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Based on record review, observation, and interview, the hospital failed to meet the requirements for the Condition of Participation for Patient's Rights as evidenced by failure to ensure all patients were free from abuse or harassment. This deficient practice resulted in prohibited physical contact between staff and patients. This was evidenced by 2 (#1, #2) patients being struck by staff out of 4 (#1, #2, #3, #4) sampled patients reviewed for alleged staff abuse; 1 (#1) patient being dragged along the floor to his room by staff out of 4 (#1, #2, #3, #4) sampled patients reviewed for alleged staff abuse; and 1 (#3) patient being struck with a blood pressure cuff by staff out of 4 (#1, #2, #3, #4) sampled patients reviewed for alleged staff abuse, from a total patient sample of 5 (#1- #5). See findings in A-0145.

Based on record review, observation, and interview, the hospital failed to ensure all patients were free from abuse or harassment. This deficient practice resulted in prohibited physical contact between staff and patients. This was evidenced by 2 (#1, #2) patients being struck by staff out of 4 (#1, #2, #3, #4) sampled patients reviewed for alleged staff abuse; 1 (#1) patient being dragged along the floor to his room by staff out of 4 (#1, #2, #3, #4) sampled patients reviewed for alleged staff abuse; and 1 (#3) patient being struck with a blood pressure cuff by staff out of 4 (#1, #2, #3, #4) sampled patients reviewed for alleged staff abuse, from a total patient sample of 5 (#1- #5).
Findings:

Review of the hospital policy titled, "Abuse and Neglect Policies and Procedures for LDH", effective date 06/06/2016, revealed the following, in part: I. Policy Statement: LDH is committed to preserving the right of each person receiving services to be free from abuse. All forms of abuse of clients by employees of LDH and its affiliates are prohibited. While definitions and examples of abuse are provided in this policy, it must be understood that all possible situations cannot be anticipated and each case must be evaluated based on the particular facts available.
II. Purpose: To establish a policy prohibiting abuse, neglect, exploitation, or extortion (hereafter termed "abuse") of clients and to establish procedures for reporting, investigating, reviewing, and resolving alleged incidents of abuse.
III. Applicability: This policy applies to all employees of LDH and its affiliates and to all persons receiving services from LDH and its affiliates.
VI. Statutory Definitions of Abuse: A. Definitions of abuse, neglect, exploitation, and extortion are found in the state and Federal laws and regulations cited below. These definitions apply to different client populations and/or in different settings. The text of these definitions is included as Appendix A of this policy. It is the responsibility of each program office and/or facility within LDH to include in its internal policy and procedures those definitions which apply to the clients they serve and the settings in which services are delivered and to ensure that its employees and affiliates are trained in those definitions.
1. Louisiana Revised Statutes 15.1503 Adult Protective Services Law. These definitions apply to any person ages 18-59 (or an emancipated minor) who, due to a physical, mental, or developmental disability or the infirmities of aging, is unable to manage his own resources, carry out the activities of daily living, or protect himself from abuse, neglect, or exploitation. They apply in any setting.
2. Louisiana Revised Statues 40:2009:20. These definitions apply to any person residing in a facility or receiving services from a provider licensed by the Health Standards Section of the LDH Bureau of Health Services Financing. This includes, but is not limited to clients residing in a licensed ICF-DD, a licensed nursing home, a licensed hospital, or other licensed health facility as defined in LA RS 40:2009.13.
3. Code of Federal Regulations 45 CFR 1386.19 (State System for Protection Advocacy of the Rights of Individuals with Developmental Disabilities) and 42CFR 51.2 These definitions are contained in the Federal Regulations establishing protective and advocacy programs and apply to the facilities serving the developmentally disabled and the mentally ill, respectively.
4. Code of Federal Regulations 42 CFR 488.301. These definitions apply to long-term care facilities participating in the Medicaid and/or Medicare programs.
I. Examples of Abuse:
A. Listed below are examples of the type of conduct which constitutes abuse. This list of examples is not exhaustive and represents general categories of prohibited conduct. Conduct of a like or similar nature is also prohibited. Examples include, but are not limited to:
1. Physical Abuse: Physical contact such as hitting, slapping, pinching, kicking, choking, scratching, pushing, twisting of head, arms or legs, tripping; the use of physical force which is unnecessary or excessive; and inappropriate or unauthorized use of restraint.
2. Verbal/Emotional/Psychological Abuse: Verbal conduct may be abusive because of either the manner of communication or the content of the communication. Examples include yelling, cursing, ridiculing, harassment, coercion, threats, intimidation, and other communication which is derogatory or disrespectful. Non-verbal communication, such as gestures, that have the same effect may be considered emotional or psychological abuse.
IX. Procedures for Reporting: 1 .... 2. Immediately take appropriate measures to protect the safety and well-being of the client(s) involved. This may include such actions as removing client(s) from danger, seeking medical attention, or notifying external agencies as outlined in Section IX.C. of this policy.
B. Responsibility of facility/program managers: Upon receiving a report of abuse, facility/program managers or their designees shall:
1. Ensure that any client(s) involved is removed from a hazard or danger and receives appropriate care and/or medical treatment.
2. When the allegation involves staff, contact the supervisor of the staff involved (LDH or affiliate) and assure initiation of administrative action to ensure the protection of the client(s). This may include, but is not limited to, removal of staff in accordance with Civil Service Rules or removal of clients.
XIII. Consequences of abuse and disciplinary actions:
A. Violation of this policy will be grounds for disciplinary action, up to and including termination. Violations include but are not limited to:
1. Committing abuse, neglect, exploitation, or extortion;
B. Disciplinary action should be administered by the appropriate appointing authority in accordance with LDH Policy #30.1 and Civil Service Rules. When the appointing authority anticipates that disciplinary action may be warranted for violation of this policy, he/she shall notify the LDH Bureau of Legal Services.
C. The expectation is that a staff member confirmed to have physically abused a client will be terminated from his/her employment. Any variance from this expectation requires a detailed justification by the facility/program administrator and approval by the Office's Assistant Secretary.

Patient #2
Review of Patient #2's treatment plan, dated 06/21/2022, revealed an admission date of 09/10/2021 with admission diagnoses of unspecified disruptive impulse control and conduct disorder, substance abuse disorder (environmentally controlled), intellectual disability-mild, and history of seizure disorder.

Review of hospital provided self-reports to LDH - HSS for alleged abuse/neglect from 01/2022 - 08/15/2022 (current), revealed a self-report for alleged physical abuse of Patient #2 by staff on 07/07/2022.

Review of the initial self-report to LDH - HSS for alleged physical abuse of Patient #2 by staff revealed the following: On 07/07/2022 at 3:15 p.m. (6 a.m.-6 p.m. shift) Evangeline 2, B Hall, Room "a", S5CGT, appeared to strike Patient #2 three times after patient struck him. Video was recorded and the video surveillance was reviewed by S9FormerCEO. Incident was reported by staff member. Preparer of report: S8RN. Incident became known at the time of occurrence. Client assessed and no injuries. Actions taken: S5CGT was removed from unit and client placed in locked seclusion.

Review of the hospital provided video recording, assisted by S2AsstCEO, on 08/16/2022 at 10:00 a.m., of an incident that occurred on 07/07/2022, with S1CEO, S3QA, S4QADir, and S10DON present, revealed the following, in part:
Evangeline Ward 2/Hall South
3:08:16-42 p.m. : S5CGT is facing the doorway of Room "a" and appears to be speaking to Patient #2 who was out of camera view in the room.
Evangeline Ward 2/Room "a": 3:09:22-27 p.m.: S5CGT is pushing Patient #2 with his arms extended and Patient #2's back is facing the wall of the room. Patient #2 grabbed S5CGT's shirt and spun him around with his back facing the back wall of the room. He was observed striking S5CGT in the head. Further review revealed Patient #2 fell on the bed and S5CGT hit Patient #2 a total of five times. S12Lt was assisting with holding Patient #2 down on the bed, he was kicking and trying to get up again, when the last two of the five blows were landed.

Review of the APS Investigative Statement given by S5CGT revealed the following, in part: On 07/07/2022 I was working a call back on Evangeline 2. Patient #2 is up front and punches the glass of the monitor station. I went and spoke with Patient #2 and was able to calm him down. I escorted him to his room. I talked to him, telling him to calm down. It is not working. Patient #2 who is in the same room with my RPM, grabs a urinal my RPM uses when he cannot get up to use the restroom. Patient #2 came out the room with his urinal. He wanted to go up to the monitor station and throw the urine on the women. I placed my arm between Patient #2 and the door frame to try to stop him. During this time, Patient #2 is pushing against me to try to push me out of the way. Patient #2 said, 'I am going to throw the urine on you.' I never answered. He then put the urine down and said to me, 'I will punch you in your [expletive]'. I did not do or say anything. He came up to me, swung and hit me two times in the right side of my forehead. I grabbed him and tried to hold him. He was still hitting me. I am not sure how many times I hit him it happened so fast. This was a reflex action on my part."

Review of the documented hospital review of the investigation findings revealed the following, in part: ELMHS has not substantiated the physical abuse allegation against S5CGT. The video shows Patient #2 swinging at S5CGT. S5CGT did swing 5 times but it appears to be more reactionary than abuse. The statements from S5CGT and Patient #2 seem to support this. The facility doesn't see the need to change any policies or procedures as a result of this incident. Patient #2's actions appear to be a manifestation of his condition and have been referred to his treatment team to be addressed in a clinical and therapeutic manner. ELMHS is committed to being diligent in its efforts to maintain a safe and therapeutic environment.

In an interview on 08/16/2022 at 9:50 a.m. with S10DON, present during review of the video recordings of the incidents involving Patient #2, he confirmed the only physical contact staff should have with patients is performing therapeutic holds and he agreed striking patients was a violation of the hospital's abuse policy.

In an interview on 08/17/2022 at 10:48 a.m. with S5CGT, he confirmed he had been re-assigned to Evangeline Ward 3 after the incident with Patient #2. He further confirmed he had worked on 08/16/2022 and on 08/17/2022 on Evangeline Ward 3. S5CGT reported on 07/07/2022 he had been involved in an incident with Patient #2. He explained Patient #2 was aggressive toward female staff (nurses and CGTs) and would hit women. He said he was the only male staff on the all-male unit. He said Patient #2 was in the same room as his 1:1 patient and he grabbed the urinal and was going to throw urine on the nurses. He turned towards him, and said "I will throw urine on you", and then he said "I'll come and punch you in your [expletive]." He reported Patient #2 hit him 3 times and then his (S5CGT's) reflexes kicked in and he hit Patient #2. He said the nurses came in so he guessed the camera room had called about seeing the incident. He reported he had left the unit. He said he waited on the Major, they called S9FormerCEO and placed him on administrative leave, for 2 weeks and 2 days while they were investigating. He said when he got off of administrative leave S9FormerCEO told him to go to the Chief and he got a counseling letter. He explained S9FormerCEO told him he had watched the video and it was mostly reflexive action and he had to get a verbal warning, then had to have a written warning and he had to sign it. He further explained they told him if there was another incident it would result in termination.

Patient #1
Review of Patient #1's treatment plan assessment dated 07/08/2022, revealed an admission date of 01/25/2017 with admission diagnoses including Schizophrenia, Borderline Personality Disorder, and Mild Intellectual Disability.

Review of a hospital provided incident report dated 07/17/22, date of reported incident 07/16/2022 time unknown, revealed Patient #1 alleged staff "beat me down last night". Patient #1 lifted his shirt to show superficial scratching to his side extending around the flank region approximately 6 inches. Also points to right posterior shoulder stating, "I'm bruised, too." Pale bluish discoloration.

Review of the hospital provided video recording, assisted by S2AsstCEO, on 08/16/2022 at 9:30 a.m., of the incident that occurred on 07/16/2022, with S1CEO, S3QA, S4QADir, and S10DON present, revealed the following, in part:
9:04:19-37 p.m.: Patient #1 stood up from the bed. S11CGMT was right beside the patient. Patient #1 swung twice at S11CGMT who was walking off. S6CGT was observed to be hitting Patient #1 in the chest area. S14CGT entered into camera view. S6CGT was observed swinging at least five times at the patient and she hit Patient #1's left arm. S6CGT was observed leaving the camera view area. Patient #1 was further observed exiting his room a second time and he entered the dayroom.

At 9:06:06-37 p.m.: Patient #1 began hitting the Plexiglas with his right hand after he entered the dayroom. Patient #1 was observed biting his hand and walking towards another patient. Patient #1 began swinging at the other patient again. S14CGT and S15RN could be seen on camera entering the dayroom. Patient #1 was facing S15RN. S11CGMT grabbed Patient #1's shirt and he was pulled to the floor. S11CGMT was trying to get a grip on Patient #1 who was on his back on the floor at this time.

9:06:37-45 p.m.: S6CGT was observed assisting S11CGMT with Patient #1. S11CGMT grabbed Patient #1's feet and was holding them. S6CGT was grasping/holding Patient #1's wrist area and he was observed being pulled/dragged on the floor, from the dayroom to his bedroom.

Wing 2 Hall Mid Front:
9:06:47-55: S6CGT and S11CGMT were observed pulling/dragging Patient #1 down the hallway to his room (Room "b"). S6CGT was holding Patient #1's head/shoulder area and S11CGMT had patient by his feet. Patient #1 was observed to be in his room.

Review of the hospital's documented review of the investigative findings revealed the following, in part: ELMHS has substantiated the physical abuse allegation against S6CGT. Allegations of physical abuse against S14CGT and S11CGMT were unsubstantiated. According to the video evidence, S6CGT struck the client. Although it appears S11CGMT pushed the client it is not definitive. S11CGMT's statement indicates he accidently stepped on the back of Patient #1's foot which is possible but not definitive. S6CGT has been placed on Administrative Leave. The case has been turned over to LDH Legal for review on appropriate disciplinary actions. The facility doesn't see the need to change any policies or procedures as a result of this incident. Further review of the findings reveal no documented evidence that S11CGMT and S6CGT dragging/pulling Patient #1 on the floor, to bring him to his room, was addressed as potentially abusive patient treatment.

In an interview on 08/16/2022 at 9:50 a.m. with S10DON, present during review of the video recordings of the incidents involving Patient #1, he confimed dragging Patient #1 on the floor by his arms and legs to get him to his room was not appropriate.

In an interview on 08/16/2022 at 9:55 a.m. with S4QADir, present when reviewing the video recordings of the incidents involving Patient #1 and #2, she confirmed both incidents involved staff striking patients. She indicated they appeared similar in nature but there may have been other circumstances she was not aware of that may have made the situations different.

In an interview on 08/17/2022 at 3:00 p.m. with S3QA, she reported since the other alleged patient abuse allegations investigated against S11CGMT ( possibly pushing the patient) were considered unsubstantiated, there had been no investigation or counseling related to S11CGMT dragging Patient #1 on the floor to bring him to his room.

In an interview on 08/17/2022 at 3:33 p.m. with S11CGMT, he reported he and S6CGT had been placed on administrative leave during investigation into the incident of alleged physical abuse of Patient #1. He said the report indicated he was not abusive. S11CGMT said, "to be honest, nobody told them anything about what they were being investigated for." He confirmed he had not been spoken to about dragging Patient #1 on the floor to his room as potentially abusive actions.

Patient #3
Review of Patient #3's treatment plan of care, dated 01/17/2022, revealed under Psychosis - Patient #3 presented with delusions and disorganized thought on admit. Further review revealed under Risk of self -harm/aggressive behavior, documentation indicated Patient #3 had been involved in several verbal and physical altercations during his hospitalization.

Review of a self-report of alleged patient abuse, reported to LDH -HSS on 02/01/2022, classified as alleged emotional/physical abuse by staff, revealed on 01/29/2022 at 4:45 p.m. S16CGT and Patient #3 allegedly argued, cursed and screamed at each other in the dayroom. S16CGT reportedly threw a blood pressure cuff at Patient #3's face. Further review revealed S17CGT told the patient, after he said his family would kill all of them, "Your family doesn't want you, that is why you are here." The local Sheriff's Office also had been notified of the incident and the incident was investigated by APS.

Review of the APS report revealed it was noted during review of the video that S16CGT did swing the BP cuff and hit Patient #3 in the upper chest with it. S16CGT was also observed running towards Patient #3 after he threw the cuff towards her but didn't hit her. Another staff member, S19CGT, appeared be to holding S16CGT back by placing his right arm across her chest to separate her from Patient #3.
Further review revealed the allegation of emotional abuse was substantiated due to both S16CGT and S17CGT being verbally abusive to Patient #3. S16CGT also was observed on video posturing in a threatening and confrontational manner. ELMHS Administrator, HR, and LDH legal will convene to decide best course of disciplinary action.

Additional review of investigative documentation provided to the surveyor revealed ELMHS response to HSS was as follows: As per ELMHS/LDH policy after an initial allegation of abuse or neglect was received and APS was notified, ELMHS took immediate action to protect the safety or the client by moving the accused staff members. ELMHS allowed APS to collect statements and review other materials available for investigation. Video footage was reviewed of the incident by APS investigator and the Administrator.

Review of a counseling report dated 01/29/2022 at 5:55 p.m. signed by S17CGT and S18CLT, revealed S17CGT was counseled on code of conduct and ethical behavior for offensive comments towards the client. Further review revealed S17CGT failed to abide by code of conduct, that this type of behavior is not tolerated, and it could result in further disciplinary action.

Review of the current staff roster revealed S16CGT and S17CGT were still listed as employed by ELMHS.

In an interview on 08/16/2022 at 12:15 p.m. with S3QA, she reported HR was handling S16CGT's substantiated emotional abuse allegation. She reported it had not been finalized because there was another HR issue with S16CGT and the paperwork for the substantiated emotional abuse allegation had been attached to the other HR paperwork and had been overlooked. She reported S16CGT had worked on Evangeline 2, Evangeline 3 and then CRU Units.

In an interview on 08/17/2022 at 9:00 a.m. with S16CGT, she reported she had been asking Patient #3 to come over so she could get his vital signs. She said he cursed her and didn't come when she asked. She said he "jumped up and raised up at her." S16CGT said she just "kind of" slapped Patient #3 on the shoulder with the BP cuff. S16CGT reported S20RN told her to get some fresh air and she walked out and left the unit. She said after the incident she was temporarily assigned to another unit while it was investigated.

In an interview on 08/17/2022 at 9:43 a.m. with S18CLt, she reported she had been called by the camera room on 01/29/2022 because S16CGT was observed arguing back and forth with Patient #3. S18CLt reported she had gone to the unit and had asked S16CGT to leave the unit. She reported it was the way S16CGT was arguing and carrying on with Patient #3 that caused her to think maybe S16CGT was the aggressor and not Patient #3, who was a quiet patient. S18CLt said the nurse had informed her that S16CGT had thrown the BP cuff at Patient #3. She reported S16CGT was having to be held back to keep her from going back at Patient #3. S18CLt indicated S16CGT's actions, body language, and trying to get back at Patient #3 made her feel, in her opinion, that S16CGT needed to be off of that unit and to be kept away from Patient #3. S18CLt confirmed, based on the hospital's policy on abuse/neglectt hat it is never acceptable to have physical contact such as striking or throwing things at the patients. She further confirmed the only staff/patient contact should be if performing therapeutic holds.

On 08/16/2022 at 1:39 p.m. an interview was conducted with S1CEO and S2AsstCEO regarding incidents of alleged staff abuse involving above referenced Patients #1, #2, and #3. S1CEO reported S5CGT, who struck Patient #2, as far as she could tell, had not been terminated and was counseled for his actions because he had been employed at ELMHS for 3 years, had a good record, and had good feedback on him from other staff. S1CEO reported S5CGT had admitted he had been wrong, was counseled, and reprimanded according to documentation of the counseling. S1CEO confirmed, based on the hospital policy's physical abuse definition, that the action taken after an incident of abuse is usually termination. She said she really had no answer as to why this incident was not determined to be substantiated physical abuse.
During the same interview, S2AsstCEO reported when an employee is to be terminated, a letter is sent to inform the employee that they can come in to discuss their termination with the Administrator. She indicated S6CGT, who had struck Patient #1, had chosen to resign in lieu of being terminated and had not met with the Administrator. S2AsstCEO indicated based upon the details of S16CGT throwing a blood pressure cuff and striking Patient #3 in the chest with it. She said she would have to see the case notes to try to determine why a physical abuse allegation wasn't substantiated.

In an interview on 08/17/2022 at 2:00 p.m. with S1CEO, she indicated there had been inconsistencies with determination of substantiated abuse as observed with the review of the video recordings of incidents involving staff and Patients #1 and #2. She reported employees are now placed on administrative leave until APS finishes their investigation, the findings are reviewed, and a final decision is made. She indicated, in general, her understanding is there is a decision tree HR has on file and it is used to determine what course of action should be taken. She indicated in an allegation of abuse, there is no option for disciplinary action for a temporary status employee, they are terminated. She reported for abuse that is substantiated the permanent employee tree is dismissal unless there is evidence that the employee can provide to plead their case.

Based on record review and interview the hospital failed to implement policies and procedures to ensure 100 % of staff are fully vaccinated for COVID-19 or have a medical, religious, or medical delay exemption. This deficient practice was evidenced by failure to maintain documented evidence of vaccination status for all employees for 3 (S21Dietary, S22Dietary, S23Dietary ) of 10 (S7Cook, S21Dietary, S22Dietary, S23Dietary, S25RN, S26Dietary, S27Aide, S28RN, S29MD, S30CGT) sampled personnel records reviewed for COVID-19 vaccine status.

Findings:

In an interview on 08/17/2022 at 12:00 p.m., during review of the employee COVID -19 vaccine documentation, S24IC confirmed she had no documentation of current COVID-19 vaccination status for S21Dietary, S22Dietary, and S23Dietary. She reported the referenced employees were contracted dietary staff. She further reported she had requested COVID-19 vaccination information for the referenced employees and had not received that information as of 08/17/2022.

In an interview on 08/17/2022 at 3:00 p.m. with S3QA, prior to survey team exit, she verified there was still no documentation of current COVID-19 vaccination status for S21Dietary, S22Dietary, and S23Dietary.