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OUR LADY OF THE LAKE REGIONAL MEDICAL CENTER 5000 HENNESSY BLVD BATON ROUGE, LA 70808 Jan. 3, 2013
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the hospital failed to ensure it had a process for prompt resolutions of grievances by failing to investigate allegations of alleged abuse for 1 (#2) of 10 patients sampled.
Findings:
A review of the Policy titled Patient Rights, Complaints, and Grievance Process, Policy Reference #: OrgClin/020, Last Revision Date: June 21, 2012 revealed in part:
Grievance:
A patient grievance is a formal or informal written or verbal expression of dissatisfaction that is made to the hospital by a patient, or the patients representative, regarding the patient ' s care (when the concern is not resolved at the time reported by staff present), abuse or neglect, issues related to the hospital ' s compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing issue.
A written complaint is always considered a grievance.

Review of the History and Physical for Patient #2 dated 10/14/12 revealed she was a [AGE] year old female that had been admitted on [DATE] with complaints of depression and suicidal thoughts.

Review of Nursing Notes for Patient #2 dated 10/22/12 at 1600 revealed in part: ...Pt then stated " I want to file a grievance on this unit, because the tech (technician), which she did not name, dug their fingernail in my arm and smashed their hand in my mid back. " When asked by the nurse the name of the staff and the day the incident happened, pt replied, bluntly " I don ' t remember. "

Review of the Grievance log from 6/12 to 1/13 revealed no grievance had been filed for Patient #2 in reference to her allegation that a technician had dug their fingernails into her arm and smashed their hand into her mid back.

In an interview on 1/3/13 at 10:11 a.m. with Divisional Director S2, she said if a staff member is accused of abuse, it is investigated and reported to state office at DHH. S2 reviewed a copy of the nurse ' s notes for Patient #2 dated 10/23/12 where she alleges abuse and said she wanted to file a grievance. After reading the note, she said it seemed apparent that the nurse assessed the patient and she determined the patient was delusional and no physical signs of abuse were noted so no grievance was filed.

An interview was conducted on 1/3/13 at 10:00 a.m. with the Divisional Director of Mission Services and Chair of the Grievance committee S11. S11 said whichever staff member learns of a patient concern enters it into the computer in Quantros feedback manager. S11 said then she and the manager of the area where the concern took place were automatically notified and they begin their investigation. S11 said she also made sure the grievance/complaint was assigned to the correct person and it was handled appropriately.

In an interview on 1/3/13 at 10:17 a.m. with the Administrator of Psychiatric Services S4, she said if a patient made a complaint of abuse, a form was completed that was sent to the state and an investigation was performed. S4 said on the psychiatric unit, claims of abuse are looked at to see if the patient is delusional and paranoid and making claims that are irrational. S4 said if it was a delusion, it would not be further investigated, but that was a decision by the doctor as to whether it was delusional thinking or fact. S4 said if they thought there was any basis of truth to Patient #2 ' s claims of abuse, they would have certainly been investigated. S4 said the nurse whom Patient #2 told that staff grabbed her asked Patient #2 who the staff was and when it happened, but Patient #2 said she did not know. S4 said Patient #2 was also checked physically for any signs of abuse and the Psychiatrist S5 was made aware of her accusations. S4 said based on Patient #2 ' s accusations, the psychiatrist deemed her claims to be delusions.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review, the hospital failed to ensure each patient who filed a grievance was provided a written notice of the hospitals decision regarding the resolution of the grievance for 1 (#1) of 3 grievances reviewed.
Findings:
A review of the Policy titled Patient Rights, Complaints, and Grievance Process, Policy Reference #: OrgClin/020, Last Revision Date: June 21, 2012 revealed in part:
Grievance:
A patient grievance is a formal or informal written or verbal expression of dissatisfaction that is made to the hospital by a patient, or the patients representative, regarding the patient ' s care (when the concern is not resolved at the time reported by staff present), abuse or neglect, issues related to the hospital ' s compliance with the CMS Hospital Conditions of participation (CoPs), or a Medicare beneficiary billing issue.
A written complaint is always considered a grievance.
Investigation of Grievances:
3. The investigation can include but is not limited to speaking with the patient or the patient ' s representative, discussing the concern with staff involved, reviewing the medical record, reviewing any appropriate policies and procedures, reviewing any medical or clinical process, performing a physical and/or psychosocial assessment of the patient.
4. Based on the findings of the investigation the director/manager of the department (s) involved take appropriate actions to resolve the patient or patient ' s representative ' s concern.
6. ...However, in all cases, a written response is provided to each patient grievance.

Review of the History and Physical for Patient #2 dated 10/14/12 revealed she was a [AGE] year old female that had been admitted on [DATE] with complaints of depression and suicidal thoughts.
Review of the grievance log from 6/12 to 1/2/13 revealed the only grievance that had been filed by Patient #2 was on 10/25/12. The complaint issue was listed as " other " .

A review was made of a Quantros Feedback Manager Report (grievance computer reporting system) for Patient #2 dated 10/28/12 at 17:10. Review of the report revealed Patient #2 had complained on 10/25/12 that she had a violation of her patient rights. The notes section stated the following: Patient wrote notes indicating multiple patient rights from the Patient Handbook which she felt were violated by the staff and her physician. Primary complaints were regarding request to be discharged being denied and other patients ' activities being unpleasant to her. Further review revealed Patient #2 had presented a 7 page letter to the facility on [DATE] listing 24 patient rights which she felt had been violated with an explanation of how each had been violated.

A review was made of the follow up ticket for the complaint filed by Patient #2 on 10/25/12 in reference to her patient rights being violated. The resolution date/time was listed as 10/26/2012 16Hrs: 15 Min. The investigation read in part:
Summary Finding: Patient #2 was focused on discharge and associated most of the complaint toward that. She was unclear regarding the rights as she understood them. Patient #2 stated she was satisfied but it is doubtful she retains much of the information discussed.

A review was made of a 7 page typed document dated 10/26/12 presented by the Administrator of Psychiatric Services S4. In the document, each of the patient rights Patient #2 said the facility violated on 10/25/12 was addressed by S4. The discussions between S4 and Patient #2 were written and the resolutions of the problems were listed.

In an interview with the Administrator of the Psychiatric Division S4 on 1/2/13 at 3:20 p.m., she said she remembered the grievance filed by Patient #2 on 10/25/12 because Patient #2 went through the hospital ' s patient rights list and wrote a complaint for every one of them. S4 said she went through each one of the rights with Patient #2 and talked about them for a couple of hours. S4 stated this list was not provided to the patient.

An interview was conducted on 1/3/13 at 10:00 a.m. with the Divisional Director of Mission Services and Chair of the Grievance committee S11. S11 said whichever staff member learned of a patient concern entered it into the computer in Quantros feedback manager. S11 said then she and the manager of the area where the concern took place were automatically notified and they would have began their investigation. S11 said she also made sure the grievance/complaint was assigned to the correct person and it was handled appropriately. If it was a grievance, S11 said a written response was provided to the patient. S11 said Patient #2 ' s grievance was reclassified as a complaint because the Administrator of Psychiatric Services S4 had met with her and Patient #2 was satisfied with the resolution. S11 said since it had been reclassified as a complaint, no written response was given to Patient #2.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review, the hospital failed to ensure a patient was free from all forms of abuse or harassment as evidenced by failing to report alleged allegations of abuse to the Department of Health and Hospitals within 24 hours of receipt of the allegation for 1 (#2) of 10 patients sampled.
Findings:
Review of the History and Physical for Patient #2 dated 10/14/12 revealed she was a [AGE] year old female that had been admitted on [DATE] with complaints of depression and suicidal thoughts.

A review of the Policy titled Suspected Abuse or Neglect, Reporting of Child/Adult, Policy Reference #: OrgClin-027, Last review date: March 9, 2010 revealed in part:
Abuse/Neglect
1. Abuse-the willful infliction of injury (bodily harm), sexual molestation, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain or mental anguish.
B. All occurrences of alleged abuse and/or neglect are reported to the appropriate law enforcement/protective agencies.
Reporting of Internal Occurrences of Abuse/Neglect
1. All occurrences of internal abuse/neglect must be reported immediately to the manager during regular business hours. After hours occurrences of internal abuse/neglect are reported immediately to the house manager.
3. Regulatory Management, or designee, is responsible for reporting occurrences of internal abuse to either the local law enforcement agency or the Department of Health and Hospitals (DHH) within 24 hours of receiving knowledge of the allegation of abuse/neglect.

Review of Nursing Notes for Patient #2 dated 10/22/12 at 1600 revealed in part: ...Pt then stated " I want to file a grievance on this unit, because the tech (technician), which she did not name, dug their fingernail in my arm and smashed their hand in my mid back. " When asked by the nurse the name of the staff and the day the incident happened, pt replied, bluntly " I don ' t remember. " ...

Review of Progress Notes for Patient #2 dated 10/23/12 at 1420 revealed in part: Pt seen with female nurse because the last 2 days she has made irrational claims about incidents with techs. Nurse is relating patient ' s claim to nurse manager despite no current indication of any basis for her claim ...

In an interview on 1/3/13 at 10:11 a.m. with Divisional Director S2, she said if a staff member is accused of abuse, it is investigated and reported to state office at DHH. Divisional Director S2 reviewed a copy of the nurse ' s notes for Patient #2 dated 10/23/12 where she alleges abuse and said she wanted to file a grievance. After reading the Nurse's Note, S2 said it seemed apparent that the nurse assessed Patient #2 and determined she was delusional and had no physical signs of abuse so no grievance was filed.

In an interview on 1/3/13 at 10:17 a.m. with the Administrator of Psychiatric Services S4, she said if any patient made a complaint of abuse, a form would have been completed and sent to the state and an investigation would have been performed. S4 said on the psychiatric unit, claims of abuse are looked at to see if the patient is delusional and paranoid and making irrational claims. S4 said if the complaint was a delusion, it would not be investigated further. However, the decision as to whether it was delusional or rational would be a decision by thedoctor. S4 said if they thought there was any basis of truth to her claims, they would have certainly been investigated. S4 said Patient #2 was also checked physically for any signs of abuse and the Psychiatrist S5 was made aware of her accusations. S4 said based on Patient #2 ' s accusations, the psychiatrist deemed her claims to be delusions. S4 verified no reports of abuse had been sent to a state agency for Patient #2.