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Based on record review and interview, the facility failed to meet the requirements of the Condition of Participation of Patient Rights. This was evidenced by the facility's failure to ensure each patient received care in a safe setting by allowing a driver to continue transporting patients after demonstrating patient neglect and unsafe practices on three separate occasions.
(See findings under Tag A0144)

Based on record review and interview the facility failed to ensure patient complaints were recognized as grievances. This deficient practice was evidenced by failing to correctly identify patient grievances for 2 (#1 and #R1) of 2 (#1 and #R1) patients reviewed for complaints/grievances from a total patient sample of 4.
Findings:

Review of facility policy revised 03/21/2018, titled "Patient Complaint and Grievance Process" revealed, in part: Policy, in part: A grievance is defined as 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, abuse or neglect. If a patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, them the complaint is a grievance for the purposes of this policy. A complaint is considered resolved when the patient is satisfied with the actions taken on their behalf. A statement of dissatisfaction may be considered a grievance whether it comes from the patient or any patient representative.

Review of the Grievance/complaint log revealed no evidence of grievances related to Patient #1 and patient #R1.

Patient #1
Review of facility document titled "Beacon Unusual Occurrence Incident Report-Employee" dated 08/04/2023 revealed S5D was assisting Patient #1 into her group room. He stated that the patient stumbled over her own feet. He was holding on to her the whole time. He did hold her as she fell to her knees. He stated after falling to her knees she shifted and sat on the group room floor. He asked her if she was o.k., Patient replied yes. He stated he helped her up and into her chair. The incident occurred around 9:15 a.m. The incident was reported to S1PD after 2:00 p.m. by a phone call from Patient #1's daughter. Patient #1's daughter was informed that S1PD was not made aware of an incident today but that he would reach out to the driver as soon as he was finished his route. S1PD checked in with other staff to see if they were aware of Patient #1 falling on this day. The other staff were not aware. Actions taken: S1PD informed S5D that if a patient falls, no matter a hard fall or soft fall, he is to have the patient remain seated and call for the nurse. Never assist helping someone up until the nurse has assessed the patient. S5D was informed this was his 1st verbal warning of improper protocol for reporting and incident.

Review of S2C's note on 07/24/2023 revealed staff spoke with Patient #1's daughter who reported she was upset that client was not walked all the way to her door on Friday upon returning home from IOP. She states her mother needs assistance at all times.

In an interview on 10/02/2023 at 2:37 p.m., S2C reported that Patient #1's daughter had called her on 07/24/2023 to complain about S5D. The daughter said when she arrived at her mother's home she noted that her mother's walker was sitting by the steps to the front door. When she went into the house her mother had soiled on herself, was dizzy and told her that no one helped her up the steps and she could not get up the steps with her lunch box, water bottle and the walker. The daughter was upset because she related that her mother was not helped to her door as agreed on admit. S2C reported that she notified S1PD about the incident and S1PD said he would handle it.

In an interview on 10/02/2023 at 2:27 p.m., S1PD reported that the daughter had asked on admission to have the drivers escort her mother to the door. The daughter was told that they would tell the drivers to walk her to the door and that they would put instructions on the drivers list of patients. Regarding the incident on 08/04/2023 involving the S5D, patients' daughter called around 2:00 p.m. on 08/04/2023 stating her mother had fallen after getting off the bus at the facility and reported her mother's leg was hurting her. Daughter stated she did not want this driver to pick up her mother anymore and wanted her discharged. S1PD had not heard of this incident and stated S5D did not report this to administration. S1PD said that they did not complete the grievance process because he thought it was covered in the incident report. S1PD further stated he did not realize he was supposed to start the grievance process. S1PD stated he could not recall the daughter previously calling and complaining about S5D before this incident.

In a telephone interview on 10/03/2023 at 9:37 a.m. Patient #1's daughter stated, she called S2C on 07/21/2023 and complained that her mother had not been walked to the door as agreed upon at admission. She was assured that she would be walked to the door. S2C told her the administrator was gone for the day and he would call back. When he did not call back, she called the S1PD herself. She told him what had happened and he said that the bus driver said she did not need assistance. Patient #1's daughter confirmed that there was no grievance process started at this time. Patient #1's daughter stated that her mother has been in the hospital since 08/04/2023. She was admitted after falling at the facility. She had walked all day around the facility with a hematoma. Her hemoglobin and hematocrit were low and T12 compression fracture and low hemoglobin and hematocrit due to hematoma on her leg. Patient #1's daughter was concerned that fall precautions were not implemented. Her complaint is that this was the second time an incident happened involving S5D and her mother without her notification. She is concerned that a nurse or healthcare professional failed to assess Patient #1 after the fall and no one called her or implemented a grievance process. She asked S1PD to send her a letter that the grievance process was implemented and S1PD said he would start the process. Patient #1's daughter confirmed she did not received a letter for either incident.

In an interview on 10/02/2023 at 9:44 a.m., S5D reported he did not walk a patient with a walker to their door unless they had an upper body impairment, such as a shoulder injury.

In an interview on 10/02/2023 at 2:43 p.m., S12CCO confirmed that the grievance process should have been implemented for both incidents involving Patient #1.

Patient #R1
In an interview on 10/03/2023 at 2:00 p.m., S1PD reported Patient #R1 was in the van at the time of the crash incident involving S5D on 09/18/2023. Patient #R1 called the facility on 09/21/2023 and told a counselor that she was not sure what to do about seeing a doctor since her back was hurting. Patient #R1 reported she was a mess from prior injuries and this pain from the accident was aggravating older injuries. Patient #R1 called to back to speak with S1PD about the pain and her inability to come to IOP because of the pain and he told her that he would pass on the information and someone would call her. Patient #R1 had not been able to return to Intensive Outpatient (IOP) since the accident. S1PD further stated Patient #R1 stated she did not want to come back because she was moving slowly and having trouble with pain. S1PD attempted calling her again on the 09/29/2023 and no answer. S1PD documented he would call her the next week. S1PD called Patient #R1 on 10/02/2023 and she said she did not want to come back to the program because of her pain. S1PD documented he would call her in a month.

In an interview on 10/03/2023 at 2:45 p.m., S1PD confirmed that the grievance process should have been implemented for Patient #R1.

Based on record review and interview, the facility and its staff failed to ensure the health and safety of all patients. This deficient practice was evidenced by:
1) failure to ensure each patient received care in a safe setting by allowing a driver to continue transporting patients after demonstrating patient neglect and unsafe practices on three separate occasions;
2) failure to ensure each employee's personnel file had documented evidence they were free of TB (tuberculosis) in a communicable state, as required per Louisiana Public Health Sanitary Code, Title 51, Part II., for 7 (S1PD, S2C, S3LPN, S4SW, S5D, S6MHT and S13PCA) of 10 (S1PD, S2C, S3LPN, S4SW, S5D, S6MHT, S7MD, S8PNP, S9PNP, and S13PCA) personnel records reviewed;
3) failure to ensure fall precautions were implemented on patients with high risk for falls in 3 (#1-#3) of 3 (#1-#3) patient records reviewed.
Findings:

1) Failure to ensure each patient received care in a safe setting by allowing a driver who repeatedly demonstrated patient neglect and unsafe practices to continue transporting patients.
Incident #1
Review of S2C's therapist note on 07/24/2023 revealed staff spoke with Patient #1's daughter who reported she was upset that client was not walked all the way to her door on Friday upon returning home from IOP. She stated her mother needs assistance at all times.

In an interview on 10/02/2023 at 2:37 p.m., S2C reported that Patient #1's daughter had called her on 07/24/2023 to complain about S5D who was the hosptial IOP driver who transported her home. The daughter said when she arrived at her mother's home she noted that her mother's walker was sitting by the steps to the front door. Patient #1's daughter stated she went into the house, and found her mother had soiled on herself, was dizzy and told her that S5D did not help her up the steps. She could not get up the steps with her lunch box, water bottle and the walker on her own. The daughter was upset because her mother was not helped to her door by S5D as agreed upon admit. S2C reported that she notified S1PD about the incident involving driver S5D and S1PD said he would handle it.

In an interview on 10/02/2023 at 2:27 p.m., S1PD reported that the daughter had asked on admission to have the drivers escort her mother to the door. The daughter was told that they would tell the drivers to walk her to the door and that they would put instructions on the drivers list of patients. S1PD stated he could not recall the daughter previously calling and complaining about S5D not helping her mother up the steps to her front door.

In a telephone interview on 10/03/2023 at 9:37 a.m. Patient #1's daughter stated, she called S2C on 07/21/2023 and complained that her mother had not been walked to the door as agreed upon at admission. She was assured that she would be walked to the door. S2C told her the administrator was gone for the day and he would call back. When he did not call back, she called the S1PD herself. She told him what had happened. S1PD reported that S5D said Patient #1 did not need assistance. S1PD told her he would take care of it and make sure it did not happen again.

In an interview on 10/02/2023 at 9:44 a.m., S5D reported he did not walk a patient with a walker to their door unless they had an upper body impairment, such as a shoulder injury.

Review of facility records failed to reveal an incident report regarding the incident that occurred on 07/24/2023 involving Patient #1 after her daughter notified the facility of the events. Further review failed to reveal documentation that S5D was educated regarding this incidence.

Incident #2
Review of facility document titled "Beacon Unusual Occurrence Incident Report-Employee" dated 08/04/2023 revealed S5D had returned to the IOP after picking up Patient #1 and was assisting Patient #1 into the facility. He stated that the patient stumbled over her own feet. He was holding on to her the whole time. He did hold her as she fell to her knees. He stated after falling to her knees she shifted and sat on the group room floor. He asked her if she was okay, Patient replied yes. He stated he helped her up and into her chair. The incident occurred around 9:15 a.m. The incident was reported to S1PD after 2:00 p.m. by a phone call from Patient #1's daughter. Patient #1's daughter was informed that S1PD was not made aware of an incident today but that he would reach out to the driver as soon as he was finished his route. S1PD checked in with other staff to see if they were aware of Patient #1 falling on this day. The other staff were not aware.
Actions taken: S1PD informed S5D that if a patient falls, no matter a hard fall or soft fall, he is to have the patient remain seated and call for the nurse. Never assist helping someone up until the nurse has assessed the patient. S5D was informed this was his first verbal warning of improper protocol for reporting an incident.

Incident #3
Review of incident report dated 09/15/2023 revealed city of 'A' police arrived at the clinic 2:45 p.m. stating they received a report from a woman that one of the facility drivers ran into the back of her and then pulled off. Police produced a license plate number and it matched a facility vehicle driven by S5D. Police stated they were going to call S5D to get more information. S5D called S1PD around 3:00 p.m. after S1PD sent him a text about the police coming by the clinic. S5D stated no one was hurt and there was no damage to either vehicle. Stated that the person in front of him did not signal that she wanted to do anything so he proceeded to drop off the rest of the patients.
S5D was informed that he needed to pull over with the other driver so that they could speak and inspect the vehicles. Since he did not pull over and continued with his route the other driver filed a hit and run report. S5D was to be written up for not follow protocol. Education about protocol would be given.

Review of "Louisiana Uniform Crash Report Narrative" dated 09/18/2023 revealed the driver of vehicle one stated S5D was stopped behind vehicle two, when his foot slipped off of the brake pedal and his vehicle rolled into the back of vehicle two. S5D stated vehicle two pulled to the side of the road and stopped and he took that as the driver of vehicle two not wanting to file a crash report. S5D stated he proceeded along with his day until he was contacted by the police. S5D stated he did not sustain any injuries because of the crash and did not require medical attention. The driver of vehicle one turned himself in to Officer later in the day and was cited for hit and run driving. The driver of vehicle two stated she was rear ended by vehicle one. She stated after the crash, she pulled over to the side of the road, then the vehicle one fled the scene but not before she was able to acquire the license plate of vehicle one. She stated she had pain in her back because of the crash but her son was fine. Driver two did not request medical attention.

In an interview on 10/02/2023 at 11:10 a.m., S1PD reported police came to facility on 09/15/2023 at 2:45 p.m. to investigate a hit and run by one of the drivers. The driver, S5D, was sitting at the red light and his foot slipped off the brake pedal, the car pulled over and he waved at her and then drove off thinking she did not need to speak with him because he thought there was nothing to address. There were clients in the car. One client reported that she had back pain following the incident. S1PD stated that insurance was going to reach out to patient. The driver of the other car had a 2 year old boy in the back seat without injuries.
S1PD further stated that he verbally reviewed protocol with S5D and that S5D signed an employee conference document on 09/18/2023.

2) Failure to ensure each employee's personnel file had documented evidence they were free of TB (tuberculosis) in a communicable state, as required per Louisiana Public Health Sanitary Code, Title 51, Part II., for 7 (S1PD, S2C, S3LPN, S4SW, S5D, S6MHT and S13PCA) of 10 (S1PD, S2C, S3LPN, S4SW, S5D, S6MHT, S7MD, S8PNP, S9PNP, and S13PCA) personnel records reviewed.

Review of the Louisiana Public Health Sanitary Code, Title 51, Part II. The Control of Diseases - Health Examinations for Employees, Volunteers and Patients at Certain Medical Facilities, Section 503, Mandatory Tuberculosis Testing, revealed in part: A. [formerly paragraph 2:022] All persons, including employees, students or volunteers, having no history of latent tuberculosis infection or tuberculosis disease, prior to or at the time of employment, beginning clinical rotations in the healthcare profession, or volunteering at any hospital or nursing home (as defined in Parts XIX and XX of the Sanitary Code, respectively, herein, and including intermediate care facilities for the developmentally disabled) requiring licensing by the Louisiana Department of Health or at any Louisiana Department of Health, Office of Public Health (LDH-OPH) parish health unit or an LDH-OPH outpatient health care facility, whose duties include direct patient care, shall be free of tuberculosis in a communicable state as evidenced by either:
1. a negative purified protein derivative skin test for tuberculosis, 5 tuberculin unit strength, given by the Mantoux method or a blood assay for Mycobacterium tuberculosis approved by the United States Food and Drug Administration;
2. a normal chest X-ray, if the skin test or a blood assay for Mycobacterium tuberculosis approved by the United States Food and Drug Administration is positive; or
3. All initial screening test results and all follow-up screening test results shall be kept in each employee's, Student's, or volunteer's health record or facility's personnel record.
D. Annually, but no sooner than 6 months since last receiving tuberculosis educational information (more fully described at the end of this sentence) or symptom screening, all employees, students in the healthcare professions, or volunteers at any medical or 24-hour residential facility requiring licensing by LDH or at any hospital or nursing home (as defined in Parts XIX and XX of the Sanitary Code, respectively, herein, and including intermediate care facilities for the developmentally disabled) requiring licensing by the LDH or at any LDH-OPH parish health unit or and LDH-OPH out-patient health care facility shall receive, at a minimum, educational information explaining the health concerns, signs, symptoms, and risks of tuberculosis.

A review of the personnel files of S1PD, S2C, S3LPN, S4SW, S5D, S6MHT and S13PCA failed to reveal evidence yearly screening for tuberculosis infection.

In an interview on 10/03/2023 at 9:08 a.m., S12CCO confirmed S1PD, S2C, S3LPN, S4SW, S5D, S6MHT and S13PCA did not receive yearly screening for tuberculosis infection.

3) Failure to ensure fall precautions were implemented on patients with high risk for falls in 3 (#1-#3) of 3 (#1-#3) patient records reviewed.

Review of facility policy revised 03/21/2018, titled "Precautions", revealed, in part: All direct care staff members are fully trained on the complnents of all Precautions. The need for Precautions will be reflected in the patient's Treatment Plan. Standardized Precautions used, in part: Fall Risk. Fall Risk Precautions, in part: are ordered based on the findings of a Fall Risk Assessment conducted upon admission, at specific intervals as ordered, and whenever patient experiences or reports a fall. A patient may be at increased risk for falling due to any of the following, in part: Gait disturbance, Weakness or dizziness, visual disturbances such as hallucinations or impaired vision, sedating medications, polypharmacy, neurological, cardiovascular or musculoskeletal conditions such as Parkinson's.
Review of drivers' list of transported patients dated 10/04/2023 revealed Patients #2 and #3. Further review failed to reveal Fall Precautions notifying the driver of the high risk for falls for Patients #2 and #3.
Patient #1
Review of Patient #1's medical record revealed a Psychiatric Evaluation dated 07/18/2023. Further review revealed Patient had dementia and a recent stroke with gait disturbance requiring the use of a walker. Patient also had a medical history of trochanter bursitis of the left hip and lumbar compression fracture. The patient cannot drive or take care of herself independently. The provider further documented that Patient #1 had increased confusion with cognitive deficits and poor concentration.

Review of Patient #1's plan of care dated 07/18/2023 revealed patient ambulates with a walker and had a compression fracture of lumbar spine. The plan of care revealed Problem: fall risk related to multiple medical issues and loss of independence as evidenced by use of walker and reports of pain.

Review of S2C's note on 07/24/2023 revealed staff spoke with Patient #1's daughter who reported she was upset that client was not walked all the way to her door on Friday upon returning home from IOP. She states her mother needs assistance at all times.

Review of S2C's note on 08/08/2023 revealed staff was told by supervisor to discharge client per the request of the client's daughter for a recent fall client had while in IOP.

Review of Patient #1's physician orders and medical record failed to reveal fall precautions implemented.
In an interview on 10/03/2023 at 10:35 a.m., S13Dir confirmed that there were no Fall Precautions implemented for Patient #1. S13Dir stated that there should have been Fall Precautions implemented for Patient #1 because she is a high fall risk based on facility policy.

Patient #2
Review of Patient #2's medical record revealed a Psychiatric Evaluation dated 09/07/2023. Further review revealed Patient #2 diagnosed with Lewy body dementia and Hallucinations with schizoaffective disorder. Further review revealed patient with physical limitation requiring the use of a rolling walker. Patient #2 is blind in the left eye with macular degeneration of both eyes and Parkinson's. The provider also assessed Patient #2 with balance issues secondary to Parkinson's. Medications included Remeron 15 mg at night and Seroquel 200 mg at night.
Further review of Patient #2's medical record failed to reveal Fall Precautions implemented as per hospital policy regarding patients with high fall risk.

In an interview on 10/03/2023 at 10:45 a.m., S13Dir confirmed that there were no Fall Precautions implemented for Patient #2. S13Dir stated that there should have been Fall Precautions implemented for Patient #2 because he is a high fall risk based on facility policy.

Patient #3
Review of Patient #3's medical record revealed a Psychiatric Evaluation dated 09/20/2023. Diagnoses are Major Depressive Disorder and opiate use disorder. Patient date of birth is 10/16/1956 (66 y). Patient medications include Valium 6 mg twice a day, Seroquel 25 mg at night (not taking) and Prozac 20 mg every day.
Further review of Patient #3's medical record revealed patient was recently in the emergency room due to a fall from over taking her anxiety and pain medications. She has a history of overtaking these medications.

Review of Patient #3's plan of care dated 09/20/2023 revealed a problem listed: patient had a potential for falls related to chronic pain as evidenced by reports of daily pain and use of walker.

Further review of Patient #3's medical record failed to reveal Fall Precautions implemented as per hospital policy regarding patients with high fall risk.

In an interview on 10/03/2023 at 10:56 a.m., S13Dir confirmed that there were no Fall Precautions implemented for Patient #3. S13Dir stated that there should have been Fall Precautions implemented for Patient #3 because she is a high fall risk based on facility policy.

Based on record review and interview, the hospital failed to assure any incidents of abuse, neglect, and/or harassment were reported and analyzed, and 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 (regarding a hit and run accident involving facility driver S5D and potential injury to Patient #R1 who was one of the patients in the vehicle at the time of the incident) within 24 hours to the Department of Health and Hospitals.
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.

Review of facility policy titled "Incident/Accident Reporting", revised 03/21/2018, revealed, in part: Policy, in part: All incidents/accidents must be reported ...

Review of incident report dated 09/15/2023 revealed 'A' police arrived at the clinic 2:45 p.m. stating they received a report from a woman that one of the facility drivers ran into the back of her and then pulled off. Police produced a license plate number and it matched a facility vehicle driven by S5D. Police stated they were going to call S5D to get more information. S5D called S1PD around 3:00 p.m. after S1PD sent him a text about the police coming by the clinic. S5D stated no one was hurt and there was no damage to either vehicle. Stated that the person in front of him did not signal that she wanted to do anything so he proceeded to drop off the rest of the patients. S5D was informed that he needed to pull over with the other driver so that they could speak and inspect the vehicles. Since he did not pull over and continued with his route the other driver filed a hit and run report. S5D was to be written up for not follow protocol. Education about protocol would be given.

Review of "Louisiana Uniform Crash Report Narrative" dated 09/18/2023 revealed the driver of vehicle one stated S5D was stopped behind vehicle two, when his foot slipped off of the brake pedal and his vehicle rolled into the back of vehicle two. S5D stated vehicle two pulled to the side of the road and stopped and he took that as the driver of vehicle two not wanting to file a crash report. S5D stated he proceeded along with his day until he was contacted by the police. S5D stated he did not sustain any injuries because of the crash and did not require medical attention. The driver of vehicle one turned himself in to Officer later in the day and was cited for hit and run driving. The driver of vehicle two stated she was rear ended by vehicle one. She stated after the crash, she pulled over to the side of the road, then the vehicle one fled the scene but not before she was able to acquire the license plate of vehicle one. She stated she had pain in her back because of the crash but her son was fine. Driver two did not request medical attention.

In an interview on 10/02/2023 at 11:10 a.m., S1PD reported police came to facility on 09/15/2023 at 2:45 p.m. to investigate a hit and run by one of the drivers. The driver, S5D, was sitting at the red light and his foot slipped off the brake pedal, the car pulled over and he waved at her and then drove off thinking she did not need to speak with him because he thought there was nothing to address. There were clients in the car. One client reported that she had back pain following the incident. S1PD stated that insurance was going to reach out to patient. The driver of the other car had a 2 year old boy in the back seat without injuries. S1PD further stated that he verbally reviewed protocol with S5D and that S5D signed an employee conference document on 09/18/2023.

Review of facility records failed to reveal submission of a critical incident report to the Louisiana Department of Health for the hit and run accident involving facility driver S5D.

Patient #R1
Review of incident report dated 09/15/2023 revealed a hit and run crash involving a facility van driven by S5D.

Review of facility records failed to reveal submission of a critical incident report to the Louisiana Department of Health for the hit and run accident involving a potential injury to Patient #R1 who was one of the patients in the vehicle at the time of the incident.

In an interview on 10/03/2023 at 2:00 p.m., S1PD reported Patient #R1 was in the van, driven by S5D, when the van rear-ended another vehicle. Patient #R1 started with back pain after the crash and had not been able to return to Intensive Outpatient (IOP) since the accident. S1PD further stated Patient #R1 stated she did not want to come back because she was moving slowly and having trouble with pain. Patient #R1 called the facility on the 09/21/2023 and told a counselor that she was not sure what to do about seeing a doctor since her back was hurting. Patient #R1 reported she was a mess from prior injuries and this pain from the accident was aggravating older injuries. Patient #R1 called to back to speak with S1PD about the pain and her inability to come to IOP because of the pain and he told her that he would pass on the information and someone would call her. S1PD attempted calling her again on the 09/29/2023 and no answer. S1PD documented he would call her the next week. S1PD called Patient #R1 on 10/02/2023 and she said she did not want to come back to the program because of her pain. S1PD documented he would call her in a month.

In an interview on 10/03/2023 at 2:40 p.m., S1PD confirmed that he did not submit a critical report to Louisiana Department of Health describing the crash involving S5D as per state rules and regulation. S1PD further confirmed he did not submit an incident report, a grievance report or a self-report describing the condition and concerns of Patient #R1 following the crash.

Based on record review and interview, the hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) program established clear expectations of patient safety. This deficient practice was evidenced by:
1) failing to complete two incident reports for two separate occurrences involving Patient #1 and Patient #R1;
2) falling to measure, analyze, and track falls and implement preventive actions.
Findings:

1) Failing to complete two incident reports for two separate occurrences involving Patient #1 and Patient #R1.
Review of facility policy titled "Incident/Accident Reporting", revised 03/21/2018, revealed, in part: Policy, in part: All incidents/accidents must be reported ...

Patient #1
Review of S2C's therapist note on 07/24/2023 revealed staff spoke with Patient #1's daughter who reported she was upset that client was not walked all the way to her door on Friday upon returning home from IOP. She states her mother needs assistance at all times.

In an interview on 10/02/2023 at 2:37 p.m., S2C reported that Patient #1's daughter had called her on 07/24/2023 to complain about S5D. The daughter said when she arrived at her mother's home she noted that her mother's walker was sitting by the steps to the front door. Patient #1's daughter stated she went into the house, and found her mother had soiled on herself, was dizzy and told her that no one helped her up the steps. She could not get up the steps with her lunch box, water bottle and the walker on her own. The daughter was upset because her mother was not helped to her door as agreed upon admit. S2C reported that she notified S1PD about the incident and S1PD said he would handle it.

In an interview on 10/02/2023 at 2:27 p.m., S1PD reported that the daughter had asked on admission to have the drivers escort her mother to the door. The daughter was told that they would tell the drivers to walk her to the door and that they would put instructions on the drivers list of patients. S1PD stated he could not recall the daughter previously calling and complaining about S5D not helping her mother up the steps to her front door.

In a telephone interview on 10/03/2023 at 9:37 a.m. Patient #1's daughter stated, she called S2C on 07/21/2023 and complained that her mother had not been walked to the door as agreed upon at admission. She was assured that she would be walked to the door. S2C told her the administrator was gone for the day and he would call back. When he did not call back, she called the S1PD herself. She told him what had happened and he said that the bus driver said she did not need assistance. S1PD told her he would take care of it and make sure it did not happen again.

Review of facility records failed to reveal an incident report regarding the incident that occurred on 07/24/2023 involving Patient #1 after her daughter notified the facility of the events.

Patient #R1
Review of incident report dated 09/15/2023 revealed a hit and run crash involving a facility van driven by S5D.

Review of facility records failed to reveal submission of a critical incident report to the Louisiana Department of Health for the hit and run accident involving facility driver S5D and potential injury to Patient #R1 who was one of the patients in the vehicle at the time of the incident.

Further review of facility records failed to reveal an incident report regarding the concerns and complaints of Patient #R1.

In an interview on 10/03/2023 at 2:00 p.m., S1PD reported Patient #R1 who was in the van when the crash occurred started with back pain after the crash and had not been able to return to Intensive Outpatient (IOP) since the accident. S1PD further stated Patient #R1 stated she did not want to come back because she was moving slowly and having trouble with pain. Patient #R1 called the facility on the 09/21/2023 and told a counselor that she was not sure what to do about seeing a doctor since her back was hurting. Patient #R1 reported she was a mess from prior injuries and this pain from the accident was aggravating older injuries. Patient #R1 called to back to speak with S1PD about the pain and her inability to come to IOP because of the pain and he told her that he would pass on the information and someone would call her. S1PD attempted calling her again on the 09/29/2023 and no answer. S1PD documented he would call her the next week. S1PD called Patient #R1 on 10/02/2023 and she said she did not want to come back to the program because of her pain. S1PD documented he would call her in a month.

In an interview on 10/03/2023 at 2:40 p.m., S1PD confirmed that he did not submit a critical report to Louisiana Department of Health describing the crash involving S5D as per state rules and regulation. S1PD further confirmed he did not submit an incident report, a grievance report or a self-report describing the condition and concerns of Patient #R1 following the crash.

2) falling to measure, analyze, and track falls and implement preventive actions.
Review of hospital's policy titled, Quality Assurance and Performance Improvement Measures, revealed in part, hospital leadership, under the supervision of the QAPI Coordinator, determines how the data are used identify, prioritize and monitor Quality Assurance and Performance Improvement (QAPI) activities. Additionally the QAPI Coordinator collects and maintains written reports.

Review of facility document titled "Beacon Unusual Occurrence Incident Report-Employee" dated 08/04/2023 revealed S5D was assisting Patient #1 into her group room. He stated that the patient stumbled over her own feet. He was holding on to her the whole time. He did hold her as she fell to her knees. He stated after falling to her knees she shifted and sat on the group room floor. He asked her if she was o.k., Patient replied yes. He stated he helped her up and into her chair. The incident occurred around 9:15 a.m. The incident was reported to S1PD after 2:00 p.m. by a phone call from Patient #1's daughter. Patient #1's daughter was informed that S1PD was not made aware of an incident today but that he would reach out to the driver as soon as he was finished his route. S1PD checked in with other staff to see if they were aware of Patient #1 falling on this day. The other staff were not aware.

Review of facility Operational Report for COW dated August 2023 revealed a statement listed under Physical Environment/Safety Concerns stating, No falls this month.

In an interview on 10/03/2023 at 8:30 a.m., S12CCO confirmed that the facility failed to measure, analyze, and track falls and implement preventive actions.

Based on record review and interview, the hospital failed to ensure outpatient services are appropriately organized as evidenced by:
1) failure to ensure medical staff providing outpatient services are appointed by the governing board in a timely manner;
2) failure of the hospital to have the ability to provide Medical Executive Committee and Governing Body meetings to the outpatient facility administration.
Findings:

1) Failure to ensure medical staff providing outpatient services are appointed by the governing board.
On 10/02/2023 a review of the personnel record of S9PNP revealed an agreement dated 04/26/2023. The agreement was for Psychiatric Coverage and on-call services by and between the outpatient facility and S9PNP. Further review revealed the agreement was signed by S14Dir. Further review failed to reveal S9PNP was appointed to Medical Staff by the Governing Board.

On 10/03/2023, S12CCO presented a new copy of S9PNP's agreement dated 04/26/2023 signed by S15SVP. S12CCO stated S15SVP was on the governing board and approved the appointment.

In an interview on 10/03/2023 at 1:50 p.m., S12CCO stated that S9PNP was an off cycle emergency approval and approved by CEO, Sean Wendell and Medical Director Dr. Rodriquez. S12CCO reported she did not have documentation available confirming the temporary appointment on 04/26/2023.

2) failure of the hospital to have the ability to provide Medical Executive Committee and Governing Body meetings to the outpatient facility administration.

A document request was made for a copy of the Medical Executive Committee (MEC) meeting minutes and the Governing Body Meeting Minutes for the last year for confirmation of the appointment of S9PNP to medical staff. S12CCO stated the MEC meeting minutes were not available to the outpatient facility.

Based on record reviews and interviews, the facility failed to ensure that personnel providing outpatient services were qualified and oriented to the facility before providing services. This deficient practice is evidenced by failure to have documented evidence of current CPR certifications, de-escalation training and/or orientation by appropriately qualified staff for 1 (S5D) of 1 driver personnel file reviewed and 2 (S8PNP and S9PNP) of 2 medical personnel files reviewed from a total of 10 (S1PD, S2C, S3LPN, S4SW, S5D, S6MHT, S7MD, S8PNP, S9PNP, and S13PCA) outpatient services personnel files reviewed.
Findings:

Review of facility policy titled "Patient Rights", revised 03/21/2018, revealed, in part: In accordance with Loiuisana Licensing Regulations for Hospitals 9319 every patient has the right to, in part" 18. Receive care in a safe setting.

S5D
A review of facility document titled "Driver" revealed, in part: Specific Responsibilities and Duties, in part: Ability to satisfy requirements for Healthcare Provider CPR and Crisis Prevention certification. Ability to satisfy requirements for crisis prevention and intervention training.

A review of facility policy titled "Hospital Transportation Services" revised 03/21/2018, revealed, in part: Drivers...are employees with...certification in BLS and taining and certification in managing the escalating patient.

Review of S5D's personnel file revealed he was hired on 02/03/2023 as a driver of the outpatient facility. Further review failed to reveal evidence of CPR and Crisis Prevention certification and the ability to satisfy requirements for crisis prevention and intervention training.

In an interview on 10/02/2023 at 1:15 p.m., S12CCO confirmed that there was no evidence of S5D's CPR and Crisis Prevention certification and the ability to satisfy requirements for crisis prevention and intervention training.

S8PNP and S9PNP
Review of the S8PNP personnel file revealed date of hire 04/26/2023. Further review failed to reveal that S8PNP underwent facility orientation before providing patient care.

Review of the S9PNP personnel file revealed date of hire 08/12/2021. Further review failed to reveal that S9PNP underwent facility orientation before providing patient care.

In an interview on 10/03/2023 at 2:55 p.m., S12CCO confirmed that S8PNP and S9PNP did not undergo facility orientation before providing patient care.