Baton Rouge Behavioral Hospital

“NURSING SERVICES CFR(s): 482.23 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: 48051 Based on record review and interview the hospital failed to meet the Conditions of Participation (CoP) of Nursing Services. This deficient practice was evidenced by: 1) Failure to obtain orders from a physician or licensed practitioner upon admissions; and 2) Failure to document receiving admission orders from a qualified physician or licensed practitioner on 3 (#2, #4, #5) of 6 (#1 -#6) patient medical records reviewed. (See findings under Tag A0395)”

“CARE OF PATIENTS - ADMISSION CFR(s): 482.12(c)(2) [ ...the governing body must ensure that the following requirements are met:] Patients are admitted to the hospital only on the recommendation of a licensed practitioner permitted by the State to admit patients to a hospital. This Standard is not met as evidenced by: 48051 Based on record reviews and interviews, the hospital failed to ensure all patients were admitted to the hospital only on the recommendation of a licensed practitioner as evidenced by failing to consult a provider to make a final decision for admission or denial on 1 (#1) of 6 (#1 - #6) patient medical records reviewed. Findings: A review of facility policy “Initial Screening and Criteria for Admission,” Policy Number NUR 2:001/ADM 1.003, revised 05/11/2023, revealed in part, Procedure #5. The attending Psychiatrist or designee will make final decision for admission or denial of patients to facility. A medical record review of Patient #1 revealed the patient being admitted on 11/27/2023 at 7:50 p.m. The admission orders were dated and timed for 11/27/2023 at 9:47 p.m. These orders were noted as being received by Telephone Order Read Back S5MD and signed by S7RN 11/27/2023 at 9:47 p.m. A progress noted on 11/28/2023 at 8:23 a.m. by S6NP revealed in part, “I was notified of admit on 11/28/2023 at 12:06 a.m.” There was no documentation regarding the contact of a provider or provider review of initial screening to make a decision on approval or denial of admissions. In telephone interviews on 01/03/2023 at 2:40 p.m. and 01/04/2023 at 10:15 a.m. S7RN confirmed in both interviews, the documented date and time on the Admission Orders/24 Hour Orders of 11/27/23 at 9:47 p.m. was incorrect. S7RN confirmed she made contact with S6NP on 11/28/2023 at 12:06 a.m. and a psychiatric NP around the same time. S7RN was unable to give the name or exact time of the contact with the Psychiatric NP because she was unable to remember. S7RN confirmed this was the first contact she had made with the two providers in regards to the admission of this patient. S7RN revealed she would not obtain the admissions orders and this would take place with intake staff. S7RN confirmed she was the night shift RN and the night shift RN would be the intake staff and admissions nurse. In an interview on 01/04/2023 at 10:20 a.m. S8RNIntake confirmed the Admission Orders/24 Hour Orders and the orders are used by S5MD as his standing orders upon admission. S8RNIntake indicated these orders are checked off by the admitting nurse and the date and time at the top of the orders would be used as the time the provider was contacted. S8RNIntake further acknowledge there would be no other documentation in regards to the admitting provider being contacted. S8RNIntake confirmed the contact of the provider for approval or denial of an admission is completed by the Intake RN during on the day shift. S8RNIntake confirmed the 7:00 p.m. - 7:00 a.m. RN supervisor or unit nurse on duty would make contact with the provider regarding approval or denial of admission. In an interview on 01/04/2023 at 7:30 a.m. S2DON confirmed the night shift RN on the unit would make contact with the admitting provider for approval or denial of an admission. S2DON also confirmed there is no documentation a provider was contacted regarding Patient #1 admissions until 11/27/2023 at 12:06 a.m.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48051 Based on record review and interview the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient. This deficient practice is evidenced by: 1) Failure to obtain orders from a physician or licensed practitioner upon admissions; and 2) Failure to document receiving admission orders from a qualified physician or licensed practitioner on 3 (#2, #4, #5) of 6 (#1 -#6) patient medical records reviewed. Findings: 1) Failure to obtain orders from a physician or licensed practitioner upon admissions A medical record review of Patient #1 revealed the patient being admitted on 11/27/2023 at 7:50 p.m. The admission orders were dated and timed for 11/27/2023 at 9:47 p.m. These orders were noted as being received by Telephone Order Read Back S5MD and signed by S7RN 11/27/2023 at 9:47 p.m. A progress noted on 11/28/2023 at 8:23 a.m. by S6NP revealed in part, “I was notified of admit on 11/28/2023 at 12:06 a.m.” The patient was admitted to the hospital for approximately 4 hours without a practitioner’s orders. In telephone interviews on 01/03/2023 at 2:40 p.m. and 01/04/2023 at 10:15 a.m. S7RN confirmed in both interviews, the documented date and time written on the Admission Orders/24 Hour Orders of 11/27/2023 at 9:47 p.m. was incorrect. S7RN confirmed she made contact with S6NP on 11/28/2023 at 12:06 a.m. and a psychiatric NP (nurse practitioner) around the same time. S7RN was unable to give the name or exact time of the contact with the Psychiatric NP because she was unable to remember. S7RN confirmed this was the first contact she had made with the two NP’s in regards to the admission of this patient. S7RN confirmed she completed the admission orders for Patient #1 by placing the checks by each item and these orders were not completed by a physician or NP. S7RN confirmed she was the night shift RN and the night shift RN would be the intake staff and admissions nurse. In an interview on 01/04/2023 at 10:20 a.m. DON confirmed Patient #1’s above mentioned time frames regarding admissions and NP contact. DON confirmed the approximate 4 hour time frame of the patient being admitted with no physicians’ admission orders. 2) Failure to document receiving admission orders from a qualified physician or licensed practitioner on 3 (#2, #4, #5) of 6 (#1 -#6) patient medical records reviewed A review of facility policy, “Transcription of Physician Orders,” Policy Number NUR 6:012, effective 03/01/2018 revealed in part, Procedure 5. Item e-i. The receiver of a telephone order documents the order immediately on the prescriber order form including the date, time, authorized prescriber’s name/receivers name, status, and signature. A medical record review revealed Admission Orders/24 Hour Orders being initiated with no indication of which physician or licensed practitioner initiated the admission orders. The last entry on the order set is written as TROB Dr. ____. The entries on each patient are as follows: Patient #2 admission’s orders failed to reveal an initiating practitioner on 11/19/2023 at 5:30 p.m. and the admission orders were signed by the provider on 11/20/2023 at 9:00 a.m. Patient #4 admission’s orders failed to reveal an initiating practitioner on 01/03/2024 at 2:00 p.m. and the admission orders were signed by the provider on 01/04/2024 at 5:30 a.m. Patient #5 admission’s orders failed to reveal an initiating practitioner on 01/03/2024 at 12:00 noon and the admission orders were signed by the provider on 01/04/2024 at 5:00 a.m. In an interview on 01/04/2023 at 11:30 a.m. S2DON confirmed the above mentioned findings on the medical records.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure nursing staff administered drugs and biologicals according to accepted standards of practice. This deficient practice is evidenced by staff administrating medication without a physician order in 1 (#1) of 6 (#1-#6) patients sampled. Findings: A medical record review of Patient #1 revealed an order set, Admission Orders/24 Hour Orders being initiated on 11/27/2023 at 9:47 p.m. The order set was initiated and signed by S7RN as telephone read back orders from S5MD. These orders included an order for Trazadone 50mg PO QHS PRN insomnia being initiated. The medication administration record revealed Trazadone 50mg being administered on 11/27/2023 at 10:00 p.m. A nursing assessment by S7RN and documented as being completed on 11/27/2023 at 9:47 p.m. revealed an entry for Trazadone 50mg being received by Patient #1 at 10:00 p.m. In telephone interviews on 01/03/2023 at 2:40 p.m. and 01/04/2023 at 10:15 a.m. S7RN confirmed in both interviews, the documented date and time on the Admission Orders/24 Hour Orders of 11/27/23 at 9:47 p.m. was incorrect. S7RN confirmed she made contact with S6NP on 11/28/2023 at 12:06 a.m. and a psychiatric NP around the same time. S7RN was unable to give the name or exact time of the contact with the Psychiatric NP because she was unable to remember. S7RN confirmed this was the first contact she had made with the two providers in regards to the admission of this patient and she had not contacted S5MD. In an interview on 01/04/2023 at 9:15 am S2DON confirmed Patient #1 had been administered Trazadone 50mg on 11/27/2023 at 10:00 p.m. and the medication was administered prior to the providers being contacted upon admission of the patient.”

“CONTENT OF RECORD: ORDERS DATED & SIGNED CFR(s): 482.24(c)(2) All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations. This Standard is not met as evidenced by: 48051 Based on record review and interview the hospital failed to ensure all hospital orders were signed, dated, and timed by the physician or licensed practitioner. This deficient practice was evidenced by 1 (#1) of 6 (#1 - #6) patient medical records reviewed. Findings: A review of facility policy, “Transcription of Physician Orders,” Policy Number NUR 6:012, effective 03/01/2018 revealed in part, Procedure 5. Item b. Telephone orders must be signed, dated and timed by the physician with 48 hours of the order being given. A medical record review of Patient #1 revealed the Admission Orders/24 Hour Orders were not signed by the physician or licensed practitioner per hospital policy. In an interview on 01/03/2023 at 3:00 p.m. S2DON confirmed the orders had not been signed by the physician or licensed practitioner within 48 hours.”

“CONTENT OF RECORD: STANDING ORDERS CFR(s): 482.24(c)(3) (3) Hospitals may use pre-printed and electronic standing orders, order sets, and protocols for patient orders only if the hospital: (i) Establishes that such orders and protocols have been reviewed and approved by the medical staff and the hospital’s nursing and pharmacy leadership; (ii) Demonstrates that such orders and protocols are consistent with nationally recognized and evidence-based guidelines; (iii) Ensures that the periodic and regular review of such orders and protocols is conducted by the medical staff and the hospital’s nursing and pharmacy leadership to determine the continuing usefulness and safety of the orders and protocols; and (iv) Ensures that such orders and protocols are dated, timed, and authenticated promptly in the patient’s medical record by the ordering practitioner or another practitioner responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations. This Standard is not met as evidenced by: 48051 Based on record review and interview the hospital failed to demonstrate orders and protocols are consistent with nationally recognized evidenced based guidelines. This deficient practice is evidenced by 1 (#1) of 6 (#1-#6) patient medical records reviewed having admission order sets being completed by the registered nurse. Findings: A medical record review of Patient #1 revealed an admission order set titled Admission Orders/24 Hour Orders. The order set consist of 26 line item entries with boxes to check off to initiate an order. The options include Admit to___; Legal Status: pick option; Program: pick option; Precaution: pick option; Diet: pick option; Consults: Medical Physician and Other:___; Consult Dietician for: ___; Diagnostic Tests Required: pick option; For All Diabetic Patients: pick options; Activities as Tolerated; and 17 as needed medications that can give an option to each; and the last option is TORB Dr. ___. In an interview on 01/04/2023 at 10:15 a.m. S7RN confirmed when she admits a patient, she completes this order set on admission by checking each item down the page. S7RN confirmed it is not completed with the physician going down the page reviewing each item. S7RN also confirmed the physician’s name is placed in the TRBO fill in blank. S7RN confirmed this is S5MD standing orders and this is what is used for admissions. In an interview on 01/04/2023 at 10:20 a.m. S8RNIntake confirmed the Admission Orders/24 Hour Orders and their use as standing admission orders for S5MD. S8RNIntake also confirmed these orders are checked off by the admitting nurse without reviewing each item with the admitting physician or licensed practitioner.”

“DELIVERY OF DRUGS CFR(s): 482.25(b) §482.25(b) Standard: Delivery of Services 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: 48051 Based on record review and interview, the hospital failed to ensure patient safety related to drugs and biologicals being controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This deficient practice was evidenced by failing to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications. Findings: Review of the Louisiana Administrative Code, Professional and Occupational Standards, Title 46: LIII, Pharmacist, Chapter 15, Hospital Pharmacy, §1511, revealed in part: Prescription Drug Orders: Item A. The pharmacist shall review the practitioner’s medical order prior to dispensing the initial dose of medication, except in cases of emergency. A review of facility policy “Pharmacists Review of New Orders,” Pharmacy Policy Number: P1.007 and submitted by S10Pharm revealed in part, all new medication orders shall be reviewed by a licensed pharmacist prior to medication being passed to patient: Only medication orders that have been reviewed and approved by a licensed pharmacist are approved to be given to patients. A medical record review of Patient #1 revealed an order set, Admission Orders/24 Hour Orders being initiated on 11/27/2023 at 9:47 p.m. The order set was initiated and signed by S7RN as telephone read back orders from S5MD. These orders included an order for Trazadone 50mg PO QHS PRN insomnia being initiated. The medication administration record revealed Trazadone 50mg being administer on 11/27/2023 at 10:00 p.m. A nursing assessment by S7RN and documented as being completed on 11/27/2023 at 9:47 p.m. revealed an entry for Trazadone 50mg being received by Patient #1 at 10:00 p.m. The medical record failed to reveal any documentation related to the first medication dose being reviewed by a pharmacist before the first dose was dispensed for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications. In telephone interviews on 01/03/2023 at 2:40 p.m. and 01/04/2023 at 10:15 a.m. S7RN confirmed in both interviews, the documented date and time on the Admission Orders/24 Hour Orders of 11/27/23 at 9:47 p.m. was incorrect. S7RN confirmed she made contact with S6NP on 11/28/2023 at 12:06 a.m. and a psychiatric NP around the same time. S7RN was unable to give the name or exact time of the contact with the Psychiatric NP because she was unable to remember. S7RN confirmed this was the first contact she had made with the two providers in regards to the admission of this patient and she had not contacted S5MD. S7RN also confirmed there had been no contact with a registered pharmacist to review and approve this medication. In an interview on 01/04/2023 at 9:15 am S2DON confirmed Patient #1 had been administered Trazadone 50mg on 11/27/2023 at 10:00 p.m., this was prior to the providers being contacted and receiving admission orders and she was unaware of a first dose review being performed by pharmacist.”