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Based on record review and interview, the hospital 1) failed to ensure that employees immediately reported witnessed abuse (Patient #1) and 2) failed to thoroughly investigate all incidents of possible abuse and/or neglect and implement corrective action. This deficient practice is evidenced by failure to immediately report observed physical abuse and thoroughly investigate and implement corrective actions for all reported cases of possible abuse or neglect in 4 of 4 reviewed incidents reports involving physical abuse (Patient #1), elopements (Patient #2, 3, 4) and vape use (Patient #2).
Findings:

1) Failure to ensure that employees immediately report witnessed abuse as required by R.S. 40:2009.20 for 1 incident involving patient abuse (Patient #1)

Review of LA R.S. 40:2009.20 revealed in part, "Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, licensed practical nurse, nurse's aide, home- and community-based service provider employee or worker, personal care attendant, respite worker, physician's assistant, physical therapist, or any other direct caregiver 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."

Review of the policy titled, "Reporting Abuse/Neglect,"(no date), revealed in part, "All staff members are required to immediately report alleged, suspected or witnessed abuse and/or neglect to their supervisors. The administrator on duty is notified of all alleged, suspected, or witnessed abuse and/or neglect immediately."

Review of the abuse/neglect self-report submitted to LDH dated 03/05/2024 revealed that on 03/03/2024 at 8:15 a.m., S2RN (Charge Nurse) slapped Patient #1 across her face. Further review of the report revealed that S1Compliance reviewed the video footage and observed the physical abuse involving S2RN and Patient #1.

The report revealed that S4BHT Supervisor was notified of the incident on 03/03/2024 at 9:00 p.m. and S3DON was notified on 03/03/2024 at 10:00 p.m. The report did not indicate what staff member reported the abuse to S4BHT Supervisor and S3DON. The report did not indicate if S2RN was immediately sent home after this incident of physical abuse.

The bottom of the report indicated that S2RN was an agency nurse and would not be scheduled to work at this hospital anymore. At handoff report, all staff members are reminded that they must report alleged, suspected or witnessed abuse immediately. Formalized mandatory trainings are scheduled for all staff members, for the remainder of March 2024 and will conclude no later than 03/29/2024.

Review of Patient #1's night shift nurses note completed by S2RN, dated 03/03/2024 (no time) revealed in part that Patient #1 was on the floor and tried to kick S2RN and "this nurse tap her on the face no bruises/swelling/redness on client".

On 04/08/2024 at 2:30 p.m., Patient #1's abuse self-report, completion date of 03/05/2024, was reviewed with S1Compliance and S5CEO. They confirmed that the report revealed that S3DON and S4BHT Supervisor was notified of the abuse on the night it occurred. When asked if S2RN was removed of her duties immediately after the incident was reported, they stated no. They stated that S2RN completed her shift at the hospital on the night of 03/03/2024. When asked how they found out about the abuse, they stated that staff was talking about it the next morning and that is when they began to investigate it. When asked if there was any documented evidence that trainings had occurred with all staff regarding abuse reporting, S1Compliance stated no.

On 04/09/2024 at 9:45 a.m., interview with S3DON revealed that the ward clerk and S2RN called her on the night of 03/03/2024. When asked what they reported, S3DON stated they reported Patient #1's behaviors that night. When asked if they reported any physical abuse to her, S3DON stated no. When asked if it was normal for the ward clerk to call her late at night, S3DON stated, "she calls me for everything". S3DON stated she was not aware of the incident until the next morning when staff were talking about it.

On 04/09/2024 at 10:50 a.m., interview with S4BHT Supervisor was conducted. S4BHT Supervisor stated that on the night of 03/03/2024, the ward clerk contacted him and informed him that S2RN slapped Patient #1 across the face. S4BHT Supervisor stated he immediately notified S6RN/Administrative and S3DON on the night of 03/03/2024 of the physical abuse that was reported to him by the ward clerk. He further stated that one of the techs working that night also called him and reported that S2RN "lost it" on Patient #1. When asked if he had performed any recent trainings on abuse and abuse reporting, S4BHT Supervisor stated no.

On 04/09/2024 at 11:10 a.m., interview with S5CEO revealed that he was not sure where the breakdown was on the night of 03/03/2024, but confirmed that S2RN should not have continued to work her shift after being witnessed abusing Patient #1. S5CEO further confirmed that there was no documented evidence that an action plan was implemented after this incident to prevent it from happening again in the future.

2) Failure to thoroughly investigate all incidents of abuse and neglect and implement corrective action

Patient #1
Review of the LDH abuse/neglect self report revealed the patient was slapped across the face by S2RN. The report indicated that the abuse was witnessed by staff, but no documented investigation as to who the staff reported the abuse to or why S2RN continued to finish her shift after witnessed physical abuse. The self report indicated that all staff members are reminded that they must report alleged, suspected or witnessed abuse immediately. Formalized mandatory trainings are scheduled for all staff members, for the remainder of March 2024 and will conclude no later than 03/29/2024.

On 04/08/2024 at 2:30 p.m., S1Compliance was asked if there was any documented evidence that the staff had received any recent trainings regarding abuse or abuse reporting and he stated no.

Patient #2 and #3
Review of the abuse/neglect self-report submitted to LDH on 03/25/2024 revealed that on 03/23/2024, Patients #2 and #3 eloped from the hospital after placing blankets and sheets in their beds to resemble bodies under the covers. The patients eloped from a non-functional door on their hallway. Video surveillance was reviewed which revealed the patients eloped at 9:47 p.m. on 03/23/2024. The staff was not aware of the patients being missing until Patient #4's mother called the hospital that night to inform them that the patient had just called her from a fast food restaurant in the town. The police were called and they returned the patients to the hospital on 03/24/2024 at 12:56 a.m.

The self-report further revealed that all direct care staff will be educated to observe for signs of life when doing rounds. This will commence on 03/25/2024 and will be mandatory to be completed by 03/31/2024, or the staff member will not be assigned to rounds until completed. A tech will be stationed at the faulty door until it can be repaired.

Review of the medical records for Patients #2 and #3 revealed their close observation logs (every 15 minute checks) revealed inaccurate documentation that the patients were asleep in the beds during the entire time of the elopement on 03/23/2024 and 03/24/2024.

On 04/09/2024 at 1:30 p.m., interview with S1Compliance confirmed there was no documented evidence that education was performed to all direct care staff regarding observing for signs of life during rounds. S1Compliance further stated that he and the hospital's consultant developed the action plan but it was not passed on S4BHT Supervisor, who could implement the plan and perform the training.

Patient #2
Review of an incident report dated 03/15/2024 revealed it was reported that Patient #2 had stolen a vape from the nurses station on 03/14/2024. The report further stated that a pink vape was recovered where patient was said to have had it all night and used it. Peer states that patient told her she stole it from the nurses station and was using it all night.

There was no documented evidence that the incident was thoroughly investigated to determine how the patient got into the nurses station in order to steal the vape.

On 04/09/2024 at 12:40 p.m., interview with S1Compliance revealed that the nurses station should be locked at all times and patients should not be in the nurses station. When asked if there was any documented evidence that an investigation was completed to determine how the patient got into the nurses station to prevent an incident like this one from occurring again, S1Compliance stated no.

Patient #4
Review of an abuse/neglect self-report submitted to LDH on 04/02/2024 revealed that Patient #4 ran toward an open gate on the north lawn adjacent to the dumpsters after housekeeping left the door open after taking out the trash. A tech saw the patient outside the fence and escorted him back to the dorm.

The self-report further stated that housekeeper that left the gate open was re-educated by S4BHT Supervisor on the importance of ensuring that all exits/entrances remain locked.

On 04/09/2024 at 2:45 p.m., interview with S4BHT Supervisor revealed that he is over the techs, housekeepers and maintenance. He stated that he re-educated the housekeeper that left the gate open on 04/02/2024. When asked how many staff have the key to unlock the gate that was left open on 04/02/2024, S4BHT Supervisor stated 4 staff members. When asked if he had re-educated the other staff members that have the potential to leave the gate unlocked on the importance of locking all exits/entrances, he stated no.

On 04/09/2024 at 3:45 p.m., interview with S1Compliance confirmed that all staff that have access to keys that lock exit/entrance gates should have been re-educated. When asked if there was a documented investigation to determine why the door was left open, such as a faulty lock or faulty gate, S1Compliance stated no.

Based on record review and interview, the hospital failed to ensure that the director of nursing service provided adequate supervision and evaluation of all nursing personnel who provide services in the hospital as evidenced by failing to have evidence of orientation or competency skills on 2 of 2 contracted agency nurses who provide care at the hospital (S2RN, S7RN)
Findings:

On 04/08/2024 at 1:30 p.m., S3DON and S5CEO was asked for the personnel file for S27RN, an agency nurse who currently works nights at the hospital. At that time, they confirmed that there was no personnel file for the nurse, only a contract with the staffing agency stating they had checked the nurses qualifications. When asked if the nurse had CPI or CPR certification, they stated they were unsure. When asked if the nurse had been assessed for competency, S3DON stated no, but stated the nurse had worked in a psychiatric hospital in the past.

Further interview with S3DON and S5CEO revealed that there was no personnel file for S2RN, an agency nurse who was witnessed by staff of slapping a patient on the face on 03/03/2024. They further stated that the hospital has no policy and procedure that addresses training/competency/personnel files for agency nurses.