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Based on record review and interviews, the hospital failed to ensure a patient complaint of alleged sexual harassment was recognized as a grievance. This deficient practice was evidenced by failing to correctly identify a patient grievance for 1 (#1) of 3 (#1-#3) patients reviewed for complaints/grievances.
Findings:

Review of the hospital's policy number RM-038 titled "Patient Grievance" last reviewed on 02/2024 revealed in part: POLICY: 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. All patient grievances will be investigated and the results of the investigation reported back to the complainant. DEFINITION: A patient grievance (as defined by Centers of Medicare & Medicaid Services, ref. 482.13(a)(2)) 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 (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoPs), Medicare beneficiary billing complaint related to rights and limitations by 42CRF489. Any reported grievance by patients, families, staff and/or visitors that directly relate to patient neglect or abuse will be forwarded to the Administrator On-Call IMMEDIATELY for review.

Review of LDH Health Standard Section document titled Self-Reporting Process for Hospitals - Abuse/Neglect revealed in part: "11. Facility Investigation (Administrative Review) and Final Investigative Report: In accordance with regulations, facilities are directed to process an allegation of abuse or neglect as a grievance in accordance with facility Grievance Processes and Abuse/Neglect policies. In accordance with §482.13, an allegation of abuse/neglect is to be treated as a grievance even if the complainant recants or indicates that the issue is resolved. A written response must be issued to the reporting patient or patient's representative. In many cases, the presentation of an abuse investigation handled in this manner will satisfy surveyor reviews related to the manner in which a facility processes grievances."

Review of Patient #1's medical record revealed Patient #1 was admitted on 11/22/2024 Major Depressive Disorder. On 11/28/2024 the nurse documents the following: "Patient compliant with meds; participates with group. Patient stated that she was being sexually harassed by other male patients and this is the reason she was so anxious and uncomfortable because she is a rape survivor. I informed the nurse supervisor of her complaint".
In an interview on 08/05/2025 at 3:25 PM, S1ADM stated that the facility has not had any documented grievances/complaints logged since November 2024 regarding Patient #1. S1ADM also reported when the facility became aware of possible sexual harassment of Patient #1, is was not treated as a grievance and was not self-reported to LDH.

Based on record review and interview, the hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice was evidenced by failure to identify and investigate potential allegations of abuse by a patient.
Findings:

Review of the hospital's policy number NU207 titled "Patient and Family Rights" last reviewed on 02/2025 revealed in part: I. POLICY: The facility protects and promotes each patient's rights according to LAC 48:1 Chapter 9319 Patient Rights and Privacy. Every patient shall have the following rights, none of which shall be abridged by the hospital or any of its staff. The hospital administrator shall be responsible for developing and implementing policies to protect patient rights and to respond to questions and grievances pertaining to patient rights. Patients and families area advised of the following rights upon admission to the facility: 17. The right to be free from all forms of abuse and harassment. 18. The right to receive care in a safe setting.

Review of the hospital's policy number HR.014 titled "Sexual and Unlawful Harassment" last reviewed on 02/2025 revealed in part: III. PROCEDURE: A. the hospital is committed to maintaining an environment that is free of sexual and unlawful harassment and has zero tolerance for this type of behavior. F. Management's responsibility will be as follows: 1. All management personnel are expected to be alert to the possible presence of sexual harassment in the work place, to take appropriate measures to prevent incidents from occurring, and to initiate action immediately in the event incidents occur. G. General Guidelines: 2. All complaints, incidents, or practices will be investigated promptly examined impartially and resolved by the hospital as promptly as possible. The events surrounding the investigation and the outcome will be documented and kept confidential.

Review of Patient #1's medical record revealed Patient #1 was admitted on 11/22/2024 Major Depressive Disorder. On 11/28/2024 the nurse documents the following: "Patient compliant with meds; participates with group. Patient stated that she was being sexually harassed by other male patients and this is the reason she was so anxious and uncomfortable because she is a rape survivor. I informed the nurse supervisor of her complaint".
S1ADM presented a letter from Sexual Trauma Awareness & Response (STAR) dated 02/24/2025 and received by the facility on 03/2025 which revealed in part the following: This letter is in behalf of Patient #1 regarding the sexual harassment incident experienced during her hospitalization in November 2024. We have already received Patient #1's medical records; however, the records include only one brief notation that the incident was reported by Patient #1 to the nurse on duty, who subsequently reported to the supervising nurse on duty. In order to fully understand the hospital's response and any subsequent actions taken, we respectfully request copies of any and all internal documentation related to the this incident.

On 08/05/2025 between 3:25 PM to 3:45 PM, an interview was conducted with S1ADM. S1ADM revealed the hospital became aware Patient #1's allegations of sexual harassment when the hospital received the letter from STAR. Further review of Patient #1's medical record revealed a nurse note dated 11/28/2025 that documented Patient #1's complaint and that it was reported to the nursing supervisor. S1ADM reported she interviewed the supervisor who stated she didn't remember being told about patient #1's complaint. S1ADM admits to not interviewing the nurse who documented Patient #1's complaint of sexual harassment, but educated the nursing staff in a team meeting on 04/07/2025 regarding incidents that should be reported immediately to nursing supervisors. S1ADM verified the facility had no documentation to prove a thorough investigation was performed after learning of the allegation.

On 08/07/2025 between 8:35 AM to 8:40 AM an interview was conducted with S5RN who stated that she doesn't remember the incident with Patient #1, but stands by her documentation in Patient #1's medical record dated 11/28/2024.

On 08/07/2025 between 9:35 AM to 9:45 AM an interview was conducted with S4SRN who stated that she doesn't remember the incident with Patient #1 on 11/28/2025.

On 08/07/2025 between 10:55 AM to 11:05 AM an interview was conducted with S6NP who stated that she remembers Patient #1, but doesn't remember any complaints by Patient #1 that she experienced any sexual harassment while hospitalized.