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Based on record review and interviews, the hospital failed to ensure the patient rights were protected. This deficient practice is evidenced by failing to comply with the documented directives of the patient and informing the representative of an injury discovered while admitted to the hospital.
Findings:

Review of hospital policy titled "Patient Rights, Responsibilities, Complaints, and Grievance Process," last reviewed: 02/01/2024, revealed in part: "POLICY: Patients shall receive care, treatment and services with compassion and respect that fosters dignity, autonomy, positive self-regard, civil rights and the involvement of the patient, or when appropriate, the patient's representative in care. The patient, or when appropriate the patient's representative are informed of patient's rights in advance of furnishing or discontinuing patient care whenever possible."

Review of hospital organizational policy titled "Advance Directives," last approved: 05/07/2018, revealed in part: "PURPOSE: To acknowledge and respect the patient's right and responsibility to determine his or her own level of health care, and honor and abide by a person's decision to have life-sustaining procedures withheld or withdrawn in instances where such persons are diagnosed as having a terminal and irreversible condition. In furtherance of this purpose, this policy is implemented to educate patients and their caregivers on the availability of various forms of Advanced Directives and to facilitate the execution of these documents for patients and/or their families wishing to do so. POLICY: In compliance with Louisiana and federal law, and the Ethical and Religious Directives for Catholic Healthcare Services, FMOLHS will provide patients with information regarding Advance Directives and resources for assistance in formulating Advance Directives upon request, promote the use of Advance Directives during a patient's hospitalization, emergency care, residential care in nursing facilities or outpatient care and treatment, document patient Advance Directives in the patient's medical record, and honor the patient's Advance Directive."

Review of Patient #1's medical record revealed that Patient #1 was admitted 10/14/2024 after a fall that resulted in a left femur fracture requiring surgery. Patient #1 also arrived with a previously diagnosed closed left calcaneal fracture from an injury at home. Patient #1's medical record revealed that Patient #1 had an active Medical Power of Attorney on file, listing her sister as POA. Further review revealed Patient #1 had the following medical diagnoses: ESRD with dialysis, Hypertension, Type 2 Diabetes, Schizophrenia, CHF, Vitamin D Deficiency, Hypercalcemia, Hyperparathyroidism, and Hypermagnesemia. On 10/21/2024 Patient #1 was placed on a PEC for being gravely disabled. On 10/22/2024 Patient #1 was deemed medically appropriate to discharge to the inpatient psychiatric unit, and was admitted to the inpatient psychiatric unit on 10/23/2024.

Review of Patient #1's nursing documentation revealed an assessment on 11/05/2024 at 7:30 AM documenting that Patient #1 had swelling noted to her left hand. On 11/05/2024 at 11:42 AM a provider notification note was entered for evaluation of left hand pain. Further review of Patient #1's medical record failed to reveal documentation that Patient #1's legal representative was notified of the injury.

Review of Patient #1's provider notes revealed an orthopedic consult note on 11/05/2024 at 7:48 PM which revealed an x-ray was obtained of the left hand. Patient #1's x-ray of the left hand revealed a fracture to the 4th metacarpal. The orthopedic provider documented due to patient significant past medical history, we will treat this non-operatively. Further review of Patient #1's provider notes failed to reveal documentation that Patient #1's legal representative was notified of the injury.

In an interview on 12/17/2024 at 2:52 PM, S2DOQ and S3INF confirmed that there was no documentation in Patient #1's medical record that their representative was informed of the injury that was discovered on 11/05/2024 while admitted to the hospital.

Based on record review and interviews, the hospital failed to track all adverse patient events. This deficient practice is evidenced by failure of the hospital staff to complete an incident report after a patient injury while admitted to the hospital.
Findings:

A review of hospital policy titled "Safety Event (Incident or Variance) Reporting," last reviewed: 11/13/2024, revealed in part: "Purpose: The purpose of this policy is to establish a systematic and consistent approach for reporting safety events that occur within Our Lady of the Lake Health. The aim is to ensure all safety events are reported, analyzed, and addressed in a timely manner to prevent recurrence and improve patient safety. Definitions: B. Safety event (variance or incident) - any occurrence, which deviates from policy or procedure of the hospital, interrupts orderly routine care, or exposes the hospital to risk. a. Near Miss Safety Event - refers to an event that could have resulted in harm to a patient but did not. b. Actual Safety Event - a safety event which reaches a patient and may result in no harm, temporary harm, severe harm, or death. Refers to an event which impacts the patient in such a way that the patient may require additional treatment or monitoring, prolonged hospitalization, or where the patient has experienced serious physical or emotional harm or death. Patient Safety Event: Reporting Process: 4. Safety event reports are reviewed by quality outcomes analyst or other designated personnel and assigned to an appropriate department for investigation and analysis. Appropriate supervisory and management personnel are notified of the event through the safety event reporting system. 5. Investigation of the safety event is completed and documented by the appropriate leader, appointed delegate or subject matter expert within time frames as set forth by the safety event management workflow."

Review of Patient #1's medical record revealed a diagnosis of ESRD with dialysis, Hypertension, Type 2 Diabetes, Schizophrenia, CHF, Vitamin D Deficiency, Hypercalcemia, Hyperparathyroidism, Hypermagnesemia, and a left calcaneal fracture. Patient #1 was admitted to the inpatient psychiatric unit on 10/23/2024 after inpatient treatment for a left femur fracture.

Review of Patient #1's nursing documentation revealed on 11/05/2024 at 7:30 AM an assessment documented that Patient #1 had swelling noted to her left hand. The provider was notified and an x-ray was ordered of the left hand. Further review of Patient #1's medical record failed to reveal nursing documentation of what led to the injury.

Review of Patient #1's provider notes revealed an orthopedic consult note on 11/05/2024 at 7:48 PM. The x-ray results of the left hand revealed a fracture to the left 4th metacarpal. The Orthopedic consult note also revealed they were consulted after Patient #1 was trying to adjust herself in bed last night when she felt a hand pain and then this morning the nurse noticed it was swollen and painful.

Review of the list of incident reports provided failed to reveal an incident report involving Patient #1.

In interview on 12/17/2024 at 1:30 PM, S7SDNM confirmed there was not an incident report completed for Patient #1 on 11/05/2024 following the injury.

In an interview on 12/17/2024 at 2:40 PM, S3INF confirmed there were no nursing notes documented about the incident in Patient #1's medical record.

Based on record reviews and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by failure of the nursing staff to accurately document patient observations for 1 (#1) of 3 (#1-#3) patient records reviewed.
Findings:

A review of hospital policy titled "Special Precautions," last reviewed 06/27/2024, revealed in part: "PURPOSE: To ensure that a decision-making process is used which includes, ongoing assessment of patient need for special precaution monitoring, goal setting within the plan of care, use of alternative strategies, documentation of continued need for special precautions by the nurse every 4 hours and by the psychiatrist daily, reassessment, monitoring and discontinuation of special precautions."

Review of the Behavioral Patient Observation Record for Patient #1 revealed the registered nurse failed to review and sign the following observation records every 4 hours within the timeframes below:
11/01/2024 between 12:00 PM - 7:30 PM
11/02/2024 between 12:00 AM - 6:45 AM and 11:00 AM - 7:00 PM
11/03/2024 between 7:30 AM - 7:30 PM
11/04/2024 between 7:00 AM - 6:45 PM
11/08/2024 between 2:30 PM - 7:30 PM
11/09/2024 between 12:00 PM - 7:15 PM
11/10/2024 between 12:00 AM - 7:00 AM
11/11/2024 between 2:15 PM - 7:15 PM
11/17/2024 between 11:00 AM - 7:00 PM

In an interview on 12/17/2024 at 2:37 PM, S3INF and S4DIP confirmed the findings mentioned above.