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Based on policy review, 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 (LDH) within 24 hours of awareness of the allegation, as required by LDH-HSS, for 4 (#4, #8, #9, #10 ) of 11 patients reviewed for self-reports to LDH-HSS from a total patient sample of 13.
Findings:

Review of Policy/Procedure RI.055 titled, "Patient Complaint Procedures" revealed in part: All allegation of abuse or neglect are considered grievances and cannot be resolved at the unit level. Investigation is being initiated immediately as directed by the nursing supervisor.

Review of Policy/Procedure PE.032A and PE.032B titled, "Abuse and Neglect Assessment/Reporting revealed in part: Everyone is a mandatory reporter of abuse, neglect, or exploitation. If you are a mandatory reporter and you have cause to believe that a reportable incident has occurred, you must report. Mandatory reporters are not obligated to obtain permission to report. You must fulfill your own mandatory reporting obligations.

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 #4
Review of Patient Advocate note dated 04/30/2023 revealed Advocate interviewed Patient #4 who stated a Mental Health Tech (MHT) placed her hand on his shoulder and squeezed it tight as she had him walk to the front of the line after Patient #4 had a verbal altercation with peer while in the cafeteria line. There was no documented evidence that this incident was self-reported to LDH-HSS.

On 05/24/2023 at 10:30 a.m., an interview with S1CNO confirmed there was no self-report completed and sent to LDH-HSS.

Patient #8
Review of an Incident Report and investigation dated 04/26/2023 at 10:00 a.m. revealed that Patient #8 walked up behind a female peer in very close contact and remarked, "Hey, baby." Peers were separated for safety reasons. There was no documented evidence that this incident was self-reported to LDH-HSS.

On 05/24/2023 at 10:30 a.m., an interview with S1CNO confirmed there was no self-report completed and sent to LDH-HSS.

Patients #9 and #10

Review of an Incident Report and investigation dated 4/22/2023 at 4:30 p.m. revealed that Patient #9 admitted to putting a hickey on the neck of Patient #10. There was no documented evidence that this incident was self-reported to LDH-HSS.

On 05/24/2023 at 10:30 a.m., an interview with S1CNO confirmed there was no self-report completed and sent to LDH-HSS.







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