HospitalInspections.org

Based on record review and interview, the hospital failed to ensure all allegations of abuse were reported to the appropriate state agency, Department of Health and Hospitals for 1 (Patient #2) of 1 patients' records reviewed with an allegation of abuse from a total sample of 6. Findings:

Review of the hospital policy, Assessment and Reporting of Abuse, Neglect, Exploitation, and/or Extortion of Youth and Adults, Policy Number AS-18, revealed in part, In order to protect children, adults, and elderly from harm by identifying, evaluation all allegations, observations and suspected cases of neglect, exploitation and abuse external to the organization and that which could occur while the patient is receiving care, treatment and services; provide appropriate advocacy, care; and report abuse, this organization supports and maintains compliance with assessment/reporting standards set by these organization....Department of Health and Hospitals...Self Reporting Administrator/DON: Notify the COO (Chief Operating Officer) prior to reporting. A facility must self-report internal allegations of abuse/neglect to maintain compliance with CMS Regulation 482.13 (c)/LA R.S. 40:2009.20. LA R.S. 40:2009/20 calls for reporting of knowledge of potential abuse incidents within 24 hours to either local law enforcement or DHH (Department of Heath and Hospitals).

Review of the medical record for Patient #2 revealed he was a 93 year old male admitted to the hospital on 11/27/15 with the diagnosis of Dementia.

Review of the Complaint Form, from Patient #2's daughter, dated 12/6/15 and 12/7/15, revealed in part, Pt's daughter complained of ....Pt stated on 12/2/15 that a "big black guy picked him up under his arms from bed and shook him". Deferred to Grievance Procedure.

Review of the Grievance Report, completed by S1Adm on 12/11/15, revealed in part,...3. Patient was allegedly pulled up by underarms and shaken-unable to substantiate patient's complaint to his daughter/family.

An interview was conducted with S1Adm on 2/2/16 at 10:00 a.m. She reported she did not report the allegation of abuse to the Department of Health and Hospitals. She further reported she should had reported the allegation of the abuse, but she made a poor judgment call.

An interview was conducted with S6RegDir of Clinical Services on 2/2/16 at 10:15 a.m. She reported all allegations of abuse should be reported to the Department of Health and Hospitals and this allegation should have been reported.

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as evidenced by the RN failing to ensure every patient who needed assistance with activities of daily living received a bath/shower daily for 3 (Patient#1, #2, and #3) of 6 patients' records (Patient#1-#6) reviewed for assistance with ADLs (Activities of Daily Living). Findings:


Review of the memo, dated 10/6/15 and addressed to all nursing staff, revealed in part, To help achieve the highest patient care standards, it is expected that all our patients receive a shower or bed bath (as applicable) once in a 24 hour period...If a patient refuses, the nurse must be notified to re-attempt and he/she will document in pink notes if patient continues to refuse. Example: "pt refuse to take shower..., prompted x 2. Responsible party notified...

Review of Patient #1's medical record revealed he was 83 years old, admitted to the hospital on 1/14/16 with a diagnosis of Dementia, who needed assistance with all ADLs (Activity of Daily Living), including baths/showers. Review of the Observations Sheets for Patient #1 revealed on 1/18/16 and 1/22/16 there was no documentation the patient was assisted with a bath and/or shower and there was no documentation the patient refused assistance with his bath/shower.

Review of Patient #2's medical record revealed he was a 93 year old male, admitted to the hospital on 11/27/15 with a diagnosis of Dementia, who needed assistance with all ADLs, including baths/showers. Review of Patient #2's Observation Sheets for 12/2/15, 12/3/15 and 12/4/15 revealed no documentation to indicate assistance was provided to Patient #2 with his shower/bath or his refusal of assistance with baths/showers.

Review of Patient #3's medical record revealed she was a 83 year old female, admitted to the hospital on 1/19/16 with the diagnosis of Dementia, who needed assistance with all ADLs, including baths/showers. Review of Patient #3's Observation Sheets for 1/22/16 and 1/26/16 revealed no documentation to indicate assistance was provided to Patient #3 with her bath/shower or her refusal of assistance with baths/showers.

An interview was conducted with S2DON on 2/1/16 at 3:15 p.m. He reported baths should be done daily, unless the patient refuses. If the patient refuses the MHT should report to the patient's nurse and if the patient continues to refuse and it becomes a pattern, the nurse should notify the family/responsible party. The baths/showers are documented on the patients' observation sheets. S2DON was unable to find documentation of Patient #1's baths or refusals on 1/18/16 and 1/22/16; Patient #2's on 12/2/15, 12/3/15 and 12/4/15; and Patient #3's on 1/22/16 and 1/26/16.