HospitalInspections.org

Based on record review and interview, the hospital:

1) failed to ensure the staff was knowledgeable and compliant with all relevant federal, state and local municipal laws and regulations by failing to report an allegation of physical abuse to administration, the local law enforcement agency, the physician, and the family at the time of discovery, and the appropriate state agency within 24 hours as required for 1 (#2) of 5 sampled patients. The hospital also failed to notify the appropriate state agency of an allegation of verbal abuse by a staff member for 1 (#3) of 5 sampled patients; and

2) failed to ensure patients were protected from potential abuse. This deficient practice is evidenced by the hospital allowing S6RN to work on 10/4/16 despite being made aware on 10/3/16 of an alleged incident of abuse that took place on 9/30/16.
Findings:

1) Failing to ensure the staff was knowledgeable and compliant with all relevant federal, state and local municipal laws and regulations by failing to report an allegation of physical abuse to administration, the local law enforcement agency, the physician, and the family at the time of discovery, and the appropriate state agency within 24 hours.
Review of the Louisiana Revised Statutes, Title 40. Public Health and Safety, Chapter 11. State Department of Health and Hospitals
§2009.2. Definitions (Excerpt)
(3) "Department" shall mean the Department of Health and Hospitals.
(4) "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.
§2009.20. Duty to make complaints; penalty; immunity
A. As used in this Section, the following terms shall mean:

(1) "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.

(2) "Neglect" is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer's well-being.

B. (1) Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, licensed practical nurse, nurse's aide, home- and community-based service provider employee or worker, personal care attendant, respite worker, physician's assistant, physical therapist, or any other direct caregiver 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.

Patient #2
Review of Patient #2's medical record revealed she had been admitted to the hospital on 9/12/16 with an admission diagnosis of Schizoaffective disorder, unspecified.

Review of a Hospital Abuse/Neglect Initial Report submitted to the Louisiana Department of Health for Patient #2 dated 10/5/16 revealed the date of the incident was listed as 9/30/16 between 6:30 a.m. and 7:00 a.m. A description of the alleged incident was as follows:
Per S4MHT, on September 30, 2016, Patient #2 was calling patients and staff racial slurs. S6RN asked S5MHT to help her get Patient #2 in her room, Patient #2 goes into her room followed by S6RN and S5MHT. Patient #2 began stripping off her clothes, S6RN asked Patient #2 to put her clothes back on then Patient #2 called S6RN a (explicative). S6RN grabbed Patient #2 around the neck from behind. S4MHT walked in at this point as S6RN seen S4MHT and quickly let go of the patient. Patient #2 then attempted to hit S6RN but S5MHT grabbed her arm and was able to de-escalate her.
Physician S7MD was notified on 10/4/16
Family was notified on 10/5/16 at 1300 (brother)
Hospital Personnel Notified:
S3ADON 10/4/16 at 0830
S2DON 10/4/16 at 0930
S1CEO at 10/5/16 at 1100

Review of a Physician's Progress Note for Patient #2 dated 9/30/16 at 12:30 p.m. revealed the physician wrote Patient #2 said she had been beaten by the staff and she wanted to call the police (day of alleged incident).

Review of Interdisciplinary Notes for Patient #2 dated 10/6/16 at 4:00 p.m. revealed S8MSW had entered the following:
Spoke to S2DON this morning and was informed that Patient #2 was allegedly abused by a staff member on Friday 9/30 at 6:00 a.m. S2DON indicated that two staff members witnessed the abuse and reported it earlier this week. S2DON requested that I contact the police to conduct an additional investigation. S2DON also requested that I contact Patient #2's brother and Power of Attorney.

Review of the hospital's policies and procedures for abuse/neglect revealed no policy requiring allegations of abuse or neglect to be reported to the appropriate state agency within 24 hours of discovery.

In an interview on 11/17/16 at 9:07 a.m. with S4MHT, he said if the hospital had any polices about abuse he was not aware of it. S4MHT said he did not report the abuse he witnessed on 9/30/16 because he was uncomfortable since he needed his job and he was afraid of retaliation.

In an in interview on 11/17/16 at 9:24 a.m. with S5MHT, she said the way S6RN grabbed Patient #2 was not a CPI hold and it was not an appropriate hold. S5MHT said it was time to go home so they did not report it on the morning the incident happened. S5MHT said the hospital policy said it had to be reported immediately.

In an interview on 11/17/16 at 9:50 a.m. with S2DON, he said he was made aware of the allegation against S6RN on Monday 10/3/16 and it was reported on Wednesday 10/5/16 to the Louisiana Department of Health. S2DON also verified on the form he had written that the incident was discovered on 10/4/16 instead of 10/3/16. S2DON verified the alleged abuse should have been reported on Friday 9/30/16, the day of the incident. He said Patient #2's family and the police were not notified until the investigation had been completed by the hospital.


Patient #3
Review of the hospital policy titled Rights, Responsibilities and Organizational Ethics, Policy Number: RI 000, revealed in part:
VII. Abuse and Neglect of Patients
A. Each patient shall be free of abuse and neglect.
1) The issues that constitute abuse/neglect shall be:
Physical or verbal abuse

Review of an incident report dated 1/17/16 at 5:15 p.m. revealed S9MHT had an altercation with Patient #3. The report indicated:
Patient (Patient #3) in dining area. Staff requested patient to leave the area. Patient began to threaten. Staff (S9MHT) was heard saying, "I'll take off my badge and punch you in the face". At this point patient was removed from dayroom. Patient required medication to calm him down.

In an interview on 11/17/16 at 11:49 a.m. with S2DON, he verified a staff member threatening a patient with physical violence would be considered verbal abuse. He said the incident was not reported to the Louisiana Department of Health.

2) Failing to ensure patients were protected from potential abuse.

Review of the hospital policy titled Rights, Responsibilities and Organizational Ethics, Policy Number: RI 000, revealed in part:
VII. Abuse and Neglect of Patients
A. Each patient shall be free of abuse and neglect.
1) The issues that constitute abuse/neglect shall be:
Physical or verbal abuse
C. A patient who believes he/she has been abused or neglected shall maintain the right to report such an issue to any staff member. The accused staff member shall be placed upon paid suspension.

Review of a Hospital Abuse/Neglect Initial Report submitted to the Louisiana Department of Health for Patient #2 dated 10/5/16 revealed the date of the incident was listed as 9/30/16 between 6:30 a.m. and 7:00 a.m. The alleged incident involved S6RN grabbing Patient #2 around the neck with her arm.

Review of the staffing schedule for October 2016 revealed S6RN had worked on the night of 10/4/16.

In an interview on 11/17/16 at 9:50 a.m. with S2DON, he said he was made aware of the allegation against S6RN on Monday 10/3/16. He said he did not have an answer and to why S6RN was allowed to work on 10/4/16 since he was made aware of the incident on 10/3/16. He said S6RN should have been placed on leave until the investigation was completed once the allegation was discovered.