HospitalInspections.org

Based on record reviews and interview, the hospital failed to ensure the patient right to be free from abuse/neglect. This deficient practice was evidenced by the hospital failing to conduct a thorough investigation into alleged sexual abuse for 1 (#1) of 1 alleged abuse patient sampled in a total of 6 (#1-#6) patients sampled.
Findings:

Review of hospital policy titled Patient Rights Louisiana revealed, in part:
Individual Client Rights: 8. Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect and/or exploitation.

Review of Patient #1's medical records revealed the patient was an 83 year old female with diagnoses of neurocognitive disorder with behavioral disturbances/psychosis and dementia. Patient #1 had an admit date of 05/03/2023 and a discharge date of 05/08/2023.

Review of document titled Louisiana Department of Health Hospital/Licensed Provider Abuse/Neglect Initial Report dated 05/19/2023 and updated 05/25/2023, revealed Patient #1 as the victim of alleged sexual abuse. Review of Section J. Comments revealed, in part: A complete investigation of the allegations is being conducted. More information will follow in the final investigation.
Final Report: Male patients that were hospitalized 05/03/2023 to 05/08/2023: Patient #2, Patient #3, and Patient #4 were the only male patients listed on the final report.

Review of hospital census records 05/03/2023 to 05/08/2023 revealed Patient #5 and Patient #6 were hospitalized male patients.

In an interview on 06/20/2023 at 1:19 p.m., S1Director of Quality confirmed Patient #5 and Patient #6 were male patients hospitalized 05/03/2023 to 05/08/2023. S1Director of Quality confirmed Patient #5 and Patient #6 were not included in the investigation of alleged sexual abuse of Patient #1. S1Director of Quality confirmed Patient #5 and Patient #6 should have been included in the investigation of the alleged sexual abuse of Patient #1.

Based on record reviews and interview, the registered nurse failed to supervise and evaluate the nursing care of each patient. This deficient practice was evidenced by failure of nursing staff to perform neurological assessments after unwitnessed falls for 2 (#1, #6) of 6 (#1-#6) patients sampled.
Findings:

Review of hospital policy titled Neurological Assessment revealed, in part: Policy: A neurological assessment is indicated after any head injury or unwitnessed fall.
Procedure: 1. Responsible Nurse:
Assess level of consciousness
Assess motor strength
Assess abnormal movements
Assess pupils for size, shape, equality, reaction to light
Assess pulses.
5. Guidelines for completing Neurological Assessment Checklist:
Neurological Assessment will be initiated immediately after an unwitnessed fall or fall with possible head injury. This included a continuation of neuro checks to be completed after return from Emergency room due to a fall if patient returns within 24 hours of the fall.
Neurological Assessment Checklist will be completed as follows:
Upon initial finding then,
Every 15 minutes after initial assessment x 4 then,
Every 30 minutes x 2 then,
Every 60 minutes x 2 then,
Once per shift for 2 days or as indicated by physician/non-physician practitioner order.
6. All Neurological Assessments should include vital signs which will be documented in conjunction with the medical record.

1. Review of Patient #6's Multi-Disciplinary Note dated 06/11/2023 revealed at 11:30 a.m. Patient #6 had an unwitnessed fall to the floor. Further review revealed at 11:35 a.m. neuro assessment in progress, see flowsheet.

Review of Patient #6's Neuro Flow Sheet dated 06/11/2023 revealed, in part, assessments documented at 11:30 a.m., 12:30 p.m. and 1:30 p.m.

Review of Patient #6's Physician's Order dated 06/11/2023 at 2:20 p.m. revealed an order to discontinue neuro checks.

In an interview on 06/20/2023 at 12:51 p.m., S1Director of Quality confirmed there was no documented evidence a registered nurse completed the hospital neurological assessment checklist for Patient #6 as stated in the hospital Neurological Assessment policy. S1Director of Quality confirmed Patient #6 should have had additional neurological assessments performed by a registered nurse between 11:30 a.m. and 2:20 p.m.

2. Review of Patient #1's Multi-Disciplinary Note dated 05/04/2023 at 2:07 a.m. revealed on 05/03/2023 at 11:17 p.m. Patient #1 had an unwitnessed fall, sent to the emergency room, and returned within 24 hours of the fall. Further review revealed on 05/04/2023 at 5:45 p.m. Patient #1 was found on the floor holding her head and stated she hit her head. Patient #1 sent to the emergency room and returned within 24 hours of the fall.

Review of Patient #1's Neuro Flow Sheet dated 05/04/2023 revealed, in part, assessments documented at 11:18 p.m. (05/03/2023), 12:00 p.m., 4:00 p.m. and 5:45 p.m. There were no further neurological assessments documented after 05/04/2023, 5:45 p.m.

Review of Patient #1's Physician's Order dated 05/04/2023 at 9:25 a.m. revealed an order for neuro checks every 4 hours. This order was prior to 05/04/2023 at 5:45 p.m. when Patient #1 was found on the floor holding her head and stated she hit her head.

In an interview on 06/20/2023 at 9:41 a.m., S1Director of Quality confirmed there was no documented evidence a registered nurse completed the hospital neurological assessment checklist for Patient #1 as stated in the hospital Neurological Assessment policy. S1Director of Quality confirmed Patient #1 should have had additional neurological assessments performed by a registered nurse.