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Based on record review and staff interviews, the hospital failed to ensure an effective grievance process was in place for outpatient services. This deficient practice is evidenced by the facility failing to investigate and report a patient's grievance for 1 (Patient #6) of 10 sampled patients.
Findings:

Review of the hospital's policy RI.012 titled, "Patient Grievance Procedure" revealed in part: A patient grievance is a formal or informal written issue with care that is made to the hospital by a patient. This will also include situations where patients or patient's representative call or write the hospital regarding concerns related to care or services, who were not able to resolved their concern during their stay or who did not wish to address their issue during their stay in the hospital.

Review of Patient #6's medical record revealed in part: 06/21/2023 ECT/Nursing Phase 2 Recovery Note 10:50 a.m. patient awake alert and oriented x 3. Able to tolerate liquids. 11:25 a.m. Patient discovered he had soiled himself during treatment and became agitated and upset. Patient began cursing and stated he would not do any more treatments. Pt contacted a lawyer for a malpractice claim.
Review of the 06/21/2023 Consent/Request and Authorization for Index Course of Electroconvulsive Therapy (ECT) and the ECT Educational Literature provided to the patient failed to include "Incontinence" as a side effect.

In an interview on 08/22/2023 at 9:26 a.m., S2RN Electroconvulsive Therapy Nurse Manager stated she spoke with Patient #6 by telephone the day following his procedure in an attempt to try and have the patient continue his treatments. She stated she also referred him to the patient advocate and stated the advocate completes the grievance process.

Interview 08/22/2023 at 9:43 a.m. with S3Patient Advocate revealed she had talked to Patient #6 by telephone and had forwarded the patient to S2RN for additional assistance with his complaints. She continued to state that she does not do grievance investigations or reports for the outpatient services.

Interview 08/22/2023 at 1:55 p.m. with S1QA Director confirmed that grievance investigations and the grievance process was not being completed for their outpatient services of the hospital.

Based on record review, and interview, the hospital failed to ensure initial reports of allegations of patient abuse/neglect of care were reported to Louisiana Department of Health (LDH) within 24 hours of awareness of the allegation, as required by LDH-HSS, for 2 (Patient #4, #5 ) of 4 patients reviewed for self-reports to LDH-HSS from a total patient sample of 5.
Findings:

Review of the policy/procedure titled, Patient Grievance Procedures, revealed in part that when a report of sexual or physical abuse or neglect is received, the Department of Health and Hospitals will be notified within 24 hours from the time the facility was notified of the complaint.

Review of the LDH hospital/licensed provider Abuse/Neglect Initial Report form revealed in part that the self-report form was to be completed and submitted via email to HSS within 24 hours of awareness of an allegation of abuse/neglect.

Review of an incident report dated 07/09/2023 revealed that Patient #4 informed the staff that Patient #5 had grabbed her breast.

There was no documented evidence that this incident was self-reported to LDH-HSS.

On 08/21/2023 at 2:40 p.m., interview with S1QA Director revealed that this incident with Patients #4 and #5 should have been reported to LDH-HSS, but it was not.