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Based on record review and interview, the hospital failed to ensure incidents of alleged neglect were reported to LDH within 24 hours of discovery. This deficient practice was evidenced by failure to report an allegation of neglect for 1 (#3) of 2 (#3, #R1) sampled patients reviewed for grievances/allegations of abuse/neglect.

Findings:

Review of the hospital policy titled, "Abuse and/or Neglect of Patients by Staff Memebers, Students, Interns", Policy number: RTS-10, revealed in part: Policy: Patients have the right to be free from neglect, exploitation, and verbal, mental, physical and sexual abuse. The facility supports and conforms to all state and federal guidelines for protection of patients' rights. Definition of neglect is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer's well-being. Example of actions/inactions which could be considered mistreatment/abuse: failing to or refusing to attend to necessary care and treatment.

Review of the hospital policy titled,"Assessment and Reporting of Abuse, Neglect, Exploitation, and/or Extortion of Youth and Adults", Policy Number: AS-18, revealed in part: Self-reporting: Adminsitrator/DON: Notify the COO prior to reporting. A facility must self report internal allegations of abuse/neglect to maintain compliance with CMS Regulations 482.113 (c)/LA R.S. 40:2009.20. which calls for reporting of knowledge of potential abuse incidents within 24 hours to either local law enforcement or LDH.

Review of the hospital provided grievances for the last year revealed a grievance filed by a family member of Patient #3 on 12/4/17 alleging the patient had not been been bathed or taken care of during his hospital stay. Additional review revealed the complainant alleged Patient #3 had been left in a soiled diaper with urine running out of the diaper.

In an interview on 2/28/18 at 3:00 p.m. with S1Adm, she confirmed she had not reported the allegation of neglect of Patient #3 during his hospital stay within 24 hours of receipt of the grievance. S1Adm indicated she had investigated the grievance and had found it to be unfounded so she had not notified LDH.

Based on interview and record review, the registered nurse failed to supervise and evaluate the nursing care provided to each patient as evidenced by failing to ensure the condition of patients' skin was accurately assessed, on admit, daily per shift , and upon discharge for 2 (#2, #3) of 5 (#1-#5) sampled patients reviewed for skin assessments.

Findings:

Review of the hospital policy titled, "Skin/Wound Care Protocol", Policy Number: NS-39, revealed in part: Policy: A skin assessment is completed by the nurse on all patients upon admission, weekly, after a fall/injury, upon new findings and at discharge. Wound care prevention protocol: Pictures of wounds should be placed on each patient's wound assessment form. Other skin abnormalities such as skin tears and abrasions will be identified utilizing the nursing assessment process and documented on the skin assessment and wound assessment form as applicable. Procedure: Description of skin abnormalities should be documented according to the assessed findings and initiate the impaired skin integrity treatment plan.

Patient #2
Review of Patient # 2's medical record revealed an admission date of 11/20/17 with an admission diagnosis of Dementia with Behavioral Disturbances and a co-morbid diagnosis of Anemia. Further review revealed the patient was receiving Aspirin (blood thinner) 81milligrams by mouth once a day and Plavix (anticoagulant) 75 milligrams by mouth once a day.

Review of Patient #2's medical record revealed an admission skin assessment had been performed on Patient #2 on 11/20/17 at 9:00 p.m. The skin assessment had been documented as skin check completed (including scalp), no significant findings, and color normal with no wounds. Additional review of Patient #2's medical record revealed a discharge skin assessment had not been performed on the patient as per the skin assessment directive referenced above.

Review of Patient #2's daily nurses' notes revealed the following, in part:
11/21/17 - 7:00 a.m. and 7:00 p.m.: skin documented as integumentary assess with no other detail/description of the condition of the patient's skin.
11/22/17 - 7:00 a.m. and 7:00 p.m.: a box indicating bruises was checked. Further review revealed no documentation of a description of the bruising such as location, number, color, size, and whether the bruise was flat or raised.
11/23/17 - 7:00 a.m.: a box indicating bruises was checked. Further review revealed no documentation of a description of the bruising such as location, number, color, size, and whether the bruise was flat or raised.
11/23/17 - 7:00 p.m.: a box indicating wounds was checked. Further review revealed no documented evidence of a description of the type, location and appearance of the wound. The choice for bruises was left blank.
11/24/17 - 7:00 a.m.: skin documented as integumentary assess with no other detail/description of the condition of the patient's skin. The choice for bruises was left blank.
11/24/17 - 7:00 p.m.: skin assessment choice was checked as other with intact written in as a notation. The choice for bruises was left blank.
11/25/17 - 7:00 a.m.: skin documented as integumentary assess with no other detail/description of the condition of the patient's skin. The choice for bruises was left blank.
11/25/17 - 7:00 p.m.: skin assessment choice was checked as other with intact written in as a notation. The choice for bruises was left blank.
11/26/17 - 7:00 a.m.: skin documented as integumentary assess with no other detail/description of the condition of the patient's skin. The choice for bruises was left blank.
11/26/17 - 7:00 p.m.: skin assessment choice was checked as other with intact written in as a notation. The choice for bruises was left blank.
11/27/17 - 7:00 a.m.: boxes indicating bruises and integumentary assess were both checked. Further review revealed no documentation of a description of the bruising such as location, number, color, size, and whether the bruise was flat or raised. Patient #2 was discharged on 11/27/17.

In an interview on 2/28/18 at 12:12 p.m. with S5RN, she confirmed she had cared for Patient #2 after review of the patient's medical record. S5RN indicated she doesn't really remember the patient. S5RN confirmed she had charted bruising on the patient and that she had discharged the patient as well. S5RN acknowledged she should have performed a skin assessment, should have described the bruising and should have taken a picture both upon discovery of the bruising and upon patient discharge.

In an interview on 2/28/18 at 12:21 p.m. with S1Adm, she confirmed patient skin assessments should have been performed on admission, weekly, after a fall/injury, with new findings, and at discharge. S1Adm reported if a skin finding is not present on admit and is later found then it is considered a change in patient condition. S1Adm indicated that at bare minimum the staff must be able to answer questions about the source of the new finding. S1Adm further indicated another Braden skin assessment should have been done and pictures should have been taken when any new finding is discovered, including bruising. S1Adm confirmed there had been no documented incident reports completed regarding Patient #2's bruising and Patient #2 had no reports of having fallen.

Patient #3
Review of Patient #3's medical record revealed an admission date of 11/28/17 with an admission diagnosis of Vascular Dementia with behavioral disturbance.

Review of Patient #3's admission skin assessment on 11/28/17 revealed the patient's skin had been documented as intact (finding verified per review by S2DON). Additional review of Patient #3's medical record revealed a discharge skin assessment had been performed on 12/7/17 at 12:05 p.m. and the assessment had indicated the patient had 3 small red dots on the back and side of his left leg and a mild, pink/red area on his buttocks (finding verified per review by S2DON).

Review of Patient #3's medical record revealed a progress note, dated 12/5/17, completed by S3NP, indicating staff had informed her that Patient #3 had redness to his buttocks, Calmoseptic was ordered and the plan was to continue treatment.

Review of Patient #3's physician's orders, dated 12/5/17 at 1:08 p.m., revealed an order for Calmoseptic ointment to affected area of buttocks.

Review of Patient #3's Discharge Summary, dated 12/7/17, revealed documentation indicating the patient had a Stage I buttock wound.

Review of Patient #3's daily nurses' notes revealed the following, in part:
The patient's daily nurses' notes from 11/28/17 to the 7:00 p.m. shift of 12/5/17 revealed documentation that Patient #3's skin was intact.

Further review of Patient #3's daily nurses' notes revealed the following entries:
12/6/17 7:00 a.m. - skin assessment documented as patient having a sacral wound. Further review revealed no documented evidence of any further description of the wound.
12/6/17 7:00 p.m.: skin documented as integumentary assess with no other detail/description of the condition of the patient's skin and no mention of a wound.
12/7/17 7:00 a.m.: skin documented as integumentary assess with no other detail/description of the condition of the patient's skin and no mention of a wound.

In an interview on 2/28/18 at 2:35 p.m. with S2DON, she reviewed Patient #3's medical record and verified the inconsistencies in the patient's skin assessment documentation.

Based on record review and interview, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan for each patient. This deficient practice was evidenced by failure of the nursing staff to update the patient's plan of care to include identified skin issues as problems to be addressed on the plan of care for 2 (#2, #3) of 5 sampled patients reviewed for care plans.

Findings:

Review of the hospital policy titled, "Skin/Wound Care Protocol", Policy Number: NS-39, revealed in part: A skin assessment is completed by the nurse on all patients upon admission, weekly, after a fall/injury, upon new findings, and at discharge. Wound care prevention protocol: Pictures of wounds should be placed on each patient's wound assessment form. Other skin abnormalities such as skin tears and abrasions will be identified utilizing the nursing assessment process and documented on the skin assessment and wound assessment form as applicable. Procedure: Description of skin abnormalities should be documented according to the assessed findings and initiate the impaired skin integrity treatment plan.

Patient #2
Review of Patient # 2's medical record revealed an admission date of 11/20/17 with an admission diagnosis of Dementia with Behavioral Disturbances and a co-morbid diagnosis of Anemia. Further review revealed the patient was receiving Aspirin (blood thinner) 81milligrams by mouth once a day and Plavix (anticoagulant) 75 milligrams by mouth once a day.

Review of Patient #2's daily nurses' notes revealed the patient had developed bruises on 11/22/17.

Review of Patient #2's treatment plan revealed no documented evidence that the bruising had been addressed as a problem on the patient's plan of care.

Patient #3
Review of Patient #3's medical record revealed an admission date of 11/28/17 with an admission diagnosis of Vascular Dementia with behavioral disturbance.

Review of Patient #3's medical record revealed a progress note, dated 12/5/17, completed by S3NP, indicating staff had informed her that Patient #3 had redness to his buttocks, Calmoseptic was ordered and the plan was to continue treatment.

Review of Patient #3's Discharge Summary, dated 12/7/17, revealed documentation indicating the patient had a Stage I buttock wound.

Review of Patient #3's treatment plan revealed no documented evidence that the Stage I buttock wound had been addressed on the patient's plan of care.

In an interview on 2/28/18 at 3:30 p.m. with S2DON, she agreed skin issues should have been addressed on the patients' plans of care.

Based on record review, observation, and interview, the hospital failed to ensure medical records were accurately written. This deficient practice was evidenced by failure of the hospital to ensure a patient's (# 1 ) skin condition was accurately assessed and documented by the LIP providing the patient's care for 1 (# 1) of 4 (#1,#2,#3,#4) sampled patients reviewed for wound/skin assessments from a total patient sample of 5 (#1-#5) and 1 random sampled patient (#R1).

Findings:

Review of Patient #1's medical record revealed an admission date of 2/15/18 with an admission diagnosis of Dementia with Behavioral Disturbances.

Review of Patient #1's weekly skin assessment, dated 2/24/18, revealed the following notation: no sacral wound noted - resolved.

Review of Patient #1's physician's progress notes, dated 2/27/18 at 11:42 a.m. , revealed in part: A/P (Assessment/Plan): 7. Stage III Pressure Ulcer Sacral - Continue treatment. The progress note had been completed by S3NP.

On 2/27/18 at 4:05 p.m. an observation was made of Patient #1's sacral and buttock area and the skin was noted to be intact with no evidence of breakdown/irritation of any type. S1Adm and S2DON were present during the observation and verified there was no current breakdown/irritation of any type on the patient's sacral and buttock area.

In an interview on 2/27/18 at 3:40 p.m. with S3NP, she indicated S4WoundNurse had told her Patient #1's nursing home paperwork had indicated the patient had a Stage III pressure ulcer. S3NP reported the patient's sacral/buttock area was covered with a barrier paste and she had not observed/assessed the area. S3NP indicated S4WoundNurse had told her once a patient had a Stage III pressure wound it remained a Stage III so she had said documented that the patient had a Stage III pressure wound without assessing the patient's skin.

In an interview on 2/27/18 at 3:50 p.m. with S1Adm, she agreed S3NP's documentation of Patient #1's skin condition had not been an accurate description of the current appearance of the patient's sacral and buttock area. S1Adm agreed S3NP should have documented the appearance of the patient's skin as it appeared currently and not based upon report of the patient's skin status from the nursing home documentation.