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Based on record review and interview, the hospital failed to ensure that patients have the right to care in a safe setting as evidenced by staff failing to continuously observe Patient #1, who was on line of sight observation level, and as a result, the patient was touched inappropriately by another patient. The hospital failed to ensure that after this incident, all staff were re-educated on the proper procedures for line of sight observations in order to prevent future occurrences.
Findings:

Review of the hospital policy and procedure titled Precautions and Level of Observation Procedures, revealed in part that a line of sight observation level is when the patient is in view of staff at all times.

Review of the LDH Abuse/Neglect Initial Report, dated 11/17/2023, revealed in part that on 11/16/2023, another patient reported to S1MHT that Patient #1 (who was on line of sight observation level) and another patient were being inappropriate under the dayroom table. The report further revealed that after investigating the incident and reviewing video footage of the date 11/16/2023, it was revealed that S1MHT was assigned to watch Patient #1 at all times but was observed on video to have his back to the patients in the day room. During the time S1MHT's back was to the patients, another patient was observed to be touching Patient #1 under her shorts for less than 15 seconds. The report further revealed that patient neglect was substantiated due to the patients engaging in inappropriate behavior at the dayroom table while not being observed by S1MHT. The report further stated that all staff was in-serviced on line of sight observations.

S4Administrator provided an inservice sign-in sheet dated 11/17/23. Review of this sign-in sheet revealed that S2DON educated staff on "precautions/line of sight". Review of the staff signatures on the sign in sheet compared to the staffing schedule from 11/17/2023 to present revealed that 7 of 13 MHTs and 5 of 9 nurses who had been working with patients, including patients on line of sight observation levels, had not received any re-education on line of sight observation level.

On 11/27/2023 at 1:50 p.m., S3MHT was asked by the surveyor if she had received any education in the past month regarding observation levels and she stated no.

On 11/28/2023 at 3:00 p.m., interview with S4Administrator confirmed there was no other documentation of staff re-education that could be provided. S4Administrator confirmed that all staff who had been working since the incident with Patient #1 on 11/16/2023, had not been re-educated on the proper procedures for line of sight observations.