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Based on observation, record review and interview, the psychiatric hospital failed to ensure the patient right to receive care in a safe setting. This deficient practice is evidenced by:
1) Failure to ensure the patient care area was free of ligature risks; and
2) Failure to ensure unattended rooms in the patient care area were locked and secured from unauthorized entry by patients.
Findings:

1) Failure to ensure the patient care area was free of ligature risks

Observations during a walk-through of the psychiatric hospital on 09/23/2025 from 1:00 PM to 1:35 PM revealed the toilet seats in Rooms "c" - "j" restrooms being loosely secured. Also, the front edge of each toilet seat was bowed upwards and away from underlying edge of the toilet bowl rim, which created a pass through space for an object such as a sheet or towel. Further, it appeared there was a metal L-bracket mounted to the inner front edge of the toilet bowl rim and just under each of the toilet seats. This metal bracket could enhance the strength of this area as a potential ligature risk, as this bracket would prevent any object passed under the toilet seat from slipping off the front edge of the toilet rim. The pass through space of each toilet was as follows:
Room "c" was approximately ¼ inch;
Room "d" was approximately ½ inch;
Room "e" was approximately ¼ inch;
Room "f" was approximately ½ inch;
Room "g" was approximately 1 inch;
Room "h" was approximately ½ inch;
Room "i" was approximately ½ inch; and
Room "j" was approximately ½ inch.

In an interview on 09/23/2025 and present during the psychiatric hospital walk-through, S1CEO and S4CNO confirmed the above mentioned findings.

2) Failure to ensure unattended rooms in the patient care area were locked and secured from unauthorized entry by patients

A review of hospital self-report received by Louisiana Department of Health - Health Standards Section (LDH HSS) on 09/03/2025 revealed an incident of alleged patient to patient sexual assault taking place on 08/26/2025 at approximately 10:23 AM, with the date of discovery of the alleged event being 09/02/2025 at 11:36 AM. This hospital self-report revealed in part, S1CEO being informed by Patient #1's guardian that Patient #1 and Patient #2 had engaged in sex on 08/26/2025 between breakfast and lunch and this had reportedly taken place in a bathroom. The hospital self-report also revealed the review by S1CEO of recorded video from 08/26/2025. S1CEO's notes revealed Patient #2 entering Room "a" at 10:22:23 AM, Patient #1 entering Room "a" at 10:23:40 AM and closing the door, Patient #1 exiting Room "a" at 10:25:04 AM and Patient #2 exiting Room "a" at 10:25:28 AM.

Observations of recorded video, with S1CEO navigating the computer and identifying patients and rooms, revealed the before mentioned incident on 08/26/2025. The recorded video was captured by Camera 7 and it provided a view of the hospital's main hallway leading to Rooms "a" - "j". The observed video revealed the same before mentioned sequence of events and timeframes. Further observations of the recorded video revealed the door of Room "a" unlocked and completely open with no staff member present.

In an interview on 09/23/2025 and present during the review of recorded video, S1CEO confirmed the above mentioned findings. He further confirmed the door of Room "a" should be closed and locked when not in use and a staff member should be present when the room is being utilized by any patient regardless of the patient's ordered observation level.

Based on observations, record review and interview, the psychiatric hospital failed to measure, analyze and track all adverse patient events. The deficient practice is evidenced by the failure to ensure documentation of preventative actions that were implemented to educate staff related to observations of patients per provider orders and the securing of areas the patients are not allowed to enter unsupervised in the patient care area.
Findings:

A review of the psychiatric hospital policy, "PC-1013: Levels of Patient Observation," with an effective date of 07/10/2012 and last revised 01/08/2025, revealed in part: "POLICY All patients are monitored as to their location and activity at regular intervals. The degree of this monitoring is dependent upon the individual patient's assessed psychiatric condition. PROCEDURE The charge RN, in conjunction with the staff providing direct patient care, is responsible for assessing the observation status of all patients and increasing the level of observation when required, until Physician's Orders can be obtained. Any decrease in observation status requires a physician's order prior to decrease in status. All patients admitted to the hospital will be assigned routine level of observation unless the physician orders a special level of observation. A) Routine levels of Observation 1) All patient are monitored a minimum of every 15 minutes. 2) Location of patients is monitored at each change of shift by a staff member from the off-going shift together with a member of the on-coming shift. Location is noted on observation sheet for appropriate shift. 3) Staff assigned to the charting on patients will include documentation in the Nursing Progress Notes as to the location and frequency of checks. B) Special Levels of Observation An increased degree of monitoring is applied to patients whose psychiatric conditions is assessed as needing more intense external controls and/or increased frequency of staff contract for patients to be able to maintain their internal controls. Patients assessed as needing any of the following increased levels of observation are to be maintained in the hospital. Special Levels of Observation are as follows: 1) Constant Observation - may be referred to as "Line of Sight" or "Close Observation" a. A patient is maintained in community areas where their entire body can be observed at all times. b. Staff must be able to maintain a "line-of-sight" to the patient at all times. c. Staff shall accompany the patient on constant observation at any time they leave community areas, e.g., to the bathroom or to change clothes. d. Documentation of constant observation will be completed on the Q15 Observation sheet. 2) One-to-One Observation a. This is an extreme level of observation reserved for patients whose psychiatric, medical, and/or cognitive stats is such that control/safety cannot be maintained otherwise. b. A staff member is assigned to this patient and remains in physical proximity at all times, within 4 feet of a non-violent patient, within 8 feet of a violent patient, or as specified by the ordering provider. c. Documentation in Nursing Progress Notes must state that one-to-one supervision was provided throughout the shift. The staff member providing on-to-one supervision shall give report to the on-coming shift."

A review of hospital self-report received by Louisiana Department of Health - Health Standards Section (LDH HSS) on 09/03/2025 revealed an incident of alleged patient to patient sexual assault taking place on 08/26/2025 at approximately 10:23 AM, with the date of discovery of the alleged event being 09/02/2025 at 11:36 AM. This hospital self-report revealed in part, S1CEO being informed by Patient #1's guardian that Patient #1 and Patient #2 had engaged in sex on 08/26/2025 between breakfast and lunch and this had reportedly taken place in a bathroom. The hospital self-report also revealed the review by S1CEO of recorded video from 08/26/2025. S1CEO's notes revealed Patient #2 entering Room "a" at 10:22:23 AM, Patient #1 entering Room "a" at 10:23:40 AM and closing the door, Patient #1 exiting Room "a" at 10:25:04 AM and Patient #2 exiting Room "a" at 10:25:28 AM.

Observations of recorded video, with S1CEO navigating the computer and identifying patients and rooms, revealed the before mentioned incident on 08/26/2025. The recorded video was captured by Camera 7 and it provided a view of the hospital's main hallway leading to Rooms "a" - "j". The observed video revealed the same before mentioned sequence of events and timeframes. Further observations of the recorded video revealed the door of Room "a" unlocked and completely open with no staff member present.

A review of the hospital's daily census sheet and staffing sheet for 08/26/2025 revealed Patient #2 and #R1 as being observed as a Line of Sight and Patient #1 and #R2 - #R11 as being observed as Routine level of observation (q15min). A review the hospital's daily staffing sheet for 08/26/2025 day shift revealed S7RN, S8LPN, S5MHT and S6MHT on duty.

A review of Patient #2's medical record revealed provider observation orders for Line of Sight during the before mentioned timeframe. A review of Patient #2's Patient Observation Record dated 08/26/2025 revealed S6MHT as the staff member performing observations on Patient #2 from 10:00 AM to 10:45 AM which would include the time frame of the before mentioned event.

A review Patient #R1's medical record revealed provider observation orders for Line of Sight during the before mentioned timeframe. A review of Patient #R1's Patient Observation Record dated 08/26/2025 revealed S6MHT as the staff member performing observations on Patient #R1 from 10:00 AM to 10:45 AM which would include the time frame of the before mentioned event.

A review of Patients #R4 - #R7 observation sheets from 08/26/2025 revealed S6MHT performing observations from 10:00 AM to 10:45 AM which would include the time frame of the before mentioned event.

A request was initiated with S1CEO and S2DON for documentation of educational in-services performed with staff since 08/26/2025 related to a review of the levels of observations and what each level would encompass and a review of which rooms should be locked and secured in the patient care areas to prevent a patient to gain access while unattended or being monitored.

In an interview on 09/23/2025 at 11:10 AM, S1CEO confirmed the above mentioned findings. S1CEO confirmed it would be impossible to watch 2 Line of Sight patients at one time if the patients were mobile and moving around the unit and further confirmed S6MHT should not have been assigned other patients while being assigned to a Line of Sight patient. S1CEO confirmed S6MHT was not maintaining a Line of Sight on Patient #2 while he was located in Room "a" and S6MHT was located in Room "k" while Patients #1 and #2 were in Room "a" per video he had reviewed but is now unavailable. S1CEO confirmed the door of Room "a" should have been closed and locked when not in use and a staff member should be present when the room is being utilized by any patient regardless of the patient's ordered observation level.

In an interview on 09/23/2025 at 1:15 PM, S2DON confirmed the hospital had no documentation of educational in-services being performed related to a review of the levels of observations and the securing of doors in the patient care areas since 08/26/2025.

Based on record review and interview, the psychiatric hospital failed to ensure nursing services have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. This deficient practice is evidenced by the failure to ensure adequate staffing was on duty to provide nursing care to all patients.
Findings:

A review of the psychiatric hospital policy, "PC-114: Staffing Patterns, Variances and Acuity," with an effective date of 07/10/2012 and last revised 12/19/2024, revealed in part: "Scope The staffing pattern for the program is based on aspects of care and services provided to facilitate a ratio of staff to patients that is conducive to providing high quality, safe, efficient and compassionate care. Responsible Party Director of Nursing and Assistant Director of Nursing is responsible for ensuring that these patterns are communicated to department staff. Staff Patterns 1. There will be a minimum of 1 RN on all shifts. 2. A nursing staff to patient ratio of no less that 1:5 will be maintained at all times. 3. Additional staff may be called in at the discretion of the charge RN or to maintain a staffing ratio of no less than 1:5. 4. The charge nurse on duty will notify on-call nurse if additional staffing is needed. Daily Clinical Staffing and Management Report The night charge nurse will complete the Daily Clinical Staffing and Management Report for the day. The day, evening, and night shifts will document any changes/updates to the report. In the event that the census or acuity increases, additional staff members may be called in to ensure high quality, individualized care for every patient. If any patient's score reach Level 3, additional staff may be needed. The charge nurse on duty will notify the on-call nurse for the need for additional staff."

A review of the psychiatric hospital policy, "PC-1013: Levels of Patient Observation," with an effective date of 07/10/2012 and last revised 01/08/2025, revealed in part: "POLICY All patients are monitored as to their location and activity at regular intervals. The degree of this monitoring is dependent upon the individual patient's assessed psychiatric condition. PROCEDURE The charge RN, in conjunction with the staff providing direct patient care, is responsible for assessing the observation status of all patients and increasing the level of observation when required, until Physician's Orders can be obtained. Any decrease in observation status requires a physician's order prior to decrease in status. All patients admitted to the hospital will be assigned routine level of observation unless the physician orders a special level of observation. A) Routine levels of Observation 1) All patient are monitored a minimum of every 15 minutes. 2) Location of patients is monitored at each change of shift by a staff member from the off-going shift together with a member of the on-coming shift. Location is noted on observation sheet for appropriate shift. 3) Staff assigned to the charting on patients will include documentation in the Nursing Progress Notes as to the location and frequency of checks. B) Special Levels of Observation An increased degree of monitoring is applied to patients whose psychiatric conditions is assessed as needing more intense external controls and/or increased frequency of staff contract for patients to be able to maintain their internal controls. Patients assessed as needing any of the following increased levels of observation are to be maintained in the hospital. Special Levels of Observation are as follows: 1) Constant Observation - may be referred to as "Line of Sight" or "Close Observation" a. A patient is maintained in community areas where their entire body can be observed at all times. b. Staff must be able to maintain a "line-of-sight" to the patient at all times. c. Staff shall accompany the patient on constant observation at any time they leave community areas, e.g., to the bathroom or to change clothes. d. Documentation of constant observation will be completed on the Q15 Observation sheet. 2) One-to-One Observation a. This is an extreme level of observation reserved for patients whose psychiatric, medical, and/or cognitive stats is such that control/safety cannot be maintained otherwise. b. A staff member is assigned to this patient and remains in physical proximity at all times, within 4 feet of a non-violent patient, within 8 feet of a violent patient, or as specified by the ordering provider. c. Documentation in Nursing Progress Notes must state that one-to-one supervision was provided throughout the shift. The staff member providing on-to-one supervision shall give report to the on-coming shift."
A review of the psychiatric hospital's staffing matrix revealed a day shift census of 13 patients would indicated a need for 1 RN, 1 LPN and 3 MHTs.

A review of the hospital's daily census sheet for 08/26/2025 revealed Patient #2 and #R1 as being observed as a Line of Sight and Patient #1 and #R2 - #R11 being observed as Routine Q15min observations. A review the hospital's daily staffing sheet for 08/26/2025 day shift revealed S7RN, S8LPN, S5MHT and S6MHT on duty. Per staffing matrix, there was not an adequate number of staff on duty. Additionally, each MHT would not be able to maintain a constant Line of Sight on a patient and/or have the ability to perform routine monitoring and observations on other patients whom have the opportunity to constantly move around the unit.

In a telephone interview on 09/24/2025 at 10:22 AM, S5MHT confirmed he remembered the day of 08/26/2025 and confirmed there were 2 MHTs on duty that day, himself and S6MHT. S5MHT indicated he was assigned to Patient #R1 and S6MHT was assigned to Patient #2. S5MHTconfirmed he was assisting with treatment team meeting on this day and he handed off Patient #R1 to S6MHT. S5MHT further confirmed during the time he was assisting with treatment team, S6MHT had the responsibility to monitor 2 Line of Sight patients (#2 and #R1) and perform routine observations on the other patients which included Patients #1 and #R2 - #R11.

In an interview on 09/24/2025 at 10:35 AM, S1CEO and S2DON confirmed the above mentioned findings and further confirmed that shift was short at minimum 1 MHT.

Based on observation, record review and interview, the psychiatric hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient. This deficient practice was evidenced by the failure to properly observe and monitor patients per provider orders.
Findings:

A review of the psychiatric hospital policy, "PC-1013: Levels of Patient Observation," with an effective date of 07/10/2012 and last revised 01/08/2025, revealed in part: "POLICY All patients are monitored as to their location and activity at regular intervals. The degree of this monitoring is dependent upon the individual patient's assessed psychiatric condition. PROCEDURE The charge RN, in conjunction with the staff providing direct patient care, is responsible for assessing the observation status of all patients and increasing the level of observation when required, until Physician's Orders can be obtained. Any decrease in observation status requires a physician's order prior to decrease in status. All patients admitted to the hospital will be assigned routine level of observation unless the physician orders a special level of observation. A) Routine Levels of Observation 1) All patient are monitored a minimum of every 15 minutes. 2) Location of patients is monitored at each change of shift by a staff member from the off-going shift together with a member of the on-coming shift. Location is noted on observation sheet for appropriate shift. 3) Staff assigned to the charting on patients will include documentation in the Nursing Progress Notes as to the location and frequency of checks. B) Special Levels of Observation An increased degree of monitoring is applied to patients whose psychiatric conditions is assessed as needing more intense external controls and/or increased frequency of staff contract for patients to be able to maintain their internal controls. Patients assessed as needing any of the following increased levels of observation are to be maintained in the hospital. Special Levels of Observation are as follows: 1) Constant Observation - may be referred to as "Line of Sight" or "Close Observation" a. A patient is maintained in community areas where their entire body can be observed at all times. b. Staff must be able to maintain a "line-of-sight" to the patient at all times. c. Staff shall accompany the patient on constant observation at any time they leave community areas, e.g., to the bathroom or to change clothes. d. Documentation of constant observation will be completed on the Q15 Observation sheet. 2) One-to-One Observation a. This is an extreme level of observation reserved for patients whose psychiatric, medical, and/or cognitive stats is such that control/safety cannot be maintained otherwise. b. A staff member is assigned to this patient and remains in physical proximity at all times, within 4 feet of a non-violent patient, within 8 feet of a violent patient, or as specified by the ordering provider. c. Documentation in Nursing Progress Notes must state that one-to-one supervision was provided throughout the shift. The staff member providing on-to-one supervision shall give report to the on-coming shift."

A review of hospital self-report received by Louisiana Department of Health - Health Standards Section (LDH HSS) on 09/03/2025 revealed an incident of alleged patient to patient sexual assault taking place on 08/26/2025 at approximately 10:23 AM, with the date of discovery of the alleged event being 09/02/2025 at 11:36 AM. This hospital self-report revealed in part, S1CEO being informed by Patient #1's guardian that Patient #1 and Patient #2 had engaged in sex on 08/26/2025 between breakfast and lunch and this had reportedly taken place in a bathroom. The hospital self-report also revealed the review by S1CEO of recorded video from 08/26/2025. S1CEO's notes revealed Patient #2 entering Room "a" at 10:22:23 AM, Patient #1 entering Room "a" at 10:23:40 AM and closing the door, Patient #1 exiting Room "a" at 10:25:04 AM and Patient #2 exiting Room "a" at 10:25:28 AM.

Observations of recorded video, with S1CEO navigating the computer and identifying patients and rooms, revealed the before mentioned incident on 08/26/2025. The recorded video was captured by Camera 7 and it provided a view of the hospital's main hallway leading to Rooms "a" - "j". The observed video revealed the same before mentioned sequence of events and timeframes. Further observations of the recorded video revealed the door of Room "a" unlocked and completely open with no staff member present.

A review of the hospital's daily census sheet and staffing sheet for 08/26/2025 revealed Patient #2 and #R1 as being observed as a Line of Sight and Patient #1 and #R2 - #R11 as being observed as Routine level of observation (q15min). A review the hospital's daily staffing sheet for 08/26/2025 day shift revealed S7RN, S8LPN, S5MHT and S6MHT on duty. A review of Patient #1, #2, and #R1- #R11 revealed the following provider observation orders and the MHT whom performed the observation on 08/26/2025 from 10:00 AM to 10:45 AM:
Provider observation orders for Line of Sight on the following patients:
--Patient #2: 10:00 AM-S6MHT, 10:15 AM-S6MHT, 10:30 AM-S6MHT, 10:45 AM-S6MHT; and
--Patient #R1: 10:00 AM-S6MHT, 10:15 AM-S6MHT, 10:30 AM-S6MHT, 10:45 AM-S6MHT.
Provider orders for Routine level of observation (q15min) on the following patients:
--Patient #1: 10:00 AM-S5MHT, 10:15 AM-S5MHT, 10:30 AM-S5MHT, 10:45 AM-S5MHT;
--Patient #R2: 10:00 AM-S5MHT, 10:15 AM-S5MHT, 10:30 AM-S5MHT, 10:45 AM-S5MHT;
--Patient #R3: 10:00 AM-S5MHT, 10:15 AM-S5MHT, 10:30 AM-S5MHT, 10:45 AM-S5MHT;
--Patient #R4: 10:00 AM-S6MHT, 10:15 AM-S6MHT, 10:30 AM-S6MHT, 10:45 AM-S6MHT;
--Patient #R5: 10:00 AM-S6MHT, 10:15 AM-S6MHT, 10:30 AM-S6MHT, 10:45 AM-S6MHT;
--Patient #R6: 10:00 AM-S6MHT, 10:15 AM-S6MHT, 10:30 AM-S6MHT, 10:45 AM-S6MHT;
--Patient #R7: 10:00 AM-S6MHT, 10:15 AM-S6MHT, 10:30 AM-S6MHT, 10:45 AM-S6MHT;
--Patient #R8: 10:00 AM-S5MHT, 10:15 AM-S5MHT, 10:30 AM-S5MHT, 10:45 AM-S5MHT;
--Patient #R9: 10:00 AM-S5MHT, 10:15 AM-S5MHT, 10:30 AM-S5MHT, 10:45 AM-S5MHT;
--Patient #R10: 10:00 AM-S5MHT, 10:15 AM-S5MHT, 10:30 AM-S5MHT, 10:45 AM-S5MHT; and
--Patient #R11: 10:00 AM-S5MHT, 10:15 AM-S5MHT, 10:30 AM-S5MHT, 10:45 AM-S5MHT.
The review of observation sheet revealed S6MHT maintaining a Line of Sight on 2 (#2, #R1) and patients maintaining routine observation on 4 (#R4- #R7) patients during the before mentioned event. The review of recorded video failed to reveal S6MHT or any staff member around Room "a" with the door open.

In a telephone interview on 09/24/2025 at 10:22 AM, S5MHT confirmed he remembered the day of 08/26/2025 and confirmed there were 2 MHTs on duty that day, himself and S6MHT. S5MHT indicated he was assigned to Patient #R1 and S6MHT was assigned to Patient #2. S5MHTconfirmed he was assisting with treatment team meeting on this day and he handed off Patient #R1 to S6MHT. S5MHT further confirmed during the time he was assisting with treatment team, S6MHT had the responsibility to monitor 2 Line of Sight patients (#2 and #R1) and perform routine observations on the other patients which included Patients #1 and #R2 - #R11.

In an interview on 09/23/2025 at 11:10 AM, S1CEO confirmed the above mentioned findings. S1CEO confirmed it would be impossible to watch 2 Line of Sight patients at one time if the patients were mobile and moving around the unit and further confirmed S6MHT should not have been assigned other patients while being assigned to a Line of Sight patient. S1CEO confirmed S6MHT was not maintaining a Line of Sight on Patient #2 while he was located in Room "a" and S6MHT was located in Room "k" while Patients #1 and #2 were in Room "a" per video he had reviewed but is now unavailable. S1CEO confirmed the door of Room "a" should have been closed and locked when not in use and a staff member should be present when the room is being utilized by any patient regardless of the patient's ordered observation level.

Based on record review and interview, the psychiatric hospital failed to ensure all licensed nurses who provide services in the hospital adhere to the policies and procedures of the hospital and the director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services. This deficient practice is evidenced by the failure to ensure the documentation of all agency nurses completing the same orientation a staff RN would complete upon hire and prior to performing unsupervised patient care.
Findings:

A review of the psychiatric hospital policy, "HR-603: Temporary Service Agencies," with an effective date of 1998 and last revised 10/2022, revealed in part: "POLICY Temporary Services are used on an as-needed basis only and require that they be coordinated through Administration to ensure control of such services. All contract employees shall receive training and orientation prior to performing his/her assigned duties. In addition, records on all contract employees shall be maintained in accordance with current regulations, standards and law. PROCEDURE Prior to performing any duties, the contract employee shall complete training and orientation. Training and orientation shall be facilitated by the facility."

A review of S9RNA personnel file failed to reveal documentation of this staff member completing hospital orientation which would include hospital policies and procedures as they relate to hospital's emergency procedures, nursing services policies and procedures, and safety policies and procedures. The personnel file further failed to reveal documentation of competencies as this would relate to the performance of clinical activities.
A review of staffing schedules revealed S9RNA had already worked as the charge nurse on the night shifts of 09/20/2025.

In an interview on 09/24/2025 at 2:35 PM, S2DON confirmed the above mentioned findings and further confirmed S9RNA had worked as the charge nurse with no supervision on the nights of 09/15/2025, 09/16/2025, 09/20/2025, and 09/21/2025.