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Tag No.: A0145
Based on record review and interview, the hospital failled to timely submit an allegation of abuse to the Louisiana Department of Health, Health Standards Section. This deficient practice was evidenced by 1 (Pt. #5) of 2 (Pt. #4, Pt. #5) LDH Hospital Provider Abuse/Neglect reports reviewed as part of the sample.
Findings:
Review of the hospital's policy and procedure titled, Patient Rights, Responsibilities and Advocacy effective 01/02/2013 and last revised on 10/25/2022 revealed, in part, 8. Notify LDH/Health Standards Section of all allegations, no matter how irrational the allegation may be, within 24 hours. Hospital Abuse/Neglect initial report, HSS-HO-41 form is completed electronically, and emailed to the CEO, DON, Risk Manager, attending MD and LDH (hsshospitalself-report@la.gov).
Review of the hospital's LDH Hospital Provider Abuse/Neglect initial report form revealed instructions including, in part, email completed form to hsshospitalself-report@la.gov within 24 hours of awareness of allegation.
Review of the hospital's submitted LDH Hospital Provider Abuse/Neglect initial report Section C. Incident Information revealed the date of the incident as 06/25/2023 and the time of the incident as unknown. Further review revealed the date and time of discovery as 06/25/2023 at 9:50 p.m.
Review of the hospital's submitted LDH Hospital Provider Abuse/Neglect initial report Section J. Comments revealed comments, in part, that this is the initial and final report. A complete investigation has been completed. Witness statements have been collected and footage reviewed. Further review revealed the form was signed by S4RM on 06/27/2023.
In an interview on 07/12/23 at 11:26 a.m. S4RMverified the report was submitted more than 24 hours after the date of discovery.