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Based on record review and interview, the hospital failed to ensure patient complaints were recognized as grievances. This deficient practice was evidenced by failing to correctly identify a patient's grievance for 1 (#2) of 1 (#2) patients reviewed for complaints/grievances from a total patient sample of 5.
Findings:

Review of the hospital's policy, titled Patient Grievance, revealed in part, A patient's grievance (as defined by Centers for Medicare & Medicaid Services, ref 482.13(a) (2)) is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CRF 489.

Review of Patient #2's Case Management Progress Note by S4LMSW, dated 09/13/2021, revealed S4LMSW was speaking to Patient #2's mother over the phone obtaining information on the patient. Patient #2's mother reported to S4LMSW that her daughter was attacked by a patient and she wanted her daughter discharged.

Review of the Grievance/complaint log for September 2021 revealed no evidence of a grievance related to Patient #2.

An interview was conducted with S4LMSW on 10/06/2021 at 10:40 a.m. She reported at the conclusion of the phone interview with Patient #2's mother, she reported the conversation to her supervisor.

An interview was conducted with S2Risk Manager and S5Director of Social Services on 10/05/2021 at 10:50 a.m. They reported they spoke to Patient #2's mother on the phone on 09/13/2021. S2Risk Manager and S5Director of Social Services further reported they took the conversation as more as a clarification on her daughter's condition and on what medications had provided the best results in the past for Patient #2. S2Risk Manager and S5Director reported in hindsight that they should have treated the complaint as a grievance.

Based on observation and interviews, the hospital failed to ensure patients requiring acute inpatient psychiatric care, who have been admitted for being a danger to self and others, received care in a safe setting. This deficient practice was evidenced by failure to ensure the physical environment was maintained in a manner to assure an acceptable level of safety for patients by having toilet seats that raise with anchor points and by having wall air conditioner units with sharp metal corners on the locked metal access plates. Findings:

An observation was conducted on 10/06/2021 at 9:00 a.m. of Unit A and C. All the bathrooms on Unit A and C (22 bathrooms including the seclusion bathrooms) had toilet seats that raised and had anchoring points which posed a ligature risk.

An interview was conducted with S2Risk Manager and S3DON at the time of the observations and they confirmed the toilet seats had an anchoring point and was a ligature risk.

An observation was conducted on 10/06/2021 at 8:45 a.m. of Unit A and C. Each patient bedroom and seclusion room had a wall air condition unit (22 air conditioner units). On the wall air conditioner unit was a metal plate that locked that allowed access to the controls. The metal plate did not sit flush to the air conditioner unit and had sharp metal corners that could cause injury.

An interview was conducted with S2Risk Manager on 10/06/2021 at 8:45 a.m. She confirmed the corner edges to the metal access plates were sharp and could cause injury.

Based on record review and interview, the hospital failed to assure any incidents of abuse, neglect, and/or harassment were reported and analyzed, and the hospital was in compliance with applicable local, State, and Federal Laws and Regulations. This deficient practice was evidenced by:

1. failure to report an allegation of patient (Patient #2) being abused by another patient (Patient #3) within 24 hours to LDH-HSS for 1 (#2) of 1 patient reviewed for allegations of abuse/neglect from a total patient sample of 5 (#1-#5) and;

2. failure to complete an incident report when a family member of a patient had the police visit the hospital after an allegation of assault. Findings:

1. Failure to report an allegation of a patient (Patient #2) being abused by another patient (Patient #3) within 24 hours to LDH-HSS.

Review of the Louisiana Revised Statutes, Title 40. Public Health and Safety, Chapter 11, State Department of Health and Hospitals revealed "Department" shall mean the Department of Health and Hospitals. "Unit" means the Medicaid fraud control unit created within the office of criminal law of the Department of Justice and which is certified by the secretary of the United States Department of Health, Education and Welfare. Regarding §2009.20. Duty to make complaints; penalty; immunity.

"Abuse" is the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including but not limited to sexual abuse, or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered.

"Neglect" is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer's well-being. Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, ... having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report.

Review of the Incident Report Form, dated 09/11/2021 at 12:50 p.m., revealed in part, Patient #2 approached Patient #3's room talking to herself and having auditory hallucinations. Patient #2 began running towards nursing station's door trying to get in, followed by Patient #3 behind her. Patient #3 grabbed Patient #2's hair and began attacking her. Medical Staff separated the two apart. Patients seen by S6NP who was present on the unit.

An interview was conducted with S2Risk Manager on 10/05/2021 at 2:00 p.m. She reported the hospital did not submit a self- report of the incident to LDH-HSS.

2. Failure to complete an incident report when a family member called the police related to an assault on Patient #2

Review of the hospital's policy titled, Incident Reporting, revealed in part, An "incident" is an unanticipated event which was not consistent with the standard of care/and or operation of the facility and my have occurred due to a violation of policy and procedure...In the event law enforcement is involved, the facility Risk Manager or Designee must notify Chief Compliance Officer and Chief Risk Officer.

An interview was conducted with S5LPN on 10/05/2021 at 2:00 p.m. She reported Patient #2 and Patient #3 got into an altercation on the unit and Patient #2's hair was pulled by Patient #3. She went on to report Patient #2's mother called the police after she heard about the incident and two police officers came to the unit to check on the patient.

An interview was conducted with S2Risk Manager on 10/06/2021 at 9:30 a.m. S2Risk Manager reported she was not aware two police officers came to check on Patient #2 at the request of the patient's mother. She further reported an incident report should have been completed when law enforcement comes to the facility and checks on a patient.