The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ST JAMES BEHAVIORAL HEALTH HOSPITAL, INC 3136 SOUTH ST LANDRY ROAD GONZALES, LA July 21, 2016
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on record reviews and staff interviews, the hospital failed to ensure a written notice/letter of the hospital's response to the complainant's grievance was provided to the complainant for 3 (#R1, #R2, #R3) of 8 patient grievances reviewed, and the hospital failed to ensure the written notice/letter provided to the complainant contained the steps taken on behalf of the patient to investigate the grievance and the results of the grievance process for 5 (#R4, #R5, #R6, #R7, #R8) of 8 (#R1, #R2, #R3, #R4, #R5, #R6, #R7, #R8) patient grievances reviewed.
Findings:

Review of the hospital's Patient/Family Complaints Policy 1.29, Section: Patient Rights/Organizational Ethics policies and procedures revealed, in part:
Definitions: Patient/Family Grievance is defined as something that affords just cause for complaint or protest; and/or an issue unresolved following the normal complaint procedure that cannot be resolved promptly by staff present.
Procedure: Formal Grievance.
B. The Director of Nurses, Case Manager, or Administrative Representative receiving the grievance will initiate the Formal Grievance Form and take any steps available to resolve the grievance. Any additional steps taken to resolve the grievance will be documented and forwarded to the Administrator.
D. A written response will be provided within (7) days of the grievance if a resolution can be achieved. If within (7) days of the receipt of a grievance, resolution cannot be achieved, it will be forwarded to the appropriate committee or ad hoc group to assist with resolution (i.e. Governing Board, Medical Executive Committee, Quality, Safety or Ethics Committee). The patient/family/representative will be notified that the hospital is still working on resolution and a written response is forthcoming and will be forwarded to complainants within 30 days of original receipt of the grievance.

Patient #R3:
Review of the hospital's Grievance log revealed on 04/07/16 the father of patient #R3 voiced complaints the patient was not well when she was discharged , and he was not notified of the patient's discharge from the hospital. Review of the Grievance Form dated 04/07/16, and other related documents, revealed no documented evidence a written response/letter was sent to the complainant.

Patient #R1:
Review of the hospital's Grievance log revealed on 07/05/16 the patient voiced complaints about the way he and other patients were treated by hospital staff. Review of the Grievance Form dated 07/05/16, and other related documents, revealed no documented evidence a written response/letter was sent to the complainant.

Patient #R2:
Review of the hospital's Grievance log revealed on 07/06/16 the patient voiced complaints about a medication he received during his hospital stay. Review of the Grievance Form dated 07/06/16, and other related documents, revealed no documented evidence a written response/letter was sent to the complainant.

In an interview on 07/21/16 at 12:30 p.m., S2DON reviewed the above referenced grievances and confirmed the complainants for patients #R1, # R2, and #R3 had not received a written response/letter from the hospital regarding their grievances.

Review of the hospital's Grievance log revealed the written letters provided to the complainants for patients #R4, #R5, #R6, #R7, and #R8's grievances did not contain the steps taken on behalf of the patient to investigate the grievance and the results of the grievance process.

In an interview on 07/21/16 at 12:32 p.m., S2DON confirmed the letters sent to the complainants for patients #R4, #R5, #R6, #R7, and #R8 did not contain all of the required elements for a grievance response letter.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure the staff was knowledgeable and compliant with all relevant federal, state and local municipal laws and regulations by failing to report an allegation of sexual abuse to administration, the local law enforcement agency, the physician, and the family at the time of discovery, and the appropriate state agency within 24 hours as required for 1 (#1) of 5 sampled patients in a total sample of 5.
Findings:
Review of the Louisiana Revised Statutes, Title 40. Public Health and Safety, Chapter 11. State Department of Health and Hospitals
2009.2. Definitions (Excerpt)
(3) "Department" shall mean the Department of Health and Hospitals.
(4) "Unit" means the Medicaid fraud control unit created within the office of criminal law of the Department of Justice and which is certified by the secretary of the United States Department of Health, Education and Welfare.
2009.20. Duty to make complaints; penalty; immunity
A. As used in this Section, the following terms shall mean:

(1) "Abuse" is the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including but not limited to sexual abuse, or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered.

(2) "Neglect" is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer's well-being.

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 caregiver 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. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report.

Patient #1
A review of the medical record for Patient #1 revealed she was a [AGE]-year-old admitted on [DATE] at 9:26 p.m. with a diagnosis of paranoid schizophrenia. Further review revealed the patient was delusional and having episodes of auditory hallucinations.

Review of the nurse's notes documented by S3RN on 06/26/16 for the 6:00 a.m. to 6:00 p.m. shift revealed, in part, under the section, Thought Content: "Patient reports men coming in her room at night and getting in bed with her."

Review of the Multidisciplinary Notes-Nursing documented by S3RN on 06/26/16 at 7:00 a.m. revealed, in part: "S4MHT, reported patient reported to her that a man comes into their room at night and gets in the bed with her roommate; roommate was questioned and denied that a man comes into their room at night and gets into her bed. S8RN notified."

In an interview on 07/20/16 at 12:10 p.m., S2DON clarified S4MHT had reported to S3RN on 06/26/16 at 7:00 a.m. Patient #1 had stated to S4MHT that morning that she thought a man was coming into the room during the night and getting in the bed with her roommate. Patient #1 also stated to S4MHT she thought that maybe someone had messed with her because her panties were on in a different way when she woke up in the morning.

Review of the medical record revealed an order written by the Physician Assistant on 06/27/16 at 12:45 p.m. which stated, in part: "Notify Administration of patient's allegations that peer had sex with her last week." An order dated 06/27/16 at 6:15 p.m. was written by S6MD which stated "Transfer patient to (name of hospital) emergency room for evaluation of alleged sexual assault." Review of the nurses' notes, documented by S7RN dated 06/27/16 at 11:00 p.m., revealed the staff called Patient#1's daughter and "informed her, her mother was sent to the hospital for an assessment after making an allegation that men were going in and out of her room and touching her inappropriately." The daughter then stated, in part: "I'm aware my mother is at the hospital. I just spoke to a police officer."

Further review of Patient #1's medical record revealed no documented evidence the staff had contacted administration, the local law enforcement agency, the physician, or the family at the point of discovery of the alleged sexual assault/abuse.

In an interview on 07/20/16 at 2:10 p.m., S8RN indicated he was not taking care of Patient #1 on 06/26/16, but he was the RN charge nurse on the unit. He indicated he was informed of Patient #1's comments and instructed Patient #1's assigned nurse to investigate the allegation. S8RN indicated after the investigation by the unit nursing staff on 06/26/16, it was concluded the alleged event did not take place as reported by Patient #1. S8RN confirmed he did not notify administration, the physician, the local law enforcement agency, or the family at the time of discovery of the alleged event because the staff investigating the allegations concluded the event (allegation) did not take place.

In an interview on 07/21/16 at 8:40 a.m., S2DON indicated S9PA came into her office on 06/27/16 at around 2:00 p.m. and informed her Patient #1 had made a claim to her that she was "sexually assaulted last week." S2DON indicated this was the first time she was made aware of the allegations by Patient #1, and she began her investigation immediately. S2DON indicated, when questioned about the delay in sending Patient #1 to the emergency department, the delay was due to the completion of the hospital investigation. S2DON confirmed the hospital staff had not followed proper procedures in handling the allegation of a sexual assault at the time of discovery by immediately notifying the administrator, the local law enforcement agency, the physician, and the family, and S2DON agreed all parties should have been notified at the time of discovery on 06/27/16 at 7:00 a.m., and the patient should have been sent to the emergency department for an examination after the immediate notification of the physician and the receipt of a physician's order.

Review of the document entitled "Hospital Abuse/Neglect Initial Report" submitted to the state department revealed, in part, the initial report was submitted to the state office on 06/28/16. Further review revealed the date of discovery was 06/26/16 and the time of discovery was 7:00 a.m.

In an interview on 07/21/16 at 8:50 a.m., S2DON indicated she was aware of the 24-hour reporting requirement for abuse and neglect allegations. S2DON further indicated she waited to submit the initial report to the state office until she had completed her investigation, and S2DON confirmed this was not in compliance with the 24-hour reporting requirement, and the report should have been submitted within the 24 hours prior to her completion of the investigation.