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Based on record review and interview, the hospital failed to meet the requirement for Condition of Participation of Governing Body. This deficient practice was evidenced by the failure to inform the medical staff and governing body of a change in the delivery of respiratory care services in the emergency department and inpatient/observation unit of the offsite location (See Tag A-0049).

Based on record review and interview, the hospital failed to meet the requirement for Condition of Participation of Respiratory Services as evidenced by:
1) Failure to maintain respiratory care services by eliminating respiratory therapist staff in 2 units of the hospital's offsite location (See Tag A-1154); and
2) Failure to adopt policies related to nursing staff delivery of respiratory care services (See Tag A-1160).

Based on record review and interview, the hospital failed to ensure the medical staff's accountability to the governing body for the quality of care provided to patients. This deficient practice was evidenced by the failure to inform the medical staff and governing body of a change in the delivery of respiratory care services in the emergency department and inpatient/observation unit of the offsite location
Findings:

A review of meeting minutes titled, "ED Clinician Conference Call, Baton Rouge General Medical Center," from 07/02/2025 at 9:00 AM revealed in part: "5. Ascension Campus REMINDERS Respiratory transition GO Live Tuesday, July 1st; Respiratory will no longer be in the building as of July 1st. Providers are expected to give orders for all vent/Bipap/Cpap settings. This includes recommendations for changes based upon changing assessment or ABG/VBG results. Nurses do not give settings. At this point, we are just trying to make sure we can operate the equipment properly. Ventilator patients will be given top priority for transfer to Bluebonnet. For intubated patients, will be using CMV mode for now. If need help, the intensivist agreed to consult by phone for Ascension patients. ABG's are the Providers responsibility."

Review of medical executive committee (MEC) meeting minutes from 01/13/2025 and Board of Trustees (GB) meeting minutes from 02/25/2025 and 04/28/2025 failed to reveal any discussion of the change in the method of respiratory services delivery at the offsite location.

In an interview on 07/08/2025 at 10:05 AM, S2DER confirmed the offsite location had eliminated respiratory therapist staff.

In an interview on 07/14/2025 at 1:37 PM, S11MDED confirmed the offsite location had eliminated respiratory therapist staff. S11MDED further confirmed this change in the method of respiratory services delivery was an ED inter-departmental change and it was not formally brought to the medical executive committee or governing body. S11MDED further confirmed hospital medicine was involved with the approval of the inpatient respiratory services delivery at this offsite location.

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient. This deficient practice was evidenced by the failure to document a focal assessment and/or an updated transfer record at the time of the transfer in 1 (#3) of 3 (#1 - #3) patient medical records reviewed.
Findings:

A review of hospital policy, "Assessment/Reassessment," Number ED-A2, being effective as of 09/1997, last revised 05/2024 and last reviewed 12/2020, revealed in part: "PURPOSE: To ensure Emergency Department Staff integrate the information from various assessments of the patient to plan patient care based on needs. POLICY: 2. An initial assessment by a registered nurse is completed during triage. Patient reassessment will be performed at a minimum of every 2 hours for patients awaiting medical evaluation. After initiation of the medical exam, patient reassessment will be based on acuity and/or further orders and changes in the patient's medical condition. PROCEDURE: 2. Reassessment is a process of periodic re-evaluation of the patient's condition, symptoms, and response to ordered treatment. Reassessment may include some or all of the following: vital signs, a focused physical assessment, pain assessment, general appearance, and/or responses to interventions and treatments. 5. Reassessment will occur based on patient acuity, nursing clinical judgment, and/or physician orders: C. Immediately prior to a patient's discharge or within 30 minutes, a focused reassessment should be completed and documented. Vital signs will follow the Repeat Vital Sign Policy, ED-R2."

A review of hospital policy, "Assessment/Reassessment," Number ED-D4, with an effective date unavailable, last revised 05/2024 and last reviewed 12/2021, revealed in part: "POLICY: The Emergency Department utilizes a documented focused assessment, based on patient's presenting complaint. Documentation of the patient visit will be recorded using the electronic documentation tool determined by the hospital. PROCEDURE: 1. Emergency Department: B. Documentation of patient care shall reflect a focused assessment based on the patient's presenting complaint. Documentation shall include identifying problems/needs, interventions, and evaluation of care for the duration for the Emergency Department visit."

A review of Patient #3's medical record revealed the patient arrived to the ED on 05/30/2025 at 10:23 AM with the chief complaint of shortness of breath. Patient #3 was evaluated and diagnosed with Acute Respiratory Failure with Hypoxia and Acute, Chronic Systolic CHF by S6MD. The patient was recommended for admissions, the patient chose to be admitted to Provider B and the request for transfer to Provider B was initiated on 05/30/2025 at 12:45 PM by S7RN. A review of nursing documentation from 05/30/2025 at 5:04 PM by S7RN revealed in part: "Transfer Record; Transfer Assessment: Stable; Transfer Assessment Time: 05/30/2024 17:07; Neurological Status: Alert-oriented to person, place, time, reason" and from 05/30/2025 at 5:47 PM, "Discharge Vital Signs: Discharge Vitals obtained and documented in Patient flowsheets." Patient #3 remained in the ED on 05/30/2025 to approximately 10:00 PM, the discharge date/time documented on the face sheet. The last documentation in the medical record was on 05/30/2025 at 9:30 PM by S8RN and revealed in part: "Task: bed low/locked, siderails up x 2, call light w/in reach; Patient Updates: pt comfortable, in bed, visitor at bedside, vital signs stable, no complaint; Group Note: still awaiting [Provider C] transport." Documentation failed to reveal an updated transfer record to include a transfer assessment, departure time, or patient status.

In an interview on 07/08/2025 at 8:45 AM, S5RNDR confirmed the above mentioned findings and the patient assessment/status should be updated when the transfer takes place.

Based on record review and interview, the hospital failed to ensure the medical record contained all information necessary to monitor the patient's condition. This deficient practice was evidenced by the failure to obtain and document an active list of home medications prior to disposition in 2 (#2, #3) of 3 (#1 - #3) ED patient medical records reviewed.
Findings:

A review of hospital policy, "Medication Reconciliation for Emergency Dept. Patients," Number ED-42, being effective as of 01/2009, last revised 05/2013 and last reviewed 05/2024, revealed in part: "Purpose: To provide a consistent medication reconciliation process for the Emergency Department patients in accordance with Joint Commission patient safety goals. POLICY: A list of patient medications will be obtained at the time of entry into the Emergency Department on all patients and will included as part of the permanent medical record. PROCEDURE: 1. Refer to Policy TX-306."

A review of hospital policy, "Medication Reconciliation," Number TX-306, being effective as of 01/2006, last revised 02/2021 and last reviewed 03/2024, revealed in part: "POLICY: 1. A complete list of the medications the patient is taking at home is created and documented in the patient's profile in the Electronic Medical Record. The medication list will include the medication (name, dose, route, frequency [)]. As-needed medications that are routinely and/or recently taken will be included, along with an indication for use if able to obtain from the patient or records. The patient and, as needed, the family are involved in creating this list, supplemented by information from the patient's care facility (if any) or outpatient pharmacy, as needed. 2. The pharmacy medication history technician (in ED only) or a nurse will complete the medication history. 4. Patients transferred outside the hospital to acute or long-term care facilities will have an up-to-date reconciled medication list communicated from the hospital to the next provider of care. 7. In setting where medication are used minimally, or prescribed for short duration, modified medication reconciliation processes are performed. Obtaining information on the dose, route, and frequency of use is not required. PROCEDURE: OUTPATIENTS: 1. Outpatient settings in which medication are not used, are used minimally, or are prescribed for only a short duration will use a modified medication reconciliation process. These settings will not require obtain information on the dose, route, and frequency. These areas may include but are not limited to the emergency department, clinic/office-based surgery, outpatient radiology, outpatient radiation oncology, ambulatory care and outpatient burn, and hyperbaric wound care setting. 2. The hospital obtains and documents an accurate list of the patient's current medication and known allergies in order to safely prescribe any setting-specific medications (for example, intravenous contrast media, local anesthesia, antibiotics) and to assess for potential allergic or adverse drug reactions. 4. When patients leave these settings, a list of the original, known and current medications does not need to be provided, unless the patient is assessed to be confused or unable to comprehend adequately. In this case, the patient's family is provided bother medication lists and the circumstances documented. 5. In these settings, a complete, documented medication reconciliation process is used when: C. The patient is required to be subsequently admitted to an organization from these setting for ongoing care."

A review of hospital policy, "Discharge/Transfer," Number ED-D2, being effective as of 02/1980, last revised 12/2021 and last reviewed 05/2024, revealed in part: "Purpose: To assist the patient in leaving the Emergency Department and to terminate emergency services/charges to discharge patient. To enhance the continuity of patient care by providing the floor/critical care unit/receiving facility with information needed. PROCEDURE: 2. Transfer to Hospital Bed: H. Transfer to outside facility, see Transfer Policy CC-100."

A review of hospital policy, "Admission/Discharge/Transfer," Number CC-100, being effective as of 05/1994, last revised 06/2025 and last reviewed 04/2024, revealed in part: "PURPOSE: To provide guidelines for the admission, discharge, and transfer of all patients. POLICY: Patients will be admitted to, discharged from or transferred from the Baton Rouge General Medical Center (BRGMC) facilities according to established guidelines and requirements set forth by regulatory agencies. 3. Transfers to Another Healthcare Facility: C. A copy of pertinent medical records will be sent to the receiving facility/unit for transferred patients, which include physical exam, discharge medications, diet treatments, and any other follow-up instructions. PROCEDURES: 2. Transfers/Discharges to another healthcare facility: C. The physician will complete medication reconciliation upon discharge. D. Send copy of Discharge Report Sheet, face sheet, the physician's progress notes, the history and physical as well as consultations, pertinent diagnostic reports (recent lab, x-ray, etc), physician orders for the most recent 3 days, and the current electronic Medication Administration Record (EMAR) and nurses' notes."

Patient #2
A review of Patient #2's ED medical record revealed an admissions on 07/05/2025 at 9:49 PM. The medications listed below were documented in the record on 05/23/2025 and were not verified on the current visit.
-Acetaminophen Tablet, Dose: 650 mg, Route: oral, Frequency: every 6 hours as needed, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified;
-Artificial Tears (polyvinyl alcohol/porvidone) 0.5%-0.6% eye drops, Dose: 2 drops, Route: opthalmic, Frequency: twice daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:01 AM, and indicated unverified;
-Complex-Vitamin B12, Dose: 1 tablet, Route: oral, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified;
-Claritin Oral, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified;
-Entresto, Dose: [empty space], Route: [empty space], Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified;
-Farxiga, Dose: 10 mg, Route: oral, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified;
-Levothyroxine, Dose: 50 mcg, Route: oral, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified;
-Nicoderm CQ 21mg/24 hr daily transdermal patch, Dose: 1 patch, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified;
-Vitamin D3 Oral, Dose: Frequency: daily, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified;
-Zofran ODT, Dose: 4 mg, Route: oral, Frequency: every 8 hours, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified;
-albuterol sulfate HFA 90 mcg/actuation aerosol inhaler, Dose: 2 puffs, Route: inhalation, Frequency: every 6 hours, Status: Active, Last Documented by: S9MD on 05/23/2025 9:01 AM, and indicated unverified;
-allopurinol 100 mg tablet, Dose: 50 mg, Route: oral, Frequency: one time daily, Status: Active, Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified;
-amiodarone, Dose: 400 mg, Route: oral, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified;
-aspirin, Dose: 81 mg, Route: oral, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified;
-bisacodyl Supp, Dose: 10 mg, Route: rectal, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified;
-carvedilol, Dose: 6.25 mg, Route: oral, Frequency: twice daily, Status: Active, Documented by: S9MD on 05/23/2025 9:01 AM, and indicated unverified;
-famotidine, Dose: 40 mg, Route: oral, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified;
-fluticasone 50 mcg/actuation Spray, Dose: 2 sprays, Route: intranasal, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified;
-hydrocodone 5mg-acetaminophen 325 mg tablet, Dose: 1 tablet, Route: oral, Frequency: every 6 hours as needed, Status: Active, Last Documented by: S9MD on 05/23/2025 9:01 AM, and indicated unverified;
-iron, Dose: Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified;
-meclizine, Dose: 25 mg, Route: oral, Frequency: 3 times daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified;
-multivitamin, Dose: 1 tablet, Route: oral, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified;
-omega 3 fatty acids-fish oil 300 mg-1000 mg, Dose: 1 capsule, Route: oral, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified;
-pantoprazole Delay Release Tab, Dose: 40 mg, Route: oral, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified;
-potassium chloride ER tab, Dose: 20 mill equivalent, Route: oral, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified;
-sucralfate, Dose: 1 gram, Route: oral, Frequency: 4 times per day, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified;
-torsemide, Dose: 20 mg, Route: oral, Frequency: 2 times per day, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified; and
-trelegy, Frequency: daily, Status: Active, Last Documented by: S9MD on 05/23/2025 9:00 AM, and indicated unverified.

Patient #3
A review of Patient #3's ED medical record revealed an admission on 05/30/2025 at 10:23 AM. The medications listed below were documented in the record on 03/04/2025 and were not verified on the current visit.
-Crestor, Dose: 10 mg, Route: oral, Frequency: daily, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified;
-Cymbalta, Dose: 20 mg, Route: oral, Frequency: 2 times per day, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified;
-Lyrica, Dose: 25 mg, Route: oral, Frequency: 2 times per day, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified;
-Magnesium Hydroxide Susp, Dose: 15 ml, Route: oral, Frequency: daily, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified;
-Nitroglycerin, Dose: 0.4 mg, Route: sublingual, Frequency: every 5 minutes, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified;
-Protonix Delay Release Tab, Dose: 40 mg, Route: oral, Frequency: daily, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified;
-Ranolazine 12 hr Tab, Dose: 500 mg, Route: oral, Frequency: every 12 hours, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified;
-Synthroid, Dose: 75 mcg, Route: oral, Frequency: daily, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified;
- albuterol sulfate HFA 90 mcg/actuation aerosol inhaler, Dose: 1 puff, Route: inhalation, Frequency: every 6 hours, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified;
-aspirin, Dose: 81 mg, Route: oral, Frequency: daily, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified;
-clopidogrel, Dose: 75 mg, Route: oral, Frequency: daily, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified;
-lidocaine 4% patch, Dose: 2 patch, Route: topical, Frequency: daily, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified;
-metoprolol (Tartrate), Dose: 12.5 mg, Route: oral, Frequency: daily, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified;
-midodrine oral, Dose: 5 mg, Frequency: 3 times per day, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified; and
-torsemide oral, Dose: 40 mg, Frequency: 2 times per day, Status: Active, Last Documented by: S10NP on 03/04/2025 7:20 AM, and indicated unverified.

A review of the version of Patient #3's medical record sent to Provider B upon transfer and titled, "Baton Rouge General Medical Center - ED Patient Transfer Continuity of Care Document," revealed in part, all of the before mentioned medications as being active, home medications.

A review of Patient #2's and #3's ED medical record failed to reveal documentation of the patient's home medication having been reviewed and updated during the timeframe of each patient's admission to the ED. Further, Patient #3's home medication list was included as part of the transfer record to Provider B without being reviewed and updated.

In an interview on 07/08/2025 at 8:45 AM, S5RNDR confirmed the above mentioned findings.

Based on state regulation review, hospital meeting minute review and interview, the hospital failed to ensure adequate numbers of respiratory therapist consistent with State law. This deficient practice was evidenced by the failure to maintain respiratory care services by eliminating respiratory therapist staff in 2 units of the hospital's offsite location.
Findings:

A review of Louisiana Administrative Code, Title 48, Public Health-General, Chapter 93 Hospitals, Subchapter Q. Respiratory Care Services (Mandatory), §9489. Organization and Staffing: B. There shall be adequate numbers of respiratory therapists, respiratory therapy technicians and other personnel who meet the qualifications specified by the medical staff and approved by the governing body, consistent with Louisiana law.

A review of meeting minutes titled, "ED Clinician Conference Call, Baton Rouge General Medical Center," from 07/02/2025 at 9:00 AM revealed in part: "5. Ascension Campus REMINDERS Respiratory transition GO Live Tuesday, July 1st; Respiratory will no longer be in the building as of July 1st. Providers are expected to give orders for all vent/Bipap/Cpap settings. This includes recommendations for changes based upon changing assessment or ABG/VBG results. Nurses do not give settings. At this point, we are just trying to make sure we can operate the equipment properly. Ventilator patients will be given top priority for transfer to Bluebonnet. For intubated patients, will be using CMV mode for now. If need help, the intensivist agreed to consult by phone for Ascension patients. ABG's are the Providers responsibility."

The offsite campus consisted of 2 acute care units - a 14 bed emergency department and a 10 bed inpatient/observation unit.

In an interview on 07/08/2025 at 10:05 AM, S2DER confirmed the offsite location had eliminated respiratory therapist staff.

In an interview on 07/14/2025 at 1:37 PM, S11MDED confirmed the offsite location had eliminated respiratory therapist staff.

Based on interview, the hospital failed to ensure respiratory care services were being delivered in accordance with medical staff directives. This deficient practice was evidenced by the failure to adopt policies related to nursing staff delivery of respiratory care services.
Findings:

In an interview on 07/14/2025 at 1:25 PM, S5RNDR confirmed the hospital had not updated policies and procedures related to the nursing staff's delivery of respiratory care services that would be within the scope of nursing practice.