HospitalInspections.org

Based on record review, hospital policy and staff interview, the hospital failed to ensure an effective grievance process was in place. The deficient practice is evidenced by the facility failing to identify an adolescent patient's guardian's grievance for 1 (#5) of 5 (#1-#5) sampled patients.
Findings:

Review of the policy and procedure titled, "Grievance, Patient" last revised in July 2022 revealed, in part, the facility will provide an effective mechanism for handling patient/family grievances as an important part of providing quality care and service to our patients. A grievance is considered resolved when the patient is satisfied with the actions taken on his/her behalf or if hospital has taken appropriate and reasonable action and followed the CMS/State required processes. Definitions: A patient grievance is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with CMS Hospital Conditions of Participation.

Review of the facility's Incident Report Form revealed, in part, on 08/20/2022 at 4:00 p.m., Patient #5's guardian was contacted to advise him of his daughter's, Patient #5's sexual encounter with Patient #3.

Review of the hospital's complaint/grievance log revealed no grievance had been initiated for the above mentioned incident.

In interview on 09/01/2022 at 2:42 p.m., S2RM indicated when she spoke with patient #5's guardian, he was upset about what happened to his daughter and she failed to document this as a grievance. S2RM further indicated that this should have been processed as a grievance.

Based on medical record reviews, policy reviews and interviews the hospital failed to provide care in a safe setting. This deficiency is evidenced by failure of the hospital to perform timely rounds for 2 (#3, #5) of 5 (#1-#5) patients sampled resulting in the 2 (#3, #5) patients to have sexual intercourse.
Findings:

Review of the program description and services offered by the hospital revealed Patient #3 and Patient #5 were assigned to Unit 'a'. Further review revealed on unit 'a', patients will receive 24/7 care.

Review of the Unit 'a' schedule revealed bed time was scheduled between 9:30 p.m. and 10:00 p.m. Further review revealed lights out was scheduled for 10:00 p.m.

Review of the policy and procedure titled, "Observation, Patient" last revised in July 2022, revealed, in part, in order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner or initiated by the nurse. Procedure: The physician will order one of three levels of observation at time of admission and as the patient's condition warrants a change: 15 minute check, 5 minute check and one-to-one. The physician may also order a precaution level of observation for Suicide and Sexual Acting out.

Review of Patient #3's medical record revealed he was a 16 year old admitted to unit 'a' under a Physician's Emergency Certificate on 08/10/2022 at 8:59 p.m. Further review revealed Patient #3 was treatment planned for depressed mood, suicidal ideation and was placed on suicide precautions with every 5 minute observation rounds for safety.

Review of Patient #5's medical record revealed she was a 16 year old admitted to unit 'a' under a Physician's Emergency Certificate on 08/18/2022 at 1:48 a.m. Further review revealed Patient #5 was treatment planned for depressed mood, suicidal ideation and was placed on suicide precautions with every 5 minute observation rounds for safety.

Review of the Incident Report Form revealed on 08/18/2022 at 11:45 p.m., Patient #3 was found in the room of Patient #5. Further review revealed both patients admitted to having sexual intercourse in Patient #5's room.

In interview on 09/02/2022 at 7:05 a.m., S5BHA indicated she was assigned to unit 'a' on the night shift of 08/18/2022. S5BHA recalled there were admits to the unit and while S4RN was processing one of the admits, S5BHA was conducting rounds, taking out the trash and cleaning the unit. S5BHA indicated S4RN did an observation round prior to the incident. S5BHA indicated that she did the round behind S4RN and this is when she found Patient #3 in Patient #5's room. S5BHA indicated Patient #3 was in Patient #5's room "no longer than 10 minutes". S5BHA indicated Patient #3 and Patient #5 were on every 5 minute observation rounds, but could not comment on how Patient #3 and Patient #5 were in the room long enough to have sexual intercourse.

In interview on 09/02/2022 at 7:15 a.m., S4RN indicated she was assigned to unit 'a' on the night shift of 08/18/2022. S4RN indicated she did an observation round on Patient #3 and Patient #5 prior to the incident and then assessed a new admit in the dayroom. S4RN further indicated "Patient #3 couldn't have been in patient #5's room any longer than 10 minutes". S4RN verified Patient #3 and Patient #5 were ordered every 5 minute observation rounds, and commented that it was a busy shift where she had 2 admits and 1 discharge.

Review of the every 5 minute observation rounds for Patients #3 and #5 revealed that on 08/18/2022 S4RN did not document any rounds prior to or after 11:45 p.m.

In interview on 09/02/2022 at 12:22 p.m., S3CNO verified that during the hospital's investigation, they identified issues with the timeliness of the observation rounds since the patients had time to have sexual intercourse.

Based on record review and interview, the hospital failed to be in compliance with state law as evidenced by failure to report a critical incident to the Louisiana Department of Health involving 2 patients (#3, #5) of 5 (#1 - #5) patients record reviewed.
Findings:

Review of the policy and procedure titled, "Required Reporting - State of Louisiana" most recently revised in 07/2022 revealed, in part, the hospital will follow the State of Louisiana's Revised Statutes required reporting of the following: Abuse/Neglect. Procedure: Allegations of Abuse/Neglect must be reported immediately to the Risk Manager or Administrator on Call ; b. Any allegations of abuse/neglect must be reported within 24 hours of receiving knowledge of the allegation to the respective agencies associated with the LDH; c. 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. D. Additionally, a "Hospital Abuses Neglect Initial Report" must be emailed to hsshospitalself-reports@la.gov via an encrypted/secure email within 24 hours of awareness of the incident/allegation/suspicion. F. The patient advocate will also be contacted to initiate the grievance process in accordance with CMS 482.13, which requires that an allegation of abuse or neglect must also be reported as a grievance, regardless of whether the complainant recants the allegation or expresses satisfaction with resolution. G. The CEO and or designee will contact LDH to insure that the report was received and to provide any applicable additional information. H. The facility will complete and submit a final investigative report to LDH within 5 working days of the initial report submission.

Review of the policy and procedure titled, "Risk Management Incident Reporting" revealed, in part, an "incident" is an unanticipated event which results in, or nearly causes, a negative impact on patient care or visitor safety. Any harm caused can be temporary, long-term, or permanent and range in severity from no obvious or significant injury up to death. 5.4 The facility Risk Manager or Designee will notify appropriate agencies of reportable incidents as required i.e., State Agency. 6.0 Incident Type Categorization: 01. Patient Care/Treatment: Incidents involving a patient while they are actively participant in treatment that can or does cause harm or disruption. 04. Sexual Intercourse 04b. Patient/Patient. 7.0 Severity Level Classification: In states where the facility is required to report certain adverse events to an outside regulatory agency, it must be done within State agency requirements with notification of such external reporting obligations to Corporate Risk Management and Corporate Quality and Compliance. 7.3. The following severity level classifications shall be assigned in incident reporting: 7.3.1. Level I (Major): Incidents which are considered serious events. This may include sentinel events.

Review of the facility's Incident Report Form completed on 08/19/2022 with supplemental documentation attached revealed, in part, on 08/18/2022 at 2345, Patient #3 and Patient #5 who were both minors and on 5 minute observation rounds, admitted to having sexual intercourse in Patient #5's room.

In interview on 09/01/2022 at 2:42 p.m., S2RM indicated she failed to report the incident to the Louisiana Department of Health (LDH).

Based on personnel record review, policy review and interview, the hospital failed to ensure the Quality Assurance Performance Improvement (QAPI) program implemented preventive actions for the timeliness of observation rounds to prevent sexual encounters between patients. This deficient practice was evidence by failure to implement effective monitoring of every 5 minute observation rounds following a sexual encounter between 2 (#3, #5) of 5 (#1-#5) patients sampled.
Findings:

Review of the hospital's organizational chart revealed S2RM was charged with the functions of Risk Management and Performance Improvement.

Review of S2RM's Job Description revealed an essential function of monitoring and analyzing program performance to determine program effectiveness and identify opportunities for improvement. Further review revealed to delegate and support the QAPI and risk management activities of department directors to ensure desired, department-related outcomes for patient care and safety.

Review of the policy and procedure titled, "Process Improvement Program" revealed, in part, the hospital is dedicated to providing measurement-based, quality care and services for all patients in a safe, clean and therapeutic environment. The hospital fulfills its responsibilities to patients, professionals, support staff, and the community through continuous and systematic measurement, assessment, and improvement of its systems and processes.

In interview on 09/02/2022 at 9:05 a.m., S2RM indicated the hospital's QAPI program did not implement any additional monitoring of observation rounds following the adverse incident involving patients #3 and #5.
The hospital staff was unable to provide any evidence of additional tracking, monitoring or analyzing of data following the adverse event on 08/18/2022 between Patient #3 and Patient #5.

Based on policy review, review of daily assignment sheets and interview, the hospital failed to ensure the Registered Nurse assigned the nursing care of each patient to other nursing personnel in accordance with the patient's needs. This deficiency is evidenced by failure to have evidence of assignments made and failure to complete the assignment sheets as per policy and procedure.
Findings:

Review of the policy and procedure titled, "Assignment of Nursing Staff" revealed, in part, to assure quality nursing care and a safe patient environment, nursing personnel staffing and assignments are based on at least the following, in part: The assignment sheet is to be forwarded to the Chief Nursing Officer (CNO) at the end of each shift; The staffing assignment sheets will be reviewed and maintained by the CNO.

Review of the job description for the CNO revealed, in part, develop and maintain documentation systems for continuity of care and record storage that assures compliance with local, state and federal regulations as well as facility policies and procedures; Develop and implement tools to measure, assess and improve quality of nursing care, treatment and services; Oversee nursing services documentation to ensure it meets all standards.

Review of the job description for the Registered Nurse (RN) revealed, in part, provide and coordinate care by assessing physical and behavioral health needs of patient, develop and implement nursing care plans, maintain medical records; Provide direction or coordinate the activities of the unit as directed.

Review of the job description for the Behavioral Health Associate (BHA) revealed, in part, responsible for conducting safety rounds and ensuring that supervision is conducted at 15 minute intervals, as noted in special precautions, or in accordance with individualized supervision guidelines as needed.

Review of the assignment sheet for the night shift of 08/18/2022 for unit 'a' revealed no assignment sheet for this shift.
In interview on 08/02/2022 at 8:35 a.m., S3CNO indicated there was no staffing assignment sheet available for the night shift beginning at 7:00 p.m. on 08/18/2022.

Review of the subsequent Unit 'a' assignment sheets and computerized daily staffing reports for the day and night shifts revealed the following deficiencies:
08/21/2022 - No assignments by the RN to the 3 BHAs;
08/22/2022 - The RN assigned the same patients to 2 BHAs;
08/23/2022 - No assignment sheet for the day shift (7:00AM - 7:00PM);
08/24/2022 - No duties checked as assigned for the day and night shift BHAs;
08/25/2022 - No duties checked as assigned for the day and night shift BHAs and no patients assigned on the night shift to the RN or BHAs;
08/26/2022 - No duties checked as assigned for the day and night shift BHAs and no documentation of patients assigned to the RN on the night shift;
08/27/2022 - No BHA's signatures assigned to patients on the night shift;
08/29/2022 - No duties checked as assigned for the day and night shifts for BHAs and no patients assigned on the night shift to the RN or BHA;
08/30/2022 - No duties checked as assigned for the day and night shifts for BHAs and no patients assigned on the night shift to the RN or BHAs;
08/31/2022 - No duties checked as assigned for the day shift for 1 of the BHAs;
09/01/2022 - No duties checked as assigned for 1 of the 3 day shift BHAs and no duties checked as assigned for the 1 night shift BHA and no signature of the BHA.

In interview on 08/02/2022 at 12:22 p.m., S3CNO verified the insufficient documentation related to the Registered Nurse's assignments of patient care noted above.