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Based on record review and interview, the hospital failed to ensure that all personnel underwent criminal background checks by an authorized agent of the Louisiana State Police in the manner required by R.S. 15:587.1 et seq. prior to hire or employment for all unlicensed personnel providing care for adults and for all staff providing care to children. This deficient practice was evidence by 6 (S5LPN, S6LPN, S7RN, S8RN, S9CNA, S10CNA) of 6 (S5LPN, S6LPN, S7RN, S8RN, S9CNA, S10CNA) personnel records reviewed regarding criminal background checks.
Findings:

Review of S7RN human resource file revealed a criminal background check was completed by Company A, who is not an authorized agency of the Louisiana State Police.

Review of S8RN and S9CNA human resource files revealed a criminal background check was completed by Company B, who is not an authorized agency of the Louisiana State Police.

Review of S5LPN, S6LPN, and S10CNA human resource files revealed a criminal background check was completed by Company C, who is not an authorized agency of the Louisiana State Police.

In an interview on 08/01/2023 at 12:10 p.m. S4HR verified the hospital used Company A, B and C for all employee background checks. Company A, B, and C are not an authorized agency of the Louisiana State Police for background checks. S4HR verified Company A, B, and C are not authorized agencies on the Louisiana State Police background check list.

Based on record review and interview, the hospital failed to ensure patients were free from abuse and failed to ensure all incidents of abuse, neglect, and/or harassment were reported and analyzed, and the hospital was in compliance with applicable local, State, and Federal Laws and Regulations. This deficient practice was evidenced by the hospital's failure to investigate and report abuse within 24 hours to the Department of Health and Hospitals or law enforcement for 1 (Pt #2) of 5 (Pt# 1-5) patients reviewed for mandatory reporting.
Findings:

Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report abuse/neglect allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Louisiana Department of Health (LDH). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence.

Review of the policy and procedure titled, "Patient Rights and Responsibilities" effective 2007 and most recently reviewed on 01/2023 revealed, in part, All disciplines within the hospital are expected to demonstrate respect for the human rights and individual dignity of each patient in the delivery of all aspects of health care and services.

Review of the policy and procedure titled, "Abuse, Neglect, Exploitation" effective date 2007 and most recently reviewed/approved on 02/10/2021 revealed, in part, it is the policy of the hospital to protect patients under the care of the hospital staff and to comply with state and federal guidelines. Definitions: Abuse: deliberate acts designed to cause physical or mental harm to another person can include pushing, slapping, making inappropriate comments, and sexual abuse. Procedure: 6. If at any time, there is reason to believe that a patient has been abused, neglected or exploited, authorities will be contacted by hospital management.

Review of the interdisciplinary notes for Patient #2 dated 05/29/2023 at 12:10 p.m. revealed, in part, "Patients mother reporting that the CNA was rough with her during ADL care and grab her arm while calling her a curse word".

In an interview on 08/01/2023 at 1:43 p.m. S1DR verified during the investigation regarding the allegation of abuse towards Patient #2, that the allegations were not substantiated. S1DR verified the allegations of abuse were not reported to LDH within 24 hours of discovery.