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Based on record reviews and interview, the hospital failed to ensure each patient was informed of all their rights prior to furnishing or discontinuing patient care as evidenced by failing to have all of the required patient rights included in the patient rights policy and the "Patient Rights" given to the patient upon admission.

Findings:

Review of the hospital's policy titled, "Patient Rights and Responsibilities", revised 2/11, revealed the following patient rights were not addressed:

1. The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital.

2. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.

Review of the "Patient Rights" form given to patients or patient's representative upon admission revealed the above rights were not addressed.

On 03/05/2024 at 3:00 p.m. - 3:50 p.m., S1CNO reviewed the "Patient Rights" given to patients upon admission and verified that patients were not informed of all required patient rights, including the above listed patient rights.

Based on record reviews and interviews, the hospital failed to ensure each patient was free from abuse, neglect, and harassment. This deficient practice was evidenced by:
1.) failing to ensure initial reports of allegations of patient abuse/neglect of care were reported to Louisiana Department of Health (LDH) within 24 hours of awareness of the allegation, as required by LDH-HSS, for 1 (Patient #2) of 1 patients reviewed for self-reports to LDH-HSS from a total patient sample of 3; and
2.) failing to have a policy in place addressing patient abuse and neglect.

Findings:

1.) Failing to ensure initial reports of allegations of patient abuse/neglect of care were reported to Louisiana Department of Health (LDH) within 24 hours of awareness of the allegation, as required by LDH-HSS, for 1 (Patient #2) of 1 patients reviewed for self-reports to LDH-HSS from a total patient sample of 3.

Review of the LDH Hospital/Licensed Provider Abuse/Neglect Initial Report form revealed in part that the self-report form was to be completed and submitted via email to HSS within 24 hours of awareness of an allegation of abuse/neglect. Further review revealed in part, on 06/26/2023 Patient #2 was in Same Day Surgery Unit and was being taken care of by S2RN. Patient #2 was having difficulty voiding. Patient #2 reported that S2RN kept wanting to look at the incision and was rubbing on his genitals and nipples. Patient #2 reported S2RN then assisted him to the restroom and S2RN got on his knees and placed his genitals in his mouth. The date of discovery by the hospital was 06/26/2023 and the hospital reported this allegation to LDH/HSS on 07/05/2023.

In an interview on 03/04/2024 at 10:27 a.m. S3DRC verified the hospital sent the initial self-report to LDH/HSS on 07/05/2023. S3DRC stated the hospital did not know they had to self-report the allegation to LDH/HSS and that was why the report was not sent within 24 hours of awareness.

2.) Failing to have a policy in place addressing patient abuse and neglect.

Requests were made for a policy addressing patient abuse and neglect on 03/04/2024 and 03/05/2024. The hospital failed to provide a policy addressing patient abuse and neglect prior to exit on 03/05/2024.

In an interview on 03/05/2024 at 11:38 a.m. S1CNO and S4CCO verified the hospital did not have a policy addressing patient abuse and neglect.

Based on record review and interview, the hospital failed to ensure each RN's nursing license was verified to be valid and current. This deficient practice was evidenced by failing to verify each RN's nursing license to be valid and current for 1 (S2RN) of 4 (S2RN, S6RN, S7RN, S8RN) RN personnel records reviewed.

Findings:

Review of S2RN's personnel record revealed RN license verification documentation with an expiration date of 01/31/2023.

In an interview on 03/05/2024 at 4:13 p.m. S5HRD verified the license verification documentation that was included in S2RN's personnel record had expired on 01/31/2023.