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Based on record review and interview, the hospital failed to ensure the QAPI program analyzed adverse patient events that impacted patient safety and quality of care. This deficient practice was evidenced by failure of the hospital to conduct a thorough investigation to determine if the transportation company was safe for psychiatric patients after 1 (#2) of 5 (#1, #2, #3, #4, #5) sampled patients, who was under a Phyisican's Emergency Certificate, strangled themselves with a seatbelt while being transported from this hospital as an inpatient to an inpatient psychiatric facility.

Findings:

Review of Patient #2's medical record revealed he had presented to the hospital's Emergency Department on 04/03/2021 with the diagnosis of acute encephalopathy. Patient #2 was admitted to the telemetry floor of the hospital on 04/03/2021 at 8:25 p.m. for treatment of acute encephalopathy.

Review of a Physician's Emergency Certificate dated 04/04/2021 at 4:30 p.m. revealed Patient #2 was assessed by a physician and found to be emotional, dysphoric, guilty and depressed. He was determined to be in the need of immediate psychiatric treatment in a treatment facility because he was seriously mentally ill or suffering from substance abuse so that he was dangerous to himself, unwilling to seek voluntary treatment, and dangerous to others.

Patient #2's assessment by nursing staff by the Columbia Suicide Severity Rating Scale revealed to following results:
04/03/2021 at 5:40 p.m. - No risk
04/05/2021 at 7:45 a.m. - High risk

Review of Patient #2's medical record revealed on 04/05/2021 at 7:50 p.m. he was discharged to a psychiatric hospital.

Review of a self-report to the Louisiana Department of Health for potential patient neglect, provided by the hospital, revealed in part:
Patient #2 was placed under Physician's Emergency Certificate (PEC) due to depression, being emotional and dysphoric. Psychiatry was consulted and determined patient to be dangerous to self and others and unwilling to seek voluntary admission. At 8:40 p.m. on 04/05/2021, a driver from Transport Company "A" called the hospital to report that during the transport from the hospital to Psychiatric Hospital "B", the patient wrapped the seatbelt around his neck. It was reported that 911 was called and Ambulance Service "D" responded. Patient #2 was taken to Acute Care Hospital "C".

Review of the hospital's contract with Transport Company "A" revealed the following policies attached:
Review of the Transport Company "A" Policy titled Emergency Protocols-Procedural Emergency revealed in part:
The Transport Company "A" attendant accompanying the patient during transport will actively monitor the patient through visual and audio observation, utilizing equipment specified in the Transportation Equipment Specifications, for signs of crisis development.

Review of the Transport Company "A" policy titled Transportation Equipment Specifications revealed in part:
A video monitor installed in the front area of the vehicle allows the driver and attendant to safely monitor the rear seat activity without turning around.

Review of the Transport Company "A" policy titled Emergency Protocols-Medical Emergency revealed in part:
If a medical emergency occurs at any time during transport:
Attendant duties- The Transport Company "A" attendant will immediately contact 911 and provide the nature of the emergency and the appropriate location. The attendant will follow all 911 operator instructions, providing appropriate care to the patient as necessary. This may include:
Removing the patient from the vehicle and performing CPR

In an interview on 04/15/2021 at 12:35 p.m. with Owner Transport Company "A", he verified he was one of several owners of Transport Company "A". He said he had interviewed his drivers and said on 04/05/2021 they transported Patient #2 from Ochsner in Baton Rouge to Psychiatric Hospital "B". He said there was a driver and a passenger (2nd employee) in the front seat and the patient was in the back seat. Owner Transport Company "A" said Patient #2 was upset and was crying and kicking. He reported his staff had called ahead to Psychiatric Hospital "B" about 5 minutes before arrival and had asked staff to meet them outside with a wheelchair. He said he was told, by his staff, that on the transport the patient quit making noise shortly before arrival to the psychiatric hospital. When they arrived, he said the passenger got out of the car and then the driver turned around to tell the patient they were there and the patient had a seatbelt around his neck. Owner Transport Company "A" said the Psychiatric Hospital "B" staff had arrived to the car as the driver opened the back door. He reported the driver said they were told to leave the patient where he was by the hospital staff. He said neither his staff or the psychiatric hospital did CPR. He said the cameras on the dashboard are forward facing and inward facing. He said the cameras track the driver's actions and are also for patient safety. He said it is more difficult to see the patients at night. He said the video can't be watched live but they can go back and view the footage. He verified it was a retrospective review of what happened, not in real time. He also verified the driver or passenger could not view the patient in the backseat with the dashboard camera. He said the last time he saw movement from Patient #2 when he reviewed the dashboard camera video was at 8:10 p.m. and they arrived to the psychiatric hospital at 8:15 p.m. He said it is the passenger's responsibility to view the patient and make sure they are safe. He said he did not see either the passenger or the driver turn around and view Patient #2 when he reviewed the dashboard video from that night.

In an interview on 4/15/2021 at 1:01 p.m. Admin Psychiatric Hospital "B", she said the charge nurse called her and let her know what happened on 04/05/2021. She said she knew a patient was coming from Baton Rouge. She said she got in report that he would need a wheelchair. She said Transport Company "A" called at 4 minutes out and said they needed a wheelchair. Admin Psychiatric Hospital "B" reported that one patient care technician (PCT) was outside with the wheelchair when Transport Company "A" driver opened the door to the car and Patient #2 was in the back seat with the seatbelt around his neck. She said the PCT said the patient was laying with his head behind the driver. She said the PCT told the Transport Company "A" drivers to start CPR and went back inside Psychiatric Hospital "B" to call 911. She said when the police arrived the officer removed the seat belt from around Patient #2's neck and began CPR. She said a nurse went out to the car at the same time the police arrived. When asked why the seatbelt had not been removed from Patient #2's neck until the police arrived, Admin Psychiatric Hospital "B" said she did not know.

Review of Patient #2's medical record from Acute Care Hospital "C" revealed the following documentation from the ED:
Patient arrives by Ambulance Service "D" after being found unresponsive in the backseat of a car with a seatbelt wrapped around his neck. Reportedly the patient was being transported to a mental health facility and was found in this state after arriving there. The police later arrived and removed the seatbelt from around the patient's neck and Ambulance Service "D" was engaged. Ambulance Service "D" reports finding the patient pulseless and apneic. Patient arrives unstable and critical condition.

In an interview on 04/15/2021 at 12:15 p.m. with S4Quality, she said they had not yet viewed the dashboard video of Patient #2's transport by Transport Company "A" when the survey team arrived on 04/14/2021. She said they asked for it from the owner but had not yet received a copy. S4Quality said they talked to the owner of the company on 04/06/2021 and they asked to participate in the interviews with his staff. S4Quality said at first the owner said he would set it up but then told them later he was advised to get a hand written statement from them first. He said he would drop the statements off to them but had not provided the statements as of 04/14/2021. She said after they talked to the hospital's legal department, they asked Owner Transport Company "A" for a written action plan for the changes he was going to make. She said he had not sent the action plan as of 04/14/2021. When asked if the hospital had interviewed the staff from Psychiatric Hospital "B", S4Quality said they had not. She verified the hospital continued to use Transport Company "A" to transport psychiatric patients from the hospital as of 04/14/2021 when the survey was started.

In an interview on 04/15/2021 at 2:40 p.m. with S1CNO, she said her expectation of the actions that should have been taken by Transport Company "A" was that when the drivers found Patient #2 with a seatbelt around his neck, the seatbelt should have been removed from around the patient's neck, and CPR should have been started.

Review of Patients transported by Transport Company "A" to inpatient psychiatric units between 04/06/2021 (day after Patient #2's incident) and 04/14/2021 revealed the following:
04/07/2021 - Patient #R1 diagnosed with paranoid ideation and acute psychosis.
04/09/2021 - Patient # R2 diagnosed with mania and acute psychosis and Patient # R3 diagnosed with visual hallucinations, accidental drug overdose and psychosis
04/11/2021 - Patient # R4 diagnosed with overdose and Patient # R5 diagnosed with acute psychosis
04/13/2021 - Patient #R6 diagnosed with schizophrenia and acute psychosis