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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 patient grievances for 1 (#2) of 1 (#2) patients reviewed for complaints/grievances from a total patient sample of 4.
Findings:

Review of the hospital policy titled, Patient Rights, Responsibilities. Complaints, and Grievance Process, revealed in part, "Grievance" is a formal or informal written or verbal expression of dissatisfaction 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, issue related to the hospital's compliance with CMS Hospital Condition of Participation, or Medicare beneficiary billing issues.

Review of hospital document titled "Weekly Grievances" revealed inclusion of grievances dated 09/07/2023-12/18/2023. Further review failed to reveal Patient #2 was included on the "Affected Person" list of the Grievance document.

In an interview on 12/27/2023 at 8:20 a.m., Patient #2 stated he submitted two verbal complaints over a month ago. One was with the billing department and the other with the hospital grievance department. Patient #2 reported he expected contact from the hospital regarding the grievances he submitted and was surprised he had not had a representative from the hospital contact him regarding his concerns. Patient #2 reported he received a new hospital invoice showing the hospital reversed the charges originally invoiced to him for the second surgery required to remove the surgical needle that was found after his first surgery was completed.

In an interview on 12/19/2023 at 11:15 a.m., S7RM stated that the hospital did not initiate the grievance process because the incident disclosure was located in Patient #2's chart.

Based on record review and interview, the hospital failed to ensure each patient received care in a secure setting. This deficient practice is evidenced by:
1) failure to ensure that contracted non-licensed security personnel had completed criminal background checks by an authorized agent of the Louisiana State Police in the manner required by R.S. 15:587.1 et seq. prior to hire or employment for all non-licensed personnel;
2) failure to ensure the LDH- Louisiana Adverse Action List Search website was reviewed before hire and every six months for all non-licensed contracted security personnel;
3) failure to ensure staff and patients were protected from infectious disease as evidenced by failure to assure all contracted security personnel files had documented evidence they were free of TB (tuberculosis) in a communicable state, as required per Louisiana Public Health Sanitary Code, Title 51, Part II.
Findings:

1) Failure to ensure that contracted security personnel completed criminal background checks by an authorized agent of the Louisiana State Police in the manner required by R.S. 15:587.1 et seq. prior to hire or employment for all non-licensed contracted security personnel.
Review of S4SEC's human resource file revealed a hire date of 09/2023. Further review failed to reveal evidence of a completedcriminal background check .

2) Failure to ensure the LDH- Louisiana Adverse Action List Search website was reviewed before hire and every six months for all non-licensed contracted security personnel.
Review of S4SEC's human resource file failed to reveal evidence that the Adverse Action List Search website was reviewed before hire.

3) Failure to ensure all contracted security personnel files had documented evidence they were free of TB (tuberculosis) in a communicable state, as required per Louisiana Public Health Sanitary Code, Title 51, Part II.
Review of S4SEC's human resource file failed to reveal evidence that S4SEC was screened for Tuberculosis and was provided annual educational information explaining the health concerns, signs, symptoms, and risks of Tuberculosis.

In an interview on 12/19/2023 at 2:35 p.m., S6RM verified the hospital did not have documented evidence of completed criminal background checks and reviews of Adverse Action List Search website for any of the contracted security personnel. S6RM confirmed the hospital did not have documented evidence that each contracted security personnel was screened for Tuberculosis and was provided annual educational information explaining the health concerns, signs, symptoms, and risks of Tuberculosis.