Beacon Behavioral Hospital - Central

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48051 Based on observation and interview, the psychiatric hospital failed to ensure the patient right to receive care in a safe setting. This deficient practice is evidenced by: 1) Failure to ensure the patient care area was free of ligature risk; and 2) Failure to ensure the patient care area was free of items that could potentially cause harm or injury. Findings: 1) Failure to ensure the patient care area was free of ligature risk Observations during a hospital walk-through on 08/28/2025 from 12:05 PM to 12:30 PM revealed patient toilets being a potential ligature risk. There was a space of approximately 1.5 inches to 3 inches between the wall and the lower portion of the tank and top of the underlying toilet pedestal. This surveyor was able to place his hands in this space on each side approximately 5 inches. The patient toilets were as follows: -Room “e”: 2 inch space on either side; -Room “j”: 2.5 inch space on either side; -Room “l”: 2.5 inch space on either side; and -Room “n”: 2 inch space on either side. In an interview on 08/28/2025 and present during this hospital walk-through, S1ADM confirmed the above mentioned findings. 2) Failure to ensure the patient care area was free of items that could potentially cause harm or injury Observations during a hospital walk-through on 08/28/2025 from 12:05 PM to 12:30 PM revealed the following: a) Missing call light covers above the entry doors of Rooms “l”, “m”, and “o”. The missing covers exposed the following potential hazards in the patient care area: Room “l”: 2 glass bulbs were exposed; Room “m”: 2 electrical sockets (glass bulbs were missing) were exposed; and Room “o”: 1 glass bulb and 1 electrical socket (glass bulb was missing) were exposed. Of note, this surveyor (height 59 inches) was able to extend arm/hand and be within approximately 2-3 inches of these bulbs and electrical sockets. b) Packaged Terminal Air Conditioners (PTACs) in Rooms “b” - “n”. Although each PTAC had the manufactured plastic cover installed and attached, these plastic covers were not tamper resistant. Without a tamper resistant covering, these PTACs could expose the patient to potential injury and/or harm if access were gained to the electrical and mechanical parts of the inner PTAC. In an interview on 08/28/2025 and present during this hospital walk-through, S1ADM confirmed the above mentioned findings.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) 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: 48051 Based on observation and interview, the psychiatric hospital failed to ensure the condition of the physical plant the overall hospital environment was maintained in such a manner that the safety and well-being of patients are assured. This deficient practice was evidenced by towels being placed under Room “k’s” and “m’s” restroom doors. Findings: Observations during a hospital walk-through on 08/28/2025 from 12:05 PM to 12:30 PM revealed the restrooms of Rooms “k” and “m” having 2 entries/doorways. The restroom entries/doorways not being utilized by Rooms “k” and “m” had brown, stained towels which appeared to be wedged under each restroom door. From these towels’ placements and their brown, stained appearances, it appeared these towels were purposely placed to block the space under each doorway and seemed to be positioned in these doorways for more than a day. In an interview on 08/28/2025 and present during this hospital walk-through, S1ADM confirmed the above mentioned findings and indicated the towels should not be used for the purpose of blocking the space under each of these doors.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 48051 Based on observation, record review and interview the psychiatric hospital failed to maintain facilities, supplies and equipment to ensure an acceptable level of safety and quality. This deficient practice was evidenced by the failure to perform daily refrigerator temperature checks on the lab specimen refrigerator. Findings: A review of hospital policy, “INFECTION PREVENTION AND CONTROL PROGRAM,” policy number unavailable, being effective 09/01/2011, last revised 01/11/2021 and Governing Body approval 01/24/2023, revealed in part: “PROCEDURE Responsibilities of Hospital Personnel: The responsibilities for implementing and maintaining an effective Infection Control and Prevention Plan are not limited to nursing. A variety of departments are required to perform certain activities to make the program effective. On an ongoing basis: =All hospital refrigerator contain thermometers and temperature logs to ensure that the proper temperature are maintained. To ensure preventive measures are in place, the hospital provides refrigerator: Specifically, for the temporary storage of laboratory specimens of blood or body fluids will be labeled for specimens only. Laboratory specimen refrigerators are separate from refrigerator used to store medications and food, respectively. Authorized personnel shall have access. *A temperature log will be maintained for each refrigerator. Documentation on the log will be daily in inpatient settings and on days of operation in outpatient settings. A staff member will record the temperature readings and, if outside the acceptable range (as indicated by LAC51), will immediately notify a supervisor. The supervisor is responsible to: Schedule repairs; Arrange for interim safe placement of the contents elsewhere; Place a notice on the refrigerator that it is not to be used; Notify personnel and removed the notice when the refrigerator has returned to normal functioning; and Ensure that the temperature log contains documentation that reflects all actions.” Observations during a hospital walk-through on 08/27/2025 from 2:35 PM to 3:30 PM revealed the lab specimen refrigerator in Room “a” and the associated cleaning and temperature document titled, “REFRIGERATOR/FREEZER CLEANING & TEMPERATURE LOG,” A review of this document dated 08/2025 failed to reveal temperature checks being performed on 08/04/2025, 08/05/2025, 08/08/2025 - 08/10/2025, 08/13/2025, 08/14/2025, 08/18/2025, 08/19/2025, and 08/22/2025 - 08/24/2025. Further review of this document revealed the instructions: “3. Temperature Checks a. The temperature of the refrigerator and freezer will be checked and recorded for each day that the unit/office/department is occupied, i.e., the temperatures do not have to be checked on weekends and holidays if the department is not open on those days. A review of the hospital’s admissions and discharges did not reveal any of the above mentioned dates as not having patients or the unit not being occupied. In an interview on 08/27/2025 and accompanied on hospital walk-through, S1ADM and S2URLPN confirmed the above mentioned findings and agreed these checks should be performed daily.”

“Discharge Summary CFR(s): The record of each patient who has been discharged must have a discharge summary that includes a recapitulation of the patient’s hospitalization… This Standard is not met as evidenced by: 48051 Based on record review and interview, the psychiatric hospital failed to ensure the medical record of each patient who has been discharged has a discharge summary that includes a recapitulation of the patient’s hospitalization. This deficient practice was evidenced by the failure to have a discharge summary on the 1 (#3) of 3 (#1 - #3) medical records reviewed for discharge summaries. Findings: A review of hospital policy, “Timely Documentation in Medical Record,” policy number unavailable, being effective 09/01/2011, last revised 03/21/2018 and Governing Body approval 01/25/2024, revealed in part: “POLICY Beacon Behavioral Hospital requires that Medical Records are complete within 30 days, per federal regulation.” A review of Patient #3’s medical record on 08/28/2025 revealed a discharge date of 07/25/2025 at 12:23 PM. The medical record failed to reveal a discharge summary as of the day of this review and this review was completed approximately 34 days post discharge. In an interview on 08/28/2025 and present for the medical record review, S2URLPN confirmed the above mentioned findings.”

“Social Services Staff Responsibilities CFR(s): Social service staff responsibilities must include, but are not limited to, participating in discharge, planning, arranging for follow-up care, and developing mechanisms for exchange of appropriate information with sources outside the hospital. This Standard is not met as evidenced by: 48051 Based on record review and interview, the psychiatric hospital failed to ensure social service staff participating in discharge planning, arranging for follow-up care, and exchanging appropriate information with sources outside the hospital communicated the patient’s entire hospitalization from admission to discharge. This deficient practice was evidenced by: 1) Failure to update the Discharge Instructions to reflect the discharge date and the signatures of staff and patient at the actual discharge date in 1 (#1) of 3 (#1 - #3) medical records reviewed; 2) Failure to reveal the documentation of the pharmacy being utilized on the Discharge Instructions in 1 (#1) of 3 (#1 - #3) medical records reviewed; 3) Failure to reveal the documentation of a 30-day supply of discharge medications as being provided in the Discharge Instructions in 1 (#1) of 3 (#1 - #3) medical records reviewed; 4) Failure to reveal the documentation of provider notification that a patient admitted for inpatient behavioral health services pursuant to an emergency certificate was being referred to for follow-up behavioral health services within twenty-four hours of discharge in 1 (#1) of 3 (#1 - #3) medical records reviewed; and 5) Failure to reveal the documentation of a patient admitted for inpatient behavioral health services pursuant to an emergency certificate, received patient educational documents published by the Louisiana Department of Health prior to or at the time of discharge in 1 (#1) of 3 (#1 - #3) medical records reviewed. Findings: A review of hospital policy, “Discharge of the Patient,” policy number unavailable, being effective 09/01/2011, last revised 03/21/2018 and Governing Body approval 01/25/2024, revealed in part: “POLICY Beacon Behavioral Hospital supports the need for accurate and adequate Discharge Instructions that enable the patient to transition to a different level of care as seamlessly as possible. Discharge Instructions represent a summary of the Discharge Plan that instructs the patient on the treatment regime to be maintained after leaving the program. Discharge Instructions are reviewed with the patient by the discharging nurse or other clinician. PROCEDURE 3.A nurse transcribes the orders and initiates the Discharge Instructions form and Discharge Medications list. 5. The counselor provides information to be included in the Discharge Instructions with regard to follow-up and aftercare. The information includes, but is not necessarily limited to: a. Name of the Provider (for follow-up or aftercare) b. Address and Phone Number of Provider c. Date and time of appointment with Provider (if able to schedule) d. Instructions to contact Provider for appointment (if unable to schedule) 6. At a minimum, the completed Discharge Instructions include: b. Admission and Discharge Dates g. Confirmation of 30-day Prescriptions sent to a discharging inpatient’s Pharmacy (including Name, Address, and Phone Number for Pharmacy) 8. Shortly prior to leaving the hospital, the patient is provided with a copy of the Discharge Instructions and a list of Discharge Medications, at which time the nurse or discharging clinician reviews both documents with the patient (and possible family member or caregiver), ensuring that the patient understands the instructions. 9. The patient is asked to sign the Discharge Instructions to indicate that the instructions were reviewed with, and that a copy was received by, the patient. 10. The nurse or clinician that reviewed the instructions and gave a copy to the patient also signs the document. 13. A copy of the Discharge Instructions is entered into the Medical Record and the nurse or clinician completes a note that includes, at a minimum: f. Prescriptions for Discharge Meds sent to patient’s pharmacy (inpatients).” 1) Failure to update the Discharge Instructions to reflect the discharge date and the signatures of staff and patient at the actual discharge date in 1 (#1) of 3 (#1 - #3) medical records reviewed A review of Patient #1’s medical record revealed the patient being discharge on 08/25/2025 at 9:53 AM. A review of the document titled, “Form: Discharge Instructions,” revealed in part: “Date of Discharge: 08/22/2025; Discharge information Reviewed with: Patient, 08/21/2025 8:19 AM; Copy of Instructions provided to patient/caregiver: yes, 08/22/2025 8:12 AM; Patient Choice Information & Signatures: Patient signature: [Patient #1] 08/19/2025 5:02 PM; Social Worker/therapist signature: S5CSW 08/19/2025 5:03 PM; Nursing Signature: S4RN 08/21/2025 8:21 AM.” The before mentioned dates do not correspond with Patient #1’s actual discharge date. Further, Patient #1 and S5CSW signatures reflected the signing taking place 6 days prior to the actual discharge date - 08/25/2025. S4RN signature corresponded to the time of the discharge information being reviewed with Patient #1 - 08/21/2025, however, this information was reviewed 4 days prior to the actual discharge date - 08/25/2025. In an interview on 08/28/2025 at 11:30 AM, S2URLPN confirmed the above mentioned findings and indicated Patient #1’s discharge date was pushed back, however the Discharge Instructions did not reflect the updates related to these changes or accurately reflect the correct discharge date. 2) Failure to reveal the documentation of the pharmacy being utilized on the Discharge Instructions in 1 (#1) of 3 (#1 - #3) medical records reviewed A review of Patient #1’s medical record revealed the document titled, “Form: Discharge Instructions,” and this form revealed in part: “Medications: Needs assistance with obtaining medications (Describe) [no information on this form to describe this assistance]; Medical Follow Up: 30 day supply of medication sent to patient’s pharmacy.” The Discharge Instruction failed to reveal the pharmacy being utilized for discharge medications or the assistance needed to obtain medications. In an interview on 08/28/2025 at 11:30 AM, S2URLPN confirmed the above mentioned findings and a pharmacy should appear on the discharge instructions. S2URLPN further confirmed Patient #1 was provided a 30-day supply of medications upon discharge and this information was not on the Discharge Instructions. 3) Failure to reveal the documentation of a 30-day supply of discharge medications as being provided in the Discharge Instructions in 1 (#1) of 3 (#1 - #3) medical records reviewed A review of Patient #1’s medical record revealed the document titled, “Form: Discharge Instructions,” and this form failed to reveal the documentation of a 30-day supply of discharge medications being provided to Patient #1 upon discharge. In an interview on 08/28/2025 at 11:30 AM, S2URLPN confirmed the above mentioned findings and Patient #1 was provided with a 30-day supply of medications upon discharge. 4) Failure to reveal the documentation of provider notification that a patient admitted for inpatient behavioral health services pursuant to an emergency certificate was being referred to for follow-up behavioral health services within twenty-four hours of discharge in 1 (#1) of 3 (#1 - #3) medical records reviewed Pursuant La R. S. 28:53:1 (2024 Regular Legislative Session (Act 737) Matthew Samuel Milam Act) Discharge plan; healthcare provider notification requirements: If a patient is admitted for inpatient behavioral healthcare services pursuant to an emergency certificate issued in accordance with R.S. 28:53, the individual who is responsible for discharge planning at the healthcare facility where the patient has been admitted shall make a reasonable effort to do all of the following: (1) Provide written or telephonic notification to any healthcare professional that is currently providing behavioral health services to the patient, if known, of the date and time the patient is scheduled to be discharged unless the patient objects to that information being communicated. (2) Provide written or telephonic notification within twenty-four hours of discharge to any healthcare professional that the patient is being referred to for follow-up behavioral health services. The healthcare professional that the patient is being referred to shall be provided with a summary of the patient’s medical history and any current mental health conditions the patient is suffering from at the time of discharge. The summary shall be transmitted no later than the date the patient has been scheduled for follow-up behavioral services. (3) Provide to the patient educational documents published by the Louisiana Department of Health prior to or at the time of discharge. A review of Patient #1’s medical record revealed the patient being discharge on 08/25/2025 at 9:53 AM. A review of the document provided by S6DCP revealed a “Fax Message Transmission Result to +1 (337) 4621354 - Sent” which indicated it had been sent on 08/19/2025 at 11:57 AM and consisted of a 68 page file named [Patient #1.pdf]. This fax transmittal would have taken place 6 days prior to Patient #1’s discharge and would not have reflected all of Patient #1’s medical care, therapy, treatments and current mental health condition at the time of discharge. In an interview on 08/28/2025 at 11:25 AM, S6DCP confirmed the above mentioned information and Provider A was not sent Patient #1’s last 6 days of admissions. In an interview on 08/28/2025 at 11:30 AM, S2URLPN confirmed the above mentioned findings and the medical record failed to reveal documentation related to Provider A being notified. 5) Failure to reveal the documentation of a patient admitted for inpatient behavioral health services pursuant to an emergency certificate, received patient educational documents published by the Louisiana Department of Health prior to or at the time of discharge in 1 (#1) of 3 (#1 - #3) medical records reviewed Pursuant La R. S. 28:53:1 (2024 Regular Legislative Session (Act 737) Matthew Samuel Milam Act) Discharge plan; healthcare provider notification requirements: If a patient is admitted for inpatient behavioral healthcare services pursuant to an emergency certificate issued in accordance with R.S. 28:53, the individual who is responsible for discharge planning at the healthcare facility where the patient has been admitted shall make a reasonable effort to do all of the following: (1) Provide written or telephonic notification to any healthcare professional that is currently providing behavioral health services to the patient, if known, of the date and time the patient is scheduled to be discharged unless the patient objects to that information being communicated. (2) Provide written or telephonic notification within twenty-four hours of discharge to any healthcare professional that the patient is being referred to for follow-up behavioral health services. The healthcare professional that the patient is being referred to shall be provided with a summary of the patient’s medical history and any current mental health conditions the patient is suffering from at the time of discharge. The summary shall be transmitted no later than the date the patient has been scheduled for follow-up behavioral services. (3) Provide to the patient educational documents published by the Louisiana Department of Health prior to or at the time of discharge. A review of Patient #1 medical record revealed the patient being admitted on 08/13/2025 under a Physician’s Emergency Certificate (PEC) for suicidal ideations with a plan, homicidal ideations and auditory hallucinations. Patient #1 was subsequently placed under a Coroner’s Emergency Certificate (CEC). The medical record’s Discharge Instructions failed to reveal the patient educational documents published by the Louisiana Department of Health and to be given upon discharge relate to La R. S, 28:53:1. In an interview on 08/28/2025 at 11:30 AM, S1ADM and S2URLPN confirmed the above mentioned findings.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 48537 Based on record review and interviews, the hospital failed to ensure patients were free from abuse and neglect and ensure all incidents of abuse and neglect were reported and analyzed to ensure the hospital was in compliance with applicable local, State, and Federal Laws and Regulations. This deficient practice was evidenced by failure to thoroughly investigate and report allegations of neglect within 24 hours to the Department of Health and Hospitals or law enforcement for 1 (#1) of 3 (#1-#3) patients reviewed for neglect. Findings: Review of the Louisiana Revised Statutes, Title 40. Public Health and Safety, Chapter 11, State Department of Health and Hospitals revealed “Department” shall mean the Department of Health and Hospitals. “Unit” means the Medicaid fraud control unit created within the office of criminal law of the Department of Justice and which is certified by the secretary of the United States Department of Health, Education and Welfare. Regarding §2009.20. Duty to make complaints; penalty; immunity, “Abuse” is the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including but not limited to sexual abuse, or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered. “Neglect” is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer’s well-being. Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, ... having knowledge that a consumer’s physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report. Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report abuse/neglect allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Louisiana Department of Health (LDH). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence. Review of Patient #1’s medical record revealed he was admitted to the hospital on 06/12/2025 at 10:03 PM from an outside referring facility’s emergency room for Impulsive Disorder; Bipolar Disorder with Depression; and Mild Neurocognitive Disorder due to Known Physiological Condition without Behavioral Disturbances. Review of Patient #1’s Provider Orders for June 2025 revealed the following orders: 06/12/2025 at 11:51 PM Regular Diet, Double Portions, Mechanical Soft Consistency 06/12/2025 at 11:52 PM Dietician Consult Indication: easily choked, swallowing precautions 06/15/2025 at 9:00 AM Swallowing Precautions every shift 06/17/2025 at 5:05 PM Transfer Patient to Hospital Now 06/18/2025 at 9:00 AM Dietary Supplement - Thicken Liquids-All liquids are to be thickened with thickener due to swallowing precautions 06/18/2025 at 9:00 AM Nurse Communication - Patient is to have Thicken Liquids and ALL medications to be crushed in pudding or apple sauce. Review of Patient #1’s Initial Nutritional Consult completed by S4RD on 06/14/2025 at 9:29 AM revealed in part: Date Ordered: 06/13/2025 Reason for Consult: Requiring Therapeutic Diet Oral: Difficulty Chewing, Difficulty Swallowing, Comments - Since motorcycle wreck, but able to eat mechanical soft and thickened liquids diet. Assessment/Summary: Patient #1 lying in bed awake, alert, able to answer dietary questions, feed self, food preferences noted. Goals - stable weight, optimize nutritional status and prevent skin breakdowns. RD Recommendations: Provide 1 can Ensure three times a day between meals, continue to monitor weight, labs, oral intake, skin and hydration. Electronically Signed by: S4RD Review of Patient #1’s Nursing Note by S7RN dated 06/17/2025 at 6:14 PM revealed the following note: “At 4:45 PM - MHT reported to nurse that patient was in dayroom choking off his supper. When nurse entered dayroom medication nurse was preforming abdominal thrust on patient in dayroom (Heimlich maneuver) on patient. Multiple attempts were made to open patient mouth to visualize lodged object with no success. Jaw thrust applied. Call was placed to 911 as staff alternated continuation of abdominal thrust. Unsuccessful with abdominal thrust. Patient face and lips turned blue, cyanosis noted, O2 saturation dropped staff laid patient on his side and continued with jaw thrust success and suctioned out some of the lodged object. Local ambulance service arrived and took over. Patient was transported to local emergency room for further evaluation and treatment. Patient #1’s emergency contact/mother, S5MD and S6MD notified.” Review of the incident report (was in progress at the time of the survey) last modified on 06/23/2025 for Patient #1 for a “Safety, Health and Infection Prevention: Respiratory/Cardiac Arrest of Loss of Consciousness” revealed in part: Case Type: Incident/Event Intake Method: Internal Incident/Unusual Occurrence Form Date/Time of Occurrence: 06/17/2025 at 4:45 PM Was family/representative made aware of incident? Yes What family/representative was made aware of incident? Patient #1’s emergency contact/mother When did family/representative receive notification? 06/17/2025 Was Physician/Provider made aware of incident? Yes What Physician/Provider received notification? S5MD and S6MD When did Physician/Provider receive notification? 06/17/2025 Did this incident result in an injury? Yes Type of Injury: Other Body Part Affected: Mouth, Abdomen and Jaw If this was a medical event, were any medications given to the patient within 8 hours prior? No Was treatment offered (if applicable)? Yes What type of treatment was offered? EMS/EMR Brief description of treatment provided: 4:45 PM - MHT reported to nurse that patient was in dayroom choking off his supper. When nurse entered dayroom medication nurse was preforming abdominal thrust on patient in dayroom (Heimlich maneuver) on patient. Multiple attempts were made to open patient mouth to visualize lodged object with no success. Jaw thrust applied. Call was placed to 911 as staff alternated continuation of abdominal thrust. Unsuccessful with abdominal thrust. Patient face and lips turned blue, cyanosis noted, O2 saturation dropped staff laid patient on his side and continued with jaw thrust success and suctioned out some of the lodged object. Local ambulance service arrived and took over. Patient was transported to local emergency room for further evaluation and treatment. Patient #1’s emergency contact/mother, S5MD and S6MD notified. Signed by S7RN Review of the facility Self- Reports for June 2025 revealed no submitted Self-Reports to LDH within 24 hours of Patient #1’s medical emergency resulting in transfer to the local emergency room for a higher level of care. On 06/25/2025 at 12:55 PM, an interview was conducted with S2DON. S2DON stated the process for getting meal trays prior to Patient #1’s incident was, the MHT would get the meal cart from the shared nursing home kitchen. Once the meal cart was back on the unit, the MHT would verify the meal ticket was for the correct patient when delivering the meal tray to the patient in the dining hall. S2DON stated the MHT would not actually check the tray to ensure the food on the tray matched what was listed on the meal ticket. Prior to the incident, the process for a patient to change their meal option if they did not want what was going to be served for the standing meal listed on the menu for the day for the specific meal time, the patient would alert any nursing staff member, either the nurse or MHT, that they would like the alternate meal option. S2DON stated on this specific day, Patient #1 had alerted one of the MHTs that he wanted a hot dog for dinner and that was how his meal was changed. On 06/25/2025 at 1:10 PM an interview was conducted with S1ADM regarding the incident with Patient #1. S1ADM provide all documents regarding training, policy development and the facility’s root cause analysis (RCA) investigation surrounding incident. S1ADM stated when he reached out to Corporate about reporting the incident to LDH, it was communicated to him that only an internal investigation would be necessary and not to report to LDH because it did not appear the situation was neglectful in nature by the staff. When asked, S1ADM would not confirm there was neglectful actions or behaviors taken on behalf of the staff at the facility during the incident, but he did confirm the incident warranted immediate mandatory staff training, policy development and an RCA investigation into the situation to figure out what had happened and how to prevent it from happening again.”

“Treatment Plan - Team Responsibilities CFR(s): [The written plan must include] The responsibilities of each member of the treatment team; and This Standard is not met as evidenced by: 48537 Based on record review and interviews, the hospital failed to ensure all patient treatments were within compliance of particular aspects of the patients’ individual treatment program as evidenced by failure to have a signed and dated master treatment plan by the patient and complete treatment team for 1 (#1) of 3 (#1 - #3) patients’ treatment plans reviewed for the sample. Findings: Review of the hospital’s policy titled, “Multidisciplinary Treatment Plan” last revised on 01/25/2024, revealed in part: “Policy: Members of all disciplines participate in developing, implementing, and evaluating an individualized Multidisciplinary Treatment Plan. This comprehensive plan of care is formulated based on the findings of the evaluations conducted by disciplines that include, but are not limited to: Nursing, Medicine, Psychiatry, Social Services, and Activity Therapy. The comprehensive Multidisciplinary Treatment Plan is expected to be completed in the inpatient’s Medical Record no later than 5 days after admission. Procedure: Inpatient - 2. The registered nurse will initiate the Multidisciplinary Treatment Plan. 3. Over the three days following admission, the patient will be assessed by members of other disciplines including, but not limited to: a. Medicine; b. Psychiatry; c. Social Services; and d. Activity Therapy; 5. By the 5th day of the patient’s hospitalization the treatment team will meet and determine the focus of treatment, goals of care and interventions to be provided and by whom. Whenever possible, all members of the treatment team should be present to discuss these plans, but in any event the meeting must include the treating prescriber, a registered nurse, and a qualified social worker or counselor. 6. All treatment team members participating in the development of the Multidisciplinary Treatment Plan will provide their signatures to indicate their involvement. Review of Patient #1’s medical record revealed he was admitted to the hospital on 06/12/2025 at 10:03 PM from an outside referring facility’s emergency room for Impulsive Disorder; Bipolar Disorder with Depression; and Mild Neurocognitive Disorder due to Known Physiological Condition without Behavioral Disturbances. Review of Patient #1’s Multidisciplinary Master Treatment Plan dated 06/12/2025 at 10:38 PM revealed the patient signature line was signed by blank, but no additional documentation stating Patient #1 was unable and/or unwilling to sign was provided. Further review revealed a staff signature for S3RN, but there was no date or time associated with the signature. Continued review revealed there were no signatures for a social worker/therapist or a physician. On 06/25/2025 at 1:25 PM, S2DON confirmed Patient #1, social worker/therapist and physician did not sign and date and the registered nurse did not date and timestamp the Multidisciplinary Master Treatment Plan within the required timeframe after admission and they should have.”

“Director of Nursing Qualifications CFR(s): The director of psychiatric nursing services must be a registered nurse who has a master’s degree in psychiatric or mental health nursing or its equivalent from a school of nursing accredited by the National League for Nursing, or be qualified by education and experience in the care of the mentally ill. This Standard is not met as evidenced by: 48537 Based on record review and interview, the hospital failed to ensure the registered nurse hired as the director of nursing (DON) services had a master’s degree in psychiatric or mental health nursing or be qualified by education and experience in the care of the mentally ill. Findings: Review of the hospital’s policy titled “Director of Nursing” last revised on 03/21/2018 revealed in part: “Policy: The Director of Nursing (DON) provides nursing leadership for the hopsital and off-site campuses licensed under the hospital. The DON is a qualified registered nurse that meets the following requirements: Be qualified by educations and/or experiences in the care of the behaviorally ill patient - Holds a master’s degree psychiatric or mental health nursing from a school accredited by the National League for Nursing (NLN); or Hold a master’s degree in a related field (e.g. psychology, nursing education), a Baccalaureate or associate degree in nursing, or a Diploma in nursing; and -Have at least five (5) years of documented full-time experience as a registered nurse; -Have a minimum of three (3) years of documented experience providing full-time care, as a registered nurse to behaviorally ill patients requiring hospital-level care (NOTE: The three years may constitute a portion of the five years as a full-time registered nurse); and -Have documented evidence of ongoing education in the field of behavioral health nursing, obtained within the prior twelve (12) months, designed to keep the registered nurse current on psychiatric nursing techniques. Ongoing continuing education in behavioral health nursing may include, but is not limited to: -Enrollment in nursing courses offered by an NLN-accredited program (whether to obtain a degree or not); -Contact hours or Continuing Education Units (CEU) obtained through an organization approved to awarded accredited CEU to registered nurses (e.g. through the American Nurses Association, the Louisiana State Nurses Association, or the NLN, etc.); and/or -Participating in ongoing, documented consultation with and/or supervision by a master’s prepared psychiatric nurse. When selecting personnel to serve as the Director of Nursing, the Hospital takes into consideration the scope and complexity of the nursing care needs of the major patient population(s) served by the hospital. The hospital shall have available a similarly qualified registered nurse to provide nursing leadership in the absence of the Director of Nursing.” Reviewed of the personnel file for S2DON revealed she graduated from Louisiana State University Alexandria in December of 2020 where she received her Bachelor’s in Science-Nursing (BSN) degree. S2DON was hired by the hospital on 01/22/2025 as a registered nurse and was then promoted to interim director of nursing on 06/06/2025. Complete review of her personnel file revealed no record of her obtaining her Master’s degree in psychiatric or mental health nursing or having a combination of qualified education and experience in the care of mentally ill patients. On 06/25/2025 at 3:00 PM, an interview was conducted with S2DON. S2DON confirmed she did had her BSN and did not have a Master’s degree in any type of nursing. On 06/25/2025 at 3:40 PM, an interview was conducted with S1ADM. S1ADM stated he thought it was a state regulation that was going to be taking effect in a few years, but was not aware it was a current regulation. S1ADM stated he was unaware it was a federal regulation the DON needed to have a master’s degree in psychiatric or mental health nursing, but confirmed he knew S2DON only had her BSN.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to ensure that patients have the right to care in a safe setting as evidenced by staff failing to continuously observe Patient #1, who was on line of sight observation level, and as a result, the patient was touched inappropriately by another patient. The hospital failed to ensure that after this incident, all staff were re-educated on the proper procedures for line of sight observations in order to prevent future occurrences. Findings: Review of the hospital policy and procedure titled Precautions and Level of Observation Procedures, revealed in part that a line of sight observation level is when the patient is in view of staff at all times. Review of the LDH Abuse/Neglect Initial Report, dated 11/17/2023, revealed in part that on 11/16/2023, another patient reported to S1MHT that Patient #1 (who was on line of sight observation level) and another patient were being inappropriate under the dayroom table. The report further revealed that after investigating the incident and reviewing video footage of the date 11/16/2023, it was revealed that S1MHT was assigned to watch Patient #1 at all times but was observed on video to have his back to the patients in the day room. During the time S1MHT’s back was to the patients, another patient was observed to be touching Patient #1 under her shorts for less than 15 seconds. The report further revealed that patient neglect was substantiated due to the patients engaging in inappropriate behavior at the dayroom table while not being observed by S1MHT. The report further stated that all staff was in-serviced on line of sight observations. S4Administrator provided an inservice sign-in sheet dated 11/17/23. Review of this sign-in sheet revealed that S2DON educated staff on “precautions/line of sight”. Review of the staff signatures on the sign in sheet compared to the staffing schedule from 11/17/2023 to present revealed that 7 of 13 MHTs and 5 of 9 nurses who had been working with patients, including patients on line of sight observation levels, had not received any re-education on line of sight observation level. On 11/27/2023 at 1:50 p.m., S3MHT was asked by the surveyor if she had received any education in the past month regarding observation levels and she stated no. On 11/28/2023 at 3:00 p.m., interview with S4Administrator confirmed there was no other documentation of staff re-education that could be provided. S4Administrator confirmed that all staff who had been working since the incident with Patient #1 on 11/16/2023, had not been re-educated on the proper procedures for line of sight observations.”