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23515 HIGHWAY 190

MANDEVILLE, LA 70448

PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT

Tag No.: A0145

Based on record review and interview, the hospital failed to ensure initial reports of allegations of patient abuse/neglect of care were reported to Louisiana Department of Health within 24 hours of awareness of the allegation, as required by LDH-HSS, for 1 (#1) of 5 sampled patients.
Findings:

Review of the LDH hospital/licensed provider Abuse/Neglect Initial Report form revealed the self-report form was to be completed and submitted via email to HSS within 24 hours of awareness of an allegation of abuse/neglect.

Patient #1
Review of medical record revealed Patient #1 was admitted on 10/07/2020 with diagnosis of psychosis, Bipolar I disorder and borderline disorder. Patient #1 was discharged to a group home on 11/26/2021.

Review of Incident Report Form dated 12/19/2020 at 2:15 p.m., revealed the following, in part: Location of event: Entrance hallway. Patient #2 targeted Patient #1 for the 2nd time and attempted to hit Patient #1. Patient #1 stated she wasn't sure if she was hit or not. Patients were separated by staff.

Review of Incident Report Form dated 2/1/2021 at 4:35 p.m., revealed the following, in part: Location of event: Dining room. Patient #2 attacked Patient #1 unprovoked and tried to pull her glasses off. Patient #2 punched Patient #1 on the right facial cheek then Patient #1 punched Patient #2 in the nose to get her off of her. Patient #2 was also pulling Patient #1's hair. Patients separated.

Review of Incident Report Form dated 4/10/2021 at 3:08 p.m., revealed the following, in part: Location of incident: Hallway. Patient #1 hit Patient #2 several times in her face and head in the hallway with a closed fist after Patient #2 ran out of Patient #1's room hitting at her and throwing shoes at Patient #1 while Patient #1 was lying in bed.

Review of Incident Report Form, dated 7/2/2021 at 3:45 p.m., revealed the following, in part: Location of incident: Dining room. Patient #2 punched Patient #1 in the face, no reason

Review of Incident Report Form dated 7/3/2021 at 7:55 p.m., revealed the following, in part: Location of incident: Dining room. Patient #1 was getting in line for meds. Patient #2 intentionally bumped into her. Patient #1 threw water on Patient #2. A fight started, which was broken up immediately by staff. Patient #1 was escorted to room to calm down.

Review of Incident Report Form dated 09/17/2021 at 7:45 a.m., revealed the following, in part: Location of incident: Hallway. Patient #2 punched Patient #1 in the face twice.

Review of Incident Report Form dated 10/25/2021 at 11:00 a.m., revealed the following, in part: Patient #2 threw hot coffee on Patient #1 while in recreation group unprovoked.

An interview was conducted with S1Risk Manager on 10/18/2022 at 2:00 p.m. He stated the hospital did not submit a self- report for any of the above incidents to LDH-HSS.