HospitalInspections.org

Based on record review and interviews, the hospital failed to ensure a patient complaint of alleged sexual abuse was recognized as a grievance. This deficient practice was evidenced by failing to correctly identify a patient grievance for 1 (#1) of 3 (#1-#3) patients reviewed for complaints/grievances.
Findings:

Review of hospital policy titled "Patient Grievance Procedures, RI.012", last revised on 09/2024, revealed in part:
Policy
Grievances that endanger the patient, such as neglect and abuse, will be reviewed immediately upon receipt by the Patient Advocate, Chief Nursing Officer, or Nursing Supervisor. On "off shifts" or weekends, the weekend Patient Advocate will communicate with the Administrator on call to resolve any immediate potential for harm ...All complaints of abuse or neglect will be considered a grievance. When a report of sexual or physical abuse or neglect, whether directly by referral is received, the Department of Health and Hospitals will be notified within 24 hours from the time the facility was notified of the complaint and the Administer on call is also notified of any occurrences on nights and weekends. At all times, the local law enforcement agency will be notified to assist in this process of investigating abuse violations ...
Review of LDH Health Standard Section document titled Self-Reporting Process for Hospitals - Abuse/Neglect revealed in part: "11. Facility Investigation (Administrative Review) and Final Investigative Report: In accordance with regulations, facilities are directed to process an allegation of abuse or neglect as a grievance in accordance with facility Grievance Processes and Abuse/Neglect policies. In accordance with §482.13, an allegation of abuse/neglect is to be treated as a grievance even if the complainant recants or indicates that the issue is resolved. A written response must be issued to the reporting patient or patient's representative. In many cases, the presentation of an abuse investigation handled in this manner will satisfy surveyor reviews related to the manner in which a facility processes grievances."

Review of Patient #1's medical record revealed Patient #1 was admitted to the hospital on 06/10/2025 and was discharged from the hospital on 06/19/2025. Patient #1's admitting diagnosis was disruptive mood dysregulation. Secondary diagnosis was attention deficit hyperactive disorder.

Review of Patient #2's medical record revealed Patient #2 was admitted to the facility on 01/30/2025 and was still at the hospital as of 07/02/2025. Admitting diagnosis was major depressive disorder, recurrent, severe without psych features.

Review of the facility's incident log for Patient #2 read as follows- Sexual misconduct patient to patient 06/18/2025 11:20 PM, inpatient psych adolescents. On 06/19/2025 at 12:03 PM, it was reported to the Medical Doctor that a peer (Patient #2) came into peer's (Patient #1) room, took his (Patient #2) pants off and humped him (Patient #1) in his face.

During an interview on 07/01/2025 at 2:55 PM S1Performance Improvement reported a grievance was not completed for the incident between Patient #1 and Patient #2.

Based on record review and interview the hospital failed to ensure compliance with reporting abuse and neglect. The deficient practice is evidenced by failure of the facility to report an accusation of sexual assault to the Louisiana Department of Health.
Findings:

Review of the instructions provided in the document "Louisiana Department of Health
Health Standards Section, Self-Reporting Process for Hospitals - Abuse/Neglect, Revised 12/01/2021, revealed in part: "Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report these allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Louisiana Department of Health (LDH) (or the Medicaid Fraud Unit as applicable)." And "Patient-to-patient assaults should be categorized as "Neglect" in relation to "Patient-to-Patient Physical Assault" or "Patient-to-Patient Sexual Assault." From a LDH standpoint, the issue under review is to determine whether the facility failed to take prudent action to prevent, and/or respond to, the (alleged) occurrence. These incidents should be assessed as alleged "Neglect" (i.e. the hospital's failure to act with due diligence). Also indicate what the allegation of neglect involves (i.e. sexual assault, physical assault, elopement, death, or other)."

Review of the facility's incident log revealed the following incident:
Sexual misconduct patient to patient 06/18/2025 11:20 PM, inpatient psych adolescents. On 06/19/2025 at 12:03 PM, it was reported to the Medical Doctor that a peer (Patient #2) came into peer's (Patient #1) room, took his (Patient #2) pants off and humped him (Patient #1) in his face.

Review of the medical record for Patient #2 revealed the patient was on one to one observation form 06/13/2025 until 06/30/2025 while awake.

Review of the video footage revealed Patient #2 was not under one to one observation at the time of the incident on 06/18/2025. Patient #2 was seen on video footage going up and down hallway and going into other patients rooms. There was no visible evidence of a staff member within arms length of Patient #2.

Review of the provided documentation revealed the incident was reported to Louisiana Department of Child and Family Services but not to Louisiana Department of Health. Further review revealed disciplinary action was received by the MHT for failure to perform hall presence. The nurse and house supervisor also received disciplinary action for documentation and education on the one to one policy was provided to the staff.

During an interview on 07/01/2025 at 2:55 PM S1Performance Improvement verified Patient #2 did not receive one to one observation while awake on the date of the incident of 06/18/2025. S1Performance Improvement also verified Louisiana Department of Health was not notified after the patient to patient sexual misconduct allegations were noted on 06/19/2025.