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Based on record review and interview the hospital failed to report all cases of possible abuse and neglect to the licensing authority within 24 hours of awareness of the allegation. The deficient practice is evidenced by failure of the hospital to notify the Louisiana Department of Health of an attempted suicide in the Behavioral Health Emergency Department.
Findings:

Review of Policy #5228, "Management of High-Risk Patients Levels of Observation," last reviewed 02/2022, revealed in part, "Policy Statement: . . .Patients who are identified as high risk due to behaviors, diagnosis, and/or physical conditions, or are being held without consent on an Emergency Certificate or Judicial Commitment shall be placed on levels of observation appropriate to maintain their safety. One example of a patient that is identified as high-risk would be an individual that has attempted or expressed the desire to commit suicide or to self-inflict injury. As indicated by physician' orders, these patients shall be monitored closely by an assigned staff member to ensure the patient's safety and security. Although a physician's order is required, specifying the level of observation, a registered nurse may increase a level of observation to ensure patient safety, pending an order."

Review of the medical record for Patient #1 revealed she was brought to the hospital on 09/21/2024 at 6:11 a.m. by police after calling 911 after endorsing suicidal ideations with an attempt. The patient attempted to slit her wrists and was noted to have bilateral superficial wrist lacerations with no active bleeding at the time of presentation. The Chief Complaint was listed as "Suicidal." An initial suicide screen was performed on 09/21/2024 at 6:13 a.m. revealed the patient answered yes to the following questions from the Columbia Suicide Severity Rating Scale: 1) "Have you wished you were dead or would go to sleep and not wake up; 2) Are you had any thoughts about killing yourself; 3) Have you thought about how you might do this?

Further review of the medical record revealed she was initially evaluated in the emergency department by a physician at 6:22 a.m. who documented at 6:28 a.m., "Patient #1 is a 38 year old with past medical history of schizoaffective disorder here with chief complaint of suicidal ideations. Patient reports plan to hang herself. She reports that she witnessed a murder and no one believes her. Reports auditory hallucinations. Also reports homicidal ideations towards, 'those bitches who were doing the killing.' She reports she has been off her medication for the last few days." The physical examination documented, "Thought Content: thought content is delusional. Thought content includes homicidal and suicidal ideation. Thought content includes suicidal plan."

After Patient #1 was medically cleared, she was sent to the Behavioral Health Emergency Room on 09/21/2024 at 6:23 a.m. The Columbia Suicide Severity Rating Scale was repeated at 6:31 a.m. and Patient #1 responded "No" to Question #1, "Have you wished you were dead or would go to sleep and not wake up; and she responded "No" to Question #6, "Have you done anything, started to do anything or prepared to do anything to end your life?"

Review of the nursing note from 09/21/2024 at 6:31 a.m., revealed "Patient arrives to the unit. Calm and cooperative. Flat and withdrawn. Upon her arrival the patient states, 'A boy was murdered and no one believes me.' Patient appears paranoid. Speaks at a low whisper and stares intensely at hospital police. Patient has limited engagement with nursing staff. Just stares towards the wall when questions are asked."

Review of the nursing note from 09/21/2024 at 11:21 a.m. revealed, "Patient attempting to wrap her socks and other clothing around her neck. Patient given a PRN medication. And now in direct observation."

Review of the orders revealed no order for level of observation was placed at the time of transfer to the Behavioral Health Emergency Department. After the incident, an order was placed for one-to one observation.

In interview during the record review on 10/21/2024 between 2:20 p.m. and 3:30 p.m., S5RN verified there were no orders for level of observation at the time she was brought on the unit for evaluation and explained that routine level of observation was every 15 minutes and orders were only placed if the patient required a higher level of observation. The surveyor questioned why a patient who had slit her wrists in a reported suicide attempt at home would not have been considered high risk for suicide and placed on line of sight or one-to-one observation at the time she was admitted. S5RN and S3DPSQ both verified Patient #1 was not considered high risk by the staff at that time and routine observation was appropriate and followed hospital policy.

Review of the incident report revealed a statement a provided by the behavioral health tech assigned to Patient #1. The tech documented she was working with another patient when she was notified by security that Patient #1 was shirtless in her room. The tech returned to the room to find the patient sitting on the floor with yellow hospital socks tied around her neck loosely. The tech tried to remove the socks, the patient resisted, but with the help of security the socks were removed. The patient was examined and found to be unharmed and was placed on one-to-one observation at that point.

Further review of the incident report revealed the first Follow-Up Action documented was a chart review by S6RN on 09/22/2024 at 3:57 p.m. The next documented Follow-Up Actions were a sign-off by S5RN on 09/23/2024 at 8:28 a.m., "work done on file" by S6RN on 09/23/2024 at 1:52 p.m. and then her sign-off on 09/23/2024 at 1:56 p.m., and a sign-off by S4RN on 09/30/2024 at 11:45 a.m.

In interview on 10/22/2024 at 11:09 a.m., S10RM verified the incident was not reported to the licensing authority within 24 hours of awareness, as required for all possible cases of neglect or abuse, because it was determined that there was never any concern about the quality of care provided. S10RM verified that she had consulted with nursing and legal staff and they determined it did not meet the requirement for reporting because all hospital processes were performed according to hospital policy. S10RM verified the investigation documented in the incident report, which began on 09/22/2024 at 3:57 p.m., was only performed because reviews are required for all incidents.

Based on record review and interview, the hospital failed to recognize opportunities for improvement and initiate changes to ensure compliance. The deficient practice is evidenced by failure of the hospital to initiate changes and monitor for compliance after staff failed to immediately initiate an incident report after an allegation of sexual abuse was made against a member of the Behavioral Health Emergency Room staff.
Findings:

Review of Policy #5999, "Communication for Patient Safety Events," last reviewed 12/2021, revealed in part, "B. Sentinel Event: A "sentinel event" defined by The Joint Commission as a patient safety event (not primarily related to the natural course of the [patient's] illness or underlying condition) that reaches a [patient] and results in death, severe harm (regardless of duration of harm), or permanent harm (regardless of severity of harm). . . An event is also considered sentinel if it is one of the following: . . . 8. Sexual abuse/assault of any patient while receiving care, treatment, and services while on site at the organization/ facility or while under the supervision/care of the organization. . . . C. Never Events or Serious Reportable Events . . . C. vii. Criminal Events . . . 3. Sexual abuse/assault on a patient within or on the grounds of a health care setting." Further review revealed, "SECTION III: RESPONSE TO A PATIENT SAFETY EVENT . . . 1. Any potential sentinel event, never event, or serious safety event shall be immediately reported to the designated person or person(s) within the hospital in accordance with that Hospital's policies and procedures. 2. The designated person or person(s) within the Hospital who was originally alerted to the incident or his/her designee is responsible for immediately notifying the following via telephone within twenty-four (24) hours of the discovery of the event: 1) Hospital's President & CEO and 2) LCMC Health's President of Clinical and System Operations."

Review of the incident initially reported to Louisiana Department of Health on 09/04/2024, and the final report which was submitted on 09/18/2024, revealed S13RN reported to S6RN on 08/14/2024 that she saw S14RN grab a patient by the genitals in an effort to subdue the patient. S13RN was unable to provide S6RN with the date of the incident or the name of the patient who was abused. Both S13RN and S6RN failed to start formal report of the accusations in the BSafe reporting system at that time. S6RN began an investigation and on 09/04/2024, S8HRD became aware of the investigation and immediately initiated documentation and began a proper investigation of the allegation including the notification of Louisiana Department of Health.

In interview on 10/21/2024 between 1:38 p.m. and 1:57 p.m., S8HRD verified that hospital policy for reporting had not been followed. S8HRD said she was never given a clear explanation as to why the incident was not immediately reported in the BSafe system (the system used by the hospital to report patient safety issues or concerns), but said that during her interviews with S13RN, S6RN, S11RN, S12RN and S15UC she emphasized that the system should be used and would result in thorough and fair investigations. S8HRD verified she was not aware of any formal re-education after the incident and was not aware of any monitoring for compliance.

In interview on 10/21/2024 at 2:07 p.m., S4RN verified S6RN came to him with the allegations but he did not know the date, only that it was sometime before 09/04/2024, because that is the date he went out on a vacation. S4RN verified he did not feel it was right to initiate a BSafe report at that point because there were no facts to support the allegation. S4RN informed the surveyor that S6RN was out of the country and not available for interview. S4RN verified there had been no re-education on the reporting of allegations of abuse or neglect since he was back and stated he was not sure if the staff had been re-educated while he was out. S4RN explained he returned from vacation on 09/26/2024 and S6RN went out shortly after he got back, and they never really had time to discuss the matter. S4RN was informed that the surveyor would be onsite another day and he was encouraged to bring any information related to education after the event.

There was no additional information provided to the surveyor prior to the exit conference on 10/22/2024 at 11:40 p.m.

Based on record review and interview, the hospital failed to recognize patient safety issues through the Quality Assurance and Performance Improvement (QAPI) review process. The deficient practice is evidenced by failure of hospital to identify deviations from hospital policy for reporting safety events and deviations from CMS guidelines after deployment of pepper gel to detain an eloped patient on a public sidewalk.
Findings:

Review of Policy Number 10.01, "Public Safety: Use of Control," last reviewed 09/2024, revealed in part:

Types of Control/Applications
1. Warning- whenever possible members shall exercise persuasion, advice, and/or warning of impending use of control. Warnings need not specify the type or amount of control to be applied and need only indicate that appropriate control will be utilized if compliance is not obtained. However, members are not expected to place themselves or others in jeopardy in order to deliver such warnings, and if a warning is ineffective, appropriate control should be used to effect the arrest.
2. Weaponless Control Techniques:
a) Non-Impact Methods- firm grip and pain compliance techniques designed for subject come-a-longs. When verbalization proves ineffective, a firm grip and/or pain compliance control methods may be all that is necessary to overcome a subject's resistance.
b) Oleoresin Capsicum [pepper gel] to stop aggressive or combative behavior.

Further review of policy Number 10.01 revealed in part:

Levels of Control . . . .
5. Level 2 uses of control include use of Oleoresin Capsicum; . . .
[and]
Use of Control Investigations . . .
3. For all level 2 and 3 uses of control, the investigating supervisor shall:
a. Respond to the scene, examine the subject of the control for injury, interview the subject for complaints of pain after advising the subject of his/her rights, and ensure that the subject receives appropriate medical attention.
b. Notify the Operations Commander, and Deputy Director of Public Safety immediately. . . .

Review of Policy #5999, "Communication for Patient Safety Events," last reviewed and revised 12/2021, revealed in part, "Policy: Section I: . . .B. Sentinel Event: A "sentinel event" defined by the Joint Commission as a patient safety event (not primarily related to the natural course of the [patient's] illness or underlying condition) that reaches a [patient] and results in death, severe harm (regardless of the duration of harm), or permanent harm (regardless of severity of harm) . . .An event is also considered sentinel if it is one of the following: . . .6. An elopement (that is, unauthorized departure) of a patient from a staffed around-the-clock setting (including the ED), leading to death, permanent harm or severe temporary harm to the patient."

Further review of Policy #5999 revealed, "Section II: Comprehensive Systemic Analysis, Corrective Action Plan and Staff Recovery- LCMC is expected to identify and respond appropriately to all sentinel events occurring in its Hospitals . . . appropriate response to a sentinel event, never event, and an HPI classified Serious Safety Event includes completion of a comprehensive systemic analysis for identifying the causal and contributory factors. . . . Each hospital shall prepare a through and credible comprehensive systemic analysis and corrective action plan within forty-five (45) business days of the event or of becoming aware of the event."

Review of the medical record for Patient #2 revealed he presented to the emergency department on 09/23/2024 at 4:06 a.m. with complaints of auditory hallucinations telling him to harm himself but he denied suicidal ideation. Patient #2 reported that he had been recently discharged from a local inpatient psychiatric facility. At 4:26 a.m., after being informed that he would be placed under a Physicians Emergency Certificate (PEC), the patient grabbed his luggage and proceeded to leave. He could not be stopped by medical staff, and he was closely followed by staff as he exited the emergency department. The patient was intercepted outside of the hospital, sprayed with pepper gel and returned to the emergency department. Patient #2 was medically cleared and then observed for several hours. The patient was seen by a psychiatrist on 09/23/2024 at 11:55 a.m. The psychiatrist recommended that the PEC be rescinded. Patient #2 was determined to not be a danger to self, nor to others, and was not gravely disabled. Patient #2 was discharged on 09/23/2024 at 11:58 a.m.

Review of the report submitted to the licensing authority on 09/24/2024, as the initial and final investigation report, revealed on 09/23/2024 at 4:58 a.m. Patient #2 eloped from the hospital as medical staff were in the process of initiating a Physicians Emergency Certificate (PEC). The nurse who was assigned to the patient did try to block the triage exit, but the patient threatened her stating, "move out of my fucking way before I beat your ass up." The nurse then followed him out and notified police. Video review confirmed the patient was seen exiting the emergency department with his suitcase followed by two nurses, a contracted security officer and a directly employed security officer. The video also showed the patient being intercepted by a hospital patrol car which pulled up at the base of the ramp. The report then documented, "De-escalation efforts by hospital security officers were unsuccessful and the patient began to threaten the officers. The officers deployed pepper gel. The patient was then escorted back to the emergency department." The investigation concluded, ". . . the staff reacted quickly and appropriately. There were no processes broken and the patient was escorted back to the emergency department and was transferred to the behavioral health emergency room for further evaluation."

In interview on 10/22/2024 at 8:20 a.m., the surveyor discussed with S3DPSQ the use of the pepper spray and the position of CMS as stated in the guidance under Resident/ Patient/ Client Rights. The guidance clearly indicates that if the use of pepper spray is necessary, it is best practice to involve local police. S3DPSQ verified she was not aware of the guidance.

The Security Report was then provided to the surveyor. Review of the security incident report prepared by the designated Supervisor on Duty revealed the following narrative:

On 09/23/2024, I, S17SC, was on duty as Shift Commander from 5:45 p.m. until 6:15 a.m. When at 4:38 a.m., Officer S18SO initiated a Dr. Flight for Patient #2 in triage room 5.

Upon being informed he would be placed under PEC (Physicians Emergency Certificate) Patient #2 grabbed his rolling luggage and was attempting to leave UMCNO property while the Dr. was writing the PEC order. Responding officers S19SO, S20SO, and S21AO intercepted the patient on S. Roman Street. SO20 stated he gave loud and clear verbal commands for Patient #2 to stop and that he was not free to go. Patient #2 became combative and attempted to strike S20SO with a closed fist. According to all three responding officers, this took place at the bottom of the ED ramp, in the grassy area prior to re-entering S. Roman Street (see attached statements). Patient #2 allegedly stated to S20SO that his "whole family was dead" at this time. S20SO gave one more loud verbal command to stop before deploying his duty issued OC gel. The patient was escorted by Charge Nurse to the decontamination room and back to room 2501 for further treatment under the care of S22MD.

S20SO did not pursue charges for the attempted strike.

CCTV footage was reviewed, provided to House Supervisor, and attached to this report.

Further review of the provided documentation revealed the report did contain statements from S19SO, S20SO, and S21AO, but none of the responders mentioned where the interaction took place as stated in the narrative by S17SC. The two officers in the patrol car were not identified. The review of the CCTV footage was not included as a part of the report. The report did not contain statements from S18SO, who initiated the Dr. Flight, and S23SO, who was also documented as dispatched to the incident. The report did not document that Patient #2 was examined and advised of his rights by S17SC as required in the policy. The report did not contain documentation of an interview by S17SC with Patient #2 after the incident as required by the policy. There was no documentation of notification of the Operations Commander, and Deputy Director of Public Safety.


On 10/22/2024 at 8:55 a.m., S16DCPS was interviewed. S16DCPS verified he was familiar with the investigation into the incident and was interviewed between 8:55 a.m. and 8:59 a.m. S16DCPS verified Patient #2 was on the sidewalk on South Roman Street heading towards Tulane Avenue when he was intercepted. S16DCPS verified the sidewalk is public property and Patient #2 was not on hospital property when the pepper gel was deployed. S16DCPS verified the security officers had authority to detain the patient on public property because it was to ensure the safety of the patient and the public. S16DCPS verified the use of the pepper gel was warranted after Patient #2 tried to hit the officers and made threats. When asked if he was aware of the CMS position on the use of pepper gel, he verified it did not apply to the situation because they were not trying to put the patient in restraints, they were trying to detain him. S16DCPS verified New Orleans Police Department was not notified of the incident. S16DCPS verified the use of the pepper gel was justified, and the incident was properly reviewed and documented, and all hospital security policies were followed.