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Based on record review and interview the hospital failed to ensure patients were free from abuse and neglect. This failed practice was evidenced by staff not following Louisiana Law and hospital policy for reporting the suspected case of neglect of Patient #3, received from Facility A, to the appropriate agency, which was Louisiana Department of Health and Hospitals.
Findings:

Review of a hospital policy titled,"Victim of Abuse, Adult, Geriatric, Handicapped", number 1.01.01, provided by S7PI as current, revealed, in part, Mandatory reporting of suspected cases of abuse, neglect, or exploitation in disabled adults who cannot physically or mentally protect themselves is required, as mandated by Louisiana Law. The procedure included all cases of suspected abuse, neglect, or exploitation should be referred to the appropriate investigative agency. Further review revealed residents of Nursing homes were to be referred to the Department of Health and Hospitals (phone number provided). Under the heading of "Evaluation", poor hygiene and dehydration were listed in the profile characteristics of a victim. Review of attached Addendum A revealed the resource for reports against institutions was the Department of Health and Hospitals, with a phone number provided.

Review of a hospital policy from the Social Services Policy Manual, titled, "Abuse and Neglect Policy and Procedure", Number 6.13, provided by S11LCSW as current, revealed, in part a procedure that included notification of the social worker. Further review revealed , "... 4. The Social Services personnel shall review the chart and see the patient for assessment. Social Services will consult with other involved parties to evaluate the allegation of abuse/neglect...5. Social Services shall notify appropriate State Agency...

Review of the medical record for Patient #3 revealed he was admitted to the ED 4/12/15 from Facility A, with the chief complaint of decreased level of consciousness. Further review of the ED record revealed the following Nursing notes:
Triage: "arrived via stretcher, via EMS, accompanied by no one...Patient from "Facility A". Past Medical history included hypertension, Bipolar Disorder, Dementia, Parkinson's, and Schizophrenia." A nursing note documented, "cleaned pt's skin to start IV and black came off of skin. Pt had a body odor..."
Nursing note:" Pt smells strongly of body odor and has dry flaky skin all over his body. Pt has dry chapped lips with large flakes of skin partially attached to lips. Pt's hands caked with dead skin as well as his feet. Pt has multiple sores on his body... Pt has visible dirt around his neck... Pt's perineal area caked with dead skin and skin to scrotum and penis shiny and tight. Pt moans when being cleaned in his perineal area. Wipes to perineal area, neck, arm pits and legs are brown with one swipe when cleaning the patient..." "(name) with Baton Rouge Elder Abuse notified of Pt's status on Presentation to [ED] for investigation of possible neglect."
Review of ED Physician notes revealed, in part, the following:
"...Dementia, dehydrated. VERY UNKEPT AND DIRTY WITH STRONG BODY ODOR... ORAL MUCOUSA AND LIPS GROSSLY DRY AND FLAKY... DOES NOT MOVE EXTREMITIES...poor (skin) turgor; mucous membranes are dry; mucous membranes are pale..."
Further review of the medical record revealed Patient #3 was admitted to the hospital from ED.

Review of a Social Service Assessment for Patient #3 dated 4/15/15 revealed the following, in part:
"Received call from (name) with Adult Protective Services. State APS received a report from the ER on this patient. After further discussion and review of the pt's chart it was apparent that Adult Protective Services was not the appropriate reporting agency since the pt is a resident of a nursing home (Facility A). Reviewed ER documentation. Noted pt's condition upon arrival to the ER (body odor, dirty, skin in poor condition)."
Further review revealed S11LCSW spoke with the administrator of Facility A, who reported Patient #3 was bed bound, incontinent, was a long time resident of the facility. The notes stated Facility A's administrator reported the patient sweated profusely and therefor it was difficult to avoid body odor, and that their (Facility A's) documentation reflected that the patient had been bathed earlier that day. S11LCSW's notes documented that she spoke with the patient's nurse, and the nurse reported that she had not noted any profuse sweating by the patient on that day.

Review of a Social Service Assessment note dated 4/16/15 revealed S11LCSW spoke with S12 MD that morning and he reported that he was the patient's doctor at the nursing facility and he had not had any concerns regarding the patient's care in the nursing home. Plans for the patient were, at that time, to return to the nursing home.

In an interview 11/12/15 at 9:00 a.m. S12MD reported that he was Patient #3's primary care physician. S12MD reported that he was the Medical Director at Facility A until last November (2014), when he resigned that position. He reported prior to that time he would see Patient #3 every month or two. When asked if he recalled Patient #3 being dirty, or unkempt when he saw him (Patient #3) in the nursing facility, he responded, "He was about average for a nursing home resident; (I) don't recall him being dirty. He was severely dehydrated every time he came to ER"

In an interview 11/12/14 at 9:30 a.m. S9RN confirmed he had taken care of Patient #3 4/12/15 in the ED. He reported that he remembered the patient and had reviewed his medical record. He stated, " I was appalled at the patient's condition when he came in." S9RN reported that he phoned the Elder Abuse hotline, but did not remember what was said. He reported that he did not remember entering a social service consult into the computer. S9RN indicated since it was a Sunday and the patient was being admitted as an impatient, so the ED staff did not feel the need to call the social worker out to come to the hospital at that time. He reported he was not sure exactly what the hospital procedure was for reporting abuse and neglect. The RN indicated that the ED sort of functioned as a separate entity, so they (ED staff) usually reported directly to the reporting agencies.

In an interview 11/12/15 at 10:02 a.m. S16RN reported that she was the charge nurse in the ED on 4/12/15 and triaged Patient #3. S16RN stated, " The condition of the patient was hideous. I was shocked at the condition he appeared in." S16RN verified her documentation on Patient #3's ED record regarding his skin and hygiene. The RN reported that the patient had a tremendous amount of dry skin, with dirt and dry skin in all the crevices of his skin; she stated she wasn't sure when he last had a bath. S16RN reported she would "NEVER forget the look on S9RN's face when he came out of Patient #3's room (after his first contact and assessment). S16RN reported that S9RN bathed the patient in the ED. S16RN reported that the staff were mandated to report allegations or suspicion of abuse or neglect. She indicated she would sometimes tell someone else, like the house supervisor if they came by. She reported that she could not remember if any supervisor had been notified. S16RN reported that the physician should enter a Social Service consult order. After a review of Patient #3's orders S16RN confirmed no order for a Social Service consult on the medical record was found.

In an interview 11/12/15 at 11:20 a.m. S11LCSW reported that she first learned of suspected neglect of Patient #3 when she received a phone call form Adult Protective Services, who let her know a report had been made, but that they (Adult Protective Services) were not the correct agency in which to report neglect when a facility or institution was alleged to have neglected a patient or resident. S11LCSW reported that she spoke with S12MD, who told her he had not had any concerns regarding the care of the patient in Facility A. The Social Worker reported she also spoke with the Administrator at Facility A, who she knew and with whom she had a good working relationship. She reported the administrator told her the patient sweated a lot and his records indicated he had been bathed the morning of his admission to the ED. S11LCSW confirmed she did not make a report of suspected neglect of Patient #3 to DHH, as required by Louisiana Law and hospital policy. S11LCSW confirmed she should have reported the information to the DHH agency, as required by law, and the hospital policy.

Based on record reviews and interviews, the RN failed to supervise and evaluate the nursing care provided to each patient as evidenced by failing to ensure a pressure ulcer that was re-assessed by nursing from a Stage II to a Stage III pressure ulcer was provided appropriate wound care by failing to initiate the appropriate wound care protocol per hospital policy for 1 (#2) of 5 patients reviewed for pressure ulcers.

Findings:

A review of the hospital policy titled, "Pressure Ulcer Prevention and Wound Care", provided by S6WCN, as the most current policy, revealed in part: Upon admission and daily, the nurse will assess the patient's risk for skin breakdown and wound care. All open wounds, including pressure ulcers, will be measured upon admit and weekly for changes in patient wound status and should be documented on the patient's skin assessment flowsheet. The nurse will use assessment findings to initiate the hospital's wound care protocol using the "red", "yellow", " black" system until orders are obtained and verified by the physician.

A review of the current Patient #2's medical record revealed he was a 76 year old male, admitted on 11/03/15 with the following admit diagnoses: Altered Mental Status, Urinary Tract Infection, Dehydration and a Stage II Pressure Ulcer to the Sacrum. During the RN initial assessment by S17RN, the RN documented that the Stage II Pressure Ulcer to the sacrum measured 3.0 x 0.5 x 0.2 with red granulation, no slough, and no eschar noted. Wound care photos and measurements were obtained. The S17RN initiated the wound care, "Red Wound Care" protocol upon admit. A further review of Patient #2's medical record revealed on 11/08/15 that S15RN was caring for the patient and assessed the patient's Stage II sacral pressure ulcer. S15RN documented that the sacral pressure ulcer was measured as 4.0 x 0.5 x 0.2 and S15RN re-staged the sacral pressure ulcer as a Stage III and documented that the wound was a Stage III due to yellow slough noted on the wound. A further review of the medical record revealed no documented evidence that S15RN initiated the "Yellow Wound Care" protocol as per hospital policy.

In an interview on 11/9/15 at 3:15 p.m. with S6WCN, she indicated that she was the Wound Care Nurse. S6WCN indicated that all wounds are assessed upon admit during the RN's initial assessment. S6WCN indicated that all nurses are trained in wound care and wound competency assessment upon hire and annually at the hospital's annual competency fair that is conducted by S6WCN and all nurses are able to assess and stage pressure ulcers. S6WCN indicated that depending upon the nurse's assessment and the color of the wound, (red, yellow, black), an appropriate wound care protocol is generated by the RN and initiated on the patient immediately. S6WCN indicated that wound measurements are performed weekly by the nurse assigned to the patient that day and are documented on the Wound/Skin Care Assessment Flowsheets. S6WCN further indicated that the skin/wound care protocols are standing orders that were agreed upon by the facility's physicians. Patient #2's Wound/Skin Care Assessment Flowsheet from 11/08/15 was reviewed with S6WCN. S6WCN indicated that S15RN probably should have initiated the "Yellow Wound Care" protocol as per hospital policy due to the yellow slough noted on the wound.

Based on record reviews and interviews, the hospital failed to ensure that the nursing staff developed and kept current a nursing care plan for each patient as evidenced by failing to individualize the patient's nursing care plan to include all the patient's medical diagnoses for which the patient was being treated and failing to establish target dates for the patient's goals for 3 (#1, #2, #5) of 5 sampled patient medical records reviewed for nursing care plans.

Findings:

A review of the hospital policy titled "Patient Care Plans", provided by S4LPN, Nurse Educator, as the most current policy, revealed in part: Patients will have patient care plans which is appropriate and individualized to meet the patient's needs. The care plans must be individualized by adding to and deleting appropriate diagnosis, goals or interventions. To continue to meet the patient's unique needs, the care plan must be maintained and revised based on the patient's response to the current interventions.

Patient #1
A review of the current Patient #1's medical record revealed he was a 68 year old male, admitted on 11/03/15 with the following admit diagnoses: Vomiting and Nausea. A review further revealed that the patient's other medical diagnoses included in part: Diabetes and Hypertension. A review of Patient #1's care plan revealed that Diabetes and Hypertension was not addressed as one of the patient's identified problems in his plan of care. The patient's care plan review further revealed that the nursing staff did not establish any target dates for any of the patient's care plan goals and interventions.

Patient #2
A review of the current Patient #2's medical record revealed he was a 76 year old male, admitted on 11/03/15 with the following admit diagnoses: Altered Mental Status, Urinary Tract Infection, Dehydration and a Stage II Pressure Ulcer to the Sacrum. A review further revealed that the patient's other medical diagnoses included in part: Diabetes, Hypertension, Coronary Artery Disease, Seizures, Renal Disease, and Atrial Fibrillation. A review of Patient #2's care plan revealed Seizures, Hypertension, Renal Disease, and Coronary Artery Disease was not addressed as one of the patient's identified problems in his plan of care. The patient's care plan review further revealed that the nursing staff did not establish any target dates for any of the patient's care plan goals and interventions.

Patient #5
A review of the discharged Patient #5's closed medical record revealed he was a 80 year old male, admitted on 10/22/15 with the following admit diagnoses: Bradycardia, Hypothermia, Dehydration, and Altered Mental Status. A review revealed that the patient's other medical diagnoses included in part: History of Falls, Atrial Fibrillation, and Healing Pressure Ulcer to Buttocks. A review of the patient's care plan revealed that the nursing staff did not establish any target dates for any of the patient's care plan goals and interventions.

In an interview on 11/10/15 at 2:45 p.m. with S3RN, Staff Development Director and S7PI, Performance Improvement Officer, the above patient's care plans were reviewed. S3RN indicated that during the RN's initial nursing assessment of a patient, the system triggered certain Nursing Diagnoses/Care Plans, and the RN could initiate other Diagnoses/Care Plans. S3RN indicated that the above referenced care plans were not inclusive. S3RN further indicated that the patient's care plans should have been comprehensive and included all of the patient's medical diagnoses and not solely those care needs related to the admitting diagnosis. S7PI indicated that there was a "glitch" in the nursing care plan documentation regarding documenting patient target dates for patient goals, where target dates were not entered and that the hospital had to address this problem.

Based on records reviews and interview, the hospital failed to ensure the infection control officer developed an effective system that included measures to prevent and control infections and communicable diseases of patients and personnel as evidenced by failing to ensure that contact precautions were implemented by staff for 1 (#1) of 5 sampled patient's medical records reviewed for isolation precautions.

Findings:
A review of the hospital policy titled, "Isolation Policies and Procedures", provided by S5IP as the most current policy revealed in part: The Isolation System at the hospital is established to prevent the transmission of microorganisms from infected patients to other patients, personnel or visitors. The CDC Guidelines for Isolation Precautions in Hospitals has been used as a reference for reviewing our system. For patients known or suspected to have transmittable microorganisms that can be transmitted by direct patient care or by contact with items in the patient's environment, such as MRSA, will be placed on contact precautions when known.
A review of the current Patient #1's medical record revealed he was a 68 year old male, admitted to the hospital from the Emergency Room on 11/03/15 with the following admit diagnoses: Vomiting and Nausea and with other medical diagnoses to include in part: Diabetes and Hypertension. A review of Patient #1's medical record revealed that a urine culture was obtained in the Emergency Room and sent to the laboratory on 11/03/15. A further review of the patient's medical record revealed that the laboratory results on the urine culture was obtained on 11/06/15 and indicated MRSA in the urine. A review of Patient #1's medical record revealed that the patient was not placed on contact precautions until 11/09/15.

In an interview on 11/10/15 at 1:15 pm with S5IP, she indicated that she was the Infection Control Officer for the hospital and that she was responsible for reviewing all patient medical records daily for infection control issues. Patient #1's medical record was reviewed with S5IP. S5IP indicated that she became aware of Patient #1's urine culture of MRSA (that was obtained in the Emergency Room on 11/03/15) when she returned to work on 11/09/15. S5IP indicated that she reviewed the urine culture report from the laboratory and placed Patient #1 on contact precautions on 11/09/15. S5IP indicated that Patient #1 should have been placed on contact precautions on 11/06/15 when the culture results were reported to the nursing unit. S5IP further indicated that the nurses should have picked up that the patient's urine was positive for MRSA and the patient should have been placed on contact precautions on 11/06/15.