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Based on observation and interview, the facility failed to ensure care in a safe setting. The deficient practice is evidenced by the finding of items considered contraband on the unit.
Findings:

Tour of the facility, on 04/14/2025 between 9:50 AM and 10:05 AM, revealed a backpack and a lunch bag that belonged to staff stored on a shelf in a patient room, an Inspire remote with a battery in a patient room, and the plastic cover from the television remote in the day room.

In interview at the time of discovery, S1Adm and S2CNO verified the objects had the potential for harm should not have been left unmonitored on the unit. S1Adm also verified the remote for the Inspire unit needed to be secured to prevent theft and ensure availability for the patient with the implant while sleeping.

Based on record review and interview, the facility failed to ensure compliance with reporting of potential abuse and neglect. The deficient practice is evidenced by failure of the facility to submit and initial report to Louisiana Department of Health within 24 hours of becoming aware of an event involving potential abuse or neglect.
Findings:

Review of the form "Self-Reporting Process for Hospitals - Abuse/Neglect," revised 12/01/2024, 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). 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."
Further review of the document revealed, "The initial and final reports shall be emailed to hsshospitalself-reports@la.gov via an encrypted/secure email. As indicated above, the initial report must be submitted within 24 hours of awareness of the incident/allegation/suspicion. Since hospitals must operate 24 hours a day, seven days a week, no adjustment is made to accommodate weekends or holidays. In other words, if an event is noted to occur (or an allegation is received) on Friday at 10:30 p.m., the initial report shall be emailed no later than Saturday at 10:30 p.m.
E-mails are automatically tagged with the date and time of receipt, providing proof that reports were submitted in a timely manner. The e-mail address listed below is relevant to hospitals only."

Review of an initial report submitted on 03/26/2026 to Louisiana Department of Health (LDH) revealed an incident that involved potential neglect by nursing staff and occurred on 03/23/2025 during the day shift. Further review revealed the date of discovery as 03/24/2025 and the initial report was submitted to LDH on 03/26/2025.

In interview on 04/14/2025 at 3:51 PM, S4RMC verified the submission of the initial report was not within 24 hours of awareness of the event.

Based on record review and interview, the hospital failed to ensure restraints were documented according to hospital policy and standard of care. The deficient practice is evidenced by failure of the nursing staff to document an order for a therapeutic hold anddocument the use of a restraint in the patiet record for 1 (#R2) of 1 reviewed record with the use of a restraint. .
Findings:

Review of a self-reported incident that occurred 04/02/2025 at 10:35 AM revealed Patient #R2 was in an altercation with another patient. The two patients were separated and Patient #R2 "was placed in a short therapeutic hold and then brought to the seclusion room (door open) where he was given a PRN medication and allowed to self-calm."

Review of the medical record for #R2 failed to reveal an order or documentation of the restraint.

In interview on 04/14/2025 at 12:39 PM, S2CNO verified a therapeutic hold was used and the nursing staff failed to document a verbal order and failed to fill out the documentation required after the use of a restraint.

Based on record review and interview, the hospital failed to identify deviations from hospital policy affecting patient safety. The deficient practice is evidenced by failure the hospital to identify neglect when a patient with orders for one to one observation was left alone in her room.
Findings:

Review of the policy POC-28, "Observations, Patient," revised 02/2025, revealed in part, "1:1 Observation- . . . .Staff are to remain within visual range and close proximity (easy reach) of patient at all times."

Review of an incident that occurred on 03/23/2025 at 1:15 PM and self-reported to the Louisiana Department of Health, revealed the reviewer of the incident verified the nurse providing ordered one to one care a patient for a patient left the patient alone in the room for 20 seconds while the nurse went to the nursing station. The reviewer of the incident concluded that the allegation of neglect could not be substantiated and staff followed the one to one policy.

In interview on 04/14/2025 at 10:45 AM, S2CNO verified there was neglect when the nurse left the patient in the room alone.

Based on record review and interview, the registered nurse failed to supervise the care provided to each patient. The deficient practice is evidenced by failure of the RN to enter the precautions for 8(#2, #3, #R3, #R4, #R5, #R6, #R7, #R8) of 9 (#2, #3, #R3, #R4, #R5, #R6, #R7, #R8, #R9) patients with special precautions into the patient observation system to ensure the BHA knew the special precautions for monitoring each patient.
Findings:

During tour of the facility on 04/14/2025 between 9:50 AM and 10:05 AM, S5BHA was asked about the precautions ordered for Patient #3. S5BHA checked the tablet used for tracking the patients but the precautions for Patient #3 had not been entered into the system.S5BHA verified she did not know what precautions were ordered for Patient #3. Further review of the list of patients on the unit revealed precautions were not listed for 8 of 9 patients.

Review of the daily census for the unit revealed the following precautions for each patient:
Patient #2-Suicide, assault, and fall;
Patient #3- Suicide precautions
#R3- Suicide, seizure, and fall;
#R4- Suicide
#R5- Assault and suicide
#R6- Assault and suicide
#R7- Assault and suicide
#R8- Suicide
#R9- Suicide, seizure, and fall

In interview on 04/14/2025 at 10:15 AM, S2CNO verified the nurse had not put the precautions in the system to assist the BHAs in their observations.

Based on record review and interview, the hospital failed to ensure the Registered Nurse (RN) assigned patients to the BHAs on each shift. The deficient practice is evidenced by and incompletely filled out assignment sheet for one of three days reviewed.
Findings:

Review of the requested "Unit Assignment" sheets revealed the sheets were organized in a binder for each day of the current month. Review of the second sheet in the binder revealed the charge nurse on 04/01/2025 for the day shift revealed there were 25 patients on the unit. Further review revealed the listed staffing included the charge nurse, 1 LPN, and 1 BHA assigned to a one to one. The assignment sheet did not list the other BHA's working that day or which patients each was assigned to observe. There was only a note that read, "See attached Census dated 04/01/2025."

In interview on 04/14/2025 at 2:02 PM, S3NS verified that the nurse should have listed all working staff on the sheet and indicated which BHAs were assigned to each patient on the census if she did not have time to list all 25 patients on the assignment sheet.

Based on record review an interview, the registered nursed failed to ensure the nursing staff followed all hospital policies for patient care. The deficient practice is evidenced by failure to perform neurological checks after a patient was kicked in the head during an altercation.
Findings:

Review of the policy, POC-06, "Assessment, Neurological," last revised 02/2024, revealed in part, "POLICY- Neurological assessment will be initiated when a patient has sustained a head injury, had a change in level of consciousness, un-witnessed fall or per practitioner order." Further review of the policy revealed the assessment was to include a documentation of level of consciousness, pupillary size and reaction, vital signs, handgrip, speech and responsiveness. Evaluations were to be performed every 15 minutes for one hour, the every thirty minutes for 1 hour, then every hour for 4 hours, then every 4 hours for 4 checks, and the every eight hours for 6 checks.

Review of an incident self-reported to the Louisiana Department of Health revealed on 04/08/2025 at 9:15 AM a patient grabbed Patient #R1 by the hair, struck her in the head and then kicked her in the head. Patient #R1 denied any injury after the incident.

Review of documentation by the nurse on 04/08/2025 at 1:04 PM revealed Patient #R1 complained of mild head pain but no injuries were noted. The physician was notified.

Review of the progress note by the licensed practitioner on 04/08/2025 at 3:02 PM revealed the patient was evaluated and acetaminophen was ordered for the headache.

In interview on 04/14/2025 at 12:15 PM, S3NS verified the nursing staff did not perform neurological checks on Patient #R1 who was hit and kicked in the head and there was no documentation that the licensed practitioner had given orders that the assessments were not needed.

Based on record review and interview, the registered nurse failed to administer medications according to hospital policy. The deficient practice is evidenced by failure to reassess the patient in 2 (#2, #3) of 3 (#1, #2, #3) reviewed records after a PRN (as needed) medication was administered.
Findings:

Review of policy POC-07, "Assessment/Reassessment," last revised 02/2023, revealed in part, "Additionally, reassessments of patient response to PRN medications shall be documented post intervention. Documentation shall include the patient's response to the intervention as well as presence of negative side effects (or lack thereof)."

Review of the medical record for Patient #2 revealed an order for Melatonin tablet; 6 milligrams; Oral; Nightly PRN for insomnia. Further review revealed the melatonin was administered on 04/13/2024 at 8:42 PM and the nurse failed to document a follow-up assessment for effectiveness.

Review of the medical record for Patient #3 revealed an order for Melatonin tablet; 6 milligrams; Oral; Nightly PRN for insomnia. Further review revealed the melatonin was administered on 04/11/2024 at 8:14 PM and the nurse failed to document a follow-up assessment for effectiveness.

In interview during the record review on 04/14/2025 at 11:59 AM, S3NS verified the nurse failed to reassess Patient #2 after the administration of the PRN melatonin. At 1:43 PM S3NS verified the nurse failed to reassess Patient #3 after the administration of PRN melatonin.