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Based on a record review and staff interview, the Critical Access Hospital failed to ensure documentation of a History and Physical examination which included a descriptive neurological examination indicating what tests were performed to assess neurological functioning for 3 (#1-#3) of 3 sampled patients. The absence of this information limits the clinician's ability to accurately diagnose the patient's condition and to provide a measure of baseline function, thereby potentially adversely affecting care.
Findings:

Review of the hospital's policy PC-403 titled, "History and Physical Assessment", revealed in part: A complete admission history and physical examination, to include an examination of cranial nerves, shall be recorded within 24 hours of admission.

Review of Patient #1's history and physical completed on 05/15/2025 failed to reveal a detailed cranial nerves assessment and only included cranial nerves II-XI grossly intact.

Review of Patient #2's history and physical completed on 05/19/2025 failed to reveal a detailed cranial nerves assessment and only included cranial nerves II-XI grossly intact.

Review of Patient #3's history and physical completed on 05/14/2025 failed to reveal a detailed cranial nerves assessment and only included cranial nerves II-XI grossly intact.

In an interview on 06/03/2025 at 3:15 PM, S3PM confirmed Patients #1, #2, and #3's history and physical did not contain a detailed cranial nerves assessment but merely listed cranial nerves 2-11 intact.

Based on record review and interview the governing body failed to ensure policies were administered to ensure quality healthcare. The deficient practice was evidenced by failure to ensure contract staff working in the hospital's behavioral unit were oriented to the hospital policies/procedures for 7 (S7RN, S8RN, S9LPN, S10MHT, S11MHT, S12MHT, S13MHT) of 7 (S7RN, S8RN, S9LPN, S10MHT, S11MHT, S12MHT, S13MHT) sampled contracted staff personnel records reviewed.
Findings:

Review of personnel records revealed orientation documentation only contained education to the behavioral health unit. Further review failed to reveal that contract staff received education on the hospital policies/procedures that were not specific to the behavioral health unit.

In an interview on 06/03/2025 at 4:00 PM, S4CPO verified the above information mentioned.

Based on record review and interview, the hospital failed to ensure the Registered Nurse supervised and evaluated the care of each patient on an ongoing basis, in accordance with the accepted standards of nursing practice and hospital policy. This deficient practice is evidenced by failure of the Registered Nurse to document on admission a body/contraband search, and skin assessment for 1 (#3) of 3 (#1-#3) patient medical records reviewed.
Findings:

Review of hospital policy number NU 613, titled "Sharps/Contraband Search and Inventory," effective date 08/28/2024, revealed in part: "POLCY: Patient belongings will be searched upon admission and as clinically appropriate or ordered. This search will be initiated immediately. II. PURPOSE: To provide a safe environment for staff and patients."

Review of hospital policy number NU 403, titled "Body Search," effective date 08/28/2024, revealed in part: "PERSONAL SEARCH GUIDELINES: C. A visual body search shall be conducted on all new patients immediately upon admission to the unit. The patient should remain under staff visual supervision until a body search is completed. II. PROCEDURE: F. Document this procedure in the medical record."

A review of Patient #3's medical record revealed Patient #3 was admitted on 05/14/2025 at 6:50 PM for Schizophrenia with substance abuse. Further review did not reveal documentation of contraband or body search assessments.

A review of the hospital's incident reports revealed in part on 05/15/2025 at 4:01 PM Patient #3 was found sitting on the patio slumped over, drooling from the mouth and not verbally able to respond. Medical care rendered immediately. Staff searched Patient #3's room and found a small clear plastic bag or plastic wrap that was tied with small bead like substance. When Patient #3 was questioned, he admitted to smoking "MOJO/SPICE".

In an interview on 06/03/2025 at 11:09 AM, S1RNPM confirmed that there was no documentation in the medical record by the nurse that a contraband or body search assessment had been performed on Patient #3.

In an interview on 06/02/2025 at 1:30 PM, S2DSS confirmed incident regarding Patient #3 was not reported to LDH-HSS as possible neglect nor was an investigation documented.

Based on record review and interview, the hospital failed to ensure the nursing staff developed, and kept a current, and individualized nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs. This deficient practice is evidenced by the failure to update the care plan of 2 (#2, #3) of 3 (#1-#3) patient reviewed for completed and updated care plans.
Findings:

A review of the hospital policy number PM 002A last reviewed 08/28/2024 titled, "Treatment Plan," revealed in part: POLICY: Each patient will have a written, individualized; interdisciplinary treatment plan based on assessments of their clinical needs and strengths. III. PROCEDURE: B. 2. Problems requiring immediate attention are added to the problem list by the treatment team as needed and/or applicable. J. the treatment plan is adapted throughout the patient's admission.

A review of the hospital policy number NU 432B last reviewed 08/28/2025 titled, "Precautions: Fall, Seizure, Withdrawal, Elopement, Suicide/Self Harm, Homicidal/Aggression, and Sexual," revealed in part: I. POLICY: It is the policy of the hospital to ensure the safety and well-being of patients by placing them on precautions such as fall, seizure, elopement, suicide, homicide/ aggression withdrawal/seizure, and sexual. Upon admission, all patients will have staff present during their initial shower/bath. III. PROCEDURE: A. Falls: 1. When a patient gives evidence of fall risk due to previous history, clinical or medical presentation, high-risk scores on the Falls Risk Assessment, or fall experienced during hospital stay, the patient may be placed on fall precautions by the Physician.

A review of Patient #2's medical record revealed Patient #2 was admitted on 04/15/2025 with Delusional Disorder, Amphetamine/Opioid use disorder. Further review of Patient #2's Fall Risk Assessment scored a 35 which puts Patient #2 at risk for falls. Review of Patient #2's Master Treatment Plan did not reveal fall precautions as per hospital policy or address patient's diagnosis of substance abuse.

In an interview on 06/03/2025 at 10:15 AM, S1RNPM verified above mentioned findings.

Based on observation, record review, and interview, the hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by failure of the staff to monitor 1(#1) of 3 (#1-#3) patients according to the physician's orders including special precautions and documented the care provided in real time according to accepted standards and hospital policy.
Findings:

Review of hospital policy number NU432B, titled "Precautions: Fall, Seizure, Withdrawal, Elopement, Suicide/Self Harm, Homicidal/Aggression, and Sexual," revision date 07/2021, revealed in part: I. POLICY: it is the policy to ensure safety and well-being of patients by placing them on precautions such as fall, seizure, elopement, suicide, homicide/aggression, withdrawal/seizure, and sexual. G. 1. If at any time during the patient's stay, a patient is classified as requiring sexual precautions, the attending physician will be notified, and the patient may be placed on a higher level of observation. 2. Notification of MHT, Nursing personnel, and staff regarding observation level and precautions.

Review of Patient #1's medical record revealed Patient #1 was placed on sexual precautions on 05/20/2025 at 2:36 PM after an incident with a male peer. Further review of Patient #1's medical record revealed mental health observation forms dated 05/20/2025 through 05/23/2025 did not have sexual precautions indicated.

In an interview on 06/02/2025 at 3:30 PM, S1RNPM verified Patient #1 was placed on sexual precautions on 05/20/2025. S1RNPM verified RNs routinely place the precautions ordered by the provider on the MHT's observation forms and further verified Patient #1's MHT observation forms dated 05/20/2025 to 05/23/2025 did not indicate sexual precautions.

Based on record review and interview, the hospital failed to ensure patients were kept free of all forms of abuse or harassment. This deficient practice is evidenced by the hospital failing to report potential allegations of abuse/neglect related to 1 (#3) of 3(#1-#3) patients reviewed to LDH-HSS (Louisiana Department of Health - Health Standards Section) within 24 hours of the awareness of this potential allegation.
Findings:

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.

Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report these allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Department of Health and Hospitals (LDH) (or the Medicaid Fraud Unit as applicable). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence.

A review of incident logs from 01/2025 to 5/2025 revealed Patient #3 became unresponsive after smoking unknown substance on 05/15/2025 resulting in transfer to the ED. A review of the hospital's self-reports to LDH-HSS did not reveal the possible neglect being self-reported.

In an interview on 06/03/2025 at 10:10 AM S2DSS confirmed the above mentioned findings.