Louisiana Behavioral Health

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) 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 needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 20310 Based on observation, record review and interview, the hospital failed to ensure it had an adequate number of RNs to provide nursing care to all patients. The hospital failed to have supervisory staff for each nursing unit to ensure the immediate availability of an RN as evidenced by the absence of a designated RN in the Adolescent Psychiatric Unit. Findings: Review of the hospital’s policy NSG-06, revised 09/01/22, titled Staffing Plan revealed, in part, the following Procedure: ...A registered nurse is physically present and immediately available at all times when a patient is present on the unit. As used in this policy, “immediately available” requires the registered nurse to be physically present in the patient common area, nursing station, lounge area adjacent to the nursing station, or in other areas in which the overhead paging system is audible. ...The facility will be staffed with a minimum of 2 nursing staff, one of which is a RN with one additional direct patient care staff (LPN/LVN, MHT, CNA), to maintain a therapeutic milieu and a safe environment. Review of the hospital’s staffing grid revealed the following staffing plan for the Adolescent Unit with 14 licensed beds: RN - 24 hours. On 10/01/2024 at 1:30p.m., review of the grid and interview with S1Administrator and S2Clinical Director confirmed that an RN should be present in the unit 24 hours per day, one on each shift. On 09/30/2024 at 11:15 a.m., a tour of the Adolescent Unit and interview with S3LPN confirmed the current census of 12 patients. She stated the staff included 2 LPNs and 4 MHTs. She confirmed there was no RN assigned to the unit. She further confirmed that 1 patient was on a one-to-one level of observation, 2 patients on line of sight level of observation, and the remaining 9 patients were on an every 15 minutes level of observation. On 10/01/24 at 2:40 p.m., an interview with S4DON confirmed that he had scheduled an RN for the Adolescent Unit on the 09/30/2024 day shift, but that RN had called in for her shift. He confirmed that he did not replace the RN with another RN, but staffed with a second LPN instead. He further confirmed there were other available RNs available in the hospital that could have been assigned to the unit for that shift until they could find a replacement. Instead, he stated the plan was for an RN charge nurse who was assigned to another unit to leave her unit in order to come to the Adolescent Unit for any tasks or duties required to be performed by an RN.”

“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: 36293 Based on record review, observations and interviews, the hospital failed to provide care in a safe setting. This deficient practice is evidenced by failing to monitor the safety of patients for 3 (#1, R1, R2) of 10 patients observed out of a total population of 11 patients (#1, 2, 3, R1-R8). Findings: Review of the hospital’s policy CS-23 titled, “Level of Observations” revealed in part: Purpose - Observation should be both safe and therapeutic. Respect should be shown for the patients’ need for autonomy while ensuring safety.\ Policy - Three levels of observation are utilized: every 15-minute (Q-15 minute) observation; Line of Sight (Constant Observation); and one-to-one observation. The level of observation is determined by the individual needs of the patient and treatment team recommendation and ultimately requires a physician order. Observation Levels: Every 15 minutes - staff will visually observe the patient Q15 to monitor location and activity, with emphasis on any noticeable behaviors of escalation, aggression and unsafe activities. Line of Sight - staff will ensure patient is visually within sight at all times. One-to-one (1:1) - staff will ensure patient is visually within sight and within arms-reach of a staff member at all times and in all circumstances. Procedure - Physician provides order for one-to-one. Charge nurse explains procedure to patient. 1:1 can be initiated by Director of Nursning (DON) or Administrator based on identified risk prior to physician order. Documents in chart and nurse report sheet/ the level of observation ordered and implemented. Reassesses patient every 4 hours for continued risk and need for 1:1. Registered Nurse (RN) will initial off on the observation sheet every 2 hours with our current model of RN availability. 1:1 staff is to be relieved at least every 4 hours for at least 15 minute periods. Patient 1 Review of physician orders dated 03/14/2024 revealed 1:1 observation ordered for Patient #1. Observation on 03/21/2024 at 12:10 p.m. revealed Patient #1 seated and eating lunch in bed and S3MHT seated in the vestibule adjoining Patient #1’s bedroom. S3MHT was not in arms-length of Patient #1. In an interview at this time, S2RN confirmed the finding and acknowledge S3MHT was not monitoring Patient #1 according to the patient’s orders. Patient R1 Review of the hospital’s list of current patients with orders for Line of Sight monitoring revealed Patient R1. Observations on 03/25/2024 at 12:45 revealed S3MHT open Patient R1’s door, make an observation, close the door and return to the opposite end of the hall. In an interview at this time, S1Administrator acknowledged Patient R1’s door was closed and the patient was not being monitored as ordered. Patient R2 Review of the hospital’s list of current patients with orders for Line of Sight monitoring revealed Patient R2. Observations on 03/25/2024 at 12:46 revealed S3MHT open Patient R2’s door, make an observation, close the door and return to the opposite end of the hall. In an interview at this time, S1Administrator acknowledged Patient R2’s door was closed and the patient was not being monitored as ordered.”