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31048

Based on record review and interview, the hospital failed to ensure staff identified a grievance and initiated the grievance process for 1 (#1) of 2 (#1, #2) patients reviewed for grievances, and failed to ensure, in its resolution of the grievance, the hospital provided the patient with a written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of the completion for 1 (#2) of 2 (#1, #2) patients reviewed with grievances.
Findings: Review of a Policy and Procedure entitled Patient Abuse and/or Neglect, Policy 2.7, revealed, in part: . . . b. Any abuse or neglect allegations will automatically initiate the Grievance process.

Review of the hospital policy entitled Grievance Procedure, Policy Number 1.36, revealed in part: "A complaint is a statement of unhappiness: a statement expressing discontent or unhappiness about a situation. A grievance is reason for complaint: a cause for complaint or resentment that may or may not be well founded. It is formal objection: a formal complaint made on the basis of something that somebody feels is unfair. Complaints: 1. Any minor complaints not resolved to the patient's/family's satisfaction or those of a more serious nature should be immediately brought to the attention of the Director of Nursing or Administrator for resolution. 5. Complaints are to be addressed in a timely manner. If the issue/concern cannot be immediately addressed, the complainant is to be contacted, via telephone, or by letter, acknowledging the receipt of the complaint, and letting them know what additional steps are needed to resolve the matter. 6. A complaint may be communicated verbally or in writing. 7. The employee who receives a complaint from a patient will: . . .d. Provide a solution only if is in the scope of your job description to solve. e. If you can't solve the complaint, report the information to your supervisor. h. Always report patient concerns and complaints to your supervisor whether it has been resolved or not. i. Any minor complaint not resolved to the patient's/family's satisfaction or those of a more serious nature should be immediately brought to the attention of the DON. j. Unresolved complaints requiring administrative intervention should be brought to the attention of the Director of Nursing or the Administrator. k. For complaints of a very serious nature, the Hospital Administrator should be contacted immediately. m. Complaints that involve the threat of legal action are to be immediately brought to the attention of the Risk Manager. Procedure for filing a grievance: . . 8. A written notice of the hospital's determination regarding the grievance will be communicated to the patient or the patient's legal representative in a language and manner the patient or the patient's legal representative understands within 7 days. 9. In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. 11. This written notice will include the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion."

Patient #1
A review of the medical record for Patient #1 revealed, in part, the following documentation by S7RSW, dated 07/01/16 at 10:15 a.m.: "Patient's mother was informed of group home arrangements after patient's mother insisted patient would not be allowed to return home. Patient's mother stated "I know that area-you need to find another group home." Patient's mother began to yell: no, that will not be-he hasn't seen the doctor in 2 days and ya'll will keep him. I will have this reported. I have had no success with none of ya'll there ..."

In an interview on 09/06/16 at 1:45 p.m., S2DON reviewed the above-referenced documentation by S7RSW and confirmed he was not informed of this information, and he had not received any information regarding a complaint and/or grievance for Patient #1. S2DON agreed and confirmed this should have been considered a grievance, and the grievance process should have been initiated by S7RSW.

Patient #2
Review of the grievance log provided by the hospital revealed a written grievance from Patient #2 dated 08/25/16 at 9:00 a.m. The grievance was written as the following: "The tech named (S6MHT) has always had an attitude with me. We shared some words in the hallway. I flipped her off, then she punched me in the head and called me bi-polar and a bitch. I tried to get some licks in, but not sure I did. Male tech pulled us apart and threw me into room onto floor and put his hands around my throat. I kicked him and said I didn't do anything to you. I was crying and he said not to leave my room. Then it was over. The nurse came in and gave me a shot."

In an interview on 09/07/16 at 1:51 p.m. with S2DON, he verified he did not provide Patient #2 with a written response to her grievance on 08/25/16.

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 and/or neglect within 24 hours to the Louisiana Department of Health for 1 (R1) of 2 (#2, R1) clients sampled for abuse and neglect.
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.

Review of a Policy and Procedure entitled Patient Abuse and/or Neglect, Policy 2.7, revealed, in part: . . . "1) Prohibit all forms of abuse, neglect (as a form of abuse) and harassment whether from staff, other patients or visitors, or other persons; 2) ensure that patients are free from all forms of abuse, neglect, or harassment while under our care; 3) have mechanisms of reporting suspected abuse. 4) Identify, Protect a. When an incident arises that constitutes possible neglect and/or abuse during any course of the patient's care at (name of hospital), the following procedure is to be followed: (1) A staff person witnessing or suspecting patient abuse or neglect must report the incident to their immediate supervisor as soon as they are aware of the incident. Failure to do so is grounds for immediate termination. (2) A complaint may be received from any of the following: a. a patient who thinks they may have been a victim. b. A family member/significant other of the patient. c. A patient who may have witnessed the incident. d. Any responsible citizen who may have witnessed the incident. e. Any person with second hand information (a patient tells roommate and roommate reports). (3) The employee documents all information concerning the incident on the Incident Report form, being as descriptive and factual as possible. (4) The RN will assume care of the patient. (5) The safety of the patient will be ensured immediately. If a staff member is accused of abuse or neglect, they will be removed from the care of the alleged victim. The involved staff person may be suspended pending further investigation. If another patient is accused of abuse or neglect, the patients will be separated and the alleged victim will be removed from the location of the other patient. (6) Once the patient is safe, The DON, Administrator, and patient's physician will be notified. 6. Report, Respond: a. A DHH Initial Abuse and Neglect reporting form will be completed and submitted to DHH via fax no later than 24 hours after the incident was first reported to (name of hospital) a staff member. b. Any abuse or neglect allegations will automatically initiate the Grievance process. The potential victim will be given information on what is being done to investigate the incident and progress of finding by the DON or his/her designee. d. Appropriate protective agencies and licensing agencies will be notified in accordance with State and Federal laws individualized to the situation."

Patient R1
Review of the occurrence/incident reports revealed a grievance form dated 07/17/16 (time documented with different writing as 2:00 a.m.) completed by R1, revealed, in part: "Last night while I was asleep, one of the techs, a male tech, was touching me on my behind with his hands. The reason that I know that this occurred is because I woke up to him with his hands on me. As soon as I woke up, he stopped and left the room. When it was time to wake up, I walked past him a couple of times and he couldn't look me in the eye. He then stayed at the front end of the hallway until it was time for him to go, signifying to me that he knew what happened and was guilty about it. In addition, my room's door was mostly closed than all the other doors when I got up to look at them. I think he closed most of the door to cover what he did." 'What solution would you like to see happen'? For him to resign his post because I don't want to press charges." Further review of the Grievance form revealed there was no staff signature at the bottom of the grievance form indicating if/who/when a staff viewed this document.

Review of the Occurrence and/or Incident Report, dated 07/17/16, regarding Patient R1, revealed the date of the incident was documented as 07/17/16, the date and time the incident was reported was 07/17/17 at 7:15 a.m. Under the section, Describe Incident and/or Injury, the following, in part, was documented by the RN staff member: "Patient approached nursing station, stated 'I'm afraid'; stated she woke up and the male tech was fondling her buttock and legs. She also stated she did not report it at the time, because she did not want to get anyone in trouble."

In an interview on 09/07/16 at 2:30 p.m., S2DON reviewed the above-referenced documentation. He verified that he (S2DON) had worked the 7:00 p.m. to 7:00 a.m. shift on 07/16/16 as a staff nurse. S2DON indicated he initiated the investigation of the allegation on the morning of 07/17/16, and that he and S1ADM had reviewed the video recordings for the entire shift; he and S1ADM had not witnessed any male tech going into R1's room during the entire 12-hour shift. S2DON indicated he continued the investigation on 07/18/16 and 07/19/16 interviewing and receiving written statements by associated staff members. S2DON indicated the allegation/incident would have been reported to the State Department of Health if he had substantiated Patient R1's allegation. S2DON confirmed the above-referenced incident had not been reported to the State Department of Health because he and S1ADM had concluded, after their investigation, the allegation of abuse had not taken place.

Based on record review and interview, the hospital failed to ensure the discharge planning evaluation and implementation was appropriate to meet the needs of patients for 1 (#1) of 5 (#1-#5) records reviewed for discharge planning.

Findings:

Review of a policy and procedure entitled Discharge Planning, Policy 3.26, revealed, in part: "It is the policy of the Hospital that preparation for discharge be a priority in the Treatment Planning Process and is aggressively pursued through the coordinated efforts of the treatment team. The discharge planning process will be initiated on admission and formally addressed on the treatment plan and continued throughout hospitalization. Procedure: 1. Discharge considerations will be assessed by the RN, Social Worker, or other appropriately qualified personnel and must develop or supervise the development of, the discharge initiation process within 24 hours of admission ..." 3. The discharge plan will address the individual needs of the patient, be realistic and achievable, and include, but not limited to, the following: a. Aftercare, b. Disposition, and c. Education/Teaching Needs ..."

Review of the medical record for Patient #1 revealed he was a 36 year-old male admitted to the hospital on 06/21/16 per a Physician's Emergency Certificate with diagnoses of Paranoid Schizophrenia and THC (illegal substance) Dependence. Further review of the medical record revealed Patient #1's History and Physical included documentation under past surgical history "had leg surgery at age 16." Review of the initial nursing assessment dated 06/21/16 revealed, in part: "Arthritis Bilateral Knee." Review of the medical record revealed Patient #1 was living at home with his mother prior to this hospitalization. Further review revealed Patient #1 was discharged to an independent living group home on 07/01/16.

In an interview on 09/06/16 at 12:20 p.m., S2DON indicated S7RSW was responsible for discharge planning services at the hospital.

In an interview on 09/07/16 at 8:15 a.m., the Complainant indicated Patient #1 had a history of Blount's Disease which made it very difficult for him to navigate stairs. The Complainant also indicated Patient #1's placement at the group home was an apartment comples, and his apartment was located on the second floor.

In an interview on 09/06/16 at 3:20 p.m., S7RSW indicated she had observed Patient #1 walked with a "sort of limp." S7RSW also indicated she was not aware the group home she referred Patient #1 to was a two-story building, and Patient #1's apartment was on the second floor. S7RSW confirmed she was not aware Patient #1 had difficulty climbing stairs when she referred him to the group home.

31048

Based on record review and interview, the hospital failed to ensure staff identified a grievance and initiated the grievance process for 1 (#1) of 2 (#1, #2) patients reviewed for grievances, and failed to ensure, in its resolution of the grievance, the hospital provided the patient with a written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of the completion for 1 (#2) of 2 (#1, #2) patients reviewed with grievances.
Findings: Review of a Policy and Procedure entitled Patient Abuse and/or Neglect, Policy 2.7, revealed, in part: . . . b. Any abuse or neglect allegations will automatically initiate the Grievance process.

Review of the hospital policy entitled Grievance Procedure, Policy Number 1.36, revealed in part: "A complaint is a statement of unhappiness: a statement expressing discontent or unhappiness about a situation. A grievance is reason for complaint: a cause for complaint or resentment that may or may not be well founded. It is formal objection: a formal complaint made on the basis of something that somebody feels is unfair. Complaints: 1. Any minor complaints not resolved to the patient's/family's satisfaction or those of a more serious nature should be immediately brought to the attention of the Director of Nursing or Administrator for resolution. 5. Complaints are to be addressed in a timely manner. If the issue/concern cannot be immediately addressed, the complainant is to be contacted, via telephone, or by letter, acknowledging the receipt of the complaint, and letting them know what additional steps are needed to resolve the matter. 6. A complaint may be communicated verbally or in writing. 7. The employee who receives a complaint from a patient will: . . .d. Provide a solution only if is in the scope of your job description to solve. e. If you can't solve the complaint, report the information to your supervisor. h. Always report patient concerns and complaints to your supervisor whether it has been resolved or not. i. Any minor complaint not resolved to the patient's/family's satisfaction or those of a more serious nature should be immediately brought to the attention of the DON. j. Unresolved complaints requiring administrative intervention should be brought to the attention of the Director of Nursing or the Administrator. k. For complaints of a very serious nature, the Hospital Administrator should be contacted immediately. m. Complaints that involve the threat of legal action are to be immediately brought to the attention of the Risk Manager. Procedure for filing a grievance: . . 8. A written notice of the hospital's determination regarding the grievance will be communicated to the patient or the patient's legal representative in a language and manner the patient or the patient's legal representative understands within 7 days. 9. In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. 11. This written notice will include the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion."

Patient #1
A review of the medical record for Patient #1 revealed, in part, the following documentation by S7RSW, dated 07/01/16 at 10:15 a.m.: "Patient's mother was informed of group home arrangements after patient's mother insisted patient would not be allowed to return home. Patient's mother stated "I know that area-you need to find another group home." Patient's mother began to yell: no, that will not be-he hasn't seen the doctor in 2 days and ya'll will keep him. I will have this reported. I have had no success with none of ya'll there ..."

In an interview on 09/06/16 at 1:45 p.m., S2DON reviewed the above-referenced documentation by S7RSW and confirmed he was not informed of this information, and he had not received any information regarding a complaint and/or grievance for Patient #1. S2DON agreed and confirmed this should have been considered a grievance, and the grievance process should have been initiated by S7RSW.

Patient #2
Review of the grievance log provided by the hospital revealed a written grievance from Patient #2 dated 08/25/16 at 9:00 a.m. The grievance was written as the following: "The tech named (S6MHT) has always had an attitude with me. We shared some words in the hallway. I flipped her off, then she punched me in the head and called me bi-polar and a bitch. I tried to get some licks in, but not sure I did. Male tech pulled us apart and threw me into room onto floor and put his hands around my throat. I kicked him and said I didn't do anything to you. I was crying and he said not to leave my room. Then it was over. The nurse came in and gave me a shot."

In an interview on 09/07/16 at 1:51 p.m. with S2DON, he verified he did not provide Patient #2 with a written response to her grievance on 08/25/16.