State and Federal regulators cite Brentwood for understaffing; cites incidents of ER care delays and patient elopements

Brentwood Hospital in Shreveport, Louisiana, was cited during a full certification survey conducted by the Centers for Medicare and Medicaid Services (CMS) and the Louisiana Department of Health and Hospitals for deficiencies related to patient rights, nursing services, special staff requirements for psychiatric hospitals, quality assessment and performance improvement (QAPI), and respiratory care services.

CMS found the hospital failed to meet the Condition of Participation [in the Medicare program] for Patient Rights. This was evidenced by the Hospital’s failure to:

  1. Ensure patient care was provided in a safe setting relative to:
  • Allowing patients on the Adolescent Open Unit to sleep in Rooms #244 and #246 (designated as Consultation Rooms) when they were short of beds on the unit.
  • Having crank beds and side rails available on the Adult Psychiatric Unit which posed a ligature hazard
  • Investigate the causative factors of patient elopements and ensure adequate supervision of patients
  • Transfer a patient to a local emergency room for evaluation and treatment after an attack by another patient for 7 hours and 2 minutes after the Physician’s Order had been written due to lack of staffing
  • Have a policy and procedure in place for crank beds and side rails that were available on the Adult Psychiatric Unit which posed a ligature hazard.

2. Ensure each patient’s rights were protected related to patient #18 being denied the             right to contact the Mental Health Advocacy Services.

CMS also cited Brentwood Hospital for condition-level deficiencies for its failures in ensuring the nursing service had adequate numbers of licensed registered nurses, licensed practical nurses, and mental health technicians to provide nursing care to all patients. During an interview with the Director of Nursing, she “verified the staffing needed to be increased on the unit for 2/23/14 and the staffing for the 7:00am to 3:00pm did not meet the hospital staffing grid requirements. She also said from 3:00pm until 11:00pm, the Adolescent Enhanced Unit had 5 staff but 3 patients on 1:1 which still left the unit short one staff member.

CMS cited Brentwood Hospital for condition level deficiencies related to special staff requirements for psychiatric hospitals. CMS found:

“The hospital failed to have adequate numbers of qualified professional and supportive staff to assure for patient safety and the effective implementation of the patients treatment plan. This was evidenced by nursing services failure to have adequate numbers of licensed registered nurses, licensed practical nurses, and mental health technicians to provide nursing care to all patients as needed.”

During the inspection, CMS observed the following:

  1. The Open Adolescent Unit had 5 patients (#s 2,3,19,20,21) on roll away beds located in the dayroom. S35 Mental Health Technician (MHT) confirmed the 5 patients were sleeping in the dayroom because “they are all on constant visual observation and it was easier to observe them all in here.” Census revealed a total of 26 females on the Adolescent Unit with 1 Registered Nurse and 1 MHT
  2. The failure to transfer a patient to a local emergency room for evaluation and treatment after an attack by another patient
  3. The failure to transfer an adolescent patient with a broken wrist to the emergency room for treatment for 1 hour and 45 minutes after the order had been written

In one incident in the Adult Unit, it was revealed:

“Patient #5 (a 57 year old female) was attacked by a male peer (a 23 year old male) while she was standing at nurse’s station speaking with nurse. A male peer walked up behind her, placed his hands on her head in a crushing like motion. He then put his arm with elbow around her neck in a head back type motion. He released her neck and shoved her to the floor and was kicked by him 2-3 times..she stated, “He beat me and I want the police.”

The patient was not sent to the hospital until 7:47pm, over 7 hours after the physician’s orders. In an interview with the nursing supervisor on the weekends revealed he wanted 5 staff for the Adult Enhanced Unit but could only find 4 staff to work. The RN said that Adult Unit “was 1 person short on staffing because the unit had 2 patients that were 1:1 observations.” The Nursing Supervisor also said “the physician ordered patient #5 to go to the ER to be examined at 12:45pm, but another patient from another unit was medically unstable and had to be sent to the hospital. The RN said at the time if he would have sent 2 staff members to the hospital with patients the hospital would have been too short staffed.” Another RN said the Adult Enhanced Unit is short staffed a lot because of the high acuity of the patients.

The facility was also cited for multiple elopements from the facility out of the Youth Enhanced Unit. In one example”

Patient #30 was a 16 year old male admitted to the hospital on 2/27/14 under a Physician Emergency Certificate for suicidal, dangerous to self, and unable to seek voluntary admission. Patient #30 eloped from the building after he kicked the exit door of the unit open and ran down the stair well to the basement and out of the building. Nursing Progress Notes revealed the patient returned to the hospital at 12:15p.m. and was brought back to the unit. Upon returning to the unit, Patient #30 kicked the door open again with three other male patients. The other patients were returned by the police but patient #30 returned on his own. The note revealed the patient attempted to kick the door open a third time, but was redirected and then transferred to a more secure unit.

Review of the Assignment sheet and Daily Staffing Worksheet revealed a census of 40 patients with 3 MHTs, 1 LPN, and 3RNs. The LPN and 1 RN were assigned to the desk/medications, leaving 3MHTs and 1RN and 1RN charge nurse to monitor 40 patients. On the morning of the incident, prior to the elopement, the Fire Alarm System was being tested. Once the testing of the alarm system is completed the magnetic doors did not re-engaged that day as patients were able to elope through the door.

On the Female Adolescent Unit, CMS revealed that 5 patients were sleeping in the dayroom on roll-away beds. The RN House Supervisor revealed:

“the adolescent Unit was a 42 bed unit, but they adjusted the rooms to sleep 4 more people on the unit…the chairs and desks were removed from 2 rooms (identified as room #s 244, 246 that were used as Consultation offices) and put roll away beds in the rooms for the patients to sleep.”

CMS found that the hospital did not take steps to ensure patient safety related to the ceilings located in these rooms and bathrooms. Any patient who utilized both of these rooms could remove the ceiling tiles and either make attempts to escape, injure, or hang themselves.

CMS also found medication and treatment plan related deficiencies during a review of the February 2014 and March 2014 Quality Management Committee meeting report that revealed 11 and 14, respectively, medication variances were reported and the wrong medical administered was the most prominent variance. CMS also found during a review of Patient #s 1,2,6,9,10,27 and 30 medical records that they all had psychiatric admission diagnoses that included Suicidal Ideation and the patients’ Interdisciplinary Treatment Plans revealed the same generic plans for suicidal ideation as patients (#s 3,11,15,20,21,22,23,and 25).

Lastly, the inspection by both CMS and the Department of Health found that the hospital failed to ensure the overall hospital environment was developed and maintained in such a manner that the safety and well-being of patients are assured as evidenced by:

  1. Failing to ensure electrical receptacles in the patient rooms were of the safety type or protected by ground-fault-interrupters
  2. Failing to ensure all rooms where psychiatric patients slept had tamper proof or monolithic ceilings
  3. Failing to ensure there were not plastic trash liners present in the common areas on the Adult Psychiatric Unit, the Adult Enhanced Unit, the Geriatric Unit, the Child Psychiatric Unit, and the Child Enhanced Unit.
  4. Failing to ensure the shower room on the Youth Enhanced Unit did not have safety risks including non-monolithic ceilings, accessible fluorescent light bulbs, and ligature risks
  5. Failing to ensure the shower room on the Geriatric Psychiatric Unit did not have a shower wand with a hose that posted a ligature risk
  6. Failing to ensure showers were clean on the Youth Enhanced Unit; other safety issues and contraband found on YEU
  7. Failing to ensure seclusion rooms on the Adolescent Open Unit did not have a dirty wax build up along the baseboards; and the Youth Enhanced Unit’s seclusion room was missing layers of “chalkboard” wall covering in a couple of areas
  8. Failing to ensure hinges on patient room doors and patient bathroom doors were of the anti-ligature type

The inspection report did not include a plan of correction.