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Based on record review and interviews, the hospital failed to ensure patients were free from abuse and neglect and ensure all incidents of abuse and neglect were reported and analyzed to ensure the hospital was in compliance with applicable local, State, and Federal Laws and Regulations. This deficient practice was evidenced by failure to thoroughly investigate and report allegations of neglect within 24 hours to the Department of Health and Hospitals or law enforcement for 1 (#1) of 3 (#1-#3) patients reviewed for neglect.
Findings:

Review of the Louisiana Revised Statutes, Title 40. Public Health and Safety, Chapter 11, State Department of Health and Hospitals revealed "Department" shall mean the Department of Health and Hospitals. "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. Regarding §2009.20. Duty to make complaints; penalty; immunity, "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. "Neglect" is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer's well-being. Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, ... 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.

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 Patient #1's medical record revealed he was admitted to the hospital on 06/12/2025 at 10:03 PM from an outside referring facility's emergency room for Impulsive Disorder; Bipolar Disorder with Depression; and Mild Neurocognitive Disorder due to Known Physiological Condition without Behavioral Disturbances.

Review of Patient #1's Provider Orders for June 2025 revealed the following orders:
06/12/2025 at 11:51 PM Regular Diet, Double Portions, Mechanical Soft Consistency
06/12/2025 at 11:52 PM Dietician Consult Indication: easily choked, swallowing precautions
06/15/2025 at 9:00 AM Swallowing Precautions every shift
06/17/2025 at 5:05 PM Transfer Patient to Hospital Now
06/18/2025 at 9:00 AM Dietary Supplement - Thicken Liquids-All liquids are to be thickened with thickener due to swallowing precautions
06/18/2025 at 9:00 AM Nurse Communication - Patient is to have Thicken Liquids and ALL medications to be crushed in pudding or apple sauce.

Review of Patient #1's Initial Nutritional Consult completed by S4RD on 06/14/2025 at 9:29 AM revealed in part:
Date Ordered: 06/13/2025
Reason for Consult: Requiring Therapeutic Diet
Oral: Difficulty Chewing, Difficulty Swallowing, Comments - Since motorcycle wreck, but able to eat mechanical soft and thickened liquids diet.
Assessment/Summary: Patient #1 lying in bed awake, alert, able to answer dietary questions, feed self, food preferences noted. Goals - stable weight, optimize nutritional status and prevent skin breakdowns.
RD Recommendations: Provide 1 can Ensure three times a day between meals, continue to monitor weight, labs, oral intake, skin and hydration.
Electronically Signed by: S4RD

Review of Patient #1's Nursing Note by S7RN dated 06/17/2025 at 6:14 PM revealed the following note:
"At 4:45 PM - MHT reported to nurse that patient was in dayroom choking off his supper. When nurse entered dayroom medication nurse was preforming abdominal thrust on patient in dayroom (Heimlich maneuver) on patient. Multiple attempts were made to open patient mouth to visualize lodged object with no success. Jaw thrust applied. Call was placed to 911 as staff alternated continuation of abdominal thrust. Unsuccessful with abdominal thrust. Patient face and lips turned blue, cyanosis noted, O2 saturation dropped staff laid patient on his side and continued with jaw thrust success and suctioned out some of the lodged object. Local ambulance service arrived and took over. Patient was transported to local emergency room for further evaluation and treatment. Patient #1's emergency contact/mother, S5MD and S6MD notified."

Review of the incident report (was in progress at the time of the survey) last modified on 06/23/2025 for Patient #1 for a "Safety, Health and Infection Prevention: Respiratory/Cardiac Arrest of Loss of Consciousness" revealed in part:
Case Type: Incident/Event
Intake Method: Internal Incident/Unusual Occurrence Form
Date/Time of Occurrence: 06/17/2025 at 4:45 PM
Was family/representative made aware of incident? Yes
What family/representative was made aware of incident? Patient #1's emergency contact/mother
When did family/representative receive notification? 06/17/2025
Was Physician/Provider made aware of incident? Yes
What Physician/Provider received notification? S5MD and S6MD
When did Physician/Provider receive notification? 06/17/2025
Did this incident result in an injury? Yes
Type of Injury: Other
Body Part Affected: Mouth, Abdomen and Jaw
If this was a medical event, were any medications given to the patient within 8 hours prior? No
Was treatment offered (if applicable)? Yes
What type of treatment was offered? EMS/EMR
Brief description of treatment provided: 4:45 PM - MHT reported to nurse that patient was in dayroom choking off his supper. When nurse entered dayroom medication nurse was preforming abdominal thrust on patient in dayroom (Heimlich maneuver) on patient. Multiple attempts were made to open patient mouth to visualize lodged object with no success. Jaw thrust applied. Call was placed to 911 as staff alternated continuation of abdominal thrust. Unsuccessful with abdominal thrust. Patient face and lips turned blue, cyanosis noted, O2 saturation dropped staff laid patient on his side and continued with jaw thrust success and suctioned out some of the lodged object. Local ambulance service arrived and took over. Patient was transported to local emergency room for further evaluation and treatment. Patient #1's emergency contact/mother, S5MD and S6MD notified. Signed by S7RN

Review of the facility Self- Reports for June 2025 revealed no submitted Self-Reports to LDH within 24 hours of Patient #1's medical emergency resulting in transfer to the local emergency room for a higher level of care.

On 06/25/2025 at 12:55 PM, an interview was conducted with S2DON. S2DON stated the process for getting meal trays prior to Patient #1's incident was, the MHT would get the meal cart from the shared nursing home kitchen. Once the meal cart was back on the unit, the MHT would verify the meal ticket was for the correct patient when delivering the meal tray to the patient in the dining hall. S2DON stated the MHT would not actually check the tray to ensure the food on the tray matched what was listed on the meal ticket. Prior to the incident, the process for a patient to change their meal option if they did not want what was going to be served for the standing meal listed on the menu for the day for the specific meal time, the patient would alert any nursing staff member, either the nurse or MHT, that they would like the alternate meal option. S2DON stated on this specific day, Patient #1 had alerted one of the MHTs that he wanted a hot dog for dinner and that was how his meal was changed.

On 06/25/2025 at 1:10 PM an interview was conducted with S1ADM regarding the incident with Patient #1. S1ADM provide all documents regarding training, policy development and the facility's root cause analysis (RCA) investigation surrounding incident. S1ADM stated when he reached out to Corporate about reporting the incident to LDH, it was communicated to him that only an internal investigation would be necessary and not to report to LDH because it did not appear the situation was neglectful in nature by the staff. When asked, S1ADM would not confirm there was neglectful actions or behaviors taken on behalf of the staff at the facility during the incident, but he did confirm the incident warranted immediate mandatory staff training, policy development and an RCA investigation into the situation to figure out what had happened and how to prevent it from happening again.

Based on record review and interviews, the hospital failed to ensure all patient treatments were within compliance of particular aspects of the patients' individual treatment program as evidenced by failure to have a signed and dated master treatment plan by the patient and complete treatment team for 1 (#1) of 3 (#1 - #3) patients' treatment plans reviewed for the sample.
Findings:

Review of the hospital's policy titled, "Multidisciplinary Treatment Plan" last revised on 01/25/2024, revealed in part:
"Policy: Members of all disciplines participate in developing, implementing, and evaluating an individualized Multidisciplinary Treatment Plan. This comprehensive plan of care is formulated based on the findings of the evaluations conducted by disciplines that include, but are not limited to: Nursing, Medicine, Psychiatry, Social Services, and Activity Therapy. The comprehensive Multidisciplinary Treatment Plan is expected to be completed in the inpatient's Medical Record no later than 5 days after admission.
Procedure: Inpatient - 2. The registered nurse will initiate the Multidisciplinary Treatment Plan. 3. Over the three days following admission, the patient will be assessed by members of other disciplines including, but not limited to: a. Medicine; b. Psychiatry; c. Social Services; and d. Activity Therapy; 5. By the 5th day of the patient's hospitalization the treatment team will meet and determine the focus of treatment, goals of care and interventions to be provided and by whom. Whenever possible, all members of the treatment team should be present to discuss these plans, but in any event the meeting must include the treating prescriber, a registered nurse, and a qualified social worker or counselor. 6. All treatment team members participating in the development of the Multidisciplinary Treatment Plan will provide their signatures to indicate their involvement.

Review of Patient #1's medical record revealed he was admitted to the hospital on 06/12/2025 at 10:03 PM from an outside referring facility's emergency room for Impulsive Disorder; Bipolar Disorder with Depression; and Mild Neurocognitive Disorder due to Known Physiological Condition without Behavioral Disturbances.

Review of Patient #1's Multidisciplinary Master Treatment Plan dated 06/12/2025 at 10:38 PM revealed the patient signature line was signed by blank, but no additional documentation stating Patient #1 was unable and/or unwilling to sign was provided. Further review revealed a staff signature for S3RN, but there was no date or time associated with the signature. Continued review revealed there were no signatures for a social worker/therapist or a physician.

On 06/25/2025 at 1:25 PM, S2DON confirmed Patient #1, social worker/therapist and physician did not sign and date and the registered nurse did not date and timestamp the Multidisciplinary Master Treatment Plan within the required timeframe after admission and they should have.

Based on record review and interview, the hospital failed to ensure the registered nurse hired as the director of nursing (DON) services had a master's degree in psychiatric or mental health nursing or be qualified by education and experience in the care of the mentally ill.
Findings:

Review of the hospital's policy titled "Director of Nursing" last revised on 03/21/2018 revealed in part:
"Policy: The Director of Nursing (DON) provides nursing leadership for the hopsital and off-site campuses licensed under the hospital. The DON is a qualified registered nurse that meets the following requirements: Be qualified by educations and/or experiences in the care of the behaviorally ill patient - Holds a master's degree psychiatric or mental health nursing from a school accredited by the National League for Nursing (NLN); or Hold a master's degree in a related field (e.g. psychology, nursing education), a Baccalaureate or associate degree in nursing, or a Diploma in nursing; and -Have at least five (5) years of documented full-time experience as a registered nurse; -Have a minimum of three (3) years of documented experience providing full-time care, as a registered nurse to behaviorally ill patients requiring hospital-level care (NOTE: The three years may constitute a portion of the five years as a full-time registered nurse); and -Have documented evidence of ongoing education in the field of behavioral health nursing, obtained within the prior twelve (12) months, designed to keep the registered nurse current on psychiatric nursing techniques. Ongoing continuing education in behavioral health nursing may include, but is not limited to: -Enrollment in nursing courses offered by an NLN-accredited program (whether to obtain a degree or not); -Contact hours or Continuing Education Units (CEU) obtained through an organization approved to awarded accredited CEU to registered nurses (e.g. through the American Nurses Association, the Louisiana State Nurses Association, or the NLN, etc.); and/or -Participating in ongoing, documented consultation with and/or supervision by a master's prepared psychiatric nurse. When selecting personnel to serve as the Director of Nursing, the Hospital takes into consideration the scope and complexity of the nursing care needs of the major patient population(s) served by the hospital. The hospital shall have available a similarly qualified registered nurse to provide nursing leadership in the absence of the Director of Nursing."

Reviewed of the personnel file for S2DON revealed she graduated from Louisiana State University Alexandria in December of 2020 where she received her Bachelor's in Science-Nursing (BSN) degree. S2DON was hired by the hospital on 01/22/2025 as a registered nurse and was then promoted to interim director of nursing on 06/06/2025. Complete review of her personnel file revealed no record of her obtaining her Master's degree in psychiatric or mental health nursing or having a combination of qualified education and experience in the care of mentally ill patients.

On 06/25/2025 at 3:00 PM, an interview was conducted with S2DON. S2DON confirmed she did had her BSN and did not have a Master's degree in any type of nursing.

On 06/25/2025 at 3:40 PM, an interview was conducted with S1ADM. S1ADM stated he thought it was a state regulation that was going to be taking effect in a few years, but was not aware it was a current regulation. S1ADM stated he was unaware it was a federal regulation the DON needed to have a master's degree in psychiatric or mental health nursing, but confirmed he knew S2DON only had her BSN.