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Based on record review and interview, the hospital failed to ensure all incidents of abuse, neglect, and/or harassment were reported and analyzed, and the hospital was in compliance with applicable local, State, and Federal Laws and Regulations. This deficient practice was evidenced by the hospital's failure to report abuse within 24 hours to the Department of Health and Hospitals or law enforcement in 1 (#5) of 4 ( #2, #3, #4, #5) reviewed patients records involving abuse.

Findings:

Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report abuse/neglect allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Louisiana Department of Health (LDH) (or the Medicaid Fraud Unit as applicable). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that 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 occurrence report for 03/10/23 at 5:10 p.m. revealed Patient #5 was hit in the face by another patient. The report states, "Pt. was sitting in day room, watching tv and a verbal altercation occurred between two pts., techs were getting other pts for meds and dinner, patient was physically attacked by other pt." The patient sustained an injury to the "right eye and forehead." The mid-level practitioner was notified at 5:12 p.m., first aid was administered and the patient was transferred to the local emergency room. The report also stated, "ED reported orbital fracture as a result of assault." There was no notification of the local police, the family, or Louisiana Department of Health.

In interview on 03/28/2023 at 1:50 p.m., S2RM verified the incident was not reported and the physical injury was a form of abuse.

Based on record review and interview, the facility failed to recognize factors related to safety and quality improvement on risk management review. This deficiency is evidenced by failure of S2RM to identify neglect of 2 (#2 and #3) of 3 (# 2, #3, #4) reviewed patient incidents self-reported to state office.

Findings:

Review of the facility policy, "Vital Signs and Weights," last revised 5/2022, revealed in part,

Policy
Vital signs will be taken at the time of admission, as ordered by the practitioner and no less frequently than twice a day.

Procedure
Vital signs will be taken at the time of admission, as ordered by the practitioner and as the patient's condition warrants:
-Temperature
-Blood Pressure
-Pulse
-Respirations
-Respirations
-O2 saturation Level
-Pain rating
Weights will be taken upon admission and the weekly unless ordered more frequently
All vital signs will be recorded by the assigned staff member.

Reporting of Vital signs:
The staff member who takes the vital signs will alert the Registered Nurse immediately if they are abnormal, based on history or normal ranges. Vital signs will be repeated at a frequency determined by the Registered Nurse if they are abnormal. The nurse will contact the practitioner if the vital signs continue abnormal.

Patient #2
Review of the medical record for Patient #2 revealed admission on 02/13/2022 with a diagnosis of delirium, dementia, brief psychotic disorder and anxiety.

Review of the vital signs for Patient #2 revealed the following abnormal vital signs highlighted with "!" in the electronic medical record:
On 02/14/2023 at 8:00 a.m.
Blood pressure- 129/84
Pulse -113!
SpO2- 98%
Respiratory Rate- 18
Temperature- 97.7º F

On 02/15/2023 at 8:30 a.m.
Blood pressure- 128/77
Pulse -120!
SpO2- 98%
Respiratory Rate- 20
Temperature- 98.1º F

On 02/16/2023 at 7:43 a.m.
Blood pressure- 124/83
Pulse -130!
SpO2- 94%!
Respiratory Rate- 20
Temperature- 98.3º F

On 02/16/2023 at 7:24 p.m.
Blood pressure- 109/75
Pulse -113!
SpO2- 96%
Respiratory Rate- 16
Temperature- 97.8º F

On 02/17/2023 at 8:15 a.m. the vital signs were documented as:
Blood pressure- 110/76
Pulse -140!
SpO2- 90%!
Respiratory Rate- 17
Temperature- 98.5º F

On 02/17/2023 at 9:00 p.m. the vital signs were documented as:
Blood pressure- 103/79
Pulse-103
SpO2- Not documented
Respiratory rate- 16
Temperature- 98º F

Review of the Hospital / Licensed Provider Abuse/ Neglect Initial Report dated 03/03/2023 revealed an incident report for the death of Patient #2 which occurred the morning of 02/18/2023. The patient was found not breathing and without a pulse in bed when staff tried to wake the patient for breakfast. The report prepared by S2RM addressed the missing documentation of Sp02 the evening of 02/17/2023 and the lack of notification of the licensed practitioner of the abnormal vital signs. In the report S2RM stated, "Although, the vitals should have been communicated to IM team, there was no malice or intent to cause harm. The nurse stated that had Patient #2 presented differently (shortness of breath, in pain, etc.) in combination with the abnormal vital, the IM team would have been contacted." In the investigation report, S11RM stated the allegation of neglect was not substantiated.

In interview on 03/29/2023 at 2:50 p.m., S2RM verified nursing staff did not follow hospital policy and failure to follow the policy resulted in neglect of care for Patient #2. S2RM verified nursing staff did not repeat the vitals per facility policy, did not accurately document all the vital signs, and did not notify the medical staff of the abnormal vital signs.

Patient #3
Review of the medical record for Patient #3 revealed admission on 3/11/2023 with a diagnosis of depression, alcohol abuse, and anxiety.

Review of the orders for Patient #3 revealed on 03/12/2023 at 7:55 a.m., admission orders were entered. Assessment of vital signs were ordered, "vital signs while awake," and "q4 while awake." Clinical Institute Withdrawal Assessment (CIWA) was ordered every 8 hours.

Review of the nursing assessments revealed vital signs were only assessed each 12 hour shift and review of the CIWA revealed it was last performed on 03/13/2023 at 8:00 p.m. and was not performed on 03/14/2023 at 4:00 a.m., which was approximately 1 ½ hour before Patient #3 was found dead.

Review of the Hospital / Licensed Provider Abuse/ Neglect Initial Report dated 03/24/2023 revealed an incident report for the death of Patient #3 which occurred the morning of 03/14/2023. The patient was found unresponsive and not breathing during a routine check around 5:30 a.m. S2RM stated, " The orders for vitals Q4 hours and CIWAs Q8 hrs were not consistantly carried out," and " The allegation of neglect was unable to be substantiated due to lack of evidence."

In interview on 03/28/2023 at 1:30 p.m., S2RM verified assessment of the vitals and performance of the CIWA were not as ordered.

In interview on 03/29/2023 at 2:50 p.m., S2RM verified nursing staff did not follow the physician's orders and agreed this failure to perform duties as ordered was neglect. S2RM verified she did not find neglect in both reports because she did not feel it was intentional neglect.

Based on observation and interview the registered nursed failed to supervise and evaluate the nursing care of each patient. This deficiency is evidenced by the failure of the nursing staff to document vital signs as ordered on 2 (#3, and #5) of 4 ( #1, #3, #4, #5) reviewed records for patients admitted after implementing corrective actions and surveillance for previously noted deficient practices.

Findings:

Review of the policy titled "Vital Signs and Weights" revealed in part, "Vital signs will be taken at the time of admission, as ordered by the practitioner and no less frequently then twice a day."


Review of the actions implemented after the death of Patient #2 revealed in part, "5. An audit of CPR compliance and Vital Sign and Emergency Equipment Competency has been conducted, staff that has fallen out of compliance are currently being educated . . . 8. Administration will continue to monitor vitals to ensure abnormal vital ranges, identified in the Change of Condition Policy, are being reported, documented and receive intervention (and documentation of such)."

Patient #3
Review of the medical record for Patient #3 revealed admission on 3/11/2023 with a diagnosis of depression, alcohol abuse, and anxiety. The patient was 59 years old and was on the geriatric psych unit.

Review of the orders for Patient #3 revealed on 03/12/2023 at 7:55 a.m., admission orders were entered. Assessment of vital signs were ordered, "vital signs while awake," and "q4 while awake."

Review of the vital signs revealed assessment of vital signs was performed once each 12 hour shift.

In interview on 03/28/2023 at 1:30 p.m., S2RM verified the nursing staff did not assess the vital signs as ordered.

Review of the Licensed Provider Abuse/Neglect Initial Report submitted to the licensing authority after the death of Patient #3 revealed actions included, "Staff is currently monitoring/ auditing patient's vital signs. All patient's 55 and older are being seen at least 3x a week by medical team. We will continue to monitoring high risk patient's vitals. We have started re-educating providers on QT prolongation risk for medication reactions."

In interview on 03/29/2023 at 12:15 p.m., S2RM verified the staff had been re-educated on the hospital's policy for vital signs the week of 2/20/2023- 02/24/2023 and the audits of charts did not begin until 03/16/2023. These actions were initiated after the death of Patient #2. S2RM verified the nursing staff did not correctly assess the vitals of Patient #3 from 3/12/2023 until her death on 03/14/2023.

Patient #5
Review of the medical record for Patient #5 revealed admission on 03/07/2023 with a diagnosis of schizophrenia, alcohol abuse, and acute psychosis. Patient #5 was 33 years old and admitted to the detox unit.

Review of the orders from admission revealed there were not orders given for the frequency of vital signs.

Review of the vital signs for Patient #5 revealed vital signs were assessed once on 03/12/2023 at 8:06 a.m.

In interview on 03/28/2023 at 12:50 p.m., S2RM verified the vital signs were not performed according to policy and this was not identified in the chart audits of vital signs.

In interview on 03/29/2023 at 12:57 p.m., S2RM verified the audit of charts for vital signs on the detox unit started on 03/16/2023 while Patient #5 was still admitted and the missing vitals were not identified.

Based on record review and interview, the facility failed to ensure a complete medical history was documented for each patient admitted to the psychiatric hospital. This deficiency is evidenced by failure to obtain a complete history for 1 (#2) of 5 (#1-#5) reviewed records.
Findings:

Review of the history and physical for Patient #2 revealed in part, "No past medical history on file. . . . No past surgical history not on file. . . .Family History: None. . . . Smoking status: Not on file. . . .Alcohol use: Not on file . . . Drug use: Not on file. . . .Sexual activity: Not on file."

Review of the psychiatric evaluation for Patient #2 revealed in part, "No past medical history on file. . . No past surgical history on file. . . ."

In interview on 03/29/2023 at 12:00 p.m., S2RM verified the evaluating licensed practitioners did not obtain a complete medical history and there was no evidence in the electronic medical record that efforts were made to obtain a history from Patient #2's family.