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Based on record review and interviews, the hospital failed to ensure personnel met applicable standards required by State regulations for hospital personnel. This deficient practice is evidenced by 1) failure to ensure MHTs had CPR training as required by their job description for 12 of 14 MHTs (S4MHT, S5MHT, S6MHT, S7MHT, S8MHT, S9MHT, S10MHT, S11MHT, S13MHT, S14MHT, S15MHT, S17MHT and 2) failure to have documented evidence of a check/review of the Louisiana Department of Health's "Louisiana Adverse Action Website" before hire and every 6 months after for 5 of 5 unlicensed personnel files reviewed (S12MHT, S14MHT, S15MHT, S16MHT, S17MHT).
Findings:

1. Review of the Nursing Departments MHT Job Description revealed the MHT was required to have a current CPR certification and certification in a Crisis Prevention Intervention course.

Review of the MHT's CPR certifications revealed S12MHT and S16MHT had CPR training and current certification.

In an interview on 06/21/2022 at 1:00 p.m., S2Compliance stated the MHTs must have their CPR certification 30 days after they are hired. She continued to state that of the MHTs hired greater than 30 days ago, only two MHTs (S12MHT and S16MHT) have CPR certification.

2. Review of the Louisiana Department of Health's "Louisiana Adverse Action Website" revealed, in part that all licensed and/or certified providers that employ unlicensed direct care staff that meet the provisions of LAC 48:1, Chapter 92 related to Direct Service Workers are required to check the Adverse Actions Website prior to hire and every six months thereafter to assure that a finding of abuse, neglect or misappropriation of property has not been placed against a prospective hire or a currently employed or contracted DSW.

In an interview on 06/21/2022 at 1:30 p.m., S3Human Resources stated S12MHT, S14MHT, S15MHT, S16MHT, S17MHT had only their initial pre-employment check/review of the "Louisiana Adverse Action Website" but they did not have the continued every six month check/review as is required by LDH.

Following the interview, S3Human Resources checked the "Louisiana Adverse Action Website" and printed the search results for S12MHT, S14MHT, S15MHT, S16MHT, S17MHT. Surveyor reviewed the the documents and there were no issues.

Based on record review and interview, the hospital failed to report an allegation of potential abuse to LDH-HSS (Louisiana Department of Health - Health Standards Section) or a local law enforcement agency within 24 hours of receipt of the allegation for 2 (#1, #2) of 2 patients reviewed for possible abuse from a total patient sample of 5.
Findings:

Review of the State law R.S. 40:2009.20 revealed "Any person who is engaged in the practice of medicine, social service, facility administration, psychological services or any RN, LPN, nurses' aide, personal care attendant, respite worker, physician's assistant, physical therapist, or any other healthcare giver having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within 24 hours, submit a report to the department or local law enforcement agency of such abuse or neglect."

Review of the hospital's grievance log revealed allegations of sexual abuse/harassment by an employee toward patient's #1 and #2 on 04/09/2022. Review of the grievance report revealed the MHT asked Patient #1 and Patient #2 to show him their penis. Further review revealed the employee was terminated over the allegations and the investigation completion letters regarding the grievances were mailed to Patient #1 and Patient #2 on 04/12/2022.

In an interview on 06/21/2022 at 1:00 p.m., S2Compliance stated the hospital had not reported the allegations of abuse for Patient #1 and Patient #2 to LDH-HSS or local law enforcement as required by law.