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Based on record review and interview the psychiatric hospital's governing body failed to ensure the quality of care provided to patients as evidenced by failure of the admitting physician to review and reconcile current medications on admission per hospital policy for 3 (#1-#3) of 3 (#1-#3) patient records reviewed.
Findings:

Review of psychiatric hospital's policy #MM-14 titled "Medication Management" last revised on 02/01/2021, revealed in part: "Procedure: 4. Physicians shall review the current medications with the admitting nurse and reconcile the medications that are to be continued and provide orders for the medications to the nurse. The physician/NPP will make any additions, deletions or corrections to the patient's medication orders using the physician's order sheet or the electronic medical record (EMR) order entry process. The physician/NPP will document orders for continued medications, changes, or stops on the Admission Medication Reconciliation Order form, or via EMR order entry as applicable, and authenticate. The nurse will scan all inpatient admission medication orders to pharmacy to be verified and uploaded to the patient's MAR, unless an EMR is utilized. 5. If the physician provides the above orders verbally, the nurse will document the medication orders on the Admission Medication Reconciliation Order form and indicates the medications have been reconciled with the physician/NPP. 6. The physician/NPP authenticates the verbal orders within the required States timeframe. 7. Orders are sent to the hospital pharmacist for dispensing of the medications for inpatient. The pharmacist reviews the medications for contraindications and communicates any indications to the nurse and physician/NPP."

Review of psychiatric hospital's policy #RTS-01 titled "Patient Rights" last revised on 02/01/2021, revealed in part: "Policy: The organization supports the patient's right to care, treatment, and services within its mission. Treatment: You have the right to medically appropriate treatment."

Patient #1
Review of medical record revealed an admission date of 07/29/2025 at 8:30 PM with diagnoses of psychosis, hypertension, cirrhosis, pancytopenia, Monoclonal Gammopathy of Undetermined Significance, and hyponatremia and discharged on 08/07/2025 at 5:00 PM. Continued review revealed the following home medications: Carvedilol (for hypertension), clonidine (for hypertension), Xifaxin (for hepatic encephalopathy), Benadryl (for pruritus of the skin), Ketoconazole (for skin rash), pantoprazole (for gastroesophageal reflux disease), Melatonin (for insomnia), trazodone (for sleep) and Vistaril (for anxiety).

Review of Medication Administration Record dated 07/29/2025 through 07/31/2025 revealed Patient #1 did not receive his carvedilol, Xifaxan, clonidine, Melatonin, and Trazodone until 07/30/2025 at 9:00 PM. Further review revealed Patient #1 did not receive his pantoprazole, until 07/31/2025 at 9:00 AM.

Continued review failed to reveal the admitting physician reviewed Patient #1's current medications with the admitting nurse and reconciled the medications that were to be continued and to provide orders for the medications to the nurse.

During an interview on 09/23/2025 at 2:11 PM, S2QD confirmed Patient #1 was not administered his home medications for over 24 hours from time of admission. S2QD verified the admitting physician failed to review Patient #1's current medications with the admitting nurse and reconcile the medications that were to be continued and to provide orders for the medications to the nurse.

Patient #2
Review of medical record revealed Patient #2 was admitted from a nursing home on 08/11/2025 at 6:00 PM with diagnosis of aggression and discharged as deceased on 8/12/25 at 4:58 AM.

Continued review revealed the following home medications: Ativan (for anxiety), Donepezil (for memory), Memantine (for memory), Metoprolol (for hypertension), Montelukast (for allergies), Pravastatin (for hyperlipidemia), Sertraline (for depression), Trelegy Ellipta (for Chronic Obstructive pulmonary Disease), and Trospium Chloride (for overactive bladder).

Continued review of medical record failed to reveal Patient #2 was seen by a physician from admission until deceased.

Review of Medication Administration Record dated 08/11/2025 through 08/12/2025 failed to reveal Patient #2 received any medications from time of admission on 08/11/2025 at 6:00 PM until patient found deceased at 4:58 the next morning.

Continued review failed to reveal the admitting physician reviewed Patient #2's current medications with the admitting nurse and reconciled the medications that were to be continued and to provide orders for the medications to the nurse.

During an interview on 09/23/2025 at 11:36 AM, S2QD confirmed Patient #2 was not administered any medications from admission until he was found deceased. S2QD verified the admitting physician failed to review Patient #2's current medications with the admitting nurse and reconcile the medications that were to be continued and to provide orders for the medications to the nurse.

Patient #3
Review of medical record revealed Patient #3 was admitted on 07/08/2025 at 5:45 PM with diagnosis of bipolar disorder, pituitary adenoma, ventriculoperitoneal shunt, high blood pressure, hypothyroid, and hyponatremia, discharged on 07/19/2025 at 9:00 AM.

Continued review revealed the following home medications: Abilify (for bipolar), Lexapro (for depression), Cortef (for adrenocortical insufficiency) Synthroid (for hypothyroid), Lisinopril (for hypertension), Meloxicam (for rheumatoid arthritis), pantoprazole (gastroesophageal reflux disease).

Review of Medication Administration Record dated 07/08/2025 through 07/10/2025 revealed Patient #3 did not receive his Synthroid until 07/10/2025 at 6:30 AM. Patient #3 did not receive his Cortef, Lisinopril, Meloxicam, and pantoprazole until 07/10/2025 at 9:00 AM.

Continued review failed to reveal the admitting physician reviewed Patient #3's current medications with the admitting nurse and reconciled the medications that were to be continued and to provide orders for the medications to the nurse.

During an interview on 09/23/2025 at 12:58 PM, S2QD confirmed Patient #3 was not administered his home medications from admission on 07/08/2025 at 5:45 PM until 07/10/2025 at 6:30 AM over 24 hours from time of admission. S2QD verified the admitting physician failed to review Patient #3's current medications with the admitting nurse and reconcile the medications that were to be continued and to provide orders for the medications to the nurse.

During an interview on 09/23/2025 at 1:19 PM, S1DON stated the nurses have the ability to call the provider to notify them about the home medications although the orders are triggered to the physician when put in the EMR system for him to sign and and are available for the provider to address the home medications at that time.

Based on record review and interview, the hospital failed to ensure the patient right to be free from all forms of neglect as evidenced by failure to ensure discharged Patient #1 arrived safely to Shelter 'A'.
Findings:

Review of psychiatric hospital's policy #RTS-01 titled "Patient Rights" last revised on 02/01/2021, revealed in part: "Exhibit A: Rights of Persons Suffering from Mental Illness and Substance Abuse Summarized in Layman Terms. Abuse, Neglect, Exploitation, Harassment: You have the right to be free from neglect."

Review of Patient #1's medical record revealed an admission date of 07/29/2025 at 8:30 PM with diagnoses of psychosis, hypertension, cirrhosis, pancytopenia, Monoclonal Gammopathy of Undetermined Significance, and hyponatremia, discharged on 08/07/2025 at 5:00 PM.

Review of Patient #1's Progress Note dated 07/30/2025 at 10:23 AM revealed S11SW spoke with his sister and a representative at the nursing home from which he was admitted. Patient no longer lived at the nursing home per his request. The nursing home stated he was not appropriate, and that he could live independently. It was reported patient was at a previous recovery center and left the program early. Patient #1's sister reported he previously lived at Shelter 'A' for years and that he was familiar with that facility. Patient did not have any income as reported by the sister and the nursing home.

Review of Patient #1's Multidisciplinary Progress note dated 08/07/2025 at 5:05 PM per S12RN revealed the patient was discharged from Ocean's Hospital in Hammond. Patient was discharged to Shelter 'A' in baton Rouge. Patient was escorted off unit by staff. Patient left the facility at 5:00 PM via Ride Share 'B'.

Review of Shelter 'A's website revealed hours open from 8:00 AM-4:00 PM.

During an interview on 09/23/2025 at 2:32 PM, S2QD verified Shelter 'A' was open from 8:00 AM until 4:00 PM per the website.

During an interview on 09/24/2025 at 8:11 AM, a representative from Shelter 'A' stated the shelter accepted intakes on a first-come, first-served basis starting at 8:30 AM. Intakes stop at 3:30 PM and the office closes at 4:00 PM. An individual who arrived after 3:30 PM would have to return at an earlier time the next day, and based on first-come, first-served basis, would be provided a bed.

During an interview on 09/23/2025 at 2:51 PM, S5DCS stated the psychiatric hospital did not have a blanket procedure for post-discharge follow-up and depended on the situation, whether or not the patient was aware and independent versus cognitively declined especially if they were using a different transportation other than family.
S5DCS said she was not aware Patient #1 discharged to Shelter 'A' via Ride Share 'B'. S5DCS stated initially Transport 'C' was supposed to arrive on 08/07/2025 at 9:00 in AM to bring Patient #1 to Shelter 'A'. S5DCS reported that the transportation change should have been communicated to the treatment team and she was not sure why that did not happen. There was no note as to why this changed. S5DCS reported the treatment team should have discussed the timing for discharge based on the shelters' hours in order for the patient to arrive safely. S5DCS verified the psychiatric hospital did not know if Patient #1 arrived safely to Shelter 'A' on 08/07/2025.

Based on record review and interview the psychiatric hospital failed to ensure the medical record included the accurate necessary steps for safe discharge to occur. This deficient practice is evidenced by failure to organize, document and facilitate specificities regarding transport and timing changes for Patient #1's discharge to Shelter 'A'.
Findings:

Review of psychiatric hospital's policy #PC-18 titled "Discharge planning: Transition Record" last revised on 10/01/2024, revealed in part: Procedure: 3. Discharge planning should encompass the following areas: Review of community resources needs of patient post-discharge and availability of same. 4. Social Services/Case management personnel shall: Participate/facilitate discharge planning and develops mechanisms for exchanging information with service providers outside the facility. Contact the post-discharge referral source to ascertain the suitability of placement, schedule any appointments and to facilitate coordination of transfer. Coordinates transportation arrangements. 6. The treatment Team members will complete a crisis safety plan, if applicable, and document the final discharge plans on the Transition Record. This information shall include at a minimum: 24 hours/7-day contact information including physician for emergencies related to the inpatient stay. 7. The Transition Record and any other documentation to support the continuum of care shall be transmitted to the next level of care provider within 24 hours of discharge and documented in the patient's medical record.

Review of Patient #1's medical record revealed an admission date of 07/29/2025 at 8:30 PM with diagnoses of psychosis, hypertension, cirrhosis, pancytopenia, Monoclonal Gammopathy of Undetermined Significance, and hyponatremia, discharged on 08/07/2025 at 5:00 PM.

Review of Patient #1's medical record failed to reveal discharge documentation related to the following:
1) information between the psychiatric hospital and Shelter 'A', specifically the suitability of placement and the hours of operation including time of expected arrival in order for Patient #1 to participate in the shelter's intake process;
2) transportation changes from Transport 'C' scheduled for 9:00 AM on 08/07/2025 to Ride Share 'B' at 5:00 PM on 08/07/2025 that was noted by the treatement team;
3) accurate final discharge plans on the Transition Record that included 24 hours/7-day contact information including physician for emergencies related to the inpatient stay; and
4) continuum of care information transmitted to Shelter 'A' within 24 hours of discharge.

During an interview on 09/23/2025 at 2:51 PM, S5DCS confirmed the above and stated she could not locate documentation as to why Patient #1 discharged to Shelter 'A' via Ride Share 'B'. S5DCS stated that initially Transport 'C' was supposed to arrive on 08/07/2025 at 9:00 in AM to bring Patient #1 to Shelter 'A'. S5DCS reported that the transportation change should have been communicated to the treatment team and she was not sure why that did not happen. There was no note as to why this changed. S5DCS reported the treatment team should have discussed and documented the timing for discharge based on the shelters' hours.