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Based on record review and interview, the hospital failed to ensure all incidents of abuse, neglect, and/or harassment were reported and analyzed, and the hospital was in compliance with applicable local, State, and Federal Laws and Regulations. This deficient practice was evidenced by the hospital's failure to report allegations of abuse within 24 hours to the Department of Health and Hospitals or law enforcement for 2 (I1, I2) of 2 reviewed incidents with suspected abuse.

Findings:

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 Louisiana Department of Health (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.

Incident 1
Review of incident "I1" revealed Patient R1 was admitted under a physician's emergency certificate on 05/19/2022 and a coroner's emergency certificate was issued while admitted. Patient R2 was admitted on 5/21/2022 under a physician's emergency certificate. On 05/21/2022 at 7:45 p.m., Patient R1 and R2 were witnessed exiting the dayroom restroom together. Video revealed the two patients were in the restroom together for 4 minutes. The patients were interviewed and they refused to say what transpired. The investigation concluded there was no coercion and both patients consented. The physician was notified and efforts were taken to prevent another incident.

In interview on 11/07/2022 at 1:50 p.m., S3RM verified the incident was not reported to the Department of Health and Hospitals. S3RM agreed physician's emergency certificates were issued because both patients had impaired judgement and ability to consent was impared.

Incident 2
Review of incident "I2" revealed on 05/31/2022 at 6:40 p.m., Patient R3 was harassing other patients and was hit by another patient in the hallway. The incident was verbally de-escalated. Patient R3 was examined and determined to have no visable physical injuries and the physician was notified.

In interview on 11/07/2022 at 1:50 p.m. S3RM verified the incident was not reported to the Department of Health and Hospitals. S3RM agreed that although the patient was not visably harmed, she was hit by another patient and the incident could be considered abuse.

Based on record review and interview the psychiatric hospital failed to ensure the nursing staff administered medications as ordered. This deficiency is evidenced by failure of the nursing staff to administer prn medication as ordered in 1(#5) of 5 (#1-#5) medical records reviewed.
Findings:

Review of the medical record for Patient #5 revealed admission on 09/28/2022 with a diagnosis of bipolar disorder, anxiety disorder, hypertension and pregnancy.

Review of the orders from admission revealed an order for "Catapres 0.1 mg PO every 6 hours PRN systolic BP 160 or greater or diastolic BP 92 or greater."

Review of the "Vital Signs Flowsheet" revealed the patient had blood pressure above the parameters on the following days:
09/28/2022 at 1:36 p.m. the blood pressure was 152/109
09/28/2022 at 7:00 p.m. the blood pressure was 153/100
09/29/2022 at 7:00 a.m. the blood pressure was 161/101
09/29/2022 at 7:00 p.m. the blood pressure was 151/102
09/30/2022 at 7:00 p.m. the blood pressure was 150/96
10/01/2022 at 7:00 a.m. the blood pressure was 191/113
10/01/2022 at 7:00 p.m. the blood pressure was 142/95
10/02/2022 at 7:00 a.m. the blood pressure was 166/101
10/03/2022 at 7:00 a.m. the blood pressure was 139/96
10/03/2022 at 7:00 p.m. the blood pressure was 147/94
10/04/2022 at 7:00 a.m. the blood pressure was 142/97

Review of the medication administration record revealed the prescribed medication was only given on 09/28/2022 at 8:10 p.m..

In interview on 11/08/2022 between 9:50 a.m. and 9:58 a.m., S1Adm and S2DON verified the medication was not given as prescribed.