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Based on record reviews and interviews, the hospital failed to follow its process for evaluating and acting on patient grievances for 2 of 6 sampled patients (#1, #6). This deficient practice had the potential to impact the 12 patients on census.
Findings:

Review of the hospital's Grievance and Complaint policies and procedures revealed, in part:
Policy: St. Catherine Memorial Hospital will identify a mechanism for reporting, evaluation and acting on patient/family and medical staff grievances to improve patient care and organization performance.
Procedure:
1. When a grievance of any kind is noted, the Grievance Report form is used. The top part of the form is to be completed by the person receiving the grievance.
2. The grievance form is then referred to the Director of Nursing/Administrator for initial review and action. The signature of the Director of Nursing/Administrator and date are completed along with the details of the review and action recommended and taken. This is to be completed within 24 hours. The Director of Nursing/Administrator will make every effort to resolve the problem consistent with needs of the patient and proper management of the hospital. The patient will be appropriately informed of the department manager's decision or action. A written response to the grievance will be made within 24 hours.
3. The grievance report is then forwarded to the CEO for review.

1. Patient #1:

Review of the medical record revealed the patient was admitted to the hospital on 10/16/15.

Review of the St. Catherine Memorial Hospital Grievance/Complaint report form dated 11/13/15 revealed the patient and her husband voiced a grievance that patient #3 was "very obnoxious" when he spoke to them and made patient #1 cry. Further review revealed action on this concern was not taken until 11/16/15.

Review of the St. Catherine Memorial Hospital Grievance/Complaint report form dated 11/14/15 revealed the patient voiced a grievance that she felt threatened by patient #3. Further review revealed the facility follow-up and resolution of grievance sections of the form was not completed.

Review of the St. Catherine Memorial Hospital Grievance/Complaint report form dated 11/14/15 revealed the patient voiced a another grievance that patient #3 had made threats to her and the patient started to cry. Further review revealed the facility follow-up and resolution of grievance sections of the form was not completed.

Patient #6:

Review of the medical record revealed the patient was admitted to the hospital on 11/13/15.

Review of the St. Catherine Memorial Hospital Grievance/Complaint report form dated 11/14/15 revealed the patient was yelled and cursed at by patient #3 and the patient was extremely upset. Further review revealed the facility follow-up and resolution of grievance sections of the form was not completed.

In an interview on 12/01/15 at 9:19 a.m., patient #6 indicated he was cursed and yelled at by patient #3. The patient indicated this upset him and he stayed in his room to avoid contact with patient #3.

In an interview on 12/02/15 at 10:06 a.m., S2DON confirmed that there was no documented evidence the hospital's grievance policies and procedures were implemented timely for patient #1's and patient #6's grievances.

Based on record reviews and staff interviews, the hospital failed to ensure a patient's right to participate in his plan of care by failing to allow the patient to return to the hospital after an emergency room visit for 1 of 6 sampled patients (#3). This deficient practice had the potential to impact the 12 patients on census.
Findings:

Patient #3:

Review of the medical record revealed the patient was admitted to the hospital on 11/10/15.

Review of the medical record revealed the patient was having behavioral issues and was sent to an acute care hospital emergency room on 11/17/15 for evaluation and possible admit by physician emergency certificate.

Review of the medical record revealed the patient was not admitted to the acute care hospital and transferred back to St. Catherine Memorial Hospital. Further review revealed the patient's re-admission to the hospital was denied by staff members and administration.

In an interview on 12/02/15 at 10:06 a.m., S2DON confirmed that patient #3 was not allowed to return to the hospital because administration felt that the patient was a threat to staff and other patients.

Based on record reviews and interviews, the hospital failed to ensure patients were free from all forms of abuse by failing to investigate and report suspected abuse to the Louisiana Department of Health and Hospitals for 2 of 2 (#1, #6) patients reviewed with allegations of abuse. This deficient practice had the potential to impact the 12 patients on census.
Findings:

1. Patient #1:

Review of the medical record revealed the patient was admitted to the hospital on 10/16/15.

Review of the St. Catherine Memorial Hospital Grievance/Complaint report form dated 11/13/15 revealed the patient and her husband voiced a grievance that patient #3 was "very obnoxious" when he spoke to them and made patient #1 cry.

Review of the St. Catherine Memorial Hospital Grievance/Complaint report form dated 11/14/15 revealed the patient voiced a grievance that she felt threatened by patient #3.

Review of the St. Catherine Memorial Hospital Grievance/Complaint report form dated 11/14/15 revealed the patient voiced another grievance that patient #3 had made threats to her and the patient started to cry.

2. Patient #6:

Review of the medical record revealed the patient was admitted to the hospital on 11/13/15.

Review of the St. Catherine Memorial Hospital Grievance/Complaint report form dated 11/14/15 revealed the patient was yelled and cursed at by patient #3 and the patient was extremely upset.

In an interview on 12/01/15 at 9:19 a.m., patient #6 indicated he was cursed and yelled at by patient #3. The patient indicated this upset him and he stayed in his room to avoid contact with patient #3.

Review of the hospital's Abuse and Neglect policies and procedures revealed, in part: Patients have the right to be free from all anxiety or acts of violence that could threaten their physical or mental well-being and the full enjoyment of their possessions.

Review of the hospital's DHH-Health Standards Section-24 Hour Notification of Abuse/Neglect form revealed the 11/13/15 and 11/14/15 incidents of psychological/emotional and verbal abuse that occurred between patient #3 and patient #1 and patient #6 were documented on the same form. Review of the information provided to the surveyor revealed no documented evidence a thorough investigation of the alleged psychological/emotional and verbal abuse incidents were conducted. Further review revealed the Date/Time Final Report due to HSS, Facility/CEO finding and Date Final Report Completed sections of the form were not completed.

In an interview on 12/02/15 at 10:49 a.m., S2DON confirmed the hospital had no documented evidence the suspected abuse was thoroughly investigated nor reported to the Louisiana Department of Health and Hospitals.

Based on record reviews and staff interviews, the hospital failed to ensure discharge planning evaluations were conducted for 3 of 5 sampled patients reviewed for discharge planning (#2, #3, and #5). This deficient practice had the potential to impact the 12 patients on census.
Findings:

1. Patient #3:

Review of the medical record revealed the patient was admitted to the hospital on 11/10/15.

Review of the medical record revealed the patient was having behavioral issues and was sent to an acute care hospital emergency room on 11/17/15 for evaluation and possible admit by physician emergency certificate.

Review of the medical record revealed the patient was not admitted to the acute care hospital and transferred back to St. Catherine Memorial Hospital. Further review revealed the patient's re-admission to the hospital was denied.

Review of the medical record revealed no documented evidence that a discharge planning evaluation was conducted and there was no evidence of discharge plans. Further review revealed the discharge instructions and home medication program forms were not completed.

2. Patient #2:

Review of the medical record revealed the patient was admitted to the hospital on 10/13/15.

Review of the medical record revealed the patient was discharged from the hospital on 11/02/15.

Review of the medical record revealed no documented evidence of a discharge planning evaluation or discharge plans. Further review revealed the discharge instructions and home medications forms were not completed.

3. Patient #5:

Review of the medical record revealed the patient was admitted to the hospital on 11/17/15.

Review of the medical record revealed the patient was discharged from the hospital on 11/20/15.

Review of the medical record revealed no documented evidence of a discharge planning evaluation or discharge plans. Further review revealed the discharge instructions and home medication program forms were not completed.

In an interview on 12/01/15 at 2:21 p.m., S5LPN/Case Manager indicated all patients should have a discharge planning evaluation done. S5LPN/Case Manager indicated the hospital had a Discharge Planning Evaluation/Discharge Summary form, but this form was not being utilized.