HospitalInspections.org

Based on record reviews and interviews, the hospital failed to ensure all allegations of abuse were handled as grievances. This deficient practice was evidenced by failure to document the complaint as a grievance and failing to provide a written notice of the grievance resolution after a complaint of sexual abuse was made for 2 of 2 (#1, #2) patients reviewed for grievances from a total sample of 3.

Findings:

Review of the hospital's policy titled "PC-803: Patient Rights and Responsibilities" effective 08/06/2012, revealed in part, "Grievance Procedure: The patient has a right to be free from abuse, harassment, and neglect and from misappropriation of property, and to exercise all rights of a Patient under Louisiana and Federal law. Patients are entitled to information about the hospital's mechanism for the initiation, review, and resolution of patient complaints. If a Patient believes that these or other rights (or the rights of another Patient) are being violated in any way that the staff cannot resolve or has not resolved, the Patient should bring the matter to the attention of the Charge Nurse or Administration. The Hospital hopes that Patients will make known any complaints about the services they receive, or grievance they may have with respect to another Patient and that all complaints can be immediately resolved. The Patient should submit the complaint to the Charge Nurse or Administration in writing or verbally, stating specifically the facts upon which the complaint is based and the decision or action the Patient seeks. Upon receiving a verbal complaint, a complaint report form will be completed by the employee receiving the complaint. Administration or administrative on-call personnel will be notified immediately upon receipt of a complaint. The patient has a right to complain regarding the quality of care and will receive response from the organization that substantially addresses the complaint." Further review of the policy revealed in part, "The Lead Investigator will provide the following written communication to the complainant within 7 days.
-Description of complaint
-Steps taken to resolve complaint
-Date of completion/resolution"

Review of the grievance log revealed there were no documented grievances from this year (2025).

Review of the initial Self- Report revealed in part, on 02/12/2025 Patient #1 told Patient #2 that S3MHT was inappropriate with her but then later recanted and told staff she was lying. Patient #2 wrote a letter to staff detailing inappropriate behavior between her and S3MHT as well as inappropriate behavior between S3MHT and Patient #1.

In an interview on 03/17/2025 at 10:30 AM S2CCC stated Patient #1 wrote a letter stating that an employee, S3MHT touched her inappropriately and said inappropriate things to her. S2CCC stated Patient #1 told Patient #2 about S3MHT going into her room and being inappropriate. S2CCC stated Patient #2 then told Patient #1 that it happened to her too. S2CCC stated Patient #1 and Patient #2 wrote letters reporting the incidents. S2CCC stated Patient #1 wrote a letter reporting the incident and then right after, Patient #1 wrote another letter saying she was lying.

In an interview on 03/17/2025 at 4:13 PM S2CCC verified the hospital did not document the complaints of alleged sexual abuse from Patient #1 and Patient #2 as grievances. S2CCC verified the hospital did not provide a written letter of the grievance resolution to Patient #1, Patient #2, or their guardians.

Based on record reviews and interviews, the hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice was evidenced by failure to investigate an alleged adverse patient event for 1 (#1) of 2 (#1, #2) patients involved in staff member-to-patient sexual abuse involving adolescents from a total sample of 3.

Findings:

Review of the hospital's policy titled "PC-1017: Alleged Patient Abuse or Neglect During Hospitalization", revised 09/2019, revealed in part, "Procedures: I. Whenever a staff member becomes aware that a patient has been abused or patient alleges abuse: c. The incident of alleged abuse does not have to be witnessed by staff member. Every report of alleged abuse is to be thoroughly investigated, while maintaining patient's safety and privacy. k. An internal investigation of the alleged incident will be conducted to determine and record the facts of the incident."

Review of the initial Self- Report revealed in part, on 02/12/2025 Patient #1 told Patient #2 that S3MHT was inappropriate with her but then later recanted and told staff she was lying. Patient #2 wrote a letter to staff detailing inappropriate behavior between her and S3MHT as well as inappropriate behavior between S3MHT and Patient #1.

Review of the final Self-Report included interviews that were conducted during the hospital investigation. The final Self-Report failed to include an interview that was conducted with Patient #1.

In an interview on 03/17/2025 at 10:30 AM S2CCC stated Patient #1 wrote a letter stating that an employee, S3MHT touched her inappropriately and said inappropriate things to her. S2CCC stated Patient #1 told Patient #2 about S3MHT going into her room and being inappropriate. S2CCC stated Patient #2 then told Patient #1 that it happened to her too. S2CCC stated Patient #1 and Patient #2 wrote letters reporting the incidents. S2CCC stated Patient #1 wrote a letter reporting the incident and then right after, Patient #1 wrote another letter saying she was lying.

In an interview on 03/17/2025 at 4:01 PM S2CCC stated the allegation was reported on 02/12/2025 night shift. She stated Patient #1 was discharged the next morning on 02/13/2025.

In an interview on 03/17/2025 at 4:40 PM S2CCC verified there was no documentation of hospital staff interviewing Patient #1 after she reported the allegation and there was no investigation into her allegations.