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Based on record review and interview, the facility failed to thoroughly investigate and report all incidents of possible neglect. The deficient practice is evidenced by 1) failure to report possible neglect as required by R.S. 40:2009.20 for 3 incidents involving 1 (#4) of 4 (#1- #4) reviewed records; and 2) failure to thoroughly investigate all reported cases of possible abuse or neglect in 1(#3) of 1 reviewed incident that was reported to Louisiana Department of Health/ Health Standards Section.

Findings:

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 Policy Number CS-23, "Level of Observations," effective 01/11/2016 and last revised 03/01/2023, revealed in part, "One-to-one observation- the staff will ensure the patient is visually within sight and within arms-reach of a staff member at all times and in all circumstances. . . .1:1 Observation is defined as: Keeping the patient under direct observation within one arm's reach of the patient at all times. This includes use of the bathroom and bathing."

1) Failure of the facility to report possible abuse or neglect as required by R.S. 40:2009.2.0.

Review of the medical record for Patient #4 revealed admission on 02/26/2024 under a Corner's Emergency Certificate for suicidal ideation. The patient had a history of previous suicide attempts and was diagnosed with anxiety, borderline personality disorder, and depression. The patient was admitted with suicide precautions.

Review of the incident reports revealed 3 incidents of attempted self-injury for Patient #4. Review of the binder with the incidents reported to Louisiana Department of Health failed to reveal the incidents for Patient #4 were reported.

In interview on 03/05/2024 at 11:17 a.m., S3LPN verified the incidents were not reported to Louisiana Department of Health as possible neglect.

Review of the first incident revealed on 02/27/2024 at 4:30 p.m., the patient was in her room on one-to-one observation and was found to have several cuts to both arms. First aid was rendered and the physician and supervisor were notified. A body search was completed and the patient gave them a small piece of glass. The patient reported having brought the small piece of glass into the facility in her mouth.

In interview on 03/05/2024 between 1:00 p.m. and 1:30 p.m., S2NS verified the patient had been on one-to-one observation and suicide precautions at the time of the incident. S2NS verified the incident happened in the bedroom while the patient was in the bed under the covers. S2NS verified the one-to-one observation is to prevent such occurrences and should not have happened. S2NS verified there was no documentation the room was searched after the incident to remove other objects that could be used for self-injury. S2NS verified those involved were re-educated on the importance of a thorough search at the time of admission.

Review of the second incident revealed on 02/28/2024 at 10:30 a.m., the Patient #4 cut herself across the arms again with a second piece of glass in the bathroom. Patient #4 was still on one-to-one observation. The patient was examined by the physician and the wounds were documented in the wound care section of the medical record and the care plan was updated. Staff was again counseled on body search at the time of admission.

In interview on 03/05/2024 between 1:00 p.m. and 1:30 p.m., S9NS verified Patient #4 was still on one-to-one observation and suicide precautions at the time of the incident. S9NS verified the incident occurred in the patient's restroom, but was discovered when the patient was meeting with the treatment team. S9NS said she immediately went into Patient #4's room with the mental health technician and nurse and searched the room thoroughly. S9NS verified the search was documented in the medical record. S2NS verified patients on one-to-one are not allowed in the bathroom alone and there was no documentation the staff providing the one-to-one observation were questioned as part of the investigation.

Review of the third incident revealed on 03/01/2024 at 4:45 p.m., Patient #4 was found sitting on the floor of the dayroom, behind a chair, cutting her forearm. Patient #4 had "2 EKG leads" that were being used to cut her arm. The nurse practitioner and the nursing supervisor were notified, first aid rendered, and a search was performed.

In interview on 03/05/2024 between 1:00 p.m. and 1:30 p.m., S2NS verified Patient #4 should not have been "found sitting in the dayroom behind a chair cutting her forearm," because she was on one-to-one observation. S2NS verified there was no documented interview of the staff providing one to one observation. S2NS stated the patient did not tell them where she got the EKG equipment, but it was assumed to have been brought into the facility by her roommate, who returned to the facility after midnight on 03/01/2024 after an emergency department visit. S2NS verified there was no documentation the roommate, Patient #FR1, had been searched upon return to the facility.

During the tour of the facility on 03/05/2024 between 10:23 a.m. and 10:45 a.m., Patient #4 was observed in her room lying in the bed on one-to-one observation. The patient was noted to have a solid deodorant stick in a plastic container on the shelf beside the bed.

At the time of discovery, S2NS verified it should not be in the room and promptly removed it.

In interview on 03/05/2024 at 1:30 p.m., S2NS verified the incidents should have been self-reported to Louisiana Department of Health.

2) Failure of the facility to thoroughly investigate all reported cases of possible abuse or neglect.

Review of the final report sent to Louisiana Department of Health/ Health Standards Section on 02/26/2024 revealed on 02/15/2024 at 4:33 p.m., Patient #3 was witnessed leaving the room of Patient #2. When interviewed Patient #3 reported "she had had sex with Patient #2." When Patient #2 was interviewed he "denied the encounter took place." The report indicates that the police and the physician were notified and Patient #3 was sent for a forensic rape examination. Video from the hall where the room was located was reviewed and Patient #3 was seen entering the room of Patient #2 at 4:24 p.m. and exit the room at 4:33 p.m. The door was noted to be open and staff could be seen in the vicinity. The report concluded that the facility was unable to substantiate the allegation due to lack of evidence.

Review of the medical record for Patient #2 revealed admission on 02/12/2024 under a Corner's Emergency Certificate with suicidal and homicidal hallucinations. Patient #2 was admitted with a diagnosis of schizoaffective disorder- bipolar type, methamphetamine use, and cocaine abuse. Patient #2 was on 15 minute observation and was noted to be in his room at the time of the event.

Review of the medical record for Patient #3 revealed admission on 02/13/2024 under a Physician's Order of Protection. Patient #3 was admitted with a diagnosis of bipolar disorder- manic state and delusional disorder. Patient #3 was on 15 minute observation. Review of the observation sheet revealed Patient #3 was in the dayroom from 3:45 p.m. until 4:45 p.m.

In interview on 03/05/2024 at 12:18 p.m., S2NS verified Patient #3 could not have been in the dayroom at 3:30 p.m. as documented on the observation sheet when video proved she was in the room of Patient #2. S2NS verified the mental health technician should have been searching for her when she was not seen in the dayroom at 3:30 p.m. and was negligent in his observations.

In interview on 03/05/2024 at 2:10 p.m., S1ADM verified the conclusion in the report was there was not enough evidence to substantiate the allegation of sexual abuse and the possibility of neglect of care by the mental health technician was not investigated.