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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
(X2) MULTIPLE CONSTRUCTION
C
02/19/2014
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 INFORr.tATION)
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
A000 INITIAL COMMENTS
A000
A complaint survey was conducted 02/13/14
through 02/1 9/1 4.
A115 482.13PATIENTRIGHTS
A115
9(5)
COMPLETION
OATE
A hospital must protect and promote each
patient’s rights.
This CONDITION is not met as evidenced by:
Based upon review of 12 of 18 medical reCords,
Quality Assurance/Performance Improvement
data, nurse staffing ratios, observations, and staff
interviews, the hospital failed to meet the
Condition of Participation for Patient Rights as
evidenced by:
1) Failing to provide care in a safe setting to
ensure that sexual contact was not allowed for 12
of 18 patients (#‘s 2,6-11, 14-18) who were
inpatients on the Adult Psychiatric Unit, the
Adolescent Unit, and the Youth Enhanced Unit
and failure to provide adequate staff on the Adult
Psychiatric Unit on 2/17/14 for patient #13 who
was on 1:1 observations, and patient #12 and two
random patients who were on Constant Visual
Observations. (Tag A144) and,
2) Failing to ensure additional staff were on the
Adult Psychiatric Unit, the Adolescent Unit, and
the Youth Enhanced Unit to ensure all patients
were free of abuse and neglect:
a) Adequate staff failed to be available on the
Adult Psychiatric Unit on 2/17/14 in order to
provide 1:1 observations (prior to 10:37 am.) for
patient #13, and Constant Visual Observations for
three patients (#12 and 2 random patients) with
only 2 staff members available to monitor 15
LABORATORY DIRECTOR’S OR PROVIDERI5UPPLIER REPRESENTATIVE’S SIGNATURE
TITLE
(XE) 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.
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Event ID:YK3B11
FacIlity ID: H0000172S
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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
0211912014
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
(X3) DATE SURVEY
COMPLETED
A BUILDING
AilS Continued From page 1
patients;
PROVIDERS PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
fX5}
COMPLETION
DATE
A115
b) Adequate staff failed to be available on the
Adolescent Unit on 01/26/14 when there were 2
random patients (census 43) who were ordered
1:1 observations;
c) Adequate staff failed to be available on the
Youth Enhanced Unit on 1/26/14 for physician
ordered observations levels (1:1; Close Visual
Observation-CVO) for 2 of 8 patients (#2, #7),
who were allowed to engage in alleged sexual
misconduct;
I
d) Adequate staff failed to be available on
12/25113 during the 3:00 p.m. to 11:00p.m. shift
when there were 6 patient admissions to the Adult
Psychiatric Unit raising the staffing level from 2
staff members to 3. (During this shift, patient #16
(female) alleged a sexual encounter occurred
where male patient #17 came into her room and
had sex with her);
e) Failure to ensure all incidents of sexual
misconduct were investigated and reported to the
state agency (Health Standards Section) within
24 hours in accordance with the policy and
procedure for 12 of 18 medical record reviews
(Patient #s 2, 6-11, 14-18).
See Tag 145.
A 122 482.13(a)(2)(ii) PATIENT RIGHTS: GRIEVANCE
REVIEW TIME FRAMES
A 122
At a minimum:
The grievance process must specify time frames
for review of the grievance and the provision of a
response.
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Evenl ID:YK3B1I
Facilily ID: H0000172B
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0MB NO. 0938-039
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(Xl) PROVIDERSUPPLIERICLIA
IDENTIFICATION NUMBER:
194020
(X2) MULTIPLE CONSTRUCTION
C
02119/2014
B. WING
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
1006 HK3HLAND AVENUE
BRENTW000 HOSPITAL
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 122 Continued From page 2
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
A 122
This STANDARD is not met as evidenced by:
Based upon interview and review of the
grievance policy and procedure, grievances filed
from November 2013 to February 13, 2014, the
hospital failed to ensure that the grievance policy
and procedure identified reasonable time frames
for a response to complaints. According to the
grievance policy and procedure, the grievance
would be first reported to the grievance
committee, which according to interview was held
every three months, then a response would be
forwarded to the complainant.
Findings:
Review of policy #Rl.01 2 titled “Patient Grievance
Procedures”, part II. Procedure revealed “3.3 A
grievance, such as a patients rights violation will
be addressed by the patient advocate and will be
reported on in the Grievance Committee Review
committee meeting. A written response will be
provided to the patient within 7 days of the
committee’s review...”
Interview with S2 Risk Manager/Quality
Assurance Director (RM/QA) on 02/1 4/1 4, at 9:05
am., revealed she was also the patient advocate
and received the patient grievances. When
asked when the Grievance Committee Review
held their meetings, S2 RM/QA replied “every
three months’ and after the meeting the patient
was then notified of their findings of the complaint
investigation.
A132 482.13(b)(3) PATIENT RIGHTS: INFORMED
DECISION
A132
The patient has the right to formulate advance
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Facility ID: H00001728
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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
0211912014
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 132 Continued From page 3
PROVIDERS PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
A 132
directives and to have hospital staff and
practitioners who provide care in the hospital
comply with these directives, in accordance With
§489.100 of this part (Definition), §489.102 of this
part (Requirements for providers), and §489.104
of this part (Effective dates).
This STANDARD is not met as evidenced by:
Based upon review of 1 of 18 medical records
(#16), Quality Assurance/Performance
Improvement data, Hospital Abuse/Neglect Initial
Report forms, and interviews, the hospital failed
to ensure that the practitioners who provide care
to the patients comply with directives related to
the execution of a legal guardianship and inform
the designated individual(s) (parents of patient
#16) of an incident Which occurred between
female patient #16 and male patient #17.
Findings:
Review of the medical record for patient #16, a 27
year old female, revealed that the patient was
admitted to the hospital on 12/21/13 for violent
and aggressive behaviors and suicidal ideation.
According to the initial screening exam and the
initial nursing assessment, documentation
revealed that patient #16’s mother and father
were identified as the patient’s legal guardians.
On 12/26/13, patient #16 (female) reported that a
sexual encounter had occurred between herself
and patient #17 (male). Reviewoftheform titled
Hospital Abuse/Neglect Initial Report, completed
by S2 Risk Manager/Quality Assurance Director
(RM/QM) revealed documentation that patient
#16 refused to have her parents notified of the
incident.
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Facility ID: H0000I 728
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0MB NO. 0938-039
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(xl) PROvIDER’suPPLIEcLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CON5TRUCTION
(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
0211912014
SHREVEPORT, LA 71106
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING NFORtIATION)
A 132 Continued From page 4
Review of the information provided by the
Hospital Complaint Program Manager revealed a
document titled ‘LETTERS OF
CO-GUARDIANSHIP AND
CO-CONSERVATORSHIP” dated 12/13 2004.
This document identified “Full power and
authority in the premises, including all the powers
and duties of a guardian. The following rights
and duties of a conservator, as set forth in K.S.A
59-3078 (Supp. 2002) and amendments thereto,
are hereby assigned to (mother and father of
patient #16), to be exercised jointly or
individually.” This document was submitted and
approved through the District Court in the state of
Kansas.
Even though the hospital identified patient #1 6’s
parents had legal guardianship, there was no
documented evidence that the hospital staff
requested further information regarding the
guardianship. The parents of patient #16 were
not notified at the time of the sexual encounter
between their daughter and male patient #17.
According to the documented grievances, patient
#16 called her parents and told them of the
sexual encounter while still an inpatient in the
hospital.
A 144 482.1 3(c)(2) PATIENT RIGHTS: CARE IN SAFE
SETTING
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
1X5)
COMPLETION
DATE
A 132
A 144
The patient has the right to receive care in a safe
setting.
This STANDARD is not met as evidenced by:
Based upon review of Quality
Assurance/Performance Improvement data, 12 of
18 medical records, policy and procedures, and
staff interviews, the hospital failed to ensure
FORM CMS-2567(O2-99) Previous versions Obsolete
Event ID:YK3BI1
FaciILty ID: H00001728
If Continuation sheet Page 5 of 5
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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
02119/2014
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 144 Continued From page 5
patients received care in a safe setting. This was
evidenced by the hospitals failure to ensure;
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5I
COMPLETION
DATE
A 144
I) the staff monitored patients to ensure that
sexual contact was not allowed for 12 of 18
patients (#‘s 2,6-11, 14-18) hospitalized on the
Adult Psychiatric Unit, the Adolescent Unit, and
the Youth Enhanced Unit, and
II) adequate Staff were present on the Adult
Psychiatric Unit on 2/17/14 to ensure that
physician ordered Constant Visual Observations
were implemented for patients #12, #13, and two
random patients. Findings;
I) Review of the QualityAssurance Reports of
incidents from November 2013 to February 14th,
2014 revealed;
A) 12/25/13 an allegation of sexual misconduct
occurred between patients #16 (female) and #17
(male); reported on 12/26/1 3.
B) 01/25/14 an allegation of sexual misconduct
between patients #15 (male) and #9 (male);
reported on 01/27/1 4.
C) 01/26/14 an allegation of sexual misconduct
between patients #2 (male) and #7 (male);
reported on 01/29/14.
D) 02/03/14 an allegation of sexual misconduct
between patients #18 and #10; reported on
02/03/14.
E) 12/04/13 an allegation of sexual misconduct
between patients #6 (male) and #8 (male);
reported on 12/05/1 3.
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Facility ID: H0000172B
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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
02/19/2014
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 144 Continued From page 6
F) 11/28/13 an allegation of sexual misconduct
between patients #14 (female) and #11 (female);
reported on 11/29/13.
i
ID
PREFIX
TAG
PROVIDERS PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
1X5)
COMPLETION
DATE
A 144
A) Review of patient #16’s medical record
(female patient) revealed the patient was
admitted, 12)21/13, with the diagnoses of Mood
Disorder, Obsessive-Compulsive Disorder,
Autism, and Rule Out Bipolar Disorder.
Review of patient #17’s medical record (male
patient) revealed the patient was admitted to the
hospital on 12/02/13 for Suicidal and Homicidal
I Ideations, and auditory and visual hallucinations
and diagnosed with Bipolar Disorder.
Further review of patient #16’s (female patient)
medical record revealed that the patient reported
on 12/26/1 3, at 9:30 am., something happened
last night at shower time. I went into shower and
I guess someone came in and had sex with me.”
At 9:40 a.m., the patient recanted her statement
after staff told her they would review the video
tape.
Review of patient #17’s (male patient) medical
record revealed according to the Nursing
Progress Notes dated 12/25/1 3, timed 12:00
p.m., revealed “(patient #17) has spastic
uncontrolled movements. Intrusive behavior,
makes sexually inappropriate comments. Poor
impulse control, needs frequent redirection...”.
According to the incident report, patient #17 was
observed on video tape to enter patient #16’s
room and stay for approximately 30 minutes.
Interview with S2 RM/QA Director on 2/14/14, at
9:05 a.m., revealed when the video tape of this
incident was reviewed during the 3:00 p.m. to
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Facility ID: H00001728
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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
02119/2014
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 144 Continued From page 7
11:00 p.m. shift, it did show patient #17 go into
patient #16’s room and stayed for approximately
30 minutes. S2 RM/QA Director further stated
she interviewed patient #17 regarding the sexual
encounter and the patient admitted to her that he
did have sex with patient #16.
ID
PREFIX
TAG
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
A 144
Review of the 15 minute observation Rounds
Sheet for patient #17 on 12/25/13, for the 3:00
p.m. to 11:00 p.m. shift, revealed from 2:15 p.m.
to 3:00 p.m. S26 Licensed Practical Nurse (LPN)
documented the patient was in his room lying
down and from 3:15 p.m. to 10:00 p.m., S26 LPN
documented the patient was in the day room
Even though the RN documented patient #17 was
making inappropriate sexual comments during
the day of 12/25/13 there failed to be documented
evidence that the staff protected patient #16 from
the sexual advances of patient #17 by allowing
this patient access to patient #16’s room.
There was no further documentation of a
follow-up investigation regarding the incident
between patient #16 and patient #1 7 until the
video tape was actually reviewed in January
2014. According to a plan of correction submitted
by S2 RM/QA Director it was revealed Si
RN/DON, S2 RM/QA Director, Nurse Manager for
Youth Services, and the Weekend Nursing
Supervisor met on 1/10/14 to review the findings
of the sexual encounter between patient #16 and
patient #17. It was at this time that a plan of
correction was developed. According to their
findings, it was found the nursing staff on the
Adult Psychiatric Unit did not follow policy and
procedure related to observations of the patients
on the unit. There failed to be further
documentation the incident between patients #16
and #17 was investigated at the time of
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Facility ID: H00001728
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0MB NO. 0938-039’
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(Xl) PROVIDERISUPPLIERCLIA
IDENTIFICATION NUMBER:
194020
(X2) MULTIPLE CONSTRUCTION
C
02/1 912014
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
SUMNtARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 144 Continued From page 8
occurrence.
ID
PREFIX
TAG
‘
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
A 144
B) Review of patient #9’S medical record
revealed: 9 year old male admitted 01/22/1 4, at
3:00 am., under a Physician Emergency
Certificate (PEC) and Coroner’s Emergency
Certificate (CEC), and discharged 02/1 7/1 4.
Patient #9 was admitted with the diagnoses of
Bipolar Mood Disorder, Type I, Mixed, Severe
with Psychosis; Impulse Control Disorder, NOS;
ADHD; Oppositional Defiant Disorder; Relational
Problems, NOS; and Rule Out Posttraumatic
Stress Disorder. Patient #9 has a history of
multiple inpatient psychiatric admissions--last
admit was 12/20/13. History of being “bullied” by
peers at school. Initial Nursing Assessments
revealed history of Suicidal Ideation, Homicidal
Ideation, Self Mutilation, Depression, auditory
hallucinations, and sexual abuse.
Review of Seclusion/Restraint Orders revealed
Patient #9 required:
01 /29/14 Seclusion;
02/01/14 physical hold;
02/02/14 physical hold and seclusion;
02/03/14 Seclusion;
02/04/14 physical hold and Seclusion;
02/09/14 physical hold and Seclusion;
02/10/14 mechanical restraint;
02/12/14 physical hold;
02/13/14 physical hold;
02/16/14 physical hold and seclusion for hitting,
spitting, trying to bite staff and peers, scratching
himself, cursing at peers and staff.
Review of Nursing Progress Notes, 01/26/14
6:04pm, revealed S23 RN documented, “(patient
#9’s) mother spoke with me via phone, states
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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
02/19/2014
8. WING
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY. STATE, ZIP CODE
1OILNOAN
BRENTW000 HOSPITAL
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 144 Continued From page 9
‘(patient #9) told me [a peer’s name] (identified as
patient #15) touched his private parts, and he
wouldn’t make something like that up’ Ensured
mother they are no longer roommates, that was
changed today due to an incident during the first
shift (7a-3p) when (patient #9) was angry and
agitated at the same peer
Patient #9 was
placed on 1:1 observation 01/26/14 at 9:00 p.m.
per physician’s order.
PROVIDERS PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
CDMPLETION
DATE
A 144
Review of Physician’s Orders, dated 01/23/14
2:50 pm, revealed SlO Psychiatrist documented
‘Transfer to CEU (Children’s Enhanced Unit)...”.
Continued review of Physician’s Orders revealed,
on 01/26/14 9:33 p. m., S24 RN documented (a
telephone order from S11 Psychiatrist) “Place on
1:1, Place on SAP precautions (sexually acting
out)...also recommends enough staff to watch
patients, Oft peer restriction from (patient #15)”
Review of the medical record for patient #15
revealed the patient was admitted to the hospital
on 1/20/14 for homicidal ideation and violent
behavior and diagnosed with Mood Disorder and
Impulse Control Disorder. According to the
admission orders from 511 psychiatrist, the
precautions were: Elopement, Behavioral,
Suicidal, Violence/Assaultive, and Sexual; Victim.
Review of the Nursing Progress Notes dated
1/26/1 4, at 7:00 pm., 523 RN documented
“(Patient #15) is irritable, escalates quickly, but
responds to redirection if he is given 1:1 attention
regarding incident leading up to outburst. Defiant
at first, but once engaged, calms down quickly.”
7:30 p.m. “(Patient #1 5) replied when asked
about incident, ‘He asked me to do it and I did.”
Review of the physician orders revealed on
1/26/14 at 9:33 p.m., a telephone order from Sil
Psychiatrist was obtained and revealed “Place on
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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
(X3) DATE SURVEY
COMPLETED
A. BUILDING
C
0211912014
B. WING
NAME OF PROVIDER OR SUPPLIER
STREETADDRESS. CITY. STATE, ZIP CODE
BREN1WOOD HOSPITAL
(X4) ID
PREFIX
TAG
A 144
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
Continued From page 10
SAP precautions (sexually acting out).. 6 ft. peer
restriction from (patient #9)”. Even though Sli
Psychiatrist ordered sexual precautions, there
was no documented evidence that a safe
environment was provided for patient #15 to
ensure there were no sexual encounters.
There failed to be further evidence that this
incident was investigated and reported other than
the initial documentation of the incident.
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
{X5)
COMPLETION
DATE
A 144
C) Review of patient #2’s medical record
revealed: 13 year old male admitted, 01/21/14,
under a PEC (Physician Emergency Certificate)
for “explosive behavior ...threatening to kick his
brother and tear down the house, being mean to
family dog”. Patient #2 was discharged 01/31/14
with appointments for outpatient psychiatric follow
up.
Review of Patient #2’s Psychiatric Evaluation,
dated 01/22/14, revealed S8 Psychiatrist
documented: “...LEGAL DIFFICULTIES: The
patient has multiple arrests for aggression toward
others ...MENTAL STATUS EXAM
Thought
content is positive for harmful behavior toward
others denied suicidal ideation
DIAGNOSTIC IMPRESSIONS: Axis I: Bipolar
Disorder, Type I, Mixed, Severe; Axis II:
Deferred; Axis III: Noonan syndrome; Axis IV:
Psychological Stressors Extreme...”
...
-
Review of a Family Session form, dated 01/30/1 4,
revealed S8 LMSW (Licensed Masters Social
Worker), documented in the summary note,
has a hx (history) of fire setting and cruelty to
animals. GM (grandmother) reports pt (patient)
burned the school library and was kicked out of
school ...has been diagnosed (with) Explosive
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...
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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
B.
194020
C
02/19/2014
WING
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE. ZIP CODE
BRENTWOOD HOSPITAL
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING
SHREVEPOflLA 71106
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 144 Continued From page 11
Behavior Disorders, ADHD, and Mild MR (mental
retardation) reports a hX of sexual abuse by
older half brother
PROVIDERS PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X51
COMPLETION
DATE
A 144
. . .
Review of Physician admission orders, dated
01/21/1 4, revealed 517 RN documented the
following verbal orders: “ ...Precautions:
Elopement, Suicidal, and Violence/Assaultive...”
Review of Patient #7’s medical record revealed:
16 year old male admitted, 01/23/14, with
diagnoses of Medication Non-compliance and
Mood Instability. Patient #7 was discharged on
01/28/14 into the custody of the local police for an
existing arrest warrant for assault with a
dangerous weapon.
Review of the information obtained during
admission, 01/23/14, revealed S20 Counselor
documented S25 Psychiatrist was notified of the
following: “ Risk Factors Noted “ : Elopement;
Sexually Acting Out Victim; and Behavior
Precautions. The date and time was documented
by S20 Counselor as 01/23/14 at 2:00pm.
-
Review of Physician’s Orders, dated 01/23/1 4,
revealed RN S24 documented the following
telephone orders, Admit to Adolescent Unit,
Precautions: Behavioral, Elopement, Sexually
Acting Out.
Review of a report to the Child Protective Service
(CPS), dated 01/31 /1 4, revealed 518 RN
documented, (page 2), “(name Patient #2) came
to me and stated ‘my roommate made me touch
and suck his penis’ “ S18 RN documented,
on 1-28-14 @ around 6:30pm, (name Patient #2)
came to me as Charge Nurse and stated, ‘I have
something to tell you ‘
.
.
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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) PROVIDERISUPPLIECLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
C
02119/2014
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, LA 71106
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 144 Continued From page 12
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
X5)
CDMPLETION
DATE
A 144
Review of a form titled “Rounds Sheet” revealed
from 01/21/14 through 01/31/14 there tailed to be
documented evidence of any type of incident.
Review of a form titled ‘Interdisciplinary Notes”
dated 1/27/14 at 9:30pm, revealed 512 RN
Manager Youth Services documented Patient #2
required restraining and was placed in “time out”
for banging on the walls of his room and
disrupting the unit with his yelling.
Reviews of the “Rounds Sheets” for Patients #2
and #7 revealed on the alleged night, 01/26/14,
the MHT (Mental Health Technician) documented
both patients were in the “patient room” “lying
down.” (Note: Patient #2 and #7 had been
assigned to the same patient room).
Review of video evidence, performed by S2 QA
Director/Risk Manager, revealed on the night of
the allegation (01/26/1 4), the MHT assigned to
observe Patients #2 and #7 was himself observed
sitting at a table in the dayroom of the Youth
Enhanced Unit (YEU) and did not get up and
physically look into the patients’ room even
though he documented on the Rounds Sheets
(these were observation forms utilized by the
hospital), that Patient #2 and #7 ‘s location was
“patient room” and activity was recorded as “lying
down”. The hospital staff failed to ensure these
2 patients were kept safe and not victimized
sexually as per Patient #2’s allegation.
D) Review of the medical record for patient #18
revealed this 11 year old patient was admitted to
the hospital on 1/22/1 4, with the diagnoses of
AXIS I: Bipolar Disorder, Impulse Control
Disorder and AXIS II: Mental Retardation, Mild.
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Faciljty ID: H00001728
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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
02119/2014
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 144 Continued From page 13
According to the physician admission orders,
precautions were to include: Sexual: Victim.
Review of the Interdisciplinary Notes dated
2/2/14, and timed at 9:55 a.m., revealed the RN
documented “Patient #18 comes walking out of
his room behind his roommate directed to day
room. (patient #18) stopped in hail and nurse
asked ‘What happened?’ (patient #18) states,
‘He asked me if I wanted to have sex, and I said
NO.’ Staff prompted (patient #18) to continue
telling story by asking ‘Then what,’ (patient #18)
replied ‘He sucked my penis.’ Roommate denies
this allegation.”
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 Patient #10’s medical record revealed
an 8 year old male admitted, 01/20/14, with
diagnoses of Homicidal Ideation, Mood Disorder,
Impulse Control Disorder, history of severe,
violent behavior towards others. Parents state
Patient #10 was destroying property, cursing at
his parents and uncontrollable; increasingly worse
over last week and refuses to take his
medications. Review of Interdisciplinary Notes,
dated 02/02/1 4, 8:00pm, S24 RN documented,
observed pt laying on floor, fully covered in
blanket and hiding his head under his pillow.
Staff asked, ‘what happened?’ He scooted in
opposite direction, away from staff. Advised he
would not be in trouble, but encouraged to
behave, he said, ‘ok. I asked him if he wanted to
do sex. He said No, No, No.’ Pt denies any
further contact...”
There was no documented evidence that the
hospital investigated this incident other than what
nurse’s documented in the patients’ medical
records.
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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
BREN1W000 HOSPITAL
(X4) ID
PREFIX
TAG
02/19/2014
SHREVEPORT, LA 71106
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 144 Continued From page 14
E) Review of patient #6’s medical record
revealed an admission date of 01/21/14, with
diagnoses of Homicidal Ideation and Depressive
Mood. Review of patient #8’s medical records
revealed an admission date of 01/23/1 4, under a
Formal VoluntaryAdmission. Diagnoses
documented were Medication Non-compliance
and Depression.
PROVIDERS PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
A 144
Review of an incident report revealed patient #6
reported to a staff member that patient #8 “was
lying on top of me while I was in bed, I told her to
get off’. Continued review of the incident report
revealed patient #8 had gotten off of patient #6,
went over to her own bed, then came back over
to patient #6’s bed and sat on the edge; then got
off patient #6’s bed and left the room.
Review of the Rounds Sheets and Nursing
Progress Notes revealed no documentation
relative to staff actions in relation to patient
complaints/concerns to ensure all patients were
safe and not subject to unwanted
touching/harassment/abuse.
There was no evidence of further investigation to
ensure Patient #8 did not repeat these behaviors
with other patients.
F) Review of the medical record for patient #14
revealed according to the Interdisciplinary Notes
dated 11/28/13, at 5:45 am., the Registered
Nurse (RN) documented “Upon routine nursing
rounds, (patient #14) was found in a male peers
room 170 bed A, lying in bed with male peer in left
lateral recumbent position. (Patient #14) was fully
dressed but pressed against male peer. Staff
called her name and escorted her to nurses
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Facility ID: H00001728
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CENTERS FOR MEDICARE & MEDICAID SERVICES
0MB NO. 0938-039
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
0211912014
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
BRENTWOOD HOSPITAL
1006 HIGHLAND AVENUE
SHREVEPORT, LA 71106
(X4) ID
PREFIX
TAG
A
144
SUM&4RY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORItATION)
Continued From page
15
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5}
COMPLETION
DATE
A 144
station where she began apologizing profusely
stating ‘I just wanted to tell him good morning and
.
Review of the
my feet were on the floor’
rounds sheet dated 11/28/1 3, revealed the same
RN documented at 5:45 a.m. that patient (patient
#14) was in her room lying down.
Review of the medical record for patient #11
revealed the following documentation on the
Interdisciplinary Notes dated 11/28/1 3, 5:45 p.m.,
“Upon routine nursing rounds a female peer was
found in (patient #11)’s bed in room 170-A.
(Patient #11) was asleep in bed, lateral
recumbent position, and appeared to be unaware
of patient’s presence when startled. When
brought down to nurses station, (patient #11)
stated ‘I was sleeping and I didn’t know she was
there. I did not ask her to come in my room, she
knows the rules...”. Review of the Rounds Sheet
dated 11/28/13 revealed at 5:45 a.m., the RN
documented patient #11 was asleep in his room.
There was no documented evidence that this
incident was investigated and identified the
discrepancy between the RN’s documentation on
the Interdisciplinary Notes and the Rounds Sheet
and the staffs failure to ensure female/males
patients were not allowed in each others rooms
during the 11:00 p.m. to 7:00 a.m. shift.
II) Observations made on the Adult Psychiatric
Unit (ADU) on 2/1 7/1 4, at 1:20 p.m., revealed
according to the eraser board located in the
nursing station, there was a total of 1 5 patients on
the unit.
One patient (#13) was listed as a 1:1 (one staff
member/one patient) and three patients were
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Facility ID: H00001728
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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
B. WING
194020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS. CITY, STATE, ZIP CODE
1006 HIGHLAND AVENUE
BRENTWOOD HOSPITAL
(X4) ID
PREFIX
TAG
02/19/2014
SHREVEPORT, LA 71106
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A144 Continued From page 16
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
A144
identified as CVO (Constant Visual Observation)
(patient #10 and two random patients).
Two staff members were on the unit, one RN and
one LPN. At the time of observations, the 1:1
patient (#13) was sitting at a table in the day
room. The RN was sitting in a chair at the day
room door approximately 8 feet away from the
patient. Interview with S14 RN during the
observations revealed when asked if patient #1
was a 1:1, 514 RN replied ‘let me look at my
sheet’. S14 RN then stated “yes, she is 1:1”.
When asked what 1:1 level meant, 514 RN
indicated the patient was to be within arms length.
Review of patient #13’s medical record revealed
the 1:1 had been discontinued on 2/17/14 at
10:37 a.m.; however, 514 RN was unaware that
the order had been changed almost three hours
earlier. When asked about the staff members on
the unit, S14 RN stated that the unit also had a
Mental Health Technician; however, this MHT was
on break. When asked about the patients who
were on Constant Visual Observation, S14 RN
stated two of these patients, one of whom had
received an injection, were in their rooms lying
down and the third patient was in the day room
attending group therapy with the counselor.
Observations made, 02/19/14, at 11:00am, on the
Adolescent Unit (ADO) revealed according to the
census board at the nurses station there were 21
females. Further review of the census board
revealed 5 females, out of the 21, were identified
as Constant Visual Observation (CVO). There
were 2 staff members on the female hall of the
ADO. The RN was conducting an assessment on
a patient and the MHT (Mental Health Technician)
had a patient in a room conducting a search.
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FaciliIy ID: H00001728
If continuation sheet Page 17 of 5’
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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
(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
02/1912014
SHREVEPORT, LA 71106
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 144 Continued From page 17
The nurse staffing level on 2117/14, failed to
ensure enough Staff were available to provide
Constant Visual Observations as ordered by the
physician and to ensure all patients remained
safe.
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
Review of a Nursing Staffing schedule, dated
01/26/14, revealed on the Adolescent Unit
(ADOL), the staffing was 4 Registered Nurses
(RN) and 2 Mental Health Technicians (MHT) for
a census of 43 which met the staffing grid
requirement. However, the hospital failed to
ensure adequate numbers of nursing staff were
present to ensure the safety of all patients as
there were 2 patients on 1:1 (1:1 observation
required one staff member with the patient, at
arms length at all times). The hospital failed to
adjust staffing to ensure staff members were
added to provide the supervision of patients
ordered to be on a 1:1 observation level.
Review of a Nursing Staffing schedule, dated
01/26/1 4, revealed on the Youth Enhanced Unit
(YEU Adolescent patients were transferred to
this unit when they required a higher/more
intensive observation/treatment), the staffing was
3 (no breakdown of RN-LPN-MHT) and census
was 8 the staffing was appropriate for the census
according to the staffing grid; however, there was
one patient who was ordered on 1:1 observation,
so an additional staff member should have been
present. The hospital failed to adjust staffing to
ensure staff members were added to provide the
supervision of patients ordered to be on a 1:1
observation level.
A 145 482.13(c)(3) PATIENT RIGHTS: FREE FROM
ABUSE/HARASSMENT
-
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A 145
Facility ID: H0000l 728
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(Xl) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
FORM APPROVEL
0MB NO. 0938-039’
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
C
0211 9/2014
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
SHREVEPORT, LA 71106
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 145 Continued From page 18
The patient has the right to be free from all forms
of abuse or harassment.
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X51
COMPLETION
DATE
A 145
This STANDARD is not met as evidenced by:
Based upon observations, review of medical
records, policies and procedures, QA Incident
Report data/reports, staffing schedules/grids,
nursing supervisor reports and interviews the
hospital failed to ensure all patientts were free of
abuse and neglect. This was evidenced by the
failure to ensure:
1) additional staff were present on the Adult
Psychiatric Unit on 2/17/14 to provide physician
ordered observation levels for 4 of 15 patients
(#12, #13 and 2 random patients);
2) additional staff were present on the Adolescent
Unit on 01/26/14 when there were 2 random
patients (census 43) who were ordered 1:1
observations;
3) additional staff were present on the Youth
Enhanced Unit on 1/26/14 for physician ordered
observations levels (1:1; Close Visual
Observation-CVO) for 2 of 8 patients (#2, #7),
who were allowed to engage in alleged sexual
misconduct;
4) failure to provide additional staff on 12/25/13
during the 3:00 p.m. to 11:00 p.m. shift when
there were 6 patient admissions to the Adult
Psychiatric Unit raising the staffing level from 2
staff members to 3. (During this shift, patient #16
(female) alleged a sexual encounter occurred
where patient #17 (male) came into her room and
had sex with her); and
5) all incidents of sexual misconduct were
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Facility ID: H00001728
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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:
(X3) DATE SURVEY
COMPLETED
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
C
194020
B. WING
NAME OF PROVIDER OR SUPPLIER
1006 HIGHLAND AVENUE
BRENTW000 HOSPITAL
(X4) ID
PREFIX
TAG
A 145
SHREVEPORT, LA 71106
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
Continued From page
02/1912014
STREET ADDRESS, CITY, STATE, ZIP CODE
19
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
X5)
COMPLETION
DATE
A 145
investigated and reported to the state agency
(Health Standards Section) within 24 hours in
accordance with the policy and procedure for 12
of 18 medical record reviews (Patient #s 2, 6-11,
14-18).
Findings:
Review of a hospital policy, titled “Safety
Rounds/Accountability”, #TX.064, revealed:
“I. POLICY’
to provide a Safe, Secure
environment..by ensuring accountability for their
well-being.
II. PROCEDURE: Guidelines for
monitoring...patients...follows: SAFETY
ROUNDS PROCEDURE: The charge nurse
assigns...patient observation rounds.,,
1. Every patient not on Constant Observation or
one to one (1:1) precaution will be monitored at
least every 15 minutes. All CO and 1:1 patients
will be monitored constantly but documented
every 15 minutes...
2...any point in time that the patient is not visible
through video monitoring, staff will physically go
and visualize the patient...
8. Visually observe patients when behind closed
doors by: 8.1 Knocking on bedroom...door. 8.2
Announce...stepping into room for rounds. 8.3
Open the door and visually observe the safety of
the patient...
10...lf the patient is...therapist’s office or is in with
a physician, the staff will notate that the patient is
in the meeting but must check on the patient
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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
0211912014
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 145 Continued From page 20
every 15 minutes. The exception is any 1:1 or
CVO (constant Visual observation) patient that
must be either within arm’s reach at all times or
within the line of vision at all times...ROOMS: ...2.
When patients are in their rooms, a staff
member...to be stationed in center of the hallways
to monitor patients and prevent inappropriate
patient contact...will station self in the hallways at
all times. 3. Patient bedroom doors to stay open
when patients are in their rooms, except when
patients are taking showers, to allow for
appropriate staff monitoring...”
ID
PREFIX
TAG
PROVIDERS PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
IX5)
COMPLETION
DATE
A 145
Observations on 2/17/14, at 1:20 p.m., on the
Adult Psychiatric Unit revealed according to the
patient list, there were 15 adult female and male
patients on the unit. Of these 15 patients, 1 was
identified as being 1:1 (patient #1 3), and patient
#12 and 2 random patients were identified as
being on Close Visual Observation.
At the time of the observation, staff present on
the Adult Unit were one Licensed Practical Nurse,
who was in and out of the medication room, and
one Registered Nurse who was sitting next to the
door of the group therapy room. Patient #13, who
was the 1:1 was sitting at a table in the middle of
the group therapy room and 514 RN was
approximately 8 feet away from the patient.
Other than the Counselor conducting therapy,
there were no other direct staff in the group
therapy room.
Interview with S14 RN on 2/17/14, at 1:40 p.m.,
revealed when asked about the 1:1 ordered for
patient #13, S14 RN stated “let me look at my
sheet” then stated “yes patient #13 is a 1:1”
When asked what 1:1 observation meant, 514
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Event ID:YK3B11
Facility ID: H00001728
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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
02/1 912014
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 145 Continued From page 21
RN motioned and replied “at arms length”.
PROVIDERS PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
1X5)
COMPLETION
DATE
A 145
Review of patient #13’s medical record revealed
on 2/17/14, the psychiatrist wrote an order dated
2/17/14 and timed 10:37 am. for the 1:1
observation to be discontinued; however, S14 RN
failed to be aware that her patient’s 1:1
observation level had been discontinued.
Further observations on 2/17/14 revealed patient
#12, on Close Visual Observations (CVO) was in
her room lying down. The 2 random patients who
were on CVO were also in their rooms lying
down. Further interview with 514 RN during the
observation revealed the staff assigned to the
Adult Psychiatric Unit was an RN, an LPN, and a
Mental Health Technician (MHT); however, the
MHT was off the unit on break which left only the
RN and LPN to monitor 15 patients.
Review of the staffing ratio grid requirements
revealed for 15 patients there were to be 3 staff
members present on the Adult Psychiatric Unit;
however the hospital failed to provide additional
staff to provide the 1:1 observation (1:1
observation required one staff member with the
patient, at arms length at all times) for patient #13
on 2/17/14 prior to the order being discontinued
at 10:37 am. and the Constant Visual
Observations for patient #12 and 2 random
patients. At 1:30 p.m., the nursing staff failed to
call for additional staff when the MHT went on
break, leaving only two staff members on the unit
to monitor 15 patients.
2) Review of a census and staffing form, dated
01/26/1 4, revealed there were 43 patients on the
Adolescent Unit. According to the nursing
FORM CM5-2567(02-99) PrevIous versions Obsolete
Event ID:YK3811
FacililylD: H00001728
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continuation sheet Page 22 of 5’
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0MB NO. 0938-039
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
(Xl) PROVIDERISUPPLIERICLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
194020
(X2) MULTIPLE CONSTRUCTION
C
02/19/2014
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 145 Continued From page 22
staffing schedule there were 4 RegiStered Nurses
(RNs) and 2 Mental Health Technicians (MHTs)
assigned the Adolescent Unit. Review of the
staffing grid indicated this was the required
number of staff (6 total) for the census (43).
However, the staffing grid did not take into
consideration the need for additional staff when
the acuity was increased (i.e. 1:1 observation
ordered on 2 patients, which indicated the need
for 2 additional staff members in order to ensure
patient and staff safety).
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
IX5I
COMPLETION
DATE
A 145
3) Review of patient #2’s medical record
revealed: 13 year old male admitted, 01/21/14,
under a PEC (Physician Emergency Certificate)
for “explosive behavior ..threatening to kick his
brother and tear down the house, being mean to
family dog”. Patient #2 was discharged 01/31/14
with appointments for outpatient psychiatric follow
upReview of Patient #2’s Psychiatric Evaluation,
dated 01/22/14, revealed S8 Psychiatrist
documented: ...LEGAL DIFFICULTIES: The
patient has multiple arrests for aggression toward
others ..MENTAL STATUS EXAM: ..Thought
content is positive for harmful behavior toward
others denied suicidal ideation
DIAGNOSTIC IMPRESSIONS: Axis I: Bipolar
Disorder, Type I, Mixed, Severe; Axis II:
Deferred; Axis Ill: Noonan syndrome; Axis IV:
Psychological Stressors Extreme...”
“
...
-
Review of a Family Session form, dated 01/30/14,
revealed S8 LMSW (Licensed Masters Social
Worker), documented in the summary note,
has a hx (history) of fire setting and cruelty to
animals. GM (grandmother) reports pt (patient)
• - -
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Event ID: YK3B11
Facilily ID: H00001728
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0MB NO. 0938-039
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
(Xl) PROVIDER’SUPPLIERICLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(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
0211912014
SHREVEPORT, LA 71106
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A145 Continued From page 23
burned the school library and was kicked out of
School ...has been diagnosed (with) Explosive
Behavior Disorders, ADHD, and Mild MR (mental
retardation) reports a hx of sexual abuse by
older half brother
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
{X5
COMPLETION
DATE
A145
...
Review of Physician admission orders, dated
01/21/1 4, revealed S17 RN documented the
following verbal orders: “ Precautions:
Elopement, Suicidal, and Violence/Assaultive...
Review of Patient #7’s medical record revealed:
16 year old male admitted, 01/23/1 4, with
diagnoses of Medication Non-compliance and
Mood Instability. Patient #7 was discharged on
01/28/14 into the custody of the local police for an
existing arrest warrant for assault with a
dangerous weapon.
Review of the information obtained during
admission, 01/23/1 4, revealed S20 Counselor
documented S25 Psychiatrist was notified of the
following: “Risk Factors Noted” : Elopement;
Sexually Acting Out Victim; and Behavior
Precautions. The date and time was documented
by S20 Counselor as 01/23/14 at 2:00pm.
-
Review of Physician’s Orders, dated 01/23/1 4,
revealed RN S24 documented the following
telephone orders, Admit to Adolescent Unit,
Precautions: Behavioral, Elopement, Sexually
Acting Out.
Review of a report to the Child Protective Service
(CPS), dated 01/31/1 4, revealed 518 RN
documented, (page 2), “(name Patient #2) came
to me and stated ‘my roommate made me touch
and suck his penis’ “ 518 RN documented, “on
1-28-14 @ around 6:30pm, (name Patient #2)
.
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Facility ID: H0000172B
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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
i
02/1912014
SHREVEPORT, LA 71106
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A145 Continued From page 24
came to me as Charge Nurse and stated, ‘I have
something to tell you’.”
PROVIDERS PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
A145
Review of a form titled “Rounds Sheet” revealed
from 01/21/14 through 01/31/14, there was no
documented evidence of any type of incident.
Review of a form titled “Interdisciplinary Notes,”
dated 1/27/1 4, at 9:30pm, revealed S12 RN
Manager Youth Services documented Patient #2
required restraining and was placed in “time out”
for banging on the walls of his room and
disrupting the unit with his yelling.
Reviews of the “Rounds Sheets” for Patients #2
and #7 revealed on the alleged night, 01/26/14,
the MHT (Mental Health Technician) documented
both patients were in the “patient room” “lying
down.” (Note: Patient #2 and #7 had been
assigned
to
the same patient room).
Review of video evidence, performed by S2 QA
Director/Risk Manager, revealed on the night of
the allegation (01/26/1 4), the MHT assigned to
observe Patients #2 and #7 was himself observed
sitting at a table in the dayroom of the Youth
Enhanced Unit (YEU) and did not get up and
physically look into the patients’ room even
though he documented on the Rounds Sheets
(these were observation forms utilized by the
hospital), that Patient #2 and #7’s location was
“patient room” and activity was recorded as lying
down” The hospital staff failed to ensure these
2 patients were kept safe and not victimized
sexually as per Patient #2’s allegation.
-
Review of a Nursing Staffing schedule, dated
01/26/14, revealed on the Adolescent Unit
(ADOL), the staffing was 4 Registered Nurses
(RN) and 2 Mental Health Technicians (MHT) for
FORM cM5-2567(02-99) Previous versions Obsolete
Evenl ID:YK3B11
Facility ID: H00001726
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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
0211912014
SHREVEPORT, LA 71106
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 145 Continued From page 25
PROVIDERS PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
{X5)
COMPLETION
DATE
A 145
a census of 43 which met the staffing grid
requirement; however, there number of nUrsing
staff present was not adequate to ensure the
safety of all patients as there were 2 patients on
1:1 (1:1 observation required one Staff member
with the patient, at arms length at all times), there
should have been additional staff members
present to care for the 2 patients on 1:1
observation.
Review of a Nursing Staffing schedule, dated
01/26/1 4, revealed on the Youth Enhanced Unit
(YEU--Adolescent patients were transferred to
this unit when they required a higher/more
intensive observation/treatment), the staffing was
3 (no breakdown of RN-LPN-MHT) and census
was 8. The staffing was appropriate for the
census according to the staffing grid. However,
there was one patient who was ordered on 1:1
observation, so an additional staff member
should have been present.
Interviews, 02/19/14, at 11:15a.m., with Si
Director of Nursing revealed when asked if there
had been adequate nursing staff present, she
replied the staffing was based on the staffing grid.
Unfortunately, the hospital failed to provide
additional staff members on the ADOL and YEU
for 01/26/14 for monitoring of patients who were
ordered 1:1.
There number of staff present was not adequate
to ensure the safety of all patients as evidenced
by the alleged sexual misconduct that was
allowed to occur between patients #2 and #7
when they were patients on the YEU.
4) Review of the Quality Assurance/Performance
FORM CM5-2567(02-99) Previous versions Obsolele
Event ID:YK3B11
Facility ID: H00001728
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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:
A. BUILDING
STREET ADDRESS, CITY, STATE, ZIP CODE
NAME OF PROVIDER OR SUPPLIER
1006 HIGHLAND AVENUE
BRENTW000 HOSPITAL
SHREVEPORT, LA
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 145 Continued From page 26
Improvement data revealed on 12/26/1 3, an
allegation of a sexual incident had been reported
between female patient #16 and male patient
#17.
i
C
0211 9/2014
B. WING
194020
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
(X2) MULTIPLE CONSTRUCTION
71106
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(XSI
CDMPLETICN
DATE
A 145
Review of the medical record for patient #16
revealed on 12/26/13 the patient reported to the
nurse that during the 3:00 p.m. to 11:00 p.m. shift
of 12/25/13, a male patient (#17) had come into
her room and had sex with her while she was in
the shower.
Review of the nurse staffing form dated,
12/25/13, it was revealed at the beginning of the
7:00 am. to 3:00 p.m. and the 3:00 p.m. to 11:00
p.m. (when patient #16 identified the sexual
encounter occurred) shifts it was identified there
were 7 patient on the Adult Psychiatric Unit. At
the beginning of the 11:00 p.m. to 7:00 am. shift,
it was identified there were 13 patients on the
Adult Psychiatric Unit, which meant during the
3:00 p.m. to 11:00 p.m. Shift there were 6 patient
admissions. According to the staffing form,
during the 3:00 p.m to 11:00p.m. shift, there was
one LPN and one RN. According to the staffing
grid requirements, when the patient level was at
13, an additional staff member should have been
added in order to provide enough staff to monitor
the patients.
There was no further documentation of a
follow-up investigation regarding the incident
between patient #16 and patient #17 until the
video tape was aclually reviewed in January
2014. According to a plan of correction submitted
by S2 RM/QA it was revealed 51 RN/DON, 52
RM/QA, Nurse Manager for Youth Services, and
the Weekend Nursing Supervisor met on 1/1 0/1 4,
to review the findings of the sexual encounter
FORM cMs-2567(02-99) Previous Versions Obsolete
Event ID:YK3B1I
Facilily ID: H00001728
If continuation sheet Page 27 of 5
PRINTED: 06/26/201
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(Xl) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
0MB NO. 0938-039
(X2) MULTIPLE CONSTRUCTION
C
02/19/2014
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)
A 145 Continued From page 27
between patient #6 and patient #17. It was at this
time that a plan of correction was developed.
According to their findings, it was found that the
nursing staff on the Adult Psychiatric Unit did not
follow policy and procedure related to
observations of the patients on the unit. There
was no further documentation that the incident
between patients #16 and #17 was investigated
when it was reported by patient #16.
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETIDN
DATE
A 145
5) Review of incident reports related to sexual
misconduct between patients reviewed through
the QNPI Program revealed the following:
A) 02/03/14--allegation of sexual misconduct
between patients #18 and #10; reported on
02/03/14.
Review of the medical record for patient #18
revealed this 11 year old patient was admitted to
the hospital on 1/22/14 with the diagnoses of
AXIS I: Bipolar Disorder, Impulse Control
Disorder and AXIS II: Mental Retardation, Mild.
According to the physician admission orders,
precautions were to include: Sexual: victim.
Review of the Interdisciplinary Notes dated 2/2/14
and timed at 9:55 a.m. revealed the RN
documented “Patient #18 comes walking out of
his room behind his roommate directed to day
room. (Patient #18) stopped in hall and nurse
asked ‘What happened?’ (Patient #18) states,
‘He asked me if I wanted to have sex, and I said
NO.’ Staff prompted (patient #18) to continue
telling story by asking ‘Then what,’ (patient #18)
replied ‘He sucked my penis.’ Roommate denies
this allegation.”
Review of Patient #10’s medical record revealed
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Event ID:YK3B11
FacililylD: H00001728
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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
02/1912014
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 145 Continued From page 28
an 8 year old male admitted, 01/20/14, with
diagnoses of Homicidal Ideation, Mood Disorder,
Impulse Control Disorder, history of severe,
violent behavior towards others. Parents state
Patient #10 was destroying property, cursing at
his parents and uncontrollable; increasingly worse
over last week and refuses to take his
i medications. Review of Interdisciplinary Notes,
dated 02)02/14, 8:00pm, S24 RN documented,
“...observed pt laying on floor, fully covered in
blanket and hiding his head under his pillow.
Staff asked, ‘what happened?’ He scooted in
opposite direction, away from staff. Advised he
would not be in trouble, but encouraged to
behave, he said, ok. I asked him if he wanted to
do sex. He said No, No, No.’ Pt denies any
further contact...”
PROVIDERS PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
cROSS.REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
{X5I
COMPLETION
DATE
A 145
B) 12/04/13—allegation of sexual misconduct
between patients #6 and #8; reported on
12)05/13;
Review of patient #6’s medical record revealed an
admission date of 01/21/14, with diagnoses of
Homicidal Ideation and Depressive Mood.
Review of patient #8’s medical records revealed
an admission date of 01/23/1 4, under a Formal
Voluntary Admission. Diagnoses documented
were Medication Non-compliance and
Depression.
Review of an incident report revealed patient #6
reported to a staff member that patient #8 “was
lying on top of me while I was in bed, I told her to
get off’. Continued review of the incident report
revealed patient #8 had gotten off of patient #6,
went over to her own bed, then came back over
FORM CM5-2567(02-99) Previous versions Obsolete
Event ID: YR3B1I
Facility ID: H00001728
If continuation sheet Page 29 of 51
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0MB NO. 0938-039
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(Xl) PROVIDERISUPPLIEWCLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
C
0211912014
8. WING
196020
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 145 Continued From page 29
to patient #0’S bed and sat on the edge; then got
off patient #6’S bed and left the room.
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
A 145
Review of the Rounds Sheets and Nursing
Progress Notes revealed there was no
documentation relative to staff actions in relation
to patient complaints/concerns to ensure all
patients were Safe and not Subject to unwanted
touching/harassment/abuse.
There was no evidence of a further investigation
to ensure Patient #8 did not repeat these
behaviors with other patients.
C) 01/25/14 an allegation of sexual misconduct
between patients #9 and #15 and was reported
on 01/27/14.
Review of patient #9’s medical record revealed: 9
year old male admitted 01/22/14 at 3:00am,
under a Physician Emergency Certificate (PEC)
and Coroner’s Emergency Certificate (CEC), and
discharged 02/17/14.
Patient #9 was admitted with the diagnoses of
Bipolar Mood Disorder, Type I, Mixed, Severe
with Psychosis; Impulse Control Disorder, NOS;
ADHD; Oppositional Defiant Disorder; Relational
Problems, NOS; and Rule Out Posttraumatic
Stress Disorder.
Patient #9 has a history of multiple inpatient
psychiatric admissions--last admit was 12/20/13.
History of being “bullied” by peers at school.
Initial Nursing Assessments revealed history of
Suicidal Ideation, Homicidal Ideation, Self
Mutilation, Depression, auditory hallucinations,
and sexual abuse.
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Event ID:YK3B11
Facility ID: H00001728
If continuation sheet Page 30 of 5’
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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) PRO VIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
194020
(X2) MULTIPLE CONSTRUCTION
C
02119/2014
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 145 Continued From page 30
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
A 145
Review of Seclusion/Restraint Orders revealed
Patient #9 required:
01/29/14 Seclusion;
02/01/14 physical hold;
02/02/14 physical hold and seclusion;
02/03/14 Seclusion;
02/04/14 physical hold and Seclusion;
02/09/14 physical hold and Seclusion;
02/10/14 mechanical restraint;
02/12)14 physical hold;
02/13/14 physical hold;
02/16/14 physical hold and seclusion for hitting,
spitting, trying to bite staff and peers, scratching
himself, cursing at peers and staff.
Review of Nursing Progress Notes, 01/26/1 4,
6:04 pm, revealed S23 RN documented, “(patient
#9’s) mother spoke with me via phone, states
‘(patient #9) told me [a peer’s name] (identified as
patient #15) touched his private parts, and he
wouldn’t make something like that up’ Ensured
I mother they are no longer roommates, that was
changed today due to an incident first shift
(7a-3p) when (patient #9) was angry and agitated
i
at the same peer
Patient #9 was placed on 1:1
observation 01/26/14 at 9:00 p.m. per physician’s
order.
Review of Physician’s Orders, dated 01/23/14
2:50pm, revealed SlO Psychiatrist documented
“Transfer to CEU (Children’s Enhanced Unit)...’.
Continued review of Physician’s Orders revealed,
on 01/26/14 9:33 p. m., S24 RN documented (a
telephone order from Sil Psychiatrist) “Place on
1:1, Place on SAP precautions (sexually acting
out)...also recommends enough staff to watch
patients, 6 ft peer restriction from (patient #15)”
FORM cMS-2567(02-99) Previous versions Obsolete
Event ID:YK3B11
Facilily ID: H00001728
If continuation sheet Page 31 of 51
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:
194020
A. BUILDING
C
0211912014
aWING
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 145 Continued From page 31
Review of the medical record for patient #15
revealed the patient was admitted to the hospital
on 1/20/14 for homicidal ideation and violent
behavior and diagnosed with Mood Disorder and
Impulse Control Disorder. According to the
admission orders from Sil psychiatrist, the
precautions were: Elopement, Behavioral,
Suicidal, Violence/AssaUltive, and Sexual: Victim.
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
IXS)
COMPLETION
DATE
A 145
Review of the Nursing Progress Notes dated
1/26/14, at 7:00 p.m., S23 RN documented
“(Patient #15) is irritable, escalates quickly, but
responds to redirection if he is given 1:1 attention
regarding incident leading up to outburst. Defiant
at first, but once engaged, calms down quickly.”
7:30 p.m. “(Patient #15) replied when asked
about incident, ‘He asked me to do it and I did.”
Review of the physician orders revealed on
1/26/14, at 9:33 p.m., a telephone order from Sli
Psychiatrist was obtained and revealed “Place on
SAP precautions (sexually acting out).. 6 ft. peer
restriction from (patient #9)”. Even though Sli
Psychiatrist ordered sexual precautions, there
was no documented evidence that a safe
environment was provided for patient #15 to
ensure there were no sexual encounters.
There was no further evidence this incident had
been investigated and reported other than the
initial documentation of the incident.
There was no documented evidence the hospital
investigated this incident other than what nurse’s
documented in the patients’ medical records.
D) 11/28/13--allegation of sexual misconduct
between patients #14 and #11, reported on
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Facilily ID: H00001728
If continuation sheet Page 32 of 5
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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:
(X2) MULTIPLE CONSTRUCTION
(X3) DATE SURVEY
COMPLETED
A. BUILDING
C
194020
B. WING
NAME OF PROVIDER OR SUPPLIER
0211912014
STREETADDRESS, CITY. STATE. ZIP CODE
BREN1WOOD HOSPITAL
(X4) ID
PREFIX
TAG
06
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 145 Continued From
11/29/13.
page
32
PROVIDERS PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
A 145
Review of the medical record for patient #14
revealed according to the Interdisciplinary Notes
dated 11/28/13, at 5:45 a.m., the Registered
Nurse (RN) documented “Upon routine nursing
rounds, (patient #14) was found in a male peers
room 1 70 bed A, lying in bed with male peer in left
lateral recumbent position. (Patient #14) was fully
dressed but pressed against male peer. Staff
called her name and escorted her to nurses
station where she began apologizing profusely
stating ‘I just wanted to tell him good morning and
my feet were on the floor...’.
Review of the rounds sheet dated 11/28/13,
revealed the same RN documented at 5:45 a.m.
the patient (patient #14) was in her room lying
down. Review of the medical record for patient
#11 revealed the following documentation on the
Interdisciplinary Notes dated 11/28/1 3, 5:45 p.m.
“Upon routine nursing rounds a female peer was
found in (patient #11)’s bed in room 170-A.
(Patient #11) was asleep in bed lateral recumbent
position and appeared to be unaware of patient’s
presence when startled. When brought down to
nurses station, (patient #11) stated ‘I was
sleeping and I didn’t know she was there. I did
not ask her to come in my room, she knows the
rules
Review of the Rounds Sheet dated
11/28/13 revealed at 5:45 am., the RN
documented patient #11 was asleep in his room.
.
Interview, 02/19/14, at 9:30am, with 52 RM/QA
Director revealed when asked if the above
incidents of sexual misconduct were investigated,
she replied, “not all of them”. When questioned
why they were not all investigated, S2 RM/QA
Director replied she really did not have an
FORM CM5-2567(02-99) Previous versions Obsolete
Event ID:YK3BI1
Facility ID: H00001728
If continuation sheet Page 33 of 5
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) PRO VIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
C
02/1912014
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
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 145 Continued From page 33
answer. Continued interview with 52 RM/QA
Director revealed the incident of sexual
misconduct between Patient #s 16 and 17, had
been investigated and was reported to the State
Agency; however, the investigation was not
conducted when it was discovered and reported
on 12/26/13 and was not reported to the State
Agency within the required 24 hours of discovery.
ID
PREFIX
TAG
‘
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLE11ON
DATE
A 145
Review of the incident between patient #2 and
patient #7 revealed the incident occurred on
1/26/1 3; however, the incident was not reported
to the state agency until 2/3/14. The sexual
incidents for patients identified as A, B, C, and D
were not reported.
The surveyors discovered the telephone number
identified in the Grievance Policy was incorrect.
The telephone number listed for reporting
allegations of abuse/neglect to the state agency
(Health Standards Section) was for a Bahamas
vacation.
A385 482.23 NURSING SERVICES
A385
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 upon review of medical records,
policies/procedures, QA Incident Report data,
reports, staffing schedules/grids and interviews,
the hospital failed to meet the Condition of
Participation for Nursing Services as evidenced
by the failure of the Director of Nursing to ensure:
I.) there were enough staff members present on
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Event ID:YX3BI1
Facility ID: H0000172B
It continuation sheet Page 34 o15’
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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:
(X2) MULTIPLE CONSTRUCTION
(X3) DATE SURVEY
COMPLETED
A. BUILDING
C
194020
B. WING
1006 HIGHLAND AVENUE
BRENTWOOD HOSPITAL
(X4) ID
PREFIX
TAG
0211912014
STREET ADDRESS. CITY, STATE, ZIP CODE
NAME OF PROVIDER OR SUPPLIER
SHREVEPORT, LA 7ll06
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 385 Continued From page 34
the units to provide patients with nursing
care/monitoring based on their various acuities as
evidenced by:
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
CDMPLETION
DATE
A 385
1) Failure to adequately staff the Adult
Psychiatric Unit on 2/1 7/14 to ensure 4 oilS
patients were provided monitoring in accordance
with the physician orders (#12, #13, and 2
random patients);
2) Failure to adequately staff the Youth
Enhanced Unit for 2 of 8 patients (#2, #7) who
were allowed to engage in sexual misconduct
when #7 was ordered on 1:1 observation; and
3) Failure to obtain additional staff on the
Adolescent Psychiatric Unit, 1/26/14, for 2
random patients who had physician orders for 1:1
observation. (A0392); and
II.) The RNs performed on-going evaluations of
nursing care for 12 of 18 patients (Patient #s 2,
6-11, 14-18) who had physician orders for specific
precautions (i.e. Suicide, Behavioral, Assault,
Sexual Acting Out, Elopement, etc.), who were
allowed to engage in alleged sexual misconduct.
See Tag A395.
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
needed, the immediate availability of a registered
nurse for bedside care of any patient.
FORM cM5-2557(02-99) Previous versions Obsolete
Event ID:YK3B11
Facility ID: H0000l728
If continuation sheet Page 35 of 51
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
(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
0211912014
SHREVEPORT, LA 71106
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 392 Continued From page 35
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(XE)
COMPLETION
DATE
A 392
This STANDARD is not met as evidenced by:
Based upon observations, review of nurse
staffing schedules, the hospital’s staffing grid,
medical records, and interviews, the hospital
failed to ensure there were enough staff
members present on the units to provide patients
with nursing care/monitoring based on their
Various acuities, as evidenced by:
1) Failure to adequately staff the Adult
Psychiatric Unit on 2/17/14 to ensure 4 of 15
patients were provided monitoring in accordance
with the physician orders (#12, #1 3, and 2
random patients);
2) Failure to adequately staff the Youth
Enhanced Unit for 2 of 8 patients (#2, #7) who
were allowed to engage in sexual misconduct
when #7 was ordered on 1:1 observation; and
3) Failure to obtain additional staff on the
Adolescent Psychiatric Unit, 1/26/14, for2
random patients who had physician orders for 1:1
observation.
Findings:
1) Observations on 2/1 7/1 4, at 1:20 p.m., on the
Adult Psychiatric Unit revealed according to the
patient list, there were 15 adult female and male
patients on the unit. Of these 15 patients, 1 was
identified as being 1:1 (patient #13), and patient
#12 and 2 random patients were identified as
being on Close Visual Observation.
At the time of the observation, staff present on
the Adult Unit were one Licensed Practical Nurse,
who was in and out of the medication room, and
FORM CM52567(O2-99) Previous VersIons Obsolete
Event ID:YK3B1I
Facilily ID: H00001728
If continuaUon sheet Page 36 of 5
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) PROVIDERJSUPPLIER’CLIA
IDENTIFICATION NUMBER:
194020
(X2) MULTIPLE CONSTRUCTION
C
0211 9/2014
8. WING
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS CITY, STATE, ZIP CODE
GRENTW000 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 INFORMATION)
A 392 ContinUed From page 36
one Registered Nurse who was sitting next to the
door of the group therapy room. Patient #13, who
was the 1:1 was sitting at a table in the middle of
the group therapy room and S14 RN was
approximately 8 feet away from the patient.
Other than the Counselor Conducting therapy,
there were no other direct staff in the group
therapy room.
PROVIDERS PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5l
COMPLEnON
DATE
A 392
lnterviewwith 514 RN on 2/17/14, at 1:40 p.m.,
revealed when asked about the 1:1 ordered for
patient #13, S14 RN stated “let me look at my
sheet” then stated “yes patient #13 isa 1:1”
When asked what 1:1 observation meant, S14
RN motioned and replied “at arms length”.
Review of patient #13’s medical record revealed
‘on 2/1 7/14, the psychiatrist wrote an order dated
2)17/14 and timed 10:37 a.m. for the 1:1
observation to be discontinued; however, S14 RN
failed to be aware that her patient’s 1:1
observation level had been discontinued.
Further observations on 2/1 7/1 4, revealed patient
#12, on Close Visual Observations (CVO) was in
her room lying down. The 2 random patients who
were on CVO were also in their rooms lng
down.
Further interview with S14 RN during the
observation revealed that the staff assigned to
the Adult Psychiatric Unit was an RN, an LPN,
and a Mental Health Technician (MHT); however,
the MHT was off the unit on break which left only
the RN and LPN to monitor 15 patients.
Review of the staffing ratio grid requirements
revealed for 15 patients there were to be 3 staff
members present on the Adult Psychiatric Unit.
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Event ID:YK3BI1
Facility ID: H00001728
If Continuation sheet Page 37 of 51
PRINTED: 06/26/201
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(Xl) PROVIDERISUPPLIER’CLIA
IDENTIFICATION NUMBER:
194020
FORM APPROVEI
0MB NO. 0938-039
(X2) MULTIPLE CONSTRUCTION
C
02/19/2014
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 392 ContinUed From page 37
However, the hospital failed to provide additional
staff to provide the 1:1 observation (1:1
observation required one staff member with the
patient, at arms length at all times) for patient #13
on 2117114 prior to the order being discontinued
ID
PREFIX
TAG
‘
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS.REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETION
DATE
A 392
at 10:37 a.m. and the Constant Visual
Observations for patient #12 and 2 random
patients. At 1:30 p.m., the nursing staff failed to
call for additional staff when the MHT when on
break, leaving only two staff members on the unit
to monitor 15 patients.
2) Review of the hospital’s nurse staffing
schedule, dated 01/26/1 4, revealed the following:
Youth Enhanced Unit (YEW-Adolescent patients
were transferred to this unit when they required a
higher/more intensive observation/treatment), the
staffing was 3 (no breakdown of RN-LPN-MHT)
and census was 8. The staffing was appropriate
for the census according to the staffing grid.
However, there was one patient (#7) who was
physician ordered on 1:1 observation, so an
additional staff member should have been
present. (NOTE: Physician ordered 1:1
observation required one staff member with the
patient at all times).
3) Review of the hospital’s nurse staffing
schedule, dated 01/26/14, revealed the following:
Adolescent Unit (ADOL), the nurse staffing
schedule reflected there were 4 Registered
Nurses (RNs), and 2 Mental Health Technicians
(MHTs) assigned on 01/26/1 4, with a census of
41. According to the nurse staffing grid, this was
appropriate. However, the grid did not take into
consideration the increased acuities (i.e. Close
FORM CM5-2567(02-99) Previous versions Obsolete
Event ID: YR3BI1
Facility ID: H00001728
If continuation sheet Page 38 of 5’
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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:
C
02119/2014
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
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
SHREVEPORT, LA
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A 392 Continued From page 38
Visual Observation—CVO; 1:1 observation) of 2
random patients
71106
PROVIDERS PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
IX5)
COMPLETION
DATE
A 392
Interview, 02/1 9/1 4, at 11:15am, with 51 Director
of Nursing revealed when asked if there had been
adequate nursing staff present to provide
on-going nursing re-assessments and monitoring,
She replied the staffing was based on the staffing
grid.
Review of the hospital’s staffing grid failed to
account for increased acuity in patients, i.e. 1:1
observations, Close Visual Observations;
although the Director of Nursing based nursing
staff on the staffing grid, they failed to ensure
patient acuity was also included in the
determination of additional staff.
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 upon reviews of medical records,
policies/procedures, QA Incident Report data,
reports, staffing schedules/grids and interviews,
the Director of Nursing failed to ensure RNs
performed on-going evaluations of nursing care
for each patient as evidenced by 12 of 18 patients
(Patient #s 2,6-11, 14-18) who had physician
orders for specific precautions (i.e. Suicide,
Behavioral, Assault, Sexual Acting Out,
Elopement, etc.), who were allowed to engage in
alleged sexual misconduct.
Findings:
FORM CMS-2567(02-99) Previous versions Obsolete
Event ID: YK3BI1
Facility ID: H00001726
If continuation sheet Page 39 of 5
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
02/1912014
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
BRENTW000 HOSPITAL
(X4) ID
PREFIX
TAG
A 395
SHREVEPORT, LA 71106
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
39
Review of Patient #s 2,6-11 and 14-18’s medical
records revealed their individual
physician/psychiatrist had ordered specific
precautions upon the patients’ admission.
Review of the Interdisciplinary Treatment Plans
revealed none of the physician ordered
precautions had been care planned. Further
reviews of Patient #s 2,6-11 and 14-18’s medical
records revealed that the RNs failed to reassess
and address the issues of the patients’ sexual
misconduct in order to provide for each patients’
individual needs, care and safety.
Continued From page
ID
PREFIX
TAG
PROVIDERS PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
IX5)
COMPLETION
DATE
A 395
Review of a hospital policy, titled “Safety
Rounds/Accountability”, #TX.064, revealed:
9. POLICY: ...to provide a safe, secure
environment..by ensuring accountability for their
wefl-being.
II. PROCEDURE: Guidelines for
monitoring.,,patients...follows: SAFETY
ROUNDS PROCEDURE: The charge nurse
assigns...patient observation rounds...
1. Every patient not on Constant Observation or
one to one (1:1) precaution will be monitored at
least every 15 minutes. All CO and 1:1 patients
will be monitored constantly but documented
every 15 minutes...
2...any point in time that the patient is not visible
through video monitoring, staff will physically go
and visualize the patient...
8. Visually observe patients when behind closed
doors by: 8.1 Knocking on bedroom...door. 8.2
Announce...stepping into room for rounds. 8.3
Open the door and visually observe the safety of
FORM cMs-2s67(o2-99) Previous versions Obsolete
Event ID:YK3B11
Facility ID: H00001J2B
It continuation sheet Page 40 of 51
PRINTED: 06/26/201’
FDRM 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:
194020
(X2) MULTIPLE CONSTRUCTION
C
02/19/2014
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 40
the patient...
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
‘
1X51
COMPLETION
DATE
A 395
10...If the patient is...therapist’s office or is in With
a physician, the staff Will notate that the patient is
in the meeting but must check on the patient
every 15 minutes. The exception is any 1:1 or
CVO (constant Visual observation) patient that
must be either within arm’s reach at all times or
within the line of vision at all times...ROOMS: ...2.
When patients are in their rooms, a staff
member...to be stationed in center of the hallways
to monitor patients and prevent inappropriate
patient contact.. will station self in the hallways at
all times. 3. Patient bedroom doors to stay open
when patients are in their rooms, except when
patients are taking showers, to allow for
appropriate staff monitoring...”
Review of incident reports revealed:
11/28/13--allegation of sexual
misconduct between patients #14 and #11,
reported on 11/29/1 3.
12/04/1 3--allegation of sexual
misconduct between patients #6 and #8; reported
on 12/05/1 3.
12/25/13 an allegation of sexual
misconduct occurred between patients #16 and
#17, and reported on 12/26/1 3.
01/25/14 an allegation of sexual
misconduct between patients #15 and #9 and
was reported on 01/27/1 4.
01/26/14--allegation of sexual
misconduct between patients #2 and #7; reported
on 01/29/14.
FORM CM5-2567(02-99) Previous Versions Obsolete
Event ID: YK3B1I
Facility ID: H0000l728
If continuation sheet Page 41 of 51
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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
STREET ADDRESS. CITY. STATE, ZIP CODE
1006 HIGHLAND AVENUE
BRENTW000 HOSPITAL
A 395
‘
SHREVEPORT, LA 71106
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
Continued From page
C
0211912014
B. WING
NAME OF PROVIDER OR SUPPLIER
(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
41
(X5)
COMPLE11ON
DATE
A 395
02/03/14—allegation of sexual
#18 and #10;
misconduct between patients
reported on 02/03/14.
Interview,
02/19/14, at 11:15am, with 51 Director
asked if there had been
of Nursing revealed When
adequate nursing staff present to provide
on-going nursing re-assessments, she replied
staffing was based on the staff ng grid.
the
Review of the hospital’s staffing grid failed to
account for increased acuity in patients, i.e. 1:1
observations, Close Visual Observations;
although the Director of Nursing based nursing
staff on the staffing grid, they failed to ensure
patient acuity was also included in the
determination of additional staff.
B 122 482.61(c)(1)(iU) TREATMENT PLAN
B 122
The written plan must include the specific
I treatment modalities utilized.
This STANDARD is not met as evidenced by:
Based on review of medical records and
interviews, the hospital failed to ensure every
patient received a treatment plan that stated the
specific purpose and focus of the treatment
modalities as evidenced by:
1)10 of 18 patients (Patient #5 1,2,7-10,15-18)
with generalized treatment plans that did not
address specific modalities and interventions for
Elopement, Suicidal, Homicidal, Cognitive
Impairment, Violence/Assaultive and/or Sexual
Acting Out Precautions which were ordered by
FORM CMS-2567(02-99) Previous versions Obsolete
Event ID:YKSB1I
Facility ID: H00001728
If continuation sheet Page 42 of 51
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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) PROVIDER’SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
C
02/19/2014
B WING
194020
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)
B 122 Continued From page 42
the Psychiatrist and
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
{X5)
CDMPLETIDN
DATE
B 122
2) lack of focus on the Treatment Plans for 10 of
18 patients (#1,2,7-10, 15-18).
Findings:
Review of Patient #2’s medical record revealed a
13 year old male admitted under a Physician
Emergency Certificate (PEC), dated 01/20/2014,
for “history of explosive behavior”, ADHD
(attention deficit hyperaCtivity disorder),
“threatening to kick his brother and tear down the
house, being mean to family dog”.
Patient #2 was admitted under the orders of 59
Psychiatrist with a diagnosis of Major Depressive
Disorder (MDD). 59 Psychiatrist had ordered the
following Precautions: Elopement, Suicidal, and
Violence/Assaultive.
Review of a form titled “Brentwood Hospital
Hand-Off Communication” revealed under a
section titled “Risk Factors Noted” S16 Counselor
had identified the following Risks: Homicide:
Ideation/Intent/Plan/Attempt; Violent; Sexually
Acting Out Precautions: Victim--prior
victimization suspected; and Potential for
Aggression Precautions.
Review of Patient #2’s Initial Psycho-Social and
Nursing Assessments revealed both S16
Counselor and S17 Registered Nurse (RN) had
identified Patient #2 as a victim of sexual abuse
(history of being raped by his half-brother when
he was 11).
Review of Patient #2’s Interdisciplinary Treatment
Plan,
dated
01/21/14,
revealed
FORM cM5-2567(02-99) PreviDus versions Obsolete
the
problems
Event ID: YR3611
Facihty ID: H0000I 728
If continuation sheet Page 43 of 51
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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
194020
B. WING
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
1006 HIGHLAND AVENUE
BRENTWOOD HOSPITAL
(X4) ID
PREFIX
TAG
B 122
0211912014
SHREVEPORT, LA 71106
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
Continued From page
43
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
1X5)
COMPLETION
DATE
B 122
identified were: #1 Homicidal Ideation; #2
Depressed Mood; and #3 Asthma,
The Treatment Team failed to formulate and
implement a Treatment Plan that addressed
behaviors exhibited by Patient #2 when he
reported to S18, on 01/30/14, that another patient
(identified as Patient #7) had “made him touch his
penis and suck it”. The Treatment Plan was
simply “naming” modalities (i.e., individual
therapy, group therapy, occupational therapy,
medication education) The focus of the
treatment was not included.
Review of Patient #7’s medical record revealed a
16 year old male admitted, 01/23/1 4, under a
Formal Voluntary Admission (FVA) for Mood
Instability.
Review of a Hand-Off Communication sheet,
dated 01/23/14, revealed 620 Counselor
documented Risk Factors Noted were Elopement
Precautions, Sexually Acting Out
Precautions--Victim prior victimization
suspected, and Behavior Problems.
-
Continued review of Patient #7’s medical record
revealed Social Services had identified Patient #7
had been physically and sexually abused by his
biological parents until age 3 when he was
removed from his biological parents and
subsequently was adopted. S20 Counselor
documented Patient #7 had alleged that his
adoptive father was also sexually abusing him.
Review of Physician Admission Orders, 01/23/1 4,
revealed the following Precautions were ordered:
Elopement, Behavioral, and Sexual Victim.
-
FORM CMs-2567(02-99) Previous versions Obsolete
Event ID:YK3B11
Facility ID: H00C01728
If continuation sheet Page 44 of 5
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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
02/19/2014
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
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
B 122 Continued From page 44
Review of Patient #7’s Interdisciplinary Treatment
Plan, dated 01/23/14, revealed the problems
identified were: #1 Anxiety and #2 Medication
non-compliance.
71106
PROVIDERS PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X51
COMPLETION
DATE
B 122
The Treatment Team failed to develop and
implement a Treatment Plan that addressed risk
factors identified upon admission by S20
Counselor which were Behavior Problems and
Sexually Acting OUt.
Review of Patient #s 1, 8-10, 15-18 revealed all
had physician orders for varied precautions (i.e.
Assault, Behavior, Cognitive, Elopement, Suicide,
Sexual Acting Out, etc.).
Reviews of Patient #s 1, 8-10, and 15-18
revealed their individual Treatment Plans did not
address the physician ordered precautions and all
lacked specific treatment modalities to be utilized
in the Treatment Plans.
Interview with Sil Psychiatrist on 01/19/14, at
9:20 am, confirmed that the Treatment Plans
were not developed relative to the physician
ordered precautions nor were specific treatment
modalities identified and implemented.
B 150 482.62(d)(2) NURSING SERVICES
6 150
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:
FORM cM5-2567(02-99) Previous versions Obsolete
Event ID:YK3Bll
Facility ID: H00001728
If continuation sheet Page 45 of 5
PRINTED: 06/26/201
FORM APPROVEC
0MB NO. 0938-0391
(X3) 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:
194020
(X2) MULTIPLE
COMPLETED
B. WING
C
02/1912014
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS. CITY, STATE, ZIP CODE
1006 HIGHLAND AVENUE
BRENTWOOD HOSPITAL
(X4) ID
PREFIX
TAG
CONSTRUCTION
A. BUILDING
SHREVEPORT, LA 71106
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
8 150 Continued From page 45
Based upon observations, reviews of medical
records, policies/procedures, QA Incident Report
data, reports, staffing Schedules/grids and
interviews, the Director of Nursing failed to
ensure additional staff was present when
increased observations were ordered for patients
as evidenced by 12 of 18 patients (#2, 6-11,
14-16) who were allowed to engage in alleged
sexual misconduct.
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
B 150
Findings:
Review of Patient #s 2,6-11,14-18’s medical
records revealed that their individual
physician/psychiatrist had ordered specific
precautions (Elopement, Behavioral, Assaultive,
Sexual Acting Out), upon the patients’ admission.
Review of the Interdisciplinary Treatment Plans
revealed none of the physician ordered
precautions were care planned.
Review of a hospital policy, titled “Safety
Round&Accountability”, #TX.064. revealed:
“I. POLICY to provide a safe, secure
environment..by ensuring accountability for their
well-being,
II. PROCEDURE: Guidelines for
monitoring...patients...follows: SAFETY
ROUNDS PROCEDURE: The charge nurse
assigns...patient observation rounds...
1. Every patient not on Constant Observation or
one to one (1:1) precaution will be monitored at
least every 15 minutes. All CO and 1:1 patients
will be monitored constantly but documented
every 15 minutes...
FORM CM5-2567(O2-99) Previous Versions Obsolete
Event ID:YK3B1I
Facility ID: H00001T2B
If
Continuation
sheet Page 46 of 51
PRINTED: 06/26/201
FORM APPROVE[
0MB NO. 0938-0391
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
0211912014
B. WING
STREET ADDRESS. CITY. STATE, ZIP CODE
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
(X3) DATE SURVEY
COMPLETED
(X2) MULTIPLE CONSTRUCTION
A. BUILDING
B 150 Continued From page 46
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
CDMPLETIDN
DATE
B 150
2...any point in time that the patient is not visible
through Video monitoring, staff will physically go
and visualize the patient...
I
p
8. Visually observe patients when behind closed
doors by: 8.1 Knocking on bedroom...door. 8.2
Announce...stepping into room for rounds. 8.3
Open the door and visually observe the safety of
the patient...
10...lf the patient is..,therapist’s office or is in with
a physician, the staff will notate that the patient is
in the meeting but must check on the patient
every 15 minutes. The exception is any 1:1 or
CVO (constant visual observation) patient that
must be either within arm’s reach at all times or
within the line of vision at all times..ROOMS
2.
When patients are in their rooms, a staff
member...to be stationed in center of the hallways
to monitor patients and prevent inappropriate
patient contact.. will station self in the hallways at
all times. 3. Patient bedroom doors to stay open
when patients are in their rooms, except when
patients are taking showers, to allow for
appropriate staff monitoring...
Review of incident reports revealed:
11/28/13--allegation of sexual
misconduct between patients #14 and #11,
reported on 11/29/1 3.
12)04/1 3--allegation of sexual
misconduct between patients #6 and #8; reported
on 12/05/1 3.
12/25/13 an allegation of sexual
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID:YK3B11
Facility ID: H00001728
If continuation sheet Page 47 of 51
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
0211912014
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 47
misconduCt occurred between patients #16 and
#17, and reported on 12/26/1 3.
PROVIDERS PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
B 150
01/25/14 an allegation of sexual
misconduct between patients #15 and #9 and
was reported on 01/27/1 4.
01/26/14--allegation of sexual
misconduct between patients #2 and #7; reported
on 01/29/14.
02/03/14--allegation of sexual
misconduct between patients #18 and #10;
reported on 02/03/1 4.
Observations on 2/17/14, at 1:20 p.m., on the
Adult Psychiatric Unit revealed, according to the
patient list, that there were 15 adult female and
male patients on the unit. Of these 15 patients, 1
was identified as being 1:1 (patient #1 3), and
patient #12 and 2 random patients were identified
as being on Close Visual Observation.
At the time of the observation, staff present on
the Adult Unit were one Licensed Practical Nurse,
who was in and out of the medication room, and
one Registered Nurse who was sitting next to the
door of the group therapy room. Patient #13, who
was the 1:1 was sitting at a table in the middle of
the group therapy room and S14 RN was
approximately 8 feet away from the patient.
Other than the Counselor conducting therapy,
there were no other direct staff in the group
therapy room.
Interview with S14 RN on 2/17/14, at 1:40 pm.,
revealed when asked about the 1:1 ordered for
patient #1 3, S14 RN stated “let me look at my
FORM CMS-2567(02-99) Previous versions Obsolete
Event ID:YK3Bll
Facitty ID: H0000l728
If Continuation sheet Page 48 of 51
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
0211912014
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
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 48
sheet” then stated “yes patient #13 is a 1:1
When asked what 1:1 observation meant, S14
RN motioned and replied “at arms length”.
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X51
COMPLETION
DATE
B 150
Review of patient #13’s medical record revealed
on 2/17/14, the psychiatrist wrote an order dated
2/17/14 and timed 10:37 a.m. for the 1:1
observation to be discontinued; however, S14 RN
failed to be aware that her patient’s 1:1
observation level had been discontinued.
Further observations on 2/17/14, revealed patient
#12, on Close Visual Observations (CVO) was in
her room lying down. The 2 random patients who
were on CVO were also in their rooms lying
down.
Further interview with S14 RN during the
observation revealed the staff assigned to the
Adult Psychiatric Unit was an RN, an LPN, and a
Mental Health TeChnician (MHT), however, the
MHT was off the unit on break which left only the
RN and LPN to monitor 15 patients.
Review of the staffing ratio grid requirements
revealed for 15 patients there were to be 3 staff
members present on the Adult Psychiatric Unit.
However, the hospital failed to provide additional
staff to provide the 1:1 observation (1:1
observation required one staff member with the
patient, at arms length at all times) for patient #13
on 2/1 7/1 4, prior to the order being discontinued
at 10:37 am. and the Constant Visual
Observations for patient #12 and 2 random
patients. At 1:30 p.m., the nursing staff failed to
Call for additional staff when the MHT when on
break, leaving only two staff members on the unit
to monitor 15 patients.
FORM CM5-2567(O2-99) Previous versions Obsolete
Event ID:YK3B1I
Facility ID: H00001728
If continuation shoot Page 49 of 5
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FORM APPROVEt
0MB NO. 0938-039’
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(Xl) PROVIDERISUPPLIERCLIA
IDENTIFICATION NUMBER:
194020
(X2) MULTIPLE CONSTRUCTION
C
0211912014
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 49
Review of a Nursing Staffing schedule, dated
01/26/1 4, revealed on the Adolescent Unit
(ADOL), the staffing was 4 Registered Nurses
(RN) and 2 Mental Health Technicians (MHT) for
a census of 43 which met the staffing grid
I requirement. However, the number of nursing
staff present was not adequate to ensure the
safety of all patients as there were 2 random
patients on 1:1 (1:1 observation required one staff
member with the patient, at arms length at all
times), there should have been additional staff
members present to care for the 2 random
patients on 1:1 observation.
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
{XS)
COMPLETIDN
DATE
B 150
Review of a Nursing Staffing schedule, dated
01/26/1 4, revealed on the Youth Enhanced Unit
(YEU--Adolescent patients were transferred to
this unit when they required a higher/more
intensive observation/treatment), the staffing was
3 (no breakdown of RN-LPN-MHT) and census
was 8. The staffing was appropriate for the
census, according to the staffing grid. However,
there was one patient (#7) who was ordered on
1:1 observation, so an additional staff member
should have been present.
Interviews, 02/1 9/1 4, at 11:15am, with Si Director
of Nursing revealed when asked if (here had been
adequate nursing staff present, she replied the
staffing was based on the staffing grid.
The staffing grid utilized by the hospital failed to
take into account increased acuity levels on
patients and failed to ensure additional staff were
working to provide the monitoring required for
patients to remain safe.
The hospital failed to provide additional staff
members on the ADOL and YEU on 01/26/14 for
FORM cMs-2557(o2-gg) PrevIous Versions Obsolete
Event ID:YK3BII
FacililylD: H00001728
If contThuation sheet Page 50 of 51
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) OATE SURVEY
COMPLETED
A. BUILDING
C
194020
SWING
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
1006 HIGHLAND AVENUE
BREN1WOOD HOSPITAL
(X4) ID
PREFIX
TAG
0211912014
SHREVEPORT, LA 71106
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
8150 Continued From page 50
monitoring of patients who were ordered 1:1 and
Constant Visual Observation..
PROVIDER’S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
IX5)
COMPLETION
DATE
B 150
The number of staff present was not adequate to
ensure the safety of all patients as evidenced by
the alleged sexual misconduct that was allowed
to occur between patients.
FORM CMS-2567(O2-99) Previous Versions Obsolete
Event ID: YK3B1I
Facility ID: H0000l 728
If
Continuation
sheet Page 51
of
51