HospitalInspections.org

30984

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 within 24 hours of awareness of the allegation, as required by LDH-HSS, for 5 (#3, #4, #6, #7, #8, ) of 7 patients reviewed for self-reports to LDH-HSS from a total patient sample of 10.

Findings:

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.

Review of the hospital policy titled, "Alleged Patient Abuse, Neglect, Exploitation", Policy Number RI.018, revealed the following, in part: Policy: To provide a safe, therapeutic environment of care includes the prevention of patient to patient sexual incidents.
Definitions: Sexual Intercourse: Oral, vaginal, or anal penetration or fondling of the patient's sex organs by another individual's hand, sex organ, or object.
Notification: Person discovering the incident/event: notify the Charge Nurse/Unit Supervisor and/or CNO/Charge Nurse. Attending Psychiatrist, Administrator/On call, and Facility Risk Manager.
Risk Manager/Designee: Notify State Agencies, as required by State Statutes, as well as managed care companies, as required by provider requirements.

Patients #3 and #4
Review of the self-report for Patients #3 and #4 revealed the patients reported on 11/05/2021 that staff pulled them out of their beds and put them in the hallway. Further review of the report revealed the self-report had been submitted to LDH-HSS on 11/8/2021 which was 3 days after the hospital became aware of the alleged abuse.

Patient #6
Review of the self-report for Patient #6 revealed the patient reported on 11/3/2021 that a MHT had pushed him and cursed him after he made some inappropriate statements to her on 10/29/2021. Further review of the report revealed the self-report had been submitted to LDH-HSS on 11/8/2021 which was 5 days after the hospital became aware of the alleged abuse.

Patients #7 and #8
Review of a self-report involving Patients #7 and #8 revealed the patients had sexual intercourse in Patient #8's room. Patient #8 reported the sexual encounter to hospital staff on 11/09/2021. Further review of the report revealed the self-report had been submitted to LDH-HSS on 11/12/2021 which was 3 days after the hospital became aware that Patients #7 and #8 had engaged in sexual intercourse.

In an interview on 12/15/2021 at 10:15 a.m. with S2DCS, she confirmed the self-reports referenced above had not been submitted within 24 hours of the hospital becoming aware of the incidents. She indicated she had thought weekends did not count in the required reporting time-frame when submitting self-reports of alleged abuse/neglect incidents to LDH-HSS.

Based on record reviews, observation, and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient as evidenced by:

1. failing to ensure elopement mitigation protocols were followed after breaches in those procedures contributed to adolescent patients ( # , #10) being able to elope from the hospital for 2 ( # 5, #10) of 5 sampled adolescent patient records reviewed from a total patient sample of 10; and

2. failing to ensure a patient in monitored according to the hospital's Safety Rounds Procedure policy for 1 (#5) of 5 sampled adolescent patient records reviewed; and

3. failing to ensure patients' ordered precautions were documented on the patients' Observation/Rounds/Precautions forms for 3 ( #5, #7, #8 ) of 10 total sampled patient records reviewed;

Findings:

1. Failing to ensure elopement mitigation protocols were followed after breaches in those procedures contributed to adolescent patients being able to elope from the hospital.

Patient #10
Review of Patient #10's medical record revealed the patient was a 16 year-old male with an admission date of 10/23/2021 with admitting diagnoses of Disruptive Mood Dysregulation and Conduct Disorder. Further review revealed the patient's admit status was Voluntary admission due to suicidal ideation with a plan to cut wrists using a spoon while being held in Juvenile Detention Center custody. The hospital received a report that Patient #10's charges were burglary with simple escape.

Review of the hospital's incident reports revealed Patient #10 had eloped on 10/31/2021. Review of the hospital's investigation revealed the following description of the event: The patients were on their way to the cafeteria for lunch. S5RN was at the front of the line and a female RN was at the end of the line of 22 adolescent male patients. As they approached the cafeteria door, the male RN opened the door and that was when he heard lots of noise and discovered that the entire panel of the bottom of the PsychSafe door had been kicked out and that Patient #10 had eloped. The female RN at the end of the line was yelling for him to stop but it was only 3 rapid kicks, and the pane was kicked out of the door allowing the patient to escape. The male RN secured the patients and made sure that they were in cafeteria by conducting a roll call and paging overhead for additional assistance. S3RN was on the scene and maintaining security of the broken glass and safety the patients as the male RN looked for the patient outside. They saw him running on one of the streets that bordered the hospital.

Review of a RCA performed regarding Patient #10's elopement revealed an issue identified was failure of the staff to have a walkie-talkie with them during transport of the patients to the cafeteria (which was part of the elopement risk protocols to be used when walking patients to and from the unit). Further review revealed there were also no phones in the hallway or in the stairwell; therefore there was no immediate way to alert the hospital of the elopement.

On 12/15/2021 at 8:00 a.m., an observation was conducted of 20 male adolescent patients being walked from the cafeteria back to the adolescent unit after breakfast. S5RN, S6MHT, and S7MHT were accompanying the patients as they walked through the hall towards the exit doors. Further observation revealed the staff was not carrying a walkie-talkie as required as part of the procedure for walking the patients to the cafeteria and back to the adolescent unit. S3RN was present during the observation, accompanying the surveyor, and answering questions regarding the procedure for movement of the patients from the adolescent unit, to the cafeteria, and back to the unit. S3RN verified she had not seen the staff carrying a walkie-talkie and further verified they should have had one as part of the procedure for walking the adolescents to and from the cafeteria.

In an interview on 12/14/2021 at 4:00 p.m. with S1CNO, she reported when transporting patients you should visualize all patients, do a head count, perform a roll call, and staff should have a walkie-talkie with them as part of the patient transport protocol for mitigation of elopements.

In an interview on 12/15/2021 at 9:43 a.m. with S6MHT, he reported the process for bringing the adolescent boys to the cafeteria was as follows: The boys are lined up on the unit before they leave, roll call roll is performed, they visualized the patients and performed a count before leaving unit. He said they grab a radio before they begin walking the patients down to the cafeteria. S6MHT explained there is 1 staff member in front of the line, 1 in the middle, and 1 at the back of the line. S6MHT reported the hospital's maze-like hallways could lead to losing track of the patients while they were being walked to the cafeteria. He said he didn't have the walkie-talkie radio and thought S5RN had the walkie-talkie radio during breakfast this morning.

In an interview on 12/15/2021 at 11:48 a.m. with S5RN Charge Nurse on the Adolescent Boys Unit, he confirmed he had escorted the male adolescent patients to breakfast this morning (12/15/2021) and also confirmed he had been present when Patient #10 had eloped from the hospital on 10/31/2021. He reported he leads and controls the pace of flow when bringing the male adolescent patients to the cafeteria. He confirmed they carry a walkie-talkie as part of the protocol for walking the patients when they are off of the unit. He indicated he thought the MHTs had the walkie-talkie this morning during breakfast and confirmed he had not been carrying it.

2. Failing to ensure a patient in monitored according to the hospital's Safety Rounds Procedure policy.

Review of the hospital policy TX.064 titled "Safety Rounds/Accountability" revealed in part:
I.POLICY: It is the policy of the hospital to provide a safe, secure environment for our patients by ensuring accountability for their well-being. Il.PROCEDURE: Guidelines for monitoring all hospital patients are as follows:
SAFETY ROUNDS PROCEDURE: Intake starts patient observation/ monitoring upon arrival to intake area to prevent self-harm, worsening of their condition, elopement, etc. Intake conducts direct visual monitoring at a minimum of every 15 minutes. Intake documents handing off rounds sheets to unit staff. 2. The staff assigned to each patient will keep an individual patient round sheet which will be documented on every 15 minutes, beginning with the admissions process. Staff will physically go and visualize the patient. Business office (intake for after hour admissions) will print 10 copies of the 15 minute close observation sheet with the patient's picture embedded on it, along with a picture for the initial observation sheet.

Review of Patient #5's observation/rounds/precautions form dated 11/14/2021 with observation for suicide, behavioral, cognitive, violence precautions and elopement failed to reveal documented observations from 3:00 p.m. through 10:15 p.m.

In an interview on 12/15/21 at 10:21 a.m., S2DCS reviewed Patient #5's medical record and confirmed the findings.

In an interview on 12/15/2021 at 10:30 p.m., S1CNO reviewed Patient #5's medical record and acknowledged there was no documented evidence of observations from 3:00 p.m. through 10:15 p.m.

3. Failing to ensure patients' ordered precautions were documented on the patients' observation/rounds/precautions forms.

Patient #5
Review of Patient #5's medical record revealed a 10/30/2021 7:00 p.m. telephone order with a start time for Elopement Precautions at 7:00 p.m. with no stop time noted. Review of the Observation Rounds Precautions 15 minute check list failed to reveal the Elopement precaution was denoted and documented for 10/312021 and 11/01/2021.

In an interview on 12/15/2021 at 10:20 a.m., S2DCS reviewed Patient #5's medical record and confirmed the findings.

Patient #7
Review of Patient #7's medical record revealed a physician's order dated 11/08/2021 placing Patient #7 on suicide, behavioral, cognitive, elopement risk, fall risk, seizure, and violence precautions. Further review revealed the patient was placed on sexually acting out precautions on 11/09/2021 after he engaged in sexual intercourse with a female peer (Patient #8).

Review of Patient #7's Observation/Rounds/Precautions form, dated 11/08/2021, revealed staff members providing supervision of Patient #7 failed to document the ordered precautions for suicide, fall, and elopement on the observation/rounds/precautions form.

Review of Patient #7's Observation/Rounds/Precautions form, dated 11/09/2021 and 11/10/2021, revealed staff members providing supervision of Patient #7 left the section blank, failing to indicate any of the patients ordered precaution types.

Patient #8
Review of Patient #8's medical record revealed a physician's order dated 11/09/2021 placing Patient #8 on sexually acting out precautions after she engaged in sexual intercourse with a male peer (Patient #7).

Review of Patient #8's Observation/Rounds/Precautions forms, dated 11/09/2021 - 11/12/2021, revealed sexually acting out precautions were not chosen as ordered precautions, by unit staff performing supervision of the patient, when the observations were documented.

In an interview on 12/14/2021 at 3:00 p.m. with S8RN charge nurse, she confirmed RNs reviewed patients' Observation/Rounds/Precautions forms for accuracy and signed off on them every 4 hours. She further confirmed LPN staff did not review and sign off on patients' observation records.

In an interview on 12/14/2021 at 4:00 p.m. with S1CNO, she confirmed the patients' ordered precautions should have been documented on the patients' Observation/Rounds/Precautions forms, by unit staff performing supervision of the patient, when the observations were documented.