HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the Quality Assurance/Performance Improvement program measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of services and quality of care. This deficient practice was evidenced by failing to ensure self-reporting of allegations of abuse were completed and submitted to Louisiana Department of Health following incident reports regarding peer to peer sexual abuse allegations for 4 of 8 incident reports reviewed (Patients #1, 2, 3, 4).
Findings:

Review of the Hospital's Policy PE.032A titled, "Abuse and Neglect Assessment / Reporting" revealed in part: 1. It is the policy of this hospital to adhered to Louisiana Children's Code article 609, which provides that a mandatory reporter who has cause to believed that a child's physical or mental health or welfare is endangered as a result of abuse, sexual abuse or neglect, or that abuse or neglect contributed to the death of a child, must report immediately to the Department of Children and Family Services.

Review of the Hospital's Policy RI.018 titled, " Alleged Patient Abuse, Neglect, Exploitation" revealed in part: To provide a Response and Notification Plan in the event of a sexual allegation and/or incident. Notify State Agencies as required by state statues.

Review of the hospital's documentation failed to reveal a self-report was filed with Louisiana Department of Health following alleged peer to peer sexual abuse for Patients #1, 2, 3 and 4.

Interview 12/13/2023 at 2:00 p.m., S1Director of Risk Management reviewed his documents and confirmed a Self-Report to Louisiana Department of Health was not submitted for Patients 1, 2, 3, 4.