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Based on record review and interview, the hospital failed to ensure patients were free from all forms of abuse or harassment as evidenced by:

1) failure to report a substantiated allegation of abuse/neglect against a nurse (S4RN) to the appropriate licensing board for 1 (#R2) of 3 (#R2, #R3, #R4) sampled patients reviewed for self-reports of alleged abuse/neglect to LDH-HSS; and

2) failure to investigate prior Louisiana State Board of Nursing actions denoted on a nurses' license verification documentation, prior to hiring the Registered Nurse (S4RN).

Findings:

1) Failure to report a substantiated allegation of abuse/neglect against a nurse (S4RN) to the appropriate licensing board.

Review of policy number RR-01, titled, "Abuse and Neglect", revealed the purpose of the policy was to establish procedures to be followed when a patient is suspected to have been, or at risk for abuse, neglect, misappropriation of property and/or injuries of unknown sources and to establish procedures to be followed when there is a report or observation of abuse or neglect of a patient in the hospital. Further review revealed if the allegation of abuse against staff is substantiated through a thorough and complete investigation, the staff member shall be terminated and reported to the appropriate licensing board, as applicable.

Review of policy number HR-245, titled, "Patient Abuse and Neglect", revealed in part: The hospital maintains Zero Tolerance policy for patient abuse and/or neglect.....Upon the discretion of the facility and in accordance with applicable State or Federal requirements, such violations may be reported to the employee's state licensing agency and/or law enforcement agencies.

Review of a LDH Hospital Abuse/Neglect Initial Self-Report document revealed on 8/16/19, S5NP witnessed S4RN verbally threaten Patient #R2. Further review of the documentation revealed S5NP immediately reported this to S1Adm. Additional review revealed S8RN witnessed S4RN upset and disrespectfully yelling and approaching Patient #R2 when he (S8RN) had to step between them and had to move S4RN to end the altercation.

In an interview on 10/1/19 at 11:30 a.m. with S1Adm, he verified S4RN was terminated for verbal abuse towards a patient following a full investigation which substantiated the allegation. S1Adm confirmed he had reported the incident to LDH-HSS. He confirmed S4RN, at the time of the interview, had not been reported to the appropriate licensing board which was the Louisiana State Board of Nursing.

In an interview on 10/2/19 at 12:25 p.m. with S5NP, she stated on 8/16/19, she saw and heard S4RN verbally threaten Patient #R2. S4RN was threatening Patient #R2 with prn pain medication. S4RN further told Patient #R2 he was a drug addict, didn't belong there, and was malingering. S5NP stated, "it was so bad, I immediately reported this to the CEO".


2) Failure to investigate prior board actions denoted on a nurses' licensure verification documentation prior to hiring the RN.

Review of S4RN's personnel record revealed the following Louisiana Registered Nursing License Verification Report:
License Active - Yes
License Status - Reprimand (see history)
Basis for action - NPDB code 99 - other - not classified
NPDB code: 1140 - Reprimand or Censure
NPDB code: 1173 - Publicly Available Fine/Monetary Penalty
Initial action date: 12/28/04
Effective date: 12/28/04 - Indefinite/Unspecified
The Disclaimer of Representation and Warranties revealed in part, discipline/final orders data are submitted by the primary source Boards of Nursing. Boards may choose whether or not to report discipline actions with accompanying codes and copies of final orders. No distinction should be drawn from the presence or absence of this supplementary information. Please contact the boards of nursing for all questions.

Review of the personnel file for S4RN revealed no documented evidence of a request for Public Record Disciplinary Information history from the Louisiana State Board of Nursing regarding the disciplinary actions filed against S4RN's Louisiana Registered Nursing License.

In an interview on 10/1/19 at 3:50 p.m. with S7Corp, she stated she had spoken with S1Adm and indicated she had told S1Adm the hiring process should be halted until the type of disciplinary action associated with an employee's license was identified.

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Based on record reviews and interviews, the hospital failed to ensure the nursing staff developed, and kept current, an individualized nursing care plan for each patient. This deficient practice was evidenced by failure of the nursing staff to address all identified patient problems for which the patient was being treated on the care plan and failure to update the care plan with changes in levels of observations and precuations for 3 (#5, #6, #R4) of 7 (#1- #6, #R4) sampled patient records reviewed for nursing care plans from a total patient sample of 6 (#1- #6) and a random patient sample of 4 (#R1- #R4).

Findings:

Patient #5
Review of Patient #5's electronic medical record, navigated by S3ADON, revealed an admission date of 9/29/19. Further review revealed the patient's legal status when admitted was PEC and CEC due to suicidal ideation. Additional review revealed Patient #5 was a Diabetic with accuchecks, sliding scale insulin, and on an ADA diet.

Review of Patient #5's plan of care revealed Diabetes was not addressed as an identified problem on the patient's care plan.

In an interview on 10/1/19 at 1:00 p.m. with S3ADON, she verified Diabetes was not identified as a problem on Patient #5's care plan.

Patient # 6
Review of Patient #6's electronic medical record, navigated by S2DON, revealed an admission date of 9/27/19. Further review revealed the patient had admission diagnoses of suicidal ideations and attempted suicide by overdose on her prescription medications prior to admission. Additional review revealed Patient #6 was on 1:1 level of observation. S2DON indicated Patient #6 was on 1:1 level of observation due to requiring continuous Oxygen.

Review of Patient #6's current care plan revealed impaired respiratory function and the patient's 1:1 level of observation were not addressed as identified problems on the patient's plan of care.


Patient #R4
Review of Patient #R4's electronic medical record, navigated by S2DON, revealed Patient #R4 was admitted on 8/4/19 with an admission diagnosis of Depression with Suicidal Ideation.

Review of the hospital's abuse/neglect self-reports to LDH-HSS revealed Patient #R4 was accused of allegedly raping Patient #R3 on 8/5/19. Further review of the documentation revealed Patient #R4 had been placed on sexually acting out precautions and his level of observation had been increased to 1:1 (within staff eyesight at all times).

Review of Patient #R4's treatment plan revealed the plan was not updated after the patient was placed on sexually acting out precautions and increased to 1:1 level of observation due to the alleged rape.

In an interview on 10/2/19 at 11:30 a.m. with S2DON, she acknowledged levels of observation/changes in levels of observation should be addressed on patient care plans. She also acknowledged Patient #6's care plan should have included the patient being on continuous oxygen and 1:1 level of observation.