St Charles Parish Hospital

“PATIENT RIGHTS: REVIEW OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 44495 Based on record review and interview, the hospital failed to review and resolve all grievances according to the hospital policy. The deficient practice is evidenced by failure to process 2 of 2 reviewed allegations of sexual abuse as grievances. Findings: Review the provided hospital policy #OSCPH.QUAL.008, “Patient Grievance Management,” with no date of approval, revealed in part, “II.C. Patient Grievance- a formal or informal written or verbal complaint that is made to the facility by a patient, or the patient’s representative regarding the patient’s care (when the complaint is not resolved at the time of the complaint by Staff Present), abuse or neglect, issues related to the facility’s compliance with the CMS Hospital Conditions of Participation (CoP), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR Section 489.” Review of the Occurrence Log revealed on 03/20/2024 Patient #1 brushed the right thigh of Patient #R1 in a provocative manner. Further review of the Occurrence Log revealed on 03/21/2024 Patient #1 exposed his genitals and began masturbating in front of Patient #R1. Review of the Grievance Log failed to reveal the two incidents of sexual assault. In interview on 05/16/2024 at 11:24 a.m., S1AVPN verified the two incidents were not resolved as grievances.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 44495 Based on record review and interview, the hospital failed to ensure a resolution letter was sent to the complainant after an allegation of sexual assault. The deficient practice is evidenced by failure of the hospital to provide a letter describing the steps taken to investigate the patient’s claims for 2 of 2 reviewed allegations of sexual assault that occurred in the hospital. Findings: Review the provided hospital policy #OSCPH.QUAL.008, “Patient Grievance Management,” with no date of approval, revealed in part, “II.C. Patient Grievance- a formal or informal written or verbal complaint that is made to the facility by a patient, or the patient’s representative regarding the patient’s care (when the complaint is not resolved at the time of the complaint by Staff Present), abuse or neglect issues related to the facility’s compliance with the CMS Hospital Conditions of Participation (CoP), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR Section 489. . . . IV.D. A written resolution letter will be sent to the patient that addresses the substance of each complaint made . . .” Review of the Occurrence Log revealed on 03/20/2024 Patient #1 brushed the right thigh of Patient #R1 in a provocative manner. Further review of the Occurrence Log revealed on 03/21/2024 Patient #1 exposed his genitals and began masturbating in front of Patient #R1. Review of the provided list of grievances failed to reveal the two incidents of sexual assault. In interview on 05/16/2024 at 11:24 a.m., S1AVPN verified the patient who was the victim of the sexual assault was not sent a letter explaining the steps taken and the results of the investigation of the incident.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 44495 Based on record review and interview, the hospital failed to provide care in a safe setting. The deficient practice is evidenced by failure to initiate interventions to restrict the behavior of a sexually aggressive patient which resulted in the sexual harassment of several females on the behavioral health unit. Findings: Review of the medical record for Patient #1 revealed admission on 03/13/2024 under a Physician’s Emergency Certificate with a diagnosis of psychosis and traumatic brain injury. The patient had a history of sexually inappropriate behavior including public masturbation. The observation level on admission was every 15 minutes and a Coroner’s Emergency Certificate was initiated. Review of the physician’s notes from 03/15/2024 at 11:42 p.m. revealed the patient had inappropriately touched another patient. Review of the physician’s orders revealed there was no change in the level of observation after the incident and review of the occurrence log revealed the occurrence was not reported. Review of the provided occurrence log revealed Patient #1 was the aggressor in four occurrences on 03/20/2024 and included the following: -On 03/20/2024 at an undocumented time, “MHT was attempting to obtain patient’s blood pressure when he used his hand to flick her breast provocatively . . . “ -On 03/20/2024 during a recreation therapy session that was scheduled for 1:00 p.m., the occurrence report documented, “While the staff member was leading a RT group in the back of the room, the aforementioned patient grabbed/brushed her right thigh and leg with his hand in a sexually suggestive manner, proceeding to grab her right thigh and leg when the staff member told him to stop.” -On 05/20/2024 at an undocumented time read, “Patient [#1] attempted to kiss staff member twice, intruding into her face and puckering his lips. Patient [#1] was verbally redirected by staff member and RN/Charge nurse was informed. MD was informed of incident.” -On 05/20/2024 an occurrence listed under the victim’s name, Patient #R1, revealed in part, “While standing in the hallway, Patient [R1] received inappropriate/ unsolicited attention from male peer [#1], including a brush of the hand to her right thigh in a provocative manner. Patient #R1 was upset about this occurrence and informed staff, who then informed MD. Male peer [#1] was placed on one to one to prevent this.” Review of the nursing note of S8RN from 03/20/2024 at 3:43 p.m., revealed “Patient [#1] observed pacing in the hallway yelling out, “help.” Staff offered assistance and he attempted to grab and kiss MHT. He was redirected and reminded of appropriate behaviors and he refused to respond. He began to pace the unit trying to walk in to peer rooms. He is difficult to redirect and not accepting any direction from staff. PRN Zyprexia IM administered with mild effect noted. He continues to pace, yell out and refuse to talk to staff. Plan of care continues.” Review of the therapy notes from 03/20/2024 at 3:48 p.m. revealed in part, “he [#1] has been scratching his buttocks, he began pulling on cabinet doors, attempted to take a female peer’s food and stroke this writer leg when passing by. He responded poorly to redirection and was +lability and hypersexual behavior.” Review of the nursing notes from 03/20/2024 at 6:38 p.m. revealed, “Multiple issues regarding this patient [#1] inappropriately touching staff and peers have been made today. He’s groped the rec therapist’s thigh, flicked an MHT on the chest, and has grabbed two separate female peers today. Staff continue to monitor to ensure everyone is safe, but he is unpredictable. He has also been aggressively masturbating throughout the day with his door wide opened. We close it for his privacy, but he gets up and opens it and begins again. Staff continue to redirect and monitor for safety. S7MD is aware.” Review of the orders for Patient #1 on 03/20/2024 at 6:43 p.m. revealed the order: “Please place patient on 1:1 sitter.” Review of the notes for Patient #1 documented by the resident physician, S7MD, from 03/21/2024 at 9:06 a.m. revealed in part, “However, when addressing his behavior from yesterday, patient visibly began to tear up, especially when re-iterating that the facility prioritizes patient/staff safety and that his inappropriate sexual advances, patient disruption, public masturbation and public urination are threatening to that safety.” Review of the occurrence reports for 03/21/2024 revealed Patient #1 was the aggressor in two incidents, which included the following: -On 05/21/2024 an occurrence was submitted into the system at 2:30 p.m. which revealed in part, “Patient [#1] brushed RN’s thigh/leg while in the hallway with his hand in a sexually provocative manner. Patient was verbally redirected.” -On 05/21/2024 an occurrence listed under the victim’s name, Patient #R1, revealed in part, “Patient [R1] informed staff that other patient/ male peer [#1] stood outside the door of her room and masturbated in front of her. . . . “ Review of the Clinical Outcome/ Specific Event Outcome revealed in part, “Patient [#1] with history of traumatic brain injury. Impulsive, was on one to one for hypersexual behavior. Removed briefly from one to one as ordered by MD to trial in therapeutic milieu. Approximately 45 minutes passed and patient had failed by entering another patient’s room and exposing himself. Patient [R1] requested to file charges, sheriff’s office called, deputy arrived to take report and informed behavior reported was a felony and wanted to arrest the patient. House Supervisor, AVP Nursing, Director of Security, PI notified, as well as S6MD, who agreed patient [#1] should be discharged in to police custody. Patient [#1] discharged and taken in to custody and transported to jail. . . . “ Review of the orders revealed on 03/21/2024 at 3:14 p.m., the one to one observation was discontinued. In interview on 05/15/ 2024 at 1:57 p.m., S8RN verified the sexual behaviors exhibited by Patient #1 were constant and escalating on 05/20/2024. S8RN verified while Patient #1 was exposing himself they tried to keep his door closed, but he would just open it again. S8RN verified there was one patient who was pacing outside the room of Patient #1 during his repetitive exposures. S8RN stated the sexual behavior got so bad she began “asking if we could give him some estrogen or a Depoprovera shot.” In interview on 05/16/2024 between 9:44 a.m. and 11:09 a.m., S3RN verified the incident documented in the physician’s note from 03/15/2024 was never reported as an occurrence to administration. S3RN verified on 03/20/2024 there were no new orders for interventions until after the fourth documented incident where Patient #1 touched Patient #R1. S3RN verified there is no documentation in the medical record that the physician was notified of the actions of Patient #1 on 03/20/2024 until 6:38 p.m. S3RN also verified that Patient #1 was on one to one observation on 03/21/2024 when the assault on a staff member was submitted into the reporting system. In interview on 05/16/2024 at 11:15 a.m., S5RN verified on 05/20/2024 when the behavior of Patient #1 was escalating and he was repeatedly masturbating with his room door open and attempting to expose himself, there was no attempt to relocate the patient to an area away from the other patients. S5RN also verified there was no attempt to keep Patient #1 away from Patient #R1 after the first sexual assault. In interview on 05/16/2024 between 11:36 a.m. and 11:49 a.m., the attending physician, S6MD verified Patient #1 had inappropriately touched another patient and a nurse on 05/15/2024. S6MD verified this was a continuous behavior while admitted. When asked if he was aware of the actions of Patient #1 on 05/20/2024, he responded, “To some degree, I was surprised when I saw that he was placed on one to one observation.” S6MD expressed that he was not sure if it was the right thing, because some patients increase the behaviors when placed on one to one. S6MD verified he preferred to use a positive reward system which was his approach when he made a “verbal contract” with Patient #1 on 05/21/2024 and the one to one observation was discontinued. S6MD verified he did not think seclusion or a time out in the seclusion room was appropriate because he felt Patient #1 was redirectable. S6MD verified the medications given to Patient #1 were not controlling his behavior and if he had allowed Patient #1 to remain at the hospital until the end of his Coroner’s Emergency Certificate, he would have continued to sexually assault the other patients and staff.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 44495 Based on record review and interview, the hospital failed to ensure all incidents of suspected abuse/neglect were reported in accordance with LA R.S. 40:2009.20. The deficient practice is evidenced by failure of the hospital to report inappropriate touching of a hospitalized patient by her peer. Findings: Review of the provided occurrence log revealed on 03/20/2024, Patient #R1 was inappropriately touched by another patient. The report documented, “While standing in the hallway, patient was received inappropriate/ unsolicited attention from male peer, including a brush of the hand to her right thigh in a provocative manner. Patient [R1] was upset about this occurrence and informed staff who then informed MD. Male peer was placed on one to one to prevent this.” Review of the provided occurrences self-reported to the licensing agency failed to reveal the incident was reported as required. In interview on 05/16/2024 at 11:52 a.m., S2DQ verified the incident was not reported as possible abuse.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 44495 Based on record review and interview, the hospital failed to identify opportunities for improvement after the initiation of a grievance. The deficient practice is evidenced by failure to perform a complete review of the incidents and care provided that lead to the early discharge of a patient into police custody. Findings: Review of the grievance submitted by the mother of Patient #1 revealed she questioned the ability of the hospital to provide care in a setting that ensured the safety of her son. She expressed concern that her son’s actions were not closely monitored and lead to the incident that resulted in his being arrested and brought to jail. Review of the grievance investigation revealed it was based on review the video of the occurrence on 03/21/2024 and conversations with the charge nurse, unit manager, the AVP of Nursing and the attending physician. The letter sent at the completion of the investigation stated the review included video footage as well and staff interviews. The investigation did not include a record review, a review of the reported and unreported incidents leading up to the early discharge, the interventions utilized for de-escalation of the patient, or interventions initiated for the safety of the other patients. Review of the associated self-report of the incident sent to the licensing authority revealed in the conclusion, “An investigation was conducted into the occurrence to include chart review of both patients, interview of all staff present, provider review of the medical records and review of video footage. Video review confirms that within span of 90 seconds, the male patient entered the room of the female patient, female patient then exited her room, followed by male patient seen on camera pulling his pants down and masturbating in the doorway. All required checks of male patient was done per monitoring policy and validated by ObservSmart. . . . Based on review and investigation of the occurrence, the allegation of patient to patient sexual assault is unsubstantiated.” The grievance and occurrence investigations did not mention on 03/20/2024 the patient inappropriately touched or tried to touch 3 female staff members with no effective interventions prior to touching Patient #R1, which resulted in his placement on one to one observation. The reports also failed to recognize that no restrictions were placed to prevent Patient #1 from re-victimizing Patient #R1 after the initial assault. The reports did not mention an RN was inappropriately touched around 2:30 p.m. on 03/21/2024, just before the one to one observation was discontinued at 3:14 p.m. The grievance and occurrence investigations did not attempt to explain the actions of the resident physician who in his note on 03/21/2024 at 7:12 a.m. stated the actions of Patient #1 threatened the safety of the patients and staff and “Likely remains with auditory and visual hallucinations. Attention is impaired. Concentration is impaired. Unfortunately insight is quite impaired.” And later, per the nurse’s notes on 03/21/2024 at 5:04 p.m., the resident physician, the nurse and Patient #1 “verbally contracted for safety on the unit,” resulting in an order to discontinue the one to one observation. The grievance and occurence investigations failed to reveal there were no documented communications with the physician in the medical record during the day on 03/20/2023. The first documentation in the medical record that the resident physician was aware was in the nurse’s notes on 05/20/2024 at 6:38 p.m. The reviewers of the incident reports failed to identify that none of the incident reports submitted on 03/20/2024 had the time of the incident, which physician was notified, and the time of the notifications. These details were also missing from the medical record. In interview on 05/16/2025 between 9:44 a.m. and 11:09 a.m., S3RN verified there were no additional orders placed as an attempt to control the behavior of Patient #1 on 03/20/2024 while his behavioral was escalating, until he sexually assaulted Patient #R1 and was then placed on one to one observation. S3RN verified the incident on 03/21/2024 involving the touching of the RN’s thigh occurred while the patient was still on one to one observation. S3RN also verified that the time of the incidents on 03/20/2024, which physican was notified of the incident and the time of the notification could not be found in the incident report or the medical record. In interview on 05/16/2024 at 11:15 a.m., S5RN verified when Patient #1 was escalating in his behavior on 03/20/2024, there were no attempts to decreased exposure of the other patients other than to close the door that he continued to open. There were no attempts to move his room or limit his interaction with the other patients. S5RN also verified there were no interventions initiated for the protection of Patient #R1 after he inappropriately touched her other than the temporary initiation of 1 to 1 observation which was discontinued and resulted in the second assault of Patient #R1 by Patient #1 and the release of Patiennt #1 into police custody. In interview on 05/15/2024 at 10:20 a.m., S2DQ verified a thourogh investigation of the incident had been performed and the facility had concluded that there was no neglect and nothing more the facility could have done to prevent the incident.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 44495 Based on record review and interview the hospital failed to analyze and track all adverse patient events. The deficient practice is evidenced by 1) failure of hospital staff to initiate an occurrence report after a possible incident of sexual assault; and 2) failure of hospital staff to initiate an occurrence report for a patient who fell on the Behavioral Health Unit. Findings: Review of hospital policy #OSCPH.QM.003, Safety on Site Occurrence Reporting, issued March 2017, revealed in part, “ III.A. Front Line User - S.O.S. role assigned to all SCPH employees, which grants the ability to report occurrences. All Employees have the ability to submit an occurrence by logging into the S.O.S. system and completing the online tool . . . B. Occurrence- any unforeseen event that affects or could have affected (near miss) a patient, visitor and/or employee.” 1) Failure of hospital staff to initiate an occurrence report after a possible incident of sexual assault. Review of the medical record of Patient #1 revealed on 03/15/2024 at 11:42 a.m., S6MD documented Patient #1 had inappropriately touched another patient. Review of the Occurrence Log and the Grievance Log failed to reveal documentation of the event. In interview on 05/15/2024 at 1:39 p.m., S3RN verified there was no documentation administration was notified and there was no incident report for a sexual assault on that day. In interview on 05/16/2024 between 11:38 a.m. and 11:49 a.m., S6MD verified Patient #1 had inappropriately touched a patient and a nurse within the 24-hours prior to the note. 2) Failure of hospital staff to initiate an occurrence report for a patient who fell on the Behavioral Health Unit. Medical record review for Patient #2 revealed on 05/12/2024 at 5:57 p.m., Patient #2 fell from the toilet and hit her head. The rapid response team was called and imaging studies were performed after the event. Review of the Occurrence Log failed to reveal a report of the incident. In interview on 05/15/2024 2:40 p.m., S4RN verified there was no documentation of the fall in the system used to report occurrences.”

“Social Services Staff Responsibilities CFR(s): Social service staff responsibilities must include, but are not limited to, participating in discharge, planning, arranging for follow-up care, and developing mechanisms for exchange of appropriate information with sources outside the hospital. This Standard is not met as evidenced by: 44495 Based on record review and interview, the facility failed to ensure social services staff completed all designated responsibilities. The deficient practice is evidenced by failure to the social services staff to complete a psychosocial evaluation in 2 (#1, #3) of 3 (#1-#3) reviewed medical records. Findings: Review of hospital policy #OSCPH.BHU.OS.009, “Admission/Discharge Responsibilities,” approved 06/20/2022, revealed in part, “V.A.1.j. - Social Worker Responsibilities: The social worker will interview the patient. Documentation of the interview will be entered in the medical record within 72 hours of admission and include the following: a. psychosocial assessment . . . “ Review of the medical record for Patient #1 revealed admission on 03/13/2024. Further review revealed the social worker attempted to complete the psychosocial assessment on 03/15/2024 at 3:21 p.m. but the patient refused to cooperate. Further review of the record failed to reveal any additional efforts to complete the assessment at a later time. In interview on 05/15/2024 at 12:46 p.m., S3RN verified the assessment was incomplete and there was no documentation the social worker tried to completed the assessment at another time. Review of the medical record for Patient #3 revealed admission on 04/15/2024. Further review of the medical record failed to reveal a psychosocial evaluation by the social worker. In interview on 05/15/2024 at 3:03 p.m., S3RN and S4RN verified they could not find a psychosocial evaluation in the medical record of Patient #3.”