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Based on record review and interview, the hospital failed to ensure any incidents of abuse or neglect were reported as required by applicable local, State, and Federal Laws and Regulations. This deficient practice was evidenced by failure of the hospital to report an allegation of physical and verbal abuse involving two patients (#2, #3) within 24 hours to Louisiana Department of Health- Health Standards Section from a total of 5 (#1, #2, #3, #4, #5) sampled patients.

Findings:

Review of the hospital's policy titled "Required Reporting - State of Louisiana" revealed in part, any allegations of abuse/neglect must be reported within 24 hours of receiving knowledge of the allegation to the respective agencies associated with the Louisiana Department of Health. 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.

Review of the initial self-report to State Office dated 12/13/2022 revealed in part, the incident occurred on 12/10/2022. Further review revealed S3CMC witnessed and reported the incident.

In an interview on 01/11/2023 at 4:50 p.m. S2PI verified the allegation of patient abuse was not reported to Louisiana Department of Health- Health Standards Section within 24 hours of the acknowledgement of the allegation.

Based on record review and interview, the hospital failed to ensure the use of seclusion was in accordance with the order of a physician or other licensed independent practitioner who was responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This deficient practice is evidenced by 1 (#3) of 1 (#3) patient sampled being placed in seclusion with an incomplete order for seclusion from a total of 5 sampled patients.

Findings:
Review of the hospital rules and regulations of the Medical Staff revealed in part, Order Authentication. Authentication of orders are to be completed no later than 24 after order given.

Review of Patient #3's medical record revealed a seclusion order dated 12/10/2022 at 2:15 p.m. Further review revealed this seclusion order was not signed by the physician or licensed practitioner.

In an interview on 01/11/2023 at 2:50 p.m. S1CNO confirmed the seclusion order dated 12/10/2022 was not a complete order due to the order not including the physician or licensed practitioner's signature.

In an interview on 01/11/2023 at 4:55 p.m. S2PI verified authentication of orders are to be completed no later than 24 hours after order given.