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Based on record review and interview, the hospital failed to provide a written notice of grievance resolution to the patient representative for 1 of 2 patients (Patient #1) with a grievance in a total sample of 12 patients.
Findings:

Review of the hospital's policy RI.012 titled, "Patient Grievance Procedures" revealed in part: II. Procedure - 7. The hospital will provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion. 8. If a prompt resolution is not possible, a written response will be forwarded to the person filing the grievance within seven days of receipt stating the issue is being investigated. A second/final response will be sent when the investigation is completed within 30 days ... This notice will be sent after the investigation is completed.

Review of Patient #1's Interdisciplinary Note dated 02/05/2024 at 7:00 p.m. revealed in part: During discharge process, patient's father expressed dissatisfaction with hospital and demanded to see reports of prior incidents that occurred with his child while a patient in this hospital. House supervisor aware of situation.

Review of the Grievance Log for February 2024 listed Patient #1 as having two separate grievances dated 02/04/202 and 02/05/2024.

Review of the grievance letter dated 02/07/2024 revealed it included both above allegations and stated "an investigation was completed" but failed to include the results of the investigation as detailed in the hospital's policy.

An interview 02/21/2024 at 3:00 p.m. with S3Director of Patient Advocacy revealed the written grievance response notice sent to the Patient #1's father did not include the results of the investigation.

Based on 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 (LDH) within 24 hours of awareness of the allegation, as required by LDH-HSS, for 1 (Patient #6 ) of 8 patients reviewed for self-reports to LDH-HSS in a total patient sample of 12.
Findings:

Review of the policy/procedure titled, Patient Grievance Procedures, revealed in part that when a report of sexual or physical abuse or neglect is received, the Department of Health and Hospitals will be notified within 24 hours from the time the facility was notified of the complaint.

Review of the LDH hospital/licensed provider Abuse/Neglect Initial Report form revealed in part that 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 psychiatrist progress note dated 02/06/2024 at 9:38 a.m. revealed that Patient #6 stated she was having back pain and abdominal cramping due to being hit in the stomach last night by a peer.

Review of the nurse practitioner progress note dated 02/06/2024 (no time) revealed Patient #6 was struck in the stomach last night. Further review of the note revealed the 16 year old patient was 18 weeks pregnant and was ordered to be sent to the hospital for an ultrasound.

On 2/19/2024 at 10:00 a.m., interview with S1Director of QA confirmed that he was unaware of Patient #6 being hit in the stomach. S1Director of QA revealed that there was no evidence that an incident report was initiated or that the incident had been investigated. S1Director of QA further revealed that a Self Report should have been submitted to LDH within 24 hours of the incident, but it was not.

On 02/19/2024 at 12:20 p.m., interview with S2CNO revealed that she was unaware that Patient #6 had been hit in her stomach. S2CNO confirmed the patient was currently pregnant.

Based on record review and interview, the hospital failed to ensure that the nursing staff developed, and kept a current, and individualized nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs. This deficient practice is evidenced by the failure to update the care plans of 5 (Patient #2, 7, 9, 11, 12) of 12 (#1-12) patients reviewed for completed and updated care plans.
Findings:

Review of the hospital's policy TX.018 titled, "Multi-Disciplinary Treatment Planning revealed in part: 3. Treatment Team - 1. The master treatment plan shall be reviewed and revised in the treatment team meeting at least every 7 days after it has been initiated for acute patients and more frequently if the patient exhibits significant change of behavior or requires special treatment procedures such as seclusion or restraint.

Review of the Treatment Plans for patients Patients #2, 7, 9, 11 and 12 failed to reveal the plans were updated following documented physical altercations with peers and incident reports.

On 02/20/2024 at 10:53 a.m., S1Director of QA reviewed Patient #7's medical record and acknowledged the treatment/care plan was not updated to include assaultive/aggressive behaviors.

On 02/21/2024 at 1:53 p.m., S2CNO reviewed Patients #2, #9, #11 and #12's treatment/care plan and acknowledged the treatment/care plans were not updated to include assaultive/aggressive behaviors. S2CNO further stated the treatment/care plans should have been updated for the assaultive/aggressive behaviors.