HospitalInspections.org

Based on record review and interview, the hospital failed to report an allegation of abuse to LDH-HSS (Louisiana Department of Health - Health Standards Section) or a local law enforcement agency within 24 hours of receipt of the allegation for 1 (#2) of 2 (#2,#5) sampled patients reviewed for allegations of abuse.

Findings:

Review of the State law R.S. 40:2009.20 revealed "Any person who is engaged in the practice of medicine, social service, facility administration, psychological services or any RN, LPN, nurses' aide, personal care attendant, respite worker, physician's assistant, physical therapist, or any other healthcare giver 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 24 hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect."

Review of Patient #2's medical record revealed an admission date of 3/31/17. Further review revealed the following entry, in part, documented on 4/11/17 at 10:00 a.m. by S6SW. The entry revealed Patient #2 had reported, to S6SW, that she had gone to the bathroom, was bleeding, and should not have been bleeding due to having had a hysterectomy. Additional review revealed the patient had indicated "she knew she had been raped here." S6SW had also documented in her note that she had informed the patient's nurse, S5Psychiatrist, and S7PatAdvocate of the patient's allegation of rape.

Review of the hospital's self-reports of allegations of abuse/neglect submitted to LDH-HSS from 1/1/2017-5/7/2018 revealed no documented evidence of a self-report regarding Patient #2's rape allegation.

In an interview on 5/7/18 at 2:02 p.m. with S5Psychiatrist, he confirmed Patient #2 had alleged that she had been sexually assaulted and had been sent to an area Emergency Department for evaluation for rape. S5Psychiatrist indicated he and S2DON had reviewed the hospital's video recordings to investigate the allegation.

In an interview on 5/8/18 at 3:30 p.m. with S3RiskMgr, he confirmed the hospital had investigated Patient #2's allegation of rape. S3RiskMgr indicated he had not reported the above-referenced allegations to LDH-HSS within 24 hours of discovery because the hospital had investigated the complaint and had found it to be unsubstantiated. S3RiskMgr also confirmed he had no documented evidence indicating whether or not the hospital had filed a police report regarding Patient #2's allegations.

Based on record reviews and interviews, the hospital failed to ensure the RN (registered nurse) supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by failure of the RN to assess a patient who had reported new onset of bleeding for 1 (#2) of 4 (#1-#4) sampled patient records comprehensively reviewed.

Findings:

Review of the hospital policy titled,"Acute Changes in Patient Conditions", policy Number: PC-038, revealed in part: The purpose of this policy is to establish guidelines and protocols in relation to visible and emergent baseline changes in the population that this hospital serves.
Procedure: ....2. Abnormal findings will not constitute as a change, however, will be closely monitored and can be treated as such if deemed necessary by the physician or charge nurse.... 4. Medical changes in patient condition may include, but are not limited to: g. bleeding....8. Any acute changes in patient's condition will also be documented in the nurses' notes, located in the patient's chart.

Review of Patient #2's medical record revealed an admission date of 3/31/17 with an admission diagnosis of major depressive disorder with suicidal ideations.

Further review of Patient #2's medical record revealed the following entry, in part, documented on 4/11/17 at 10:00 a.m. by S6SW. The entry revealed Patient #2 had reported, to S6SW, that she had gone to the bathroom, was bleeding, and should not have been bleeding due to having had a hysterectomy. Additional review revealed the patient had indicated "she knew she had been raped here." S6SW had also documented in her note that she had informed the patient's nurse, S5Psychiatrist, and S7PatAdvocate of the patient's allegation of rape.

Review of Patient #2's nurses note documentation, multidisciplinary notes, and the entire patient record revealed no documented evidence that the RN had performed a physical assessment to evaluate the patient's report of bleeding (new onset/change in condition).

In an interview on 5/8/18 at 10:15 a.m. with S5RN, she reported she had remembered Patient #2 (after review of the patient's medical record). S5RN confirmed, after review of Patient #2's medical record, that the patient had reported she had bleeding and should not have been bleeding due to having had a hysterectomy. S5RN also confirmed there was no documented evidence of an exam of the patient, by the patient's nurse, on 4/12/17 to evaluate if bleeding had been present as reported by patient. S5RN indicated even if a patient had refused an examination, the attempt to perform an evaluation and the patient's refusal should have been documented in the patient's record.