HospitalInspections.org

Based on observation, record review, and interview the hospital failed to meet the Conditions of Participation (CoP) of Patient Rights. This deficient practice was evidenced by:
1. Failing to ensure the safety and protection of 1 (#4) of 4 (#1 - #4) patients from the ingestion of alcohol based hand sanitizer (See Findings Tag A0144);
2. Failing to ensure the safety and protection of 1 (#1) of 4 (#1 - #4) patients from bodily injury during two altercations with peers (See Findings Tag A0144);
3. Failing to fully investigate an incident resulting in bodily injury to 1 (#1) of 4 (#1 - #4) patients (See Findings Tag A0144); and
4. Failing to timely report allegations of abuse/neglect on 1 (#1) of 4 (#1 - #4) patients to Louisiana Department of Health - Health Standards Section (LDH-HSS) (See Findings Tag A0144).

Based on observation, record review and interview, the hospital failed to provide patient care in a safe setting. This deficient practice was evidenced:
1. Failing to ensure the safety and protection of 1 (#4) of 4 (#1 - #4) patients from the ingestion of alcohol based hand sanitizer;
2. Failing to ensure the safety and protection of 1 (#1) of 4 (#1 - #4) patients from bodily injury during two altercations with peers;
3. Failing to fully investigate an incident resulting in bodily injury to 1 (#1) of 4 (#1 - #4) patients; and
4. Failing to timely report allegations of abuse/neglect on 1 (#1) of 4 (#1 - #4) patients to Louisiana Department of Health - Health Standards Section (LDH-HSS).
Findings:

1. Failing to ensure the safety and protection of 1 (#4) of 4 (#1 - #4) patients from the ingestion of alcohol based hand sanitizer

A review of facility policy, "Contraband - Clients," Policy Number LD-12, effective on 04/15/2013, last revision 04/08/2015 and approved 04/21/2025, revealed in part, I. Definitions: A. Contraband: Any item that can be considered dangerous, injurious or that might be a threat to the integrity or security of the Hospital. Categorized as Class I, II, III, or IV. II. Purpose: To identify contraband material, ensure the protection and safety of all clients, visitors, and employees, and comply with State law. Policy: The Hospital recognizes its responsibility to identify and security risks created by possession of contraband. The Hospital takes action to prevent incidents of contraband from coming into the hospital and develops processes for surveillance, conducting searches, reporting, and proper disposing of confiscated items. Clients, staff and visitors have the right to a safe and secure environment. V. Procedures: A. Contraband List: The general list consists of four classes of items: Class II - Not allowed in client's possession at any time. Appendix C - Contraband Lists: Class II - Not allowed in client's possession at any time: item 23. Any substance containing over 8% alcohol. Appendix A: D. Contraband as used here means: (1) ... or substance that if taken internally, whether separately or in combination with another drug or substance, produces or may produce a hypnotic effect.

A review of facility policy, "Client Abuse and Neglect," Policy Number: LD-25, with an effective date of 05/16/2024 and approved on 05/28/2024, revealed in part, I. Policy: The Hospital is committed to preserving the right of each person receiving services to be free of abuse and neglect. Purpose: The purpose of this policy is to ensure that client's rights are protected and to establish a uniform system for timely reporting and investigating all allegations of abuse/neglect of clients. V. Statutory Definitions and Examples: D. 42 CFR 482.13(c)(3) definition in the Code of Federal Regulations (CFR) apply to hospitals participating in the Medicaid and/or Medicare programs. D-i. Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. D-ii. Neglect: the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. H. Examples of the types of conduct that constitute abuse and neglect. H-i. Physical Abuse: a. Physical contact such as hitting, slapping, pinching, kicking, choking, scratching, pushing, or twisting of head, arm or legs. H-vi. Neglect: a. Acts or omissions by a person responsible for providing care of treatment which caused harm to, or placed a client at risk of harm, or which deprived a client of sufficient or appropriate services, treatment or basic care. b. Failure to provide or withhold appropriate services, nutrition, clothing, treatment, or care by gross errors in judgement, inattention, or ignoring. d. Failure to provide a safe environment. f. Failure to supervise a client such that the client is placed in danger. VI. Duty to Report: B. Any employee or affiliate of the hospital who has knowledge of possible abuse or neglect of a client or who receives a complaint of abuse from a client or any other person, shall report in accordance with the provisions of this policy and applicable law. VII. Initial Reporting Procedures: A-ii: The nurse in charge of the area/building will immediately, within 1 hour, make a verbal report to the Appointing Authority/Designee during normal business hours or the Administrator on Duty as to whether outside agencies (Health Standards Section (HSS), Adult Protective Services (APS), and/or local law enforcement) should be notified of the report. B-v: The Building/Unit RN (Registered Nurse) Manager or designee will: a. complete the online HSS Hospital Abuse/Neglect Initial Report form and submit using the "submit" button on the electronic form before the end of the shift.

A review of hospital incident reports revealed an incident report on 07/11/2024 involving Patient #4. The Client Incident, Injury, and Data Reporting Form revealed in part, the incident occurred on 07/11/2024 at 10:38 a.m. The description of the incident included, "Client disoriented and acting intoxicated." Further, the report revealed in part, other patients in Patient #4 room reported he had been drinking hand sanitizer through the night shift. Room search by correctional guard therapeutic (CGT) revealed, " ... med cup with hand sanitizer found in room at client's bedside."
Medical record review of Patient #4 revealed a prior incident involving the ingestion of hand sanitizer. A medical progress note dated 11/01/2023 revealed in part the patient was seen at Hospital A last night (10/31/2023) for hand sanitizer - alcohol poisoning and the patient did not remember where he picked up the hand sanitizer. A medical progress note by S10MD from 07/11/2024 at 10:58 a.m. revealed in part, called secondary to altered mental status. Per nurse's report, patient witnessed him drinking hand sanitizer earlier. Further, the note indicated, "Pt (patient) has done this before." A review of a urine drug screen from 07/12/2024 at 9:00 a.m. reveled Patient #4 positive for Ethyl Glucuronide - a byproduct of alcohol that can be detected after the consumption of alcohol. A review of nursing and CGT progress notes revealed Patient #4 refusing to give a urine sample from the time of the discovery of the incident until the morning of 07/12/2024.

In an interview on 07/16/2024 at 3:00 p.m. S11PMI confirmed the above mentioned findings. S11PMI further confirmed the source of the hand sanitizer was not able to be identified and Patient #4 was not cooperative in providing the source.

2. Failing to ensure the safety and protection of 1 (#1) of 4 (#1 - #4) patients from bodily injury during two altercations with peers

A review of facility policy, "Client Abuse and Neglect," Policy Number: LD-25, with an effective date of 05/16/2024 and approved on 05/28/2024, revealed in part, I Policy: The Hospital is committed to preserving the right of each person receiving services to be free of abuse and neglect. Purpose: The purpose of this policy is to ensure that client's rights are protected and to establish a uniform system for timely reporting and investigating all allegations of abuse/neglect of clients. V. Statutory Definitions and Examples: D. 42 CFR 482.13(c)(3) definition in the Code of Federal Regulations (CFR) apply to hospitals participating in the Medicaid and/or Medicare programs. D-i. Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. D-ii. Neglect: the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. H. Examples of the types of conduct that constitute abuse and neglect. H-i. Physical Abuse: a. Physical contact such as hitting, slapping, pinching, kicking, choking, scratching, pushing, or twisting of head, arm or legs. H-vi. Neglect: a. Acts or omissions by a person responsible for providing care of treatment which caused harm to, or placed a client at risk of harm, or which deprived a client of sufficient or appropriate services, treatment or basic care. b. Failure to provide or withhold appropriate services, nutrition, clothing, treatment, or care by gross errors in judgement, inattention, or ignoring. d. Failure to provide a safe environment. f. Failure to supervise a client such that the client is placed in danger. VI. Duty to Report: B. Any employee or affiliate of the hospital who has knowledge of possible abuse or neglect of a client or who receives a complaint of abuse from a client or any other person, shall report in accordance with the provisions of this policy and applicable law. VII. Initial Reporting Procedures: A-ii: The nurse in charge of the area/building will immediately, within 1 hour, make a verbal report to the Appointing Authority/Designee during normal business hours or the Administrator on Duty as to whether outside agencies (Health Standards Section (HSS), Adult Protective Services (APS), and/or local law enforcement) should be notified of the report. B-v: The Building/Unit RN (Registered Nurse) Manager or designee will: a. complete the online HSS Hospital Abuse/Neglect Initial Report form and submit using the "submit" button on the electronic form before the end of the shift.

A review of hospital policy, "Observations and Precautions," Policy Number PC-NUR-12, with an effective date of 03/2005, last revised 02/2022 and approved 03/29/2022 revealed in part, I Definitions: A. One-To-One Direct: on staff member must continuously monitor a client at not more than eight (8) feet in distance with physician's order. One staff member may be assigned to only one (1) client on One-To-One Direct at a time. Client must be visualized at all times. V. Procedure: A. One-To-One Direct. A-ii. Nursing Care: c. Reasonable privacy may be given for a client who is on one-to-one observation with the exclusion of suicide precautions. While the client is toileting, a staff member may stand just outside of the toilet stall door. However, staff must remain vigilant for any signs/behaviors that would indicate possible harm to the client.

Observations 07/16/2024 at 3:25 p.m. of recorded video from House B camera view RM1 OC-157 W4 Sleep on 05/11/2024 from 8:18 p.m. to 8:22 p.m. with S11PMI present and identifying staff revealed in part, Patient #1 lying in bed and S12CGT sitting in chair approximately 10 to 15 feet from the patient's bed. On 05/11/2024 at 8:21:28 p.m., 3 patients (Patients #R5, #R6, and #R7 identified from incident reports) enter Patient #1's cubicle, walk directly to his bed and immediately begin to strike Patient #1 with their hands (appear to be closed hand strikes). 2 of the aggressor patients' hands appear to be hitting Patient #1 in the head area, while the 3rd aggressor patient's hand are striking the torso/chest area. Each of the 3 aggressor patients appear to hit Patient #1 approximately 5 times and the altercation lasted approximately 9-10 seconds. At 8:21:34 S12CGT stands to his feet and sounds like he said, "Calvin, Calvin," but does not walk towards Patient #1 until 8:21:39. As S12CGT walks towards Patient #1's bed the sound revealed, "flip off, flip off, flip off," and the 3 aggressor patients retreat from Patient #1 and exit the cubicle. S12CGT did not appear to be in a rush to physically intervene in the altercation, 10 seconds elapse before he begins to walk towards Patient #1's bed. Further, S12CGT observation location prior to the incident appears to be greater than 8 feet from the patient.

A medical record review of Patient #1 revealed in part, a nursing note from 05/11/2024 at 8:25 p.m. indicating Patient #1 was lying in bed sleeping when he was attacked by multiple peers. Patient had a quarter sized knot on the left side of his head. Patient stated he had a headache. Ice pack was applied, Tylenol was administered, assessment/neuro checks completed and the patient was being transferred to another unit for safety. Patient #1's current observation level was 1:1 Direct, at not more than 8 feet for aggressive behaviors and this observation level was initiated on 05/02/2024 at 5:50 p.m. This observation level was continued, with the addition of being monitored by a male CGT only, on 05/11/2024 at 6:58 p.m. A restrictive management progress note from 05/11/2024 at 6:58 p.m. revealed in part, the patient smeared feces in the CGT's (female CGT) face, became verbally aggressive with her and due to the behavior, RPM (restrictive patient management) remained in place with male CGT only.

In an interview on 07/16/2024 at 3:45 p.m. S11PMI confirmed the above mentioned findings and confirmed the above incident was not reviewed by the hospital as a potential case of abuse/neglect.

Observations 07/16/2024 at 2:10 p.m. of recorded video from House C camera view Hall OC-131 on 06/01/2024 from 8:07 p.m. to 8:16 p.m. with S11PMI present and identifying staff revealed in part, Patient #1 entering the restroom at 8:07:05 p.m. The S13CGT remained outside the doorway and across the hall from the bathroom door the entire time Patient #1 is in the restroom-approximately 8 minutes. During this time frame, patients would enter and exit the restroom, but these patients were alone with Patient #1, not as a group. S13CGT was never seen opening the door or glancing through the window on the door to observe the patients. His only view in the restroom was when the door opens and closes when other patients are entering and exiting the restroom. At 8:15:03 p.m. S13CGT moved towards the door as it is seen opening, Patient #1 is seen exiting the restroom and walking towards the dormitory. Recorded video from House C camera view RM7 OC-155 W2 Sleep on 06/01/2024 at 8:20:23 p.m. revealed Patient #1's nose area appeared to have a red substance on it.

A medical record review of Patient #1's observation level during the 06/01/2024 incident revealed 1:1 Direct at not more than 8 feet for aggressive behaviors with male CGT only. A nurse note from 06/01/2024 at 8:20 p.m. revealed in part the patient was hit in the nose and had a nose bleed.

A review of the hospital final investigative report revealed Patient #1 indicated another patient hit him but he did not know who the other patient was or what they looked like. S13CGT statement indicated he remained outside the restroom door as he was trained.

In an interview on 07/16/2024 at 2:45 p.m. S11PMI confirmed the above mentioned findings.

In an interview on 07/17/2024 at 12:40 p.m. S9DON confirmed the observation policy indicated the CGT should be stationed outside the bathroom stall door.

3. Failing to fully investigate an incident resulting in bodily injury to 1 (#1) of 4 (#1 - #4) patients

A review of facility policy, "Abuse and Neglect Policy and Procedures for LDH," Policy Number: 76.3, with an effective date of 06/06/2016. This policy was in effect through 05/16/2024. The policy revealed in part, I Policy: LDH is committed to preserving the right of each person receiving services to be free of abuse. Purpose: To establish a policy prohibiting abuse, neglect, exploitation, or extortion (hereafter termed "abuse") of clients and to establish a procedures for reporting, investigating reviewing, and resolving alleged incidents of abuse. VII. Examples of Abuse: A-1. Physical Abuse: Physical contact such as hitting, slapping, pinching, kicking, choking, scratching, pushing, or twisting of head, arm or legs; the use of physical force which is unnecessary or excessive; and inappropriate or unauthorized use of restraint. A-6. Neglect: Acts or omissions by a person responsible for providing care or treatment which caused harm to a client, which placed the client at risk of harm, or which deprived a client of sufficient or appropriate services, treatment or basic care. Failure to provide appropriate services, treatment, or care by gross errors in judgement, inattention, or ignoring may also be considered a form of neglect. 6-c. Failure to provide a safe environment. 6-e. Failure to supervise a client such that the client is placed in danger. VIII. Duty to Report Abuse: B. Any employee of LDH or an affiliate who has knowledge of possible abuse of a client or who receives a complaint of abuse from a client or any other person, shall report in accordance with the provisions of this policy, applicable law, and the facility or programs office's internal policy and procedures. IX. Procedures for Reporting: C. Reporting outside the facility/program: All incidents of possible abuse involving LDH clients as alleged victims and/or LDH or affiliate staff as the accused shall be reported immediately to Adult Protective Services (ADP). For purposes of this LDH policy, it is the responsibility of the facility/program manager to ensure that the appropriate external agencies listed below are notified in a timely manner. C-2. The Health Standards section of the LDH Bureau of Health Services Financing for allegations involving persons who are receiving care in a facility licensed by that Section. Reposts should be made immediately or as soon as possible, but in no case later than 24 hours after knowledge. XVI. Investigative Review Process for 24-Hour Facilities: E. Conducting the Investigation: 3. If the facility is required by law or regulations to report to Health Standards, the APS investigator shall gather and analyze all available facts, and submit all available statements of witnesses and evidence in a preliminary written report within 5 working days from the date the incident was reported. Once the investigation and review process is complete, Health Standards shall be notified of the final outcome.

A review of hospital policy, "Observations and Precautions," Policy Number PC-NUR-12, with an effective date of 03/2005, last revised 02/2022 and approved 03/29/2022 revealed in part, I Definitions: A. One-To-One Direct: on staff member must continuously monitor a client at not more than eight (8) feet in distance with physician's order. One staff member may be assigned to only one (1) client on One-To-One Direct at a time

Observations 07/16/2024 at 3:25 p.m. of recorded video from House B camera view RM1 OC-157 W4 Sleep on 05/11/2024 from 8:18 p.m. to 8:22 p.m. with S11PMI present and identifying staff revealed in part, Patient #1 lying in bed and S12CGT sitting in chair approximately 10 to 15 feet from the patient's bed. On 05/11/2024 at 8:21:28 p.m., 3 patients (Patients #R5, #R6, and #R7 identified from incident reports) enter Patient #1's cubicle, walk directly to his bed and immediately begin to strike Patient #1 with their hands (appear to be closed hand strikes). 2 of the aggressor patients' hands appear to be hitting Patient #1 in the head area, while the 3rd aggressor patient is striking the torso/chest area. Each of the 3 aggressor patients appear to hit Patient #1 approximately 5 times and the altercation lasted approximately 9-10 seconds. At 8:21:34 S12CGT stands to his feet and sounds like he said, "Calvin, Calvin," but does not walk towards Patient #1 until 8:21:39. As S12CGT walks towards Patients #1's bed the sound revealed, "flip off, flip off, flip off," and the 3 aggressor patients retreat from Patient #1 and exit the cubicle. S12CGT did not appear to be in a rush to physically intervene in the altercation, 10 seconds elapse before he begins to walk towards Patient #1's bed. Further, S12CGT observation location prior to the incident appears to be greater than 8 feet from the patient.

A medical record review of Patient #1 revealed in part, a nursing note from 05/11/2024 at 8:25 p.m. indicating Patient #1 was lying in bed sleeping when he was attacked by multiple peers. This note is what prompted the surveyor to request more information related to this incident. The before mentioned nursing note further revealed in part, the patient had a quarter sized knot on the left side of his head. The patient stated he had a headache. Ice pack was applied, Tylenol was administered, assessment/neuro checks completed and the patient was being transferred to another unit for safety. Patient #1's current observation level was 1:1 Direct at not more than 8 feet for aggressive behaviors and this observation level was initiated on 05/02/2024 at 5:50 p.m. This observation level was continued, with the addition of being monitored by a male CGT only, on 05/11/2024 at 6:58 p.m. A restrictive management progress note from 05/11/2024 at 6:58 p.m. revealed in part, the patient smeared feces in the CGT's (female CGT) face, became verbally aggressive with her and due to the behavior, RPM (restrictive patient management) remained in place with male CGT only.

In an interview on 07/16/2024 at 3:45 p.m. S11PMI confirmed the above mentioned findings and confirmed the above incident was not reviewed by the hospital as a potential case of abuse/neglect.

4. Failing to timely report allegations of abuse/neglect on 1 (#1) of 4 (#1 - #4) patients to Louisiana Department of Health - Health Standards Section (LDH-HSS)

Review of the Louisiana Revised Statutes, Title 40. Public Health and Safety, Chapter 11, State Department of Health and Hospitals revealed "Department" shall mean the Department of Health and Hospitals. "Unit" means the Medicaid fraud control unit created within the office of criminal law of the Department of Justice and which is certified by the secretary of the United States Department of Health, Education and Welfare. Regarding §2009.20. Duty to make complaints; penalty; immunity, "Abuse" is the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including but not limited to sexual abuse, or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered. "Neglect" is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer's well-being. Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, ... 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. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report.

Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report these allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Department of Health and Hospitals (LDH) (or the Medicaid Fraud Unit as applicable). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence.

A review of facility policy, "Client Abuse and Neglect," Policy Number: LD-25, with an effective date of 05/16/2024 and approved on 05/28/2024, revealed in part, I Policy: The Hospital is committed to preserving the right of each person receiving services to be free of abuse and neglect. Purpose: The purpose of this policy is to ensure that client's rights are protected and to establish a uniform system for timely reporting and investigating all allegations of abuse/neglect of clients. V. Statutory Definitions and Examples: D. 42 CFR 482.13(c)(3) definition in the Code of Federal Regulations (CFR) apply to hospitals participating in the Medicaid and/or Medicare programs. D-i. Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. D-ii. Neglect: the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. H. Examples of the types of conduct that constitute abuse and neglect. H-i. Physical Abuse: a. Physical contact such as hitting, slapping, pinching, kicking, choking, scratching, pushing, or twisting of head, arm or legs. H-vi. Neglect: a. Acts or omissions by a person responsible for providing care of treatment which caused harm to, or placed a client at risk of harm, or which deprived a client of sufficient or appropriate services, treatment or basic care. b. Failure to provide or withhold appropriate services, nutrition, clothing, treatment, or care by gross errors in judgement, inattention, or ignoring. d. Failure to provide a safe environment. f. Failure to supervise a client such that the client is placed in danger. VI. Duty to Report: B. Any employee or affiliate of the hospital who has knowledge of possible abuse or neglect of a client or who receives a complaint of abuse from a client or any other person, shall report in accordance with the provisions of this policy and applicable law. VII. Initial Reporting Procedures: A-ii: The nurse in charge of the area/building will immediately, within 1 hour, make a verbal report to the Appointing Authority/Designee during normal business hours or the Administrator on Duty as to whether outside agencies (Health Standards Section (HSS), Adult Protective Services (APS), and/or local law enforcement) should be notified of the report. B-v: The Building/Unit RN (Registered Nurse) Manager or designee will: a. complete the online HSS Hospital Abuse/Neglect Initial Report form and submit using the "submit" button on the electronic form before the end of the shift.

A review of hospital policy, "Observations and Precautions," Policy Number PC-NUR-12, with an effective date of 03/2005, last revised 02/2022 and approved 03/29/2022 revealed in part, I Definitions: A. One-To-One Direct: on staff member must continuously monitor a client at not more than eight (8) feet in distance with physician's order. One staff member may be assigned to only one (1) client on One-To-One Direct at a time. Client must be visualized at all times. V. Procedure: A. One-To-One Direct. A-ii. Nursing Care: c. Reasonable privacy may be given for a client who is on one-to-one observation with the exclusion of suicide precautions. While the client is toileting, a staff member may stand just outside of the toilet stall door. However, staff must remain vigilant for any signs/behaviors that would indicate possible harm to the client.

Observations 07/16/2024 at 3:25 p.m. of recorded video from House B camera view RM1 OC-157 W4 Sleep on 05/11/2024 from 8:18 p.m. to 8:22 p.m. with S11PMI present and identifying staff revealed in part, Patient #1 lying in bed and S12CGT sitting in chair approximately 10 to 15 feet from the patient's bed. On 05/11/2024 at 8:21:28 p.m., 3 patients (Patients #R5, #R6, and #R7 identified from incident reports) enter Patient #1's cubicle, walk directly to his bed and immediately begin to strike Patient #1 with their hands (appear to be closed hand strikes). 2 of the aggressor patients' hands appear to be hitting Patient #1 in the head area, while the 3rd aggressor patient is striking the torso/chest area. Each of the 3 aggressor patients appear to hit Patient #1 approximately 5 times and the altercation lasted approximately 9-10 seconds. At 8:21:34 S12CGT stands to his feet and sounds like he said, "Calvin, Calvin," but does not walk towards Patient #1 until 8:21:39. As S12CGT walks towards Patients #1's bed the sound revealed, "flip off, flip off, flip off," and the 3 aggressor patients retreat from Patient #1 and exit the cubicle. S12CGT did not appear to be in a rush to physically intervene in the altercation, 10 seconds elapse before he begins to walk towards Patient #1's bed. Further, S12CGT observation location prior to the incident appears to be greater than 8 feet from the patient. A medical record review of Patient #1 revealed in part, a nursing note from 05/11/2024 at 8:25 p.m. indicating Patient #1 was lying in bed sleeping when he was attacked by multiple peers. Patient had a quarter sized knot on the left side of his head. Patient stated he had a headache. Ice pack was applied, Tylenol was administered, assessment/neuro checks completed and the patient was being transferred to another unit for safety. Patient #1's current observation level was 1:1 Direct at not more than 8 feet for aggressive behaviors and this observation level was initiated on 05/02/2024 at 5:50 p.m. This observation level was continued, with the addition of being monitored by a male CGT only, on 05/11/2024 at 6:58 p.m. A restrictive management progress note from 05/11/2024 at 6:58 p.m. revealed in part, the patient smeared feces in the CGT's (female CGT) face, became verbally aggressive with her and due to the behavior, RPM (restrictive patient management) remained in place with male CGT only.

A review of the facility Hospital Abuse/Neglect Initial Report revealed the date of the incident was 05/11/2024, the date of discovery was 07/16/2024 and the report submit date was 07/16/2024.

In an interview on 07/16/2024 at 3:45 p.m. S11PMI confirmed the above mentioned findings and confirmed the above incident was not reviewed by the hospital as a potential case of abuse/neglect.

Observations 07/16/2024 at 2:10 p.m. of recorded video from House C camera view Hall OC-131 on 06/01/2024 from 8:07 p.m. to 8:16 p.m. with S11PMI present and identifying staff revealed in part, Patient #1 entering the restroom at 8:07:05 p.m. The S13CGT remained outside the doorway and across the hall from the bathroom door the entire time Patient #1 is in the restroom-approximately 8 minutes. During this time frame, patients would enter and exit the restroom, but these patients were alone with Patient #1, not as a group. S13CGT was never seen opening the door or glancing through the window on the door to observe the patients. His only view in the restroom was when the door opens and closes when other patients are entering and exiting the restroom. At 8:15:03 p.m. S13CGT moved towards the door as it is seen opening, Patient #1 is seen exiting the restroom and walking towards the dormitory. Recorded video from House C camera view RM7 OC-155 W2 Sleep on 06/01/2024 at 8:20:23 p.m. revealed Patient #1's nose area appeared to have a red substance on it.

A medical record review of Patient #1's observation level during the 06/01/2024 incident revealed 1:1 Direct at not more than 8 feet for aggressive behaviors with male CGT only. A nurse note from 06/01/2024 at 8:20 p.m. revealed in part the patient was hit in the nose and had a nose bleed.

A review of the hospital final investigative report revealed Patient #1 indicated another patient hit him but he did not know who the other patient was or what they looked like. S13CGT statement indicated he remained outside the restroom door as he was trained.

A review of the facility Hospital Abuse/Neglect Initial Report revealed the date of the incident was 06/01/2024, the date of discovery was 06/18/2024 and the report submit date was 07/16/2024

In an interview on 07/16/2024 at 2:45 p.m. S11PMI confirmed the above mentioned findings.

Based on record review and interview the facility failed to ensure an initial psychosocial assessment was completed within 30 days of admission for 1 (Patient #2) of 3 (Patients #1, #2, #3) sampled patients.

Findings:

Review of the hospital's Social Services Policy and Procedures Manual revealed, in part:
III. Psychosocial Assessment
Psychosocial assessments have a standardized format as determined by the Uniform Medical Records Committee of OBH (Office of Behavior Health). This basic outline (or sequence of categories) is designed to serve the purpose of both initial assessment, as well as annual update.
A. Social Worker Role and Expectations
1. A psychosocial assessment will be completed by the assigned Social Worker on each patient shortly after admission to obtain pertinent information needed for the development of the individualized treatment plan and subsequent discharge planning...
a) East Division, Community Homes, Forensic Division, and SFF (Secure Forensic Facility) - Typed or dictated within 15 days post admission. Completed copy signed and on chart in 30 days...

Review of Patient #2's Initial Psychosocial Assessment revealed the patient's admit date was 11/07/2023 and the date of assessment was 01/29/2024. Date received was on 02/02/2024. Date formatted was on 02/05/2024.

During an interview on 07/16/2024 at 2:45 p.m., S4TQM verified Patient #2's Initial Psychosocial Assessment was not completed within 30 days after Patient #2 was admitted to the facility.