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Based on record review, and interview, the facility failed to meet the requirements for the Condition of Participation (CoP) for Patients' Rights. The deficient practice is evidenced by the hospital failing to properly observe 1 (#1) of 3 (#1-#3) patients according to ordered observation levels. (see Tag A0144).

Based on record review and interview, the hospital failed to provide care in a safe setting. The deficient practice is evidenced by the hospital failing to properly observe 1 (#1) of 3 (#1-#3) patients according to ordered observation levels. (see Tag A0144).
Findings:

A review of facility policy titled, "Observation Precautions" Policy 8.08, revealed in part, each patient will be monitored throughout his or her hospitalization according to an assigned observation status. The patient's status is assigned at the time of admission, re-evaluated and changed as clinically indicated. Procedure A. Level I: One to One Observation (staff must be within arms-length of patient at all times). Item 1. Definition; This a strict one-to-one (1:1) observation with staff constantly monitoring the patient at all time, i.e. bathroom, shower, walking out of group, etc. The assigned staff member must be within arms-length of the patient at all times. The patient's face and hands must be seen by the staff member at all times. Item 4. Used for: Extremely disturbed patients who are in imminent risk of harming themselves or others.

A review of facility policy titled, "Rights of All Patients" Policy 1.11, revealed in part, it is the policy of the Hospital to maintain and protect the individual's fundamental human, civil, constitutional, and statutory rights in accordance with Federal and State laws. Patient Rights, section: Basic Rights, item 30: The right to receive care in a safe setting. Section: Rights Which May Not Be Limited, item 4: To the extent that facilities, equipment, and personnel are available, the right to medical care and treatment in accordance with the highest standards accepted in medical practice.

A medical record review of Patient #1 revealed the patient inserted a foreign object into his rectum on three different occasions. The facility did not follow proper policy and procedures while monitoring the patient during the second and third instance of Patient #1 placing a deodorant bottle into his rectum. All instances require the patient to be transferred to the emergency room with subsequent interventions for foreign body removal from the rectum under general anesthesia. The patient was originally admitted on 01/13/2024 at 11:00 a.m. for suicide ideations. He was placed on an every 15 minute observation level. The patient was allowed to take a shower around 8:00 p.m. and he placed a deodorant bottle in his rectum. The patient was sent to the emergency room and returned to this facility on 01/14/2024. His observation level was changed to one to one observation upon his return. On 01/14/2024 at approximately 9:55 a.m. while the patient was showering, the patient obtained a deodorant bottle and inserted the object into his rectum. The patient was sent to the emergency room and return around 4:30 p.m. On 01/15/2024 at approximately 8:00 a.m. while in his restroom grooming, he obtained a deodorant bottle and inserted the object into his rectum. The patient was sent to the emergency room and did not return to this facility.

In an interview on 01/23/2024 at 11:45, S5MHT confirmed she was on 1:1 observation with Patient #1 on 01/14/2024. S5MHT indicated she began monitoring the patient approximately 1 hour prior to the incident, she was aware of the patient placing an object in his rectum on the preceding day and she stated, "But I was unaware of the full extent." S5MHT handed the patient off to S6MHT for shower time and she went to perform other job duties. S5MHT also indicated she left the patient with a wash cloth, towel and a plastic medicine cup size of soap. S5MHT returned to the doorway of the shower room as the Patient #1 was complete with shower. Patient #1 informed her that he had inserted a deodorant bottle into his rectum. S5MHT asked him where the bottle had come, Patient #1 told her he had stuck his head out of the shower, did not see anyone and this is when he inserted the deodorant bottle into his rectum. S5MHT also indicated Patient #1 stated had found the deodorant bottle in the shower room.

In an interview on 01/23/2024 at 1:00 p.m. S6MHT confirmed she was observing Patient #1 on 01/14/2023 during his shower. S6MHT confirmed she had left the patient to retrieve larger patient gown. S6MHT confirmed Patient #1 had completed his shower and that is when he informed the MHTs that he had inserted a deodorant bottle in his rectum. S6MHT indicated Patient#1 had to have found the deodorant bottle in the shower room because his shower supplies did not include deodorant.

In an interview on 01/23/2024 at 11:30 a.m. and on 01/24/2023 at 12:05 p.m. S7MHT confirmed he was the MHT on 1:1 with Patient #1 on 01/15/2024. S7MHT described the incident as the patient was using his toiletries at the time, Patient #1 used his toothbrush and toothpaste, then handed it back to S7MHT. Patient #1 asked for his deodorant, the patient used the deodorant and immediately moved from using the deodorant to shoving the deodorant up his rectum. S7MHT indicated the patient was partially clothed and was not wearing any clothing on his bottom.

Based on record review and interview, the hospital failed to ensure patients were kept free of all forms of abuse or harassment. This deficient practice is evidenced by:
1) Failure to report allegations of self-harm to LDH-HSS on 1 (#1) of 3 (#1 -#3) patients; and
2) Failure to timely report allegation of self-harm to LDH-HSS on 1 (#1) of 3 (#1 -#3) patients.
Findings:

Review of the Louisiana Revised Statutes, Title 40. Public Health and Safety, Chapter 11, State Department of Health and Hospitals revealed "Department" shall mean the Department of Health and Hospitals. "Unit" means the Medicaid fraud control unit created within the office of criminal law of the Department of Justice and which is certified by the secretary of the United States Department of Health, Education and Welfare. Regarding §2009.20. Duty to make complaints; penalty; immunity, "Abuse" is the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including but not limited to sexual abuse, or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered. "Neglect" is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer's well-being. Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, ... 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 twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report.

Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report these allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Department of Health and Hospitals (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.

1) Failure to report allegations of self-harm to LDH-HSS on 1 (#1) of 3 (#1 -#3) patients

A medical record review of Patient #1 had 2 (01/13/2024 and 01/14/2024) prior incidents of placing foreign objects into his rectum and having to be transferred to Emergency Department for further treatment and removal. Both of these incidents were not reported to LDH-HSS. The only reported incident was the incident occurring on 01/15/2024.

In an interview on 01/24/2023 at 4:00 p.m. S1CEO, S2DON and S3QA confirmed the facility did not report incident #1 and #2 mentioned above. DON and S3QA were unaware instances of self- harm were reportable and also considered this to be a behavior of Patient #1 and not self-harm.

2) Failure to timely report allegation of self-harm to LDH-HSS on 1 (#1) of 3 (#1 -#3) patients

A review of the facility initial report sent to LDH-HSS revealed the incident occurring 01/15/2024 at 8:20 a.m. This initial report was received by LDH-HSS on 01/17/2024. The submitted initial report was not properly submitted to LDH-HSS within 24 hours of the facility becoming aware of the incident.

In an interview on 01/24/2023 at 4:00 p.m. S1CEO, S2DON and S3QA confirmed they considered the 24 hour reporting time frame to be from the time administration was made aware of a reportable incident.