HospitalInspections.org

Based on record review and interviews, the hospital failed to ensure all alleged incidents of patient abuse and neglect were reported and analyzed to ensure the hospital was in compliance with applicable local, State, and Federal Laws and Regulations. This deficient practice was evidenced by the hospital's failure to report an allegation of neglect within 24 hours to the Department of Health and Hospitals for 1 (#3) of (#1 - #3) patients reviewed for abuse.
Findings:

Review of the Louisiana Revised Statutes, Title 40. Public Health and Safety, Chapter 11, State Department of Health and Hospitals revealed "Department" shall mean the Department of Health and Hospitals. "Unit" means the Medicaid fraud control unit created within the office of criminal law of the Department of Justice and which is certified by the secretary of the United States Department of Health, Education and Welfare. Regarding §2009.20. Duty to make complaints; penalty; immunity, "Abuse" is the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including but not limited to sexual abuse, or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered. "Neglect" is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer's well-being. Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, ... having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report.

Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report abuse/neglect allegations within 24 hours of receiving knowledge of the allegation to the Louisiana Department of Health (LDH). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that 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.

Review of the hospital's policy number RTS-04 titled "Patient Grievance Process" last revised 09/01/2024 revealed in part:
"Purpose To provide an internal process that establishes guidelines for: Submission of a patient and/or family's grievance allegation to the facility; Timely review and investigation of the allegation; Provision of a response; and Timely referral to the appropriate external agency as deemed necessary.
Policy: The Governing Body is responsible for the effective operation of the compliant/grievance resolution process. Each facility has identified an individual to serve as the facility' Patient Advocate who is responsible for the follow up and response to grievances submitted by a patient or caregiver. This facility has adopted an internal grievance process in accordance with Title 42 CFR, §482.13 which provides for prompt resolution of patient and/or patient representative concern regarding violation of a patient's rights, quality of care, and other complaints involving the patient's treatment stay. Utilization of this grievance procedure is not a prerequisite to the pursuit of other remedies - at all times, patients have free and unrestricted access to the Mental Health Advocate organization in each state.
Definitions: Complaint - An expression of dissatisfaction, however made, about the standard of service, actions or lack of action by staff or regarding the facility and is resolved by staff present at the time the complaint is made, requiring no further resolution. Grievance - 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 (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, and/or patient's rights.
Procedure: Grievance Procedures 1. The Patient Advocate logs the grievance allegation onto the "Complaint/Grievance Log" and contacts the patient, or patient representative, and opens an investigation to determine the validity of the grievance allegation within 48 hours of notification or receipt of the grievance allegation. If the grievance is regarding an allegation of abuse or neglect, the appropriate state mandatory guidelines for reporting will be followed. Role of the Administrator 1. Ensure appropriate policies and procedures are followed for grievances alleging abuse and neglect of patients."

Review of Patient #3's medical record revealed he was admitted to the hospital on 04/26/2025 at 1:30 PM from a nearby hospital for substance abuse.

Review of the hospital incident report regarding Patient #3 dated 04/27/2025 at 3:15 AM by S10RN revealed in part:
CASE INFORMATION:
Occurrence Type: Incident
Category: Aggression
Severity: Unsafe Condition
Location: Nursing Station
Cause: N/A
Length of Stay Prior to Occurrence: 1 day
Notifications:
S6MD - Attending Physician on 04/27/2025 at 3:24 AM
S8DON - Director of Nursing on 04/27/2025 at 3:34 AM
S4ACEO - Administrator on 04/27/2025 at 4:10 AM
Other Witnesses:
S12MHT
S13MHT
S11LPN
INCIDENT REPORT INSTRUCTIONS:
Category: Injury
Brief factual description of the incident: 3:15 AM Patient #3 woke up from sleeping and came in the hallway cursing at staff and being aggressive. Staff asked Patient #3 what he needed and he said, "B*tch you know what I need." Staff attempted to redirect but patient was undirectable. Another patient came in his face because she was upset about him causing a disturbance and called him a n*gga. He threatened to hit her so the medication nurse (S11LPN) opened the door and attempted to talk Patient #3 down, but he charged in the nursing station and started choking the medication nurse. Nurse and other staff ran out the nursing station from Patient #3 because he was too violent to control and would not leave. Police/DON/MD notified.
Injury or Adverse Outcome: Other - Violent behavior/injury to staff
Related Causes & Factors: Unprovoked act
Actions Taken Post-Incident: MD notified, Supervisor notified, Discharged to Local Police Department
Follow Up/Resolution (QD): MDN completed, MD notified, police contacted. Patient arrested.
Follow Up/ Resolution (DON): On 04/27/2025, the medical record and video were reviewed collectively by S1COO; S2CLO; S3SVPO; S4ACEO and S5VPCO. Video review indicated patient rapidly escalated with no opportunity for staff to de-escalate. Staff retreated to nursing station for safety and continued attempts to verbally de-escalate the patient. The patient broke through the nursing station window and gained entrance into the nursing station through the window. The patient attempted to choke the LPN. 911 was called and law enforcement arrived to intervene. The patient began to fight with 5 law enforcement officers who finally arrested and removed the patient from facility. The physician was notified and provided AMA discharge orders for the patient. Two employees were sent to the emergency department for evaluation and treatment (LPN due to choked by patient and MHT who fell during event). During review of the incident, the individuals listed above analyzed and discussed reporting requirements and upon review of information provided in presentation at LHA meeting by LDH staff regarding self-reporting requirements and review of email clarification provided following the meeting, it was determined there was additional reporting requirement other that law enforcement related to workplace violence. Upon conclusion of incident review, it was determined there were no policy violations as the patient appropriately assessed for violence risk and was found to be a low risk requiring no violence related precautions and staff had no indication to expect the sudden, violent event that occurred. Following this review S8DON spoke with a patient witness who indicated the patient was unprovoked and there was no precipitating occurrence to this event and Patient #3 escalated rapidly without provocation. No additional actions required.
Electronically Signed By:
S10RN 04/27/2025 7:04 AM
S5VPCO 04/28/2025 3:36 PM
S7QD 04/29/2025 2:05 PM

Review of the hospital's Grievances & Complaints Log for 04/27/2025 revealed the following for Patient #3:
Date Received: 04/27/2025
Type: Grievance
Nature of Complaint/Grievance: Treatment, Patient #3's mother filed regarding law enforcement being called on patient.
Resolution: No actions deemed necessary.
Date of Patient/Family Contact & Start of Investigation: 04/27/2025
Date Investigation Completed: 05/01/2025
Mail Date of Copy of Grievance Report/Letter to Patient/Family: 05/02/2025

Review of the Grievance Report Letter dated 05/02/2025 sent to the mother of Patient #3 following the investigation of her filed grievance revealed in part:
"After you spoke with our administrator on 04/27/2025, we immediately began an investigation into your concerns. Based on your conversation via phone, the concerns you identified included feeling that your son was mistreated due to law enforcement being called during the incident with your son on 04/27/2025. You expressed feeling that law enforcement should not be involved due to this being a behavioral health facility."

No self-report was submitted related to the investigation of this grievance.

On 05/05/2024 at 11:44 AM, a request was made to S7QD to review the video footage of the incident on 04/27/2025 at 3:15 AM, but it was no longer available to be viewed. Following, an interview was then conducted with S7QD regarding her viewing of the video footage. S7QD stated she viewed the video footage on 04/28/2025. She stated Patient #3 was seen on video coming out of his room and walking into dayroom B around 3:00 AM. She said it appeared like he had some paranoid behaviors because he was ripping the clipboard logs out of both of the MHT's (S12MHT & S13MHT) hands who were seated in the day room. S7QD stated he was then seen talking with the nurse, S10RN who was also in the dayroom. S7QD stated there was no audio so she was unable to hear what was said, but it did appear he was yelling at S10RN. S7QD stated Patient #3 was then seen approaching the nurses' station monitor box, where he began pounding on the window. S7QD stated inside the monitor box was the medication nurse, S11LPN and another MHT, S14MHT. S7QD stated S11LPN went to exit the monitor box in an attempt to deescalate Patient #3, but as soon as S11LPN opened the door, Patient #3 charged the Nurses' station door gaining access to nurses' station and began strangling S11LPN. S7QD stated she was unable to see inside the nurses' station at the time Patient #3 had gained entry because there weren't cameras in the monitor box, however she could see S10RN and the two MHTs (S12MHT &S13MHT) who were in the dayroom B run off the unit and into the lobby to call the local police department, DON and the MD about the situation. S7QD stated it wasn't long after, S11LPN was seen exiting the nurses' station with the S14MHT onto dayroom B and Patient #3 was seen exiting the nurses' station through the opposite door placing himself on dayroom A. S7QD stated Patient #3 was then seen kicking the sliding window of the nurses' station in and subsequently breaking it. Shortly after, S7QD stated 2 local police officers arrive to the facility and appear on camera entering the unit. Both officers attempt to take down Patient #3, but were unsuccessful. S7QD stated after multiple attempts and a struggle, Patient #3 was tased twice by the officers because the first time was unsuccessful resulting in him removing the taser darts immediately after being struck by them. S7QD stated in total the take down, struggle and tasing of Patient #3 with the officers took around 15-20 minutes before the local law enforcement officers were able to finally detain him safely and remove him from the facility, to which he was discharged and transported for booking to the local parish prison. S7QD stated she didn't believe the incident was reported due to this being an incident where Patient #3 attacked staff unprovoked.

On 05/05/2025 at 12:35 PM, an interview was conducted with S4ACEO, he stated based on an LDH presentation he had attended regarding work place violence submissions, he understood it to mean that if the patient initiated the violence towards the staff it is not to be reported and only law enforcement needed to be informed. He confirmed no self-report was submitted for potential abuse and/or neglect of the patient or for the grievance filed by Patient #3's mother.

On 05/06/2025 at 10:23 AM, an interview was conducted with S8DON. S8DDON stated she did not complete a self-report and was unaware if one was completed for this incident because she was not a part of the self-report process for the facility, but thought this would be the type of incident which would require a self-report.