p.m. with reason for admission listed as potential danger to self, unable to seek voluntary admission. Review of Patient #10’s medical record revealed a seclusion/restraint order/record dated 2/28/14 at 6:55 a.m. The explanation given for the order was as follows: Patient agitated yelling at females on unit stating, “One of you B (expletive) gonna suck my (penis) today” Fighting staff when redirected and asked to stop and go to time out. Review of Patient #10’ s Master Treatment Plan revealed sexually inappropriate behavior/language was not identified as a problem on the treatment plan after the first incident which occurred on 3/10/14. Asecond incident of inappropriate sexual behavior by Patient#10, almost identical to first incident, was reported by another female on 3/16/14. Review of Patient #10 ‘ s medical record revealed the following entries, in part: Interdisciplinary Notes, dated 3/1 0/1 4, 8:00 p.m.: Hypersexual most of shift. Telling female peers, You want to sit on it” as well as hugging another female peer who didn’t complain, however was . FORM CM5-2567(02-99) Previous Versions Obsolete Event ID:vaD2ll Facility ID: H00001728 If Continuation sheet Page 89 or 10 PRINTED; 06/26/201 FORM APPROVEI 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C B. WING 194020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG 04/1112014 SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 118 Continued From page 89 redirected yet again not to touch any peers. When redirected by charge nurse to go to room as everyone else did he said, “F (expletive) you ho.” Told a peer I need another hug, can I touch your body. PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG 1X51 COMPLETION DATE B 118 Nursing Progress Notes, dated 3/10/14, 10:00 p.m., 3-11 shift: Patient #10 presents with labile affect, pushing limits, refusing to redirect at times. Female peer accused Patient #10 of touching her breast, patient stated, “I was gonna touch her but I didn’t.” In an interview on 4/10/14 at 2:12p.m. with S 12 Youth Services Manager she was asked if she was familiar with Patient#10 ‘s sexually inappropriate behavior/language and she replied, “Yes”. She reviewed Patient #10’s MD orders, MD progress notes, Nurses notes, Interdisciplinary Notes and the Master Treatment Plan and confirmed there was no update to the Master Treatment Plan identifying sexually inappropriate behavior as a problem until 3/18/14 (after the second incident had occurred). II) Review of the policy entitled Multi-Disciplinary Treatment Planning, last review/revision date: 3/14, revealed the following, in part: I. Policy: The purpose of the treatment plan is to provide a complete plan of care based on an integrated assessment of the patient’s specific needs and problems. The treatment plan also provides appropriate communication between team members that fosters consistency and continuity in the care of the patient. Each patient will have a multidisciplinary, individualized treatment plan. The treatment plan serves as an organizational tool whereby the care rendered each patient is designed, implemented, FORM CM5-2567(O2-99) Previous versions Obsolete Event ID:v3D2ll Facility ID: H0000172B If continuation sheet Page 90 of 101 PRINTED: 06/26/201’ FORM APPROVE 0MB NO. 0938-039’ DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (xl) PROVIDERI5UPPLIERCLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION C 04111/2014 B. WING 194020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 118 Continued From page 90 assessed and updated in an orderly and clinically sound manner. Review of Patient #3’s medical record revealed a 13 year old female admitted 03/20/14 with psychiatric diagnoses of Suicidal Ideation, Self Mutilating, and depression. Review of Patient #3’s Interdisciplinary Treatment Plan revealed: Short Term Goals: “Pt will verbalize no longer having thoughts of self harm x (times) (left blank) consecutive days. Pt will express feelings that underlie suicidal ideation within (left blank) days. Pt will verbalize positive talk about self and the future X (left blank) consecutive days Under Interventions, the following was listed: “Monitor and adjust meds daily.” Responsible Staff was listed as the physician. “Encourage positive talk about self and future. Daily. Responsible staff was listed as social services. Provide active/passive listening in order to facilitate expression of feelings...Process with pt about feelings and behaviors which lead to Sl...WiIl be placed on suicide precautions...” LA 71106 PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5I COMPLETION DATE B 118 Review of Patient #11’s medical record revealed a 15 year old female admitted 02/21/14 with multiple psychiatric diagnoses which included: Suicidal Ideation, Depression, and self mutilating behaviors. Review of Patient #11’s Interdisciplinary Treatment Plan revealed under a section titled “SHORT TERM GOALS”: “Problem #1” was identified as Suicidal Ideation. Further review revealed under “GOALS” they were listed as: “Pt (patient) will verbalize no longer having thoughts of self harm x 5 consecutive days.”; “Pt will express feelings that underlie suicidal ideation within 5 days.”; “Pt will verbalize positive talk about self and the future X 5 consecutive days.”...Under a section titled “INTERVENTIONS” were the following: “MODALITY 1:1 FORM CM5-2567(02-99) Previous Versions Obsolete Event ID:V3D211 Facility ID: HOODD1728 If conunuation sheet Page 91 of 10 PRINTED: 06/26/201 FORM APPROVE[ 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERISUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 194020 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG 04/11/2014 SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 118 Continued From page 91 INTERVENTION Monitor and adjust meds (medications) pin (as needed) FREQ (frequency) qd (every day) RESP (responsible) STAFF MD (physician) DISCIPLINE physician; 1:1 Encourage expression of feelings. Daily RN (registered nurse) Nrsg/SS (nursing/social services); 1:1 Reinforce positive talk about self and future. PRN. RN. Nrsg; Provide active/passive listening in order to facilitate expression of feelings. PRN. RN. Nrsg.; 1:1 Process with pt about feelings and behaviors which lead to SI (suicidal ideation). PRN. RN. Nrsg.;... PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD SE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5I COMPLETION DATE B 118 Review of Patient #15’s medical record revealed a 13 year old female admitted 04/02/14 with psychiatric diagnoses of Suicidal Ideation, Self Mutilating and Auditory Hallucinations. Review of Patient #15’s Interdisciplinary Treatment Plan revealed the same treatment for Suicidal ldeatjons as for Patient #s3 and 11. Review of Patient #20’s medical record revealed: 13 year old female admitted 04/05/14 with psychiatric diagnoses of Suicidal Ideation, Self Mutilating, AuditoryNisual Hallucinations, and Depression. Review of the Interdisciplinary Treatment Plan for Suicidal Ideation revealed it was the same as Patient #S 3, 11 and 15. Review of Patient #21’s medical record revealed 13 year old female admitted 03/28/14 with psychiatric diagnoses of Suicidal Ideation, Self Mutilating, Aggression, and Depression. Her Interdisciplinary Treatment Plan for Suicidal Ideation mirrored the plans for Patient #s 3, 11, 15 and 20. Review of Patient #22’s medical record revealed FORM CM5-2567(O2-99) PrevIous versions Obsolete Event ID:v3D2ll Facility ID: H00001728 If continuation sheet Page 92 of 101 PRINTED: 06/26/201 FORM APPROVE 0MB NO. 0938-039’ DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 04111/2014 SWING 194020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BRENTW000 HOSPITAL 1006 HIGHLAND AVENUE SHREVEPORT, LA 71106 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 118 Continued From page 92 a 13 year old female admitted 04/05/14 with psychiatric diagnoses of Suicidal Ideation, Auditory/Visual Hallucinations, and Sexual Abuse Victim. Review of Patient #22’s Interdisciplinary Treatment Plan revealed the plan for SUicidal Ideation was the same as Patient #S 3, 11, 15, 20 and 21. PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE B 118 Review of Patient #23’S medical record revealed a 12 year old female admitted 03/25/14 with psychiatric diagnoses of Suicidal Ideation, Potential for violence and anger management issues. Review of the Interdisciplinary Treatment Plan for Suicidal Ideation was the same as for Patient#s 3, 11,15,20,21 and 22. Review of Patient #25’s medical record revealed a 10 year old female admitted 03/27/14 with psychiatric diagnoses of Suicidal Ideation, Depression, and Poor Impulse Control. Review of Patient #25’s Interdisciplinary Treatment Plan for Suicidal Ideation was the same as Patient #S 3, 11, 15, 20, 21, 22 and 23. Continued reviews of Patient #s 1, 2, 6, 9, 10, 27 and 30 revealed all had psychiatric admission diagnoses that included Suicidal Ideation. Reviews of Interdisciplinary Treatment Plans for Patient #s 1, 2, 6, 9, 10, 27 and 30 revealed the same generic plans for suicidal ideation as for the above referenced patients (#s 3, 11, 15, 20, 21, 22, 23, and 25). Ill) Review of patient #7’s medical record revealed the patient was admitted to the hospital on 10/25/13 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder and Impulse Control Disorder. On 2/20/14, patient #7 alleged S42 Mental Health Technician pushed FORM cMS-2567(02-99) Previous versions Obsolete Event ID:v3D21l Facility ID: H00001728 If continualion sheet Page 93 of 101 PRINTED: 06/26/201 FORM APPROVE[ 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 194020 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG B 118 SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 0411112014 93 PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE B 118 him down onto the bed and “back handed” him across the mouth when he called her an “old bitch”. According to the abuse allegation investigation Conducted 2/20/14 and 2/21/14 by 53 Risk Manager/Patient Advocate to was revealed on the Final Report “(S42 MHT) stated when (patient #7) was redirected he told her she couldn’t tell him what to do, was spitting at her and calling her a bitch. The MHT stated she placed her hands, one on each of his shoulders and encouraged him to lie down and relax. (S42 MHT) stated she placed her index and middle finger on his mouth and encouraged him to deep breathe. (S42 MHT) stated after she did this (patient #7) started hollering he was going to tell on her and she responded by telling him no he wasn’t because she was going to tell first...” Review of the Master Treatment Plan dated 2/1/14 revealed problem #7 was identified as “Seclusion and physical hold to patient exhibiting out of control behavior, a severe disruption in milieu, or patient is a danger to self or other as exhibited by: combative and violent towards staff, hitting and kicking, charging to attack, refusing to stay in time out room. The interventions listed were 1) Staff will lay eyes on patient Q 15 minutes, 2) Staff will remove all contraband prior to placing patient in seclusion/restraints, 3) Staff will remove all other patients from immediate danger, and 4) Staff will notify MD/family to give an update, 5) Administer any PRN medication. On 2/1 2/1 4, the Treatment Plan was updated and the patient’s progress towards the goals since last review were identified as impulsive, hyperactive, withdrawn, aggressive, isolative, poor social skills, anxious, and attacks others. The revised interventions were: 1) medication management, 2) Set up aftercare appointments, FORM cM5-2567(O2-99) Previous versions Obsolete Event ID:v3D2ll Facility ID: H00001728 If continuation sheet Page 94 of 101 PRINTED: 06/26/201 FORM APPROVEL 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER’SUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C B. WING 194020 0411112014 STREET ADDRESS, CITY. STATE. ZIP CODE NAME OF PROVIDER OR SUPPLIER 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 118 Continued From page 94 3) Group, Family, Recreational Therapy, and 4) Education on communications skills. PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG IX5) COMPLETION DATE B 118 On 2/26/1 4, the Treatment Plan was again updated with the addition of the patient’s progress towards goals identified as attention seeking behaviors, disrespectful, manipulative, pushes limits, obnoxious, demanding, and extremely intrusive. Review of the revised interventions for 2/26/14 revealed they were the same as 2/12/14 even though the patient was exhibiting more behaviors. The Treatment Plan failed to identify the interventions implemented by S42 MHT which included taking patient #7 by the shoulders and placing her fingers over the patient’s mouth in order to calm him down. B 131 482.61(d) RECORDING PROGRESS 8 131 Progress notes must contain recommendations for revisions in the treatment plan as indicated. This STANDARD is not met as evidenced by: Based on interview and record review the hospital failed: 1) to record patient progress as evidenced by failing to ensure the patient’s doctor made recommendations for revisions to the patient’s treatment plan to address sexually inappropriate behavior/language for 1 (#1 0) of 1 (#10) patients reviewed for sexually inappropriate behavior/language; and 2) to ensure documentation placed in patient records was factual relative to activity participation for 2 of 4 patients reviewed (#s 16, 30). FORM cM5-2567(02-99) Previous versions Obsolete Event ID: V3D211 Facility ID: H00001728 If continuation sheet Page 95 of 101 PRINTED: 06/26/201 FORM APPROVEI 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION I (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION I(X3) DATE SURVEY A. BUILDING I STREET ADDRESS, CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL B 131 C 04/11/2014 B. WING NAME OF PROVIDER OR SUPPLIER (X4) ID PREFIX TAG COMPLETED SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 95 Findings: Review of the policy entitled Multi-Disciplinary Treatment Planning, last review/revision date: 3/14, revealed the following, in part: I. Policy: The purpose of the treatment plan is to provide a complete plan of care based on an integrated assessment of the patients specific needs and problems. The treatment plan also provides appropriate communication between team members that fosters consistency and continuity in the care of the patient. Each patient will have a multidisciplinary, individualized treatment plan. The treatment plan serves as an organizational tool whereby the care rendered each patient is designed, implemented, assessed and updated in an orderly and clinically sound manner. Review of the Hospital s incident reports for the last three months revealed the following incidents involving Patient #10: PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE B 131 ‘ 2)17/14: Patient loud, disruptive, yelling and cursing staff, took an aggressive stance and threatened to “beat up staff”. 2)18/14: Physical altercation with peer. 2/28/14: agitated, threatening and cursing peers. fighting staff. 3/3/14: Patient #10 attempted to attack staff. 3/10/14: alleged touching of female peer’s breast. Patient denies touching female peer. 3/18/14: Patient denies touching female peer. Review of the hospital s grievance log for the last three months revealed the following complaints related to allegations of inappropriate sexual conduct against Patient #10: Complaint #1: Date submitted: 3/12/14, Date to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:v3D2ll FaCility ID: H00001728 If continuation sheet Page 96 of 10 PRINTED: 06/26/201’ FORM APPROVE[ 0MB NO. 0938-039’ DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION I (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION I(X3) DATE SURVEY A. BUILDING I I NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BREN1WOOD HOSPITAL B 131 C 04111/2014 B. WING 194020 (X4) ID PREFIX TAG COMPLETED SHREVEPORT, SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 96 Patient Advocate: 3/1 2/1 4, Complainant: Patient #11: Date resolved: 3/18/14; Program involved: Nursing; Complaint Issue: Accused male peer (Patient #10) of touching. Complaint #2: Date Submitted: 3/1 6/1 4, Date to Patient Advocate: 3/1 9/1 4, Complainant: Patient #12: Date resolved: 3/20/1 4; Program involved: Nursing, Social Services; Complaint Issue: Accused male peer (Patient #10) of touching. LA 71106 PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XSI COMPLETION DATE B 131 Review of Patient #10 s medical record revealed he was a 13 year old male who had been admitted to the Hospital on 2/3/14 with diagnoses including the following: Attention Deficit Hyperactivity Disorder (ADHD), Depression/Psychosis: Severe; Mild Intellectual Disability, and Conduct Disturbance. Further review revealed the patient’ s legal status was PEC (Physician’s Emergency Certificate) 213/14 at 12:45 p.m. with reason for admission listed as potential danger to self, unable to seek voluntary admission. Review of Patient #10’s medical record revealed a Seclusion/restraint order/record dated 2/28/14 at 6:55 a.m. The explanation given for the order was as follows: Patient agitated yelling at females on unit stating, “One of you B (expletive) gonna suck my (penis) today “. Fighting staff when redirected and asked to stop and go to time out. Review of Patient #10’s medical record revealed the following entries, in part: ‘ Interdisciplinary Notes, dated 3/10/14, 8:00 p.m.: Hypersexual most of shift. Telling female peers, You want to sit on it “ as well as hugging another female peer who didn ‘t complain, however was redirected yet again not to touch any peers. When redirected by charge nurse to go to room as everyone else did he said, “F (expletive) you FORM CM52567(O2-99) Previous versions Obsolete Event ID: V3D211 Facility ID: H000D1728 If conbnuation sheet Page 97 of 1 rn PRINTED: 06/26/201 FORM APPROVEI 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER’SUPPLIERICLIA IDENTIFICATION NUMBER 194020 (X2) MULTIPLE CONSTRUCTION C 0411112014 B. WING NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE BREN1WOOD HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING 06 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORtMJION) B 131 Continued From page 97 ho.” Told a peer I need another hug, can I touch your body. PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE B 131 Nursing Progress Notes, dated 3/10/14, 10:00 p.m., 3-11 shift: Patient #10 presents with labile affect, pushing limits, refusing to redirect at times. Female peer accused Patient #10 of touching her breast, patient stated, “I was gonna touch her but I didn ‘t. Review of Patient #10 s Master Treatment Plan revealed sexually inappropriate behavior/language was not identified as a problem on the treatment plan after the first incident which occurred on 3/10/14. Asecond incident of inappropriate sexual behavior by Patient#10, almost identical to first incident, was reported byanotherfemale peer on 3/16/14. In an interview on 4/10/14 at 2:12 p.m. with Si 2YouthServicesManager She was asked if she was familiar with Patient#10 ‘s sexually inappropriate behavior/language and she replied, “Yes”. She reviewed Patient #10’s MD progress notes and the Master Treatment Plan and confirmed there were no MD progress notes that had addressed the need for revisions in Patient#10’s Master Treatment Plan related to management of his sexually inappropriate behavior/language after the first allegation of sexually inappropriate behavior on 3/12/14 (occurred on 3/10/14, reported on 3/1 2/1 4). ‘ Review of Incident/Accident Reports, dated 03/21/1 4, revealed 4 patients (#s16, 7??) eloped from the hospital on 03/21/14 at 7:40am. Review of Patient #s 16 and 30 revealed a form titled, “Activity Group”. Review of the Activity Group form for each of the above patients revealed Activity Therapist had documented, FORM CMS-2567(O2-99) Previous versions Obsolete Event ID:v3D21I Facility ID: H00001728 If continuation sheet Page 98 of 101 PRINTED: 06/26/201 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PRO VIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: FORM APPROVE 0MB NO. 0938-039 (X2) MULTIPLE CONSTRUCTION C 0411112014 B. WING 194020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTW000 HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 131 Continued From page 98 03/21/14 at 10:00am, attended and participated in the group activity. This was not possible as these patients had eloped at 7:40am on 03/21/14 and were not found and returned to the hospital until 11:30am; therefore it would not be possible for them to have attended group at 10:00am on 03/21/14. B 136 482.62 SPECIAL STAFF REQS FOR PSYCH HOSP ITALS PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE B 131 B 136 The hospital must have adequate numbers of qualified professional and supportive staff to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures and engage in disCharge planning. This CONDITION is not met as evidenced by: Based on observations, interviews and record reviews, the hospital failed to have adequate numbers of qualified professional and supportive staff to assure for patient safety and the effective implemenation of the patients treatment plan. This was evidenced by nursing services failure to have adequate numbers of licensed registered nurses, licensed practical nurses, and mental health technicians to provide nursing care to all patients as needed. This deficient practice is evidenced by: I) observations conducted, 04/08/14 at 5:25am through 5:45am, on the girls hall of the Open Adolescent Unit revealed 5 patients (#s 2, 3, 19, 20, 21) were on roll away beds located in the dayroom. S35 Mental Health Technician (MHT) confirmed the 5 patients were sleeping in the dayroom because they are all on constant visual observation and it was easier to observe them all FORM CM5-2567(02-99) Previous versions Obsolete Evenl ID:V3D211 Facility ID: H0000l728 If continuation sheet Page 99 of 101 PRINTED: 06/26/201 FORM APPROVEE 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDEWSUPPLIER’CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C B. WING 194020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG 04111/2014 SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORNtATION) B 136 Continued From page 99 in here’. Census revealed a total of 26 females on the Adolescent Unit with 1 Registered Nurse and 1 MHT. II) failing to transfer a patient to a local emergency room for evaluation and treatment after an attack by another patient for 7 hours and 2 minutes after the Physician ‘ s Order had been written due to lack of staffing for 1 (#5) of 3 (#5, i #32, #35) patients reviewed for response to injury. :111) failing to transfer an adolescent patient with a broken wrist to the emergency room for treatment for 1 hour and 45 minutes after the order had been written for 1 (#32) of 3 (#5, #32, #35) patients reviewed for response to injury. See findings at B0150. B 150 482.62(d)(2) NURSING SERVICES PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X51 COMPLETION DATE B 136 B 150 There must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient’s active treatment program. This STANDARD is not met as evidenced by: Based on observations, interviews and record reviews, the hospital failed to ensure the nursing service had adequate numbers of licensed registered nurses, licensed practical nurses, and mental health technicians to provide nursing care to all patients as needed. This deficient practice is evidenced by: I) observations conducted, 04/08/14 at 5:25am through 5:45am, on the girls hall of the Open Adolescent Unit revealed 5 patients (#s 2, 3, 19, FORM CM5-2567(02-99) Previous Versions Obsolete Event ID:V3D211 Facility ID: H00001728 If continuation sheet Page 100 of 10 PRINTED: 06/26/201 FORM APPROVE[ 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 194020 A. BUILDING C 04/11/2014 B. WING STREET ADDRESS. CITY. STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 150 ContinUed From page 100 20, 21) were on roll away beds located in the dayroom. 535 Mental Health Technician (MHT) confirmed the 5 patients were sleeping in the dayroom because “they are all on constant visual observation and it was easier to observe them all in here”. Census revealed a total of 26 females on the Adolescent Unit with 1 Registered Nurse and 1 MHT. II) failing to transfer a patient to a local emergency room for evaluation and treatment after an attack by another patient for 7 hours and 2 minutes after the Physician ‘s Order had been written due to lack of staffing for 1 (#5) of 3 (#5, #32, #35) patients reviewed for response to PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XS) CDMPLETIDN DATE B 150 injury. Ill) failing to transfer an adolescent patient with a broken wrist to the emergency room for treatment for 1 hour and 45 minutes after the order had been written for 1 (#32) of 3 (#5, #32, #35) patients reviewed for response to injury. Findings: I) Observations, 04/08/14 at 5:25am through 5:45am, revealed there were 5 female patients (#s2, 3, 19, 20, and 21) lying on roll away beds in the dayroom of the girls hall of the Adolescent Open Unit. Review of the census for the Adolescent Open Unit revealed 26 female patients; and of the 26 female patients, 5 of them were ordered on “Constant Visual Observations” (CVO). Interview, 04/08/14 at 5:35am, with 535 MHT confirmed the reason the 5 patients were sleeping in the dayroom was a result of lack of staff available. Review of the staffing grid for the Adolescent Unit revealed (for a total of 40 patients) the staffing was set at 5 for the llp-7a shift; however the “Daily Staffing Worksheet” revealed there were only 4 staff members working the Adolescent Unit on 04/07/14 llp-7a shift. FORM cMs-2567(02-99) Previous versions Obsolete Event ID:V3D211 Facility ID: H0000I 728 Ilcontinuation sheet Page 101 of 10 PRINTED: 06/26/201 FORM APPROVEI 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PRO VIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION C 04/1112014 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 1006 HIGHLAND AVENUE BRENTW000 HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 150 Continued From page 101 Interview, 04/09/14 at 1:30pm, with S2 Director of Nursing (DON) revealed when questioned about the staffing patterns for the various units, 52 DON stated the hospital utilized a staffing grid which had all the units listed with different patient and staffing numbers that would be required depending on the number of patients that was on eaCh unit. The surveyors asked 52 DON how did the staffing grid take into consideration the need for additional staffing for patients who were ordered on 1:1 (a staff member must be at arms length from the 1:1 patient at all times), or Constant Visual Observation (CVO--line of sight at all times); S2 DON stated she had attempted to hire additional staff, especially MHTs, however, they “either can’t pass the background check or they can’t pass the testing”. S2 DON confirmed nursing staffing has been lacking on some units and some shifts. PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG {X5) COMPLETION DATE B 150 II) Failing to transfer a patient to a local emergency room for evaluation and treatment after an attack by another patient for 7 hours and 2 minutes after the Physician ‘ s Order had been written due to lack of staffing. Review of the medical record for Patient #5 revealed she was a 57 year old female admitted to the hospital on 2/19/14 with diagnosis which included Paranoid Schizophrenia, Review of the medical record for Patient #4 revealed he was a 23 year old male admitted to the hospital on 2/20/14 with diagnosis which included Schizoaffective Disorder. Further review revealed Patient #4 had a PEC dated 2/18/14 which listed him as gravely disabled and a CEC dated 2/19/14 which listed him as acutely psychotic. Review of the Hospital hand off communication sheet for Patient #4 dated FORM CMS-2567(02-99) Previous versions Obsolete Event ID:v3D2ll Facility ID: H00001728 If continuation sheet Page 102 of 101 PRlNTE06/26/20i’ DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER’SUPPLIERICLIA IDENTIFICATION NUMBER 194020 0MB NO. 0938-039’ (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING C 04/11/2014 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE BRENTWOOD HOSPITAL 1006 HIGHLAND AVENUE SHREVEPORT, LA 71106 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 150 Continued From page 102 2/20/14 at 10:30 a.m. revealed his reason for admission was, Danger to self and others, paranoid and his risk factors included violence, hit another patient. PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS.REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (XC) COMPLETION DATE B 150 “ Review of an Interdisciplinary Note for Patient #4 dated 2/23/14 at 11:50 a.m. revealed in part: Patient #4 came to nurse 5 station asking for his ‘codeine” and gesturing like he was smoking, fingers to lips saying, “marijuana.” Laughing inappropriately. A female peer (Patient #5) was already at nurse’ s station window when Patient #4 came up. When he was told he did not have “Codeine” available Patient #4 hit the nurse’s station window forcefully with an open hand. He then reached forward and put his hands on the female peers head (Patient #5). One hand on each side of her head simulating a crushing motion. Patient #4 then put his arm around the patient’s neck, his arm and elbow bent, putting patient in a head lock. Patient #4 then released female peer’s neck and threw her to the floor and began kicking her. Code Green called, Patient #4 made threats to harm a female nurse and required assistance of multiple staff members to calm him and assist him with seif-de-escalation. Patient #4 abruptly stated, “He was fine and wanted to go to the time out room, per his own request, not at staffs direction so he could be by himself. Patient #4 laid on mattress in time out room and went to sleep.” ‘ A review of the medical record for Patient #5 revealed an interdisciplinary note dated 2123/14 at 11:50 am. Review of the note revealed in part: “Patient #5 was attacked by a male peer while she was standing at nurses station speaking with nurse. A male peer walked up behind her, placed his hands on her head in a crushing like motion. FORM CMS-2567(02-99) Previous Versions ObscIete Event ID:V3D211 Facility ID: HOCC01728 If continuation sheet Page 103 of 101 PRINTED: 06/26/201 FORM APPROVE 0MB NO. 0938-039’ DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 194020 (X2) MULTIPLE CONSTRUCTION C 04111/2014 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 150 Continued From page 103 He then put his arm with elbow around her neck in a head back type motion. He released her neck and shoved her to the floor and she was kicked by him 2-3 times. Patient was on the floor, on her right side and was kicked on her left side lower rib and hip area. Staff assisted Patient to shelter in the ladies shower room. Patient was crying and emotionally shaken. Her body was examined for injury. No broken skin, bleeding or bruising noted. Patient did complain of pain to her right hip area. She was able to walk and move all extremities well. She stated, ‘He beat me and I want the police.’ Local Police Department was notified by nursing supervisors. Officer responded and collected information. Ultimately a summons was issued to the male peer and he was charged with simple battery. S43MD notified regarding patient being beat up. 543MD called Hospital A and spoke with ER MD. Patient to be taken there for evaluation”. PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG IX5) COMPLETION DATE B 150 Review of the medical record for Patient #5 revealed a Physician’s Order dated 2/23/14 at 12:45 p.m. which read in part: “Send pt (patient) to Hospital A ER (Emergency Room) for evaluation. Pt was physically assaulted by a male peer/ choked/ hit and thrown to the floor, kicked repeatedly when shoved to the floor.” Review of the Interdisciplinary Notes for Patient # 5 revealed an entry on 2/23/14 at 7:47 p.m. which stated in part: “To Hospital A ER via ambulance transport for physical evaluation. Patient #5 is complaining of R (right) side pain between breast and hip. She rates 10/10 at this time. Further review of the Notes and Physician’s Orders revealed no documentation that the Physician had been notified that Patient #5 was not going to be sent to the ER for over 7 hours. “ FORM cM5-2567(02-99) Previous versions Obsolete Event ID: V3D211 Facility ID: H0000l 728 If continuation sheet Page 104 of 101 PRINTED: 06/26/201 FORM APPROVE 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 194020 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG 0411112014 SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 150 Continued From page 104 PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE B 150 In an interview on 4/8/14 at 2:30 p.m. with S22RN, he said he was a nursing supervisor on the weekends at the hospital. 522RN said on 2/23/14 he wanted 5 Staff for the Adult Enhanced Unit (AEU) but could only find 4 staff to work. 522RN said the AEU was 1 person short on staffing because the unit had 2 patients that were 1:1 observations. 522RN said on 2/23/14 he remembered when the ADU called a Code Green, he went to the unit and Patient #4 was already in the dining room with staff. 522RN said he talked to Patient #5 and she was complaining of pain to her abdomen where she had been kicked by Patient #4. He said the physician ordered Patient #5 to go to the Emergency Room to be examined at 12:45 p.m., but another patient from another unit was medically unstable and had to be sent to the hospital. S22RN said at the time if he would have sent 2 staff members to the hospital with patients the hospital would have been too short staffed. 522RN said he was not aware if the physician was notified of the delay in treatment. After review of the medical record for Patient #5, he verified there was no documentation of physician notification for the delay in sending Patient #5 to the hospital until 7:47 p.m. (7 Hours and 2 minutes after the Physician s Order).S22RN also verified after Patient #4 was made a 1:1, there were 3 patients on 1:1 for 3 staff members and 11 other patients on theAEU for 1 staff member. S22RN said the unit was definitely short staffed on 2/23/14. 522RN also said the hospital was short at least 4 staff members on various units for the 7-3 shift on 2/23/14. ‘ Review of the Daily Staffing Worksheet for 7am-3pm on 2/23/14 revealed the beginning FORM cMs-2567(o2-gg) PrevIous versions Obsolete Event ID:v3D211 Facility ID: H00001728 If Continuation sheet Page 105 of 1O PRINTED: 06/26/201 FORM APPROVE[ 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROVIDERISUPPLIER’CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. BUILDING C 194020 B. WING NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY. STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTW000 HOSPITAL (X4) ID PREFIX TAG 0411112014 SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 150 Continued From page 105 census on theAEU was 13 and the ending census was 14. The 1:1 patients were listed as 2 females. “3 + 2” was written above the staff’ s names. In an interview on 4/8/14 at 2:30 p.m. with 522RN he said he filled out the staffing sheets for the units on 2/23/14. He said the “3” above the staff’ s names was what staff he had available and the 0+2k was how many more staff he needed for the shift. He said he needed 5 people for the shift on the AEU, but had 4 available. He also verified by the end of the shift, 3 of the 14 patients were 1:1 observation patients with only 4 staff members. He said being 1:1 required the staff member to be within arm ‘s length of the patients at all times. PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG IXS) COMPLETION DATE B 150 In an interview on 4/9/14 at 1:16p.m. with S24RN, she said she worked on the AEU and was in the nurses’ station when the altercation happened between Patient #4 and Patient #5 on 2/23/1 4. 524RN said the doctor was not notified until 25-30 minutes after the incident because she was examining Patient #5 and calming her down. 524RN said she was the first one to call the doctor and he ordered Patient #4 to be on a 1:1 observation, made some medication changes for Patient #4 and ordered Patient #5 to be sent to the Emergency Department for evaluation. S24RN said she called the nursing supervisor for more help during the shift, but he could not get anybody. 524RN also said she notified the supervisor about Patient #4 needing to go to the ED, but she did not go until about 8:00 at night. S24RN said she called back a couple of times to get Patient #4 sent to the ED, but she assumed the patient did not go until later because of staffing. 524RN said none of the phone calls were documented. S24RN was unable to locate documentation that Patient #5 was reassessed by FORM cM5-2567(02-99) Previous Versions Obsolete Event ID:v3D2ll Facirity ID: H00001728 If continuation sheet Page 106 of lDl PRINTED: 06/26/201 FORM APPROVEI 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES (XI) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION C 04/1112014 B. WING 194020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING SHREVEPORT, LA 7l106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B 150 Continued From page 106 a nurse after the initial assessment at 11:50 a.m. Until she was transferred to the hospital at 7:47 p.m. PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG {X5) COMPLETICN DATE B 150 In an interview on 4/9/14 2:05 p.m. with S9RN, she said She was working on 2/23/14 on the Adult Enhanced Unit (AEU). S9RN said the two 1:1 patients she and S25MHT had were not actually being watched 1:1 because of staffing. S9RN said Patient #5 did not go to the hospital for several hours after the attack because the supervisor (S22RN) and S24RN told her there was not enough staff to transport patient #5 to the ED. S9RN said to her knowledge the physician was never notified about Patient #5 not going to the ED immediately. S9RN said she knows the AEU was short staffed on 2/23/1 4. S9RN said the Adult Enhanced Unit is short staffed a lot because of the high acuity of the patients. Review of the hospital Document titled Staffing Ratios by Unit and Census Level (staffing grid) revealed in part: Adult Enhanced Unit (AEU): 14 bed unit. 3 staff on days (7:00 a.m. 3:00 p.m.) for 5-12 patients. Further review revealed no staffing grid for a census over 12 patients. In an interview on 4/10/14 at 2:50 p.m. with S2DON, she verified the staffing needed to be increased on the unit for 2/23/14 and the staffing for the 7:00 a.m. to 3:00 p.m. did not meet the hospital staffing grid requirements. S2DON said the 2 of 4 staff assigned to 1:1 patients should have not been included in the grid.S2DON said for 12 patients other than the 1:1 patients on 2/23/14, the unit required 3 staff members per the staffing grid but only had 2. She said from 3:00 p.m. until 11:00 p.m., the AEU had 5 staff but 3 patients on 1:1 which still left the unit short one staff member. S2DON also verified she could not - FORM CMS-2567(D2-99) Previous versions Obsolete Event ID:v3D2I1 Facility ID: H00001728 If continuation sheet Page 107 of 10; PRINTED: 06/26/201 FORM APPROVEI 0MB NO. 0938-039 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xl) PROvIDER’SuppLIER’cLIA IDENTIFICATION NUMBER: A. BUILDING C 04/11/2014 B. WING 194020 STREET ADDRESS, CITY, STATE, ZIP CODE NAME OF PROVIDER OR SUPPLIER 1006 HIGHLAND AVENUE BRENTWOOD HOSPITAL (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION SHREVEPORT, LA 71106 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORNtTION) B 150 Continued From page 107 locate a nursing or physician assessment of Patient #5 after the initial assessment at 11:50 a.m. until she was transferred to the hospital at 7:47 p.m. Ill) Failing to transfer an adolescent patient with a i broken wrist to the emergency room for treatment for 1 hour and 45 minutes after the order had been written PROVIDER’S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE B 150 Review of patient #32’s medical record revealed the following documentation on “Interdisciplinary Notes, dated 04/07/2014: 3:00pm Patient #32 on floor of room scream ing...states ‘my arm got slammed in the door’: patient #32 holding his right forearm/wrist area, edema noted, bruising noted at right lower forearm, arm immobilized on pillow for support: 3:1 5pm 558 psychiatrist notified, and X-ray ordered: 6:50pm X-ray perIormed...7:45pm 558 psychiatrist notified of X-ray results and orders to transfer patient to Hospital A obtained: 9:30pm patient #32 transported to Hospital Afor treatment. Review of Physician’s Orders, dated 04/07/1 4, 3:10pm, revealed “X-Ray (R) [right] Forearm today”...04/07/14, 7:45pm, “Transfer” to Hospital A’ior evaluation of’ right arm. Interview, 04/09/14 at 3:00pm, with S2 Director of Nursing revealed the reason for the delay for transferring Patient #32 was as a result of not having enough personnel on staff to transport this patient. S2 DON stated Patient #32 waited because a staff member had to be called in to transport Patient #32. FORM CMS-2567(02-99) Previcus Versions Obsolete Event ID: V30211 Facility ID: H00001728 If continuation sheet Page 108 of 10 1 / [<