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Based on record review and interview, the facility failed to ensure the medical record contained documented evidence of patient notification of their rights. This deficient practice was evidenced by failing to have the patient/patient representative sign the statement of Patient Acknowledgment of Rights for 1 (#3) of 3 (#1-#3) patients reviewed.
Findings:

Review of the hospital policy number RTS-01 titled, "Patient Rights Louisiana," last revised 09/01/2023, revealed in part: "PURPOSE: To ensure that all patients are aware of their rights while being treated at this facility and to provide guidance to the program staff regarding the method for ensuring patient rights are respected and the method for restricting a patient's rights if deemed necessary. Every patient shall receive a written copy of their rights and responsibilities as a patient as part of the Patient Handbook and shall sign an acknowledgement that they are aware of their rights. The written copy shall include all applicable state and federal rights protections afforded to the patient. PROCEDURE: 1. The patient is to be given a copy of the Patient's Rights as part of the Patient Handbook that is reviewed at the time of admission by a program staff member. The patient acknowledges receipt of their written statement of rights by signing the Statement of Patient Acknowledgement which becomes part of the medical record. 5. If the patient is a minor, the rights shall be reviewed orally with the patient parent/guardian, when applicable, and have the patient sign the "acknowledgement of Rights" form and document verbal acknowledgement from the parent/guardian.

Review of Patient #3's medical record revealed an admission date of 05/30/2025 under a Physician Emergency Certificate (PEC). Patient #3's medical record failed to reveal documented evidence that Patient #3 or their parent/guardian were notified of all patient rights. Further review failed to reveal a signed acknowledgement of rights form in the medical record.

In an interview on 06/03/2025 at 9:20 AM, S1ADON confirmed the medical record failed to reveal evidence Patient #3 or his parent/guardian were given the opportunity to acknowledge that they were aware of all patient rights. S1ADON also confirmed that there was no signed acknowledgement of rights form in the medical record for Patient #3.

Based on record review and interview, the hospital failed to ensure the patient/patient representative's right to participate in the development and implementation of his or her plan of care. This deficient practice is evidenced by failing to document the reason the patient did not participate in the treatment plan for 1 (#3) of 3 (#1-#3) patient treatment plans reviewed.
Findings:

Review of the hospital policy number RTS-01 titled, "Patient Rights Louisiana," last revised 09/01/2023, revealed in part: "Treatment: You have the right too an individualized treatment plan and periodic reviews to determine your progress. You have the right to be involved in making decisions regarding the nature of care, treatment, and services that you will receive and to make decisions about your care. Rights of Minors: Q. A minor patient admitted to a treatment facility has the right to an individualized treatment plan and periodic review to determine his progress."

Review of the hospital policy number CS-02 titled, "Treatment Planning; Integrated/Multidisciplinary," last revised 05/01/2025, revealed in part: "PURPOSE: To document and implement treatment objectives/interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of patient's treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided. POLICY: The Treatment Plan shall be initiated as a component of the admissions process with continual development and formulation by the attending physician and multi-disciplinary treatment team, with the patient's involvement, throughout the course of treatment. PROCEDURE: 4. If the patient is unable and/or unwilling to sign the treatment plan, the reason or circumstances of such inability or unwillingness shall be documented in the patient's medical record."

Review of Patient #3's medical record revealed an admission date of 05/30/2025 with a diagnosis of Major Depressive Disorder (MDD) and Bipolar.

Review of Patient #3's medical document titled "Interdisciplinary Treatment Plan Master Sheet" initiated on 05/30/2025, revealed the patient signature line was signed "verbal" by the nurse, but no additional documentation stating the reason that Patient #3 was unable and/or unwilling to sign was provided.

In an interview on 06/03/2025 at 9:47 AM, S1ADON confirmed the nurse signed verbal on the patient signature line, but did not provide any documentation as to why Patient #3 was unable and/or unwilling to sign the treatment plan.

Based on record review and interview, the hospital failed to ensure the patient/representative was provided information about his/her health status, diagnosis, and prognosis in order to make "informed" decisions regarding his/her care. This deficient practice was evidenced by failing to have a signed consent for treatment form by the patient/representative for 1 (#3) of 3 (#1-#3) patients reviewed for signed consents.
Findings:

Review of hospital policy number RTS-11, titled "Informed Consent, Care Decisions, and Conflicts Resolution," last revised 11/01/2024, revealed in part: "PURPOSE: To outline the responsibility of the facility in establishing a mutual understanding between the patient/patient's family/representative and the facility about patient services received. To involve patients and significant others, when appropriate, in care decisions, conflict resolution, and the informed consent process. POLICY: The facility recognizes the benefit and the need to involve patients and significant others, when appropriate, in care, treatment and service decisions, conflict resolution, and to ensure that appropriate informed consent is obtained as outlined by the State, Federal and other regulatory bodies. PROCEDURE: Informed Consent: 1. The Governing Body/Administration dictates that informed consent is mandatory on those procedures, care, treatment, and services normally requiring informed consent and mandates that all staff responsible for the delivery of care, treatment and services educate patients/patient's family/representative to allow for informed decision making as to participate in the care, treatment, and services being delivered. 3. The facility will, during the admission process, obtain signature on informed consent forms. If the patient is unable to sign due to physical impairments, verbal consent can be obtained and documented with two witnesses. In the case of involuntary commitment, the facility will follow the policies of the organization related to involuntary admission. 4. Specific informed consent is required in the following circumstances: Facility treatment programming/admission."

Review of Patient #3's medical record revealed an admission date of 05/30/2025 under a Physician Emergency Certificate (PEC). Patient #3's medical record failed to have documented evidence that Patient #3 or his representative signed an informed consent for treatment.

In an interview on 06/03/2025 at 9:20 AM, S1ADON confirmed that there was no signed informed consent for treatment in the medical record for Patient #3.

Based on observation, record review, and interview, the psychiatric hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by failure of the staff to prepare for a scheduled power outage and ensure 12 (#3, #R1-#R11) of 12 (#3, #R1-#R11) patients were monitored according to the physician's orders including special precautions and documented the care provided in real time according to accepted standards and hospital policy.
Findings:

Review of hospital policy number IS-03, titled "Electronic Medical Record (EMR) Downtime Procedures," effective date 07/01/2023, revealed in part: "PURPOSE: To mitigate the risk associated with planned and unplanned downtimes related to the Electronic Medical Record (EMR) and to outline the processes for access to patient information for the purposes of documentation of patient care during those downtime periods. POLICY: The facility recognizes that interruptions in the availability of the EMR may occur which can be planned or unplanned and outlines a process for ensuring the care delivered during a period of EMR downtime is appropriately documented. PROCEDURE: 1. Notification will be sent out to all employees for planned downtime. When possible and deemed necessary, timing of planned downtime shall be coordinated with the facility and pharmacy. 11. All documentation requirements and related policies and procedures shall remain in effect for the period of downtime."

Review of hospital policy number CS-23, titled "Level of Observations," last revised 03/01/2023, revealed in part: "PURPOSE: To provide staff with a framework for monitoring patients to ensure safety. POLICY: Observation Levels: Every 15 minutes- the staff member will visually observe the patient every 15 minutes to monitor their location and activity, with an emphasis on any noticeable behaviors of escalation, aggression, and unsafe activities. PROCEDURE: 3. Staff members utilize the close observation checklist form (Q15 check sheet) to document the ongoing observation and location of the patient. The observing staff initials the 15-minute increments on the form to indicate the patient was observed. The staff member signs the signature line at the bottom of the form to validate their initials and credentials."

Review of hospital policy number AS-19, titled "Suicide/Homicide Risk Assessment," last revised 11/01/2023, revealed in part: "PURPOSE: The purpose of this policy is to ensure an effective method for suicide/homicide screening, assessment, monitoring, and treatment of patients at risk for suicide/homicide. POLICY: Prevention techniques will be accomplished by a comprehensive approach that identifies and mitigates process and system level issues contained within the hospital environment that can contribute to self-harm. Direct Care Staff who conduct suicide screening, assessment, or re-assessment will be trained and successfully pass competency test on the screening and/or assessment process and screening/assessment tools as part of new hire orientation and annually thereafter. PROCEDURE: Inpatient: 3. All direct care staff needs to be aware of suicidal/homicide/violence risks. Suicide, homicide, and/or violence precautions will be noted in the medical record. 5. The following Risk Levels and Interventions will be used in the assessment to mitigate any suicide/homicide/violence risk: Levels of risk and appropriate interventions (Inpatient): Suicidal Risk Stratification: HIGH Suicide Risk: Suicidal ideation with intent or intent with plan in the last month or suicidal behavior within the past 3 months. Suicidal Intervention: HIGH Suicide Risk: Stay patient, initiate 1:1 observation, and notify provider to obtain order. Patient may be placed on lower level of observation based on clinical judgement of the Medical Staff and the documented justification. Initiate a "Potential for Self-Harm" treatment plan. Maintain a SAFE environment & evaluate personal belongings for ligature risk. Develop Safety Plan with suicide resources for discharge planning. Notify multidisciplinary team of patient's "high suicide risk" status. Suicidal Risk Stratification: MODERATE Suicide Risk: Suicidal ideation with method, WITHOUT plan, intent or behavior in the past month Or Suicidal behavior more than 3 months ago Or Multiple risk factors and few protective factors. Suicidal Intervention: MODERATE Suicide Risk: Implement q15 min observation. Place patient close to nurses' station with roommate, if possible. Initiate a "Potential for Self-Harm" treatment plan. Maintain a SAFE environment & evaluate personal belongings for ligature risk. Develop Safety Plan with suicide resources for discharge planning. Notify multidisciplinary team of patient's "moderate suicide risk" status. Suicidal Risk Stratification: LOW Suicide Risk: Wish to die or Suicidal Ideation WITHOUT method, intent, plan, or behavior Or Modifiable risk factors and strong protective factors Or No reported history of Suicidal Ideation or Behavior. LOW Suicide Risk: Implement q15 min observation. Continue to monitor for changes in suicidal ideation or behavior."

Review of hospital policy number CS-04, titled "Elopements," last revised 01/01/2025, revealed in part: "PURPOSE: To identify those at risk for elopement and to prevent the occurrence. PROCEDURE: 2. For patients who are screened or assessed to be at risk for elopement, the physician is notified and an order for elopement precautions is obtained. The prescribed level of observation is implemented immediately. 5. Elopement prevention strategies and interventions include, but not limited to: Initiate 1:1 or Line of sight observation level. Limit/restrict outdoor privileges (requires physician order which must be renewed every 24 hours). Ensure all staff practice door safety by ensuring all doors on and off the unit are closed and appropriately latched/locked before leaving the door area. Redirect patients away from immediate proximity of doors. Staff vigilance during outdoor time by walking the inside perimeter of fencing to stay between patients and fence. Always having two or more staff present when patients are off the locked unit within the facility. Ensure no items such as chairs, benches, garbage cans, etc. are in the outdoor courtyard that could be used to leverage patient over fencing. Direct patients away from fence during outdoor times."

Review of hospital policy number CS-44, titled "Sexual Acting Out (SAO) Identification and Precautions," effective date 12/19/2022, revealed in part: "PURPOSE: To provide staff with a framework for identifying patients who are at risk for exhibiting sexually inappropriate behavior and to provide for the implementation of precautions to ensure the safety of all patients. POLICY: Definitions: Sexual Precautions: Sexual Precautions are defined as intensified levels of staff awareness and attention to patient safety/security related to sexual acting out behaviors. Sexual Precautions require varying levels of observing patients and the initiation of specific protocols and supplemental documentation, when warranted. PROCEDURE: 4. The RN/LVN/LPN ensures all patient orders for SAO Precautions are recorded and posted. 5. The RN ensures the SAO Precaution level is communicated on the hand off report and all staff are aware of the SAO Order. Sexual Acting Out (SAO) Precautions: 1. LOS or 1:1 or 15 minute observation based on clinical assessment; 2. Assess location of patient rooms based on vulnerability of the patient population in particular at-risk patients; 3. Determine if level of SAO risk requires that a patient requires his/her patient room; 4. Room visible from the nurses' station or patient lounge when possible; 5. Door open when patient is his/her room; 8. Ensure all staff members are aware of SAO behavior (including volunteers, students); 9. Ensure two staff members are present when the patient needs assistance in his/her room or isolated areas; 10. Monitor relationships, interactions, not passing, whispering, etc., among patients. 11. Screen reading materials, ensure appropriate media is viewed on the unit; 12. Visitor restrictions if appropriate."

In an interview during the entrance conference on 06/02/2025 at 8:25 AM, S1ADON stated there would be a scheduled power outage around 10:00 AM - 11:00 AM. Per S1ADON, the outage is to install a new part on the generator. S1ADON confirmed at that time that staff working had been made aware of the power outage and that staff would be documenting patient care on paper forms during the electrical power downtime.

Observations during a tour on 06/02/2025 from 10:53 AM - 11:15 AM revealed all 12 patients were in the secured outdoor area playing while being observed by 2 nurses and 2 MHT's.

Review of the Observation Check Sheet for Patient #3 and Patients #R1-#R11 revealed that observations were initiated for each patient on paper at 10:45 AM. Review of the Observation Check Sheets for Patient #3 and Patients #R1-R11 failed to reveal an assigned observation level checked per physician order by the Registered Nurse, the ordered precaution level, or the date the observations were being performed.

Review of the bedboard for 06/02/2025 revealed Patient #3 and Patients #R1-R11 were all on Q15 minute observations.
Further review revealed the following ordered precaution levels:
Patient #3- Suicide, Violence, and Sexually Acting Out
Patient #R1, #R2- Violence
Patient #R3, #R8- Homicide, Violence
Patient #R4, #R10, #R11- Suicide
Patient #R5- Suicide, Homicide, Violence
Patient #R6- SAO, Violence
Patient #R7- SAO, Suicide, Violence
Patient #R9- Elopement

In an interview on 06/02/2025 at 11:08 AM, S7MHTconfirmed that she is unable to verify which precaution level each patient was on without a copy of the bedboard, which they use as a reference. S1ADON and S7MHT confirmed that the staff observing the patients did not have a copy of the bedboard with them at this time, which jeopardized their safety and well-being.

Additional review of the Observation Check Sheets for 8 (#3, #R1-#R7) of the 12 (#3, #R1-#R11) patients failed to reveal staff initials by the observing staff for 10:45 AM or 11:00 AM to indicate the patient was being observed.

In an interview on 06/02/2025 at 11:11 AM, S1ADON confirmed the above mentioned findings. S1ADON further confirmed that staff should have been prepared since this was a scheduled downtime.

In an interview on 06/02/2025 at 11:25, S3RCEO confirmed the Observation Check Sheets should have been appropriately filled out because staff has been "aware for hours" that this was going to happen.

Based on record review and interview, the hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice was evidenced by failure to accurately self-report an incident which involved an alleged patient to patient sexual assault.
Findings:

Review of hospital policy number QAPI-004, titled "Incident Reporting," last revised 08/01/2024, revealed in part: "PURPOSE: To document any potential or adverse incident within the facility or on the facility grounds/property/vehicle, with the facts available at the time, recorded by persons involved, either in the incident or in the discovery of the incident. Information to Provide in the Incident Report: 1. The Incident Report shall be limited to factual statements (who, what, where, and when) related to the patient safety incident and any interventions take to reduce the risk of future incidents and promote safety."

Review of Patient #1's medical record revealed Patient #1 was a 12 year old male admitted on 05/02/2025 with a diagnosis of Major Depressive Disorder (MDD). On the night of 05/04/2025, Patient #1 was involved in an alleged patient to patient sexual assault incident with his roommate, Patient #2. Further review revealed after Patient #1 was evaluated by the provider, he was transferred on 05/05/2025 to the ER for an evaluation at which point the Patient #1 was discharged into the care of his mother.

Review of Patient #2's medical record revealed Patient #2 was a 17 year old male admitted on 05/02/2025 with a diagnosis of Major Depressive Disorder (MDD). On the night of 05/04/2025, Patient #2 was involved in an alleged patient to patient sexual assault incident with his roommate, Patient #1. Further review revealed Patient #2 was discharged on 05/04/2025 at 10:48 PM into police custody.

Review of the Nursing Assignment Sheet dated 05/04/2025 7a-7p and 7p-7a shift revealed a census of 15 patients. Further review revealed that Patient #R12 was on Line of Sight Observations.

Review of the Hospital/Licensed Provider Abuse/Neglect Initial Report finalized on 05/05/2025 revealed in part the following documentation:
Incident Type: Alleged Sexual Abuse (Patient to Patient Sexual Assault)
Date/Time of Incident: 05/04/2025; exact time unknown, only reported time is known
Shift of incident: 7p-7a
Date/Time of Discovery: 05/04/2025 at 9:10 PM

Patient Information documented on report included:
Patient #1 as Victim
Patient #2 as Aggressor

Incident details revealed in part:
Patient #2 reported that he forced Patient #1 to perform oral sex on him while in their room the evening of 05/04/2025.
Both patients were on a PEC status.
Both patients were close observation (every 15 minute) monitoring.
Census on the unit was 15, no elevated observation at time of the incident. Staffing was 1 RN, 1 LPN, 2 MHT's.

The report failed to reveal that at the time of the incident Patient #R12 was on Line of Sight observations.

In an interview on 06/03/2025 at 8:55 AM, S1ADON confirmed that information included in the self-report was not reported accurately. S1ADON further confirmed that at the time of the incident involving Patient #1 and Patient #2, the unit had a patient who was on an elevated observation level. S1ADON verified the Nursing Assignment Sheet for 05/04/2025 7P-7A revealed Patient #R12 was on Line of Sight observations.

Based on record review and interview, the hospital failed to ensure the Registered Nurse supervised and evaluated the care of each patient on an ongoing basis, in accordance with the accepted standards of nursing practice and hospital policy. This deficient practice is evidenced by failure of the Registered Nurse to document a provider notification for an alleged patient to patient sexual assault in 1 (#1) of 3 (#1-#3) patient medical records reviewed.
Findings:

Review of hospital policy number CS-44, titled "Sexual Acting Out (SAO) Identification and Precautions," effective date 12/19/2022, revealed in part: "PURPOSE: To provide staff with a framework for identifying patients who are at risk for exhibiting sexually inappropriate behavior and to provide for the implementation of precautions to ensure the safety of all patients. To define actions to take in response to reports or allegations of sexual behavior or sexual acting out between patients. Criteria: 2. If it is suspected, reported, or observed that there has been sexual contact between patients, the attending provider or designee, the Charge Nurse, Hospital Administrator or Administrator on-call, Director of Nursing (DON), will be notified immediately."

A review of the incident report involving Patient #1 revealed in part that Patient #1 was identified as the alleged victim of a patient to patient sexual assault that was reported on 05/04/2025 at 9:10 PM.

Review of Patient #1's medical record revealed Patient #1 was admitted on 05/02/2025 with a diagnosis of Major Depressive Disorder (MDD). Further review failed to reveal documented evidence by the nurse that the attending provider was immediately notified that Patient #1 was an alleged victim of a sexual assault.

In an interview on 06/02/2025 at 2:05 PM, S1ADON confirmed that there was no documentation in the medical record by the nurse that the provider was notified of the sexual assault incident involving Patient #1.

Based on record review and interview, the nursing staff failed to develop and update an individualized plan of care for each patient. This deficient practice was evidenced by failing to update the care plan following an incident for 1 (#2) of 3 (#1-#3) patient records reviewed.
Findings:

Review of hospital policy number CS-44, titled "Sexual Acting Out (SAO) Identification and Precautions," effective date 12/19/2022, revealed in part: "PURPOSE: To define actions to take in response to reports of allegations of sexual behavior or sexual acting out between patients. PROCEDURE: 15. Update treatment plan for each patient."

Patient #2
Review of incident report involving Patient #2 revealed the following:
Date of Incident: 05/04/2025, time of discovery: 9:10 PM, Type of occurrence: Alleged Patient to Patient Sexual Abuse.

Review of Patient #2's medical record revealed Patient #2 was placed on Sexually Acting Out precautions on 05/04/2025 at 9:40 PM. Further review failed to reveal evidence that Patient #2's care plan was updated to include Sexually Acting Out precautions.

In an interview on 06/03/2025 at 9:01 AM, S1ADON confirmed that the plan of care for Patient #2 was not updated to include Sexually Acting Out precautions.

Based on observation, record review, and interview, the hospital failed to ensure a registered nurse assigned the nursing care of each patient to other nursing personnel in accordance with hospital policy and the patient's needs. This deficiency is evidenced by failing to ensure a Registered Nurse completed patient care assignments at the beginning of shift for 12 (#3, #R1-#R11) of 12 (#3, #R1-#R11) patients on the census.
Findings:

Review of hospital policy number NSG-05, titled "Nursing Assignments," last revised 06/01/2023, revealed in part: "POLICY: It is the charge nurse's responsibility to complete the nursing assignment sheet at the onset of every shift. All nursing staff members are held accountable for duties assigned. Charge nurses will supervise assignments and ensure completion of all delegated duties. PROCEDURE: In-Patient: 1. The charge nurse will determine the nursing care assignments for that shift based on patient acuity, and capabilities and scope of practice of available staff. Every patient will be assigned to a specific person."

Observations during a tour on 06/02/2025 from 10:53 AM - 11:15 AM revealed the 7A-7P Nursing Assignment Sheet, dated 06/02/2025. Review of the Nursing Assignment Sheet revealed the only information completed was the date, shift, census number, and name of charge nurse. Further review of the Nursing Assignment Sheet failed to reveal staff or patient assignments.

In an interview on 06/02/2025 at 11:00 AM, S1ADON confirmed the above mentioned findings. S1ADON also confirmed that the Nursing Assignment Sheet should have been completed at the beginning of the shift.

Based on observation and interview, the hospital failed to have an effective infection prevention and control program as evidenced by failing to have a clean and sanitary environment.
Findings:

Observations during a tour on 06/03/2025 from 8:35 AM - 8:50 AM revealed Room "a" with soiled towels on the floor and 2 used bottles of mouth wash on the sink.

In an interview on 06/03/2025 during the tour, S1ADON confirmed the above mentioned findings.

Based on record review and interviews, the hospital failed to ensure all patient treatments were within compliance of particular aspects of the patients' individual treatment program as evidenced by failure to have a signed master treatment plan by the social worker/therapist and attending physician for 1 (#3) of 3 (#1-#3) patient treatment plans reviewed.
Findings:

Review of the hospital's policy number CS-02 titled, "Treatment Planning; Integrated/Multidisciplinary," last revised on 05/01/2025, revealed in part: "PURPOSE: To document and implement treatment objectives/interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of patient's treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided. POLICY: The multi-disciplinary treatment team, under the direction and supervision of the attending physician, shall develop an integrated written, comprehensive Treatment Plan with specific goals and objectives necessary to address deficits and cultivate strengths identified in the assessments process. The Treatment Plan shall be initiated as a component of the admissions process with continual development and formulation by the attending physician and multi-disciplinary treatment team, with the patient's involvement, throughout the course of treatment. PROCEDURE: 4. The treatment plan shall be signed by all members of the interdisciplinary team (IDT)."

Review of Patient #3's medical record revealed he was admitted on 05/30/2025 at 1:13 AM for Major Depressive Disorder (MDD) and Bipolar.

Review of Patient #3's Interdisciplinary Treatment Plan Master Sheet dated 05/30/2025 failed to reveal staff signatures from the therapist or physician.

In an interview on 06/03/2025 at 9:47 AM, S1ADON confirmed there was no signature for the therapist or the physician on the Master Treatment Plan for Patient #3. S1ADON further confirmed there should have been signatures for the therapist and physician on the Master Treatment Plan for Patient #3.