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Based on record review and interview the hospital failed to meet the Conditions of Participation (CoP) of Patient Rights. This deficient practice was evidenced by:

1) failure to protect patients by refraining to place S8CGT on administrative leave and to submit abuse reports in a timely manner as outlined in psychiatric hospital policy, following the accusation of physical abuse against Client #2 potentially resulting in the abuse of Client #4.(See findings in A0145).

2) failure to ensure the hospital's contract nursing staff were educated, trained and demonstrated knowledge on the use of nonphysical intervention skills as evidenced by 1 (#S11RN) of 1 (#S11RN) contract nursing staff sampled for nonphysical intervention skills training failing to have documented evidence of nonviolent behavior training within the last 3 years (See findings in A0200).

Based on record review and interview the hospital failed to protect patients as evidenced by failure to place S8CGT on administrative leave and to submit abuse reports in a timely manner as outlined in psychiatric hospital policy, following the accusation of physical abuse against Client #2 potentially resulting in the abuse of Client #4.
Findings:

Review of psychiatric hospital's policy #LD-25 titled, "Client Abuse and Neglect Policy and Procedures", effective 05/16/24, revealed in part: "I. Policy: Eastern Louisiana Mental Health System (ELMHS) is committed to preserving the right of each person receiving services to be free of abuse and neglect. All forms of abuse/neglect of clients by employees of ELMHS and its affiliates are prohibited. IV in part: General Definitions: Substantiated: a determination based on the evidence that there is reasonable cause to believe that conduct in violation of the abuse/neglect policy occurred and, where applicable, whether such conduct is attributable to the accused. X in part: Investigation Review Process For 24-hour Facilities, in part: D. iv. A final report shall be submitted to HSS (Health Standards Section) with the findings as soon as it is concluded but within five (5) working days of submitting the initial report. If an extension is needed, a request may be submitted to HSS and must include the reason for the extension request. XIV in part: Consequences of Abuse and/or Neglect. C. The staff member confirmed to have physically or sexually abused a client will be terminated from his/her employment.

Review of psychiatric hospital's document titled "Eastern Louisiana Mental Health System Hospital Abuse/Neglect Initial Report", dated 01/15/2025 revealed a submission date of 01/15/2025. The report described an allegation that S8CGT hit Client #2 in the face while on Unit C. Further review of the document revealed S8CGT had been removed from contact with patients and reassigned from alleged victim and monitored by supervisors.

Review of Unit Assignments document provided by psychiatric hospital dated 01/15/2025 revealed S8CGT was scheduled on Unit A, day shift. S8CGT was assigned to rounds and hall monitor as senior officer from 2:00 PM-6:00 PM. Continued review revealed S8CGT was also scheduled on Unit A, day shift and assigned to rounds and hall monitor as senior officer on 01/18/2025, 01/19/2025, 01/20/2025, 01/23/2025, 01/24/2025, 01/27/2025, 01/28/2025, 01/29/2025, 02/01/2025, 02/02/2025, and 02/04/2025. Of note Unit C was closed on 01/22/2025.

Review of the letter for request of protection from the Adult Protective Services (APS) investigator provided by psychiatric hospital dated 01/16/2025, revealed a direction to move S8CGT off Unit C and away from Client #2 until further notice due to an allegation of physical abuse.

Review of document provided by psychiatric hospital titled "Video Footage Report," dated and signed on 01/29/2025, revealed footage of Unit C on 01/15/2025 at 9:29:46-50 AM from 2 perspectives in hallway. The footage indicated where Client #2 was on the floor in the hallway and S8CGT was standing over Client #2 when he swung in a downward motion one time and appeared to hit Client #2 in the face. Another CGT was standing a few feet away from the incident and did not intervene. Of note, the cameras were not working on 01/15/2025 in Client #2's room.

Review of psychiatric hospital's document titled "Case No. LA76082", dated 02/05/2025 revealed the following video footage on 01/15/2025 at 09:29:51: S8CGT raised his right closed hand (fist) and hit Client #2 one time in his facial area while holding Client #2's shirt with his left hand. Continued review revealed that based upon the facility review, Eastern Louisiana Mental Helath System (ELMHS) had substantiated the physical abuse allegation for S8CGT.

Review of psychiatric hospital documents dated 02/06/2025, provided by S20HRS, revealed an incident occurring on 01/15/2025, involved the physical abuse of Client #2 by S8CGT and was substantiated due to evidence. Continued review revealed the recommended corrective action to be taken for substantiated abuse and or neglect was dismissal.

Review of psychiatric hospital documents dated 02/25/2025, provided by S20HRS, revealed an incident occurring on 02/02/2025, involved the physical abuse of Client #4 by S8CGT and was substantiated due to evidence. Continued review revealed the recommended corrective action to be taken for substantiated abuse and or neglect was dismissal.

Review of psychiatric hospital's document titled "Eastern Louisiana Mental Health System Hospital Abuse/Neglect Initial Report", dated 02/05/2025, revealed in part, Client #4 made an allegation to S25SW, that on 02/02/25 after being asked to brush his teeth, he and a guard cursed each other, the guard then asked him "what you want to do?" He then stated S8CGT "sucker punched me and I went down to the bed." Review of initial actions taken revealed S8CGT was reassigned from alleged victim and was monitored by supervisors.

Review of psychiatric hospital's document titled "Eastern LA Mental Health System (Facility #330), Abuse/Neglect Review", dated 02/21/2025, revealed in part: Date of incident: 02/02/2025. Incident Type Classification: Appointing Authority Findings: 01-Physical Abuse: is the use of physical force that may result in bodily injury, physical pain, or impairment. Substantiated due to the evidence. 03-Neglect: a failure to provide a patient care with proper food, clothing, shelter, supervision, medical care, or emotional stability. Substantiated due to the evidence. Explanation of findings, in part: The incident has been substantiated for physical abuse against S8CGT. On 02/02/2025 at approximately 6:33 AM, S8SGT can be observed making contact with Client #4 in a very aggressive manner. At this time S8CGT can be heard cursing and being very disrespectful to Client #4. At approximately 6:33 AM, S8CGT can be observed punching Client #4. He punched him approximately 6 to 8 times. Two CGTs walked into Client #4's room and saw S8CGT hitting Client #4 while he was on the bed. The writer of the document stated, "This is a clear case of physical abuse."

Review of hospital document dated 11/11/2024-02/22/2025, provided by S19RNPC, revealed a list of separated (terminated) staff. Continued review failed to reveal S8CGT.

During an interview on 2/26/25 at 9:44 AM, S20HRS reported she noticed that on 02/05/2025, TQM had entered the incident occurring on 01/15/2025 involving Client #2 into the system. S20HRS realized that after the incident on 01/15/2025, S8CGT had not been placed on administrative leave until the investigation was completed. She alerted administration and S8CGT was placed on administrative leave with pay on 02/05/2025 at 3:46 PM. She did not receive the case file from administration until 02/06/25. S20HRS stated she did not receive the 2nd case file involving Client #4 until 2/25/25 and S8CGT was on administrative leave with pay at this point. S20HRS contacted legal and was advised to hold both investigations and complete as one, in case there was an appeal and both cases could be combined into one appeal. On 02/26/2025, S8CGT was still on administrative leave with pay, which would end on 03/30/25. S20HRS stated if the process was not completed by that time, then administration will enforce annual leave. S20HRS indicated she would prepare a letter that stated recommendation for separation/termination with planned completion by 02/27/2025. S20HRS would submit the letter to the legal department who would then proceed with the process of termination/separation of S8CGT from Eastern LA Mental Health System.

During an interview on 02/24/2025 at 9:45 AM, S2QD verified the initial report regarding the investigation of Client #2's abuse allegation occurring on 01/15/2025, was submitted to HSS on 01/15/2025. The requested extension was made on 01/27/2025 13 days following the incident and the final report was submitted on 02/05/2025, 21 days following the incident and 3 days following the abuse of Client #4.

During an interview on 02/24/2025 at 9:50 AM, S2QD verified the initial report regarding the investigation of Client #4's abuse allegation occurring on 02/02/2025, was submitted to HSS on 02/05/2025. The requested extension was made on 02/18/2025 16 days following the incident and the final report was not submitted as of 03/05/2025, 31 days following the incident.

During an interview on 02/27/2025 at 2:23 PM, S2QD recognized that if the investigations were completed by the psychiatric hospital within the five-day requirement per hospital policy, then the incident involving the physical abuse of Client #4 by S8CGT on 02/02/2025 may not have occurred.

Based on record review and interview, the hospital failed to ensure the hospital's contract nursing staff were educated, trained and demonstrated knowledge on the use of nonphysical intervention skills as evidenced by 1 (#S11RNC) of 1 (#S11RNC) contract nursing staff sampled for nonphysical intervention skills training failing to have documented evidence of nonviolent behavior training within the last 3 years.
Findings:

Review of psychiatric hospital's policy #Nursing-2005-604, PC-Nur-00 titled, "Usage of Seclusion and Restraints", revised 01/31/2025, revealed in part: V. Procedure, in part: A. Verbal Intervention and Redirection: i. All staff shall complete state approved mandatory training for management of aggressive/hostile behaviors.

Review of psychiatric hospital's document titled "Contract Nurses Roster, updated January 2025" revealed in part: S11RNC.

Review of psychiatric hospital's document titled "Nursing Location Sheet", dated 01/06/2025-03/02/2025, revealed S11RNC was scheduled on Unit A for the following dates: 01/07/2025, 01/11/2025. 01/12/2025, 01/13/2025, 01/16/2025, 01/21/2025. 01/22/2025, 01/25/2025, 01/26/2025, 01/27/2025, 01/20/2025, 01/31/2025, 02/04/2025, 02/05/2025, 02/08/2025, 02/09/2025, 02/10/2025, 02/13/2025, 02/14/2025, 02/18/2025, 02/19/2025, 02/22/2025, 02/24/2025. 02/27/2025, and 02/28/2025.

Review of S11RNC's personnel file revealed "Nonviolent Crisis Intervention Training" was completed on 03/16/2021 and the training expired on 03/16/2022.

In an interview on 02/26/2025 at 11:59 AM, S21HRA confirmed S11RNC's "Nonviolent Crisis Intervention Training" expired on 03/16/2022, which was approximately 3 years ago.

Based on record review and interview, the hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice was evidenced by:
1) failure to fully investigate and identify physical abuse in a timely manner potentially leading to the abuse of Client #4; and
2) failure to adhere to hospital policy and ensure video surveillance was available 24 hours a day, 7 days a week to protect the safety of the of the clients, staff, visitors and Eastern Louisiana Mental Health System (ELMHS) property.
Findings:

1) Failure to fully investigate and identify physical abuse in a timely manner potentially leading to abuse of Client #4.

Review of psychiatric hospital's policy #LD-25 titled, "Client Abuse and Neglect Policy and Procedures", effective 05/16/24, revealed in part: "X in part: Investigation Review Process For 24-hour Facilities, in part: D. iv. A final report shall be submitted to HSS with the findings as soon as it is concluded but within five (5) working days of submitting the initial report. If an extension is needed, a request may be submitted to HSS and must include the reason for the extension request.

Review of initial self-report regarding an incident that occured on 01/15/2025 revealed submission date of 01/15/2025. The report described an allegation that S8CGT hit Client #2 in the face. Further review revealed staff had been removed from contact with patients, reassigned from alleged victim, and monitored by supervisors.

Review of final self-report to Lousiana Department of Health (LDH) revealeded ELMHS substantiated the allegation of physical abuse of Client #2 by S8CGT occurring on 01/15/2025 and submitted the report on 02/05/2025, approximately 20 days after submission of the initial report.

Review of initial self-report submitted to Lousiana Department of Health (LDH0 regarding and incident occurring on 02/02/2025 revealed submission date of 02/05/2025. The incident involved allegation of the physical abuse of Client #4 by S8CGT. As of 03/05/2025, LDH had not received a final submission in regards to the incident that occurred on 02/02/2025.

Review of psychiatric hospital's document titled "Eastern LA Mental Health System (Facility #330), Abuse/Neglect Review", dated 02/21/2025, revealed in part: Date of incident: 02/02/2025. Incident Type Classification: Appointing Authority Findings: 01-Physical Abuse: is the use of physical force that may result in bodily injury, physical pain, or impairment. Substantiated due to the evidence. 03-Neglect: a failure to provide a patient care with proper food, clothing, shelter, supervision, medical care, or emotional stability. Substantiated due to the evidence. Explanation of findings, in part: The incident has been substantiated for physical abuse against S8CGT. On 02/02/2025 at approximately 6:33 AM, S8SGT can be observed making contact with Client #4 in a very aggressive manner. At this time S8CGT can be heard cursing and being very disrespectful to Client #4. At approximately 6:33 AM, S8CGT can be observed punching Client #4. He punched him approximately 6 to 8 times. Two CGTs walked into Client #4's room and saw S8CGT hitting Client #4 while he was on the bed. The writer of the document stated, "This is a clear case of physical abuse." This incident was substantiated approximately 19 days after the initial incident occurred.

Of note, since January 15th, 2025, the psychiatric hospital requested extensions on the following 8 initial reports related to incidents:

76690-submitted 02/19/2025-requested extension on 02/27/2025-Final report had not been submitted as of 03/05/2025, 14 days following initial submission.

76683-submitted 02/18/2025-requested extension on 02/25/2025-Final report had not been submitted as of 03/05/2025, 15 days following initial submission.

76652-submitted 02/17/2025-requested extension on 02/25/2025-Final report had not been submitted as of 03/05/2025, 16 days following initial submission.

76643-submitted 02/17/2025-requested extension on 02/25/2025-Final report had not been submitted as of 03/05/2025, 16 days following initial submission.

76537-submitted 02/12/2025-requested extension on 02/25/2025-Final report submitted on 02/26/2025, 13 days following initial submission.

76481-submitted 02/10/2025-requested extension on 02/18/2025-Final report had not been submitted as of 03/05/2025, 23 days following initial submission.

76424-submitted 02/06/2025-requested extension on 02/18/2025-Final report had not been submitted as of 03/05/2025. 27 days following initial submission.

76082-submitted 01/15/2025-requested extension on 01/27/2025-Final report submitted on 02/05/3035, 21 days following initial submission.

During an interview on 02/24/2025 at 9:45 AM, S2QD stated that the psychiatric hospital was required to notify APS (Adult Protective Services) of any sexual or abuse allegations. APS had 10 days to complete their investigation. APS asked ELMHS not to investigate the incidents because it could compromise the APS investigation.

2) Failure to adhere to hospital policy and ensure video surveillance was available on Unit B 24 hours a day, 7 days a week to protect the safety of the of the clients, staff, visitors and ELMHS property.

Review of psychiatric hospital's document titled "Client Handbook", revised 06/2024, revealed in part: "Video Surveillance, in part: ELMHS uses Video Surveillance 24 hours a day 7 days a week to protect the safety of the clients, staff, visitors and ELMHS Property".

Review of Client #R1's complaint dated 01/11/2025 revealed his concern that one of the CGTs on Unit B was sleeping that night while on duty as another client was acting in a disturbing manner by shadow boxing and slapping himself, leaving the nurse to try to maintain peace. Further review revealed a notation by staff stating, "Client reported that he would like to withdraw this complaint. Resolved at initial level via office phone on 1/16/2025."

During an interview on 02/27/2025 at 12:32 PM, S22PM stated the cameras on Unit B were non-functioning for January and February of 2025, therefore the surveyor would be unable to view the video footage for Unit B on the night of 01/11/2025 in order to investigate R1's complaint.

Review of psychiatric hospital's document titled "Notification Overview", dated 02/27/2025 at 12:37 PM, revealed a notification that the cameras needed repair on Unit B. The notification stated the following: "The cameras are not showing video from January or February".

Based on record review and interview, the psychiatric hospital failed to ensure 2 (#3 and #5) of 6 (#1-#6) client medical records reviewed had an individualized treatment plan.
Findings:

Review of psychiatric hospital's document titled "Client Handbook", revised 06/2024, revealed in part: "Civil and Treatment Rights", in part: S. The right to an individualized treatment plan.

Client #3
Review of Client #3's medical record revealed an admission date of 04/26/2023 with diagnoses of Traumatic Brain Injury 2nd to MVA, disruptive mood dysregulation, impulse disorder, conduct disorder, mild intellect disorder, convulsions, GERD (Gastroesophageal Reflux Disease), Hyperlipidemia, and obesity.

Continued review of Client #3's medical record revealed a document titled "Modified Texture Diet Flow Sheet (Choking)", dated 02/23/2025. The document revealed Client #3 was on a diet prescription related to dysphagia, level 3 Advanced (Chopped meat and Puree bread) Close Visual Observation (CVO) for choking while having meals/snacks.

Review of Client #3's treatment plan, last updated 02/24/2025, failed to reveal problems related to Traumatic Brain Injury or Dysphagia requiring CVO for meals and snacks.

During an interview on 02/26/2025 at 2:50 PM, S19RNPC verified Client #3's treatment plan did not contain problems related to Traumatic Brain Injury or Dysphagia requiring CVO for meals and snacks.

Client #5
Review of Client #5's medical record revealed an admission date 01/25/2017 with diagnoses of Schizophrenia, Intellectual Disability, alcohol dependence, cannabis dependence, iron deficient anemia.

Review of Client #5's treatment plan, last updated 12/24/2024, failed to reveal problems related to Intellectual Disability.

During an interview on 02/26/2025 at 3:05 PM, S19RNPC verified Client #5's treatment plan did not contain problems related to Intellectual Disability.

Based on record review and interview, the psychiatric hospital failed to ensure a registered nurse assigned the nursing care of each patient to other personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available. This deficient practice is evidenced by failure to ensure an RN made all patient care assignments.
Findings:

Review of psychiatric hospital's policy #11 titled, "Minimum Coverage Staff Assignment", effective 10/30/2013, revealed in part: "Policy: The Security Department will set standards to maintain adequate security coverage to meet the requirements necessary for each level of Patient Care on the Units. Procedure, in part: The shift Captains on Teams A, B, C, and D are responsible for scheduling the CGT's daily assignments.

Review of psychiatric hospital's policy #Nursing-2005-504, PC-NUR-12 titled, "Observations and Precautions", last revised 09/27/2024, revealed in part: I. Definitions, in part: A. One-to-One (1:1) direct observations. The client must be visualized at all times. B. Two-to one (2:1) The client must be visualized at all times. C. Continuous Visual Observation (CVO) at fifteen feet. D. Fifteen (15) Minute Check Observation. E. Precaution Observation. F. Routine Observation. G. Emergent. H. Monitor/Evaluate. IV. Policy: It is the policy of ELMHS to provide professionally supervised care consistent with the Louisiana Office of Behavioral Health (OBH) policy and regulatory accrediting agencies ensuring the utilization of preventative strategies, non-physical interventions and the provision of a safe therapeutic environment of care. V. Procedure, in part: A. Initiation of D. Routine Observation, in part: Procedure, in part: a. the nurse shall assign clients on routine observation to staff based on the unit's acuity level and the client's current system level. E. Initiation of the Restrictive Management Observation and Precaution Sheet, in part: ii. RN responsibilities, in part: c. Assign a Nursing-Security staff member (CGTT, CGT, CLT) or PA to monitor the client while on restrictive management."

Review of psychiatric hospital's documents titled "Building/Unit Assignments" dated 01/06/2025-02/24/2025 revealed the following:
-The forms were divided into sections, 1 section for each of the 4 wards: Units A, B, C, and D.
-Each section contained a list of the names of clients that were on precautions other than routine observation.
- Each section was signed by an RN under the list of staff assigned to each ward.
-The form failed to reveal the names of the clients who were on routine observation.

During an interview on 02/24/2025 at 10:25 AM, S12CLT stated she made the building assignments for the CGTs for each ward and then brought the form to each ward and had the nurse approve and sign the assignment form.

During an interview on 02/24/2025 at 10:30 AM, S24RNM stated the patients on routine observations were not assigned a CGT. Each ward has a CGT that rounds on the patients on routine observations. Only the patients on precautions are assigned a CGT.

During an interview on 02/24/2025 at 10:52 AM, S23RN confirmed she signed the assignment sheet after S12CLT completed it.

Based on record review and interview, the psychiatric hospital and the director of the nursing service failed to ensure that each non-employee nursing care staff person's clinical activities were evaluated. This deficient practice is evidenced by failure to ensure 31 (S11RNC, S26RNC-S56RNC) of 31 (S11RNC, S26RNC-S56RNC) contracted nurses underwent a performance evaluation.
Findings:

A review of psychiatric hospital's document titled "Contract Nurses Roster, Updated January 2025" revealed S11RNC among the 31 (S11RNC, S26RNC-S56RNC) contract nurses hired for the psychiatric hospital.

A review of S11RNC's personnel file revealed date of hire 04/20/2020. Further review failed to reveal a performance evaluation completed on S11RNC since her date of hire.

During an interview on 02/26/2025 at 11:54 AM, S21HRA verified the hospital did not complete performance evaluations on the contracted nurses.