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WEST CARROLL MEMORIAL HOSPITAL 706 ROSS STREET OAK GROVE, LA 71263 Nov. 7, 2013
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based upon reviews of complaint, incident/accident reports, policies and procedures, state law LA. R.S. 40:2009, and staff interviews, the hospital failed to follow state law LA. R.S. 40:2009.20 related to reporting to the Health Standards Section, Louisiana Department of Health and Hospitals, allegations of sexual assaults. Findings:

Review of a complaint, dated 08/04/2013 at 1:30 p.m., revealed S2 Hospital Assistant Administrator documented the following: "COMPLAINT FORM Name of Person Making Complaint: Unknown...Date Received: 8-4-2013 Time Received: 1:30PM Received By: (name S2 Assistant Administrator) Report Received: Telephone Specifics of Complaint: I received a phone call from the operator stating a person on the phone wanted to report abuse. Call was forwarded to me . The caller was a well-spoken female who refused to identify herself. She stated '(name of S6 hospital driver)' was selling drugs on hospital property and that (name of S4 alleged perpetrator) was sexually abusing elderly patients. Stated she had not witnessed any of this but a 'friend' had. Stated she had called a hot line to report it but was told she would have to call us first. I asked if there was any proof of these aligations and she responded to 'check your cameras'. At that point she broke the connection. Summary of Investigation: We have two employees that go by (name of S6 hospital driver). One is a maintenance employee and the other works with (name of S4 alleged perpetrator). After speaking with them both, it was determined that the caller was probably talking about (name of S7 maintenance employee). Cameras were randomly watched with no suspicious activity noted. Both men do not go into rooms where patients are and no evidence was seen of such. Several employees were interviewed on this subject as well. This phone call was unable to be substantiated. Both men were made aware of the complaint. (Name of S4 perpetrator) is a full-time contract worker who does maintenance. He does not or should not enter any rooms where there are patients."

Review of the hospital's Grievance Process (no policy number or dates) revealed: "All patients...have the right to submit a verbal or written complaint/grievance...we have a process for handling their complaints...Upon receipt of the grievance, an investigation will begin. The person initiating the complaint shall be contacted within four working days and informed of the steps taken to investigate the grievance, the results of the investigation, and the date of completion. This process shall be documented and a response made in writing to the complainant..."

Review of LA. R.S. 40:2009.20 revealed "B. (1) Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, licensed practical nurse, nurse's aide, home and community based service provider employee or worker, personal care attendant, respite worker, physician's assistant, physical therapist, or any other direct care giver 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..."

Interviews, 11/07/13 10:00 a.m., with S1 Administrator and S2 Hospital Assistant Administrator revealed when asked if they had reported the allegations of sexual assaults to Health Standards Section, of the Louisiana State Department of Health and Hospitals, both replied the allegations were not reported to the state. Further conversations with S1 Administrator and S2 Hospital Assistant Administrator revealed there was an ongoing investigation of these allegations by the local Sheriff's office and police department.

Interview, 11/07/13 at 3:45 p.m., with S3 Director of Nursing confirmed he had not reported the allegations to the state, nor had the Administrator.