HospitalInspections.org

Based on record reviews and interview, the hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by failing to ensure patients were being monitored according to the provider order for 1 (#3) of 3 (#1, #2, #3) patients reviewed.

Findings:

Review of the hospital's policy titled "Observations, Patient", revised 09/2024, revealed in part, "In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN [registered nurse]. Level of observation can be increased by the RN any time there is a concern but only a psychiatric practitioner may decrease the level."

Review of Patient #3's medical record revealed Patient #3 was admitted on 04/22/2025 with diagnoses of major depressive disorder recurrent severe with psychotic features, attention-deficient hyperactivity disorder combined type, and nightmare disorder. Review of the provider's order dated 04/28/2025 12:04 PM revealed observation Q (every) 5 - suicide high.

Review of the observation sheet dated 04/28/2025 revealed Observation - from 12:11 AM to 11:52 PM interval 15 min (minutes). Review of the observation sheet dated 04/29/2025 revealed Observation - from 12:06 AM to 7:35 AM interval 15 min, Observation - from 7:42 AM to 11:58 PM interval 5 min. The Q15 minute observations status was not changed in the electronic observation system to Q5 minute observations until the day after the order was changed by the provider. Further review of the documents revealed there were 99 observations that were not every 5 minutes from the date/time the order was changed by the provider to the date/time the observation status was changed in the electronic observation system.

In an interview on 04/30/2025 at 5:01 PM S3DC verified the above stated findings.

Based on record reviews and interviews, the hospital failed to ensure the patient's right to be free from all forms of abuse or harassment. This deficient practice was evidenced by:

1.) failure to ensure allegations of potential abuse and/or neglect were reported to the Louisiana Department of Health (LDH) Health Standards Section (HSS) within 24 hours of the hospital becoming aware of the allegations and

2.) failure to implement the hospital's grievance process for an allegation of potential abuse and/or neglect.


Findings:

1.) Failure to ensure allegations of potential abuse and/or neglect were reported to the Louisiana Department of Health (LDH) Health Standards Section (HSS) within 24 hours of the hospital becoming aware of the allegations.

Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report allegations and/or suspicion of abuse and/or neglect within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or LDH. This statute would include any issue under review for the determination whether the facility failed to take prudent action to prevent, and/or respond to an alleged occurrence such as a potential self-injurious behavior or an elopement.

Review of the LDH Hospital / Licensed Provider Abuse / Neglect Initial Report form revealed in part, on 02/21/2025 7:00 PM - 7:00 AM shift S4RN was in the process of admitting Patient #2 and she told the admitting nurse that Patient #1 (another patient that was in the adolescent intake area) touched her inappropriately and tried to kiss her.

In an interview on 04/29/2025 at 2:34 PM S3DC verified the hospital could not find the documentation of the above stated Self-Report being sent to LDH.

2.) Failure to implement the hospital's grievance process for an allegation of potential abuse and/or neglect.

Review of the hospital's policy titled "Grievance, Patient", revised 04/2020, revealed in part, "All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS [Centers for Medicare & Medicaid Services] requirements are considered grievances for the purposes of these requirements."

Review of the LDH Hospital / Licensed Provider Abuse / Neglect Initial Report form revealed in part, on 02/21/2025 7:00 PM - 7:00 AM shift S4RN was in the process of admitting Patient #2 and she told the admitting nurse that Patient #1 (another patient that was in the adolescent intake area) touched her inappropriately and tried to kiss her.

Review of the grievance log for February and March 2025 failed to reveal the above stated allegation of potential abuse/neglect as a grievance.

In an interview on 04/30/2025 at 10:05 AM S5PA verified the above stated allegation of potential abuse/neglect was not handled as a grievance by the hospital. She stated no one called her regarding this allegation.