Abuses at Northlake Behavioral Health System, Mandeville, LA

March 1, 2019

Northlake Behavioral Health System is a Mandeville, Louisiana psychiatric facility that treats adolescents and adults. 

Between 2012 and 2018, the Centers for Medicaid and Medicare Services (CMS) conducted nine inspections of Northlake and found more than 40 violations--more than a dozen of which were violations of patients rights: 

December 10, 2012

CMS cited Northlake for the violation "Patient Rights: Care in Safe Setting," which means the facility failed to protect patients from harm by other patients.

The report concerns a teenage patient whom Northlake personnel failed to subdue when he attempted to exit a transport van while traveling on an interstate highway. The driver was forced to pull onto the shoulder, at which point the teen bolted from the vehicle and ran across the traffic lanes, where he was struck and killed by a tow truck.  

The facility also failed to ensure patients with a history of suicidal ideations were in an environment free of potentially harmful objects, such as shoestrings, that could have been used for strangulation. The hospital did not have policies and procedures that addressed the use of shoestrings, cords, or belts as potentially harmful objects. 

May 23, 2013

CMS cited Northlake for failing to ensure that each patient was free from all forms of abuse and failed to ensure its abuse policy required an employee with an allegation of patient abuse to be removed immediately from providing direct patient care.

Review of surveillance video showed that a mental health technician pushed a teenage patient toward his bedroom, then grabbed his shoulder and clothing to further bring him toward his bedroom. The facility provided the technician a written notification of his suspension pending full investigation. However, CMS found that hospital policy allowed the technician to be transferred to a different patient unit rather than calling for such offenders to be removed from contact with patients. 

On March 21, 2014

Northlake failed to ensure that its mental health technicians observed patients according to physician's orders and hospital policy

This report refers to eight patients housed in various units at Northlake, whom facility staff failed to monitor as per physician’s orders. These include patients who were ordered to be on 1-to-1 visual observation by staff because of suicide precaution, and unpredictable or violent behavior.

Staff allowed patients to return to their rooms alone, use the bathroom unattended, and sit by themselves unmonitored in common areas.

The facility’s psychiatrist admitted that the patients were not continuously being watched according to the observation levels whcih had been ordered.

Northlake failed to ensure that the hospital’s physical environment was maintained in a way that did not pose risk to acute patients who were admitted for being a danger to self or others, noting numerous ligature points (providing a location to which something can be tightly bound, such as a towel, shoelaces, etc.) such round doorknobs throughout the facility, protruding interior door hinges, and protruding bathroom stall door handles.

Other noted hazards included fixtures in the bathroom which were not secured, allowing access to fluorescent bulbs which could easily be removed; and easy access to sheets, towels, or blankets, which were freely available from a large plastic tub in the bathrooms.

Northlake also failed to prevent a patient on physician-ordered visual contact precautions from physically assaulting another patient. The female patient, who was ordered to be on constant visual contact for violence, had hit and pulled the hair of another patient. She was placed in a seclusion room for a time and then was allowed to go to her room. After staff left her room she ran to the other patient’s room and hit her several times. 

On November 17, 2014

Northlake failed to track and analyze significant adverse patient events—such as attempted suicide, elopement from the facility, or any incident that requires emergency medical treatment—and to put preventive actions in place for feedback and learning throughout the hospital. Northlake also failed to produce incident reports for such adverse occurrences.

A CMS review found that hospital’s policy was to define serious occurrences and develop a system for reporting incidents to external agencies and internal departments for follow-up. The staff member closest to the event was to initiate a report containing a clear description of the events which led to the situation and outcome. The report was to then be reviewed by several specific Northlake clinical and administrative personnel, who would determine the appropriate follow-up action(s) needed and conduct further investigation and corrective action. Copies of Serious Occurrence reports were to be kept in a location in administration where staff from monitoring agencies (CMS, etc.) could easily access them. Northlake’s Executive Director was to maintain a serious occurrence log detailing serious occurrences.

Yet CMS, in interviewing a Northlake administrator, found that he didn't recall a significant adverse patient event other than the most recent one (August 2014). He confirmed that he was not aware of any staff member who maintained a log of serious occurrences.

The report details numerous cases of adverse events—an unpredictable patient making suicidal and homicidal gestures; to patients who conspired to escape the facility; a patient requiring emergency medical treatment for a rash of unknown origin; a choking patient who required the Heimlich Maneuver

The reports of these incidents were not reviewed by Northlake’s clinical and/or administrative reviewer and did not contain analysis of cause and/or plans for prevention.

In one case, in which a patient had his teeth loosened after being hit in the mouth by another patient, Northlake personnel failed to even document the incident.

Northlake also failed to ensure a patient was free from all forms of abuse, neglect, or harassment by failing to conduct a timely, thorough, objective investigation of allegations of sexual abuse and inappropriate sexual behavior regarding five patients.

A review showed that Northlake had policy in place which required such allegations to be immediately reported to the nurse of the unit in which the incident occurred—within one hour. The nurse supervisor was then to ensure that the patient has been removed from further hazard and has received appropriate care; contact an administrator to determine whether the staff concerned should be suspended or re-assigned; ensure evidence is safeguarded and preserved; gather witness statements, and more—all within an hour of the incident.

Northlake was to notify the state Department of Health & Hospitals’ Health Standards section (DHH) of all allegations, no matter how irrational the allegation may be, within 24 hours.

Per the policy, Northlake’s Patient Rights Officer and CEO also had responsibilities for collecting statements and reviewing evidence.

CMS’s report of investigations of five incidents reveals numerous departures and violations of the Northlake’s own policies. 

In one instance, Northlake failed to even consider that one patient's allegations of sexual abuse was an actual grievance. A further review of Northlake's "Abuse/Neglect Log" revealed no evidence that any of the reported sexual abuse incidents was considered by Northlake to be an actual grievance.

April 19, 2016

Northlake's governing body failed to identify and promptly resolve patient grievances as evidenced by failure to initiate the grievance process in the case of a patient who was involved in an altercation with another patient who punched him in the face and head 12 times in 11 seconds, sustaining a swollen left eye, right cheek, and upper lip. The patient was observed to lie motionless on the floor for almost one minute after the offending patient had been separated from him.

Northlake’s policy required the hospital to respond promptly and effectively to patient complaints and grievances.

A review revealed that the patient’s neurological status had not been evaluated after the altercation or at all for the duration of the shift. The patient was not evaluated until the next day.

The patient’s sister, surprised and upset at her brother’s “beaten up” appearance. She expressed to Northlake’s program director that she was concerned that the staff had let it happen to him, delaying response because the staff didn't like him. The program director reported to CMS investigators that she felt that the sister was “on a fact-finding mission” and did not document the sister's concerns as a grievance, because she had not felt it was a complaint or grievance.

Feeling that Northlake personnel had not lived up to its policies, or acted in the best interests of the patient, the sister called the police because she wanted someone outside the hospital to investigate the incident.

The Louisiana law, "Title 40. Public Health and Safety, Chapter 11, State Department of Health and Hospitals" states: 

"Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, ... having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect."

A CMS review of Northlake’s policies revealed showed that it was aware of the law and was that it was to notify DHH of all allegations, no matter how irrational the allegation may be, within 24 hours.

However, Northlake never reported the incident to DHH.

July 21, 2017

Northlake failed to ensure patients were free from abuse or harassment by staff.

Interviews revealed that a Northlake mental health technician called a patient a “pussy.” This was corroborated by another Northlake employee who heard the technician say it. That employee reported it to the nurse of the unit and the nurse removed the offending technician from the unit but failed to report it to anyone higher up, as required.

However, CMS found no note of the incident in Northlake’s incident log. Northlake policy required any employee who had knowledge of patient abuse or who received a complaint of abuse from a patient or any other person, to immediately (within one hour) report it in accordance with Northlake policies and procedures. 

Northlake also used restraints and seclusion measures on two patients in violation of their documented plans of care.

CMS found that one patient had been locked in seclusion five times in a one-month period, for violent behavior. In one instance, the seclusion was in combination with a “chemical restraint” injection. Yet this was against the patient’s written care, which did not include the use of restraint of seclusion.

CMS found that staff that manually restrained the other patient or placed him in locked seclusion four times in a one-month period for violent behavior though this patient’s care plan also did not contain provisions for use of restraint or seclusion. 

Source: Northlake Behavioral Health System report published by Association of Health Care Journalists, URL: http://www.hospitalinspections.org/hospital/northlake-behavioral-194007#